(Uornell Imocrattg Slibrarg 
 
 THE 
 
 CHARLES EDWARD VAN CLEEF 
 MEMORIAL LIBRARY 
 
 BOUGHT WITH THE INCOME OF A FUND GIVEN FOR 
 THE USE OF THE ITHACA DIVISION OF 
 
 THE CORNELL UNIVERSITY MEDICAL 
 
 COLLEGE 
 
 BY 
 
 MYNDERSE VAN CLEEF 
 
 CLASS OF 1874 
 1921 
 
/ersity Library 
 IllJimii™" '=°">"'>utions 
 
(flornEll MmoerBitg ffitbri 
 
 THE X 
 
 CHARLES EDWARD VAN CL 
 MEMORIAL LIBRARY 
 
 BOUGHT WITH THE INCOME OF A FU 
 THE USE OF THE ITHACA DIV 
 
 THE CORNELL UNIVERSIT 
 COLLEGE 
 BY 
 
 MYNDERSE VAN CI 
 
 CLASS OF 1874 
 1921 
 
Cornell University Library 
 RG 508.S61 
 
 V.I 
 
 The obstetric memoirs and contributions 
 
 3 1924 012 179 614 
 
The original of tiiis book is in 
 tine Cornell University Library. 
 
 There are no known copyright restrictions in 
 the United States on the use of the text. 
 
 http://archive.org/details/cu31924012179614 
 
OBSTETEIC 
 MEMOIRS AND CONTRIBUTIONS. 
 
THE 
 1/ 
 
 OBSTETEIC 
 
 MEMOIRS AND CONTEIBUTIONS 
 
 JAMES Y. |IMPSON, M.D., F.R.S.E. 
 
 PROFESSOR OF MIDT7IFEEY IN THE TJNITEESITT OF EBIHBUBGH, ETC., ETC. 
 
 EDITED BY 
 
 W. 0. PRIESTLEY, M.D., EDINBirEGH, 
 
 FOKMEELT VICE-PRESIDENT OF THE PARISIAN MEDICAL SOCIETY) 
 
 HORATIO R. STORER, M.D., BOSTOE", U. S., 
 
 ONE OF THE PHYSICIANS TO THE BOSTON LYINQ-IN HOSPITAL. 
 MEMBERS OF THE MEDICO CHIEBEQICAL AND OBSTETRIC SOCIETIES OF EDISBUEGHj ETC., ETC., ETC. 
 
 VOLUME I. 
 
 PHILADELPHIA: 
 
 J. B. LIPPINCOTT & CO. 
 1855. 
 
DEDICATION. 
 
 TO DE. MAGMJS C. EETZIUS, 
 
 PE0FES30R or MIDWIFEBT IN THE XTNIVERSITT OF STOCKHOLM, PHYSICIAN TO THE 
 KOTAL FAMILY OF SWEDEN, ETC., ETC., ETC. 
 
 My dear Dr. Retzius : 
 
 As I have reserved the right of dedicating these volumes, 
 I beg to have the pleasure of inscribing the following pages to 
 you. And pray accept of the offering as a slight tribute, on 
 my part, to your profound professional acquirements — as a 
 mark of my sincere esteem for your personal friendship — and 
 as a small memento of the delightful weeks which we spent 
 together in the summer of 1852. 
 
 I feel deeply that I owe many apologies to you, and to my 
 other professional brethren, for the publication of the Me- 
 moirs and Contributions of which these volumes consist, in so 
 unusual and crude a form. Believe me, no one can be more 
 sincerely impressed with their great and numerous imperfec- 
 tions, than I am myself Most, if not all, of these Communi- 
 cations were, as you well know, written hurriedly and amid 
 the incessant distractions of practice. If I had attempted to 
 remodel, extend, and correct them, in the manner and to the 
 amount which I have sometimes anxiously desired, they would, 
 I fear, never have been published in a collected form. In this 
 view, my friends and assistants. Dr. Priestley and Dr. Storer, 
 were right, I believe, in urging the sheets through the press 
 
VI DEDICATION. 
 
 as rapidly as possible, after they had themselves arranged and 
 annotated them. And for the great care and toil which they 
 have expended upon the task, thus voluntarily assumed, I 
 cannot possibly feel too grateful. 
 
 Allow me to add, that I sometimes venture to look forward 
 with hope and pleasure to the possibility of the renewal of 
 our personal intercourse. Nor, though far separated from you, 
 are you ever allowed to be long absent from my thoughts, for 
 one merry face around ray hearth — that of your little name- 
 sake — is ever reminding me and mine of your happy sojourn 
 among us. — Believe me, with heartfelt regards. 
 
 Ever faithfully yours, 
 
 J. Y. SIMPSON. 
 
 Edinburgh, 16th April, 1855. 
 
TO 
 
 DRS. JOHN WARE AND J. MASON WARREN, OF BOSTON, 
 
 THOMPSON, 01' NORTHAMPTON, 
 
 AUSTIN FLINT, OP BUFFALO, 
 
 DUNQLISON, OF PHILADELPHIA, 
 
 KINLOCH AND JENKINS, OF SOUTH CAROLINA, 
 
 AND 
 
 MORISON, OF SAN FRANCISCO, 
 
 WHO AT VAEIODS TIMES DtTRINO HIS KESIDENOE IN EDINBUKQH, SHARED WITH 
 HIM THE ADVANTAGES OF DR. SIMPSON'S PRIVATE PKAOTIOE, 
 
 AND TO PRIESTLEY, 
 
 ASSOCIATED WITH EVERY PLEASANT REMINISCENCE, 
 
 THIS, THE AMERICAN EDITION", 
 
 IS INSCRIBED BY THEIR FRIEND, 
 
 THE JUNIOR EDITOR. 
 
EDITORS' PEEFACE. 
 
 The greater portion of the following pages has appeared at 
 various times in the British Journals of Medicine, as occa- 
 sional contributions to Obstetric Pathology and Practice. 
 
 The object of the Editors has been to present these to the 
 Profession in a more readily available form, believing that 
 such compilations have at least the merit of greatly facilitating 
 the study of any special inquiry, — an object of no slight impor- 
 tance to most Medical Men engaged in active practice. 
 
 In reprinting Dr. Simpson's Obstetric Memoirs and Essays, 
 the Editors moreover believe that they will be the means of 
 supplying many of his former pupils with papers they have 
 vainly striven to possess themselves of, inasmuch as they were 
 published originally in journals which are now out of print. 
 Most of the Contributions thus scattered over many years and 
 many volumes, while they do honor to the literature of the 
 Profession, bear the impress of an almost unlimited practical 
 knowledge and experience. The evidence of the latter appears 
 to us especially to enhance their value, and it seems but justice 
 to Dr. Simpson's acknowledged reputation as an Obstetrician, 
 that some more tangible and permanent form should be given 
 to his works. 
 
X EDITORS PREFACE. 
 
 Several of the Memoirs included in these volumes have 
 been deemed of sufficient value, by our Continental brethren, 
 to be translated into their own languages, and many of them 
 have likewise been reprinted in American journals. Besides 
 those already published, the present volumes contain a num- 
 ber of entirely new contributions, and Dr. Simpson has himself 
 revised two or three of the older papers, which hence appear 
 in an almost re-written form. 
 
 "We believe that Dr. Simpson, after repeated requests from 
 his professional friends and pupils, has only been prevented 
 from, himself, republishing these Essays, and thus presenting 
 them to the public in a more valuable form, by an impression 
 that one or more of them must necessarily be finished, and 
 many others elaborated and re-written ; while the little leisure 
 time at his disposal seemed entirely to preclude the accom- 
 plishment of so much extra labor. 
 
 We may, however, state that Dr. Simpson, after assenting 
 to our request to allow these papers to be republished, has, 
 whenever we needed it, given his cordial co-operation in our 
 editorial labors ; and that, while he is not responsible for the 
 appearance of these volumes in their present form, he has 
 most kindly placed at our disposal such of his papers as we 
 desired, and has at all times been willing to assist us in any 
 difficulty which presented itself during the preparation of the 
 work. 
 
 The nature of the papers, from the mode of their original 
 publication, was necessarily desultory, but we have endeavored 
 to^ arrange them in different parts, according as they seemed 
 to belong more especially to the Diseases of Women, Natural 
 and Morbid Parturition, &c., &c. We have thought it better 
 so to classify, than to arrange them chronologically, in order 
 to give the book a more systematic form, and to facilitate refe- 
 
EDITORS PREFACE. XI 
 
 rence ; while it may thus be of more use to Students who are 
 attending Dr. Simpson's Midwifery Class. 
 
 We have, at Dr. Simpson's special request, endeavored to 
 avoid as much as possible entering into the controversies which 
 have occurred on more than one occasion — always in self de- 
 fence on his part — on the subject of some of the Memoirs here 
 republished, and we have only extracted from such correspon- 
 dence those portions which seemed to throw light on the sub- 
 ject under discussion. Our object has been to represent fairly 
 the opinions of Dr. Simpson, written or spoken, on many im- 
 portant Obstetric matters; and we would refer our readers 
 who may desire to see the controversial correspondences 
 (more especially those with Drs. Lee and Radford on Placenta 
 Prgevia, and with Dr. Collins on Hospital Statistics, and the 
 Eifects of the Duration of Labor), to the Journals in which 
 they were respectively published. 
 
 It will be found, we believe, that we have given all of Dr. 
 Simpson's Obstetric writings, up to the present date (April, 
 1855), with but a single exception. We refer to a series of 
 short articles on some of the most common diseases of women, 
 written many years ago for the Library of Medicine. These 
 are regarded by Dr. Simpson as of little value; and they 
 would only have been a needless repetition of some of the 
 pages in the first volume. 
 
 Many will ask, as has already been done, why we have not 
 also published in the present work Dr. Simpson's more general 
 Medical writings. Others will be surprised to learn, that a man 
 not yet forty-four years of age, with such engrossing practice, 
 and who has accomplished so much in his own peculiar field, 
 should have yet found time for other subjects of thought. 
 
 We subjoin a list of the more important of Dr. Simpson's 
 general Essays and Papers: 
 
xii EDITOKS' PEIFACB. 
 
 1. "The Contagiousness of Cliolera." 
 
 Ed. Med. and Surg. Jour., April 1838. 
 Also a Paper containing further evidence. (Kead to the Medico-Chir. 
 Society, Dec. 13, 1848.) 
 
 Ed. Monthly Jour, of Med. Science, Feb. 1849. 
 
 2. "Antiquarian Notices of Leprosy and Leper Hospitals in Scotland and 
 
 England." (Three papers read before Med. Chir. Society, March 3, 
 1841.) 
 
 Ed. Med. and Surg. Journal, Oct. 1841, and Jan. and 
 
 April 1842. 
 
 3. " The Conduct and Duties of Young Physicians." 
 
 Edinburgh Graduation Address, 1842. 
 
 4. "Description of the Bones of the Distorted Foot of a Chinese Woman." 
 
 (Read before Med. Chir. Soc, 4th June 1845.) 
 
 Northern Journal of Med., Aug. 1845. 
 
 5. "Solutions of Grun Cotton, Gutta Percha, and Caoutchouc, as dressings 
 
 for wounds, &c." (Read before Med. Chir. Society, May, 1848.) 
 
 Ed. Monthly Journal of Med. Sc, July 1848. 
 
 6. "Ancient Roman Medicine Stamps." Three papers. 
 
 Ed. Monthly Journal of Med. Sc, Jan., March, and April 1851. 
 
 7. "Repudiation of Mesmerism." 
 
 Ed. Monthly Journ. of Med. Sc, May 1851, and Lancet, Sept. 1851. 
 
 8. "Was the Roman Army provided with Medical Officers?" 
 
 Printed and privately circulated, 1851. 
 
 9. "Notes on some Ancient Greek Medical Vases for containing Lykion ; 
 
 and on the modern use of the same drug in India." 
 
 Ed. Monthly Journ. of Med. Sc, Jan. 1853. 
 
 10. " Modern Advancement of Practical Medicine and Surgery." (Inau- 
 
 gural Address as President of Med. Chir. Society, 5th Jan. 1853.) 
 
 Ed. Monthly Journ. of Med. Sc, April 1853. 
 
 11. "Homoeopathy; its Tenets and Tendencies." 
 
 Edinburgh, 1853. (3d Edition. Now out of print.) 
 
EDITORS PREFACE. XIU 
 
 These would of themselves have formed a large volume. 
 We could not properly have embodied them with the papers 
 we now present, to the collection and arrangement of which 
 we have devoted several months. 
 
 For valuable aid in procuring papers out of print we are 
 indebted to Drs. Malcolm and Wm. Ziegler, and to Messrs. 
 Carmichael and Hunter Adam ; and for opportunities of con- 
 sulting the MSS. Records of the Obstetric Society, we are 
 under obligations to its Secretary, Dr. Keiller. 
 
 52 Queen Street, Edinbukgh, 
 10th April 1855. 
 
PREFACE TO THE AMERICAN EDITION. 
 
 Without need of apology and without fear for its reception, 
 the American edition of these papers is offered by the junior 
 editor to his countrymen. Dr. Simpson is now probably better 
 known throughout the United States than any other living 
 obstetrician ; the pages of our medical journals, for many 
 years past, show with what avidity his opinions have ever 
 been seized; the changes that have come over our practice, 
 the extent and celerity of their adopj;ion. 
 
 There are points of Dr. Simpson's practice, however, on 
 which some are in doubt, and others, I believe, misinformed. 
 The importance of these questions will warrant me in espe- 
 cially directing attention to several of them, and in claiming 
 for them all a more extended and impartial investigation. No 
 suggestion, I do believe, however impracticable or useless it 
 might seem at first sight, ever came from this man's mind 
 without being called forth by a felt want, being based on logical 
 reasoning, and supported by experiment. In almost every in- 
 stance thus far, the soundness and propriety of these suggestions 
 have already been acknowledged; where such has not been 
 done, it will be. 
 
 In 1844, Dr. Simpson proposed, in certain cases of placenta 
 prsevia, the extraction of the placenta before the child : 
 In 1845, the use of alkaline salts in placental phthisis: 
 In 1847, the operation of turning as an alternative for 
 craniotomy : 
 
Xvi PREFACE TO THE AMEEICAK EDITION. 
 
 And, in the same year, the use of anaesthetics in labor. 
 
 Three of these proposals, either of which were worth a life- 
 time to have made, were in turn received with ridicule and 
 fierce attack. Within ten years these same proposals will have 
 saved thousands of lives; and they now command the respect 
 and assent of a large proportion of the profession. But yester- 
 day, and the man who dared give ether or chloroform in labor 
 was considered as breaking alike the laws of Nature and of 
 God ; the time is probably close at hand when such will be 
 said of all who withhold them, even in natural labor. 
 
 In 1843, Dr. Simpson proposed the sound in uterine diagnosis : 
 
 And, in the same year, the treatment of displacements by 
 intra-uterine pessaries. 
 
 In 1844, the incision of the cervix uteri in obstructive 
 dysmenorrhoea : 
 
 And in 1849, the employment of sponge tents to expose intra- 
 uterine polypi. 
 
 Regarding each of these latter proposals, many fears are still 
 held, often openly expressed, — though upon two of them, the 
 first and the last, the sense of the profession is doubtlessly now 
 with Dr. Simpson. "Without the sound, no man can satisfac- 
 torily diagnose some of the diseases of women ; without the 
 tent, though the sponge is very likely yet to give place to some 
 safer agent, there are others that no man can cure. 
 
 Intra-uterine pessaries have, on the whole, been very un- 
 fairly dealt with. The very idea of manipulating an organ so 
 important and apparently so sensitive as the uterus with such 
 seeming heroism, was of itself enough to alarm very many 
 honest and brave men, and to create an almost invincible pre- 
 judice. Such objections, though the subject was one somewhat 
 more difiicult of investigation, might yet have been answered 
 by pointing to the successful and closely analogous use of the 
 sound. 
 
 Other influences, however, were brought to bear upon this 
 question, — influences which, in themselves, should never have 
 been allowed for an instant to weigh, and never would have 
 
PEBFACB TO THE AMERICAN EDITION. XVU 
 
 done so with an entirely unprej,udicecl mind. Of these I shall 
 enumerate two, — the circumstances of the latter of which are 
 in part already well known in this country. The other I shall 
 allude to entirely without Dr. Simpson's knowledge, and, I may 
 add, without his permission, which he utterly refused to grant 
 when we asked it for the Scotch edition, so desirous was he 
 that bygones should be past, and the wrongs he had received 
 forgotten. 
 
 I should, however, he unmindful of my duty, as one of his 
 editors, to Dr. Simpson's reputation, did I not now mention 
 these facts. Abroad, where they are so well known, recapitu- 
 lation would have been unnecessary ; but to many here, the 
 proposed practice is a new one. 
 
 Dr. Eobert Lee of London, though himself a Scotchman, 
 has for many years been Dr. Simpson's inveterate opponent, 
 and has successively attacked every proposition of any impor- 
 tance he has made since 1840, — the date of their competing 
 together for the chair Dr. Simpson now holds in the University 
 of Edinburgh. To several of these attacks Dr. Simpson has 
 replied at length ; the remainder he has probably considered 
 beneath his notice. Among others, Dr. Simpson's proposal of 
 the intra-uterine pessary could not, of course, remain unnoticed, 
 and on various occasions and in various connections. Dr. Lee 
 has subjected it to unmeasured ridicule,* and at no time has he 
 been at all temperate in his use of language. He has attacked 
 Dr. Simpson at all times and seasons. Within even a year he 
 has published in one of the London journals a most furious 
 tirade upon anaasthetics in labor. He has written alike in his 
 own name and anonymously ;f and I think no one can sys- 
 tematically follow out the whole details of this warfare, as I 
 have done, and still consider Dr. Lee an earnest physician 
 laboring only for truth's sake. I regret to say this, and have 
 done so with great reluctance. I know that it will give Dr. 
 Simpson pain. But I must add that Dr. Lee's chief works 
 
 * London Med. Gazette, and Lancet, 1845-51. 
 ■)" Vide papers by "Isaac Irons/' loc. cit. 
 
 lA 
 
xviii PREFACE TO THE AMERICAN EDITION. 
 
 on obstetrics, which formeriy gained for him such reputation as 
 a practitioner and as a writer, are now becoming considered 
 entirely unreliable. His famous system of uterine nerves has 
 been proved by Dr. Snow Beck, from the same identical speci- 
 mens, not to exist ; and the honors conferred upon him by one 
 of the highest societies in Great Britain* have been formally 
 and ignominiously cancelled. 
 
 Objections to the intra-uterine pessary coming from such a 
 source as this, and probably based on not a single truthful 
 observation, should certainly gain no credence. 
 
 Again, a report has recently been submitted to the French 
 Academy adverse to the employment of these pessaries, and 
 has attracted much attention. To this report also I must warn 
 the profession against lending too ready an ear. The opinions 
 which led to it were many of them given by already and un- 
 duly biassed men ; the cases experimented upon were many of 
 them unfair and improper ones, and the instrument chiefly 
 used, that of M. Valleix, was not at all that of Dr. Simpson, 
 but an unwise, unjustifiable, and no doubt often dangerous 
 modification. Judgment should be set aside, or at least with- 
 held, and before long Dr. Simpson will no doubt himself answer 
 all issues most satisfactorily. 
 
 In all cases these pessaries should perfectly fit the patient, 
 or else there will of course be trouble : a man can no more 
 make a single instrument answer for a series of patients than 
 he could a single shoe; and I am satisfied that there are many 
 cases which can no more be treated by any other form of pes- 
 sary, than can the displacement itself be properly diagnosed by 
 the speculum instead of by the finger or sound. 
 
 Incision of the cervix uteri by the hysterotome is an opera- 
 tion that, in experienced hands, and with proper care and pre- 
 caution, is attended with little or no danger. In obstinate 
 cases of dysmenorrheea, that have undergone dilatation and all 
 the other usual forms of treatment, it will 'usually be found 
 productive of great relief, — often of complete cure. 
 
 * The Royal Society of London. 
 
PREFACE TO THE AMERICAN EDITION. XIX 
 
 In conclusion, we omitted these matters, as I have said, in 
 the Edinburgh edition, and I have referred to them here^ 
 because in the one case they seem needed. In doing sO, I have 
 perhaps overstepped my bounds, and exchanged the coldness 
 of an editor for the warmth — I trust still impartial — of a 
 friend. If such is the case, I shall look for excuse to the 
 peculiar relations in which I have stood to Dr. Simpson. For 
 one year I was admitted to close intimacy with him — to his 
 home. I learned to love him as my father ; he treated me 
 as a son. I am proud to call him master. In selecting an 
 American as one of his editors, he testified to his regard for our 
 country. I could only promise him a hearty welcome among 
 us, and I am sure he will everywhere receive it. 
 
 H. R. S. 
 
 7 Chestee Steeet, Boston, 
 September, 1855. 
 
CONTENTS. 
 
 PAKT I. 
 
 SPECIAL PATHOLOGY OF THE UNIMPREGNATED FEMALE. 
 
 General Remarks on Uterine Diagnosis, . 
 
 On the Position of the Patient for the Use of the Speculum, . 
 
 Memoir on the Uterine Sound, .... 
 
 Antiquity of Uterine Sounds and Pessaries, . 
 
 On the Use of the Exploring Needle, 
 
 Anaesthesia as a means of Diagnosis, 
 
 Inflammatory Eruptions upon the Mucous Membrane of the Cervix Uteri, 
 
 Medicated Pessaries, ...... 
 
 Chloride of Zinc in Ulceration of the Cervix, 
 Potassa fusa in Inflammatory Induration of the Cervix Uteri, 
 Morbid Deviations of Involution of the Uterus, . 
 Terminations and Treatment of Fibroid Tumors of the Uterus, 
 Artificial Removal of a large Uterine Fibrous Tumor, 
 Diagnosis of Polypi growing from the Lips of the Cervix Uteri, 
 Detection and Treatment of Intra-Uterine Polypi, 
 
 (Nolie on Uterine Hemorrhoids.) 
 Excision of large Pedunculated Uterine Polypi, . 
 Amputation of the Cervix for Cauliflower Excrescence, 
 Amputation for Carcinoma, .... 
 
 Occasional Latency of Symptoms in advanced Carcinoma Uteri, 
 
 Carcinomatous Disease of the Fundus Uteri, 
 
 Retroversion of the Unimpregnated Uterus, . 
 
 Ascent of the Unimpregnated Uterus, 
 
 Gout of the Uterus, .... 
 
 Fistul® as the Results of Pelvic Abscess, 
 
 Position of the Patient for Tapping in Ovarian Dropsy, 
 
 Plaster-belt in Abdominal Tumors, 
 
 Inflammatory and Non-Inflammatory Ruptures of Ovarian Cysts, 
 
 Injections of Iodine into Ovarian Cysts, . 
 
 Ovariotomy — Its Justification, .... 
 
 
 FAOE 
 
 , 
 
 17 
 
 , 
 
 44 
 
 
 45 
 
 
 98 
 
 . 
 
 99 
 
 . 
 
 100 
 
 vix Uteri, 
 
 101 
 
 , 
 
 102 
 
 
 104 
 
 , 
 
 104 
 
 , 
 
 106 
 
 . 
 
 115 
 
 , 
 
 118 
 
 , 
 
 120 
 
 
 122 
 
 
 146 
 
 
 157 
 
 , 
 
 166 
 
 . 
 
 181 
 
 . 
 
 183 
 
 
 188 
 
 , 
 
 212 
 
 
 215 
 
 . 
 
 216 
 
 . 
 
 222 
 
 
 228 
 
 ) • 
 
 228 
 
 
 239 
 
 
 242 
 
xxu 
 
 CONTENTS. 
 
 Ameuorrhoea from imperfect development of the Uteras, 
 
 Nature of the Membrane expelled in Dysmenorrhoea, 
 
 Dilatation and Incision of the Cervix Uteri in Dysmenorrhoea, 
 
 Retention of Menstrual Secretion, 
 
 Gallic Acid in Menorrhagia, . . . • • 
 
 Direct Application of Remedies to the Cavity of the Uterus, 
 
 Therapeutic Action of Furfurine, Nickel, &c.. 
 
 Spurious Pregnancy, . . . . ■ 
 
 Fatal Venous Hemorrhage from Pudenda, 
 
 Ball Valve Obstruction of the Rectum, . 
 
 Peritoneal Hydatids in Fluid Removed by Tapping, . 
 
 Eruptions on the Intestinal Mucous Membrane, . 
 
 Therapeutic Action of the Salts of Cerium, . 
 
 Alleged Infecundity of Females born co-twin with Males, 
 
 PAOB 
 
 258 
 258 
 264 
 267 
 267 
 269 
 270 
 273 
 277 
 278 
 279 
 279 
 284 
 285 
 
 PAKT 11. 
 
 PHYSIOLOGY AND PATHOLOGY OF PREGNANCY. 
 
 Duration of Human Pregnancy, ...••• 
 
 Appearance of the Areola as a Sign of Pregnancy, . 
 
 Influence of the Death of the Foetus on its Retention or Expulsion, 
 
 Treatment of Hemorrhage in connection with Abortion, 
 
 Inhalation of Laudanum for the Vomiting of Pregnancy, 
 
 298 
 312 
 312 
 314 
 315 
 
 PART III. 
 
 NATURAL AND MORBID PARTURITION. 
 
 The Determining Cause of Parturition, 
 
 Sound heard during Detachment and Expulsion of the Placenta, 
 
 Mechanism of Natural Labor, 
 
 Laceration of Perineum and Cervix Uteri during Natural Labor, 
 
 Inefficiency of Uterine Action as a Cause of Tedious Labor, 
 
 " Pulvis ad Partum" of the First Edinburgh Pharmacopoeia, 
 
 Indian Hemp as an Oxytoxic, .... 
 
 Influence of Galvanism on the Action of the Uterus, 
 
 Sex of Child as a Cause of DifSoulty during Parturition, 
 
 Irregularities of Head Presentations, 
 
 Treatment of Face Presentations, 
 
 Dystocia from Displacement of the Arm, 
 
 Mode of Application of the Long Forceps, 
 
 The Air Tractor, ...... 
 
 316 
 316 
 317 
 329 
 331 
 ,334 
 335 
 336 
 352 
 404 
 428 
 434 
 437 
 442 
 
CONTENTS. 
 
 XXUl 
 
 Turning as a substitute for Craniotomy and the Long Forceps, 
 
 Remarks on the Operation of Craniotomy, 
 
 Eelative Statistics of Artificial Delivery, 
 
 Indication from the Foetal Pulse of Danger to the Child, 
 
 Transverse Presentations, ..... 
 
 Spontaneous Evolution or Expulsion of the Foetus, 
 
 Vaginal Hysterotomy in Obstruction from Carcinoma Uteri, 
 
 Danger of Rupture of the Uterus from Hydrocephalus, 
 
 Case of Malacosteon — Indications for Cesarean Section, 
 
 On the Separation of the Placenta before the Birth of the Child in Placenta Prasvia, 
 
 Summary of Principles of Treatment in Placental Presentations^ 
 
 Transfusion in Hemorrhage, ....... 
 
 Entrance of Air through Uterine Sinuses, ... 
 
 Sudden Death after Delivery, ....... 
 
 Inversion of the Uterus, . . .... 
 
 Albuminuria in Convulsions, ....... 
 
 Complication of Labor by Fibrous Tumors, .... 
 
 Induction of Premature Labor, ..... 
 
 Report of Edinburgh Royal Maternity Hospital, . ^ . . 
 
 449 
 552 
 554 
 557 
 557 
 572 
 574 
 579 
 581 
 599 
 710 
 719 
 719 
 722 
 722 
 725 
 735 
 738 
 745 
 
PART I. 
 
 SPECIAL PATHOLOGY 
 
 OF 
 
 THE UNIMPREGNATED FEMALE. 
 
 GENERAL REMARKS ON UTERINE DIAGNOSIS. 
 
 (From Edinburgh Monthly Journal of Medical Science, February 1851, p. 155.) 
 
 I SHALL begin these Lectures^ with the consideration of the diag- 
 nosis of the diseases of the uterus and its appendages; and it is 
 the more necessary in this respect, that, in studying these aifeetions, 
 you enter upon a field of practice in which the means of diagnosis 
 are peculiar in various respects, in consequence of the anatomical 
 and other peculiarities of the organs themselves, the diseases of 
 which it is our object to investigate. 
 
 But you must permit me to make one or two preliminary remarks. 
 And first of all, I would earnestly beg you to hold this important 
 fact in view — namely, that the diseases of the uterus do not essen- 
 tially differ, in their principles of pathology and treatment, from the 
 diseases of other individual organs of the body. The uterus is 
 liable, for example, to be the seat of congestion, inflammation, car- 
 cinoma, &c., like any other organ of the body which you can name. 
 It may be, and certainly is, more liable than other organs to some 
 morbid states and actions ; but what I wish to impress upon you is, 
 that its diseases are generically the same as the diseases of other 
 organs ; and the general principles of their treatment are also the 
 same, the special modifications of management which they require 
 not being greater than the special modifications that must be 
 attended to in applying any general principles of cure to any other 
 
 ' This lecture is the first of a series on Uterine Diagnosis, given annually by Dr. Simpson, 
 when treating of the Diseases of Women. It is the only one of the course which he has 
 published. — (Ed.) 
 
 VOL. I. 2 
 
18 ON THE DIAGNOSIS OF THE DISEASES OP 
 
 individual organ, or set of organs. You treat and cure, for exam- 
 ple, an attack of acute inflammation of the uterus, or a chronic 
 inflammatory ulcer of the cervix of the organ, as you would treat an 
 acute inflammation or a chronic inflammatory ulcer of the cornea, 
 or of the pharynx, or larynx, or of any other part of the body — 
 with this difference, that you can apply local antiphlogistic and other 
 curative measures much more readily and easily to the uterus than 
 to many other more internal organs. In fact, you may, if you deem it 
 necessary, apply lotions and dressings to an ulcer, for example, of 
 the cervix uteri, with as much certainty and precision as if you 
 applied them to an ulcer on the external surface of the hody ; you 
 can thus almosj; reduce the organ, in relation to treatment, to the 
 facilities presented in treatment by an external as compared with 
 an internal organ. 
 
 Modern pathology has made great advances in the management 
 of uterine diseases. These advances, however, have not, let me 
 repeat, consisted so much in finding out that the uterus is the seat 
 of any new, or any peculiar affections, as by finding out means and 
 methods by which we can detect and diagnosticate the affections 
 that are actually present in it. Here, as elsewhere, after being 
 enabled to discover what its diseases really are, the chief diflttculty 
 of the physician is removed ; for, as I have stated to you, the same 
 principles of treatment apply to the treatment of specific morbid 
 actions in the uterus as apply to the treatment of the same specific 
 morbid actions in other organs. Indeed, if you will attempt to 
 analyze what the great progress in the medicine of modern times 
 has actually consisted of, you will, I believe, find that it has con- 
 sisted, not so much in the detection of any new principles of thera- 
 peutic treatment, as in the detection of appropriate means for 
 enabling the practitioner to detect and discover in different indi- 
 vidual organs what the actual diseased actions are, in those organs 
 for which his aid may be required. The treatment, for instance, of 
 inflammation, ulceration, and most other morbid states, was per- 
 fectly well known and established hundreds of years ago ; but, to 
 take our example from the uterus itself, it was not till of late years 
 that we had certain means and measures of knowing when inflam- 
 mation and when ulceration, &c., &c., were present in this organ. 
 
 The study and practice of medicine has confessedly made, within 
 the last fifty years, enormous advances ; but these advances have 
 been advances in pathology and diagnosis, much more than ad- 
 vances in therapeutics. And yet, what we still wish and desiderate 
 in actual practice are still greater advances in our diagnostic means; 
 or, to state the same circumstances in other words, at the bedsides 
 of our patients we find that it is in diagnostic means, and not in thera- 
 
THE UTERUS AND INTERNAL FEMALE ORGANS. 19 
 
 peutie resources, that our existing knowledge is most frequently 
 deficient. 
 
 Every medical man is constantly meeting with difficulties in prac- 
 tice, and would often gladly avail himself of an opportunity of 
 resolving these difficulties by appealing to the judgment of some 
 older and more experienced practitioner. Ask the medical practi- 
 tioner what the nature of the difficulties is which he most frequently 
 encounters in practice. If he will properly analyze the subject, he 
 will confess to you that his difficulties most usually consist in ex- 
 actly determining what the special disease, or diseased action, in 
 his patient may be ; not in determining what he should employ for 
 its cure, provided he were once perfectly certain of its precise na- 
 ture, and precise seat and extent. The real difficulties of the prac- 
 titioner do not commonly consist of doubts about the nature and 
 details of the therapeutic measures which he ought to use ; but 
 they consist of primary doubts and uncertainties as to what the 
 diseased action is, against which he is to turn his diversified thera- 
 peutic resources. They are doubts, not about therapeutics, but 
 about diagnosis. 
 
 Since the diseases of the uterus and its appendages have of late 
 years attracted so much more the attention of the profession than 
 they formerly did, 9ne grievous error has been committed in their 
 study and investigation. It is an error which has been committed 
 often in the study and investigation of the diseases of other organs, 
 before we arrived at a sufficiently full and sufficiently comprehensive 
 view of the morbid affections of these organs. The error I allude 
 to is the error of exclusiveness. Formerly many practitioners 
 seemed to look upon all diseases of the uterus as diseases indicative 
 of debility ; and they treated almost every one of them with muriate 
 of iron and other chalybeate preparations; sometimes adding, 
 where there was any discharge, the local employment of astringent 
 or tonic injections. I fear that even yet you will find some old 
 practitioners treating their uterine cases upon this sole principle. 
 Then a second set of pathologists would, if we may judge from 
 their writings, seem to suppose that all diseases of the uterus are 
 marked by, if they do not consist of, congestion and engorgement 
 of blood ; and that they are to be remedied by the remedies appli- 
 cable to this state. A third set, again, look upon the general run 
 of uterine cases as almost invariably infiammatory in their nature, 
 and imagine that we are sure, or almost sure, to find in every case 
 inflammation, or some of its results ; as ulceration, purulent dis- 
 charges, &c. A fourth set would seem to fancy all uterine ailments 
 to be produced by some mechanical displacement or dislocation of 
 the uterus, and to consist of prolapsus, versions, and flexions of 
 
20 ON THE DIAGNOSIS OF THE DISEASES OF 
 
 this organ upon itself, and upon tlie neighboring parts. Again, 
 there are some practitioners — one, in particular, in immense prac- 
 tice in America — who would appear to believe that the affections of 
 the uterus are fundamentally nervous or neuralgic d.isorders, and 
 that they are always to be treated by the local inunction upon the 
 cervix uteri, of morphia, aconite, and similar sedatives. Another 
 section of pathologists imagine the so-called uterine diseases are, 
 after all, not uterine, but ovarian ; and that ovarian irritation and 
 inflammation is actually the source and origin of much of the suf- 
 fering that is imagined to be uterine in its seat. Lastly, for it is 
 needless to extend this tedious enumeration, you will find another 
 set enjoying the belief that these supposed uterine or ovarian dis- 
 eases are not at all uterine or ovarian in their, origin, but in reality 
 diseases of the general system ; they may not deny that local affec- 
 tions do occur in the uterus and ovaries, but these local affections 
 are, in their opinion, results and effects of some more general con- 
 stitutional disease of the nervous system, or of the economy at 
 large. 
 
 All of these views are correct in one respect,that they are all founded 
 partially, though only very partially, upon truth. For, no doubt, 
 the uterus is in practice seen to be liable to one and to all of these 
 morbid states. Thus it is liable to congestion, to inflammation and 
 its consequences, to displacement, to neuralgia, &c. ; and the ovary 
 is liable also to ovaritis, &c. But all these opinions are excessively 
 unsound and excessively wrong in another point of view, viz., from 
 their having been in practice pushed by those who have adopted 
 them, to such an extreme and exclusive length, as to amount in 
 some instances to a practical fallacy and a practical error of the 
 greatest possible magnitude. It shall be my earnest endeavor to 
 prove to you that in relation to the uterine, as in relation to other 
 organs, all such extreme and exclusive views are ever en-oneous 
 views. The diseases of the uterus are not always of one kind and 
 of one character ; they are of many different kinds and different 
 characters, and require in consequence many different modes of 
 treatment ; and we should place ourselves under the most foolish 
 and fatal fallacy, if we supposed that there was only one series of 
 morbid actions liable to go on in the uterus and its appendages, 
 and only one method of treatment applicable to all their diseased 
 states. 
 
 'No doubt all such en'ors in pathology and practice as I have just 
 now adverted to, will gradually die away, as medical men become 
 more intimately acquainted with uterine affections, with their 
 pathology and treatment, and above all, as they become more inti- 
 mate with the proper means of making a diagnosis of the affections 
 
THE UTERUS AND INTERNAL FEMALE ORGANS. 21 
 
 of the internal reproductive organs in the human female. Certainly 
 such errors will be best corrected in each of you, by each of you 
 studying earnestly and carefully the means of diagnosticating the 
 different morbid states and morbid actions to which these organs are 
 subject. And, as I have already mentioned, it is my main object at 
 present to point out to you by what different means the diagnosis of 
 uterine and ovarian diseases may be effected, and to state to you the 
 general principles of diagnosis which we can apply to their detec- 
 tion and discrimination. In doing so, I shall enter into no histori- 
 cal details ; the knowledge I wish to impart to you is that kind of 
 practical knowledge which we constantly require to use and apply 
 at the bedside, and which we must be able to employ in the daily 
 and hourly exercise of our profession. 
 
 In attempting to make a diagnosis of the diseases of the uterus 
 and its appendages, as in attempting to make a diagnosis of the 
 diseases of most internal organs, the physician calls in to his aid 
 two sets of symptoms, viz. : ftrst, the Rational, Dynamic, or Func- 
 tional Symptoms, as they have been termed ; and secondly, the 
 Physical or Anatomical Signs and Symptoms. Let us first note the 
 very marked and important difference which exists between these 
 two sets of diagnostic phenomena — since we thus may have the 
 
 SYMPTOMS OF UTERINE DISEASE, EITHER 1. DYNAMIC, OR 2. PHYSICAL. 
 
 Under the Dynamic, Rational, or Eunctional Symptoms are in- 
 cluded all those lesions, deviations, or derangements in the func- 
 tions of the affected organ, in the functions of other organs that 
 sympathize with it, and in the functions and state of the system 
 generally, that can possibly be excited by the disease or diseases 
 that we may happen to be investigating. 
 
 On the other hand, the Physical Signs or Symptoms consist of 
 those means of diagnosis, and particularly of those exercises of the 
 senses of touch, sight, hearing, &c., by which we can attain a know- 
 ledge of the anatomical structure, form, density, color, position, &c., 
 &c., of the organ which is diseased. By this latter set of symptoms 
 or signs — the Physical — we attempt, in fact, to read and discover 
 within the living body the actual morbid anatomy of the organ or 
 organs that are affected. We endeavor by them to study and to 
 ascertain, as exactly as possible, upon the living patient, those 
 anatomical lesions and changes which we should expect to detect on 
 the post-mortem examination of that patient, provided the disease 
 proved fatal. 
 
 In detecting and diagnosticating the diseases of the different 
 organs and parts of the body, the practical medical man has recourse 
 
22 ON THE DIAGNOSIS OP THE DISEASES OP 
 
 sometimes more to one of these sets of symptoms, sometimes more 
 to the other. A diagnosis always becomes more and more accurate 
 the more we can conjoin both means of investigation, and draw our 
 deductions from both sources of evidence. Of the two sets, the 
 rational or functional symptoms are the least to be depended upon ; 
 or, at all events, our diagnosis is always the less accurate, the less 
 we can take advantage of the physical or anatomical signs. 
 
 Surgical diagnosis is, as a whole, more accurate than medical diag- 
 nosis. But why is the surgeon more accurate in the discrimination 
 of the affections which he treats than the physician ? Merely be- 
 cause he can, and does, found his diagnostic deductions far more 
 upon physical symptoms ; while the physician is of necessity driven 
 to depend more upon the rational or dynamic symptoms. In fact, 
 in making a diagnosis of the diseases submitted to his care, viz. : 
 those placed upon the external surface of the body, the surgeon 
 relies almost entirely upon physical diagnosis alone, because he can 
 handle and examine the diseased parts by direct tactile examina- 
 tion, and by direct visual inspection. Deprive a surgeon of these 
 means of physical diagnosis, and throw him back merely upon the 
 functional or dynamic symptoms that may be present, without 
 allowing him to exercise his sense of touch, or sight, or hearing, in 
 the discrimination of the cases submitted to him, and you will find 
 him as much or more at fault than the physician sometimes is. 
 Take, for example, a case of any disease of the eye, leading on to 
 imperfection and dimness of sight. No surgeon would venture to 
 make a decided diagnosis of what that dimness or blindness was 
 produced by, provided he were allowed to appeal to the dynamic or 
 functional symptoms only. He might be told fully as to the mode 
 and manner in which the blindness came on, as to its varieties 
 under different circumstances, as to its being accompanied or not 
 with pain or lachrymation, &c., &c. ; but these and other circum- 
 stances would often be inadequate to enable him to decide whether 
 the imperfection of vision arose from an affection of the cornea, or 
 of the iris, or of the lens, or of the retina, or of some other parts ; 
 or by what particular affection of these parts it was produced ; 
 while an inspection of the diseased eye itself by the surgeon — ^that 
 is to say, a glance at the physical symptoms or physical diagnosis — 
 would probably enable him to resolve at once all these difiJculties, 
 and to ascertain determinately and unequivocally what the diseased 
 state of the organ really was. 
 
 I| is very different with the physician, in reference at least to 
 some classes of affections. For in some he cannot avail himself of 
 any of these measures of physical diagnosis which the surgeon finds 
 to be so absolutely necessary to enable him to come to a correct de- 
 
THE UTBEUS AND INTERNAL FEMALE ORGANS. 23 
 
 cision in surgical cases. In affections for example, of the brain and 
 spinal cord, and of their membranes and component parts, the 
 physician can, with a few rare exceptions, make use only, in his 
 diagnosis, of the dynamic or functional symptoms. It is only these 
 symptoms that he can reach in this class of diseases. For we 
 have no means as yet, and, in all probability, will never have any, 
 in this special class of affections, of ascertaining, in the yet living 
 subject, what the special anatomical lesions are, that maybe present 
 in the encephalon or in the spinal canal. We cannot reach and 
 search these cavities and their contents by any modification of 
 hearing, or touch, or sight. We can ascertain the morbid derange- 
 ments that may take place in them only by studying the changes 
 and derangement of function to which their presence gives rise in 
 the nervous system generally, in the different parts of this system, 
 and in the functions of those organs which are liable to be more 
 directly or indirectly influenced by that system. 
 
 In other classes of disease, the physician, however, has fortunately 
 the power of appealing to physical signs as well as to rational symp- 
 toms. He can derive his deductions of the diseased states of the 
 organs themselves from both classes of proof; and you will always find 
 that in medicine our practical knowledge of these diseases has pro- 
 gressed proportionally with the amount and extent to which physical 
 diagnosis has been applied in their discrimination. There is no set 
 of organs, for example, the pathology and practical knowledge of 
 which has advanced more in modern times than that of the organs 
 contained within the chest. If you look into any work on the affec- 
 tions of the heart or lungs, written thirty or forty years ago, you 
 will find a strange contrast between its contents and those of any 
 modern work written on the same subject. Formerly, physicians 
 were often in error in regard to their cases, as to what this or that 
 thoracic affection might be; and their true nature was often only 
 accurately detected after death. The modern physician has almost 
 always the power of discovering what the affections of the heart 
 and lungs are, even during the life of the patient ; and can trace, 
 usually with great accuracy, their morbid anatomy while the patient 
 is still alive. Mark what this difference between thoracic medicine, 
 thirty or forty years ago, and that department of medicine now is 
 to be attributed to. It is entirely attributable to the fact, that while 
 in former times physicians were obliged and necessitated to attempt 
 the diagnosis of these diseases by functional symptoms only, they 
 have now the power of aiding and correcting that method of diag- 
 nosis by ascertaining a series of physical signs appertaining to 
 almost every disease of the heart and lungs, through the instrumen- 
 tality of auscultation and percussion. E"o careful or judicious 
 
24 ON THE DIAGNOSIS OF THE DISEASES OF 
 
 physician depends now for the diagnosis of these chest affections 
 upon functional symptoms only ; but he appeals constantly, in aid 
 of his diagnosis, to the more certain signs which may be derived 
 from the pleximeter and the stethoscope. 
 
 I might safely repeat the same remark, and with nearly exactly 
 the same degree of truth, with regard to the affections of the uterus 
 and internal female organs. Formerly, and even in our own days 
 still far too frequently, the physician has been led to suppose that 
 he could make a diagnosis of diseases of the uterus by depending 
 and relying upon functional symptoms only. A little practice will, 
 however, I believe, readily convince you, that in most cases we are 
 necessitated to have recourse to a physical diagnosis in order to ob- 
 tain anything like an accurate knowledge of the diseases under 
 which our patients are laboring. Do not suppose that, in making 
 this remark, I mean to imply that the functional symptoms are of 
 no value. Nothing could be farther from my belief and convic- 
 tion. I by no means wish to state that they are of no value ; all I 
 mean to state is, that they are not of sufficient value to make a 
 sufficient distinction between the different individual or special dis- 
 eases of the uterus and uterine appendages. 
 
 And now having made these too diffuse introductory remarks, let 
 me call your attention to what the functional and what the physical 
 symptoms of the diseases of the uterus and ovaries really consist of. 
 And first, let us consider 
 
 THE RATIONAL OR DYNAMIC SYMPTOMS OF UTERINE DISEASE. 
 
 The uterus performs at different times different functions. During 
 menstruation its lining membrane forms and exudes the so-called 
 menstrual fluid. In the intervals between menstruation we have 
 merely a mucous secretion flowing from the same tissue. And 
 again, it performs from time to time a variety of important func- 
 tions connected with conception and pregnancy. Under different 
 states of disease, one or more or all of these functions may become 
 perverted. In other words, the first division of dynamical symp- 
 toms liable to occur in uterine disease consists of — 
 
 I. Derangements in the Functions and vital Condition of 
 THE Uterus itself. — Thus the function of menstruation may become 
 irregular in regard to the time of its occurrence, or the duration of 
 its appearance ; — or the quantity of the menstrual fluid which is 
 thrown off; — or the nature of that fluid may vary ; and it may or 
 it may not be accompanied by pain and suffering ; — and pain, if 
 present, may be constant, or it may be spasmodic or paroxysmal. 
 The mucous secretion may be increased or diminished in its quan- 
 
THE UTERUS AND INTERNAL FEMALE ORGANS. 25 
 
 tity or quality, or it may become occasionally or constantly mixed 
 with blood or pus. The function of conception may be interfered 
 with, so that sterility is the result ; or the uterus may not have the 
 power of carrying the foetus beyond the second, fourth, or sixth 
 month, the patient being subjected to a series of abortions or pre- 
 mature labors. 
 
 The natural states of sensation of the uterus and its appendages 
 may also be altered and perverted. They may be decreased, but this 
 is rare. Far more frequently they are increased to a degree amount- 
 ing to actual pain ; and the pain may appear under very different , 
 modifications. It may be continuous or intermittent; it may be 
 dull and aching, or pulsative, or lancinating, and extremely severe. 
 Often when it is present, it is accompanied with a feeling of heat 
 and tension ; and far more frequently still, with a feeling of weight 
 and bearing down. Almost all these pains, resulting from diseases 
 of the uterus, or its appendages, are diminished by the reclining po- 
 sition, and increased by two circumstances, — by along continuance 
 in the erect posture, and by the active and congested state of the 
 organs, which accompanies the secretion and elimination of the 
 catamenial discharge. Most of the so-called local pains of the 
 uterus are not situated in the position of the uterus itself, or at least 
 in the central part of the pelvis ; but the patient more frequently 
 complains of them as located in one or other of the sides of the 
 pelvis ; most generally in the left side, in consequence, no doubt, of 
 the left side of the uterus and left broad ligament and ovary being 
 more liable to be irritated than the right, by the varying condition 
 of the rectum, which enters the pelvis towards the left ; and the dis- 
 tensions and accumulations in this portion of the intestinal canal 
 are certainly often the more immediate exciting causes of uterine 
 and pelvic pains, if the uterus and its appendages are tender and 
 predisposed to suffer pain, in consequence of any diseased condition 
 existing in them. 
 
 At present it would be out of place for me to dwell upon the ir- 
 regularities and deviations which we meet with in practice, in these 
 functional symptoms of the uterus in uterine diseases generally, and 
 in different cases of the same disease. But let me make this on e remark 
 as a caution to you, I shall insist upon it more afterwards, viz., that 
 identically the same pathological affection does not always affect 
 identically in the same way the functions of the uterus. You may 
 have, for instance, fibrous tumors in the walls of the uterus, one of 
 the most frequent organic diseases in this organ, producing, as local 
 functional symptoms, increased menstruation, or menorrhagia; — 
 increased mucous secretion, or leucorrhoea ; — pain during menstru- 
 ation, or dysmenorrhoea ; and, in the intervals between the men- 
 
26 ON THE DIAGNOSIS OF THE DISEASES OF 
 
 struations, constant uterine pains and bearing down, and irritation 
 of the bladder and surrounding parts. But in other cases of exactly 
 the same organic disease, more or fewer, or indeed all of these 
 symptoms, may be entirely wanting. 
 
 Anatomists tell us that the cerebro-spinal nerves which come to 
 the uterus are principally distributed to the cervix uteri;— and 
 hence it has been considered by some pathologists, that the diseases 
 of this part of the organ ought to be accompanied with pain, although 
 the maladies of the body and fundus of the organ may not necessa- 
 rily give rise to this sypiptom. But the results of practice by no 
 means bear out this theory. The two most common affections of the 
 cervix uteri are, — 1. Chronic inflammation and its consequences 
 — ^hypertrophy, ulceration, &c. ; and, 2. Carcinoma of this part. 
 In practice, cases of both of these diseases from time to time occur, 
 in which, though the disease has progressed far, yet the patient has 
 not been made aware of its presence by any increased tenderness 
 or pain in the part, sufficient, at least, to attract her attention ; and 
 it is frequently very difficult to persuade the patient — nay, sometimes 
 difficult to persuade the medical attendant — ^that such serious affec- 
 tions are present, because they incorrectly believe and argue that 
 such affections could not exist without the accompaniments of local 
 pain and suffering. 
 
 n. Dynamic Symptoms in other neighbobing Pelvic Organs. — 
 Dynamic symptoms often exist, in connection with uterine disease, 
 not in the uterus or its appendages, but in the parts and organs in 
 their more immediate vicinity. There may be pains, for example, 
 about the bladder or rectum ; about the coccyx or sacrum ; in the 
 groins ; or along the crest of the ilium, and, what is exceedingly 
 frequent, down the limbs, along the course of the cruj^al or sciatic 
 nerves. Pains running from the lower lumbar region, or from the 
 groins, down along the limbs, are felt, and often felt severely, by 
 females even during common menstruation ; and intermittent pains 
 in the lower part of the abdomen, or uterine colics, as they have 
 been termed, are common under the same circumstances, as well as 
 in different varieties of morbid uterine irritation. The functions of 
 the rectum or bladder may be interfered with. Defecation may be 
 difficult or painful. Often in uterine diseases there is constipation ; 
 and sometimes a want of power to expel the feculent matter, as if 
 there was a kind of paralysis of the rectum ; this last occurs not un- 
 frequently in cases of retroversion of the unimpregnated uterus. In 
 many cases the functions of the bladder are more or less affected. 
 Micturition may be too frequent— a symptom that is common to 
 many uterine diseases; or there maybe great dysuria, as is often 
 seen in cases of pelvic cellulitis, &c. ; or there may be complete re- 
 
THE TJTBRtJS AND INTERNAL FEMALE ORGANS. 27 
 
 tention, as from the pressure of uterine tumors ; or the result may 
 be incontinence and impossibility of retaining the urine. 
 
 These various pelvic symptoms are, in some instances, mechanical 
 in their pathology ; in other instances they are sympathetic results. 
 In other words, they are occasionally the direct result of the physical 
 pressure of the enlarged or displaced uterus upon the rectum, or 
 bladder, or trunks of the affected nerves. But, again, they may be 
 present, and equally strongly marked, although the uterus is not 
 unnatural in size, or unnatural in position ; and, consequently, when 
 the origin of these symptoms cannot be mechanical. In these last 
 instances, and perhaps they are the more numerous class, we speak 
 of the resulting disturbances of function and increased sensations, as 
 sympathetic or reflex — ^that is, as originating in an irritation pri- 
 marily seated in the uterus and uterine nerves, but terminating and 
 felt, secondarily, in the sensitive nerves of those other neighboring 
 parts which are affected. 
 
 This last remark leads me next to show you, that, in diseases of 
 the uterus and its appendages, we have often the principal pains 
 and sufferings of the patient not located in the uterus or in the 
 pelvis itself, but located in other parts of the body ; or we have a 
 third series of dynamic symptoms, consisting of 
 
 m. Sympathetic Pains in difebrent and distant parts of the 
 Body. — This'important class of reflex sympathetic pains or neuralgias 
 is often so marked and severe as to draw away the attention of the 
 patient, and even of the practitioner, from the real nature and seat 
 of the original and primary malady. 
 
 Of late years, much important physiological and pathological 
 information has been laid before the profession regarding what are 
 termed reflex*motions. You are all well acquainted with the nature 
 and mechanism of the motions that are designated by that term. 
 Tou all know that they are muscular movements created by excitation 
 upon distant mucous and cutaneous surfaces, the impression made 
 upon these surfaces being conveyed by a nervous arc, which arc 
 always passes through the spinal cord, to those muscles that are ulti- 
 mately set into contraction by it. The surface or part primarily 
 irritated and excited is often, in this way, far removed from the 
 muscles or sets of muscles secondarily called into action. I believe 
 that often morbid sensations originate in the same way ; and that 
 you can speak as truly of reflex sensations as of reflex motions. 
 In your surgical studies you have all studied one form of reflex 
 sensations, viz., the severe morbid pain in the knee-joint, which is 
 so frequently found to accompany the early stage of morbus eoxa- 
 rius. It is impossible to explain, upon any mechanical principle, 
 
28 ON THE DIAGNOSIS OP THE DISEASES OF 
 
 why a patient, laboring under disease of the hip-joint, should have 
 the principal pain in the knee-joint. It is not explicable by re- 
 ference to any amount of swelling in or around the diseased hip- 
 joint, compressing the trunks of those nerves that supply the knee. 
 In fact, the sympathetic or reflex pain in the knee occurs most 
 generally in the very commencement of the disease, when the lining 
 membrane merely of the hip-joint is as yet affected, and when there 
 is as yet little or no swelling or effusion. An impression, or excita- 
 tion, is conveyed from this affected membrane by the nerves which 
 are distributed to it, and this impression is probably conveyed by 
 them upwards, as high as the spinal cord ; and then another im- 
 pression would seem to be reflected or conveyed downwards from 
 the cord along another set of nerves, viz., along those the branches 
 of which are ultimately distributed to the knee-joint, the immediate 
 seat of the so-called sympathetic pain. Or, perhaps, we may state 
 the matter more correctly, if we say, that the trunk of the nerve 
 going to the knee, has a morbid sensitive impression made upon it 
 somewhere during its course, as it passes through one of its higher 
 plexuses, or at its origin in the cord itself, producing a change in it, 
 as if its own branches in the knee were painfully affected. Irrita- 
 tion of the mucous membrane of the bladder, to take another 
 example, often gives rise to sympathetic or reflex pains in the orifice 
 of the urethra, and along the course of the lower extremities. I 
 have seen several cases where the small, red, granular, and very 
 painful sensitive tumor which sometimes grows at the orifice of the 
 female urethra, was accompanied with, distressing pain in the heel 
 and sole of the foot. But it is needless to go to other organs in 
 search of such examples ; the uterus itself affords us many marked 
 instances, even when it is not diseased. 'Thus, when the uterus is 
 distended and irritated in pregnancy, the patient oftfen complains 
 of reflex or sympathetic pains in the lumbar region, in the mammae, 
 in the nerves of the teeth, &c. When the uterus is the seat of 
 actual disease, such reflex pains are, as I have just now stated, often 
 very marked ; and, at the same time, they are very apt to deceive 
 and mask the original and primary disease. Some years ago, I saw 
 a case, with Dr. Johnston of Berwick, which made a strong impres- 
 sion upon my mind, in relation to this question. The lady had 
 been under the care of an eminent London accoucheur, and com- 
 plained to him principally of pain in the mammae, for which he had 
 ordered, at different times, leeches, and a sufficiently varied course 
 of sedative local applications, and numerous internal remedies. But 
 he had not once examined into the condition of the uterus, which 
 was the source of the sympathetic pain in the mammse. She was 
 suffering, in fact, not from any diseased state of the mamma, the 
 
THE XJTBRUS AND INTERNAL FEMALE ORGANS. 29 
 
 organ whicli the physician was so assiduously treating, hut she was 
 suffering under a slow corroding carcinoma of the cervix uteri. 
 At the time I saw her, the disease had already destroyed almost the 
 whole tissue of the cervix, leaving the remainder of its excavated 
 walls hard, rough, and indurated like the interior of a dice-hox. 
 The dependence of the reflex or sympathetic pains seen in uterine 
 cases upon the uterine irritation itself, as their primary source, is 
 best seen in cases of displacement. By , restoring a displaced 
 uterus to its natural position, even though only temporarily, you 
 generally at once moderate or entirely remove the attendant sym- 
 pathetic effects. We cannot have the same precise proof in other 
 uterine diseases, as ulcer, cancer, &c., because we cannot make the 
 experiment of at once removing the primaiy irritation. 
 
 The reflex or sympathetic pains under which patients suffer- 
 ing from uterine diseases are liable to complain, may be situated 
 in very different parts of the body. I shall enumerate the prin- 
 cipal of them, and that, as far as possible, in the order of their 
 frequency. 
 
 Pain in one or both mammce, such as occurred in the case I 
 have just now alluded to, is very common in many forms of 
 uterine irritation or disease ; but is seldom so very severe as it 
 was in that instance. It is often accompanied by some degree 
 of swelling or tension in the gland ; and occasionally the areola 
 becomes somewhat dai'ker and changed, as in pregnancy. These 
 mammary symptoms are particularly liable to be increased at the 
 period of menstruation. If a patient complains to you of pain 
 in this part of the body, without your being able to trace any 
 local affection of the mamma itself capable of creating it, always 
 make the necessary inquiries and investigations, in order to know 
 whether some congestive, or inflammatory, or other diseased action, 
 is not going on in the uterus. 
 
 JPain under the left mamma and upon the edges of the ribs on that 
 side, is also very frequent, perhaps even more so than pain in the 
 mamma itself. It has sometimes appeared to me to be more com- 
 mon, in cases of uterine or ovarian disease, occurring in the unmar- 
 ried than in the married. It is probably as frequent in cases of 
 uterine affections, as pain in the shoulder is in cases of hepatic 
 affections. This pain under the left mamma is sometimes diffused 
 along the side ; but more usually it is limited, and the patient will 
 tell you that she thinks she could cover the whole of the pained 
 spot with a crown piece. When it is not severe, it is not affected 
 by the act of respiration ; but in more severe cases, it is increased 
 by deep inspiration ; and many a poor patient has been bled and 
 leeched, &c., over and over again, under the idea that this pain was 
 
30 ON THE DIASNOSIS OF THE DISEASES OF 
 
 an indication of pleuritic inflammation, when in fact, it had nothmg 
 to do with pleurisy, or any disease of the chest ; but was merely a 
 sympathetic or reflex pain, and one entirely resulting from uterine 
 irritation. 
 
 Pains in the right side, or right hypochondriac region, are much 
 more rare, but are still sometimes also to be met with. 
 
 Pain in some of the vertebrce of the back, imitating spinal irritar 
 tion, is often also an accompaniment of uterine irritation, and is 
 not unfrequently combined with the existence of the pain under 
 the left mamma. The patient principally complains of it when the 
 part is pressed. Many a patient suffering from these sympathetic 
 vertebral pains, in consequence of uterine derangement or disease, 
 has been laid up and counter-irritated with the cautery, moxa, &c., 
 under the idea that there was actual spinal disease present. 
 
 Pain in the lumbar region, or in the sacral and lumbar region com- 
 bined, is especially common, as a sympathetic morbid sensation in 
 uterine diseases, but particularly in those which consist of any dis- 
 placement or enlargement of the organ. The great sacro-lumbar 
 pain which the woman in labor suffers in the same part, is itself 
 entirely a reflex or sympathetic pain of the character that we are 
 speaking of. 
 
 Pains in the abdominal parietes also occasionally occur. Some- 
 times they are limited to one or other side, occupying the site of 
 the ascending or of the descending colon. Occasionally they are 
 confined to a limited spot. But in other instances we find the 
 whole surface of the abdominal walls tender and neuralgic. And 
 when this is the case, there is often coexisting a greater or .less de- 
 gree also of tympanitis — a kind of combination which is very apt to 
 deceive the young practitioner into the idea, that the disease of his 
 patient is really more formidable than it actually is. For the com- 
 bination may lead him to suppose, that he has to do with a case of 
 acute peritonitis, or, if it is of longer standing, with a case of 
 serious enlargement and organic disease of the uterus, or ovary, or 
 some abdominal organ. In some cases, the apparent tenderness is 
 so great that the patient timidly shrinks under the least touch, and 
 is even terrified at the approach and pressure of the hand of the 
 practitioner. 
 
 Pains in the extremities and joints are sometimes secondary mor- 
 bid results when the primary morbid irritation or disease is seated 
 in the uterus. I have already stated to you that pain, stretching 
 from the loins or pelvis downwards, along one or both of the lower 
 extremities, is a very common symptom indeed in uterine diseases. 
 In ovarian enlargement there is sometimes, particularly in the ear- 
 lier stages of the disease, a morbid sensation of numbness and 
 
THE UTERUS AND INTERNAL FEMALE ORGANS. 31 
 
 prickling in the corresponding limb ; but this effect is probably 
 mechanical, the consequence, that is to say, of pressure upon the 
 nerves of the limb, and not true reflex or sympathetic results. I 
 had occasion also to mention the occasional excitation of reflex 
 morbid pain in the heel and foot, by the small sensitive vascular 
 tumor that occasionally grovps in and around the orifice of the female 
 urethra. Other forms of irritation in the urinary canals may excite 
 morbid pains in the same distant part ; and I have met -with them 
 also, but more rarely, in uterine cases, in which I could not trace 
 any primary pathological disease in the kidneys, bladder, or urethra. 
 Under the name of hysterical knee-joint, surgical authors describe 
 a painful affection of that joint, occasionally accompanied by swell- 
 ing and apparent effusion, and which has often been mistaken for 
 the common white swelling, or scrofulous disease, of the same part 
 of the body. The pain and other symptoms are so chronic and so 
 marked, as sometimes to have led the surgeon to amputate the limb 
 for supposed incurable disease of the joint. I feel well assured 
 that in these cases the pain in the knee is almost always, or indeed, 
 always, a secondary or reflex pain, and that the primary source of 
 irritation will be found in some other distant organ, and very often, 
 indeed, in the uterus or ovary. Similar pains in the other joints of 
 the extremities seem rarer ; but are not altogether unknown. At 
 present I have a patient suffering under chronic inflammatory ulcera- 
 tion of the cervix uteri, and profuse purulent discharge from that 
 part, with much pain and tenderness in the canal of the vagina. 
 But she is suffering still more from severe pain and tenderness of 
 the skin and tissues lying over the head of the right radius. This 
 pain in the arm has sometimes been so excessive as to deprive her 
 of rest, and she herself maintains that it decreases and increases in 
 correspondence with the changing state of the uterine irritation 
 and discharge. 
 
 Pains in the face and head may also occur. I have already stated 
 to you, that toothache, as a sympathetic pain, occurs occasionally 
 in patients in the state of pregnancy. I have not had occasion to 
 trace it distinctly, as a mere reflex and sympathetic pain excited by 
 disease of the uterus. Local and limited pains, as over one or 
 other eyebrow, in the forehead, in the occiput, in the temple (clavus 
 hystericus), &c., have appeared to me sometimes to be the secondary 
 consequences of uterine irritation. The headaches, however, under 
 which uterine patients so often suffer, are not generally direct 
 secondary sympathetic effects of uterine aflection. The cephalalgia in 
 these cases is almost always a kind of indirect result either of the 
 ansemia, or of the deranged digestion and assimilation, which so 
 often come to attend upon chronic uterine affections. For uterine 
 
32 ON THE DIAGNOSIS OP THE DISEASES OF 
 
 diseases frequently produce other deviations in the functions of the 
 body, than mere painful sensations. They often derange the func- 
 tions performed by different organs. Let me state to you_ what 
 phenomena, as rational or dynamic symptoms of uterine disease, 
 we find most frequently referable to such, 
 
 IV. Derangements oe Functions in distant Oegans.— "We have 
 already considered the urinary bladder as liable to be irritated and 
 deranged in its function in uterine disease— sometimes mechanically, 
 but very frequently sympathetically. Let me merely add on this 
 point, that occasionally the urinary secretion is altered and very 
 various in' its character. The irritation of pregnancy is well known 
 to produce changes in the urinary secretion, which have been 
 considered as quite characteristic of pregnancy ; sometimes the 
 morbid secretion of albuminous urine occurs ; and one or two 
 rare cases have been recorded, in which women have suffered from 
 diabetes when pregnant, and have recovered their usual health com- 
 pletely after delivery. It may yet be found that uterine diseases 
 are also liable occasionally to derange and alter the urinary secre- 
 tion itself; but the subject, as a source of any rational symptoms 
 of uterine disease, has hitherto attracted no degree of attention. 
 Uterine patients, when questioned on the matter, tell you generally, 
 in relation to it, that the urinary secretion is most variable, and 
 especially that it alters, from time to time, from being very profuse 
 and watery, to being small in quantity and loaded with sediment. 
 This sediment is usually composed of the urates ; but I have seen 
 the triple phosphate, oxalates, and other morbid ingredients in the 
 urine, in uterine cases. I am not acquainted, however, with a suffi- 
 cient number of facts to be able to state to you whether these occur- 
 rences are mere coincidences, or whether, in any case, the derange- 
 ment 4n the urinary secretion, and the derangement in the morbid 
 state of the uterus, stand in relation to each other in any respect 
 as cause and effect. 
 
 The intestinal canal is an organ more frequently deranged in its 
 functions in uterine disease than perhaps any other organ of the 
 body. Usually the functions of it are performed sluggishly and 
 inertly. Constipation is very often present ; and the lower portions 
 of the canal especially appear to have lost their healthy tone and 
 power. At the second or third month of pregnancy the abdomen 
 of the human female is often larger than it is when the uterus is 
 actually still more enlarged at the fourth or fifth month. This early 
 enlargement is the result of the derangement of the functions of the 
 bowels, and more particularly of the accumulation of gases within 
 them. In the same way a partial tympanitis often accompanies 
 other morbid irritations of the uterus, as well as the irritation of it 
 
THE UTERUS AND INTERNAL FEMALE ORGANS. 33 
 
 from pregnancy. Pregnancy is, as you are all aware, not nnfre- 
 quently accompanied with dyspepsia in the form of gastrodynia, 
 pyrosis, and other morbid symptoms ; and nausea and vomiting are 
 very common sympathetic phenomena in the pregnant state. All 
 these symptoms occur also in connection with diseases of the 
 uterus ; though more rarely than with pregnancy. 
 
 Further, in uterine disease we find another abdominal organ not 
 unfrequently sympathetically affected — I mean the liver. In very 
 many women the biliary secretion becomes disordered at the return 
 of each menstruation — in some a state of constipation, in others a 
 state of diarrhoea, recurring during each menstrual period. The 
 biliary and catamenial secretions seem almost vicarious of each 
 other ; and, as in other cases in which such physiological relations 
 exist, the two functions are not unfrequently simultaneously de- 
 ranged in their pathological actions also — ^both being occasionally 
 increased or decreased together; or, what oftener happens, one 
 being increased in extent and activity when the other is diminished. 
 In some cases the cure of a uterine disease seems also to rectify the 
 coexistent, and perhaps resultant, hepatic derangement ; while, no 
 doubt, also, in other cases we find ourselves altogether unable to 
 amend and arrest uterine diseases and discharges, till we have, 
 in the first instance, used appropriate means to modify and correct 
 the attendant hepatic disorder. 
 
 The organs within the chest are more rarely afiected. Often, in- 
 deed, there is palpitation present, but it is principally in cases where 
 there has been a loss of blood from uterine disease, or a constant 
 and profuse leucorrhoeal discharge, weakening and debilitating the 
 patient ; or when a deranged state of the digestive functions has 
 led on to the same result. Besides in prolonged uterine disease, 
 we very often find the mobility of the nervous system greatly in- 
 creased ; and palpitation in all such patients occurs readily under 
 any excitement, and sometimes forms a sufiiciently distressing, and, 
 in their own opinion, an alarming symptom. 
 
 At first thought, one would scarcely expect to find the respiratory 
 function ever affected sympathetically in uterine disease. I have, 
 however, seen a sufficient number of cases, fully to convince me 
 that there is in reality a true kind of asthma uterinum, as mentioned 
 by the older nosologists. I saw, for example, within the last few 
 days, a lady whose history is briefly this : — She never menstruated 
 till she was twenty-eight years of age, but every month, or at the 
 period of the menstrual molimen, there was, instead of menstruation, 
 a distinct attack of asthma, lasting generally for two or three days, 
 and sadly shattering and breaking down her constitution. Her 
 state greatly alarmed her brother, who was himself a medical man. 
 
34 ON THE DIAGNOSIS OF THE DISEASES OF 
 
 I attempted, during several successive months, to induce menstrua- 
 tion, by applying at the expected periods, nitrate of silver freely to 
 the interior of the uterus, by the usual instrument adapted to that 
 purpose. Some sanguineous discharge was the result, with marked 
 and evident alleviation of the asthmatic symptoms. At last, I intro- 
 duced a small galvanic pessary into the interior of the uterine cavity, 
 and left it there for several months. After wearing it for a time, 
 the patient menstruated regularly, the asthma entirely disappeared, 
 her health and strength became restored, and, for the first time for 
 many long years, she was able again to join in general society. 
 Menstruation continued regular for some months after the instru- 
 ment was removed, and the asthma was kept in perfect abeyance ; 
 but, on the recurrence of cold weather, she again failed to men- 
 struate, and, instead of it, had one of her old attacks of asthma. 
 At her own earnest suggestion and solicitation, I have, in conse- 
 quence, again replaced the pessary, to which she herself correctly 
 attributes the new life, as she describes it, which she has of late 
 years gained. Perhaps such a result may appear not so paradoxical 
 as at first sight it might look, when we remember that several Ger- 
 man physiologists have insisted that menstruation is a kind of vica^ 
 rious respiration, intended to rid the female system of a cumulative 
 amount of carbon. And you know that Andral and Gavarret have 
 proved experimentally, a few years ago, that in the human female 
 there is a kind of direct relation and interchange between the amount 
 of carbon discharged in expiration, and the amount of menstruation 
 present ; more carbon being always exhaled from the lungs when 
 the patient is suffering under amenorrhcea, or when menstruation 
 is arrested by pregnancy, than when she is not pregnant, and when 
 she is menstruating regularly.' 
 
 The nervous system, as I have just now had occasion to state to 
 you, becomes weakened or mobile and supersensitive in most pa- 
 tients suffering under any protracted, and especially under any 
 weakening form of uterine disease. There is languor, and at the 
 same time excitability of mind observable to a distressing degree in 
 many such patients. There is not the usual capacity for mental 
 exertion. ITot a few are morbidly despondent of themselves and of 
 their state. "We see, sometimes, sad evidence of the effects of 
 uterine irritation upon the mind and nervous system, in the produc- 
 tion of puerperal insanity. In all large asylums you will find cases 
 
 ' Dr. Simpson, on the 17th of January, 18515, further directed the attention of the Obstetric 
 Society of Edinburgh to the periodical attacks of asthma occurring in eases of amenorrhcea 
 He reported several instances which he had observed since writing the above, and reiterated 
 his conviction, that were the subject properly investigated, the importance of the connection 
 would become evident. — (Ed.) 
 
THE UTERUS AND INTERNAL FEMALE ORGANS. 35 
 
 of insanity combined with, if not resulting from, uterine irritation 
 and disease ; and in such institutions the paroxysms of mental ex- 
 citement are very often seen to be regulated by the monthly recur- 
 ring irritation in the uterus which exists during the days of men- 
 struation. Occasionally, in cases of uterine disease, there are lesions 
 of the senses, more particularly of the sense of sight — sometimes 
 , the vision being impaired, and motes floating before the eyes. The 
 whole muscular system, under such a condition, sometimes becomes 
 debilitated and reduced in tone, the patient being unable to take 
 anything like her usual amount of exercise. You have the same 
 class of patients, in whom the nervous system is thus weakened 
 and exhausted, occasionally complaining of prickling and numbness 
 of the extremities, as if these parts were losing their power of motion 
 and sensation. And local paralyses seem sometimes, though very 
 rarely, to occur from the irritation of uterine disease, in the same way 
 as they are seen to occur from the irritation of pregnancy. The power 
 of standing and walking is sometimes weakened and abrogated from 
 another cause in uterine ailments, viz., from the uterus being so 
 much enlarged or displaced, as to produce compression upon the 
 nerves, &c., in the interior of the pelvis. I have seen several cases 
 where this power was restored to the lower extremities, by restoring 
 to its position a uterus that was retroverted. 
 
 In pregnancy, the autaneous surface is sometimes affected sympa- 
 thetically, ephelis and other eruptions appearing upon it. In uterine 
 disease the skin is often dry and parched, and in an unhealthy state ; 
 and the cutaneous surface of the hands and feet is particularly liable 
 to be easily chilled, perhaps from imperfect capillary circulation, or 
 from imperfect innervation. I have under my care at present, in 
 private practice, two cases of amenorrhoea in both of which the face 
 is thickly covered with acne rosacea. In one of these the cutaneous 
 eruption has become more than once greatly diminished when the 
 menstrual discharge was restored, by the application of nitrate of 
 silver and dry cupping to the interior of the uterus — so much dimi- 
 nished, as to impress my mind with the belief, that the eruption 
 itself was a derangement in some way or other the direct or indirect 
 result of the uterine disorder. Some women have, at each men- 
 strual period, a slight erythematic appearance upon the skin of the 
 face. 
 
 Some time ago I showed Dr. Christison an interesting case, in 
 which there was amenorrhoea coexisting with such a profuse degree 
 of chronic salivation and ulceration of the lips and gums, as at first to 
 have impressed me, as it had impressed other practitioners, with the 
 idea, that she was suffering under the effects of mercurial salivation. 
 My inquiries, however, regarding her, quite satisfied me that she 
 could not possibly have been taking any mercury. In what relation 
 
36 ON THE DIAGNOSIS OF THB DISEASES OP 
 
 the amenorriiCEa and salivation stood to each other, in this case, 
 as in other cases, I cannot venture to determine. But you all 
 know that in some women salivation is a very common dynamical 
 symptom in pregnancy. The pregnant patient sometimes loses, in 
 this way, large quantities of saliva daily, up to the very period of 
 delivery. 
 
 The thyroid gland, in occasional and rare cases, enlarges in preg-, 
 nancy. I have seen it enlarged also in uterine cases ; but in this, 
 as in others of these complications that I have named, we yet cer- 
 tainly want sufficient evidence to determine the actual relation be- 
 tween these functional derangements and the coexisting uterine 
 disease and irritation. We have yet to study and learn, how far 
 they stand related to each other as simple coincidences, or as regular 
 sequences. And a more careful and complete investigation of them 
 by pathologists would probably add considerably to the amount and 
 value of the rational or dynamic symptoms of uterine disease. 
 
 In reference to all these morbid pains and morbid derangements 
 of function, which may thus in different cases accompany, and be 
 produced by, derangement or disease of the uterus or ovaries, let 
 me make one more general remark, viz., that they are all liable to be 
 more or less increased in character and in intensity at the men- 
 strual period, when the uterus and ovaries become congested during 
 the days of the usual menstrual molimen. 
 
 Lastly, among the dynamic symptoms produced by uterine dis- 
 ease, I have yet to state to you that these affections sometimes 
 produce, and are accompanied by, 
 
 V. States of General Constitutional Derangement. — The 
 states of general constitutional derangement that may be found at- 
 tendant upon uterine disease vary with the disease itself. 
 
 The inflammatory diseases of the uterus are seldom so acute, ex- 
 cept in the puerperal state, as to lead to much secondary fever ; but 
 inflammation in the cellular tissue of the pelvis, or Pelvic Cellulitis, 
 fi-equently leads to much constitutional disturbance ; and if the dis- 
 ease is prolonged, and ends, as it often does, in suppuration, then 
 you have very well-marked hectic symptoms usually supervening. 
 I have more than once seen the hectic accompanying a pelvic 
 abscess, mistaken for the hectic fever of phthisis. 
 
 "Where there is much and continued loss of blood from polypus, 
 or cancer, or other causes, you have the results and general effects 
 of anaemia and chlorosis superinduced, with their usual accompani- 
 ments of headache, palpitation, nervousness, &c. 
 
 But you have often chlorosis supervening, apparently parodoxi- 
 cally, under the very opposite set of circumstances, viz., where there 
 
THE TJTEUUS AND INTERNAL FEMALE ORGANS. 37 
 
 is amenorrhoea, and partial or total suppression of the catamenial 
 discharge. 
 
 In carcinoma of the uterus, the patient, after the disease begins to 
 break up, usually exhibits the sallow, yellow complexion of organic 
 disease ; but it is generally mixed up also with pallid lips, gums, 
 and other symptoms of anaemia, in consequence of the frequent vio- 
 lence of the accompanying hemorrhages. In most such instances, 
 and in the advanced stages of ovarian dropsy, the general atrophy 
 and emaciation of the patient become at last extremely striking. 
 
 Butin a large proportion of uterine ailments, especially in those of 
 the slighter description, little, or, indeed, no appreciable amount of 
 constitutional disturbance is produced. Let me merely farther add, 
 that when the disease is attended with exhaustion, or if the irritation 
 of it has excited and weakened the nervous system, so as to render 
 it supersensitive and impressible, hysteria in one or other of its 
 multifarious forms is always apt to supervene. 
 
 We come now to another question, — one I have already slightly 
 alluded to, viz. : 
 
 WHAT IS THE DIAGNOSTIC VALUE OF THESE VAEIOrS FORMS OF DYNAMIC 
 OR RATIONAL SYMPTOMS, IN THE DETECTION AND DISCRIMINATION OF 
 UTERINE DISEASES ? 
 
 This question is in itself a very important one, and I think we 
 can answer it satisfactorily and decidedly. For I feel assured that 
 no man, who is practically acquainted with the diseases of the uterus, 
 can have any hesitation in declaring, that the dynamic symptoms 
 of which I have spoken, taken either individually or conjointly, are 
 in the general run of such cases, altogether incompetent and inade- 
 quate for the purpose of a perfectly correct and practical diagnosis 
 of the different or specific affections, to which the uterus and uterine 
 appendages are liable. But do not mistake me in what I wish to 
 state to you upon this point. 
 
 There are two objects of diagnosis which the medical man is to 
 consider, in relation to every case applying to him for relief, viz., 
 first. What organ of the body is affected ? and secondly. How is that 
 organ affected ? In other words, his first duty is, to trace out the 
 seat of the disease, or the organ or organs which are diseased ; and 
 his second object is, to determine what special or particular affection 
 of that organ or organs is present in his patient. Now, I do believe 
 that the dynamic symptoms of uterine disease, such as I have de- 
 scribed them to you, may enable us in most cases to determine that 
 the uterus is affected. They are, in many cases at least, sufficient 
 
38 ON THE DIAGNOSIS OP THE DISEASES OF 
 
 to decide us in relation to the first point that I have named ; but 
 they are perfectly insufficient, by their own unassisted evidence,^ to 
 enable us to come to a decision in regard to the second point, viz., 
 What is the special disease of the uterus, or uterine appendages, 
 under which our patient is suffering ? They generally afford us 
 proof enough of the probability of the uterus being affected, livithoijt 
 proving to us how it is affected. They may enable us to decide that 
 it is the seat of some morbid state, or some morbid action ; without 
 enabling us to determine at all exactly what that morbid state, or 
 that morbid action, may be ; and, consequently, without enabling 
 us to decide what should be the proper line of treatment requisite 
 for the relief of our patient. 
 
 In treating of this important point — in endeavoring to show that 
 the dynamic symptoms are not sufficient to enable a practitioner to 
 make a differential diagnosis among the different diseases of the 
 uterus — I have often found it difficult to impress deeply enough 
 upon the mind of the student the fact, that there is no practical 
 guiding relation between the kind or amount of uterine disease that 
 may be present, and the character of the secondaiy dynamic symp- 
 toms to which it gives rise ; and hence, that he cannot, in practice, 
 depend for the discrimination of the different diseases of the uterus 
 from each other upon the dynamical or functional symptoms. But I 
 think I can adduce in evidence, a case, with the peculiarities of 
 which you are all 8uffi.ciently familiar to enable you to understand 
 the argument, in relation to this question, that may be derivable 
 from it. 
 
 The rapidly dilating and developing condition of the uterus dur- 
 ing pregnancy, and the state of irritation produced by the ovum 
 enlarging within it, may be regarded as the same condition in all 
 women. Pregnancy is the same disease, if I may so term it, in all. 
 In all cases the vital changes and actions going on in the walls and 
 in the cavity of the uterus are identically the same. Yet mark how 
 very different are the dynamic symptoms accompanying this same 
 condition in different patients. Some patients during pregnancy 
 are long unaware of the condition in which they actually are; 
 they suffer from no kind of complaint— from no form of distress — 
 no functional derangement, or dynamic symptom. A second set of 
 patients during pregnancy are afflicted with severe local suffering, 
 from irritation, induced by the enlarged organ, in the bladder and 
 the rectum ; or they have a feeling of prolapsus and bearing down 
 of the uterus, with pains in the loins, &c. You will find another 
 and a third series, not complaining of any local feeling or distress, 
 but suffering under sickness and nausea — under general derange 
 ment of the stomach and intestinal canal — under headache and 
 
THE UTERUS AND INTERNAL FEMALE ORGANS. 39 
 
 nervous affections — under toothaclie or salivation, and other de- 
 rangements of the sensations and secretions of the body. But, 
 again, in another and in a fourth set of cases, we occasionally find 
 all the most frequent dynamic symptoms, local and constitutional, 
 of pregnancy present, and so vfell marked, as to impress both the 
 patient, and sometimes even the practitioner, with the certainty of 
 the existence of that state ; and yet, after the lapse of a little time, 
 it may be found that the patient is really not pregnant at all ; the 
 symptoms being sympathetic merely of some morbid state of the 
 uterus or ovaries, but not sympathetic of the state of pregnancy, 
 though very exactly similar to the symptoms which most commonly 
 accompany it. 
 
 Observe, for a moment, what important evidence these well- 
 known facts afford. They afford us evidence to this extent — 
 first, that in pregjaancy we have the same identical condition of the 
 uterus, not by any means always accompanied by the same identical 
 dynamical symptoms, these symptoms varying greatly in different 
 patients ; and, secondly, they show us that the most usual dynamic 
 symptoms — local, sympathetic, and constitutional — ^which we see 
 produced by pregnancy, may be present in other conditions of the 
 uterus than in the pregnant condition. But exactly the same two 
 conclusions are true in regard to almost every one of the diseases 
 of the uterus, as well as to its state of pregnancy. In different dis- 
 eased conditions of the uterus, as in the condition of it in pregnancy, 
 we constantly find the same specific affection of the organ exciting 
 very different phenomena in different women. And, further, we 
 find that apparently, phenomena, or dynamic symptoms, which are 
 nearly if not entirely identical, may be excited by two or more dis- 
 eases of the uterus that are entirely different from each other in 
 their pathology and in their treatment. 
 
 I have already alliided to the frequency of fibrous tumors in the 
 walls of the uterus. Let me take them as an example of the 
 remark — though, in fact, uterine pathology is full of similar in- 
 stances. Fibrous tumors do not, in some patients, produce any very 
 decided dynamic symptoms ; and even when of large size, occasion- 
 ally they may pass for years altogether undiscovered either by the 
 patient or by the practitioner. Menstruation may be perfectly re- 
 gular; and pregnancy even may take place. In other patients, 
 however, these fibrous tumors, even when still small in size, some- 
 times, as I have already stated to you, produce distressing irritation 
 among the pelvic viscera, and derange in various ways the physiolo- 
 gical fanctions of the organ, leading on to menorrhagia, leucorrhcea, 
 dysmenorrhoea, &c. Here, then, we have a disease identical in 
 character in different patients, but producing in these different pa- 
 
40 ON THE DIAGNOSIS OF THE DISEASES OP 
 
 tients very different kinds of symptoms. And, if it were necessary, 
 I might repeat the same kind of deduction, as derivable from the 
 consideration of the different symptoms attending all other organic 
 diseases of the uterus in different patients, as chronic inflammation, 
 hypertrophy, polypus, cauliflower excrescence, carcinoma, &c. &c. 
 In many cases carcinoma of the uterus produces, from a very early 
 stage of its progress, distressing dynamic symptoms. But in others 
 it marches onward in its fatal course for a long time, without occa- 
 sioning almost a single dynamic symptom calculated to excite the 
 attention or rouse the alarm of the patient ; and when marked dy- 
 namic symptoms do at last supervene, how commonly are they mis- 
 taken for the symptoms of other and milder diseases of the uterus. 
 I have often, on the other hand, seen cases which have been sup- 
 posed to be cases of incurable carcinoma, when the disease was 
 some more benign and perfectly curable form of uterine malady, 
 such as inflammatory induration of the cervix, or polypus. In most, 
 if not in all such cases, the error committed has consisted in the 
 practitioner supposing he could make out the differential diagnosis 
 of the disease by dynamic symptoms alone, and without calling in 
 to his aid the evidence to be derived from physical diagnosis. 
 
 The most malignant organic diseases of the uterus may, as I have 
 just remarked in relation to carcinoma, long remain occult and 
 latent in their character ; they may have marched far on to a fatal 
 termination, without a single dynamic symptom being present cal- 
 culated to warn the patient to any knowledge of her state of danger. 
 But, on the contrary, we have often severe local and constitutional 
 dynamic symptoms of uterine disease developed, and developed 
 early, in instances of slight and remedial organic affections of the 
 organs, as in simple chronic ulceration, and inflammatory eruptions 
 upon the cervix. And again — mark this other perplexing fact — ^in 
 other instances, all, or almost all, these dynamic symptoms may be 
 present, in their most aggravated forms, for months, and even for 
 years, in instances of the so-called irritable uterus, or in neuralgia 
 of the organ — ^that is to say, in a set of cases where there is actually 
 no organic disease at all, and where there may be much real dis- 
 tress, but not much real danger. 
 
 To sum up these remarks in one more general deduction, let me 
 observe, that we sometimes have the same apparent train of local 
 and secondary dynamic symptoms in neuralgic, in inflammatory, 
 and in benign and malignant organic diseases of the uterus. And, 
 in whatever way we may explain the fact, it is still an undoubted 
 important pathological and practical fact, that, in uterine diseases, 
 there is generally no very direct or fixed relation observable between 
 the intensity and character of the local pathological disease which 
 
THE UTERUS AND INTERNAL FEMALE ORGANS. 41 
 
 is present, and tlie intensity and character of the dynamic symptoms 
 to which, that disease gives rise. The accompanying dynamic 
 symptoms may be severe, where the local disease of the uterus is 
 slight and simple ; and, on the other hand, it too frequently hap- 
 pens that the local disease of the uterus is severe and serious in its 
 nature, when the dynamic symptoms that accompany it are appa- 
 rently trivial and transient in their character. It is in consequence 
 of this want of relation between uterine diseases and their dynamic 
 symptoms, that it becomes so requisite in this class of affections to 
 have recourse to physical diagnosis, in order to determine what 
 ascertainable changes have taken place in the structure and organi- 
 zation of the uterus or its appendages. It is only by instituting, in 
 this way, a physical diagnosis that you can hope, in most instances, 
 to decide upon the specific nature of the uterine disease that may 
 be present. In many cases we may make, as I have already re- 
 peatedly stated to you, the general diagnosis of the existence of 
 uterine disease, by the consideration alone of the rational symptoms 
 or functional derangements, to which such diseases give rise. "We 
 can only make a differential diagnosis of what the existing specific 
 disease is by physical diagnosis ; or, in other words, by the physical 
 examination of the anatomical conditions of the organ itself. 
 
 The necessity of physical diagnosis will, I believe, be vtillingly 
 confessed by all practitioners in relation to the diagnosis of one 
 uterine state, that is not a state of disease. I specially allude to 
 the illustration which I have already brought before you, viz. : the 
 state of pregnancy. In deciding upon the existence or non-exist- 
 ence of pregnancy in any cases of doubt or importance, no medical 
 man, who valued his professional reputation, would deem himself 
 justified in offering a final and decided opinion upon the subject, 
 by considering the dynamical symptoms alone — symptoms, which 
 I have already described to you to be sufficiently varying and 
 equivocal in different patients. "So medical man would venture 
 to form a definite deduction and judgment upon the matter until 
 he was allowed to make some physical diagnosis of the condition 
 of the uterus, — that is, until he had ascertained by sight or touch, 
 or both, that the abdomen was really enlarged ; until, probably, by 
 a careful external examination of the abdomen by the hand and 
 stethoscope, he had ascertained that the existing tumor was really 
 uterine, and really contained a foetus ; or, in the earlier months, 
 until, perhaps, he was permitted to make a vaginal examination, in 
 order to make out the state of development, size, &c., of the 
 uterus. Exactly in the same way, in deciding upon the pathological 
 nature of any marked uterine disease, and consequently upon the 
 line of treatment which it may require, we believe precisely the 
 
42 UTERINE DIAGNOSIS. 
 
 same caution to be necessary, and the same local examination to be 
 requisite, where there exists any doubt, and where such a local 
 examination is not otherwise counter-indicated. And in a practical 
 point of view, the examination in a ease of uterine disease is far 
 more necessary, because far more important, than in the case of 
 pregnancy. In pregnancy the local examination is had recourse to, 
 in order to determine a point which time itself would soon alone 
 determine. In uterine diseases the same physical examination is 
 had recourse to, for an object of much more immediate and prac- 
 tical moment, viz. : to obtain information sufficient to enable us to 
 form a correct and precise judgment as to the specific pathological 
 nature of the case before us, and, consequently, to enable us to 
 select the proper remedial measures for its treatment and cure. 
 
 WHAT ARE THE MEANS OF PHTSICAL DIAGNOSIS, THAT WE MAY USB 
 IN DISEASES OE THE IJTERUS, OVARIES, ETC. ? 
 
 Now, in the diagnosis of these diseases, we require to use the 
 sense of touch, and occasionally of sight, hearing, and smell. We 
 require to use the sense of touch in the external and internal exa- 
 mination of the region of the uterus and of the surrounding parts. 
 We require to use the sense of hearing in the employment of aus- 
 cultation or percussion. We require to use sight in the use of the 
 speculum. And the nature of the foetor emitted by the vaginal 
 discharge is sometimes almost enough in itself to decide for or 
 against the existence of extensive carcinomatous ulceration and 
 disintegration. 
 
 The OS uteri is, as you are aware, an opening so narrow as not to 
 allow the passage of the finger through it for the examination of 
 the interior of the cavity or walls of the viscus. But it is most 
 important, in some cases, to be able to make an examination of this 
 cavity and of these walls, for the purpose of ascertaining various 
 points with regard to their condition ; and in order to do so, we 
 may pass through the os a slender metallic finger, or, in other words, 
 use the uterine sound. Or, if necessary, we may enlarge the size 
 of the opening of the os, so as even to admit the finger itself, by 
 introducing a series of dilating sponge-tents into the cavity of the 
 OS and cervix uteri. Occasionally matters are discharged from the 
 cavity of the uterus, of which it is necessary to ascertain the cha- 
 racter and source ; and, in some instances, we are aided in coming to 
 a decision upon this matter by the use of the microscope and by 
 chemical tests. Sometimes there are fluid collections in the cellular 
 tissue of the pelvis, or in the ovary ; and it may become a matter of 
 life or death to the patient that we should be able to trace what the 
 character of these effusions really is, and, in particular, whether 
 
UTERINE DIAGNOSIS. 43 
 
 they are inflammatory and purulent or not. We cannot reach them 
 with the finger, but we may reach them with the exploring needle, 
 and in this way trace their true character. Lastly, in cases of neu- 
 ralgic tenderness of the abdomen and passages, and more especially 
 when these are combined, as they often are, with tympanitic disten- 
 sion and enlargement of the abdomen, giving an appearance of 
 formidable enlargement and very serious disease, it is sometimes 
 impossible to make an accurate examination of the abdominal and 
 pelvic viscera till the patient is fully anaesthetized ; and you have 
 seen in the hospital more than one case where the employment of 
 chloroform has, in this way, at once dispelled what previously 
 seemed to be an undoubted and enormous ovarian or uterine tumor. 
 "We have thus, you will observe, a variety of means of physical 
 diagnosis, that we may resort to in the detection and discrimination 
 of the diseases of the uterus, and ovaries, and neighboring parts ; 
 and, if we attempt to classify them, we may reduce them to the 
 following order: 
 
 1. The external or abdominal examination of the patient by 
 sight, touch, auscultation, and percussion. 
 
 2. The tactile examination of the uterus, ovaries, &c., by the 
 vagina or by the rectum. 
 
 3. That most important mode of diagnosis, viz. : the simultaneous 
 combination of the external and internal modes of tactile examina- 
 tion. 
 
 4. The use of the speculum. 
 
 6. The use of the uterine sound. 
 
 6. The use of sponge-tents, with the view of dilating the os 
 uteri, so that the finger can be introduced into the cavity of the 
 cervix or cavity of the body of the organ. 
 
 7. The microscopic and chemical examination of the discharges 
 from' the uterus and vagina. 
 
 8. The employment of the exploring needle in cases of fluid col- 
 lections, in order to ascertain the contents of such collections ; and 
 
 9. The adoption of anaesthetic agents, to relax the abdominal 
 parietes, and enable us to practise the different modes of examina- 
 tion, in cases of excessive or neuralgic tenderness of the abdominal 
 surface or vagina, &c. 
 
 Most of the above means of physical diagnosis are discussed in the following chapters of 
 this division of the volume. For the introduction of four of these means of uterine diag- 
 nosis, viz., the sound, sponge tents, the exploring needle, and the production of auEESthesia 
 to facilitate examination, modern pathology is, vi^e believe, indebted to Dr. Simpson. — (Ed.) 
 
44 THE USE OF THE SPECULUM. 
 
 ON THE POSITION OF THE PATIENT FOR THE USE 
 OF THE SPECULUM.i 
 
 (From Edinburgh Medical and Surgical Journal, January, 1841, p. 155.) 
 
 It is almost unnecessary to insist at the present day, upon the 
 importance of the early and accurate local examination of the uterus 
 in all cases of suspicious vaginal discharges. In some instances, 
 examination by the finger may be sufficient ; but in every doubtful 
 case the speculum should likewise be resorted to, if there is any 
 affection of the vagina or cervix. It will be often found confirming, 
 and not unfrequently also changing and rectifying the opinion which 
 the mere tactile examination had led the practitioner to adopt. In 
 this country great difficulties have been raised against the more 
 general introduction of the speculum into practice, in consequence 
 of the very disagreeable exposure of the person of the patient, 
 which is usually considered necessary in its employment. In my 
 own practice I have latterly endeavored to avoid this very natural 
 objection, by teaching myself to introduce and use the instrument 
 when the patient was placed on her left side in the position usually 
 assumed in making a tactile examination, and with the nates near 
 the edge of the bed. I strongly recommend my professional brethren 
 to follow this plan, as by it, and with attention to the management 
 of the bed-clothes, I have found that the instrument can be perfectly 
 employed with little, or indeed without any exposure of the body of 
 the patient. The speculum is introduced easily without the assistance 
 of sight, and the mouth of it only requires to be afterwards unco- 
 vered, in order to enable us to examine the cervix uteri and top of 
 the vagina. I have made trials of many different forms of specula, 
 and find, for almost all purposes, that of Charriere by far the most 
 manageable. In exposing the cervix uteri for the purpose of draw- 
 ing blood from it by scarification, in cases of chronic congestion and 
 metritis, I have occasionally employed a tubular speculum with ad- 
 vantage, but even in this case the three-bladed instrument is equally 
 useful, and in some instances preferable. In a case of ulcer of the 
 OS uteri which I am at present attending with Dr. John Gairdner, 
 and where the passages are much relaxed and the uterus very low in 
 the vagina, I have, on Dr. Gairdner's suggestion, employed with 
 much advantage a short tubular speculum of only an inch and a half 
 
 ' See further on this subject, p. 65. 
 
MEMOIR ON THE UTERINE SOUND. 45 
 
 in length, and with a deficiency or opening along the course of one 
 side of it, of sufficient size to enable me to pass my finger for the 
 purpose of placing the diseased part in the proper centre of the in- 
 strument. We have thus been enabled to touch easily the ulcerated 
 surface with different applications ; while with the usual instruments 
 it was found a very difficult task to fix in this instance the very mobile 
 cervix uteri. 
 
 The speculum generally employed by Dr. Simpson, is the three-bladed instrument of Char- 
 ri&re, with the handles so arranged as to fold backwards when not used. This modification 
 of the handles renders the instrument much more convenient for the pocket. Sometimes 
 we have seen him employ a tubular glass speculum ; and occasionally Coxeter's two-bladed 
 instrument. — (Ed.) 
 
 MEMOIR ON THE UTERINE SOUND. 
 
 (From London and Edinburgh Monthly Journal of Medical Science, June, 1843, p. 547.)' 
 
 SECTION I. 
 
 The symptoms by which the diseased states of the various indi- 
 vidual organs of the body are detected and discriminated from each 
 other, are divisible into two great classes. The first class, forming 
 the Functional, Dynamical, or Rational symptoms of various patholo- 
 gical writers, includes all the ascertainable derangements of functions, 
 local and sympathetic, that may be present ; the second class, con- 
 stituting the Physical symptoms of the same authors, comprehends 
 all the ascertainable circumstances connected with the structure, 
 density, form, and other anatomical conditions of the organ which 
 is the primary seat of disease. 
 
 Our diagnosis is always the more exact and perfect the more we 
 can combine the information that may be gained from both classes 
 or sets of symptoms — and especially the more that we can manage 
 to confirm or correct the knowledge derivable fi-om our study of the 
 functional symptoms, by ascertaining, by the cognizance of our own 
 senses, the exact physical state of the affected organ with which 
 these symptoms happen to coexist. 
 
 ' Bead before the Medico-Chirurgical Society of Edinburgh, April 19, 1843. 
 
 We have preferred, rather than disjoint this memoir, to retain it in its original form ; 
 although the introductory portion may appear in some points a repetition of the previous 
 lecture. — (Ed.) 
 
46 UTERINE DIAGNOSIS. 
 
 In morbid affections of the exterior parts of the body, the Physical 
 Diagnosis of the disease can be in general easily accomplished, by 
 the direct tactile examination and visual inspection of the affected 
 organ. It is this facility of examination and inspection which ren- 
 ders the diagnosis of these more external diseases, which belong to 
 the province of the surgeon, so much more precise and accurate 
 than the discrimination of those maladies of the more internal 
 parts of the body, that fall under the investigation of the physician. 
 
 Within the last half century, however, the diagnosis of the 
 diseases of the deeper-seated organs has been very greatly advanced 
 by the application of various measures to improve our knowledge 
 of their existing structural states. In fact, the medical science of 
 the present day owes its superiority over that of an earlier date to 
 no circumstance more, than to the increased degree of attention that 
 has, for a considerable time past, been devoted to the study and im- 
 provement of Physical Diagnosis. As the knowledge of the struc- 
 tural lesions which the various organs may undergo from disease, 
 has of later years extended in the hands of the pathological anatomist 
 from his examination of the body after death, the practical physician 
 has, for the purpose of his diagnosis and the guidance of his treat- 
 ment, exerted himself in discovering means of detecting these same 
 morbid alterations during the lifetime of his patient, and thus of 
 studying, if I may so speak, necroscopic anatomy upon the living 
 body. It is true that, in the discrimination of the diseases of some 
 organs, as of the brain or spinal cord, we are, with some slight 
 exceptions, obliged to trust entirely to the functional symptoms, 
 because we have no means of detecting the morbid states of these 
 organs except in the derangements produced in their functions. 
 Hence arises the occult character of this class of diseases. In the 
 diseases, however, of other organs, as those of the chest, the fact is 
 different. Formerly the affections of the thoracic organs were also, 
 as those of the head still are, detected and distinguished by their 
 functional symptoms and derangements only, and their diagnosis 
 was consequently always more or less doubtful, and often exceed- 
 ingly obscure. Now that we can ascertain, with so much precision, 
 the existing anatomical state of the lungs and heart by auscultation, 
 percussion, &c., and thus combine the physical with the functional 
 diagnosis of pulmonary and cardiac diseases, much of the difficulty 
 and obscurity that was formerly connected with their detection and 
 discrimination has entirely disappeared. 
 
 In ascertaining the Diseases of the Uterus, we have it in our 
 power to avail ourselves of both the classes of symptoms of which 
 I have spoken ; or, in other words, we may form our judgment of 
 its morbid conditions, both by studying the vital Functional De- 
 
FUNCTIONAL OR DYNAMIC SYMPTOMS. 47 
 
 rangements, local, sympathetic, and constitutional, that may be 
 present ; and by informing ourselves, by Physical Diagnosis, of the 
 exact existing state or states of the organ itself. Each of these 
 classes of symptoms may aiford us most important information ; 
 and in all cases where both can be had recourse to, our diagnosis 
 will be greatly more certain under their combined evidence, than 
 if the data furnished by either were alone trusted to. Of the two, 
 if we are to make comparisons between them, the physical symp- 
 toms, are assuredly, in most cases, by far the most valuable and 
 trustworthy — and yet in the common course of medical practice, 
 the testimony which they are capable of affording, is but too fre- 
 quently neglected and overlooked — and the functional and much 
 less faithful class of symptoms alone relied upon, as well in forming 
 the diagnosis, as in directing the measures of treatment. 
 
 Thus, if we attempt to analyze the mode in which the medical 
 practitioner usually endeavors, in any suspected case of uterine 
 disease, to detect the presence and character, or ascertain the 
 absence of such an affection, we shall find, I believe, that he gene- 
 rally proceeds by taking into consideration some or all of the fol- 
 lowing sources and varieties of information : 
 
 First, The local and functional state of the uterus, so far as it is 
 indicated by the quantity, character, periodicity, &c., of the men- 
 strual and mucous secretion of the organ ; by the occurrence and 
 non-occurrence of morbid uterine or vaginal discharges, as blood, 
 serous fluid, pus, &c. ; by the existence or not of morbid sensations 
 in the region of the uterus, such as different modifications of pain, 
 intermittent or continuous, feelings of heat, weight, tension, bear- 
 ing down, &c. ; and, if the patient be married, by the reproductive 
 powers of the organ, as shown by sterility, by the recurrence of 
 abortions, &c. 
 
 Secondly, The presence or absence of various morbid affections 
 of the neighboring viscera, particularly of the rectum and bladder, 
 and of branches of the vessels and nerves passing through the 
 pelvis — as indicative either of their sympathetic irritation or of 
 their mechanical compression by the enlarged or displaced uterus. 
 
 Thirdly, The existence or non-existence of secondary local 
 neuralgic pains in the mammse, along the lower extremities, in the 
 loins, and at points along the course of the spinal column, in the 
 parietes of the thorax or abdomen on one or other side, and espe- 
 cially under the left breast, and under the margin of the ribs, along 
 the colon, &c., increased in their intensity by any causes of in- 
 creased action in the uterus itself, by the erect posture, by men- 
 struation, &c. 
 
 Fourthly, The state of the general constitution of the patient, as 
 
48 UTERINE DIAGNOSIS. 
 
 marked by various degrees of deviation from the standard of health 
 —and especially by the supervention of nervous, hysterical, dys- 
 peptic, chlorotic, or cachectic symptoms. 
 
 The several preceding series of morbid phenomena consist of 
 derangements in the vital actions of the uterus— or of other parts 
 and organs secondarily affected— or of the constitution at large — 
 and so far strictly belong to the class of Functional or Dynamic 
 symptoms only. Tip to a late date in the history of uterine diag- 
 nosis, most practitioners remained, and some still remain satisfied 
 with the degree of knowledge which is afforded by the above 
 sources of information, ^o one, however, who is practically ac- 
 quainted with the diseases of the uterus can have any hesitation in 
 declaring that the symptoms derivable from these sources are utterly 
 inadequate, in the general routine of such cases, for the purposes of 
 correct diagnosis, and are constantly liable to lead into fallacy and 
 error when their individual evidence is alone trusted to. In mak- 
 ing this observation, I do not mean to allege that these classes of 
 symptoms are not sufficient to give us the power, in most, though 
 not in all instances, of detecting the actual presence of uterine 
 disease. They are perfectly deficient, however, in this other point, 
 that, by their single unassisted aid, we cannot ascertain what the 
 exact character and nature of the existing disease is — nor, conse- 
 quently, what may be the proper line of treatment requisite for its 
 alleviation or removal. They may generally, in other words, enable 
 us to decide that the uterus is the seat of some morbid condition, 
 but are not adequate to inform us what that morbid condition really 
 is. They may show that the organ is affected, without showing us 
 how it is affected. 
 
 If we attempted to throw the generalities, regarding the diagnosis 
 of uterine diseases, into propositions, we would, therefore, be in- 
 clined to lay down the following as our 
 
 FIRST PROPOSITION. 
 
 The general and local Functional Symptoms of Disease of the Uterus are such as enable us to 
 localize, without enabling us to specialize, the exact existing affection of the organ. 
 
 One or two instances may serve to illustrate and impress more 
 strongly than any mere abstract statement, the force and truth of 
 the above proposition. 
 
 In the changed and changing state of the uterus during Preg- 
 nancy, we have in all cases a constancy in the primary site and 
 character of the existing irritation — if we may apply a term so far 
 pathological, to a state which, in its object, at least, is strictly phy- 
 
FUNCTIONAL OR DYNAMIC SYMPTOMS. 49 
 
 siological. "But thouglx in the pregnant female the local uterine 
 irritation is constantly and specifically the same in its source and 
 nature, the local and constitutional phenomena or Functional 
 Symptoms to which it gives rise, are well known to vary infinitely 
 in different individuals, and even in the same individual in difierent 
 pregnancies. In one case, the health of the woman remains in all 
 respects unimpaired, notwithstanding the altered condition of the 
 uterus. In a second, we find her suffer from distressing local 
 symptoms, such as weight, distension, and bearing-down sensations 
 in the interior of the pelvis, derangements in the state of the 
 bladder and rectum, oedema and stiffness in the lower extremities, 
 &c. In a third, the local affections may be slight or altogether 
 absent, but there may be severe and even serious sympathetic 
 affections of the general constitution, or of particular and distant 
 organs, such as of the stomach, with cardialgia or vomiting, or of 
 the brain, with headache and sleeplessness, or even with convul- 
 sions or mania. 
 
 Again, in other instances, we occasionally find all the usual 
 symptoms, both local and constitutional, of pregnancy present, in 
 so marked a degree, as to impress both the patient and the prac- 
 titioner with the certainty of the existence of that state ; and yet 
 these symptoms may all, after a short time, be found dependent on 
 the irritation produced by some subacute functional or organic 
 disease of the uterus, that has no relation whatever to utero-gesta- 
 tion, except in the identity of its primary seat, and in the similarity 
 of the symptoms to which it gives rise. 
 
 The few well-known facts to which I have thus adverted directly 
 point to the two following important deductions: — 1st, That in 
 pregnancy we have the same identical condition of the uterus, not 
 always accompanied by the same identical symptoms ; and 2d, That 
 the usual concourse and succession of functional phenomena to 
 which pregnancy generally gives rise, may be induced by other 
 states of the organ than the state of utero-gestation. 
 
 The same two important inferences are true in regard to the 
 various individual morbid affections of the uterus. The marked 
 uncertainty which exists regarding the effects produced by the con- 
 dition of the organ in pregnancy, holds equally good regarding the 
 effects produced by it in its different states of actual disease. In 
 uterine disease, as in pregnancy, the same specific affection of the 
 organ excites sometimes very different phenomena in different 
 cases ; and the same specific phenomena frequently result from 
 affections of the organ that are entirely at variance with each other 
 in their pathological character, in their course, and in their treat- 
 ment. 
 
 VOL. 1. 4 
 
50 UTERINE DIAGNOSIS. 
 
 Probably the most common organic disease of the uterus consists 
 in tbe development of those fibrous tumors which are so frequent 
 in the tissues of the body and fundus, and so rare in those of the 
 cervix of the organ. These tumors do not, in some cases, occasion 
 any very decided symptoms, and are often, as I have repeatedly 
 known, only accidentally discovered in the living subject, after 
 reaching a very large size ; or, as frequently happens, they are not 
 suspected or detected before they are found on the post-mortem 
 examination of the body. I have one such tumor in my museum, 
 which weighed fourteen pounds, and where the principal or only 
 symptom during life was the mere enlargement of the lower portion 
 of the abdomen, produced by the presence of this great mass. But 
 in other cases, these fibrous tumors of the uterus, even when still 
 small, often produce distressing irritation among the pelvic viscera, 
 and derange in various ways the physiological function of the organ 
 — producing sometimes diminution or suppression of the menstrual 
 secretion, or again, especially when they are situated near the 
 mucous surface, inducing leucorrhcea and attacks of menorrhagia, 
 that are occasionally most formidable, both from their severity and 
 permanency. But the remarkable circumstance with regard to this, 
 and almost all other structural diseases of the uterus is, that though 
 the walls of th-e organ be the seat of extensive morbid transforma- 
 tions and deposits, the menstrual secretion frequently remains so 
 regular and normal as to deceive both the patient and her medical 
 attendant; and I have known conception — the principal physiolo- 
 gical function of the uterus — to take place, not only where fibrous 
 tumors were present, but, in more than one case, where the cervix 
 of the organ was the seat of malignant disease, that destroyed the 
 patient shortly after her abortion or delivery. 
 
 Let us consider for a moment one other instance, illustrative of 
 the important practical fact that the same organic disease of the 
 uterus is often attended, by the most varied, and even apparently 
 opposite sets of external symptoms. 
 
 Scirrhous degeneration of the cervix uteri is an aflfection constant- 
 ly occurring in the course of practice. This disease sometimes gives 
 rise, at an early period of its progress, to severe pains and sufferings 
 in the uterine region ; to great local irritation of the bladder and 
 neighboring parts ; and to the supervention of marked sympathetic 
 and constitutional phenomena. In other numerous instances, how- 
 ever, it marches onwards to an advanced stage without occasioning 
 almost one single symptom in the way of local pains, discharges, or 
 otherwise, calculated to rouse the attention of the patient to the im- 
 pending work of destruction that is, with slow but fatal steps, going 
 on within her. I have repeatedly seen cases of the kind where the 
 
FUNCTIONAL OE DYNAMIC SYMPTOMS. 51 
 
 disease was under assiduous treatment for simple leucorrhoea, or 
 monorrhagia, merely because no examination had been instituted, 
 in order to learn upon what local states the leucorrhcEa or monor- 
 rhagia depended. In other cases the intensity of the sympathetic 
 or secondary symptoms may be such as to conceal and disguise en- 
 tirely the primary disease. In an instance of fatal carcinoma uteri 
 that occurred lately in this city, the symptoms complained of daring 
 the lifetime of the patient were entirely referred to the urinary, and 
 not to the uterine organs. I have known the mammse most actively 
 treated by leeching, &c.,for the sympathetic pains present in them, 
 while the state of the uterus itself (the primary cause of the pains) 
 was altogether held out of view, until at last, when attention was 
 ultimately called to it, its whole cervix was found utterly destroyed 
 by cancerous ulceration. 
 
 While we thus not unfrequently find the most malignant organic 
 diseases of the uterus more or less latent or marked in their symp- 
 toms, we have, on the other hand, sometimes the most severe local 
 and constitutional symptoms of uterine disease developed in in- 
 stances of slight and remediable organic affections of the part, as in 
 cases of simple Ulcerative and Granular Inflammation of the cervix ; 
 and these symptoms may be all present in their most aggravated 
 forms for months and even for years, where the local examination 
 and final result show us that there is certainly no organic disease 
 whatever, as in cases of " irritable uterus," or hysteralgia. Indeed, 
 in some females, we have all these symptoms strongly but tempora- 
 rily excited at every recurrence of the catamenial discharge, in con- 
 nection merely with that congestion and increased vital activity of 
 the organ which accompanies its natural menstrual secretion. 
 
 We may meet, in short, with the same train of local and secon- 
 dary functional symptoms indicative of uterine disease, in neuralgic, 
 in congestive, in inflammatory, and malignant diseases of the organ ; 
 and whether we explain it by the slowness with which morbid de- 
 positions are apt to develope themselves in this orgaai — by the slight 
 sensibility of the component tissues of the viscus — or by the inter- 
 mittent and latent nature of its vital actions — there can be no doubt of 
 the fact, that there seems to be no organ in which there is a less strict 
 relation observable between the intensity and character of the exist- 
 ing pathological disease, and the intensity and character of the ac- 
 companying symptoms, or between the exact nature of the structural 
 lesions that are present, and the exact combination and succession 
 of functional derangements to which they give rise. Hence, in 
 order to form in any case a correct diagnosis in regard to the exist- 
 ing state of the uterus, it is necessary to ascertain, as far as possible, 
 if any anatomical alteration may be present in the structure and or- 
 ganization of the organ — as well as in its physiological functions — 
 
52 UTERINE DIAGNOSIS. 
 
 and what these alterations are. In other words, we must institute 
 a local examination of the organ itself, by the sense of touch, and, 
 if necessary, by the use of the speculum. It is assuredly only by 
 doing so, that we can hope with any certainty to decide upon the 
 specific nature of the uterine disease that may be present. We 
 may make the general diagnosis of the existence of uterine disease, 
 by the consideration of the functional derangements to which such 
 disease gives rise. We can only make the differential diagnosis of 
 what the specific disease really is, by aiding this by the examination 
 of the structural condition of the organ itself. 
 
 In deciding upon the existence or non-existence of pregnancy, 
 especially in any cases of importance or doubt, no medical man, 
 who valued his own professional character, would deem himself 
 justified in offering a final and dogmatic opinion, from the mere 
 fanctional symptoms only, which we have already seen to be some- 
 times very equivocal — nor would he venture to form a definite 
 judgment, until he had made a suflaciently accurate physical exami- 
 nation of the state of the uterus itself. In deciding in the same way 
 upon the pathological nature, and consequently upon the line of 
 treatment which any marked uterine disease may require, we believe 
 exactly the same caution to be necessary, and the same local exami^ 
 nation to be demanded, where there exists any doubt, and where 
 the examination is not otherwise counter-indicated. The local ex- 
 amination of the uterus is had recourse to, in the case of pregnancy, 
 to settle a point which time itself would alone ultimately decide. 
 The local examination is had recourse to in the case of uterine dis- 
 ease, for an object of much more immediate and practical moment, 
 namely, to obtain that information which can alone enable us to 
 form a proper and precise judgment of the nature of the case before 
 us, and to select the proper remedial measures for its mitigation, 
 arrestment, or timely removal. We have seen some uijfortunate 
 cases, where its unwarrantable omission in the earlier and curable 
 stages of disease has allowed the morbid action to make so extensive 
 and fatal progress before sufficient alarm was excited, as to be 
 utterly beyond the reach of treatment. Consequently it appears to 
 us, that in uterine diagnosis it may be most safely and justly laid 
 down as a 
 
 SECOND PROPOSITION. 
 
 In almost all instances of diseases of the Uterus, it is only by the Physical Examination of the 
 organ itself that we can distinguish the precise nature of the existing affection, and fix its 
 character, extent, ^c. 
 
 The information thus obtained may be merely negative, but it is 
 not the less useful either in a diagnostic or in a practical point of 
 view. In a case of morbid dischai'ge of blood from the vagina, for 
 
MEANS HITHERTO EMPLOYED INSUFFICIENT. 53 
 
 example, we may only ascertain that there is no appreciable organic 
 disease of the uterus. Our prognosis and treatment, however, of a 
 case of menorrhagia would, under such circumstances, be very dif- 
 ferent from those which we should adopt, if, by the same examination, 
 we discovered a state of simple ulceration of the cervix,or congestive 
 enlargement of the uterus, or the presence of a polypus, or the ex- 
 istence of a cauliflower excrescence, or carcinomatous degeneration. 
 Local examination, however, usually affords us much positive and 
 direct information with regard to the seat and character of the ex- 
 isting disease, by informing us of all those changes that have taken 
 place in the vagina and uterus, which can be recognized by touch 
 or sight. By it we are thus often enabled to detect the different 
 morbid conditions of the cervix, whether congestive, inflammatory, 
 or more strictly organic. We can generally distinguish, by the 
 same means, these states from each other, and discriminate between 
 the equally enlarged and dark-colored congestion of the cervix, and 
 the different forms of inflammation to which its structures are liable, 
 whether that inflammation has assumed the granular, ulcerative, 
 aphthous, or pustular type ; — between simple, syphilitic, corroding, 
 and carcinomatous ulcers of this part ; — between granular enlarge- 
 ments, cauliflower excrescence, and cancerous degeneration of the 
 cervix ; — between the vaginal tumors formed by prolapsus, or by 
 inversion of the uterus, and those formed by the presence of a simply 
 hypertrophied cervix, or of a true polypus ; — and between the gene- 
 ral diffused enlargement of the organ produced by hypertrophy of 
 its walls, or distension of its cavity, and that irregular, roundish, 
 knobbed form which it almost invariably assumes in cases of 
 fibrous tumors, and in such cases only. 
 
 THIRD PROPOSITION. 
 
 The Physical Examination, as hitherto practised, seldom enables us to ascertain accurately, the 
 organic condition of more than the cervix and lower part of the body of the Uterus. 
 
 If the uterus be large, and the woman of a spare and lax habit, 
 we may indeed be able to feel the fundus of the organ through the 
 walls of the abdomen, by the hand pressed in above the pubis. It 
 generally, however, lies so low in the pelvis, and usually moves 
 away so readily under the touch and pressure of the fingers, that, 
 even in such persons, this means of examination is of no great avail. 
 In all persons of an opposite habit, and in most cases where the 
 uterus is misplaced without enlargement, the hypogastric examina- 
 tion is of little or no use whatever. 
 
 By examination per vaginam with the finger, we can only. 
 
54 UTEEINE DIAGNOSIS. 
 
 except when the uterus is prolapsed, feel the cei-vix, and the parts 
 resting on the roof of the vagina. Hence, diseased states of the 
 cervix having been far more easily ascertained than diseased states 
 of the body and fundus of the organ, have, probably, been very 
 much overrated, both in frequency and importance, at least since 
 the speculum has come into more general use. In regard to the 
 parts that are felt through the roof of the vagina, the touch alone 
 does not, in many instances, give us information at all sufficiently 
 satisfactory and decisive. We can, no doubt, when the tumor is 
 large, often ascertain with considerable accuracy, its size and form, 
 by combining the vaginal examination with the aid derived from 
 examination by the rectum, and above the pubis. But we are still, 
 in many cases, left entirely in the dark as to whether the existing 
 tumor is an enlargement of the whole mass of the uterus, or a 
 distension of its cavity, or a morbid growth; and, if the latter, 
 whether the growth is seated in the uterus itself, or in one of the 
 ovaries or other neighboring parts. If the tumor is small, and 
 cannot be felt above the brim, we then have it not even in our 
 power to ascertain its size and form, as we can examine it only on 
 one side, namely, on that next the vagina. Under these circum- 
 stances we are unable to tell whether it arises from a new morbid 
 structure attached to the uterine parietes, or from a simple displace- 
 ment, or flexion of the fundus of the uterus itself. 
 
 To meet these and other difficulties in uterine diagnosis, I have 
 for some time past been in the habit of using a metallic Uterine 
 Sound or Bougie of nearly the size and shape of a small male 
 catheter, which, when introduced, as it can easily be done, into the 
 interior of the uterus, and manipulated there in different ways, has 
 proved to me of great service in rendering the diagnosis of the 
 diseases in question, and more particularly those of the fundus, 
 hody, and cavity of the organ, parts usually considered beyond the 
 reach of examination, much more accurate and precise than can 
 be effected by any other means with which I am acquainted. I am 
 induced to bring this means before the notice of the profession, 
 under the strong hope that the instrument will be found of equal 
 service in the hands of others ; and the results which have been 
 obtained by it seem already sufficient to enable us to place, among 
 the generalities of uterine diagnosis, the following as a 
 
SUGGESTION OF UTERINE SOUND. 55 
 
 FOURTH PROPOSITION. 
 
 It is possible, hy the use of a Uterine Sound or Bougie introduced into the uterine cavity, to 
 ascertain the exact position and direction of the body and fundus of the organ — to bring 
 these higher parts of the uterus, in most instances, within the reach of tactile examination, 
 and to ascertain various important circumstances regarding the os, cavity, lining membrane, 
 and walls of the viscus. 
 
 Having already exhausted my present limits by these preliminary 
 observations, I must reserve the particular description of the instru- 
 ment, — ^the modes of introducing and using it, — and the different 
 diagnostic indications which it is capable of fulfilling, for a second 
 communication. 
 
 SECTION II. 
 
 PROPOSALS FOR THE IMPROVEMENT AND ELUCIDATION OF UTERINE 
 DIAGNOSIS, BY MEANS OF A SOUND OR BOUGIE PASSED INTO THE 
 UTERINE CAVITY. 
 
 (From Lond. and Edin. Monthly Journal of Med. Science, August, 1843, p. 701.) 
 
 In my former paper I took occasion to speak of the uncertainty 
 of those symptoms of Uterine Disease that consist merely of 
 derangements in the functions of the uterus itself, and of other 
 contiguous and sjonpathizing parts. Some facts were adduced to 
 show, that, in uterine pathology, this uncertainty was so marked, 
 that frequently the same affection of the organ was accompanied in 
 different cases by different trains of functional symptoms ; while it 
 held equally true, that occasionally the same train of symptoms 
 was found indiscriminately in connection with a number of morbid 
 conditions of the uterus, that were essentially and practically dis- 
 similar from one another both in their nature and treatment. 
 From this frequent want of relation between morbid states of the 
 uterus and their functional effects — from finding identical lesions 
 combined, in a variety of instances, with very diversified symptoms 
 — and identical symptoms connected with very different lesions — it 
 followed, that in order to form a sure and perfect diagnosis in this 
 class of affections, it is generally requisite to take into conside- 
 ration the exact structural state of the uterus itself, and hence to 
 institute, for the ascertainment of this point, a careful local exami- 
 nation of the organ. In urging the necessity of such a physical 
 examination of the uterus in uterine diseases, I endeavored only to 
 claim for that organ a means of diagnosis, which, when practicable, 
 is regarded as indispensable in the case of every other part of the 
 
56 UTERINE DIAGNOSIS. 
 
 system. In discriminating from each other, for example, the 
 various kinds of morbid affections of the eye, no medical man 
 would trust merely to the knowledge that he might acquire regard- 
 ing the derangements of vision that might be present, the degree 
 and character of the local and sympathetic pains, the quality and 
 nature of the lachrymal and conjunctival secretions, the accom- 
 panying state of the system in general, &c., — ^he would farther, in 
 order to arrive at such an accurate diagnosis as would enable him 
 to institute a rational course of treatment, examine as thoroughly 
 as possible the local structural condition of the organ itself, as the 
 only means of determining in what individual texture or textures, 
 whether the conjunctiva, cornea, lens, &c., the disease was specially 
 localized, and what the precise nature of the morbid action reaUy 
 was in the texture that was affected. In the same way, in a case 
 of excessive morbid irritation of the urinary passages, nos urgeon 
 would venture to decide precisely what the extent, seat, and nature 
 of the affection was — and whether renal, vesical, or urethral — until 
 he had made a strict local or physical examination of the urinary 
 organs themselves. He might, by the kind of functional derange- 
 ments present, be led to suppose that the morbid irritation was 
 connected with a stone in the bladder, or an enlargement of the 
 prostate, or a stricture of the urethra, &c. ; but he could never be 
 perfectly certain that one or other of these was the cause, until he 
 had instituted, with the finger, sound, &c., a local examination of 
 the parts implicated. It is exactly the same with uterine diseases. 
 The external symptoms may show the presence of disease in the 
 uterine organs, and occasionally may be such as to lead us to adopt 
 some opinion as to its nature ; but we can never, in any case of the 
 slightest doubt, be certain of its exact character and extent, to such 
 a degree as to sei-ve for guides to our diagnosis, prognosis, and 
 treatment, unless we have the aid of the knowledge of the local 
 structural state of the viscus itself. 
 
 A portion of my former communication was further taken up in 
 showing, that the methods of uterine diagnosis as hitherto prac- 
 tised, whether by touch, or the speculum, or both, were, except 
 where the patient was of a spare and relaxed form, calculated prin- 
 cipally or only to distinguish the various morbid states of the 
 cervix uteri. Lastly, I ventured to suggest, as an addition to our 
 other means of uterine diagnosis, that the higher and more interior 
 parts of the uterus should be examined by a Sound or Bougie 
 introduced into the uterine cavity, and stated that various points of 
 great importance, and otherwise unascertainable, could be made 
 out by its assistance. 
 
 In the present chapter I intend briefly to state the kind of 
 
DESCRIPTION OF TJTEEINE SOUND. 57 
 
 instrument I have used, and the modes of introducing and mani- 
 pulating it, with some of the points of information which we can 
 obtain through its employment. 
 
 DESCRIPTION OF THE UTERINE SOUND. 
 
 I have already stated that the instrument which I employ is 
 somewhat similar to a small male catheter. It is, moreover, pro- 
 vided, like the common male sound, with a flat handle, to facilitate 
 its manipulation ; and terminates at its other extremity in a rounded 
 knob or bulb, to prevent injury to the uterine textures.' The inter- 
 vening stem tapers gradually from the handle to the knob, the 
 thickest part being nearly one-fifth of an inch in diameter, equal to 
 the size of a catheter No. 8, and the thinnest part about one-tenth 
 of an inch, or equal to a catheter N'o. 3. The greater thickness of 
 the attached extremity is necessary to give that portion of the 
 instrument the requisite degree of strength and resistance; it is 
 more slender towards its other extremity, to allow of its easily 
 entering into, and being moved in the orifice and canal of the 
 uterus. The terminating bulb is about one-eighth of an inch in 
 diameter. The stem is about nine inches in length, and graduated 
 so as to render its employment, and some of its indications with 
 regard to the measurement of the uterus, more precise. Different 
 modes may be had recourse to in marking it, but the marks, what- 
 ever they may be, must be such that they can be easily felt with 
 the finger while the instrument is within 'the vagina. For this 
 purpose, they must be placed on the convex or posterior surface of 
 the instrument, the surface, namely, with which the directing 
 finger is in contact. The mode of graduation adopted in the 
 instrument I have myself used, and which is figured in the en- 
 graving, is as follows : — At two inches and a half from the extre- 
 mity of the instrument, this measurement being the usual length 
 of the uterine cavity, there is placed a slight elevation or knob, 
 which, in the employment of the Bougie, at once serves to show 
 that it is introduced to the full extent into the interior of the organ, 
 and at the same time forms a fixed or standard point from which 
 the instrument may be farther graduated towards either of its two 
 extremities. This farther graduation is marked by shallow grooves, 
 which may be placed at the distance of either half an inch or an 
 inch from each other, and, by their assistance, it becomes an easy 
 matter to measure the exact length of the uterine cavity, when 
 either it is diminished, or, as much more frequently happens, when 
 it is prolonged to diflerent degrees beyond its usual dimensions. 
 
58 UTEEISE DIAGNOSIS. 
 
 The alternate groove may be double, to facilitate the measurement 
 by the finger. The form of curvature at the extremity of the 
 
 Fig. 1. 
 
 instrument is nearly that of a common catheter, and like it, begins 
 about three or four inches from its point ; but the degriee and 
 extent of this curvature require to be varied according to the 
 necessities of individual cases, and according to the indications 
 which it is wished to bring out. Hence the stem of the Bougie 
 requires to be formed of a metal that admits of being pretty freely 
 and frequently bent without the risk of fracture, and at the same 
 time is capable of adequately maintaining any form that may be 
 temporarily given to it. These objects are fully attained when the 
 stem is made of solid silver, but probably some composition of the 
 inferior metals may also be found to have the necessary combina- 
 tion of pliability and strength. The handle of the Bougie is made 
 of wood or ivory, is about three inches long, three-fourths of an 
 inch at its broadest part, and rather more than a quarter of an inch 
 in thickness. The posterior surface of it is smooth, whilst its 
 anterior surface, or that corresponding to the concave aspect of the 
 Bougie, is roughened, in order to make the operator constantly 
 aware of the direction of the point of the instrument when it is 
 hid in the uterine cavity — a circumstance which we shall after- 
 wards see to be of great importance in reference to some of its 
 diagnostic uses. 
 
 Mode of Introduction. — In introducing the Bougie or Sound into 
 the uterine cavity, the patient may be placed either on her back or 
 left side. If on her back, the fore-finger of the right hand is intro- 
 duced into the vagina, and its extremity brought in contact with 
 the indentation formed in the cervix uteri by the os tincse, so as to 
 act as a guide to the point of the instrument. The instrument itself 
 is held in the left hand, and its point slipped along the palmar sur- 
 face of the finger in the vagina, and directed by it into the uterine 
 orifice. If the patient is placed on her side, she must lie with her 
 body directly across the bed — a position which facilitates greatly 
 the manipulations required both for common tactile examination, 
 and for examination by the Sound and Speculum. In this case 
 the fore-finger of the left hand is used as a guide to the os uteri, 
 and the instrument is held in and directed by the right. In some 
 
MODE OF INTRODUCINa THE SOUND, 59 
 
 instances where the parts are very lax, and the cervix uteri in any- 
 way displaced, the introduction of the Bougie is facilitated by pass- 
 ing both the fore and middle fingers into the vagina, fixing the 
 cei-vix with them in the axis of the passages, and gliding the instru- 
 ment along the groove between the two up to the os. In whichever 
 of these ways the Sound is guided up to and passed within the os 
 uteri, it generally afterwards glides easily, under a slight propulsive 
 force, along the canal of the cervix and body, till, as shown by the 
 elevated mark already alluded to as placed on the stem, its extre- 
 mity has passed onward to the fundus of the organ. Sometimes 
 the extremity of the instrument is slightly obstructed about an inch 
 or less within the os tincse, by the natural contraction existing there 
 between the cavity of the cervix and cavity of the body. This ob- 
 stacle is easily overcome by a little additional impulse, or, if that 
 fail, by slightly retracting and altering the direction of the point of 
 the Sound. The direction which the instrument should naturally 
 follow in passing along the uterine canal, must always be held in 
 view. In the normal condition of the parts, the uterus and vagina 
 meet at a considerable angle, the former passing upwards and at 
 the same time considerably forwards, and varying somewhat its in- 
 clination with the varying degrees of distension of the bladder and 
 rectum. In using the Bougie, therefore, supposing the organ to be 
 in the natural position, its concavity should be directed forwards to- 
 wards the walls of the abdomen ; or, in other words, it should be 
 passed in the same direction as in most other manipulations in this 
 part of the body, namely, in the line of the axis of the brim of the 
 pelvis. 
 
 The degree of uneasiness felt by the patient during the passage 
 of the instrument is in general veiy trifling, and not more, if so 
 much, as is felt on passing the catheter along the urethra of the 
 female, and certainly not by any means nearly so great as in using 
 the Sound or Bougie in the male. In a few cases, I have seen it, 
 like the passing of the sound in the male, produce a feeling of sick- 
 ness and nausea. In the healthy state, however, of the organ, the 
 lining membrane of the uterus does not in fact appear to be more 
 sensitive than that of the vagina, so that the existence of any true 
 and actual pain in making the examination with the Bougie is to be 
 considered so far anormal, that it is generally, as we shall after- 
 wards see, indicative of the existence of some morbid state or other 
 of the part or parts with which the extremity of the instrument is 
 at the time in contact. 
 
 In the average run of cases, the introduction of the Sound into 
 the uterine cavity is probably not more difiicult to accomplish than 
 the introduction of the catheter into the bladder of the female. The 
 
60 THE UTERINE SOUND 
 
 OS uteri is, in fact, usually much more easily and certainly detected 
 by the finger, than the orifice of the urethra; and generally the one 
 and the other instrument passes readily along its appropriate canal 
 after it has once entered it. If it is otherwise, the very difficulty 
 may be in itself important, as marking the existence of some anormal 
 and probably diseased state. It is almost unnecessary to add, that 
 the power of passing either instrument with perfect facility and cer- 
 tainty, is only to be gained by a little perseverance in the practical 
 employment of them. 
 
 The manner in which the instrument should be manipulated, 
 after it is fully introduced into the uterine cavity, varies according 
 to the object or objects which we wish to ascertain. The mode of 
 using it with these views will be best explained by now pointing out 
 individually, and at some length, the difierent diagnostic indications 
 which it is capable of fulfilling. 
 
 USES OF THE UTEEINB SOUND. 
 
 I. The Sound increases to a great degree our power of making a perfect and precise tactile 
 examination of the Fundus, Body, and Cervix of the Uterus. 
 
 I have already stated, that the body and fundus of the uterus are 
 so deeply included in the cavity of the pelvis, and at the same time 
 are generally so mobile under the pressure of the fingers, whether 
 applied to the organ from above or below, that it is difficult to ascer- 
 tain anything precise with regard to the condition of these parts, 
 either by a common vaginal, or by a hypogastric examination. 
 
 The obstacles which thus so effectually oppose an accurate and 
 complete tactile investigation of the surfaces and walls of the body 
 and fundus of the uterus, may be in most cases, in a great measure, 
 overcome by the aid of the Uterine Sound, if we employ it for the 
 double purpose — first, of giving sufficient resistance to the organ for 
 its exploration by the fingers ; and secondly, of altering the position 
 of its parts, so as to bring them each successively within the reach 
 of tactile examination. 
 
 When the pliable and mobile uterus is held steady by the sound 
 being placed in its cavity, and the central axis of the organ is for 
 the time being thus rendered, as it were, firm, and solid — the exami- 
 nation of its external surface and of its walls becomes a matter of 
 far more certainty and accuracy than if we had the organ indefinitely 
 yielding and receding before each slight touch of the fingers. 
 
 But besides thus rendering the organ fixed and resistant for our 
 examination, the Uterine Sound will, as a diagnostic means, be 
 found of still greater use and importance, by the control which its 
 
RENDERS TACTILE EXAMINATION MORE PRECISE. 61 
 
 presence in the uterine cavity gives us over the position of the whole 
 organ, and by its enabling us to alter at will the situation of the 
 viscus to such a degree, that we can in succession bring within the 
 range of a tactile investigation different parts of its external surface 
 and parietes, that are generally considered to be entirely beyond our 
 reach. In reference to this remark, it must be specially kept in 
 mind that in the healthy state the uterus is so loosely fixed in its 
 situation in the pelvic cavity, that its position is capable of being 
 changed to a very considerable extent, without incommodity or 
 injury, by such exteriqr influences as may naturally or accidentally 
 act upon it. Its position is so far constantly changed by the varying 
 states of distension of the bladder and rectum. Under voluntary 
 efforts of straining, it can in general be readily pushed down half an 
 inch or an inch in t^e cavity of the vagina. It may be drawn down 
 by instruments till the cervix reaches the external parts themselves, 
 or even protrudes beyond them — a circumstance which facilitates 
 immensely the operation of excision of this part of the organ. In 
 consequence of the same anatomical peculiarity, we are able, through 
 the use of the Uterine Bougie, to move the organ upwards, forwards, 
 &c., to such degrees as are requisite for a complete hypogastric 
 examination, without in general causing any marked inconvenience 
 or pain to the patient.^ 
 
 K, after the bougie is introduced into the uterine cavity, we carry 
 the handle backwards towards the perineum, the upper extremity 
 of the instrument — and consequently the fundus uteri placed upon 
 
 ^ In corroboration of the statements in the text witli regard to the natural mohility of the 
 uterus, I would beg to fortify the remarks I have there made, by quoting upon the subject 
 the opinions of two of the latest authors who have adverted to this particular point — Cru- 
 veilhier and Lisfranc. When speaking of the uterus, in his excellent System of Descriptive 
 Anatomy, Cruveilhier observes, " The looseness and extensibility of its connections enable 
 it to float, as it were, in the cavity of the pelvis, and to be moved to a greater or less 
 extent. The facility with which it can be drawn towards the vulva in certain surgical 
 operations, and its displacement during pregnancy, when it rises into the abdomen, are 
 proofs of its great mobility." — Vol. i. p, 61S of Dr. Madden's translation. Lisfranc's obser- 
 vations are still stronger. " There is," he remarks, " a physiological fact of importance, but 
 little known, and which hitherto has scarcely been alluded to by any writer. The uterus 
 in the normal condition, and even when affected with engorgement, has a truly extraordi- 
 nary mobility. To prove this, a very simple experiment will suffice. Let a speculum be 
 introduced as high up the vagina as possible, so as to embrace the cervix uteri within its 
 upper extremity ; then bid the patient bear down as if at stool ; and you will perceive that 
 as the instrument descends, the uterus follows it to the extent of one, or even of two 
 inches j an immense advantage when the surgeon wishes to bring down the uierus to near 
 the vulva. In cases requiring operation about the cervix, all that the surgeon has to do is, 
 to lay hold of the os uteri witli a hook, and draw it gently down, until it comes fairly 
 within sight; this may be effected without difficulty, and with very little inconvenience to 
 the patient." — Translated from the second volume of the Clinique de la Pitie, into the 
 Medioo-Chirurgical Review, for April, 1843, p. 360. 
 
62 THE UTBEINE SOUND. 
 
 that extremity— will be proportionally moved forwards into the 
 hypogastric region. One hand placed above the pubes will now 
 feel the fundus uteri with the central and thinnest part only of the 
 abdominal parietes intervening between the fingers and the surface 
 of the uterus. Provided the woman be not of a full habit, and the 
 abdominal muscles sufficiently relaxed by position, we can now 
 pretty accurately examine with the hand placed on the hypogastric 
 region, the state of the uterus as it is held forwards on the end of 
 the bougie, and we may always make ourselves still more certain of 
 its condition by retracting and otherwise moying the handle of the 
 instrument so as to bring the different parts of the superior and 
 anterior surfaces of the uterine tumor under the touch of the fingers. 
 By a slight turn of the instrument to either side, the lateral surfaces 
 of the upper part of the viscus may, in the same way, be brought 
 under our tactile examination ; and in spare subjects, I have occa^ 
 sionally found it possible, when the fundus was pushed against the 
 abdominal parietes, to extend the manual examination to some dis- 
 tance along the posterior "wall of the organ. 
 
 In those cases where this cannot be effected, the sound still enables 
 us to make a more perfect tactile examination of this — ^the posterior, 
 part of the uterus, than we could otherwise effect, by giving us the 
 power of temporarily depressing and reflecting its posterior wall, so 
 that it may be felt by a rectal examination. The vaginal examina- 
 tion of the lower part of its anterior surface may be in general ren- 
 dered more complete, by a similar aid from the instrument. 
 
 In these different steps of examination, the degree and accuracy 
 of the information obtained is varied in different individuals by the 
 differences which exist in the thickness of the tissues placed between 
 the uterine surface and the fingers ; but in most instances the pre- 
 sence of any marked irregularity in the uterine structures — such as 
 the presence of one or more small fibrous tumors — ^their hyper- 
 trophic thickness, &c., may be readily made out — and, under still 
 more favorable circumstances, the exact physical conditions of the 
 organ in relation to its volume and dimensions, the morbid ten- 
 derness of individual parts of it, &c., may be precisely determined. 
 
 When we employ the sound for the purposes alluded to in the 
 preceding sentences, namely, for enabling us to make hypogastric 
 examinations of the fundus and body of the uterus, the instrument, 
 before its introduction, should have its extremity bent upon its stem 
 at as nearly a right angle as the conformation of the genital canals 
 admit, and, after being introduced, its handle should be well retracted 
 towards the perineum. By attending to these circumstances, the 
 fundus and body of the uterus will be more easily and fully turned 
 forwards, and our examination of them very much facilitated. The 
 
EXAMINATION OF BODY AND FUNDUS OF UTERUS. 63 
 
 same object will also be much promoted by retaining the directing 
 finger at the cervix during the course of the examination, both to 
 steady the instrument and to serve as a fulcrum to it. In that case 
 the handle may be retracted or pushed backwards to any required 
 degree by the forearm, while the other hand is employed in the 
 hypogastric examination. 
 
 The preceding remarks apply to the examination of the fundus 
 and body of the uterus, parts which — unless when much enlarged, 
 or the patient very thin — are generally looked upon as beyond reach 
 of any physical diagnosis. 
 
 The physical states and relations of the cervix uteri are generally 
 ascertainable by the finger alone. Still, in various morbid conditions 
 of the cervix, our tactile examination of the organ may be much 
 promoted by the assistance of the bougie introduced into the uterine 
 cavity. For instance, in chronic enlargement, cauliflower excre- 
 scence, and other organic diseases of that part, it is sometimes a 
 matter of moment, both as regards our prognosis and our treatment, 
 to ascertain if the existing diseased state stretches upwards so far as 
 to involve or not the lower portion of the body of the uterus. In 
 several such cases, I have found much assistance in determining 
 this point by gently depressing the uterus by the bougie introduced 
 into it, and having the power thus of examining the organ, imme- 
 diately above the cervix, by compressing the structures of that part 
 between a finger or two in the vagina, and the resistant sound placed 
 in the uterine cavity, and consequently in the very axis of the viscus. 
 In this way, each point in the circumference of this portion of the 
 organ may be successively examined. 
 
 These observations apply generally to such indications as can be 
 made out through the use of the bougie, when the uterus still retains 
 that freedom of motion which we have seen it to possess, when it is 
 itself in a healthy condition, and when there are no obstructions or 
 impediments to its mobility in the surrounding parts. But there are 
 cases where, from the organ having become more or less fixed and 
 immobile, no advantage can be taken of those facilities which the 
 power of partially displacing it in general allows us. In these 
 instances, the very circumstance, however, of the mobility of the 
 organ being lost, and still more the degree and extent of its immo- 
 bility, often materially assists in pointing out the true nature of the 
 affection that is present. Thus in scirrhus of the cervix, the early im- 
 mobility of that part, in consequence of the morbid degeneration in- 
 vading the contiguous tissues from almost the very commencement of 
 the disease, is often one of the first and l^est characteristics of that 
 dreaded malady. In this instance, the fixed state of the cervix of the 
 organ is detected by the direct application of the finger. In other states 
 
64 THE UTERINE SOUND. 
 
 of disease, the cervix remaining comparatively free and unaffected, 
 the body and fundus may be immobile from various pathological 
 causes, as from morbid adhesions, the consequence of inflammation 
 of its peritoneal surface, from the pressure of tumors or abscesses, 
 &c. Or, again, both cervix and fundus may be immobile at the same < 
 time, from general carcinoma of the organ, &c. In all these cases 
 the immobility of the body and fundus, its degree, extent, and seat, 
 can only be discovered by the bougie ; and its use, along with other 
 considerations, may further lead us to detect the special pathological 
 state that may be the cause of the morbid attachment or fixture of 
 these parts of the organ. 
 
 II. — The previous introduction of the Sound facilitates and simplifies the subsequent Visual 
 examination of the Cervix Uteri with the Speculum. 
 
 In employing the speculum uteri, the principal obstacle which 
 we have to contend with, is the impossibility of always catching 
 easily and accurately the os and cervix uteri in the upper or internal 
 extremity of the instrument, so that these parts may be brought at 
 once and completely within the range of sight. Indeed the search 
 after the cervix uteri, when it is not at first caught in the open end 
 of the speculum, is sometimes so painful to the patient, and this 
 part of the manipulation is occasionally so difficult to the operator, 
 that every one who has made much use of the speculum will, I 
 believe, be ready to confess that in some cases where the uterus is 
 situated obliquely, or where the cervix is high and displaced, the 
 object is almost impossible of attainment.^ The previous introduc- 
 tion and use of the uterine sound, oflfers a simple and certain means, 
 both of overcoming the difficulty in question, and of facilitating the 
 employment of the speculum in our ordinary cases of examination 
 with that instrument. After making such tactile examination as 
 may be required with the sound, leave it in the uterine cavity, and 
 using it as a general guide, slip the uterine extremity of the speculum, 
 whether tubular or bladed, over its handle and along its stem, till 
 the instrument be fully introduced. The upper or uterine extremity 
 of the speculum is thus guided with almost unerring certainty along 
 the stem of the sound, till the cervix uteri is touched and included 
 in its opening. Further, if we still keep the sound in the uterus, 
 we have in it a means of turning the cervix to one or other side at 
 will, so as to give ourselves a complete view of the mucous mem- 
 
 ' Thus, in their excellent Treatise on Diseases of the Uterus, Boivin and Duges state that 
 " The cervix uteri is sometimes so inclined backward that the speculum cannot show it by 
 any movement." — Heming's Translation, p. 33. See, also, Lisfrano's Lectures as reported 
 by Pauly, Maladies de I'Uterus d'apr&s les Leyons Cliniques de M. Lisfrano, Paris, 1836, 
 pp. 59, 60; and TSallier, Du Cancer de la Matrice, pp. 70, 71, &c. 
 
RELATIONS OF PELVIC AND HYPOaASTEIC TUMORS. 65 
 
 brane covering the wliole vaginal surface of this part of the organ. 
 This last step in the examination is much facilitated by first drawing 
 aside the stena of the bougie into the cleft between the two blades 
 of the speculum — provided we are using a double-bladed instrument. 
 In making these remarks, I presuppose that the patient, during 
 the employment of the sound and speculum, is placed upon the 
 left side in bed, in the position already pointed out as most favorable 
 for making a common tactile examination. "When occupying this 
 position, with, as previously recommended, the body laid across the 
 bed, the speculum can be employed with perfect ease and success, 
 and, at the same time, without any of that revolting exposure of 
 the person of the patient, which is unavoidable when she is turned, 
 as is so commonly practised, upon her back during this operation. 
 The instrument can be introduced readily without the assistance of 
 sight, and if the bed and body-clothes be placed with a little care in 
 contact with the surface of the patient, and the latter be closely 
 arranged around the tube of the instrument, the mouth of the 
 speculum is the only part which actually requires to be uncovered 
 in order to enable us to examine the cervix uteri and canal of the 
 vagina, and there ascertain those changes of color, superficial altera^ 
 tions of structure, &c., that the speculum is occasionally of so great 
 service in divulging, and by which we may have an opportunity, in 
 doubtful instances, of either confirming or correcting the previous 
 evidence afforded by the sense of touch. 
 
 III. — By the use of the Uterine Sound we may, in many instances of Pelvic and Eypogastric 
 or Abdominal Tumors, ascertain the connection or non-connection of these Tumors with the 
 Uterus. 
 
 "We have already seen the advantages of having the uterus fixed 
 upon the bougie in facilitating the tactile examination of the outer 
 surface of the organ. This use of the sound is of still greater im- 
 portance, when a chronic pelvic, or hypogastric tumor is present, 
 and we wish to ascertain whether this additional structure has its 
 origin in, or any connection with, the tissues of the uterus, or is 
 attached to some of the neighboring parts or organs. The power 
 of making such a distinction leads, in some instances, to practical 
 distinctions in the treatment, and in almost all cases to diSerences 
 with regard to our opinion of the future progress of the disease. 
 The prognosis, for example, is very different in ovarian dropsy, and 
 in enlargement of the uterus from the presence of a large mass of 
 fibrous tumors in its walls. I have found, however, no mistake to 
 be more common in practice, than to suppose a tumor in the hypo- 
 gastric or iliac region to be an enlarged and dropsical ovary, when 
 it actually consisted of the other much less formidable disease of a 
 
 VOL. I. 5 
 
66 THE UTERINE SOUND. 
 
 great mass of fibrous tumors in the uterine structures. When 
 these fibrous tumors "attain," to quote the words of Dr. Lee, "a 
 large size, and come to occupy a great part of the abdominal cavity, 
 they produce all the injurious consequences of enlarged ovaria, 
 from which indeed during life, they are distinguished with the 
 greatest difficulty."* " It is often," says Dr. Ashwell, " exceedingly 
 difficult where a growth, occupying the abdominal cavity, is large, 
 filling perhaps its greater portion, to determine whether the uterus 
 or ovary, or both, may not be diseased."^ This difficulty is, in some 
 cases, more or less removed by the evidence aflbrded by the use of 
 the uterine sound. 
 
 When the tumor which is present is uterine, and consists of 
 either some general or partial enlargement of that organ, I have 
 usually been able to gain satisfactory evidence of the fact by the 
 bougie, when passed into the uterine cavity, entering, as it were, 
 more or less directly into the very structure of the morbid mass, 
 and by the tumor and instrument afterwards reciprocally moving in 
 exact correspondence with all the possible motions imparted re- 
 spectively to each of them. 
 
 In other instances, where the tumor is not uterine, I have repeat- 
 edly made myself and others certain of the fact, by first introducing 
 the bougie, and so far giving us at once a knowledge of the exact 
 position of the uterus, and a control over its movements, and then 
 proceeding in one of three ways : — 1. The uterus may be retained 
 in its situation with the bougie, and then, by the assistance of the 
 hand above the pubis, or by some fingers in the vagina, the tumor, 
 if unattached to the uterine tissues, may be moved away from the 
 fixed uterus : — 2. The tumor being left in its situation, it may be 
 possible to move away the uterus from it to such a degree as to 
 show them to be unconnected : — or, 3. Instead of keeping the 
 uterus fixed and moving the tumor — or fixing the tumor and mov- 
 ing the uterus, both may be moved simultaneously, the uterus by 
 the bougie, and the tumor by the hand or fingers, to opposite sides 
 of the pelvis, to such an extent, as to give still more conclusive evi- 
 dence of the same fact. In a case, for example, which I saw 
 during the last winter, there were two distinct, firm, defined tumors 
 to be felt at the brim of the pelvis when the hand was placed above 
 the pubis. The smaller of these tumors was placed to the left, and 
 somewhat anterior to the other. The two tumors lay so close as to 
 seem to be connected with each other, and this, with their semi- 
 globular form, impressed the physician who had charge of the case 
 with the belief, that his patient had one of those masses of roundish 
 
 ' CyclopEedia of Medicine, vol. iv. p. 388. 
 
 * Practical Treatise on the Diseases peculiar to Women, Part ii. p. 291. 
 
RELATIONS OF PELVIC AND HYPOGASTRIC TUMORS. 67 
 
 fibrous growths affixed to the uterine walls, that I have already 
 spoken of as not unfrequently met with in this part of the body. 
 The hypogastric examination of the swelling induced me at first to 
 adopt the same opinion, but the employment of the bougie readily 
 showed us to be both in error. The instrument, when introduced 
 through the os into the uterine cavity, passed directly upwards to 
 the top of that tumor which lay towards the left side, and the apex 
 of the sound could be felt through the intervening tissues, at once 
 demonstrating that this apparent tumor was formed by the fundus 
 of the somewhat enlarged and displaced uterus. Eetaining the 
 instrument in this position, the uterus was next moved by means of 
 the bougie still further to the left, whilst the other tumor was at the 
 same time pushed still further to the right or opposite side, by the 
 pressure of the hand, with such ease and to such an extent, as to 
 prove that it had no immediate organic connection with the uterus. 
 The further examination of the tumor on the right side — its rounded 
 form and other physical characters — its position behind the broad 
 ligament, &c., showed it to be ovarifin. Without, however, the aid 
 of the' bougie, the two hypogastric swellings in this case would 
 assuredly have passed for uterine fibrous tumors, instead of the one 
 being formed by the fundus of the uterus, and the other by an 
 enlarged ovary. 
 
 The rules of diagnosis which I have been stating, evidently 
 apply only to those cases in which the uterus and pelvic or hypo- 
 gastric tumor are neither organically adherent to each other, nor so 
 closely wedged together as to render them mutually immovable. 
 But it often happens, that, in consequence of the existence of one 
 or more of these lastrmentioned conditions, none of the tests that I 
 have just now spoken of can be applied, and in such instances the 
 bougie affords no very affirmative evidence. Still, however, the 
 knowledge which we can gain by it, and by it alone, of the state of 
 the uterine cavity, of the increased or diminished length of that 
 cavity, and especially of its relative situation and direction in regard 
 to the existing morbid mass, are calculated in some of these more 
 difficult and comphcated instances to afibrd no small degree of as- 
 sistance in the diagnosis. 
 
 In one common set of cases, the knowledge of the exact situation 
 of the uterine cavity, and hence of the uterus itself, in relation to 
 the tumor that is present, even when both were immobile, has in 
 repeated instances appeared to me especially important. The ovary 
 normally lies behind the uterus, being attached to the posterior sur- 
 face of the broad ligament. If, therefore, in a case of chronic 
 tumor situated in the pelvis, the sound shows the tumor to lie on 
 the anterior surface of the uterus ; or, in other words, if the uterine 
 
68 THE TJTEEINE SOUND. 
 
 cavity runs up tlie posterior surface of the morbid mass, the disease 
 may be considered as certainly not ovarian, and the farther difficul- 
 ties of the diagnosis will thus be so far very much simplified by 
 ■way of exclusion. This remark particularly applies to those cases 
 in which the tumor, of whatever nature it may be, is still not so 
 large as to have passed out of the pelvic cavity and become abdo- 
 minal. 
 
 I have found, however, advantage from the negative information 
 given in other ways by the bougie, even when the tumor was 
 abdominal in its seat. An example will best illustrate my meaning. 
 In a case sent to Edinburgh a few months ago, for the purpose of 
 having some opinion given in regard to its nature, an immense 
 abdominal swelling that was present, and which had been supposed 
 by some medical gentlemen who had seen the patient to be ovarian, 
 was shown not to be so, by sufficient evidence of the following 
 nature. The uterus was displaced obliquely backwards and the 
 fundus of the bladder was displaced towards the right iliac region 
 by the abominal enlargement — circumstances which were easily 
 ascertained by introducing the uterine sound into the cavities of 
 both of these organs. Further, the uterus, though displaced, was 
 quite mobile: and when its fundus was turned by the bougie to- 
 wards the site of either ovary, and the abdominal tumor lifted at 
 the same time as high as possible towards the epigastrium, no ob- 
 struction was met with, nor was this great change upwards in the 
 direction of the tumor found to produce any dragging effects what- 
 ever upon the uterus as held by the bougie, or upon its connections 
 — effects which, unless under the improbable supposition of a pedicle 
 several inches long, would have inevitably occurred if the diseased 
 mass had originated in or was connected with the ovaries or uterine 
 appendages. So far, the evidence was negative, but still, neverthe- 
 less, important. I may add, that other characters of a more posi- 
 tive nature — the history, particular form, and consistence of the 
 tumor — ^its position in front of the intestines as ascertained by per- 
 cussion, &c. &c. — seemed to show it, seeing that it was not ovarian, 
 to be in all probability one of those hydatigenous tumors that some- 
 times form in the tissue of the omentum, and whose physical 
 symptoms during life in many respects correspond with those of 
 ovarian dropsy. 
 
 In a case, in which a very large hard and solid tumor was situ- 
 ated in the mesial line of the abdomen, and had been growing for 
 years, the aid of the uterine bougie assisted us greatly in making 
 a diagnosis of its pathological seat and character, by a kind of evi- 
 dence which was exactly the reverse of that stated in the preceding 
 instance. In the case we speak of, the os uteri was in its usual 
 situation in the pelvis ; the bougie, however, after passing through 
 
NEGATIVE INFORMATION AFFORDED, 69 
 
 it, glided onwards, obliquely forwards, and towards the left, showing 
 the body of the uterus to be displaced in that direction. Farther, 
 it was ascertained, by moving the bougie in the uterine cavity, that 
 the progress of the uterus towards the right side was entirely pre- 
 vented by the presence of the opposing morbid mass, whilst it could 
 be moved to the left side to a slight extent, but still so much so as 
 to show that its surface was not immediately adherent to the tumor. 
 Holding the bougie in the uterus, with a finger in contact with the 
 cervix uteri, the body of the growth was next strongly pushed both 
 upwards and to the right, with the other hand placed upon the lower 
 part of the abdomen. When so moved, the tumor distinctly pulled 
 upwards along with it the uterine bougie, and consequently, the 
 uterus itself. The whole examination by the bougie thus showed ; 
 — ^that, first. The tumor was not a fibrous growth developed in the 
 uterine structure, or intimately attached to its exterior surface, be- 
 cause the body of the uterus, though displaced by the presence of 
 the growth, was still movable to a certain degree independently of 
 it ; secondly, It was probably an enlarged ovary, or tumor connected 
 with the ovary or uterine appendages, because when moved upwards 
 or to the right, it dragged the uterus along with it ; thirdly, Though 
 mesial in its position, it was attached to the side of the right ovary, 
 or to the posterior surface of the right broad ligament, because the 
 body and fundus of the uterus were displaced forwards and towards 
 the left, and had some remaining mobility in that direction, but 
 could not be moved by the bougie in any degree backwards or 
 towards the right side, in consequence of the presence of the oppo- 
 sing mass of the tumor. These circumstances in the physical diag- 
 nosis of the tumor, as ascertained by the bougie, were confirmed by 
 the other symptoms of the case ; but these other symptoms would 
 certainly, in consequence of the equivocal character and position of 
 the tumor, have been in themselves insufficient to have fixed its 
 true pathological seat and character. 
 
 In the preceding remarks, I have pointed out the uses of the 
 uterine bougie, in so far as they aid our examination of the exterior 
 of the uterus, or of the outer surface of the Fundus, Body, and Cer- 
 vix, and enable us to distinguish between tumors of the uterus 
 itself, and those situated in structures altogether external to it. 
 
 In continuing the subject in my next communication, I shall at- 
 tempt to state the still more important uses to which the instrument 
 can be put, in examining the interior of the organ, and the state of 
 its walls, and in determining the presence of those common but 
 hitherto little known forms of displacement that pass under the 
 names of retroflexion, anteflexion, &c. I shall take the same oppor- 
 tunity of showing the circumstances which counter-indicate the use 
 of the sound, and the cautions required in its employment. 
 
70 
 
 THE UTERINK SOUND. 
 
 SECTION III. 
 
 ON THE MEASUREMENT OF THE CAVITY OP THE UTERUS AS A MEANS OP 
 DIAGNOSIS IN SOME OF THE MORBID STATES OF THAT ORGAN. 
 
 (London and Edinburgh Journal of Medical Science, Nov. 1843, p. 1009.) 
 
 No organ of the body is, in its normal and physiological state^ 
 more subject than the uterus to great and striking alterations of 
 volume. Witness its rapid increase during pregnancy, and its still 
 more rapid diminution in the puerperal female. In some of its 
 anormal and pathological conditions, the same organ strongly dis- 
 plays the same tendeney to enlarge in different directions and di- 
 mensions. "1^0 tissue," observes Cruveilhier, "is more extensible, 
 more malleable (jilus extensible, flus malleable), than the tissue of the 
 uterus, when it has undergone the softening which, constantly ac- 
 companies its hypertrophy. It becomes elongated and extended in 
 all directions ; and it is only when its distension is carried beyond 
 measure, that upon its hypertrophy supervenes atrophy."' Again, 
 on the other hand, the cavity of the unimpregnated uterus is so 
 small, and its canal of communication with the vagina is so narrow, 
 that they are liable to be found more or less obliterated by malcon- 
 formation or disease ; while the uterine walls themselves are some- 
 times observed, by their partial displacement and inversion, to 
 shorten, and even to efface the internal cavity of the viscus. 
 
 The changes in the capacity and dimensions of the uterus, which 
 are thus so often produced by disease, have been long well known 
 to the pathological anatomist. They have hitherto, however, in a 
 great measure, escaped the observation of the medical practitioner, 
 because, though frequently discovered by him upon the dead body, 
 he possessed no certain means of detecting their presence during 
 the lifetime of his patient. In the following communication, it is 
 my purpose to show, that this blank in uterine pathology may be 
 filled up, and that we can ascertain, by means of the bougie, with 
 sufficient facility and precision, upon the living subject, the varying 
 sizes of the uterine cavity. And here, as in all other cases in which 
 physical signs have enabled us to determine pathological lesions 
 during life, we shall find that the knowledge of them may be 
 rendered of the highest avail in diagnosis and practice. 
 
 With these views, we shall attempt to illustrate, as our next pro- 
 position, with regard to the uses of the instrument which we are 
 describing, that 
 
 IV. — The Uterine Bougie ia capable of affording valuable diagnostic information, by enabling 
 us to measure the Length of the Uterine Cavity. 
 
 The uterus varies in its dimensions, and consequently in its length, 
 
 ' Anatomie Pathologique, livr. xiii. 
 
INCREASED LENGTH OF UTERINE CAVITY. 71 
 
 in different persons, independently both of pregnancy and disease. 
 In the unimpregnated state, and in its normal and healthy condi- 
 tion, I have found the cavity of the organ to measure, on an average 
 of a pretty extensive number of observations made both upon the 
 living and dead body, about two inches and a half from the os to 
 the fundus. The bougie has, as already stated, an elevated mark 
 upon its stem at this distance, two inches and a half, from its point, 
 for the purpose of showing whether or not the instrument is com- 
 pletely introduced into the uterine cavity. The cavity is, in its nor- 
 mal varieties, more often above than below the standard. Further, 
 the instrument, as previously mentioned in the description that has 
 been given of it, is so graduated by inch or half-inch marks upon 
 its stem, as to indicate, when it is introduced up to the fundus uteri, 
 the exact degree of elongation, or of shortening of the interior of 
 the organ. In illustrating its utility in this respect, I propose to 
 demonstrate its application to the discovery, first, Of some morbid 
 states in which the uterine cavity is preternaturally increased; and, 
 secondly, Of others in which it is preternaturally diminished in 
 length. In the present communication, we shall limit our attention 
 to the first of these divisions, or to 
 
 INSTANCES OF INCEEASED LENGTH OF THE UTERINE CAVITY. 
 
 The cavity of the uterus may be found elongated under a variety 
 of circumstances which we shall consider somewhat in detail. 
 
 1. Morbid Permanence of the State of Puerperal Hypertrophy. — 
 This peculiar condition does not appear to have as yet attracted 
 the attention of obstetric pathologists, as the cause of one of those 
 forms of chronic hypogastric tumors that are occasionally met with 
 during the first weeks and months after delivery. The want of any 
 decisive means of recognizing it has doubtlessly led to this omission. 
 The notes of a case will show better than any comment, the nature 
 of the affection to which we allude, and the facility and certainty 
 vrith which it may be recognized by means of the uterine bougie. 
 
 During the summer of 1842, I attended, along with Dr. Aber- 
 crombie, a lady, who, after a premature confinement in the country, 
 had suffered from a smart attack of puerperal fever. After so far 
 recovering for a few weeks she was sent from a considerable dis- 
 tance into town, to be treated for what appeared to be a large tumor, 
 stretching upwards from the pelvis into the right iliac region. The 
 tumor had not been observed before delivery, and was somewhat 
 painful to the touch. It seemed at first sight extremely doubtful 
 whether the mass consisted of an inflamed uterine fibrous tumor, or 
 enlarged ovary, or of one of those chronic purulent collections 
 
72 THE UTEKINB SOUND. 
 
 whicli are apt to form towards one or other iliac region in connection 
 witli puerperal fever or inflammation. The sound, when introduced 
 into the os uteri, passed easily and directly upwards for several inches 
 to the superior end of the tumor, and its apex could be felt there by 
 the hand placed externally. This at once showed the supposed 
 diseased mass to consist of the enlarged uterus. Further examina- 
 tion proved that there was nothing strictly abnormal about the 
 uterus except its great size. In fact, it was a case where the organ 
 had apparently remained nearly undiminished after delivery, pro- 
 bably from the puerperal attack arresting the usual progress of its 
 absoi-ption and diminution. It decreased rapidly and fully under 
 leeches and other local antiphlogistic treatment.' 
 
 May not some instances of pelvic or hypogastric swellings after 
 delivery, which have been recorded by Puzos and others^ as lacteal 
 collections {depdts laiteux) or inflammatory eflfusions, and that ulti- 
 mately yielded without suppuration, be of the above nature ? The 
 lateral position of the swelling is, as shown by the preceding case, 
 not a sufficient criterion. 
 
 In one of those cases of subacute inflammatory tumors that occa- 
 sionally form in the pelvis of the puerperal female, and that lately 
 came under our care, the information aflForded by the sound was per- 
 fectly the reverse of that obtained in the preceding instance, and yet 
 still of considerable importance. I did not see the patient till nearly 
 two months after her confinement. She had not regained much 
 strength, and there were symptoms present which indicated a degree 
 of subacute inflammation in the region of the uterus. A rounded 
 and circumscribed tumor could be readily felt rising from the pelvis 
 to the height of an inch or two above the brim of the pelvis. Was 
 this a swelling resulting from some limited inflammatory effusion 
 among the pelvic viscera ? was it the uterus itself, or some neigh- 
 boring organ, enlarged and diseased ? or what was its nature? On 
 passing the bougie through the os uteri, which was a matter of some 
 
 ' Long after the above case and the observations preceding it were written, I met with 
 Jhe following passage in Dr. Hooper's work, showing that the diseased state that I had recog- 
 nized during life, was known to him as a post-mortem appearance : " When » fffitus has 
 been recently expelled, it is, in some instances, a long time before the uterus returns to its 
 original state ; and it is larger and softer during the period. I have examined uteri four 
 times their natural size from this cause, two months, and even more, after the f(Etus was 
 expelled." — Morbid Anatomy of the Human Uterus, p. 5. Is this the disease alluded to in 
 Kleinert's Repertorium, Bd. ii. 1838, s. 51, as described by Kopp under the name of Hys- 
 teranesis, in the first volume of his Denkwiirdigkeiten, p. 168? I regret that I have no 
 access to this work, 
 
 2 See Levret's Art des Aocouchemens, p. 168. Des Engorgemens Laiteux dans le Bassin, 
 &c. Deleurye's Trait^ des Aocouchemens, p. 509. Des depots laiteux dans les ligamens 
 larges, &c., &o. In a MS. copy of William Hunter's Lectures, belonging to the College of 
 Physicians, Edinburgh, among the remarks on puerperal diseases, is a short chapter on 
 the " iliac abscess." 
 
PERMANENCE OF PUERPERAL HYPERTROPHY. 73 
 
 difficulty, in consequence of its distance from the vulva, it slipped 
 easily upwards to the top of the hypogastric swelling, and showed 
 the apparent tumor to he the uterus itself, situated much higher, and 
 more anteriorly than usual. It showed farther that the uterine 
 cavity was of its usual length, and consequently that, though dis- 
 placed, the organ was not enlarged. It was, however, found to be 
 firmly fixed in its abnormal position by some morbid cause, which 
 prevented its fundus and body from being moved by the bougie 
 either backwards or laterally. On searching further into the nature 
 of the morbid cause which could thus anormally displace and fix the 
 organ, I found a large swelling situated at the upper part of the 
 vagina, and between the uterus and rectum. It pressed downwards 
 upon the roof of the vagina, and backwards upon the rectum, and 
 pushed upwards the uterus in front. Its extent and situation in the 
 pelvis were made out by a combined rectal and vaginal examination. 
 Its nature was more obscure, and the feeling of fluctuation, if any, 
 was very indistinct. In the presence of Mr. Ziegler, Dr. Keith, and 
 Dr. Murray, a very slender exploring needle was passed from the 
 rectum through the dense walls of the tumor, in order to ascertain 
 whether it contained fluid, and if so, the nature of that fluid. A drop 
 or two of thin pus escaped along the tube of the instrument. This 
 at once satisfied us of the nature of the tumor. I immediately made 
 a larger perforation into it from the bowel with Pouteau's trocar. 
 A quantity of pus escaped, and continued to do so for a considerable 
 time. The local and general symptoms under which the patient 
 was suffering speedily abated, and she has since entirely recovered 
 her general health and strength. The catamenia have returned. 
 The uterus, however, still remains preternaturally fixed and immobile. 
 
 In the case which I have just detailed, the results were to me 
 the more gratifying, inasmuch as some months previously I had 
 seen, in the Lying-in Hospital, an instance of the same disease, in 
 which the afiection proved fatal, from the collection of matter 
 bursting into the general cavity of the peritoneum. On the post- 
 mortem inspection of the body, it was evident that from the thin- 
 ness of the partition intervening between the purulent collection 
 and the cavity of the rectum, the abscess would have soon burst 
 into the bowel, if it had not given way superiorly into the perito- 
 neum itself ; and it was equally evident that an artificial opening, 
 made from the rectum into the purulent sac before the period of its 
 rupture, might have saved the life of the patient. 
 
 M. Martin of Montpellier, who has written one of the best 
 memoirs extant upon this subject,' under the title of Des depdts des 
 
 ' See also among the more recent descriptions of the disease, the observations of Dance 
 and Husson in Breschet's Repertoire d'Anatomie, torn. iv. p. 172 (8vo. edit.); Meniere in 
 Archives G^n^r. de M^decine, torn. xvii. p. 529 ; Grisolle^in ibid. torn. xlix. p. 37 ; Kyll in 
 
74 THE UTERINE SOUND. 
 
 annexes de la Matrice qui surviennent a la suite des Couches,^ recom- 
 mends, in the treatment of the purulent collection, that, in order 
 both to open it externally, and to produce previous adhesions of 
 the containing sac to the abdominal parietes, caustic potass should 
 be applied to that part of the hypogastrium which fornas the most 
 prominent point [le point le plus saillant) of the swelling.' This 
 rule of practice, which seems to have been very successful in 
 M. Martin's own hands, would, if universally followed out as a 
 mode of evacuating the collection, sometimes lead to an irreparable 
 and fatal blunder. In the case that I have detailed, the most pro- 
 minent hypogastric point of the swelling was, as we have seen, 
 formed by the uterus itself, as demonstrated by the bougie. The 
 use of the instrument would easily guard against such a mistake as 
 applying — as might have happened in such an instance — the 
 caustic or knife over the uterus, instead of over the purulent cyst 
 itself. 
 
 In these cases of subacute or chronic purulent collection in the 
 pelvis after delivery, the pus seems to be in the first instance 
 efiused beneath the peritoneum of the uterine appendages, and 
 between it and the pelvic fascia. The original inflammation 
 appears to be seated in the structures intervening between these 
 two membranes. I have seen several cases in the female of chronic 
 "pelvic inflammatory tumors" of the same seat and nature, uncon- 
 nected with the puerperal state, and where the fixed state of the 
 body of the uterus, the surrounding tumefaction, and the apparent, 
 almost ebony induration produced in the roof of the vagina at one 
 stage of the disease, by the tenseness and distension of the pelvic 
 fascia, gave rise to the idea that the affection was organic and car- 
 cinomatous, and not simply inflammatory. I may revert to this 
 subject in a future part. Already the present digression on it is 
 much too long. 
 
 2. Normal Elongation of the Puerperal Uterus as a Sign of De- 
 livery. — ^Immediately after delivery, the uterine cavity is in general 
 froni six to eight inches in length. I have seen it measure between 
 eight and nine inches in three women, who each died within 
 twenty-four hours after delivery, with the organ imperfectly con- 
 tracted. In one of these cases death apparently resulted from the 
 
 Rust's Magazin fur die Ges. Heilkunde, Ed. xli. s. 311 ; Imbert in Ijis Trait^ des Maladies 
 des Fetnmes, torn. i. p. 160 ; Dupuytren in his Le50ns Orales, torn. iii. p. 347 ; Meissner in 
 Kleineit's Repertorium, Bd. vi. 1842, s. 38; Charlton in the Edinburgh Monthly Journal 
 for 1841, p. 329; Doherty in the Dublin Journal for 1842, p. 199. I observe that in the 
 last or September number of the Dublin Journal, my friend Dr. Churchill has published an 
 excellent memoir on this affection, but does not seem to be aware that the disease has 
 already attracted the attention of many modern writers. 
 ' M^moires de M4decine et de Chirurgie Pratique, p. 312. 
 
NORMAL ELONGATION" OF THE PUERPERAL UTERUS. 75 
 
 introduction of air into the venous circulation through the free 
 openings of the uterine sinuses ; the second sank after a twin 
 labor and severe hemorrhage ; the third died about six hours after 
 delivery, having labored under convulsions and deep coma during 
 the vs'hole previous day ; and in both these last cases extensive and 
 well-marked granular disease of the kidney was found on dis- 
 section.' In the course of the natural changes of the puei'peral 
 state, the uterus gradually diminishes and regains its natural size 
 in the course of four or five weeks, and, in some, not till a longer 
 period after parturition. In two cases which I have lately seen, 
 where it was requisite for the purposes of criminal law to ascertain 
 the existence of the signs of delivery, the uterine cavity was, about 
 the seventh day after the accouchement, still between four and five 
 inches in length. In a third case, in which the date of the partu- 
 rition is still uncertain, two most intelligent medical men gave in a 
 report, certifying the existence of all the ordinary signs of deliveiy 
 upon the body of a woman nearly fifty years old, with the single 
 but important exception, that no uterine tumor could be felt by 
 them above the pubis, probably in consequence of the organ being 
 so flaccid or so low in the pelvis, as not to be felt by the common 
 hypogastric examination. Eight days subsequently, I saw the 
 accused along with one of the medical reporters, and at that time 
 found that the uterine cavity still measured fully four inches in 
 length, and that the fundus of the organ could be pressed easily 
 forwards by the end of the introduced bougie, so as to make us 
 both perfectly certain of the existence of enlarged uterine tumor. 
 This completion of the evidence was the more satisfactory, as the 
 person still pertinaciously denied the crime of concealment in con- 
 nection with child-murder, on an accusation for which she was at 
 the time incarcerated, and the proof, independently of the facts 
 ascertained by the medical witnesses, was very vague and uncertain. 
 In this last case, the use of the bougie proved the presence of 
 
 ' The third case alhided to in the text, offered me the first opportunity of confirming, by 
 inspection after death, an opinion tliat I had been led to adopt from the examination of the 
 symptoms during life, and had publicly tanght for the last two sessions, viz., that patients 
 attacked with puerperal convulsions had almost invariably albuminous urine, and some 
 accompanying, or rather preceding, dropsical complications, and hence probably granular 
 renal disease. Pathologists are now well aware of the occasional great tendency to con- 
 vulsions and other head symptoms in patients affected with Bright's disease, and of the 
 influence which that affection has over the progress of both medical and surgical affections. 
 The present occasion is not a proper field to discuss its bearings in relation to parturition 
 and the puerperal state, or otherwise its importance might be easily illustrated. A very 
 able and zealous investigator (Mr. Lever of Guy's Hospital) has already so far entered on 
 the inquiry, by pointing out that, as in one of the cases adverted to in the text, inertia of 
 the uterus and hemorrhage are sometimes the accompaniments, if not the consequences, 
 of an albuminous state of the urine, and granular disease of the kidney. — See Guy's Hos- 
 pital Reports, vol. vii. 1842, p. 325. 
 
76 THE UTEKINE SOUND. 
 
 the enlarged uterus, when, as long as a week previously, it could 
 not be felt above the pubis by an abdominal examination carefally 
 conducted in the ordinary mode. It showed the uterine tumor to 
 exist when it could not be felt by the usual means of examination. 
 In other instances of the same kind, it may prove useful in the 
 converse way, by demonstrating the tumor that may be felt, not to 
 be formed by the enlarged uterus. Dr. Montgomery, in his essay 
 On the Signs of Delivery, justly states, that "the chief points of 
 attention ought to be the state of the uterus, of the external parts, 
 and of the breasts."' But in regard to the first of these, as felt 
 above the pubis, he properly remarks, " a tumor may be felt so 
 situated, and yet may not be the uterus."^ The introduction of the 
 bougie into the uterine cavity would at once decide this point. 
 
 In any doubtful case, the evidence derivable from the measure- 
 ment of the uterus might be made the more complete by repeating 
 it from time to time, so as to note the gradual diminution of the 
 length of the organ, till it ultimately returned to its natural size. 
 
 This sign, like all the other proofs of delivery, can never be 
 relied upon alone, but must always be taken in connection with 
 the other data that are present. It may be considered, however, 
 as an addition to their number, which is the more valuable in this 
 respect, that it can be ascertained at a date later than most of them. 
 To render its evidence still more certain and precise, it would be 
 necessary to know the general rate of diminution in the length of 
 the uterine cavity after delivery, and its variations. An extensive 
 series of observations, both upon the living and dead subjects after 
 delivery, could alone fally determine these points. The exami- 
 nations of puerperal uteri after death, which have been recorded 
 by Euysch, Roederer, Montgomery, &c., will aid in such an inquiry.^ 
 
 In cases of feigned delivery, the sign that we have pointed out 
 from the measurement of the uterus, might be equally useful in 
 demonstrating the organ to be of its normal length and dimensions. 
 
 3. Increased length in Metritic and Congestive Hypertrophy of the 
 Body of the Uterus. — When the body and fundus of the uterus are 
 
 1 Loc. oit. p. 317. 2 Ii,i(i_ p 307_ 
 
 ' I may add, that in one of the ■women above alluded to, and whom I saw in prison, 
 along with Dr. Graham Weir, we detected another sign of delivery, not hitherto pointed 
 out, as far as I know, by any medical jurist. All of them mention the value of the evi- 
 dence afforded by the tactile examination of the os uteri. The visual examination of this 
 part with the speculum afforded in the instances alluded to a still stronger proof The 
 swollen, ecchymosed, and gaping state of the labia and os uteri presented such striking 
 peculiarities, as made it almost impossible to confound it with any other morbid condition 
 of the parts, such as the inequalities, ulcers, &c., attendant on syphilis, and against the 
 similarity to which as ascertained by touch, Gardien {Traili d'Accouchemens, torn. i. p. 132), 
 so particularly guards us. 
 
METRITIC AND CONGESTIVE HYPERTROPHY. 77 
 
 the seat of any continued morbid irritation, the walls of the organ 
 become hypertrophied in the same manner, though by no means to 
 the same degree, or with the same uniformity, as under the con- 
 tinued normal irritation of pregnancy. The most common patho- 
 logical cause of uterine hypertrophy, when uncomplicated with 
 organic disease, is chronic congestion or metritis. It happens in 
 hypertrophy from this source, that, as in cases of excentric hyper- 
 trophy of the heart, the cavity of the organ becomes in general 
 enlarged, along with the enlarged state of the parietes. This en- 
 largement of the cavity generally takes place in all directions, so 
 that it is increased in its length, as well as in its other dimensions. 
 The increase of length or elongation of the uterine cavity, may be 
 ascertained and measured by the bougie. There are as yet few or 
 no precise data which can be referred to, to indicate the degree of 
 hypertrophy and consequent elongation in such cases. In an excel- 
 lent specimen of simple hypertrophy of the uterus, contained in 
 Dr. William Hunter's museum, the length of the cavity of the 
 organ, from the os to the fundus, is exactly three inches and one- 
 fourth. It is set down in the catalogue, as a "Uterus split open 
 from before ; it is the size of the impregnated uterus at two months ; 
 the woman, however, was not pregnant, but had the furor uterinus."^ 
 The hypertrophy and accompanying elongation may be occasionally 
 greater. I have repeatedly found the uterine cavity measuring as 
 much as three and a half inches. When speaking of hypertrophy 
 as a result of chronic metritis, Boivin and Duges observe, that in 
 thi^ state " the uterus is often distended throughout, and its volume 
 assumes the dimensions presented in the second month of preg- 
 nancy." And they add, "In sopie cases it enlarges so as to fill the 
 hypogastrium, and reach the umbilicus."'' " With this state (of 
 simple hypertrophy)," says Dr. Hooper, "the whole of the uterus is 
 of a preternatural size, more especially the body of the uterus, 
 without any other morbid or unnatural appearance ; and this in- 
 crease of size is caused by an unusual formation of the healthy 
 structure of the organ. With regard to the extent of this unnatu- 
 ral occurrence, I have found the uterus more than twice the usual 
 size ; and this may be considered as the mean, or most common 
 size in hypertrophy ; but it is sometimes much larger."^ "I have 
 known," observes Dr. Burns, " the cervix thicker, the body evi- 
 dently swollen, and, if not deluded, the fundus rising above the 
 pubis, and yet the tumor disappear."^ Dr. Hamilton says he has 
 
 ' Printed Catalogue, p. 147, No. 97, g. ^ Chapter on Chronic Metritis, p. 352. 
 
 ' Morbid Anatomy of the Human Uterus, p. 5. 
 
 * Burns's Principles of Midwifery, p. 122, 10th edit. 
 
78 THE UTERINE SOUND. 
 
 seen the "uterine tumor as large as the womb in the fifth month, 
 and yet it was removed."^ 
 
 We would qualify these remarks upon the increased admeasure- 
 ment of the uterus in congestive or inflammatory hypertrophy, by 
 adding that, judging from our own experience of it, probably this 
 mode of physical diagnosis will, in the morbid condition under 
 consideration, be found of more use practically in showing us with 
 sufficient precision the gradual diminution of the organ, and hence 
 the rate of progress towards recovery, under the treatment that we 
 may be following, than in forming by itself, in the first instance, a 
 perfect diagnostic criterion of the original existence of the disease. 
 For we must hold in view, that the length of the cavity of the 
 organ is, from natural conformation, liable in different persons to 
 exceed the usual standard by a few lines, even when no disease is 
 present ; and in chronic hypertrophy the increase of the longitu- 
 dinal dimensions of the uterus will not be to any very marked or 
 notable extent, unless the affection has proceeded to a considerable 
 degree. Besides, there may exist, although we cannot call to our 
 recollection any example of it, a form of metritic enlargement, in 
 which, as sometimes occurs in the heart, the hypertrophy is con- 
 centric, and not excentrie, to borrow the cardiac nomenclature of 
 Bertin, and where the length of the uterine cavity would conse- 
 quently not be increased by the presence of the disease. 
 
 In employing the bougie in the diagnosis of simple hypertrophy 
 of the uterus, the instrument is of use in other respects than by 
 merely enabling us to measure the length of the uterine cavity. It 
 gives us at the same time the power of examining, in the mode 
 that we have already shown, much more accurately than we could 
 otherwise do, the condition of the fundus and anterior and posterior 
 walls of the uterus, through the abdominal parietes and rectum — 
 so that we can at the same time ascertain, that while the organ is 
 increased in length, its external surface is quite regular, and pre- 
 sents none of the inequalities which indicate the existence of any 
 more fixed or formidable organic change. 
 
 4. Longitudinal Hypertrophy of the Uterus, and especially of the 
 Cervix. — In that form of simple or metritic hypertrophy which we 
 have last described, the morbid enlargement of the organ affects 
 equally all its dimensions, and increases its breadth as well as its 
 length. Occasionally, however, it happens, that in hypertrophy of 
 the uterus, the increase in the dimensions of the organ is princi- 
 pally, or even entirely in its longitudinal direction, and that in 
 consequence the uterine cavity becomes so elongated, as to afford us 
 
 ' Pract. Observ. p. 65. 
 
LONaiTTJDINAL HyPBKTROPHT. 79 
 
 a mucli more decisive physical sign of its morbid state, wlien sub- 
 mitted to the measurement of the Uterine Sound. One of the 
 most remarkable examples of this type of uterine hypertrophy 
 hitherto placed on record is that mentioned by Dr. Kennedy, in an 
 excellent paper' in the Dublin Journal, as having occurred in a 
 case of extra-uterine gestation. The uterus was " developed in its 
 length, with very little increase of breadth, to the extent of twelve 
 inches."^ 
 
 When this longitudinal hypertrophy takes place in the unim- 
 pregnated uterus, it almost always results from morbid elongation 
 of the cervix. The body and lips of the organ are natural in size 
 and dimensions ; but the intervening part, or cervix, appears as if 
 its tissues had become ductile, and been extended and drawn out to 
 a greater or less degree. The elongated cervix may either retain 
 its normal diameter, or, as more rarely happens, it is attenuated in 
 thickness nearly in proportion to its increase in length. 
 
 Two different varieties of the morbid hypertrophy that we are 
 considering seem to occur, and have not been sufficiently distin- 
 guished by authors. In one, the elongated portion of cervix is 
 placed altogether above the reflection of the roof of the vagina ; in 
 the other, the hypertrophy is situated below that reflection, or affects 
 only the vaginal cervix, as it has been termed. In the former 
 variety, the altered uterus is reduced in form to the shape and type 
 of the organ in infancy. "We have seen this variety in some cases 
 of complete procidentia of the uterus,' and found the uterine canal, 
 as measured by the bougie, to be stretched out to four and five 
 inches in length. Mr. Heming supposes that this form of cervical 
 elongation is most apt to take place in connection with prolapsus of 
 the uterus, " complicated with hernia at its posterior part," whilst 
 the cervix remains unchanged inprolapus " complicated with hernia 
 at its anterior part."'' I have examined one case where the reverse 
 holds true ; the os uteri is prolapsed an inch or two beyond the 
 vulva, and the cervix much elongated ; but the posterior wall of 
 the vagina remains in situ, forming a deep reflection behind the 
 protruding tumor; and the anterior wall of it with the bladder forms 
 part of the external swelling. I may add that this variety of hyper- 
 trophy is met with also in instances in which the elongation of the 
 body of the organ takes place in connection with the presence of 
 
 ' " On Hypertrophy of the Os Uteri." — Dublin Journal of Med. Science, vol. xiv. 
 
 « Ibid. p. 221. 
 
 ' See good illustrative sketches of this form of the neck of the uterus in the cases of pro- 
 lapsus uteri figured in Cloquet's Pathologie Chirurgicale, 1S31, pi. viii. fig. 3, and Froriep's 
 Chirurgische Kupferfeln, t. 417, figs. 1 and 4. 
 
 * Med. and Phys. Journal, vol. Ixviii. p. 107. 
 
80 THE UTERINE SOUND. 
 
 fibrous or other tumors, wlien they happen to drag and raise 
 upwards into the abdomen the fundus uteri, while the cervix re- 
 mains fixed. Cruveilhier has represented an example of this com- 
 plication, in which the canal of the cervix alone is stretched out to 
 the length of five or six inches.^ 
 
 When the portion of cervix which is below the vaginal reflection 
 is hypertrophied, the elongated structure projects downwards from 
 the vaginal roof, like the cylindroid finger of a glove or a cow-teat. 
 I have had occasion to excise one, in consequence of the constant 
 discomfort which it produced. In another case of this kind, in 
 which the patient has suffered often from recurrent attacks of severe 
 uterine irritation, and has the os uteri almost projecting through 
 the vulva, the neck of the organ is about two inches in length, and 
 the body of the uterus is, as I have ascertained by the sound, acutely 
 bent or retroflected backwards and to the right; and it has its 
 fundus firmly adhering in this anormal position to the pelvic peri- 
 toneum, covering a firm solid tumor lodged behind the rectum, 
 and filling up the upper part of the hollow of the sacrum. The 
 shape and consistence of the tumor at first gave me the idea that it 
 was one of those osteo-sarcomatous masses that are sometimes seen 
 in this locality; but the use of the exploring needle showed that 
 the induration was not from any bony deposit. When of still 
 greater size than in these instances, the hypertrophied cervix has 
 prolapsed externally, and by its shape and configuration has been 
 mistaken for the male penis. Some of the cases of spurious her- 
 maphroditism in the human female, as those described by Saviard, 
 Valentin, and Home, appear to have been merely examples of this 
 disease.^ Its presence generally prevents impregnation ; and in 
 fact, the tapering, conical form of the cervix uteri, which is so com- 
 monly found in women long married without becoming mothers, is 
 a minor degree of this same diseased state. Ollivier, Lisfranc, and 
 others, have mentioned the frequent connection of this state with 
 sterility ; and I have repeatedly had occasion to verify it. In a 
 case that came under the care of Dupuytren, the elongated cervix 
 was reduced to its natural length by the knife. The patient had 
 been previously eight years married, and asked medical advice on 
 account of her want of family. Two months after the operation 
 she became pregnant. 
 
 The morbid elongation of the cervix uteri is spoken of by Eoux 
 as " a pretty frequent condition {etat assez frequent), and one that 
 
 ' Anat. Path, livrais. xiii. pi. 2. 
 
 2 Dr. Todd's Cyclopaedia of Anatomy, vol. i. p. 690. 
 
 " Dumont's Thfese sur I'Agenesie, I'lmpaissance, et la Dysgenesie, Paris, 1830. No. 2231 ; 
 and Archives G6n. de M^deoine, torn. xxv. p. 266. 
 
MORBID ELONGATION OF CERVIX. 81 
 
 has been hitherto mistaken for procidentia or prolapsus by the 
 greater number of practitioners."' Roux ascribes the first notice 
 of this morbid state to Lallemand and Bichat.^ It was, however, 
 long before described by Morgagni,^ Levret," and Hoin,' and has 
 since been commented upon at greater or less length by Desor- 
 meaux,^ Murat,' Gardien,' Dance,' Heming,'" Boivin and Duges," 
 Lobstein,'^ Cruveilhier,'^ Davis," Kennedy," &c. &c. 
 
 The longitudinal hypertrophy of the cervix uteri is liable to be 
 confounded with other morbid states of the organ. " This disease," 
 says Dr. Kennedy, " has been mistaken for polypus, and its re- 
 moval has been attended with fatal results. In the hypertrophy of 
 the neck, from the os remaining open, with the exception of its 
 altered position, it is, however, most likely to be mistaken for pro- 
 lapsus. The detecting, by a carefully conducted examination per 
 vaginam, and, if necessary, by the rectum, the elongated or out- 
 stretched neck of the uterus, whilst the fundus of the organ is 
 perceptible of its natural size, and in its usual position in the pelvis, 
 will sufficiently establish the diagnosis."'" The exact height and 
 position of the fundus uteri, which are thus requisite for the diag- 
 nosis in some cases, can only, as we have already shown, be ascer- 
 tained by the aid of the bougie, when the abdominal parietes are 
 sufficiently dense to oppose a perfect tactile examination at the 
 hypogastrium. In hypertrophy of the cervix, the use, however, of 
 the bougie is still greater in another view. " A sound," says Desor- 
 meaux, in his article on "AUongement du col de V Uterus," " carried 
 into the os tincse penetrates to the depth of five, six, seven inches, 
 or even more." " This last circumstance," he observes, " is pri- 
 marily important in fixing the diagnosis.'.'" Desormeaux is at the 
 same time certainly wrong when he adds that we may thus " easily 
 distinguish elongation of the cervix from complete prolapsus of the 
 uterus, inasmuch as, that in the latter a sound would scarcely pene- 
 trate above two inches in depth." In complete prolapsus, the 
 uterus, it is true, does occasionally retain its normal length ; but, as 
 I have already stated, the reverse is much more generally the case, 
 and the prolapsus is usually accompanied with cervical elongation 
 
 * Preface to Bichat's Anatomie Descriptive, torn. v. p. 7. 
 
 2 lb. torn. V. p. 282. ^ Epist. xlv. obs. 11. ^ Jour. Anoien. de Med. torn. xl. 
 
 * Journal de Msdecine, torn. xl. p. 352. ^ Diet, de M^decine, torn. ii. p. 12. 
 ' Diet, des Sciences M^d. torn. xxxi. p. 186. 
 
 * Trait^ d'Accouchemens, &c., torn. i. p. 118. 
 ' Archives G^n^rales, torn. xx. p. 524, 1829. 
 
 '" Medical and Pliysical Journal, vol. Ixviii. p. 107. " Loc. cit., torn. i. p. 193, &c. 
 
 '2 Path. Anat. torn. i. p. 57. 
 
 ■' Anat. Path, livraison xxxiv. pi. 2. '* Obstetric Medicine, p. 208. 
 
 '5 Dublin Journal, vol. xiv. p. 322. '« Ibid. 
 
 " Dictionnaire de M^decine, torn. ii. p. 13. 
 
 VOL. I. 6 
 
82 THE UTERINE SOUND. 
 
 of the organ, more especially if its fundus, as it very often happens, 
 has become morbidly adherent to some of the neighboring portions 
 of pelvic peritoneum, during the course and increase of the dis- 
 placement. Even in simple and incomplete prolapsus, the uterine 
 cavity is not unfrequently somevrhat elongated ; because that pro- 
 lapsus in recent and subacute cases is very often the result merely 
 of the general hypertrophy and increased weight of the organ ; and 
 here its increased length may so far form a valuable sign, in show- 
 ing that in the treatment we must act against the hypertrophy, as 
 tlie pathological cause, before we can hope to ameliorate the pro- 
 lapsus, which is simply its mechanical effect.^ 
 
 When the cervix is elongated downwards from the upper part of 
 the vagina, we may easily measure by the uterine sound, and by a 
 finger in the vagina, the exact extent of its morbid prolongation ; 
 and, on the other hand, when the hypertrophied portion is situated 
 above the vaginal roof, we may attain the same object by tracing 
 with a finger, in the posterior reflection of the vagina, or in the rec- 
 tum, the progress of the sound as it passes upwards through the 
 elongated and tapering cervix, until it reaches the entrance (and 
 there the canal is generally contracted) of the cavity of the broader 
 and bulging out body of the uterus itself. In making such an ex- 
 amination we must guard against the error of supposing the instru- 
 ment to be fully introduced into the cavity of the body of the uterus 
 when it has only reached the upper part of the occasionally dilated 
 cavity of the cervix. Lobstein describes an instance of the disease in 
 which the error might have been easily fallen into. " The museum," 
 he observes, " of our faculty (at Strasburg) contains a very interest- 
 ing example. The neck of the uterus has a length of three inches 
 and one line, its thickness as its superior part is six lines ; in de- 
 scending it becomes enlarged, and its cavity dilated so as to give it 
 a size of an inch and seven lines. At first view it looks like a piece 
 composed of two uteri touching each other by their necks ; no 
 change of tissue is discoverable."^ 
 
 5. Hypertrophy of the Uterus and Uterine Cavity, from the growth 
 of Fibrous Tumors in the Parietes of the Organ. — ^When fibrous 
 tumors, the most common of all the organic diseases of the uterus, 
 
 ' The partial prolapsus, which often takes place in metritic hypertrophy, " furnishes," 
 observes Duparcque, " the means of assuring ourselves more directly of the state of the 
 uterus. Unfortunately, practitioners rarely know how to profit by it. They consider solely 
 the prolapsus, and apply a pessary, and they are astonished when it cannot be borne, or 
 that so far from putting an end to the various pains and uneasiness which they attributed to 
 the prolapsus, the presence of the instrument exasperates them, or becomes even the excit- 
 ing cause of more serious alterations." — Traitfi sur les Alterations Organiques de la Matrice, 
 p. 201. 
 
 2 Traits d'Anat. Pathologique, torn. i. p. 57. 
 
HYPERTBOPHY FROM HBROUS TUMORS. 83 
 
 grow in tlie walls of the viscus, they are generally accompanied 
 with a hypertrophied condition of the uterine parietes, exactly re- 
 semhling in its nature and appearance their hypertrophied state in 
 pregnancy. Under the irritation of an isolated fibrous tumor or 
 tumors the surrounding hypertrophy is usually local in its seat, and 
 confined to the uterine walls in its immediate vicinity ; when the 
 fibrous masses are larger or more numerous, the uterine hyper- 
 trophy becomes more general.' I have a preparation of a case of 
 this kind, in which the organ resembled in size, and in the thick- 
 ness and characters of its parietes, the uterus of the female a day or 
 two after delivery. "The natural substance of the uterus," ob- 
 serves Dr. Hooper, " in which this tumor is imbedded, is almost 
 always found to have undergone a decided change, having become 
 more distinctly fibrous, and the fibres more obviously fasciculated. 
 The quantity of these fibres, that is of the natural fleshy fibres of 
 the uterus, is very much increased, so that the diseased structure is 
 often surrounded by walls much thicker than]those ofa healthy uterus." 
 "In these instances," he remarks in another page, "the uterus 
 very much exceeds its natural bulk and weight after the morbid 
 structure has been completely removed. I have found the uterus in 
 many of these cases weigh two pounds, after having dissected out 
 masses of subcartilaginous (fibrous) tumors or other substances."" 
 
 In cases of fibrous tumors leading to uterine hypertrophy in the 
 manner just described, the cavity of the uterus is frequently enlarged, 
 as well as its parietes. "When fibrous tumors," says Bayle, in 
 his admirable essay on this disease, " are numerous or very large, 
 they deform altogether the body of the uterus. Almost always 
 when they become so large as a man's head, they enlarge (aggran- 
 dissent) the uterus in every direction, and dilate considerably its 
 cavity {dilatent considerahlement sa caviU)."^ 
 
 The cavity of the uterus, however, is not always enlarged, even 
 when the fibrous tumors are both large and numerous. This result 
 in regard to the cavity, seems to be regulated by the seat and rela- 
 tions of the tumors. We have observed in the disease the three 
 following conditions of the uterine cavity : 
 
 ' " The hypertrophy of the uterus is,'' observes Cruveilhier, " general when the fibrous 
 tumor directs itself towards the side of the uterine cavity ; it is partial when the tumor follows 
 an opposite course; if it occupies the fundus, it is the fundus alone which becomes deve- 
 loped, and the rest is moulded upon it ; if the anterior wall is its seat, it is the anterior wall 
 which becomes developed ; if it approaches the peritoneum, the fibres intervening between 
 it and that membrane undergo the change. In the cases of partial hypertrophy of the uterus, 
 the remainder of the organ may be in its natural state, but this is rare, because if the uterus is 
 not sohcited to development in the direction of its thickness, it is so in the direction of its 
 height, in consequence of the slow or rapid increase of the fibrous bodies. Now a develop- 
 ment in height or length is still always a hypertrophy." — Anal. Pathol. Uvr. xix. pi. 1, 2. 
 
 2 Morbid Anatomy, pp. 11 and 6. ' Diet, des Scien. M6d. tom. vii. p. 72. 
 
84 THE UTEEINE SOUND. 
 
 First, The cavity is elongated and enlarged with the enlarging 
 state of the tumor and uterine parietes, when the morbid mass grows 
 from any point towards the interior of the organ, or when it is ori- 
 ginally situated in the lateral walls of the body of the uterus, and 
 so during its development tends to stretch out these walls, and con- 
 sequently the contiguous cavity along with them, in a longitudinal 
 direction. 
 
 In cases in which the fibrous tumor is seated on one side or walls 
 of the organ, and becomes of a great size, the lengthened uterus 
 sometimes comes to be wrapped and welded for some distance 
 around the exterior surface of the fibrous growth. " I have seen," 
 says Cruveilhier, " in these cases the uterus considerably elongated, 
 and form a kind of a half-belt {demi-cintre) around the tumor."^ The 
 degree of elongation and dilatation of the uterine cavity under these 
 circumstances is very various. I have repeatedly found it, both 
 upon the living and dead subject, measuring three, four, and five 
 inches in depth. Madam Boivin describes and represents a uterus 
 of a conical shape, containing in its parietes several fibrous tumors, 
 and having its cavily prolonged in the form of a narrow canal, to the 
 length of nine inches.^ I have in my museum a preparation of this 
 kind, in which the uterine canal measures above ten inches. The 
 greatest elongations of the uterine cavity that I have as yet ascertained 
 by the bougie in cases of fibrous tumors in the living subject, are two 
 instances where the canal was, in the one six inches in length from 
 the OS uteri to the fundus, and in the other seven and a half inches. 
 Dr. Beilby saw with me the former, and Dr. Girdwood of Padding- 
 ton the latter case, and both of these gentlemen assured themselves, 
 by personal examination with the uterine bougie, of the accuracy 
 of the measurements that I have stated. This hypertrophy of the 
 walls and cavity of the uterus seems liable to occur in its greatest 
 degree when the tumor or tumors are rapid in their growth, and 
 make their appearance during the childbearing periods of life. In 
 using the bougie in these cases the instrument sometimes requires 
 to be so much unbent as to be nearly straight before it can be intro- 
 duced ; and where the elongated uterus curves around the exterior 
 of the fibrous mass, the apex of the sound must be passed so as to 
 follow the particular direction of the uterine cavity. 
 ^ Secondly, The uterine cavity may retain nearly its natural dimen- 
 sions and depth, or be only very slightly increased, even when the 
 fibrous tumors are both large and numerous, provided they grow 
 from any part towards the exterior surface of the organ, or are ori- 
 ginally seated in the fundus uteri and not in its lateral parietes. I 
 
 ' Anat. Path. livr. xiv. pi. 1, 2. 2 Heming's Boivin and Dugfes, p. 179, pi. 14. 
 
HYPERTROPHY FROM FIBROUS TUMORS. 85 
 
 have seen a mass of uterine fibrous tumors so large as to have been 
 mistaken by one practitioner for an enormous hepatic, growth 
 where the uterine cavity was only about three inches in depth. In 
 this instance the tumors were evidently all growing from the peri- 
 toneal surface of the uterus, and could be felt through the thin 
 abdominal walls adhering to it with pedicles of varying sizes, 
 like a number of exterior polypi. 
 
 Thirdly, In connection with the existence of fibrous tumors in the 
 uterus, the uterine cavity may be found apparently shortened in 
 consequence of some portion of it being obliterated by adhesive in- 
 flammation from the pressure together of its opposing surfaces by 
 the presence of the tumors. I shall state afterwards a case of this 
 kind, where the uterine canal, as examined from the vagina, ap- 
 peared only an inch in depth. In this, as in most other such cases, 
 the cavity of the body was found concealed higher up, enlarged to 
 some degree, but forming a short cavity, from the obliteration of 
 its inferior part. This result, as the effect of the presence of fibrous 
 tumors, is principally observed when the tumors have been of very 
 long standing, and when the hypertrophy of the uterine tissues 
 that accompanied their earlier development has at last been followed 
 by a state of atrophy of the included and compressed walls of the 
 organ. 
 
 The practical deductions that may be drawn from the preceding 
 remarks regarding the length of the cavity of the uterus in fibrous 
 tumors of the organ, are so evident as to require little or no comment. 
 I have already stated my opinion, and would repeat it here in the 
 strongest terms, that no error is more common in practice than to 
 mistake a fibrous tumor of the uterus for a dropsical ovary, or a 
 dropsical ovaiy for a fibrous tumor.' I shall take another opportu- 
 nity, in these contributions, of offering some suggestions for the 
 more perfect diagnosis of ovarian tumors and their connections. 
 In the mean time I may merely state that in the lengthened state of the 
 uterine cavity, as easily ascertained by the bougie during life, we 
 have in many instances, an additional physical sign between the two 
 classes of diseases alluded to, subject to exceptions which I will sub- 
 sequently mention ; and if the elongated uterine cavity is discovered 
 by the bougie to run behind the tumor that is present, it is another 
 and still more decisive reason for concluding that the affection is 
 uterine and not ovarian. At the same time it is to be held in re- 
 
 ' In illustration of this remark, I shall content myself with adducing one fact. Few men 
 in England seem to have attended more zealously to the subject of ovarian tumors, and no 
 one has labored so much to reintroduce the excision of them, as Mr. Clay of Manchester. 
 Yet out of five cases which he has lately recorded, of operations for the extirpation of en- 
 larged ovaries, in two it was found, ailer the abdomen had been laid open, that the disease 
 was not ovarian, but consisted "of anomalous and uterine tumors." — See his Cases of 
 Peritoneal Section for the Extirpation of Diseased Ovaria, p. 18. 
 
86 THE UTERINE SOUND. 
 
 coUection'that iftlie uterine cavity is of its natural deph, it is no suffi- 
 cient reason that tlie hypogastric or abdominal growth is not a 
 fibrous uterine tumor, and more careM examination under such 
 circumstances will often show the tumor or tumors to be such, and 
 to have either a more or less pediculated form, and attachments to 
 the external uterine surface, or to be imbedded in the walls of the 
 fundus. Lastly, the uterine canal is sometimes greatly shortened in 
 the way described, in connection with the existence of fibrous tumors 
 in the uterine walls. I am not aware that it is ever in this way 
 diminished in depth from the presence of ovarian disease. 
 
 6. Enlargement and distension of the Uterus from Polypi, ^e., in its 
 Oavity. — ^When polypi or other morbid structures form in the cavity 
 of the uterus, they act like the presence of an ovum, enlarge the 
 interior of the organ in proportion to their growth and size, and gene- 
 rally at the same time induce, as in pregnancy, a corresponding 
 degree of thickening and hypertrophy in the uterine parietes. In 
 such cases the Uterine Bougie shows an increased depth of the 
 uterine cavity. The degree of increase will necessarily vary in every 
 different instance. I have seen a retained polypus enlarging the 
 uterus to the size of the organ at the fourth month of pregnancy. 
 Cruveilheir has represented a large fibrous polypus as included 
 within and distending the uterine cavity, so that the organ measured 
 above eight inches from the os to the fundus. "We shall see after- 
 wards that it is not the mere length to which the Bougie may pass 
 that forms the diagnostic mark under such circumstances, but that 
 it is by the possibility of passing it on more than one side between 
 the surface of the tumor and the interior of the uterus, or by the 
 power of so far revolving it round, and isolating, as it were, the con- 
 tained mass, that we draw the distinction between tumors situated 
 in the cavity and those which, as described under the last head, are 
 still imbedded in the parietes of the organ. 
 
 7. Elongation of the Uterus in Hernia of the Organ. — ^Hernia of the 
 unimpregnated uterus is a disease of very rare occurrence. The 
 organ, however, has been found protruding into the tumors formed 
 by different varieties of abdominal hernia. It had passed through 
 the crural ring in cases met with by Lallemand^ and Cruveilhier f 
 through the inguinal canal, in instances detailed by Desault and 
 Chopart,^ and Lallemand.^ Most of the cases of hernia of the 
 impregnated uterus which have been recorded by Sennertus, Hil- 
 danus, Ruysch, Ladesma, Fisher, &c.,^ were instances in which 
 
 ' Bulletins de la Facnlte de M^deoine, 1816, torn, i. c. 1. 
 
 2 Anat. Pathologique, livr. xxxiv. pi. vi. 
 
 3 Trait^ des Maladies Chirurgicales, torn. ii. p. 305. 
 
 * Memoires de la Soc. Med. d'Eniulation, 3rae ann6e, p. 323. 
 
 * See the details of them collected by Dr. Cormaok, in Edinburgh Monthly Journal for 
 1841, p. 491, and ibid, for 1842, p. 28. 
 
DISTENSION OF THE UTERUS PROM POLYPI. 87 
 
 the uterus seems to liave become displaced after conception took 
 place. 
 
 Wlien the unimpregnated uterus forms the subject of hernia, it 
 seems in general to be considerably elongated. In Chopart's case 
 the organ is described as smaller than usual, rounded and lengthened 
 in form {arrondie, alongSe) ; in Cruveilhier's plate the displaced viscus 
 is represented as drawn out to the length of five or six inches. In 
 fact, the uterus itself must in all such cases be either much drawn 
 out in length, in order to allow its fundus to be the subject of such 
 great displacement, or the vaginal canal must be extended into the 
 neck of the hernial sac, as happened in the example already referred 
 to, as recorded in the Bulletins de la Faculte de MSdecine. 
 
 In one of the cases of hernia of the uterus described by Lalle- 
 mand, the patient applied for advice in consequence of the super- 
 vention of symptoms of strangulation. The sac, on examination, 
 was supposed to contain a portion of intestine : but the age of the 
 patient, &c., prevented an operation being attempted. On examina- 
 tion after death, the hernial tumor was found to be composed of two 
 folds of omentum, two hydatic cysts, the ovaries. Fallopian tubes, 
 and uterus. In relation to the difficulty of the diagnosis in this 
 and similar cases, Murat observes, that " hernia of the unimpreg- 
 nated uterus is most frequently confounded with that of other parts 
 of the abdomen, and there are no pathognomonic signs by which we 
 can recognize it."* "We may, as K'auche advises, so far overcome 
 the difficulty, by finding, on vaginal examination, " the uterus 
 situated high in that canal more or less devious, the orifice turned 
 to the side opposite that of the hernia, and on pressing it with the 
 finger, we impart a certain mobility to the hernial tumor. "^ A much 
 more decisive means of solving the problem will be afibrded by the 
 use of the Uterine Bougie. If, instead of trusting to the preceding 
 points as ascertainable by the examination of the os and cervix with 
 the finger, we pass the Bougie into the uterine orifice and its elon- 
 gated cavity, both the direction which the instrument will, during 
 the course of its introduction, take towards and into the mass of the 
 tumor, and the power of feeling its apex in the fundus uteri, through 
 the hernial walls, after it is fully introduced, will at once place the 
 matter beyond the possibility of doubt. In this procedure it vsdll 
 be proper to recollect, that in some cases a slender, and it may be even 
 a flexible Bougie, will be required, in order to overcome the con- 
 tractions and irregularities of the uterine cavity that may be present. 
 
 ' Diet, des So. Mid. torn. xxxi. p. 228. ' Maladies de rUterus,p. 114. 
 
88 THE UTERINE SOUND. 
 
 SECTION lY. 
 
 ON THE MEASUREMENT OF THE CAVITY OF THE UTERUS AS A MEANS 
 OF DIAGNOSIS IN SOME OF THE MORBID STATES OF THAT ORGAN.— Co«- 
 
 tinued. 
 
 (From London and Edinburgh Monthly Journal of _Medioal Science, March, 1844, p. 208.) 
 
 In our last communication we described a number of morbid con- 
 ditions of the uterus, in whicli the cavity of that organ is more 
 or less elongated. We showed that the diagnosis of these affec- 
 tions could be greatly advanced by ascertaining, through the use 
 of the Uterine Bougie, the exact extent and degree of the existing 
 elongation. It was at the same time remarked that in some patho- 
 logical states of the uterus its cavity is shortened and diminished in 
 depth. On the present occasion, we purpose to describe briefly this 
 latter set of cases, and will point out in what respects their discrimi- 
 nation during life may be promoted by the employment of the 
 Uterine Sound. 
 
 INSTANCES OF DIMINISHED LENGTH OF THE UTERINE CAVITY. 
 
 The cavity of the Uterus, when shorter than natural, may have 
 its depth diminished as the result of malformation, of disease, or of 
 displacement. * 
 
 1. Preternatural shortness of the Uterus from original malformation 
 of the organ. — Few of the malformations of the uterus, with the 
 exception of the duplicity and absolute deficiency of the organ, 
 have as yet attracted much attention. It would, however, be easy, 
 we beheve, to bring together, by a little patient research, a con- 
 siderable series of cases, in which the organ was found less than its 
 normal length by an inch or an inch and a half.^ In some instances, 
 in fact, the cervix of the uterus is alone present, and the body and 
 fundus of the organ are imperfectly or totally undeveloped. In 
 more strict terms, the lower extremities of the Fallopian tubes, instead 
 of coalescing and becoming evolved into the body and fundus of the 
 uterus, remain separate, retain their tubal character, and open into 
 the superior part of the single cavity of the cervix. Such appears 
 to us to^ be the explanation of the case, for example, described by 
 Lauth, in which the cervix was sufficiently well formed, with the 
 tubes opening into it ahnost directly, and only separated by a small 
 cavity.^ Morgagni speaks of a uterus in which the distance from 
 
 ' For further remarks on this subject, see p. 113. 
 ^ Andral's Anatomie Pathologique, torn. i. p. 677. 
 
DIMINISHED LENGTH OF UTEEINB CAVITY. 89 
 
 the OS to tlie fundus was not so much as the breadth of the thumb. 
 The genital organs were in other respects malformed.^ Dr. Dewees 
 mentions an instance of amenorrhoea, in which the uterus was of 
 "a size not exceeding the thumb of a man."^ 
 
 In that particular variety of malformation which various patho- 
 logists have described under the name of " oblique uterus," and 
 where the organ originally lies with its fundus directed to one side 
 of the pelvis, and has one set of its lateral ligaments shorter than 
 another, the organ is sometimes, though not always, shorter than 
 natural. Tiedemann describes an oblique uterus two inches and a 
 line in length, and in which the cavity would measure considerably 
 under two inches.^ 
 
 In all cases in which the uterus is malformed and shortened in 
 the modes we have alluded to, the Uterine Sound will probably 
 afford us important diagnostic information, by enabling us to 
 measure the exact degree of diminution in the length of the cavity 
 of the organ. To make the information more certain and precise, 
 it will be necessary at the same time to ascertain, by a hypogastric 
 or rectal examination, that the apex of the instrument has really 
 reached the superior end of the uterine body, and hence, that it is 
 not arrested in its progress by any structure in the cavity, or by 
 any flexion in the walls of the viscus, such as we shall afterwards 
 fully describe. 
 
 2. Uterine canal shortened from stricture or partial obliteration. — 
 "A stricture," says Dr. Baillie, "is sometimes formed within the 
 cavity of the uterus, so that its cavity ,at one part is obliterated 
 entirely. This," he adds, "I believe almost always to take place at 
 one part, namely, where the cavity of the fundus uteri terminates, 
 and that of the cervix begins, for in this place the cavity of the 
 uterus is narrowest. As the sides of the cavity round this place lie 
 very near each other, and form naturally a small aperture, it is pro- 
 bable that some slight inflammation may unite the parts together, 
 and shut up the aperture; or the parts may gradually approach 
 each other without this cause, as in the stricture of the urethra."^ 
 
 The morbid state which Dr. Baillie has so accurately described 
 in the above quotation, as the result of his observations upon the 
 dead body, could only be detected upon the living subject, by exa- 
 mination with a uterine probe or bougie. Nor would the diagnosis 
 be difficult, for at the same time that it was found that the Bougie 
 was completely arrested in its progress upwards, at the distance of 
 
 ' Epist. xlvi. 20, Alexander's Translation, vol. ii. p. 661. 
 2 System of Midwifery, p. 69, ed. of 1837. 
 ' Von den Cowpersohen Drusen des Weibs, &o. p. 26. 
 * Morbid Anatomy, edit, of 1812, p. 379. 
 
90 THE UTERINE SOUND. 
 
 an inch, or an inch and a half from the os tincse, it might be ascer- 
 tained, by a hypogastric examination, that it was still far from 
 having reached the fundus uteri. 
 
 Since the time that Dr. Baillie wrote. Professor Mayer of Bonn 
 has shown that in old persons, the os internum or cervico-uterine 
 orifice is so often obliterated, that it may be almost looked upon as 
 a norm&,l condition, connected with the general atrophy of the 
 viscus that takes place in very advanced life.' In one or two 'aged 
 patients I have found it impossible, during life, to pass the smallest 
 probe through the os internum, probably owing to the contraction 
 in question. The eases I allude to were those of females who in 
 earlier life had produced children, and where there was therefore 
 no original stricture or malformation. 
 
 Stricture of the os internum is, like diminution in the size of the 
 OS tincse, not unfrequent in females affected with dysmenorrhcea, 
 and who, though married, have never had children. In several 
 cases I have met with difficulty and obstruction in passing through 
 the opening between the cavities of the neck and body of the 
 uterus, a sound or probe that had already passed easily and freely 
 through the os tincse. I have at present under my care a case of 
 this kind, in which there is a most remarkable degree of antro- 
 version of the whole uterus. Jahn, in his Essay on the Oblique 
 Uterus, mentions an instance of that malconformation where, after 
 death, the os internum was found so narrow that a fine probe could 
 not be passed through it (ut suhtilissimo stilo transitum denegaret) ; and 
 yet the os tincse was well formed.^ In Euysch's Catalogue a uterus 
 is mentioned, with the os internum so small as not even to admit 
 the head of a small needle (we caput quidem aciculce minoris admit- 
 tere posset).^ Occasionally the whole cavity of the body of the 
 uterus is obliterated, from the os internum to the fundus, and yet 
 the cavity of the cervix continues patent. Cruveilhier speaks of 
 having seen a case of this kind, " in which there was no trace of a 
 cavity in the body of the organ, although the cavity of the neck 
 remained."'' An example of the same kind has been represented 
 by Madame Boivin in the plates attached to her treatise on diseases 
 of the uterus.^ 
 
 The cavity of the uterus is, in some rare cases, partially oblite- 
 rated, in consequence, as has been already stated, of the develop- 
 ment of fibrous tumors in the walls of the organ. Under such 
 
 ' Besohreibung einer Graviditas Interstitialis Uteri, p. 14. 
 
 2 De Situ Uteri Obliquo, in Sohlegel's Sylloge Operum Obstetr. torn. i. p. 268. 
 
 ^ Thesaurus Anatomicus, vi. No. 85. 
 
 * Descriptive Anatomy, vol. i. p. 621, of Dr. Madden's translation. 
 
 5 Loo. cit. pi. xiii. fig. 3. 
 
DIMINISHED CAVITY IN INVERSION OF THE UTERUS. 91 
 
 circumstances, the obliteration is the result of inflammatory adhe- 
 sions, formed between those portions of the opposed surfaces of 
 the lining membrane of the uterus, that happened to be maintained 
 in a state of close and morbid apposition, by the presence and 
 pressure of the neighboring tumors. The adhesive inflammation 
 thus excited occasionally extends to some distance from its original 
 seat. In all cases, however, the cavity of the cervix seems to 
 escape, and the portion of the cavity of the body that is placed 
 above the stricture frequently becomes distended and enlarged, 
 from the accumulation of morbid mucous secretions within it. 
 Cruveilhier has described a very illustrative case of this kind.^ A 
 preparation was presented to the Anatomical Society of Paris, as a 
 morbid ovary. In external appearance, it had much more resem- 
 blance to an ovarian than a uterine disease. On more minute 
 examination and dissection, however, it was fonnd to consist of an 
 agglomerated mass of fibrous and fibro-calcareous tumors, the 
 whole forming a shapeless body, vsdth an irregular, tuberculated 
 surface. The tumors varied in size, from a pea to a large com- 
 pound one weighing by itself about 1| pounds. On cutting into 
 the midst of the mass, a cavity was found filled with reddish 
 serum, which it was easy to see was the cavity of the body of the 
 uterus. This cavity was a shut sac, there being no opening from 
 it. Inferiorly, its communication with the cervix uteri was entirely 
 obliterated. When examined as to its vaginal relations, the uterus, 
 or uterine canal, seemed to terminate at an inch above the os tincse. 
 A blunt stilet, adds Cruveilhier, passed in all directions, could not 
 discover above this point any op6ning into the uterine cavity. If 
 the same means had been employed, as a matter of diagnosis 
 during life, the same result would have been obtained as in the 
 post-mortem examination, and that result would have aflbrded 
 pretty conclusive evidence that the disease was not ovarian, because 
 the uterus does not seem to be liable to become occluded in the 
 course of its cavity, in connection with ovarian growths; and 
 besides, the use of the Bougie would have shown the uterus 
 imbedded in the tumor, and probably the partial canal of the cervix 
 running in such a direction in relation to the tumor as to add 
 further testimony to its non-ovarian character. 
 
 3. Diminished depth and effacing of the Uterine Oavity in Inver- 
 sion of the Uterus.-^'We believe that the diminution in depth, and, 
 in extreme cases, the total obliteration which the canal of the 
 uterus undergoes in inversion of the organ, will generally give us 
 the power of distinguishing this morbid state from all others to 
 
 ' Anatomie Pathologique, livrais. xiv. 
 
92 THE UTERINE SOUND. 
 
 which it is symptomatically allied; and more especially from those 
 forms of polypus that occasionally so strictly resemble it, and with 
 which it has been frequently and sometimes fatally confounded. 
 
 When inversion of the uterus occurs immediately after delivery, 
 it can, in general, be easily distinguished from a polypus that has 
 passed through the os uteri after the expulsion of the child, or 
 placenta, or both, because, omitting other considerations, though 
 in each we may find in the vulva or vagina, if we are led to make 
 an examination by the severity of the symptoms, a large fleshy 
 tumor, yet this tumor, in the case of polypus, can be proved not to 
 be the displaced uterus, as the fundus uteri can still be felt above 
 the pubis, whilst the reverse is true of inversion. If any doubt 
 remained, in consequence of difficulties in the way of the hypo- 
 gastric examination, or otherwise,^ a Bougie cautiously passed by 
 the stalk of the vaginal tumor, would, if it were a polypus, prove 
 at once the uterine cavity to extend upwards to the length of six or 
 seven inches, and if desired, would enable us further to feel more 
 distinctly through the hypogastrium, the fundus uteri still remain- 
 ing in situ. If the tumor were the inverted fundus of the uterus, 
 the cavity of the organ would, on the contrary, be found shortened 
 to an inch or two on all sides, and it would be found difficult, or 
 impossible to bring, as usual, any part fully within the reach of an 
 abdominal examination. In those rare instances in which the 
 inversion was complete, the orifice and cavity of the uterus would 
 be found entirely effaced. 
 
 The difficulty, however, of distinguishing between polypus and 
 inversio uteri is greatly increased when the diagnosis is attempted 
 after the puerperal uterus has diminished to its normal volume, or 
 when the patient applies for advice at a distance from the period of 
 confinement, and the inversion is only partial. Under such cir- 
 cumstances it has repeatedly happened that a polypus has been 
 mistaken for an inverted uterus,' or the still more dangerous error 
 committed of considering an inverted uterus to be a polypus, and 
 treating it accordingly.' Such errors involve not only the comfort 
 but the life of the patient. 
 
 ' For cases of polypus of the vagina after delivery mistaken for inversion, see Rams- 
 botham's Practical Observations, vol. ii. p. 473, and Gooch's Account of Diseases of Women, 
 p. 282 ; and for cases of inversion under the same circumstances, mistaken for polypus, see 
 Gazette MMicale for 1832, p. 422. 
 
 2 Seecasesin AusiauxCliniqueChirurgicaleip. 207; Acta Havniensia, 18 L8, torn. v. p. 51. 
 
 ^ On cases of inverted uteri mistaken for polypi, see Morgagni, de Sedibus, &o., epist. xlv. 
 No. 4; Palletas' Exercitationes Pathologioaj, pp. 17, 18. Gooch in his Diseases of Women, 
 1831, p. 265, gives an instance vfhere Dr. Hunter applied by mistake a ligature to an 
 inverted uterus. A preparation illustrative of this error was in the museum of the late 
 Dr. Hamilton; the patient, as in Dr. Hunter's case, having died with the uterus partially 
 out through with the ligature. Occasionally the uterus has been included without fatal 
 effects; see numerous quotations in Dr. Burns's Principles of Midwifery, 1837, p. 128. 
 
DIAGNOSIS OF POLYPI AND INVERSIO UTERI. 93 
 
 It is true that a diagnosis can generally be established with con- 
 siderable certainty between polypus of the uterus and partial 
 chronic inversion of the organ, by attending, amongst other points, 
 particularly to the two circumstances, that however similar in other 
 respects, the tumor formed by inversion is, 1st, — ^in its history, 
 traceable to having appeared immediately after delivery ; and, 2d, in 
 its character, it differs from polypus in being sensitive to a greater 
 or less degree to the touch, while the polypus is not so. "We must, 
 however, at the same time, hold in view that some fibrous polypi, 
 when they carry down before them and are covered with a layer of 
 true uterine tissue, or when temporarily inflamed, are found to be 
 sensitive,' and that the inverted uterus becomes almost insensible 
 when long exposed f and again the fact, that the tumor first ap- 
 peared immediately after delivery, is not itself conclusive, because 
 in some cases of inversion the accident has not caused such severe 
 symptoms as to be recognized at that moment,^ and again, the first 
 time a polypus passes from the uterus to the vagina is occasionally 
 immediately after labor.'' In their physical character, the two 
 diseases often very nearly resemble one another. "When the 
 uterus," says Dr. Gooch, "is only partially inverted, that is, when 
 
 ' " It is said that an inverted uterus is sensible to the touch, while polypi, on the contrary, 
 are void of feeling. This can never be an accurate mode of forming a diagnosis, as we 
 can only judge of the sensibility of the tumor by the expressions of the patient, which are 
 regulated more by disposition than by the extent of her sufferings. I lately attended a lady 
 with uterine polypus, and had I judged solely by the complaints of my patient, I should 
 have pronounced the polypus to have been more sensible than an inverted uterus usually 
 is." — Dr. Chas. Johnstone in Dublin Med. Reports, vol. iii. p. 488. 
 
 " We shall always find it difficult to distinguish between the sensibility of the tuinor and 
 sensation occurring in neighboring viscera, which are irritated by the process of examination j 
 while, too, it must be remembered, that the sensibility of the inverted uterus is greatly 
 diminished in its chronic stage, and that the sensibility of polypus may be increased by the 
 presence of inflammatory action." — Newnham on Inversio Uteri, p. 83. 
 
 ^ " It is said that the polypus is usually indolent, and that the fundus of the uterus has an 
 exquisite sensibility, but very often one meets with painful polypi ; and it must be so, since 
 they are very often covered with the tissue of the uterus. Their lower part may be insen- 
 sible, because this envelope is too thin, or it may be perforated. On the other hand, it is 
 certain that the sensibility of the inverted uterus gets duller after a time." — Lisfrano, Cli- 
 nique de la Piti6, tom. vii. p. 133. 
 
 " In time, the surface of an inverted uterus becomes less sensible to external impres- 
 sions." — Jourdan, Diet, des Sciences MSdicales, tom. xxiii. p. 288. 
 
 " Dr. Montgomery has in his museum a preparation of inverted uterus which had during 
 life been quite insensible to the application of the needle." — Dr. Burns's Midwifery, p. 561. 
 
 " " The nature and even the facts of the accident have often not been discovered till 
 after the lapse of many days, weeks, or months subsequently ; and in a smaller number of 
 cases not till after the death of the subject." — Davis's Obstetric Medicine, p. 1088. 
 
 * Two cases of this nature are given by Levret in his paper on uterine polypi, in the 
 M^moires de I'AcadSmie Royale de Chirurgie, tom. iii. pp. 543, 545. — See also Gardien's 
 Traits des Accouchemens, tom. iii. p. 316; Delpech's Prfcis des Maladies Chirurgicales, 
 tom. ii. p. 586 ; three cases in the Journal Hebdomadaire de Medecine, No. 44 ; Rams- 
 botham's Observations, vol. ii. p. 473. I have seen one come down after a prematute labor. 
 
94 THE UTERINE SOUND. 
 
 its fundus only is drawn down tlirougli its orifice into the vagina, 
 and the patient has survived for many months, the tumor feels ex- 
 actly like a polypus of the fundus. ... In the smoothness of 
 its surface, the roundness of its body, the narrowness of its neck, 
 and its being encircled by the orifice of the uterus, it sometimes 
 exactly resembles polypus of the fundus."^ 
 
 To show still more strongly the difficulties which occasionally 
 intervene in the distinction between chronic inversion of the uterus 
 and polypus, I will adduce the testimony of one or two writers, 
 whose authorities on this point are such as to command all con- 
 fidence. 
 
 Mr. Ifewnham, in his learnedjessay on Inversion of the Uterus, 
 after having brought together the opinions of many authors — 
 ancient and modern — ^British and foreign — upon this question in 
 diagnosis, adds, " On reviewing the foregoing testimony we shall be 
 induced to conclude that it is always difficult and sometimes impos- 
 sible, with our present knowledge, to distinguish partial and chronic 
 inversion of the uterus from polypus."^ 
 
 In his elaborate work on Operative Midwifery, Professor Kilian 
 ofiers a nearly similar observation — "An inverted uterus may so 
 deceitfully (tauschend) resemble a polypus that the diagnosis is 
 scarcely possible."^ 
 
 In a clinical lecture on inversion of the uterus, Velpeau, in al- 
 luding to the diagnosis of that disease from polypus in some very 
 difficult instances, adds, " There are cases in which doubt is the only 
 rational opinion (le doute est la seule opinion rationelle.)"* 
 
 " When," observes Lisfranc,' " the polypus or inversion has only 
 partially opened the os uteri, we are assured that the diagnosis is 
 impossible — authors do not even consider the case." "From the 
 facts we have adduced," he adds,^ "one may easily conceive the im- 
 mense difficulties met with in cases of this nature ; thus under a 
 great number of circumstances, the most distinguished practitioners 
 have believed that they had tied polypi, when they had included 
 the organ of generation itself in the ligature ; and in other cases 
 they have supposed they had removed the uterus either wholly or 
 in part, when they had only relieved their patients of polypous 
 tumors." 
 
 In order to resolve the difficult problem in uterine diagnosis to 
 which these remarks refer, Malgaigne some time ago proposed a 
 means which is thus described :' " A curved catheter is introduced 
 
 ' Loo. cit. p. S55. 
 
 ' Essay on the Symptoms, &o. of Inversio Uteri.— London, 1818, p. 82. 
 
 3 Loc. cit. Bd. ii. p. 280. ■> Clinique Chirurgioale, Paris, 1841, torn. ii. p. 425. 
 
 ^ Clinique, tom. iii. p. 135. 6 n,id. p. 136, 
 
 ' Lisfrano, Clinique de la Piti§, tom. iii. p. 137. 
 
DIAGNOSIS OF POLYPI AND INVBRSIO UTERI. 95 
 
 into tte bladder ; it is then carried backwards, and its concavity 
 directed downwards, so as to bring tbe point of the instrument into 
 the bottom of the uterine sac ; the index finger is then introduced 
 into the vagina, where the point of the catheter is as easily felt as it 
 is in the hypogastrium in ordinary catheterism." Thus the diag- 
 nosis is established : " But there are circumstances," continues Lis- 
 franc, " in which the catheter, in consequence of the adhesion of the 
 organs, cannot penetrate into the sac of the inverted uterus ; then 
 it might be erroneously believed that we had to do with a polypus." 
 Setting this last objection aside, we doubt entirely the appUcability 
 of such a means of diagnosis in this case as that proposed by Mal- 
 gaigne. The urethra of the female is placed in such a direction in 
 relation to the other pelvic contents, that if the stem of an ordinary 
 male catheter be held in it, the apex of the instrument, when turned 
 backwards, will look posteriorly to the hollow of the sacrum, and 
 cannot, without lacerating the urethral connections, be made to re- 
 turn downwards towards the vagina. To enable it to do so, the 
 instrument would require to be curved at an acute angle, and not at 
 an obtuse — and if of the former shape, it could not be made to pass 
 into the bladder, and even if passed, could not probably be used 
 with safety. "We make these remarks after having tried repeatedly 
 the experiment upon the dead subject. 
 
 A more safe and easy means of distinguishing a polypus from a 
 partially inverted uterus, will be found in the measurement of the 
 uterine cavity, by the introduction of the sound. In some doubtful 
 instances its aid will afford us a certain mode of completing the 
 diagnosis in this, a class of uterine cases in which, above all others, 
 the prognosis and treatment are almost entirely dependent upon the 
 accuracy of our diagnosis. 
 
 To avail ourselves of the information afforded by the measure- 
 ment of the bougie, it is to be held in view that in polypus the depth 
 of the uterine cavity is not necessarily diminished, but sometimes 
 the reverse, while in inversion it is always diminished to a great and 
 notable degree. 
 
 In four cases of polypi of considerable size, projecting through 
 the OS uteri, and which I have had occasion to remove within the 
 last three months, the Bougie in all, when passed by the side of 
 their pedicles into the interior of the uterus, showed its cavity to be 
 of the natural depth. In some preparations, I have seen the cavity 
 elongated, in consequence probably of its distension by the polypus 
 previous to the protrusion* of the latter. On the other hand, in 
 partial chronic inversion of the uterus, with the fundus uteri passed 
 downwards, and projecting through the os, the uterine cavity must 
 be necessarily diminished on all sides in depth, by this doubling up 
 
96 THE UTERINE SOUND. 
 
 of the organ ; and farther, this diminution of its depth must hfe 
 proportionate in its degree to the degree of the inversion, so that 
 ultimately, if the inversion becomes, as sometimes happens, com- 
 plete, the cavity will of course be entirely obliterated. In a common 
 case of such partial inversion and protrusion of the fundus as is 
 liable to be confounded with a polypus projecting through the os, 
 the depth of the interior cavity would be found diminished at least 
 by more than a half, or might measure on all sides about an inch or 
 less in depth, instead of the usual length of two and a half inches.^ 
 In making this measurement with the Bougie, it will always be re- 
 quisite to ascertain accurately that the depth of the uterus is les- 
 sened in the same way at every point around the stem of the tumor, 
 otherwise we might mistake a polypus, which by adhering to one 
 side of the cavity, diminishes by the presence of its pedicle the 
 depth of that one side merely, for an inversion of the uterus which 
 diminishes the depth of the cavity equally on all sides. It is for 
 this reason that we believe the employment of the finger alone, to 
 ascertain this shortening of the uterine cavity, as recommended by 
 Boyer^ and Dupuytren,^ is quite insufficient. In most cases it is too 
 large a body to be passed without force and pain, if at all, into the 
 contracted cervical cul-de-sac — and even if passed to its full depth, 
 it could never leave us perfectly sure that there was not a narrow 
 communication at some point with the uterine cavity beyond. 
 
 As a general rule then, it vsdll, we believe, be found that, in cases 
 of tumors projecting through the os uteri, and when the other 
 symptoms leave any doubt as to whether the tumor be a true polypus 
 or merely the fundus of the organ chronically inverted, the employ- 
 ment of the Uterine Bougie will enable us to decide the diagnosis, 
 and hence also, in a great measure, the prognosis and treatment, by 
 the positive or negative information which it affords with regard to 
 the shortening or non-shortening of the uterine cavity. For — 
 
 1. If the Bougie passes into the uterine cavity to its usual depth, 
 of two inches and a half or more, the disease is not inversion of 
 the fundus — a fact, the certainty of which may, while the Bougie is 
 still in utero, be further corroborated, by the fundus in situ being 
 actually felt through the hypogastric walls whilst it is pushed for- 
 ward on the apex of the instrument, or through the rectum, whilst 
 
 ' In a case in which the inverted uterus was tied in the Lyons Hospital, under the idea 
 that it was a polypus, the patient died on the fifth day. On the post-mortem examination, 
 the vagina and uterus were of the natural size, and the uterine cavity was on all sides re- 
 duced to seven or eight lines in depth (dans tous les points de son etendue sept ou huit lignes 
 de profondeur). Petit, in whose practice the case occurred, relates that four " Maitres de 
 1 Art, after a careful tactile examination, all pronounced the inverted uterus in this instance 
 to be a polypus. Recueil des Actes de la Society de Sant« de Lyon, 1798, p. 103. 
 
 2 Maladies Chirurgicales,'tom. a. p. 583. " Lesons Orales, tom. iii. p. 535. 
 
DIAGNOSIS OP POLYPI AND INVERSIO UTEEI. 97 
 
 by the same means it is retroflected in the mode already described 
 upon the front wall of the bowel. In this case the tumor is one 
 which is in general safely and easily removable. But — 
 
 2. If the Uterine Bougie cannot pass at any point around the 
 stem of the tumor to a greater extent than about one inch, the 
 uterine cavity may be considered as shortened by inversion, and the 
 protruding mass cannot be interfered with, without imminent danger 
 to the patient. When in any case this last point is positively ascer- 
 tained, another consideration may arise. Is the general shortening 
 of the uterine canal the result of simple inversion of the uterus, or 
 of inversion complicated with, and produced by the attachment of 
 a polypus to the interior of the fundus uteri ? The decision of this 
 point may be of the first importance, both as regards the propriety 
 and the safety of any further interference. If the disease be simple 
 inversion, no operation would be attempted, unless under the call 
 of very anxious and urgent reasons. If the inversion be the result 
 of the weight and dragging of a polypus, then by removing the 
 latter, the uterus may itself become replaced, and the patient be 
 restored to the enjoyment of perfect health. In making this addi- 
 tional diagnosis between simple and complicated inversion, the 
 previous history of the patient, and the characters of the tumor, 
 may be sufficient to guide us, but both again may be liable, in par- 
 ticular instances, to lead us into error. 'The length of the whole 
 interior of the uterus, as made up by the double measurement, first 
 of the depth of the cul-de-sac of the cervix, and secondly, of the 
 inverted portion from the roof of this cul-de-sac to the apex of the 
 inverted tumor, may afibrd us more positive information. When 
 added together, the two measurements will, in a case of simple in- 
 versio uteri, not exceed much, if at all, the normal length of the 
 cavity of the organ ; in a case of inversion complicated with polypus, 
 they will exceed this standard in a ratio proportioned to the size of 
 the polypus and the probable elongation of the uterine tissues which 
 it has produced. 
 
 " The only danger," says Dr. Gooch, " attendant on the operation 
 on polypus is, that the ligature may include a portion of the uterus."' 
 This danger, which has led to a fatal result in many master-hands,2 
 will be easily avoided, by the previous use of the Bougie in the way 
 we have suggested, so as to ascertain the presence or absence of any 
 coexistent degree of inversion. If the polypus be found complicated 
 with inversion, but yet has a sufficiently marked narrower part or 
 pedicle connecting it with the fundus uteri, its removal in the usual 
 
 ' Loc. oit. p. 264. 
 
 2 See, for example, a case of Dr. Denman's in his introduction to Midwifery, p. 106, ed. 
 of 1816. Herbiniaux, Trait^ siir divers accoiichemens, &o. tona. ii. p. 35, and obs. xvii. &o. 
 VOL. 1. 7 
 
98 ANTIQUITY OP UTERINE SOUND. 
 
 way, by the ligature or knife, may be safely accomplished, if great 
 caution be employed. If the polypus, however, adheres by a broad 
 base, and is decidedly fibrous or cartilaginous in its structure, the 
 case would probably form an appropriate one for the operation that 
 has been had recourse to in several instances of late for the removal 
 of fibrous tumors on the wall of the uterus — namely, dividing by a 
 longitudinal or crucial incision, the thin layer of uterine tissue, 
 covering the projecting part of the tumor, and afterwards enuclea- 
 ting the mass of which it consists. In this way the source of 
 danger pointed out in the quotation from Dr. Gooch would be so far 
 avoided. 
 
 In the preceding observations I have not adverted to the distinc- 
 tion between complete chronic inversion of the uterus, where the 
 cavity is entirely efiaced, and polypus of the neck or lips of the 
 uterus. 
 
 The remaining chapters of tlie preceding unfinished memoir were, we believe, intended 
 to point out several other diagnostic uses of the Uterine Sound, or Metroscope, and especially 
 the important indications which the direction of the introduced sound, and consequently of 
 the uterine cavity, affords in distinguishing the mere displacement of the organ, from tumors 
 in its walls, &o. This subject will be found, however, discussed to some extent in a subse- 
 quent memoir on Retroversion of the Unimpregnated Uterus. — (Ed.) 
 
 ANTIQUITY OF UTERINE SOUNDS AND PESSARIES. 
 
 Last year Dr. Simpson made a communication to the Obstetric 
 Society on the History of the Uterine Sound and of Intra-uterine 
 Pessaries. He showed that the introduction of a probe or sound 
 into the os and cavity of the uterus is repeatedly mentioned in the 
 Hippocratic writings ; as is also a form of intra-uterine pessary, 
 worn for some days in the uterine cavity. A uterine probe or 
 bougie is alluded to also in Avicenna and some Arabian authors, 
 and in the sixteenth and seventeenth centuries it is spoken of by 
 Hilken, Cooke, and other writers. These authors, however, like 
 the late Dr. Mackintosh, of Edinburgh, employed the introduction 
 of sounds or probes into the cervix of the uterus more as a means 
 of treatment — and particularly for the mechanical dilatation of a 
 contracted or strictured os — than as a means of physical diagnosis, 
 such as is described in the preceding memoir. — (Ed.) 
 
ON THE USE OF THE EXPLORING NEEDLE. 99 
 
 ON THE USE OF THE EXPLORING NEEDLE 
 
 IN THE DIAGNOSIS OP DOUBTFUL FORMS OF PELVIC AND OTHER 
 
 TUMORS.' 
 
 (From Edinburgh Monthly Journal of Medical Science, February, 1850, p. 196.) 
 
 Those authors who, some years ago, wrote at great length upon 
 acupuncture, as Beclard, Cloquet, Carraro, &c., all spoke of the im- 
 punity with which they found that acupuncture needles could be 
 introduced into the muscles, vessels, and even the viscera of the 
 living body. It was well known that small punctured wounds did 
 not bleed, and the parts punctured generally closed immediately, 
 and left little ot no trace of the separation of their tissues by the 
 puncturing instrument, provided it were small. 
 
 Fig. 2. 
 
 Taking advantage of the knowledge of these facts, it has been 
 found that using a small grooved needle, or very slender trocar, we 
 can introduce it into various morbid parts, so as to ascertain the 
 nature of their contents. Surgeons had used such exploring needles 
 for this purpose, in cases of doubtful tumors, in order to ascertain 
 whether they were abscesses, or cysts, or anem'isms, &c. They have 
 been used to explore even large aneurisms without any dangerous 
 result. Dr. Simpson alluded to a case in which a celebrated surgeon 
 was showing to his pupils the use of the exploring needle, in de- 
 tecting matter in what was_supposed to be an inflamed bubo, before 
 laying it open. Air, however, rushed out, instead of pus, showing 
 the swelling to be formed by the skin inflamed over a hernial sac. 
 
 Dr. S. mentioned that he had repeatedly used the exploring 
 needle to detect the nature and contents of various kinds of pelvic 
 tumor, when no other means of diagnosis were sufficient for that 
 purpose. He especially adverted to its advantages as a means of 
 
 ' Read before Obstetric Society of Edinburgh, December, 1849. 
 
100 THE EXPLOEING NEEDLE IN DIAGNOSIS. 
 
 diagnosis in some doubtful cases of pelvic abscess and ovarian tu- 
 mors, and in cases in wbicb tumors existed about the cervix uteri, 
 the cystic or other nature of which it was otherwise impossible^ to 
 determine. Would it serve to diagnosticate cases of extra-uterine 
 pregnancy, either by the instrument striking against bone, or by 
 any contents that might pass through the tube ? 
 
 The instrument which he employed was that figured in the 
 woodcut on page 99. It was simply a very slender silver trocar 
 and canula, the former tipped with a short steel point, of the form 
 of that of a graving instrument. The tube of the trocar is open for 
 nearly an inch along one side at its point, as is seen in the cut, so 
 as to admit more easily of the escape through the canal of the tube, 
 of any fluid in which its point may be placed. Sometimes he had 
 applied an exhausting syringe to the outer end of the instrument, 
 in order to procure the flow along its tube of any more viscid fluid. 
 a, shows the canula, or tube of the instrument ; h, the trocar ; and e, 
 the canula, with the trocar introduced as ready for use. Thin fluids 
 like those of most ovarian cysts, flow readily along the tube, and 
 can be recognized by their microscopic and other characters. When 
 introduced into a sac containing pus, generally a few drops only of 
 the fluid enter the tube of the instrument, from which, however, it 
 can be readily forced, after withdrawing the instrument, by blowing 
 through the tube. If our'microscopic characters of specific tumors 
 and morbid structures were more exact than they are at present, the 
 pathologist might ascertain the nature of most morbid tumors that 
 appear in the living body, by the use of such an instrument, for he 
 could remove by it a sufficient amount of its structure or contents 
 for histological purposes. 
 
 ON THE STATE OF ARTIFICIAL ANiESTHESIA 
 
 AS A MEANS OF FACILITATING UTERINE DIAGNOSIS. 
 (From MS. Proceedings of Obstetric Society of Edinburgh, 14th March, 1855.) 
 
 Since the first introduction of ether and chloroform into obstetric 
 practice in 1847, Dr. Simpson stated that he had annually endea- 
 vored to point out in his lectures the great advantages that were 
 occasionally derivable from their employment, in the way of facili- 
 tating obstetric diagnosis. The production of a state of anaesthesia 
 has been found specially useful as a means of physical diagnosis, 
 under the following circumstances : 
 
 1. In cases of difficult parturition, the state of anaesthesia enables 
 the accoucheur to ascertain more easily and exactly, by his tactile 
 
INFLAMMATORY ERUPTIONS UPON THE CERVIX UTERI. 101 
 
 examination, any peculiarities in the position or presentation of the 
 child, or in the nature and amount of any impediments existing in 
 the pelvic bones or maternal passages. 
 
