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PRACTICAL TREATISE 
 
 ON 
 
 MIDWIFE»!. 
 
 M. CHAIL1Ï. 
 
 EMBliTION, &C, &C, &C. 
 
 ILLUSTRATED WITH 216 WOODCUTS. 
 A WORK ADOPTED BY THE BOYAL COUNCIL OF PUBLIC INSTRUCTION. 
 
 TRANSLATED FROM THE FRENCH AND EDITED 
 
 BY 
 
 GUNNING S. BEDFORD, A.M., M.D., 
 
 PEOPESSOE OP «..WERT ANP THE P.SE.SES OP WOMEH i8 CHINEE* ™ THE OR!- 
 
 VERSITY OF NEW-YORK. 
 
 NEW-YORK: 
 
 HARPER & BROTHERS, 82 CLIFF-STREET. 
 1844. 
 
6c S^X 
 
 UNIVERSITY OF FRANCE. 
 
 MINISTRY OF PUBLIC INSTRUCTION. 
 
 Paris, July 23d, 1842. 
 
 Sir: 
 
 The Royal Council of Public Instruction, at its session of the 
 12th inst., has examined the Practical Treatise on Midwifery which 
 you have presented for the adoption of the University. 
 
 After the deliberation of the Royal Council, the use of this 
 Treatise is authorized in the Faculties, in the schools of Medicine, 
 and in the different courses instituted for the instruction of sage- 
 femmes. 
 
 Receive, sir, the assurance of my distinguished consideration, 
 Peer of France, Minister of Public Instruction, 
 
 VlLLEMAIN. 
 To Chailly, M.D., &c, &c, &c. 
 
 Entered, according to Act of Congress, in the year 1844, by 
 
 Harder & Brothers, 
 In the Clerk's Office of the Southern District of New-York. 
 
EDITOR'S PREFACE. 
 
 I have been induced to translate and edit Dr. Chailly's Treatise 
 on Midwifery from a conviction of its great practical value. The 
 encomiums which have been passed on this work by some of the 
 best European journals, and the high character of Paul Dubois, 
 whose instructions and experience it imbodies, will, I am sure, se- 
 cure for it a favourable reception on this side of the Atlantic. To 
 all Americans who have visited the Parisian schools the name of 
 Paul Dubois must be familiar ; he is at this day the oracle of 
 French midwifery, and Dr. Chailly has, in this treatise, presented 
 the reader with a faithful and graphic view of the opinions of this 
 accomplished obstetrician. 
 
 For myself personally, this work possesses more than ordinary 
 interest ; it mentions many cases of which I was an eyewitness 
 during my residence in Paris, and it brings vividly to my recollec- 
 tion the valuable lessons which I received from my old masters, 
 Desormeaux, Dubois, and Capuron. To the learned Desormeaux 
 I owe much. It was through his kindness that I was permitted to 
 enter the Maternité of Paris, and it was under his instruction that 
 I was enabled, for nearly a period of two years, to avail myself of 
 the inappreciable advantages of that extensive charity. To the 
 venerable Capuron I am under the deepest obligations. He, too, 
 was a kind and efficient preceptor. Nor can I ever forget the les- 
 sons of the eloquent and accomplished Dubois. 
 
 I therefore offer this treatise to the student, as combining all 
 that is new and valuable in obstetric science ; every topic is treat- 
 ed in detail, and bears the impress of the master's mind. I offer it 
 as a faithful guide, im>>odying the learning and experience of a 
 man who, by common consent, is acknowledged to be among the 
 ablest of his cotemporaries. 
 
11 PREFACE. 
 
 I like this book because it is practical. It purposely avoids all 
 that is speculative, and adheres almost exclusively to bedside facts. 
 
 The students of the University know how much value I attach 
 to this species of instruction ; and with a view of affording them 
 every possible facility for studying midwifery and the diseases of 
 women and children practically, I established, on the organization 
 of the University School of Medicine, an obstetric clinique devoted 
 exclusively to the instruction of the members of my class. This 
 clinique, now in the third winter of its existence, has enabled me 
 to furnish gratuitously to the pupils of the University 740 cases of 
 midwifery. The clinique is now so thoroughly organized that, in 
 future, I shall have at my command an unlimited number of cases. 
 In no other way can this important department be efficiently 
 taught. It is essentially a practical branch, and to become ac- 
 quainted with its details, the pupil must be introduced into the ly- 
 ing-in chamber. 
 
 I trust the translation of this treatise may prove acceptable to 
 the reader. The notes I have added are marked as editorial. 
 
 G. S. Bedford. 
 
 New-York, March, 1844. 
 
 I have thought proper to preserve the measures recorded in the 
 text, but that they may be intelligible to all, I subjoin the following 
 table; 
 
 A millimetre 0*039 inch. 
 
 A centigramme . . . . . 0*154 grain. 
 
 A gramme 1*540 grains. 
 
 G. S. B. 
 
PREFACE. 
 
 The practical part of midwifery is what I particularly endeavour 
 to present in this work ; I have imbodied in it as briefly as pos- 
 sible, but always in sufficient detail, all the precepts the excellence 
 of which I have been enabled to test. 
 
 Devoted for fourteen years to the practice of the obstetric art, I 
 am indebted to the kindness of M. P. Dubois for having at an early 
 period been placed by him in a position altogether unexceptionable, 
 at first as his pupil, afterward as his assistant in the city, and, finally, 
 as his chef de clinique in the midwifery clinique of Paris ; and I 
 have been enabled, in an excellent school, often in the city, some- 
 times at La Maternité, and every day at La Clinique, to verify by 
 my own experience, and much more by that of my master, the great 
 value of the rules I recommend. 
 
 The reader will not, then, be surprised to find the opinions of M. 
 P. Dubois so exactly reproduced in this treatise, and likewise to 
 see described here the simple and accurate manipulations, freed 
 from that multitude of absurd rules, inculcated even by some of 
 the latest writers, and which, for the most part, are impossible, and 
 often dangerous when attempted to be reduced to practice. 
 
 I have also availed myself largely of the valuable works of 
 Madame Lachapelle, Desormeaux, MM. Naegele, Velpeau, Stoltz, 
 Moreau, &c. I have made, however, but few extracts, content- 
 ing myself to imbody whatever I judged valuable, and permitting 
 each to claim what he may be entitled to in this treatise ; reserving 
 to myself, however, the choice of the rules, their practical applica- 
 tion, and the order in which they should be arranged. 
 
 Most of the treatises on midwifery embrace discussions, the value 
 of which I fully appreciate for those who wish merely to study this 
 subject as a science, but which is of no value to the practitioner;. 
 I have purposely omitted them, believing it to be much more prof- 
 itable to enter as fully as possible on the consideration of purely 
 practical points, which have either not been discussed at all, or, at 
 least, not with that precision their importance claims. 
 
 The order which I have adopted in the arrangement of my sub- 
 jects appears to me reasonable. The science of obstetrics is com- 
 
IV PREFACE. 
 
 posed of very dissimilar parts, some of which are divided, in order 
 to accommodate them to others. 
 
 Thus, if we place the manipulations at the head of the chapter, 
 we shall have the entire combination, but then it will become ne- 
 cessary to arrange pregnancy, labour, and the consequences of de- 
 livery, under as many subdivisions as there are rules ; and to un- 
 derstand the indication in any given case, we will be compelled to 
 search through numerous chapters for these isolated subjects, in 
 order to arrive at just results. 
 
 The accoucheur will embrace in a coup d'oeil all the details of a 
 rule, but he will not find combined in the same article all the in- 
 dications to be fulfilled in pregnancy, in each presentation of the 
 fœtus, and in the treatment after delivery. 
 
 This course, pursued by my predecessors, except Madame La- 
 chapelle, appears to me much less practicable ; it moreover causes 
 more numerous repetitions than the plan I have adopted. I have 
 combined together the accidents and their treatment, first during 
 pregnancy, then in each presentation of the fœtus, and, finally, du- 
 ring the puerperal period. 
 
 Thus, I have not divided the accidents into genera and species, 
 into those which affect the mother, and those which affect the 
 fœtus, and into those which require the employment of the hand, 
 and blunt or cutting instruments ; these divisions I consider arbitrary 
 and useless ; and they possess the great inconvenience of separa- 
 ting the methods and indications to be fulfilled from the accidents 
 requiring their employment. 
 
 But I have treated pregnancy first in all its relations, and I have 
 successively enumerated its possible complications, and the means 
 of remedying them ; then I have in the same manner considered 
 delivery in the presentations of the vertex, face, pelvic extremity, 
 and trunk ; finally, I have pursued the same course for the puer- 
 peral period. 
 
 In this way, pregnancy, delivery subdivided into four presenta- 
 tions, and the puerperal period, form undivided parts, in which the 
 accidents and treatment are grouped together ; thus, the manipu- 
 lations cease to be abstractions, and are appropriated to each spe- 
 cific case. 
 
 This practical arrangement will enable the accoucheur, at one 
 glance, to embrace all the accidents which may occur either during 
 pregnancy, in the various presentations of the fœtus, or during the 
 puerperal period ; he will, likewise, have the order in which the 
 indications are to be fulfilled. 
 
PREFACE. 
 
 With this arrangement, I have been enabled to enter into nu- 
 merous small details, which may appear somewhat tedious to the 
 purely scientific, but which will be fully appreciated by the prac- 
 tical accoucheur, and which will be valued by the pupils themselves. 
 
 Finally, in order to avoid all obscurity, I have incorporated in the 
 text a large number of woodcuts ; and, in order to ensure their ac- 
 curacy, I have designed them myself; I am convinced that they 
 will add much to the value of the text. 
 
 The most methodical and accurate descriptions are of but little 
 value when applied to rules composed of a multitude of details ; 
 but, on the contrary, they become perfectly plain and intelligible 
 when, in studying them, we have before the eye a faithful repre- 
 sentation of the position of parts, and of the route to be pursued 
 either by the hand or by instruments. 
 
 In conclusion, I must return my grateful thanks to M. Honoré, 
 my father-in-law, for his excellent counsel ; to M. Rigaud, professor 
 of the faculty of Strasbourg ; and to Drs. Devilliers and Brasier 
 for their kind co-operation. 
 
INTRODUCTION. 
 
 We understand by natural delivery the spontaneous and success- 
 ful expulsion of the fœtus and its annexa? through the pelvis, in vir- 
 tue of the action of certain organs ; and the restoration of the uterus 
 and its appendages to their original condition. 
 
 The knowledge, therefore, of spontaneous delivery should neces- 
 sarily precede the study of the manipulations required in difficult 
 labour; for it is on the rules pursued by nature, in determining 
 the expulsion of the fœtus, that are based the methods which art is 
 to follow in the extraction of the infant ; to this, however, there are 
 some exceptions, which will be hereafter pointed out. 
 
 But, in order thoroughly to comprehend the phenomena of spon- 
 taneous expulsion, the accoucheur must have a perfect knowledge 
 of the maternal organs which the fœtus is to traverse ; he should un- 
 derstand the different regions of the fœtus which may present at 
 the orifice (presentations), and the relations of these parts with those 
 of the mother (positions). 
 
 I shall, therefore, commence with the description of the pelvis 
 and organs connected with parturition ; then with the fœtus ; and 
 I shall afterward proceed to spontaneous delivery in the different 
 presentations and positions of the fœtus, and terminate with the 
 manipulations. I have adopted, as will be seen, a method which 
 will not enjoin upon me the frequent repetitions so usual in the ar- 
 rangement generally pursued ; and which will enable me to classify 
 the obstacles and accidents which the accoucheur will be called 
 upon to combat, in the order in which they may appear in the fe- 
 male, from the commencement to the termination of the labour. 
 In this manner, the accoucheur will have a complete view of the 
 spontaneous phenomena of expulsion in each presentation, and all 
 the indications which each presentation may require in case of ac- 
 cident. 
 
 Everything connected with the practice of midwifery forming a 
 part of this arrangement, I have not limited myself to the consid- 
 eration of the accidents to which the female is exposed during la- 
 bour, but I have also imbodied in this treatise the diseases of preg- 
 nancy and the puerperal period ; and also the accidents which may 
 compromise the safety of the infant, and the treatment it requires 
 from the moment of conception until the first six weeks after birth. 
 

PRACTICAL TREATISE 
 
 ON 
 
 MIDWIFERY. 
 
 PART I. 
 
 ORGANS OF THE FEMALE CONCERNED IN PARTURITION. 
 
 CHAPTER I. 
 
 PELVIS. 
 
 The study of the pelvis becomes useful to the accoucheur only 
 when its constituent parts are studied together ; I shall, therefore, 
 briefly describe each of the bones composing it, and shall present a 
 general view of it as a whole, and especially of its internal surface. 
 
 The pelvis, situated between the trunk which it supports, and 
 the inferior extremities, is a crooked canal, composed of various 
 bones, the shape and dimensions of which are modified by the 
 soft parts. This canal is formed of four bones, the sacrum,, coc- 
 cyx, and the two ossa innominata, all of which are connected to- 
 gether by articulations and ligaments. 
 
 Art. I. — Bones of the Pelvis. 
 
 ■ § 1. Sacrum. 
 The sacrum is situated at the posterior part of the pelvis ; it i» 
 
BONES OF THE PELVIS. 
 
 
 triangular in shape, flattened from before backward, and divided 
 into lour surfaces, a base, and a summit. 
 
 The posterior surface presents at the median line the rudiments 
 of the vertebral spinous processes, and beneath these there is a 
 groove formed by the extremity of the sacral canal, and termi- 
 nated laterally by two tubercles. On either side, we observe the 
 four sacral foramina, which give passage to the sacral nerves ; 
 more outwardly, there is a series of eminences resembling the 
 articulating processes of the vertebrae ; and, lastly, two depres- 
 sions, into which are inserted the sacro-iliac ligaments. The an- 
 terior surface is divided by four prominent lines, between which 
 are found superficial grooves.; on either side, the anterior openings 
 for the anterior sacral nerves ; more outwardly, a concave sur- 
 face, which affords attachment to the pyriformis muscle, and 
 which is grooved by transverse furrows, in which the sacral 
 nerves are situated. 
 
 The two lateral surfaces, at their anterior and superior part, pre- 
 sent a rough, semilunar face, which articulates with the os ilium ; 
 in the rest of their extent are rough prominences, to which are 
 attached the sacro-iliac ligaments ; and at the lower portion of 
 the bone there is observed a thin, cutting border, into which are 
 inserted the sacro-sciatic ligaments. 
 
 The base presents an articulating surface, on which rests the 
 last lumbar vertebra. 
 
 The summit, looking downward, is united to the coccyx by a 
 small oval facette. 
 
 § 2. Coccyx. 
 
 The coccyx, composed of three or four small bones connected 
 together by ; fibro-cartilages, is situated at the inferior portion of 
 the sacrum. Its posterior surface is convex, and is separated 
 from the integuments by the posterior sacro-coccygeal ligament, 
 and affords attachment to the glutei maximi muscles. 
 
 Its anterior or pelvic surface is smooth, and covered by the an- 
 terior sacro-coccygeal ligament ; on this surface are noticed trans- 
 verse lines separating the bones. 
 
 The lateral edges receive the insertion of the anterior sacro- 
 sciatic ligaments, and ischio-coccygeal muscles. 
 
 Its base is articulated to the sacrum, while its apex affords at- 
 tachment to the levator-ani muscle. 
 
 •■■§ 3. Os Innominatum. 
 
 The os innominatum is an irregular, broad bone, and, as it were, 
 twisted in two different directions ; it is narrow at its middle, and 
 presents two surfaces and four borders. 
 
 The external surface is divided into two parts ; the most poste- 
 rior, called the external iliac fossa, presents a small, irregular sur- 
 face, into which is inserted the gluteus maximus muscle ; more 
 anteriorly, the superior curved line offers a concave surface, 
 into which is inserted the gluteus médius muscle. Immediately 
 
PELVIS. 3 
 
 beneath the inferior curved line is inserted the gluteus minimus 
 muscle ; the most anterior part of the external surface of this 
 bone presents, above, the cotyloid cavity ; below this, the triangu- 
 lar foramen thyroideum, giving attachment, at its circumference, 
 to a fibrous membrane, with the exception of its upper part, 
 through which pass the obturator nerves and vessels. On the 
 outer side of this foramen there is a surface nearly plane, to which 
 are attached the adductor muscles of the thigh, and the external 
 obturator muscle ; also a groove for the tendon of the obturator 
 internus. 
 
 The internal or abdominal surface is formed above by the in- 
 ternal iliac fossa, posteriorly by an articular surface united to the 
 sacrum, and prominent inequalities into which are inserted the 
 sacro-iliac ligaments. This superior portion of the bone is sep- 
 arated from the inferior by a line, which forms part of the supe- 
 rior strait ; below this line, there is a flat surface nearly triangu- 
 lar, which corresponds to the posterior part of the cotyloid cavity; 
 it is covered by the obturator internus and levator ani muscles ; 
 besides this, there is the thyroid foramen. 
 
 The superior border, or iliac crest, is thick, convex, and of the 
 shape of the letter S ; it affords attachment externally to the latis- 
 simus dorsi and obliquus externus muscles, and also to the crural 
 aponeurosis ; internally to the transversalis abdominis and quadra- 
 tic lumborum, and in its interstice to the obliquus internus muscle ; 
 it is bounded posteriorly by the posterior superior spinous process 
 of the ilium, and in front by the anterior superior spinous process. 
 
 The inferior border articulates with that of the opposite side, 
 and forms the pubic arch ; the posterior border, very irregular, 
 forms, by its union with the superior border, the posterior superior 
 iliac spine, separated by the notches of the posterior inferior iliac 
 spine ; below is the great ischiatic notch ; and, lastly, the tuberos- 
 ity of the ischium. 
 
 The anterior border forms, by its union with the superior, the 
 anterior superior spinous process, which is separated from the 
 anterior inferior spinous process by the semilunar groove. A lit- 
 tle lower down there is observed a smooth surface, over which 
 pass the united tendons of the psoas and iliac muscles. Lastly, 
 we observe the linea ileo-pectinea and pubic spine. 
 
 Art. II. — Articulations of the Pelvis. 
 
 The articulations of the pelvis are five in number: 1. That 
 which unites the two inferior borders of the ossa innominata, and 
 which takes the name of symphysis pubis ; the two sacro-iliac sym- 
 physes, which unite the innominata to the lateral portions of the 
 sacrum ; and, finally, the sacro-coccygeal symphysis. 
 
 During pregnancy, these articulations enlarge and become soft- 
 ened ; and some authors have supposed that this softening is in- 
 tended to favour parturition. But I have convinced myself, by 
 numerous experiments made on the pelves of women recently de- 
 livered, that the fact is not so. The greatest effort will not add to 
 
ARTICULATIONS OF THE PELVIS. 
 
 t 
 
 the capacity of the pelvis a millimetre. In order that this soften- 
 ing of the symphyses should facilitate the expulsion of the fœtus, it 
 must be very marked, which, it is true, is sometimes the case, but 
 then it constitutes a diseased condition of the female, and often ren- 
 ders progression impossible ; but in the living woman this disposition 
 of the articulations is never so manifest as to be perceived. Such, 
 however, is not the fact with regard to certain inferior animals, 
 among which this softening, without which parturition would often 
 be impossible, is sometimes so distinct, that the bones appear lost 
 in the midst of the soft parts ; and if the traces of this condition are 
 occasionally met with in the human female, it must be considered 
 only as a mark of one of those general laws which rule in the or- 
 ganization of all animals. 
 
 § 1. Symphysis Pubis. 
 This articulation is formed by the approximation of the two 
 pubic facettes, which are covered by a cartilaginous layer, and 
 which are almost entirely united by an inter-pubic fibro-carLlage, 
 except posteriorly, where these surfaces touch each other in a small 
 portion of their extent. The bones are maintained in these rela- 
 tions, anteriorly, by a thick fibrous plane ; posteriorly, by very 
 thin ligamentous fasciculi, which pass off from the periosteum ; and 
 inferiorly, by a ligament called the sub-pubic, of a triangular shape, 
 which is formed by an expansion of the most inferior fibres of the 
 inter-pubic ligament. 
 
 § 2. Sacro-iliac Symphyses. 
 These symphyses result from the union of the semilunar facettes, 
 which are found on the borders of the ossa innominata, and on those 
 of the sacrum, where these facettes are covered by a very thick 
 diarthrodial, corrugated cartilage. These articulations are strength- 
 ened, 1st, in front, by a slender ligament called the anterior sacro- 
 iliac ; and, behind, by numerous bands of yellow elastic fibres, 
 which interlace with each other, directed from below upward, and 
 from within outward, and which are termed the posterior sacro- 
 iliac ligaments ; 2d, by a small ligament called superior sacro-iliac, 
 a very thick fibrous fasciculus, extending from the base of the sa- 
 crum to the os innominatum ; 3d, by an inferior sacro-iliac liga- 
 ment (the vertical of M. Cruveilhier), which passes from the border 
 of the sacrum and great sacro-sciatic ligament to the posterior su- 
 perior spine of the ilium ; 4th, by the two sacro-sciatic ligaments, 
 which convert the sciatic notches into a foramen, and complete the 
 floor of the pelvis ; these two ligaments are triangular, thin, flatten- 
 ed, and formed of fibres attached to the inferior half of the borders 
 of the sacrum, and to the whole extent of the coccyx, dividing into 
 two fasciculi ; the first, formed by the posterior and superior fibres, 
 is called the great sacro-sciatic ligament, and is inserted into the 
 tuberosity of the ischium, after crossing the other fasciculus, com- 
 posed of the anterior and inferior fibres ; the second, which is the 
 small sacro-sciatic ligament, is attached to the spine of the ischium. 
 
 
PELVIS. 
 
 § 3. Sacro-coccygeal Symphysis. 
 The coccyx is united to the last bone of the sacrum by means 
 of a fibro-cartilage, strengthened by anterior and posterior liga- 
 mentous fibres, which, stretching to all the pieces of this bone, unite 
 them firmly to each other. The ossification of the fibro-cartilages 
 which are interposed between the various portions of these bones 
 does not take place until the female is somewhat advanced in age ; 
 this circumstance, which permits the coccyx to recede as it is press- 
 ed upon by the head of the fœtus at the time it is passing through 
 the inferior strait, increases the length of the antero-posterior diam- 
 eter of this strait.* 
 
 Art. III. — Pelvis in General. 
 
 The pelvis is divided into the great or abdominal pelvis, and into 
 the small pelvis, or cavity. 
 
 § 1. The Great or Abdominal Pelvis. 
 The abdominal pelvis having a large excavation in front, which 
 is closed up by the inferior part of the anterior abdominal walls, is 
 destined to contain the product of conception during the latter pe- 
 riod of its development ; it is bounded laterally by the iliac fossae ; 
 posteriorly, by the last two lumbar vertebrae. A circular line, call- 
 ed the superior strait, separates it from the small pelvis; this latter, 
 in an obstetric point of view, is the only part of the pelvis which 
 embodies any interest for the accoucheur, for it is through this por- 
 
 * The sacro-coccygeal articulation is sometimes the cause of serious difficulty in delivery. 
 The complete anchylosis of this joint is, I think, comparatively rare ; for if it be examined 
 after death in women before the fiftieth year of age, it will be found merely rigid, and not an- 
 chylosed. Females who marry late in life, and who, consequently, labour under more or less 
 rigidity of this articulation, as also of the external genitals, are frequently exposed to the 
 most alarming danger, and if great care be not taken by the accoucheur, fatal consequences 
 will certainly ensue to the child. Let us suppose, for example, that a woman has attained 
 her thirtieth year before she marries : the parts not having been previously called upon to 
 yield, are necessarily more or less resisting. But it must be remembered that in these 
 cases, as a general rule, there is no difficulty experienced until the head has descended to 
 the inferior strait. Now, in consequence of the rigidity of the coccyx, the unyielding 
 character of the perineum and vulva, no progress is made in the delivery, notwithstanding 
 the strong and continued expulsive effort of the uterus. The head and soft parts are pressed 
 upon— the accoucheur, finding that the head is at the inferior strait, and that the uterus 
 contracts with great force, believes that the labour will soon be terminated ; he encourages 
 the woman, and assures the attendants that the delivery will be speedily ended. Several 
 hours pass, and there is no progress ; the head is so pressed upon that the scalp becomes cor- 
 rugated ; there is engendered in the vagina excessive heat, and everything indicates severe 
 and dangerous pressure on the head, giving just ground of apprehension that congestion of 
 the brain may ensue. But this is not all : in consequence of the continued pressure on the 
 soft parts of the mother, there is danger of inflammation resulting in sloughing, thus produ- 
 cing either a recto-vaginal or vesico-vaginal fistula. Timely and judicious interference in 
 this case will protect the mother, and save the child ; whereas delay, or an unreasonable dé- 
 pendance on nature, will as certainly lead to the destruction of the latter, and seriously com- 
 promise the comfort of the former. As soon as it is discovered that, in consequence of the 
 rigidity of the soft parts and the unyielding nature of the sacro-coccygeal articulation, the 
 farther progress of the delivery is arrested, and that the whole expulsive power of the womb 
 is expended on the head of the infant without in any way accelerating the delivery, I would 
 recommend to proceed at once to artificial delivery by the application of the forceps. It 
 will, however, frequently be advisable to premise blood-letting, which sometimes has the hap- 
 piest effects in relaxing'the rigidity of the soft parts. Delay is certain to produce the death 
 of the child. Act, therefore, promptly, but not rashly. In another part of this work I shall 
 mention the details of a case which elucidate fully the necessity of this precept.— Ed. 
 
6 
 
 PELVIS. 
 
 tion of the narrow canal that the fœtus is to pass, when the phenom- 
 ena of labour commence. 
 
 § 2. The Supeî'ior Strait. 
 
 The superior strait, the form of which has been compared to 
 the heart of a playing card, presents certain dimensions or diameters, 
 a plane and an axis, all of which should be clearly understood. Its 
 plane is directed from behind forward, and from above downward. 
 This direction is much more marked in the child and female than 
 in the adult and male. In infants just born it is such that the plane 
 of the superior strait is parallel to the axis of the body. The di- 
 rection of this plane, too, varies considerably in the standing position. 
 M. Nsegele thinks that the angle which the plane forms with a 
 horizontal line is from 55 to 60°. 
 
 The diameters of this strait are four in number : 
 
 (Piff- 2.) 
 
 The antero-posterior (A B) diameter, which extends from the sa- 
 cro-vertebral prominence to the summit of the symphysis pubis, 
 measures four inches ; the two oblique diameters (C D, E F), which 
 extend from the sacro-iliac symphyses to the ileo-pectineal eminence 
 of the opposite side, measure four inches and a half; the bis-iliac 
 or transverse diameter (G F), which extends from the lower border 
 of the two iliac fossse, measures five inches. But it will be seen 
 hereafter that these diameters are modified by the soft parts, which 
 are found to line the pelvis. 
 
 § 3. Cavity, or Small Pelvis. 
 
 The pelvic cavity is situated between the superior and inferior 
 straits ; it is nearly cylindrical in form, becomes larger at its mid- 
 dle part, and is curved in front. 
 
 This cavity is divided into four regions : 
 
 The anterior region is concave transversely, and presents in its 
 middle the posterior part of the articulation of the pubes ; on the 
 right and left there is a flat surface, and we also observe the inter- 
 nal orifice of the sub-pubic opening, through which pass the ex- 
 ternal obturator vessels and nerves, the compression of which du- 
 
PELVIS. 7 
 
 ring the transmission of the fœtal head frequently occasions cramps 
 along the internal muscles of the thigh. 
 
 The posterior region, concave from above downward, is com- 
 posed of the anterior surface of the sacrum and coccyx. 
 
 The lateral regions are divided into two portions : one is solid, 
 and is formed by the posterior part of the colytoid cavity and the 
 body of the ischiatic tuberosity ; the other, flexible, is composed of 
 the sacro-sciatic ligaments, which convert the ischiatic notches into 
 foramina. 
 
 The inclined planes of the pelvic cavity have occupied a great 
 deal of attention, and, until recently, they have been regarded as the 
 cause of the movement of rotation, which the fœtal head undergoes 
 in passing through the pelvis. Two of these planes, formed by the 
 anterior and lateral walls of the cavity, are charged, it is alleged, 
 with bringing the occiput in front, while the other two planes, com- 
 posed of the posterior and lateral walls of this canal, direct the oc- 
 ciput backward, as will be seen in the article on Spontaneous De- 
 livery. This rotation is performed almost always below the sphere 
 of action of these planes, when the perineum begins to distend, 
 and frequently, also, in a direction inverse of that which should be 
 imparted to it by these planes. The resistance of the soft parts is, 
 according to M. Dubois, the sole cause of this rotation. 
 
 (Fig. 3.) 
 
 All the diameters of the cavity measure about four inches and a 
 half. In front, the depth of the cavity is one inch and a half ; on the 
 sides, three inches and a half; and posteriorly, about four inches, 
 if a straight line be drawn from the sacro-vertebral prominence to 
 the summit of the coccyx ; five inches and three lines, if the curva- 
 ture of the sacrum be followed. 
 
 § 4. The Inferior Strait. 
 The inferior strait, or inferior opening of the pelvic cavity, is 
 very irregular in its form ; it is composed of three open angles — 
 the pubic arch, and the two ischiatic notches ; and of three promi- 
 nent angles — the two tuberosities of the ischium, and the coccyx. 
 However, throwing out of view the coccyx, which is pushed back- 
 ward during labour, this strait forms a perfect ovoid, elongated 
 
8 CHANGES IN THE STRUCTURE OF THE PELVIS. 
 
 from before backward. The plane of this strait is, according to 
 M. Velpeau, at the moment of accouchement, on account of the re- 
 gression of the coccyx, oblique from below upward, and from be- 
 hind forward. 
 
 The diameters of this strait are also four in number: 
 
 
 The antero-posterior (I K), which extends from the point of the 
 coccyx to the inferior portion of the symphysis pubis, measures four 
 inches, but, owing to the repulsion of the coccyx, this diameter is 
 increased several lines during parturition. The two oblique di- 
 ameters (N O, P Q), which extend from the union of the descend- 
 ing branch of the pubes and ascending branch of the ischium to 
 the middle of the great sacro-sciatic ligament, measure four inches, 
 and may acquire a few lines in addition, in consequence of the 
 partial yielding of the sacro-sciatic ligament during the passage of 
 the child's head. 
 
 The transverse, or bis-ischiatic diameter (M L), extending from 
 the tuberosity of the ischium to that of the other, measures four 
 inches ; this diameter is not increased, unless we admit the relaxa- 
 tion of the symphyses as necessary to parturition. 
 
 Art. IV. — Changes in the Structure of the Pelvis occasion- 
 ed by the Soft Parts. 
 
 It is especially in this point of view that it becomes indispensa- 
 ble to study the pelvis as a whole. The presence of the soft parts 
 modifies the configuration and dimensions of the straits of the pel- 
 vis, and renders the curvature of this canal much more marked. 
 
 At the superior strait, the psoas (1) and iliacus internus mus- 
 cles (2), together with the internal iliac arteries and veins, form on 
 each side a soft border, on which the uterus rests ; and this bor- 
 der protects the crural nerves against undue pressure. This re- 
 sult, however, is not always obtained, for some women, during the 
 latter period of pregnancy, are much troubled with cramps and 
 numbness in the inferior extremities. 
 
 The muscles and vessels on the sides, a slight layer of cellular 
 tissue posteriorly, the bladder in front, and the thickness of the 
 
PELVIS. 
 
 uterine walls, all tend to curtail somewhat the diameters of this 
 strait. 
 
 Thus, the antero-posterior diameter is a little less than four inch- 
 es, and the oblique less than four inches and a half. They lose but 
 little, it is true, at the anterior part ; while the psoas muscles pos- 
 teriorly diminish them more, though these muscles themselves are 
 slightly pushed aside at the time the head is passing through the 
 pelvis. 
 
 But of all the diameters, the transverse is the one which is the 
 most changed ; it is curtailed at both extremities ; thus, instead of 
 five inches, it is reduced to four inches. However, if the lower 
 extremities are well flexed at the time of accouchement, the psoas 
 muscles will be in a state of relaxation, and this diameter, conse- 
 quently, would be less diminished. 
 
 The cavity is also modified in its form and extent by the internal 
 obturator and pyramidal muscles, the rectum, the posterior portion 
 of the urethra, and a layer of cellular tissue sometimes quite abun- 
 dant, so that its diameters measure, instead of four inches and a 
 half, only four inches and a quarter. 
 
 The inferior or perineal strait undergoes very slight alteration. 
 The bis-ischiatic diameter preserves its dimensions of four inches ; 
 the antero-posterior loses very trifling! y by the soft parts under the 
 pubic arch. The same thing obtains with regard to the oblique 
 diameters ; but this strait, more than any other part, is modified in 
 its form by the floor of the pelvis. 
 
 (Fig. 5.) 
 
 § 1 . Floor of the Pelvis. 
 It is of great importance to the accoucheur to understand thor- 
 oughly what is meant by the floor of the pelvis ; for it is almost 
 always on this part that the different movements of the foetus are 
 executed ; and on its greater or less suppleness and extensibility 
 will very materially depend the rapid or protracted expulsion of 
 the child. Situated at the most inferior portion of the perineal 
 strait, it is composed of the levator-ani and ischio-coccygeal mus- 
 cles, which constitute the superior plane, and which is concave 
 
 R 
 
10 
 
 CHANGES IN THE STRUCTURE OF THE PELVIS. 
 
 above ; the sphincter-ani, transversalis perinei, ischio-cavernosus, 
 and sphincter vulvae muscles, and the aponeuroses, which are 
 less resisting in the female than in the male, compose the inferior 
 plane. The pubic vessels and nerves, a thin layer of cellular 
 tissue together with the integuments, complete this floor. The 
 space included between the anterior part of the floor (the ante- 
 rior commissure of the perineum) and the lower portion of the 
 symphysis pubis constitutes the vulva. The anterior wall of the 
 cavity remains, therefore, the same, while the posterior wall is in- 
 creased by the entire length of the perineum. Thus the pelvis rep- 
 resents a crooked canal with two openings, the superior strait and 
 vulva, the planes of which are nearly perpendicular. The curva- 
 ture of this canal, the resistance of the perineum and vulva, are so 
 many obstacles which nature opposes in the female to the too rap- 
 id delivery of the foetus ; a wise precaution, without which both 
 mother and child would be exposed to serious evils, such as the 
 falling of the foetus upon the ground, inversion of the womb, inertia 
 of this organ, and, consequently, hemorrhage. In early childhood, 
 and in the Africans and Boch.smans, the curvature of the canal is 
 much less marked ; and this diminution of curvature is more sen- 
 sible as we leave the human subject and descend in the animal 
 scale ; so that it may be truly affirmed that the facility of parturi- 
 tion is in a direct ratio with the simplicity of organization. 
 
 § 2. Axes of the Pelvis. 
 
 Now that we understand the structure of the pelvis in its whole, 
 it is proper that we should study the direction which the foetus pur- 
 sues in passing through this crooked canal ; that is, the direction of 
 the different axes of the two straits. They are three in number : 
 the axis of the superior strait, inferior strait, and vulva. 
 
 The axis of the superior strait (A) is a line pursued by the foetus 
 in descending, and which is supposed to proceed from the umbil- 
 icus to the sacro-coccygeal articulation, passing through the centre 
 of the superior strait. 
 
 (Fig. 6.) 
 
 The axis of the inferior strait (B) passes from the sacro-verte- 
 bral prominence through the inferior strait. 
 
ORGANS OF GENERATION. 
 
 11 
 
 Finally, the axis of the vulva (C) passes through the centre of this 
 orifice, and extends to the middle portion of the sacrum. These 
 axes, considered in their aggregate, represent a curved line (A C), 
 which the fœtus pursues in its expulsion. This line also indicates 
 the direction to be given to the hand of the accoucheur, when in- 
 troduced into the maternal organs with a view to reach the fœtus. 
 
 CHAPTER II. 
 
 ORGANS OF GENERATION. 
 
 The genital apparatus of the female is composed of organs pla- 
 ced in the interior of the pelvis ; such as the ovaries, fallopian tubes, 
 uterus, and vagina ; and of organs situated externally, the mons 
 veneris, vulva, and perineum. 
 
 (Fig. 7.) 
 
 Art. I. — Ovaries. 
 The ovaries (I I), both in the organic and functional scale, repre- 
 sent the testicles of the male. They are two in number, situated 
 on each side of the uterus, in the posterior wing of the broad liga- 
 ments, near the fallopian tube ; they possess an ovoid form of the 
 thickness of the finger, and become more developed at the period 
 of puberty, and at the approach of the menses. They acquire a 
 considerable size during pregnancy, and preserve it for a long 
 time after delivery ; and, finally, become quite small in old age. 
 They are covered almost entirely by the peritoneum, except at 
 their inferior part, where they receive their vessels. They are 
 composed of a fibrous shell, which is an expansion of the utero- 
 ovarian ligament, and in which are distinguished interior filaments, 
 a peculiar dense, fibrous tissue, of a reddish white, and from fif- 
 teen to twenty transparent vesicles, filled with a clear liquid, some- 
 times red or yellow, called the ova of Graaf, and which, accord- 
 ing to certain authors, are nothing more than small cysts, the use 
 of which is unknown. On the surface of the ovary, on the con- 
 trary, are observed veritable tubercles, of a yellowish brown, and 
 
12 
 
 OVARIES. 
 
 possessing a firm consistence, called corpora lutea; they are exca- 
 vated on their surface. These tubercles present a small cicatrix, 
 which is evidently occasioned by the separation of a fecundated 
 ovum. M. P. Dubois has frequently exhibited these corpora lutea 
 to his class, and in some instances, before cicatrization had taken 
 place, a species of cell was seen, in which the ovule had undoubt- 
 edly been contained. 
 
 (Fig. 8.) 
 Entire Ovary. 
 
 (Fig. 9.) 
 Ovary laid open. 
 
 The first of these ovaries exhibits on its surface small ovules 
 ready to burst ; the second, which is laid open, represents the in- 
 ter or of the cell, and the opening through which the ovule has 
 escaped. Care must be taken not to confound the corpus luteum 
 with a peculiar disposition, similar in appearance, and which is 
 sometimes met with in women who die during the menstrual pe- 
 riod. 
 