 2. In instances of uterine or ovarian_^disease, connected with neu- 
 ralgic tenderness of the abdominal walls and pelvis, it is often im- 
 possible to make a complete and useful tactile examination, unless 
 the patient be previously ansesthetized. 
 
 3. In spurious pregnancy, with its usual characteristic, abdomi- 
 nal distension, the use of chloroform at once, as is now well known, 
 enables the practitioner to decide the nature of the case ; the abdo- 
 minal enlargement disappearing as the state of deep anaesthesia 
 supervenes. 
 
 4. In the two preceding morbid states, and in any other cases of 
 uterine or ovarian disease, requiring a very accurate tactile exami- 
 nation, the previous production of ansesthesia not only allows the 
 tactile examination to be gone through without suffering, but further 
 it very greatly facilitates the examination by the state of local and 
 general relaxation which it induces. Under such relaxation, the 
 physical examination of the uterine organs by touch is rendered 
 infinitely more perfect. 
 
 5. In instances where a required examination is objected to from 
 motives of delicacy, the state of ansesthesia saves the feelings of the 
 patient — a matter of no slight moment in the practice of the obste- 
 tric profession. 
 
 INFLAMMATORY ERUPTIONS 
 
 UPON THE MUCOUS MEMBRANE OF THE CERVIX UTERI.' 
 (From Edinburgh Monthly Journal of Medical Science, April,. 1850, p. 386.) 
 
 The common forms and effects of inflammation of the cervix uteri, 
 viz., ulceration, hypertrophy, and induration of the cervix, were 
 now well known to the profession. But the surface of the cervix 
 was liable to other types of inflammation of an eruptive character, 
 which apparently had hitherto been little, or not at all, studied by 
 obstetricians ; and were not yet described in works upon the patho- 
 logy of uterine diseases. Among these special inflammations of 
 the cervix uteri and top of the vagina. Dr. Simpson had observed 
 eruptions referable to the vesicular, pustular, tubercular, papular, 
 and erythematic orders of the classification of Willan and Bateman. 
 Serpes {herpes uterinus) he had seen following the usual course of 
 
 ' Read before MedicoChirurgical Society of Edinburgh, March 6, 1850. 
 
102 MEDICATED PESSAEIES. 
 
 Jierpes labialis in two or three instances, in patients who had months 
 previously been under treatment for common ulceration of the 
 cervix; and Dr. S. suggested that perhaps this and other eruptions 
 were occasionally the origin and basis of the common variety of 
 granular cervical ulcer. Acne, in the form of chronic hard tubercles 
 and pustules, was by no means uncommon, and often coexisted 
 with common ulceration. A papular form of eruption sometimes 
 supervened in chronic cases of uterine disease, and was usually dif- 
 fused oyer both the cervix uteri and interior of the vagina ; some- 
 times having the characters of Lichen ; in other instances present- 
 ing the appearances and severe itching symptoms of Prurigo. 
 Mzema and patches of Aphthce also occurred. The treatment 
 required to be varied according to the nature and character of the 
 eruption, and consisted of the application of nitrate of silver, medi- 
 cated washes, and medicated pessaries, &c. In severe and distress- 
 ing cases of prurigo of the cervix, vagina, and vulva, brushing the 
 affected surface often with hydrocyanic acid (the strength of that of 
 the Edinburgh Pharmacopoeia), was mentioned as frequently giving 
 the greatest relief. 
 
 MEDICATED PESSARIES.^ 
 
 (From Edinburgh Monthly Journal of Medical Science, June, 1848, p. 886.) 
 
 In diseased states of the cervix uteri and vagina, medicinal sub- 
 stances have been applied locally to those parts under various forms, 
 but principally, either in a solid state, as nitrate of silver, potassa, 
 &e., or in a liquid form, as in the great varieties of medicated in- 
 jections in common use in leucorrhoea, &c. "When thus used, the 
 local application is temporary, and applied for a few minutes only. 
 But in various forms of disease it seems an indication of no small 
 importance to have the medicated substance applied continuously, 
 and not temporarily. Medicated pessaries, which Dr. Simpson first 
 introduced into practice several years ago, and which have since 
 been extensively adopted by various practitioners in London and 
 elsewhere (see descriptions of them published by Dr. Stafford Lee,^ 
 Dr. Oldham,' &c.), enable us to fulfil this indication. By their use, 
 for instance, we can keep the cervix uteri, when ulcerated and in- 
 durated, constantly imbedded in mercurial or iodine ointment for 
 weeks, and sometimes with the most marked benefit and success. 
 
 ' Read before Obstetric Society of Edinburgh, March 12, 1848. 
 
 ^ On Tumors of the Uterus, p. 25. 
 
 ' Guy's Hospital Reports, vol. vi. pt. i. p. 193. 
 
DISEASES OF VAGINA AND CERVIX UTERI. 103 
 
 They fulfil another indication in cases of irritation and inflamma- 
 tion of the mucous membrane of the cervix uteri and vagina. They 
 keep the opposed diseased surfaces from coming in contact"; and it 
 is well known how important a matter this is in the pathology of 
 mucous and cutaneous surfaces. 
 
 Dr. Simpson has been in the habit of applying a variety of sub- 
 stances in the form of medicated pessaries, particularly zinc and 
 lead ointment, &c., as simple emollients ; mercury and iodine as 
 discutients, and particularly the iodide of lead ; tannin, alum, and 
 catechu, as astringents ; opium, belladonna, &c., as anodynes. The 
 pessaries are made of the size of walnuts, and can be easily intro- 
 duced by the patients themselves ; one or two in the twenty-four 
 hours. They are composed of the medicine used, mixed up in the 
 form of an ointment, and brought to a requisite degree of consistence 
 with one or two drachms of yellow wax to the ounce of ointment. 
 Messrs. Duncan and Floekhart, druggists, have found the following 
 proportions requisite in the subjoined forms, those in most frequent 
 use in Edinburgh ; and they might serve as models for the others. 
 After being made up in the proper form, they are usually coated by 
 the druggists with a firmer covering, by dipping them into an oint- 
 ment made up with wax and resin, kept liquid by heat. About an 
 ounce of the different ointments makes four balls. 
 
 1. Zinc Pessaries. — R Oxydi Zinci 5j, Cerse Albse 5j, Axungias 
 gvj, Misce, et divide in pessos quatuor. 
 
 2. Lead Pessaries. — R Acet. Plumbi. 5ss, Cerse Albse giss, Axun- 
 gise 3vj, Misce. 
 
 3. Mercurial Pessaries. — R Unguent. Hydrarg. Fort. Jij, Cerse 
 Flavse 3ij, Axungise gss, Misce. 
 
 4. Iodide of Lead Pessaries. — R lodidi Plumbi. 9j, Cerse Flavse 
 V, Axungise 5vj, Misce. 
 
 5. Tannin Pessaries. — R Tanninse 9ij, Cerse Albse 9v, Axungise, 
 5v), Misce. 
 
 6. Alum and Catechu Pessaries. — R Sulph. Aluminis 3j, Pulv. 
 Catechu 3j, Cerse Flavse 3j, Axungise 3'^sb, Misce. 
 
 7. Belladonna Pessaries. — R Extr. Belladonnse 9ij, Cerse Flavse 
 3iss, Axungise 3vi, Misce. 
 
 FOR APPLICATION OP GASES TO VAGINA, 
 See Chajpter on Local Anaesthesia, in Volume IL 
 
104 DISEASES OF CEKVIX UTEEI. 
 
 EMPLOYMENT OF CHLOKIDE OF ZINC 
 
 IN ULCERATION OP THE CERVIX UTERI.' 
 (From Edinburgh Monthly Journal of Medical Science, July, 1851, p. 82.) 
 
 De. Pbddie having read a paper before tlie Society on the employ- 
 ment of chloride of zinc as an escharotic, Dr. Simpson stated that 
 last year he had had chloride of zinc made up for applying to 
 unhealthy ulcerations of the cervix uteri, by Mr. Hunter. But in- 
 stead of using it as Dr. Peddie did in flat plates, he had then got 
 Mr. Hunter to run it into moulds — so as to be formed into round 
 sticks like those of nitrate of silver or potassa fiisa, when it could be 
 much easier used. When quite pure, it very rapidly deliquesced and 
 was very apt to run. As, however, we can always readily restrain 
 and arrest potassa fusa from spreading by partially filling the specu- 
 lum with vinegar, and injecting freely acetic acid into it immediately 
 after the potassa was applied, so he found that chloride of zinc could 
 be similarly rapidly decomposed and restrained by using, instead of 
 vinegar, a solution of carbonate of soda. Less pure preparations of 
 the chloride, like the potassa cum calce, did not deliquesce so rapidly, 
 and he believed Dr. Peddie had used such a preparation. He 
 doubted if a slough separated by chloride of zinc left a more healing 
 granulating surface than a slough separated by potassa fasa, or 
 potassa cum calce. But he believed chloride of ziic would be found 
 a manageable caustic, particularly if the neighboring parts were 
 protected with an alkaline solution — or if the preparations were 
 made impure by being mixed with other material so as to prevent it 
 deliquescing very rapidly : it was usually sold in this impure form. 
 
 TREATMENT OF INFLAMMATORY INDURATION OF THE 
 CERVIX UTERI 
 
 BY DEEP CAUTERIZATION WITH POTASSA FUSA.^ 
 (From Edinburgh Monthly Journal of Medical Science, July, 1847, p. 71.) 
 
 Dk. Simpson stated that his own observations fully confirmed the 
 recorded opinions of Dr. Bennett and others regarding the general 
 dependence of leucorrhoea upon inflammatory ulceration and indu- 
 ration of the cervix uteri. He had found inflammatory enlarge- 
 
 ' Extracted from Proceedings of Obstetric Society of Edinburgh, March 26, 1851. 
 2 Ibid. April 13, 1847. 
 
DISEASES OF CERVIX UTERI. 105 
 
 ment and induration of the tissues of the cervix very frequent in 
 practice, and existing, in fact, in most cases of very chronic and 
 aggravated leucorrhcea. In practice he had seen it mistaken for 
 the induration and ulceration of carcinoma, &c. Formerly, in the 
 treatment of these common cases, he had employed the frequent 
 local application of leeches, and counter-irritation to the sacrum, 
 &c., with the use of pessaries of mercurial and iodine ointment, 
 keeping the indurated tissues imbedded in these applications, &c. 
 The cure in this way is tedious, and months are often required be- 
 fore the indurated parts become reduced. Various local escharotics, 
 partly to destroy the indurated tissues by direct decomposition, and 
 partly to soften down the remainder by new inflammatory action, 
 had been in modern times employed for the same purpose, and 
 with much more certain and expeditious effect. He had in this 
 way employed in a number of cases nitrate of silver often applied, 
 Vienna paste {potassa cum calce), and nitric acid. He stated the 
 particulars of a case which he had treated successfully four years 
 ago with nitric acid, and he had lately seen the patient in perfect 
 health ; it was at the time supposed that she had cancer uteri. 
 Latterly, he had abandoned these and other escharotics, and now 
 always used the common potassa fusa. He had found it far more 
 manageable, speedy, and certain than any other method. He used 
 it of course through the speculum, applying a stick of it freely 
 with a proper caustic-holder to the ulcerated and indurated tissues. 
 It required to be rubbed or held strongly for a time against the part 
 which was to be destroyed. In general a piece three-quarters of an 
 inch, or an inch long, was melted down. The decomposition pro- 
 duced by it often caused a hissing sound. If the induration is 
 extensive, and the whole cannot be removed at once, increased 
 action and absorption are set up in what remains, and the parts 
 adjacent become softened and diminished in size. Absorption in 
 this way is truly one of the results or consequences of inflammation, 
 though still an undescribed termination. In some aggravated cases 
 two or more applications of the caustic are required, at intervals of 
 eight or ten days. He had never seen pelvic cellulitis, or any other 
 bad result follow. The appearance after the operation is as if a 
 portion had been clean cut out with the knife. A large quantity of 
 vinegar and water is immediately thrown up through the speculum 
 to neutralize the potassa, and prevent it from injuring the sound 
 parts. A copious purulent discharge usually follows for several 
 days, requiring the use of astringent washes, or zinc ointment pes- 
 saries. "When the whole of the induration is once removed, the 
 remaining ulcer heals rapidly and permanently. An ulcer over an 
 indurated part may be cicatrized, but it is almost certain to break 
 out again and again till the induration itself is reduced. 
 
106 DISEASES OF THE UTERUS. 
 
 MORBID DEFICIENCY AND MORBID EXCESS IN THE 
 INVOLUTION OF THE UTERUS AFTER DELIVERY. 
 
 (From Edinburgh Monthly Journal of Medical Science, August, 1852.) 
 
 The enormous increase which occurs in the parietes of the uterus 
 during the nine short months of pregnancy has long attracted the 
 attention of professional observers. It is a kind of physiological 
 hypertrophy unequalled, either in regard to its magnitude or its 
 rapidity, in any other organ in the adult human body. For, during 
 the forty weeks of utero-gestation, the uterus enlarges from nearly 3 
 inches in length and If of an inch in breadth, to 12 or 15 inches 
 in length and nine or 10 inches in breadth. It increases from about 
 2 ounces in weight to 25 or 30 ounces. The cavity of the uterus 
 before impregnation is less than one cubic inch, while at the full term 
 of pregnancy it is extended to above 400 cubic inches ; and the 
 surface of the organ increases from about 5 or 6 square inches to 
 nearly 350 square inches. Before impregnation, the uterine cavity 
 would not hold above a drachm or two of fluid : at the ninth month 
 of utero-gestation, its contents usually weigh from 120 to 150 
 ounces. 
 
 The rapidity, however, with which the uterus diminishes in size 
 after delivery, is perhaps still more marvellous than the rapidity 
 with which it increases in size after impregnation. The celerity 
 of its involution in the puerperal state is in fact more striking and 
 remarkable than the celerity of its evolution during the pregnant 
 state. If the process of absorption of organs in the adult is ever 
 studied successfally anywhere, it will probably be by making ob- 
 servations on the reduction or involution of the uterus in women 
 or in the lower animals subsequent to parturition.'' Whilst the 
 human uterus takes forty weeks to attain the dimensions pertaining 
 
 ' Read before Edinburgh Obstetric Society, February 11, 1852. 
 
 We have preferred placing this Essay among those on uterine diseases, rather than in- 
 cluding it with puerperal derangements; inasmuch as instances of it 'will not be likely to 
 come under the notice of the obstetrician during the first few weeks after parturition, but at 
 a later period when such local or constitutional disburbance has arisen as to lead the patient 
 again to seek the advice of her medical attendant. — (Ed.) 
 
 " In the Swedish Hygieia of last year, my friend. Professor M. Retzius, of Stockholm, pub- 
 lished some interesting observations on the process by which nature effects the reduction of 
 the puerperal uterus. He found in a series of anatomical and histological observations on 
 the subject, that the process of absorption of the walls of the puerperal uterus was preceded, 
 as absorption of other deposits is, by fatty transformation of its component fibres j and that 
 the blood during puerperal convalescence shows under the microscope a corresponding 
 superabundance of globules or granules of fat. 
 
MOKBID DEFICIENCY AND EXCESS IN INVOLUTION. lOT 
 
 to the fully developed state of pregnancy, it requires only, on the 
 contrary, from four to eight weeks to decrease from the, extreme 
 size of the organ peculiar to pregnancy, down to the small size pecu- 
 liar to the same organ in its unimpregnated condition. 
 
 But in the vital mechanism -of the involution or reduction of the 
 uterus after delivery, various pathological derangements are liable 
 from time to time to occur. This, like every other process in the 
 animal economy, is apt, for example, to fail, either in the way of 
 defect or of excess. Some years ago, I endeavored to point out to 
 my professional brethren, that occasionally, as one of the derange- 
 ments in this mechanism of involution, the uterus is morbidly slow 
 in regaining its original dimensions — its involution becomes impeded 
 or arrested — and the organ is in consequence liable to be found, 
 weeks or even months after parturition, still so large and unre- 
 duced, as at first to be readily mistaken for a tumor of the uterus or 
 ovary. I described this peculiar condition of the puerperal uterus, 
 under the name of " Morbid Permanence of the State of Puerperal 
 Hypertrophy,"' and illustrated it with the following example : 
 
 Case I. — During the summer of 1842, 1 attended, along with Dr. 
 Abercrombie, a lady, who, after a premature^ confinement in the 
 country, had suffered from a smart attack of puerperal fever. After 
 so far recovering for a few weeks, she was sent from a considerable 
 distance into town, to be treated for what appeared to be a large 
 tumor, stretching upwards from the pelvis into the right iliac region. 
 The tumor had not been observed before delivery, and was some- 
 what painful to the touch. It seemed at first sight extremely 
 doubtful whether the mass consisted of an inflamed uterine fibrous 
 tumor, or enlarged ovary, or of one of those chronic purulent col- 
 lections which are apt to form towards one or other iliac region in 
 connection with puerperal fever or inflammation. The uterine sound, 
 when introduced into the os uteri, passed easily and directly upwards 
 for several inches to the superior end of the tumor, and its apex 
 could be felt there by the hand placed externally. This at once 
 showed the supposed diseased mass to consist of the enlarged uterus. 
 Further examination proved that there was nothing strictly abnormal 
 about the uterus, except its great size. In fact, it was a case where 
 the organ had apparently remained nearly undiminished after de- 
 livery, probably from the puerperal attack arresting the usual pro- 
 gress of its absorption and diminution. It decreased rapidly and 
 fully under leeches and other local antiphlogistic treatment. 
 
 In alluding to the pathological state of the uterus, of which the 
 
 ' See Memoir on the Uterine Sound, ante, p. 72. 
 
108 DISEASES OF THE UTEEUS. 
 
 preceding case is a well-marked example, Dr. Lever has adopted the 
 same designation which I originally applied to the affection/ More 
 lately (1851), Dr. Snow Beck described to the London Medical 
 Society a case of this malady, under the simple term of " A ISTew 
 Disease of the Uterus. "^ On examining microscopically the structure 
 of the hypertrophied uterus in this instance, no inflammatory or 
 heterologous deposits could be detected ; but the tissue of the organ 
 was, it is stated, similar in its histological characters to the tissue of 
 the uterus at the ninth month of pregnancy, except only that its 
 component muscular fibres were smaller in size, or like those of a 
 uterus at the middle period of utero-gestation. 
 
 Retarded involution or reduction of the uterus after delivery is not 
 unfrequent in its less marked degrees ; especially when inflammatory 
 or febrile action supervenes and interferes with the phenomena of 
 the puerperal state. It is often, for example, observable both during 
 life and after death, in women who are the subjects of puerperal 
 fever, pelvic cellulitis, and phlegmasia dolens. Chronic hypertrophy 
 of the uterus in any excessive degree, from morbidly retarded or 
 arrested involution, is more rarely met with. I have sometimes, 
 however, seen it ten or twelve weeks subsequent to delivery, in the 
 form of an apparent tumor, twice or more the'bulk of the normal 
 uterus. In lesser, though still sufficiently remarkable degrees, it 
 often persists for many long months, or even years, after parturition ; 
 particularly when combined, as I have repeatedly found it, with ante- 
 flexion or retroflexion of the fundus uteri, or with the state of pro- 
 lapsus. 
 
 The day after (July 18) the preceding remarks were written, I 
 saw with Dr. Eetzius the following instance of this combination of 
 retarded involution with retroversion of the uterus, in a lady, who 
 came for advice from the north of England. 
 
 Case II.— The patient, aged 28, and married for three years, was 
 delivered of her first child two years ago. She was so well as to be 
 allowed to leave her bed at the end of a fortnight. The lochia, 
 however, were very abundant, and continued for eight weeks. She 
 nursed her child for seven months, and during this period of lacta- 
 tion the menses recurred, as they have done since, regularly, pro- 
 fasely, and each month somewhat prematurely. She complains of 
 pain in the back, weakness, etc. In making a vaginal examination, 
 the body of the uterus, which is retroverted, feels large and heavy, 
 like a uterus at the third month of pregnancy. Its cavity is, as 
 appears by examination with the sound, nearly an inch greater than 
 
 ' Guy's Hospital Reports, vol. ii. 1844, p. l7. 
 • Lancet for 19th April, 1851, p. 447. 
 
PERMANENCE OF PUERPERAL HYPERTROPHY. 109 
 
 the natural length. The cervix is large, and fills entirely the ex- 
 tremity of the largest sized speculum. Its surface is red and con- 
 gested, but presents no appearance whatever of abrasion or ulcera- 
 tion. The OS is unusually patent, and admits the tip of the finger 
 for about half an inch. The lining membrane of the cervical cavity 
 feels, with the os, hypertrophied, and thrown into prominent folds, 
 and some of the IS'abothian glands are much enlarged. The hyper- 
 trophied body and fundus of the uterus seem quite free from fibrous 
 tumor, or any other heterologous disease. 
 
 Sometimes hypertrophy of the uterus, from arrested reduction or 
 sub-involution of the uterus, follows upon abortion or premature 
 labor. I have at present the following instance under my care : 
 
 Case m. The patient, set. 35, and the mother of six living chil- 
 dren, had a premature labor on the 11th December, 1861, under the 
 charge of my friend. Dr. Dickson of Bathgate. The labor came on 
 about the fifth or sixth month of pregnancy, and was in itself simple 
 and easy. The convalescence, however, proved slow and imperfect ; 
 and she was indeed in a great measure confined to bed for three or 
 four months afterwards. The lochial discharge stopped on the second 
 or third day. Menstruation has recurred regularly, but with some 
 degree of menorrhagia. There- is slight leucorrhcea. The uterus 
 feels heavy and hypertrophied when examined per vaginam, but 
 without any organic disease in its walls. The cervix is also much 
 enlarged, particularly the anterior lip, which is considerably thicker 
 than the posterior. Immediately around the os there is a line or 
 two of granular ulceration. The uterine cavity measures between 
 three inches and three inches and a half. 
 
 The preceding instances and remarks refer to deficient, impeded, 
 or arrested involution. But a morbid excess of involution or 
 reduction in the uterus after delivery (super-involution) is still more 
 rare than a morbid defect in it (suh-involution) ; and I am not aware 
 that hitherto any obstetric pathologist has described the former as 
 a diseased state of the uterus. The following remarkable instance 
 of such super-involution, as ascertained both during life and by 
 dissection after death, has lately fallen under my notice : 
 
 Case IV". The subject of this rare pathological affection began to 
 menstruate at the age of thirteen; and the catamenia recurred 
 regularly every four weeks till she became pregnant when eighteen 
 years old. Utero-gestation went on without any unusual pheno- 
 mena to the full term ; and her parturition was natural but tedious, 
 
110 DISEASES OF THE UTERUS. 
 
 a male cMld being born after a labor of seventeen hours. Nothing- 
 unusual occurred during her puerperal convalescence and lactation. 
 But subsequently to delivery she never menstruated. She was, 
 however, subject to frequent attacks of diarrhoea, which she herself 
 believed to be generally most severe at recurring monthly intervals ; 
 and the dejections were then sometimes tinged with blood. 
 
 Two years after her accouchement, she became a patient in the 
 female ward of the Royal Infirmary, complaining of the state of 
 amenorrhoea, with attendant broken health. She suffered from 
 pain in the back and hypogastrium, with a sensation of weight and 
 pressure in the pelvic region; dysuria; a furred tongue; and a 
 weak compressible pulse, generally beating from 80 to 90 in the 
 minute. She was thin, feeble, and ansemic in appearance. The 
 mammte were shrunk and flat. For some time before admission 
 she had suffered much from occasional headaches and giddiness ; 
 frequent nausea and vomiting ; palpitation and occasional rigors. 
 
 On making a vaginal examination, I found the uterus small and 
 mobile. The cervix uteri was much atrophied, and the vaginal 
 portion of it scarcely made any projection into the canal of the 
 vagina. The os uteri was so much contracted as to admit a sur- 
 geon's probe with difficulty. It was dilated by a slender Bougie 
 being left in it for two or three days ; and, when the uterine sound 
 was subsequently used, the uterine cavity was found to be only one 
 and a half inches in length, or about an inch less than normal. 
 
 A variety of means were employed with the view of benefiting 
 the general health of the patient, and of exciting action in the 
 uterine system, but with little or no effect. 
 
 Diarrhoea repeatedly occurred during the three or four weeks she 
 remained under my care, requiring the free use of opiates for its 
 restraint ; and as the uterine symptoms did not at the time seem to 
 admit of special attention and treatment, the patient was trans- 
 ferred to one of the general wards of the hospital, where she was 
 placed under the care of my colleague, Dr. Bennett. 
 
 During the following month, the diarrhoea recurred from time to 
 time very severely. At last, anasarca in the lower extremities and 
 albuminuria supervened ; ascites followed ; and shortly afterwards 
 her face and arms became cedematous. About a month after these 
 symptoms appeared, delirium at last came on, the faeces passed 
 involuntarily, and ultimately she died in a state of prolonged coma. 
 
 On post-mortem inspection, some crude tubercles were found in 
 both lungs — especially in the left. The liver was enlarged, and 
 showed some fatty transformation. The kidneys presented also 
 some stearoid degeneration ; and in the right there was, in addition, 
 a small tubercular abscess. The large intestines were very much 
 
SUPER-INVOLUTION OF THE UTEBUS. 
 
 Ill 
 
 thickened in their parietes, and contracted in their calibre ; while 
 their mucous membrane was ulcerated in various parts. Along the 
 
 Fig. 3. 
 
112 DISEASES OF THE UTERUS. 
 
 lower end of the ileum several large ulcerations were seen running 
 circumferentially around the interior of the bowel. One or two 
 ulcerations were also found in the stomach. The uterus was very 
 small, and atrophied in its length and breadth; its size being 
 diminished about a third below the natural standard in all its 
 measurements; and its parietes were correspondingly thin and 
 reduced. The whole length of the uterine cavity from the os to 
 the fundus was not more than one inch and a half, while the 
 normal uterus usually measures in this direction two inches and a 
 half. When a section was made of the posterior wall of the organ, 
 the thickness of its parietes at their deepest or most developed 
 point was not above three lines, instead of the normal measure- 
 ment of five or six lines. The tissue of the uterus appeared dense 
 and fibrous, and the section of it presented the orifices of numerous 
 small vessels. The ovaries seemed also much atrophied, and 
 smaller than natural. Their tissue was dense and fibrous, and 
 presented no appearance of Graafian vesicles. There was no 
 inflammatory deposit on the peritoneal surface of the uterus or its- 
 appendages ; but some thick pus, or tubercular matter, existed in 
 the distended cavity of the right Fallopian tube. 
 
 The wood-cut on the preceding page presents the uterus and 
 upper part of the vagina, the broad ligaments, and ovaries, of the 
 exact size which they presented, and their degree of atrophy may 
 be easily judged of by comparing the sketch with the same parts 
 when of the normal size. The sketch represents the posterior 
 surface of the uterus and broad ligaments, with the uterine cavity 
 exposed, in order to show the diminished thickness of the parietes 
 of the viscus. The whole parts represented in the wood-cut weighed 
 only one ounce, four drachms, twenty-five grains, in apothecaries' 
 weight. 
 
 In females, subsequently to the cessation of the menses, the 
 uterus, along with the ovaries, undergoes a slow but marked 
 reduction in size. The uterus in this way, in some extreme 
 instances, recurs subsequently to menstruation nearly to the small 
 dimensions appertaining to it previously to puberty; it becomes 
 atrophied and shrunk in all its measurements and dimensions ; the 
 vaginal portion of the cervix can be specially felt flattened and 
 reduced in size; and occasionally the canal of the cervix, espe- 
 cially at its upper part, is found so contracted as not to admit of 
 the passage of a probe. This form of senile atrophy of the uterus 
 is doubtlessly connected with the natural suspension of the func- 
 tions of the reproductive organs; and in this respect is so far 
 similar to the results which we sometimes see in other viscera, as 
 
SENILE ATROPHY OF THE UTERUS, 113 
 
 the testes, when the functions of these viscera are arrested in the 
 course of nature, or when they happen to be prematurely suspended 
 by chronic inflammation, or other forms of disorganizing disease. 
 
 The principal peculiarities in the instance of the marasmus, or 
 atrophy of the uterus, which I have detailed, are two-fold : — 1. The 
 occurrence of the affection in a very young female, as a consequence 
 of pregnancy and parturition ; and 2. The excessive degree of that 
 atrophy or super-involution — ^the uterus being, as we have seen, 
 reduced fully a third in size below its natural dimensions. 
 
 During the last few years I have seen a number of cases of per- 
 manent amenorrhcea connected with an atrophied, or rather unde- 
 veloped condition of the uterus. In these cases the cavity of the 
 uterus generally measures from one and a half to two inches in 
 length, as ascertained by the use of the uterine sound ; the shrunk 
 cervix usually projects but slightly into the cavity of the vagina ; 
 and the opening of the os is small and contracted. In these cases 
 the uterus has apparently not taken on its usual degree of evolution 
 and growth at the period of puberty. The organ, by a kind of 
 malformation from defective development, as teratologists would 
 describe it, retains after the date of puberty the type and size which 
 normally pertain to it in the state of girlhood. But the particular 
 case of undersized uterus which I have described in the preceding 
 paragraphs is quite difl^erent from these ; for in it the uterus, after 
 being fully developed at puberty, and after performing normally the 
 several functions of menstruation, pregnancy, and parturition, re- 
 turned, as" it were, suddenly to the type peculiar to the organ ante- 
 cedently to the commencement of menstrual life ; or, perhaps, we 
 may more correctly say, it assumed, at the early age of nineteen, 
 by an excess of the natural involution or absorption pertaining to 
 the puerperal state, a degree of anatomical atrophy of its structures, 
 and physiological arrestment of its functions, such as does not occur 
 normally till the age of forty-five or fifty ; and even then, at that 
 advanced period of life, the degree of physical reduction in the size 
 of the organ only rarely becomes so very great as was observed in 
 the case which I have detailed above. 
 
 The case itself affords no precise data for determining whether 
 the atrophy of the ovaries and uterus stood to each other in any 
 respect in the relation of cause and efiiect ; or whether they were 
 both simultaneous results of one common agency. 
 
 Instances from time to time occur, in which, as in the preceding 
 case, permanent amenorrhcea follows parturition. It will not, of 
 course, be found that all such instances depend upon excess in that 
 process of natural absorption or involution which follows upon de- 
 
114 DISEASES OF THE UTERUS. 
 
 livery. But the case in question shows that this super-involution 
 of the uterus may be expected to be met with, in some instances, 
 in connection with this type of amenorrhoea. 
 
 At present I see professionally, from time to time, a case in which 
 amenorrhoea has followed parturition, and in which the uterus is 
 also reduced below its natural size. The following are the principal 
 points in its history : 
 
 Case V. — The patient, now aged 30, has been married ten years. 
 She has borne three children. From the time of her third labor, 
 which occurred four years ago, no menstruation has recurred. The 
 catamenia thus ceased at the age of twenty-six. After this third 
 labor she made a good recovery, and left her bed on the eighth day. 
 She nursed the child for fourteen months. I first saw her about 
 two years subsequently to the birth of her last child. She then 
 supposed herself to be again near her confinement ; but the case 
 was only a marked example of spurious pregnancy. The uterus, 
 instead of being enlarged, felt looser and smaller than natural ; 
 and the vaginal portion of the cervix was specially reduced below 
 the natural standard in length and breadth. The cavity of the 
 organ was somewhat diminished below the usual length, and did not 
 allow the stem of the sound to pass up to quite two inches and a 
 half. In this patient the mammae are flat and atrophied ; and she 
 is thin, weak, pale, and impaired in health and strength. 
 
 Sometimes super-involution of the uterus follows abortion, or 
 premature labor. During the present month, I have had placed 
 under my care an instance of this complication, in a patient from 
 Canada. 
 
 Case VI. — A mother of eight living children, now aged 35, had, 
 on the 29th July, 1851, a dead premature child, about the sixth or 
 seventh month, under the charge of Dr. Campbell. Nothing oc- 
 curred to impede her convalescence. Before, however, her confine- 
 ment, her health was not so good as usual, and she was disappointed 
 to find it remained so after delivery. She has only once seen the 
 catamenia during the past twelve months — ^viz., in September. 
 There is slight leucorrhoea. She is anaemic and chlorotic, with pal- 
 pitation, etc. The mammse, which she states were previously very 
 full and large, are now shrunk and flaccid. The uterus is of nearly 
 its natural length, but the vaginal portion of the cervix is very 
 short and atrophied, with the lips somewhat everted. The superior 
 portion of the cervix, above the reflection of the vagina, can be felt 
 small, firm, and cylindrical ; and the body and fundus of the uterus 
 when grasped between the left hand placed above the pubes, and 
 
FIBROID TUMORS OP THE UTERUS. 115 
 
 the two first fingers of the right hand introduced per vaginam, 
 appears under examination unusually mobile and slender, and alto- 
 gether reduced below the usual standard of size. 
 
 Since the publication of this essay we have had ample opportunities of verifying the 
 correctness of Dr. Simpson's vievirs with regard to these morbid conditions of involution of 
 the uterus. As observed by him, we have found the condition of super-involution by far 
 the rarer of the two. Cases of sub-involution, however, we have frequently seen in Dr. 
 Simpson's practice ; within the last few days we have met with an unmistakable instance. 
 The patient, aged twenty-one, had suffered from amenorrhcea since her first confinement, 
 two years ago, and presented on examination a distinct hypogastric tumor. The cavity of 
 the uterus, in tins instance, measured fully six inches, while there was no trace of tumor in 
 its walls. — (Ed.) 
 
 ON THE MORE COMMON TERMINATIONS AND ON THE 
 TREATMENT OF FIBROID TUMORS OF THE UTERUS. 
 
 By far the most frequent form of organic disease met with in the 
 body and fundus of the uterus, is that species of growth which 
 usually passes under the name of the " fleshy," " fibrous," or 
 " fibroid" uterine tumor. These tumors, which generally affect a 
 roundish form, and are almost always gregarious, vary greatly in 
 size. They are sometimes not larger than peas or hazelnuts, and 
 occasionally they acquire, singly or gregariously, the size of a 
 uterus at the sixth month, or even at the full term of pregnancy. 
 Their anatomical relations and characters, their symptoms and 
 general treatment, I have dwelt upon at some length in another 
 work. 
 
 In former times, the common fibrous or fibroid tumors of the 
 uterus were generally considered as malignant in their type, and 
 too often confounded with cancer. Some obstetric writers of the 
 present day even look upon these fibrous uterine growths as having 
 a kind of scirrhous or carcinomatous nature. And no doubt the 
 texture of a chronic fibroid tumor may, like any other tissue, 
 natural or morbid, become occasionally, though rarely, the seat of 
 carcinomatous deposit. But primarily and essentially, they have 
 nothing carcinomatous in their character, nor any tendency to 
 undergo the changes to which carcinomatous structures are liable.^ 
 On the contrary, the changes to which they are subject are patho- 
 logically very different, and vary in different instances, 
 
 1 See Essays on the Diseases of the Uterus, in the Library of Medicine, vol. iv. p. 332. 
 
 2 I have now several times seen the uterine tissue with which a pedioulated fibrous 
 tumor or polypus was long in contact, become in those predisposed to cancer, the seat of 
 carcinomatous degeneration and ulceration, apparently from the constant irritation of the 
 tumor as a foreign body upon the contiguous uterine tissue. Carcinoma of the cervix as 
 well as of the cavity of the uterus is sometimes induced indirectly in this way, without the 
 fibroid tumor or polypus itself degenerating into cancer. 
 
116 DISEASES OF THE UTEKUS. 
 
 1. Fibroid uterine tumors sometimes go on growing— usually 
 very slowly — sometimes intermittingly — and retain throughout life 
 their original fibrous character, increasing merely in volume, with- 
 out any specific change in their structure. 
 
 2. Often, after increasing for years, they entirely cease from 
 further growth, without any further marked change in their size or 
 structure. This termination appears to occur principally when the 
 tumors are imbedded in the uterine walls, or are intramural in 
 their seat, and when they are restrained in their development by 
 the strength and denseness of the tissues surrounding them. 
 
 3. When they cease growing, however, the fibroid structure of 
 the tumor is frequently found to become changed into cartilaginous 
 tissue, and subsequently to become more or less the seat of osseous 
 or calcareous degeneration ; a transformation observed equally in 
 the smallest fibrous tumors as in those of a larger volume. This 
 calcareous degeneration in uterine fibroids seems to indicate the 
 death, and consequently the cessation of the reproductive action, 
 of those cells which form the essential growing constituent in these 
 tumors.' 
 
 4. In a few cases observed by Clarke and other pathologists, 
 fibroid tumors of the uterus have appeared to undergo another and 
 most important change, viz., they have gradually atrophied and 
 become diminished both in volume and density. 
 
 If we looked upon fibrous uterine tumors as purely heterologous 
 structures, it would be difficult indeed to believe in the possibility 
 of their atrophy and involution — either spontaneously or under any 
 form of treatment. But the more I have examined these struc- 
 tures of late years, the more have I become convinced that they are 
 essentially and primarily homologous structures only, and that they 
 essentially consist, in fact, of local masses, nodose collections, or 
 hypertrophies, if I may so speak, of the normal fleshy or fibrous 
 tissue of the uterus. Most physicians further are, we believe, 
 ready to acknowledge that mere hypertrophies of the natural 
 
 ' I have elsewhere tried to show (see Proceedings of Obstetrio Society, in Edinburgh 
 Monthly Journal for August, 1847, p. 137), that we have a similar change and deposit in 
 the case of some human entozoa — for example, the trichina and cysticercus — the cyst 
 belonging to and enclosing these entozoa ossifying or becoming calcareous after their death. 
 At the same time I mentioned the interesting experiments of Rayer, in which that patho- 
 logist induced the artificial transformation of normal fibrous tissue, such as the ear of the 
 rabbit, into cartilaginous and osseous substance, by the repeated or continued irritation of it. 
 And as a result of these remarks, the possible artificial induction of osseous transformation 
 as an indication of treatment in fibrous uterine tumors, was suggested. 
 
CHANGES UNDERGONE BY FIBROID TUMORS. 117 
 
 structures of organs Bometimes diminisli and are amenable to 
 treatment; and we all know that the uterus, immediately after 
 delivery, is in a state of great physiological hypertrophy, from 
 which it is rapidly reduced by a normal process of involution or 
 atrophy. During the process of puerperal involution the uterine 
 structures undergo a fatty form of degeneration. Occasionally on 
 dissection we have observed uterine fibroid tumors presenting what 
 we conceived to be an analogous white fatty-like transformation. 
 And during the last few years I have watched, upon the living sub- 
 ject, the progress of a number of cases of uterine fibroids, that have 
 appeared to me gradually to involve and atrophy to a greater or 
 less extent under treatment. 
 
 In Germany, the waters of Kreuznach have obtained some 
 repute for their supposed efficiency in the reduction of tumors, and 
 especially of fibroid tumors, in the walls of the uterus. I have 
 seen a considerable number of such cases after they had been sub- 
 jected to full courses of this water drank internally, and applied 
 locally. In most of them, this treatment had most completely 
 failed ; but one or two have appeared to benefit by it. I have seen 
 a far larger proportion of cases do well under a long-continued 
 course of bromide of potassium, given in doses of from three to 
 five grains taken thrice a day ; and sometimes combined with its 
 local application, leeching, &c. The Kreuznach waters contain 
 bromine ; but only in very small quantity. If the bromine is, as it 
 is supposed to be, the chief deobstruent in these waters, the 
 methodic exhibition of this ingredient artificially in more powerful 
 and continuous doses ought to be followed, as I believe it is, by 
 more beneficial and decisive effects than the waters themselves. It 
 stands thus in the same relation to the Kreuznach waters, as qui- 
 nine does to cinchona.' One of the first patients who used the 
 bromine alone, with this view, I saw along with my friend Dr. 
 Wyse. The lady had been at Kreuznach, and taken full courses 
 of the waters there without any benefit whatever. The uterine 
 fibrous tumor was of large size, and incommoded her much from 
 its weight and pressure. Under a course of bromide of potassium 
 and local leeching, continued in perseveringly for many long 
 months, the tumor involved and decreased in a most marked 
 manner; and her health and power of walking and exertion 
 became quite restored. I have found the same remedy succeed in 
 several similar cases, in arresting and more or less reducing uterine 
 fibroids, and again in others I have seen it fail. But to most 
 
 ' On the efBcacy of bromine in fibroid tumors, and on their nature, see a fe«r remarks 
 by Dr. Simpson at a meeting of the Medico-Chirurgical Society, December 7, 1853, in 
 Association Medical Journal for that year, p. 1116. — (Ed.) 
 
118 DISEASES OP THE UTERUS. 
 
 persons the bromide of potassium can be given for a great length 
 of time without any interference with the general health. In fact, 
 it usually serves apparently as a tonic as well as a deobstruent, in 
 this respect having a marked advantage over iodide of potassium. 
 
 5. When fibroid tumors are situated more immediately under 
 the serous or mucous coats of the uterus, they usually become 
 gradually more or less pediculated, forming fibroid polypi. Some- 
 times the pedicle becomes more and more attenuated and at last 
 gives way, allowing the tumor when subperitoneal to fall into the 
 cavity of the abdomen (of which I have seen several instances) ; or, 
 when it is submucous, the tumor or polypus drops into the cavity 
 of the uterus and vagina, and thence escapes. The accoucheur 
 imitates this latter process in the surgical removal of uterine polypi. 
 
 6. When the tumor is non-pediculated and intramural, another 
 termination is occasionally observed. The tumor sometimes in- 
 flames, and sloughs, and the intervening uterine tissues ulcerating, 
 it is ultimately eliminated from the genital canals in smaller or 
 larger masses. I have seen several instances in which nature thus 
 reduced and threw off successfully by ulceration and gangrene, 
 large portions and masses of intra-mural fibroid tumors. Attempts 
 have been made by Amussat, Maisseneuve, Atlee, and others, to 
 imitate by the knife this process of spontaneous or natural elimi- 
 nation ; but we believe it to be, from the cases which we have seen, 
 an operation that, as at present practised, will very rarely indeed 
 succeed, and which ought to be very rarely, if ever, undertaken. 
 
 ARTIFICIAL REMOVAL OF A LARGE FIBROUS TUMOR, 
 
 IMBEDDED IN THE POSTERIOR WALL OP THE UTERUS.' 
 (From Edinburgh Monthly Journal of Medical Science, March, 1S48, p. 695.) 
 
 Dn. Simpson explained to the Society the mode in which he had 
 lately removed a large fibrous tumor from the posterior wall of the 
 uterus. The patient was forty-six years of age ; she had borne ten 
 children, the youngest being six years old, naturally strong and 
 healthy. During the last two years she had been subject to severe 
 fioodings, which recurred every fortnight, and had reduced her 
 excessively. Her general health had become quite broken up, and 
 for several months she had suffered much from sore throat, and 
 general irritation of the mucous membranes. He found, on exa- 
 
 ' Extracted from Proceedings of Edinburgh Obstetric Society, Dec. 22,-1847. 
 
ARTIFICIAL ENTJCLEATION OP A FIBROUS TUMOR. 119 
 
 mination, a large fibrous tumor imbedded in the back wall of tlie 
 uterus, and protruding downwards upon tbe top of the vagina in a 
 rounded form, the os uteri and uterine cavity lying in front of it — 
 as ascertained by the uterine sound. 
 
 Accompanied by Drs. Malcolm, Ziegler, "Weir, and Keith, he 
 made an opening, by means of caustic potass, into the most pro- 
 minent part of the tumor, about one inch behind the os uteri. It 
 extended through the layer of uterine substance, and into the mass 
 of the tumor itself. On inserting the finger into the hole thus 
 made, it was found that it could be passed easily between the sub- 
 stance of the tumor and the uterine wall. The tumor, in fact, 
 seemed to be very loosely connected with its uterine envelope, and 
 could be separated from it with great ease as far as the finger 
 could pass between them. Two days after the caustic was used, 
 he found the artificial opening enlarging like the os uteri in labor, 
 and the tumor beginning to protrude through it. It opened up 
 gradually, the patient taking some ergot, and on the fifth day 
 a large piece of the tumor was found pushed low down into the 
 vagina, while the edge of the uterine wall could barely be felt, 
 encircling it like the rim of the os uteri when fully dilated. The 
 abdominal tumor had subsided considerably. On the eighth day 
 he attempted to pass a ligature round the mass, but found it could 
 not possibly be made to include more than a very small portion. 
 He separated, however, and brought away a small fragment, not 
 without giving a good deal of pain. The tumor now gradually 
 and more completely filled the vagina. The uterus, however, 
 seemed unable to throw it of£ entirely, and the patient was getting 
 exhausted from the quantity of the discharge, which was very fetid 
 and ofifensive. On the twelfth day. Dr. Simpson, while she was 
 completely under the influence of chloroform, passed up his hand 
 by the side of the tumor, completed the separation of the remain- 
 ing adhesion, like an adherent placenta, and brought away the 
 tumor in one mass. This was done in a very few minutes. The 
 patient awoke quietly, and said she had felt no pain whatever ; nor 
 did she complain at all of pain in the region of the uterus subse- 
 quently. She proceeded very well for three days, her pulse not 
 above eighty ; when, in consequence of her nurse having taken 
 unwarrantable liberties with her in making her get out of bed, 
 w£fshing, &c., she was seized with rigors, followed by severe sore 
 throat and irritative fever. This completely exhausted her remain- 
 ing strength, and she died six days after the tumor was removed. 
 The body was examined by Drs. Bennett, Scott, Simpson, and 
 Keith. The peritoneal surface of the uterus was perfectly healthy, 
 and showed no trace whatever of inflammatoiy action. The 
 
120 DISEASES OF THE UTERUS. 
 
 cavity in the back wall, in which the tumor had been imbedded, 
 was much reduced in size, and appeared to be tending to a healthy 
 cicatrization. 
 
 The tumor weighed three pounds eight ounces when removed. 
 It must have previously been somewhat heavier, as the great dis- 
 charge for several days was no doubt from partial softening and de- 
 composition of the tumor. Various Trench surgeons had cut down 
 upon such tumors, and enucleated them by instruments, or by the 
 hand. In the above case Dr. S. had merely formed an artificial 
 opening into the uterine cyst, as it were, containing the tumor, and 
 then allowed the uterine walls, which are hypertrophied around such 
 masses, exactly like the uterus in pregnancy, to push down and 
 expel the foreign body. It was, he believed, the first time this new 
 operation had been performed, and the largest fibrous tumor ever 
 yet enucleated. The tumor, on division, was shown to be the com- 
 mon fibrous tumor of the uterus. 
 
 ON THE DIAGNOSIS OF POLYPI GROWING FROM THE 
 LIPS OF THE CERVIX UTERI.^ 
 
 (From Lond. and Edin. Monthly Journal of Med. Science, April, 1845, p. 319.) 
 
 In polypi arising from any part of the interior of the uterus, and 
 projecting into the vaginal cavity, the stalk of the tumor is always 
 found more or less encircled by the lips of the dilated os and cervix 
 of the organ. The tracing, with the finger, of this circle of the 
 cervix, round the pedicle of the polypus, forms always an important 
 diagnostic mark in such forms of the disease. Thus Dupuytren 
 remarks, " The essence of diagnosis is always the exploration of 
 the neck — of its central orifice, and of the circular cul-de-sac, 
 which separates it from the vagina." 
 
 When, however, a polypus arises from the edge of the os uteri or 
 vaginal surface of the cervix, the above important diagnostic mark 
 is wanting ; and the case, in consequence, becomes one, the nature 
 of which is often much more difficult to determine. Speaking of 
 this form of the disease, Dr. Gooch states strongly the difficulty of 
 diagnosis in such cases. " I have seen," he observes, in regard to 
 
 ' Previous to the appearance of the paper on the Detection and Treatment of Intra-uterine 
 Polypi, we find published the accompanying extract from a MS. clinical lecture, which, as 
 it illustrates some of the difSculties of diagnosis of polypi, and the aid to be derived from 
 the Uterine Sound, we have thought it well to reprint. It also discusses the differential 
 diagnosis of Uterine Polypi and Inversion of the organ, hitherto only alluded to. See ante, p. 
 43.— (Ed.) 
 
DIFFERENTIAL DIAGNOSIS OP POLYPI. 121 
 
 them, " the most experienced practitioners in London puzzled to 
 tell what was the nature of the tumor in the vagina, and what ought 
 to be done for it;" andLefaucheux describes the appearances on dis- 
 section of a case of this form of polypus, which during life could 
 not be discriminated from complete inversion of the uterus. 
 
 The difficulty of diagnosis of polypi of this kind, arising from the 
 edge of the os uteri, or from the vaginal surface of the cei-vix, does 
 not depend merely upon our not finding the pedicle of the tumor 
 encircled, as usual in other forms of uterine polypi, by the dilated 
 orifice of the uterus, but also from this still more fallacious circum- 
 stance, that the os uteri, though traceable in the stalk of the tumor, 
 is generally so displaced in situation, and altered in form, as to 
 render its identity doubtful. " In these cases," remarks Lefaueheux, 
 " the orifice of the uterus has always lost its natural form. It is 
 found situated obliquely, and the lip of the cervix which is not the 
 seat of the pedicle is the most elevated, the pedicle elongating, on 
 the other hand, that lip to which it is attached. When the pedicle," 
 he adds, "has taken its rise in the cellular tissue of the greater part 
 of the circumference of the orifice of the uterus, it is sometimes very 
 difficult to distinguish between such a polypus and inversion of the 
 organ, for the remainder of the orifice forms only a kind of fissure, 
 which is detected with difficulty, and through which it is impossible 
 to introduce the finger." The difficulties attending the diagnosis 
 of the form of polypus to which these remarks refer, would in most, 
 if not in all cases, be perfectly removed, if we could assure ourselves 
 that the body of the uterus itself was of the natural size, and in its 
 natural position, and that the opening or imperfect cleft that may 
 be traceable on the inside of the tumor was in reality the os uteri. 
 If these points could be fixed with certainty, the attachment and 
 nature of the tumor would become at once evident — ^the question 
 of the propriety of its removal would be resolved — and the exact 
 point of its removal more safely and certainly determined, than it 
 otherwise could be ; in those cases where the stalk grows from the 
 cervix, the rule being, as laid down by Gooch, that the liiiife or 
 ligature ought to be applied a little below the orifice, if it can be 
 distinguished. These important points in diagnosis and practice we 
 would, in future cases, propose to fix by introducing the sound into 
 the uterine cavity, so as to determine the real situation of the os, 
 and the position and state of the uterus itself, as ascertained by the 
 direction and length of its cavity. The introduction of the instru- 
 ment in particular cases of this complication will require unusual 
 care and patience, in order to pass it through the displaced and al- 
 tered uterine orifice ; and a sound of a smaller size than usual may 
 in some instances be necessary. But the clear information afforded 
 
122 DISEASES OF THE UTEKUS. 
 
 by the examination in a set of cases that are so often doubtful and 
 perplexing in their character, will amply repay the mastering of any 
 such difficulties as I have presupposed in the employment of the 
 means. 
 
 ON THE DETECTION AND TREATMENT OF INTRA- 
 UTERINE POLYPI.' 
 
 (From Edinburgh Monthly Journal of Medical Science, January 1850, p. 3.) 
 
 After a polypus, or pediculated tumor, arising from any part of the 
 interior of the uterus, has once passed downwards into the vagina, 
 the diagnosis of the disease is, generally speaking, very easy, the 
 operation for its removal comparatively simple, and the result of the 
 treatment in the highest degree successful and satisfactory. 
 
 But before a uterine polypus has passed through the os uteri — in 
 other words, as long as it is still intra-uterine, or shut up and con- 
 tained within the uterine cavity — the disease has hitherto been usu- 
 ally regarded and described as entirely beyond the reach of legitimate 
 diagnosis and treatment. "It very frequently happens," observes 
 Dupuytren, "that polypi concealed in the uterine cavity, inaccessible 
 to our senses and instruments, give rise to severe symptoms, the 
 true cause of which cannot be determined."^ "When polypi," he 
 again states, " are entirely included within the uterus, the rational 
 symptoms aiford room only for conjecture ; and examination by the 
 finger or speculum are both alike insufficient."^ " So long," remarks 
 Madame Boivin, " as the polypus is concealed within the uterus, all 
 that can be ascertained is the increased size of that organ."* "If 
 the polypus," says Dr. Eamsbotham, "be still included within the 
 titerine cavity, and if the mouth of the organ be closely shut, it is 
 impossible to reach it by the finger, and consequently quite out of 
 our power to ascertain its presence."^ "So long," according to 
 Mende, " as a polypus is enclosed in the uterine cavity, its diagnosis 
 is scarcely possible."^ " True uterine polypi, while theyremain en- 
 closed in the uterine cavity, furnish," observe Roche and Sanson, 
 "none but equivocal symptoms, which may be confounded with 
 those of pregnancy. These different symptoms may also depend on 
 chronic inflammation of the womb ; and it is often impossible to 
 distinguish this affection from polypus. In the actual state of the 
 
 ' Read before Medieo-Chirurgical Society of Edinburgh, November 21, 1849. 
 
 2 Legons Orales, vol. iii. p. 542. = Ibid. p. 490. 
 
 ■• Practical Treatise on Disj;ases of tlxe Uterus.— Heming's Translation, p. 200. 
 
 s Medical Gazette, vol. xvi. p. 406. 6 Krankheiten des Weibes, p. 591. 
 
FATAL HEMORRHAGE FROM INTRA-UTERINE POLYPUS. 123 
 
 science, there is but one case in which a certain diagnosis may be 
 formed, viz., when, the neck being effaced, and partly opened, it is 
 possible to feel the rounded tumor within."^ 
 
 These, and other passages that might be cited, show that intra- 
 uterine polypi are generally considered at the present day as placed 
 beyond the pale of any certain means of detection, or any possible 
 means of operative removal. And some of the older pathologists, 
 indeed, would seem to have believed that there was no necessity for 
 devising such means, inasmuch as, in their opinion, no danger was 
 connected with the disease as long as the polypus remained intra- 
 uterine. They held that the great source of prostration and peril 
 attendant upon uterine polypi — namely, the hemorrhage or menor- 
 rhagia which accompanies them — is not liable to supervene, till the 
 polypus has passed through the os uteri. Levret, for instance, was 
 of opinion that, as long as a polypus remained within the uterine 
 cavity, there was no accompanying hemorrhage, and that floodings 
 appeared only after the tumor had left the uterine cavity.^ 
 
 Several years ago, I saw, with Dr. Alexander "Wood, a case, the 
 result of which was distressingly opposed to this doctrine. 
 
 Case I. — The patient was about fifty-five years of age, and un- 
 married. She had been sufiering long under severe menorrhagia. 
 The face was pale and anaemic, and her health and strength broken 
 down. On examining, per vaginam, the os uteri was found closed ; 
 but the uterus felt somewhat large and distended ; and Dr. "Wood 
 believing with me, that the hemorrhagic drain which was present 
 might be the result of an intra-uterine polypus, the mechanical dila- 
 tation of the uterine cavity was advised, but given up in consequence 
 of local treatment being objected to. In a few weeks the patient 
 sank, under the continuance of the hemorrhage. On opening the 
 body, Dr. "Wood and I found the lower part of the cavity of the 
 uterus distended by a polypus, of the size of a small plum, and 
 attached to the back wall of the uterus by a narrow half-broken 
 stalk. The lining-membrane of the uterus was white and bloodless, 
 but the polypus was red, from engorgement and effusion of blood 
 in its tissues. Its structure was fibrous ; and there was another 
 small fibrous tumor imbedded in the walls of the uterus, near the 
 uterine extremity of the right Fallopian tube. It had descended 
 lower down than at the time we examined, so as to have already 
 dilated the cavity of the cervix ; and the os, at the time of death, 
 had begun to open. It was evident that, if the cavity of the os and 
 
 ' Nouveaux El^mens de Pathol. Med. Chir. torn. iii. p. 284. 
 
 ^ Leviet, Sur la Cure Radioale de Plusieurs Polypes de la Matrice, p. 25, &c. &c. 
 
124 
 
 DISEASES OF THE UTBKUS. 
 
 cervix could have been artificially dilated during life, the polypus 
 would have come within reach, and the patient's life been saved/ 
 
 I have seen several other cases of intra-uterine polypus, where 
 the hemorrhage was both long in confinuance and great in quantity. 
 Some years ago, along with the late Dr. Henderson of Corstorphine, 
 I excised a slender pendulous polypus, hanging from the os uteri, 
 in a patient who, some time previously, had nearly died of excessive 
 uterine hemorrhage of several days' duration, at Leamington ; but 
 at the period of that dangerous attack, the attendant physicians had 
 been unable to discover any uterine organic disease, to account for 
 the discharge. The polypus had not yet passed the os uteri.^ 
 
 When nature, in cases of intra-uterine polypi, begins to expel the 
 tumor, and open up the os uteri, we may, at that stage, as stated in 
 a preceding quotation from the work of Roche and Sanson, find it 
 possible to make a diagnosis of the disease by being able to "/eeZ 
 the rounded tumor within." If art could furnish us with any means 
 of producing, at will, the same extent of opening of the os uteri, 
 it would enable us in the same way to "feel the rounded tumor 
 within" with our finger; and it is evident that, by this means, we 
 
 ' The uterus and its included polypus, from this patient, are in the University Museum ; 
 and the above wood-out presents a faithful sketch of them, diminished two-thirds, made 
 from the preparation, and showing the size and site of the polypus, its place and mode of 
 attachment, and the slight dilatation of the os, that had taken place before death. 
 
 In this, and in one or two other instances in which I have seen extreme degrees of 
 flooding attendant upon small polypi, the narrower elongated polypus was of a cellular 
 structure internally, and externally spotted and roughened over by numerous small linear- 
 placed elevations, like those on the shell of the echinus. 
 
SUGGESTION OF SPONGE-TENTS. 125 
 
 would possess a power of detecting, with all the certainty of physical 
 diagnosis, the existence or not of the disease within the cavity of 
 the uterus, in cases in which the attendant rational symptoms — as 
 the menorrhagia, uterine leucorrhoea, and perhaps the swelled state 
 of the neck or body of the uterus — might lead us to conjecture the 
 probable presence of an intra-uterine polypus. 
 
 In 1844, in a communication' laid before the Medico-Chirurgical 
 Society of Edinburgh, I proposed a means of safely opening up the 
 cavity of the cervix and body of the uterus, to such an extent as 
 might enable us to introduce a finger into the uterine cavity, for the 
 purposes of diagnosis and operation in this and other diseased states 
 of the organ. The means described consisted in the introduction 
 of sponge-tents into the os and cavity of the uterus, so as gradually 
 to dilate these parts to the degree required. For several years past 
 I have been constantly employing this means of dilatation of the 
 uterine os and cavity, for a variety of purposes and indications. 
 The sponge-tents used by myself and my professional brethren in 
 Edinburgh are manufactured by Duncan, Plockhart, and Co. They 
 are of a narrow conical or pyramidal form ; and used of many dif- 
 ferent sizes and lengths, according to the object in view. One of 
 nearly the medium size is represented in the next cut. These tents 
 are made by dipping a piece of sponge in a strong solution of gum- 
 arabic, tying and compressing this sponge around a central wire, as 
 its axis, into the required conical form, by a continuous layer of 
 
 Fig. 5. 
 
 ) V 
 
 whip-cord, drying it thoroughly, removing the cord, and subse- 
 quently slightly coating the surface of the tent with tallow, or 
 axunge and wax, to facilitate its introduction. The central wire 
 passes only for half an inch or an inch into the base of the cone 
 (see section of one above) ; and the opening left by it serves as an 
 aperture to transfix the tent with the tip of the metalUe director 
 
 ^ " Mechanical Dilatation of the Cavity of the Os and Cervix of the Uterus, as a Means 
 of Diagnosis and Treatment in some Affections of that Organ." See abstract of it in the 
 Monthly Journal of Medical Science, August, 1844, p. 734. 
 
126 DISEASES OF THE UTERUS. 
 
 (Figs. 5 and 6), used for guiding and introducing the tents through 
 the OS uteri. This metallic director, which, at the distance of nearly 
 
 Fig. 6. 
 
 two inches from its extremity, is bent at an obtuse angle, thence 
 tapering to a blunt point, is introduced like the uterine sound or 
 the catheter ; its handle, with the sponge affixed to it, is held and 
 manipulated by the left hand, while the fore-finger of the right hand 
 touches the os uteri, in order to guide and direct the apex of the tent 
 into that opening. The old forms of sponge-tent used by surgeons, 
 and made of sponge steeped in preparations of wax, required for 
 their expansion and development the aid of heat, in order to dissolve 
 their retaining ingredient. The tent I have described, made by 
 steeping sponge in a solution of gum, requires moisture, and not 
 heat, for the solution of its retaining material, and for the expansion 
 of the sponge. Very generally the secretions of the surrounding 
 mucous canal afibrd a sufficient quantity of moisture for these two 
 purposes ; but if not, a small quantity of tepid water maybe injected 
 from time to time into the vagina. Usually a well-made tent takes 
 twenty or thirty hours to expand to its full extent in the os uteri ; 
 and dilates to four or five times the diameter it presented in its 
 orginal compressed state. Generally the first tent opens up the os 
 and cavity of the cervix, and allows the finger ample space to examine 
 sufficiently its contents, and the state of its parietes. If it is neces- 
 sary to open the uterine cavity higher, to enable the finger to pass 
 into the cavity of the body of the organ, a succession of tents are 
 usually required ; and they must be passed completely through the 
 OS internum or narrow portion, lying between the cavity of the 
 cervix and cavity of the body of the organ. The use of the tent 
 for a day, generally, as I have already stated, dilates the os uteri and 
 cavity of the cervix sufficiently ; and the employment of the sponge 
 is accompanied with little or no feeling of uneasiness. When it is 
 necessary to examine the state and conditions of the interior of the 
 cavity of the body of the organ, the persevering use of a series of 
 larger and larger tents for several days is usually requisite ; and the 
 dilatation of the os internum and body of the organ sometimes, 
 but not always, causes a feeling of uneasiness and pain, that may 
 require the use of an opiate. I have omitted to state that the tent is 
 always prepared with a string affixed to its base, to allow of its easy 
 
THE USE OP SPONGE-TENTS IN DIAGNOSIS. 127 
 
 removal. (See Fig. 5.) In using sponge-tents, it should be remem- 
 bered that, when sponge is in contact with the maternal passages 
 for some hours, it always exhales, when removed, a very fetid odor. 
 
 For dilatation of the unimpregnated os uteri, the tent should be 
 selected as regularly conical as possible ; and with the apex neither 
 too blunt and rounded to pass the os, nor too slender and flexible, so 
 as to double back in the attempt. The spirally grooved surface of 
 the tent, resulting from the compression of it by the whip-cord 
 during its manufacture, tends to retain it in situ, till its expansion 
 commences. It perhaps ought to be added, that the introduction of 
 the sponge-tent into the os and cavity of the uterus should be 
 effected without the use of the speculum. The sense of touch serves 
 in this and some other analogous operations, infinitely better than 
 the sense of sight. 
 
 By the use of sponge-tents introduced daily, and of increasing 
 size and length, we may reach a polypus when affixed and sessile 
 even upon the fundus uteri. One of the first cases in which I 
 dilated the uterine cavity to its extreme height, was the following : 
 
 Case II. — In 1844, a patient, set. thirty-six, under the care of Dr. 
 Graham of Dalkeith, had a miscarriage, from the effects of which 
 she never satisfactorily recovered. Previously she had borne four 
 children. When I first saw her, two or three years afterwards, she 
 was emaciated and extremely pallid from the excessive loss of blood 
 which she had been sustaining for some time ; and her weakness 
 was such, that it was with difficulty she could rise and walk across 
 her bed-room. In August, 1847, 1 dilated fully the interior of the 
 cervix and body of the uterus by a succession of sponge-tents, and 
 at last felt a hard round fibrous polypus seated at the very fundus of 
 the uterus, and projecting, of the size of a walnut, into the upper 
 part of the cavity of the organ. Dr. Ziegler, Dr. Toogood of Tor- 
 quay, and other professional friends, confirmed this diagnosis. It 
 was impossible to ascertain how it was pediculated, or to operate 
 upon the pedicle. We could only reach the round body of the 
 tumor ; and that I compressed strongly and repeatedly in the blades 
 of a lithotomy forceps, with the view of breaking down its tissue, 
 so as to destroy the vitality of the polypus. A purulent discharge 
 followed, and three largish pieces of organized structure were sub- 
 sequently cast off. Her recovery of health, after these discharges 
 ceased, was gradual but perfect. There has been no return of 
 monorrhagia. About a year ago she called upon me, and the 
 change from excessive pallor and emaciation of the face, to the hue 
 and ruddiness of health, was so great, that I had difficulty in being 
 convinced of the identity of my former patient. 
 
128 DISEASES OF THE UTERUS. 
 
 The Symptoms which might, a 'priori, induce a practitioner to 
 conjecture the probahle existence of an intra-uterine polypus, are, 
 as we have seen in the quotations I have already given, of a, very 
 uncertain and equivocal character. The polypus, while still in- 
 cluded within the uterus, is principally liable to give rise to the fol- 
 lowing groups of symptoms : 
 
 1st. Menorrhagia, in consequence of the discharge of blood from 
 the surface of the tumor.^ The attendant hemorrhages take place 
 particularly at the menstrual periods, but are apt to recur also at 
 other times ; and the blood is sometimes fluid, sometimes coagu- 
 lated; occasionally there is an almost constant red-stained dis- 
 charge. The eifects of these repeated floodings upon the constitu- 
 tion of the patient vary with their amount ; but if they go on 
 increasing, as they usually do, in quantity and frequency, the 
 patient's constitution becomes gradually more and more shattered 
 and broken down by the amount of hemorrhagic discharge ; and all 
 the symptoms of anaemia, in their most marked degree, at last 
 supervene, as pallor of the face and lips, great muscular debility, 
 palpitation, vertigo, dyspepsia, cedema, &c. 
 
 2dly. The discharge of mucous, purulent, or serous matter from 
 the cavity of the uterus, in consequence of the mucous membrane 
 of the organ becoming often irritated, inflamed, and even ulcerated 
 by the presence and pressure of the polypus. If a severe leucor- 
 rhoeal discharge is present, and we ascertain by the speculum that 
 it does not originate in ulceration or other morbid state of the ex- 
 ternal surface of the cervix, or of the vagina ; and if we further 
 detect, with the speculum, the discharge issuing from the cavity 
 itself of the uterus, the probabilities of it originating in some patho- 
 logical iiTitation within the uterus, will be necessarily increased. 
 Sometimes the discharge, in cases of polypi, is fetid, especially if 
 it be retained, or mixed with decomposing blood. 
 
 3dly. Increased size of the cervix and body of the uterus, in con- 
 sequence of its interior being distended by the presence of the 
 polypus, is traceable in those cases in which the polypus is of any 
 great size. N'ot unfrequently intra-uterine, like vaginal polypi, are 
 found combined with the presence of fibrous tumors in the walls of 
 
 ' The following notice of the source of hemorrhage in cases of uterine polypus occurs in 
 the Proceedings of the Edinburgh Medioo-Chirurgical Society, March 6, 1850, as reported in 
 the Monthly Journal of Med. Science for April, 1850 : 
 
 Dr. W. T. Gairdner having inquired whether Dr. Simpson could throw any light upon the 
 source of hemorrhage in cases of uterine polypi. Dr. S. replied, that in certain cases of pro- 
 fuse hemorrhage, lasting for months, which had fallen under his own observation, he be- 
 lieved that the blood proceeded not from any laceration, but from the mucous surface of the 
 tumor. If, as some authors asserted, the bleeding took place from the general mucous sur- 
 face of the uterus, why should hemorrhage cease when the polypus was tied? — (Ed.) 
 
SYMPTOMS OF INTRA-UTERINE POLYPI. 129 
 
 the uterus ; and by these tumors the magnitude of the organ is in- 
 creased, and its shape rendered more or less irregular. Fibrous 
 tumors of the uterus are seldom or never situated in the walls of 
 the cervix ; and if the swelling and distension affect the cervix, 
 there is consequently much more chance of its being a polypus and 
 not an interstitial fibrous tumor, than when we have similar symp- 
 toms attendant upon a similarly augmented state of the body of the 
 organ. Further, the probability of the disease being intraruterine 
 polypus would be increased, if, on successive examinations, we had 
 an opportunity of ascertaining that the enlarged and distended state 
 of the cervix was descending gradually lower and lower down to- 
 wards the OS ; for polypi in their progress and descent, as seen in 
 Case I. p. 123, gradually dilate the cervix from above downwards in 
 the same way as happens in pregnancy or abortion. They are bom 
 by a kind of chronic labor. 
 
 4, There may be symptoms of irritation and pressure upon the 
 bladder, rectum, &c., if the polypus happen to be so large as to 
 exert mechanical compression upon these or other parts, or dysme- 
 norrhcea if it fills up the cavity of the cervix. And sympathetic 
 pains may be present in the loins, limbs, &c. ; or there may be 
 sympathetic disturbance of the stomach, heart, &c., if the uterus is 
 much irritated and excited by the presence and distension of the 
 polypus. 
 
 But one or more of the preceding groups of symptoms may be 
 altogether absent, though the uterus contain an intra-uterine poly- 
 pus. The mechanical and sympathetic symptoms last alluded to 
 are the most uncertain of all. For while almost all uterine diseases, 
 however intrinsically different, give rise to similar secondary and 
 sympathetic symptoms, we have often in other instances of the 
 very same diseases, these same symptoms entirely wanting ; just as 
 in one woman during pregnancy we sometimes see severe, even 
 serious, local and constitutional symptoms ; and in another woman, 
 or even in the same woman in another pregnancy, we see the same 
 condition of the uterus unattended by any special, local, or consti- 
 tutional disturbance. Again, there may be no ascertainable in- 
 creased volume of the uterus, as the polypus, especially if it is 
 vesicular, and originates in the interior of the cervix, may be far too 
 small to lead to any appreciable augmentation in the size of the 
 organ, although, notwithstanding, the menorrhagia may be great ; 
 for the extent of flooding does not depend on the size of the poly- 
 pus, small polypi like small hemorrhoidal excrescences, often being 
 the source of severe and repeated hemorrhages. Further, the 
 leucorrhceal discharge which is sometimes attendant, may be en- 
 tirely absent, as the polypus may not be irritating the mucous 
 
130 DISEASES 01 THE UTERUS. 
 
 surface of the ca^dty in which it is enclosed. And lastly, polypi 
 occasionally, thoughnot very frequently, are present for a long series 
 of years without producing any degree of hemorrhage or menor- 
 rhagia. In the following case, for example, there was a state of long- 
 standing amenorrhoea, instead of menorrhagia, coexistent with 
 the presence of a polypus, though the two conditions, the amenor- 
 rhcea and polypus, had probably no causal relation to each other. 
 
 Case in. — ^A poor woman, from East Lothian, aged about 35, 
 and of a weak and debilitated frame, came, some three or four years 
 ago, to ask for advice regarding the state of her health. She de- 
 scribed her case as one of long-standing amenorrhoea. For five or six 
 years the catamenia had been entirely absent ; and she ascribed her 
 broken health to this cause. On examining the uterus and ovaries, 
 in order to ascertain if there was any organic change to account for 
 the amenorrhoea, I found, with the uterine bougie, the cavity of the 
 OS and cervix uteri very small, and the latter apparently obstructed 
 about three-quarters of an inch from the orifice. I introduced a 
 long thin sponge tent, with the view of determining more correctly 
 the state of the cervical cavity. On removing the sponge, two days 
 subsequently, I found the lower part of the cervix natural, but a 
 fiattened polypus, of the size of a small cherry, attached by a short 
 pedicle to the interior of the higher portion of the cervical cavity. 
 The pedicle was easily seized with a pair of long slender polypus- 
 forceps, and separated by torsion or avulsion. For some time sub- 
 sequently to this little operation, menstruation recurred — ^the irritar 
 tion of the sponge tent having probably so far roused the uterus to 
 a restoration of its secreting functions ; but a patient from the same 
 neighborhood, about half a year ago, informed me that her health 
 had relapsed again into its former unsatisfactory state. 
 
 The polypus, in the preceding case, was intra-uterine. During 
 the past autumn I removed a uterine polypus, which had long passed 
 down into the vagina, and yet had never given rise to menorrhagia. 
 
 Case IV. — The patient, 55 years of age, had, for at least twenty- 
 five years, been aware of the occasional protrusion, between the 
 labia, of a portion of what she supposed a fold of thickened and in- 
 sensible skin. When she first noticed it, she had called the atten- 
 tion of her medical attendant to it, an eminent London obstetrician, 
 under whose kind care she was for many years placed. He exa- 
 mined the tumor and its relations ; but advised her to let it alone. 
 Two or three years ago a little sanious discharge began, to appear, 
 and continued to recur almost daily. On examining the projecting 
 body, I found it an elongated polypus, of the size and figure of the 
 
DETECTION OF INTRA-UTBRINB POLYPI. 131 
 
 fruit of the date, and depending by a long slender stalk, wMcli passed 
 upwards through the os uteri. I divided the stalk with a pair 
 of blunt-pointed scissors, immediately below the os uteri, and in 
 four daysafterwards the patient set off on a long j ourney. The poly- 
 pus was of a dense cellular structure. At one point, near its fundus, 
 its surface was ulcerated. The ulcer was about the size of a six- 
 pence, and, no doubt, the source of the discharge that had latterly 
 appeared. Perhaps the removal of this polypus, when it was first 
 discovered, would have enabled the patient to become a mother, and 
 saved from extinction one of the highest and oldest titles in the 
 kingdom. 
 
 Cases, however, like the above, of uterine polypi, of long duration, 
 without attendant hemorrhage, are exceptions, and not very com- 
 mon exceptions, to the general rule. And certainly the existence 
 and return of attacks of menorrhagia, draining and undermining 
 the powers of the constitution — without the presence of any ascer- 
 tainable organic disease in the vagina, or around the os uteri, to 
 account for the floodings, and the persistence of this discharge, in 
 despite of all constitutional care and treatment — forms always the 
 most frequent and principal symptom that would induce the practi- 
 tioner to use means to ascertain if there existed an intra-uterine 
 polypus, or any other intra-uterine lesion, that was the probable 
 source of the hemorrhage. He would, a priori, have more expecta^ 
 tions of detecting, in his investigation, an intra-uterine polypus, 
 provided, along with the menorrhagia, there was an occasional leu- 
 corrhceal or sanious discharge, coming — as proved by the speculum — 
 from the cavity itself of the uterus, and not from the surface of the 
 cervix ; and provided, also, there was an increased size or misshapen 
 state of the cervix or body of the uterus, such as might result from 
 the enclosure and distension of a polypus. 
 
 To convert, however, the probability derivable from such symp- 
 toms into a certainty, we must endeavor to read the true value of 
 these rational symptoms by obtaining access to the cavity of the 
 uterus itself, and ascertaining, by a digital examination, if a polypus 
 be present in that cavity or not, or if there be any other coexistent 
 uterine lesion, capable of accounting for the symptoms. It is be- 
 coming every day more and more acknowledged, that we can alone 
 discover uterine diseases, and discriminate them from each other, 
 by appealing in this way to the evidence of physical diagnosis. 
 And no remark could be, pathologically and practically speaking, 
 more sound and true than that which Sir Charles Clarke many 
 years ago made : " The true character of any disease of the internal 
 
132 DISEASES OF THB UTEEUS. 
 
 female organs can only be ascertained by examination."* With this 
 view, in order to enable the finger to reach and examine the cavity 
 of the uterus, the os and cervix must be opened up by a succession 
 of sponge-tents in the way already described. When an adequate 
 degree of dilatation is obtained, the finger will be enabled to touch 
 the tip of the polypus ; and then the pediculated or polypous char 
 racter of the tumor may be farther made out by passing either the 
 finger or a uterine sound between its body and the containing cavity 
 of the uterus. In making this examination, as in making most other 
 examinations of the uterus, a rule requires to be followed which is 
 too often forgot, namely to use both hands for the purpose. For if 
 we are examining the uterus internally with the forefinger, or fingers 
 of the right hand, the facility and precision of this examination will 
 be found to be immensely promoted by placing the left hand ex- 
 ternally over the hypogastric region, so as to enable us by it to 
 steady, or depress, or otherwise operate upon the fundus uteri. The 
 external hand greatly assists the operations of that which is intro- 
 duced internally ; and farther we can generally measure, between 
 them, the size, relations, &c., of the included uterus. 
 
 If without, or before, using sponge-tents, we are desirous to ex- 
 amine at the time when the os uteri is naturally most relaxed, we 
 shall find that time to be either immediately after a menstrual dis- 
 charge, or immediately subsequent to any severe attack of intercur- 
 rent hemorrhage. Under such circumstances, we can sometimes 
 introduce the finger partially into the os uteri, and ascertain the 
 presence of any morbid body in the lower segment of the cervix ; 
 when in the same patient, at other times, this orifice is so completely 
 shut as to prevent entirely such a proceeding. Sometimes, indeed, 
 a small or elongated intra-uterine polypus will pass through the os 
 uteri at these times, so as to be felt by the usual vaginal examination, 
 but it will become retracted into the cavity of the cervix during the 
 interval between the hemorrhagic discharges. In the following 
 case^ this occurrence was observed : 
 
 Case V. — About eight years ago, I occasionally saw a patient who 
 suffered much from leucorrhoea and menorrhagia. At last her 
 health became so much broken in consequence of these discharges, 
 and the pallor of the face and lips, and other symptoms of anaemia, so 
 alarmed the patient, that she agreed reluctantly to submit to a vagi- 
 nal examination. She had an objection, however, to me on the score 
 of youth ; and the late Dr. Beilby was so good as to make the exa- 
 
 ' Diseases of Females, vol. i. p. 250. 
 
 ' See notice of an analogous case, by Dr. Kamsbotham, in the Medical Gazette for 1835, p. 
 406. 
 
PAINS FROM INTEA-UTERINE POLYPI. 133 
 
 mination, and found a polypus, of the size of an almond, projecting 
 from the lips of the os uteri. On Dr. Beilby returning, two or three 
 days subsequently, to put a ligature around the heck of the polypus, 
 none could he found, and the os uteri was shut. The other symp- 
 toms, however, did not change ; and, on the recurrence of a new 
 hemorrhage. Dr. Beilby made another examination, again found the 
 polypus protruding, ligatured, and remoyed it. 
 
 In this instance, as in many others, the passage of the polypus 
 through the os uteri did not produce any appreciable degree of pain. 
 In enumerating the symptoms of intra-uterine polypus, I have omit- 
 ted to state that, like polypi which have passed through the os uteri, 
 they very rarely are attended vnth. feelings of pain ; and too often, 
 both by the patient and the practitioner, the absence of pain is erro- 
 neously supposed to be a proof of the absence of organic disease. 
 Sometimes, however, as they are pressing upon the lower part of 
 the cervix and os uteri, or distending and passing through these 
 parts, uterine contractions and pains temporarily supervene, similar 
 to those of miscarriage ; and, if there is any difficulty in the passage 
 of the tumor, these pains may become exceedingly severe. In a 
 case in which a fibrous tumor of the uterus had undergone the cal- 
 careous degeneration, and part of it had assumed a semi-pedieulated 
 or polypous form, the recurrent pains, when the mass came down 
 upon the os uteri, appeared at times as extreme as those of the last 
 stage of labor. 
 
 Case VI. — The patient, now sixty-nine years of age, the mother 
 of several children, had for several years suffered from recurring 
 slight attacks of uterine hemorrhage. In February, 1848, 1 saw her, 
 with Dr. Hunter. The os uteri was drawn up so high, that it was 
 with great difficulty I could reach and touch it ; the top of the 
 vagina stretched up in the form of an inverted funnel, the apex 
 being placed at its upper or narrow extremity, and hence it was im- 
 possible to introduce or use a speculum. At the same time, the 
 abdominal parietes were so thick and full, that it was impracticable 
 to ascertain in any way the state of the uterus by an external exami- 
 nation. Not feeling a polypus, however, I left with the idea that 
 the cause of menorrhagia was some form of carcinomatous disease of 
 the uterus. Subsequently, in the month of July, all her symptoms 
 became aggravated, and very severe bearing-down pains were 
 superadded. These pains recurred regularly once a day, lasted in 
 paroxysms for several long hours, and always left the patient 
 weakened and prostrated. In consequence of their persistence. Dr. 
 Hunter made another examination of the vagina, and found the os 
 
134 DISEASES OF THE UTERUS. 
 
 uteri, which was now pressed lower down, filled with an apparently 
 irregular bony mass. I saw her again, and removed the calcareous 
 mass, filling up the os uteri, with a portion also of fibro-calcareous 
 tumor which we found above it, and distending the lower part of 
 the cervix. The irregular calcareous portion protruded through the 
 OS uteri, was about the size of a hazel-nut, and the portion of fibro- 
 calcareous tumor above it nearly four times that volume. The daily 
 fearful pain, which the patient had been lately enduring immediately 
 ceased, and everything looked so favorable that we had every hope 
 that the whole of the fibro-calcareous tumor, or polypus, had been 
 removed. Last February, however, after some unusual exertion, 
 the pains again recurred more severely, if possible, than before ; 
 and with this difference, that the attacks of them were now twice 
 a day, instead of being only once, as on the first occasion. Opiates 
 and sedatives had little or no effect towards their alleviation. On 
 examining the os uteri, no new foreign body could be found any- 
 where within reach. As the patient's strength and spirits, how- 
 ever, were rapidly giving way, I dilated the os fully, by a succession 
 of sponge-tents, and found the cavity of the cervix occupied by 
 another fibro-calcareous mass, larger than the first. After an inef- 
 fectual attempt to break it down and remove it, by strong lithotomy 
 and other forceps, I dilated the os still farther with tents, with the 
 view of, if possible, getting two or three fingers up to seize the 
 tumor, and assist in its detritus and extraction. To allow the 
 hand to pass into the vagina for this object, I was obliged to incise 
 its orifice ; and, after no small difficulty, I was enabled to break off, 
 by the fingers and forceps, four or five fibro-calcareous pieces from 
 the mass in the cervix; and these pieces, when afterwards conjoined 
 together, were found to form a roundish semi-pediculated tumor, of 
 the size of an orange. In order to enable her to sustain the pain of 
 these proceedings, the patient was kept, during this tedious opera- 
 tion, under the influence of chloroform. The pains again ceased 
 from the date of the removal of this second intra-uterine tumor ; 
 and, under the kind care of her son, himself a physician, our patient 
 made a good and steady recovery, and her health was restored by 
 spending some of the autumn in the country. There still, however, 
 remains in the uterine parietes some fibro-calcareous structure, as I 
 lately ascertained by passing a uterine bougie into the elongated 
 cavity of the uterus, and striking it against its hard stony surface. 
 
 The Treatment of intra-uterine polypi requires to be varied ac- 
 cording to different circumstances, but particularly by the tendency 
 or probability of the tumor passing downwards or not through the 
 OS ; by the effects of the symptoms or the urgency of the case ; and 
 by the size and site of the polypus. 
 
TREATMENT OF INTRA-UTEEINB POLYPI. 135 
 
 Two plans of procedure may be followed according to the nature 
 and necessities of tlie case, viz., first, to wait till the polypus descends 
 farther ; or, secondly, to remove it immediately. It is a generally 
 acknowledged principle in obstetric surgery, that a polypus of the 
 uterus should be extirpated as early after its discovery as possible.* 
 But when such a tumor is discovered still included within the uterine 
 cavity, and the polypus seems gradually but certainly making its 
 way downwards through the cervical cavity, and the hemorrhage 
 and other symptoms are not urgent, it will assuredly be better to 
 wait forits descent through the os ; for after that its removal becomes 
 much more easy and simple. The dilatation of the os and cervix 
 by the sponge-tents mil promote and facilitate its descent ; and per- 
 haps the internal use of the ergot of rye may»aid it. But the degree 
 of attendant hemorrhage and debility may be too great to entitle 
 us to postpone the removal of the polypus ; or the tumor may be 
 attached by such a short pedicle as not to be capable of leaving the 
 uterine cavity without dragging down vrith it, or inverting, the 
 fundus or some part of the parietes of the uterus f or it may be 
 retained in its descent by adhesions formed between the surface of 
 the uterus and the surface of the polypus., I once witnessed the 
 dissection of a case of large fibrous polypus included in the cavity 
 of the uterus, and where inflammation had been present before 
 death ; the surface of the polypus was adherent to the surface of the 
 uterus through the medium of a recently effused false membrane.' 
 Even when an intraruterine polypus has descended so far as even 
 partially to open up the os uteri, it may remain in that situation for 
 such a length of time, and with such results, as to place the patient 
 in no small degree of danger. I shall quote, in illustration of this 
 remark, an interesting case reported by Dr. Meigs, of Philadelphia, 
 in his work on Female Diseases. Dr. Meigs,'' who quotes Dr. Lee, 
 
 ' " In the treatment of this disease (uterine polypus) the first principle, undisputed, I 
 suppose, by those who are possessed of experience in the management of these morbid 
 growths, is, that it ought by all means to be extirpated ; but unless it be removed, it will 
 continue to grow larger and larger, till it utterly wears out life, and this especially if it be 
 shooting from the upper part of the uterus, or even from the neck. It is, moreover, of vast 
 importance in polypus, not only that it should be extirpated, but that this extirpation should 
 be accomplished as early as possible. Lay this down, then, as a most important part of 
 your practice, that polypi are not only to be taken away, but that they are to be extirpated 
 early, as soon as they are discovered, and as soon as it is practicable." — Blundell's Observa- 
 tions on Diseases of Women, p. 126. 
 
 2 Cases of intra-uterine and vaginal polypi tending thus to invert the uterus at the site of 
 the pedicles are detailed by Denman, Introduction to Midwifery, p. 106; Davis, Obstetric 
 Medicine, p. 618; Dr. Oldham, Guy's Hospital Reports, New Series, vol. ii. p. 105; Scou- 
 tetten, Gazette Medicale, for August, 1839; Crosse, Transactions of Provincial Medical Asso- 
 ciation for 1845, p. 321, &c. 
 
 * Library of Medicine, vol. iv. p. 335. 
 
 ■* Females and their Diseases, p. 255. Philadelphia, 1848. 
 
136 DISEASES OF THE UTERUS. 
 
 to the effect, that "it would be folly to attempt the ^removal" of a 
 polypus still retained in utero, details the case referred to in the 
 following words : 
 
 Case VIL— " Some months ago a lady came to me from New 
 Jersey. She had been for some years laboring under a uterine 
 disease, accompanied with violent and exhausting floodings. Upon 
 arriving here, she was wholly unable to walk or sit up in her chair. 
 I discovered a hard polypus, whose apex was lying just within the 
 OS uteri, which was a circular opening as large as a half dollar. 
 The OS uteri was pretty low down in the pelvis, it was very hard, 
 and completely undilatable. The fundus uteri was half way up to 
 the umbilicus, and the uterus hard and solid, so as to allow me to 
 trace its outlines very clearly in my hypogastric palpation. I assure 
 you I have rarely met with a more extreme case of anasmia than in 
 this person. This anaemia was evinced not only in the pallor of her 
 surface, and its flabbiness, and in her irregular breathing, the frequent 
 palpitation of the heart, and the ansemiacal throb of her pulses, but 
 in the state of all her innervations, which were Inost miserable indeed, 
 except when lying profoundly still in a low recumbency. 
 
 "After a few days' refreshment from the journey, I attempted to 
 do what I thought I should fail to do, namely, to get a ligature on 
 the tumor. But I soon found how vain was such an attempt, for I 
 never found the uterus a moment to relax, nor open beyond the size 
 of a half dollar. My attempt caused an attack of hemorrhage to 
 come on, that I was glad to suppress by cold, by rest, and by opium. 
 
 " I kept her here many months, in hopes of seeing the uterus enter 
 into powerful contractions to throw off the morbid mass. I gave 
 her large doses of ergot. I thought the ergotism that was produced 
 might expel the polypus, but I was disappointed, and subsequently 
 had reason to believe the tumor had formed strong attachments to 
 the inside of the uterine walls, so low down, that I could reach them 
 with my finger, but could not break them up.^ 
 
 " During her residence here, I thought to see her bleed to death 
 before my eyes ; her life was hardly saved by the tampon, so perverse 
 was the hemorrhage. At length I sent her home, with directions as 
 to her health, and a request to be informed if the tumor descended 
 into the vagina. It will never descend into the vagina, if the adhe- 
 sions I supposed to exist are truly there." 
 
 But, secondly, the severity of the attendant hemorrhages, or the 
 
 'The use of the uterine bougie would probably have determined this point; or the 
 mechanical dilatation of the os by tents would have enabled the finger fully to reach and 
 break the adhesions. 
 
TREATMENT OF INTEA-UTBRINE POLYPI. 137 
 
 improbabilities of the speedy and entire descent of tbe intra-uterine 
 polypus, may induce us to remove tbe tumor at once ; and certainly 
 tbis may be effected in most cases, tbougb witb greater difficulties 
 tban in cases wbere tbe polypus bas passed down into tbe vagina. 
 To admit at all of tbe removal of an intrar-uterine polypus of any 
 considerable size, tbe os uteri must be previously very fally dilated 
 by sponge-tents ; and perbaps it will sometimes be found necessary, 
 at tbe time of operating, to , gain additional freedom, by dividing 
 any obstructing band of tbe os or cervix tbat may not bave been 
 fully dilated by tbe tents. Afterwards, we sball require to proceed 
 differently in different cases, in order to destroy or remove tbe 
 polypus. We may only be able to accomplisb this object by con- 
 tusing and crusbing tbe tumor, as I bave described in a case already 
 detailed. See Case II. In tbe instance in question, I grasped tbe 
 polypus, for tbis purpose, witb strong litbotomy forceps. In anotber 
 similar case, after fully dilating tbe os and cervix, I seized a large 
 intra-uterine polypus between tbe jaws of a screw-propelled litbo- 
 tripsy instrument— invented for tbe purpose of crusbing vesical 
 calculi^and was enabled, by it, to crusb and destroy readily tbe 
 structure and vitality of tbe included tumor. Occasionally, we may 
 be enabled to divide tbe stalk of tbe polypus witb a silver wire or 
 ligature, acting on tbe principle of tbe cbain-saw ; or we may reacb 
 it witb very curved blunt-pointed scissors. Tbe two following cases 
 may serve to illustrate tbese two last-mentioned metbods of ope- 
 rating : 
 
 Case \11L^A patient, set. 36, about tbree years ago began to 
 suffer under menorrbagia and dysmenorrboea. Tbe catamenia be- 
 came botb too frequent in tbeir return, as well as mucb too great in 
 quantity; but there was little or no leucorrbceal discbarge. Latterly 
 coagula of blood accompanied the menstrual periods, and the 
 patient felt much weakened by each attack. The dysmenorrhcea 
 gentrally supervened on the second day of menstruation, and con- 
 fined the patient for a couple of days, the third day being usually 
 one of much sickness as well as pain, particularly if tbe patient 
 tried to assume the erect posture. I first saw this lady in July of 
 tbe present year, and found the uterus somewhat enlarged, and ex- 
 ternally irregular in form, from the presence of one or two small 
 fibrous tumors in its body and fundus. But the os uteri was shut, 
 and I could not ascertain if the debilitating hemorrhage was the 
 result merely of the irritation of these tumors in tbe parietes of the 
 uterus ; or whether one of them, forming a polypus in the cavity of 
 the organ, was its source. I wrote her medical attendant to dilate 
 tbe os in order to determine this point ; and she returned home to 
 
138 DISEASES OF THE UTERUS. 
 
 England. In September she came back to Edinburgh ; but, in con- 
 sequence of the state of her health, I did not venture to dilate fully 
 the 08 and uterine cavity till towards the end of October. On doing 
 so, I was enabled to detect the rounded extremity of a polypus 
 hanging down into the cervical cavity. During two or three days 
 it descended somewhat lower, but ultimately remained fixed and 
 stationary above and within the os. I found I could not move it 
 farther downwards by fixing a vulsellum into it, and applying some 
 dragging force. On the 6th November, assisted by Dr. Duncan, I 
 applied a silver wire above the body, and around the neck of the 
 tumor, by means of an instrument presently to be described. After 
 the instrument was fixed and adjusted, a few turns of the screw 
 made the wire cut through the pedicle of the polj^us, and without 
 any pain or suffering on the part of the patient. The separated 
 tumor was then pulled by the vulsellum through the os uteri. The 
 polypus was of the size and shape of a plum, with a small portion 
 of the pedicle attached. It was fibrous in its internal structure. 
 The patient's recovery was slow, but uninterrupted. She has men- 
 struated once since the operation, but without the discharge being 
 excessive, as formerly, either in quantity or duration (it lasted only 
 three days) ; and also without her former distressing dysmenor- 
 rhoeal pains. 
 
 The instrument employed in the preceding case was a modificar 
 tion of one kindly sent to me by my friend Dr. Sabine, of "Rew 
 York. I am told it has been successfully used by various American 
 practitioners for the removal of polypi in the vagina. The advan- 
 tage which it possesses over the instruments of lessens, Gooch, 
 Davis, and others, in the removal of intra-uterine polypi, is, that 
 the gcrew power with which it is famished enables us to use it with 
 the power of a small chain-saw, for the immediate division of the 
 pedicles of the polypi. And it is almost superfluous to observe, 
 that if we can finish our operation at once, it will be much safer for 
 our patient than leaving a rough instrument within the cavity of 
 the uterus. The instrument itself consists of two parts, viz. : two 
 hollow canulse, like those pertaining to the instruments of Messens 
 and Grooch ; and of a second part, resembling the polypus instru- 
 ment of Grraefe, of Berlin, with this difference, that it has a ring 
 affixed to its top, of a heart-shaped figure, and intended, first, to 
 receive the two canulse, with their contained ligatures, and after- 
 wards to serve as a point of resistance during the cutting action of 
 the ligature upon the pedicle of the tumor. The canulse and liga- 
 tures are first applied in the same way, and according to the same 
 rules, as those of Ifiessens and Gooch. After the pedicle is en- 
 
EXCISION OF INTRA-UTBRINB POLYPI. 139 
 
 circled by the ligature, the two lower extremities of the canulse and 
 included ligatures are passed through the ring of the second portion 
 of the instrument. This second portion of the instrument is then 
 run up, with its ring surrounding the included canulse, till it reaches 
 the pedicle of the tumor ; the projecting .side of the ring being 
 turned towards the pedicle. The canulse are then slipped off and 
 withdrawn, leaving the wires or ligatures alone in the terminal 
 ring of the instrument. Subsequently these wires are twisted 
 around, and fixed upon the knob attached to the screw. Lastly, by 
 moving the knob downwards, by the operation of the screw, the 
 ligature is made to cut into and through the pedicle.' 
 
 In the following case, I was enabled to divide the pedicle of a 
 large intra-uterine polypus with a pair of well-curved blunt-pointed 
 scissors. 
 
 Case IX. — The patient was 48, and unmarried. About fourteen 
 years ago she was first seized, when in service, with a severe flood- 
 ing. It returned at short intervals, and reduced her strength so 
 much that she was obliged to leave her situation, and has never 
 been able to take another. The hemorrhage she describes as hav- 
 ing been almost constant for many years ; that is, there was always 
 some red oozing, and fluid blood and clots often escaped when she 
 made any exertion. She had been treated by various medical gen- 
 tlemen during this period, chiefly with iron, styptics and astringents. 
 A vaginal examination had never been made, in order to ascertain 
 the source of the hemorrhage. During last autumn she presented 
 herself for advice at my house. She was blanched, thin, and de- 
 bilitated, and scarcely able to walk. On examination per vaginam, 
 the uterus felt enlarged, more particularly in its cervical region. A 
 sponge-tent was introduced, and on her returning, two days after- 
 wards, I found a polypus descended upon the distended os. Dr. 
 Ziegler, Mr, Carmichael, and Dr. Duncan, were present at the re- 
 moval of the polypus. In order to reach, if possible, with the 
 scissors, the pedicle of the polypus, I required to make a slight 
 incision into the thin lips of the os, I was enabled at last, after 
 some difficulty, and by seizing the polypus with a vulsellum on one 
 of its sides, to turn the polypus laterally, and obtain access, with 
 the scissors, to its pedicle, which was small and easily divided. 
 After the polypus was completely separated, it took no inconside- 
 rable amount of traction to drag it through the os uteri. The 
 
 ' When tliis essay appeared in the Monthly Medical Journal, it was accompanied by an 
 engraving of the instrument above described ; but as Dr. Simpson has lately abandoned its 
 use in favor of excision by the polyptome, as vi^ill be seen in a subsequent page, it has been 
 thought unnecessary to introduce it here. — (Ed.) 
 
140 DISEASES OF THE UTERUS. 
 
 polypus was round, of tlie size of a small orange, and of a fibrous 
 structure. The patient was rendered anaesthetic during the opera- 
 tion. The vagina was plugged with sponge, and the woman sent 
 home. Next day the plug was removed. The patient has ever 
 since kept free, from any return of the flooding, and a degree of 
 leucorrhcea, which followed, as often happens, the removal of 
 polypi, is subsiding under the use of medicated pessaries. A 
 month subsequent to the operation, she stated her strength to be 
 greatly improved beyond what it had been for many years. 
 
 The preceding remarks, relative to the treatment of intra-uterine 
 polypi, principally refer to these tumors when they happen to be of 
 a large size. But uterine polypi are often too small to be removed 
 by the knife, scissors, or ligatures ; and yet these small polypi not 
 unfrequently lead to severe and long-continued menorrhagia. From 
 the analogy of hemorrhoidal tumors, we know that the mere size of 
 a polypus is not to be taken as any measure of its capability of pro- 
 ducing hemorrhage. Small vesicular, mucous, or cellular polypi 
 sometimes grow from the fundus uteri, giving rise to considerable 
 and long-continued hemorrhagic discharge. I have preserved 
 specimens of them from the dead subject, and have met with them 
 in the living. They can hardly be properly termed polypi, as they 
 are scarcely pediculated at their attachment, and sometimes short, 
 but in other cases long and slender, in their body. 
 
 The following case may be cited as an illustration of this form of 
 the disease : 
 
 Case X. — A lady, the mother of ten children, became irregular in 
 her menstrual discharge during her 44th year. At times it was 
 wanting at the usual monthly periods, at others it amounted to 
 menorrhagia. About a year after this irregularity commenced, 
 such an amount of fluid blood and coagula escaped as at first to lead 
 on her part to some suspicion of miscarriage ; but it continued to 
 go on profusely for two or three weeks. At the end of that time I 
 visited her, with Mr. B. Bell and Dr. Malcolm. On examining the 
 uterus, we found a small vesicular polypus attached to the inner 
 surface of one of the lips of the os, and it was easily removed by 
 avulsion. The discharge, however, was not abated in consequence, 
 as we expected. A series of sponge-tents was then introduced, so 
 as to open up, first, the cavity of the cervix, which was found free 
 from additional polypi, and ultimately the cavity of the body of the 
 uterus. When the distension of the whole uterine cavity was at 
 last completely effected, both Dr. Malcolm and myself found that 
 we could touch two or three small slender polypoid bodies, hanging 
 
SMALL VESICULAR POLYPI. 
 
 141 
 
 from the very fundus of the uterus. I removed them cautiously, 
 from the surface to which they were attached, with the nail of the 
 first finger. After this the heiporrhage ceased, but some local 
 treatment was required to cure tiie ulcerated state of the cervix. 
 •The polypi were removed in April. The patient went soon after- 
 wards to spend the summer in the country, where she soon gained 
 strength, and enjoyed much improved health. I saw her lately. 
 The menorrhagia had not recurred, but she still looked anaemic, 
 haAdng never recovered her color since the hemorrhages in spring. 
 
 Dr. Malcolm informs me that, since meeting with the above case, 
 he has seen another similar one, and treated it successfully in the 
 same way. I may add, that in several cases of chronic and severe 
 menorrhagia, in which I haye been induced to open up the cavity 
 
 Fig. 7. 
 
 of the uterus with sponge-tents, in order to ascertain whether there 
 was any small intra-uterine polypus present or not, I have merely 
 
 Fig. 8. 
 
 found the interior of the uterine cavity rough and granulated at 
 particular points, which I have generally tried to remove and scratch 
 
 Fig. 7. From Cruveilhier's plates of Pathological Anatomy, faso. xiii. pi. vi. Fig. i. The 
 cut shows some small pedioulated polypi of the cervix uteri. Here, as often happens, there 
 was coexistent disease in the body and fundus of the uterus. 
 
 Fig. 8. Taken from a plate appended to a paper by Dr. Lee, in the nineteenth volume of 
 the London Medico-Chirurgical Transactions. 
 
142 
 
 DISEASES OF THE UTERUS. 
 
 off with the nail. Whether owing to their removal or not, or 
 owing to the irritation resulting from the pressure and distension of 
 the sponge, I know not, but certainly, in two or three cases, the 
 menorrhagia has subsequently abated and ceased. 
 
 By far, however, the most common site for the origin of small- 
 vesicular polypi, is the interior of the cervix uteri. In fact, the 
 small cellular or vesicular form of cervical polypus is infinitely the 
 most common form of polypous disease of the uterus. Several 
 specimens of them are represented in the wood-cuts. These cer- 
 vical vesicular polypi are generally of a small size, like a pea, or 
 orange pip, and vary from this size to the size of a hazel-nut. 
 Sometimes they are sessile, and sometimes pediculated, as repre- 
 sented in the sketch from Cruveilhier (Fig. 7). Occasionally they 
 are single (Fig. 8), or they form a single complex cluster ; but more 
 
 Fig. 9. 
 
 frequently they are gregarious, as represented in Madame Boivin's 
 drawing of them, copied in Fig. 9. Indeed it is, I believe, the rule 
 
 Fig. 10. 
 
 rather than the exception to it, that when we find one, perhaps pro- 
 truding at the OS uteri, as in Fig. 10, we shall find, on further 
 
 Figs. 9 and 10 are representations of a single uterus. In the latter a pisiforna cystic 
 polypus is shown projecting from the os, in the former the cervix is opened up, and three 
 small cystic polypi seen on its walls. They are from Madame Boivin's work on Diseases of 
 the Uterus, plate xviii. figs. 1 and 2. 
 
TREATMENT OF SMALL VESICULAR POLYPI. 143 
 
 searcli, that there are others, sometimes to the nnmher of four, five, 
 or six, springing from other points of the interior of the cervix, and 
 not discoverable till the cavity of the cervix is dilated by a sponge- 
 tent. "When hanging from the os uteri, their stalk is sometimes so 
 loose and long, and the small depending polypus is itself so small 
 and soft, that it moves away before the finger in making a tactile 
 examination, and one unaccustomed to this peculiarity will not feel 
 perfectly sure of the presence of such a polypus till the speculum is 
 used, when the polypous body will be easily seen, generally of a 
 cherry-red or purplish color. Such polypi, though small, are often 
 apparently the source of much menorrhagia and leucorrhoea, for 
 they almost always coexist with, and probably produce, some de- 
 gree of ulcerative inflammation of the contiguous surface of the 
 cervix.^ 
 
 In trying to remove these small vesicular polypi of the cervix, it 
 is, therefore, to be held in recollection, that there are generally 
 more than one present, and that to ascertain this point with any 
 precision, it is necessary to dilate and expand the cavity of the 
 cervix with a sponge-tent. 
 
 In more than one instance I have found these polypi, when their 
 pedicles were perhaps long and easily broken, come away, im- 
 bedded in the surface and foramina of the sponge, which had torn 
 them off during its expansion. But in twenty-nine out of thirty 
 cases, more methodic measures are required for their removal — as 
 scratching them off with the sharp finger-nail, seizing and tearing 
 them off with polypus-forceps, or dividing their stalks with a pair 
 of scissors. If we can use the speculum, these modes of removal 
 are greatly facilitated by the sense of sight. Indeed, if we require 
 to use the polypus-forceps or scissors, for the removal of these small 
 polypi, and are guided by touch alone, we shall generally find the 
 operation, though apparently simple in principle, one which is 
 tedious and difficult to perform in practice. 
 
 In a considerable number of instances of obstinate slight menor- 
 rhagia and leucorrhoea, I have been enabled to detect the presence of 
 vesicular polypi attached to the interior of the walls of the cervix 
 uteri, by opening up the cavity of the os and cervix with sponge- 
 
 ' A small cervical polypus may even produce death by the extent of hemorrhage to 
 which it gives rise. In an excellent practical paper on polypi, published by Dr. Locock, in 
 the London Medico-Chirnrgical > Transactions for 1848, he states (p. 171), "Upwards of 
 twenty years ago, the late Dr. Robert Hooper showed me a preparation of a uterus laid 
 open, having a polypus not larger than a pea, with a short and narrow peduncle attached 
 within the cervix, high up, considerably within the os uteri, and not perceptible till the 
 cervix was slit open. All the history which he could give me was, that the uterus was 
 removed from the body of a young woman, who had died in the Marylebone Infirmary from 
 long-continued uterine hemorrhage.'' 
 
144 DISEASES OF THE UTERUS. 
 
 tents, and have afterwards removed them by the methods alluded 
 to. The following was one of the first instances in which I pur- 
 sued this practice : 
 
 Case XL — ^A lady was confined of a premature child in early 
 married life, and afterwards her health remained broken and 
 wretched. She did not again conceive ; and was unable to take 
 walking exercise. There was a constant feeling of dragging and 
 pressure about the pelvis. Betimes monorrhagia, and some degree 
 of leucorrhoea, supervened. She was seen by many medical men 
 in difierent parts of Europe. It was generally considered that 
 there was a tumor on the back wall of the uterus ; and for some 
 years previous to my first seeing her, in 1842, she had been under- 
 going a course of local leeching, and other treatment, under the 
 idea that the enlargement of the uterus was hypertrophic, and that 
 her irregular menstruation was the result of congestion. I found 
 the apparent tumor or hypertrophy of the uterus was formed by a 
 complete retroversion of the organ. The cervix uteri was ulcerated, 
 and I thought I could touch a small vesicular polypus, on pressing 
 my finger against the os. I distended the cervical cavity with a 
 sponge-tent; and, on removing it next day, I was easily able to 
 trace three or four small cystic polypi attached to the interior of the 
 cervix. I removed them, by picking each individual polypus care- 
 fully off" with small forceps. An amelioration in the irregular 
 menstruation immediately followed ; and other means were subse- 
 quently adopted for the treatment of the other complications. 
 
 The small vesicular polypi of the cervix have sometimes, as we 
 have already seen, long pedicles. Occasionally, however, we find, 
 coexisting with these pediculated polypi, others that are non-pedi- 
 culated or sessile : and, occasionally, after the cervix is dilated, we 
 find others not raised yet above the level of the general surface of 
 the mucous membrane of the part, but feeling imbedded like shot 
 or peas in or beneath that membrane. In other words, we find, in 
 seme cases, these vesicular polypi in all their stages of formation, 
 from small shut cysts, up to pediculated vesicular tumors. "When 
 such is the state of matters, we can only remove those that are more 
 fully formejj, by the nails, scissors, or forceps. To efiect a complete 
 cure, we require other means ; and for this purpose the application 
 of caustics to the mucous membrane of the cervix answers eveiy 
 indication. Nitrate of silver generally proves too weak for this 
 purpose, unless repeated very often, and combined with scarification 
 of the mucous surface. "We possess a far more potent and certain 
 caustic for the purpose, and one that is perfectly manageable, in 
 potassa fasa. The surface of the os and cervix, when small vesicular 
 
HEMORRHOIDAL STATE OF CERVIX. 145 
 
 polypi exist, are often found to be the seat of clironic inflammatory 
 ulceration ; and sometimes the submucous tissue, and the structure 
 of the cervix, is also the seat of chronic inflammatory hypertrophy 
 and induration. When such a combination exists, the potassa fusa 
 is doubly useful, as its application at once destroys the polypi, and 
 sets up a new and healthy action in the affected and morbid tissues 
 of the cervix. I have described elsewhere, its great value and 
 mode of application in inflammatory induration of the cervix,' and 
 the power we have of immediately arresting and limiting its action 
 by the neutralizing efiects of acetic acid. I need only add here, 
 that I have now repeatedly found this caustic of the greatest possible 
 use in obstinate and complicated cases of vesicular polypi of the 
 cervix, such as I have above alluded to. In illustration of its effects, 
 I shall only cite one instance, and that because it was a case which 
 was peculiar in several respects. 
 
 Case x ii . — On the 1st October last I was called into Eoxburgh- 
 shire by Dr. Anderson, of Jedburgh, to see a lady who had been 
 losing large quantities of blood for three weeks previously, and in 
 whom the hemorrhage had continued to go on profusely, day after 
 day, in despite of all the means which he had tried for its suppression. 
 The patient's strength had, in consequence, become greatly exhausted. 
 She was between forty and fifty years of age, was the mother of a 
 family, and for some years past had suffered under occasional menor- 
 rhagia. Three years ago a uterine polypus had been detected at Brus- 
 sels, and afterwards removed in London, apparently with some diffi- 
 culty, as the first physician who attempted it failed. Her present attack 
 of hemorrhage was much more long-continued and severe than those 
 that had occurred previously. Before being able to make a tactile 
 examination of the uterus, I had to remove several large clots of 
 blood lying in the vagina. I found the anterior lip of the os uteri 
 very much enlarged, indurated, and roughened on the surface. By 
 the speculum we saw this lip greatly enlarged and dotted over with 
 small pediculated red-colored polypi, like red currants ; and the use 
 of the mop showed them to be the source of the flooding. About 
 a dozen of these small red polypi were within the field of the specu- 
 lum, but others could be felt on the internal aspect of the enlarged 
 lip. As it seemed hopeless to attempt to detach them all one after 
 another by the forceps, and as doing so would not remove the sus- 
 piciously indurated and enlarged anterior lip of the cervix, I at once 
 had recourse to the application of potassa fusa to the diseased lip 
 itself, and melted it down, with the polypi attached, by decomposing 
 upon it a couple of sticks of potassa, of above an inch in length 
 
 ' See page 105 of this volume. 
 VOL. I. 10 
 
146 
 
 DISEASES OF THE UTERUS. 
 
 each, and followed this immediately by the free and abundant injec- 
 tion of vinegar to neutralize the alkali. Subsequently, under the 
 use of astringent injections and medicated pessaries, the surface 
 took on a healthy cicatrization,' and her health greatly improved 
 under Dr. Anderson's kind and able care. I saw the patient in 
 Edinburgh two months afterwards, on her way home to London, 
 There were no remains of the induration or polypi. The uterus 
 felt natural in size, and the surface of the cei-vix was entirely cica- 
 trized. There has been no recurrence of the menorrhagia. The 
 menses have been present once, but not in unnatural quantity. 
 (This patient has remained free from any return of the disease. — Ed.) 
 
 Since this essay was written (see page]125), dipping the piece of sponge for sponge-tents 
 in gum water has been discontinued ; experience having proved that simply moistening It 
 i n water before compression is sufficient, probably because sponge itself contains glutinous 
 matter. — (Ed.) 
 
 NOTE ON UTERINE HEMORRHOIDS. 
 
 Dr. Simpson has frequently pointed out to us a condition of the os uteri in many respects 
 analogous to a hemorrhoidal state of the rectum. In this affection there are usually leucor- 
 rhcea and frequent hemorrhage, giving rise to all the consequences and effects of anaemia, as 
 observed in patients who have lost blood in the way usually noticed in hemorrhoids. By the 
 aid of the speculum, the os uteri is found roughened and highly injected, like the mucous 
 surface of an internal rectal hemorrhoid, when the end of the bowel is everted.- The part 
 is apt to bleed when touched with the finger or a probe. Dilatation by sponge-tents dis- 
 covers no polypus in the uterine cavity, but the roughness may be often recognized by the 
 finger to a considerable distance within the cervical cavity. In treating this abnormal con- 
 dition, we have seen the vascular portions scraped off by the instrument of Recamier, when 
 deeply seated ; or, if nearer the os uteri, and accompanied by an hypertrophied condition of 
 the substance of the cervix, the potassa fusa answers the double purpose of destroying the 
 hemorrhoidal mucous membrane, and reducing the induration of the general tissue. — (Ed.) 
 
 OF THE EXCISION OF LARGE PEDUNCULATED UTERINE 
 
 POLYPI, 
 
 AND ITS ADVANTAGES OVER DELIGATION. 
 (From Edinburgh Monthly Journal of Medical Science, January, 1 855, p. 10.) 
 
 A VARIETY of operative means have been proposed and practised 
 for the removal of uterine polypi, after they have once passed the 
 OS uteri and come within the reach of surgical interference. The 
 means usually followed differ according to the size and consistence 
 of the polypus. 
 
 Li the removal of small and soft uterine polypi of the mucous or 
 
EXCISION OF LARGE UTERINE POLYPI. 147 
 
 cellular type, the practitioners employ — -1. Simple avulsion with 
 proper forceps, or with the fingers ; or 2. Avulsion by torsion ; or 
 3. Compression or crushing of the neck or body of the polypoid 
 growth; or 4. Scooping out its attachment with the nail, if the 
 cervix is opened, or with the scraping or gouging instruments in- 
 vented by Recamier and Dr. Locock ; and 5. The introduction and 
 application of a stick ofpotassafusa inside the os, followed by the 
 free application of vinegar, is sometimes most advantageously had 
 recourse to, where, as is often seen in practice, several small, sessile 
 or pediculated polypi — formed by dilatation of the IN'abothian fol- 
 licles — are attached to the lips of the os and along the interior of 
 the cavity of the cervix uteri. 
 
 In the present communication, however, I wish only to speak of 
 the larger and firmer forms of pediculated uterine polypi. These 
 are usually fibroid or cellulo-fibroid in their structure, and vary fi-om 
 the size of a small walnut to that of a new-born child's head. In 
 the removal of them one or other of the following operations is 
 generally had recourse to, viz., either, 
 
 I. The slow and gradual division of the pedicle of the polypus by 
 Deligation, or by the constriction of ligatures of silk, catgut, silver 
 wire, etc., applied by means of various forms of canulse ; or, 
 
 n. The instantaneous division of the pedicle by Excision with the 
 scissors, scalpel, or bistoury, and the consequent immediate re- 
 moval of the amputated polypus. 
 
 Some practitioners combine together these two methods — applying 
 deligation first, and then — either immediately or some days subse- 
 quently — using excision or resection in addition. 
 
 In this country the operation by deligation alone has been the 
 plan usually adopted. "In England," as Dr. Ashwell states, "the 
 ligature has always had a decided preference. "' " British practitioners 
 have," says Dr. Hamilton, "universally agreed that the safe mode of 
 operating is by ligature."'' "I shall," observes Dr. Ramsbotham, 
 " consider this as a point settled, at least in our island."^ 
 
 The removal, however, of large uterine polypi by excision, has 
 long appeared to me to be in many respects a simpler and safer ope- 
 ration than their removal by ligature. It is, on the whole, more 
 easily accomplished ; the cure of the disease by it is infinitely quicker ; 
 it is accomplished vsdth far less restraint and annoyance to the pa- 
 tient; with less risk of local irritation ; and, as I believe, with less 
 ultimate chance of actual peril to health and life. 
 
 Two objections have usually been urged by accoucheurs against 
 the removal of large uterine polypi by excision. The first of these 
 
 ' Diseases Peculiar to Women, p. 485. 
 
 ' Practical Observations on Midwifery, p. 40. ' Medical Gazette for 1835, p. 433. 
 
148 DISEASES OF THE UTERUS. 
 
 objections, viz., the danger of hemorrhage, has been particularly 
 insisted on by those practitioners who have -written in favor of deli- 
 gation. But the fact is, that excessive hemorrhage is not common 
 after division of the peduncle of the polypus ; and however great 
 that or any other traumatic hemorrhage from the unimpregnated 
 uterus may be, it can always be arrested by properly filling the 
 vagina for a few hours with pieces of sponge or other appropriate 
 plug. Dupuytren, though using no plug or other means to prevent 
 bleeding, only met with two cases of severe hemorrhage out of some 
 two hundred instances in which he removed uterine polypi by exci- 
 sion ; and Lisfranc only observed it twice out of one hundred and 
 sixty-five similar operations practised by himself.^ I believe, how- 
 ever, from what I have myself seen, that the practitioner, in em- 
 ploying excision, must expect considerable hemorrhage in a propor- 
 tion of cases much greater than this ; but at the same time he can, 
 I repeat, always: readily arrest it, when it does occur, with proper 
 plugging ; and it is perhaps best — as a general rule — to prevent and 
 forestall its occurrence by introducing, for ten or twelve hours after 
 every case of resection, a proper tampon of fine sponge into the 
 vagina. Let me add, that it is well to have each piece of sponge 
 which is used previously transfixed by a strong thread, the end of 
 \vhich should be left out of the vagina, in order to permit of the 
 more easy withdrawal of the plug. 
 
 The second objection usually urged against excision is of greater 
 weight, viz. that more or less injury is always liable to occur to the 
 pelvic attachments of the uterus, if it and the polypus are forcibly 
 dragged down by Museux's forceps, or by hooked vulsella, so as to 
 bring the peduncle of the tumor into view before dividing it,^ a plan 
 followed by most operators ;^ or, on the other hand, if the peduncle 
 is divided while the polypus and uterus are in situ, the scissors or 
 knife employed are, it is averred, apt to iiijure and cut the vaginal 
 walls and neighboring tissues, while worked within the vaginal 
 cavity.'' 
 
 Of late years I have used a means of excising large uterine 
 polypi, that seems to me to obviate entirely this last class of objec- 
 tions, and by which, as I have been led to believe, the whole opera- 
 
 ' Ltsftanc's Clinique Chirurgioale, vol. iii. p. 210. 
 
 * Dr. Heming's Translations of Mad. Boivin's Treatise on Diseases of the Uterus, pp. 
 210,211. 
 
 * When the texture of the polypus is too soft to allow, without tearing, of the mass being 
 drawn downwards by vulsella, Lisfranc even advises the hooks of the forceps to be fixed in the 
 cervix uteri itself, to get a sufficient hold for dragging down it and the polypus with it to the 
 vulva. — Gazette Medioale, 1834, p. 149. 
 
 * Quia secantia instirumenta a^gre in vaginam immitti possunf, ne partes vicinas laedent, 
 et facile lethales hamorrhagias gignant. — Nissen De Polypis Uteri, 1789, p. 34. 
 
THE POLYPTOME. 149 
 
 tion is mucli simplified, and rendered both greatly more easy to the 
 practitioner, and more safe to the patient. By the means or instru- 
 ment in question, the peduncle of the polypus is divided in situ, and 
 without any chance of its cutting portion injuring the structures of 
 the vagina or vulva. 
 
 The instrument, or polypus-knife, to which I refer, is sketched in 
 Fig. 11. It is of the form of the usual midwifery hook ; with the con- 
 cavity, however, of the hook not blunt, but turned into a cutting 
 surface by the insertion of a small piece of well-tempered steel blade 
 into it. A transverse section of the curved.or cutting portion of the 
 instrument, and of its included knife-blade, is also shown in the 
 wood-cut. The entire length of the instrument which I have hitherto 
 employed in my own practice, is ten inches- — the length of the 
 wooden handle being four inches, and that of the metallic shaft six 
 inches. A shorter instrument might, perhaps, suffice equally well. 
 The cut represents the curved portion, or hook at the extremity, as 
 somewhat wider and larger than in the polyptome made for me in 
 the first instance, and which I have generally employed in practice. 
 
 Fisr. 11. 
 
 Perhaps an increased or a diminished size and width, in the curved 
 hook at the extremity of the instrument, would render the operation 
 of division by it more easy, according as the stalk of the polypus is 
 very thick, or comparatively slender. The extreme point of the in- 
 strument is blunt and rounded ; and the cutting portion of the blade 
 is so protected and concealed by it, and by the back wall of the 
 curve, that it can be introduced into and withdrawn into the vagina, 
 without any chance of its edge injuring or dividing the vaginal 
 sti'uctures themselves. To be always able to discover the direction 
 to which its hooked extremity points after it is introduced into the 
 vagina, the front aspect of the handle is distinguished by having a 
 slight knob or other mark upon it.^ 
 
 In employing this polyptome, the stalk of the polypus is first to 
 be reached by the apex of the first finger of the right hand, intro- 
 
 ' The use of the polyptome was first proposed to the Obstetric Society of Edinburgh at its 
 meeting of June 25, 1851, at which time Dr. Simpson " showed two polypi, which he removed 
 a few days before, by a nevf kind of instrument — viz., a hook, like Dr. Ramsbotham's 
 decapitation instrument. One of these polypi was very large, and when the stalk was 
 divided by the instrument in question, the polypus required to be removed from the vagina 
 by a pair of forceps." — Edinburgh Monthly Journal of Medical Science, Nov. 1851, p. 
 492.— (Ed.) 
 
150 DISEASES OF THE UTEEUS, 
 
 dueed along the short anterior or pubic surface of the vagina ; the 
 instrument is then pushed by the left hand along this finger as a 
 guide, and passed over or above the peduncle of the tumor, in such 
 a direction that the concavity of the hook will come down upon and 
 embrace this peduncle, as the instrument is pulled downwards. The 
 next step is to make the blade of the polypus-knife cut through the 
 stalk of the tumor. For this purpose, a little simple traction, with 
 a slight rolling or sawing motion, is all that is generally required. 
 K the tissue of the peduncle is dense and strong, the dividing force 
 of the instrument may be increased by the fore-finger of one hand 
 being applied with a tractive power to the blunt extremity of the 
 instrument, while the handle is dragged down and moved in a sawing 
 direction, by the other hand of the operator. Sometimes when the 
 polypus is round and loose, after the curve or hook is applied to its 
 pedicle, the cutting portion of the polyptome will divide this stalk 
 most readily, by merely doubling backwards with the fingers the 
 body of the polypus upon its own stalk, and pulling the knife 
 against the bent peduncle. In such a case, the peduncle is divided 
 as much, by pressing it against the knife, as by pulling the knife 
 through the peduncle. 
 
 During the last few years, I have removed a very considerable 
 number of uterine polypi of different sizes, and some of them of 
 large dimensions, with this curved polyptome ; and I can now speak 
 from somewhat extensive experience of the perfect facility and safety 
 of its employment. 
 
 Sometimes soft and cellular and canaliculated polypi, usually of 
 an elongated form, are met with in practice, which afford no suffi- 
 cient resistance for a knife to divide them or their peduncles. In 
 such cases, the peduncle of the polypus is, perhaps, most easily 
 severed, by the careful clip of a pair of blunt-pointed curved scissors. 
 In all other forms of the disease, where the tumor was large and 
 pedunculated, I have of late employed the polyptome. In using it, 
 the patient is placed in bed, in the common position on the left side ; 
 and generally the whole operation is accomplished so readily and 
 easily, that she is often not aware that more than a common digital 
 examination has been made. I have several times seen some diffi- 
 culty attend the removal of the amputated polypus itself from the 
 vagina, after its stalk was divided, in consequence of the great size 
 of the tumor ; and in order to effect extraction, I have occasionally 
 been obliged to transfix it with the teeth of a large vulsellum. But 
 hitherto I have met with no special difficulty, in at once and easily 
 dividing the peduncles themselves of the polypi, with this polypus 
 knife. 
 
 The whole operation is simple and safe, expeditious, and painless, 
 
EXCISION OF LARGE UTERINE POLYPI, 
 
 151 
 
 and approaches, perhaps,: more than any other in practice, to the 
 Asclepiadean character of the object of the physician : " ut tuto, ut 
 celeriter, ut jucunde curet." 
 
 In conclusion, let us compare and contrast, in a few points, the 
 operation of the excision of a common or a large-sized uterine 
 polypus, by the method I have described, and its removal by the 
 ordinary operation of deligation. 
 
 I. — Relative Difficulty of the Excision and Deligation of Uterine Polypi. 
 
 No practitioner can ever be perfectly certain that any large 
 growth detected in the vagina, is a uterine polypus, until his finger 
 touches and traces the peduncle itself of the tumor. And wherever 
 the finger can thus be made to pass and detect the stalk of the 
 polypus, the polyptome may certainly be guided to, and applied so 
 as to divide that stalk. I refer here to cases of considerable diffi- 
 culty, from the unusual shape or size of the polypus. In such in- 
 stances, one cannot but conceive it easier to pass upwards a solid 
 
 Fig. 12. 
 
 curved instrument directly around the mere stalk of the tumor, 
 than to pass a piece of whip-cord or other ligature behind and over 
 the whole body and mass of the polypus itself, till, in being re- 
 tracted, it comes indirectly and ultimately to embrace the stalk. 
 For example : in Fig. 12, there is a sketch of a large uterine poly- 
 
152 DISEASES OF THE UTERUS. 
 
 pus, which I some time ago amputated with the polyptome. The 
 figure represents the polypus diminished two-thirds — a, marking the 
 upper, and h, the inferior extremity of the polypus, while e, denotes 
 the site and thickness of the peduncle of the tumor, as divided by 
 the polyptome. In this instance, the polypus is of an elongated 
 form, its peduncle being attached to its middle, and not to its upper 
 extremity. The tumor had evidently grown into this form, after 
 being expelled from the uterus into the vagina. It had developed 
 upwards towards the roof of the vagina, as much, or more than 
 downwards. In this case, the peduncle of the tumor was readily 
 caught and divided by the polyptome ; but it would evidently have 
 been a matter of great difficulty to have passed a ligature over the 
 back and top of such a polypus, so as to embrace with it the 
 peduncle from above. 
 
 When, however, a polypus is smaller, round, or oblong, and its 
 peduncle is attached to its upper part, there is not more difficulty in 
 applying the ligature, than in applying the knife to the stalk of it. 
 Some, however, of the practitioners who have had most experience 
 with the ligature, confess to the occasional difficulty of its appliear 
 tion, with even the best kind of canula. " By practice and dex- 
 terity," says Dr. Burns, "this instrument (the double fixed canula) 
 may doubtless be adequate to the object in view, but without these 
 requisites, the operator will be foiled — the ligature twisting, or 
 going past the tumor; every attempt giving much uneasiness to the 
 patient, and not unfrequently, after many trials and much irritation 
 the patient is left exhausted with fatigue, vexation, and loss of 
 blood." This is very likely to happen if the polypus be so large as 
 to fill the vagina. "Dr. Hunter," adds Dr. Burns, " after repeated 
 trials failed in a case, where the polypus filled the vagina ; the 
 pedicle in the preparation is long, and as thick as the finger."' The 
 application of a ligature to a large uterine polypus is, " in many 
 cases," Dr. Hamilton^ testifies, " one of the most difficult and dan- 
 gerous operations in surgery;" and he tells us that "he has seen 
 some of the most eminent practical surgeons of this part of the 
 kingdom foiled in their endeavors to apply the ligature." 
 
 I quote, in preference, such opinions from the writings of Pro- 
 fessors Burns and Hamilton, because both of these gentlemen were 
 strongly in favor of the operation of deligation. 
 
 II. — Relative Duration of the Operation of Deligation and Excision. 
 
 The process of excision is generally accomplished in the course 
 of two or three minutes at most ; sometimes in a shorter period. 
 
 ' Burns's Principles of Midwifery, p. 130. ^ Hamilton's Practical Observations, p. 40. 
 
EXCISION OP LARGE UTERINE POLYPI. 153 
 
 On the contrary, the deligation of a uterine polypus consists of a 
 succession of operations rather than of one ; and is usually pro- 
 tracted through a period, varying from two or three days to two or 
 three weeks. The application itself of the ligature and canula, in 
 the fii'st instance, requires as nauch, or indeed more, time and pains 
 than the act of excision. But, after its first application, the ligature 
 requires to be tightened and adjusted from time to time. " Twice 
 a day," as Dr. Gooch directs, " the ligature is to be untwisted from 
 the shoulder of the canula, drawn tighter, and then fixed again round 
 the projecting part ; and this is to be done morning and night." 
 "Every day," observes Sir Charles Clarke, another advocate, like 
 Dr. Gooch, for this mode of treatment — "Every day the prac- 
 titioner is to examine the state of the ligature, and as often as it is 
 found to be at all slack, it is to be tightened. The mode of tight- 
 ening it," he continues, " requires particular attention. K the 
 canula should happen to be long, the practitioner should not 
 hold the end of it whilst he tightens the ligature, lest with the 
 force used the ligature should cut through the neck of the tumor, 
 and the other extremity of the canula should be suddenly and 
 forcibly pushed against the internal parts of the woman. The 
 time," he adds, " at which the ligature will come away will de- 
 pend upon the thickness and firmness of the neck of the tumor, 
 and the tightness with which the ligature is at first applied. 
 The neck of the tumor sometimes is cut through in four days, 
 sometimes ten or twelve days will elapse between the application of 
 the ligature and the removal of the tumor, and occasionally the 
 separation of the tumor will take up three weeks ; but this is 
 an uncommon occurrence. "^ "After an interval," observes Dr. 
 Churchill, " varying from six days to three weeks, the canula will 
 be found loose in the vagina, and the stalk of the polypus severed."^ 
 
 in. — Relative Care and Management after the two Operations. 
 
 After the operation of excision, the only special treatment in 
 general required is the introduction of a sufficient plug, of sponge 
 or other soft material, into the vagina, to prevent the chance of 
 bleeding; and the withdrawal of this plug after ten or tweniy 
 hours. After, however, the application of the ligature in deligation 
 of a uterine polypus, a considerable amount of continuous care and 
 caution is necessary up to the time at which the pedicle is ultimately 
 divided. " The patient is," says Sir Charles Clarke, " to be desired 
 to remain constantly upon her side, and should not be allowed to 
 
 ' Observations on the Diseases of Females, p. 263. 
 2 On the Diseases of Females, p. 220. 
 
154 DISEASES OF THE UTEKUS. 
 
 move from one side to another unless when the practitioner is 
 present. For want of attention to this caution, there is," he adds, 
 " reason to believe that the canula has been inadvertently pressed 
 against, and its extremity pushed through the uterus of the patient, 
 so as to occasion her death."^ " The woman," as Dr. Ramsbotham 
 states, " will be obliged to keep her bed during the sloughing pro- 
 cess ; and she ought to be cautioned, upon attending to her natural 
 calls, to beware of any accidental occurrence which might push the 
 point of the instruments against the internal surface of the uterus."^ 
 "As the instrument," Dr. Gooch remarks, "projects out of the 
 vagina, if the patient was, whilst turning from side to side, to sit 
 down upon it, she might impale herself on it — an accident which 
 I have heard once took place, and terminated fatally."^ 
 
 IV. — Relative Chance of Local Irritation of the Vagina and Uterus. 
 
 Local lesion and irritation of the vagina and cervix uteri are not 
 liable to follow upon the practice of excision, unless some local 
 injury has resulted in the operation from very incautious manipula- 
 tion. But in addition to this danger, there is after deligation, other 
 sources of local disease in the sloughing and putrefaction of the 
 polypus before its complete separation ; in the presence of the very 
 fetid and excoriating fluid with which the surface of the vagina and 
 vulva is in consequence constantly bathed ; and in the irritation by 
 the ligature itself, as a foreign body, upon the constricted and ulce- 
 rating stalk of the tumor — not to speak of the constant application 
 to this ulcerated surface of the foul and acrid discharges that issue 
 from the dead and decomposing polypoid structure. The polypus 
 usually swells after the first application of the ligature. " On ac- 
 count," observes Chelius, " of the increasing bulk of the polyp, it 
 is generally necessary for the first few days after deligation, to 
 empty the bladder with the catheter, and the rectum by clysters. 
 The symptoms," he further states, " which may occur after the tie 
 has been made, are violent infiammation and fever, pain, spasms, 
 bleeding, and other symptoms, from the pressure of the swelling 
 polyp. To prevent," he adds, " the effect of the stinking ichor, 
 repeated injections of decoctions of aromatic herbs must be em- 
 ployed."" After the ligature is applied, " When putrefaction has 
 commenced, the discharge from the vagina," to quote the words of 
 Dr. Ramsbotham, " becomes fetid and highly offensive. . . It is, 
 
 ' Observations, &o., p. 262. 
 
 ^ Dr. John Ramsbotham 's Practical Observations, vol. ii. p. 468. 
 
 ' On some of the most important Diseases peculiar to Women, p. 264. 
 
 * System of Surgery, South's Edition, vol. ii. p. 752. 
 
EXCISION OF LAEGE UTERINE POLYPI. 155 
 
 indeed, the best sign we can observe, as it proves that decay is 
 going on, that the stem is sufficiently compressed to strangulate the 
 vessels which nourished the diseased growth. If ever," he adds, 
 " such a discharge did not take place in a day or two, I should be 
 stispicious that the operation would not succeed."' 
 
 V. — Relative Danger of the two Operations to the Health a?id Life of the Patient. 
 
 Those authors who have written in favor of deligation usually 
 quote one solitary case of death from hemorrhage after excision, 
 recorded by Zacutus Luzitanus, in the seventeenth century. It was 
 an instance of the fact that the amount of attendant hemorrhage is 
 not regulated by the mere size of the polypus ; for in the case in 
 question, it is stated that the amputated polypus was not larger than 
 an almond.^ In this instance the operation was performed by an 
 empiric, and no plug or other means for arresting the hemorrhage 
 appear to have been employed. The patient died, not so much 
 from the operation, as from neglect of all proper means to restrain 
 the hemorrhage resulting from it. At the same time let me remark, 
 in passing, that the operation of deligation itself is not free from the 
 risk of hemorrhage, both from the abrasion of the surface of the 
 tumor in working with the canula and ligature, and from the division 
 of the vessels of the stalk, as they are cut through in the process of 
 deligation. " I think," maintains Dr. Meigs of Philadelphia, " the 
 ligature is to be preferred to all other modes of extirpation. It is 
 not in every case to be eifected without hemorrhage. I know," he 
 adds, " of two cases here in which the hemorrhage was terrible."^ 
 
 But the principal danger to health and life in this, as after other 
 surgical operations, is the danger of phlebitis and surgical fever. Is 
 such a consequence more liable to follow upon the instantaneous 
 resection of the peduncle of a polypus, and the subsequent imme- 
 diate removal of the amputated polypus itself — or is it more likely 
 to supervene upon the slow process of disjunctive ulceration being 
 set up in the stalk of the polypus by the ligature, while the gangre- 
 nous and putrefying polypus itself is left decomposing in the cavity 
 of the vagina? 
 
 I believe that no physician or surgeon acquainted with modern 
 pathology will have any difficulty in answering, that the danger of 
 phlebitis is much greater under the latter circumstances than under 
 the former. The recorded experience of some of those who have 
 
 ' London Medical Gazette for 1835, p, 435. ^ Praxis Medica, lib. ii. Obs. 86. 
 
 " Meigs's FemalesSind their Diseases, p. 255. See also Examples in Colombat de I'Isere's 
 Traite des Maladies des Femmes, p. 817. 
 
156 
 
 DISEASES OF THE UTERUS. 
 
 written in favor of the ligature, shows strongly enough the occasional 
 liability under deligation to the occurrence of irritative fever and 
 internal inflammations, from phlebitis and the absoi-ption of putrid 
 and purulent matter from the vagina. Dr. Hamilton^ mentions 
 three cases of death which he had seen follow the removal of uterine 
 polypi by ligature, " On a close inquiry," observes Mr. Arnott, "I 
 find that even those who use it (the ligature) acknowledge that oc- 
 casionally cases have been met with, where the ligature, in cutting 
 its way through, has excited irritation and fever, and even death. 
 Two cases have been described to me by the practitioners concerned 
 where this occurred, and in casually referring to the interesting 
 works of Boivin and Duges I find two similar ones."^ In his lec- 
 tures on fibrous tumors of the uterus, Depuytren^ states, " I possess 
 eight or ten observations of women who have perished, from verita- 
 ble poisoning and absorption of pus, after the application of the 
 ligature for uterine polypus." 
 
 I have myself seen a woman die with a ligature still fixed around 
 the partially divided neck of a uterine poljrpus ;^ and other cases 
 where severe but not fatal attacks of phlegmasia dolens and phlebi- 
 tis followed deligation. Twelve or thirteen years ago, on a patient 
 of Dr. Edgar's of Berwick, I applied a silver wire ligature to the 
 neck of a large polypus and tightened it from time to time, ac- 
 cording to the usual rules. In the course of a few days the polypus 
 was dead and putrefying ; there was much heat and irritation in the 
 vagina ; and the patient's pulse became rapid under the irritative 
 fever that followed. On strongly tightening the ligature to expe- 
 dite as much as possible the total amputation of the polypus, the 
 wire broke : and the canula and wire slipped ofi". I immediately pro- 
 ceeded to remove the polypus by excision instead of making any re- 
 newed attempt at deligation ; and the result to me was very striking 
 and satisfactory. Within twenty-four hours the local irritation had 
 greatly subsided, and the constitutional disturbance entirely disap- 
 peared. From that time to this I have operated on many uterine 
 polypi, but never again by the process of slow deligation. And the 
 more that I have seen of the practice of removing large pediculated 
 uterine polypi by excision, the more deeply has the conviction 
 
 ■ Hamilton's Pract. Observ. p. 37, 
 
 * Arnott in Lond. Med. Gazette, 1836, p. 412. Seealsonotioesof two other cases of death 
 from uterine phlebitis after deligation, in Cyclopedia of Practical Medicine, vol. iv. p. 393. 
 
 » Le5ons Orales.— Brussels ed. 1826, p. 237. 
 
 * A short notice of this case, which he had seen in consultation with Dr. Girdwood of Fal- 
 kirk, was communicated to the Obstetric Society of Edinburgh by Dr. Simpson, at its meet- 
 ing of February 10, 1847, and appears in the Edinburgh Monthly Journal for April of that 
 year, p. 797.— (Ed.) 
 
AMPUTATION OF THE NECK OF THE WOMB. 157 
 
 grown upon my mind, that tHs method is very superior to the usual 
 method followed in this country, of the removal o.f them by eanula 
 and ligature. 
 
 ON AMPUTATION OF THE NECK OF THE WOMB. 
 
 Ko. I. 
 
 CASE FOLLOWED BY PEEGNANCY, WITH EEMAEKS ON THE PATHO- 
 LOGY AND EADICAL TEBATMENT OP THE CATJLIPLOWEE EXCEE- 
 ^SCENCE PEOM THE OS UTEEL' 
 
 (From Edinburgh Medical and Surgical Journal, January, 1841, p. 154.) 
 
 In his learned work on the Diseases of Females, Dr. Churchill re- 
 marks,^ " I am not aware that any attempts have been made in 
 Great Britain to excise the cervix uteri." 
 
 The following instance of this operation may therefore not be 
 uninteresting, either as regards its details, or the hitherto flattering 
 success that has resulted from it : 
 
 In the beginning of May last I was requested by Dr. Lewins of 
 Leith to visit with him Mrs. Cameron, who, as he informed me, had 
 a tumor attached to the cervix uteri. 
 
 The patient, aged 33, had been married for thirteen years. During 
 that period she had borne five' living children, and suiFered from a 
 miscarriage at the sixth month. In June, 1838, she weaned her 
 youngest child. For about a month previously to that date she had 
 had a red discharge from the vaginai, which was constant in its oc- 
 currence, though not great in its quantity. It continued during the 
 autumn. In October she passed, with labor pains of three or four 
 hours' duration, a body which the midwife in attendance supposed 
 to be an abortion of the second month. During the period of preg- 
 nancy with' this alleged abortion, the vaginal discharge was still 
 present. It increased considerably after October, and was now often 
 mixed -with eoagula of blood. It had always a very oiFensive smell, 
 and more or less of a red tint, but sometimes it appeared compara- 
 tively pale and. watery. The discharge was as profuse, though less 
 discolored, during the night, and when at rest, as during the day, 
 and when taking free exercise. From the supposed period of abor- 
 tion in October, up to the period that I saw her with Dr. Lewins, 
 
 ' Read before the Medioo-Chirurgical Society of Edinburgh, November, 1840. 
 » Churchill, Diseases of Females.— Dublin, 1838, p. 249. 
 
158 
 
 DISEASES OF THE UTERUS. 
 
 in May, three or four cloths were soaked regularly every twenty- 
 four hours by it. Whenever she ventured to walk about without 
 napkins she felt the discharge " running," to use her own expression 
 from her. On two separate occasions the escape of pui'e blood be- 
 came suddenly so great as to pass through all the cloths, and create 
 great alarm. Mrs. 0. was not aware of any causes which excited 
 these attacks of hemorrhage. One of them occurred during the 
 night. She never observed any monthly increase in the discharge 
 answering to the catamenial periods. 
 
 During the whole course of the disease Mrs. C. had not suffered, 
 if we except the temporary expulsive uterine action in October, any 
 pain or uneasiness whatever in the region of the uterus ; but by the 
 time that I first saw her she had become greatly weakened and 
 reduced by the abundant discharges. Her face was pale and anaemic, 
 and she was occasionally obliged to keep her bed, in consequence of 
 debility and exhaustion. 
 
 Dr. Lewins was first called in to see the patient a short time pre- 
 viously to my visiting her along with him. On examination per 
 vaginam I found, as Dr. Lewins had described to me, a tumor fixed 
 to the posterior lip of the uterus. It was then about the size of a 
 small pear, and was attached by a very broad base. ' The surface of 
 the tumor felt somewhat rugged and granulated. It was firm but 
 not hard in its consistence. The patient did not complain of any 
 pain upon touching or pressing its surface. Its superficial vessels 
 bled freely under every attempt at examination. On introducing 
 the speculum, and embracing the diseased mass within the further 
 extremity of the instrument, the surface of the tumor was seen to 
 be irregular, and of a bright red strawberry color. 
 
 It appeared possible to grasp the basis of the tumor with a liga- 
 ture ; but both Dr. Lewins and I were of opinion that the free am- 
 putation-of the cervix uteri, with the diseased structure attached to 
 it, offered by far the most probable means of success. We commu- 
 nicated this opinion to the patient's husband, and at the same time 
 stated, that, even under this method of treatment, the disease would 
 probably recur. After a delay of about three weeks, Mrs. C. an- 
 nounced that she was ready to submit to the operation that we had 
 proposed. In making a re-examination after that short interval, I 
 was perfectly convinced that the excrescence had grown considerably, 
 and was extended in its base so as to involve more of the angles of 
 the OS uteri, as well as of its posterior lip. 
 
 On the 25th May^ I proceeded to excise the cervix uteri, and was 
 assisted in the operation by Dr. Lewins and Mr. Ziegler. 
 
 The patient was laid upon her face, her body placed across the 
 bed, and her lower extremities allowed to hang over the front of it. 
 
EXCISION OF THE CERVIX. 159 
 
 The thighs were held separate from one another. My object was to 
 pull down the diseased neck of the uterus till it protruded externally 
 beyond the mouth of the vagina, and then freely excise it. For this 
 purpose I introduced the two first fingers of my left hand into the 
 vaginal canal up as far as the tumor, and used them as a guide by 
 which I fixed the teeth of a long vulsellum into the sides of the 
 excrescence. Its tissue, however, was so soft as to tear under slight 
 traction, and thus afibrd me little purchase for pulling the mass 
 downwards. The instrument was refixed nearer the root of the 
 excrescence, and a second vulsellum was superadded to render the 
 purchase the more secure. With these I was enabled to pull down 
 the tumor gradually and cautiously until it was entirely protruded 
 beyond the external parts. Dr. Lewins and Mr. Ziegler having 
 satisfied themselves that the cervix uteri and whole bulk of the 
 tumor was extruded, I cut off the protruded mass, dividing it from 
 behind forwards, and removing the whole vaginal portion of the 
 cervix uteri. The uterus immediately slipped up into its natural 
 position. Very little hemorrhage followed. I stuffed, however, the 
 vagina pretty firmly, under the fear that dangerous bleeding might 
 supervene. 
 
 The patient bore the operation well, and complained wonderfully 
 little during it. In the evening Dr. Lewins had to remove the 
 vaginal plug, in order to allow her to evacuate the bladder. It was 
 not considered necessary to replace it. 'No marked morbid symp- 
 toms whatever, either local or constitutional, followed. The great 
 vaginal discharge immediately ceased. On being interrogated in 
 relation to this point on the second day, the patient emphatically 
 described herself to Dr. Lewins as " quite dry" and that for the first 
 time for many months. The incised surface, when examined through 
 the speculum a few days after the operation,* presented a healthy 
 granulating appearance. It was not considered advisable to allow 
 her to sit up till the tenth day after the operation was performed, 
 and in a few days more she began to walk about the house and per- 
 form her usual domestic duties. 
 
 She has not been one hour sick since the period of the operation, 
 and has now regained her usual strength and spirits. 
 
 E'o morbid discharge from the vagina of any Icind has hitherto 
 appeared. She has never since menstruated ; and about five weeks 
 ago she fancied that she felt the symptoms of quickening. On 
 examining the abdomen to-day, 14th Ifovember, with the stetho- 
 scope, I heard distinctly both the placental souffle and the sounds of 
 the foetal heart. The os uteri is closed, and on examination by the 
 finger, gives the sensation of a firm puckered cicatrix. 
 
 The excrescence after its removal was found to measure two inches 
 
16a 
 
 DISEASES OP THE UTERUS. 
 
 and three-quarters at its broadest part, and two inches and a quarter 
 at its greatest depth. The thickness of it where it implicated the 
 posterior lip of the os uteri was one and three-eighths of an inch, 
 but on either side it stretched forward and involved the angle be- 
 tween the anterior and posterior lips ; thus rendering this admea- 
 
 Fig. 13. 
 
 surement greater on its lateral parts. The anterior lip of the os 
 uteri (Fig. 13), which was fully removed as high as the reflection of 
 
 Fig. 14. 
 
 b 
 
 the vagina, seemed sound except at the above angles. The posterior 
 surface (Fig. 14) of the posterior lip was densely and completely 
 
 Fig. 1 3. a a, probe passed through the cavity of the os and cervix uteri ; b, anterior lip of 
 the uterus ; c, posterior lip ; d d, line of incision by which the cervix uteri was removed ; 
 e, rou<5h surface of the tumor attached to the posterior lip. 
 
 Fig. 14. a a, Under surface of the tumor; b b, portions lacerated by the vulsellum. 
 
NATURE OF CAULIFLOWEK EXCRESCENCE. 161 
 
 covered by the excrescence, up to the reflection upon the vagina. 
 In excising the diseased part, I removed it so high as to bring away 
 all around, a small portion of the reflection itself of the mucous 
 membrane of the vagina. The surface of this portion of membrane, 
 as thus removed in attachment to the upper edge of the excrescence, 
 appeared quite healthy on careful examination of the excised mass 
 — (Fig. 14). The surface of the tumor presented a well-marked 
 small granulated appearance, with deeper fissures crossing it, and 
 giving it an irregular and lobulated appearance. The sides of it 
 were considerably and deeply lacerated in various places by the 
 teeth of the vulsellum. On rubbing down any small part of the 
 recent tumor between the finger and thumb, a kind of vascular or 
 cellular framework was all that was left behind. The mass, before 
 dividing it, was steeped in a strong alcoholic solution of corrosive 
 sublimate, in order to insure its preservation. On making a section 
 of the tumor after it had been thus sufficiently indurated, it presented 
 to the touch and sight an appearance greatly resembling that of the 
 brain when hardened by the same menstruum. A number of minute 
 cells were scattered over the surface of the section. On slightly 
 rubbing any part of the section (Fig. 15), but particularly the more 
 external part of it, with the handle of the scalpel, its apparently 
 homogeneous structure at once broke up, and resolved itself into an 
 immense number of very small, connected, grape-like granules. 
 These same granules imparted to the external surface of the excre- 
 scence its peculiar minutely mammilated structure ; while their 
 
 Fig. IS. 
 
 arrangement into nodules, in consequence of the divided and lobu- 
 lated arrangement of the superficies of the tumor, gave to the whole 
 a striking resemblance to the head of the cauliflower. The accom- 
 panying wood-cuts, from drawings of the tumor by my friend Dr. 
 Paterson, give excellent representations of its external form. 
 
 On submitting some very thin slices from the surface of the sec- 
 tion of the tumor, to a powerful microscope in the possession of 
 Dr. Reid, it was seen to be composed of a number of cells, arranged 
 in some places in groups, in others in irregular lines. These cells 
 contained each a large nucleus, and this nucleus enclosed several 
 
 VOL. I. 11 
 
162 DISEASES OF THE UTERUS. 
 
 small nucleoli. The structure in question, of cells or cytoblasts, 
 encasing nuclei aud nucleoli, has been shown to be so common as 
 an elementary form of natural structure, by Schleiden and Schwann, 
 and as an elementary form of various morbid tissues, by Valentin, 
 GHuge, and Miiller, that no conclusion, in the present state of our 
 knowledge, can be positively drawn from this microscopic structure 
 alone. But it may be interesting to add, that none of the caudate 
 or spindle-shaped bodies, described by Miiller as often existing in 
 ihorbid encephaloid structures, were seen in any section that was ex- 
 amined.' The microscopic appearance of the compound cell- 
 globules constituting the granules, and composing the mass of the 
 excrescence, are well represented in the wood-cut from a drawing 
 kindly made for me by Mr. Goodsir. 
 
 Pathological Nature of Cauliflower Excrescence. — The history, 
 symptoms, physical characters, and minute structure, of the pre- 
 ceding tumor appear to refer it indubitably to that species of growth 
 which was first accurately distinguished and described by Dr. 
 Clarke, under the quaint but expressive name of the " Cauliflower 
 Excrescence from the os uteri. "^ 
 
 The pathological nature of this variety of morbid growth has 
 given rise to a considerable difference of opinion among physicians. 
 Drs. Gooch, Hooper, Davis, and Lee, regard it as truly cancerous 
 in its character. Others, as Drs. Clarke, Burns, and Waller, con- 
 sider it as a morbid tissue, not necessarily of a malignant or carci- 
 nomatous nature. A number of circumstances appear to me to 
 show, that in reference to, at least, the first stage of cauliflower 
 excrescence, the opinion of these latter authors is probably correct. 
 The occurrence of the disease in some cases as early as the twen- 
 tieth year of life f — its occasional shrinking and almost total disap- 
 pearance upon the application of a ligature, or after death ;■• — the 
 frequent slowness of its general progress during life ; the apparent 
 absence of diseased deposits in the neighboring tissues and parts 
 upon the dead body f — and, above all, the alleged restriction and 
 even complete removal of the tumor, in one or two instances, by the 
 use of astringent applications and other simple means,° form so 
 
 ' At the time this paper appeared, the term Epithelial Cancer, as applied to this and 
 other morbid structures, was not generally in use among pathologists ; but the diseased 
 structure described is evidently of this type. — (J: Y. S.) 
 
 ^ See Transactions of a Society for the Improvement of Medical and Chirurgical KnovF- 
 ledge,vol. iii. p. 321.— 1809. 
 
 ^ Sir C. M. Clarke on the Diseases of Females, vol. ii. p. 62. 
 
 1 Ibid. pp. 70 and 75. 5 jbid. pp. 66 and 70. 
 
 ^ Ibid. pp. 105 and 108. A lady, aged 32, had a continued profuse watery discharge 
 mixed occasionally with blood. She was greatly weakened, pale and emaciated. A cauli- 
 
TREATMENT OF CAULIFLOWER EXCRESCENCE. 163 
 
 many circumstancea strongly pointing to the opinion that in the 
 earlier part of its progress the tumor cannot be regarded as of a 
 carcinomatotis character. 
 
 Has it any analogy in its pathological nature and origin — as it 
 certainly has in its physical characters^-with the soft warts and 
 condylomata that sometimes form on the mucous membrane of the 
 vulva and entrance of the vagina ? These warts and condylomata 
 have the same tendency to regeneration after their imperfect removal, 
 andpresenttous a striking exception to the general pathological law 
 of the local reproduction of a morbid growth being a sign of its 
 malignancy. 
 
 But whatever view we may take of the primary nature of the 
 cauliflower excrescence of the cervix uteri, we have sufficient evi- 
 dence for believing either that this disease has been often con- 
 founded with carcinomatous or medullary fungus from the cervix 
 uteri, from the want of adequate diagnostic marks to distinguish 
 them; or that, though non-malignant in its commencement, the 
 cauliflower excrescence may, like some other local benign growths 
 become the seat of carcinomatous deposit and malignant action, 
 during its progress. Thus it has been found by Gooch' and 
 Madame Boivin^ to return again in a malignant form, after its im- 
 perfect removal by the ligature or knife. In an instance mentioned 
 by Pr. Davis,^ its removal was followed, after the lapse of a conside- 
 rable period, by its reproduction, and ultimately by carcinomatous 
 ulceration ; and in two cases that occurred to Professors P'Outre- 
 ponf and Siebold,' in which large tumors having a cauliflower form 
 were found affixed to the cervix uteri during parturition, the neigh- 
 boring uterine tissues, as well as the contiguous structures of the 
 bladder and uterus, were found in a carcinomatous state upon the 
 post-mortem dissection. In another case, in which Michaelis^ ex- 
 cised what he termed a fungus meduUaris with a cauliflower appear- 
 ance, from the anterior lip of the uterus during labor, the posterior 
 lip of the organ afterwards degenerated, and cancer of the stomach 
 ultimately supervened. 
 
 If these latter cases were not merely more advanced stages of the 
 
 flower mass projected from the surface of the os uteri. Several remedies, with cupping, and 
 local astringents, were ordered and assiduously persevered in. After two years, " no differ- 
 ence could be felt between the os uteri of the patient and that of a woman in perfect 
 health."— Clarke, p. 107. 
 
 ' On the most important Diseases peculiar to Women, p. 288. 
 
 2 Heming's translation of Boivin and Duges' work, p. 300. 
 
 ' Principles of Obstetric Medicine, vol. ii. p. 744. 
 
 * Abhandlungen Geburtshulfliohen Inhalts, Th. i. p. 276. 
 
 ^ Dissertatio sistens casum singnlarem carcinomatis uteri cum graviditate oonjunoti. 
 
 * Neue Zeitschrift fur Geburtskunde, Bd. iv. S. 176. 
 
164 DISEASES OF THE 0TERUS. 
 
 cauliflower excrescence, but, as appears to us not improbable, dis- 
 eases originally and patbologically different from it, though resem- 
 bling true cauliflower excrescence in its peculiar form and external 
 physical characters, are there any means which might enable us to 
 form a diagnosis between the two affections? The whole subject is 
 one certainly demanding more carefnl observation and deeper in- 
 vestigation. The nature and characters, both physical and chemical, 
 of the vaginal discharges in these and other maladies of the sexual 
 parts, require to be more accurately examined and discriminated. 
 May the degree of mobility of the cervix uteri serve in any case as 
 a source af diagnosis? " The tendency of cancer," as observed by 
 Muller,' " is to interfere with the natural structure of surrounding 
 parts, while those formations which are of a benignant nature leave 
 the neighboring healthy tissues unaltered." In carcinoma of the 
 cervix uteri, we thus generally find, at even a pretty early stage of 
 the disease, that the organ has become more fixed and immovable 
 than natural, in consequence of the morbid deposit affecting both 
 the structure of the neck of the organ and the contiguous surround- 
 ing tissues. Does the reverse of this hold good with regard to 
 Cauliflower excrescence of the cervix uteri ? 
 
 Radical Treatment of Cauliflower Exerescence. — ^Different measures 
 have been proposed for the radical removal of cauliflower excres- 
 cence from the cervix uteri. The caustic, ligature, and knife have 
 each been employed. "With regard to the two former, it seems 
 superfluous to hope that the good results following upon their use 
 can be more than temporary. The base of the diseased structure 
 will in all probability be left. Occasionally both the caustic and 
 the ligature appeared to have produced injury rather than good, by 
 the irritation and increased action that they have excited in the 
 diseased parts. 
 
 If any radical operation and cure for cauliflower excrescence be 
 attempted, the excision of the tumor with the whole of the vaginal 
 portion of the cervix uteri, to which it is attached as a base, appears 
 to me to be the only measure which can at all be hoped to insure 
 ultimate success. The disease has no doubt recurred in repeated 
 instances even after this operation. In some of these cases it 
 probably had advanced too far onwards to a carcinomatous charac- 
 ter. In others, the failure might be attributable, as confessed by 
 Boivin and Duges, in regard to the cases which they themselves 
 report, to " the tumor being alone removed," and not the cervix 
 uteri also, which forms its seat, and " is always more or less af- 
 fected."^ In a few authenticated cases on record, in which complete 
 
 ' On the Nature and Structural Characteristics of Cancer. — West's transl. p. 66. 
 ^ Heming's Translation, p. 301. 
 
EXCISION OF THE CERVIX UTERI. 165 
 
 amputation of the cervix uteri with the attached tumor was per- 
 formed, the patient was known to have remained free from any 
 symptoms of the disease for several years afterwards. A search 
 through the medical literature of the last twenty years would, in all 
 probability, enable me to adduce several such instances ; but it 
 may be sufficient for my present purpose to adduce three cases, of 
 which I have the notes lying before me, and that appear to me, as 
 far as I can judge from the details and expressions of the reporters, 
 to have been probably instances of the same species of tumor that 
 Dr. Clarke originally described. 
 
 Case I. — In an instance of what is termed fungous cancer {cancer 
 fongeux) by Colombat,^ that surgeon amputated the cervix uteri on 
 the 2d June, 1830. The wound completely cicatrized, and the pa- 
 tient's health was re-established. She died in April, 1832, of epidemic 
 cholera. 
 
 The fungous cancer, Colombat observes in another part of his 
 work,^ is one of the forms of cancer which is the least liable to re- 
 turn after excision of the parts. 
 
 Case II. — Boivin and Duges mention a case of cauliflower ex- 
 crescence of more than two inches in diameter, which was attached 
 to the anterior lip of the cervix uteri. It was removed, along with 
 more than six lines of the cervix uteri, in Ifovember, 1828. The 
 patient was alive in October, 1832, and is then reported by the 
 above authors as only laboring under some symptom of menor- 
 rhagia and dysmenorrhcea at the menstrual periods.^ 
 
 Case HE. — An instance is reported by Duparcque, under the 
 head of " Exuberance de I'llterus," in which Hei-vez de Chegoin 
 excised the two lips of the uterus, affected with what the operator 
 terms " a granular strawberiy inflammation," and which he alleges 
 has often been confounded with cancer. The discharge and other 
 symptoms of the disease had been present two years previously to 
 the operation. At the date of the report, four years after the exci- 
 sion of the diseased part, the patient remained perfectly well. 
 
 In the case of Mrs. C, which I have above reported, I undertook 
 tiie amputation of the diseased part, with, as has been already said, 
 strong doubts as to its ultimate success. The patient's peace of 
 mind was broken and her constitution so rapidly breaking down 
 under the constant, profuse, and weakening discharges which afflict- 
 
 ' Colombat de I'lsere, Traite des Maladies des Femraes, torn. ii. p. 701. 
 2 Ibid. p. 711. 
 
 ' See Heming's Translation of Boivin and Duges' Treatise on Diseases of the Uterus, pp. 
 300-301, and drawings of the excrescence in the Atlas, pi. xxiv. figs. 3 and 4. 
 
166 DISEASES OF THE TJTEHUS. 
 
 ed her, that she would in all probahility have soon sunk under them. 
 Immediately after the operation was performed, these discharges 
 completely ceased, and have never since returned. Her health and 
 strength have been in the meantime restored to her ; and she is at the 
 present moment, as I have already shown, advanced beyond the 
 middle period of pregnancy. The morbid characters of the diseased 
 structure that I removed are such, certainly, as to render its future 
 regeneration not at all improbable, but as yet there are no local ap- 
 pearances of its return; and, taking the very worst view of the case, 
 there seems to be no reasonable doubt but that the operation has 
 restored the bodily comfort, and prolonged the life of the patient, if 
 it has not entirely freed her from the risk of a future return of the 
 disease. 
 
 EXCISION OF THE CERVIX UTERI.' 
 No. n. 
 
 WITH REMARKS UPON THE OPERATIOISr IN CARCINOMATOUS 
 
 DISEASE. 
 
 (From Dublin Quarterly Journal, November, 1846, p. 332.) 
 
 In eight instances I have had occasion to perform excision of the 
 cervix uteri. In three of these eight cases the operation was had 
 recourse to for the removal of excrescences or morbid structures, 
 possessed of a carcinomatous tendency and character. In the follow- 
 ing remarks I propose to describe the more leading facts connected 
 with these three cases, and the results of the operation adopted for 
 their treatment. I shall append a few observations on the method 
 I have followed in performing the operation, and on the cases of 
 uterine disease that appear to be most adapted for its employment. 
 
 Case I. — Between four and five years ago, I laid before the Me- 
 dico-Chirurgical Society of Edinburgh some details of this case, and 
 had an opportunity of showing them the characters of the excised 
 structures, while still in a recent state.^ 
 
 The patient, aged 33, weaned her fifth child in June, 1839. Foj- 
 about a month previous to that date, and during several months 
 subsequently, there was a constant slight menorrhagic discharge 
 present. She aborted in October, and afterwards the reddish vagi- 
 nal discharge increased, was oft;en mixed with coagula of blood, and 
 
 ' Read before the Edinburgh Medioo-Chirurgioal Society, December 3, 1845. 
 2 See ante, p. 157. 
 
EXCISION OF^^THB CERVIX UTEKI. 167 
 
 had an offensive smell. At times it lost so much of its red tint as 
 to appear comparatively pale and wateiy. For some months before 
 I saw the patient, the discharge was so profuse as to require the 
 daily use of several napkins. Twice there occurred alarming he- 
 morrhage without any obvious exciting cause. There was no local 
 uterine pain or uneasiness. By the time I first visited the patient 
 with Dr. Lewins in May, 1840, eleven months after the discharge first 
 appeared, she had become greatly weakened and reduced. Her 
 face was pale and anaemic, and she was occasionally obliged to keep 
 her bed, in consequence of debility and exhaustion. 
 
 On making a vaginal examination. Dr. Lewins and I found a tu- 
 mor, the size of a small pear, attached to the whole posterior lip of 
 the OS uteri ; its basis of attachment was very broad ; its surface was 
 of a strawberry color, rough, granulated, and fissured ; it was insen- 
 sible to touch ; but the superficial vessels upon it bled freely under 
 slight pressure or abrasion with the finger or speculum. 
 
 On the 25th May, 1840, 1 excised the whole vaginal portion of the 
 cervix uteri, with the tumor attached to it. In order to secure its 
 complete removal, and insure that my incision was, if practicable, 
 through healthy tissue, and above the seat of the morbid degenera- 
 tion, I divided the cervix as high up as the reflection of the vagina 
 would permit, and even removed at one point a line or two of the 
 reflected mucous membrane of that part. The excrescence mea- 
 sured 2f inches at its broadest part, and 2J in its greatest depth 
 (Figs. 13 and 14). After the tumor was steeped in a strong alcoho- 
 lic solution of corrosive sublimate, its section presented to the touch 
 and sight an appearance greatly resembling that of brain hardened 
 by the same menstruum. It was microscopically examined by Mr. 
 Goodsir, and found to present a nucleated cellular structure, but 
 no condyloid or spindle-shaped bodies were observed in it. 
 
 The patient recovered rapidly from the operation. The morbid 
 discharge, from which she suffered so much, ceased from the date of 
 the removal of the tumor ; and, when I last reported the case, in 
 November, 1840, she was advanced several months in pregnancy. 
 
 My most sanguine expectations regarding the case have been 
 more than realized by its subsequent history. Since the date of the 
 operation, May 25, 1840, the patient has been three times pregnant, 
 .and has given birth to three children, all of them now alive and well, 
 viz., the first, born on the 14th of February, 1841,^ the second on 
 the 18th of May, 1843, and the third on the 19th of April, 1845. 
 
 ' See an account of the first labor after the excision of tlieoervix uteri, with some interest- 
 ing remarks upon the operation, by Dr. Lewins, Jun., in the Edinburgh Medical and Surgical 
 Journal, Jan. 1841. The os uteri was very rigid, and dilated with difficulty. Her two 
 subsequent labors have been much easier. 
 
168 DISEASES OP THE UTERUS. 
 
 When I lately saw her, 10th August, 1846, still nursing this third 
 child, now nearly fifteen months old, she declared to me that she 
 never had enjoyed, in all respects, better health than at present.' 
 
 On examination, I found the os uteri presenting an indentation or 
 fossa resembling the fossa of the umbilicus, instead of the usual 
 nipple-like projection of the cervix. 
 
 Case n. — In the autumn of 1843, I was called to Kincardine, 
 Clackmannanshire, to see this case. It was under the care of Dr. 
 Wilson, now of Edinburgh, and who was then practising at Kin- 
 cardine. The patient, aged 40, had been eight years a widow. She 
 had been previously married eleven years, and born five living chil- 
 dren. After sufiering for some time under considerable leucorrhoea 
 and pain in the back, the symptoms increased much in intensity 
 about the beginning of August, 1843, six or seven weeks before I 
 first saw her. The discharge then assumed a more watery character, 
 and imparted an excoriating, burning feeling to the parts as it passed. 
 It was augmented very greatly in quantity, especially in the erect 
 posture, and was generally mixed with blood under the slight strain- 
 ing eflbrts required to empty the bladder and rectum. After this 
 watery " boiling discharge," as the patient herself termed it, had 
 lasted profusely for about a fortnight, severe hemorrhage came on. 
 It was kept under imperfect restraint by the supine posture, &c., for 
 the next few days, when, at the return of the normal catamenial 
 period, great flooding supervened, and in despite of the use of cold 
 astringents, the plug, and other active and appropriate measures, 
 much blood was lost. The patient, though naturally a very strong 
 and robust woman, was, in consequence, soon reduced to such an 
 extreme state of anaemic weakness and exhaustion, that she required 
 to be lifted with sheets when they ventured, from time to time, to 
 get her bed made dry, and she became sick and faint whenever her 
 head was attempted to be raised. I saw her at this time, with Dr. 
 Wilson and other practitioners of the neighborhood. On cautiously 
 removing the vaginal plug, I found the posterior lip of the os uteri 
 enlarged, indurated, and roughened, and the surface of it and of the 
 anterior lip the seat of ulceration of an apparently malignant kind. 
 The base, however, of the cervix appeared so far free from disease 
 as to allow the possibility of the excision of the parts above the line^ 
 of the morbid structure. Two days afterwards, viz., on the 13th of 
 September, I accordingly excised the whole cervix uteri. Dr. Wilson, 
 Dr. Girdwood of London, Dr. Adamson, and Mr. Crawford, were 
 present. 
 
 The excised mass measured about an inch and a half in diameter 
 
 ' This patient still survives, and has borne more children. — (Ed.) 
 
EXCISION OP THE CERVIX UTERI. 
 
 169 
 
 at its base, and the incision througli the cervix uteri passed, appa- 
 rently at all points, through a healthy structure. In other words, 
 the line of incision was above the seat of disease, and, consequently, 
 the whole diseased tissue seemed removed. The posterior lip of the 
 cervix was enlarged, in the form of a tumor, to the size of a pigeon's 
 egg, and roughish and tuberculated upon its surface, as- is seen in 
 the wood-cut. The base of the tumor found upon the posterior lip. 
 
 Figs. IC and 17. 
 
 and some parts of the unenlarged anterior lip, were the seat of ulce- 
 ration, marked by an acute sharp edge. The diseased structure of 
 the posterior lip slightly passed the angle or commissure of the left 
 side, and partially invaded the anterior lip. Dr. Anderson, Professor 
 of Medicine in the Andersonian University, Glasgow, and an ex- 
 cellent morphological anatomist, kindly examined for me a section 
 taken from the enlarged posterior lip. Its structure was found by 
 Dr. Anderson to present, in a well-marked degree, all the usual 
 microscopic and anatomical characters of Miller's carcinomata fasei- 
 culatum. 
 
 After the excision of the diseased structures, the lumbar pains 
 and local Avatery and hemorrhagic discharges entirely ceased. Pus 
 was secreted for some days from the surface of the wound. The 
 patient rallied so speedily in health and strength, that within a 
 fortnight she was able to be taken into the garden. For two months 
 subsequently she did not menstruate, but afterwards the catame- 
 nial discharge occurred regularly, accompanied with dysmenorrhoeal 
 symptoms. A year after the operation I visited my patient, when I 
 happened to be in the neighborhood, and found her in excellent 
 health, busily employed in active and fatiguing duties, and again 
 ruddy and florid in complexion. On examination, the os uteri felt 
 firm and puckered, like the cicatrix of a common stump, upon a 
 small scale. 
 
 Figs. 16 and 17. a a. Piece of whalebone passed through the cavity of the os and cervix ; 
 b b, tumor attacheil to the posterior lip ; c c, line of incision by which the cervix uteri was 
 removed. 
 
170 DISEASES OF THE UTERUS. 
 
 I had a letter from this patient a few montlis ago, in which she 
 
 I am happy to state to you that I enjoy the best of good health. 
 The monthly period is regular and right. I have no pain or un- 
 easiness in the stomach." 
 
 In a communication of a later date, 15th August, 1846, the same 
 favorable report is, in all respects, confirmed. 
 
 Case HI. — The subject of this case was a patient of Dr. Paterson 
 of Leith. I am principally indebted for the notes of it to Dr. 
 Jackson, who, along with Dr. Paterson, watched over the poor 
 woman with great care and kindness. 
 
 The patient, aged 36, had been twice married, and had borne two 
 children to her first husband. She had been married a second time 
 for six years without having any family. During her first marriage 
 she had contracted syphilis from her husband, and it was nearly two 
 years before she entirely recovered from it. 
 
 For a long time previously to her seeking medical advice, she had 
 labored under menorrhagia and leucorrhoea. Four months before I 
 fij'st saw her, there was a great increase of the leucorrhoea, and the 
 discharge assumed an offensive smell. After being under treatment 
 for some weeks for this aggravated leucorrhoea, menorrhagia super- 
 vened about the middle of June, 1844, recurring to a considerable 
 amount every three or four days. The discharge sometimes changed 
 from a red and clotted appearance to a dark-brown color, and more 
 fluid consistence. 
 
 I now quote Dr. Jackson's notes of the case : 
 
 " In the beginning of August, on examination per vaginam, I 
 discovered a tumor or excrescence, about the size of a large walnut, 
 attached to the anterior lip of the os uteri. It had a rough, warty, 
 softish feel, and bled on being touched. 
 
 " Soon after this the discharge increased, amounting to nearly 
 what we see in severe flooding after delivery. The plug was intro- 
 duced, and had the effect of arresting it. On the withdrawal of the 
 plug a few days afterwards, a discharge of clear watery fluid com- 
 menced, and continued for some days in large quantity. The patient 
 now began to lose color and strength ; by and by the pulse sank, and 
 long and protracted faintings took place. At this time, 13th August, 
 1844, Professor Simpson saw the case, and it was agreed to excise 
 the cervix uteri and attached tumor as soon as arrangements could 
 be made. This was accordingly done on the 16th. 
 
 " The patient bore the operation well ; simple laxative medicines 
 were given, the vagina frequently washed out with tepid water, and 
 an occasional anodyne exhibited. The only unfavorable symptoms 
 
EXCISION OF THE CERVIX UTERI. 171 
 
 that followed the operation were thirst and vomiting. For a time 
 these were very distressing, but soon disappeared ; and subsequently, 
 under the use of tonics, the patient regained her usual health and 
 strength, menstruating regularly, and during the intervals had only 
 a slight whitish discharge at times. 
 
 " In the commencement of April in the following year, 1845, 
 eight months after the operation, I again," Dr. Jackson continues, 
 " saw the patient, who informed me she still was well, and continued 
 as when last described. 
 
 " This happy state did not last long, for on the end of the same 
 month there was a sudden and violent discharge of blood from the 
 uterus, demanding the immediate use of the plug. This kind of 
 discharge took place occasionally during the next few months ; and 
 in the intervals there supervened a discharge of greenish and clear- 
 colored fluid, having an offensive smell. This discharge increased 
 and continued in very great quantity till the day of her death, 24th 
 October, 1845, fourteen months after the operation. 
 
 " The amount," Dr. Jackson adds, " of this clear-colored discharge 
 may be fancied, when I state that her linen and lower bed-clothes 
 used to be soaked three or four times a day. Many remedies were 
 tried in vain, and examination per vaginam discovered the cut sur- 
 face of the neck of the uterus amidst much softening of the neigh- 
 boring parts, all of which felt covered with a thick mucus. 
 
 "During the continuance of the discharge, and about three 
 months before her death, she had a severe attack of anasarca, with 
 a great loathing of food, and vomiting, and complained of dull and 
 obscure pain in the lower part of the abdomen. The oedema, how- 
 ever, yielded to treatment, but again returned a fortnight previous 
 to her death ; and she apparently sank ultimately under pure ex- 
 haustion from the excess of the discharge." 
 
 The excrescence which I removed in the preceding case was of 
 an oval form, and nearly the size of a small peach. It was slightly 
 irregular and lobulated on its inferior or free surface, and on more 
 narrow examination this surface presented a small granulated 
 appearance. The line of incision by which it was removed seemed 
 to pass through healthy tissue. On microscopic examination. Dr. 
 Anderson found the structure of the tumor to present all the cha- 
 racters of Muller's carcinoma reticulare. 
 
 On inspecting the body of the patient after death, Drs. Paterson 
 and Jackson could not detect any traces of disease in any part 
 except the pelvis. The body and fundus of the uterus were slightly 
 enlarged ; and in several places its peritoneal coat was strongly 
 united to the Fallopian tubes, and the neighboring serous surfaces, 
 by old false membranes. The site of the excised cervix uteri, the 
 
172 DISEASES OF THE UTEEUS. 
 
 upper portion of the vagina, and the cellular suhstance intervening 
 between these points, and the bladder and rectum, were the seat of 
 pultaceous softening and ulceration, but there was little or no thick- 
 ening or actual morbid deposit in these parts. Dr. Anderson ex- 
 amined microscopically the structure of the uterus at the seat of 
 excision and ulceration, but could discover no decided marks of 
 carcinoma reticulare, or other specific form of malignant structure in 
 the tissues of the part. From the softened condition of the affected 
 textures, it was found impossible to ascertain, at the time of the 
 autopsy, whether the degeneration and ulceration extended, or not, 
 through the recto-vaginal septum into the rectum itself. 
 
 METHOD OF OPERATING ; COMPLICATIONS AND CONSEQUENCES. 
 
 In performing the excision of the cervix uteri, in the three in- 
 stances I have detailed, and in the other cases in which I have ope- 
 rated, I have proceeded on the following plan : I have fixed one or two 
 vulsella into the outer or vaginal side of the diseased cervix, as high 
 as it was possible to insert them, and, by the purchase which they 
 afforded, have gradually and cautiously dragged this part down in 
 the lines respectively of the axis of the pelvic brim, cavity, and 
 outlet, till it appeared so far beyond the vulva as to allow me to cut 
 through the base of the protruding cervix. In one or two cases I 
 used a knife in making the incisions. But in consequence of the 
 powerful retraction under which the cervix uteri is placed during 
 the operation, it is difficult, or indeed impossible, to make the in- 
 cision in this way so equable and perfect as to remove with certainty 
 all the diseased part. After a partial cut or two the uterus is 
 strongly retracted at the points of incision, and the remainder of 
 the operation requires to be finished with the line of incision thus 
 rendered irregular and confused. A pair of large, curved, blunt- 
 pointed scissors, such as were used in this operation by Osiander 
 and Dupuytren, is in this respect preferable. We are enabled by 
 them to surround and embrace the whole cervix at once ; and hav- 
 ing cautiously and carefully adjusted their edges to the very points 
 which we wish to divide, and thus calculated, by this preliminary 
 step, the exact Hmits of the incision, we may then immediately 
 complete the amputation of the part, by one or two strong and 
 rapid strokes of the instrument. The blades must be placed around 
 the cervix, above the line of the teeth of the vulsellum ; and then 
 our object is, as it were, to cut out the vulsellum along with the 
 whole inferior and diseased parts of the cervix, in which it is fixed. 
 The operation is much facilitated by the labia being strongly pressed 
 aside by broad copper spatulse. 
 
DANGERS OF EXCISING CERVIX. 173 
 
 I have always placed my patients upon the face, the body being 
 situated across the bed^and the lower extremities hanging over it, 
 as in the operation for hemorrhoids. "We are thus enabled to make 
 our incision through the cervix uteri from behind forwards, instead 
 of from before backwards — a matter, in my opinion, of no small 
 moment. For if we cut in this latter direction, viz., from before 
 backwards, we would sometimes run a greater danger of opening 
 into the peritoneum, which stretches downwards so much more 
 behind than in front of the cervix uteri, and offers a very thin wall 
 of partition between the cavity of the vagina and the cavity of the 
 abdomen. Latterly, I have found the first portion of the operation, 
 namely, the seizure and traction of the cervix uteri, much facilitated 
 by using a very large and strong vulsellum, made with the common 
 loose joint of the obstetric forceps, instead of the usual fixed pivot 
 or scissors joint. "With the common scissors-jointed vulsellum, 
 whilst we are intent on fixing the teeth of one blade in a proper 
 situation, the teeth of the other blade are always apt to become 
 entangled in the tumor or walls of the vagina itself, and thus im- 
 pede and embarrass the operator. But with the modification of the 
 vulsellum that I have alluded to, this difficulty is avoided, for the 
 individual blades are introduced, adjusted, and fixed, separately and 
 successively; and then, afterwards, they are easily united together 
 for further use. Besides, in this way we far more readily effect 
 what are, I believe, the two principal secrets in the operation, viz. : 
 1st. "We fix both blades of the instrument, and more especially that 
 corresponding to the diseased lip, as high upon the cervix, and as 
 near its line of reflection upon the roof of the vagina, as possible ; 
 and 2dly, by making our line of incision immediately above the 
 hold of the vulsellum, as if our object were to cut out that instru- 
 ment and the part which it embraces, we secure this important 
 point, that the incision which we make is more likely, than if we 
 followed any other plan, to pass through a stratum of healthy 
 tissue, as we thus inevitably remove the whole vaginal portion of 
 the cervix uteri, and the diseased structure of which it is the seat. 
 In thus attempting to insert the vulsellum as high as possible in the 
 cervix, we will succeed far better by guiding it directly to the point 
 required by the finger and the sense of touch, than by attempting 
 to direct it by the speculum and the sense of sight. In fact, if the 
 cervix is, as generally happens, at all much increased in size, it is, 
 of necessity, utterly impossible to see, with any speculum, the part 
 in which the teeth of the vulsellum should be fixed — that part lying 
 much higher than the sphere of vision. 
 
 Several forms of danger have been found to attend upon excision 
 of the cervix uteri. A feai-ful variety of nervous depression is 
 
174 
 
 DISEASES OF THE UTERUS. 
 
 alleged by some authors to supervene occasionally upon the opera- 
 tion. I have seen no instance of it. Severe hemorrhage sometimes 
 occurs, but it is much rarer than we might d priori expect. In only 
 one case have I met with it in any considerable amount, and in 
 that instance it was readily and effectually restrained by the plug. 
 Out of nineteen private patients operated on by Lisfranc, Paley 
 avers that four died within twenty-four hours. Subsequently there 
 is farther danger to the patient from inflammation kindling in some 
 of the uterine structures, or in the peritoneum itself. Out of the 
 eight cases in which I have operated, seven recovered perfectly. 
 The remaining eighth patient recovered so far as to leave her bed- 
 room, but was then, from an unfortunate domestic quarrel, subjected 
 to great mental excitement, after which she relapsed, and died under 
 symptoms resembling those of phlebitis. In his Operative Medi- 
 cine, Velpeau, after stating that he had himself only operated in 
 two cases, in one of which death occurred in three days, and in the 
 other six weeks after the excision of the cervix, proceeds to re- 
 mark: "A patient operated upon by M. Blandin died of uterine 
 phlebitis ; one of those that Lisfranc lost was carried off by peri- 
 tonitis; others have sunk under a nervous state, the gravity of 
 which it is not easy to explain. Up to the present time," he con- 
 tinues, " scarcely any one has been seen to die directly of hemor- 
 rhage. Eust and Graefe of Berlin, Roux and Dupuytren, who 
 have all seen their patients perish from the immediate results of the 
 operation, do not ascribe the fatal result to this complication (hemor- 
 rhage). Excision of the neck of the uterus, although easy and by 
 no means severe, is nevertheless sometimes extremely dangerous 
 and speedily fatal. However, Osiander has practised it twenty-eight 
 times, Dupuytren fifteen to twenty times, Lisfranc forty to fifty 
 times, without its having caused death more than once out of every 
 six or seven operated upon."^ 
 
 CASES ADAPTED FOR THE OPERATION. 
 
 Since excision of the cervix uteri is an operation attended with 
 so many chances of danger, as Velpeau exposes in the passage 
 which I have quoted, it evidently follows that it should only be 
 adopted in cases, and under circumstances, in which milder and 
 safer means of cure are insufficient. The forms of disease in which, 
 upon this principle, it seems justifiable to avail ourselves of the aid 
 of this operation, supposing no contra-indication to be present, are, 
 in my opinion, principally — 
 
 ' Velpeau, Op. Med. vol. ii. p. 268. 
 
RESULTS OF EXCISION OF CERVIX. 175 
 
 1st. Great morbid hypertrophy, by elongation, of the vaginal 
 portion of the cervix uteri. I have operated successfully in two 
 such cases. 
 
 2d. Corroding ulcer, when limited to the lips of the cervix, and 
 pathologically identical with the form of lupus or malignant ulcer 
 so well known on the face ; and 
 
 3d. Circumscribed and local forma of carcinomatous disease or 
 excrescence, of the lips and lower segment of the cervix uteri. 
 
 Some continental surgeons, and more especially Lisfranc, advo- 
 cate the propriety and necessity of excision, in various other cases 
 besides those I have just enumerated. I have myself twice excised 
 the part when affected by chronic induration and thickening, with- 
 out carcinomatous degeneration ; but I would now, most assuredly, 
 by no means resort to it again under the same condition, as I be- 
 lieve that morbid state of the cervix to be quite removable by milder 
 measures. In the case that I have alluded to as having terminated 
 fatally, the structure of the excised cervix presented a great degree 
 of condensation and induration, with two small cystic tumors en- 
 closed in the morbid tissue. The symptoms attendant on this lesion 
 had been of very long standing, and had previously broken down 
 the health of the patient. 
 
 Certainly, however, the set of cases in which, of all others, the 
 operation is likely to prove an occasional and important addition to 
 our previous means of treatment, is that in which there exists local 
 carcinoma of the cervix uteri. 
 
 Every practitioner knows that, of all uterine diseases, cancer is 
 the one which the female mind most constantly and most justly 
 dreads. A patient scarcely ever suffers for a length of time under 
 any severe affection of the uterus, without her own anxieties and 
 fears magnifying it into an instance of cancer, and investing it with 
 all the horrors pertaining to this most fearful and loathsome malady. 
 And certainly it is a disease which does occur sufficiently often. 
 The female constitution seems much more disposed than the male, 
 to assume the carcinomatous diathesis ; and the absolute number of 
 deaths from cancer, as recorded in our own and other mortality bills, 
 is in the proportion of two or three females for every one male that 
 sinks under this specific form of morbid action.' Some pathologists 
 besides, as Tanchou, Stern, and others, believe that cancer of the 
 uterus is becoming much more frequent at the present time than it 
 was formerly. Be this the fact or not, there can be no doubt of 
 this other circumstance, that in consequence of the more advanced 
 
 ' As a statistical illustration of the truth of this remarlc, I may adduce the proportion of 
 fatal oases of cancer in the two sexes, reported by the Registrar-General as having occurred 
 
176 
 
 DISEASES OF THE UTEEUS. 
 
 knowledge of the diagnosis and pathology of uterine diseases, the 
 practitioner has now ample means of separating and distinguishing 
 at once from carcinoma, various forms of uterine affection that were 
 not long ago, g-enerally looked upon as doubtful or decided instances 
 of uterine cancer, and consequently regarded with all the utter 
 hopelessness of despair. 
 
 Fibrous tumors of the uterus, for instance, one very common 
 form of structural disease in this organ, were formerly very fre- 
 quently confounded with cancer, but it is now well known that 
 they have a different anatomical seat, a different pathological course, 
 and a very different morbid termination. 
 
 I have known a patient supposed to be laboring under irremedia- 
 ble cancer of the uterus, when the disease was only a severe but re- 
 mediable form of polypus. The accompanying symptoms are often 
 very much alike in the two diseases even to the character of the 
 discharges. " The fcetor of the discharges in polypus," observes Sir 
 C. Clarke, " induces in the mind of the patient, and sometimes of 
 the practitioner, a belief that the disease is cancer, and this is con- 
 firmed by the sickness which generally attends the disease." San- 
 son and Roche tell us that they have repeatedly, to quote their own 
 words, " seen Dupuytren perform the removal of polypi which vari- 
 ous of the most able surgeons of the French capital had mistaken 
 for uterine cancer, and thus render back to life patients condemned 
 to a most certain death by those mistakes of which they had been 
 the subject." 
 
 Various other forms of uterine disease are liable to be mistaken 
 for cancer of this organ. In one of the first cases in which I recog- 
 nized by the uterine bougie the existence of retroflexion of the un- 
 impregnated uterus, the patient had some years previously been 
 doomed by the highest obstetric and pathological authorities in Eng- 
 land, as suffering under the first stage of scirrhus uteri — the dis- 
 placed fundus of the retroverted organ having been mistaken for a 
 
 in England, excluding the metropolis, daring the first five full years in which the Registra- 
 tion Act has been in operation. 
 
 MortaMtyfram Cawxr in England as Regulated by Sex. 
 
 Year of Report. 
 
 Total fatal Cases 
 of Cancer. 
 
 In the Female Sex. 
 
 In the Male Sei. 
 
 1838, 
 1839, 
 1840, 
 1S41, 
 1842, 
 
 2.S04 
 2649 
 2238 
 2 16 
 23.16 
 
 1717 
 1924 
 1666 
 1692 
 1757 
 
 687 
 625 
 682 
 623 
 
 Toial, 
 
 11662 
 
 8746 
 
 2916 
 
DISEASES CONFOUNDED WITH CARCINOMA. 177 
 
 carcinomatous tumor. The uterine displacement was easily rectified 
 by tie use of a wire pessary worn for some months in the uterine 
 cavity, and the patient is now in the enjoyment of the best of health. 
 I have seen other cases of the same mistake, with this same curious 
 but common form of uterine displacement. 
 
 Two varieties of an inflammatory, and hence of a curable form of 
 disease, are certainly not unfrequently confounded with cancer uteri. 
 I have now seen four cases in which patients had been condemned, 
 as afflicted with cancer uteri, and who each had indurated, irregular 
 tumors of the pelvis, formed by effusion of coagulable lymph, or 
 pus, or both, into the cellular tissue situated around the cervix uteri, 
 and forming hard, firm swellings in that locality, in consequence of 
 the inflammatory deposit of which they consisted lying above the 
 dense pelvic fascia of this part. All of these cases have perfectly 
 recovered, and two of the patients have borne children since the 
 attack. The second form of inflammatory disease, which is liable 
 to be mistaken for cancer, consists of inflammatory induration, and 
 often ulceration, of the proper tissues of the cervix uteri. I have 
 now had occasion to see no small number of instances, in which this 
 chronic inflammatory affection of the cervix uteri has been con- 
 founded with cancer of the part, and where the non-carcinomatous 
 character of the disease has ultimately been established by the ulcera- 
 tion and induration totally disappearing under appropriate local 
 treatment.^ 
 
 In any case, then, of suspected cancer uteri, and where, as often 
 happens, the local and constitutional symptoms are such as are 
 usually described as accompanying that affection, as local pains, 
 sanguineous and morbid discharges, general cachexia, &c., we may 
 always hope that a careful physical diagnosis will disclose the local 
 disease to be one or other of those more safe and more curable forms 
 of morbid action that I have above adverted to. And let me here 
 add, at the same time, that as a general rule, I believe it utterly im- 
 possible to make, with any certainty, such a diagnosis by the mere 
 
 ' Dr. Valentine Mott, the distinguished American surgeon, in the account which he pub- 
 lished at New York, in 1842, of his "Travels in Europe and the East," inadvertently states 
 a fact which to every one conversant with uterine pathology, must abundantly prove, that 
 in most cases in which Lisfranc of Paris performed excision of the cervix uteri, the opera- 
 tion was undertaken for simple inflammatory induration and ulceration of the amputated 
 part. For after mentioning Lisfranc in very laudatory terras, Dr. Mott observes, " I am 
 delighted to have it in my power to say, that in one of my visits, by express invitation, to 
 examine a great many cases of a peculiar and distressing malady of the female sex, for which 
 he had performed in previous years more than sixty operations — exsection of the neck of 
 the uterus — he now stated to me that he readily effected a cure by a much more simple and 
 less painful process ; a ^fact highly honorable, I consider, to his humanity, and denoting 
 clearly the advancing march of surgical science. His remedy" Dr. Mott simply adds, " is 
 merely the application of hmar caustic to the part affected." — Travels, &e., p. 38. 
 
 VOL. I. 12 
 
178 DISEASES OF THE UTERUS. 
 
 rational or external symptoms only, such as tlie nature of the dis- 
 charges, the degree and character of the attendant pains, &c. ; for in 
 practice we constantly meet with uterine cases having all these 
 symptoms well developed, without the local disease being carcino- 
 matous ; and, on the other hand, we occasionally meet with cancer 
 of the uterus without these symptoms being present in any very 
 marked or appreciable degree. In this, as in most other uterine 
 affections, "the true character of the disease can only," as was 
 many years ago most justly observed by Sir Charles Clarke, " be 
 ascertained by an examination." 
 
 But the question again recurs to us, supposing that we do dis- 
 cover, by a proper physical diagnosis, that true carcinoma of the 
 uterus is present, is the case consequently to be looked upon as 
 always utterly hopeless ? 
 
 I believe that in forty-nine instances out of every fifty in which 
 we find the uterus or any part of it the seat of true carcinomatous 
 deposit, the disease inevitably leacTs, sooner or later, to a fatal ter- 
 mination. The rapidity of its march is various, and may deceive an 
 incautious observer by its duration. I have known death occur a 
 few weeks after the disease first attracted the special attention of the 
 patient ; and I have had occasion to watch the course of a case, 
 where the patient dragged on a miserable existence for seven years 
 after the first discovery of the malady by the late Dr. Hamilton. 
 But whilst thus fatal in almost every instance, there are still, as we 
 have already seen, some rare varieties or forms of carcinoma uteri, 
 that are apparently within the j ust range of surgical treatment. And 
 one condition favoring this is the generally admitted fact, that the 
 disease almost always begins in, and for a time is limited to, the 
 structure of the lips and cervix of the uterus. Professor Eokitansky 
 of Vienna, perhaps the most profound and experienced morbid ana- 
 tomist of the present day, in speaking of the first locality and origin 
 of cancer of the uterus, observes — " Carcinomatous induration gene- 
 rally limits itself to the vaginal portion and cervix, and very often 
 in a refined and sharp manner {mit einer sehr bezeiehnenden Weise 
 und schdrfe)." In another paragraph he remarks—^" The primitive 
 seat of cancer is always the cervix uteri, and first of aU and particu- 
 larly the- vaginal portion. The primary appearance of cancer in 
 the fundus uteri is limited to so extremely rare cases, that what we 
 have just said remains one of the most fixed rules (erne der ausge- 
 maehtesten Begeln.") " It forms," he adds, " in this respect a contrast 
 with fibrous and tuberculous tumors of the uterus, a contrast which 
 also holds with regard to its involving the parts around, and its 
 ulcerative destruction."' 
 
 ' Handbuch der Pathologischen Anatomie, vol. iii. pp. 551, 552. 
 
PROPER TREATMENT FOE CARCINOMA OP THE CERVIX. 179 
 
 In relation to tlie same question, we must bear in recollection 
 another circumstance in tlie natural history of carcinoma uteri, 
 granted by most of the best pathologists who have written upon 
 this disease. " Uterine cancer," observes Professor "Walshe, one of 
 the latest and most learned writers on the subject, " is commonly 
 primary, and possessed of comparatively slight tendency to con- 
 taminate the system generally." And again — " There can be no 
 question that the womb ranks among those organs less prone than 
 certain others, as, for instance, the mammse and testes, to contami- 
 nate distant viscera. Among thirty-seven females, cut oif by uterine 
 cancer, and examined by M. Ferrus, seven only exhibited secondary 
 formations elsewhere."^ 
 
 In these two important respects, therefore, uterine carcinoma 
 presents conditions favorable for surgical interference. Still, how- 
 ever, in order that a case may offer any chance of operative success, 
 several conditions seem requisite : 
 
 1st. The disease must be in an early stage. 
 
 /2d. The morbid structure must be strictly limited to the lip or 
 lips of the cervix, or at all events be distinctly situated below the 
 line of reflection of the vagina upon the cervix uteri. 
 
 In actual practice, however, it rarely indeed happens that the 
 above combination of circumstances is met with, because, in truth, 
 the medical attendant is very seldom called in till the disease is so 
 far advanced as to have passed the limits in question. In fact cancer 
 uteri generally proceeds throughout the first stage of deposition and 
 induration with such slow and stealthy steps, that the attention of 
 the patient is not awakened to its presence by any particular local 
 symptoms ; and it is commonly not till the malady is advancing or 
 has advanced towards its higher states of morbid development and 
 disintegration, that a sudden and unaccountable loss of blood, or 
 the unexpected appearance of some purulent or sanious discharge, 
 or the supervention of uterine pain, first rouses the lurking suspicions 
 of the sufferer to the nature of the fearful fate that is impending 
 over her. 
 
 3d. Future inquiry will in all probability prove that there are some 
 varieties, types, or species of carcinoma of the cervix uteri which are 
 much more within the pale of surgical treatment than others. I 
 believe this last to be a most important subject of inquiry ; but it 
 is confessedly a department of uterine pathology to which, valuable 
 as its results may be, no laborer has as yet directed his attention. 
 
 The three different cases which I have detailed present three dif- 
 ferent species or forms of carcinoma of this part. Though the ma- 
 terials which these three cases ftimish afford a very meagre and 
 
 ' On the Nature and Treatment of Cancer. — London, 1846, p. 443. 
 
180 ' DISEASES OF THE UTERUS. 
 
 imperfect nucleus for such an inquiry as I suggest, still they are 
 neither without interest nor importance ; and in this point of view 
 I will here venture, in conclusion, to recapitulate the principal patho- 
 logical and practical data which they seem to supply. 
 
 In the first case which I have described, the excised morbid mass 
 had all the usual characters of cauliflower excrescence, a disease 
 which, in its ultimate course, always takes on malignant action, 
 whatever difference of opinion may exist as to its pathological nature 
 in the incipient stages. The tumor removed from the second patient 
 was an example, as I have already stated, of Muller's carcinoma fasci- 
 culatum ; and that from the third Was an equally characteristic speci- 
 men of the carcinoma reticulare of the same author. 
 
 Every pathologist will, I believe, readily grant that these are forms 
 of malignant structure regarding the truly carcinomatous nature of 
 which there can be no rational doubt. All the three patients were 
 extremely sunk and prostrated by the attendant discharges, before 
 I had recourse to the excision of the cervix uteri and the morbid 
 excrescences attached to it. All the three were so far benefited by 
 the operation as to recover their usual health and strength, and be 
 again able for the duties of life. But in the last case the disease 
 recurred after eight months of comparative health, and after four- 
 teen months, it terminated fatally. The other two patients still 
 remain in the enjoyment of perfect health, although in one instance 
 upwards of six, and in the other about three years have elapsed 
 since the period of the operation. And, as I have already stated, 
 the first of the patients has now conceived, borne, and nursed three 
 children since the date of the excision of the diseased parts — a suffi- 
 cient proof both of the completeness of her own recovery, and of 
 the safety of the operation, so far as regards the primary and most 
 important of the physiological actions of the organ operated upon. 
 
 It will be evident that excision of the cervix uteri may be resorted to, vcith the greatest 
 hope of ultimate success in those cases where the morbid hypertrophy or elongation ap- 
 proaches least towards a malignant type. We are acquainted with at least three instances 
 where the operation was, during the last two or three years, successfully performed by Dr. 
 Simpson, on account of such non-malignant hypertrophy. In the Royal Infirmary, just now, 
 is a strong healthy-looking woman, on whom Dr. Simpson excised the cervix uteri some 
 two years ago. The mass amputated, consisted of the elongated and hypertrophied cervix, 
 covered with warty-looking excrescences to such an extent as to protrude like a large tumor, 
 the size of the closed fist, through the vulva. The patient has returned lately to Edinburgh, 
 and is now under treatment for retention of the menstrual secretion, from occlusion of the 
 OS uteri, consequent on adhesion of the opposed lips after amputation. Dr. Simpson has 
 made an incision into the cavity of the uterus through the cicatrized cervix, and allowed a 
 quantity of thick retained menstrual fluid to escape. — (Ed.) 
 
LATENCY OF SYMPTOMS IN CARCINOMA. 181 
 
 OCCASIONAL LATENCY OF THE SYMPTOMS IN ADVANCED 
 CARCINOMA UTERI. 
 
 (From Edinburgh Monthly Journal of Medical Science, January, 1852, p. 39.) 
 
 In the earlier stages of cancer of the uterus, the disease is, as a 
 general rule, accompanied by few, or indeed no, well-marked dynamic 
 symptoms. Patients themselves, and sometimes also the members 
 of the profession, seem to expect that the advent and presence of 
 this fatal malady should be very constantly accompanied with local 
 pain and suffering. The reverse, however, of aU this seems to be 
 the general rule. In fact, it rarely happens that a patient affected 
 with uterine cancer applies at all for medical advice till the disease 
 has advanced beyond the stage of deposit, and has already made 
 more or less progress in the stage of ulceration. Even then the 
 local symptoms which excite the patient's attention are usually not 
 the expected pathognomonic pain, but occasional attacks of hemor- 
 rhage, attended with leucorrhceal discharge. Or, if the pain is 
 present, it often as yet only amounts to a sensation of discomfort 
 and uneasiness, and not to a feeling of actual suffering. N'ay, some- 
 times any feeling of pain in the ut«rus or uterine region itself never 
 supervenes at all, or not till the veiy last period of the affection. In 
 the course of practice, I have happened to see a number of cases to 
 which this remark applies. Instances also occasionally occur where 
 the patient suffers more or less severely from pain ; but that symptom 
 is in the form of a sympathetic or reflex pain, situated not in the 
 uterus, but in the limbs, loins, or some other distant part. Several 
 years ago, I had occasion to examine a ease in which the cervix uteri 
 was entirely eaten away by extensive cancerous ulceration ; but with- 
 out any marked local pain. The patient, however, had complained so 
 much of pain in the mamma, that local anodyne and other applica- 
 tions had been applied to that part of the body. Dr. Davidson told 
 me the particulars of a case, in which the patient complained to her 
 medical attendant of nothing during life, except a series of severe 
 urinary symptoms, for which she had ineffectually undergone a 
 variety of treatment. On opening her body after death, the coats 
 of the bladder were found deeply implicated in a mass of ulcerated 
 uterine carcinoma. The following case, which I saw within the last 
 few weeks with Dr. Cowan, in a patient who came from a distance 
 in the countiy, is one of the most striking illustrations which I have 
 met with of the occasional latency of the local symptoms of cancer 
 
182 DISEASES OP THE UTEEUS. 
 
 of the uterus, even in a very advanced and ulcerated stage, and of 
 the transference, as it were, of tlie principal suffering and symptoms 
 to another organ : 
 
 Case.— A lady, set. 43, married at a very early age, and the 
 mother of six children, had enjoyed the most rohust health until 
 twelve months ago. About that period, she first observed a white 
 discharge from the vagina, which she believed to be common 
 leucorrhoea. There likewise occurred repeated discharges of blood ; 
 sometimes in large coagulated masses and shreds. At the same 
 time, the catamenia recurred with regularity, and without pain. 
 About three months since, she first complained of such prostration 
 as prevented her taking her usual amount of exercise. Difficulty 
 and pain also in passing water, and latterly incontinence of urine 
 supervened. During all this period, she experienced no feeling of 
 uneasiness referable to the uterus itself; nor were the leucorrhoea 
 or monorrhagia of a nature or extent calculated to excite in the 
 mind of the patient any feelings of alarm. In fact, the principal, 
 and, according to her own account, her almost sole symptoms were 
 the debility already mentioned, and the painful dysuria, which had, 
 however, been relieved by alkalies.- 
 
 On making a vaginal examination, I found the cervix uteri, with 
 the upper and anterior part of the vagina, the seat of extensive 
 carcinomatous induration and ulceration. The disease in its ulce- 
 rative process had in fact proceeded so far at one point that it had 
 implicated and already perforated the neck of the bladder — ^thus 
 leading first to the dysuria, and subsequently to the incontinence of 
 urine, of which the patient so much complained. , -i- . 
 
 In a note from Dr. Cowan, dat6d December 20th, he states':-^— 
 " At present our patient's appetite is good ; bowels regular. She 
 sleeps well, and the general appearance is improved, rather than 
 otherwise, since you saw her. All she complains of is, general 
 debility, incontinence of urine, with a thin white non-acrid dis- 
 charge, and occasionally, but not constantly, heat in the region of 
 the uterus, unaccompanied with pain. All other symptoms of 
 extensive uterine disease are absent." 
 
 Dr. Cowan has further stated to me, in a recent communication : 
 — " Mrs. C. died ten months after you and I visited her together in 
 Edinburgh. She gradually sank under the extension of the can- 
 cerous disease. Some time after you and I saw her, the symptoms 
 were still so slight and trivial, that another medical man whom she 
 saw declared that it was impossible she could have such a serious 
 malady as cancer. She died in Paris, and the French physicians 
 
CAKCINOMA OP THE FUNDUS. 183 
 
 whom she consulted, for a time doubted the correctness of your 
 diagnosis and prognosis, her symptoms looking still so slight. But 
 the subsequent course of the affection showed them the true can- 
 cerous nature of her disease." 
 
 ON CAECINOMATOUS DISEASE OF THE CAVITY, BODY, 
 AND FUNDUS OF THE UTERUS, 
 
 THE CERVIX BBINa UNAFFECTED. 
 
 Most pathologists and practitioners have laid it down that the 
 cervix uteri is always, or almost always, the portion of the uterus 
 that is first and principally affected in cases of cancer. 
 
 In a preceding page, we have seen Rokitansky stating that 
 cancer of the uterus "always attacks the cervix in the first in- 
 stance."^ " Cancer of the uterus," observes Dr. "Walshe,^ "almost 
 invariably originates in the cervix." In describing carcinoma uteri 
 in his work on the Diseases of Females, Sir Charles Clarke 
 remarks, " This disease attacks only in the first instance the cervix 
 of the uterus, and the author," he adds, " lays great stress on this 
 observation."^ " The cancerous action," according to Dr. Francis 
 Ramsbotham, " first assails the tissues of the os and cervix uteri. 
 I believe," he continues, "this is invariably the case."'' 
 
 Such strong statements are liable to mislead the practitioner, 
 and to cause ever and anon, errors in diagnosis and prognosis, l^o 
 doubt, the cervix of the uterus is much more frequently the seat of 
 carcinomatous disease than the cavity of the organ, or the tissues 
 of the body. and fundus. But I have been myself deceived, and 
 have seen others deceived by the common belief that cancerous 
 affections never originate in the cavity, body, or fiindus of the 
 uterus, and without the cervix being primarily or cotemporaneously 
 attacked. In the course of practice, I have seen, on the contrary, 
 a very considerable number of instances in which carcinomatous 
 disease, when affecting the uterus, has primarily sprung up in the 
 cavity of the organ, or in the walls of the ftmdus or body, and in 
 which the tissues of the cervix have remained sound to the last, or 
 at most been only affected secondarily. 
 
 ' Manual of Pathological Anatomy, vol. il. p. 300; or ante, p. 178. 
 ^ The Nature and Treatment of Cancer, p. 96. 
 ' Observations on the Diseases of Females, p. 207. 
 ^ London Medical Gazette for 1835, p. 466. 
 
184 
 
 DISEASES OF THE UTERUS. 
 
 Carcinoma, when it attacks the cavity, body, or fundus of the 
 uterus, may appear under different types or forms. The principal 
 varieties of it which I have had occasion to observe in practice are 
 the following': 
 
 1. When carcinomatous disease attacks the cavity of the uterus, 
 it sometimes presents the form of an irregular, flat, or roundish 
 fungoid excrescence, attached by a broad basis to a greater or less 
 extent of the interior of the organ. 
 
 Case I. — The first decided instance of this Mnd which I had an 
 opportunity of seeing was in an unmarried lady, forty years of age, 
 the sister of a distinguished English physician. For many months 
 she had suffered under a constant and copious discharge of watery 
 fluid fi:om the genital canals, with occasional slight hemorrhage, 
 and gradual emaciation; but there was no local pelvic pain or 
 suffering. She was for some time under the care of an esteemed 
 obstetric practitioner 'here — a friend of her brother's — and a great 
 variety of applications were employed by him to arrest the profuse 
 serous discharge. These applications had been all made to the 
 surfaces of the vagina and cervix uteri : but without any effect on 
 the copious morbid secretion. When I saw the patient with her 
 physician and relative — as there was apparently no diseased state 
 of the vaginal canal or cervix uteri, I suggested the introduction of 
 a sponge-tent into the os uteri, with a view of shutting up that 
 aperture for a time, and thus ascertaining if the abundant watery 
 secretion did not proceed from the cavity of the uterus itself. As 
 long as the tent remained in the os uteri the discharge was arrested 
 — a phenomenon not observed for many months before ; and on 
 withdrawing it there wafi a copious rush of the characteristic clear 
 fluid. The morbid source of it was thus proved to be some point 
 or points in the interior of the uterine cavity. On opening up the 
 OS and cavity of the cervix more fully with sponge-tents, we were 
 able to reach the edge of a rough tuberose excrescence, attached 
 by a broad basis to the interior of apparently a great part of the 
 cavity of the uterus. Small granular portions of it were easily 
 detached by the finger or nail. It seemed to all of us a sessile 
 carcinomatous or cauliflower growth growing in the cavity of the 
 uterus. The discharge continued and increased ; and the patient 
 ultimately sank under the usual course of cancer about eighteen 
 months subsequently. 
 
 Case n. — A short time afterwards I was sent for to the Highlands 
 to see, a week or two before hex death, a patient who had long 
 
CAECINOMA OF THE FUNDUS. 185 
 
 suffered under the eame kind of profuse wateiy discharge ; but in 
 her the local disease was much farther advanced. The os uteri was 
 dilated to the size of a two-shilling piece ; the orifice was round, 
 and its lips thin and healthy — exactly like the uterine orifice in the 
 first stage of natural lahor. There projected, however, through 
 this opening, not any part of an ovum or fcetus, but a rough irre- 
 gular mass, granular on its surface, and very friable and lacerable in 
 its structure. It bled profusely when touched. On passing the 
 finger over the edge of the dilated os, and within its interior, the 
 fdngating structure protruding firom the uterine opening was found 
 springing, as it were, from the interior of the cervix uteri aU around 
 at a height varying from a few lines to about an inch. In the 
 centre of the protruding excrescence there was an opening leading 
 up, as shown by the uterine sound, into the cavity of the uterus. ' 
 The uterus itself was enlarged, and could be felt midway between 
 the pubes and umbilicus. Its whole interior seemed to be filled by 
 an accumulation of this epithelial cancer. This patient was about 
 33 years of age. She had been long married without having any 
 children. 
 
 Since the above period I have seen several cases of the same 
 nature as the above at different stages of their progress. Occa- 
 sionally, as in the last case I have described, the os uteri was so 
 open as to allow the carcinomatous structure springing up from the 
 interior of the cavity, to be felt at once by the finger. In one or 
 two instances, I have seen the carcinomatous fungus protruding 
 through the os, sloughing and gangrenous from the stricture and 
 compression of the circle of the os upon it. But in most instances 
 the disease has been in an earlier stage ; the patient complaining of 
 watery and bloody discharge from the cavity of the uterus ; and the 
 true nature of the malady was not ascertained till the canal of the 
 cervix was artificially dilated for the purpose of a more accurate 
 diagnosis by the finger. 
 
 In some of these instances of carcinoma a^ecting the interior of 
 the uterus, the whole bulk of the organ is little, if at all, increased 
 beyond its natural dimensions, and the discharge is bloody rather 
 than serous ; but towards the termination of the disease, it begins 
 to present the odor peculiar to cancer, with shreds and fragments of 
 the cancerous tissue passing along with it. 
 
 Case m. — ^In a patient, aged 50, 1 saw the disease of the uterus 
 followed by cancerous disease of the mamma. A few years after 
 the regular catamenia had ceased, this lady observed from time to 
 time a slight bloody or sero-sanguineous discharge from the vagina. 
 On examination, the cervix uteri felt normal and healthy, and the 
 
186 DISEASES OF THE UTERUS. 
 
 whole uterus was of the natural size. After suflfering in this way 
 for a couple of years, carcinomatous disease appeared in the right 
 mamma, and she died in the course of a twelvemonth, without, 
 however, the affected mamma ulcerating or fungating, A few 
 weeks hefore her death, portions of cancerous excrescence protruded 
 from the os uteri; but up to the last the cervix uteri remained 
 unaffected. 
 
 2. Occasionally, cancer affects the cavity of the body and fundus 
 of the uterus, in the form of carcinomatous ulceration, and without 
 any appearance of excrescence and fungation. 
 
 I have seen this form of uterine cancer destroy life without any 
 other complication. But more frequently, I have seen it result 
 apparently as the effect of the long-continued irritation of a pedicu- 
 lated fibroid polypus upon the interior of the uterus. 
 
 Case IV. — In a case of long-standing menorrhagia, after dilating 
 the uterine canals with sponge-tents, I removed, in the presence of 
 Dr. Arneth of Vienna, a small hard intra-uterine polypus, attached 
 by a short pedicle to the fundus uteri. ^ The menorrhagia, however, 
 shortly afterwards returned, and the patient died with the usual 
 symptoms of uterine cancer about eight months afterwards, the 
 cervix remaining, however, still unaffected. 
 
 Case V. — Three years ago, I saw repeatedly, during the last 
 twelvemonth of her life, a patient of Dr. Brotherston of AUoa, who 
 complained of bloody and fetid discharges from the vagina, with the 
 OS and cervix uteri, however, apparently quite healthy. She was 
 above sixty years of age, had borne a large family, and menstrua- 
 tion had ceased thirteen years before the morbid discharge appeared. 
 The discharge was from the first offensive in smell, and of a green- 
 ish color. There was a feeling of weight and uneasiness which 
 never amounted to pain. At last, a fibroid polypus, which was in 
 the interior of the ut^us, sloughed and separated, and was removed 
 artificially in a succession of pieces. For some time the patient's 
 health seemed to be comparatively restored, and the discharges 
 diminished ; but again they became greater in quantity, very offen- 
 sive, and occasionally mixed with blood. After one severe attack 
 of hemorrhage ten days before death, all discharge whatever ceased, 
 as if the canal into the cavity of the uterus had become occluded. 
 Shortly afterwards, great collapse supervened ; the ulcerated uterine 
 
 ' Dr. Arnetli has recorded the case in his Geburtshttlfe und Gynsekologie in Frankreioh, 
 Grossbritannien, und Irland. 
 
CARCINOMA OF THE FUNDUS. 187 
 
 walls having become lacerated or perforated by the retained and 
 distending secretion. On dissection, the cervix of the uterus, from 
 the OS externum to the os internum,, presented a perfectly healthy 
 appearance. The body of the organ was distended into a large 
 cavity, about five inches long, containing a semi-putrid fluid, and 
 with its surface in several parts excavated by cancerous ulcerations, 
 one of which had completely perforated or broken through the back 
 wall of the uterus. The os internum uteri seemed to form a com- 
 plete hne of demarcation between the diseased and healthy parts. 
 There was an abundance of pus and lymph in the peritoneal cavity. 
 
 Case VI. — Last year I showed to the Medico-Chirurgical Society,^ 
 the drawing and preparation of a case of cancerous ulceration and 
 perforation of the fundus uteri, where there still existed, attached 
 by a short pedicle to the interior of the uterus, the remains of a 
 fibroid polypus. The cervix uteri was unaflected with the can- 
 cerous disease. The patient had long suffered from menorrhagia 
 and fetid discharges from the genital passages. But as in most 
 other cases of carcinoma of the cavity of the uterus, she com- 
 plained of little or no local pain during the course of the malady. 
 
 Let me observe in passing, that I have seen two or three well- 
 marked instances of carcinoma of the cervix uteri follow appa- 
 rently the irritation of a polypus when allowed to remain long with- 
 out removal, even after the body of it had passed from the cavity 
 of the uterus to the cavity of the vagina. 
 
 3. The soft or encephaloid variety of cancer sometimes affects 
 the structures of the fundus and body of the uterus, without im- 
 plicating the tissues of the cervix. In this variety of the disease 
 the cancerous structure is seated in the walls of the fiindus and 
 body, and not in the cavity of the uterus. Sometimes the tumor 
 reaches rapidly the size of a uterus at the fourth or fifth month of 
 pregnancy. In this form there is not usually any menorrhagia or 
 any peculiar discharge from the vagina. In the following instance, 
 while the patient was under my care, hemorrhage accompanied it, 
 but the hemorrhage was from the urinary, and not from the genital 
 canals. 
 
 Case VII. — An unmarried lady, 40 years of age, suffered for 
 some time from pains in the back and lower extremities, particularly 
 after exertion. When at last an examination was instituted by her 
 physician, in Dublin, in 1851, a large tumor was found in the uterine 
 region. Early in 1854 the tumor increased much and rapidly in 
 
 ' See Edinburgh Monthly Journal of Medical Science, March, 1854, p. 285. 
 
188 DISEASES OF THE UTERUS. 
 
 size, and when I saw her soon after, it already reached half-way 
 between the pubis and umbilicus. But still th«re was no appear- 
 ance of general cachexia observable. After a few weeks the morbid 
 structure again suddenly assumed a rapid growth ; a dark, sanious, 
 and bloody discharge was passed from the bladder ; and the patient 
 sank exhausted in the course of a few days. 
 
 On laying open the abdominal cavity, the omentum was found 
 adherent to a morbid mass, reaching from the pelvis to a point 
 higher than the umbilicus. This mass or tumor was covered by 
 large tortuous vessels ; had a soft general consistence ; and near the 
 summit it was broken down and pulpy, and had evidently all but 
 burst into the cavity of the peritoneum. The whole ftmdus and 
 anterior wall of the uterus was implicated in the structure ; but the 
 cervix and tissues immediately surrounding it were free from mor- 
 bid deposit, except in the form of two or three minute nodules. 
 The bladder, however, was perforated posteriorly, and a portion of 
 dark fangus from the uterine tumor projected into its cavity. The 
 tumor, which was carefully examined, had all the characteristics of 
 the Encephaloid or Hasmateid variety of cancer. The cavity of the 
 uterus presented no appearance of the disease, while the structure 
 of the anterior wall and fundus of the organ were lost and merged 
 in the encephaloid mass itself. 
 
 ON RETROVERSION OF THE UNIMPREGNATED UTERUS. 
 
 (From Dublin Quarterly Journal of Medical Science, May, 1848, p. 371.) 
 PRELIMINARY REMARKS AND DEFINITION. 
 
 Diseases are sometimes regarded as rare, merely in consequence 
 of a deficiency on our part of a proper and easy means of detecting 
 them during life, or from our overlooking their existence in the 
 dead body. JS^ot many years ago, for instance, emphysema of the 
 lung and granular degeneration of the kidney were supposed to be 
 afiections that were very seldom met with in practice. After, how- 
 ever, Laennec and Bright pointed out simple and ready modes of 
 diagnosticating these diseases, they were speedily found to be morbid 
 affections that were extremely common, instead of extremely rare, in 
 their occurrence ; and every physician at the present day is now 
 ready to acknowledge their great frequency. 
 
 With some of the displacements of the unimpregnated uterus 
 practitioners have long been familiar. In particular, the displace- 
 
RETROVERSION. 
 
 189 
 
 ments of the organ downwards, in tlie form of prolapsus and proci- 
 dentia, are recognized and acknowledged by aU, and elaborately 
 described in every work on female diseases. But displacements of 
 the unimpregnated uterus, in the form of versions or flexions, either 
 of the whole or of the upper part of the uterus, posteriorly, ante- 
 riorly, or laterally, have hitherto been looked upon as rare ; and this, 
 far more however from our past want of power of diagnosticating 
 them, than from their own infrequency. 
 
 In the present communication, it is my object to describe briefly 
 some new and simple means that I have practised for the last four 
 or five years for detecting and treating these displacements. 
 
 Let me premise that, in the normal and healthy state, the long 
 axis of the uterus is situated in a line parallel with the line of the 
 axis of the brim of the pelvis, or in the relative direction represented 
 in the accompanying diagram (Fig. 18, h). But the fundus of the 
 uterus, instead of looking upwards, may be turned downwards and 
 
 Fig. 18. 
 
 forwards, or downwards and backwards. In e it is represented as 
 directed downwards and forwards, constituting anteversion. In a, 
 d, e, it is directed downwards and backwards, constituting retrover- 
 sion. These three figures of retroversion represent different forms 
 or degrees of this displacement. The diagram a, represents an 
 aggravated degree of retroversion, taken from a drawing of a case 
 of this displacement by Frank. The mode in which the rectum is 
 
 Fig. 18. These diagrams are intended to represent vertical or antero-posterior sections of 
 the uterus, and upper part of the vagina. In b the uterus is supposed to be placed in its 
 normal position, and the other four figures represent difierent deviations of the organ from 
 this position. 
 
190 
 
 DISEASES OF THE UTEEUS. 
 
 impressed by the retroverted uterus is here shown. He found this 
 instance of displacement in the body of a patient who had died of 
 chest disease, but he does not give her previous history.^ 
 
 Some authors have attempted to draw a specific line of distinction 
 between the forms of posterior displacement of the uterus portrayed 
 in d and e, and have described the form given in e as retroflexion, 
 and that given in d as retroversion. In other words, by retroversion, 
 properly so called, they would understand a displacement backwards 
 of the entire organ, d — ^the flexion taking place in the upper part of 
 the vagina, and the uterus itself not being necessarily changed in 
 form. On the other hand, retroflexion e, is a term proposed to 
 designate the displacement backwards of the fundus only, along 
 with more or less of the body of the uterus ; the lower part of the 
 cervix uteri retaining in some degree, its natural position, and the 
 flexion taking place in the substance of the body, or upper part of 
 the cervix of the organ. But in reality, in the living subject, we 
 meet with all possible intermediate shades and degrees of these pos- 
 terior displacements ; and I believe it to be an incorrect and unne- 
 cessary refinement to draw such theoretical nosological distinctions 
 between them. Practically and pathologically, there is no true dif- 
 ference between these modifications or degrees of this morbid posi- 
 tion of the uterus ; and I shall in my subsequent remarks include 
 them, and all other varieties of posterior diplacement, under the 
 generic term of Retroversion. Farther, in order to avoid repetition, 
 I shall in the present communication treat only of retroversion of 
 the uterus. It will be found that the same principles of diagnosis 
 and treatment apply, mutatis mutandis, to the almost equally common 
 displacement of the uterus, which I have defined above as Ante- 
 version. 
 
 ALLEGED SARITY OE KETKOVEESION OP THE UNIMPREGNATBD UTERUS. 
 
 In all our English systematic books on midwifery and female 
 diseases, down to the very latest works, retroversion of the unim- 
 pregnated uterus is described as an exceedingly rare disease. 
 
 In his work on the Diseases peculiar to "Women (1846), Dr. Ash- 
 well tells us that he has " been long in the habit of observing uterine 
 organic disease ;" but he states " the published cases of retroversion 
 are nearly silent on any other cause than pregnancy ;" and he speaks 
 of this as the result also of his own observations." 
 
 Dr. Bums (1844) says: "Mr. Pearson relates a case where the 
 uterus was retroverted in consequence of being scirrhous. Dr. 
 Marcet gives an instance where the uterus was retroverted without 
 
 ' Opuscula Posthuma, p. 78. * Practical Treatise on the Diseases peculiar to Women, p. 598. 
 
EBTEOVBKSION. 191 
 
 pregnancy, producing constipation and vomiting. Dr. Aiken of 
 Berglieim relates a case where a woman, after suffering from diffi- 
 culty of passing the urine and stools, had in fourteen days complete 
 retention of both. The bladder reached to the umbilicus ; the ex- 
 tremities were cold, the pulse small, vomiting, &c. : the urine was 
 drawn off. After bleeding and the warm bath, force was employed 
 in opposite directions, both from the rectum and vagina, and in an 
 hour the uterus was replaced. It was, however, displaced again next 
 day, but was reduced, and the retroversion did not return. The 
 uterus was unimpregnated." Dr. Burns himself quotes these eases 
 in illustration of his own opinion, that retroversion, besides occurring 
 during pregnancy, '■'■may also be produced when the womb is enlarged 
 to a certain degree by disease."' 
 
 Writing in 1844, Dr. Churchill observes : "I have known retro- 
 version to happen the first day of a menstrual period, when the 
 weight of the uterus was in created by afflux of blood. Mr. Pearson 
 and Dr. Blundell ftiet with cases of retroversion caused by scirrhus. 
 Callisen and Blundell mention cases where this accident followed 
 delivery, hut such must he exceedingly rare."^ 
 
 The experience of the few last years has amply convinced me that 
 these opinions regarding the supposed rarity of retroversion of the 
 unimpregnated uterus are entirely wrong. Since discovering an 
 easy method of detecting its existence, I have found it one of the 
 most common and frequent displacements and affections of the un- 
 impregnated uterus.^ My observations in this respect have been 
 fully confirmed by several of my professional brethren in Edinburgh. 
 Three or four years ago I pointed out its frequency, mode of diag- 
 nosis, and treatment, to my friends, Drs. Eigby and Protheroe Smith, 
 of London ; and I have much pleasure in adding, that their exten- 
 sive opportunities at the London Hospital for Uterine Diseases have 
 enabled them and the pupils of that useful institution to confirm 
 amply the justness of my previous deductions, with regard to the 
 great frequency of retroversion, and the advantages of my proposed 
 methods of detecting and treating it. 
 
 SYMPTOMS AND DIAGNOSIS OP EETROVEKSION. 
 
 Greneral Remarks. — ^I have before stated'' that the morbid condi- 
 
 ' Principles of Midwifery, p. 288. ^ On the Principal Diseases of Females, p. 267. 
 
 ' In April, 1843, 1 stated these results in a communication to the Medico-Chirurgical So- 
 ciety of Edinburgh j showed the frequency of retroversion of the unimpregnated uterus, and 
 its means of detection and cure. See Monthly Journal of Medical Science for July, 1843, 
 p. 660. 
 
 * See p. 52 of this volume. To avoid repetition we have here omitted a page which 
 
192 DISEASES OF THE UTBEUS. 
 
 tions of the uterus are recognized in practice by two classes of symp- 
 toms, viz., the functional and physical. The evidence derived from 
 these two different classes is different in its nature and value. 
 
 All accoucheurs will, I believe, readily admit that the two follow- 
 ing observations hold good with regard to the symptoms and diag- 
 nosis of utero-gestation, viz. — 1. That the state of the uterus in 
 pregnancy, one and identical as it is, is liable to be accompanied, 
 in different women, or in the same woman in different pregnancies, 
 with very different local, sympathetic, and general effects or func- 
 tional symptoms ; and, 2. That the usual concourse and succession 
 of functional phenomena, to which pregnancy generally gives rise, 
 may be induced by other states and irritations of the organ than 
 utero-gestation. Hence, then, I attach far less importance to the 
 functional symptoms of retroversion which I have first to enumerate, 
 than to the physical signs, which I shall afterwards consider. 
 
 EUNOTIONAL SYMPTOMS OE DBKANGElrfllNTS. 
 
 In some cases of retroversion of the unimpregnated uterus, more 
 especially when the displacement is chronic and the pelvis large, as 
 in some other forms of serious uterine disease and of pregnancy, 
 few or no marked functional or sympathetic symptoms, either local 
 or general, are present ; while in other instances the attendant func- 
 tional derangements and irritations are excessively severe and dis- 
 tressing. And in this, as in other uterine affections, between these 
 two extremes we may meet with every shade of difference. 
 
 In retroversion, as in other morbid conditions and diseases of the 
 unimpregnated uterus, the accompanying sympathetic derange- 
 ments or symptoms are, when they are well and highly marked, 
 more or less perfect imitations of the secondary phenomena of preg- 
 nancy. Dyspeptic and hysterical symptoms are sometimes present, 
 with local neuralgic pains in the mammse ; in some portions of the 
 vertebral column ; or, what is still more frequent, in the parietes of 
 the abdomen or chest, and more especially in a limited spot beneath 
 the left mamma. The displaced position of the uterus often gives rise 
 to mechanical irritations and symptoms of the same kind as if the 
 organ were actually morbidly enlarged. Constipation and impeded 
 defecation are frequent results, partly from the fundus of the dis- 
 placed uterus physically compressing the calibre of the rectum, and 
 partly from its producing a functional inability to expel the feculent 
 contents of the bowel through the lowest part of the canal. Occar 
 sionally the bowel is irritated, and there are discharged from it, 
 
 formed part of the original memoir, and which, in its detached form, was then necessary 
 to complete the monograph. — (Ed.) 
 
DIAGNOSIS OF RETROVERSION. 193 
 
 from time to time, quantities of mucous or fibrinous-like efiusiona. 
 The bladder frequently suffers from dysuria or retention ; and, much 
 more rarely, I have seen a degree of ineontinence, especially where 
 the urine has become phosphatic, from the v^ant of power in some 
 cases of completely emptying the bladder. Symptoms of weight, 
 tension, and bearing down in the regions of the uterus and rectum, 
 with dragging at the loins and in the regions of the uterine liga- 
 ments, are very common. Pains often stretch down one or both of 
 the lower extremities. Occasionally there is an inability to bear 
 carriage exercise, and walking and standing speedily produce fa- 
 tigue. In a few cases I have known the patients to find themselves 
 forced to remain almost constantly in the horizontal position, from 
 the intense and overpowering feeling of pressure and malaise which 
 the erect posture always brought on, and the power of standing and 
 progression restored by the spontaneous or artificial reposition of 
 the uterus. In general, all the symptoms, local and constitutional, 
 which I have alluded to, are aggravated more or less by exercise in 
 the erect position ; and they are more particularly liable to be in- 
 creased in their intensity when the uterus becomes periodically 
 congested and heavier, at the recurrence of each menstrual period. 
 
 In some cases of retroversion the menstrual function is not mor- 
 bidly altered. In other cases, however, I have seen the catamenial 
 discharge affected most oppositely and variously — occasionally in 
 the way of amenorrhoea, sometimes of dysmenorrhoea, and not 
 unfrequently of menorrhagia, particularly after miscarriage. 
 
 The mucous secretion of the uterus is not altered by retroversion, 
 unless congestion or inflammation supervene ; it may then change 
 into leucorrhoea. Occasionally there is a sudden temporary increase 
 of discharge, once or oftener during the intervals between the cata- 
 menial periods, as if it had collected in the cavity of the retroverted 
 organ, and escaped, or become expelled, only from time to time. 
 
 When a patient with a retroverted uterus becomes pregnant, 
 abortion is apt to take place. But I have seen various instances in 
 which the uterus became spontaneously rectified in position as it 
 became larger, and utero-gestation went on to the full time. Usu- 
 ally the existence of retroversion interferes with the function of con- 
 ception. Often it is a cause of sterility, as shown by impregnation 
 taking place after the displacement is rectified. In women who 
 have borne children at distances of several years between each, I 
 have several times found the uterus permanently retroverted in the 
 unimpregnated state. 
 
 The functional symptoms that I have enumerated may make us 
 suspect the existence of retroversion of the uterus. But retroversion 
 may be present without most, or almost any of them ; and they may 
 
 VOL. I. 13 
 
19 i DISEASES OF THE UTERUS. 
 
 be present with other diseases besides retroversion. Hence tbe 
 necessity here, as elsewhere — in this, as in other uterine affections 
 — of having recourse to the physical examination of the uterus, in 
 order to decide and determine its actual morbid state. 
 
 PHYSICAL SIGNS OF RETEOVERSION. 
 
 The usual physical means of diagnosis of uterine disease are 
 reducible to the observation of phenomena by the senses of sight 
 and touch.' 
 
 Speculum. — The employment of sight, by means of the speculum, 
 assists us in no respect in the diagnosis of retroversion. 
 
 Tactile Examination. — On an accurate vaginal examination we 
 feel an apparent projection of a solid tumor between the uterus and 
 rectum, when applying our finger, or fingers, behind the cervix 
 uteri to the posterior part of the upper reflection, or roof of the va- 
 gina. (At a, Fig. 19.) The same firm mass is felt through the 
 anterior wall of the bowel in making an anal examination. The 
 tumor or mass feels smooth and roundish on its surface ; is often 
 sensitive on pressure, more especially if the retroversion is recent, 
 or when the posterior wall is, as often happens, congested and en- 
 gorged ; is generally capable of being moved more or less easily by 
 the finger ; and varies in size according to the degree of displace- 
 ment, and the morbid or healthy state of the uterine walls. 
 
 The OS and cervix uteri may be displaced forwards, or they may 
 maintain their usual position. The whole body of the uterus is 
 often prolapsed and lower than its natural situation ; but occasion- 
 ally it is quite normal in these respects. 
 
 How are we to determine that the solid tumor lying upon the 
 back part of the roof of the vagina, and between the rectum and 
 uterus, is the displaced fundus and body of the uterus ? 
 
 If the patient be unusually thin and emaciated, and we examine 
 simultaneously with one or two fingers of the right hand placed in 
 the vagina, and those of the left hand placed above the pubis, we 
 can almost feel the uterus between the two hands, and ascertain 
 the whole position and relations of the organ ; but this, however, 
 can rarely be accomplished. 
 
 Generally, we have by tactile examination no other means of 
 
 ' In a few cases the sense of hearing is also had recourse to. I have repeatedly heard 
 with the stethoscope a sound like the placental souffle in large fibrous tumors of the uterus. 
 The uterine walls around these tumors are sometimes hypertrophied and thickened, exactly 
 like the walls of the uterus in pregnancy, and their vascular structure undergoes a similar 
 increase and mutation. Hence, probably, the origin of the sound in question. When pre- 
 sent, I believe it to serve, among others, as a diagnostic mark between fibrous tumors of the 
 uterus and ovarian tumors. 
 
PHYSICAL SIGNS OF EETROVBESION. 195 
 
 knowing the probability of tlie apparent tumor being formed by 
 the displaced fundus and body of the uterus, than by tracing along 
 with the finger, between the tumor and cervix uteri, a direct conti- 
 nuity of structure, and this may be done either per vaginam or per 
 rectum. But this physical sign is in itself apt to lead into error, if 
 alone depended on. K the uterus is retroflected more than retro- 
 verted, the continuity cannot be traced at the point or angle of 
 flexion ; while on the other hand, a fibrous or other tumor attached to 
 the back wall of the uterus sometimes may be distinctly traced to be 
 in continuity with the uterine structure, and moves with all motions 
 imparted to the cervix. JSTor is the position of the os uteri any 
 more certain guide, for sometimes it is not displaced when the 
 fundus is so ; and it may be thrown forwards by a tumor, when 
 the fundus retains its normal position. 
 
 Other and additional means, therefore, of diagnosis become ne- 
 cessary. M. Pereyra, of Bordeaux, suggested, a few years ago, to 
 attempt to obtain a more correct physical diagnosis for retroversion, 
 by conducting the examination by the rectum or bladder. " The 
 difficulty," he observes, "of distinguishing diseased growths from 
 retroversion of the uterus is greater than might at first be supposed ; 
 the only way of attaining a correct diagnosis is to ascertain if the 
 uterus be or not in its normal situation. Two methods are proposed 
 for this end ; either the forefinger is introduced into the rectum, or 
 a male catheter into the bladder, by the extremity of which instru- 
 ment an exploratory process is conducted. The latter mode, 
 treated of by Malgaigne,^ requires, of course, some tact, but to the 
 experienced surgeon it will give the more certain indication."^ 
 
 The determination of the case by an examination per rectum is 
 impossible ; and I have elsewhere shown that Malgaigne's method 
 of diagnosis is attended with difficulties and uncertainties that 
 render it quite useless in practice.^ 
 
 A far more simple and certain method is to determine the precise 
 situation of the fundus and body of the uterus, not through either 
 the intestinal canal behind, or the urinary canal in front, but 
 through the intermediate genital canal itself. The proper canal of 
 the uterus is, of course, too narrow to allow us to introduce our 
 finger into it ; but by passing into it a slender metallic finger, if we 
 may so speak, we can easily by it ascertain, amongst other matters, 
 any change in the direction of its cavity, and consequently in the 
 direction of the body and fundus of the uterus itself. The employ- 
 ment of the uterine bougie readily enables us to do this. 
 
 ' These du Concouis, 1833. 
 
 ' American Journal of Medical Sciences, April, 1843, p. 483. 
 
 ' See ante, p. 95. 
 
196 DISEASES OF THE UTEETJS. 
 
 Uxamination hy the Uterine Sound or Bougie. — The fonn, &c., of 
 the uterine bougie is represented in Pig. 1, and consequently 
 requires little or no description. Some years ago I gave a full 
 account of the instrument, and the mode of using it.^ It has 
 the configuration of a slender male catheter; tapering in form; 
 knobbed at the extremity ; divided into sections, so as to measure, 
 vfhen required, the length of the uterine cavity; and provided 
 with a handle, smooth on its posterior surface and roughened on 
 its anterior, that surface represented in the wood-cut, in order to 
 make the operator constantly aware of the position and ^direction 
 of the point and concavity of the instrument, when it is passed 
 into and hid in the uterine cavity. 
 
 This instrument can be easily and readily passed into the uterine 
 cavity, so as to enable us to measure its depth ; to examine, more 
 distinctly than we have otherwise the power of doing, its fundus, 
 body, and cervix ; to ascertain the presence of strictures in the 
 canal ; diseased states of the cavity, and walls of the organ, &c. I 
 have used it daily for five or six years past, and have never, in any 
 instance, seen any serious irritation, or any bad result to the uterus, 
 follow its employment ; whilst it has enabled myself and others to 
 detect and discriminate morbid conditions of this organ, that were, 
 by any other means, entirely beyond the reach of correct diagnosis. 
 
 Its power of detecting retroversion of the unimpregnated uterus 
 depends, as I have already stated, upon its directly and easily 
 enabling us to ascertain the direction of the uterine cavity, and 
 hence of the body and fundus of the uterus, which form the walls 
 of that cavity. 
 
 When the uterus is in its normal position, and is placed with the 
 long axis of the organ, and consequently the long axis of its 
 , cavity, in a line parallel with the axis of the pelvic brim, the point 
 of the bougie, when introduced into the uterus, passes upwards 
 and forwards in the direction of the umbilicus ; ,and the concavity 
 of the" instrument, or the rough side of its handle, is directed 
 towards the symphysis pubis. When, however, the uterus is retro- 
 verted, the point of the instrument, instead of passing up vertically 
 and forwards, is resisted in that direction, and can only be passed 
 horizontally and backwards towards the hollow of the sacrum ; its 
 concavity and the rough side of its handle thus looking towards 
 the sacrum instead of towards the pubis, and at once showing the 
 altered position of the cavity, body, and fundus of the uterus. 
 
 But the diagnosis may be made out still more completely and 
 accurately by the further use of the bougie. For — 
 
 1. Besides showing in the manner stated, the direction of the 
 
 ' See ante, p. 58. 
 
DIFFERENTIAL DIAGNOSIS OF KETROVEESION. 197 
 
 uterine cavity, and hence of tlie body and fundus of the uterus, by 
 the direction in which the instrument itself passes, — 
 
 2. We can ascertain by a vaginal or anal examination of the 
 supposed tumor, that the extremity of the uterine bougie is lodged 
 in its centre, showing the swelling to be produced merely by the 
 displaced fundus of the uterus ; and, — 
 
 3. After this, by turning the bougie gently round so as to bring 
 the concavity, or the rough side of its handle, to look to the pubis, 
 instead of looking, as at first, to the sacrum, we can replace the 
 uterus and feel it upon the bougie if required, through the abdo- 
 minal parietes in front. . "We can thus certify to our own minds 
 that we have nothing on the point of the instrument except the 
 fundus uteri. And again, if necessary, by introducing a finger 
 into the rectum or vagina, and then retroverting or replacing the 
 uterus at will, we can as it were make and unmake, as often as 
 required, the apparent tumor lying between the uterus and rectum, 
 and thus further prove this tumor to be nothing whatever but the 
 retroverted fundus uteri. 
 
 DIFFERENTIAL DIAGNOSIS OF RETROVERSION. 
 
 I have seen retroversion of the unimpi-egnated uterus not only 
 very frequently and entirely overlooked, but also very often mis- 
 taken for other morbid states and lesions of the uterus. I shall 
 point out the principal morbid conditions with which I have known 
 it to be confounded, and the modes of distinguishing retroversion 
 from them. 
 
 1. From Pregnancy. — ^In a considerable number of instances I 
 have had occasion to see the feeling of fulness and apparently 
 increased size of the uterus in retroversion mistaken for the earlier 
 periods of utero-gestation. A few weeks ago I was called to a 
 case at a distance from Edinburgh, where this error of diagnosis 
 had led to much distress : fi-om an unmarried lady, suffering 
 severely from dysmenorrhoea and menorrhagia, being supposed by 
 her medical attendant to be pregnant and aborting, by his mis- 
 taking the retroverted fundus and body of the uterus for general 
 enlargement of the organ. This error is still more liable to be 
 committed when the retroversion is accompanied, as it sometimes 
 is, with occasional amenorrhoea. Two or three years ago, I had 
 under my care a patient with retroversion of the uterus and tempo- 
 rary amenorrhoea, who had been pronounced as undoubtedly preg- 
 nant by her usual medical attendant, an excellent practitioner and 
 lecturer on midwifery in another medical school. About the same 
 
198 DISEASES OF THE UTERUS. 
 
 time I had a patient under my own care with retroversion, who 
 passed three successive menstrual periods ; but I was certain, from 
 no corresponding increase in the size of the retroverted uterus, 
 that she was not pregnant. In this case the difficulty of the diag- 
 nosis was rendered the greater in consequence of the areolae 
 becoming darker and their follicles enlarged as in pregnancy. A 
 drawing was made of the areolae at the time ; and afterwards, when 
 the uterus was replaced, and the patient at last became pregnant, 
 the areolffl were most certainly not deeper marked at the same 
 period in the true, than they had been in the spurious pregnancy. 
 
 2. From Fibrous and other Tumors in the posterior Wall, ^c, of the 
 Uterus. — This is one of the most frequent errors of diagnosis 
 which I have met with, and one into which, in former times, I 
 myself frequently fell. 
 
 The attendant functional symptoms are in all respects the same ; 
 and on examination there is the same continuity of structure felt 
 between the cervix uteri and the body lying between it and the 
 rectum. In this way retroversion of the uterus has very often been 
 mistaken for a morbid growth upon the back part of the uterus, 
 and even described as such.^ But the introduction and direction 
 of the uterine bougie at once enables us to solve the difficulty. 
 The bougie passes backwards into the very body and centre of tihe 
 apparent tumor, at once showing it to be the retroverted -fundus 
 uteri. It may be proper, however, to add, that instances are by no 
 means rare in practice of the presence of small fibrous tumors 
 attached to the posterior wall of the uterus being conjoined with 
 retroversion. 
 
 ^ Dr. Hamilton, in his Outlines of Midwifery, describes retroversion as an " unequal pro- 
 jection" on the posterior part of the uterus. I have seen one or two patients whom he had 
 pronounced in writing to be laboring under these " projections," and where the apparent 
 tumor was the retroverted fundus uteri. In the work quoted he observes : " An unequal 
 projection of different sizes is occasionally discovered on the posterior part of the uterus, 
 resembling in shape the tubera which form upon the surface of the liver, but differing 
 from tubera in being of a more resisting texture, and in being pained on pressure. From 
 the cases which have fallen under the author's notice, it appears to him that the following 
 is the progress of this fortunately rare disease. At first there is a slight enlargement of the 
 uterus, with a little thickening and tenderness of its posterior surface, occasioning a sense 
 of bearing down on making any unusual exertion, and an obscure gnawing pain towards 
 the back part of the pelvis. In the progress of the disease the posterior surface of the 
 uterus becomes more and more unequal, till at last a distinct projection Uke a walnut, or 
 even larger, can be felt on examination per anum. At this stage of the disease the patient 
 can neither stand nor sit upright, such is the continued uneasiness in the back part of the 
 pelvis. It is remarkable that in this, as well as in several other of the local diseases of the 
 uterus, the catamenia continued to flow as usual. In the early stages of this disease the 
 progress has been generally checked by the means employed in cases of chronic enlarge- 
 ment of the uterus ; but in the latter stages, that is, after the circumscribed projection has 
 
 taken place, no other means of treatment have hitherto proved successful." Outlines of 
 
 Midwifery, p. 134. 
 
DIFFERENTIAL DIAGNOSIS OF EETROVBUSION. 199 
 
 I have known tlie retroverted fundus uteri to be pronounced a 
 carcinomatous tumor, local thickening of the back walls, &c. The 
 differential diagnosis is readily made, in the way I have just men- 
 tioned. When it has occurred after deliveiy I have seen it mistaken 
 for the common puerperal hypertrophy of the uterus. The means 
 of differential diagnosis are the same. And cases, in which the 
 apparent swelling formed by the back wall of the deflected uterus 
 have been, out of the pregnant and puerperal states, mistaken for 
 simple general hypertrophy of the uterus, and assiduously treated 
 by mercury, iodine, &c., have frequently come under my notice. 
 
 3. From Ovarian Tumors in their earlier Stages. — When the ovary 
 enlarges from multilocular degeneration, or other causes, it almost 
 always first grows downwards into the space lying between the back 
 wall of the uterus and the anterior part of the rectum, resting thus 
 upon the roof of the vagina behind. In its enlargement it almost 
 invariably pushes the uterus anteriorly, and before it ; and this rela- 
 tive position of the uterus to ovarian tumors is often an important 
 matter in the uterine diagnosis of ovarian disease in its latter and 
 more advanced stages. At first the body of the enlarged ovary may 
 be mistaken for the retroverted fundus uteri, more especially as the 
 OS uteri is generally displaced forwards. But the introduction of 
 the bougie shows the uterus to be in its normal situation, and at the 
 same time generally enables us to draw the uterus so far forwards 
 as to make us certain that it is not attached to the existing tumor, 
 and does not form one continuous structure with it. So far the 
 evidence is merely negative. If farther evidence of a positive 
 kind, of the nature of the tumor, is required, we may obtain it by 
 the use of a fine exploring needle, a means of diagnosis of great 
 value in this as in other complications. 
 
 4. From Pelvic Cellulitis. — Inflammation of the cellular tissue of 
 the pelvis, limited or more diffuse, is certainly a frequent disease, 
 both after delivery and in the unimpregnated state. I have seen it 
 now at many different periods of life, from six years up to sixty. It 
 is generally spoken of as " pelvic abscess," but improperly so, for it 
 does not always necessarily terminate in empyema. When the 
 inflammatory ejfRision seems limited, as it sometimes is, to the space 
 between the uterus and rectum, the firm tumor, or swelling formed 
 by it, may be mistaken for retroversion. The direction of the bougie, 
 when introduced into the uterus is not retroverted ; and the accom- 
 panying symptoms, and if necessary, the use of the exploring needle, 
 will enable us to complete the diagnosis. 
 
 5. From Extra-uterine Conceptions lodged between the Uterus and 
 Bectum. — ^Nauche' mentions a case in which an extra-uterine concep- 
 
 ' Maladies des Feromes, p. 108. 
 
200 
 
 DISEASES OP THE UTERUS. 
 
 tion was mistaken for a retroverted uterus. I lately met with an 
 instance where it was a matter at first of great doubt and difficulty, 
 whether a tumor lying on the anterior wall of the rectum, and 
 accompanied with sudden symptoms of rupture into the peritoneum, 
 was an enlarged and retroverted utems or an extra-uterine concep- 
 tion. Examinations with the bougie at once showed the uterus to be 
 both noi-mal in its size and in its position. 
 
 6. J'rom Organic Disease in the Anterior Wall of the Rectum. — ^In 
 a case of Dr. Marnoch's the tactile examination of a tumor lying 
 between the uterus and rectum gave me the idea that it was a retro- 
 verted uterus. The employment of the bougie, however, showed 
 the uterus to be normally placed. On more minutely examining 
 per anum, the anterior wall of the rectum was found much thick- 
 ened and indurated ; the patient died some months subsequently of 
 carcinomatous stricture and disease of the rectum. 
 
 7. From Stricture of the Rectum. — The diagram of retroversion 
 in Fig. 19 shows how readily this disease may be mistaken for stric- 
 
 Fig. 19. 
 
 ture in the rectum ; the deflected fundus uteri pressing in upon and 
 sometimes diminishing greatly, the calibre of the bowel. But the 
 use of the bougie always readily dispels the difficulty, by showing 
 first the direction of the fundus, and secondly, when the instrument 
 is turned round, by at once removing the ftmdus and the supposed 
 stricture. But I know that the mistake of confounding a retroverted 
 uterus with stricture of the rectum is by no means infrequent in 
 practice. Sir Charles Bell states that he had found a surgeon em- 
 ploying rectum bougies for years, on account of an obstruction from 
 
 Fig. 19 is a diagram of the position of the retroverted uterus b - and its replacement to c, 
 by tlie sound, d; /being the sacrum ; e, the rectum ; and a, the vagina. 
 
KETKOVERSION FEEQUBNTLY OVERLOOKED. 201 
 
 displaced uterus." A case of retroversion of tlie unimpregnated 
 uterus some time ago came under the care of a medical friend of 
 mine in Edinburgh. He discovered the displacement, introduced 
 the wire pessary (Fig. 22), which I shall afterwards describe, and at 
 once rendered his patient comfortable, and capable of taking ex- 
 ercise. She returned to her own distant home, with a line to her 
 physician, who declared that he knew the instrument well, but 
 thqfight it necessary to take it out at the menstrual period, and could 
 not again replace it. Another distinguished obstetrician was called 
 in his place. He said the uterus was enlarged, and not displaced ; 
 used leeches, &c. !N"ot finding the desired benefit from this treat- 
 ment, the lady placed herself under the care of an eminent surgeon, 
 who pronounced all the previous opinions wrong, and that the real 
 disease was stricture of the rectum. The last time I heard of the 
 patient she was submitting to the frequent use of bougies for the 
 cure of this imaginary affection. 
 
 EETROVEESION LIABLE TO ESCAPE NOTICE EVEN IN POST-MORTEM 
 EXAMINATIONS. 
 
 In the preceding pages I have spoken of retroversion of the unim- 
 pregnated uterus being with extreme frequency entirely mistaken in 
 practice, and overlooked during life. But even after death the same 
 error is liable to occur. Dr. Robertson details^ a case most illus- 
 trative of this remark. A woman died of tenesmus, constipation, 
 and symptoms of obstructed bowel, ending in enteritis. Before 
 death the rectum was examined for the obstruction, and the gut was 
 found " encroached on by a tumor which, per vaginam, was dis- 
 covered to be the uterus." " But," adds Dr. E., " on the post- 
 mortem examination, to our surprise, no uterine tumor was found to 
 encroach on the rectum." In this, as in other cases in which retro- 
 version of the uterus has existed, the morbid displacement has, on 
 the inspection of the body after death, escaped notice, from the form 
 and structure, and not the mere position, oi the uterus being looked 
 , to. In our common post-mortem method of examining the pelvic 
 contents from above, the attention of the morbid anatomist is rarely 
 or never directed to the observation of any mere deflection of the 
 fundus and body of the uterus ; and when once the parts are dragged 
 out of their situation, it is impossible to ascertain the amount and 
 degrea of retroversion. 
 
 1 Institutes of Surgery, vol. ii. p. 216. 
 
 2 Edinburgh Medical and Surgical Journal for 1822, p. 525. 
 
202 DISEASES OP THE UTERUS. 
 
 ORGANIC STATE OF THE UTERUS IN RETROVERSION. 
 
 This is very variable. I have seen it several times coexisting 
 with the presence of fibrous tumors in the uterine parietes. More 
 frequently the uterus is hypertrophied merely from chronic metritis, 
 and the enlargement more especially marked in the posterior walls. 
 The organ is at the same time elongated as well as hypertrophjpd ; 
 and its cavity, instead of measuring two and a half inches in len^h, 
 will measure three or three and a half inches. Many authors seem 
 to think that enlargement of the uterus, under some form or another, 
 is a necessary preliminary to retroversion taking place, and that we 
 never meet with the displacement, without finding it combined with 
 some increase in the size of the organ. Such, however, is assuredly 
 not the fact. In a large proportion of cases the retroverted uterus 
 is in no degree enlarged or increased in volume, but natural in size. 
 Nay, I have on more than one occasion seen the uterus retroverted, 
 when it was less than normal in its length and dimensions. Latterly 
 I have happened to be consulted in several instances of amenorrhoea 
 in women advanced beyond twenty or thirty years of life, in whom 
 the menstrual secretion had never appeared, and where, on exami- 
 nation, the uterus was found to be imperfectly developed, and the 
 length of its cavity, as measured by the uterine bougie, was not 
 above one, one and a half, or at most two inches. In one of these 
 instances, in which the cavity of the uterus was only one and a half 
 inches long, the fundus of the preternaturally small organ was, at 
 the same time, distinctly retroverted, and felt like a small roundish 
 tumor through the vagina and rectum. Some time ago I saw, with 
 my friend Dr. Girdwood of Paddington, a case still more rare. The 
 uterus was retroverted, as he had ascertained by examination and 
 the use of the bougie. There was a second orifice in the cendx 
 uteri. On introducing a second bougie into this additional orifice, 
 I found it pass into a second uterine cavity, quite separated and dis- 
 tinct from the first, and with the fundus of each diverging from the 
 other. In fact, the uterus was not only retroverted, but double. It 
 is, as far as I am aware, the first case in which a double uterus has 
 been distinctly diagnosticated upon the living subject. 
 
 TREATMENT OF RETROVERSION OF THE UNIMPREGNATED UTERUS. 
 
 When recent, and occurring after some straining efibrt, oj- from 
 congestion and infiammation of the uterus, or subsequent to deli- 
 very, mere replacement of the organ by the bougie or finger will 
 sometimes suffice, provided, along with it, we enforce for a length 
 
TREATMENT OF EETEO VERSION. 203 
 
 of time the horizontal position, or rather lying on the side or face? 
 prevent over distension of the rectum and bladder, reduce any local 
 congestive or inflammatory state that may be present, and restore 
 the local tone of the relaxed soft structures of the pelvis by astringent 
 vaginal injections, or by the use of medicated pessaries made with 
 ointment containing extract of oak-bark, or tannin, or iodide of 
 lead, &c. 
 
 But such simple treatment rarely succeeds, even when the retro- 
 version is recent ; and still more seldom when, as is almost always 
 the case in practice, the displacement is already chronic and con- 
 firmed. Under these circumstances we have three principal indica- 
 tions to perform : — 1. To remove, if necessary and possible, any 
 morbid action in the uterine structures that may exist along with 
 the displacement. 2. To restore the uterus to its normal situation. 
 3. To use means to retain it in its replaced and natural position. I 
 shall speak separately of these several indications. 
 
 1. Removal of any Morbid State of the Uterus that may coexist with 
 the Retroversion. — ^Not unfrequently, along with retroversion, the 
 uterus is congested and hypertrophied, and the uterine bougie shows 
 it to be elongated half an inch or more. Sometimes chronic inflam- 
 mation of the body of the organ is present, and more especially in 
 its posterior wall, which often feels tumefied and tender to the 
 touch ; or the cervix is enlarged, condensed, and ulcerated, espe- 
 cially in its posterior hp. The os uteri, or the uterine canal, an inch 
 or so above the os, is not unfrequently contracted and strictured, 
 and may have been giving rise to retention of the menses and con- 
 gestion. Occasionally one or both ovaries can be felt through the 
 roof of the vagina, enlarged and painful from congestive or inflamma- 
 tory irritation. As a general rule, all these morbid states should, 
 when possible, be reduced and removed, or at least moderated by 
 their appropriate means of treatment, before engaging with the 
 other indications to be fiilfilled, particularly when they are appa- 
 rently in any respect the cause of the retroversion. More frequently, 
 however, they are the effects of the retroversion ; and in this latter 
 case our means of combating them will usually fail, or only par- 
 tially succeed, till we have first restored the organ to its natural 
 form and situation, by our fulfilling the second and third indications 
 which I have laid down, before we fulfil the first. When the retro- 
 version is combined with and produced by the presence of fibrous 
 tumors in the posterior wall or fundus of the uterus, the first indi- 
 cation cannot, of course, be accompHshed, as we as yet possess no 
 certain power of removing and discussing these tumors. 
 
 2. Restoration of the Uterus to its Normal Situation. — Most authors 
 who have treated of retroversion of the unimpregnated uterus have 
 
204 DISEASES OF THE UTEEUS. 
 
 spoken as if its replacement could generally be fully effected by the 
 fingers alone. In practice, however, its complete replacement by 
 this means is almost always found to be impossible. By pushing up 
 the retroverted fundus, or by pulling down the cervix, or by com- 
 bining simultaneously both measures, the replacement can some- 
 times be effected by the fingers alone ; but rarely. For it is scarcely 
 ever possible, by any pressure which we can make with the fingers 
 upon the posterior surface of the uterus, either through the vagina 
 or through the rectum, to push the fundus uteri upwards and for- 
 wards to a sufficient degree. Some authors finding their fingers to 
 fail, from their shortness, &c., have proposed instruments for the 
 purpose. Eichter and Evrat suggested a species of vectis or probang, 
 to be used through the rectum. Bellanger, Lallemand, and Duges, 
 have spoken of introducing a strong sound into the urethra and 
 bladder, to act as a lever upon the os uteri. Siebold and Drejer 
 attempted to replace the uterus by instruments made of whalebone, 
 introduced into the vagina, and made to press by their upper and 
 blunted extremities upon the fundus uteri through the upper and 
 back portion of the vaginal parietes. 
 
 The simplest and most easy method of temporarily replacing the 
 retroverted uterus, is by introducing an instrument into the cavity 
 of the organ itself, and using it as a mechanical means or lever, for 
 the purpose. In treating of the physical diagnosis of retroversion, 
 I have shown how the uterine bougie can be readily used for this 
 purpose. The very means of diagnosis are thus, at the same time, 
 the very means of replacement. 
 
 3. Retention of the Replaced Uterus in its Normal Situation. — This 
 is necessary to effect a cure. Some, as Schmitt and Schweighauser, 
 have supposed that it could be accomplished by the mere position of 
 the patient, and that lying on the side or face, with the pelvis some- 
 what elevated, would be sufficient. I have already stated that in 
 few — exceedingly few cases, indeed — ^will it be found to succeed, and 
 these only of recent origin. Instruments for the purpose of sup- 
 porting and retaining the uterus in situ are therefore necessary. 
 They have been proposed to be worn in the rectum,^ and in the 
 vagina.^ Various forms and modifications of vaginal pessaries have 
 been invented by Hervez, Drej er, Sander, &c. They are all intended 
 either to press principally, by guarded stems or otherwise, through 
 the roof of the vagina, upon the tumor formed by the fundus uteri; 
 or to keep the cervix uteri pushed back, with the view of throwing 
 the fundus forwards. I have used sponges for this last purpose ; and 
 Siebold and Kilian state, that they believe they form the best pessar 
 
 ' iEtius, Verandois, Desault. 2 Colombat, Duges, &c. 
 
RETENTION OF REPLACED TTERUS IN SITU. 205 
 
 ries for retroversion, modified according to the necessities of eacli 
 case. Moreau conceives that the principle of treatment should be 
 to fill up the space between the uterus and rectum, so as to take 
 away any room for the retroversion to recur: he uses a kind of 
 caoutchouc pessary for this purpose. Two years ago, I removed 
 from a patient one which had been worn for some months, and 
 which Moreau himself had introduced. It had not in any degree 
 benefited the retroversion. 
 
 After detecting the ease and certainty with which the uterine 
 bougie could be used for the discovery of retroversion, and for the 
 temporary restitution of the organ, it appeared to me that the most 
 direct and perfect method of retaining the replaced uterus in situ 
 would consist in some means of retaining and fixing, as it were, the 
 end of the bougie for a time in the uterine cavity. I soon found 
 that the restoration of the uterus temporarily, from day to day, with 
 the bougie, was insufiicient, and that some more permanent means 
 of keeping the organ replaced and retained were necessary. But 
 one primary and important point required to be solved : — Would 
 the uterus bear with impunity the presence of such a body for a 
 length of time in its own cavity ? My first experiment on the sub- 
 ject I made with extreme anxiety, and great misgivings as to the 
 result. I watched the case from hour to hour, and from day to day, 
 and was delighted to find that the presence of the instrument was 
 borne by the uterus without irritation or annoyance. The patient was 
 almost entirely incapacitated from walking, by retroversion of the 
 uterus, before it was used. After thus wearing for some months a 
 wire pessary in the cavity of the uterus, she so far recovered as to 
 bear two children, one in this country, and subsequently another in 
 India. I soon found in other cases, that, when the instrument was 
 once properly fitted and adjusted, it could be borne with perfect 
 safety, and without any pain or inconvenience. Occasionally I have 
 since met with cases in which the uterine pessary has created so 
 much irritation as to render its withdrawal necessary in a few days 
 after it was introduced. But these cases have been exceptions, to 
 the general rule ; and I have allowed the instrument sometimes to 
 remain in the uterus for two, four, six months, or longer. "Within 
 the last few weeks I have removed two uterine pessaries, one of which 
 I had introduced eight, and the other nearly ten months previously. 
 They are not to be interfered with at the menstrual periods. Some- 
 times, though by no means always, a slight menorrhagia follows 
 their use, particularly for the first period or two after their intro- 
 duction. 
 
 It is unnecessary to detail the changes of form which were tried, 
 and the difficulties I met with, in first attempting to construct a 
 
206 
 
 DISEASES OF THE UTERUS. 
 
 proper uterine pessary. The three forms which I have been in the 
 habit of using, for the last three or four years are those depicted in 
 the wood-cuts.^ 
 
 First Form of Uterine Pessary, Fig. 20, a, b, ^.— The stem of the 
 instrument, d, 2J inches long, is introduced into the uterine cavity; 
 the lips of the cervix uteri rest upon the flattened ovoid bulb or 
 
 Fig. 20. 
 
 Fig. 21. 
 
 V 
 
 ball ; a, shovrs the lower surface of the bulb or ball, with an orifice in 
 it to allow of the end of a staff, c, about 8 inches in length, to be fixed 
 in it, for facilitating its introduction into the uterus.^ This form of 
 pessary generally answers much better for anteversion than for retro- 
 version. Occasionally I have had the bulb made of lead, that it might 
 serve as a counterpoise to hold the os uteri in situ. The instrument, 
 however, is imperfect, from the impossibility usually of retaining it 
 in the uterus above a few days, the canal relaxing and dilating, and 
 allowing of its escape. In fact it is exactly the form of bougie 
 which I generally use to dilate the os and canal of the uterus in 
 cases of stricture, in any cases in which I do not employ the knife 
 or hysterotome for that purpose. 
 
 Second Form of Pessary, Fig. 21, has a similar uterine stem and 
 bulb, and in addition a large ovoid disk, 2| inches in length, IJ 
 inches broad, and J an inch in depth, to retain the instrument in 
 situ. The bulb, 5, for the cervix uteri to rest upon, is fixed in the 
 middle of the disk, and the uterine stem, d, is movable to a certain 
 extent upon it. This is necessary in consequence of the size of the 
 retaining disk, and the impossibility of introducing the instrument 
 ^nto the uterus and genital passages, with the stem fixed upright, 
 and at right angles to the plane of the disk. The dotted line repre- 
 sents the stem laid down, as is required in the introduction and 
 withdrawal of the instrument. On the lower surface of the instru- 
 
 ' Mr. Young, our cutler in Edinburgh, makes them of German silver ; sometimes he has 
 electrotyped them for me, but this addition is unnecessary. 
 
 ^ Dr. Simpson has found in practice that generally the experienced hand does not need 
 the assistance of the staif. This we have also observed ourselves. — (Ed.) 
 
INTRA-UTBRINB EKAME PESSARY. 
 
 207 
 
 ment, which is not seen in the figure, there is a spring-catch to hold 
 the stem fixed and upright after the instrument is introduced, and 
 capable of being unlocked by the nail when the instrument requires 
 to be again withdrawn. The expanded disk, by pressing on the 
 sides of the vagina, enables the uterine portion of the pessary to 
 keep its situation. In some cases this instrument answers well in 
 retaining the replaced uterus. But occasionally, when the tendency 
 to displacement is great, this form of pessary is altogether inade- 
 quate, and will be moved about by the changes of position which 
 the uterus itself undergoes. The remaining form which I most 
 frequently employ is free from these disadvantages. The first two 
 forms are, when used, altogether concealed within the genital 
 passages. In this third form a portion of the instrument is placed 
 externally, and another internally. 
 
 Third Form of Pessary, Fig. 22.' — It is. made up of two parts : 1. 
 An internal part, provided, like the two preceding pessaries, with a 
 
 Fig. 22. 
 
 stem, /, to pass into the uterine cavity ; a bulb or ball, g, for the 
 cervix to rest upon ; and in addition, a vaginal portion, or curvili- 
 near tube, h. 2. An external part, consisting of a wire firamework, 
 a, b, c, to maintain and hold the internal portion in situ. This ex- 
 ternal part, or wire frame, is about 5 inches long ; at its lowest or 
 vaginal portion it is about J an inch broad ; and towards its upper 
 or pubic portion, it suddenly swells out to 8 inches in breadth. From 
 the vaginal extremity of this frame projects, at nearly right angles 
 to it, a flat tubular portion, c, 2J inches long, closed at its further 
 extremity, like the point of a female catheter, and fitted to slide 
 
 ' The different parts of the pessaries are represented in the wood-cuts as somewhat below 
 their actual size. The bulb or ball is, in general, made an inch and a half long, one inch 
 broad, and about half an inch thick. I have sometimes used a larger bulb. When smaller, 
 it is apt to produce dilatation of the 03 uteri, and even to pass partially into it. 
 
208 DISEASES OF .THE UTERUS. 
 
 into and fix in the corresponding open tube, h, attached to the bulb 
 of the internal half of the instrument, g} 
 
 In the wood-cut the uterine stem of the instrument is represented 
 as placed in the cavity, e, of the uterus, a section of the organ d, 
 being outlined around it. In introducing the instrument, the inter- 
 nal portion, /, is first passed into the uterus and vagina, in the same 
 way as the uterine bougie is passed for the purpose of diagnosis. 
 The retroverted uterus is then replaced by raising it up upon this 
 portion of the instrument, which is turned round for that purpose. 
 After the organ is replaced, the solid vaginal portion attached to 
 the external frame of the pessary is slid into the corresponding 
 vaginal tube, Ji, of the internal half of the instrument, locking into 
 it on the same principle as the stilet locks into the canula of a 
 curved trocar. Thus the instrument is, as it were, rendered at once 
 completely solid and fixed. In order to have room to lock the two 
 portions together, it is necessary, in general, first to bend back the 
 pubic portion of the external framework to a very considerable 
 extent, for the purpose of avoiding its being caught and impeded 
 by the anterior part of the pelvis or pubis. After the locking is 
 accomplished, this pubic portion of the instrument is bent, and 
 moulded upon the anterior portion of the pelvis, so as to fit it as 
 exactly as possible. Formerly I was in the habit of attempting to 
 keep the instrument more permanently fixed, by having elastic tapes 
 fixed posteriorly into the apertures, h, and anteriorly into those still 
 represented in the upper part of the pubic portion of the instrument ; 
 and both attached to a band encircling the trunk of the body. 
 This arrangement I always now dispense with as unnecessary. If 
 the pubic portion of the pe'ssary is properly bent in over the pubis, 
 it generally takes a sufficient hold ; and if aught more is found 
 necessary, all that is required, in addition, is, that the patient wear 
 a common napkin, or understrap, to pass between the limbs and 
 over the instrument. Latterly I have had the instrument made 
 without the part, 6, projecting posteriorly. 
 
 It is, perhaps, almost unnecessary to add that, if the instrument 
 is found to press disagreeably on any part, it may be easily bent 
 without removing it, so as to take ofiTthat pressure ; and it may 
 thus require to be ;remodelled and adjusted again and again in 
 various parts, in order that it may be ultimately worn without 
 annoyance and inconvenience. 
 
 When required to be withdrawn, the pubic portion is first bent 
 
 ' I have a patient at present weaving one of these pessaries with a stem three and a half 
 inches long. The retroverted uterus is enlarged and elongated by fibrous tumors in its walls, 
 and one of the ordinary pessaries did not suffice to hold it replaced. 
 
BIBLIOGRAPnY OF RETROVEKSION. 209 
 
 back, so as to be clear of the pubis ; then the vaginal pieces are un- 
 locked ; and, lastly, the internal part is extracted. 
 
 The time during which it requires to be worn, in order to effect 
 a cure, varies in different cases from one to two weeks to many 
 months. The recent or chronio character of the case, and particu- 
 larly the degree of tendency to the recurrence of the retroversion, 
 are our principal guides on this head. 
 
 The employment of these uterine pessaries will cure many, but 
 by no means all cases of retroversion of the unimpregnated uterus. 
 And even when not sufficient to cure, they will generally relieve 
 the patient, and palliate her annoyances and sufferings. 
 
 If the retroversion were causing no unpleasant symptoms nor 
 interfering with the functions of the uterus, I have always recom- 
 mended the avoidance instead of the adoption of local measures 
 and remedies, either mechanical or others. "When the reverse was 
 the case, I have employed the means I have mentioned, with the 
 effect of curing many and of relieving others. In the few excep- 
 tional cases in which no pessary could be borne, in consequence of 
 the irritable state of the uterus, or where they fail to produce a cure, 
 I have contented myself with reducing this morbid state of the 
 parts by leeching, external counter-irritation, the application of 
 belladonna ointment pessaries, &c., and rest, in the first instance, 
 followed afterwards by the employment of local and general tonic 
 measures. The patient often derives much relief from wearing an 
 abdominal bandage, as those of Hamilton and Hull, with a support- 
 ing perineal pad. 
 
 I have not entered into the consideration of the Causes of retro- 
 version of the unimpregnated uterus. An explanation of these 
 causes, and, indeed, of uterine displacement in general, is only to 
 be found, I believe, in a complete study of the forms, relations, and 
 functions of the different parts and layers of the pelvic fascia. In 
 retroversion, those portions of this fascia which unite the back part 
 of the uterus to the rectum and pelvic cavity behind, partially yield 
 and give way. To restrengthen this support, and allow of its reno- 
 vation, retention of the uterus for a length of time in the position 
 and mode I have described often suffices. The simultaneous use of 
 local injections and baths aid farther the same view. But I allude 
 here to the subject principally to observe that we may yet find further 
 means of strengthening the weakened tissues, by indurating and 
 contracting the upper and posterior portion of the vagina, as by the 
 use of caustics, thus taking advantage of that contracting and 
 strengthening power of the new tissue of cicatrices which burned 
 surfaces particularly have. I think I have seen the application of 
 
 VOL. I. 14 
 
210 DISEASES OF THE UTERUS. 
 
 nitric acid and potasaa to the posterior lip of the uterus produce 
 replacement. 
 
 BIBLIOGRAPHICAL NOTE. 
 
 In the fifth century ^tius treated definitely and at length, of , 
 retroversion of the unimpregnated uterus (Tetrabiblos, sermo iv. 
 cap. 77) ; Moschion has left us some notices of it (Spachius' GynaBcia, 
 p. 24) ; and in his work on female diseases, Roderic a Castro has 
 some observations upon it (De Universi Muliebrium Morborum 
 Medicin^, p. 274). In modern medical literature, the first individual 
 case of retroversion of the unimpregnated uterus that was put upon 
 record was reported by Saxtorph, in 1775 (CoUectania Hauvniensia, 
 vol. ii. p. 129). In 1779, "Willich described a second case (Eichter's 
 Bibliothek, vol. v.) In 1786, in a woman who died of pulmonary 
 disease, Peter Frank found the uterus greatly retroverted, and pub- 
 lished a notice and drawing of the displacement (Opuscula Posthuma, 
 p. 78). In 1787, Jahn noticed its occasional occurrence in the un- 
 impregnated uterus, but considered it " too obscure and too unim- 
 portant to deserve the name of a disease" (Dissertatio de Utero 
 Retroflexo, in Schlegel's Sylloge Operum Minorum Prsestantiorum 
 ad Artem Obstetricam, &c., p. 612). A few years subsequently, 
 Schneider (Richter's Bibliothek, vol. xi.) and Kirschner (Stark's 
 Archives, vol. iv.) published each a case of this afiection. In 1817, 
 Schweighauser pf Strasburg pointed out that retroversion of the 
 unimpregnated uterus was far from being rare, and he asserted it to 
 occur much more frequently than in the gravid uterus (Aufsatze 
 liber einige Physiologische und Praktische Gegenstande der Geburt- 
 shiilfe). In 1820, Schmitt published at Vienna an essay taking the 
 same view (TJeber die Zuriickbeuguug der Gebarmutter bei Mcht- 
 schwangeren, &c.) Subsequently individual cases of retroversion of 
 the unimpregnated uterus, or more general remarks regarding it, 
 have been published by D'Outrepont (Zeitschrift fur Geburtskunde, 
 1827), Denman (Introduction to the Practice of Midwifery, p. 138), 
 Cooper (Anatomy and Surgical Treatment of Abdominal Hernia, 
 part ii. p. 59, 1827), Robertson (Edinburgh Medical and Surgical 
 Journal, 1822, vol. xviii. p. 520), Velpeau (Traits de I'Art des Ac- 
 couchemens, vol. ii. p. 622), Bazin de Basseneville (Memoire sur la. 
 Retroversion de I'TIterus, 1837), Moreau (Traits Pratique des Ac- 
 couchemens, vol. i. 1838), &c. &c. I have referred in a preceding 
 page to the first observations which I published on the matter, in 
 the Abstract of the Proceedings of the Medico-Chirurgical Society 
 of Edinburgh. I shall extract these remarks fi-om the Monthly 
 Journal of Medical Science for July, 1843, p. 660 : " As one of 
 
BIBLIOGEAPHT OF KETROVBRSION. 211 
 
 the Inost important of all these applications of the uterine bougie, 
 Dr. Simpson demonstrated that, by showing the direction ©f the 
 uterine cavity, and hence of the uterus itself, and by its enabling us, 
 when it is introduced, to change at will the position of the organ, it 
 afforded a simple means of detecting those displacements of the un- 
 impregnated uterus known by the names of retroversion and retro- 
 flexion and anteversion and anteflexion — states, that Dr. Simpson fur- 
 ther showed were very common, and which, from the want of proper 
 means of diagnosis, had been almost constantly mistaken for fibrous, 
 carcinomatous, and other tumors situated between the uterus and rec- 
 tum, or between the uterus and bladder. In cases of retroflexion and 
 anteflexion of the unimpregnated uterus, the organ can with facility 
 be temporarily restored to its normal position and relations, by turn- 
 ing the uterine bougie, when used as a means of diagnosis. Dr. 
 Simpson proposed to maintain and fix the bougie in the uterine 
 cavity for a length of time as a means of cure. He laid before the 
 Society a number of utero-vaginal pessaries, which had been used 
 by him for this purpose. They were constructed of nickel and silver- 
 vsdre, and had each attached to them a part which passed up to the 
 fandus uteri. Some of them had been worn for weeks and months 
 in the uterine cavity, and had produced little or no irritation." In 
 1846, Dr. Eigby published some excellent and accurate observations 
 on the disease (Medical Times, p. 292, &c.) ; and more lately Dr. 
 Protheroe Smith has written on the subject (Obstetric Eecord, p. 35, 
 &c.) ; see, also, Mr. Hensley (Provincial Medical and Surgical Journal 
 for January, 1848) ; and Dr. Beatty (Dublin Journal for l*[ovember, 
 1847); &c. 
 
 Although the treatment of uterine displacements by intra-uterine pessaries seems to be 
 generally known to the profession, it has by no means become universally adopted — great, 
 and as experience proves, unnecessary fears being entertained as to the safety of introducing 
 instruments into the uterine cavity. Still further obstacles seem to have been thrown in the 
 way by the recent report of M, Depaul to the French Academy. For ourselves, we can only 
 say, that though we have witnessed a great number of cases treated by these means in the 
 practice of Dr. Simpson, as also in the Hqpital de la Piti^, under the care of M. Valleix, and 
 have sometimes seen such irritation produced as to necessitate the withdrawal of the instru- 
 ment, we have never observed a fatal result follow the introduction of an intra-uterine pessary 
 That such may follow, we are not prepared to deny ; all we wish to insist upon is, that dele- 
 terious results in any form are the exception and not the rule ; and we can testify that many 
 patients, who for years had been wretched invalids, are now, from their employment, enjoying 
 comparative health and comfort. — (Ed) 
 
212 DISEASES OF THE UTEKUS. 
 
 ASCENT OF THE UNIMPREGNATED UTERUS 
 
 (ELEVATIO UTERI.) 
 (From Edinburgh Monthly Journal of Medical Science, October, 1852, p. 366.) 
 
 ]S"o subject in uterine pathology is better known to the practitioner 
 than the displacement of the uterus downwards, or the so-called 
 Prolapsus Uteri. But the occurrence of the ascent, or displacement 
 of the uterus upwards, has been left comparatively unnoticed. In 
 my observations on paracentesis, I have alluded to its elevation and 
 position upwards in front of an enlarged ovarian tumor, as occa- 
 sionally rendering it liable to be injured by the trocar of the surgeon. 
 Voison has published a case in which the elevated uterus was fatally 
 wounded from this cause, in the operation of tapping an ovarian 
 dropsy.' I have seen several instances of multilocular dropsy of the 
 ovary, in which the uterus was drawn up and elevated more or less 
 in front of the ovarian tumor, but only very rarely so as to be beyond 
 the reach of the finger. The same upward displacement, or Elevatio 
 Uteri, occasionally happens in connection with the presence of fibrous 
 uterine tumors. In cases of fibrous tumors, I have known this dis- 
 placement so great that the os and cervix uteri could not be readily 
 or at all reached by a vaginal examination with the first finger or 
 fingers of the right hand, till the mass of the tumor was pressed 
 downward, and, at the same time, somewhat rotated forwards upon 
 its transverse axis by the left hand placed externally upon the abdo- 
 men. "Within the last two weeks, I have met with an instance of 
 this elevation of the' uterus to a higher degree than I remember to 
 have previously observed. The displacement in this instance has 
 occurred in connection with the presence of several large fibrous 
 tumors in the uterine parietes. 
 
 Case I. — The patient, aged forty, had been married twenty years, 
 had borne one child about a year after marriage, but had never been 
 again pregnant. The abdominal cavity is now distended by a mass 
 of dense, firm, fibrous uterine tumors, which stretch upwards to 
 nearly ;the scrobiculus cordis, and are altogether as large as the 
 uterus in the eighth month of pregnancy. The mass consists of one 
 great tumor stretching upwards above the umbilicus, and superadded 
 to this are several comparatively smaller masses above and laterally, 
 forming tuberose elevations and projections upon the sides of the 
 larger central tumor. One of these smaller tumors, situated towards 
 
 ' Recueil Periodique de M^decine, vol. vii. p. 362. 
 
UPWARD DISPLACEMENT. 213 
 
 the left side, of a flattish form, and about two and a half inches 
 broad, is pediculated and mobile, like a peritoneal polypus. On 
 examination per vaginam, a rounded elongated portion of the largest 
 tumor is felt pressing low down into the pelvis, and filling up the 
 space in front of the rectum. The vagina, from the lowest point of 
 the tumor upward, is narrowed and flattened between the tumor and 
 the pubis ; but the finger, when passed along this contracted canal, 
 cannot reach the os or cervix uteri. In fact, a sound passed into 
 this canal runs a considerable distance upward from the vulvS, before 
 it touches the upper extremity of the vagina, and consequently before 
 it reaches the cervical portion of the elevated uterus ; and the end 
 of the sound arrested at the junction of the va;gina and uterus can 
 be felt through the abdominal parietes as high as two and a half inches 
 above the edge of the symphysis pubis. The body of the uterus can be 
 felt as a flattened projecting mass above this part. 
 
 This patient, who has come for medical advice from Australia, 
 was there considered to be laboring under ovarian dropsy; and 
 it was supposed to be a case admitting of removal by operation. 
 But that it is a fibrous tumor, and not a multilocular cyst of the 
 ovary, is certain from its slow growth, from the density of the 
 tissue of the tumor, fi'om the arrangement alluded to of superadded 
 external tumors, and fi-om one of these superadded tumors having 
 become pediculated like an external polypus — a morbid arrange- 
 ment which we never see" in ovarian disease. Besides, there is this 
 common, and, as I believe, pathognomonic sign present, that in 
 various parts of the larger tumor, and particularly on its right side, 
 a loud'souflle is heard synchronous with the pulse, when the stetho- 
 scope is used — a phenomenon very common in fibrous tumors 
 imbedded in the substance of the parietes of the uterus, but which 
 I have never met with in any instance of dropsical disease of the 
 ovary. The affirmative evidence of the enlargement being a 
 fibrous uterine tumor, which can be usually derived from the 
 simultaneous movement and union of the mass of the tumor with 
 the body and cervix uteri, under a combined abdominal and vagi- 
 nal examination, is here of course wanting ; in consequence of it 
 being impossible to reach the elevated uterus. N'or, for the same 
 reason, can we take advantage of those other means of diagnosis 
 between fibrous tumors of the uterus and cystic degeneration of 
 the ovary, which depend upon the respective measurements of the 
 length of the cavity of the uterus in these two diseases, as ascer- 
 tained by the employment of the uterine sound. 
 
 At present I have under my care, from Berwickshire, a case of 
 very large fibrous tumor of the uterus, in which the os uteri is 
 elevated above the pubis ; though not to the great height men- 
 tioned in the preceding instance. 
 
214 DISEASES OF fHB UTEKUS. 
 
 Case II.— The patieM, set. 38, has been married seventeen years, 
 but has had no family. Menstruation has been regular ; and only 
 lately somewhat menorrhagic. Her general health is good. About 
 years ago she first noticed an abdominal enlargement, which has 
 gradually and slowly increased. The tumor is now of as great size 
 as the uterus at the ninth month of pregnancy. It touches the 
 lower edge of the ribs upon the right side. Its external form, 
 however, is somewhat irregular, particularly from a large projection 
 upon it 'towards the right iliac region. The tumor is not so firm 
 in consistence as fibrous tumors generally are ; and towards its 
 centre, and near the umbilicus, it feels comparatively so soft as to 
 give a deceitful idea of fluctuation, like that sometimes imparted 
 by subcutaneous adipose tumors. Three months ago a trocar was 
 passed in this situation, without drawing oflf any fluid whatever. 
 There is a deep musical souflle, synchronous with the pulse, to be 
 heard on the sides of the tumor, particularly on the left side. On 
 making a vaginal examination, the os uteri cannot be reached, but 
 a decreasing, conical-shaped cavity may be felt, passing up in front 
 of the tumor, and somewhat towards the left side. When the 
 patient is placed upon her face, and the finger deeply passed along 
 and behind the symphysis pubis, the os uteri can with considerable 
 difficulty be touched, lying above the upper edge of the pubis. 
 The uterine bougie, when introduced into the os, passes readily for 
 several inches, showing the uterus to be elongated and hyper- 
 trophied upon the side of the tumor. In this instance, there is no 
 projection downwards of the tumor, as in the preceding case, into 
 the pelvic excavation. The pelvic cavity is, in fact, quite free, and 
 the roof of the vagina is altogether higher than usual. 
 
 It does not seem difficiilt to understand the mechanism by which 
 the uterus becomes morbidly elevated in such cases of ovarian and 
 uterine disease as I have alluded to in the preceding remarks. If 
 an ovarian or fibrous tumor, attached organically to the back wall 
 of -the uterus, grow downward upon the roof of the vagina, or, in 
 other words, into the reflection of peritoneum between the rectum 
 and uterus, and develope itself steadily in this its lower segment, 
 the extension of the tumor in this downward direction, upon the 
 resisting roof of the vagina, forces the tumor to lift the uterus, 
 which is attached to the anterior surface or body of the tumor, 
 higher and higher with it during the longitudinal development of 
 the mass to which it is united. The tumor, in its downward longi- 
 tudinal development, necessarily carries upward more and more 
 the uterus afiixed to its anterior part; in the same way as the 
 uterus, in its own enlargement during pregnancy carries and 
 elevates upwards the Fallopian tubes and ovaries attached to its 
 
GOUT OF THE UTERUS. 215 
 
 two Bides. Or the enlarging uterine or ovarian tumor may, as in 
 the second case detailed above, obtain a similar elevating influence 
 upon the uterus, by resting its lower and growing segment upon 
 the pubis or sides of the brim of the pelvis, instead of upon the 
 roof of the vagina ; thus ultimately displacing the uterus upwards 
 by somewhat the same kind of mechanism, as the os and cervix 
 uteri are often, in common pregnancy, raised upwards and back- 
 wards above their usual level for some time after the uterus expands 
 into the cavity of the abdomen, and rests, during its enlargement, 
 upon the anterior circle of the pelvis. 
 
 Morbid ^ascent or elevation of the uterus sometimes occurs in 
 connection with other morbid states besides the two mentioned — 
 ovarian dropsy and fibrous uterine tumors. Occasionally, indeed, 
 the cervix uteri, and, consequently, the whole organ, is found 
 placed at an unusual height from the vaginal orifice as a natural 
 conformation ; and in advanced life, when the uterus becomes 
 atrophied, it sometimes is situated higher than natural, with the 
 vagina drawn upwards in a funnel shape. I have seen it displaced 
 upwards from diseased action in connection with, and as a result 
 of, pelvic cellulitis or pelvic abscess ; as well as from the effects of 
 simple pelvic peritoneal inflammation and adhesions {Perimetritis). 
 
 GOUT OF THE UTERUS. 
 
 (From Edinburgh Medical and Surgical Journal, January, 1854, p. 16.) 
 
 I HAVE seen several cases of inflammation of the uterus, or rather 
 of the uterine region, of the nature of simple gout, or rheumatic 
 gout ; or, at all events, I believed these inflammatory attacks to be 
 of this special pathological nature, in consequence of their co-exist- 
 ing with, or following immediately upon, the presence of undoubted 
 gout in other parts of the system. 
 
 In one instance, which I had the pleasure of seeing repeatedly 
 with Dr. Begbie last summer, the attack of uterine gout came on 
 during the existence of a marked prolonged fit of the same disease 
 in the fingers, &c. The principal organic effect, as ascertained by 
 vaginal examination, was effusion into the cellular tissue of the 
 broad ligaments (pelvic cellulitis), giving rise to tumefactions of 
 considerable size around the sides of the uterus. This pelvic 
 effusion was gradually absorbed under some local antiphlogistic 
 means, and the use internally of colchicum and other'medicines. 
 
216 DISEASES OF THE UTERUS. 
 
 About the same period I visited repeatedly, at some distance from 
 town, a lady, hereditarily predisposed to gout, who, after some pro- 
 longed constitutional derangement, was seized with excruciating 
 pain followed by redness and swelling, in and around the right ankle. 
 The agony attendant on this attack was so great, that she could not 
 move the limb in the least for two or three weeks. There were 
 large quantities of oxalates in the urine. After recovery, however, 
 did begin, convalescence was very rapid for two or three weeks ; 
 when she travelled home to her own residence, a journey of nearly 
 a hundred miles. Shortly after arriving, she was seized with severe 
 pelvic pain ; and two days subsequently there was a large inflamma- 
 tory swelling in the right broad ligament, and at the same time 
 much effusion of serum into the cellular tissue of the upper portion 
 of the posterior wall of the vagina. This last formed a tumor like 
 an orange, or larger, projecting backwards into the rectum. Under 
 leeches and mercury these swellings subsided, but with a rapidity 
 seldom or never seen in common cases of similar inflammatory 
 swellings attendant upon common pelvic cellulitis. 
 
 In the first case of uterine gout which I ever saw, now some years 
 ago, the lady suffered repeatedly and metastatically in the uterus, 
 simultaneously with, and sometimes after, the appearance of the 
 disease in the extremities. The uterus was very large ; was fixed 
 as if there had been perimetritis ; and in the attacks which I watched, 
 it appeared to me that the wall of the organ and the peritoneal sur- 
 face were usually the seats of the morbid action. In her there was 
 no effusion into the neighboring cellular tissue. 
 
 In none of the instances of gout of the uterus which I have 
 watched, have I seen the inflammatory action attack the neck of the 
 uterus, or the mucous membrane of the organ. Eheumatic inflam- 
 mation seems to do so. 
 
 We have extracted the preceding remarks from a paper by Dr. Begbie tipon Gout and the 
 Gouty Diathesis, to which they had been contributed by Dr. Simpson. — (Ed). 
 
 ON VESICO-UTEEINE, VESICO-INTESTINAL, AND UTERO- 
 INTESTINAL FISTULA, 
 
 AS RESULTS OF PELVIC ABSCESS. 
 (From Edinburgh Monthly Journal of Medical Science, December, 1852, p. 532.) 
 
 Cellular tissue exists abundantly within the pelvis, along the 
 lining of the' walls of the pelvic cavity, within the layers of the 
 
FISTTJLiE FROM PELVIC ABSCESS. 217 
 
 broad ligament, and between the intestinal, genital, and urinary 
 canals, at all those points in wbicli they come into organic coherence. 
 Inflammation of this tissue, or Pelvic Cellulitis, is a common aftec- 
 tion, particularly as a consequence of parturition, &c. Pelvic Cellu- 
 litis, after giving rise to great swelling and induration, by the effu- 
 sion of serum, coagulable lymph, &c., into the inflamed portion of 
 the cellular tissue, very often terminates sooner or later in resolu- 
 tion ; — the disease not unfrequently assuming a subacute or chronic 
 type. In other instances, however, the inflammatory action runs on 
 towards suppuration, and forms a so-called Pelvic Abscess. "When 
 this termination occurs, the collected purulent matter is found to 
 obtain egress by different outlets. The abscess sometimes bursts into 
 the intestinal canal, or into the genital canal, or into the urinary 
 bladder. Occasionally it discharges externally upon the cutaneous 
 surface ; and in a few rare instances it opens into the cavity of the 
 peritoneum. Sometimes the collected pus is found to make its 
 escape simultaneously, or rather consecutively, by two different exits. 
 Thus we may have the cavity of the same abscess opening into two 
 different pelvic mucous canals. Where such double perforations, 
 originating in the escape of matter from a pelvic abscess, become 
 chronic in their character, they lead to the formation of several 
 species of deep pelvic fistulse, which have not, so far as I am aware, 
 been hitherto described by obstetric pathologists. 
 
 Very few instances of the existence of fistula of any kind between 
 the bladder and uterus have hitherto been put upon record. Indeed, 
 the number of vesico-uterine fistulse hitherto recorded seems to be 
 limited to three instances, reported severally by Mad. Lachapelle, 
 Professor Stoltz, and M. Jobert ; and in all of these three cases, the 
 perforation which existed between the bladder and cavity of the 
 neck of the uterus was the result of injury during parturition. 
 
 In the following case this rare form of lesion was produced as a 
 consequence of pelvic cellulitis ; or, to speak more definitely, it was 
 produced by a purulent collection formed in the cellular tissue lying 
 between the bladder and the neck of the uterus, and which ulti- 
 mately ruptured — on one side into the bladder, and on the other side 
 into the cavity of the uterus, or rather the cavity of the cervix uteri. 
 
 Case I. — The patient, aged 22, and the mother of two children, 
 was admitted into the female ward of the Royal Infirmary in June 
 last. Her youngest child was then eleven months old ; and she had 
 made a perfect recovery after her confinement with it. About six 
 months, however, subsequently to her delivery, she was seized with 
 local pelvic pain, dysuria, and the usual symptoms of pelvic cellular 
 inflammation. Three or four weeks after the commencement of this 
 attack she had shiverings and perspirations, and other symptoms of 
 
218 DISEASES OF THE UTEEUS. 
 
 hectic fever. These symptoms were shortly followed by evidence of 
 the escape of purulent matter ; and subsequently complete incon- 
 tinence of urine came on. After this the urine continued to be 
 discharged per vaginam up to the date of her admission into the 
 hospital, four months after the commencement of the inflammatory 
 symptoms. The urine contained a considerable quantity of pus. 
 On examination, the urethra was found perfectly patent, although 
 the urinary secretion was not discharged through it. There was 
 still a considerable mass of fixed inflammatory deposit in front of 
 the cervix uteri, or in the cellular tissue between it and the posterior 
 wall of the bladder. The cervix uteri itself was considerably hyper- 
 trophied, particularly its anterior lip. That the urine passed from 
 the bladder through the os and cervix uteri, was ascertained by the 
 simple experiment of filling up the os uteri for a day with a small 
 sponge tent. During the time the cavity of the os uteri was stopped 
 up with this plug, the urinary discharge was evacuated through 
 the urethra ; but immediately began again, and continued, to pass 
 through the artificial vesico-uterine opening as soon as the sponge- 
 plug was withdrawn. After withdravidng the plug, the cervical 
 cavity, which had been dilated by its presence, was examined by 
 the finger, and tw6 apertures were found passing into it, or rather 
 leading from it — one, the normal aperture leading upwards into the 
 cavity of the uterus, as ascertained by the uterine sound — ^the other, 
 tending obliquely forwards towards the cavity of the bladder. This 
 latter artificial opening was freely cauterized by solid nitrate of 
 silver. Subsequently, local and general measures were employed, 
 as external counter-irritation, iodine, &c., to promote the absorption 
 of the inflammatory deposit. In the course of a few weeks the 
 swelling from the deposit between the bladder and the cervix uteri 
 diminished, the incontinence of urine became gradually lessened, 
 and was ultimately totally arrested ; the cure being, as I believe, 
 the result of the natural contraction of the parts, foUovsdng upon 
 the absoi-ption of the original inflammatory deposit. Subsequently 
 this poor patient was attacked with symptoms of acute pulmonary 
 phthisis, and died a short time ago at a distance in the country, but 
 without any return whatever of the incontinence of urine. 
 
 I have seen other cases of pelvic cellulitis which had run on to 
 suppuration, leave other forms of fistulous perforation, perhaps still 
 more strange and singular in their anatomical relations. 
 
 Two years ago, I had under my care, a case in which there was 
 produced as the result of this disease, a utero-intestinal fistula. 
 
 Case n. — A lady, a few days after her first confinement, was 
 
FISTULA FROM PELVIC ABSCESS. 219 
 
 attacked with symptoms of fever, and local pelvic inflammation. 
 These terminated in a very tedious pelvic ahscess. About a year 
 subsequent to her accouchement, she was brought to Edinburgh, 
 and placed for some time under my care. She still had considerable 
 thickening and pain on pressure in the left side of the pelvis, which 
 had been the seat of the pelvic cellulitis. The cervix uteri, and 
 indeed the whole uterus, was elevated upwards, and di'awn con- 
 siderably to the same side. On examining simultaneously, with the 
 lingers of the right hand on the roof of the vagina, and vrith those 
 of the left hand placed externally over the left iliac region, much 
 thickening and agglutination of the uterus and intestines could be 
 readily ascertai'ned in the left pelvic and iliac regions. Discharges 
 of slight accumulations of pus recurred from time to time through 
 the OS uteri ; and, occasionally, after these discharges, small quan- 
 tities of feculent matter were found in the vagina — showing a com- 
 munication to exist between the intestinal canal, at some part, per- 
 haps the sigmoid flexure, and the cavity of the uterus. Wlien the 
 canal of the cervix uteri was gently examined by a slender probe or 
 sound, a fistulous communication could be traced, passing up from 
 the cavity of the cervix laterally towards the left iliac region ; but 
 this sinus could not be followed for any great length. 
 
 In this case there was a constant tendency to the recurrence of 
 inflammatory attacks in the original seat of the pelvic inflammation, 
 some of which were extremely severe. The patient subsequently 
 removed to the south of England, where she died under, I believe, 
 one of these renewed inflammatory attacks. My friend, Professor 
 Lawrie of Glasgow, saw this case repeatedly. 
 
 Some time since, I was consulted by a patient, in whom there ex- 
 isted a still more rare and curious form of fistula, the result of a 
 pelvic abscess under which she had suffered. Professor Macfarlane 
 of Grlasgow, and Dr. Miller of London, also saw the case. Its pecu- 
 liarity consisted in this — that, as a result of pelvic abscess, a fistula 
 was formed between the bladder and rectum — arecto-vesical&stvla — 
 and yet the intermediate uterine and vaginal canals were not 
 implicated in it. The principal particulars regarding the case are 
 as follow: 
 
 Case m. — The patient, when about twenty-three years of age, 
 and unmarried, was attacked with fever and severe local inflamma- 
 tory pain in the pelvis and left groin. Aftor these symptoms had 
 continued for some weeks, she was at length relieved by the dis- 
 charge of a large quantity of purulent matter fi:om the rectum. 
 
220 DISEASES OF THE TJTEETJS. 
 
 About twelve months after the occurrence of this pelvic abscess, 
 she was considered so well as to be allowed to be married. But 
 from that time she suffered from repeated attacks of pelvic irritation 
 and inflammation, with leucorrhcea, irregular menstruation, &c. 
 She never became pregnant. Several years subsequent to marriage, 
 during one of these recurrent pelvic attacks, the bladder became 
 greatly irritated ; and after this painful dysuria had lasted for some 
 time, purulent matter was discharged along with the urine. Sub- 
 sequently to this period, and on to the time of her death, four years 
 afterwards, small portions of feculent matter and flatus passed from 
 time to time by the urethra, along with the urine — showing a com- 
 munication to exist between the intestinal and urinary canals. As 
 high up the rectum as could be reached with the finger, a fistulous 
 opening was traceable in the anterior and lateral part of the bowel, 
 and a probe could be passed forwards to some extent through it. 
 There was much thickening and agglutination of the pelvic tissues 
 at that part. ISTo treatment was of any avail in relieving the patient 
 from her distressing symptoms. She died ultimately of a short 
 illness, from, as reported to me by Dr. Miller, some affection of the 
 brain. 
 
 In the preceding and in other cases of pelvic abscess, the different 
 openings through which the matter becomes discharged do not, as I 
 have already remarked, always occur simultaneously, but generally 
 consecutively. After the purulent matter has escaped, apparently 
 with sufiicient freedom, by one opening, it will occasionally, in con- 
 sequence either of its temporary obstruction and retention in the 
 sac of the abscess, or in consequence of the walls of the abscess 
 themselves ulcerating, again open at a subsequent period into 
 another canal. The following case, which I had occasion to see 
 often under the kind and able care of Dr. Johnson of Stirling, will 
 serve to illustrate this remark : 
 
 Case rV. — A patient in the country was seized with acute symp- 
 toms of pelvic cellulitis ; and a large inflammatory tumor speedily 
 formed in the cellular tissue of the left broad ligament, and in the left 
 iliac fossa. In despite of the active antiphlogistic treatment that 
 was adopted the disease ran on towards suppuration, and dangerous 
 symptoms of irritative fever and exhaustion supervened, with great 
 local tenderness in the affected part. An exploring needle, intro-' 
 duced by the spine of the ilium into the inflammatory swelling, 
 lying in the iliac fossa, showed the presence of a deep collection of 
 pus. I evacuated it twice by a trocar, with great relief to the patient. 
 Pus continued to be freely discharged for a considerable time through 
 
fistulas: from pelvic abscess. 221 
 
 this artificial opening on the edge of the left iliac fossa. After this 
 discharge had gone on for some weeks, the opening from time to 
 time oft'ering to become nearly closed, a new and distressing symp- 
 tom supervened. For, along with a discharge of matter through 
 the artificial opening, there passed from time to time some flatus, 
 and occasionally a slight appearance of feculent matter — showing 
 that the abscess had ulcerated into the bowel, probably the sigmoid 
 flexure of the colon.. 
 
 In this instance, the spontaneous opening of the abscess into the > 
 intestinal canal did not, as I have said, occur till weeks subsequent 
 to the discharge of the matter through the external opening. After 
 this occurrence, the external fistula was attempted to be shut up by 
 various means, but for some time without avail. At last, by altering 
 the position of the external orifice, by a new incision, the whole ex- 
 ternal aperture was happily obliterated, and the patient has made 
 a perfect recovery. 
 
 In the preceding cases, the fistulous communications resulting 
 from the pelvic abscess were probably valvular in their form, inas- 
 much as apparently the fluids and air escaped through the track of 
 the fistula only occasionally, and not constantly. Perhaps, in some, 
 the transit of these matters was only efi^eeted when the canal of the 
 fistula was preternaturally distended by an accumulation withiii and 
 behind it of the morbid matters that passed ; the walls of the canal 
 at other times being so much, in contact as not to allow of the 
 passage of any foreign body. 
 
 In the case of vesico-intestinal fistula which I have mentioned-^ — 
 (see Case III.) feculent matter and flatus appeared to pass from the 
 bowel into the bladder ; but the patient was never aware of the urine 
 passing from the bladder backward into the bowel. It is quite 
 possible, however, that it may occasionally have done so in small 
 quantity, without her being able to recognize it distinctly. If it 
 were not so, then, in that case, the fistulous communication was of 
 such a valvular structure, as to allow of the transit of matters in 
 one direction, and not in another — a point in its anatomy, which 
 it is not difficult to conceive. 
 
 Since the preceding notes were written, I have received a com- 
 munication from an old pupil. Dr. Heslop, directing my attention 
 to a case published by him,' in which the left ovary was found after 
 death of the size of an orange, adhering intimately to the rectum 
 and bladder. The cavity of the enlarged ovary contained " a soft, 
 
 ' Dublin Quarterly Journal for 1850, p. 220. 
 
222 DISEASES OF THE UTERUS. 
 
 pultaceous, half-fsecal, half-caseous-looking matter;" and commu- 
 nicated posteriorly witli the lower portion of the sigmoid flexure of 
 the colon, and anteriorly with the urinary bladder. In this case a 
 fistulous communication seemed to be formed between the intesti- 
 nal and urinary canals, through the cavity of this diseased ovary; 
 and air, and probably feculent matter, are said to have passed occa- 
 sionally from the bladder for twelve months before death. The 
 patient had, in addition, a calculus in the left Mdney, enlargement 
 of the liver, &c. 
 
 Latterly Dr. Simpson has treated several of these cases of pelvic fistulEe successfully, by 
 repeated and frequent injections into their tracts of strong tincture of iodine. We have seen 
 one patient who had a complex fistula opening into the uterine cavity, attended with very 
 fetid discharges, quite cured in this way. Dr. Simpson has used injections of tincture of iodine 
 also as a means of diagnosis in such cases. In a patient who had come over from Holland 
 two years ago to be under his care, the iodine injected into an external fistulous opening in 
 the upper part of the thigh passed directly into the rectum — showing at once the course 
 of the fistula. We have seen him also occasionally make counter-openings below, and thus 
 effect a cure of the fistula. In one case of pelvic fistula of twelve years' standing, the 
 patient has perfectly recovered under this treatment. — (En.) 
 
 ON THE POSITION OF THE PATIENT FOR PARACENTESIS 
 IN OVARIAN DROPSY, 
 
 AND ON THE PLACE OF PUNGTURE.i 
 (From Edinburgh Monthly Journal of Medical Science, October, 1852, p. 366.) 
 
 "When paracentesis is resorted to for the relief of ovarian dropsy, 
 the method in which the operation is performed among us is gene- 
 rally, if not invariably, the following : — The patient.is seated more 
 or less upright upon the edge of the bed, or upon a chair — a broad 
 bandage is placed around the lower part of the trunk, and the two 
 ends of it, crossed behind, are each intrusted to an assistant, with 
 the view of pulling and tightening it as an abdominal compress, in 
 proportion as the fluid is evacuated — and a small opening is cut in 
 the anterior part of the bandage, as an aperture by which a trocar 
 of sufficient size is introduced through the abdominal parietes into 
 the ovarian cyst. 
 
 The bandage or compress encircling the trunk is generally alleged 
 to be used with two objects : first, To aid by abdominal pressure in 
 the evacuation of the ovarian fluid ; and secondly, To secure the 
 patient against the chances of faintness and syncope upon the sudden 
 
 ' Read before Edinburgh Obstetric Society, Session XII. 1853. 
 
POSITION FOR PARACENTESIS. 223 
 
 withdrawal of sucli a large quantity of fluid from a person seated in the 
 upright position. Different kinds of compressing bandages, as linen, 
 flannel, caoutchouc cloth, &c. &c., have been recommended to be 
 employed; and the ends of them are sometimes slit or perforated, 
 with the view both of making the compression exerted by them 
 more complete, and of allowing the bandage to be run and applied 
 more easily and accurately in proportion as the abdomen diminishes 
 in size, during the evacuation of the contained fluid through the 
 trocar. I have seen the operation of paracentesis in ovarian dropsy 
 performed often, and by many different hands ; but I have rarely 
 seen the bandage run correctly, even when in the first instance it 
 was most carefully applied, and afterwards as carefully pulled by 
 the two assistants in charge of the two ends of it. As the fluid 
 is gradually evacuated, the bandage, in fact, is ever liable to lose its 
 proper adaptation to the diminishing shape of the abdomen ; or it 
 becomes oblique in its position, and, pressing upon the canula of the 
 trocar, threatens to displace it; or, as sometimes happens, it rolls 
 up, and strongly compresses one circle or portion of the abdomen, 
 leaving the other parts of the abdominal tumor comparatively un- 
 compressed and unsupported. Besides, any one who has acted as 
 an assistant in a case of tedious tapping, knows that the mere pulling 
 at the end of the bandage is a task sufficiently irksome and fatiguing. 
 
 Latterly, when performing the operation of tapping in ovarian 
 dropsy, I have placed the patient in the horizontal position, and dis- 
 pensed entirely with the use of the compressing bandage during the 
 operation, with I think, no small advantage and relief to the patient, 
 to myself, and to my assistants. If the patient be placed in the 
 supine position, there need be no dread of the tendency to fainting 
 and syncope, for the prevention of which the bandage is specially 
 recommended ; and at the same time, the contents of the dropsical 
 cyst or cysts, are, it appears to me, even more easily, and certainly 
 more completely, evacuated, than when the operation is performed 
 with the patient placed in the upright position. 
 
 In tapping an ovarian cyst in the horizontal position, the patient 
 requires to lie as near the front of her bed or couch as possible, with 
 the face of course turned towards it, and indeed, with the distended 
 ovarian sac projecting, if possible, over the edge of the bed. If it 
 is previously and accurately known that it is the right or left ovary 
 which is affected, and that there is a prospect of the tumor being 
 very completely evacuated of its contents by the operation, the 
 patient should lie upon the right side if it be the right ovary, and 
 upon the left side if it be the left ovary that is diseased. The trocar 
 is then introduced into the distended cyst at the usual part in the 
 abdominal parietes, and with the usual precautions. Towards the 
 
224 DISEASES OF THE UTERUS. 
 
 termination of the operation, the most complete evacuation of the 
 cyst may be secured when necessary, by turning the patient some- 
 what upon her breast, so as to make the puncture as dependent as 
 possible — and, when necessary by compressing the abdominal parietes 
 with the hands^the latter a proceeding which requires to be followed 
 in most cases of paracentesis in the upright position. One great dan- 
 ger attendant upon tapping an ovarian cyst consists in the liability 
 of air to go backwards into the emptied cavity towards the latter part 
 of the operation, when the stream through the trocar becomes im- 
 perfect, or actually intermits, in consequence of the irregularity of 
 the abdominal compression. I believe that this accident, and its 
 consequences, inflammation of the walls of the cyst from decompo-» 
 sition of its remaining contents, will be found to be much less liable 
 to occur when the patient is tapped in the horizontal position, and 
 the parietes of the abdomen are allowed to compress the cyst merely 
 by their own elasticity, and by the external pressure of the atmo- 
 sphere, than when the operation is performed with the patient sitting 
 upright, and with the compression in a special degree intrusted to 
 the proper adaptation and action of a bandage, the mechanism of 
 which is not easily regulated. Let me further add, that the prepara- 
 tions for the operation are far less formidable to the patient when the 
 tapping is performed in a horizontal position, and without bandages; 
 and, besides, the necessity of assistants to manage the bandage is 
 dispensed with. The compression itself of the bandage amounts to 
 a feeling of distress and suffering with some patients ; and I have 
 been strongly assured by those who have been tapped at different 
 times in both ways, that the absence of the bandage, combined with 
 the horizontal position, were great advantages to them, as far as 
 their feelings and comfort were concerned. It is almost unnecessary 
 to add, that the edge of the bed requires to be protected by several 
 plies of sheeting or towels ; and, if deemed necessary, a bandage 
 may be placed round the abdomen, when the patient lies back in 
 bed, subsequent to the operation, particularly if the abdominal 
 parietes are greatly relaxed, and the remaining mass of ovarian 
 tumor feels very loose and mobile in the cavity of the abdomen. 
 Sometimes, however, I have dispensed even with this secondary 
 bandage. 
 
 In performing paracentesis for the evacuation of an ovarian cyst, 
 the trocar is usually introduced in one of two situations, viz., either 
 centrally, in the course of the linea alba ; or laterally, in the course 
 of the linea semilunaris. It perhaps is of little moment which of 
 these two places is adopted, provided only the trocar is introduced 
 in a situation in which the fluctuation is very distinct, and the 
 parietes of the cyst thin and equal, and in which, therefore, the in- 
 strument easily reaches the cavity of the cyst. 
 
POSITION FOR PARACENTESIS. 225 
 
 In selecting the place of the puncture, it must be held in remem- 
 brance, that various causes may render the introduction of the 
 trocar at particular sites difficult and dangerous ; and that the pre- 
 sence of one or other of these causes should induce us to select 
 another situation. For example : — First, The chance of wounding 
 the urinary bladder must be avoided. The evacuation of the organ 
 immediately before the operation, is our best security against this. 
 Secondly, The uterus is sometimes elevated and drawn upwards in 
 front of an ovarian tumor, and has been fatally wounded by the 
 trocar in the operation of paracentesis. This ascent and displace- 
 ment of the uterus can be ascertained before the operation ; and all 
 *chance of injuring it would be avoided, if, as I have already stated, 
 a point in the cyst sufficiently fluctuating and thin in its parietes, be 
 selected as the site of the puncture. Thirdly, Ovarian cysts have 
 been occasionally found so turned upon their axes, that the elon- 
 gated Fallopian tube has stretched across the diseased ovary, and 
 interfered with the introduction of the trocar ; and a dense, fibrous 
 state of the cyst at particular parts has led to the same mischance — 
 the cyst thus becoming merely displaced and not perforated by the 
 pressure of the point of the instrument. A case of obstruction to 
 tapping from this cause is detailed by Dr. Bright, in the Guy's Hos- 
 pital Eeports. The puncture, in consequence, must not be made 
 over a point which feels unequal and condensed in its structure. 
 Fourthly, In the later stages of ovarian dropsy, the tumor often so 
 compresses the contents and parietes of the abdomen, that the cir- 
 culation of the blood through the abdominal portion of the vena 
 cava is much interfered with. I have twice, in dissection of ovarian 
 dropsy, seen the cavity of the vena cava obstructed from this cause. 
 In consequence, a vicarious venous circulation is set up in many cases 
 through the superficial veins of the abdominal parietes which hence 
 become greatly enlarged. These veins are often seen of the size of 
 goose-quills or larger, and running immediately beneath the skin. 
 In paracentesis, the wounding of one of these large veins with the 
 trocar must be carefully avoided. Lastly, The epigastric artery has 
 been opened by the instrument in ovarian paracentesis. It is on 
 this account that some authors have advised us to select the linea 
 alba in preference to the linea semilunaris, as the site of puncture. 
 Mr. South relates a case, however, in which this artery was fatally 
 wounded when the tapping was made in the first of these sites — the 
 linea alba. Coitimon care, and a little examination beforehand for the 
 seat of a pulsating artery in the thin and distended abdominal parietes, 
 should enable us to avoid this source of danger. And if we avoid 
 this difficulty, and at the same time select as our proper site for the 
 operation, the part where the fluctuation is most distinct, and the 
 
 VOL. I. 15 
 
226 DISEASES OF THE OVAKT. 
 
 parietes of the sac most tMn and equable, it matters not whether 
 that be in the course of the linea alba or of the linea semilunaris. 
 The latter is perhaps the best, because the most dependent site, if 
 we have our patient lying, during the operation, in the horizontal 
 position. 
 
 It has been suggested by Callisen, Macarn, Delpech, Eeeamier, 
 Arnott, and others, that dropsical ovaries should be tapped through 
 the roof of the vagina in preference to the abdominal walls. If the 
 so-called ovarian cyst is unilocular, its contents may certainly be 
 evacuated by this means, as well as by tapping through the parietes 
 of the abdomen ; and I have more than once evacuated the contents 
 of a dropsy of the Fallopian tube, by introducing the small trocar, ' 
 which forms the usual exploring needle, in this position. In one 
 of these cases the elongated sac formed by the distended Fallopian 
 tube inflamed after its evacuation, and, in consequence, 'seemed, to 
 become entirely obliterated. The patient, a lady from New York, 
 had previously been almost incapacitated from taking exercise, and 
 had been in bad health for several years. Since her return home 
 she has been pregnant, and borne a dead child. But it is excessively 
 rare that a true ovarian dropsy, so distended as to require tapping, 
 is unilocular. In forty-nine cases out of fifty, or perhaps in a larger 
 proportion, the enlarged ovarian dropsy requiring the operation of 
 paracentesis, consists of the multilocular form of degeneration of 
 the organ. And in this compound or multilocular cystic dropsy of 
 the ovary, paracentesis by the vagina can very seldom readily or 
 safely evacuate the contents of the diseased mass. For, in the ope- 
 ration of paracentesis in the common multilocular form of ovarian 
 dropsy, we evacuate merely the contents of the largest cell or cells 
 in the mass ; and we reach this largest cell or cells easily through 
 the abdomen, but cannot usually reach them readily through the 
 vagina. This important circumstance depends upon|a simple patho- 
 logical law, which has not been adverted to, as far as I know, in 
 any of the numerous essays or observations, which have been pub- 
 lished on ovarian disease. Cystic tumors of the ovary, like other 
 morbid tumors and collections, increase always most readily and 
 rapidly towards that direction in which there exists the least physi- 
 cal resistance to their growth ; and on the other hand, most slowly 
 and imperfectly towards that side or sides on which they meet with 
 most opposition to their mechanical development and increase of 
 size. Ovarian tumors do not usually grow readily, or largely, to- 
 wards their inferior or pelvic sides, because the resistance of the 
 floor of the abdomen and pelvic parietes offers in that direction suf- 
 ficient impediment to their development. But they increase and 
 develope readily in an upward direction towards the abdomen, because 
 
POSITION FOR PARACENTESIS. 227 
 
 in that direction they meet with comparatively little resistance or 
 opposition to their growth. And while the cells in the pelvic por- 
 tion of the remaining multilocular tumor are, as far as I have exa- 
 mined them in a considerable number of preparations and dissec- 
 tions, usually very small in size, however great in number — ^we 
 have on the contrary, in consequence of the above pathological law, 
 the largest cyst or cysts in the mass generally, if not always, placed, 
 first, at the upper or abdominal extremity of the tumor — and, se- 
 condly, on the anterior part of the abdominal tumor, rather than on 
 its lateral or posterior parts — the cyst or cysts in front growing more 
 readily, because they are less" resisted in their growth by the abdo- 
 minal parietes in Jfront, than the cyst or cysts placed towards the 
 sides or back of the tumor, inasmuch as these latter are repressed 
 by the denser fabric of the lateral and posterior walls of the abdo- 
 minal cavity of the patient. It is, I repeat in consequence of this 
 pathological arrangement, that, fortunately, by the operation of ab- 
 dominal paracentesis, we are usually able to evacuate the largest cyst 
 or cysts in the mass ; and in consonance also with the same law, 
 the contents of such more prominent cyst or cysts are usually far 
 more fluid, and hence more easily capable of being evacuated 
 through the trocar, than are the contents of the more condensed 
 and undeveloped cysts of the tumor. In fact, the larger and more 
 anterior cyst or cysts have often their contents sufficiently fluid for 
 evacuation by paracentesis, at the very time that the more undeve- 
 loped and more compressed cysts still contain a thick gelatiniform 
 matter, quite incapable of being evacuated through any trocar. 
 
 It is almost unnecessary to add, that the horizontal position of 
 the patient answers as well for paracentesis in ascites as for paracen- 
 tesis in ovarian dropsy. It sometimes happens that the two are 
 combined in a greater or less degree. A few days ago I saw, with 
 Mr. Goodsir, a case of this combination, viz., a very large multilo- 
 cular ovarian tumor floating in, and surrounded by a quantity of 
 ascitic fluid. On placing the patient in a horizontal position, the 
 ovarian cyst was first evacuated of its contents, which were of a very 
 dark brown color, and mixed with old-effiised blood. After the 
 ovarian cyst was completely emptied, a second puncture of the 
 abdominal parietes was necessary, while the patient was still lying 
 in the horizontal position, to remove the collection of ascitic fluid. 
 
228 DISEASES OP THE OVARY. 
 
 PLASTER-BELT IN ABDOMINAL TUMORS, ETC.* 
 
 (From Edinburgh Monthly Journal of Medical Science, June, 1848, p. 887. 
 
 Dr. Simpson stated, that patients affected with pediculated ovarian 
 tumors, large fibrous tumors of the uterus, &c., often suffered from 
 the morbid masses being loose and mobile, and impinging on the 
 bladder, &c., in different positions of the body. Patients sometimes 
 instinctively applied their hands to the tumors, under >uch circum- 
 stances, to steady and fix them. In these cases different means had 
 been tried, with the view of preventing the tumors rolling and 
 moving — such as various bandages, air pads of Mackintosh cloth, 
 &c. The best and simplest means, however, consisted in surround- 
 ing the whole trunk with a continuous belt of lambskin or chamois 
 leather, eight or ten inches deep, and shaped and sewed so as care- 
 fully and exactly to fit the loins and lower part of the abdomen of 
 the patient, like a common abdominal bandage, and embossed in 
 front so as to contain and include, as in a bowl or cup, the protube- 
 rant portion or portions of the tumor. To fix the belt, its interior 
 was spread with a plaster composed of one part of adhesive to two 
 parts of soap plaster. It generally gave the patient much relief; 
 abated the feeling of abdominal weight and pressure and pain in 
 the back ; held the tumor steady ; and could be applied so as even 
 to compress it. In other cases where no tumors were present, but 
 the abdominal parietes and contents were relaxed, or the spine weak, 
 the same form of plaster often afforded a great degree of comfort 
 and relief, and enabled patients to take exercise, &c., when, other- 
 wise, they could not without fatigue and suffering. They generally 
 required to be removed and renewed every four or six weeks. 
 
 ON INFLAMMATORY AND NON-INFLAMMATORY RUP- 
 TURES OF OVARIAN DROPSICAL CYSTS. 
 
 (From Edinburgh Monthly Journal of Medical Science, December, 1852, p. 52.) 
 
 The common multilocular dropsy of the ovary may terminate 
 fajtally in various ways when left altogether uninterfered with by art. 
 
 In some cases, when the tumor at last reaches those enormous 
 dimensions which it sometimes acquires, the mere strong com- 
 
 » Extracted from Proceedings of Edinburgh Obstetric Society, March 12, 1848. 
 
EUPTTJRE OP DROPSICAL CYSTS. 229 
 
 pression laterally, backwards, and forwards, of the diseased mass 
 upon the various abdominal viscera, vessels, and walls, and upwards 
 upon tbe diaphragm and thoracic organs, proves sufficient in itself 
 to lead gradually on to a fatal termination, preceded by marasmus, 
 exhaustion, dyspnoea, &c. In such instances there is a slow but 
 increasing physical clog set to the machinery of various organs that 
 are necessary to the continuance of life — more particularly to the 
 processes of nutrition and assimilation; but latterly, even respira- 
 tion and circulation come to be more and more interfered with : till 
 at last the impaired and obstructed mechanism of the body is fatally 
 arrested. Very often, however, before such a termination occurs, 
 oedema, particularly of the- lower extremities, and ascites, come to 
 be superadded, hastening the fatal result by their presence ; and 
 almost always it is also hurried onward by the supervention, during 
 the last stages of the disease, of a greater or less amount of irri- 
 tative fever. 
 
 But patients suffering under dropsy of the ovary do not always 
 die from the mere mechanical increase of the tumor, and its mere 
 mechanical pressure and irritation. Much more frequently inflam- 
 matory action attacks the walls or dissepiments of the diseased mass 
 during the latter stages of its growth, and expedites the progress of 
 the malady towards a fatal termination. Occasionally the inflam- 
 matory action recurs from time to time in the same cyst or in dif- 
 ferent cysts, accompanied with fever and local pains, generally of a 
 slight and obscure kind. Under repetitions of such attacks, the 
 cysts rapidly increase in size, inflammatory effusions being poured 
 into their cavities or deposited upon their lining-membranes ; and 
 sometimes the intervening septa and walls of the tumor become dis- 
 eased and broken down under them. Its external or peritoneal sur- 
 face is frequently also the seat of inflammatory efiusions, and of 
 consequent local adhesions between it and the neighboring viscera 
 and surfaces. One or more cysts, left vrith purulent effusions in 
 their cavities, or with the structure of their walls disintegrated, often 
 enough remain as permanent sources of local and constantly recur- 
 rent inflammatory action in the tumor. Hectic fever generally comes 
 to be set up in the system as a consequence ; and under the repeated 
 recurrence of such local and constitutional irritation, the powers of 
 life graduMly give way. 
 
 Again, occasionally, when inflammatory action, whether acute or 
 subacute in its course, is present in an ovarian multilocular tumor, 
 it proves fearfully more rapid in its course, and. leads to speedy 
 death by a different mode. For when the tumor, in one or more of 
 its cysts, is the seat of acute inflammation, such cyst or cysts some- 
 times become so over-distended by inflammatory effusions, as ulti- 
 
230 DISEASES OF THE OVARY. 
 
 mately to rupture, and allow of the escape of their contents into 
 the peritoneum. In these cases the walls of the over-dilated cysts 
 are occasionally rendered friable and lacerable in their structure by 
 the inflammatory action of which they are the seat, and in conse- 
 quence of this morbid softening of tissues, the rupture in question 
 the more readily occurs. In one or two cases, I have seen the walls 
 of the inflamed and ruptured cyst present ulcerations upon its inte- 
 rior, the perforation of the cyst in such instances being begun by 
 ulceration of the lining membrane and tissues of the cyst, and per- 
 forated by mechanical laceration of its exterior or peritoneal coat. 
 
 During the last two months I have met with two cases of rapid 
 death from the rupture of inflamed multilocular tumors of the ovary, 
 and the consequent effiision of their morbid contents into the cavity 
 of the abdomen. The first of these cases occurred in a patient 
 under my care in the ward set aside for female diseases in the Royal 
 Infirmary. She had been previously under the care of Dr. Brown 
 of Carronshore. 
 
 Case 1. — Mary "W — , set. 34, married, was admitted October 6, 
 1852. She had borne three children, the youngest of them now four 
 years old. In May last, she first observed a small rounded tumor ia 
 the lower part of the abdomen. The tumor was then of firm con- 
 sistence, painful on pressure, and slightly movable. At the date of 
 admission, the abdominal tumor was nearly as large as the uterus at 
 the full term of utero-gestation, and unequal and bosselated on its 
 surface. It was tense and painful under pressure, and a distinct 
 fluctuation could be traced in it. The os uteri was situated very 
 high in the pelvis {elevatio uteri), and the vagina was much narrowed 
 and stretched at its upper extremity. 
 
 During the week subsequent to her admission, the patient was 
 merely confined to bed for the sake of rest, and placed under some 
 simple antiphlogistic treatment. On the morning of October 13th, 
 seven days after she entered the hospital, she was suddenly attacked 
 with severe pain in the right hypochondriac region, preceded 
 by a feeling as if something had burst in the abdomen. This 
 pain increased in intensity during the forenoon, vdth great and 
 general tenderness of the abdomen on pressure. In the after part 
 of the day, nausea and vomiting supervened, and the pulse rose in 
 frequency and sank in strength. 
 
 On the following day, at the time of visit, she expressed herself, 
 however, much easier ; the abdomen was tense, and increased in 
 size, but scarcely now painful on pressure. The face, however, was 
 very pinched and anxious, the surface cold, and the pulse so small, 
 
RUPTURE OE DROPSICAL CTSTS. 231 
 
 that it could not be counted, and she was altogether so collapsed that 
 there seemed little hope of her surviving the attack. That night, 
 however, and during the subsequent day, she rallied considerably. 
 The pulse became stronger and reduced in frequency, and she im- 
 proved gradually for the next fifty or sixty hours. Five days, how- 
 ever, after this first rupture and attack of peritonitis another and 
 more fatal one supervened. For, early in the morning of the 18th, 
 when attempting to raise herself in bed, she was suddenly seized 
 with great renewed pain in the epigastrium, followed by vomiting 
 of greenish-colored fluid, extreme coldness of the surface, and other 
 symptoms of sinking and collapse. The pulse became impercep- 
 tible ; and she died within twelve hours. 
 
 On a post-mortem examination, the abdomen was found to con- 
 tain two or three quarts of turbid serum, while thick layers of un- 
 organized and recently secreted coagulable lymph covered the peri- 
 toneal surface of the ovarian tumor and the more exposed parts of 
 the abdominal viscera. At some parts, this layer of lymph was 
 fully an inch in thickness, but quite soft and easily broken down. 
 The left ovary was small and slightly indurated. The enormous 
 ovarian tumor which was present, was attached to the site of the 
 right ovary by a pedicle measuring about two fingers in breadth and 
 thickness. 
 
 On removing the tumor out of the abdomen, a quantity of dirty, 
 fetid, purulent fluid made its escape from an opening at the upper 
 and back part of its right side. The aperture was of such size as 
 to admit the forefinger. Its edges were ragged and ulcerated ; and 
 it exactly corresponded in position to the seat of pain, when the 
 symptoms of sinking first appeared. On cutting into the cyst with 
 which the opening communicated, it was found to contain upwards 
 of a pint of fluid such as has been described. The wall of the cyst, 
 for about an inch around the point of rupture, was much thinned 
 and softened, and presented a black color. 
 
 The remaining portion of the lining membrane of the cyst was 
 covered with patches of recent lymph, and red spots, having the 
 granulated appearance of the intestinal canal in, acute dysentery. 
 At the lower and anterior part of the left side of the ovarian tumor, 
 there existed another largish cyst, presenting similar characters when 
 cut into. Several of the smaller cysts of the tumor showed strong 
 signs of recent acute inflammatory action ; and pus oozed out in 
 various parts when the large multilocular mass was bisected. The 
 intervening septa were at some parts found to vary from half an inch 
 to an inch in thickness, and presented on division a fibro-cystic 
 structure. No other opening could be found in the external or peri- 
 toneal coat of the tumor, except the one already noticed. 
 
232 DISEASES OF THE OVAKT. 
 
 The following analogous case of fatal inflammatory laceration of 
 an ovarian dropsical tumor, has occurred still more lately in my 
 private practice. In this, as in the preceding instance, the tumor 
 was unusually rapid in its general growth. 
 
 Case n.— The patient, aged forty-three, was married in 1836, and 
 had been for two years a widow. She was the mother of three 
 children. Up to the middle of last year she enjoyed uninterrupted 
 good health. At that time she began to complain of pain in the 
 right side ; and at the commencement of the present year, the pre- 
 sence of an abdominal swelling was detected by her medical atten- 
 dants at Boulogne, where she was residing. In May last she came 
 to Edinburgh, and a large ovarian tumor was then easily diagnosed. 
 It continued to increase and soften with extreme rapidity ; and in 
 despite of antiphlogistic measures, iodine, &e., the abdominal swell- 
 ing and distension were so very great by the first week of September, 
 that tapping became necessary. Twelve imperial pints of a clear 
 glairy fluid were withdrawn, but the bulk of the tumor seemed not 
 much reduced in size by this evacuation ; and it was evident that 
 an enormous mass of cysts remained untouched, while a single and 
 comparatively small one only had been opened; She speedily re- 
 covered from this paracentesis. By the 16th of October the reaccu- 
 mulation of fluid was already so great, that tapping was again had 
 recourse to. The fluid now evacuated was of a dark color, and was 
 evidently commixed with pus and inflammatory secretions from the 
 lining-membrane of the perforated cyst. During the few following 
 weeks she complained occasionally of more or less pain and tender- 
 ness in the tumor, but was able to take some out-door exercise. On 
 November 17th, she walked to my house, a distance of about half a 
 mile, to ask if I would allow her again to begin the use of some 
 iodine which she had formerly taken. She became sick and vomited 
 on her return home, and subsequently complained of some abdo- 
 minal pain. Next day vomiting again recurred, and the pain became 
 far more severe and difiused over the whole abdomen. By evening 
 the pulse was very rapid, and almost imperceptible at the wrist, the 
 extremities cold, and the vomiting almost incessant. The symptoms 
 of sinking increased during the night, and she died on the following 
 day about two o'clock, retaining her consciousness to the last, and 
 expressing herself, for some hours previously, as free from all pain. 
 
 On making a post mortem examination, a very large multilocular 
 tumor of the right ovary was found, adhering in different parts to 
 the abdominal parietes. A quantity of yellow glairy fluid, mixed 
 with coagulable lymph, was effused into the cavity of the peritoneum. 
 Upon the right side of the tumor, immediately below the liver, two 
 
ETJPTITEB OF DROPSICAL CYSTS. 233 
 
 small apertures, in two different but neighboring cysts, were ob- 
 served ; and from tbese, fluid similar to that in the abdomen welled 
 out upon pressure. At that part of the tumor the cysts were exceed- 
 ingly numerous, and their walls, at various points, so transparent 
 and attenuated, that under slight pressure they burst, and had their 
 contents evacuated. 
 
 Most of the larger cysts in the tumor, and several of the smaller, 
 showed signs of high preceding inflammatory action in their pa- 
 rietes. Many of them contained pus in their cavities, and their 
 injected lining membrane was coated freely, in various parts, with 
 particles and layers of yellowish coagulable lymph. There were 
 perforations in the walls of most of the larger cysts, allowing of free 
 communication between their cavities and the cysts adjoining them. 
 
 In few or none of our accounts of the pathology of ovarian tu- 
 mors, are those morbid appearances described which are produced 
 by inflammation in ovarian multilocular cysts. But when the lining 
 membrane of a compound ovarian cyst is the seat of inflammatory 
 action, it generally presents, as in the preceding instances, morbid 
 appearances similar to those that we see upon inflamed normal 
 serous surfaces, such as the pleura and pericardium'. When the 
 effusion from the inflamed membrane is limited to serum merely, 
 this alone is scarcely traceable ; because it becomes at once com- 
 mixed with, and lost among, the normal serous or gelatinous con- 
 tents of the cyst. But pus is very often a result of inflammation of 
 an ovarian cyst, more particularly if the inflammation has been sub- 
 acute rather than acute in its type. The purulent matter is usually 
 not seen on tapping or dissection, till the very lowest part of the cyst 
 is emptied, for it is generally observed to have gravitated downwards 
 to the more dependent parts of it. Flakes and masses of loose 
 coagulable lymph are also often present in the contents of the in- 
 flamed cyst ; or the lymph is attached to the lining surface of it, in 
 the form of granulated spots, or larger patches and layers, or as an 
 organized false membrane covering the interior of the cyst. When 
 the coagulable lymph effused on the interior of an ovarian cyst be- 
 comes organized,' and the walls of the cyst again happen to be the 
 seat of renewed inflammation, blood is frequently poured out to a 
 greater or less extent into the cavity of the cyst, as in hemorrhagic 
 pleurisy; and this termination is perhaps more frequently the result 
 of inflammation of the ovarian cyst, than the result of inflammation 
 of any natural serous membrane. Occasionally the organized lymph 
 
 ' In the Anatomical Museum of the University there are some specimens of ovarian cysts 
 ■beautifully injected by Professor Goodsir, and the lymph on their interior is seen to be 
 highly vascular 
 
234 DISEASES OF THE OVAET. 
 
 deposited by inflammation upon the interior of an ovarian cyst, 
 becomes highly injected under subacute or chronic inflammation ; 
 and I have seen it give an appearance of roughness to the interior of 
 the cyst, as if it had been lined by mucous membrane, beset with 
 numerous elongated injected villi. In a few instances the interior 
 of an inflamed ovarian cyst becomes ulcerated, the ulcerated spots 
 being sometimes round, in other cases irregular. The perforations 
 of the walls of continuous cysts seem sometimes to be the result of 
 ulceration ; but more frequently, perhaps, they are ruptures produc- 
 ed by mechanical or inflammatory distension. And now and again 
 portions of the walls of a cyst, or of several cysts, are found dead and 
 gangrenous, either as the result of destructive inflammatory action 
 in their tissues, or from the circulation through them being mecha- 
 nically arrested by the compression and obliteration of the vessels 
 which supplied them with blood. 
 
 In both the cases which I have above described, the eflnision of 
 the contents of the lacerated ovarian cyst into the cavity of the 
 peritoneum, was followed by rapid and fatal peritonitis. But many 
 cases are on record, and I have myself seen several, in which the 
 rupture of ovarian cysts into the cavity of the abdomen, led to no 
 such pathological result. And it becomes not only an interesting, 
 but an important practical question to consider — 
 
 Under what circumstances is the rupture of an ovarian cyst followed by inflammatory action in 
 the peritoneum ; and under what circumstances does this dangerous consequence not supervene ? 
 
 I believe the proper answer to this question consists in a reference 
 to the condition and contents of the cyst at the time of its laceration. 
 If the walls of the cyst, previous to laceration, had been the seat of 
 inflammatory action, and its contents consist of inflammatory secre- 
 tions, or perhaps of some other forms of morbid irritating matter, 
 the escape of such morbific fluids intothe cavity of the peritoneum will 
 be found, I imagine, to give rise invariably to inflammatory action 
 in the peritoneum itself; and hence, to be always accompanied with 
 danger to the life of the patient. But if, on the other hand, the 
 cyst does not lacerate under inflammatory distension, but has either 
 given way in consequence merely of the gradual thinning and at- 
 tenuation of its own over-distended walls — or has ruptured under 
 external mechanical injury, as falls, &c., — and the fluid which escapes 
 through the laceration into the cavity of the peritoneum, is of the 
 mild unirritating character which naturally belongs to ovarian cysts 
 in an uninflamed condition, then inflammation of the peritoneum 
 has little or no tendency to supervene. The bland fluid which, 
 under these last conditions, becomes discharged into the cavity of 
 the peritoneum, is not a morbific irritant to that serous membrane, 
 
RUPTURE OF DROPSICAL CYSTS. 235 
 
 sucli as a fluid commixed with inflammatory secretions is. JSTay, 
 the lacerations of multilocular uninflamed ovarian cysts instead of 
 leading to imminent danger and probably speedy death, have fre- 
 quently, though accidentally, led to the actual preservation, or at 
 least to the prolongation, of the life of the patient. The explanation 
 of this result perhaps merits one or two remarks. 
 
 The interior of an ovarian cyst has no power whatever of absorp- 
 tion ; and consequently no diuretics, or deobstruents of any kind, 
 have any therapeutic influence on the reduction of an ovarian 
 tumor by removal of its fluid contents by the tissues of the tumor 
 itself. But if the bland uninflamed contents of an ovarian cyst 
 become evacuated by accidental rupture into the cavity of the peri- 
 toneum, they may be, and often are, readily absorbed from that 
 position ; the peritoneum being normally provided with abundant 
 absorbing powers, and these powers being generally capable of being 
 excited, when required, by the action of diuretics, &c. Consequently 
 when an escape of innocuous unirritating fluid takes place from the 
 sac of an ovarian cyst into the sac of the peritoneum, it may be, and 
 often is, rapidly absorbed and removed from the peritoneal cavity. 
 Cases occasionally occur where nature in this way from time to 
 time spontaneously taps, if we may so speak, an ovarian dropsy into 
 the cavity of the peritoneum ; thus ever and anon relieving the 
 patient of the recurrent accumulations of fluid. But another and 
 still happier result has sometimes followed the mechanical laceration 
 of an ovarian cyst into the peritoneal cavity. In fact, in repeated 
 instances it has been observed that in this way, a cure which may 
 be termed a permanent, though a palliative one, has taken place. 
 For, when the laceration in the walls of the ovarian cyst has been 
 originally large — or though originally small, has remained perma- 
 nently open — so as to allow of the continuous escape of the fluid se- 
 creted by the ovarian sac into the cavity of the peritoneum itself, 
 the peritoneum under these circumstances, has sometimes acted as 
 a permanent absorbing surface, removing constantly the fluid elimi- 
 nated by the lining membrane of the ovarian cyst, as a permanent 
 secreting surface. In these fortunate, but rare cases, another result 
 appears sometimes to follow, namely, the ovarian tumor, if it has 
 happened to contain one large and preponderating cyst, becomes col- 
 lapsed, the fluids which have originally escaped from its own cavity 
 surrounding and compressing its walls externally ; and the interior 
 of the cyst, thus kept with its walls in apposition, at last secretes 
 little or no fluid ; and possibly perhaps its sides may ultimately 
 adhere together in some very rare cases. 
 
 I am acquainted with the history of two cases in which the first 
 
236 DISEASES OP THE OVAET, 
 
 tapping of an ovarian dropsy has never been followed by any reac- 
 cumulation, the operation in both having now been performed several 
 years ago. And I believe that the secret of this very unusual termi- 
 nation in the two cases in question, is ascribable to the circumstance, 
 that the perforation formed in the walls of the ovarian cyst by the 
 trocar, has remained permanently open like a fistula, allowing of 
 the continuous drain of the ovarian fluid into the cavity of the 
 peritoneum. 
 
 Perhaps art will yet be able to imitate, both successfully and with 
 certainty in an appropriate set of ovarian cases, this fortunate acci- 
 dental termination. 
 
 Occasionally, after a patient has been often submitted to the ope- 
 ration of paracentesis, an accidental rupture of the ovarian cyst 
 has produced a comparatively permanent cure, as in the following 
 instance : 
 
 Case m. — ^A patient, now aged 56, the mother of five children, 
 and naturally of a very robust and strong constitution, had up to 
 the end of last year been tapped for ovarian dropsy 44 times by 
 myself and others. Latterly, the paracentesis was required eveiy 
 few weeks, and an enormous amount of fiuid was always evacuated. 
 I have repeatedly seen above four gallons of fiuid drawn off at a 
 single tapping. Last winter this patient slipped in walking upon a 
 frozen path, and so violently struck the abdomen and ovarian tumor 
 against the ground in her fall as to rupture the cyst. Since that time, 
 however, no new tapping has been required. The abdominal swell- 
 ing, though still large, is considerably less than it was at the time of 
 the fall, and does not increase in size. For a time the fiuid of the 
 cyst evidently escaped freely into the cavity of the peritoneum, and 
 was as regularly absorbed from it. Latterly there has been appa- 
 rently much less, or, indeed, no perceptible amount of fiuid in the 
 cavity of the peritoneum. For several months the patient's skin was 
 in an almost constant state of diaphoresis — a result which to her 
 appeared the more strange, as for years previously she had never 
 been able to excite any perceptible degree of perspiration. This 
 tendency to spontaneous diaphoresis has latterly decreased. The 
 urinary secretion was often previously affected, and greatly dimi- 
 nished as the ovarian tumor enlarged. Since the fall and rupture 
 of the cyst, the kidneys have continued to act very freely and 
 uninterruptedly, the urine secreted being now always clear and 
 limpid. 
 
 In the course of the preceding remarks, I have referred to the 
 rupture of ovarian cysts into the cavity of the peritoneum only; but 
 
RUPTUKE OF DROPSICAL CYSTS. 237 
 
 they rupture occasionally also into the intestinal, genital, or urinary 
 canals, or upon the external surface of the abdomen. When ovarian 
 cysts rupture, not into the peritoneum, but into these mucous canals, 
 or on the external cutaneous surface, it is a matter of little moment, 
 in relation to the life and safety of the mother, whether the cysts, 
 before bursting, have been inflamed or not inflamed, and whether 
 their contents be of an acrid and irritating, or of a bland and un- 
 irritating character ; for there is no danger to the mother from the 
 mere nature of the contents of the cysts when these contents have 
 once escaped into a free mucous canal, or upon the free cutaneous 
 surface of the body. And whatever may be the character of the 
 escaped or escaping fluid, we may equally hope for a temporary or 
 more permanent amelioration of the disease. If the opening is 
 slight and valvular, the fluid accumulating in the cyst may only 
 escape intermittingly or imperfectly ; if the opening is larger and 
 more permanent, the contents of the cyst are sometimes kept con- 
 stantly draining ofi" from the morbid cavity of the ovarian tumor ; 
 and this cavity has in consequence, in some cases, diminished and 
 collapsed to a degree amounting to a kind of perfect cure. 
 
 I have seen two or three instances in which ovarian cysts have 
 ruptured externally, or into the adjoining mucous canals. The case 
 which I have had an opportunity of watching the longest is the 
 following : 
 
 Case IV. — This patient felt a movable tumor in the abdomen, of 
 the size of the fist, about the age of sixteen or seventeen. I first 
 saw her about eight years afterwards, when the abdomen was greatly 
 distended by a dropsical ovary, larger than the uterus at the full 
 period of pregnancy. She was complaining greatly of the symp- 
 toms of over-distension. I removed the fluid by tapping in 1840. 
 Fifteen months afterwards the same operation was repeated, in con- 
 sequence of the reaccumulation of the fluid. But no paracentesis 
 has been required since that time ; and at the present date, IsTovem- 
 ber, 1852, she enjoys good health. A few months after the second 
 tapping, the patient had a tedious attack of typhus fever, accompa- 
 nied and followed by peritoneal inflammation. She was conflned 
 for many long weeks to bed. Some time after her recovery, and 
 when the tumor was again increased to a great size, there suddenly 
 supervened, one night on going to bed, much soreness in the tumor; 
 and this was followed ere morning by an abundant and large escape 
 of thickish clouded fluid from the genital canals. The tumor sub- 
 sided much in size under this discharge, which only, however, lasted 
 for a few days. Again, after this discharge ceased, the tumor in- 
 creased to an exceeding size ; and, on the patient one day twisting 
 
238 DISEASES OF THE OVARY. 
 
 herself round on the sofa, she felt, as she herself described it, 
 " something tear" in the right side. In the course of that day, a 
 clear limpid fluid again began to pour profusely from the vagina, 
 and the tumor immediately softened and decreased in size. This 
 discharge has since that time continued, and has now gone on for 
 several years. The discharge is always greatest when the patient is 
 lying or walking, but its total daily amount is at present not great. 
 The ovarian tumor is, she herself believes, now much less in size 
 than after its last rupture, though it is still larger in volume than 
 the adult head. It moves readily under pressure. The patient's 
 menstrual life is regular and normal in all respects ; she now enjoys, 
 as I have already stated, the most excellent health ; daily performs 
 active house duties ; and has latterly become so stout as to weigh 
 upwards of fourteen stone. 
 
 The seat of the opening between the ovarian cyst and the genital 
 tubes in the preceding case, it is of course impossible to ascertain. 
 But judging from the dissections which have been made in analo- 
 gous eases of ovarian cysts emptying themselves by the genital 
 canals, the seat of communication is, in all likelihood, between the 
 ovarian cyst and the Fallopian tube. Lately, Richard has shown, 
 that ovarian cysts do not so unfrequently as was formerly supposed, 
 communicate with the Fallopian tube, and that the cavity of the 
 tube in consequence often becomes distended with the fluid of the 
 adjoining cyst. But though thus distended, the tube is not in 
 many cases sufficiently open at its uterine extremity to allow of 
 the escape through the uterus of the contained fluid. Several cases, 
 however, have now been observed by Morgagni, Boivin, Eobertson, 
 and others, in which, after death, ovarian cysts have been found to 
 have such a free communication along the canal of the Fallopian 
 tube, and this tube again with the cavity of the uterus, that the 
 contents of the cyst escaped freely outward along the course of the 
 genital canals. 
 
 The desultory observations offered in the preceding remarks may, 
 perhaps, be all briefly recapitulated in the form of the following 
 conclusions : 
 
 1. The cyst forming an ovarian dropsy, occasionally rupture,^rsf, 
 from inflammatory efiusion into and distension of their cavities ; or, 
 secondly, the contents of the cysts, being only the common bland 
 secretion of such cysts, and unmixed with any inflammatory matter, 
 they may rupture from mere over-dilatation and gradual attenuation 
 of their coats, or under sudden mechanical pressure and injury. 
 
 2. When a cyst ruptures from the effects of inflammation, or con- 
 
INJECTIONS OF IODINE INTO OVARIAN CYSTS. 239 
 
 tains witHn it at tlie time of rupture inflammatory secretions and 
 materials, the escaping fluid, if effused into the cavity of the peri- 
 toneum, is always liable to be followed by dangerous, and generally 
 fatal, peritonitis. 
 
 3. If, however, a cyst bursts into the peritoneum under mechanical 
 injury, or in consequence of simple laceration from over-distension 
 of its cavity, and the fluid effiised into the sac of the peritoneum is 
 consequently not commixed with inflammatory secretion, there is 
 little or no great tendency to peritonitis. 
 
 4. Sometimes, indeed, when a non-inflamed ovarian cyst thus rup- 
 tures into the cavity of the peritoneum, the life of the patient is pre- 
 served, or at least prolonged, by this accident. 
 
 5. When an ovarian cyst ruptures into a mucous canal, or upon 
 the cutaneous surface, the safety or danger attendant on the lacera- 
 tion is not regulated by the inflamed or non-inflamed character of 
 the effused fluid. 
 
 6. In cases in which the fluid of an ovarian cyst obtains an outlet 
 by a mucous canal, or by the skin, a temporary or more permanent 
 reduction of the tumor- and comparative cure of it may be the con- 
 sequence. 
 
 Lastly, let me add that, as in many cases and points the surgery 
 of art is an imitation of the surgery of nature, possibly the artificial 
 repetition and establishment of the above modes of relief if they 
 could be imitated safely and certainly, may yet be found capable of 
 temporarily arresting, if not curing, ovarian dropsies in some appro- 
 priate cases ; and more particularly in instances in which the great 
 bulk of the tumor is formed by one original, large, preponderating 
 cyst, or by several cysts broken up and conjoined into one common 
 cavity or cell. 
 
 ON THE TREATMENT OF OVARIAN DROPSY BY INJEC- 
 TIONS OF IODINE INTO THE CYSTS.' 
 
 (From Edinburgh Monthly Journal of Medical Science, May, 1854, p. 467.) 
 
 It has been often proposed to treat dropsy of the ovaiy upon the 
 same principles as hydrocele or dropsy of the tunica vaginalis. In 
 accordance with this view, Dr. Hamilton, Scudamore, and others, 
 
 ' Read before Edinburgh Obstetric Society, Session XII. 1852-3. 
 
240 DISl^ASES OP THE OVARY. 
 
 have in former times injected ovarian cysts witli irritating solutions 
 of sulphate of zinc, &c. ; but the results have in general proved so 
 unfortunate and disastrous as to prevent a repetition of the practice. 
 
 In 1832, Mr. Martin first recommended the use of tincture of 
 iodine as the surest and safest injection for the cure of hydrocele ; 
 and this drug seems now almost universally adopted by surgeons in 
 the obliterative treatment of this variety of local dropsy in the male 
 subject. 
 
 Latterly, various surgeons, particularly Velpeau, Bonnet, Bellue- 
 rimi, &c., have extended the practice of iodine injections to the 
 treatment of other local dropsies and cysts ; to chronic abscesses ; 
 diseases of the joints, &c. And the past experience of surgeons on 
 the subject would certainly seem to show that while the local and 
 direct application of iodine to morbid secreting surfaces has a great 
 power of modifying, altering, and arresting even the secretory action 
 of these surfaces, and often changes suppurative into adhesive in- 
 flammation, it shows at the same time wonderfully little aptitude to 
 excite any excess of local irritation and pain. Hence naturally arose 
 the question whether it could be safely injected into such large cysts 
 as those of the common form of dropsical ovary. 
 
 In 1846, Dr. Alison of Indiana recorded the history of a chronic 
 case of ovarian dropsy that had been repeatedly tapped, and which 
 he injected at last with a solution of iodine. Severe symptoms fol- 
 lowed, but the ultimate result seems to have been favorable. In 
 1851, Dr. Simpson assisted Mr. Syme in injecting a cyst in the 
 neighborhood of the ovaries, but not a common cystiform ovary. 
 The symptoms which ensued were those of considerable excitement ; 
 but the orignal cyst apparently became obliterated. Another one 
 in its vicinity has lately shown itself in this patient. 
 
 "Within the last year Dr. Simpson has, subsequently to tapping, 
 injected into dropsical ovarian cysts the tincture of iodine in seven 
 or eight cases. Por this purpose he has employed the common tinc- 
 ture of iodine of the Edinburgh Pharmacopeia, undiluted. He has 
 usually thrown into the cyst two or three ounces of the tincture. In 
 some cases he has allowed a portion of the injected fluid to re-escape ; 
 in others has retained the whole of it in the sac of the cyst that was 
 tapped. From these cases he drew the following conclusions : 
 
 1. In none of the cases of ovarian dropsy treated with iodine in- 
 jections after tapping has he yet seen any considerable amount of 
 local pain follow the injection, with one exception ; in most instances 
 no pain at all is felt ; and in none has constitutional irritation or 
 fever ensued. In the one exceptional case, considerable local irrita- 
 tion followed ; and the pulse rose to 110 ; but the same phenomena 
 occurred in the same patient after previous tappings, without iodine 
 being used. 
 
INJECTIONS OP IODINE INTO OVARIAN CYSTS. 241 
 
 2. While the practice seems thus so far perfectly safe in itself, it 
 has by no means proved always as successful as in hydrocele, in pre- 
 venting a reaccumulation of the dropsical fluid ; for in several in- 
 stances the efliision into the sac seems to have gone on as rapidly as 
 after a simple tapping without iodine injection. 
 
 3. But, in two or three of the cases, the iodine injection appears 
 to have quite arrested, for the time being, the progress of the dis- 
 ease, and to have produced obliteration of the tapped cyst, as there 
 is no sign whatever of any reaccumulation, though several months 
 have now elapsed since the date of the operation. 
 
 Lastly. Accumulated experience will be required to point out 
 more precisely the special varieties of ovarian dropsy most likely to 
 benefit from iodine injections, the proper times of operating, the 
 quantities of the tincture to be injected, and other correlative points. 
 Perhaps the want of success in some cases has arisen from an insuffi- 
 cient quantity of iodine being used, and from the whole interior of 
 the cyst not being touched by it. The greatest advantage would of 
 course be expected from it in the rare form of unilocular ovarian 
 cysts. In the common compound cyst, the largest and most pre- 
 ponderating cyst is usually alone opened in paracentesis ; and though 
 it were obliterated, it would not necessarily prevent some of the 
 other smaller cysts from afterwards enlarging and developing into 
 the usual aggravated form of the disease. 
 
 At a meeting of the Edinburgh Medico-Chirurgieal Society, 'No- 
 vember 15, 1854, Dr. Simpson further reported the result of the in- 
 jection of iodine, in cases which he had recently had under his care 
 at the Royal Infirmary." He mentioned that he had injected a case 
 in his wards a few days ago, from which he had removed 200 ounces 
 of fluid, and that he had tested the urine for iodine, but without suc- 
 cess. It was usually present in the urine, however, after the injection 
 of a hydrocele. He had now injected some ten or twelve cases of 
 ovarian dropsy ; the disease had recurred in a few of the cases, but 
 in the others, the cure had as yet been permanent. The operation 
 was unattended with any bad results. Indeed, the pulse never rose, 
 and little or no uneasiness was expressed, and that only, if present, 
 in drawing the fluid, apparently the result of adhesions. He em- 
 ployed the Edinburgh tincture of iodine, which had also been recom- 
 mended for its strength by Mr. Martin, in his paper on the cure of 
 hydrocele by injection. 
 
 ' See Edinburgh Monthly Journal of Medical Science, December, 1854, p. 565. 
 voi. I. 16 
 
242 DISEASES OF THE OVARY. 
 
 OVAEIOTOMY: 
 
 IS IT— OR IS IT NOT— AN OPERATION JUSTIFIABLE UPON THE 
 COMMON PRINCIPLES OF SURGERY? 
 
 ARE- OR ARE NOT-CAPITAL OPERATIONS IN SURGERY JUSTIFIABLE 
 TO THE EXTENT GENERALLY PRACTISED ? 
 
 "In truth there are Brothers who will brag of the many they have dismembered; but 
 they that truly understand Amputation and their Trade, well know how villainous a 
 thing it is to glory in such a Work— it being more for your credit to save one Member than 
 to cut off many." — Richard Wiseman's 6th Chirurgical Treatise. 
 
 " Cut off— 
 Unshriven, unanointed, unaneled : — 
 If thou hast nature in thee, bear it not." 
 
 Complaint of the Ghost in Hamlet. 
 
 De. Bennett having communicated to the Medico-Chirurgieal 
 Society of Edinburgh, on the 17th of December, 1845,' a case in which 
 ovariotomy had been performed, Professor Simpson stated, that he 
 believed ovariotomy quite unjustifiable in many of the cases in which 
 it had been had recourse to, but in a few rare instances, like that of 
 Dr. Bennett's patient, quite as justifiable as most of the operations 
 performed in surgery for chronic affections. And it appeared to him 
 that two circumstances prevented ovariotomy from obtaining a fair 
 consideration and fair trial, especially with professed surgeons. First, 
 the diagnosis and the operation were, under the existing divisions 
 and arrangements of practice, undertaken by two difierent sets of 
 practitioners — the former by the obstetric physician, and the latter 
 by the operating surgeon. It was, perhaps, the only capital opera- 
 tion in which the surgeon was now required to proceed upon the 
 diagnostic knowledge of another party ; and no one was to be 
 blamed if he felt a natural repugnance to incur so serious a respon- 
 sibility on such grounds. Secondly, surgeons, as a class, still con- 
 fessedly allow themselves to be greatly bound and swayed by the 
 trammels of authority, and the mere fact that some of the highest 
 names in surgery had once declared, with or without due investiga- 
 tion, against ovariotomy, is with most others an ample and satisfac- 
 tory reason for totally rejecting the operation. In the same way, 
 but in an opposite direction, the leading authorities in the surgical 
 world having agreed to consider ligature of the arteria innominata as 
 a legitimate operation, it has now been repeatedly performed. But 
 what has been the result ? Why, the vessel has been tied some 
 
 • See Report in Edinburgh Monthly Journal of Medical Science, January, 1846, p. 35. 
 
OVARIOTOMY. 243 
 
 twelve times, according to Mr. Phillips — it migM be oftener, or it 
 might not be so often — ^but at all events, as often as the operation 
 had been performed, it had proved fatal ; and yet, because it had 
 been decreed proper and justifiable by authority, we find it in the 
 very last text-books on surgery still commented on as such ; whilst 
 ovariotomy, as proving fatal in one out of every two or three cases, 
 was loudly denounced as improper and unjustifiable. In the im- 
 portant department of surgery, such inconsistency would doubtlessly 
 betimes become rectified — when, as had been long the case in medi- 
 cine and midwifery, the dogmatism of mere facts and experience 
 came to be more respected than the dogmatism of mere opinion 
 and authority. 
 
 The diseased condition of the ovary, to which the operation of 
 ovariotomy was particularly applicable, if applicable at all, was, in 
 Dr. S.'s opinion, that form of ovarian dropsy which was by far the 
 most fi-equent of all, and consisted in multilocular cystic degenera- 
 tion of the organ — the gelatiniform, or areolar cancer of some 
 authors. All other forms of ovarian dropsy, as they were called, 
 were rare in comparison to this ; and to it all remarks, in such a dis- 
 cussion as this, principally or entirely applied. In most instances — 
 in nine cases out of ten — this species of ovarian dropsy pursued, he 
 believed, a regular progress onward, towards greater or less enlarge- 
 ment, insufferable distension, more or less repeated palliative tap- 
 pings, frequently disintegration of the morbid structure, local irrita- 
 tion, constitutional exhaustion, and death. Generally, it took a series 
 of years to run its course, but sometimes it passed through its phases 
 and progress more rapidly. We want a sufficient body of well-ob- 
 served facts to know the average duration and simple natural history 
 of this, as of most other diseases. Some authorities averred that the 
 disease occasionally went on for twenty, thirty, forty, or fifty years. 
 He doubted entirely the truth of such alleged cases, and believed 
 that abdominal tumors, with this history, were not affections of the 
 ovary at all, certainly not its cystic multilocular disease, but fibrous 
 tumors of the uterus, which were often exceedingly chronic in their 
 progress, and, as he had repeatedly seen, were very frequently mis- 
 taken for the ovarian affection under dispute. Again it had been as 
 strongly averred that cases of multilocular dropsy of the ovary had' 
 been absorbed and cured. He equally and entirely doubted the 
 validity of this observation. Errors in diagnosis would, he believed, 
 account readily for all such therapeutical incredibilities. He had 
 seen hysterical tympanitic distension of a portion of bowel, and col- 
 lections of faeces, mistaken for ovarian tumors ; and these were cer- 
 tainly quite curable. He had, in several instances, seen also ovarian 
 dropsy very perfectly simulated in form, figure, situation, &c., by 
 
244 DISEASES OF THE OVARY. 
 
 large clironic inflammatory effusions into the cellular tissue of 
 the pelvis and broad ligament, always commencing with and ac- 
 companied by inflammatory phenomena, and these, like similar 
 inflammatory effiisions elsewhere, were always more or less com- 
 pletely amenable to medical treatment. But he had no belief 
 whatever that iodine, or mercury, or muriate of lime, or aqua 
 potassse, or diuretics, or deobstruents, or aught else, were capable 
 of absorbing and removing the complicated structure and contents 
 of a multilocular cystic tumor of the ovary. He would almost as 
 soon believe that the head could be absorbed and removed by medi- 
 cine. When the disease was accompanied with much local vascular 
 action and congestion, the occasional loss of blood was certainly 
 sometimes beneficial. But in the general run of cases of this 
 malady, he had long come to the conclusion that we did all that 
 was possible with medicine, when we kept the individual functions 
 of the economy as near as possible to their individual standards of 
 health. Break down the activity and vigor of the system by mer- 
 cury or other debilitating medicines, and then the ovarian disease 
 only too often progressed with double strides. 
 
 Seeing medicine was of so little direct use — what measures had 
 surgery to propose ? The cystic structure of the tumor had been 
 tapped and injected in imitation of the treatment of hydrocele — 
 setons had been passed into it, and through it — ^incisions had been 
 made into its walls, &c. &c. ; but all such operations were now, he 
 believed, abandoned by general consent, as useless in their effects, 
 and far too often fatal in their practice to admit at all of repetition. 
 In fact, two measures only were at the present day apphed to the 
 surgical treatment of the disease, namely, 1. Tapping ; and, 2. Total 
 extirpation. The first of these operations — tapping — ^was professedly 
 adopted merely as a palliative measure — for the present relief of the 
 patient — not for the cure of the disease. In a very few instances 
 the tumor appears to become bound down by adhesions after tap- 
 ping, and no 'reaccumulation takes place ; but these cases are so 
 very rare, that in practising the operation, we scarcely even venture 
 to reckon upon the possibility of this occurrence. In some cases 
 where the tumor is very large, but the cells small, and containing 
 gelatiniform matter, tapping is of no use, and cannot in any degree 
 evacuate or diminish its contents. Fortunately for the success of 
 this operative procedure, the anterior and superior cell or series of 
 cells were generally large, and dilated more than the others, in con- 
 sequence of least resistance being opposed to their growth and dis- 
 tension in this direction. And tapping, when adopted, though a pal- 
 liative measure only, was by no means so free from danger, as some 
 practitioners think, and some writers would seem to allege. We had 
 
OVAKIOTOMT. 245 
 
 as yet no sufficient collection of data to show its actual results. But 
 Mr. Southam had commenced the inquiry, by tabulating the results 
 of twenty cases of the operation. Fifteen of these cases had been 
 recorded by Drs. Bright and Barlow, without apparently any view 
 to such an investigation, and hence afforded the more valuable and 
 unprejudiced evidence. Four of the twenty patients, or one in five, 
 died of the effects of the first tapping. Four patients died of in- 
 flammation within a few days after the operation ; three more died 
 in one month ; fourteen in all died within nine months after the 
 first tapping. Of the remaining six, two died in eighteen months, 
 and four lived fi-om periods varying from four to nine years. 
 
 Paracentesis, whilst thus merely a means of palliation, was still a 
 proceeding in which no inconsiderable amount of danger appeared 
 to be incurred. Ovariotomy, on the other hand, was an operation 
 which, if successful, was professedly a means for the perfect and 
 radical cure of the disease. But it was undoubtedly a most serious 
 and dangerous operation ; was it therefore warrantable or unwar- 
 rantable, when judged of by the principles applied by surgeons to 
 the determination of the propriety of other capital operations in 
 chronic diseases ? Let us consider ovariotomy and the objections to 
 it in this point of view ; for by such a comparative test will the pro- 
 priety or the impropriety of the operation be best ascertained and 
 determined. The principal objections which Dr. Simpson had 
 heard urged against ovariotomy were as follows : 
 
 1. It was an operation accompanied, with gnat danger and mortality. 
 
 All parties are ready fully to admit this point. But it is by no 
 means a matter decisive, as some think, of the impropriety of the 
 operation. At all events, if ovariotomy is to be condemned and 
 suppressed on this account, several of the legitimatized capital opera- 
 tions in surgery must be equally, or still more strongly, condemned 
 on exactly the same charge ; for it is in reality not more fatal than 
 many of these operations, and even not so fatal as some of them. 
 On this subject, the mortality accompanying capital operations in 
 genera], very erroneous views seem to be entertained by many 
 members of the profession. The statement of a few simple statis- 
 tical facts will serve to prove the position assumed, and may, per- 
 haps, surprise those who have not directed particular attention to 
 the subject. Dr. Churchill, Mr. Phillips, Dr. Atlee, and Dr. Cormack, 
 (see his Journal for May last), had each calculated the mortality in 
 ovariotomy, from the cases on record, and came to nearly the same 
 conclusion. Dr. Simpson took Dr. Cormack's results as being those 
 
246 DISEASES OF THE OVAKT. 
 
 of a writer against the operation, and hence his tables could not be 
 suspected of any unfair leaning towards ovariotomy. 
 
 Out of 89 cases in which ovariotomy had been either performed 
 or attempted, 34 sunk, or nearly 4 in every 10 patients died. 
 
 Out of 65 cases, collected by Dr. Cormack, in which the operation 
 had been perfected, 25 died, or between 3 and 4 out of every 10 
 patients were lost. 
 
 Now Malgaigne has shown, that out of 852 amputations of the 
 extremities of all kinds, including those of the fingers and toes, 
 which were performed in the Parisian hospitals from 1836 to 1841, 
 332 died, or about 4 out of every 10 proved fatal. 
 
 Among these, out of 201 amputations of the thigh, 126 died, or 6 in every 10 
 « " 192 " leg, 106 died, or S4 " 10 
 
 " " 91 " arm, 41 died, or 4^ " 10 
 
 Of the amputations of the thigh, in 46 cases the operation was 
 performed for severe injury of the limb : of these 34 died, or more 
 than 7 out of every 10. 
 
 When we looked to the results of amputation nearer home, the 
 results were not much more encouraging. In the Glasgow Infirmary, 
 from 1795 to 1840, Dr. Lawrie has shown that out of 276 amputa- 
 tions performed, 101 proved fatal, or nearly 4 in 10 died. 
 
 Among these, out of 128 amputations of the thigh, 46 died, or 3^ in every 10 
 
 " 62 " leg, 30 died, or 5 " 10 
 
 " " 53 « arm, 21 died, or 44 " 10 
 
 In the Edinburgh Infirmary, during the four years commencing 
 July, 1839, there occurred 72 amputations of the thigh, leg, shoulder 
 joint, arm, and fore-arm. Of the 72 patients, 37 recovered and 35 
 died — or nearly 5 in every 10. Of these amputations, 18 were 
 primary. Out of 4 primary amputations of the leg, one patient 
 recovered and 3 died. Out of 4 similar amputations at the shoulder- 
 joint, 1 recovered, and 3 died. There was one primary amputation 
 of the arm ; the patient died. There were eight primary amputa- 
 tions of the thigh ; all the eight patients died.' 
 
 Mr. Phillips has collected the histories of 171 cases in which the 
 larger arteries of the body were tied ; of these 57 died, or about 3J 
 in every 10. Dr. Inman has collected 199 cases of these operations; 
 66 died, or about 3 J in every 10, Out of 40 cases of ligature of the 
 subclavian artery which he has tabulated, 18 proved fatal, or nearly 
 5 in every 10 died. 
 
 In his work on hernia Sir A. Cooper records 36 deaths among 77 
 operations for that disease, or nearly 5 in every 10 died. Dr. Inman 
 
 ' See Dr. Peacock's Official Reports. 
 
OVARIOTOMY. 247 
 
 has collated 545 cases of operation for hernia ; 260 proved fatal, or 
 nearly 5 in every 10 of the patients died. 
 
 In the earlier years of life, lithotomy is comparatively a safe and 
 legitimate operation, and few die. But it is quite different when 
 the operation is submitted to at forty years of age, and upwards. 
 At and above this term of life, Dr. "Willis has shown, from numerous 
 statistical returns, that from 2 to 5 out of every 10 operated upon, die. 
 
 Even what we deem slighter operations are sometimes attended 
 in the absolute by no inconsiderable danger to life. Out of 95 cases 
 of excision of the mamma, referred to in Dr. Cormack's Journal for 
 February, 1843, 20 died, or 2 in every 10. In how many cases of 
 the remaining 75 would the disease inevitably return and ultipaately 
 destroy the patient ? 
 
 Ovariotomy, then, is fatal in the proportion of about 35 or 40 in 
 every 100 operated upon ; but in most capital operations we have 
 singly as high or even a higher mortality than 35 or 40 per cent. 
 Amputation of the thigh has a higher mortality. So has amputa- 
 tion of the arm. So has ligature of the subclavian, for aneurism. 
 Tying the innominata is fatal in every case. The operation for 
 hernia has a higher mortality. Lithotomy is as fatal in most hands 
 after the middle term of life. Even amputation of the leg below 
 the knee is scarcely more safe, or at all events as many, or more, die 
 after amputation of the leg, in the hospital practice of Paris and 
 Glasgow, as die after ovariotomy. 
 
 It had been foolishly objected to the statistics of ovariotomy, that 
 we did not know all the unsuccessftil cases. Dr. S. believed that the 
 ascertained statistics regarding it were as full and complete as the 
 statistics regarding any other capital operation. It was too serious 
 and too startling an operation for any cases of it to remain easily 
 hid. On the other hand, it could be readily shown that the statistics 
 of our major surgical operations were not always reported in the 
 most faithful manner, and so as to give the most accurate results. 
 Malgaigne candidly confesses as much in regard to the elaborate 
 statistics which he has collected of various surgical operations from 
 different hospitals. 
 
 The existing results regarding ovariotomy would, probably, be on 
 all hands allowed to demonstrate one point, namely, that exposure 
 of the cavity of the peritoneum was not so dangerous a proceeding 
 as was formerly thought by pathologists. Surgeons have exposed it 
 often in hernial operations, and even left ligatures upon its omental 
 vessels when necessary, and not unfrequently with impunity. In 
 1842-43 a portion of the omentum was removed in six operations for 
 hernia at St. George's Hospital, London. " In some of the cases, 
 two ligatures, each embracing one-half of the omental mass, were 
 
248 DISEASES OE THE OTART, 
 
 applied; in the other cases, ligatures were applied to all the bleed- 
 ing vessels." Five of the six patients recovered. One died coma- 
 tose, a few hours after the operation, from disease of the brain.' 
 But still, it must be confessed, extreme dread of all such abdominal 
 surgery was, and probably is, the prevailing idea. The comparative 
 success of the Csesarean section in the hands of continental ac- 
 coucheurs, might almost have taught us a different lesson, the peri- 
 toneal cavity in that operation being of necessity freely opened up ; 
 and we may daily see the same done upon the females of some of 
 our domestic animals, vnth remarkable impunity, in the coarse 
 operation of spaying. 
 
 2. The ultimate results of cases of Ovariotomy were alleged to be unknown and 
 unfavorabU. 
 
 It was urged that the reports of cases had been published with 
 too great haste, and before the final effects could be known 
 months and years afterwards. Great weight had been attached 
 to this argument in the question of ovariotomy. But it probably 
 would be found to tell against other capital operations with much 
 more truth and effect than against ovariotomy. In how few in- 
 stances were the published reports of capital surgical operations 
 carried beyond a few weeks ? And what a large proportion did die 
 within a short period after escaping from the more immediate con- 
 sequences of the operation for aneurism, and stone, and cancer, and 
 amputation — and that with very broken and imperfect health, too, 
 during the intei-val. The primary history of cases of these opera- 
 tions was given, yet not their ultimate history. Dr. Simpson at the 
 same time adduced various facts to show that as far as regarded 
 ovariotomy, the allegation did not in reality hold good. The process 
 of reparation after ovariotomy is, say some, too great to be accom- 
 plished with health and safety. Theory may argue so — but facts 
 here give a direct and practical denial to theory, by demonstrating 
 the reverse to be true. In one of the first cases operated on, Emi- 
 liani's in 1816, the patient has since become the mother of five living 
 children — an ample proof of the completeness of the cure. Dr. 
 Simpson read a note from Dr. Clay of Manchester, stating the 
 present condition, on 14th December, 1845, of the patients that he 
 had operated upon two or three years back. His first patient, ope- 
 rated on 12th September, 1842, "continues quite well, and follows 
 her household duties with ease and comfort." A patient, subjected 
 to ovariotomy on the 25th September, 1842, " is at this time per- 
 fectly well, and capable of greater exertion than most women of her 
 age, viz., 60." Regarding a third patient operated upon in No- 
 
 " Hewett, in Medico-Chirurgioal Transactions, Vol. XXVIl. 
 
OVARIOTOMY. 249 
 
 vember, 1842, Dr, Clay states, "I saw this case a few days ago on 
 account of a polypus of the nose — in every other respect she is 
 quite well." A patient, operated upon in August, 1843, " is at this 
 time perfectly well — saw her a few days ago." Dr. Clay operated 
 on two cases in October, 1843, " the first remains at this time quite 
 veil" — the second reports herself "in better health now than in 
 any part of her former life." A case was operated upon in ITovem- 
 ber, 1843 : " I have," says Dr. Clay, " seen this woman frequently of 
 late whilst attending other branches of the family — she is quite 
 well ;" — and so on with regard to some others. 
 
 3. Itwas argued that the extirpation of the affected ovary would not necessarily effect a perfect 
 cure of the disease, or secure the patient against its return. 
 
 This certainly holds true of the diseases for which several of the 
 major operations in surgery were performed, but as certainly it did 
 not hold true of multilocular dropsy of the ovary. The surgeon 
 amputates a limb, or excises a tumor for some form of carcinomatous 
 disease, hazarding more or less the life of his patient for the tempo- 
 rary removal of a diseased action which is almost perfectly certain 
 to recur. He ties the subclavian for aneurism — ^but is it not a dis- 
 ease which is very liable to coexist in different vessels at the same 
 time, or to form consecutively in different parts — and if the patient 
 escapes the great and immediate dangers of the operation, has he 
 any surety against its reappearance elsewhere ? You amputate the 
 thigh to get rid of a scrofulous or tubercular knee joint. But in 
 how many cases is local tubercular disease the mere result of a 
 general diathesis, that ere long will betray itself in some other part 
 or organ. Dr. Simpson thought it a point of the highest practical 
 moment to consider that, on the contrary, the pathological nature of 
 multilocular disease of the ovary was such that it had no tendency 
 to recur after its complete removal. From the character of its mor- 
 bid structure, and its clinical history, it was certain that it presented 
 no liability to spring up again, like malignant or tubercular disease, 
 in the same locality — or in distant and in different organs of the 
 body. The other ovary might be partially affected, and if so, might 
 require removal along with the first — a step which at the time would 
 probably not add much to the absolute danger of the operation — 
 seeing the abdomen was once opened. Do not surgeons operate for 
 popliteal aneurism, when it is present in both limbs, even with the 
 additional chances of an analogous diseased condition of the vessels 
 existing internally. Probably it will be found that a surgeon would 
 more rarely require to repeat ovariotomy, in consequence of the re- 
 
250 DISEASES OF THE OVAKT. 
 
 maining ovary subsequently becoming diseased, than he now requires 
 to repeat lithotomy, in consequence of a second or a third stone form- 
 ing after a time in the bladder. 
 
 4. Ovarian disease, it was averred, does not produce such dangerous and urgent 
 symptoms as to demand an operation. 
 
 Dr. Simpson said that he had already adverted sufficiently to the 
 dangerous and ultimately fatal tendency of the common multilocular 
 dropsy of the ovary. He had at present charge of one case, where 
 an enormous ovarian tumor produced occasional most intense suf- 
 fering, in the form of severe abdominal pains and spasms resembling 
 the agonies of labor. In many cases where it had reached a large 
 size, it more or less incapacitated the patient, by its simple weight 
 and volume, from following the ordinary duties belonging to her 
 station ; and if poor, threw her upon the bounty and charity of 
 others. In most it was, after a time, liable to be attended with local 
 attacks of irritation and inflammation, fever, &c., or produced 
 dyspnoea, difficult progression, &c. 
 
 He doubted if, in many cases operated upon, of aneurism or 
 necrosis, or ulcers, &c., supposed to demand amputation, &c., the 
 suffering or the incapacity from the duties of life were greater than 
 in a large proportion of ovarian cases. But, argue the surgeons, 
 we operate early in aneurisms, &c., because they continue to increase 
 — the same is true of ovarian tumors ; because the aneurismal swell- 
 ing is, after a time, liable to affect the structure of neighboring parts, 
 and render late operative interference less successful — ^the same is 
 true of ovarian tumors ; because with the aneurismal disease the 
 constitution will sympathize and become debilitated — the same is 
 true of the ovarian tumor ; because the aneurism may burst and 
 endanger life — ^the same is true of ovarian tumors. He had, two 
 years ago, seen one burst into the peritoneum, and prove fatal ; its 
 parietes were eroded by small internal ulcerations at several points, 
 and at last had given way. Any argument urging haste in the one 
 case, would, he feared, equally apply to the other. On the contrary, 
 would proper palliative treatment applied to Zoca? aneurisms not stay 
 their progress, and make them as chronic, if not more so, in their 
 course, than multilocular tumors ? Mr. Fergusson has lately stated 
 that he has watched one case of axillary aneurism "for several 
 years" without its increasing. And aneurisms sometimes are, at 
 last, spontaneously cured ; much oftener, he believed, than ovarian 
 dropsies. Take another case that happened in the Hospital prac- 
 tice this morning. A man applied with stricture, and symptoms of 
 stricture only. On passing a small bougie, a stone is struck in the 
 
OVARIOTOMY. 251 
 
 bladder, and the patient is fortliwith advised to submit his life to all 
 the perils and consequences of lithotomy, though he has no suffering 
 traceable to the calculus. "Would it be justifiable to advise a patient 
 with an ovarian dropsy, giving her no trouble, to submit in the same 
 V7ay to ovariotomy ? He most assuredly thought it would be utterly 
 unwarrantable. And the palliative treatment for urinary deposits 
 and calculus was, it must be further recollected, now far more ad- 
 vanced than the palliative treatment of ovarian dropsy. A calculus 
 of this kind would not be likely to increase so rapidly as to destroy 
 the patient in five or ten years. An ovarian tumor very likely 
 would do so. And sometimes, as in this case, a urinary calculus 
 does not really give rise to such uneasiness as to demand any very 
 active palliative treatment. Do we not sometimes see calculi in the 
 bladder after death, which have never given rise to any marked 
 symptoms during life ? Again, does not the operation for the ob- 
 literation of the varicose veins of a limb sometimes prove speedily 
 fatal, and yet the disease itself is one easily palliated by rest and 
 bandages. Besides, this recognized legitimate surgical operation for 
 varicose enlargement was not only dangerous to life, but, he feai'ed, 
 useless in its efifects. In most cases, at least, the disease was as bad 
 again in a few months as it was before surgical interference was 
 adopted. Did we not sometimes see surgeons amputate the limb, 
 when it was merely the seat of simple and benign, but untractable 
 ulceration ? And ulceration might be a very serious inconvenience 
 to a laboring man ; but here we have a dangerous and often fatal 
 operation performed for a disease which was not fatal nor dan- 
 gerous in its own character, and that easily admitted of palliative 
 treatment. Altogether, it appeared to him, that the question of 
 when we should conscientiously deem ourselves entitled to practise 
 ovariotomy, or any other dangerous operation for a chronic disease, 
 was one that had hitherto received no sufficient attention. It was a 
 question that probably must always be decided much upon the 
 merits of each individual case, and in regard to which different 
 minds may come to opposite and yet conscientious conclusions. It 
 always embraced a difficult moral and professional problem, in cases 
 where the required operation was, as in ovariotomy, ligature of the 
 larger vessels, amputation, lithotomy, &c., directly and immediately 
 dangerous to the life of our patient. It resolved itself in such a 
 case into a question of this kind : Am I conscientiously entitled to 
 inflict deliberately upon my own fellow-creature, with my own hands, 
 the imminent and immediate chance of death, for the problematical and 
 prospective chance of his future improved health and prolonged life ? 
 In calculating what amount of danger of present death ought to be 
 incurred for the hazard of future good, many secondary elements 
 
252 DISEASES OF THE OVARY. 
 
 uecessarily entered into the problem— such as the existing chance 
 of otherwise palliating the disease and prolonging life with certainty 
 for months or years— the extent of attendant suffering— the prohar 
 bility of the affection recurring— or already existing elsewhere, 
 &c. &c. In such a calculation, the ideal glory of a successful ope- 
 rative result has probably been too often allowed to dazzle the calm 
 judgment of both the operator and his patient, and the darker but 
 equally truthful shades of the picture have been, for the moment, so 
 far obscured and unseen. "With the patient, the stern reality of 
 danger and death too frequently vanishes, here or elsewhere, before 
 the strong hope of life. And the surgeon, like the soldier, is, in the 
 computation of his successes, perhaps too liable to forget the actual 
 amount of human suffering and human fatality through which these 
 successes are obtained. 
 
 5. It has often been argued against ovariotomy, that the operation, when begun, could not 
 sometimes be completed from adhesions, ^c. ; or no tumor could be found. 
 
 These circumstances were the results of imperfect diagnosis ; and 
 he adverted to the occasional difficulties connected with the dis- 
 crimination of the ovarian tumors, and admitted them to their full 
 extent. He explained that he could scarcely conceive the repetition 
 of some of these errors if due caution were adopted. If other means 
 failed, an exploring needle would always certify the presence of 
 a tumor, and its structure or nature ; the uterine bougie would show 
 if the tumor were situated in the uterus or ovary, &c. The chief and 
 ruling difficulty at this moment was assuredly that of discovering 
 the existence or not of adhesions of the- tumor by false membranes, 
 their extent, &c. If this point could by any measures be cleared 
 up, it would remove one of the great, perhaps the greatest, existing 
 objection to ovariotomy. iN'or was it totally hopeless. One of the 
 most sure and solid advances made by modern pathology was our 
 gradual but great improvement in the physical diagnosis of the 
 diseased states of different organs. Probably the next marked step 
 in this path would be the detection of some measure or measures 
 for improving our knowledge of the physical diagnosis of diseases 
 of the abdominal viscera. It was not more extravagant to expect 
 this than thirty years ago it would have been extravagant to expect 
 all the vast aid and certainty which we now derive from auscultation 
 in the physical diagnosis of diseases of the chest ; and he believed 
 some important steps had been already made regarding the detection 
 of ovarian adhesions by Dr. Frederick Bird of London, and others. 
 Dr. Bennett's contribution was under this head of the highest 
 
OVARIOTOMY. 253 
 
 pathological and practical value. As soon as the ovarian tumor in 
 the case described by him was exposed, it was evident to all who 
 had taken an interest in the question, that the accompanying ascitic 
 efiusion oozed by apertures from the interior of the ovarian tumor, 
 and was a secondary result. But if, as Dr. Bennett would, he 
 doubted not, be able ultimately to show, it was possible to dis- 
 tinguish by microscopic characters between the fluid of common 
 ascites and the fluid of ascites thrown into the peritoneum through 
 small ulcerated apertures in the walls of an ovarian tumor, it would 
 clear up various points in a set of cases formerly surrounded with 
 perplexing difficulties. It would enable us to detect the pathological 
 cause and source of the great ascitic collections sometimes attendant 
 upon comparatively small ovarian tumors. Cases with this compli- 
 cation, that is, ovarian tumors with apertures allowing their secre- 
 tions to pass into the general peritonear cavity, evidently in general 
 run a very rapid and fatal course. If these secretions were acrid 
 and irritating, as when mixed with inflammatory efiusions froni the 
 walls or cysts, they might at once excite fatal peritonitis. This, 
 however, was rare, and the exception to the rule. Usually the 
 secreted fluid appeared to be blander, distilled slowly through the 
 morbid openings in the parietes of the tumor, and, accumulating in 
 the peritoneum, required ever and anon to be removed from that 
 cavity by tappings, which soon became more and mor'e frequent, 
 and more and more exhausting. This variety was probably, hfe sug- 
 gested, of all ovarian cases, that most surely justifying the adoption 
 of extirpation. And besides, in these very cases, it was generally 
 ascertainable whether there were adhesions or not, for the tumor 
 was surrounded by a fluid medium, and hence admitted more easily 
 of this point of diagnosis being made out by its mobility in that 
 medium. Perhaps it was, on the other hand, unjustifiable in our 
 present state of knowledge to operate where there were many adhe- 
 sions, or any great want of certainty about the existence and extent 
 of them ; as it was, where the tappings, though many and frequent, 
 did not, as was seen in a few exceptional cases on record, exhaust 
 rapidly the powers of the patient, or threaten her life with any pros- 
 pect of urgent or immediate danger. 
 
 But, admitting to their fallest extent the occasional difficulties 
 which have been found to beset the diagnosis of ovarian tumors for 
 operation, do we not meet with occasional difficulties of exactly the 
 same kind in other surgical operations, and which do not yet deter 
 surgeons from interfering? Is the trephine never used without 
 detecting any effused blood, or pus, or depressed and fractured frag- 
 ments of bone ? In tying the carotid and subclavian and iliac arte- 
 ries for aneurism, it has now repeatedly happened that all the great 
 
264 DISEASES OF THE OVARY. 
 
 dangers of these operations had been submitted to most uselessly, 
 the disease, during the operation or after death, being found not to 
 be aneurismal at all,' and hence not at all curable by such a pro- 
 cedure ; and when aneurismal, the operation has been sometimes 
 left incompleted— the vessel searched for either not being secured, 
 or, as has happened with Dupuytren and others, it has been reached 
 and ifatally transfixed with the ligature, instead of being surrounded 
 by it. Have not the antrum, and the mamma, and the testicle, &e., 
 been sometimes found to be the seat of simple inflammatory and 
 curable effusion, after all the usual operative measures for the re- 
 moval of supposed malignant tumors from these localities had been 
 commenced, or even completed. A surgeon had excised ten scir- 
 rhous mammee, and in every case with perfect success. In not one 
 was there any return of the disease. Sir Benjamin Brodie was re- 
 quested by this active operator to see a new case of scirrhus which 
 he had determined to remove. " It was nothing more," says Sir 
 Benjamin, " than a chronic abscess of the breast, which he denomi- 
 nated scirrhus."^ Dr. S. had seen amputation of the thigh performed 
 by a celebrated surgeon for supposed serofalous disease of the knee- 
 joint, and where, on examining afterwards the amputated limb, no 
 traces of such a disease could be found. Most of them had seen 
 cases of diseased limbs threatened with, or actually condemned to 
 the knife, and which yet afterwards got quite well, when surgical 
 interference would not be submitted to by the patient. In some 
 cases of hernia, is it not occasionally found impossible, as in some 
 cases of ovariotomy, to finish the operation, and return the bowel 
 in consequence of extensive morbid adhesions or other causes ? Is 
 not the stone sometimes found encysted in lithotomy, and for that 
 or other causes its removal rendered impossible after the bladder is 
 cut into ? Is the operation for the removal of an incarcerated piece 
 of necrosed bone not sometimes found impossible after it was begun ? 
 Grave errors have been committed in diagnosis in ovariotomy cases, 
 in relation to the propriety and practicability of the operation, but 
 he doubted if as grave errors were not as frequently committed in 
 some other recognized capital operations. A much greater amount , 
 of caution was undoubtedly requisite on this head. 
 
 In summing up his statement, Dr. Simpson allowed that ovario- 
 tomy was a most serious and dangerous operation ; but at the same 
 time he maintained, that surgeons in declaiming against it had used a 
 
 ' During the discussion, Dr. Spittal mentioned, that out of fifty-nine cases, collected by Dr. 
 Norns,of Hgature of the subclavian artery for aneurism, " in three no aneurism existed, and 
 in two the tumor was mistaken for aneurism and punctured," Hence, in one out of every 
 twelve of these eases, the diagnosis was perfectly wrong. 
 
 ' Medical Gazette, 1844. 
 
OVAKIOTOMT. 255 
 
 series of arguments, all, or almost all, of wMch would equally, and 
 some of them still more strongly, apply against those capital opera- 
 tions for chronic maladies, regarding the propriety of which they 
 did not affect to entertain one single doubt, and which they every 
 day performed without the slightest scruple. For his own part, 
 however, he entirely doubted whether surgeons should resort to 
 many of these operations, under the circumstances in which they 
 often adopted them. He doubted whether, for example, they should 
 at once subject a man to all the immediate and fearful perils of litho- 
 tomy and lithotrity, because he had a stone in the bladder which 
 gave him little or no uneasiness, and which might allow him, under 
 proper regimen and treatment, to live and perform the duties of life 
 for a long series of years. He doubted whether, in a case of axillary, 
 or carotid, orpopliteal aneurism, slowly increasing or not increasing at 
 all, having some small chance of spontaneous cure, and having no in- 
 considerable chance of being followed or accompanied with the same 
 disease in other parts of the arterial system, all the dangers of the liga- 
 ture of the vessel nearer the heart, should be at once recklessly en- 
 countered. He doubted whether, in malignant or carcinomatous dis- 
 ease of the forearm or leg, amputation of the arm or thigh should be at 
 once resorted to, with the hazard of death in a few hours or days in 
 one outof everytwo operations, andthealmost perfect certainty of the 
 same morbid action reappearing sooner or later in the stump, or in 
 some other part, if the patient did happen to survive. And, on the 
 same principle, he doubted whether ovariotomy had not been em- 
 ployed in some cases under perfectly unjustifiable conditions, when 
 the health and life of the patient were not immediately threatened 
 by the stage and progress of the malady, when the tumor was a 
 source of inconvenience and deformity, rather than a source of dan- 
 ger, and when the evils of the disease were as yet prospective rather 
 than real. But if the health of the patient were becoming rapidly 
 undermined by the disease — if the progress of the affection showed 
 that ere long it would inevitably prove fatal — if the question were 
 thus reduced to one of certain and not distant death from the course 
 of the malady, or possibly an entire escape from the affection, with 
 prolonged life and health from the operation — and if, in addition, 
 the ascertained or apparent freedom of the tumor from adhesions 
 and other circumstances were such as to present no counter-indica- 
 tion — ^then he believed that ovariotomy might be undertaken under 
 conditions far more justifiable and legitimate than the surgeon could 
 possibly urge in favor of some of his stone, and aneurism, and other 
 capital operations for pathological lesions of a similarly chronic 
 character, and course. 
 Lastly, he stated, that if betimes ovariotomy came to be recog- 
 
256 DISEASES OF THE OVARY. 
 
 nized as a surgical operation, fit and proper in such cases of ovarian 
 disease as lie adverted to, or others, he had no doubt the steps of 
 the operation itself would meet with improvements. Such improve- 
 ments were almost always wrought out hy experience.^ How dif- 
 ferent is amputation now, from what it'was formerly with the hot 
 iron, or boiling pitch, to seal up the cut vessels. How comparatively 
 safe and simple is the tying of an artery now from what it was half 
 a century ago, with the flat double ligatures, and ligatures of reserve, 
 &c. One great source of danger in ovariotomy was the irritation 
 and injury inflicted on the intestinal canal and peritoneum from the 
 strong ligature which was required for the stalk of the tumor, being 
 passed through the abdominal cavity, and out at the external wound 
 — ^remaining there for days or weeks, and keeping a portion of the 
 wound in the abdomen necessarily open by its presence, and, con- 
 sequently, so far still more hazarding the occurrence of peritonitis. 
 Probably it might be possible to devise some other measures of 
 securing the lai'ge vessels, principally veins, be it remarked, of the 
 pedicle, and thus save the several dangers arising, 1st. From leaving 
 the ligature to irritate there ; 2d. From the ligature, by its constric- 
 tion of the stalk, producing strangulation ; and 3d. From its exciting 
 phlebitis. And if the ligature still continues to be employed, it 
 would, he believed, be found a great improvement, as had been sug- 
 gested to him by his excellent friend and assistant, Dr. Keith, to 
 pass it down, perforate the very thin layer of serous and mucous 
 membranes dividing the utero-rectal reflection of the peritoneum 
 from the upper and back part of the vagina, and bring it out along 
 the vaginal canal. He knew that on the dead subject this could be 
 done with the greatest facility. It would have several advantages. 
 1. It would enable the surgeon to close at once the whole length of 
 the incision in the abdominal parietes ; 2. The sides of the vaginal 
 canal, being in contact, would act as a valve sufficient to prevent 
 that dangerous access and egress of air to and from the peritoneum 
 under strong respiration, vomiting, &c., which had sometimes oc- 
 curred through the aperture kept open by the ligature, in the old 
 form of operating; 3. The ligature would not pass through the 
 same extent of the peritoneal cavity, and would scarcely, if at all, 
 touch or irritate the folds of the intestinal canal ; and, 4. If the 
 uterus happened to be displaced backwards upon the rectum, the 
 ligature applied to the posterior surface of its broad ligament 
 would be included and imbedded in a cavity almost divided and 
 separated from the general cavity of the peritoneum, and where the 
 process of reparation and adhesion might often go on without fatally 
 extending upwards into the general peritoneal sac. Farther, the 
 cases already published recounted some errors which the experience 
 
OVARIOTOMY, 257 
 
 derived from them showed might be avoided in future. We were 
 thus warned to take great care to close, as accurately as possible, 
 the peritoneal side of the wound, to prevent strangulation of a fold 
 of intestine in its edges ; to adopt precautions with the same view, 
 of not allowing a similar effect from the portion of ligature passing 
 through the abdomen ; not to allow the bladder to become dis- 
 tended, lest it drag upon the uterus, or disturb the reparative pro- 
 cess ; not to excite inflammation by dragging at the ligatures, &c. &c. 
 Dr. Simpson subsequently added a few observations in reply to 
 some remarks made by Mr. Spence. According to Mr. Spence, 
 trephining for the discovery of effiised blood, and tying the arteria 
 innominata, were not now looked upon by surgeons as justifiable 
 operations. Probably, the Society would allow that the lately pub- 
 lished text-books by Professors Fergusson and Syme were fair stan- 
 dards of the existing state of British Surgery. Now, Mr. Fergusson 
 not only in his work advises trepanning for effiised blood, but even 
 speaks of cutting through the dura mater in search of it. Mr. Syme, 
 in treating of the ligature of the innominata, states that it is a dan- 
 gerous operation, but he does not give the most remote hint as to 
 its being regarded by him or others, as an unjustifiable one ; and, on 
 the contrary, he describes the steps of the operation, and suggests 
 means for rendering it safer. Mr. Spence had alluded to the spon- 
 taneous cure of aneurism, and thought him wrong in his ideas about 
 its frequency. Dr. S. did not know of any data calculated to show 
 how often, or how seldom, the spontaneous cure of a local circum- 
 scribed aneurism — such as surgeons operated for — might be expected ; 
 but pf eight or ten cases of popliteal aneurism, seen in the hospital 
 within as many years, nature set up an inflammatory action in the 
 sac or vessel, or both, and cured one case, a patient of Dr. Cun- 
 ningham, before art had an opportunity of interfering. At all 
 events, he felt assured, that if local external aneurisms were treated 
 by common palliative measures, their spontaneous cure would be 
 found not to be so rare as the spontaneous cure of ovarian dropsy ; 
 and he feared that all Mr. Spence's arguments for early operation in 
 the one case, most unwittingly applied with similar appropriateness 
 to the other. 
 
 TOL. I. ,11 
 
258 DISEASES OF MENSTRUATION. 
 
 IMPERFECT DEVELOPMENT OF THE UTERUS, GIVING 
 RISE TO AMENORRHEA, ETC 
 
 (From Edinburgh Monthly Journal of Medical Science, September, 1854, p. 275.) 
 
 De. Simpson mentioned, that he had seen a considerable number 
 of cases of short or imperfectly developed uteri in the living subject. 
 The imperfect development of the organ was ascertained, on examina- 
 tion by the finger, by the small and atrophied cervix uteri, and by 
 actual admeasurement of the length of the cavity by the uterine sound. 
 Instead of being 2 J inches in length, the cavity in such cases was only 
 2 inches, or more frequently only IJ or 1 inch long. The subjects 
 of this imperfect development were often well made arid formed in 
 other respects. But the malformation led to various functional 
 defects, especially amenorrhoea and sterility. The amenorrhcea was 
 usually persistent, and when a patient applied for medical relief, 
 who was already twenty-five or thirty years of age, this malforma- 
 tion would in a large proportion of cases be found to be the organic 
 cause. In some such cases of amenorrhcea, there was great vascu- 
 larity of the face, and occasionally a most unconquerable form of 
 acne. He had seen in some of these instances the wearing of an 
 intra-uterine galvanic, or zinc and copper, pessary — ^gradually in- 
 creased in size — followed by the best results, and even occasionally 
 by cure of the amenorrhoea. The uterus developed itself around 
 such a foreign body, when it filled its cavity, as it did around a 
 fibrous tumor or an ovum.^ 
 
 We have often seen galvanic pessaries used by Dr. S. in ordinary cases of amenorrhosa, 
 which had resisted all the usual means of treatment, and with perfect success. The galvanic 
 pessary has the same form as Fig. 20, but one portion of the intra-uterine stem is of zinc 
 and the other of copper. — (Ed.) 
 
 ON THE NATURE OF THE MEMBRANE OCCASIONALLY 
 EXPELLED IN DYSMENORRHCEA. 
 
 (From Edinburgh Monthly Journal of Medical Science, September, 1846, p. 161.) 
 
 It is well known that in some cases of dysmenorrhcea an orga- 
 nized membrane is expelled, with much pain, from the uterus during 
 
 ' Extracted from Proceedings of the Edinburgh Obstetric Society, January 26, 1853. 
 * See ante, pages 89 and 113. 
 
DYSMENOEEHfflAL MEMBRANE. 259 
 
 the course of the catamenial discharge, and that this happens either 
 occasionally only, or, what is far more common, during a long suc- 
 cession of menstrual periods. 
 
 All authors who have expressed an opinion regarding the nature 
 of this dysmenorrhceal memhrane have, so far as I am aware, re- 
 garded it as a morhid structure formed by the exudation of coagu- 
 lable lymph or fibrin upon the free surface of the mucous membrane 
 of the uterus. 
 
 "It is composed," says Dr. Churchill, " of plastic lymph, such as 
 we see secreted by the mucous membrane of the trachea in croup, 
 thrown ofT by the lining membrane of the uterus, and taking gene- 
 rally the form of the cavity of that organ, although it may be dis- 
 charged in shreds."' 
 
 "We shall probably be correct," Dr. Montgomery observes, "in 
 referring such productions [dysmenorrhceal membranes] to any cause 
 capable of exciting a certain degree of irritation, or perhaps of in- 
 flammation, by which fibrin is poured out on the internal surface of 
 the cavity of the uterus, and assumes a membranous texture, as we 
 find occurring in other hollow organs lined with a mucous mem- 
 brane, as, for instance, in the intestines in cases of diarrhoea tubu- 
 laris, and in the trachea and air-tubes."^ 
 
 " The membranous shreds passed in some of these cases [of dys- 
 menorrhoea] evidently," remarks Dr. Copland, " consist of plastic 
 
 lymph thrown out in the cavity of the womb That a 
 
 degree of inflammatory irritation exists in the internal surface of 
 the uterus, even in the neuralgic form of the disease, is proved by 
 the formation and expulsion of a false membrane in many cases of 
 that form. That this membrane is induced by the similar state of 
 inflammatory action to that which sometimes occurs in other mucous 
 surfaces, and gives rise to a similar exudation, is most probable, not- 
 withstanding the absence of other inflammatory phenomena, and 
 the neuralgic character of the pain."^ 
 
 In a number of cases, I have had an opportunity of examining 
 fii-om time to time the form and structure of these dysmenorrhceal 
 membranes. Two or three years ago, my observations upon them 
 led me to believe that they were not new or false membranes formed 
 of coagulable lymph, and secreted by the mucous smface of the 
 
 ' Diseases of Females, p. 102, Edition of 1844. 2 Sig„g of Pregnancy, p. 147. 
 
 ' Dictionary of Practical Medicine, vol. ii. pp. 844, 845. See, also. Dr. Fergusson in the 
 Library of Medicine, vol. iv. p. 311, "a not uncommon effect of dysmenorrlwEa is the forma- 
 tion of coagulable lymph modelled to the shape of the inner surface of the uterus." Dr. 
 Rigby's Essay on Dysmenorrhoea, p. 39, "fibrinous exudations every now and then attend these 
 cases of Dysmenorrhoea." — Dr. Ashwell's Treatise on Female Diseases, pp. 105 and 107, &o. 
 
260' DISEASES OP MENSTRUATION. 
 
 uterus, but that they in reality consisted of the superficial layer of 
 the mucous membrane of the uterus itself, hypertrophied and sepa- 
 rated. All my later observations have gone to confirm me in the 
 same opinion, viz., that the productions in question are not the 
 results, as is generally supposed, of fibrinous or plastic exudations 
 upon the free surface of the mucous membrane of the uterus, but 
 that they consist of actual exfoliations of that membrane itself. 
 The proof of this opinion rests upon difierent grounds : 
 First, The dysmenorrhoeal membrane presents anatomical pecu- 
 liarities that are never seen in any simple fibrinous or inflammatory 
 exudation ; and these anatomical peculiarities, on the other hand, 
 specially pertain to, and are characteristic of, the structure of some 
 mucous tissues, such as that of the uterus. One special illustration 
 may suffice. Professor Reid, Krauss, and others, have shown, that 
 the surface of the mucous membrane of the uterus is marked by 
 numerous orifices of small tubular glands, crypts, or follicles, open- 
 ing upon it (the uterine glands of some modern authors). This 
 structure I have distinctly traced in difierent specimens of dys- 
 menorrhoeal membrane from different individuals. 
 
 Secondly, The general configuration and character of the surfaces of 
 the dysmenorrhoeal membrane are such as would result from the origin 
 which I have attributed to it, namely, the exfoliation or detachment 
 of the mucous membrane of the uterus. In those instances in which 
 the membrane is thrown off in one piece, and without disintegration, 
 it presents exactly the flattened triangular appearance of the uterine 
 cavity. Its sides may be so compressed that the expelled mass at 
 first appears solid ; but a little careful dissection or maceration will 
 readily show that it consists of two layers, and that there are the 
 remains of a cavity between them. The interior of the cavity is 
 smooth, and marked by the orifices of the uterine mucous ciypts 
 that I have above alluded to. Occasionally we can easily trace three 
 large openings at its three angles, corresponding to the openings of 
 the two Fallopian tubes and cervix uteri. But the external surface 
 of the mass is rough and shaggy, marking the effects of dilaceration 
 from the tissue of the uterus. Sometimes we see a piece discharged 
 quite smooth on one surface, and rough on the other. "When this 
 is the case, we may be perfectly certain that it is a portion only of 
 the membrane which has been expelled, or, at least, preserved for 
 inspection. For, if the portion of mucous membrane lining the 
 anterior wall of the uterus alone, or lining its posterior wall alone, 
 be discharged and examined, and not that of the whole cavity, it 
 will necessarily display the apparent anomaly alluded to. If the 
 membrane is thrown off" in broken or disintegrated fragments, as 
 sometimes happens, it will be more difficult to trace the structural 
 
BYSMENOERHCEAL MEMBRANE. 261 
 
 characteristics that I have mentioned. Another form of difficulty 
 is occasionally produced by blood being infiltrated into or upon the 
 dysmenorrhceal membrane. In some instances the membrane is 
 found encased in one or more layers of coagulated blood ; and if 
 that blood has already become decolorized, and assumed a fibrinous 
 appearances, mistakes might easily occur, provided the inquirer were 
 not av?are of this source of fallacy. 
 
 One of the earliest descriptions of the dysmenorrhceal membrane 
 upon record is given by Morgagni. He gives an exact account of 
 the appearances which it presented in the case of a " noble matron," 
 long afflicted at the menstrual period with "pains like those of 
 childbirth." Morgagni's description of the dysmenorrhteal mem- 
 brane expelled on these occasions is so exact and excellent, that I 
 shall perhaps be excused quoting it. " In almost the middle," as he 
 states, " of the membranous flux, a membranous body, as it appeared, 
 was discharged from the uterus ; and that in such a form, and of 
 such a magnitude, as perfectly corresponded to the triangular form 
 of the uterus ; being moderately convex externally ; on which sur- 
 face it was unequal and not without many filaments that seemed to 
 have been broken off from the parts to which they had adhered, but 
 internally hollow ; on which surface it was smooth and moist, as if 
 from an aqueous humor, which it had before contained, but had 
 discharged, at its own exit, by an ample opening, which was at one 
 of its angles, that had been readily opened by rupture."' 
 
 Thirdly, The dysmenorrhceal membrane exactly resembles the 
 decidual membrane, the decidua vera ; and all our highest authorities 
 in anatomy are, I believe, now willing to grant that, as pointed out 
 by the researches of Sharpey, Weber, Goodsir, and others, the 
 decidua vera is not a new membrane, formed in the uterus after con- 
 ception, but merely the normal mucous membrane of the uterus, 
 hypertrophied, with its mucous crypts or follicles increased in size, 
 and the cells of its interstitial tissue greatly developed and multiplied. 
 In the dysmenorrhceal membrane the mucous follicles or crypts are 
 perhaps not enlarged and developed to the same proportionate degree 
 as they are in the decidual membrane. In other respects the two 
 membranes are identical. They have the same triangular form. 
 There is the same appearance in both, of openings at their three 
 angles, and in both, these openings are occasionally more or less 
 perfectly sealed up when the tissue of the membrane, in their im- 
 mediate neighborhood, is developed in an unusual degree. The 
 external surface of each membrane has the same shaggy, ragged 
 form. In each we have the same cribriform appearance upon their 
 
 ' Morgagni, " The Seats and Causes of Diseases," &c. vol. ii. p. 706. 
 
262 DISEASES OF MENSTRUATION. 
 
 smootli internal surface, marking the orifices of the mucous follicles. 
 When examined under the microscope, the interstitial or inter- 
 foUicular tissue of both membranes, shows a similar structure, 
 namely, one wholly composed of an agglomeration or superposition 
 of simple nucleated cells. And altogether, if, on the one hand, it 
 be allowed that the structure of the decidua proves it to be the 
 mucous membrane of the uterus in a state of high development and 
 hypertrophy, then, on the other hand, the structure of the dys- 
 menorrhoeal membrane is so similar to that of the decidua, as to 
 prove a perfect identity with the decidua in its characters, and, con- 
 sequently, also in its origin. 
 
 In some respects the evidence which we have in favor of the deci- 
 dual membrane being merely a hypertrophied state of the mucous 
 membrane of the uterus, is still wanting, in so far as regards the 
 dysmenorrhceal membrane. For, first, in cases of patients dying at 
 different periods of early pregnancy, a regular progression of ob- 
 servations has now been made, showing the gradual transformation 
 of the true mucous into the true decidual membrane ; and, secondly, in 
 patients dying after delivery, and, consequently, after the separation 
 of the decidual or lining membrane of the uterus, the actual absence 
 of the mucous surface of the uterus has been often ascertained on 
 dissection. I lately saw a case where the patient died six weeks 
 after delivery, and still, at that late date after confinement, the 
 mucous lining of the uterus was not yet regenerated. No corre- 
 sponding series of observations has hitherto been made upon the 
 actual formation of the dysmenorrhceal membrane before menstrua- 
 tion, or upon its actual absence after that period. But a more careful 
 investigation of the state of the uterus after death, in patients who 
 have happened to be suffering under membranous dysmenorrhcea, 
 during life, will, I have no doubt, afford the requisite data. It may 
 not be uninteresting to add, that the absence of the mucous lining 
 of the uterus in persons who have died after delivery, or who have 
 been previously subject to membranous dysmenorrhoea, may have 
 given rise to the strong opinions expressed in former times by several 
 anatomists, and particularly by Morgagni, Chaussier, and Gordon, 
 in regard to the human uterus not being normally provided with a 
 mucous membrane. Not meeting with that membrane under some 
 circumstances and in some cases, they were induced to doubt its 
 presence under any circumstances or in any cases. 
 
 Modern physiology has made us sufficiently acquainted with the 
 curious fact, that a portion of the epithelial layer of the mucous sur- 
 face of various organs, exfoliates constantly and normally during 
 the performance of the special functions of these organs. For in- 
 
DYSMENORRHCEAL MEMBRANE. 263 
 
 stance, this holds true with regard to the epithelium of the stomach 
 during digestion, and that of the uterus during menstruation. But 
 there are few circumstances, either in healthy or morbid anatomy, so 
 strange as that which I have attempted to prove in the preceding 
 remarks, namely, that the proper mucous tissue of the uterus itself 
 may, within the compass of a menstrual period, form, enlarge, sepa- 
 rate, and again be reproduced ; and further, that all this may occur 
 and continue regularly for a succession of months, or, as sometimes 
 happens, for a succession of years. 
 
 I have no intention, however, at present of dwelling either upon 
 the various pathological or practical views to which the opinion that I 
 have above propounded regarding the origin and nature of the dys- 
 menorrhceal membrane, very evidently points. It is enough perhaps 
 to remark, that the observations which I have made go to demonstrate 
 that the dysmenorrhoeal membrane is not formed, as is generally be- 
 lieved, by a simple inflammatory effusion of plastic or coagulable 
 lymph, and hence is not to be successfully prevented and combated 
 by simple anti-inflammatory treatment. The action giving rise to 
 it may in some cases be combined or complicated with inflamma- 
 tion. I have seen, for example, the membranous dysmenorrhcea in 
 several instances coexisting with inflammatory induration and ulcera- 
 tion of the cervix uteri. But essentially, the normal action of the 
 uterus or ovaries giving rise to the formation of the dysmenorrhoeal 
 membrane is not a state identical with inflammation, but a state 
 identical with the condition of these organs after impregnation and 
 during the earlier weeks of pregnancy. It is so far a state and pro- 
 duct natural to one special condition of the uterus, but here occur- 
 ring at an unnatural time, under unnatural circumstances, and with 
 unnatural frequency. 
 
 The views entertained by Dr. Simpson as to the nature of the membrane expelled in some 
 cases of dysmenorrhcea, have received singular confirmation from the more recent researches 
 of M. Lebert and Dr. Handfield Jones. The latter found the membrane composed of epithelial 
 " scales, resembling those of the healthy buccal mucous membrane'" — the former, besides the 
 epitlieUal particles, has traced distinctly the presence of the shed uterine follicles and glands.^ 
 We may add, that on more than one occasion we have ourselves observed, with the aid of the 
 microscope, the simple utricules, and more tortuous uterine glands, in dysmenorrhoaal mem- 
 branes, furnished us by Dr. Simpson ; and have preserved drawings of such prepara- 
 tions. — (Ed.) 
 
 ' See Transactions of the Pathological Society of London, vol. iii. p. 392. 
 2 See Gazette Medicale, July, 1850, p. 557. 
 
264 DISEASES OF MENSTRUATION. 
 
 DILATATION AND INCISION OF THE CERVIX UTERI IN 
 CASES OF OBSTRUCTIVE DYSMENORRHCEA.' 
 
 (From Edinburgh Monthly Journal of Medical Science, August, 1844, p. 734.) 
 
 Dr. Simpson, in speaking of dilatation of the os and cervix uteri 
 as a means of treatment, pointed out the results of this practice in 
 the hands of the late Dr. Mackintosh in the cure of dysmenorrhcea 
 and sterility, connected with normal and inflammatory strictures of 
 the OS uteri. His own results had not been so successful as those of 
 Dr. Mackintosh ; but he had now seen a considerable number of 
 severe cases, in which dysmenorrhcea that had previously resisted all 
 other kind of treatment, had at once yielded to the mechanical dila- 
 tation. Dr. Simpson had found the stricture occasionally at the os 
 internum, or opening between the cavities of the cervix and body, 
 and not at the os tincse. Dr. Mackintosh had effected the dilatation 
 by long straight bougies of different sizes. Dr. Simpson had found 
 them more easily used when slightly curved. He also showed other 
 instruments, one of them like the dilator for the female urethra, 
 which he had occasionally employed for this purpose. These in- 
 struments were all of them intended to be left in the os uteri 
 for only a short period, and their introduction repeated from time 
 to time, as in the usual treatment of stricture of the urethra in 
 the male. Latterly Dr. Simpson had in his practice thrown these 
 aside, and used another, a form of permanent bougie, for this pur- 
 pose, which he considered to be greatly preferable. These perma- 
 nent bougies (Fig. 20) were made of Berlin silver ; the stem or part 
 included in the uterine cavity was two inches and a quarter in 
 length, the lower end which rested in the vagina was bulbed and 
 enlarged to the size of a large almond, and was perforated below 
 for the purpose of being placed on a temporary handle, used in the 
 introduction.^ One of the instruments was left in the uterine cavity 
 for three or four days, and by that time the part was so much relaxed, 
 that another of a much larger size could, in general, be readily intro- 
 duced. They could easily be borne without the slightest inconve- 
 nience, and, indeed, without the patient being aware of their pre- 
 sence. Dr. Simpson pointed out that this permanent form of bougie 
 gave altogether much less pain to the patient and less trouble to the 
 practitioner ; was more certain and expeditious in its effects, and was 
 especially useful when the surrounding tissues of the lips and cervix 
 were in any degree indurated. Obstructive dysmenorrhcea some- 
 times depends on other circumstances than ordinary strictures of the 
 
 ' Extracted from Proceedings of Medioo-Chirurgical Society of Edin., July 3, 1844. 
 
INCISION OP CERVIX FOR DYSMENORRHCEA. 265 
 
 OS. It is sometimes seen in connection with the conical hypertrophy 
 and elongation of the cervix. He had found it in several instances 
 accompanied with much morbid thickening of the anterior lip of 
 the OS uteri, the posterior lip heing thin and healthy, and the os 
 stretched out between them of an irregular crescentic shape. In 
 such, and other instances, he had divided the os uteri on each side 
 to the extent of a few lines with a very narrow knife or " lithotome 
 cache," and subsequently kept the part temporarily dilated by the 
 sponge-tent. He quoted cases of the perfect success of this simple 
 and safe measure ; it placed the parts in somewhat the same condition 
 as that which they present subsequent to miscai'riage ; and this latter 
 occurrence is known in general to leave without dysmenorrhoea those 
 who have previously been laboring under that aifection, whilst at 
 the same time, women after aborting usually soon again become 
 pregnant, there being no such great lacteal determination to the 
 mammae as occurs after parturition at the full period, and which 
 seems then usually to interfere with the early repetition of con- 
 ception. 
 
 From the Proceedings of the Edinburgh Obstetric Society, March 
 10, 184T, we have also the following •} — Dr. Simpson stated that he 
 had now been in the habit for three or four years past of perform- 
 ing the operation of incision of the cervix uteri for obstructive 
 dysmenorrhoea. He first described the operation to the Medico- 
 Chirurgical Society in 1844, and it had latterly been adopted by 
 Dr. Rigby, Dr. Protheroe Smith, Dr. Oldham, and other accoucheurs 
 in London and elsewhere. He had frequently been asked if he had 
 occasion to perform the operation often. Certainly he had. In 
 the last week he had operated in seven cases. He was in the first 
 instance led to incise, instead of dilating the os uteri vnth bougies, 
 by meeting several years ago with a patient sufiering from dysmenor- 
 rhoea, who could only remain a few days under his charge. The 
 incisions had in this instance the desired efiect ; and the lady was 
 delivered of a son within a twelvemonth. She had been previously 
 six or seven years married, but had never been pregnant. 
 
 He ftirther explained that he believed the sufferings in obstruc- 
 tive dysmenorrhoea to arise from the uterus being driven into con- 
 tractions, like those of abortion, to expel its own retained menstrual 
 secretions. 'Sow, the menstrual secretion need not necessarily be 
 retained when the os uteri is small ; for the secretion might form 
 very slowly, and so escape without accumulation and distension. 
 On the other hand, it might be secreted so abundantly by the lining 
 membrane of the uterus, as not to escape sufficiently freely even 
 
 ' See Edinburgh Monthly Journal of Medical Science, May, 1847, p. 870. 
 
266 DISEASES OF MENSTRUATION. 
 
 when tlie os was of the natural size, and thus, under that condition, 
 lead to retention, accumulation, and expulsive pains. In fact, in 
 order to produce obstructive dysmenorrhoea, there must be a want 
 of relation between the quantity of fluid secreted, and the quantity 
 allowed to escape, so that a greater or less degree of retention is the 
 result. It was of course most apt to occur with a small and con- 
 tracted OS uteri, and these were the cases most frequently requiring 
 the operation. 
 
 The instrument which he makes use of is a kind of lithotome 
 cach^, manufactured by Mr. Young, cutler. The end of the instru- 
 
 Fig. 23. 
 
 
 ment is passed up through the cavity of the cervix, and within the 
 OS internum. It is then slightly opened laterally, first on one side 
 and then on the other, so as to divide any fibres that may be caus- 
 ing constriction of the internal orifice. The principal incision is 
 then made in withdrawing the instrument. This incision com- 
 mences at the union of the cervix with the body of the uterus, 
 and passing gradually more and more into the substance of the 
 cervix as it descends, the blade is brought out at the outer and 
 lower edge of the cervix, at the point of reflection of the mucous 
 membrane upon the wall of the vagina. The instrument is then 
 turned ; and a similar cut made on the other side ; or the incisions 
 may be made antero-posteriorly instead of laterally. The incision 
 is thus of a conical form, and at its lower part includes the whole 
 thickness of the cervix. Care must be taken that it does not pass 
 beyond the substance of the cervix, as it is closely surrounded by a 
 plexus of veins, which, if cut, would certainly cause severe hemor- 
 rhage. If care be taken to regulate the incision in this way, the 
 hemorrhage is usually very trifling. The operation causes little or 
 no pain. The lips of the wound generally get everted, and have 
 very little tendency to cohere. If they oflfer to do so, it is necessary 
 to touch the raw surface, more especially the angles of the wound, 
 every three or four days, with nitrate of silver. 
 
GALLIC ACID IN MENOBRHAGIA. 267 
 
 CASE OF ACCUMULATED AND EETAINED MENSTRUAL 
 SECRETION." 
 
 (From Edinburgh Monthly Journal of Medical Science, April, 1850, p. 388.) 
 
 Dr. Simpson exhibited to tlie Society a very large quantity of a 
 thick viscid fluid, dark-red in color, which had been removed that 
 day by Mr. Syme from a young woman in the Royal Infirmary. 
 
 The girl was nineteen years of age, had never menstruated in the 
 usual way, and made great complaints of severe pains in the back 
 and loins, which were much exacerbated every three or four weeks. 
 About five months ago she was for the first time sensible of a 
 swelling in the hypogastrium about the size of the fist. Since then 
 it had gradually increased, but chiefly at the periods of the monthly 
 exacerbations. On examination, the hymen was found perfect and 
 entire, and the vagina and uterus greatly dilated by the accumulated 
 menstrual secretion. The hymen was divided by Mr. Syme, and 
 the fluid exhibited was evacuated. 
 
 Dr. Simpson stated that the same operation had been performed 
 by him in the Maternity Hospital, in a case where the cause -of oc- 
 clusion was adhesion and contraction of the vagina from sloughing, 
 following a previous diflacult labor. The quantity of fluid eva- 
 cuated was almost as great. This patient, like many others who 
 underwent this apparently simple operation, had suffered under a 
 smart attack of irritative fever after it. Dr. Ramsbotham^ had col- 
 lected five or six cases, in which- this irritative fever had gone on to 
 a fatal termination. 
 
 GALLIC ACID IN MENORRHAGIA.^ 
 
 (From Lond. and Edin. Monthly Journal of Med. Science, July, 1843, p. 661.) 
 
 Professor Simpson stated that for the last year he had employed 
 gallic acid in some cases of menorrhagia, with the most successful 
 results. Like all the other remedies directed against that disease, it 
 had also occasionally failed in his hands. Some of the cases, which 
 had completely yielded under its use, were of an old standing, and 
 aggravated description. He gave it during the intervals, as well as 
 
 ' Extracted from Proceedings of Edinburgh Obstetric Society, February 13, 1850. 
 ^ Lecture on Diseases of Women in London Medical Gazette, vol. xvi.p. 327. 
 ' Extracted from Proceedings of Medico-Chirurgical Society, April 19, 1843. 
 
268 DISEASES OF MENSTRUATION. 
 
 during the discharge, in doses of from ten to twenty grains per day, 
 made into pills. It had this advantage over most other anti-hemor- 
 rhagic medicines, that it had no constipating effect upon the bowels. 
 He was first induced to use it, by finding a case of very obstinate 
 menorrhagia get well under the use of Ruspini's styptic, after many 
 other remedies had utterly failed, and from it being alleged that 
 gallic acid was the active ingredient in that styptic. He suggested 
 whether the anti-hemorrhagic properties of some of our common 
 astringent drugs may not depend upon the gallic acid as much or 
 more than upon the tannin which they contain, or upon the tannin 
 becoming changed into gallic acid within the body. 
 
 At a subsequent meeting of the Society, February f, 1855,' Dr. 
 Simpson stated, as the result of his experience in cases of hemor- 
 rhage, that gallic acid was only occasionally successful. Some ten 
 or twelve years ago, he had had occasion to treat a case of severe 
 menorrhagia, where all kinds of medicines had been used without 
 effect. From the recommendation given by Sir Benjamin Brodie 
 in his chapter on Scematuria, he prescribed Ruspini's styptic; and 
 relief speedily followed. The disease recurred, however ; and the 
 patent medicine was found to be too expensive. Acting on the hint 
 of Dr^ Anthony Todd Thomson, that Ruspini's styptic contained it, 
 he gave gallic acid, and similar benefit was obtained. Dr. Gairdner 
 said that tannin had greater effect as an astringent in the treatment 
 of haemoptysis ; but this it was difficult to reconcile with the obser- 
 vation of "Wohler, that tannin was converted into gallic acid in its 
 passage through the circulation, and consequently before it reached 
 the lungs. He believed in fact that rhatany, krameria, and other 
 vegetable astringents containing tannin, acted as secondary haemo- 
 statics upon the lungs, kidneys, and uterus, by being carried in the 
 blood of these parts as gallic acid ; and that their efficacy in restrain- 
 ing hemorrhage was thus to be explained. Dr. Andrew "Wood had 
 stated his experience of the efficacy of the acid in purpura ; while it 
 was well known that Grarrod had as strongly recommended alkalies 
 in that disease. Such statements he thought could be reconciled 
 by supposing that there might be several forms of purpura, each 
 with their stronger affinity to particular remedies ; and he believed 
 that the uncertainty in the treatment of menorrhagia admitted of a 
 similar explanation. After such astringents were given by the 
 stomach, just as after gallic acid, gallic acid, as stated by Liebig, was 
 found in the urine ; and consequently was present in the blood. 
 
 A paper by Dr. Gairdner upon gallic acid in albuminuria and haemoptysis having led to 
 some discussion, Dr. Simpson also said that the case which had first impressed his mind 
 
 ' See Association Journal, Feb. 1855, p. 186. 
 
APPLICATION OF KBMEDIES TO THE UTBKUS. 269 
 
 with the efficacy of gallic acid in the treatment of albuminuria was that of a brother prac- 
 titioner who labored under the disease, and was compelled to relinquish practice in conse- 
 quence. Gallic acid was at length tried, and with the best results. He resumed practice 
 some eight or ten years ago, and to this day remained comparatively well, and had no symp- 
 toms of albuminuria. The cure in this instance was very probably, however, a mere coin- 
 cidence, as he himself had never perceived the slightest benefit from the use of the remedy 
 in any of his other cases of this disease. Besides, there were many sources of fallacy ; as, 
 in acute cases of albuminuria, the patient generally got speedily well ; and, in the more 
 chronic forms of the disease, it was long before the health was seriously interfered witli. 
 One patient he knew who suffered from Bright's disease so long ago as 1826, and Dr. Bright 
 himself had predicted a speedy and a fatal issue. The gentleman was still alive, and one 
 of the strongest individuals in his native town, though the albuminuria remained as before. 
 Dr. Gairdner had exhibited the acid with alkalies — a combination which, according to the 
 observations of Liebig on the effect of gallic acid on the blood, must destroy its efficacy as 
 an astringent. — (Ed.) 
 
 DIRECT LOCAL APPLICATION OF REMEDIES TO THE 
 CAVITY OF THE UTERUS.' 
 
 (From Lend, and Edin. Monthly Journal of Med. Science, July, 1843, p. 661.) 
 
 Dr. Simpson stated to the Society that he had of late applied 
 nitrate of silver, &c., to the lining membrane of the cavity of the 
 uterus, in cases of uterine leucorrhoea, and of dysmenorrhcea, con- 
 nected with a morbidly sensitive state of portions of the inner sur- 
 face of the organ, as ascertained by the bougie, and with membra- 
 nous, sub-inflammatory effusions ; in chronic suppression of the 
 menstrual discharge, &c. The results proved, that while direct local 
 applications could thus be made with perfect ease and safety to the 
 diseased lining membrane of the uterine cavity, the effects were 
 such, as to lead to the hope of a successful issue in some cases of 
 uterine disease, otherwise almost or indeed totally unmanageable. 
 
 In applying nitrate of silver and other solid powders and substances to the interior of the 
 uterus. Dr. Simpson uses an instrument similar to the porte-camtic employed by Lallemand 
 for touching sensitive parts of the male urethra. 
 
 We may here state, that for some time past. Dr. S. has been in the habit of applying 
 various medicated substances in the form of powder, to the cervix uteri and vagina, in cases 
 of leucorrhoea dependent upon vaginal eruptions, &c. Powders of oxide of zinc, subnitrate 
 of bismuth, &c., when thus freely applied, act most successfully in some instances of obsti- 
 nate leuoorrhcea. They are readily applied with the bone tube and piston usually employed 
 in leeching the os uteri. — (Ed.) 
 
 ' Extracted from Proceedings of the Edinburgh Medico-Chirurgical Society, April 19, 1843. 
 
270 DISEASES OF MENSTKUATION. 
 
 NOTES ON THE THERAPEUTIC ACTION OF FUEFURINE, 
 
 NICKEL, ETC. 
 
 (From Monthly Journal of Medical Science, August, 1852, p. 135.) 
 
 Fob many centuries past, the principal and most important addi- 
 tions which have been made to the Materia Medica have been in 
 the form of substances or principles derived from the vegetable 
 kingdom. But new, and perhaps still more potent, remedies will 
 in all probability be yet derived from other sources. Chemistry is 
 daily multiplying upon us the already almost innumerable class of 
 organic compounds. Some of these compounds will no doubt yet 
 be found to possess powerful and important therapeutic properties. 
 Chloroform is an instance to which I may venture to refer in illus- 
 tration of this remark. Again, among the most potent therapeutic 
 instruments in our present pharmacopoeias are to be reckoned the 
 vegetable alkaloids. Modern chemisty has, as is well known, found 
 out the riieans of forming artificially several alkaloid substances 
 analogous to those existing naturally in the vegetable kingdom. 
 Upon some of these I have made experiments, but particularly upon 
 furfurine — an alkaloid that produces, in experiments with poisonous 
 doses upon the lower animals, many of the symptoms of quinine ; 
 and the salts of which I have found to act as a tonic, if not as an 
 antiperiodic, when exhibited to the human subject. 
 
 Our modern pharmacopoeias contain preparations from the oxides 
 or salts of various metals, as antimony, arsenic, bismuth, copper, 
 iron, lead, mercury, silver, and zinc, besides metalloids and metallic 
 earths. Some of these possess a most decided and valuable thera- 
 peutic action upon the human economy. But all, or almost all, of 
 these metals were already used medicinally by the ancient Greek 
 and Eoman physicians ; and though in later times the list of known 
 metals has been greatly increased by the researches of chemists, the 
 therapeutic action, if any, of these metals has not been made a 
 matter of research by medical men. It seems, however, a priori, 
 highly probable that some of the new, like some of the old, metals, 
 will turn out to have decided, and it may be important therapeutic 
 properties. At all events, few fields seem so likely to yield new 
 therapeutic results — if such results are to be obtained at all — as ex- 
 periments and observations upon the preparations and salts of those 
 metals that have hitherto not been tested medicinally. 
 
 Last year, impressed with these views, I began making various 
 therapeutic experiments upon myself and others with different 
 
TEEATMENT OF PERIODIC HEADACHE BY NICKEL. 271 
 
 metals, as cadmium, iridium, tellurium, &c. I have had little leisure 
 to prosecute the inquiry. But I have obtained some results which 
 seem to me not without interest or importance. One of the new 
 metals which I have used most frequently is nickel. As with the 
 others, I have used it generally in the form of a salt, a sulphate, 
 believing that, as in the case of the metals already known, the use 
 of one of its salts would give a sufficient view of the generic medical 
 action of the metal. 
 
 Sulphate of nickel has appeared to me to act as a gentle metallic 
 tonic. I have generally used it in doses of half a grain or a grain, re- 
 peated thrice daily ; and have given it in the form either of simple 
 solution or of pill. In large doses it is liable, like sulphate of zinc or 
 copper, to produce sickness and nausea, particularly if taken upon an 
 empty stomach. I have generally requested it to be taken half an 
 hour or an hour after meals. It has appeared to me, as the result of 
 pretty numerous experiments and observations, that the therapeutic 
 actions of the salts of nickel and manganese correspond in a consider- 
 able degree with the therapeutic actions of the salts of iron upon the 
 economy ; and that these three metals might, under many conditions, 
 be almost used as therapeutic substitutes for each other. But they 
 also specifically differ from each other in some respects. For ex- 
 ample, in one most interesting case, the sulphate of nickel arrested 
 a severe form of periodic headache, which had previously defied iron 
 in many different forms, and all other kinds of treatment that had 
 been employed. The patient came from Italy last autumn, in order 
 to place herself under my professional care ; and for some months I 
 was as unsuccessful as my predecessors had been in affording her 
 any relief. But let me give the history of the affection, and the 
 ultimate result, in the lady's own words. She drew up the following 
 note of her case several weeks ago : — 
 
 " My headaches," she writes, " came on soon after my second con- 
 finement, in August, 1847, and continued to return every tenth day 
 without intermission, up to the 1st of February, 1852. During the 
 first four years I was in Italy, and was attended by medical men of 
 all countries — ^English, French, German, and Italian. I also tried 
 hydropathy and homoeopathy, the latter for six months, but all with- 
 out the slightest effect. The pain came on in a small spot on the 
 right temple, and lasted from twenty-four to thirty-six hours. After 
 the first eight hours, severe sickness followed, which continued up 
 to the sixteenth hour. During the attacks I had violent cold shiver- 
 ing fits, succeeded by a burning fever. At times I was quite delirious 
 from the violence of the pain. I have taken large doses of steel, 
 iron, and quinine, besides many other sorts of medicines. The 
 quinine I took at first only two days before the attack was expected. 
 
272 DISEASES OF MENSTRUATION. 
 
 I then took six grains every day for a year and a half, but it never 
 put off the headache a moment beyond its day and hour, nor would 
 anything that I could do bring it on before the time. When I first 
 came to Scotland to be under the advice of Dr. Simpson, in August, 
 1851, he gave me thirty grains of quinine a day for three days 
 before the headache was to come on ; but it returned to its hour, and 
 as severe as ever. This was tried also with the next fit, with no 
 better success. Dr. Simpson then tried successively furfarine, be- 
 beerine, and arsenic, but the headaches still continued up to the Ist 
 of February, 1852, on which day I had a most severe attack. On 
 the 4th of February, he gave me the solution of sulphate of nickel 
 to take ; since which time, to my astonishment, my usual headaches 
 have altogether disappeared." 
 
 To the preceding account I have merely to add, that, if we may 
 judge from the result up to the present time, the cure of this patient 
 by the use of nickel appears entire and complete. And perhaps it 
 is but proper to remark, that this result seems fairly attributable to 
 the action of the nickel alone, inasmuch as there was no relief under 
 the use of any of the means or medicines previously employed for 
 years ; while convalescence distinctly began from the date of the 
 employment of the metal in question. 
 
 Further, it is perhaps not unimportant to observe, that while the 
 disease had lasted four years without abatement, its subsidence in 
 February could not be the result of change of climate, as the lady 
 had already resided about five months in Edinburgh or its neighbor- 
 hood, without any noticeable amelioration in the recurrence and 
 intensity of the headaches ; and at last they disappeared under the 
 nickel, at a period of the year, viz., the commencement of spring — 
 at which, in our climate, headaches and other periodic diseases are 
 known to be specially liable to become increased and aggravated. 
 
 In no kind of case is the beneficial action of iron more remarkable 
 than in the treatment of chlorosis and amenorrhcea. I have seen 
 nickel in a similar way apparently serviceable under the same cir- 
 cumstances. In the latter end of last year, I gave it in a case of 
 amenorrhcea often years' duration. The amenorrhcea supervened at 
 the age of twenty-two. At the same time a galvanic intra-uterine 
 bougie was introduced, and left for some time in the cavity of the 
 uterus. In the course of three or four weeks menstruation took 
 place, and has recurred regularly from that period. In such a case, 
 however, it is difficult to say how far the result was attributable to 
 the local means used, and what share the nickel had in the restora- 
 tion of the patient's health. 
 
SPURIOUS PREGNANCY. 273 
 
 SPURIOUS PREGNANCY-ITS FREQUENCY AND NATURE.' 
 
 (From Edinburgh Monthly Journal of Medical Science, July, 1850, p. 90.) 
 
 Dr. Simpson first showed how frequent and marked the phe- 
 nomena of spurious pregnancy were among domestic animals, as in 
 the bitch, cow, &c. In these animals such phenomena often occur- 
 red both subsequently to unsuccessful sexual intercourse, and also 
 frequently after seasons of heat, during which there was no inter- 
 course with the male. Occasionally the-symptoms were in them sud- 
 denly interrupted, and terminated a short time after their commence- 
 ment ; sometimes, however, they went on increasing to the full term 
 of pregnancy, and ended in a series of puerperal phenomena, as the 
 presence of milk in the mammse, &c. &c. He adduced a variety of 
 facts, showing the great frequency with which the same symptoms 
 of spurious pregnancy occur in the human female in a more or less 
 marked degree, and how they are often mistaken for dyspepsia, 
 hysteria, and various anomalous and perplexing ailments. And as 
 these phenomena sometimes occur in the virgin state among the 
 lower animals, so do we find them also sometimes occurring in the 
 unmarried human female, and giving rise to symptoms that have 
 hitherto defied any nosological arrangement. Lastly, he spoke of 
 the great use of aperients combined with tonics, and with nux 
 vomica and galbanum, in the subjugation of the phenomena of 
 spurious pregnancy. 
 
 The following further remarks on this subject were made by Dr. 
 Simpson, April 6, 1854.^ A case of hysteria and spurious preg- 
 nancy having at that time been read by Dr. Keiller, before the 
 Medico-Chirurgical Society of Edinburgh, the President, Dr. S., 
 observed that he believed cases of spurious pregnancy were often 
 met with in practice ; for many a married lady would acknowledge, 
 when questioned, that she had once or twice thought herself preg- 
 nant when, as the result showed, she was not. He had in his own 
 practice seen several cases in which ladies had removed into town 
 with their entire establishments, in the full belief of their approach- 
 ing confinement, and where he had had the disagreeable duty of 
 informing them that they were not in the family way. Shortly be- 
 fore his predecessor. Dr. Hamilton, died, one lady, in her anxiety to 
 reach Edinburgh, had had the roads cleared of snow for a long 
 series of miles, to enable her to accomplish the journey, which 
 
 ' Extracted from Proceedings of Obstetric Society of Edinburgh, March, 1850. 
 ' See Association Medical Journal, April, 1854, p. 357. 
 VOL. I. 18 
 
274 DISEASES OF WOMEN. 
 
 proved after all a useless one, as Dr. Hamilton pronounced her not 
 pregnant. These were instances in which patients progressed on- 
 wards to near the full term of pregnancy, suffering all the usual 
 symptoms and discomforts of that state. Sometimes phenomena 
 exactly like those of labor came on at the full term. This seemed 
 to have occurred in Dr. Keiller's patient. He had seen several 
 analogous instances of spurious pregnancy terminating in spurious 
 parturition. In one of the first cases of this kind which he had 
 witnessed, and which occurred in the Maternity Hospital of Edin- 
 burgh, he had been suddenly called from lecture to see it ; the case 
 being reported by the house-surgeon, a man of remarkable acute- 
 ness, to be one of placenta prsevia, and requiring the operation of 
 turning. The patient had the phenomena of labor present, with 
 severe menorrhagia ; but there was no child to turn, as she was not 
 pregnant. Besides the cases of pseudo-pregnancy, in which, as in 
 the above, the patient went on with the usual symptoms of preg- 
 nancy till near or up to the full period of labor, there were other 
 varieties of this curious morbid state. In some, for example, the 
 affection lasted only for a few months ; in others, it occasionally 
 continued far beyond nine months, and became, as it were, chronic 
 in its character. As to the symptoms themselves, they consisted of 
 the presence of more or fewer of all the usual sympathetic symp- 
 toms of pregnancy, as swelling of the abdomen, nausea and sick- 
 ness, a feeling of quickening and motion of the child, &c. Dr. 
 Keiller had stated that the mammary signs were not well marked in 
 his patient. Sometimes, however, they were ; and he had sketches 
 illustrative of this fact, executed by the patient herself during a 
 state of spurious pregnancy, and in whom, in a subsequent veritable 
 pregnancy, her first, the areolae did not present a deeper tint than 
 they had done during her pseudo-pregnancy. As to the sensations 
 which had been described in such cases, they were very frequent, 
 and sometimes there were true motory contractions in the abdominal 
 walls. He saw, about a year ago, with Drs. Moir and Weir, a 
 patient who had been sent from the country on account of a sup- 
 posed difficulty in the delivery, the woman having, according to her 
 statement, been in labor for three days. In this case, there were 
 very strong motions visible in the abdominal walls ; so much so 
 that the husband, who was present during the consultation, declared, 
 on their affirming that there was no child, that then there must be an 
 animal inside his wife. Dr. Simpson was inclined to believe that 
 the malady was connected with the ovary. In one aggravated case 
 which had fallen under his observation, there was marked ovaritis, 
 and the ovary subsequently suppurated. Again, it was observed 
 that, although menstruation did occur in the cases which had been 
 
spumous PREGNANCY. 275 
 
 noticed, yet that it was much scantier than usual, and sometimes the 
 catamenia were wanting for several months. It was well known 
 that the complaint wa|S not peculiar to the human female. Harvey 
 had long ago remarked that, in hounds who were well fed, many of 
 the phenomena of pregnancy, such as swelling of the ahdomen, and 
 the presence of milk in the mammse, occurred both subsequently to 
 unsuccessful sexual intercourse, and also frequently after seasons of 
 heat, during which there was no intercourse with the male ; kittens 
 and other young animals were frequently stolen by the animal, to 
 make the semblance of a litter. The curious observation had also 
 been made by Harvey, that the animals were liable to the diseases 
 of bitches which had recently been delivered. Dr. Simpson stated 
 some similar facts in the case of the domestic cow. The symptoms 
 of spurious pregnancy often occurred in the virgin female dog. 
 And he believed that, when some of the cases of the so-called 
 hysteria in unmarried females were inquired into, they would be 
 found, as he thought he had repeatedly seen, to be really symptoms 
 only of spurious pregnancy. Dr. Keiller had alluded to retraction 
 of the limb as having been a well-marked symptom in his patient. 
 He himself had seen a case many years before the introduction of 
 chloroform, in which the symptom was a prominent one. The lady 
 had been under treatment in Paris, and, on her return to Scotland, 
 a surgeon examined her, and recognized, as he supposed, the pre- 
 sence of a large ovarian tumor — not an uncommon mistake, as, in 
 the records of ovariotomy, six cases are detailed in which no tumor 
 could be found after the abdomen was opened. Dr. Simpson was 
 consulted, and, on percussing, Tie found the abdomen quite tym- 
 panitic, and of course negatived the tapping, and the presence of 
 any ovarian tumor. The leg in this case was much drawn up, and 
 he was informed that, while in Paris, the heel was for a time closely 
 applied to the back of the neck. About two years ago, he saw a 
 lady, with Mr. Syme, whose limb was strongly and permanently 
 retracted, and presented the appearance of hip disease. He was 
 uncertain whether there was abdominal fulness in this case, or not. 
 The appearances were so deceptive, that a practitioner had used the 
 exploring needle for the purpose of evacuating matter. As soon as 
 the patient was brought under the influence of chloroform, how- 
 ever, the limb was readily straightened for the first time for many 
 long months, and the case was at once ascertained to be one of 
 "hysterical disease" of the joint. With regard to the nature of 
 the abdominal swelling in spurious pregnancy, he had tried various 
 experiments to ascertain its cause, but in vain ; and as yet he could 
 come to no decided conclusion on the subject. It had been sug- 
 
276 DISEASES OF WOMEN. 
 
 gested that, while the patient was deeply under the influence of 
 chloroform, contained air escaped unobserved ; but, in one very- 
 marked case in the hospital, he had passed a tube per^ anum, its 
 nozzle being kept under water ; but not a bubble of air escaped. 
 The diaphragm he was inclined to suspect to be a chief agent in 
 the production of the swelling. One patient who had a small 
 fibrous tumor of the uterus, and a rounded tympanitic abdomen, 
 could greatly diminish the prominence of the abdomen by drawing 
 herself up, and, on allowing the diaphragm to fall, the fulness and 
 the appearance of pregnancy returned. The chloroform, he be- 
 lieved, here acted by relieving the muscles, diaphragmatic and ab- 
 dominal, from the influence of reflex action, and permitting their 
 relaxation. In one case, he had also seen the Csesarian section 
 proposed, though in somewhat different circumstances from the 
 case of Dr. Keiller. The patient was dying from another disease, 
 but spurious pregnancy was present ; she was positive about the 
 child's being alive, and he had been asked to operate after the 
 mother's death to save the child. On a vaginal examination, &c., the 
 uterus was found small and unimpregnated. The idea of some living 
 animal being contained within the abdomen, in such cases as in Dr. 
 Keiller's patient, was not unfrequent. On two or three occasions, 
 such a belief had been expressed to himself. Dr. Keiller had 
 classed the interesting case which he had communicated under the 
 head of hysteria ; but some of the cases to which he himself had 
 alluded could scarcely be properly included under that designation. 
 The phenomena were common to the females of our domestic quad- 
 rupeds, and in them would not be designated hysteria. Dr. Simp- 
 son suggested that a series of experiments should be made on the 
 bitch during the occurrence of the anomalous pregnancy, to ascer- 
 tain, by examination of the state of the ovaries and uterus, the true 
 nature of the cause. He thought that some cases of membranous 
 dysmenorrhoea might be referred to the same category as the one 
 under consideration ; for in some patients, besides the throwing off 
 a membranous structure or maternal decidua, the other constitu- 
 tional symptoms were also present. In some cases, the similarity to 
 true pregnancy was very marked even in special and minor details. 
 In a case from Ayrshire, which he had lately seen with Dr. Taylor, 
 a peculiar eruption of intense prurigo was present, which the patient 
 declared had hitherto only appeared when she was really pregnant. 
 He concluded by asking if any member could suggest a rationale of 
 the occurrence of the abdominal swelling, or explain the peculiar 
 effect produced upon it by the inhalation of chloroform ? 
 
 Dr. Simpson had made some experiments on the subject in the 
 
FATAL VENOUS HEM0ERHA6E FROM THE PUDENDA. 277 
 
 wards of the hospital, and had satisfactorily ascertained that, in the 
 cases he had examined, the prominence of the abdomen did not 
 depend upon any arching of the spine. 
 
 For the aid afforded by anffisthetios in the diagnosis of spurious pregnancy, seepage 100. 
 _(Ed.) 
 
 FATAL VENOUS HEMORRHAGE FROM THE PUDENDA.^ 
 
 (From Edinburgh Monthly Journal of Medical Science, February, 1850, p. 195.) 
 
 Dr. Simpson related the circumstances of a fatal case of this 
 nature, as reported to him by Dr. Kyle of Dundee, who was called 
 to see the woman, but did not arrive till after she had expired. No 
 grounds could be discovered for any suspicion that the woman had 
 received a wound. She was in the lower ranks of life, but respect- 
 able, and living on good terms with her husband and neighbors. 
 She had been straining at the night-stool when the hemorrhage 
 came on. A large quantity of blood was found about her person ; — 
 it had flowed from the genital organs. On making the autopsy. Dr. 
 Kyle paid particular attention to the state of the uterus, which was 
 fully expanded in pregnancy ; but no eifused blood was discovered 
 in or around it. On examining the vagina and vulva. Dr. Kyle 
 found a recent aperture in one labium, which, on further dissection, 
 he traced into a large vein. 
 
 Dr. Simpson alluded to the anatomical fact, that there was at the 
 root of each labium a plexus of very large veins, which extended 
 some way into the vagina. One of these veins, probably in a vari- 
 cose state, had burst in this instance. Possibly the coat of the vein 
 was thickened, as well as dilated, and, consequently, it would not 
 collapse, as veins usually do, but remained open like an elastic 
 artery. 
 
 Dr. Simpson further stated, that the case seemed to him particu- 
 larly interesting and important in relation to medical jurisprudence. 
 A number of criminal trials had taken place in Scotland, within the 
 memory of the members, in consequence of women, generally, but 
 not always, pregnant, having died from hemorrhage from the pu- 
 denda, similar to the above. In most or all of these cases it had 
 been averred that the wound had been inflicted, vnth criminal intent, 
 by the husband or others. Dr. Watson^ has recorded two or three 
 
 ' Extracted from Proceedings of Obstetric Society of Edinburgh, December 12, 1849. See 
 also Proceedings of Obstetric Society, May 12, 1847, reported in Edinburgh Monthly Jour- 
 nal of Medical Science, August, 1847, p. 137. 
 
 'Edinburgh Medical and Surgical Journal, vol. xxxvi. 1831. 
 
278 DISEASES OF WOMEN. 
 
 sucli cases ; Dr. Seller has recorded others ; and he himself had seen 
 the examination of the hody in two criminal cases of this kind. 
 In both, the women bled to death from very small wounds of the 
 pudenda. He was not aware that in any of the five or six cases, 
 of late years tried before the Scottish courts, the plea of the apparent 
 wound being a spontaneous rupture had been adduced. But such 
 a case as this, that had lately occurred at Dundee, had evidently 
 important bearings on the value of such a plea. 
 
 BALL-VALVE OBSTRUCTION OF THE EECTUM BY 
 SCYBALOUS MASSES.^ 
 
 (From Edinburgh Monthly Journal of Medical Science, April, 1849, p. 705.) 
 
 De. Simpson described a recent case of this not uncommon com- 
 plication which he had seen with Dr. Husband. The patient, when 
 Dr. Simpson visited her, was sufiering from intermitting paroxysms 
 of abdominal muscular effort, like those of labor. Dr. H., on 
 making a vaginal examination, had detected the impacted and dis- 
 tended state of the rectum. A large, hard, oblong, scybalous mass 
 filled up the canal of the rectum. It was incrusted with phosphatic 
 deposit on its external surface. The rectum was in consequence 
 irritated by it, and tender under examination. The patient was 
 chloroformed, the mass broken down by an iron instrument, and 
 with some difficulty removed piecemeal. Subsequently, some 
 smaller and higher-placed masses were expelled by the action of 
 aperients, and the patient was relieved from her sufferings. 
 
 Dr. Simpson alluded to some other cases of the same kind which 
 he had seen. Such ball-valve obstructions often caused great dis- 
 tress to the patient ; and the disease was occasionally altogether 
 overlooked for a time, and its nature mistaken. This was more 
 particularly liable to happen in consequence of the circumstance, 
 that a small quantity of thin feculent matter often escaped from day 
 to day in these cases, leading to the idea that the uneasy sensations 
 of the patient, and ultimately the paroxysmal and expulsive pains, 
 could not be the result of obstruction in the bowel. Thin feculent 
 matter in this way escaped, in consequence of the scybalous mass 
 not necessarily occupying and shutting up the whole calibre of the 
 bowel, but allowing the more fluid matter to pass between its sur- 
 face and the sides of the intestinal canal. When, however, the 
 patient used, as was instinctively done, any straining effort to mal^ 
 
 ' Extracted from Proceedings of Edinburgh Obstetric Society, January 10, 1849. 
 
INTESTINAL ERUPTIONS. 279 
 
 the expulsion more complete, the scybalous mass was by this means 
 pushed down upon the lower and more contracted portion of the 
 rectum, and acted exactly like a ball-valve, so far temporarily closing 
 the bowel, and preventing any further evacuation from it for the 
 time. Such patients could sometimes partially evacuate the bowel 
 in a lying, when they could not effect it in a sitting posture, a result 
 easily understood when we consider the mechanical character of the 
 disease. It was an affection liable to recur from time to time in 
 those who had been once subject to it. 
 
 PEEITONEAL HYDATIDS IN FLUID REMOVED BY 
 TAPPING.' 
 
 (From Edinburgh Monthly Journal of Medical Science, March, 1854, p. 285.) 
 
 Dk. Simpson showed a fluid containing a number of hydatids, 
 which he had procured on tapping a patient, who had previously 
 undergone that operation without the escape of any such fluid. On 
 admission into hospital she presented fearful distension of the ab- 
 domen, more so, indeed, than Dr. S. had ever before observed. 
 Fluctuation was present, more particularly in the centre of the 
 swelling. On tapping, a large quantity of fluid containing hydatids 
 was, with difficulty, evacuated. The patient subsequently died, 
 when the hydatids were found to have been contained in the cavity 
 of the peritoneum, and external to a large ovarian cyst. Their 
 origin was traceable to the peritoneal basement membrane, from 
 which they sprung ; and in their process of growth they probably 
 projected into the cavity of the peritoneum, and subsequently be- 
 came detached. They appeared to belong to the genus astoma of 
 Goodsir, and many of them presented in their interior curious thread- 
 like bodies resembling vibriones. 
 
 CHRONIC PELLICULAR OR ERUPTIVE INFLAMMATION 
 OF THE INTESTINAL MUCOUS MEMBRANE. 
 
 (From Edinburgh Monthly Journal of Medical Science, June, 1846, p. 462.) 
 
 Pkofessob Simpson stated that observations he had lately made 
 convinced him that this disease, pellicular intestinal inflammation, 
 was not rare, as was generally believed, but, on the other hand, 
 
 'Extracted from Proceedings of Edinburgh Medico- Chirurgical Society, Feb. 1, 1854. 
 
280 DISEASES OP WOMEN. 
 
 that it was often to be met with in practice. A characteristic symp- 
 tom was the passing of shreds, or membranes, formed, as shown by 
 the microscope, of plastic or coagulable lymph. He had also found 
 in a number of cases, debility, great marasmus, palpitation, mental 
 depression, and irritability, and in fact all the symptoms usually 
 seen in cases where blood is long and slowly escaping from the 
 system. He traced the symptoms not so much to the actual loss of 
 blood, as to the circumstance that its formation was prevented, by 
 the intestinal extremities of the lacteals being morbidly interfered 
 with by the mucous pellicular inflammation of the bowel. He had 
 treated the disease on the same general principles as are employed 
 in chronic cutaneous eruptions, and had found counter-irritation of 
 much use.' 
 
 Since specially pointing out some years ago to the notice of my 
 professional brethren in Edinburgh the disease alluded to in the 
 preceding brief notice, its frequency in practice has become gene- 
 rally recognized among us ; and all, I believe, are now willing to 
 acknowledge that it is infinitely more common than the total, or 
 almost total silence on the subject of all our best writers on practical 
 medicine would, a priori, lead us to infer. 
 
 Acute exanthematous eruptions — small-pox, measles, scarlatina, 
 erysipelas, &c. — are usually recognized as occasionally attacking 
 some parts of the mucous surface, as well as the general cutaneous 
 surface of the body. And there are some specific local inflamma- 
 tions of the mucous membrane, which, if present on the skin, 
 would, no doubt, there be termed eruptions — as diphtherite, dothin- 
 enterite, and perhaps more than one form of diarrhoea and dysen- 
 tery, &c. 
 
 Ghronie eruptions, however, of the intestinal and other mucous 
 membranes of the body, have scarcely been acknowledged in mo- 
 dern pathology. But perhaps such chronic eruptions and irritations 
 of the mucous surface will yet be found to be scarcely less frequent 
 or less various in type than the well-known chronic eruptions and 
 irritations of the cutaneous surface. (See p. 101). 
 
 Chronic eruptive inflammations of the intestinal mucous mem- 
 brane are frequently attended, as stated in the preceding notice, 
 with the ejection, in greater or less quantity, of shreds or pellicles 
 of thickened mucus, or of actual coagulable lymph, along with the 
 usual contents of the bowels ; and sometimes this pellicular efiiision 
 presents the appearance of a gelatinous shapeless mass, or of por- 
 tions of a roundish or tubular false membrane, which is frequently 
 considered by the patient as " worms." Often, however, in appa- 
 
 ' Proceedings of the Medico-Chirurgical Society of Edin., April 1, 1846. 
 
INTESTINAL ERUPTIONS. 281 
 
 rently other species of chronic mucous or intestinal eruptions, no 
 Buch secretion is thrown off. 
 
 The pathological anatomy of these morhid eruptions of the mu- 
 cous membrane has scarcely yet been at all studied on the dead 
 body. In a case where, some months before death from pulmonary 
 tubercular disease, the patient had passed large quanties of "mem- 
 branous crusts or tubes" from the bowels. Dr. Abererombie found 
 the mucous membrane of the colon, throughout its whole extent, 
 covered with an immense number of small spots of a clear white 
 color, which, " on minute examination, were distinctly ascertained 
 to be vesicles, very little elevated, but, when punctured, discharging 
 a small quantity of clear fluid. "^ In a case of a still more chronic 
 character, with similar pellicular discharges, which I attended with 
 the late Dr. Wright, and where the patient died in an extreme state 
 of marasmus, the mucous membrane of the colon and the lower 
 portion of the small intestine was everywhere studded with a thickly- 
 set papular eruption. 
 
 The principal general symptoms which I have observed in cases 
 of chronic mucous or intestinal eruption, are the following, in dif- 
 ferent numbers and combinations, and in different degrees of 
 severity in different patients : — 
 
 General indefinable debility and emaciation ; a condition often of 
 broken and impaired health, without any very appreciable cause ; the 
 muscular system easily fatigued and exhausted ; sometimes so much 
 palpitation as to lead to the idea of heart disease ; the circulation 
 weak, as shown by the coldness of the extremities, &c. ; diminution of 
 nervous and mental power and energy, vnth hypochondriasis, irrita- 
 bility of temper. Very often impairment of the memory, sensations 
 of prickling and semiparalysis in the arms or legs, and sometimes 
 lesions of sense ; skin very generally dry and inactive, and in some 
 cases eruptions appear upon it, cotemporaneous with, or vicarious 
 of, the internal mucous irritation. The appetite, provided the mu- 
 cous membrane of the stomach itself is unaffected, may be found 
 scarcely, if at all diminished, but the patient complains of the food 
 swallowed not producing any corresponding amount of strength or 
 nourishment; occasionally, again, there is marked dyspepsia ; often, 
 but by no means constantly, there is a feeling of heat and rawness' 
 in some part of the intestinal canal, and a feeling of uneasiness and 
 distension rather than pain, in the abdomen ; the action of the 
 bowels IS sometimes comparatively normal or easily regulated but 
 they vary in other instances, both as to torpidity and irritability 
 ihe sleep is usually unrefreshing in proportion to its amount. 
 
 ' Researches on Diseases of the Stomach, case cxiv. p. 298. 
 
282 DISEASES OF WOMEN. 
 
 Direct evidence of the presence of, and tendency to, mucous 
 eruptions in such subjects, can generally be obtained by carefully 
 examining the state of the mucous membrane that is within sight. 
 Spots of eruption, and sometimes small ulcerations left by them, will 
 fi-equentlybe detected on the inside of the lips and cheeks, and on the 
 gums and tongue. Much more frequently the palate and throat 
 present, more or less distinctly, the appearances of chronic eruptive 
 disease ; as likewise the mucous membrane of the nose. The 
 tongue, with the mucous membrane lining the cheeks, is not un- 
 frequently so swollen as to be marked and indented by the impres- 
 sion of the teeth. Sometimes, when thus enlarged, the tongue is 
 whiter than usual ; but in other cases we see it red and irritable ; 
 and, more rarely, one or more distinct and broad patches of erup- 
 tion are seen on its surface. The mucous membrane of the mouth 
 and throat seems often, in such cases, to be the seat of successive 
 new crops of eruption ; and the variation in the general symptoms 
 of the patient would appear further to show that such is also proba- 
 bly the history of the disease on its more internal sites ; these suc- 
 cessive re-aggravations being sometimes accompanied by a shght 
 degree of chronic feverishness. Sometimes there is a kind of daily 
 periodicity in the morbid suflerings and feelings of the patient. 
 
 The general principles of treatment are, as already stated, the 
 same as those used in chronic skin eruptions. 
 
 The affection — ^particularly in its occasional periods of aggravar 
 tion — is allayed by the use of lime or Carrara water, by aqua 
 potasses, by subnitrate of bismuth, by doses of nitrate or oxide of 
 silver, or of oxalate or nitrate of cerium ; by bitter infusions, as that 
 of quassia, with the addition of two or three drops of medicinal 
 prussic acid ; by the cold infusion of Virginian cherry bark, &c. But 
 these medicines act perhaps principally as local sedatives to the 
 diseased mucous surface. 
 
 As curative constitutional remedies in this affection, I have seen 
 most advantage from the salts of cerium, from the use of pitch pills, 
 or capsules of tar,^ and from the preparations of arsenic. 
 
 The preparations of pitch or tar have always seemed to me most 
 useful when they produced their characteristic scarlatinoid eruption 
 on the skin. 
 
 But most reliance ought, so far as I am able to judge, to be 
 placed on small and very long-continued doses of arsenic, as two 
 drops of Fowler's solution, or a pill containing the sixtieth of a 
 grain of arsenite of potass, taken three or four times a day. Either 
 
 In these cases of chronic mucous eruptions I was induced to use pitch or tar from know- 
 ing that, in the latter years of his practice, Dr. Willan trusted to it as his principal constitu- 
 tional remedy in the treatment of chronic cutaneous eruptions. 
 
INTKSTINAL ERUPTIONS. 283 
 
 preparation should be taken with or after meals ; and it is, I be- 
 lieve, infinitely better and safer to trust to the curative efifect of the 
 long continuance of such small doses of this remedy, than to attempt 
 to arrive at the same result by throwing in larger doses for a shorter 
 period. 
 
 After a length of time, and when the general symptoms are much 
 abated, a more direct tonic, as quinine or iron, may be added to the 
 cerium, pitch, or arsenic. But at first all tonic remedies appear to 
 be entirely useless, or to lead even to the aggravation of the morbid 
 state of the patient. 
 
 The diet requires to be regulated by the usual rules applicable to 
 dyspepsia. But animal food, in a concentrated form, is often re- 
 quired to sustain the strength, provided it does not irritate. Wine 
 or stimulants veiy seldom are of benefit. The state of emaciation 
 is sometimes improved by food containing large quantities of fat, as 
 cream, butter, olive and eodliver oil, &c. When the patient's 
 stomach will not bear or digest such fatty matters, I have seen the 
 daily inunction of two or three ounces of warm olive oil into the 
 general surface of the skin, followed by the very best effects upon 
 the health and strength of the patient. 
 
 Most remedies will fail to produce a permanent remedial effect, 
 unless the state of the skin be attended to, and its healthy condition 
 restored by frequent sponging with warm water, or with warm 
 stimulating lotions. 
 
 . Lastly, external counter-irritation over the abdomen seems to be 
 an auxiliary means of almost indispensable necessity. A mustard 
 poultice every night at bedtime forms one of the best and simplest 
 means of effecting it ; or external counter-irritation with stimulating 
 liniments, or with croton oil, or antimonial ointment, or a strong 
 tincture of iodine, &c., may be used to fiilfil this important indica- 
 tion. 
 
 From the nature of my practice, I have seen the disease far more 
 frequently in the female sex, and often in patients suffering under 
 obstinate leucorrhea, vaginal eruptions (see page 101), and other 
 uterine diseases. But it also often occurs in the male subject, and 
 especially, as it has appeared to me, in men who, like clergymen 
 and others, are subjected to an unusual amount of intellectual work 
 or mental anxiety. — (April, 1855.) 
 
284 DISEASES OF WOMEN. 
 
 NOTE ON THE THERAPEUTIC ACTION OF THE SALTS 
 
 OF CERIUM, 
 
 IN mRITATIONS OP THE ALIMENTARY CANAL, ETC 
 
 Chemists are at present acquainted with forty-nine different 
 metals. Preparations, in the form of oxides and salts, from seven- 
 teen of these metals are to be found in our British pharmacopeias. 
 Most of the remaining thirty-two metals are of comparatively late 
 discovery, and few, or almost none, have been tried medicinally. 
 But, betimes, the oxides or salts of some, at least, of these newer 
 metals will, in all probability, be found to possess therapeutic quali- 
 ties as marked as the preparations, that have been so long used, of 
 the older known metallic bodies. 
 
 In attempting to make some observations on the therapeutic char 
 racter of the untried metals, I have been especially gratified by the 
 results which I have found to be produced by the medicinal use of 
 salts of cerium. 
 
 This metal, cerium, or cererium, was first discovered in 1803, and 
 almost simultaneously by Hisinger and Berzelius, and by Klaproth. 
 It has been found by these and other chemists to exist in a variety 
 of minerals, as the Edwardsite, Cerite, Euxenite, G-adolinite, &c. 
 The G-reenland Allanite is said to contain thirty-four per cent, of 
 cerium. 
 
 It is usually found in nature combined with two other metals, 
 lanthanum, or lantanium, and didymium. In the complex process 
 of separating the cerium fi-om these two other metallic bodies, oxalic 
 acid, or rather oxalate of ammonia, is employed in the last stage ; 
 and in the markets cerium is thus most readily procured in the form 
 of an oxalate of the protoxide. In using cerium medicinally, I 
 have generally employed the oxalate in the form of small pills, and 
 in the dose of one to two grains, or a solution of the nitrate in 
 water, and in the same proportionate doses. 
 
 The principal therapeutic action of the salts of cerium appears to 
 me to be that of a useful sedative and tonic, or, if we may use such 
 an expression, "sedative tonic," — like the pharmaceutical oxide and 
 salts of silver and bismuth. I have employed it pretty extensively 
 in the treatment of the class of cases described in the preceding 
 paper, chronic intestinal eruptions, and occasionally with the most 
 marked good effect in them, in instances that had resisted all other 
 forms of treatment. It is often useful also in common cases of irri- 
 table dyspepsia, gastrodynia, &c. In my own practice and in that 
 
 *, 
 
 ' A short notice of the medicinal action of cerium, tellurium, &c., was read before the 
 Medico-Chirurgical Society of Edinburgh by Dr. Simpson, Nov. 15, 1854.— See Edinburgh 
 Monthly Journal, Deo. 1854, p. 564. — (Ed.) 
 
ALLEGED INFECUNDITT. 
 
 285 
 
 of Others, I have seen the above preparations of cerium succeed in 
 at once allaying irritable and obstinate vomiting after all other 
 means had failed. Sometimes I have observed it fail, like all other 
 remedies, in giving relief in the sickness and vomiting of preg- 
 nancy ; but far more frequently I have found its employment ac- 
 companied by direct beneficial effects ; and I have now repeatedly 
 had occasion to see it both immediately and perfectly successful in 
 some instances where the usual succession of medicines, — prussic 
 acid, naphtha, opium, bismuth, ice, &c.— had all been previously and 
 perseveringly tried in vain. — {April, 1855.) 
 
 ON THE ALLEGED INFECUNDITY OF FEMALES BOEN CO- 
 TWIN WITH MALES, 
 
 WITH SOME NOTES ON THE AVERAGE PROPORTION OP MARRIAGES 
 WITHOUT ISSUE IN GENERAL SOCIETY. 
 
 (From Edinburgh Medical and Surgical Journal, January, 1844, p. 107.) 
 
 " It is," says Dr. Burns, " a popular opinion, and I do not know 
 any instance to discountenance it, that if twins be of different sexes, 
 the female is sterile." "I have never," he adds, "had an oppor- 
 tunity of examining the state of the uterus and its appendages after 
 death."' 
 
 Some years ago I took considerable pains to collect a series of 
 data for the purpose of testing the validity of the opinion alluded 
 to by Dr. Burns in the preceding paragraph. The results of the 
 inquiry were, in 1839, laid before the Edinburgh Medico-Chirurgical 
 Society in the following form.^ I venture to publish the observa- 
 tions now, with a few additions and corrections, under the idea that 
 the subject is not devoid of interest in relation to physiology and 
 legal medicine, and involves one or two correlative questions worthy 
 of some degree of investigation. Besides, I know well the many 
 difficulties connected with a statistical inquiry like the present, 
 however brief and simple it may appear when condensed into its 
 ultimate results ; and the publication of the evidence that I have 
 obtained upon the topics in view may probably be fortunate enough 
 to save others from expending time and trouble upon the same 
 research. 
 
 • See the last edition (1843) of his well-known Principles of Midwifery, p. 236. 
 
 ^ In an article on Hermaphroditism in Dr. Todd's Cyclopedia of Anatomy, Part xvi. 
 (1839) p. 736, I have stated some of the results of the earlier part of this inquiry. See vol. 
 ii. of this work. 
 
286 ALLEGED INFECUNDITT OF 
 
 ON THE REPRODUCTIVE POWERS OF FEMALES BORN CO-TWIN WITH 
 MALES AMON& OUR DOMESTIC UNIPAKOUS ANIMALS, AND IN THE 
 HUMAN SUBJECT. 
 
 Mr. Jolm Hunter, in an essay read before the Royal Society of 
 London, in 1779, and afterwards published both in the Philosophical 
 Transactions for that year, and in his work on the Animal Economy, 
 showed that, when among black cattle the cow brings forth a male 
 and female at the same birth, the male is a perfect bull calf, but the 
 apparent female is almost always imperfect in its sexual organiza- 
 tion. Female cattle of this kind, born co-twin with males, have 
 long been distinguished in this country under the name of free- 
 martins. In external appearance and form of body, they usually 
 resemble the ox and spayed heifer more than either the entire male 
 or entire female of the species. They commonly grow to a larger 
 size than either the bull or the cow, and have horns like those of an 
 ox, and a tone of bellowing similar to his, with the same marked 
 disposition to become fat under the use of nourishing food. In 
 general they do not show any sexual desire for the bull or the bull 
 for them. 
 
 The defective sexual conformation of free-martin cattle is at- 
 tested, not only by the observation of their sterility during life, but 
 also by the anatomical examination of their reproductive organs. 
 Mr. Hunter had an opportuity of dissecting several free-martin 
 cows. In all of them the external sexual organs were of the female 
 type — ^the vulva and os vaginse being in general well developed. 
 The vaginal canal, however, was contracted at its upper part, and 
 the internal female organs, the uterus. Fallopian tubes, and ovaries, 
 were altogether rudimentary and imperfect in their structure. In 
 some there was an apparent superaddition of male organs, testes, 
 and vasa deferentia, probably 'from a permanence of the Wolffian 
 bodies' and ducts of the early embryo ; and in one case the ovaries 
 were replaced by bodies having all the external characters of male 
 testicles. 
 
 Mr. Hunter's observations have been since corroborated by ad- 
 ditional cases and dissections made by Scai-pa,' Gurlt,^ and Allnatt.^ 
 I have myself had an opportunity of dissecting the sexual parts of 
 two adults and a third young free-martin, killed in the shambles of 
 this city, and have found all of them formed after the abnormal and 
 
 ' Mem. della Sooieta Italiana, torn. ii. p. 846. 
 
 * Lehrbuch der Pathologisclien Anatomic der Haus-Saugethiere, Bd. ii. s. 188. Tab. xxi. 
 Fig. 2, 3, and 4. 
 
 ' London Medical Gazette, vol. xviii. p. 528. 
 
FEMALES BORN CO-TWIN WITH MALES. 
 
 287 
 
 imperfect sexual type pointed out by Mr. Hunter.' My friend Dr. 
 Allen Thomson made some years ago a similar observation upon a 
 free-martin twin foetal calf. 
 
 The butchers in Edinburgh audits neighborhood, of a number of 
 whom I have made inquiries upon the subject, seem to be perfectly 
 familiar with the fact, that in the free-martin, whose flesh they 
 usually reckon of a superior quality, the womb, or calf-bed, as they 
 term it, is in almost all cases apparently wanting ; and all our in- 
 telligent agriculturists in the Lothians are acquainted with the 
 sterile character of these animals. 
 
 Though we are certainly indebted to the sagacity of Mr. Hunter 
 for first fully appreciating the value of the physiological sexual 
 anomaly observed in free-martins, and for confirming the fact by 
 accurate anatomical investigation, yet it is but proper to mention, 
 that the circumstance itself of the infecundity of the free-martin 
 cow, has long, as was indeed pointed out by Mr. Hunter himself, 
 been notorious among agriculturists in Great Britain, and is promi- 
 nently mentioned by Leslie, and some of the older authors on hus- 
 bandry. 
 
 Indeed, the Eoman agriculturists seem not to have been unac- 
 quainted with the variety of barren female cattle under considera- 
 tion ; or at least their attention appears to have been so often at- 
 tracted by cases of sterility in the cow, that they found it a matter 
 of convenience to employ, as we do, for their designation and dis- 
 tinction, a specific noun, and named them Taurce. Thus Varro in 
 his work "De Re Rustic^," tells us " Quae sterilis est vacca taura 
 appellatur;"^ and Columella, in speaking of the sorting [delectus) of 
 the flock, directs that, "those which have brought forth, and the 
 old cows which have ceased to breed are to be removed, and so also 
 the taurce, which occupy the place of fertile cattle, are to be set 
 aside, or to be trained to the plough, since they are not by their 
 sterility rendered less fit for labor than the common heifer."^ 
 There is no direct evidence, however, to show that the Romans were 
 aware of the particular circumstances, in respect of plural births, 
 under which such taurce were produced. 
 
 Though the infecundity of free-martin cows be a very general 
 fact, still it is by no means a universal one. Mr. Hunter, in his 
 original essay on the subject, mentions that in one instance, in exa- 
 
 ' I have described at length the particular anatomical appearances met with in these 
 cases in my Essay on Hermaphroditism. 
 
 * Libri de Rustica Catonis, Varronis, Columellae, &c., Paris Edit., Liber ii. p. 82. 
 
 ' Enixse et vetust* quae gignere desierint summovendse sunt, et utique toAira, qua locum 
 fcecundarum occupant, ablegandtE, vel aratro domandae, quoniam laboris et operis non minus 
 quam juvenca?, propter uteri sterilitatem patientes sunt. Ibid. Lib. vi. Cap. xxii p. 232. 
 
288 ALLEGED INFECUNDITT OF 
 
 mining a free-martin that died wlien about a monti. old, he found 
 all the organs of generation well formed. After stating this case, 
 he adds, " I have heard of other twin cows breeding ; but as I can- 
 not call to mind the names of the individuals who communicated 
 the circumstances to me, I have only mentioned one of undoubted 
 authority." 
 
 An anonymous author in the Farmers' Magazine for November, 
 1806,1 j^as described such an instance in a free-martin belonging 
 to Mr. Buchan of Killingtringham. This cow was well made and 
 a good milker ; she produced one calf. The same gentleman, Mr. 
 Buchan, had a second free-martin which never bred. Another 
 writer in the same Magazine for ISTovember, 1807, makes the fol- 
 lowing statements : " On the 11th of ISTovember, 1804, a cow of 
 mine brought forth two calves, one a bull, and the other a cow 
 calf; and in spring last the female twin produced a very good male 
 calf; yet a neighbor of mine assures me that a female twin belonging 
 to him would never take the bull, and was sold on that account to 
 the butcher at the age of four or five." Dr. Moulson of Halifaxmen- 
 tions, in Loudon's Magazide,^ the case of a free-martin cow reared by 
 Joseph Holroyd, Esq., of "Withers, near Leeds, which copulated with 
 its own twin bull. " In due time," he adds, " the heifer brought 
 forth a bull calf, and she regularly had calves for six or seven years 
 afterwards." 
 
 In. the course of making some inquiries in "West Lothian after 
 cases of free-martin cows, I have become acquainted with two well- 
 authenticated instances in which these animals proved capable of 
 propagating. One of these cases occurred some years ago at New- 
 ton, near Queensferry. The second was reared by Mrs. Cochran of 
 Stewartsfield, Broxburn, and produced several calves. Such excep- 
 tional cases, however, as those to which I have alluded, appear, on 
 the whole, to be comparatively so rare in their occurrence, as not to 
 invalidate the generality of the fact with regard to the sterility of 
 the free-martin twin cow, and render it a question of interesting 
 inquiry, whether this law of infecundity in the female of male and 
 female co-twins be confined only to plural conceptions among black- 
 cattle, or extends also to twins among other species of uniparous 
 animals. 
 
 In reference to the females of opposite sexed twins among sheep, 
 I have been assured from different quarters that the law of the sexual 
 imperfection and infecundity of the free-martin cow does not hold 
 good with respect to them. Several varieties of sheep, particularly 
 some of those belonging to the white-faced breeds, produce twins 
 with such constancy that we may truly consider this as one of their 
 
 ' See Youatt on Catlle, p. 539. ' Magazine of Natural History, vol. v. p. 763. 
 
FEMALES BORN CO-TWIN WITH MALES. 289 
 
 occasional hereditary characters. These twins are not unfrequently 
 of different sexes, and yet instances of sterility are rarely if ever 
 observed among such flocks.* 
 
 I have not been able to learn how the matter stands with regard 
 to twins among goats, not having access in this district of the country 
 to any information or direct observation upon the subject in that 
 animal. 
 
 I have hitherto been equally unsuccessful in tracing out any instance 
 of a twin mare or she-ass, born under the circumstance already 
 pointed out, being reared to maturity. The mare, indeed, appears 
 only in extremely rare cases to produce twins, and these twins are 
 almost always endowed with such feeble powers of life as seldom to 
 survive for any length of time after birth. 
 
 Sir Everard Home, in a paper " On Animals preternaturally 
 formed at the time of birth," inserted in the Philosophical Transac- 
 tions for 1799, and in the third volume of his Comparative Anatomy, 
 after assuming that certain sexual organs in the male and female are 
 originally identical or neuter in their character, and are only after- 
 wards changed to the male or female type according to ulterior cir- 
 cumstances, adds the following observations : "If it is allowed that 
 the sex is impressed upon the ovum at the time of impregnation, it 
 may in some measure account for the free-martins occurring when 
 two young are to be impressed with different sexes at one impregna- 
 tion, which must be a less simple operation, and, therefore, more 
 liable to a partial failure than when two of any greater number of 
 ova are impressed with the same sex." 
 
 "It may also account," he remarks in reference to the human sub- 
 ject, " for twins being most commonly of the same sex ; and when 
 they are of different sexes, it leads us to inquire whether the female, 
 when grown up, has not, in some instances, less of the true female 
 character than other women, and is not incapable of having chil- 
 dren." " In warm countries," Sir Everard adds, " nurses and mid- 
 wives have a prejudice that such twins seldom breed. "^ 
 
 In reference to this last remark, it is not unimportant to observe, 
 that, as I have repeatedly found during the course of my inquiries 
 upon this subject, a similar prejudice in reference to the infecundity 
 of human females born co-twin with males, exists to a considerable 
 extent among the peasantry of the Lothians, and has very probably 
 been derived from the analogy of the free-martin cow. " The mis- 
 
 ' The tendency to the production of twins in the human subject is sometimes so marked 
 in particular families as to entitle it to be considered as almost an hereditary peculiarity I 
 know of one family, in the different branches of which twelve pair of twins have been born 
 within three generations, 
 
 ^ Comparative Anatomy, vol. iii. pp. 333-4. 
 
 TOL. I. 19 
 
290 ALLEGED INFECUNDITT OF 
 
 chief," justly observes a late physiological author, " to which the 
 opinion might give rise in causing a girl to be rejected as a wife for 
 a defect, or taken for an excellence, according as sterility might be 
 regarded, which she did not possess, is incalculable."' 
 
 The truth or falsity of the opinion itself can only be satisfactorily 
 settled by an appeal to a sufficient number of accurately ascertained 
 histories of cases in which women, born co-twin vrith males, have 
 reached an adult age and become married. 
 
 I have collected what may probably be considered as a sufficient 
 number of such cases for forming some just conclusions upon this 
 subject. 
 
 Before, however, bringing forward the results derivable from these 
 collected cases, as bearing upon the question of the fecundity or 
 sterility of human females born under the circumstances in question, 
 I may, in the first place, mention that instances of twins in the human 
 subject, of whom one child is male and the other female, seem not 
 to be at all rare in their occurrence, though the contrary position is 
 generally believed, and as we have seen, was assumed by Home, and 
 made by him at one and the same time a deduction -from, and an 
 argument in favor of, the particular theory which he held in respect 
 to sexual development. In proof of this statement, I have analyzed 
 the records of all the labors that occurred in the Edinburgh General 
 Lying-in Hospital from 1823 to 1836, both years included, as well as 
 the published returns of all the cases occurring in the Dublin Lying- 
 in Hospital from 1787 to 1793, as given by Dr. Clarke, and fi-om 
 1826 to 1833, as given by Dr. Collins,^ as also those occun-ing in the 
 London Maternity Charity from 1828 to 1840,^ which are the only 
 returns that I am aware of in which the average number of twin- 
 labors and the sexes of the different co-twins have been noted. The 
 three following tables have been constructed from these reports. 
 The first of them shows the average number of twin-labors as they 
 occurred in these institutions respectively; the second presents the 
 sexes of the different pairs of twins as they occurred in each; and 
 the third illustrates the proportion in which the differently sexed 
 co-twins were to the general number of labors. 
 
 I. Total number and proportion of twin-labors. 
 
 Total number Number of Proportion of 
 
 of Labors. Twin-Labors. Twin-Labors. 
 
 Edinburgh Hospital, 2,888 46 1 in 63 
 
 Dublin Hospital (Clarke), 10,337 184 1 in 56 
 
 Dublin Hospital (Collins) 16,414 240 1 in 65 
 
 London Maternity Charity, 29,489 318 1 in 93 
 
 59,178 788 1 in 75 
 
 ' See footnote at page 74 of Dr. Fletcher's Rudiments of Physiology. 
 ' Dr. Collins' Practical Treatise on Midwifery, table beginning p. 331. 
 ' Dr. Ramsbotham's Principles and Practice of Obstetric Medicine and Surgery, p. 621, 
 footnote. 
 
FEMALES BORN CO-TWIN WITH MALES. 291 
 
 II. Sexes of the different co-twins m the above 788 cases. 
 
 Two Two Male and Tot. num. 
 
 males. females, female, of twins. 
 
 Edinburgh Hospital, . 16 IV 13 46 
 
 Dublin Hospital (Clarke), 47 66 71 184 
 
 Dublin Hospital (Collins), 73» 67 100 240 
 
 London Maternity Charity, 93 111 114 318 
 
 229 261 298 788 
 
 TTT . Proportion in whicli the differently sexed co-twins occurred 
 to the whole 59,178 cases of labor : 
 
 Male and female twins once in every 199 labors. 
 Two female twins once in every 226 labors. 
 Two male twins once in every 258 labors. 
 
 The result of these two last tables goes to show, in opposition to 
 the opinion of Sir Everard Home, that twins of opposite sexes are 
 not by any means uncommon.' And this circumstance, of co-twins 
 of opposite sexes occurring so proportionally frequent, may perhaps 
 be adduced as bearing somewhat against the opinion of M. Girou, 
 that the sex of the offspring is determined by the sex of that parent 
 whose reproductive power or organism {puissance proUfique) is at 
 the time of conception either absolutely or relatively in the greatest 
 degree of vigor. 
 
 But to return from this digression. The only data hitherto pub- 
 lished, so far, at least, as I am aware, containing an appeal to actual 
 facts for the determination of the question of the fecundity or in- 
 fecundity of the human female, when born co-twin with a male, are 
 to be found in a short paper published by Mr. Cribb, in the Medical 
 Repository for 1823,^ and in the notice of a single case of this kind 
 brought forward by the late Professor Meckel, in his essay on Her- 
 maphrodites in Reil's Archives.^ 
 
 In the paper referred to, Mr. Cribb has adduced the histories of 
 seven married women, who were born co-twin with males, of which 
 the following is the result : six had a family ; one had no children, 
 though married several years ; or one in six was without issue. 
 
 The woman mentioned by Meckel was a mother. 
 
 I have endeavored to obtain as accurate and authentic reports as 
 possible of the married history of various females born co-twin with 
 
 ' As far as the data of these tables go, they would seem also to show, that, among twin 
 births as a whole, more female than male children are produced. Out of the 1576 children 
 born in the above 788 twin oases, 756 were male, and 820 female. 
 
 ' London Med. Repos. vol. xx. pp. 213-16. 
 
 ' Reil's Archives fiir die Physiologie, Bd. xi. p. 282. 
 
292 ALLEGED INFECUNDITT OF 
 
 males, and have so far been successful in gaming sucli information 
 as I could implicitly rely upon in relation to 113 females born under 
 such circumstances.' Of these 113 female co-twins, 103 had a 
 family ; 10 had none ; or about one in ten was without issue. Of 
 the ten cases in which there was no family, one had been married 
 above five years ; nine from ten to forty years. 
 
 The history of the male co-twin in the 103 cases in which the 
 female was productive was as follows — in 53 he was the father of a 
 family ; in 24, he died in early life, unmarried ; in 8, he remained 
 unmarried ; in 2, he was married, but had no issue ; and in 14, his 
 history could not be accurately ascertained. 
 
 In addition to the above cases of twins of opposite sexes, I have 
 traced the married history of the female in four instances of triplets, 
 in which there were born either two males and one female, or two 
 females and one male.^ In all of these four cases the female, whose 
 history I ascertained, had a family. In a case of quadruplets, re- 
 corded in the Medical Eepository for 1827, there were three males 
 and one female. The males were all reared, and the female became 
 herself the mother of triplets. 
 
 If we unite together all the various facts I have alluded to, we 
 shall have the married history of 123 females born co-twin with 
 males. The results, so far as they refer to the question we are dis- 
 cussing, may be stated in the following form ; of 123 females born 
 co-twin with males, 112, had a family and 11 had no issue, though 
 married for several years. In other words, the marriages of the 
 females, born under the circumstances we are considering, were 
 unproductive in the proportion of one in ten. 
 
 It may at first sight be supposed that this result, though not fully 
 bearing out, yet supports rather than otherwise the popular opinion 
 and the statement of Sir E. Home, with regard to the infecundity 
 of the female in twins of opposite sexes. Before, however, assent- 
 ing to such a modification of the view, it is incumbent on us to 
 inquire — 
 
 ' For assistance in the collection of these cases, I am much indebted to various professional 
 friends, and particularly to Mr. F. Angus of Holytown, Mr. Girdwood of Falkirk, Dr. Gil- 
 christ of Leith, and Dr. Cowan and Mr. Carmichael of Edinburgh. Tables, containing the 
 name, address, and other particulars of each case, are in the hands of the Secretary of the 
 Medico-Chirurgical Society. 
 
 ^ In one of these eases of triplets the three, two males and one female, all reached adult 
 life. Dr. Merriman (Synopsis of the various kinds of Difficult Parturition, 4th edition) ob- 
 serves, p. 260, " So many years had elapsed, notwithstanding repeated inquiries, before I 
 could meet with a well-authenticated instance of three children at a birth being all reared, 
 that I began very much to doubt the fact." Besides the above, three other well-authenticated 
 instances have been reported to me of triplets being viable and reared to maturity. Most 
 certainly, however, one or more generally die shortly after birth. 
 
FEMALES BOEN CO-TWIN WITH MALES. 293 
 
 WHAT IS THE AVERAGE PROPORTION OF PRODUCTIVB AND UNPRODUC- 
 TIVE MARRIAGES IN GENERAL SOCIETY. 
 
 On this point I have been able to gain but little precise infor- 
 mation from the statistical or physiological works that I have had 
 an opportunity of consulting. I have made personal inquiry on 
 the same matter of several of our most eminent statisticians without 
 being able to obtain any accurate facts bearing on the subject. In 
 the Dictionnaire des Sciences M^dicales,' it is stated that H^din, a 
 Swedish minister, had noticed that in his parish, composed of 800 
 souls, one barren woman is not met with for ten fertile. It is further 
 stated, that Frank asserted, but from what data is not mentioned, 
 that it would be found on investigation, that in most communities 
 containing 300 to 400 couples, at least 6 or 7 would be sterile, with- 
 out anything in their physical condition to explain the fact. It 
 seems to have been from this assertion of Frank's, that Burdach, 
 who is almost the only author who even alludes to the matter, has 
 given the general statement that one marriage only in 50 is unpro- 
 ductive.^ 
 
 For the purpose of ascertaining the point by numerical data, I 
 had a census taken of two villages of considerable size, viz., Grange- 
 mouth in Stirlingshire, and Bathgate in West Lothian,' — ^the one 
 consisting principally of a seafaring population, and the other of 
 persons engaged in agriculture and manufacture. 
 
 The following form the results in these two places : 
 
 Of 210 marriages in Grangemouth, 182 had oiFspring ; 27 had 
 none ; or about one marriage in ten was without issue. 
 
 Of the 27 unproductive marriages, all the subjects had lived in 
 wedlock upwards of five years, and in all the female had been 
 married that period before she reached the age of 45. 
 
 Again, of 402 marriages in Bathgate, 365 had offspring ; 37 had 
 none ; or about one marriage in eleven was unproductive. There 
 were at the same time living in the village 122 relicts of marriages, 
 and of these 102 were mothers ; 20 were not mothers ; or about one 
 in six had no family. In all, of 467 wives and widows, 410 had 
 offspring ; 57 had none ; or about one marriage in 8 was unproduc- 
 
 ' Loo. cit. vol. vi. p. 245. See also Neue Abhandliingen der Sohwedischen Akademie 
 der Wissensohaften, vol. xi. p. 70. 
 
 ^ Dr. Allen Thomson's excellent essay on Generation, in Todd's Cyclopedia, vol. i. p. 478 
 footnote. 
 
 » My young friend, Mr. Thomas Girdwood of Falkirk, was so good as to make the census 
 of Grangemouth for me. For the data relative to Bathgate I am indebted to the kindness 
 of Mr. William Dick of that place. 
 
294 ALLEGED INFECUNDITY OF 
 
 tive. Of these last 57, six had not been five years married, and 
 there were other six above the age of 45 when married. If we sub- 
 tract these twelve, we have, of 455 marriages, 410 productive ; 45 
 unproductive ; or one in 10 1 without issue. 
 
 Eeturns such as I have just now adduced are exceedingly difficult 
 to obtain, in consequence of no registers being anywhere kept, so 
 far as I know, that could be brought to bear upon the question. If 
 it had been otherwise, I would here, if possible, have gladly appealed 
 to a larger body of statistical facts, in order to arrive at a more 
 certain and determinate average of the proportion of unproductive 
 marriages in the general community. For the purpose, however, of 
 extending this basis of data, I have analyzed with some care and 
 trouble the history of 503 marriages detailed by Sharpe in his work 
 on the British Peerage for 1833. 
 
 Among the British Peers there were 401 marriages with issue ; 
 102 without issue ; or of 
 
 503 existing marriages among British Peers in 1833, 
 74 were without issue after a period of five years. Of those who 
 had not yet lived in the married state for five years, 28 were 
 still without family ; and in Burke's Peerage for 1842, there 
 still remained among these 28 marriages, 
 
 7 without issue, making 
 
 81 as the total number of unproductive marriages among the 
 original 503 ; or the proportion of the unproductive to the produc- 
 tive marriages among this number is as nearly as possible, 1 in 6f. 
 In the above calculation I have excluded eight unproductive 
 marriages, in which the age of the husband at the date of marriage 
 exceeded 56. These eight, however, ought to be deducted from the 
 original sum of total marriages that were included, or, in other 
 words, the 503 should be reduced to 495, and then the whole result 
 would stand thus ; among 495 marriages in the British Peerage, 81 
 were unproductive, or 1 in 6^ were without any family. 
 
 The total result of the three series of facts that I have brought 
 forward with regard to the average number of unfruitful marriages 
 may be tabulated, then, as follows : 
 
 Total Marriages Proportion of 
 
 marriages, without issue. unprod. marriages. 
 
 In Grangemouth, 202 20 1 in lOJ 
 
 In Bathgate 455 45 1 in lOJ 
 
 In British Peerage 493 81 1 in 6 J 
 
 1252 146 or 1 in 8^ 
 
 "We thus see that if the marriages of females born co-twin with 
 males are, as we have found them, unproductive in the proportion 
 of 1-in 10, they do not, in this respect, exceed the degree of un- 
 
FEMALES BOKN CO-TWIN WITH MALES. 295 
 
 productiveness of marriages in other portions of tlie general com- 
 munity. Nor would I be inclined to forego this deduction, even if 
 the average of unproductive marriages in society should be found, 
 on a broader and more extensive basis of data, to be less than the 
 above facts would seem to show. For certainly my own impression 
 is, that probably I have had reported to me, and have entered among 
 my notes and calculations, a greater proportional number of unpro- 
 ductive females among opposite sexed twins than may actually exist. 
 In relation to such a question as the present, all minds are too liable 
 to be impressed with, and recollect instances illustrative of the sup- 
 posed rule and common opinion, whilst the apparent exceptions to 
 it are unattended to or forgotten. In the earlier part of the inquiry 
 I happened to take notes of several cases that had, in this way, been 
 long stored up, by those that reported them to me, as evidence of 
 the infecundity of the female co-twin, and who deemed them so far 
 to afford sufficient proof of the popular opinion. The latter part of 
 the investigation has, in a great measure, if not entirely, escaped 
 this source of fallacy. 
 
 Before finally attempting to draw all the conclusions that are 
 deducible from the facts we have collected, let us consider for a 
 moment the question under another point of view, and inquire — 
 
 WHAT IS THE AVERAGE PEODUCTIVENESS OF MARRIAGES IN GENERAL, 
 AND DOES THAT OF THE FEMALE IN OPPOSITE SEXED TWINS COME 
 UP TO THE COMMON STANDARD? 
 
 Various authors, in treating of statistics and population, have cal- 
 culated the average degree of fecundity of marriages in different 
 climates and districts, as Malthus,^ MaccuUoeh," Hawkins,' Saddler," 
 Sussmilch,' Quetelet,^ and others.'' Their observations show this 
 average to vary from the number of 3 children to each marriage as 
 a minimum, to 5J or 5^% as a maximum. In an elaborate investi- 
 gation into the subject made by Benoiston de ChSteauneuf,' that 
 eminent statistician states as average results upon a large series of 
 observations, the following general conclusions : 
 
 ' Essay on the Principle of Population, 1803, p. 224. 
 
 * Statistics of the British Empire, vol. ii. p. 413. 
 'Elements of Medical Statistics, p. 221. 
 
 * The Law of Population, vol. ii. p. 380, &o. 
 
 * Gottliche Ordnung, Th. iii. s. 64. 
 
 ^ Sur I'Homme, ouEssai de Physique Sooiale, 1836, tom. i. 
 
 ' See a collection of evidence on this point in the Report from His Majesty's Commis- 
 sioners for inquiring into the Poor Laws, 1834. Appendix F. of Foreign Communications, 
 and table in Preface, p. xcix. &c. 
 
 8 Annales des Sciences Naturelles, tom. ix. p. 431. " Notice sur I'lntensite de la Fecun- 
 dity en Europe au commencement du dix-neuvieme sifeole." 
 
296 ALLEGED INFECUNDITY OF 
 
 In Southern Europe, 457 births result from every 100 marriages, 
 or about 4i from each ; in I'forthern Europe, 430 births result from 
 every 100 marriages, or about 4/o from each. 
 
 Mr. Farre' calculates the mean fruitftilness of marriages in Eng- 
 land in ordinary periods to be in every 
 
 Marriages. No. of children. Prop, of children to each mar. 
 
 100 420 4^ 
 
 In relation to Scotland, Benoiston de Ch^teauneuf states,'' that 
 he had the patience to go over the tables of population in seventeen 
 out of the twenty-one volumes of Sir John Sinclair's Statistical 
 Account of this kingdom, and found in every 
 
 Marriagee. No. of children. Prop, of children to each mar. 
 
 100 430 4/j 
 
 What is the usual degree of fruitfulness in married life of females 
 born co-twin with males ? To make as near an approximation as 
 possible to the solution of this question, I have added together the 
 total number of children produced by 94 of those female co-twins, 
 whose history I have collected. "We omit the others remaining on 
 the list, merely because we have no notes taken of the exact extent 
 of their families. The total number of children produced by the 
 94 mothers alluded to, amounts to 409, or the result, when stated in 
 relation to the standard of every 100 marriages of them, would be 
 as follows : — In 
 
 Marriages. No. of children. Prop, of children to each mar. 
 
 100 424 4^ 
 
 But in 15 of the 94 cases, the mother had as yet only one child at 
 the time her case was noted, having either only lived in wedlock for 
 a year or two previously, or the single child being the result of 
 illegitimate intercourse. If we deduct these 15 cases only, though 
 other mothers with a young and increasing family of two or three 
 children might be excepted from the calculation in the same way, 
 and on the same grounds, we shall then have 79 mothers producing 
 364 children ; or, again, to state it in reference to the supposed 
 standard of 100 marriages, we have this result as the degree of 
 fniitfalness of such co-twin females. In every 
 
 Marriages. No. of children. Prop, of children to each mar. 
 
 100 460 4j% 
 
 ' See Macoulloch's British Empire, loc. cit. 
 
 * Annales des Sciences Naturelles, tom. ix. p. 447. 
 
FEMALES BORN CO-TWIN WITH MALES. 297 
 
 The whole inquiry detailed in the few preceding pages forms an 
 apt illustration of an old remark, that in medicine it often requires 
 a much greater extent of observation and research to disprove satis- 
 factorily an alleged and accredited fact, than was ever expended, 
 either upon the original development or subsequent confirmation 
 of it. In the present instance, the results have turned out to be 
 perfectly contradictory of the opinion which I, in common with 
 others, held regarding the infecundity of the female in double 
 sexed twins, when I commenced looking into the subject ; and in- 
 stead of finding my preconceived ideas confirmed by the investiga- 
 tion, they have on the other hand, been completely confuted by it. 
 For the data that I have adduced do, so far as they go, evidently 
 prove — 
 
 1. That, in the human subject, females born co-twin with males 
 are, when married, as likely to have children as any other females 
 belonging to the general community. 
 
 2. That, when they are married and become mothers, they are, 
 in respect to the number of their children, as productive as other 
 females. 
 
 3. That the same law of the fecundity of the female in opposite 
 sexed twins seems to hold good among all our uniparous domestic 
 animals, with the exception of the eow alone. 
 