 Art. II. — Fallopian Tubes. 
 The uterine or fallopian tubes, of the size of a goose-quill, four 
 inches in length, and situated in the thickness of the broad liga- 
 ments, are two channels which communicate with the cavity of 
 the uterus, and pass off from the angles of this organ, and open into 
 the peritoneum, where their fimbriated extremity floats free. Their 
 internal cavity is narrow, especially at the lower part ; their struc- 
 ture is simple. Externally, it is composed of a semi-muscular tis- 
 sue ; internally, it has a mucous coat, which, different in this re- 
 spect from all other mucous surfaces, is continuous with a serous 
 lin ng, the peritoneum. The use of the tube is to apply itself upon 
 the surface of the ovary, by means of its fimbriated extremity, du- 
 ring fecundation ; thus serving as a channel of transmission for the 
 fecundating principle to the ovary, and for the fecundated ovum to 
 the uterus. 
 
 Art. III. — The Uterus. 
 
 The uterus or matrix is the receiving organ, in which the fecun- 
 dated ovum is developed from the moment it is deposited by the 
 tube until its final expulsion. 
 
 The uterus (1) in a state of vacuity is situated in the pelvis, on 
 the median line, between the bladder (2) and rectum (3), and be- 
 
ORGANS OF GENERATION. 
 
 13 
 
 low the intestines ; it is above the vagina, and is sustained on ei- 
 ther side by the broad ligaments. Its dimensions after puberty 
 are, for its vertical diameter, from two and a half to three inches ; 
 the transverse diameter at the fundus from fifteen to eighteen lines, 
 and at the neck seven lines. It measures about six lines in thick- 
 ness, while its walls do not measure more than three lines. It is 
 of a firm consistence, and its direction is parallel to the axis of the 
 superior strait. 
 
 (Fig. 10.) 
 
 Viewed externally, the uterus is pyriform in shape, flattened 
 slightly from before backward, with its base above and its summit 
 below. Its largest portion is called the body, while the inferior 
 and narrowest portion receives the name of neck. 
 
 The external surface of the uterus presents, 1st. An anterior sur- 
 face, covered by the peritoneum in its two superior thirds, and which 
 in its inferior third is in contact with the base of the bladder. 2d. 
 A posterior surface, covered in its whole extent by the peritoneum, 
 as may be seen in the diagram ; the posterior cul-de-sac of the peri- 
 toneum, which separates the uterus from the rectum, is deeper than 
 the anterior cul-de-sac, which is found between the uterus and up- 
 per portion of the bladder. 3d. A base covered by the peritone- 
 um. 4th. And, lastly, a summit, or cervix uteri. 
 
 § 1. Cervix Uteri. 
 
 The neck of the womb exhibits very remarkable differences in 
 the female, according as she may have borne children or not ; and 
 it is important to examine it in these two aspects. 
 
 In the woman who has never brought forth children, the vagi- 
 nal neck is pointed, somewhat enlarged at its middle portion, and 
 in length measures from an inch and a half to two inches ; in 
 thickness it is about eight lines, while in width it measures nine 
 lines. It is, as it were, constricted by a groove deeper posteriorly 
 than in front, formed by the mucous membrane of the vagina, 
 which is reflected on the neck at the point of junction between its 
 superior third with the two inferior thirds. The inferior portion 
 of the cervix, or 05 tincœ, is divided into two lips by a transverse 
 slit, which constitutes its external orifice. This slit, in the young 
 virgin, is scarcely perceptible (o). M. Ant. Dubois has compa- 
 
14 
 
 UTERUS. 
 
 red, very justly, the sensation imparted to the finger in touching it 
 to what is experienced in pressing against the extremity of the 
 nose. The anterior lip (I) is thicker and slightly more elongated 
 than the posterior ; and this elongation will be more sensible to the 
 touch as the fundus is more inclined forward ; the neck, in this 
 case, being directed backward, the anterior lip is lower down, and 
 appears much longer. This direction of the neck is, indeed, most 
 usually observed, the axis of the uterus being nearly parallel to the 
 axis of the superior strait, which terminates at the sacro-coccygeal 
 articulation. (See fig. 10.) 
 
 (Fig. 12.) 
 
 (Fig. 11.) 
 
 That portion of the cervix (see fig. 14) (Î) comprised between 
 the insertion of the vagina and the body of the uterus constitutes 
 about the third of the whole length of the neck ; its cavity is con- 
 tinuous below with the vaginal portion, and opens above into the 
 uterus, and is endowed with great power of retraction during preg- 
 nancy. This part is termed the internal orifice (o). 
 
 It is difficult to assign any exact form and dimensions to the cer- 
 vix uteri of a woman who has borne children ; often it. is a shape- 
 less and nipple-like body, which occupies the upper portion of the 
 vagina, with an orifice more or less large and irregular ; this body 
 is shorter in proportion to the number of children the female may 
 have brought forth. Sometimes it happens that the neck makes 
 but a very slight projection into the vagina, and the only evidence 
 of it which the accoucheur recognises are two tubercles situated 
 around the orifice, which occupies the summit of the vagina. The 
 inferior orifice is more or less open ; in general, the apex of the 
 finger can be introduced into it. The two commissures of this 
 transverse slit are more or less lacerated, especially the left. These 
 
 (Fig. 13.) 
 
 fissures, more or less numerous and more or less deep, are the 
 
 cic- 
 
ORGANS OF GENERATION. 
 
 15 
 
 atrices resulting from the lacerations made by the passage of the 
 foetus during labour ; they are most usually found on the left side, 
 where they are also deeper, in consequence of the greater frequen- 
 cy of the right obliquity of the uterus. The whole force of uterine 
 contraction is ordinarily directed from right to left and from above 
 downward ; the fœtus is expelled in the direction of the left com- 
 missure of the neck, which, consequently, is called upon to sustain 
 the force of these efforts. These fissures are very rarely observed 
 in the middle portion of the lips. I have, however, occasionally 
 remarked these cicatrices so numerous as entirely to encircle the 
 neck. 
 
 § 2. Cavity of the Uterus. 
 
 The cavity of the body of the uterus, viewed in front, presents 
 the form of a triangle flattened from before backward ; while 
 viewed in profile, it has the appearance of a fissure, in consequence 
 of the contiguity of its walls. It has three angles, two of which 
 are superior, in which are situated the orifices, scarcely visible, 
 however, of the fallopian tubes ; the other angle is inferior, called 
 the os internum (o), which is the point of communication between 
 this cavity and that of the cervix. The cavity of the cervix is 
 narrow and cylindrical, and presents a peculiar appearance, called 
 the arbor vitœ ; we also observe a number of follicles, the pretend- 
 ed ova of Naboth, but which, in reality, are nothing more than mu- 
 cous cryptas, obliterated at their orifice. This disposition is much 
 more manifest after accouchement. (See fig. 16.) 
 
 (Fig. 14.) 
 
 § 3. Structure of the Uterus. 
 The dissection of the uterus, from without inward, or in the order 
 of superposition, shows, 1st. A portion of the peritoneum, which en- 
 velops it almost entirely except in the inferior fourth of its anterior 
 surface, in its lateral borders, and in the vaginal portion of its neck. 
 On the sides, this membrane forms two duplications, the broad liga- 
 ments. The anterior and posterior folds of these ligaments, ap- 
 plied the one against the other, contain the uterine and ovarian 
 vessels and nerves, together with some muscular fasciculi. Their 
 superior border is divided into three folds or wings, containing the 
 
16 
 
 VAGINA. 
 
 round ligament, fallopian tube, and ovary. Posteriorly and in front 
 of the uterus there are likewise two small falciform duplications, 
 which Madame Boivin has termed the anterior and posterior liga- 
 ments of the womb. 2d. Beneath the peritoneum is the proper 
 tissue of the uterus ; it is grayish, dense, resisting, and crepitant un- 
 der the scalpel, especially at the neck ; in a state of vacuity it ex- 
 hibits a fibril appearance, and a muscular one during pregnancy. 
 It is, therefore, in women who have been recently delivered that 
 we should examine the proper tissue of the uterus ; for at that time 
 it can be distinguished without difficulty, and even the direction of 
 its muscular fibres recognised. We observe, 1st, in the body of the 
 organ a superfic.al layer composed of a vertical fasciculus extend- 
 ing upon the two surfaces ; then, descending and ascending oblique 
 fibres, directed towards the appendages of the uterus ; a deep- 
 seated layer, more marked, resulting from the union of the circular 
 fibres in the form of a cone, which are prolonged by the fallopian 
 tubes. At the neck, the muscular fibres are almost entirely cir- 
 cular. 
 
 The interior of the womb is lined by a mucous membrane, the 
 presence of which, it is true, cannot be demonstrated by the scalpel ; 
 but analogy, comparative anatomy, and its pathological condition, 
 necessarily force us to admit its existence. 
 
 (Fig. 15.) 
 
 (Fig. 16.) 
 
 The uterus receives the uterine arteries coming from the hypo- 
 gastric and ovarian arteries ; it supplies veins which, being de- 
 veloped in pregnancy, appear, when cut, like the hepatic veins in 
 transverse incisions of the liver ; that is, they present simply their 
 peculiar coat, and adhere to the tissue of the organ. The lym- 
 phatic vessels are abundant, especially on the surface. They go 
 to the pelvic and lumbar ganglia, and communicate with those of 
 the appendages. The nerves are supplied by the cauda equina 
 and the great sympathetic. 
 
 Art. IV. — The Vagina. 
 This canal is membranous in the whole of its extent ; it com- 
 mences at the junction of the superior third with the two inferior 
 thirds of the neck of the uterus, which it surrounds, forming a circu- 
 
ORGANS OF GENERATION. 17 
 
 lar groove, the depth of which is in a direct ratio with the promi- 
 nence of the neck itself. This groove, as I have said when speak- 
 ing of the neck, is deeper posteriorly than anteriorly. The largest 
 diameter of the vagina is at its superior part, and this is very re- 
 markable in women who have borne many children. The vagina 
 descends towards the vulva, having behind it the rectum, from 
 which it is separated in its superior fifth by the posterior cul-de- 
 sac of the peritoneum, while in the four inferior fifths its rela- 
 tions with the intestine are almost immediate ; and intervening 
 between the rectum and vagina is a layer of cellular tissue, which 
 M. Cruveilhier has named dartoid.* In front, and a little above, 
 is the bladder, which is united to the vagina by compact filament- 
 ous cellular tissue. This union is so intimate that, in the formation 
 of vesico-vaginal fistulse, urinary infiltration is never observed be- 
 tween the corresponding walls of these cavities. There is a great 
 difference in the length of the anterior and posterior wall of the 
 vagina, the posterior being one third longer. The direction of this 
 canal is the same as that of the axes of the inferior strait and vulva 
 combined. 
 
 The anterior extremity of the vagina is sensibly narrowed ; this 
 opening is generally provided with a mucous fold more or less 
 prominent, and of a semi-lunar form, sometimes constituting a spe- 
 cies of diaphragm, presenting superiorly an orifice, and sometimes 
 completely closing the pelvis so as to oppose the flow of the men- 
 ses. This fold or duplicature is called the hymen ; occasionally, 
 however, it is so small as scarcely to exhibit the slightest trace. It 
 has been pretended that after defloration, the remains of the hy- 
 men form the carunculse myrtiformes ; but M. Ph. Rigaud is con- 
 vinced that these carunculse do not result from the laceration of the 
 hymen, but that they are mucous folds existing constantly behind 
 this membrane. 
 
 Exteriorly, the vagina affords insertion at its lateral and superi r 
 portions to the broad ligaments. The internal surface does not 
 present any very determinate form in its ordinary state, for the sides 
 of the canal are in contact, except above, where the neck of the 
 uterus keeps them separated. The anterior wall is crowded down- 
 ward, and is seen at the vulva ; on it is observed a median line 
 much more prominent than on the posterior wall, and from each 
 side of which pass off transverse folds, more numerous and con- 
 spicuous as they approach the orifice of the vulva. 
 
 The mucous membrane, which lines the vagina, is of a reddish 
 or simply rosy colour, and is covered with a very distinct epithe- 
 lium ; this latter, however, does not extend farther than the lips 
 of the womb, for the mucous surface of this cavity is deprived of 
 the epithelium. 
 
 *»It would, perhaps, be more accurate to divide the posterior surface of the vagina into 
 five fifths ; the three middle fifths of which are in contact with the rectum, the superior fifth 
 is floating and covered by peritoneum, while the inferior fifth is separated from the rectum 
 by the interposition of the perineum. — Ed. 
 
 c 
 
18 VULVA. 
 
 • 
 
 Art. V. — The Vulva. 
 
 The vulva forms nearly a horizontal fissure, situated between the 
 thighs, and directed from before backward, somewhat oblique, how- 
 ever, from above downward. Above the vulva is the mons vene- 
 ris, which is composed of cellular tissue, fibrous filaments, and adi- 
 pose matter, and, at puberty, it is covered with hair. From the in- 
 ferior portion of the mons veneris there proceed two folds of integ- 
 ument, in the substance of which there is a layer of adipose and 
 cellular tissue, the internal surface of which is well supplied with 
 bloodvessels ; these folds constitute the labia majora. The labia 
 majora are thick, broad, and prominent at their anterior and middle 
 portion, become thinner posteriorly, and unite by a membranous 
 commissure of a crescent form, called the fourchette ; between this 
 latter and the hymen is a small concave space, termed the fossa 
 navicularis. 
 
 Between the labia majora are situated the labia minora or 
 nymphae, mucous duplications, bounding on either side a triangu- 
 lar surface, the vestibulum, of which we shall speak directly. 
 Broader at their central portion, they become smaller as they pro- 
 ceed, and lose themselves insensibly about the middle of the inter- 
 nal surface of the labia majora. In front, each of the nymphae bi- 
 furcates, the superior branch of the bifurcation passing over to that 
 of the opposite side in order to reflect on the clitoris, and furnish it 
 a sheath or prepuce incomplete inferior! y. The inferior branch of 
 the bifurcation joins its fellow and terminates at the inferior part of 
 the clitoris. In the substance of the nymphae there are numerous 
 sebaceous follicles, which secrete in abundance a thick, yellowish, 
 and odorous fluid.* 
 
 The vestibulum is that triangular space bounded laterally by the 
 nymphae, and placed above and in front of the orifice of the vagi- 
 na. At its superior or anterior angle is found the clitoris ; while 
 at its base or posterior angle, a little below the clitoris, there is a 
 small flat tubercle, on the median line, at which is observed the 
 outer opening of the female urethra. The urethra lies on the an- 
 terior wall of the vagina. It measures from an inch to an inch 
 and a half in length ; it is wide, conical, and very slightly curved ; 
 it occasionally is considerably dilated. Flamand cites an instance 
 in which he could introduce the finger, f 
 
 * Sebaceous Follicles. — These follicles, found so abundantly on the nymphae, secrete, in 
 certain morbid conditions of the system, and especially in women inattentive to personal 
 cleanliness, an acrid, irritating fluid. It is possible that, if sexual intercourse be had under 
 these circumstances, this fluid may produce in the urethra of tbe male an irritation which 
 will give rise to most of the symptoms of an ordinary urethritis or clap. I have on several 
 occasions been consulted in similar cases, and it requires all the tact and discretion of the 
 accoucheur to be well guarded in his opinion. If he were thoughtlessly to pronounce this 
 irritation a veritable clap, he might inflict a serious wound on the domestic happiness of his 
 patient, and entail unmerited disgrace on a family whom it was his duty to protect against 
 suspicion. In women of a cancerous or scrofulous diathesis the secretion from these folli- 
 cles is particularly irritating.— Ed. 
 
 t Female Urethra. — The student should be perfectly familiar with the position and direction 
 of the urethra, for it often becomes necessary to introduce the catheter, and J know of no 
 situation more embarrassing for a medical man to be placed in than to attempt this operation 
 
ORGANS OF GENERATION. 
 
 Art. VI. — Perineum. 
 
 The perineum is all that space comprised between the anus and 
 the inferior commissure of the vulva. Its length is from an inch 
 to an inch and a half; but it is very readily distended, and may, 
 during the passage of the head, be increased to three inches. 
 
 Art. VII. — Appendages of the Genital Apparatus of the 
 
 Female. 
 
 § 1. Mammary Glands. 
 
 The mammary glands are sub-cutaneous, possessing a large 
 quantity of adipose cellular tissue. A delicate light-red skin covers 
 them towards their centre, and forms the areola, which is sur- 
 mounted by an eminence more or less prominent, called the nipple. 
 Of a delicate red colour in youth, the areola becomes dark with 
 age, and during pregnancy. (See Diagnosis of Pregnancy.) 
 
 The structure of the mammae is composed of a glandular tissue, 
 under the form of a w T hitish, hard substance, lost in a cellulo-adi- 
 pose bed. The mammary glands are divided into granulations, 
 lobules, and lobes, and are separated by a cellular tissue, which is 
 nearly fibrous. These anatomical characters are particularly well 
 marked in women who may have died during lactation. 
 
 The mammae receive several arteries from the thoracic, superior 
 intercostal, and internal mammary arteries. The veins are deep- 
 seated and superficial, and accompany the arteries. 
 
 The lymphatic vessels of the mammae pass to the ganglia of the 
 axilla ; some of the vessels go to the infra-sternal and intercostal 
 ganglia. Among the nerves of the cervical region, there are some 
 which appear to distribute themselves especially upon the gland, 
 such, for example, as the branch of the thoracic and intercostals ; 
 others, such as the sub-clavicular branch of the superior cervical 
 plexus, supply the integuments. 
 
 § 2. Milk Tubes. 
 
 The milk tubes, like all glandular ducts, proceed from the gran- 
 ulations, and ramify after the manner of the veins, so that there are 
 
 and fail. There are but two things to be kept in view in the introduction of the catheter: 
 1st. To find the meatus urinarius, or outer opening of the urethra ; 2d. To remember how the 
 direction of ihe urethra may be modified by pregnancy, or any other condition of the system 
 causing distention of the uterus. 
 
 The rule which I recommend, it will be observed, is founded on the anatomical structure of 
 the parts ; and unless there should be malformation, it will always be an unerring guide for 
 the performance of this very common and important operation. There is no necessity for 
 uncovering the patient, and the catheter should be introduced without subjecting her to the 
 slightest exposure. The index finger of either hand is to be well lubricated with oil or some 
 mucilaginous substance ; and it should be carried to the superior commissure of the vulva, 
 or the point at which the labia majora commence. At this point will be found the clitoris ; 
 passing the finger immediately down from the clitoris the vestibulum will be felt, a small 
 triangular space, bounded on either side by the nymphae ; at the inferior boundary of the'ves- 
 tibulum is the meatus urinarius ; this point being attained, much of the difficulty will have 
 been overcome ; with the other hand the catheter is introduced, remembering, always, that 
 in proportion as the uterus ascends in pregnancy, the urethra becomes straighter or more 
 perpendicular. — Ed. 
 
20 CONCEPTION. 
 
 about fifteen trunks all uniting towards the nipple. At the base of 
 the nipple, and below the areola, they present a remarkable dilata- 
 tion in the form of a sinus ; then they assume their ordinary calibre, 
 agglomerate, and form the nipple, on the surface of which they open 
 by as many orifices. Their structure is cellulo-mucous, the cellu- 
 lar portion becoming almost dartoid on a level with the nipple. 
 
 PART SECOND. 
 TITLE I. 
 
 CONCEPTION. 
 
 At the period of puberty the ovule is already formed in the ovary 
 of the female. As soon as fecundation takes place, the vesicle 
 which contains it breaks, and the ovule is seized by the fallopian 
 tube ; it traverses this tube, and finally arrives in the uterus, push- 
 ing before it the membrana decidua, and there becomes developed, 
 being surrounded by the decidua, the relations of which to the 
 ovule are the same as the pleura to the lungs. 
 
 (Pig. 17.) 
 
 
 1. Uterine caduca. 3. Ovule. 
 
 2. Caduca reflexa. 4. Orifice of the fallopian tube, through 
 
 which the ovule has passed. 
 
 This is the only positive knowledge we possess with regard 
 to this interesting point. To endeavour to discover how the 
 ovule is fecundated, and in what way this fecundation results in 
 the formation of a new being, would be to attempt to penetrate a 
 mystery which the most ingenious theories have not been enabled 
 to clear up, and which will probably always remain impenetrable 
 to human observation. For more ample details which do not com- 
 port with a practical work, I refer the reader to authors who have 
 written more particularly on this subject.* 
 
 * Haller, Prévost and Dumas, Velpeau, Raspail, Dutrochet. 
 
NORMAL PREGNANCY. 21 
 
 TITLE IL 
 
 PREGNANCY. 
 
 Immediately after conception commences the development of 
 the fœtus, or pregnancy, which terminates by delivery 270 days or 
 nine months after impregnation. 
 
 Pregnancy is simple when the uterus contains one fœtus ; it is 
 compound when several foetuses are present ; and complicated when 
 a tumour is developed at the same time with the fœtus ; finally, 
 it is abnormal when the fœtus is developed without the uterine 
 cavity (extra-uterine pregnancy). 
 
 CHAPTER I. 
 
 NORMAL PREGNANCY. 
 
 Art. I. — Changes in the Uterus and Fœtus. — Diagnosis 
 of Pregnancy. 
 
 The numerous modifications which take place in the uterus and 
 fœtus, from the moment of impregnation until the full period of 
 utero-gestation, elicit in the economy numerous sympathies, which 
 are brought to the observation of the accoucheur by certain signs, 
 through the aid of which he is enabled to recognise the existence 
 of pregnancy. 
 
 Some of these modifications may be perceived in the uterus, and 
 constitute, by themselves, signs which lead to a correct diagnosis 
 of pregnancy, and even to its precise period. 
 
 Certain changes of the uterus are manifested only by their ef- 
 fects, veritable sympathetic reactions, such as darkening of the 
 areola, disturbance of the digestive and nervous systems, &c, the 
 anatomical character of which cannot be detected during life ; 
 while other changes may be directly appreciated during pregnan- 
 cy, and in the uterus itself, either mediately through the abdom- 
 inal walls, or immediately by the vaginal touch (changes in the 
 neck an* 4 Dody of the organ), &c. 
 
 It ; j the knowledge of these changes, and of the sympathies 
 which they determine in the economy, that constitutes the diag- 
 nosis of pregnancy. 
 
 But as it frequently, in a medico-legal sense, becomes important 
 to distinguish the age of premature ova, and also the exact period of 
 pregnancy after death, it will be necessary to accompany the study 
 of the changes of the uterus and fœtus, which can be ascertained di- 
 rectly, and which constitute the essential diagnosis of pregnancy, 
 with an investigation of those modifications which, manifesting them- 
 selves only by their effects, cannot be recognised except after the 
 
NORMAL PREGNANCY. 
 
 death of the female, or by an examination of the aborted ovum. 
 With this view, at each period of pregnancy, I will examine the 
 changes which characterize each period, whether they are appre- 
 ciable or not during life ; then I will pass to the diagnosis founded 
 on the sensible signs furnished by these changes. This course will 
 present a complete assemblage of facts, which will enable us to 
 follow, month after month, the evolution of the new being, and of 
 the organs destined to contain and expel it, and, at the same time, 
 to ascertain, by these evolutions, whether pregnancy exists, and 
 also its particular period. 
 
 § 1. Development of the Fœtus during the first three Months. 
 
 It is not until about the twelfth day of pregnancy that the em- 
 bryo can be distinctly seen; it then measures about three lines, 
 and the entire ovum about six to seven lines. At first pyriform in 
 shape, and curved forward, the superior extremity of the embryo 
 is free, while the inferior is united to the membranes. All the 
 parts which compose it are homogeneous, and a white filament, 
 which is scarcely distinguishable, designates the spinal marrow. 
 The mouth is the first organ of sense that is perceptible ; it is visi- 
 ble from the twelfth to the twentieth day ; frequently, too, at this 
 period, the eyes may be distinguished. 
 
 (Fig. 18.) (Fig. 19.) 
 
 Ovule opened, twelfth day. Ovule entire, natural size. 
 
 4- 
 
 ; 4§t% 
 
 1. Membrana decidua. 4. Embryo and amnios. 
 
 2. Membrana reflexa. 5. Umbilical vesicle. 
 
 3. Chorion and its villosities. 
 
 The decidua or epichorion is a secretion from the internal sur- 
 face of the uterus ; it is thick during the first periods of gestation, 
 and is formed of two distinct portions, one of which lines the ute- 
 rus, and has received the name of caduca vera ; the other, which 
 is united to the chorion, is called the caduca reflexa ; these two 
 surfaces of the caduca are separated by a space, which diminishes 
 as pregnancy advances. Authors differ in reference to the struc- 
 ture of this membrane. M. Velpeau considers it an unorganized 
 membrane, and has given it the name of anhiste. 
 
 The vhorion, for the first fifteen days, is very villous on its ex- 
 ternal surface ; these villosities appear to be spongy. 
 
 The amnios is a translucent, thin membrane at this period, and 
 is separated from the chorion by the umbilical vesicle. It con- 
 
NORMAL PREGNANCY. 23 
 
 tains a transparent fluid, which is furnished by the uterine capil- 
 lary vessels ; this fluid penetrates the interior of the amnios by trans- 
 udation. 
 
 The umbilical vesicle has the form of an ovoid, slightly flattened^ 
 and which, perhaps, precedes in existence the embryo, to the ab- 
 domen of which it is united. Its use seems to be to nourish the em- 
 bryo during its first evolution, for at that time there is no umbil- 
 ical cord. 
 
 From fifteen to twenty days, the embryo measures from five to 
 six lines in length. At one month, it is eight to ten lines long. 
 At this period, the extremities appear under the form of small tu. 
 bercles, which elongate, flatten, and progressively enlarge. Before 
 the thirtieth day, the umbilical cord does not exist, the fœtus be- 
 ing in immediate contact with the membranes. But at one month, 
 the cord is visible, and this fact I have verified in numerous instan- 
 ces. It is about one third the length of the fœtus, and is contin-. 
 uous with the prolongation of the umbilical vesicle (1) ; this pro- 
 longation measures from two to three lines, and, after the end of 
 the first month, loses itself in the cord. There is a slight projec- 
 tion behind the insertion of the umbilical cord, the base of which 
 encloses the intestine. At thirty days, we can often distinguish the 
 openings of the nose. The ear is also quite manifest at this period, 
 as are likewise the eyes ; but there is no trace of the genital organs. 
 
 (Fig. 20.) 
 Embryo of one Month, natural size. 
 
 At two months, the embryo measures eighteen lines ; the trunk 
 becomes as large, and even larger than the head. Two round, 
 black points designate the eyes, and a small transverse slit points 
 out the mouth, above which are observed two small black points, 
 the nostrils. 
 
 (Fig. 31.) 
 
 Although the genital organs are now visible, it is, however, diffi- 
 cult to distinguish the sex, the clitoris and penis having an identical 
 
24 NORMAL PREGNANCY. 
 
 development. The extremities and fingers elongate, the clavicles, 
 ribs, and maxillary bones present ossifie points, all the other bones 
 being yet in a cartilaginous state. The cord increases in thick- 
 ness, and the placenta, the first traces of which are not observed 
 until the sixth week, becomes more and more compact, and from 
 this period it ceases to increase in a proportional ratio to the foetus 
 and uterus. The amniotic fluid, until now small in quantity, un- 
 dergoes a sensible increase. 
 
 § 2. Changes in the Uterus. 
 
 After the ovule has reached the uterine cavity, the womb begins 
 gradually to develop itself until the full period of gestation ; but, be- 
 fore the third month, the changes which the uterus has undergone 
 are not immediately appreciable except after death. 
 
 Diagnosis of Pregnancy. — The different characteristic symp- 
 toms of pregnancy are far from possessing the same degree of value. 
 Their importance varies, in general, according to the period of ges- 
 tation at which we seek to recognise them. M. P. Dubois has, 
 therefore, divided them into the presumptive, probable, and certain 
 signs of pregnancy. 
 
 But it must be remembered that this division is not always rigor- 
 ously correct ; for one of the presumptive signs, under peculiar 
 circumstances, may constitute a probability ; and, for the same 
 reason, a probable sign may amount to a certainty : this, however, 
 will be more particularly demonstrated in the sequel. 
 
 Before the third month, neither the changes of the uterus, nor 
 those of the embryo, can be directly appreciated in the living 
 woman. The only mode of distinguishing them is through the 
 numerous sympathies which the womb exerts on the rest of the 
 economy ; thus, at this time, we have nothing but the presumptive 
 signs to guide us. 
 
 However, certain authors have imagined that the neck of the 
 uterus becomes somewhat more pointed from the first month ; 
 that its orifice presents a circular form, and that the inferior por- 
 tion of the uterus, especially that part in contact with the bladder, 
 is softer and more prominent. But it is so common to meet with 
 these characters in women who are not pregnant, that, unless a dif- 
 ferent disposition should have been previously ascertained, we .can- 
 not, with propriety, hazard an opinion on such equivocal evidence. 
 
 § 1. Presumptive Signs. 
 Among the presumptive signs, some, such as horripilations, colic, 
 and syncope, follow immediately after conception ; others, on the 
 contrary, manifest themselves by degrees, either after or before 
 the suppression of the menses, and at variable periods ; it is thus 
 impossible to classify them, like the others, from month to month, 
 according to the time of their appearance. During the first three 
 months, however, the eyes become sunken, lose their vivacity and 
 brilliancy, and are surrounded by a blue circle ; the features be- 
 come sharp, the face is pale and covered with reddish spots, and 
 sometimes with morohew ; the neck increases in thickness. 
 
NORMAL PREGNANCY. 25 
 
 Suppression of the Menses. — The suppression of the menses is 
 the most valuable of all the presumptive signs. However, there 
 are many circumstances foreign from conception, which may cause 
 this phenomenon; thus suppression alone will not enable us to say 
 that pregnancy exists. Farther, although suppression of the men- 
 ses almost always accompanies pregnancy, yet the flow of the 
 menses may continue during the first month, and sometimes even 
 during the whole period of gestation ; and thus the accoucheur be 
 led to suppose that pregnancy does not exist. But the contin- 
 uance of menstruation during gestation is a very rare circum- 
 stance, and if the suppression of this function only establish a pre- 
 sumption in favour of pregnancy, its continuance renders it almost 
 certain that the female is not pregnant. This opinion I have fre- 
 quently heard advanced by M. P. Dubois, and M. Moreau like- 
 wise concurs in it. This latter professor even maintains that the 
 sanguineous discharges which he has observed during pregnancy 
 possess none of the characters of menstrual blood, either as to 
 quantity, consistence, colour, or periods of recurrence ; and he 
 also remarks, that he has experienced no difficulty in distinguish- 
 ing them from the menses. These characters are, however, so 
 equivocal, that it appears to me very difficult to distinguish the 
 menstrual evacuation from the discharges capable of simulating it. 
 
 Finally, this sign loses all its value in women who are subject to 
 irregularities in their menstrual periods ; in such, for example, as 
 have ceased to menstruate, either in consequence of disease or the 
 progress of age, or who are giving suck, and especially in those 
 who have become pregnant without ever having menstruated. 
 De venter and Baudelocque cite cases of women who menstruated 
 only during pregnancy.* 
 
 * The opinion advanced by MM. Dubois and Moreau, that the continuance of the men- 
 ses renders it almost certain that pregnancy does not exist, must be received with due cau- 
 tion. It is entirely too general, and it would be unsafe to let it pass without qualification. 
 I think facts have shown that women do sometimes menstruate, not only during the first 
 month, but during the entire period of their pregnancy ; and if experience be appealed to, 
 it will be found that such cases are, at least, not so rare as not to form important exceptions 
 to so sweeping a declaration. I have attended a lady in three confinements, who has men- 
 struated regularly for the entire period of all her pregnancies ; and she is not aware of her 
 being pregnant until she feels the movements of the foetus, which have invariably become 
 manifest at the fourth month. This lady was subsequently under the care of Professor 
 Warren, of Boston. 
 
 About three years since I was requested by a physician of this city to visit his wife in 
 consultation with Dr. Freeman. The lady in question was the mother of two children. For 
 a year previous to my seeing her, she had begun to decline in health, and there had been a 
 gradual enlargement of the abdomen. Her menstrual evacuation had never been inter- 
 rupted since the weaning of her last child, but occurred with great regularity at its ac- 
 customed periods. She was somewhat emaciated, and I found that about four weeks be- 
 fore my visit, pus had commenced discharging through her rectum, which continued, in 
 greater or less quantity, up to the time that I saw her. The opinion which Dr. Freeman 
 had formed was, that this was a case of ovarian disease, with purulent secretion in the sub- 
 stance of the ovary. This opinion I fully concurred in ; and after an attentive examination 
 both per vaginam and per rectum, I discovered that the uterus itself was also enlarged so 
 as to extend about three fingers' breadth above the symphysis pubis. By placing my finger 
 on the posterior surface of the neck of the womb, and gently raising it, I distinctly discov- 
 ered the motion of a fœtus. This fact I communicated to Dr. F., and also to the husband ; 
 I pronounced the lady pregnant, and, at the same time, to be labouring under ovarian en- 
 largement. Dr. Freeman being the family physician, delivered her, about five months after 
 this, of a child. Here, then, was a case of pregnancy, without any interruption in the men- 
 strual periods. I am at this time attending a lady from Mobile, who has been under my 
 care for the last eighteen months. She, too, is affected with ovarian disease, and has never 
 
 D 
 
26 NORMAL PREGNANCY. 
 
 A. Disturbance of the Digestive Functions. — The taste becomes 
 perverted; digestion is more laborious; nausea and vomiting su- 
 pervene, and are followed by complete loss of appetite. It is now 
 that those depraved tastes manifest themselves, known as longings, 
 which sometimes are for the most delicious articles of diet, sp.rit- 
 uous liquors in large quantity, and sometimes for unnatural obj cts, 
 such as charcoal, earth, chalk, unclean animals, &c, &c. But 
 after the first months, these depraved fancies are succeeded by a 
 good appetite, sometimes even voracious, and by easy digestion, 
 wh.ch, however, becomes incommoded at the latter period of preg- 
 nancy, in consequence of the oppression produced upon the stom- 
 ach by the increased growth of the womb. 
 
 B. Disturbance of the Nervous System. — The functions of the mind 
 are also occas'onally subject to almost incredible changes. Some 
 females become misanthropic and unsocial during pregnancy; 
 some, of the most gentle and amiable deposition, are led on by an 
 invincible influence to the commission of the most atrocious crimes ; 
 others, again, whose passions do not acquire this degree of vio- 
 lence, become sad and melancholy, and hate those whom they had 
 most loved previous to their pregnancy. Some, indeed, of a mo- 
 rose temper when not pregnant, exhibit the most remarkable gen- 
 tleness of character as soon as pregnancy commences. 
 
 C. Changes effected in the Breasts. — S welling, tension, painful sen- 
 sation, brown colour and elevation of the areola, erection of the 
 nipple, the presence of papillary tubercles, and the secretion of 
 milk, are among the signs of value. 
 
 The tumefaction, pain, and tension are sometimes, however, 
 present without pregnancy; the first conjugal approaches, reten- 
 tion of the menses, the period of their return, a chronic metritis, 
 may determine this condition of the breasts. Gardien has also re- 
 marked that, when the menses continue during pregnancy, this 
 reaction towards the mammae is very slight. 
 
 The coloration and elevation of the areola are, according to 
 some authors, important signs, the more so, indeed, because they 
 exist dur ng the first months, when the diagnosis is necessarily 
 very obscure. The coloration depends upon a deposite of pig- 
 mentum in the mucous portion of the skin (fig. 22). 
 
 Hunter, who regarded this darkening of the areola as conclu- 
 sive, maintained, in the presence of his pupils, that a young girl, 
 in whom the hymen existed, was nevertheless pregnant, simply be- 
 cause there was change of colour in the areola ; on making a post 
 mortem examination, it was found that she was, in fact, four months 
 
 suffered from menstrual irregularity. About six months since, she thought her size was in- 
 creasing rapidly, and complained of great inconvenience. On instituting a vaginal exam- 
 ination, I discovered that the uterus was considerably developed, but could not recognise 
 any active motion of the fœtus, nor, after several attempts, could I succeed in detecting any 
 evidence of pregnancy by the ballottement. The stethoscope, however, enabled me to hear 
 the pulsations of the fœtal heart, and much to the happiness of the lady, I pronounced her 
 pregnant. On the 20th of August of the present year, 1 delivered her of a healthy boy. Here, 
 again, was a case of pregnancy, and no interruption of the menses. Could the diseased 
 ovaries, in these two cases, have had any influence in continuing the menstrual flow during 
 gestation 1 I think it probable. Dr Denman, I conceive, has done much injury by his 
 broad and unequivocal denial that a pregnant female can menstruate. Many of the admi- 
 rers of this excellent writer have, I fear, too hastily adopted his opinion. — Ed. 
 
NORMAL PREGNANCY. 
 (Fig. 22.) 
 
 27 
 
 in gestation. The colour varies from a clear lustre to a very dark 
 hue. I have had drawings made at La Clinique from women who 
 presented this latter tint, and the colour is more manifest as preg- 
 nancy is farther advanced. The elevation of the areola above the 
 level of the integument (see fig. 23) almost always accompanies 
 the change of colour. 
 
 (Fig. 23.) 
 
 It is the same with the erection of the nipple, which enlarges 
 and becomes darker, but. this sign does not appear until somewhat 
 later, from the fourth to the fifth month. About the same period 
 there also appear on the areola small papillary tubercles, more or 
 less numerous, which are species of small glands, having an excre- 
 tory duct, from which by pressure there will exude a sero-lactes- 
 cent fluid : this fact I have often observed. M. Montgomery, who 
 has given an excellent description of the signs furnished by the 
 breasts, which he has accompanied by graphic illustrations, attach- 
 es great importance to the development of these tubercles. This 
 sign he considers infallible ; but it is necessary to state that it, as 
 well as the preceding, is sometimes wanting when there is preg- 
 nancy ; or becomes developed without pregnancy, which, howev- 
 er, is more rare. It may be remarked, too, that these signs lose all 
 their value when the woman has previously borne children, for they 
 do not always become effaced after delivery, but continue for a 
 greater or less period, especially in women who nurse ; and if, un- 
 der these circumstances, the female again becomes pregnant, how 
 
2© NORMAL PREGNANCY. 
 
 are we to ascertain whether these changes are the result of the 
 present or preceding pregnancy ? But these are merely exceptions 
 to a general rule, and in a female not previously pregnant, this 
 darkening and elevation of the areola, the erection and coloration 
 of the nipple, the development of the papillary tubercles, are of 
 great importance ; and in this case, on seeing these characters 
 alone, I would decide that pregnancy existed. 
 