 Indeed, the strong confirmatory evidence which the preceding in- 
 quiry affords of this last exceptional point constitutes one of its 
 most interesting results. For certainly it cannot but be considered 
 as an extraordinary circumstance, that, in the cow, the twin exis- 
 tence in utero of a male along with a female should, as a general 
 principle, lead — 
 
 1. To so great a degree of malformation as we have described, in 
 the sexual organs, and in the sexual organs only. 
 
 2. That this malformation should be limited entirely to the repro- 
 ductive organs of the female twin, while those of the male twin are 
 perfectly and fiiUy developed. 
 
 3. That this sexual malformation should, apparently so far as we 
 yet know, occur in the case of twins in the cow only, and in this 
 species of uniparous animal alone. The curiosity of the fact be- 
 comes heightened and increased when we recollect that when the 
 cow has both twins of the same sex, as two males or two females, 
 these animals are always both perfectly formed in their sexual or- 
 ganization, and both capable of propagating. The whole series of 
 circumstances, when considered in conjunction with each other 
 
 • seems to form, in relation to the origin of malformations, one of 
 the strangest and most inexplicable facts to be met within the study 
 of anormal development. 
 
PART 11. 
 
 PHYSIOLOGY AND PATHOLOGY OE PEEGMNCY. 
 
 DURATION OF HUMAN PREGNANCY; 
 
 ITS FREQUENT lEREaULARITY AND OCCASIONAL PROTRACTION. 
 (From Edinburgh Monthly Journal of Medical Science, July, 1853, p. 50.) 
 
 "I HAVE never," declared Sir Charles Clarke, "yet seen a single 
 instance in wliicli the laws of nature have been changed, believing 
 the law of nature to be, that parturition should take place forty 
 weeks after conception." 
 
 The preceding statement was made by Sir Charles Clarke when 
 giving his evidence on the famous Gardner Peerage Case, before the 
 House of Lords, in 1816. 
 
 On the same occasion, four other London medical practitioners, 
 viz., Dr. Gooch, Professor Davis, Dr. Blegborough, and Mr. Pen- 
 nington, averred it was their belief that women never passed the 
 normal period of pregnancy ; or, at least, never passed it beyond 
 two or three days at the utmost. These various witnesses, however, 
 against the protraction of pregnancy beyond its normal period, were 
 by no means agreed among themselves as to what the normal period 
 of pregnancy actually was. Por, while Sir Charles Clarke stated it 
 as forty weeks, that is, 280 days, or ten lunar months, or nine cal- 
 endar months and a week — on the other hand. Dr. Gooch observed, 
 in relation to the period of pregnancy, that " its normal duration is 
 nine calendar months, or rather less than nine calendar months," 
 or from 273 to 275 days. "It is," he observed, "generally stated 
 in the books to be forty weeks, but I believe forty weeks to exceed 
 the usual term of pregnancy. The writers," Dr. Gooch added " say 
 nine calendar months or forty weeks ; now the fact is, that nine calen- 
 dar months is scarcely more than thirty-nine weeks." Dr. Blegbo- 
 rough declared it as his opinion, that " the period of gestation is thirty- 
 
DURATION OF PREGNANCY. 299 
 
 nine weeks or 273 days ; but," he adds, " forty weeks I consider 
 as the ultimatum."' 
 
 While these gentlemen thus varied as to what they considered 
 the normal period of pregnancy— some stating that period to be 
 thirty-nine weeks, others forty weeks— all of them agreed, to quote 
 again Sir Charles Clarke, that " forty weeks is the ultimum tempus 
 pariendi mulierihus constitutwm." Some physicians of the present 
 day still hold that the law of nature is quite fixed in this respect, 
 and that human pregnancy never exceeds the term in question. 
 "We have now, I believe, however, sufficient physiological and ob- 
 stetric evidence accumulated to prove — 1. That this doctrine re- 
 garding the ultimate length of gestation is incorrect ; 2. That the 
 term of human pregnancy is not, as a general law, so very definite 
 and precise as many practitioners think it to be ; and 3. That de- 
 viations from it, both in the way of diminution and of excess of 
 time, are perhaps far more common than is generally supposed 
 among the members of the profession at large. On the present 
 occasion, I leave out of view the subject of abridged or shortened 
 gestation ; and I will chiefly confine my remarks to the much more 
 vexed and debatable question of its occasional prolongation or 
 protraction. 
 
 Most practitioners, from time to time, meet with cases in which 
 there is apparently every reason to believe, that the term of preg- 
 nancy has exceeded the usual normal duration of 274 to 280 days. 
 During the course of the last year or two, after setting aside some 
 less remarkable instances, I have taken notes of two or three cases 
 in my practice, in which, after making the common calculation of 
 280 days, or nine months and a week from the cessation of the eata- 
 menial discharge, pregnancy exceeded this period by several weeks, 
 keeping the patients and their friends in a state of anxious waiting ; 
 and in all of the instances inflicting the unnecessary, as it proved, 
 presence of a nurse in the house for a considerable time before 
 labor actually occurred. The obstetrio history of the first of these 
 cases is interesting in more than this one respect. 
 
 Case I. — This patient was married in September, 1845, and was 
 supposed by her medical attendant to be pregnant in the earlier 
 months of 1846. The case, however, proved one of that common 
 affection, "spurious pregnancy;" and the catamenia, after being 
 eight months obstructed, returned regularly. I first saw her in the 
 course of the following year, in consequence of her suffering under 
 leucorrhoea, and symptoms of chronic inflammation of the cervix 
 
 ' See Lyall's Medical Evidence in the Gardner Peerage Case, pp. 4-9, &o. 
 
300 PREGNANCY. 
 
 uteri. The cervix uteri was enlarged and ulcerated, and tlie fundus 
 greatly anteverted. The uterine inflammatory symptoms yielded 
 under appropriate treatment; but the anteversion remained. In 
 July, 1848, an intra-uterine pessary was introduced with the view 
 of rectifying this displacement. The instrument remained in the 
 uterine cavity till the end of October following. Immediately after 
 its removal, pregnancy occurred, and she was delivered of a daughter 
 in July, 1849, the labor being rendered very severe and tedious, 
 by extreme rigidity of the tissues of the cervix uteri. From this 
 cause the patient was, during parturition, fourteen hours continu- 
 ously under chloroform. It was in her next or second pregnancy, 
 that there was the apparent prolongation of utero-gestation. In the 
 first week of January, 1851, the menses were present, and disap- 
 peared on the 4th or 5th of the month. On the 20th of the same 
 month, January, there occurred a return of menstrual discharge for 
 six days, in consequence of great mental distress at the death of a 
 favorite brother. No menstrual discharge appeared from this date, 
 and she was confined on the 28th of December, that is, 336 days 
 after the last appearance of the catamenia. From the patient wish- 
 ing to go abroad, I was asked to ascertain if she were in the family 
 way, towards the end of April. In consequence of the size and 
 shape of the uterus, &c., I had no hesitation in concluding at the 
 time, that she was then at least two months advanced in pregnancy ; 
 and I calculated for her that she would be confined about the middle 
 of Ifovember. Parturition, however, as I have already stated, did 
 not occur till the 28th of December. 
 
 Case n. — Mrs. , the mother of two children, and always 
 
 quite regular in her catamenial periods, except when pregnant and 
 nursing, began to menstruate about the 20th of September, 1851, 
 and the discharge ceased on the 24th. Shortly after this date, she 
 had feverish symptoms, and from the catamenia not returning, she 
 considered herself pregnant. . She was not delivered, however, till 
 August 3d, that is, 332 days from the last day on which the cata- 
 menial discharge appeared. 
 
 This lady's case was interesting in another point of view. In the 
 middle of December, while in London, in consequence of a long 
 walk, she was threatened with symptoms of miscarriage, requiring 
 rest and treatment. On the 3d, or rather morning of the 4th of 
 January, a large steamer in which she was, caught fire when two or 
 three days out at sea, and only a small number of the passengers 
 and crew escaped. After making almost superhuman exertions to 
 save herself and a young son seventeen months old, whom she held 
 in her arms, and after having her body severely bruised and con- 
 
ITS DUEATION. 
 
 301 
 
 tused, she was exposed for seventeen hours in an open boat, with 
 little or no clothing, and sitting immersed several inches deep in 
 water, during the whole of that long and anxious period. Yet, all 
 the fearful mental excitement and bodily exertion to which she was 
 thus subjected were accompanied by no tendency to miscarriage, 
 though, as I have ah-eady said, two or three weeks previously a 
 long walk had nearly brought on abortion. Could the protracted 
 mental agitation and trial have in any way led to the unusual pro- 
 longation of her pregnancy ? 
 
 Case m. — A patient had the usual menstrual discharge in March, 
 1852, and it left her on the 23d day of that month. She was not 
 delivered till the 5th of February 1853, or till 319 days after the last 
 appearance of the catamenia. That the patient became pregnant 
 very shortly, if not immediately, after her last menstruation, I have 
 every ground for believing ; for, in May, I was asked to see her 
 before she left Edinburgh for the country, in order to determine 
 whether the obstruction which had occurred was the result of preg- 
 nancy or not, as various arrangements depended upon this. On 
 examination, I found the uterus so enlarged, as to leave no doubt 
 whatever that she was then about two months pregnant. The 
 patient was, like myself, distrustful of the obstructed menstruation 
 being a sufficient test, from one point in her previous histoiy. She 
 had been married several years, and without any family, when she 
 first came under my care. The uterus was retroflexed, and for this 
 she wore for some time an intra^uterine pessary. "Within the first 
 half-year after its removal, menstruation was absent for three 
 months, and she had various symptoms of pregnancy ; among others, 
 the areolae became dark, and their glandulse enlarged. The uterus, 
 however, did not increase in size — showing the symptoms to be 
 those merely of spurious pregnancy. The areolae were altogether 
 so dark and marked, that a drawing of them was made about the 
 third month. These sketches presented all the usual changes as 
 distinctly as those figured by my friend Dr. Montgomery in his plate 
 of the true areola at that period — and being preserved, they were 
 found on comparison as marked as the patient's own breasts were 
 at the same date a short time subsequently, when actual pregnancy 
 had supervened. The prolonged pregnancy mentioned above oc- 
 curred with this lady's fourth child. 
 
 When lately conversing vnth my friend Dr. Young, upon the pos- 
 sible prolongation of pregnancy, he stated to me a case which some 
 time ago had occurred in his own practice ; and of which the fol- 
 lowing is a note of the date and circumstances : 
 
302 PREGNANCY. 
 
 Case IV. — The patient was always regular in her menstrual life • 
 and had the catamenia present from the 9th to the 14th of July. 
 This was the last appearance of the menses. She felt sickness 
 towards the end of the same month, which continued more or less 
 for four months, or till the end of ITovember. Foetal movements 
 were distinctly felt on the 17th of November. She was delivered 
 on the 3d of June, or in ten months and eighteen days ; being 324 
 days after the last appearance of the catamenial discharge, and six 
 months and sixteen days, or 198 days after the first symptoms of 
 quickening. 
 
 In the preceding cases, the duration of pregnancy as calculated 
 from the date of the last appearance of the last menstruation, up to 
 the date of delivery, were respectively 836, 332, 319, and 324 days. 
 But, of course, it does not necessarily follow that the pregnancy in 
 these instances actually extended to the preceding durations. Eor, 
 it may be objected, that none of the patients became pregnant till 
 immediately befora the return of the next menstrual period ; or, on 
 an average, till twenty-three days later than the date of the day of 
 the last catamenial discharge. Even, however, if, for this reason, 
 we thus subtract twenty-three days from each of these cases, the 
 duration of gestation would still considerably exceed the normal 
 limits ; for twenty-three days thus subtracted from the first case 
 would still leave a pregnancy of the duration of 313 days ; from the 
 second case, of 309 days ; from the third, of 296 days ; and from 
 the fourth, of 301 days. Or the cases would stand thus : 
 
 Case I. No. of Days from last Menstruation 336 — 23=313 
 
 11. " " " .... 332 — 23 = 309 
 
 HI. " « " .... 319 — 23 = 296 
 
 IV. " " " .... 324 — 23 = 301 
 
 There is another and greater source of fallacy to which such ob- 
 servations are liable, viz., that the catamenia are sometimes arrested 
 from other causes than impregnation, for a month or two before 
 conception actually occurs ; and that hence, if we date the duration 
 of gestation from the last appearance of the catamenia, we may fall 
 into a serious error of calculation. I have specially recorded Cases 
 I. and m., because in these instances where gestation happened to 
 be so much prolonged, this source of error was fortuitously avoided ; 
 in both, the actual existence of pregnancy having been ascertained 
 within eight or nine weeks after conception, by the most certain of 
 all tests at that time, viz., the regularly marked enlargement and 
 altered shape of the uterus.^ 
 
 ' It has sometimes seemed to me also not improbable, that some cases of apparently pro- 
 longed gestation can be accounted for by another explanation. All our latest and best anato- 
 
ITS DURATION. 
 
 303 
 
 Three authors— Dr. Merriman, Dr. Murphy, and Dr. Eeid— have 
 each published a long series of ohservations from their own practice, 
 to show the date of delivery as calculated from the last day of the 
 catamenial discharge. Dr. Merriman gives as data for making this 
 calculation, the dates of the birth of 114 mature children, calculated 
 from the day on which the catamenia were last distinguishable, but 
 not including that day.^ Dr. Murphy's cases analogous amount to 
 168 f and Dr. Reid's to 500.' In the following table I have at- 
 tempted to bring into a comparative view the results obtained by 
 these three physicians in the 782 cases upon which their observa- 
 tions are founded. The table shows in divisions of weekly periods 
 the data of delivery of these 782 patients, as calculated from the 
 last day of the appearance of the last catamenial discharge in each 
 individual : 
 
 TABLE I. 
 
 DATES OF DELIVEKT, CALCULATED EKOM LAST DAT OF CATAMENIA. 
 
 Weeks. 
 
 Days. 
 
 Merriman. 
 
 Murphy. 
 
 Efiid. 
 
 37th 
 
 From 252d to 259th 
 
 3 
 
 12 
 
 23 
 
 3Sth 
 
 " 260th to 265th 
 
 13 
 
 14 
 
 48 
 
 39th 
 
 " 267th to 373d 
 
 14 
 
 27 
 
 81 
 
 40th 
 
 " 274th to 2S0th 
 
 33 
 
 28 
 
 131 
 
 41st 
 
 " 281st to 287th 
 
 22 
 
 39 
 
 112 
 
 42d 
 
 " 288th to 294th 
 
 15 
 
 21 
 
 63 
 
 43d 
 
 « 295th to 301st 
 
 10 
 
 25 
 
 28 
 
 44th 
 
 J 
 
 
 
 
 and 
 upwards. 
 
 V " 302d to 326th 
 
 4 
 
 2 
 
 14 
 
 114 
 
 168 
 
 500 
 
 The result of the preceding observations of Dr. Merriman, Dr. 
 Murphy, and Dr. Reid, may perhaps, however, be shown still more 
 accurately by reducing the facts mentioned by them into another 
 form, and calculating the weekly percentage of deliveries from the 
 last day of the catamenial discharge, as brought out in the observa- 
 
 mists seem now to agree that the deoidua of impregnation is merely an altered and hyper- 
 trophied state of the mucous membrane of the cavity of the uterus ; and that, consequently, 
 the deoidua is not at first a shut sac, but has the orifices of the Fallopian tubes and os uteri 
 for a time opening into it. And it seems not entirely impossible that the ovulum of one 
 impregnation dying without the deoidua being immediately cast ofl^, the cavity of the deoidua 
 — or, in other words, of the uterus — remairiing permeable, a second impregnation may pos- 
 sibly take place within a short time, and the decidua of the first impregnation serve as the 
 decidua of the second conception. If ever such an occurrence takes place, a catamenial 
 period might be passed without any catamenial discharge — and hence an unavoidable error 
 in calculation be fallen into. 
 
 ' Medico-Chir. Trans, vol. xiii. p. 340. 
 
 2 Report of the Obstetric Practice of University College Hospital, p. 9. 
 
 ' Lancet, for July 20, 1850, p. 81. 
 
304 
 
 PREGNANCY. 
 
 tions of each of these authors. The following table is intended to 
 give this view of the subject : 
 
 TABLE II. 
 
 PEECENTAGE OF WEEKLY DELIVERIES FROM LAST DAT OF CAIAMBNIA. 
 
 Weeks. 
 
 Days. 
 
 Merriman. 
 
 Murphy. 
 
 Eeid. 
 
 37th 
 
 From 252d to 259th 
 
 2-65 
 
 7-14 
 
 4-60 
 
 38th 
 
 " 260th to 266th 
 
 11-40 
 
 8-33 
 
 9-60 
 
 39th 
 
 " 267th to 273d 
 
 12-28 
 
 16-07 
 
 16-20 
 
 40th 
 
 « 274th to 280th 
 
 29-00 
 
 16-66 
 
 26-20 
 
 41st 
 
 " 281st to 287th 
 
 19-30 
 
 23-21 
 
 22-40 
 
 43d 
 
 " 288th to 294th 
 
 13-16 
 
 12-50 
 
 12-60 
 
 43d 
 
 " 295th to 301st 
 
 8-77 
 
 14-86 
 
 5-60 
 
 44 th 
 
 J 
 
 
 
 
 and 
 
 { " 302d to 324th 
 
 3-50 
 
 1-20 
 
 2-80 
 
 upwards. 
 
 
 
 
 
 100- 
 
 100- 
 
 100- 
 
 The preceding facts show, that if we take as the starting-point or 
 commencement of our calculations regarding the duration of preg- 
 nancy, the last day of the last catamenia, the date of delivery is far 
 less decided and determinate than is generally believed by the medi- 
 cal profession ; the cases registered in these tables showing very 
 great irregularities and deviations in this respect. It is further de- 
 serving of especial remark, that a large proportion of all the cases, 
 from 12 to 16 per cent, terminated as early as during the course of 
 the 39th week, or from 267 to 273 days after the last day of the last 
 menstruation. On any one individual day, only a small proportion 
 of deliveries occurred. The largest actual number of mothers de- 
 livered on individual days was in Dr. Murphy's series of 186 cases, 
 10, or 6 in every 100, on the 285th day after menstruation ; 7 on the 
 278d, 279th, and 283d days ; and 6 on the 270th, 278th, 284th, 287th, 
 and 297th days after the same date. In Dr. Reid's series of 500 
 cases, the greatest number of mothers delivered on individual days 
 was 25, or 5 per cent on the 282d day after the last catamenia ; 22 
 on the 278th day ; and 21 on the 274th and 279th, &c. Out of Dr. 
 Merriman's 114 cases, 9 were delivered on the 280th day; 8 on the 
 277th ; 6 on the 283d ; 5 on the 281st and 288th day; 4 on the 264th, 
 274th, 285th, 298th, &c. 
 
 One circumstance accounting, no doubt, for much of the apparent 
 irregularity or instability in the duration of pregnancy, as shown in 
 the above tables, in the cases prolonged to the 40th week, or beyond 
 it, is the fact, that though impregnation usually takes place within 
 a very few days after the last catamenial discharge, it may not neces- 
 sarily do so. For conception may in fact occur at any date previous 
 
ITS DURATION. 
 
 305 
 
 to the recurrence of the next menstrual period. This gives an un- 
 certain limit for the actual date of impregnation, of twenty-two or 
 twenty-three days— the average interval between two menstrual 
 periods. But the possibility of variation from this circumstance 
 will by no means account for the great amount of variation m ges- 
 tation which is so frequently observed. For there has now been 
 recorded a long comparative series of observations- upon the dura- 
 tion of pregnancy among our domestic animals, and particularly 
 upon the cow, in which these sources of variation and fallacy 
 with regard to the length of gestation, were avoided by the fact, 
 that the exact day and date of impregnation in these experiments, 
 from a single intercourse with the male, were in each instance 
 accurately noted and fixed. Thus Lord Spencer has reported the 
 date of delivery in 754 cows, in which the day of impregnation from 
 a single coitus with the bull had been carefally registered.^ M. 
 Tessier had previously published 572 observations of a similar kind 
 upon the same animal.^ If we omit a number of cases in each of 
 these two series of observations, in which delivery supervened earlier 
 than the thirty-seventh week, we have the results of Lord Spencer's 
 and M. Tessier' s observations presented in the following table. 
 
 TABLE III. 
 
 PERIODS OF GESTATION IN COWS. 
 
 Weeis. 
 
 Days. 
 
 Spencer. 
 
 Tessier. 
 
 37th 
 
 From 252d to 259th 
 
 12 
 
 6 
 
 38th 
 
 " 260th to 266th 
 
 4 
 
 8 
 
 39th 
 
 " 267th to 273d 
 
 24 
 
 51 
 
 40th 
 
 " 274th to 280th 
 
 121 
 
 166 
 
 41st 
 
 « 281st to 287th 
 
 392 
 
 202 
 
 42d 
 
 " 288th to 294th 
 
 175 
 
 105 
 
 43d 
 
 « 295th to 301st 
 
 16 
 
 27 
 
 44th 
 
 ) 
 
 
 
 and 
 
 > « 302d to 321st 
 
 7 
 
 7 
 
 upwards 
 
 s 
 
 
 
 751 
 
 572 
 
 This table shows that in the cow, even when the day of impreg- 
 nation was fixed and ascertained, the period of delivery was still 
 very far indeed from being quite stable and determinate. 
 
 But to make the comparisons between these observations on the 
 cow, and those reported above on the human subject, more com- 
 plete, let us reduce the experiments on the gestation of the cow to 
 a percentage form, as we have already done in Table IE., in relation 
 
 ' Journal of the English Agricultural Society, Part ii. 1839. 
 ' Memoires de I'Aoademie Koyale des Sciences, 1819, Tom. ii. p. i. 
 VOL. I. 20 
 
306 
 
 PKEGNANCT. 
 
 to the cases in tlie human subject, recorded by Drs. Merriman, 
 Murphy, and Eeid. The following table shows the actual propor- 
 tion of weekly deliveries in Lord Spencer's and M. Tessier's obser- 
 vations on the cow, as calculated from the known date of impreg- 
 nation of the animal ; or, in other words, the proportion of cases 
 in every 100 in which the gestation was normal, abridged, or pro- 
 longed : 
 
 TABLE IV. 
 
 PERCENTAGE OP DIFFERENT PERIODS OF GESTATION IN COWS. 
 
 Weeks. 
 
 Days. 
 
 Spencer. 
 
 Tessier. 
 
 37th 
 
 From 252d to 259th 
 
 1-60 
 
 1-05 
 
 38th 
 
 " 260th to 266th 
 
 055 
 
 1-40 
 
 39th 
 
 " 267th to 273d 
 
 2-80 
 
 8-91 
 
 40th 
 
 " 274th to 280th 
 
 16-53 
 
 29-02 
 
 41st 
 
 " 281st to 287th 
 
 S2-27 
 
 35-31 
 
 42d 
 
 " 288th to 294th 
 
 23-18 
 
 18-36 
 
 43d 
 
 " 293d to 301st 
 
 2-12 
 
 4-72 
 
 44th 
 
 ■\ 
 
 
 
 and 
 
 [ « 302d to 321st 
 
 0-93 
 
 1-22 
 
 upwards 
 
 ) 
 
 
 
 In making any comparison between the results of the period of 
 gestation in the cow, as shown in Table IV., and the period of ges- 
 tation in the human female, as shown in Table 11., it is necessary 
 to remember, that, while the normal period of gestation in the 
 human female is probably from 274 to 280 days, that of the cow 
 extends, according to Lord Spencer, to 284 or 285 days. And 
 hence, while we find that the largest percentage of deliveries in the 
 cow takes place fi?om the 281st to the 287th day of gestation, the 
 largest percentage of deliveries in the human female, as calculated 
 even from the last day of the catamenial discharge, occurred in Dr. 
 Merriman's and in Dr. Reid's observations, from the 274th to the 
 280th day; though in Dr. Murphy's series of cases, his largest 
 weekly percentage occurred in the week following the 280th day 
 from the last catamenia — an occurrence probably to be explained 
 by the circumstance of impregnation not following till two, three, 
 or more days after the last menstruation. 
 
 Amongst the various observations which might be elicited by a 
 comparison of these tables, let me state one more : That though 
 the period of gestation in the cow is found liable to considerable 
 variations, and is by no means so precise and determined as many 
 authorities have supposed it to be, yet the period of pregnancy in 
 the human mother is not even so regular as the period of gestation 
 in the cow. This greater apparent variation of the duration of 
 pregnancy in the human subject in these tables, doubtless depends 
 
ITS DURATION. 
 
 307 
 
 upon the fact already adverted to, that the last day of the catamenia 
 does not by any means, in the human mother, fix determinately the 
 actual day of conception. 
 
 Occasionally, however, in the human mother, pregnancy occurs 
 under circumstances which fix the date of conception to a precise 
 day. Dr. Reid, for example, has collected from the observations of 
 various authors, and fi-om his own practice, the history of forty 
 cases in the human female, where impregnation was the result of a 
 single intercourse, the date of which was accurately known ; the 
 cases being all of them " instances of single women who dated from 
 one coitus, or of married females whose husbands had been absent 
 for a considerable time before the last intercourse," and all of them 
 being selected with a view to avoid as far as possible every source 
 of deception. Below I have thrown these forty cases of gestation 
 into a tabular form. This table demonstrates the varying duration 
 of pregnancy, and consequently the variable date of parturition and 
 delivery, in the human female, even when the date of impregna,tion 
 is previously accurately established and known. The last column 
 in the table presents in the percentage form, so far as can be calcu- 
 lated from so small a number, the relative proportion delivered at 
 different dates from the day on which conception occurred. 
 
 TABLE V. 
 
 PERIODS OF FORTY DELIVERIES IN HUMAN MOTHERS — IMPREGNATION BEING 
 CALCULATED FROM A SINGLE INTERCOURSE. 
 
 Weeks. 
 
 Days. 
 
 Total Number 
 of Cases. 
 
 Percentage. 
 
 38th 
 39th 
 40th 
 41st 
 42d 
 
 From 260th to 266th 
 " 267th to 273d 
 " 274th to 280th 
 " 281st to 287th 
 " 288th to 294th 
 
 5 
 7 
 18 
 6 
 4 
 
 12-50 
 17-50 
 4500 
 15-00 
 10-00 
 
 This table shows that in the human subject, and vdth the day of 
 impregnation known, pregnancy in nearly one-half, or in 45 per 
 cent, extended from 274 to 280 days ; that in 15 per cent it was 
 protracted from the 281st to the 287th day ; and in 10 per cent^ it 
 was prolonged from the 288th to the 294th day. Three only out of 
 these 40 cases, or 1 in 13, were delivered on the 280th day after 
 conception. Seven, or 1 in 6, were delivered on the 274th day. 
 
 Admitting then the possibility of the occasional protraction ot 
 human gestation beyond its common normal period, another ques- 
 
 ' Perhaps this proportion is made larger than it should be, by some of the published cases 
 ■which Dr. Keid has collated having been possibly recorded merely because they were 
 marked instances of protraction. 
 
308 PREGNANCY. 
 
 tion lias sometimes been asked, viz., What is the extreme limit of 
 this protraction, or, in other words, to how many days beyond the 
 normal period of gestation is it possible for a woman to carry a child ? 
 I confess that some of the late cases recorded, particularly by our 
 American brethren, appear to me to be beyond the bounds of this 
 possibility. Thus, Dr. Meigs of Philadelphia has reported a case 
 on " facts" which he conceives to be " trustworthy," where a patient 
 supposed herself pregnant in July, 1839, quickened on the 20th of 
 November, had spurious labor pains on the 10th of April, but her 
 child was not born till " the 13th of September, 1840, about day- 
 light;" the pregnancy thus, according to Dr. Meigs, having "endured 
 nearly fourteen months or 420 days."^ 
 
 Professor Atlee of Philadelphia has published two cases of pro- 
 tracted gestation occurring under his own observation. In the first 
 of these, the patient lost her catamenia on March 22d, 1832 — quick- 
 ened August 5th of the same year — and was delivered with forceps 
 March 22d, 1833. It was her fourth pregnancy. In Dr. Atlee's 
 second case, the patient saw appearance of menstruation for the last 
 time on August 6th, 1832 — quickened on December 25th — but was 
 not delivered till August 13th, 1833. Dr. Atlee, who states that he 
 has not "the least doubt of the truthfulness of the evidence in the 
 above cases," imagines, from the date of the quickening in each, 
 that both mothers became pregnant shortly after their last catame- 
 nial periods, and that consequently, in both instances, the patient 
 went pregnant nearly the entire circle of the calendar, or 365 days.^ 
 
 Without stopping to inquire as to the various sources of fallacy in 
 these and similar observations, let me merely add, that I believe our 
 best criterion for fixing the "legal limit," or ultimate possible period 
 of gestation in the human female, will be derived from carefal and 
 repeated observations upon the ultimate period of gestation in the 
 cow ; allowing always for the difference of four or five days of 
 excess in the normal period of pregnancy in the cow, as compared 
 with the human mother. Lord Spencer, in one instance, found the 
 
 ' Obstetrics, the Science and the Art, 1852, p. 230. 
 
 f Tucker's Elements of Midwifery, p. 149. — Dr. Tucker records at some length the opinion 
 of the American Court regarding the possible protraction of pregnancy, as elicited at a trial 
 for bastardy at the Lancaster Quarter Session. In this case the prosecutrix swore that her 
 child was begotten on the 23d of March, 1845, and was born on the 30th of January, 1846 — 
 making the period of gestation 313 days — or two days longer than the alleged term of ges- 
 tation, 311 days, in the Gardner Peerage case. In the American trial, six medical practi- 
 tioners testified with more or less positiveness, against the possibility of the protraction of 
 pregnancy. On the other side, five medical practitioners declared their belief in the occa- 
 sional extension of gestation beyond the normal period, and in the possibility of its protrac- 
 tion to 313 days. In charging the Jury, the President of the Court held, that protracted 
 gestation for a period of 313 days, "although unusual and improbable, was not impossible;" 
 and in accordance with this charge the Jury found the defendant guilty. 
 
ITS DTTRATIOIf. 309 
 
 period ^f gestation in the cow to extend to 313 days from tlie date 
 of impregnation ; and in one of his observations on tlie same 
 animal, M. Tessier states, that parturition did not supervene till 321 
 days from the date of conception. 
 
 Such direct experiments and observations upon the lower animals 
 afford evidence, which necessarily, I think, forces us to admit, that 
 in exceptional cases in the cow — and hence also, as we certainly 
 may fairly infer, in the human female — the period of gestation may 
 be prolonged 30 or 35 days beyond its normal and usual duration. 
 And it is not impossible that farther accurate and repeated experi- 
 ments, of the nature of those performed by Lord Spencer and M. 
 Tessier, may yet establish, by the same kind of proof, even a more 
 extended limit as the ultimum tempus pariendi. 
 
 Those obstetricians who maintain that the period of human ges- 
 tation is a fixed period, and can never by any possibility exceed the 
 fortieth week (as was sworn to by the five London accoucheurs who 
 gave evidence in the Gardner peerage cause, and by the six medical 
 practitioners who more lately gave similar evidence in an analogous 
 cause before the American Court at Lancaster,') have none of them 
 adduced any reason why the period of pregnancy should be thus 
 stable and invariable, while all other periodic processes in the 
 human body — as dentition, puberty, menstruation, the date of quick- 
 ening, &c., are universally known and acknowledged to be apt to 
 vary extremely. These obstetricians have offered no reasons, so far 
 as I know, for holding that similar variations could not take place 
 in the duration of pregnancy. Indeed, it would be against all 
 analogies from other actions and processes in the animal kingdom 
 to suppose that such variations did not occur in regard to the func- 
 tion of gestation. 
 
 Cases of protraction of utero-gestation beyond the usual average 
 period have been attempted to be accounted for by some physiolo- 
 gists, by tardiness in the escape of the ovulum from the ovary after 
 impregnation, by delay in its transit through the Fallopian tube, 
 and by other deviations in time connected with the earlier history of 
 development. These explanations, however, are at the best mere 
 assumptions and hypotheses. There are, however, one or two 
 known circumstances which seem to have an occasional, though not 
 very marked, influence on the prolongation of pregnancy. 
 
 In the individual cases of protraction which I have detailed to- 
 wards the commencement of the present communication, the pro- 
 traction was limited to individual pregnancies in the mothers. "With 
 other children, these mothers had not exceeded the normal term. 
 Occasionally, however, a disposition to prolongation appears to be 
 
 ' See preceding footnote from Dr. Tucker's work. 
 
310 PKEGNANCY. 
 
 peculiar to some mothers in all their pregnancies. Dr. Dewees 
 states, that he had occasion to observe the anormal prolongation of 
 pregnancy to upwards of ten calendar months, or above 300 days, 
 as an habitual arrangement in at least four females whom he had at- 
 tended.' Dr. Hamilton has recorded the protraction of pregnancy 
 as a marked individual peculiarity in one of his patients. In this 
 case the lady lost her first two children from what was supposed to 
 be prolonged gestation to the eleventh menstrual period. In her 
 three next pregnancies Dr. Hamilton induced labor with success a 
 week after the tenth menstrual period ; in all of these pregnancies, 
 the patient seeming to show the same tendency to the prolongation 
 of gestation.^ My friend, Professor Eetzius of Stockholm, has in- 
 formed me of a still more strange example that has occurred in his 
 practice of extreme protraction of pregnancy, not as a peculiarity 
 in an individual mother, nor as attending individual pregnancies 
 only, but as an hereditary peculiarity in a mother and her two 
 daughters. 
 
 It is a common idea among agriculturists in this country, that 
 pregnancy is more apt to be protracted in cows, &c., in proportion 
 to the frequency of their previous pregnancies. I am not aware of 
 any collected facts calculated to prove or disprove this idea. The 
 sex of the calf is also very usually supposed by farmers to have 
 some influence upon the duration of pregnancy — cows when they 
 pass beyond the normal period being averred to produce more fre- 
 quently a male than a female calf. In Lord Spencer's experiments 
 — if we omit the cases of twin births — among all the cows deli- 
 vered up to the 284th day after impregnation, there were 53 per cent, 
 of female, and 47 per cent, of male calves born ; while among 381 
 cows whose period of gestatipn lasted from 285 to 313 days, as 
 many as 61 per cent, of the calves produced were males, and only 
 39 per cent, females. In the table which Dr. Murphy has published 
 of the duration of pregnancy in 184 human females, the sex of the 
 child is stated in each with a few exceptions. I find that out of 90 
 cases noted in which the mothers were not delivered till upwards of 
 280 days after menstruation, 67 per cent, of the children born were 
 boys, and 43 per cent, were girls. 
 
 Perhaps the state of health and activity of the uterus as an indi- 
 vidual organ of the body, may sometimes have the efiect of leading 
 on to prolongation of gestation. In two of the cases, viz., Cases I. 
 and in., which I have detailed, it is not impossible that this condi- 
 tion may have been the cause of the protraction. 
 
 The cause why parturition generally comes on in the human 
 female from the 274th to the 280th day has been much debated 
 
 » Compendium of Midwifery, p. 465. " Practical Observations, p. 106. 
 
ITS DUEATION. 311 
 
 among ptysiologists and accoucheurs ; and perhaps a knowledge of 
 it may be necessary before we can understand all the circumstances 
 which lead to the frequent irregularities and occasional prolongation 
 of pregnancy. All the explanations which, so far as I know, have 
 been hitherto offered on this subject, such as those that refer the 
 excitation or supervention of labor to the development of the body 
 of the uterus, to the state of the cervix, to the state of the ovary, 
 to the state of the foetus, &c., will, I believe, be found untenable. 
 And I would venture to suggest that, in 'the human female, the ex- 
 citing cause of parturition is to be traced to changes going on, or 
 rather accomplished, between the uterus and its deciduous lining, — 
 which changes lead to parturition, when they have proceeded so far 
 as to effect the necessary amount of disintegration and separation 
 between the relatively attached surfaces of the uterus and decidua. 
 In these communications, I may take another opportunity of stating 
 the different facts which seem to me to bear on this view of the 
 question, and show more particularly the changes in the structure 
 of the decidua — both vera and serotina, but especially the former — 
 and in particular of its outer or attached surface, to which I allude. 
 Let me in the meantime merely observe, that these changes, in the 
 connection between the decidua and uterus, seem of a nature analo- 
 gous to the so-called fatty degeneration, which occurs in effete 
 and worn-out structures in other parts of the body ; and that we 
 artificially imitate these changes and their effects in inducing pre- 
 mature labor, when we separate the membranes from the interior of 
 the uterus with the finger or the sound, or when we inject water 
 into the uterine cavity, &c. These changes of textural degeneration 
 and detachment are not necessarily accomplished with precision to 
 a certain fixed day ; and hence, I believe, the very great irregularity 
 which we have seen in the preceding tables to exist in relation to 
 the time at which parturition supervenes after impregnation. In 
 Lord Spencer's and M. Tessier's tables, we have evidence of the ex- 
 treme irregularity of the period of utero-gestation, and the com- 
 parative frequency with which anormal protraction of gestation 
 occurred in a series of experiments, which, it must be remembered, 
 were limited to about 1300 cases only; — and when we call to mind, 
 at the same time, that in Great Britain alone, some 600,000 cases of 
 human gestation and parturition take place annually, we cannot 
 avoid concluding, that irregularities and anormal protractions in 
 human gestation might be found in obstetric practice far more fre- 
 quently than the profession generally suppose, provided the circum- 
 stances bearing upon this point were always duly and properly 
 investigated. 
 
812 ALLEGED SUPEKFffiTATIONS EXPLAINED. 
 
 THE APPEAKANCE OF THE AEEOLA AS A SIGN OF 
 PREGNANCY.' 
 
 (From Edinburgh Monthly Journal of Medical Science, March, 1848, p. 693.) 
 
 Dr. Simpson showed to the Society a woman seven months gone 
 with child, whose breasts gave no indication whatever of her 
 pregnant state. The case«was a peculiar one. There was no doubt 
 of her being pregnant, as the foetal heart could be distinctly heard ; 
 but, at an earlier stage, great doubt had been thrown on the nature 
 of the case, from the presence of several large fibrous tumors in the 
 walls of the uterus. These had even given rise to the suspicion, on 
 the part of the physician she had consulted, that the foetus was extra- 
 uterine. She had been four years married, and was now pregnant 
 for the first time. On examining both breasts, there is no appear- 
 ance whatever of a single enlarged gland in the areola ; besides, the 
 areola is not at all tumid, and is scarcely darker than the surround- 
 ing skin. Dr. Simpson had caused a drawing to be made of this 
 breast, which he contrasted with another of the areola of a lady who 
 had never been pregnant, but was suflering from great uterine 
 irritation. In this last instance the areola was turgid, and of a dark 
 brown color, the papillae were numerous and much enlarged, and 
 the superficial veins very large and prominent. He had observed 
 the same appearance as in the last case in other non-pregnant wo- 
 men.^ In one, the woman could never be pregnant, as the uterus 
 was malformed, and not more than one inch and a half in length. 
 In another case, the marks were so distinct, that the late Dr. Hamil- 
 ton, trusting mainly to them as undoubted indications of pregnancy, 
 had, two or three years before, pronounced the lady pregnant, when 
 the uterus was only enlarged by a mass of fibrous tumors. 
 
 OBSERVATIONS ON THE INFLUENCE OF THE DEATH 
 OF THE F(ETUS, 
 
 IN RELATION TO ITS RETENTION IN OR EXPULSION FROM THE 
 
 UTERUS.' 
 
 (From Edinburgh Monthly Journal of Medical Science, May, 1848, p. 836.) 
 
 Dr. Simpson, in exhibiting some " secondary" foetuses from the 
 University Museum, stated the following general propositions re- 
 
 • Extracted from Proceedings of Edinburgh Obstetric Society, December 22, 1847. 
 
 ^ See ante, page 274. 
 
 = Extracted from Proceedings of Edinburgh Obstetric Society, February 9, 1848. 
 
ALLEGED SUPERFOBTATIONS EXPLAINED. 313 
 
 garding them. The general law which regulated the occurrence of 
 labor in relation to the death of the foetus was well known to he 
 this: 
 
 1. That usually, in from one to three weeks after the foetus dies, 
 uterine contractions supervene, and effect its expulsion. But to this 
 very general law there are various exceptions. For — 
 
 2. If the embryo die in early embryo^c life, and the foetal ap- 
 pendages continue to live and vegetate, expulsion may not super- 
 vene for months. He showed a case of hydatigenous ovum, where 
 the embryo was not larger than an embryo of the sixth week, but 
 the placenta, or rather the chorion, was the seat of hydatigenous 
 hypertrophy and degeneration ; and the mother, a patient of Mr. 
 Girdwood's of Falkirk, calculated that she had passed the usual 
 term of utero-gestation, not having menstruated for eleven months 
 previously to the expulsion of this diseased ovum. 
 
 3. "When the foetus dies from the third month onwards, in conse- 
 quence either of disease in its own organization, in its umbilical 
 cord, or in its placenta, and a second twin living fcetus exists at the 
 same time in utero, and this second foetus continues to grow and 
 keeps up a correspondence of development between the organ and 
 its contents, the dead and undeveloped twin may be retained up to 
 the fall term of pregnancy, and be then born along with the other 
 living and full-sized child. 
 
 4. When the dead foetus is thus retained, it is preserved free from 
 the decomposition usually following death, by all access of air to it 
 being prevented. Sometimes it retains its usual rounded appear- 
 ance and form, if it continues to be surrounded by a sufficient 
 quantity of liquor ainnii ; but in other cases where this protecting 
 medium of liquor amnii is defective, the foetus becomes gradually 
 more and more squeezed between two forces, viz., the parietes of the 
 uterus on one side of it, and the other living twin or its membranes 
 on the opposite side ; and at last, when born, it is found compressed 
 and flattened in form. Two such flattened foetuses are in the Uni- 
 versity Museum ; and many such cases are on record. 
 
 5. The birth of such undeveloped dead twins has sometimes given 
 rise to most groundless and erroneous ideas of the existence of 
 Buperfoetation. 
 
 6. Occasionally when one of twins dies early in pregnancy, it is 
 after a time expelled, when it happens to be situated near or over 
 
314 HBMOERHAGB IN CONNECTION WITH ABORTION. 
 
 the OS uteri ; afterwards the uterus closes, and pregnancy goes on 
 to the full time with the remaining living child. He mentioned 
 the case of a lady aborting of a foetus about the third month, going 
 on in pregnancy to the full time, and then being delivered of twins ; 
 having originally conceived of triplets. 
 
 7. This last circumstance evidently led to the practical deduction — 
 that when a dead fcetus in its envelopes is expelled during the cur- 
 rency of pregnancy, and the uterus notwithstanding still remains 
 large and apparently distended, its further contents should not be 
 in any way interfered with ; but rest and other means employed to 
 avert the excitement of any additional uterine contraction, under 
 the hope that a living twin may still be retained, and be carried 
 onwards to the full term of utero-gestation. 
 
 HEMOREHAGE IN CONNECTION WITH ABORTION. 
 
 INDICATIONS OF TREATMENT. 
 (From Edinburgh Monthly Journaal of Medical Science, September, 1854, p. 277.) 
 
 Various authors have described cases of fatal hemorrhage accom- 
 panying abortion. Dr. Denman has given a drawing of the ovum 
 in such a case still partially attached to the interior of the fundus. 
 A fatal result from this cause is, however, of very rare occurrence. 
 Dr. Simpson described to the Obstetric Society, in 1853, a case to 
 which he had been called some miles from town, where great 
 hemorrhage had been going on for days, and the patient was already 
 moribund. He removed with ease the ovum, which was impacted 
 in the os uteri. The flooding ceased ; but despite of the free use of 
 stimulants, the patient sank in two or three hours. An attempt 
 was made at transfusion ; but the surgeon failed to find a proper vein. 
 
 Dr. Simpson previously had offered to the Medico-Chirurgical 
 Society, July 3, 1844,' some observations on the introduction of the 
 sponge-tent into the os of the pregnant uterus, in certain conditions 
 connected with abortion, as well as a means of inducing premature 
 labor. When abortion was inevitable, and the hemorrhage great, a 
 small expanding sponge-tent, passed into the os uteri, was, he stated, 
 more effectual than a large vaginal plug. It at the same time opened 
 up the OS uteri, so as to allow of the more easy escape of the con- 
 tents, whilst uterine contractions were, in most instances, ultimately 
 
 ' See Edinburgh Monthly Journal of Medical Science, August, 1844, p. 735. 
 
INHALATION OF LAUDANUM FOR VOMITING IN PHEGNANCT. 315 
 
 induced by its presence. For the same reasons it was often a valu- 
 able means botb of opening up the os uteri, and exciting the neces- 
 sary degree of uterine action in those occasionally perplexing cases 
 where, in abortion, the embryo escapes, but the secundines are long 
 retained. He found that the tent, when made and introduced in 
 the mode already stated, required no vaginal plug, or other means 
 to hold it in situ. By its use the first stage of labor, or the dilatation 
 of the OS uteri, could, in a great degree, be advanced, before the 
 labor itself actually began. 
 
 INHALATION OF LAUDANUM 
 
 AS A REMEDY FOR VOMITINa DURING PREGNANCY." 
 (From Edinburgh Monthly Journal of Medical Science, April, 1847, p. 795.) 
 
 Dk. Simpson mentioned to the Society a case in which he had 
 employed the inhalation of laudanum. It was the lady's second 
 pregnancy. She miscarried at the third month during her first 
 pregnancy. On the present occasion, severe sickness and vomiting 
 came on at about the same time after conception, creating great fear 
 of another miscarriage. The retching and vomiting had continued, 
 with slight intermission, for nearly two days, in despite of the use 
 of ice, prussic acid, half-grain opium pills, &c. ; and the patient was 
 complaining much of weakness and want of sleep, when Dr. Simp- 
 son made her inhale some laudanum for a few minutes from a small 
 ether inhaler, hot water being applied to promote its evaporation. 
 The patient speedily began to complain of drowsiness, and was left 
 in a state of sleep, from which she wakened in a few hours, much 
 refreshed. The irritability of the stomach afterwards disappeared ; 
 and in four or five days she was able to proceed on a journey of 300 
 or 400 miles. 
 
 The treatment of obstinate vomiting during pregnancy by oxalate of cerium, will be 
 found on a previous page. — (Ed.) 
 
 • Extracted from Proceedings of Edinburgh Obstetric Society, February 10, 1847. 
 
PART III. 
 
 NATURAL AND MORBID PARTURITION. 
 
 THE DETERMINING CAUSE OF PARTUEITION.' 
 
 (From Edinburgh Monthly Journal of Medical Science, September, 1 S54, p. 276.) 
 
 Aftek stating and refuting tlie various theories that had been 
 suggested on this point, such as the supposed origin of the act of 
 labor in certain states of vital development or physical expansion of 
 the fundus, body, or cervix uteri — in some supposed conditions of 
 the foetus, liquor amnii, or placenta, &c.. Dr. Simpson suggested 
 that the loosening or decadence of the membranes, or membranes 
 and placenta, from the interior of the uterus, constituted the deter- 
 mining cause of parturition ; and that this loosening or decadence 
 was itself the result of the effete degeneration of the structure of 
 the decidua towards the full term of pregnancy. Various circum- 
 stances in obstetric physiology and pathology were stated in evi- 
 dence of this view. It was so far also proved experimentally, for 
 we bring on labor artificially by imitating this process when we 
 separate the membranes with the fingers or catheter ; or when we 
 inject tepid water into the cavity of the uterus, or, in other words, 
 between the membranes and interior of the uterus — ^the latter a 
 plan which Dr. Simpson had followed in twenty or thirty cases.^ 
 
 SOUND HEARD DURING DETACHMENT AND EXPULSION 
 OF THE PLACENTA.' 
 
 (From Edinburgh Monthly Journal of Med. Science, August, 1852, p. 188.) 
 
 M. Caillant has described* a new stethoscopic sound that he 
 considers indicative of the separation of the placenta. " On apply- 
 ing the stethoscope," he alleges, "to the hypogastric region, after 
 
 ' Extracted from Proceedings of Edinburgh Obstetric Society, session xii. 1853. 
 ' See ante, page 311. 
 
 ' Extracted from Proceedings of Edinburgh Obstetric Society, January 14, 1852. 
 ■* See rUnion Medicale for 1850, and more lately his Thfese Inaugurale, Paris, 1852. 
 
MECHANISM OF NATURAL LABOR. 317 
 
 the expulsion of the child, and before the expulsion of the placenta, 
 a sound is heard with each returning uterine contraction, feeble at 
 first, but the intensity of which increases in proportion as the 
 uterine contraction becomes more energetic, and then subsequently 
 diminishes and disappears as the uterine contraction subsides. The 
 sound is composed of a series of rapid small scratching noises, 
 somewhat like those produced by drawing the nails at right angles 
 across the seat of a sofa. It returns with each uterine contraction 
 till the placenta is expelled from the uterus, when it ceases." M. 
 Gaillant believes "that it depends, not upon the uterine contrac- 
 tions, but upon the mechanical disunion or separation of the pla- 
 centa ;" and hence he proposes to term the sound " bruit de decoUe- 
 ment placentaire." 
 
 Dr. Simpson stated the result of M. Caillant's investigations on 
 this supposed stethoscopic indication of the separation of the pla- 
 centa ; but while describing and admitting the sound, he added 
 various reasons for dissenting altogether from the explanation offered 
 of it by M. Gaillant. He believed the sound to be produced by the 
 mere physical compression of the placenta, as it is being crushed 
 within and expelled from the uterus ; and in various experiments on 
 the subject, he found that it could be artificially imitated with a 
 placenta, after its expulsion fi-om the body, by pressing it through 
 such an aperture as that of the os uteri and os vaginae. 
 
 MECHANISM OF NATURAL LABOE.' 
 
 (From British and Foreign Medical Review, October, 1841, p. 462.) 
 
 In looking at the subject of natural labor, the first important topic 
 which meets us is that of the mechanism of the process. The me- 
 chanism of parturition, or the mode in which the fcetal head is appHed 
 to and enters the pelvis of the mother, and the different changes 
 which it undergoes in its relations, during its passage from the brim 
 through the cavity and outlet, independent of its physiological and 
 anatomical interest, is undoubtedly of the highest importance in its 
 bearings on practical midwifery. It forms, indeed, the very basis 
 both of the theory and of the art. Its mere mechanical nature may, 
 in the eyes of some, place it inferior in medical interest to other 
 pathological and physiological questions in the department of ob- 
 stetric medicine, but it is certainly subordinate to none in actual 
 utility. 
 
 ' From a Review of the works of Rigby, Ramsbotham, and Davis, by Dr. Simpson. 
 
318 NATURAL LABOR. 
 
 "We cannot see how any one can detect, with certainty, the various 
 deviations that are apt to occur jfrom the usual course of labor, unless 
 he be thoroughly acquainted with every step of the mechanism in the 
 natural process. Nor can we see how any one can expect to assist 
 instrumentally with perfect certainty, and to the fullest advantage, 
 the various evolutions and motions of the foetal head in the different 
 varieties of labor, without knowing what the most natural and con- 
 sequently the most easy evolutions of each particular variety actually 
 are. No remark, however, is certainly more true than that made by 
 Dr. Denman, that natural labor was the last sort of labor properly 
 studied and properly understood, and we have no hesitation in pro- 
 nouncing our opinion even at the present day, that though it is a 
 subj ect worthy of the greatest attention, it has, at least in this country, 
 hitherto excited very little notice, and though a topic on which, above 
 all others, it is necessary to have correct opinions, there are certainly 
 few departments in midwifery upon which the practitioners of Great 
 Britain entertain, generally speaking, more loose and more incorrect 
 ideas. 
 
 It is curious, in looking back to the past history of practical mid- 
 wifery, to weigh the talent and ingenuity that have been bestowed 
 upon the fabrication of instruments to assist, as it was called, in 
 difficult labors, and at the same time to reflect that the fundamental 
 facts on which the principles of their application and employment 
 rest, were entirely unknown to their inventors. Thus, when the 
 Chamberlens first invented the forceps to drag the foetal head through 
 the pelvis, they neither knew the manner in which the foetal head 
 enters the pelvis, nor any one of the relations which it occupies in 
 its passage through the pelvic cavity. They, and many of their fol- 
 lowers, endeavored to assist nature in her movements before they 
 knew what these movements were. 
 
 In making these remarks, we beg to state that we are perfectly 
 aware that various authors, both British and foreign, have long ago 
 endeavored to describe more or less minutely the mechanism of 
 natural labor and its different modifications. Their descriptions, 
 however, were drawn from theory rather than from experience, firom 
 fancy more than fact, from rude experiments made with the dry 
 bones of the head and mother's pelvis, and not by careful and 
 minute observation of the process as it is conducted in nature. 
 Hence the accounts of different authors, as might readily be ex- 
 pected, show the greatest discrepancy and discordance even on the 
 same points. Whole paragraphs, and whole pages, as Naegele in 
 his comments upon this subject has remarked, are to be found in 
 obstetric works, with their contents respecting the mechanism of 
 parturition perfectly disagreeing with one another, and still more 
 
ITS MECHANISM. 
 
 319 
 
 disagreeing witli nature. Eelations and movements are described 
 which do not occur, and those that do occur are in many instances left 
 undescribed. Authors have but too often shown how they would 
 move the head through the pelvis, if they had the direction of it, 
 rather than endeavored to show how nature herself conducts the 
 process. 
 
 In an article such as the present it is impossible for us to enter at 
 length into the various questions connected with the mechanism of 
 labor. "We will offer merely a few remarks to illustrate some more 
 general facts with regard to it, and to show the truth of what we 
 have previously stated in regard to the discrepancy of opinions that 
 long prevailed upon the subject. 
 
 In the first place, it is almost unnecessary to observe, that all 
 admit that the head of the child presents at the brim of the pelvis 
 in a very large proportion of cases of labor. This proportion is as 
 great as 94 or 95 in the hundred ; or, in other words, the exceptions 
 to this general rule are only about 1 in every 30 cases of labor 
 according to Collins, 1 in 33 according to Osiander, 1 in 34 accord- 
 ing to Carus, or, as Meckel has derived it from various obstetric 
 statistics, only 1 in 35. 
 
 But the next question in the consideration of the mechanism of 
 parturition is a much more undecided one, namely, in what direc- 
 tion does the head of the child enter the brim of the mother's pelvis ? 
 Important as an accurate knowledge of this fundamental fact is to 
 an acquaintance with the subsequent evolutions which the child's 
 head undergoes, and to the practical management of labor, it was 
 not till the middle of the last century that the slightest approach 
 was made to an accurate opinion on this subject. Since that period 
 several different doctrines have been promulgated in respect to the 
 direction in which the long or antero-posterior diameter of the 
 child's head enters the brim at the commencement of the process 
 of parturition. 
 
 A glance at the history of these opinions will illustrate the subject 
 better than any formal comments on it. 
 
 1. By all the older authors the head seems to have been supposed 
 to enter the superior margin of the pelvis, in the same relation in 
 which they observed it to emerge from the outlet, namely, with the 
 sagittal suture or long diameter parallel to the conjugate or antero- 
 posterior diameter of the brim. 
 
 2. In 1742, Sir Fielding Ould, of Dublin, called this first opinion 
 in question, and maintained that, in entering the pelvis, the long 
 diameter of the head lay para,llel to the transverse diameter of the 
 brim. We shall quote his own words, as his work is now somewhat 
 rare, and his original observations on this point little known : 
 
 " When a child presents itself naturally, it comes with the head 
 
320 NATURAL LABOR. 
 
 foremost, and, according to all authors that I have seen, with its 
 face towards the sacrum of the mother, so that when she lies on her 
 back, it seems to creep into the world on its hands and feet. But 
 here I must differ from this description in one point, which at first 
 sight may probably seem very trivial: the breast of the child does 
 certainly lie 6n the sacrum of the mother, but the face does not, for 
 it always, when naturally presented, is turned either to the one side 
 or the other, so as to have the chin directly on one of the shoulders."' 
 
 From this it is evident that Ould believed the child's head to be 
 so greatly twisted round on its trunk " as to have the chin on one 
 shoulder." In 1752, Smellie corrected this notion with regard to 
 the contortion of the child's neck, but otherwise fully adopted Quid's 
 views of the direction of the head. In 1771, Deleurye first pro- 
 mulgated the same opinions in regard to the position of the head 
 in labor, in France ; and in later times Schmitt and Mampe, in 
 Germany, have upheld the same doctrine. 
 
 3. In 1771, two obstetric essays were published upon the conti- 
 nent, the one by Saxtorph of Copenhagen, and the other by Solayres 
 de Renhac of Montpellier, containing observations made indepen- 
 dently of each other, but both agreeing in this one great fact — ^that 
 the long diameter of the head of the child in natural labor entered 
 the pelvis in a direction neither parallel to the conjugate nor to the 
 transverse diameter of the brim, but parallel to one of its oblique 
 diameters ; that is, with the sagittal suture running in a line directed 
 at one extremity to the sacro-iliae synchondrosis behind, and to the 
 foramen ovale anteriorly. They further both showed that of the 
 two oblique diameters, the long axis of the head, in a very large pro- 
 portion, occupied the right, or that running between the right sacro- 
 iliac synchondrosis and left foramen ovale. 
 
 Baudelocque, the pupil of Solayres, adopted the opinions of his 
 master as one of the great foundations of his classification of labors, 
 though he did not adhere exclusively to his master's views. The great 
 influence of Baudelocque over the French and other schools of mid- 
 wifery has spread widely the knowledge of this doctrine of the 
 oblique position of the head at the brim. It was assuredly, how- 
 ever, not until Professor Naegele of Heidelberg published his incom- 
 parable essay on the Mechanism of Parturition, in 1818, that the 
 great and almost exclusive predominance of the oblique direction of 
 the head at the commencement of labor was fully acknowledged. His 
 opinions have daily gained more and more ground on the continent 
 of Europe, but though his essay was translated into our own lan- 
 guage in 1828, we regret to add that the older opinions on the sub- 
 
 ' Quid's Midwifery, p. 28. 
 
ITS MECHANISM. 321 
 
 ject of parturition are still taught in many of our British schools. 
 We feel certain, however, that the more his essay is studied, and the 
 more his observations are accurately compared with what occurs in 
 nature, the more will Naegele's opinions he found to gain weight 
 with the practitioners of this country. 
 
 From the preceding slight historical sketch it is evident that it 
 has been supposed that the head of the child may, at the commence- 
 ment of labor, enter the brim of the pelvis in four different positions ; 
 namely, with its long diameter, 1st, parallel to the conjugate diame- 
 ter of the pelvis ; or, 2d, parallel to its transverse diameter ; or, 
 3d, parallel to its right oblique diameter ; or, 4th, to its left oblique 
 diameter. The first two have been sometimes named the direct or 
 straight positions of the head, the last two the oblique or diagonal. 
 Further, the long diameter of the head may be placed in each one 
 of these pelvic diameters, in two different relations, viz., with the 
 forehead directed to one extremity of it, or the head being com- 
 pletely reversed, the occiput may be directed to the same point. 
 
 "We make these remarks in order to show the foundation on which 
 different authors have based the classifications of cranial presenta- 
 tions that they have proposed. Various writers have described the 
 head as capable of entering the brim of the pelvis in natural labor 
 in all of these eight positions ; others have reduced them to six, 
 and among the authors who have done so, there are some who, as 
 Baudelocque and his followers, have thrown out the two positions 
 referable to the conjugate diameter of the brim, and others who, as 
 Lachapelle, on the contrary, have renounced the two positions re- 
 ferable to the transverse diameter. All our best observers for the 
 last sixty or seventy years have reckoned the oblique positions as 
 the most common. Capuron, Naegele, &c., consider the four oblique 
 as the only position seen in cases of natural labor, and Dr. E,igby 
 has endeavored still farther to refine upon this, by reducing the 
 natural presentations of the head at the brim to the two that can 
 occur in the right oblique diameter alone, namely, 1st, with the face 
 pointed towards the right sacro-iliac synchondrosis, and the occiput 
 to the left acetabulum ; and 2dly, with the face looking to the left 
 acetabulum, and the occiput to the right sacro-iliac synchondrosis. 
 
 The different authors who have adopted the different classifica- 
 tions of cranial presentations to which we have referred, have aflBxed 
 to each an ordinal number to designate them, but, unfoi-tunately, 
 they have but too often employed the same number to designate 
 difterent presentations. Hence we find, for example, the third or 
 fourth positions of one author not at all corresponding to the third 
 or fourth of others. It is unnecessary to comment on the discord- 
 ance to which this has led. In taking up each separate author on 
 
 VOL. I. 21 
 
322 
 
 NATURAL LABOE. 
 
 the subject, we have first to teach ourselves his particular language 
 on this point, before we can either understand his observations or 
 the rules of treatment which he lays down. As a key to the ob- 
 stetric reader in his study of some of the more valuable authors of 
 the present day, we beg to offer the following table : 
 
 Table showing the Numerical Order of Classification followed hy different Authorities in their 
 systematic Arrangements of Cranial Presentation. 
 
 Numbere affixed to Presentations, by 
 
 DiSOEITTION OF PRESENTATION. 
 
 1 
 
 Naegele. 
 
 Gapuron. 
 
 Maygrier. 
 
 Cuges. 
 
 Ualmagrand. 
 
 Baudelociiue. 
 
 Dubois. 
 
 Gardien. 
 
 Davis. 
 
 Deweeg. 
 
 J2 
 
 1 
 
 4i 
 
 ■?a£ 
 
 i 
 
 Anterior part of Cranium jointing 
 
 1 
 
 2 
 
 1 
 2 
 3 
 4 
 
 1 
 2 
 4 
 5 
 3 
 6 
 
 1 
 
 2 
 3 
 4 
 
 5 
 
 6 
 
 1 
 2 
 4 
 5 
 3 
 6 
 7 
 8 
 
 3 
 4 
 
 6 
 5 
 
 7 
 8 
 1 
 2 
 
 To Right Sacro-iliao Synchondrosis. 
 " Left " " 
 " Left Foramen Ovale. 
 " Right 
 
 " Promontory of Sacrum. 
 " Symphysis Pubis. 
 " Right Os Ilium. 
 " Left 
 
 The classification of head presentations adopted by the authors 
 whose works we have under review will be sufficiently apparent 
 from this table. In it we have placed Dr. Davis as following Baude- 
 locque's arrangement, as he evidently professes to do at page 621 of 
 his work, though at the same time we must remark that, after 
 announcing it, he himself does not strictly adhere to that arrange- 
 ment, for, and we could quote other examples, while at page 622 he 
 describes the third position as that in which the occiput lies behind 
 the symphysis pubis, in page 808 he describes the same third position 
 as that in which the right ear lies immediately behind the symphysis 
 pubis and the occiput directed to the left side of the pelvis. We 
 do not stop to comment on the confusion to which such a discre- 
 pancy of statement must lead in the mind of the obstetric student. 
 
 Though Dr. Rigby has admirably described the mechanism of 
 parturition in his work, we confess that we feel somewhat dissatis- 
 fied with his innovations upon the arrangement and nomenclature 
 of Naegele, whose work he himself first introduced to the British 
 public. 
 
 We are so old as to dislike to learn a new language to designate 
 objects with which we have long been familiar. In other respects 
 we can earnestly recommend Dr. Eigby's chapter on the mechanism 
 of labor to the attention of all those who wish to obtain accurate 
 ideas with regard to this matter. 
 
ITS MECHANISM. 323 
 
 Dr. Eamsbotham has, as will appear from the foregoiug table, 
 proposed an arrangement of cranial positions with a numerical order 
 peculiar to himself. We have the same objection, of unnecessary 
 innovation, to urge against him in this respect as we have just made 
 against Dr. Rigby. Further, we certainly consider the number of 
 presentations that Dr. Eamsbotham has described, as too great and 
 complicated. We are not inclined with some authors absolutely to 
 deny that the direct position of the head in the conjugate and 
 transverse diameters cannot possibly occur. We could, we think, 
 if this were a proper place, point out some particular elongated 
 forms of the brim of the pelvis, which would almost oblige nature, 
 if we may so speak, to enter the child's head in one or other of 
 these diameters. But these forms are so exceedingly rare, and these 
 varieties of presentation so very seldom occur in practice, when the 
 child's head and mother's pelvis are of the natural size, that they 
 may certainly be kept out of any classification of labors that are 
 purely normal. Obstetric writers have almost always numbered the 
 presentations in correspondence with the comparative frequency 
 according to which they respectively occur, or, as Jfaegele has done 
 in regard to his second position, in deference to the numbers already 
 appended to them by others. Dr. Eamsbotham has set aside both 
 these circumstances as the basis for his nomenclature. The numbers 
 he has appended to the positions are, we believe, different from 
 those appended to them by any preceding author ; and though he 
 inadvertently states, at page 135, that his first four presentations are 
 " by far the most fi'equent," yet his fourth (the second position of 
 Naegele) is certainly seldom met with, and is greatly less frequent 
 than his sixth (the third position of Naegele), while both his first 
 and second are alleged by Baudelocque, who introduced them into his 
 own classification of presentations, to be so exceedingly uncommon, 
 that he had himself never met with one instance of them out of 
 many thousand cases ; Boivin found them twice in 19,000 labors, 
 and they are hence entirely rejected from the works of most of our 
 recent and best authors. 
 
 After this last remark we could have wished that our space had 
 permitted us to show, by the statistical reports of Lachapelle, Boivin, 
 Naegele, Duges, Halmagrand, and others, the comparative propor- 
 tion of instances in which _the different positions of the head have 
 been ascertained to occur in actual practice. It is an important 
 topic, and one to which we may recall the notice of our readers at 
 an early period. In the meantime we shall content ourselves with 
 presenting the few following calculations of the percentages of 
 frequency of the four oblique positions of the head. 
 
 The _^?-s* position of Naegele, with the child's face to the right 
 
324 NATURAL LABOR. 
 
 sacro-iliac synchondrosis, has occurred to that author in his own 
 practice in 69 per cent, of all his head presentations, to Halmagrand 
 in 74 per cent., to Madame Lachapelle in 77 per cent, and to Madame 
 Boivin in the ratio of 80 per cent. 
 
 T!h.Q fourth position of JSTaegele, with the child's face directed to 
 the right foramen ovale, has occuiTcd in his own practice in the very 
 small proportion of -03 per cent. It has been met with equally 
 rarely by others. Lachapelle and Halmagrand have found it in -04 
 per cent, and Boivin in -05 per cent. 
 
 So far we find a striking correspondence in the diiferent ob- 
 servations of these authors, in a series of cases amounting in all 
 to nearly 60,000. Their results, however, are much more discrepant 
 as regards the relative frequency of the second and third positions 
 of ISTaegele. They all nearly agree, be it remarked, in regard to 
 the absolute proportion of cases in which the face is directed to the 
 left side of the pelvis, in the same way as they all nearly agree as 
 to the absolute proportion of cases in which the face is directed to 
 the right side. They differ, however, much as to the proportionate 
 number of instances in which the face, being directed to the left 
 side, is pointed originally towards the left sacro-iliac synchondrosis 
 (constituting the second position of Ifaegele), or towards the left 
 foramen ovale (constituting the same author's third position of the 
 head). Thus while Ifaegele states that in above 1290 cases he only 
 met with the second position in one instance, or in the proportion of 
 about "07 per cent, Halmagrand describes it as occurring in 5 per 
 cent, of his cases, Boivin in 19 per cent., and Lachapelle in as great 
 a ratio as 21 per cent. On the other hand, while Naegele found 
 not less than 359 cases of the third position in 1210 cases of cranial 
 presentations, or as many as 29 per cent, of instances in which the 
 face looked, at the commencement of labor, to the left groin, Lacha^ 
 pelle reports only -07, and Boivin, -05 per cent, as presenting in the 
 same situation. 
 
 Various explanations have been attempted of these and other 
 reported differences of results in the comparative frequency of the 
 second and third positions. The obsei-vations of Naegele were, we 
 believe, made by himself in most if not in all the cases to which he 
 refers, most of those of Lachapelle and Boivin by females attached to 
 the Maternity Hospital of Paris. The obsei-vations at the hospital 
 were collected, without there having been previously strongly pointed 
 out a great source of fallacy in confounding the second and third 
 positions, and those of ISTaegele were conducted with a perfect 
 knowledge of and a view to this fallacy. We are inclined, therefore,_ 
 both from what we have ascertained by our own experience, and 
 from what we know of the high character and candor of Naegele, 
 
ITS MECHANISM. 
 
 325 
 
 to attacli more credit to the results of his observations than to those 
 who have been opposed to him on this point. And we further 
 believe that the great source of fallacy to which we have alluded 
 and which is so apt to deceive is this, that if the face present to the 
 left, and the position of the head be not examined till it is emerging 
 through the outlet, it will in a very great proportion of cases be 
 found by that time turned round into the second position, though 
 it originally presented in the third. "We shall afterwards see that 
 this rotation of the face backwards is the general and normal course 
 followed by cases of the third position. 
 
 We haVe not space to pause and point out the anatomical reasons 
 which, on physical principles, prevent the occurrence of the direct 
 positions, and lead, on the other hand, to such an overwhelming 
 proportion of cases in the right oblique diameter. The subject, 
 however, is one of great interest. 
 
 The part of the child's head that lies lowest in the pelvis, or in 
 other words, the exact nature of the presenting part in cranial pre- 
 sentations, has given rise to almost as great difference of opinion as 
 the direction of the head itself. Daventer long ago pointed out the 
 oblique position of the foetus and the uterus itself in relation to the 
 vaginal and pelvic cavity ; but, notwithstanding his observations, 
 we find misstatements in works up even to the present time in re- 
 spect to this point, and more especially in respect to its influence 
 upon the regulation of the presenting part. The anterior fontanelle, 
 sagittal suture, and still more commonly the vertex, have each been 
 alleged to be the parts that the finger of the accoucheur first touches 
 upon. The acknowledged obliquity of the child's body and head 
 in relation to the vaginal canal might have been sufficient alone to 
 have taught the fact, that it could not be a mesial part of the child's 
 head that presented in natural labor, and we believe that eveiy 
 one now, who has actually studied the matter in nature, agrees with 
 what Naegele first distinctly pointed out, that the posterior and 
 superior portion of one or other of the parietal bones is first felt on 
 examination by the accoucheur. When the head presents with the 
 face looking towards the right side of the pelvis, it is the right 
 parietal bone that first descends ; when the face looks towards the 
 left, it is the left parietal bone. On the above points Dr. Rigby 
 oflTers the following sound generalizations, in his consideration of 
 the mechanism of head-cases of the first position, or with the face 
 looking to the right sacro-iliac synchondrosis : 
 
 " The head enters, passes through, and emerges from, the pelvis 
 obliquely; and this is the case not only as to its transverse diameter, 
 but also as to the axis of its brim ; the side of ihe head being always 
 lowest or deepest in the pelvis. This shows the beautiful mechan- 
 
326 NATURAL LABOR. 
 
 ism of the process, for on account of its oblique position, there is 
 no moment during the whole labor at which the greatest breadth 
 (still less length) of the head is occupying any of the pelvic diame- 
 ters ; even at the last, when the head is passing under the pubic 
 arch, the complete obliquity of its position, in order that it should 
 take up the least possible room, is very remarkable, for the ring of 
 soft parts, by which the head is now encircled, passes obliquely 
 across it, running close behind the left and before the right parietal 
 protuberance. The head never advances with the occiput forwards 
 under the pubic arch, as is stated in works on midwifery ; still less 
 vsdth the sagittal suture parallel to the antero-posterior diameter of 
 the pelvis ; for the direction of the right lambdoidal suture, as also 
 of the posterior fontanelle, and the position of the cranial swelling, 
 or caput succedaneum, as it has been called, completely prove the 
 inaccuracy of such a theory. The sagittal suture crosses the left 
 labium at an acute angle, the right lambdoidal suture being parallel 
 with the left descending ramus of the ischium."' 
 
 He adds another important remark : 
 
 " Not less incorrect is the theory, for we can call it nothing else, 
 of the head presenting with the vertex, and turning with its long 
 diameter from the oblique into the antero-posterior or conjugate 
 diameter, and the face into the hollow of the sacrum, for it is dis- 
 proved by all the above-mentioned facts, which careful examination 
 during labor puts us in possession of. When the head is born, 
 the face looks backwards and to the right, viz., to the back part of 
 the mother's right thigh, for the shoulders are by this time passing 
 through the pelvis in its left oblique diameter, the right shoulder 
 being forwards and to the right, and lowest in the pelvis ; it is also 
 that which is first expelled."" 
 
 Dr. Eamsbotham, in the beautiful plates which accompany his 
 work, has given us eight figures illustrative of the modes in which 
 the head of the child may be supposed to enter the brim of the 
 pelvis in each of his eight positions. In these his artist has un- 
 fortunately represented throughout, the fcetal cranium as entering 
 the pelvis directly, and not in the oblique mode in which it does in 
 nature. In plate 35, indeed, the foetal heads are seen, by looking 
 at the basis of the cranium, to be somewhat oblique, but the artist 
 has shaded them so that they look obliquely backwards instead of 
 forwards. In plate 39, as representing the second stage of labor, 
 the face is turned far too directly into the hollow of the pelvis. 
 "We much admire, however, plate 41, representing the position of 
 the child immediately after the head is expelled. Dr. Hamsbo- 
 tham's own description of the usual course of natural labor is in 
 
 ' Rigby's System of Midwifery, p. 126. 2 Ibid. p. 127. 
 
ITS MECHANISM. 327 
 
 most respects excellent, as are his directions for its treatment. On 
 tlie management, indeed, both of natural and morbid labors, we 
 have a precision and minuteness that must render his work a valu- 
 able practical compendium for the student and practitioner. Dr. 
 Eamsbotham recommends the first two fingers of the left hand to 
 be used in vaginal examinations in the first stage, in those cases in 
 which the os uteri is situated so high that it cannot be perfectly in- 
 vestigated by the fore-finger of the right hand. We believe this to 
 be a very useful direction. The artist in representing this mode of 
 examination, plate 42, has incorrectly represented the whole hand, 
 with the exception of the thumb, as introduced into the orifice of 
 the vaginal cavity. 
 
 In supporting the perineum. Dr. Eamsbotham justly states that 
 it is not necessary that we should make powerful pressure, nor resist 
 the child's exit by the employment of any exertion. Continuing, 
 as it were, the resistance and curvature of the sacrum by our hand, 
 we are only to afford passive support ; to allow the head, covered 
 by the perineum to be protruded against our hand, rather than 
 forcibly press our hand up against the head. We must recollect 
 further, that, as Dr. E,igby particularly mentions, " the passage of 
 the head is not the only moment of danger to the perineum, for 
 laceration is even still more liable to be produced during the expul- 
 sion of the shoulders ; any slight rupture of the anterior edge is 
 now apt to be converted into a considerable laceration, unless the 
 support be continued until the thorax be expelled." As a specimen 
 of the excellence of Dr. Eamsbotham's practical directions, and the 
 vigorous style in which he lays down his rules and doctrines on this 
 and other subjects, we extract - the following short passage on an 
 important point of treatment first very prominently brought under 
 the attention of the profession by Mr. White of Manchester, viz., 
 the treatment of the delivery of the body after the head is born : 
 
 " It used to be the custom to surround the neck with the thumbs 
 and fingers of both hands, and forcibly extract the body the moment 
 the head was in the world, for the purpose of liberating the woman 
 from pain, and terminating the delivery as speedily as possible. 
 Such practice is attended with double danger ; great chance of in- 
 jury to the child, by the tension of the neck, and no small proba- 
 bility of hazard to the mother, by the uterus being prematurely 
 emptied. It is thus left in a flaccid state ; the stimulus which pre- 
 viously disposed it to contract is suddenly taken away ; that disposi- 
 tion ceases or is suspended ; hemorrhage is induced ; and necessity 
 probably arises for the artificial removal of the placenta, and incal- 
 culable mischief is the consequence. Those persons who commend 
 such meddling interference, and who estimate the skill of the obste- 
 
328 NATURAL LABOR. 
 
 trical attendant by the rapidity with which he can extract the body 
 after the head is born, found their eulogium on the most dangerous 
 premises."' 
 
 Dr. Rigby describes, with gr6at minuteness and clearness, the 
 treatment, &c., of natural labor, and of the puerperal state. He 
 directs the attention of his readers to auscultatory and other phe- 
 nomena of labor that have hitherto been little described in English 
 systematic treatises. "We extract from his work some remarks 
 relative to a source of prognosis of the duration of labor which we 
 believe will be new to most of our readers : 
 
 "The celebrated Wigand of Hamburg considered that the form 
 of the vagina would frequently furnish the means of a pretty certain 
 prognosis as to the duration of labor ; thus, if it were wide and 
 yielding throughout its whole length, the labor would be quick, 
 both at its beginning and termination ; if, on the other hand, it were 
 small, rigid, and contracted throughout, the labor might be expected 
 to be of a very opposite character. If, on examination, the vagina 
 is found roomy and well dilated at its upper part, but contracted 
 and rigid near the os externum, the labor will be probably quick 
 and easy during the first half, but slow and difficult afterwards ; on 
 the contrary, when the os externum is yielding and wide, but the 
 upper portion of the vagina narrow, the labor may be expected to 
 be slow at first, but to be brisk and active afterwards. We have 
 already stated that the course of labor varies in every possible way; 
 in sonle cases, the same peculiar character of labor shows itself 
 through two or three successive generations ; hence it has been ob- 
 served, that very tedious or very violent and rapid labors sometimes 
 seem to be hereditary ; the mother, the daughters, and grand- 
 daughters being all remarkable for their lingering or rapid labors."^ 
 
 "We extract from Dr. Kigby's chapter on natural labor one more 
 passage to show the difierent positions, &c., in which women are 
 placed in different countries during the process of parturition. After 
 speaking shortly of the history and form of the old labor-chairs of 
 the continent, he remarks : 
 
 " In some remote parts of Ireland and also of Germany, the 
 patient sits upon the knees of another person, and this office of sub- 
 stitute for a labor-chair is usually performed by her husband. Labor- 
 chairs, as far as we are acquainted with their history, were never 
 used in this country, nor have they been used for the last century 
 in France, where the patients are usually delivered in the supine 
 posture on a small bed upon the floor, which has not inaptly been 
 termed lit de misere. A modification of the labor-chair is the labor- 
 cushion first used by linger, and afterwards by the late Professor 
 
 ' Kamsbotham'B Principles and Practice, p. 137. ^ Rigby's System of Midwifery, p. 111. 
 
FREQUENCT OF LACERATION OF CERVIX UTERI IN LABOR. 
 
 329 
 
 Von Siebold of Berlin, and Professor Carus of Dresden ; it is a 
 species of mattress, with a hollow beneath the nates of the patient 
 for receiving the discharges which take place during the labor. The 
 patient is compelled to lie upon her back during the greater part of 
 the labor, and thus maintain the same posture for some time, which 
 must necessarily become irksome and even painful to her. In this 
 country and in Germany, the patient is delivered upon a common 
 bed, prepared for the purpose, as above mentioned ; in England she 
 is placed upon her left side, the nates projecting to the edge of the 
 bed, for the greater convenience of the accoucheur ; in Germany, 
 except in Vienna and Heidelberg, where the English midwifery has 
 in a great measure been introduced by Boer and ITaegele, the patient 
 is delivered upon her back. In former times the supine posture 
 was also used in this country, but for about a century the position 
 on the left side has been preferred."' 
 
 The position upon the left side is still, we have reason to know, 
 changed by some old practitioners at the present day into that upon 
 the back, whenever the labor becomes instrumental. This practice 
 is certainly open to many objections, and attended with no advan- 
 tages of which we are aware." "We have heard that in the Edin- 
 burgh Infirmaiy a regular perforated obstetric chair was employed 
 about half a century ago, and we recollect that some thirty years 
 since it was shown by the late Dr. Hamilton to his midwifery class. 
 In Mr. Michael's work on the Ergot of Eye, it is alleged that in 
 Cornwall even at the present day it is difficult to persuade the 
 female in labor to adopt any other than the standing posture, or a 
 position upon her knees. 
 
 ON THE FREQUENCY OF 
 
 nSSURING AND LACERATION OF THE STRUCTURES OF 
 THE PERINEUM AND CERVIX UTERI IN LABOR.' 
 
 (From Edinburgh Monthly Journal of Medical Science, May, 1851, p. 488.) 
 
 Dr. Simpson directed the attention of the Society to this impor- 
 tant subject; and, as the result of a long series of observations on 
 the matter, he drew the following conclusions : 
 
 First, Fissuring and laceration of the cervix uteri and perineum 
 are not, as is generally conceived, rare lesions during labor ; on the 
 
 ' Rigby's System of Midwifery, p. 109. 
 
 ' Latterly Dr. Simpson has found advantage from placing patients upon the back, particu- 
 larly in long-forceps cases ; and he is inclined to recommend this position as sometimes the 
 most favorable for operating. — (Ed.) 
 
 ' From Transactions of Edinburgh Obstetric Society, January 23, 1851. 
 
830 NATURAL LABOR. 
 
 contrary, they are very common occurrences, especially in primi- 
 parous labors. 
 
 Secondly, These lesions are not, as has been often alleged, neces- 
 sarily the result of mismanagement, but they occur constantly in 
 practice, despite every modification of management, and in cases 
 also in which no kind of management has been adopted. 
 
 Thirdly, Evidence of the great frequency of laceration of the an- 
 terior structures of the perineum is furnished by, — 1. Almost every 
 careful autopsy of women after delivery, whether assisted or not 
 assisted during their labor ; 2. By the contracted or shortened state 
 in which the perineum is almost always found, when vaginal exami- 
 nations are made for uterine disease in women who have borne a 
 family ; and 3. By the Assuring or laceration itself being usually 
 traceable, under careful tactile examination, particularly in first 
 labors, when that examination is instituted in the interval of pain, 
 immediately before the passage of the child's head, or after its birth. 
 
 Fourthly, Lacerations of the perineum may be often felt begin- 
 ning in the form of slight roughish rents or fissures upon the 
 mucous surface of the perineum, and these may extend either back- 
 wards or forwards ; and if they extend forwards, they at last run 
 over the edge of the perineum, and along its cutaneous surface ; the 
 mucous and cutaneous structures of the perineum being thus some- 
 times lacerated, while its middle, cellular, and fascial tissues are 
 comparatively entire, or at least not so deeply and extensively in 
 jured. 
 
 Fifthly, The proper management and support of the perineum 
 no doubt modifies and diminishes this form of perineal lesion, but 
 it fails far more frequently than is generally supposed, in entirely 
 preventing it. 
 
 Sixthly, The evidence of the frequency of Assuring of the os and 
 lower or vaginal portion of the cervix uteri is the same in character, 
 and consists principally — 1. In the frequency with which slight 
 laceration of the edges of the os, and of the mucous and middle 
 coat of the cervix, is detected in autopsies after natural labors, and 
 particularly with first children ; and 2. In the permanent marks of 
 its previous occurrence, as exhibited in those cicatrices and irregu- 
 larities of the cervix uteri, which anatomists have long empirically, 
 but correctly, laid down as proofs that they, in whose bodies they 
 are found, have been previously mothers. 
 
 Seventhly, Fissures and lacerations of the vaginal portion of the 
 cervix uteri not unfrequently occur to a very considerable extent in 
 cases in which the tissues of the cervix have been rendered rigid by 
 previous inflammation, by carcinoma, or by other morbid causes ; 
 and in such cases this Assuring or laceration, if limited to the lower 
 
UTBKINE INERTIA. 
 
 331 
 
 or vaginal portion of tlie cervix, seems to be accompanied with little 
 or no danger. 
 
 In a later part of the Transactions of the Society,' it is stated 
 that " Dr. Simpson communicated some observations on the pro- 
 priety of incising the cervix uteri, in certain cases of rigidity, and 
 referred to the lacerations which frequently take place in the os in 
 natural labor ; from the occurrence of such natural wounds, Dr. S. 
 deduced the propriety of having recourse to artificial wounds or 
 lacerations in some cases by incision." 
 
 INEFFICIENCY OF UTERINE ACTION AS A CAUSE OF 
 TEDIOUS LABOR.^ 
 
 (From British and Foreign Medical Review, October, l!i41, p. 477.) 
 
 Dks. Davis and Ramsbotham discuss in single pages the nature 
 and symptoms of inefficient uterine action as a cause of lingering 
 labor. The subject is one most highly interesting to the practitioner 
 from the frequency with which it occurs, and important as an object 
 of study from our defective knowledge of its pathology. The various 
 local morbid causes of delay and difficulty, both on the part of the 
 child or body to be expelled, and of the maternal passages through 
 which that body has to pass, have each and all been made objects 
 of successful investigation by various accoucheurs. "We do not 
 recollect one author who has endeavored, on the other hand, to 
 ascertain and fix the varieties of morbid action and states that, by 
 their presence, may interfere with the organ or organs which are 
 concerned in mechanically expelling the child. And yet we believe, 
 as we have already stated, that, practically speaking, the considera- 
 tion of this last subject is one of very great moment — perhaps of 
 greater moment than the former. 
 
 Dr. Eigby has devoted a very instructive chapter to this topic. It 
 is a chapter which is full of matter calculated to excite the reflection 
 and direct the observations of the obstetric pathologist. We are 
 certainly not prepared to adhere to all the opinions that Dr. Eigby 
 has broached in this part of his work, but we think it requires no 
 stretch of sagacity to predict that it will prove highly useful in 
 rousing the attention of British accoucheurs to the subject, and 
 
 ' Proceedings of Obstetric Society, Sess. xii. 1853. See Edinburgh Monthly Journal of 
 Medical Science, February, 1855, p. 178. 
 " From a review of the works of Kigby, Ramsbotham, and Davis. 
 
332 TEDIOUS LABOE. 
 
 probably it will be more frequently referred to by after writers, than 
 some of the more finished parts of Dr. Rigby's publication. 
 
 The mechanical powers by which the child is expelled from the 
 uterus are of two kinds, 1st, the involuntary action of the uterus, 
 assisted, 2dly, by the partly voluntary and partly involuntary action of 
 the abdominal muscles and diaphragm. Dr. Rigby, in reference to 
 the morbid conditions of the latter or accessory expulsive powers, 
 states briefly various pathological causes which may more or less im- 
 pede their action. It would have delighted us if he had entered into 
 this fertile field of inquiry more fully. We have a conviction that the 
 cultivation of it will ere long yield results which will explain the 
 difficulties of many dangerous obstetric cases, and determine more 
 precisely the practice to be pursued in them. The full investigation 
 of the effects of existing cardiac and pulmonary diseases alone upon 
 labor would, we believe, clear up the history and treatment of many 
 at present anomalous cases. Dr. Rigby discusses at considerable 
 length the causes which may retard labor, by inducing a faulty or 
 morbid condition in the involuntaiy action of the uterus. We wish 
 we had space to extract his views on this matter. For them we 
 earnestly refer our readers to the work itself. We shall give merely 
 some of his opening general observations, to show the spirit in 
 which he treats the subject. 
 
 " On the approach of labor, the uterus, which hitherto had been 
 merely performing the office of a receptacle and a means of con- 
 veying nourishment to the fcetus, now assumes a totally difierent 
 character ; from being in a nearly passive state, it assumes an en- 
 tirely opposite condition, namely, of high irritability and powerful 
 action. We might almost suppose, that its connection with the 
 nervous system was become more close and intimate ; for it is now 
 sensible to the influence of impressions which had before produced 
 no effect upon it. Thus, we see, that affections of the mind, even 
 but of moderate intensity, and to which it was before labor nearly 
 if not quite insensible, are now capable either of rousing its efforts 
 to the utmost violence, or of arresting them in the midst of full 
 activity ; and on the other hand, we see that where its action has 
 been deranged or interrupted, it gives rise to serious affections of 
 the nervous system, or even convulsions. With all this, it now dis- 
 plays peculiarities of function which strikingly distinguish it from 
 all other organs of the body ; in some cases it appears to annihilate 
 or to absorb, by its all-pervading influence, the functional energies 
 of other organs ; and in spite of its increased nervous power and 
 susceptibility to various impressions, it seems to possess the faculty of 
 continuing its efforts, uninfluenced by general disease, unimpaired 
 by exhaustion, and for a time almost independent of the life itself 
 
UTERINE INERTIA. 
 
 333 
 
 of the mother. In convulsions and paralysis, in general fever and 
 inflammation of vital organs, its powers appear to be undiminished; 
 on the contrary, where the patient, from whatever cause, is rendered 
 incapable of assisting its efforts by the abdominal muscles, the 
 uterus will take upon itself the whole task of expelling the child, 
 which will be born apparently without a single effort on the part of 
 the mother. We also observe that organs, the various conditions 
 and derangements of which have exerted little or no influence upon 
 the uterus in its state of quiescence during pregnancy, now affect 
 it powerfully, and are capable of modifying its action very con- 
 siderably. The stomach, the intestinal canal, and the skin, are 
 remarkable instances of this,, and seldom fail to disturb or prevent 
 the natural efforts of the uterus whenever these organs deviate from 
 a healthy condition. It will be, therefore, of the highest import- 
 ance to watch their functions narrowly, in order that we may form 
 a correct estimate of their effect upon the uterus."^ 
 
 Dr. Rigby goes on to show that derangements in the contractile 
 powers of the uterus itself may arise from various morbid states of 
 the organ, both functional and mechanical, as from relative inac- 
 tivity or debility, from derangement in the digestive organs, from 
 affections of the mind, from age and temperament, from general 
 plethora, or what is probably more frequent, from local uterine con- 
 gestion, from simple or specific inflammation of the uterine tissues, 
 from irregular or spasmodic contraction in its fibres, from organic 
 disease in its fundus, body or cervix, &c. Each of these divisions 
 receives a separate notice, and their nature, diagnosis, and treat- 
 ment, are excellently commented on, but for their full discussion 
 we must again refer the reader to the work itself. 
 
 In the general management of such cases Dr. Eigby makes one 
 remark which we beg to extract, namely, that " the more carefully 
 such cases are investigated, the less frequently will practitioners 
 require ergot and other oxytoxic medicines." We quote this ob- 
 servation because we believe it strictly true, and because we have 
 seen and heard enough to convince us, that from want of attention 
 to it, the ergot is too often given under circumstances for which it 
 is little or not at all adapted, and where its exhibition is attended 
 with deleterious results both to mother and child. We do not re- 
 pudiate the use of that drug ; we would wish merely, so far as such 
 an observation may serve, to guard against its abuse, and we fear that 
 few medicines are actually more abused in practice. When em- 
 ployed, Drs. Davis and Ramsbotham both recommend the ergot to 
 be given in the form of infusion, and in doses containing half a 
 drachm of the powder, every ten or fifteen minutes. Dr. Davis 
 
 ' Eigby's System of Midwifery, p. 205. 
 
334 TEDIOUS LABOR. 
 
 alleges, that the ordinary mode of exhibiting this drug in America 
 is in an infusion of seven or eight grains of the powder every ten 
 minutes. We have not Prescott's Dissertation at hand to refer to, 
 but assuredly eitfeer the dose is accidentally understated, or it is in 
 itself far too little to be of any certain avail.' Dr. Rigby employs 
 the powder of ergot in cinnamon water, a scruple or two of the 
 former to an ounce and a half of the latter, and adds a few grains 
 of borax. The cinnamon is an old oxytoxic, and long ago the 
 borax was held in high repute by some practitioners upon the con- 
 tinent, for its supposed efficacy in exciting or increasing uterine 
 contractions. Lamotte speaks of its employment, and in our own 
 day its use has been again revived by Hufeland, L'Offler, and the 
 late Professor Lobstein o£Strasburg. Its alleged efficacy is surely 
 a legitimate subject for direct experiments and observations. 
 
 NOTICE OF A "PULVIS AB PAETUM" 
 
 IN THE FIRST EDINBURGH PHARMACOPCEIA.^ 
 
 (From Edinburgh Monthly Journal of Medical Science, May, 1851, p. 493.) 
 
 By the older authors, many different medicines are described as 
 being supposed to have an oxytoxic effect upon the uterus ; or, in 
 other words, as capable of either originating or increasing the par- 
 turient contractions of that organ. From the time of Dioscorides 
 and Galen downwards, various and diversified plants, &c., have 
 been described in medical works, as possessing these alleged virtues. 
 The only two believed at the present day to have a decided oxytoxic 
 effect, are ergot of rye and Indian hemp ; and each of these plants, 
 when used medicinally, seems to possess also in common, a depress- 
 ing or sedative effect upon the spinal nervous system. Is their oxy- 
 toxic power dependent upon this action on the centre of the reflex 
 system ? Various mineral substances used to be reputed also oxytoxic 
 in their properties, as eagle-stone, &c. Borax has long enjoyed 
 such a reputation. Homberg^ and Lamotte" long ago spoke of its 
 oxytoxic properties. In the first edition of the Edinburgh Phar- 
 
 ' See Wood and Bache's United States Dispensatory, 1851, p. 323. 
 
 " The dose of the powder to a woman in labor is fifteen or twenty grains, to be repeated 
 every twenty minutes till its peculiar effects are experienced, or till the amount of a drachm 
 has been taken." — (Ed.) 
 
 ^ Extracted from Proceedings of Edinburgh Obstetric Society, March 26, 1851. 
 
 ' Histoire de TAcademie Royal^ des Sciences, 1702. 
 
 < Lamotte's Midwifery, translated by Tomltyns, 1746, p. 237. 
 
INDIAN HEMP AS AN OXYTOXIC. 335 
 
 macopceia, publislied in 1699, there is given a recipe for a " Pulvis 
 ad Partum," containing borax as its first ingredient. The powder 
 contains, besides, crocus and amber, substances to which oxytoxic 
 powers were ascribed in olden times ; and two animal ingredients 
 that were endowed with the same properties. Its exact composition 
 consists of Venetian borax, British crocus, the livers of eels dried 
 with their gall, white amber, of each two drachms, and of horses' 
 testicles dried in an oven, one ounce. 
 
 " R- Boracis VenetaB. 
 Croci Britannici. 
 
 Jecorum cum felle Anguillarum exsiccatorum. 
 Succini albissimi, ana drachmas duas. 
 
 Testiculorum Caballinorum in clibano siccatorum unciam unam. 
 M. F. Pulvis s. a." • 
 
 This last ingredient is almost a forestalling of the absurd modern 
 therapeutic doctrine of isopathy. And the whole is perhaps not 
 uninteresting as showing one of the resources officially recom- 
 mended in tedious labor, in Edinburgh practice, some hundred and 
 fifty years ago. 
 
 INDIAN HEMP AS AN OXYTOXIC 
 
 (From Edinburgh Monthly Journal of Medical Science, July, 1850, p. 91.) 
 
 De. Simpson stated, that, in the early part of the winter session, 
 he had given Indian hemp (Cannabis Indica) in several cases of 
 tedious labor, with the view of ascertaining if it possessed any 
 oxytoxic effect, like ergot of rye, in increasing and exciting the par- 
 turient action of the uterus. He had been induced to try the effects, 
 if any, of Indian hemp during labor, in consequence of Dr. 
 ChurchilP stating, that it possessed powers similar to those of ergot 
 of rye in arresting hemorrhage, when dependent upon congested 
 states of the unimpregnaUd uterus. In the few cases of labor in 
 which it was tried, parturient action seemed to be very markedly 
 and directly increased after the exhibition of the hemp ; but far 
 more extensive and careful experiments would be required, before a 
 definite opinion could be arrived at, relative to its possession of 
 oxytoxic powers, and the amount of those powers. 
 
 ' Extracted from Proceedings of Edinburgh Obstetric Society, March 13, 1850. 
 ' Diseases of Women, 3d edition, p. 113. 
 
336 TEDIOUS I/ABOB. 
 
 OBSERVATIONS REGAEDING THE INFLUENCE OF 
 GALVANISM 
 
 UPON THE ACTION OF THE UTERUS DURING LABOR. 
 (From Monthly Journal of Medical Science, July, 1846, p. 33.) 
 
 It lias been repeatedly proposed and attempted to induce and in- 
 crease the parturient contractions of the uterus, by the applicatioij 
 of galvanism to the organ. 
 
 In 1803, Herder appears to have first suggested the employment 
 of galvanism for this purpose, in cases of slow and tedious labor, in 
 which the contractile action of the uterus offered to become insuf- 
 ficient and defective.^ 
 
 Dr. F. Eamsbotham of London, when treating of " lingering 
 labor," in the excellent Lectures upon Midwifery, which he pub- 
 lished in the Medical Gazette in 1834, &c., obsei"ves — " I am in- 
 clined to think that electrical shocks — ^particularly derived from the 
 galvanic battery — would excite the flagging powers of the uterus 
 under labor, and perhaps even induce action ah initio. This is a 
 means, however, of which I would not, in the present state of our 
 knowledge, recommend a trial ; and I only judge by analogy, in con- 
 sideration of the influence the electrical fluid exerts over the ner- 
 vous system generally, and, through that system, over muscular 
 fibre."'" 
 
 Some obstetric authorities are inclined to attribute no small por- 
 tion of the good results derived from the use of the forceps in lin- 
 gering labors, to the irritating eflect of the instrument upon the 
 contractile power of the uterus. They believe, that in addition to 
 its action as a simple mechanical power or agent, the introduction 
 and irritation of the instrument exerts a dynamical effect upon the 
 uterus, by stimulating the organ to renewed and increased contrac- 
 tile efforts. Professors Stein and Kilian have in a particular man- 
 ner supported this view ; and, some years ago, Kilian constructed 
 forceps, with the blades made of different metals, in order that the 
 dynamical action of the instrument might be rendered greater and 
 more equable, by being of a galvanic nature. In 1839, he pub- 
 
 ' See his Diagnostische Praktische Beitrige ziir Erweiterung der Geburtshulfe, Leipsic, 
 1803; and Meissner, Art des Accoucheraens, au 19me Sifccle, p. 175; Velpeau, Trait^ de 
 I'Art des Accouchemens, torn. ii. p. 62. 
 
 ^ Medical Gazette for 19th April, 1834. See also the same opinion expressed by Dr. 
 Ramsbotham in the same words, in the two editions of his well-known work on " The Prin- 
 ciples and Practice of Obstetric Medicine and Surgery," p. 176 of second edit. 1814. 
 
ALLEGED VALUE OF GALVANISM. 337 
 
 lished' the first case in wMcli he employed this galvanic forceps. 
 The labor had been progressing slowly from insufficient uterine 
 action, and for two hours and a half the head of the child had 
 scarcely, if at all, moved. The forceps were introduced ; and, as 
 soon as the blades were joined, the uterus appeared to the operator 
 to contract with more power and energy, but still the contractions 
 themselves were quite inadequate, without extractive force, to pro- 
 mote the expulsion of the infant. In the last edition of his learned 
 work on Operative Midwifery, Kilian candidly states, in regard to 
 his galvanic forceps, " After having now (1845) repeatedly employed 
 them, the results have fallen short of my expectations, probably in 
 consequence of the insufficient power of the instrument. I will, 
 however," he adds, " at some subsequent time attempt to ascertain, 
 in a more complete manner, the influence of a strong galvanic 
 stream upon the uterine structure, and perhaps I shall then be en- 
 abled to offer something more precise regarding this subject.'"' 
 
 A case, in which galvanism was employed, in order to induce pre- 
 mature labor, was published in Germany^ in 1844, by Drs. Hoeninger 
 and Jacobi. The os uteti was opened up by a sponge-tent, and 
 ergot of rye exhibited, before the galvanism was applied. 
 
 In the Provincial Medical and Surgical Journal of the same year," 
 Dr. Eadford of Manchester, published a lecture " on galvanism ap- 
 plied to the treatment of uterine hemorrhage." He proposed, by 
 the aid of galvanism, to induce a state of tonic contraction of the 
 uterus, in " extreme cases of exhaustion from hemorrhage." He 
 farther ingeniously suggested the use of the same agent " in hour- 
 glass contraction, and other forms of irregular uterine action ;" "in 
 tedious labor, depending upoia want of power in the uterus ;" " in 
 cases where it may be considered necessary to induce premature 
 labor ;" and " in certain cases of menorrhagia in the ungravid state." 
 Dr. Radford, at the same time, stated that he had practically ascer- 
 tained its action. " Galvanism," he observes, " produces an effec- 
 tive and powerful contraction of the uterus ; and not only so as 
 regards its tonic contraction, but it has also the power of energeti- 
 cally exciting alternate contraction when applied at intervals. I can," 
 he adds, " tell you most seriously and most solemnly, that it pro- 
 duces these two important changes upon the uterus, in such a degree 
 as in my previous reflections on the subject I had no conception of. 
 The alternate contraction excited by this agent is analogous to, and 
 
 ' Medioinische Zeitung des Vereins fOr Heilkunde in Preussen, No. xii. 1839. Forbes, 
 British and Foreign Review, vol. viii. 1839, p. 566. 
 2 Operationslehre far Geburtshelfer, Hft. 4, 184!), p. 516. 
 " Neue Zeitschrift fflr Gebnrtsltunde. Bd. xvi. Hft. 3, p. 424. 
 * Provincial Medical and Surgical Journal for December 24, 1S44, p. 605. 
 VOL. I. 22 
 
338 TEDIOUS LABOK. 
 
 as powerful as, that wMcli is observed in normal labor, and the tonic 
 contraction is greater." 
 
 The publication of Dr. Radford's observations had the effect of 
 strongly calling the attention of the profession in this country to the 
 subject; and several cases, intended to show the probable influence 
 of galvanism upon the parturient action of the uterus, have latterly 
 been published in different Medical Journals. 
 
 In conducting physiological or therapeutical experiments upon the 
 living economy, where so many disturbing and deranging influences 
 are ever present to perplex and embarrass our results, all are ready 
 to acknowledge the extreme uncertainty which we generally encoun- 
 ter in attempting to trace a true chain of sequence and causation 
 between applied agencies and their apparent or expected results. 
 The difficulty of distinguishing between the post and the propter hoe 
 in such inquiries is assuredly as great in regard to experiments upon 
 the uterus, as in regard to similar observations upon any other 
 organ of the body. In some instances, and especially where the 
 process of parturition is lingering, the contractile efforts of the 
 uterus occasionally diminish in power, or even altogether cease, and 
 again more or less suddenly or gradually recommence, without our 
 being able to trace out any appi-eciable cause — mental, vital, or 
 physical — of a nature suflacient in any way to account for the varia- 
 tions which the labor-pains seem to undergo. Besides, the uterus, 
 particularly during labor, is well known to be very readily, and 
 sometimes very powerfully, influenced in its parturient action, by 
 mere states and emotions of the mind alone ; and through the me- 
 dium of the excito-motory system of nerves, the simple application 
 of cold, and other forms of chemical and physical irritation to the 
 surfaces of the abdomen, vagina, cervix uteri, &c., is frequently and 
 strongly capable of stimulating and increasing the contractile func- 
 tions of this organ. In attempting, therefore, to ascertain the exact 
 influence of galvanism itself upon the uterus during parturition, 
 these and other sources of fallacy in such an investigation must be 
 necessarily, as far as possible, guarded against. With this view, I 
 some time ago planned and instituted a series of experiments, the 
 results of which I now propose to state. 
 
 The experiments were begun for the purpose of ascertaining, as 
 far as possible, the exact degree of influence which galvanism pos- 
 sessed over the contractile action of the uterus during labor, and 
 consequently the amount of aid which we might expect to derive 
 from this power, in any case in which we had recourse to its assis- 
 tance. I did not in the first instance doubt, as I was afterwards led 
 to do by the results of the experiments, the actual oxytoxic influence 
 
EXPEEIMENTS WITH GALVANISM. 339 
 
 of galvanism. I believed in its actual existence, and was merely 
 anxious to ascertain and fix its actual amount. 
 
 A little consideration will readily show, that any agent capable 
 of increasing the parturient action of the uterus may produce that 
 result in one of three ways. First, It may increase the force or 
 intensity of the pains, without increasing their duration or frequency ; 
 Secondly, It may increase the duration of the pains, without increas- 
 ing their intensity or frequency ; and. Thirdly, It may increase the 
 number or frequency of the pains that occur within a given period, 
 without increasing either the intensity or the duration of the indi- 
 vidual pains themselves. 
 
 "We have evidently little or no power of measuring the existing 
 amount of uterine action by any observations upon the supposed 
 mere intensity of individual pains. The sufferings of the patient, 
 as marking this intensity, would, no one can doubt, prove a most 
 inadequate and fallacious guide in such an inquiry as the present. 
 But we have the power of measuring, with the stop-watch, the 
 number of pains that recur within a given time, and the actual dura- 
 tion of each pain as it occurs ; and these two criteria certainly afford 
 us ample and sufficient means for ascertaining and determining the 
 actual amount of parturient action that may exist within any pre- 
 scribed period. 
 
 In the experiments which I have to detail, we measured the 
 amount of parturient action that was present at different limited 
 periods,— first, by length or duration of the individual uterine con- 
 tractions or pains ; and, secondly, by the number or frequency with 
 which they recurred within these periods. 
 
 But an explanation of the different data contained within the 
 four different columns, into which the results of the experiments 
 are thrown in the subsequent tables of cases, will illustrate the mode 
 of procedure that was adopted, and its objects, much better than 
 any more lengthened comment. 
 
 The first column shows the duration of the pains, and the length of 
 the intervals between each, or, in other words, the frequency with 
 which they recurred, for some time before either the galvanism, or 
 the apparatus for it, was put in requisition. Hence this column 
 displays in each case the duration and frequency of the pains, whilst 
 they were still in no respect interfered with by the experimental 
 arrangements subsequently adopted. 
 
 The second column marks, in a similar way, the duration of the 
 pains, and of the intervals between them for some time after the 
 galvanic apparatus was arranged about the patient, but before any 
 galvanic current was passed through the wires. This method was 
 pursued in order to avoid any mental or physical influence which 
 
340 TEDIOUS LABOR. 
 
 the aiTangement of the apparatus might possibly have upon the 
 patient. Some minutes were generally required in thus adjusting 
 and applying the machine and wires. 
 
 The third column denotes the duration of the pains, and the length 
 of the intervals between (or their frequency), after the galvanic circle 
 was completed, and the galvanic current thus allowed to pass through 
 the patient. 
 
 The fourth column presents, on a similar plan, the length of the 
 pains and intervals, for a limited period after the vaginal circle was 
 entirely broken. 
 
 In applying the galvanism in the succeeding cases, the galvanic 
 current was generally used of as great a strength as the patient 
 could possibly be induced to bear. In some of the experiments an 
 electro-magnetic coil machine, made by Messrs. Abraham and 
 Dancer of Manchester, and recommended by Dr. Radford, was em- 
 ployed ; in others we used an apparatus of a similar construction, 
 and of equal if not greater power, that has long been manufactured 
 for physiological and medical purposes by the Messrs. Kemp of 
 Edinburgh.' With either instrument it was easy to excite a stronger 
 galvanic current than the arms of the most determined person could 
 bear for any length of time, when the extremities of the conducting 
 wires were taken hold of by the two hands. In all the experiments, 
 we employed the "vaginal conductor" devised by Dr. Eadford, 
 consisting of a strong brass stem, seven inches long, and covered 
 with a nonconducting material up to near its uterine extremity. 
 And the directions which, in the lecture previously cited, Dr. Eadford 
 has laid down for the employment of the galvanism, were strictly 
 adhered to.^ 
 
 The subjects of the first six succeeding cases were in-door patients 
 of the Edinburgh Eoyal Maternity Hospital. The observations 
 upon them, contained in the appended tables, were all noted and 
 collected by Dr. Martin Barry, who was at the time acting as House 
 Surgeon to the Hospital. And in thus mentioning Dr. Barry's 
 name, I am sure that I ofier a sufficient guarantee to my profes- 
 sional brethren as to the scrupulous accuracy and conscientious 
 fidelity with which the experiments were conducted, and every item 
 in the results of them carefully noted. They were witnessed by 
 various pupils and others. 
 
 ' See a description of this instrument given by Mr. Kemp, in the Monthly Journal of 
 Medical Science for November, 1 845. 
 
 2 " When the remedy is applied, the brass ball of the vaginal conductor is to be passed 
 up to the OS uteri, and moved about at intervals on to various parts of this organ. At the 
 same time, the other conductor must be applied to the abdominal parietes, over the fundus 
 uteri. Shocks may be also passed transversely through the uterus by simultaneously apply- 
 ing the conductor on each side of the belly." — Dr. Radford's Lecture, p. 608. 
 
EXPERIMENTS WITH GALVANISM. 
 
 341 
 
 Case L — Ann M'Pherson, set. 20 ; first pregnancy. Labor came 
 on about the seventb month, and the child was born in a putrid 
 state ; the head presented in the first position. The length of the 
 first stage was 9 hours ; the second stage only occupied 6 minutes. 
 The labor began on the 6th of April, 1845, at 8 o'clock a.m. ; she 
 was delivered at 5J p.m. The galvanism was used during the first 
 stage. The following observations were begun at 11-13' a.m., and 
 were finished at 1-47' p.m. : 
 
 Before 
 
 Application of 
 
 Wires. 
 
 Wires applied, but 
 
 Galvanic Circle left 
 
 Incomplete. 
 
 Wires applied, and 
 
 Galvanic Circle 
 
 Completed. 
 
 After 
 
 Removal of 
 
 Wires. 
 
 Duratioa 
 of PaiDS. 
 
 Duration 
 of Intervals. 
 
 Duration 
 of Pains. 
 
 Duration 
 of Intervals. 
 
 Duration 
 of Pains. 
 
 Duration 
 of Intervals. 
 
 Duration 
 of Pains. 
 
 Duration 
 of Intervals. 
 
 Seconds. 
 30 
 
 Seconds. 
 30 
 
 Seconds. 
 40 
 
 Seconds. 
 80 
 
 Seconds. 
 45 
 
 Seconds. 
 75 
 
 Seconds. 
 45 
 
 Seconds. 
 165 
 
 33 
 
 267 
 
 38 
 
 22 
 
 40 
 
 170 
 
 37 
 
 368 
 
 31 
 
 209 
 
 40 
 
 50 
 
 35 
 
 145 
 
 45 
 
 300 
 
 33 
 
 147 
 
 38 
 
 172 
 
 30 
 
 120 
 
 40 
 
 95 
 
 35 
 
 205 
 
 45 
 
 135 
 
 45 
 
 195 
 
 30 
 
 105 
 
 30 
 
 150 
 
 40 
 
 140 
 
 32 
 
 163 
 
 25 
 
 95 
 
 35 
 
 325 
 
 35 
 
 205 
 
 30 
 
 195 
 
 28 
 
 182 
 
 35 
 
 175 
 
 50 
 
 190 
 
 33 
 
 117 
 
 35 
 
 145 
 
 32 
 
 
 42 
 
 
 40 
 
 
 28 
 
 
 Avr. 33. 
 
 188 
 
 41 
 
 124 
 
 37 
 
 147 
 
 56 
 
 125 
 
 Case II. — Jane Young, set. 22 ; second pregnancy ; was delivered 
 of a living child on the 12th of May, 1845. The head presented. 
 The labor was very tedious ; the first stage lasting 53J hours, and 
 the second, 20 minutes. The observations contained in the table 
 below were made during the first stage, being commenced at 7*49' 
 of the 11th, and terminating at 41 minutes past 10 that morning. 
 The labor began about 11 p.m. of the 9th, and she was delivered on 
 the 12th at 4i a.m. 
 
 Before 
 
 Application Of 
 
 Wires. 
 
 Wires applied, but 
 
 Galvanic Circle left 
 
 Incomplete. 
 
 Wires applied, 
 
 and Galvanic Circle 
 
 Completed. 
 
 After 
 
 Removal of 
 
 Wires. 
 
 Duration 
 of Pains. 
 
 Duration 
 of Intervals. 
 
 Duration 
 of Pains. 
 
 Duration 
 of Intervals. 
 
 Duration 
 of Pains. 
 
 Duration 
 of Intervals. 
 
 Duration 
 of Pains. 
 
 Duration 
 of Intervals. 
 
 Seconds. 
 70 
 
 Seconds. 
 305 
 
 Seconds. 
 40 
 
 Seconds. 
 170 
 
 Seconds. 
 30 
 
 Seconds. 
 90 
 
 Seconds. 
 40 
 
 Seconds. 
 230 
 
 60 
 
 255 
 
 40 
 
 215 
 
 33 
 
 162 
 
 43 
 
 227 
 
 60 
 
 210 
 
 38 
 
 112 
 
 30 
 
 105 
 
 35 
 
 205 
 
 45 
 
 135 
 
 39 
 
 171 
 
 33 
 
 87 
 
 37 
 
 263 
 
 40 
 
 170 
 
 40 
 
 200 
 
 31 
 
 59 
 
 37 
 
 1S8 
 
 45 
 
 180 
 
 42 
 
 258 
 
 34 
 
 71 
 
 36 
 
 219 
 
 40 
 
 140 
 
 41 
 
 244 
 
 35 
 
 25 
 
 36 
 
 204 
 
 45 
 
 150 
 
 39 
 
 201 
 
 30. 
 
 150 
 
 37 
 
 263 
 
 50 
 
 
 37 
 
 
 34 
 
 
 38 
 
 
 Avr. 51 
 
 193 
 
 40 
 
 196 
 
 32 
 
 94 
 
 83 
 
 225 
 
342 
 
 TEDIOUS LABOR. 
 
 Case HI. — Isabella Bowman, set. 25 ; first pregnancy ; tempera- 
 ment excessively nervous ; was delivered of a living child on the 
 11th August, 1845. The head presented, but the labor was very 
 tedious. The first stage was protracted to 51 hours ; the second 
 stage was nearly 3 hours in length. The galvanic experiments 
 were made during the first stage. Labor began at 12 a.m. of the 
 9th ; she was delivered at 7 a.m. on the 11th. The succeeding 
 series of observations were commenced at 9'31' p.m. on the 10th, 
 and were terminated at 8 minutes past 11. 
 
 Before 
 
 Application of 
 
 Wires. 
 
 Wires applied, but 
 
 Galvanic Circle left 
 
 Incomplete. 
 
 Wires applied, and 
 
 Galvanic Circle 
 
 Completed. 
 
 After 
 
 Removal of 
 
 Wires. 
 
 Duration 
 of Pains. 
 
 Duration 
 of Intervals. 
 
 Duration 
 of Pains. 
 
 Duration 
 of Intervals. 
 
 Duration 
 of Pains. 
 
 Duration 
 of Intervals 
 
 Duration 
 of Pains. 
 
 Du^.^tion 
 of Intervals. 
 
 Seconds. 
 
 Seconds. 
 
 Seconds. 
 
 Seconds. 
 
 Seconds. 
 
 Seconds. 
 
 Seconds. 
 
 SKConds. 
 
 60 
 
 210 
 
 35 
 
 55 
 
 37 
 
 83 
 
 60 
 
 150 
 
 65 
 
 205 
 
 35 
 
 85 
 
 40 
 
 380 
 
 20 
 
 160 
 
 30 
 
 210 
 
 23 
 
 7 
 
 33 
 
 207 
 
 36 
 
 234 
 
 68 
 
 202 
 
 40 
 
 260 
 
 40 
 
 140 
 
 75 
 
 225 
 
 40 
 
 140 
 
 50 
 
 190 
 
 40 
 
 140 
 
 60 
 
 300 
 
 60 
 
 120 
 
 30 
 
 180 
 
 35 
 
 25 
 
 70 
 
 230 
 
 58 
 
 62 
 
 60 
 
 240 
 
 30 
 
 210 
 
 47 
 
 193 
 
 30 
 
 90 
 
 43 
 
 197 
 
 70 
 
 230 
 
 60 
 
 60 
 
 55 
 
 
 73 
 
 
 60 
 
 
 37 
 
 
 Avr. 51 
 
 155 
 
 43 
 
 152 
 
 43 
 
 177 
 
 52 194 
 
 Case IV. — Mary Maedonald, set. 18 ; first (?) pregnancy ; was 
 delivered on the 28th August, 1845, of a premature child, which 
 only gasped a few times after birth. The length of the first stage 
 was 8 J hours ; that of the second only three minutes. Labor began 
 about 4 o'clock, a.m., and was completed about half-past 12 p.m. 
 The galvanism was employed during the first stage. The observa- 
 tions were begun at 7*40' a.m., and completed at 9*54'. The patient 
 was not nervous in the slightest degree. The galvanism caused a 
 continuous tremor. Breaking the connection of the wires produced 
 starts, and nothing more ; re-forming the connection had the same 
 effect. It ought perhaps to be observed, that in this, as in the other 
 hospital cases, I have altered the tables in one point — and in one 
 point only — from the mode in which they stand in Dr. Barry's 
 manuscript copies of them. I have omitted, and that merely for 
 the sake of their abridgment and perspicuity, the exact date in 
 minutes and seconds, which Dr. Bariy carefully gives in all the 
 observations of the commencement of each individual pain. 
 
EXPERIMENTS WITH GALVANISM. 
 
 343 
 
 Before 
 
 Application of 
 
 Wires. 
 
 Wires applied, but 
 
 Galvanic Circle left 
 
 Incomplete. 
 
 Wires applied, and 
 
 Galvanic Circle 
 
 Completed. 
 
 After 
 
 Removal of 
 
 Wires. 
 
 Duration 
 of Pains. 
 
 Duration 
 of Intervals. 
 
 Duration 
 of Pains. 
 
 Duration 
 of Intervals 
 
 Duration 
 of Pains. 
 
 Duration 
 of Intervals. 
 
 Duration 
 of Pains. 
 
 Duration 
 of IntervalF. 
 
 Seconds. 
 50 
 
 Seconds. 
 115 
 
 Seconds. 
 25 
 
 Seconds. 
 175 
 
 Seconds. 
 45 
 
 Seconds. 
 90 
 
 Seconds. 
 45 
 
 Seconds. 
 45 
 
 40 
 
 145 
 
 58 
 
 42 
 
 50 
 
 85 
 
 40 
 
 65 
 
 65 
 
 65 
 
 45 
 
 90 
 
 52 
 
 98 
 
 55 
 
 50 
 
 45 
 
 75 
 
 44 
 
 81 
 
 59 
 
 31 
 
 62 
 
 98 
 
 63 
 
 42 
 
 59 
 
 71 
 
 35 
 
 70 
 
 61 
 
 79 
 
 ,64 
 •76 
 
 41 
 
 54 
 
 111 
 
 57 
 
 48 
 
 60 
 
 105 
 
 74 
 
 38 
 
 97 
 
 52 
 
 78 
 
 52 
 
 83 
 
 52 
 
 53 
 
 35 
 
 85 
 
 *118 
 
 83 
 
 62 
 
 18 
 
 52 
 
 
 53 
 
 
 80 
 62 
 47 
 
 62 
 90 
 38 
 
 50 
 
 
 Avr. 56 
 
 76 
 
 46 
 
 94 
 
 55 
 
 70 
 
 54 
 
 68 
 
 In this case the galvanic circle was immediately afterwards a 
 second time completed and broken with the following results : 
 
 Connected Wires re-applied. 
 
 Wires again removed. 
 
 Duration of Pains. 
 
 Duration of Intervals. 
 
 Duration of Pains. 
 
 Duration of Intervals. 
 
 Seconds. 
 55 
 57 
 62 
 45 
 55 
 58 
 
 Seconds. 
 70 
 138 
 18 
 53 
 35 
 
 Seconds. 
 62 
 56 
 60 
 49 
 65 
 62 
 
 Seconds. 
 
 63 
 109 
 
 30 
 101 
 
 55 
 
 Average 55 
 
 63 
 
 59 
 
 72 
 
 Case V. — Mrs. Ross, set 23 ; first pregnancy ; lymphatic tempera^ 
 ment ; was delivered of a living child, born at the full time, head 
 presenting, on the 20th November, 1845. The first stage was 23J 
 hours long ; the second stage was completed in 85 minutes. Labor 
 commenced at 11 a.m. of the 19th, and terminated at 11'35' a.m. 
 of the 20th. The galvanism was used in the first stage. The fol- 
 lowing observations were begun at 6-9' a.m. At that time the os 
 uteri was dilated to the size of a sixpence. It was about the size of 
 a shilling when the observations were completed, at 8*53' a.m. 
 
 ' Probably two pains, with incomplete cessation of the first." — M. Baeet. 
 
344 
 
 TEDIOUS LABOR. 
 
 Before 
 
 Wires applied, but 
 
 Wires applied, 
 
 After 
 
 Application of 
 
 Galvanic Circle left 
 
 and Galvanic Circle 
 
 Removal of 
 
 Wires. 
 
 Incomplete. 
 
 Completed. 
 
 Wires. 
 
 Duratiou 
 
 
 
 Duration 
 
 Duration 
 
 Duration 
 
 Duration 
 
 Duration 
 
 of Pains. 
 
 of Intervals. 
 
 of Pains. 
 
 of Intervals. 
 
 of Pains. 
 
 of Intervals. 
 
 of Pains. 
 
 of Intervals. 
 
 Seconds. 
 
 Seconds. 
 
 Seconds. 
 
 Seconds. 
 
 Seconds. 
 
 
 Seconds. 
 
 Seconds. 
 
 65 
 
 205 
 
 60 
 
 210 
 
 65 
 
 
 70 
 
 110 
 
 70 } 
 
 80 
 
 70 
 
 65 
 
 
 
 65 
 
 160 
 
 40' 
 
 80 
 
 50 
 
 205 
 
 After 23 minutes, 
 
 70 
 
 125 
 
 65 
 
 175 
 
 65 
 
 70 
 
 during which there 
 
 85 
 
 12 
 
 68 
 
 232 
 
 55 
 
 215 
 
 was no pain, the 
 
 70 
 
 200 
 
 70 
 
 llO 
 
 70 
 
 95 
 
 wires were re- 
 
 75 
 
 120 
 
 •105 
 
 135 
 
 70 
 
 155 
 
 moved, when, in 
 
 ?5 
 
 140 
 
 80 
 
 130 
 
 80 
 
 220 
 
 the course of a 
 
 80 
 
 230 
 
 65 
 
 
 80 
 55 
 75 
 70 
 55 
 75 
 80 
 65 
 40 
 65 
 
 100 
 
 185 
 
 105 
 
 65 
 
 80 
 
 255 
 
 70 
 
 70 
 
 20 
 
 minute and a quar- 
 ter, the contractions 
 returned according 
 to the rate noted in 
 the next column. 
 
 70 
 
 
 Avr. 63 
 
 143 
 
 66 
 
 129 
 
 
 71 
 
 152 
 
 Case VI. — Catherine Eiley, set. 24. Temperament sanguineous ; 
 was delivered on the 23d October of a living child, at the full time, 
 the head presenting. The labor began about 11 o'clock p.m. of the 
 21st, and terminated at 2 a.m. on the 28d. The following obser- 
 vations were commenced at 47 minutes past 8 o'clock p.m. on the 
 22d, and terminated that evening at 10-23'. 
 
 Before 
 
 Application of 
 
 Wires. 
 
 Wires applied, but 
 
 Galvanic Circle left 
 
 Incomplete. 
 
 Wires applied 
 
 and Galvanic Circle 
 
 Completed. 
 
 After 
 
 Eemoval of 
 
 Wires. 
 
 Duration 
 of Pains. 
 
 Duration 
 of Intervals. 
 
 Duration 
 of Pains. 
 
 Duration 
 of Intervals. 
 
 Duration 
 of Pains. 
 
 Duration 
 of Intervals. 
 
 Duration | Duration 
 of Pains, of Intervals. 
 
 Seconds. 
 75 
 
 Seconds. 
 15 
 
 Seconds. 
 80 
 
 Seconds. 
 10 
 
 Seconds. 
 60 
 
 Seconds. 
 45 
 
 Seconds. 
 66 
 
 Seconds. 
 69 
 
 35 
 
 55 
 
 45 
 
 90 
 
 95 
 
 100 
 
 •185 
 
 85 
 
 45 
 
 60 
 
 75 
 
 105 
 
 90 
 
 15 
 
 78 
 
 57 
 
 95 
 
 85 
 
 95 
 
 10 
 
 *225 
 
 45 
 
 90 
 
 90 
 
 85 
 
 20 
 
 60 
 
 90 
 
 80 
 
 25 
 
 105 
 
 15 
 
 90 
 
 30 
 
 85 
 
 170 
 
 55 
 
 80 
 
 85 
 
 50 
 
 95 
 
 55 
 
 75 
 
 15 
 
 80 
 
 85 
 
 70 
 
 50 
 
 85 
 
 65 
 
 65 
 
 130 
 
 74 
 
 106 
 
 80 
 
 55 
 
 *160 
 
 
 170 
 
 
 63 
 
 
 75 
 
 
 Avr, 77 
 
 48 
 
 75 
 
 77 
 
 82 
 
 63 
 
 83 
 
 59 
 
 At the commencement of the preceding observations in this 
 case, the os uteri was about the size of a crown piece ; it became 
 
 * " Probably two pains, with incomplete cessation between them." — M. Bahby. 
 
INEFFICACY OF GALVANISM. 345 
 
 fully dilated, and, consequently, the first stage was terminated by 10 
 o'clock, before the observations were completed. 
 
 In all the six preceding cases the labor was more or less lingering 
 and protracted. Such cases were selected because it was only in 
 them that adequate time could be obtained for making the required 
 series of careful and uninterrupted observations. For the same 
 reasons, the continuance of the first stage was chosen as the proper 
 time for conducting the investigation, the changes in the second 
 stage, or at least in the latter part of it, being generally too rapid 
 and great to allow of accuracy in such an inquiry. The results 
 would doubtless have been more satisfactory if the trials and obser- 
 vations had been more extensive. But we met with no small diffi- 
 culty in extending the inquiry among the hospital patients, even to 
 the length that we have done. In a number of other instances a 
 similar series of observations was begun, but sooner or later inter- 
 rupted by various circumstances — more particularly by objections on 
 the part of the patient, in consequence of the disagreeable pain and 
 suffering which they underwent fi-om the passage of the galvanic 
 current through their bodies, without that current directly exciting 
 increased uterine contractions.' 
 
 The data contained in the preceding tables prove, that in the 
 circumstances under which the observations were made, neither 
 does the duration of the pain always go on progressively increasing, 
 nor does the duration of the interval go on progressively decreasing 
 with the continuance of the labor, as some obstetric authorities have 
 alleged. 
 
 Further, neither the frequency of the pains, nor their duration, 
 appeared to be affected in any appreciable or direct manner by the 
 employment of the galvanism. An examination of the mean or 
 average results obtained in each case, during the four different 
 periods indicated by the four different columns, will afford us evi- 
 dence of the justice of this last remark. To accomplish more 
 readily this analysis, I shall collect into a tabular form the mean or 
 average results under each period in four of the cases (viz. the I., 
 in., rV., and VI. cases). I shall immediately allude to the excep- 
 tional data afforded by the other two cases, the 11. and V. 
 
 ' Indeed, if it were proved that the galvanism had a direct and useful oxytoxic effect, I 
 believe it vi'ould be found no easy task to get patients to submit to the action of so formidable 
 and painful a measure — not to speak of the niceties required in managing the machine, in 
 setting it, and keeping it in proper action — and the difficulty of being able at all times to 
 have such an apparatus speedily and at once within our reaoh when its services might be 
 necessary, as in sudden hemorrhages. 
 
346 
 
 TEDIOUS LABOK. 
 
 General Mean Results of Observations upon the Contractile Action, of the Uterus in four of tlte 
 preceding Cases during the four stated Periods. 
 
 
 Before 
 
 Wires 
 
 applied. 
 
 Wires applied, 
 
 After 
 
 
 Application of 
 
 but Galvanic Circle 
 
 and Galvanic Circle 
 
 Kfimoval of 
 
 Cases. 
 
 Wires. 
 
 not completed. 
 
 completed. 
 
 Wires. 
 
 Duration 
 
 Duration 
 
 Duration 
 
 Duration 
 
 Duration 
 
 Duration 
 
 OuratiOD 
 
 Duration 
 
 
 of 
 
 of 
 
 of 
 
 of 
 
 of 
 
 of 
 
 of 
 
 Of 
 
 
 Pains. 
 
 Intervals 
 
 Pains. 
 
 Intervals 
 
 Pains. 
 
 Intervals 
 
 Pains. 
 
 Intervals 
 
 
 
 
 Seconds. 
 
 Seconds. 
 
 Seconds. 
 
 Seconds. 
 
 Seconds. 
 
 Seconds 
 
 No. I. 
 
 33 
 
 188 
 
 41 
 
 124 
 
 37 
 
 147 
 
 35 
 
 182 
 
 No. III. 
 
 51 
 
 155 
 
 43 
 
 152 
 
 43 
 
 177 
 
 52 
 
 194 
 
 No. IV. 
 
 56 
 
 76 
 
 46 
 
 94 
 
 55 
 
 70 
 
 54 
 
 68 
 
 No. VI. 
 
 77 
 
 48 
 
 75 
 
 77 
 
 82 
 
 63 
 
 83 
 
 59 
 
 Average. 
 
 54 
 
 117 
 
 50 
 
 112 
 
 54 
 
 114 
 
 56 125 
 
 The analysis of the individual cases contained in the preceding 
 table affords the following results, in regard to the periods at which 
 in them, the pains were (1) most frequent in their recurrence, and 
 (2) longest in their duration. 
 
 1. Frequency of the Pains. — In two cases (I. and III.) the interval 
 between the pains was least, and the pains themselves were con- 
 sequently most frequent during the second period in the observa- 
 tions, namely, when the apparatus was simply applied, and before 
 the galvanism was used. In Case IV. they were most frequent 
 during the period following that in which the galvanic action was 
 put in force ; and in Case VI. they were most frequent during the 
 first period, or previously to either the apparatus being arranged or 
 the galvanism applied. 
 
 2. Duration of the Pains. — In one case (I.), the pains were longest 
 during the second period, when the apparatus was applied without 
 the galvanism ; in another (IV.), they were longest in the first 
 period, or before any experimental applications were tried ; and in 
 two others (III. and VI.), they were of the greatest length during 
 the period subsequent to the removal of the galvanism. 
 
 The last column in the above table shows that, on the whole, the 
 length of the pains and of the intervals was changed and modified 
 in only a slight degree, in these four cases, by the arrangements and 
 applications adopted during the four periods. But in not one of 
 these four cases were the pains either most frequent in their recurrence, 
 or longest in their duration, during the period of the employment of the 
 galvanism, and whilst the galvanic current was passing through the 
 uterus. 
 
 The two remaining cases (II. and V.), were, as I have already 
 stated, somewhat exceptional, and that in two opposite directions. 
 
 In Case II., during the period that the galvanism was applied, the 
 pains were less in their duration than at any other of the three 
 periods — ^but the intervals between them were also less ; or, though 
 
INEFFICACT OF GALVANISM. 347 
 
 shorter in lengtli under the galvanic action, they were more frequent 
 in their recurrence. 
 
 In Case V., the result was different from what it was in any of 
 the other five instances — for, as I have already stated, subsequently 
 to the completion of the galvanic circle, only one pain occurred, 
 and then uterine action entirely disappeared during. the twenty-three 
 minutes that the galvanic current continued to be passed through 
 the body of the patient. The result was rendered only the more 
 remarkable by the fact, that the uterine contractions and pains 
 were regular before the galvanism was applied, and again became 
 regular as soon as the galvanic influence was removed. 
 
 In some of the cases above detailed, the labor was of a very pro- 
 tracted nature, and consequently presented so far, exactly one of 
 those conditions in which, as suggested by Herder, and by Drs. 
 Eamsbotham and Radford, the galvanism would probably be useful 
 in strengthening and increasing the pains. We have seen this re- 
 sult unfulfilled. Last year, in two cases of very lingering and 
 difficult labor, occurring, the one in consultation, and the other in 
 my own private practice, I took a farther opportunity of attempting 
 to increase the defective action of the uterus by the influence of the 
 electro-magnetic apparatus,^ and in both instances as signally failed 
 in producing any beneficial effect. I shall state one or two particu- 
 lars regarding them. 
 
 Case VII. — This case proved so protracted, after the os uteri was 
 fully opened, and at last such local and general symptoms super- 
 vened, as to force me to use instruments for the delivery of the 
 patient. Some time previously, I carefully applied, for upwards of 
 an hour, the action of galvanism in the mode already described, but 
 without making the infant's head descend, or increasing either the 
 length or the frequency of the pains. I watched the result with a 
 stop-watch in my hand — contrasting, as in the above tables, the 
 duration of the pains and intervals before, during, and after, the 
 application of the galvanism. And I employed the galvanic cur- 
 rent as strong as the patient could be made to endure it. In fact, 
 the skin of the abdomen became at last quite red and erythematie 
 under the irritation of the external conductor. 
 
 Case VIII. — The subject of this second case of protracted labor 
 was deformed, and came from a distance to Edinburgh, in order to 
 be confined under my care. The pelvis was very narrow at the 
 brim, and when the child's head was at last expelled, it was found 
 
 ' Throughout these remarks, I have spoken of the power employed, as Galvanism, and in 
 doing so, have conformed to general and conventional usage. Speaking in strictly technical 
 language, it ought to be more properly, I believe, designated Electro-magnetism. 
 
348 
 
 TEDIOUS LABOR. 
 
 mucli compressed and flattened. The labor was extremely tedious, 
 the intervals between the pains being long. The membranes had 
 been ruptured for some hours, and the os uteri was well dilated 
 when the galvanism was applied at 2 p.m. on the 10th August. At 
 this time the paius were steady, and made the patient complain 
 considerably, but they appeared to have no effect in forcing down 
 the child's head. She had not slept during the previous night, but 
 she was by no means weak or exhausted, and she had taken some 
 nourishment. Her pulse was quiet, and the parts were soft and 
 cool. My assistant. Dr. Keith, carefully noted the duration of the 
 pains and intervals for a period before the apparatus was employed 
 — their length and frequency after the apparatus was arranged, but 
 the galvanic circle not completed — and the effects after the galvanic 
 current began to pass through the patient. The results are stated 
 in the following table : 
 
 Before Application | 
 
 Wires applied 
 
 but Galvanic 
 
 Wires applied 
 
 and Galvanic 
 
 of TV 
 
 ires. 
 
 Circle not completed. 
 
 Circle completed. 1 
 
 Duration of 
 
 Duration of 
 
 Duration of 
 
 Duration of 
 
 Duration of 
 
 Duration of 
 
 Pains. 
 
 Intervals. 
 
 Pains. 
 
 iQtervals. 
 
 Pains. 
 
 Intervals. 
 
 Seconds. 
 
 Seconds. 
 
 Seconds. 
 
 Seconds. 
 
 Seconds. 
 
 Seconds. 
 
 90 
 
 390 
 
 75 
 
 390 
 
 90 
 
 390 
 
 60 
 
 330 
 
 90 
 
 420 
 
 75 
 
 360 
 
 90 
 
 360 
 
 * 
 
 300 
 
 100 
 
 420 
 
 150 
 
 300 
 
 120 
 
 300 
 
 80 
 
 
 60 
 
 420 
 
 60 
 
 420 
 
 Pains subse- 
 
 
 75 
 
 
 
 
 quently ceased. 
 
 
 Average 87 
 
 340 
 
 86 
 
 366 
 
 86 
 
 390 
 
 The patient was not at all alarmed, but seemed rather to be 
 amused with the operation of the galvanism. After the last pain 
 of 80 seconds, noted in the table, there was no appearance of uterine 
 contraction for 13 minutes, when one almost imperceptible pain 
 occurred. The galvanism was continued for some minutes, longer, 
 but no uterine action reappeared ; and from this time till the evening 
 only three slight sensations of pains were felt. As the patient had 
 long wanted sleep, and the passages were perfectly free fi-om irrita- 
 tion, an opiate was then given. She slept well during the night. 
 Uterine contractions, however, did not again occur till the afternoon, 
 or till 24 hours after the use of the galvanism, when they again 
 came on gradually, and increased in severity till the child was born. 
 "When born, the heart of the child was pulsating, but all efforts 
 were ineffectual in establishing respiration. Its head, as I have 
 already stated, was much compressed ; and on opening it we found 
 clots of blood effused both at the base and into the ventricles of the 
 brain. The mother made a speedy recovery. 
 
 * This pain was slight, and short. 
 
INEFFICACY OF GALVANISM. 349 
 
 The general results obtained from the employment of galvanism, 
 in the eight cases which I have detailed, may be summarily stated 
 as follows : — 
 
 In one instance (Case 11.), the pains were more frequent in their 
 recurrence, but shorter in their duration, during the application of 
 the galvanism. In five other cases (Cases I., III., IV., VI., and 
 VH.), the employment of the galvanism neither increased the 
 average frequency of the pains, nor their average duration. In one 
 (Case v.), the pains ceased whilst the galvanism was applied, and 
 returned upon its removal. In the instance which I have last 
 detailed (Case Viii.), the uterine action ceased while the galvanism 
 was applied, and did not return upon the withdrawal of the galvanic 
 action, nor for 24 hours subsequently. There was no reason what- 
 ever at the time to expect this as a probable occurrence, indepen- 
 dently of the galvanism. But even admitting, for the sake of argu- 
 ment, that the cessation of the uterine action was not the result of 
 the galvanic influence used, still the fact is amply sufficient to show 
 that the galvanic current had not, at least, the power either of in- 
 creasing the pains, or even of continuing and maintaining them 
 when they offered to fail. It may be proper to add, that during 
 the galvanic action, in none of the experiments did Dr. Barry or I 
 find, in the intervals between the clonic uterine contractions or 
 pains, any evidence whatever of unusual tonic contraction of the 
 uterus, as shown either by any degree of hardness in the general 
 uterine tumor, or by any degree of tension in the pressui'e of the 
 bag of membranes or the child's head against the cervix uteri. 
 
 It would be hasty and logically incorrect to deduce from the pre- 
 ceding observations, that under no modification, and under no 
 manner of application, does galvanism possess the power of directly 
 exciting or increasing the contractile action of the uterus. Forms 
 or methods of employing it may yet possibly be detected or devised, 
 aflfording a different result. But I beheve I am justified in inferring 
 from the preceding inquiry, that as employed at the present time, 
 and in its present mode, it is not a means which can be in any 
 degree relied upon for the purpose in question ; and is so far prac- 
 tically and entirely useless as a stimulant to the parturient action of 
 the uterus. 
 
 In stating the above conclusions as the result of my own experi- 
 ence, I, of course, by no means wish to impugn, in any way, the 
 validity of the observations made in one or two isolated cases by 
 others, and in which an opposite effect was supposed to be obtained 
 under the employment of galvanism during labor. Uterine con- 
 traction may certainly have become occasionally increased while the 
 galvanism was being used, but I strongly question if that increase 
 
350 TEDIOUS LABOR. 
 
 was the result of the galvanic agency. I have already hinted, 
 towards the commencement of this communication, how much and 
 readily the existing degree of uterine action may be occasionally 
 modified by the state of the patient's mind, or by other still more un- 
 appreciable conditions, and how greatly it is in some cases influenced 
 and excited by the application of cold to the surface of the abdomen, 
 or, of mere mechanical irritants to the mucous surfaces of the vagina 
 and cervix uteri. The use of so portentous an apparatus as the 
 electro-galvanic machine, may certainly sometimes influence the 
 uterus through the mind of the patient, by raising feelings of hope 
 and confidence in the results; or the application, to the skin of the 
 abdomen, of the wet sponge attached to the external conducting wire, 
 may excite uterine contraction by reflex action, upon the same 
 principle as cold thus used very generally leads to this efieet, both 
 during labor and after delivery. The mere galvanic irritation of 
 the skin or muscles of the abdominal parietes may possibly produce 
 the same result, without the uterus being itself directly influenced 
 by this agency. Or, lastly, and principally, the mere introduction 
 and mechanical irritation of the "vaginal conductor" upon the 
 surface of the vagina and cervix uteri will, I doubt not, occasionally 
 excite more strong and powerful uterine pains, in the same way, 
 and upon the same principle, as the mechanical irritation of the 
 fingers or of the lever or forceps certainly sometimes produces the 
 same consequence. I have already alluded to Stein as attributing 
 much of the good which may be derived from the forceps to their 
 simple dynamical or irritating eft'ect upon the uterine contractions.' 
 He has thus shown, according to Kilian, that through the mere 
 dynamical influence of the instrument, altogether independently of 
 its mechanical action, " sometimes the irregular character of the 
 pains is reduced to regularity — sometimes when exhausted, the 
 activity of the uterus is reinforced — and sometimes when normal, its 
 power becomes greatly increased."^ Some years ago, the late Pro- 
 fessor Lobstein of Strasburg illustrated this dynamical effect of the 
 forceps by the following case: "Being one day," says he, "upon 
 the point of terminating a labor by the forceps, where its application 
 was indicated by a prolapsus of the cord, scarcely had I introduced 
 the two branches of the instrument, when the contractions, which 
 had already ceased, reappeared with a new force, and drove the 
 head through the cavity, and outlet of the pelvis, with such rapidity, 
 that I had not time to disengage the blades, &c. I attribute," he 
 adds, " to this irritation exercised by an instrument upon the uterus 
 
 ' " On the Action of the Forceps,'" in the Gemeins-Zeitsohrift fUr Geburtskunde, vol. iv. 
 p. 374. 
 
 2 Operationslehre filr Geburtshelfer, p. 514. 
 
INEFFICACT OF GALVANISM. 351 
 
 a great part of that astonishing success which the partisans of the 
 lever have obtained."' Long before this, Baudelocque expressed 
 the same opinion with regard to the success of Hiberniaux with the 
 lever. "lam fully persuaded," he observes, "that the lever has 
 very little share in it, and that in his hands it is nothing more than 
 a means of irritating the uterus and exciting it to contract with 
 more energy, as we sometimes irritate it with the end of the finger 
 conveyed under the edge of the orifice, and the hand placed on the 
 belly. "^ 
 
 It is almost unnecessary to point out how apposite these remarks 
 are to the introduction and employment of the long vaginal con- 
 ductor — as one possible and probable source of fallacy in any ob- 
 servations made, without due caution, respecting the supposed 
 influence of galvanism upon the parturient action of the uterus. 
 
 I have already stated that the results at which I have arrived in 
 the preceding inquiry are quite the reverse of those which I ex- 
 pected to obtain when I commenced the investigation. One reason 
 which specially and principally led me to believe that I would find 
 the uterus quite susceptible of galvanic influence, was the knowledge 
 of the long ascertained and acknowledged fact, that all voluntary, 
 and some involuntary, muscles are readily capable of being forced 
 into contraction through its agency. But this argument from analogy 
 did not, as we have seen, prove good in point of fact — and is proba- 
 bly not even correct in point of theory. Last autumn, when men- 
 tioning the results of some of the preceding experiments to Dr. 
 Sharpey of London, that gentleman directed my attention to a paper 
 published by Jordan,' upon the structure and action of the dartos 
 in the male. The dartos, like the uterus, presents under the micro- 
 scope a structure somewhat difierent from the ordinaiy tissue of 
 involuntary muscles, though not exactly similar to each other. 
 Like the uterus, the dartos contracts under the application of cold, 
 and of different mental states, and other stimuli,* and like the uterus 
 also, its contractions seem incapable of being excited by the agency 
 of galvanism. Jordan submitted it experimentally to the action of 
 a galvanic battery of sixty-five pairs of plates, without producing 
 any effect whatever upon its contractility. 
 
 As a concluding remark, I would beg to take the liberty of sug- 
 
 ' Compte de la Salle des Aooouehees, &o., 1804 to 1814, p. 17. 
 
 2 Heath's Translation of Baudelocque, vol. ii. p. 431. 
 
 ' Meckel's Archives filr Physiologie, bd. i. 1834, p. 410. 
 
 * "The dartos," remarks Cruveilhier, "possesses the property of active contractility, as is 
 seen in the contraction of the scrotum, and the vermicular motions observed in persons ex- 
 posed to cold, or under the influence of great dread, or of the venereal orgasm, and also in the 
 much more evident contraction of the scrotum after an irritating injection has been thrown 
 into the cavity of the tunica vaginalis." — Crnveilhier's Anatomy, by Madden, p. 596. 
 
352 TEDIOUS LABOR. 
 
 gesting, that perhaps the plan of investigation which I pursued in 
 the present inquiiy is one that might be usefully and successfully- 
 employed to test the validity, or fix the value, of other supposed 
 oxytoxic measures besides galvanism. 
 
 ON THE SEX OF THE CHILD' 
 
 AS A CAUSE OF DIFFICULTY AND DANGER IN HUMAN PARTURITION. 
 (From Edinburgh Medical and Surgical Journal, October, 1844, p. 387.) 
 
 My object in the following observations is to show, that the Sex 
 of the child has a very marked and demonstrable influence upon the 
 difficulties and dangers of human parturition, in relation to the fate 
 both of the mother and of the infant. 
 
 Two winters ago I had occasion to undertake some investigations 
 into the causes of the difficulties attendant upon parturition in the 
 white, as compared with the black tribes of mankind ; and in the 
 human female, as compared with the female of the lower animals. 
 In consequence of these investigations I was led to conclude that 
 the adaptation of the head of the foetus to the maternal canals is so 
 very close and accurate in the process of parturition, as it occurs in 
 the female of our own race, that deviations of a very slight degree 
 in the relative size of the cranium of the child, and of the pelvic 
 passages of the mother, should, when viewed on the large scale, 
 lead to differences of a very appreciable and notable extent in the 
 relative safety or danger of the whole process. 
 
 On further considering the subject it appeared to me, that in the 
 slight difference which is known to exist between the size of the 
 heads of the male and female child at birth, and in the effects which 
 this difference might or might not be traced to produce upon the 
 results of parturition — a criterion existed by which the truth of the 
 opinion in question might be fully tested. It was at the same time 
 manifest that the subject was one of such a nature that the only 
 evidence by which it could be settled obviously consisted of an 
 appeal to an extensive body of statistical facts. The first difficulty 
 was that of obtaining these required data. The numerous and ex- 
 cellent reports of instances of morbid and instrumental labor pub- 
 lished by various authors are, however valuable in other respects, 
 totally useless, in regard to the present subject — in consequence of 
 
 ' Read before Edinburgh Obstetric Society, January 10, 1843. 
 
SEX OF CHILD AS A CAUSE OF DIFFICULTY. 353 
 
 the sex of the child being rarely or never mentioned by them in the 
 details which they give of their individual cases. The only excep- 
 tion to this general remark that I am acquainted with is to be found 
 in the admirable Practical Treatise of Dr. Collins.^ In his invaluable 
 record of the morbid cases which occurred in the Dublin Lying-in 
 Hospital during his Mastership,^ Dr. Collins gives, at the end of the 
 different chapters that treat of the individual difficulties and com- 
 plications attendant upon labor, a table showing, amongst other 
 items, the sex of the infant in each case. Dr. Collins himself pro- 
 perly suggests, that "an extensive record" of the kind which he 
 has published might "materially assist the physician in obscure 
 investigations."^ For the data forming the grounds of the follow- 
 ing calculations I am, as will be seen in the sequel, principally 
 indebted to the facts recorded in Dr. Collins' work ; and while the 
 inferences I am about to draw form one instance of the fulfilment 
 of his own suggestion, regarding the utility of such data as he has 
 collected, my deductions will, I doubt not, be regarded as the more 
 valuable and trustworthy, seeing that the facts on which they are 
 chiefly founded, were originally collected and published by Dr. 
 Collins, without apparently any view whatever to the special inquiry 
 upon which we propose to enter. 
 
 Having made these preliminary remarks, I shall now proceed to 
 show that the sex of the child exerts a manifest influence upon the 
 general maternal mortality accompanying human parturition, upon 
 the frequency and fatality of its individual morbid complications, and 
 upon the safety and life of the infant itself, both during birth and for 
 some time subsequently to it. In all of these respects the birth of 
 male children is attended with much greater danger than the birth 
 of females. In proof of this, I have to adduce different series of 
 corroborative details. These details will probably be exhibited with 
 the greatest clearness, in the form of such a series of propositions 
 as the data which I have to bring forward may seem to warrant. 
 And I may further arrange these propositions into more general 
 heads or chapters, so as to show the effect, during parturition, of the 
 sex of the child as bearing — 1. Upon the safety and life of the 
 mother ; and — 2. Upon the life and safety of the infant itself; 3. I 
 shall enter into some investigations with the view of developing the 
 cause of the greater comparative dangers accompanying the birth of 
 
 ' "A Practical Treatise on Midwifery, containing the result of 16,654 births occurring in 
 the Dublin Hospital, during a period of seven years, commencing November, 1826. 
 London, 1836. 
 
 ' " Master is the title of the physician to whose care this hospital is intrusted for a period 
 not exceeding seven years." See Dr. Collins' preface. 
 
 ' Ibid. p. 1. 
 
 VOL. I. 23 
 
354 TEDIOUS LABOR. 
 
 male children ; and, lastly, I shall allude to Bome practical inferences, 
 and attempt to point out the extent to which the mortality in 
 childbirth and early infancy is influenced by the mere sex of the 
 offspring. 
 
 THE DANGERS AND DIFFICULTIES OF PARTURITION ARE GREATER TO 
 THE MOTHER IN MALE THAN IN FEMALE BIRTHS. 
 
 The greater danger and difficulties which the mother incurs in 
 connection with male births may be demonstrated both by an 
 appeal to the general mortality among parturient mothers, and by 
 a reference to the sex of the infant in a variety of the most formida- 
 ble complications that are found to accompany the process of labor. 
 
 One or two propositions, and the statistical proofs on which they 
 are founded, will illustrate this remark. 
 
 FIRST PROPOSITION. 
 
 Of the mothers that die tmder parturition and its immediate consequences, a much greater 
 proportion have given birth to male than female children. 
 
 During Dr. Collins' term of mastership 16,414 women were 
 delivered in the Dublin Lying-in Hospital. Of these, 164 died. Of 
 the 164 that died, 7 had been delivered of twins, and 157 of single 
 children. In searching for the effect of the sex of the infants in 
 relation to the maternal mortality, I shall on this, as on other occa- 
 sions in the following remarks, reject from the calculations the twin 
 cases, because the plurality of the offspring is an element that would 
 obviously disturb and pervert, in different ways, the accuracy of any 
 investigations like the present ; for the foetuses, in compound births, 
 are frequently of opposite sexes — they are in general considerably 
 below the average size and weight — and the expulsion of the second 
 of them, when once the maternal canals are dilated, is not attended 
 with such obstacles, nor hence with such danger, as the passage of 
 the first or the transit of a single child. If we confine, then, our 
 attention to the 157 cases in which the mothers died in connection 
 with the birth of a single child, we will find that in 3 the sex of the 
 infant was not noted ; in 105 it was male ; and in 49 female. The 
 number of maternal deaths was therefore much higher after male 
 than after female births. But, to show with more clearness and 
 precision the relative excess of mothers that died after giving birth 
 to male, as compared with those that died after giving birth to 
 female children, I shall, on this as on other occasions throughout 
 the present essay, compute the casualties connected with female 
 
SEX OP CHILD AS A CAUSE OF DIFFICULTY. 
 
 355 
 
 births as equal to 100, and calculate the proportion of those con- 
 nected with male births in reference to this fixed standard. In this 
 manner the absolute numbers and relative proportion of maternal 
 deaths, after male and female births, contained in Dr. Collins' 
 returns, would, according to the above data, stand as follows : 
 
 Total maternal 
 deaths. 
 
 154 
 
 In these the sex of child. 
 Male. Female. 
 
 105 
 
 49 
 
 Or in proportion of male 
 to female as 
 
 214 to 100 
 
 It is proper further to remark, that 38 out of 157 cases appear to 
 have died from "causes not the result of childbirth." I have not 
 been able, from the details given by Dr. Collins, to separate these 
 38 cases from the general number, but if they were so subtracted, 
 the remaining 119 cases would not improbably show a greater pro- 
 portion of male births in connection with those maternal deaths 
 that thus directly resulted from parturition or its immediate effects. 
 
 SECOND PEOPOSITION. 
 
 Among labors presenting morbid complications and difficulties, the, child is much oftener 
 
 ■male than female. 
 
 This proposition may be proved by a reference to many of the 
 more formidable accidents that are found to accompany labor, as 
 convulsions, laceration of the uterus, post-partum hemorrhage, in- 
 strumental cases, &c. 
 
 Convulsions. — Of 28^ cases of convulsions described by Dr. Collins, 
 in 17 the oftspring was male, and in 11 female ; of the male children, 
 8 were still-born ; of the female, 4. 
 
 Rupture of the Uterus. — This formidable accident occurred in 34 
 instances during Dr. Collins' mastership. In 23 cases the rupture 
 was in connection with the birth of male children, and in 11, Qr in 
 less than the third of the whole, it occurred in connection with the 
 birth of female children.^ 
 
 Puerperal Fever. — ^From l^ovember, 1826, to ITovember, 1833, 88 
 patients were attacked with puerperal fever in the Dublin Lying-in 
 Hospital. Among these 88 women, 54, or five-eighths, had given 
 birth to male, and 34, or three-eighths, to female children. 
 
 » Here, as in most other eases, our calculations include only, as already stated, the results 
 of uniparous births. 
 
 2 Dr. Collins adduces 20 cases of rupture of the uterus mentioned by Dr. M'Keever an{l 
 out of these, in 15 the child was male, and female in the remaining 5, or in about one-fourth 
 of the whole. 
 
356 TEDIOUS LABOR. 
 
 Post-Partum Hemorrhage. — This complication is known to occur 
 especially after those confinements in which the contractile powers 
 of the uterus have been unusually taxed and exhausted during the 
 previous stages of the labor. Dr. Collins reports 44 cases of hemor- 
 rhage after the expulsion of the placenta. In 31 of these the child 
 was of the male, and in 13, or less than one-third, it was of the 
 female sex. 
 
 Tedious and Difficult Labors. — The duration of the labor was noted 
 by Dr. Collins in 15,580 cases. In 264 of these cases the process 
 was prolonged beyond 24 hours. Dr. Collins has not, in his chapter 
 on tedious labors, published the particulars of all these 264 instances, 
 nor given such data as to enable us to ascertain the sex of the 
 children in them. These data would, in all probability, have shown 
 a great ovei-proportion of male infants — more especially in that 
 class of instances in which the delay was produced by protraction 
 of the second stage of labor, in consequence of want oi proper 
 relative size between the foetal head and the maternal passages. 
 
 In another part of his work. Dr. Collins details a set of facts that 
 may in a great measure fill up the deficiency to which we allude. 
 In his chapter on "Still-born Children" he notes a variety of im- 
 portant circumstances, relative to 1121 cases in which the child was 
 dead at birth. He further observes,^ " In 106 of the 1121, the labor 
 was extremely severe, and in nearly half of these the patients had 
 been one, two, three, days ill, or even more, before admission into the 
 hospital, and most of them grossly mismanaged." He gives a short 
 outline of 49 of the 106 cases of tedious labor in the General Table 
 on Still-born Children, and marks out by asterisks 60 additional 
 instances, which were, to use his own words, "similar in most 
 respects to those detailed."^ These two sets of cases of protracted 
 labor with death of the infant, amount in all to 109 instead of 106.' 
 Out of this number the sex of the child was male in 65, and female 
 in 44. 
 
 Forceps Cases. — The forceps were used in 24 cases during Dr. 
 Collins' mastership. Of the children thus delivered, 16 were males, 
 and 8 females." 
 
 Crotchet Cases. — " Of the 16,654 births which occurred in the hos- 
 pital, in 79," says Dr. Collins,' " delivery was efiected by lessening 
 the head, on account of extreme difliculty in the labor, or where 
 the child was dead and interference necessary for the patient's 
 
 ' Practical Treatise, p. 462. 2 Ibid. p. 485. 
 
 ' In 97 of these 109 instances of tedious labor, the number of hours during which the 
 patients were in labor is stated. Five were under 12 hours in labor; ]4 were from 12 to 
 24 hours ; 19 were from 24 to 36 hours j 27 from 36 to 48 hours ; 21 from 48 to 60 hours ; 
 10 from 60 to 72 hours ; and 1 was 90 hours ilL 
 
 * Ibid. pp. 11 and 15. * n,jj p 48g_ 
 
SEX OF CHIID AS A CAUSE OF DIFFICULTY. 
 
 357 
 
 safety." In the section on Still-born Children, 41 of the 79 are 
 recorded, and references given to other 33 of the cases.' Among 
 these 74 crotchet cases that are thus noted, the offspring was male 
 in 50, and female in the remaining 24 instances. 
 
 If we attempt to throw the proofs that we have collected of our 
 present proposition under the seven preceding heads into a tabular 
 form, and, taking again, for the facility of comparison, the female 
 births at the fixed standard of 100, calculate the proportion of 
 males to them, we shall find the result to be as follows : 
 
 Nature of Complication. 
 
 Total 
 Cases. 
 
 No. Male 
 Children. 
 
 No. Female 
 Children. 
 
 Proportion of Males to 
 Females as 
 
 Tedious Labors, 
 Convulsions, 
 Puerperal Fever, 
 Rupture of Uterus, 
 Post-Partnm Hem., 
 Forceps Cases, 
 Crotchet Cases, 
 
 109 
 28 
 88 
 34 
 44 
 24 
 74 
 
 65 
 17 
 54 
 23 
 31 
 16 
 50 
 
 44 
 11 
 34 
 11 
 13 
 8 
 24 
 
 148 to 100 
 153 to 100 
 161 to 100 
 
 207 to 100 
 240 to 100 
 200 to 100 
 
 208 to 100 
 
 Total, 
 
 401 256 
 
 145 
 
 165 to 100 
 
 It is unnecessary to qualify the proof which the above table 
 affords of the proposition that we have laid down, by venturing 
 to offer any comments. It is proper, however, to add that here, 
 as elsewhere throughout the calculations of the present «ssay, it 
 should be held in recollection that about 6 per cent, ought always 
 to be deducted from the column of the male children, in conse- 
 quence of there having occurred, in concurrence with an acknow- 
 ledged law in human statistics, that proportion of male over female 
 births during Dr. Collins' term of mastership in the Dubhn Hos- 
 pital. He noted 8548 male births, and 8068 female births, being in 
 the proportion of 106 males to 100 females. 
 
 Whilst it is requisite to correct our arithmetical results and tables 
 to this extent, it will, at the same time, at once be seen that the 
 required deduction is so slight as not in any material degree to 
 interfere with the essential evidence of our various propositions. 
 
 THE DANGERS AND ACCIDENTS FROM PARTURITION AND ITS RESULTS 
 ARE GREATER TO THE CHILD IN MALE THAN IN FEMALE BIRTHS. 
 
 The increased danger to infantile life dependent upon tTie sex at 
 birth, maybe demonstrated by a reference to the sex of the children 
 in those cases in which the mothers die from labor or its conse- 
 quences. It may be proved still more strongly and easily, by an 
 appeal simply to the sexes of those children that are dead at the 
 
 ' Practical Treatise, p. 487. 
 
358 
 
 TEDIOUS LABOR. 
 
 moment of birth, without any regard to the fate of the mother; and 
 by the consideration of the comparative number of accidents and 
 deaths among male and female infants consequent upon delivery. 
 
 "We proceed to illustrate each of these points in the form of two 
 or three propositions and their proofs. 
 
 THIRD PROPOSITION. 
 
 Amongst the children of the mothers that die from labor or its consequences, a larger proportion 
 of those that are still-horn are male than female ; and, on the contrary, of those that are born 
 alive, a larger proportion are female than male. 
 
 This proposition may evidently be considered under two heads. 
 In the first place, we shall show that a greater proportion of male 
 than female children are found among those infants that were 
 brought forth still-born, by mothers who themselves died from 
 labor or its consequences. 
 
 During Dr. Collins' mastership there occurred, as we have for- 
 merly seen, 154 cases in which the mother died after the birth of 
 single children. The 154 mothers produced 105 male and 49 female 
 children. 
 
 The result of the mortality of these infants at birth relatively to 
 their sex, may be reduced to the following short tabular form : 
 
 Total male births 105 ; of these, born dead 50, or 49 per cent. 
 Total female births 49; of these, born dead 16, or 34 per cent. 
 
 In the second place, we remark, that, of those children who were 
 born alive by mothers that died from labor or its consequences, a 
 greater proportion were females than males. 
 
 Here we must again take into our calculation the number of 
 mothers who died after uniparous births in connection with the ab- 
 solute number of male and female children which they produced, 
 when the result, as far as regards those children who were born 
 alive, may be stated in the following form : 
 
 Total male births 105 ; of these, born alive 55, or 52 per cent. 
 Total female births 49 ; of these, born alive 33, or 67 per cent. 
 
 The general proposition may be further proved and illustrated by 
 throwing the results we have just given into one such common 
 table as the following : 
 
 Sex. 
 
 Total 
 Number. 
 
 Of these, 
 dewi. 
 
 Of these, 
 living. 
 
 Proportion of dead 
 to living, as 
 
 Male, 
 Female, 
 
 105 
 49 
 
 50 
 16 
 
 55 
 33 
 
 95 to 100 
 
 48 to 100 
 
SEX OF CHILD AS A CAUSE OF DIFFICULTY. 
 
 359 
 
 Or to state it conversely : 
 
 Sex. 
 
 Total 
 Number. 
 
 Of these, 
 living. 
 
 Of these, 
 dead. 
 
 Proportion of living 
 to dead, as 
 
 Male, 
 Female, 
 
 105 
 49 
 
 55 
 33 
 
 50 
 16 
 
 110 to 100 
 206 to 100 
 
 We thus observe, that, amongst the children of mothers dying 
 after uniparous labors, males are born dead in the ratio of 95 to 100 
 living, while with females the ratio amounts only to 48 dead to 100 
 living. But we find, on the other hand, under the same circum- 
 stances, that males are born living in the ratio of 110 to 100 dead, 
 while among females the average amounts to the ratio of 206 living 
 to 100 dead.1 
 
 FOURTH PROPOSITION. 
 
 Of siill-born children a larger proportion are male than female. 
 
 It has already been stated, that, including the whole births in the 
 Dublin Hospital, the male children born were, to the female, in the 
 ratio of 106 to 100. By extended statistical returns, a similar ob- 
 servation has been proved to hold good as a general law in human 
 reproduction, at least among European females.^ M. Bickes, whose 
 results are founded on seventy millions of observations, has shown 
 the proportion of male births to female births to vary in European 
 nations from 104 to 108 boys for every 100 girls.' 
 
 All writers on human statistics seem further to acknowledge, 
 that among still-born children, males occur in a much greater ratio 
 than females. This ratio exceeds very considerably the normal dis- 
 
 ' It was not till after the preceding calculations and remarks had been written that I met 
 with the following confirmatory statement in Dr. Clarke's able letters to Dr. Price. — (Sea 
 Philosophical Transactions for 1786, p. 349.) Speaking of the maternal mortality in the 
 Dublin Lying-in Hospital from 1757 to 1784, Dr. Clarke observes — " I found that of 214 
 women dead of single children, 50 were delivered of still-born males, and 15 of still-born 
 females ; 76 of living males, and 73 of living females." Hence, calculating upon these 
 data of Dr. Clarke, it would appear that, during the above period, male children were born 
 dead in the Dublin Hospital in the ratio of 66 to 100 living, while with female children the 
 ratio amounted only to 20 dead to 100 living ; and, on the other hand, the males were bom 
 living in the ratio of 152 to 100 dead, whilst the females were born living in the much 
 higher ratio of 487 to 100 dead. 
 
 2 For an exception among the free population residing at the Cape of Good Hope see 
 Hawkins' Medical Statistics, p. 51. It is not unworthy of remark,that, among twin children, 
 there seems to be more females than males born. In the Edinburgh Medical and Surgical 
 Journal for January, 1844, p. 113, 1 have reported the sexes of the children in 788 twin 
 cases. Among these there were 756 males and 820 females, or the males were to the 
 females in the proportion of 92 boys to 100 girls. See page 291 of this volume. 
 
 ' Die Bewegung der BevOlkerung mehrerer Europ. Staaten. 
 
360 
 
 TEDIOUS LABOR. 
 
 proportion between the sexes at birth, and is therefore not explicable 
 by it. 
 
 The excess of male still-births and the different degrees of it in 
 different returns, may perhaps be exhibited most simply in the form 
 of a table, such as we have used in speaking on this subject in our 
 lectures, and which we here insert. 
 
 
 Proportion, among 
 
 
 Locality. 
 
 Still-iom Children, of 
 Males to Females- 
 
 Reporters. 
 
 In Amsterdam, 
 
 120 to 100 
 
 Lobatto. 
 
 Geneva, 
 
 125 " 100 
 
 Mallet. 
 
 Wurtemburg, 
 
 127" 100 
 
 Riecke. 
 
 Prussia, 
 
 135 " 100 
 
 Hoffmann. 
 
 Halle, 
 
 140 " 100 
 
 Guete. 
 
 London, 
 
 140 " 100 
 
 Bland. 
 
 Berlin, 
 
 143 " 100 
 
 Sflssmilch. 
 
 During Dr. Collins' superintendence of the Dublin Hospital, 1121 
 children were born dead. The number of males to females among 
 these 1121 children stood as follows : 
 
 still born 
 Males. 
 
 Still-bom 
 Females. 
 
 Or in proportion of Males 
 to females, as 
 
 614 
 
 507 
 
 122 to 100 
 
 In Dr. Collins' reports, the over-proportion of still-born males, 
 though strongly marked, is not so great as in some of the other re- 
 turns we have quoted. We believe that probably the variation in 
 this respect among the evidence adduced in the preceding table, 
 may be partially explained by the supposition, that in some of the 
 returns, premature children, and perhaps in others those that were 
 putrid at birth, have not been included. At all events, whenever 
 these are omitted, the number of still-born males in proportion to 
 females will be found to increase. In other words, if we limit our 
 calculations to infants still-born at the full time, and if we consider 
 only those that die during the process of labor, we shall find among 
 them the ratio of males to females to be greatly higher than the 
 average is among still-born children taken indiscriminately, and 
 without reference to the time and cause of their death. 
 
 We shall devote our next proposition to the proof of this. 
 
 FIFTH PROPOSITION. 
 
 Of the children thai die during the actual progress of parturition, the number of males is much 
 greater than the number of females. 
 
 It will easily be seen that the data required in proof of this pro- 
 position are very difficult to be obtained. Indeed, they could only 
 
SEX or CHILD AS A CAUSE OF DIFFICULTY. 361 
 
 be accurately ascertained by a series of minute observations insti- 
 tuted through the medium of the stethoscope. This has not yet 
 been done, so far as we know, by any observer. From the want of 
 such evidence, we are under the necessity of approaching as nearly 
 as possible the proper proof, by taking advantage of a mark entered 
 in the elaborate tables of Dr. Collins. He has placed a note of "p" 
 (signifying putrid), opposite to all those children that were born in 
 that state. These " putrid" children had evidently all, or almost 
 all,* died from causes that had operated during intra-uterine life, 
 and before the commencement of parturition. We may, therefore, 
 probably reject such infants from our present calculations, inasmuch 
 as these calculations refer only to children dying during the con- 
 tinuance and progress of the parturient process. Of the 1121 
 children that were still-born, as many as 527 were found putrid at 
 birth. The sexes of the remaining 594 stand in the relation shown 
 by the following table : 
 
 Still-born Children 
 not putrid. 
 
 No. of 
 Males. 
 
 No. of 
 Temales. 
 
 Proportion of 
 Males to Females, as 
 
 594 
 
 357 
 
 237 
 
 151 to 100 
 
 In the general rate of infantile mortality at birth, we have already 
 6een, under the previous proposition, that in Dr. Collins' cases the 
 proportion amounted to about 122 males for every 100 females. In 
 the present instance, and when the children that had died some 
 time before labor began, are excluded, the ratio rises as high as 150 
 boys to every 100 still-born girls, or as 3 to 2. "We might further 
 from the 594, exclude 62 premature still-born children that were 
 not putrid, viz., 37 males and 25 females, and retain only those that 
 had reached the full time. This, however, would not alter our 
 results above 1 in the column of 151 males. 
 
 But the ratio of these male still-births would probably have been 
 made somewhat greater, and our present proposition still more 
 strongly borne out, had we been able, on the one hand, to take into 
 the calculation those children only who died subsequent to the com- 
 mencement of the process of parturition, and to exclude, on the 
 other hand, all those that perished, however shortly before, under 
 the influence of other morbific agents than the eiFects of labor. 
 The fact of the still-born children being "putrid," shows generally 
 that death has occurred several days at least before birth. It is a 
 condition which has enabled us therefore to exclude most, but not 
 
 ' For two remarkable exceptions see Dr. Collins' treatise, pp. 470 and 483, oases 461 and 
 1058. In a paper on Peritonitis in the Foetus (Edinburgh Medical and Surgical Journal, 
 October, 1838, p. 390), I have attempted to show that a large number of those children that 
 are still-born and putrid have died of peritoneal inflammation. See, also, vol. ii. of this work. 
 
362 TEDIOUS LABOE. 
 
 all, of those who had died antecedently to the commencement of 
 actual labor. I repeat, that if we had possessed the power of ex- 
 cluding all — and thus so far improving our data — the proportion of 
 male to female children who died during labor, high as we have 
 shown it to be, would, in all probability, have been found raised 
 still higher. 
 
 SIXTH PROPOSITION. 
 
 Of those children that are born alive, more males than females are seen to suffer from the 
 morbid states and injuries resullvng. from parturition. 
 
 Among the accidents and injuries to the child more immediately 
 resulting from parturition, no one has, of late years, been made the 
 subject of such minute pathological investigation as the "bloody 
 tumor" or "ecchymosis" of the head — ^the Cephalcematoma neona- 
 torum of ITaegele, Valleix, Dubois, Walshe, and various other 
 modern authors. " The unequal pressure," says Velpeau, "which 
 the cranium experiences, and the tendency that its bones have to 
 override one another, during most labors, when the head is travers- 
 ing the pelvis, and whether the labor be natural or artificial, is in- 
 contestably the most common cause of this tumor."' N'o author, 
 that I am acquainted with, has given any statistics regarding the 
 sexes of the infants affected with cephalsematomata, with the excep- 
 tion of Burchard. The data which he adduces are not so extensive 
 as could be wished, but still they furnish strong and indubitable 
 proof of our present position. In his essay, "De tumore cranii 
 recens-natorum sanguineo," he mentions that out of 43 cases, which 
 he had observed at the Breslau Hospital, the child was male in 34 
 and female in 9 of the instances, so that the relative frequency of 
 the disease in the two sexes stood thus : 
 
 Male 
 Children. 
 
 Female 
 Children. 
 
 Proportion of 
 Males to Females. 
 
 34 
 
 9 
 
 377 to 100 
 
 I am not aware that there have been hitherto published such data 
 regarding serious swellings of the infant's scalp, the caput sueceda- 
 neum of the older authors, or the asphyxia or apoplexy of children 
 at birth, or any of the other accidents to which they are subjected 
 during labor, as would enable us to make similar calculations with 
 respect to them. As they are all confessedly more or less direct 
 results of the physical pressure which the infant's head suffers dur- 
 
 ' Traite Complet des Accouohemens, torn. ii. p. 594. 
 
SEX OF CHILD AS A CAUSE OF DIFFICULTY. 363 
 
 ing parturition, the calculations, derived from one, would probably 
 apply with greater or less force to each of tbe others. Since addi- 
 tional data from individual morbid states and injuries are thus want- 
 ing in support of the proposition we have laid down, we shall 
 appeal, in confirmation of it, to some calculations we have made 
 from Dr. Collins' data regarding the general mortality observed 
 among children immediately after delivery. In his chapter on 
 "Children dying in the Hospital," Dr. Collins observes, "thirty- 
 two children born at the full period died a few minutes after birth ; 
 in six of these, respiration' could not be established, though the heart's 
 action continued for some time."i Dr. Collins does not offer any 
 clue by which these 32 cases can be discovered in the table attached 
 to this chapter, and thus their sexes ascertained. I find, however, 
 in that table, that 17 single children, born at the full period, are 
 marked as dying within the first half-hour after birth. They hence 
 probably perished from morbid states the more immediate results of 
 labor. Of the 17 children, 9 died within five minutes after birth ; 
 1 in ten minutes ; 4 in fifteen minutes ; and 3 in thirty minutes. 
 One of the 17 children was female, and 16 of them, males. If we 
 might venture to make the same form of calculation as we have 
 hitherto used, of the respective sexes of the children from these very 
 small and insufficient data, it would stand thus : 
 
 Male 
 Children. 
 
 Female 
 Children. 
 
 Proportion of Malea 
 to Females, as 
 
 16 
 
 1 
 
 1600 to 100 
 
 SEVENTH PROPOSITION. 
 
 More male than female children, die in the earliest periods of infancy ; and the disproportion 
 between the mortality of the two sexes gradually diminishes from birth onwards till some 
 time subsequently to it. 
 
 This proposition follows as almost a necessary corollary from 
 those that have preceded it. If, in consequence of the pressure and 
 greater injuries to which male children are subjected during birth, 
 more male than female infants perish during labor ; and if, again, 
 among those born alive more males than females are found to suffer 
 under such morbid states as are the immediate results of parturition, 
 it might justly be a priori expected that the same causes which pro- 
 duced these results during delivery and immediately after it, would 
 so far continue to affect the male constitution, for some time subse- 
 quently, as to predispose it more to disease, and likewise render 
 the diseases which did occur in it more dangerous and fatal in their 
 course than those that affect the female. Further, if this greater 
 
 ■ Practical Treatise, p. 501. 
 
364 
 
 TEDIOUS LABOE. 
 
 liability to morbid action, and its greater intensity and fatality in 
 the male, as compared with the female infant, were the consequence 
 of the male being subjected to greater physical injuries at the time 
 of parturition, the pathological characteristics in question should be 
 observed to diminish more 'and more in the male system from the 
 moment of birth onwards, because the morbific effects, resulting from 
 any cause or causes operating during birth, would thus progressively 
 diminish, and ultimately pass away. At last, therefore, at some date 
 in early infantile life, the mortality among male and female children, 
 though very different at first, should become nearly or entirely equal. 
 And such, indeed, is the actual state of facts, when the mortality 
 during infancy is investigated upon a large scale. Thus in his obser- 
 vations regarding the " infiuence of sexes" upon mortality, Quetelet, 
 in his elaborate " Treatise on Man," remarks, as a matter of statistics, 
 that among male as compared with female children, " the ratio of 
 deaths before [during] birth is as 3 males to 2 females ; during the 
 first two months after birth the ratio is as 4 to 3 ; during the third, 
 fourth, and fifth months, as 5 to 4 ; and," he adds, " after the eighth 
 or tenth month a difference scarcely exists." ' 
 
 I shall endeavor to bring forward some statistical evidence in 
 support of the preceding statements. 
 
 Dr. Collins has given in his Treatise,^ a table containing a variety 
 of particulars regarding 284 children that died in the Dublin Hos- 
 pital within a few days after their birth. Excluding twins and pre- 
 mature children, the date of the death of 148 of these infants is 
 noted in the table referred to. Six of them died on the 8th day 
 after birth; two on the 9th; and one on the 10th. These nine 
 included 5 boys and 4 girls. With regard to the remaining 139 
 infants that died during the first seven days after birth, the follow- 
 ing table, which has been compiled with considerable care, will 
 show the periods of their demise, and the relative proportion which 
 the mortality among the male and female children presented at 
 different dates during the first week of life.^ 
 
 Period of Death. 
 
 Males. 
 
 Females. 
 
 Proportion of males 
 to females. 
 
 Ratio of Kxcess 
 of male mortality. 
 
 Within first lialf liour, 
 Witliin first hour, 
 Within first 6 hours, 
 Within first 1 2 hours. 
 Within first 18 hours. 
 Within first day, . 
 Within first week, . 
 
 
 16 
 19 
 29 
 34 
 36 
 49 
 80 
 
 1 
 2 
 7 
 15 
 19 
 28 
 59 
 
 1600 to 100 
 950 to 100 
 414 to 100 
 226 to 100 
 191 to 100 
 175 to 100 
 136 to 100 
 
 1500 
 
 850 
 
 314 
 
 126 
 
 91 
 
 75 
 
 36 
 
 ' Treatise on Man, Chambers' English edition, p. 50. 
 2 Dr. Collins' Treatise, p. 519, &c. 
 
 " The time the mothers remained in the institution, in most instances, was for " a period 
 of eight, nine, or ten days after delivery." — Ibid. p. 500. 
 
SEX OF CHILD AS A CAUSE OF DIFFICULTY. 
 
 365 
 
 The last column in the above table shows in the most striking 
 manner both the great proportion of male over female deaths in the 
 first few hours and days of extra-uterine existence, and the rapid 
 diminution which takes place from the moment of birth onward in 
 the relative superabundance of the male over the female mortality. 
 The principal and strongest objection that may be urged against the 
 table is the small number of data which is made in it the basis of 
 such interesting statistical deductions. I have given it, however, 
 such as it stands, in consequence of the want, so far as I know, of 
 any more numerous or complete series of similar facts bearing upon 
 the relative male and female mortality in the first week of life. 
 Against the table which I have next to bring forward, the same 
 objection cannot be urged, as the individual data are sufiiciently 
 ample, and yet the results are exactly the same in their nature, and 
 equally confirmatory of the proposition we are discussing. For the 
 data upon which I haVe constructed the table, I am indebted to an 
 elaborate extract of deaths at diflPerent ages, contained in one of the 
 invaluable reports of the Registrar-General of England. At pp. 
 144 and 145 of his Fifth Annual Eeport, the last published, are 
 given, in two separate tables, the numbers, ages, and sexes of all 
 the individuals that died in England and Wales in the year 1841. 
 In that year 134,563 died who had not passed the age of five; 
 namely, 71,595 males and 62,968 females. In the following table 
 I have arranged these data regarding the male and female deaths, 
 and made calculations from them of such a kind as bear upon the 
 objects of our present proposition. 
 
 Total number and relative proportion of male and female deaths, during the year 1 84 i , in England 
 and WaleSf within the first five years of life. 
 
 Ages. 
 
 Males. 
 
 Females. 
 
 Proportion of 
 
 Ratio of Excess of 
 
 
 
 males to females. 
 
 male mortality. 
 
 to 1 month, . . 
 
 13,351 
 
 9,741 
 
 137 to 100 
 
 37 
 
 1 to 2 months, . . 
 
 4,858 
 
 3.703 
 
 131 to 100 
 
 31 
 
 2 to 3 months, . . 
 
 3,313 
 
 2,676 
 
 124 to 100 
 
 24 
 
 3 to 6 months, . . 
 
 8,008 
 
 6,451 
 
 122 to 100 
 
 22 
 
 6 to 9 months, . . 
 
 6,341 
 
 5,182 
 
 110 to 100 
 
 10 
 
 9 to 12 months, . . 
 
 5,573 
 
 5,013 
 
 105 to 100 
 
 5 
 
 1 to 2 years, . . 
 
 13,987 
 
 13,281 
 
 100 to 100 
 
 
 
 *2 to 5 years, . . 
 
 16,164 
 
 15,941 
 
 101 to 100 
 
 1 
 
 • In England the proportion of living males and living females does not become equal 
 till about the twentieth year of life. After that period, an excess of the living population 
 is female ; before it, a small excess of it is of the male sex, there being originally born 105 
 males for every 100 females. — Fourth Report, p. 12. Hence, other circumstances being 
 equal, a slightly greater number of males than of females should necessarily be found in the 
 mortality bills in early life, as seen in the last two lines of the table. — See the Register's 
 Fifth Report, p. 23. 
 
366 
 
 TEDIOUS LABOE. 
 
 A different arrangement of the facts included in the preceding 
 table may probably show still more strikingly the great propor- 
 tionate male mortality in the period immediately following birth. 
 During the second year of life, that is, from the twelfth to the 
 twenty-fourth month, 13,987 males and 13,281 females died, or 
 nearly an equal number of the two sexes, the excess on the part 
 of the males amounting only to about 700. During the first month 
 of life, that is, from birth up to the twenty-ninth day following it, 
 there died of male infants a number nearly similar to that of those 
 who perished in the whole course of the second year, namely, 
 13,351. But the corresponding female mortality during the sajne 
 period was very much less, amounting only to 9741. Whilst the 
 difference, therefore, between the mortality of the two sexes, during 
 the second year, did not, in the numbers given, show an excess of 
 much more than 700 on the side of the males, this excess ran to 
 upwards of 3500 during the single first month of life, or was five 
 times greater ib. amount. A tabular arrangement of these figures 
 will point out this contrast more plainly. 
 
 Deaths in England 
 in 1841. 
 
 Of male 
 Cliildren. 
 
 Of female 
 Children. 
 
 Excess of 
 male mortality. 
 
 During first month of life, 
 During second year of life, 
 
 13,351 
 13,987 
 
 9,741 
 13,281 
 
 3610 
 700 
 
 If it were necessary, and our space permitted, it would be easy 
 to adduce additional tables constructed from the Eegistrar's Eeturns 
 of other years for England and Wales, and from the reports of the 
 mortality in other countries, showing, in correspondence with our 
 proposition, the two facts — 1st, that the male mortality, as compared 
 with the female, is much greater immediately after birth, and 2d, 
 that the male excess of deaths gradually and regularly diminishes 
 from that time onwards, to about the end of the first year of life. 
 The only new and remarkable circumstance that would be proved 
 by these additional tables is, that the rate of the decrease of the 
 male mortality is everywhere nearly the same. 
 
 In illustration of this last remark, I shall content myself with 
 giving the male as compared with the female infantile mortality in 
 England during 1841, and in Western Flanders from 1827-30. The 
 Flanders mortality is calculated upon a return of 37,203 deaths for 
 the first five years of life, including 21,198 males and 16,005 females.' 
 
 ' See Quetelet on the Natural History of Man, p. 30. The town and country mortality 
 are given separately by Quetelet. I have added both together, and computed the propor- 
 tions in the table from their conjoined sums. 
 
SEX OE CHILD AS A CAUSE OF DIFFICULTY. 
 
 367 
 
 Ages. 
 
 Male mortality in 
 
 Female 
 
 England. 
 
 Flanders. 
 
 mortality. 
 
 to 1 month, . . 
 
 137 
 
 139 
 
 100 
 
 1 to 2 months, 
 
 
 
 131 
 
 128 
 
 100 
 
 2 to 3 " 
 
 
 
 124 
 
 126 
 
 100 
 
 3 to 6 " 
 
 
 
 122 
 
 122 
 
 100 
 
 *6 to 9 " 
 
 
 
 110 
 
 117 
 
 100 
 
 •9 to 12 " 
 
 
 
 105 
 
 104 
 
 100 
 
 1 to 2 years. 
 
 
 
 100 
 
 103 
 
 100 
 
 2 to 5 " . 
 
 
 
 101 
 
 99 
 
 100 
 
 CAUSES OF THE GREATER MATERNAL AND INFANTILE DANGER AND 
 FATALITY ACCOMPANYING THE BIRTH OF MALE CHILDREN. 
 
 On tHs point, Dr. Clarke, in his excellent " Observations on some 
 Causes of the Excess of the Mortality of Males above that of Fe- 
 males," published in the Philosophical Transactions for 1786, justly 
 remarks that it may be safely asserted, " anatomy has not hitherto 
 detected any internal difference between the animal economy of the 
 male and female, which can be supposed to account for their dif- 
 ference of mortality, more especially in early infancy."^ The same 
 author then suggests two sets of causes in explanation of the higher 
 mortality among male children, namely, first, their larger size and 
 consequent more difficult delivery; ahd, secondly, their greater lia- 
 bility during their intra-uterine life to disease and debility, from 
 their requiring in consequence of their size, more actual nourish- 
 ment from the mother than smaller female children stand in need 
 of. We shall discuss this latter opinion before attempting to show 
 the greater truth and correctness of the former one. 
 
 "As the stamina of the male are naturally," says Dr. Clarke, 
 " constituted to grow of a greater size, a greater supply of nourish- 
 ment in utero will be necessary to his growth than to that of the 
 female. Defects in this particular (nourishment), proceeding from 
 delicacy of constitution or diseases of the mother, must, of course, 
 be more injurious to the male sex."^ 
 
 "It appears beyond doubt," says Quetelet, "that there is a par- 
 ticular cause of mortality which attacks male children by preference, 
 before and immediately after their birth." " It will be interesting," 
 he further observes, " to investigate the causes of a circumstance 
 
 f The dates of the two original returns, from the 6th to the 12th month, do not precisely 
 correspond. In the English tables the returns are from the 6th to ttie 9th month, and from 
 the 9th to the 12th; in those of Flanders the corresponding returns here calculated upon are 
 from the 6th to the 8th month (not the 9th), from the 8th to the 12th. The 8th month is 
 not given separately in the pubUshed returns, for if so, we should have been enabled to 
 equalize the two exactly. 
 
 ' Philosophical Transactions, vol. Ixxvi. p. 352. ' Ibid. p. 353. 
 
368 TEDIOUS LABOR. 
 
 wMch is so unfavorable to the male sex." " If," he continues, " we 
 were desirous of guessing at this point, we might say with those 
 who suppose that a male conception requires a certain excess of 
 energy in the woman, that this excess of energy was absent or 
 wanting during the growth of the fcstus, and, that energy failing, 
 the child would suffer more from it if a boy than if a girl. Hence 
 the disproportion of dead births between the sexes," &c.' 
 
 In a review of Dr. Collins' Treatise in the Dublin Medical Journal, 
 Dr. Graves makes several remarks on the same subject. After 
 showing that Quetelet and Caspar had found respectively in Flan- 
 ders and Prussia the number of still-born males to still-born females 
 to be 140 to 100, and that in Paris the ratio was 122 to 100, Dr. 
 Graves adds, " In Dublin, Dr. Collins' numbers give the proportion 
 very nearly the same as that of Paris, so that here we have the addi- 
 tional fact corroborative of those already brought forward, to prove 
 that a greater mortality before birth prevails among males than 
 females — a most curious result, well calculated to puzzle both 
 physiologists and philosophers."^ 
 
 I shall not attempt to solve, as Clarke and Quetelet have done, 
 the problem broached by Dr. Graves, but will content myself with 
 showing, that the observations on which it is founded are in them- 
 selves erroneous, and that the tables of Dr. Collins, appealed to by 
 Dr. Graves, prove, when studied minutely, that, contrary to the 
 general opinion entertained on this point, a greater mortality does 
 not prevail before birth among male than female infants. With this 
 view we bring forward the following as our 
 
 EIGHTH PROPOSITION. 
 
 Of the children thai die in utero, and before the commencement of labor, as large a proportion 
 
 are female as male. 
 
 I have already had occasion to state, that, among the 1121 still- 
 born children so often already referred to as occurring during Dr. 
 Collins' mastership, 527 were putrid, and hence had perished before 
 the supervention of parturition. 
 
 If we contrast together the proportionate number of males and 
 females among these 527 children, as well as the sexes of the infants 
 among them that were born at the full time, but putrid, and the 
 sexes of all those that were still-born prematurely, whether putrid 
 or not, we shall find the result to be as follows : 
 
 ' Treatise on Man, English edition, pp. 25 and 30. 
 
 ' Dublin Journal of Medical Science, vol. viii. pp. 518-19. 
 
SEX OF CHILD AS A CAUSE OF DIFFICULTY. 
 
 369 
 
 State of the Children. 
 
 Total 
 cases. 
 
 Male. 
 
 Female. 
 
 Proportion of 
 Male to Temale. 
 
 No. of still-born putrid children, 
 No. of still-born at full time and ) 
 putrid, . . . . 5 
 No. of premature stillbirths, . 
 
 527 
 296 
 293 
 
 257 
 148 
 146 
 
 270 
 148 
 147 
 
 95 to 100 
 100 to 100 
 100 to 100 
 
 This table seems particularly valuable and instructive in one re- 
 spect. It demonstrates satisfactorily, that the intra-uterine morbific 
 agencies, whatever they may be, which act fatally on the fcBtus be- 
 fore birth, act equally on the female as on the male child ; and that 
 it is to other agencies than these that we are to look for the remark- 
 able proportion of male over female deaths which is observable 
 among still births. 
 
 In premature births the comparative compressibility and flexi- 
 bility of the bones of the cranium is so decidedly greater as to offer 
 no such marked difference between the size and resistance of the 
 male and female head, as we shall immediately see to exist at the 
 full time. !N"ow the last column of the table shows, that, in this 
 class of still-births, the premature, the number of dead-born male 
 and female children was exactly equal. The second column testi- 
 fies, that the same fact holds true of children born at the full time, 
 and in a state of putridity. Further, in looking to the evidence 
 afforded by the first column, we may there observe, that of all the 
 children that had perished from intra-uterine causes, and before 
 the commencement of labor (as demonstrated by their putrid state), 
 the females were even more numerous than the males. 
 
 The whole series of facts proves, contrary to what is generally 
 alleged, that the proportion of male children that die before birth is 
 not greater than the proportion of females. Indeed, if we deducted 
 the usual 6 per cent, for the normal over-proportion of males, the 
 ratio of girls dying before parturition would be found to be greater 
 than that of boys — a conclusion which the first column would seem 
 to go far to corroborate and strengthen, for in that computation the 
 number of the dead females distinctly and considerably exceeds that 
 of the dead males. 
 
 This result with regard to the equality of the sexes among putrid 
 and premature still-born children, becomes only the more striking 
 when we couple and contrast it with the fact which we have already 
 brought out, that of the children who are still-born, and not putrid, 
 as many as two out of every three are boys. In other words, among 
 the infants that die before labor, the females are equal, if not greater 
 in number than the males. Among the infants that die during 
 labor the males are raised to the high proportion of 150 boys for 
 every 100 girls. For this sudden and surprising increase during 
 VOL. I. 24 
 
370 TEDIOUS LABOR. 
 
 labor, of the male infantile mortality over the female, there must' 
 be some cause or causes traceable in the conditions of the pro- 
 cess of parturition. Let us now see, in accordance with what we 
 have already proposed, whether the cause or causes in question be 
 not referable to 'the greater size of the male infant, and the effects 
 of this size upon the compression of the cranium and its contents. 
 And in order to understand more thoroughly the investigation, let 
 us inquire, in the first place, into the actual average difference be- 
 tween the volume and weight of the male and female at birth. 
 
 RELATIVE WEIGHT AND SIZE OF THE MALE AND FEMALE AT BIRTH. 
 
 In the Dublin Hospital, Dr. Clarke long ago endeavored to dis- 
 cover the relative weights of the new-born male and female child, by 
 observations made upon 60 children of each sex. In his paper in 
 the Philosophical Transactions of 1786, to which we have repeatedly 
 referred, he gives both the absolute and average weights of these 60 
 male and 60 female infants. 
 
 The 60 males weighed in all 442 lbs." 
 
 The 60 females weighed in all 404J lbs. 
 
 The average weight of the male was 7 lbs. 5 oz. 2 dr. 
 
 The average weight of the female was 6 lbs. 11 oz. 2 dr. 
 
 The average difference between the weight of the male and female 
 child, as calculated from these 120 instances, thus amounted to 
 about nine ounces. 
 
 In the Edinburgh Lying-in Hospital 50 male and 50 female chil- 
 dren, born during the latter months of 1842 and the earlier part of 
 1843, were weighed by my friend and assistant. Dr. Johnstone. 
 
 The 50 males weighed in all 383 lbs. 11 oz. 4 dr. 
 
 The 50 females weighed in all 342 lbs. 12 oz. 4 dr. 
 
 The average weight of the male was 7 lbs. 9 oz. 1 dr. 
 
 The average weight of the female was 6 lbs. 12 oz. 
 
 The difference between the weight of the male and female child, 
 as calculated from these 100 cases, thus amounted to about ten 
 ounces on the average. 
 
 The respective lengths of these 60 male and 50 female children 
 were also carefully ascertained in the Edinburgh Hospital. 
 
 The total length of the 50 males was 1020J inches. 
 
 The total length of the 50 females was 990J inches. 
 
 The average length of the male child was 20 inches 5 lines. 
 
 The average length of the female child was 19 inches 10 lines. 
 
 The average difference between the length of the 50 males and 
 
 ' The Troy or Apothecaries' weight is there used. 
 
SEX OF CHILD AS A CAUSE OF DIFFICULTY. 
 
 371 
 
 50 females thus amounted to 7 lines, or somewhat upwards of half 
 an inch. 
 
 These results are sufficient to prove, that at birth, as at other 
 Buhsequent periods of life, the male is usually of a greater weight 
 and size than the female. The general volume, however, of the 
 body of the child is not, in relation to the mechanism of parturition, 
 a matter of such immediate importance as the size of the head itself, 
 the facility or difficulty of the process being principally dependent 
 upon the relative size of the latter. The greater weight and volume 
 of the male than the female child at birth might, a priori, entitle 
 us to calculate that the head of the male would, in correspondence 
 with the other parts of the body, be larger than the head of the 
 female. In such an inquiry, however, as the present, it is better to 
 refer to direct arithmetical facts than indirect though probable in- 
 ferences, and Dr. Clarke has left us a series of measurements of the 
 heads of male and female children, at birth, that are valuable in 
 giving us more precise ideas upon this point. His obsei'vations 
 were made upon the 120 male and female children whose respective 
 weights we have already detailed. " For measuring their heads, I 
 made use," he observes, " of a piece of painted or varnished linen 
 tape, divided into inches, halves, and quarters. I took first the 
 greatest circumference of the head, from the most prominent part of 
 the occiput, around the frontal sinuses ; and, secondly, the transverse 
 dimensions, from the superior and anterior part of one ear across 
 the fontanelle to a similar part of the other ear. These data ap- 
 peared to me the most likely to afford data for determining the 
 respective sizes of the brain in the diffisrent sexes."^ 
 
 The result of Dr. Clarke's measurements may be exhibited in the 
 following manner.^ 
 
 Circumference of ) 
 head, . ■ ■ 5 
 
 Dimensions from 
 ear to ear, 
 
 M 
 
 Absolute dimensions in 
 60 males. 60 females. 
 
 Inches. 
 839 
 
 445| 
 
 Inches. 
 817 
 
 433^ 
 
 ATerage dimeDsions in 
 60 males. 60 females. 
 
 Inches. Lines. 
 13 llf 
 
 ^ 
 
 Inches. Lmes. 
 13 7| 
 
 7 2| 
 
 The differences brought out in the preceding table, between the 
 male and female head, may appear more precise if we reduce them 
 to decimal figures. 
 
 ' Phil. Trans. Ixxvi. p. .358. 
 
 2 Since these remarks were sent to press, I have incidentally met with the following re- 
 mark in Dr. Forbes's Quarterly Medical Review, vol. x. p. 492. "M. Nevermann gives us 
 the results of the measurements of the heads of 384 children by Professor Thulstrup of 
 Christiana, which fully bear out Dr. Clarke's statements." 
 
372 
 
 TEDIOUS LABOR. 
 
 
 Average circumference 
 of head. 
 
 Average dimi-nsious 
 from ear to ear. 
 
 In male child, 
 In female child, 
 
 Inches. 
 13 983 
 13-617 
 
 Inches. 
 7-429 
 7-221 
 
 Difference, 
 
 0-366 
 
 0-208 
 
 According to these observations upon new-born cbildren, it would 
 appear that — 
 
 1. The head of the male infant, when measured across from ear 
 to ear, over the fontanelle, is about 2^ lines, or nearly two-eighths 
 of an inch greater than that of the female. 
 
 2. In circumference, the head of the male is 4f lines, or almost 
 precisely three-eighths of an inch greater than that of the female. 
 Hence — 
 
 3. The transverse diameter of the male head is nearly one-eighth 
 of an inch greater than the transverse diameter of the head of the 
 female child.' 
 
 The preceding difference between the absolute size and weight of 
 the male and of the female child at birth, and between the relative 
 dimensions of the male and female infantile head, may appear to 
 some to be on the whole so slight, as not to afford in themselves 
 any sufficient explanation of the differences that we have seen to 
 exist, between the dangers and mortality incident respectively to 
 male and female births. The general greater size of the head and 
 body of the boy at birth may not seem adequately to account, by 
 any influence traceable to it alone, for the general greater peril 
 and fatality accompanying the birth of male as compared with 
 female children. The alleged cause may appear unequal to the pro- 
 duction of the alleged effects. Let us state, therefore, the reasons 
 that induce us to hold the contrary opinion, and which impress us 
 with the belief that the difference between the size of the male and 
 female head at birth, inconsiderable as it may seem, is the true cause 
 of that greater danger and fatality to mother and child, which ac- 
 companies the birth of male infants. 
 
 Before doing so it may be proper to premise, that under our fifth 
 and eighth propositions I have already shown, on the one hand, that 
 the explanation of the cause of the greater number of male than 
 female still-born infants proposed by Clarke, Quetelet, &c., as de- 
 
 ' Calculating upon the accuracy of Dr. Clarke's linear measurements of the fffital head, it 
 would appeal: that the surface of the cranium of the male infant, above the circumferential 
 line of measurement, is about 27-8 square inches ; that of the female about 26-3 square 
 inches. The arch of the male cranium, at birth, is therefore, superficially, upivards of one 
 square inch greater than that of the female. To state it in other -words, the proportion of 
 the surface of the head of the male new-born child to that of the female is nearly as 19 to 
 J.8 — or the surface of the head of the female is one-nineteenth part less than that of the male. 
 
SEX OF CHILD AS A CAUSE OF DIFFICULTY. 373 
 
 pending upon intra-uterine agencies, is totally incorrect, and dis- 
 proved by statistical facts ; and, on the other hand, we have seen 
 that the increased mortality of children of the one sex over those of 
 the other at the time of birth is a result of some circumstance or 
 circumstances connected with, or at least only in operation during, 
 the process of labor. Whilst this holds true as regards the child, 
 it is of consequence, at the same time, to recollect that the compli- 
 cations and dangers on the part of the mother, which we have found 
 so much more frequently attendant upon male than female births, 
 are all of such a nature as to be confessedly the direct or indirect 
 consequences of causes acting during parturition. Further, it will, 
 we imagine, be granted by every accoucheur, that whatever circum- 
 stance or circumstances may, by operating as a cause of obstruction, 
 lead to the greater danger and fatality of the male infant during the 
 progress of labor, will, at the same time, in all probability, equally 
 explain that greater peril and fatality to the mother during the pro- 
 cess, which is incident to the birth of males. 
 
 For the solution of the present problem, both as regards the fate 
 of the mother and of the infant, we believe that we ought to look 
 alone to the greater size of the head of the male infant, and that for 
 a variety of reasons which we shall now endeavor to state seriatim^ 
 adding such illustrative remarks and evidence as they may seem to 
 require, and throwing the more important deductions that may seem 
 to flow from the statistical proofs brought forward, into the shape 
 of additional propositions. 
 
 REASONS FOR CONSIDERING THE GREATER SIZE OF THE HEAD OF THE 
 MALE CHILD AS THE CAUSE OF THE GREATER NUMBER OF COMPLI- 
 CATIONS AND CASUALTIES ACCOMPANYING MALE BIRTHS. 
 
 We shall begin our enumeration of these reasons by stating that — 
 
 First, For the very marked differences existing between the difficulties and perils of male as 
 compared with female births, there is no other traceable cause in the mechanism of parturition 
 than the larger size of the head of the male child. 
 
 Parturition, at the completed term of pregnancy, is a process con- 
 sisting of a combination of mechanism, intended for the extrusion 
 of the full-grown infant from the cavity of the uterus. For the 
 perfect action of this mechanism, three sets of physical conditions 
 are essentially necessary. First, A certain degree of mechanical 
 expulsive power is required, and this is supplied principally by the 
 vital contractions of the uterus. Secondly, An adequate degree of 
 capacity and dilatation is necessary on the part of those matei'nal 
 passages through which the child is to be expelled. Thirdly, The 
 
374 TEDIOUS LABOR. 
 
 body whicli is to be expelled (viz., the infant) must be of such size, 
 and be placed in such a position or positions, as to allow of its 
 sufficiently easy entrance and progress through these maternal 
 passages. A perfect and equitable adjustment between these three 
 different conditions is necessary to the constitution of natural labor ; 
 and on the other hand, a deviation — absolute or relative — ^in any 
 one or more of these conditions, leads on to tedious and difficult 
 parturition, and its results. In which of these three essential con- 
 ditions could a deviation be possibly effected by the sex of the child, 
 so as to account for the greater dangers and complications attendant 
 upon male births ? 
 
 The mere sex of the child, and the circumstance whether it was 
 a male or female, could evidently produce no primary effect upon 
 the vital muscular contractions of the uterus, so as to alter them in 
 any morbid manner. Consequently we may exclude from our con- 
 sideration the first set of physical conditions that we have above 
 named. 
 
 We may do equally the same with the second, because it is 
 impossible to conceive that the measurements of the pelvis and 
 maternal passages could be directly altered in any way by the child 
 which has to pass through them being male rather than female. 
 
 In searching for a possible cause of deviation in the mechanism 
 of parturition, explanatory of the facts which we have traced, we 
 are thus, by a method of exclusion, compelled to look to the third 
 set of physical conditions of labor, viz., the position and size of the 
 infant. 
 
 The consideration of the position of the infant will afford us no 
 clue to the problem, because in most of the cases from which we 
 have drawn our data, the presentation and position were natural. 
 Wlien it was otherwise, the deviation was as frequently on the part 
 of the female as of the male child. 
 
 The only item, therefore, that is left in which we may trace any 
 distinction whatever between the mechanism of labor in male and 
 in female births is the relatively greater size of the infant of the 
 male sex, and this relatively greater size could only influence labor 
 or its consequences in so far as it affected the dimensions of the 
 head of the child — ^the increased volume of its body never, unless 
 when excessive in degree, retarding or complicating, to any extent, 
 the progress of the labor in cases of cephalic presentations. The 
 difference between the male and female infant's head is indeed 
 slight, but we are forced, at this stage of the inquiry, to believe it 
 to be the probable origin of the greater dangers and more numer- 
 ous complications accompanying male births, simply in consequence 
 of our being utterly unable to trace any other appreciable difference, 
 
SEX OF CHILD AS A CAUSE OF DIFFICULTT. 375 
 
 or imagine any other possible circumstance, in the conditions of 
 parturition, which could afford the most distant explanation of the 
 series of phenomena that we are discussing. It is the only circum- 
 stance which we can detect as an apparent and constant antecedent 
 to the consequences we have described ; and hence seems to be that 
 particular condition which we ought to look upon as the cause of 
 these effects. 
 
 In the foregoing remarks we have arrived at the conclusion that 
 has just been stated by a kind of reasoning by exclusion. The 
 argument we have been considering is in a great measure negative. 
 But others of a more positive character are not wanting in confirpaa- 
 tion of the same view. For — j- Ji ; 
 
 Seconely, An increase in the effects may he shown to he connected with an increase.iri the' 
 
 alleged cause. 
 
 ""When," observes Dr. Hamilton, "the head of the infant is 
 pushed foremost, and the labor is not completed within twenty-four 
 hours from its actual commencement, the case is styled laborious, 
 and it may terminate in one of three ways. Thus, the natural 
 powers may at last complete the delivery ; or, though these fail, it 
 may be possible for the practitioner to complete the delivery by 
 mechanical means, with safety both to mother and child ; or it may 
 be impossible to draw the infant alive through the natural passages. 
 These three several terminations constitute three different orders of 
 laborious labors."^ 
 
 ~Sow, if it were granted us, for the sake of argument alone, that 
 the greater obstacles and perils attendant upon male births are 
 attributable to the larger size of the male infant's head, it would 
 almost necessarily follow, that just in proportion as the difficulties 
 connected with the above three different orders of laborious labor 
 progressively increased over one another in intensity, so the amount 
 of male children connected with these labors would, in like manner, 
 probably progressively increase in number. 
 
 Let us interrogate the data to be found in Dr. Collins' reports, in 
 order to test practically the truth of an opinion which is so far 
 merely theoretical. 
 
 Under the second proposition, we have already had occasion to 
 state that, during Dr. Collins' mastership in the Dublin Lying-in 
 Hospital, among the 16,414 labors which he has reported, the sexes 
 
 ' Outlines, p. 45. " It is," says Dr. Cliurohill, " peculiar to midwifery operations (and the 
 same remark applies equally to the different orders of laborious labors), that they form an 
 ascending series, increasing in gravity from the simplest to the most severe — no two being 
 equal." — Researches in Operative Midwifery, p. 12. 
 
376 
 
 TEDIOUS LABOR. 
 
 of the infants born were in the proportion of 106 males to 100 
 females. 
 
 Out of 109 tedious and difficult labors, in which Dr. Collins has 
 recorded the sex of the infant, and that occurred among these 16,414 
 deliveries, 65 of the children were male and 44 female. 
 
 In 24 forceps cases met with by Dr. Collins, the proportion of 
 male to female children was still greater, the males being 16 and 
 the females 8 in number. 
 
 The ratio of male infants mounts yet higher, when we turn to the 
 cases in which the labor was so difficult as to require craniotomy. 
 Among 74 instances in which the crotchet was used by Dr. Collins, 
 and where the sex of the child is mentioned, the infant was male in 
 50 instances, and female in 24. 
 
 A tabular arrangement of the above results will show the pro- 
 portion of male to female children under these different classes of 
 head presentations. 
 
 Nature of the Labor and 
 Complication. 
 
 Total 
 Cases. 
 
 No. of 
 
 Male 
 
 Children 
 
 No. of 
 Female 
 Children. 
 
 Proportion of 
 Males to Females. 
 
 Ratio of 
 
 Exce.«s of 
 
 Males. 
 
 Labors generally, . 
 Tedious labors, . . 
 Forceps cases, . . 
 Crotchet cases, . 
 
 16,654 
 
 109 
 
 24 
 
 74 
 
 8548 
 65 
 16 
 50 
 
 8069 
 
 44 
 
 8 
 
 24 
 
 106 to 100 
 148 " 100 
 200 " 100 
 208 " 100 
 
 6 
 
 48 
 100 
 108 
 
 The preceding data prominently show, that as the classes of 
 labors increase in severity and difficulty, the proportion of male to 
 female children in them increases in a corresponding degree. 
 Evidence of exactly the same kind, in support of this opinion, may 
 be gathered from a tabular extract of the cases that occurred in the 
 Dublin Hospital during the mastership of Dr. Clarke (viz., from 
 1787 to 1793), published by that gentleman in the first volume of 
 the Transactions of the King's and Queen's College of Physicians 
 of Ireland, p. 400. In this abstract Dr. Clarke states the sex of 
 those infants that were still-born in the three classes of 1. ordinary, 
 2. tedious, and 3. laborious labors. 
 
 During Dr. Clarke's mastership there occurred 10,199 cases of 
 single or uniparous births. Among these, 340 children were still- 
 born though the labor was natural, that is, was terminated within 
 24 hours, and with the head of the foetus presenting. Of these 340 
 still-born children, 170 were male, and 170 female. The ratio of 
 the sexes shows this perfect equality in consequence probably of this 
 list including principally putrid and premature children, among 
 whom we have already found (see the eighth proposition) the number 
 of still-born boys and girls to be nearly alike, and the over-pro- 
 portion, if any, to be rather on the side of the females. 
 
SEX OF CHILD AS A CAUSE OF DIFFICULTY. 
 
 377 
 
 Under the term "Tedious E'atui'al Labors," Dr. Clarke includes 
 those which exceeded 24 hours in duration, but where there was no 
 such disproportion between the head of the foetus and the mother's 
 pelvis, as to render destructive instruments necessary. This class of 
 labors is produced either, he observes,^ " by causes weakening the 
 expelling powers of the mother, or increasing resistance to the 
 passage of the foetus." In Dr. Clarke's report, 134 cases are referred 
 to this division, including 16 forceps cases. In these 134 labors, the 
 child was still-born in 41 cases. Among these 41 still-born children, 
 26 were male and 15 female. 
 
 Dr. Clarke further reports the sex of the child in 48 cases of what 
 he terms "Laborious Ifatural Labors," and where, to use his own 
 words, " the disproportion between the head of the foetus and the 
 pelvis was so great that it became necessary to diminish the bulk 
 of the former to save the life of the latter." Among these 48 
 crotchet cases, 32 of the children belonged to the male, and 16 to 
 the female sex. 
 
 Of the 429 children that were thus still-born, in these different 
 classes of natural or head presentations in Dr. Clarke's practice, the 
 proportion of the sexes was therefore in the following ratio : 
 
 Nature of the Labor 
 and Complication. 
 
 Total No. 
 
 of still-bom 
 
 Children. 
 
 Of these 
 were 
 Male. 
 
 Of these 
 
 were 
 Female. 
 
 Proportion of 
 Males to Females. 
 
 Katio of 
 
 Excess of 
 
 Males. 
 
 Ordinary Natural ) 
 labor, . . : 
 
 Tedious Natural " 
 labor, . . ]■ 
 
 Laborious Natural } 
 labor (Crotchet } 
 cases), . . ) 
 
 340 
 41 
 
 48 
 
 170 
 26 
 
 32 
 
 170 
 15 
 
 16 
 
 100 to 100 
 173 " 100 
 
 200 " 100 
 
 
 73 
 
 100 
 
 The preceding data, from Dr. Collins' and Dr. Clarke's returns, 
 will be probably admitted to be sufficient to prove the point that 
 we have in view, and to warrant the following inference as a 
 
 NINTH PROPOSITION. 
 
 In "laborious labors,'' with Ihe head presenting, inproportion as the order of labor rises in 
 difficulty, the amount of male births in them rises in number. 
 
 To the proof that I have just given of the truth of this proposition, 
 from the reports of Drs. Collins and Clarke, it gives me much satis- 
 faction to add the following general confirmatory statement, con- 
 tained in an analysis of Eiecke's elaborate obstetric statistics of 
 the kingdom of Wurtemberg, published in the Archives Gfen^rales.^ 
 
 ' Dr. Clarke's Paper, p. 371. 
 
 2 Archives G6n6rales de M^decine, torn. xx. p. 76. 
 
378 TEDIOUS LABOR. 
 
 As one of the results of these statistics (the most extensive hitherto 
 IDublished in midwifery)/ it is stated that " the proportion of boys 
 to girls is much greater in ' artificial' than in ordinary labors, for it 
 includes 7 boys for every 5 girls (or 140 male children for every 100 
 female). There is the same fact observable among the sexes of 
 those children that are the products of artificial births, and who are 
 either dead-born or die shortly afterwards, for among them the pro- 
 portion of boys to girls is as 8 to 5 (or as 160 male to every 100 
 female infants). Often enough," it is added, "it happens that the 
 same woman cannot, without aid, be delivered of a boy, who, at all 
 her other confinements, when the child was female, required no 
 assistance."^ 
 
 Thirdly, A diminution of the cause leads to a diminution of the effects ascribed to it. 
 
 "We have alleged the cause of the increased i!asualties connecte<i 
 with male births to be the greater size of the head of the male than 
 of the female infant. 
 
 In premature infants there does not exist so great a difference, ag 
 in those born at the full time, between thes,. Azh of the head of the 
 male and female child. The foetuses of the two sexes approach cpie 
 another more and more in physical and other characters, the earlier 
 the period at which we compare them. Besides, the eran'i;iJA:<'of!ithe 
 premature (?hild is so compressible, from its deficiency of-.cffi^ft^^^tion, 
 as to be niucSi more easily reduced in size under ,th4Vp*fe*§Tire to 
 which it is naturally subjected in the process of 'IJarMntion; and 
 hence the slighter difference which may actiisirilyfi^Bt' 'between the 
 dimensions of the heads of male and femaW-^ipt^i^ture infants is 
 still more diminished in its effects and oper'afciOT-;idating the course 
 
 of labor. " '*■ > iv' ■' '. ' 
 
 Possessing such physical conditions, the;birth of premature chil- 
 dren should, from the diminished size and ' diminished resistance 
 offered by their heads, give rise to fewer of those casualties in labor 
 that we have attempted to trace to the influence arising from the 
 greater size of the head of the full-grown male child. 
 
 I have no evidence to bring forward with a view of showing the 
 influence of the birth of premature children or their sex, on the 
 difficulties of the labor in reference to the safety and life of the 
 mother, because the labors with them are seldom or never so diffi- 
 
 ' They include 219,353 deliveries which occurred in Wurtemberg, during the four years, 
 ,1821-25. The artificial deliveries [accovchemms nrtij\delhs),or those requiring some special 
 aid or interference, amounted to 7949: In these 7949 cases, 630 of the mothers and 3754 
 of the children virere lost. The generalization in the text seems to be founded upon the 
 sex of the infants in these 7949 labors, and 3754 still-births. * Ibid. p. 88. 
 
BEX OF CHILD AS A CAUSE OF DIFFICULTY. 
 
 379 
 
 cult as to induce any marked maternal complications. But we may 
 derive equally good evidence in illustration of the point we are dis- 
 cussing by studying the effects of the labors with premature children 
 — not upon the mothers but upon the infants themselves. "With this 
 view I shall collect, from the data contained in Dr. Collins' report, the 
 number of male and female children expelled prematurely and not 
 putrid, in order to contrast them with the proportion of males and 
 females among still-born children expelled at the full time and not 
 putrid. Of the former there were born in all 62, of the latter 532. 
 The ratio of the sexes in each series stands thus : — 
 
 Non-putrid Children 
 still-born. 
 
 Total. 
 
 Males. 
 
 Females. 
 
 Proportion of 
 Males to I'emales 
 
 At full time, . 
 Prematurely, . 
 
 532 
 62 
 
 320 
 34 
 
 212 
 28 
 
 151 to 100 
 121 to 100 
 
 The comparison of the two columns in the above table shows 
 that, among the children who died immediately before or during 
 labor, and who had reached the ninth month of utero-gestation, the 
 proportion of males to females lost was considerably greater than 
 among still-born children born prematurely — and, as we believe, for 
 this reason, that in the latter (the premature still-births), there is 
 not, as we have pointed out, so great a distinction between the male 
 and female heads as among children at the full time. The com- 
 parison of the proportion of males to females who died within ten 
 days after delivery among, 1st, children bom at the full time, and 
 2d, those born prematurely, leads to the same inference, viz., that 
 as in the latter the alleged cause of distinction between the relative 
 size of the male and female head is diminished, the alleged effect 
 upon the differences displayed between the mortality of the two 
 sexes is also proportionally lessened. The following table is in- 
 tended to illustrate this point. The calculations are from the data 
 in Dr. Collins' chapter on children dying in the hospital. 
 
 Children dying within 
 10 days after birth. 
 
 Total. 
 
 Males. 
 
 Females. 
 
 Proportion of 
 Males to Females. 
 
 Born at full time, 
 Born prematurely, 
 
 171 
 
 102 
 
 106 
 56 
 
 65 
 46 
 
 163 to 100 
 121 to 100 
 
 The remarks that we have made regarding the heads of prema- 
 ture children should apply equally to those of twins. Twin children, 
 like those born prematurely, are in general below the standard size 
 and weight, and, in the same manner, have their heads less ossified, 
 and hence more compressible than those of single infants at the full 
 
380 TEDIOUS LABOR. 
 
 time. There is, consequently, also a less marked difference between 
 tlie relative size of the male and female head, among twin children, 
 than among single children at the full time ; and for the same reason, 
 if our views are true, there should be a similar less marked differ- 
 ence between the mortality of the two sexes among twins, at birth 
 and for some time after it. That such is in reality the case I shall 
 allow Dr. Clarke to state in his own words. Speaking of the rela- 
 tive male and female infantile mortality in the Dublin Hospital, 
 he observes,' " it is worthy of observation that though double the 
 number of twins die and are still-born, compared to single children, 
 yet the proportion of male twins lost to females is less. Only one- 
 fifth more of the male sex die than of the female, and only one-third 
 more is still-born. Whereas of single children, whose proportional 
 mortality is one-half less, one-fourth more of the male sex die, and 
 near double the number is still-born. To what, then, are we to 
 attribute this lessened mortality in favor of male twins ? Probably 
 to their brain and nervous system suffering less during delivery, on 
 account of their heads being much smaller than those of single chil- 
 dren."^ In other words, the cause of the higher mortality, or the 
 relative size of the male over the female head, being diminished, 
 the effects which we attribute to it, viz., the higher infantile mor- 
 tality among male children, is also proportionately diminished. 
 
 FouKTHLT, In those morbid complications in labor in which the cause is in abeyance, the effect 
 
 is also absent. 
 
 There are some morbid complications . during labor which are 
 independent of the presence, and hence of the sex or size of the 
 infant. I allude especially to those complications which occasion- 
 ally occur during the third stage of labor, and consequently after 
 the total expulsion of the child. It would afford no small corrobo- 
 ration of the preceding remarks and inferences, if in these cases, 
 where all agency from the conditions of the infant was for the time 
 being excluded, the morbid complications which may take place 
 were found to occur as frequently in connection with the birth of 
 female as of male infants. And such, we believe, may be shown 
 to be the fact. 
 
 ' Philosophical Transactions, vol. Ixxvi. p. 354. 
 
 2 In the Dublin Hospital, from the years 1757 to 1784, it appears from Dr. Clarke's tables 
 that among the twin-births, 29 males and 20 females were still-born, and 116 male and 91 
 female children died within a fortnight after delivery ; on the other hand, among the uni- 
 parous or single births 602 males and 351 females were still-born ; and 1656 males and 
 1247 female children died within a fortnight after birth. These data form the ground of 
 the inferences drawn by Dr. Clarice in the passage quoted in the text. 
 
SEX OF CHILD AS A CAUSE OF DIFFICULTY. 
 
 381 
 
 The two principal complications that occur during the third stage 
 of labor are morbid retention of the placenta and hemorrhage. 
 
 Dr. Collins reports 70 cases of retention of the placenta, 35 of 
 them after male, and 85 after female births. 
 
 Hemorrhage took place during the third stage of labor, or between 
 the birth of titie child and placenta, in 71 cases during Dr. Collins' 
 mastership. In 86 of these 71 labors the child was of the male, and 
 in 35 of the female sex. 
 
 These observations, when thrown into a tabular form, would con- 
 sequently stand thus : 
 
 Nature of 
 complication. 
 
 Total 
 cases. 
 
 With male 
 children. 
 
 With female 
 children. 
 
 Proportion of males 
 to females. 
 
 Retention of pla- 
 centa, 
 
 Hemorrhage dur- 
 ing third stage, 
 
 ^70 
 
 35 
 36 
 
 35 
 
 35 
 
 100 to 100 
 100 to 100 
 
 The evidence afforded bj the above table is probably sufficient to 
 entitle us to add to those inferences that we have already laid down, 
 the following deduction as a 
 
 TENTH PROPOSITION. 
 
 Of the morbid accidents that are liable to happen in connection with the third stage of labor, as 
 many take place with female as with male births. 
 
 To prove that the slight increase of size of the male over the 
 female infant's head is the true antecedent or cause of the greater 
 number of casualties accompanying male births, we may so far 
 change the ground of direct proof which we have been hitherto 
 attempting to pursue, and proceed to show, as a matter of strong 
 though indirect evidence, that — 
 
 FiPTHLY, Similar effects upon the mother and child are produced by other causes similar 
 in their character and amount. 
 
 If the larger dimensions of the head of the male infant be the 
 immediate cause of the larger number of accidents and deaths 
 attendant upon male births, its greater degree of size could only 
 possibly lead to the results in question, by offering a greater propor- 
 tionate degree of impediment to the passage of the fcetus through 
 the pelvic canals. Its effects, therefore, upon the mother and child 
 should be such as are produced by obstructed labor. That the 
 various consequences which we have previously traced are all of 
 that description, it is unnecessary for us to point out to the obstetric 
 
382 TEDIOUS LABOR. 
 
 pathologist. It might be considered, however, as confirmatory of 
 this fact, and, at the same time, as the strongest correlative evidence 
 that could be adduced of the power of slight obstructions, during 
 labor, to lead to these effects, if we could prove that in any other 
 extended series of cases, in which obstructions of the same amount 
 existed, the same or similar effects resulted both to the mother and 
 child. Our evidence would only be the stronger if, in this class of 
 cases, we could so far reverse the state of matters as to transfer the 
 existing slight obstruction from the body passing to the passages 
 themselves. The circumstances connected with first labors offer 
 the exact conditions which we seek. 
 
 In first labors, taken as a class, there is a greater obstruction to 
 the transit of the child than in subsequent deliveries, in consequence 
 of the maternal passages being less dilatable than aftei-wards. The 
 two causes of obstruction, viz. the increased size of the foetal head, 
 and the diminished size of the maternal passages, though different 
 in their seat, are nearly analogous in the nature of their influence, 
 and in the amount of that influence. 
 
 In male births, the body passing (the head of the infant) is slightly 
 greater than in female births, whilst, cceteris paribus, the maternal 
 passages are the same. In flrst labors the capacity or dilatability of 
 the maternal passages is slightly less than in subsequent labors, 
 whilst, cceteris paribus, the head of the infant remains the same, 
 there being at least an equal number amongst them of males and 
 females. Having stated these premises we shall go on to point out, 
 as another reason for supposing the size of the male head to be the 
 sole cause of the danger of male births, that, in accordance with our 
 proposition, most of the complications and accidents, which have 
 been already described as arising in male, as compared with female 
 births, from the comparatively slight increase in the dimensions of 
 the male head, occur also, in first, as compared with future labors, 
 in consequence of the comparatively slight diminution of the dimen- 
 sions or dilatability of the passages in these labors. 
 
 We shall give the proofs of this as an illustration of another, or 
 
 ELEVENTH PROPOSITION. 
 
 More dangers and deaths ocmr both to mothers and children in first than in subsequent labors. 
 
 Among the 16,414 women delivered in the Dublin Hospital 
 during Dr. Collins' seven years' mastership, 4987 were confined for 
 the first time. First deliveries occurred, therefore, in the proportion 
 of about 30 in every 100 cases. If, however, in studying the various 
 morbid complications which have been statistically reported by Dr. 
 Collins, we find the proportion of these complications in first labors 
 
SEX OF CHILD AS A CAUSE OF DIFFICULTY. 883 
 
 to be greatly above the ratio of 30 per cent., it would tend to show 
 that there is a stronger liability to their occurrence in first than in 
 future deliveries. To gain some data in this question, let us examine 
 into the facts which may be gathered from Dr. Collins' returns in 
 regard to the proportion of these morbid accidents arising from 
 obstruction during parturition, which were met with in first as com- 
 pared with subsequent labors. 
 
 Convulsions. — Of 30 cases of convulsions described by Dr. Collins, 
 29 occurred in women who were pregnant for the first time.' Thus 
 they were found in connection with first pregnancies in the ratio of 
 216 in 100. 
 
 Crotchet cases. — Of the 79 cases which Dr. Collins mentions as 
 requiring craniotomy, the number of the pregnancy in each can be 
 made out only in T5. Of these, 51 were first labors ;^ or out of every 
 100 cases in which the crotchet was used, 68 were first deliveries. 
 
 Forceps cases. — The forceps were employed in 24 instances. Of 
 these, 18 were first labors.^ Hence out of every 100 instances in 
 which this instrument was used, the proportion of first labors, 
 according to this average, would be 75. 
 
 Tedious labors. — ^Under our second proposition I have already 
 stated that Dr. Collins has given so far the history of 109 instances 
 of tedious labors." Of the 109 cases, 75 were first confinements ;' 
 thus giving for every 100 cases a proportion of 69 as pertaining to 
 first deliveries. 
 
 Puerperal fever. — Out of 88 women attacked with puerperal fever, 
 44 were confined for the first time.* Thus this complication super- 
 vened upon first labors in the ratio of 50 in every 100 cases. 
 
 Maternal deaths. — We have already seen, under the first proposi- 
 tion, that of the 16,414 women delivered in the Dublin Hospital 
 during Dr. Collins' charge of it, 164 died. Of these 164 mothers, 
 86 had given birth to first children ;' or of every 100 women who 
 died, 53 had been confined for the first time. 
 
 Still-births. — ^Under this head we exclude from our calculation 
 all those children who were born putrid, either prematurely or at 
 the full time. Of 1121 still-births in all, observed by Dr. Collins, 
 594 were born not putrid. Of these 594 children, 260 were the pro- 
 duct of first confinements; or in other words, they were found in 
 connection with first pregnancies in the ratio of 45 to 100. 
 
 Infantile deaths during the first eight or ten days after birth. — The 
 mothers and their infants generally, as we have seen, remained for 
 that time in the hospital after dehvery. During it 284 of the chil- 
 
 ' Practical Treatise, p. 201. " Ibid. Table, p. 490, et seq. ' Ibid. p. 15. 
 
 " Ibid. p. 462, at seq. ^ i^ij. Table, p. 400, et seq. " Ibid. p. 284 ' Ibid. p. 363. 
 
384 
 
 TEDIOUS LABOR. 
 
 dren died. Of these, 170 were single children born at the full time.' 
 Of the 170, 75 were the offspring of primiparse ; or infantile deaths, 
 during the first ten days, among single children born at the full 
 time, occurred in connection with first pregnancies in the ratio of 
 44 in every 100. 
 
 The preceding series of facts, if arranged together into a general 
 tabular form, would stand as follows. In reading these arranged 
 results, it is to be recollected that the standard proportion of first 
 pregnancies, in the general sum of the labors, amounts to 30 per cent. ; 
 whilst, as shown by the table, the proportion was much higher in 
 the various complications under-mentioned. 
 
 
 
 
 Proportion of 1st 
 
 Complication. 
 
 Total Cases. 
 
 Ist Pregnancies. 
 
 pregnancies. 
 
 Convulsions, 
 
 30 
 
 29 
 
 96 in 100 
 
 Forceps cases 
 
 24 
 
 18 
 
 75 in 100 
 
 Crotchet cases, .... 
 
 75 
 
 51 
 
 68 in 100 
 
 Tedious labors, .... 
 
 109 
 
 75 
 
 69 in 100 
 
 Puerperal fever, .... 
 
 88 
 
 44 
 
 50 in 100 
 
 Maternal deaths, . . . 
 
 164 
 
 86 
 
 53 in 100 
 
 Still births, not putrid, 
 
 594 
 
 260 
 
 45 in 100 
 
 Infantile deaths during 1st ^ 
 
 
 
 
 10 days ; born single and ^ 
 
 170 
 
 75 
 
 44 in 100 
 
 at full time, . . . ) 
 
 
 
 
 The results which the above table is intended to display might 
 perhaps be brought out more strongly by another arrangement, if 
 our data for it were more complete. Dr. Collins mentions the 
 number out of the 16,414 patients that were delivered for the first 
 time, viz., 4987; of these 72 were twin births. Unfortunately, 
 however, for our present purpose, he has omitted to give the exact 
 numbers of those that were confined in their second, third, and 
 other subsequent labors. But an approximation, sufficiently near 
 for the purpose we have in view, may perhaps be made without any 
 probability of a very serious error. To have the required standard 
 of comparison, I shall take it for granted, for reasons which it ia 
 unnecessary to dwell upon, that the percentage of first and future 
 labors in the Dublin Hospital was nearly as follows: Of all the 
 cases, about 30 per cent, were first pregnancies ; 22 per cent, second 
 pregnancies ; 15 per cent, third pregnancies ; 11 per cent, fourth 
 pregnancies ; 8 per cent, fifth pregnancies ; 5 per cent. 6th preg- 
 nancies ; 3 per cent, seventh pregnancies ; 2 per cent, eighth preg- 
 nancies ; 1 per cent, ninth pregnancies ; and 3 per cent, belong to 
 women who were confined for the tenth time or upwards.^ If we 
 
 ' Practical Treatise, Analysis of Table, p. 519, et seq. 
 
 ^ This calculation of percentages proceeds on the assumed' probability that, of the 16,414 
 women delivered in the Dublin Hospital under Dr. Collins, 4926 were cases of first labor; 
 3611 were of second labors; 2462 third labors; 1806 fourth labors; 1313 fifth labors; 826 
 
SEX OF CHILD AS A CAUSE OF DIFFICULTY. 
 
 385 
 
 compare with this given standard the proportion of instances in 
 which the different complications we have been considering occurred 
 in different pregnancies, we shall see in a marked degree the great 
 over-proportion of them in connection with first deliveries. I have 
 constructed the following table with this view. 
 
 Table showing the percentage of cases of natural and morbid labors belonging to different 
 
 pregnancies. 
 
 Percentage of 
 Pregnancies. 
 
 iBt 
 
 2ii 
 
 34 
 
 4tli 
 
 5th 
 
 eth 
 
 7th 
 
 8th 
 
 9th 
 
 10th and 
 subaeq. 
 
 Total No. deli- ) 
 
 an 
 
 99, 
 
 15 
 
 11 
 
 8 
 
 5 
 
 3 
 
 9 
 
 1 
 
 3 
 
 vered in Hosp. 5 
 
 
 
 
 
 
 
 
 
 
 
 Coavulsions, 
 
 96 
 
 4 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Tedious labors, 
 
 fifl 
 
 9 
 
 7 
 
 3 
 
 2 
 
 3 
 
 2 
 
 1 
 
 3 
 
 1 
 
 Forceps cases, 
 
 75 
 
 1 
 
 1 
 
 1 
 
 1 
 
 t 
 
 a 
 
 1 
 
 1 
 
 'I 
 
 Crotchet cases. 
 
 fiS 
 
 10 
 
 7 
 
 4 
 
 
 
 3 
 
 1 
 
 
 
 2 
 
 4 
 
 Puerperal fever, 
 
 sn 
 
 19 
 
 10 
 
 7 
 
 8 
 
 
 
 2 
 
 4 
 
 
 
 
 
 Maternal deaths. 
 
 .13 
 
 16 
 
 7 
 
 7 
 
 5 
 
 4 
 
 1 
 
 3 
 
 1 
 
 3 
 
 Still-births, 
 
 45 
 
 17 
 
 11 
 
 8 
 
 5 
 
 5 
 
 4 
 
 3 
 
 4 
 
 8 
 
 Infantile deaths J 
 
 
 
 
 
 
 
 
 
 
 
 for 10 days V 
 
 44 
 
 15 
 
 11 
 
 8 
 
 8 
 
 7 
 
 2 
 
 3 
 
 1 
 
 2 
 
 after birth, ) 
 
 
 
 
 
 
 
 
 
 
 
 Post-partum I 
 hemorrhage, / 
 
 33 
 
 16 
 
 10 
 
 9 
 
 9 
 
 5 
 
 4 
 
 6 
 
 3 
 
 6 
 
 Rupture of uterus, 
 
 21 
 
 IB 
 
 18 
 
 6 
 
 6 
 
 16 
 
 6 
 
 3 
 
 3 
 
 10 
 
 In regard to the two complications which we have placed at the 
 bottom of the above table, viz., post-partum hemorrhage and rup- 
 ture of the uterus, it will be observed that our present proposition 
 does not hold out so strictly with regard to them, and that they do 
 occur comparatively more frequently in first than in subsequent 
 labors. But this does not detract in any way from the previous 
 view which we took of them, as occasional results of the partial 
 obstruction offered by the male head. For there are sufficient 
 reasons why they should occur more rarely in first labors, though 
 these labors are more obstructed than those that occur subsequently. 
 In regard to rupture of the uterus, for example, it is now well 
 known to obstetricians that two causes may give rise to its occur- 
 rence, namely, first, over-action of the uterus, in consequence of 
 impediment to the passage of the child ;' and, secondly, any such 
 diseased condition of a portion of the uterine parietes as renders 
 that portion less resistant, and hence more easily lacerated, than the 
 
 sixth labors; 495 seventh labors ; 328 eighth labors; 164 ninth labors; and 491 were 
 instances in which the women were delivered for a tenth or later time. 
 
 ' " There is one fact," observes Dr. Collins, " which clearly shows disproportion to be a 
 frequent cause, namely, its being oftener met with in the expulsion of male children. Thus, 
 of thirty-four cases which I am about to state, twenty-three of the children were males, &o. 
 This is satisfactorily accounted for by the greater size of the male head, as proved by accu- 
 rate measurements made by Dr. Joseph Clarke." — Chapter on Rupture of the Uterus and 
 Vagina, in Practical Treatise, p. 242. 
 
 TOL. I. 25 
 
386 
 
 TEDIOUS LABOR. 
 
 other parts of the uterine walls. The first of these two causes is in 
 much stronger operation in male than in female births, and in first 
 than in future labors ; but the second cause comes more and more 
 into action with the frequency of the previous parturitions, the 
 uterine tissues being more and more liable to disease under the 
 strain of each successive pregnancy and labor. Hence, though 
 lacerations from obstruction are more common in first confinements, 
 the same accident, as a result of disease of the uterine structures, is 
 far more frequent in subsequent and later parturitions, so much so 
 indeed, as to cancel any argument that might be derived in favor of 
 its origin from mere obstruction, by the study of it in primiparous 
 mothers. 
 
 Again, post-partum hemorrhage, though more apt, as we have 
 already stated, to occur in cases in which the uterine action 
 has been protracted, and the contractile powers of the organ mor- 
 bidly exhausted, is not so liable to appear after tedious first labors 
 as after tedious subsequent labors, because it is a well-known and 
 acknowledged fact, that altogether the uterus contracts more per- 
 fectly and securely after first labors than after others. Hence the 
 well-known rarity of after-pains subsequently to first parturitions. 
 " A woman," says Dr. Power, " experiences little or no after-pain 
 with her first parturition, because the parietes of the uterus, not 
 having been weakened by previous distension, contract more per- 
 fectly and permanently, so as to obliterate and empty the cavity 
 thoroughly."' 
 
 In reference to the bearing of some of the results included in the 
 above tables upon the question we are discussing, it is proper also 
 to add, that the ratio in which some of the complications occurred 
 in first pregnancies, is greater in degree than can be accounted for 
 upon the doctrine of obstruction, and is partially dependent upon 
 other co-existing causes. I allude more particularly to the case of 
 puerperal convulsions. It is well known that in the practice of 
 all accoucheurs this complication is met with, principally in first, 
 and comparatively rarely in future deliveries.^ The mere amount 
 
 • Treatise on Midwifery, p. 190. 
 
 * The following table will show this fact better than any lengthened commentary : 
 
 Keported by 
 
 Total No. of 
 Puerperal Convulsiona. 
 
 No. of these occurring 
 in first labors. 
 
 F. Kamsbotham, . 
 J. Kamsbotham, 
 
 Lee 
 
 Merriman, .... 
 
 Clarke, 
 
 JohnB, 
 
 CollinB, 
 
 69 
 22 
 46 
 43 
 19 
 9 
 30 
 
 45, or 57 per cent. 
 15, or 68 " 
 30, or 65 " 
 36, or 75 « 
 15, or 79 " 
 8, or 89 " 
 29, or 96 " 
 
 Total, 
 
 233 
 
 178, or 76 per cent. 
 
SEX OF CHILD AS A CAUSE OF DIFFICULTY. 387 
 
 of obstruction present in first labors is not the sole explanation of 
 the large percentage of convulsions occurring in first confinements, 
 for impediments in the maternal passages in future deliveries are 
 not followed in any such degree by the same consequence ; and, 
 further, obstetric pathologists are now well aware that in almost 
 every case of puerperal convulsions, a predisposition t6 the aflfection 
 is given by one or more particular pre-existing morbid states of the 
 system. Various authors, as Demanet,' Osiander, Chailly, Johns, 
 &c., have correctly described the most common pre-existing morbid 
 condition as one marked by dropsical efiiisions in the face and else- 
 where. Of late years the pathology of these cases has been ad- 
 vanced a step farther, and the complication of convulsions shown to 
 occur only, or almost only, in women who have such confirmed or 
 temporary renal derangement as is marked by an albuminous state 
 of the urine. Dr. Lever suggests that this albuminous state of the 
 urine, the common state predisposing to puerperal convulsions, is 
 produced by pressure of the enlarged uterus upon the renal veins. 
 If this were the explanation, this complication should occur as fre- 
 quently in subsequent as in first labors, because the renal veins are 
 not more especially compressed in the one than in the other. But 
 to discuss any such question at present would be wandering from 
 our subject. "We have said enough to show that, in regard to puer- 
 peral convulsions and their frequency in first labors, we must takp 
 other points into consideration than the mere degree of obstruction 
 in order to account for their high over-proportion in first pregnan- 
 cies. 
 
 Before we proceed farther, let us pause for a minute, and simply 
 recapitulate the reasons that we have already given for considering 
 the greater size of the head of the male child as the cause of the 
 greater number of complications and casualties connected with 
 male births. First, I have shown that for the very marked differ- 
 ences existing between the difficulties and perils of male, as com- 
 pared with female births, there is no other traceable cause, in the 
 mechanism of parturition, than the larger size of the head of the 
 male child. "We have seen, Secondly, that an increase in the morbid 
 effects may be proved to be connected with an increase in this re- 
 puted morbific cause ; Thirdly, that when the alleged cause is di- 
 minished, the effects are diminished; and Fourthly, that in those 
 morbid complications in labor in which the cause is in abeyance, 
 the effect is also absent. Lastly, we have found that similar efifects 
 upon both mother and child are produced by other causes which are 
 similar in their character and amount. 
 
 • " Regarde I'anasarque comme une de leurs causes essentielles." — Reoueil Periodique de 
 la Society de M^deoine, torn. ix. for 1800-1, p. 110. 
 
388 TEDIOUS LABOR. 
 
 Wow, if in conducting any investigation into the explanation or 
 mode of production of a number of ascertained and acknowledged 
 facts, we found, amidst tlie assemblage of phenomena submitted to 
 our study, one supposed antecedent condition or probable proximate 
 cause perfectly answering the various reasons and tests to which, in 
 the preceding pages, we have already subjected the increased size of 
 the male over the female infant's head as the alleged cause of the 
 reputed greater danger and mortality attendant upon male births, 
 the evidence, in support of that circumstance as the vera causa of 
 these consequences, would be deemed of a very strong and decided 
 character. The evidence would become still more conclusive if it 
 could be shown, that though this vera causa appeared at first sight 
 to be in itself an agent quite inadequate for an explanation of the 
 various important effects traced to it, yet, when studied in its full 
 and proper relations, it could be proved to have necessarily sufficient 
 power and influence for the production of the results. Such we 
 shall now endeavor to prove to be the case with the slightly in- 
 creased volume of the head of the male over that of the female 
 infant, as the cause of the greater number of the casualties accom- 
 panying the birth of male children. 
 
 Sixthly, The greater size of the male than of the female infant's head is sufficient in itself to 
 explain the greater dangers attendant upon male than female births, when we consider it in re- 
 lation to its absolute and cumulative effects. 
 
 "No arguments are required," as Dr. Denman observes, "to 
 prove that a small body will pass through a small space with more 
 facility than one that is large ; the size of the body being supposed 
 to bear any reasonable comparison to the dimensions of the space. 
 Of course it may be presumed that the larger the head of the child 
 is at the time of birth, with the greater difficulty it will be expelled." 
 JSTor does the well-known compressibility of the human cranium at 
 birth alter this view in regard to the effects which an increased size 
 of the head is calculated to produce. " For though nature has, with 
 admirable wisdom," I quote the words of Dr. Osborne, " by means 
 of sutures and fontanelles, so constructed the head of the human 
 foetus that, in the passage through the pelvis, it may suffer the form 
 to be altered and the volume to be considerably diminished without 
 such injury to its contents as shall necessarily destroy life ; yet as 
 there is a volume beyond which each foetal head cannot suffer com- 
 pression with safety — so there is another and still smaller into which 
 it cannot be compressed at all."' 
 
 No one will be inclined to doubt the fact, that when the foetal 
 
 ' Essays on the PractioB of Midwifery, p. 188. 
 
BEX OF CHILD AS A CAUSE OF DIFFICULTY. 389 
 
 head is much increased beyond the common size at birth, its expul- 
 sion will be attended with more than the usual degree of difficulty. 
 But exactly the same effect may be produced by the infantile head 
 exceeding the required dimensions in only the most trifling degree, 
 provided it happens, from the particular conformation of the mother, 
 that the maternal pelvis and fcetal cranium are otherwise very nearly 
 and accurately adapted to one another. In such instances a dif- 
 ference in the size of the head, of the smallest amount, may involve 
 and change the whole question of the physical possibility or impos- 
 sibility of the passage of the infant. Dr. Hamilton, in his "Practi- 
 cal Observations," when speaking of the occasional difficulty of de- 
 termining in individual cases in practice, whether the maternal pas- 
 sages are or are not of such dimensions as to allow the child to pass, 
 and whether the infant's head may or not require to be diminished 
 by craniotomy, strongly remarks, " that in this question even a mis- 
 calculation of the sixteenth part of an inch might be fatal to the life 
 of an infant." " The author," he adds in a footnote, " has been ac- 
 customed to illustrate this practical remark to his pupils by a very 
 simple mechanical demonstration. He first shows the smallest pos- 
 sible aperture through which the foetal head of ordinary size can be 
 squeezed, and he then covers the head with a common towel, and 
 proves the utter impossibility of its then passing through the same 
 aperture. He does not believe that the addition of a common towel 
 can increase the diameter of the head more than the sixteenth part 
 of an inch."' 
 
 If Dr. Hamilton's calculation regarding the increase of the dia- 
 meter of the head in this experiment be true, viz., one sixteenth of 
 an inch, then here we have the transit of the foetal head entirely 
 prevented by an increase of size which is not more than half of that 
 difference (one-eighth of an inch), which we have seen to exist be- 
 tween the diameter of the standard male and the standard female 
 head at birth. 
 
 In relation to the question of the greater difficulties attendant 
 upon male births, it ought further to be always held in view, that when 
 the foetal head is notably above the medium standard, the infant is, in 
 a great majority of instances, of the male sex. Among the 120 in- 
 fants whose heads were measured by Dr. Clarke, only six were above 
 14-|- inches in circumference. These six were all males. Twenty- 
 nine of the children were as high as 8 lbs. and upwards in weight. 
 Of these 29, as many as 19 were of the male, and 10 only of the 
 female sex. Such facts require no comment. 
 
 But let us throw altogether out of consideration the more extreme 
 cases to which we have adverted, and look upon the question of the 
 
 ' Hamilton's Practical Observations, Second Edition, p. 254. 
 
390 TEDIOUS LABOR. 
 
 more numerous dangers attendant upon male births as the result 
 merely of the average slight increase of the standard male over the 
 standard female head at birth. Even under this limited view the 
 normal difference in size between them (about one-eighth of an inch 
 in diameter), inconsiderable as it may at first appear, will, we be- 
 lieve, afford us a perfectly sufficient explanation of the statistical 
 facts which we have brought forward in the preceding pages, provided 
 we consider what the accumulated mechanical effects of this differ- 
 ence in measurement would be when operating over a very wide and 
 extended range of cases of parturition. A few remarks will illustrate 
 our meaning. "We take for granted, that the act of parturition con- 
 sists of the dilatation of the female passages, and of the expulsion 
 of the foetus through them. Before the process can be terminated, 
 a very considerable amount and continuance of expulsive and dilat- 
 ing force is in general required. During it, the parietes of the 
 maternal passages are necessarily subjected to pressure from the ad- 
 vancing foetal head, and in turn the wedge-like foetal head itself is 
 compressed by the resisting passages. The whole process is rendered 
 the more tedious and difficult in consequence of the size of the head 
 of the foetus being nearly proportioned to the size of the passages of 
 the mother. What, then, will be the effects upon this whole pro- 
 cess, of such a difference in the dimensions of the foetal head as holds 
 good with regard to the relative sizes of the male and female at 
 birth, supposing the mother's pelvis and passages to be always, cceteris 
 paribus, the same in their capacity ? If the female infant's head, 
 when of the standard size, require for its transit a certain extent of 
 dilating and expulsive force — if it necessarily produce, during its 
 egress through the maternal passages, a certain amount of pressure 
 upon their walls in order to overcome the resistance which they 
 offer — and if, in turn, the head of the child be, under the same ac- 
 tion, compressed itself to a certain degree ; — then the standard male 
 infant's head (as being an eighth of an inch greater in diameter, 
 and consequently demanding more actual space for its transit), will 
 require proportionately a greater exent of dilatation in the maternal 
 passages, and a greater expenditure of force to effect this greater 
 dilatation ; it will hence also produce, during its egress through the 
 maternal canals, a greater amount of pressure upon their parietes, 
 and be itself reciprocally compressed to a greater degree. The dif- 
 ficulties and dangers to child and mother entailed by this latter state 
 of matters might well a priori be supposed to be exactly those that 
 we have shown them really to be under the various propositions that 
 we have previously laid down. 
 
 But that the birth of the male, as compared with the female child 
 is accompanied with more obstacles and delay, need not be an in- 
 
SEX or CHILD AS A CAUSE OF DIFFICULTY. 891 
 
 ference resting solely, as it does above, upon abstract though satis- 
 factory reasoning — for it is a matter which should admit of direct 
 statistical and arithmetical proof. If our data were sufficiently pre- 
 cise and extensive, we ought to be able to prove, that, as a 
 
 TWELFTH PROPOSITION 
 The average duration of labor is longer with male than with female children. 
 