 The secretion of milk, as a sign of pregnancy, should also be con- 
 sidered, although other circumstances than pregnancy may produce 
 it ; such as puberty, the approach of the menses. &c, &c. Young 
 women have been known to give suck to children without ever hav- 
 ing been pregnant ; and we must distrust this sign in legal medicine, 
 where a woman who is nursing (but concealing this latter circum- 
 stance) might endeavour to simulate pregnancy, and present as an 
 evidence of her condition the fact that she had milk in her breasts. 
 
 M. Jacquemin regards the bluish colour assumed by the mucous 
 membrane of the vagina as a most significant sign, and I entirely 
 concur in opinion with him. His position as surgeon-in-chief at 
 La Force has enabled him to establish the fact that this change of 
 colour in the vagina is very seldom absent in pregnant women. 
 
 M. Beccaria attaches great weight as a sign to pain felt in the 
 occiput ; and M. Nauche thinks he can derive the most positive 
 evidence of pregnancy from an inspection of the urine : others, 
 again, contend that the state of the pulse is a sure indication. Nu- 
 merous experiments made at La Clinique have convinced me that 
 these conditions do not exist in most cases, or, at least, that it 
 is impossible to recognise them ; and as to the pulse, I have re- 
 marked only that it is harder and more developed, but I have never 
 been able to detect any other characteristic difference. 
 
 Lastly, we have the development of the abdomen, which may 
 be divided into two periods ; the first appertains to the presump- 
 tive signs, and is caused by a temporary flatulence, which ceases 
 towards the third month. At this period, the abdomen, which was 
 manifestly elevated, becomes so flattened as to induce the woman 
 to doubt whether she is pregnant. But soon, the uterus continuing 
 to rise, pushes before it the abdominal walls, and the abdomen 
 again begins to enlarge. This constitutes the second period, which 
 furnishes a number of important signs, and which must be classed 
 among the probable evidences. It also presents other signs, of 
 which I shall speak hereafter, such as the darkening of the linea 
 alba, transverse wrinkles of the integument of the abdomen, and 
 prominence of the umbilicus. 
 
 In fine, the presumptive signs, which have no great value when 
 isolated, acquire much more importance when observed united in 
 the same woman; this combination constitutes a probability. 
 However, we must be guarded against error even under these cir- 
 cumstances, for it is well known that the first conjugal embraces 
 may determine suppression of the menses, which, in this case, is al- 
 ways accompanied by reaction in the breasts, slight meteorism of 
 the* abdomen, and disturbance in the digestive functions, although 
 pregnancy does not exist. 
 
NORMAL PREGNANCY. 29 
 
 § 2. End of the third Month — Probable Signs. 
 
 I have just mentioned, in the preceding section, how the chan- 
 ges effected in the uterus, reacting on the entire economy, are made 
 apparent by means of signs, which have no certain value. It now 
 remains for me to show how the marked alterations which preg- 
 nancy determines in the uterus and neighbouring organs, after the 
 third month, constitute signs to which is attached a higher value, 
 and which are named the probable signs. These different signs 
 are perceived in the body and neck of the uterus ; the mode of in- 
 vestigation must, of course, vary. In the body we have recourse 
 to abdominal percussion and auscultation ; for the neck we employ 
 the vaginal touch. 
 
 It is by the aid of these different means that I shall now succes- 
 sively examine the changes in the uterus, in proportion as they 
 manifest themselves from month to month. I shall be careful, also, 
 to mention those which cannot be appreciated until after the death 
 of the woman, or the expulsion of the aborted ovum. 
 
 It is not until the end of the third month that we can assure our- 
 selves of the development of the uterus, but at this period we can- 
 not say that pregnancy exists. The uterus may be modified in its 
 form, consistence, and volume, and yet not contain a normal con- 
 ception. And these changes may then depend on the presence of 
 a mole, polypus, or on some morbid condition of the organ. It is 
 not, therefore, until a more advanced period of gestation that the 
 existence of pregnancy can be positively ascertained. The chan- 
 ges produced in the inferior portion of the womb are those which 
 can be soonest recognised, and this is done by means of the touch. 
 
 § 3. The Vaginal Touch. 
 
 The touch, or introduction of one or more fingers into the geni- 
 tal organs of the female, is performed with a view to ascertain the 
 condition of the external organs of generation, the conformation of 
 the pelvis, the changes in the inferior portion of the uterus and ad- 
 joining organs, and, finally, the nature of the uterine contents. 
 
 This operation is practised when the woman is either in the 
 standing or horizontal position ; standing, if, in consequence of a 
 lesion of the organs of respiration or circulation, she cannot take 
 the horizontal position ; and in this latter posture if she is debili- 
 tated, threatened with hemorrhage, or is labouring under a decided 
 ante-version of the uterus. In the latter case, the fundus of the 
 organ is thrown considerably forward, and it will be very difficult 
 to reach the neck, in consequence of its being high up and thrown 
 backward. Under these circumstances, it will be made more ac- 
 cessible to the finger by placing the fundus of the womb in its nat- 
 ural position. 
 
 Whether the female is in the erect or horizontal posture, it is im- 
 portant to have the abdominal muscles in a state of relaxation, by 
 causing the legs and thighs to be flexed. In the standing attitude 
 it will be useful to recommend the woman to throw the body back- 
 
80 NORMAL PREGNANCl. 
 
 ward, although this position, in rendering the muscles of the abdo- 
 men tense, destroys in part the effect obtained by the flexion of the 
 legs. I am, however, satisfied that in thus bringing the pelvis of 
 the woman forward by means of the other hand placed behind the 
 loins, the neck of the uterus can be more effectually brought to the 
 centre, and the facility of reaching it much increased. It is with 
 this view that, when the female is lying down, after having re- 
 quested her to flex her lower extremities, she is told to elevate the 
 pelvis, and, if necessary, she is sustained in this position by means 
 of a cushion or the hand placed under the lower part of the back. 
 
 Having taken these precautions, the index finger is lubricated 
 with some oleaginous substance, as well to render its introduction 
 easy, as to avoid the danger of contagion. It is extended and ap- 
 plied upon the perineum by its radial border; thence it ascends 
 gently towards the vulva, following the raphe of the perineum; 
 it passes the inferior commissure and penetrates the vagina, sep- 
 arating the labia and pursuing the axis of the vulva. In this 
 course, the accoucheur should examine the state of the perineum 
 and labia majora, the conformation of the pubic arch, the bladder, 
 the vaginal walls, and rectum ; then, in passing his finger in the 
 direction of the sacro-vertebral angle, he will be enabled to appre- 
 ciate the condition of the superior strait ; finally, he reaches the 
 vaginal neck, or os tineas. He will now ascertain its form, absolute 
 length, the relative length of its lips, its direction, consistence, and 
 regularity ; the degree of opening and uniformity of contour of its 
 orifice ; the weight of the entire organ, by slightly raising it ; its 
 height, by endeavouring to include the uterus between the finger 
 applied upon the neck and the hand placed upon the fundus, through 
 the hypogastric walls ; its development or its vacuity, by attempt- 
 ing to feel the body of the organ through the cul-de-sac of the va- 
 gina. It is by this same procedure that the condition of the neck 
 of the womb above the vagina may be ascertained. In fine, the 
 nature of the bodies contained in the uterus will be recognised by 
 the ballottement, a sensation which does not become manifest until 
 a more advanced period of pregnancy, and of which we have not 
 yet spoken. 
 
 In the examination of these various conditions, we must not lose 
 sight of the changes which previous accouchements may have pro- 
 duced in the organs ; and it is also necessary to consider the diag- 
 nos's in a woman who has had children, and in a primipara. 
 
 A. Development of the Fœtus. — At three months, the fœtus 
 measures three inches; its integuments are gelatinous, but easily 
 distinguished, and of a reddish white. The head is very large ; 
 the eyelids and mouth are closed ; the nose is very prominent ; the 
 fingers and toes are perfectly separated, and covered at their ex- 
 tremity by a reddish material which represents the nail ; the brain 
 is no longer fluid, and assumes a caseous consistence ; the spinal 
 marrow tills the length of the vertebral canal ; the coccygeal 
 prominence is effaced, and sometimes the umbilical vesicle has 
 disappeared. The umbilical cord still contains a portion of the in- 
 
NORMAL PREGNANCY. 31 
 
 testine, the omphalomesenteric vessels which pass from the vesi- 
 cle, and the two arteries and umbilical vein. The mass of amnio- 
 tic fluid at tLs period exceeds that of the fœtus. 
 
 B. Situation of the Uterus. — The uterus is contained in the cav- 
 ity of the pelvis ; its fundus does not extend above the pubes ; how- 
 ever, with one hand placed upon the hypogastric walls, especially 
 if the neck is raised by the finger introduced into the vagina, it will 
 be easy to feel the fundus of the womb, which is thrown a little 
 backward and to the right; this viscus is softened in its whole ex- 
 tent, and particularly at its inferior part. Some authors have 
 thought that the os tineas is longer at this period than in the unim- 
 pregnated state, but such is not the fact. The descent of the en- 
 tire organ, which is determined by its weight and softness, has 
 given rise to the belief that the neck becomes lengthened. In fact, 
 if the neck be circumscribed by the index finger, it will be per- 
 ceived that the vagina is slightly shortened, that the extremity of 
 the finger is arrested by the cul-de-sac of the vagina, and that 
 above this cul-de-sac there is felt a resisting body, which is nothing 
 more than the inferior segment of the enlarged womb. And, more- 
 over, if the finger placed upon the neck attempts to elevate the 
 organ, its weight and immobility are immediately perceived. We 
 may also form an idea of the length of the uterus by including it 
 between the finger placed upon the neck and the hand applied to 
 the exterior of its fundus. 
 
 C. Length. — Measured on the cadaver, the length of the body of 
 the womb is three inches, and if be added to this for the length of 
 the neck twenty-two lines, we shall have for the vertical diameter 
 four inches and eight lines ; but, in consequence of the sinking 
 down of the uterus, this diameter is not more than four inches and 
 six lines. 
 
 D. Form. — The uterus, which, in its unimpregnated state, was 
 pyriform, flattened from before backward, now becomes somewhat 
 rounded. The anterior surface, a little more convex than the pos- 
 terior before conception, maintains this «same character during 
 pregnancy. 
 
 E. Thickness. — The thickness of the walls increases slightly in 
 consequence of the development of the muscular and vascular tis- 
 sues ; but it is difficult to recognise these changes at so early a pe- 
 riod of pregnancy. 
 
 The first changes in the body of the uterus are nearly the same 
 in a primipara as in subsequent pregnancies. But in a female who 
 has borne children, such is not the case with the changes produced 
 by pregnancy in the neck. 
 
 However, the primipara and female who has borne children 
 have some characters in common. The finger introduced into the 
 vagina discovers the vaginal portion of the neck low down, en- 
 larged, and softened at its base, while that portion of the neck 
 above the vagina is not yet changed. 
 
 In the primipara, the transverse orifice of the womb becomes 
 circular : it is regular in its contour, and closed ; the os tineas 
 
32 
 
 NORMAL PREGNANCY. 
 
 (Fig. 24.) 
 Primipara. 
 
 (Tig. 25.) 
 Female who has had children. 
 
 Reduced to one third its natural size. 
 
 is smooth and polished ; the two lips are nearly on the same level, 
 in consequence of the shortening of the anterior lip : this latter 
 sign is not very positive. The entire neck measures about two 
 inches. 
 
 In the female who has had children the orifice is likewise round- 
 ed, but it is irregular, and presents a number of cicatrices, especial- 
 ly on the left ; it is sometimes open, and will admit the extremity 
 of the finger. The neck is much larger than in the primipara ; 
 and it is also shorter, softer, and less smooth. 
 
 F. Difficulty of appreciating these Signs. — It is not always pos- 
 sible fully to recognise these different characters. Certain circum- 
 stances, such as a painful condition of the abdominal walls, tume- 
 faction of the labia majora and sensibility of the womb, will occa- 
 sionally render it impossible to detect these signs. And again, if, 
 in their absence, it is, at least in a majority of cases, possible to 
 deny the existence of pregnancy, yet we cannot always, when the 
 signs are present, positively affirm that pregnancy exists ; for at 
 this period of gestation, as has already been observed, ail that we 
 can do is to ascertain that the uterus is enlarged; but whether 
 this development depends upon the presence of a foetus or upon 
 an abnormal condition, is a point possible, it is true, to establish in 
 some instances ; while in others the whole matter rests in doubt 
 until additional symptoms render the diagnosis positive. 
 
 In fact, at the approach of the menstrual period in some women, 
 the uterus, in consequence of its congested condition, occasionally 
 becomes as large as in the third month of pregnancy, and we are 
 more liable to error, because in this case the neck is slightly soften- 
 ed and open. At other times, the menses retained in the cavity of 
 the uterus, in consequence of the closing of its internal orifice, dis- 
 tend, by their accumulation, the walls of this organ, and thus 
 give rise sympathetically to many of the presumptive signs, such as 
 tumefaction and pain in the breasts, disturbance in the digestive 
 functions, &c, &c. — circumstances which increase the chances of 
 error. 
 
 In vain will it be urged that in these cases it will be easy to dis- 
 
 
NORMAL PREGNANCY. 
 
 33 
 
 tinguish the physiological from the pathological condition of the 
 uterus, by the suppleness of its walls ; this is possible in some cir- 
 cumstances, especially if care be taken to push the fundus of the 
 womb backward, in order that it may become more accessible to 
 the finger introduced into the posterior cul-de-sac of the vagina. 
 I have succeeded sometimes in this manner ; but it must be admit- 
 ted that it is often impossible to establish the diagnosis 
 
 § 4. End of the Fourth Month. 
 
 A. Development of the Fœtus. — At the end of the fourth month, 
 the foetus, estimated from the occiput to the coccyx, measures about 
 five inches. Its skin has now become somewhat firm ; slight gran- 
 ulations of cellular tissue are already observed ; the muscles be- 
 gin to be fibrinous and contractile; the head is covered with a 
 light down ; the anus opens ; the scrotum, labia majora, and 
 nymphae swell out ; the spinal marrow leaves the inferior portion 
 of the vertebral canal. 
 
 (Figr.27.) 
 Woman who has borne children. 
 
 B. Changes in the Uterus. — The entire uterus can no longer be 
 contained in the cavity of the pelvis ; it rises above the superior 
 strait, and the vagina becomes elongated. At this time the second 
 period of the development of the abdomen begins to be manifest, 
 less to the view than to the abdominal exploration. The hands 
 applied to the abdomen distinguish between the pubes and umbil- 
 icus a spheroid, regular, elastic tumour, which rises on a median 
 line, and feels like a bladder nearly filled with water. The uterus 
 in women who have borne children does not rise so high, because 
 the abdominal parietes, being relaxed, do not support the organ 
 so firmly in its ascent. 
 
 C. Length. — Examined in the cadaver, the body of the uterus 
 measures three inches and six lines. 
 
 The changes in the vaginal portion of the womb after the end of 
 the third month do not exhibit such defined differences as. to be 
 readily appreciated; it is not until the end of the fifth month that 
 we can distinctly recognise marked alterations in this part of the 
 uterus. (See End of the Fifth Month.) 
 
 D. Active Motions of the Fœtus. — It is generally about this pe- 
 riod, the end of the fourth month, that the female begins to feel the 
 active movements of the fœtus. At first it is nothing more than a 
 confused vibratory sensation, which gradually increases, and which 
 
 E 
 
34 NORMAL PREGNANCY. 
 
 the accoucheur even can feel by placing his cold hand on the 
 abdomen. This sensation of cold is probably felt by the foetus 
 through the abdominal and uterine walls, for it is generally found 
 to move with rapidity. But, notwithstanding the real value of this 
 sign, we should not place exclusive confidence in it; for some 
 women have believed they have experienced the foetal movements, 
 and therefore supposed themselves pregnant, when in fact they 
 were not so. A woman who died at the clinique of the faculty of 
 an ovarian tumour, which had been mistaken in the city for an 
 extra-uterine pregnancy, thought she felt life, when M. Dubois sat- 
 isfied himself she was not pregnant. This case was the more re- 
 markable, as, at the supposed period of nine months, she experienced 
 all the external signs of commencing labour, without, however, any 
 evident dilatation of the neck ; her physician having been sent for, 
 found her bearing down with all her force in order to hasten the 
 expulsion of the child. M. P. Dubois has frequently mentioned in- 
 stances of women who presented themselves at his lectures for 
 the practical exercises of the pupils, and who possessed in a high 
 degree the faculty of simulating the movements of the foetus by the 
 partial contractions of the abdominal muscles. 
 
 It is evident, from these examples, that it is exceedingly easy to 
 commit an error at so early a period of pregnancy. The phenom- 
 ena which may be mistaken for the active movements of the foetus, 
 arise from the circulation of gas in the intestines, the contraction 
 of the intestines, a common circumstance in hysteria, and, finally, 
 from the voluntary or involuntary contraction of the abdominal 
 walls. 
 
 It may also happen that the female is pregnant, and yet neither 
 she nor the accoucheur be conscious of the foetal movements. I 
 have known women quicken, not until a very advanced period of 
 pregnancy ; some, even, which is rare, however, bring forth healthy 
 living children without ever having perceived this sensation. 
 
 These movements may cease entirely after having been felt, 
 without the death of the child. This circumstance is generally 
 attributed to local or general plethora of the mother reacting upon 
 the foetus ; and this view is confirmed by the fact that, after a 
 slight sanguineous depletion, movements of the foetus are again 
 experienced.* 
 
 * I recently met with an interesting case of disease in a lady, the wife of a physician, and 
 whom I saw with Professor Mott. She had been labouring, for about three months previous 
 to my seeing her, under ascites. Her general health was bad, together with considerable de- 
 rangement about her uterus ; sometimes menstruating copiously, and then passing her pe- 
 riods without the slightest show. In a vaginal examination, I ascertained that the uterus 
 was enlarged about four times its ordinary size. From the great accumulation of fluid in her 
 abdomen, it became necessary to remove it by tapping. This operation was performed by 
 Professor Mott four times, at intervals of six or eight weeks. The last tapping was fol- 
 lowed by severe inflammation ; and for four months there was no appearance of water. 
 However, about three weeks since, on visiting her, I found the abdomen somewhat distend- 
 ed with fluid, and in exploring the abdomen carefully, I distinctly felt two small tumours, 
 floating about in the fluid, and attached, as I suppose, to the fundus of the womb ; being the 
 ordinary fibrous growths, which are not uncommon, and which are frequently pediculated to 
 some portion (most usually the fundus) of the womb. These tumours would move with the 
 motion of the patient, and might have been mistaken for either the passive or active mo- 
 tions of the foetus. — Ed. 
 
NORMAL PREGNANCY. 
 
 35 
 
 Passive Motion of the Fœtus. — The accoucheur can also, at the 
 end of the fourth month, determine the passive motions of the fcetus, 
 either by means of the abdominal ballottement, or by a vaginal ex- 
 amination, and this sign is of great value. In order to perceive 
 this sensation by the abdominal ballottement, it will be necessary 
 to place one hand on the tumour formed by the uterus, and depress 
 the abdomen by a successive series of brisk and rapid movements 
 with the extremity of the fingers united. We then feel, in the 
 midst of a fluid, a light, floating body, which passes under the fin- 
 gers at each impulse communicated to it. This body is the fcetus. 
 It is not difficult to distinguish this phenomenon, after having no- 
 ticed it a few times, from the impression imparted to the fingers 
 by movable tumours developed in the abdomen. 
 
 (Fig. 28.) 
 
 To obtain the same result by the vaginal touch, the woman should 
 stand up or lie down, and the index finger, the palmar surface being 
 in front, should be placed on a soft tumour felt at the superior part 
 of the vagina, between the symphysis pubis and anterior lip of the 
 os tincse, and the finger should then be moved rapidly from behind 
 forward, and from below upward, the wrist being generally mo- 
 tionless. This slight shock is communicated to the fcetus through 
 the inferior uterine wall ; and the accoucheur is sensible that he 
 displaces a small, movable body which floats in the liquor amnii. 
 But this small body is very rarely felt to fall back on the finger. 
 At this period of pregnancy, the fœtus is too small for this last sen- 
 sation to be perceptible, and the only evidence that this body has 
 again returned to the inferior portion of the womb is that it can be 
 displaced by a repetition of the operation. 
 
 Sometimes, especially when the female is lying down, this move- 
 ment of the finger alone will not suffice ; it becomes necessary to 
 assist it with a slight action of the arm. Indeed, sometimes the 
 sensation will be more manifest at the posterior part of the inferior 
 segment of the uterus, that is to say, in the posterior cul-de-sac, but 
 this is rare. Finally, notwithstanding all these precautions, it will 
 occasionally be the case that, at this period of gestation, the pass- 
 ive motion of the fœtus cannot be felt several times successively, 
 in consequence of the fœtus, after being displaced the first time, 
 
36 NORMAL PREGNANCY. 
 
 becoming so situated as to render it impossible to reach it ; and some- 
 times, too, it cannot be felt at all.* 
 
 Difficulty in detecting this Sign. — The difficulties frequently met 
 with in detecting the passive motions of the fœtus may depend on 
 extreme distention of the uterus, on the thickness of the abdominal 
 and uterine walls, or on pain of these parts ; and sometimes an 
 obstacle is presented by displacement of the inferior segment of 
 the uterus, in consequence of tumours developed below it. Again, 
 certain presentations, such as the head, favour the ballottement ; 
 while others, such as the pelvic extremity or trunk, prevent its de- 
 tection. As I shall explain hereafter, the head pushes before it, in 
 the cavity, the inferior segment of the uterus, and renders it more 
 accessible to the finger, while the other parts, which remain ele- 
 vated above the superior strait, cannot be easily reached. Several 
 circumstances may delude us as to the ballottement ; for example, 
 a calculus contained in the bladder, or an ante-version, with soft- 
 ening of the body of the uterus. This latter case can only give 
 rise to momentary error, for the direction of the neck, which in ante- 
 version is carried backward, indicates perfectly well that it is the 
 inclined fundus of the organ, which presses upon the superior wall 
 of the vagina. I must confess, however, that the sensation expe- 
 rienced in this case is very deceptive, and that it sometimes exactly 
 simulates the ballottement. I have had occasion to test this fact ; 
 but, by causing the woman to lie down, the uterus would resume 
 its natural position, and all difficulty is at an end. 
 
 * Active Motion of the Fœtus. — Women who have never bome children, and whose desire 
 has been to have offspring, are generally very apt to imagine themselves pregnant ; and there 
 are few symptoms about which they are more readily deceived than the active motion of the 
 foetus. The accoucheur should never rely upon any statements made by his patient in cases 
 of doubtful pregnancy, especially if any important interest, such as character or property, be 
 involved in the issue. It is his duty to judge for himself, irrespective of all adventitious 
 or other influences ; let his mind be free from all bias, and judge of the case according to 
 the evidence which may be presented to his senses. Such is the rule of conduct I would 
 most earnestly enjoin on all who may wish to discharge their trust fearlessly, and, at the 
 same time, justly. A most amusing case occurred in this city some ten years since, and 
 will, perhaps, serve more effectually to illustrate an important truth in midwifery than any 
 argument I could advance. A lady, aged forty-seven, who had been married since her thir- 
 tieth year, had entertained a most anxious desire to become a mother, but had not succeed- 
 ed in her wishes, and was about abandoning all hope, when, of a sudden, she noticed that her 
 abdomen began gradually to enlarge, and she really imagined herself pregnant. In addition to 
 the ordinary symptoms of gestation, she thought she distinctly felt the motion of her child. 
 She received the congratulations of her friends, was complimented on her prowess and the final 
 accomplishment of her hopes after years of fruitless effort, and commenced making the ne- 
 cessary preparations for her approaching accouchement. Her physician was sent for, and 
 was informed that his services would be required, &c. In the course of a few months, the 
 labour commenced ; a messenger hastened to admonish the doctor that the lady's time had 
 come, with a request that he would lose no time in reaching the bedside of his delighted pa- 
 tient. The doctor arrived— all in the house was confusion — the nurse was enchanted — the 
 husband could scarcely realize the advent of this long-expected era in his life— the patient 
 was in actual labour — the pains frequent and distressing — the physician was entreated to 
 lose no time in assisting madam— he instituted an examination — the silence of death now 
 pervaded the lying-in chamber to hear from the lips of the oracle the exact facts of the case. 
 Thev were soon made joyful by hearing from the doctor that all was right — that the labour 
 was quite advanced, and in a very short time would be completed. The sufferings of the pa- 
 tient increased — she was requested to make the most of her pains — to bear down and assist 
 nature — when, lo ! in the midst of one of those powerful efforts to "assist nature," there was 
 heard an explosion, which struck terror into the hearts of all present, the docter included. 
 The patient immediately exclaimed, " Oh ! dear doctor, it's all over ; do tell me if it is a boy." The 
 explosion was nothing more than an escape of air from the bowels, the patient having mis- 
 taken flatulence for pregnancy, and the rumbling of the gas in the intestines for the motions 
 of the foetus. Comment is here unnecessary ; let this case, however, admonish the pupil of 
 the necessity of caution. — Ed. 
 
NORMAL PREGNANCY. 37 
 
 y ;t7viuistanding all these causes of error, this sign, it must be 
 recollected, is very positive. 
 
 The uterine souffle is very frequently perceived at this period, 
 as are also the pulsations of the heart ; but it is not until the fol- 
 lowing month that these changes in the circulation become quite 
 manifest. 
 
 § 5. End of the Fifth Month. 
 
 Development of the Fœtus. — At five months the fœtus measures, 
 from the occiput to the coccyx, from six to seven inches. The ab- 
 dominal extremities, including the feet, begin to exceed the tho- 
 racic. The skin assumes a greater degree of consistence ; it loses 
 its transparency, and in certain parts of it there is observed a se- 
 baceous material. The hair commences to grow, but is yet white ; 
 the nails are evident ; the umbilical cord is longer ; the auricles of 
 the heart, previously larger than the ventricles, are now reduced 
 to the same dimensions. The stomach and small intestines are 
 filled with reddish meconium ; the pupil cannot be distinguished. 
 
 Position of the Uterus. — At the end of the fifth month the ute- 
 rus has already acquired too much increase to remain in the ex- 
 cavation; it rises more and more above the superior strait, so 
 that the fundus of this organ is almost on a level with the umbili- 
 cus in a primipara ; it is a little inclined to the right and in front. 
 In consequence of the elevation of the uterus, the vagina becomes 
 elongated ; the uterus raises with it the peritoneum ; the folds and 
 ligaments of this membrane become effaced ; the ovaries approach 
 the vertical line, and are close to the uterine walls ; the round lig- 
 aments lengthen, and begin to present a muscular organization. 
 
 Form of the Uterus. — The body of the uterus is nearly round ; 
 the thickness of its walls is the same as in a state of vacuity. 
 
 a. Length. — Measured from the internal orifice to the summit of 
 the organ, the body gives five inches ; and if to this be added fif- 
 teen to eighteen lines for the length of the neck, the entire long di- 
 ameter of the uterus will be six inches and a half. 
 
 (Fig. 29.) (Fig. 30.) 
 
 Primipara. Female who has borne children. 
 
 Changes in the Inferior Part of the Organ. — The uterus being 
 elevated above the superior strait, the finger, in seeking the neck, 
 will have to pass higher up than at the previous period. The fun- 
 dus being slightly inclined to the right and in front, the neck will, 
 of course, be directed a little backward and to the left; the neck, 
 in its totality, still measures from fifteen to eighteen lines, and this 
 
38 NORMAL PREGNANCY. 
 
 diminution in the length is effected at the expense of its vaginal 
 portion only, the portion of the neck above the vagina having un- 
 dergone no diminution, which circumstance can sometimes be as- 
 certained at this period by introducing a finger into the cul-de-sac 
 of the vagina. In primiparae, the vaginal portion has preserved a 
 certain regularity in its form ; it is, however, softer, and the two 
 lips are about on a level, but the orifice is still closed. In women 
 who have borne children, the neck is considerably softer and short- 
 er ; the external orifice, which is irregular, begins to open, and will 
 permit the introduction of half of the first phalanx of the fore fin- 
 ger, and sometimes more. 
 
 Passive and Active Motions of the Fœtus. — The abdominal and 
 vaginal ballottement becomes more manifest ; the active movements 
 are also much more perceptible. 
 
 b. Auscultation. — At this period, the signs furnished by the ute- 
 rine and fcetal circulation are readily perceived by the ear. 
 
 It was M. Mayor who, in 1818, first applied auscultation to preg- 
 nancy. M. Kergaradec, after him, stated that, in the pregnant 
 woman, two different sounds could be detected, one of which, con- 
 sisting in a series of double pulsations, is occasioned by the fcetal 
 circulation; the other, similar to the bellows sound, appeared to 
 him to be the result of the placental circulation. 
 
 c. The Bellows Sound. — The intermittent bellows sound, which is 
 generally compared to the sound in the carotids of chlorotic persons, 
 is synchronous with the pulse of the mother. Each author gives a 
 different name to it, according to the cause which he supposes to 
 have produced it. 
 
 Thus it is called the placental souffle, because its production is 
 attributed exclusively to the circulation in the placenta; but, if 
 this were the case, the souffle should be heard in the same woman 
 at the same point during the whole duration of pregnancy ; and, as 
 I shall immediately remark, nothing is more variable than the seat 
 of this sound. Moreover, it is heard with precisely the same char- 
 acter in cases in which the uterus is enlarged by an abnormal 
 growth, or in the development of the ovaries ; and in cases in 
 which the placenta does not exist ; often even after accouchement, 
 when the placenta has been extracted, this sound is still manifest. 
 These facts will undoubtedly suffice to show that it is not owing 
 to the placenta. 
 
 M. Bouillaud,* who has given it the name of abdominal souffle, 
 thinks that it is produced by the compression of the large vessels 
 placed in the posterior and lateral portions of the abdomen — the 
 aorta and iliac arteries. 
 
 M. P. Dubois, on the contrary, who regards it as fhe result of 
 the uterine circulation, denominates it the uterine souffle, and he 
 maintains this opinion on the strength of an anatomical fact, which 
 I myself have observed. 
 
 It is easy to demonstrate that there exist, in the uterine vascular 
 
 * Clinical Treatise on Diseases of the Heart, 2d éd., Paris, 1841, t. i., p. 274. 
 
NORMAL PREGNANCY. 39 
 
 apparatus, modified by pregnancy, ready communications between 
 the arteries and veins, so that the walls of the uterus appear to be 
 transformed into an erectile tissue ; the blood, passing with rapidity 
 from the arterial orifices, meets in the veins, which present a larger 
 calibre, a column of blood which flows less rapidly, and from this 
 passage results the souffle. This sound will be the more apparent 
 as the auscultation is made at a point nearer the placenta, where 
 the uterine circulation is necessarily more active. 
 
 This opinion appears to me highly probable. It is certainly in 
 the walls of the uterus that the souffle takes place ; but may it not 
 be possible to reconcile, in part at least, the theory of M. Bouillaud, 
 to which I attach great importance, with the opinion of M. P. Du- 
 bois ? I must confess that it does not appear to me at all impossi- 
 ble, and in this way I have been enabled to explain many cir- 
 cumstances, which I shall now enumerate. 
 
 In a great number of experiments made at La Clinique, either 
 alone, or with the assistance of my friend, Doctor Devilliers, I have 
 observed the following facts : 1st. This sound is not perceptible in 
 all women; 2d. After having recognised its existence once or 
 twice, it is sometimes impossible again to detect it, no matter on 
 what part of the abdomen the stethoscope is applied ; again, when 
 least expected, it is heard, and increases in a remarkable manner ; 
 it passes rapidly away, frequently by changing its place. I have 
 often remarked that this fact coincided with a rapid movement of 
 the foetus, a circumstance to which I shall allude immediately. 
 Nothing is more variable than the seat of this» sound ; it may be 
 heard over the entire periphery of the organ, and with the same 
 intensity in the most opposite points. 
 
 The portions in which I have most frequently perceived this 
 sound correspond to the parts of the pelvis on which the uterus re- 
 poses, towards the two iliac fossae, when the woman is standing ; 
 somewhat lower down when in the horizontal posture. 
 
 From these facts, it is reasonable to infer that this sound occurs 
 in the uterine walls, as contended for by M. P. Dubois ; for it has 
 no fixed seat, and it should always be heard in the same place, if, 
 as M. Bouillaud believes, it depended on the compression of ves- 
 sels out of the uterus ; and that the compression is certainly the de- 
 termining cause of this sound, but that it is exerted on the walls of 
 the uterus, and not on the neighbouring vessels of the organ, wheth- 
 er the organ itself be compressed on the parts which sustain it, 
 which fact would explain, without admitting the compression of 
 the iliac vessels, how it is that the sound is heard in the iliac fossae 
 when the female is standing, and higher up and more posteriorly 
 when she is lying down ; or whether its walls undergo compres- 
 sion between the foetus and abdominal parietes. This compression 
 is increased by the stethoscope, and this latter circumstance satis- 
 factorily shows how, in consequence of a rapid movement of the 
 foetus, displaced by the instrument, the sound ceases, and again 
 manifests itself in an opposite point. 
 
 In fine, it might be possible that it depended on the united cir- 
 
40 NORMAL PREGNANCY. 
 
 culation of the uterine vessels, and of those adjoining this organ. 
 The remarkable differences observed in its rhythm, according to 
 the place at which it is perceived, rather tend to corroborate this 
 latter opinion. I have often observed, with my friend Doctor De- 
 villiers. and frequently called the attention of my pupils to a slight 
 peculiar sound, which accompanies the souffle at its expiration ; it 
 is shrill, and resembles somewhat the noise which follows the coo- 
 ing of the turtle-dove. I am entirely ignorant how this peculiarity 
 is effected, nor am I disposed to attach any importance to it. 
 
 The uterine souffle will not serve to point out the insertion of 
 the placenta, for the reason already stated, its want of fixedness ; 
 for it is frequently heard with the same intensity at different points. 
 Finally, the souffle, as a practical sign, possesses only secondary 
 value, for it is not always distinguishable, and even when perceived, 
 it may be determined by the growth of a fibrous tumour in the 
 uterus, a mole, &c, &c. It also is sometimes observed in cases of 
 ovarian enlargement simulating pregnancy. 
 
 D. Sound of the Heart — Positive Sign. — The pulsations of the 
 fcetal heart constitute the only positive evidence of pregnancy, and 
 I place them among the probable signs merely not to invert the or- 
 der according to which the various signs characterizing human ges- 
 tation manifest themselves. Sometimes a practised ear may, as I 
 have already said, perceive these pulsations as early as the fourth 
 month ; but ordinarily not until the end of the fifth month, and often 
 even between the fifth and sixth month. 
 
 They are not synchronous with the beats of the maternal pulse, 
 and they number by minute from 130 to 140: they are not regu- 
 lar, and become very frequent or slow without our being able to 
 assign any cause for these changes. 
 
 These pulsations are usually heard in circumscribed points ; but 
 they may likewise be perceived over almost the entire of the abdo- 
 men ; but in this case they have not throughout the same inten- 
 sity. I will allude again to this circumstance. During the first 
 months the part at which these pulsations are best heard is not 
 fixed, for at this period the foetus may move, and suddenly change 
 the relations of contiguity between the point of the abdomen on 
 which we auscult, and the posterior precordial region of the foetus 
 where these sounds are most distinctly recognised. 
 
 It is not until after the seventh month that the fœtus, by its size, 
 has acquired sufficient fixedness to render the seat of these pulsa- 
 tions less variable ; and this circumstance, as I shall immediately 
 explain, will sometimes enable us to specify at an advanced period 
 the particular portion of the child that is at the uterine orifice 
 (presentation), and the relations it bears to the parts of the mother 
 (position). If the pulsations are more distinctly heard on the point 
 of the abdomen with which the dorsal region of the foetus is in re- 
 lation, this depends on the attitude of the foetus in the womb ; the 
 anterior curvature of the trunk, the flexion of the extremities and 
 head, conceal the anterior precordial region, situated at the base 
 of the space, which separates the upper from the lower extremity 
 
NORMAL PREGNANCY. 41 
 
 of the foetus ; the stethoscope, therefore, cannot be applied imme- 
 diately on this part, while, in consequence of this attitude, the pos- 
 terior precordial region is in relation with the abdominal walls of 
 the mother, and the transmission of sound is, therefore, much more 
 direct. 
 
 (Fig. 31.) 
 
 Before the seventh month these pulsations are most commonly 
 heard in the middle of the space comprised between the pubes and 
 umbilicus. Their intensity increases with the advancement of 
 pregnancy. 
 
 The pulsations, according to some authors, cannot always be 
 perceived. M. P. Dubois, however, in one hundred and ninety- 
 five women examined by him, heard these pulsations distinctly in 
 one hundred and eighty-five ; and in ten instances only they were 
 not manifest. Certainly, we should infer that, in these cases, the 
 foetus had ceased to live. And I do not hesitate to affirm, found- 
 ing my opinion on a great number of observations made at La 
 Clinique and in my lecture-room, that, in all instances in which the 
 child is alive, the pulsations of the heart can be detected. In these 
 circumstances, I have always heard them after the sixth month, 
 not always, it is true, with the same facility ; for it will be readily 
 conceived that the facility of sound will be more or less interfered 
 with by the position of the foetus, the interposition of the intes- 
 tines between the uterus and abdominal walls, the muscular con- 
 traction of these walls, &c, &c. 
 
 The pulsations, or double beats, are composed of two periods, 
 the first more feeble, the second stronger and sharper, so that it 
 sometimes presents a metallic sound ; a circumstance which M. P. 
 Dubois was the first to point out, and which I myself have very 
 frequently observed. 
 
 The pulsations serve also to inform us in reference to the actual 
 condition of the foetus, whether it be living or dead. As regards 
 this latter point, if the pulsations cease to be heard, or if it is impos- 
 sible to perceive them, when all the other signs establishing the 
 reality of pregnancy are present, the death of the child is no 
 longer doubtful, as I have already remarked. But this is not the 
 place for the consideration of this topic ; it will receive due atten- 
 tion in the articles entitled Death of the Fœtus, and Compression 
 of the Cord. 
 
 F 
 
42 NORMAL PREGNANCY. 
 
 When we seek for the uterine souffle, or the pulsations of the 
 heart, the woman should be in the recumbent posture. This pre- 
 caution is indispensable during the first months ; and it is useful at 
 a more advanced period. The bed should not be too low ; for 
 when the accoucheur is obliged to remain a long time in the bend- 
 ing position, the ear becomes more or less congested, which occa- 
 sions a humming, and the sense of hearing is thus completely dead- 
 ened. It will not be necessary to uncover the abdomen ; but it 
 should not have more than a single fold of linen over it. The ear 
 should be assisted by the stethoscope, in order that the patient may 
 be saved the unpleasant consequences of immediate contact with 
 the ear, as well as because, by the aid of the instrument, it will be 
 easier to limit the sound, and reach more precisely the point at 
 which it is most distinct, by pressing more or less on the abdom- 
 inal walls. By the stethoscope, also, we can much more readily 
 distinguish the souffle and pulsations of the heart from other sounds 
 caused by borborygmi, muscular contraction of the intestines, &c. ; 
 and thus avoid the friction of the ear upon the linen, which is pro- 
 duced at each inspiration, and which renders the sensations more 
 confused. 
 
 § 6. End of the Sixth Month. 
 
 Development of the Fœtus. — At six months, the period of legal 
 liability, the foetus, from the occiput to the coccyx, measures 
 from eight to nine inches ; the skin is covered with a very appa- 
 rent down, and white plates of sebaceous mucus. The hair be- 
 comes darker, the eyelids are opaque, and the pupil very much 
 dilated ; the large intestine exhibits crimplings, and is filled with a 
 brownish meconium. 
 
 At the end of the sixth month, the fundus of the uterus extends 
 above the umbilicus in a primipara ; it has, however, scarcely 
 reached the umbilical region in a female who has already borne 
 children, either in consequence of the sinking down of the womb 
 upon itself, or because the relaxed abdominal walls permit it to in- 
 cline more forward. Moreover, in both, it inclines a little more to 
 the right and in front than at the fifth month ; the vagina is still 
 elongated, and the bladder begins to rise above the superior strait. 
 
 B. Form. — The body of the uterus becomes more and more 
 spherical, and represents tolerably well a balloon, the neck of 
 which is formed by the cervix ; the thickness of the walls is some- 
 what less than in the unimpregnated state. 
 
 (Fig. 32.) (Fig. 33.) 
 
 Primipara. Female who has borne Children. 
 
NORMAL PREGNANCY. 43 
 
 C. Length. — Measured from the internal orifice to the summit 
 of the organ, the body of the uterus is nearly six inches ; the entire 
 neck twelve to fifteen lines ; while the whole length of the organ 
 is seven inches and three lines. 
 
 D. Changes in the Inferior Portion of the Uterus. — The vaginal 
 portion continues to soften and diminish in length ; the orifice, also, 
 opens more and more. The first phalanx may sometimes be in- 
 troduced in primiparse, which, however, is rare. In women who 
 have had children, the finger will penetrate to one half the neck ; 
 it will occasionally even reach the internal orifice, but will not 
 pass beyond it. 
 
 E. Active and Passive Motion of the Fœtus. — The active motion 
 is more manifest ; the abdominal and vaginal ballottement is perceiv- 
 ed much more readily, and at this period the fœtus has acquired 
 sufficient weight and mobility to fall back upon the finger after 
 having been removed by it from the inferior portion of the uterus. 
 
 F. Auscultation. — The souffle and pulsations of the heart are 
 heard still more distinctly, particularly the latter. 
 
 § 7. End of the Seventh Month. 
 
 A. Development of the Fœtus. — At seven months, the fœtus meas- 
 ures, from the occiput to the coccyx, from nine to ten inches ; the 
 skin is less red ; the cellular tissue is furnished with adipose mat- 
 ter ; and the nails are broad. The iris becomes formed ; it con- 
 stitutes at first, according to M. Velpeau, a simple ring, which 
 increases in a concentric manner, and ultimately leaves an open- 
 ing called the pupil. Others suppose that the iris is formed by the 
 rupture of the pupillary membrane. The umbilicus is still below 
 the middle portion of the fœtus; the testicles leave the renal region, 
 and approach the inguinal ring. 
 
 B. Position of the Uterus. — At this period, the fundus of the 
 womb is between the umbilicus and epigastric region, and its in- 
 clination to the right, until now quite slight, becomes very evident. 
 It is frequently asked why this inclination should be so often to the 
 right, and so rarely to the left. Desormeaux supposed that it was 
 occasioned by the repletion of the iliac portion of the colon, con- 
 stipation being a condition which almost always accompanies preg- 
 nancy. But M. P. Dubois does not admit the truth of this propo- 
 sition, predicating his objection upon the fact that the cœcum on 
 the right, which is equally liable to distension, antagonizes the influ- 
 ence of the colon, which is on the left. Other authors have thought 
 that it was owing to the more frequent use of the right arm ; this 
 explanation appears to me to be without foundation. Finally, it 
 has been referred to the habit of lying down on the right side ; 
 this habit, if it were general, would undoubtedly explain the cause 
 of the inclination ; but this right obliquity of the womb is observed 
 equally often in women who rest on their left, as in those who 
 from choice lay on the right side. 
 
 The opinion of Madame Boivin appears to be the most reasonable. 
 According to this skilful sage-femme, the right round ligament, strong- 
 
44 NORMAL PREGNANCY. 
 
 er than the left, draws the fundus of the womb to the right side ; in- 
 deed, it may be said that she has mistaken the cause for the effect, 
 and that, if the round ligament of the right side acquires more 
 strength, it is because it has a greater weight to sustain. In a 
 word, the true cause of this obliquity is not well understood. 
 
 As the uterus rises and closes up more and more the superior 
 strait, the bladder is pushed above this strait, and the tumified ure- 
 thra becomes situated behind the symphysis pubis, a circumstance 
 which at once explains why, in some instances, the introduction of 
 the catheter can be accomplished only by means of a flexible and 
 sufficiently long sound, and not by the ordinary female instrument. 
 I should likewise mention here certain changes which can only be 
 observed after death : thus, the peritoneum will be found pushed up- 
 ward, and its folds or posterior and anterior ligaments completely 
 effaced ; the broad ligaments are still apparent, but, like the fallo- 
 pian tubes and ovaries, they rest against the two sides of the uterus. 
 
 Form. — The body of the uterus loses its spherical form ; it be- 
 comes ovoid, and broader at its superior portion ; its walls are thin- 
 ner than at full term. 
 
 Length. — From the internal orifice to the fundus of the organ, 
 the length is ten inches in a primipara ; and if to this be added 
 twelve to fifteen lines for the neck, the entire length of the uterus 
 will be eleven inches and a few lines. 
 
 (Fig. 34.) (Fig. 35.) 
 
 Primipara. Female who has borne Children. 
 
 C. Changes in the Neck. — The neck is carried far backward, 
 and to the left ; it is sometimes difficult to reach, and measures in 
 its whole length twelve to fifteen lines ; this diminution is effected 
 at the expense of the vaginal portion only, which has become 
 larger, and, in primiparae, measures but a few lines ; it is even at 
 this period almost completely effaced in women who have had 
 children. In the former, the vaginal orifice will allow the finger 
 to penetrate sometimes to one half of the neck ; in the latter, the 
 finger often reaches to the internal orifice, into which, indeed, it 
 may enter provided the woman has had many children. 
 
 D. Active and Passive Motion of the Child. — The movements 
 of the foetus are now much more energetic, and sometimes occa- 
 sion a painful sensation. These movements are manifest to the 
 view ; the ballottement is also very easily perceived. 
 
 E. Auscultation. — The signs furnished by the uterine and fcetal 
 circulation are recognised with great facility. 
 
NORMAL PREGNANCY. 45 
 
 § S. End of the Eighth Month. 
 
 A. Development of the Fœtus. — At the end of the eighth month 
 the foetus measures from ten to eleven inches ; its skin, covered 
 with down, is thicker and less smooth ; the sebaceous material is 
 abundant ; the inferior maxillary bone, at first very short, is, at this 
 period, nearly as long as the superior. The nails are much firmer, 
 and the testicles pass through the ring to the scrotum. 
 
 B. Situation of the Uterus. — The fundus of the womb is in the 
 epigastric region, inclined to the right, and in front. 
 
 C. Form of the Uterus. — Its form is nearly the same as it is at 
 the seventh month, which it preserves until the completion of preg- 
 nancy. 
 
 D. Length. — The whole length of the uterus varies from twelve 
 to fourteen inches ; the entire length of the neck being included in 
 this measurement, gives from ten to twelve lines ; measured at its 
 fundus, the body of the uterus, in its transverse diameter, affords 
 eight inches, and in its antero-posterior seven inches and a half. 
 
 E. Changes in the Neck. — I have shown that, up to this time, the 
 vaginal portion of the neck alone became changed from month to 
 month, both in its consistence and form, and especially in its length. 
 We have observed it successively at each period lose some lines 
 of its length, while the portion of the neck above the vagina re- 
 mained unaltered. At the end of the eighth month the vaginal 
 neck is almost entirely effaced ; however, in primiparae, the lips still 
 measure a few lines. It is directed considerably backward and 
 to the left, and this circumstance renders it very difficult to reach. 
 This difficulty, however, depends more upon the ante-version of 
 the body, which carries the neck considerably backward, than upon 
 the height of the neck itself. In women who have borne a num- 
 ber of children, the vaginal orifice is so soft and open that it be- 
 comes confounded with the walls of the vagina ; and the only cer- 
 tainty the accoucheur has that he has reached the neck is, that the 
 finger penetrates an orifice widely open, in front of which is felt a 
 small tubercle, which is nothing more than the rudiment of the an- 
 terior lip. This orifice is funnel-shaped, and the finger penetrates it 
 deeply in order to pass the internal opening, which is more or less 
 dilated. 
 
 In primipares, the neck, less soft and dilated, permits the finger 
 to reach only as far as the internal orifice, which is closed. 
 
 Whether the female is a primipara, or has already borne children, 
 the portion of the neck above the vagina does not undergo any 
 change until this period, and often not until the eighth month and a 
 half. It was formerly supposed that this portion contributed to the 
 enlargement of the inferior part of the uterus from the sixth to the 
 seventh month. M. Stoltz was the first to show that this opinion 
 is incorrect; he has also stated that, even at term, this part is 
 not always effaced. M. P. Dubois concurs in this opinion ; and 
 I have had occasion to notice, in women who have died at the 
 eighth month of pregnancy, the integrity of this portion of the ute- 
 
46 NORMAL PREGNANCY. 
 
 rine cervix. Indeed, it is a fact which any one can ascertain for 
 himself in practising the vaginal touch. The distance which the 
 finger has to pass, after being introduced into the external orifice, 
 in order to reach the internal, will give exactly the length of the 
 supra-vaginal portion, which alone remains unchanged, the lower 
 portion being completely effaced. Besides, this part is not changed, 
 as was formerly supposed, by a widening of the superior part of 
 this supra-vaginal neck ; but it is now ascertained that it is by the 
 flattening of this part, by which flattening the upper and lower 
 orifices gradually approximate, and form only one and the same 
 opening. 
 
 It is only at this period that certain of the presumptive signs can 
 be well examined ; the vergetures in the integuments of the abdo- 
 men, the prominence of the umbilicus, and the coloration of the 
 linea alba ; but it must be remembered that these signs, which, at 
 a less advanced period, have but little value, possess no more at 
 the eighth month, when, indeed, we have so many others that are 
 really important. 
 
 F. The vergetures, species of lozenge-shaped separations in the 
 mucous bodies of the skin, are seen through the epidermis with a 
 bluish colour ; they are more abundant in primiparae, and in women 
 whose abdominal walls are rigid ; they extend occasionally to the 
 superior portion of the thighs; and sometimes they are entirely 
 wanting when there is pregnancy, and may manifest themselves in 
 cases in which the abdomen is distended by any other cause than 
 a fœtus. It is the same with regard to the prominence of the umbil- 
 icus and the coloration of the linea alba. This latter sign seems, 
 however, to be more common in cases of pregnancy. 
 
 G. Active and Passive Motion of the Child. — The active move- 
 ments are more and more energetic ; they may, indeed, at this period, 
 when the fœtus begins to be more fixed in utero, serve to deter- 
 mine what the presentation and position will be at the time of la- 
 bour. Thus, in the presentation of the vertex, the female experi- 
 ences a heavy pressure below, together with slight movements, ex- 
 ecuted, as it were, by friction, and determined by the head ; she 
 feels also at the fundus of the womb slight motions, produced by 
 the abdominal extremities of the fœtus. The contrary is observed 
 in the opposite presentation. If these motions should be felt on 
 the left side, the back is ordinarily on the right; if on the right, the 
 back will be on the left. 
 
 H. Passive Motion. — The abdominal ballottement is perceived 
 with as much facility as at the end of the seventh month ; such, how- 
 ever, is not the case with the vaginal ballottement. This sensation 
 begins to be more obscure ; the finger applied to the inferior portion 
 of the uterus is sensible that it raises a heavy body, which rests on this 
 segment, but it feels also that the body does not quit this part. In 
 fine, the development of the fœtus proceeds, during the latter peri- 
 od of gestation, much more rapidly than that of the uterus itself; 
 and it now finds itself in a narrow compass, and, consequently, it is 
 more difficult to displace it. Although, as I have already remark- 
 
 
NORMAL PREGNANCY. 
 
 47 
 
 ed, the ballottement is most readily felt when the head presents, 
 yet at this period the head is ordinarily too stationary at the up- 
 per strait to allow of much mobility. 
 
 I. Auscultation. — Diagnosis of Presentations and Positions. — 
 The souffle is very easily perceived ; so also are the pulsations of the 
 foetal heart, which, in consequence of the immobility of the fœtus at 
 this period, will enable us to ascertain in advance the particular pre- 
 sentation and position which the fœtus will occupy at the time of la- 
 bour. Long before this period, if is true, we can arrive pretty accu- 
 rately at this diagnosis, but, in consequence of the greater mobility of 
 the fœtus, it may change its situation before the expiration of the full 
 term. It is not, therefore, until the eighth or ninth month that it is 
 
 (Fig. 36.) 
 Primipara. 
 
 (Fi ff . 37.) 
 Female who has borne children. 
 
 Supra-vaginal Portion. 
 
 possible to ascertain in advance what will be the presentation and 
 position of the fœtus at labour ; and, indeed, it must be admitted 
 that, even at this period, the fœtus sometimes is so mobile as to be 
 able to change its position by presenting the feet instead of the 
 head, and vice versa. This is observed particularly in women who 
 have had many children ; in them the uterus is so distensible that 
 the fœtus can place its longest diameter, which measures eleven 
 inches, in relation with the transverse diameter of the womb, which 
 measures only eight inches. Without this yielding of the uterine 
 walls, the fœtus could also change its position by executing a move- 
 ment of rotation, which brings, in the presentation of the vertex, for 
 example, the occiput to the right, when it was originally at the left. 
 I have already stated that the pulsations of the heart are most 
 distinctly heard at the point of the abdomen to which the posterior 
 precordial region of the fœtus corresponds. This being recollect- 
 ed, it will be easy for a practised ear, as soon as the part of the ab- 
 domen at which the sound is best heard is well determined, to as- 
 certain how the back of the fœtus is situated, whether to the left or 
 the right, in front or posteriorly, that is to say, what is the exact 
 position, and to what height of the abdomen the precordial region 
 is found to correspond ; a circumstance which will serve to estab- 
 
48 
 
 NORMAL TREGNANCY. 
 
 lish the presentation. In order to discover the presentation, it will 
 be necessary to draw a line, which shall divide the abdomen trans- 
 versely into two equal parts ; and whenever the summum of inten- 
 
 (Fig. 38.) 
 
 A. On a level with the upper Strait. 
 
 sity of the pulsations is heard below this line (I), we infer that there 
 is a presentation of the head ; and when, on the contrary, it is heard 
 above the line, a presentation of the pelvic extremity. 
 
 (Fig. 39.) 
 
 A. Superior Strait. 
 
 I have often been enabled to distinguish, in this manner, the pres- 
 entations of the lower extremity from those of the head. Is it pos- 
 sible to ascertain with equal certainty a presentation of the trunk ? 
 I think not. In some cases of this latter presentation, which I could 
 not know until after delivery, I was led to suppose, from the results 
 furnished by auscultation during pregnancy, that there was pres- 
 
 (Fig. 40.) 
 
 A. Superior Strait. 
 
NORMAL PREGNANCY. 
 
 entation of the vertex ; for the intensity of the pulsations was ob- 
 served below the transverse line, either to the left or right and in 
 front (fig. 40), and yet the presentation of the head did not exist. 
 
 If, in other instances, my diagnosis proved correct, I attrib- 
 ute it rather to the signs furnished by abdominal percussion and 
 the form of the uterus, than to those derived from auscultation. 
 
 Moreover, although it is frequently possible to ascertain the 
 presentations, yet we must be guarded against certain circumstan- 
 ces which might lead us into error. 
 
 Thus, in some women, the head may remain at the superior 
 strait, the inferior segment of the uterus not passing below this 
 strait, and then the pulsations of the heart will be heard with more 
 force above the transverse line, and we may be induced to suppose 
 there is a pelvic presentation, when, in fact, it is the head. I have 
 committed more than one error of this kind, which, however, the 
 vaginal touch enabled me to correct before the labour commenced. 
 
 (Fig. 41.) 
 
 A. Superior Strait. 
 
 So, likewise, the pelvic extremity, in breech presentations, may 
 be considerably descended below the strait (fig. 42), which is more 
 rare than for the head, and thus we may be imposed upon and in- 
 
 (Fir 
 
 fer a presentation of the vertex, because the intensity of the pulsa- 
 tions is below the line (1). 
 
 As to the position, I am of opinion that, in the great majority of 
 cases, we can ascertain whether the back is to the left or to the 
 
 G 
 
50 
 
 NORMAL PREGNANCY. 
 
 right. But I have been less successful when I have endeavoured 
 to distinguish a left or right posterior from a left or right anterior 
 position, and I think all correct observers have arrived at the same 
 conclusion. 
 
 Be it as it may, auscultation is nevertheless, under these circum- 
 stances, of great value when united to other signs, which may 
 throw light on the diagnosis ; for the important point is, especially 
 in cases where it becomes necessary to operate, and where the 
 other signs will not enable us to judge of the position, to know to 
 whtch side the back of the fœtus corresponds ; now I have already 
 shown that this latter result is readily obtained ; and then, whether 
 the head or pelvic extremity presents, the hand introduced into the 
 womb should have its palmar surface corresponding with the ante- 
 rior portion of the foetus. 
 
 It is sometimes also possible to detect the presence of twins in 
 utero ; but it has always appeared to me extremely difficult to as- 
 certain their presentation and position. (See Compound Preg- 
 nancy.) 
 
 K. Changes in the Adjoining Parts. — At this period, the dia- 
 phragm, pushed upward by the uterus and intestines, impedes 
 respiration. By its weight, the uterus also obstructs the venous 
 circulation, and causes œdema in the labia majora and inferior 
 extremities. Constipation is likewise common at this time. The 
 vagina secretes abundant mucosities, and sometimes on the neck 
 of the womb and mucous membrane of the vagina we can feel 
 small elevations, which are abnormal developments of the mucous 
 follicles,. 
 
 (Fig. 43.) 
 
 nu,.. dder is pushed still higher up; and the urethra forms a 
 prominence at the superior part of the vagina. The pressure ex- 
 perienced by the body and neck of the bladder occasions a kind 
 of tenesmus, and a frequent but illusory desire to pass water. 
 
 § 9. End of the Ninth Month. 
 A. Position of the Uterus. — Having arrived at the term of its de- 
 velopment, the uterus does not ascend after the end of the eighth 
 month ; sometimes, even, it descends, especially in presentations of 
 the head ; for this portion, pushing before it the inferior segment 
 of the uterus, engages more or less in the superior strait, and thus 
 permits the womb to descend. 
 
NORMAL PREGNANCY. 
 
 51 
 
 This circumstance shortens somewhat the vagina ; and the other 
 relations of the uterus are the same as at the eighth month. It 
 corresponds below to the sacro-vertebral prominence ; above, to 
 the anterior abdominal wall, mesentery, and intestines ; in front, to 
 the anterior abdominal wall, to the body and neck of the bladder ; 
 on the left, to the iliac vessels, psoas muscle, and iliac portion of 
 the colon ; on the right, to the iliac vessels, psoas muscle, coecum, 
 and abdominal wall ; it is, moreover, considerably inclined to the 
 right, and in front. 
 
 B. Form. — Its form is the same as at the seventh and eighth 
 month. 
 
 C. Length. — The length is the same as at the eighth month ; the 
 long diameter measures from a foot to fourteen inches ; the trans- 
 verse diameter, eight inches ; and the antero-posterior, seven inches 
 
 l and six lines. 
 
 D. Changes in the Neck. — In women who have had children, 
 there is no longer any neck ; the internal and external orifices be- 
 come confounded, and are dilated so as to allow the finger to feel, 
 through the membranes, the presenting part of the foetus. In 
 primiparse, however, the supra-vaginal portion still preserves a few 
 lines in length, which do not become effaced until after labour has 
 commenced. The vaginal portion is alone completely effaced, 
 and a very slight thickness of the tissues separates the two ori- 
 fices ; the external is open, but the finger cannot enter the internal. 
 In both, the vaginal opening is capacious, and is directed back- 
 ward and to the left, which renders it difficult to be reached and 
 distinguished, notwithstanding the shortening of the vagina. 
 
 (Fig. 44.) 
 Primipara. 
 
 (Fig. 45.) 
 Woman who has had Children. 
 
 I. Supra-vaginal Portion. 
 
 E. Thickness. — The thickness of the uterine walls is less at the full 
 term of gestation than in the unimpregnated state, especially at 
 the inferior portion ; except at the insertion of the placenta, where 
 it is as thick. This thinness of the walls may be partial, and the 
 more evident, according to the number of children borne by the 
 female ; and I have seen at La Clinique several women in whom 
 
52 NORMAL PREGNANCY. 
 
 this disposition was so manifest, together with great suppleness of 
 the abdominal walls, that it became easy, by means of an abdom- 
 inal examination, to ascertain all the relations of the fœtus with 
 the womb, and also to observe that the fœtus enjoyed extreme mo- 
 bility ; but I have never met with this thinness of the walls, and this 
 mobility so marked, as in the two women whose cases I shall re- 
 port in the article — Version through the Abdominal Walls. 
 
 F. Weight — The weight of the empty uterus, at the full term 
 of gestation, is about two pounds. 
 
 G. Active and Passive Motion. — The active motion of the child has 
 still increased in energy since the end of the eighth month ; for the 
 fœtus has acquired additional development, although the uterus it- 
 self has not increased in its dimensions. In consequence of this 
 growth of the fœtus, and of the constraint it experiences, the bal- 
 lottement, or perception of the active and passive motions, is more 
 obscure than at the eighth month. 
 
 H. Auscultation. — This furnishes nothing that cannot be per- 
 ceived with equal facility at the eighth month. 
 
 The development acquired by the vascular system of the uterus 
 determines, in the whole organ and in its annexas, an increase of 
 heat, which is very manifest in the vagina. This increase in the 
 circulation furnishes also to the vagina the materials of an abun- 
 dant mucous secretion, which has often been mistaken for a symp- 
 tom of a disease of a doubtful nature. 
 
 But we must not attribute to the same influence the enlarged 
 veinsof the vagina and labia majora, for these are caused by the 
 obstruction which the weight of the uterus occasions in the venous 
 circulation. 
 
 I. Changes in the Neighbouring Parts. — At this period consti- 
 pation is very obstinate, and the vesical tenesmus quite marked. 
 Sometimes, however, the bladder is more compressed at its supe- 
 rior part, and is made to project into the upper portion of the va- 
 gina. I have witnessed the truth of this fact, which M. Velpeau 
 also has frequently noted. The diaphragm is somewhat lower, and 
 respiration more easy. 
 
NORMAL PREGNANCY. 
 
 53 
 
54 NORMAL PREGNANCY. 
 
 § 10. The Human Ovum at Term. 
 In the human species, the name of ovum is given to a sort of 
 membranous vesicle, which is composed of the foetus, several mem- 
 branous tunics which envelop it, or organs of protection ; and of 
 the umbilical cord and placenta, or organs of communication. 
 
 1. Envelopes of the Ovum. 
 The protective organs are composed of three perfectly distinct 
 membranes, the caduca, chorion, and amnios. 
 
 A. The caduca, or external membrane of the ovum, at the full pe- 
 riod of pregnancy is of a grayish colour, and covers the whole of 
 the ovum, except at the point at which the ovum, in proportion as 
 it grows, forces it to double or reflect on itself. At this point the 
 ovule is in immediate contact with the walls of the uterus. This 
 membrane is composed of two portions, the external of which is 
 termed the external or uterine caduca, while the internal, or the re- 
 flected portion of the ovule, has received the name of the internal 
 or reflected caduca, or epichorion. This membrane bears the 
 same relations to the ovule that the pleura does to the lungs. 
 
 Of these two portions, the first, or external, preserves, in its de- 
 velopment, a tolerable thickness ; the other, or internal, extremely 
 thin, adheres firmly to the first ; the slight exhalation of a serous 
 fluid which filled its cavity, and which M. Breschet termed hydro- 
 perion, has then completely disappeared. 
 
 The organization of the caduca appears in every respect to be 
 similar to the false membranes ; M. Velpeau denies that it is or- 
 ganized, and calls it the anhiste ; other anatomists, on the contra- 
 ry, maintain that they have discovered vessels in it. I am aware 
 that, in placing this membrane on a plate of glass, and examining 
 it through the light, there will be seen species of arborizations ; and 
 I have been enabled, before it became dry, to cause with the nail 
 blood to circulate, which appeared to me to be contained in it. 
 But I cannot, however, affirm that this blood did not reach the 
 membrane by imbibition, and that it was really contained in vessels. 
 
 The surface of the caduca is unequal and porous ; it is always 
 met with during pregnancy, and the uses of it are to fix the ovum 
 upon some one point of the uterine cavity, and to prevent its being 
 carried without. 
 
 B. Chorion. — The chorion, a middle envelope of the ovum, is a 
 thin, transparent membrane, the texture of which very much re- 
 sembles a serous tissue. 
 
 Notwithstanding the opinion of certain anatomists, no one has 
 yet succeeded in demonstrating the existence of either vessels or 
 nerves in this membrane. 
 
 At the placenta, the chorion furnishes the umbilical vessels a 
 species of sheath, which accompanies them in their whole ex- 
 tent ; it forms, with the integuments of the foetus, a line of demar- 
 cation, which indicates the point at which the cord should separate 
 from the child. 
 
NORMAL PREGNANCY. 55 
 
 The functions of the chorion are to protect the embryo, and con- 
 tribute to the formation of the placenta, and the exhalation of the 
 fluids contained in the ovum. 
 
 Its external surface is in relation with the caduca reflexa, and its 
 internal with the amnios. 
 
 C. Amnios. — The amnios, or internal membrane of the ovum, 
 affords an immediate envelope to the umbilical cord, foetus, and to 
 the liquid in which this latter is enveloped. 
 
 According to the opinion of the ancients, the amnios is contin- 
 uous with the integuments of the foetus : this opinion, which was 
 abandoned for a long time, was revived, about twenty years since, 
 by an Italian professor, M. Mondini, of Bologna ; and quite recently 
 M. Breschet has stated, in fact, that the amnios, without being con- 
 tinuous with the epidermis, furnishes to the foetus a covering, the 
 separation of which is effected by the desquamation which is ob- 
 served in the child during the first few weeks of its life. This opin- 
 ion does not appear to me to be sufficiently established. 
 
 At the completion of pregnancy, the amnios presents an internal 
 surface, which is smooth and polished ; separated from the foetus by 
 the amniotic liquor, its external surface is in relation with the cho- 
 rion, to which it adheres rather closely, near the insertion of the 
 placenta, and in the whole extent of the umbilical cord ; but in the 
 rest of its surface this adhesion is much less, and it yields readily ; 
 also, at the end of pregnancy, there is collected between the two 
 membranes a certain quantity of fluid, which accoucheurs have de- 
 nominated the false waters. 
 
 The tissue of the amnios, although very similar to that of the 
 chorion, is, however, of a more dense texture ; neither vessels nor 
 nerves have yet been seen in it. But in this membrane, as well as 
 in the preceding, we can, by microscopic analysis, perceive certain 
 porosities, through which the water exhaled by the uterine capilla- 
 ries passes around the fœtus by a simple endosmose. 
 
 2. Placenta. 
 
 The placenta is a soft, spongy, vascular mass, resembling a cake 
 (gâteau). 
 
 The round form which it ordinarily assumes varies sometimes, 
 in consequence of the insertion of the umbilical cord. This inser- 
 tion, which is most usually in the centre, may also take place on 
 one of the borders of the placenta. 
 
 When the insertion is in the centre, the placenta is more or less 
 circular, and resembles in form a mushroom ; but when the inser- 
 tion is near the border or circumference, the organ assumes an ellip- 
 tical shape, which gives it more or less the appearance of a kidney. 
 Occasionally, instead of being flat, and of an equal size, it is much 
 thicker in the centre, and becomes thinner towards the borders, so 
 as to present the form of a cone ; at other times, instead of forming 
 but one mass, it is divided into several lobes. This disposition may 
 give rise to serious accidents at the time of delivery. 
 
56 NORMAL PREGNANCY. 
 
 (Fig. 40.) (Fig. 47.) 
 
 1. Placenta. 1 4. Remains of the Membranes. 
 
 2. Coronary Sinus. | 5. Knot in the Cord. 
 
 3. Uterine Sinus, anastomosing with the Coronary Sinus. 
 
 The ordinary diameter of the placenta is from six to seven inches ; 
 but these dimensions vary, and sometimes the placenta measures 
 nine inches in length by six in width. In these cases, the length is in- 
 creased at the expense of the thickness, which, in its normal state, 
 is about an inch to an inch and a half, and it is always greater at 
 the insertion of the umbilical cord. 
 
 It is of a grayish-red colour, and this is more marked, depend- 
 ing upon the greater or less engorgement of the organ with blood. 
 
 The placenta presents two surfaces, one external or uterine, the 
 other internal or fcetal. The external surface is more or less con- 
 vex in proportion to the concavity of the uterus, and adheres to 
 the walls of this organ. At the time of delivery, it exhibits fissures, 
 which result from the separation of the cotyledons composing the 
 organ ; but while the placenta is still adhering to the womb, these 
 fissures are concealed by a cellulo-vascular membrane, which cov- 
 ers the whole external surface, and renders it perfectly uniform. 
 
 The internal or fœtal surface is concave, firmer, more smooth 
 and polished than the external ; on it is remarked a vascular plex- 
 us, from which arise the vessels of the umbilical cord. This sur- 
 face is covered by the amnios and chorion. The circumference 
 of the placenta is in relation with the fold of the caduca ; at this 
 part there is observed a vascular circle called the coronary sinus 
 of the placenta. — (See fig. 46.) These vessels communicate on the 
 one part with the uterus, and on the other with the placenta, which 
 they penetrate through the fissures which separate the cotyledons. 
 
 The placenta is formed by an agglomeration of lobes or cotyle- 
 dons separated by fissures, which are termed placental sinuses, and 
 into which passes the cellulo-vascular membrane mentioned above. 
 Authors are wrong in denying the existence of these sinuses ; after 
 the expulsion of the placenta, it is easy to distinguish, between each 
 cotyledon, the inter-lôbular membrane, especially where the cotyl- 
 edons have not been separated by uterine contraction. It is this 
 
 
NORMAL PREGNANCY. 57 
 
 membrane which, in cases of injection, prevents its passage from 
 one cotyledon to another. 
 
 The placenta is composed of blood-vessels, cellular tissue, and 
 whitish filaments, which appear to be an expansion of the chorion, 
 and which have been mistaken by some anatomists for nerves. 
 
 The placenta may be inserted on any point of the uterine cav- 
 ity ; but it is most commonly found near the orifice of one or other 
 of the fallopian tubes ; it is likewise sometimes attached to the cer- 
 vix ; but to whatever point it becomes fixed, it is always that par- 
 ticular portion of the uterus which was in immediate contact with 
 the ovule, after the reflexion of the caduca. 
 
 The placenta adheres to the uterus by cellular tissue more or 
 less dense and compact, which is ordinarily broken up by the con- 
 tractions of the uterus ; at other times, on the contrary, this adhe- 
 sion is so firm that it requires the interference of the hand. 
 
 The placenta is frequently the seat of morbid alterations, such 
 as ramollissement, scirrhous, cartilaginous structure, partial ossifi- 
 cation, formation of cysts, &c, &c, which, when they present 
 themselves to any extent, are very apt to interfere with the devel- 
 opment of the foetus, and occasion premature expulsion. 
 
 The functions of the placenta are to contribute to the nourish- 
 ment and respiration of the foetus. 
 
 In cases of multiple pregnancy, there is usually a placenta to 
 each foetus, and they are intimately united together ; it is only in 
 rare cases that but one placenta exists. 
 
 Umbilical Cord, 
 
 The umbilical cord is a long, cylindrical, and flexible string, 
 which unites the foetus to the placenta. Its length is extremely 
 variable ; it usually measures from eighteen to twenty-four inches ; 
 and instances are mentioned in which it equalled five feet in ex- 
 tent. Its thickness is about that of the little finger, sometimes 
 much larger. Mauriceau knew it to equal the arm of the infant. 
 At other times it is so small that the vessels which it contains are 
 not sufficient to maintain the life of the foetus. Roederer cites an 
 example of this kind. 
 
 The increase or diminution in the volume of the umbilical cord 
 depends frequently on a fluid contained in the cellular tissue, and 
 which is called the gelatine of Wharton ; but when this increase 
 is more sensible near its foetal insertion, it may arise from the pres- 
 ence of a portion of the intestine in the sheath of the cord, and 
 it is of great importance to ascertain this fact before placing a lig- 
 ature around it. 
 
 The manner in which the vessels of the cord comport with each 
 other has a singular influence on its solidity, whether, for example, 
 they separate or unite before they become inserted into the pla- 
 centa. I obtained at La Clinique a placenta in which the vessels 
 of the cord were inserted into the membranes. M. Voillemier, 
 interne of La Clinique, has made a preparation of one, which like- 
 wise presented this arrangement (fig. 48). 
 
 H 
 
58 NORMAL PREGNANCY. 
 
 (Fig. 48.) 
 
 1. Cord inserted into the membranes. 
 
 2. Opening of the membranes through which the foetus has passed. 
 
 3. Fœtal portion of the placenta. 
 
 If, in this case, the rupture of the membranes should take place 
 near one of the three vessels, it might lacerate one of them, and 
 occasion a very serious hemorrhage. But this insertion, as I have 
 already remarked, most usually takes place in the centre of the 
 placenta. The fœtal insertion occurs at the umbilicus, near which 
 there is an annular projection, which indicates very precisely the 
 place at which the separation of the cord is effected. 
 
 The cord is composed of an umbilical vein and two umbilical 
 arteries ; the latter twist round the former, and give it the appear- 
 ance of a cable ; of very loose cellular tissue, pervious to fluids, 
 which explains why it is the cord becomes so easily infiltrated ; of 
 the gelatine of Wharton, a species of viscid liquid, which contrib- 
 utes to increase the volume of the cord ; and, finally, it is compo- 
 sed of the urachus, and of a sheath formed by the prolongation of 
 the chorion and amnios. 
 
 Enlargements of the vein, irregularities, and even knots, are some- 
 times met with in the umbilical cord. When these anomalies are 
 slight, they are unimportant ; but if, on the contrary, they are con- 
 siderable, they often occasion abortion. 
 
 The cord serves for the transmission of the circulating fluid from 
 the placenta to the foetus, and vice versa. 
 
 4. Amniotic Liquor. 
 
 The amniotic liquor is contained within the amnios membrane, 
 and the fœtus and umbilical cord float in the midst of it during the 
 whole period of gestation. 
 
 At the full period of pregnancy, the quantity of this fluid is 
 from sixteen to twenty-four ounces. But this valuation is unim- 
 portant, for the quantity of the amniotic liquid is very variable, 
 and almost always in an inverse ratio to the force and size of the 
 fœtus, and the strength of the mother. It presents a milky turbid- 
 
NORMAL PREGNANCY. 59 
 
 ness, preserves a greenish or lemon colour, and is denser than 
 distilled water. It contains a flocculent material of a greenish 
 white, and appears to be at the same time both acid and alkaline, 
 for it reddens the tincture of turnsol, and changes the sirup of 
 violet to green ; it has a slightly saltish taste, and contains (accord- 
 ing to Vauquelin and Buniva) ninety-eight parts of water, and 
 two parts of albumen, sulphate of soda, and lime. The origin of 
 it is obscure ; it has been pretended successively that it was form- 
 ed from the perspiration, the urine, the saliva of the foetus, from 
 the gelatine of Warthon, &c, &c. ; but none of these views are 
 sufficiently established. It is now generally supposed that the 
 amniotic fluid is produced by an exhalation from the internal sur- 
 face of the membranes of the ovum. 
 
 The liquor amnii serves to nourish the fœtus, and protect it 
 against the effects of concussion and the violence of uterine contrac- 
 tion ; it favours the movements of the fœtus, prevents the adhesion 
 of the limbs to each other or to the trunk, when the epidermis is 
 not yet formed or covered with sebaceous matter ; it breaks the 
 violence of shocks produced by the movements of the fœtus against 
 the uterine walls, and contributes to the development of the ute- 
 rus ; it facilitates the dilatation of the cervix uteri during labour ; 
 and, finally, lubricates the maternal organs, and thus renders the 
 passage of the fœtus more easy at the moment of birth. 
 
 §11. The Fœtus at Term. 
 The fœtus, at the full period of utero-gestation, differs from one 
 of eight months only in its dimensions. Measured from the head 
 to the breech, it is from eleven to twelve inches ; from the head to 
 
 (Fig. 49.) 
 
 the feet, from seventeen to twenty inches. Its weight is usually 
 between six and seven pounds. Sometimes, however, it weighs 
 twelve pounds. I delivered one at La Clinique weighing nine 
 pounds ; but this is rare, and we must not credit the stories of au- 
 
60 NORMAL PREGNANCY. 
 
 thors who state they have seen infants weighing twenty, twenty- 
 four, and thirty pounds. 
 