 Dr. Collins has given a table' showing the number of his 
 patients that were delivered in " one quarter of an hour," " in one 
 hour," "in two hours," &c., from the commencement of labor. 
 The sexes, however, of the children are not distinguished, so that the 
 data are of no avail in regard to their bearing upon the proposition 
 we have just stated. I^or am I aware that there has been as yet any- 
 where published such a series of facts as would enable us to prove 
 statistically that the birth of the male child is absolutely longer than 
 that of the female, in the time required for its completion. The 
 average duration of labor in the European female is about four or 
 five hours. The average duration of male births will probably be 
 found, when sufficient evidence is collected, to be about a quarter 
 of an hour or half an hour longer than that of females. I venture 
 to make this allegation, in regard to the common run of labors, 
 upon the evidence affijrded by an assemblage of cases, now lying 
 before me, in which the process was somewhat protracted beyond 
 the usual standard. The cases I allude to were collected under the 
 following circumstances. In 1836 a separate register was begun in 
 the Edinburgh Lying-in Hospital of those labors in which the date 
 of the commencement of the process and the comparative length of 
 each successive stage could be ascertained with sufficient accuracy. 
 Those cases in which the labor was very speedy, and indeed all that 
 were less than three or four hours ill, were not entered, because in 
 most of them the duration of the labor and its stages could not be 
 noted with the accuracy required ; many of these patients only en- 
 tering the hospital a few minutes before delivery. About half of 
 the labors in the Dublin Hospital appear to have been terminated 
 within the first two or three hours,^ so that our Edinburgh register, 
 as wanting that proportion of the more rapid cases, cannot show the 
 average length of the process in ordinary instances. The records, 
 however, which it contains of the cases protracted beyond the 
 period mentioned have, I know, been kept with adequate care,^ and 
 
 ' Practical Treatise, p. 22. 
 
 '^ Of the 15,850 cases noted by Dr. Collins, 7063 were terminated within two hours, and 
 9550 were within three hours from their commencement. 
 
 'A number of the entries were made by myself when annual pupil at the hospitalin 1836- 
 7, and have been continued by others in that office. 
 
392 
 
 TEDIOUS LABOR. 
 
 seem capable of furnisWrig us with sound and unprejudiced evidence 
 upon the present topic, inasmuch as they were originally noted 
 without any view to such an inquiry as this into the comparative 
 duration of male and female births. In analyzing the register I find, 
 that, from 1836 to 1841 inclusive, 249 male and 178 female births 
 are entered, with notes of the precise length of the labor in each. 
 The following table will show the absolute and average duration of 
 the labors with male and female children in these 427 cases. 
 
 Labors. 
 
 Absolute duration of the 
 whole cases. 
 
 Average duration of each 
 labor. 
 
 With male children. ) 
 (249 in number), ) 
 
 With female children ) 
 (178 in number). 5 
 
 Hours. Minutes. 
 2646 33 
 
 1702 29 
 
 Hours. Minutes. 
 10 38 
 
 9 34 
 
 Average greater length of the male birth, 
 
 1 4 
 
 In those classes of labor in which the process becomes morbid 
 from tediousness or other complications and difficulties of a more 
 serious character, the difference between the duration of the male 
 and female births would seem to be even greater than the above 
 table displays. At least such an inference appears deducible from 
 the analysis which I have made, from Dr. Collins' tables, of the com- 
 parative length of the male and female births in the records which 
 he has given of 507 still-born children (including the putrid and 
 premature), of 97 morbidly tedious labors, 68 crotchet cases, and of 
 130 instances in which the mother died in connection with delivery. 
 The preceding numbers include all the cases, under these several 
 heads, in which the exact duration of the labor is mentioned in Dr. 
 Collins' tables. The result is this : — 
 
 
 The average duration 
 
 The average duration 
 
 The average greater 
 
 Labors. 
 
 of the male births 
 
 ofthe female births 
 
 length of the male 
 
 
 was 
 
 ■was 
 
 births was 
 
 With still-births (310^ 
 
 Hours. Minutes. 
 
 Hours. Minutes. 
 
 Hours. Minutes. 
 
 males and 197 fe- > 
 
 14 27 
 
 12 10 
 
 2 17 
 
 males), ) 
 
 
 
 
 Morbidly tedious (56 ^ 
 
 
 
 
 males and 41 fe- y 
 
 43 18 
 
 40 12 
 
 3 6 
 
 males), ) 
 
 
 
 
 Requiring crotchets J 
 
 
 
 
 (44 males and 24 > 
 
 42 22 
 
 38 20 
 
 4 2 
 
 females), ) 
 
 
 
 
 Leading to death of the J 
 
 
 
 
 mother (86 males \ 
 
 18 9 
 
 12 58 
 
 5 11 
 
 and 44 females), ) 
 
 
 
 
 The evidence afforded by the foregoing table appears almost enough 
 to warrant us in qualifying the proposition we have laid down, to 
 
SEX OF CHILD AS A CAUSE OF DIFFICULTY. 393 
 
 this extent, that the " average duration of labor is longer with male 
 than female children, and the difference in this respect between male 
 and female births, becomes increased in length when the labors 
 become more severe and dangerous in their character." 
 
 The remarks and proofs that we have now offered may tend to 
 remove the difficulty which the inquirer may at first entertain re- 
 garding the supposed inadequatenesss of the slightly increased size 
 of the male head to produce all the greater number of casualties and 
 complications that we have traced to be connected with male births. 
 For it will probably be allowed that the principal, or indeed sole 
 obstacle, which the mind has to contend with, in allovnng the very 
 small size of the male over the female infant's head to be the cause 
 of the remarkable differences which we have traced between the re- 
 sults of male and female births, consists in the difficulty of at first 
 supposing so slight an apparent cause to be the agent by which such 
 remarkable consequences are brought about. But in considering 
 this and the analogous questions, it must be held in recollection, 
 that in all processes, whether vital or physical, in which, as in par- 
 turition, an established relation of mechanical conditions is required, 
 any disturbance in these conditions, however small and trifling in 
 itself will, ultimately, and when followed out through numerous and 
 extended series of observations, be found to lead to results the mag- 
 nitude of which could scarcely have been previously surmised. 
 These results may not be appreciable when we confipe ourselves to 
 the study of the agency in an individual case, or in a small number 
 of cases merely, but they become more and more marked in pro- 
 portion as the number of our instances become more and more ex- 
 tensive. The effects cannot be distinctly seen when we look for 
 them in a limited series of data, but they may be evoked with all 
 the force of a mathematical demonstration, when we prosecute our 
 calculations for them among large and accumulated masses of ob- 
 servations. Prom any study, however minute and accurate, of a 
 limited number of cases of labor, no man would probably feel him- 
 self entitled to conclude that male are in any notable degree more 
 difficult and dangerous than female births ; but this, as we have 
 seen, becomes a demonstrable and strongly marked fact, when we 
 direct our inquiries after the truth of it into the records of hun- 
 dreds or thousands of carefully reported observations, such as we 
 have made use of in the course of the preceding inquiry. 
 
 The remarks we have hitherto made upon the male sex of the 
 child as a cause of delay, difficulty, and danger during labor, have 
 referred principally to the larger size of the male infant's head or 
 cranium. In that condition, and its effects, we have so far found a 
 satisfactory explanation of the numerous complications and casual- 
 
394 TEDIOUS LABOR. 
 
 ties to wHeh the mother herself is subjected in male births. One 
 or two additional observations may be required to show more 
 specifically in what manner the safety and life of the mal6 child 
 during labor, and for some time after it, is endangered by the same 
 circumstance. We believe that the larger size of the contents of 
 the male, than of the female cranium, or, in other words, the larger 
 size of the male brain or encephalon at birth, and the consequent 
 greater compression and injury to which it is subjected during 
 birth, affords us the proper clue to the explanation of these peculiari- 
 ties in the male infantile mortality. 
 
 The weight, and hence the size of the brain, is now well ascer- 
 tained to be absolutely more in the adult male than in the adult 
 female. From measurements of the interior of numerous crania, 
 Sir William Hamilton' computes the male adult encephalon as 
 weighing 3 lbs. 8 oz. Troy, and that of the adult female as 3 lbs. 
 4 oz. Professor Eeid carefully weighed in the Edinburgh Infirmary 
 the encephalon of 53 adult males and 34 adult females. The average 
 weight of the male brain in these observations was 8 lbs. 2 oz. 3J 
 drachms ; that of the female, 2 lbs. 12 oz. 8J drachms ; and the 
 average difference in favor of the male encephalon thus amounted 
 to 5 oz. 11 drachms.^ This difference in weight between the ence- 
 phalic contents in the two sexes exists also at birth. In an elaborate 
 paper on the weights of the brain in the different sexes, &c., by 
 Professor Tiedemann,^ founded on numerous observations, that 
 distinguished anatomist states that " the female brain weighs on an 
 average 8 ounces less than that of the male, and this difference is," 
 he adds, " already perceptible in a new-born child." In one of his 
 tables Tiedemann adduces the weight of the brains of two male and 
 two female infants at birth. The average weight of the two male 
 brains was 13 oz. 6 drachms 20 grains ; the average weight of the 
 two female, 10 oz. 44 grains ; and the average excess of size of the 
 encephalon of the male infant, as deducible from these four observa- 
 tions, 3 oz. 5 drachms 36 grains. But this result is probably much 
 higher than a more extended number of data would give, in con- 
 sequence of one of the female children in the table being evidently 
 below the standard size and weight of the girl at birth. 
 
 There is another way by which, in the present deficiency of direct 
 facts bearing upon this point, we may arrive at the same conclusion, 
 with equal or greater certainty. " The weight of the brain," says 
 Tiedemann, " of a new-born child is relatively to the size of the 
 
 ' Monro's Anatomy of the Brain, 1831, p. 12. 
 
 2 London and Edinburgh Monthly Journal for 1843, p. 322. See also Dr. Sim's paper in 
 the London Medico-Chirurgical Transactions, vol. xix., for similar results. 
 ' London Philosophical Transactions for 1836, p. 502. 
 
SEX OP CHILD AS A CAUSE OP DIFFICULTY. 395 
 
 body as one to six." The male infant at birth is, as we have seen, 
 on an average, about nine or ten ounces heavier than the female. 
 If the above ratio between the brain and whole body holds equally 
 true (as there is every reason to believe) of the two sexes, the male 
 brain should, on an average, be one-sixth part of this heavier than 
 the female brain at the time of delivery. Hence the male ence- 
 phalon is, in the infant at birth, about IJ ounces heavier than the 
 female encephalon, and the male brain and cerebellum altogether 
 about one-ninth or one-tenth greater in weight, and consequently 
 in size, than the brain and cerebellum of the female. 
 
 The immediate effects, during parturition, of this much greater 
 size of the male encephalon upon its own delicate structures are 
 evident. For as, cceteris paribus, the pelvic passages are always the 
 same in their dimensions, the larger and heavier male brain will, in 
 its forcible transit through the given standard space of the maternal 
 canal, of necessity suffer more physical compression and injury than 
 the smaller female head and brain. 
 
 Connected with the structural economy of the brain of the new- 
 born infant, there are some circumstances which are calculated to 
 render such degrees of injury as we have adverted to, more extensive 
 in their influence, and more permanent in their results, than similar 
 amounts of injury of these same parts at other later periods of life. 
 For, First, the brain of the infant at birth is still so soft and almost 
 semifluid, and its vessels so large, as to be more easily lacerated 
 than years afterwards under the same extent of pressure. Secondly, 
 the brain at that particular period of life, and for ten or twelve 
 months afterwards, is undergoing great and rapid normal changes 
 from its imperfect embryonic state to the anatomical consistence, 
 form, and organization which it is to present during the remainder 
 of life. "From birth," observes Billard, "to the first year, the 
 brain of the infant is in a true state of transition, so that this organ, 
 which is scarcely formed at first, arrives, towards the ninth month 
 or first year, at the organization proper to the brain of adults. 
 Ought we not," he adds, "to attribute to this modification super- 
 vening in the brain of infants, the frequency of cerebral affections 
 at the age of which we speak ?"^ 
 
 But there is a third peculiarity, probably even more important 
 than the two others. The human brain is very much larger in pro- 
 portion to the body in the infant, than it is in the adult. In a full- 
 grown adult the proportion of the brain to the body is as about 1 to 
 40 ; in the infant it is, as we have already stated, about 1 to 6, or 
 nearly seven times greater. The infiuence of this immense differ- 
 
 ' Billard, Traite des Maladies des Enfans, p. 335, Brussels ed. 
 
396 TEDIOUS LABOR. 
 
 ence is important botli pliysiologically and pathologically.* The 
 nervous system in the infant is thus rendered naturally much more 
 susceptible and sensitive of physical and sympathetic morbid 
 impressions than at a more advanced age f — pathological irritations 
 and disturbances of other parts are far more readily and strongly 
 reflected upon the nervous centres; — and, for the same reason, any 
 direct lesion or disease of the brain itself comes also in turn to exert 
 a more potent and extended effect upon the general and individual 
 functions of the body, than at other later periods of life. All these 
 conditions are heightened and increased in the male as compared 
 with the female infant at birth, both, first, by the greater absolute 
 size of the male brain; and, secondly/, by the greater lesions and 
 injuries to which it is subjected during the process of labor. I have 
 collected some statistical data to show that the particular diseases 
 which destroy so many more male than female children immediately 
 after birth and for a short time subsequent to it, and which are 
 therefore the evident and demonstrable causes of the excess of the 
 male over the female mortality at that early period of hfe, are all 
 such as are capable of receiving an explanation of their more marked 
 frequency, severity, and danger upon the above principles, in con- 
 junction with the consideration of the increased size and increased 
 injuries, at birth, of the male as compared with the female ence- 
 phalon. To adduce evidence of this to the amount that might be 
 necessary, would require us to extend this essay far beyond the 
 limits prescribed to -it, and these it has already far overstepped. I 
 may, on another occasion, return to the subject ; and, in the mean- 
 time, shall only add, that the particular affections alluded to, as 
 producing the excess of the male over the female mortality, which 
 
 ' Tiedemann, on whose authority I have given the respective proportion, stated in the 
 text, of the whole brain in the infant and in the adult, observes, in relation to this point, and 
 his words apply equally to the morbid as to the healthy states of the system, " The different 
 degrees of susceptibility and sensibility of the nervous system seems to depend on the 
 relative size of the brain as compared with that of the body. Children and young people 
 are more susceptible, irritable, and sensitive than adults, and have a relative larger brain. 
 In diseases which affect the nourishment of the body, the susceptibility increases as the 
 patients grow thinner. The susceptibility and sensibility decreases on the other hand, with 
 persons recovering from a long illness gradually as they regain their strength. The degree 
 of sensibility in animals is also in proportion to the size of the brain. Mammalia and birds 
 have a large brain, and are more susceptible than amphibious animals and fishes." — Lon- 
 don Philosophical Transactions, vol. cxxvi. p. 503. 
 
 ^ " The nervous system in infants is naturally in a very susceptible condition ; it is 
 consequently easily excited on tlie application of the slightest impressions. This constitu- 
 tional irritability is characteristic of the infant state .... The nervous sensibility is 
 in excess at this age, and whatever be the disease with which the infant is affected, a 
 morbid excitability and irregularity of action in the nervous system are more or less its 
 attendants." — Stewart's Practical Treatise on the Diseases of Children, New York, 1841, p. 
 494. See also Maunsell and Evanson on the Diseases of Children, p. 13, &c. 
 
SEX OF CHILD AS A CAUSE OF DIFFICULTY. 397 
 
 is 80 remarkable at birth, and progressively decreases from that 
 time onwards, are almost all referable in their origin or course to 
 morbid states and disturbances of the nervous system,' and to func- 
 tional derangements and inflammatory action in it and other organs 
 of the body. 
 
 PRACTICAL INFERENCES, AND EXTENT OF INFLUENCE EXERTED BY THE 
 MALE SEX OF THE INFANT UPON THE GENERAL MATERNAL AND IN- 
 FANTILE MORTALITY DURING PARTURITION AND FOR SOME TIME SUB- 
 SEQUENT TO IT. 
 
 The subject of the preceding inquiry is certainly not without 
 interest in a physiological point of view. 'Not is it devoid of im- 
 portance in a pathological and practical light. The results of the 
 whole investigation show us with demonstrative force that the 
 adaptation of the foetus to the maternal passages in human parturi- 
 tion is, in general, so close and perfect, that a deviation in their 
 relative size of the slightest possible extent, is capable of altering 
 immensely, when the subject is viewed on a large scale, the conse- 
 quences of the process as regards both the immediate safety and 
 life of the mother and infant, and their subsequent welfare. We 
 may be hence led to see more strongly than previously the advan- 
 tages attendant upon the presentation of the head of the infant in 
 its most natural position, and consequently in its smallest diameter, 
 and the disadvantages accompanying any deviations in its presenta- 
 tion, seeing that all these deviations ofler a larger circumference 
 than the normal parietal case. The same inquiry illustrates well the 
 importance of saving, and particularly in cases in any degree tedious, 
 or in any slight malpresentation, the space of the pelvic passages as 
 much as possible, by keeping the rectum and bladder empty, by 
 carefully guarding against congestion and tumefaction of the soft 
 tissues lining the pelvis, and by promoting, by all appropriate 
 means, the dilatability of the maternal passages. "We can easily, 
 from the same data, understand how greatly the dangers of the 
 mother and child are increased by organic contractions, however 
 slight, in the pelvic passages and bones themselves, and by increased 
 volume on the part of the infant, whether that increased volume be 
 the efiect merely of excessive growth or the result of actual disease. 
 
 The object of our investigation becomes one of still more prac- 
 tical moment when we consider it in relation to the extensive cha- 
 racter of its operation and influence. 
 
 ' " The diseases of the nervous system," observes Mr. Farre, " are twenty-three per cent. 
 more fatal to males than females, tke chief difference arising from the diseasei which affect 
 children." — Registrar-General's Second Annual Report, Appendix, p. 4. 
 
398 TEDIOUS LABOK. 
 
 The importance of any cause of human disease not so much 
 depend upon the immediate intensity and danger of the morbid 
 action which it is calculated to excite in single individuals; as upon 
 the frequency and extent of its operation, and the consequent amount 
 of its effects upon the general community. In this way a slight 
 disease or slight cause of disease, which acts upon a great propor- 
 tion of the population, may become as important in its ultimate 
 and practical results as a malady of the most formidable character, 
 provided that malady is much more narrowed and limited in its 
 attacks. " The cholera," observes Quetelet,' " and the influenza 
 are diseases which differ greatly from each other; the one is a 
 dreadful scourge, which manifests itself in the most dreadful man- 
 ner; the other, in its ordinary external appearance, resembles a 
 catarrh or common cold ; and yet the tables of mortality prove, 
 that, although the latter disease is not so deadly, it nevertheless, in 
 consequence of its universality, and in consequence of the sufferings 
 it causes, produces results nearly as extensively fatal as cholera. 
 Facts serving to confirm this opinion may be found in the excellent 
 work published by Dr. Gluge on the History of Influenza."^ 
 
 The remark which we have applied to diseases and the causes of 
 disease holds equally true with regard to morbid complications in 
 midwifery and their causes. Those special states which, in obstetric 
 practice, are seen to lead to some of the most formidable causes of 
 difficult labor, such as tumors in the pelvis, malpositions of the 
 infant, inertia of the uterus, &c., are certainly often most disastrous 
 in their immediate effects, but yet, upon the whole, they are com- 
 paratively so rare in their occurrence as not individually to lead, 
 upon a large scale, to consequences of so severe and fatal a cha- 
 racter, as disturbing agencies of a far slighter, but far more general 
 kind, such as that inconsiderable enlargement of the ihale over the 
 female head, which we have been considering in the preceding 
 pages. A few computations will best illustrate and enforce the 
 truth of this abstract remark. These computations I shall found 
 on the idea that the bases of calculation offered by the data of the 
 Dublin Hospital are sufficiently correct to serve for a ground of 
 analysis of other analogous statistical results. To avoid as far as 
 possible any probability of great errors, we shall keep our calcula- 
 tions considerably within the limits that our apparent standards 
 might seem to warrant. 
 
 With this explanation, let us proceed to inquire to what extent 
 the cause of difficulty and danger during labor, which forms the 
 topic of our present essay, fatally influences each single year in 
 
 ' Natural History of Man, p. 112. 
 
 ' Die Influenza oder Grippe, u. s. w. Minden, 1837, 8vo. 
 
SEX OF CHILD AS A CAUSE OF DIFFICULTY. 
 
 399 
 
 England, or during a succession of years, the results of parturition, 
 as respects the fate both of the mother and infant. Some facts, 
 recorded by Mr. Farre, in his admirable contributions to the dif- 
 ferent annual reports of the Eegistrar-General, will serve as matters 
 of comparison on these points with the Dublin Hospital returns. 
 
 Number of maternal deaths referable annually in Cheat Britain to the influence of the compara- 
 tively great size of the head of the male infant. 
 
 In the returns of Drs. Clarke and Collins, we have reports in the 
 Dublin Hospital of the sex of the child in 368 cases in which the 
 mother died from labor or its consequences. In 231 instances the 
 child was male ; in 137 cases it was of the female sex. The pro- 
 portion of maternal deaths, after male and female births, was there- 
 fore as follows : 
 
 Total deaths. 
 
 With male 
 children. 
 
 With female 
 children. 
 
 Proportion of 
 males to females. 
 
 368 
 
 231 
 
 137 
 
 168 to 100 
 
 If we venture, then, to compute from this data, that out of 250 
 mothers that die in childbirth from parturition or its effects, 150 
 have given birth to males and 100 to females, as the above table 
 would seem to show, then we have in every 250 maternal deaths an 
 actual excess of 50 cases of loss of the mothers after male births, for 
 which, for reasons which we have previously stated at length, we 
 can find no other explanation than the greater comparative size of 
 the male head, and we have already attempted to prove that this 
 explanation is in itself logically and amply sufficient to account 
 for the consequences which we have attributed to it. In other 
 words, among every 100 parturient mothers that die, we have 
 40 perishing after producing female children, other 40 perishing 
 after producing male children, and the remaining or additional 
 20 in the 100 perishing also after the birth of males, but so far 
 forming a regular and constant excess of 20 per cent, of deaths in 
 connection with male births, traceable to no other cause than the 
 sex and consequent size of the infant. One in every 5 maternal 
 deaths, or 20 in every 100, and 200 in every 1000, are so far 
 the direct or indirect consequences of the greater dimensions of 
 the head of the male infant. IJfow, at the present day in Great 
 Britain, upwards of 3000 women die every year from childbirth 
 or its immediate effects. Hence, according to the above compu- 
 
400 TEDIOUS LABOR. 
 
 tation, 600 of these 3000 cases,* as forming the excess of male over 
 female births, are more or less immediately the results of the 
 sex and size of the male infant. In Great Britain, therefore, the 
 valuable lives of 500 mothers, to speak within terms, are annually 
 lost in childbirth through the influence and agency of the cause in 
 question. 
 
 Number of infantile deaths occurring annually in Great Britain during labor, and referable to 
 the sex and size of the male infant. 
 
 We have seen under our fourth proposition, that in the Dublin 
 Hospital there died, during the process of parturition, and probably 
 as a consequence of the injuries to vs^hich they were subjected, 151 
 male children for every 100 females. According to the mode of 
 argument followed in the preceding paragraph, there was thus an 
 excess of 50 male deaths among every 250 children, or 20 in every 
 100, referable to the greater size of the head of the male infant. 
 Further, we may take it for granted that, on a low computation, 1 
 in every 50 children born dies during labor, about 1 in every 25 
 cases being a still-birth. To be certain, however, not to overstep 
 our limits, let us reckon only one in every 75 children to die during 
 parturition, and 1 in every 5, or 20 per cent, of those that thus perish, 
 to be formed by that excess of the mortality of males over females 
 which we can trace to no other cause than the influence of the greater 
 dimensions of the male head. In England and Wales about 500,000 
 births take place annually.'' By the above computation more than 
 6500 of the ofispring of these births die during labor, and one- 
 fifth of that number are lost in consequence of the sex and size of 
 the male child. In Great Britain, therefore, the lives of 1500 infants 
 are annually lost in childbirth from the operation of this agency. 
 
 ' During the four years from 1838 to 1841, there died in childbirth in England and Wales 
 1 ] ,722 mothers. In 1 841, the last year of which the returns are yet published, 3007 women 
 died in childbed in England and Wales. — Fifth Annual Report of the Registrar-General, p. 
 380. If to these we add 500 deaths as occurring in childbed in Scotland, we will be much 
 within the limits in computing 3000 maternal deaths to take place annually in Great Britain 
 from labor or its immediate consequences. I reckon 500 deaths as occurring annually in 
 Scotland in childbed on the calculation which seems to hold in regard to England, that 
 nearly 200 deaths happen every year from this cause in every million of the general 
 population. 
 
 2 " In 1841, 512,158 births were registered, 1840,502, 203, and in 1839, 492,574."— Regis- 
 trar General's Fifth Report, p. 8. It seems doubtful if all the births that occurred were 
 registered, as this, like the other branches of registration, could not at onee be made per- 
 fectly efBcient. Certainly it is to be greatly lamented that there is no official return of 
 the still-births. The omission is a most extraordinary one, and surely ought to be corrected. 
 
SEX OF CHILD AS A CAUSE OF DIFFICULTY. 401 
 
 Number of infantile deaths occurring annually in Great Britain within the first year of life, 
 referable to the influence of the sex and size of the male'child during labor. 
 
 In 1841 there died in England and Wales, within the first year of 
 life, 41,444 boys and 32,766 girls. There was thus an excess of 
 8678 deaths of male infants within the first year, and 3610 of this 
 excess occurred within the first month after birth. In considering 
 this subject under our seventh proposition, I have already stated our 
 reasons for considering the excess in question of male over female 
 deaths, in very early infantile life, as owing to the greater injury 
 sustained by the head and nervous system of the male child in its 
 passage through the pelvis during delivery. I have further com- 
 mented on the same subject in speaking of the excess of size of the 
 male head and encephalon as the probable cause of the greater 
 difllculties attendant upon male births. Under these points enough 
 has been stated to show that a large proportion, if not the whole, of 
 the remarkable excess of the male over the female mortality, which 
 is observable for some time after birth, is traceable to the greater 
 dimensions of the male head and encephalon, and their consequent 
 greater compression and injury during delivery. Supposing these 
 views to be perfectly correct, there die annually in Great Britain 
 upwards of 5000 children within the first year after birth, whose 
 death is referable to the influence of the sex and greater size of the 
 male head during labor. 
 
 If we add together the three series of observations that have been 
 stated under the preceding heads, the result is as follows : upwards 
 of 7000 deaths in all, namely, above 6500 of the deaths of infants during 
 and after hirth, and 500 of the deaths of mothers in ehildbed occurring 
 annually in Great Britain, are referable to the direct or indirect agency 
 of the cause that we have been discussing, viz., the sex and larger size of 
 the head of the male child. 
 
 In using here the term cause in reference to the slightly greater 
 size of the male head as the source of the results that we have above 
 ascribed to its influence, it may be proper to state the precise meaning 
 which we attach to this term. Amidst all the uncertainties of 
 medical language, there is no phrase which has had more vague and 
 contradictory significations attached to it. Except in the cases in 
 which disease and death are produced by the immediate action upon 
 the body of severe physical injuries, or strong chemical agents, it 
 rarely or never happens that serious and fatal morbid actions are 
 excited in the economy through the operation of one single morbific 
 cause. In most, if not in all, other instances, a number of causes 
 are found to have acted either in concourse or succession towards 
 the production of the disease that may be present, and the effect to 
 
 TOL. I. 26 
 
402 TEDIOUS LABOR. 
 
 which it leads. According to the order which these several causes 
 may occupy in the series or chain of antecedent sequences, and ac- 
 cording, in some instances, to their supposed relative importance 
 and intensity in the production of the existing morbid action, they 
 are individually described by pathologists as accessory or determining 
 — remote or immediate — predisposing or exciting — in relation to the 
 disease that has been originated by their combined influence. Hence 
 a cause which may be termed predisposing in one case may be more 
 properly designated exciting in another, or the reverse, and conse- 
 quently different authors often describe the same cause under oppo- 
 site heads.' Further, it seldom occurs during the course of a fatal 
 disease that the same cause which had especially excited the original 
 malady continues, by the intensity of its own immediate action, to 
 lead to the fatal result. An example will illustrate our meaning. 
 All pathologists look upon excess in eating and drinking as a com- 
 mon cause of disease. If the body be debilitated by previous morbific 
 agencies, a fit of intemperance may suddenly excite in it some serious 
 and deadly morbid action, as extensive effusions or inflammation, 
 severe fevers, &c., and thus act as an exciting cause of these diseases ; 
 or when the powers of the constitution happen at any time to be 
 impaired by intemperance, the appHcation of an excess of cold or 
 heat may lead to similar consequences, and then the cause we are 
 considering (the intemperance), would be regarded as a predisposing 
 one. Further, it rarely happens that intemperance in eating or 
 drinking leads to death by the mere excess of their own action and 
 influence on the body. Few men, in other words, die of direct 
 gluttony, or direct intoxication ; but many die from intemperance 
 in .eating and drinking, leading directly or indirectly to a variety of 
 maladies, such, according to Dr. Copland, as " plethora, inflamma- 
 tory complaints, functional and organic diseases of the stomach, 
 liver, and bowels, gout, apoplexy, paralysis," &c.^ 
 
 The view which we have stated as generally taken by pathologists 
 with regard to intemperance as a cause of disease and death, applies 
 exactly to the greater size of the male head as a cause of the greater 
 number of complications and casualties connected with male births. 
 In some instances this excess of size acts as a predisposing cause to 
 
 ' For instance, Drs. Copland and Craigie, two of the latest British writers on practical 
 medicine, speak of intemperance in food and drink under two different heads. " Amongst 
 the most frequent predisposing causes to disease is," says Dr. Copland, " intemperance in 
 food and drink.'' — Dictionary of Practical Medicine, Partii. p. 562. Dr. Craigie enumerates 
 the same morbific agency among his exciting or occasional causes of disease. — Elements of 
 the Practice of Physic, p. 18. Dr. Williams, again, describes excess of aliment among his 
 eJcoiting causes of disease, and habitual excess in stimulating drinks among his class of pre- 
 disposing causes. — Principles of Medicine, 1843, pp. 9 and 24. 
 
 ' Medical Dictionary, Part ii. p. 562. 
 
SEX OF CHILD AS A CAUSE OF DIFFICULTY. 403 
 
 the accidents and diseases that are consequent to it, and, without its 
 antecedent or concurrent agency, these accidents and diseases would 
 not be produced. In other instances, it acts as a determining or 
 exciting cause of the morbid conditions and complications resulting 
 from its operations. We will take an illustrative example from an 
 accident which we have already spoken of in a previous page, viz., 
 rupture of the uterus. When rupture of the uterus occurs in a 
 patient who has already borne a large family, and where the uterine 
 parietes are, from some pre-existing disease, much more weak and 
 lacerable at one part than another, the greater delay and difficulty 
 of the labor in connection with the larger sized male head may give 
 rise ultimately to the complication in question, when the shorter and 
 more easy passage of a smaller foetal head would not have led to 
 the same disastrous consequence. Here the previously diseased 
 state of the uterus acts as the predisposing, whilst the larger size of 
 the male head acts as the exciting or determining cause of the lesion. 
 On the other hand, when rupture of the uterus occurs in a first 
 labor in consequence of the larger size of the male head calling 
 forth a morbid and inordinate degree of uterine contraction for its 
 expulsion, we have this inordinate uterine contraction acting as the 
 exciting or determining cause of the injury, and the excess of size 
 of the male head standing now in the relation of the predisposing 
 cause to it. Further, like other pathological causes, the excess of 
 size of the male head does not so often lead to accidents and death 
 by the mere influence of its own intensity, or by the effects of direct 
 compression upon the maternal passages or infantile head, as by 
 leading to the supervention and excitement of various other formi- 
 dable and fatal complications, such as morbid delays in the labor 
 demanding instrumental interference, eclampsia, post-partum hemor- 
 rhage, puerperal fever, &c., on the part of the mother — and convul- 
 sions, nervous and inflammatory diseases, &c., on the part of the 
 infant. 
 
 Under the signiflcation and reservations which we have thus 
 stated, we repeat that the greater size of the male foetal head is the 
 more or less immediate cause of a large number of those maternal 
 and infantile deaths that take place in connection with labor, or as 
 a result of that process. In illustration of this remark, I shall venture 
 to add another observation — one which may at first seem sufficiently 
 startling to those who have not practically directed their attention 
 to the subject, though it is but a simple and direct deduction from 
 the facts we have so imperfectly brought forward in the preceding 
 pages. It is this : 
 
 The official returns of the mortality of England and Wales have 
 only, as yet (1844), been collected for somewhat upwards of seven 
 
404 TEDIOUS LABOR. 
 
 years, viz., from 1st July, 1837, to the present date. If tlie calcula- 
 tions we have already given are accordant with truth (and we believe 
 them to be much within the limits), there have been lost in Great 
 Britain during that limited period, as a consequence of the slightly 
 larger size of the male than of the female head at birth about 50,000 
 
 LIVES, INCLUDING THOSE OF ABOUT 46,000 OR 47,000 INFANTS, AND OP 
 BETWEEN 3000 AND 4000 MOTHERS WHO HAVE DIED IN CHILDBED. 
 
 Since the appearance of the preceding memoir, additional and confirmatory statistics 
 have been given to the profession. In France, M. Chereau, whose attention was called 
 to the subject by the perusal of Dr. Simpson's paper, has analyzed the official returns of still- 
 births in Paris from 1817-36, drawing deductions from them similar to those expressed in 
 the propositions laid down by Dr. Simpson. His paper will be found in the Annales 
 d'Hygifene Publique, 1846, torn, xxxvi. p. 65. — (Ed.) 
 
 ON HEAD PRESENTATIONS, 
 
 WITH THE FOREHEAD ORIGINALLY DIRECTED FORWARDS OR 
 TOWARDS THE PUBIS.' 
 
 (From the Northern Journal of Medicine, April, 1846, p. 216.) 
 
 At the Maternity Hospital, you have had repeated opportunities 
 of watching cranial presentations in which the face or forehead of 
 the child was primarily directed forwards, or towards the pubis. 
 The Hospital records amply testify to the frequency with which 
 some of you have met with this position of the infant's head. At 
 the same time, you must permit me to remark that, for obvious 
 reasons, I do not place any great reliance upon the perfect accuracy 
 of the reports of positions entered in these records by the younger 
 pupils. In fact, one of their principal objects in Hospital and Dis- 
 pensary instruction is, to acquire, among other matters, a practical 
 knowledge of the subject of positions — and to consider them always 
 accurate on this point, is to presuppose them already proficients in 
 a difficult department of clinical observation. But Dr. Martin Barry 
 (our invaluable House Surgeon, and a gentleman to whose talents, 
 and zeal, and humanity, the hospital is deeply indebted for its pros- 
 perity) has been so kind as to furnish me with a table showing the 
 positions of the head in 335 cranial presentations, that he had him- 
 self carefully observed and noted among the patients of the Insti- 
 tution, and on which, therefore, we may place implicit confidence. 
 I shall classify these 335 presentations according to the four positions 
 and numerical nomenclature used by many of the German schools. 
 
 ' A Clinical Lecture. 
 
IRRBGTJLAIIITIES OF HEAD PRESENTATIONS. 405 
 
 Table showing the Positions of the Head in 335 Cranial Presentations at the Edinburgh 
 ^Maternity Hospital, 
 
 I. — OCCIPITO-ANTEBIOK POSITIONS. 
 
 First Position ; or occiput directed to left foramen ovale, in . . . 256 cases. 
 Second Position ; or occiput directed to right foramen ovale, in . 1 " 
 
 II. — OCOIPITO-POSTEBIOR POSITIONS. 
 
 Third Position ; or occiput directed to right sacro-iliac synchondrosis, in 76 oases. 
 Fourth Position ; or occiput directed to left sacro-iliac synchondrosis, in 2 " 
 
 Total, 335 
 
 It is to this latter division of cases {the oecipito-posterior), that I 
 wish particularly to call your attention at our meeting to-day. And 
 I do so, in order to point out to you at some length their mechanism 
 and management — to show you the strange and instructive errors 
 that have been fallen into by most British authors, in the study and 
 description of them — and to enable you to examine more fiilly for 
 yourselves, into the actual phenomena of these cases when they 
 happen to occur in your future hospital and dispensary practice. 
 
 NOMBNCLATUE.B AND NATURE. 
 
 You will find the class of cases to which I advert discussed by 
 different writers under a variety of different appellations. Dr. Clarke 
 has described them as cases in which " the face of the child presents 
 to the OS pubis." Various English authors speak of them as cases 
 in which the forehead, instead of the occiput, of the child, is turned 
 or inclined forwards to the pubis, or to either groin. They form the 
 fronto-cotyloid positions of some foreign authors, the occipito-sacral, 
 and oocipito-sacro-iliao of others. They constitute, as you are aware,' 
 the third and fourth positions of those German authorities, who use 
 the numerical nomenclature, illustrated by the preceding table. 
 
 In order that you may understand more precisely the nature of 
 the cases to which I wish at present to direct your attention, allow 
 me to recall to your memory, that anatomists and obstetricians 
 describe four diameters of the brim of the pelvis, viz., 1, the con- 
 jugate ; 2, the transverse ; 3, the left oblique ; and, 4, the right 
 oblique ; that it very rarely, or indeed, almost never happens that, 
 at the commencement of labor, the long diameter of the child's 
 head enters the pelvis in either of the first two or direct diameters ; 
 and that of the last two or oblique diameters, the left, or that marked 
 by a line running from the left sacro-iliac synchondrosis to the 
 opposite or right foramen ovale, is comparatively seldom occupied 
 
406 
 
 TEDIOUS LABOR. 
 
 by the head, because behind, its length is curtailed by the presence 
 of the rectum. In fact, in 99 out of every 100 cases of cranial pre- 
 sentation, the long diameter of the head of the infant is found 
 placed, at the commencement of parturition, in the direction of the 
 right oblique or diagonal diameter of the brim, or in a line running 
 from the right sacro-iliac synchondrosis to the left foramen ovale. 
 In the living subject, this diameter — the right oblique — is the 
 longest. The child's head is of an ovoid form, and, consequently, 
 has a long and short diameter ; and the longest diameter of the 
 child's head is, as an almost invariable rule, found placed by nature 
 in this, the longest diameter of the brim of the mother's pelvis, in 
 order that it may pass through it with the least possible degree of 
 obstruction, and, consequently, with the least possible degree of 
 difficulty and danger. 
 
 in considering, therefore, the mechanism of normal cranial pre- 
 sentations, we hold it as an important and established principle, 
 that the line of the long diameter of the child's head is, on entering 
 the pelvis, placed in the line of the right oblique diameter of the 
 brim ; that, at the commencement of labor, it is comparatively 
 seldom parallel with the line of the shorter or left oblique diameter ; 
 and that still more rarely, and, in fact, only when the pelvis is mis- 
 shapen, or the child very small, is it ever found situated in the 
 direction of the conjugate or transverse diameters. 
 
 In proof of this somewhat abstract statement, I ijiay appeal to 
 the table of cases which I have already shown you as the result of 
 Dr. Barry's observations ; or I may illustrate my remarks by the 
 following evidence published by the younger Naegele, with regard 
 to the ascertained positions of the head in 3491 cranial presentations 
 observed at the Heidelberg Hospital, from 1827 to 1841. 
 
 Table showing the positions of the head in 3491 Cranial presentations at the Heidelberg 
 
 Lying-in Hospital. 
 
 I. — OCCIPITO-ANTERIOR POSITIONS. 
 
 First Position ; or occiput to left foramen ovale, in ....'.. . 2262 cases. 
 Second Position ; or occiput to right foramen ovale, in 4 " 
 
 II. — OCOIPITO-POSTEEIOB POSITIONS^ 
 
 Third Position ; or occiput to right sacro-iliac synchondrosis, in . . . 1217 cases. 
 Fourth Position ; or occiput to left saoro-iliao synchondrosis, in . . , 8 " 
 
 Total, 3491 
 
 In none, I believe, of these 3491 cranial presentations was the 
 head found lying in the transverse or conjugate diameter of the brim ; 
 in 12 only (viz., in the four cases of the second position, and the 
 
IRUEGTJLABITIES OF HEAD PRESENTATIONS. 407 
 
 eigbt cases of the fourth position) was it found placed in the 
 left oblique diameter of the brim, and in all the remaining 3479 it 
 was primarily situated in the right oblique diameter. 
 
 To prevent, therefore, unnecessary complications and repetitions, I 
 beg you to observe that in my future remarks in this lecture I shall 
 leave entirely out of view those rare, and, from their rarity, almost 
 anormal cases in which the head enters the brim in the left oblique 
 diameter. This omission will simplify our subject for us. 
 
 Next, observe this other point — either end of the axis of the long 
 diameter of the foetal head — that is — either its occiput or fore- 
 head — may be placed at either end of the long or right oblique dia- 
 meter of the brim of the pelvis. Most frequently we find the 
 occipital extremity of the infant's head placed forwards, or situated at 
 the anterior extremity of the right oblique diameter. In other 
 words, most frequently the occiput is placed behind the left foramen 
 ovale ; and this constitutes the first position of most authors who use 
 a numerical nomenclature. But the arrangement is sometimes 
 exactly reversed ; that is to say, occasionally the frontal extremity or 
 forehead of the infant is placed forwards or behind the left foramen 
 ovale, and consequently the occiput is, under this cranial position, 
 directed backwards, and to the right sacro-iliac synchondrosis. To 
 recapitulate ; — in this last variety of cranial position (the immediate 
 object of our investigations), the long diameter of the child's head 
 lies as usual at the commencement of labor, parallel with the left 
 oblique diameter of the brim, but with the face or forehead, instead 
 of the occiput, placed behind the left foramen ovale ; or in other 
 words, pointing forwards to the left groin. Dr. Hamilton and others 
 have properly stated, that these are not strictly cases of presen- 
 tations of the forehead " to the pubis," but of presentations of 
 the forehead to one or other groin. And I have already shown 
 you why the groin to which the forehead points is so far more fre- 
 quently the left than the right, that for the present, I leave the latter 
 variety out of consideration, and apply my subsequent remarks 
 entirely to that cranial position in which the forehead points to the 
 left foramen ovale or left groin. This position is the third position 
 of the head in the two tables of cases which I have already shown 
 you. 
 
 Having premised these dry but necessary details, let me now solicit 
 your special attention to several more important and practical points 
 connected with the clinical history of this important class of cases. 
 I have repeatedly remarked to you, that, in its theoretical and prac- 
 tical results, the study of the mechanism of labor in some cranial 
 and other presentations forms a sad satire upon the general accuracy 
 of obstetric observation. I could not easily adduce a better clinical 
 example of this remark than the whole study of oceipito-posterior 
 
408 TEDIOUS LABOR. 
 
 positions of the head will now afford us. And first let us inquire, 
 when, at the commencement of labor, the occiput is situated poste- 
 riorly in passing through the brim of the pelvis, in what relative 
 position does it emerge from the outlet ? In other words, in occipito- 
 posterior positions, 
 
 DOBS THE OCCIPUT MAINTAIN THE SAME ftELATIVB POSITION TO THE 
 BACK OP THE PELVIS IN PASSING THROUGH THE BRIM, CAVITY, 
 AND OUTLET. 
 
 In most of your text-books you will find this question answered 
 in the affirmative. For instance, Denman, Merriman, Blundell, 
 Hamilton, and others, allege, that in the natural mechanism of this 
 class of cases the head retains throughout the same position rela- 
 tively to the parts of the mother — ^that it enters the brim of the 
 pelvis, passes down into the cavity, and makes its exit through the 
 outlet in the same position : that is, with the forehead or face always 
 directed anteriorly, and consequently the occiput always pointing 
 posteriorly. Long ago, Solayres showed distinctly that this was by 
 no means the common and natural course of events in instances of 
 this presentation, but his observations were unattended to. Since 
 Naegele, however, vrrote his admirable essay on the Mechanism of 
 Parturition, the whole subject has been much more studied; and we 
 now know, from abundant and accumulated evidence, that the ideas 
 generally held with regard to the mode in which labor proceeds in 
 occipito-posterior positions are quite incorrect. For it has been as- 
 certained, beyond the possibility of doubt and cavil, and you shall 
 have constant opportunities of confirming it by your own observar 
 tions, that in almost all cases in which the occiput is originally 
 placed posteriorly, the head, upon descending down upon the floor 
 of the pelvis, so far changes its position as to rotate round, so that 
 at last the occiput, and not the forehead, emerges anteriorly under 
 the arch of the pubis ; and consequently, the face, which looked 
 forwards, or towards the pubis at the commencement of labor, is 
 turned backwards towards the sacrum or perineum at the conclusion 
 of it. In short, in reference to cranial presentations, we may lay it 
 down as a, generallaw, admitting offew and occasional exceptions only, 
 that in whatever position the head is found entering the brim, 
 whether with the occiput directed anteriorly, or directed posteriorly, 
 it will ultimately pass through the outlet and vulva vnth the occiput 
 placed under the arch of the pubis, and the forehead and face gliding 
 over the perineum. When the forehead is primarily situated behind 
 the left foramen ovale, as occurs in the cases forming the Subject of 
 my remarks, the head, in passing through the lower pelvic apertures, 
 
IRREGULARITIES OF HEAD PRESENTATIONS. 409 
 
 rotates to the left and backwards a quarter of a circle, and at last 
 comes out at a position at right angles to that in which it entered ; 
 the occiput, which was originally placed opposite the right sacro- 
 iliac synchondrosis, rotates to the right and forwards in a correspond- 
 ing degree, so as to be placed opposite the foramen ovale of the 
 same side, and emerges under the arch of the pubis ; and the long 
 diameter of the infant's head, instead of remaining parallel with the 
 right oblique diameter of the pelvis, is latterly born in parallelism 
 with the left oblique diameter of the outlet. 
 
 But what evidence have we of the actual occurrence of this curious 
 change in the relative positions of the occiput and forehead at the 
 brim and outlet ? I shall state to you the principal 
 
 PROOFS OF THE ROTATION OF THE OCCIPUT FROM THE POSTERIOR 
 TO THE ANTERIOR PART OF THE PELVIS. 
 
 1. You may have constant opportunities of proving to yourselves 
 the occurrence of the rotation in occipito-posterior positions, by ob- 
 servations of this kind. Keep your forefinger, in such a case, 
 steadily upon the anterior fontanelle during the whole passage of 
 the head down into the cavity, and through the outlet of the pelvis, 
 and each of you will, by this form of direct and personal observa- 
 tion upon the living subject, readily convince yourself that the fore- 
 head of the infant does rotate round from the anterior to the poste- 
 rior segment of the pelvis when the head is about to pass through 
 the vulva, or that it makes a rotation from the left foramen ovale 
 round to the left sacro-iliac synchondrosis. The evidence amounts 
 to this — ^you can actually /eeZ the rotation take place. 
 
 2. Experiments made by pressing a dead child, placed in an occi- 
 pito-posterior position, through the pelvis of a dead mother, give 
 the same result. In this experiment, which I have tried in several 
 instances, we can see the head placed in the brim of the pelvis in 
 one position, viz., with the occiput directed posteriorly, emerge 
 from the outlet in another position, viz., with the occiput directed 
 anteriorly. This experiment will even so far succeed with the dried 
 fcetal skull and the dried pelvic bones, provided you select a skull 
 and pelvis adapted in size to each other, and apply the impelling 
 force in a proper direction.. Thus [^showing the experiment] this fcetal 
 skull cannot, for want of space and adaptation, be forced through 
 the outlet of this pel\^is in an occipito-posterior position ; but as 
 soon as the occiput turns forwards, it not only passes easily, but 
 even admits, in addition, of one or two fingers passing out along 
 with it. 
 
 3. I have had occasion to show to you more than once at the hos- 
 
410 
 
 TEDIOUS LABOR. 
 
 pital, that, in natural or artificial footling cases, wlien the toes, ab- 
 domen, and face point, as they sometimes do, anteriorly, the child 
 rotates round in the course of its expulsion, and at last is born with 
 the toes, abdomen, and face pointing posteriorly. The rotation is 
 of the same extent and nature as the rotation of the head itself in 
 occipito-posterior positions ; but in these footling cases we have 
 actual visual evidence of the turning — an observation which, in the 
 living subject, cannot of course be made in the corresponding cra- 
 nial positions. 
 
 But in a few cases, the head in occipito-posterior positions may 
 be observed by you to pass out with the occiput still placed pos- 
 teriorly. In other words, you will from time to time see 
 
 EXCEPTIONS TO THE GENERAL RULE OF THE ROTATION OF THE OCCIPUT 
 
 FORWARDS. 
 
 Out of 76 cases of occipito-posterior positions, carefully watched 
 by Dr. Barry at the Edinburgh Maternity Hospital, within the last 
 year, in 74 the occiput turned forwards and emerged from under 
 the arch of the pubis ; and in 2 the occiput retained its primary 
 posterior position, so that the forehead at last passed out under the 
 arch of the pubis. In 96 cases noted by Naegele, he found the head 
 to rotate as I have described in 93 ; and in the remaining 3, no 
 rotation occurred. These important facts may perhaps be expressed 
 more strongly in a tabular form thus : 
 
 Proportion of occipito-posterior positions in which the occiput ultimately passed through the vulva 
 
 antericyrly or posteriorly. 
 
 Total cases. Occiput at last Occiput at last 
 posterior. anterior, 
 
 Heidelberg Hospital, .... 96 in 3 in 93 
 
 Edinburgh Hospital, .... 76 in 2 in 74 
 
 The exceptions to the rotation occur, therefore, not more frequently 
 than once in thirty cases ; — and further, in the exceptional instances 
 you will generally find either the head unusually small, or the pelvis 
 of the mother unusually large. Yet, as I have already stated, 
 almost all obstetric authors describe the exception as the rule — and 
 the rule as the exception. Now, 
 
 BY WHAT POWERS OR MECHANISM IS THE ROTATION EFFECTED? 
 
 That the rotation of the head in labor is not produced by vital 
 actions on the part of either the infant or the pelvic canals, is 
 demonstrated by this one simple fact — that, as I have already stated 
 to you, the rotation may be seen to occur when, in imitation of 
 
IREEGTJLARITIES OF HEAD PRESENTATIONS. 411 
 
 labor, the experiment is tried of forcing the body of a dead infant 
 through the pelvic canals of a dead mother. Here, as during life, 
 the rotation of the foetal head upon the floor of the pelvis is, on a 
 contracted scale, like that of the spindle of a screw upon a nut, 
 provided with one-half of a single or broken thread. If relatively 
 the spindle is too small, or the nut too large, the former may pass 
 through the cavity of the latter without any rotation — as in the 
 exceptional cases just now alluded to; — ^but if they are properly 
 adapted in size to each other, the spindle can only make its transit 
 by its helix rotating upon the inclined plane of the corresponding 
 helix of the imperfect nut. 
 
 Further, it appears to me that very incorrect and erroneous 
 opinions are generally held by obstetric authorities as to the 
 mechanism of the partial rotation of the head in occipito-posterior 
 positions, and at the same time I am inclined to look upon it as a 
 physical problem of no very difficult solution. In order that you 
 may understand the explanation of it which I have to propose to 
 you, it is necessary to hold in view the following axioms : 1. That 
 the impelling power of the uterus is transmitted to the head of the 
 infant along the line of the spine ; 2. That the spine is articulated 
 to the head nearer the occiput than the chin, and consequently 
 (more especially after the flexion of the chin upon the breast) the 
 expulsive force of the uterus bears most strongly and directly upon 
 the occipital region ; and 3. That the mobility of the smooth and 
 lubricated surface of the foetus upon the smooth and lubricated 
 surface of the uterine and vaginal cavities is such, that if the occiput 
 is forced to rotate in any degree, the occiput will, in turn, produce 
 a secondary but corresponding rotation upon the forehead and other 
 parts of the infant's head, and consequently upon the body also, 
 unless it happen to be morbidly and tonically grasped by the uterus, 
 which is rare. Observe one point more — the direction in which the 
 power of the contracting uterus first impels the body and head of 
 the child, is in the line of the axis of the brim of the pelvis — that 
 imaginaiy line which is usually represented as running fi'om the 
 umbilicus to the lowest point of the sacrum. In the common 
 occipito-posterior position, the impelling power of the uterus thus 
 forces the right side of the occiput (for the head is placed obliquely) 
 against the concave floor of the pelvis, and its further progress 
 downwards and backwards in that direction is arrested by the 
 resisting structures of that floor. The occiput is thus submitted to 
 two forces meeting at an obtuse angle, viz., to the impelling power 
 of the uterus from above, and to the resisting power of the pelvic 
 floor from below — and these two powers act upon it with similar 
 force — ^physical action and reaction being always equal. The neces- 
 
412 
 
 TEDIOUS LABOR. 
 
 sary result is, that the part acted upon, viz., the occiput, moves 
 forward and to the right with a screw-hke movement — sometimes 
 rapidly — sometimes slowly, and in a line diagonal to the lines of the 
 forces acting upon it — exactly as if it were impelled by a single 
 force. Or, as mathematicians express it, it moves in a line diagonal 
 to- a parallelogram, two of the sides of which are formed by the lines 
 of the two existing forces. The diagonal or resultant line of motion 
 of the occiput, at this point in the labor, is in a line running ante- 
 riorly in the direction of the axis of the outlet, and the movement of 
 the occiput forwards in this direction is further greatly promoted and 
 facilitated by this being, at the same time, the direction in which it 
 encounters incomparably the least resistance to its further progress. 
 
 What part of the floor of the pelvis serves as the resisting plane 
 upon, and by the aid of which, the occiput is thus made to rotate for- 
 wards ? — In some — any, and in others, apparently every successive, 
 portion of the concavity of the floor of the pelvis seems to serve this 
 purpose. But the spines of the ischia contribute far less than is 
 generally believed. I have repeatedly observed the rotation, when, in 
 fact, the occiput was so low as to be beyond the influence of the bones 
 and ligaments, and where the required resistance was apparently 
 afforded by the soft tissues alone — as in the very last throes of labor. 
 And I have seen the conca^dty formed by the prolapsed posterior 
 lip of the uterus serve the same purpose before the head could be 
 much or at all influenced by the counter-pressure of the pelvic floor. 
 Generally, however, the rotation occurs on the concavity of the 
 floor of the pelvis itself; — and I consider it of great moment that 
 you should particularly note this fact, as demonstrating that if we 
 try to turn the head, as some recommend, whilst it is still high in 
 the pelvis, we do not imitate the mechanism of nature in this 
 position, but so far act in direct opposition to the laws with which 
 she has regulated this mechanism. 
 
 The best evidence which I can offer you of the correctness of that 
 explanation of the rotation which I have stated, is afforded by this 
 sufficiently rude and simple experiment. Place a full-sized infant's 
 skull in the common occipito-posterior position, and try to force it 
 through the outlet of a well-formed bony pelvis, in which the counter- 
 pressure of the soft parts is, for the time being, imitated by the appli- 
 cation of your hand, placed, as it were, so as to form a continuation of 
 the concavity of the sacrum. Apply the requisite impelling force to 
 the foetal skull by passing a wooden or metallic rod through the fora- 
 men ovale, so that the sum of the momentum employed be, as it is in 
 nature, directed to the occiput. The occiput will become thrown 
 forwards under the pressure acting upon it from above, and the 
 counter-pressure acting upon it from below. No obstetric author 
 
IREEGTJLAKITIES OF HEAD PRESENTATIONS. 413 
 
 has, SO far as I am aware, shown what I have attempted to point 
 out to you, that it is the movement of the occiput that we are to 
 study in this position, as being that part, the movement of which 
 regulates the whole. We must leave the forehead out of the 
 question of the mechanism of the rotation, as its motions are secon- 
 dary and entirely the result of those of the occiput ; and, without 
 holding these facts in view, it will, I believe, be found difficult or 
 impossible to give a rational explanation of the phenomena. 
 But let us pass on to another and less difficult inquiry, viz. : 
 
 ARE OCCIPITO-POSTERIOR POSITIONS OF THE HEAD FREQUENTLY MET 
 WITH IN PRACTICE? 
 
 In former times, and up, indeed, to the present day, this position 
 has been generally represented as exceedingly rare. Thus Dr. 
 Clarke of London, in a special essay on the " management of cases 
 in which the face of the child presents to the os pubis," almost con- 
 gratulates himself upon having had the good fortune to observe 14 
 cases in the course of several years of his very extensive practice. 
 A few years ago, Wigand of Hamburgh, who is said to have seen 
 more midwifery than almost any other European accoucheur, states 
 that he had only met with six or seven cases. Dr. Collins has 
 recorded 12 cases as having occurred from 1825 to, 1832, out of 
 16,000 deliveries in the Dublin Lying-in Hospital. 
 
 In contradistinction to the preceding statements, I beg to observe 
 that, so far from seeing such cases rarely and at long intervals, I 
 find that in one out of every three or four cases, among my private 
 patients, I meet with this position of the head, or with the forehead 
 looking forwards to the left foramen ovale or left groin. It is so 
 very frequent, that I have repeatedly seen two or three instances of 
 it occur in succession. Among the patients of the Maternity 
 Hospital you will find this position as frequent as I have just stated 
 it to be. And Dr. Barry's results, as to the frequency with which 
 this position was observed among the patients here, contrasts 
 strangely with the frequency with which the same position was 
 observed among the patients of the Dublin Lying-in Hospital, as 
 given by Dr. Collins in his invaluable report. The difierence may 
 be correctly expressed as follows : 
 
 Absolute number and proportion of Occipito-posierior Positions in the Dublin and Edinburgh 
 
 Hospitals. 
 
 Total Head Occipito-posterior 
 PresentatJODS. Positions. Proportion. 
 
 Dublin Hospital, 16,041 12 or 1 in 1336 
 
 Edinburgh Hospital, .... 335 78 or 1 in 4 
 
414 TEDIOUS LABOR. 
 
 If you searcll the records of obstetric statistics, you will find an 
 infinite discrepancy upon the relative proportion in which this class of 
 cases was noted by different observers. The following table, illus- 
 trative of this point, requires no comment : 
 
 Frequena/ of Presentations of the Face to the Pubis, or of Occipito-posterior Positions, as 
 given by different Practitioners. 
 
 Collins reports them as 1 in every 1336 labors. 
 
 Bland " 1 in « 374 " 
 
 Baudelocque " ' 1 in " 346 " 
 
 Lachapelle " 1 in « 171 " 
 
 Cusack " 1 in " 151 " 
 
 Maunsell " 1 in « 121 « 
 
 Merriman " 1 in " 67 " 
 
 Lobstein " 1 in " 18 " 
 
 Gregoire " 1 in " 14 '' 
 
 Murphy " lin " 7 " 
 
 Villeneuve " 1 in " 7 " 
 
 Barry.^Joseph Bell Rigby, Dubois, 1 . . . i ;„ every 3 or 4 labors. 
 Stoltz, Naegele, &o., J • • ■ 
 
 I have already stated that my own experience is perfectly in ac- 
 cordance with that of those practitioners whom I have placed last 
 upon the preceding list. Indeed, I feel the most certain conviction 
 that if any of you arrive at a different conclusion when you examine 
 cranial presentations upon a large scale, it will not be from the facts 
 being diiFerent, but from your interpreting them differently ; and do 
 not attribute your results, if they vary from that which I have last 
 stated, to defective powers of observation on your part, but rather 
 to a defective use of those powers which you do possess. 
 
 But the question naturally presents itself, how has it happened 
 that, if occipito-posterior positions are so frequent, they should be 
 reported and represented as so rare by various authors ? The solu- 
 tion of this problem is easy when we consider the 
 
 FALLACIES COMMITTED IN JUDfllNG OF THE POSITIONS OF THE HEAD 
 
 IN LABOR. 
 
 Many practitioners report merely the position of the head as it is 
 observed to emerge ultimately from the outlet, and not as it may be 
 found higher up in the pelvis. But we have seen, that in occipito- 
 posterior positions the occiput almost always rotates forwards, 
 before it passes the vulva. Hence one enormous source of error. 
 For all, or nearly all those cases which were originally occipito- 
 posterior positions come to be thus inadvertently reported among 
 the number in which the occiput is situated anteriorly. 
 
 The following table vrill enable you to understand another great 
 
lEKEGULARITIES OF HEAD PRESENTATIONS. 415 
 
 and common source of fallacy. In constructing and explaining it, 
 I use tlie numerical nomenclature of positions which I have em- 
 ployed in giving Dr. Barry's observations at the beginning of the 
 Lecture : 
 
 Selative Proportion of the four most common Positions of the Head given by different Observers, 
 and calculated to a standard of 1000 Cases each, 
 
 A.— Occiput to left side B.— Occiput to right side 
 of PelTis. of Pelvis. 
 
 Positions. Positions. 
 
 ls(. ith. 3d. 2d. 
 
 Naegele, .... 698 3 298 1 
 
 Dubois, .... 702 6 259 3 
 
 Barry 763 4 228 3 
 
 Bell, 750 4 240 7 
 
 Halmagrand, .... 700 4 240 50 
 
 Murphy, 632 46 161 161 
 
 Boivin, 800 5 50 190 
 
 Lachapelle, .... 770 4 70 200 
 
 Now, in examining the returns collected into this table, you will 
 observe that all agree as to the frequency of the first position of the 
 head, or that in which the occiput is directed forwards to the left 
 foramen ovale ; and further, that they represent the fourth, or that 
 in which the occiput is directed backward, to the left sacro-iliac 
 synchondrosis, as being of very rare occurrence. But of the pro- 
 portional numbers of the other positions, namely, those in which 
 the occiput looks to the right, and either anteriorly or posteriorly, 
 there are very discordant statements. I shall easily, however, be 
 able to show you how to reconcile this difiference. 
 
 One set of authors, among whom we have Lachapelle and Boivin, 
 make the second position, viz., that with the occiput directed for- 
 wards to the right foramen ovale, common, at the expense of the 
 third, or that with the occiput directed backwards and to the right 
 sacro-iliac symphysis, and which they account much rarer. The 
 others, among whom we have the names of Ifaegele, Dubois, Barry, 
 and an able country practitioner, Mr. Bell of Barrhead, give a con- 
 trary account, for they correctly describe the third position as a 
 frequent primary position, and the second as, on the other hand, 
 the very reverse. This incongruity arises entirely from the former 
 class of authors not adverting to the fact, that the second position 
 is an ulterior stage in the progress of cases which originally be- 
 longed to the third. And, as they either omitted to make early and 
 careful examinations, or preferred trusting entirely to observations, 
 more easily made in a later period of the labor, so we are not to be 
 surprised that they range and enumerate under the second position, 
 cases which ought to have been referred to the lists of the third. 
 
416 TEDIOUS LABOR. 
 
 Every careful observer, however, who takes the pains to examine 
 early, will find the cases of the third, or common occipito-posterior 
 position, to be of common occurrence, while th& second position 
 may be almost excluded from our accounts of the mechanism of 
 parturition, unless as a mere stage in the course of the other. Pro- 
 bably one of the most fallacious of all marks, and yet one sometimes 
 relied upon, for determining the position of the cranium at the 
 brim, is to observe the direction of the face after the head has 
 passed the outlet. It is alleged, that if the face turn, during the 
 passage of the shoulder, to the mother's left thigh, it marks that it 
 has been a third or occipito-posterior position, and the reverse if it 
 turns to the right. But such a criterion would constantly lead you 
 into error. For the face of the infant sometimes does turn to the 
 right after it has passed the outlet, even though it were originally 
 an occipito-posterior position ; and, in feet, you will often find, that 
 if you abstain from all interference in the passage of the body, the 
 head will, occasionally revolve round to a greater or less extent, so 
 that the face turns more or less anteriorly in correspondence as the 
 body turns in a half spiral mode, in consequence of the shoulders 
 making a screw-like motion upon the floor of the pelvic canal, as 
 they become forced down upon and through the pelvic and vaginal 
 outlet. 
 
 The occipito-posterior are also perhaps frequently confounded 
 with occipito-anterior positions in the earlier stages of the labor, in 
 consequence of the distinctive marks between them not being 
 attended to and appreciated. To avoid this error, let us next then 
 consider the 
 
 DIAGNOSIS OF CASES IN THE OCCIPITO-POSTERIOR POSITION, OR WITH 
 THE FOREHEAD TO THE PUBIS. 
 
 There are three modes by which we may arrive at a diagnostic 
 knowledge of the usual occipito-posterior position of the head with 
 the forehead behind the left foramen ovale, viz., 1st, the locality of 
 the foetal movements as felt by the mother ; 2d, the situation of the 
 festal heart as determined by auscultation ; and 3d, the tactile ex- 
 amination of the foetal head itself. The first two may aflbrd us a 
 greater or less degree of certainty as to the position of the head 
 before labor begins, or in the first commencement of it before the 
 OS uteri is much opened. It is to the third, however, that we prin- 
 cipally or almost solely trust as our guide after labor has fully set 
 in. I shall ofter you a few details regarding each of these signs, 
 
 I. The movements of the Foetus. — The foetal movements are often 
 felt by the mother much more on one side of the abdomen than on 
 
IRREGULARITIES OF HEAD PRESENTATIONS. 417 
 
 the other. The movements which she feels are principally the 
 movements of the hands and feet, or rather the extremities of the 
 infant. Hence the side of the uterus on which they are felt, indi- 
 cates the side to which the extremities, abdomen, and face are 
 turned. Consequently the back and occiput of the child look to 
 the opposite side. Recollecting then, that the infant's head is 
 almost always placed in the right oblique diameter of the brim, we 
 may feel pretty confident that the occiput is placed to the right and 
 anteriorly, if the foetal movements are principally or only felt on 
 the left side ; and, on the other hand, that the occiput is placed to 
 the left and posteriorly, if the fcetal movements are principally or 
 only felt on the right side. The degree of distinctness with which 
 the sensations of the foetal movements are felt by the mother, con- 
 fined to one or other side, will principally determine the degree of 
 reliance that we may, in individual patients, place upon this sign. 
 Many mothers, however, are not aware of the movements being 
 greater in one part than another, and in such instances we must 
 depend upon other aid. 
 
 II. The sounds of the Fcetal Heart. — When using the stethoscope, 
 th« foetal heart is most distinctly heard over the left scapular region ; 
 and, if the foetus is in the occipito-anterior position, the sounds of 
 the heart will be heard most distinctly above the left groin of the 
 mother, or in the left iliac region. If the foetus is in the occipito-poste- 
 rior position, or with the face towards the pubis, these sounds will 
 be heard most distinctly, on applying the stethoscope to the right iliac 
 region of the mother. Thus, in most cranial cases, the use of the 
 ear gives you a strong presumption of the position, by marking 
 whether it be placed with the occiput anteriorly and to the left 
 — or posteriorly and to the right. 
 
 m. The tactile examination of the Child's Head. — ^Both the signs 
 which I have already mentioned, the sensations of the foetal move- 
 ments, and the seat of the sounds of the foetal heart, yield in value 
 to the more direct and more certain evidence derived from actually 
 feeling and touching the foetal head with the fingers in a vaginal 
 examination. When the finger is introduced, you feel the sagittal 
 suture of the infant's head crossing obliquely the opening of the os 
 uteri, in a line parallel with that of the right oblique diameter of 
 the pelvis. Both in the common occipito-anterior, and common 
 occipito-posterior position, this is the direction of the sagittal suture 
 — so that the mere direction of the suture will not afford you a dis- 
 tinctive diagnostic sign. Eun your finger, however, along the suture 
 to either of its extremities — say to its anterior extremity, which is 
 VOL. I. 27 
 
418 
 
 TEDIOUS LABOR. 
 
 generally easily reached, and you may at once fully determine the 
 position of the head, by ascertaining which of the two fontanelles 
 is placed at the anterior or pubic extremity of the suture. If the 
 fontanelle which you touch in this situation is four-limbed and qua- 
 drangular, it is of course the anterior fontanelle, and necessarily 
 shows the forehead to be placed anteriorly ; and consequently the 
 occiput must be directed to the posterior part of the pelvis. But 
 always be perfectly certain, that it is the anterior and not the poste- 
 rior fontanelle which you are touching, that is, that it is a space or 
 bregma quadrangular, and not triangular in its figure, and formed 
 by the meeting of four, and not of three sutures. If you are not, 
 especially in early practice — strongly upon your guard in relation 
 to this source of fallacy — ^you will be exceedingly liable to fall into 
 error on the point. But with due care and caution, you may readily 
 surmount such a difficulty. In no case, I believe, will you find it 
 necessary to force your finger up so far as to touch the ear of the child, 
 as some authorities advise. But your ear may, by the medium of the 
 stethoscope, add to the certainty of the tactile diagnosis by ascer- 
 taining, in the mode I have pointed out, the exact locality of the 
 foetal heart. 
 
 One subject more remains for our consideration in referenccto 
 cases of the occipito-posterior position of the head, viz., their 
 
 TKEATMENT. 
 
 IJpon this subject, let me, in the first place, state to you this strong 
 and important fact — in not one of Dr. Barry's 77 cases — and in not 
 one of the other 200 or 300 cases of head presentation, with the 
 forehead directed forwards, which have occurred among the patients 
 of the Maternity Hospital since its first institution — in none, I 
 repeat, has any kind of aid or interference by the hand, or forceps, 
 or other instrument, been required or given. In stating this as the 
 result of our observations and practice here, I state what I beheve 
 should be the result of your observations, and the line of your prac- 
 tice, in your future professional experience. In a vast majority of 
 occipito-anterior positions you require to ofier no unusual aid or 
 interference. In exactly the same way, in a vast majority of occi- 
 pito-posterior positions — in 99 out of the 100 — ^you require to offer 
 no unusual aid or interference of any kind or description whatever. 
 You must equally look upon the one position and the other as con- 
 stituting a perfectly natural labor — so far as in each the mode and 
 mechanism of parturition are concerned. 
 
 You will find, however, doctrines and practices very different from 
 this, taught in regard to the treatment of occipito-posterior positions 
 in most obstetric works and text-books, modern as well as ancient. 
 
■ IRREGULARITIES OF HEAD PRESENTATIONS. 419 
 
 For very many advise and practise interference of an active cha- 
 racter in all such cases ; — and then, when the case ends favorably, 
 as it generally does, they unhesitatingly ascribe the result solely to 
 their interference — ^forgetful of the fact, that nature, as I have just 
 shown you, does generally conduct the mechanism of the labor to 
 this safe termination — and that too, sometimes in opposition to, and 
 despite of the supposed assistance of art. In precisely the same 
 way, in many of those diseases, the natural history of which is, 
 that they will terminate favorably if time is allowed, and quietude 
 and proper regiminal means be enforced — many practitioners will 
 insist on inflicting upon their patients a continual system of drug- 
 ging, and then subsequently arrogate entirely the patient's recovery to 
 the influence of their drugs, allowing nothing to where everything 
 perhaps is due, viz., the curative influence of nature herself. 
 
 In the treatment of occipito-posterior positions, the mode of in- 
 terference recommended is sometimes most active. And one class 
 of practitioners seem to believe that without interference nature 
 could never, by her own unaided mechanism and efforts, bring a 
 case of this kind to a successful termination. 
 
 Thus, a few years ago, Capuron read before the French Academy, 
 and afterwards published in the Journal Hebdomadaire, a paper 
 with this significant title, " On the impossibility of natural delivery, 
 and the necessity of applying the forceps, in occipito-posterior posi- 
 tions of the cranium." In these cases Capuron avers, that unless 
 the pelvis be unnaturally large, or the child unnaturally small — if 
 the forceps are not iised as a "precaution," failure of the powers of 
 the mother, pressure, contusion, and inflammation of the intro-pelvic 
 organs, will follow, with apoplexy and death of the infant. He 
 attempts to prove all this on mathematical and theoretical grounds, 
 rather than on the results of observation and practice — and correctly 
 enough shows, by various admeasurements and arguments, that in the 
 great majority of cases, the head cannot physically pass through the 
 pelvic outlet if the forehead is placed anteriorly ; — ^but he seems quite 
 unaware of the other all-important fact, that in exactly this great ma- 
 jority of cases, the head is rotated round by the natural efibrts, so 
 that the forehead is ultimately placed posteriorly, and not anteriorly, 
 and passes with perfect facility. 
 
 In relation to the supposed indispensable necessity of instruments in 
 occipito-posterior positions, Puzos, Basignan, and others, have pub- 
 lished opinions more or less similar to these opinions of Capuron. 
 The general mass, however, of obstetric writers do not look upon arti- 
 ficial aid in such cases as entirely indispensable. But many seem to 
 regard it as useful and proper in most cases of the kind, and have 
 advised various modes of interference. 
 
 "When you detect the occipito-posterior position upon the break- 
 
420 TEDIOUS LABOR. 
 
 ing of the membranes, you are, observes Pugb, "to lay the woman 
 in a proper posture, turn, and extract the child by the feet, being 
 the best and safest method that can be taken ; but if sent for ^fter 
 a midwife, who perhaps has kept the patient too long, so that turn- 
 ing is impracticable, then you must have recourse to the curve forceps. 
 Chapman details the case of a " lady of distinction" whom he de- 
 livered by turning, in consequence of the forehead or face coming 
 towards the os pubis. Dr. Smellie, in the first case of the kind 
 which he details, tells us he first tried to turn the forehead back- 
 wards, then attempted to bring the child footling, but, failing in 
 this, he subsequently applied the forceps and blunt hook. In the 
 latter part of his practice, he seems to have trusted to the forceps 
 alone, when aid was required, and rotated the head with them. He 
 details one case where he turned the forehead backwards with his 
 fingers. Exton advises interference upon this last plan. In 1800, 
 Dr. Clarke of London published a paper " on the management of 
 cases in which the face of the child presents towards the os pubis." 
 He speaks of the cases as " comparatively rare," " attended with 
 considerable difficulty," and as having had no proper means sug- 
 gested for their special treatment. The means, however, which he 
 proposed and practised was not novel, and consisted of " introducing 
 one or two fingers between the side of the head, near the coronal 
 suture, and the symphysis pubis, and pressing steadily against the 
 parietal or frontal bone during the labor pains, till the forehead is 
 pressed backwards, and at length the occiput is brought to the 
 groin." "I have now," he states, "met with 14 cases, in 13 of 
 which the practice has succeeded, and as some years have elapsed 
 since the first case, I think myself fully authorized in recommend- 
 ing this method to be always pursued, when the face is found in the 
 situation above described." 
 
 From what I have stated of the natural mechanism of these cases, 
 you know that in 13 out of the 14 cases of which Dr. Clarke speaks, 
 nature would have herself performed the rotation in question, and 
 that, too, with greatly less risk, and annoyance, and pain to the 
 mother, than by the fingers of the accoucheur thrust up between 
 the head and pelvis, and at the same time less danger to the child. 
 " I have known," says Dr. Merriman, " one instance in which the 
 space opened between the pelvis and the child's head, by passing 
 the finger (as Dr. Clarke advised), allowed the funis to prolapse, 
 and thus destroyed the infant." 
 
 In the "Practical Observations on Midwifery" which Dr. Hamil- 
 ton published a few years ago, he adopts Dr. Clarke's practice in 
 this set of cases, though criticising him, in so far that he properly 
 points out the forehead to lie towards one or other groin, and not 
 
IRREGULARITIES 01 HEAD PRESENTATIONS. 421 
 
 directly forwards to the pubis. " In such cases," Dr. Hamilton re- 
 marks, " there is a risk that the face be turned towards the pubis, if 
 the practitioner have not sufficient intelligence to make strong 
 pressure upon the brow, which is generally sufficient in the course 
 of a few pains to turn the face into the hollow of the sacrum." 
 
 Dr. Dewees, in his valuable work on midwifery, declares, that he 
 considers that " man incompetent to practise midwifery, who cannot 
 detect and change this position of the head," in the mode recom- 
 mended by Baudelocque and Clarke. His countryman. Professor 
 Bedford of ISew York, in writing on the same subject in 1844, after 
 commenting upon nature as " full of wisdom and benevolence, 
 always vigilant and prompt," &c., proceeds to state,- that when the 
 practitioner " arrives at the bedside, and in making a vaginal ex- 
 amination, ascertains that the occiput is at one of the posterior 
 points of the pelvis, he should, as soon as the mouth of the womb 
 is sufficiently opened to admit the manipulation, introduce, with 
 great gentleness and caution, his hand, and place his thumb on one 
 of the lateral portions' of the head, and the fingers on the other, 
 and slowly elevate the head, at the same time bringing the occiput 
 to one of the anterior points of the pelvis, either the left or the right 
 acetabulum ; for example, if the occiput be at the right sacro-iliac 
 symphysis, it should be brought to the right acetabulum, if at the 
 left sacro-iliac symphysis, to the left acetabulum. "When this change 
 has been eftected, nature will usually be competent to accomplish 
 the delivery, and the foetus will not be exposed to the same hazard 
 of a protracted birth. Indeed, if the change be not made, it will 
 often be necessary to resort to the forceps to terminate the deliveiy ; 
 and if the labor be submitted to nature, the child will frequently 
 be sacrificed." 
 
 In oceipito-posterior positions. Dr. Burns recommends, like Dr. 
 Bedford, early rectification of the head. "As," he observes, " this 
 presentation, whichever way the head turn, is generally productive 
 of a labor more tedious than the natural one, we should co-operate 
 in the acceleration of the process of turning the head. K it be 
 discovered early, it is certainly proper to rupture the membranes, 
 and turn the vertex round, which is easily accomplished." Dr. 
 Burns further advises us, that "if this opportunity be lost, we may 
 still give efficient assistance," by Dr. Clarke's method of inter- 
 ference ; — and in corroboration, he adds, that he has been himself 
 successful in thus artificially pushing backwards the forehead, in 
 cases " where the head seemed rather to be turning with the vertex 
 towards the sacrum, and had descended so low as to have the nose 
 on a line with the arch of the pubes." It is sometimes at this late 
 point that nature turns the head by her own efibrts, and occasionally 
 
422 TEDIOUS LABOR. 
 
 during the course of a single pain. And I doubt whether Dr. Burna 
 does not here ascribe to the efforts of art what belonged to the efforts 
 of nature. 
 
 I shall cite only one other esteemed modern authority, viz., Dr. 
 BlundeU of London. Dr. Blundell's rules of practice in occipito- 
 posterior positions are more heroic than that of any other of the 
 writers I have mentioned — for his rules embrace one and all of the 
 modes of active interference which I have hitherto named. His 
 observations are too long for quotation ; but he tells us that " when 
 the case is indisputable, the dexterity great, and the circumstances 
 are conducive, he will not venture to assert that turning the child 
 is universally unjustifiable;" that if the softer parts are lax, the 
 pelvis large, &c., rectification of the position of the head above the 
 brim may be justifiable with the hand, or this may be subsequently 
 done with the forceps, " remembering that you are operating upon 
 the softer sex ;" that in all cases, Dr. Clarke's method recommends 
 itself to your adoption by its ease and safety, ." unless turbulence 
 and violence unfit you for the duties of an accoucheur ;" that in the 
 majority of cases, however, and especially if yet inexperienced in 
 the practice of midwifery, you may trust with confidence to the 
 natural efforts ; that if all these methods, and nature also fail, the 
 lever or forceps might be tried " with tenderness and prudence ;" 
 or at last, " compelled by an inexorable necessity, you must have 
 recourse to the perforator." "Adhering to these directions, I am 
 persuaded," says Dr. BlundeU, " you cannot wander far from the 
 correct line of practice." 
 
 Strangely enough, Dr. BlundeU introduces his long remarks upon 
 this subject with the following pertinent criticisms. " It seems," 
 he observes, "that where the face throughout the labor is lying 
 forward on the symphysis, many difficulties are occasioned. What 
 is it then," he asks, " that the accoucheur can do in order to diminish, 
 surmount, or remove them ? "What is there that he can do with 
 prudence, without committing the unpardonable sin of midwifery — 
 the sin I mean of those obstetric reprobates, the meddlesome, and 
 the pragmatic ?" And he closes his discussion of the treatment in 
 the following words : " Under the best management, unless you 
 can rectify, these are bad cases, for bruising, laceration, and slough- 
 ing of the parts, and the death of the child, are to be apprehended." 
 I leave you to decide upon the evidence which I have already laid 
 before you, whether or not Dr. Blundell's own criticisms do or do 
 not aptly apply to Dr. Blundell's own practice, and whether the 
 child's death, and that " bruising, laceration, and sloughing" of the 
 maternal parts, which he apprehends in oceipito-posterior positions, 
 is more likely to be the result of the natural mechanism and unin- 
 
IRREGULARITIES OF HEAD PRESENTATIONS, 423 
 
 terfered-with course of nature in such cases, or the result of that 
 formidable list of operative procedures which he prescribes in this 
 form of labor — and which list includes, in fact, according to his own 
 enumeration, almost every obstetric operation except the Sigaultian 
 and Csesarean sections. 
 
 Let us now pause for an instant, and recapitulate one or two of 
 the principal results at which we have arrived in the course of the 
 preceding inquiry. "We have found many estimable authors con- 
 sidering occipito-posterior positions to be exceedingly rare ; I have 
 shown you that, on the other hand, they are exceedingly common. 
 They are generally represented as maintaining throughout the labor 
 their original position with the forehead anteriorly ; I have pointed 
 out to you that, on the contrary, in twenty-nine out of thirty cases, 
 the forehead rotates round, and ultimately emerges posteriorly. 
 Formerly it was believed that this internal rotation of the head was 
 never performed by the unaided natural mechanism ; now we know 
 it to be easily accomplished in every, or in almost every case, and 
 without the slightest artificial assistance of any kind. Many ex- 
 cellent authors allege that, in occipito-posterior positions, the process 
 of labor as a whole is attended with unusual difficulty and danger ; 
 but we have seen abundant evidence to prove that this is a most 
 ungrounded fear, and that the labor — like that in occipito-anterior 
 positions — ^belongs most strictly to the class of natural labors. And, 
 lastly, we have seen no small variety of artificial and operative 
 measures more or less strenuously recommended in the treatment 
 of these cases in some of our best and ablest text-books ; but on 
 consulting the text-book of nature, we have further found that the 
 peculiarities of cases of this position require, in the way of artificial 
 or operative aid — nothing — absolutely nothing. In commenting 
 upon these cases elsewhere, I some years ago observed, " If there 
 is any truth whatever in statistics, we venture to say, from the data 
 we have adduced, that such cases daily occur, and pass over unob- 
 served in hundreds of instances in which the labor is supposed to 
 be, and no doubt is, perfectly natural."' Occipito-posterior positions 
 of the head, " require," says ITaegele, " no peculiarly favorable cir- 
 cumstances, but these species of labors can be completed by the 
 natural powers under the most usual proportions, in the same time, 
 with the same expense of strength, and without greater difficulty, 
 than when the head takes the more common position." Perhaps 
 these remarks of E'aegele are too absolute ; for, in occipito-posterior 
 
 ' See a review of the works of Rigby, Ramsbotham, and Davis, in the British and Foreign 
 Medical Review, Oct. 1841, p. 473. The portion of the review here referred to, we have 
 omitted, because the subject of occipito-posterior presentations is discussed at greater length, 
 and with fuller details, in the present lecture. — (Ed.) 
 
.424 TEDIOUS LABOR. 
 
 positions, the occiput requires to pass in its transit, through a longer 
 and more curved pelvic line, than in occipito-anterior positions; 
 consequently in the Hospital statistics, dravs^n up for me by Dr. 
 Barry, occipito-posterior positions seem on the whole to require a 
 somevsrhat greater length of time than occipito-anterior positions. 
 The difference, however, is so inconsiderable as not to invalidate in 
 any, the slightest degree, what I have already stated regarding the 
 perfect safety and facility with which unaided nature is capable of 
 finishing the labor in this common class of cases. 
 
 But supposing that, in consequence of inertia of the uterus, or 
 constitutional exhaustion, or the state of the maternal passages, or 
 size of the head of the infant, or any other of those causes which 
 sometimes force us to deliver by the forceps in occipito-anterior 
 positions, we were necessitated to use the same instrumental aid in 
 an occipito-posterior position, is there any notable difference in the 
 mode in which we should conduct the operation in the latter case, 
 from the mode in which we should conduct it in the former ? I 
 believe there is, in one respect, an important difference, and that 
 there is 
 
 ONE SPECIAL BULE IN DELIVERY WITH THE FORCEPS IN OCCIPITO- 
 POSTERIOR POSITIONS. 
 
 It is this. In occipito-posterior positions the mechanism of the ex- 
 traction of the head with the forceps should he an exact imitation of the 
 mechanism of the expulsion of the head by nature. In other words, I 
 am strongly convinced that, in the artificial extraction of the 
 head, in occipito-posterior positions, we should make the fore- 
 head rotate backwards, and the occiput forwards, according to 
 those rules which we have seen nature following under the same 
 conditions. For here, as elsewhere, the more perfectly we imitate 
 her principles, the more perfect will our own practice be. If the 
 infant's head is of such a size as to pass with comparative facility 
 through the maternal pelvis, we may, after seizing the head, for- 
 cibly pull it down and extract it in the position in which it was 
 originally placed, namely, with the forehead still looking anteriorly. 
 But if the head and pelvis are more accurately fitted in size to 
 each other, such efforts will be fruitless, unless at the expense of 
 great and unnecessary bruising and compression of either the mother, 
 or infant, or both. Almost all authorities, however, in midwifery, 
 seem to recommend and practise this direct traction. But the prin- 
 ciple of the practice amounts to this — it is as if (reverting to a pre- 
 vious simile) we attempted to push or pull forcibly the spindle of 
 
IRREGULARITIES OF HEAD PRESENTATIONS. 425 
 
 a screw through its corresponding nut, in a direct and straight line, 
 instead of effecting the same object with far more ease and sim- 
 plicity, by revolving the former upon and within the latter. I have 
 now happened to be called to several cases of occipito-posterior po- 
 sitions, in which the forceps had been applied with the greatest 
 adroitness and dexterity ; where, subsequently, every allowable de- 
 gree of force had been employed, but employed in vain to pull forth 
 the head in its original position, with the forehead directed ante- 
 riorly ; and where I have succeeded, with a tithe of the power pre- 
 viously used, by adding to the requisite act of extraction a simul- 
 taneous act of rotation of the head, so as to turn the occiput ante- 
 riorly, and to the right, and the forehead posteriorly, and to the 
 left. 
 
 Indeed, I sincerely believe that such cases as those I have just 
 spoken of, are not unfrequently regarded as unfit and improper 
 cases for the forceps — and that, as a consequence, the child's 
 head is opened and broken down by embryuleia — merely because 
 the forceps have failed from the position of the head having been 
 unattended to, or, if attended to, from the forceps not having 
 been employed in a proper manner in the attempts at delivery 
 made with that instrument. An obstetric friend told me that some 
 years since he received from nature a most instructive lesson upon 
 this point. He had fixed a pair of curved forceps upon a head 
 lying in an occipito-posterior position, and ineffectually pulled at it 
 in that position till he was afraid to pull more. He was resting for 
 a pain or two, cogitating what step he should take next, and whether 
 he should perforate the infant's head or not, when a very strong 
 uterine contraction came on. During the contraction, the handles 
 of the forceps were wheeled round in his hand, and the head was 
 expelled, with the occiput under the arch of the pubes, and the con- 
 cavity of his forceps turned towards the concavity of the sacrum. 
 Nature thus strongly preached to him how he should have acted 
 in order to assist her. 
 
 Dr. Smellie knew the propriety of rotating as well as extracting 
 the head in these cases. He tells us, that in 1745 he applied the 
 forceps in a case in which the large fontanelle was at " the left 
 groin." Under the efforts which he made at direct traction, and so 
 as to bring the forehead out anteriorly, the instrument slipped off 
 three times, one of the blades giving way. He was still (he con- 
 tinues) " loth to destroy the child by opening the head," or to apply 
 the blunt hook, and " luckily thought" of trying the forceps again, 
 and turning the forehead backwards into the hollow of the sacrum, 
 and by this last plan he safely delivered the infant. " This method," 
 he ingenuously adds, "succeeding so well, gave me great joy, and 
 was the first hint, in consequence of which I deviated from the com- 
 
426 TEDIOUS LABOR. 
 
 mon method of pulling forcibly along, and fixing the forceps at 
 random upon the head. My eyes were now opened to a new field 
 of improvement, on the method of using the forceps in this posi- 
 tion [the occipito-posterior], as well as in all others that happen 
 when the head presents." 
 
 Unfortunately, Smellie's observations on this point appear to have 
 been, in general, completely overlooked by his various pupils and 
 followers. "Wallace Johnson, Denman, Hamilton, Ramsbotham, 
 Davis, &c., tell us to extract the head with the forehead directed 
 anteriorly, and passing under the arch of the pubes. They seem 
 all afraid that if we acted otherwise, and rotated (as I believe we 
 should do), the forehead backwards from the left foramen ovale 
 to the left sacro-iliac sychondrosis, we should produce a violent 
 and dangerous twisting of the neck of the infant. "We have seen, 
 however, that in twenty-nine out of every thirty such cases, nature 
 produces exactly this same rotation of the head in this same class 
 of cases, and without any risk or danger whatever to the neck of 
 the child. But in order that our mechanism should be equally safe 
 with hers, we must imitate nature in the process as nearly as pos- 
 sible, and only turn, or attempt to turn the head after it has already 
 reached the pelvic floor — never when higher — and only during a 
 pain, when the trunk and head are compressed together by the 
 uterine contraction into, as it were, one mass, so that the body 
 readily follows the movements of the head. The highest authori- 
 ties, also, in the continental schools, seem to have similar fears 
 regarding the rotation, and lay down the same plan of extracting 
 the head in the position in which it is already placed, viz., with 
 the occiput posteriorly. Even those obstetricians who know most 
 perfectly the natural mechanism in such cases, totally disregard and 
 deviate from that mechanism in their own instrumental procedures. 
 Thus, Naegele himself advises us to bring out the forehead ante- 
 riorly, when we use the forceps in occipito-posterior positions of 
 the head. But, then, in explanation of this apparent inconsis- 
 tency, we must remember that the different varieties of Levret's 
 forceps used by Naegele and most other continental practitioners, 
 are so large and curved as not to enable us to rotate them and the 
 head after they are applied, without the most imminent hazard to 
 the vaginal structures of the mother. It is in occipito-posterior 
 positions, above all others, that we see the superior advantage of 
 employing a straight pair of short forceps, such as those of Dr. 
 Denman or Dr. Ziegler. They enable us to rotate the head easily 
 and safely, as I can testify to you from sufficient experience. If we 
 employed a curved pair in this position, and tried to turn the head 
 with them we should be obliged either to introduce them at first, or 
 extract them at last, with their concavity, instead of their convexity, 
 
IRREflDLARITIBS OF HEAD PRESENTATIONS. 427 
 
 looking backwards, and consequently witli great and unnecessary- 
 risk of contusion and laceration of the soft structures of the mother, 
 from the projecting ends and sides of the blades. 
 
 MIGHT THE VECTIS BE SUBSTITUTED FOR THE FORCEPS IN OOCIPITO- 
 POSTERIOR POSITIONS REQUIRING INSTRUMENTAL AID ? 
 
 I put the question problematically, and must answer it problema- 
 tically too, because I have no personal experience of the vectis. At 
 the present day, when the vectis is scarcely used by a single prac- 
 titioner, it does appear to. us strange to be told, as we are by Dr. 
 Denman, that by many of those men who, before him, had succes- 
 sively enjoyed "the chief practice" in London, the vectis was pre- 
 ferred to the forceps, and that several of his most experienced and 
 eminent cotemporaries were of the same opinion. Of late I have 
 sometimes thought that if useful at all, the vectis might be useftil in 
 occipito-posterior positions, when such cases happened, from any 
 cause, to require instrumental assistance. In order that the rota- 
 tion of the occiput forwards should be accomplished with adequate 
 freedom, I have shown you that the head must be flexed upon the 
 neck, in order that the impelling force sent from the uterus along 
 the infant's spine may act in a proper line upon the occipital re- 
 gion of the cranium. Sometimes, however, when the head is not 
 sufficiently flexed, and the occiput and forehead are thus placed 
 too much upon the same plane {when they reach the floor of the 
 pelvis), the momentum of the action of the uterus is received upon 
 the middle or forepart of the head, and not upon the occiput. The 
 mechanism of the labor thus comes to be perverted, and delay and 
 danger may follow. In such a complication, three alternatives pre- 
 sent themselves : 1. Rectification of the position, by depressing the 
 occiput, or raising the forehead. 2. Rotation; and, 3. Torcible 
 extraction of the head. With the straight forceps we may fulfil the 
 two last objects — rotation and traction — but with that instrument 
 we have no power of effecting the first, or rectification. 
 
 On the other hand, the lever or vectis, introduced over the left 
 mastoid or occipital region of the infarct's head, would enable us 
 to fulfil all the three indications, that is, rectifying the position, ro- 
 tating the head, and probably applying any sufficient degree of 
 further extractive force that may be required. In most cases, the 
 rectification and rotation — one or both — are the only conditions 
 that are required under such circumstances, the unassisted uterus 
 readily finishing the expulsion when the normal mechanism of the 
 labor is so far restored. And Smellie, Lachapelle, and Montgo- 
 
428 TEDIOUS LABOE. 
 
 mery, have all shown us that we may occasionally and completely 
 effect these first two objects in such morbid cases, and when 
 the head is at the same time transverse to the outlet, by raising 
 and rotating the forehead with the fingers alone. K these fail, the 
 vectis applied over and above the occiput would sometimes perhaps 
 greatly and safely aid in the operation, the fingers being applied to 
 the opposite temple or forehead ; and we know that afterwards the 
 fingers may be thus further made to serve as a kind of second blade 
 to the vectis, if we wish subsequently to use that instrument with 
 • the extractive action of the forceps. K the delay, therefore, be 
 owing to the perversion in the mechanism which I have alluded 
 to, the vectis may be occasionally of as great or greater use than 
 the forceps. But if the delay be the result of simple inertia of 
 the uterus, or of any other cause in which the fiexion of the head 
 is not interfered with, or the forehead not made to descend too low 
 — and when extraction and rotation are required without rectifica- 
 tion, then I believe the forceps will certainly be the safer and prefer- 
 able instrument. 
 
 The remarks which I have made apply to the action of the straight 
 forceps, as compared with the action of the lever, in occipito-pos- 
 terior positions. But if we compare the curved forceps with the 
 vectis, or with one blade of the straight forceps used as a vectis, in 
 this class of cases, then the result, I believe, must be still more 
 strongly in favor of the lever. Tor while, with the curved forceps, 
 more especially when the curve is great, or the instrument of a 
 large form, it is impossible to do aught but simply extract, we may, 
 on the contrary, with the vectis, successively or simultaneously, as 
 ' circumstances require, alike rectify, rotate, and extract. 
 
 But, above all, it is necessary for you to remember, that it is rarely 
 — very rarely, that you will be driven to apply any instrumental as- 
 sistance in either occipito-posterior, or occipito-anterior positions of 
 the head ; for in the one class of positions, equally as in the other, 
 nature seldom — very seldom indeed^ — so far fails as to require the 
 direct aid and operative interference of art. 
 
 TKEATMENT OF FACE PRESENTATIONS.' 
 
 (From British and Foreign Medical Review, October, 1841, p. 473.) 
 
 The history of the treatment of face presentations is an illustra- 
 tion of how very much may be gained by studying obstetric mechar 
 
 ' Review of the Worlcs of Bigby, Ramsbotham, atid Davis. 
 
FACE PRESENTATIONS. 429 
 
 nism, and by observing how much nature can eiFect in particular 
 instances. 
 
 Many authors of the seventeenth and first half of the eighteenth 
 century, seem to have looked upon face cases as sopreternatui-al and 
 difiicult, that it was generally necessary in the treatment of them, 
 as in the treatment of a hand or shoulder presentation, to have re- 
 course to the operation of turning. Lamotte, Cooper, Smellie, 
 Burton, &c., all appear to have followed this practice, particularly 
 when called in at an early stage of the labor. Giffard, in his post- 
 humous work, published in 1734, seems to apologize for finishing 
 two face cases with his extractor or forceps, by truly observing, that 
 turning is attended with great difficulty where the " waters are 
 gone ofi^, and the uterus closely envelopes the child." Again, Per- 
 fect, Baudelocque, and others, while they deem it unnecessary to 
 have recourse to the dangerous operation of turning, still considered 
 active interference necessary, and have, as a common rule, recom- 
 mended the face to be pushed up and the vertex brought down, 
 contenting themselves thus with a rotation of the head of the in- 
 fant, and not a rotation of its whole body. Peu speaks of the 
 crotchet — if the face has already descended into the pelvis ; and 
 Stein recommends the conjoined use of the fillet and forceps in 
 managing these presentations. Indeed Stein maintained that with- 
 out some such interference face cases would always be cases of 
 delay and danger. He avers that their spontaneous termination is 
 impossible, except where the fcBtus is preternaturally small, or the 
 pelvis preternaturally large. Mesnard endeavored to prove this by 
 geometrical measurements of the child's head and mother's pelvis, 
 and we regret to add, that one of the most distinguished accouch- 
 eurs of the present day, M. Capuron, still upholds the same doctrine, 
 and obstinately opposes the result of his observations with the rule 
 and compass upon the dead and dry head and pelvis, to the result of 
 the direct observations of all his contemporaries upon living nature ; 
 thus forgetting or despising one of the great rules of the father of 
 the inductive philosophy — " ISTon arctandus est mundus ad angustias 
 intellectus, sed expandendus est intellectus ad mundi imaginem re- 
 cipiendum qualis invenitur." 
 
 The sufficiency and success, however, of unassisted nature in face 
 cases was long ago announced to the profession. In 1685, Paul 
 Portal, who in this and several other matters far outstripped the 
 age in which he lived, taught that in face presentations the child 
 might suffer, and its face be black and swollen, but there is not, he 
 adds, more mystery in this than in a natural or vertex presentation. 
 " I have," he says, " delivered several women whose children came 
 with the face foremost, and always without any great difficulty, it 
 
430 TEDIOUS LABOR. 
 
 being only observed, that in such cases no violence must be used, 
 but nature left to its own course, vehich done, there is no danger 
 either of mother or child." In 1769, "Wallace Johnson in this 
 country, and in 1770 Deleurye in France, both publicly avowed the 
 same opinion in regard to the safety and propriety of leaving face 
 presentations to the unaided efforts of nature ; and latterly such an 
 accumulation of statistical proof has been collected upon this ques- 
 tion, as must, we think, prove perfectly satisfactory to every un- 
 prejudiced mind, and carry conviction to all that prefer the force of 
 simple facts to arguments and dogmatic theories. In 1789 Zeller 
 published 43 cases of face presentations, all of which terminated 
 without operative or artificial interference. In 1793 the celebrated 
 Boer declared, that out of 80 face cases which he had himself ob- 
 served and noted down, none of the mothers suffered in the slight- 
 est degree ; three, or at most four, of the children were born dead, 
 and in one case only was artificial assistance (by the forceps) deemed 
 necessary. In 1826 Chevreuil, physician to the Maternity Hospital 
 at Angers, stated that in 18 face cases which he had met vdth, all 
 terminated naturally. The infants were of the ordinary size ; 15 
 were born alive, and 8 were dead ; but apparently, he adds, in these 
 cases death had taken place before delivery. In 1836 Dr. Collins of 
 Dublin, in his excellent account of the cases in the Lying-in Hos- 
 pital of that city, reports 33 face cases as having occurred during 
 his charge of the institution. All the 33 were delivered without 
 assistance, and recovered well. Four of the children were still- 
 born, and one of the four was acephalous (anencephalous). In one 
 of the four the labor had been allowed to be prolonged thirty-six 
 hours. With the two others it lasted seven or eight hours. In 5 
 the labor was over within an hour, " Some cases of face presenta- 
 tions," Dr. Collins ingeniously adds, " I am disposed to think were 
 not noted, delivery having taken place so very speedily." 
 
 If it were necessary, we might add to the foregoing the statistics 
 in face cases of the Prague Hospital, as given by Kilian ; or those 
 of Bourg, as reported by Pacoud ; and the observations in Copen- 
 hagen, made by Bang ; but it is unnecessary to accumulate further 
 proof, when that proof all tends to the same conclusion. These 
 last three authors conjointly report above 200 face presentations, all 
 showing the great sufficiency of nature in such cases, and the im- 
 propriety of rash interference. 
 
 In the works of Drs. Kigby, Eamsbotham, and Davis, we find 
 different doctrines of practice inculcated, in regard to face cases. 
 Dr. Eigby gives no direct rules for their management, but his ob- 
 servations all show that he believes face cases to require no particu- 
 lar interference on the part of the practitioner. Dr. Eamsbotham 
 
FACE PBBSENTATIONS. 431 
 
 expresses the same opinion, and shows the same repugnance to the 
 employment of any artificial management in ordinary face cases. 
 "We have already seen some practitioners advising an attempt at 
 rectifying the position of the head, by transforming the face into a 
 cranial presentation. This is a line of practice too often attempted 
 even at the present day. "We believe its performance to be impos- 
 sible after the face has been pushed down into the cavity of the 
 pelvis, when the child and pelvis are both of the natural dimen- 
 sions, for we believe it physically impossible to turn the foetal head 
 on its long or occipito-mental axis of five inches through the cavity 
 of the pelvis, which is normally only four inches and a half. "We 
 quote one or two excellent remarks of Dr. Eamsbotham on this 
 topic : 
 
 " It becomes a most important question whether, under a face 
 presentation, any means should be adopted to place the child under 
 a more favorable position. So difficult and almost impossible was 
 the transmission of the head under this presentation at one time 
 thought, that it was recommended that the hand should be intro- 
 duced into the uterus, that the feet should be laid hold of, and that 
 the child should be delivered by turning. This operation, per- 
 formed under the most favorable circumstances, is always attended 
 with great pain, and frequently with great danger, danger both to 
 the mother and the child ; to the mother, from the chance of injury 
 to which her structures (particularly the uterus) are exposed ; to the 
 child, in consequence of the pressure which the fanis umbilicalis 
 must more or less experience, when the head is passing through the 
 pelvic cavity. All these circumstances, then, being taken into con- 
 sideration, the practice of changing the position of the child, under 
 a face presentation, by turning, is now almost entirely exploded ; 
 and we rather leave the case to nature so long as we can safely trust 
 her, than subject the woman and the infant to such dangers. But 
 suppose, on watching the case, we find no advantage gained, no 
 alteration in the position of the head, no advance from hour to 
 hour, what then is to be done ? "We must here also act upon the 
 same unerring principles elsewhere laid down, wait till symptoms 
 require our interference^ and then use that instrument which seems 
 most applicable to the emergency; for it is impossible, by any 
 counter pressure, to make a beneficial change in the situation of 
 the head under a face presentation. We cannot cause the head to 
 turn upon the neck so as to approximate the chin to the chest by 
 pressure."' 
 
 "We have said that Dr. Eigby has not thought it necessary to 
 ofier any rules for the treatment of face cases. Dr. Davis, on the 
 
 « ' Principles and Practice, p. 209. 
 
432 TEDIOUS LABOR. 
 
 other hand, has laid down rules enough forthe management of these 
 cases, but these rules are, in our opinion, in various respects highly 
 objectionable. Indeed, if our continental neighbors judge by them 
 of the state of British midwifery, we fear they will consider us as 
 undoubtedly retrograding rather than advancing in this department 
 of the healing art. In order to avoid all risk of misrepresentation 
 we shall here quote his own words : 
 
 " "When the face is discovered to present at the brim of the pelvis 
 at an early period of a labor, whether before or very soon after the 
 escape of the liquor amnii, there can, in the author's opinion, be no 
 doubt as to the preferableness of turning to all other modes of treat- 
 ment. That operation dexterously performed would, at all events, 
 give the child a good chance of preservation of its life, whilst it 
 would also be the means of rescuing the mother on the very brink 
 of a great impending danger." ^ 
 
 We certainly regret to find such practical doctrines published by 
 an author of Dr. Davis' name and standing, and, above all, by a 
 lecturer on midwifery. The interference he thus teaches is, as we 
 have already seen from the statistical data, useless and unnecessary. 
 We wish this were all we could say against it. We must add our 
 solemn conviction that the practice is not only superfluous, but that 
 it is fraught with great danger to both the child and mother. In 
 original footling cases, about one in every four is lost from com- 
 pression upon the cord, and other causes which it is unnecessary at 
 present to inquire into. Dr. Davis advises us to change artificially 
 the face into a footling case, and if so, we could not certainly expect 
 to save more than in the natural footling cases. We believe we 
 should save fewer. How strongly, then, does this degree of danger 
 to the child contrast with the degree of danger to which it was 
 found subjected in Boer's cases ; when leaving the case to nature, 
 not more than 1 in 20 was lost. In the exercise of our profession 
 we have too often to blame ourselves for errors of omission. Here 
 we think human life is manifestly endangered by an error of com- 
 mission, if meddlesome and unnecessary interference may bear that 
 name. But the practice aflects not the safety and life merely of the 
 child : it afiects also the safety and life of the mother. Turning 
 the foetus in utero is an operation which, as Dr. Churchill calculates 
 from various data, proves fatal to the mother in about 1 in every 15 
 cases in which it is had recourse to. Are we justified in subjecting 
 any woman to even a fraction of this danger in rectifying or 
 attempting to rectify a presentation, any supposed difficulties con- 
 
 ' Elements of Obstetric Medicine, p. 659. 
 
FACE PRESENTATIONS. 433 
 
 nected with which nature every day shows us she can easily and 
 safely overcome without any assistance on our part ? 
 
 Let us not be misunderstood. We by no means inculcate that 
 the practitioner is to remain perfectly apathetic because the pre- 
 sentation is discovered to be a face one. We would rather wish to 
 guard him against the opposite and more dangerous extreme of 
 direct and dangerous interference with the head or body of the child 
 itself. In all such cases we firmly believe, as a general rule, that 
 the infant or its position should not be interfered with. The only 
 exception is the rare case where the head is too large for the face to 
 enter the brim at all. We shall not stop to inquire whether the 
 conical-shaped head of the child, when it passes through the pelvis 
 with the face or base of the cone first, is much or in any degree 
 larger than when the vertex or apex of the cone forms its present- 
 ing part. But even admitting, what we conceive to be true, that 
 the head when it passes down Avith the face presenting is slightly 
 larger and more unyielding, and consequently requires a somewhat 
 larger space to pass through than in vertex or cranial cases, — still 
 we would strongly repudiate any attempt to manage such cases 
 by intermeddling with the child, while we deem it proper and 
 justifiable to use every simple and safe expedient within our power, 
 which may act upon the mother so as to render either the uterine 
 action more decisive, or the parturient passages more dilated, or at 
 least more easily dilatable. For this purpose we avert more carefully 
 all causes that could interfere deleteriously with the functions of the 
 uterus, and at the same time, we also have recourse to bloodletting 
 and other measures calculated to fulfil this indication, earlier and 
 more decidedly in face than in cranial presentations, when there is 
 even any tendency to delay ; the membranes should be allowed to 
 remain as long entire as possible; the rectum and bladder kept 
 empty; and if, as not unfrequently happens, a fold of the cervix 
 uteri happens to be pushed down before the presenting part, it 
 should be very gently relieved and pushed aside ; and the perineum 
 in this, as in all malpresentations of the head, must be guarded with 
 especial care under the unusual degree of distension to which it is 
 subjected. 
 
 Cases of delay and difficulty and danger will happen with pre- 
 sentations of the face, as with presentations of the cranium, and 
 from the very same causes which in cranial cases may render the 
 uterine powers insufficient to complete the expulsion of the child. 
 Under such circumstances our interference or non-interference must 
 be regulated by the same principles as in natural or cranial pre- 
 sentations. We will only add one remark: If in a laborious face 
 case we use the forceps or the vectis as an extracting instrument, 
 
 VOL. I. 28 
 
434 TEDIOUS LABOR. 
 
 we must hold it ever in our recollection to direct at tlie outlet the 
 chin and not the forehead under the arch of the pubis. If the chin 
 were turned backwards instead of forwards, all our physical eftbrts 
 at the extraction of the head would be utterly fruitless. 
 
 NEW FORM OF OBSTRUCTION IN HEAD PRESENTATIONS,' 
 
 FROM DISPLACEMENT OP THE ARM. 
 (From Edinburgh Monthly Journal of Medical Science, April, 1850, p. 389.) 
 
 Dr. Simpson stated that he considered the case to which he 
 wished to direct the attention of the Society an important one, 
 because the peculiar obstruction in head presentations which it 
 illustrated was, so far as he knew, hitherto undescribed. The form 
 of obstruction consisted in one of the arms of the infant being dis- 
 placed backwards across the neck or occipital region; or more 
 properly speaking, it was the forearm that was thus thrown across 
 the back of the head and neck, the arm being thrown upwards in a 
 line with the body, in order to admit of this malposition of the 
 forearm. In this abnormal position the displaced elbow and fore- 
 arm of the child first increased greatly the dimensions of the basis 
 of the head ; and secondly, these same parts formed a kind of pro- 
 jecting obstruction, which readily hitched and caught upon the brim 
 of the pelvis, thus preventing the descent of the head. But the 
 effects might be better judged of by detailing the case itself. 
 
 The patient had previously borne nine children. All the labors 
 had been easy, and she had frequently been delivered so speedily, 
 that the labor was over before the medical attendant could reach the 
 house. In her last and tenth labor, pains came on about four in 
 the afternoon, and the os uteri was not completely opened up till 
 about ten o'clock. About an hour before, the membranes ruptured. 
 At six next morning, Dr. S. received a note from her medical 
 attendant, Mr. Carmichael, asking him to see her, as the head had 
 remained in the same position at the brim for several hours, the 
 uterine contractions were becoming weak, and the woman herself 
 exhausted. On placing the patient deeply under the influence of 
 chloroform, in order to make a complete examination, Dr. S. found 
 the maternal passages perfectly relaxed and open, and the head of 
 the child to be by no means large, and not even entirely filling up 
 the brim. The vertex presented, and the face was directed towards 
 
 ' Extracted from Proceedings of Edinburgh Obstetric Society, February 13, 1850. 
 
BISPLACEMENT OF ARM BEHIND HEAD. 
 
 435 
 
 the left sacro-iliac synchondrosis — a rare enough position, hut one 
 
 not in any degree calculated to account for the delay. On passing 
 
 the examining fingers farther upwards, in order to trace a'ny possible 
 
 obstruction, he touched a projecting body (the -p^^ 24. 
 
 elbow) beyond the left ear of the child ; and on now 
 
 making the examination more carefdlly, he traced 
 
 this body backwards across the neck of the infant, 
 
 and found it to consist of the left forearm of the 
 
 child thrown back posteriorly behind the head. He 
 
 then brought the hand downwards and forwards, 
 
 believing that if it were converted into a head and 
 
 arm presentation, the case might terminate without 
 
 further interference. During the next half hour, 
 
 however, the pains, which had for some time been 
 
 weak, had little effect in forwarding the presenting 
 
 parts, and as the pulsation of the child's heart had 
 
 now sunk as low as 78 beats in the minute, Dr. S., 
 in order to preserve the child, again chloroformed 
 the patient deeply, and delivered the child by podalic turning. The 
 mother made a speedy recovery. The child soon cried strongly, 
 and went on quite well. Its left arm was for a day or two after 
 deliveiy easily thrown into the position described. The occipito- 
 frontal circumference of the head was afterwards measured by Mr. 
 Carmichael, and found to be 14J inches ; when the arm was placed 
 in its anomalous position, the same circumference measured 15J 
 inches. The circumference of the shoulders was 13J inches. The 
 child was of about the usual size, and weighed 7J lbs. 
 
 The treatment of such a cause of obstruction, when it was once 
 recognized, should probably consist in bringing the hand downward 
 and forward over the side of the head, so as to convert the case into 
 one of simple presentation of the head and arm. Perhaps it might 
 occasionally be possible to push the elbow forwards in the direction 
 of the lower end of the sternum, and thus draw back the displaced 
 arm into its normal position in front of the chest. If either of these 
 measures proved impossible, or failed, then the podalic version would 
 be required.' 
 
 The Diagnosis of the case was the most difficult point in its 
 management. And in this, as in other complications — as detention 
 from intra-uterine hydrocephalus, &c. — ^the assistance of anaesthetics 
 in midwifery was invaluable as a means of enabling the accoucheur 
 to make a far more searching and successful manual examination 
 
 'Dr. Simpson lias latterly seen this cause of difficulty overcome without any artificial aid. 
 He has had various communications showing the comparative frequency of the compli- 
 cation — (Ed.) 
 
436 TEDIOUS LABOR. 
 
 and diagnosis, in cases of obstructed labor, than it was possible to 
 do when the patient was awake and incapable of bearing with 
 steadiness, «nd without unnecessary suffering, the introduction of 
 the hand for the purpose. 
 
 When a labor, as in the preceding case, notwithstanding steady 
 and continued uterine contractions, became morbidly prolonged in 
 a mother who had previously borne easily a large family, there was 
 every probability of obstruction of some kind on the part of the 
 infant. Dr. S. had seen two such cases, where the detention was 
 the result of intra-uterine hydrocephalus. In the present instance 
 it was the result of the malposition of the arm. Some time since 
 he had mentioned to the Society two cases of tedious labor, which, 
 several years ago, he had seen with Dr. Ziegler: in both, the head, 
 despite of strong pains, remained in the pelvic brim without de- 
 scending ; in both, the head was evidently not disproportionately 
 large to the maternal passages; in both, some point of the shoulder 
 or arm could be touched by theJinger on examination ; and, perhaps, 
 if the examination could have Itfeen made more complete by the use 
 of ether or chloroform, which were then unknown, a malposition 
 of the arm, similar to tlie one above, described, might have been 
 detected. Various cases are recorded of obstructed labor, with the 
 head, as usual, presenting, in mothers who had previously had 
 natural deliveries, and where the forceps failed to extract the child, 
 and where even extraction after craniotomy was difficult. Some of 
 these cases were in all probability instances of obstruction from 
 dorsal malposition of the arm, or rather of the forearm. The late 
 Dr. Campbell, shortly before his death, had told him of a case where 
 there was no pelvic or other deformity on the part of the mother, 
 no want of uterine contraction, and no disproportionate size of the 
 head of the child, and yet he and others had entirely failed in ex- 
 tracting the detained infant by the forceps, and at last were obliged 
 to open its head.' 
 
 "WTien looked for, Dr. S. believed, therefore, that the dorsal mal- 
 position of the forearm would be found a more frequent cause of 
 obstructed labor than the total silence of obstetric authors on the 
 subject might, a priori, lead us to suppose. Further, he considered 
 the present case as interesting, not only as an instance of an unde- 
 scribed species of malposition and obstruction, but probably as one 
 of a new class of malpositions as yet unrecognized in any of our 
 accounts of the mechanism of labor, and the malpositions of the 
 child. It would probably be found that other degrees and forms of 
 malposition of the arm might occasionally lead to the same result. 
 
 ' For a full description of this case by Dr. Gumming, see Edinburgh Monthly Journal of 
 Medical Science, April, 1850, p. 389.— (Ed.) 
 
THE LONG rOKCEPS. ' 437 
 
 At the same meeting Dr. Simpson observed, that sometimes, in women who had previously 
 borne a large family, a cause of obstruction might exist in a late labor, not on the part of the 
 child, as was generally the fact, but on the part of the uterus. Last summer he saw, with 
 Dr. Skae, a case of this kind, where the source of detention was a firm and contracted circular 
 band of the uterus around the site of the neck of the child A patient who had had a 
 large family and easy labors, complained of a feeling of tightness across the lower part of 
 the abdomen, during the last three months of her last gestation. Dilatation of the os uteri 
 did not seem actually to begin until the patient had been suffering at least 48 hours from 
 labor pains. Nor could the head be detected as the presenting part for nearly 24 hours 
 longer. For several hours more, the patient continued suffering apparently from severe labor 
 pains, during which the head descended to the brim, but never entered it. (Edema of the 
 OS uteri now showed itself, and the strength of the patient began to flag. 
 
 Dr. Skae felt satisfied that the obstruction to labor must be of some unusual kind, for the 
 pelvis was large and well formed, and the size, firmness, and configuration of the child's 
 head opposed the idea of hydrocephalus. He therefore sent for Dr. Simpson, and after the 
 patient was placed under a full dose of chloroform, the cause of obstruction was found to 
 depend on the presence of a rigid stricture, situated in the lower third of the uterus, upon 
 which rested the shoulders of the fostus. After administering 120 drops of Sol. Mur. Mor- 
 phise, and keeping her pretty deeply under the influence of chloroform for two hours, it was 
 found that no material relaxation of the stricture had taken place, to admit of turning with- 
 out endangering the integrity of the uterine walls. It was feared that ovariotomy might be 
 ultimately necessary ; but employment of the long forceps was first resolved upon, notwith- 
 standing the unusual difficulty of applying them so high up, as necessarily to require their 
 being locked within the vagina. Dr. Simpson, however, succeeded readily in applying 
 them, and accomplished delivery in some fifteen or twenty minutes, by dragging the shoulders 
 of the foetus through the stricture. In this case both mother and child did well, the recovery 
 being unattended by any unfavorable symptoms. See a fuller account by Dr. Skae, in Edin- 
 burgh Monthly Journal for April, 1850, p. 390.— (En.) 
 
 ON THE MODE OF APPLICATION OF THE LONG 
 FORCEPS.' 
 
 (From Edinburgh Monthly Journal of Medical Science, September, 1848, p. 193.) 
 
 When the head of the child becomes fixed in the brim of the 
 pelvis, and the powers of the uterus fail in propelling it through 
 that aperture, one of two modes of instrumental delivery is usually- 
 resorted to — namely, either, 1. Diminution of the infant's head by 
 perforation and craniotomy ; or, 2. Extraction of it by the long 
 forceps. 
 
 Craniotomy is the preferable operation where the child is dead, 
 and where the pelvic brim is much contracted, or the child's head 
 very much above the average size. But besides being always necessa- 
 rily fatal to the child, craniotomy is an operation by no means with- 
 out danger to the mother ; — one in every five mothers, according to 
 
 ' Proceedings of Edinburgh Obstetric Society, May 10, 18-18. 
 
438 
 
 TEDIOUS LABOR. 
 
 Dr. Churcliill,' dying, upon whom it is performed. And in most 
 schools of midwifery, it is now, consequently, much more rarely 
 practised than heretofore. Still many authors and practitioners, as 
 Drs. Collins, Johnson, Lee, &c., appear to resort to it in all cases in 
 which the bulk of the head is unable to pass the brim, and reject 
 entirely the other alternative of the long forceps. 
 
 The long forceps afford in these cases the best chance of life to 
 the child, and when used with proper views of their mechanism and 
 mode of application, their employment, as is often seen in Edin- 
 burgh practice, is by no means so difficult and dangerous as some 
 authorities seem to believe. Misapprehension on these points is 
 perhaps the cause why they are not more frequently used. They 
 differ from the short forceps in some points of construction, but 
 more particularly in regard to their mode of application and work- 
 ing. They differ for example in their length ; in the shanks being 
 parallel for some distance beyond the lock, an indispensable point 
 in order to prevent their injuring the outlet ; in their blades being 
 curved ; and in the part intended to embrace the head being suffi- 
 ciently long and large. The instrument which Dr. Simpson has fre- 
 quently and successfully used during the last five or six years, has 
 some additional peculiarities, as is seen in the woodcut. The blades 
 are the same as Dr. F. Ramsbotham's, but scarcely so much curved. 
 The lock is Smellie's, but with knees or projections above it of 
 such size as to prevent the blades 
 readily unlocking in the interval^ 
 between the pains, thus giving it the 
 fixed character of the locks of Levret 
 and Brunninghausen's instruments, 
 without their complexity. The joints 
 are made so loose as to allow of their 
 lateral motion and overlapping to a 
 very considerable degree, thus facili- 
 tating their introduction and appli- 
 cation. And, lastly, the handle is 
 that used by Naegele and other Ger- 
 man accoucheurs, viz., with trans- 
 verse knees or rests below the lock , 
 for one or two of the first fingers of \. 
 the right hand to drag by, the long 
 forceps being only properly used as 
 an instrument of traction, not of com- 
 pression. In addition, the handles 
 are grooved and marked on the anterior side, to distinguish that 
 
 ' Operative Midwifery, p. 173. 
 
 Fig. 25. 
 
 9.% 
 
THE LONG FORCEPS. 439 
 
 from the other side when the blades are within the pelvis. Tie 
 following are some of the dimensions of Dr. Simpson's forceps : 
 Length of the entire instrument, 13f inches ; length of handle, 
 including the lock, 5J inches ; length of shank, from the lock to 
 the commencement of the curve of the blade, 2J inches ; length of 
 the blade, 6J inches ; extreme breadth of blade at 1 J inches dis- 
 tance from the point of the instrument. If inches ; length of the 
 fenestra, 4 J inches ; extreme breadth of the fenestra, 13 lines ; 
 breadth of the groove of the lock, f inch ; thickness of the shank 
 to fit in the groove of the lock, f inch ; extreme distance between 
 the blades at three inches distance from the point of the forceps 
 when locked, 3 inches ; distance between the points of the two 
 blades when locked, 1 inch. 
 
 In their modes of application, the long forceps difier from the 
 short. The short forceps are applied always to the lateral surfaces 
 of the child's head, in whatever position the head may be. Gene- 
 rally, the long diameter of the head lies in the right diagonal 
 diameter of the pelvis; and, consequently, the short forceps are 
 placed in the opposite or left diagonal diameter ; or, in other words, 
 at right angles to the long diameter of the head. The mode in 
 which the long forceps ought to be applied, and are really applied 
 in practice, has given rise to considerable diiference of opinion. 
 
 If the long forceps are ever, for inertia, hemorrhage, or other such 
 complications, in any case applied while the head is passing through 
 the brim, and the brim and head are natural in size, the instrument 
 may be perhaps applied, like the short forceps, directly to the lateral 
 surfaces of the child's head. But the common reason for the em- 
 ployment of the long forceps is morbid contraction of the brim of 
 the pelvis in its most general form, and from its most general cause, 
 viz., in the conjugate or antero-posterior diameter, from projection 
 forward of the promontory of the sacrum. How are the long forceps 
 applied when used in this, the case in which they are most generally 
 had recourse to in practice ? It is first requisite to state, that under 
 this complication the child's head is found situated in the brim, 
 with its long or fronto-occipital diameter lying in the transverse 
 diameter of the brim, or with the forehead looking to one ilium, and 
 the occiput looking to the other. In other words, the long diameter 
 of the head is not placed, as usual, in the right diagonal diameter of 
 the brim, but more in its transverse ; for where the promontory of 
 the sacrum forms a morbid projection, the transverse forms the 
 longest diameter of the brim, and, consequently, the one in which 
 the child's head comes to be placed by the uterine efforts. The face 
 or forehead looking to the ilium, and the occiput to the other ilium, 
 the lateral surfaces of the child's head come to be compressed be- 
 
440 TEDIOUS LABOR. 
 
 tween the protruding sacral promontory and tlie interior of the 
 symphysis pubis. Now, in seizing the head in this case some 
 authors aver, that — 
 
 1st. The blades of the long forceps are placed, as in applying the 
 short forceps, on the lateral or aural surfaces of the child's head, and 
 consequently with one blade in front of the sacral promontory, and 
 the other behind the symphysis pubis. Burns,' Dewees,^ &c., speak 
 of thus applying the long forceps in the conjugate diameter of the 
 brim ; and Dr. Churchill ' has published a wood-cut representing 
 this as the actual method of their application in practice. But its 
 application in this position is impossible in the very cases in which 
 the long forceps are generally required, viz., where the conjugate 
 diameter is contracted, for there is not room for the additional thick- 
 ness of the blades of the instrument ; if applied, they add to the 
 thickness of the head in that one diameter and place in which it is 
 already too thick and large ; their pressure would greatly endanger 
 the urethra and bladder in front, and the soft structures placed over 
 the promontory of the sacrum behind ; and they could not thus be 
 placed in the axis of the brim in consequence of the pressure of the 
 perineum upon the instrument below. Other authors aver, that — 
 
 2dly. The Hades of the long forceps should he placed over the occiput 
 and forehead or face of the child, and consequently in the transverse 
 diameter of the brim. This is the view of their mode of application 
 taken by Deleurye,"* Davis,^ &c. &c., and approaches much nearer the 
 reality than the former opinion ; but that it is not strictly true, is 
 shown by the marking of the place of application of the blades of 
 the instrument after the child is born, and by a more attentive con- 
 sideration of the mechanism of such labors. One blade is found to 
 have been placed behind one ear, and the point of the other to have 
 pressed upon the side of the forehead, temple, or region of the eye ; 
 but these would not be the places of the markings of the blades if 
 they were applied in the transverse diameter, upon a head placed 
 directly transverse. Dr. Eamsbotham^ has published a beautiful 
 plate of the mode of application of the long forceps, and has given 
 an excellent chapter on the subject in his work on Midwifery. He 
 correctly represents in the plate the anterior bjade as placed upon 
 the side of the forehead and eyebrow ; but in order to give this view 
 with the forceps placed in the transverse diameter of the brim, he 
 has been obliged to represent the face as turned backwards, whilst 
 in reality, in morbid contractions of the conjugate diameter of the 
 brim, it is actually turned laterally ; and he places the long diameter 
 
 ' Burns' Midwifery, p. 488. ' Dewees' System of Midwifery, p. 315. 
 
 ' Chiireliill's Midwifery, fig. 70, p. 298. * Deleurye, Trait^ des Accoucbemens, p. 340. 
 
 ' Davis's Operative Midwifery, p. 24.'. " Ranisbothatns Obstetric Medicine, plate Ivi. 
 
MODE OF APPLYING THE LONG FORCEPS. 
 
 441 
 
 of the blades of the forceps so as to traverse the right oblique, in- 
 stead of the left oblique pelvic diameter. 
 
 3d]y. The Hades of the long forceps should, I believe, be placed 
 obliquely upon the child's head — one, the posterior, ove^ the side of the 
 occiput ; and the other, or anterior, over the side of the hrow or temple ; 
 and consequently they should be generally situated somewhat in the 
 oblique diameter of the brim, as Fig. 26. 
 
 in the wood-cut. The markings 
 on the child's head after birth 
 always show this mode of ap- 
 plication of the instrument; 
 when properly applied upon the 
 mother, and when their situa- 
 tion relative to the pelvis is ex- 
 amined, they are found to have 
 assumed this position; and in 
 experiments with the instru- 
 ment, when the head of a dead 
 child is fixed in a pelvis with a 
 contracted brim, this is the 
 position and relation which the 
 instrument will be seen to as- 
 sume with relation to the in- 
 fantile head and maternal pelvis. 
 Besides, in thus placing the in- 
 strument, while we incur less 
 danger of injuring the urethra and other important parts, we place 
 the blades of the instrument in exactly those parts of the pelvic 
 circle where there is least pressure, and consequently most room for 
 them. It is apparently in consequence of misconception on this 
 point, that some authors have come to prefer the use of the per- 
 forator to that of the long forceps. Dr. Collins, for example, argues 
 that when the head is detained in the pelvic brim, the brim 
 " measuring little more than three inches from pubis to sacrum," 
 there cannot possibly be space for the long forceps even were the 
 bones denuded, seeing that the blades of the smallest-sized forceps 
 used in Britain, even when completely closed, measure from 3| 
 to 3J. " How," he adds, " is it possible with the forceps to drag a 
 child through a pelvis where there is not space, except by force, to 
 introduce, as is commonly said, a straw, or where the smallest 
 flexible catheter cannot be passed in some instances into the blad- 
 der 1" These and such opinions proceed on the erroneous idea, that 
 the long forceps are to be applied, within the pelvis, at the parts, or 
 in the diameter in which the pelvis is most contracted, and they 
 
442 TEDIOUS LABOR. 
 
 suppose that tlie head, when fixed in the pelvic brim, fills completely 
 the whole circle of the brim. The usual shape of the morbidly con- 
 tracted pelvic brim is cordate, or rather elliptico-cordate ; but the 
 child's head is not of this shape, it is ovoid, and consequently, 
 when applied to the cordate brim, leaves unoccupied spaces. The 
 most unoccupied spaces, before and behind, are at the extremities of 
 the oblique diameters of the brim, where sufficient room is left for 
 the passage of the blades of the forceps, and in these points they 
 are passed when properly applied. 
 
 We are led to believe that a practitioner will have little need of possessing a pair of short 
 forceps, if furnished with such a pair of long ones as those described in the preceding paper. 
 We have repeatedly heard Dr. Simpson assert, that the more frequently he applied the 
 forceps, the more firmly he became convinced that one pair of proper form and workman- 
 ship would answer for all forceps cases ; and that he believed an obstetrician much more 
 likely to become dexterous in manipulating, who confined himself to one pair of forceps, 
 and studied that form carefully, than if repeatedly changing the form of instrument, accord- 
 ing as the fcEtal head was situated high or low in the pelvis. The curve of Dr. Simpson's 
 forceps is so slight as to keep them available for altering an occipito-posterior position of the 
 head into occipito-anterior, as described at p. 428 of this volume. The curve of the German 
 and French instruments, and of many English forms, is generally so great as to prevent 
 them entirely from being used for this rotation of the head. — (Ed.) 
 
 THE AIR-TRACTOR' 
 
 AS A SUBSTITUTE FOR THE FORCEPS IN TEDIOUS LABORS. 
 (From Edinburgh Monthly Journal of Medical Science, Feb. 1849, p. 556.) 
 
 Cases ever and anon occur of morbid protraction and delay in the 
 second stage of labor, with the head of the child sunk down into 
 the pelvic cavity, or resting upon the perineum; with the caput 
 succedaneum enlarging more and more under the pressure and pro- 
 longed uterine contractions, and yet these contractions producing 
 little or no effect upon the actual advancement of the infant ; and 
 with local and general symptoms threatening to supervene, and 
 showing the propriety, if not the necessity, of the patient being 
 relieved, and delivery being completed. 
 
 In such tedious and trying cases, if there were space for us to 
 pass our hands between the soft parts and head, so as to seize with 
 them, and drag upon the head, we could curtail the patient's suffer- 
 ings. There is not room for this. Our hands are too thick for the 
 purpose. As a substitute, accoucheurs under such circumstances 
 introduce a thin metallic hand, so to speak, on each side of the 
 
 ' Extracted from Proceedings of Edinburgh Obstetric Society, Dec. 20, IBIS. 
 
THE AIR-TRACTOK. 443 
 
 child's head — viz., the forceps — which exactly, like a couple of 
 Blender hauds, take hold of the head, and enable us to apply, when 
 necessary, extractive force to it. One objection which has been 
 often urged against the use of the forceps (though it is an objection 
 against their abuse rather than their use) is this, that the instrument, 
 in being introduced between the maternal passages and head, is apt 
 to injure these passages, and to contuse and even lacerate them 
 during their working; that they are thus liable to inflict local 
 damage on the mother at the very same time that they shorten the 
 term of her suflferings and save her infant. 
 
 Is there any other mechanical power which it is possible for us to 
 apply to the infant's head in order to seize and move it forward, 
 which would not be liable to the same objection of danger to the 
 mother ? 
 
 In such tedious cases as seem to require the use of the short for- 
 ceps, the idea has perhaps crossed the minds of most accoucheurs, 
 that if they could get hold of the exposed portion of the scalp of the 
 child, or of the skin forming the caput succedaneum, and could 
 possibly pull by this hold, they might thus expedite the process of 
 delivery, and abridge the sufferings of their patients. The spherical 
 form of the infant's head, and the intimate mode in which the scalp 
 is spread over the arch of the cranium, prevent the possibility of 
 taking any such hold by the fingers alone. By means of a small 
 suctorial disk, the shell of the patella or limpet, which is so common 
 upon our shores, fixes itself with great force to the stones or rocks 
 on which it is placed. Dibranchiate cephalopods — as the common 
 cuttle-fish — fix their arms, by similar suctorial disks, so firmly to 
 different surfaces, that their arms themselves will often tear before 
 the suckers with which they are attached will give way. If we 
 could fix upon the exposed portion of the fcetal scalp the suctorial 
 disk of a limpet or cuttle-fish with the usual force with which they 
 adhere to the sea-rocks, &c., to which they are attached, we should 
 have, in many cases, a power sufficient to enable us to apply by 
 them the necessary amount of extractive force. The disks of the 
 limpet and of the cuttle-fish attach themselves firmly to the surfaces 
 to which they adhere, by being formed so as to act upon the prin- 
 ciple of the common sucker used by the schoolboy to lift stones, 
 &c. — viz., by removing, or rarifying as far as possible, the air placed 
 between the attaching and attached bodies, and' thus taking advan- 
 tage of the great power exercised by pressure of the atmosphere upon 
 the surfaces of solids. This pressure is, as is well known to all, 
 equal to nearly fifteen pounds upon the square inch when the sub- 
 jacent vacuum is perfect; or, in other words, it would require a 
 force equal to fifteen pounds for every square inch attached, to effect 
 
444 TEDIOUS LABOR. 
 
 the separation of surfaces thus united. The limpet and cuttle-fish 
 have the surface of the acetabula or disks with which they fix them- 
 selves so strongly upon the rocks, bedewed with a thick mucous 
 secretion ; after placing the surface of the disk upon the part to 
 which they are to attach themselves, they, by a muscular movement, 
 raise the centre of the disk so as to produce a more or less perfect 
 vacuum; and the cuttle-fish has a central body in the middle of each 
 disk, which it draws up and uses for this purpose, exactly on the 
 principle of the piston of a syringe. 
 
 Such an arrangement and apparatus may be imitated by art ; and 
 when rendered more perfect and complete, may perhaps give us a 
 simpler and safer obstetric power for some cases than even the for- 
 ceps. In one protracted case which Dr. Simpson described, he had 
 lately made use of this power to extract the child. When applied, 
 the head was still high up in the pelvic cavity, and the instrument 
 easily afforded such a hold of the head as to allow it to be slowly 
 dragged forwards and extracted. During this extraction the instru- 
 ment required to be reapplied once or twice. Dr. Duncan and Mr. 
 Dickson were present at the delivery. 
 
 The instrument used in this case was very rude and imperfect. 
 It consisted of a common metallic vaginal speculum, fitted with a 
 piston, and with the edge of the trumpet-shaped concave disk at its 
 outer or broader end covered with leather. This broader and 
 leathered end was coated with lard, and applied to the head of the 
 child ; and then an exhausting effect produced by moving the piston 
 forwards. The apparatus would admit of much improvement and 
 simplification, as by its mouth being made expansible, and capable 
 of altering in shape, instead of metallic and fi:xed ; by its inner edge 
 being coated, as in atmospheric railways, by a thin layer or cushion 
 of air enclosed in caoutchouc ; by the exhausting apparatus being 
 valved and more perfect, &c., &c. But if the air-tractor could not be 
 made both simple and satisfactory in its application, it would not 
 replace the forceps ; and more experience would be required to 
 decide whether it had any title to do so. 
 
 If the instrument, when properly constructed, should be found to 
 succeed, it would be still more advantageous in replacing the lon§, 
 than in replacing the short forceps. In the case in which it was 
 used, the head was at the height for which long forceps are usually 
 required. If a suctorial tractor should answer in some long forceps 
 cases, and enable us to drag with sufiicient force, upon the exposed 
 portion of the scalp, it should save the danger dreaded by many, of 
 wounding the uterus by introducing and working the blades of so 
 long an instrument as the long forceps, ' high up in the neck and 
 cavity of the uterus itsBlf. 
 
THE AIR-TEACTOE. 445 
 
 Presentations of the breecli sometimes require instrumental 
 assistance. The hook passed over the flexure of the thigh is 
 dangerous, and very apt to injure. The forceps, as recommended 
 in these presentations by some authorities, are often inapplicable 
 and inefficient. Perhaps the air-tractor may afibrd us a new and 
 sufficient instrumental force for the management of some of these 
 cases. Its use would be simpler and safer than any of the other 
 methods proposed. 
 
 Dr. Simpson further observed, that he was not aware that any one 
 had applied practically this obstetric means before it was employed 
 in the case detailed to the Society. But the idea of using such a 
 power had been long ago proposed by a gentleman, for whose works 
 and talents they all entertained the utmost respect, Dr. Arnott of 
 London. In his admirable work on Physics, Dr. Arnott alludes to 
 the subject in the following words: "The forceps," says he, "to 
 be well and safely used, require address, which even the naturally 
 dexterous man cannot possess without a certain degree of continued 
 practical familiarity with it : and, except in large towns, a man must 
 be unfortunate in his practice who often requires it ; hence the 
 really small number of persons who use it well. A tractor of three 
 inches in diameter would act upon anybody, to lift or draw it, with 
 a force of about a hundred pounds — with more, therefore, than is 
 ever required or allowable in obstetric practice. In lifting a stone, 
 the tractor does not act as if it were glued or nailed to the stone, 
 but merely bears or takes off the atmospheric pressure from one 
 part, and allows the pressure on the opposite side, not then counter- 
 balanced, to push the stone in the direction of the tractor ; so when 
 placed upon the child's head, it would not pull by the skin, in the 
 manner of a very strong adhesive plaster applied there, as unin- 
 formed persons would be apt to suppose ; but by taking off" a certain 
 atmospheric pressure from the part of the head on which it rested, 
 it would allow the pressure on the other side or behind to urge the 
 head forward on its way. Of course the pressure in such a case 
 would not operate on the head directly, but through the intervening 
 parietes and contents of the abdomen. It would be preferable to 
 Have a gentle and diffused action of the tractor over a large space, 
 rather than an intense action on a small space, and therefore a 
 tractor for the pui-pose now contemplated should not be very small, 
 ' and should have a little air underneath it in a slight depression or 
 cavity at its centre. The forceps must be more effective than the 
 tractor for rectifying malpositions of the head, and diminishing its 
 transverse diameter ; but the tractor will answer both these purposes 
 in a greater degree than might at first be expected." ' 
 
 ' Elements of Physics, p. 63C. 
 
446 TEDIOUS LABOR. 
 
 Several of the old surgeons, as ParS,' Paaw,^ Hildanus,' Scultetus/ 
 &c., have described and figured suckers, or tractors, as applied to 
 the head with the object of removing depressions of the cranium in 
 children. 
 
 The following additional remarks were read before the Medico- 
 Chirurgical Society of Edinburgh, February 7, 1849 : ' 
 
 If the opposed and adapted surfaces of two bodies have the air 
 removed from between them, then the external atmosphere presses 
 these bodies together, and consequently keeps them united with a 
 force equal to about 15 lbs. upon each square inch. A round disk 
 of two inches in diameter would thus, if the exhaustion of the air 
 were complete, adhere to any proper surface to which it was adapted 
 with a force of 47 lbs. ; or, in other words, it would require a power 
 of traction equal to a weight of 47 lbs. to separate it from the sur- 
 face to which it was attached. A round disk of two and a half 
 inches would adhere with a power amounting to 73 lbs. ; a disk of 
 three inches, with a power amounting to 105 lbs. ; and one of three 
 inches and a half would sustain a dragging force of 143 lbs. before 
 it separated. 
 
 In physiology, more especially in comparative physiology, nature 
 frequently employs this power of atmospheric pressure for the pur- 
 poses of prehension, locomotion, adhesion, &c. She has provided, 
 in other words, various animals with suckers or organs by which 
 they are enabled to create a more or less perfect vacuum between 
 the surface of these suckers, or cotyledons, and any body or surface 
 on which these suckers rest, so as to produce a pressure of the 
 atmosphere on the external surface of the suctorial organ, and thus 
 cause it to adhere firmly to the body on which it was placed. The 
 suckers on the head of the remora, on the feet of the gecho, on the 
 legs of the dytiseus, in the mouth and adhering acetabulum of the 
 distoma, on the arms of the loligo and octopus, in the disk of the 
 patella, &c., &c., are illustrations of nature's taking advantage of the 
 principle of atmospheric pressure for the performance of various 
 physiological functions. The human infant, the common medicinal 
 leech, &c., provide themselves with nourishment by availing them- 
 selves of the aid of the same principle. 
 
 In surgery, the principle of atmospheric pressure is converted to 
 practical purposes in the operation of cupping ; in one mode of 
 fixina; artificial teeth, &c. 
 
 ^s 
 
 ' Parfe's Surgery, lib. 10, cap. 5. * Succenturiatus Anatomiciis, p. 89. 
 
 ' Opera Medico-Chirurgio. 1846, p. 84. '' The Chyrurgeon's Storehouse. 
 
 * See Monthly Journal of Medical Science, March, 1849, p. 6 IS. 
 
THE AIR-TRACTOK. 447 
 
 Several of the older surgeons, from Ambrose ParS downwards, 
 proposed to elevate depressions of the skull, particularly in children, 
 by applying a sucker, or kind of cupping-glass or cupping-horn, 
 over the seat of the depression.* Between twenty and thirty years 
 ago, Dr. IS'eil Arnott of London suggested the possibility of apply- 
 ing the same principle in obstetric surgery. 
 
 The power that an air-tractor of 2J or 3 inches in diameter, when 
 fixed on the head of the child, should give us, is theoretically as 
 much as is required in most, if not in all cases of tedious labor in 
 which the forceps are at present employed. In trying various ex- 
 periments upon the power of traction usually employed by the 
 forceps. Dr. Simpson found it not in general to amount to more 
 than from 25 to 35 lbs. Some practitioners thought the common 
 power of traction used by the short forceps to be below this. In a 
 few rare cases, especially in long forceps operations, and where the 
 obstruction was great, the power employed might rise to 40 or 50 
 lbs. or more. The experiments upon which these results were 
 founded, were made by traction with forceps fixed upon a Salter's 
 spiral balance, used as a dynamometer. 
 
 In attempting to construct a proper obstetric air-tractor, a great 
 variety of forms had been tried by Dr. Simpson. The form which 
 he had found most effectual consisted of a slender short brass 
 syringe, IJ or 2 inches long, worked by a double-valved piston, like 
 a breast-pump, having attached to its lower extremity a cup of half 
 an inch in depth, and IJ inches broad at its edge. Over this inner 
 cup was placed a second cup formed of vulcanized caoutchouc, and 
 so deep as to overlap the edge of the inner by six or eight lines. 
 The mouth of the inner cup was covered by a diaphragm of very 
 open brass wire gauze, and over it a piece of thin sponge, flannel, 
 or the like, was placed, with the view of preventing injui-y to the 
 scalp, and not allowing it to be elongated and drawn up into the 
 vacuous space in the manner which we see occurring with the skin 
 in the common operation of cupping. The parts thus applied to 
 the child's head consisted of caoutchouc and sponge. 
 
 Such an instrument, when fixed to the palm of the hand, lifted 
 readily without detachment a weight of 30 or 40 lbs. This Dr. 
 Simpson showed by experiments performed before the Society. An 
 air-tractor, with a caoutchouc cup of three inches in diameter at its 
 mouth, lifts, when applied to and stretched upon the hand, a weight 
 of 60 or 80 lbs. 
 
 ' Dr. Simpson has, with Dr. Weir, applied the tractor to a deep indentation of an infant's 
 skull, with the result of immediately restoring the bone to its proper elevation. He has 
 likewise, sinse the publication of these notices, applied it with success in breech presenta- 
 tions — (Ed.) 
 
448 TEDIOUS LABOR. 
 
 The inner cup might be round, ova], &c., and varying in form 
 and size. The outer caoutcliouc cup would admit of much further 
 improvement. A double cup of caoutchouc seemed to render the 
 instrument stronger. Of course, with all this, the vacuum, however 
 great, was still always more or less imperfect. 
 
 The air-tractor seemed to possess various advantages over the 
 forceps. It was far less dangerous to the mother, as it was attached 
 to the exposed part only of the scalp of the infant ; the forceps were 
 required to be passed high up between the head and maternal 
 passages, and in incautious and inexperienced hands were apt to 
 injure one or both. The materials of the air-tractor, caoutchouc 
 and sponge, were safer to the mother and child than the material 
 of the forceps (steel). The forceps always took up a certain amount 
 of space between the head and passages ; the air-tractor did not. 
 The air-tractor was greatly less in size, and consequently far more 
 portable. It could be applied with sufficient firmness and power to 
 enable us to rotate the head, or change its position ; as from, for ex- 
 ample, an occipito-posterior to an occipito-anterior position, the 
 form of rotation most frequently required in practice. It probably 
 could be applied also to change the presentation — which the forceps 
 could not effect — as, for instance, to bring down the occiput, when 
 fixed there, in frontal presentations. Perhaps it may be found as 
 useful, or more so, when the head is at the brim as when it is at the 
 outlet. It may be made so as to fix upon the breech — in cases in 
 which the forceps cannot be very readily or safely used. If found 
 perfectly easy of application, it may enable the accoucheur, by 
 adding a few pounds to the strength of each pain, to bring to a 
 safer and speedier termination cases that would otherwise go on 
 tediously, hour after hour, and in which we should still not choose 
 to use so formidable an instrument as the forceps ; for it is to be 
 recollected that the danger of parturition to both mother and child 
 increases in a ratio progressive with its duration. In cases of inertia 
 of the uterus — the most common cases for the short forceps — it will 
 probably be found specially applicable. And in such instances it is 
 surely better to extract the child by a safe force, thus applied ah 
 anteriori, than to effect its expulsion by the ergot of rye — ^which 
 produces its result by forcing the uterus to push and press its 
 parietes with renewed power and violence against the opposing body 
 of the foetus. 
 
 In conclusion. Dr. Simpson stated that he had now used the air- 
 tractor which he had constructed, in several cases of labor, and with 
 results answering his best expectations. But it doubtless admitted 
 of much further improvement in construction, in mode of applica- 
 tion, in working, and other details. 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 449 
 
 The two preceding abstracts of communications on the air-tractor, read before the 
 Medico-Cbirurgical 'and Obstetric Societies, express tha same views, but somewhat differ- 
 ently illustrated in the detail. We have chosen to reprint them complete, rather than omit 
 any portions which might be regarded as repetitions. We observe that Scanzoni, in his 
 Lehrbuch der Geburtshilfe, alludes to some experiments before the Medico-Physical Society 
 of Wiirzburg, in which M. Schierlinger demonstrated that the air-tractor would not litl more 
 than 15 or 20 lbs. without separating from the surface to which it had been applied, and 
 that this force must be totally ineffectual for the purpose of extracting a f(Etal head detained 
 at the outlet of the pelvis. 
 
 We can only understand how this should be the case with an imperfect iustruftient, as 
 we have on many occasions seen a tractor of the size described by Dr. Simpson, bear 70 or 
 80 lbs. without pulling off. 
 
 The chief objection in the practical use of the tractor is doubtless in its application, and 
 not in its power of traction ; the large size of the caoutchouc cup rendering difficult its 
 introduction within the maternal passages. To this may be added the difficulty of keeping 
 the valves in working order. 
 
 Dr. Simpson however holds, and we believe correctly, that if ingenuity could suggest any 
 form of tractor which, umbrella-like, could be folded into little space for introduction, and 
 afterwards expanded over the scalp, and then exhausted by the attached piston, it might 
 supersede the forceps in many cases. 
 
 Mr. Young, the instrument-maker, has shown to us a recent letter from an English prac- 
 titioner, who speaks in the highest terms of the value of the tractor in his obstetric practice. 
 Indeed, although in its present form the air-tractor may not be so generally applicable in 
 obstetric practice, as to lead to its common adoption amongst practitioners j yet when we 
 revert to the history of some of our most useful obstetric instruments (contrast, for example, 
 the rude form of the early forceps with their present improved construction), we have 
 reason to hope, that the tractor may, at some future time, be so far improved, as to be easily 
 applied and used. — (Ed.) 
 
 ON TURNING, 
 
 AS AN ALTERNATIVE FOB CRANIOTOMY AND THE LONG FORCEPS, 
 IN DEFORMITY OF THE BRIM OF THE PELVIS, ETC. 
 
 Dr. Simpson, presenting the following papers on this subject in 
 1850, in a collected form to his pupils, prefaced them with the 
 following remarks : 
 
 " During a residence of a few weeks on the west coast of Scotland 
 in the autumn of 1847, I wrote the following imperfect Memoir ; 
 and it was subsequently published in different numbers of the ' Pro- 
 vincial Medical Journal.' The date of absence from my duties in 
 Edinburgh expired before I had time to finish the Essay; and 
 hitherto, other avocations and inquiries have prevented me from 
 redirecting my attention to the subject. Four additional sections 
 or chapters were intended to be added — namely, one on the mecha- 
 nism of the proposed mode of delivery as influencing the steps of 
 the practice itself; a second, on the cases of obstructed labor chiefly 
 adapted for delivery by turning ; a third, on the best mode of con- 
 
 voL. I. 29 
 
450 DYSTOCIA. 
 
 ducting tlie operation in these special cases ; and a fourtli, or last, 
 upon tlie history of the practice in ancient and in modern times. 
 
 " The Essay is placed in' its present unfinished form in the hands 
 of my pupils, principally with the view of saving time in the discus- 
 sion of the subject in the class-room ; and the preceding notice is 
 offered to them as some apology for its many deficiencies." 
 
 Sect. I. — ^Illustrative Case, and Introduotort Remarks.' 
 
 At a meeting of the Obstetric Society of Edinburgh, held on the 
 20th of January, 1847, I had an opportunity of showing to the 
 members a large infant, extracted on the preceding evening by the 
 operation of turning, through a pelvis, the brim of which was greatly 
 contracted. The following particulars were at the same time stated 
 regarding the history of the case. 
 
 Case I. — The mother was very lame, with the lumbar vertebrae 
 much distorted, and had been twice pregnant. Her first labor had 
 been extremely protracted, in consequence of the promontory of the 
 sacrum projecting forwards and downwards, so as to diminish much 
 the conjugate diameter of the brim. After being several days in 
 labor, symptoms requiring interference supervened, and Mr. Figg, 
 her medical attendant, availed himself of the able advice of my 
 friends Drs. Malcolm and Marr. These gentlemen considered it 
 proper to ascertain whether the child might not be capable of being 
 delivered, without the dire necessity of embryulcio. After a long 
 and cautious trial, however, of the long forceps, they found it im- 
 possible to advance the head with them, and were at last driven to 
 have recourse to craniotomy. Even after the cranium was perforated, 
 and freely broken down, it was found a matter of much time and 
 difficulty to drag with the crotchet the collapsed head of the fcetus 
 through the distorted brim, and the patient made a very long and 
 protracted convalescence. 
 
 She was earnestly advised to have premature labor induced, pro- 
 vided she again fell in the family way ; but Mr. Figg was not made 
 aware of her state till she was near the end of the ninth month of 
 her second pregnancy, and when it was too late to justify interfe- 
 rence. Parturition supervened in a few days. I saw her with Mr. 
 Eigg on the afternoon of the 19th of January, a few hours after the 
 first labor-pains had commenced. The os uteri was tolerably well 
 dilated, the membranes still entire ; and the head, which was difficult 
 
 ' From Provincial Medical and Surgical Journal, December, 1847, p. 073. 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 451 
 
 to reach, was found high and mobile above the brim of the pelvis ; 
 a pulsating loop of the umbilical cord was prolapsed before it. 
 During the course of the few follovdng hours, no advance being 
 made, I proceeded shortly after nine in the evening, for the labor had 
 commenced in the forenoon, to make the mother inhale the vapor 
 of sulphuric ether, and to extract the child, as I had previously de- 
 termined to do, by the operation of turning. The os uteri was so 
 dilated, as not to offer any impediment to the introduction of the 
 hand ; the head was pushed aside, and a knee seized with great ease. 
 With this hold the infant was readily turned, and its extremities and 
 trunk drawn down, but the extraction of the head through the dis- 
 torted brim was a more difficult task. After the arms were brought 
 down, very great exertion in the direction of the axis of the brim 
 was required before the head was extracted ; still not above two or 
 three minutes elapsed from the first introduction of the hand till the 
 complete extraction of the infant. It gasped several times after it 
 was born, but full respiration could not be established. Its head 
 was compressed laterally, the left parietal region flattened, and the 
 anterior part of the right parietal bone deeply indented by the pres- 
 sure to which it had been subjected against the projecting promon- 
 tory of the sacrum. The transverse or bi-temporal diameter of the 
 head, at the seat of the indentation, was found, on careful admeasure- 
 ment, and when held compressed by the fingers, not to be above 
 two and a half inches. Hence the conjugate diameter of the brim 
 did not, in any probability, exceed this. The infant, a female, was 
 large, and above the usual size ; it weighed exactly eight pounds, 
 the average weight of the female infant at birth being about six 
 pounds and three quarters. In consequence of being placed under 
 the complete anaesthetic influence of the inhalation of sulphuric 
 ether before the operation was begun, the mother was quite uncon- 
 scious of pain or suffering during the whole process of the turning 
 and extraction of the infant. She made a recovery that was unin- 
 terruptedly good and rapid, and left her bed, dressed, and walked 
 into the next room, on the fourth day after delivery. 
 
 The preceding case was, at the time of its occurrence, one of in- 
 tense interest to me in two points of view. For, first, it was the 
 first case in which I or any other accoucheur had ever tried the 
 effects of ether-inhalation during labor, and so far it is, I believe, 
 destined to form the commencement of a new and important epoch 
 in obstetric practice. But secondly, the case appeared to me to be 
 one of great moment as an apposite illustration of views which I had 
 been previously led to entertain, as to the possibility and propriety 
 of substituting, in some instances, extraction by the feetfor extraction 
 
452 DYSTOCIA. 
 
 by the crotchet — ^the delivery of the infant by the hand of the accou- 
 cheur instead of its delivery by instruments — the lateral compression 
 of the child's head by the contracted sides of the pelvis, instead of 
 its more dangerous oblique or longitudinal compression by the long 
 forceps — and, above all, the transient and not necessarily fatal depression 
 of the flexible shull of the foetus, for the destructive and necessarily deadly 
 perforation of it. 
 
 It is in this second or latter point of view that I propose to con- 
 sider the preceding and other analogous cases in the present 
 memoir. 
 
 In directing the attention of the Obstetric Society in Januaay 
 last to the case which I have stated above, and its relations to the 
 question of turning, I took occasion to state that I had practised 
 the same operation as an alternative for craniotomy and the long 
 forceps, in other instances in which the head had been morbidly 
 detained at the brim, from the existence of disproportion between 
 the two ; and that I believed it to present the following advantages 
 over embryulcio : It gave the child a chance of life ; it was more 
 safe to the mother, because it could be performed earlier in labor 
 and more speedily ; it enabled us to adjust and extract the head of 
 the child through the contracted pelvic brim in the most advanta- 
 geous form and direction, the head flattening laterally under the 
 traction ; the neck, if the child were living or only lately dead, was 
 so strong as to allow us to exert such a degree of traction upon the 
 obstructed head, that the sides of the cranium might become very 
 greatly compressed, or even indented under it, and that without 
 necessarily destroying the child ; and lastly, it was a practice which 
 could be followed when proper instruments were not at hand, and 
 the avoidance of instruments was generally desirable, when it was 
 possible. 
 
 These observations were published in the March number of the 
 "Monthly Journal of Medical Science," for 1847, p. 718.' In a 
 later number of the same Journal, in describing a case of delivery 
 through a pelvis extremely deformed by malacosteon, I took occa- 
 sion to discuss, in brief terms, the difierent means of treatment 
 required in contracted pelves of different dimensions ; and I re- 
 peated in the same words the above advantages of turning in com- 
 parison with embryulcio. At the same time I stated in addition, in 
 relation to the theory of the practice, my belief " that when the 
 child presents by the feet, and thus the apex, instead of the vertex 
 or base of the cone, formed by the head and body of the foetus, 
 comes first, it may make its transit without embryulcio, through a 
 
 ' I bad previously staled the details of the case just related at page 639, and I again had 
 occasion to do so at page 7il of that Journal. 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 453 
 
 pelvis, the smallness of wMch would otherwise have necessitated 
 mutilation or the operation of craniotomy." 
 
 The essay from which I make this extract appeared in the number 
 of the Journal for the 1st of July, 1847. 
 
 A few weeks subsequently — viz., in the "Provincial Medical and 
 Surgical Journal" for July 28th, Dr. Radford of Manchester engaged 
 in the investigation of the question, by publishing a communication 
 " On Turning in Labors rendered Difficult by Distortion of the 
 Pelvis." In this communication Dr. Radford avoids all allusion, 
 by name or reference at least, to the previous observations which I 
 had ventured to offer to the profession on the subject, and he pro- 
 pounds the practice to his readers as if it were a new and original 
 suggestion on his own part, as far as British midwifery is concerned. 
 At the same time, in a spirit of true humanity, which does him 
 high honor, he strongly declares that " whatever practice can 
 safely supersede the murderous operation — craniotomy — should be 
 adopted." "The records of operative midwifery ought not," he 
 observes, "to be stained with so barbarous a procedure, which, 
 according to the present recognized principles of practice, is so 
 unconditionally and so unhesitatingly performed." " And," he 
 adds, "it cannot be a matter of surprise that I should, entertaining 
 opinions that craniotomy ought to be considered an operation of 
 necessity, and not of election, hail with delight any measure which 
 only promises to lessen the number of these destructive operations." 
 
 Afterwards, Dr. Radford proceeds to offer some remarks which 
 evidently show that he has mistaken, alike in its principles and in 
 most of its details, the alternative operation which I had proposed 
 to substitute for instrumental delivery ; the fault, however, is, I be- 
 lieve, chiefly or entirely my own, and is a natural result of the 
 brevity and imperfections of my previous notices on the subject. 
 Indeed, I have reason to know, that Dr. Radford's misconceptions 
 of the proposed practice are, on this very account, shared in by 
 many others. It is with the anxious view of remedying this defect 
 that I draw up the present communication, and I trust that the 
 great practical importance of the questions discussed in it will stand 
 as some apology for the otherwise unwarrantable prolixity and repe- 
 tions that may possibly be observed in the discussion. 
 
 In following out the subject I have indicated, I shall treat severally 
 and successively of the kind of cases which gave rise to the sugges- 
 tions of the proposed practice ; of the theory, principles, or mecha- 
 nism of the practice ; and of its advantages in relation to the cur- 
 tailment of the duration of labor. I shall then answer the objec- 
 tions which I have heard raised against it, in relation to the safety 
 of the infant, and the safety of the mother ; and lastly, I shall con- 
 
454 DYSTOCIA. 
 
 sider tlie classes of cases best adapted for the practice, and the con- 
 ditions requisite for its success. 
 
 Sect. II. — ^Evidence Suggestive of the Practice. 
 
 In studying in their more minute details, the obstetric histories 
 of recorded cases of morbid contractions of the pelvis, I have often 
 been forcibly struck by the circumstance, that apparently when the 
 child presented preternaturally, and in consequence, ultimately 
 passed with the feet or pelvic extremity first, the labor seemed fre- 
 quently both easier and safer to the mother and infant, than when, 
 in other labors in the same patients, the head of the fcetus happened 
 to form the presenting part. In this way, mothers who had always 
 suffered under very severe and instrumental labors, when their 
 children presented with the head foremost, were, I found, not un- 
 frequently fortunate enough to escape far more easily, when, at 
 other times, the infant chanced either to present originally with the 
 feet, or had the feet artificially brought down during the labor in 
 consequence of the infant lying transversely with the arm or shoulder 
 constituting the presenting part ; nay, the history of some few cases 
 incidentally but strongly showed, that when the distortion and ob- 
 struction in the maternal passages were so great as to have invariably 
 necessitated in all the previous labors the death of the infant by the 
 operation of craniotomy, a living child was occasionally at last hap- 
 pily born alive, when it happened to pass, or to be brought through 
 the contracted pelvis as an original or artificial footling presentation. 
 In such instances the presentation of a hand or foot, when first dis- 
 covered at the commencement of labor, has been regarded as an 
 undoubted source of increased danger and difficulty, but it has at 
 last more frequently proved a source of increased safety to the 
 mother, and the indirect means of the preservation of the infant. 
 
 As an illustration of these remarks, I might appeal to the evidence 
 of many different cases observed and recorded by different authors, 
 without any view to such a question as that which forms the subject 
 of the present memoir. But to avoid superfluity of proof, I will 
 in the meantime restrict the evidence to a very abridged statement 
 of similar cases recorded by one or two authors ; and for this pur- 
 pose, I first select the work of Dr. Smellie, believing, as I sincerely 
 do, that his writings are not less remarkable for the strong thought 
 and singular practical sagacity which they display, than for the 
 spirit of candor and truthfulness with which all his facts are re- 
 ported. In his volumes. Dr. Smellie has recorded an unusual 
 number of contracted and distorted pelves ; among them I find the 
 
TUENING AS A SUBSTITUTE FOR CRANIOTOMY. 455 
 
 following cases illustrative of the remarks wliich I have ventured 
 to offer in the preceding paragraphs. The first three cases relate 
 to natural pelvic presentations ; the last two are instances in which 
 the child was extracted footling, in consequence of its presenting 
 transversely, or vsdth the upper extremity. 
 
 Case II. — To a woman "who had suffered very much in her 
 former labors from the pelvis being distorted," Dr. Smellie was 
 called, and found the breech of the child presenting. The extrac- 
 tion of the head required considerable management, but the child 
 was saved.' 
 
 Case Hr. — ^Dr. Smellie's assistance was requested for a patient 
 with "the breech presenting, and the pelvis distorted." The mid- 
 wife told him " that the woman's former labors had been very diffi- 
 cult and tedious, but now as the breech presented she was afraid 
 the difficulty would be greater." He " saved this child also, although 
 a good deal of force was used to deliver the head."^ 
 
 Case IV. — A woman, with the " pelvis narrow," and " who for- 
 merly was used to have tedious labors," had a breech presentation. 
 Dr. Smellie brought down the legs, " as the breech did not advance 
 with the assistance of the strong pains." The child was delivered 
 with difficulty, but alive.' 
 
 Case V. — A woman, with the " pelvis distorted and awry, from 
 the right ilium being much higher than the other," was three times 
 pregnant. The first labor was terminated by craniotomy. The 
 child in the second labor was premature, and presented by the arm. 
 It was brought away alive by turning. In her third labor the child 
 reached the full time, presented by the head, was turned, and lost." 
 
 Case VI. — A woman, with " a narrow and distorted pelvis, from 
 the three lowest vertebrse of the loins bending forward," four times 
 reached the full period of pregnancy. In her first and third labors 
 the child required to be mutilated by craniotomy before delivery 
 could be accomplished. The infant in the second labor was small, 
 and " with the greatest difficulty saved, by the assistance of the 
 forceps." At the fourth confinement the right shoulder of the child 
 presented. Dr. Smellie first tried cephalic version, but failed. He 
 then seized one leg, turned the child, brought out the body and 
 extremities, and ultimately, after much exertion, extracted the head. 
 
 ' Collect. 32, Case 10. « Ibid. Case 2. « Ibid. Case 13. " Ibid. 34, No. 2, Case 1. 
 
456 DYSTOCIA. 
 
 The child was alive. The mother recovered better than in any of 
 her preceding labors.* 
 
 In his " Clinical Midwifery," Dr. Lee reports the following case 
 as one probably similar to those which first suggested the propriety 
 of the artificial induction of premature labor : 
 
 Case. — The patient had been five times pregnant. She was 
 delivered of her first child by craniotomy. Dr. Lee employed the 
 same operation to deliver her at her fourth confinement. " At the 
 end of the seventh month of her second pregnancy labor came on 
 spontaneously, and the child was born alive without artificial assist- 
 ance, and has been reared." Her third pregnancy was terminated 
 by labor coming on at the commencement of the eighth month. 
 "The nates presented, and the child was also extracted alive." 
 " Dr. H. Davies induced premature labor at the seventh and a half 
 month of her fifth pregnancy, and the child was born alive, but 
 died soon after in convulsions." 
 
 Occurrences similar to what happened in the preceding case must, 
 observes Dr. Lee, " originally have suggested the idea of bi-inging 
 on premature labor artificially in cases of distorted pelvis, and 
 probably led, in 1756, to that consultation of the most eminent 
 practitioners in London, at which the practice was approved of, and 
 soon after successfully carried into effect by Dr. Macauley -"^ and 
 by a similar study of the modes of delivery occasionally adopted by 
 nature in the same cases of distorted pelvis, we have, I think, sug-r 
 gested to us likewise the propriety of artificially turning and ex- 
 tracting the infant as a footling presentation. I shall cite only one 
 other case from the same writer, showing the degree of difficulty in 
 contracted pelvis to be less when the child passes by a pelvic or 
 footling presentation, than when it presents and passes by the 
 cephalic extremity. 
 
 Case Vii. — A patient, with the outlet and brim of the pelvis 
 both considerably contracted, was delivered of her first child by 
 craniotomy, after being more than forty-eight hours in labor, and 
 extremely exhausted. " The difficulty," Dr. Lee remarks, " ex- 
 perienced in extracting the head with the crotchet, after it was 
 opened, proved that delivery could not have been completed by any 
 other method." At her third labor she was again delivered by 
 craniotomy, after the labot had endured for some time, and four fits 
 of convulsion had supervened. " I found her," says Dr. Lee, " com- 
 
 > Collect, No. 5, Case 2. ' Clinical Midwifery, Case 81, p. 39. 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 457 
 
 pletely insensible, witli dilated pupils and constant convulsive move- 
 ments of the muscles of the face. The pains continued with such 
 violence, and recurred at such short intervals, that I dreaded rupture 
 of the uterus. * * * The small size of the pelvis, the impossi- 
 bility of applying the forceps to the head, the imminent risk of 
 rupture of the uterus, with the result of the former labor, were the 
 circumstances which made me determine to open the head." At 
 her fourth confinement, the child's head was again perforated. 
 Labor had commenced on the 2d of December ; the liquor amnii 
 escaped soon after ; the pains continued strong and regular during 
 the whole night. On the morning of the 8th, six days after labor 
 "had commenced," the head being still wedged in the brim, the 
 abdomen tense, the patient occasionally delirious, &c., craniotomy 
 was performed. The patient was thus delivered by embryulcio in 
 her first, third and fourth labors. The history of her second con- 
 finement is this, — " I proposed to induce premature labor on the 
 21st of July, 1835, when she was seven months and a half pregnant ; 
 but she would not consent to this. Labor came on spontaneously 
 at the commencement of the ninth month of pregnancy ; a foot 
 presented, and the child was extracted dead, without craniotomy."^ 
 These, I repeat, and similar instances (and I shall have occasion 
 to quote cases still more striking in the sequel), appear to me to 
 point evidently to this probable conclusion — that in particular forms 
 and instances at least, of distorted pelvis, the passage of the child 
 by the feet or pelvic extremity aiFords to it and the mother some 
 special facility of transit which is wanting when the head or cephalic 
 extremity forms the presenting part. And we have thus placed 
 before us this problem : Upon what does this greater facility and 
 safety of footling, as compared with head presentations, in such 
 cases, depend ? Let us proceed to the consideration of this point, 
 and attempt to ascertain how this result is obtained. 
 
 n. 
 
 Sect. m. — Theory or Principles of the Proposed Practice.* 
 
 The form of the infant at birth has often and justly been com- 
 pared to that of a cone ; the feet serving as the apex, and the arch 
 or bi-parietal diameter of the head forming the basis of the cone, 
 and there being a gradual tapering and increase of size from the 
 former to the latter point. Consequently, when in cephalic pre- 
 
 ^ Clinical Midwifery, p. 62. 
 
 ' From Provincial Medical and Surgical Journal, January, 1848, p. 1. 
 
458 DYSTOCIA. 
 
 sentations, the head or broad end of the cone once dilates and 
 passes a given point, the narrow remainder of the cone, viz., the 
 trunk and extremities, afterwards pass it without impediment. In 
 fact, both in cranial and in footling presentations— even in instances 
 of contracted peh-is— the transit of the body is usually attended 
 with no special difficulty or delay. The obstruction is referable to 
 the child's head alone ; and hence the necessity of accurately study- 
 ing the obstetric configuration and relations of the fcetal head, in 
 order to be able to overcome the obstruction offered by this part. 
 Now, besides that the whole infant is, as I have just stated, of a 
 Fig. 27, conical figure, the head taken alone, presents 
 
 more imperfectly the same configuration ; 
 for the basis of the skull is considerably nar- 
 \a rower than the arch ; or, in other words, its 
 bi-mastoid diameter (5 b, Fig. 27) is less than 
 its bi-parietal diameter (a a), so that the 
 cranium increases gradually in breadth and 
 size, like the whole body, from below up- 
 wards. 
 
 The bi-parietal diameter of the head or vertex is, in this way, the 
 basis both of the cone of the whole body, and of the cone of the 
 head taken singly. 
 
 To understand thoroughly, however, the subject of our present 
 inquiries, it is necessary to have some more precise and definite 
 ideas of the degree of tapering of the cranium from its broad arch 
 to its narrow basis ; or, in other words, it is requisite to fix more 
 accurately the degrees of difference between the bi-parietal and bi- 
 mastoid diameters of the head. "With this view, I made, some 
 months ago, upon the heads of several new-born infants, a variety 
 of measurements relative to these two points. I arrived at nearly 
 the same conclusions as those which I afterwards found Mr. Tom- 
 linson had previously obtained, when admeasuring the fcetal head 
 for the purpose of assisting Dr. Hull in his inquiries as to the 
 smallest dimensions the skull could be possibly reduced to, by the 
 operation of craniotomy. And to prevent all cavil, I will here take 
 Mr. Tomlinson's measurements as standard and correct, and the 
 more valuable on this account, that they were made and published 
 without any view to such a question as the present. 
 
 Mr. Tomlinson gives, among other measurements of the head, 
 the breadth of the bi-parietal and bi-mastoid diameters in six infants 
 at birth. I shall throw them into a tabular form, and add a column, 
 showing the difference between these two diameters in each case. 
 
 Fig. 27. Vertical section of a fcEtal skull, showing its conical form. 
 
TURNING AS A SUBSTITUTE FOE CRANIOTOMY. 
 
 459 
 
 TABLE I. 
 
 ''easurements of the Bi-parietal and Bi-mastoid Diameters of the Heads of 
 Six Infants at Birth. 
 
 Number of Case. 
 
 Bi-pnrietal 
 Diameter. 
 
 Bi-mastoid 
 Diameter. 
 
 DitTerence 
 between the two. 
 
 I. 
 
 II. 
 
 III. (a twin) 
 IV. 
 
 V. 
 VI. 
 
 In. Sths. 
 3 4 
 3 6 
 3 1 
 3 2 
 3 3 
 3 4 
 
 In. Sths. 
 
 2 7 
 
 3 2 
 2 6 
 2 6 
 2 6 
 2 6 
 
 In. Sths. 
 
 — 5 
 
 — 4 
 
 — 3 
 
 — 4 
 
 — 5 
 
 — 6 
 
 We thus find a difference between tlie bi-mastoid and bi-parietal 
 diameters of the head, varying from three-eighths to six-eighths of 
 an inch, or from four and a half to nine lines. Or, if we exclude, 
 as in fact should properly be done, the third case, as being a twin 
 infant, and consequently having the head and body smaller and less 
 remarkable than in a single and full-sized child — ^then we have, in 
 the remainder, a difference between the bi-parietal and bi-mastoid 
 diameters, varying from six to nine lines — that is, fi'om four to six- 
 eighths of an inch ; or, in other words, /row half an inch to three- 
 quarters of an inch.^ And in artificially extracting an infant through 
 a narrow pelvis, as a footling instead of a head presentation, we 
 may gain, I believe, when necessary, this great difference between 
 the size of the body to be extracted, by varying the method of the 
 extraction itself. For it must be further held in view that at its 
 base (or bi-mastoid diameter), the cranium of the infant is so strong, 
 and its bones so firmly and densely united, as to render it quite in- 
 compressible. On the other hand, at its arch (or bi-parietal diame- 
 ter), the cranium at birth is, in general, so thin, and its bones so 
 loosely and imperfectly united, as to permit of the head being 
 much flattened and compressed, or even depressed and indented at 
 some point, without necessarily destroying life. 
 
 Now, when the brim of the pelvis is morbidly contracted at one 
 part — let us imagine, for instance, its conjugate diameter to measure 
 only three inches instead of four — then the child, upon being forced 
 down upon it as a head-presentation, meets with difficulties which, 
 probably, no uterine effort could possibly surmount. A round body, 
 the diameter of which is some lines above three inches, is attempted 
 to be pushed through an opening measuring only three inches. 
 
 ' " From the one parietal protuberance to the other, a transverse line measures from three 
 inches and a quarter (3^) to three inches and a half (3^). From one mastoid process to 
 the other along the base is about two inches (2). From the one temple to the other is two 
 inches and a half (2 J)." — Dr. Burns' Principles of Midwifery, 10th Edition, p. 25. 
 
460 DYSTOCIA. 
 
 But, turn the child, extract it footling, and let the head pass through 
 the contracted brim by engaging in it, first the base or bi-mastoid 
 diameter of the cranium, and the difficulty may possibly be over- 
 come ; for then we have the head entering the contracted brim of 
 three inches as a body less in its diameter than three inches, and 
 capable of having its broader upper portion flattened and reduced 
 to the size necessary for its complete transit, by the force vs^hich we 
 can apply to the already protruded body of the infant, producing 
 the requisite degree of lateral compression of the cranium against 
 the opposed sides of the contracted pelvic brim. 
 
 Or, let us take another and perhaps simpler view of the subject. 
 Suppose, in want of a better wood-cut, we take the letter A a.s a 
 round cone simulating the figure of the infant, the apex of the letter 
 corresponding to the feet of the infant, the base of it corresponding 
 to the bi-parietal diameter of the head, and the cross-bar of the letter 
 representing the incompressible floor or basis of the skull, and the 
 two divergent feet of it representing the elastic and compressible 
 arch of the cranium. Now, if we desired to pass this round cone A 
 through an oblong aperture Q, the diameter of which was somewhat 
 less than the diameter of the basis of the cone, should we succeed 
 best by pushing it through the oval opening with its basis foremost, 
 or by dragging it through it with its apex foremost ? If we extract 
 the cone through the aperture by bringing its narrow end foremost 
 — or, in other words, if we bring the child by the feet instead of the 
 head — ^then two objects are gained; for, first, we have the power of 
 using any justifiable degree of force that may be required, by the 
 command we thus obtain of the protruded and narrow end of the 
 cone ; and, secondly, the elastic sides of the base of the cone situated 
 above the cross-bar — or, in other words, the sides of the cranium 
 itself above its basis — ^will yield and become compressed together to 
 such an extent as to enable the collapsed body to pass through the 
 supposed opening. If, on the other hand, we attempt to make the 
 broad basis of the cone, or the vertex of the head, to pass first 
 through an aperture less than its own diameters, then we are apt, 
 the more we press, to increase rather than diminish the difficulty 
 attendant upon its transit ; for the more force we apply we are liable 
 to render that part which is already too broad, still broader, by 
 fiattening it against the sides of the aperture, and making its limbs 
 or parietes at one point or another diverge and widen, instead of 
 converge and contract. It is true that if we can insinuate obliquely 
 or otherwise, the basis of the compressible cone (or the arch of the 
 head), into the contracted aperture, so as to get its sides compressed 
 between the sides of the opening, and consequently its bi-parietal 
 diameter lessened by the force with which the body of the cone is 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 461 
 
 pushed downwards, a similar object would be gained, but in a more 
 uncertain and imperfect degree. Besides, there is always in this 
 way the chance of making the- two sides of the cranial arch (2 2, Fig. 
 28) spur out, and diverge lower down at their basis, in proportion to 
 the amount of force applied to the upper surface of the arch itself 
 (c c), so that while we contract the sides of the arch above by the 
 kind of pressure applied to it, the direction of that pressure may 
 possibly widen and open the limbs of the arch below, and so far 
 increase, for the time being, the diflSlculty accompanying the transit 
 of that part. 
 
 But this transverse or lateral form of flattening and compression 
 of the cranium is very far indeed from being 
 always obtained when the vertex is allowed 
 to present at the brim of a distorted pelvis; 
 for frequently the whole, or the greater mass 
 at least, of the head remains obstinately 
 above the brim, despite the action of the 
 propelling efforts upon it of labor-pains, both 
 dangerous in the amount of their duration, 
 and dangerous in the amount of their force. 
 By bringing, however, the apex of our cone, 
 
 or the narrow diameters of the cranium foremost, we not only im- 
 prove and simplify the mechanism of the labor by so fai' converting 
 the entrance and passage of the child's head into the contracted 
 pelvic brim, from a matter of comparative chance into a matter of 
 comparative certainty ; but further, we effect, thus, in the course of 
 minutes, by turning, what it might require the course of hours or 
 days to accomplish, provided the transit of the foetal head were left 
 as a head-presentation to nature alone, or to nature assisted at last 
 artificially by the long forceps or crotchet. 
 
 But other advantages are obtained by turning, as compared with 
 embryulcio and the long forceps, in the class of cases which we are 
 considering. We not only bring the tapering or cone-shaped foetal 
 head through the distorted brim, by making its narrow extremity 
 enter first into the contracted aperture, and afterwards using the 
 sides of that aperture to compress the elastic parietes of the broader 
 and higher part of the cranium, but in some cases we in this way, I 
 believe, eschew altogether engaging the broadest part of the head 
 {a a, Fig. 28), in the narrowest part of the contracted pelvic opening 
 — a circumstance and adjustment that, in a head-presentation, would 
 
 Fig. 28. Jllustiatingthe effect of pressure upon the top of the arch of the fretal cranium, as 
 happens when the head presents. The dotted line, c b b c, is the vertical section of a normal 
 foetal skull, as seen in Fig. 27. The outline, 12 2, shows the disadvantageous alteration iu 
 form produced by the presentation of the head to a contracted pelvis. 
 
462 DYSTOCIA. 
 
 be otherwise quite unavoidable. For besides being found of a coni- 
 cal form when looked at vertically, the infantile bead shows the 
 same configuration also when viewed antero-posteriorly. The ac- 
 companying outline, for instance, of the foetal head, as seen from 
 above, is an exact copy of that given in Chailly's late work on 
 Midwifery, and shows that while the head is very broad behind in 
 Fig. 29. its bi-parietal diameter (a a, Fig. 29), it gra- 
 
 ® dually tapers and diminishes in breadth as 
 we proceed forwards to its bi-temporal and 
 bi-frontal (J b) diameters ; and its bi-temporal 
 diameter is in general fully half an inch less 
 than its bi-parietal. But, in the mechanism 
 of head cases, the neck, as is well known, 
 " becomes early flexed in the labor, so that the 
 chin is brought towards the top of the 
 sternum, and the vertex or upper and back 
 portion of the head first becomes pushed 
 downwards into the pelvic aperture, and thus constitutes the pre- 
 senting part — in other words, the broadest part of the cone of the 
 whole child, because the broadest part of the head, or its bi-parietal 
 diameter, is thus naturally first driven downwards into the pelvic 
 cavity, and is first directed against the contracted brim. The same 
 head, when extracted as a footling presentation through the same 
 distorted pelvis, will in some instances entirely escape having this, 
 its broadest part, placed and engaged in the narrowest part of the 
 pelvic aperture ; for, as the extremities and the body of the child 
 are gradually extracted in the operation of turning, the head, in 
 ultimately adapting itself to the shape of the pelvis, comes to have 
 its bi-temporal, and not its bi-parietal, diameter implicated in the 
 narrowest or conjugate diameter, the parietal protuberances passing 
 into the wider lateral space opposite the sacro-iliac synchondrosis. 
 That such is the fact, the position of the mark or indentation upon 
 the skull, produced by compression against the protruding promon- 
 tory of the sacrum in Case I., and in other instances which I shall 
 afterwards quote, amply proves.' The injury and depression of the 
 cranium, if any, seems always situated before the ear, and con- 
 sequently much before the parietal protuberance ; or, in other words, 
 it is, as I have said, in the temporal region. The anterior edge of 
 the parietal bone, or the anterior edge of it and the corresponding 
 posterior edge of the frontal, are generally the osseous points that 
 
 Fig. 29. Outline of the fcetal head as seen from above. — (Frotn Chailly). 
 ' See, for example, the figures of indented fostal skulls given by Professor Sandifort, in 
 pi. xxxiv. of vol. ii. of his Museum Anatomicum. 
 
TURNING AS A SUBSTITUTE FOB CKANIOTOMY. 
 
 463 
 
 are depressed and indented, as represented in the accompanying 
 diagram. 
 
 Now, the child's head narrows greatly from behind forwards, 
 from the occiput towards the forehead, as seen in Figure 29 ; and 
 in the temporal region its diameter is generally from three to five- 
 eighths of an inch, or from four and a half to seven and a half lines 
 less than between the two parietal protuberances.' Hence it is 
 evident that a great gain is effected by the head passing through 
 the narrowest part of the brim, with a diameter at least several lines 
 less than it otherwise would offer, provided it happened that the 
 vertex of the head had been kept and retained as the presenting 
 part. 
 
 Fig. 30. 
 
 Fig. 31. 
 
 In order that the full-sized foetal head may pass through a con- 
 tracted pelvic brim we require to have the head flattened laterally, 
 and its sides at its anterior parietal or temporal region collapsed and 
 compressed. The outline, ab ah, Figure 31, is the outline of the 
 vertical section of the infant's skull that I have already given in 
 Figure 27. The line, 12 1, marks what we may presume, for the 
 sake of illustration, to be the shape and degree of compression to 
 which the head would require to be reduced in order to pass the 
 contracted pelvic aperture. 
 
 * See preceding note from Dr. Burn's Midwifery. Chailly gives the bi-parietal diameter 
 as three inches and a quarter (3^) to three inches and a half (3^) ; and the bi-temporal 
 diameter as two inches and a half (2J) to three inches (3). — See'his Treatise on Midwifery, 
 1844, translated by Dr. Bedford, p. 62. ' 
 
 Fig. 30. The form in which the bones of the foetal cranium are compressed in passing 
 through a contracted brim. A. Promontory of sacrum. B. Symphysis pubis. C. Unoccu- 
 pied space between the ilium and forehead of the child. D. Depression in child's head 
 corresponding to the promontory of the sacrum. E. Anterior fontanelle. F. Posterior 
 fontanelle. 
 
 Fig. 31. Illustrating the effect of lateral compression upon the sides of the arch of the 
 foetal cranium, as happens when the child is extracted footling. The dotted line, ab, ab, 
 is the vertical section of a normal foetal skull, as seen in Figure 27. The outline, 12 1, 
 shows the advantageous alteration in form produced upon the festal cranium by extracting 
 the child footling through a contracted pelvis. 
 
464: DYSTOCIA. 
 
 "Would this necessary degree of compression be effected more 
 easily and by less amount of force if the bead were drawn through 
 the narrow pelvis as a footling presentation, than if it were driven 
 into it as a cephalic presentation? I certainly believe that less 
 power would be required to produce the same degree of lateral com- 
 pression and collapse in the cranial arch, provided the compressing 
 force were applied, as in cases in which the child is extracted foot- 
 ling, directly to the two sides or lateral surfaces (1 1, Fig. 31) of the 
 arch itself, than under the alternative condition supposed. For if 
 the child descended into the pelvic brim as a head presentation, the 
 uterine contractions would drive it against the narrow points of the 
 pelvic brim, so that the reacting compressing power of these points 
 would be applied either to the two upper surfaces of the arch (e c. 
 Fig. 28), or partly to one of them (c), and partly to one of its opposite 
 lateral surfaces (a a, Fig. 31). In such circumstances the compressing 
 powers would be acting much more indirectly and far more at a 
 disadvantage in effecting the required compression, than if thej were 
 applied, as in extracting the child footling, directly and immediately 
 to the sides themselves (a a, Fig. 31) that are to be compressed. 
 
 "Does the head," asks Dr. Radford, "elongate more readily 
 upwards than downwards ? If only," he answers, " the same degree 
 of extractile force is used, it does not." But what I have stated 
 shows that the same degree of extractile force will produce the 
 desired effect more easily, and as we shall afterwards see, more 
 safely also, when the child passes with the pelvis, than when it passes 
 with the head first. And this, I believe, affords us another advantage 
 in the mechanism of footling as compared with cephalic presenta- 
 tions in instances of diminished pelvic brim. We are enabled to 
 produce by it the same amount of compression of the foetal head by 
 a less expenditure of compressing force, for we apply it to the lateral 
 surfaces or piers of the cranial arch (a a, Fig. 31), and not to its 
 pedentures or upper surfaces (e c, Fig. 28). We effect a saving of 
 force by the direction in which we apply the force. 
 
 I am well aware both that it is exceedingly difficult to state 
 accurately and intelligibly the opinions one may happen to entertain 
 on such a subject as we have been discussing in the present section, 
 and that I am far from having succeeded in making the demonstra- 
 tion so simple as I could wish. It may assist, however, our com- 
 prehension of the matter if, before concluding it, we try to recapitu- 
 late and sum up the advantages which, in regard to the mechanism 
 of labor, are, in the contracted states of the pelvic brim, obtained 
 by the child passing as a footling instead of as a cephalic presenta- 
 tion. These advantages, as far as I have hitherto attempted to trace 
 them in the preceding remarks, for we shall trace out more of them 
 afterwards, amount to the following: 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 465 
 
 1. The foetal cranium is of a conical form, enlarging from below 
 upwards, and when the child passes as a footling presentation, the 
 lower and narrower part of the cone-shaped head is generally quite 
 small enough to enter and engage in the contracted pelvic brim. 
 
 2. The hold which we have of the protruded body of the child, 
 after its extremities and trunk are born, gives us the power of 
 employing so much extractive force and traction at the engaged 
 foetal head, as to make the elastic sides of the upper and broader 
 portion of the cone (viz., the bi-parietal diameter of the cranium) 
 become compressed, and, if necessary, indented, between the op- 
 posite parts of the contracted pelvic brim, to such a degree as to 
 allow the transit of the entire volume of the head. 
 
 3. The head in being dragged downwards into the distorted 
 pelvis, generally arranges itself, or may be artificially adjusted, so 
 that its narrow bi-temporal, instead of its bi-parietal, diameter, 
 becomes engaged in the most contracted diameter of the pelvic 
 brim. 
 
 4. The arch of the cranium or head is more readily compressed 
 to the flattened form and size required for its passage through a 
 contracted brim, by having the compressing power apphed, as in 
 footling presentations and extraction, directly to its sides or lateral 
 surfaces, than by having it applied, as in cephalic presentations, 
 partly to the lateral and partly to the upper surfaces of the arch. 
 
 Lastly, I may add, as a result of the whole mechanism, that the 
 duration of the efforts and sufl'erings of the mother is greatly abridged 
 by turning, when used as an alternative for craniotomy and the long 
 forceps, and that thereby her chances of recovery and safety are 
 increased. But as this is in itself a matter of the highest moment, 
 in reference to the whole question of the proposed practice, we shall 
 devote a special section to the consideration of it. 
 
 Sec. IV. — The Duration, and consequently the Danger, of 
 THE Labor is decreased by the proposed Practice.' 
 
 In the short summary which I gave in January last of the ad- 
 vantages of turning, over embryulcio, I stated one strong reason in 
 favor of delivery by the alternate operation to be this — " that it was 
 more safe to the mother, because it could be performed earlier in the labor, 
 and more speedily,"^ than craniotomy, or the application of the long 
 forceps. And I have the most sincere belief that the practice I pro- 
 pose may be the means of saving much, both of maternal and in- 
 fantile life, by enabling us in some cases to abridge the mere dura- 
 
 ' From Provincial Medical and Surgical Journal, February, 1848, p. 57. 
 2 Monthly Journal of Medical Science, March, 1847, p. 718. 
 TOL. I. 30 • 
 
466 DYSTOCIA. 
 
 tion of a difficult labor, so that we may terminate in a few minutes 
 a delivery, wMch. under other plans of treatment, might still be 
 protracted onwards for hours or even for days. At the same time 
 I am fully aware that when I state my conviction that the mere 
 degree of duration and continuance of a labor is, per se, dangerous 
 both to the mother and child, and very often fatal even in its in- 
 fluence, I venture to broach a doctrine which stands up alike against 
 the opinion and the practice of some of the highest authorities in 
 the obstetric profession. 
 
 About half a century ago, when treating of the influence of the 
 duration of labor in difficult and instrumental deliveries. Dr. Osborne 
 observed — "I believe it is confirmed by general observation, that 
 women recover at least as well, after long, lingering, and laborious 
 labors, the duration of which may have been extended to several 
 days, as after the easiest, quickest, and most natural delivery."' In 
 making this remark. Dr. Osborne stated not his own opinion only, 
 but, I believe, the general opinion of the accoucheurs of his time ; 
 and the same doctrine, little or not at all modified, still continues to 
 be taught and acted upon, down to the present day, in the great 
 English and Irish schools of midwifery, as the able and excellent 
 writings of, for example. Professors Davis and Murphy in London, 
 and Drs. Collins and Beatty in Dublin, &c., fully testify. 
 
 That, per se, the duration of labor has no very direct nor decisive 
 influence upon the degree of danger and fatality accompanying 
 parturition, is a doctrine which probably originated in, and has 
 been perpetuated by, an erroneous system of observation. In 
 founding and supporting it, obstetricians have, I believe, drawn 
 their deductions, not from the whole of their practice, but from 
 parts only of it ; they have not reckoned upon the certain results 
 of their general collection of facts, but depended upon the fallacious 
 results of isolated and individual instances : they have not, in short, 
 counted up the terminations and consequences of all their protracted 
 cases, but have relied upon the evidence of some single striking case 
 or cases of perfect, and it may be, rapid recovery after labor of a 
 very prolonged duration. In proceeding thus, obstetric authors 
 have not followed a course altogether diflerent from that pursued 
 in the study and investigation of many other similar questions in 
 medical science and practice. For confessedly, the medical mind 
 has ever been too apt to recollect and reason upon those facts only 
 which are in favor of any preconceived opinion or opinions it may 
 chance to have adopted ; and the cases of failure are too often for- 
 gotten amid the more agreeable remembrance of the cases of suc- 
 cess. It is on this account that the numerical method of reasoning 
 
 ' Essays on the Practice of Midwifery in Natural and Difficult Labors, p. 66. 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 467 
 
 and investigation, by obliging us to count up all our cases, and all 
 our results, whether good or bad — whether instances of recovery or 
 instances of death — is no doubt destined to revolutionize, in a great 
 degree, our modes of inquiry, particularly in surgery and mid- 
 wifery, by imparting infinitely more precision and certainty to our 
 present deductions and precepts where they are true, and showing 
 us in language that cannot be misunderstood, the erroneousness of 
 our doctrines where they are not true. 
 
 The question of the duration of labor in relation to its effects 
 upon the danger and mortality accompanying parturition will be 
 found, in my humble opinion, to afford an apposite example of the 
 truth of these remarks — for when this question is examined, as it 
 can alone properly be examined — by the numerical or statistical 
 method, the results that are thus yielded, assuredly directly gain- 
 say and contradict the accredited impressions and common belief 
 of the profession upon the subject. "With the exception of Dr. 
 Collins of Dublin, few, or indeed no writers have, in their obstetric 
 reports of hospital or private practice, furnished us with data show- 
 ing the duration of labor either in their natural or in their operative 
 cases of midwifery. In his "Practical Treatise on Midwifery" (a 
 work, the great value and candor of the facts contained in which it 
 would be difficult to overpraise) Dr. Collins has given the result of 
 the cases which occurred in the Dublin Lying-in Hospital during a 
 period of seven years, commencing N'ovember, 1826, and he has 
 published throughout the work, and especially at the end of its 
 individual chapters, tables, and data, from which the duration of 
 the labor in most cases and complications can easily be calculated 
 and compared. I shall state briefly some of the results regarding 
 the influence of the duration of labor which I have obtained by 
 summing and counting up the individual facts and data which Dr. 
 Collins has published. And the results which I have in this way 
 obtained will, no doubt, be regarded by some as the more valuable 
 and trustworthy, seeing that the data from which they are calculated 
 have been collated by Dr. Collins, and given by him to the world 
 under the generally prevailing idea that the mere length of the 
 labor was no guide or test of its danger or mortality. 
 
 During the seven years that Dr. Collins had charge of the Dublin 
 Lying-in Hospital, 16,414 women were delivered in it ; and of these 
 164 died, or one in every hundred of the mothers were lost. In 
 15,850 of these cases the duration of the labor has been marked 
 and published ; in 1 in 29 only it was not noted. Out of the 164 
 fatal cases, in 138 the duration of the labor has been marked and 
 published ; in 1 in 6 it was not noted. Now, if in relation to the 
 duration of labor as bearing upon the maternal mortality, we calcu- 
 
468 
 
 DYSTOCIA. 
 
 late the proportion of the 138 maternal to the whole 15,850 labors, 
 I find that the interesting result is that which is shown in the fol- 
 lowing table. Let me merely premise that the table reads as follows : 
 Out of all the women delivered within one hour, 1 in 322 died; out 
 of all those in whom the labor continued from two to three hours, 1 
 in 231 died ; and so on. 
 
 TABLE II. 
 
 Showing the Proportim of Maternal Deaths in relation to the Duration of Labor 
 in 15,850 cases of Delivery. 
 
 Duration of Labor. 
 
 Proportion of Mothers Lost. 
 
 Within 1 hour, 
 
 One in 322 died. 
 
 From 2 to 3 hours. 
 
 " in 231 " 
 
 4 to 6 " 
 
 « in 134 " 
 
 " 7 to 12 " 
 
 " in 80 " 
 
 " 13 to 24 " 
 
 « in 26 « 
 
 " 25 to 36 " 
 
 " in 17 " 
 
 Above 36 hours. 
 
 " in 6 " 
 
 The preceding table affords ample evidence that, contrary to the 
 general opinion of the obstetric profession, the mere length of the 
 labor is a most serious and important element in reference to 
 the degree of danger and fataUty accompanying the process. For, 
 in fact, as shown by these calculations, "the mortality attendant 
 upon parturition increases in a ratio progressive with the increased dura- 
 tion of the lahor."^ And this does not hold true with regard to the 
 
 ' The law itself — and I believe it to be a most important one — was originally educed by 
 a series of calculations from Dr. Collins' cases. I formerly published merely the results of 
 the calculation, without publishing the data on which these results were founded ; for my 
 object was not to overload my paper, or the pages of the Journal unnecessarily. As Dr. 
 Collins believes, however, that these results are obscure, I shall simply insert, in a tabular 
 form, the data themselves upon which this law and its results were founded. 
 
 Table showing the Proportion of 138 Matet-nal Deaths in Sdation to the Ihiratum of Labor 
 in 15,850 Cases of Delivery recorded by Dr. CoUins. 
 
 Duration of Labor. 
 
 Number of 
 DeliTeries. 
 
 Number of 
 Deaths. 
 
 Proportion 
 of Deaths. 
 
 Witbin 1 hour, 
 From 2 to 3 hours, 
 From 4 to 6 hours, 
 From 7 to 12 hours, 
 From 13 to 24 hours, 
 From 25 to 36 hours, 
 AbOTO 36 hours. 
 
 3^537 
 
 6,000 
 
 3,875 
 
 1,672 
 
 602 
 
 134 
 
 130 
 
 H 
 26 
 29 
 21 
 19 
 8 
 24 
 
 1 in 322 
 1 in 231 
 lin 131 
 lin 80 
 lin 26 
 1 in 17 
 lin 6 
 
 Total, 
 
 15,850 
 
 138 
 
 lin 115 
 
 Out of Dr. Collins' 16,414 cases, he noted the duration of the labor in 15,850; and among 
 these 15,850 cases, 138 maternal deaths occurred. The preceding table contains, in its first 
 column of figures, the total number of deliveries that took place under each specified period 
 of duration ; in the second column is stated the corresponding number of deaths occurring 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 
 
 469 
 
 life of the motlier alone. It equally holds true with regard to the 
 life of the infant. Fcvr, exactly in the same way, as proved from 
 the same collection of data, I find also that, as a general fact, '■Hhe 
 infantile mortality attendant upon parturition inoreases in a ratio pro- 
 gressive with the increased duration of the labor." Dr. Collins reports 
 1121 children as having heen still-born. In 1045 of these cases, the 
 duration of the labor was noted. The following table shows the 
 proportion of the children lost in labors of different degrees of dura- 
 tion. Like the preceding table, it reads thus: Out of all the women 
 delivered within two hours, one in twenty of the children was lost ; 
 out of all the women whose labor endured from three to six hours, 
 one in eighteen of the children was lost ; and so on. 
 
 TABLE III. 
 
 Showing the Proportion of Infantile Deaths in relation to the Duration of 
 Labor in 15,850 cases of Delivery} 
 
 Duration of Labor. 
 
 Number of Infants Still-born. 
 
 From 1 to 2 hours. 
 
 One in 20 was lost. 
 
 3 to 6 " 
 
 '• in 18 
 
 " 7 to 12 " 
 
 " in 11 
 
 " 13 to 24 " 
 
 " in 6 " 
 
 " 25 to 36 " 
 
 " in 3 
 
 Above 36 hours, 
 
 " in 2 
 
 among each set of these deliveries ; and in the third column is given the proportion which 
 the deaths bear to the whole deliveries in labors of each specified degree of duration. In 
 other words, the table reads thus ;* — 3,537 mothers had their labors terminated within one 
 hour from their commencement; and of these'3,537 mothers 11 died, or 1 in every 322. The 
 labor contintied from 2 to 3 hours in 6000 cases, and out of these 6000 cases 26 mothers died, 
 or 1 in every 231; and so on. — Letter to Dr. Collins. — Prov. Med. and Surg. Journal, Nov. 
 1848. 
 
 ' The above rule is merely a simple generalization of Dr. Collins' own experience and 
 cases, as will be seen in the following table, also dedpced from Dr. Collins' own data: 
 
 Table sliowing the proportion of SUnrbirths in Reference to the Duratum of Labor 
 in 15,850 Cases of Detivery. 
 
 Duration of Labor. 
 
 Number of 
 Deliveries. 
 
 Number of 
 Still-born 
 Children. 
 
 Proportion 
 
 of Still-born 
 
 Children. 
 
 Within 2 hours, 
 Prom 3 to 6 hours, 
 From 7 to 12 hours, 
 From 13 to 24 hours, 
 From 25 to 36 hours, 
 Above 36 hours, 
 
 7,050 
 
 6,362 
 
 1,672 
 
 602 
 
 134 
 
 130 
 
 347 
 346 
 161 
 88 
 42 
 71 
 
 Iin23 
 1 jnl8 
 linll 
 lin 6 
 lin 3 
 lin 2 
 
 Total, 
 
 15,850 
 
 1045 
 
 lin 15 
 
 Dr. Collins also reported 284 cases of death of the child subsequent to birth. 
 If we throw out of these 284 cases, the premature or twin children, as too sinall in size 
 to be influenced much in their passage during labor, and those born imperfect or diseased 
 
 * The other tables that follow are constructed on the same plan, and read in the same way. 
 
470 
 
 DYSTOCIA. 
 
 The two preceding tables refer to the proportion of maternal and 
 infantile deaths as regulated hy the duration of the la,bor. But 
 many morbid complications and accidents may arise during partu- 
 rition without necessarily proving fatal either to the mother or 
 infant. The occurrence, however, of these complications and acci- 
 dents is regulated by the same law of duration as I have above 
 shown to regulate the actual deaths of the mother and children. 
 For, exactly in the same way, it may be laid down as a general pro- 
 position, that " «Ae liahility to moat of the morbid complications con- 
 nected with, labor increases in proportion as the labor is increased in its 
 duration."^ It would be easy to demonstrate, for instance, that this 
 holds good with regard to various obstetric complications taken 
 
 we have 155 children left, born at the full time, and apparently perfect in formation at birth. 
 The following table of these cases will prove that tedious and protracted labor is also a 
 cause of death to the child after birth. 
 
 Tabu of Vuratimi of Labor in 155 Deliveries where the Children Died within a 
 few Days after Birth. {From, Dr. CoUin^ data.) 
 
 Duration of Labor. 
 
 Number of 
 Deliveries. 
 
 Number of 
 Deaths. 
 
 Proportion 
 of Deaths. 
 
 Within 6 hours, 
 From 7 to 12 hours, 
 Above 12 hours, , 
 
 13,412 
 
 1,672 
 
 766 
 
 110 
 24 
 21 
 
 1 in 122 
 lin 70 
 lin 36 
 
 Total, 
 
 16,850 
 
 166 
 
 1 in 102 
 
 — Letter to Dr. Collins. 
 ■ Dr. Collins remarks that this does not accord with his experience. But bis own facts 
 and data show the opinion to be true. The following table is a brief way of expressing 
 these data in reference to the eighty-four cases of puerperal fever, in which the previous 
 duration of the labor was noted'by him, and it suflBciently shows that the liability to this, 
 like other complications, increases as the labor increases in duration : 
 
 TaUe of Duration of Laior in 84 Cases of Puerperal Fever, in the Dublin Hospital, 
 during Dr. Colling Mastership. 
 
 Duration of Labor. 
 
 Number of 
 Deliveries. 
 
 Number of 
 , Cases. 
 
 Proportion 
 of Cases. 
 
 Witliin 6 hours. 
 From 7 to 12 hours, 
 Above 12 hours, 
 
 13,412 
 
 , 1,672 
 
 766 
 
 61 
 10 
 13 
 
 1 in 219 
 1 in 167 
 lin 69 
 
 Total, . 
 
 . 15,860 
 
 84 
 
 1 in 186 
 
 One fundamental mistake in his statistics and calculations, led Dr. Collins into numerous 
 errors and inaccuracies relative to the effects arising from the morbid protraction of labor. 
 This error has made him repeatedly express and maintain, as the supposed result of his 
 own facts and experience, opinions which his own facts and experience, when properly 
 interpreted, totally and altogether contradict. 
 
 The error 1 allude to is this: in calculating from his experience of 16,414 deliveries, the 
 effects upon the maternal mortality of morbid prolongation of the labor, as a special or 
 individual complication, he calculates the resulting number of deaths in relation to the total 
 sum of all the cases delivered (16,414), instead of calculating them in relation to the total sum 
 of all the cases merely that were protracted (452) ; he calculates the effects of the complication 
 
TURNINa AS A SUBSTITUTE FOR CRANIOTOMY, 
 
 471 
 
 individually — such as convulsions, rupture of the uterus, retention 
 of the placenta, or hemorrhage before and after its removal, puer- 
 peral fevers, puerperal inflammations, &c. The liability to each one 
 of these complications and results certainly increases vpith the length 
 of the process of parturition. But it may be enough for my present 
 purpose to show that, taking these complications collectively, such 
 is the result: the tendency to their general occurrence becomes 
 greater and greater in proportion as the length of the labor is allowed 
 to become greater and greater. 
 
 In his Treatise, Dr. Collins has recorded the duration of the 
 labor in 24 cases of puerperal convulsions ; in 24 cases of rupture 
 of the uterus and vagina ; in 62 cases of retention of the placenta ; 
 in 102 cases during and after the third stage of labor ; in 84 cases 
 of puerperal fever ; in 5 cases of fatal pelvic abscess ; and in 5 fatal 
 cases of inflammation and sloughing of the vagina ; in all, 306 
 cases of complication occurring in 296 patients. The following 
 table shows the proportion in which these 306 complications occur- 
 red in labors of difierent durations. It reads thus : Of all the women 
 who were delivered within one hour after the commencement of 
 labor, one in 114 suffered from one or other of these obstetric com- 
 plications; of all those whose labors were prolonged from one to 
 two hours, one in 90 sufiered from one or other of these complica- 
 tions ; and so on. 
 
 TABLE IV. 
 Showing the Proportion in which 306 Morbid Complications occurred in 15,850 
 
 Labors of Different Durations. 
 
 Duration of Labor. 
 
 Proportion of ComplicationB. 
 
 Williin 1 hour, 
 
 One in 114 was complicated. 
 
 From 1 to 2 hours, 
 
 " in 90 " 
 
 2 to 3 " 
 
 " in 09 " 
 
 « 4 to 6 " 
 
 " in 58 " 
 
 7 to 12 " 
 
 " in 32 
 
 " 13 to 24 " 
 
 " in 12 " 
 
 " 25 to 36 " 
 
 " in 9 
 
 Above 36 hours, 
 
 " in 5 
 
 relatively to the whole number of cases of delivery, instead of relatively to the whole num- 
 ber oC cases of this special complication (protraction). An example may illustrate my 
 meaning. I shall take it from the subject of rupture of the uterus and vagina. 
 
 During Dr. Collins' seven years Mastership of the Dublin Hospital, 34 cases of rupture 
 of the uterus and vagina occurred, and 33 of the mothers died ; 2 only of the 34 survived. 
 If he argued upon this special complication as he does with regard to the special complica- 
 tion of protraction, he would maintain that the mortality from rupture was strikingly small : 
 for only 32 mothers out of 16,414, or about 1 in every 013, died of it. This would show, 
 certainly, the proportion of deaths from rupture in relation to the total sum of all the oases 
 delivered ; but it would not show what was wanted, viz., the proportion of deaths from 
 rupture in relation to the total sum of all the cases in which rupture happened. If he 
 wished, in short, to state the real risk and danger attendant upon this special complication, 
 
472 DYSTOCIA. 
 
 The evidence whicli I have adduced in the preceding tables 
 affords ample proof that the proportion of maternal and infantile 
 deaths, and of obstetric complications, becomes, as a general law, 
 gradually more and more numerous as the process of labor be- 
 comes more and more prolonged in its duration. But I have 
 brought forward the facts principally for the purpose of showing 
 that out of them, and in connection with them, there is deducible 
 another all-important principle, in reference to a practical and 
 operative obstetric inquiry of the present nature, viz., that when 
 operative interference, such as the forceps, crotchet, turning, &c., is 
 required, in order to terminate a difficult and morbid labor, the time 
 of the labor at which that interference is had recourse to, regulates 
 the amount of attendant danger much more than the details and 
 effects of the operation itself. In other words, in accordance with 
 the general law already illustrated, the extent of danger or fatality 
 attendant upon operative and instrumental delivery is regulated in 
 a direct and demonstrable degree by the previous length of time 
 allowed to elapse before the artificial interference is had recourse to ; 
 the resulting mortality increasing in amount according as the period 
 at which the operation is performed is proportionally more distant 
 from the date of the first commencement of the labor. 
 
 It is not in my power to prove from Dr. Collins' Treatise that 
 this law holds true in regard to the alternative operation of delivery 
 by the long forceps, for his work affords no data on this point. In 
 fact, in instances in which the head of the child is arrested at the 
 brim, he and the profession generally in Dublin prefer the jise of 
 the perforator to the use of the long forceps ; and during the course 
 of the seven years throughout which his report extends, this latter 
 instrument does not seem to have been employed once in the Dublin 
 Hospital, while craniotomy was, during the same period, employed 
 above eighty times. During these seven years, however, the short 
 forceps were used to terminate the delivery in twenty-four patients 
 in whom the head was sufficiently low down in the maternal pas- 
 sages ; and perhaps the results in these twenty-four cases will be 
 regarded as a sufficient illustration that in forceps operations the 
 general law holds good, that " the operation is dangerous and fatal in 
 proportion to the length of labor allowed to elapse before the artificial 
 delivery is practised." 
 
 rupture, he should state that 32 mothers died of it out of 34 cases in which it occurred, in- 
 stead of stating that only 1 in 513 died of it. And, exactly in the same way, if asked 
 what was the degree of maternal risk and danger attendant upon another special compli 
 cation, viz., protraction of labor beyond twenty hours, his answer upon the same prin- 
 ciple should not have been 42 deaths in 16,414 labors, or in the proportion of 1 in 391 ; 
 but 42 deaths in 452 labors, the whole number protracted beyond twenty hours, or ] death 
 in every 1 1 cases of labor prolonged to this amount of protractiori.— See Letters to Dr. Col- 
 lins.— Prov. Med. and Surg. Journal, Nov. and Dec. 1848, pp. 601 and 683. 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 
 
 473 
 
 TABLE V. 
 
 Showing the Maternal Mortality attendant upon 24 Forceps Operations to be regulated 
 
 by the previous Degree of Duration of the Labor. 
 
 Date of Operation. 
 
 Results to the Mothers. 
 
 In labors terminated within 24 hours, 
 In labors terminated in from 25 to 36 hours, 
 In labors terminated in from 37 to 48 hours, 
 In labors terminated in above 48 hours. 
 
 One out of 13 died.' 
 II 11 g 11 
 
 « « 2 " 
 
 Dr. Collins' data regarding the operation of craniotomy are more 
 extensive, and hence more valuable. During the seven years in- 
 cluded in his report, perforation of the head of the infant was prac- 
 tised in eighty-five cases in which there was extreme difficulty in 
 the labor, or where the child was dead, and interference necessary 
 for the patient's safety, or for the full completion of the delivery. 
 In seventy-six out of these eighty-five cases, data are afforded for 
 ascertaining the duration of the labor. 
 
 Out of the seventy-six women, fourteen, or one in every five and 
 a half, died. The following table of the results of these seventy-six 
 cases of craniotomy, as influenced by the previous duration of the 
 labor, affords direct evidence of the proposition which I have already 
 stated, that the fatality attendant upon this, as upon the other allied 
 forms of forced or artificial delivery, is regulated by the date or 
 period of the labor at which the operative interference is had re- 
 course to. 
 
 TABLE VI. 
 
 Showing the Maternal Mortality dependent vpon 7G Craniotomy Operations to be regulated 
 by the previous Degree of Duration of the Labor. 
 
 Date of Operation. 
 
 Besults to the Mothers. 
 
 In labors under 24 hours, 
 " " from 25 to 48 hours, 
 " " above 48 hours, 
 
 One out of 19 died, 
 u 11 8 11 
 11 .1 3 u 
 
 The preceding body of evidence might easily be rendered more 
 minute and detailed if it were necessary. But I hold that it affords 
 proofs sufficiently strong and direct for our present inquiry. And 
 the important relations which it has to that inquiry amount to this, 
 that the facts adduced demonstrate — 
 
 1st. That, as a general law, the amount and proportion of mater- 
 nal and infantile deaths accompanying parturition are regulated and 
 modified by the length and duration of the labor. 
 
 ' In the single fatal case of forceps operation out of thirteen in which the women were 
 delivered before the labor had continued twenty-four hours, the mother became insensible 
 after the pains had set in for a few hours, and the instruments were apparently used in con- 
 sequence. The whole labor was only of eight hours' duration. She died in tliree hours 
 after delivery. * 
 
474 DYSTOCIA. 
 
 M. That the liability to various morbid obstetric complications 
 during and after delivery is modified and regulated by the same 
 law; and — 
 
 M. That the mortality attendant upon obstetric operations, such 
 as the use of the forceps and crotchet, is also strictly modified and 
 regulated by it — operative delivery being more and more fatal in 
 proportion to the lateness in the course of the labor at which it is 
 adopted ; and, on the other hand, less and lees fatal in proportion 
 to the earliness in the course of the labor at which it is practised. 
 
 I^ow, the object of the present memoir is to propose that in cases 
 of arrestment of the head at the brim of the pelvis, artificial de- 
 livery should be accomplished by turning, instead of by the long 
 forceps or craniotomy. And the operation which I thus wish to 
 substitute has, as I have stated at the commencement of this sec- 
 tion, this grea,t and high advantage over both the two others, for 
 which I propose it as an alternative, that cceteris paribus, delivery by 
 turning can, and must, as a general rule, be practised far earlier in 
 the labor, than delivery either by the long forceps or the crotchet ; 
 and in proportion as it is practised earlier, so far also will it be &t- 
 tended by greater safety and greater success. A few remarks upon 
 the time at which the employment of the long forceps or perforator 
 is usually adopted will render this deduction more evident. In our 
 next communication we shall consider this point, and the value of 
 auscultation in relation to operative delivery. 
 
 Sect. V. — Eelative Periods of the Labor at which the Long 
 Forceps, Perforation, and Turning, are respectively em- 
 ployed: Value of Auscultation in Operative Deliveries.' 
 
 In the preceding section I have attempted to show the compara- 
 tive advantage of turning over the employment of the long forceps 
 or crotchet, on the ground that we could thus accomplish the de- 
 livery much earlier in the course of the labor, and hence much more 
 safely for the mother. In fact, when the long forceps are used in 
 instances of arrestment of the head at the brim, they are in general 
 never applied till the cranium is thrust and wedged down into the 
 upper pelvic aperture to as great an extent as can possibly be efl^cted 
 by the unassisted uterine eflbrts, and till symptoms of local irrita- 
 tion, or constitutional reaction or exhaustion ofier to appear. But 
 before all this state of matters is brought about, both much expen- 
 diture of muscular and vital exertion on the part of the mother, and 
 also much expenditure of time is usually required ; and the walls 
 of the maternal passages are liable to have become injured by irri- 
 tation and compression. Before the assigned conditions are pro- 
 
 ' From Provincial Medical and Surgical Journal, February, 1848, p. 85. 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 475 
 
 duced, many long hours commonly elapse, each one of them directly 
 and rapidly adding to the chances of danger to the mother. On 
 the other hand, in the same set of cases, if artificial delivery by 
 turning were adopted, it might and would be practised as early as 
 the passages were adequately dilated, before the head were pushed 
 down into the pelvic brim, and long before any symptoms of local 
 lesion or general irritation and exhaustion presented themselves. 
 
 But it is principally as a substitute for craniotomy that I venture to 
 suggest the operation of turning in instances of arrestment of the 
 head at or above the brim of the pelvis. And when we contrast 
 the different times, as far as regards the duration of labor, at which 
 these two modes of delivery (craniotomy and turning) would be 
 respectively followed in the same class of cases, we shall perceive 
 still more strongly the advantages of the alternative practice. For 
 turning, as I have just now stated, would necessarily be performed 
 early in the course of the labor, and so far at a period when the 
 danger would be comparatively slight, according to the law of dura- 
 tion which I have attempted to establish. Commit, however, the 
 same morbid cases to the usual rules of management, by which they 
 would be treated under the prospective idea that they would in all 
 probability ultimately become cases of craniotomy, and mark the 
 difference. The labor is allowed to go on from hour to hour, and 
 possibly for one or two long and weary, days, in order to give the 
 child every legitimate chance of being at last expelled alive, or, at 
 least, expelled without operative mutilation.' In the meantime, 
 however, as the preceding tables abundantly prove, the chance of 
 immediate or ultimate danger to both mother and infant increases 
 fearfully in proportion as the labor drags on its duration. How 
 long, then, shall we allow it to' continue before we perforate and 
 break up the child's head ? Most modern authorities would answer 
 that question by earnestly inculcating the propriety of not applying 
 the perforator till the child were distinctly and certainly dead, unless 
 indeed, the appearances of danger to the mother were extremely 
 marked and imminent, for almost all eagerly and properly declare 
 their abhorrence at the idea of "pliinging an iron instrument into 
 the centre of the skull of a living human being." 
 
 But how long must we prohably wait before the child really ■ dies ? 
 We have seen (Table HE.) that the infantile, like the maternal mor- 
 tality, increases in a ratio progressive with the increased length of 
 the labor; and that out of all cases in which, in the Dublin Hos- 
 pital, the process of parturition was prolonged beyond thirty-six 
 hours, one in every two of the children was lost. But still the 
 labor may go on to the fortieth, fiftieth, or sixtieth hour, and yet the 
 child live. Out of twenty-seven cases in all, reported by Dr. Col- 
 lins, in which the labor was prolonged to sixty hours and upwards, 
 
476 DYSTOCIA. 
 
 in sixteen the child was ultimately born dead ; and in the remain- 
 ing eleven it seems to have still survived, and ultimately to have 
 been expelled alive. "Whilst, however, we are thus waiting and 
 watching for the certainty of the child's death before we operate, 
 the chance of the mother's death increases with the lapse of every 
 hour. Out of these same twenty-seven cases of labor prolonged 
 sixty hours or upwards, seven of the mothers, or one in every four, 
 perished. We may thus wait with the expectation of the infant's 
 death, till at last we run the imminent hazard of also losing the 
 mother ; and even then, when at last we find ourselves driven to have 
 recourse to craniotomy in order not to place the parent in greater 
 jeopardy, we maybe unwillingly compelled to practise the operation 
 while the child still really lives, goaded on by a dire, but now irre- 
 sistible necessity, to attempt to save the life of the mother by taking 
 away the life of her child. 
 
 Auscultation is the criterion upon which all modern accoucheurs 
 properly and mainly depend for ascertaining the death of the infant 
 and fixing the date at which it threatens to perish, or actually does 
 perish, during a protracted labor. And certainly, in the progress of 
 a long case, auscultation is, as Dr. Collins states, of "immense 
 value in ascertaining the life or death of the child." " I know," he 
 remarks, " of no case where the advantage derived from the use of 
 the stethoscope is more fully demonstrated than in the information 
 it enables us to arrive at with regard to the life or death of the 
 fcBtus, in the progress of tedious and difficult labors. It is, in my 
 opinion, one of the greatest improvements made in the practice of 
 midwifery.'" The whole evidence of Dr. Collins' general remarks 
 and individual cases shows, that in protracted parturition the special 
 advantage which he has found and expects others to find, from the 
 employment of auscultation, is a far more precise and certain 
 knowledge than we could otherwise possess, of the life or death of 
 the infant, and of the exact time at which it does die, with a view 
 of fixiing more exactly the time at which we should deliver it by 
 craniotomy. Actuated by the best and most humane feelings. Dr. 
 Collins believes that in tedious and difficult labors, obstetricians 
 should rarely or never perform craniotomy upon the head of a living 
 child, and that auscultation will enable us to eschew this otherwise 
 unavoidable error. For, in one set of cases, it will show us the 
 propriety of postponing the operation, by showing us that the 
 child's heart is still beating. In another set of cases it will show us 
 the propriety of practising it earlier than we should otherwise do, 
 by showing us that the child is already dead. At the same time 
 we must still not use our perforator immediately after the feetal 
 
 ' Practical Treatise, p. 18. 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 477 
 
 heart ceases to be heard by the stethoscope, or indeed for some 
 hours afterwards, lest life be not perfectly and entirely extinct in 
 the child. "It is totally contrary," says Dr. Collins,^ " to every rule 
 of practice to deliver the patient with the crotchet when the foetal 
 heart's action first becomes inaudible. It is only after frequent ex- 
 aminations, with some interval between each, that this is ever 
 resorted to, except where the mother's life is in very imminent danger 
 indeed." 
 
 Such is the use and value of auscultation in protracted labors, 
 according to the opinion of Dr. Collins and of the Dublin school 
 generally ; and certainly, while for one, I most gladly and gratefully 
 acknowledge that it is to that school that British midwifery stands 
 indebted for the first introduction of auscultation into English ob- 
 stetric practice, still I cannot help declaring my conscientious con- 
 viction here, as I have often done in lecturing upon the subject, 
 that the preceding application of it in tedious labors is so far un- 
 doubtedly erroneous in two most important and ftmdamental points. 
 
 Errors in Practical Application of Auscultation, 
 
 For, first, according to the principles upon which the Dublin 
 practitioners use auscultation in tedious labor, viz., in order to. fix 
 the fact of the death or life of the child, with a view to the imme- 
 diate performance or farther postponement of craniotomy, they 
 altogether leave out of consideration the great influence which the 
 mere duration of the labor exerts upon the maternal constitution 
 and life. They forget that whilst they are delaying for the death 
 of the child, the very delay is rapidly destroying the mother ; whilst 
 they are waiting and watching for the foetal life to become extinct, 
 the maternal life is every hour becoming placed in greater and 
 greater danger. " Under proper management," argues Dr. Collins, 
 "the death of the child takes place in laborious and difficult labors 
 before the symptoms become so alarming as to cause any expe- 
 rienced physician to open its head for the sake of the safety of the 
 mother.'' But I believe his own facts totally and sternly contradict 
 this argument. When for this or other causes he waited till the 
 labor had continued from twenty-five to thirty-six hours from its 
 first commencement, one in every seventeen of the mothers died 
 (see Table 11.) ; when he waited for twelve hours longer, allowing the 
 labor to be prolonged from thirty-seven to forty-eight hours, then 
 one in every six of the mothers was lost ; when he waited for twelve 
 more hours (namely, foriy-nine to sixty hours), then one in every 
 
 • Dublin Medical Journal, vol. xiii. 1838, p. 423. 
 
478 DYSTOCIA. 
 
 five of the mothers was lost; and when interference was not 
 adopted, or delivery completed, till the labor had gone on for sixty 
 hours or upwards, then one in every four of the mothers perished : 
 and that too, although, as we have already seen, in eleven out of 
 twenty-seven cases, or in about one in two and a half of these very 
 same protracted labors, the child was still living, and was indeed 
 ultimately expelled alive, thus still contra-indicating craniotomy, as 
 far as its life was concerned, notwithstanding that the life of the 
 mother was reduced to an extreme degree of danger and hazard. 
 
 But, secondly, the opinions which Dr. Collins and others of the 
 Dublin school profess with regard to the application of auscultation, 
 as a valuable aid to the management of tedious and instrumental 
 labors, are, I conceive, still more objectionable in another point of 
 view. In cases of protracted parturition they use the stethoscope, 
 as we have shown, in order to ascertain the life or death of the child, 
 and in order to decide and determine the proper time at which em- 
 bryotomy should be performed. For this purpose they employ it 
 with the special object of fixing the fact that the child is dead ; and 
 fixing, when requisite, the true time when it does die. But I am 
 strongly of opinion that the mighty boon which auscultation ofiers 
 us in protracted parturition is quite diflerent and far more important. 
 For it is not by any means so valuable in thus often afibrding us 
 evidence that the child is dead ; it is not so much of real and prac- 
 tical use in showing us that we may now perform embryotomy upon 
 a dead infant, as in showing us wAen, in protracted cases, we ought 
 to extract the child by the forceps, turning, or other safe means, if 
 we wish to preserve its life, as well as the life of the mother. In 
 this way I have repeatedly found auscultation of incalculable benefit 
 in protracted labors, and been, I believe, enabled by its evidence 
 alone to save several times the life of the child by the timely appli- 
 cation of the long and short forceps. And though the principle 
 upon which I have thus acted in the management of tedious labors 
 is not acknowledged by Dr. Collins under that subject, yet certainly, 
 the very same principle of using instrumental delivery for the sake of 
 the safety of the child is acknowledged by him under another head, 
 and in dependence upon another form of evidence of the danger of 
 the infant. In speaking of the treatment of cases of prolapsus of 
 the umbilical cord, he observes :' " The forceps I consider highly de- 
 sirable when the child is so situated that the head can be reached 
 with safety ; but as the funis generally descends at the commence- 
 ment of labor, it is very seldom that this instrument is applicable 
 till fostal life is extinct. We should not fail, however, to apply them 
 when practicable, should any delay occur in the delivery likely to 
 
 ' Practical Treatise, p. 344. 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 479 
 
 endanger the life of tlie child, or if we find the pulsation in the cord 
 becoming gradually slower and more feeble." Now, exactly on the 
 same principle, when in tedious lahors, in which there is no contra- 
 indication, we have evidence that the life of the child is hecoming 
 endangered, when by the stethoscope we learn that the pulsations in 
 the fcEtal heart are becoming gradually slower and more feeble, it is 
 in my opinion equally our bounden and solemn duty to interfere by 
 the same means in order to attain the same end, viz., the preserva- 
 tion of the infant's life. For I hold that neither in principle nor in 
 practice does it make any diiFerence whether with this view we 
 ascertain the imminent danger of the child, and the fact that the 
 pulsations of its heart are becoming slower and more feeble, by 
 feeling the pulsations of the cord, or by listening to the pulsations of 
 the heart itself. The sense of hearing affords us precisely the same 
 evidence in the one case as the sense of touch affords us in the 
 other, and it indicates also precisely the same line of treatment. 
 
 The bearing of this long discussion and digression upon the 
 practice of turning in contracted pelves, &c., is sufficiently evident. 
 Over both of the operations for which I propose it as a substitute, 
 viz., delivery by the long forceps and crotchet, it possesses this 
 great and weighty advantage, that it can be practised at a far earlier, 
 and consequently at a far safer, period of the labor. But it is princi- 
 pally as an alternative for craniotomy that I feel anxious to intro- 
 duce the operation of turning to the consideration of my professional 
 brethren; and over craniotomy it possesses, in addition to the 
 above, this other all-important advantage, that it offers the child a 
 chance of life, while craniotomy implies the very certainty of death : 
 and that while the existence of the sounds of the foetal heart, and 
 the continuance of the infant's life, would determine us to postpone, 
 and postpone almost indefinitely, the deliveiy by embryulcio, the 
 existence of these sounds, and the evidence they give of the con- 
 tinuance of the infant's life, would determine us to adopt, and form 
 indeed, cceteris paribus, the very strongest reason for adopting, deli- 
 very by turning. In the one operation we would delay, and per- 
 haps delay long, and hence dangerously, the delivery of the mother, 
 because the child was living ; in the other operation we would pro- 
 mote and hasten the delivery of the mother on exactly the same 
 grounds on which we postponed it in the first, viz., because the 
 infant was still living, and might still be extracted alive. 
 
 Perhaps the detail of one or two cases may impress this view 
 more strongly than any more lengthened remarks. I shall select 
 the first two from the Clinical Report of Dr. Lee of London, who, 
 like Dr. Collins, rejects the emplojntnent of the long forceps when 
 the head is delayed at the brim, and prefers the extraction of it by 
 the perforator and crotchet. 
 
480 DYSTOCIA. 
 
 Case IX.— In a woman whose pelvis and extremities were dis- 
 torted by rickets, the labor began on the 9th of February, 1842.* 
 " The membranes," to quote Dr. Lee's own words, " ruptured on 
 the 10th. On the 11th, the os uteri was not dilated to the size of 
 half a crown, the head was wholly above the brim, and the base of 
 the sacrum easily felt. Active pains came on and lasted during the 
 night, and till two p. m. of the 12th. The os uteri was still very 
 imperfectly dilated. The head, entirely above the brim, now much 
 swollen. It was clearly right to interfere, which I did (by cranio- 
 tomy), and she recovered without a bad symptom, though I now 
 feel persuaded that she ought not to have been left so long in labor. 
 The danger," he adds, "of rupture and fatal contusion of the uterus 
 is great in all such cases, and delivery should be effected as soon as 
 it is evident that the head cannot pass. I knew from the first, in 
 this case, that it would not pass through the brim, but was jprez^ewf erf 
 from interfering in consequence of hearing the pulsations of the foetal 
 heart." 
 
 In the preceding case Dr. Lee states his conviction that the 
 patient ought not, in reference to her own safety, to have been left 
 so long in labor. The continuance, however, of the pulsations of 
 the fcEtal heart prevented him for some time from interfering and 
 delivering by craniotomy. It is not stated whether the child con- 
 tinued alive or not till that operation was at last adopted. But the 
 circumstance which thus directly deterred him from earlier delivery, 
 viz., the life of the foetus, would have directly urged him to the new 
 practice which I am here venturing to propose in such cases. The 
 reason he had for longer postponing the operation of craniotomy 
 would have been the strongest of all reasons for at once preferring 
 the operation of turning, and giving so far, a chance of life to the 
 child, and at the same time preventing the continued duration of 
 the labor from placing the mother in greater danger and jeopardy. 
 
 I quote the following case from the same author for the purpose 
 of showing what I have omitted to insist upon in the course of the 
 preceding remarks, that in instances in which the brim of the pelvis 
 is contracted, the protracted duration of the labor may occasionally 
 lead to the most deplorable morbid consequences on the part of the 
 mother, even though it do not actually destroy her life. An earlier 
 delivery by turning would, I believe, as has been already often 
 stated, not only enable us to avoid these results to the mother, but 
 offer a chance of escape and life to the child. 
 
 Case X. — The patient^ had borne nine children ; all her labors 
 had been difficult, and the two last so much so that artificial assist- 
 
 • Clinical Midwifery, Case 113, p. 51. » Ibid. Case 84, p. 40. 
 
TURNING AS A SUBSTITUTE FOE CRANIOTOMY. 481 
 
 ance was required, and tlie children were still-born. Her tenth 
 labor commenced on the 3d of December, and the membranes were 
 soon after ruptured. During the 4th the pains were feeble and 
 irregular. Thirty-five drops of laudanum were given. On the 
 morning of the 5th they returned, but again feebly and irregularly. 
 
 At ten o'clock on the evening of the 5th, two doses of the ergot 
 were given, and soon several strong forcing pains were experienced. 
 , "The movements of the infant were not felt after this," and the 
 uterine contractions appear to have ceased. "When Dr. Lee visited 
 her next forenoon— viz., at eleven o'clock on the morning of the 
 6th (three days after the labor had commenced and the membranes 
 had been ruptured), the state of the patient was as follows : " The 
 discharge from the parts has become offensive ; bladder filled with 
 water ; the vagina is swollen and tender ; the head greatly swelled 
 and compressed, is firmly fixed in the brim of the pelvis, and the 
 finger cannot be passed around it without giving great pain ; the 
 ear cannot be felt, the greater portion of the head being still above 
 the brim." Dr. Lee opened the head, and two hours elapsed before 
 he could complete its extraction by the crotchet. He thus continues 
 the report : " December 7th. A bad night ; retention of urine ; 
 great swelling and tenderness of the parts ; pulse rapid ; tongue 
 loaded ; headache ; rigors. Sloughing of the vagina took place, 
 and on the 14th a, fistulous communication had been formed between 
 it and the bladder. This unfortunate woman," adds Dr. Lee, " was 
 soon after deserted by her husband, and has led a life of great indi- 
 gence and misery ever since." 
 
 In ottering some general concluding remarks upon this and sixty- 
 five other cases' of " difficult labor from distortion of the pelvis, &c. 
 &c., in which delivery was effected by the operation of craniotomy," 
 contained in his second report, Dr. Lee observes — " In thirty-eight 
 of the cases 4n this report, the labor continued from forty to seventy 
 hours." — "In a very large proportion of the cases the difficulty 
 arose from distortion, or a contracted state of the pelvis. Rupture 
 of the uterus took place in three before perforation, and the inflam- 
 mation and sloughing of the uterus, vagina, and rectum, which 
 proved fatal to eight others, were chiefly or solely produced by the 
 long-continued violent pressure on the soft parts by the head of the 
 child before it was opened and extracted. In those who recovered 
 with vesico-vaginal fistulse or contractions of the vagina from 
 cicatrices, the unfortunate occurrences arose from craniotomy being 
 too long delayed." — " In several, had the delivery been sooner 
 effected, the fatal consequences which ensued would have been 
 wholly prevented." 
 
 ' Clinical Midwifery, 1842, p. 59. 
 VOL. I. 31 
 
482 DYSTOCIA. 
 
 In some of the following cases from Dr. Collins' report, the delivery 
 of the patients by craniotomy was evidently postponed till such time 
 as the child was ascertained by the stethoscope to have died. The 
 state of the foetal heart is not mentioned by Dr. Collins in all, but 
 the omission was probably made in order to avoid unnecessary repe- 
 tition ; and except for this counter-indicating circumstance (the con- 
 tinuance of foetal life), the mothers would probably not have been 
 allowed to have had their sufferings protracted, or so much con- 
 stitutional excitement created, before resorting to artificial delivery. 
 In the last, or last two cases, the state of the mother probably ulti- 
 mately necessitated delivery, independently of any considerations 
 relative to the life of the infant. I shall quote the cases in Dr. 
 Collins' own words. 
 
 Case XI. — " Was admitted in labor of her eleventh child ; uterine 
 action very frequent and strong ; the os uteri dilated to the size of 
 a crown, and the fundus very much inclined to the right side. In 
 twenty-four hours after admission (the head not having made any 
 progress for the last eight), the foetal heart having ceased to act for 
 some time, it was thought advisable to lessen the head, and deliver 
 with the crotchet."^ 
 
 Case Xii. — " "Was admitted in labor of her seventh child ; she 
 had been delivered artificially in her previous labors, and had but 
 .one child born alive. She had been ill a considerable time before 
 she was brought to the hospital, and in nine hours afterwards, there 
 being no progress made, the pulse 132, her strength much exhausted, 
 and the child dead, she was delivered by the crotchet."^ 
 
 Case Xm. — " This patient was admitted in labor of her first 
 child ; uterine action was feeble, and continued so for seventy-two 
 hours after she came in. As the foetal heart had ceased to act for 
 some time, and the pulse became hurried, it was considered advisable 
 to deliver her. The os uteri was not fully dilated ; the head was high, 
 and resting on the pubis ; it was lessened, and cautiously brought 
 down with the crotchet."' 
 
 Case XTV". — " Was reported to have been in labor two days be- 
 fore admission ; the head was high in the pelvis, and pressing 
 strongly on the pubis. It remained in this situation for twenty-four 
 hours after, during which time she suffered great distress, uterine 
 action being almost constant. This was her tenth child ; she had 
 
 ' Collins' Practical Treatise on Midwifery, p. 480, No. 1032. 
 ? Ibid. p. 480, No. 1005. ^ i^id. p. 481^ No. 1038. 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 483 
 
 been twice force-delivered in this hospital ; dreading every moment 
 rupture of the uterus, the head was lessened and brought down by 
 the crotchet, as it had still remained so high as to be scarcely within 
 reach of the finger."' 
 
 Case XV. — " Was reported to have been twenty-four hours in labor 
 before admission. About twelve hours after she came in, it was 
 discovered that the face was turned towards the pubis, and pressing 
 so strongly on the urethra that the catheter could with difficulty be 
 passed. The pains continued strong for fifteen hours from this 
 time, yet the head did not advance. It was deemed advisable to 
 lessen it."^ 
 
 Case XVI. — " Was thirty-three hours in labor of her third child 
 without having made the least progress for the last twelve. The 
 bladder was forced down before the head. Her pulse became much 
 hurried, and strength greatly exhausted, rendering immediate de- 
 livery necessary. The head was lessened, and the child brought 
 away by the crotchet. It was very large ; all her former children 
 were still-born."^ 
 
 Case XVH. — " S. B. was forty hours in labor ; it was her fourth 
 child ; all still-born. The head not having made any progress for 
 the last twelve hours, and the fcetal heart having ceased to act, the 
 delivery was effected by the crotchet ; the face was turned towards 
 the pubis. She had been force-delivered in this hospital two years 
 ago, when the face presented — (see ' Observation on Still-born 
 Children,' No. 441); pelvis very defective. The placenta in the 
 present instance had to be removed by the hand, in consequence of 
 hemorrhage ; it was firmly adherent to the fundus of the uterus. 
 She died on the ninth day, and on examination, extensive ulceration 
 of the vagina was found, forming a communication with the rectum. 
 At one point the vagina presented the appearance as if a laceration 
 had taken place."'' 
 
 In thjese cases delivery by turning, instead of by craniotomy, by 
 being performed earlier, would, I believe, have preserved the 
 patients alike from the sufierings and the dangers which the con- 
 tinued duration of the labor entailed upon them ; and the children, 
 instead of being necessarily sacrificed by the operation adopted and 
 the delay attending upon it, might possibly have been saved by the 
 adoption of turning, and by the earlier period at which delivery 
 
 ' Collins' Practical Treatise on Midwifery, p. 470, No. 808. 
 2 Ibid. p. 470, No. 526. » Ibid. p. 470, No. 509. 
 
 4 Ibid. p. 136, No. 79. 
 
484 DYSTOCIA. 
 
 could thus have been practised. But it has been doubted whether 
 the object I have just alluded to, namely, the preservation of the 
 infant's life, could ever be the result of forcible extraction of the 
 child through a contracted pelvis by turning. I shall next therefore 
 notice this and other objections to the proposed practice on the 
 allegation of danger to the mother, and disarrangement of the 
 mechanism of parturition. The investigation of the objections 
 urged on these several grounds will, I believe, leave us only vrith 
 higher and more certain ideas of the real advantage of the proposed 
 practice itself. 
 
 Sect. VI. — The Depression and Indentation during Labor op 
 THE Sides of the Infantile Cranium, is compatible with the 
 Life of the Child.* 
 
 Among the advantages of turning as compared with embryuloio, 
 I have stated that "it gives the child a chance of life," and that the 
 " neck of the child, if it be living or only recently dead, is so strong 
 as to allow us to exert such a degree of traction upon the obstructed 
 head, that the sides of the cranium may become greatly compressed 
 or even indented under it ; and that without necessarily destroying 
 the child. "^ 
 
 As a comment upon these statements. Dr. Radford observes, " It 
 has been said that the neck of the child, alive or recently dead, is 
 so strong as to allow such a degree of force to be used as to greatly 
 compress the sides of the cranium ; lut," he adds, '■'^ such a procedure 
 is at variance with all scientific views, and incompatible with the safety 
 of hath mother and child."^ 
 
 The accuracy or inaccuracy of the two different, and indeed, 
 opposite opinions, thus expressed upon the same point by Dr. Rad- 
 ford and myself, is one of those questions in pathology which no 
 mere opinion or mere reasoning could ever settle. In order to de- 
 cide it, we must have recourse to facts and experience alone. And 
 it is of the highest moment in relation to the whole object of the 
 present inquiry, that the evidence on the matter be as perfect and 
 unequivocal as possible ; for, in fact, the practice proposed is based 
 in the main, on the fundamental idea that the required compression 
 and indentation of the infantile skull is not incompatible — as cranio- 
 tomy is — with the continuance of infantile life. 
 
 Now, the records of midwifery contain numerous accurately ob- 
 served cases in which the cranium of the child has become greatly 
 
 ' From Provincial Medical and Surgical Journal, March, 1848, p. 141. 
 * Monthly Journal of Medical Science, March, 1847, p. 718. 
 ' Provincial Medical and Surgical Journal, 1847, p. 405. 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 485 
 
 compressed or flattened, or actually depressed and indented in one 
 of its sides, while passing through a very contracted pelvis, and 
 that too, without necessarily destroying the life of the infant. Vel- 
 peau, for instance, the only author whom Dr. Radford quotes, tells 
 us in a part of his work, which has evidently escaped Dr. Eadford's 
 observation, that the depression or " indentation [enfonoement) of the 
 parietal or frontal bone, with or without fracture, has been noticed 
 several times at the Maternity Hospital of Paris." * * * And 
 " if," he observes, " the fracture or depression of the bones is not 
 accompanied with effusion, nature ordinarily suffices to restore 
 things to their primary state, and charges herself with the burden 
 of the cure. Otherwise death is the usual consequence of them, or 
 at least they produce drowsiness (assoupissement) and a great tendency 
 to convulsions."* 
 
 Chaussier, who tells us that he had reported some examples of 
 these depressions and indentations of the infantile skull in 1807 and 
 1810, makes the following judicious observations upon their general 
 pathology and effects. " Sometimes," he observes, " when the 
 sacro-vertebral angle projects too far forward, we find on the portion 
 of bone which rested on this prominence an indentation or depres- 
 sion (enfoncement ou depression), at which we often remark several 
 small linear fissures [f Mures) in the form of a star, proceeding from 
 the centre of the depression, and limited to the internal surface of 
 the bone ; at other times the bone is fractured in all its thickness, 
 and its fragments are more or less separated, or forced in upon the 
 brain ; most commonly the infant dies in the act of delivery, or a 
 short time after its birth." * * * * " These lesions, however, 
 which would," he adds, "be always fatal for an adult, do not always 
 terminate so badly in the new-born infant, for at this age the brain 
 has neither the consistence, nor the action or use which it ought to 
 have subsequently ; they even heal easily and spontaneously if the 
 infant be vigorous, and the labor has not been too prolonged."^ 
 
 Various practical authors have left incidental notices of such 
 cases of depression observed in the skull of the infant at birth, 
 without the life of the child being compromised by the injury. 
 Sometimes the injury has been the result of an excessive degree of 
 compression by the forceps ; but more usually it has been produced, 
 as pointed out by Chaussier, by the head of the infant being strongly 
 crushed against the projecting promontory of the sacrum, and that 
 whether the infant passed as a cranial or footling presentation. Dr. 
 Smellie, in his " Collection of lingering cases from a small, narrow, 
 or distorted pelvis," prefaces his observations with this general 
 
 ' Traits des Accoucheniens, torn ii p. 588. 
 
 2 Recueil des Memoires, &o., sur divers Objets de M6decine Legale, Paris, 1824, p. 436. 
 
486 DYSTOCIA. 
 
 remark, " that althougli these labors may seem to be of the same 
 class, and require the same management with those that proceed 
 from a large head, there is an essential difference ; for though they 
 are much the same with regard to the efforts of the woman, the 
 operator in these has much less room when he is obliged to assist 
 with his hand, and the child's head is disfigured and compressed 
 into large indentations, occasioned by the jetting in of the upper part 
 of the sacrum, and of the vertebrse of the loins."^ 
 
 in the course of his valuable volumes Dr. Smellie in different parts 
 casually details several instances bearing out this remark, and at the 
 same time showing that the injury is not necessarily fatal to the 
 infant. I shall abridge some of these cases. 
 
 Case JLVJLLL. — ^In a woman,'' "sickly from her infancy and very 
 much distorted," Dr. Smellie effected the delivery of a living child 
 by a double application of the forceps. " The forceps when first 
 fixed had impressed the forehead, though the mark disappeared in 
 five or six days after birth ; but they made a very considerable 
 impression when they were fixed a second time along the ears." 
 The pelvis was " distorted from the jetting forwards of the upper 
 part of the sacrum," and this projection had produced an indentation, 
 distinct from those produced by the forceps ; " the head was of a 
 lengthened form, and contorted to one side, and there was a deep 
 impression above the ear." — " Had the child been large its life could 
 not possibly have been saved." 
 
 Case XIX.' — The descent of the infant's " head was retarded by 
 a jetting in at the middle of the sacrum," and the forceps were used. 
 " The child's head was squeezed into a longitudinal form, fiattened 
 on the sides, with a deep impression on the cranium above the ears ; 
 and from an indentation on the os frontis by a blade of the forceps, 
 which had been fixed on that and the occiput, I discovered the ears 
 were not to the sides, as I had imagined. These impressions," the 
 author continues, " had very much galled and infiamed the parts, 
 but in consequence of proper care they digested, and the child re- 
 covered, and as he grew up the marks diminished and disap- 
 peared." 
 
 Dr. Smellie describes a case of depression and injury of the infant's 
 cranium at birth that is still more important than the preceding two 
 in reference to the subject of the present inquiry, for in it the cranial 
 indentation was produced in following the very practice which I am 
 
 ' Collection of Cases and Observations in Midwifery, vol. ii. p. 358. 2d Edit. London, 
 1758. 
 ' Ibid., vol. ii. p. 458. 3 Ibid. vol. ii. p. 461. 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 487 
 
 discussing, viz., in turning the infant when the brim of' the pelvis 
 was narrow and contracted. The following are the principal parti- 
 culars : 
 
 Case XX.' — A patient had a "narrow and distorted pelvis," in 
 consequence of "the three lowest vertebrae of the loins bending 
 forwards." The patient was delivered four times. At her first and 
 third labors the infants were obliged to be extracted by the crotchet. 
 Dr. Smellie tells us that he " managed her second labor from the 
 beginning in a slow and cautious manner ; but," adds he, " although 
 the child was small, I with the greatest difficulty saved it by the 
 assistance of the forceps." At her fourth accouchement the shoulder 
 presented. Dr. Smellie tried ineffectually to perform cephalic 
 version, and then with some effort seized one of the legs of the 
 infant and turned it, and extracted it as far as the neck, the head 
 still remaining above the contracted part of the pelvis. After using 
 considerable exertion in order to drag it through the deformed brim, 
 Dr. Smellie states that he began to despair of the child's life, but 
 adds, " as there was still a weak pulsation in the funis, I resolved to 
 make another effort with all my strength, by which the head was 
 moved a little lower ; then forcing up my fingers to the forehead, I 
 got a firm hold of it, and finished the delivery." The infant showed 
 some weak signs of life, and in about ten or fifteen minutes began 
 to ciy. " The infant," adds Dr. Smellie, " continuing to cry inces- 
 santly while the head was washing, I examined and perceived a 
 large tumor above the right ear; I likewise found a depresszon of 
 the temporal lone before the ear, and the frontal and parietal bones 
 pushed outwards ; these formed the swelling, and were the parts 
 that stopped at the distorted bones of the vertebrse." The child was 
 quieted by applying pressure on the tumor with a compress and 
 bandage. N'ext day the swelling had disappeared. The mother 
 recovered better than in any of her preceding labors. 
 
 Dr. Smellie relates another case,^ in which the head of the child 
 was apparently injured in a similar manner in dragging it through 
 " a distorted pelvis." 
 
 Case XXI. — The infant presented by the breech. After the body 
 and extremities were born, " a good deal of force was used to deliver 
 the head." Five minutes elapsed before the child breathed ; at last 
 it began to cry incessantly, "till one of the women observed a large 
 swelling betwixt the left ear and temple." Pressure with the fingers 
 first, and ultimately vnth a compress, quieted the child in the same 
 manner as in the preceding case. " When I examined it," says Dr. 
 
 ' Collection of Cases and Observations in Midwifery, vol. iii. p. 230. 
 _4^Ibid. vol. iii. p. 95. Collect. 32, Case 11. 
 
488 DYSTOCIA. 
 
 Smellle, " next day, the swelling was gone, and it appeared to have 
 been that part which stopped so long at the projection of the upper 
 part of the sacrum before the head was delivered." 
 
 Dr. Denman has recorded one exceedingly interesting case, in 
 which the head of the infant was much injured during the version 
 and extraction of it through a deformed pelvis, and that, as in the 
 preceding cases of Dr. Smellie, without compromising the infant's 
 life. The case is altogether so pertinent to the subject of the present 
 remarks, and affords so much important corroborative evidence, that 
 I feel assured I shall be excused in giving the details in full, and in 
 Dr. Denman's own words : 
 
 Case XXII. — "Many years ago I attended a patient in two 
 labors, in both of which there was a necessity of delivering with 
 instruments, on account of the smallness and distortion of the pelvis, 
 and neither of the children could be preserved. In her next preg- 
 nancy I made a proposal to bring on premature labor, to which she 
 and her friends would not consent, and I was dismissed from my 
 attendance. In the course of twelve or fourteen years she had five 
 more children, not one of which was born living. In the forty-sixth 
 year of her age she proved with child, and again applied to me. 
 When her labor came on, the first stage was suffered to proceed 
 without interruption, but when the membranes broke, I without 
 delay passed my hand into the uterus, and easily brought down the 
 feet and body of the child ; but the head being stopped by the 
 narrowness of the superior aperture of the pelvis, I was obliged to 
 exert and continue much force, before it could be extracted. The 
 child was bom with very little or no appearance of life, but by the 
 strenuous use of the common means recommended for this purpose, 
 it was recovered. On the left parietal bone there was a depression 
 of considerable extent, and to my apprehension, of full one inch in 
 depth, occasioned by the projection of the sacrum, but the depressed 
 part gradually rose. In the course of a few months the bone 
 regained its natural form, and the child was for several years in 
 good health, with its faculties perfect. The woman recovered with- 
 out any untoward circumstance. 
 
 "But," adds Dr. Denman, in a cautious and contradictory note, 
 " the success of such attempts to preserve the life of a child is very 
 precarious ; and the operation of turning a child, under the circum- 
 stances before stated, is rather to be considered among those things 
 of which an experienced man may sometimes avail himself in 
 critical situations, than as submitting to the ordinary rules of 
 practice."' 
 
 ' Introduction to the Pxactice of Midwifery, p. 382. 
 
TURNING AS A SUBSTITUTE FOE CRANIOTOMY. 489 
 
 In the second volume of her "Pratique des Accouchemens," 
 Madame Lachapelle relates the following instance of footling pre- 
 sentation in which the child was born with a depression of the 
 parietal bone : 
 
 Case XXIII. — A woman, pregnant for the second time, had a 
 large accumulation of liquor amnii, and the child floated so easily 
 in it, that when labor pains first supervened, the presentation altered 
 from time to time. The membranes at last were broken, and the 
 left foot descended. By dragging at this foot, the lower extremities 
 and then the trunk passed with facility. The left arm, however, 
 got fixed between the head and pubis, and was disengaged with 
 some trouble. "The head, however," to quote the author's own 
 account, " although directed transversely, offered still greater diffi- 
 culties in its extraction, either because the pelvis was a little dis- 
 torted, or because our efibrts were not absolutely directed according 
 to the axis of the brim. At all events it is certain, that after the 
 birth of the foetus we found a considerable depression on the right 
 parietal bone, which had rested upon the sacro-vertebral angle. In 
 despite of this lesion, the infant, which was at first apparently still- 
 born, not only lived, but the depression was dissipated, and indeed 
 was scarcely visible fifteen days afterwards. The mother did not 
 experience the slightest bad symptom."' 
 
 Dug^s has recorded two cases which came under his observation, 
 in which the cranium was very deeply depressed and indented in 
 the way described in the preceding instances, and yet both children 
 lived and did well. 
 
 Cases XX IV. and XXV. — In one of these cases of Dugds the 
 frontal bone was so much depressed, that the left eye appeared as it 
 were protruded firom the orbit ; still the child neither suffered from 
 convulsions, nor any other special symptoms. In the second case 
 the child had come footling through a pelvis, the great [conjugate ?] 
 diameter of which was estimated at' three and a quarter inches. 
 (Pont le grand diametre etait evalue a trots pouces un quart.) The 
 head could not at first be extracted by the aid even of very strong 
 tractions on the inferior jaw and shoulders, but scarcely were these 
 artificial efforts momentarily suspended, when the head passed 
 rapidly without assistance, and was expelled by the action of the 
 abdominal muscles. The left parietal bone, which had pressed upon 
 the promontory of the sacrum, was depressed and indented to the 
 depth of half an inch, and throughout an extent of two inches. 
 Two or three spoonfuls of blood were allowed to escape from the 
 vessels of the cord, which yet beat with sufficient force, although the 
 
 ' Pratique des Accouchemens, vol. ii. p. 166. 
 
490 DYSTOCIA. 
 
 infant was apparently dead ; and betimes the child became gradually 
 reanimated, and began to cry, and passed meconium. It was trou- 
 bled with constant hiccup, puckering of the lips, and torsion of the 
 mouth to the left side ; spasmodic closure of the right eye, imC- 
 mobility of the left ; rigidity of the hands ; fingers extended and 
 separate, with the exception of the thumhs and the last phalanx of 
 one of the index fingers, which were flexed inwards; rigidity of the 
 arms and limbs. These symptoms were remittent, and returned in 
 fits at intervals of ten minutes. Two leeches were applied to the 
 left temple. The fits continued during the evening and night, but 
 gradually became less and less severe. On the morrow the infant 
 drank ; it took the breast the following day ; and in fifteen days 
 after birth the cranial depression had almost entirely disappeared. 
 
 In his " Manual of Midwifery," the same writer (Dugds) observes, 
 " The bones of the cranium are often fractured with indentation, 
 by the sacro-vertebral angle of the mother. It is one of the frontal, 
 or one of the temporal regions, which is the most common seat of 
 these lesions. * * * These fractures often heal spontaneously ; the 
 indentations even rise in a few days."' 
 
 Jacquemier, one of the latest French writers on midwifery, and 
 from whose work I have quoted Dug^s' cases, states that these 
 fractures of the fcetal cranium, with depression, are not by them- 
 selves a cause of certain death ; " the depression," he remarks, 
 " relieves itself by degrees, and after ten or fifteen days, there 
 scarcely remain any vestiges of it."^ 
 
 If it were required, I might cite other cases and remarks of the 
 same description from other authors in evidence of the fact, that the 
 state of compression and indentation of the bones of the infant's 
 cranium at birth is not necessarily fatal to the infant's life. Some 
 additional proofs will be quoted in the sequel ; in the meantime I 
 have, I believe, stated enough to show — first, that the neck of the 
 child, if it be living, or only lately dead, is so strong, as to allow us 
 to exert such a degree of traction upon the obstructed head, that the 
 sides of the cranium may become greatly compressed, or even 
 indented, under it ; and, secondly, that Dr. Radford is truly wrong 
 in stating that such a lesion and practice is incompatible with the 
 safety of the child. On the contrary, the recorded experience of 
 Velpeau, Chaussier, Smellie, Denman, Lachapelle, Duges, Jacque- 
 mier, &c., &c., proves (as we have seen), that the depression and in- 
 dentation of the child's head do not necessarily destroy the child's 
 life. Nay, Dr. Radford's own experience on this point is, I know, 
 not in favor of his own views, but of mine. In evidence of this I 
 
 ' Manuel d'Obstetrique, pp. 358, 359. 
 
 ° Manuel des Aooouchemens, torn. ii. p. 773. 
 
TURNING AS A STJBSTITITTB FOR CRANIOTOMY. 491 
 
 shall quote a case in point, recorded by Dr. Radford himself, from 
 his own practice. 
 
 Case XXVI. — "I was requested," says Dr. Eadford, "by Mr. 
 Dick, to visit a poor woman in New Blakely Street, who was suffer- 
 ing from protracted labor, caused by contraction of the brim of the 
 pelvis. The long forceps were applied, and the child delivered 
 alive. A depression of considerable size was produced on the left parietal 
 hone, from the pressure it had sustained from the promontory of the 
 sacrum. The signs which the child manifested were those of 
 apoplexy. The funis was divided, but no blood followed, as the 
 pulsation had previously ceased. The child continued in the same 
 state during the day, and in the evening was attacked with con- 
 vulsions, which were frequent. Two leeches were applied to the 
 temples, the bowels were opened, and the child recovered."* 
 
 But farther, argues Dr. Radford, such a procedure as I propose is 
 "at variance with all scientific views." I shall not stop at present 
 to debate here whether the practice I suggest be " scientific" or not ; 
 but in a medical point of view I hold that appellation to be truly 
 merited by any propositions and measures that tend, like the present, 
 to promote the great essence and object of all medical science — 
 namely, the preservation of human life ; and in the various cases 
 which I have quoted in the preceding sections, while none of the 
 mothers were lost, the lives of the infants were at the same time all 
 saved. But assuredly the heads of most of these children would 
 have been opened by the perforator, and their lives thus destroyed, 
 provided, in each instance, the structure of the cranium had not 
 yielded, and its bony parietes become fortunately depressed and 
 indented, to the degree required to admit of its safe transit through 
 the contracted aperture of the pelvis. 
 
 Sect. VII. — Physiological and Pathological Reasons for the 
 Life of the Child not being necessarily compromised under 
 THE Proposed Practice.^ 
 
 It has been alleged that the preservation of the life of the infant 
 is not compatible with its forcible extraction by turning through a 
 contracted pelvic brim. It must perish, it has been urged, in con- 
 sequence of the lesions it necessarily sustains, and especially — 1st, 
 in consequence of the injurious compression to which its head is 
 subjected during the forced delivery ; and, 2d, in consequence of 
 the required injurious traction upon its neck. Let us examine, in 
 
 ' Essays on Various Subjects connected with Midwifery, p. 11. 
 ' From Provincial Medical and Surgical Journal, April, 1848, p. 172. 
 
492 DYSTOCIA. 
 
 detail, eaeli of these alleged necessary causes of death to the child 
 under the practice in question. 
 
 1.— Is THE Compression to which the Infant's Head is subjected 
 
 INCOMPATIBLE WITH ITS SaFETT AND LiFE ? 
 
 In the remarks which I offered under the last section, with regard 
 to the question whether, in turning in contracted pelves, the degree 
 of injury to which the child's head is subjected, is or is not com- 
 patible with its future safety and life, I confined the observations 
 which I made and the illustrative cases I adduced, to that form of 
 cranial lesion in which the sides of the foetal skull are both com- 
 pressed and indented. In some instances, however, even when the 
 pelvis is much distorted, one of these states only, as the lateral com- 
 pression alone, without the indentation of the cranium, is all that is 
 required in order to reduce the head to the size necessary for its 
 transit. On one occasion, through a pelvis, the conjugate diameter 
 of the brim of which was less than three inches, from projection of 
 the promontory of the sacrum and disease of the symphysis pubis, 
 I extracted a full-grown infant by turning; the head passing 
 through/ in a flattened and compressed form, but without any 
 depression or indentation upon it. It is, I believe, unnecessary for 
 me tO' prove, that when the extraction can be effected with this 
 single lesion, the child is not necessarily sacrificed ; because I have 
 already proved, that even when the two lesions of compression and 
 indentation coexist, the presence of both forms of injury is not 
 necessarily incompatible with the continuance of life. And some- 
 times by compression alone, more especially if the skull is not very 
 fully ossified, the foetal head may certainly be very greatly reduced 
 in size without compromising life. Dr. Denman conjectures that, 
 to quote his own expression, " it may be reduced one-third below 
 its original size, without the destruction or even injury of the child 
 from the compression."^ 
 
 It would, however, be improper to leave this subject without 
 attending to some anatomical and physiological circumstances, in 
 the structure of the foetal head, that enable it to bear this great 
 degree of lateral compression which we have been considering, 
 without the necessary destruction of life. Indeed, perhaps the very 
 knowledge of these circumstances may impart to the mind greater 
 faith in the correctness of the principles of the proposed practice. 
 
 We shall afterwards have occasion to see that by far the most 
 frequent form of morbid contraction of the brim of the pelvis con- 
 sists in the projection forwards of the promontory of the sacrum, 
 
 ' Introduction to the Practice of Midwifery, 1816, p. 352. 
 
TURKING AS A SUBSTITUTE FOB CRANIOTOMY. 493 
 
 and this is a kind of distortion especially adapted for the artificial 
 delivery of the mother by turning, instead of craniotomy. Under 
 this kidney-shaped pelvic brim, and other varieties of pelvic con- 
 traction, when the child is delivered by turning, the direction of the 
 compression of the head is, as we have already found, lateral and 
 transverse, or, in other words, in the line of its bi-temporal or 
 bi-parietal diameters, these diameters being reduced and shortened 
 by it. 
 
 Now, of all directions, the lateral is the one in which the child's 
 head can endure the greatest degree of compression, with the least 
 degree of danger. The power of diminution of the child's head 
 under labor, "is greatest," observes Dr. Eamsbotham, "in the 
 lateral diameter, and," he continues, " a full-grown foetal head may 
 be lessened from side to side, without endangering the child's life, 
 one-seventh of its own extent, or from three inches and a half to 
 three inches."' Dr. Eamsbotham states that this degree of com- 
 pression of the head, namely, to one-seventh, may be accomplished 
 without the life of the child being endangered. We have just now 
 seen that Dr. Denman imagines that the amount of compression 
 may be carried much farther, namely, to one-third, without the life 
 of the child being necessarily injured and destroyed. ISTo author 
 has pointed out more correctly than Dr. Eadford, the fact that the 
 child's head will bear with comparative safety, a far higher amount 
 of compression in its transverse or bi-parietal diameter, than in its 
 longitudinal or occipito-frontal diameter. When the head is com- 
 pressed in the first of these modes, or transversely, "the brain," he 
 observes,^ " bears this alteration in the figure of the cranium with 
 comparatively little inconvenience, because the pressure it sustains 
 is parallel with the fibres of some of those parts which lie between 
 the two hemispheres, and with the falx, which in its natural state 
 supports this organ. The pressure is also less injurious, because it 
 is applied upon the sides of the vessels, but not in such a degree as 
 considerably to influence their calibres." When, however, the 
 direction of the pressure happens to be in the opposite or longitu- 
 dinal axis of the head, the results are very difierent, and far more 
 dangerous. Then "the alteration," Dr. Eadford remarks, "which 
 takes place in the head is as follows : A considerable diminution 
 in the length of the occipito-frontal diameter is produced, in conse- 
 quence of approximation between the frontal and occipital bones ; 
 the fontanelles become nearly obliterated, and the sagittal suture is 
 wider and more prominent. The brain is pushed into this space, 
 which is insufficient for its accommodation ; its organization is 
 
 ' Obstetric Medicine and Surgery, p. 25. 
 
 ^ Essays on various Subjects connected with Midwifery, p. 7, &c. 
 
494 DYSTOCIA. 
 
 injured, and the child, when born, is either dead or dies soon after 
 birth. The pressure applied to the fore and hind part of the head 
 has a tendency to change the relative situation of many parts of 
 the brain. It forces one hemisphere from the other, which, if car- 
 ried beyond a certain degree, will inevitably produce laceration of 
 the coats of the veins which pass to the longitudinal sinus ; and 
 this danger is increased by the great congestion which exists. These 
 serious effects," he again states, viz., apoplectic congestion, san- 
 guineous effusion, and softening of the brain, " are produced by 
 the brain being compressed in a direction contrary to the course of 
 the fibres of some of those parts which lie between the hemispheres, 
 and also to the current of blood along the longitudinal sinus." Dr. 
 Eadford adds, that injuries of this character are sometimes met with 
 when the head has been compressed and dragged through the pelvis 
 by the long forceps ; and he gives two dissections of the foetal 
 encephalon to show these results, congestion, effusions of blood, 
 &c., in two cases in which the delivery was accomplished by this in- 
 strument. The cause for instrumental delivery and the application 
 of the long forceps is not specified in one of these cases ; in the 
 other they were used on account of distortion of the brim of the 
 pelvis. And certainly, if we employ the long forceps to overcome 
 this difficulty, and place them as Deleurye, Haighton, Davis, Eams- 
 botham, and other excellent operators have recommended, with one 
 blade over the face or forehead and another over the occiput of the 
 child, we in our extractive efforts, must compress the foetal head 
 with the instrument so applied, in its longitudinal or antero-posterior 
 axis ; and hence the actual direction of our pressure would en- 
 danger the child more than the actual degree of it. If, in the same 
 case, and under the same obstruction, however, the child were ex- 
 tracted by turning, the required reduction of its head, by being 
 effected entirely by lateral compression, would be effected, as we 
 have already seen, not only with much greater facility but with 
 much greater safety to the infant ; and the chance of injury to the 
 brain and of congestion and sanguineous effusion upon it would be 
 greatly less. 
 
 But, though the danger of cerebral congestion and its effects is 
 diminished in lateral as compared with longitudinal compression of 
 the child's head, yet it is by no means abrogated and removed ; and 
 in those cases of lateral compression and indentation of the cranium, 
 which, under either footling or head presentations, prove fatal, it is 
 this effusion and its dangers more than the mere compression of the 
 proper structure of the brain, that seems to lead to this result. At 
 all events, the cases I have already cited, in the last section, show 
 that the cerebral tissue may be compressed, or, at least, displaced, 
 
TURNING AS A SUBSTITUTE FOE CRANIOTOMY. 495 
 
 in a lateral direction by the grooved and depressed cranium^ not 
 only without destroying or endangering life, but without producing 
 coma or convulsions, or any greater lesion of function than a mere 
 temporary asphyxia, provided always ther^ be no serous or san- 
 guineous congestion and effusion accompanying and resulting from 
 it. The escape of the infant under this form of injury in which we 
 are thus interested, is favored by other circumstances. When the 
 foetal skull and encephalon are decreased by pressure in one dia- 
 meter, they become lengthened and increased in others. In the 
 form, for instance, of lateral compression resulting from extraction 
 through a distorted pelvis by turning, while the head is flattened 
 and diminished in its transverse diameter, it is temporarily length- 
 ened to a corresponding degree in its vertical and longitudinal 
 diameters. The anatomical peculiarities of the faetal skull, the 
 existence of fontanelles and sutures between its component bones, 
 and the consequent isolation and mobility of the individual bones 
 themselves, freely admit of this ; and so far under cranial depres- 
 sions, no doubt, save the proper tissue of the brain from a dele- 
 terious and destructive amount of pressure in a way that, under the 
 same form of injury, would be quite unavoidable with the cerebral 
 contents of the solid adult cranium. Besides, the immunity of the 
 infant at birth under such apparently severe injuries may partly be 
 owing to another and a physiological cause. The embryo and fcetus 
 possess a much lower physiological type of life than that which 
 pertains to the adult ; nor is the transition from the one to the 
 other abruptly and entirely completed when the infant passes from 
 its intra-uterine to its extra-uterine existence. It is stated by 
 Billard,' and I could quote no more accurate observer, that symp- 
 tomatic fever seems incapable of being excited in the constitution 
 of the infant, by injury or otherwise, till the time of teething ; and 
 in all probability lesions such as these to which the crania and ence- 
 phala are subjected at birth in the class of cases we have been con- 
 sidering, are less dangerous and fatal in their effects, in consequence 
 of the general law, that the power of resisting and repairing in- 
 juries is greater in proportion as the type of animal life is lower. It 
 is true, besides, that individual infants, like individual adults, have 
 a power of withstanding injuries much more than others, and in a 
 way that it is impossible to account for on any known principles. 
 Speaking of the differences among children in relation to the 
 
 ' "L'absence de toute reaction febrile, lors mfime qu'il existe des lesions graves ohez les 
 nouveau-n^s ; la promptitude, au contraire, avec laquelle la fifevre s'allume par la moindre 
 cause chez les enfants qui orit d^pass^ I'^ge de la dentition, imprime aux maladies de ces 
 deux (Spoques un caract^re diflSrentiel de la plus grande importance." — Maladies des En- 
 fans, Preface, p. 2. 
 
496 DYSTOCIA. 
 
 danger they incur, from compresaion of the head during labor, 
 Jacquemier remarks : " One infant, of a feeble constitution, will 
 resist a long compression by the parts of the mother, or by the 
 energetic and reiterated action of the forceps ; another, of a strong 
 constitution, whose head has not been a very long time, or very 
 strongly, compressed by the pelvis, or between the blades of the 
 forceps, readily dies, or only has a few hours' existence."' 
 
 Lastly, let me observe that the kind and degree of ossification of 
 the bones of the festal cranium at birth, admit of their yielding and 
 becoming depressed in a manner that, no doubt, contributes to 
 the safety of the infant. The ossification is as yet, in general, so 
 imperfect that the fiat individual bones, such as the parietal and 
 frontal, are still sufficiently thin and fiexible to allow of their being 
 partially indented and altered in shape by strong pressure applied 
 to one point of their surface. They are, at the same time, usually 
 so elastic as easily to be made to regain their former shape. And 
 this indentation and restoration may occur without any appreciable 
 fracture. In the first case which I have related, the right parietal 
 and frontal bones, when their external surface was carefully exa- 
 mined after the removal of the scalp, were found deeply depressed, 
 but apparently not fractured. They afterwards fissured, however, 
 at the site of the indentation when being dried and prepared for 
 preservation. However, if the indentation is extremely deep, or 
 the bones unusually ossified, no doubt fracture will take place, but 
 still probably without danger, if without internal or encephalic 
 eflusion. 
 
 "We have found Velpeau, and the other authors we have quoted, 
 generally stating that the compressed cranium, and especially de- 
 pressed portions of it, usually become spontaneously replaced and 
 restored in the course of a short time after birth. This is, however, 
 not always the case ; nor is its occurrence absolutely necessary for 
 the viability of the child. In evidence of this I shall content 
 myself by citing a single illustrative case. 
 
 Case XXVII. — In the course of the last winter, after lecturing on 
 the subject of these indentations in the foetal cranium, one of the 
 students in my class afterwards showed me, on his own person, two 
 deep impressions, one on each side of the cranium, which had been 
 produced by the use of the forceps, and which had afterwards con- 
 tinued permanently depressed. He was 20 years old. On the right 
 side of the head, a little above the ear, there were two pretty deep, 
 curved fissures or indentations, from two to three inches long. On 
 the left side there was a single shorter indentation above the com- 
 mencement of the temporal ridge. 
 
 ' Manuel des Accouchemens, p. 770. 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 497 
 
 2. Is THE Traction to which the Infant's Neck is subjected 
 
 INCOMPATIBLE WITH ITS SAFETY AND LiFB ? 
 
 The answer to this inquiry need not detain us long ; in fact, the 
 proper reply to it has already been virtually given, when considering 
 whether the existing degree of cranial compression and indentation 
 was necessarily fatal or not. For if, as we have found, children can 
 survive after being turned and extracted through so narrow a pelvic 
 brim, that the sides of their crania are sufficiently collapsed and 
 depressed against the sides of the contracted maternal pelvis, to 
 admit of the complete transit of the head, then it is evident that 
 the neck is not fatally injured under the proposed traction ; for in 
 all these cases the degree of traction upon it was adequate to pro- 
 duce all the results wanted, without destroying the child. In these 
 instances the extractive force necessary to drag the head through 
 the contracted pelvis was applied to the neck, and the neck was 
 found sufficient to bear it without compromising the life of the 
 child ; and I believe, as I have stated previously, that this will gene- 
 rally, if not always, be found to be the case, " provided the child be 
 living, or only lately dead." It will be very different, however, if 
 the child has been for some time dead, and decomposing ; the struc- 
 tures of the neck, certainly, vrill not then bear such traction as is 
 required to extract a full-sized head through a distorted brim ; nor is 
 it of any practical importance that it should, for such cases are cases 
 for craniotomy, the child being dead, and forming no element for 
 consideration in the mode or kind of delivery that is followed. 
 
 But, independently of the above decisive and conclusive testi- 
 mony, and even if it were wanting, it would be easy, I believe, to 
 adduce such cases and observations from obstetric clinical reports 
 and other works, as would, a priori, have rendered probable what 
 these cases render certain, viz., that the degree of traction to which 
 the child's neck is subjected under the proposed practice, is com- 
 patible wdth its safety and life. I shall, for the sake of brevity, con- 
 fine my illustrations of this remark to a note or two of some cases 
 recorded by Dr. Smellie, and some observations offered by the ever- 
 cautious Dr. Denman. Dr. Smellie gives various cases in which he 
 was evidently himself astonished, as other practitioners have often 
 been, at the excessive degi'ee of traction which the neck of the infant 
 stood during delivery in natural or artificial pelvic presentations, 
 without the life of the child being compromised by it. For example : 
 
 Case XX. V 111. — In a breech case, where the woman was long in 
 labor with a large child, and was suffering fi-om some hemorrhage, 
 
 TOL. I. 32 
 
498 DYSTOCIA. 
 
 Dr. Smellie brought down one foot, extracted the body and extremi- 
 ties, but the progress of the delivery was " stopped at the head," 
 and required much traction for its transit. Dr. Smellie being " obliged 
 to increase the force at every attempt." "I palled," he observes, 
 " so long, and with so great force, before the head was delivered, 
 that I was surprised to find the child alive."' 
 
 Case XXIX. — ^In the next instance which he reports, one of the 
 breech presenting in a narrow and distorted pelvis, after the body of 
 the child was born, Dr. Smellie brought down the right arm, and 
 "helped down the forehead; but," he adds, "before I could deliver 
 the head, I was obliged to bring down the other arm, and saved the 
 child also, though a good deal of force was used to deliver the head."^ 
 
 Case XXX. — ^A young woman, of " a small size," was in her first 
 labor. The thighs of the child, which was large, presented. The 
 labor was very slow and lingering. Dr. Smellie brought down the 
 feet, and eifected the extraction of the infant. " I delivered," he 
 remarks, " the head, but not without a good deal of force. The 
 child was alive, which I scarcely expected."^ 
 
 Case XXXI. — The breech presented, and the pelvis was narrow, 
 and the child was born living. In attempting to deliver the head. 
 Dr. Smellie tells us — " I imagined it was impossible the child would 
 be alive, as I found the neck was so overstretched," having met 
 "with greater difficulty than any that I ever delivered in that 
 manner."^ 
 
 In his classical and highly practical introduction to midwifery, 
 Dr. Denman has devoted a special section to the consideration of 
 the practice to be followed, in order to extract the head through 
 the brim, in cases in which preternatural presentations happen to 
 be complicated with distortions of the' pelvis. His observations 
 are most valuable in regard to the necessity of combined perse- 
 verance and caution, but they are too long to quote in detail. He 
 tells us that "it has been said that children have been sometimes 
 born alive when the strongest efforts, and those continued for many 
 hours, have been made, to extract the head in this position, but I 
 have not been so fortunate as to meet with any such instances, a 
 short space of time having generally been sufficient to frustrate my 
 hopes, and convince me that the child was dead, though when the 
 head has been detained a considerable time, a few cases have termi- 
 
 ' Collection 32, Case 10. ^ Ibid. Case 11. ^ itij q^^^ jg^ 4 ibid. Case 13. 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 499 
 
 nated more favorably than I could have expected, and I have been 
 agreeably surprised with the discovery of some faint signs of life, 
 which, by the assiduous and careful use of the common means, 
 have been improved, and the life of the child at length perfectly 
 recovered." 
 
 " When we have," he continues, "in vain exerted all the force 
 which we think reasonable and proper, and which, in some cases, 
 must be more than any circumstance would be thought to require, 
 it will be expedient to rest, for the purpose of gaining all the advan- 
 tage to be attained by the compression of the head. On this account 
 the mother will actually suffer no more inconvenience than would 
 have been produced if the head had originally presented and been 
 locked in the pelvis. After waiting some time, we must renew our 
 attempts to extract, and thus proceed, alternately resting and acting 
 with efficacy and resolution, and if the hold we may have of the 
 body or extremities of the child does not suit, a silk handkerchief 
 or other band may be passed round its neck, and this will be found 
 a very handy and convenient instrument." 
 
 " It must be a wry great disproportion," adds Dr. Denman, " be- 
 tween the head of the child and the pelvis, which is able to with- 
 stand this method of proceeding, if we persevere in it with prudence 
 and steadiness ; because the integuments of the head will burst, or 
 the bones be bent inwards in an extraordinary degree, or even 
 broken." If it fail, " it then only remains that we should lessen the 
 head of the child, and the operation may be as easily performed 
 in this as in the natural presentation of the head." "But it will," 
 he continues, " be scarcely believed, how seldom this operation is 
 necessary under these circumstances, if we have not been in a hurry, 
 but have acted with prudence ; nor have I ever known any ill con- 
 sequences follow the compression which the soft parts undergo 
 between the head of the child and the sides of the pelvis, if proper 
 attention were afterwards paid to the state of the bladder and 
 rectum."' 
 
 "We have already found, that when the child is extracted by turn- 
 ing through a contracted pelvic brim, its life is not necessarily 
 sacrificed, as has been alleged by some, — either, 1st, by the injurious 
 compression to which its head is consequently subjected ; or, 2d, by 
 the degree of traction required to be made upon its neck. 
 
 One more special objection to the proposed operation of turning 
 remains for our consideration, viz. : 
 
 ' Introduction to the Practice of Midwifery, pp. 497, 498, 499. 
 
500 DYSTOCIA. 
 
 3. Is THE Practice incompatible ok not with the safety and 
 Life of the Child in consequence of the Compression of the 
 Umbilical Cord ?' 
 
 In speaking of tlie propriety of delivery by turning in the class 
 of cases for whicli I have proposed it, Dr. Radford states as an 
 objection to it, the danger of death to the infant from pressure upon 
 the funis, and consequent obstruction of the umbilical circulation. 
 In footling presentations, " the funis," he observes, " is subject to 
 fatal compression ;" and he imagines this danger must be greatly 
 increased in cases in vrhich the child has been turned on account of 
 distortion of the maternal pelvis. 
 
 Perhaps the proper and the most direct answer to this, as to the 
 other objections to turning, drawn from supposed dangers to the 
 child, is simply a reference to the actual results of the cases which 
 I have already quoted, and may yet have occasion to quote in the 
 sequel. In many of these the child will be found to have passed or 
 been drawn footling through a contracted pelvis, and yet, in despite 
 of the alleged fatal danger of compression of the funis between the 
 body or head of the child, and the interior of the maternal passages, 
 the infant has been born alive. The infant has been subjected to 
 the alleged cause of danger and death without the alleged effects 
 following ; and hence we are surely entitled to conclude that the 
 influence of the cause is not so likely to interfere with the operation 
 of delivery as has been theoretically presupposed. 
 
 Let me not be misunderstood. I by no means wish to argue that 
 in turning in distorted pelvis there is no danger to the child from 
 umbilical compression, for I believe quite the reverse ; but I imagine, 
 at the same time, that on first thinking over this undoubted source 
 of danger, we are apt in our own minds to magnify its effects. 
 Experience, as I have just now stated, teaches us that they are not 
 so great as theory might lead us d priori to believe ; and when we 
 consider the subject for a moment we shall find, I think, suflacient 
 reason for seeing — 1st, that the risk and occurrence of umbilical 
 compression in footling presentations and turning is not so very 
 great as to invalidate the practice, and that it is in part averted by 
 the very form of distortion to which the pelvic brim is most usually 
 subject ; besides, supposing, 2d, the compression to take place, there 
 may still, I believe, be measures in the resources of science, by 
 which, if we cannot now avert the occurrence of compression of the 
 cord, we may prevent at least the more dangerous consequences of 
 
 ' From Provincial Medical and Surgical Journal, July, 1848, p. 393. 
 
TUENING AS A SUBSTITUTE TOR CKANIOTOMY. 501 
 
 the complication for the child. I shall speak briefly of each of these 
 points. 
 
 The Danger and Mortality from Compression of the Cord is not so 
 great as to invalidate the Practice of Turning. — Dr. Churchill has 
 published a table of 542 cases of turning in which the result to the 
 child is mentioned. In these 542 cases 182 children were lost, or 
 rather less than 1 in 3. And when we recollect that no doubt in 
 many of these 182 cases the child was dead before turning was 
 adopted, and that in others the cause demanding the delivery, such 
 as presentation of the placenta, was the cause also of the infant's 
 death, &c., we shall see reason to believe that the chance of death 
 to the child from the compression of the cord, would be found to be 
 less than the chance of death from the application, and compression, 
 and traction of the long forceps ; for, even in the more common form 
 of delivery by the short forceps — an operation which is generally 
 looked upon as less dangerous to the child than delivery by the long 
 forceps — the mortality among the infants is as great or greater than 
 by turning. 
 
 Out of 871 cases of delivery by the forceps, and almost always the 
 short forceps, collected by Dr. Churchill, 175 children were lost, or . 
 1 in every 5. 
 
 Out of twenty-four short forceps cases which occurred in the 
 Dublin Hospital during Dr. Collins' mastership, eight of the children 
 were still-bom, or 1 in 3. Out of thirty-three cases of presentation 
 of the shoulder or arm which he treated by turning, in two the 
 child was putrid, and in two others there was hemoiThage, in one, 
 of the unavoidable, and in the other, of the accidental form, and 
 death of the children. Among the twenty-eight remaining cases, 
 nine were born dead, or nearly 1 in 3. Hei'e, suppose we admit 
 that the cause of death in these nine children was traceable to com- 
 pression of the umbilical cord ; still the infantile mortality was pro- 
 bably as little or indeed less than would be found to result from 
 delivery with the long forceps. 
 
 Out of forty-two forceps cases related by Dr. Lee in his " Clinical 
 Midwifery," in thirty-one cases the child was still-born, or 3 out of 
 every 4 of the infants were lost. In thirty-nine instances in which 
 he had recourse to turning in transverse presentations, twenty-nine 
 of the infants were born dead, or about 3 out of every 4. His deli- 
 veries by the forceps were fatal to the children in 3 out of every 4 
 cases ; and his deliveries by turning were fatal to the children in 
 nearly the same proportion of 3 out of every 4 cases. 
 
 Out of ninety-three forceps cases related by Madame Lachapelle 
 in her " Pratique des Accouchemens," in fifteen the children were 
 still-born, or 1 in eveiy 6 of the infants was lost. In sixty instances 
 
502 
 
 DYSTOCIA. 
 
 in wHch she had recourse to turning in transverse presentation, 
 eleven of the infants were born dead, or 1 in every 5J. Her deli- 
 veries by the forceps were fatal to the children in the proportion of 
 1 in 6 ; her deliveries by turning were fatal also in a similar propor- 
 tion, namely, about 1 in SJ. Of ninety-six forceps cases occurring 
 in the practice of Madame Boivin,^ in twenty the children were 
 born dead, or 1 in every 5 of them was lost. In sixty-two cases in 
 which she resorted to turning in transverse presentations, seven of 
 the infants were still-born, or about 1 in 9 was lost. 
 
 To obtain with more certainty the general comparative average 
 mortality of forceps cases and cases of turning in transverse pre- 
 sentation, let lis combine the data above given from the practice of 
 Collins, Lee, Lachapelle, and Boivin. 
 
 The following table exhibits in an abridged and simplified form, 
 the results of this collection of cases : 
 
 TABLE VII. 
 
 Comparative Mortality of Children in Cases of Delivery by the Forceps, and by Turning in 
 Transverse Presentation, in the Practice of Collins, Lee, Lachapelle, and Boivin. 
 
 Mode of Delivery. 
 
 No. of 
 Cases. 
 
 No. of 
 Children 
 Stillborn. 
 
 Proportion of 
 Still-born Children. 
 
 Forceps cases, 
 Turning in transverse ) 
 presentation, 5 
 
 255 
 ■194 
 
 74 
 58 
 
 1 in every 3 died. 
 1 in every 3J died. 
 
 Arrangements and Means by which Compression of the Cord, and its 
 Effects, may be averted. — Dr. Radford believes that when the child is 
 extracted by turning on account of distortion of the maternal pelvis, 
 the danger of fatal compression of the umbilical cord is then greatly 
 increased by the fact of the distortion. But the common variety of 
 contracted pelvis requiring turning is (as I have already stated, and 
 shall insist more upon afterwards), the peculiar and common kidney- 
 shaped distortion of the pelvic brim, which is produced by the 
 anterior prominence and proj ection of the sacral promontory. When 
 the foetal head enters it, as it does under extraction by turning, with 
 its long, or occipito-frontal diameter lying in the transverse diameter 
 of the brim, then we have (see Fig. 30, page 463), a free space left, 
 of greater or less size, between the face or forehead of the child, and 
 the ilium to which it looks. In this space sufficient room may 
 certainly, in general, be found for the free lodgment of the cord 
 without injurious compression. The very narrowness of the conju- 
 gate diameter of the brim prevents this space from being entirely 
 
 ' Memorial de I'Ait des Accouchemens, Table, p. 464. 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 503 
 
 filled up and encroaclied upon, by preventing the great mass and 
 breadth of the head, from the coronal suture backwards, from further 
 passing over to this partially occupied side of the pelvis. Besides, 
 this uncompressed lateral space is the very site along or near which 
 the cord necessarily passes in descending from the uterus, and 
 stretching between the placenta and umbilicus. For the anterior 
 surface of the abdomen of the child, to which the lower end of the 
 cord is attached, always, of course, looks to that side of the pelvis to 
 which the face is directed ; and it is on that side that we have the 
 free and uncompressed space I speak of, as fitted for the safe transit 
 and lodgment of the cord. In thus stating the space as free and 
 uncompressed, I mean in so far as the adjoining opposite surfaces 
 of the child's head and interior of the pelvis are concerned. The 
 space itself may be filled up, or the cord in it pressed upon by the 
 circle of the cervix uteri or other soft parts, but, certainly, a little 
 adjustment and management may often prevent any fatal compres- 
 sion from these sources ; for the cord may be carried round by the 
 accoucheur to that point in which there appears the greatest space, 
 and consequently the greatest freedom from compression ; and he 
 may sometimes defend it from the pressure of the cervix by allow- 
 ing it to pass between two fingers, introduced either for the sole 
 purpose of protecting it, or with the view of simultaneously assisting 
 the extraction of the head by applying some force to the cheeks or 
 lower jaw. In both natural and artificial footling presentations it 
 has even been proposed to defend the cord more methodically, by 
 shielding and enveloping it at the part liable to compression in a 
 kind of special protecting instrument. Dr. Joos of Schaff'hausen 
 has ingeniously proposed an instrument for this purpose.' It con- 
 sists of a tube, from four to eight inches in length, and of calibre 
 sufficient to contain the umbilical cord, leaving a longitudinal slit 
 or fissure equal to ^jth of its circumference. It is composed of 
 caoutchouc or leather, in which are embedded a series of steel rings 
 three lines broad, and at the distance of one line from each other. 
 The slit is opened up at one end by the finger, so as to admit the 
 umbilical cord, and in the same manner it is made to receive it 
 along its whole length, the fissure closing up as the finger is removed. 
 A handle may be required subsequently, to keep the instrument in 
 its proper place. " The application of the instrument," says Dr. 
 Joos, " takes place during the act of birth, by presentation of the 
 breech or feet, in cases where delivery is efi"ected by version and 
 bringing down the feet, and in cases where the cord is prolapsed 
 and cannot be returned." But I greatly doubt whether, even if we 
 
 ' Medical Gazette, Oct. 22, 1847. 
 
50 i DYSTOCIA. 
 
 were provided with such an instrument as Dr. Joes describes, we 
 should not find the difficulties of applying it, and the time required 
 for that purpose, more dangerous to the infant than the extraction 
 of the child's head by more simple and direct means. It is always 
 well to avoid instruments when we can avoid them ; and such a one 
 as the present might not be used without some danger to the struc- 
 tures of the OS uteri. 
 
 Suppose, however, that the means we used to avoid compression 
 of the cord, by placing it in the least occupied point at the brim, or 
 by preventing the soft parts from pressing upon it, by the fingers, or 
 otherwise, were in vain, and that at last it really became irretrieva- 
 bly compressed, and its pulsations arrested before the head could 
 possibly be extracted, is the safety of the child utterly hopeless ? I 
 believe not. Long ago, Pugh and Morlanne recommended a prac- 
 tice that has been latterly followed by Bigelow and others, and which 
 I believe, is calculated in some instances to enable us to continue 
 the life of the child, by continuing its respiratory function, whilst 
 we go on exerting from time to time, those cautious yet decided 
 means, which we have seen Dr.Denman recommending, for efiecting 
 the complete extraction of the obstructed head. The means to which 
 I allude consist in exciting pulmonary respiration in the half-born 
 child, now that its placental respiration is stopped, and in making 
 it continue that vital process by the action of the lungs, now that 
 it is prevented from being exercised by the medium of the placenta 
 and umbilical cord. " When the parts are well made," says Pugh,' 
 " and the child in proportion, happy the case ! It will come 
 then any way ; the arms being brought down, the head only remains 
 to be extracted, which must be done with as much expedition as 
 possible, as indeed the arms ought to be ; for, consider, when the 
 child has passed the navel, the circulation between it and the mother 
 is stopped from the pressure of the umbilical rope ; you must then 
 introduce the fingers of your left hand into the vagina, under the 
 child's breast, and put the first and second fingers into the child's 
 mouth pretty far ; so far, however, that you are able to press down 
 the child's tongue in such a manner, that by keeping your hand 
 hollow, and pressing it upon the mother's rectum, the air may have 
 access to the larynx ; you will soon perceive the thorax expand, as 
 the air gets into the lungs. By this method," he adds, " of giving the 
 child air, 1 have saved great numbers of children's lives which otherwise 
 must have died." 
 
 Acting on the plan thus suggested by Pugh, we may in some 
 cases be able, with a little management, to change thus the respira- 
 tion of the infant from its intra-uterine to its extra-uterine type 
 
 ' Treatise on Midwifery, 1754, p. 49. 
 
TUKNING AS A SXJBSTITTJTB FOK CEANIOTOMT, 505 
 
 thougli the head be still held and arrested at the brim ; for the 
 mouth of the infant is always then within reach, and could I believe 
 be used for the purpose of admitting a proper quantity of air into 
 thfe pi^monary passages, even when the great bulk of the head is 
 still held above the brim. It is a practice, at all events, which some- 
 times succeeds sufficiently well when the head is down in the pelvis, 
 and we have all the difficulties of a rigid outlet and perineum to con- 
 tend against, in our attempts either to extract the head, or to admit 
 a sufficiently free access of air to the mouth of the foetus. The two 
 following cases which I extract from Dr. Lee's " Clinical Midwifery," 
 will illustrate and impress the practice and the remarks upon it, 
 which I have just made : 
 
 Case XXX II. — The nates presenting, the trunk and extremities 
 were extracted, " but the head could not be drawn through the ex- 
 ternal parts, from the rigid state of the perineum, and the pulsa- 
 tions of the cord were becoming more and more feeble. So great 
 was the resistance of the perineum, that it was impossible to over- 
 come it without destroying the child. I pressed back its edge, how- 
 ever, so far, that the external air could enter the mouth of the child 
 and it respired in this way fully twenty minutes after the pulsations 
 of the cord had ceased. In spite of all our care the edge of the 
 perineum gave way as the bulky part of the head passed through 
 the external parts, but the child sustained no injury, and continued 
 to live.'" 
 
 Case XX X TTI. — " I attended a lady in her first labor, on the 22d 
 of October, 1837. The nates presented, and the cord ceased to pul- 
 sate after the trunk and extremities of the child had been extracted. 
 The perineum was so rigid, that the head could not have been de- 
 livered without using so much force, that the parts must have been 
 torn, and the neck of the child injured. I held the body of the child 
 as far forward as possible, while Dr. H. Davies assisted me in holding 
 back the perineum, that the air might enter the mouth of the child. 
 The respiration went on for nearly half an hour before the head 
 could be safely drawn into the world, and during the whole of the 
 time there was no pulsation in the cord. The child is alive, and the 
 perineum was not injured."'' 
 
 The child may not only be able to breathe, but even heard to cry, 
 with the head stiU unborn, when this form of treatment is adopted. 
 In his paper on the subject, published in the American Journal of 
 Medical Sciences for 1829, Professor Bigelow (of Boston) states, 
 amongst others, the following case : 
 
 ' Clinical Midwifery, Case 239, p. 129. ' Ibid. Case 241, p. 131. 
 
506 DYSTOCIA. 
 
 Case XXXIV.— In a case of arm presentation, in which the feet 
 were brought down, and the body delivered, "the face turned 
 towards the perineum, the mouth was easily reached, and the fingers 
 were opened to give passage to the air as before described. JSTo 
 struggle nor attempt at respiration however occurred. A handful 
 of cold water was then dashed upon the body, upon which the child 
 immediately gave a spring, and began to cry. The head was not 
 delivered till some minutes afterwards."' 
 
 In his observations and directions upon this modification of prac- 
 tice, Dr. Bigelow observes : " After the body is expelled, if the 
 head can be seasonably delivered, either by the recurrence of pains, 
 or by the successful efforts of the practitioner, no difficulty ordinarily 
 occurs. But this desirable state of things cannot always be realized ; 
 too frequently the size of the head, and the resistance of the pelvis 
 or soft parts, renders the delivery difficult or hazardous, and the 
 practitioner, in the midst of his efforts, is apprised by a convulsive 
 jerk, or spring of the body, that a state of extreme danger exists, 
 and that the time has come at which the child must breathe, or will 
 speedily die. If at this period the fingers be introduced, so as to 
 reach the mouth of the child, it will be perceived that each jerk of 
 the body is attended with a gasp, and convulsive effort at inspiration, 
 performed by the mouth and chest of the child. In this state of 
 things, if air be conveyed to the mouth of the child, it will im- 
 mediately breathe, and the efforts of nature, as will hereafter be 
 shown, may, in most cases, be safely waited for to assist in expelhng 
 the head. "2 
 
 " The method to be pursued," he continues, " in conveying air to 
 the mouth, depends upon the situation of the head. If the chin has 
 descended low in the pelvis, so that the mouth rests upon the 
 perineum, or lower part of the sacrum, and can be readily reached 
 by the fingers, the hand of the operator alone is sufficient to give 
 the assistance required. But if the mouth is situated so high in the 
 pelvis as to be reached with difficulty, or if, from the large relative 
 size of the head, there is much compression, the assistance of a tube 
 may be of use. The mode of proceeding which I have found suc- 
 cessful in various instances is as follows : As soon as the body and 
 arms are extracted, supposing the face towards the sacrum, an as- 
 sistant supports the body, carrying it towards the pubis ; or the 
 reverse, should the position of the face be to the pubis. The ac- 
 coucheur should then introduce the hand to which the face looks, 
 till the middle fingers rest upon the mouth of the child ; the hand 
 is then to be raised from the throat of the child, making the ends 
 of the fingers a fulcrum, and pushing the perineum baclcwards ; the 
 
 ' American Journal of Med. Science, Aug. 1829, p. 288, Case 3. ^ Ibid. p. 285. 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 507 
 
 air will thus pass upwards as far as the chin of the child ; the middle 
 fingers are now to be separated about half an inch from each other, 
 and thus a complete passage will be formed between them, by which 
 the air will reach the mouth of the child. If the child be in a healthy- 
 state up to this period, it will immediately breathe and cry, and the 
 delivery of the head may be safely postponed till the natural pains 
 recur. If, from any degree of asphyxia, the child does not im- 
 mediately breathe, it may often be made to do so by dashing cold 
 water upon the body, or by other stimulating processes. It has 
 even appeared to me practicable to inflate the lungs, in some cases, 
 through an elastic catheter. When the mouth is so high in the 
 pelvis as to be reached with difliculty, or when the compression is 
 so great as to obliterate the cavity between the fingers, a fiat tube 
 will be found useful, made of metal, of spiral wire covered with 
 leather, or of elastic gum, and having its largest diameter about 
 half an inch. If the tube be of metal, or of any incompressible 
 material, it should be withdrawn during a pain, to prevent contusion 
 of the soft parts, and immediately replaced if the pain subsides 
 without expelling the head. Such a tube may be considered as a 
 prolongation of the trachea, and is fully sufiicient to sustain life by 
 respiration for a considerable time. The tube must be guarded and 
 directed by keeping it between the fingers of the inserted hand." 
 In addition to the above remarks on the possible means of pre- 
 venting fatal compression of the umbilical cord, there is one obser- 
 vation more which I am anxious to make. If all the preceding 
 measures fail to avert compression, there is always still one strong 
 hope left, namely, that if after complete compression of the um- 
 bilical vessels has occurred, no very great length of time is lost in 
 the extraction of the head, the child may yet be born alive. For 
 the type of vitality in the unborn infant is such that it will often 
 survive, and be capable of being resuscitated, although the placental 
 respiration be ai-rested for several minutes before its actual birth. 
 And with others, I have been repeatedly surprised, in such cases as 
 we are considering, both at the great amount of extractive force 
 which the structures of the infant will sometimes undergo without 
 life being destroyed, and at the apparently great length of time 
 during which, in making these extractive exertions, the infant will 
 still survive, and that too, although the cord was compressed during 
 their continuance. If the infant be perfectly viable, and its heart 
 sounding normally at the time that turning is adopted, there are 
 perhaps comparatively few cases in which it will be requisite to 
 expend so much time upon the forcible compression and extraction 
 of the head, as to destroy during that time the child's life by simple 
 compression of the cord alone. The following case, which occurred 
 
508 DYSTOCIA. 
 
 within tlie last few days, may perhaps impress this remark. In it 
 the foetal heart continued to beat regularly, not only after the cord 
 was compressed for a considerable time, during which very strong 
 exertions were made in order to extract a large and very firm head 
 through a pelvis three inches in its antero-posterior diameter, but 
 its pulsations went on for several minutes, even after the head was 
 perforated, an operation that required some time for its performance, 
 and after the cervical spine had yielded under the traction applied. 
 
 Case XX X V . — ^With Drs. Ziegler and "Weir, I delivered at the 
 Maternity Hospital, on April 17th, a woman aged 19, in labor with 
 her first child. The os uteri was fully dilated, and the child's head 
 had remained at the brim during nearly ten hours of active labor- 
 pains. The parietal bones were riding over each other at the sagittal 
 suture, and the right parietal bone was somewhat indented by the 
 sacrum, upon which it rested. The conjugate diameter measured 
 about three inches. A very deep dose of chloroform was given. 
 Turning was effected, and the body of the child delivered. Strong 
 traction was applied in vain to bring the head through the contracted 
 brim, and at last the bones of the neck threatened to give way. The 
 cranium was then perforated behind the ear, and by the aid of a 
 crotchet in the mouth the delivery was completed. The child did 
 not breathe, but the pulsations of its heart went on regularly for 
 several minutes after delivery. The child weighed upwards of seven 
 pounds. It measured twenty-one inches in length. Its head was 
 large and firmly ossified. 
 
 CONCLTJDING REMARKS REGARDING THE OBJECTIONS TO THE PROPOSED 
 PRACTICE FOUNDED ON THE ALLEGED DANGER AND DEATH OF THE 
 CHILD. 
 
 In terminating the present section of our subject, I would again 
 repeat in regard to the whole, the argument which I have used 
 against the alleged fatality of the individual sources of danger that 
 we have inquired into. It has been averred that under the proposed 
 practice of turning in distorted and contracted pelvis, the injury 
 which the foetal head must sustain would be fatal to the child — the 
 injuiy of the neck would be fatal to it — the injury of the cord would 
 be fatal to it. I have shown the principal fallacies to which these 
 arguments are individually liable. Against the truth of the whole in 
 a combined form, I would here again simply and strongly appeal to 
 the evidence of facts and experience. For the results of the cases 
 of the practice that I have given, and of others that I may yet have 
 occasion to give, amply attest thai in various instances in which it 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 509 
 
 has been adopted, the indentation and depression of the skull of the 
 infant were not fatal to it, nor was the traction of the neck fatal to it, 
 nor the pressure upon its funis. It was submitted to one and all of 
 these sources of supposed danger and death, and yet escaped alive 
 from all. And having done so when the principles and details of the 
 practice were not at all understood, may we not expect still happier 
 and more successful results when these principles and details come 
 to be better comprehended, and more systematically acted upon ? 
 
 I have heard turning objected to by some, in arrestment of the 
 head at the brim, on the ground of its inevitably occasional, or 
 rather frequent, fatality to the child. But when we have any new 
 operation proposed, with the view of replacing other operations, 
 such as turning in distorted pelvis, instead of delivery by the long 
 forceps or craniotomy, we can only properly judge of the real and 
 relative value of the new operation, not by looking at its own abso- 
 lute and isolated results, but by looking at its results as compared 
 with the results of those other operative measures for which it is 
 suggested as an alternative. Now, as regards the respective value 
 of turning, to the infant, in comparison with the two operations for 
 which I propose it as a substitute, the case is, of course, very different, 
 according as we contrast it, first, with the long forceps ; or, secondly, 
 with craniotomy. 
 
 "We have seen that the fatality to the child from the common 
 operation of turning in transverse and cephalic presentations, was, 
 in the Dublin and Parisian hospitals, nearly the same as the common 
 operation with the short forceps, or indeed was in favor of turning, 
 there having been in neither set of cases any very special state of 
 pelvic contraction ; and perhaps, if we had a^y adequate data, we 
 should find that the same analogy in their results held good whed 
 they were respectively applied under greater and increased degrees 
 of difficulty, as in morbid contractions of the pelvic brim, always, 
 however, with this important difference in favor of turning — ^that it 
 could be employed at a much earlier, and, consequently, as respects 
 both the mother and child, at a much safer period of the labor than 
 was fitted for the adoption of delivery by the long forceps ; and 
 always also, recollecting that the comparison of the results of turn- 
 ing, with the results of short forceps operations is imperfect in this 
 respect, that from the direction of the compression in long forceps 
 operations, viz., in the antero-posterior or oblique diameter of the 
 foetal head, the danger and mortality to the child is generally far 
 greater than when the short instruments merely are used, the direc- 
 tion of the compression with them being transverse. 
 
 But, delivery by the long forceps, under any conditions, is an 
 operation entirely rejected by many eminent accoucheurs, and very 
 
510 DYSTOCIA, 
 
 seldom indeed adopted in country practice. And I have already 
 often stated, but cannot, perhaps, too often repeat, that it is princi- 
 pally as a substitute and alternative for craniotomy in contracted 
 states of the pelvic brim, that I bring forward the operation of turn- 
 ing. l!fow, as far as regards the child, the results of these two 
 modes of delivery — craniotomy and turning — in this special and not 
 unfrequent set of cases, is easy of comparison and settlement. For 
 the very essence of the one operation, craniotomy, is the actual death 
 and instrumental destruction and mutilation of the child. The 
 object of the other operation, turning, is to offer the child, under 
 the very same circumstances, a chance of escape and of life. Cranio- 
 tomy implies the inevitable sacrifice of the infant. Turning im- 
 plies its possible safety and probable survival. And the distinction 
 between them which has latterly been always uppermost in my own 
 mind, is this — delivery by craniotomy consists in opening and 
 breaking down the skull so as thus to reduce it to such dimensions 
 as will allow it to pass through the contracted pelvic brim ; but the 
 operation which I propose to substitute for it, and by which the 
 requisite diminution of the foetal head may likewise be produced, 
 consists, not in fatal opening and emptying of the skull, but in com- 
 pressing, and, if necessary, depressing its flexible and elastic parietes ; 
 and further, I have shown that extraction by turning affords us the 
 means of effecting this compression and indentation without always 
 compromising the life of the infant. As far then as regards the 
 safety and life of the infant, I hold that any general comparison 
 between craniotomy and turning is altogether and entirely in favor 
 of the new practice. But how stands the comparison between the 
 effects of the two operations in relation to the safety and life of the 
 mother ? To answer this question a separate section is required. 
 
 Sect. "Viii. — Supposed Objections to the Practice in Eblation to 
 THE Life of the Mother.^ 
 
 In the last section, when treating of the effect upon the infant, of 
 the practice which I propose in distortions of the pelvis, I took 
 occasion to state, that the only proper test or measure of value 
 between a novel operative measure like this, and those operative 
 measures for which it is suggested as a substitute, consists in ascer- 
 taining, not the absolute mortality attendant upon the new opera- 
 tion alone, but the comparative mortality attendant upon the new 
 as compared with the other and older forms of treatment. In the 
 same way, in the present section, the question is not — what is the 
 absolute maternal mortality attendant upon delivery by turning in 
 
 ' From Provincial Medical and Surgical Journal, October, 1848, p. 533. 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 
 
 511 
 
 cases of contracted pelvis? but, what is the mortality attendant 
 upon that operation, as compared with the mortality accompanying 
 the alternative operations of delivery by the long forceps and by 
 craniotomy ? 
 
 In the records of midwifery, there do not yet exist, so far as I am 
 aware, any data by which it is possible to compute either the general 
 or relative mortality to the mother, from the use of the long forceps ? 
 ISTor can we obtain any satisfactory approximation to the probable 
 results of their employment upon the mother, by studying the mater- 
 nal mortality attendant upon the use of the short forceps. For the 
 short forceps are employed only in cases in which the head is already 
 sunk down into the pelvic cavity, and when the application of the 
 instrument is far less difficult, and its effects less dangerous, than 
 when the long forceps are had recourse to in consequence of the 
 child's head being arrested high up in the passages, from the 
 obstruction of a distorted pelvic brim. 
 
 It is principally, however, as an alternative for craniotomy that 
 we have to consider the propriety of turning ; and there exist nume- 
 rous data by which we may compare the relative mortality of these 
 two operations. On this and other points in the statistics of mid- 
 wifery, the laborious and valuable investigations of Dr. Churchill 
 have thrown much light. The following table, which I have drawn 
 up from Dr. Churchill's collection of data, shows us the general 
 relative mortality attendant upon craniotomy and turning, in so far 
 as regards the life of the mother, 
 
 TABLE VIII. 
 Showing the Results to the Mother in Craniotomy and Turning. 
 
 Operation. 
 
 Number of 
 Cases Collected. 
 
 Number of 
 Mothers Lost. 
 
 Proportion of 
 Motbers Lost. 
 
 Craniotomy, 
 Turning, 
 
 251 
 169 
 
 52 
 11 
 
 1 in 5. 
 
 1 in 15. 
 
 In some of these cases of turning, the deaths may, as Dr. Churchill 
 points out, have been owing to the cause which demanded the opera- 
 tion, such as placenta prsevia, and not owing to the operation itself; 
 but, I believe with him, that the resulting calculations are "not 
 very far from the truth. "^ 
 
 So far, such an imperfect estimate of the mere mortality of the 
 two operations gives a result highly in favor of turning. But there , 
 is another element which comes into action, and which is not in- 
 
 • Principles of the Practice of Midwifery, p. 245. 
 
612 DYSTOCIA. 
 
 eluded in the above comparison. Most of the turning cases were 
 instances in which the operation was performed in consequence of 
 the child presenting transversely, and with most of them com- 
 paratively little or no difficulty was probably encountered in getting 
 the head to pass the pelvic brim. In the class of cases in which it 
 is my object to recommend turning — ^viz., with the brim narrow and 
 distorted — ^would the operation, from its requiring the forcible ex- 
 traction and compression of the head, be attended with much in- 
 crease of peril to the mother ? 
 
 On such a question being first suggested, most accoucheurs, I 
 believe, would be inclined, d priori, to argue that the compression, 
 however transitory, of the soft tissues included in the maternal 
 pelvis, between the interior of the maternal pelvic bones and the 
 solid though elastic head of the infant, would be sure to be attended 
 with inevitable danger and evil consequences to the maternal struc- 
 tures ; that the practice would, in short, be, as Dr. Radford has ex- 
 pressed it, "incompatible with the safety of the mother." 
 
 Prejudgments, however, even in pathological and practical matters 
 of this description, are often wrong. Let us lay aside argument for 
 experience, and supposition for fact, and examine, quietly and with- 
 out prejudice, the actual and probable results of forced operative 
 extraction of the infant's head in cases of obstruction of the pelvic 
 brim. 
 
 Dr. Denman had evidently some experience of the forcible extrac- 
 tion of the infant's head through contracted pelves, in the preternatu- 
 ral presentations of the child. The rules of treatment, which I have 
 already quoted from his chapter " On the Complication of Breech 
 Cases with Distortion of the Pelvis," show how entirely, or almost 
 entirely, he trusted in these instances to the forced extraction of the 
 head, and how very rarely, if ever, he had occasion to assist the 
 delivery by craniotomy. And he states the results of all his observa- 
 tions in these instances, in terms most significant of its safety. 
 " Nor have I ever known," says he, " any ill consequences follow the 
 compression, which the soft parts of the mother undergo, between 
 the head of the child and the sides of the pelvis, if proper attention 
 were paid to the state of the bladder and rectum."' 
 
 The cases I have cited from Dr. Denman, and others adduced 
 in the preceding sections, so far afford corroborative evidence of this 
 important remark. Altogether, I have already referred to twelve 
 or thirteen cases, in which the force of extraction or expulsion was so 
 great, that the head was not only compressed but indented. In 
 none of these does the mother seem to have suffered from the com- 
 pression or contusion. But these cases, it may be argued, are too 
 
 ' Practice of Midwifery, 1816, p. 469. 
 
TURNING AS A SUBSTITTJTB FOR CRANIOTOMY. 513 
 
 few to entitle us to speak over positively on the point. Let us turn 
 then, to others. 
 
 It often enough happens, among cases of pelvic distortion, 
 that when the head of the child presents, and becomes obstructed at 
 the brim, the mere perforation of the head, or first part of the ope- 
 ration of craniotomy, is not adequate to allow the operator to over- 
 come, with subsequent ease, all the resistance of the obstacle oppos- 
 ing delivery. In many cases, the second or succeeding part of the 
 operation of craniotomy, viz., the extraction of the head with the 
 crotchet, through the contracted and obstructing brim, is still 
 attended with difficulty, and requires for its completion more or less 
 prolonged exertion by pulling and force. Under such circumstances, 
 and though the child presents by the head and not by the feet, we 
 have exactly the same form of danger threatening the soft structures 
 of the maternal pelvis, as if the excessive traction were made, not 
 in craniotomy, but in turning. The two cases agree in this one 
 common condition, that in both, an exertion of traction and force is 
 required to pull the obstructed head through the contratoted pelvic 
 brim ; and in both, the soft tissues lining the pelvis of the mother 
 are equally liable to be contused and compressed, under this traction 
 and force. 
 
 Now, in cases of craniotomy, such as I here allude to, and which 
 require the operator to use great exertions in dragging the head 
 with the crotchet through the obstructing brim, is the mortality to 
 the mother much increased above what it is in the common run of 
 craniotomy cases? Or, to state the question in other terms, are 
 such cases of craniotomy decidedly more dangerous and fatal than 
 other cases of the same operation, in which such excess of traction 
 is not required ? 
 
 Dr. Lee's " Clinical Midwifery" presents us vsdth a series of data 
 relative to craniotomy operations, that may enable us to arrive at 
 some accuracy of information regarding this question. In the first 
 and second Reports of his work. Dr. Lee details eighty-seven cases 
 of craniotomy. Table IX. gives a condensed view of the principal 
 facts and results connected with these eighty-seven cases. 
 
 33 
 
514 
 
 DYSTOCIA. 
 
 TABLE 
 Analysis of SI Cases of Craniotomy, recorded by Dr. Lee, 
 
 i 
 
 4 
 
 B 
 
 Cause of Obstruction and Delay. 
 
 
 Length of Labor before 
 Operation. 
 
 1 
 
 2 
 
 1 
 
 2 
 
 Rigid OS uteri ; vagina swollen and tender, . 
 Head never through brim — convulsions, 
 
 1 
 1 
 
 Three days and nights, 
 fifty hours, .... 
 
 3 
 
 4 
 
 
 
 
 4 
 
 5 
 
 Head not passed brim. Os uteri half dilated, 
 
 2 
 
 Two days (48 hours), 
 
 5 
 6 
 7 
 
 " 8 
 8 
 8 
 
 Head not passed brim, 
 
 Scalp tumid ; bones riding 
 
 Head wedged in brim 
 
 1 
 2 
 3 
 
 Nearly 60 hours, . . 
 Strong, above 30 hours, 
 
 8 
 
 9 
 
 Impacted in brim, 
 
 
 
 9 
 
 16 
 
 Not through brim. Os uteri rigid, not fully 
 dilated. 
 
 1 
 
 About 50 hours, . . 
 
 10 
 
 17 
 
 Head low but riot through the pelvis ; ante- 
 rior lip of uterus locked ; labia swollen. 
 
 1 
 
 About 48 hours, . . 
 
 11 
 
 25 
 
 Head and arm jammed in brim 
 
 2 
 
 Above 30 hours, . . 
 
 12 
 13 
 
 29 
 30 
 
 The greater part of the head had passed 
 
 through the brim. 
 Great part of the head still above brim, . . 
 
 1 
 
 Forty-six hours, . . 
 Above 20 hours, . . 
 
 14 
 
 31 
 
 Head not completely in the cavity of pelvis, 
 
 
 
 15 
 16 
 
 17 
 
 32 
 
 34 
 
 35 
 
 Head so low that the ear could be felt, . . 
 Head sufficiently low for the forceps, . . . 
 
 Head filled the cavity of the pelvis, . . . 
 
 1 
 
 1 
 
 1 
 
 Above 72 hours, . . 
 
 So long that she was 
 
 quite exhausted, . 
 
 Above 41 hours, . . 
 
 18 
 
 38 
 
 Cavity of the pelvis occupied by a tumor 
 the size of a cricket ball, or larger. 
 
 
 Twenty-four hours, . 
 
 19 
 20 
 
 39 
 40 
 
 Os uteri not fully dilated, thick and rigid, 
 and pressed down with the head through 
 the brim of the pelvis. 
 
 Head firmly impacted in brim of the pelvis. 
 
 1 
 
 1 
 
 Above 50 hours, . . 
 Above 30 hours, . . 
 
 21 
 22 
 23 
 
 41 
 
 42 
 43 
 
 Distortion of pelvis, and hard cicatrix of vagina. 
 
 Head jammed in the brim, 
 
 Head within reach of forceps, 
 
 
 
 1 
 
 1 
 
 Long in labor, . . 
 
 24 
 
 56 
 
 Pelvis distorted, 
 
 1 
 
 Sixty-seven hours, . 
 
 Above 48 hours, . . 
 Seventy-two hours, . 
 
 Forty hours, . . . 
 Thirty-six hours, . . 
 
 25 
 26 
 
 57 
 58 
 
 Face presentation, 
 
 
 Head and arm, 
 
 1 
 
 27 
 28 
 
 59 
 60 
 
 Head long fixed in the brim, 
 
 Head many hours impacted in the brim; 
 vagina swollen and tender. 
 
 3 
 1 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 
 
 515 
 
 IX. 
 
 in the First and Second Reports of his " Clinical Midwifery.' 
 
 Difficulty or not in 
 Extraction. 
 
 Death or 
 
 Recovery of 
 
 Mother. 
 
 Other Results, 
 Inflammation, Sloughing, 
 
 Remarks. 
 
 Not stated, . . . 
 Not stated, . . . 
 
 Required IJ hours, 
 bones of head, 
 &c., much torn. 
 
 Great difficulty. 
 
 Long cont'd efforts, 
 Little difficulty, 
 Not stated, . . . 
 
 Strong efforts, . 
 Force required, 
 
 Not, except in 
 overcoming peri- 
 rineum. 
 
 With difficulty, . . 
 
 Not stated, . . . 
 
 Great force, . . . 
 
 Great force, . . . 
 Tedious & difficult. 
 
 Not without much 
 
 difficulty. 
 Much difficulty, . 
 
 Difficult, . . . . 
 
 Difficult 
 
 Not stated, . . . 
 
 Not stated, . . . 
 
 Not stated, . . . 
 
 Tedious & difficult. 
 
 Not stated, . . . 
 
 Not stated, . . . 
 
 Difficult, . . . . 
 
 Not difficult, . . 
 
 Recovery, 
 Recovery, 
 
 Recovery, 
 
 Recovery, 
 
 Recovery, 
 Recovery. 
 Death, . . 
 
 Death, . . 
 Recovery, 
 
 Recovery, 
 
 Recovery, 
 
 Recovery, 
 
 Recovery, 
 
 Recovery, 
 
 Recovery, 
 Not stated, 
 
 Recovery, 
 
 Recovery, 
 
 Not stated. 
 
 Recovery, 
 
 Recovery. 
 Recovery, 
 Death, . . 
 
 Recovery, 
 
 Recovery, 
 Recovery, 
 
 Recovery. 
 Recovery. 
 
 Sloughing; fistula, . 
 Violent inflammation 
 
 of uterus, 
 Post-partum liemor- 
 
 rhage. 
 
 Slight uterine inflam- 
 mation. 
 
 Inflammation and 
 sloughing of va- 
 gina and cicatrix. 
 
 No bad effect, . . 
 
 Perineum torn by 
 shoulders of infant. 
 
 Retention of urine; 
 violent inflamma- 
 tion of vagina; fever. 
 
 Slight uterine in- 
 flammation. 
 
 Hemorrhage, . . . 
 
 Severe inflammation 
 of uterus, 
 
 Long forceps tried first. 
 Long forceps tried first. 
 
 Tried first to apply forceps. 
 
 Tried first to apply forceps ; 
 
 craniotomy in former 
 
 labor. 
 Recovered rapidly. 
 
 Ergot and repeated efforts 
 with forceps tried previ- 
 ously. 
 
 Forceps tried first; vagina 
 enormously swollen. 
 
 Not able to apply the forceps. 
 No bad consequences fol- 
 lowed. 
 
 Delivered of first child by 
 
 forceps. 
 Forceps tried first. 
 
 Forceps tried first ; delivered 
 since without assistance. 
 
 Forceps tried first, A face 
 presentation. 
 
 Forceps tried first. 
 
 Forceps tried first. 
 
 Forceps tried first. 
 
 Forceps tried first. Next 
 child delivered naturally 
 at full period. 
 
 Not able to apply the forceps. 
 
 Not able to apply the forceps. 
 Convulsions. Forceps tried 
 first. 
 
 Face presentation. 
 
 Many efforts made at turning. 
 
516 
 
 DYSTOCIA. 
 
 g^ 
 
 Cause of Obstruction and Delay. 
 
 Length of Labor before 
 Operation. 
 
 29 
 30 
 
 31 
 32 
 
 33 
 34 
 35 
 
 36 
 37 
 38 
 
 39 
 40 
 41 
 
 42 
 43 
 44 
 
 45 
 
 47 
 48 
 
 49 
 
 50 
 51 
 52 
 
 53 
 54 
 
 55 
 
 56 
 57 
 
 61 
 62 
 
 63 
 64 
 
 65 
 66 
 67 
 
 68 
 69 
 70 
 
 71 
 72 
 73 
 
 74 
 75 
 76 
 
 77 
 
 78 
 
 79 
 80 
 
 85 
 
 87 
 
 Head in the pelvis, and an ear felt, 
 Os uteri rigid and partially dilated. 
 
 compressed in the brim. 
 Head fixed in the brim, . . . 
 
 Head of child passed into the pelvis. 
 
 swollen to the size of a child's head. 
 Great distortion of the pelvis, . . . . 
 Head fixed in the brim ; pelvis small, . 
 Head above the brim 
 
 Head 
 
 Labia 
 
 Small pelvis ; os uteri rigid, 
 Great sv?elling of soft parts. 
 
 Os uteri half dilated, . 
 
 Distortion of pelvis, 
 
 Head half through brim 
 
 Distortion of pelvis ; head not in the cavity of 
 
 pelvis. 
 Head scarcely entered the brim, 
 
 Head firmly compressed betvreen sacrum and 
 pubis. 
 
 Distortion of pelvis ; head in the brim, . . 
 
 Distortion of pelvis ; head above the brim, . 
 
 Distortion of pelvis ; greater part of head still 
 
 above brim. 
 Head firmly jammed in the pelvis, . . . 
 Head fixed in the brim. 
 
 Tvi^enty-four hours. 
 Seventy-two hours, 
 
 Above 24 hours, . . 
 
 First stage very pro- 
 tracted, 
 
 Thirty-six hours, . . 
 
 Forty-eight hours, . . 
 
 Great protraction 
 (above 24 hours). 
 
 Forty-six hours, . . . 
 
 About 72 hours, . . . 
 
 Head firmly fixed in the brim, 10 
 
 Contraction of pelvis. 
 
 Distorted by rickets ; head above the brim, 
 
 Head firmly impacted in the pelvis, . . . 
 
 Head so low in pelvis that an ear was felt ; 
 
 closely surrounded by the inflamed vagina. 
 
 Twenty-four hours, 
 
 Above 12 hours, . . 
 
 After great protraction. 
 
 Above 30 hours, . . 
 
 About 72 hours, . . . 
 
 About 48 hours, . . . 
 
 Forty-eight hours, . . 
 
 Above 48 hours, . . 
 
 Thirty-six hours, . . 
 
 Above 48 hours, 
 
 Above 15 hours, 
 Above 6 days, . 
 About 24 hours, 
 
 About 30 hours. 
 
 Nearly 60 hours. 
 
 Forty-eight hours, . 
 Seventy-two hours, . 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 
 
 517 
 
 Difficulty or not in 
 Extraction. 
 
 Death or 
 
 Recovery of 
 
 Mother. 
 
 Other Results. 
 Inflammation, Sloughing, 
 
 Remabes. 
 
 Not stated, 
 Not stated, 
 
 Not stated, 
 Not stated, 
 
 Not stated. 
 Great force. 
 Not stated. 
 
 Not stated. 
 Not stated. 
 Not stated, 
 
 Not stated, . . . 
 
 Not stated, . 
 
 Without much dif- 
 ficulty. 
 
 Not stated, . . . 
 
 Not stated, . . . 
 
 Great force, . . . 
 
 Difficult 
 
 Great force, . . . 
 
 Not stated, . . . 
 Slowly, . . . . 
 
 Difficulty,. . . . 
 
 Easily 
 
 Readily, . . 
 Difficulty, . . . 
 
 Easily, . . . . 
 Extreme difficulty. 
 
 Delivered by turn- 
 ing. 
 
 Great force, . . 
 Some difficulty, . 
 
 Recovery, 
 Death, . . 
 
 Recovery. 
 Death, . . 
 
 Recovery. 
 Recovery, 
 Recovery. 
 
 Recovery. 
 Recovery, 
 Recovery, 
 
 Recovery, 
 Recovery, 
 Death, . . 
 
 Recovery. 
 Recovery, 
 Recovery, 
 
 Recovery, 
 
 Recovery, 
 
 Recovery, 
 Recovery, 
 
 Recovery, 
 
 Recovery, 
 Recovery. 
 Recovery, 
 
 Recovery, ■ 
 Recovery, 
 
 Recovery, 
 
 Recovery. 
 Recovery, 
 
 Great inflammation 
 and sloughing. 
 
 Gangrene of vagina 
 and external parts. 
 
 Uterine inflammation. 
 
 Retention of Urine ; 
 sloughing of va- 
 gina; vesico- vagi- 
 nal fistula. 
 
 Sloughing ; vesico- 
 vaginal fistula. 
 
 Uterine inflammation. 
 
 Retention of urine ; 
 violent inflamma- 
 tion and slough- 
 ing ; cicatrix left 
 in vagina. 
 
 Veotis and forceps tried first. 
 
 Not able to apply the forceps. 
 
 First tried forceps. Twins. 
 Violent puerperal convul- 
 sions. 
 Placenta prsevia. 
 Puerperal convulsions. 
 Rupture of uterus. 
 
 Retained placenta. 
 
 Soft parts must have been 
 severely contused. 
 
 Delivered by craniotomy be- 
 fore. 
 
 Right parietal bone of the 
 child depressed and frac- 
 tured. 
 
 First child delivered by cra- 
 niotomy. 
 
 The operation lasted two 
 hours, and the bones of 
 the skull were all torn to 
 pieces before the head 
 could be extracted. 
 
 Next child delivered without 
 aid. Thebreechpresented. 
 
 Convulsions occurred. 
 
 A dwarf The operation 
 lasted nearly five hours, and 
 the head of the fcetus could 
 not be drawn through the 
 brim of the pelvis, until the 
 bones of the base of the 
 skull were all torn to 
 pieces. 
 
 Turning resorted to in con- 
 sequence of an arm having 
 been brought down by the 
 crotchet. 
 
518 
 
 DYSTOCIA. 
 
 
 
 Cause of Obstruction and Delay. 
 
 Iiength of Labor befon 
 Operation. 
 
 58 
 
 59 
 
 90 
 
 92 
 
 93 
 94 
 95 
 96 
 
 97 
 
 98 
 
 99 
 
 100 
 
 101 
 
 102 
 103 
 
 104 
 105 
 
 106 
 
 107 
 
 108 
 109 
 111 
 
 112 
 113 
 114 
 
 82 
 
 115 
 
 83 
 
 116 
 
 84 
 
 117 
 
 85 
 
 118 
 
 86 
 
 119 
 
 87 
 
 120 
 
 Head at the external parts, . 
 
 Seventy-two hours, 
 
 91 Pelvis distorted ; head in the brim. 
 
 Part of the head above the brim ; os uteri 
 partially dilated. 
 
 Head wedged in the brim, 
 
 Greater part of head above the brim, . . . 
 
 Head squeezed in the brim, 
 
 Head firmly impacted in the brim 
 
 Head jammed in brim ; distortion of pelvis. 
 
 Head far advanced into the pelvis; vagina 
 swollen. 
 Head compressed in brim ; os uteri partially 
 
 dilated. 
 Head has scarcely entered the brim ; os uteri 
 
 rigid and not half dilated. 
 Head deep in the pelvis, great swelling of the 
 
 vagina, &o. 
 Os uteri partially dilated j head above brim, . 
 Head and right arm presenting ; os uteri half 
 ■ dilated. 
 
 Head fixed in brim ; vagina swollen and tender. 
 Head strongly compressed in the brim; os 
 
 uteri not fully dilated. 
 Soft parts immensely swollen, 
 
 Head firmly wedged in the brim; vagina 
 swollen and tender. 
 
 Head not passed brim, 
 
 Head impacted in the brim, 
 
 Distortion of the pelvis; head compressed in 
 
 the pelvis. 
 Distortion of the pelvis ; head not in brim, . 
 Distortion of the pelvis ; head above brim, . 
 Head above the brim ; os uteri not completely 
 dilated. 
 
 Greater part of the head above the brim, . . 
 The head would not pass till perforated, being 
 
 distended with fluid. 
 Head above brim, and distended with fluid, . 
 Head above brim, and distended with fluid, . 
 
 Head distended with fluid, , 
 Head distended with fluid, , 
 
 Very protracted, . 
 
 Very tedious, . . 
 Fifty hours, . . 
 Forty-eight hours. 
 Seventy-two hours. 
 
 Fifty-three hours, 
 Seveuty-two hours. 
 Thirty-eight hours. 
 Thirty-seven hours. 
 Forty hours, . . 
 
 About 72 hours, . 
 Above 30 hours, . 
 
 Very protracted, . 
 
 Above 78 hours, . 
 
 Forty-eight hours. 
 Forty-one hours, . 
 Eighty-six hours, . 
 
 About 48 hours, . 
 Above 62 hours, . 
 Above 78 hours, . 
 
 Above 53 hours, , 
 
 Nearly 60 hours, , 
 Long in labor. 
 
 Above 21 hours. 
 
TUKNING AS A SUBSTITUTE FOR CRANIOTOMY, 
 
 519 
 
 Difficulty or not in 
 KxtraAtiou. 
 
 Death or 
 
 Recovery of 
 
 Mother. 
 
 Other Hesults. 
 Inflammation, Sloughing, 
 
 Remarks. 
 
 Not stated, 
 
 Not stated, 
 
 Not stated, 
 
 Not stated, 
 Not stated, 
 Not stated. 
 
 Not stated, 
 
 Not stated, 
 
 Not stated. 
 
 Not stated. 
 
 Tedious, . 
 
 Great force, 
 Not stated, 
 
 Not stated. 
 Great force. 
 
 Two hours re- 
 quired. 
 Great difficulty, . . 
 
 Easy, . . 
 Much force. 
 Not stated, 
 
 Great force. 
 Not stated. 
 Not stated. 
 
 Force required. 
 
 Easy, . . . 
 Easy, . . . 
 
 Easy, . . . 
 Little difficulty. 
 
 Eeoovery, 
 
 Recovery, 
 
 Recovery, 
 
 Death, . 
 Recovery. 
 Recovery. 
 Recovery, 
 
 Recovery. 
 
 Recovery. 
 
 Recovery. 
 
 Recovery. 
 
 Recovery. 
 
 Recovery. 
 Recovery. 
 
 Recovery, 
 Recovery. 
 
 Recovery, 
 
 Death, . 
 
 Recovery. 
 Recovery. 
 Death. 
 
 Recovery. 
 Recovery. 
 Recovery, 
 
 Recovery. 
 Death, . 
 
 Death, . 
 Death, . 
 
 Death, 
 Death, 
 
 Retention of urine; 
 sloughing. 
 
 Inflammat'n of bladder 
 
 Sloughing ; vesico- 
 vaginal fistula. 
 
 Retention of urine and 
 
 sloughing of vagina. 
 
 Uterine inflammation. 
 
 Inflammation of mus- 
 cular coat of uterus. 
 
 Inflammat'n of uterus. 
 
 Disease of chest ; in- 
 flammation of veins 
 in pelvis. 
 
 Rupture of uterus, . 
 
 Rupture of uterus, . 
 
 The tumefaction of the labia 
 and vagina was such that 
 the blades of the forceps 
 could not be introduced. 
 
 An unsuccessful effort had 
 been made to deliver with 
 the forceps. 
 
 Delirium for nearly a day. 
 
 Face presentation. Bursting 
 of a thrombus of the vulva. 
 
 Perineum slightly lacerated; 
 retained placenta ; slight 
 henvorrhage. 
 
 There was a peculiar thick- 
 ening at the upper and 
 back part of the vagina, 
 which seemed to arrest the 
 progress of the head. 
 
 Placenta prEBvia. Child turned 
 
 first. 
 Child turned. 
 
520 DYSTOCIA. 
 
 lu most of the eighty-seven cases in the preceding table, the 
 operation of embryulcio was performed while the volume of the 
 head was still above the brim. In the detail of many of the cases, 
 Dr. Lee mentions whether the operation of extraction, after the skull 
 was opened, was difficult or not ; in thirty, however, of the eighty- 
 seven, he particularly notes the extraction of the perforated head 
 with the crotchet as having been attended with difficulty and force. 
 The footnote below^ contains a list of these thirty cases, and Dr. 
 Lee's own expressions with regard to the degree of difficulty met 
 with in each case, in this, the second part of the operation, viz., the 
 extraction with the crotchet. In twenty-two of these thirty cases it 
 is stated that the head of the child was not through the brim at the 
 time craniotomy was performed, but required to be pulled through 
 
 ' Case 5. — "After perforation, great difficulty was experienced in extracting the head 
 with the crotchet." Case 8. — " From the long-continued efforts required to drag the head 
 into the cavity of the pelvis, it was evident that the deUvery could have been accomplished 
 in no other way with safety to the mother." Case 9. — " After perforation, strong efforts were 
 required to complete the delivery, and she died within forty-eight hours." Case 16. — " The 
 force afterwards required to extract the head with the crotchet made us regret that we had 
 not interfered sooner." Case 29. — •' After perforation, the head was extracted with difficulty 
 by the craniotomy forceps.'' Case 31. — "The head was perforated, and the force afterwards 
 required to extract it with the craniotomy forceps was so great, that I regretted having 
 endeavored to deliver before lessening the volume of the head." Case 32. — " After perfo- 
 ration, so much force was required to draw the head through the pelvis with the craniotomy 
 forceps, that I regretted having attempted to save the child." Case 34. — " The extraction of 
 the head with the crotchet was a tedious and difficult operation." Case 35. — " I did not 
 succeed without much difficulty in delivering with the craniotomy forceps." Case 38. — "I 
 opened the head, and had much difficulty afterwards in drawing it down with the crotchet." 
 Case 39. — " Perforation and extraction difficult." Case 40. — " Extraction difficult." Case 
 56. — " Extraction with the crotchet tedious and difficult." Case 59. — " Extraction difficult." 
 Case 66. — " Great force required to extract." Case 76. — " The bones of the cranium were 
 all torn away with the crotchet before I succeeded in drawing the base of the skull through 
 
 the brim of the pelvis Great force was afterwards required to drag the shoulders 
 
 into the cavity of the pelvis." Case 77. — " The operation of craniotomy was difficult." 
 Case 78. — " Great force was required to extract the head after being opened." Case 81. — 
 " The difficulty experienced in extracting the head with the crotchet after it was opened, 
 proved that delivery could not have been completed by any other method." Case 84. — 
 " After the head had been opened, two hours elapsed before I could extract it with the 
 crotchet." Case 86. — " The operation lasted nearly five hours, and the head of the foetus 
 could not be drawn through the brim of the pelvis until the bones of the base of the skull 
 were all torn to pieces with the crotchet." Case 88 — " After the perforation, so much force 
 was required to extract the head, as to make it certain that the head could never have been 
 extracted without its size being reduced." Case 89. — " I opened the head and had some 
 difficulty in extracting it." Case 102. — " Great force required to extract." Case 105. — 
 "The head required great force to extract it after perforation." Case 106. — " Two hours 
 required to extract the head with the craniotomy forceps." Case 107 — " Great difficulty in 
 extracting the head." Case 109. — " So much force required to extract the head that it was 
 obvious it never could have been delivered with the forceps, or expelled by the natural 
 efforts." Casell2. — ^" The extraction required great force." Case 115. — " The force required 
 to extract the head after perforation rendered it obvious that the head could never have 
 passed in the exhausted state in which she was." 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 
 
 521 
 
 it with tlie crotcliet. In most of the remaining eight cases the 
 position of the head at the time of operating is not mentioned. 
 
 Out of the thirty cases presenting the subjoined degree of force 
 and difficulty in the extraction of the head, two only of the mothers 
 died. In the remaining fifty-seven cases, either the extraction is 
 noted as easy, or was not so difficult as to have been considered 
 worthy of being noted ; and out of these fifty-seven cases thirteen 
 mothers died. The following arrangement expresses these results 
 in a tabular form : 
 
 TABLE X. 
 
 Table of Eighty-seven Craniotomy Cases, reported \>y Dr. Lee, showing the Numbers in which 
 Extraction with the Crotchet was — 1, noted as difficult; or, 2, not noted as difficult; and the 
 results of these two Classes. 
 
 Extraction of the Head 
 after Perforation. 
 
 ' Numljer of 
 Cases. 
 
 Number of 
 Deaths. 
 
 Proportion 
 of Deaths. 
 
 Noted as difficult, 
 Not noted as such, 
 
 30 
 57 
 
 2 
 13 
 
 1 in 15 
 1 in 4J 
 
 These interesting facts evidently point to one conclusion, viz., 
 that in distorted pelvis, the amount of force required for the delivery 
 and extraction of the head of the child, in cases of craniotomy, and 
 hence, also in cases of turning, has far less influence upon the ulti- 
 mate results and mortality of the operation than we could well have 
 anticipated. But I anxiously desire not to be misunderstood on 
 this point. I by no means wish to maintain that the degree of force 
 used in delivery has no influence upon the resulting degree of danger 
 and mortality to the mother. ITothing could be more different from 
 either my intentions or my convictions. But the above table shows 
 that in the ordinary forms of distorted pelvis, the degree of force em- 
 ployed for effecting the transit of the head is far less an element of dan- 
 ger than could have been previously imagined; and the explanation 
 of the apparent paradox is, I believe, two-fold. For, first, temporary 
 compression applied to two special points in the circle of the pelvis 
 (as in the case when the child's head is dragged, by operative 
 measures, through a brim contracted only in one diameter) is by no 
 means so dangerous as more prolonged, though slighter, degrees of 
 compression of the maternal structures, when the compression is 
 equable, and diffused over the whole circle of the pelvic aperture, 
 or the whole interior of the pelvic cavity, as in instances in which 
 a hydrocephalic foetal head is pressing like an hydraulic bag, equally, 
 and on all sides. But, secondly, the effect of the law of the in- 
 fluence of force is counteracted by, and subsidiary to, another law 
 
522 DTSTOCIA. 
 
 of a far Mglier degree of practical generalization, viz., tlie law 
 which I have illustrated at length in a preceding section, that " the 
 danger attendant upon parturition increases in a ratio progressive 
 with the increased duration of the labor." And I have littie doubt 
 that if we had proper and adequate data for conducting the inquiiy, 
 it would be found that the safe result of those craniotomy cases in 
 which force is employed in the delivery is in a great measure owing 
 to the time of the labor at which the delivery is accomplished ; and 
 that when the result is fatal, it is as much owing to the previous 
 length or duration of the labor, as to the force employed. Dr. 
 Collins, in his chapter on still-born children, details eight cases of 
 craniotomy in which, after perforation, the extraction of the head 
 with the crotchet required more or less severe exertion and force.' 
 
 ' These eight cases are the following : — 1. " No. 49 was forty-eight hours in labor of her 
 first child. Having made no progress for the last twenty-four hours, the pulse becoming 
 extremely quick, with great general debility, the head was lessened, and delivery effected 
 by the crotchet. Considerable difficulty was experienced in getting the head through the 
 pelvis in consequence of the hand having descended with it." — Practical Treatise, p. 462. 
 2. " No. 56 was a diminutive woman, much deformed ; had been twice force-delivered in 
 this Hospital, as from the size of the pelvis it was impossible for a child to pass entire ; even 
 after the bones of the head were completely broken down, much difficulty was experienced 
 in completing the delivery." 3. " No. 209 was admitted, reported to have been four days 
 in labor, and attended by a midwife ; the uterus continued to act strongly, yet after waiting 
 eleven hours the labor made no progress, and, as there was no doubt the child was dead 
 the head was lessened. Many of the bones were removed before the delivery could be 
 completed ; the child was large and putrid." 4. " No. 210 ; after three days' labor, the 
 head, still at the brim of the pelvis, was lessened, and almost every bone removed before it 
 could be delivered, and even after it was brought down much exertion was required to free 
 the shoulders and body. The child was large, and the abdomen somewhat distended with 
 air. The mother seemed at this time almost lifeless, having lost the power of swallowing. 
 The hand was introduced into the uterus, which was quite relaxed, the placenta was gently 
 removed, and the patient expired immediately. On dissection,' the uterus was found healthy, 
 but badly contracted, containing a small quantity of coagulated blood ; the intestines were 
 in the highest state of congestion, and there was about a pint of fluid in the abdominal cavity, 
 with portions of coagulable lymph in different parts, seemingly the effects of inflammation 
 previous to labor. On opening the chest, the lungs were observed to adhere so firmly as to 
 require the knife in many places to separate them. Nothing was discovered to account for 
 the suddenness of death." 5. " No. 256 was thirty-two hours in labor previous to admis- 
 sion ; her pulse was rapid, and tongue foul. She was delivered some hours after she came 
 in, by lessening the head, which was greatly enlarged from hydrocephalus ; there was some 
 diffiouhy in completing the delivery, even after the bulk of the head had been as much as 
 possible reduced." 6. "No. 303 was admitted, reported to have been three days in labor of 
 her first child ; thehead was low and firmly fixed in the pelvis; the bladder greatly dis- 
 tended with urine, it having been retained for thirty hours; pulse 140; tongue dry and 
 white. The catheter was passed and three pints of urine removed. As the abdomen was 
 free from pain, it was thought advisable to watch the effect of uterine action for some time. 
 After waiting five hours, during which the pains were pretty brisk at intervals, still the head 
 made no advance ; it was lessened and brought away with the crotchet. There was con- 
 siderable exertion required to bring down the shoulders ; the abdomen was much distended 
 with air, the consequence of putrefaction. She died on the fourth day from delivery.'' 7. 
 " No. 667 ; the labor lasted thirty hours; the head was firmly fixed in the pelvis, and had 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 
 
 523 
 
 One of the eight patients died, but she had been seventy two hours 
 in labor when the operation was undertaken ; all the other seven 
 recovered. In six out of these seven cases, craniotomy was adopted 
 earlier ; in one, before the labor had reached sixteen hours in length ; 
 in all, before it had passed forty-eight hours from its commencement. 
 The manner and extent, in which the laws of danger attendant 
 upon this and other particular obstetric operations, are controlled 
 by, and absorbed in, the more general law of the attendant mor- 
 tality, depending upon the length or duration of the labor, have 
 been already illustrated (see Section IV.), in reference to delivery 
 by the forceps, and delivery by the crotchet, taken individually. The 
 law and its results, however, are so extremely important as bearing 
 upon the question of the present section, that I will, in further con- 
 firmation of it, and at some risk of repetition, throw into a com- 
 bined form and table, all the forceps and all the craniotomy cases 
 mentioned by Dr. Collins in which he specifies the duration of the 
 labor. In other words, we will conjoin the two tables previously 
 given in Section TV., into one ; and examine how much the mater- 
 nal mortality was modified in tedious and laborious labors, requiring 
 instrumental aid, by the date of the labor at which that aid was 
 given. Our former tables contained 24 cases delivered by the for- 
 ceps, and 77 delivered by craniotomy; in all 101 instrumental labors. 
 The results were as follows : 
 
 TABLE XI. 
 
 Showing the Results of 101 Instrumental Deliveries in which the Duration of Labor at the 
 time of the Operation was noted. 
 
 Duration of Labor. 
 
 Numljer of 
 Gases. 
 
 Number of 
 Deaths. 
 
 Proportion of 
 Deaths. 
 
 Under 24 hours, 
 From 25 to 48 hours, 
 Above 48 hours, 
 
 32 
 
 42 
 27 
 
 2 
 
 6 
 
 11 
 
 1 in 16 died. 
 1 in 7 died. 
 1 in 2J died. 
 
 Total, 
 
 101 
 
 19 
 
 1 in 5 died. 
 
 This combined table of Dr. Collins' instrumental deliveries fiiUy 
 
 made no progress for twelve hours. As the heart's action had some time ceased, and the 
 mother's pulse was 140, the head was lessened. Great exertion was necessary to effect 
 delivery in consequence of the head being much ossified." 8. " No. 725 j this patient, when 
 admitted, was reported to have been sixty hours in labor ; the os uteri was very little dilated, 
 and the head high up in the pelvis. The pains continued constant for twenty-four hours 
 after she came in, yet tlie labor made little progress ; the mouth of the womb was rigid, 
 jagged, and had the feel of cartilage. The child being dead, as indicated by the stethoscope, 
 the head was lessened and left in that state fbr some hours, and afterwards cautiously, 
 brought down. Considerable force was necessary to complete the delivery, though the 
 child was putrid." 
 
524 DYSTOCIA. 
 
 bears out the important conclusion regarding the influence of the 
 antecedent duration of labor, that we have already seen to be 
 derivable from the study of the two operative measures, the forceps 
 and crotchet, taken singly and individually. The evidence of the 
 present table, like the evidence of those previously given (see 
 Tables V. and VI.) amounts to this — that the maternal mortality 
 accompanying instrumental delivery is regulated more by the period 
 of the labor at which the artificial interference is practised, than by 
 the nature of the operation itself, or by any other contingent cir- 
 cumstance — ^the general fatality being decreased in proportion as 
 the operation is performed early, and increased in proportion as it 
 is postponed and delayed longer and longer from the date of the 
 first commencement of parturition. But, admitting that this holds 
 true in regard to instrumental delivery by the forceps and craniotomy, 
 it may be doubted and objected that it perhaps does not hold true 
 in regard to artificial delivery by the operation we propose to em- 
 ploy, viz., turning. Let us interrogate Dr. Collins' facts, in order 
 to obtain an answer. 
 
 In his Report of the Dublin Lying-in Hospital, Dr. Collins gives 
 the result of thirty-three cases, in which turning was practised in 
 consequence of presentation of the shoulder or arm. In one of 
 these cases the placenta presented, and I exclude it as thus contain- 
 ing a source of danger quite independent of the turning. Among 
 the remaining thirty-two cases, there are two deaths, or one in six- 
 teen ; and twenty-four in which the date of the duration of the 
 labor, at the time of turning, is stated as ascertainable. In only 
 one of these twenty-four cases is the labor noted as having exceeded 
 thirty hours in length, and this protracted case was an instance of 
 twins, i^which the second child presented preternaturally, and re- 
 quired turning. In twenty-one of the cases the labor was terminated 
 before twenty-four hours ; among these, one died — a case compli- 
 cated before delivery by severe accidental hemorrhage ; in three it 
 was prolonged beyond twenty-four hours, and one of these three 
 mothers died. When arranged in a tabular form, the results are as 
 follows : 
 
 TABLE XII. 
 
 Shou/ing the Mortality accompanifing Twenty-four Cases of Turning for Presentation of the 
 Arm and Shoulder, as regulated by the Previous Duration of Labor. 
 
 Previous Duration 
 of Labor. 
 
 Proportion of Deaths 
 of Mothers. 
 
 Below 24 hours, 
 Above 24 hours, 
 
 1 in 21 died. 
 1 in 3 died. 
 
TURNING AS A SUBSTITUTE FOE CRANIOTOMY. 525 
 
 The data in the preceding table are not numerous, but still they 
 will probably be allowed to be sufficient evidence of the fact, that 
 the degree of maternal danger attendant upon turning, as upon 
 other modes of operative delivery, is regulated and modified by the 
 date of the labor at which the delivery is practised ; artificial labors, 
 like spontaneous labors, increasing in their mortality in proportion 
 as the previous parturient action has been allowed to be increased 
 and prolonged in its duration and length. Hence, also, necessarily 
 follows the same deductions which I have already more than once 
 adduced, viz.— 
 
 1. A means of artificial delivery, such as turning, which, in cases 
 of pelvic contraction, would enable us to finish the labor at an early 
 date, should, as a general rule, add greatly to the safety and chance 
 of life of the mother, as compared with a means of delivery such 
 as the long forceps or craniotomy, which cannot be usually and 
 legitimately practised till a much later period after the commence- 
 ment of parturition. 
 
 2. The facts I have adduced in the present section show, that the 
 exertion of force in artificial delivery is attended with comparatively 
 little danger, provided always the delivery is early ; and that the 
 employment of it is by no means so hazardous as the simple long 
 continuance and protraction of the labor. 
 
 3. All these deductions are only corollaries to the higher and 
 more comprehensive law, that the degree of danger and fatality 
 attendant either upon natural or morbid parturition, increases in a 
 ratio progressive with the increased duration of the labor. 
 
 Section IX. — On the Comparative Danger op Local Lesions op 
 THE Maternal Organs (Vagina and Uterus), in Delivery by 
 Turning, and Delivery by Lststruments.' 
 
 As far as the observations in the preceding section go, they refer 
 to the comparative degree of actual danger to the life of the mother 
 under the opposite means of treatment, by which cases of labor, 
 with arrestment of the head, and distortion of the pelvic brim, may 
 be treated. They refer merely to the question of the probable 
 death or probable survival of the mother, under the two difierent 
 lines of practice spoken of, viz., delivery by instruments and delivery 
 by turning. But it is possible, that, under such a form of labor as 
 we have been considering, the mother may survive, that she may 
 escape with life, and yet the maternal passages and neighboring soft 
 parts may be so much damaged and injured, as to interfere, in a 
 more or less dangerous or distressing manner, with the state of her 
 
 ' From Provincial Medical and Surgical Journal, January, 1849, p. 9. 
 
526 DYSTOCIA. 
 
 ftiture health and future happiness. The cervix uteri, or the walls 
 of the vagina, are sometimes so contused, or become so inflamed, 
 that gangrene and sloughing supervenes, and lead to the formation 
 of cicatrices and strictures ; or, what is still more deplorable, this 
 resulting gangrenous inflammation may produce fistulous communi- 
 cations between the vaginal canal, and the rectum, or urethra, or 
 bladder. No consequence could be possibly more deplorable than 
 this last — the occurrence of recto-vaginal or vesico-vaginal fistulse. 
 
 Speaking of sloughing of the urethra or neck of the bladder, as a 
 consequence of severe labor. Dr. Collins remarks, in words dictated 
 by the best possible feelings : "I do not know of any occurrence 
 more calculated to render the patient's life one of endless sorrow ; 
 or, at the same time, more likely to cause thb practitioner such 
 lasting regret. When it unfortunately happens, as in some instances 
 is unavoidable, in consequence of the protracted length to which 
 we are at times compelled to permit the labor to proceed, owing to 
 great difficulty in the passage of the head, the child being alive, here 
 the medical attendant's mind cannot, on his own account, feel dis- 
 tressed, as the only means he could adopt to guard against the danger 
 would be to lessen the head, which, in my opinion, no consideration 
 should induce him to do under such circumstances."' 
 
 Are such distressing results as Dr. Collins here describes, more 
 liable to occur under the present practices of delivery by instruments, 
 or under the new practice which I propose of delivery by turning 1 
 In other terms the question which I wish to consider is this : 
 
 Are Local Lmons from Inflammation of the Vagina, such as Sloughing, Fistulce, S;c., more 
 liable, in a Contracted Pelvis, to supervene after Delivery hy Turning, or Delivery by Instru- 
 ments ? 
 
 Vaginal inflammation terminating in sloughing, cicatrices, and 
 fistulse, is not unfrequently observed after protracted labors that are 
 terminated by the forceps or crotchet. In his " Clinical Midwifery," 
 after detailing " the histories of fifty-five cases of difficult parturition 
 in which the forceps was employed," Dr. Lee remarks,^ " Five of 
 the mothers whose cases have now been related died from puerperal 
 convulsions, and four from the rash and inconsiderate use of the 
 forceps ; seven had the perineum more or less injured ; one the 
 recto-vaginal septum torn; five were left with cicatrices of the 
 vagina after sloughing ; and one with an incurable vesico-vaginal 
 fistula." After describing the histories of sixty-five cases of " diffi- 
 cult labors from distortion of the pelvis, swelling of the soft parts, 
 convulsions, hydrocephalus in the fcetus, and other causes in which 
 delivery was effected by the operation of craniotomy," Dr. Lee again 
 observes,' "In thirty-eight of the cases in this report, the labor con- 
 
 ' Practical Treatise, p. 359. 2 Clinical Midwifery, p. 32. » Ibid. p. 59. 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 527 
 
 tinned from forty to seventy hours. In the cases of spontaneous 
 rupture of the uterus and convulsions only, was the delivery effected 
 before the labor had lasted upwards of thirty hours. In a very 
 large proportion of the cases, the difficulty arose from distortion, or 
 a contracted state of the pelvis. Rupture of the uterus took place 
 in three before perforation, and the inflammation and sloughing of 
 the uterus, vagina, and bladder, which proved fatal to eight others, 
 were chiefly or solely produced by the long-continued violent pres- 
 sure on the soft parts by the head of the child before it was opened 
 and extracted. In those who recovered with vesico-vaginal fistulas, 
 or contraction of the vagina from cicatrices, the unfortunate occur- 
 rences arose from craniotomy being too long delayed." 
 
 In the table which I have previously given from the same author 
 (see Table IX.) of the results of 87 cases of craniotomy, local lesions 
 on the part of the mother are noted as having occurred in several 
 instances. Out of the 87 cases, eight,' or about 1 in every 10, suf- 
 fered from vaginal inflammation and sloughing ; four,^ or nearly 1 
 in every 20, were left with vaginal fistulse. 
 
 On the other hand, I am not aware of a single recorded instance 
 in which vaginal sloughing and fistula ever followed transverse pre- 
 sentations of the foetus, and where the delivery is, as a general rule, 
 always accomplished by turning. Two circumstances lead to this 
 immunity : 
 
 1st. In presentations of the arm and shoulder, the presenting part 
 does not so completely fill up and compress the tissues of the brim 
 as in head-presentations. Hence both the tendency to, and the 
 occurrence of, congestion of the vessels and inflammation in the 
 tissues, situated below the site of the compression, viz., the vagina, 
 &c., is far rarer. But — 
 
 2dli/. The delivery is always, or almost always, accomplished 
 early in the labor, and no doubt the mere length and protraction of 
 the labor is one of the great, if not the greatest, predisposing and 
 exciting causes of gangrenous inflammation and sloughing, of the 
 vagina. 
 
 In many cases vaginal sloughings and fistulse have been attributed 
 to the use of instruments, when they were more truly owing to gan- 
 grenous inflammation and sloughing, ensuing in consequence of the 
 delay that was allowed to occur before instrumental delivery was 
 adopted. In the history of most instances of vesico-vaginal and 
 recto-vaginal fistulse following labor, there is one simple fact, proving 
 that they are not the direct effect, as is too often supposed, of lesions 
 and lacerations by the forceps or crotchet. If vesico-vaginal fistulse 
 were, in this way, the direct effect of injuries produced by cutting 
 
 > See Cases 10, 20, 30, 32, 57, 58, 61, 74. ' See Cases 1, 52, 53, 64. 
 
528 DYSTOCIA. 
 
 with the instruments, then escape of urine through the vagina 
 would be observed immediately after labor. But this is rarely the 
 case ; the general fact being, that the escape of urine through the 
 false opening between the urinary and vaginal canals is not seen 
 for several days after delivery ; because it is not till several days 
 have elapsed, that the gangrenous slough in the parietes of Ihese 
 canals separates. No soft parts, any more than the maternal canals, 
 could stand, without endangering their vitality, the steady pressure 
 of a firm body upon them for twenty or thirty hours, such as that 
 which the detained foetal head exerts in contracted pelves upon the 
 two points of contraction — the symphysis pubis before, and the pro- 
 montory of the sacrum behind. It is not a matter of wonder that 
 the soft structures compressed at these special points between the 
 foetal head and maternal bones, should sometimes inflame and 
 slough. It is rather, perhaps, surprising, that this consequence does 
 not oftener follow. On this point Dr. Beatty of Dublin makes one 
 or two remarks of such importance, that I shall offer no apology 
 for quoting them at length. "'With respect," says he, "to lacera- 
 tion and sloughing of the vagina, bladder, &c., stated by some 
 authors to be caused by the forceps, and used as an argument 
 against their employment, I am of opinion, that in the majority of 
 cases, when these lamentable results occur, the blame is unmerited ; 
 because I have seen the worst inflammation and sloughings of these 
 parts follow in cases where the perforator had been used, and even 
 in some where no instrument whatever was employed. The truth 
 is, the mischief is effected by the pressure of the infant's head upon 
 the soft parts of the mother, and after this has been continued with 
 sufficient intensity, for a sufficient length of time, the inflammation 
 caused thereby will run its course, no matter in what way delivery 
 is accomplished, whether by the natural efforts or by instruments. 
 But it frequently happens that delivery is effected in these cases by 
 instruments, too late to prevent the unhappy results alluded to, and 
 then the operation is charged with the consequences. If an accu- 
 rate account of the subsequent condition of all women after delivery 
 could be obtained, I much fear that the histories of those cases in 
 which labor had been allowed to run too long before interference, 
 would be anything but satisfactory. The lamentable sloughings of 
 the vagina, with subsequent closure of the passage by the process of 
 cicatrization, or the still more distressing sloughing of the bladder, 
 with its attendant urinary fistulse, are seldom mentioned in lying- 
 in hospital reports, because the patients are usually removed from 
 those institutions before such results have become very apparent ; 
 and thus, a case left to nature in which delivery is effected by the 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 
 
 529 
 
 natural efforts, is set down as a favorable one, without any notice of 
 its consequences."* 
 
 Dr. Beatty elsewhere soundly and correctly remarks in regard to 
 the causation of gangrene and sloughing, &c., of parts of the vaginal 
 walls by the pressure of the child's head, " that it is the continuance 
 of the pressure that does the mischief rather than its intensity. "We 
 know that the soft tissues of the body are endowed with a resiliency 
 — a power of resistance that enables thejn to bear a temporary com- 
 pression of great amount without injury, while inferior pressure 
 continued for a length of time will terminate in their disorganiza- 
 tion. The malingering soldier is well aware of this fact, and acts 
 upon it, when he wishes to produce an ulcer. He straps a piece of 
 coin or other hard substance tightly upon the part. At first no effect 
 is produced, and if the apparatus is removed in a short time, there 
 is no evil consequence ; but if the same amount of pressure is con- 
 tinued for some hours, such a degree of injury is inflicted as termi- 
 nates in the destruction of the part, and a sloughing ulcer is the 
 result."'' 
 
 That the mere morbid protraction of labor is the great predis- 
 posing cause of gangrenous inflammation and sloughing of the 
 vagina, as suggested in these remarks, is shown by Dr. Collins' 
 results. Dr. Collins has recorded the duration of the labor in six 
 cases where sloughing of the vagina was detected after death. The 
 following table shows that the accident occurred in an immensely 
 greater proportion in prolonged than in short labors ; and that, 
 consequently, protraction is, as I have just stated, almost a necessary 
 antecedent to the occurrence. The case, I may remark, in which 
 sloughing followed a labor less than twenty-four hours in duration, 
 required instrumental delivery, but the mode of delivery, whether 
 by the crotchet or forceps, is not specialized by Dr. Collins.^ 
 
 TABLE XIV. 
 Duration of Labor in six Fatal Cases of Slonghing of the Vagina. 
 
 Lengtb of Labor. 
 
 Number of 
 Deliveries. 
 
 Number of 
 Cases. 
 
 Proportion of 
 Cases. 
 
 Within 24 hours, 
 Beyond 24 hours. 
 
 15,586 
 264 
 
 1 
 5 
 
 1 in 15,586. 
 1 in 53. 
 
 If, as these data show, the protraction of labor is a main and 
 almost necessary element in the production of gangrenous inflam- 
 mation of the vagina, it is equally evident that turning, in the 
 
 ' Dublin Journal of Medical Science, vol. xii. p. 290. 
 2 Dublin Quarterly Journal, vol. xxi. p. 344. 
 VOL. I. 34 
 
 ' See Practical Treatise, p. 358. 
 
530 DYSTOCIA. 
 
 class of cases we are considering, while it frees the mother fi'om 
 the danger of a fatal termination, as shown in the last section, 
 would at the same time free her also from the chance of suffering 
 from these local complications that are apt to follow upon protracted 
 labors. 
 
 In the passage which I have quoted from Dr. Collins, at the com- 
 mencement of the present section, that experienced practitioner 
 laments our being occasionally compelled to subject our patients to 
 the chance of local dangers and complications, in consequence of 
 our being compelled, in some unavoidable instances, to allow the 
 labor to proceed onward to a protracted degree, from the child being 
 still alive, " for then the only means the practitioner could adopt to 
 guard against the danger, would," says Dr. Collins, "be to lessen 
 the head, which, in my opinion, no consideration should induce him 
 to do under such circumstances," viz., as long as the infant is still 
 living. The proposition which I have made of turning in such 
 instances resolves the difficulties attending upon them, in two ways. 
 For, first, it enables us to deliver the patient early and at once, and 
 thus frees us from the dread of these consequences of protraction ; 
 and, secondly, the continued vitality of the infant would, under the 
 treatment by turning, not be a reason and incentive for our danger- 
 ously delaying the delivery, but would form a strong reason and 
 incentive for our proceeding with the practice at as early a period 
 as is proper and possible. The details of a case or two may enforce 
 these observations ; and I shall select some from Dr. Collins, cal- 
 culated both to illustrate these remarks, and to show, that in pro- 
 tracted labors, occasionally before the time that the child does at 
 last die, the dreaded amount of local mischief has been accom- 
 plished, so that if we waited always for the certainty of the infant's 
 death, in order to deliver by craniotomy, we should wait beyond 
 the time that was necessary, in order to save (locally) the maternal 
 structures from inflammation and gangrene. 
 
 It will be remarked, that in the first of the following instances, 
 the foetal heart was heard six hours, and in the second case, eight 
 hours, before delivery, and consequently ceased some time between 
 these periods and the period at which the perforator was used — in 
 short, necessarily not long before craniotomy was practised. Con- 
 sequently, we have here cases which, in the severity of their local, 
 and, I may add, in the severity also of their general symptoms, show 
 what I have before argued, that the mother may herself be assur- 
 edly placed in the greatest possible danger and hazard from the 
 protraction of the labor, before that protraction kills the child. I 
 may add, that in the first case, the position of the foetal heart, viz., 
 in the right iliac region, showed the infant to be in the occipito- 
 posterior position (the third position of Naegele). 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 531 
 
 Case XXXVI. — " Fo. 126. This woman was fifty-nine hours in 
 labor ; it was her first "child. The pains were for a considerable time 
 very trifling, with long intervals ; however, for the last twenty-four 
 hours the uterus acted with tolerable regularity, the pains being at 
 times strong, causing the head to press with much force against the 
 ischia, where it remained stationary for the greater part of that 
 time. Her pulse was very much increased in frequency, varying 
 between 120 and 130 ; the external parts were cedematous. As the 
 foetal heart had ceased to act, having been distinctly audible in the 
 right iliac region six hours before, the head was lessened and the 
 crotchet applied. The placenta was expelled in forty-five minutes, 
 immediately after which, in consequence of hemorrhage, the hand 
 was introduced, and so it was arrested. Violent inflammation and 
 sloughing set in, resisting all treatment, and she died on the 9th 
 day. For four days previous she had severe diarrhoea, a succession 
 of motions coming on suddenly, with severe pain ; she had also 
 severe hiccough. On examination after death, the vagina was 
 found in a state of slough ; the sides opposite the spines of the 
 ischia were broken through with the slightest force, and were com- 
 pletely gangrenous. A circular opening the size of a shilling was 
 found, forming a communication between this cavity and the 
 rectum, the mucous surface of which, as also that of the colon, 
 was softened, and had, in the vicinity of the opening, a gangrenous 
 appearance. There was no symptom of inflammation in the peri- 
 toneum or uterus."' 
 
 Case XXXVII.— " No. 1091. Was admitted August 28d, in 
 labor of her first child, and was not delivered until the 25th, being 
 a period of fifty-six hours. Uterine action from the commencement 
 until within six hours of the expulsion of the child, was extremely 
 feeble, with long intervals. The head remained high in the pelvis, 
 and although the ear could not be reached, it was evident the head 
 had sufficient room to pass; to eflect which uterine action was 
 alone wanting. As soon as the pains began to be brisk, the labor 
 proceeded without difficulty. The foetal heart was quite audible 
 until eight hours previous to the birth. In three hours after the 
 hand was passed to remove the placenta, it was found separated, and 
 without the slightest efibrt the uterus contracted and expelled both. 
 The perineum had suffered considerably in the passage of the headi 
 The patient never seemed to rally after delivery ; the pulse con- 
 tinued quick ; there was considerable tenderness on pressure over 
 the uterus, with a foul discharge from the vagina. * * * Qjj 
 the 7th and 8th, she had distinct rigors, followed by perspiration, 
 
 ' Practical Treatise, p. 158. 
 
532 DYSTOCIA. 
 
 after which her strength became greatly reduced. The vaginal dis- 
 charges continued foul, notwithstanding the most rigid attention 
 to cleanliness and the use of stimulating injections. She gradually 
 sank and died on the 11th day, having for two days previously suf- 
 fered from frequent hiccough. On dissection, the only morbid 
 appearances found were in the bladder and vagina. In the bladder, 
 the mucous surface was covered with yellow lymph, and it contained 
 a quantity of muco-purulent fluid. In the vagina, opposite the 
 right ischium, a portion appeared to have been destroyed by slough."' 
 Hitherto, under the present section, I have spoken of the dangers 
 which the mother may avoid by employing the operation of turning 
 as a substitute for instrumental delivery, in cases of contraction of 
 the pelvic brim. But while turning enables us, as I have shown, to 
 eschew some of the gravest and most imminent dangers connected 
 with the use of the long forceps and crotchet, it is, on the other 
 hand, by no means to be forgotten, that it subjects the mother to 
 one great form of danger, from which, in common belief, she would 
 be comparatively free under the adoption of instrumental delivery. 
 The special maternal danger attending upon turning is laceration or 
 rupture of the uterus, confessedly the most fatal complication that 
 can occur in connection with delivery. Is the liability to rupture 
 tinder turning so great as to make us avoid this practice and trust 
 rather to the forceps and crotchet? Or, in other words — 
 
 Is Rupture of the Uterus in Contracted Pelvis much more apt to be produced by Delivery by 
 Turning than by Delivery with Instruments ? 
 
 Most authors describe laceration of the uterus as one of the prin- 
 cipal hazards which the mother runs in cases of turning. But in- 
 jury and laceration of the uterus are perhaps not so liable to follow 
 this operation as is generally imagined. " Between the years 1823 
 and 1834," says Dr. Ramsbotham, "I delivered more than one hun- 
 dred and twenty women under transverse presentations ; indepen- 
 dently of a few cases to which I was summoned where spontaneous 
 evolution occurred. Many of these cases presented a formidable 
 appearance ; for in one, the membranes had been ruptured a whole 
 week ; in another, sixty-nine hours ; in a third, fifty-eight hours ; 
 in another, fifty-five ; in another, fifty-three ; and in many, more 
 than forty-eight ; and as a general principle, we presume that the 
 longer the liquor amnii has been evacuated, the more likely is the 
 uterus to have embraced the foetal body firmly, and the more diffi- 
 culty will there be in overcoming the resistance. In none of these 
 cases did I exhibit large doses of opium, and in those few where 
 
 ' Practical Treatise, p. 483. 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 533 
 
 bleeding was practised, that operation was had recourse to, not for 
 the purpose of relaxing the uterine fibres, but to relieve the inflam- 
 mation which the soft structures were sufiering, and to remove 
 tumefaction. In not one of these instances was any injury inflicted on 
 the uterine structure ; nor did any permanent evil arise that could he 
 attributed to the operation. In four cases only was the uterus so pow- 
 erfully contracted as to refuse admittance to the hand, and compel 
 me to adopt the alternative of eviscerating or decapitating the 
 foetus.'" 
 
 Besides that injury of the uterus is thus not so apt, as is perhaps 
 generally imagined, to follow upon turning when carefully and 
 cautiously performed, there are other considerations, which are 
 calculated strongly to show that the danger of laceration in the 
 cases of pelvic contraction most fitted for the practice we suggest, 
 is not much, if at all, increased by the proposed operation. I shall 
 state the considerations to which I refer. 
 
 In the first place, I would premise this important remark, that, 
 according to all our best obstetric pathologists, those degrees and 
 forms of morbid contraction of the brim of the pelvis which I deem 
 to be the cases best adapted for delivery by turning, are exactly 
 those cases in which, under any plan of management, whether the 
 patient be delivered by the natural efibrts, or by the forceps or 
 crochet, rupture and laceration are exceedingly apt to take place. 
 On this subject I am anxious to adduce full evidence, and will con- 
 sequently appeal to the unprejudiced testimony of Kamsbotham, 
 Denman, Churchill, &c. 
 
 " Laceration of the uterus," says Dr. Eamsbotham, " is most 
 likely to happen to a patient who has had three or four children, 
 who possesses a slightly distorted pelvis, and who has been in strong 
 labor for a number of hours. Although," he further observes, "the 
 same rent may take place in any portion of the organ, its most 
 frequent seat is at the neck, either at the posterior part opposite the 
 prominence of the sacrum, or anteriorly, behind the symphysis 
 pubis. The direction is also mostly transverse, or slightly oblique. 
 It is not difficult to account for this being the most usual situation 
 of the injury ; for since, during the latter part of gestation, the neck 
 of the womb rests upon the pelvic brim, if the promontory of the 
 sacrum dip too far forward, or the ridge of the pubis be preternatu- 
 rally sharp, it is reasonable to suppose that the uterine structure 
 may be afiected, that inflammation may occur as a consequence of 
 pressure, and that a thinning or softening of the substance may be 
 induced, and, under these circumstances, should the structure give 
 way at all, it is likely that the weakened part will be the first to 
 
 ' Obstetric Medicine and Surgery, p. 350. 
 
534 DYSTOCIA. 
 
 suffer. Denman, indeed, says that, independently of disease, the 
 uterus may be worn through mechanically, in long and severe labors, 
 by pressure and attrition between the head of the child and the pro- 
 jecting bones of a distorted pelvis, especially if they be drawn into 
 points, or a sharp edge. One or other of these causes may explain," 
 Dr. Ramsbotham concludes, " why we more frequently meet with 
 laceration of the uterus, when the pelvis is slightly contracted in the 
 conjugate diameter of the brim, than when the distortion is exces- 
 sive."^ And he adds one case. " In one of the last cases," says he, 
 " of ruptured uterus to which I was called, dissection showed that the 
 linea ileo-pectinea, where it traverses the pubis, was formed into a very 
 sharp ridge, that there were a number of bony prominences jutting 
 from the inner surface of the pubic bones towards the cavity, and 
 one, especially, situated above the left thyroid foramen, which was 
 so pointed as to pain the finger when hard pressure was made on it. 
 The sacro-pubic diameter was two inches and three-quarters in ex- 
 tent. It was the woman's second pregnancy; the first child had 
 been delivered by craniotomy. After a consultation was held, labor 
 on this occasion was induced in the eighth month by the exhibition 
 of four doses of ergot. The membranes broke spontaneously three 
 hours and a half before the accident occurred. I was sent for by 
 the gentleman in attendance, immediately, and delivered by turning ; 
 she died on the night of the fourth day."^ 
 
 Dr. Churchill expresses similar Adews in regard to contraction of 
 the pelvis as a cause of rupture. " A certain amount," says he, 
 " of narrowing of the upper outlet may give rise to it. This is a 
 purely mechanical cause. The head of the child is forced down by 
 violent labor-pains, but is unable to enter the pelvis from the con- 
 traction of the upper strait. Now, if the pains continue with great 
 power, the head is turned to one side or the other, or posteriorly, 
 and the only obstacle here being the uterine or vaginal parietes the 
 head is drawn through them at the weakest part. They offer the less 
 resistance, probably fi'om the woman having born several children,"^ 
 
 Other authorities might be adduced to the same effect, viz., that 
 rupture of the uterus is especially liable to happen under protracted 
 labor or instrumental delivery, when the brim of the pelvis is 
 slightly contracted, that is, in exactly the class of cases most likely 
 to be adapted for delivery by turning." 
 
 ' Obstetric Medicine and Surgery, p. 469. ^ Ibid., p. 469. 
 
 " Theory and Practice of Midwifery, p. 408. 
 
 ■* See, for example, Dr. Robinson, Edin. Med. and Surg. Journal, vol. xlii. p. 61. " In a 
 great majority of instances," says he, " of slight contraction of the inlet, in perhaps three 
 cases out of four, the diminution of space is caused by the promontory of the sacrum en- 
 croaching upon the antero-posterior diameter. On this ground, perhaps, we may explain 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 
 
 535 
 
 In the second place, let me observe that, while contraction of the 
 pelvic brim is thus acknowledged to be a strong predisposing and 
 exciting cause of rupture, it must, at the same time, be held in view 
 as a most important correlative fact, that it seldom does lead to lace- 
 ration of the uterus, unless the effects of its mischievous agency are 
 allowed to be combined with, and increased by, a morbid degree of 
 prolongation and protraction of the labor itself. Dr. Denman's ob- 
 servation is, doubtless, so far quite true, as to the possibility that 
 the " uterus may be worn through mechanically in long and severe 
 labors, by pressure and attrition between the head of the child and 
 the projecting bones of a distorted pelvis, especially if they be 
 drawn into points, or a sharp edge."' In fact the liability to rup- 
 ture, like the liability to most other obstetric complications, increases 
 progressively with the increased duration of the labor, as the follow- 
 ing table, calculated from Dr. Collins' returns," sufficiently attests : 
 
 TABLE XV. 
 
 Duration of Labor in 24 cases of Rupture of the Uterus. 
 
 Length of Labor. 
 
 Number 
 
 of 
 Deliveries. 
 
 Number of 
 Cases of 
 Rupture. 
 
 Proportion of 
 Cases of 
 Rupture. 
 
 Within 6 liours, 
 From 7 to 24 hours, 
 Above 24 hours, 
 
 13,412 
 
 2,174 
 
 264 
 
 7 
 
 10 
 
 7 
 
 1 in 1,916. 
 1 in 217. 
 1 in 38. 
 
 The principle inculcated by the evidence of this table is so im- 
 portant in its bearing upon the practice suggested in the present 
 memoir, that I shall take an opportunity of enforcing it by adducing 
 three instances of distorted pelvis, in which laceration of the uterus 
 took place after the labor had been allowed to become protracted ; 
 and that, though the mode of ultimate delivery in each of the three 
 was different, in the first, being effected spontaneously, in the 
 second, by instruments, and in the third, by turning. 
 
 Case XXXVm.— " No. 22. On the fifth day after delivery, 
 
 why, in a somewhat greater number of cases of laceration, the rent is found in the posterior 
 rather than the anterior part of the uterus." 
 
 Out of 300 oases of rupture of the uterus, reported by Dr. Traslt, Montlily Journal and 
 Retrospect for August, 1848, p. 178, contraction of the brim of the pelvis was found noted 
 as existing in sixty cases. Drs. M'Clintoclc and Hardy, in their excellent work on Mid- 
 wifery, observe, in regard to the pathology of rupture (p. 295), that the accident is more 
 likely to be produced " where the deformity of the pelvis is slight than where it is exces- 
 sive," — that is, in precisely those cases best fitted for turning. 
 
 ' Ramsbotham's Principles of Obstetric Medicine and Surgery, p. 469. 
 
 ' Dr. Collins met with 34 cases of rupture during his Mastership. In 24 out of 34 he 
 has given the duration of the labors in a table in his Treatise, p. 370. 
 
536 DYSTOCIA. 
 
 without any apparent cause, was seized with violent hemorrhage. 
 When we saw her, which was immediately after, no pulse could be 
 felt, and, though most prompt and active measures were employed, 
 she died in less than an hour. She had been delivered by the 
 natural efforts, of a living child, after a labor, not very severe, of 
 forty-eight hours; nor from that time was there distress of any 
 kind perceptible. 
 
 " On dissection, the abdominal viscera appeared healthy, as did 
 the uterus at first sight, but on raising it out of the pelvis, about the 
 size of a shilling of its muscular substance, corresponding to the 
 projection of the sacrum, was found to have given way, the peritoneal 
 covering remaining uninjured. There were two spots in the vagina 
 approaching to a state of slough."* 
 
 Case XXXIX. — "l^o. 28. The labor pains in this case were 
 feeble, yet the child continued to advance. The heart's action was 
 audible with the aid of the stethoscope, the mother's pulse natural, 
 and no unpleasant symptom. Suddenly, however, the most alarm- 
 ing debility came on, the pulse being scarcely perceptible, accom- 
 panied with vomiting and much pain on pressure over the uterine 
 region. Immediate delivery was necessary, and the perforator was 
 used. She was a. feeble, delicate woman, was thirty-six hours in 
 labor previous to the setting in of the above symptoms, and had 
 been force-deUvered eleven months ago. She died in fourteen 
 hours. 
 
 " On dissection, an opening was found at the junction of the 
 uterus with the vagina (exactly opposite a projection of the last 
 lumbar vertebra), not larger than to admit the passage of one finger. 
 The muscular substance of the uterus, anteriorly, had also given 
 way to a considerable extent, the peritoneum being whole. The 
 pelvis scarcely measured three and a half inches from pubis to 
 
 Case XL. — "A patient with her spine somewhat curved, and who, 
 in her first confinement, had borne a dead infant after several days' 
 suffering, was taken in labor of her second child, early on the 16th 
 of November, 1846. The pains had been constant and strong for 
 about thirty hours, when I saw her, with Dr. Gordon, who had been 
 called in, and the head had remained stationary and fixed at the 
 same point of the brim for the last twenty-four hours. On exami- 
 nation. Dr. Grordon and I found the pelvis small, the os uteri fully 
 dilated, and the head of the infant imperfectly entered into the 
 brim, and apparently uninfiuenced in its descent by the powerful 
 
 ■ Dr. Collins' Practical Treatise, p. 2S7. » Ibid. p. 300. 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 537 
 
 uterine contractions that were present. The sutures of the fcetal 
 head were strongly overlapping, and a triangular portion of the foetal 
 cranium terminating in the posterior fontanelle, was driven deeply 
 in and helow the level of the two other portions of bone that went 
 to the formation of that fontanelle. On first touching the head, I 
 thought this indented bone was, as usual, the occipital, but a more 
 careful examination showed me that it was the left parietal bone, 
 and that the head presented its right side, instead of the vertex. 
 The head, though thus greatly compressed transversely, still filled 
 very imperfectly the pelvic brim, and the right side of the pelvis was 
 BO unoccupied as to allow a long loop of the umbilical cord to pro- 
 lapse. The vessels of the cord were beating, showing the child to 
 be still living. The local and constitutional symptoms under which 
 the patient was suffering, showed the necessity of immediate inter- 
 ference and delivery ; but how was the delivery to be accomplished ? 
 The mass of the head was too high above the brim to allow of the 
 successful use of the long forceps, even if there were space suflicient 
 (which was very doubtful) in the contracted pelvis, to allow of the 
 head passing in this form. The perforation and breaking up of the 
 head by craniotomy would allow of delivery, but the cord showed 
 the child to be alive, and I had doubts here, as in other cases, of the 
 propriety of murdering the infant, when delivery by other means 
 was possible ; the other remaining means consisted in its extraction 
 by turning, and, with Dr. Gordon's consent, I proceeded to deliver 
 the patient by this operation ; it was accomplished without much 
 difficulty. The child was still-born, but was recovered by the usual 
 means of resuscitation ; it survived, however, only a few hours. 
 That part of the scalp covering the parietal bone, which had infringed 
 so long on the promontory of the sacrum, remained depressed, and 
 pitted like an umbilical mark; the left parietal bone itself remained 
 also deeply displaced, and indented below the corresponding edges 
 of the occipital and right parietal, and on dissection, some blood 
 was found effused beneath it. The mother continued well for a few 
 hours, but then began to sink with symptoms of abdominal effiision 
 and rupture. She died on the following day. On dissection, the 
 neck and lower part of the body of the uterus were found lacerated, 
 and at one part the oblique and valvular-like laceration extended 
 through the peritoneum. The pelvic brim was obliquely ovate in 
 form, the right side being much larger than the left, but the con- 
 jugate diameter of the brim was very narrow. At its most contracted 
 point, a piece of wood wedged in between the promontory of the 
 sacrum and the nearest point of the pubis, measured only two inches 
 and seven-eighths. The pelvic joints felt loose and mobile." 
 
538 DYSTOCIA. 
 
 The observations which I have adduced in the preceding pages 
 seem then to point to the following deductions : 
 
 Mrst, Morbid contraction of the pelvic brim is, whatever mode 
 of delivery is adopted, liable to be a cause of rupture of the uterus. 
 
 Secondly, This morbid contraction principally, and almost only, 
 becomes a cause of rupture, when in conjunction with it, the labor, 
 as in the three cases just now detailed, has been allowed to become 
 long and protracted in its duration, and the compressed tissues of 
 the cervix are consequently rendered preternaturally friable and 
 laeerable.. Then — 
 
 Thirdly, It necessarily follows, that this complication would in all 
 probability be avoided, when morbid contraction of the pelvis exists, 
 provided either nature or art was enabled to deliver the patient 
 early, and did not permit of the tissues of the lower part of the 
 uterus becoming wedged in, contused, inflamed, and softened, 
 between the presenting head of the infant and the opposing points 
 of contraction in the pelvic brim. Hence a power of artificially 
 terminating labors with this complication, as soon after their com- 
 mencement as the dilatation or dilatability of the passages would 
 allow, would be, so far, a means of averting this fearful accident 
 under these circumstances. In the delivery by the operation of 
 turning, we possess such a power ; and by the exercise of it in these 
 cases we may, I believe, not only sometimes save the mother from 
 danger, but the child also from death. And I have already' shown 
 at sufficient length, that the degree of force required to extract the 
 head, will depress and groove the cranial bones of the child, without 
 necessarily injuring or tearing the soft pelvic tissues of the mother ; 
 provided always these tissues have not been previously brought into 
 a state of congestive and inflammatory friability by the previous 
 duration of the labor, and by the impaction of the head having been 
 allowed to be prolonged to an excessive and morbid degree. All 
 the evidence which I have adduced in different parts of the present 
 memoir goes to show this fact — that the danger attendant upon 
 turning, and other modes of operative delivery is, as a general law, 
 regulated less by the mere performance of the operation, than by the 
 degree of protraction allowed to elapse before operative interference 
 is adopted. And, in addition, the evidence which was brought for- 
 ward in the last section appears to entitle us to deduce as a supple- 
 ment or corollary to this important general law, that (supposing the 
 maternal passages are once dilated or dilatable) when operative de- 
 livery by the forceps, or crotchet, or turning, is accomplished with 
 comparative force, it is safer, cceteris paribus, to the mother when per- 
 formed early, than the same or other modes of operative delivery 
 would be if accomplished with comparative facility, but performed 
 
TTJENING AS A SUBSTITUTE FOR CRANIOTOMY. 539 
 
 late ; — 4liat, in other words, force is less dangerous than protraction ; 
 — that the hazards of operative delivery are more regulated by the 
 time of its adoption than by the difficulties of its accomplishment. 
 
 Fourthly, It must still be held constantly and prominently in view 
 that, in the proposed practice of turning, the great maternal danger 
 which the practitioner has to avoid, is injury and laceration of the 
 uterus, and he must use all due care and caution to avert any chance 
 of this accident. The preceding observations show some of the 
 leading points and objects which he should attend to, in order to 
 avoid it. These points are, principally — 1, the early perfermance 
 of the operation ; 2, when possible (as in Case I.) it should be effected 
 even before the membranes rupture, as turning is greatly more easy 
 and more safe before, than after, the evacuation of the liquor amnii ; 
 3, if the liquor amnii has escaped, and the uterus has contracted, 
 the uterine fibres should be previously, and perfectly, relaxed by the 
 use of opium or chloroform ; and, 4, the part of the operation con- 
 sisting in the actual turning and version of the child should be done 
 with extreme caution, and only and always attempted and accom- 
 plished during a perfect interval between two uterine contrac- 
 tions. 
 
 Other requisite rules and precautions are enumerated so fally in 
 most obstetric works, and so well known to obstetric practitioners, 
 that it is perhaps unnecessary to dwell here at great length upon 
 them. 
 
 The pages immediately following appeared several years after the publication of the pre- 
 ceding memoir, as one of Dr. Simpson's occasional contributions to obstetric pathology and 
 practice. We introduce them as showing still further the success of the proposed prac- 
 tice. — (Ed.) 
 
 m. 
 
 (From Edinburgh Monthly Journal of Medical Science, Feb. 1852, p. 135.) 
 
 Formerly, medical practitioners seem to have thought little, and 
 medical writers said little, regarding the very repulsive and revolting 
 character of the operation of craniotomy, when performed, as it fre- 
 quently was, when the child was still living. Apparently, some 
 obstetric practitioners and writers of the present day continue to 
 look upon the practice of craniotomy as one that should not unfre- 
 quently be adopted, and one which it is quite justifiable to adopt. 
 Obstetric reports and collections of cases have been published within 
 the last few years, describing craniotomy as performed forty or fifty 
 
540 DYSTOCIA. 
 
 times, or oftener, by the hand of the same practitioner. But per- 
 haps, ere long, it will become a question of professional ethics — 
 "Wbether a professional man is, under the name of a so-called opera- 
 tion, justified in deliberately destroying the life of a living human 
 being ? For one, I have a strong conviction that, in the kind of 
 case in which the operation is most frequently performed — namely, 
 where there is some obstruction from disproportion, not very great 
 in degree,* between the maternal pelvic brim and the fcEtal head, 
 the operation is not one which is either morally or professionally 
 justifiable, if the child be still living. Not many years ago, the 
 medical practitioner had this one plea to urge in favor of the adop- 
 tion of the operation — ^that perhaps the child was already dead ; inas- 
 much as there then existed no certain means of knowing that it was 
 still alive. Auscultation, however, now furnishes us with certain 
 means of settling this question in practice, and has consequently 
 removed this argument in favor of the adoption of the operation. 
 Or perhaps the result would be more correctly given by stating, that 
 in cases of lingering and difficult labor, from some disproportion 
 between the size of the foetal head and maternal pelvic brim, auscul- 
 tation can now determine the instances in which the child is dead, 
 and in which, therefore, it is justifiable and right to have recourse 
 to delivery by craniotomy ; while it shows us also, on the other hand, 
 the strong impropriety and illegitimacy of adopting the same opera- 
 tion in other analogous instances, where the sounds of the foetal 
 heart indubitably prove, to the ear of the medical attendant, that the 
 infant continues alive and well. 
 
 Assuredly no man would consider himself justified, on any plea 
 whatever, in perforating, and breaking down with a pointed iron 
 instrument, the skull of a living child an hour after birth, and sub- 
 sequently scooping out its brain. But is the crime less, when per- 
 petrated an hour before birth ? Modern physiology has fully shown, 
 that there is no such distinction between the mental and physiolo- 
 gical life of an infant, an hour before labor is terminated, and an 
 hour after it, as to make any adequate distinction between the enor- 
 mity of the act, as perpetrated at the one or at the other of these 
 two periods. And, as if to add to the horrors of craniotomy, when 
 
 ' During Dr. Collins' charge of the Dublin Lying-in Hospital, craniotomy was used in 124 
 cases ; in 79 instances on account of tediousness or difficulty in the labor. In only one of 
 these cases was the conjugate diameter of the pelvis as small as 2J inches. " This," he 
 says, " was by much the most defective pelvis I ever met with in the hospital." " The only 
 means," he observes, " of effecting delivery, where the disproportion between the head of 
 the child and the pelvis is so great as to prevent reaching the ear with the finger, is by reducing 
 the size of the head, and using the crotchet." 
 
 In most cases requiring craniotomy, the contraction at the brim is in the conjugate 
 diameter, from the projection forwards of the promontory of the sacrum — the very Itind of 
 deformity in which turning is most likely to be the means of saving the life of the infant. 
 
TTJBNING AS A STJBSTITUTB FOR CRANIOTOMY, 541 
 
 performed upon a living infant, some authors (and among them even 
 the very latest), tell us, that whatever doubts may have existed as 
 to the child being alive or not at the date of operating, the results of 
 the operation itself will decide this point ; for if it be alive at the 
 time of the deadly perforation of its scalp, skull, and brain, this 
 fearful fact will be revealed to the practitioner by warm and fluid 
 streams of blood pouring along his fingers and hand, before any 
 masses of broken brain escape ; or the reverse. 
 
 Unfortunately, no operation in morbid labors is more easy than 
 craniotomy. " Of all instrumental operations in obstetric surgery," 
 says Dr. Ramsbotham, "the perforation of the skull, and extraction 
 of the mutilated fcetus, is the easiest which could be undertaken, for 
 delivery in any case of compacted head ; and much do I fear that to 
 the facility with which this operation can be accomplished, have 
 been sacrificed the lives of many children."^ The operations which 
 midwifery possesses as substitutes for craniotomy are, however, not 
 very difficult in performance. And no conscientious practitioner 
 would surely hold the mere difficulty of an operation, as the criterion 
 by which he should decide upon the act of child-murder or not. 
 
 In women who, in previous labors, have had the children removed 
 from them by the operation of craniotomy, nature has herself occa- 
 sionally pointed out to us, in other labors in the same patients, 
 various means and resources by which that operation could be 
 avoided. Midwifery, as an art, has appropriated some of these hints, 
 and happily applied them in practice. Ever and anon, women, who 
 had been previously the subjects of difficult and dangerous labors, 
 have, when parturition came on accidentally, at the seventh or eighth 
 month, borne living children easily and safely. Accoucheurs have, 
 in similar cases, taken advantage of this suggestion, and have had 
 recourse to the artificial induction of premature labor. In other 
 instances, in which previous labors have been found difiicult or im- 
 possible without craniotomy, in consequence of the form of the 
 maternal pelvis, a successful termination has occasionally occurred, 
 when the child happened, in subsequent labors, to present with the 
 feet or pelvic extremity, instead of the head. In such instances, the 
 presentation of the feet or pelvis, or of a hand (requiring the pre- 
 sentation to be ultimately made footling), has sometimes, when first 
 discovered at the commencement of labor, been regarded as a source 
 of undoubtedly increased danger and difficulty ; when it has at last 
 in reality proved a source of increased safety to the mother, and led 
 indirectly to the preservation of the life of the infant. 
 
 The records of cases of difficult labor left us by Mauriceau, 
 Smellie, Hull, &c., show, that in particular forms of difficult labor 
 
 ' Obstetric Medicine and Surgery, p. 290. 
 
542 DYSTOCIA. 
 
 and deformed pelvis, the passage of the child by the feet or pelvic 
 extremity affords some special facility of transit, which is wanting 
 when the head or cephalic extremity forms the presenting part. 
 
 I believe that this apparent paradox is explicable by a reference 
 to the anatomical structure or form of the foetal head itself. At birth 
 the whole body of the child has in its configuration, been justly 
 compared to that of a cone — the arch, or bi-parietal diameter, of the 
 skull forming the base of the cone — ^the feet forming its apex j and 
 there being a gradual tapering and diminution of size from the former 
 to the latter points. But the festal head itself, when taken alone, 
 presents also, though more imperfectly, the configuration of a cone ; 
 p. , the base of the skull being considerably nar- 
 
 O rower than the arch, or, in other words, when 
 (as represented in the accompanying wood- 
 cut) we make a vertical transverse section of 
 "" the foetal skull, we find its bi-mastoid diam- 
 eter, 6 5, is considerably less than its bi-pari- 
 etal diameter, a a, — the cranium increasing 
 gradually in breadth and size from below 
 upwards. The difference between these two 
 diameters in the child at birth generally 
 amounts to from half an inch to three-quarters. 
 
 Further, it must be held in view, that at its base, or bi-mastoid 
 diameter, the foetal cranium is so strong, and its bones so strongly 
 united, as to render it quite incompressible. On the other hand, in 
 its arch, or bi-parietal diameter, the cranium at birth is generally so 
 thin and elastic in its bony parietes, and its sutures are so imperfectly 
 united, as to admit of the head being in its upper parts laterally 
 compressed, or even depressed and indented, at some point, without 
 necessarily destroying the life of the child. 
 
 In consequence of the above conformation, it happens, that when 
 the child, in a somewhat contracted pelvis, passes as a footling pre- 
 sentation, the cone-shaped head of the child first enters the contract- 
 ed brim by its narrower, or bi-mastoid diameter ; and the hold which 
 we have of the protruded body of the child, after its extremities and 
 trunk are born, gives us, when necessary, the power of employing 
 so much extractive force and traction upon the engaged foetal head, 
 as to compress the elastic sides of the broader, or bi-parietal, portion 
 of the cone, between the opposite sides or parts of the contracted 
 pelvic brim, to such a degree as to allow of the transit of the entire 
 volume of the head. In natural labor, the mechanism consists in 
 passing a conical-shaped body (viz., the child) through an aperture 
 (the maternal pelvis) somewhat larger than thebaseof the cone itself 
 (the arch of the foetal skull) ; and in this case, when once the base 
 
TURNING AS A SUBSTITUTE FOR CRANIOTOMY. 643 
 
 of the cone or head does pass, a single pain is generally sufficient to 
 expel the remainder of the infant — an arrangement by which dan- 
 gerous compression of the cord is avoided by nature. But when the 
 brim of the pelvis is somewhat less than the natural standard, 
 or the head somewhat above that standard, either from size or 
 malpresentation, the conditions are so far altered, that we have 
 now a conical-shaped body (the child) to be passed through an 
 aperture (the brim of the maternal pelvis) somewhat smaller than the 
 body that is to pass. And a little reflection is sufficient to show, 
 that under such circumstances, the passing body would be more 
 easily dragged through the contracted aperture, by bringing the 
 narrow apex of the cone first, than it could be pushed through that 
 aperture by allowing the base, or broad end of the cone, to be pre- 
 sented to it ; more particularly, if that broad end is, as we have sup- 
 posed, somewhat larger than the aperture through which it is to pass. 
 
 Since vsriting upon this subject at considerable length a fewyears"" 
 back, I have repeatedly had occasion to turn the child in difficult 
 cases, where the head was not far entered into the brim, and 
 where the long forceps failed, or were contra-indicated; and in which 
 the alternative of craniotomy seemed the only other measure 
 that could be adopted. A number of my professional brethren 
 have reported to me the success with which they have also followed 
 this practice. In the way of illustration, I adduce the three following 
 cases which have occurred in my own practice and in that of my 
 friends Drs. Weir and Peddie, within the last few weeks. I have 
 the pleasure of detailing the cases recently met with by Dr. Weir and 
 Dr. Peddie in their own words. 
 
 Case I.— On the evening of January 11th, I was asked to see a 
 case of lingering labor, under the charge of Mr. Keeling and Dr. 
 Cooper. The patient, set. 26, and pregnant for the first time, had 
 been in labor for about forty-eight hours. The first stage of labor 
 had been terminated about thirteen hours before I saw her ; and the 
 head had remained at the brim of the pelvis, without advancing in 
 any degree further down, for upwards of ten hours. On examining, 
 I found the vagina fully relaxed, but its mucous membrane was be- 
 coming heated and (Edematous, in consequence, in all probability, of 
 the lengthened obstruction of the brim above. The infant's head 
 was elongated, down into the cavity of the pelvis ; but the broad 
 part of the head had not passed the brim. The promontory of the 
 sacrum was so easily reached by the finger, as at once to give the 
 idea, that it projected forwards to an extent greater than natural. 
 The direction of the sagittal suture showed that the head lay more 
 transversely than in the usual normal presentation. The face of the 
 infant was directed to the right sacro-iliac synchondrosis, or rather 
 
544 DYSTOCIA. 
 
 to tlie right ilium. The patient was put fully under the influence 
 of chloroform, and the long forceps were easily applied. The blades 
 of the instrument were, as we found after the birth of the child, ap- 
 phed as usual, obliquely over the head, and did not offer to slip in 
 any degree under the traction that was applied. But no amount of 
 traction that I thought it justifiable to employ could move the head 
 downwards ; and Mr. Drummond failed also in making any impres- 
 sion upon the advancement of the cranium, when I gave him the 
 instrument to use. I altered, in several ways, the direction of the 
 traction, and the position of the patient, but still without any suc- 
 cess, and at last withdrew the forceps. Conceiving that possibly 
 there might be some obstruction to the advancement and passage of 
 the child, from some malposition of the arm about the neck, or from 
 some malformation, I introduced the hand by the side of the child's 
 head, for the purpose of ascertaining these circumstances, but found 
 nothing that appeared to me capable of explaining the delay, and 
 the impossibility of advancing the head by the .forceps, except it 
 were some oblique position of the head, relatively to the neck 
 or trunk of the infant. A few years ago, I should perhaps in such a 
 case have deemed the operation of craniotomy the only remaining re- 
 source. But the stethoscope showed that the child was still alive and 
 well. And, under these circumstances, I resolved to attempt to ex- 
 tract it by the operation of turning. The patient was deeply anses- 
 thetized, in order to relax the uterus as much as possible ; and at a 
 time when all uterine contraction seemed absent, I passed up my 
 hand and brought down one of the lower extremities of the child. 
 While doing so, a large loop of the umbilical cord fell down into 
 the vagina. I now found an obstruction to the complete version 
 of the infant, which I had met with previously in other cases of 
 turning, when the head was the originally presenting part. For, 
 though one foot was down at the orifice of the vagina, the version 
 of the fcetus upon its own axis had not been complete, and 
 the head was still at, or near the brim. Consequently, while Mr. 
 Drummond held and retained the extruded foot, I passed up my 
 right hand to the head to push it upwards, so as to complete the 
 version — a part of the operation which, in this as in other cases, is 
 always much aided by the manipulation of the left hand upon the 
 abdomen externally. Subsequently the trunk and arms were easily 
 extracted, and the traction requisite to make the head pass the brim 
 was much less than I had seen in several similar cases. The child 
 after birth had the heart still pulsating, and was readily revived by 
 repeatedly plunging its body alternately from a warm into a cold 
 bath. Yesterday, 21st of January 1852, I saw both the, infant, 
 which was, perhaps, rather above the usual size, and the mother 
 quite well. 
 
TURNING AS A SUBSTITUTE FOE CBANIOTOMT. 545 
 
 Case n. — " On the evening of the 2d of December 1851, 1 was 
 requested," Dr. "Weir writes ine, "by my pupil Dr. Bone, to 
 give an opinion upon a case of protracted labor. The patient bad 
 been eighteen hours in labor of her fifth child. She had been on 
 previous occasions the subject of tedious and difficult labor, except 
 in one confinement, when the child was born below the usual size. 
 Her face was flushed, eyes suffused, skin hot, pulse quick, and rest- 
 lessness great. The os uteri was completely dilated, and the liquor 
 amnii discharged. The head was still at the brim of the pelvis, and 
 although the pains had been for many hours quick, strong, and ex- 
 pulsive, a very small portion of it penetrated the pelvic cavity, and 
 so much as did, receded above the brim upon the cessation of the 
 uterine contractions. Under these circumstances, .1 determined to 
 deliver her immediately ; and as it appeared a favorable case for turn- 
 ing, decided upon doing so in preference to using the long forceps. 
 The chloroform was administered till deep snoring was produced, and 
 the hand introduced in the usual manner. So completely were the 
 uterine efforts suspended, that I grasped both the feet before the 
 uterus contracted in the slightest degree upon my hand. No diffi- 
 culty was experienced in extracting the child till the head reached 
 the brim, when considerable force was required to draw it through, 
 but not so much as to prevent its being born alive. The mother 
 did well, and in a few days was attending to her household duties. 
 The child presented after birth a deep depression of the cranium on 
 the anterior part of the left parietal bone, immediately above the 
 ear — the result, no doubt, of compression against the promontory of 
 the sacrum. But this has not affected the health of the child, which 
 now, 20th January 1852, is otherwise thriving and well." 
 
 Case HE. — " On the 30th IJfovember 1851, I was called," writes 
 Dr. Peddie, " to Mrs. , aged 30, in her sixth confinement. 
 
 " At her first confinement, ISTovember 10, 1843, in consequence 
 of contraction at the brim of the pelvis, principally on account of 
 an exostosis projecting from the promontory of the sacrum, and to 
 some extent also from an under-average size of the pelvis, she was 
 delivered by embryulcio. This extreme measure was not resorted 
 to until forcible natural pains had existed for many hours, without 
 effecting an entrance for the head at the brim of the pelvis ; until 
 the long forceps had been applied, first by myself, and then by Dr. 
 Simpson, without obtaining any advance of the head ; and until the 
 foetal circulation had been ascertained to have ceased. After the 
 perforation was employed, no small difficulty was experienced in 
 dragging the child through the pelvis. 
 
 • "At her second confinement, 26th September 1844, after allowing 
 VOL. I. 35 
 
546 DYSTOCIA. 
 
 four hours to elapse from the time when the os uteri was fully 
 dilated without the smallest descent of the head, I succeeded, with 
 the long forceps and powerful traction, in dehvering thp child safely. 
 This fortunate termination was the more satisfactory, that the induc- 
 tion of premature labor had been considered and decided against 
 some months previously. 
 
 " At her third confinement, 20th April 1846, the labor went on 
 naturally, and the child was expelled without artificial assistance. 
 The explanation of this fortunate event appeared to be, that the child 
 was a female one, and considerably under the average size, the head 
 more particularly being small. 
 
 " At her fourth confinement, 28th October 1847, the labor re- 
 sembled Mrs. 's first, the first stage being short, while the 
 
 second had existed for many hours before I saw her. The pains 
 were extremely forcible, conveying the impression of danger from 
 rupture of the uterus. After trying two different pairs of long 
 forceps, I sent for Dr. Simpson, who furnished me with a third pair 
 — which, though easily applied and powerful, did not enable me to 
 bring forward the head in the least degree. Dr. Simpson then pro- 
 posed turning in preference to perforation — the more especially as 
 the child was ascertained to be still alive ; and this he accomplished 
 readily, the patient being very deeply under chloroform, and de- 
 livered her after the employment of very powerful traction. The 
 child was at first as if still-born, but was brought about after the 
 continued use of the usual means. 
 
 " At her fifth confinement, 11th December 1848, the presentation 
 was a footling one — as if nature was indicating the right mode of 
 procedure ; and, accordingly, when the first stage was completed, I 
 seized hold of the other foot, brought it down, and delivered the 
 child safely, but not without the employment of very considerable 
 traction in bringing the head through the pelvis. 
 
 " At her sixth and last confinement, 30th November 1851, I saw 
 
 Mrs. at eleven a.m. Pains had begun about twelve o'clock 
 
 on the previous night, and had gone on regularly, but not severely, 
 until within two hours of the time of my visit. I found the os com- 
 pletely dilated, the vagina filled with tensely distended membranes, 
 and the head above the brim. On passing the hand to make a 
 proper examination, I recognized the old exostosis, but decidedly 
 larger, fully the size of a small walnut, projecting from the sacrum 
 immediately within the right sacro-iliac symphysis. I found also 
 that the head was lying with the occiput to the sacrum, pointing 
 somewhat to its left iliac symphysis, and the forehead to the right 
 side of the symphysis pubis. I was also satisfied that the head was 
 of large size, while the pelvis generally was small. 
 
TURNING AS A SUBSTITUTE FOE CRANIOTOMY. 547 
 
 " Considering previous experience in the case of this patient, 
 and the remarkable success of turning in her fourth labor, when 
 she could not have been delivered otherwise than by the life-sacri- 
 ficing perforator; and considering that in the present labor the 
 peculiar position of the head would render efibrts by the long for- 
 ceps — ^however well employed — useless, I resolved at once to turn. 
 This I accomplished, and brought down the body very satisfactorily, 
 while the patient was placed deeply under chloroform by Dr. Harper 
 of Leith, who kindly assisted me. As was to be expected, much 
 exertion and pulling were necessary to drag the head through the 
 pelvis, although the most favorable respective diameters were chosen. 
 A towel slipt round the anterior part of the neck and chest, and 
 crossed over the shoulders behind, gave steady purchase, and enabled 
 me more readily to complete the delivery. The child was a large 
 boy, and at first apparently still-born ; but in about twenty minutes 
 after unceasing attention, by giving alternate plunges in hot and 
 cold baths, as practised in the first and second labors, and by the 
 use of artificial respiration, he was completely restored. He ulti- 
 mately did well, and Mrs. made an excellent recovery. The 
 
 child weighed 9 lbs. 5 oz." 
 
 In conclusion, let me briefly recapitulate some of the principal 
 advantages which, as it appears to me, the operation of turning 
 has over the operation of craniotomy, in cases such as we have 
 been considering in the present communication, viz., where the 
 pelvis is somewhat too small, or the foetal head somewhat too 
 large, to allow the infant to pass by the unaided efforts of nature, 
 or even with the assistance of the long forceps, if that instrument is 
 had recourse to. 
 
 1. It substitutes the delivery of the infant by the hand of the 
 accoucheur, for its delivery by formidable steel instruments. And, 
 certainly, the avoidance of instruments is, as a general principle, 
 desirable when it is possible. 
 
 2. The transit of the cone-shaped head of the child through a 
 somewhat narrow brim is facilitated by the narrow end of the cone 
 (or bi-mastoid diameter of the head) being made to enter and engage 
 first in the contracted brim ; and the hold which we obtain of the 
 extruded body of the child enables us to employ so much extractive 
 force upon the engaged foetal head, as to make the elastic sides of 
 the upper and broader portion of the cone (or bi-parietal diameter 
 of the cranium) to become compressed, and if necessary indented, 
 between the sides of the contracted brim. 
 
548 DYSTOCIA. 
 
 3. When the child is brought down footling, we have far more 
 power than when the spherical arch of the cranium presents, of 
 manually adapting and adjusting, when necessary, the shape of the 
 head to the shape of the contracted brim ; the rounded form of the 
 cranium not afibrding us any sufficient hold and purchase for this 
 purpose in cranial presentations. 
 
 4. The lateral and very temporary compression of the, foetal head 
 by the contracted sides of the pelvis, such as we can produce and 
 effect on artificial turning and contraction, is less dangerous to the 
 life of the child than its oblique or longitudinal compression with the 
 long forceps, or by the long impaction of the head itself in the con- 
 tracted brim. 
 
 5. In cases where the narrowness is greater, and such as to pro- 
 duce a depression or indentation in the elastic and flexible cranium 
 of the child, still this transient depression, or indentation, is not 
 necessarily destructive to life, as the perforation of the head in cra- 
 niotomy is. Children often survive and recover, when born with 
 the head much distorted and even indented. See, for example, the 
 child in Case IT., and other similar instances recorded by Smellie, 
 Denman, Velpeau, Duges, Jacquemier, Radford, &c. &c. 
 
 6. On these accounts, the operation of turning affords a fair 
 chance of life to the child, while craniotomy affords none. And 
 even when the turning and extraction require some considerable 
 time for their performance, the resulting temporary asphyxia of the 
 child is not necessarily so deep and fatal but that the infant may be 
 revived by appropriate measures applied after birth. I can, for one, 
 state that in these cases, and in instances of common footling and 
 turning cases, I have repeatedly been astonished at the viability of 
 the infant after traction had been applied to it, both so strong in 
 degree and so long in duration as to leave apparently little hope of 
 its survival ; and I have heard other practitioners make the same 
 remark as the result of their experience. 
 
 7. The operation of turning, under the circumstances we speak of, 
 will, I believe, be found also to be more safe to the life of the mother 
 than the operation of craniotomy. In every instance the operation 
 of craniotomy is necessarily fatal to the infant ; but in a very large 
 proportion also, this operation is fatal to the mother. The statistical 
 results collected by Dr. Churchill and others show that craniotomy 
 is fatal to the mother in about 1 in every 5 cases in which it is per- 
 formed ; while turning does not generally prove fatal in above 1 
 
TURNiNO AS A SUBSTITUTE FOR CRANIOTOMY. 549 
 
 in every 15 or 16 patients, even including complicated cases.' Be- 
 sides, it affords this great source of safety to the mother, that, 
 cceteris paribus, delivery by turning can be, and is, as a general rule, 
 adopted far earlier in the labor than delivery by craniotomy; 
 and in proportion as it is practised earlier, so far also will it be 
 practised with greater safety and greater success — the maternal mor- 
 tality attendant upon parturition, whether natural or operative, in- 
 creasing always in a ratio progressive with the increased duration of 
 the labor. 
 
 Among the operative deliveries which occurred in the Dublin 
 Hospital when Dr. Collins was master of the institution, the dura- 
 tion of the labors at the time of operating is stated in 125 cases. 
 Among these 125 instrumental and operative deliveries, only 1 in 
 every 17 of the mothers was lost, when the delivery was accom- 
 plished within twenty-four hours from the commencement of labor; 
 1 in every 7 of the mothers died when the delivery was delayed till 
 from twenty-four to forty-eight hours ; and nearly 1 in every 2 mothers 
 perished when the delivery was delayed till the labor had gone on 
 above forty-eight hours. Obstetricians have often argued, that if, 
 in cases of obstructed labor, the delivery is delayed for a sufficient 
 length of time, the child will be ultimately destroyed by the uterine 
 action and compression, and that thus craniotomy will be at last per- 
 formed upon the dead infant — the child being killed by an act of omis- 
 sion, and not of commission. But even such very protracted delay is 
 not always fatal to the infant — some continuing to survive when the 
 labor is prolonged for sixty, or seventy, or more hours.* And it is 
 
 ' Out of 303 craniotomy operations, 60 of the mothers died, or 1 in 5. — Churchill's Mid- 
 wifery, p. 314. Out of 192 cases of turning, 12 mothers died, or 1 in 16. — Ibid. p. 250. 
 "Between," says Dr. Ramsbotham, "the years 1823 and 1834, 1 delivered more than 120 
 women tinder transverse presentations, independently of a few cases to which I was sum- 
 moned, where spontaneous evolution occurred. Many of these cases presented a formidable 
 appearance ; for in one the membranes had bfeen ruptured a whole week ; in another, 69 
 hours ; in a third, 58 hours ; in another, 55 ; in another, 53 ; and in many, more than 48 ; 
 and, as a general principle, we presume, that the longer the liquor amnii has been evacu- 
 ated, the more likely is the uterus to have embraced the foetal body firmly, and the more 
 difficulty will there be in overcoming the resistance. In none of these cases did I exhibit 
 large doses of opium, and in those few where bleeding was practised, that operation was 
 had recourse to, not for the purpose of relaxing the rigidity of the uterine fibres, but to relieve 
 the inflammation which the soft structures were suffering, and to remove tumefaction. In 
 not one of these instances was any injury inflicted on the uterine structure by the hand, nor 
 did any permanent evil arise that could be attributed to the operation. In four cases only 
 was the uterus so powerfully contracted as to refuse admittance to the hand, and compel me 
 to adopt the alternative of eviscerating or decapitating the fostus." — Obstetric Medicine and 
 Surgery, p. 362. 
 
 2 Out of 27 cases reported by Dr. Collins, in which labor was prolonged to 60 hours and 
 upwards, in 16 the child was born dead; and in 11 it was still alive at birth. Of the 27 
 mothers, 1 in 4 died. 
 
550 DYSTOCIA. 
 
 always to be remembered, that the delay itself, if dangerous to the 
 life of the child, is also, as the above and other evidence shows, 
 almost equally dangerous to the life of the mother. In such cases 
 of long obstruction and delay, even after the head is perforated by 
 craniotomy, much traction is often required to drag the shoulders 
 through the contracted brim, and that at a time when the structures 
 at the brim are so damaged by previous pressure as to be little able 
 to bear compression with safety. And I do think that we have 
 most ample grounds for believing, that the long compression of the 
 soft parts, such as occurs in very protracted labor, is more truly 
 dangerous to the structures than a short compression of them, greater 
 in amount, such as occurs in the operation of turning when early 
 performed. 
 
 In not a few cases, in which the operation of turning is resorted 
 to in consequence of the complication which we have been con- 
 sidering, the practitioner must be prepared to meet with such re- 
 sistance to the passage of the head through the brim as will require 
 some adjustment and considerable physical exertion on his part in 
 order to overcome it. But if the head be so adjusted in the brim, 
 that the shape of the one is, as much as possible, adapted to the 
 shape of the other ; if the chin be kept depressed towards the 
 sternum ; and if the traction applied be made in the proper axis of 
 the brim itself, no small amount of extractive force may be used 
 without compromising the safety of the mother or infant. The 
 degree of traction which the structures of the infant's neck will, in 
 this way, undergo, is much greater than one would a priori suppose. 
 And, as a very general rule, the elastic lateral walls of the cranium 
 of the child will become compressed or indented, before any dan- 
 gerous injury is inflicted upon the structures of the neck. But on 
 this subject I most willingly substitute, for any remarks of my own, 
 two or three sentences from the work of an author — always prac- 
 tical and always cautious — ^Dr. Denman, who, in speaking of the 
 occasional difficulty of extracting the head in common pelvic and 
 turning cases when the brim is somewhat contracted, gives, among 
 others, the following directions : 
 
 " The force with which we endeavor to bring down the head of 
 the child must then be gradually increased, till we are convinced 
 that a greater degree is inconsistent with the safety of the child, or 
 induces the hazard of separating the body from the head. Should 
 the head descend in ever so small a degree, we must not act pre- 
 cipitately, and increase the force in order to finish the delivery sud- 
 denly ; but we must proceed with circumspection, or we shall add 
 
TURNING AS A SUBSTITDTE FOR CRANIOTOMY. 551 
 
 to the danger which the child is already in, and run the risk of 
 doing injury to the mother ; though, when the head begins to ad- 
 vance, there is seldom much remaining difficulty, the cause usually 
 existing at one particular part of the pelvis. It has been said that 
 children have sometimes been born alive, when the strongest efforts, 
 and these continued for many hours, have been made to extract the 
 head detained in this position. But I have not been so fortunate 
 as to meet with any such instances, a short space of time having 
 generally been sufficient to frustrate my hopes, and convince me 
 that the child was dead. Though, when the head has been detained 
 a considerable time, a few cases have terminated more favorably 
 than I could have expected, and I have been agreeably surprised 
 with the discovery of some faint signs of life, which by the assiduous 
 and careful use of the common means, have been improved, and 
 the life of the child at length perfectly recovered. * * * "When 
 we have in vain exerted all the force which we think reasonable and 
 proper, and which, in some cases, must be more than any circum- 
 stance would be thought to require, it will be expedient to rest, for 
 the purpose of gaining all the advantage to be gained by the com- 
 pression of the head. On this account the mother will actually 
 suffer no more inconvenience than would have been purchased if 
 the head had originally presented, and been locked in the pelvis. 
 After waiting some time, we must renew our attempts to extract, 
 and thus proceed, alternately resting and acting with efficacy and 
 resolution, and if the hold we may have of the body or extremities 
 of the child does not suit, a silk handkerchief or other band may 
 be passed round its neck, and this will be found a very handy and 
 convenient instrument. It must," Dr. Denman adds, "be a very 
 great disproportion between the head of the child and the pelvis, 
 which is able to withstand this method of proceeding, if we persevere 
 in it with prudence and steadiness ; because the integuments of the 
 head will burst, or the bones be bent inwards in an extraordinary 
 degree, or even broken. * * * If it fail, it then only remains 
 that we should lessen the head of the child ; and the operation may 
 be as easily performed in this as in the natural presentation of the 
 head. When," he continues, "the perforation is made, and the 
 brain evacuated, the head may be readily extracted either by pulling 
 by the body of the child or by inserting a crotchet in the opening 
 made by the operator as in other cases. But it will be scarcely 
 believed how seldom this operation is necessary under these circum- 
 stances, if we have not been in a hurry, but have acted with pru- 
 dence. Nor," concludes Dr. Denman, "have I ever known any ill 
 consequences follow the compression which the soft parts undergo 
 
552 ARTIFICIAL DELIVERY. 
 
 between the head of the child and the sides of the pelvis, if proper 
 attention were afterwards paid to the state of the bladder and 
 rectum."' 
 
 REMARKS ON THE OPERATION OF CRANIOTOMY." 
 
 (From British and Foreign Medical Review, Oct., 1841, p. 486, etc.) 
 
 No surgical operation whatever is, abstractly considered, more _ 
 revolting to human nature than that of craniotomy or embryulcio ; 
 it is, at the best, a dreadful expedient. In too many instances it 
 implies the direct and deliberate murder of a fellow-being by the 
 hand of the accoucheur. It is one of the few operations, the pro- 
 priety or non-propriety of which has engaged all the logical subtlety 
 of the metaphysicians. Some of the greatest foreign authorities of 
 the present day doubt if it ever ought to be performed so long as 
 the child is alive. But we have no desire to discuss the question of 
 the morality of the operation. 
 
 In performing the first part of the operation, namely, the perfora- 
 tion of the head, Drs. Ramsbotham and Davis both advise us to use 
 Smellie's scissors, made with a cutting edge to both sides of each 
 blade ; Dr. Eigby recommends the perforator of N"aegele, the chief 
 peculiarity of which is that, like the analogous instruments invented 
 by Steidele and Von Busch on the continent, and by Drs. Bone and 
 Holmes in our own country, the blades do not cross at the lock, 
 and the operator can, by closing the handles together with one hand, 
 make their cutting points sufficiently diverge, thus leaving free the 
 fingers of the other hand in the vagina to guard and protect the 
 maternal parts from any threatened injury. Both authors properly 
 advise the perforation to be always made in the presenting parietal 
 bone, and not at a suture. Dr. Rigby, after perforating, throws a 
 strong stream of water into the cavity of the skull through a long 
 elastic tube, in order to break down and wash out as much as pos- 
 sible of the substance of the brain, and thus allow the cranial 
 bones to collapse more readily and completely. 
 
 In extracting, after perforation, Dr. Ramsbotham uses the common 
 straight crotchet, and well remarks that simple as the instrument is, 
 it is one of the most difficult in midwifery to procure good, as the 
 least variation of the degree of sharpness of its point makes a con- 
 siderable difierence in its value. He states further that the use of 
 
 ' Introduction to the Practice of Midwifery, p. 495, &c. 
 
 * From a Review of the works of Rigby, Ramsbotham, and Davis. 
 
CEANIOTOMT. 553 
 
 the blunt hook may sometimes supersede the employment of the 
 crotchet when the bones are too loose and fragile to afford a pur- 
 chase to the latter. The craniotomy forceps are in his opinion 
 more dangerous, and less to be trusted to than the crotchet, but the 
 several objections which he makes to these forceps refer to the in- 
 strument in its worst form, with a Smellie joint and immense teeth, 
 and scarcely apply to the simpler and more efficient varieties of it. 
 
 We beg to add only one remark in regard to extraction. What- 
 ever means or whatever instruments are employed to effect it, we 
 have long been of opinion that one great principle should direct 
 their application, namely, they ought to be fixed in such places and 
 used in such ways as will enable us to bring down the head in its 
 most natural and consequently most favorable position. We have 
 long been convinced that the great peril, not merely of injury but 
 of death to the mother from this operation, arises in a great mea- 
 sure from the head being so often so altered in its presentation, and 
 hence necessarily so increased in its diameters by the mode and 
 place in which the crotchet is fixed, that the cranium is at last torn 
 as it were through the pelvic passages by pure physical force alone ; 
 while a little attention to the proper adaptation of the instrument 
 so that the head may be brought down in its most favorable position, 
 will generally be found to lessen immensely both the difficulty and 
 the danger of the operation.^ We speak here of the more common 
 cases of embryotomy. We are perfectly aware that when the pelvis 
 is much contracted, we are obliged, as has been well pointed out by 
 Dr. Hull, to alter in different ways the presentation of the head, 
 . always, however, bringing it into such positions that its diameters 
 are in each case those requiring the least possible space. 
 
 As regards the mother, craniotomy has, in general, proved an in- 
 finitely more dangerous operation than the forceps, and we have the 
 greatest doubts of the soundness of the rule laid down by some ac- 
 coucheurs, that in individual cases the presence of signs of the death 
 of the child ought to determine our having recourse to the perfora- 
 tor and crotchet in preference to the forceps. The rule is a danger- 
 ous one in two points of view : first, because, as we have just stated, 
 craniotomy seems attended with actually greater risk to the mother; 
 and secondly, because it is exceedingly difficult to make ourselves 
 certain, in special instances, of the death of the infant. All nega- 
 tive symptoms of its death are very equivocal ; even if the cord be 
 
 ' When the crotchet is fixed upon the posterior part of the parietal or upon the occipital 
 region, the infant's head can be brought down through an aperture an inch or so less in 
 diameter than when the crotchet is fixed upon the frontal region. In fact, when the crotchet 
 is fixed on the forehead, it brings the head down in the increased diameter required by an 
 ordinary forehead presentation. Yet Dr. Ramsbotham (plate 59) and Dr. Churchill (Fig. 
 89) have both inadvertently represented the crotchet as usually fixed to the frontal region. 
 
554 ARTIFICIAL DBLIVEKY. 
 
 felt pulseless, still we may not be certain that it is tlie cord of the 
 child whose head is presenting. Dr. Ramsbotham has properly- 
 shown this one source of error, that it may happen to be the cord 
 of another twin infant. The stethoscope in some of these doubtful 
 instances is of the greatest use in determining the presence of life 
 in the infant ; and in thus encouraging us to persevere as long as 
 possible in other means, as in the use of the long or short forceps, 
 before we have recourse to the final and fatal operation of cran- 
 iotomy. By its aid in this way we have been induced to use the 
 forceps, and with the happy result of saving the child, when, pre^ 
 viously to auscultation, its head had been doomed to perforation by 
 others. We do not, however, on the other hand, hold that because 
 the sound of the foetal heart cannot be heard, the indication is of 
 equal value. "We do not perform craniotomy in individual cases 
 because the child is dead, but because the mother's life is in danger, 
 and delivery cannot be completed by other means less safe to her. 
 That the employment of the forceps is, as a general rule, safer to 
 the mother herself than the employment of the crotchet, is a pro- 
 position which Dr. Churchill of Dublin and others have proved by 
 ample statistical data. Our German and French neighbors have of 
 late years, in consequence of this and other reasons, been employ- 
 ing the forceps much more, and the crotchet much less, frequently 
 than we do in Great Britain. We trust yet to see the same reform 
 work its way into English obstetric practice. 
 
 RELATIVE STATISTICS OF ARTIFICIAL DELIVERY. 
 
 VIENNA— PAEIS— DUBLIN." 
 (From Edinburgh Monthly Journal of Medical Science, June, 1851, p. 546.) 
 
 The following are the results to the mothers and children, from 
 artificial delivery by the forceps, vectis, craniotomy, and turning, in 
 the three largest lying-in hospitals of Europe, as respectively re- 
 ported by B er and Arneth relatively to the Vienna Hospital, by 
 Lachapelle and Boivin relatively to the Paris Hospital, and by Drs. 
 Collins, M'Clintock, and Hardy, relatively to the Dublin Hospital. 
 
 1. The proportion of cases of operative or artificial delivery of 
 the child is very nearly the same in all these three great hospitals. 
 In the Vienna Hospital, under Boer, 1 out of every 55 women was 
 delivered by one of the operations we have named, namely, by the 
 
 ' From a Review of Arneth's Midwifery. 
 
HOSPITAL STATISTICS. 555 
 
 forceps, vectis, craniotomy, or version ; and during the time of Dr. 
 Arneth's report, operative delivery was resorted to in 1 out of every 
 69 cases. In the Paris Hospital, Madame Boivin reports 1 out of 
 every 61 labors as requiring delivery by operation. Madame La- 
 chapelle found that in the 10 years preceding 1810, 1 in 57 mothers 
 wajs delivered artificially, and during the subsequent 10 years, 1 in 
 82 required such a procedure. In the Dublin Hospital, Dr. Collins 
 reports 1 out of every 86 women as having been delivered artificially ; 
 and Drs. M'Clintock and Hardy describe 1 out of eveiy 52 of their 
 cases as having been similarly assisted. 
 
 2. Though the total proportion of operations is thus not very 
 different in these three large hospitals, yet the results to the children 
 are very diverse. "We shall give these results in round numbers, 
 and without copying the minute fractions that Dr. Arneth has ap- 
 pended. In the Vienna Hospital, in his operative deliveries, Boer 
 lost nearly 1 in 2 of all the children ; Arneth, 1 in 3, or 33 out of 
 95 cases ; in the Paris Hospital, in the same kind of cases, Lacha- 
 pelle reports less than 1 in 2 of all the children as having been still- 
 bom, or 207 were still-born out of 541 deliveries ; while Madame 
 Boivin reports about 1 in 4 of the children as having been lost, 95 
 having been still-born in 334 artificial deliveries. In the Dublin 
 Hospital, in his cases of artificial or operative delivery. Dr. Collins 
 reports about 3 in every 4 children as having been lost — 150 of 
 the children out of 193 cases having been still-born ; and Drs. 
 M'Clintock and Hardy return, under the same circumstances, a 
 nearly similar amount of infantile mortality out of 128 operative 
 cases reported by them — the infants being still-born in 98 instances. 
 Or perhaps we may state these results, as regards the infantile mor- 
 tality in operative cases, more intelligibly in percentage proportions. 
 Taking this method, the results are as follows : Out of every 100 
 operative cases, Boer lost about 47 of the children ; Arneth 34 ; 
 Lachapelle 36 ; Boivin 28 ; Collins 77 ; and M'Clintock and Hardy 
 76. 
 
 3. The maternal mortality in operative cases is a matter of even 
 still greater moment and greater diversity. Unfortunately, we have 
 no records on this point from the Parisian Hospital, as Lachapelle 
 and Boivin have not published any general statistics relative to the 
 fate of the mothers. The maternal results, however, in these cases, 
 are given with suflicient fulness in both the Vienna and Dublin 
 reports. Boer lost 1 out of every 17 mothers in his cases of opera- 
 tive delivery ; Arneth 1 out of every 9. In his cases of operative 
 delivery. Dr. Collins lost 1 out of every 4 mothers; and Drs. 
 M'Clintock and Hardy nearly 1 out of every 5. Or, to state the 
 
556 
 
 ARTIFICIAL DELIVERY. 
 
 result in percentage proportions, out of every 100 operative or arti- 
 ficial deliveries, Boer lost 6 mothers; Arneth 12 ; Collins 25 ; and 
 M'Clintock and Hardy 22. 
 
 As some explanation of these difierences in cases of morbid labor, 
 in the results to the mothers and children, we may state one fact, 
 without entering farther into the discussion of the subject. In 
 almost all, or indeed all, operative cases in the Dubhn Hospital, in 
 which the head of the child has not completely passed down into the 
 pelvic cavity, craniotomy is employed — an operation always, of 
 course, fatal to the child, and extremely dangerous to the mother.^ 
 In the Vienna Hospital, on the other hand, they deliver the child by 
 turning, and not by craniotomy, when the head is above the brim ; 
 and they apply the forceps in other cases, where the head has 
 partially descended through the brim, but which in Dublin would 
 still be regarded and treated as crotchet cases. 
 
 "We cannot but express our regret, first, that such statistical returns 
 from our larger hospitals should not appear more frequently ; and, 
 secondly, that some general and uniform system of statistical observa- 
 tion has not yet been agreed upon among the accoucheurs of the 
 different lying-in Hospitals of Europe and America — an arrange- 
 ment that would add greatly to the practical value and importance 
 of such reports. 
 
 We have thrown the preceding statistics into a tabular form, to render the contrast they 
 present still more evident. — (Ed.) 
 
 Reporters. 
 
 Proportion of 
 Operative Cases. 
 
 Percentage of 
 Infants Lost. 
 
 Percentage of 
 Mothers Lost. 
 
 ^--. iSb, . : : 
 
 fBoivin, . . . . 
 Pnri« Laehapellet— 
 Pans, 1800-10, . . 
 
 { 1810-20, . . 
 
 f Collins, . . . 
 Dublin, I M'Clintock ) 
 
 ( and Hardy, J ' 
 
 1 in 55 labors, 
 1 in 69 " 
 1 in 61 '' 
 
 1 in 67 " ) 
 1 in 82 •' 5 
 linSe « 
 
 lin52 " 
 
 47 in 100 
 34 in 100 
 23 in 100 
 
 36 in 100 
 77 in 100 
 76 in 100 
 
 6 in 100 
 12 in 100 
 
 25 in 100 
 22 in 100 
 
 ' The two great causes of maternal danger and death attendant upon craniotomy appear 
 to be — 1st. The very long duration to which the labor is generally allowed to go on before 
 this mode of delivery is adopted — (see antecedently,' p. 473) ; and 2d. The mode and 
 position in v^hioh the head is liable to be seized and dragged down — (see p. 553). — (Ed.) 
 
TRAKSVERSE PRESENTATIONS. 557 
 
 ON THE STATE OF THE FCETAL PULSE DURING LABOR 
 
 AS AN INDICATION OF DANGER TO THE CHILD.' 
 (From Edinburgh Monthly Journal of Medicine, April, 1855, p. 346.) 
 
 Dr. Simpson made some remarks on the indications afforded by 
 the stethoscope for expediting delivery, and especially directed the 
 attention of the Society to the fact, that while danger was usually 
 indicated to the mother during labor, by the increased rapidity of 
 her pulse, the death of the child was most frequently threatened 
 when the foetal pulse became slower and slower. 
 
 It was known that in cases where, during labor, pressure was ex- 
 ercised upon the cord, as in presentations of the cord, the pulsations 
 of the foetal heart became feebler, and were at length suspended by 
 the continuous pressure. This was apparently the way in which the 
 foetus^ generally perished, during severe and prolonged labors — ^the 
 aeration of the blood by the placenta being thus rendered imperfect, 
 or entirely suspended. 
 
 There were, however, rarer cases in which danger was indicated to 
 the child, by the foetal pulse becoming much more rapid than ordi- 
 nary, reaching 150 or 160 beats in the minute, at the same time 
 being often very irregular or intermittent. Dr. S. believed the 
 danger in these latter instances did not result from pressure on the 
 umbilical cord, as in the cases where the pulsations became slower 
 and slower, but arose from pressure or some source of imtation 
 acting on the brain. 
 
 TRANSVERSE PRESENTATIONS.^ 
 
 (From Lond. and Edin. Monthly Journal of Medical Science, February, 1845, p. 109.) 
 
 At this Meeting I propose to offer a few observations on the in- 
 stance of transverse presentation and turning, which you witnessed 
 in the Maternity Hospital two days ago. Eirst of all, allow me to 
 read to you the case as it has been reported by my excellent friend 
 Dr. Martin Barry. 
 
 ' Proceedings of Obstetrical Society of Edinburgh, Session xiii. 1854-55. 
 2 For some practical deductions and remarks on this subject, see a preceding paper, pp. 
 476, 479.— (Ed.) 
 
 ' A Clinical Lecture. Reported by Mr. C. D. Arnott. 
 
558 PRETERNATURAL LABOR. 
 
 " Christina Anderson, aged 28, married — ^third pregnancy— last 
 catamenia in tlie beginning of March, continuing for two or three 
 days — time of quickening uncertain. 
 
 " On the morning of Saturday, 7th of December, had a fall, in 
 which the left hypochondrium was violently dashed against the 
 corner of a large stone ; says that she did not feel the movements of 
 the child for longer than a day or two after this. On Tuesday the 
 17th — ^ten days afterwards — the child, when born, presented the 
 separation of nearly the whole cuticle, with sero-sanguinolent infil- 
 tration of the scalp, and a state of looseness of all the cranial bones. 
 The abdomen was swollen, and on laying it open, the spleen was 
 found much enlarged, and patches of coagulable lymph were seen 
 on its peritoneal surface ; similar patches were present in the iliac 
 and pelvic region connecting the peritoneum of the abdomen with 
 that of the intestines ; other portions of a similar inflammatory 
 effusion were scattered over the intestines, more especially in the 
 lower part of the abdomen. 
 
 "Labor commenced on Monday, 16th of December, and was 
 completed in seventeen hours. The membranes ruptured twelve 
 hours before the full dilatation of the os uteri. 
 
 " During the labor the patient was bled, and had an ounce of 
 antimonial wine exhibited in 3ss doses, to promote the dilatability 
 of the cervix uteri. Shortly before turning, 3i of laudanum was 
 exhibited, in order to moderate the uterine contractions, and facili- 
 tate the process of turning. 
 
 " The presentation was the right shoulder with the cord, and the 
 child was removed by turning and extraction. This was performed 
 by Professor Simpson, who, observing from the feet and legs, when 
 they had been drawn down, that the position of the pelvic extremity 
 of the child corresponded to the third position of the head with the 
 toes pointing forwards, stated that the body as it came into the 
 world would present a corresponding movement of rotation — a 
 movement forthwith seen by the writer and several others who 
 were present. The head was then born in the second, or right 
 occipito-cotyloid position." 
 
 Most of you are aware that we cannot, except in the rarest cases, 
 leave instances of shoulder presentations to nature. Experience 
 abundantly shows us, that if we do not offer the required aid in 
 these presentations, the woman, in general, either dies exhausted 
 from the long-continued but fruitless efforts of the uterus to empty 
 itself of its contents, or the organ, by the violence of its own con- 
 tractions, lacerates its own structure, and thus establishes one of 
 the most fatal complications to be met with in the practice of mid- 
 
SHOULDER PRESENTATIONS. 559 
 
 wifery, namely, rupture of the uterine walls. In these presenta- 
 tions, therefore, interference is imperatively required, and this inter- 
 ference consists in so far altering the morbid position of the infant, 
 that, instead of allowing it to remain with its long axis across, or at 
 right angles to the long axis of the uterus, we introduce our hand, 
 and bring down to the os uteri one of the two extremities of the ovoid 
 mass of the child (the child in the latter months being, as you know, 
 folded up into an irregular ovoid form), in order to make the long 
 axis of the body of the infant and the long axis of the body of the 
 uterus parallel to each other. For this purpose, we may bring down 
 either the cephalic or the pelvic extremity of the infant. 
 
 The cases are few in which it is proper and possible to bring down 
 the head of the child to the os uteri, or, in other words, in which we 
 can and should perform what is termed cephalic turning or version. 
 
 In almost all cases, but especially in one like Anderson's, with the 
 child dead, and the passages well dilated or dilatable, we bring 
 down the pelvic extremity of the infant, and so far change the pre- 
 sentation from one of the shoulder or arm into one of the breech, 
 feet, or knees. 
 
 Many modifications of this last operation — podalic version or turn- 
 ing, as it is termed — have been proposed, and different varieties of 
 it are advocated by different practitioners. By some we are advised 
 in all cases, to bring down both feet of the infant. Others, again, 
 assert that to bring down one is always sufiicient. Some advise a 
 foot or feet ; others one or both knees. Let us inquire what method 
 would be the most simple and most practicable in a case like the 
 one before us. 
 
 I would first, however, remark, that in turning, in any case, where 
 the membranes are still fortunately entire, the female passages 
 dilated, and the foetus perfectly mobile in the liquor amnii, it 
 matters, I believe, little whether we seize one or both feet, or one 
 or both knees. All these parts are, under such conditions, so easily 
 reached, and the whole operation of seizure and version of the child 
 is then so simple, that it is almost needless to lay down set and 
 formal rules (as some authors have done) for the exact part of the 
 child which you should seize, and the exact mode in which you 
 should seize that part. There is so much room to turn, as the child 
 still floats in the liquor amnii, that, if you can seize firmly almost any 
 part of pne or both of the lower extremities with the introduced 
 hand, you will readily effect your purpose. The flexure of the 
 knees affords a firmer and better hold than the foot or feet, and is 
 hence probably preferable. It is, however, I repeat, sufficient to 
 seize firmly any of these two parts, whichever of them first comes 
 within your reach. 
 
560 PRETEKNATUEAL LABOB. 
 
 But the operation of version, in a shoulder or arm presentation, 
 becomes a much more difficult, delicate and dangerous operation, 
 when you require to turn, as in Anderson's case, with the waters 
 already evacuated, and the uterus tonically contracted, and folded 
 around the body of the child. Under such circumstances, we require 
 to know, and to study beforehand, the easiest method of operating 
 for ourselves, and the most safe mode of operating for the mother. 
 
 Let us consider, therefore, what method of turning is the most 
 simple, and the most practicable, under such conditions as I have 
 just stated ; and first of all let us inquire — 
 
 SHOULD WE SEIZE BOTH FEET OP THE INFANT ? 
 
 You see this method of procedure represented in the plates before 
 us of Moreau, and it is a mode which is strongly inculcated by some 
 of our latest authorities in midwifery, "l^ever be content," says 
 Dr. Lee, in his lately published lectures on midwifery, " never be 
 content with one foot, when it is at all possible to grasp both." In 
 most cases, I hold this method to be improper and unjustifiable, 
 because it is almost always more difficult to seize both extremities 
 than to seize one ; because one is quite sufficient for our purpose, 
 and more safe for the life of the mother ; and because by pulling at 
 one extremity, when pulling does happen to be required after the ver- 
 sion is accomplished, we more perfectly imitate the natural oblique'posi- 
 tion and passage of the breech of the infant, than when we drag it 
 down more directly and more upon the same plane, by grasping and 
 dragging at both limbs equally. The infant also assuredly incurs 
 less risk of impaction of the head, and above all, less chance of 
 fatal compression of the umbilical cord, when the os uteri and ma- 
 ternal canals have been dilated by the previous passage of the 
 breech, increased in size by one of the lower extremities being 
 doubled up on the abdomen, than when both extremities being 
 seized and extended, these same passages are more imperfectly 
 opened up by the lesser-sized wedge of the breech alone. 
 
 Notwithstanding, however, the greater difficulties, and conse- 
 quently the greater dangers attendant on the operation, when we 
 search for, and grasp both lower extremities, instead of one, it is still 
 BO dogmatically laid down as a rule by most obstetric authorities, that 
 many practitioners seem to deem it a duty not to attempt to turn 
 the child without having previously secured both feet. 
 
 About two years ago, I was sent for by an accoucheur, enjoying 
 a deservedly extensive practice, in order to assist him in the opera- 
 tion of turning in such a case as Anderson's. He had introduced 
 his hand, and brought down one foot into the passages. For a long 
 
PROPER METHOD OE ITJRNING. 561 
 
 time he had been attempting to reintroduce his hand into the uterus, 
 for the purpose of seizing and biinging down the remaining foot. 
 His continued efforts, however, had proved perfectly useless, and 
 he requested my attendance under this supposed difficulty. "With- 
 out endeavoring to effect what he had labored to accomplish, namely, 
 the seizure and extraction of the retained extremity, I contented 
 myself with dragging at the one foot already protruded, and with it 
 alone pulled down the child without difficulty. 
 
 In few or no cases of turning is it proper or requisite to bring 
 down both extremities, unless in the complication of turning under 
 rupture of the uterus. In that case, but in that only, ought we to 
 follow at once this procedure — and here we follow it, because, if we 
 left the other extremity loose in the uterus or abdomen, it would 
 be apt to increase the lesion in the walls of the organ, if it happened 
 to get involved in the aperture, or impacted against its edges. In 
 some very rare instances in which, after version by one leg has been 
 effected, and immediate delivery is necessary, the cervix and os in- 
 ternum occasionally contract so forcibly and strongly upon the pro- 
 truded limb, whenever we drag upon it, as not to allow of a suffi- 
 cient amount of traction being applied to this extremity without 
 fear of lacerating its structures. In such cases also it may be well 
 to attempt to repass the hand to secure the other extremity, for then 
 by pulling at both extremities together, we incur less chance of in- 
 juring them than if we applied the same required amount of force 
 to either of them singly. 
 
 SHOULD WB SEIZE ONE EXTREMITY ONLY ? 
 
 From what I have already stated, you know my opinion, as to 
 this being the proper method of proceeding in almost all cases of diffi- 
 cult turning. The method was long ago spoken of by Portal ; and 
 within the present century, Hoffman and Joerg in Germany, and 
 my friend Dr. Eadford in this country, have severally written on 
 the subject, and upheld, that in no case of turning ought we to lay 
 hold of more than one extremity, for the purpose of effecting the 
 version of the infant. I have just pointed out what I conceive to 
 be two — perhaps the only two — exceptional conditions to this gene- 
 ral rule. 
 
 Another question meets us. Supposing we intended, in turning, 
 to bring down the pelvic extremity of the ovoid mass of the child, 
 what part of that extremity should we lay hold of in order to make it 
 the presenting part at the os uteri ? 
 
 Some accoucheurs have thought, that if we seized and brought 
 down the breech of the infant, it would be the safest mode of turn- 
 
 ^oL. I. 36 
 
562 PRETERNATURAL LABOR. 
 
 ing. This method, however, presents so many disadvantages, that 
 it seems now entirely rejected from practice as a common mode of 
 performing version ; for it is difficult to reach up to the breech of 
 the child— and it is difficult to take a sufficiently firm hold of it when 
 you have once reached it — and it is difficult, when once you have 
 taken hold of it, to perform the evolution or version of the child 
 with such a purchase. 
 
 We may limit, then, the part which we ought to lay hold of to 
 the lower extremities, and I have already told you that I believe one 
 extremity sufficient. The remaining question, therefore, is this — 
 What part of that extremity should we seize upon ? 
 
 SHOULD WE TAKE HOLD OF THE FOOT OR THE KNEE ? 
 
 I believe the seizure of the knee to be preferable in most, if not 
 in all cases, to the seizure of the foot, or rather, as it should be 
 more correctly stated, to the seizure of the ankle of the child. I 
 speak, you wiU recollect, of turning in cases of shoulder or arm 
 presentation, in which the liquor amnii has been for some time 
 evacuated, as in Anderson's case, and the uterus, by its tonic con- 
 traction, has clasped itself around the body and head of the child. 
 Under such circumstancfes, it is an object of importance not to be 
 obliged to introduce our hand farther than is absolutely necessary, 
 into the cavity of the uterus, because the contraction of the organ, 
 in many cases, opposes its introduction, and the forced introduction 
 of it is apt to produce laceration. It is an object also of equal 
 moment to attempt to turn by a part which produces as little change 
 as possible in the figure and form of the infant ; because, if we 
 thrust any of the angulated parts of the child against the interior of 
 the contracted uterus, we would also thus be still more liable to 
 produce rupture of that organ. I^ow, holding these points in view, 
 it appears to me, that the turning of the child by seizure of the knee 
 presents several decided advantages over turning of the child by 
 seizure of the foot. For — 
 
 First. The knee is more easily reached. As we slip our hand 
 along the anterior surface of the protruding arm, and along the 
 anterior surface of the thorax of the child, we always, if the attitude 
 of the child has not been altered by improper attempts at version, 
 or very irregular uterine action, find the knees near the region of 
 the umbilicus of the infant — ^the lower extremities, as you are aware, 
 being folded up in utero so that the knees are brought up to that 
 part, and the legs flexed upon the thighs in such a manner that the 
 heels and feet lie nearly in apposition with the breech of the child. 
 To seize a foot, therefore, we would require to pass our hand about 
 
PKOPER METHOD OF TTJENINS. 563 
 
 three inches, or, in fact, the whole length of the leg, further than 
 we required to do in order to seize a knee. 
 
 Secondly. The knee affords the hand of the operator a much 
 better hold than the foot. By inserting one or two fingers into the 
 ham or the flexure of the knee, we have a kind of hooked hold 
 which is not liable to betray us. Every one, on the other hand, 
 who has turned by the foot or feet, knows how very apt the fingers 
 are to slip during the required traction, and how much in this way 
 the diflaculties of the operation are sometimes increased. 
 
 Thirdly. We produce, I believe, the necessary version of the body 
 of the child more easily by our purchase upon the knee — because 
 thus we act more directly on the pelvic extremity of the infant's 
 spine, than when we have hold of a foot. 
 
 Fourthly. Turning by the foot appears to me to endanger greatly 
 more the laceration of the uterus than turning by the knee. The 
 reason of this is sufficiently evident. "When we turn by the foot 
 
 Fig. 33. 
 
 we have to flex the leg round upon the thigh, and thus at one stage 
 of the operation, and during one part of the flexion of the leg, we 
 are obliged to have the leg bent to a right angle with the thigh, and 
 the foot of the infant thus projected and crushed against the interior 
 of the uterus. You see this when, on the infant before me, I seize 
 hold of the foot, and turn it round from its position at the breech, 
 till I bring it up to the shoulder, the part which we are supposing to 
 present at the os uteri. You can easily thus perceive (as in the 
 woodcut) that when the leg of the child is thus brought round, it 
 must rasp and scratch, if I may so speak, along the interior of the 
 contracted uterus, and endanger to a fearful degree, the laceration 
 ©f the organ. It is needless to say how much this danger is increased, 
 when after having brought down one foot, we pass again our hand, . 
 and attempt to bring down a second foot, as is recommended by 
 some authors, for thus we only double the danger of laceration of 
 the uterus, from the forced and obstructed passage along its interior, 
 of this other extremity. 
 
564 PRETERNATURAL LABOR. 
 
 One pointremains for our consideration. Granting that it is proper 
 to seize a knee, I think it a matter of the very first moment to know 
 
 WHICH KNEE SHOULD BE SEIZED ? 
 
 On this point you will find no directions in any of our modern 
 obstetric works, British or foreign, so far as I know them ; and yet 
 I believe the secret of turning with facility and safety in such a case 
 as Anderson's— with the waters evacuated and the uterus contracted 
 — depends upon the knowledge of which of the two lower extremi- 
 ties of the infant should be seized. K we turn with one of the ex- 
 tremities — and whether the foot or the knee — it should be the foot 
 or knee of the limb on the opposite side of the body to that which is 
 presenting. Thus, if the right shoulder or arm presents, we should 
 take hold of the left knee or foot ; and if the left arm or shoulder 
 presents, we should take hold of the right knee or foot. I repeat, 
 that I believe this point to be one of the most essential importance : 
 and the reasons for the rule are simple. 
 
 In bringing down the foetus in the operation of turning, we may, 
 and should, produce two kinds of alteration in its position and 
 figure. Thus, we may bend or flex the body forwards upon the 
 transverse axis of the trunk ; and we may rotate or turn the body 
 round upon the longitudinal axis of the trunk. If we merely flex 
 it, the operation of version will be one of difficulty ; if we both flex 
 and rotate the trunk at the same time, the operation will be one of 
 comparative facility. By merely flexing the body upon its transverse 
 axis, we are liable to bring down one of the lower extremities, 
 whilst we do not displace the upper extremity, which is primarily 
 presenting at the os uteri. If we both rotate and flex the body — 
 that is, turn it both on its transverse and longitudinal axes — at the 
 same moment, whilst we bring down the pelvic extremity of the 
 child, the turning of the body of the infant carries away from the 
 OS uteri the part originally presenting. 
 
 Many of you must be acquainted with the fact, that obstetric 
 authors have proposed various methods of removing away from the 
 cervix uteri the presenting arm or shoulder, in order to allow of 
 more space for the part which is brought down, and to produce the 
 necessary evolutions of the child. Thus some recommend the pre- 
 senting part to be pushed up before we seize the feet ; others advise 
 the foot to be seized with one hand, and the presenting part to be 
 pushed up with the other ; and others again counsel us to bring 
 down one or both feet, secure them with a tape (as you see in a plate 
 of Moreau), and, whilst pulling with this tape, to introduce the 
 hand, after the lower extremities are brought down, for the purpose 
 of pushing up the presenting portion of the upper extremity. 
 
PROPER METHOD Ol TURNING. 
 
 665 
 
 All these rules and complications are at once avoided by following 
 tlie principle that I have just stated to you, of bringing down, 
 whenever it is possible, the knee opposite that of the presenting arm 
 or shoulder. When we do this, by carrying the knee diagonally 
 across, if I may so speak, the abdomen of the child to the os uteri, 
 we both, as I have said, flex and rotate at the same time the trunk 
 of the infant, and in doing so, the semi-rotation of the trunk in- 
 evitably carries up the presenting arm, in proportion as the knee 
 which is laid hold of, is pulled down by the operator. I would add 
 this, as another of the advantages of turning with one extremity, 
 for if we pulled down both knees or both feet, or the foot or knee 
 which was nearest to us, we should produce in many instances mere 
 flexion of the body, without that rotation of it which is necessary to 
 carry up and out of the os uteri, the presenting part of the infant. 
 
 I have insisted upon the advantages of taking hold of the knee 
 that is highest and furthest from you, and believe this to be a matter 
 of the very first moment. N"ow, it may appear to some of you that 
 it would be more difficult to seize this knee than the knee of the 
 side corresponding to the presenting arm ; but if you reflect for a 
 moment you will see that this difficulty is more imaginary than real. 
 Both knees of the child, as the infant lies folded up in utero, are 
 generally in juxtaposition, and lying upon the abdomen of the infant, 
 near the umbilicus. If, therefore, in passing your hand into the 
 uterus, you insinuate it, as you ought to do, along the anterior sur- 
 face of the thorax and abdomen of the child, you come in contact 
 with both knees at the same time (see the woodcuts). And the rule 
 which I would give you is this,' that instead of hooking your finger 
 or fingers into the flexure of the lower or nearer knee (a), you hook 
 
 Fig. 34. 
 
 them instead into the flexure of the upper, more distant, or opposite 
 one (5). Both are so far, in general, equally near, or equally distant. 
 
566 PKETERNATUKAL LABOR. 
 
 and you seize the one or the other, according as you take care to 
 turn your finger so as to hook it into the flexure of the lower or the 
 flexure of the upper. It has been strongly objected by some authors 
 to the mode of turning by the knee or knees, that we cannot with 
 the hand in utero make a sufficient 
 
 DIAGNOSIS BETWEEN THE KNEE AND THE ELBOW. 
 
 It is averred that the operator is exceedingly liable to mistake the 
 elbow of the child for the knee, and thus to bring down the opposite 
 arm instead of lower extremity — a result that would certainly render 
 the case only the more complicated. I believe, however, that we 
 might be, and are, equally liable to confound the foot with the hand, 
 and thus lead to the same consequence, while the following simple 
 rule will always enable you to escape the error and danger of mis- 
 taking an elbow for a knee : Suppose the child to be lying, as it 
 does, with its extremities doubled up in the uterus, the elbow and 
 knee may be always distinguished from each other by the opposite 
 directions in which they point. You have the salient angle, con- 
 vexity, or rotundity of the knee, always looldng upwards towards 
 the upper or cephalic extremity of the child, whereas you have the 
 salient angle, convexity, or rotundity of the elbow, always looking 
 towards the lower or pelvic extremity of the infant. A glance at 
 the sketches will show you this. Hence, if we know the position 
 in which the infant is lying (and this we always do, for other reasons, 
 ascertain previous to commencing our operations), we may, by at- 
 tending to this single fact, easily distinguish in all cases a knee from 
 an elbow. 
 
 There is one point worthy of every attention in regard to the 
 operation we have been considering, which I have not yet alluded to. 
 It is this, that — particularly in cases of difficulty — ^you require to 
 
 USE BOTH YOUR HANDS FOR THE OPERATION OF TURNING. 
 
 In making this observation, I mean that whilst we have one hand 
 internally in the uterus, we derive the greatest possible aid, in most 
 cases, from manipulating the uterus and infant with the other hand 
 placed externally on the surface of the abdomen. Each hand thus 
 assists the other to a degree which it would not be easy to appreciate, 
 except you yourselves were actually performing the operation. It 
 would be extremely aifficult, if not impossible, in some cases, to 
 effect the operation with the single introduced hand ; and in all 
 cases it greatly aids and facilitates the operation. The external 
 
PROPER METHOD OE TURNING. 567 
 
 hand fixes the uterus and fcetus during the introduction of the in- 
 ternal one : it holds the fcetus in situ, while we attempt to seize the 
 necessary limb or limbs, or' it assists in moving those parts, when 
 required, towards the introduced hand ; and it often aids us vastly 
 in promoting the version or evolution of the body of the child, after 
 we have seized the part which we search for. Indeed, this power 
 of assisting one hand with the other, in the different steps of the 
 operation of turning, forms the principal reason for introducing, 
 as I have sometimes done, the left as the operating hand into the 
 uterus — for thus we can, by passing the right hand between the 
 thighs, and over the abdominal surface of the uterus (the woman 
 lying on her left side), have more perfect control over the child by 
 our external manipulations with the latter hand. Besides, the left 
 hand, when the patient is in the position I have described, more 
 readily adapts itself to the configuration and axes of the pelvis. If 
 we introduce and turn with the right hand, it is more awkward and 
 difficult to manipulate the abdominal surface of the uterus with 
 the left. 
 
 The mode of turning which I have recommended to you was 
 followed in the case of Anderson. "When I was first called to see 
 her, all things were in a condition suitable for undertaking the 
 operation. The membranes had burst some hours previously, when 
 the OS uteri was still comparatively rigid. It is, no doubt, a matter 
 of moment to be able to turn before the waters have escaped, be- 
 cause, as I have already stated to you, the operation is then greatly 
 more simple ; but when the membranes do break — as in the case 
 before us — ^with the os uteri still undilated and undilatable, we must 
 wait with patience, and employ such measures as tend to relax that 
 part. In the present instance, bloodletting was had recourse to for 
 this purpose, and antimony exhibited. A short time before I saw 
 her. Dr. Barry had very properly given her a large dose of opium, 
 in order to moderate the spasmodic or clonic contractions of the 
 uterus, so as to admit of the more easy performance of the version 
 of the child. The os uteri was quite dilatable when I reached the 
 hospital, but the tonic contraction of the organ was so great that I 
 feared there might be some delay and difficulty in the introduction 
 of the hand, and evolution of the child. Such, however, was not 
 the case to the degree anticipated, and the version was accomplished 
 in two or three minutes. 
 
 The child was lying with its head towards the right iliac fossa, 
 and its pelvis towards the left. The face, abdomen, and extremities 
 of the infant, were looking forwards. (See Fig. 34.) I therefore, 
 as we always do in such cases, passed up my hand between the 
 anterior or pubic surface of the uterus and the infant, in order to 
 reach more easily the knee which I wished to seize. 
 
568 PKETERNATURAL LABOR. 
 
 ^ • As to the place or side where we ought to pass our hand — that is 
 whether between the infant and the pubis, or between the infant 
 and the sacrum— the rule is simple and evident. We pass our 
 hand, as in the case before us, between the pubis and the infant, 
 when we know the extremities of the child are looking anteriorly. 
 "We pass our hand between the sacrum and the infant, in those other 
 cases in which we know the limbs of the child to look posteriorly. 
 We do so for two reasons— ^rsi, because there is always the greatest 
 space for the introduction of the hand on that side of the foetus to 
 which its face, abdomen, and angulated extremities look; and, 
 secondly, it is only, of course, on this side of the fcetus that we can 
 find and secure the lower extremities in order to produce the re- 
 quired evolution and extraction. Dr. Lee lays it down as one of 
 his " two most important rules" in turning, that — however the 
 trunk and extremities of the child maybe situated — ^that is, whether 
 the extremities look anteriorly or posteriorly — ^you ought " to pass up 
 the hand between the anterior and shallow part of the pelvis, and 
 the presenting part of the child." If the back of the infant were 
 turned, as it sometimes is, to this "anterior or shallow part," it 
 would be impossible, by any search in that situation, to get hold of 
 one or other of the legs of the child, which are situated in the very 
 opposite part of the uterus, and on the opposite side of the body of 
 the foetus ; and if the feet were thus really seized, they would be 
 brought over the back of the child, and the spine so far greatly 
 endangered. But Dr. Lee's rule is so very obviously erroneous, 
 and the result of some misconception or disregard of the mechanism 
 of transverse presentation and turning, as not to require any formal 
 refutation. His second important rule, " that when one hand is 
 rendered powerless by the pressure of the uterus, you ought to vnth- 
 draw this hand and replace it by the other," will doubtless be in 
 many cases, I fear, an unavoidable result of the mismanagement 
 advocated by the first — and is rarely if ever required when you 
 employ the proper hand at once. And every new and unnecessary 
 introduction of the hand must be reprobated, as inflicting a new 
 and additional source of danger upon the patient — and hence, should 
 be avoided as far as possible. 
 
 You saw, in this instance, what are the usual preliminary measures 
 adopted in connection with the operation of turning. We kept, as 
 I showed you at the time, the patient placed upon her left side, with 
 the trunk of her body situated across the bed. The right knee was 
 raised by the hand of an assistant, and the uterus kept fixed and 
 steady by pressure on the external surface of the abdomen. In pre- 
 paring the hand and forearm for the operation of turning, these 
 parts were perfectly uncovered, and everywhere anointed with lard, 
 
MECHANISM OF PELVIC PRESENTATIONS. 00^ 
 
 with the exception of the palmar aspect of the hand and fingers. 
 These latter parts require always to he kept free, in order to secure 
 a proper hold of the presenting part. 
 
 After cautiously passing the hand into the uterus along the ante- 
 rior surface of the protruded arm, 'I glided it between the anterior 
 surface of the thorax of the child, and the anterior wall of the 
 uterus, laying it flat during one slight pain that supervened, and 
 insinuating it onwards immediately afterwards, till I reached the 
 two knees lying in the umbilical region of the infant. I passed 
 one finger into the flexure of the upper knee, and thus got suffi- 
 ciently firm hold of that part, without displacing the lower extremi- 
 ties to any extent. Assuring myself, as we always do in the process 
 of version of the child, of the complete absence of all clonic contrac- 
 tion of the uterus, I easily turned it round with the purchase I had, 
 and brought down the left lower extremity, the infant making a 
 complete rotation during its evolution, as we shall see immediately 
 from the direction of the toes, abdomen, and face. 
 
 "We thus, you observe, make the version or evolution of the child 
 during the absence of any uterine pain, but, after bringing down the 
 extremity, should any farther assistance be required towards the ex- 
 traction of the child — ^it must, I beg you especially to remark, be 
 made not during the absence of uterine contractions, but during 
 the presence of them. In most cases, indeed, after the version is 
 performed, we allow the uterine contractions themselves to expel 
 the infant, but it was not necessary to wait in such a case as Ander- 
 son's, the pains being trifling, and the child being dead. I therefore 
 pulled gently at the protruding leg during each subsequent contrac- 
 tion, and ultimately extracted the head from the pelvis by a purchase 
 obtained by passing two fingers of the right hand over the neck of 
 the child, and introducing two others into its mouth. 
 
 You will recollect that, in Dr. Barry's report of the case, as I read 
 it to you, he states an interesting and important fact with regard to 
 the evidence which it afibrded of the 
 
 NATURAL MECHANISM OF LABOR IN FOOTLING PRESENTATIONS. 
 
 In this instance, as occasionally happens in pelvic presentations — 
 both spontaneous and artificial — we found the toes looking towards 
 the pubis, from which we knew that the face and chest of the child 
 must be turned in the same direction — and I stated to the gentle- 
 men present, that this would not interfere with the process of ex- 
 traction of the infant, for the child, during its further transit, would 
 rotate round with its toes, &c., towards the nearest sacro-iliac syn- 
 chondrosis, and not require any manipulation on our part to make 
 
570 PRETERNATURAL LABOR. 
 
 it come out in that — its proper and most easy, position. This is 
 a subject I would wish particularly to impress upon your minds, 
 for you will find it stated in almost every text-book, that in all pelvic 
 presentations, whether they occur spontaneously, or whether they 
 are artificial, as in cases of turning, it is proper and necessary 
 for us to rotate so far the body of the child, that its toes, and 
 hence its face, should be turned towards the posterior aspect of 
 the pelvis, or, as some more properly advise, towards the nearest 
 sacro-iliac synchondrosis. 
 
 "We are recommended, for instance, by Dr. Hamilton, to ob- 
 serve, as soon as the child is born as far as the knees, whether 
 the toes point forwards or not — and if they do point forwards, as 
 they did in Anderson's case, we are further directed immediately 
 to turn the child round, so that they may look to the nearest sacro- 
 iliac symphysis. 
 
 But no such manipulation is required as a general rule in spon- 
 taneous pelvic presentations, and none in artificial pelvic presenta- 
 tions, especially when you bring down only one extremity. In all 
 the cases which I have watched, the infant, as in Anderson's, during 
 the passage of the trunk, rotates and assumes this position itself, 
 without any interference on our part, and upon the principle which 
 I stated to you at lecture this morning, when speaking of similar 
 rotations in head cases, of the mutual physical relation of the child 
 and pelvis, the former turning within the latter, as the helix of a 
 partial screw will partially turn within its nut. 
 
 In natural or spontaneous pelvic presentations, this rotation that 
 I allude to, occurs normally and naturally during the passage of the 
 trunk ; and that the rotation itself is a mere physical result, and 
 independent of any vital actions on the part either of the child or 
 mother, is proved to demonstration by an experiment which I have 
 several times taken occasion to make — namely, that of dragging 
 by one foot a dead foetus through the pelvis of a dead mother. 
 If, at the commencement of this experiment, we place the child 
 with its toes, abdomen, and face, looking forwards, we shall find 
 that, as the trunk passes through the pelvic cavity, it regularly ro- 
 tates round, so that these parts come to present at the nearest sacro- 
 iliac synchondrosis. 
 
 IsTow, what holds good in regard to the mechanism of natural 
 pelvic presentations, holds good also in regard to the mechanism of 
 artificial pelvic presentations, or of those which we make in the pro- 
 cess of turning. In artificial, as in natural footling and breech cases, 
 we ought, I believe, to discard in a great measure from our mind any 
 necessity for interfering, so as to turn the infant from one position 
 to another as it passes through the pelvis ; for in 9 out of 10, or in 
 
MECHANISM OF PELVIC PRESENTATIONS. 571 
 
 19 out of 20 cases, it will sooner or later assume for itself the easiest 
 and best position for the passage of the head, namely, with the face 
 turnedtowards the nearest sacro-iliae synchondrosis. This will almost 
 invariably be the case if we do not hurry the extraction of the child 
 by pulling at the protruded extremities, or if we pull merely by one 
 — and that the one nearest the pubis. By dragging, when it is re- 
 quired, at the limb of the child lying next the pubis, and at this limb only 
 — we pull down the pelvis of the infant obliquely, so far imitating 
 the presentation and easy transit of this part of the body in normal 
 pelvic cases where the anterior ischium is always the lowest ; and 
 by the same means we promote the necessary rotation of the child's 
 body, while we should prevent it, on the other hand, by dragging 
 at the sacrum or posterior limb — or by grasping and dragging simul- 
 taneously at both. 
 
 All obstetric authors seem to me to err, in advising direct inter- 
 ference, for the rotation of the child in artificial pelvic cases to 
 be made by the hands of the practitioner. In speaking of the 
 duties required in such circumstances, even my friend Dr. Rigby 
 (who, in other points, inculcates such sound and excellent doctrines 
 with regard to the mechanism of parturition and non-interference 
 with it on the part of the attendant), observes, " the uterus must be 
 emptied as slowly as possible, and the anterior part of the child 
 must be directed more or less backwards." It will, as I have stated 
 to you, be directed more or less backwards by the physical rela- 
 tions between its own trunk and the interior of the maternal pel- 
 vis, so as to require no such adaptation to be attempted by any 
 intermeddling on our part. A simple experiment will convince you 
 that this will occur. I have already stated to you, that in re- 
 peated experiments made by dragging a dead child by one limb 
 through the pelvis of a dead mother, I have seen the rotation spon- 
 taneously take place. But it will even take place, if I perform 
 the same experiment much more rudely, by attempting to drag 
 the leather foetus before us through the bony cavity of this dry 
 pelvis. If I place, thus, the foetus with the feet in the pelvis, and 
 the toes directed towards the pubis, or, as is the case in nature, 
 somewhat obliquely to one side of the pubis, say towards the right 
 foramen ovale, and drag the foetus through by pulling only at the 
 anterior or pubic limb of the child, it turns, you observe, spontane- 
 ously, as the trunk passes through the pelvis, so that the face looks at 
 last to one ilium, or even backwards towards the nearest, or right, 
 sacro-iliac synchondrosis ; and this extent of rotation will more surely 
 occur if the right arm chance to pass into the unoccupied space of 
 the left sacro-iliac symphysis, or rather if that arm be removed so as 
 not to prevent the rotation of the shoulders and head. The curious 
 
572 PEETERNATUKAL LABOR. 
 
 and illustrative experiment I have just shown you, was first pointed 
 out to me by my esteemed friend Dr. Ziegler. 
 
 SPONTANEOUS EVOLUTION OR EXPULSION OF THE 
 
 FGETUS.' 
 
 DECAPITATION AND EVISCERATION IN TRANSVERSE 
 PRESENTATIONS. 
 
 (From Edinburgh Monthly Journal of Medical Science, May, 1847, p. 869.) 
 
 Case I. — Dr. Simpson described a case of spontaneous peMo 
 evolution which he had seen in the second child of a twin case. 
 He was called in about an hour after the first child was born, when 
 the arm and chest of the second child were already protruding 
 through the vagina, and the process of its spontaneous expulsion 
 going rapidly forwards. It was born dead by the unassisted efibrts 
 of the uterus, in the course of a few pains, and by the usual me- 
 chanism. He further alluded to a case some years ago, attended 
 here by Dr. Cowan, the arm presenting, and the breech at last pass- 
 ing first. 
 
 Case H.' — Dr. Simpson subsequently stated another case of its 
 occurrence. The patient was under the charge of a midwife. Mr. 
 Alexander, who was called in, requested Dr. S. to see the case, with 
 the view of turning the child. The mother had already borne four 
 children. The present pregnancy had advanced to between the 
 seventh and eighth month. When born, the child weighed 3 lbs. 
 9 oz., and measured 17J inches in length. The labor commenced 
 at 8 A. M., but made very little progress till the afternoon. At 7 
 p. M., when Dr. S. arrived, the shoulder of the child was pressing 
 deeply into the pelvis. The rectum seemed loaded ; and they left 
 the room for a short time, in order that the nurse might empty the 
 bowel with an enema, before turning was practised. On being re- 
 called, they found the pains strong, and the bodi/ of the child begin- 
 ning to press down through the pelvic brim — ^indicating the com- 
 mencement of the usual process of spontaneous evolution. Dr. S. 
 remarked that this peculiarity and change in the presentation had 
 
 ■ In the section on the Pathology of- the Products of Conception, Vol. II. will be found 
 some remarks on peritonitis in the foetus, which originally formed a portion of this lecture. 
 -(Ed.) 
 
 ^ Extracted from Proceedings of Edinburgh Obstetric Society. 
 
 ' See Edinburgh Monthly Journal of Med. Science, Feb. 1849, p. 560. 
 
SPONTANEOUS EVOLUTION. 573 
 
 taken place during the ten or fifteen minutes since they had left 
 the patient — ihe foetus had made a slight turn upon its long axis, so 
 that it presented much more of the back, and less of the side, than 
 before,the shoulder still, however, maintaining its deep position in the 
 cavity of the pelvis. The child's body came down, in other words, 
 not with the spine or trunk bent and doubled up laterally, but bent 
 and doubled up in a great measure anteriorly. The anatomical 
 structure of the spinal column admitted far more easily of this an- 
 terior flexion than of lateral flexion. Was this a common turn or 
 rotation in the mechanism of spontaneous expulsion ? If so, did the 
 want of it delay or prevent the process of spontaneous expulsion 
 in some cases. And could it be imitated by art so as to allow the 
 process to go on in appropriate cases ? After being forced into this 
 new position, the child was very quickly expelled by the natural 
 efiibrts, and according to the common mechanism of spontaneous 
 evolution. As usual, it was born dead. 
 
 He had also met with two cases of cephalic spontaneous evolution 
 or expulsion, the arm presenting, the head and thorax becoming 
 impacted together in the pelvis, and the head ultimately passing 
 out before the lower part of the body. One of these cases occurred 
 in the Maternity Hospital ; the other he saw in consultation with 
 Dr. Skae. 
 
 General Deductions regarding Spontaneous Evolution. ' 
 
 1st. Spontaneoiis evolution in transverse presentations was not so 
 rare as some authors averred, and it would probably occur oftener if 
 proper and timely assistance were not rendered. 
 
 2d. Under some circumstances, arm and shoulder cases should 
 probably be left to be expelled by the mechanism of spontaneous 
 evolution, assisting, if necessary, this mechanism by art. 
 
 Zd. This ought to be our practice, if, in an arm or shoulder case, 
 the chest and trunk of the child be already thrust down into the 
 cavity of the pelvis ; for to turn under such a complication, and 
 with that object, attempt to push back the body of the child from 
 the cavity of the pelvis into the cavity of the contracted uterus, 
 would necessitate the redilatation of the uterus, and hence, in all 
 probability, produce a rupture of its coats. 
 
 'Uh. If the process of spontaneous evolution failed, two opera- 
 tions had been recommended to effect delivery, viz., evisceration 
 and decapitation ; and they had always been described as applicable 
 to the same set of cases ; but they were individually applicable in 
 two different sets. 
 
 ' See Edinbuvgh Monthly Journal of Medical Science, May, 1847, p. 870. 
 
574 OBSTRUCTED LABOK. 
 
 bth. Evisceration was only applicable to cases oi pelvic sponta- 
 neous evolution, demanding operative interference ; and Decapita- 
 tion principally applicable to cases of cephalic spontaneous evolution. 
 
 &th. Of course, in all common transverse presentations seen 
 before the body and bulk of the infant was doubled and tbrust 
 down into the cavity of the pelvis, and while it was still in fact in 
 the cavity of the uterus, turning was the proper practice, and to 
 wait for the prospect of spontaneous evolution would be utterly 
 wrong ; and — 
 
 1th. A child of the common size could never, in a transverse 
 presentation, be forced and doubled down into the cavity of the 
 pelvis, unless the mother's pelvis were large in its dimensions ;' and 
 hence, when the process of spontaneous evolution is found in an 
 advanced stage, it is almost a certain sign that the pelvis is of such 
 measurements as to give a chance of its completion. 
 
 Of the two preceding operations, evisceration and decapitation, 
 the former is generally extremely tedious, an hour or more being 
 usually necessary — 1. To empty the contents of the thorax and ab- 
 domen ; and, 2. To drag down the breech with the crotchet. Per- 
 haps the division of the bony spine would facilitate the whole 
 matter, and allow the body more easily to double up. Decapitation, 
 on the contrary, is usually rapid in its execution, and far more 
 simple. Dr. Ramsbotham's decapitating hook (an instrument the 
 same as a large polyptome) enables the neck to be surrounded and 
 severed with little or no difficulty in cases threatening cephalic 
 evolution, and perhaps could be applied also, if used early, in most 
 cases threatening pelvic evolution. From the facility with which 
 we have found decapitation to be effiscted in two or three instances 
 of transverse presentation, where the child was distinctly dead, and 
 turning was rendered difficult either by the contraction of the 
 uterus, or by the actual advance of the child downwards into the 
 pelvic brim or cavity, we have a strong conviction that it is a mode 
 of delivery infinitely to be preferred, under such circumstances, to 
 violent and repeated effisrts at version. 
 
 VAGINAL HYSTEEOTOMY, ETC., IN LABORS OBSTRUCTED 
 BY UTERINE AND VAGINAL CANCER.' 
 
 Carcinoma in the walls of the cervix uteri and vagina is occa^ 
 sionally found coexisting with pregnancy and parturition. Such 
 
 ' See Proceedings of Edinburgh Obstetric Society, February 10, 1847, in Monthly Journal 
 of Medical Science for that year, p. 794. 
 
CAECINOMA IMPEDING DELIVERY. 575 
 
 deplorable cases have been seen to terminate variously. Sometimes 
 the cervix has been still found so very slightly diseased and indu- 
 rated, at the time when labor at last supervened, that it has spon- 
 taneously relaxed and opened for the transit of the child. Far 
 more frequently its unyielding structures have fissured and torn 
 under the pressure of the presenting part of the infant ; the labor, 
 however, thus terminating ultimately without artificial aid, after 
 sufl3,cient space was obtained by the spontaneous lacerations. In 
 some instances the patient has, some days after labor supervened, 
 died undelivered, in consequence either of pure exhaustion, or of 
 laceration of the walls of the body and fundus of the uterus. And 
 in one or two rare cases, the pains of parturition, after coming on 
 regularly at the full term of pregnancy, have after a time ceased — 
 and as in the " missed labors," that so often happen in the cow and 
 sheep — ^the dead fcetus has been retained in utero for weeks, or even 
 months, beyond the normal period of delivery.' 
 
 Case I. — In a patient pregnant, and with extensive cancer of the 
 cervix uteri, whom I saw at Hamilton, efforts at labor seemed to 
 come on more than once, when and after the mother herself cal- 
 culated the term of utero-gestation to be complete. She died at 
 last undelivered, apparently of peritonitis. The foetus was found 
 decomposing in utero. There was an extensive effusion of lymph 
 on the peritoneal surface of the uteras ; but apparently no rupture. 
 She refused to submit to any treatment.^ 
 
 What treatment should we pursue in cases of parturition morbidly 
 delayed and obstructed by cancerous disease of the cervix uteri or 
 vagina? It has been long laid down as a principle in British 
 midwifery, that when in labor it is found impossible, from the 
 amount of obstruction which exists, that the lives of both the mother 
 and child can be preserved — the life of the infant should be sacrificed 
 by craniotomy, for the safety of the mother, provided there is space 
 to extract the mutilated child through the maternal passages. In 
 accordance with this principle, I have known the mother, in a case 
 of labor obstructed by carcinoma uteri, delivered by the perforation 
 and breaking down of the head of the infant; and cases of delivery 
 by craniotomy, under the same complication, have been recorded by 
 Denman, Dorrington, and others. 
 
 But surely we have a true and important exception to this principle 
 when parturition is rendered difficult or impossible, by cancer of the 
 
 ' In a most interesting case described by Dr. Menzies, in the Glasgow Journal for July, 
 1843, p. 229, gestation seemed in this way prolonged to the 17th month. 
 
 ' For more details of the case, see a communication by Dr. Miller, in the Edinburgh 
 Monthly Journal of Medical Science for 1844, p. 279. 
 
576 OBSTRUCTED LABOR. 
 
 cervix uteri or vagina. In consequence of the fatal disease under 
 which the mother is suffering, her ovfn life is not worth more than 
 a few weeks', or at most a few months', purchase ; while the child, 
 if saved and not sacrificed, may possibly grow up and become a 
 useful and important member of society. Under such circumstances, 
 we are assuredly justified in preserving the life of the child, even 
 were it at the expense of some additional immediate risk to the life 
 of the mother. "When, however, in this complication, the unassisted 
 efforts of nature prove insufiicient, and operative measures come to 
 be really required, those that are best, are, I believe, of a kind that 
 usually do not add to the danger of the mother, while they are cal- 
 culated to preserve the child. In most cases the cancerous part at 
 last spontaneously fissures and lacerates in order to allow the child 
 to pass. By practising vaginal hysterotomy in these same instances, 
 we arrive at the same end ; but more certainly and safely. For, 
 instead of allowing the muscular contractions of the uterus to make, 
 by long and exhausting efforts, the necessary lacerations, and gain 
 for us the necessary space, we make these lacerations or incisions 
 with the bistoury ; and further, when we do so, we can select the 
 safest time for effecting them — namely, early, and before exhaustion 
 sets in ; and we can select also the safest locality for the division of 
 the tissues of the cervix, instead of leaving this entirely to chance. 
 After the incisions are made, the expulsion of the child may be left 
 to nature, or it may be extracted artificially by turning or the long 
 forceps. In the two following cases the long forceps were used after 
 the necessary incisions were made. 
 
 Case II. — In a woman in the Royal Infirmary, six months preg- 
 nant, the septum between the rectum and vagina was already per- 
 forated by carcinomatous ulceration. She went on to the fall time. 
 As the disease did not extend to the uterus, but affected only the 
 vagina and surrounding textures, the first stage of labor was com- 
 pleted naturally ; the child was then extracted by the forceps. But 
 it was necessary, first, to incise freely the carcinomatous mass obstruc- 
 ting the vagina ; and, in bringing down the head, the perineum, 
 which was quite indurated and tuberculated, tore in its whole extent. 
 The infant was alive and healthy. The woman had a rapid conva- 
 lescence, and lived for more than two years afterwards : the carcino- 
 matous ulceration gradually excavating and destroying almost the 
 whole contents of the pelvis. 
 
 Case m. — A patient, the subject of extensive cancerous disease 
 of the cervix uteri, was seized in the Infirmary with premature labor 
 near the eighth month. After the parturient efforts had lasted for 
 
CARCINOMA IMPEDING DELIVERY. 577 
 
 a considerable time, without any prospect of successful dilatation 
 and delivery, I enlarged the os uteri by lateral incisions, and extracted 
 the infant with the long forceps. The child survived. The mother 
 suffered no special aggravation of her symptoms in consequence of 
 delivery. ' The cancerous disease proceeded on its usual course, and 
 proved fatal a few months subsequently. 
 
 In the following instance the uterine efforts very speedily expelled 
 the child, after the obstruction from the indurated cervix was removed 
 by incision. 
 
 Case IV. — I saw this patient with my esteemed friend Dr. Martin 
 Barry, when he was attached to the Maternity Hospital. The woman 
 had been ill for three days. She was very much exhausted, and her 
 pulse extremely rapid. The cervix was indurated by carcinomatous 
 degeneration at one side, and did not seem at all inclined to yield. 
 Two or three small incisions were made through the indurated 
 portions This allowed the head to pass, and the delivery was com- 
 pleted after five pains. It was too late, however, to save the patient. 
 Her pulse never fell, and she sank in two or three days afterwards. 
 
 The cancerous disease at the time of labor supervening may be 
 found not so great or extensive as to prevent the os uteri opening to 
 nearly its full extent, and yet it may prevent the head from entering 
 the brim. In the following case I delivered the patient by turning, 
 instead of the long forceps — the head being detained so very high 
 up, as to suggest the former as preferable to the latter mode of 
 delivery. 
 
 Case V. — A patient, under the care of Dr. Burns, who had pre- 
 viously borne a large family easily, had her last labor very protracted, 
 in consequence of carcinomatous induration of the posterior lip of 
 the uterus. Symptoms demanding artificial delivery supervened by 
 the time the os uteri was nearly dilated. The child was extracted 
 by turning, and survived. The diseased cervix tore slightly as the 
 head passed ; and perhaps it would have been better to have deter- 
 mined the seat of this laceration by a previous incision. The cance- 
 rous disease proceeded slowly onwards, and she died in about a 
 year. 
 
 Case VI. — ^In another patient of Dr. Burns', premature labor 
 came on spontaneously between the seventh and eighth month ; and 
 though the whole circle of the cervix uteri seemed affected with the 
 cancerous disease, the os at last dilated and fissured sufficiently to 
 allow a living child to pass. The disease proved fatal to the mother 
 a few months subsequently. 
 
 VOL. 1. 37 
 
578 OBSTRUCTED LABOR. 
 
 In cancer complicating pregnancy, the preservation of the life of 
 the child is, we have ventured to state, the great object which the 
 practitioner should desire to effect— especially if he can accomplish 
 this object by means not directly detrimental to the mother— and 
 such cases as this last have suggested the propriety of sometimes 
 attempting to attain this double end by the artificial induction of 
 premature labor. This mode of delivery ought probably to be 
 adopted, if the disease is so severe or acute as to threaten to destroy 
 the life of the mother before the full completion of pregnancy ; or if 
 we fear that the mechanical obstruction, from the rapid growth and 
 development of the disease, is likely to prove too great for the pos- 
 sible passage or extraction of a child allowed to reach the full term. 
 At the same time, as our calculations are specially directed to the 
 preservation of the child, it would be wrong to peril its life by bring- 
 ing it with any unnecessary prematurity into the world ; and certainly 
 the idea suggested by one or two authorities, of treating this com- 
 plication by inducing artificial abortion or premature labor, before 
 the infant was visible, seems to us a practice indefensible either on 
 moral or professional grounds. 
 
 In almost all the known and recorded instances of cancer uteri 
 complicating parturition, the obstruction to delivery has arisen far 
 more from the induration, and consequent non-dilatability of the 
 structures that were the seat of the disease, than from their increased 
 physical volume or bulk. And hence the reason why we may hope 
 to overcome the diflaculty, in a great maj ority of cases, by the division, 
 when necessary, of the affected tissues. But where, unfortunately, 
 in the exceptional case, there exists, from the mere size of the car- 
 cinomatous deposit, such obstruction of the maternal passages as to 
 prevent delivery entirely, per vias naturales, unless the child be des- 
 troyed and mutilated, then it does certainly appear justifiable to 
 extract the infant, if it is still alive, by the Csesarean section. In 
 this complication of labor obstructed by carcinoma uteri, craniotomy, 
 when adopted, besides proving of necessity directly fatal to the child, 
 has almost always resulted also in the very speedy death of the 
 mother. Few or none in the instances recorded have survived above 
 a few hours, or a few days at most. The Csesarean section offers 
 every possible chance of preservation to the life of the child, and is 
 scarcely more rapidly fatal to the mother. Some years ago, my 
 friend. Dr. Oldham, published a case of large carcinoma uteri 
 obstructing labor, in which the child was saved by this mode of 
 delivery, and the mother did not die in consequence of the operation, 
 as has happened in most instances in which the Csesarean section 
 has been performed in British practice. 
 
HYDROCEPHALUS COMPLICATING DELIVERY. 679 
 
 ON THE DANGER OF RUPTURE OF THE UTERUS FROM 
 HYDROCEPHALUS IN THE FCETUS/ 
 
 MODES OF DIAGNOSIS AND TREATMENT. 
 (From Edinburgh Monthly Journal of Medical Science, June, 1848, p. 885.) 
 
 Dr. Simpson described two cases to which he had recently been 
 called, and in which fatal rupture of the uterus had previously occur- 
 red in consequence of hydrocephalus in the foetus. Both mothers had 
 borne large families without difficulty. In both cases their present 
 labors were very prolonged, and the pains severe before the lacera- 
 tion occurred. And, it might perhaps be laid down as a general 
 principle, that when a mother who had previously borne children 
 with the usual facility and safety, suffered a long and difficult labor, 
 with the head never properly entering the brim, dangerous enlarge- 
 ment of the head from hydrocephalus or other causes should be 
 suspected, and the most careful means instituted in order to make 
 out a correct diagnosis. In this, as in other important cases, if the 
 patient were put into an anaesthetic state, great facilities would be 
 given for making a careful and leisurely diagnostic examination of 
 the child's head by the hand, without suffering or resistance on the 
 part of the mother. The iinusual size and dimensions of the head 
 might be thus ascertained ; but one source of fallacy was to be 
 guarded against, namely, that the sutures and fontanelles were not, 
 as was usually described, always preternaturally open and enlarged 
 in hydrocephalic cases ; for the cranial bones were in some instances, 
 where the internal effiision was very great, so largely and abnor- 
 mally developed as to destroy this supposed pathognomonic sign, 
 and to form an almost complete osseous covering for the enlarged 
 head. In one of the two cases described by Dr. Simpson, the cranial 
 bones were, in this way, as large as in a child two or three years old. 
 When hydrocephalus was attended with imperfect ossification, the 
 enlarged and fluid head sometimes moulded itself so readily to the 
 maternal passages as to pass without much difficulty even when of 
 very great size. But the danger and difficulty was much increased 
 when to this was added the impediment arising from enlargement 
 of the bones themselves. 
 
 Mechanism of Rupture in Cases of Hydrocephalus. 
 
 The danger of rupture of the uterus, and consequent death of the 
 mother, was much greater under hydrocephalus than obstetric au- 
 
 ' Extracted from Proceedings of Edinburgh Obstetric Society, March 12, 1848. 
 
580 OBSTRUCTED LABOR. 
 
 tliors commonly described. In a collection of cases of intra-uterine 
 hydrocephalus made this year by Dr. Thomas Keith for his thesis, 
 out of 74 instances of the disease which he had found on record, in 
 16 the uterus ruptured during labor. In fact, the diseased head of 
 the infant, distended by the effused fluid, acted, under the impres- 
 sion conveyed to it by the body and spine of the infant during labor, 
 like a hydraulic bag or machine, pressing equally and in all direc- 
 tions on the cervix uteri, or parts with which it was in contact, vsdth 
 a force under which these compressed structures were almost certain 
 to rend, provided the pressure was of any great duration ; because 
 the force itself contained the sum and concentration of the whole 
 power of the uterine contractions bearing on each point with which 
 the bag of the head was in contact. Under such compression, any 
 weak or fissured point, was almost certain to yield. And if any 
 hydrocephalic head or fluid bag of this kind passed into the vagina 
 and remained there, the kind of universal compression of the vaginal 
 walls to which it gave rise, was apt, if it did not lead to direct rend- 
 ing and laceration, to produce, if long continued, sloughing inflam- 
 mation in these parts. 
 
 Removal of Hydrocephalic Head by Trocar. 
 
 Hence labors, in which the child's head was hydrocephalic, should 
 not, if possible, be allowed to become prolonged; but when the 
 delivery was not effected by the natural efforts, it was not perhaps 
 necessary to destroy entirely such an infant during labor, by using, 
 as was universally recommended, the crotchet or other mortal 
 operative procedure. In some instances it was a matter of legal 
 importance for the parents that the child should be born alive, 
 though not capable of surviving. And a small trocar passed into 
 the hydrocephalic collection was capable of evacuating the contained 
 fluid as efficiently as a more extensive and fatal laceration by the 
 usual obstetric perforator or scissors ; nor was such an evacuation 
 by the trocar necessarily fatal to the foetus, for we know that in the 
 operation for hydrocephalus on the child afterbirth, by Dr. Conquest 
 and others, the simple puncture of the head was by no means a 
 fatal operation. Those operated on seldom or never died of the 
 operation itself, but of the subsequent reaccumulations and con- 
 sequences. 
 
 Evacuation of Fluid by the Spinal Canal when the presentation is Pelvic. 
 
 The hydrocephalic foetus not unfrequently presented by the feet 
 or breech. In a case of this kind which occurred some time ago to 
 Mr. Girdwood of Falkirk, and where the child was dead and putrid, 
 
INDICATIONS OF PRACTICE IN PELVIC DEFORMITIES. 581 
 
 the spine and skin over it lacerated at the neck, in making the usual 
 tractions to bring down the head. A great quantity of water escaped 
 from the laceration, and the enlarged head, which had previously- 
 resisted the force applied to it, was now easily extracted in its col- 
 lapsed state. This case afforded a suggestion, that under a similar 
 complication, with the body already born, instead of passing our 
 hand and perforator to the brim of the pelvis in order to puncture 
 the head, which was sometimes a matter of no small difficulty, we 
 might attain the same end, the evacuation of the hydrocephalic 
 effusion, by the more simple and safe measure of opening the verte- 
 bral canal, in any part of the course of the spine. 
 
 CASE OF DELIVERY WITHOUT OPERATIVE AID, THROUGH 
 A PELVIS EXTREMELY NARROWED BY MALACOSTEON ; 
 
 WITH PRACTICAL REMARKS.' 
 (From Edinburgh Monthly Journal of Medical Science, July, 1847, p. 22.) 
 
 DiPFEKENT classifications of the morbid conditions and deformities 
 of the maternal pelvis have been proposed by obstetric pathologists. 
 Some have arranged them in relation to their causes, others in rela- 
 tion to their nature, seats, &c. But the most practical classification 
 consists in dividing the morbid states of this part of the skeleton 
 into several grades, according to the actual degree and amount of 
 physical contraction in the pelvic apertures, which is induced by 
 these states; and consequently, according to the kind and modi- 
 fication of measures required to extract through the defective aper- 
 tures, a child arrived at or near the full term of utero-gestation. 
 
 Drs. Denman and Eamsbotham, and Professor Paul Dubois, have, 
 for instance, followed this principle of classification in discussing 
 the effects of diseased and deformed conditions of the pelvis upon 
 the process of parturition. Laying aside all pelves of the normal 
 form and standard dimensions, as requiring no accessory aid from 
 art for the transit of an infant through them, these authors have 
 divided all varieties of pelvic contractions into the three following 
 gradations. 
 
 L Pelves somewhat diminished below the natural -standard, but 
 still admitting of the child being expelled through them by nature, 
 or extracted by instruments safe (such as the forceps and vectis) 
 both to the mother and infant. 
 
 ' Read before Edinburgh Medico-Chirurgical Society, June 2, 1 847. 
 
582 OBSTRUCTED LABOE. 
 
 11. Pelves contracted to such a degree as not to allow a cliild, at 
 or near the full term, to pass through their apertures till its head 
 was reduced in size by craniotomy. 
 
 m. Pelves so very small as not to admit of the extraction through 
 them of a child even after it was mangled and mutilated by embry- 
 ulcio, and where that last resort of the obstetric art, Csesarean section, 
 constituted the only possible mode of delivery. 
 
 It is evident that the reference of individual cases of labor to one 
 or other of the preceding degrees of difficulty in the process of de- 
 livery, must be often regulated by other circumstances than the mere 
 physical dimensions of the maternal pelvis. The strength and powers 
 of endurance of the patient, the activity of the uterus, and above all 
 the dimensions and compressibility of the infant's head, as modified 
 by its actual volume, and by its state of ossification, the width of its 
 sutures and fontanelles, the separation or not of the bones by pre- 
 vious death and putrefaction, &c., are so many matters forming im- 
 portant points and elements of difference in different instances. 
 But still, however, most of our highest authorities in midwifery have 
 attempted to lay down, in the form of general principles, more or 
 less exact and fixed pelvic admeasurements between the several 
 classes or gradations of pelvic deformity that I have mentioned. In 
 other words, they have endeavored to reduce to abstract arithmetical 
 formulae, as it were, the boundaries and limits between morbid states 
 of pelvic contraction, admitting respectively of delivery at or near 
 the full time, first, without the necessity of embryuleio ; secondly, by 
 means of embryuleio ; and thirdly, where embryuleio is inadequate 
 and insufficient for the purpose. 
 
 For the purpose of illustrating these points and statements, I shall 
 collect and throw into a condensed tabular form the opinions of 
 some of our most eminent British accoucheurs on the pelvic dimen- 
 sions relatively fitted for these different modes of management and 
 delivery. It is necessary, however, to premise one observation in 
 order to understand the figures and formulae which I shall quote. 
 The apertures of the brim and outlet of the human pelvis are nor- 
 mally of an irregularly ovoid form, and they maintain more or less 
 of this configuration under all kinds of morbid contraction and de- 
 formity. Indeed it generally happens, more particularly in cases of 
 rickets and malacosteon, that when either of these pelvic apertures 
 is morbidly contracted in one diameter, it comes to be elongated in 
 the other. One of the diameters, either of the brim or outlet, how- 
 ever, is always contracted ; and hence in speaking of the relative 
 size of different deformed pelves, accoucheurs often note their di- 
 mensions by simply stating, as in the first of the following tables, 
 the length of their shortest or narrowest diameter. 
 
CONTRACTIONS OF PELVIS REQUIRING BMBRYULCIO, 583 
 
 Smallest size of pelvis through which, a child may pass without mutila- 
 tion. — In the standard and normally formed pelvis, the narrowest 
 diameter of the brim (the conjugate), and the narrowest diameter of 
 the outlet (the transverse), are each, on an average, about four inches 
 in length. A child may, however, pass through these pelvic open- 
 ings, though their narrowest diameter be reduced very considerably. 
 The following table shows the opinion of some of the most eminent 
 British accoucheurs on this point. 
 
 Smallest Pelvic Diameter admitting of the Passage of a Child vnthout Embryulcio. 
 
 3J inches — Joseph Clarke,' Burns.^ 
 
 3 " Denman,' Davis,* Eamsbotham.' 
 
 2f " Osborne,^ Hamilton,' Barlow.' 
 
 ' " Having examined, by dissection, the bodies of many women who died after tedious and 
 laborious labors, I am enabled to state, with some confidence, that three inches and a quarter 
 from pubis to sacrum is the least diameter through which I have known a full-grown foetus 
 to pass entire ; but it was a very putrid ftetus, consequently the head was soft and pliable.' 
 — Dr. Clarke in Transactions of the Irish College of Physicians, vol. i. p. 374. 
 
 * Dr. Burns considers Dr. Clarke " correct when he says that the head cannot pass entire 
 if the diameter be under 3|, and even this will generally require the perforator." — Principles 
 of Midwifery, 1843, p. 471.— See also p. 473. 
 
 ' " Should the capacity of the pelvis be reduced under three inches, we have no good 
 reason to expect a living child of its full growth, however small, to pass through it, either 
 naturally or by the assistance of art ; though the head of one that is dead, especially if it be 
 putrified, or one much below the common size, may be pressed through a pelvis of these 
 dimensions, even without artificial assistance. Should the capacity of a pelvis not exceed, 
 according to our judgment, two inches and a half, then the head of a child, unless the con- 
 tents be evacuated, cannot pass or be extracted through it." — Denman's Introduction to Mid- 
 wifery, pp. 457-58. Edition of 1816. 
 
 * " Pelves of somewhat less dimensions than those of a standard pelvis may occasionally 
 admit of children being born alive at the full period of gestation. For example, a living 
 child of average size at that period might be born alive, provided the conjugate diameter of 
 the brim of the mother's pelvis was three inches and three-tjuarters, and the head presented 
 in the best possible position. But, if it amounted to no more than three inches, a well-grown 
 child at full period could not be expected to pass without an operation to reduce the bulk 
 of its head.'' — Davis' Principles and Practice of Midwifery, vol. i. p. 25. 
 
 ' " Some practitioners have thought that a pelvis measuring only two inches and three- 
 quarters in the conjugate diameter would allow of the bead passing whole, provided there was 
 suflioient room laterally. My own conviction, derived from clinical observations, is, that 
 the dimensions I have just mentioned (three inches in the conjugate by four in the lateral 
 diameter) are the smallest which will grant the passage to a full-grown fcEtus." — Rams- 
 botham's Obstetric Medicine and Surgery, second edition, page 30. 
 