 The root of the cord is elevated, but it does not correspond to 
 the centre of the body of the fœtus. 
 
 The bis-acromial diameter A B, extending from one shoulder to 
 the other (fig. 49), measures about four inches, but in consequence 
 of the compression the parts undergo in passing the superior strait, 
 this diameter is reducible to three inches six lines. 
 
 The bis-iliac diameter B I, which represents the width of the 
 pelvic extremity, presents the same dimensions as the preceding, 
 but it is somewhat more reducible ; thus, at the time of its passage 
 through the pelvis, it ordinarily does not measure more than from 
 three inches to three inches four lines. This difference is owing to 
 the fact that the foetal pelvis, which is narrow, is covered with soft 
 parts, pretty thick, to be sure, but which readily yield ; while the 
 points between which the bis-acromial diameter is measured are 
 scarcely covered at all by soft parts, and the only diminution caus- 
 ed in this diameter is in consequence of the compression of the 
 chest. 
 
 Head of the Fœtus at Term, 
 But of all the parts of the foetus, the head merits most attention ; 
 it is the largest, and that which most generally presents ; it is of an 
 ovoid shape, and consists of the cranium and face. 
 
 (Figr. 51.) 
 
 The cranium is formed by the union of several bones ; the os 
 frontis (1), divided into two parts ; the two parietalia (2) ; the oc 
 ciput (3) ; and two ossa tempora (4). The bones of the face are, 
 the two superior maxillary, inferior maxillary, and malar bones, to 
 which must be added the inferior portion of the frontal bone. 
 
 The bones of the cranium are separated by membranous spaces, 
 more or less extensive, called sutures and fontanelles. The knowl- 
 edge of these parts is of great importance, for they serve to estab- 
 lish the diagnosis of the presentation of the head, and also that of 
 its positions. 
 
 A. Sutures. — The antero-posterior or sagittal suture (A B C) 
 
NORMAL PREGNANCY. 
 
 61 
 
 extends from the root of the nose to the point of the occiput ; it 
 separates in front the two portions of the os frontis, and in the mid- 
 dle the two parietal bones. In front, this suture receives on each 
 side the two fronto-parietal sutures (O), which form lines of de- 
 marcation between the frontal and parietal bones. 
 
 B. Anterior Fontanelle. — At the point of crossing of these four 
 branches of sutures, the two extremities of the sagittal suture and 
 the two fronto-parietal branches, there is a membranous, broad, 
 quadrilateral space, called the anterior fontanelle or bregma (B) ; 
 on its circumference there are four bony angles formed by the pa- 
 rietal and frontal bones. 
 
 C. Posterior Fontanelle. — The sagittal suture receives at its pos- 
 terior extremity the two branches of the lambdoidal suture (L), 
 which separate the occiput from the parietal bones, and these three 
 branches of suture constitute, by their union, the posterior (E) or 
 occipital fontanelle, less open than the preceding ; it is triangular, 
 and presents three bony angles. 
 
 D. Temporal Fontanelle. — Two other fontanelles, situated one 
 on the right and the other on the left, at the junction of the tempo- 
 ral with the parietal bone, less important than the others, yet de- 
 serve to be mentioned, for they enable us to arrive at accurate di- 
 agnosis in the inclined presentations of the head. (See Varieties of 
 Presentation.) 
 
 These sutures and fontanelles exhibit anomalies which I shall 
 take care to note when treating of the presentations and positions 
 of the head. 
 
 Diameters of the Head. — The principal diameters of the head are 
 ten in number. 
 
 (Fig. 52.) 
 
 (Fig. 53.) 
 
 I shall now enumerate them in the order of their length. 
 
 Occipito-mental (0 M), five inches. 
 
 Mento-bregmatic (MB), \ 
 
 Occipito-frontal (OF), > Four inches. 
 
 Trachelo-occipital (T O), ) 
 
 Sub-occipito-bregmatic (S o B), ) Three inches and a half to 
 
 Trachelo-bregmatic (T B), ) three inches and three fourths. 
 
62 NORMAL PREGNANCY. 
 
 Bi-parietal (B P), three inches and a quarter to three inches and 
 
 a half. 
 
 Trachelo-frontal (T F), ) m. . , , + r 
 
 , . . r ; i /o T7\ [ Three inches and two lines, 
 bub-occipito-trontal (b o r), ) 
 
 Bi-temporal (B T), two inches and a half to three inches. 
 
 It is indispensable to understand thoroughly the measurement of 
 these various diameters ; for on this measurement depends the pos- 
 sibility or impossibility of the descent and passage of the head in 
 certain presentations and positions. I shall refer again to the 
 names and dimensions of each of these diameters, when speaking 
 particularly of their practical application. This is the only mode 
 of impressing upon the memory these numerous points, which the 
 comparison between the old and new measurements has rendered 
 still more difficult to retain. Authors are in the habit of giving the 
 names of the principal circumferences of the head, but, when the 
 diameters are well understood, the circumferences will be readily 
 known ; to enumerate them, therefore, would crowd the memory 
 with useless details. 
 
 Now, if we compare the diameters of the fœtus with those of the 
 canal through which it has to pass, the largest diameter of the su- 
 perior strait being four inches and a quarter to four inches and a 
 half, and that of the inferior strait measuring about the same, it will 
 be at once perceived that, in order that labour may be spontane- 
 ous, it will be necessary for the fœtus, at full term, to present by 
 the head or pelvic extremity, and not by one of the points of its long 
 diameter (E D ; see fig. 49), which measures eleven inches, and 
 which is observed to be the case in presentations of the trunk, 
 which, with very rare exceptions, prevent spontaneous delivery. 
 It must also be remembered, that even when the head presents, it 
 will be necessary that its relations with the superior strait be such 
 that the occipito-mental diameter does not occupy this strait, for this 
 diameter of the head, measuring five inches, should it present, can- 
 not pass. The same thing obtains with regard to the inferior 
 strait ; for the head may, after having descended, assume in the 
 pelvic excavation an untoward position with regard to the occipito- 
 mental diameter, which, however, is rare.* 
 
 Finally, it is necessary that the fœtus be flexible, in order to ac- 
 commodate itself to the curvature of the pelvis through which it has 
 to pass, and its conformation enables it to become readily flexed on 
 all its surfaces. When the flexion is required to be very consid- 
 erable, it is accomplished much more easily, and without danger to 
 the fœtus, in the natural curvature of the body (the anterior) ; thus, 
 when the fœtus is to be extracted, it should always be flexed in 
 this manner. 
 
 But, in the spontaneous expulsion of the fœtus, in which flexion 
 is never complete, it sometimes flexes forward, sometimes back- 
 
 * This diameter can present only in the presentation of the face, which is placed in the 
 excavation in the direct mento-posterior position ; and at the two straits of the pelvis, in 
 the presentation of the pelvic extremity, after the delivery of the trunk, when the head is 
 extended. 
 
NORMAL PREGNANCY. 
 
 63 
 
 ward, according to the presentation and point of the pelvis which 
 it occupies in order to render the expulsion more easy. 
 
 Thus, in presentation of the vertex, at the moment of descend- 
 ing it flexes forward ; at the moment of expulsion it flexes back- 
 ward, in order that the occiput may pass out first, an indispensa- 
 ble condition. In presentation of the face, it is the reverse ; the 
 head at first flexes backward at the time of its descent, then during 
 the delivery it flexes forward, in order that the chin may be de- 
 livered first. I shall revert to these details in speaking of sponta- 
 neous delivery. 
 
 The articulation of the head with the first cervical vertebra, the 
 atlas, is nearly immovable. It only permits movements of flexion. 
 The articulation between the atlas and vertebra dentata is a gyn- 
 glimus, which allows the movement of rotation, but which is limited 
 to the fourth of a circle ; however, this limit can be somewhat ex- 
 ceeded without compromising the safety of the foetus. Madame 
 Lachapelle cites numerous examples of this. M. P. Dubois men- 
 tioned two cases to me in which this torsion was very remarkable, 
 and yet without injury to the child. Recently, at La Clinique, M. 
 Dubois executed, by means of the forceps, a complete demi-tour of 
 rotation on the head of a foetus, in the right occipito-posterior po- 
 sition, and the child was in no way injured ; these instances, how- 
 ever, constitute exceptions, and we should avoid, as far as possible, 
 rotating the head more than the fourth of a circle, the body re- 
 maining fixed. I shall hereafter particularly insist upon these pre- 
 cautions. 
 
 (Fig. 54.) 
 
 2. Attitude of the Fœtus at Term. 
 The foetus is curved on its anterior surface, the chin resting on 
 the chest, the arms applied upon the sides of 
 the thorax, the fore-arms flexed and crossed 
 on the front of the sternum, the feet turned on 
 the front of the legs, the legs resting on the 
 posterior surface of the thighs, and the thighs 
 on the anterior surface of the abdomen. Thus 
 flexed, the foetus presents the form of nearly 
 a regular ovoid, which form is determined by 
 that of the ovum which contains the foetus ; 
 in fact, although the ovum may not compress 
 all the parts of the foetus, there is yet not suffi- 
 cient space in the cavity of the membranes, at 
 an advanced period of pregnancy, for the foe- 
 tus to be extended. ■* 
 
 Causes of Head Presentation. 
 Almost every point of the foetal surface 
 may occupy the inferior portion of the ute- 
 rus, but the cephalic and pelvic extremities 
 are those most frequently found presenting, and of these the for- 
 mer is most common. 
 
64 NORMAL PREGNANCY. 
 
 For a long time authors have endeavoured to discover the cause 
 of this greater frequency in head presentations ; it has been sup- 
 posed that the law of gravity determined this arrangement, and 
 that the foetus, being suspended by the umbilical cord, the cephalic 
 extremity, more heavy than the other, was very naturally made to 
 occupy the inferior part of the womb. 
 
 M. P. Dubois, in a memoir read at the Academy of Medicine* 
 in 1833, has, in my judgment, triumphantly refuted this opinion, 
 and substituted for it another resting on numerous proofs, and 
 which it is difficult not to admit. 
 
 In a word, is it possible to believe that the foetus is suspended by 
 the umbilical cord, when, as early as the third month, we know the 
 cord is already longer than the longest diameter of the cavity in 
 which the ovum is contained ? Can we admit that it is the weight 
 of the head which occasions it to present at the superior strait, 
 when it is easy to satisfy ourselves that the weight of the head and 
 pelvic extremity is the same ? To prove this fact, M. Dubois has 
 repeatedly plunged, horizontally, into a quantity of water, a dead 
 foetus, and he has uniformly observed that all the parts of the foetus 
 descend with equal rapidity, and that the back is the first to reach 
 the bottom of the base. He still farther adds, that in women who, 
 during their pregnancy, retain the horizontal posture, the foetus as 
 commonly presents the head ; that, before the full term, head pres- 
 entations are less frequent, although, at this period, the head is 
 really heavier than the pelvic extremity ; that in foetuses who have 
 a tumour on the pelvic extremity, the tumour being even heavier 
 than the head, this latter still presents ;f and that, finally, in ani- 
 mals where the inferior portion of the organ does not correspond 
 to the cervix, but to the fundus, head are more common than foot- 
 ling presentations. 
 
 Concluding, therefore, from all these facts, that the weight of the 
 head has nothing to do with the production of this phenomenon, 
 he has sought another explanation for the circumstance. Accord- 
 ing to M. Dubois, an instinctive determination of the foetus itself 
 presides over the accomplishment of this law, and this instinct is 
 proved, during foetal life, by that regular and almost constant suc- 
 cession of impressions and movements following them, which indi- 
 cate that there is, during intra-uterine life, between these two func- 
 tions the same connexion which is known to exist after birth. No 
 attentive observer will deny this. And why should voluntary de- 
 terminations be denied the foetus while contained in its mother's 
 womb, when immediately after its expulsion these determinations 
 become manifest ? Who instructs it to seize the mother's breast, 
 and extract nourishment from it ? and often, even in presentations 
 of the face, who teaches it, before its birth, to suck the finger of the 
 accoucheur ? Who indicates to the young of the opossum, when 
 
 * Memoirs of the Royal Academy of Medicine, Paris, 1833, t. iii., p. 430, et t. iv., p. 475. 
 
 f Since the publication of his Memoir, M. P. Dubois has reported a case of this nature; 
 the child was born at the Maternité, and it had on its breech a large tumour ; the head, how- 
 ever, presented first, and very serious difficulty attended the extraction of the pelvic extrem- 
 ity. A similar case also occurred at La Clinique. 
 
NORMAL PREGNANCY. 65 
 
 they are expelled from the uterus, that their organization is imper- 
 fect, and renders them unfit for external existence ? who, I ask, 
 points out to them the necessity of grafting themselves, so to speak, 
 on the tits of their mother, in order that they may undergo in the 
 marsupial pouch this second incubation indispensable to the per- 
 fection of their organization ? What is it that leads the child and 
 animals to the accomplishment of these acts, if it be not the same 
 instinct which presides over the acts of their intra-uterine life, and 
 which indicates to them to present to the mouth of the womb that 
 portion of their body which will admit of the readiest issue ? 
 
 § 12. Functions of the Fœtus. 
 
 The principal functions of the fœtus are nutrition, circulation, 
 and respiration. 
 
 Nutrition. 
 
 Of all the hypotheses advanced in reference to the nutrition of 
 the foetus, one only merits the attention of the accoucheur ; it is 
 that which regards the utero-placental system as alone contribu- 
 ting to this physiological act. I except, however, the nutrition, 
 which goes on at the very commencement of pregnancy, and 
 which for the first fifteen days, as I have already stated, is effected 
 at the expense of the umbilical vesicle, and also, according to M. 
 Velpeau, of the fluid contained in the uterine and reflected caduca. 
 
 I shall now very cursorily examine these various hypotheses, in 
 order that I may bestow more attention on that which we deem to 
 be the only probable one. 
 
 A. Nutrition by the Amniotic Liquor. — Nutrition by the amni- 
 otic liquor may occur in one of two ways : in the one, it is absorb- 
 ed ; in the other, it is swallowed and digested. 
 
 Is the amniotic fluid nutritive 1 Chemical analysis shows that it 
 is. It contains osmazome, albumen, and salts. Direct experiment 
 likewise proves it. Calves have been nourished for several days 
 with nothing but this fluid ; but is it right to conclude that, because 
 this liquid is more nourishing than common water, it serves to nour- 
 ish the foetus either by ingestion or absorption? Certainly not. 
 Again, because coloured injections thrown into the vessels of the 
 mother colour the liquor amnii and skin of the foetus, is this any 
 proof that the amniotic fluid penetrates the organs in order to nour- 
 ish them ? By no means. If there be a species of cutaneous imbi- 
 bition (and the injections have never been known to reach beyond 
 the skin), this is no reason why there should be complete absorp- 
 tion and nutrition. Can we admit that this fluid is swallowed and 
 digested, and that nutrition is thus carried on ? M. Velpeau thinks 
 not, and I certainly concur in opinion with him. 
 
 During gestation, the foetus has its mouth closed, and, moreover, 
 there can be no deglutition without inspiration and expiration. 
 Acephalous children, and children that are born with the natu- 
 ral mucous openings imperforate, are as well developed as oth- 
 
66 NORMAL PREGNANCY. 
 
 ers ; their digestive tube, as M. Velpeau has shown, contains the 
 ordinary quantity of meconium, and even hair. 
 
 Because the liquor amnii has been found mixed with the meco- 
 nium in the stomach of dead foetuses, should we infer that this fluid 
 has served to nourish the foetus ? Certainly not ; nor are we to 
 admit, because water is detected in the stomachs of drowned per- 
 sons, that it has been swallowed.* 
 
 Besides, do we not often see foetuses continuing alive in utero 
 after the entire escape of the liquor amnii. M. Velpeau cites one 
 case in which the foetus lived for more than a month under these 
 circumstances. 
 
 B. Nutrition through the Utero- Placental System. — Authors, in 
 reference to this question, are divided into three classes. The first 
 maintain that the foetus is nourished at the expense of the maternal 
 blood, transmitted directly from the parent to the child ; such was 
 the opinion of M. Antoine Dubois, who, admitting the existence of 
 utero-placental vessels, thought that the radicles of these vessels 
 communicated directly with those of the umbilical vessels, a com- 
 munication which he imagined he had demonstrated by the aid of 
 injection. But the passage of the fluid from one vessel into an- 
 other after death does not prove that, during life, the same thing 
 obtained with regard to the natural fluids. Thus, a fine injection 
 thrown into the arteries of the abdomen will be found on the in- 
 ternal surface of the intestines ; but it will not be inferred from this 
 that the blood continually transudes in this manner into the ali- 
 mentary canal. Injections most commonly prove nothing more 
 than the existence of vessels, and not the course of the fluid which 
 they contain. 
 
 Besides, even if chemistry had pointed out no marked difference 
 between the blood of the adult and that of the foetus, it would be 
 difficult to admit that the maternal blood, in all its purity, without 
 previous elaboration, could be proper to maintain life at the vari- 
 ous periods of foetal evolution; it should be regarded a poison 
 rather than the element of nutrition. 
 
 M. P. Dubois has modified the opinion of his father ; he admits 
 the existence of utero-placental vessels ; but, in his opinion, these 
 vessels are not directly continuous with the umbilical vessels; their 
 communication is established by means of an areolar erectile tissue, 
 situated between the placenta and uterus. I observed perfectly 
 well this inter-utero-placental tissue in a case which I had injected 
 at La Clinique, with M. Després. M. Dubois called my attention 
 to the existence of this tissue in another case, injected by M. Des- 
 prés, where this arrangement was most conclusive. It was impos- 
 sible to separate the surfaces in contact without rupturing the ves- 
 sels which opened into this intermediate erectile tissue in order to 
 
 * The introduction of water and meconium into the air and digestive passages can only 
 take place under certain circumstances. After the rupture of the membranes has permit- 
 ted atmospheric air to penetrate the uterus, and when simultaneously the cord has been 
 compressed in some one point, the fœtus, no longer receiving blood from its mother, makes 
 an effort to execute the acts of external life, expels its meconium and urine, and attempts 
 inspiration and suction. — Ed. 
 
NORMAL PREGNANCY. 67 
 
 communicate directly with the sinuses of the placenta, so that the 
 two surfaces of the uterus and placenta were filled with orifices of 
 variable calibre ; those for the arteries were smaller, while those for 
 the veins were larger. Indeed, there were small prolongations of 
 these vessels observed, which, passing from the uterine surface, 
 appeared to penetrate to the cotyledons of the placenta. 
 
 But after these vessels have traversed the intermediate tissue, 
 do they become directly continuous with the radicles of the umbil- 
 ical vessels, or is there between them, in the placenta, simple con- 
 tact without anastomosis ? I am not prepared to say. This latter 
 view, however, is advocated by M. Jacquemier, who admits the 
 existence of this inter-utero-placental tissue, but who regards it 
 only as a fold of the caduca, in which the vessels do not open, but 
 simply pass through to meet the divisions of the umbilical vein and 
 arteries, with which they come in contact in the substance even of 
 the placenta, but without anastomosing directly. 
 
 (Fig. 55.) 
 
 1. Uterus. 2. Intermediate tissue. 3. Placenta. 
 
 In all cases, the maternal blood is transmitted to the foetus after 
 having undergone a suitable elaboration in the placenta; then, after 
 distributing throughout the system of the fœtus its nutritive princi- 
 ples, it is brought back to the placenta to be purified, according to 
 some, by immediate contact with the blood of the mother ; accord- 
 ing to others, by the mediate contact of the coats of the maternal 
 and foetal vessels ; and this change produced in the blood of the 
 foetus is analogous to what takes place in regard to the venous 
 blood in the lungs of the adult. This is also the opinion of M. Vel- 
 peau, and it is generally adopted. 
 
 C. Respiration. — By foetal respiration is meant the phenomenon 
 by which the blood which has served for the nourishment of the 
 foetus is elaborated in the placenta. 
 
 D. However, the placenta alone does not appear destined to 
 remove from the blood the materials unfit for nutrition ; the liver 
 is associated with it in these functions ; and it is from these ele- 
 ments that the bile is formed. 
 
 Fœtal Circulation. 
 
 The arrangement of the circulating organs, and the phenomena 
 of the circulation in the foetus, are not the same as in the adult. 
 
 In the adult, the partition which separates the auricles of the 
 heart is complete ; in the foetus, on the contrary, this partition is 
 pierced by an opening — the foramen ovale. In the adult, the trunk 
 
68 NORMAL PREGNANCY. 
 
 of the pulmonary artery divides into two large branches, which 
 go to each of the lungs ; in the fœtus, this pulmonary artery gives 
 origin to a trunk, called ductus artreiosus (A), which opens into the 
 arch of the aorta, while the lungs receive small branches. 
 
 The hypogastric branches of the primitive iliac arteries course 
 along the sides of the bladder and urachus, under the name of 
 umbilical arteries (B), and, together with the vein, constitute the 
 umbilical cord, which enters the abdomen. This vein passes on to 
 the longitudinal fissure of the liver, giving off branches, which ram- 
 ify in the right and left lobes of this organ. It then divides into 
 two trunks, one of which, the ductus venosus, or canal of Arantius, 
 continues the course of the primitive trunk, and opens above the di- 
 aphragm into the inferior vena cava ; the other branch, which is 
 larger, passes to the right, and unites with the trunk of the abdom- 
 inal vena portée (F) ; it then ramifies in the liver, and anastomoses 
 with the radicles of the hepatic veins, which empty, as in the adult, 
 a little above the ductus venosus. 
 
 A. Course of the Blood. — The blood, starting from the radicles of 
 the umbilical vein, traverses this vein the whole length of the cord, 
 enters the umbilicus, and proceeds to the longitudinal sinus of the 
 liver, distributing itself to the right and left in the lobes of this 
 organ. Having arrived at the point where the two fissures cross 
 each other, the blood divides into two principal columns, one of 
 which follows the ductus venosus, in order to mix with the blood 
 of the inferior vena cava ; the other follows the umbilical branch 
 of the vena portas, reaches the right lobe of the liver, and is 
 taken up by the hepatic veins, which throw it into the inferior vena 
 cava just as it is traversing the diaphragm. To these two col- 
 umns of blood is joined a third, composed of the blood brought 
 by the inferior cava from the lower portions of the body. These 
 three columns unite, and enter together the right auricle, thence 
 through the foramen ovale into the left auricle, and then into the 
 left ventricle, which sends it through the aorta to all parts of 
 the body, but principally to the head and superior extremities ; 
 it is soon brought back from the superior parts by the jugular and 
 axillary veins ; it then passes into the subclavians, and from thence 
 into the superior vena cava, which throws it into the right auricle ; 
 but, instead of passing through the foramen ovale, this blood goes 
 into the right ventricle, and thence into the pulmonary artery, 
 which sends off two small branches to the lungs, while the 
 greatest part of it is carried through the ductus arteriosus to the 
 descending aorta ; there the blood commingles with that from the 
 left ventricle, and passes down the descending aorta ; a small por- 
 tion of it is distributed to the inferior extremities, but the major 
 part returns to the placenta by the umbilical arteries, to be again 
 taken up by the umbilical vein, after it has undergone fresh elab- 
 oration by the contact of the maternal blood. 
 
 B. Changes in the Circulation after Birth. — In proportion as 
 respiration becomes established, the blood flows in greater quantity 
 to the lungs ; it ceases to pass through the foramen ovale, ductus 
 
NORMAL PREGNANCY. 69 
 
 arteriosus, &c. ; and the circulation becomes similar to that in the 
 adult. 
 
 These changes take place as follow: the umbilical arteries, 
 from the second day, begin to obliterate, but this obliteration is not 
 complete until after the third or fourth day ; and it is not until the 
 third or fourth week that they assume the form of a fibrous cord. 
 
 The umbilical vein and ductus venosus become obliterated a lit- 
 tle later than the arteries, say about the eighth day. 
 
 The foramen ovale and ductus arteriosus do not, in general, be- 
 come closed until the end of eight days. Billard has sometimes 
 found them open as late as three weeks, without occasioning any 
 suffering to the child. (For Fig. 56, and a Table showing the 
 Course of the Blood in the Foetus, see pages 70, 71.) 
 
 Viability of the Fœtus 
 
 By the viability of the foetus, we understand that condition of it 
 which enables it to live an independent existence. An infant may 
 be viable before the full period of gestation ; and it may happen 
 that it is not so even at the completion of this period, when affected 
 by disease or deformity. 
 
 " The fœtal evolution not being fixed, it is the degree of perfec- 
 tion which its organs have attained, and not the period of pregnan- 
 cy, that is to determine its capability for external life. However, 
 the law has pointed out a determinate period ; and it has decided 
 that a child is not viable before the end of the sixth month, and that 
 the husband may disown it if declared viable before the hundred 
 and eightieth day of marriage. 
 
 If we consult authors, this extremely wise law may not always 
 appear just, for we find instances mentioned of children born be- 
 fore the sixth month, who were not only healthy, but who, notwith- 
 standing their small size, lived for a long time. Such is the his- 
 tory, reported by Van Swieten, of Fortunio Liceti, who, born be- 
 fore the sixth month, and not being larger than the hand, attain- 
 ed his seventy-first year; and there are other cases cited* of chil- 
 dren, born at the the end of the fifth month, who were enveloped 
 until nine months had passed by in cotton, exposed to a gentle 
 heat, and nourished with a few drops of milk, who, at the comple- 
 
 * October 10, 1842, 1 requested two of my pupils, Messrs. Arendell and Morris, to attend 
 Mrs. H., who was one of my clinique patients, and whom I had previously attended in three 
 confinements. There was a singular predisposition in this woman to flood immediately after 
 the birth of the child ; and on one occasion, having arrived after she was in a state of col- 
 lapse from loss of blood, I experienced great difficulty in rallying her, which, however, was 
 finally accomplished by administering large doses of laudanum. 
 
 A few hours after the gentlemen reached her house, she was delivered of an infant which 
 presented the most singular aspect of any foetus I had ever seen. It weighed two pounds 
 nine ounces ; its face was extremely shrivelled, giving it the appearance of a superannuated 
 woman ; the surface of its body was of a scarlet hue ; and there was every indication of its 
 being premature. It was, indeed, an unsightly object; yet it breathed, and, in a short time 
 after its birth, cried feebly. I ordered it to be wrapped in soft cotton well lubricated with warm 
 sweet oil. It was nourished with the mother's milk, by having a few drops put into its 
 mouth; at first it laboured under great difficulty in swallowing; but gradually it succeeded 
 in taking sufficient to nourish it, and it is now a vigorous, healthy child. Independently of 
 the evidence afforded by the physical appearance of this infant, I am satisfied, from other cir- 
 cumstances, that the mother could not have completed her sixth month of pregnancy. — Ed. 
 
70 
 
 NORMAL PREGNANCY. 
 
 (Fig. 56.) 
 
NORMAL PREGNANCY. 
 
 Head and upper limbs. 
 
 71 
 
 » $ 
 
 c 2 
 
 CD » 
 
 o es 
 
 3 «s 
 
 Right auricle. — Foramen ovale. — Left auricle. — Left ventricle. 
 
 -Right ventricle. — Pulmonary artery. — Ductus arteriosus. 
 
 I 2.2 
 
 fc>.S 
 
 <D 3 o 
 
 i V 
 
 * I ■ 
 
 S Si® 
 
 < -squni •teAvoq > 
 
 ■saue^JB raoijiquifi 
 
72 NORMAL PREGNANCY. 
 
 tion of the ninth month, were enabled to take the breast, and con- 
 tinued to thrive as well as if born at the ordinary period of gesta- 
 tion. 
 
 Nevertheless, although no one can deny that the fœtus may 
 live before the end of the sixth month, notwithstanding the rarity 
 of these cases and the difficulty of proving them, yet it must be 
 remembered that it is generally not until after the seventh month 
 that the fœtus is viable. The law, therefore, has adopted a medi- 
 um period, the end of the sixth month. 
 
 Art. II. — Compound Pregnancy. 
 
 Pregnancy is called compound when the uterus contains two or 
 more foetuses. It is impossible to comprehend the cause of this 
 anomaly. Twin pregnancies are tolerably frequent : in 37,441 ac- 
 couchements in the Maternité, there were 444 cases of twin preg- 
 nancies. Triplets, although less frequent, are not, however, very 
 rare ; but quadruple births are so rare that some authors have 
 doubted their existence ; some examples, however, are mentioned. 
 Peu states that at the Hôtel Dieu there were five living children 
 at one birth. 
 
 But as to pregnancies of six and seven foetuses, I certainly doubt 
 them ; and in order to credit such extraordinary facts, they need a 
 degree of authenticity which is deficient in most of those mention- 
 ed. Farther, if the examples cited are correct, it is very doubtful 
 whether the presence of so great a number of foetuses in utero 
 could be detected except by post-mortem examination or sponta- 
 neous abortion. How can we, in a word, admit the possibility of 
 the uterus undergoing this degree of distention? 
 
 Authors admit four species of twin pregnancy : 
 
 1st. In the first, two ovules are fecundated in a common caduca, 
 and each fœtus is covered by a separate amnios and chorion. 
 These apartments, formed by the chorion and amnios, are united 
 to each other by a very delicate cellular tissue, whence it happens 
 that each membranous partition separating the foetuses is composed 
 of four folds, two amnions and two chorions. The placentas fre- 
 quently become blended with each other, or are united by mem- 
 brane ; but in most cases, notwithstanding this arrangement, there 
 is no vascular communication between them. 
 
 2d. In the second species, the ovule contains two embryos, which 
 are each enveloped by a different amnios, but which are contained 
 in a common chorion and caduca ; each partition is, therefore, 
 composed of only two folds, the amnions. In this case, the pla- 
 centa is single, and there are almost always numerous vascular 
 communications between the two points into which are inserted 
 the umbilical cords. 
 
 3d. In the third, the embryos are enclosed in a single cavity, and 
 have likewise only one placenta. 
 
 4th. Lastly, in the fourth, one ovule contains another, and it is 
 this that gives rise to monstrosities by inclusion. 
 
NORMAL PREGNANCY. 
 
 73 
 
 Diagnosis. 
 Can the presence of several children in the womb be ascertained 
 before delivery ? The volume of the abdomen, and the multipli- 
 city of active movements, are the only data on which we can pre- 
 sume that the uterus contains more than one foetus. But this sort 
 of investigation is quite uncertain. Such, however, is not the case 
 with the signs by which we are to judge of the presence of twins 
 in utero. The fulness, and not the form, of the abdomen, although 
 we may be satisfied that the uterus is bi-lobed, may serve as a 
 ground of presumption in favour of a double pregnancy. By ex- 
 amining the abdomen externally, if the uterus be not much distend- 
 ed by the liquor amnii, we may frequently be enabled to recognise 
 the different parts of the foetus, as also their situation. Thus, it is 
 possible to ascertain that, at the summit of the ovum, there are two 
 tumours, one to the right and above, solid, spherical, formed by 
 the head of a foetus ; the other, to the left and above, less solid and 
 more irregular, united to small movable parts, is composed of the 
 pelvic extremity of another foetus. Besides, the active movements 
 
 (Fig. 57.) 
 
 are perceived at several different points at the same time ; the im- 
 pulses communicated to the mother by the inferior extremities are 
 felt, above and below, in two opposite directions. The vaginal 
 ballottement becomes exceedingly difficult, often impossible to de- 
 termine, in consequence of the situation of the two foetuses. Press- 
 ed the one by the other in the cavity which contains them, they do 
 not repose on the inferior segment of the uterus, and cannot, there- 
 fore, be displaced by the finger. M. Velpeau, however, mentions 
 a case in which Desormeaux mistook a twin pregnancy in conse- 
 quence of the facility with which he determined the ballottement. 
 Auscultation will here be of essential service. It enables us to 
 detect, on two different points of the abdomen, the pulsations of the 
 foetal heart, one above the transverse line, and to the right (I), the 
 other below it, and to the left. It should, however, be stated that, 
 
 K 
 
74 NORMAL PREGNANCY. 
 
 if the two foetuses are placed above or in front of each other, the 
 pulsations of only one heart will be heard. 
 
 Be it as it may, it is not very difficult to detect a twin pregnan- 
 cy. Thirteen years ago I ascertained the existence of twins in a 
 female, whom I have since several times attended in child-birth. 
 The same thing occurred twice at La Clinique, when, once du- 
 ring labour, and once before accouchement, I predicted the pres- 
 ence of two foetuses. 
 
 Termination. 
 
 As to the mode of conducting these cases, it will depend on the 
 kind of double pregnancy. Thus, in the first species, twofœtuses 
 contained in one caduca, having each a particular amnios and cho- 
 rion, the infants are ordinarily expelled at once ; but the uterus, 
 in consequence of its enormous distention, may contract prema- 
 turely, and one foetus be expelled before term, while the other, 
 retained by the retraction of the organ, may not be born until 
 some days, or even weeks, afterward. Cases similar to these, 
 which certainly are not rare, have given rise to the remarks of 
 authors with regard to superfoetation. One of the foetuses may 
 cease to live and be expelled, or remain in the uterine cavity, the 
 other continuing to grow ; and in this latter case, the dead foetus 
 may be expelled simultaneously with the one that has arrived at 
 full term, or remain for a longer period in the uterine cavity, and 
 then become exsiccated. 
 
 Thus instances are cited of foetuses being expelled several years 
 after the birth of the other twin ; I saw a foetus of this kind at the 
 Salpétrière, in a woman who had not conceived for thirty years. 
 
 In the second species, in which the caduca and chorions are 
 common to the two fœtuses, the children are expelled simultane- 
 ously. However, it is not impossible that the second foetus may 
 be retained for some hours after the first, if the rupture of the sac 
 should take place at that portion of the chorion only, correspond- 
 ing with the amnios of one of the foetuses. 
 
 In the third kind, the fœtuses being enclosed in the same apart- 
 ment, their expulsion cannot be otherwise than simultaneous. 
 
 In the fourth, monstrosities by inclusion, the two foetuses con- 
 stituting but one, the expulsion is the same as in the case of a single 
 foetus. 
 
 As to the mechanism of these various expulsions, the precautions 
 they require, the difficulties they occasion, I refer the reader to 
 future details. 
 
ABNORMAL PREGNANCY. 75 
 
 CHAPTER II. 
 
 ABNORMAL PREGNANCY. 
 
 Art. I. — Extra-Uterine Pregnancy. 
 
 The fecundated ovule, instead of penetrating the uterine cav- 
 ity, will sometimes deviate more or less from the route which it 
 should pursue ; it becomes arrested in different points of its course, 
 and is there developed. Pregnancy is then called extra-uterine. 
 
 There are several forms of extra-uterine pregnancy, depending 
 on the place in which the ovum becomes fixed. 
 
 1st. Ovarian Pregnancy. — The ovule in this species is devel- 
 oped either in the substance of the ovary, or on its surface. In 
 the former case, the pregnancy is denominated internal ovarian ; 
 in the latter, external ovarian. 
 
 It is very difficult, indeed I regard it as almost impossible, to 
 distinguish these two species from each other ; it is probably owing 
 to this circumstance that M. Velpeau has been induced to deny 
 the possibility of an internal ovarian pregnancy. The ovary, in 
 both of these cases, is so completely compromised by the devel- 
 opment of the ovule, that we cannot detect a trace of it. 
 
 2d. Sub-peritoneal-pelvic Pregnancy. — In this species, the ovule 
 is developed between the two folds of the broad ligaments, out- 
 side of the peritoneal and pelvic cavity. 
 
 3d. Tubo-ovarian Pregnancy. — A portion of the ovary, and of 
 the dilated fallopian tube, constitutes, in this case, the cyst in which 
 the fcetus is contained. 
 
 4th. Abdominal Pregnancy. — This variety, in which the ovule 
 is developed in the abdominal cavity, is divided into primitive and 
 secondary ; primitive, when the ovum has ingrafted itself on some 
 point of the abdomen before leaving it ; secondary, when, in con- 
 sequence of the rupture of its primitive cavity, the uterus, tube, 
 or ovary, &c, it penetrates the abdominal cavity. 
 
 5th. Tubal Pregnancy. — This is the most common of all the 
 various forms of extra-uterine pregnancy ; and the fœtus is devel- 
 oped in some portion of the tube between its fimbriated extremity 
 and the external surface of the womb. 
 
 6th. Tubo-interstitial Pregnancy. — The ovum is arrested in that 
 portion of the tube which is found in the substance of the uterine 
 walls, and becomes developed at that point. 
 
 7th. Interstitial Pregnancy. — The ovum, as in the preceding 
 species, is arrested in the tube, but instead of becoming developed 
 there, it passes through the walls of the tube, and penetrates be- 
 tween the fibrous layers of the uterus, where it receives its growth. 
 8th. Utero-tubal Pregnancy. The ovule is developed partly in 
 
76 ABNORMAL PREGNANCY. 
 
 the tube, and partly in the uterus ; this variety is not admitted by 
 M. Velpeau. 
 
 9th. Tubo-abdominal Pregnancy. — In this form, the foetus is de- 
 veloped in the abdomen, the placenta is inserted into the uterus, 
 and the umbilical cord traverses the whole extent of the fallopian 
 tube, in order to put the foetus in communication with the placenta ; 
 Hunter, Patuna, Hofmeister, each report an example of this vari- 
 ety, which is the most rare of all.* 
 
 § 1. Pathological Condition, 
 
 In extra-uterine pregnancies, the ovum is furnished with the cho- 
 rion and amnios. Moreover, in the sub-peritoneal-pelvic and sec- 
 ondary abdominal varieties, it is contained in a pseudo-membra- 
 nous cyst, which represents the caduca. This cyst does not exist 
 in primitive abdominal pregnancy. 
 
 The parts of the mother to which the ovum is attached be- 
 come the seat of a sanguineous congestion, and large vessels ram- 
 ify under the peritoneum at the point into which the placenta is 
 inserted. 
 
 The uterus becomes sympathetically enlarged ; its tissue softens, 
 and its internal surface is covered by a membrane presenting all 
 the characters of the caduca. 
 
 § 2. Causes of Extra- Uterine Pregnancy. 
 