 ' " Whenever the capacity of the pelvis is only two inches and three-quarters or certainly 
 less than three inches," there is. Dr. Osborne conceives, " an utter impossibility for a child of 
 ordinary size, at full time, being born alive by any means, either of nature or art, through 
 so small a pelvis." — Osborne's Essays on the Practice of Midwifery, p. 223. At p. 194, he 
 states that, " when the bones approach much nearer than three inches it is utterly impossible 
 for a living child at full maturity, by any means to pass," and embryulcio should be performed 
 early in the labor. 
 
 ' Dr. A. Hamilton, in his Letters to Dr. Osborne, adduces several cases in which delivery, 
 took place safely and spontaneously, " where the deformity of the pelvis seemed to be such 
 
584 
 
 OBSTRUCTED LABOR. 
 
 I am not aware that any English writer on midwifery has stated it as 
 practicable that a child could pass, without mutilation, through a pel- 
 vic diameter less than that mentioned in the last line of the preceding 
 table ; namely, two inches and three-fourths. Instances, however, 
 in which children, at or near the full time, have been expelled by 
 the uterus, or extracted with forceps, through pelves measuring only 
 two inches and ^ half in their narrowest diameter, have been men- 
 tioned by some foreign authors. Solayres, Baudeloeque, and Ca- 
 puron,V each advert to cases illustrating the possibility of this 
 occurrence. 
 
 In an obliquely deformed pelvis in my Museum, the conjugate di- 
 ameter of the brim is one or two lines below 3 inches ; and yet 
 through it a dead fall-sized child passed as a head presentation, after 
 a long labor, but without instruments. I extracted a second infant 
 by the feet through the same pelvis. Further, I believe, that when 
 the child presents by the feet, and thus the apex, instead of the base 
 of the cone formed by the head and body of the fcetus, comes first, 
 that it may make its transit without embryulcio through a pelvis, the 
 smallness of which would otherwise have necessitated mutilation or 
 the operation of craniotomy. In this way I have through a pelvis 
 probably not above 2^ inches in its narrowest diameter, extracted a 
 child by the operation of turning, the parietes of the skull becoming 
 compressed and indented to allow of its passage.^ 
 
 that acording to your (Dr. O.'s) data, the head of the child should have been opened 
 at the beginning of labor," p. 119. In the first case detailed by Dr. Hamilton, a living child 
 passed, though the pelvic brim was ascertained by admeasurement after death, to be " sen- 
 tibly under three inches.'' — P. 101. 
 
 8 Dr. Barlow, in his Essays on Surgery and Midwifery, p. 354, gives the following Synop- 
 sical Table of the various degrees of distortion of the pelvis and their appropriate treatment : — 
 
 Degrees of Deformed 
 Pelvis. 
 
 Conjugate Diameter of Brim. 
 
 Modes of Delivery. 
 
 First degree, . . . 
 
 Second degree, . . 
 Third degree, . . . 
 
 Fourth degree, . j 
 
 From 4 to 3 or 2J inches, j 
 
 From 2} to 2i inches, . . . 
 From 2i to H inches, . . . 
 From li to the lowest poB-l 
 Bible degree of distortion, j 
 
 Efforts of Nature, or as- 
 sisted by forceps or lever. 
 Premature delivery. 
 Embryulcio. 
 
 Csesarean operation. 
 
 ' Bandelocque's Midwifery, Heath's Translation, vol. ii. p. 370. Capuron's Cours des 
 Aocouchemens, Brussels Edit. p. 221. 
 
 ' See p. 450. I have elsewhere stated the advantages, in deformed pelves, from turning 
 in comparison with embryulcio to be, that — 1. It gives the child a chance of life ; 2. It is 
 more safe to the mother, because it can be performed earlier in the labor, and more speedily- 
 
 3. It enables us to adjust and extract the head of the child through the imperfect pelvic brim 
 in the most advantageous form and direction, the head flattening laterally under the traction • 
 
 4. The neck of the child, if it be living or only lately dead, is so strong as to allow us to 
 exert such a degree of traction upon the obstructed head, that the sides of the cranium may 
 become very greatly compressed, or even indented under it, and that without necessarily de- 
 
CONTRACTIONS OF PELVIS REQUIRING CESAREAN SECTION. 585 
 
 Highest pelvic dimensions necessitating the performance of the Ccesa- 
 rean section. — It is well known that Continental practitioners have 
 sometimes recourse to the Csesarean section under degrees of pelvic 
 contraction that are not considered by British accoucheurs to demand 
 an operation of such great severity and hazard. 
 
 In one of the last and best works upon Midwifery, published in 
 Germany, the following observations occur in reference to the de- 
 gree of pelvic deformity, indicating the Csesarean operation : — 
 
 " When the smallest diameter amounts to only 2f inches, the ter- 
 mination of labor is possible only by making an artificial passage, 
 or by breaking up the child. The possibility of terminating it in 
 the latter manner ceases whenever the small diameter amounts only 
 to 2\ inches or less, and the Csesarean section is then the only possi- 
 ble mode of delivery, and that to which we must have recourse in 
 all cases, whether the child be dead or not. If the contracted pelvis 
 measures from 2J to under 3 inches, then the Csesarean section is 
 indicated when the child is alive, while, if it is dead, perforation is 
 to be had recourse to."^ 
 
 Jacquemier, the latest French writer on Midwifery, states, that 
 when the pelvis is below two inches in its narrowest diameter, the 
 Csesarean section is the only justifiable mode of delivery, even when 
 the child is dead ; and when it varies from two inches to two inches 
 and a half, and the child is alive, the Csesarean operation should be 
 adopted in preference to embryotomy, not only for the sake of 
 the life of the child — but as, perhaps, not more dangerous to the 
 mother than a protracted and difficult delivery by embryulcio, 
 generally proves to be.^ 
 
 So far as I am aware, Velpeau is the only author who has 
 hitherto attempted to collect, in a generalized form, the measure- 
 ments of the pelvis of patients who have been submitted to the 
 Csesarean section. He tells us that out of 80 cases in which the 
 cause for the operation was specified, in 62 cases it was required by 
 contraction of the pelvis, particularly in the antero-posterior diameter 
 of the brim. Thus it was' 
 
 1 inch . . . in 1 case. 
 
 1 " to IJ inches in 8 cases. 
 li '■ to 2 " in 23 " 
 
 2 « to 24 " in 25 " 
 2J " to2| " in 5 " 
 
 In a number of these cases, the Csesarean operation was adopted 
 
 stroying the child; and, 5. It is a practice which can be followed when proper instruments 
 are not at hand, and the avoidance of instruments is generally desirable when it is possible. 
 
 ' Busch and Moser's Handbuch der Geburtskunde, Berlin, 1842, Bd. iii. p. 108. 
 
 2 Manuel des Accouchemens, Paris, 1846, torn. ii. p. 162. 
 
 ' Trait^ Complet de I'Art des Accouchemens, torn. ii. p. 458. 
 
686 OBSTRUCTED LABOR. 
 
 under degrees of pelvic contraction, in which delivery by means of 
 embryulcio, would have been followed by British practitioners. 
 This remark especially applies to the thirty cases included in the 
 last two lines of the table ; and it applies to them the more strongly 
 when we further recollect that the sizes of these pelves in English 
 measurements would have been somewhat more than they appear 
 under French measurements, the French inch being about ts longer 
 than the English inch. 
 
 In choosing, in any case of contracted pelvis, between the alter- 
 natives of craniotomy and the Cesarean section, Continental prac- 
 titioners generally look upon the life of the child, as well as the 
 probable degree of difficulty and danger likely to ensue to the 
 mother from a painful and protracted delivery by embryulcio, as 
 important points and elements in deciding between these two me- 
 thods of delivery. In this country, little, or indeed no, attention 
 has hitherto been given to these considerations in forming a prac- 
 tical conclusion on the question. In fact, British accoucheurs have 
 never deemed themselves entitled to have recourse to the Csesarean 
 section, unless the pelvic apertures were so much reduced as to 
 prohibit the practicability of the extraction of the child through 
 them by embryulcio. With them the propriety of delivery by the 
 Csesarean section begins exactly with that degree of pelvic deformity 
 at which the possibility of delivery by embryulcio terminates. 
 
 Hence, in order to fix and determine the highest limit of pelvic 
 contraction which necessitates the performance of the Csesarean sec- 
 tion, we have merely, in the first instance, to fix and determine the 
 lowest limit of pelvic contraction at which delivery by embryulcio 
 is capable of being effected. 
 
 The following table presents, in a condensed form, the opinions 
 of various British and American obstetricians upon this question, 
 namely, the actual degree of pelvic contraction above which it is con- 
 sidered still possible to deliver by embryulcio, and below which it is 
 deemed proper, and absolutely necessary, to extract the infant by 
 the Csesarean section. 
 
 Smallest Pelvic Diameters admitting of the passage of a Child by Embryulcio. 
 
 3J inches by 2 inches — Dewees,^ Bedford,^ &c. 
 
 ' " By a sufficient diameter I mean, where there is at least two inches in the antero- 
 posterior, and at least three and a half in the transverse ; below this, delivery per vias na- 
 turales, I repeat, I believe to be impossible." — Dewees' System of Midwifery, 1837, p. 579. 
 
 ^ " I do not believe it is possible to remove a child by embryotomy, when the antero-pos- 
 terior diameter of the superior strait measures less than two inches, without subjecting the 
 mother to severe hazard, provided the child be of the ordinary size. I am satisfied, that 
 even with the space of 2 J inches, all the dexterity which the operator can bring to his aid, 
 
CONTRACTIONS OF PELVIS REQUIRING CiESAREAN SECTION. 587 
 
 3 inches by 1| inclies — Burns,' Hull,^ &c. 
 
 3 " by IJ " Barlow,' Hamilton,*' &c. 
 
 During the last ten or twenty years, various improvements have 
 been proposed in our embryulcio instruments, particularly with the 
 view of rendering that operation more safe and easy in cases of un- 
 usual difficulty and deformity. Lest, with such additions and im- 
 provements, the preceding table be supposed to misrepresent the 
 existing rules and doctrines of our modern British schools of Mid- 
 wifery respecting the degree of pelvic contraction necessitating the 
 adoption of the Csesarean section, I shall cite, in reference to the in- 
 dications for this operation, the opinions expressed upon the subject 
 in the last three obstetric text-books that have issued respectively 
 from Edinburgh, Dublin, and London. 
 
 In his " Introduction to the Study and Practice of Midwifery," 
 Edinburgh, 1843, Dr. Campbell observes, " unless we have a clear 
 space of two inches, or nearly so, in the transverse (conjugate), 
 and fully three in the lateral diameter of the brim, embryotomy 
 must be abandoned, as not likely to insure the safety of the 
 parent.* 
 
 In his work " On the Theory and Practice of Midwifery," 1843, 
 Dr. Churchill, of Dublin, after an elaborate investigation of the sub- 
 ject, draws the following deduction. " "We may therefore," he ob- 
 serves, " safely conclude, that when from any cause, the antero- 
 posterior diameter of the upper outlet, or the transverse diameter of 
 the lower, is not more than IJ inches, there is no possibility of de- 
 livery per vias naturales, but that we must have recourse to the Csesa- 
 rean section. "° 
 
 will be required to protect the mother from serious, if not fatal injury. I, without hesitation, 
 would prefer the Caesarean section, if I had certain evidence that the child lived, to any at- 
 tempt to extract it, per vias naturales, if the antero-posterior diameter measured less than 2 J 
 inches." — Dr. Bedford in his Translation of Chailly's Midwifery, note, p. 386. 
 
 ■ " The crotchet cannot be used, when the head as of the full size, unless we have a pas- 
 sage through the pelvis and its linings measuring fully an inch and three-quarters in the short 
 diameter, and three inches in length ; or if the child be premature and soft, an inch and a 
 half broad, and two inches and three-quarters long." — Dr. Burns' Principles of Midwifery, 
 1843, p. 508. 
 
 * " I am of opinion, that it still remains to be proved whether a mature foetus of the ordi- 
 nary size has ever been extracted, with safety to the mother, through a pelvis, in the superior 
 aperture of which there was not in any point, from the fore to the hind part, a space equal 
 to H^ inch.'' — Dr. Hull's Defence of the Csesarean Section, p. 391. 
 
 ' See Dr. Barlow's Synoptical Table, quoted on page 584, from his Essays on Surgery and 
 Midwifery, p. 354. 
 
 ■> " Whenever the short diameter of the pelvis, either at the brim or at the outlet, will not 
 admit above one ordinary sized finger, or really falls under one inch and a half, no other 
 means are justifiable for the delivery, if the child be arrived at the full period of gestation, 
 than that tremendous expedient, the Caesarean operation." — Dr. A. Hamilton's Letter to Dr. 
 Osborne, p. 139 * Introduction, &c., p. 319. ^ Midwifery, p. 314. 
 
588 OBSTRUCTED LABOR. 
 
 Dr. Francis Eamsbotliam of London, in his " Obstetric Medicine 
 and Surgery," London, 1844, observes, when speaking of deformity 
 of the pelvis,' " I am quite convinced, that unless there be at the 
 brim one inch and three-eighths in the conjugate, by three and a 
 half in the iliac (diameter), or IJ inches in the conjugate by three 
 in the iliac, it would be useless to attempt delivery per vias natu- 
 rales." And again, when treating of difficult labors, he remarks, 
 " If upon a measurement conducted with the utmost care, we find 
 there is less space at the brim than three inches and a half late- 
 rally by one inch and three-eighths in the conjugate diameter ; or 
 three inches by one inch and a half; we ought to consider it our 
 duty, however painful and appalling that may be, at once to pro- 
 pose the Csesarean section as the only means by which it is pos- 
 sible to save the mother's life ; and as offering also the sole chance 
 of safety to the child. "^ 
 
 Our highest, as well as latest, authorities in British Midwifery 
 seem thus to have fijxed upon a degree of pelvic contraction in 
 which the dimensions varied from 3J to 3 inches in the long dia- 
 meter, and from 2 to IJ in the short diameter, as the lowest limit 
 at which delivery by embryulcio can be performed,^ and below 
 which it is always and invariably necessary to have recourse to the 
 Csesarean section, when the child has reached the full time. In the 
 case, which it is my object in this communication to detail, the in- 
 ferior pelvic aperture of the patient was so deformed and contracted 
 from Malacosteon, that it was considerably less in its dimensions 
 than the lowest limit stated in the preceding table and extracts, as 
 
 ' Loc. cit. p. 30. 2 Obstetric Medicine and Surgery, p. 179. 
 
 ' I do not stop to discuss die question, whether, in all cases of great deformity, embryulcio 
 is always proper where it is possible. The difficulty attendant upon its performance in in- 
 stances of marked contraction has sometimes been extreme. In a case where the narrowest 
 diameter of the brim was thought to measure (wo inches, Dr. Meigs required many hours to 
 break down the cranium, and afterwards three or four hours' pulling to extract the child 
 with the crotchet. The mother was altogether three or four days in labor. — Philadelphia 
 Practice of Midwifery, p. 322. In a woman with a pelvis, the conjugate diameter of which 
 " was estimated at little more than an inch and a half," Dr. Hamilton effected delivery by em- 
 bryulcio. The extraction alone occupied four hours, and " required such an exertion of force, 
 that he was literally obliged from exhaustion to be carried home in a sedan chair." — Prac- 
 tical Observations, p. 263. Lately, my friend Professor Murphy extracted a child by embry- 
 ulcio through a pelvis, the brim of which measured one and a half inches in its conjugate, and 
 four and a half in its lateral diameter. The operation required about seven hours' work 
 on the part o'f Dr. M. The patient was in labor from Tuesday to Friday. — Lancet for April 
 3, 1847. " I question much," observes Dr. Burns, " if extreme cases of embryulcio be not as 
 dangerous to the patient as the Caesarean operation ; certainly they are more painful." — Mid- 
 wifery, p. 501 . And he elsewhere adds (p. 509), " I shall not be surprised, if in a few years, 
 British practitioners come to resort more frequently, especially in extreme cases, to the Cgesa- 
 reau section," 
 
CASE OF MALACOSTEON. 589 
 
 capable of permitting delivery by embryulcio, and yet the mother 
 after an'iving at, if not past, the fall time of utero-gestation, was 
 delivered, not only without embryulcio, and without the Csesarean 
 section, but in fact without instrumental interference of any kind. 
 Further, the child after its birth, was passed through an unyielding 
 aperture measuring under one inch in its short, and two and a half 
 inches in its long diameter ; or, in other words, this aperture was 
 fully half an inch in all its dimensions below the limits supposed to 
 demand the necessity of the Cesarean section. Before showing the 
 solution of such a seeming obstetric enigma, I shall briefly state the 
 anterior history of the patient.^ 
 
 DETAILS OF THE CASE OF MALACOSTEON, AND INFERENCES FROM IT. 
 
 Mrs. D , Cupar in Fife, now 34 years of age, was in early life 
 
 regarded as a robust and large child. She became a dressmaker in 
 Edinburgh at fourteen years of age. The sedentary habits of this 
 profession, betimes rendered her catamenia very irregular, and 
 brought on so much general delicacy of health that she was advised 
 to forego the occupation. She went to Cupar, and lived there with 
 a relation. In 1837, when about 24 years of age, she married. Two 
 years subsequently to that event she began to complain of pains in 
 the back and sides, and stiffness about the knee-joints. From this 
 attack she never recovered so fully as to be able to walk without 
 support, and continued to suffer much with shifting pains. In 1840 
 she fell, while walking with a staff across her room, and after this 
 the pains in the limbs were for a considerable time far more severe, 
 and the lameness greatly increased. Since recovering she has been 
 able to walk out of doors with the assistance of crutches. But 
 various bones of the trunk and extremities have become shortened 
 and deformed under the effects of the malacosteon. The spine is 
 bent backwards and outwards in the form of a bow, with the ribs 
 and sternum correspondingly displaced. Some of the phalanges of 
 the fingers are bent ; the right thigh bone is curved forward into a 
 semicircular shape. And from being a handsome and somewhat 
 tall woman, she has shrunk down, during the course of the last 
 seven or eight years, into a deformed dwarf-like figure, measuring 
 about four feet in height. 
 
 From the time of her marriage up to last June (1846), Mrs. D. 
 had never become pregnant. Some time, however, during the course 
 
 ' For these particulars I am much indebted to tlie Idndness of Mr. Wiseman of Cupar, the 
 patient's medical attendant. 
 
590 OBSTRUCTED LABOB. 
 
 of June— but she is not certain at wliat precise period of the month 
 — ^the catamenia appeared for the last time. She was delivered on 
 the 28th of April, or ten months after the last menstruation. 
 
 For some time after pregnancy commenced, Mrs. D. feared that 
 the swelling and increased size of the abdomen were the result of 
 dropsy, and did not watch her own feelings so as to be aware of the 
 period of quickening. At last, however, the motion of the child, 
 &c., became so unequivocal, that she applied to Mr. Wiseman to 
 attend her in her approaching confinement. 
 
 On examining into the condition of the pelvis, Mr. "Wiseman at 
 once found that its outlet was extremely contracted, but the preg- 
 nancy was already so far advanced as to preclude, under such a 
 degree of deformity, the idea of delivery by the induction of abor- 
 tion or premature labor. Besides, all attempts to touch the os uteri 
 proved ineffectual, so that none of the ordinary means of arresting 
 pregnancy, and exciting uterine action, could have been put into 
 practice. 
 
 Early in March I visited Mrs. D. with Mr. Wiseman, Dr. Graham, 
 and Dr. Grace. She was quite incapable of moving or turning in 
 bed without assistance. The uterine tumor was high, and pressed 
 over to the right side. On applying my stethoscope to it, I readily 
 detected the usual rapid pulsations of the fcetal heart. I found fully 
 borne out, the correct description which had previously been given 
 me of the excessive deformity and contraction of the pelvis. The 
 sacrum was straight above, so that its promontory did not probably 
 encroach on the brim ; but its inferior extremity was strongly and 
 anormally curved forwards. In front, the walls of the pelvis felt 
 doubled or collapsed together ; and the outlet, which was the only 
 part that could be very accurately examined, was exceedingly de- 
 formed and diminished in size. The transverse diameter was par- 
 ticularly contracted. I found it impossible to introduce two fingers 
 between the tuberosities of the ischia. Hence this diameter of the 
 outlet was evidently under an inch. Posteriorly, or opposite the 
 sacro-sciatic ligaments, there was transversely more space, but the 
 strong anterior curvature of the coccyx and lower end of the sacrum 
 seemed to curtail the conjugate diameter of the opening, and to 
 prevent the probability of its admitting, when fully dilated, more 
 than three, or, at most, four fingers even in this direction. 
 
 Under these circumstances, with a living child advanced to the 
 eighth month, and a pelvic outlet so extremely contracted, I had no 
 hesitation in coming to the same conclusion as the patient's medical 
 advisers had all previously done, namely, that the Csesarean section 
 was the only practicable mode of delivery. I was aware thatDarlow, 
 Conradi, Sprengel, and others, had seen and published cases of mol- 
 
CASE OF MALACOSTEON. 591 
 
 lities ossium, in wHcli tlie softened and still flexible pelvic bones 
 had bent and yielded during labor so as to permit the passage of the 
 child without operative interference ; but in Mrs. D. the osseous 
 tissue appeared far too firm to permit us to indulge even in this 
 faint hope. Nature, however, provided, and was perhaps already 
 preparing, for the mother a mode of delivery that was still more safe 
 and easy. 
 
 Having agreed to operate in case the Csesarean section was re- 
 quired, I anxiously waited in the daily expectation of being called 
 to Mrs. D. At last, on the morning of the 28th of April, I received 
 from Mr. "Wiseman a note, dated the previous night, intimating that 
 our patient had begun to complain of labor pains — ^that the os uteri 
 could be felt projected low down into the vagina — ^that it was not 
 opened more than two or three lines — and that the presenting part 
 of the child could not yet be detected. With some professional 
 friends who had agreed to accompany me, I forthwith proceeded to 
 Cupar, a distance of about thirty miles. On arriving there, we 
 were surprised to hear that the patient was delivered, and our sur- 
 prise was only increased by learning that no kind of instrumental 
 aid had been required. A visit, however, to the room in which the 
 child was, readily solved the apparent riddle. 
 
 The infant had been dead for some time in utero. It looked 
 nearly the natural length, and as it lay extended on the table, it 
 measured 18 J inches from the crown of the head to the heels. But 
 its limbs and body were thin, lank, and atrophied ; and its weight 
 was only 3 pounds 2 ounces. Its head appeared very large and dis- 
 proportionate in size, and indeed had been considered hydrocephalic. 
 This seemingly increased volume, however, was not the consequence 
 of effusion, but the result of putrefaction. The encephalon was in 
 a dissolved and semi-fluid state ; and as the head lay on the table, 
 it was extended and flattened out laterally and superiorly, as if it 
 consisted of a bag or bladder, half filled with liquid or semi-liquid 
 contents ; and such in fact it really was. For all the bones of the 
 arch of the cranium were separated from their attachments, and 
 floated about in the dissolved and liquefied cerebral matter. The 
 bones of the basis of the skull were also loosened, and more or less 
 separated from each other — a rarer occurrence. On handling the 
 vertex, the first piece of bone which I touched was the orbital por- 
 tion of one of the ossa frontis. The symphysis even of the inferior, 
 as well as of the superior, maxillary bones, were loosened, and ad- 
 mitted of free motion. And the component parts of the head and 
 face were so easily displaced and compressed that, on placing one 
 of my fingers in the lower occipital region behind, and another on 
 the nose or cheek in front, I found that, without any considerable 
 
592 OBSTRUCTED LABOR. 
 
 degree of exertion, the two could be made to approximate to 
 within a few lines of each other. Yet the skin of the scalp and 
 face was continuous and entire, the epidermis only being separated 
 at different parts.' The chest and abdomen of the child seemed 
 quite soft and pliable, though not in so disintegrated a state as the 
 head. 
 
 Thus far the macerated and diffluent state of the fcetus appeared 
 to afford an easy explanation of the possibility of its transitthrough the 
 very contracted pelvic outlet of the mother. 
 Fig. 35. -gjj^ J ^g^g anxious to have more fall and 
 
 complete proof that the foetus, even in this 
 state, was capable of passing through an aper- 
 ture, of dimensions so small as we knew the 
 pelvis to present in the case of Mrs. T>. In 
 order to obtain this proof, I got oblong open- 
 ings of two or three different sizes cut in 
 plates of white iron. The smallest of these 
 perforations, however, though only 3J inches 
 long by I broad, proved unnecessarily large 
 for the experiment. "We diminished it by 
 filling it up at one end with strong, thick and 
 perfectly unyielding sole leather, so that the 
 whole opening measured only 2f inches in 
 its largest, by ^ of an inch in its shortest 
 diameter ; and yet through this aperture, of 
 which the accompanying woodcut gives the 
 exact outline,' the child was pulled without any great degree of force 
 or difficulty. In dragging the infant through this aperture, no par- 
 ticular resistance was met with from the bones of the head and 
 face ; but the size of the liver impeded its transit for a minute or 
 two, as the lower part of the thorax was passing through the me- 
 tallic opening. Dr. Graham, Dr. Ziegler, Dr. Weir, Mr. "Wiseman, 
 &c., witnessed these experiments with me ; and, if our limited time 
 had allowed us to remain longer in Cupar, and to have got another 
 plate perforated, probably we should have found the child capable 
 of passing through an aperture one or two lines smaller in some of 
 its dimensions. 
 
 The placenta had been preserved. It was small and atrophic, 
 and contained scattered through it a number of those white 
 tubercles, as they are sometimes improperly termed, which we so 
 often see connected with, and causing marasmus and death of the 
 
 ' The perforated iron plate and superadded piece of leather, are preserved in the Obste- 
 tric Museum of the University. 
 
CASE OF MALACOSTEON. 593 
 
 foetus in utero. Some of these tubercles or fibrinous deposits were 
 of the size of hazel-nuts, or larger. 
 
 The history of the delivery had been this. Slight labor-pains had 
 come on during the afternoon of the 27th. She was seen in the 
 course of the evening by Drs. Graham and Grace and Mr. Wise- 
 man, who found the os uteri beginning to dilate, but the pains were 
 not severe, and the husband and attendants of Mrs. D. all went to 
 bed. About one o'clock in the morning of the 28th, Mr. "Wiseman 
 was raised, the waters having escaped about an hour previously, and 
 the uterine contractions having become strong, and bearing down. 
 When Mr. Wiseman reached the house of the patient, he found the 
 soft scalp of the child already bulging through the external parts. 
 Some detached bones, included in the portion of scalp that had 
 passed, allowed him to obtain a firm hold of the protruded portion 
 of the head, and thus enabled him to use some extractive force. 
 By thus assisting the effects of the pains, the child was entirely 
 born about half an hour after Mr. Wiseman's arrival. The mother 
 has made a very good recovery, and declares that " having a child 
 is nothing." 
 
 There are no sufficient data to determine at what precise time the 
 infant died. Milk had been discharging from the nipples for three 
 or four weeks before delivery ; but whether the child had perished 
 about that period, it is impossible to say. Mrs. D. deceived herself 
 with the idea that she felt it living and moving up to the time of 
 delivery. 
 
 The preceding case is, I believe, unique in the annals of mid- 
 wifery. It will perhaps, therefore, require no apology if I add one 
 or two brief inferences which the history and details of it appear to 
 suggest. 
 
 1. It has taught me, and is, I conceive, calculated to teach others, 
 a strong lesson of caution in regard to our prognosis, under appa- 
 rently even the most desperate circumstances. In such rare forms 
 of complication as this, we must depend for our prognosis, &c., 
 upon the anterior observations and recorded facts of others. Here 
 all such records led me to expect a very different result, and offered 
 no hope whatever of such a fortunate termination as actually 
 occurred. 
 
 2. The case affords a new and striking illustration of the just and 
 well-known remark of Dr. Denman, that " the resources of nature 
 in everything which relates to parturition, are infinite, and con- 
 stantly exerted for the preservation of both the parent and child ; 
 yet, when the two objects are incompatible, the life of the child is 
 almost uniformly yielded to that of the parent."* And the mode 
 
 ' Practice of Midwifery, p. 415. 
 VOL. I. 38 
 
594 OBSTRUCTED LABOB. 
 
 and mechanism by whicli nature 'brouglit about tbis unexpected 
 result in tbe present instance are bigbly worthy of special notice. 
 For, first she set up a diseased condition of the placenta, which pre- 
 vented the Ml and proper nourishment of the foetus, and thus re- 
 strained as far as possible its development and growth. Secondly, 
 she carried this state of marasmus to such a degree, as at last proved 
 slowly fatal to the child, without superinducing that expulsive action 
 which generally soon follows the death of the infant. Thirdly, the 
 dead infant was subsequently retained for so long a time in utero, 
 that not only the bones of the cranium, but the bones of the basis 
 of the skull and face were loosened and separated from each other, 
 and the head and other parts of the body thus rendered readily and 
 easily compressible, i And, lastly, the emaciated, dead, and highly 
 putrefied infant, after being thus reduced to this diffluent and com- 
 pressible mass, and now capable of being moulded to the contracted 
 apertures of the pelvis, was ultimately and without difficulty expelled 
 through them by the supervention of natural uterine contractions. 
 Each stage and step in this mechanism was necessary for the success 
 
 ' No individual case in Midwifery has given rise to so much discussion, as that of Elizabeth 
 Sherwood. Her pelvis was estimated by Dr. Osborne as below the lowest standard which 
 I have given in a preceding page, as capable of allowing of the passage of a child by em- 
 bryulcio, being only about J of an inch from the sacrum to the pubis ; and yet he delivered 
 her successfully by craniotomy after working and pulling three hours with the crotchet. 
 Many authors have stated that Dr. Osborne must undoubtedly have under-measured the 
 pelvis of Sherwood ; — and Drs. Hull, Burns, Hamilton, &c., have denounced the operation 
 of embryulcio as " impracticable" if Dr. Osborne's measurements were at all true and accu- 
 rate. Dr. Campbell, for instance, observes, " It would be idle to enter largely on the refu- 
 tation of this extraordinary case, since Dr. Osborne's narrative of what he thought he had 
 accomplished is irreconcilable with common sense ; for how could the base of the cra- 
 nium which is IJ inches in thickness, and nearly three in breadth, be brought through 
 the aperture which he describes. A fair estimate," Dr. Campbell continues, " of the utter 
 impossibility of effecting it may be afforded by the simple experiment of forming in a plate 
 of hard wood, an opening, in shape and size exactly corresponding to the pelvis of Sher- 
 wood, and attempting to force through it the base simply, divested of the other portions of 
 the skull." — Midwifery, pp. 317 and 318. In the case of Mrs. D., I obtained the corrobora- 
 tive evidence afforded by the very experiment which Dr. Campbell here properly suggests ; 
 and I have already stated the facility with which the child was passed through the perfo- 
 rated plate. In Sherwood's case there was, I believe, the same reason for the practicability 
 of delivery, for the foetus seems to have been in the same putrid and decomposed state as 
 Mrs. D.'s child, and perhaps the bones of the face and basis of the cranium were in a 
 similar way loosened and compressible. " The whole body" of the fcEWs was, to quote Dr. 
 Osborne's own words, " in the most putrid and almost dissolved state." See p. 101 of his 
 Essays. — But, besides, the brim of the pelvis in Sherwood was in reality not so small as the 
 measurement of its conjugate diameter would seem to indicate. During delivery the os uteri 
 was pulled by Dr. Osborne over to the right side, or to the space intervening between the line 
 of the conjugate diameter and the right ilium. Here there was an oblong aperture 3 inches 
 long (as measured from the ihum to the symphysis pubis), and 1| inches broad : and hence 
 in fact an aperture as great as Drs. Hamilton, Burns, Churchill, Ramsbotham, &c., deem 
 necessary for the peformance of embryulcio ; and greater than that through which we 
 pulled Mrs. D.'s child. — See drawing of the brim of Sherwood's pelvis in Dr. Hull's Defence 
 of the Caesarean Section, pi. v. fig. 1. 
 
DEDUCTIONS FROM CASE OE MALACOSTEON. 595 
 
 of that which followed it, and the imperfection or omission of any 
 one of them would probably have entirely subverted and prevented 
 the very fortunate and very unlocked for result that occurred from 
 the combination of the whole. 
 
 3. Does the mode in which the delivery was effected in this in- 
 stance by nature, suggest any measures of practice which, under 
 similar complications, we could induce and imitate by art ? I put 
 this question, because, in the greater deformities of the pelvis, all 
 the standard operations and means which we employ for delivery 
 are in fact imitations of processes and operations which nature her- 
 self employs under the same conditions. IV hen the pelvis has been 
 much contracted, abortion has occasionally come on in the earlier 
 months and saved the mother ; or premature labor has supervened 
 about the seventh month, and saved both the parent and child. 
 These natural processes we imitate successfully in the artificial in- 
 duction of abortion and premature labor. If, in morbid contraction 
 and deformity of the pelvis, the pregnancy goes on to the full time, 
 nature is still sometimes capable of delivering the mother by other 
 and various measures. Occasionally, during labor, the symphysis 
 pubis has been rent asunder under the intense and wedge-like pres- 
 sure of the infant's head ; or the uterus has been lacerated, or, as 
 has happened now in two recorded cases, both the uterus and abdo- 
 minal parietes have simultaneously ruptured and allowed the escape 
 of the child through this double opening ; or the bones of the 
 child's cranium have become deeply compressed and fractured, so 
 as at last to allow the reduced head to pass ; or the same has been 
 effected by the infant dying, putrefying, and at last its scalp and 
 sutures bursting, so as to produce the necessary diminution in the 
 size and dimensions of the encephalon. These several operations 
 of nature are all imitated by art in the respective operations of sym- 
 physeotomy, the Csesarean section, cephalotripsy, and craniotomy. 
 And while art thus adopts the operative principles of nature, she 
 attempts to improve both upon their facility and safety, by selecting 
 an earlier and hence less dangerous period for their performance ; 
 and by making the required openings and lesions by cutting instru- 
 ments, instead of submitting to the chance of their being made by 
 nature by means simply of an enormous and hazardous expenditure 
 of muscular effort and compression on her part. 
 
 But, I repeat, does the mechanism of the delivery in Mrs. D.'s 
 case suggest any principles for imitation? Let us consider the 
 answer, as it might be varied by the date of the pregnancy of the 
 mother ; and according as she had reached the periods,_^r8^, of artifi- 
 cial abortion ; or, secondly, of premature labor ; or, thirdly, had already 
 advanced to the full time. 
 
596 OBSTEUCTED LABOR. 
 
 The case shows that through an opening of very small dimensions 
 a child may pass, provided it be in a very compressible state. So 
 far it evidently suggests that the induction of abortion at the fourth 
 or fifth month, when the head of the foetus is still small, soft, and 
 very easily reducible, would, as long ago proposed by Cooper, &c., 
 succeed in such extreme deformities in saving the mother from many 
 of the dangers accompanying delivery at a later period of utero- 
 gestation. I have stated above that Mrs. D. applied to Mr. "Wise- 
 man at a time when it was already considered too late to have re- 
 course either to artificial abortion or premature labor ; and further 
 the high position of the os would probably have rendered either 
 of them impracticable. 
 
 The induction of premature labor at or about the seventh month 
 would not, of course, have sufficed with a pelvis of such small 
 dimensions, unless we could modify the operation so as both to pro- 
 duce the death of the child and retain it in utero, for the purpose 
 of allowing its structures to become dissolved and disintegrated 
 before labor at last supervened. Now, we have no known means 
 of inducing that diseased state of the placenta which produced the 
 attendant emaciation and death, in the case of Mrs. D.'s infant ; nor 
 am I acquainted with any measures which would destroy the life of 
 the child in the later months, without superinducing labor. The 
 retention, however, in utero of the infant and its maceration or 
 putrefaction, would be as necessary for success as its death, under 
 such great degrees of contraction. And the result shows, that when 
 the pelvis is much deformed, and labor with a dead child is threat- 
 ened, or the infant is destroyed by craniotomy, the longer we can 
 retain it in utero without danger to the mother, and the more it 
 thus becomes putrefied, and disintegrated, the easier will its ultimate 
 expulsion or extraction prove. 
 
 Lastly, suppose a patient with a very diminished and deformed 
 pelvis to have arrived at the full time of utero-gestation, does Mrs. 
 D.'s case suggest any new principles or modifications of treatment 
 for the delivery of the mother ? I believe that, under these circum- 
 stances, oar conduct and practice should be, in a great degree, regu- 
 lated by the state of the child. If it be alive, as ascertained by 
 auscultation, &c., and the pelvis is as small as in Mrs. D.'s case, or 
 even half an inch larger in its measurements, then I am decidedly 
 of opinion that it is our duty to perform the Csesarean section. We 
 have two human lives committed to our charge, and it is our duty 
 to try to preserve both, provided we can attain that object without 
 subjecting the mother to a degree of danger, much greater than she 
 would otherwise undergo. Let us take, however, the other alter- 
 native, and suppose the child already dead. With this complication 
 
INDICATION FOE CESAREAN SECTION, 597 
 
 most Britisli accouclieurs would attempt delivery by craniotomy, if 
 the dimensions of the pelvis permitted at all of the possibility of it. 
 And the case of Mrs. D. seems to me to suggest one means of ren- 
 dering it thus possible, under states of contraction, where it is at 
 present properly regarded as in the highest degree unsafe or totally 
 impracticable. The grand obgtaele to the delivery of the child by 
 embryulcio, in greatly contracted pelvis, arises from our want of 
 means to reduce the size, or alter the shape and compressibility, of 
 the bones of the base of the skull and face. In Mrs. D.'s child, 
 nature had disintegrated and separated these bones, had removed in 
 fact this obstacle, and thus rendered the delivery not only possible 
 but easy. Could we imitate or induce this same fortunate result by 
 artificial means ? All our present means of reducing the size of the 
 foetal head in embryulcio, are limited to the destruction of the arch 
 of the skull. I am not aware that with any proposed form of 
 osteotomist' we are capable of cutting or disintegrating the base of 
 the cranium or face, when the pelvis is diminished to IJ or 1 J inches 
 in its shortest diameter. Yet, probably, some modification of me- 
 chanical means would give us the power of eftecting this desirable 
 object. The common perforator might enable us to loosen and 
 break up the bones of the base in some cases, in the same way as 
 with it we break up the arch, of the skull. The disjunction or 
 fracture of these bones, without their removal, might prove sufficient 
 to permit the required degree of compressibility and alteration of 
 shape. Or the common bone-forceps of the surgeon, or a modifica- 
 tion of such powerful pliers as are used in dividing the needles in 
 the operation for harelip, &c., might answer. At all events, the 
 object seems anything but a hopeless one, more especially when we 
 call to recollection that modern surgeons are now provided with 
 mechanical means, which sometimes enable them to seize, break up, 
 and extract from the cavity of the bladder, large and solid stones — 
 and that too, through a canal relatively so small and elongated as 
 the male urethra.^ 
 
 ' The Kephalepsalis of Dr. Campbell appears to me to be an instrument preferable to, 
 and more powerful than, any of the forms of osteotomist invented by Dr. Davis or others. 
 Yet, as we have already seen, Dr. Campbell believes embryulcio to be impracticable, even 
 with its assistance, in a pelvis less than 3 by 2 inches. It is almost unnecessary to add, that 
 the French operation of Cephalotripsy is founded on the idea of crushing and compressing 
 the bones of the base, as well as of the circle, of the cranium. It is used by some of the 
 leading accoucheurs of Paris, instead of craniotomy, particularly in cases where the child is 
 dead, and the pelvis below the dimensions that would admit the use of the forceps. But 
 the instrument with which the operation is performed — the Cephalotribe — is of such enor- 
 mous dimensions, its blade being of solid iron, 1 J inches wide, the whole above 2 feet long 
 and several pounds in weight, that it could not of course be applied in cases where the 
 pelvis was contracted to any extreme degree. 
 
 2 For some additional remarks on this subject, see Lancet, for Oct. 1847, p. 381, and March 
 1, 1851, p. 284.— (Ed.) 
 
598 OBSTRUCTED LABOR. 
 
 The subsequent history of the patient, whose case is described in 
 the preceding pages, was as follows :' 
 
 Mrs. D. remained in much the same state of health for several 
 years after her deliveiy. The deformity of the skeleton did not 
 seem to advance in any degree during that period, and was con- 
 sidered by herself and friends to be quite arrested in its progress. 
 In 1853 she again became pregnant. But she did not inform her 
 medical attendant, Mr. Wiseman, of her state, nor consult him in 
 any way in regard to it ; and he was not called to see her till she 
 had been a considerable time in labor, under the charge of a inid- 
 wife. Parturition supervened at the supposed full term of gestation. 
 She was not aware of the exact date of the last catamenia ; but she 
 had felt the movements of the child for five months before labor 
 commenced. Mrs. Adam, the midwife, was called to Mrs. D.'s 
 assistance about 10 or 11 o'clock on Wednesday, the 21st of June, 
 1854. Mr. Wiseman was first sent for next morning, about four 
 o'clock. The patient continued in labor during that and the two 
 subsequent days. On Friday morning a summons was sent for me 
 to Edinburgh; but in consequence of some mal-arrangementatthe 
 telegraph office, it was not delivered; and a second message by rail- 
 way arrived that evening. Accompanied by my friends Drs. Mal- 
 colm and Storer, I reached Cupar early next morning. The patient 
 was by this time very weak and exhausted, and, indeed, almost 
 moribund ; but the child's heart could be still heard beating, though 
 feebly. I performed the Csesarean section, more with the hope of 
 still saving the child, than of being of any possible use to the mother. 
 'So special difficulty occurred in the operation, except from an artery 
 in the divided walls of the uterus bleeding profusely by a per-saltum 
 stream, till it was arrested after a time by torsion. The patient 
 died about two hours subsequently. The child, the care of which 
 was entrusted to Dr. G-raham, breathed only once or twice after birth; 
 but its heart continued to pulsate slightly for ten or fifteen minutes. 
 It seemed to die from cerebral effusion. 
 
 A post-mortem examination was permitted. Mr. Wiseman has 
 kindly furnished me with the following notes of it : 
 
 " The entire length of the body was found to be 4 feet 4 inches. 
 The left femur was curved forward, rendering that limb shorter by 
 an inch and a half than the right limb. The measurement from 
 the superior anterior spinous process to the heel, being in the one 
 case 31 inches, in the other 32 J. The ribs projected much forward, 
 from the point of the insertion of the clavicles, which bones were 
 greatly twisted, and the sides of the chest were thrown down upon 
 the bones of the pelvis. This arched line, from the upper end of 
 
 ' A short notice of the termination of this case was read to the Medico-Chirurgical Society 
 on the 15th of November 1854.— (Ed.) 
 
DANGERS OF PLACENTAL PRESENTATIONS. 599 
 
 the sternum to the scrobiculus cordis, measured 6 inches. From the 
 junction of the clavicles to the superior anterior spinous process of 
 the ilium, lOJ inches. 
 
 " Posteriorly, the line of the spine from the end of the os coccygis 
 to the nape of the neck, measured 20 inches. The spine projected 
 to a considerable extent at the upper part of the back, and again to 
 a smaller extent in the sacral region. 
 
 " We found the length of the incision made in the operation to 
 be 6 inches ; and, the stitches being removed, about 4 ounces of 
 coagulated blood were found in the abdomen. 
 
 " The distance between the two superior and anterior spinous 
 processes of the ilia was nearly 10 inches, or more precisely, 9|. 
 The brim of the pelvis was triangular, or cordate, in form ; the 
 transverse and antero-posterior diameters measuring each nearly 3f 
 inches at their widest points. The capacity of the brim, however, 
 was not in proportion to the above measurement, from the great 
 projection forward of the sacrum and pubis, and the collapse inwards 
 of the sides of the ilia. The outlet of the pelvis was far more con- 
 tracted. From the symphysis pubis to the coccyx, it measured 3 
 inches, but the transverse diameter, or distance between the tube- 
 rosities of the ischia, was only half an inch. The depth of the pelvis 
 at the symphysis pubis was two inches." 
 
 At the Medico-Chirurgioal Society's Meeting, June S, 1850, Dr. Simpson mentioned four 
 cases, two of them collected by Dr. Hull, in which the Csesarean section had been performed 
 accidentally upon healthy women by the goring of cows. All these four mothers recovered ; 
 and he considered that the successful result of such cases, and under such rude surgery, 
 showed that the soundness of the constitution of the patient formed the most important 
 element in the result. — See Edinburgh Monthly Journal of Medical Science, December 
 1854.— (Ed.) 
 
 ON THE 
 
 SPONTANEOUS EXPULSION AND ARTIFICIAL EXTRACTION 
 OF THE PLACENTA BEFORE THE CHILD, 
 
 IN PLACENTAL PRESENTATIONS.' 
 (From Lond. and Edin. Monthly Journal of Med. Science, March 1845, p. 169.) 
 
 L 
 
 Section I. — ^Dangers of Placental Presentations: Opinions op 
 Authors : Statistical Evidence op the Fatality of these 
 Presentations. 
 
 All obstetric authors seem to agree on this point, that there is no 
 one complication in midwifery attended with more anxiety to the 
 
 ' The substance of the following memoir was, on the 4ili of December 1844, laid before 
 
600 COMPLEX LABOK. 
 
 practitioner, and few, if any, with more real danger to the patient, 
 than cases of unavoidable liemorrhage from presentation of the 
 placenta.^ 
 
 " Placental presentations," says Dr. F. Ramsbotham, " are always 
 fraught with extreme peril. "^ "The attachment of the placenta," 
 observes Dr. Collins,^ " to the mouth of the womb, is one of the most 
 dangerous complications to be met with in midwifery." " There 
 are few dangers," to quote the words of Dr. Edward Rigby," " con- 
 nected with the practice of midwifery, which are more deservedly 
 dreaded, and which are wont to come more unexpectedly, both to 
 the patient as well as to the practitioner, than that species of hemor- 
 rhage which occurs in cases where the placenta is implanted, either 
 centrally or partially, over the os uteri." " It is," says Dr. Dewees," 
 " confessed on all hands, that no accident attendant on conception, 
 is equally menacing, as unavoidable hemorrhage ; and it also em- 
 phatically declares to the physician, that much depends on him, 
 that it shall not be very often fatal. It is one," he adds, "of those 
 extraordinary cases, in which nature does less for the preservation 
 of the individual than in almost any other." " That form of hemor- 
 rhage," remarks Madame Lachapelle,^ " which depends upon the 
 implantation of the placenta upon the internal orifice of the uterus, 
 is one of the most dangerous accidents to which pregnant women 
 are exposed." "It is perhaps," long ago observed Deleurye,' "of 
 all labors, that in which the mother and the child run the greatest 
 danger." Still earlier, Lamotte states,^ that "amongst all the acci- 
 dents of child-birth, there is not any one more perilous {il n'y en a 
 point un plus perileux) than that in which the after-birth presents 
 before the child." 
 
 The actual results of practice fully bear out the observations 
 which I have selected from the preceding authors upon the danger 
 of unavoidable hemorrhage from placental presentation. My friend 
 
 the Medico-Chirurgioal Society of Edinburgh. — See Edinburgh Monthly Journal, February 
 1845, pp. 158-161. Since that time a number of additional cases have been incorporated 
 with the essay, and the deductions altered in a corresponding degree. 
 
 ' " During the last months of gestation, and at the commencement of labor," observes Dr. 
 Churchill, " patients are exposed to two forms of hemorrhage, differing in their causes, but 
 depending upon the situation of the placenta. The first has been called ' accidental hemor- 
 rhage,' because it arises fiom a partial and accidental separation of the placenta, which 
 occupies its usual situation ; and the second is justly termed ' unavoidable hemorrhage,' 
 because the placenta being placed partially or wholly over the os uteri, the dilatation of this 
 will unavoidably separate the after-birth, and give rife to hemorrhage." — Theory and Practice 
 of Midwifery, p. 383. Our investigations in the present memoir refer to the last of these 
 two forms of uterine hemorrhage. 
 
 2 Obstetric Medicine and Surgery, 2d edition, p. 391. 
 
 ' Practical Observations on Midwifery, p. 90. * 
 
 " System of Midwifery, p. 248. 5 Midwifery, p. 390. 
 
 * Pratique des Accouchemens, torn. iv. p. 362. 
 
 ' Trait6 Complet des Accouchemens, p. 404. 8 Trait^ des Accouchemens, p. 36. 
 
DANGERS OF PLACENTAL PRESENTATIONS. 
 
 601 
 
 Dr. Churchill, in his late excellent work upon the Theory and Prac- 
 tice of Midwifery, has collected from different sources the records of 
 174 cases of this complication. Amongst these 174 cases, 48 proved 
 fatal to the mothers ; or nearly one in every three of them died. I 
 have attempted to make a still more extensive analysis of recorded 
 cases of placenta prsevia, or placental presentation, and the conse- 
 quences of this complication as hearing on the life of the mother. 
 The following table^ shows the results of the inquiry : — 
 
 Table of Maternal Mortality in Placental Presentations. 
 
 Heporters. 
 
 No. of Cases. 
 
 Mothers Lost. 
 
 Mauriceau,^ 
 
 Portal,' 
 
 Giffard,* 
 
 Smellie.s 
 
 E'gby,8 
 
 Clarke' and Collins,* . . 
 
 Busch,9 
 
 Schweighauser,'** . . . 
 
 Lachapelle,'' 
 
 J. Rarasbothara,'^ . . . 
 F. Ramsbotham," . . . 
 
 Lever," 
 
 Lee,'fi 
 
 Wilson ,'8 
 
 18 
 14 
 19 
 18 
 42 
 16 
 13 
 65 
 21 
 129 
 189 
 34 
 46 
 30 
 
 3 
 
 1 
 
 5 
 
 7 
 
 10 
 
 4 
 
 2 
 
 16 
 
 10 
 
 41 
 
 49 
 
 8 
 
 14 
 
 10 
 
 Total, .... 
 
 654 
 
 180 
 
 ' We print this table as published by Dr. S. in the Lancet for September 1847, p. 276, in 
 a corrected form, and with additional data furnished to him by Dr. Ramsbotbam, Dr. Wilson, 
 &c. See also Lancet for 1847, p. 517, in reference to the correctness of the data.— (Ed.) 
 
 ^ Observations sut la Grossesse et les Accouchemens, vol. ii. pp. 8, 48, &c. &c. ; and Edin- 
 burgh Medical and Surgical Journal, vol. li. pp. 383-84. 
 
 ' La Pratique des Accouchemens, 1785, Observ. ii-xxix., &c. &o. 
 
 •• Cases in Midwifery, pp. 22, 36, 38, 52, 87, &c. &c. 
 
 ^ Collection of Cases, &c , vol. ii. pp. 307-315; and vol. iii. pp. 141-178. I have, with 
 Dr. Churchill and others, here and in a subsequent table, marked all those cases of Dr. 
 Smellie's as recoveries, where an opposite result is not directly stated. The context seems 
 to warrant this. 
 
 ' An Essay on Uterine Hemorrhage, 6th Edition, p. 262. ' 
 
 ' Transactions of King and Queen's College of Physicians, vol. i. p. 380. 
 
 ' Practical Observations in Midwifery, p. 96. The returns of Drs. Clarke and Collins are 
 classed together, as both coming from the Dublin Lying-in Hospital. 
 
 9 Forbes' British and Foreign Review, vol. v. p. 587. 
 
 ■" La Pratique des Accouchemens, p. 224. 
 
 " Pratique des Accouchemens, tom. ii. pp. 415-461. 
 
 '2 Practical Observations in Midwifery, part ii. pp. 195-233, and MSS. Notes. 
 
 " Principles of Obstetric Medicine and Surgery, 2d Edition, pp. 395-96. Dr. F. Rams- 
 botbam kindly drew out for Dr. S., in 1 847, a list of all the cases of placenta prsevia attended 
 by his father and himself, with their results, as given in the above table. — (Ed.) 
 
 " Guy's Hospital Reports, vol. vi. p. 66. 
 
 '^ Lectures on the Theory and Practice of Midwifery, p. 371. 
 
 ■^ From MS. notes of Dr. Wilson, formerly Lecturer on Midwifery, and deservedly one of 
 the most highly esteemed and distinguished obstetric practitioners in Glasgow. Many of the 
 fatal cases were instances which Dr. W. saw in consultation. 
 
602 COMPLEX LABOR. 
 
 From the preceding Table, it thus appears that out of 654 cases of 
 placental presentations which are collected into it, the result was 
 fatal to the mother in 180 instances, or, in other words, 1 in every 
 Sj^j of the mothers perished in connection with this complication. 
 
 The dangers of placental presentations to the mother may appear 
 stronger to some minds if I state them in other terms. Two of the 
 most fatal epidemics of modern times, are yellow fever and Indian 
 or malignant cholera. In the well-known yellow fever of Gibraltar 
 of 1828, the mortality among those attacked was nearly 1 in 4J.i 
 In 1832-33, about one in 3J of those affected in England with the 
 epidemic cholera, died.= Hence those mothers who are the subjects 
 of placental presentations, are submitted to as great peril of life from 
 this obstetric complication, as they would be if seized with yellow 
 fever or malignant cholera. Further, the operation of lithotomy is 
 generally regarded as one of the most formidable in surgery, and is 
 calculated to be fatal in the proportion.of 1 in every 6 or 8 subjected 
 to it.« The occurrence of placenta prsevia is twice as dangerous and 
 fatal as the operation of lithotomy — 1 in every 3 perishing under 
 the first, and 1 in every 6 or 8 perishing under the last. 
 
 Looking at these results, it will, we believe, be readily conceded, 
 that any attempt — such as is the professed object of the present 
 memoir — to diminish this fearful maternal mortality in placenta 
 prsevia, is entitled at least to the consideration of the obstetric pro- 
 fession, even should it fail to be so fortunate as to secure their con- 
 currence and conviction. 
 
 Section n. — ^Recognized Principles of Treatment: — 1. Eva- 
 cuation OF THE Liquor Amnii ; and, 2. Delivery by Turning. 
 Proposal of a Third Principle : The Complete Separation 
 OF THE Placenta; Grounds for Proposing it: Illustrative 
 
 Cases. 
 
 Hitherto, two great principles of treatment — if we leave out the 
 minor details of management — may be said to have been pursued 
 by obstetric practitioners in the treatment of placental presentations. 
 And the two modes of practice I allude to are supposed by many to 
 
 ' Out of 5383 persons attacked, 1183 died. — See Researches on the Yellow Fever of 
 Gibraltar by Dr. Louis of Paris, Boston, 1839, p. 259. 
 
 ^ Dr. Merriman has calculated, from official returns, that 49,594 individiials were affected 
 with epidemic cholera in England, and that 14,807 of them died, giving the proportion in 
 the text. In Scotland and Ireland the mortality was greater. See Medico-Chirurgioal 
 Transactions, vol. xxvii. p. 416. 
 
 ' " The average mortality from lithotomy, on all hands, appears at present to be about 1 
 in 8." — Dr. Willis' Urinary Diseases, 1838, p. 347. Mr. Inman has calculated the mortality 
 from lithotomy to be 1 in every 7| cases, 765 patients having died out of 5900 operations 
 which he had collected. — See Lancet for October 5, 1844. 
 
USUAL TBEATMENT OF PLACENTA PRiEVIA. 603 
 
 be applicable to two different stages or degrees of the complication. 
 They consist of the two following measures : — 
 
 1. The Evacuation of the Liquor Amnii. 
 
 In some cases of placenta prsevia, and under some circumstances, 
 the artificial evacuation of the liquor amnii is recommended to 
 be had recourse to, and thus the same treatment is followed for 
 " unavoidable" hemorrhage, as is followed by most practitioners in 
 instances of " accidental" hemorrhage. This mode of practice has 
 been especially applied of late to cases in which the presentation of 
 the placenta was only partial, and where, consequently, a portion of 
 the membranes was within reach, and to instances in which the 
 hemorrhage was comparatively slight in its degree and effects. 
 About a centuiy and a half ago, the same treatment seems to have 
 been employed also by some practitioners, in instances in which 
 the placenta presented completely over the os uteri, the placental 
 structure being perforated artificially by the finger or an instrument, 
 in order to permit the liquor amnii to escape. After recommending 
 that, in placenta prsevia, the membranes should be pierced, or the 
 fingers thrust through the placenta, " that at last it be perforated, 
 and instead of the constant flux of blood which appeared before, 
 the humors will presently flow out," Daventer,' writing about the 
 year 1700, adds, " some penetrate the secundines with a hair needle,^ 
 which I do not approve of if it can be done with the fingers, be- 
 cause the infant is easily hurt." Under some conditions in placenta 
 prsevia, Deleurye' recommends the piercing of the placenta with a 
 trocar, in order to allow the liquor amnii to be drained off". Bau- 
 delocque^ speaks of the same practice as probably useful in instances 
 of complete or central presentation of the placenta, when the cervix 
 will not allow of turning ; and in later years the same plan has 
 been again proposed by the elder Dr. Eamsbotham," and success- 
 folly put in practice by Gendrin* of Paris. 
 
 2. The Delivery of the Child by Turning. 
 
 In the generality of cases of unavoidable hemorrhage from 
 placental presentation, the practice which is adopted consists in 
 forcing the delivery, by passing the hand through the os uteri up to 
 
 ' The Art of Midwifery Improved, London, 1715, pp. 153-54. 
 
 ' " Plaoentara vel secundinam acu crinali perfodiunt," to quote the original Latin. See p. 
 l.'JS of the second edition of Daventer's Novum Lumen, &c., Leyden, 1733. The first 
 edition vras published in 1701. 
 
 ' Trait^ des Accouchemens, Paris, 1777, p. 369. 
 
 * System of Midwifery, translated by Heath, vol. ii. p. 38. 
 
 ^ Practical Observations, part ii. p. 189. 
 
 ' Traill Philos. de M^decine Pratique, torn. ii. p. 548. 
 
604 COMPLEX LABOR. 
 
 the feet of the infant, and extracting the child by the operation of 
 podalic turning. This last mode of practice is the one universally 
 followed when the hemorrhage is very severe, and whether the ar- 
 tificial evacuation of the liquor amnii has preceded it or not, and it 
 is the plan of treatment usually pursued where the presentation of 
 the placenta over the os uteri is central or entire. By some ac- 
 coucheurs indeed, as Drs. Burns and Hamilton, Baudelocque, Ca- 
 puron, and others, the forcible delivery of the woman by the opera- 
 tion of turning is the only mode of treatment that is thought 
 advisable under any circumstances in connection with placenta 
 prsevia. It is, according to Plenck, " nuUo remedio sed sol4 extrac- 
 tione fcetus curanda."^ " All the best practical writers are," says 
 Dr. Merriman, " unanimous on this point, that the case of placenta 
 adhering over the cervix uteri is not to be trusted to nature. In all 
 cases of attachment of the placenta over the os uteri, it is incum- 
 bent upon the accoucheur to make up his mind to the operation of 
 turning the child, and bringing it into the world by the feet."^ 
 " This is a case," Dr. Conquest remarks,^ "in which we ought never 
 to confide in the powers of nature, because expulsatory uterine 
 eflibrts only augment the peril of the patient ; and therefore the 
 hand must be either bored through the substance, or, what is better, 
 passed by the edge of the placenta, and the child turned." " It is 
 completely established," to quote the words of Dr. Dewees,^ " that 
 the only chance the woman has for life, is by a well-timed and well- 
 conducted delivery, in every case of placental presentation." 
 "When hemorrhage," says Dr. Denman,' "from this cause (pla- 
 cental presentation) comes on, though all women without proper 
 assistance would not die, none are free from danger till they are 
 delivered. As there is a very doubtful chance of the delivery by 
 the pains of labor, and as experience has fully proved the frequent 
 insufficiency of all other methods intended to suppress the hemor- 
 rhage, and how little reliance ought to be placed on them, though 
 they are always to be tried ; it is a practice established by high and 
 multiplied authority, and sanctioned by success, to deliver women 
 by art, in all cases of dangerous hemorrhage, without confiding in 
 the resources of the constitution. This practice is no longer a 
 matter of partial opinion, on the propriety of which we may think 
 ourselves at liberty to debate ; it has for near two centuries met the 
 
 ' Elementa Artis ObstetrioEE, 1781, p. 133. 
 
 ' Synopsis, &c. of Difficult Parturition, 1826, pp. 126, 127. 
 
 ' Outlines of Midwifery, p. 157. 
 
 * System of Midwifery, p. 394. 
 
 ' Introduction to Midwifery, p. 527. 
 
NEW PKACTICE PROPOSED FOR PLACENTA PRiEVIA. 605 
 
 consent and approbation of every practitioner of judgment and 
 reputation in this and many other countries. See Mauriceau and 
 almost every succeeding writer." 
 
 Cases of Placenta Prsevia not unfrequently occur in practice in 
 which neither of the two preceding plans can be successfully adopted 
 — where the artificial evacuation of the liquor amnii is insufficient 
 to moderate the hemorrhage to a safe degree — and where forced 
 delivery by turning is inapplicable or extremely dangerous if 
 adopted. In these and other cases, I would beg to submit to my 
 obstetric bretliren an additional principle of treatment, viz. : 
 
 3. The Complete Separation, and, if necessary, Extraction of the Placenta before the Child. 
 
 I shall first state the grounds on which I venture to found the 
 propriety of this proposed addition to the treatment of the very 
 anxious and very dangerous cases of which we speak. 
 
 Obstetric pathologists seem unanimous in the opinion that all the 
 more formidable varieties of hemorrhage which occur from the 
 uterus in the latter months of utero-gestation, or the earlier periods 
 of labor, are attributable to the separation of the vascular connec- 
 tions between the placenta and the interior of the uterus, and the 
 escape of blood from the vessels which are laid open in conse- 
 quence of this separation. 
 
 Paradoxical as it may appear, there are sufficient grounds and 
 facts for believing, that when the placenta is separated slightly and 
 partially, the chance of fatal hemorrhage to the mother is greater 
 than when the disunion of the organ is entu-e and complete. 
 Various authors have detailed cases in which the death of the 
 mother speedily took place, though the portion of the placenta sepa- 
 rated from the uterus was exceedingly small. Thus Dr. Hamilton 
 mentions that in several cases which had fallen under his observa^ 
 tion, and where he was called too late to affiard proper assistance, it 
 was discovered that the fatal hemorrhage had proceeded from the 
 separation of " a very small portion of the placenta." In one 
 instance of fatal hemorrhage between the 7th and 8th month of 
 utero-gestation, he found on dissection that " the area of the sepa- 
 rated placenta was less than a square inch."' 
 
 On the other hand, I believe I have collected a sufficient number 
 of data to prove that, when the disjunction of the placenta from the 
 uterus is perfect and complete, the degree of maternal hemorrhage 
 
 ' Practical Observations, 2d edition, p. 314.^ 
 
606 COMPLEX LABOK. 
 
 that occurs is in general exceedingly slight and trifling, or it is 
 altogether arrested. The details of a few cases may illustrate and 
 impress the fact which I wish to point out. 
 
 Case I.— Placenta expelled upwards of three hours before the child; 
 no hemorrhage in the interval ff child removed hy decapitation and 
 extraction.— InlSiO I was requested by my friend Dr. Graham Weir 
 to see a patient at about the 5th month of pregnancy, who had been 
 attacked with very severe hemorrhage. It was her third or fourth 
 pregnancy. After the flooding had continued for some time, the 
 placenta was expelled. From, the time of its expulsion the hemorrhage 
 ceased. The shoulder and neck of the infant were presenting over 
 the 08 uteri. The os uteri was so contracted and the whole organ 
 so small, as to prevent the possibility of the introduction of the 
 hand for the operation of turning. At my suggestion. Dr. Weir 
 severed the neck of the infant. Its body was then easily extracted 
 by pulling at the presenting arm ; and its head was immediately 
 afterwards expelled by the unassisted action of the uterus. From 
 three to four hours elapsed between the protrusion of the placenta 
 and the complete delivery of the woman, yet during that time she 
 lost little or no blood, and her recovery was speedy and perfect.* 
 
 Case II. — Placenta expelled about two hours before the child ; elbow 
 of the child presenting. — In 1841, 1 was requested by Dr. Lewins of 
 Leith to visit a case of complicated unavoidable hemorrhage. I saw 
 the patient shortly after 9 o'clock in the morning. Labor pains had 
 come on about 4, and a considerable degree of hemorrhage had 
 accompanied them. Shortly after T o'clock. Dr. Lewins, on visiting 
 the patient, found the placenta expelled through the os uteri. 
 When I saw the woman, nearly two hours afterwards, the placental 
 mass was lying between her thighs, and attached to her by the 
 umbilical cord. She was weak from the hemorrhage that had oc- 
 curred previous to the expulsion of the placenta, but from the time 
 that organ had been extruded, the flooding had almost entirely ceased. 
 I found the elbow of the child presenting ; and as the os uteri was 
 well dilated, it was easy to bring down a lower extremity, and ter- 
 miaate the labor. The patient recovered without a bad symptom. 
 
 Case m. — Placenta expelled some minutes before the child; no in- 
 tervening hemorrhage ; child expelled by natural pains, and revived. 
 — For the details of this case I am indebted to Dr. Dewar of Dun- 
 fermline, and shall give the circumstances in his own graphic words. 
 " Some blood," he says, " had been lost as nearly as we could calcu- 
 
 • See Subsequent General Table, No. 17. 2 Table, No. 21. 
 
PLACENTA PEiEVIA. 607 
 
 late at wliat would have been the seventh and eighth menstrual 
 periods, and several times between the eighth and ninth months, 
 and that in spite of an entire cessation from all exercise. Labor 
 took place at the full time, and, as was dreaded, was accompanied 
 with severe hemorrhage from the beginning. "When I saw her, 
 about an hour after pain had begun, the orifice of the uterus was 
 pretty well dilated, and a soft spongy mass, apparently the centre 
 of the placenta, protruded from it.* There was no time for inter- 
 ference, for almost instantly a strong pain forcibly expelled the 
 whole of the placenta from the vagina. To my surprise the flooding 
 ceased. Pains continued active, and the child was born in less than 
 ten minutes. After a little time the infant revived, and the mother 
 recovered well, though considerably exhausted."^ 
 
 Case IV. — G-reat hemorrhage, and expulsion of the placenta under 
 strong uterine action ; child extracted hy turning some hours afterwards. 
 — Mrs. H., during her second pregnancy, her first child having been 
 premature, had a slight flooding about the seventh month. When 
 in the eighth month, labor commenced early on the morning of the 
 18th of May, with slight pains, and sanguineous discharge. These 
 continued more or less severely till the evening of the 19th, when, 
 as Mrs. H. was resting upon her knees and elbows, an immense 
 gush took place, along with an unusually strong pain. Immediately 
 afterwards, on being laid down, the placenta was found protruding 
 from the external parts. The attendant midwife immediately sent 
 oflT to a distance of several miles for two medical gentlemen, who 
 arrived about half-past one o'clock on the morning of the 20th. In 
 the meantime, the hemorrhage was inconsiderable. The medical 
 men attempted to turn, and deliver the child, but encountered great 
 difficulties in doing so, the head having remained fixed in the pelvis 
 for an hour or two after the body was born. The recovery was 
 tedious. The patient, now one of the most respected and intelligent 
 midwives in Edinburgh, has had three children since the above 
 period.^ 
 
 Case V. — Unavoidable hemorrhage terminated hy the expulsion of the 
 placenta ; child allowed to he delivered hy the natural pains. — " About 
 half-past six on the morning of April 29th, 1818, a messenger," 
 says Dr. Eamsbotham, " arrived at my house, sent by two medical 
 gentlemen, with a note to this purport: 'We are in attendance 
 upon Mrs. H., whose situation is involved in great uncertainty, from 
 a placental presentation ; the bleeding is going on pretty actively, 
 
 ' Table, No. 48. 2 jable, No. 2. 
 
608 COMPLEX LABOR. 
 
 and we wish for your immediate opinion.' On my arrival at the 
 house of the lady, about eight, I was told by one of the gentlemen 
 'that since the note was sent off, some strong expulsive pams had 
 come on, which had expelled the placenta through the external 
 parts before the head of the child, and that it was lying upon the 
 bed. That before this occurrence the hemorrhage had been violent, 
 yet not to that extent as apparently to endanger the woman's life ; 
 but that since the appearance* of the placenta the flooding had very 
 much abated: During our conversation on this unusual occurrence, 
 the gentleman more immediately in attendance, who, at my arrival, 
 was in the bed-room of his patient, came down stairs and reported, 
 ' that the head was presenting at the brim of the pelvis, with a 
 hand down by its side ; that there was no want of uterine action ; 
 that the flooding had ceased; and that his patient did not seem much 
 exhausted.' An appeal was now made to my opinion, as to the 
 further management of the case, to which I replied, ' that as the 
 flooding, the most dangerous symptom, had abated, as the labor- 
 pains continued active, and especially as the woman's strength kept 
 up, there did not appear to be an immediate necessity for a recourse 
 to any means for hastening delivery ; watch your patient for a short 
 time, and wait the result ; if the flooding should return, or if any 
 dangerous symptom make its appearance, let us know.' In about 
 half an hour after this interview, the gentleman returned with a 
 cheerful countenance, and stated that the child was expelled with- 
 out further loss of blood, and that his patient was promising to do 
 extremely well," &c.* 
 
 Case VI. — Placenta gradually coming down, during the labor, into the 
 OS uteri, and being at last expelled four hours before the child; with no 
 intermediate hemorrhage. — Mrs. C.,in the eighth month of her fourth 
 pregnancy, was taken in labor on Sunday evening, about nine o'clock, 
 Mr. Chapman was called to her about twelve o'clock. He was in- 
 formed that the membranes had been ruptured for some time. The 
 OS uteri was dilated to the size of a crown-piece, and the head pre- 
 senting, but still very high. The pains were very strong and regu- 
 lar. On a second examination, an edge of the placenta was dis- 
 covered " beginning to protrude through the os uteri," with a hemor- 
 rhage which was trifling, but increased upon the return of the pains, 
 though still so inconsiderable as not to be directly alarming. Mr. 
 C. did not hence conceive himself justified in proceeding to imme- 
 diate delivery. But as upon every return of pain the placenta 
 became more and more protruded through the os uteri, without the 
 
 ' Table, No. 36. 
 
PLACENTA PREVIA. 609 
 
 head advancing, the advice of another practitioner was sought. 
 Previous, however, to his arrival, the pains proved so strong that 
 the OS uteri became dilated, and the placenta was completely ex- 
 pelled through the os externum, about three o'clock on Monday 
 morning, with very little hemorrhage. From this moment the pain 
 entirely ceased. The other practitioner did not arrive till five o'clock. 
 " There had not," to use Mr. Chapman's own words, " leen the least 
 hemorrhage since the expulsion of the placenta." It was now resolved 
 to turn the child ; but after two prolonged attempts the feet could not 
 be seized, the uterus being spasmodically contracted in the longi- 
 tudinal direction, and the circular fibres appearing to act without the 
 consent of the longitudinal. " During the whole of this time the 
 hemorrhage had not in the least increased." Twelve drops of the 
 tincture of opium were now administered. In a very short time the 
 patient became easy and comfortable ; and in less than half an hour 
 the natural pains returned, and speedily expelled the child, with the 
 head and arm presenting. ]S"othing remarkable happened in the 
 convalescence, except a trifling attack of phlegmasia dolens, an 
 affection from which the patient had likewise suffered after her first 
 labor.' 
 
 Case VH. — Placental and shoulder presentation ; placenta expelled ; 
 turning. — The patient, in the sixth month of her fifteenth preg- 
 nancy, was attacked with hemorrhage that was alarming in extent, 
 but not so great in quantity as to produce syncope. " I saw her," 
 Dr. Eamsbotham writes, " two hours after the first attack of fiooding. 
 The placenta was now lying completely in the vagina, and there 
 was not the least hemorrhage. The membranes were ruptured. The 
 shoulder of the child presented. The cervix uteri was unexpanded 
 and rigid, and it was consequently impossible to get my whole hand 
 into the uterine cavity, but I succeeded in reaching the ham of the 
 infant, and was by this means enabled to turn and deliver." ■ "An 
 hour or more" elapsed between the complete detachment of the pla- 
 centa and the birth of the child. It had been dead for some time. 
 The mother recovered perfectly." 
 
 Case Vm. — Placental and arm presentation ; placenta in the vagina, 
 and without hemorrhage, for about eight hours before the child was born. 
 — ^In a woman who had completed the full time of pregnancy. Dr. 
 Macaulay found the placenta expelled fi-om the uterus, and lying in 
 the vagina. She had been flooding previously, but it had ceased 
 about eight o'clock on the morning of the 13th of February, 1816. 
 The late distinguished Dr. Kellie of Leith visited the patient with 
 
 ' Table, No. 14. 2 Ibid. No. 27. 
 
 VOL. I. 39 
 
610 COMPLEX LABOR. 
 
 him. The woman peremptorily refused to allow Drs. Macaulay and 
 Kellie to deliver her. About four o'clock, p.m. the pains quickened, 
 the placenta was expelled from the vagina, and about half an hour 
 afterwards an anencephalous infant followed. The child was in every 
 way well shaped, except as regarded the head. " Dr. Kellie told 
 me," to quote the note which Dr. Macaulay made at the time, " that 
 the head was the smallest he had ever seen, and remarked, that 
 though it was an axiom in midwifery, that when the placenta was 
 implanted over the os uteri, hemorrhage must continue till the 
 uterus was emptied, yet here it stopped as soon as the placenta came 
 down."^ 
 
 ' Table, No. 10. 
 
PLACENTA PREVIA. 611 
 
 Section m. — Table of 141 Cases of Expulsion and Extraction of 
 THE Placenta before the Child : Arrangement and Divi- 
 sions OF the Table. 
 
 I have been able to find upon record fifty-six cases of Placental 
 Presentation in wHcbtbe placental mass was expelled before the 
 child, as in the preceding seven or eight instances which I have 
 brought forward in the last section. Through the kindness of my 
 professional friends, I have collated the notes of seventy-four addi- 
 tional unpublished instances in which the same accident happened. 
 As the entire detail of more instances than those I have already 
 stated, would at the present stage of our inquiries only swell out 
 our pages, without any corresponding advantage, I have deemed it 
 better to throw the principal facts connected with all the cases which 
 I have collated, into a tabular form, in order to present thus in a 
 more concise manner, their general features and individual pecu- 
 liarities. It is only necessary to premise, in regard to the following 
 table, that under the heads referring to the degree of hemorrhage 
 before and after the separation of the placenta, and the time or in- 
 terval between the expulsion of the placenta and expulsion of the 
 child, I have as nearly as possible adhered to the identical words 
 used by the reporters themselves, in each case. The table com- 
 mences with those instances in which the interval between the birth 
 of the'^lacenta and the birth of the child was longest, and progres- 
 sively proceeds to those in which this interval became shorter and 
 shorter, till at last we come to a set of cases in which the placenta 
 and infant were expelled simultaneously. 
 
 For the purpose of assisting in some subsequent deductions, the 
 table is split up into the four following divisions : — 
 
612 
 
 COMPLEX LABOK. 
 
 GENEKAL TABULAR VIEW OF ONE HUNDRED AND FORTY- 
 
 OF THE PLACENTA PRECEDED 
 
 FIRST 
 Cases in which a Consideeable Intekval (feom 10 Hotos to 10 Minutes) 
 
 
 
 Decree of hemor- 
 
 Degree of hemor- 
 
 
 By whom Observed or 
 Reported. 
 
 No. of 
 the Preg- 
 
 Pcriod of 
 
 phage befm-e the 
 
 rhage after the 
 
 Mode of Delivery 
 
 Delivery. 
 
 entire separation 
 
 entire separation 
 
 of the Child. 
 
 nancy. 
 
 
 of the placenta. 
 
 of the placenta. 
 
 
 1 
 2 
 
 Dr. Collins, Dublin, 
 J. Y. Simpson, 
 
 
 Qtb TTinTi 
 
 
 
 
 '2d,' 
 
 8tli " 
 
 Excessive, 
 
 Inconsiderable, 
 
 Turning, 
 
 3 
 
 Mr. Cripps, Liverpool, 
 
 3d, 
 
 9tli " 
 
 A good deal. 
 
 None, 
 
 Turning. 
 
 4 
 
 Dr. Merriman, London, 
 
 
 
 
 
 By natural pains. 
 
 6 
 6 
 
 Mr. Hewitt, Earlston, 
 Dr. J. Ramsbotham, 
 
 
 
 Little or none, 
 
 Little," 
 
 By natural pains, 
 Turning, 
 
 
 
 7 
 
 Dr. Newman, Glasgow, 
 
 
 9th mon., 
 
 Great,* 
 
 None, 
 
 By natural pains, 
 
 3 
 
 Baudelocque, 
 Walter, 
 
 
 
 
 
 
 9 
 
 
 
 ( Almost none ) 
 \ uot2oz.inall J 
 
 Almost none, 
 
 Turning, 
 
 
 
 10 
 
 Dr. Macaulay, Edinburgh, 
 
 Not 1st, 
 
 Full time. 
 
 Great, 
 
 None, 
 
 By natural pains, 
 
 11 
 
 Velpeau, 
 
 
 
 None, 
 
 None, 
 
 
 12 
 
 Mr. Perfect, 
 
 
 
 Slig-ht, 
 
 Slight, 
 
 Turning, 
 
 13 
 
 Mr. Small, Wemyss, 
 
 7th', 
 
 7tli mon., 
 
 Very great, 
 
 Very trifling, 
 
 By natural pains, 
 
 14 
 
 Mr. Chapman, 
 
 4th, 
 
 8tli " 
 
 Slight, 
 
 Very alight, 
 
 By natural pains, 
 
 16 
 
 Dr. Radford, Manchester, 
 
 9th, 
 
 9th " 
 
 Very great, 
 
 Quite arrested, 
 
 Long Forceps, 
 
 16 
 
 Mr. Sidebottom, ditto. 
 
 7th, 
 
 9th « 
 
 Profuse, 
 
 Ceased, 
 
 By natural pains, 
 
 17 
 
 J. T. Simpson, 
 
 3d or 4th, 
 
 5th " 
 
 Great, 
 
 None, 
 
 Decapitation, 
 
 18 
 
 Br. Radford, Manchester, 
 
 7th, 
 
 9th « 
 
 Very consider'ble 
 
 Quite arrested, 
 
 By natural pains, 
 
 19 
 
 Dr. Ingleby, Birmingham, 
 
 Several, 
 
 9th « 
 
 Not very great. 
 
 None, 
 
 Turning, 
 
 20 
 
 Mr. Bailey. Thetford, 
 
 
 7th « 
 
 Profuse, 
 
 
 Turning, 
 
 21 
 
 J. Y. Simpson, 
 
 
 7th « 
 
 Not great, 
 
 None, 
 
 Turning, 
 
 22 
 
 J. Y. Simpson, 
 
 6th, 
 
 7th & 8th, 
 
 Very great, 
 
 None, 
 
 By natural pains, 
 
 23 
 
 Dr. Todd, Colinsburgh, 
 
 Several, 
 
 8th " 
 
 Not alarming. 
 
 
 
 24 
 
 Dr. Frazer, Aberdeen, 
 
 Ist, 
 
 9th « 
 
 Moderate, 
 
 Scarcely any, 
 
 Turning, 
 
 25 
 
 Dr. Radford, Manchester, 
 
 3d, 
 
 9th « 
 
 Very profuse, 
 
 Quite arrested, 
 
 By natural pains. 
 
 26 
 
 Dr. Gardiner, Glasgow, 
 
 Ist 
 
 9th « 
 
 Very great, 
 
 None, 
 
 By natural pains. 
 
 27 
 
 Dr. F. Ramsliotham, 
 
 16th, 
 
 6th " 
 
 Alarming, 
 
 Not the least, 
 
 Turning, 
 
 28 
 
 Professor Glendrin, 
 
 2d, 
 
 8J^ mon's, 
 
 None during lar 
 
 None, 
 
 By natural pains. 
 
 29 
 
 Mr. Wood, Manchester, 
 
 8th, 
 
 9th " 
 
 Very great, [bor. 
 
 Quite stopped, 
 
 By natural pains, 
 
 30 
 
 Dr. Campbell, Edinburgh, 
 Dr. Gardiner, Dundee, 
 
 1st, 
 
 8th " 
 
 Little, 
 
 
 
 31 
 
 Ist, 
 
 7th « 
 
 Moderate, 
 
 Very slight. 
 
 By natural pains, 
 
 32 
 
 Mr. Hay, Glasgow, 
 
 1st, 
 
 9th « 
 
 Excessive, 
 
 Very little, 
 
 Naturally, 
 
 33 
 
 Dr. Ingleby, Birmingham, 
 
 9th, 
 
 5th « 
 
 Great, 
 
 None, 
 
 Turning, 
 
 34 
 
 Dr. Irvine, Pitlochrie, 
 
 10th 
 
 9th « 
 
 None, 
 
 None, 
 
 Extraction, 
 
 36 
 
 Dr. Young, Glasgow, 
 
 1st, 
 
 6th & 7th, 
 
 Very great, 
 
 None, 
 
 By natiu^al pains, 
 
 36 
 
 Dr. John Ramsbotham, 
 
 
 
 Violent, 
 
 Soon ceased, 
 
 By natural pains. 
 
 37 
 
 Dr. Todd, Colinsburgh, 
 Dr. Radford, Manchester, 
 
 Several, 
 
 
 Not great. 
 Very great, 
 
 
 
 38 
 
 6th, 
 
 8th mon., 
 
 Quite arrested, 
 
 By natural pains, 
 
 39 
 
 Dr. Wharrie, Hamilton, 
 
 9th, 
 
 8th to 9th, 
 
 Considerable, 
 
 None, 
 
 By natural pains. 
 
 40 
 
 Mr. Dorifington, Manches'r, 
 
 7th, 
 
 9th " 
 
 Great, 
 
 None, 
 
 By natural pains, 
 
 41 
 
 Dr. Forbes, Kennoway, 
 
 4th, 
 
 9th « 
 
 Very great, 
 
 j None of any | 
 \ consequence, \ 
 
 Forceps, 
 
 42 
 
 Dr. Millaj, Kilmarnock, 
 
 Ist, 
 
 7th " 
 
 \ Great, 61bs. ( 
 \ in 2 days, ( 
 
 Slight oozing, 
 
 Turning, 
 
 REMARKS. 
 
 4. See details under Section VI. 
 
 5. Mr. H. was sent for on account of the expulsion of the placenta, nothing unusual having occurred be- 
 
 forehand. He was some miles distant, but arrived just before the child was born. There was little or 
 no hemorrhage- 
 
 8. " A midwife h^ extracted the placenta some hours before, and had been unable to turn the child, whose 
 
 arm presented with the head. The uterus was strongly contracted on the child, but discharged a few 
 drops of blood." 
 
 9. See details under Section VI. 
 
 10. See Case under Section II. 
 
 11. See Section V. 
 
 14. " In this case, very little more blood wm lost than women usually do, when the placenta is expelled in 
 
 the usual manner." 
 
 15. "In this case the expulsatory efforts were energetic to the time of accomplishing the separation and 
 
 expulsion of the placenta, when they ceased. No hemorrhage occurring afterwards, it was deemed 
 
 advisable to wait the 4 hours." 
 13. " The hemorrhage being arrested, there was no need to interfere, further than to adopt those measures 
 
 which are necessary to support the vital powers." 
 19. "The placenta had been expelled nearly through the os externum. A large quantity — nine-tenths. I 
 
 should say — had been cut off with a pair of scissors. I saw the case very soon afterwards ; passed my 
 
 hand, and delivered the child, and then removed the small bit of placenta and membranes." 
 
PLACENTA PREVIA. 
 
 613 
 
 ONE CASES IN WHICH THE EXPULSION OR EXTRACTION 
 THE BIRTH OF THE CHILD. 
 
 DIVISION. 
 
 ELAPSED BETWEEN THE EXPULSION OF THE PLACENTA AND THE BiRTH OF THE ChILD. 
 
 Time between Birth 
 
 of Placenta 
 and Birth of ChUa. 
 
 Presentation 
 
 of 
 
 the Child. 
 
 Results. 
 
 Where Reported, or by whom 
 Communicated. 
 
 To Mother. 
 
 To Child 
 
 Evening before, 
 
 Foot, 
 
 Recovered, 
 
 Dead, 
 
 Practical Observations, p. 192. 
 
 Several hours. 
 
 
 do. 
 
 do. 
 
 See Case of Mrs. H. in Section 11. 
 
 10 hours, 
 
 Arm, 
 
 do. 
 
 do. 
 
 Communicated by Mr. Cripps. 
 
 Many hours, 
 
 
 Died, 
 
 
 Synopsis, p. 126. 
 
 A considerable time, 
 
 
 Recovered, 
 
 
 Communicated by Dr. Tait, Edinburgh. 
 
 A considerable time, 
 
 kead. 
 
 do. 
 
 
 Practical Observations, vol. ii. p. 232. 
 
 Several hours, 
 
 Head, 
 
 do. 
 
 bead, 
 
 Communicated by Dr. Smith, Glasgow. 
 
 Some hours. 
 
 Arm & head 
 
 do. 
 
 
 Baudelocque, vol. ii., p. 37 
 
 Probably some hours, 
 
 Crosshirth, 
 
 Died, 
 
 Dead, 
 
 De Morbis Peritonei, p. 33. 
 
 About 8 hours. 
 
 Arm & head 
 
 Recovered, 
 
 do. 
 
 Communicated by Dr. Macaulay. 
 
 Above 6 hours, 
 
 
 do. 
 
 do. 
 
 Trait6 des Accouchemens, i., p. 356. 
 
 5 hours. 
 
 Abdomen, 
 
 do. 
 
 Alive, 
 
 Cases in Midwifery, vol. ii., p. 288. 
 
 4 to 6 hours, 
 
 Head, 
 
 do. 
 
 Dead, 
 
 Communicated by Dr. Skae, Leven. 
 
 4 hours, 
 
 Head & arn^ 
 
 do. 
 
 
 Annals of Medicine, vol. iv., p. 308. 
 
 4 hours. 
 
 Head, 
 
 do. 
 
 beadi 
 
 Communicated by Dr. Radford, 
 
 4 hours, 
 
 Head, 
 
 do. 
 
 do. 
 
 Communicated hy Dr. Radford. 
 
 3 or 4 hours. 
 
 Shoulder, 
 
 do. 
 
 do. 
 
 Seen with Dr. Graham Weir. 
 
 3 hours. 
 
 Head, 
 
 do. 
 
 do. 
 
 Communicated by Dr. Radford. 
 
 About 3 hours. 
 
 Head, 
 
 do. 
 
 do. 
 
 Communicated by Dr. Ingleby. 
 
 Above 2 hours, 
 
 
 do. 
 
 do. 
 
 Prov. Trans., vol. vii., p. S3S. 
 
 Above 2 hours. 
 
 Arm, 
 
 do. 
 
 do. 
 
 Seen with Dr. Lewins of Leith, 
 
 Nearly 2 hours, 
 
 Head, 
 
 do. 
 
 do. 
 
 Seen with Mr. Hill, Portobello. 
 
 Less than 2 hours, 
 
 
 do. 
 
 do. 
 
 Communicated by Dr. Todd. 
 
 1^ hours. 
 
 Arm, 
 
 do. 
 
 do. 
 
 Communicated by Dr. Fraser. 
 
 I5 hours. 
 
 Head, 
 
 do. 
 
 do. 
 
 Communicated by Dr. Radford. 
 
 About li hours, 
 
 Head, 
 
 do. 
 
 do. 
 
 Communicated by Dr. Smith, Glasgow. 
 
 An hour or more. 
 
 Shoulder, 
 
 do. 
 
 Putrid, 
 
 Communicated by Dr. Ramsbotham. 
 
 1 hour. 
 
 
 do. 
 
 do. 
 
 M^deoine Pratique, torn, ii., p. 224. 
 
 1 hour. 
 
 Head, 
 
 do. 
 
 Dead, 
 
 Communicated by Dr. Radford. 
 
 
 Breech, 
 
 do. 
 
 do. 
 
 System of Midwifery, p. 360. 
 Communicated by Dr. Gardiner. 
 
 About 1 hour. 
 
 Breech, 
 
 do. 
 
 do. 
 
 About 1 hour. 
 
 Head. 
 
 Died, 
 
 do. 
 
 Communicated by Dr. Smith, Glasgow. 
 
 About 1 hour. 
 
 Head, 
 
 Recovered, 
 
 do. 
 
 Communicated by Dr. Ingleby. 
 
 About 1 hour. 
 
 Feet, 
 
 do. 
 
 Putrid, 
 
 Communicated by Dr. Irvine. 
 
 Above J hour, 
 
 Head, 
 
 do. 
 
 Dead, 
 
 Communicated by Dr. Smith, Glasgow, 
 
 Above i hour at least. 
 
 
 do. 
 
 
 Pract. Obs., Case 164, vol. ii., p. 229. 
 
 At least i hour, 
 
 
 do. 
 
 bead'. 
 
 Communicated by Dr. Todd. 
 
 i hour. 
 
 Head, 
 
 do. 
 
 do. 
 
 Communicated by Dr. Radford. 
 
 i hour. 
 
 Head, 
 
 do. 
 
 do. 
 
 Communicated by Dr. Thompson, Hamilton. 
 
 i hour. 
 
 Head, 
 
 do. 
 
 do. 
 
 Communicated by Dr. Radford. 
 
 "Within i hour. 
 
 Head, 
 
 do. 
 
 do. 
 
 Communicated by Dr. Skae, Leveu. 
 
 About J hour. 
 
 Shoulder, 
 
 do. 
 
 do. 
 
 Communicated by Dr. Paxton. 
 
 REMARKS. 
 
 20. " I found the vagina completely filled with the placenta, and the os uteri firmly contracting upon the 
 
 funis." 
 25. "The hemorrhage was very excessive, so long as the placenta waa only partially separated, but was 
 
 ' immediately suppressed by completely detaching it." 
 27. Dr. R. saw her " two hours after the first attack of flooding. The placenta was then wholly in the vagina, 
 
 but there was not the least hemorrhage; the membranes were ruptured; the cervix unexpanded." 
 
 29. "Flooding 9 hours before placenta was expelled, but was immediately suppressed on its expulsion." 
 
 30. Dr. C. kindly informs me that the woman recovered perfectly. 
 
 31. Note by Dr. G. "There was no flooding previous to the commencement of labor pains, and it was 
 
 moderate throughout." 
 
 32. See case given in full in Section VI. 
 
 34. "Absolutely no more hemorrhage than in a common natural labor." 
 
 37. Dr. T. found the placenta lying in the vagina; the pains were strong and effective; and the infant was 
 
 expelled in half an hour. 
 39. Dr. Wharrie found the placenta partly in the vagina, and partly in the os uteri. He extracted it by a 
 
 kind of twisting motion, and the hemorrhage immediately ceased. 
 42. "In this case, the pains entirely left her after the expulsion of the placenta; a full dose of ergot was 
 
 given, the os uteri being fully dilated, and was followed. by one or two smart pains, by which the child 
 
 was expelled." 
 
614 
 
 COMPLEX LABOR. 
 
 (FiEST Division 
 
 By whom Observed or 
 Reported. 
 
 No. of 
 the Preg- 
 nancy. 
 
 Period of 
 Delivery. 
 
 Degree of hemor- 
 rhage 6e/ore the 
 entire separation 
 of the placenta. 
 
 Degree of hemor- 
 rhage afUr the 
 
 entire separation 
 of the placenta. 
 
 Mode of Delivery 
 of the Child. 
 
 43 
 44 
 45 
 46 
 47 
 
 Dr. Millar, Kilmarnock, 
 
 Mr. Malcolm, Dundee, 
 
 Lamotte, 
 
 Dr. F. Eamsbotham, 
 
 Mr. Johnstone, Brompton, 
 
 10th. 
 Lge. fam. 
 
 9th mon. 
 
 Great, 8 Iba. in 3 
 Very little, [d'ys. 
 Great, 
 Very great, 
 Very great, 
 
 About a pound. 
 
 Gentle traction. 
 
 Turning, 
 
 Turning, 
 
 By natural pains, 
 
 By natural pains, 
 
 None, 
 None, 
 
 9th, 
 6th, 
 
 9th mon. 
 9th " 
 
 SECOND 
 Cases in which a Shorter Interval (less than 10 Minutes) elapsed 
 
 48 
 49 
 60 
 51 
 62 
 63 
 64 
 65 
 66 
 67 
 68 
 69 
 60 
 61 
 62 
 63 
 64 
 65 
 66 
 67 
 68 
 69 
 70 
 71 
 
 Dr. Dewar, Dunfermline, 
 
 Dr. Fraaer, Aberdeen, 
 
 Mr. Nimmo, Dundee, 
 
 Dr. John Ramsbotham, 
 
 Dr. John Ramsbotham, 
 
 Dr. F. Ramsbotham, 
 
 Dr. Smith, Lasswade, 
 
 Dr. Maxwell Adams, 
 
 Dr. Barlow, 
 
 Mr. Crawford, Glasgow, 
 
 Mr. Crawford, " 
 
 Dr. M'Donald, " 
 
 Dr. F. Ramsbotham, 
 
 Dr. P. Ramsbotham, 
 
 Mr. Tindal, Glasgow, 
 
 Mr. Denny, 
 
 Dr. Conquest, London, 
 
 Mr. Elkington,Birmingh'm 
 
 Mr. Rose, Swaffham, 
 
 Reviewer, 
 
 Dr. Menzies, Glasgow, 
 
 Mr. James, 
 
 Dr. Francis, 
 
 Dr. Wilson, Whitburn, 
 
 6th. 
 Lge. fam. 
 
 9th mon. 
 8th » 
 
 Profuse, 
 
 Very moderate, 
 
 Considerable, 
 
 Serere, 
 
 None, 
 Great, 
 
 Stopped, 
 
 None, 
 
 None, 
 
 By natural pains, 
 
 Turning, 
 
 By natural pains, 
 
 By natural pains, 
 
 By natural pains, 
 
 Turning, 
 
 By natural pains, 
 
 3d, 
 
 12th, 
 
 3d, 
 
 ■2d,' 
 6th, 
 4th, 
 7th, 
 2d, 
 3d, 
 lOlh, 
 
 
 9th « 
 9th " 
 7th « 
 9th « 
 9th " 
 9 th " 
 9th « 
 6^ mons. 
 8th '• 
 9th « 
 
 Exhausting, 
 
 Excessive, 
 
 Very profuse, 
 
 Profuse, 
 
 Not great, 
 
 Exhausting, 
 
 Excessive, 
 
 Exhausting, 
 
 Most violent, 
 
 Fearful, 
 
 Profuse, 
 
 None, 
 
 None, 
 
 "A good deal," 
 
 None, 
 
 None, 
 
 None, 
 
 Turning, 
 
 Turning, 
 
 Turning, 
 
 Turning, 
 
 Evisceration, 
 
 By natural pains, 
 
 Turning, 
 
 By natural pains, 
 
 By natural pains, 
 By natural pains. 
 By natural pains, 
 By natural pains, 
 By natural pains. 
 By natural pains, 
 By natural pains, 
 
 Lge. fam. 
 ' 7th, 
 
 6^ mons. 
 7th, 8th " 
 9th " 
 
 Active, 
 
 A good deal. 
 
 Not alarming, 
 
 None, 
 
 6 th, 
 
 8th, 9 th" 
 8th " 
 
 Considerable, 
 Very great, 
 
 None, 
 Slight, 
 
 4th, 
 
 
 Slight, 
 
 
 THIRD 
 
 Cases in which the Placenta was expelled immediately 
 
 72 
 
 Mr. Greenhow, Newcastle, 
 
 6th, 
 
 7th mon. 
 
 Considerable, 
 
 
 
 Extracted, 
 
 73 
 
 Mr. Campbell, Glasgow, 
 
 1st, 
 
 7th, 8th " 
 
 Excessive, 
 
 
 
 Turning, 
 
 74 
 
 Mr. Flemming, " 
 
 6th, 
 
 
 Considerable, 
 
 
 
 Turning, 
 
 76 
 
 Mr. Hardcastle, Newcastle, 
 
 Several, 
 
 7th, 8th" 
 
 Very great. 
 
 
 
 By natural pains, 
 
 76 
 
 Mr. Lowe, Manchester, 
 
 3d, 
 
 8th " 
 
 Very profuse. 
 
 
 
 By natural pains. 
 
 77 
 
 Mr. Sidebottom, " 
 
 3d, 
 
 9th " 
 
 Very copious. 
 
 
 
 By natural pains, 
 
 TS 
 
 Dr. Smellie, 
 
 Several, 
 
 9th « 
 
 Slight, 
 
 
 
 By natural pains. 
 
 79 
 
 Dr. Stewart, Eelso, 
 
 6th, 
 
 8th « 
 
 Severe, 
 
 
 
 By natural pains, 
 
 80 
 
 Mr. Tulloch, Newcastle, 
 
 Several, 
 
 7th " 
 
 
 
 
 
 81 
 
 Mr. Wood, Manchester, 
 
 6th, 
 
 8th '■ 
 
 Very profuse. 
 
 
 
 By turning, 
 
 82 
 
 Mr. Wood, " 
 
 6th, 
 
 9th « 
 
 Veryconsider'ble 
 
 
 
 By natural pains. 
 
 83 
 
 Dr. Young, Edinburgh, 
 
 
 9th " 
 
 Very great. 
 
 
 
 By turning. 
 
 84 
 
 Dr. Currie, Lanark, 
 
 4th, 
 
 
 Violent, 
 
 
 . . . . 
 
 By natural pains, 
 
 85 
 
 Dr. Carruthers, Dundee, 
 
 3d or 4th, 
 
 9th mon. 
 
 Considerable, 
 
 
 
 By natural pains, 
 
 86 
 
 Dr. F. Ramsbotham, 
 
 4th, 
 
 8th '" 
 
 Violent, 
 
 
 
 By natural pains, 
 
 REMARKS. 
 43. "The placenta was lying partly in the vagina, and partly in the uterus. After its extraction, th^feet 
 presented, which were laid hold of, and, at each pain, firm but gentle traction employed, till the child 
 was delivered." 
 
 45. "I found the placenta occupying wholly the vagina, and pushing almost out of it. I immediately pulled 
 
 it away, whereupon, the membranes being torn, the waters came in great plenty, and I brought away 
 a dead child by the feet." The flooding had been excessive. 
 
 46. Dr. R. found the membranes pressing on the perineum, and the whole of the placenta almost in the 
 
 vagina. It passed outside immediately on rupturing the membranes. 
 
 48. See Case under Section II. 
 
 49. See Case under Section VI. 
 
 52. Violent hemorrhage came on two days before delivery. It ceased entirely, however," and did not return. 
 
 53. Copious hemorrhage came on 3^ hours before delivery, on the membranes spontaneously rupturing. 
 
 Dr. R. found great part of the placenta in the vagina; there was no pain nor hemorrhage ; and he 
 would not have turned, had the shoulder not been the presenting part. The placenta came away as 
 the shoulders were passing the brim, before the head was extracted. 
 56. The placenta was expelled while she was on her feet. « She attempted to walk up stairs, and before she 
 could reach the bed, a violent pain seized her, which instantly expelled the placenta, and disparted 
 
PLACENTA F-RMYIA. 
 
 615 
 
 — continued.) 
 
 Time between the 
 
 Birth of Placenta and 
 
 Birth of the Child. 
 
 Presentation 
 
 of 
 
 the Child. 
 
 Results. 
 
 Where Reported, or by whom 
 Communicated. 
 
 To Mother. 
 
 To Child 
 
 20 minutea^ 
 Upwards of 20 min., 
 Not i of an hour, 
 10 minutes, 
 Ahout 10 minutes. 
 
 Feet, 
 Arm, 
 
 Head, ' 
 Head, 
 
 Recovered, 
 do. 
 do. 
 do. 
 do. 
 
 Bead, 
 do. 
 do. 
 do. 
 do. 
 
 Communicated by Dr. Paxton. 
 Communicated by Dr. Eeiller.J 
 Trait6 des Accouchemeus, p. 407. 
 Communicated by Dr. Ramsbotham. 
 Communicated by Dr. Elliott, Carlisle. 
 
 DIVISION. 
 
 BETWEEN THE SEPARATION OF THE PLACENTA AND THE BiRTH OF THE ChILD. 
 
 Less than 10 min., 
 
 
 Recovered, 
 
 Alive, 
 
 Communicated by Dr. Dewar. 
 
 5 or 10 minutee, 
 
 
 Died, 
 
 do. 
 
 Communicated by Dr. Frazer. 
 
 A short time, 
 
 Breech, 
 
 Recovered, 
 
 Dead, 
 
 Communicated by Dr. Keillor. 
 
 A short time, 
 
 
 do. 
 
 
 Pract. ObB., Case 155, vol. ii., p. 231. 
 
 A short time, 
 
 Breech, 
 
 do. 
 
 Putrid, 
 
 Pract. Obs., Case 156, vol. ii., p, 233. 
 
 A short time, 
 
 Shoulder, 
 
 do. 
 
 Dead, 
 
 Communicated by Dr. F. Ramsbotham. 
 
 A few pains, 
 
 Head, 
 
 do. 
 
 Alive, 
 
 Communicated by Dr. Smith. 
 
 A few minutes, 
 
 Toot, 
 
 do. 
 
 Putrid, 
 
 Monthly Journal, vol. iv., p. 936. 
 
 A few minutes, 
 
 Shoulder, 
 
 do. 
 
 Alive, 
 
 Essays on Midwifery, &c., p. 273. 
 
 A few minutes, 
 
 Head, 
 
 do. 
 
 do. 
 
 Communicated by Dr. Smith, Glasgow. 
 
 A few minutes, 
 
 Head, 
 
 do. 
 
 do. 
 
 Communicated by Dr. Smith, Glasgow. 
 
 A few minutes, 
 
 Head, 
 
 do. 
 
 Dead, 
 
 Communicated by Dr. Smith, Glasgow. 
 
 A few minutes, 
 
 Shoulder, 
 
 Died, 
 
 do. 
 
 Communicated by Dr. F. Ramsbotham. 
 
 A few minutes, 
 
 Head, 
 
 Recovered, 
 
 do. 
 
 Communicated by Dr. F. Ramsbotham. 
 
 A few minutes, 
 
 Head, 
 
 Died, 
 
 do. 
 
 Communicated by Dr. Smith, Glasgow. 
 
 Next pain, 
 
 
 Recovered, 
 
 Alive, 
 
 Lancet, 1831-32, vol. i., p. 110. 
 
 Next pain, 
 
 
 do. 
 
 Dead, 
 
 Communicated by Dr. Conquest. 
 
 Soon, 
 
 
 do. 
 
 do. 
 
 Communicated by Dr. Ingleby. 
 
 Quickly, 
 
 Head, 
 
 do. 
 
 Alive, 
 
 Communicated by Mr. Rose. 
 
 
 
 do. 
 do. 
 
 Alive, 
 
 Med. Chir. Review, vol. iii., p. 317. 
 Communicated by Dr. Smitl^ Glasgow. 
 
 5 minutes, 
 
 Head, 
 
 4 minutes, 
 
 Head, 
 
 do. 
 
 Dead, 
 
 London Med. Repository, vol. vi., p. 412. 
 
 3 minutes, 
 
 
 do. 
 
 Alive, 
 
 Francis's Edition of Denman, p. 485. 
 
 Less than 2 minutes, 
 
 Head, 
 
 do. 
 
 do. 
 
 Communicated by Dr. Wilson. 
 
 DIVISION. 
 
 BEFORE THE ChILD, OR BOTH WERE EXPELLED TOGETHER. 
 
 Almost immediately, 
 
 Breech, 
 
 Recovered, 
 
 Dead, 
 
 Communicated by Dr. Dawson, Newcastle. 
 
 Together, 
 
 Head, 
 
 do. 
 
 Alive, 
 
 Communicated by Mr. Campbell. 
 
 Turned immediately. 
 
 Head, 
 
 do. 
 
 do. 
 
 Communicated by Dr. Currie, Lanark. 
 
 Immediately, 
 
 Head, 
 
 do. 
 
 Dead, 
 
 Commuuicated by Dr. Dawson, Newcastle. 
 
 Immediately, 
 
 Head, 
 
 do. 
 
 do. 
 
 Communicated by Dr. Radford. 
 
 Immediately, 
 
 Head, 
 
 do. 
 
 do. 
 
 Communicated by Dr. Radford. 
 
 Immediately, 
 
 
 do. 
 
 Alive, 
 
 Midwifery, vol. ii., p. 310. 
 
 Immediately, 
 
 Head. 
 
 do. 
 
 Dead, 
 
 Communicated by Dr. Stewart. 
 
 Immediately, 
 
 
 do. 
 
 do. 
 
 Communicated by Dr. Dawson, Newcastle. 
 
 Immediately, 
 
 Head, 
 
 Died, 
 
 do. 
 
 Communicated by Dr. Radford. 
 
 Immediately, 
 
 Head, 
 
 Recovered, 
 
 do. 
 
 Communicated by Dr. Radford. 
 
 Immediately, 
 
 
 do. 
 
 
 Communicated by Dr. Young. 
 
 Almost at same time, 
 
 Head, 
 
 do. 
 
 Alive, 
 
 Communicated by Dr. Currie. 
 
 Almost at same time. 
 
 Head, 
 
 do. 
 
 do. 
 
 Communicated by Dr. Carruthers. 
 
 Not many moments, 
 
 Head, 
 
 do. 
 
 Dead, 
 
 Communicated by Dr. Ramsbotham. 
 
 REMARKS. 
 
 the funis about six inches from the child's navel. A great effusion of blood followed, and the woman 
 
 fainted ere she could be laid down on the bed." - 
 58, 59, 73. " In these three cases the placenta was detached in introducing the hand to turn, and lay in the 
 
 vagina till the feet were brought down." Dr. Smith's note. 
 60. See case at length in Section VI. 62. See case at length in Section VI. 
 
 64. Active hemorrhage had taken place before Br. C.'s arrival. "On examination, the pelvis was filled with 
 
 coagula, and somethiug like placenta. Another pain expelled an uninterrupted ovum, which was 
 
 instantly ruptured, but the child was dead." 
 68. The placenta was bom along with the head ; but Dr. M. was sensible of its being wholly detached, and 
 
 lying in the vagina for fully five minutes. 
 
 70. Though not act#,lly stated, it is clear from the context that the woman here, and in Case 143, recovered. 
 
 71. When Mr. W. saw the woman there was a little hemorrhage, but not so much as to cause any alarm, 
 
 either for the mother or child. The pains were strong and downbearing, and in about twenty 
 minutes the placenta was expelled. The next pain expelled the child. 
 
 72. The placenta was detached to some extent when Mr. G. was called in. He immediately separated the 
 
 remainder, and removed it. 
 78, 91, 92. The fact is not stated, but it is manifest from the context that the mothers recovered. 
 
616 
 
 COMPLEX LABOR. 
 
 (Third Division 
 
 By irhoni Observed or 
 Reported. 
 
 No. of 
 the Preg- 
 nancy. 
 
 Period of 
 Delivery. 
 
 Degree of hemor- Degree of hemor- 
 rhage befcn-e the rhage after the 
 entire separation entire separation 
 of the placenta, of the plaeenta. 
 
 Mode of Delivery 
 of the Child. 
 
 87 
 88 
 89 
 90 
 91 
 92 
 93 
 94 
 95 
 96 
 97 
 98 
 99 
 100 
 101 
 
 Dr. Brownlee, Shotts, 
 
 Dr. Conquest, London, 
 
 Dr. Dawson, Bathgate, 
 
 Professor Murphy, Lond., 
 
 Dr. Smellie, 
 
 Dr: Smellie, 
 
 Anonymous, 
 
 Gendrin, 
 
 Mr. Easton, Glasgow, 
 
 Mr. Easton, " 
 
 Dr. P. Ramsbotham, 
 
 Mr. Rose, Swaffham, 
 
 Mr. Rae, Edinburgh, 
 
 Sehweighauser, Strashurg, 
 
 Dr. Robert Lee, London, 
 
 6th or 7th 
 
 ' 7th,' 
 Not 1st, 
 2d, 
 
 
 
 
 By natural pains. 
 By natural pains. 
 By natural pains. 
 By natural pains. 
 By natural pains, 
 By natural pains. 
 By natural pains, 
 By natural pains. 
 By natural pains. 
 By natural pains, 
 Turning, 
 By natural pains, 
 By natural pains, 
 
 9th mon. 
 8th " 
 9th " 
 8th " 
 8th " 
 
 Violent, 
 Profuse, 
 Moderate, 
 
 
 Profuse, 
 
 
 
 
 Very great. 
 
 Considerable, 
 
 Considerable, 
 
 Exhausting, 
 
 Considerable, 
 
 Considerable, 
 
 
 Several, 
 4th, 
 4th, 
 
 9th mon. 
 9th " 
 8th & 9th, 
 9th " 
 9th « 
 
 
 7th mon. 
 
 Considerable, 
 
 
 
 
 
 FOURTH 
 Cases in which the exact pekiod between the Sepakation 
 
 102 
 103 
 104 
 106 
 106 
 107 
 108 
 109 
 110 
 111 
 112 
 
 113 
 
 114 
 116 
 116 
 117 
 118 
 119 
 120 
 121 
 122 
 123 
 124 
 126 
 126 
 127 
 128 
 129 
 130 
 131 
 132 
 133 
 134 
 185 
 136 
 137 
 138 
 139 
 140 
 141 
 
 Mr. Bailey, Thetford, 
 
 Mr. Bull, 
 
 Cauviere, 
 
 Dr. Clarke, 
 
 Dr. Hamilton, Edinburgh, 
 
 Dr. Hamilton, " 
 
 Labayle, Montpellier, 
 
 Romaine, Bagneres, 
 
 Lamotte, 
 
 Dr. Robert Lee, London, 
 
 Leroux, 
 
 Dr. Ldwenhart, 
 
 Dr. Maunsell, Dublin, 
 
 Mr. Milligen, 
 
 Sir I. Ould, 
 
 Pardigon, 
 
 Dr. F. Ramsbotham, 
 
 Dr. J. Ramsbotham, 
 
 Dr. J. Ramsbotham, 
 
 Mr. Elkington, Birmingh. 
 
 Dr. Cahill, Berwick, 
 
 Mr. Hardcastle, Newcastle, 
 
 Dr. Moody, St. Andrews, 
 
 Dr. Mather, Brechin, 
 
 Dr. Nimmo, senior, 
 
 Mr. Rose, Swaffham, 
 
 Dr. Wilson, Glasgow, 
 
 Dr. Wilson, 
 
 P. Osiander, Qottingen, 
 
 P. Osiander, " 
 
 F. Osiander, " 
 
 F. Osiander, " 
 
 Dr. Trefurt, Gottingen, 
 
 Kory, 
 
 Loss, Dorchester, 
 
 Giffard, 
 
 Mercier, 
 
 Amand, 
 
 Dr. Tennant, Falkirk, 
 
 Dr. Morrison, Dalkeith, 
 
 4th, 
 6th,' 
 
 9th mon. 
 
 Profuse, 
 
 Most alarming. 
 
 Profuse, 
 
 None, 
 
 None, 
 None, 
 
 Turning, 
 Turning, 
 Forceps, 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Turning, 
 
 
 Severe, 
 
 Profuse, 
 
 Great, 
 
 Considerable, 
 
 
 7th mon. 
 7th " 
 
 Much diminished 
 
 Decapitation, 
 
 Turning, 
 
 By natural pains. 
 By natural pains, 
 Turning, 
 Turning, 
 Turning, 
 
 
 
 Profuse, 
 
 
 
 
 
 Profuse, 
 Almost none, 
 Copious, 
 
 None, 
 Little, 
 
 Little or none. 
 Entirely ceased, 
 
 '.'.'.'. 
 
 7th mon. 
 
 
 
 
 8th, 
 
 e'th'ihh, 
 
 
 Very great. 
 
 Not much, 
 
 By natural pains. 
 
 Turning, 
 
 By natural pains. 
 
 
 
 
 
 Not great. 
 
 Severe, 
 
 Moderate, 
 
 Profuse, 
 
 Profuse, 
 
 7th, 
 Lge. fam. 
 
 9th mon. 
 
 None, 
 
 Profuse, 
 
 Profuse, 
 
 Naturally, 
 
 Turning, 
 
 Turning, 
 
 Naturally, 
 
 Naturally, 
 
 Turning, 
 
 Naturally, 
 
 Turning, 
 
 
 ■gth,' 
 
 7th mon. 
 4th " 
 7th « 
 9th " 
 3d " 
 
 
 
 Violent, 
 Very great, 
 
 None, 
 
 ' 7th,' 
 
 Lge. &m. 
 
 Violent, 
 
 None, 
 
 Profuse, 
 
 Severe, 
 
 Severe, 
 
 
 
 Almost none. 
 None, 
 
 Turning, 
 Turning, 
 Turning, 
 Forceps, 
 By natural pains. 
 
 2d, 
 Several, 
 
 9th mon. 
 
 88. On endeavoring to turn, " the os became so much irritated by the attempt to introduce the hand, that 
 the organ forcibly contracted, expelling the hand, placenta, and child, and an almost incredible quan- 
 tity of blood." 
 
 94. The hemorrhage ceased on the waters being allowed to escape by a female catheter, passed through the 
 
 placenta four houra before the birth of the infant, which was expelled with the placenta before it, 
 covering the head. Slight hemorrhage followed the delivery. 
 
 95. In this case the placenta, though born along with the head of the child, was det^hed from the uterus 
 
 about an hour. There was no hemorrhage from the time it was separated. 
 
 96. The placenta was born with the body of the child, but it had been detached for some hours. 
 
 97. The placenta passed, during the extraction of the child, before the breech. 
 
 99. I saw the woman a fortnight after delivery carrying her child, and well. 101. See Sect. V. 
 
 103, The arm was found to present after the expulsion of the placenta, and turning was then had recourse 
 
 to. There was no word of hemorrhage after the placenta was expelled. 
 
 104, "Professor Cauviere haa told me, that in one case where he introduced the forceps, for inertia of the 
 
PLACENTA PR^VU. 
 
 617 
 
 — continued.] 
 
 Time between the 
 
 Birth of Placenta and 
 
 Birth of the Child. 
 
 Presentation 
 
 of 
 
 the Child. 
 
 Besults. 
 
 
 To Mother. 
 
 To Child 
 
 Communicated. 
 
 One pain, 
 
 Head, 
 
 Recovered, 
 
 Alive, 
 
 Communicated by Dr. 'WilBon, 'Vrhitburn. 
 
 One pain, 
 
 
 do. 
 
 do. 
 
 Communicated by Dr. Conquest. 
 
 One pain, 
 
 Arm, 
 
 do. 
 
 Dead, 
 
 Communicated by Dr. Dawson. 
 
 One pain. 
 
 
 do. 
 
 do. 
 
 Communicated by Dr. Murphy. 
 
 One pain, 
 
 
 do. 
 
 do. 
 
 Cases in Midwifery, vol. ii., p. 311. 
 
 One pain. 
 
 
 do. 
 
 
 Cases in Midwifery, vol. ii., p. 313. 
 
 Same pain. 
 
 
 do. 
 
 
 Medico-Chirurg. Review, vol. iii. 
 
 Together, 
 
 
 do. 
 
 Alive, 
 
 MSdecine Pratique, tom. ii., p. 349. 
 
 Together, 
 
 Head, 
 
 do. 
 
 Dead, 
 
 Communicated by Dr. Smith, Glasgow. 
 
 Together,! 
 
 Head, 
 
 do. 
 
 do. 
 
 Communicated by Dr. Smith, Glasgow. 
 
 Together, 
 
 Head, 
 
 do. » 
 
 Alive, 
 
 Communicated by Dr. Kamsbotham; 
 
 Together, 
 
 Head, 
 
 do. 
 
 do. 
 
 Communicated by Mr. Rose. 
 
 Together, 
 
 Head, 
 
 do. 
 
 do. 
 
 Communicated by Dr. Campbell, Edinburgh. 
 
 
 
 
 
 Pratique des Accouehemens. p. 224. 
 Clinical Midwifery, p. 148, case 269. 
 
 
 
 Recovered, 
 
 
 DIVISION. 
 
 OF Placenta and the Bieth or Child not known. 
 
 Head, 
 Arm, 
 
 Arm, 
 Arm, 
 
 Head, 
 
 Head, 
 
 Shoulder, 
 
 Head, 
 
 Head, 
 
 Head, 
 
 Head, 
 
 Shoulder, 
 
 Head, 
 
 Head, 
 
 Shoulder, 
 
 Head & Arm. 
 Head, 
 Head, 
 
 Recovered, 
 
 Alive, 
 
 do. 
 
 Dead, 
 
 Died, 
 
 
 Recovered, 
 
 
 do. 
 
 
 do. 
 
 
 do. 
 
 
 do. 
 
 Alive, 
 
 do. 
 
 Dead, . 
 
 do. 
 
 do. 
 
 do. 
 
 do. 
 
 do. 
 
 
 do. 
 
 Alive, 
 
 do. 
 
 do. 
 
 do. 
 
 
 do. 
 
 . . 
 
 do. 
 
 
 do. 
 
 
 do. 
 
 Dead, 
 
 do. 
 
 do. 
 
 do. 
 
 do. 
 
 do. 
 
 Breath'd 
 
 do. 
 
 Alive, 
 
 do. 
 
 do. 
 
 do. 
 
 do. 
 
 do. 
 
 Dead, 
 
 do. 
 
 do. 
 
 do. 
 
 do. 
 
 do. 
 
 do. 
 
 do. 
 
 do. 
 
 do. 
 
 Putrid, 
 
 do. 
 
 
 do. 
 
 
 do. 
 
 Alive, 
 
 Died. 
 
 
 do. 
 
 Dead, 
 
 Recovered, 
 
 do. 
 
 do. 
 
 do. 
 
 do. 
 
 do. 
 
 London Med. Repos., vol. xvi., p. 451. 
 Medical Gazette, vol. xix., p. 622. 
 Pardigon de I'Ineertion du Placenta. 
 Collins' Midwifery, p. 91. 
 Notes of Lectures and Ob8.,,p. 313. 
 Notes of Lectures and Pract. ObB., p. 313. 
 
 > Essai sur l*H6m. Uter., Montpellier, 1827. 
 
 Trait6 des Accouehemens, p. 405. 
 Clinical Midwifery, p. 144, case 263. 
 Leroux sur les Pertes du Sang, p. 262. 
 J Neue Zeitschrift fiir Geburtsk, bd. yii., h. 3. 
 \ See Kleinert's Rep., 1842, vi., p. 58. 
 Dublin Journal, vol- v., p. 373. 
 Lancet, 1831-32, vol. i., p. 232. 
 Quid's Midwifery, p. 77. 
 De rinsertion du Placente a I'Orifice Uter. 
 Pract. Obs., vol. ii., p. 232. 
 Pract. Obs., vol. ii., p. 235. 
 Pract. Obs., vol. ii., p. 235. 
 Communicated by Dr. Ingleby. 
 Communicated by Dr. Cahill. 
 Communicated by Dr. Dawson. 
 Communicated by Dr. Smith, St. Andrews. 
 Communicated by Dr. Binning, Arbroath. 
 Communicated by Dr. Keiller, Dundee. 
 Communicated by Mr. Rose. 
 Communicated by Dr. Wilson. 
 Communicated by Dr. Wilson. 
 
 ! Kleinert's Repertorium, 1832. April Number. 
 t.24. 
 
 1 Hannoversche Annalen, Sept.,1841. Vid. Neue 
 \ Zeitschrift fiir Geburtskunde, 1843, p. 121. 
 Observationes Medicinales, Loud., 167^ p. 380. 
 Cases in Midwifery, p. 516. 
 Journal G6n. de M6decine, tom. 45, p. 305. 
 Observations sur la Pratique, &c., p. 336. 
 Communicated by Dr. Tennant. 
 Communicated by Dr. Morrison. 
 
 REMARKS. 
 
 uterus, when the head was in the pelvis, he was quite astonished to see the placenta pass out of the 
 vagina, before the child, without the slightest hemorrhage." — Pardigon's Essay, 
 
 108, 109. "It may happen," says Labayle, " that the placenta, though attached by its centre to the os, ia 
 pushed out before the head of the child, and the labor terminates in the most happy manner. I have 
 myself witnessed such a fact; and M. Romaine, Professor of Midwifery at Bagnares, has communi- 
 cated to me also an observation of this kind." 
 
 111. Dr. Lee found .the placenta protruding through the orifice of the vagina. He immediately extracted it 
 and a dead child followed. 
 
 101. In this case the placenta was protruding at the os uteri ; on drawing it forward gently, the whole ovum 
 escaped without rupture of the membranes. 
 
 113. A midwife had separated the placenta, which presented, and had drawn it out of the external parts. 
 
 119, 120. I am kindly informed by Dr. Ramsbotham that he knows " one of the mothers recovered, and he 
 believes the other also." 128, 129. See Section V. 137. See case in Section VI. 
 
 138. See case in Section VI. For details of other cases see future Sections. 
 
618 COMPLEX LABOR. 
 
 1st Division.— Cases in which a considerable interval— varying 
 from ten minutes to ten hours or upwards— elapsed between the ex- 
 pulsion of the placenta and the birth of the child, including the forty- 
 seven instances standing at the head of the table. 
 
 2d Division.— Cases, comprehending those from N'o. 48 to N'o. 
 71, in which the interval was shorter. 
 
 Sd Division.— Cases, running from No. 72 to Fo. 101, in which 
 the child was born immediately after the extrusion of the placenta, 
 or expelled with it. 
 
 Uh Division. — Cases, from ISTo. 102 onwards, in which the period 
 intervening between the expulsion of the placenta and child is not 
 specified by the reporters, though the context shows that in many 
 of this class the interval was evidently considerable. 
 
 Section IV. — Genekal Deductions regarding the preceding 141 
 Cases. — 1. Number op the pregnancy. 2. Period of Delivery. 
 3. Modes of Presentation of the Child. 4. Modes of De- 
 livery. 5. Number of Children Lost and Saved. 
 
 We shall now attempt to state in a generalized form some of the 
 more important points deducible from the consideration and exa- 
 mination of the preceding table. Before doing so, however, I would 
 take this opportunity of remarking, that the total separation and 
 expulsion of the placenta before the infant, does not seem to be 
 so very rare and uncommon a circumstance as medical men gene- 
 rally believe, and as authors allege it to be. Dr. Collins states,* 
 that it is " extremely rare to meet with a total separation of the 
 placenta in unavoidable hemorrhage." In reporting Mr. Denny's 
 case,^ Mr. Cower observes, " it is perhaps a solitary instance in the 
 annals of obstetric practice. The placenta was brought into the 
 world before the child. The uterus closed upon the body of the 
 foetus so as to prevent hemorrhage, and after another pain the child 
 was born alive. It was a quick labor, and no ill effects followed 
 from an accident, from which disastrous consequences might have 
 been reasonably apprehended to both mother and child. Perhaps," 
 adds Mr. Cower, " there is no other such case on record, and it 
 merits notice, as an example of the competency of nature to pro- 
 vide for extraordinary emergencies."^ 
 
 The number of cases included within the preceding table shows 
 
 • Treatise on Midwifery, p. 90. 2 Table, No. 63. 
 
 ' Lancet for 1831-32, vol. i. p. 119. 
 
PLACENTA PREVIA. 619 
 
 the entire separation of the placenta in placental presentations 
 to be by no means so rare as these and other authors seem to 
 suppose. I have no doubt that the records of medicine contain 
 more cases than I have had leisure or opportunity of searching 
 out ; and I feel assured that a more extensive and industrious in- 
 quiry of private practitioners than I have been able to institute, 
 might have brought to light a considerable number of additional 
 instances. 
 
 1. Number of the Pregnancy in the cases included in the Table. — 
 In 81 cases the number of the pregnancy is stated, or facts men- 
 tioned, so as to enable us to infer whether the patient had previously 
 borne a family or not. 
 
 In 12 oases the mother had " several" children previously. 
 
 4 
 
 
 (( 
 
 " a large 
 
 family." 
 
 1 case it was 
 
 the 
 
 15th 
 
 pregnancy. 
 
 1 
 
 (( 
 
 
 12th 
 
 
 (( 
 
 3 cases it 
 
 C( 
 
 
 10th 
 
 
 (( 
 
 5 
 
 u 
 
 
 9th 
 
 
 « 
 
 2 
 
 u 
 
 
 8th 
 
 
 a 
 
 8 
 
 (( 
 
 
 7th 
 
 
 u 
 
 6 « 
 
 (t 
 
 
 6th 
 
 
 (l 
 
 6 
 
 (( 
 
 
 5th 
 
 
 " 
 
 9 
 
 11 
 
 
 4th 
 
 
 (C 
 
 LO " 
 
 (( 
 
 
 3d 
 
 
 u 
 
 5 « 
 
 (C 
 
 
 2d 
 
 
 li 
 
 8 " 
 
 " 
 
 
 1st 
 
 
 u 
 
 Total, 81 
 
 2. Periods of utero-gestation at which the patients were delivered. — In 
 89 cases out of the 141, the requisite information is supplied on this 
 point. The result is as follows : 
 
 From the 6th month, . 
 From the 6th to the 7th month, 
 From the 7th to the 8th month, 
 From the 8th to the 9th month. 
 From the 9th to full time, . 
 
 3 were 
 
 delivered. 
 
 5 " 
 
 a 
 
 19 " 
 
 " 
 
 19 " 
 
 ([ 
 
 43 " 
 
 (( 
 
 Total, 
 
 The preceding data are so far corroborative of the well-known 
 fact, that in placental presentations the labor is very frequently pre- 
 mature. In 28 of his 42 cases of placenta prsevia. Dr. Rigby men- 
 tions the date at which labor came on. In 13 of the 28 the labor 
 was more or less premature ; in 15 the women are said to have 
 reached the full term of pregnancy. Dr. Lee has reported 36 cases 
 
620 COMPLEX LABOR. 
 
 of unavoidable hemorrhage;^ in 3 instances he does not state the 
 date of the labor ; in 2 only had the women reached their full time ; 
 and in the remaining 31 patients, the labor was premature. Out of 
 16 cases of the same complication reported by Madame LachapeUe,^ 
 
 1 patient was near the seventh month of pregnancy ; 6 were de- 
 livered during the seventh month ; 5 during the eighth month ; 1 at 
 the beginning of the ninth month ; 1 towards the middle of it, and 
 
 2 during the course of it. Levret discusses at some length the 
 question, " why some of the women who have the placenta im- 
 planted upon the cervix uteri arrive at the full time, and why the 
 greater part {la plupart) of those who are in the same condition do 
 not reach that period."^ 
 
 3. Modes of Presentation of the Child.— Thi^ is specified in 90 
 cases. 
 
 In 4 cases the feet presented. 
 
 In 6 " breech presented. 
 
 In 21 " trunk or upper extremity presented. 
 
 In 59 " head presented. 
 
 In 4 of the head cases (Table, E^os. 8, 14, 10, and 139), an arm 
 presented along with the head. 
 
 In the above, as in all other statistical returns, referring to the 
 presentation of the child in cases of placenta prsevia, the number of 
 preternatural presentations, and particularly of cross-births, is re- 
 markable. 
 
 4. Modes of Delivery of the Child. — The means by which the chil- 
 dren were ultimately delivered have varied greatly according to the 
 peculiarities arising from the presentation, and the supposed neces- 
 sity or non-necessity of direct instrumental or other interference. 
 
 In 1 case the child was delivered by the Long forceps. 
 
 In 3 " " " Short forceps. 
 
 In 1 " " " Evisceration. 
 
 In 2 " " " Decapitation. 
 
 In 3 " " " Simple traction. 
 
 In 40 " « " Turning. 
 
 In 66 " " " Natural pains. 
 
 Total, 116 
 
 In the remaining 25 cases, the manner of delivery is not specified. 
 
 5. Number of Children Lost and Saved. — In 113 instances in the 
 Table, the result as regards the life or death of the child is stated. 
 
 ' Clinical Midwifery, p. 142, &c. 
 
 ^ Pratique des Accouchemehs, torn. ii. p. 415. 
 
 " L'Art des Accouchemens, Paris, 1771, p. 367. 
 
PLACENTA PRiEVIA. 621 
 
 In 1 (Eo. 10) of the 113 cases, it was malformed (anencephalous) and 
 incapable of sustaining extra-uterine life, and in 6 others it was 
 putrid, or had died before labor commenced. The following state- 
 ment shows the result as respects the remaining 106 cases : 
 
 In 73 cases the infant was born dead. 
 In 33 " the infant was born alive. 
 
 According to these data, nearly 1 out of every 3 children sur- 
 vived ;— or 31 per cent, of the children were saved, and 69 per cent, of 
 them were lost. I shall again have occasion to recur to this topic in 
 the sequel of the memoir. 
 
 Section V. — Degree of Hemorrhage before the separation of 
 THE Placenta, its Absence and Exception to the Rule, De- 
 gree OF Hemorrhage after the Coivipletb Separation of the 
 Placenta, its Presence the Exception to the Rule : Pro- 
 portion of Cases: No Relation between the Extent of the 
 Hemorrhage and the Duration op Interval between the 
 Detachment of the Placenta and the Birth of the Child. 
 
 Out of the 141 cases included in the preceding Table (Sect, m.), 
 we have returns in 111 instances regarding the extent of the hemor- 
 rhage that was present, previously to the detachment and expulsion 
 of the placenta. The preceding flooding is reported as 
 
 Great in 72 cases. 
 
 Considerable in 24 '* 
 Slight in 8 " 
 
 Little or none in 7 " 
 
 Total, 111 
 
 The seven cases in which there occurred little or no hemorrhage 
 during and anterior to the disjunction of the placenta, are those 
 entered in the Table as Nos. 5, 11, 14, 28, 34, 117, and 138. Mer- 
 cier has devoted a special essay' to the consideration of such excep- 
 tional instances to the general rule of flooding occurring as an " una- 
 voidable" symptom in placental presentations. " The hemorrhage," 
 observes Caseaux,^ " which they have generally considered as inevi- 
 table in these cases (placental presentations) may, however, not show 
 itself even during the progress of labor, and the dilatation of the cer- 
 vix uteri maybe effected without there escaping one drop of blood." 
 
 ' " Les Accouchemens ou le Placenta se trouve oppos6, sur le col de la matrice, sont-ils 
 oonstamment accompagnfis de I'liemorrhagie V — Journal de M^decine, vol. xlv. p. 305. 
 ^ Traits de TArt des Accouchemens, 1841, p. 559. 
 
622 COMPLEX LABOR. 
 
 Caseaux afterwards adverts to the opinions wMcli Walter, Moreau, 
 and others have offered in explanation of this exception.^ The most 
 rational idea seems to be, that in such cases the child has been dead 
 for some time, and the utero-placental circulation in consequence 
 arrested previously to the supervention of parturition. 
 
 But in relation to the objects of our essay, it is a much more inte- 
 resting and important subject for us to inquire into the degree of 
 hemorrhage after— than the degree of hemorrhage before, the com- 
 plete separation of the placenta. 
 
 " The great and excessive losses of blood," states Mauriceau, in 
 one of his aphorisms,'' "which happen sometimes to the pregnant 
 woman, proceed almost always from the detachment, in whole or in 
 part, of the after-birth from the uterus ; and these kinds of losses of 
 blood never cease entirely till the female is delivered." 
 
 In criticising this aphorism, Levret observes — " The first part of 
 this statement is, in general, but too true, but the second part is not 
 so constant as Mauriceau gives it. For the daily practice of accou- 
 cheurs shows, that there are occasionally women attacked with great 
 hemorrhage, in consequence of partial separation of the placenta, who 
 nevertheless arrive at the natural period of delivery ; thus the word 
 never is too positive, as it does not allow of any exception, and it 
 can only apply to those cases in which the separation of the pla- 
 centa is complete, and not to those where it is only partially detached."^ 
 
 Levret elsewhere'' remarks in his essay on placenta prsevia — 
 '' Daily practice teaches us that the placenta is never detached spon- 
 taneously, without the contraction of the part where it was affixed, 
 and without the detachment of this vascular mass, whether complete 
 or partial — being followed by discharge of blood." 
 
 The allegations made by Mauriceau and Levret, regarding the 
 continuance of hemorrhage after totoZ separation of the placenta, and 
 I might quote similar averments, if necessary, from later authors, are 
 perhaps such as the mind might be inclined to draw, from reason- 
 ing upon the subject of complete detachment of the mass. But if 
 we turn from theory to fact — and from preconceived opinions to 
 careful observations, we shall find the above statements perfectly 
 and directly contradicted by the results of practical experience. For 
 I believe that the data which I have collected for the present paper 
 are amply sufficient to establish, as a great physiological and prac- 
 tical fact— that when the placenta, in cases of unavoidable hemor- 
 rhage, is once completely detached from its connections with the in- 
 terior of the uterus, the accompanying flooding in general entirely 
 
 ■ See also Velpeau's Traits Complet des Acoouohemens, vol. i. p. 356, and vol. ii. p. 81. 
 2 Traitfi des Maladies des Femmes Grosses, &o., torn. i. p. 534, aphor. 44. 
 8 L'Art des Accouchemens, &o,, p. 395. * Ibid. p. 347. 
 
PLACENTA PREVIA. 623 
 
 ceases, or becomes quite moderate and inconsiderable in quantity. 
 The cases adduced in the Table (Sect. HE.), afford the strongest pos- 
 sible evidence in favor of the truth of this important principle. A 
 slight analysis of them, in reference to this point, will sufficiently 
 demonstrate our proposition. 
 
 From the nature of the Third Division of the Table of Cases, in- 
 cluding, as it does, those instances in which the expulsion of the 
 placenta was immediately, or almost immediately, followed by the 
 birth of the infant, we can, from this section of our data, expect few 
 or no decided returns in reference to the degree of hemorrhage ex- 
 isting after the total detachment of the placental mass. In the two 
 or three cases, however, of this division, in which the complete de- 
 tachment of the organ occurred some time before its complete expul- 
 sion, the attendant hemorrhage was observed immediately to cease. 
 Thus, in reference to two instances (E^os. 95 and 96), which occurred 
 in the practice of Mr. Easton of Glasgow, it is stated in the notes of 
 them with which I have been favored, that though in both the pla^ 
 centa was only expelled immediately before the child, yet it had 
 been previously separated — in one above an hour — and in the other 
 for several hours, and in neither of the mothers did any hemorrhage 
 occur after the placenta was wholly detached from the uterine sur- 
 face. In both instances the placentae were originally affixed close 
 to the 08 uteri — ^but not over it — and were detached early in the labor. 
 
 In the 111 remaining instances, the facts in regard to the existence 
 or non-existence of hemorrhage during the interval between the de- 
 tachment or expulsion of the placenta and the birth of the child 
 stand as follows : In 39 out of the 111 cases, the absence or pre- 
 sence of hemorrhage after the expulsion of the placenta is not stated 
 or alluded to by the reporters ; but it is evident from the other cir- 
 cumstances which they describe, that in most of these cases there 
 could have been no serious, if indeed any, extent of flooding, be- 
 cause the woman was allowed to remain undelivered, in many of 
 them, for a considerable time after the placenta was separated — a 
 state of matters which would not have been permitted if there had 
 been any degree of discharge calling for the immediate delivery of 
 the patient. Three out of these 39 mothers died — one from puer- 
 peral fever (Table, ~So. 4) ; a second (ISTo. 137), apparently from 
 post-partum hemorrhage ; — the cause of death in the other case (Ko. 
 104) is not stated. 
 
 In 70 of the 111 cases, the existence and degree of hemorrhage, 
 after the complete separation of the placenta, is distinctly stated, 
 and may be tabulated as follows : 
 
624 
 
 
 
 COMPLEX 
 
 LABOK. 
 
 In 44 
 
 3ases the 
 
 hemorrhage 
 
 was completely arrested. 
 
 10 
 
 u 
 
 (1 
 
 (' 
 
 very slight, or almost none. 
 
 
 (C 
 
 (C 
 
 (C 
 
 inconsiderable. 
 
 
 a 
 
 « 
 
 
 ceased. 
 
 
 tc 
 
 u 
 
 (C 
 
 much diminished. 
 
 
 a 
 
 (( 
 
 ({ 
 
 considerable. 
 
 
 u 
 
 (( 
 
 (( 
 
 " a good deal." 
 
 5 
 
 It 
 
 (1 
 
 tc 
 
 profuse. 
 
 Total, 70 
 
 
 
 
 
 It thus appears, that after the complete detachment of the pla- 
 centa, the hemorrhage was totally arrested in a large majority of 
 the eases ; that it was not alarming in its extent in a great pro- 
 portion of the remaining instances ; and that in 5 only out of the 
 70 — or rather in 5 only out of the 111 labors — did it continue so 
 profase under the circumstances, as to be considered alarming by 
 the attendant, or in such excess as to require special notice in their 
 reports. 
 
 Hence in 1 only out of every 22 labors does there appear to have 
 been a continuance of hemorrhage to a great or profuse degree after 
 the placenta was detached. One of the five mothers died (see Dr. 
 Fraser's case in Section VI.) The other four all recovered. 
 
 But it may be proper to consider more at length the five cases in 
 which the hemorrhage is stated to have gone on to a profuse ex- 
 tent, after the separation of the placenta, in order to judge better 
 of the circumstances which may lead to its continuance in other 
 instances. 
 
 First of all, however, it seems necessary to remark, in regard to 
 the alleged continuance of the hemorrhage after the entire separa- 
 tion of the placenta, that the observation itself — simple and easy as 
 it may appear — is one which is most undoubtedly liable to several 
 sources of fallacy. Some of the authors who have described cases 
 of expulsion of the placenta before the child, and not a few of the 
 medical gentlemen who have communicated to me instances of the 
 kind, have expressed the surprise which they felt at the fiooding 
 suddenly ceasing, upon the separation of the placental mass, in con- 
 tradistinction to what their preconceived opinions had led them to 
 expect. Any degree of incaution in the observation of the case might 
 thus easily lead the medical attendant to suppose, that the blood 
 effused externally, or lying in the vagina, was the result of the con- 
 tinuance of the hemorrhage subsequently to the total disjunction of 
 the placenta, whilst in reality it might have been the result of the 
 degree of flooding existing antecedently to that event, that is, whilst 
 the placenta was still only partially detached. The blood already 
 discharged might, in other words, be readily mistaken for blood in 
 
PLACENTA PREVIA. 625 
 
 the act of being discliarged. I am the more inclined to insist upon 
 this source of error, in consequence of the strong fact, that out of 
 all the First Division of cases in our Table — forty-seven in number 
 — ^where there was a long interval between the expulsion of the pla- 
 centa and the birth of the child, and, consequently, ample time 
 allowed to confirm or correct any observation upon the degree of 
 existing hemorrhage, in not one single instance is the flooding after 
 the complete placental detachment alleged to have been profuse, or 
 even considerable in its extent. Again, if there had been going on 
 any internal accumulation of blood in the uterine cavity, or rather 
 between the membranes and the uterus, during the period of the 
 partial separation of the placenta, and before its complete detach- 
 ment, the escape of this blood after the expulsion of the placenta 
 might lead to the same error. Another occasional source of fallacy 
 may consist in this, that the membranes may become ruptured by 
 the same pain which expels the placenta through the os uteri or 
 vagina, or they may burst during a subsequent uterine contraction, 
 and the sudden gush of escaping liquor amnii, when mixed with the 
 efiused blood, might be readily mistaken for a pure hemorrhagic 
 discharge. 
 
 Of the five cases in which the hemorrhage is alleged to have con- 
 tinued to a considerable or great degree after the detachment of the 
 placenta, one affords an illustration of this last remark. I quote it 
 fi-om Lamotte. 
 
 Case IX. — Hemorrhage, with the placenta expelled from the vagina ; 
 excessive discharge; turning ; infant and mother recovered. — Lamotte 
 was summoned to a woman who had been in labor from the previous 
 day, and who had been losing blood for about two hours. " I went 
 immediately," to adopt his own narrative, "though it was a good 
 league (grande lieue) out of town. As I entered the court, several 
 women came out with frightful shrieks, indicating to me, better 
 than they could tell me, the extreme danger of my poor patient. I 
 instantly descended from my horse, and hurried to where she was. 
 I found that the after-birth had just been pushed out of the vagina 
 by the last pain, and the discharge of blood had come in such abun- 
 dance, as to have imparted that terrible fright to the bystanders, that 
 had made them utter this piercing cry. I hastened to pull away the 
 after-birth, glided my hand into the uterus, seized the feet of the 
 infant, drew them into the passage, and accomplished the delivery 
 in an instant. The infant was sufficiently alive to be baptized, but 
 died soon after. The mother recovered in a sufficiently brief period, 
 notwithstanding the fearful loss of blood." In some remarks which 
 Lamotte offers upon this case, he observes, that he judged the mem- 
 
 VOL. I. 40 
 
626 COMPLEX LABOR. 
 
 branes to have been entire from the surprising evacuation that fol- 
 lowed the placenta when he drew it out, and which could not have 
 been all blood, as it came away with much greater violence than it 
 did previously, and the woman could not have borne the loss of such 
 a quantity of blood without sinking. "But I am persuaded," he 
 adds, " that the waters escaping from the membranes in which they 
 were contained, became mixed with the blood -effused from the 
 vessels, the midwife having informed me, that the waters were ready 
 to burst, when the accident (the expulsion of the placenta) happened, 
 and they flowed out from my tearing the bag, in separating the 
 placenta."' 
 
 In the above case of Lamotte's, the evidence of a continuance of 
 true hemorrhage after the detachment of the placenta is by no means 
 decisive ; but we have placed it' in that category in order to avoid 
 the fear of error. The continuance of hemorrhage under the same 
 circumstances is probably better marked in the four following 
 cases. For the first two I am indebted to Dr. "Wilson of Glasgow, 
 in whose practice they occurred. I shall give them in his own 
 words. 
 
 Case X. — Expulsion of placenta ; hemorrhage; turning. — " Mai/ 7, 
 1821. — Mrs. Gr., the mother of a large family, was seized, near the 
 termination of pregnancy, with profuse flooding. Dr. M. was sent 
 for. He found the placenta presenting ; it very soon came away, 
 the discharge continuing. I was called in, and such was the 
 profusion of the discharge and state of exhaustion, that turning 
 was instantly resorted to. The child was dead — there was no 
 discharge after delivery. The recovery was tedious, but at length 
 complete."'' 
 
 Case XI. — Placenta lying with its fcetal surface over the os uteri; 
 hemorrhage ; turning. — " April 17, 1833. This evening I was sent 
 
 for by Dr. Cunningham to see Mrs. , Portugal Street, who was 
 
 flooding, and had been for several hours. The placenta was found 
 lying loose over the os uteri, vsdth the foetal surface downward ; the 
 finger at once touched the origin of the umbilical cord. The pla- 
 centa was turned aside, the feet laid hold of, and a dead child ex- 
 tracted. She made a good recovery."^ 
 
 This last case is, so far as I know, unique, in the circumstance of 
 the placenta being found quite inverted over the os uteri, or with 
 its fcetal, instead of its maternal surface, lying in contact with that 
 part. It may probably so far be regarded as a proof that in this in- 
 stance there was a cause for the hemorrhage continuing, in a most 
 
 ' Table, No. no. « Table, No. 128. » Table, No. 129. 
 
PLACENTA PREVIA. 627 
 
 unusual and extreme degree of atony or relaxation of the uterus — 
 a state whicli would seem necessary in order to admit of the possi- 
 bility of the inversion of the placental mass. In the two following 
 eases of Mr. Barlow and Mr. Bailey, we have the hemorrhage persist- 
 ing under different conditions, viz., the patient being in the upright 
 posture at the moment of the separation and expulsion of the pla- 
 centa ; and besides, having in the first of them that disposition of 
 the uterus, whatever its special nature may be, which gives rise to 
 post-partum hemorrhage. 
 
 Case XTT. — Expulsion of the placenta preceding the delivery of the 
 child; hemorrhage both after the expulsion and delivery. — A woman in 
 the last month of her second pregnancy suffered from uterine pains 
 and a slight discharge of blood at intervals. The hemorrhage ceased 
 when the horizontal position, &c., were adopted. IText morning 
 Mr. Barlow was summoned to see her, and found her sitting on a 
 chair in a state of great alarm, a profuse discharge of blood succeed- 
 ing every pain. " On requesting her," he continues, " to be conveyed 
 to bed, she attempted to walk up stairs, and before she could reach 
 the bed, a violent pain seized her, which instantly expelled the pla- 
 centa, and disparted the funis about six inches from the child's 
 navel. A great effusion of blood followed, and the woman fainted 
 ere she could be laid down on the bed." Mr. Barlow passed up his 
 hand into the uterus, found the os uteri in a lax and dilated state, 
 with the shoulder presenting, laid hold of the feet, and accomplished 
 the delivery of the child, by turning, in a few minutes. " The child 
 appeared feeble, but soon recovered on being placed in a warm bath. 
 A considerable hemorrhage," he adds, "followed the birth ; on per- 
 ceiving which, I returned my hand into the uterus, and by keeping 
 it moving therein for a time, its contractions were renewed, and the 
 hand was then withdrawn, and the flooding abated, and though the 
 woman appeared much reduced through the loss of blood, she soon 
 recovered."' 
 
 Case X in . — Unavoidable hemorrhage supervening during exertion ; 
 sudden expulsion of the placenta ; mother and child saved. — The case 
 occurred to Mr. Bailey of Thetford. A woman, aged 32, three 
 weeks before the time of her expected fourth confinement, when 
 exerting herself by washing, &c., was seized with a sudden and 
 violent flooding, accompanied by an extreme degree of bearing 
 down, which, to make use of her own expression, felt "as if the 
 head of the child was in the birth." In the act of stepping upon 
 the bed, she was taken with a pain, during which the placenta was 
 
 ■ Table, No. 56. 
 
628 COMPLEX LABOB. 
 
 forcibly expelled, and was suspended between the tbigbs by the 
 fanis. At this moment a deluge of blood followed, and she sunk 
 down senseless upon the bed, to all appearance dead, the pulse being 
 imperceptible, and the skin covered with a cold clammy sweat. 
 The OS uteri was found to be completely dilated, the passages were 
 well relaxed, and the head presented in the first position. Turning 
 was adopted and easily accomplished. During the operation,^ " the 
 hemorrhage was alarming, and large coagula were present in the 
 uterus, which were expelled as soon as the child was born. When 
 the uterus was excited to contraction, the hemorrhage ceased. The 
 child at first appeared to be still-born, but was restored by the proper 
 means. Both the mother and the infant did well."^ 
 
 In relation to the last two cases of alleged hemorrhage after the pla- 
 centa was totally separated, it deserves to be specially held in view 
 that, as already alluded to, in both cases the patients at the time at 
 which the placenta was detached, were in the upright position — a 
 circumstance which is well known to be a very certain cause of post- 
 partum hemorrhage when there is any tendency to that condition ; 
 in both patients the cervix uteri was very relaxed, the introduction 
 of the hand in the operation of turning being performed with great 
 ease ; in both, the complete separation of the placenta must have 
 occurred a very short time before delivery, as each of the children 
 was born alive ; and in the last patient (Mr. Bailey's), the discharge 
 of blood which took place after the expulsion of the placenta, must 
 have been to some extent the result of a previous internal accumu- 
 lation occurring during the partial separation of the placental mass, 
 as the blood itself had had time to coagulate. This internal hemor- 
 rhage and accumulation of blood probably occurred also in the re- 
 maining case upon our list of hemorrhage after the complete sepa- 
 ration. For the details of it, see Dr. Eraser's case in the next 
 section and the remarks upon it. 
 
 That the extent of the hemorrhage has no direct relation to the 
 extent of the interval between the expulsion of the placenta and 
 the delivery of the child is amply attested by the following facts : 
 All the reputed instances of hemorrhage after the complete detach- 
 ment of the placenta, have occurred in cases where the interval 
 between the birth of the placenta and that of the child, was short 
 and uncertain ; or, in other words, among the patients included in 
 the Second and Fourth Divisions of the General Table. Among 
 the cases belonging to the First Division of the Table, in which the 
 interval between the detachment of the placenta and the delivery 
 of the child was longer, and varied from ten minutes to ten hours, 
 and where, consequently, there was more time to observe any degree 
 
 • Table, No. 102. 
 
PLACENTA VRMYIA. 
 
 629 
 
 of flooding that miglit exist, in not a single instance was the hemor- 
 rhage observed to he great, or even considerable in extent. On the con- 
 trary, in one only of the forty-seven cases belonging to this division, 
 was it in any unusual degree ;' in nine, it is reported as " almost 
 none," "trifling," or "slight," or "very slight;" and in twenty- 
 three cases it was totally and completely arrested. In nine, the 
 degree of it, if any, is not stated. 
 
 I shall have occasion to revert to the practical bearing and im- 
 portance of these facts in a future section of the essay. 
 
 Section VI. — Comparative Mortality in Placenta Previa, from 
 Turning, etc, and from Expulsion or Extraction of the Pla- 
 centa : Ten Fatal Cases after Spontaneous Expulsion : De- 
 tails of each Case ; Seven of them Independent of the Sepa- 
 ration of the Placenta: II^^ature of the Three remaining 
 Cases. 
 
 In common cases of placental presentation we have already found, 
 from ample statistical data, that the average mortality to the mother 
 is about 1 in 3 (see Section I.) Among the 141 cases of expulsion 
 and extraction of the placenta, which we have collated into the 
 Table (Sect. HI.), 10 mothers died, or the average mortality to the 
 mother was 1 in 14. The difference between the two sets of cases, 
 namely, 1st. Those terminated according to the present recognized 
 rules of midwifery ; and 2d. Those terminated by the spontaneous 
 expulsion or extraction of the placenta — is sufficiently striking when 
 thus simply stated. The contrast may be more easily appreciated 
 if we tabulate the results in the following manner : 
 
 Mode of Management. 
 
 Cases treated by extracting the ] 
 cJiild before the placenta, tup- , 
 ture of the membranes, &c.' J 
 
 Cases in which the placenta was 1 
 expelled or removed before ! 
 the child, ; 
 
 Number of 'Sf?!'" f Proportion of 
 naBo« Maternal Maternal 
 
 *^'''- Deaths. Deaths. 
 
 654» 
 
 141 
 
 10 
 
 1 in 14 
 
 The evidence in favor of the safety of the termination of such 
 cases by the expulsion or extraction of the placenta before the child, 
 will become still more striking if we turn our attention specially to 
 
 ' Case 43. The patient lost 8 lbs. of blood in three days, and " about a pound" after the 
 expulsion of the placenta. 
 
 2 We have here substituted the corrected statistics, as given in the previous table, p. 
 601.— (Ed.) 
 
630 COMPLEX LABOK. 
 
 the ten fatal cases themselves ; for we shall find that the fatal result 
 in few, if any, of these cases, can be directly traced and ascribed to 
 the circumstance of the placenta being completely separated, or to 
 any possible consequence arising from that separation. An exami- 
 nation of these ten fatal cases in detail will sufficiently prove this 
 remark. 
 
 Four of the ten mothers died several days subsequently to deli- 
 very. I shall first describe these four cases, so far as I have notes 
 of them, to show more clearly the immediate cause of death in 
 each. 
 
 Case XIV. — Placenta expelled an hour before the child; patient 
 died on 10th day, after having been up, and exposed to excitement 
 and injury, on the ^th. — The case occurred in the practice of Mr. 
 Hay of Glasgow. It was a first pregnancy, and the patient had 
 arrived at the full period. Before the separation of the placenta, 
 the hemorrhage was excessive, and she was quite sunk and ex- 
 hausted. Very little blood was lost after the placenta had come 
 away, though the infant was not born for an hour. It was expelled 
 by the natural pains, and was still-born. The following is Mr. 
 Hay's note on the case : "This patient seemed to sink from excite- 
 ment. She and her husband quarrelled on the 9th day after the 
 birth of the child, and on the 10th she died." Dr. Smith of Glas- 
 gow,* who has reported this, with various other cases to me, states 
 more explicitly, that " she left her bed and fought with her husband 
 till perfectly exhausted, from which state she never recovered."^ 
 
 The fatal result in this case does not require a word of comment ; 
 the fact of the woman being able to leave her bed, and to act in the 
 way described, is sufficient proof that she was in a fair way of re- 
 covery, and that she would in all likelihood have done well, had it 
 not been for her own indiscretion. In the instance which I have 
 next to quote, the fatal event is also ascribed by the reporter to im- 
 prudence on the part of the patient, and, at all events, the degree 
 of hemorrhage was such as in no way to endanger her life. 
 
 Case XV. — Spontaneous expulsion of the placenta; little or no hemor- 
 rhage either before or after its separation ; death on the 1th day from 
 ''■purpura alba." — " About 16 years ago, I was called," says Walter,^ 
 "to the assistance of the wife of the former Castellano of thes 
 Royal Academy of Treptow. On arriving, I found her in bed; 
 
 ■ I am happy in having this opportunity of offering my best thanks to Dr. Smith for the 
 very great zeal and kindness with which he has assisted me in Glasgow, in the collection 
 of cases for the present memoir. 2 Table, No. 32. 
 
 ' De Morbis Peritonei et Apoplexi^, Berlin, 1785, p. 33. 
 
PLACENTA PREVIA. 631 
 
 labor had commenced at 4 a.m., seven hours before ; the placenta 
 was already separated, and bad fallen to the ground ; it was still 
 attacbed to tbe infant by the cord. I was astonished at this very 
 rare phenomenon, which at that time I could not explain, as I did 
 not then understand tbe structure of tbe uterus as I now do. As 
 it was a cross-presentation, I had recourse to turning, and within a 
 few moments I delivered tbe woman of a dead child. I can afiirm 
 most positively," the author adds, "that before my arrival, and 
 during tbe labor, tbe woman did not lose above two ounces of 
 blood. She did well till tbe third day, but an improper and con- 
 tentious mode of living {inordinata atque contentiosa vivendi ratio) was 
 tbe cause of her being seized with ^purpura alha,"^ of which she 
 died on tbe 7th day after delivery."^ 
 
 In two of the fatal cases tbe mothers died from puerperal fever or 
 peritonitis. These two instances have been recorded by Dr. Merri- 
 man and M. Mercier, and I shall detail them, as nearly as is con- 
 sistent with brevity, in tbe authors' own words. 
 
 Case XVT. — Placenta expelled long before the child, ^c. — " I was 
 once," Dr. Merriman states,' " consulted by a very carefal and 
 judicious practitioner, respecting a woman, who, when I first saw 
 her, was rapidly sinking under puerperal fever. In this case the 
 placenta was expelled many hours before tbe child was born, and 
 no extraordinary means were used to expedite the delivery of tbe 
 child ; a physician accoucheur, who was consulted upon the occa- 
 sion, having deemed it more prudent to leave the case to nature. 
 The fatal event, however," Dr. Merriman unadvisedly adds, " would 
 lead one to doubt whether it was wise, under such circumstances, to 
 decline tbe interference of art."'' 
 
 Case XVii. — No hemorrhage with the first part of the labor; 
 vomiting; fever ; placenta spontaneously expelled ; child delivered with 
 forceps ; mother died of peritonitis nine days after delivery. — Eor up- 
 wards of two days before Mercier saw the patient, she bad been 
 attended by a midwife, and latterly by a medical man, who, being 
 called in during tbe course of the second day, and finding the 
 woman feverish, had bled her largely. Tbe bleeding bad lessened 
 
 ' Or " miliaria," a disease which, under the old " heating" method of treating puerperal 
 women, was formerly extremely fatal. The Stockholm Academy proposed in ] 769 as a 
 prize question ; " How the different kinds of miliary fever should be prevented and cured, 
 as well in lying-in women as in others." The successful author, Schultz, showed strongly 
 the necessity of adopting a cooling regimen. Dr. Whyte's excellent Essay on Miliary Fever 
 (Treatise on Lying-in Women, pp. 25-55), did much to banish the disease from English 
 practice. ' Table, No. 9. 
 
 5 Synopsis of Difficult Parturition, p. 126. < Table, No. 4. 
 
632 COMPLEX LABOR. 
 
 the pains, which did not return till that evening. The patient had 
 not suffered from any discharge of blood from the uterus, but she 
 felt extremely uneasy ; was not able to rest in bed ; and rejected by 
 vomiting everything that was given to her. About two o'clock on 
 the morning of the third day, while she was walking about with a 
 person supporting her, a strong pain expelled the placenta, which 
 fell to the ground, followed immediately by the escape of the waters. 
 The embarrassment of the midwife was extreme. She divided, 
 however, the cord, and waited the arrival of M. Mercier, whom she 
 had immediately summoned. The pains again ceased, and the 
 woman, having been put to bed, got a little sleep. " The placenta," 
 says M. Mercier, "was shown me, of a small size, and covered with 
 dust. The cord was implanted in its middle, and about half a yard 
 of it was attached. Only a few spoonfuls of blood had been lost in 
 addition to the small quantity that had escaped from the cord when 
 it was divided." In consequence of it being impossible to excite 
 the uterus to sufficient action, it became necessary to terminate the 
 labor by the forceps. This was accomplished easily. The child did 
 not appear to be at the full time. Its extraction was followed with 
 a very moderate effusion of blood, which scarcely penetrated a cloth 
 folded four times. " This small quantity," observes Mercier, "joined 
 to what had accompanied the falling of the placenta, did not exceed 
 the loss of blood in ordinary labors."' An hour ahev delivery 
 there was sanguinolent oozing, which soon ceased. Subsequently, 
 however, the woman was attacked with peritonitis, and died of this 
 affection nine days after delivery.^ 
 
 Besides the four instances of death which we have just described, 
 at periods more or less distant from delivery, two others of the ten 
 fatal cases occurred within a very short time after the birth of the 
 infant, and a third (Dr. Eamsbotham's) appears also to come under 
 this head. Yet, as will appear from the details which we shall now 
 give, the death in these cases was not apparently in consequence of 
 any hemorrhage or other cause arising from the complete separation 
 of the placenta, the hemorrhage in all of them having ceased when 
 this separation took place. All the three mothers were delivered 
 by operative means. 
 
 Case XVm. — Severe hemorrhage and presentation of the arm; 
 child eviscerated to permit delivery ; placenta detached during the opera- 
 tion ; no hemorrhage from its detachment ; mother died. — The case 
 occurred in the practice of Dr. Eamsbotham, to whose kindness I 
 am indebted for the following details. On December 24, 1839, Dr. 
 Eamsbotham was called to see Mrs. E., who was gone 6 J months in 
 
 > Journal Anoien de M^decine, torn. xlv. " Table, No. 138. 
 
PLACENTA PREVIA. 633 
 
 her second pregnancy. She was in a state of exliaustion from 
 severe hemorrhage, having lost about two quarts of blood. " The 
 previous attendant," to give Dr. Ramsbotham's own words, " rup- 
 tured the membranes at 7 or 8 a. m., after which there was no 
 further hemorrhage. The arm now came down, which he took off. 
 I delivered her with great difficulty, owing to the undeveloped state 
 of the cervix, at 4J p. m. I could not get the hand into the uterus, 
 but managed to perforate the chest by a blunt hook, and to extract 
 many of the viscera. In trying to perforate the chest, I hooked 
 down the placenta, a part of which was hanging loose in the vagina ; 
 still there was no flooding."^ 
 
 Case XIX. — Profuse and exhausting hemorrhage, terminated by 
 expulsion of the placenta ; turning ; immediate death. — The woman 
 was a patient of Mr. "Wood's of Manchester. She had borne five 
 children previously, and had reached the eighth month of her sixth 
 pregnancy. The hemorrhage was very profuse previous to the 
 expulsion of the placenta, and had caused great exhaustion ; after 
 this it completely ceased. Turning was immediately had recourse 
 to, and a dead infant was extracted by the feet. She died imme- 
 diately after her delivery,^ 
 
 Case XX. — Head presentation and unavoidable hemorrhage, placenta 
 completely detached in the operation of turning ; previous exhaustion ; 
 death. — The woman (a patient of Mr. Tindal's of Glasgow) was at 
 the end of her tenth pregnancy. The head of the child presented. 
 There was fearful hemorrhage before the placenta was expelled, but 
 none after. Delivery was effected by turning, a few minutes after 
 the escape of the placenta. The mother died in half an hour. " III 
 this case," Dr. Smith observes, in the note which I have received 
 with it, " the patient was exhausted previous to turning, and that 
 operation was adopted to have delivery effected before she died. 
 The placenta was accidentally separated during the course of the 
 operation, and Mr. Tindal was perfectly certain that the hemor- 
 rhage ceased from that moment."^ 
 
 In the three remaining cases of maternal deaths, the fatal occur- 
 rence took place during labor, or immediately subsequent to 
 delivery. Of two of the three cases I have only very imperfect 
 notes, which I give, such as they are, before offering any comment 
 on them. 
 
 Case XXI. — " Flooding with one arm and part of the placenta 
 
 > Table, No. 60. » Table, No. 81. » Table, No. 62. 
 
634 COMPLEX LABOE. 
 
 slipped down below the os uteri internum ;" turning ; post-partum hemor- 
 rhage,- death.— Oetoher the 17th, 1731, about ten o'clock in the 
 morning, Mr. Gifiard was sent for to the wife of a printer, near 
 White Fryars ; " she had been seized," to use his own words, 
 " about an hour before with a violent flooding, and when I came, I 
 found she had lost a large quantity of blood ; and I was told she 
 was in about the seventh month of her reckoning. TJpon touching, 
 I found one arm of the child slipped out beyond the os internum, 
 as also a large part of the placenta ; wherefore, I gave it as my 
 opinion, that she ought to be immediately delivered — letting her 
 husband and others know the great danger she was in. As it was 
 entirely left to my conduct, I immediately passed up my hand, well 
 greased, into the vagina, and so on by the side of the shoulder into 
 the uterus, where I met with the remaining part of the placenta, 
 wholly separated from the uterus. I now passed my hand between 
 the placenta and the body of the child, and soon met with one foot, 
 which I drew out beyond the labia pudendi, and then taking hold 
 of it with a soft cloth, with a little difliculty, I brought out the hip 
 and the body almost to the shoulders, when, finding it stopped at 
 the head, I passed in my hand, and brought down one arm, the 
 other not being slipped up again from its first falling down. I then 
 endeavored to draw out the head, but it would not readily follow ; 
 whereupon I passed up one finger into the child's mouth, and strove, 
 by pressing upon the lower jaw, to bring the face forwards, whilst 
 at the same time I pulled above at the shoulders ; but as it was 
 closely locked between the bones that form the lower part of the 
 pelvis, I had no small trouble in bringing it out ; however, at last 
 I finished the delivery by bringing away the placenta, which, being 
 before loosened from every part of the uterus, readily followed. I 
 was then in hopes we had surmounted our greatest difficulties, and 
 that the flooding would have stopped ; but, to my great surprise, 
 she continued still draining. I therefore again gently passed up my 
 hand, believing that either some part of the placenta was torn off 
 and left, or else that some coagulated blood kept the womb dis- 
 tended ; but I could not meet with any part of the placenta, or any 
 clots of blood. I then ordered cloths dipped in vinegar to be 
 applied close to the parts, and what else I thought necessary, yet, 
 notwithstanding all my endeavors to save her, amisit cum sanguine 
 vitam."^ 
 
 Case XXII. — Unavoidable hemorrhage, with apparent hydrothqrax 
 and cardiac disease ; death speedily after the expulsion of the placenta ; 
 living child subsequently extracted. — The case occurred to Dr. Fraser 
 of Aberdeen. It was the patient's sixth pregnancy. Labor came 
 
 » Table, No. 137. 
 
PLACENTA PREVIA. 
 
 635 
 
 on at the eightli month. Very moderate hemorrhage had been 
 going on for two hours, when the placenta became very extensively 
 detached by one uterine contraction, and the mass of it was found 
 lying in the vagina. " The accompanying hemorrhage," Dr. Fraser 
 states, " was great^ and, without convulsions, she expired in two 
 minutes." A few minutes afterwards. Dr. Fraser passed his hand 
 into the uterus, and extracted the child alive. "A post-mortem 
 examination," Dr. Fraser adds, "was not allowed, but from a com- 
 bination of marked symptoms, I have a strong conviction that she 
 labored under hydrothorax, depending on a diseased state of the 
 heart."! 
 
 Case X^ III. — Fatal detachment of the placenta. — ^In speaking of 
 the complete separation of the placenta in unavoidable hemorrhage. 
 Dr. Collins states, " Dr. Clarke informed me, that he had met with 
 one case of total separation ; the patient was dying before he reached 
 the house."^ By a private note from Dr. Collins, I am informed 
 that he knows no more of the case than what is stated in the above 
 sentence, and that in consequence of Dr. Clarke's death, it is now 
 impossible to obtain more details.' 
 
 general remarks on the ten fatal cases. 
 
 In all the first seven of the preceding fatal cases, the separation of 
 the placenta, or the degree of hemorrhage after its detachment, had 
 evidently little or no connection with the death of the mothers. In 
 the first case, No. XIV. (Mr. Hay's), the blood lost during the hour 
 that elapsed between the expulsion of the placenta and birth of the 
 child, is averred to have been " very little ;" in the second case 
 (Walter's), not more than two ounces of blood escaped in all during 
 the whole labor; in the third case (Dr. Merriman's), the hemor- 
 rhage, after the expulsion of the placenta, was, in all probability, 
 inconsiderable, or altogether arrested, as it was not deemed neces- 
 sary to expedite delivery, though the placenta was thrown off several 
 hours before the infant was born ; in the fourth case, the narrator 
 (Mercier) distinctly attests, that the whole loss of blood was not 
 greater than with an ordinary labor ; in the fifth case, there was, to 
 use Dr. Kamsbotham's own expression, " no fiooding" after the pla- 
 centa was detached, and there had been none for some time pre- 
 viously ; in the sixth case (Mr. "Wood's), the hemorrhage completely 
 ceased after the total separation of the placenta ; and in the seventh 
 case (Mr. Tindal's) the same fact was observed. In these two last 
 cases, though both patients sunk principally from the effects of 
 
 ' Table, No. 49. ' Practical Treatise on Midwifery, p. 91. ' Table, No. 105. 
 
636 COMPLEX LABOR. 
 
 hemorrhage, yet in both of them that hemorrhage had occurred 
 9,ntecedently to the detachment of the placenta; the mischief, in so 
 far as the flooding was concerned, was done before that detachment 
 took place ; in neither of them did the peculiarity of the complete 
 separation of the placenta occur until the case was already so far 
 hopeless, from the antecedent discharge, and, indeed, so far from 
 being injurious, the separation of the placental mass would, on the 
 very contrary, by its immediately arresting flooding, seem to have 
 been salutary, though unfortunately in each too late to save. 
 
 On the other hand, there occurred, in the course of these seven 
 fatal cases, circumstances and complications amply adequate to 
 account for the deaths of the mothers, quite independently of the 
 separation of the placenta, or of any flooding or other possible acci- 
 dent connected with that separation. In Mr. Hay's case, the patient's 
 death was evidently the result of the strong excitement and injuries 
 to which she was subjected on the ninth day after delivery. Walter, 
 as we have seen, attributes the attack of the disease (" purpura alba," 
 or miliary fever), of which his patient died, to her own indiscretion. 
 In Dr. Merriman's and Mercier's cases, puerperal fever and perito- 
 nitis were the causes of the fatal issue — a disease that too often oc- 
 curs, independently of any morbid complication whatever, during 
 labor. Mercier's patient had, though there was no accompanying 
 flooding, become so exhausted, and the expulsive powers so ineffi- 
 cient, by the time he saw her, that instrumental delivery was deemed 
 necessary. In Dr. Ramsbotham's case (an arm presentation), the 
 child was delivered by evisceration of the chest and abdomen, an 
 operation in itself sufficiently dangerous, and never employed except 
 when even turning is impossible ; and, in the present instance, it 
 had its difficulties much enhanced by the rigid state of the os uteri. 
 Lastly, in Mr. Tindal's and Mr. Wood's cases, extraction of the 
 infants by version was had recourse to, at a time when the mothers 
 were already greatly exhausted, and little able to withstand the 
 additional shock of such an operation. Thus, in two of the fatal 
 cases (Mr. Hay's and Dr. Merriman's), the delivery was efiected by 
 the natural pains ; and the cause of death in each was apparently 
 independent of any circumstances connected with the detachment 
 of the placenta. In five of the cases (Walter's, Mercier's, Dr. Rams- 
 botham's, Mr. Tindal's, and Mr. Wood's), the delivery was accom- 
 plished by such operative means as are in themselves always more 
 or less perilous to the life of the mother, particularly when, as in 
 some of them, she had already become prostrated and exhausted by 
 the time they were adopted. 
 
 For the above reasons we are, I believe, quite entitled to reject, in 
 regard to the first seven fatal cases, the idea of the death of the 
 
PLACENTA PRiEVIA. 637 
 
 mothers being caused by the, total separation of the placenta, or by 
 its mediate or immediate consequences. 
 
 If this be granted — and we subtract on this ground the first seven 
 fatal cases — we have only, out of 141 deliveries, three maternal 
 deaths left, which can be at all ascribable, directly or indirectly, to 
 the complete detachment of the placenta, and its results. This 
 would give a mortality of only one in about every forty-seven 
 mothers from this complication during labor, in placental presenta- 
 tions ; a proportion which, it must be confessed, is surprisingly 
 small. 
 
 But it seems, indeed, even more than doubtful, whether all the 
 three remaining fatal cases (Mr. Giffard's, Dr. Fraser's, and Dr. 
 Clarke's), should be allowed to have been instances in which the 
 death of the mothers was attributable simply to complete separation 
 of the placenta, and its efieets. 
 
 Mr. Giffard's patient died, if we may judge from his own account, 
 of post-partum hemorrhage — a complication which is known to be 
 a special source of danger to the mother after placental presenta- 
 tions, under all modes of management.' The hemorrhage was here 
 probably the result of the injury and laceration of the vascular and 
 imperfectly dilated neck of the uterus, in consequence of the force 
 employed in the operation of the extraction of the shoulders and 
 head of the infant. This view would seem to be so far corroborated 
 by the fact, that the post-partum discharge was not connected with 
 the presence of any clots of blood in the uterus, and hence, was not 
 the effect of atony of the body or fundus of the organ. At all 
 events, the fatal hemorrhage was not, in Mr. Giffard's patient, in any 
 apparent way, dependent upon the previous complete detachment of 
 the placenta during the labor ; and henc8, we might probably be 
 entitled to remove this case also, like the preceding seven, from the 
 list of those in which the death of the mother could be attributed to 
 the contingent separation and expulsion of the placenta. 
 
 In Dr. Fraser's case, the chest affection may have had a principal 
 share in the sudden demise of the patient — the presence of heart 
 disease (supposing such existed) predisposing, as is well known, the 
 subjects of it to be greatly, and, in some instances, fatally, affected 
 by any rapid losses of blood, and occasionally leading, as I have 
 known in two instances, to sudden death, from the shock of the 
 delivery, when the labor was in other respects quite natural. I 
 
 ' See on this topic Dr. Hamilton's Practical Observations, second edition, p. 329. In 
 speaking of placenta prsevia, he states, in reference to flooding from the ruptured vessels of 
 the neck of the uterus (the body and fundus of the organ being contracted), that for many 
 years past he has been led to " dread this danger in every case where he has been obliged 
 to force delivery in consequence of uterine hemorrhage." 
 
638 COMPLEX LABOR. 
 
 would add, that the details wWcli I have obtained through Dr. 
 Eraser's kindness are not by any means perfectly decisive, as to the 
 whole placenta being completely detached in this instance. The 
 same remark may apply to the other remaining case of Dr. Clarke ; 
 if we may judge from the little information that we do possess in 
 reference to it, and contrasting it with the results ascertained in 
 other well-observed instances. The account of Dr. Clarke's patient 
 is so brief and defective, as to furnish us with no data whatever as 
 to the extent and nature of the accompanying hemorrhage, the ex- 
 istence or non-existence of any other complication, the delivery or 
 not of the child, or the immediate cause of the fatal event to the 
 mother. 
 
 SUMMARY OF RESULTS. 
 
 Our inquiry, so far as we have hitherto proceeded, seems legiti- 
 mately to admit of the following deductions. 
 
 1. The complete separation and expulsion of the placenta before 
 the child, in cases of unavoidable hemorrhage, is not so rare an oc- 
 currence as accoucheurs appear generally to believe. 
 
 2. It is not by any means so serious and dangerous a complication 
 as might a priori be supposed. 
 
 3. In nineteen out of twenty cases in which it has happened, the 
 attendant hemorrhage has either been at once altogether arrested, 
 or it has become so much diminished as not to be afterwards 
 alarming. 
 
 4. The presence or absence of flooding after the complete separa- 
 tion of the placenta, does not seem in any degree to be regulated 
 by the duration of time intervening between the detachment of the 
 placenta and the birth of the child. 
 
 5. In ten out of one hundred and forty-one cases, or in one out 
 of fourteen, the mother died after the complete expulsion or extrac- 
 tion of the placenta before the child. 
 
 6. In seven or eight out of these ten casualties, the death of the 
 mother seems to have had no connection with the complete detach- 
 ment of the placenta, or with results arising directly from it, and if 
 we do admit the three remaining cases, which are doubtful, as lead- 
 ing by this occurrence to a fatal termination, they would still only 
 constitute a mortality from this complication, of three in one hun- 
 dred and forty-one, or of about 1 in 47 cases. 
 
 7. On the other hand, under the present established rules of prac- 
 tice, one hundred and eighty mothers died in six hundred and fifty- 
 four placental presentations, or nearly one in three.' 
 
 ' See corrected table, p. 601. — (Ed.) 
 
PLACENTA PRiEVIA. 639 
 
 Section VII. — ^Mechanism by which Hemorehagb is prevented 
 
 AFTER THE COMPLETE DETACHMENT OF THE PlACENTA ; SOTJRCE 
 
 OF THE Discharge in Partial Detachments of the Placenta ; 
 Means bt which the Hemorrhage is arrested in Placental 
 Presentations when the Detachment is partial: and when 
 
 IT IS COMPLETE ; ANALOGOUS CaSES IN TwiN LABORS ; ANALOGOUS 
 
 Phenomena in the Third Stage of Common Labor ; Modes by 
 WHICH Hemorrhage is prevented from xhb Vascular Orifices 
 
 LEFT exposed ON THE INTERIOR OF THE UtKRUS. 
 
 In his Outlines of Midwifery, Professor A. Hamilton, after laying 
 down the necessity of turning in placental presentations, observes, 
 " In some instances, before the orificium uteri can be sufficiently 
 opened to admit the hand of the operator to pass, the whole cake 
 will actually be disengaged and protruded ; but," he adds, " the 
 separation and expulsion of the placenta previous to the birth of 
 the child is, for the most part, fatal to the mother."^ 
 
 "If the placenta," says Petit, when speaking of unavoidable 
 hemorrhage, " is entirely separated, the death of both the mother 
 and child is certain."^ 
 
 " When the placental mass is thus expelled before the child, the 
 hemorrhage," observes Carus, " must necessarily be so considerable, 
 that both child and mother usually become a prey to death (eine 
 Beute des Todes.)"* 
 
 These three quotations express what seems to be the general 
 opinion of medical men in regard to the complication which we are 
 considering. I have already, however, taken occasion to show that 
 the very reverse of the above statements is more consonant with 
 fact and experience, and that the complete disjunction and expulsion 
 of the placenta before the child is an accident neither very fatal to 
 the mother, nor very frequently followed by any great or perilous 
 degree of hemorrhage. Let us now inquire if we can explain the 
 mechanism by which it happens, that generally, after the complete 
 separation of the placenta from the uterus has occurred, not only 
 does no considerable degree of hemorrhage supervene, but the pre- 
 ceding and sometimes violent discharge is at once arrested, and thus 
 the life of the mother preserved against the impending danger of 
 
 ' This part and the following were piinted and privately distributed several years since, 
 but have not hitherto been published. — (Ed.) 
 
 ' Outlines of Midwifery, p. 44. ' Trait6 des Maladies des Femtnes, &c., torn. ii. p. 22. 
 * Lehrbuch der Gyntecologie, torn, ii, p. 44Q. 
 
640 COMPLEX LABOR. 
 
 frightful and fatal flooding. The investigation will, I believe, lead 
 us to entertain more decided views, with regard to the propriety of 
 the practice to which our present Essay points. 
 
 The explanation that would occur to most minds, on first think- 
 ing of the probable mode by which nature could arrest and prevent 
 hemorrhage after the total separation of the placenta before the 
 child, is that offered by Drs. Ramsbotham and Campbell. " I think," 
 says Dr. Eamsbotham, " it may be satisfactorily explained how the 
 woman's life is preserved. The head of the child is pushed down 
 upon the os uteri, which suddenly gives way. Under its relaxation, 
 the placenta is loosed from its previous attachment, and falls down 
 before the head, which now comes into immediate contact with the 
 bleeding vessels, and by mechanical compression closes their mouths ; 
 from this moment, therefore, the loss of blood is suspended, and 
 the head is afterwards expelled by uterine action."' Dr. Rams- 
 botham here imagines that the head of the infant acts in such cases, 
 as a compress or plug upon the open uterine orifices left by the 
 separation of the placenta from the interior of the cervix. 
 
 "It may," remarks Dr. Campbell, "be presumed, that in these 
 cases the fatal event must have been prevented by the quick descent, 
 and consequent pressure, of the body of the child, upon the point 
 whence the placenta had been detached."^ 
 
 That the above opinion' of Drs. Ramsbotham and Campbell does 
 not afford the correct explanation of the cessation of hemorrhage 
 after the complete detachment of the placenta, appears to me to be 
 evident from the following facts : 1st. That in some of those few 
 instances in which the hemorrhage continued after the total separa- 
 tion of the placenta, the infant's head did present, but did not pro- 
 duce the result here attributed to it (see for instance Mr. Bailey's 
 case. Sect. V.) ; and, 2d. On the other hand, in a considerable 
 number of the instances that we have collected, and in which the 
 placenta was entirely detached and expelled before the child, the 
 hemorrhage totally ceased, although the portion of the child that 
 presented against the cervix uteri was not the head, nor indeed any 
 such part as could produce the required degree of pressure upon 
 the open uterine orifices. 
 
 In two of the instances which I have myself seen, and already 
 
 " Observations in Midwifery, part ii. pp. 191, 192. 2 System of Midwifery, p. 369. 
 
 ' Since the above was written, I find that Dr. Radford of Manchester has published the 
 same opinion regarding the suppression of the hemorrhage as Drs. Ramsbotham and Camp- 
 bell entertain. " On a complete separation of the placenta," he remarks, " the hemorrhage 
 is immediately and completely suppressed, provided the uterus is in a condition to so far 
 contract, as to force down the head, with the placenta, upon the uterine openings." — Pro- 
 vincial Medical and Surgical Journal for January 22, 1845. 
 
PLACENTA PRMYIA. 
 
 641 
 
 detailed in a previous section (Sect. II.), tlie shoulder and neck pre- 
 sented in one, and the arm of the child in another- — parts which 
 could not be applied as plugs in the way supposed by Dr. Eams- 
 botham and Dr. Campbell. 
 
 In a considerable proportion of cases collated into our General 
 Table, the child presented preter naturally with the foot, feet, arm, 
 or shoulder. These parts are all of such a form and size, that they 
 could not be applied as compresses, upon the part of the uterus 
 which was exposed by the previous detachment of the placenta, and 
 yet the hemorrhage appears to have been as constantly and as com- 
 pletely arrested in those instances when once the placenta was per- 
 fectly separated, as it was in cases in which the head and breech of 
 the child came afterwards to press upon the cervix uteri. The fol- 
 lowing tabular view will demonstrate this important point, by show- 
 ing the number of instances in which a lower or upper extremity 
 came down after the expulsion of the placenta, and the degree of 
 the hemorrhage that was observed to follow in these cases. 
 
 Degree of Hemorrhage after 
 separation of Placenta in 
 
 Footling 
 Presentations. 
 
 Arm or Shoulder 
 Presentations. 
 
 Total. 
 
 Great, 
 
 Considerable, 
 
 Slight, 
 
 Little or none, 
 
 Not stated, 
 
 It 
 
 2 
 2 
 
 1* 
 
 2 
 8 
 
 7 
 
 1 
 1 
 2 
 10 
 9 
 
 5 
 
 18 
 
 23 
 
 These data prove, that " great" or " considerable" hemorrhage, 
 after the expulsion or detachment of the placenta, is not more liable 
 to occur, when the retained foetus afterwards presents by an upper 
 or lower extremity, than when it comes down with the head or 
 breech upon the exposed surface of the cervix uteri. The pro- 
 portion of cases in which the hemorrhage continues is not greater 
 under the one set of presentations than it is under the others, as 
 may be seen by comparing the present table with that previously 
 given at p. 624. And these observations seem to me to afford amply 
 sufficient grounds for rejecting the idea, that the prevention of the 
 hemorrhage after the complete separation of the placenta is to be 
 explained, by the presenting part of the infant coming down, and 
 acting as a compress upon the exposed orifices of the uterine vessels. 
 It may be an auxiliary, but it is not a primary or essential cause of 
 the suppression of the hemorrhage. For the mechanism of the 
 arrestment of the flooding, in cases in which the placenta happens 
 to be completely detached, and the child left in utero, is, I believe, 
 
 * See the details of this case already given and commented upon at p. 627. 
 ■j- " About a pound." Case 43. See p. 626. 
 TOL. I. 41 
 
642 COMPLEX LABOR. ^ 
 
 of a totally differfent kind. But, in order to understand it, let me 
 first premise, that obstetric pathologists are in all probability incor- 
 rect in the rationale which they currently give of the immediate 
 source of sanguineous discharge, in instances of flooding — whether 
 accidental or unavoidable — from partial separation of the placenta. 
 
 Anatomical source of the Hemorrhage, in Detachment of the Placenta. 
 
 From the time of Gruillemeau downwards, accoucheurs seem to 
 have generally believed, that in cases of unavoidable and accidental 
 hemorrhage, arising from the greater or less separation of the pla- 
 centa, the blood that is eftused escapes from the vascular maternal 
 orifices that are left uncovered, and exposed upon the internal sur- 
 face of the uterus, when the placenta is detached from that surface. 
 Thus Guillemeau, in writing on the subject, states : — " The surest 
 and most proper mode of assisting a woman when the after-birth 
 presents at the passages, is to deliver immediately {delivrer soudaine. 
 ment). This is the more necessary, from there being usually a con- 
 stant fiow of blood, owing to the mouths of the veins that are situated 
 in the walls of the uterus (those, namely, to which the placenta was 
 united) being open, and as the uterus contracts in order to expel the 
 infant, it squeezes out the blood that is contained in these vessels, 
 and which is attracted to them by the heat and pain."' 
 
 Mauriceau entertained precisely similar views. " When flooding," 
 he observes, "happens to a woman truly conceived, at whatsoever 
 time it be, it proceeds likewise from the opening of the vessels of the 
 fund of the womb, caused by some blow, slip, or other hurt, and 
 chiefly because the secundine in such cases, and sometimes in others, 
 is separated in part, if not totally, from the inside of the bottom 
 of the womb, to which it ought to adhere, that it might receive the 
 mother's blood appointed for the infant's nurture, by which separa- 
 tion, it leaves open all the orifices of the vessels where it was joined, and 
 so follows a great flux of blood, which never ceaseth (if so caused) till 
 the woman be brought to bed : For the secundine being once loos- 
 ened, although but part of it, never joins again to the womb to close 
 those vessels, which can never shut till the womb hath voided all 
 that it contained : For then, compressing and closing itself, and, as 
 it were, entering within itself (as it happens presently after delivery), 
 the orifices of the vessels are closed and stopped up by this contrac- 
 tion, whereby also this flooding ceaseth, which always continues as 
 long as the womb is distended by the child, or anything else it con- 
 tains, for the reason aforesaid."^ 
 
 ' Guillemeau, Les Oeuvres de Chirurgie, p. 320. 
 
 2 Mauriceau, Diseases of Women with Child and in Child-bed, p. 87 of Chamberlen's 
 translation. 
 
PLACENTA PREVIA. 643 
 
 In another part of his work Mauriceau again states — " But the 
 coining first of the burden is yet much more dangerous ; for, besides 
 that the children are ordinarily still-born, if they be not assisted in 
 the very instant, the mother likewise is ofben in very great peril of 
 her life, because of her great floodings which usually happen when 
 it is loosened from the womb before its due time, because it leaves all 
 the orifices of the vessels open to which it did cleave, whence flows inces- 
 santly blood, until the child be born."^ 
 
 The opinions expressed in the above quotations from Guillemeau 
 and Mauriceau have been generally adopted by obstetrical authori- 
 ties up to the present time. Thus, the writer of the last work pub- 
 lished upon Midwifery in Great Britain (Dr. Lee of London) states, 
 when discussing the pathology of accidental and unavoidable hemor- 
 rhage^" It is from the great semilunar, valvular-like, venous open- 
 ings in the lining membrane of the uterus, which we have seen in 
 various preparations, and from the arteries which are laid open by 
 the separation of the placenta, that the blood alone flows in uterine 
 hemorrhage."'' 
 
 When the placenta is partially separated from the uterus, there 
 are two surfaces left exposed by that separation, namely, a portion 
 of the internal surface of the uterus, and a portion of the exter- 
 nal surface of the placenta. According to the usual explanation, 
 such as I have above shown it to be, the hemorrhage is supposed 
 to proceed from the first of these exposed surfaces, namely, that 
 of the uterus. On the contrary, I am assuredly of opinion that 
 it chiefly, and, in most instances, entirely, proceeds from the other 
 surface, namely, that of the placenta. I feel quite convinced that 
 the pathological opinion on this point advocated by the late Profes- 
 sor Hamilton is the correct explanation. After citing the opinions 
 of Drs. Eamsbotham, Davis, Dewees, and Ingleby, in reference to 
 the origin of the hemorrhage from the exposed uterine surface in 
 unavoidable and accidental floodings, Dr. Hamilton observes : — 
 " Many other authorities may be quoted to prove the common opinion 
 upon this subject; and yet the author, from the earliest period of his 
 professional life, has been anxious to show, that the hemorrhage in 
 these cases proceeds from the separated portion of the placenta more 
 than from the ruptured uterine vessels."^ 
 
 To understand the true source of the flooding in unavoidable 
 and accidental hemorrhage the cause of the continuance when the 
 separation of the placenta is partial, and the mechanism of its arrest- 
 ment when that separation is complete, we must take into consi- 
 
 ' Mauriceau, Diseases of Women with Child and in Child-bed, pp. 218, 219 of Chamber- 
 len's translation. 
 
 2 Theory and Practice of Midwifery, 1844, p. .361. 
 ' Practical Observations, Second Edition, p. 312. 
 
644 COMPLEX LABOR. 
 
 deration the following dijfferent points -.—First, The maternal por- 
 tion of the placenta is of a cavernous structure ; tha,tis to say it con- 
 sists of a series of maternal vascular cells, or dilatations, or, perhaps, 
 more properly speaking, of one large maternal vascular bag, into v^hich 
 the blood of the mother is conveyed by the utero-placental arteries, 
 and from which it is removed by the utero-placental veins. Secondly, 
 The vascular maternal cells, or immensely dilated capillaries which 
 contain the blood of the mother in the placenta, communicate so 
 freely with each other throughout all the different portions of the 
 organ, that the blood which has access into one part, may in this 
 way be rapidly diffused into the other portions of the placental 
 mass. And, Thirdly, The deciduous or uterine surface of the pla- 
 centa has no vital, muscular or contractile power by which it can 
 constrict the orifices of the vascular tubes which pass from the 
 uterus into it, when these tubes are ruptured in consequence of 
 a greater or less detachment of the organ from the interior of the 
 uterus. 
 
 Cause of the Continuance of the Hemorrhage when the Detachment of the Placenta is partial. 
 Explanation of its occasional cessation. 
 
 From the consideration of these premises, it will readily appear, 
 that when a small portion of the placenta is detached, it occasion- 
 ally occurs, as I have already shown in the early part of the present 
 Essay, that the consequent hemorrhage is sometimes so great as to 
 be dangerous, or even fatal, in its extent. Its amount, under this 
 and other circumstances, may be also regulated and increased by 
 the occurrence, in consequence of uterine contraction,* or otherwise 
 of any laceration in the detached portion of the placenta itself ; for 
 when the substance of the organ is torn, its vascular maternal cells 
 will be more freely opened into and exposed, and a more profuse 
 discharge be allowed to issue from them. "We may further easily 
 conceive why the discharge should sometimes be actually more abun- 
 dant when the detachment of the placenta is slight, than when it is 
 greater in degree. For the quantity of blood passed into the ma- 
 ternal vascular structure of the organ, and consequently the quantity 
 liable to escape from its unattached surface, will, in some respects, 
 depend upon the extent of vascular placental connection which con- 
 tinues between it and the uterus. In other words, the intensity of 
 the resulting hemorrhage will be regulated as much, or more, by 
 
 ' See illustrative oases in Smellie's Collection, vol. iii. p. 411 (the placenta " split in the 
 middle'') ; and Ibid. vol. ii. p. 217 (" the placenta adhered to the os internum, near its 
 middle, or thickest part, in vi^hich part T perceived a laceration upwards of an inch long, 
 and penetrating almost through the substance of the placenta"). In both these cases the 
 mothers died of the excessive flooding before delivery, and the condition of the placenta was 
 ascertained on post-mortem examination. 
 
PLACENTA PRJEVIA. 645 
 
 the extent of placental surface which still remains in attachment to 
 the mother, as by the extent of surface which is already detached ; 
 for the freedom with which the blood is supplied to the placenta will 
 affect the violence of the flooding, equally, or more so, than the free- 
 dom with which that blood is allowed to escape from the open ori- 
 fices of its ruptured vessels. 
 
 Probably, in most cases, the hemorrhage will reach its maximum 
 when the quantity of blood which enters the placental cells by the 
 adherent portion is equal to what can reach, and escape from, the 
 open orifices of the separated portion. Any additional separation 
 after this will tend rather to diminish the flooding, as less blood 
 will be carried into the placenta, from the number of its channels 
 of supply being diminished. Most a-ccoucheurs seem to believe 
 that the greater the degree of detachment, the greater will be the 
 hemorrhage, and hence, we are earnestly cautioned,' in the opera- 
 tion of turning in placenta prasvia, not to separate more of the pla- 
 centa from the cervix uteri than is absolutely necessary to permit 
 of the passage of the hand. Theory as well as experience would 
 seem to throw the greatest doubts upon the soundness and pro- 
 priety of this rule. If at all true up to a certain extent of separa- 
 tion, it certainly does not hold good in regard to the detachment 
 when carried to some degree further. 
 
 There is an additional anatomical reason why the accompanying 
 hemorrhage should be excessive, in some cases where a very small 
 portion only of the edge of the placenta has been separated. I 
 have already quoted from Dr. Hamilton a case of this kind, which 
 proved fatal, and where the " area of the separated placenta was 
 less than a square inch."" The largest of the maternal vessels 
 belonging to the placenta is that which Meckel, Jacquemier, and 
 other authors, have described under the name of the circular sinus 
 of the organ. It courses round the circumference of the placenta, 
 in some parts being of a great size, and at other points more or less 
 contracted, or even absent. I have usually found this maternal pla- 
 central vessel of great dimensions in several difljerent parts of its 
 course. In the cases in which excessive hemorrhages occur, when a 
 small portion only of the edge of the organ is detached, I believe the 
 danger and fatality of the result are to be ascribed, to the fact that 
 some portion of the course of this large circular sinus has been opened, 
 and thus a rapid and free tide of maternal blood allowed to escape 
 from the disrupted part of this uncontracting tube. 
 
 ' As by Rigby, System of Midwifery, p. 262, " The less we separate the placenta, the less 
 will be the hemorrhage ;" Ramsbotham, Obstetric Medicine, p. 393, " The profuseness of 
 the discharge will be principally regulated by the degree of separation." See also Levret, 
 Accouchemens Laborieux, p. 68; Hatin, Cours d'Accouchemens, p. 178; Lachapelle, Pra- 
 tique des Accouchemens, torn. it. p. 440, &c. &c. 
 
 * Practical Observations on Midwifery, 2d edition, p. 314. 
 
646 COMPLEX LABOR. 
 
 In all instances, then, of hemorrhage from partial separation of 
 the placenta, I hold that the blood issues principally, if not entirely, 
 from the uncontracted and uncontractible maternal orifices that 
 belong to the external surface of the separated portion of the organ, 
 and that the maternal blood is supplied more or less freely to these 
 orifices, in consequence of the fi-ee communication existing among 
 the different maternal cells, and from these cells being kept filled 
 with blood through the utero-placental vessels of that portion of the 
 placental mass, which continues to remain fixed and attached to 
 the uterus. 
 
 Further investigations will probably show, that the greatest quan- 
 tity of blood that escapes, flows from the exposed orifices which lie 
 nearest to, or are actually involved in, the line of separation between 
 the placenta and uterus. Along this line of separation, and in its 
 immediate neighborhood, these orifices — consisting miainly of aper- 
 tures of the large and torn decidual veins — ^will be for a time 
 kept more stretched and patulous than in the other portions of the 
 detached surface, and more especially will this hold true if there 
 exist any tendency in the uterus to detach itself more and more fi^om 
 the placental surface along this line of junction by constant con- 
 tractions. Under such circumstances the placental orifices alluded 
 to, and those in their immediate vicinity, will afford, not only the 
 freest, but also the nearest, channel for the discharge of the mother's 
 blood flowing into its maternal cells. 
 
 In cases of partial detachment of the placenta from the interior 
 of the uterus, the attendant degree of hemorrhage is also, no doubt, 
 regulated by another important circumstance — namely, by the con- 
 dition of the blood itself in the separated portion of the organ. If 
 the blood in the maternal cells of that portion continues still to re- 
 main fluid, it will be ready to escape fi-om every ruptured orifice 
 upon the detached placental surface. Hence, when a considerable 
 portion of the placenta is at once and suddenly separated, the dis- 
 charge is sometimes excessive, until the blood in the tissue of the 
 detached part becomes more or less coagulated. Gradually, by its 
 coagulation and infiltration into the structure of the separated por- 
 tion of the organ, it obstructs the maternal cells of that part, and 
 consequently more or less completely arrests the discharge. 
 
 It is in fact to this infiltration and coagulation of blood in the 
 detached portion of the organ, that we are, as Gendrin' has well 
 shown, to look for an explanation of the occasional temporary cessa- 
 tions of those floodings which are so frequently observed during 
 the latter periods of utero-gestation, in cases of placenta prsevia. 
 It is well known that when the placenta presents, hemorrhage is 
 
 ' Medecine Pratique, torn. ii. p. 216. 
 
PLACENTA PK^VIA. 647 
 
 liable to occur at intervals, for days and weeks, or even for months, 
 previously to tlie completion of the full term of pregnancy. Each 
 of these hemorrhages depends upon a partial detachment of the 
 expanding surface of the cervix uteri, from the expanding surface of 
 the placenta. For the expansion of the cervix uteri, during the last 
 periods of pregnancy, is known to produce its detachment from the 
 placenta, when the placenta is implanted upon it, exactly in the 
 same way as the contractions, or rather, retractions, of the same part 
 during labor, lead to a similar result. 
 
 Each partial detachment occurring during pregnancy gives rise 
 to the exposure of a greater or less number of vascular placental 
 orifices, and consequently to a greater or less degree of hemorrhage 
 from these orifices. Each of these hemorrhages generally ceases 
 after a time, and the mechanism of their cessation is not so much 
 to be found in any changes in the corresponding part of the uterus, 
 as in the changes I have adverted to as occurring in the separated 
 portion of the placenta. The blood becomes infiltrated and coagu- 
 lated in the substance, and occasionally also upon the surface, of 
 this separated portion ; its vascular maternal cells are thus rendered 
 impermeable ; and the temporary arrestment of the flooding is con- 
 sequently aflfected. The blood diffused and infiltrated into and 
 upon the detached portion of the placental structure, undergoes a 
 series of changes which I have elsewhere attempted to trace mi- 
 nutely ;' and, after a time, the separated and ecchymosed tissue of 
 the placenta itself becomes yellowish and atrophied, partly from 
 the alterations which occur in the blood infiltrated through it, and 
 partly from the obliteration of its vessels, and the consequent de- 
 generation and desiccation of its tissues. In cases of placenta 
 prsevia, in which there has been a repeated recurrence of hemor- 
 rhage, and as frequent an arrest of it, we can occasionally trace in 
 the placenta, after its expulsion, diflEerent parts of it, showing a 
 series and gradation of pathological changes arising from successive 
 partial detachments, and successive apoplectic infiltrations and obli- 
 terations of its substance from coagulated blood of different ages 
 lodged in its structures. These alterations are confined to the de- 
 tached portion, and the part always presenting the most recent stage 
 of the pathological changes in question, is that lying nearest the 
 line of junction between the separated and affixed divisions of the 
 organ. The part showing the most advanced stage of the changes 
 will be found situated furthest from this point ; or is, in other terms, 
 the part which was first and earliest detached. In cases of direct 
 and central implantation of the placenta over the os, the centre of 
 
 ' See Pathological Observations on the Diseases of the Placenta, in the Edinburgh Medi- 
 cal and Surgical Journal, April, 1836, p. 275, and in vol. ii. of this work. 
 
648 COMPLEX LABOR. 
 
 the organ, having in general become first detached, will be found 
 to present the oldest morbid alterations ; and the newer forms and 
 phases of it may be sometimes traced in successive departments or 
 layers, from this to the circumference of the detached portion- 
 always supposing there has previously occurred a succession of de- 
 tachments and attacks of hemorrhage. If the edge only of the pla- 
 centa has presented— and several successive hemorrhages ha,ve in 
 the same way taken place previously to labor— the same series of 
 morbid changes will be found in the organ, running, not, as in the 
 above instance, from the centre towards the circumference, but from 
 the presenting or earliest separated point of the edge, more or less 
 towards the centre of the mass. 
 
 As affording some proof of the correctness of the view which I 
 have already ventured to give of the immediate source of the dis- 
 charge of unavoidable hemorrhage, I would beg to dwell fgr a mo- 
 ment on one other point : — Almost all obstetric authors mention, 
 as a mark of diagnosis during labor, between unavoidable and acci- 
 dental hemorrhages, that in the first or unavoidable species, the 
 flooding is greatest during the pains, and least during the intervals ; 
 whilst in the last, or accidental form, the discharge is least during 
 the pains, and greatest during the intervals. In placental presen- 
 tations, "the character of the hemorrhage," says Dr. Rigby,^ "is 
 also different from that of common hemorrhage, inasmuch as it 
 increases during a pain, and diminishes or ceases during the inter- 
 vals, whereas in hemorrhage as in ordinary circumstances it is the 
 reverse." I am not aware that any solution has been hitherto at- 
 tempted of this peculiarity in unavoidable hemorrhage. And, 
 whilst it seems very explicable upon the idea generally received 
 that the discharge comes from the exposed surface of the uterus, it 
 is a condition which we might have a priori anticipated from the 
 opposite opinion, that the effusion flows from the detached surface 
 of the placenta. For, if in placenta prsevia the hemorrhage pro- 
 ceeded from the vascular orifices laid open on the interior of the 
 uterus, it ought to be diminished and not increased in quantity during 
 the pains, as these ori&ces will necessarily be temporarily diminished 
 under the contraction of the uterine fibres. If we adopt, however, 
 the other view, that the discharge proceeds from the open vascular ori- 
 fices existing on the outer or maternal surface of the detached portion 
 of placenta, we can easily understand how its amount should be tem- 
 porarily augmented by each labor pain. For each uterine contraction, 
 in pushing down the presenting part of the child against the com- 
 pressible placental mass, will squeeze out from its maternal cells, as 
 from a sponge, a portion of the fluid blood contained in them ; and 
 hence, during the pressure, an increased flow of this blood will 
 
 ' System of Midwifery, p. 255. 
 
PLACENTA PREVIA. 
 
 649 
 
 issue from the vascular orifices opening upon its detached surface. 
 During the intervals between the pains, a reaccumulation of mater- 
 nal blood will take place in the interior of the placenta ; but the 
 quantity actually escaping will be comparatively less, till again it is 
 forced out in accumulated amount by the compression by which it 
 is subjected by a returning pain. 
 
 Cause of the Cessation of the Hemorrhage when the detachment of the Placenta is complete. 
 
 All the preceding remarks apply to the mechanism of unavoidable 
 hemorrhage, and its arrestment, when the placenta is partially sepa- 
 rated. Their application to the rationale of the complete arrestment 
 of the hemorrhage, in those instances in which the placenta is com- 
 fletely detached, is still more obvious and simple. For, if the ex- 
 planation which I have above given of the source of the hemorrhage 
 in partial detachment of the placenta, be true — namely, that it pro- 
 ceeds principally, if not entirely, from the maternal vascular cells 
 belonging to the separated portion of the organ being still, more or 
 less freely, supplied through the utero-placental vessels of the ad- 
 hering portion — we can further easily understand how it occurs, 
 that the attendant hemorrhage is immediately moderated, or en- 
 tirely arrested, when the placenta is once thoroughly and perfectly 
 separated from the interior of the uterus, as in the class of cases 
 which form the subject of the present memoir. If the flooding pro- 
 ceeds, as I have endeavored to show, from the detached and exposed 
 surface of the placenta, and not from the detached and exposed 
 surface of the uterus, the placenta must cease to yield any new or 
 additional quantity of maternal blood, as soon as its own vascular 
 connections with the mother are destroyed ; or, in other words, the 
 immediate source of supply of the hemorrhage is cut off, and its 
 continuance consequently prevented, as soon as the placenta is en- 
 tirely separated from the interior of the uterus. 
 
 Besides the preceding anatomical considerations, we must take 
 some important physiological points into consideration, in investi- 
 gating the mechanism of the complete cessation of unavoidable 
 hemorrhage upon the complete separation of the placenta. The 
 uterus, during pregnancy, has, like other organs under high vital 
 periodic activity, both its arteries and veins, but especially the 
 latter, enormously enlarged. The immediate and final object of 
 this great enlargement is to supply the necessary materials for 
 nourishment and respiration to the included foetus. The medium 
 through which these materials are supplied to the foetus is the pla- 
 centa ; and the maternal cells of that organ form the more imme- 
 diate locality in which they are transmitted from the maternal to 
 the foetal system. We have already stated, that these maternal 
 placental cells are merely dilated capillaries, inasmuch as they con- 
 
650 COMPLEX LABOR. 
 
 stitute the only vascular connection between the terminations of the 
 utero-placental arteries and the origins of the utero-placental veins. 
 The capillaries, especially of those parts and organs which are liable 
 to periodic excesses of action, are allowed to have a power of pro- 
 ducing, under these excesses of action, an increased determination 
 of blood to themselves and their corresponding arteries and veins, 
 and that quite independently of any change whatever in the central 
 organ of the circulation.^ This seems to hold true to a great and 
 remarkable degree with regard to the maternal form of capillary 
 circulation carried on in the placenta, in consequence of the great 
 and remarkable functions which this temporary portion of capillary 
 circulation is destined to perform. And if the organic relations of 
 the placenta to the uterus are disturbed, the resulting deviations are 
 equally striking. If the placenta is only partially detached, the 
 " attractive" power of the maternal circulation in the organ is, with 
 the other moving powers of the blood, generally sufficient to keep the 
 cells of the detached, as well as those of the adherent portion, filled 
 with blood; and at the same time the circulation in the uterine 
 arteries and veins in the immediate neighborhood continues to be 
 more or less vigorously maintained, in consequence of their con- 
 tiguity to the free tide of communication that is carried on between 
 the uterine vessels, and the part of the placenta that still remains 
 affixed. Hence, probably, even the orifices of the congested and 
 enlarged uterine veins opening on the interior of the uterus, and 
 lying near the existing line of junction between the uterus and the 
 placenta, may occasionally allow of some discharge, in addition to 
 the freer form of fiooding that we have seen to take place from the 
 more patulous apertures left on the exposed surface of the placenta 
 itself. But separate entirely and completely the placenta from the 
 uterus, and then you at once alter the course — as you have at once 
 removed the great physiological aim and object — of the utero-pla- 
 cental circulation. The blood in the uterine vessels being now no 
 longer attracted by the maternal capillary system of the placenta, 
 and so far the distributive influence of that system being completely 
 and suddenly abrogated, there is not only a less absolute tide of 
 blood determined towards the uterus, but that which is contained in 
 its vessels seeks the freest and most patent course backward to the 
 heart through the higher and larger communicating branches be- 
 tween the uterine arteries and veins. The placental capillary influ- 
 ence no longer turns aside from these channels, the direct and onward 
 
 ' "The capillaries possess a distributive power over the blood, so as at least to regulate 
 the local circulation, independently of the central organ, in obedience to the necessities of each 
 part." — See note in Mr. Palmer's admirable edition of the Works of John Hunter, vol iii. 
 p. 332. 
 
PLACENTA PREVIA. 651 
 
 course of the circulating current into its own set of special uterine 
 vessels. These special vessels, now that their function is arrested, 
 are comparatively empty of blood, and their collapsing or collapsed 
 sides may serve to keep the general vascular current in its proper 
 canals ; for the hemorrhage, if any, is from venous orifices, and 
 hence easily repressed by slight impediments : and we shall after- 
 wards see that it is not a direct discharge, but arises from retro- 
 gression or regurgitation of the blood in the venous tubes. 
 
 I might add, if it were necessary, some analogous instances in 
 illustration of these opinions. The case of a limb suddenly and 
 completely avulsed by machinery, or otherwise, might be shown to 
 be similar in most points. Every one knows how slight the hemor- 
 rhage generally is, which is met with in connection with this severe 
 accident. But another illustration may be regarded as more appo- 
 site. The fcetus has a circulation of blood to and from the placenta 
 through its umbilical vessels, in the same way as the mother has a 
 circulation to and from the placenta through its utero-placental 
 vessels. We have found as a general law, that when the utero- 
 placental vessels are entirely and totally divided by the complete 
 detachment of the placenta, the mother has little or no tendency to 
 lose blood from their exposed extremities. When the umbilical 
 vessels are divided, the fcetus has as little tendency to lose blood 
 from their divided extremities, if once the vicarious function of 
 the pulmonary respiration is freely established.' In the one in- 
 
 ' In reference to this point it may be necessary to state two facts. First. It is generally 
 ackno'wledged by physiologists, as the result of various observations, that immediately after 
 the child is born, the umbilical vessels cease to pulsate and carry blood, if the pulmonary 
 respiration becomes active ; and if the pulmonary respiration is by any cause interrupted or 
 arrested before the cord is divided, the circulation through the umbilical vessels again 
 becomes more or less active. Secondly, There seems to be very little danger of hemorrhage 
 from the umbilical vessels after the division of the cord, if_ previously to that division, the 
 pulmonary respiration be allowed to become completely established. Hence various prac- 
 titioners have gone so far as to aver, that it is unnecessary, as a general rule, to place a liga- 
 ture upon the foetal extremity of the cut umbilical cord, the tendency to bleed directly 
 through its arteries, or indirectly by regurgitation through its veins, being so slight as not to 
 require it, if the cofd be not cut till the child has cried loudly, and the lungs are in full and 
 free action. See, in support of this opinion and practice, Dehmel in Haller's Dissertationes 
 Anatomicse, tom. v. p. 607 ; Koltschraid, De intermissa Funiculi Umbilicalis Deligatione 
 non absolutfe lethali, Jena, 1751 ; Schweikhard, De non necessari§, Funiculi Umbilicalis Deli- 
 gatione, Argent, 1769; Carboue, Journal General de M^decine, tom. iii. p. 334 ; Van der 
 Eem, De Artis Obstetricae Hodiernorum prae Veterum PrfEstantia, in Schlegel's Sylloge 
 Operum Minorum in Arte Obstetric^;, tom. i. p. 94 ; Ziermann, Die naturgemasse Geburt 
 des Menschen, &c., Berlin, 1817. C. Martin, in a Thesis published some years ago at 
 Munich, De Ligatura. Funiculi Umbilicalis, maintains (p. 11) that the practice of tying the 
 fcEtal extremity of the cord is not only useless, but hurtful, and denounces its adoption as a 
 reprehensible crime propagated down to our times, facima damnandum ad nostra itsqtie 
 tempora prcpagatum. " Whatever," observes Velpeau, " may be the explanation, it always 
 happens, that if it is left to itself and without ligature, the cord would very rarely expose 
 the foetus to any hemorrhage, or to any accident, even if it were clean cut, and not bruised 
 or torn." — Trait6 des Accouchemens, tom. ii. p. 566. 
 
652 COMPLEX LABOR. 
 
 stance as in the other, the circulation through the divided vessels 
 is stopped, and their tendency to bleed is arrested as soon as the 
 physiological conditions which called these vessels into existence 
 and action, is completely arrested or superseded, and that though 
 some anatomical conditions of its vessels, apparently favorable to 
 hemorrhage— particularly the presence of a large venous tube or 
 tubes unprovided with valves, and admitting of regurgitation— may 
 be still found persisting. 
 
 Absence of EeTnorrhage in Twin Labors, with one or both PlacentCB entirely detached before 
 the birth of the Second Child. 
 
 There is another series of cases which, if my present space per- 
 mitted, might be adduced at length, both in corroboration of the 
 fact, that the complete separation of the placenta is not followed by 
 hemorrhage, and in evidence of the special explanation of the cessa- 
 tion of the flooding which I have above offered. I here advert 
 to cases of twins, in which it occasionally occurs, that, after the 
 birth of the first child, and before the birth of the second, one or 
 both of the remaining placentae are expelled, and yet no hemor- 
 rhage follows.^ Such cases may be arranged under three divisions, 
 namely — 
 
 1. Twins, in which, after the birth of the first child, its own placenta 
 is expelled or removed, the other infant and placenta remaining without 
 flooding, for a greater or less length of time in utero. — " When a 
 woman," says Mauriceau, "has a plurality of children, we must not 
 deliver the placenta till after the birth of the last infant ; because 
 there would be produced a great discharge of blood (une grande perte 
 de sang) if we thus detached the placenta prematurely."^ Dr. Den- 
 man adverts to this subject in language implying similar theoretical 
 doubts upon the point, and yet, at the same time, affording practical 
 confutation of it. " When," he remarks, in his observations upon 
 twins, " the placenta are separate, that of the first child should not 
 be extracted before the birth of the second child, as a discharge of 
 blood must necessarily follow, and perhaps a hemorrhage ; though 
 sometimes one placenta has been discharged before the birth of the 
 second child, without any material loss of blood. In some cases of 
 hemorrhage, when there was only one child, the placenta has been 
 expelled before the child, without any detriment, though not with- 
 out much apprehension of danger."' " I have seen," Dr. Collins 
 
 ' See Proceedings of Edinburgh Obstetric Society, December 22, 1847. — Edinburgh 
 Monthly Journal, March, 1848, p. 692. 
 
 * Aphorismes touchant la Grossesse, &c.. No. 214. 
 ^ Introduction to the Practice of Midwifery, p. 541, 
 
PLACENTA PREVIA. 653 
 
 observes, " several instances where the placenta of the first child 
 came av?ay without interference before the birth of the second, and 
 yet there was no hemorrhage of any consequence."* Several eases 
 of a similar kind have been reported to me by different professional 
 friends,^ They all tend to give a direct contradiction to the obser- 
 vation of Caseaux — th« author of one of the latest and best French 
 works on midwifery — ^that the complete detachment of the afterbirth 
 of the first child " would expose the woman to a fatal hemorrhage 
 {exposerait lafemme a une hSmorrhagie mortelle)."' In his work, Peu 
 even ventured to suggest it as a proper mode of practice in some 
 cases, to remove the first placenta, when ascertained to be quite 
 isolated, before the birth of the second child. "When there is," 
 he observes, "more than one child, the method ordinarily followed 
 is to receive the one that presents first, the cord of which should 
 serve as a guide for the others. The fingers are slipped along it to 
 the mass of the placenta, to discover if it is absolutely separated 
 from the other placentee. In this case, which is sufficiently rare, 
 one may draw it out immediately."^ 
 
 It may be objected to these twin eases, as corroborative of the fact 
 for which I adduce them, that the distended bag of the membranes 
 of the remaining child might prevent any hemorrhage by acting as 
 a sufficient compress upon the whole uterine surface laid bare by 
 the detachment of the placenta of the infant already expelled. But 
 this objection will not hold good with respect to twin cases included 
 under the two divisions which I have next to speak of. 
 
 2. Twins, in which after the birth of the first infant, the placenta of 
 the second child was expelled, one infant and placenta remaining still in 
 utero. — ^A case of this kind has been related to me by my friend Dr. 
 Andrews, Lecturer on Midwifery at the Westminster School. One 
 of his pupils was in attendance. A placenta was expelled after the 
 birth of the first child. Little or no hemorrhage occurred till the 
 
 ' Practical Treatise on Midwifery, p. 312. Dr. Collins adverts to two hospital cases. 
 The two following similar eases occurred to him in private practice : 
 
 1. "C. S. was delivered of twins, June 21, 1823. The placenta of the first child was 
 expelled immediately. The feet of the second were then found in the vagina, and brought 
 down. There was not the slightest hemorrhage. The first was born alive, the second putrid." 
 
 2. "M. C. was delivered of twins, May 6, 1823. The placenta of the first child was 
 expelled before the birth of the second, without hemorrhage. Both children were born alive 
 at the full period." See Ibid. pp. 312, 313. 
 
 2 Thus, " I have seen," Dr. Dawson of Newcastle writes me, " two cases of twins, where 
 the placenta of the first came away before the birth of the second child. There was no 
 hemorrhage in either case. Mr. Sang," Dr. Dawson adds, " has met with two cases of this 
 description, and also without hemorrhage." A case of the same kind, and with the same 
 result, occurred some time ago to Dr. Dickson, one of my own pupils. Dr. Fenton, Dr. 
 Campbell, and others, have related to me similar instances. 
 
 * Traill de I'Art des Accouchemens, Paris, 1841, p. 785. 
 
 * Pratique des Accouchemens, p. 208. 
 
654 COMPLEX LABOR. 
 
 second infant was born, some time afterwards. It was found that 
 the previously expelled placenta belonged to it, and the still retained 
 placenta belonged to the child that had been first born. Here, in a 
 case of twins, we had a child and a placenta remaining in utero, but 
 the remaining placenta was not the placenta of that child. And 
 the placenta which was previously detached and separated had 
 necessarily torn asunder the bag of membranes, leaving the portion 
 of uterine surface to which it was itself affixed exposed, vsdthout that 
 exposure leading to any marked degree of hemorrhage. 
 
 3. Twins, in which between the hirth of the first and second child, the 
 placentce belonging to both were expelled. — Dr. Dewar of Dunfermline 
 has reported to me two cases of this kind. In one " the placentae 
 were firmly united, and were discharged after the birth of the first 
 child. There was no unnatural discharge of blood. The mother 
 did well." This case occurred in the practice of Dr. Brown. The 
 other occurred under Dr. Dewar's own observation. " The mother 
 had borne several children. The first child, which was at the full 
 time, presented by the feet, and immediately after its birth the two 
 placentae, connected by a membranous but not vascular band, were 
 expelled. Labor followed briskly, and in little more than five 
 minutes the second child, which presented naturally, was bom. 
 The hemorrhage," Dr. Dewar adds, " was very slight, and not greater 
 than what occurs after some ordinary labors. The mother did 
 well." 
 
 It may be considered that, in these two cases, the interval between 
 the expulsion of the placenta and the birth of the child was too brief 
 to allow accurate observations to be made upon the degree of exist- 
 ing hemorrhage. This objection is completely answered by a third 
 case of the same kind mentioned to me by my friend Dr. Protheroe 
 Smith of London. " I was," he writes to me, " called to a patient 
 some time since who had given birth to one child, immediately 
 after which a large double placenta followed without hemorrhage, 
 leaving a second child in utero, which was expelled, dead of course, 
 three or four hours afterwards, without further discharge of blood." 
 Dr. Tyler published, two years ago, a similar case.' After the birth 
 of the first child, a double placenta was discharged. Two hours 
 afterwards, the shoulder of the second child was found presenting, 
 and the uterus in a state of " hour-glass contraction." Many un- 
 successful eiforts to turn the foetus were made. At last its thorax 
 was eviscerated, and the breech brought down. The mother made 
 a good recovery. "Here," observes Dr. Tyler, "we have a case 
 not merely of simple placenta prsevia, but a double surface exposed— 
 
 > American Journal of the Medical Sciences for October, 1843 ; or, Provincial Medical 
 Journal, vol. vii. p. 245. 
 
PLACENTA PREVIA. 655 
 
 there having been two placentae ; the fibres of the womb first in a 
 state of rigid contraction ; then the irritation consequent upon the 
 performance of the embryotomy ; and, lastly, a state of excessive 
 relaxation, and still not a dro'p of hemorrhage, and the female entirely 
 recovered." 
 
 Presence of Hemorrhage in Partial, and its absence in Complete, Detachment of the Placenta 
 in the Third or Last Stage of Ordinary Labor. 
 
 I have now referred, under the present section, to two separate 
 sets of facts, illustrative of the non-supervention of hemorrhage 
 after the complete detachment of the placenta from the interior of 
 the distended uterus. We have seen that both in t,he placental 
 presentations and in twin labors, a large portion of the internal 
 surface of the uterus may be left exposed by the entire separation 
 of the pla,centa, while the organ continues distended by the presence 
 of a remaining child, and yet the vessels of that exposed surface 
 have little or no tendency to bleed, if the placental mass be only 
 ouce completely detached from it. We have further seen, that if, 
 in the same cases, the placenta be only partially separated from its 
 uterine attachment, hemorrhage is generally present. The super- 
 vention of the hemorrhage, when the detachment of the placenta is 
 partial, is probably not more certain than its cessation is, when that 
 detachment is perfect and complete. 
 
 Though these facts have escaped the general notice of obstetric 
 pathologists, they have all been long familiar with a third set of in- 
 stances in which the same phenomena may be observed. I refer to 
 circumstances well known in connection with the last or third^ stage 
 of common labor, and after the child is born. When during that 
 period of the labor, the placenta happens to become only partially 
 separated from the uterus — as in cases where a portion of it still 
 remains firmly attached from morbid adhesion — hemorrhage is 
 generally present. When, on the other hand, the placenta becomes 
 totally separated from the interior of the uterus, either naturally or 
 artificially, all hemorrhage generally ceases. In other words, we 
 have the same consequences resulting from partial, as contrasted 
 with complete, detachment of the placenta, in the last stage of labor, 
 and when the uterus is comparatively small and contracted, as we 
 observe under the same conditions in the earlier stages of parturi- 
 tion, and when the uterine cavity is still filled and distended by the 
 presence of an infant. Under these, at first apparently different 
 circumstances, the general fact seems to be the same, namely, that 
 
 ' In correspondence with the language of Denman, Hamilton, Kamsbotham, &c., I here 
 use the words " third stage," as denoting the period intervening between the birth of the 
 child and the expulsion of the placenta. 
 
656 COMPLEX LABOR. 
 
 hemorrliage is almost sure to occur if the placenta be only partially 
 separated ; it is almost as sure to cease if the placenta be once fully 
 and entirely detached. 
 
 Means by which Hemorrhage is prevented from the Venous Orifices left exposed on the Interior of 
 
 the Uterus. 
 
 1 have no intention at present to push the present investigation 
 further, and enter upon a full inquiry into this other remaining 
 point, namely, by what special mechanism nature prevents the 
 occurrence of hemorrhage from those patulous vascular orifices that 
 are left on the interior of the uterus when the placenta is, as in the 
 instances we are considering, completely detached from its internal 
 surface. The simple empirical fact of its non-occurrence is sufficient 
 for all the practical purposes of the present essay. And I believe 
 that the subject, if fully discussed, would form an anatomical and 
 pathological problem that would require for its complete solution a 
 much more laborious and lengthened series of researches than I can 
 pretend at this time to afford to it. I have, however, but little 
 doubt, that the means by which in placental presentations, hemor- 
 rhage is prevented from the uterine vessels themselves after the 
 detachment of the placenta, will be found in all its essential points 
 to be the same by which flooding is prevented after the removal of 
 the placenta in the ultimate stage of common labors. The non- 
 occurrence of hemorrhage from the uterine vessels in this last state, 
 or after the complete detachment of the placenta in ordinary par- 
 turition, is probably not explicable, as is generally imagined, upon 
 the sole circumstance of the simple and absolute contraction that 
 occurs in the uterine fibres after delivery. "We know, fi'om the 
 observations of G-ooch,'^ Velpeau,^ Rigby," and others, that post- 
 partum hemorrhage sometimes supervenes when the uterus appears 
 contracted and reduced to its usual size after delivery. On the 
 other ihand, the facts that I have adduced in the preceding pages 
 show, that there is little or no tendency to hemorrhage after the 
 perfect expulsion of the placenta, when this simple and absolute 
 
 ' Medico-Chirurgical Transactions, vol. xii. p. 157. " The observing practitioner must," Dr. 
 Gooch observes, " have been frequently struck by the little proportion that existed between the 
 want of contraction and the degree of hemorrhage ; having found the uterus bulky without 
 any hemorrhage, and a profuse hemorrhage without greater bulk of uterus. Nay, further, 
 I have witnessed a profuse hemorrhage, though the uterus had contracted in the degree 
 which commonly indicates security ; and I have ventured to do what is seldom justifiable, 
 separate the placenta before the uterus had contracted, without more hemorrhage than after 
 a common labor. What is this circumstance that has so great an influence that its presence 
 can cause a moderately contracted uterus to bleed profusely, and its absence can cause an 
 uncontraoted uterus to bleed scarcely at all ?" — P. 152. 
 
 2 Traite de I'Art des Aocouchemens, tom. ii. p. 539. 
 
 ' London Medical Gazette, vol. xiv. p. 332, and System of Midwifery, p. 218. 
 
PLACENTA PK^VIA. 657 
 
 contraction of the uterine fibres is so far prevented by tbe presence 
 in utero of a full-grown foetus. Wben the child is born in ordinary 
 labor, and the placenta happens to be retained from want of uterine 
 contraction, hemorrhage does not necessarily supervene. It is well 
 known that Euysch, William Hunter, and others, adopted, for a 
 time, the practice of leaving the placenta in utero for hours and 
 days till nature herself threw it off, and that they were at last forced 
 to abandon this line of treatment — not because uterine hemorrhage 
 was liable to supervene, but because the dead and retained organ 
 was found to become putrid, and to give rise to symptoms of severe 
 irritation and fever. Again, after the complete evacuation of the 
 uterus in common parturition, and the total removal of the placenta, 
 hemorrhage does not necessarily supervene, though the uterine 
 fibres are not in a state of firm contraction. "We often find them 
 alternately relaxing and contracting when after-pains supervene, 
 and yet the general relaxation that is observable between the pains 
 may not give rise to the slightest degree of flooding. Every prac- 
 titioner has had occasion to watch, with more or less anxiety, the 
 uterus remaining of considerable size and softness for some time 
 after delivery, and consequently with its fibres not firmly contracted, 
 but without after-pains, and without hemorrhage supervening. In 
 the same way I shall afterwards have occasion to show that in some 
 cases of placental presentation after the placenta had become ex- 
 pelled, and while the child remained in utero, the labor-pains have 
 ceased ; and still, notwithstanding this cessation, not only has no 
 hemorrhage followed, but, on the contrary, the flooding that pre- 
 viously existed has immediately ceased. 
 
 Such instances prove that strong uterine contractions in the 
 special complication which forms the subject of our observations, 
 are not probably so essential a part in the mechanism of the pre- 
 vention of hemorrhage from the open orifices of the uterine veins 
 as we might a priori suppose. When hemorrhage does continue 
 after the expulsion or extraction of the placenta in placental pre- 
 sentations, the determining cause of the hemorrhage is probably 
 the same as gives rise to this accident in the last stage of labor, and 
 after the complete evacuation of the uterus. In two cases, which 
 have been already quoted at length, and where, in placental presen- 
 tations, the hemorrhage remained after the complete expulsion of 
 the placenta, the child being retained in utero, the flooding still 
 continued also for a time after the infant was extracted, and the 
 uterus was completely emptied. The same circumstances — ^what- 
 ever they may be — in all likelihood led to its recurrence under both 
 of these conditions. 
 
 No doubt the occurrence, after delivery, of great and decided 
 VOL. I. 42 
 
658 COMPLEX LABOE. 
 
 atony in the whole muscular system of the uterus, does assuredly 
 give rise to post-partum hemorrhage;' and the same antecedent 
 condition may be the cause of the continuation of the flooding in 
 some circumstances where this happens after the expulsion of the 
 placenta in placenta preevia. But if I may judge from my own ob- 
 servations, I would venture to remark, that the morbid condition 
 which is most frequently and earliest seen in connection with post- 
 partum hemorrhage, is a state of irregularity and want of equability 
 in the contractile action of different parts of the uterus — and, it 
 may be, in different planes of the uterine fibres — as marked by one 
 or more points in the organ feeling hard and contracted, at the 
 same time that other portions of the parietes are soft and relaxed — 
 and by the contracting and relaxing fibres slowly but frequently 
 changing their relative situations.^ 
 
 Upon the same principle, I believe that in attempting to prevent 
 or remove the morbid condition leading to post-partum hemorrhage, 
 when it is functional in its nature, and not connected with any 
 organic or traumatic causes, we ought to endeavor to produce not 
 merely a certain degree and amount of uterine contraction, the 
 great and primary practical point to which we always justly look, 
 but also a certain equability and uniformity of contraction. The 
 same may perhaps be found true, both pathologically and practically, 
 in regard to the state of the uterus, after expulsion or extraction of 
 the placenta before the child, in placental presentations. At the 
 same time, I would repeat, that this part of the subject, like the 
 whole question of the manner and means by which hemorrhage is 
 prevented from the exposed uterine veins, after every case of ordi- 
 nary labor, stands, in my opinion, in need of new, careful, and 
 extended investigations. I have, however, at present, no desire to 
 encounter so wide and complicated an inquiry ; and shall content 
 myself with stating in reference to the subject the few following 
 suggestions : 
 
 First. Uterine hemorrhage, after the separation of the placenta, 
 in any of the stages of the labor, is not Arterial in its character. 
 The utero-placental arteries are numerous, but so long and slendei-' 
 as to become readily closed ; 1. By the tonicity of their coats ; 2. 
 By contraction of the uterine fibres upon the course of these vessels 
 
 ' For similar remarks by Dr. Simpson on post-partum hemorrhage, see Northern Journal 
 of Medicine, Jan. 1846, p. 1.— (Ed.) 
 
 * " I have rarely introduced the hand into the uterus in a case of flooding without meeting 
 with it (hour-glass or irregular contraction), whether the placenta had or had not been ex- 
 pelled." — Dr. Burns's Principles of Midwifery, 9th edit. p. 543. 
 
 ^ I speak of these utero-placenial arteries as they are seen in the beautiful injected pre- 
 parations of them left by William Hunter and the second Munro, and as I have myself 
 observed them in recent specimens. 
 
PLACENTA PRiEVIA. 659 
 
 themselves as they pass through and amid the uterine structure ; 
 and, 3. And principally, by the changes in their tissues produced 
 by the mechanical rupture of their coats — torn arteries being little, 
 if at all, liable to bleed — and the placenta being separated by a true 
 process of avulsion. 
 
 Secondly. Hemorrhage, therefore, under the conditions supposed, 
 is Venous in its source and nature. Further, it is especially impor- 
 tant to mark that it is a venous hemorrhage hy retrogression. The 
 forward course of the uterine and utero-placental venous circulation 
 is from the dilated maternal capillaries or cells of the placenta 
 towards the periphery of the uterus, and the ovarian and hypo- 
 gastric venous trunks. In uterine hemorrhage, the blood that 
 escapes, instead of flowing onwards, regurgitates hachward into the 
 uterine cavity. 
 
 Thirdly. The mechanism by which, after the separation of the 
 placenta, this retrograde course of the venous circulation towards 
 the cavity of the uterus so as to lead to hemorrhage, is prevented, is 
 probably of a compound character, or is efliected by different means. 
 Each of these means may be more or less efiicient under different 
 circumstances and at different times. 
 
 Fourthly. The most powerful of these preventive measures con- 
 sists in the uniform and regulai* contraction of the uterine fibres. 
 By this contraction the canals of the supplying arteries are con- 
 stricted, and the venous tubes or sinuses which more immediately 
 yield the discharge are directly compressed. The facility of this 
 compression of the sides of the veins and the consequent diminution 
 of their cavities is promoted by the naturally thin, flattened forms of 
 their canals, and by the fact that the proper contractile tissue of the 
 uterus forms their second coat — the uterine veins consisting of the 
 usual lining membrane of the venous system placed in direct contact 
 with the muscular tissue of the uterus. At the same time, it is to be 
 recollected that there seems to be often no direct relation between the 
 degree of uterine contraction and the degree of tendency to hemor- 
 rhage, for, as we have already seen — 1. No hemorrhage may occa- 
 sionally be observed after delivery, though the uterus is not contracted 
 to its usual degree ; and, 2. It may be present when the uterus is appa- 
 rently well contracted. But, 3. There are, according to most anato- 
 mists, few or no contracting fibres in the structure of the os and cervix 
 uteri, and certainly after delivery I have generally, if not always, found 
 it remaining open, gaping, soft, and flaccid, even when the proper 
 cavity of the uterus above felt shut and contracted, and its parietes 
 hard and firm. Still when the placenta is attached to the surface of 
 this uncontracting portion of the uterus, hemorrhage is not common 
 after its separation, unless some laceration of its vessels has occurred. 
 
660 COMPLEX LABOR. 
 
 Here we have post-partmn hemorrhage prevented, without the con- 
 tractile mechanism, generally considered necessary for its avoidance, 
 being almost in existence. And lastly, in cases of spontaneous or 
 artificial extraction of the placenta in some placental presentations 
 and twin labors, the placental mass may be completely separated, and 
 the uterus still remain distended by the presence of a child in its cavity, 
 so as to prevent much contraction of its fibres, without hemorrhage 
 occurring. The venous trunks running to the uterus are not sup- 
 plied with valves, and under the above and other circumstances, by 
 what means in addition to, or in substitution of, the contraction of 
 the uterine fibres, does nature prevent the retrograde flow of venous 
 blood into the uterine cavity— or, in other words, uterine hemor- 
 rhage ? 
 
 Fifthly. The structure and mutual relations of the venous sinuses 
 of the uterus seem calculated to obstruct and prevent such a retro- 
 grade flow of blood in their tubes as to cause hemorrhage. The 
 uterine veins are large, but of a compressed, flattened form, and ar- 
 ranged in several planes or floors above one another in the uterine 
 walls. On examining these veins in several pregnant uteri, by dis- 
 secting them from the outer or peritoneal surface of the organ, down- 
 wards towards the mucous, I have found the following arrangement : 
 Each venous tube gives oflf numerous communicating branches to 
 the veins of its own plane or floor, by a set of lateral foramina. 
 When, however, a venous tube of one plane comes to commu- 
 nicate with a venous tube lying in the plane immediately be- 
 neath it, the foramen between them is not in the sides, but in the 
 floor, of the higher or more superficial vein, and the opening itself is 
 of a peculiar construction. Looking down into it from above, we 
 see the canal of the vein below partially covered by a semilunar or 
 falciform projection formed by the lining membrane ofthetwo venous 
 tubes, as they meet together at a very acute angle, the lower tube 
 always opening very obliquely into the upper.^ In the folds of these 
 falciform projections, the microscope shows the common contractile 
 tissue of the uterus. Do these semilunar or falciform projections, 
 
 ' In the course of dissecting the veins of a pregnant uterus, in the sixth month, from the 
 peritoneal surface down wards,. Mr. Owen states that he " observed that where the veins of 
 different planes communicated with eaoli other, in the substance of the walls of the uterus, 
 the central portion of the parietes of the superficial vein invariably projected in a semilunar 
 form into the deeper-seated one ; and where (as was frequently the case, and especially at 
 the point of termination on the inner surface) two, or even three of these wide venous chan- 
 nels communicated with a deeper sinus at the same point, the semilunar edges decussated each 
 other, so as to allow only a very small part of the deep-seated vein to be seen. It need 
 scarcely be observed how admirably this structure is adapted to insure the arrest of the cur- 
 rent of blood through these passages, upon the contraction of the muscular fibres with which 
 they are everywhere immediately surrounded." — Works of John Hunter, vol. iv. p. 68. See 
 also Mr. Goodsir's corroborative statement, in his admirable Anatomical and Pathological 
 Observations, p. 61. 
 
PLACENTA PREVIA. 661 
 
 and the oblique communications of tlie lower with the higher planes 
 of veins, allow the normal flow of venous blood from the deeper to 
 the more superficial veins of the uterus, while after the placenta is 
 separated, they prevent that anormal or retrograde flow of it from 
 the more superficial towards the deeper-seated venous tubes which 
 would produce hemorrhage ? Here I suppose it possible that these 
 falciform processes may act upon the same principle as the Eusta- 
 chian valve, but in a less perfect manner, while by the obliquity of 
 the communications between the different planes of veins it may be 
 that blood does not so readily retrograde into the deeper vessels, in the 
 same manner as urine does not retrograde into the ureters from the 
 bladder, in consequence of the oblique opening of the former into 
 the latter. Do the uterine fibres seen in the venous falciform pro- 
 cesses tend to aid this valve-like mechanism, by diminishing, under 
 contraction, the apertures between the different planes of veins ? 
 
 Sixthly. I have already shown that one cause contributing to pre- 
 vent hemorrhage after the total separation of the placenta, is the 
 abstraction from the uterine vascular system of the derivative or 
 sugescent power of the maternal circulation in the placental cells, 
 and the consequent tendency of the blood to flow in the more direct 
 and freely communicating channels that exist between the uterine 
 arteries and veins. Besides, the general and direct forward current 
 of the blood along the course of these larger uterine veins diminishes, 
 and, in a measure, destroys, the tendency which it might otherwise 
 have either to flow backwards, or to escape by any existing lateral 
 apertures of the vessels. 
 
 Seventhly. Among the other remaining means by which hemor- 
 rhage is more or less prevented after the detachment of the pla- 
 centa, I may mention — 1. The occasional presence of tufts of foetal 
 vessels left in the orifices of the uterine veins,' and forming not only 
 immediate mechanical obstacles, but nuclei for the ready coagulation 
 of the blood; 2. The formation of coagula in some of the collapsed 
 venous tubes and orifices ; and, 3. The presence for some hours, or 
 even days, after delivery, of the collapsed decidua over the apertures 
 seen in the veins on the interior of the uterus. 
 
 To these few and imperfect suggestions I am desirous to add one 
 remark. Some of the natural means of arresting uterine hemorrhage 
 that I have spoken of admit of extended anatomical examination 
 being applied to their more perfect investigation ; and several of the 
 observations that I have ventured to offer in this section may be yet 
 proved or disproved, by being tested by direct experiments with 
 vascular injections thrown into the dead body. 
 
 ' See, on this point, the observations of Professor Reid in his excellent paper on the 
 Anatomical Belations of the Bloodvessels of the Mother and Foetus. — Edinburgh Medical 
 and Surgical Journal, vol. Iv. p. 8. 
 
662 • COMPLEX LABOR. 
 
 Section VIII.— Instances of Placental Pebsentations, in which 
 THE Placenta has been artipiciallt removed before the 
 Child; Warnings by Authors against attempting the Prac- 
 tice ; Case of its Successful Adoption ; Recorded Instances 
 of it under supposed Mismanagement ; Cases of Portal ; 
 Suggestion of Chapman; Modern Cases of Extraction, etc. 
 
 We have already found that various obstetric authors (see Section 
 I.) have strongly declared the total inefficiency of nature in cases of 
 placenta prsevia. Several of them have especially warned us against 
 attempting to imitate her in any of her modes of management of 
 this obstetric complication, and against taking any hints from the 
 principles of treatment which she seems to follow under the circum- 
 stances. Dr. Eamsbotham has, in his admirable " Observations on 
 Midwifery," reported several cases of placental presentations in 
 which the placenta was expelled before the child. In commenting 
 upon these cases, he remarks, " Although it satisfactorily appears 
 that a spontaneous detachment of the placenta is not necessarily 
 followed by fatal consequences, that fact can furnish no precedent 
 in practice for the artificial separation and removal of it. I think," 
 he adds, " that few practitioners, aware of the probable consequences, 
 would have the temerity to make the experiment."^ " It would," 
 he again observes in another place,^ " be the extreme of hardihood 
 in any practitioner to attempt the artificial separation of this foetal 
 appendage in imitation of its natural expulsion." In a similar 
 strain Dr. Burns, the distinguished author of the well-known 
 " Principles of Midwifery," observes, " There are, doubtless, examples 
 where the patient has, by labor, been safely, and without assistance, 
 delivered of the child, when part of the placenta has presented, 
 Nay, there have been instances where the placenta has been expelled 
 first, and the child after it. These examples are to be met with in 
 collections of cases by practical writers, and some solitary instances 
 are, likewise to be found in diflerent journals. It would be much to 
 be lamented if these should ever appear without having, at the same 
 time, a most solemn warning sent along with them, to the accou- 
 cheur, to pay no attention to them in his practice. I am convinced 
 that they may do inexpressible mischief, by affording argument fbr 
 delay, and excusing the practitioner, to himself, for procrastination. 
 
 These instances are not to be converted into general rules, 
 
 nor allowed to furnish any pretext for procrastination. They happen 
 very seldom, and never ought to be related to a young man without 
 an express intimation, that he is not to neglect delivery, when 
 
 ' Practical Observations on Midwifery, part ii. p. 193. ^ Ibid. p. 286. 
 
PLACENTA PREVIA. 663 
 
 required, upon any pretence whatsoever. There is scarcely any 
 malady so veiy dreadful as not to afford some examples of a cure 
 effected by the powers of nature alone. But ought we, thence, to 
 tamper with the safety of those whose lives are committed to our 
 charge ?"* 
 
 ITotwithstanding the strong and decided opinions expressed by the 
 above authors and others, who might be cited for the purpose, I 
 became so convinced — from two cases which I happened to see, and 
 fi'om the study of others that I found upon record — that the extrac- 
 tion of the placenta before the child was the proper plan of treatment 
 in some cases of placenta prsevia, that during the course of 1841, 1 
 laid before the Obstetric Society of Edinburgh the deductions de- 
 rivable from thirty-nine cases that I had then collated, and proposed 
 that the artificial separation of the placenta ought to be our line of 
 practice in some instances of unavoidable hemorrhage. I was de- 
 terred at the time from publishing my investigations, under the 
 fear that it would be considered rash in a young member of the pro- 
 fession, propounding from the data which I had, so great a revolu- 
 tion in the usual practice of placental presentations. In the course 
 of the spring of 1844, 1 laid before the same Society an additional 
 number of cases, with the view of supporting the same opinion. 
 The data which I then had to found upon were not so extensive as 
 those I have now brought forward, but they were to my mind so dis- 
 tinct and decided, that notwithstanding the earnest counsels of Drs. 
 Kamsbotham, Burns, and others, I predetermined to have recourse 
 to the artificial extraction of the placenta itself, in any case that I 
 should happen to meet with in which the hemorrhage was very- 
 great, and where the rupture of the membranes was insufficient, 
 or the operation of turning dangerous or impossible. 
 
 It was not till last autumn that I met with an instance in point. 
 And I hope I shall be excused for stating at length a case, which was 
 to me so interesting in its nature and in its results. 
 
 Case XXIV. — Great hemorrhage ; rupture of the membranes insuffi- 
 cient ; the OS uteri not so dilated as to allow of turning ; the placenta 
 artificially extracted about two hours before the birth of the child. — I was 
 called to see the lady who was the subject of this observation, at 
 about five in the afternoon of the 1st of October, 1844. The gentle- 
 man who was in attendance upon her, Mr. Hill of Portobello, in- 
 formed me on arriving, that she was between the seventh and eighth 
 month of pregnancy ; that she had almost daily suffered from con- 
 siderable discharges of blood, without pain, for about a fortnight 
 previously ; and that she had been flooding with slight uterine con- 
 
 ' Principles of Midwifery, p. 367. 
 
664 COMPLEX LABOE. 
 
 tractions, for about ten or twelve hours before my visit. I found her 
 a weakly person, with bleached features, and much sunk and pros- 
 trated by the preceding hemorrhage. The pulse was very small, soft, 
 and compressible. The abdomen seemed much distended with liquor 
 amnii. On examination, I found the vagina filled with coagulated 
 blood. It was exceedingly difficult for me at first to reach the os 
 uteri, partly in consequence of the rigidity of the parts, and partly 
 from the very high situation of the os uteri, itself. On touching the 
 OS uteri I found it still very slightly dilated, and on passing the finger 
 through it, it came in contact with the anterior edge of the placenta ; 
 the presentation being one in which the placenta was attached to the 
 posterior lip of the cervix uteri, and so as to project over the os itself. 
 Mr. Hill and I agreed together to allow the escape of the liquor amnii, 
 provided I could reach and rupture the membranes. I was enabled to 
 do so with some little additional difficulty ; and immediately upon 
 perforating the membranes anteriorly, an immense gush of liquor 
 amnii took place, and the abdomen became comparatively smaller. I 
 had hopes that I had done enough to arrest, in all probability, the 
 hemorrhage under which the patient was evidently sinking. She got 
 at the same time a large dose of the ergot of rye, and we waited with 
 some impatience for the result. Stronger uterine contractions came 
 on, and shortly afterwards I re-examined, in order to know their effect 
 on the OS uteri. I was distressed to find the vagina again filled with 
 clotted blood, showing too manifestly that the rupture of the mem- 
 branes, and the supervention of more powerful pains had been any- 
 thing but sufficient to arrest the progress of the flooding. A small 
 portion of the anterior part of the placenta was by this time threat- 
 ening to protrude through the os uteri. I passed my finger by 
 the side of it posteriorly, endeavored to detach as freely as possi- 
 ble the organ, and then seizing the protruded part between two 
 fingers, I gradually and steadily pulled the whole mass downwards 
 into the vagina, and through the vulva. After accomplishing this, 
 I confess that for a few minutes I felt a degree of timidity at what 
 most of my professional brethren would have at once denounced as 
 a most improper line of proceeding on my part, and one in direct 
 opposition to all the most approved and established rules in ob- 
 stetric medicine. The result, however, was such as to answer my 
 best expectations. All fears were dissipated, by ascertaining in a 
 few minutes that there were no new clots, nor any new discharge of 
 blood accumulating in the vagina, and that the head of the infant 
 was presenting — a circumstance which could not be previously ascer- 
 tained. The cervix, however, was still so undilated as to hold the 
 head fi-om impinging directly on the interior of the os uteri— a band 
 of contracted fibres high up in the cervical canal acting as a shelf 
 
PLACENTA PE^VIA. 665 
 
 on which it rested.' The patient got an additional dose of ergot, 
 and I cut through the umbilical cord, and separated the placenta, 
 for the purpose of ascertaining, by ocular inspection of the mass, 
 if the whole of the organ had been extracted. It was for this pur- 
 pose placed upon a plate nearly two hours before the labor was 
 completed. The infant came down slowly, but without any addi- 
 tional hemorrhage. The mother made a perfect recovery. Her 
 pulse, during convalescence, never, I believe, rose above 80. 
 
 In the preceding instance, I adopted the practice which I have de- 
 tailed as a matter of principle and choice, and as a result of obser- 
 vation and reasoning upon the cases which I had previously seen and 
 collected. In a number of other instances upon record, the same 
 practice has been adopted through reputed ignorance, on the part 
 of the attendant, of the established rules of midwifery in this variety 
 of obstetric complication. The details, however, of some of these 
 cases may both demonstrate the truth of the principle and practice 
 which it is my wish to establish, and the practicability and propriety 
 of the treatment itself. The first case I shall quote is from Dr. 
 Collins' Treatise. He gives it as " an instance eminently calculated," 
 to quote his own expression, " to show the marvellous escapes occa- 
 sionally witnessed when the gross ignorance of the attendant blinds 
 him as to the danger of his patient." 
 