 The causes of extra-uterine pregnancy are as yet enveloped in 
 complete mystery. Authors generally admit that a sudden fright 
 at the moment of fecundation may change the ordinary course of 
 things, and that the ovule, not being seized by the fimbriated tube, 
 becomes developed in or on the ovary, or falls into the abdominal 
 cavity, &c, &c. But how are we to admit this opinion, when we 
 know that the ovule does not abandon the ovary until some days 
 after fecundation ? However, it is possible that the fright might 
 take place at the instant the ovule leaves the ovary. 
 
 M. Dezeimeris attributes this accident to external violence ; M. 
 Velpeau to the anomalies and affections of which the tube may 
 become the seat, such as narrowness, want of continuity, devia- 
 tions, curtailment of its length, engorgement, paralysis, spasm, in- 
 duration, &c, &c, &c. This opinion is undoubtedly the most rea- 
 sonable. 
 
 § 3. Diagnosis. 
 The signs which characterize an extra-uterine pregnancy are so 
 evanescent during the first months, that it becomes very difficult, 
 if not impossible, to distinguish between it and a true pregnancy, 
 or even a uterine engorgement. Thus, immediately after con- 
 ception, the woman experiences abdominal pains, similar to the 
 cramps which attend the commencement of a true pregnancy. 
 
 * For farther details, see the learned researches of MM. Velpeau, Breschet, Dezeimeris, 
 and those recently made by M. Gerdy (Bulletin de l'Académie Royale de Médecine, tome 
 iv., p. 1045.) 
 
ABNORMAL PREGNANCY. 77 
 
 Sometimes there is a fixed pain in one of the iliac fossae. At a la- 
 ter period, the changes in the body and neck of the uterus, which 
 always accompany the development of an extra-uterine fœtus, may 
 give rise to error, by inducing the belief that normal pregnancy ex- 
 ists, especially if the menses should have ceased to appear, and in 
 this case, it sometimes happens that they do not reappear until after 
 the ordinary term of accouchement has passed by, and often they 
 are absent during the entire existence of extra-uterine pregnancy. 
 However, the contrary as frequently occurs, and menstruation is in 
 no way deranged by this abnormal conception. These same varia- 
 tions present themselves with regard to the secretion of milk ; but 
 when the development of the abdomen is manifest, its irregular form, 
 divided into two portions, one of which is composed of the uterus, 
 and the other of the abnormal pregnancy, enables us to arrive at 
 a correct diagnosis in reference to this species of gestation. The 
 vaginal touch, in this case, would prove of essential service, for it 
 would afford us the means of ascertaining the vacuity of the ute- 
 rus, its separation from the tumour in which is contained the fœtus, 
 and the change of situation which the development of this tumour 
 has caused the fœtus to undergo. If the inferior portion of the 
 cyst should occupy the place of the uterus at the superior strait, 
 the neck of this organ will be reached with great difficulty ; but it 
 will be easy to determine the ballottement through the walls of 
 this tumour. I was enabled to detect this sign in a woman op- 
 erated on at La Clinique by M. Dubois, before I came into office. 
 It was so manifest, that this circumstance decided M. Dubois as to 
 the operation. (See page 79.) By the abdominal examination, 
 we can readily distinguish the active and passive motions of the 
 fœtus, which are painful to the mother. 
 
 Auscultation is here of great value in establishing positively the 
 presence of a living child, and in distinguishing it from a movable 
 body foreign from conception, and developed in the midst of a cyst. 
 In the female who, it was supposed, laboured under an extra-uterine 
 pregnancy, and of whom I spoke in the article Diagnosis of Preg- 
 nancy (page 24), the abdominal ballottement caused a belief that she 
 was pregnant, and even the examination by touch yielded a sensa- 
 tion very analogous to the vaginal ballottement ; but before the 
 pretended term of the pregnancy, auscultation exhibited nothing 
 more than a bruit de souffle in the direction of the iliac fossae. 
 
 § 4. Progress, 
 
 At the ordinary term of gestation, frequently even before this 
 period, the pains of childbirth present themselves, which continue 
 often for three or four days, and sometimes longer. If the preg- 
 nancy continues several years, the pains may return at varied in- 
 tervals, and continue for several weeks ; and they occasionally 
 manifest themselves at each period corresponding with the term of 
 gestation. 
 
 The duration of extra-uterine pregnancy is very variable ; it 
 may terminate in a few weeks, or be prolonged for several years. 
 
78 ABNORMAL PREGNANCY. 
 
 Left to itself, it usually terminates by the rupture of the cyst at 
 some indeterminate period, but which, however, does not usually 
 pass beyond the middle of pregnancy. This rupture produces al- 
 most necessarily the death of the fœtus, but in some instances it 
 has survived. It is accompanied by very serious consequen- 
 ces, as, for example, hemorrhage, which occasions the immediate 
 death of the mother ; or, if the hemorrhage be arrested, peritoneal 
 inflammation, determined by the passage of the fœtus, the liquor 
 amnii, and blood into the peritoneal cavity. Two conditions may 
 then present themselves : either the mother dies, or the peritonitis 
 yields to treatment, and then the remains of the impregnation is en- 
 veloped by a new cyst, and continues in the abdominal cavity du- 
 ring life ; in this case the fœtus appears to have undergone a com- 
 plete exsiccation ; frequently, also, the tissues are transformed into 
 an osseous substance. Sometimes, when it has been seen a long 
 time after the term of pregnancy, if the rupture of the cyst has not 
 produced the death of the fœtus, and. if it has lived for some time 
 in its new habitation, the osseous system of the fœtus will be found 
 much greater than at the ordinary period of gestation. Sometimes 
 even the existence of several teeth has been observed, but this is 
 rare ; and most commonly, the soft parts of the fœtus become more 
 or less putrid, and the remains of the skeleton are macerated in a 
 mixture of blood, amniotic fluid, and pus ; the coverings of the fœtus 
 become destroyed, fistulous openings are formed, which place them 
 in communication either with the abdominal walls or perineum, or 
 with the intestinal canal, stomach, vagina, uterus, bladder, and rec- 
 tum : in all such cases, the remains pass out through these various 
 openings. 
 
 It frequently happens that the suppuration from the wound ex- 
 hausts the patient ; at other times the suppuration ceases, the 
 wound heals, or is converted into a simple fistulous ulcer, and the 
 woman survives many years. 
 
 § 5. Treatment. 
 
 During the first months of an extra-uterine pregnancy, nothing 
 should be attempted in the way of an operation, for the remedy 
 would be more grave than the disease. We should limit ourselves 
 to general means, such as abundant and repeated bleedings, in or- 
 der to prevent local congestions, which might form near the cyst, 
 and thus favour its rupture. When this rupture occurs spontane- 
 ously, we should endeavour to prevent or moderate the hemorrhage 
 by repose, refrigerants, bleeding, &c, and combat the consecutive 
 peritoneal inflammation by the appropriate remedies. 
 
 In a case of extra-uterine pregnancy which has arrived nearly 
 at term, if labour should manifest itself, the accoucheur should at 
 once, with a view of arresting it, have recourse to the means ad- 
 vised in the article Abortion {injections of laudanum in large quan- 
 tities), and he should on no account, in order to save the child, 
 practise gastrotomy, which entails on the mother certain death. 
 
 The danger of the operation is far greater than in the gastroto- 
 
ABNORMAL PREGNANCY. 79 
 
 my practised in cases of normal pregnancy. The placenta does 
 not separate of itself from the internal surface of the cyst ; it ad- 
 heres so intimately to it that it seems to be an integral part of it. 
 Its extraction, therefore, is very difficult and dangerous. 
 
 Again, how can we decide to perform this operation when we 
 know that the unhappy woman, if she should not die immediately, 
 will undoubtedly sink gradually, and in the midst, too, of the most 
 excruciating sufferings 1 
 
 In a word, it is my opinion, that if the labour cannot be quieted 
 by opium, the cyst being intact, nothing should justify an opera- 
 tion ; and the objection, if possible, is still stronger, should the cyst 
 be ruptured. 
 
 Art cannot profitably interfere until the first phenomena have 
 passed by, whether there has been rupture of the cyst or not ; and 
 then there should be no haste: the cyst should be allowed time 
 for a new formation, and this is a slow process ; and then the op- 
 eration is only to be attempted in order to prevent imminent dan- 
 ger, or to relieve the woman from habitual suffering, which ren- 
 ders life a burden to her. 
 
 However, as an exception to this rule, I shall very briefly report 
 a case of extra-uterine pregnancy which occurred at La Clinique 
 before my entrance into it, and which has just been published by 
 M. Voillemier, interne of La Clinique at that time. 
 
 A woman presented herself, having been labouring under an 
 extra-uterine pregnancy of twenty-two months' standing. She 
 was in tolerable health, but her infirmity produced such a degree 
 of distress that she supplicated M. P. Dubois to deliver her. The 
 head of the fœtus was felt distinctly at the superior strait, through 
 the superior and posterior wall of the uterus ; and a very impor- 
 tant fact to be remembered is, that the head enjoyed considerable 
 mobility, so that the vaginal ballottement was perceived as readily 
 as in ordinary pregnancy. With these favourable dispositions, M. 
 P. Dubois hoped, by an incision made through the superior wall 
 of the vagina and the inferior of the cyst, to be able to seize the 
 head with the forceps ; and certainly there were ample grounds 
 for this hope. However, before resolving on an operation of this 
 magnitude, he thought it judicious to take the counsel of some of 
 his confrères. I was present at the consultation, and all, without 
 exception, approved of the operation, and judged, after a full ex- 
 amination, that it was possible. It is therefore untrue, as has been 
 since asserted, that the operation was performed notwithstanding 
 a strong opposition. 
 
 When the walls of the cyst and vagina were cut into, it was 
 discovered that adhesions existed between the walls of the cyst 
 and scalp, and that the mobility was only between the bones and 
 scalp. It was impossible, therefore, to attempt to seize the head, 
 and the operation was abandoned. 
 
 Nevertheless, though not immediately, it was ultimately entirely 
 successful. At the expiration of a few days, the walls of the cyst 
 became inflamed, and the fœtus, in a state of putrefaction, was de- 
 
80 FALSE PREGNANCY. 
 
 tached in small pieces ; the bones were extracted by means of the 
 long pincers and injections ; the opening closed, and the woman 
 left the hospital in a state of perfect health. Two or three months 
 afterward, the opening again presented itself in order to afford 
 passage to the tibia, which was wanting to complete all the bones 
 of the skeleton, and which the woman herself brought to La Clin- 
 ique. Since this time she has continued to enjoy uninterrupted 
 health. 
 
 CHAPTER III. 
 
 FALSE PREGNANCY, OR AFFECTIONS WHICH MAY SIMULATE IT. 
 
 Art. I. — Retention of the Menses. 
 
 The accumulation of the menstrual blood in the uterus may be 
 mistaken for pregnancy:* this error is possible during the first 
 months of the suppression ; for this retention frequently determines 
 the various sympathies which constitute the presumptive signs : the 
 difficulty, too, of ascertaining the existence of pregnancy during the 
 
 * On the 20th of June, 1842, 1 was visited by a respectable woman, the wife of a mechan- 
 ic, who told me that she had been married about six weeks. She stated that her husband, 
 about a month after her marriage, had begun to treat her cruelly, in consequence of suspi- 
 cions he entertained with regard to her chastity. When I saw her, she had the appearance 
 of being about six months pregnant ; and she frankly acknowledged that some of the female 
 relatives of her husband had impressed him with the belief that she was pregnant when he 
 married her : hence his cruel treatment. The poor woman was in deep distress, and urged 
 me to satisfy her husband that she was unjustly accused, telling me, at the same time, that 
 she would submit to any examination I might suggest. She informed me that she was twen- 
 ty-seven years of age, and had never menstruated ; and that her general health had been 
 wretched from early girlhood. On calling to see her the following day, I discovered that 
 there was an indistinct and circumscribed fluctuation in the anterior portion of the abdomen, 
 extending about one inch above the umbilicus ; and on introducing my finger into the vagi- 
 na, and reaching the cervix uteri, I discovered an entire absence of the os tincae, the lower 
 and central portion of the cervix being quite smooth and uniform on its surface. With the 
 other hand applied on the abdomen, I grasped the fundus of the womb, and felt that I embraced 
 this organ completely between the hand externally and the finger introduced into the vagi- 
 na. The diagnosis was plain— that the fluctuation felt in the first instance was the men- 
 strual blood contained within the uterus ; and that, in consequence of there being no outlet, 
 this fluid had accumulated, producing distension of the uterus, and giving rise to a suspicion 
 of pregnancy. After this examination, I stated most fully my opinion to the husband, and 
 told him that his wife could be relieved by an operation : at the same time assuring him that 
 his suspicions were entirely unfounded. 
 
 Assisted by two of my office pupils, Messrs. Burtsell and Morris, now Doctor Morris, of 
 North Carolina, 1 introduced a speculum into the vagina, and brought distinctly to view the 
 cervix uteri ; this I penetrated atitslower and central portion, and instantly not less, I am sure, 
 than three pints of blood were discharged from the uterine cavity. It is as well to mention 
 that the perineal strait was somewhat contracted in its transverse diameter. The opera- 
 tion was attended with very little pain ; the uterus was restored to its ordinary size, and the 
 patient recovered perfectly in the course of a few days, when I was much gratified with a 
 visit from her and her husband, the latter appearing really contrite, while the former as- 
 sured me that she was again restored to the confidence and love of her husband. 
 
 Precisely six months from the day I operated, I was called on by this same patient, who 
 informed me that she now really believed herself pregnant, which I found to be actually the 
 case. I attended her in her confinement, and after a severe labour of twenty-eight hours, I 
 found it necessary to apply the forceps, and delivered her of a fine living son, assisted by two. 
 of my pupils, Messrs. Meriwether and Whipple, of Alabama.— En. 
 
FALSE PREGNANCY. 81 
 
 first months, as I have already remarked in the article Diagnosis 
 of Pregnancy, is another cause for doubt. But when the suppres- 
 sion is prolonged, and the accumulation consequently considerable, 
 it is easy to distinguish it from an advanced pregnancy, which this 
 abnormal development of the uterus so closely simulates. 
 
 The absence of the active movements of the fœtus, of the pulsa- 
 tions of the heart, the abdominal or vaginal ballottement, the regu- 
 larly ovoid form of the abdomen, &c, &c, enable us to determine 
 that there is no pregnancy. The species of disease which simulates 
 pregnancy is characterized by the development of the abdomen, 
 which does not take place regularly, but indeed diminishes, and 
 again increases, particularly at the menstrual periods. The vagi- 
 nal touch will indicate either an imperforate hymen, or an occlu- 
 sion of the os tincse. 
 
 Treatment. — If there should be occlusion of the os tincse, we 
 must, in order to afford issue to the blood, introduce into the neck 
 a silver sound, a stilet, or any other similar body ; this will almost 
 always suffice to overcome the obstacle, when it is covered by a 
 simple agglutination ; but if it cannot be overcome in this way, we 
 must employ a long trochar or bistoury, the blade of which must 
 be covered with linen except at its point. After the puncture is 
 made, a small piece of lint is to be introduced, in order to prevent 
 union. If the liquid should be so thick as not to escape through 
 the puncture, it will then be necessary to make a larger incision. 
 
 If there should be occlusion of the vagina by a simple diaphragm, 
 a conical incision should be made. When the obstruction is occa- 
 sioned by the union of the vaginal walls, the operation will be 
 both difficult and dangerous ; however, by a cautious dissection, it 
 can be performed. M. Amusât cites a case of this kind in his own 
 practice. 
 
 Happily, it is at the vulva that the obstruction is most frequent- 
 ly met with, and is occasioned by the hymen. The blood occu- 
 pies the vagina, and not the uterus. The collection is between the 
 lips of the womb and vulva, and a distinct fluctuation is felt. In 
 this case, a large incision is to be made into the integuments ; but 
 if fluctuation should not be felt, then the incision is to be made 
 layer by layer, from without inward. It is proper, in both cases, 
 to remove the flaps, which frequently result from the incision. 
 
 Art. II. — Collection of Water. 
 
 The accumulation in the uterus of a clear and slightly lemon- 
 coloured fluid, sometimes mixed with blood, may also simulate preg- 
 nancy. It is the same with the accumulation of gas in uterine 
 tympanitis. In the former case, the error is frequently possible 
 before the third or fourth month. This condition is accompanied 
 by retention of the menses, and most of the presumptive signs ; but 
 after this period a mistake is scarcely possible. However, exam- 
 ples are mentioned of watery pregnancy, which, having produced 
 no disturbance in the economy, had been mistaken for true pregnan- 
 
 L 
 
82 FALSE PREGNANCY. 
 
 
 cy, even at an advanced period. One of my relatives, the daugh- 
 ter of an experienced accoucheur, presented a very remarkable in- 
 stance of this. After a suppression of eight months, she voided a 
 large quantity of clear water, and her abdomen, as large as at full 
 term, suddenly diminished in size, and her health experienced no 
 derangement. 
 
 If this accumulation of water should be due to the same causes 
 that produce the retention of the menses, the same means of relief 
 are to be employed. 
 
 In the latter case, or uterine tympanitis, the uterus is extremely 
 light, and percussion results in a characteristic resonance. This 
 affection requires the same indications as the preceding. 
 
 Art. III. — Nervous or Hysterical Pregnancy. 
 Women who have an ardent desire to become mothers frequent- 
 ly imagine themselves pregnant when they are not so. I have al- 
 ready cited the case of a female in whom the illusion was such as 
 really to cause her to believe that she felt the movements of the 
 fœtus. Such instances are by no means rare ; M. Velpeau men- 
 tions a great number of them. 
 
 Art. IV. — Molar Pregnancy. 
 
 We understand by a mole an abnormal production developed in 
 the uterus, without any manifest alteration of the uterine cavity. 
 They are exceedingly various ; the most common are the following : 
 
 1st. Fleshy Mole. — A species of membranous concretion, which 
 is deposited in the uterus at the menstrual periods. 
 
 2d. Fibrinous Bodies, or degenerated coagula of blood. — These 
 two varieties are found equally in the young girl and married wom- 
 an. But the following, which are undoubtedly foetal degenerations, 
 -are met with only in the latter. 
 
 A. Mole of Generation. — An attentive examination will almost 
 always enable us to trace in this species the remains of natural 
 structure. The degeneration affects the foetus or its envelopes. 
 If the ovum is not expelled when the foetus has been blighted, 
 some monstrosity results ; if, on the contrary, it be the annexai 
 that are affected, a veritable mole is formed. In the latter case, 
 the embryo and umbilical cord are completely destroyed ; they are 
 either absorbed or expelled through a rent of the ovum, and there 
 is no vestige of them. Under these circumstances, there is nothing 
 left but a mass more or less voluminous, possessing various forms ; 
 most commonly it is ovoid ; it contains a fluid, sometimes clear, 
 sometimes coloured. Frequently the amnios is found intact, while 
 there are only traces of the other membranes ; sometimes both the 
 amnios and chorion exist, with shreds of the caduca. I have seen 
 several of this kind, and among others one which measured from 
 four to five inches in length. Placental apoplexy, schirrous tumours, 
 and, in a word, the various degenerations of the placenta, may pro- 
 duce this species of mole. 
 
 B. Hydatid Mole. — This is the most common of all the moles of 
 
FALSE PREGNANCY. 83 
 
 generation. They are capable of assuming every variety of form, 
 which satisfactorily explains why we find in the older works such 
 wonderful narrations of women having been delivered of bodies pos- 
 sessing the shape of animals, fruits, &c, &c. M. Velpeau regards 
 it as the result of a hypertrophy of the villosities of the chorion ; this 
 is also the opinion of M. P. Dubois. This form of mole may attain 
 a considerable volume, and, in this case, the enlargement of the ab- 
 domen is similar to a pregnancy at the ninth month. M. Dubois 
 exhibited an enormous mass at his lectures, which had been expell- 
 ed by a female at the Maternité. 
 
 It is impossible, at the commencement of pregnancy, to say 
 whether the uterus contains a normal or degenerated foetus. At a 
 more advanced period it is not so difficult to ascertain that a fœtus 
 does not exist in the uterus, but we may very readily confound the 
 presence of a mole with some of those affections which simulate 
 pregnancy. When the mole is expelled, the female requires the 
 same attentions as in abortion. This accident may occur several 
 times in the same woman, and we possess no means of preventing 
 or curing it ; only, in cases in which we have detected the presence 
 of a mole in the uterus of a woman who has already thrown off 
 several of them, we may administer ergot in order to favour its 
 expulsion.* 
 
 * In 1839 I received a note, requesting me to visit, without delay, a lady who was residing 
 in the State of New-Jersey, about thirty miles from this city. I immediately repaired to her 
 residence, and on my arrival was received by her father, a venerable and accomplished gen- 
 tleman. He seemed broken in spirit, and it was evident that grief had taken a deep hold of 
 his frame. On being introduced into his daughter's room, my sympathies were at once 
 awakened on beholding the wreck of beauty which was presented to my view. She was 
 evidently labouring under phthisis, and it appeared from her wasted form that her days 
 were numbered. My presence did not seem to produce the slightest disturbance, and she 
 greeted me with this expression, " Well, doctor, I am glad to see you on my beloved father's 
 account, for he will not believe that I cannot yet be restored to health. Life has lost all its 
 charms for me, and I long for the repose of the grave." These words were spoken with ex- 
 traordinary gentleness, but yet with a firmness that at once gave me an insight into the char- 
 acter of this lovely woman. From her own lips I received the following history of her case. 
 Her father was a clergyman of high standing in the English Church, and had had a pastoral 
 charge in England, in which he continued until circumstances rendered it necessary for him 
 to leave that country and seek a residence in America. At a very early age she had lost 
 her mother, and was almost entirely educated by her father, whose talents and attainments 
 admirably fitted him for this duty. When she had attained her eighteenth year, there was 
 an attachment formed between her and a young barrister of great promise and respectability. 
 This attachment resulted in a matrimonial engagement. Soon after the engagement, she 
 began unaccountably to decline in health. There was considerable irregularity in her men- 
 strual periods, with more or less constant nausea, loss of appetite, inability to sleep, fever- 
 ishness, and an uncontrollable dislike to society ; besides, there was a general change in her 
 personal appearance : her abdomen became enlarged, her breasts increased in size, &c. 
 These changes soon attracted the attention of some of her female acquaintances, and ru- 
 mour was uncharitable enough to suspect her virtue. The barrister to whom she was affi- 
 anced heard of these reports, and, without a moment's delay, wrote a letter to her father, 
 begging to be exonerated from his engagement. This was assented to without hesitation. 
 This young lady, conscious of her own innocence, requested that a physician should be sent 
 for, in order that the nature of her case might be ascertained. A medical man accordingly 
 visited her, and, after an investigation of her symptoms, he, no doubt from very philanthropic 
 motives, informed the father that she was pregnant, and that means should be immediately 
 taken to keep the unpleasant matter secret. The father, indignant at this imputation against 
 the honour of his child, spurned the proposition, and instantly requested an additional con- 
 sultation. This resulted in a confirmation of the opinion previously expressed, and the feel- 
 ings of that father can be better appreciated than described. Without any delay, that good 
 man determined to resign his living, gather up his little property, and proceed with his 
 daughter to America. On his passage to this country his daughter became extremely ill, 
 and as there was a physician on board the steamer, his advice was requested. After seeing 
 the patient (she was at the time labouring under excessive vomiting from sea-sickness), he 
 
84 FALSE PREGNANCY. 
 
 told the father that he apprehended that she might have a premature delivery. Such, there- 
 fore, was the general appearance of this lady, that a physician, merely judging from appear- 
 ances, at once concluded she was pregnant. 
 
 This was about the substance of what I learned of the previous history of this lady; and 
 my opinion was then requested as to the character of her malady. My feelings were natu- 
 rally very much enlisted in her behalf, and I proceeded with great caution in the investigation 
 of her case. 
 
 In placing my hand upon the hypogastric region, previously flexing the thighs upon the 
 pelvis, I distinctly felt an enlargement, which, from its circumscribed character and position, 
 I recognised to be the uterus. The abdomen was excessively tympanitic, and as much dis- 
 tended as it usually is at the seventh month of gestation. In making a vaginal examination, 
 the enlarged uterus was plainly felt, and it presented a hardness to the touch which I had 
 never before experienced. It was not the hardness of schirrus, nor was there any pain expe- 
 rienced on pressure. The os tincae was slightly dilated and perfectly circular. Projecting 
 through it I felt a small body, which to the touch seemed to be of a calcareous nature. I 
 could readily grasp the uterus between one hand applied to the hypogastric region and the 
 finger introduced into the vagina ; and it appeared to equal in size the foetal head at full term. 
 The organ appeared to be much more rounded in its development than is usual in pregnan- 
 cy ; and on introducing the finger into the rectum, the same hardness of the tumour was ex- 
 perienced that was observed in the vaginal examination, but an entire freedom from pain. 
 It was very evident that there was no pregnancy, and without hesitation I gave this as my 
 opinion ; at the same time stating that the enlargement of the womb depended most proba- 
 bly upon some internal growth, the precise nature of which I could not determine. That it 
 was not a polypus was evident from the absence of all the symptoms which usually charac- 
 terize it. After I had expressed my opinion that she was not pregnant, the only observation 
 this interesting creature made was, " Doctor, you are right." These few words were full of 
 meaning, and their import I could not but appreciate. The father was soon made acquaint- 
 ed with the result of my examination, and he seemed perfectly unmoved as I expressed to 
 him my opinion. It was evident that he had never faltered for one moment in the belief of 
 his daughter's virtue, and required no assurance from me or any other living being that his 
 child had been cruelly abused. He asked me with great solicitude whether something could 
 not be done to restore her to health ; and his agitation was extreme when I told him that his 
 daughter was in the last stage of consumption. I left him with the pledge that he would 
 inform me of her dissolution, and afford me an opportunity, by a post-mortem examination, of 
 testing the truth of my opinion. About four weeks from this time I received a note an- 
 nouncing the death of this lady, and requesting that I would immediately hasten to the 
 house, for the purpose of making the autopsy. Dr. Ostrom, now practising in Goshen, in this 
 state, at my request, accompanied me, and assisted in the examination. It was discovered 
 that the enlargement of the uterus was in consequence of a fibrous tumour, which occupied 
 its whole internal surface ; and the small body which 1 had felt projecting through the os 
 tincae was a calculous concretion, of which there were several attached to the tumour. 
 Plate No. 1, page 85, shows the exterior of the tumour; fig. 2, the circular character of the 
 os tincae. Plate No. 2 exhibits the internal structure of the tumour, with several small cal- 
 culous concretions. 
 
 The mere narration of this case carries with it its own comments ; and I trust a proper 
 moral may be drawn from its perusal. — Ed. 
 
(Plate 1.) 
 
 (Plate 2.) 
 
86 DISEASES INCIDENT TO PREGNANCY. 
 
 
 CHAPTER IV. 
 
 DISTURBANCES AND DISEASES INCIDENT TO PREGNANCY. 
 
 The pregnant woman is liable to every disease, and whether the 
 disease precede pregnancy or appear during its course, it always 
 constitutes a serious complication. 
 
 But the limits of this work will not permit me to describe the in- 
 fluence which each disease exerts over pregnancy, and I shall, 
 therefore, limit myself to certain affections which ordinarily com- 
 plicate it, or which are peculiar to it. 
 
 Conception frequently occasions in the economy a disturbance, 
 the effects of which vary not only in different individuals, but some- 
 times also in the same person during successive pregnancies. 
 Thus, a female is affected with vomiting, syncope, &c, in one 
 pregnancy, and in the following enjoys perfect health. More gen- 
 erally, however, the same order of symptoms presents in each preg- 
 nancy ; and, in this case, the disturbances become almost a cer- 
 tain sign of conception. These affections are modified by the tem- 
 perament and habits of the individual, and also by the period of 
 pregnancy. 
 
 Art. I. — Digestive Lesions. 
 The sympathetic relations between the uterus and digestive or- 
 gans may occasion a derangement of their functions, and give rise 
 to several inconveniences or diseases, which, in the order of their 
 frequency, are, nausea and vomiting, anorexia, acid stomach, long- 
 ings, dyspepsia, constipation, ptyalism, and diarrhoea. 
 
 § 1. Nausea and Vomiting. 
 It is very rare for a woman to become pregnant without being 
 troubled with these ailments. They occur so constantly in preg- 
 nancy, that they constitute one of the first presumptive signs of this 
 state. When moderate, they are not of much moment, and termi- 
 nate naturally between the third and fourth month of gestation, but it 
 is not unusual for them to reappear towards the end of the term. 
 During the first months, they are occasioned by the sympathetic 
 reaction of the uterus on the stomach ; in the latter period of preg- 
 nancy, by the mechanical pressure exerted by the uterus on the 
 stomach and intestines. The particular time of the day at which 
 these vomitings present themselves varies : some women throw off 
 early in the morning a slimy fluid more or less abundant ; or, after 
 one or each meal, they reject a portion of the aliments taken into 
 the stomach. This latter case becomes serious when there is a 
 complete rejection of the food ; but it is very rare, after even re- 
 peated vomitings, that sufficient food for the purposes of nourish- 
 
DISEASES INCIDENT TO PREGNANCY. 87 
 
 ment does not remain in the stomach. I have often heard wom- 
 en complain that they could not retain food in the stomach, and yet 
 they were not sensibly emaciated ; however, I have met with other 
 cases in which repeated vomiting would have been followed by 
 the gravest consequences, if it had not been moderated. 
 
 The vomiting is in general easy, and not painful ; but it is occa- 
 sionally accompanied by such violent and long-continued efforts as 
 to induce the premature expulsion of the foetus, especially in women 
 predisposed to this accident ; and it becomes necessary for the ac- 
 coucheur to prescribe a proper regimen in order to diminish its 
 severity. 
 
 When the vomiting is quite easy, and the matter ejected con- 
 tains no food, it will suffice to prescribe for the woman some slightly 
 aromatic drink ; the infusion of orange-flowers, or linden tea, &c. 
 But if it should be attended with much violence, or takes place 
 after meals, and the food is thrown off, it will then be necessary to 
 administer cold, iced drinks, soda-water, antispasmodics, Vichy's 
 lozenges, and particularly opium, either internally or in fomenta- 
 tion, to the epigastrium. The nourishment should be light, and, in 
 the choice of articles of drink, regard should be had to the condi- 
 tion of the stomach. I have often found great benefit from sud- 
 denly placing a piece of ice on the epigastrium at the moment 
 the vomiting commenced, and from recommending the patient 
 to swallow small portions of this substance. Opium, by the en- 
 dermic method, has also very frequently proved successful with 
 me. With this view, I have placed on a blistered surface of 
 the epigastrium a centigramme or more of the hydrochlorate of 
 morphia, and I have successively increased the quantity to four 
 or five centigrammes each day. If it be observed that the vom- 
 iting has a tendency to occur regularly at the same hour, it will 
 be proper to employ the sulphate of quinine. M. Honoré has used 
 it with success in one of my patients, in whom the severity and 
 duration of the vomiting occasioned serious distress. 
 
 The tension and pain which usually accompany the vomiting 
 must be combated by leeches to the epigastrium, and still bet- 
 ter by narcotic fomentations or cataplasms ; by baths, a small 
 general bleeding, particularly if the pains extend to the loins and 
 hypogastric region ; in this latter case, in order to prevent abor- 
 tion, it will be proper to administer laudanum injections until the 
 pains cease. Authors have likewise extolled the use of wines, 
 alcoholic liquors, cups, an anodyne plaster applied to the pit of the 
 stomach, &c. These various means may be tried, for they may 
 succeed in one case while they may prove useless in another; 
 and when every kind of medication fails, they may still be em- 
 ployed, if it be only to encourage the patient, and enable her 
 to attain the period of gestation, at which this trouble usually ter- 
 minates spontaneously. 
 
 § 2. Anorexia. 
 Anorexia. — Many women, during their pregnancy, experience 
 
88 DISEASES INCIDENT TO PREGNANCY. 
 
 a want of appetite or a disgust for certain articles of food, and es- 
 pecially for meats : the cause of this is to be attributed to a pecu- 
 liar nervous condition of the stomach, or to a torpid state either of 
 this organ or the intestines, or to plethora. If it be suspected that 
 the anorexia proceed from the first cause, some antispasmodic in- 
 fusion, ether, the anodyne liquor of Hoffman, the nitrate of bis- 
 muth, &c, will suffice to dissipate it ; the torpor of the bowels re- 
 quires the use of diluents, such as lemonade, whey, &c. ; after- 
 ward, if necessary, évacuants, such as rhubarb, the neutral salts, 
 or castor oil in small doses, will be indicated. Finally, emetics 
 have been recommended in gastric derangement ; but, in my opin- 
 ion, great care, should be used in the employment of these, which, 
 although under other circumstances harmless, sometimes occasion 
 serious injury to the foetus. It will, therefore, be incumbent to omit 
 them in weak, nervous women, and in those who have already 
 aborted. Flatulence, which annoys many persons, and is some- 
 times accompanied by considerable pain, especially after eating, 
 must be controlled by an infusion of chamomile, fennel seed, Mal- 
 aga wine, &c, &c. As to plethora, we shall hereafter state the 
 means to be employed ; but, in general, the anorexia of pregnant 
 women, when slight, and unconnected with disease of the diges- 
 tive organs, does not require much attention. Indeed, it is im- 
 portant that we should not attempt to oppose the peculiar taste of 
 the patient, or constrain her to eat such diet as may be repugnant 
 to her. 
 
 § 3. Acidity, 
 Acidity, which is sometimes almost insupportable, frequently 
 manifests itself in the morning, or after a meal. It is easily cor- 
 rected by bitter infusions and aromatics, for example, such as the 
 wild endive combined with orange-flowers or chamomile ; Vichy's 
 lozenges, or the calcined magnesia, succeed very well. Let three 
 or four of the lozenges be taken daily ; the dose of magnesia will 
 vary from one to four grammes. 
 
 § 4. Longings. 
 Longings sometimes accompany anorexia ; they consist in a de- 
 sire to eat unnatural, and even disgusting articles. Numerous in- 
 stances of this depraved taste are cited as having been exhibited in 
 delicate females, who, in health, were most particular as to their 
 diet. These longings are usually of short duration, and require no 
 special treatment, if they do not proceed from anorexia. We 
 must, however, prevent the female from eating substances which 
 we know to be injurious to her, while she may be indulged in those 
 of a nutritious character. 
 
 § 5. Dyspepsia. 
 Slow or laborious digestion, or dyspepsia, is almost always ac- 
 companied by a certain degree of constipation, which we must, in 
 the first place, endeavour to remove ; but if, after this, the dyspepsia 
 
DISEASES INCIDENT TO PREGNANCY. 89 
 
 should continue, we must prescribe nourishment of easy digestion, 
 and taken in small quantities. The patient should employ all those 
 means which are proper to facilitate digestion. 
 
 § 6. Constipation. 
 Constipation, of frequent occurrence during pregnancy, is occa- 
 sioned particularly by the compression which the uterus, more or 
 less developed, exerts on the rectum ; it may also proceed from the 
 digestive derangements of which we have already spoken, or, in- 
 deed, may occasion them. This condition requires attention, for 
 the large accumulation of foecal matter in the middle of the rec- 
 tum requiring great expulsive effort, may excite the uterus to 
 premature action, and thus cause abortion. The constipation 
 must be controlled by remedies, or by a gentle and appropriate 
 diet, according to the indications. When injections prove insuffi- 
 cient, we must have recourse to other means, but the use of drastic 
 purgatives will be extremely objectionable. Castor oil, Seidlitz wa- 
 ter, or any other mild laxative, may be employed. 
 
 § 7. Diarrhœa. 
 Diarrhoea is met with more rarely ; it may proceed simply from 
 the sympathy of the uterus with the intestines, or from an irritation 
 of the latter. In the first case, antispasmodics will suffice ; and in 
 the second, we must employ mild drinks, rice or gum water 
 sweetened with the sirup of quince, and starch injections with five 
 or six drops of the laudanum of Sydenham. The diet should con- 
 sist of the mildest articles, in small quantity. 
 
 § 8. Ptyalism. 
 
 Ptyalism, or an abundant secretion of saliva, is observed more 
 particularly during the first months of pregnancy. It ordinarily 
 continues so short a time, and presents such little inconvenience, 
 that it requires no treatment. However, it may continue during 
 the whole period of pregnancy, and assume a distressing char- 
 acter. 
 
 M. Devilliers, Jr., mentioned to me a case of this kind, which M. 
 Danyau communicated to the medical society of the twelfth arron- 
 dissement. A lady, in her first pregnancy, had an abundant saliva- 
 tion until the sixth month. In her second pregnancy it continued 
 until delivery, and even some time afterward. Having become 
 pregnant the third time, the ptyalism was again renewed. This 
 lady saturated from thirty to forty handkerchiefs daily with the 
 salivary fluid. Nothing that was administered had any effect in 
 arresting this secretion, except ice water, which seemed at one 
 time to check it, but it produced such violent suffocation that it 
 was discontinued. 
 
 Authors have recommended the use of magnesia, calomel, gar- 
 gles of alum, &c. ; but we will succeed better, not in curing, but in 
 moderating this profuse secretion, by advising the patient to hold 
 in her mouth a piece of gum arabic or sugar-candy. 
 
 M 
 
90 DISEASES INCIDENT TO PREGNANCY. 
 
 Art. II. — Disturbance of the Circulation. 
 Pregnancy imparts a greater degree of activity to the circula- 
 tion; the pulse is more frequent, harder, and fuller; the blood 
 drawn from a vein is covered with a crust, as in inflammatory 
 affections ; but, however, this crust is whiter. These characters 
 are never so marked as to constitute a sign of pregnancy, as some 
 authors have supposed. In most cases, also, this condition, which 
 has some analogy with plethora, merits no attention; but it re- 
 quires treatment when excessive, and when it gives rise to incon- 
 veniences. 
 
 § 1. Plethora. 
 
 Plethora is divided into general when it manifests itself by gen- 
 eral disturbances in the circulation, and into local plethora when 
 it exhibits its action upon some particular organ. In pregnancy 
 the uterus becomes more especially the seat of this latter form. 
 
 I shall not discuss the various opinions which have been ad- 
 vanced as to the cause of this plethora ; and I shall merely remark 
 that it appears to me to be particularly determined by that increase 
 of vitality which all the organs seem to undergo during gestation. 
 
 General plethora is characterized by cephalalgia, drowsiness, 
 vertigo, dyspnoea, frequency and fulness of the pulse, flushed face, 
 excretion of red urine, &c. General bloodletting is the chief rem- 
 edy in this case. 
 
 General plethora frequently produces local plethora. It is there- 
 fore highly important to combat the former in order to prevent the 
 serious congestions which may follow the latter, and which may 
 exhibit themselves in the brain, lungs, and especially in the uterus, 
 which, during pregnancy, is the organ most disposed to congestion. 
 
 But local plethora may also exist alone, and it demands par- 
 ticular attention. Warm baths, general and local bleeding, and 
 diluent drinks, should be employed. If the uterus be the seat of 
 congestion, we should endeavour to control it by energetic revul- 
 sive bleedings only. 
 
 Uterine congestion is one of the most frequent causes of abortion; 
 it may destroy the foetus, either by breaking up, by means of hem- 
 orrhage, the vascular relations between it and the mother, or b] 
 determining placental apoplexy, or, in a word, by soliciting the 
 premature contraction of the womb. 
 
 Local plethora, and particularly that of the uterus, is most coi 
 monly met with in women of a sanguineous habit, and who men- 
 struate abundantly ; it also takes place especially at the periods 
 in which the menses had been in the habit of occurring, but only 
 during the first months of pregnancy. Physical and moral causes 
 have a remarkable influence in the production or increase of local 
 congestion, and this accounts for its frequent existence in women 
 who are eminently sensitive. 
 
 The principal symptoms which characterize it are, a sense of 
 weight and tension in the lower portion of the abdomen and groins, 
 
DISEASES INCIDENT TO PREGNANCY. 91 
 
 and transient pains in the same region, and particularly in the loins ; 
 and, finally, if the congestion be not soon removed, there will be 
 slight uterine contractions. The fœtus itself frequently feels the 
 influence of the sanguineous congestion. Its movements, quicken- 
 ed at first, become more and more feeble, and their disappearance 
 indicates the state of its suffering. Sometimes there is a slight 
 discharge of blood per vaginam ; and this is a circumstance which 
 may result most seriously if prompt relief be not afforded. 
 
 I have already remarked that the best mode of controlling the 
 evils resulting from local plethora of the uterus, consists in general 
 bloodletting, which is both depletory and revulsive. It should be 
 proportioned to the age of the patient ; but, in general, it is better 
 to have recourse to several small bleedings than to a very large 
 one. We should endeavour to avoid producing syncope, on ac- 
 count of the convulsive movements which sometimes follow this 
 condition. 
 
 If the active motions of the foetus should have ceased, they will 
 reappear immediately after the depletion. If there be a sanguine- 
 ous discharge from the vagina, it often disappears under the influ- 
 ence of the bleeding ; but this accident requires, besides, other and 
 more detailed treatment. The patient should be placed in the re- 
 cumbent posture, on a hard bed ; everything like heat about the pel- 
 vis should be avoided ; thus the clothes about the inferior portion of 
 the body should be light, and the feet very slightly covered ; cold 
 injections should be administered, together with cold drinks and 
 aliments. All physical and moral excitement should be sedulously 
 avoided. 
 
 If this discharge occur at the time corresponding with the men- 
 strual periods previous to pregnancy, all these precautions should be 
 observed eight or ten days before the menstrual return, and six or 
 eight ounces of blood should be abstracted from the arm each month. 
 I shall speak more in detail of this treatment under the head of Abor- 
 tion. I have frequently, by these means, carried women to their full 
 term, who had already aborted several times ; but in order to obtain 
 this result, the patient should be extremely docile, have great confi- 
 dence, and entertain an ardent desire to become a mother. The ac- 
 coucheur has, in such cases, a multitude of prejudices to overcome, 
 for it is generally supposed that bleeding is injurious during the 
 first months, and that it should not be practised until the fourth or 
 fifth month, at least. Indeed, it is commonly believed that these re- 
 peated bleedings are fatal to the child, and destructive to the health 
 of the mother. In a word, the accoucheur must persevere, and 
 not suffer himself to be influenced by these prejudices. How often, 
 in practice, have I not been obliged to combat similar errors, and 
 how often, too, if success had not followed my efforts, would I have 
 been severely censured ! While on this subject, I will mention the 
 following case. I found it necessary to bleed a lady seven or 
 eight times during her pregnancy, and all her friends became very 
 much opposed to this treatment, and remarked that, as a conse- 
 quence, she would be delivered of a sickly child, which could not 
 
92 DISEASES INCIDENT TO PREGNANCY. 
 
 live. After the delivery, which was not without some difficulty, 
 the friends came from all quarters to learn the result. Her hus- 
 band, concealing his joy, observed to the ladies that they had pre- 
 dicted rightly, and that the child was exceedingly small : each one 
 immediately exclaimed, " I knew it would be so ; this treatment is 
 murderous," &c. But what was their astonishment on beholding 
 an enormous healthy boy ! 
 
 Cautious bleeding, when sufficiently indicated, can never prove 
 injurious ; on the contrary, it is always of unquestionable utility. 
 
 Bleeding from the foot, and the application of leeches to the 
 groins and thighs, should be proscribed, on account of the revul- 
 sive action they are apt to produce. The same objection exists 
 against hip-baths, which, however, have been recommended in a 
 work quite recently published.* 
 
 § 2. (Edema. 
 Serous infiltration, ordinarily unaccompanied by pain, but in some 
 cases excessively painful, of the cellular tissue, inferior extremities, 
 labia majora, trunk, and more rarely of the superior extremities and 
 splanchnic cavities, occasionally exhibits itself. It is produced by 
 the compression which the impregnated uterus exerts on the iliac 
 veins and lymphatic vessels, and by the obstruction occasioned in the 
 abdominal circulation. Debility and a lymphatic temperament pre- 
 dispose to it. Some authors have ascribed it to plethora, and have 
 even denominated it serous plethora. When the oedema is lim- 
 ited to the inferior extremities, or to the vulva, which is most com- 
 monly the case, it is not at all serious ; but when it becomes gen- 
 eral, the prognosis is unfavourable, because it denotes an impor- 
 tant organic lesion, and it has also been observed that womem la- 
 bouring under this form of infiltration are liable to convulsions. 
 If the oedema be local and inconsiderable, no treatment will be re- 
 quired ; on the contrary, when general, it will be necessary to have 
 recourse to diuretics, purgatives, &c, and to the treatment for ana- 
 sarca. It must, however, be remarked, that this condition does 
 not usually cease until after the termination of pregnancy. The 
 horizontal posture would, in this case, be of essential service, but 
 the dyspnoea which it occasions renders it impossible. As to punc- 
 tures and scarifications, they should not be practised, for they are 
 often followed by gangrene. They might be proper at the mo- 
 ment of labour, if the swelling of the parts interfered with the ex- 
 pulsion of the foetus. I once saw a woman who, notwithstanding 
 
 * Pregnancy occasions most extraordinary changes in the uterine system. As soon as 
 impregnation has been accomplished, the internal surface of the uterus becomes congested, 
 the relations of this organ to the general economy are changed, and the numerous sympa- 
 thies by which it is bound to the rest of the system are brought into action. Its sensibility is 
 much exalted, and it undergoes important modifications in every portion of its structure. 
 The bloodvessels become much increased, the blood concentrating upon this viscus, to en- 
 able it to perfect the fœtal development. The nerves, too, increase both in number and 
 size ; these nerves are closely connected with the great abdominal plexuses, through which 
 the local sensibility of the uterus is soon transmitted to every portion of the economy. 
 There is, therefore, in the pregnant female, a natural susceptibility to excitement, and care 
 should be taken to keep this condition of the system within proper limits. In inflammatory 
 diseases, pregnant women will bear depletion better than under any other circumstances. — Ed. 
 
DISEASES INCIDENT TO PREGNANCY. 93 
 
 the immense infiltration of the thighs and labia, brought forth her 
 child unaided. During pregnancy we must limit ourselves to the 
 general treatment and local applications. 
 
 Anasarca constitutes a grave affection, which may occasion the 
 death of the female before she has attained her full term. But, as 
 a general rule, the oedema does not acquire a distressing develop- 
 ment until after the period of fœtal viability. If, therefore, at this 
 time, all the means indicated above fail, and if there be reasona- 
 ble ground for apprehension, we should induce artificial premature 
 delivery, which may be accomplished by means of a small cone of 
 prepared sponge introduced into the orifice, together with the use 
 of ergot. — (See farther on, Deformities of the Pelvis during Preg- 
 nancy.) i 
 
 • § 3. Hemorrhoids and Enlarged Veins. 
 These two maladies are also occasioned principally by the ob- 
 struction in the circulation in consequence of the pressure of the 
 uterus ; the hemorrhoids may likewise be the result of obstinate 
 constipation so frequent in pregnant women. In this case, they 
 require the use of laxatives and diluents ; but frequently these will 
 not suffice alone, and local and general baths produce much more 
 comfort to the patient when they can be employed ; to these may 
 be added emollient lavements, opiate liniments, cream, supposito- 
 ries of the butter of cacao, &c, &c. But leeches should not be 
 applied to the tumours unless their size should be very consider- 
 able, and the pain they occasion severe, for they may act injuri- 
 ously on the child. In general, bleeding, derivative rather than 
 depletive, would be proper in case of plethora. As to cold appli- 
 cations and immersions, which have been recommended, although 
 I have not had occasion to employ them, still I do not think they 
 should be used except in feeble women, of a soft fibre, in whom 
 gentle stimulation would not be injurious. Notwithstanding this 
 treatment, hemorrhoids, especially those which do not bleed, some- 
 times continue, and do not disappear until after delivery, when the 
 lochial discharge becomes established. Enlarged veins of the in- 
 ferior extremities or vagina are not unfrequent in women who 
 have had several children, and even in some primiparse, towards 
 the end of their pregnancy ; they are much more serious than 
 hemorrhoids, because, if they continue after delivery, they in- 
 crease from day to day, and become much larger in subsequent 
 pregnancies ; and the tumours which they form become so consid- 
 erable that they interfere with progression, are exceedingly pain- 
 ful, and result in ulcerations, which frequently prove incurable, 
 &c, &c. It is, therefore, important to prevent, if possible, their in- 
 crease, and this is to be accomplished by repose, the horizontal 
 posture, having the dress loose, and the bowels in a relaxed state. 
 If they are very large, bandages or the lace stocking should be 
 used, when located on the lower extremities. When situated in 
 the vulva or vagina, it sometimes becomes necessary to apply 
 leeches in the vicinity of these parts, in order to prevent rupture 
 
94 DISEASES INCIDENT TO PREGNANCY. 
 
 of the veins, which occasionally takes place during the passage of 
 the foetus through the pelvis. We shall speak hereafter of throm- 
 bus and other tumours produced by delivery. 
 
 The spontaneous rupture of an enlarged vein during pregnancy, 
 or at the time of delivery, may prove fatal. M. P. Dubois fre- 
 quently mentions, at his clinique, the case of a woman who, in 
 rising in the middle of the night, injured her foot by striking it 
 against a table ; the hemorrhage was so abundant that she could 
 not regain her bed, and she was found in the morning dying, be- 
 ing inundated with her blood. 
 
 § 4. Hemorrhages during Pregnancy. 
 See Abortion, Hemorrhages during Labour, and, at the end o 
 this work, a Synopsis of the Treatment of Hemorrhages at the dif- 
 ferent Periods. 
 
 Art. III.— Lesions of Respiration. 
 
 § 1. Cough. 
 Cough, whether it be a consequence of pregnancy or not, may 
 exert a very serious influence ; for the frequent efforts occasioned 
 by it may determine abortion. If the cough be in consequence of 
 the plethoric condition connected with gestation, bleeding will be 
 indicated. If, on the contrary, it be dependant on a pulmonary 
 affection, it must be treated according to the disease which produ- 
 ces it* 
 
 § 2. Dyspnoea. 
 Dyspnoea, which occurs at an advanced period of gestation, is 
 occasioned by the pressure of the diaphragm against the lungs. It 
 continues most generally until after delivery. It sometimes ex- 
 hibits itself, though rarely, during the first months, and in this case 
 it is generally due to pulmonary congestion, which must be com- 
 bated by bloodletting. 
 
 Art. IV. — Lesions of the Secretions and Excretions. 
 
 § 1. Dropsy of the Amnios. 
 The secretion of the amniotic membrane occasionally becomes 
 so much increased as to produce in its cavity an accumulation of 
 fluid much greater than usual. There are some women who, in 
 each successive pregnancy, are affected with this species of drop- 
 sy, and yet the cause has not been clearly ascertained. Certain 
 authors have ascribed it to an inflammation of the amniotic mem- 
 
 * It often happens that women in the latter months of pregnancy are annoyed with irrita- 
 tion of their lungs, resulting in cough, which is entirely unconnected with disease, and ari- 
 ses altogether from the mechanical pressure which the impregnated womb makes on the 
 diaphragm. At the end of the ninth month, when the womb descends into the pelvis, and, 
 consequently, the pressure is removed from the diaphragm, the cough is relieved. The pu- 
 pil, therefore, should distinguish between the causes capable of giving rise to this affec- 
 tion.— Ed. 
 
 
DISEASES INCIDENT TO PREGNANCY. 95 
 
 brane, or to a derangement of its secretion in consequence of syph- 
 ilis, or of some other cause capable of diminishing the action of the 
 uterus ; others, again, have traced it to a diseased condition of the 
 ovum, existing originally in the ovarium ; but as yet we have nothing 
 positive in reference to the origin of this malady. It has been ob- 
 served in women of all ages and constitutions, and at all the vari- 
 ous periods of pregnancy. It generally, however, is not noticed 
 until the sixth or seventh month of gestation. It exhibits itself in an 
 extraordinary development of the abdomen, which is much greater 
 than corresponds with the period of pregnancy. Its volume va- 
 ries according to the quantity of fluid secreted by the amnios, 
 sometimes measuring thirty to forty pints. Through the abdom- 
 inal walls we can circumscribe the uterus, recognise its hardness, 
 and at the same time become conscious of great obscurity in the 
 fluctuation, which will serve to distinguish this form of dropsy from 
 ascites, which likewise occasionally complicates pregnancy, for, 
 in this latter case, the fluid may be very readily perceived. Am- 
 niotic dropsy is likewise distinguished from ascites without preg- 
 nancy by the movements of the foetus, which, though obscure, be- 
 come sensible to the mother or accoucheur. In examining the ute- 
 rus per vaginam, we can readily assure ourselves that the ballotte- 
 ment is more easy than in the ordinary state, and the inferior seg- 
 ment of this organ being considerably developed, enables us to rec- 
 ognise the presence of a fluid. With the exception of the move- 
 ments of the fœtus, these are the same symptoms that character- 
 ize simple dropsy ; but this latter disease is known by the absence 
 of all the symptoms of pregnancy. 
 
 The urine diminishes in quantity, and the limbs are less liable to 
 infiltrations than in ordinary pregnancy ; the distension of the uterus 
 becomes oppressive, and sometimes even painful at an advanced 
 period ; but the health of the woman is less affected than in ascites, 
 and she is in no immediate danger. Dropsy of the amnios predispo- 
 ses to uterine hemorrhage, after the labour has commenced, and ren- 
 ders this latter much more protracted, because the distended uterus 
 has lost somewhat of its tone (contractility of tissue). The danger 
 is much greater for the foetus ; if the quantity of fluid should be 
 considerable, the uterus may readily be thrown into contraction ; 
 the labour thus commences before the full period, and abortion and 
 death of the foetus are the consequences. The woman may, how- 
 ever, reach the final term of utero-ge station. It has been remarked, 
 that when the labour has commenced, the foetus occupies the su- 
 perior portion of the uterus, and the fluid the inferior. 
 
 This disease may become complicated with various lésons of 
 the placenta, such as cysts, tumours, induration of a portion of this 
 organ, &c. 
 
 In the commencement of this affection, should there be symp- 
 toms of inflammation or plethora of the uterus, local and general 
 bleeding will be indicated ; laxatives should be employed at differ- 
 ent intervals, and they become, indeed, indispensable, while diuret- 
 ics appear to have no efficacy. To these means may be added 
 
96 DISEASES INCIDENT TO PREGNANCY. 
 
 tonics and the cold bath ; and, if there be reason to suspect a ve- 
 nereal taint, mercurials. When the amniotic dropsy becomes so 
 considerable as to oppress the respiration, if it should produce ex- 
 cessive pain, it will be necessary to evacuate a portion of the fluid 
 by rupturing the membranes, when the period of pregnancy and 
 state of the cervix uteri will permit ; and in extreme cases, when 
 the dilatation is not sufficient, the uterus may be punctured near 
 the neck. In the great majority of cases, however, the means first 
 indicated will suffice until labour commences spontaneously. 
 
 § 2. Hydrorrhea. 
 
 Discharges of a limpid or yellow fluid, mixed with blood, will 
 sometimes escape through the vulva at the different periods of 
 pregnancy, but especially during the latter months. The quantity 
 is variable, but may saturate several napkins during the day. 
 Sometimes this discharge takes place but once, or it may reappear 
 frequently, or be discontinued only for a short time. It sometimes 
 passes out drop by drop ; at other times its evacuation is sudden 
 and abundant. Most usually it is unaccompanied with pain ; some- 
 times, however, the sudden depletion of the uterus determines ev- 
 ident contractions, which will most frequently be calmed by re- 
 pose. 
 
 These discharges of water at the different epochs of pregnancy 
 are much more frequent than is generally supposed. If, indeed, 
 they have not been entirely misunderstood, they at least have been 
 badly explained up to the present time. Authors have attempted 
 to show that these discharges are due to an accumulation of fluid 
 between the chorion and amnios, and to the rupture of the cho- 
 rion and caduca ; to the rupture of lymphatic vessels, to hydatids, 
 to the transudation of the amniotic liquor through the mem- 
 branes, to hydropsy, to a rupture of the allantois, to a rupture of 
 the membranes in a point remote from the orifice of the uterus, 
 and, finally, to dropsy of the womb. Not one of these opinions 
 is sustained by facts ; they lose, on the contrary, all their value, if 
 it be remembered that if such, in truth, were the causes of this 
 discharge, it would almost always result seriously either to the foe- 
 tus or mother; whereas experience shows that, in nearly all the 
 cases in which this discharge manifests itself, pregnancy arrives at 
 its full term. 
 
 M. Naegele, in Germany, and M. P. Dubois, in France, were the 
 first to call the attention of accoucheurs to the frequency of this ac- 
 cident, and to its true cause. The opinion of M. Naegele was stated 
 in a thesis defended at Heidelberg in 1822, by J. B. Geil, entitled, 
 De Hydrorrhea Uteri Gravidarum. 
 
 He thinks that this discharge is owing to an evacuation of a cer- 
 tain quantity of fluid collected between the membranes of the 
 ovum and the internal surface of the womb, and the following is 
 his explanation of the phenomenon. The amniotic liquor, furnished 
 by the lymphatic vessels of the uterus, penetrates the interior of the 
 membranes by endosmosis : this opinion seems the most probable. 
 
DISEASES INCIDENT TO PREGNANCY. 97 
 
 îf a slight inflammation of the internal surface of the womb should 
 separate a small portion of these membranes, the fluid, instead of 
 penetrating the ovum, becomes effused at this point of separation ; 
 it accumulates, until it so far distends the womb as to induce con- 
 traction ; these contractions, whether perceived by the mother or 
 not, force the fluid to separate the membranes, little by little, until 
 it reaches the neck of the womb, when it escapes. We can now 
 understand how this may occur several times during pregnancy 
 without compromising it, and without requiring any treatment. 
 
 M. Nsegele, who attributes this accident to inflammation of the 
 membranes, recommends a rigid diet and bloodletting. I cannot 
 concur in this opinion. In my numerous observations on this sub- 
 ject, I have never known this accident to present any distressing 
 symptom by itself, and the small bleedings which I have sometimes 
 been obliged to practise have been directed rather against the 
 consequences of the disease than against the disease itself. 
 
 Two cases, which I shall cite, will demonstrate that the dis- 
 charge of water does not come from the interior of the membranes* 
 but from the internal surface of the uterus. A woman in La Cli- 
 nique passed, during her pregnancy, at different times, an enormous 
 quantity of fluid, which M. Dubois estimated at seven or eight 
 pints. After her delivery, she continued to pass a large quantity 
 of water, the first day but slightly mixed with blood, and which, 
 after the third day, became limpid ; this discharge, which evidently 
 took the place of the lochiae, lasted five or six weeks. 
 
 Another woman, extremely infiltrated, entered La Clinique du- 
 ring the first months of her pregnancy, and at the periods corre- 
 sponding with her menstrual returns, she lost an abundance of 
 water. The discharge of water continued fifteen days after the 
 expulsion of the foetus, which took place before the full term. At 
 the request of M. P. Dubois, this woman was transferred to the 
 Hôtel Dieu, in the service of M. Honoré, who likewise observed 
 this fact. 
 
 I have said that this accident by itself is not serious, and. that it 
 does not call for any special treatment ; # but it sometimes becomes 
 necessary to guard against the consequences of this discharge. 
 Thus, although this is not common, it is occasionally accompa- 
 nied with violent uterine contractions, which determine the ex- 
 pulsion of the fœtus. In this case absolute repose should be en- 
 joined, and after having evacuated the rectum by means of an 
 injection, eight, ten, or fifteen drops of laudanum, with a small 
 quantity of water, should be thrown up the intestines, depending 
 upon the nature of the disturbance. If there should be any evi- 
 dence of plethora, a small revulsive bleeding should be ordered. 
 
 * My friend, Dr. Desilliers, communicated to me the case of a woman in whom these 
 watery discharges had caused three successive abortions, at seven, two, and four months. 
 But in this case, notwithstanding the abundance of the evacuation, the physician did not 
 attribute the miscarriage to it ; for the discharge was almost always commingled with blood, 
 
 N 
 
98 DISEASES INCIDENT TO PREGNANCY. 
 
 § 3. Mucous Discharges. — Pustules. 
 
 I have already spoken, in the article Diagnosis of Pregnancy, of 
 vaginal mucous discharges, which ordinarily occur about the sixth 
 or seventh month of pregnancy, and cease after delivery. They 
 only require cleanliness, such as baths, ablutions, emollient injec- 
 tions, &c. Indeed, it would scarcely be worth while to mention 
 them in this chapter if it were not necessary to guard the young 
 accoucheur against an error in diagnosis which it is easy to com- 
 mit, and which might, in a moral sense, affect the woman injurious- 
 ly. I have been consulted in discharges of this kind, when the 
 husband or accoucheur supposed them to be of a doubtful charac- 
 ter ; and I have decided against this opinion, not that it is always 
 possible to establish an exact diagnosis between the discharges 
 which result from pregnancy and those which depend on a syphi- 
 litic cause, when there are no other symptoms of infection joined 
 to this, but because I know that these discharges during preg- 
 nancy are both abundant and frequent without infection. 
 
 I can say as much for the pustules which develop themselves 
 on the labia majora and minora, and which are sometimes mis- 
 taken for syphilitic chancres. Pregnancy causes them, and they 
 cease with delivery. 
 
 § 4. Lesions in the Functions of the Bladder. 
 
 In proportion as the uterus becomes developed it rises above 
 the superior strait, and draws with it the bladder, which finds itself 
 compressed. In consequence of this pressure, there is a frequent 
 desire to void urine ; and if the neck of the bladder is likewise com- 
 pressed, the frequent emission of urine is painful and difficult, and 
 sometimes impossible. . In a word, if there be not entire oblitera- 
 tion of the neck, the urine is evacuated drop by drop. This is 
 called incontinence of urine. 
 
 The excess of capacity in the pelvis, which favours the descent 
 of the womb, and the ante-version of this organ, may determine 
 these troubles during the first months, but this is rare ; they mani- 
 fest themselves much more frequently at the end of pregnancy, 
 the uterus being more or less inclined forward at this period. If 
 the ante-version is very marked, the body of the bladder is pushed 
 in front, above the pubes, and forms with the neck a right angle, 
 sometimes even an acute angle, which renders the evacuation of 
 urine and the introduction of the catheter extremely difficult. The 
 patient may be somewhat relieved by requesting her to support 
 her abdomen with the two hands applied on either side at the 
 moment of urinating. The bladder in this way is relieved from 
 the weight of the uterus, and may accomplish its functions. It 
 sometimes becomes necessary also to raise the bladder, in order 
 to reduce it to its natural position; but this pressure should be 
 moderate, otherwise the difficulty of voiding the urine would be 
 increased. 
 
DISEASES INCIDENT TO PREGNANCY. 
 
 It would be well for the woman to wear a body bandage, prop- 
 erly adjusted, and to bathe freely ; if the bladder should acquire a 
 very considerable development in consequence of the accumula- 
 tion of urine, the woman should be catheterized several times du- 
 ring the day. 
 
 The excessive distension of the bladder may determine inflamma- 
 tion and rupture of this organ. This accident would certainly have 
 happened in the case of a woman who entered, in July, 1841, the 
 Hôtel Dieu, in the service of M. Honoré, if great caution had not 
 been used. The bladder nearly reached the epigastric region, so 
 as to simulate a pregnancy at full term. She was, however, only 
 two months pregnant. The repeated introduction of the catheter 
 rapidly restored this woman, who voided her urine spontaneously 
 when she left the hospital. 
 
 When this inconvenience manifests itself from the commence- 
 ment of pregnancy, it is occasioned by the sojourn of the developed 
 uterus in the pelvic cavity ; it generally ceases in proportion as 
 the uterus rises above the superior strait. Sometimes, however, 
 this accident becomes aggravated by the growth of the uterus ; 
 under these circumstances there is no hope of cure, no matter 
 what we do ; delivery alone can accomplish this object. It is the 
 same with retention or incontinence of urine, which takes place in 
 the latter months. 
 
 When the urine is turbid, loaded with whitish flocculi or puru- 
 lent matter, when its emission is painful, and accompanied by a 
 burning sensation, we know that there is catarrh of the bladder ; 
 in this case, baths and emollient drinks are indicated. This affec- 
 tion is not unfrequent during pregnancy ; I have seen several ex- 
 amples of it at La Clinique : in one woman, among others, it did 
 not yield except after the repeated application of leeches to the 
 hypogastrium. 
 
 Art. Y. — Lesions of Locomotion. 
 
 § 1. Relaxation of the Symphyses. 
 
 The softening of the ligaments which unite the bones of the pel- 
 vis is of constant occurrence during pregnancy ; but we should 
 regard it rather as the accomplishment of a general law, which 
 governs all beings, than as a necessary consequence of parturition 
 in the female. If this softening of the symphyses is indispensable 
 to the completion of the generative functions in certain animals, in 
 which the pelvis is very narrow, it is not so in the human species. 
 
 In the various pelves of women recently delivered which have 
 been submitted to my observation, I have never found this relaxa- 
 tion sufficiently distinct to increase the diameters of the pelvis a 
 few millimetres, unless the woman had, during her gestation, ex- 
 perienced all the inconveniences which characterize a considerable 
 separation of the bones, and which is not a physiological condition, 
 but constitutes actual disease. 
 
 In this case, walking and standing are attended with great diffi- 
 
100 DISEASES INCIDENT TO PREGNANCY. 
 
 culty, fatigue, and pain. During labour, the auxiliary muscles of 
 the uterus, finding no fixed point of support in the pelvis, act pain- 
 fully on the symphyses, and afford no aid to the uterus in its con- 
 tractions. 
 
 The malady, the causes of which are little known, and which 
 some authors have attributed to rachitis, commences by dull pains 
 in the articulations of the pelvis, loins, hips, and thighs; motion 
 becomes slow, difficult, and so painful as to render progression al- 
 most impossible. Sometimes the pains are so acute that the pa- 
 tient, even while in bed, cannot make the slightest movement with- 
 out experiencing them. When she rises and walks she feels a 
 sensation of great weakness and vacillation ; it seems as if her 
 body was about to slip between her thighs, and the pelvis about to 
 separate. If the disease progresses, in consequence of some pecu- 
 liar disposition, or, what is more common, in consequence of 
 successive pregnancies, the disjunction, separation, and relaxation 
 of the symphyses become so marked that, on moving the inferior 
 extremities, the mobility of the symphyses is not only ascertained, 
 but there is heard a crackling nois \ Then it becomes utterly im- 
 possible for the woman to move 1 er lower limbs ; she is obliged 
 to be raised by assistants, and the sensibility and swelling of the 
 parts are such that the slightest to ich causes pain. The conse- 
 quences of this condition manifest themselves particularly after de- 
 livery, and are not accompanied by positive danger unless it pro- 
 ceeds from an organic vice. 
 
 The relaxation of the symphyses requires, in the first place, the 
 most absolute repose in the horizontal position, and the application 
 of the various antiphlogistic remedies, particularly local and re- 
 peated bleedings, baths, &c, &c, &c, should there be inflamma- 
 tion ; but if inflammation do not exist, we must favour the con- 
 solidation of the inter-articular cartilages by the application of com- 
 presses, saturated with warm wine mixed with an infusion of roses, 
 or with astringent decoctions of tan, quinine, solutions of the sul- 
 phate of alum, acetate of lead, to which must be added gentle, 
 gradual, and constant pressure, by means of a body bandage com- 
 posed of napkins or a large roll of flannel, or even of prepared 
 leather. If the digestive organs do not contra-indicate it, the 
 woman should be placed on a tonic and strengthening regimen ; 
 she should partake of roast meats, and drink some generous wine, 
 either pure or diluted, together with chalybeates, seltzer water, 
 &c, &c, bitter decoctions, diuretics, and occasionally laxatives. 
 Cold sea-bathing, and the use, during the period of pregnancy, 
 of the iodide of potash in sweetened water, in the dose of from 
 twenty-five to fifty centigrammes, from one, and even three or four 
 grammes daily, will frequently be found very serviceable. In this 
 case, the patient should abstain from all acid nourishment and 
 drinks. After delivery this treatment should still be continued, and 
 we should, in addition, employ blisters, cautery, and moxas. 
 
DISEASES INCIDENT TO PREGNANCY. 101 
 
 Art. VI. — Lesions of the Nervous System. 
 
 In speaking of the digestive disturbances, I remarked that the 
 depraved appetite, vomiting, and cardialgia, are frequently due to 
 a peculiar nervous condition. I merely allude to it now in order 
 that my text may be more complete. 
 
 It now only remains for me to treat of some other nervous in- 
 conveniences which occasionally complicate pregnancy : headache, 
 mania, odontalgia, vertigo, dimness of sight, syncope, palpita- 
 tions, cramps, pains in the loins, pains in the abdomen, dyspnœa and 
 nervous cough, spasm of the stomach, spasm of the uterus, uterine 
 rheumatism, convulsions. 
 
 § 1. Cephalalgia. 
 Headache frequently accompanies pregnancy from the com- 
 mencement, and some accoucheurs have regarded it as a sign of 
 gestation. It sometimes does not occur at all, or appears only at 
 indeterminate periods, and has nothing fixed in its duration, inten- 
 sity, or seat. I have known it to become agonizing to some women, 
 both by its duration and intensity ; and, unfortunately, our art does 
 not possess any efficacious remedy for this affection. We may 
 employ compresses wet with cold vinegar, baths, and bleeding, if 
 there should be symptoms of plethora. 
 
 § 2. Mania. 
 Mania, which occurs during pregnancy, requires no particular 
 treatment. The accoucheur should have his patient placed in the 
 most favourable hygienic conditions ; he should endeavour to con- 
 trol any complications that may arise, and await the termination of 
 delivery, which will certainly put an end to the disease : at least, 
 such is the opinion of Esquirol. Mania, which recognises for its 
 cause a disturbance in the functions, ceases when these functions 
 become re-established. Pregnancy may, to a certain point, be re- 
 garded as a functional disturbance. 
 
 § 3. Odontalgia. 
 Toothache, during pregnancy, is owing, in some instances, to a 
 sanguineous congestion of the jaw ; but most commonly it is mere- 
 ly nervous. In this case, there is no material lesion in the teeth ; 
 the pains are intermittent, and are seated in one or other of the 
 maxillary bones, and extend sometimes from the alveolar arch to 
 the neighbouring parts — to the face, temple, and ear. If there 
 should be alveolar congestion, moderate bleeding from the com- 
 mencement will be indicated ; in the contrary case, anodyne gar- 
 gles ; applications of the hydro-chlorate of morphine, from one to 
 four centigrammes daily, on the denuded surface of a blister ; and 
 if there should be distinct intermissions, the sulphate of quinine. If 
 the neuralgia should be caused by a carious tooth, it should not be 
 extracted, unless the patient suffers insupportable pain : we should 
 wait until the patient is more advanced in her pregnancy. This 
 
102 DISEASES INCIDENT TO PREGNANCY. 
 
 remedy should never be had recourse to until all the others have 
 failed, for the shock produced upon the system by the severe pain 
 of extracting a tooth may determine abortion. 
 
 § 4. Vertigo, Dimness of Sight, Syncope. 
 These affections may be determined by a general plethoric con- 
 dition of the system. In this case, bloodletting is indicated, but 
 they may appear without any known cause. Weak, nervous 
 women, under the influence of the slightest cause, fall into syncope. 
 Joy, anger, an agreeable or repulsive odour, the sight of a person 
 whom they love or who is disagreeable to them, may all give rise 
 to this trouble. The same thing may result from the first sensation 
 experienced of fœtal life by a woman who has for a long time de- 
 sired to become a mother. Syncope may take place frequently, 
 especially during the first months, but it is not of long duration ; 
 and although it may alarm the friends, yet, in general, it is rarely 
 followed by anything serious. It is rare, too, that in syncope there 
 is complete abolition of the sensorial and intellectual faculties, the fe- 
 male always preserving a confused idea of what is passing around 
 her. However, repeated syncope, particularly when accompanied 
 by hysterical movements, may occasion premature delivery, which 
 it is important for the accoucheur to guard against. During syn- 
 cope, the patient should be immediately placed in the horizontal 
 position on the ground, if there should be no couch or bed at hand ; 
 this will be the most certain means of overcoming the attack. 
 Salts, vinegar, ether, &c, should be held to the nose, and cold wa- 
 ter thrown with force in the face. If the succession of these faint- 
 ing turns and their duration should occasion alarm, we should en- 
 deavour to prevent them by the administration of tonics, combined 
 with antispasmodics. 
 
 § 5. Palpitations. 
 Palpitations are often met with in pregnancy, without reference 
 to any organic lesion of the heart ; they are, in this case, occasion- 
 ed by a peculiar nervous condition, which cannot be defined, and 
 which presents nothing of a serious nature. Under these circum- 
 stances, the accoucheur should have recourse to hygienic measures. 
 If found necessary, a small bleeding may be practised, and digi- 
 talis administered ; if in powder, from five to twenty centigrammes 
 at a dose ; in tincture, ten to twenty drops daily. 
 
 § 6. Cramps. 
 Cramps in the inferior extremities are produced by the pressure 
 of the uterus on the crural nerves. Art possesses no means of pre- 
 venting them ; only, they may be palliated by frictions at the time 
 of their appearance. 
 
 § 7. Pain in the Loins. 
 The cause of these pains during pregnancy is entirely unknown ; 
 it is, however, supposed that it depends on the compression of the 
 
 
DISEASES INCIDENT TO PREGNANCY. 103 
 
 anterior branches of the sacral nerves, which occurs during la- 
 bour. But the uterus in pregnancy is too much elevated for its in- 
 ferior portion to produce the compression of these organs. How- 
 ever, when these pains coincide with a descent more or less mark- 
 ed of the uterus, there will be every reason to believe that they 
 are occasioned by the pressure on the sacral nerves. 
 
 Art is also powerless in this case, unless there should be symp- 
 toms of local plethora. 
 
 8. Pains in the Abdomen. 
 
 Pregnant women experience occasionally pains in different por- 
 tions of the abdomen. Frequently they are determined by the active 
 motion of the fœtus, and occasion suffering in some one point of 
 the uterus. Often, also, the female complains more of a sensation 
 of cramp than of absolute pain : this sensation is unconnected with 
 the fœtal movements, and it may manifest itself in different points, 
 or in one only, return by paroxysms, or continue during the whole 
 gestation. 
 
 I once attended a patient who had in each pregnancy the same 
 character of pain in the same portion of the womb ; hence, during 
 the first months, she considered it a certain sign of her pregnancy. 
 
 § 9. Dyspnoea, Nervous Cough, Spasm of the Stomach. 
 These affections, of which I have already spoken in the prece- 
 ding articles, may also, as I then remarked, be determined by a 
 peculiar nervous condition. Baths, moderate exercise, and opiates 
 are here indicated. 
 
 § 10. Spasm of the Uterus. 
 
 The uterus may be attacked with convulsive action, and yet no 
 other organ participate in the disturbance. The uterine globe is 
 felt moving rapidly from one side to the other, and it is agitated 
 by frequent spasms. It is readily perceived that this affection 
 merits all the attention of the accoucheur, for its consequences are 
 at once foreseen. 
 
 Small bleedings, baths, antispasmodics, such as camphor, in the 
 dose of 20 to 30 centigrammes in injection, together with 10 to 30 
 drops of the tincture of castor, and especially laudanum, 15 to 30 
 drops, thrown up the bowel with a small quantity of fluid ; nar- 
 cotic frictions on the abdomen, with equal parts of the oil of sweet 
 almonds and laudanum, are the means to be employed. 
 
 § 11. Rheumatism of the Uterus. 
 
 M. Stoltz was one of the first who called attention to this sub- 
 ject. M. Dezeimeris has also published on this topic a series of 
 articles in his journal Expérience. For more details, the reader 
 can consult these articles. 
 
 Rheumatism of the uterus is produced by the same causes as 
 rheumatism of other parts. But persons affected with general 
 rheumatism are more predisposed to it than others ; it often arises 
 
104 DISEASES INCIDENT TO PREGNANCY. 
 
 from a rheumatismal metastasis. Pain, without any appreciable 
 cause, is the principal symptom of this affection. There is exqui- 
 site sensibility of the uterus, without contraction, sometimes lim- 
 ited to one portion of the uterus, sometimes affecting the whole of 
 the organ. In all cases, pressure and the touch increase the pain ; 
 it extends to the loins, groins, and thighs, and may change its loca- 
 tion rapidly, as happens in all rheumatismal affections ; it is liable 
 to frequent exacerbations, variable in duration and intensity, and 
 to remissions more or less complete. 
 