 Case XXV. — The placenta removed many hours hefore the hirth 
 of the child. — " G. J., at her full time was admitted in a state of 
 extreme debility, her pulse so weak and frequent as not to be 
 counted. The foot was found in the vagina, so putrid, that the 
 skin peeled off on the slightest touch. The discharge was fcetid. 
 Stimulants and cordials were freely given, and the child brought 
 away without difficulty. The uterus remaining enlarged and re- 
 laxed, the hand was passed to remove the placenta, when there 
 was none to be discovered, nor was there any hemorrhage. The 
 membranes had ruptured and been discharged a fortnight previ- 
 ous to admission, j^from which time, until the evening before she 
 was brought to the hospital, she had had more or less hemorrhage. 
 It was now ascertained that the placenta had been expelled the 
 evening before her admission, and separated by the midwife in at- 
 tendance. She had been twice visited by a medical practitioner, 
 
 ' See an analogous and very interesting case of placental presentation, witli the os 
 uteri largely dilated, and stricture in the upper part of the cervix, recorded by Dr. James 
 Reid, in the London Medical Gazette, vol. xvi. p. 145. Dr. Reid's case was further remark- 
 able, as being one of those instances in which the placenta presented mthout any attendant 
 hemorrhage. 
 
666 COMPLEX LABOR. 
 
 who bled her and gave her purgatives. She left the hospital well 
 on the 13th day."' 
 
 Dr. Eamsbotham describes graphically, in words that demon- 
 strate his own surprise, the following similar case : 
 
 Case XXYI.— Placenta extracted before the child ; the flooding ar- 
 rested; safety of the mother.—" IjSite in the evening," observes Dr. 
 Eamsbotham, " of Thursday, May 7, 1818, during a temporary 
 absence from home, a message was delivered at my house, desiring 
 me to see a woman at Wapping, who was said to be very ill, but of 
 what disease, or in what state, was not mentioned. After some 
 conversation between my servant and the messenger, it was agreed 
 that I should visit this woman early the following morning, a second 
 message was sent to countermand the first, with the intimation, 
 ' that the woman was better, and was doing well.' A few days after- 
 wards, I accidentally met the medical gentleman, who had sent the 
 above verbal message, and inquired the nature of the case upon 
 which he wished to have my opinion a few nights before. To which 
 he replied, ' It was the strangest case I ever saw ; it was a placenta 
 preseutation, with a most violent flooding ; but I got it away.' ' Got 
 what away?' said I; 'Why, the placenta,' answered he. 'What! 
 before the child ?, asked I ; ' Yes, before the child,' said he ; ' and 
 the flooding ceased, and the woman did well ; the child soon followed 
 the after-birth.' "^ 
 
 I am indebted for the following most interesting case to the 
 politeness of Dr. Cripps of Liverpool, and shall relate it in his own 
 words. Dr. Cripps' letter to me is dated 28th of December, 1844. 
 
 Case XXVn. — Placenta extracted ten hours before the child; arm 
 presentation; no intervening hemorrhage. — " I was sent for a few days 
 ago, about 8 p.m., to see a poor woman who supposed herself to be at 
 the early part of the last month of pregnancy with the third child. She 
 had had occasional flooding to no great extent for a week previously. 
 On the morning of the day on which I saw her, a surgeon had been 
 sent for in consequence of the occurrence of several labor pains, 
 together with a good deal of hemorrhage. This gentleman being 
 out of town, his assistant went ; he remained with her during the 
 day, and in the evening finding things not going on so favorably 
 as he wished, he sent for a friend of his employer's, who, soon after 
 his arrival, sent for me. On making an examination, I found an 
 arm down, which was much swollen, the pains very severe. I im- 
 
 ' Practical Treatise on Midwifery, p. 102. 
 ' Observations on Midwifery, part ii. p. 231. 
 
PLACENTA PREVIA. 667 
 
 mediately gave one draclim of laudanum, and on their subsiding, 
 turned without much difficulty. The fanis was divided, only about 
 four or five inches remaining, and appeared as though it had been 
 cut. On expressing my surprise at this circumstance, I was informed 
 that it was cut ' when the after-birth was taken away, about ten in 
 the morning.' Not believing it possible that such could be the case, 
 there having been no hemorrhage whatever from that hour until the 
 period of delivery, I searched for the other portion of the navel-string, 
 but not finding it, and being again assured that ' the after-birth had 
 come in the morning,' I introduced my hand into the uterus, and 
 made a most careful examination ; it was contracting satisfactorily, 
 but was perfectly empty. I watched her strictly until her complete 
 recovery. I had every portion of discharge saved for my inspection, 
 and am therefore perfectly satisfied that this is a case in which the 
 placenta presented, and was removed ten hours previously to the 
 birth of the child, and that, in the meantime, there was no hemorrhage 
 whatever." 
 
 The following brief notice of an analogous case, reported by Dr. 
 Lbwenhardt, is extracted from Kleinert's Eepertorium for 1842, 
 tom. vi. p. 58. 
 
 Case XXVUI. — The placenta separated and pulled away hefore the 
 child ; transverse presentation ; turning. — " Some time ago. Dr. 
 Lowenhardt of Prenzlaw met with a case where an ignorant mid- 
 wife had separated the placenta, which presented all round, and re- 
 moved it from the passages. She then discovered that the child 
 was lying transversely, and attempting to turn it, she brought down 
 an arm into the pelvis instead of a foot. The uterus being fully 
 contracted, it was with difficulty that the author accomplished the 
 turning of the child, and saved the mother." 
 
 Many years ago, Baudelocque related, in a footnote, in the second 
 volume of his well-known System of Midwifery, an instance of the 
 same kind. 
 
 Case XXIX. — Placenta extracted some hours hefore the child ; arm 
 and head presentation. — " A midwife had extracted the placenta some 
 hours before I was called, and had not been able to turn the child, 
 whose arm was engaged below the head. The uterus, irritated by 
 the manceuvres of the midwife, was strongly contracted on the child, 
 and discharged but a few drops of blood. Astonished, after the ex- 
 traction of the child, to see the cord was torn off near the umbilicus, 
 and more surprised still not to find the after-birth in the uterus, I 
 
668 COMPLEX LABOK. 
 
 discovered that it had been extracted a long time before my arrival, 
 and carefully concealed."' 
 
 In the five cases, the particulars of which have been last given, 
 the placenta was artificially extracted a considerable time before the 
 birth of the child, in simple ignorance, and hence in defiance, on 
 the part of the attendant, of the established rules of management in 
 unavoidable hemorrhage. In the first case that I have detailed in 
 the present section, I pursued, as I have stated, exactly the same 
 practice, as a matter of election, and from the belief, that, under the 
 dangerous circumstances in which the patient was placed, this mode 
 of treatment was the measure best calculated to suppress the extreme 
 attendant hemorrhage, to gain time for the rigid cervix uteri to 
 dilate, and to place the mother in the greatest relative degree of 
 safety. 
 
 "We have already seen (p. 604), that all practical authors in mid- 
 wifery insist upon the artificial extraction of the child by turning, 
 as the principal or only means of treatment in placental presenta- 
 tions, more especially when the presentation is complete. Almost 
 all of them take occasion also, to inculcate under some form or other 
 the supposed propriety of not detaching the placenta more than is 
 absolutely requisite, when the operator introduces his hand into the 
 uterus for the purpose of grasping the foot or feet of the infant. It 
 is well known that, in order to follow out this principle to its fullest 
 extent, various authorities advise that, either as a constant or occa- 
 sional rule, the presenting part of the placenta should be perforated, 
 rather than that more of the attachments of the placenta to the 
 cervix should be separated during the operation f and at all events, 
 if the hand is introduced between the cervix and placenta, it is to be 
 passed to one side only, and in such a way, as to produce as little 
 detachment as possible between the two organs. 
 
 ' Baudelocque's Midwifery, Heath's Translation, vol. ii. p. 37. 
 
 ' For the practice of perforating the placenta, " the obvious reason," says Dr. Rigby, is, 
 " that by this means not more of the placenta may be separated than is necessary for the 
 introduction of the hand, and consequently that as little increase of bleeding as possible may 
 be produced by the operation ; but if it be impracticable, as I have more than once found it, 
 and it must ever be when the middle of the placenta presents to the hand, from the thickness 
 of it near the funis, it must be carefully separated from the uterus on one side, and the hand 
 passed, till it gets to the membranes." — Essay on Uterine Hemorrhage, p. 61. Dr. Foster 
 inculcates the perforation of the placenta under all conditions as the best method of proceed- 
 ing to turn in unavoidable hemorrhage. — Principles and Practice of Midvi^ifery : London, 
 1781, pp. 231-32. In one instance, Smellie tells us, he was obliged to employ it (vol. iii. p. 
 163). Richter, in his Synopsis Praxis Medico-Obstetricae, p. 176, attributes the first recom- 
 mendation of this practice to Deleurye and Mohrenheim. Deleurye (Trait^ des Accouche- 
 mens, p. 368), argues, on the contrary, strongly and sensibly against the practice. Mohren- 
 heim did not publish his "Abhandlung uber die Entbindungskund," till 1791. 
 
PLACENTA PREVIA. 669 
 
 While all thua perfectly agree upon the general rule, that the 
 child should be extracted before the placenta, at the same time a 
 self-evident and necessary exception to this practice is mentioned by 
 Guillemeau^ (who was himself among the first, if not the very first, 
 to inculcate the necessity of turning in placental presentations), and 
 by Mauriceau,^ Daventer,^ Eoederer," Ould,^ Pugh,° "Wallace John- 
 son,' and other authors.^ Occasionally, by the time that turning 
 seems required, or before the operator is called upon to pursue this 
 measure, the placenta has been already separated by the uterine 
 contractions, and is so far protruding or pushed down into the 
 vagina, as to fill up that canal, and prevent the easy introduction of 
 the hand, or the ready extraction of the infant. Under such a com- 
 plication, the authorities I have named unite in stating, that we 
 must, as a matter of necessity, first remove the detached and ob- 
 structing placenta, in order to have the maternal passages suffi- 
 ciently clear for the operation of turning. 
 
 The cases and circumstances under which this point of manage- 
 ment has been advised are totally and essentially different, and 
 founded upon a different principle from those in which I venture to 
 recommend the extraction of the placenta before the child. A 
 quotation or two trom one or more of the authors to whom I have 
 
 1 Les CEuvres de Chirurgie, p. 320, Rouen, 1649. Guillemeau's i-ules for the management 
 of cases of placenta prsevia are so original, explicit, and brief, that I shall quote them here 
 in full. — " II faut observer deux choses. La prSmilre est de oonsiderer si ledit arrifere-fais 
 est feu ou beaucoup advance et sorty ; car estant pen advanc6 (apres avoir bien situ6 la mere) 
 il sera remis et repouss6 le plus diligemment que faire se pourra; et si la teste de I'enfant 
 se presente, elle serra conduite droict au couromiement, pour aider il Taccouchement naturel. 
 Mais s'il se trouve quelque difficult^, et que Ton appergoive que ladite teste ne se puisse tost 
 avancer, ou que la mere ou Venfant, ou tous deux ensemble soient debiles; prevoyant que 
 I'accouchement soil long, sans faute le plus expedient sera de chercher les pieds de I'enfant, 
 comme nous avons dit, et le tirer doucement par iceux. L' autre point a observer, est si ledit 
 arriere-fais e^t fort sorty ^ et qu'il ne se puisse remettre, tant pour sagrosseur que pour le flux 
 de sang qui Taccompagne ordinairement; joinct aussi que I'enfant le suit de presse, et ne 
 demands qu'&- sortir et venir au monde, il faudra, tirer du tout ledit arriere-fais ; lequel estant 
 tire et sorti sera mis h. cost^ sans couper le boyau qui est adherant &, iceluy ; Car par la guide 
 dudit boyau I'enfant se trouvera lequel s'il est viuant ou mort sera tir6 par les pieds le plus 
 dextrement que faire se pourra." — In the Provincial Medical and Surgical Journal for April 
 2, 1845, Mr. Blenkinsop has inadvertently published a literal translation of the above passage 
 into old English, as a piece of original writing, by Dr. Percival Willoughby. 
 
 2 Diseases of Women vpith Child; Charaberlen's Translat, p. 220. 
 
 " Art of Midwifery, p. 154. '' Elemens de TArt des Aocoiiohemens, p. 368. 
 
 5 Treatise on Midwifery, p. 76. « Ibid., p. 113. ' System of Midwifery, p. 33. 
 
 * Smellie (Cases, &c. in Midwifery, vol. ii. p. 307) states a case in which he followed this 
 practice, the head being "hindered from advancing by the placenta." At p. 315, he observes, 
 " I have had cases where the placenta has come down into the vagina before the child's 
 head, and was obliged to deliver it first."' It is remarkable that later authors should not 
 generally mention a rule so obvious as that spoken of in the text. Yet among the writei^p of 
 the present century. Petit is the only one, so far as I at present recollect, who even adverts 
 to it. — See his Trait($ des Maladies des Femines. tom. ii. p. 23, 1806. 
 
670 COMPLEX LABOR. 
 
 referred will point this out. I shall select for tMs purpose the 
 observations of Mauriceau and Roederer, as being at once the 
 simplest and tlie most explicit on tbe matter. 
 
 "If," observes Mauriceau— and I give as nearly as possible a 
 literal translation of Ms words, " the placenta only presents at the 
 OS uteri without passing out, and the membranes are still entire, as 
 sometimes happens, the accoucheur will push aside a little the part 
 of the placenta that presents, till he reach the membranes, which he 
 will immediately rupture with his fingers, to allow the waters to 
 escape, and at the same time to turn the child, if it presents by any 
 other part than the feet ; by which he ought immediately to draw it 
 out. For it must be observed, that the after-birth, which presents 
 first, is now nothing more than a foreign body in the womb, when 
 it is entirely separated from it, as it is now ; and that in this case 
 one ought, as it would seem, to draw it out before the infant. 
 Nevertheless, as it is strongly attached to the membranes surround- 
 ing it, one would not easily accomplish this ; for we could not pull 
 away the body of the placenta, without at the same time pulling 
 away the membranes that surround the body of the child ; besides, 
 the membranes that line the whole of the interior of the womb, 
 from their smooth and polished surface, allow the child to be more 
 easily turned, and prevent by their interposition the womb from 
 being easily injured during the operation ; which would not succeed 
 so well if the placenta were just pulled away. For these reasons it 
 is much more sure to draw away the infant first ; which is, more- 
 over, on these occasions, so feeble, that it would soon die, unless 
 promptly assisted. But if the surgeon find that the after-hirth is 
 almost completely escaped from the womb, and that its membranes have 
 been almost entirely broken up and torn, in this case he ought to draw 
 it out ; for, besides that it would now be useless to push it back into 
 the womb, it would very much incommode the surgeon in his opera- 
 tion, and make him lose time in assisting the child.'" 
 
 • Maladies des Femmes Grosses, &c., torn. i. p. 332. Speaking of Maurioeau's opinions 
 and practice in placental presentation, Dr. Lee observes, " The rules for the treatment of 
 these cases are laid down with the greatest precision. When the placenta was entirely 
 separated, then only did he consider it as a foreign body, and recommend its extraction 
 before the child ; but to this practice, he states, as an obvious objection, that the placenta is 
 strongly attached to the membranes which surround it, and that it cannot be drawn out 
 without the membranes enveloping the body of the child being drawn out also. Mauriceau 
 has related seventeen cases of uterine hemorrhage in the later months of pregnancy from 
 presentation of the placenta, and in sixteen of these, delivery was accomplished artificially 
 by passing the hand through the opening formed by the separation of the placenta from the 
 uterus, rupturing the membranes, and turning the child. Two women died after this 
 operation, and one who would not consent to have it performed, died undelivered." — An 
 Historical account of Uterine Hemorrhage in the latter months of Pregnancy, by Dr. Robert 
 Lee, Edinburgh Medical and Surgical Journal, 1839, p. 332. 
 
PLACENTA PRiEVIA. 671 
 
 Eoederer, according to the just and candid remark of Dr. Edward 
 Eigby, " stands pre-eminent as being tbe first author who gives a 
 distinct and complete description of this [the unavoidable] species 
 of hemorrhage."' After stating the propriety of passing the hand 
 between the cervix and placenta, and promptly extracting the child 
 by turning, when the hemorrhage is great, he adds, in relation to 
 the point I refer to, " If the placenta is entirely detached, and is 
 arrested in the vagina, and opposes the passage of the hand, it 
 ought to be brought out with the clots that fill the vagina. But if 
 the hand can be introduced, the placenta should be left, that it may 
 shut up the passage by which the blood and liquor amnii which dis- 
 tend the womb, might escape. In all cases when it is adherent to 
 the womb, in whole or in part, it is most advantageous both to 
 mother and child to leave it."^ 
 
 The preceding extracts show that, as I have stated, the cases and 
 circumstances under which the removal of the placenta before the 
 child has been recommended by some of the older authorities, are 
 entirely different from those in which I wish in these pages to insist 
 upon its propriety. I advise its separation in cases in which it is 
 still attached to the cervix, and often still contained within the 
 undilated os uteri ; they advised its removal only in cases in which 
 it was already separated from the cervix, and expelled through the 
 dilated os uteri. They began their practice of removing the pla- 
 centa at the very point at which I would generally end all inter- 
 ference with it, viz., after the placental mass was completely de- 
 tached. I would employ its artificial detachment as a measure of 
 election and choice ; they resorted to its removal from the passages, 
 after it was detached by nature, merely as a measure of self-evident 
 necessity and compulsion. I recommend its separation upon the 
 pathological principle of arresting the existing hemorrhage, and so 
 far cancelling the immediate source of danger to the mother ; they 
 recommend its abstraction on the physical principle of clearing the 
 obstructed maternal passages, and gaining more free space for the 
 operation of turning. They removed the placenta in order to be 
 able to have recourse immediately to turning. I would remove it, 
 in order to prevent the necessity of having recourse at all to that 
 operation. 
 
 After having become interested in the investigation of the present 
 subject, I made a somewhat extensive research among obstetric 
 works and essays, with the double object of ascertaining the average 
 mortality to the mother in placental presentations under the com- 
 
 ' System of Midwifery, p. 252. 
 
 2 Elemens de 1' Andes Aceouchemens, p. 388, Paris, 176.5. 
 
672 COMPLEX LABOR. 
 
 moD. modes of management, and with the view of attempting to 
 ascertain if any author had previously practised, or proposed as a 
 plan of treatment, the method which had suggested itself to my 
 mind, of artificially separating, and, if necessary, of removing the 
 placenta instead of the infant, and operating thus not mpon the child, 
 but upon the after-birth. The results of the first part of the inquiry 
 I have given in a preceding page. In reference to the second point, 
 I was long under the belief, that I was original in the idea of a 
 practice, which, so far as I was myself concerned, was in the first in- 
 stance the result of simple reasoning upon the data afforded by two 
 cases that I had personally observed, and by the histories of a few 
 others that I had read of, or collected. 
 
 At the time I laid a summary of the present paper before the 
 Edinburgh Medico-Chirurgical Society in December last, I had not 
 met with any cases or remarks which altered my opinions in this 
 respect. I stated at the time that I was the more surprised at such 
 a result, for, believing as many of the old«r authorities did, that 
 before the placenta could be found presenting at the os, it had 
 already become detached, and fallen down from the higher parts of 
 the uterus, I fully expected to meet with some of them recommend- 
 ing its removal at an early stage of the labor, if not upon the princi- 
 ple of arresting the attendant hemorrhage, at least for the purpose 
 of clearing away a supposed foreign and obstructing body. They 
 appear to have been generally intimidated from following such a 
 line of practice by the dread of injuring the unruptured membranes, 
 and through them the inner surface of the uterus, as intimated in 
 the quotation which I have already made on this point from Mauri- 
 ceau. And hence also the removal of the placenta, when it was 
 once found completely, or almost completely, protruded from the 
 uterus, and obstructing the vagina so as to impede turning, was 
 justified, on the similar ground that before this could happen, the 
 membranes were necessarily torn, and consequently no evil effects 
 would now ensue from this mode of interference. 
 
 Since these observations were communicated to the Medico-Chi- 
 rurgical Society, I have fallen in with two cases recorded by one 
 author, and a suggestion incidentally offered by another, both of 
 which bear, as it appears to me, so importantly upon the history of 
 the practice which forms the immediate subject of these remarks, 
 that I shall make no apology for dwelling briefiy upon them. 
 
 During my former researches among the older authors, I did not 
 examine in detail, as I certainly ought to have done, the cases of 
 placenta prsevia detailed in the work of the celebrated Paul Portal. 
 In drawing up the table of maternal mortality in placental presenta- 
 tion (see page 601), I had predetermined to take the returns of 
 
PLACENTA PR-SVIA. 673 
 
 whieli it consists, from such authors or sources only, as mentioned 
 upwards of at least ten cases, in order that I might arrive at more 
 certainty and statistical truth in the calculation. I took it for granted 
 that Portal's cases did not come within this range, in consequence 
 of Drs. Eigby,' Lee,^ and others, erroneously speaking of them as 
 being only eight in number. On the other hand, I knew well that 
 this accurate and original observer was acquainted with the fact, 
 that in placental presentations, the placenta was originally fixed 
 over the os uteri, and had not fallen down there after its attachment 
 to the fundus. Hence, I did not expect to meet among his cases 
 with any instances in which the placenta had been artifically ex- 
 tracted before the child as a foreign body, or any deviation made 
 from the treatment usually followed. In two cases, however, which 
 he has described, he most distinctly adopted the practice of detach- 
 ing the whole placenta immediately before extracting the child. 
 As these cases appear to me to be in various respects, not only his- 
 torically, but practically, interesting, I shall take the liberty of quo- 
 ting them at full length. They afford strong additional instances 
 of the success of the practice which it is my wish to inculcate. 
 
 Case XXX. — " The Delivery of a Child with the after-burthen fore- 
 most. — April the 7th, 1672. — I was called to a woman in St. Mederic's 
 Street, being in the sixth month of her reckoning, and troubled 
 with a violent flux of -blood. I told her immediately, that without 
 being delivered forthwith, she was in danger of her life. Dr. Cresse, 
 a Paris physician, was of the same opinion, and ordered her imme- 
 diately to be let blood ; however, we staid a little to see whether 
 nature would help itself, it happening sometimes that such fluxes 
 cease when the child comes to the birth well turned. But the 
 woman, growing weaker and weaker, her husband and friends asked 
 my opinion once more, and I answering, that the delivery of her 
 was the only way to secure her life, they desired me to delay no 
 longer. 
 
 "Whereupon I brought two of my flngers, well greased with 
 butter, into the inner orifice of the womb, and, finding the same 
 
 ' " In Portal's oases in Midwifery there are eight in which he was under the necessity of 
 delivering by art, in consequence pf dangerous hemorrhage, and in all of them he found 
 the placenta at the mouth of the womb." — Rigby's Essay on Uterine Hemorrhage, 6th edit, 
 p. 22. 
 
 " "Portal's Treatise, 1685, contains an account of eight cases of uterine hemorrhage, in 
 which he found the placenta not merely at the mouth of the womb, but adhering to the 
 whole neck of the uterus. In several of these eases, he felt the placenta adhering all 
 round to the internal orifice of the uterus. In those cases the treatment employed by Portal 
 did not differ from that which had been employed by Pard, Guillemeau, and Mauriceau, 
 the propriety of artificial delivery by turning being then as completely established as at the 
 present time." — Lee's CUnioal Midwifery, p. 140. 
 
 VOL. I. 43 
 
674 COMPLEX LABOR. 
 
 opened to the bigness of a French half-crown piece, I spread my 
 fingers in the nature of a screw, and thus extending it, brought in 
 my hand, and felt the after-burthen foremost. I separated the same 
 to open my way to the membranes, which being opened, the water 
 came forth, and I drew out the after-burthen, that it might not be 
 in the way afterwards.' Then, searching after the child's feet, I 
 took hold and pulled out one, which I baptized; and, wrapping a 
 cloth round the foot, I accomplished the delivery of a daughter of 
 six months, after my usual method. Immediately after the woman 
 recovered of her swooning fits, she began to breathe and speak, 
 telling us that she felt herself something stronger, but relapsed soon 
 after ; yet, being recovered again, by the care of Dr. Cresse, she did 
 very well afterwards. "We applied a plaister against the flux, made 
 of the flower of gips used by the plaisterer, mixed vrith the best 
 vinegar, laying it to the belly above the womb, and above the hips. 
 The next day we prescribed a clyster of barley and white bread, 
 boiled together, and mixed with three ounces of honey of violets ; 
 but the nurse, mistaking the matter, took honey of roses instead 
 thereof; whence, it is obvious how careful women ought to be in 
 choosing their nurses, since, by the management of clysters only, 
 many dangerous symptoms have ensued through the carelessness or 
 ignorance of the nurses. Wherefore women ought to pitch upon 
 such nurses as are used to attend in lyings-in, and such as they know, 
 that will not be employed in the small-pox and other infectious dis- 
 tempers, which thus may be communicated to the woman in 
 childbed. All nurses ought to be cautious not to give medicines 
 to women in childbed, without the advice of a physican, surgeon, 
 or expert midwife ; and especially not to apply astringent remedies 
 in the beginning of the flooding, which, if it succeeds ill, they are 
 sure to lay the blame on the man-midwife, or midwife. 'Tis but 
 lately that I knew such an ignorant and presumptuous nurse, who, 
 in the beginning of the flooding, washed the gentlewoman under 
 her care with red wine only, which, stopping the flooding, &c., fever 
 ensuing, the patient was forced to be let blood several times in the 
 arm and foot, and yet they had much ado to save her."^ 
 
 Case XXXI. — " The Delivery of a Woman affected with a most 
 violent flux of blood. — January 14, 1679. — I was called out in the 
 morning at four o'clock, to deliver a gentlewoman in the street 
 
 ' I shall quote the original French of this important passage: " Je glissayma main dans 
 I'entr^e de la matrice, 6u je sentis I'arrifere-faix qui se presentoit. L'ayant separ^, afin 
 de me frayer le chemin, je sentis les membranes des eaux que je per5ay, et les eaux s"estant 
 fecoiilees, je tiray I'arrifere-fajx le premier, afin qu'il ne m'incommodast point h la sortie de 
 I'enfant.''— La Pratique des Accourbemens, par Paul Portal, Paris, 1CS5, p. 203. 
 
 '^ Compleat Practice of Men and Women Midwjves, by Paul Portal, p. 148, Case 43. 
 London, 1763. 
 
PLACENTA PR^YIA. 675 
 
 called G-ervais Laurent, at the foot of the Bridge of Our Lady, in 
 the parish of the Holy Cross. This gentlewoman being about eight 
 months with child, was seized with a most violent flux of blood, 
 which having continued for ten or twelve days, she was reduced to 
 a miserable condition. Upon search made with my fingers (well 
 greased), I found the whole vagina or passage filled with clods of 
 coagulated blood, notwithstanding which the flux continued. As 
 soon as I had brought out the clods of blood, I conveyed my fingers 
 farther into the orifice of the womb, which I found very thin and 
 soft, and so wide, that I could put in three of my fingers foremost. 
 I searched with one finger first, and found the after-burthen foremost, 
 and closely joined round the inner orifice of the womb, which was 
 the occasion of the excessive flux of blood ; and, as it had reduced 
 the woman to a very low condition, so this, joined to the other cir- 
 cumstances, made me fear the life both of the woman and child. I 
 desiring, therefore, the assistance of a physician, Dr. Biendisant was 
 sent for, who, finding the poor patient not in a condition to dispense 
 with many remedies, prescribed her only a mixture of purslane and 
 plantain water, three ounces each, half a drachm of the confection 
 of hyacinths, without musk ; prepared pearls, one scruple, mixed 
 with an ounce and a half of the syrup of pomegranates. This 
 stopped the flux for a while, yet not quite ; so that her weakness, 
 increasing every minute, it was resolved to have her delivered, not- 
 withstanding the great danger which must needs attend it ; but 
 considering her death was infallible, unless she was delivered, I 
 went to work ; though as I laid her across the bed, there appeared 
 in her not the least signs of sense or motion, so that everybody con- 
 cluded she would die under my hands. However, I found some 
 means to convey my hands (well greased before) into the inner 
 orifice of the womb, where I again felt the after-burthen fastened to 
 it, as I had told Dr. Biendisant before. I peeled it ofl" by degrees, 
 and brought it out ; and then, turning my hand again in the womb, 
 the first thing I met with was the navel-string, along which I guided 
 my hand first to the child's belly, and then downwards to the thigh, 
 and hence lower to the leg and foot, which I brought out and bap- 
 tized.^ Whilst I was pulling this foot, the other followed, and the 
 whole body after it, as it has been observed frequently before. The 
 child being quite alive, the parish priest of the Holy Cross (who had 
 before administered the sacrament unto the mother) had the oppor- 
 
 ' "Je separay tout doucement cet arriere-faix, et je tiray dehors; ensuit je glissay ma 
 main dans la matrice. La premiere partie qui se presenta, fut I'ombilic que je suivis jusques 
 au ventre, apres lequel je suivis la cuisse jusques a la jambe et au pied, que je tiray k 
 I'orifice externa de la matrice sur lequel je jettay de I'eau, pour ondoyer I'enfant sous condi- 
 tion." — See original French edition of Portal's work, p. 293. 
 
676 COMPLEX LAEOE. 
 
 tunity of baptizing it, though contrary to his and all our expecta- 
 tions. Immediately after the delivery, the woman recovering m 
 some measure her senses, Dr. Biendisant prescribed the following 
 cordial : of succory and bugloss water, three ounces ea«h ; of the 
 confection of alkermes without musk, half a drachm; of prepared 
 pearls, one scruple ; and syrup of maidenhair, two ounces. About 
 two hours after, she was ordered to take half a cupful of broth only, 
 for fear of overcharging her stomach. She was much better the 
 next day, yet not without some symptoms of a fever, against which 
 a clyster was ordered, made of the decoction of the cooling herbs, 
 with three ounces of honey. The second day after the flooding 
 stopped, she recovered again by the use of the beforementioned cor- 
 dial. However, she complained of a tension and pain in her belly 
 (which was much swelled), as also in her hips, wherewith she had 
 been affected before her delivery : she was also afflicted with a 
 violent pain in the head (the ordinary symptom of all excessive 
 fluxes of blood), which continued even after her lying-in, with an 
 intermittent fever : she was also troubled with frequent bilious de- 
 jections, or a looseness, against which we prescribed her clysters of 
 the decoction of emollient herbs, with lintseed; yet, after some 
 time this woman recovered her health, except that three weeks after 
 her lying-in, she lost the sight of one of her eyes by a violent 
 defluxion, which by all the art that could be devised, was never re- 
 moved thence. The cause of this disaster' I attribute to a sharp, 
 viscid, and bilious humor, contained in the veins, which being put 
 in motion by the violence of the pain this woman suffered during 
 her labor, and the anxiety she lay under, was carried upwards and 
 settled in her head. "^ ,■• 
 
 In addition to the two preceding cases. Portal gives a detailed 
 account of six other placental presentations which came under his 
 care, and mentions six others that he had seen, but of which he 
 does not give the full particulars.^ In one of these cases the uterus 
 
 ' This is perhaps the earliest case on record of that Phlebitic or Puerperal Opthalmitis to 
 which the attention of the profession lias been particularly called in our own day by Drs. 
 Hall and Higgenbotham, Dr. Locock, Dr. M'Kenzie, and others. In attributing it to a 
 " humor contained in the veins," Portal almost forestalls the pathology of the disease 
 accredited at the present day. An instance of this destructive ophthalmia occurred two 
 years ago, in the practice of my friend Dr. Graham Weir, after, as in Portal's case, a pla- 
 cental presentation. The patient also ultimately recovered. I know of a case in which 
 both "eyes were affected. Some years ago, in a case of placental presentation, in which I 
 turned the child, I saw come on in a different part, namely, the region of the parotid gland, 
 a secondary inflammatory deposit from " a sharp humor contained in the veins, and carried 
 upwards and settled in the head." I have met with one other case of fatal Puerperal Paro- 
 titis. (For further observations on this subject, see Section on Pathology of Puerperal 
 State, in vol. ii.) 
 
 * Compleat Practice of Men and Women Midwivos, p. 214, Case 69. 
 
 " Ibid. pp. 29-105, 107, 135, 143, 166, 169, 250. 
 
PLACENTA PREVIA. 677 
 
 contracted so strongly, as to push tbe child through the placenta. 
 The mother recovered. In all his other eases he seems to have in- 
 troduced his hand, and turned the infant; but in none of them, 
 with the exception of the two we have already quoted, does he state 
 such particulars as to show whether, as in them, he entirely sepa- 
 rated the placenta immediately before turning the child, or only 
 partially separated it in that position, so as to enable his hand to 
 pass into the uterine caviiy, for the purpose of practising version of 
 the infant. Unfortunately he in no passage states to us in the way 
 of remark, or otherwise, what special practice, or principle of prac- 
 tice, he recommended or followed in placental presentations, and in 
 only one part does he throw out any hint of the reason which in- 
 duced him to separate the placenta in the two cases I have cited. 
 The hint in question I have already had occasion to quote, as given 
 incidentally in the details of the first case which I have already cited 
 (see Case XXX.) "I drew out," he observes, "the after-birth first, 
 that it might not incommode me during the passage of the infant. 
 (Je tiray V arriere-faix le premier, afin qu'il ne m'incommodast point d 
 la sortie de V enfant")} And in all probability this was his sole and 
 only reason for the practice. For if he had separated the placenta 
 with any idea whatever of the principle under which I have recom- 
 mended it, namely, that of totally arresting the violence of the at- 
 tendant hemorrhage, and averting the principal or only danger to 
 which the patient is subject in placental presentations, he certainly 
 would not have practised what he tells us he did — the instantaneous 
 extraction of the infant afterwards. 
 
 I have already (at page 608) mentioned some particulars of a very 
 interesting case of expulsion of the placenta before the child, de- 
 tailed by Mr. Chapman, surgeon at Ampthill, Bedfordshire, and 
 reported by him in the 4th volume of Dr. Duncan's Annals of Medi- 
 cine, published in the year 1800. My attention has been particu- 
 larly drawn to three brief remarks that Mr. Chapman appends to 
 his case. One of these remarks is specially deserving of note, from 
 containing, so far as I am aware, the first explicit suggestion as to 
 the proper principle of treatment in some placental presentations. 
 I shall quote it in the author's own words. "From the expulsion 
 of the placenta to the birth of the child was full four hours. She 
 (the mother) lost little or no blood. How far does this suggest a 
 different practice to that in general followed ? I mean that of deli- 
 vering the placenta previous to delivering the child, in those cases 
 of alarming hemorrhage where the placenta is situated on the side 
 • of, or over, the os uteri. "^ 
 
 ' Pratique des Accouohemens, p. 209. ^ Annals of Medicine, vol. iv. p. 308. 
 
678 COMPLEX LABOR. 
 
 Up to the time at whicli I communicated the views contained in 
 the present memoir to the Medico-Chirurgical Society in December 
 last, the two cases that I have quoted from Portal, and the preceding 
 interrogatory of Mr. Chapman, contain, so far as I have been able 
 to learn, all that had been put upon record with reference to extrac- 
 tion of the placenta before the child, in placenta prsevia. Since, 
 however, the first part of the present paper was printed in the 
 Monthly Journal of Medical Science, I have obtained such informa- 
 tion as to convince me, that several years ago, a medical teacher and 
 practitioner of the highest distinction in Manchester was aware that 
 the total separation of the placenta in unavoidable hemorrhage was 
 capable of arresting the attendant flooding, and adopted this prac- 
 tice as a measure of treatment in one of the classes of cases that I 
 shall have occasion to consider under the next section, namely, 
 where the woman is too exhausted to allow with safety of the ope- 
 ration of turning. The gentleman I allude to was the late Mr. 
 Kinder Wood, who for some years was lecturer on Midwifery in 
 the Manchester Medical School. He died in 1830. His opinions 
 on this matter were never, so far as I have been able to ascertain, 
 known or divulged beyond the range of his own immediate friends 
 and pupils ; and one of his own colleagues in the Manchester Lying- 
 in Hospital, Mr. Wood, confesses he was unacquainted with his 
 views till they were mentioned to him within the last few months. 
 
 In a short and interesting biographical account of Mr. Kinder 
 Wood, published in the London Medical Gazette for 1830, it is 
 stated that he left behind him a volume of midwifery essays all but 
 ready for the press.' One of the'se papers was entitled, " An Essay 
 on IJterine Hemorrhage, and the best mode of treatment in alarm- 
 ing cases of this kind." It is deeply to be regretted that this 
 volume has never been given to the public, as the opinions of so 
 acute and able an observer as Mr. Kinder Wood on any points con- 
 nected with the obstetric profession, are almost certain to be suffi- 
 ciently valuable to have entitled them to a better fate. Dr. Rad- 
 ford, who succeeded Mr. Kinder Wood as lecturer on midwifery in 
 the Manchester School, purchased, as I am informed, the manu- 
 script volume I allude to, after the author's death, and has lately 
 published the following observations and cases of Mr. Kinder 
 
 ' The biographer, Dr. Bardsley, states: " Mr. Wood had been employed for some time in 
 collecting materials for a separate volume on midwifery, embracing the consideration of some 
 of the most important points connected with the practice of the art. The essays on ' Uterine 
 Hemorrhage, and the best mode of treatment in alarming cases of this kind ;' on ' Rupture 
 of the Uterus during Labor;' on 'Inversion of the Uterus ;' and on ' Impracticable Labor 
 from Distortion,' are left in such a state of readiness for the press, as to require only a few 
 verbal, and other trivial alterations, before being submitted to the public eye, should this be 
 the intention of Mr. Wood's family."— London Medical Gazette, vol. vii. p. 624. 
 
PLACENTA PREVIA. 679 
 
 Wood, relative to unavoidable hemorrhage, probably from the 
 manuscript in question. I have very great and sincere pleasui'e in 
 inserting them here, at length, as a piece of posthumous justice 
 to the memory of a man of distinguished professional attainments.* 
 " If we find so much exhaustion as to make us fear the effect of 
 further hemorrhage, during artificial delivery, the first step after 
 passing the hand, must be to detach the whole of the placenta ; 
 by this, hemorrhage will be completely suppressed, for the effect 
 of passing the hand through the os uteri, and throwing off the 
 placenta, will always be to produce so much contraction as to arrest 
 the bleeding from the small decidual or uterine mouths. It is satis- 
 factory to know that the child is rarely living in these cases of 
 exhaustion, its blood being poured out through branches of the 
 placental structure, along with that of the mother; and when 
 brought down, its appearance, like that of the mother, is bleached 
 and exsanguined. The time required to separate the placenta is 
 very short, and the loss of blood during the attempt exceedingly 
 trifling. I know from experience, that when the placenta is wholly 
 detached, the hemorrhage will cease." 
 
 Case XXXIL — " I was desired to see Mrs. Clayton, Lad Lane. 
 The hemorrhage had been going on several days, under the inspec- 
 tion of a female midwife, without any assistance or advice. The 
 discharge had been excessively profuse, and was coming away in 
 gushes, with slight pain, every two or three minutes. She was 
 extremely exhausted ; of a deadly paleness, very cold, with a quick 
 and feeble pulse ; the os uteri was moderately dilated, the cervix 
 
 * " Since I communicated the present memoir to ihe Medico-Chirurgical Society, Dr. Radford 
 has himself given and published a lecture on galvanism, in which, among other ingenious 
 suggestions, he proposes the detachment of the placenta to be adopted in conjunction with 
 galvanism, in cases of placenta previa." — Provincial Medical and Surgical Journal for 
 December 24, 1844. In this lecture he limited the practice in question to cases of "exhaus- 
 tion" — as Mr. Kinder Wood had done. Latterly, however, in the same Journal (see Number 
 for January 22, 1843), he has adopted more fully, and published, my previous ideas of apply- 
 ing the detachment of the placenta to other cases of placenta praevia, besides those in which 
 there is simple exhaustion, erring, however, in this, that he conceives the practice is one 
 which cannot be attempted until the cervix and os uteri will safely allow the introduction 
 of the hand. Under the next section we shall find that this would exclude an important 
 range of cases to which the practice is especially applicable. I had an opportunity of stating 
 my views on the artificial detachment of the placenta to Dr. Radford when he made a visit 
 to Edinburgh last year. Dr. Catnpbell, the well-known Lecturer on Midwifery in Edin- 
 burgh, and a friend of Dr. Radford, heard the subject discussed between us. When writing 
 lately upon this matter. Dr. Campbell observes, " It does strike us as remarkable, that Dr. 
 Radford, while on a visit to this city something less than a year ago, did not, when this 
 subject was the topic of conversation, make known his knowledge of Mr. Kinder Wood's 
 views." — The Northern Journal of Medicine for July, 1845, p. 90, See further the Provin- 
 cial Medical Journal for Feb. 5th, Feb. 26th, and March 19th, 1845. See also London and 
 Edinburgh Monthly Journal of Medical Science, Feb. 1845, p. 161, 
 
680 COMPLEX LABOR. 
 
 obliterated, and the placenta presenting. I feared the effect of 
 hemorrhage, which must occur during the act of delivery in the 
 common manner. The patient was placed in a proper position, 
 and a little brandy and water exhibited, and the placenta conii- 
 pletely detached, as the hand dilated the os uteri, and before reach- 
 ing the feet of the child. No hemorrhage succeeded the separa- 
 tion. The patient recovered favorably, but slowly. Octaber 4, 
 1821." 
 
 Case XICXTH . — " I was desired to see a poor woman in Few- 
 berry Street. I found from the female midwife in attendance, that 
 the discharge had been going on long and copiously. The poor 
 patient was extremely exhausted. Feeling that she could not sur- 
 vive long if left to nature, and that she could not bear the hemor- 
 rhage consequent upon the common operation, I separated the 
 placenta, brought down the feet of the child, and delivered. The 
 effusion produced by separating the placenta was extremely slight, 
 and it ceased upon effecting the complete detachment. The child 
 was dead, and tending to putrefaction. A stimulant was given 
 before the operation, and during its continuance, but the heart never 
 recovered its energy nor the skin its warmth. She died in about an 
 hour, from pure exhaustion. Ifovember 1, 1821." 
 
 Case XXXTV.— « I attended Mrs. T., I^fewton Heath. She was 
 very much exhausted. It was obvious she could not bear the loss 
 of blood consequent upon the ordinary delivery. A cordial was 
 now administered. The hand was introduced, and the placenta, 
 which was adherent over the os uteri, was completely separated, the 
 membranes ruptured, and the feet seized. The child was easily 
 delivered. She only survived the operation a very short time, 
 although the hemorrhage ceased from the moment the placenta was 
 detached." 
 
 Case XXXV.— "I was called to Mrs. B., January, 1822, aged 25, 
 St. James's, who was violently flooding. I found her cold, and her 
 pulse scarcely perceptible ; os uteri partially dilated and soft ; brandy 
 and water given ; the discharge still continued ; she was much ex- 
 hausted. The hand was introduced, the placenta detached, and the 
 membranes ruptured. There was no further discharge ; but she 
 died in a few hours afterwards, although stimulants were freely 
 administered." 
 
 Case XXXVI.—" On the morning of the 11th April, 1822, 1 was 
 desired by a female midwife to see Mrs. Rawson, in Little Lever 
 Street. She was in the latter end of the eighth month of preg- 
 
PLACENTA PR-ffilVIA. 681 
 
 nancy. She had sustained frequent and copious discharges the two 
 previous months, and which were very profuse during the night. 
 The pains were slight, but always attended with fresh discharge. 
 The patient presented a very distressing appearance. The pulse 
 could not he counted ; the lips were white ; she was very cold, and 
 spoke in a whisper ; she had frequent syncope. "Warm brandy was 
 freely administered. The patient was placed with the utmost care 
 slowly and gently on the side, and upon making an examination, 
 the OS uteri was found low, soft, and dilated about the size of half 
 a crown, the cervix was obliterated, the placenta was found over the 
 OS uteri, one portion was loosened. Convinced that the patient 
 could not bear immediate delivery, and satisfied that the hemor- 
 rhage would be fatal very early if she was left to nature, I insinuated 
 the hand through the os externum and os uteri, detaching the 
 placenta by sweeping the fingers beneath it, as the hand was passed 
 forwards. The soft parts yielded freely, and the operation was done 
 quickly and easily, and with very trifling loss of blood. The presence 
 of the hand excited uterine contraction, and seemed to rouse the 
 languid patient. A stimulantwas given during the operation. The 
 head was found presenting. After the placenta was separated, the 
 membranes were ruptured, and the hand slowly withdrawn. She 
 was ordered to remain in a state of perfect and complete rest, to 
 take light support, and a stimulant mixture every three hours. The 
 labor pains became stronger about six hours afterwards, and in an 
 hour expelled the placenta, and a dead child, tending to putrefaction. 
 No hemorrhage occurred when the hand was withdrawn, after de- 
 taching the placenta. The patient regained health slowly, and had 
 a severe attack of phlegmasia dolens. 
 
 " In some cases I have been called to attend when the ordinary 
 method of delivery has been adopted, the patients died, and this led 
 me to modify the practice, which I adopted in some of the above 
 cases by detaching the placenta, rupturing the membranes, and then 
 delivering the child ; but after due consideration, I was again induced 
 to vary my plan ; and in those cases where we can have no hope of 
 saving the patient if we proceed to delivery, however well the opera- 
 tion be conducted, I have no hesitation in recommending that the 
 placenta be separated completely, and the membranes ruptured, that 
 the hand be withdrawn immediately upon this being effected, leaving 
 the child and placenta behind. By this practice, the patient will 
 be placed precisely in the situation which occurs in the most favor- 
 able cases of recovery [delivery] by the natural efforts. I conceive 
 no fact in midwifery rests upon a more solid foundation, than that 
 this hemorrhage will cease upon separating the placenta, and by this 
 practice the patient is placed in as favorable a situation as is possible 
 
682 COMPLEX LABOR. 
 
 for recovery. Time will be gained to support her by proper means, 
 and which can be used with greater freedom, as the hemorrhage is 
 infallibly suppressed by this operation." 
 
 On communicating, a few months ago, my ideas upon the subject 
 of this memoir to my esteemed friend Dr. Beatty of Dublin, he 
 favored me with the following account of a very interesting and 
 illustrative case from the note-book of his late father. It is dated 
 July 28, 1835 (1825 ?) 
 
 Case XXXVII. — Placenta prolaUy entirely separated for about 
 twenty-four hours before delivery ; hemorrhage arrested by it. — " The 
 practice I adopted in this case was such as I never tried before, nor 
 heard of, and from its success I think it necessary to note it. This 
 lady sent for me at four o'clock on the morning of the 27th. I 
 found that she had been flooding excessively, and, as the nurse 
 said, she was in a sea of blood. She was within three weeks of her 
 full time. I examined and found the placenta directly over the os 
 uteri. I sent for Dr. Duke, and on his coming, I introduced my 
 hand into the vagina, and, finding I could not turn without more 
 difficulty than I thought necessary, it occurred to me to separate as 
 much of the placenta as was within my reach. This I did to such 
 an extent as entirely stopped the hemorrhage, except a trifling 
 oozing. She continued all day without pain, and about three 
 o'clock the following morning, labor set in, and she was delivered 
 of a still-born child at half-past four o'clock, a. m. She had no 
 further flooding, and is likely to do well." 
 
 Since the publication of the flrst part of the present essay, three 
 instances have been published in the Medical Journals, in which 
 the proposed practice was adopted — one by Mr. "Wilkinson of Spald- 
 ing, another by Dr. "Walker of Chesterfield, and a third by Dr. Mac- 
 lean of Edinburgh. I shall append an abridged detail of these cases. 
 
 Case XXXVm. — Flooding suppressed by the artificial separation 
 of the placenta ; patient delivered in an hour and a half afterwards. — 
 Mr. "Wilkinson was called, on the 7th June, 1843, at 12 p. m., to a 
 woman between six and seven months advanced in pregnancy. 
 " Three weeks previous to my being sent for," says he, " there had 
 been, I was informed, very great hemorrhage, which had continued, 
 more or less, up to the time of my seeing her. On the evening of 
 the 7th, it had been very considerable, and previous to my seeing her, 
 excessive. I found the os uteri dilated to the size of something less 
 than a five-shilling piece ; the placenta presenting ; the hemorrhage 
 excessive ; the pains very feeble. She was greatly exhausted ; the 
 
PLACENTA PREVIA. 683 
 
 pulse scarcely perceptible ; the countenance blanched, and I found 
 that she must sink. I directed some brandy and water to be got down 
 immediately, and also a scruple of ergot of rye. I passed first three 
 fingers, and, with as little delay as possible, the whole hand, into 
 the uterus. The gush of blood was at first great ; the placenta, 
 however, was quickly and completely detached, and the hemorrhage 
 almost at once ceased. I waited a while with my hand in the uterus ; 
 I then brought away the placenta, and immediately reintroduced 
 my hand, with a view of bringing on contraction. The head of the 
 child presented ; I turned ; but feeling that my patient was not in 
 a state to bear immediate delivery, I waited an hour and a half. 
 She then having somewhat rallied, I delivered. She remained 
 during the first two or three days in a most exhausted state, from 
 which, however, she gradually recovered. I feel satisfied," Mr. 
 Wilkinson adds, " that had the usual plan been adopted in this case, 
 so great had been the hemorrhage previously to my seeing her, that 
 she must have sunk."^ 
 
 Case XXXIX. — Hxhausting flooding ; placenta extracted, and floods 
 ing suppressed ; arm presentation.; turning. — ^Dr. Walker was called 
 to see Mrs. H — ^w, about four hours after labor with her sixth child 
 had begun. She appeared in a most alarming state of exhaustion, 
 exhibiting in an extreme degree all the symptoms consequent upon 
 great loss of blood. " On making an examination," writes Dr. 
 Walker, " I found the vagina filled with clotted blood, the os uteri 
 fully dilated, and a large portion of the placenta presenting, nearly 
 closing the orifice of the uterus. With some difficulty, I passed my 
 finger round the anterior edge of the placenta, to ascertain the pre- 
 senting part of the child, and felt what I thought was either a 
 shoulder or the nates. The attempt increased the hemorrhage 
 slightly ; and, fearful of further reducing the already too exhausted 
 powers of my patient, I desisted. Having previously determined 
 to adopt the plan of treatment lately brought before the profession 
 by Drs. Radford and Simpson, I proceeded to remove the placenta. 
 Introducing my left hand, I completely, and in one mass, separated 
 the placenta, which was immediately expelled with my hand into 
 the vagina ; after its complete removal, the hemorrhage, which 
 before was considerable, entirely ceased. At this time, the pains 
 were feeble, and not of frequent occurrence. At my next examina- 
 tion, I found that a hand had followed the placenta, and now pre- 
 sented at the OS externum. With the usual precautions, version 
 was easily accomplished, and the woman safely delivered of a still- 
 born child. The uterus contracted with tolerable firmness, and no 
 
 ' Piovincial Med. and Surg. Journal for July, 1845, p. 471, 
 
684 COMPLEX LABOR. 
 
 farther hemorrhage supervened. On the day following, I found my 
 patient comfortable, though suffering slightly from the effects of 
 the hemorrhage, and in a few days she was perfectly recovered."' 
 
 Case XL. — The placenta extracted artificially before the child; rapid 
 recovery of the mother. — This case I have already alluded to as having 
 happened in the practice of Dr. Maclean. The subject of it, Mrs. 
 Mxon, was taken in labor with her eighth child on the 14th of June, 
 1845, at 4 P.M. The pains were trifling till about three next morn- 
 ing, when they became more frequent and severe, and were accom- 
 panied with a discharge of blood. The os uteri was found at this 
 time expanded to the size of a shilling, but rigid and undilatable, 
 with the placenta presenting ovef it, and a constant oozing of blood, 
 which at each pain became much increased. The pains and dis- 
 charge nearly ceased after the administration of a slight opiate, and 
 using the ordinary means to check the hemorrhage. At 11 o'clock 
 the pains and flooding returned ; and an hour and a half after this, 
 "I found," says Dr. Maclean, "the os dilated to the size of a half- 
 crown, the placenta presenting, and protruding through it about one 
 and a half inches. The hemorrhage, which had recurred with the 
 pains, had caused such a degree of faintness and collapse, that the 
 fatal termination of the case appeared inevitable ; and the pains, 
 which now came on frequently, from the great weakness of the 
 patient, had but little effect in dilating the os uteri, and advancing 
 the labor. Having ascertained," he continues, " by the stethoscope, 
 that the child was dead, and Mr. Woodhead being again in atten- 
 dance with me, it was at once agreed upon, in consultation, the 
 mother alone requiring our immediate attention, and the state of col- 
 lapse to which she was reduced rendering the forced delivery by turn- 
 ing exceedingly dangerous, whilst the evacuation of the liquor amnii 
 had entirely failed even to moderate the hemorrhage, that I should 
 immediately endeavor to suppress the discharge by separating the 
 whole body of the placenta from the uterine parietes, when the 
 patient might be allowed to rally a little before removing the child, 
 supposing the views of Dr. Simpson to be correct. Accordingly, 
 having administered a small quantity of spirits, with a few drops of 
 laudanum, to the patient, I immediately introduced my hand into 
 the womb, so as to remove the placenta. This I was easily enabled 
 to do after dilating the os uteri, by pressing down the placenta, 
 with the fingers introduced behind it, into the palm of the hand. 
 A few minutes were sufficient to effect this ; and I was much grati- 
 fied to find all hemorrhage cease, as soon as the whole placental mass 
 was detached. The placenta being carried down into the vagina, a 
 
 ' Provincial Medical and Surgical Journal for July, 1845, p. 5S7. 
 
PLACENTA PREVIA, 685 
 
 dose of ergot was administered, and, in about a quarter of an tour, 
 tlie natural pains expelled the child. There was no after-hemor- 
 rhage, and only slight lochial discharge. The mother recovered 
 without the slightest drawback, and was out of bed in a few days." 
 "The above case," observes Dr. Maclean, "from the alarming 
 symptoms attending it, and the certain fatality which must have 
 ensued, had the flooding continued for a short time longer, with the 
 immediate suppression of all hemorrhage on the placenta being 
 completely detached, thus allowing time for the patient to rally, 
 would seem to prove the operation of turning in these cases to be 
 almost needless ; at the same time that it affords another instance 
 of the accuracy of the conclusions published by Professor Simpson 
 in the London and Edinburgh Journal for March last, where he 
 proposes in such cases to remove artificially the placenta, and not 
 the child."' 
 
 After the present section was written, my attention was acciden- 
 tally called to some interesting remarks, bearing directly upon the 
 point of which it treats, and contained in the old and rare " Observa- 
 tions sur la Pratique des Accouchemens" of Viardel, printed at Paris 
 in 1671. I append a literal translation of the passage in Viardel's 
 work. 
 
 Case XLI. — " All these labors where the placenta presents or 
 escapes entirely are very dangerous, as the infant often loses its life, 
 as happened to the wife of Monsieur le F^vre, merchant, living in 
 the Eue de Gevre, in whom the after-birth presented first, and 
 occupied all the internal orifice of the womb. Being called, there- 
 fore, to deliver her, and finding matters in this state, as I discovered 
 from examination, I pushed back the after-birth with the extremity 
 of my finger, in order to return it into the womb, and having passed 
 my hand into it as far as I could, I passed it around the internal 
 orifice in order to assure myself, and thus discovered that it was the 
 after-birth which was entirely separated from the womb {entirement 
 separe de la matrice), and that the infant presented behind it by the 
 umbilicus. After observing all these things, and being assured that 
 it was the placenta, I prepared to succor her as quickly as possible, 
 in the following manner: I placed her across the bed with the 
 thighs separated and the heels drawn up to the hips, having first 
 made her take a conple of eggs with a little wine, to strengthen her. 
 I introduced my hand into the womb (as I have said above), and 
 having arrived at the internal orifice, I grasped the placenta by its 
 middle part with my open hand, and holding it firmly, drew it out 
 
 ' Northern Journal of Medicine for August, lS45, p. 132. 
 
ggg COMPLEX LABOR. 
 
 of the womb, and, the moment it was out, I put back my hand to 
 search for the feet of the child, and having found them I drew it 
 out, dead. * * * As soon as I completed the delivery, the loss 
 of blood, which had persisted till then, and all the other accidents, 
 ceased; and I believe that the infallible prognosis in such a case is, 
 that the child must be dead, although in truth the case is not always 
 so, for it may happen in similar labors, that the infant being strong 
 and vigorous, may escape shipwreck if it be promptly and timeously 
 succored ; and I may add here in confirmation of this, that I have 
 met with a case of the same kind where the infant lived for three 
 days, although very weak and feeble."' 
 
 m. 
 
 Section IX. — Cases of Placenta PRiEviA in which it is proper, 
 1. To Evacuate the Liquor Amnii ; 2. To Extract the Infant 
 BT Turning ; and, 3. To separate and extract the Placenta 
 
 BEFORE THE ChILD. — SERIES OP CASES TO WHICH THIS LAST PRAC- 
 TICE IS APPLICABLE, VIZ.: 1. WhEN THE OS UtERI IS RIGID AND 
 
 undilatable; 2. In First Labors; 3. In Premature Labors; 
 
 4. In Labors supervening earlier than the seventh month; 
 
 5. When the Uterus is too contracted to allow of turning; 
 
 6. When the Pelvis or Passages are originally contracted ; 
 
 7. In CASES OF Exhaustion; 8. When the Child is Dead; 9. 
 When it is premature and not viable. 
 
 The various cases adduced in the last section will probably be 
 admitted on all hands to demonstrate sufficiently the practicability 
 of the plan of treatment in placenta prsevia which it is my object to 
 bring before the profession in the present Essay. In the next 
 instance, it is requisite for us to consider in what special eases of 
 placental presentation it will be proper to adopt the principle of 
 treatment in question. 
 
 I have already stated (see page 605) that I believe it would be 
 found the just and legitimate mode of practice in those cases of pla- 
 cental presentation in which either the artificial evacuation of the 
 liquor amnii is unsuccessful, or forced delivery by turning is inappli- 
 cable and dangerous. 
 
 To understand, then, thoroughly the varieties of cases in which 
 we should adopt the complete separation and extraction of the pla- 
 centa before the child as a line of practice, it will facilitate our 
 inquiries if, in the first instance, we consider the class of cases in 
 which, first, The evacuation of the liquor amnii ought to be fol- 
 
 ' Pratique des Aocouohemens, p. 90. 
 
PLACENTA PREVIA. 687 
 
 lowed, and, secondly, Those in which the delivery of the child by 
 turning constitutes the suitable mode of treatment. Having cleared 
 the way by considering these two points, we shall be more able to 
 judge of and appreciate the remaining varieties of placental com- 
 plication in which this new means of treatment ought to be adopted. 
 
 1. Cases of placenta previa, in which the evacuation of the 
 
 LIQUOR AMNII forms THE PROPER PRACTICE. 
 
 The artificial evacuation of the liquor amnii appears to be princi- 
 pally followed when the placental presentation is partial only, and 
 consequently, when a segment of the bag of membranes, as well as 
 a segment of the placenta itself, is placed over the os uteri. When 
 this practice has the desired efiect, it forms undoubtedly the simplest 
 and safest of all the means of treatment. But its applicability is 
 limited. The proportion of cases in which the placenta is observed to 
 present partially, would seem not to be so great as of those in which 
 it presents completely.' Besides, when it does present partially, 
 the rupture of the membranes and the escape of the liquor amnii 
 would appear to be by no means so certain a mode of arresting 
 the hemorrhage in this form of unavoidable as it is in accidental 
 flooding. 
 
 " The method of Puzos^ cannot," Baudelocque avers, " have, in 
 these eases of partial placental presentation, those advantages which 
 have been generally found in it when the source of the hemorrhage 
 
 ' Out of 50 cases of placenta praevia reported by Dr. Francis Ramsbothani, the placenta 
 presented completely in 32, and partially in 18 instances. — Principles of Obstetric Medicine 
 and Surgery, Appendix, p. 721, 
 
 ^ Puzos wrote a very beautiful memoir upon the artificial evacuation of the liquor amnii, 
 as a means of arresting and treating cases of accidental hemorrhage (Memoire sur les Pertes, 
 &c., et sur la Methode de proc^der a I'Accouchement dans les Cas de Necessity, par une 
 voye plus douce et plus s&re que celle qu'on a coutume d'employer. — TraitS des Accouche- 
 mens, p. 323 ; or Mem. de I'Acad. de Chirurgie, 1743, torn. ii. p. 203). Hence this practice 
 is often spoken of, as in the text, under the name of the method of Puzos. The honor, hovif- 
 ever, of first proposing and adopting this particular line of treatment certainly belongs to 
 Mauriceau, who described and practised it half a century before Puzos (see his Maladies 
 des Femmes, &o., tom. ii. cases 307, 450, 459, 479, 4S0, &c.) He even preceded Puzos in 
 his explanation of the principle upon which the treatment acts in suppressing the dis- 
 charge. " The vessels of the uterus, which,'' says Mauriceau, " were open, become shut by 
 the contraction of its proper substance, as soon as the waters of the infant, which held it ex- 
 tended, are evacuated from it," tom. i. p. 334. — Daventer (Art of Midwifery Improved, p. 
 153, English trans., London, 1716), and Dionis (General Treatise of Midwifery, p. 244 of 
 English trans., London, 1719), both also recommended the practice previously to the time of 
 Puzos. " But if there are floodings,'' says Dionis, " from the separation of some part of the 
 after-birth, however little soever the womb is dilated, the membranes which contain the 
 waters must be broke, thai the distension may be taken off, and that the after-birth may not 
 be farther loosened, which both prevents the increase of the flooding, and makes way for 
 the child's advancing into the passage, and being born the sooner." 
 
688 COMPLEX LABOR. 
 
 is further off (or of the accidental form). When the placenta is at- 
 tached to the neck of the uterus, if the hemorrhage is suspended for 
 a moment, when the waters are evacuated it soon appears again, and 
 becomes so much the more abundant as the orifice of the uterus 
 dilates further, and as the violence of the labor increases. I 
 have met," he adds, " with but one case where the flooding has 
 entirely ceased, after the evacuation of the waters, out of at least 
 five-and-twenty where the placenta was attached to the neck of the 
 uterus."' 
 
 The practice of evacuating the liquor amnii in partial placental 
 presentations has generally, however, been found much more suc- 
 cessful than it appears to have proved in the hands of Baudelocque. 
 No obstetrician has probably, at the present day, had more oppor- 
 tunities of testing its value than Dr. Francis Eamsbotham of London. 
 He informs us, in his Principles and Practice of Obstetric Medicine 
 and Surgery, that he had attended, up to 1834, as many as forty- 
 four cases of partial presentation of the placenta. In forty of these 
 cases the membranes were ruptured some time before delivery. 
 The results of the treatment of the artificial evacuation of the liquor 
 amnii in thirty-nine of these cases were as follows : 
 
 In thirteen cases, or in 32 per cent, of the whole, the labor was after- 
 wards terminated by the natural powers alone. 
 
 In twenty-six cases, or in 65 per cent, of the whole, in consequence 
 of the hemorrhage not ceasing on the evacuation of the liquor 
 amnii, turning was subsequently adopted. One was terminated by 
 the forceps. 
 
 Eight of the forty-four patients died, four of them apparently from 
 the excessive loss of blood suffered before delivery was effected. 
 
 The principal arguments that have been used by obstetric authors 
 against the artificial evacuation of the liquor amnii in placental pre- 
 sentations, have been, first. Its alleged inefficiency in arresting the 
 hemorrhage ; and, secondly, The difficulty which the loss of the 
 liquor amnii entailed or produced in the operation of turning, if that 
 operation afterwards required to be adopted in consequence of the 
 continuance of the flooding. These objections, but particularly this 
 last one, will probably be entirely removed, by having the other 
 expedient in abeyance, to which our attention is directed in the 
 present essay, namely, the complete detachment of the placenta 
 itself. The previous evacuation of the liquor amnii, whether by 
 puncturing the membranes or by puncturing the placenta, would 
 not interfere with any plan that it might be afterwards considered 
 proper to adopt for the entire detachment of the placental mass. 
 The knowledge of this latter alternative will certainly entitle us to 
 
 ' System of Midwifery, Heath's Translation, vol. ii. p. 37. 
 
PLACENTA PREVIA. 689 
 
 have recourse oftener than has hitherto been done to the milder ex- 
 pedient, in the first instance, of evacuating the liquor amnii. It can 
 be practised, when necessary, at a time when the os uteri is still so 
 small and contracted as not to admit easily of the adoption of other 
 measures. Little or no difficulty is in general encountered in its 
 performance. "When, from the placental presentation being partial, 
 the membranes alone require to be perforated, the nail of the fore- 
 finger, or the end of a surgeon's probe, or of a wire or pen, will 
 suffice for the purpose. But, when the placental presentation is 
 more complete, the instrument that is employed requires to be 
 passed through its substance, and more care is required lest the pla- 
 cental structure be too much lacerated, or the foetus itself wounded. 
 The hair needle, which we have already (p. 603) found spoken of in 
 this case by Daventer, the small trocar recommended for it by 
 Deleurye, and the perforating instruments of Eoederer,' Fried,^ 
 Eitzen,^ EHuge," &c.,° consisting of hollow tubes or canulas, blunt or 
 rounded at the extremiiy, and provided with a puncturing lancet 
 worked by a spiral spring, would probably none of them be so safe 
 as other means with which the surgeon is more likely to be provided. 
 The common surgical exploring needle might be used with a blunt, 
 instead of a sharp-pointed, wire passed through it. Gendrin used 
 successfully, and he states, "with facility," a common catheter. 
 Probably its blunted extremity would, more readily than we might 
 at first conceive, pass through the membranes covering the placenta, 
 in consequence of the resistance opposed on their foetal side by the 
 distension of the liquor amnii. A common quill, with a lateral 
 aperture like that of a catheter cut near its extremity, and another 
 at the opposite end of the barrel, to allow of a free escape to the 
 waters, would perhaps answer the purpose perfectly, could always 
 be easily procured, and its blunt point, like that of the catheter, 
 would not endanger the infant. Perforating the placenta with the 
 fore-finger, and rupturing the membranes with the nail, might in 
 the same way be used with similar results, and even vdth greater 
 certainty of effect ; but from what we have said of the source of the 
 discharge in unavoidable flooding, it would seem a leading object 
 not to lacerate, to any great and unnecessary extent, the substance 
 of the placenta itself, as its maternal vascular cells might thus be 
 opened up to a more dangerous degree.' 
 
 ' Elementa Art. ObstetrioiEe, par. 627. 
 ' In Knauer's Seleotus Instrumentorum, Tab. xxv. fig. 4. 
 ' Scheibler's Dissertatio de rumpendis velamentus, &o. 
 
 ' Die Anzeigen der Meohanisohen Hdlfen bei Entbindungen, &o., mit Kupfern, p. 436. 
 ^ See Kilian's Operationslehre fiir Geburtshelfer, 1843, vol. i. p. 248 ; and Siebold's 
 Abbildungen der Geburtshulfe, p. 162. 
 
 ' M^deoine Pratique, torn. ii. pp. 350 and 352. 
 VOL. I. 44 
 
690 COMPLEX LABOR. 
 
 If the operation, in whatever way performed, failed, by not prov- 
 ing successful in sufficiently arresting the hemorrhage, it might still 
 at least gain for us some time for the greater dilatation of the os 
 uteri, and hence for the more easy separation of the placenta sub- 
 sequently, and the more safe passage of the fcetus. Long ago, 
 Deleurye stated the objects and advantages of the practice explicitly, 
 in the following terms : " There are, notwithstanding, cases of pla- 
 cental presentation in which the placenta must be pierced : as, when 
 it becomes necessary to terminate labor before the fiill term, without 
 uterine contractions, in consequence of profuse flooding, and the 
 fear of uterine inertia after this from the feebleness of the patient ; 
 then, with a thrust of a trocar, the evacuation of the waters is to be 
 facilitated. The uterus, which by this evacuation ceases to be 
 passively dilated, contracts and diminishes its volume, and we 
 facilitate the time of election for delivering the woman with more 
 safety."' 
 
 2. CASES OF PLACENTA PREVIA, IN WHICH TURNING FORMS THE PROPER 
 
 PRACTICE. 
 
 I have already shown that several of the highest obstetric authori- 
 ties look upon turning, and the artificial extraction of the infant, as 
 the only advisable mode of treatment in every case of placenta prse- 
 via, and have quoted at length the opinions of Plenck, Denman, 
 Merriman, Conquest, &c., to this effect. (See p. 604.) " When the 
 placenta," says Dr. Rigby, " is fixed to the os uteri, nothing but 
 turning the child will put a stop to the flooding."^ " It may be laid 
 down as a rule," observes Dr. Lee, " admitting of no exception, that 
 where hemorrhage occurs from the placenta being situated over the 
 OS uteri, artificial delivery must be performed."^ The same author, 
 in a later publication, candidly and correctly states, in reference to 
 this practice — ^the operation of turning in unavoidable hemorrhage: 
 "At the best, it is a dangerous operation, and you can never tell 
 with certainty whether the patient will recover after its performance, 
 however easily it may have been effected."^ 
 
 The professed object of my present inquiry is to attempt to prove 
 that the artificial removal of the placenta is a more safe and com- 
 mendable operation in different forms of placental complication, 
 than the artificial removal of the infant, is not attended with such 
 extreme hazard to the life of the mother, and is specially applicable 
 in those very cases in which turning is specially difficult and danger- 
 
 ' Trait^ des Accouohemens, p. 369. ^ Essay on Uterine Hemorrhage, 6th edit. p. 91. 
 
 ' Researches on the Pathology and Treatment of Diseases of Women, p. 207. 
 ' Lectures on the Theory and Practice of Midwifery, p. 373. 
 
PLACENTA VRMYIA. 
 
 691 
 
 ous. There are, however, very many cases of placental presentation 
 in which the artificial delivery, or turning, of the foetus, will still 
 remain as the most proper and legitimate plan of treatment. This 
 remark applies, I believe, particularly — 1. To those instances in 
 which the child is alive, and at or near the full term of utero-gestar 
 tion, when labor supervenes ; and, 2. Where fortunately the mother 
 has borne a family previously, and the os uteri, by the time the 
 hemorrhage proceeds to a dangerous extent, is either so dilated, or 
 dilatable, as to allow of the introduction of the hand of the operator 
 and the extraction of the fcEtus, without any fear of injury and 
 laceration. Under such a condition, turning affords a very fair 
 chance of life to the infant — and I presuppose the state of the os 
 uteri to be such, that the danger of lacerating it^ and thus leading 
 either to subsequent hemorrhage or phlebitis, is not so great as to 
 endanger the mother's recovery. 
 
 Further, there is another set of cases of placental presentation, 
 in which we must continue to be driven, sooner or later, to the 
 adoption of turning. I have already shown that in a considerable 
 portion of these presentations, the foetus presents preternaturally, 
 and in a number of them transversely. When the position of the 
 foettis is transverse, we must of course ultimately rectify it, and de- 
 liver by turning. But here we are driven to adopt the operation of 
 turning, not in consequence of the peculiar presentation of the 
 placenta, but in consequence of the peculiar presentation of the 
 child. ' Knowing that we can at any time safely arrest the hemor- 
 rhage by the complete detachment of the placenta, we shall be 
 farther able, in such cases of cross-birth, to delay, if in other re- 
 spects it is imperatively necessary, the operation of turning, and 
 select for it that time which may be considered most compatible 
 with the state and structure of the uterus, and the safety and life of 
 the mother ; and here also the adoption or not of the artificial de- 
 tachment of the placenta will be greatly regulated by the ascertained 
 death or life of the child. 
 
 3. Cases of placenta pk^evia in which artificial detachment 
 OF the placenta foems the proper treatment.. 
 
 When our practical acquaintance with this method of treatment 
 becomes more extensive, and the measures for effecting it are sim- 
 
 ' Cases of placental presentation, thus favorable for the safe operation of turning, are 
 much more likely ,to be met with in hospital than in private practice, because hospital 
 patients are generally near the full term of delivery before they are admitted, but of 33 
 cases mentioned by Dr. Lee, only 2 seem to have reached the full time. On the other hand, 
 out of 11 cases vphioh occurred in the Dublin Hospital during Dr. Collins' mastership, all 
 had reached the full time except 2. If turning were applied in every case, such evident 
 differences in the conditions of the patients, must of necessity greatly modify the resulting 
 maternal dangers and mortality. 
 
692 COMPLEX LABOR. 
 
 plified and better understood, it is possible that tbe practice itself 
 may come to be applied in almost all the instances of placental pre- 
 sentation that I have alluded to under the two preceding heads. 
 This, however, is by no means the case during our present know- 
 ledge of the subject, and in the meantime I would wish to point 
 out here in detail the special cases of placenta prsevia in which the 
 practice I propose seems to me to be more particularly applicable. 
 These cases include, 1. Some complications on the part of the 
 mother, especially such a degree of rigidity of the os uteri or vagina, 
 or such obstructions of any form in the maternal passages or uterus 
 itself, or such states of general constitutional exhaustion, as contra- 
 indicate and prevent the safe exercise of the operation of turning. 
 And, 2. Some complications on the part of the child, particularly 
 its death or prematurity, rendering the operation of version un- 
 necessary, so far as any view to its safety may bear upon the ques- 
 tion, provided the mother can be delivered by means that afford 
 greater safety to her. I shall now proceed to consider somewhat 
 in detail each special set or division of cases to which the present 
 mode of practice appears to be legitimately applicable. 
 
 First Series. 
 
 When the os and cervix uteri are too rigid or undilatable to allow of the safe exercise of the 
 
 operation of turning. 
 
 Obstetric authors appear, as we have already seen, to be generally 
 and perfectly agreed as to the propriety of turning in all cases of 
 complete presentation of the placenta ; they differ, however, from 
 one another in regard to the time and circumstances which ought 
 to be selected as most fit and safe for the performance of this opera- 
 tion in placenta prsevia. Some strongly advise us to operate rather 
 too soon than too late. Others as strenuously counsel us to beware 
 of operating till the time that the os uteri is so dilated or dilatable 
 as to permit of our interference, without any chance of injuring or 
 lacerating the cervix in the passage of our hand, or the extraction 
 of the infant. " In recommending early delivery, I think it right," 
 says Dr. Eigby, the highest authority I can quote on such a subject, 
 " to express a caution against the premature introduction of the 
 hand, and the too forcible dilatation of the os uteri, before it is 
 sufficiently relaxed by pain or discharge ; for it is undoubtedly very 
 certain that the turning may be performed too soon, as well as too 
 late, and that the consequences of the one may be as destructive to 
 the patient as the other. I am particularly led to observe this, as I 
 have lately been informed, from very good authority, namely, a 
 gentleman to whom one of the cases occurred, of three unhappy 
 instances of an error of this sort, which happened some years ago 
 
PLACENTA PK^VIA. 693 
 
 to three surgeons of established reputation, who, from the success 
 they had met with in delivering several who were reduced to the 
 last extremity, were encouraged to attempt it where but very little 
 blood had been lost, in hopes that tTieir patients' constitutions would 
 suffer less injury, and their recovery be more speedy ; which, till the 
 experiment was made, was a very reasonable supposition. The 
 women died, and they seemed convinced that their deaths were 
 owing to the violence of being delivered too soon, and not to the 
 loss of blood, or any other cause."' 
 
 On the other hand, Dr. Ingleby, the author of one of the best 
 works that has been written on uterine hemorrhage, tells us that 
 " a very experienced accoucheur, in whose practice about twenty 
 cases of this description have occurred, informs me that those 
 women who were delivered at an early period of gestation, re- 
 covered, but when delivery was postponed to a late period, the 
 result was fatal. Similar answers have been given to the same 
 inquiry by Other gentlemen."^ 
 
 Two great sources of danger, in fact, require to be taken into con- 
 sideration in relation to the operation of turning, in each individual 
 case of placental presentation — namely, first, The danger of too 
 long a continuance of the hemorrhage, and consequently the ex- 
 haustion, and even the death of the patient, if the operation be not 
 performed sufficiently early ; and, secondly, The danger of contusion 
 and laceration of the cervix uteri and its included vessels, if the 
 operator, afraid of delay, and of the effects of the hemorrhage, pro- 
 ceeds to deliver too soon. And it is to be especially recollected in 
 relation to this last point, that any degree of laceration in the tis- 
 sues of the cervix uteri in a case of placenta prsevia is fraught with 
 unusual and imminent danger. The part of the uterine parietes to 
 which the placenta is affixed becomes, as is well known, most freely 
 supplied with bloodvessels ; and there, in particular, the venous 
 sinuses of the uterus are especially latge and abundant. In pla- 
 cental presentations, it is the cervix uteri itself that assumes this 
 highly vascular condition ; and hence any laceration or injury of it 
 is much more liable to be followed, than under other positions of 
 the placenta, with hemorrhage immediately after delivery, or with 
 subsequent inflammation of its included and lacerated veins, giving 
 rise to uterine phlebitis, a disease which, under one or other of its 
 many forms, is found to be one of the most common causes of death 
 after the occurrence of placental presentations. 
 
 The two preceding and opposite causes of danger and death to 
 which the mother is submitted under the operation of version in 
 
 ' Essay on Uterine Hemorrhage, p. 37. 
 
 ^ Praotioal Treatise on Uterine Hemorrhage, p. 147. 
 
694 
 
 COMPLEX LABOR. 
 
 placental presentations, appear to be vejy equally balanced in their 
 consequences ; that is to say, amongst the number of fatal cases 
 which occur in practice, or are to be found upon record, nearly the 
 same proportion appear to perish from the extent of the hemor- 
 rhage before delivery, or its subsequent effects (the results of pro- 
 tracting the delivery, and from post-partum flooding from the lace- 
 rated vessels of the cervix uteri, with uterine phlebitis, and all the 
 other fatal consequences arising from injury and laceration of the 
 vascular structures of the cervix, when the os is injured by being 
 forced open too early). 
 
 As this appears a most important practical point to establish on 
 sufficient statistical data, I have collected into the following table 
 the dates of the death of the mother in 78 fatal cases of placenta 
 prsevia, reported by the different authors whose works I have quoted 
 in a former page (p. 6Q0). The table is constructed to show, first, 
 The number of mothers who died undelivered ; secondly, The num- 
 ber of those that sunk within three hours after delivery, and pro- 
 bably from exhaustion, under the hemorrhage preceding flooding, 
 or from its continuance from the lacerated vessels of the cervix, 
 after the emptying of the uterus ; thirdly. The number that died 
 within forty-eight hours after delivery, and hence, I suppose, from 
 exhaustion under hemorrhage and the operation of delivery ; and 
 lastly. The number of those that died at a later period, after the 
 immediate danger from the hemorrhage and operation had sub- 
 sided, and when the fatal result was apparently always, or almost 
 always, the consequence of uterine phlebitis, in some of its mani- 
 fold forms. 
 
 Period of Death of the Mother in Fatal Cases of Placenta Praxia. 
 
 Keporteis. 
 
 No. of Fatal 
 Cases. 
 
 Died 
 Undelivered. 
 
 Died within 
 
 3 hours after 
 
 Delivery. 
 
 Within 48 
 hours. 
 
 At a later 
 period. 
 
 Mauriceau, 
 
 Gifiard, 
 
 Smellie, 
 
 Rigby, 
 
 Collins, 
 
 Lachapelle, 
 
 J. Ramsbotham, 
 
 F. Ramsbotham, 
 
 Lee, 
 
 Total, 
 
 3 
 
 7 
 
 6 
 
 11 
 
 2 
 
 9 
 
 9 
 
 16 
 
 15 
 
 1 
 
 3 
 
 2 
 
 1 
 1 
 
 1 
 6 
 2 
 3 
 2 
 3 
 7 
 7 
 5 
 
 1 
 
 1 
 
 3 
 
 2 
 1 
 1 
 2 
 
 1 
 3 
 
 4 - 
 
 8 
 7 
 
 78 
 
 8 
 
 36 
 
 11 
 
 23 
 
 Some authors and practitioners seem to have fallen into the mis- 
 take of supposing, that in all cases of placenta prsevia, the os uteri 
 will be found dilated or dilatable by the time that the hemorrhage 
 
PLACENTA PREVIA. 695 
 
 has taken place to sucli an extent as to endanger the life of the 
 mother. It may be sufficient to quote, on such a point, the opinions 
 of an author, who has written one of the soundest and most classical 
 professional works that we have in the English language : " In 
 some cases," says Dr. Denman, " in which it has been presumed to 
 be necessary to deliver the patient on account of the hemorrhage, 
 in placenta prsevia, the parts have been in such a state, that the ope- 
 ration could not, it was thought, be performed with safety. When- 
 ever the case demands the operation, on account of the danger of 
 the hemorrhage, the state of the parts will on this account always 
 allow it to be performed with safety, though not with equal faci- 
 lity."' It must, however, be confessed with regret, that the opinion 
 here expressed by Dr. Denman rather indicates the condition which 
 we anxiously desire than that which we always meet with in prac- 
 tice. And our best practical authors seem to be becoming more and 
 more agreed, that cases of placenta prsevia are constantly occurring, 
 in which the hemorrhage may proceed to such a degree, as to ur- 
 gently demand artificial interference upon our part, in order to 
 arrest its violence or complete the delivery, without the os uteri and 
 passages being at the same time in such a condition as to permit 
 of the safe passage of the hand into the uterus, or of the- safe 
 extraction of the infant from it. 
 
 " If," says Pen, " a pregnant woman is seized with considerable 
 flooding, which does not cease, the secret is to deliver her as soon 
 as possible. * * * j'qj. i^i^^ j always suppose that there is a 
 sufficient opening. For to force and dilate the internal orifices of 
 the womb is just so many deaths, or rather lives thrown away and 
 sacrificed {c'est autant de morts, ou de viespMtdt qu'on preoipite et qu'on 
 prodigue). If then, the smallness of the opening, or the extreme 
 debility of the patient, render the thing visibly impossible, it is 
 better to leave the case to nature, than to irritate the blood so as to 
 augment the flooding without hope of alleviating it."^ 
 
 When treating of the subject of unavoidable hemorrhage. Pro- 
 fessor Davis states, that he "had met with many examples even o^ 
 fatal results of profuse uterine hemorrhage unaccompanied by any 
 amount of dilatation of the orifice of the womb."' Dr. Hamilton, 
 when speaking of placental presentations, tells us that in the month 
 of September, 1816, he was called to two cases where the patient 
 seemed to be in articulo from the deluge of the discharge, and, 
 nevertheless, where the os uteri was in the state of obstinate rigidity 
 which Dr. Davis has described, " It has been advised," Dr. Rigby 
 
 ' Introduction to the Practice of Midwifery, p. 530. 
 
 2 La Pratique des Acoouchemens, p. 516. 
 
 ' Principles and Practice of Obstetric Medicine, p. 1040. 
 
696 COMPLEX LABOK. 
 
 states, "never to introduce the hand till, nature has shown some 
 disposition to relieve herself, by the dilatation of the os uteri to the 
 size of a shilling, or a half-crown ; and this rule is certainly founded 
 on a rational principle ; for when it is so much dilated, there is no 
 doubt but the turning may be easily and safely effected ; but from 
 some of the annexed cases it appears, that a dilatation to this degree 
 sometimes does not take place at all, and that even when the woman 
 is dying from the great loss of blood, the uterus is very little open."i 
 " There is not unfrequently," remarks Dr. Lee^ "most profuse and 
 alarming flooding from complete placental presentation, where the 
 OS uteri is so thick, rigid, and undilatable, that it is impossible to 
 introduce the hand into the uterus without producing certain mis- 
 chief."^ 
 
 "Again, it is by no means impossible," Dr. Eamsbotham ob- 
 serves, " that such alarming symptoms (the patient faint, and gasp- 
 ing, and cold, &c.) may show themselves before the os uteri has 
 acquired the diameter of half a crown, as to render it extremely 
 hazardous for us to delay our means until that degree of dilatation 
 is arrived at. The blood may be gushing forth in a copious and 
 continued stream, or may be oozing away in a less violent though 
 steady draining, or coagula of considerable size may be passing 
 from the vagina every few minutes ; and it must be evident to the 
 least attentive observer, that such a state of things cannot be 
 allowed to proceed unchecked. Two modes off^r themselves for 
 our choice : either immediate delivery, or endeavoring to restrain 
 the flow, and delaying until the due degree of dilatation is effected. 
 Our practice will mainly be guided by the state of the os uteri 
 itself; if it appear soft, lax, and distensible, offering but little re- 
 sistance to our fingers in the attempt at dilatation, we shall mostly 
 be able, under the use of sufficient caution, to pass the hand entirely 
 through it without injury, even although its disk be not exceeding 
 the diameter of a shilling ; and, indeed, I have accomplished the 
 operation of turning on some few occasions, under these unpro- 
 mising circumstances, by slowly insinuating the fingers seriatim. 
 Although, then, such a proceeding be not desirable, if it can be 
 avoided, inasmuch as every minute's delay brings with it an aug- 
 mentation of danger — we are fully justified in effecting the dilata- 
 tion of the OS uteri thus artificially, even when, at the commence- 
 ment of our efforts, it will scarcely admit the introduction of the 
 tips of two fingers."^ 
 
 " I know," observes Dr. Collins, " of no circumstance so much to he 
 dreaded, as the forcible introduction of the hand where the parts are 
 
 ' Essay on Uterine Hemorrhage, p. 38. ^ Principles and Practice of Midwifery, p. 373. 
 ' Obstetric Medicine and Surgery, 2d edit. p. 387. 
 
PLACENTA PEiEVIA, 697 
 
 in a rigid or unyielding state ; for although turning the child is the 
 established and most desirable practice, yet the success of this ope- 
 ration will mainly depend on the judgment of the practitioner in 
 selecting the most proper and favorable time. Cases will happen 
 where he is obliged either to suffer his patient to sink from loss of 
 blood, or proceed to deliver when the parts are in an undilated and 
 rigid state, in order to afford her the only chance of life ; but dire 
 necessity should alone compel him to hazard the consequences of 
 such violence. We are well aware the os uteri will yield at a much 
 earlier period after a severe loss of blood than under other circum- 
 stances ; we are equally well aware of the great injury the patient 
 sustains by delaying delivery beyond the earliest moment that the 
 mouth of the womb will by gentle efforts permit the introduction 
 of the hand ; it is against premature measures we wish to guard the 
 young practitioner ; as every individual of experience will acknow- 
 ledge the great embarrassment he not unfrequently has labored 
 under, in deciding on the time, beyond which, to defer affording 
 assistance were timorously to risk his patient's safety, and previous 
 to which, delivery would be either impracticable, or, if effected by 
 violent means, truly dangerous; for even a slight injury to the 
 mouth of the womb will prove more fatal than an increased loss of 
 blood, BO long as the strength can possibly bear it.'" 
 
 That the flooding in placental presentations sometimes proceeds 
 to such an excess as to demand measures either for"its suppression, 
 or for the forcible delivery of the patient, before the os uteri is in 
 such a dilated or dilatable state as to permit vsdth safety to its struc- 
 tures of the operation of turning, admits of being still more forcibly 
 illustrated by an appeal to the history of individual cases of una- 
 voidable hemorrhage. As the matter is one of most important 
 bearing upon the argument before us, I shall offer no apology for 
 enforcing and extending the evidence in favor of it, by adducing 
 some individual facts and instances in illustration of my present 
 purpose. 
 
 " In no case," observes Dr. Edward Rigby, " is it proper or safe 
 to force delivery by artificially dilating the os uteri, when it is con- 
 tracted and unyielding ; but where the placenta is presenting, it is 
 peculiarly dangerous, for even slight laceration of the os uteri will 
 be followed by serious consequences. Where the placenta is 
 situated in the upper part of the uterus, it is of very little conse- 
 quence if the edge of the os uteri has been torn somewhat during 
 labor; but in the present case it is very different — the os uteri now 
 plays the part of the fundus, its vessels are immensely dilated, and 
 larger ones are ruptured, which cannot be closed by the firmest con- 
 
 ' Pxaclical Treatise on Midwifery, p. 93. 
 
698 COMPLEX LABOR. 
 
 traction of the Uterus. * * * Cases have occurred where the os 
 uteri has been artificially dilated, where the child was turned and 
 delivered with perfect safety, and the uterus contracted into a hard 
 ball ; in fact, everything seemed to have passed over favorably ; a 
 continued dribbling of blood has remained after labor, which resisted 
 every attempt to check it; friction upon the abdomen, and other 
 means for stopping hemorrhage by inducing firm contraction of the 
 uterus, were of no use, for the uterus was already hard and well 
 contracted ; the patient has gradually become exhausted^ and at last 
 died : on examination after death. Professor Naegele has invariably 
 found the os uteri more or less torn."' 
 
 We have sometimes proof afforded us in post-mortem examinations, 
 of the fact, that unavoidable hemorrhage may proceed to a fatal 
 extent during the fij-st stage of labor, without the tissues of the os 
 and cervix uteri ever dilating to such a degree as to allow of the 
 introduction of the hand without laceration. 
 
 In his magnificent plates of the anatomy of the gravid uterus, 
 Dr. "William Hunter has given two representations of the uterus of 
 a woman who died of unavoidable hemorrhage during the first stage 
 of labor. She had reached the ninth month of pregnancy. The 
 first plate (Tab. xi.) represents the external surface of the uterus, 
 with the enormous uterine veins about the cervix much enlarged 
 and injected. The second (Tab. xii.) shows the uterus opened, with 
 the placenta fixed over the os uteri, and the infant presenting in the 
 second position of the head, or with the face looking to the left 
 sacro-iliac synchondrosis.^ The os uteri appears very small and 
 unopened. The preparations of the parts in this case are still con- 
 tained in the Hunterian Museum, belonging to the University of 
 Glasgow. On lately examining them, I found the os uteri appa- 
 rently not opened to the size of a shilling, and the lips of the cervix, 
 particularly on one side, so thick and turgid (they are correctly 
 represented so in the plate), as to leave no doubt that it would have 
 been physically impossible to distend the uterine orifice, so as to 
 admit the hand without certain laceration. The placenta is par- 
 tially detached and slightly lacerated upon its external surface oppo- 
 
 ' Rigby's System of Midwifery, p. 259. 
 
 ^ It has always appeared to me a remarkable fact, that both in this plate and in the beau- 
 tiful engraving, Tab. iv., of the natural position of the fcetus in utero. Dr. Hunter, who is 
 justly and deservedly celebrated for his accuracy and fidelity of observation, has represented 
 the fcetus as lying in utero in a position which it very rarely occupies — so rarely indeed, 
 that Naegele avers, he only met with it once as an original position in twelve hundred cases. 
 Plates XV. and xxiii. represent the child in the third position ; none in the work shows it in 
 the first or most frequent poshion. I may add, that the " reversing" the infant is not a mis- 
 take of the engraver's, as I find it exists in the original drawings by Eymsdyk, which are 
 still preserved in the museum. Some casts also, taken probably from the same preparations, 
 show the foetus placed in this unusual position. 
 
PLACENTA PREVIA, 699 
 
 site the os. In reference to this preparation, I may add one fact 
 bearing upon the matter discussed in a former page, relative to the 
 mode in which retrograde hemorrhage is prevented, from the uterine 
 veins after the placenta is detached. The veins, as I have said, are 
 very large, as seen in the published plates, and are injected with 
 yellow wax. There is, however, no appearance whatever of any of 
 this wax having reached so far back as the utero-placental orifices 
 left by the separation of the placenta. 
 
 Long ago Dr. Smellie detailed three cases of Csesarean operation 
 performed immediately after the mothers had died from unavoida- 
 ble hemorrhage. These cases are interesting in an historical point 
 of view, as affording some of the earliest evidence which we have 
 on record of the occasional implantation arid organic adhesion of 
 the placenta to the interior of the cervix uteri being ascertained by 
 actual dissection. They all occurred during the two years of 1747 
 and 1748.' One of the cases is farther valuable in reference to our 
 present inquiry, as showing a perfectly undilatable state of the os 
 uteri, under fatal flooding from placental presentation. I shall 
 append some details of it. 
 
 Case XLII. — Ccesarean operation, after death from unavoidable 
 hemorrhage ; rigid state of os uteri as found on dissection ; its lacera- 
 tion under the attempt to open it. — " The woman was turned of forty, 
 of a gross habit, and had never borne a child." After a fall in the 
 seventh month, she had repeated discharges of blood. Two or 
 three weeks before her full time, she was taken with slight pains, 
 upon which Dr. Smellie was called, and found the os uteri opened 
 to about the size of a sixpence, and within it a soft substance that 
 felt like the placenta. As she had rested but indifferently the pre- 
 ceding night, was faint and weak, and had some small returns of 
 the discharge, Dr. Sands was consulted, and gave it as his opinion 
 that it was still proper to support the patient's strength with broths 
 and nourishing food, and more safe to wait till the slight pains 
 should bring on the right labor, than to use any violence to deliver 
 her immediately. " I was again," says Dr. Smellie, "called about 
 nine o'clock the same night, when she was taken all of a sudden 
 with frequent fai^tings, in one of which she expired as I entered 
 
 ' The first case in which there was post-mortem evidence of the organic implantation of 
 the placenta over the os and cervix uteri, seems to have been that published by Petit, in the 
 Memoires de I'Aoademie for 1723. It is well known that the general belief of accoucheurs 
 was that the placenta was always originally affixed to the interior of the fundus or body of 
 the uterus ; and when found at the os, it was believed to have separated and fallen down 
 into that position. So late as 1717, Dr. Simpson, Professor of Anatomy at St. Andrews, pub- 
 lished in the Edinburgh Medical Essays, vol. iv., a paper in which he attempted to prove 
 " that the placenta inviolably adheres to the cavity of the fundus (uteri) ; with which it is 
 ingraft, and can never again shift its place.'' 
 
700 COMPLEX LABOR. 
 
 the room. This sudden alteration prevented me from making any 
 attempt at delivery ; and, indeed, had not this event happened, I 
 should have been afraid of her dying in the operation, because of 
 her gross and weak habit of body. As soon as all present were 
 satisfied that the person was dead, I openied her abdomen, and 
 having taken out the child, examined the uterus. I found the pla- 
 centa firmly adhering to its interior and posterior parts ; aibout two 
 fingers' breadth of its lower edge was separated from the os inter- 
 num, which it covered ; and this was what Dr. Sands and I had 
 felt in the morning. Having extracted the secundines, I tried with 
 my hand to open the os internum from the inside of the uterus, which 
 with great force I performed, not without tearing it about two inches on 
 one side." "By this," he adds, "it appears how difficult it is to 
 dilate this part in women going with a first child, especially when 
 they are pretty old. Indeed, it is sometimes impossible to be done 
 before they come to their full time, and even then not until the 
 parts are. thin, soft, and largely opened by previous labors."^ 
 
 If, in such cases as the preceding, it were necessary, in conse- 
 quence of the extent of the hemorrhage, to proceed to delivery, and 
 yet the os uteri were not more dilated or dilatable than it was found 
 in Dr. Smellie's patient after death, it is evident that the forcible 
 introduction of the hand into the os uteri, and the artificial extrac- 
 tion of the child through it, would necessarily give rise to lacera- 
 tions of a greater or less extent in the tissues of the cervix, and such 
 we find to be the fact in actual practice. The simple details of some 
 cases may enforce this important point, by showing the difficulties 
 
 ■ Cases in Midwifery, vol. iii. Collection xxix. No. 1, Case ii. p. 412. — Dr. Rigby, in com- 
 menting upon this case of Dr. Smellie's, argues that the trial being made to open the mouth 
 of the uterus after death, ""when every strong membranous part is incapable of contraction 
 and extension, is no proof that if the most favorable opportunity had been watched for, and 
 a gradual and repeated endeavor to open it had been before made, it would not have suc- 
 ceeded." — Essay on Uterine Hemorrhage, p. 44. Dr. Rigby appears to forget that the ex- 
 amination of the uterus, and the laceration of the os, upon attempting to open it, occurred 
 immediately after death, and as the dilatability of the part depends upon its physical rather 
 than its vital conditions, we cannot believe that an os uteri which was thus found incapable 
 of dilatation without tearing after death, could have been found during life, a few minutes 
 previously, capable in any degree of dilatation, without the same laceration. Dr. Smellie 
 has given an additional instance of Cesarean operatioti, performed immediately after the 
 death of the patient in unavoidable hemorrhage, with the view of saving the child. The 
 dilatability of the os uteri was not in that instance in any way affected by the death of the 
 mother ; it was, as he describes, thin, soft, and open to the breadth of half-a-crown. " / 
 dilated it with ease, which showed that if I had been sent for in the evening, she might have 
 been safely delivered." On Dr. Smellie being called to this case, before he had time to put 
 her in a position for delivery, the patient fainted away, was thrown into convulsions, and 
 died instantly. Two or three years ago I had an opportunity of seeing the dissection of, a 
 woman who had died of accidental hemorrhage in the first stage of labor. The os uteri was 
 dilated to nearly the size of a half-crown, but its edges were perfectly rigid, and undilatable 
 without tearing. 
 
PLACENTA PE>EVIA. 
 
 701 
 
 of the practitioner, and the dangers of the patient under such a com- 
 plication. For this purpose I shall quote verbatim the reports of 
 two or three instances from the valuable and practical works of Dr. 
 Collins and Dr. Lee. 
 
 Case XT. TTT. — Profuse unavoidable hemorrhage ; turning required 
 while the passages were badly prepared ; laceration of the cervix uteri ; 
 death. — " "W". S. was admitted, at her full time, ITovember 12. She 
 had been shedding occasionally for five days before, which reduced 
 her to a state of great debility. There was no hemorrhage on her 
 admission, but on examination, the placenta was found at the 
 mouth of the womb, which was not more dilated than the size of a 
 half-crown, with its edge thick, but not very rigid. As the discharge 
 had ceased, and her strength was much exhausted, she was ordered 
 to be kept perfectly cool and quiet, to have some cold chicken broth. 
 About an hour and a half afterwards, suddenly, the most profuse 
 hemorrhage set in, so much so, that in two or three minutes, the 
 blood was running in every direction over the edge of the bed ; this 
 was consequent on some slight uterine action. There being no 
 chance of life without speedy delivery, we determined to make the 
 attempt, though the parts were badly prepared ; accordingly the 
 hand was very slowly and cautiously introduced, and the feet 
 brought down with little exertion ; the uterus acted strongly, and 
 felt well contracted after delivery. The placenta came away with 
 the child. Great debility succeeded the operation, with a slight 
 discharge of blood at intervals ; and on examining an hour after, a 
 laceration of the neck of the uterus, anteriorly and to the right side, 
 was discovered, commencing at its junction with the vagina, and 
 extending upwards. She died shortly afterwards. It was her fourth 
 child — a girl (living). Dissection verified the result of the vaginal 
 examination.'" 
 
 As we have seen in a previous extract, p. 696, no author seems to 
 be more thoroughly impressed than Dr. Collins, with the necessity 
 of not hastening the delivery in placental presentations, if it is at all 
 possible to avoid it — and the above case aflbrds an apt illustration 
 of Dr. Lee's remark, that " it is sometimes absolutely necessary to 
 deliver by turning, before the hand can possibly be introduced into 
 the uterus, without producing fatal contusion or laceration of the 
 part."'* The following are analogous cases from Dr. Lee's own 
 Chnical Eeports. 
 
 Case XLIV. — Complete placental presentation, with exhausting 
 
 ' Collins' Practical Treatise on Midwifery, p. 97, ' Lectures on Midwifery, p. 373. 
 
702 COMPLEX LABOR. 
 
 hemorrhage ; os uteri so rigid as not to allow the hand to pass ; foot of 
 the child seized through the os ; forcible extraction of infant; death of 
 the mother.— On the 12th of January, 1839, Mr. Jones, of Carlisle 
 Street, Soho Square, called me to see a lady in the eighth and a half 
 month of pregnancy, who had been attacked with uterine hemor- 
 rhage a month before. It first took place without any accident or 
 pain, and the quantity lost was about half a pint, and it produced 
 little efiect upon the constitution. She remained quiet for several 
 days, and then got up, and only felt a little weak. For ten days 
 she went about, but the hemorrhage returned on the fifteenth day 
 after the first attack, but not to a great extent. Seven days after 
 this, a third and more profuse hemorrhage took place ; it gradually 
 went off, but not so quickly as the other attacks. At one o'clock, 
 12th January, it was renewed to an alarming extent without any 
 pain ; about a quart of blood was suddenly lost, and she became 
 extremely faint. At four a. M.the discharge still continued. When 
 I first saw her, at seven o'clock, she felt faint ; the pulse was rapid 
 and feeble. The upper part of the vagina was filled with a large 
 clot of blood, which adhered to the os uteri. By displacing this at 
 the back part, I could distinctly feel the placenta adhering all round 
 to the neck of the uterus, which was thick and rigid, and very little 
 dilated. The effect produced by the hemorrhage was so great, that it 
 was evident death would soon take place if the delivery were not speedily 
 completed; and the state of the orifice was such, that it was certain the 
 hand could not be passed, but with the greatest difficulty. At eight 
 o'clock, Dr. Merriman saw her with us, and agreed that immediate 
 delivery was necessary. I passed the right hand into the vagina, 
 and insinuated my fingers between the uterus and placenta at the 
 back part, and reached the membranes. But the rigidity of the 
 orifice was so great, that though I employed great force for a considerable 
 time, I could not succeed in getting the hand into the uterus. Dr. 
 Merriman recommended rupturing the membranes, and I was pro- 
 ceeding to do this with the fingers, when I felt one of the feet of 
 the child, which I grasped and brought down into the vagina 
 enveloped in the membranes, which then gave way. Nearly half 
 an hour elapsed before the version could be completed, and when it 
 was effected, the neck of the uterus grasped the neck of the child 
 so firmly, that I experienced the greatest difficulty in extracting the 
 head, and not till I had made pressure for some time with the finger, 
 and dilated the orifice of the uterus. A great discharge of blood 
 instantly followed ; the placenta was removed, and every means 
 employed to stop the hemorrhage, but the breathing became hurried, 
 the extremities cold, and she died in less than an hour after delivery. 
 Dr. Merriman informed me, that a patient of his had actually died 
 
PLACENTA PREVIA. 
 
 703 
 
 under similar circumstances before the head could be extracted. He 
 considers the tampon as of little or no use in such cases."^ 
 
 Case XLV. — Exhaustion ; delivery of child postponed, from rigid 
 state of OS uteri ; craniotomy ; death of mother immediately afterwards. 
 — " Mrs. H. was attacked with uterine hemorrhage at the beginning 
 of February, 1839, when seven and a half months pregnant. About 
 twelve days after, it returned a second time, and yesterday morning 
 a third time. About half-past twelve on the 5th of March, Dr, 
 Davies requested me to see her with him, as the hemorrhage had 
 returned in a dangerous form, and the orifice of the uterus was not 
 in a condition to admit of delivery. We found the placenta adher- 
 ing all round to the neck of the uterus, the orifice rigid and undi- 
 latable, and open to the extent of a crown, the head of the child 
 presenting. By cold applied externally and internally, the hemor- 
 rhage was restrained till six o'clock in the morning, when it was 
 renewed with violence. Dr. Davies then pressed his fingers through 
 the placenta, tore it in two parts, and perforated the membranes. 
 Half-past eight A. M. no hemorrhage ; slight pains. Eleven a. m. no 
 flooding ; head pressing into the orifice of the uterus. We were 
 prevented at the time from perforating and extracting the head, by the 
 rigid state of the os uteri. She seemed to regain strength during the 
 day ; but at ten in the evening, without any further loss of blood, 
 she began to breathe with great difficulty, the lips were livid, the 
 hands and feet cold, and it was evident she would soon die unde- 
 livered, if we did not interfere. I opened the head, and extracted 
 it with the greatest difficulty, in consequence of the firm and rigid 
 state of the os uteri. The operation was scarcely completed before 
 she was dead."^ 
 
 Case XL VI. — Turning attempted while the os uteri was too rigid to 
 allow the hand to pass ; two days subsequently, syncope from sudden 
 flooding; turning; death of the mother. — "On the 26th of April, 
 1835, 1 was called to a patient of the St. Marylebone Infirmary, 
 who was more than seven months pregnant, and had been attacked 
 fourteen days before with alarming uterine hemorrhage. The first 
 discharge of blood took place during the night, when she was at 
 rest ; it was not preceded by a sense of uneasiness about the uterus, 
 and could be referred to no accident or injury of any kind. 
 
 " A considerable oozing of blood still continued, when I first saw 
 her. The placenta presented ; the orifice of the uterus was opened 
 to the size of a crown piece, but its margin was so hard and undi- 
 latable, that I found it impossible, without employing too great 
 force, to pass the hand into the uterus. After a cautious trial for 
 about half an hour to get the hand insinuated through the orifice, 
 
 ' Clinical Midwifery, p. 155, Case 282. 2 Ibid., p. 157, Case 283. 
 
704 COMPLEX LABOR. 
 
 I was compelled to withdraw it altogether, as there was no hope of 
 overcoming the resistance. On the 27th, the flow of blood con- 
 tinued, the strength remaining unimpaired, and the os uteri being 
 not less unyielding. I resolved to wait till relaxation should take 
 place, and moderate the discharge by the recumbent position, and 
 the application of cold externally and internally. 28th. A large 
 quantity of blood suddenly escaped, which produced complete 
 syncope. The countenance was afterwards pale, the extremities 
 cold, and the pulse rapid and feeble. The os uteri being soft and 
 dilatable, I immediately passed up the hand, and delivered by turn- 
 ing. The child was born alive. The placenta was removed soon 
 after ; but though no farther loss of blood was experienced, she 
 continued gradually to sink, and died in a few days."^ 
 
 ClSB XLVn. — Severe and exhausting unavoidable hemorrhage with 
 the OS uteri perfectly undilatahle ; a foot caught through the undilated 
 OS, and the child extracted ; mother in great danger, but recovered. — 
 " On the 7th of October, 1835, I was requested by Mr. Gairdner, of 
 Foley Place, to see a patient, residing in Frith Street, who had com- 
 pleted the seventh month of pregnancy, and had been attacked with 
 uterine hemorrhage three weeks before. A slight discharge of 
 blood had continued during the whole of this period, but it had 
 produced little effect upon the system until a few hours before I saw 
 her, when several pints of blood were suddenly discharged, and her 
 whole strength seemed at once extinguished. The pulse was not 
 perceptible ; the extremities were cold, and the respiration feeble. 
 The blood still continued to flow, in great quantities, and it was 
 evident death would soon take place if the uterus was not speedily 
 emptied of its contents. The os uteri was not dilated to the size of 
 a crown, and it was so rigid that I found it absolutely/ impossible, 
 though I employed a degree of force scarcely justifiable, to pass 
 more than three fingers within it. The whole hand could not be made 
 to pass, though it appeared certain that death would soon take place if 
 delivery was not immediately accorAplished. On the fingers being with- 
 drawn for a short time, the flooding continued. I made another 
 effort to turn the child, but the resistance could not be overcome. 
 I then pressed forward the fore and middle fingers of the right 
 hand between the placenta and uterus, so as to reach the mem- 
 branes, which I succeeded in tearing open. Pressing the fingers 
 still forward, they came in contact with one of the feet, which they 
 grasped and brought down into the vagina. This was pulled lower 
 and lower till the whole extremities and nates were drawn into the 
 os uteri ; but so rigid did it continue to be, that although I exerted 
 all the force I dared employ in dragging it down, half an hour 
 
 ' Clinical Midwifery, p. 145. 
 
PLACENTA PREVIA. 
 
 705 
 
 elapsed before the pelvis of the child could be made to clear the 
 orifice of the uterus. At last it was extracted with the placenta, 
 and the hemorrhage ceased. A violent rigor followed, which 
 threatened for a time to destroy the patient. Bottles of hot water 
 were applied to the feet and pit of the stomach, the whole body was 
 covered with hot blankets, and brandy was liberally administered. 
 She slowly recovered from the immense loss of blood."' 
 
 But if we pass from individual to general facts, and attempt with 
 this view, to ascertain statistically the actual results of the practice 
 of turning, under the complication of dangerous unavoidable he- 
 morrhage in connection with a rigid or insufficiently dilated os uteri, 
 the consequences are probably more disastrous than the remarks 
 which I have made, or the cases I have quoted, under the present 
 head, would lead us to suppose. Dr. Collins refers to cases of Dr. 
 Ramsbotham's in which, from the extent of the hemorrhage, and 
 other symptoms, it was considered requisite to have recourse to 
 turning with the os uteri still inadequately dilated. I find in Dr. 
 Ramsbotham's work three additional instances of the same kind. 
 In his Clinical Midwifery, Dr. Robert Lee states, that out of the 
 thirty-five cases of placental presentation which he has recorded, 
 " in eleven there had been more or less rigidity of the os uteri, with 
 dangerous hemorrhage, and turning was performed in several of 
 them where the whole hand could not be introduced into the uterus." 
 Mauriceau, Lachapelle, and Collins, give each one or two similar 
 instances. The following table shows an analytical view of the re- 
 sults of all these cases in reference to their influence upon the life 
 of the mother. 
 
 Maternal Mortality in cases of profuse unavoidable Hemorrhage while the Os Uteri 
 was still Imperfectly Dilated. 
 
 Eeporters. 
 
 No. of Cases. 
 
 Mothers Lost, 
 
 Mothers Saved. 
 
 Mauriceau,' 
 
 Lachapelle,* 
 
 J. Ramsbotham,^ 
 
 R. Lee,« 
 
 Collins,' 
 
 F. Ramsbotham,' 
 
 Total, 
 
 2 
 
 1 
 
 8 
 
 11 
 
 2 
 
 1 
 
 2 
 1 
 
 7 
 8 
 2 
 
 1 
 
 
 
 1 
 3 
 
 
 
 25 
 
 21 
 
 4 
 
 ' Clinical Midwifery, p. 146, Case 267. 
 
 2 Ibid. p. 164. These eleven cases seem to be those marked as Nos. 266, 271, 272, 274, 
 277, 282, 283, 284, 285, 287, 289. 
 
 ' Observations sur la Grossesse et I'Accouchment des Femmes, pp. 134,363. 
 
 * Pratique des Accouchemens, torn. ii. case 9. 
 
 5 Observations in Midwifery, part ii. Nos. 138, 139, 140, 141, 142, 144, 145, 149. 
 
 * Clinical Midwifery, p. 149, etseq. ' Practical Treatise on Midwifery, p. 97. 
 8 London Medical Gazette for 1844, p. 279. 
 
 TOL. I. 45 
 
706 COMPLEX LABOR. 
 
 This table sufficiently demonstrates the extreme danger which the 
 mother incurs when forcible delivery is required, and attempted to 
 be accomplished by the operation of version, with the os uteri still 
 imperfectly dilated or dilatable. The result is, that calculating from 
 the data which the table affords, 17 per cent, only of the mothers 
 were saved and 83 per cent, of them died under the complication— a 
 result far greater than we find in any legitimatized surgical opera^ 
 tion, and far more fatal than even the Csesarean section itself.^ But 
 under this complication, we believe, that the complete artificial de- 
 tachment of the placenta would be perfectly practicable in most, if 
 not in all cases, and would consequently lead to the saving of many 
 maternal lives. It would at once, as we have seen,, arrest the he- 
 morrhage which is the more immediate source of danger to the pa- 
 tient, and allow time for the os uteri to become relaxed and the 
 labor to be completed, either by the natural pains or otherwise, as 
 might be afterwards found proper or necessary. 
 
 If our statistics are sufficiently extensive to be true, we might 
 thus save 80 or 90 maternal lives out of every 100, by having re- 
 course to artificial and complete detachment of the placenta, instead 
 of losing 80 or 90 mothers out of every 100, by having recourse to 
 the operation of turning. I shall afterwards take occasion to show, 
 that in this complication the life of the child does not interfere in 
 any material degree with these results, because the infant itself is 
 almost invariably lost when turning is attempted under the particu- 
 lar complication in question. 
 
 Second Seeies. 
 In Cases of First Labor. 
 
 In another place, I have endeavored to demonstrate that almost 
 all obstetric complications are more frequent and formidable in first 
 than in subsequent labors — rupture of the uterus being the princi- 
 pal exception to this general rule. Placental presentations would 
 seem to form another exceptional instance. I am not aware that 
 any author alludes to this point, but it has struck me repeatedly in 
 pursuing the statistical inquiries upon which the present memoir is 
 
 ' Dr. Churchill states the following conclusions as the results of his extensive inquiries 
 into the mortality attendant upon the Csesarean operation. " Among British practitioners, in 
 40 cases, 11 mothers recovered and 29 died, or nearly three-fourths. Among Continental 
 practitioners, out of 369 cases, 217 mothers recovered, and 152 died, or about 1 in 2J. 
 Taking the entire number, which amounts to 409, we find that 228 mothers were saved, 
 and 181 lost, or about 1 in 2J.'' — Researches in Operative Midwifery, p. 221. 
 
 Dr. Churchill has further calculated, that in the Cossarean operation, 160 children were 
 saved, and 64 lost out of 224. We shall see afterwards, that on the other hand far more 
 children are lost than saved in turning in placental presentation, with an undilated os uteri. 
 
PLACENTA PRJilVIA. 
 
 707 
 
 founded. In tlie Dublin Lying-in Hospital, during the period of 
 Dr. Collins' mastership, the proportion of first labors amounted to 
 30 per cent, of all the deliveries. During the same period, eleven 
 cases of placental presentation were observed in the Hospital. In 
 not one of the eleven did this complication occur in first labor.' In 
 the various reports of cases of placenta prsevia, by Giffard, Smellie, 
 Rigby, Clarke, Collins, Lee, and Ramsbotham, I find in all 55 in- 
 stances in which the number of the pregnancy is mentioned.'' In 
 3 only out of these 55 eases, was the accident observed in a first 
 pregnancy. Out of 81 cases, collected from our own General Table 
 of Cases in Section HI., with the number of the labor noted, the 
 patient was pregnant for the first time in 8 instances. (See p. 619.) 
 
 Thus adding these two collections of data together, we have 136 
 cases of placental presentation, and 11 only of these were observed 
 in first labors. 
 
 If the rarity of placental presentations came to be fully established 
 in fij'st pregnancies by more extensive data,' may it not afford us 
 some clue to the explanation of the cause or causes leading to the 
 origin or production of that deviation in the site of the develop- 
 ment of the placenta which constitutes placenta prsevia ? 
 
 But though placental presentations seem to occur rarely in first 
 pregnancies, yet when they are met with, they are liable to exhibit 
 unusual difficulties in consequence of the maternal passages being 
 less dilated and dilatable than in women who have previously borne 
 a family. Hence the labor is slower, and the hemorrhage conse- 
 quently longer and more exhaxisting, before the parts are sufficiently 
 relaxed, to admit with safety, of either the artificial or natural de- 
 livery of the infant. In speaking upon this point, in connection 
 
 ■ Practical Treatise, Table, pp. 173, 175, Cases Nos. 4, 17, 33, 84, 50, 72, 77, 83, 89, 92, 
 ll9. 
 
 ^ Maurioeau does not mention the number of the pregnancy in any of his cases of placenta 
 praevia. Giffard mentions it in 2 — see his Cases in Midwifery, pp. 203, and 492 ; neither 
 of them first labors. Smellie notices it in 9 cases — Midwifery, vol. ii. pp. 308, 310, 311 ; 
 and vol. iii. pp. 141, 162, 178, 409, 412, 415; one of them a firEt pregnancy. Rigby states 
 it in 9 instances — Essay on Uterine Hemorrhage, 6th edit., pp. 203, 209, 218, 224, 232, 238, 
 240, 246, 253 ; none of them primiparee. Clarke, in 4 cases — Trans, of King and Queen's 
 Coll. of Phys., vol. i. p. 380 ; one of which was a first labor. Lee, in 4 oases, reports the 
 number of the pregnancy — Clinical Midwifery, cases 268, 272, 285, 288 ; all the patients 
 had borne children previously. Ramsbotham records the number of the pregnancy in 6 of 
 his cases— Observations in Midwifery, 1st edition, pp. 195, 200, 202, 206, 216, 233 ; one of 
 them only was confined for the first time. 
 
 ' The only evidence to the contrary, that I have been able to find, is afforded by Madame 
 Laohapelle. She states that in het 16 placental presentations, 6 were labors with first 
 children. Is this in any degree explicable by the kind of patients resorting to the Maternity 
 Hospital of Paris, where Madame Laohapelle's observations were made? Are the patients 
 in a great proportion about to be confined of illegitimate cliildren, and pregnant for the first 
 time? 
 
708 COMPLEX LABOK. 
 
 with the treatment of unavoidable hemorrhage, Dr. Smellie justly 
 observes, " The younger the woman is with child, the greater is the 
 difficulty in opening the os internum, and more so in the first child, 
 especially if she is past the age of thirty-five. "> In a previous page 
 (p. 700) I have already quoted from Dr. Smellie an account of the 
 post-mortem appearances and state of the os uteri, which he ob- 
 served in a patient that had died in her first pregnancy, of unavoid- 
 able hemorrhage. Adverting to the force required to open the os 
 uteri in that instance after death, Dr. Smellie observes, " By this it 
 appears how difficult it is to dilate this part in women going of a 
 first child, especially when they are pretty old» Indeed it is sonie- 
 times impossible to be done before they come to their full time, and 
 even then, not until the parts are thin, soft, and largely opened by 
 previous labors."' 
 
 In consequence of the preceding circumstances rendering a first 
 labor with una;voidable hemorrhage both more tedious in its course, 
 before artificial delivery can be adopted, and the artificial delivery 
 itself more difficult of execution, after it is had recourse to, placental 
 presentations, with this complication, would appear to be very 
 dangerous and fatal to the mother. Out of 10 cases of unavoida- 
 ble hemorrhage in connection with first labor, which I find in the 
 reports of Smellie, Clarke, Lachapelle, and Drs. J. and F. Rams- 
 botham, 7 of the mothers died. One or two cases may serve to 
 illustrate the difficulties and dangers to which I have adverted. Dr. 
 Francis Ramsbotham has given the following instance among his 
 elaborate and valuable tables and notes of the obstetric practice of 
 the London Maternity Charity. 
 
 Case XL Vm. — Unavoidable hemorrhage with a first child; exces- 
 sive rigidity ; turning and perforation of the infant's head ; death of 
 the mother. — The patient, the subject of this case, " was more than 
 40 years old, and it was her first child ; there was excessive rigidity 
 of the OS uteri and other structures." When first examined, the 
 OS uteri was not dilated to more than the size of a shilling. A 
 catheter was passed into the uterus " by the side of the placenta," 
 and the membranes were thus ruptured. This proceeding did not 
 arrest the hemorrhage, and two hours after, delivery, by turning, 
 
 • Treatise on Midwifery, vol. i. p. 332. Dr. Rigby, Essay on Hemorrhage, p. 36, and Dr. 
 Dewees, System of Midwifery, p. 385, both advert to the difficulty which is apt to be met 
 with in making a proper examination even of the presenting part in unavoidable hemor- 
 rhage, occurring with a first child. " It must be acknowledged," to quote Dr. Rigby, " indeed, 
 that it may sometimes happen, that at the very first coming on of the complaint, if the dis- 
 charge be small, and more especially if it be the patient's first child, and the parts be close 
 and unyielding, the admission of the hand into the vagina as I have directed, will be 
 attended with the utmost difficulty, and perhaps be almost impracticable." 
 
 * Midwifery, vol. iii p. 414. 
 
PLACENTA PK^VIA. 
 
 709 
 
 was proceeded with. " Great difficulty" was experienced in intro- 
 ducing the hand and extracting the body of the child. The head 
 was perforated to enable it to pass. " The placenta was immedi- 
 ately expelled, and although she had spoken cheerfully the minute 
 before, she expired suddenly directly it was born."' 
 
 Case XLIX. — Placental presentation in a first labor ; turning with 
 OS uteri, Sj-c, offering resistance ; death of the mother in three days 
 afterwards. — The case is detailed by Dr. Ramsbotham, in his Practi- 
 cal Observations. The patient was in the eighth month of pregnancy 
 with her first child. During the preceding month she had had 
 repeated attacks of hemorrhage, which subsided spontaneously. 
 Upon making an examination, " although the os uteri -^as rigid and 
 but little opened," the placenta could be detected. She continued 
 free from any discharge the whole of the two following days, when 
 a more violent return of hemorrhage occurred. The operation of 
 turning was proceeded to. " The external parts, the vagina and the 
 OS uteri, had shown little disposition to give way." The os uteri 
 " offered considerable resistance" to the entrance of the hand, 
 " binding it tightly around like a cord." This was overcome, a foot 
 was seized, and the breech brought down — uterine action became 
 strong and "expelled the rest of the child alive." After delivery 
 there was no farther loss ; she was, however, much exhausted. On 
 the second day she was attacked with vomitings of a dark greenish 
 fluid, and complained of pain in the belly, which felt tender and 
 swelled ; the pulse was small and quick. In the course of the 
 night she expired. " A post-mortem examination was not allowed ; 
 yet I could not," observes Dr. Eamsbothaih, " divest myself of the 
 suspicion, that some injury was inflicted upon the parts in the act 
 of delivery, although I was not aware of such a fact at the moment."^ 
 
 After what I have stated under the preceding division, upon 
 rigidity of the os uteri in placental presentations, the practical in- 
 ference which I would wish to draw from the above remarks and 
 cases, concerning unavoidable hemorrhage in first labors, is obvious. 
 In the present, as in the former instance, and for the same reasons, 
 I am inclined to believe, that the complete separation and extrac- 
 tion of the placenta will be found more safe and far more practica- 
 ble in the generality of first pregnancies with unavoidable hemor- 
 rhage, than the forced delivery of the infant by turning. The os 
 uteri, however, in some such cases may be found, at the time re- 
 quired, sufficiently dilated or dilatable to allow of the artificial 
 extraction of the infant, provided that plan be deemed, in other 
 respects, proper and preferable. I here speak of the propriety of the 
 
 'London Medical Gazette for 1844, p. 279. ^ Practical Observations, part ii. p. 206. 
 
710 COMPLEX LABOR. 
 
 sepai-ation of the placenta in first pregnancies, because I believe it 
 will be more frequently found tbe proper line of proceeding in first 
 tban in subsequent deliveries, in wMcb the passages yield earlier and 
 more speedily and readily under the relaxing effects of the labor 
 pains and the hemorrhage, and permit earlier and more safely of 
 artificial delivery. 
 
 "We believe it to have been the intention of Dr. Simpson to render the preceding Memoir 
 complete, by considering at equal length the seven remaining series of cases in which his 
 proposed practice is indicated— viz. In premature labors ; in labors supervening earlier than 
 the seventh month; when the uterus is too contracted to allow of turning ; when the pelvis 
 or passages are organically contracted ; in cases of exhaustion ; when the child is< dead ; 
 and when it is premature and not viable. These important additions, we trust, will yet 
 appear. 
 
 To render ihe papers, however, as complete as is at this time possible, we subjoin a 
 few farther facts and observations put forth by Dr. Simpson at various times, in explanation 
 of his proposal and early assertions. — (Ed.) 
 
 SUMMARY OF PEINCIPLES OF TREATMENT IN PLA- 
 CENTAL PRESENTATIONS, ETC. 
 
 (From Lancet, May, 1847, p. 479.) 
 
 In a late very interesting and very able paper on unavoidable 
 hemorrhage, published in the Lancet for March 27th, I observe that 
 the author, Mr. Barnes, argues on the idea that I recommend the 
 complete separation and detachinent of the placenta before the 
 child, as a general rule of practice in all cases of placental presen- 
 tation. Many other members of the profession appear to have had 
 the same impression. I have always, however, maintained a very 
 different doctrine. From the first observations which I published 
 on the subject, up to the present time, I have upheld that the prac- 
 tice of detaching the placenta before the child, in unavoidable 
 hemorrhage, was a method to be had recourse to in cases where the 
 other recognized modes of management were insufficient or unsafe, 
 or altogether impossible of application ; and I have always looked 
 upon this new method as possessing especial value, from its thus 
 presenting to us a rational means of treatment in precisely those 
 more formidable varieties of this obstetric complication, in which 
 all former plans of practice were attended with extreme hazard or 
 extreme difficulty. 
 
 As I am anxious to avoid future error and misconception on this 
 head, I would beg leave here to take the liberty of enumerating 
 briefly, and without entering into special details, the different 
 
PLACENTA PRiEVIA. 711 
 
 general principles of treatment wliich, in my humble opinion, ought 
 to guide our practice in this important and anxious class of cases. 
 
 Setting aside, then, those minor and palliative measures for mode- 
 rating the attendant flooding that are generally adopted by practi- 
 tioners in all cases of uterine hemorrhage, where time permits of 
 their employment (such as quietude, the supine position, cold, &c.), 
 I hold that our management of placental presentations, when either 
 labor or such severe flooding as demands interference does at last 
 supervene, should be regulated on the following principles : 
 
 I. In some cases no active interference is required. — ^In placental 
 presentations, we deem ourselves called upon to interfere opera- 
 tively, with the avowed object and purpose of saving the patient 
 from , the dangers of the attendant hemorrhage. Hence it neces- 
 sarily follows that it would not be requisite to adopt any special 
 form of artificial aid or delivery, if, in any case or cases, this com- 
 plication were accompanied with little or no flooding. 'Sow, in 
 some instances of partial presentation of the placenta, the flooding 
 ceases altogether, or abates to a safe degree, when, during the 
 natural progress of labor, the membranes rupture and the head 
 descends. And in some rare cases of complete presentation of the 
 placenta, where the vascular bleeding structure of the placental 
 mass has become obstructed and obliterated previously to the super- 
 vention of labor, little or no hemorrhage has accompanied the pro- 
 cess of delivery. In other instances, before any operative aid can 
 be applied, the hemorrhage suddenly and entirely ceases in conse- 
 quence of the placenta becoming totally separated and expelled by 
 the advancing head of the infant. Under such circumstances, and 
 others, where the present or prospective dangers attendant upon 
 operative interference, would be evidently greater than the present 
 or prospective dangers attendant upon the existing degree of hemor- 
 rhage, any form of forced delivery would, I believe, be improper. 
 But cases of placental presentation in which we can thus leave the 
 delivery altogether to nature, are rare. Generally we require to 
 adopt some active measures, with the special object of saving the 
 patient from the actual or threatened dangers of the hemorrhage. 
 These measures should, I conceive, be one or other of the plans 
 which I have now to proceed to mention, viz., 1, the artificial 
 evacuation of the liquor amnii ; or, 2, the artificial extraction of the 
 child ; or, 3, the artificial separation of the placenta. 
 
 II. Artificial Evacuation of the Liquor Amnii. — In partial presen- 
 tations of the placenta, rupturing the exposed portion of membranes 
 (according to those principles that are generally followed in acci- 
 dental floodings), is a measure which sometimes proves quite ade- 
 quate to arrest or abate the hemorrhage to such an extent, that the 
 
712 COMPLEX LABOR. 
 
 delivery may be afterwards entirely committed to the efforts of 
 nature. Various old authors, as Daventer, Deleurye, and Astruc, 
 have described this same plan of treatment as applicable to com- 
 plete, as well as to partial, presentations of the placenta, with this 
 difference, that in the complete variety the liquor amnii is evacuated, 
 not by puncturing the membranes only, but by perforating the op- 
 posing placental structure with a trocar, catheter, or other analogous 
 instrument. And the later records of midwifery contain several 
 cases in which this perforation of the placenta has, in complete pre- 
 sentations of the organ, been successfully adopted, both as regards 
 the mother and the infant. 
 
 Several high authorities, however, in midwifery, have altogether 
 repudiated the evacuation of the liquor amnii, both in partial and 
 in complete placental presentations. They have done so principally 
 under the idea, that if this measure failed to suppress the flooding, 
 the previous escape of the waters would render any subsequent 
 practice that might be required, more difficult of execution. This 
 objection certainly applies to turning, as a subsequent practice, but 
 it does not apply to artificial detachment of the placenta as an ulte- 
 rior measure of treatment. 
 
 The artificial evacuation of the liquor amnii, by perforating either 
 the placenta or membranes, affords assuredly a simple, but by no 
 means a certain, method of restraining the flooding in placenta 
 prsevia. It is a practice which is undoubtedly attended with less 
 success in unavoidable than in accidental hemorrhage. But still I 
 believe it to be a mode of treatment to which we may occasionally 
 have recourse with great advantage, especially if there is originally 
 a large quantity of liquor amnii present, and if the flooding is 
 great, while the os uteri is still small and undilatable. We must 
 beware, however, of trusting too much or too long to this, or to any 
 mere palliative measures. Whatever we do, should, if possible, be 
 always done before the hemorrhage is allowed to proceed to such 
 an extent as to induce any very marked symptoms of constitutional 
 debility and depression in our patient. If a decided state of ex- 
 haustion has been allowed to supervene, either of the two remain- 
 ing and ulterior measures, extraction of the child or extraction of 
 the placenta, will be but too liable to prove futile and unsuccessful 
 in their results. 
 
 m. Artificial Extraction of the Child. — This forms the general 
 principle of management upon which unavoidable hemorrhage has 
 hitherto been treated by most authors and practitioners. The pro- 
 fessed object of the practice is this : by forcing the delivery of the 
 child, and thus emptying the uterus, the organ is thrown into full 
 contraction, and hence further loss of blood prevented. The mode 
 
PLACENTA PRiEVIA. 
 
 713 
 
 in which the indication is fulfilled, is, in some degree, regulated by 
 the state of advancement of the infant, its presentation, &c. In a 
 great proportion of cases the accompanying hemorrhage requires 
 interference at; so early a stage of the labor, that the only proper 
 and possible mode of delivery is by the operation of turning ; and 
 various authors, as Drs. Denman, Burns, Hamilton, Conquest, and 
 others, speak of turning as the sole and only mode of treatment ap- 
 plicable to cases of placental presentation. The great objection to 
 it is the imminent danger which the mother necessarily runs from 
 the risk of some laceration of the cervix uteri during this mode of 
 forcible delivery ; and any degree of laceration of this part is espe- 
 cially dangerous in placental presentations ; for in placenta prsevia 
 the structure of the cervix is extremely vascular, being permeated by 
 those numerous and enlarged vessels which are always developed, 
 in a high degree, in the uterine walls opposite the seat of the pla- 
 centa. The laceration of these vessels leads to immediate danger, 
 from draining hemorrhage after delivery, and to more remote dan- 
 ger, from inflammation being liable to spring up in the torn and 
 wounded sinuses of this part, and extreme uterine phlebitis following 
 as a direct consequence. But still I hold turning to be the proper 
 mode of practice in unavoidable hemorrhages which cannot be re- 
 strained by less active measures, and where immediate delivery is 
 demanded, with the os uteri well dilated, or easily dilatable, and 
 the child still alive, or presenting transversely. 
 
 Besides turning, other modes of artificial delivery of the infant 
 are occasionally resorted to in placental presentations. If the attend- 
 ant fiooding is such as not to require forced delivery till after the 
 waters are evacuated, and the head well advanced in the passages, 
 then version would be dangerous and inapplicable, and the use of 
 the forceps offers the safest and easiest mode of extracting the infant. 
 Further, in original pelvic presentations, extraction may be at any 
 time effected, when required, by seizing and dragging at the feet of 
 the child. 
 
 TV. Artificial Separation of the Placenta. — The arrestment of un- 
 avoidable flooding by total detachment of the placenta should, I 
 believe, be our line of practice when the combination of circum- 
 stances is as follows, viz., the hemorrhage is so great as to show the 
 necessity of interference, and is not restrained or restrainable by 
 milder measures, such as the evacuation of the liquor amnii ; but, 
 at the same time, turning, or any other mode of immediate and 
 forcible delivery of the child, is especially hazardous or impracticable, 
 in consequence of the undilated or undeveloped state of the os uteri, 
 the contraction of the pelvic passages, &c. Or, again, the death, 
 prematurity, or non-viability of the infant, may not require us to 
 
Y14 COMPLEX LABOR. 
 
 adopt modes of delivery for its sake, that are accompanied (as turn- 
 ing is) with much peril to the mother, provided we have a simpler 
 and safer means, such as the detachment of the placenta, for at once 
 commanding and restraining the hemorrhage, and guarding the life 
 of the parent against the dangers of its continuance. Hence, as I 
 have elsewhere stated, I believe that the suppression of the flooding 
 by the total detachment of the placenta will be found the proper 
 line of practice in severe cases of unavoidable hemorrhage, compli- 
 cated with an OS uteri so insu£B.ciently dilated and un dilatable as 
 not to allow of version being performed with perfect safety to the 
 mother: therefore, in most primiparas; in many cases in which pla- 
 cental presentations are, as very often happens, connected with pre- 
 mature labor and imperfect development of the cervix and os uteri; 
 in labors supervening earlier than the seventh month ; when the 
 uterus is too contracted to allow of turning ; when the pelvis or pas- 
 sages of the mother are organically contracted ; when the child is 
 dead; when it is premature and not viable; and where the mother 
 is in such an extreme state of exhaustion as to be unable, without 
 immediate peril of life, to be submitted to the shock and dangers of 
 turning, or forcible delivery of the infant. This enumeration is far 
 from comprehending all the forms of placental presentations that 
 are met with in practice ; but it certainly includes a considerable 
 proportion of the cases of this obstetric complication, and among 
 them, all, or almost all, of the most dangerous and most difficult 
 varieties of unavoidable hemorrhage. In adopting the practice, 
 one error, which I would strongly protest against, has been com- 
 mitted in some instances. Besides completely' detachitig and ex- 
 tracting the placenta, the child has subsequently been extracted by 
 direct operative interference. If the hemorrhage ceases, as it usually 
 does, upon the placenta being completely separated, the expulsion 
 of the child should be subsequently left to nature, unless it present 
 preternaturally, or the labor afterwards show any kind of compli- 
 cation which of itself would require operative interference under 
 any other circumstances. Both to detach the placenta and extract 
 the child would be hazarding a double instead of a single operation. 
 Comparative Mortality attendant upon Turning, and upon the Total 
 Separation of the Placenta. — One circumstance which strongly led 
 me to advocate, in unavoidable hemorrhage, the preference of the 
 detachment of the placenta to the operation of turning the child, 
 was the fact of the great mortality which followed the latter opera- 
 tion, as contrasted with the few mothers that died when the placenta 
 was spontaneously expelled, or accidentally extracted before the 
 infant. In speaking of the relative maternal mortality resulting 
 from the two modes of practice, Mr. Barnes very propei-ly points 
 out that when I spoke of the mortality attendant upon the separa- 
 
PLACENTA PREVIA. 715 
 
 tion of the placenta before the child as amounting to 1 in 14 only, 
 10 mothers in 141 having died, I had included cases in which the 
 placenta was thrown off spontaneously before the child, along with 
 others in which it was artificially detached ; and he doubts if the 
 results would not be "widely different," if the statistics compre- 
 hended the latter class of cases only, " in which the severe operation 
 of detaching the placenta by the introduction of the hand had been . 
 resorted to." The best answer to this objection consists in a state- 
 ment of the results hitherto obtained from the practice of artificially 
 detaching the placenta. 
 
 "Seventeen cases," says Dr. West,' "have been recorded in the 
 English journals during the past fifteen months, of detachment of 
 the placenta before the birth of the child, in cases of placenta prsevia. 
 In the case recorded by Dr. Simpson, to whom it had been commu- 
 nicated by Mr. Cripps, the placenta was .removed by an ignorant 
 midwife, and ten hours elapsed before the child was born, during 
 which time, however, no hemorrhage took place. In 16 out of the 
 17 eases, the bleeding is said to have ceased immediately on the 
 detachment of the placenta ; but Dr. Everitt mentions, that although 
 the flooding abated on the separation of the placenta, it did not 
 entirely cease until after the application of cold externally ; and he 
 insists on the fact as proving, in cases of this kind, the hemorrhage 
 comes from the uterine as well as the placental ends of the lacerated 
 veins. The life of the mother was preserved in every case but one 
 (out of the 17), and then the previous hemorrhage had been so pro- 
 fuse as almost to exhaust the patient, who died three hours after 
 delivery. All the children were still-born, except in the case related 
 by Mr. Stickings." . 
 
 I do not stop to inquire whether in one and all of these 17 cases, 
 the artificial detachment and extraction of the placenta ought to 
 have been followed. At present I adduce them, not as affording 
 evidence of the propriety of the practice, but as affording evidence 
 of its safety.^ 
 
 ' See his able Midwifery Report for 1845-46, in Dr. Forbes' Review for January, 1847, 
 p. 286. 
 
 ^ Dr. Waller, Lecturer on Midwifery at St. Thomas' Hospital, London, and a gentleman 
 who has had extensive experience in this and other morbid complications, two years ago 
 published a long series of interesting cases of placenta previa. In a late addition to his 
 former communications in the Medical Times, he observes, " My confidence in Professor 
 Simpson's plan in these cases, remains unshaken. It will be, seen, in reference to my 
 cases, that in nine instances the placenta was separated, either namrally or artificially, 
 before the birth of the child. The same effect was produced in all, namely, the cessation of 
 the hemorrhage ; and eight of these women recovered. Surely this result could not have 
 been accidental, as some would have us imagine. I am not," Dr. Waller adds, " aware 
 that any cases have been recorded "wherein hemorrhage has continued after complete sepa- 
 ration." , See a Review of Dr. Churchill's Midwifery, by Dr. Simpson, in Edinburgh Monthly 
 Journal for July, 1850, p. -33, where the above question is discussed. — (Ed.) 
 
716 COMPLEX LABOR. 
 
 In proof of tlie maternal mortality under the old and recognized 
 forms of practice being greatly higher than under the proposed plan 
 of the extraction of the placenta before the child, Mr. Barnes refers, 
 apparently with some hesitation, to the statistics collected by Dr. 
 Churchill and myself, as showing that 1 in every S mothers was 
 usually lost in placental presentations. Among 174 cases of un- 
 avoidable hemorrhage collected by Dr. Churchill, 48 mothers died. 
 I have now before me (see page 601), a carefully collected list ot 
 654 cases of placental presentations reported by Mauriceau, Portal, 
 Giffard, Smellie, Eigby, Clarke, and Collins, Schweighauser, Lacha- 
 pelle, Drs. John and Francis Eamsbotham, Lee, Lever, and Wilson. 
 Among these 654 cases, 180 mothers died, or 1 in 3/^, In corrobo- 
 ration of the correctness of the statistical view which Dr. Churchill 
 and I have taken of the extent of maternal mortality in unavoidable 
 hemorrhage, I would further beg to refer Mr. Barnes to the obser- 
 vations of Dr. Eobert Lee.' Dr. Lee states a number of statistical 
 facts regarding uterine hemorrhage from placental presentations, 
 and, amongst other matters, he mentions the result to the mothers 
 in a considerable number of cases. I shall throw all his evidence 
 on this last point into a tabular form : 
 
 Maternal Mortality in 72 Cases of Placental Presentations, as noted by Dr. Zee. 
 
 Reporters. ^°- "^ Cases No. of Mothers 
 
 Reported. Lost. 
 
 Dr. Clarke, .14 1 
 
 Dr. Collins, , . . 11 2 
 
 Dr. Ramsbotham, 19 8 
 
 Dr. Lee 38 14 
 
 72 25 
 
 Hence, according to Dr. Lee's collection of statistics, the maternal 
 mortality in unavoidable hemorrhage, amounting to 25 in 72 cases, 
 is rather more than 1 in 3. And this evidence of Dr. Lee will pro- 
 bably be regarded as the stronger, seeing that it is totally unpre- 
 judiced in its. character, for, in 1845, Dr. Lee called into doubt the 
 accuracy of all collections of statistical data, made by others, which 
 led to the idea that the general maternal mortality in unavoidable 
 hemorrhage was so great, as to approach 1 in 3. At that time 
 he was, I believe, unaware of the general result of his own pre- 
 viously published collection of statistical data relative to the point 
 in question. 
 
 ' Midwifery Lectures, pp. 370, 371, published in 1S44. 
 
PLACENTA PKJ5VIA. 717 
 
 SPECIAL AVERAGE AMOUNT OP MATERNAL MORTALITY OBSERVED IN 
 CASES OF TURNING FOR PLACENTA PR^VIA.^ 
 
 On anothe;* occasion I took an opportunity of stating, and proving 
 by comparative statistics, that " those mothers who are the subjects 
 of placental presentations are submitted to as great peril of life from 
 this obstetric complication as they would be if seized with yellow 
 fever or malignant cholera." This refers to placental presentations 
 taken irrespectively of any special forms of treatment, or, indeed, 
 of any treatment at all. The table on page 601 is a proof of this, 180 
 mothers dying out of 654 cases, or 1 in 3t%. But though placental 
 presentations, taken as a whole, may thus be so very fatal, it has 
 been repeatedly argued, that in cases of unavoidable hemorrhage, 
 in which the child is extracted by the operation of turning, the 
 mortality must be different and less in amount. I doubt this en- 
 tirely. Out of the 654 cases forming the table previously pub- 
 lished, in 421 the child was extracted by turning. The following 
 table shows the result : 
 
 Table of Maternal Mortality in Placental Presentations treated by the Operation of Turning 
 
 the Child. 
 
 Beporters. Number of Cases. Mothers lost. 
 
 Maurioeau, 14 1 
 
 Portal, 12 1 
 
 Giffard, ]8 5 
 
 Smellie, 8 3 
 
 Kigby, 35 9 
 
 Clarke and Collins, 8 4 
 
 Busch, & 2 
 
 Schweighauser, 46 11 
 
 Lachapelle, 13 6 
 
 J. Eamsbothatn, 86 40 
 
 F. Ramsbotham, 96 37* 
 
 Lever, 30 7 
 
 Lee, 28 10 
 
 Wilson, 22 8 
 
 421 144 
 
 From the above table it appears, that out of 421 placental pre- 
 
 ' From Lancet, October, 1847, p. 381. 
 
 * In the controversy with Dr. Lee, the latter considered that 26 of the Drs. Ramsbotham's 
 cases ought not to be included in this table. If these, however, be omitted, there will remain 
 156 cases; the result of which was as follows: 
 
 Tahh of 156 seUcted Cases of Turning in Placental Presentations, the operation not having been over-delayed. 
 
 No. of Cases. Maternal Deaths. ^"""''DeatL*'"''^""'' 
 
 166 48 1 in 3 J 
 
 See particulars in Lancet for November, 1847, p. 520. 
 
718 COMPLEX LABOE. 
 
 sentations in wHeh the child was removed by turning, the result 
 was fatal to the mother in 144 instances; or, in other words, the 
 mothers were lost in the proportion of more than one in three (one 
 in two and nine-tenths). Upon the continent of Europe, the Csesa- 
 rean operation— reputed the severest in midwifery— has been fatal 
 to the mothers, according to Dr. Churchill, in 154 out of 371 casps, 
 or in 1 in 2i*ff. 
 
 Lithotomy— generally regarded as one of the most formidable 
 operations in surgery— is calculated by Drs. Willis and Inman to 
 have an average mortality of one in every seven or eight operated 
 upon. The fatality attendant upon placental presentations treated 
 by the obstetric operation of turning, is more than twice greater 
 than that accompanying the surgical operation of lithotomy. 
 
 When turning is had recourse to in some of those more severe 
 complications of unavoidable hemorrhage, which I have proposed 
 •to treat by the total detachment of the placenta, the maternal mor- 
 tality is still even greater and more startling. Out of eleven cases 
 of placental presentation reported by Dr. Lee in his " Clinical Mid- 
 wifery," and where there was the combination of "more or less 
 rigidity of the os uteri with dangerous hemorrhage," eight of the 
 mothers died, or seventy-two per cent. ; and two out of the only 
 three who did survive, evidently made very narrow escapes from 
 death. 
 
 After giving a tabular view of these eleven cases on another occa- 
 sion,' I observed, that consequently " the operation of turning and 
 artificial delivery in unavoidable hemorrhage, with the os uteri im- 
 perfectly dilated, would, &om these and other cases, appear to be 
 more deadly than any operation that is deemed justifiable in the 
 whole circle of surgery." And I sincerely believe that in such 
 cases the simple but complete separation of the placenta without 
 its removal, which could be accomplished in circumstances under 
 which turning was utterly impracticable — ^would at once arrest the 
 hemorrhage, and thus place the mother in a state of comparative 
 safety. "But," anxiously argues Dr. Lee, "to have attempted in 
 those cases to tear away" (separate) " the placenta, would have been 
 an act of insanity." " It would, undoubtedly," as anxiously argued 
 Dr. Brown, some twenty or thirty years ago, " be downright mad- 
 ness to imagine they will condescend to encourage vaccination."^ 
 
 For details of the controversy with Dr. Lee concerning the treatment of Placenta Prsevia, 
 see London Medical Gazette, 1845; and Lancet, 1847, 1848, and 1851. — (Ed.) 
 
 •Medical Gazette for 1845, p. 1013. 
 
 * Edinburgh Medical and Surgical Journal, vol. xv. p. 64. 
 
PLACENTA PR^EVIA. 719 
 
 TRANSFUSION IN HEMORRHAGE.* 
 
 (From Edinburgh Monthly Journal of Medical Science, February, 1 849, p. 560.) - 
 
 De. Simpson had seen transfusion tried, in several consultation 
 cases, where the patients were dying from the results of uterine 
 hemorrhage. In one case, the lady, who was infirm and jaundiced 
 before, kept well for an hour and a half after delivery. Sudden 
 hemorrhage then supervened, which was speedily and entirely 
 arrested by Dr. Purdie ; but the patient was left by it in a col- 
 lapsed, pulseless state, and was incapable of being rallied by the 
 strong stimulants used. Dr. S. saw her about an hour subse- 
 quently, and injected into the basilic vein twelve ounces of a saline 
 solution, like that used here in the last chalera epidemic. The 
 solution roused the patient for a short time, but not much ; and she 
 remained three hours aftei-wards in the same sunk, collapsed state, 
 and died without any renewal of the flooding.. In another case he 
 had seen the same practice followed, and when the patient was quite 
 moribund, with no result and no rallying. Three or four years ago, 
 he was called to a case a few miles from Edinburgh, where he found 
 the patienT left in the same collapsed and pulseless state, after an 
 early miscarriage, accompanied with much hemorrhage. In this as 
 in the two other cases, the state of pulseless collapse, not capable of 
 being affected by brandy or other stimulants, continued for hours 
 after the hemorrhage was stopped, and before the patient died. A 
 surgeon was called from town, but failed in finding a vein large 
 enough to inject. These results did not seem to promise much or 
 any benefit from the injection of saline fluids, intended merely to 
 fill and re-distend the vascular system. He had injected pure blood 
 in another case, of Dr. Millar's, similar to the last ; the patient ral- 
 lied and recovered. But he had seen the treatment fail in various 
 other instances — lately in two extreme cases to which he was called 
 in the course of the same night. 
 
 DOES AIR EVER BECOME INTRODUCED INTO THE 
 VENOUS SYSTEM 
 
 THROUGH THE UTERINE SINUSES AFTER DELIVERY ?2 
 (From Edinburgh Monthly Journal of Medical Science, April, 1849, p, 707.) 
 
 A SERIES of cases that Dr. Simpson saw, in consultation, and 
 that occurred in rapid succession, six or eight years ago, seemed 
 
 ' Extracted from Proceedings of Edinburgh Obstetric Society, 1848. 
 2 Ibid. Jan. 10, 1849. 
 
720 COMPLEX LABOR. 
 
 to him to suggest the idea whether air might not become introduced 
 into the venous circulation of the mother after delivery, and whether 
 one common result of this accident was not the occurrence of a red 
 or scarlatinoid eruption upon the cutaneous surface of the patient. 
 
 The first case occurred in the Lying-in Hospital. The patient 
 had been delivered of twins. Dr. Ziegler was called to visit her, 
 in consequence of some difficulty connected with the birth of the 
 second child. Considerable post-partum hemorrhage, with alternate 
 contractions and relaxations of the uterus, supervened, and she 
 seemed to rally very imperfectly from the effects of the flooding. 
 In consequence of this. Dr. S. saw her an hour or two subsequently. 
 The pulse at that time was very rapid -and weak, almost imper- 
 ceptible. The countenance extremely anxious, and here and there 
 was an evanescent red scarlatinoid rash over the body. The patient 
 died in a few hours. The body was opened a short time after death, 
 because it was considered desirable not to incur the fallacy of air 
 being present from decomposition ; and Drs. Simpson and Ziegler 
 were anxious to ascertain if the anomalous symptoms that were 
 present during life could possibly arise from the entrance of air into 
 the veins. To make the examination the more certain, the abdomen 
 was opened under water. The lower vena cava, but especially the 
 uterine and hypogastric veins, were distended with frothy blood, and 
 air bubbled up through the water when any of these tubes were 
 opened. The larger veins in the extremities were in the same state. 
 
 Some search was subsequently made into the literature of cases 
 in which air had been introduced into the veins during surgical 
 operations upon the neck, &c., in order to ascertain if the evanescent 
 patches of red or scarlatinoid rash remarked in the preceding in- 
 stance, had been observed in any of these surgical cases. Dr. 
 Warren of Boston, in an article on the subject in the American 
 " Cyclopaedia of Practical Medicine," relates two cases which occur- 
 red in his own surgical practice. The first patient recovered after 
 being insensible for a considerable time. While still comatose, 
 "the leaden color in the cheeks," says Dr. Warren, " assumed a 
 reddish tinge, and the alarming character of the symptoms was 
 evidently diminished." The second case was fatal. During the 
 period elapsing between the entrance pf the air, and the death of 
 the patient. Dr. Warren, in describing the symptoms, remarks, 
 " The livid color of the cheeks gave place to a suffusion of vermilion 
 red, and no glow in the cheek of a youthful beauty ever gave one so 
 much pleasure as that flush. But the flush soon passed off." 
 
 If the red or scarlatinoid rash which appeared in the preceding 
 obstetric case upon the surface of the skin were owing to the 
 entrance of air into the uterine veins, might the symptom be ac- 
 
ENTRANCE OF AIE THROUGH UTERINE SINUSES. 721 
 
 counted for on the idea, that the introduced air directly mixed with, 
 and oxygenated, the blood in the capillary vessels ? 
 
 After the preceding case occurred, Dr. Simpson was called to three 
 or four other instances in which a similar train of symptoms was 
 present — namely, great depression after delivery, a rapid and almost 
 imperceptible pulse, and patches of an erratic scarlatinoid rash upon 
 the surface. All the patients died within two or three days after 
 delivery. In one case, which he saw with Mr. Kerr, and where the 
 death was much more rapid, no red rash appeared, although the 
 other symptoms were analogous. The first was the only case in 
 which an autopsy was procured. Two or three of the cases had 
 been considered as malignant scarlatina, a disease which was ac- 
 knowledged by all our highest obstetric authorities to be exceed- 
 ingly fatal to the puerperal female, but which may possibly in many 
 other cases have been mistaken for, and confounded with, the affec- 
 tion to which this notice refers. 
 
 Supposing the introduction of air into the venous system after 
 delivery to be the cause of the symptoms or affection in question, 
 it is not perhaps difficult to understand the mere mechanism of 
 its introduction. Surgical pathologists generally hold, that the air 
 cannot be drawn into open veins, unless these veins are not very 
 distant from the heart. But air may perhaps be forced into open 
 veins when the open orifices are at a distance from the heart, and 
 when circumstances exist capable of causing it to enter into such 
 orifices. 
 
 A mechanism calculated to produce the entrance of air in this last 
 way, exists in the uterus after delivery. The interior surface of the 
 organ, especially opposite the late seat of the placenta, has a number 
 of ruptured venous orifices opening upon it. Supposing air once 
 introduced into the uterine cavity, which in some cases may occur 
 in consequence of the alternate relaxations and contractions of the 
 walls of the organ following delivery (as in after-pains, post-partum 
 hemorrhage, &c.) ; and supposing, further, that under the returning 
 contractions of the organ, the expulsion of this air from the cavity 
 was prevented by the presence of a clot at the os uteri, or other such 
 obstructing cause, it will then, under the compression to which it is 
 subjected, be liable to be driven into the open venous orifices exist- ^ 
 ing in the lining membrane of the uterus. A bottle of caoutchouc 
 of the shape of the uterus, and with tubes like the venous tubes of 
 the uterus opening upon its interior, would act in this way on the 
 principle of the force-pump, in sending any air sucked or drawn up 
 into its cavity along these open tubes, if, after being full, its parietes 
 were compressed, and the aerial contents prevented from escaping 
 
 VOL. I. 46 
 
722 COMPLEX LABOR. 
 
 through its mouth, as we fancied to be the case in the uterus under 
 the conditions mentioned. 
 
 See also Dr. John Reid's Researches, 1848, p, 578. Appendix by Dr. Simpson to the 
 Essay on Air introduced into the Veins. — (Ed.) 
 
 SUDDEN DEATH AFTER DELIVERY: HEART DISEASE.' 
 
 (From Edinburgh Monthly Journal of Medical Science, May, 1849, p. 767.) 
 
 Dr. Simpson stated that, ten or twelve years ago, when acting as 
 resident house surgeon in the Lying-in Hospital, he was called by 
 a midwife to see a patient who had suddenly fainted and died, im- 
 mediately after the expulsion of the infant. The uterus, as felt 
 through the abdominal parietes, appeared firm and contracted. The 
 labor had been natural, without any hemorrhage or other complica- 
 tion. An autopsy was not obtained ; but the anterior history of the 
 patient showed the probability of the existence of diseased heart. 
 
 A short time afterwards a patient, attended by one of the pupils 
 of the hospital, rose up and stood for the first time, about a week 
 after delivery. She immediately fainted and expired. There had 
 been nothing particular in the history of the labor or convalescence. 
 
 In a case, in regard to which he was consulted by Dr. Buchanan, 
 the patient died suddenly about three hours after delivery — the fatal 
 event being preceded by cough and haemoptysis. The symptoms 
 before delivery were those of disease of the mitral valve, and in 
 consequence, Dr. S. advised her not to have chloroform in her labor. 
 
 Drs. Denman, Clarke, Blundell, Meigs, &c., had recorded notices 
 of cases of this kind of sudden death during labor, or after it, vsdth- 
 out convulsions or hemorrhage. 
 
 Dr. S. had always taught that the existence of heart or chest 
 disease formed a kind of complication in labor, which was not only 
 extremely anxious in itself, but which generally incapacitated the 
 patient from bearing with impunity, for any great length of time, 
 the struggles and efforts of a prolonged second stage. He considered 
 such a complication an indication for earlier instrumental assistance 
 than would be deemed necessary under other circumstances. 
 
 INVERSION OF THE UTERUS, ITS PATHOLOGY AND 
 TREATMENT.^ 
 
 (From Edinburgh Medical and Surgical Journal, January, 1840, p. 170.) 
 
 Inversion of the uterus is an accident which is sometimes con- 
 ,cealed by the practitioner, because it is an occurrence which is very 
 
 ' Extracted from Proceedings of Edinburgh Obstetric Society, Jan. 10, 1849. 
 -^ From a Review of Dr. Radford's Obstetric Essays. 
 
INVERSION OF THE UTEKUS. 723 
 
 generally, but very undeservedly, conceived both by the patient's 
 friends, and by the medical man himself, to attach blame to his 
 character. This feeling is apt to paralyze the energies of the sur- 
 geon, and to prevent him from immediately adopting those measures 
 vehich are necessary for the reduction of the inverted organ. It is 
 this procrastination which is blameable, and not the accident itself, 
 which is one, as Dr. Eadford has shown, that may happen in the 
 best hands, seeing that it sometimes depends not so much upon any 
 practice which the surgeon may have adopted, as upon morbid 
 actions taking place in the uterus over which he has no control. 
 
 Most authors attribute inversion of the uterus to causes purely 
 mechanical — such as pulling rudely and violently at the fanis in 
 order to remove the placenta. But that this is not always the origin 
 of inversion, is evident from a number of circumstances.' 'The acci- 
 dent has happened repeatedly when the cord was of its usual lengtji, 
 before any force has been applied to it. It has been found before* 
 the child was attempted to be separated by dividing the cord ; and 
 it has occurred when the cord has been so putrid as to break with 
 the slightest effort. We might refer also to cases where it has hap- 
 pened when the process of parturition was left entirely to nature ; 
 and in support of the same view of the subject, Dr. Radford might 
 have quoted the cases recorded by Boerner' and Klaatsch," in which 
 this inversion took place in instances where the child was expelled 
 some hours after the death of the mother, and when there was no 
 person present to interfere with the process. According to the 
 prevalent idea above alluded to, of the mechanical origin of inversion 
 of the uterus, it is believed that the uterus is in a state of relaxation 
 and atony, so that it offers no resistance to any force applied through 
 the medium of the funis. Dr. Eadford, however, has shown, by the 
 history of several cases which he has Himself met with, and of others 
 recorded by Cleghorn, Brown, Merriman, &c., that the fundus and 
 body of the uterus, so far from being in a state of relaxation, are 
 generally, if not always, in a state of unnatural contraction, as 
 evinced by the strong and violent uterine pains which are present, 
 and by the firmness and hardness of the inverted viscus. At the 
 same time, however, that the fundus and body of the uterus are in 
 this state of unnatural excitement and action, the os uteri appears 
 to be comparatively relaxed and dilatable, seeing that it offers no 
 resistance to the protrusion of the tumor through it. In other 
 words, it is evident, that the fundus and os uteri are in directly op- 
 posite conditions ; the former is in a state of violent contraction, the 
 latter in a stiate of atonic relaxation, and this relative difference in 
 
 ' Lod'er's Journal fiir Chirttrgie, &c. vol. i. p. 519. 
 2 Henke's Zeitschrift for 1826, vol. iii. p. 45. 
 
724 COMPLEX LABOR. 
 
 these two parts of the organ is indispensably necessaiy, as Dr. Rad- 
 ford conceives, for the possibility of the occurrence of inversion. In 
 other words, it arises, like the hour-glass contraction of the uterus, 
 from an inequality in the time and degree of contraction of the dif- 
 ferent parts of the organ ; and in Herbin's Thesis on Incarcerated 
 Placenta, Dr. Radford will find a case of this kind highly illustrative 
 of his views of the pathology of inversion, inasmuch as in the case 
 alluded to, the portion of the uterus which formed the chamber re- 
 taining the placenta was, notwithstanding the bulk of its contents, 
 so firmly contracted, that it passed through the very relaxed os uteri, 
 and projected into the vagina. 
 
 At the same time, while we freely confess that we believe Dr. 
 Radford has proved that his explanation applies to the majority of 
 cases of inversion of the uterus, we can easily conceive other in- 
 stances in which, the whole uterus remaining uncontracted, a 
 mechanical cause, such as strong traction at the cord of an adherent 
 placenta, may lead to the same frightful accident, in the way pointed 
 out by Spence, Clarke, Gooch, Gardien, and most of our other sys- 
 tematic writers on midwifery. 
 
 The proper diagnosis of such a dangerous accident is often a point 
 of great importance. In a case detailed in the Gazette Medicale for 
 1832, the inverted uterus was mistaken for a polypus, and the 
 woman died in consequence of inflammation excited by an attempt 
 to remove it. Dr. Radford details two cases in which the tumor 
 formed by the inverted uterus was mistaken for the head of a second 
 child. We know of one distressing case of this kind, where the 
 midwife in attendance fell into the same mistake, and had dragged 
 the uterus far down between the thighs of her patient before she 
 discovered her error, and sent for further assistance. We have 
 heard of another case where the uterine tumor in the vagina was 
 mistaken for the body of the placenta, and pulled outwards, under 
 this idea, with fatal violence. 
 
 Dr. Radford's remarks on the diagnosis of inversion are extremely 
 valuable on this account ; that he has shown, contrary to the opinion 
 generally entertained by obstetric authors, that hemorrhage rarely 
 occurs to any great extent in cases of this accident, except when the 
 placenta is partially detached or broken up in its structure, or where 
 the uterus itself has been lacerated. 
 
 In the treatment of inverted uterus, and in attempting that reduc- 
 tion of the organ which always forms our most immediate indica- 
 tion, Dr. Radford strongly advises us, provided the inversion is 
 complete, and the placenta still attached, to remove this latter mass, 
 before we endeavor to compress and return the uterus itself. He 
 has, as we have just hinted, fully shown that we need not be deterred 
 
PUERPEKAL CONVULSIONS. 725 
 
 from this practice by any dread of hemorrhage. -If the placenta, he 
 observes, be completely detached from the uterus, this orgdn con- 
 tracts as under ordinary circumstances, and the bleeding ceases. 
 "We need scarcely point out how much the separation of the placen- 
 tal mass will facilitate our attempts at reduction, and how highly 
 necessary it is to effect this, if possible, before the inverted viscus 
 becomes enlarged from congestion, and before the os uteri becomes 
 too much irritated and contracted to admit of its easy return. In 
 one case, Dr. Denman was unable to reduce the organ after the 
 lapse of four hours. "We must not, however, despair, if unsuccess- 
 ful in our first efforts, or during the first stage. The inverted uterus 
 has been reduced now in a number of instances, at a distance of 
 several days from the occurrence of the accident, in cases where the 
 threatened inflammatory symptoms had been kept in abeyance by 
 the active measures that were adopted. Mr. Cawley,' in one in- 
 stance, reduced the organ after it had been down three days ; and 
 in other cases Dr. Radford reduced it after seven, and Mr. Ingleby 
 after eight days. In one case Dr. Belcombe^ succeeded, though the 
 inversion had existed as long as twelve weeks. Cautious attempts 
 of this kind, where there is no inflammatory complication, may, 
 therefore, in some cases be warrantable, at a late period after the 
 accident, with a view of saving the patient from those constant dis- 
 charges, and other annoyances and miseries which the disease, when 
 not remedied in its first stages, very generally entails. 
 
 It is perhaps unnecessary to point out how very greatly the replacement of the organ is 
 facilitated by the use of anEesthetios. On the diagnosis of inversion, see previously, p. 120. — 
 (Ed.) 
 
 ALBUMINUEIA 
 
 IN PUERPERAL AND INFANTILE CONVULSIONS AND IN PUERPERAL 
 
 AMAUROSIS, ETC. 
 
 (From Edinburgh Monthly Journal of Medical Science, October, 1852, p. 369.) 
 
 Above fifty years ago, Hamilton* and Demanet^ first stated the 
 
 ' Lend. Med, Journal, vol. vi. p. 366. ' Med. Gazette, vol. vii. p. '783. 
 
 ' We have preferred inolitding convulsions among the complications of labor, to which, 
 or to pregnancy, it as justly belongs, rather than among the more peculiar affections of the 
 puerperal state. — (Ed.) 
 
 ^ Duncan's Annals of Medicine for 1800, vol. v. p. 313. "Where (Edematous swellings 
 of the lower extremities take place to a considerable extent in the latter months of preg- 
 nancy, in "women of an unimpaired constitution, copious bloodletting alone prevents th6 occur- 
 rence of convulsions either before or during labor." See also his Practical Observations, p. 
 354. " The fits are preceded most frequently by lancinating pain of the head, sometimes 
 by crampish pain of the stomach, and sometimes by oedematous swelling of the face and 
 tipper parts of the person." 
 
 ' Kecueil Periodique de la Society de M^decine, tom. ix. 1801-2, p. 110. He regards 
 " I'anasarque comme une de leurs causes essentielles." 
 
726 COMPLEX LABOR. 
 
 important f^ct, that puerperal convulsions were liable to be preceded 
 by symptoms of anasarca in the pregnant mother. The truth of 
 this remark has been subsequently confirmed, in incidental obser- 
 vations made by Duges, JBurns, Montgomery, Ingleby, Johns, and 
 others. The special pathological nature, however, of the oedema 
 or anasarca preceding and predisposing to puerperal eclampsia 
 rernained uninvestigated, nor was any direct morbid relation at- 
 tempted to be traced between the dropsy and convulsions. Pre- 
 viously to my first course of lectures on midwifery in the University 
 of Edinburgh in 1840-41, I had, in more than one case, ascertained 
 the cedema or anasarca seen in patients affected with puerperal con- 
 vulsions, to be one of the numerous and important forms of drop- 
 sical disease which Dr. Bright had shown to be connected with the 
 existence of albumen in the urine. Up to 1843 I had detected, in 
 repeated instances, this connection of puerperal convulsions with 
 albuminuria, but hitherto I had found it only by examination of the 
 urine during life. In the spring of 1843 I saw a fatal case of puer- 
 peral convulsions, in which, in addition to the detection of albu- 
 minuria during life, I had an opportunity of observing the usual 
 granular disease of the kidney on post-mortem inspection. 
 
 Case I. — A woman, pregnant for the third time, and whose health 
 had latterly been impaired, was seized with severe puerperal con- 
 vulsions, in consequence, as her friends supposed, of strong mental 
 excitement. I saw her, along with her medical attendant, about 
 twelve hours after the convulsions began. She was at that time quite 
 comatose in the intervals between the fits. In spite of venesection 
 and various other measures of treatment, which were tried with the 
 hope of relieving and rousing the patient, the convulsions continued, 
 the coma deepened, the extremities became cold, the circulation 
 began to fail, and the patient was evidently hopelessly moribund. 
 The child's heart, however, still continued to beat, as was ascer- 
 tained from time to time by the stethoscope ; and the principal 
 indication left was the preservation, if possible, of its life. The os 
 uteri had, from the imperfect labor which had supervened from the 
 attack of the convulsions, opened to about the diameter of a shilling, 
 but its structures were rigid. In order to extract the child, I fol- 
 lowed the plan of turning recommended by Dr. Hamilton, and with 
 far more facility than I anticipated a, priori — viz., I tilted andpiished 
 upwards and aside the presenting head with two fingers of the right 
 hand introduced per vaginam, while, at the same time, by manipu- 
 lating upon the child with the left hand through the abdominal and 
 uterine parietes, a lower limb was at last brought near the opening 
 of the OS uteri, and seized. The relaxed state of the uterus and 
 
PUERPERAL CONVULSIONS. 727 
 
 adjoining parts, resulting fi'om the deep coma of the patient, no 
 doubt greatly facilitated this version. On attempting to drag the 
 body of the child through the os uteri, by pulling at the extended 
 limb, I found the rigid structures of the undilated cervix to resist 
 altogether the passage of the trunk. Under these circumstances, I 
 made two slight incisions into the. cervix, one on each side, and on 
 the reapplication of extractive force, the breech now passed the 
 yielding os uteri, and the birth of the child was readily effected. 
 The child was born alive, and it survived and throve well. The 
 placenta escaped without any hemorrhage. The mother died in the 
 course of two or three hours after the birth of the child. A post- 
 mortem examination of her body was made by Professor Bennett. 
 The lateral incisions into the lips of the undilated os, and the lace- 
 ration or Assuring accompanying these incisions, were found not to 
 extend" beyond the duplicature of tissue forming the vaginal por- 
 tion or projection of the cervix uteri ; and had not been followed 
 by any hemorrhage. There was no blood, fluid or coagulated, in 
 the cavity of the uterus or vagina, or around the incisions. The 
 kidneys presented a well-marked specimen of granular degenera- 
 tion, probably of some standing. 
 
 In allusion to the preceding instance (see p. 733) I stated in the 
 " Monthly Journal" for 1843, that this case " offered me the fii'st 
 opportunity of confirming, by inspection after death, an opinion 
 that I had been led to adopt from the examination of the symptoms 
 during life, and had publicly taught for the, last two sessions, viz., 
 that patients attacked with puerperal convulsions had almost inva- 
 riably albuminous urine, and some accompanying, or rather pre- 
 ceding dropsical complication, and hence probably granular renal 
 disease."^ 
 
 My friend Dr. Lever of London, who happened also to be direct- 
 ing his attention at the same time to the connection of puerperal 
 convulsions with albuminuria, published in the last number of 
 " Guy's Hospital Reports" for 1843, several cases of puerpera- 
 eclampsia, in five of which he had found the urine to be albumil 
 nous ; and to these cases he appended some excellent remarks on 
 the probable relations between these two morbid states. Of late 
 years, the same subject has been investigated, and the connection 
 between albuminuria and puerperal eclampsia more or less elabo- 
 rately traced and discussed by various continental authors, particu- 
 larly by Cahen and Bouchut, Bayer, Devilliers and Regnauld, 
 Depaul, Caseaux, &c. 
 
 Since the above date (1843) I have seen a variety of cases of 
 puerperal convulsions in consultation and hospital practice, and 
 
 ' Momhly Journal of Medical Science, Nov. 1843, p. 1015. 
 
728 COMPLEX LABOR. 
 
 have always (with very rare exceptions indeed) detected the exis- 
 tence of albuminuria in the urine of the mother. In one or two 
 instances (see p. 733) I have found the kidneys presenting traces of 
 recent acute inflammation ; as pus, &c. Sometimes, as in the case 
 detailed above, convulsions, or symptoms threatening them, recur 
 in successive labors in the same mothers in connection with estab- 
 lished granular disease. Usually, however, the state of albuminuria 
 which leads to puerperal convulsions, is a transitory morbid condi- 
 tion, from which the patient recovers within the course of a few 
 days after delivery; and the afleetion does not depend upon, or 
 result in, any actual change of structure in the kidney. And it 
 may be that the premonitory oedema, headaches, &c., and the actual 
 convulsions themselves, do not stand in the relation of effect, to 
 albuminuria or renal disease as a cause, but that all of these circum- 
 stances — the dropsy, the convulsions, and the albuminuria — are 
 simultaneous or successive effects of some one common central 
 cause, viz., a pathological state of the blood, to the occurrence of 
 which, pregnancy in some waypeculiarly predisposes, probably from 
 various acts of secretion, nutrition, and depuration being vastly 
 increased and altered by the conditions of utero-gestation. Occa- 
 sionally, however, the state of albuminuria, when once induced, 
 will continue for several weeks after delivery. Some time ago I 
 attended, with Dr. Fairbairn, a ease that was peculiar in this respect, 
 as well as from the lateness of the occurrence of fatal convulsions. 
 
 Case II. — The lady had been confined in the country without any 
 symptoms of eclampsia. She came to Edinburgh about seven 
 weeks after her accouchement. When Dr. Fairbairn and I then 
 saw her together, her particularly leuco-phlegmatic color, some 
 lesions of the senses, her occasional fits of stupor and want of 
 memory and the other undefined symptoms of which she was com- 
 plaining, led me to suggest the propriety of testing the urine, in 
 order to ascertain if it contained albumen. It was found highly al- 
 buminous. In the course of eight or ten days subsequently, ouf 
 patient was suddenly seized with convulsions, followed by coma, 
 under a repetition of which she soon expired. ISTo case has, so far 
 as I know, been put on record, in which eclampsia supervened so 
 very late after delivery. 
 
 In the instance just now referred to, the albuminuria was, there 
 was reason to believe, present before the termination of the patient's 
 pregnancy ; but did not lead to any attack of convulsions during or 
 immediately after labor. And I have now seen a number of such 
 instances in which the urine was albuminous during the last days 
 or weeks of pregnancy, without convulsions, or any other special 
 morbid phenomena, supervening in connection with labor. 
 
PUEEPEBAL CONVULSIONS. 729 
 
 In several of these instances, temporary, and in one or two, more 
 permanent, amaurosis supervened at the time of delivery ; accom- 
 panied in most, hut not in all, with intense headache.^ During the 
 course of the present year, I saw one such case of puerperal amau- 
 rosis in connection with albuminuria, in a patient at the sixth month 
 of pregnancy ; and the albuminuria in this, as in some other cases, 
 tended to bring on premature labor. 
 
 Case HI. — ^It was the patient's second pregnancy. Her face had 
 looked swelled for a day or two previously. During the night she 
 complained of intense headache. In the morning she complained of 
 such a degree of blindness, that she could not distinctly see objects 
 and persons. The urine was highly albuminous. She was freely 
 bled. True labor pains supervened early in the forenoon. She was 
 placed under the influence of chloroform for some hours, and de- 
 livered of a premature child, which was alive, but did not survive. 
 The amaurosis in a great measure disappeared after the bleeding, 
 andthe patient's recovery after delivery was speedy and perfect, the 
 albuminuria passing off" within a week subsequent to her confine- 
 ment. 
 
 Lately I have visited, with Mr. Sidey, an interesting case of more 
 permanent amaurosis connected with the puerperal state and chronic 
 albuminuria : 
 
 Case IV. — The patient, now aged 36, is the mother of six chil- 
 dren. In 1847, two days after the birth of her fifth child, she 
 became totally blind in the course of a single night, the amaurosis 
 being found complete when daylight came on. The blindness, 
 however, gradually and entirely passed ofi" in a few days. During 
 the second week following the birth of her last child, in July, 1850, 
 she again became suddenly and completely blind, with some accom- 
 panying symptoms of stupor, and a very slow pulse. The amau- 
 rosis has not, however, altogether disappeared on this occasion as 
 after the former attack. The patient's vision is still (September, 
 1851) so imperfect that she cannot read ; her memory is extremely 
 defective ; she often forgets the proper word to use in the middle 
 
 ' Drs. Bright and Barlow observed amaurosis in four instances of albuminuria ; but these 
 cases were not connected with pregnancy. M. Landouzy states, that he has seen thirteen 
 cases of weakness of vision commence, cease, and reappear with albuminuria, and without 
 any appreciable change in the eye or its appendages. And he considers some degree of 
 amaurosis as a common complication with albuminuria. — See Archives G^nerales de Mede- 
 cine for Nov. 1849, p. 370. Hamilton and other authors incidentally mention amaurosis as 
 a symptom connected with cases of convulsions. Dr. Ingleby has published a case in which 
 a patient was affected with common puerperal convulsions in her first pregnancy ; and in 
 a subsequent accouchement, was attacked with complete amaurosis, which continued during 
 the whole period of her labor. Vision was gradually restored. — See his Facts and Cases in 
 Obstetric Medicine, p. 53. 
 
730 COMPLEX LABOR. 
 
 of a sentence ; the iris now contracts, but for some time was dilated 
 and immobile. The last child died of convulsions about a week 
 after birth. Mr. Sidey discovered the urine to be highly albumi- 
 nous upon her first attack of amaurosis, and has found this state 
 continuing in repeated examinations of it from that time to the 
 present. 
 
 Four years ago, I met with the follovsdng instance of the compli- 
 cation in question : 
 
 Case V. — A patient who was to be under my care at her confine- 
 ment, sent for me several weeks before her expected time, to tell 
 me that her vision had become so imperfect, that she found she 
 could not distinctly see the trees before her window. There was 
 no other special symptom present ; but this degree of amaurosis led 
 me to examine the urine, which I found to be highly albuminous. 
 During the few succeeding weeks, the amaurosis increased, and in 
 addition, symptoms of hemiplegia slowly and gradually came on. 
 Convulsions did not supervene, as I feared they would, during the 
 labor, which was somewhat premature. The child survived. After 
 delivery, the mother recovered greatly, but not entirely, from the 
 nervous lesions, and is still suflering under a slight degree of hemi- 
 plegia. 
 
 Other lesions of the nervous system may present themselves under 
 the same circumstances. Some of these lesions I have already 
 noticed elsewhere (see p. 732). In fact, writers upon midwifery have 
 long stated to us as premonitory symptoms of puerperal convulsions, 
 various lesions of the nervous system, as headache, giddiness, de- 
 rangements of sight and hearing, &c., and have told us, that when 
 more or fewer of these symptoms make their appearance, an attack 
 of convulsions is to be feared in connection with labor, but does 
 not always supervene. These so-called premonitory symptoms of 
 convulsions, however, are only in fact so many symptoms of acute 
 albuminuria.. They are indicative of the future probability of puer- 
 peral eclampsia, inasmuch as they are indicative of the actual pre- 
 sence of albuminuria. And, consequently, whenever they do pre- 
 sent themselves, their existence should lead us to examine accurately 
 into the state of the urine, assured that, if they are found to be con- 
 nected with albuminuria, we may be certain of the liability of our 
 patient to the supervention of convulsions — a liability that, no doubt, 
 may be often lessened or averted by proper antiphlogistic treatment 
 before labor, and by using such means as excite and act freely upon 
 the intestinal, renal, and cutaneous secretions. 
 
 A few weeks ago, I saw an instance in which convulsions in a 
 
PUERPERAL CONVULSIONS. 731 
 
 child after birth were connected with the presence of alhuminuria 
 in its urine — or connected, as it should be perhaps more correctly 
 stated, with that condition of blood-poisoning or ursemia, which is 
 the result of albuminuria — whether that condition consists in a 
 morbid accumulation of urea, or is produced, as Frerichs' supposes, 
 by the presence of carbonate of ammonia in the blood, produced by 
 decomposition of the urea ; or is, as is iriore probable, the effect of 
 same other morbific agent in the circulating system, capable, like 
 strychnia, of increasing the centric irritability or polarity of the 
 spinal system to such an excessive^ degree that, under this super 
 excitability, comparatively slight eccentric causes of irritation in the 
 stomach, intestines, uterus, bladder, &c. &c., readily induce convul- 
 sive attacks of a general form, like those of puerperal eclampsia. 
 
 Case VI. — ^A lady, pregnant for the first time, was suddenly, 
 when near the full period of utero-gestation, attacked, when rising 
 in the morning, with a severe headache, faintness, and threatening 
 of convulsions. My friend Dr. Weir, under whose professional 
 charge she was, saw her immediately, and bled her largely at the 
 arm, &c. On making a second visit about three hours subsequently, 
 she took, when he was present, a most severe fit of convulsions, 
 which left her in a state of deep coma. Two hours afterwards I 
 saw the patient with him. She was still comatose, and remained 
 so for some hours subsequently. The child's heart, when examined 
 by Dr. "Weir and myself, with the stethoscope, and while the mother 
 was still comatose, had only 88 beats in the minute ; but in the 
 evening it had risen to its usual rate of 130. ISText afternooil labor 
 supervened ; the patient was put under the influence of chloroform 
 for some hours ; and a living child was born without any recurrence 
 of the puerperal convulsions. The mother made a slow but perfect 
 recoveiy. On the third day after birth, the child began to suffer 
 under a succession of convulsive attacks, which gradually increased 
 in severity during the next twenty-four hours, when it was placed 
 for a considerable time under the influence of chloroform inhala- 
 tion, and the fits ceased. After the convulsive attacks supervened 
 in the child, Dr. Weir and I had two opportunities of examining its 
 urine ; and on both occasions we found the renal secretion of the 
 infant, like that of the mother, highly albuminous. Some time 
 
 ' If the blood poison, which in albumiiniria produces convulsions and coma, be, as Frerichs 
 believes, carbonate of ammonia resulting from decomposition of urea, can we account for 
 the power of chloroform in restraining and- arresting, as it does, puerperal convulsions, upon 
 the ground of its preventing this decomposition? The inhalation of chloroform produces, 
 as various chemists have shown, a temporary diabetes ; sugar appears in the urine, and 
 hence probably also in the blood. The addition of a little sugar to urine out of the body, 
 prevents, for a time, the common decomposition of its urea into earbonaie of ammonia. 
 
732 COMPLEX LABOR. 
 
 subsequently, the infant died of inflammation of the cellular tissue 
 of the loins and pelvis. We were not permitted an inspection of 
 the body. 
 
 I am not aware that any one has hitherto observed albuminuria 
 coexisting with infantile convulsions ; but future observation may 
 perhaps show it to be a common pathological condition in some 
 forms of that disease ; and probably in the Trismus Naseentium. 
 In such cases, indeed, the urine has hitherto seldom or never been 
 examined, in consequence of the trouble and difficulty connected 
 with' obtaining specimens of it in the affections of infancy. Albu- 
 minuria may yet be found to play also an important part in other 
 diseases of infancy. The induration of the cellular tissue, or skin- 
 bound disease (Scl^r^me — '■'■ L' Endurcissement ou I'CEdeme du Tissu 
 Cellulaire" of French authors) is an extremely rare affection in 
 Edinburgh. I have only seen two cases of it; and, as was stated in 
 the " Monthly Journal of Medical Science" for 1843, page 699, in 
 both of these instances the urine was coagulable. Hence, at that 
 time, I ventured to suggest, that the skin-bound disease itself, or at 
 least some forms of sclerema, may be a variety or effect of Bright's 
 disease in early infancy ; the effusion into the cellular tissue which 
 constitutes the marked feature of the affection, being so far analo- 
 gous to the anasarca occurring with albuminous nephritis. For the 
 solution of this point, affirmatively or negatively, we can only look 
 to some of those continental pathologists who have ample opportu- 
 nities of studying the disease in question. 
 
 CASES OF PUERPERAL CONVULSIONS CONNECTED WITH INFLAMMATION 
 
 OF THE KIDNEY.' 
 
 Case I. — In this case, the patient, a delicate female, was exhausted 
 by the pains of labor, and complaining of severe headache when the 
 convulsions supervened. Dr. Mven promptly and easily delivered 
 the child, which was dead, by turning. The convulsions gradually 
 subsided, but reappeared several times. In the intervals she was 
 profoundly comatose ; and in this state, she died about forty hours 
 after the first attack. 
 
 Post-mortem Appearances. — ^When we opened the lateral ventricle 
 of the right side, fluid blood escaped. The corpus striatum and 
 outer part of the optic thalamus were broken up, and mixed with a 
 large quantity of coagulated blood, forming a clot of large size. 
 The fluid blood was found in the opposite lateral ventricle, also in 
 the third and fourth ventricles. The right kidney was converted 
 
 ' Extracted from Proceedings of Edinburgh Obstetric Society, June 15, 1847.— Edinburgh 
 Montlily Journal of Medical Science, September, 1847, p. 212. 
 
PTJBRPEBAL CONVULSIONS. 733 
 
 into numerous cysts, of about the size of a walnut, containing un- 
 healthy pus, which passed along the ureter and filled the bladder. 
 The left kidney exhibited an advanced stage of Bright's disease. 
 
 Case II. — I lately saw this case with Dr. Carmichael. The lady 
 had so perfectly recovered after a labor which was quite natural, as 
 to have been out at church, &c. Seven weeks, however, subsequent 
 to delivery, after some sudden anomalous afiections of sight and 
 hearing for thirty or forty hours previously, she was seized with the 
 most severe convulsions. Despite free evacuations, &c. &c., they 
 continued to recur from time to time, and proved fatal in three 
 hours ; the patient during that time never being perfectly sensible. 
 The pelvis of each kidney was filled with a whitish purulent-like 
 matter, and its mucous lining membrane coated with large patches 
 of adherent coagulable lymph, or false membrane. The ventricles 
 of the brain were distended with serous fluid. The urine, when 
 tested, presented no sign of albumen. 
 
 Case HI. — In a third case, one fit of convulsions came on a month 
 before delivery, and recurred again in a severe and fatal form four- 
 teen days after confinement. During the intervening six weeks she 
 was free from any symptoms, and the labor was natural. The last 
 attack came on suddenly in the evening, about nine o'clock; the 
 convulsions were again and again repeated, and she died comatose 
 in eight hours. 
 
 With Dr. Maclagan, and Dr. Handyside, I examined the urine 
 during this last attack, but found in it no traces of albumen. On 
 inspecting the body, some whitish turbid fluid was found in the 
 renal pelvis, and could be pressed out abundantly from the renal 
 papillse. It looked like pus. On microscopic examination, how- 
 ever, it seemed to contain merely a very large quantity of epithelial 
 cells, and no pus-globules. "Was this inflammatory ? There was 
 no effused fibrin or coagulable lymph. 
 
 LESIONS OF THE NERVOUS SYSTEM, ETC., IN THE PARTURIENT FEMALE, 
 CONNECTED WITH ALBUMINURIA.* 
 
 1. Albuminuria, when present during the last periods of preg- 
 nancy and labor, denotes a great and marked tendency to puerperal 
 convulsions. 
 
 2. Albuminuria, in the pregnant and puerperal state, sometimes 
 gives rise to other and more anomalous derangements of the nervous 
 system without proceeding to convulsions ; and I have especially 
 
 ' From Edinburgh Monthly Journal of Medical Science, Oct. 1847, p. 288, 
 
734 COMPLEX LABOR. 
 
 observed states of local paralysis and neuralgia in the extremities, 
 functional lesions of sight (amaurosis, &c.) and hearing; hemiplegia 
 and paraplegia more or less fully developed. 
 
 3. (Edema of the face and hands, going on occasionally to general 
 anasarca, is one of the most frequent results of albuminuria in the 
 pregnant female. 
 
 4. The presence of this cedema (3), or of any of the lesions of the 
 nervous system (2), vpith or without the cedema, should always make 
 us suspect albuminuria ; and, if our suspicions are verified by the 
 state of the urine, we should diligently guard, by antiphlogistic 
 means, &c., against the supei-vention of puerperal convulsions. 
 
 5. Albuminuria, and its effects (1, 2, 3), are far more common in 
 first than in later labors, and these constitute a disease which in 
 general disappears entirely after delivery. But I have seen one case 
 commencing with slight blindness, but no oedema, and ending 
 gradually in hemiplegia, where the palsy partially remained after 
 delivery, and after the disappearance of the albuminuria. In another, 
 amaurosis came on with delivery, and had been present fop six 
 months when I first saw her. She had no oedema or other symptom 
 of albuminuria except the amaurosis ; but, on testing the urine, it 
 was highly albuminous. 
 
 6. Albuminuria, with convulsions, &c., occurring in any labor 
 later than the first, generally results from fixed granular disease of 
 the kidney, and does not disappear after delivery. 
 
 7. Perhaps in puerperal convulsions, &c., produced by albumi- 
 nuria, the immediate pathological cause of the nervous lesions is 
 some unascertained but poisoned state of the blood. Was there a 
 morbid quantity of urea in the blood ? In several specimens of the 
 blood of patients suffering under severe puerperal convulsions, fur- 
 nished by me to Dr. Christison and Dr. Douglas ISIaclagan, these 
 gentlemen have been unable to detect any great traces of urea. Is 
 the poisoning material, caseine in morbid quantity or quality ? The 
 dependence, shown by Gluge and others, of albuminuria upon 
 stearosis of the kidney, makes this connection worthy perhaps of 
 some inquiry. 
 
 8. In cases of severe puerperal convulsions, &c., from albuminuria, 
 the renal secretion is in general greatly diminished, and I have found 
 active diuretics apparently of great use along with or after venesec- 
 tion, antimony, &c., especially where the case was offering to become 
 prolonged. 
 
 9. Sometimes hemiplegia supervenes during pregnancy and labor 
 without albuminuria, but this form does not seem to interfere mate- 
 rially, or very dangerously, either with the pregnancy or labor— 
 the disease running its own usual, course. In more than one case 
 
FIBEOUS TUMORS COMPLICATINe DELIVEEY. 735 
 
 I have seen the patient gradually but imperfectly recover the use 
 of the palsied limbs after delivery. In another no improvement 
 occurred. 
 
 Dr. Simpson, on May 10, 1848, further remarked to the Obstetric 
 Society,^ that he had on a previous occasion attempted to show that 
 one of the most common predisposing causes of puerperal convul- 
 sions was albuminuria, or rather some morbid state of the blood 
 dependent upon albuminuria — a doctrine which he had taught for 
 the last seven or eight years,^ and which Dr. Lever' had studied and 
 successfally illustrated. He believed this diseased condition of the 
 blood to produce a preternatural excess of irritability or polarity of 
 the nervous system, and more especially of the spinal system of 
 nerves ; and in this way a morbid predisposition in it to convulsions 
 under various forms and degrees, from irritation of the uterus, or 
 bladder, or intestinal canal, &c., that would be incapable of pro- 
 ducing this convulsive effect were not the polarity of the nervous 
 system for the time being highly exaggerated. Dr. Todd of London 
 had shown last year, that, when the polarity of the nervous system 
 was exaggerated in the lower animals bythe exhibition of strychnia, 
 the convulsive tendencies resulting from the strychnia could be 
 afterwards so far subdued and decreased by making the animals 
 inhale ether.- The ether reduced the excessive polarity and conse- 
 quent convulsions. And the application of chloroform in the same 
 way, in puerperal convulsions, had been tried with success by Dr. 
 Wilson of Glasgow, Mr. Fearn, &c. &c. 
 
 COMPLICATION OF LABOK BY LAEGE FIBEOUS 
 TUMOES.* 
 
 PROPRIETY OF INDUCING PREMATURE LABOR. 
 (From Edinburgh Monthly Journal of Medical Science, August, 1847, p. 138.) 
 
 Dr. Simpson stated that it was well known that fibrous tumors 
 were very common organic changes in the unimpregnated uterus. 
 He had seen several cases in which they were still small, and showed 
 themselves in the form of nodulated irregularities on the surface of 
 the pregnant and puerperal uterus. He had seen also a number 
 
 ' See Edinburgh Monthly Journal of Medical Science, Sept. 1848, p. 197. 
 
 ^ Ibid., Nov. 1843, foot-note, p. 1015. ' Guy's Hospital Reports, vol. vii. p. 325. 
 
 * Extracted from Proceedings of Obstetric Society, May 12, 1847. 
 
736 COMPLEX LABOR. 
 
 of instances of pregnancy and parturition complicated with large 
 tumors of this kind ; and he mentioned the particulars of the three 
 following cases in consequence of unusual circumstances connected 
 with each. 
 
 Case I. — A patient, after being married for 10 or 12 years without 
 any issue, passed two menstrual periods. A very large pelvic 
 tumor, which had long been present, began to increase in size. He 
 then saw her with Mr. Dixon and Dr. Taylor. There was a very- 
 large, hard, fibrous tumor of the uterus, and low on the left side 
 and front, a soft elastic part, having much the character of a dropsi- 
 cal ovary. It is well known, that fibrous tumors of the uterus and 
 multilocular dropsy of the ovary sometimes coexist ; but he knew 
 no other kind of cystic collection ever existing along with fibrous 
 uterine tumors. In this case, however, the soft fluctuating part was 
 not the ovary, for it was situated anteriorly to the hard uterine 
 tumor, whilst diseased ovaries lie posteriorly to the uterus. This led 
 him to suspect pregnancy, improbable as it otherwise was, and to 
 hazard a diagnosis to that effect. It proved correct. The foetal 
 heart was heard about the fifth month, and pregnancy went on to 
 the full time. During labor, one portion of the tumor filled up so 
 much of the brim of the pelvis, that the child required to be extracted 
 by turning. It was still-born. The mother made a good recovery. 
 
 Case II. — In a woman sufifering from dysuria, &c., and who had 
 not menstruated for three months, he found the uterus retroverted, 
 and an enormous fibrous tumor in the walls of the organ. The 
 case was at this time seen by Dr. Renton, Dr. Ziegler, and others. 
 The uterus was replaced with difficulty, and some weeks subse- 
 quently the fcetus was expelled. About a year afterwards, the same 
 patient again became pregnant and went to the full time. The 
 labor was extremely tedious — a portion of the tumor diminishing the 
 brim of the pelvis — and at last the child was expelled by the sponta- 
 neous efforts of the uterus, but with the head greatly compressed 
 and flattened. The mother recovered rapidly. In the unimpreg- 
 nated state, the fibrous tumor, in this instance reached to the umbi- 
 licus and was as large as a uterus at the fifth or sixth month of 
 pregnancy. The uterine cavity was found by the uterine sound to 
 be six inches in length. 
 
 Case m. — A patient, pregnant for the first time, who had long 
 been delicate, arrived at the full term of utero-gestation, and after a 
 somewhat tedious labor, was delivered of a dead child. There was a 
 slight degree of hemorrhage, but it was easily arrested. From the 
 time, however, of deliveiy onwards, the patient continued to sink 
 
FIBROUS TUMORS COMPLICATING DELIVERY. 7S7 
 
 — ^became faint and listless, and then comatose — and died in this 
 state five or six hours suhsequently. She seemed never to rally from 
 the " shock" accompanying delivery. Dr. Malcolm saw^ her with 
 him. On opening the body, they found the uterine parietes thickly 
 studded with fibrous tumors, and counted as many as forty hanging 
 in a more or less pediculated form, from its external or peritoneal 
 surface ; and of all sizes, from an orange downwards. These were 
 easily diagnosticated through the abdominal parietes during her life. 
 The cavity of the uterus contained no collection of blood. 
 
 Case IV. — ^A lady pregnant for the first time, was supposed by 
 her medical attendant to have an extra-uterine fcetation from her 
 unusual shape. There was a fibrous tumor projecting from the 
 anterior wall of the uterus. She died of peritonitis on the second 
 week after her confinement. Dr. S. found the fibrous tumor adher- 
 ing firmly to the peritoneum lining the anterior walls of the abdo- 
 men, while its pedicular attachment to the uterus had stretched and 
 lacerated during the involution of the organ after delivery. 
 
 In addition. Dr. Simpson alluded to two cases of large fibrous 
 tumors complicating labor, published in the Dublin Medical Journal, 
 the one by Dr. Montgomery, the other by Dr. Beatty. In the 
 former, the fibrous tumor, having entered the pelvis, formed such a 
 complete and perfect obstruction to the maternal passages, that the 
 Csesarean section was required. In Dr. Beatty's case, it was sup- 
 posed, before the commencement of parturition, that the same pro- 
 ceeding would be necessary ; but, in the course of the labor, the 
 tumor was gradually raised out of the pelvis by the uterine con- 
 tractions, and the child spontaneously expelled. 
 
 WHAT PRACTICE SHOULD BE FOLLOWED IN CASES OF LARGE FIBROUS 
 TUMORS COMPLICATING PREGNANCY? 
 
 Dr. Simpson adduced the opinion of Dr. Ashwell, who, in dis- 
 coursing on this subject, inculcates the propriety of inducing pre- 
 mature labor, in order to evade the danger of inflammation of the 
 pelvic tissues and peritoneum, and the still more hazardous evils of 
 unhealthy softening, suppuration, and ulceration of the tumors 
 themselves. But Dr. Simpson stated that he entertained very seri- 
 ous doubts of the correctness of Dr. Ashwell's observation, that 
 fibrous tumors had a tendency to soften during the latter months 
 more than at any other period of pregnancy ; and he disapproved of 
 the induction of premature labor as a general rule of treatment in 
 such cases, believing, that the excitement of the uterus by artificial 
 
 VOL. I. 47 
 
738 INDUCTION OF PREMATURE LABOR. 
 
 means to the premature expulsion of its contents, would be as likely 
 to induce such anticipated morbid actions, as the supervention and 
 completion of a natural pregnancy and labor. He believed, that 
 the only cases of this kind which demanded the induction of prema- 
 ture labor were those in which the tumor encroached, as in two of 
 the preceding cases, upon the brim or cavity of the pelvis, and thus 
 produced such mechanical contraction of the maternal passages as 
 rendered a natural labor impossible. Where the tumors were, as 
 was usually the fact, abdominal and above the brim, he did not con- 
 sider premature labor in any way called for, or a practice that ought 
 to be followed. 
 
 ON THE INDUCTION OF PEEMATURE LABOR.* 
 
 MODES OF BPFBCTING IT. 
 
 A VARIETY of means or plans have been proposed for the artificial 
 induction of premature labor, in those various and important com- 
 plications which are now so generally recognized by the obstetric 
 profession as demanding this mode of operative interference. 
 
 Thus it has been attempted to excite the uterus into parturient 
 action — 1. By external abdominal frictions, so as to irritate its outer 
 surface ; 2. By passing currents of electricity or galvanism through 
 its walls ; 3. By irritating other, and even distant, parts or surfaces, 
 as the vagina, rectum, or nipple, that are known to possess a marked 
 reflex power over the contractility of the uterus ; 4. By the internal 
 exhibition of ergot of rye and other oxytoxic remedies ; 5. By the 
 evacuation oi the liquor amnii ; 6. By the dilatation of the os uteri; 
 and, 7. By the separation of the membranes from the cavity of the 
 cervix or body of the uterus by the finger, by instruments or sponges, 
 or by the injection of fluids. 
 
 The first three of these modes of inducing premature labor are^ — 
 alone and singly — so very uncertain in their results, and so generally 
 and entirely fail, that few or no accoucheurs place any confidence in 
 them f and to the fourth the same objection applies, witb thisaddi- 
 
 ' See Proceedings of Obstetric Society for 1844, 1845, 1851, &c. 
 
 ' Several years ago I attended a case with Dr. Thatcher, in which we applied a child to 
 the breast with the object of exciting pains. Some hours before, I had introduced a large 
 sponge-tent into the os uteri. There was a wet nurse in attendance to suckle our patient's 
 infant as soon as it was born. It was the nurse's child which we applied to the nipples ; 
 and, as she thought, with the effect of increasing the uterine contractions and pains, which 
 had already begun to appear. I have never, however, seen such an application of an in- 
 fant to the nipples originate uterine contractions, nor in the two or three cases in which I 
 have tried the plan of Schoeller and Braun, of distending, and consequently irritating the 
 walls of the vagina with masses of sponge or a dilating caoutchouc bottle, have I been at 
 all successful in exciting the uterus to parturient action. I have not seen the abdominal 
 frictions of D'Outrepont and Ulsamer tried. — On Galvanism, see p. 336. 
 
INDUCTION OP PREMATURE LABOR. 739 
 
 tion, that the ergot, even when it has succeeded, has proved too 
 dangerous in its effects upon the child to be used in an operative 
 procedure, instituted, as this usually is, for the very purpose of saving 
 the infant. 
 
 The fifth mode which we have enumerated above, viz., the evacua- 
 tion of the liquor amnii, is, of all the methods proposed, both the 
 oldest and assuredly the most sure and fixed in its effects. But, as 
 a common means, and when labor is induced to save the infant, it 
 is liable to one strong objection, viz., that it is undoubtedly much 
 more dangerous to the child than the employment of operative pro- 
 cedures, which — as the dilatation of the os, or the separation of the 
 membranes— allow the bag of membranes to remain entire, and 
 thus keep the fragile and premature infant protected by the amniotic 
 fluid during the progress of the labor, or at least, during the earlier 
 stages of it. 
 
 In by far the greater number of instances in which I have had 
 occasion to induce premature labor in private and consultation prac- 
 tice, I have always, in the first instance, avoided the artificial 
 evacuation of the liquor amnii, and have proceeded upon the prin- 
 ciple either — I. Of dilating the cervix uteri, or, 11. Of separating 
 the membranes ; or rather I have acted upon both of these plans 
 conjointly, for it is diflicult or impossible to follow out thoroughly 
 the one indication without, in some respect at least, following out 
 the other also. 
 
 I. DILATATION OF THE OS AND CERVIX UTERI. 
 
 In exciting premature labor upon this principle, accoucheurs have 
 used three different means — 1. The finger; 2. Metallic dilating 
 forceps and instruments ; and 3. Sponge-tents. To stretch, how- 
 ever, and open the os uteri by the finger or by metallic dilators is a 
 process so irritating and painful, that few or no practitioners now 
 use it; especially as the same object can be effected more easily and 
 safely by the introduction of compressed sponge. 
 
 Sponge-tents were first proposed as a means of inducing prema- 
 ture labor by Kluge and Brunnihghausen ; and they have been 
 much employed for the purpose both in Germany and Trance. All 
 the continental accounts, however, of their employment, up even to 
 the present day, describe the introduction of the tents into the os 
 uteri as a complicated operation, requiring always the aid of the 
 speculum, and the use of a vaginal tampon, or other means, to keep 
 the tent in situ. But there is no necessity whatever for such formi- 
 dable arrangements. In 1844, when first mentioning the induction 
 
740 METHODS OF INDUCING 
 
 of premature labor in this country by sponge-tents,^ I attempted to 
 sbow that tbey could be easily introduced and employed without 
 any vaginal speculum or tampon, or in the simple mode already 
 described in a preceding paper on Intra-Uterine Polypi (see p. 126). 
 And for several years subsequent to that date, I had recourse to this 
 mode of inducing premature labor in a long series of cases ; always 
 with perfect success as regarded the mother, and in a large propor- 
 tion of cases with safety also as regarded the child. 
 
 I never found this means fail, although in a few instances, I have 
 seen the dilatation effected to the size of a half-crown or more, for 
 thirty or forty hours before true uterine contractions set in. Gene- 
 rally, however, parturient action began long before the dilatation of 
 the OB uteri had reached these dimensions ; and when it did so, a 
 considerable part of the first stage of labor was thus, as it were, 
 found finished before actual labor commenced. Sometimes uterine 
 pains and contractions began as early as four or six hdurs after the 
 sponge-tent was introduced, especially if the tent were of conside- 
 rable size, and means were used for its rapid development. In 
 almost every case, the first tent employed may be as thick as the 
 little finger; and the patient should be directed to have injected 
 into the vagina every hour or two, a small quantity of warm water 
 for the imbibition and expansion of the compressed sponge. She 
 should lie on the back during, and for some time after, each injec- 
 tion, in order that the water may be more thoroughly retained. 
 After the first sponge is fully dilated, it may be withdrawn, and a 
 second and larger one introduced ; or, vrithout removing the first, 
 tents of a greater and greater size may be introduced at intervals of 
 six or eight hours, till the os uteri is thoroughly dilated or labor 
 supervenes. 
 
 To the induction of premature labor by the use of sponge-tents, 
 I have heard some accoucheurs object, on the ground that, from want 
 of practice, they have had difficulty in introducing the compressed 
 sponge into the os uteri. A much more important drawback to the 
 method, will be found in the circumstance, that the presence of a 
 large sponge-tent in the canals of the cervix uteri and vagina, some- 
 times, as a foreign body, produces such a degree of local uneasiness 
 and irritation, as to inflict no small amount of discomfort and con- 
 tinuous pain upon the patient. It is principally on this account, 
 and to avoid this difficulty, that, of late years, I have in my own. 
 practice commonly brought on premature labor by the other means 
 already alluded to, namely, the detachment of the membranes — a 
 process not requiring the permanent retention of any material in 
 
 ' See Edinburgh Monthly Journal of Medical Science for Aug., 1844, p. 735: and Feb 
 1845, p. 122. 
 
PREMATUEE LABOB. 741 
 
 the maternal passages, and capable of being effected with probably 
 less difficulty and trouble to botb practitioner and patient. 
 
 n. SEPARATION OF THE MEMBRANES. 
 
 In the induction of premature labor, the membranes of the ovum 
 have been proposed to be mechanically separated from the interior 
 of the uterus, by different means, to different degrees, and in dif- 
 ferent localities. 
 
 The idea that the partial artificial separation of the membranes 
 would lead on to labor occurred first to the late Professor Hamilton ; 
 and he was himself the first also to put it in practice as far back as 
 1795. 
 
 Dr. Samilton's method, hy the Finger, ^c. — In operating, he de- 
 tached "a portion of the deeidua from the cervix uteri, "» by the 
 introduction, first, of his finger, and ultimately of a bent brass wire. 
 His friend. Dr. Burns, describes Dr. Hamilton's operation as con- 
 sisting of "insinuating a finger within the os uteri, and gently 
 dilating it, and detaching a part of the membranes from the portion 
 of the cervix in its immediate vicinity. K," he continues, " we 
 have not thought it prudent to dilate at once the os uteri, so as to 
 admit the finger freely to touch the membranes, we may repeat the 
 dilatation gently at the end of a few hours, and then detach the 
 membranes cautiously from the cervix nteri by the finger to the 
 extent perhaps of two inches. But for this purpose," Dr. Burns 
 adds, " it may be necessary, if the os uteri be high, to have the hand 
 introduced into the vagina ; or sometimes the detachment has been 
 accomplished with a catheter or other small instrument."* As thus 
 pursued, this mode of inducing labor by separating the membranes 
 from the cervix, was not always unaccompanied with pain, particu- 
 larly when the fingers, and especially the hand, were introduced ; it 
 was often very tedious, and sometimes it failed, as Dr. Hamilton 
 himself states, and the operation required to be completed by punc- 
 ture of the membranes and evacuation of the liquor amnii. 
 
 Br. Kiwisch's method, hy injection of water. — In 1846, Professor 
 Kiwisch proposed to bring on premature labor, by injecting a stream 
 of tepid water into the vagina, and against the cervix and os uteri.' 
 His apparatus, as delineated by Scanzoni,^ consists of a small, 
 
 ' Practical Observations on Midwifery, p. 285. ^ Principles of Midwifery, p. 503. 
 
 ' In a chapter on the induction of premature labor, Schweighauser in 18.35 speaks of, but 
 does not venture to recorainend us — " de provoquer I'accouchment prematura au moyen 
 d'injections pour decoUer les membranes de la matrioe." — La Pratique des Accouchemens, 
 p. 274. 
 
 * Lehrbuch der Geburtshilfe, vol. iii. p. 54. 
 
742 METHODS OF INDUCING 
 
 square tin box or reservoir of water, fastened to the wall at the 
 height of nine or ten feet, and from the bottom of this reservoir, a 
 tube hangs down, the end of which is, when required, introduced 
 into the vagina, so as to allow a strong continuous stream to pour 
 through it, against the cervical portion of the uterus. 
 
 The douching or injection was recommended to be repeated 
 morning and night, and commonly labor supervened on the fourth 
 or fifth day. 
 
 This plan of Dr. Kiwisch's was shortly afterwards tried success- 
 fully in Vienna, Berlin, &c., by various continental practitioners. 
 In April, 1851, I described a case to the Edinburgh Obstetric 
 Society, in which I used this method.' It was an instance where 
 the patient had repeatedly found the child to die a short time after 
 quickening, and retained it for six or eight weeks subsequently. 
 During her last pregnancy, the same occurrence took place with 
 the same symptoms. A few weeks having elapsed, she threw up 
 tepid water at my request, twice a day, with the view of bringing 
 off the dead foetus. After nine douches, applied night and morning 
 with a common syringe, expulsive pains came on, and a dead and 
 shrivelled fcetus and placenta were expelled. In the course of that 
 and the subsequent years, I had various opportunities of bringing 
 on premature labor by the same means, and, as I always found, with 
 almost perfect certainty as to the power of its induction. 
 
 Professor Kiwisch imagined that the vaginal water injection in- 
 duced labor by the imbibition of the fluid relaxing the soft parts. 
 The flow of a gentle and small stream of water into the vagina 
 ought, if this were the true principle, to act as well as a stronger 
 current. But a short experience convinced me that this was not the 
 fact ; and it soon became evident — 1. That the water douche was 
 liable to fail, unless the injected fluid accumulated and distended 
 the vagina, so as to expand that canal and enter the os uteri ; and 
 2. It seemed the more rapid and certain in its action, in proportion 
 as it entered freely into the uterine cavity itself, and in proportion, 
 therefore, as it separated more of the surface of the foetal mem- 
 branes from the interior of that cavity. 
 
 In only two or three cases did I try an elevated box and syphon 
 tube, like that originally suggested by Kiwisch. From the first, I 
 found a common enema syringe a far better and more manageable 
 apparatus. Usually I have employed the' India-rubber syringe of 
 Dr. Kennedy, or that of Mr. Higginson. At first I merely injected 
 and distended the vagina, retaining the fluid in it by closing the 
 vulva with pressure of the flngers or hand, and thus forcing the 
 water to pass upwards through the os into the uterine cavity ; but 
 
 • See Monthly Journal cf Medical Science for July, 1851, pp. 88, 492, &o. 
 
PREMATURE LABOR. 
 
 743 
 
 I soon found it a simpler and more direct plan to introduce the end 
 of the syringe tlirough the uterine orifice, and thus send the stream 
 directly into the interior of the uterus, without unnecessarily dis- 
 tending the vaginal canal. In most cases it is easy to pass for this 
 purpose the common ivory nozzle of the enema syringe through the 
 OS uteri ; but when that opening is placed very high, or far back- 
 wards, I have found that the addition of a longish gum-elastic pipe 
 or bent silver catheter to the nozzle of the tube greatly facilitates 
 the requisite introduction of the instrument through the os and up- 
 wards for an inch or two, between the membranes and the anterior 
 or posterior wall of the uterus. 
 
 While the practitioner is using the syringe and injecting the fluid, 
 the patient should lie on her left side, and with the pelvis placed 
 near the edge of the bed or sofa which she is occupying. A basin 
 properly placed immediately below, both contains the water to be 
 used, and receives it again after it re-escapes from the vulva. The 
 tubes of the catheter and syringe should be carefully filled with the 
 water before commencing the injection, lest a quantity of air be 
 thrown into the uterine cavity. Usually the injection is carried to 
 the extent of the patient complaining of a feeling of distension or 
 fulness ; and it may be repeated twice a day, or oftener, according 
 as it is an object or not to expedite as much as possible the super- 
 vention of labor. 
 
 It was not till I had used this method for a considerable time, and 
 in a number of eases, that I discovered that a similar method had 
 been suggested and described by Dr. Cohen of Hamburg.* 
 
 In several cases where the child was placed with the head over 
 the OS uteri, I have found it change its position as the water injec- 
 tion proceeded, and an upper or lower extremity to present. Occa- 
 sionally this preternatural presentation has remained; but more 
 frequently the child has again rotated, and the head again become 
 replaced over the uterine orifice. In no case have I seen any great 
 amount of hemorrhage from partial separation of the placenta. But 
 the repetition of the injection sometimes becomes irksome to the 
 mother as well as to the accoucheur. 
 
 jbetaehment of the membranes, hy the uterine Sound, from a portion 
 of the body of the uterus. — ^Believing that labor was, at the ninth 
 month, induced naturally through the degeneration and loosening 
 of the decidua (see p. 316), I was encouraged last year to try to in- 
 duce it artificially by the mechanical separation of a portion of the 
 membranes from the interior of the body of the uterus. 
 
 In general the stethoscope sufficiently certifies to us the locality 
 
 * See Scanzoni's Lehrbuch, vol. jii. p. 53. 
 
744 METHODS OF INDUCING PREMATURE LABOR. 
 
 of the placenta, and what part or side of the uterus we ought con- 
 sequently to avoid ;' and nothing in the way of an operation could 
 possibly be more simple or more easy and painless than the intro- 
 duction of a sound, through the dilatable os, and upwards for five 
 or six inches, between the membranes and the anterior wall of 
 the pregnant uterus. 
 
 In the first case in which I tried this plan, the patient, after hav- 
 ing been always delivered in the country by craniotomy, has thrice 
 had premature labor induced under my care. Her three children 
 are alive. On the first occasion, in 1851, she had an apparatus upon 
 the plan of Kiwisch's erected; but it required to be used, and that 
 frequently, for five or six days before labor supervened. On the 
 second occasion, I injected a quantity of tepid water by an enema 
 syringe into the uterine cavity, and the child was born in about 
 twenty-four hours afterwards. Last year, on the third occasion, I 
 saw her late at night along with my friend Dr. Ziegler, and passed 
 a uterine bougie for five or six inches upwards between the mem- 
 branes and the anterior wall of the uterus. The child was born be- 
 fore noon next day. At the time of passing the bougie^ the patient 
 herself was not aware that anything special had been done, but be- 
 lieved that I was merely making a common digital examination, in 
 order to ascertain the exact stage of pregnancy, &c. ; and she sub- 
 sequently declared, that, in her experience, this last method was too 
 simple to be capable of being compared with the two other methods 
 to which she had been formerly subjected. But in all cases, a single 
 introduction of the bougie will by no means suffice. Like the tents 
 and douching, it requires in most instances to be repeated more 
 than once. During the past three months of the present year, I 
 have induced labor six or seven times by this method. In one case, 
 in my own private practice, and in another under the care of Dr. 
 Scott of Musselburgh, the labor was , terminated within eighteen 
 hours. In the others, parturition did not come on till the second 
 or third day after the act of separation. In a case which I saw with 
 Dr. Thomson, he used a water injection next day, and on the sub- 
 sequent day I again separated the membranes with the bougie. 
 Parturient action began that night. In a previous labor of this 
 woman, the child was rotated, and made to present preternaturally 
 by the employment of the water injection. All the children have 
 been born alive in the ten or twelve cases in which I have induced 
 premature labor by the uterine sound. 
 
 ' In injecting water we have no control on the direction it will take in the uterine cavity, 
 while we can regulate perfectly that of the Sound. In one case, from inattention to the 
 uterine souffle, I probably separated the edge of the placenta, as a clot was found at that 
 spot. The child was born alive ; and the mother recovered perfectly. But with due cau- 
 tion such an accident should be easily avoided. 
 
STATISTICS OF EDINBURGH MATERNITY HOSPITAL, 745 
 
 The relative degree of facility or difficulty witli wMch labor is in- 
 duced artificially in different women, or even in tlie same woman in 
 different pregnancies, varies very greatly. Where one plan fails, 
 the addition of a second, or of a third method, will sometimes enable 
 us to succeed ; and if all modes less safe for the child prove ineffec- 
 tual, as the separation of the membranes with a uterine bougie, the 
 water injection, and the sponge-tent, we may always at last deter- 
 mine the certain occurreiiee of uterine contraction by the puncture 
 of the membranes. And if we have recourse to this puncture, we 
 may still in a great measure save the liquor amnii for the protection 
 of the child during labor by making the seat of the opening oblique 
 and as high as four or five inches above the os, as recommended by 
 Hamilton and Meissner. One of the best instruments for effecting 
 this object is that long ago recommended by Dr. Hamilton, viz., a 
 male catheter having an open or truncated extremity, and provided 
 with a silver wire to pass through it for the puncture of the mem- 
 branes. The membranes, I believe, will sometimes be found to 
 rupture high up when and where they are simply separated fi-om the 
 body of the uterus by the introduction of the knobbed uterine sound 
 or bougie. — (April, 1855.) 
 
 REPOKT OF EDINBURGH ROYAL MATERNITY HOSPITAL 
 
 FROM 1844 TO 1846.' 
 (From Edinburgh Monthly Journal of Medical Science, November, 1848, p. 329.) 
 
 The Edinburgh Maternity Hospital was opened in St. John's 
 Street in May, 1844, and continued in this locality till May, 1846, 
 when the Charity was removed to Milton House, Canongate. The 
 following Report comprehends an analysis of the obstetric practice 
 of the Institution during the two years in which it was located in 
 St. John Street. The Report was drawn up and communicated to 
 the Medico-Chirurgical Society twelve or eighteen months ago ; and 
 its publication was for a time postponed, under the hope that I 
 might find leisure to render it still more minute and extensive. As, 
 however, I have little prospect of fulfilling that wish, I now publish 
 it ; and I trust, that the continuation of the reports of the Institution 
 will, betimes, be drawn up and communicated to the Society by 
 some of the younger and more active medical officers attached to 
 the hospital. 
 
 ' Extracted from the Proceedings of the Edinburgh Obstetric Society, July 12, 1848. 
 
746 
 
 STATISTICS OP 
 
 At the time the hospital was opened, the directors appointed to 
 it the following medical staff: Drs. Campbell and Beilby, consulting 
 physicians ; Dr. Pagan, consulting surgeon ; Drs. Moir and Simp- 
 son, ordinary physicians ; Dr. Ziegler, ordinary surgeon ; and Drs. 
 Bell, Thomson, Mven, and Carmichael, assistant medical officers. 
 One or two advanced pupils were appointed to live in the house as 
 resident house-surgeons.' 
 
 ANALYSIS OF THE CASES. 
 
 I. The Number of Cases.— Oi women delivered in hospital, there 
 were 374. Of women delivered at their own homes in various parts 
 of the town, there were 1101 ; making a total of 1475 women de- 
 livered under the superintendence of the Institution, Among these 
 are included 68 cases of miscarriage or premature labor. 
 
 n. The Ages of the Women.— bi. 1457 of the cases, the ages of 
 the women were noted. In 18 cases the ascertaining of this point 
 was omitted. The following table exhibits, in detail, the number 
 of patients delivered, with their respective ages : 
 
 Ages of the 
 
 Number of 
 
 Ages of the 
 
 Number of 
 
 Women. 
 
 Women. 
 
 Women. 
 
 Women. 
 
 16 
 
 4 
 
 33 
 
 47 
 
 17 
 
 10 
 
 34 
 
 40 
 
 18 
 
 30 
 
 35 
 
 49 
 
 19 
 
 57 
 
 36 
 
 46 
 
 20 
 
 64 
 
 37 
 
 23 
 
 21 
 
 75 
 
 38 
 
 33 
 
 22 
 
 101 
 
 39 
 
 18 
 
 23 
 
 90 
 
 40 
 
 37 
 
 24 
 
 84 
 
 41 
 
 8 
 
 25 
 
 77 
 
 42 
 
 11 
 
 26 
 
 107 
 
 43 
 
 9 
 
 27 
 
 69 
 
 44 
 
 6 
 
 28 
 
 94 
 
 45 
 
 2 
 
 29 
 
 69 
 
 46 
 
 2 
 
 30 
 
 107 
 
 47 
 
 1 
 
 31 
 
 34 
 
 48 
 
 1 
 
 32 
 
 52 
 
 
 
 
 Total, 
 
 1457. 
 
 
 m. The Quickening. — The average period of quickening, as cal- 
 culated from the intern cases where it was noted, was 183 days after 
 the disappearance of the last catamenia. 
 
 TV. The Duration of Pregnancy. — ^In the intern cases where the 
 
 ' To one of these gentlemen, Dr. Martin Barry, the Institution was specially indebted for 
 his valuable and unwearied efforts, and for characteristic accuracy in the statistical returns 
 of the cases, &c. 
 
EDINBURGH MATERNITY HOSPITAL. 
 
 747 
 
 data are afforded, the average duration of pregnancy, calculating 
 from the end of the last catamenia, was 273 days. But on the pre- 
 ceding computation little confidence can be placed, considering the 
 class of patients from which the data are drawn. 
 
 V. The Number of Pregnancy. — ^In 1459 cases, the number of the 
 pregnancy is stated, namely, whether it is the first, second, or third 
 time, &c., the woman has been pregnant; in 16 cases it is omitted. 
 398 women were delivered of their first children ; and thus the fre- 
 quency of first deliveries was to that of all subsequent deliveries in 
 the proportion of about 1 to 4. The following table exhibits at 
 length the number of cases, with the corresponding number of the 
 pregnancy in each. 
 
 Number of the 
 
 Number of 
 
 Number of the 
 
 Number of 
 
 Pregnancy. 
 
 "Women. 
 
 Pregnancy. 
 
 Women. 
 
 1 
 
 398 
 
 10 
 
 38 
 
 2 
 
 294 
 
 11 
 
 24 
 
 3 
 
 161 
 
 12 
 
 11 
 
 4 
 
 158 
 
 13 
 
 7 
 
 5 
 
 116 
 
 14 
 
 2 
 
 6 
 
 88 
 
 15 
 
 1 
 
 7 
 
 65 
 
 16 
 
 1 
 
 8 
 
 57 
 
 17 
 
 1 
 
 9 
 
 36 
 
 20 
 
 1 
 
 
 Total 
 
 1459. 
 
 
 VI. The Number of Children. — The children resulting from the 
 1417 labors, at or near the frill time, were 1436 in number. Of 
 these there were born 
 
 In single births, 1399 children. 
 
 In twin births, 34 " 
 
 In triplet birth 3 " 
 
 Total, 1436 
 
 Vli. The: Sex and State of the Qhildren. — The children are further 
 to be distributed as follows : 
 
 Sex of the Child. 
 
 Number of 
 ChUdren. 
 
 Number Bom 
 AUye. 
 
 Number Born 
 Dead. 
 
 Proportion of 
 Stm-birtbs. 
 
 Male, 
 
 Female, 
 
 Sex not stated, 
 
 739 
 
 693 
 
 4 
 
 682 
 
 650 
 
 . 3 
 
 57, or 
 43, or 
 
 1 
 
 1 in every 13 
 1 in every 16 
 
 Total, 
 
 1436 
 
 1335 
 
 101 
 
 1 in every 14 
 
 Excluding from the above list of still-born children 37 which were 
 
748 STATISTICS OF 
 
 putrid, there remain 64 whose death was recent. Of these 64, there 
 were born 
 
 Under cranial presentations, ^^ 
 
 " breech presentations, ° 
 
 " footling presentations, ^ 
 
 " arm presentation, 1 
 
 " shoulder presentation 1 
 
 " presentation or prolapse of the cord, 8 
 
 " placental presentation 1 
 
 Presentation not stated, 1 
 
 Total, 64 
 
 In one of the cases of still-birth under cranial presentation, the 
 mother had convulsions during labor; and, in another, the child 
 was a male twin ; in a third, the cord was twisted twice around the 
 neck ; in a fourth, the child exhibited marks of abdominal disease ; 
 and in a fifth, the delivery was completed by perforation. Six of 
 the dead children were born in labors complicated with hemorrhage 
 during or before labor. 
 
 Of the 37 children born putrid, 18 were male and 19 female 
 infants ; and the presentations were as follows : 
 
 The head presented in 26 cases. 
 
 " breech 6 " 
 
 "feet 1 " 
 
 " shoulder 1 " 
 
 Presentation not stated in 3 " 
 
 Total, . . 37 
 
 During pregnancy two of the mothers whose children were born 
 putrid, labored under syphilitic complaints ; and a third was affected 
 with ascites and anasarca. In several of the still-born children 
 which I took the opportunity of examining along with the pupils, 
 effusion of coagulable lymph (the consequence of extensive inflamma- 
 tion) was found covering various parts of the peritoneal membrane. 
 
 Vm. The Length of the Children. — The extreme length or height 
 of the child at birth is stated in 330 cases of single birth completed 
 in the hospital. 169 of these children were male, and 161 female. 
 
 Of the male children there measured in length — 
 
 Under 15 inches, 1 child. Under 20 inches, 53 children. 
 
 " 16 " 1 " " 21 " 28 " 
 
 " 17 " 3 children. " 22 « 21 
 
 " 18 " 14 " " 23 '• 3 « 
 
 " 19 " 45 " 
 
 Total, . . 169 
 
EDINBURGH MATERNITY HOSPITAL. 749 
 
 Of the female children there measured in length — 
 
 Under 15 inches, 1 child. Under 20 inches, 40 children. 
 " 16 " 1 " " 21 " 32 " 
 
 " 17 " 1 " " 22 " 13 " 
 
 " 18 ■' 10 children. " 23 " 2 " 
 
 " 19 " 60 " " 24 " 1 child. 
 
 161 
 
 Average length of male child, 19 J inches. 
 " female child, 18| « 
 
 " both sexes 19| " 
 
 IX. The Weight of the Children. — The following tahle gives in 
 detail the respective weights of 337 children delivered within the 
 hospital, including 171 males and 166 females. The children born 
 in plural births are excluded from the table. 
 
 Of the male children there were : 
 
 Under 4 lbs., 4 children. Under 8 lbs., 60 children. 
 
 u 5 *' 7 " 
 " 6 " 17 " 
 " 7 " 45 " 
 
 9 « 
 
 31 
 
 10 " 
 
 3 
 
 11 " 
 
 4 
 
 Total, . . 171 
 
 Of the female children there were : 
 
 Under 4 lbs., 2 children. Under 8 lbs., 50 children. 
 
 t( 5 « 4 « " 9 " 27 " 
 
 " 6 " 17 " " 10 " 7 " 
 
 « 7 « 59 " 
 
 Total, . . 166 
 
 The lightest child (premature?), a male, 3 lbs. 4 oz. in weight. 
 
 The heaviest child, a male, 10 lbs. 8 oz. 
 
 The heaviest female child, 9 lbs. 7 oz. 
 
 The average male child, 7 lbs. 3 drs. 
 
 The average female child, 6 lbs. 10 oz. 11 drs. 
 
 The average of both sexes, 6 lbs. 13 oz. 7 drs. 
 
 X. The Length of the Umbilical Cord. — In 327 cases of children 
 delivered within the hospital, the length of the cord was noted. 
 Among these — 
 
 The shortest cord measured 12 inches in length. 
 The longest " 43 " 
 
 The average " 23^ " 
 
 In a note attached to the details of an extern case the cord is 
 stated to have been 50 inches long. 
 
 XI. Weight of the Placenta. — In 325 of the cases delivered within 
 the hospital, the weight of the placenta is noted. 
 
750 
 
 STATISTICS OF 
 
 The lightest placenta weighed 7 oz. Premature child? 
 
 The heaviest ditto, 2 lbs. 15 oz. The single placenta of twin children. 
 
 The average ditto, 1 lb. 4. oz. 14 drs. 
 
 Xn. The Duration of iaJor.— The duration of labor from the first 
 commencement of pains was ascertained in 311 cases, all delivered 
 within the hospital. The following table exhibits the average 
 length of the whole labor, and of the first, second, and third stages 
 separately in these 311 cases : 
 
 Average duration of first stage of labor, 11 hours 50 minutes. 
 " « second " " 1 " 37 « 
 
 « » third " " « 38 '' 
 
 « " whole labor " 12 « 57 « 
 
 The following table exhibits in detail the duration of the whole 
 labor, and of each stage of labor respectively, in all the cases. It 
 reads thus :— The whole labor was completed in 1 hour in 4 cases ; 
 in 2 hours in 4 cases ; and so on. The first stage of labor was com- 
 pleted in 1 hour in 3 cases ; in 35 hours in 5 cases, &c. 
 
 Duration in Hours. 
 
 Whole Labor. 
 
 First Stage. 
 
 Second Stage. 
 
 1 
 
 in 4 cases. 
 
 in 3 cases. 
 
 in 161 cases. 
 
 2 
 
 4 
 
 9 
 
 65 
 
 3 
 
 7 
 
 11 
 
 20 
 
 4 
 
 16 
 
 20 
 
 16 
 
 5 
 
 17 
 
 26 
 
 10 
 
 6 
 
 16 
 
 17 
 
 2 
 
 7 
 
 28 
 
 18 
 
 4 
 
 8 
 
 21 
 
 18 
 
 1 
 
 9 
 
 17 
 
 16 
 
 2 
 
 10 
 
 20 
 
 16 
 
 1 
 
 11 
 
 20 
 
 15 
 
 4 
 
 12 
 
 12 
 
 16 
 
 
 
 13 
 
 23 
 
 9 
 
 
 
 14 
 
 14 
 
 9 
 
 1 
 
 13 
 
 8 
 
 5 
 
 
 
 16 
 
 6 
 
 6 
 
 
 
 17 
 
 6 
 
 3 
 
 
 
 18 
 
 8 
 
 5 
 
 
 
 19 
 
 10 
 
 6 
 
 
 
 20 
 
 3 
 
 7 
 
 
 
 25 
 
 22 
 
 14 
 
 1 
 
 30 
 
 12 
 
 8 
 
 
 
 35 
 
 5 
 
 5 
 
 
 
 Above 36 
 
 14 
 
 9 
 
 
 
 Duration not " 
 stated, 
 
 61 
 
 85 
 
 103 
 
 The third stage was completed in 5 minutes in 40 cases. 
 " " " 10 " 88 
 
 « " " 15 « 80 
 
 11 11 11 30 11 104 
 
 " « "1 hour 16 
 
 Third stage completed within 1 hour in 328 
 
EDINBURGH MATERNITY HOSPITAL. 751 
 
 Third stage completed within IJ hours in 7 cases, 
 
 u « " 2 " 1 " 
 
 Duration not stated in ... . 38* " 
 
 XIII - The modes in which the Children presented. — ^In 1421 of the 
 births the presentation of the child is given. The following table 
 exhibits in detail the various presentations, and the number of each 
 respectively in 1421 cases : 
 
 Presentation. Namber of Gases. 
 
 Head, 1333 
 
 A hand descending with the head 31 
 
 Both hands descending with the head, ... 1 
 
 Face, 6 
 
 Shoulder 3 
 
 Arm 3 
 
 Breech, 27 
 
 Breech and feet, . . 2 
 
 One or both feet, 15 
 
 Total, . . . 1421 
 
 The cord presented along with some part of the foetus in 5 cases. 
 
 The cord became prolapsed in 13 cases. 
 
 The placenta presented partially, along with some part of the 
 infant, in 3 cases. 
 
 In the preceding table of presentations I have entirely omitted to 
 classify those of the cranium, according to the different positions in 
 which the head may present ; because I do not place much reliance 
 upon the perfect accuracy of the reports of positions entered in the 
 hospital records by the younger pupils. In fact, one of their prin- 
 cipal objects in hospital and dispensary instruction is to acquire, 
 among other things, a practical knowledge of the somewhat difficult 
 subject of positions. But I have great pleasure and confidence in 
 citing the notes on this subject of Dr. Martin Barry, who acted for 
 sixteen months as House-Surgeon to the hospital, more especially 
 as the data which he has obtained entirely coincide and agree with 
 the results of my own observations. Dr. Barry himself carefully 
 
 * In reference to these calculations regarding the duration of labor, it is necessary to bear 
 in mind that, in collecting the data for them, Dr. Martin Barry and the House-Surgeons 
 reckoned labor as commencing with the first periodic pains felt by the patient. In other 
 hospital returns the date of the commencement of labor is calculated differently, and conse- 
 quently very different averages of actual duration, &c., are given. The average duration of 
 labor in the Arran-Quay Hospital of Dublin, as given by Dr. Churchill, is about eighteen 
 hours, while in the Rotunda Hospital of Dublin, and consequently in the very same com- 
 munity, the average duration of the process, as given by Dr. Collins, is less than five hours — 
 Dr. Collins reckoned labor as only commencing when the os uteri was ascertained to be 
 opening under the uterine contractions ; and in some of his cases, the duration of the process 
 seems counted as beginning from the hour the patient entered the hospital, although she had 
 been previously for a considerable time suffering under the pains of parturition. 
 
752 
 
 STATISTICS OF 
 
 observed and noted the position of the head in 335 cases of cranial 
 presentation, among the patients of the Institution. I shall classify 
 these 335 cases according to the four positions and numerical no- 
 menclature used by many of the German schools : 
 
 I. Occipito-anterior Positions. 
 
 1st Position; or occiput directed to left foramen ovale, in ... . 
 2d Position ; or occiput directed to riglit foramen ovale, in . . . 
 
 II. Occipito-posterior Positions. 
 
 3d Position ; or occiput directed to right sacro-iliac synchondrosis, in 
 4th Position ; or occiput directed to left sacro-iliac synchondrosis, in 
 
 256 
 
 cases 
 
 1 
 
 (( 
 
 76 
 
 (( 
 
 2 
 
 u 
 
 Total, 
 
 335 
 
 In the cases of occipito-anterior position the head was invariably 
 found to descend and emerge, without any change or movement, 
 from the same oblique diameter of the pelvis as it was originally 
 placed in, with one exception. In this solitary case the head rotated 
 from the first into the fourth position, in which it was born. 
 
 Out of 78 cases of occipito-posterior position carefully watched, 
 in 75 the occiput turned forwards, and emerged first from under the 
 arch of the pubis. In 2 cases of the third position the occiput con- 
 tinued directed backwards, and the child was expelled without the 
 usual rotation into the first position. Thus the exceptions to the 
 rotation did not occur oftener than about once in thirty cases. 
 
 Of the two cases which presented in the fourth position, in one 
 the rotation was performed into the first position. In the other, the 
 head continued to maintain the same position till it was born. 
 
 XrV. The Plural Births.— Among the 1417 women delivered, 17, 
 or 1 in every 83, gave birth to twin children, and in one case triplets 
 were born. 
 
 In the twin cases the presentations and state of the children were 
 as shown in the following table : 
 
 Presentation. 
 
 Double cranial presentation, 
 1st child, head; 2d child, breech, 
 1st child, feet; 2d child, head, 
 1 child, arm ; other not stated, 
 1 child, head ; other not stated, 
 
 Total, 
 
 Number of 
 Cases. 
 
 17 cases or 
 34 children. 
 
 Number of 
 
 Children 
 Born Alive. 
 
 13 
 
 11 
 
 2 
 
 2 
 
 2 
 
 30 
 
 Number of 
 .Children 
 Born Bead. 
 
EDINBURGH MATERNITY HOSPITAL. 753 
 
 The sexes of the twin children were as follows : 
 
 In 3 cases, both cliildren male, ... 6 
 In 5 cases, " " female, . . 10 
 
 In 9 cases, 1 child male and 1 female, 18 
 
 Total, 17 34 
 
 The average weight of the twin child was 6 lbs. 1 oz. 
 
 In the triplet case, two of the children presented the head, the 
 third presented the feet. Two of the children were male, one 
 female. All were born alive and vigorous, but, before leaving the 
 hospital, one of the children was accidentally overlaid by its mother. 
 The male children weighed respectively, 5 lbs. 11 oz. and 5 lbs. 2 
 oz. ; the female child weighed only 3 lbs. 12 oz. The labor was 8J 
 hours in duration. 
 
 XV. The Mode of Delivery. — ^Deducting the abortions and mis- 
 carriages, which amounted in number to 58, there remain 1417 
 cases of delivery at about the full time. The following table shows 
 the mode of delivery in these 1417 cases, and their relative frequency 
 to each other. Among those naturally delivered, is included a case 
 of spontaneous cephalic evolution or expulsion : 
 
 Mode of Deliveiy. 
 
 Number of Casea. 
 
 Proportion. 
 
 Naturally, . . . . 
 
 Artificially, . . . 
 
 1404 
 13 
 
 1404 in 1417 
 1 in 107 
 
 Mode of Artificial Belivery. 
 
 Traction of presenting feet, 
 
 Bringing down a foot (breech presentation), . . 
 
 Turning, .... 
 
 Forceps, 
 
 Crotchet, 
 
 1 
 1 
 6 
 3 
 1 
 1 
 
 1 in 1417 
 1 in 1417 
 1 in 236 
 1 in 472 
 1 in 1417 
 1 in 1417 
 
 Induction of premature labor, 
 
 Turning was adopted in five cases for preternatural presentations, 
 and in one case for the purpose of hastening delivery under an 
 attack of apoplectic convulsions. The breech presentation, in 
 which a foot was brought down, was a case in which the presenting 
 part did not pass the brim, notwithstanding strong and powerful 
 pains of upwards of a day's duration. 
 
 XVI. The Complicated Labors. — The following table contains a list 
 of the chief complications observed in the 1417 labors, with the 
 respective numbers and proportion of each : 
 
 Hemorrhage from partial placenta prasvia in . , 3 cases, or 1 in every 472 cases. 
 
 Hemorrhage before labor, in . . . . 12 " 1 " 118 " 
 
 Hemorrhage during labor, in 4 " 1 " 354 " 
 
 Hemorrhage between the expulsion of the child and 
 
 of the placenta in 16 " 1 " 87 " 
 
 TOI. I. 48 
 
754 
 
 STATISTICS OF 
 
 Hemorrhage post-partura, in 
 
 Hemorrhage (indefinitely stated), in . . • ■ 
 
 Total cases of hemorrhage,' 
 
 Convulsions during labor, in 
 
 Prolapsus of the entire uterus to the outlet, in 
 Rigidity of the os uteri, in . . . 
 
 Carcinoma of the os uteri, in 
 
 Prolapsus of the anterior lip of the uterus, in 
 Expulsion of the entire ovum (membranes unbroken), in 
 
 Prolapsus of the cord, in 
 
 Cord once or twice around the child's neck, in . 
 
 Cord three times around the child's neck, in 
 
 Cord four times around the child's neck, in . 
 
 Cord encircling the neck and one hand, in . 
 
 Cord around the neck and arm, in ... . 
 
 Cord around the neck and body, in 
 
 Cord around the shoulder, in . . 
 
 Cord around the body, in 
 
 Cord around the arm, in ..... 
 
 Cord around the leg, in . . ... 
 
 Cord snapped across before delivery (12 inches long), in 
 Amaurosis and delirium before delivery, in . 
 Gangrenous slough from the interior of the rectum, in 
 
 24 oases, or 1 in every 59 
 
 cases 
 
 8 « 1 " 177 
 
 (I 
 
 67 " 1 " 21 
 
 (C 
 
 4 " 1 " 354 
 
 Cf 
 
 2 •" 1 " 708 
 
 " 
 
 11 " 1 " 128 
 
 (( 
 
 1 « 1 " 1417 
 
 u 
 
 6 « 1 " 236 
 
 (t 
 
 1 " 1 " 1417 
 
 (C 
 
 18 " 1 " 79 
 
 (1 
 
 158 " 1 " 9 
 
 u 
 
 4 " 1 " 354 
 
 (C 
 
 2 " 1 " 708 
 
 u 
 
 1 " 1 " 1417 
 
 (( 
 
 4 " 1 " 354 
 
 (; 
 
 2 « 1 " 708 
 
 c; 
 
 2 " 1 '• 708 
 
 (C 
 
 2 " 1 " 708 
 
 u 
 
 1 ■' 1 " 1417 
 
 u 
 
 2 " 1 " 708 
 
 " 
 
 1 " 1 "■ 1417 
 
 u 
 
 1 " 1 " 1417 
 
 (C 
 
 2 " 1 " 708 
 
 (( 
 
 were 
 
 had 
 
 re- 
 
 XVn. The Instrumental Deliveries. — Instrument 
 course to in very few cases. The following table exhibits the num- 
 ber and proportion of the deliveries in the 1417 labors : 
 
 Instrumental delivery, in 
 
 Viz., Delivery by the forceps, in 
 Delivery by the crotchet, in 
 
 4 cases, or 1 in every 354 cases, 
 3 " 1 " 472 " 
 
 1 " 1 ' 1417 " 
 
 Of the four mothers, one died eight days after delivery from 
 puerperal fever. She had been in labor upwards of two days, and 
 was ultimately delivered of a dead child by the short forceps. Of 
 the children extracted by the forceps, two were still-born. In both 
 cases the head had descended into the pelvis before the instruments 
 were applied. In one of these two cases the hospital record states, 
 that, from the state of the cord, the child appeared to have been 
 dead for some time before delivery. It was born after above two 
 days' labor. In the second case the woman had been upwards of 
 twenty-four hours in labor. Convulsions came on an hour and a 
 half before delivery, and returned several times. The child was of 
 very large size, weighing 10 lbs. 2J oz. , 
 
 Delivery by the crotchet was resorted to, in consequence of the 
 head of the child being arrested at the brim of a distorted pelvis. 
 
 The proportion of cases in which instrumental delivery was had 
 recourse to in the Edinburgh Hospital, was smaller than in most 
 other obstetric institutions. The following table will perhaps illus- 
 trate this point more fully than any more lengthened remarks. The 
 
 " In the Hospital books, '-hemorrhage" is frequently noted when there was a more than 
 usual loss of blood, although it may have been in comparatively small quantity. 
 
EDINBURGH MATBUNITT HOSPITAL. 
 
 755 
 
 first column of figures shows the absolute number of labor cases 
 reported by the different practitioners named ; the second column 
 shows the proportion of instances in each of the returns in which 
 the practitioner resorted to delivery by instruments ; and the third 
 and fourth columns respectively show the comparative proportion 
 in which the two modes of instrumental delivery (the forceps and 
 crotchet) were employed by each practitioner. It will be seen how 
 frequently the forceps were employed by some in comparison with 
 craniotomy ; how frequently craniotomy was employed by others in 
 comparison vsdth the forceps ; and how very diflerent the propor- 
 tion of cases supposed to require instrumental delivery at all, is in 
 the practices of different medical schools and' institutions. 
 
 Table skoiving the Proportion of Instrumental Deliveries, and of Deliveries by the Forceps 
 and by Craniotomy, in different Obstetric Institutions. 
 
 1 
 
 Name of Reporter. 
 
 Total Number 
 of Labors 
 Keported. 
 
 Proportion of 
 
 Instrumental 
 
 Deliveriea, 
 
 Proportion of 
 
 Deliveries by 
 
 Forceps. 
 
 Proportion of 
 Deliveries by 
 Craniotomy. 
 
 Siebold— Berlin, 
 
 2,093 
 
 1 in 7 
 
 lin 7 
 
 1 in 2093 
 
 Busch — Berlin, 
 
 2,056 
 
 1 " 11 
 
 1 " 12 
 
 1 " 342 
 
 Carus — Dresden, 
 
 2,549 
 
 1 " 13 
 
 1 " 14 
 
 1 " 283 
 
 Naegele — Heidelberg, 
 Bland — Westminster, 
 
 1,711 
 1,897 
 
 1 " 31 
 1 " 95 
 
 1 " 31 
 1 " 158 
 
 1 " 1711 
 1 " 237 
 
 Beatty — Dublin, 
 
 1,182 
 
 1 " 98 
 
 1 " 131 
 
 1 " 394 
 
 Collins— Dublin, 
 
 16,654 
 
 1 ' 115 
 
 1 " 617 
 
 1 " 141 
 
 Churchill— Dublin, 
 
 1,640 
 
 1 " 117 
 
 1 " 546 
 
 1 " 149 
 
 Lever— London, 
 
 4,666 
 
 1 " 137 
 
 1 " 518 
 
 1 " 186 
 
 BOer — Vienna, 
 
 9.589 
 
 1 " 199 
 
 1 " 274 
 
 1 " 737 
 
 Lachapelle — Paris, 
 Ramsbotham — London, 
 
 22,243 
 48,682 
 
 1 " 252 
 1 " 322 
 
 1 ■' 293 
 1 " 553 
 
 1 " 1854 
 1 " 773 
 
 Simpson — Edinburgh, 
 
 1,417 
 
 1 " 354 
 
 1 " 472 
 
 1 " 1417 
 
 XVm. The Maternal Deaths. — Among the 1475 women delivered 
 under the superintendence of the Institution, eleven deaths oc- 
 curred, or 1 in 134.^ Of these, seven occurred among the cases 
 delivered in the hospital, and four among the out cases. 
 
 Four of these eleven patients were in their first labors ; three in 
 their second ; and the remaining, severally in their third, sixth, 
 ninth, and twelfth. 
 
 The cause of death was — 
 
 Puerperal fever and inflammation, in . . . . 7 cases. 
 
 Puerperal convulsions, in ..... . . 2 " 
 
 Chest disease, in . . . . . 1 " 
 
 Fatal sinking, after incision of a carcinomatous os uteri, in . 1 " 
 
 Total 11 deaths. 
 
 ' An erroneous statement of Dr. Simpson's statistics regarding the mortality to the mother, 
 as read before the Medico-Chirurgical Society, was published in the Edinburgh Monthly 
 Journal of Medical Science for June, 1 847, p. 934. The attention of the profession was 
 then dravlm by Dr. Collins to the apparent discrepancy, by a letter published in the Obstetric 
 Record, 1848, p. 146. An acknowledgment of the error on behalf of the Editors appears in 
 the Edinburgh Monthly Journal of Medical Science for January, 1849, p. 494 ; the fault in 
 accuracy having been entirely that of their own reporter, and not of Dr. Simpson. — (Ed.) 
 
756 STATISTICS OF EDINBURGH MATERNITY HOSPITAL. 
 
 The delivery was effected by the natural efforts in nine of the 
 cases ; by the forceps in one of the cases dying of puerperal fever ; 
 by turning in one of the cases dying of convulsions — the body, on 
 dissection, presenting a large clot of effused blood in the brain, and 
 a collection of pus in one of the kidneys. In the case where the os 
 uteri was incised for carcinoma, the mother had been in labor for 
 two or three days, and the pulse had become very rapid, &c., before 
 the operation was adopted. The child was subsequently born in the 
 course of four or five pains. But the pulse never rallied after 
 delivery, and she died on the third day. 
 
 I have merely further to add, that the convalescence of the hos- 
 pital patients was often interrupted by febrile and inflammatory 
 attacks. The house, IsTo. 3 St. John Street, used as an hospital, 
 was, in addition to a sunk kitchen flat, three stories in height, with 
 two rooms in the flrst and second flats, and three in the third ; 
 and it was much too small for the accommodation of the patients, 
 and of the resident house-surgeons, matron, &c. The rooms them- 
 selves were low-roofed, and very imperfectly ventilated. Various 
 plans were attempted to improve the ventilation, but not with much 
 success. Whenever the hospital became in any degree crowded, 
 fevers (or weeds), with more or less abdominal tenderness, appeared 
 among the patients ; and frequently the supervention of such attacks 
 during convalescence became so common, as to constitute the rule 
 rather than the exception to it. Eveiy one acquainted with hospital 
 practice, whether obstetric, surgical, or medical, is well aware of the 
 great liability among the patients to febrile and inflammatory attacks 
 whenever the wards are overcrowded ; and in no practice is this 
 more visible than in midwifery. Indeed, I believe there are few or 
 no circumstances which would contribute more to save surgical and 
 obstetric patients from phlebitic and other analogous disorders, than 
 a total change in the present system of hospital practice. 
 
 I have often stated and taught, that if our present medical, sur- 
 gical, and obstetric hospitals were changed from being crowded 
 palaces, with a layer of sick in each flat, into villages or cottages, 
 with one, or at most two patients in each room, a great saving of 
 human life would be effected. And if the village^ere constructed 
 of iron (as is now sometimes done for other purposes), instead of 
 brick or stone, it could be taken down and rebuilt every few years ; 
 a matter apparently of much moment in hospital hygiene. Besides, 
 the value of the material would not greatly deteriorate from use ; 
 the principal outlay would be in the first cost of it. It could be 
 erected in any vacant space or spaces of ground, within or around a 
 city, that chanced to be unoccupied ; and, in cases of epidemics, 
 the accommodation could always be at once and readily increased.