 Recto-vesical tenesmus almost always accompanies this disease, 
 and increases its inconveniences. It results from sympathies 
 which bind the genito-urinary organs so closely together. 
 
 This affection is not always attended by fever ; but in the major- 
 ity of cases, a febrile reaction manifests itself, and continues as 
 long as the accession of pain. 
 
 The repetition of these accessions may solicit the contractions of 
 the uterus, and determine the expulsion of the foetus. It is there- 
 fore very important to endeavour to remedy it. The treatment 
 consists in bleeding from the arm, laxatives, such as castor oil, 
 salts, lotions of laudanum to the abdomen, and anodyne injections. 
 
 Revulsives on the arms, by means of mustard cataplasms, and, 
 if the rheumatism be due to metastasis, revulsion should be prac- 
 tised on the place which the pain has just left.* 
 
 § 12. Convulsions or Eclampsia. 
 
 Convulsions which affect women in pregnancy, labour, and 
 after delivery, are of several kinds. 
 
 We have the epileptic, hysteric, cataleptic, and tetanic eclampsia. 
 
 The epileptic eclampsia is the most common ; it may occur du- 
 ring pregnancy, labour, or as a consequence of delivery. As it 
 presents, so far as the treatment is concerned, many important dif- 
 ferences, accordingly as it exhibits itself at one or other of these 
 periods, I will speak of it first as occurring in pregnancy. Epi- 
 leptic eclampsia is rare during the first months of pregnancy ; it does 
 not, in general, occur until the seventh or eighth month. I, how- 
 ever, remarked it in the wife of a young confrère at the second 
 month of gestation ; it did not yield until after the expulsion of the 
 foetus. This accident is, unfortunately, more common than is sup- 
 posed, particularly in hospitals. The contrary opinion, however, 
 has been advanced. According to some writers, in two thou- 
 sand cases of delivery, there were but three cases of eclampsia. 
 
 * Rheumatism of the uterus must not be confounded with another painful condition of this 
 organ, which manifests itself occasionally during pregnancy, but more frequently in the un- 
 impregnated female. It is neuralgia of the womb, which, in the unimpregnated female, is 
 often mistaken for inflammation, dysmenorrhoea, &c, &c. It is usually met with in ner- 
 vous, irritable women, and is as perfectly marked as neuralgia in any other portion of the 
 system. I have seen several cases of this malady, and it produces most agonizing suffering ; 
 if it occur during pregnancy, it is apt, if not promptly relieved, to cause premature deliv- 
 ery. I have never failed in removing it with quinine. 
 R- Sulphate of Quinine, 3L 
 Acid Sulph. dilut., 3L 
 Aqua Pluviae, ^viij. 
 One tablespoonful in a wine-glass of water three times a day.— Eta 
 
DISEASES INCIDENT TO PREGNANCY. 105 
 
 I must have been singularly favoured, for I have observed at La 
 Clinique more than twelve cases of epileptic eclampsia, and one of 
 the hysteric form. I am in possession of all these observations, 
 which are also recorded in the register of La Clinique. 
 
 This affection is characterized by muscular movements inde- 
 pendent of the will, and not required by the wants of the individual. 
 
 1. Causes. 
 Essential Causes. — Pregnancy, in consequence of the changes it 
 brings about in the whole economy. 
 
 a. Predisposing Causes. — A first delivery, especially at an ad- 
 vanced age, a lymphatic temperament, and particularly infiltration. 
 In all the cases of eclampsia which I have seen, the women were 
 more or less dropsical ; rickets, peculiar conditions of the atmo- 
 sphere, and individual idiosyncrasy. M. P. Dubois does not re- 
 gard a sanguineous temperament as a predisposing cause. 
 
 b. Occasional Causes. — Lively and sudden moral impressions, ir- 
 ritation, and an acute pain. But the most evident occasional cause 
 is the sympathetic reaction of the uterus on the economy. 
 
 2. Precursory Phenomena. 
 
 Eclampsia during pregnancy is usually announced by certain 
 precursory symptoms ; at other times it is sudden ; bat this is rare. 
 It is preceded by an intense cephalalgia (Hamilton, Denman), by 
 pain in epigastrio (Chaussier), by disturbance in vision, sparks pass- 
 ing rapidly before the eyes, vertigo, tingling of the ears, embar- 
 rassment in speech, &c. 
 
 3. Invasion of the Disease. 
 
 First Period. — The countenance becomes fixed, the pupils di- 
 late, the eyes are distorted, so that the cornea is turned upward 
 either to the right or to the left ; respiration is impeded, and there 
 is complete loss of the intellectual and sensorial faculties. 
 
 Second Period. — One or two spasmodic twitchings of the body 
 succeed these first phenomena ; one of the commissures of the lips 
 is then drawn outward, the mouth opens slowly, the tongue pro- 
 jects, the head inclines to one side, the face becomes flushed, and 
 there is a considerable rush of blood towards the head. Finally, 
 the jaws approach each other. 
 
 Third Period. — Twinkling of the eyes ; the mouth is agitated, as 
 if the woman was muttering ; the nostrils are drawn upward and 
 outward ; the chin elongates ; the superior extremities are placed in 
 forced pronation ; the closed fists are applied upon the sides of the 
 trunk; the legs are stiff, and the trunk is bent backward, as in 
 tetanus. In fine, the spasmodic action of the body and of each 
 muscle manifests itself; then these spasms become less frequent, 
 and the fit terminates. 
 
 A. During the paroxysm or fit, respiration is impeded ; how- 
 ever, sufficient air enters the mouth to produce a froth, or saliva, 
 which escapes from the lips. The respiratory phenomena, ordina- 
 
106 DISEASES INCIDENT TO PREGNANCY. 
 
 rily embarrassed, have but a very slight influence in the produc- 
 tion of this ; for most commonly the ribs remain perfectly immova- 
 ble. The pulse is frequent and irregular, and the beatings of the 
 heart are very rapid ; they then become irregular, and cease alto- 
 gether. 
 
 Some of these phenomena may be absent, and vary as to their 
 intensity. Such, for example, as the determination of blood to the 
 brain ; the immobility of the ribs, which does not exist always, and 
 which, consequently, does not impede respiration. 
 
 B. After the paroxysm, stupor supervenes ; the loss of the intel- 
 lectual and sensorial faculties continues ; there is almost complete 
 flaccidity of the limbs ; the fingers, however, remain flexed, and 
 sometimes also the fore-arms are contracted, but they readily yield. 
 The lower jaw remains contracted ; the eyelids are closed, and it 
 is easy to separate them ; the pupil is contracted and movable ; 
 the respiration is stertorous, and the circulation ordinarily very 
 rapid ; the pulse is frequent and irregular ; if the woman turns on 
 her side, the uterus readily inclines to that side. In fine, slight 
 movements now manifest themselves ; sensibility and conscious- 
 ness return, but the memory is completely lost.* A first paroxysm 
 is generally followed by several others, especially in pregnancy, 
 where the original cause is not removed. After each fit, return to 
 consciousness may take place, but most commonly, when the fits 
 succeed each other, the woman remains, between each paroxysm, 
 in a complete coma. 
 
 Duration of the Paroxysms. — The duration of a paroxysm may 
 vary from one to ten minutes ; it has been known to continue for 
 half an hour. In this case, respiration and circulation are but im- 
 perfectly suspended, otherwise the woman would succumb. The 
 duration of the stupor which follows the attack may be from sev- 
 en, eight, or ten minutes to half an hour ; that which follows the 
 last attack may be prolonged to from twelve to twenty-four hours. 
 
 4. Diagnosis. 
 
 After the description just given, I may dispense with insisting on 
 farther diagnosis ; it will suffice to have seen this frightful malady 
 once always to recognise it without difficulty. I will say a word 
 in reference to the differential diagnosis of eclampsia. 
 
 A. During the paroxysm, eclampsia may be confounded with 
 hysteria and epilepsy. 
 
 In hysteria, the movements are violent ; the woman struggles, 
 and easily changes her place ; if she be on the ground, she requests 
 to be held, in order that she may not injure herself, and she utters 
 violent cries. There is not complete loss of intelligence ; sensibil- 
 ity is never extinct. A frothy saliva rarely passes from the mouth. 
 In eclampsia, on the contrary, there are no cries, no violent move- 
 
 * In some instances, there is extraordinary loss of memory connected with puerperal con- 
 vulsions. A case, it is recorded, occurred in the Hôtel Dieu at Paris, of a woman who, in 
 consequence of an attack of convulsions, so completely lost her memory that she not only 
 forgot her name, but had no recollection of her marriage, or that she had been pregnant. 
 —Ed. 
 
DISEASES INCIDENT TO PREGNANCY. 107 
 
 ments ; the patient requires to be held only that she may be pre- 
 vented from falling from the bed. Eclampsia is more frequent at 
 the end of pregnancy ; hysteria at the commencement. 
 
 In eclampsia it is rare to have but one fit ; in hysteria, on the 
 contrary, there is but one. 
 
 In epilepsy, there is such a strong resemblance between an attack 
 of eclampsia and epilepsy, that it would be impossible to distin- 
 guish them, if there were only one paroxysm of eclampsia. But 
 the knowledge of what has preceded, and the termination of the 
 disease, will enable us to distinguish these affections. 
 
 In epilepsy there is but one paroxysm ; in eclampsia there are 
 almost always several succeeding each other. However, M. P. 
 Dubois noticed in an epileptic patient that the paroxysms succeed- 
 ed each other during labour ; in this case the epilepsy was changed 
 into a veritable eclampsia. 
 
 B. After the paroxysm, and during the stupor, we may con- 
 found the comatose state into which the woman has fallen with ap- 
 oplexy, narcotism, or drunkenness. 
 
 It is rather difficult to distinguish this comatose condition from 
 apoplexy ; however, apoplexy is rarely followed by complete use 
 of the limbs ; there is, moreover, in most cases, hemiplegia. The 
 tongue is not bitten, nor is the saliva bloody. 
 
 The stupor of drunkenness is also very similar to that of eclamp- 
 sia, but this state is characterized by the smell of the breath and by 
 vomiting. The tongue is not bitten, and if there is froth, it is 
 not bloody. 
 
 Narcotism can only be distinguished by the return of the par- 
 oxysm. 
 
 Thus, if only one paroxysm occurred, we might often remain in 
 doubt ; in this case, we should endeavour to learn all the antece- 
 dent relations of the patient, in order that we may be enabled to 
 arrive at an accurate opinion. 
 
 5. Influence of Eclampsia on Pregnancy. 
 Eclampsia ceases sometimes of itself, without determining ac- 
 couchement, but this is rare ; most frequently, when eclampsia 
 ceases spontaneously or the paroxysms continue, pregnancy is en- 
 dangered ; the fœtus is destroyed during an attack, and then must 
 necessarily be expelled. But if the convulsions do not prove fatal 
 to the child, it is still ordinarily expelled from the uterine cavity, 
 for eclampsia generally causes strong uterine contractions. When 
 this occurs during the comatose state, uterine pain is announced 
 by slight malaise ; during the paroxysm it does not manifest it- 
 self by any external sign, on account of the insensibility. If preg- 
 nancy is far advanced, delivery takes place unconsciously, and the 
 child is found dead between the limbs of the mother. At a less 
 advanced period, the sanguineous discharge, which usually pre- 
 cedes the expulsion of the foetus, indicates that this is about to take 
 place. 
 
108 DISEASES INCIDENT TO PREGNANCY. 
 
 6. Possible Terminations of Eclampsia. 
 
 Eclampsia may terminate by a rapid or slow return to health, 
 depending on the intensity of the attacks, by sudden death during 
 a severe paroxysm, or it may prove gradually fatal, in the stage of 
 coma. In the first case, death may be occasioned by effusion on 
 the brain following the eclampsia, the effusion being determined by 
 a rush of blood to the head. Sudden death may also take place 
 during an attack, when there is complete and too prolonged a sus- 
 pension of respiration. It may likewise result from rupture of the 
 uterus. 
 
 When death occurs gradually, it is the result of a serious lesion 
 experienced by the nervous system, or it may be occasioned by 
 functional disturbance of the lungs and heart, which have been 
 more or less affected. 
 
 This affection may also terminate in another malady, acute or 
 chronic, such as paralysis and metro-peritonitis. 
 
 Paralysis is ordinarily the consequence of an effusion, which has 
 not been sufficient to occasion death ; but it may also be caused by 
 a peculiar change effected in the brain. In a woman at La Clinique, 
 who died of hemiplegia after seventeen successive eclamptic at- 
 tacks, M. Landouzy and myself made a post-mortem examination, 
 but found no effusion, nor was there anything to explain the cause 
 of death. It is rare, during an epidemic, for a female who has sur 
 vived an eclampsia, not to be attacked with a metro-peritonitis 
 after the birth of the foetus. This fatal disease seems, therefore, t 
 predispose to an affection still more alarming. 
 
 In those cases in which the patient is restored to health, a very 
 singular phenomenon presents itself — the complete loss of memory 
 which returns only by degrees. When memory begins to return 
 it is not in reference to matters of recent occurrence, but, on the 
 contrary, to those of a much more remote period. I saw two 
 women at La Clinique who had suffered loss of memory ; one of 
 them had forgotten even her own name, and it was not until sev- 
 eral days after her recovery that she could recollect it. 
 
 A lady of the Faubourg Poissonnière, whom M. P. Dubois had 
 attended, had entirely forgotten the names of the streets, and even 
 the topography of Paris. She was for a long time obliged to take 
 a guide to lead her about : her other faculties were perfect. 
 
 7. Prognosis. 
 
 The prognosis of eclampsia is serious for the mother, but esp 
 cially so for the child. 
 
 A. For the Mother. — According to Madame Lachapelle, one half 
 of the women attacked with this affection die. The cases, how- 
 ever, which I have observed in the city, and at La Clinique, have 
 given a more favourable result: only one fourth part have died. 
 The proportion varies according to the cause of the convulsions, 
 the period of pregnancy, and the progress of the case.* 
 
 * About four years since I attended a lady in her first confinement at full term, although 
 she had two miscarriages previously. She had been married about two years before the birth 
 
 Ï 
 
 : 
 
DISEASES INCIDENT TO PREGNANCY. 109 
 
 Convulsions are much more dangerous in women suffering from 
 infiltration, and we know not whether this depends on some special 
 inappreciable cause, or whether it arises from the fact that, in such 
 cases, it is difficult to oppose, by copious bloodlettings, the conse- 
 quences of these attacks — the determination of blood to the brain, 
 and cerebral hemorrhage. 
 
 Moreover, although a sanguineous temperament is not regarded 
 
 of her child, and, previous to her marriage, was rather of a delicate habit of body. She soon, 
 however, became exceedingly stout, and gained so rapidly in flesh during the pregnancy in 
 which I attended her, that she became an object of great anxiety to her friends, they appre- 
 hending, from this circumstance, serious trouble at the time of her delivery. I found it ne- 
 cessary to bleed this lady several times during her gestation, and was obliged to have re- 
 course to medicines with a view to keep her system, naturally torpid, in a properly -relaxed 
 state. She had an invincible objection to active exercise, and I found it almost impossible 
 to urge her to walk out. Added to this, her husband entertained an idea that if his wife did 
 not indulge freely in the pleasures of the table, the fœtus would be small and unhealthy. In 
 accordance, therefore, with this theory, this inactive and plethoric lady was in the habit of 
 partaking at night of hot suppers, &c, «fee. I admonished both the lady and husband of 
 the madness of such conduct, but without effect. When her labour came on I was in 
 attendance, and after sixteen hours of severe suffering, she was delivered of a healthy 
 living son. Everything went on well, much to my surprise, and things looked auspiciously 
 for both mother and infant. I remained with this lady for two hours after delivery, and then 
 took my leave. I had scarcely reached my house when a messenger hastened after me, re- 
 questing that I would immediately return, stating that the patient had been taken very ill, and 
 that fears were entertained of her life. I lost no time, but proceeded at once to the house, 
 and the scene I witnessed on entering her chamber was indeed fearful. The room was 
 filled with female friends, who had been summoned from the neighbourhood, all endeavour- 
 ing to administer relief to the suffering patient. She was then labouring under a severe at- 
 tack of convulsions — the face was livid — the eyes frightfully distorted — the tongue immense- 
 ly swollen, and projecting out of her mouth — the external jugular veins were prodigiously 
 distended, and the breathing stertorous. 1 feared every moment death from apoplexy : there 
 was no time to be lost ; accordingly, I opened an external jugular vein with my lancet, 
 and abstracted, as nearly as I could estimate the quantity, about forty ounces of blood ; at the 
 same time I ordered mustard cataplasms, their surface well sprinkled with Cayenne pepper, 
 to be placed on the legs and thighs ; and powerful frictions were kept up on the whole length 
 of the spine with spirits of turpentine. The bleeding seemed to break the violence of the 
 second paroxysm, which occurred precisely thirty-five minutes after the first. Soon after the 
 second attack, I placed a drop of Croton oil, mixed with powdered sugar, on the tongue. 
 The third paroxysm, which was exceedingly violent, occurred three quarters of an hour 
 after the second. I entertained serious apprehensions for the life of this lady, and resolved 
 at once on farther depletion : the force of the pulse had yielded to the first bleeding, and the 
 danger from apoplexy was not so imminent. It occurred to me that the convulsions were 
 kept up in this case (as I believe they are in most instances of puerperal eclampsia) by local 
 irritation of the womb. Accordingly, two dozen leeches were applied to the hypogastric 
 region : the bleeding occasioned by the leeches was very profuse, and certainly diminished 
 both the violence and frequency of the attacks ; but these continued at intervals, varying 
 from one hour to one hour and a half. Feeling the full responsibility of this case, and know- 
 ing that the life of the patient was in serious peril, I requested a consultation, and imme- 
 diately sent a messenger for my friend, Doctor Washington. He arrived in about an hour. 
 The patient was still unconscious, and the attacks continued. It was agreed that two 
 dozen leeches should be again applied to the hypogastrium, the revulsives on the extrem- 
 ities continued, and another drop of Croton oil administered. This treatment, most actively 
 and perseveringly continued, rescued this lady from her impending danger. The Croton oil, 
 in two hours after the second drop had been taken, produced copious evacuations, and ap- 
 peared to exert a positive influence on the malady. 
 
 A curious fact should be mentioned here in reference to the child. About an hour and a 
 half after the mother had been attacked with eclampsia the infant became convulsed, and 
 had, at intervals of from thirty to forty-five minutes, four well-marked convulsive paroxysms. 
 They yielded, however, to a stimulating warm bath. 
 
 It will now be seen that the treatment to which this patient was subjected was what may 
 be called truly heroic. Her case was one which would have justified the most unfavourable 
 prognosis ; and to have hesitated or faltered one moment as to what was to be done, would, 
 in my judgment, have been nothing more than to let her die. I could detail several other 
 cases of violent eclampsia, which alone yielded to the most energetic and uncompromising 
 depletion. 
 
 Convulsions before the delivery of the child must be treated, as a general rule, with equal 
 activity, especially if the patient be of a plethoric habit. And if the paroxysms do not yield, 
 as soon as the mouth of the uterus will permit, artificial delivery should be had recourse to. 
 —Ed. 
 
110 DISEASES INCIDENT TO PREGNANCY. 
 
 as a predisposing cause to eclampsia, yet it is very certain that, in 
 plethoric women, convulsions are often followed by cerebral con- 
 gestions and paralysis. 
 
 This affection is much more serious in women who have never 
 been previously attacked, in primiparae, for example, because in 
 these the expulsion of the fœtus is attended with more difficulty ; it 
 is, therefore, more alarming as pregnancy is less advanced, for then 
 the neck of the womb has not undergone the changes necessary to 
 permit a rapid delivery. It is also more dangerous after delivery, 
 for we are deprived of having recourse to the treatment par ex- 
 cellence-the extraction of the foetus. 
 
 In a word, it is the more dangerous as the attacks are more 
 prolonged, as they occur at shorter intervals, as the coma which 
 succeeds them is more absolute and protracted. But in nervous 
 women, when the attack has been occasioned by some mental 
 emotion, and in hysterical, epileptic, and cataleptic women, the 
 eclampsia is less serious ; it is also much less grave when the ad- 
 vanced period of pregnancy and labour enables us promptly to de- 
 liver the woman. 
 
 B. For the Child. — As regards the child, the prognosis is of the 
 most serious character. When the attacks are repeated it most 
 usually dies, and it sometimes succumbs after a short and slight 
 paroxysm. In the first case, the death of the foetus is easily ex- 
 plained. The maternal circulation being suspended, the foetus re- 
 ceives blood but imperfectly elaborated. But in the second case, 
 when the child perishes in consequence of slight attacks of eclamp- 
 sia, without the mother's being asphyxiated, its death must be at- 
 tributed to another cause. The peculiar stiffness of the still-born foe- 
 tus after eclampsia, the meningitis, and convulsions which almost 
 always ensue and occasion the death of the child, if it should have 
 been born alive after an attack of eclampsia, are strong presump- 
 tive evidences that the child received the germ of this affection 
 from the mother while in utero ; and as no nervous communication 
 exists between the mother and the child, it must be admitted that 
 the blood serves as a vehicle for the principle of the disease. 
 
 8. Post-mortem Results. 
 
 In the autopsy, no lesion is discovered which can explain the 
 intimate nature of the malady. 
 
 Thus, when a female dies some time after the last paroxysm, if 
 the determination to the head have not been considerable, we find 
 absolutely nothing. If she have died during the attack, when the 
 cerebral congestion is very great, we shall find the membranes 
 injected, and effusions to a greater or less extent. But who does 
 not see in these lesions the consequences of eclampsia, and not the 
 original cause ? 
 
 I am aware that quite an opposite opinion is held by M. Moreau. 
 This accoucheur regards the cerebral congestion as the first cause 
 of the eclampsia, and he insists with energy on the antiphlogistic 
 treatment, abundant bleeding, even to syncope ; but to my mind 
 
DISEASES INCIDENT TO PREGN^JCY. Ill 
 
 the opinion of M. P. Dubois appears much more rational, and I 
 think, with him, that, in the actual state of science, eclampsia should 
 be regarded as a neurosis, and the lesions met with after death as 
 secondary effects due to the determination of blood towards the 
 brain during the paroxysm, and not as the cause of the disease. 
 According to this view of the subject, the treatment should consist 
 of revulsives, sedatives, and antispasmodics. , The antiphlogistic 
 means, which I am far from proscribing, should be employed con- 
 jointly with the other remedies, with a view to control the conse- 
 quences of the eclampsia, and not with the hope of arresting its 
 progress. 
 
 9. Treatment of Eclampsia. 
 
 The resources of our art are, unfortunately, too often powerless 
 in checking the attacks ; but they may frequently prevent them by 
 removing the predisposition. The treatment is, therefore, divided 
 into preventive and curative. 
 
 A. Preventive Treatment. — Infiltration being one of the most 
 common predisposing causes, we should combat it, especially when 
 it is accompanied with pain in the head, disturbance of vision and 
 ideas, blindness, and deafness. Bloodletting, derivatives, baths, 
 diuretics, and antispasmodics are indicated. The patient should 
 use a drink of the wall pellitory, to which may be added from fif- 
 teen to twenty grains of the nitrate of potash. She should take 
 white wine at her meals, and every morning a pint of whey with 
 some nitre in it ; at night she should make use of a diuretic po- 
 tion, composed as follows : 
 
 #. Honey of squills, §ss. 
 Nitric ether. 3J. 
 
 Laudanum of Sydenham, gtt. v. 
 Distilled water of valerian, 5 iij. 
 Sirup des cinque racines, ^j. 
 
 Derivatives should be directed especially to the intestinal canal ; 
 and seidlitz-water, calomel, in the dose of twenty-five, forty, to fifty 
 centigrammes, should be preferred. In injections, we should ad- 
 minister the decoction of squills united with eight or ten grammes 
 of mercurialized honey, or sulphate of soda. 
 
 The application of a cataplasm, sprinkled with nitrate of potash, 
 to the hypogastrium during the night, will frequently be found ser- 
 viceable. 
 
 If there should be pain in the epigastric region, the application 
 of leeches will become necessary, and a small bleeding from the 
 arm should also be practised. 
 
 B. Treatment during the Attack. — The first care of the accou- 
 cheur should be to see that the patient, during the paroxysm, does 
 not fall out of bed, and likewise to place the tongue within the 
 mouth, for fear it should be bitten. If this cannot be done, the 
 handle of a spoon, covered with linen, should be introduced be- 
 tween the jaws to keep them asunder ; but cork should not be 
 employed for this purpose, as it may be broken under the effort 
 
112 x DISEASES INCIDENT TO PREGNANCY. 
 
 of the teeth. However, if this substance be used, it must likewise 
 be covered with linen. If the bladder be in a state of distension, 
 it must be evacuated, and cold water should be thrown upon the 
 face. 
 
 C. Treatment after the Attack. — After the attack has passed 
 over, the patient should be bled from the arm, to an extent 
 proportional to the general strength. Bleeding is proper under 
 all circumstances ; whether there is plethora or not, and even 
 when the patient is labouring under infiltration, it will be found 
 the best sedative for the nervous system. Ten leeches should be 
 applied behind each ear, and mustard cataplasms to the inferior 
 extremities ; but care should be had not to allow them to remain 
 on more than ten or fifteen minutes, and immediately to remove 
 them to some other part. The insensibility of the patient will pre- 
 vent our perceiving the effects of the sinapisms, and if, on this 
 account, we permit them to be applied for a longer time, they 
 may occasion eschars of the integuments. At the same time, an 
 enema should be administered, composed of a handful of table-salt 
 in solution ; ice and pump water should be kept applied to the 
 head in a bladder, and if the patient can swallow, she should be 
 made to take the following antispasmodic potion : 
 
 $. Sirup of orange flowers, §j. 
 Distilled water of lettuce, ^ij. 
 Distilled water of linden, 51J. 
 Sulphuric ether, 3SS. 
 Laudanum of Sydenham, gtt. x. 
 
 The best antispasmodic would be to place the patient in a warm 
 bath for some time, whether in a state of stupor or during the suc- 
 cession of the attacks ; but the greatest advantage would be de- 
 rived from this remedy if had recourse to during the intervals of 
 tranquillity. 
 
 No matter how rapid the succession of attacks may be, or how 
 serious the state of the patient, if pregnancy be not far advanced 
 we must not think of delivering, although this is certainly the most 
 effectual curative means, for the remedy would be more danger- 
 ous than the disease ; the condition of the cervix uteri, especially 
 in a primipara, not permitting, except with great difficulty and 
 danger, the rupture of the membranes. Neither should we have 
 recourse to ergot : it would probably aggravate the difficulty, and, 
 moreover, it would prove useless. 
 
 At a more advanced period, we may bring on premature artifi- 
 cial delivery by means of a small cone of prepared sponge intro- 
 duced into the neck of the uterus through a speculum, or by the 
 rupture of the membranes, if this be possible. But, even in this 
 case, the expulsion of the fœtus will not be instantaneous, and yet, 
 in order to obtain proper results, it is desirable that the evacuation 
 of the uterus be rapid. 
 
 In a word, it will be necessary to employ the remedies indicated 
 above, and not attempt to empty the womb except in cases in which 
 the extraction of the fœtus can be accomplished with facility. 
 (See Eclampsia during Labour.) 
 
DISEASES INCIDENT TO PREGNANCY. 113 
 
 Hysterical convulsions are much less frequent than the prece- 
 ding : they scarcely ever manifest themselves except during preg- 
 nancy, and in the first months only. They are produced by the 
 same causes as the first, but they are much less serious. They 
 may be readily distinguished from epileptic convulsions (although 
 nearly all the symptoms are the same), inasmuch as there is not 
 complete loss of the intellectual and sensorial faculties. They are 
 extremely rare during labour. They are to be treated in the same 
 way as hysteria. 
 
 Cataleptic and Tetanic Convulsions. — Nearly the same symp- 
 toms as in the epileptic form, but there are more automatic move- 
 ments. They are rare at all the periods of childbirth, and require 
 nearly the same treatment as eclampsia. 
 
 Art. VII.-— Deformities oe the Pelvis. 
 
 In order not to depart from the object which I have proposed in 
 a practical work, I shall pass over rapidly the different classifica- 
 tions given by authors, and speak particularly of the diagnosis of 
 pelvic deformities, their influence on pregnancy and labour, and 
 the indications they present during gestation. It is during preg- 
 nancy especially that deformities of the pelvis become objects of 
 solicitude to the accoucheur, when they are of such a character as 
 to render delivery at full term impossible without the interference 
 of cutting operations. At this period only can he guard against 
 the deplorable consequences of these deformities. 
 
 The pelvis is deformed whenever its dimensions depart from the 
 natural standard. However, a few lines more or less in the meas- 
 urement of the diameters do not, properly speaking, constitute a de- 
 formity, for there is nothing in these cases, either during pregnancy 
 or labour, which will give us cause to suspect the existence of this 
 condition. 
 
 The pelvis should be considered deformed only when its config- 
 uration occasions difficulties in the accomplishment of parturition. 
 
 § 1. Causes and Classification of Pelvic Deformities. 
 
 Rachitis and malacosteon are not the only causes of pelvic de- 
 formities, as was formerly supposed.* Other influences may, with- 
 out the concurrence of these two maladies, alter mechanically the 
 shape of the bones in infancy and in debilitated subjects. Accord- 
 ing to the causes which produce them, we may classify the deform- 
 ities as follows : 
 
 1st. Deformity by augmented capacity, with perfection of form 
 (excess of amplitude). 
 
 2d. Deformity, with diminution of all the diameters, and perfec- 
 tion of form (absolute diminution). 
 
 3d. Deformity from rachitis or malacosteon (relative diminution). 
 
 4th. Consecutive deformities determined by previous deformity of 
 some other part of the skeleton (relative diminution). 
 
 * See F. C. Naegèle, Principal Deformities of the Pelvis, translated by A. Dany au,. Paris, 
 1840, in 8vo, Fig. 
 
 P 
 
114 DISEASES INCIDENT TO PREGNANCY. 
 
 
 § 2. Deformity from Excess of Amplitude. 
 
 Increased capacity of the pelvis is not always, as we might sup- 
 pose, a favourable circumstance ; it may expose the woman to 
 grave consequences during pregnancy and labour, and even in the 
 unimpregnated state. 
 
 In the unimpregnated state, for example, the margin of the pel- 
 vis does not afford the uterus a proper support, and it is therefore 
 more exposed to displacements ; either prolapsion, ante- version, or 
 retro-version. These accidents, which are serious in the unimpreg- 
 nated condition, exert occasionally a disastrous influence during 
 pregnancy and labour. 
 
 A. Prolapsion. — During pregnancy, the uterus having abundant 
 space in the pelvic cavity, is not solicited to rise above the supe- 
 rior strait, in proportion as it becomes developed. It may even 
 remain below this strait after it has acquired a considerable vol- 
 ume ; the bladder and rectum are more or less pressed upon, and 
 hence there is more or less difficulty in the excretions. Frequently 
 the inferior extremities become infiltrated in consequence of ob- 
 struction in the circulation ; and hemorrhoids are sometimes pro- 
 duced by the same cause. 
 
 In this case, most commonly the superior strait is proportionally 
 as large as the cavity ; the uterus ascends, the symptoms cease, 
 and they do not reappear until the end of pregnancy, when the in- 
 ferior portion of the womb again descends, which takes place es- 
 pecially in presentation of the head. 
 
 But it may happen that the superior strait, not participating in 
 the enlargement of the rest of the pelvis, retains the uterus in the 
 cavity. This organ, pressed on all sides, increases, by its volume, 
 the difficulties already produced by the obstruction in the circula- 
 tion and excretions. The woman experiences a sensation of in- 
 supportable tenesmus about the bladder and rectum, painful trac- 
 tions about the groins, loins, and umbilicus ; she can neither stand 
 nor walk. Occasionally a discharge, more or less abundant and 
 fetid, takes place through the vulva ; all the symptoms of uterine 
 inflammation are present, and the woman would die if abortion did 
 not commonly terminate this condition of things. 
 
 B. Ante-version — Retro-version. — In this case the uterus may 
 incline forward or backward, displacements to which are given the 
 names of ante-version (fig. 58) and retro-version (fig. 59) ; this 
 must not be confounded with ante-flexion and retro-flexion. In the 
 
 (Fig. 58.) (Fig. 59.) 
 
DISEASES INCIDENT TO PREGNANCY. 115 
 
 former case, the uterus lies horizontally ; its body and neck have 
 the same axis ; in the latter, the body is more or less flexed on the 
 neck (fig. 60, 61). 
 
 (Fig. 60.) (Fig. 61.) 
 
 6* Cd 
 
 This accident usually occurs in the first three or four months of 
 pregnancy. Excess of capacity in the pelvis is a common cause 
 of it ; but other circumstances may determine its production. 
 Thus, it .may take place gradually, in consequence of continued 
 pressure exercised by the viscera on the womb ; or suddenly, in 
 consequence of a fall on the back, or of some violent effort. 
 
 When this displacement is slight, it is frequently unperceived, and 
 the womb becomes righted in proportion as it rises up ; but when 
 it is well marked, the uterus cannot ascend above the superior 
 strait, and all the phenomena described above manifest themselves. 
 
 Diagnosis. — In prolapsion, the finger comes in contact with the 
 cervix on the floor of the pelvis, and it soon perceives that the ute- 
 rus fills up the entire cavity ; in ante-version, the finger reaches im- 
 mediately the fundus of the womb ; and the neck, situated in the 
 concavity of the sacrum, is often inaccessible. 
 
 In ante-flexion, the body occupies the same place, but the finger 
 readily reaches the cervix, which is not displaced ; and it may be 
 easily carried to the fold which separates the body from the neck. 
 
 In retro-version, the neck presents first ; it is even often visible 
 by separating the lips of the vulva ; the fundus occupies the entire 
 concavity of the sacrum. 
 
 In retro-flexion, the fundus occupies the same place ; the neck is 
 situated naturally, and the finger, in passing beyond the neck, can 
 reach the angle formed by this portion and the body of the organ. 
 
 Indications to be fulfilled when the Pelvis is Deformed by an Ex- 
 cess of Amplitude, 
 If this species of deformity should be detected, especially if there 
 be prolapsus of the womb, the female should be made to keep the 
 horizontal position from the commencement of pregnancy until 
 after the fifth month. The accoucheur should also, from time to 
 time, make a vaginal examination, to ascertain whether the uterus 
 assumes an improper direction, and whether it continues movable 
 in the pelvic cavity. If necessary, the ascent of the womb may be 
 favoured by means of a fine sponge, having the form of a mush- 
 room. The sponge should be so placed as to allow the neck of the 
 uterus to rest in its cavity, in order that the organ may be thus 
 maintained in its proper position. This sponge should be with- 
 drawn by means of a thread attached to it, then washed and re- 
 placed, at least every two days. While in situ, it may be moist- 
 ened and washed by means of slight astringent injections, repeated 
 several times during the day. However, notwithstanding all these 
 precautions, it should not be permitted to remain more than three 
 
116 DISEASES INCIDENT TO PREGNANCY. 
 
 or four days without being properly cleansed. In this way the 
 ascent of the uterus above the superior strait will be promoted in 
 proportion as it becomes developed, and thus serious difficulties 
 will be obviated during pregnancy. 
 
 But when this disposition has not been suspected, and no prop- 
 er precaution taken, the impregnated uterus remains in the cavity, 
 and frequently in a more or less marked state of ante- version or re- 
 tro-version. If the pains and inconveniences resulting from these 
 displacements are such as to induce the patient to seek advice, the 
 accoucheur, the bladder and rectum having been emptied, should 
 endeavour with the fingers, or the whole hand if necessary, to re- 
 place the womb, and raise it above the superior strait, where it 
 will afterward continue of its own accord. In ante-version, the 
 body of the organ should be raised by means of a small director, 
 its extremity being covered with a tampon of linen, while, with 
 the index finger of the other hand, the accoucheur should endeav- 
 our to bring the cervix into the centre of the pelvic cavity. In re- 
 tro-version, two or three fingers should be carried posteriorly, with 
 a view to raise the fundus of the organ, while efforts should be made 
 to bring down the neck, which is in front. 
 
 Sometimes this reduction presents very serious difficulties. If 
 these accidents have determined at first only slight pains, for which 
 the woman has not thought proper to ask advice, the uterus may 
 have become so much developed as to be firmly fixed in the cav- 
 ity. M. Evrat has employed, in similar cases, the director which I 
 mentioned above ; he introduced it into the rectum, and raised the 
 fundus of the womb, while with the index finger he pressed on the 
 neck, which was in front. After the reduction, the patient should 
 be kept quiet for about a month ; and if any evils should result from 
 these displacements, or from the manipulations necessary to correct 
 them, they must be met by baths, bloodletting, &c. But it will 
 scarcely ever be necessary to employ any other means than the 
 sponge already spoken of. Should the reduction be impossible, we 
 must induce abortion, either by rupturing the membranes in the 
 case of simple prolapsion and retro-version, because the neck, un- 
 der these circumstances, is quite accessible ; or by puncturing the 
 uterus through the vagina in the case of ante-version, where the 
 neck cannot be reached. 
 
 This species of pelvic deformity requires also the attention of 
 the accoucheur during labour and after delivery ; I will allude to 
 this hereafter. 
 
 § 3. Deformity from diminished Capacity. 
 Pelvic deformity from diminished capacity is one of the greatest 
 accidents which the accoucheur, under any circumstances, can be 
 called upon to remedy. In order that spontaneous delivery may 
 be accomplished, it is necessary that proper proportions should ex- 
 ist between the foetus and pelvis. When these proportions are not 
 present, an operation becomes indispensable. If the disproportion 
 be slight, the difficulty may be overcome without much danger 
 
DISEASES INCIDENT TO PREGNANCY. 117 
 
 either to the mother or child ; but, in the contrary case, the ac- 
 coucheur has to choose between two extremes equally embarrass- 
 ing—to diminish the volume of the foetus, or enlarge the canal 
 through which it has to pass. 
 
 I shall return to this subject when speaking of the indications 
 presented by pelvic deformities during labour ; but will now mere- 
 ly remark that, between these two alternatives, the choice, in my 
 opinion, cannot be doubtful in cases in which, by destroying the 
 child, it will be possible to save the mother. 
 
 At present, I have only to treat of the influence of deformed pel- 
 ves on pregnancy, and the. indications to be fulfilled at the various 
 periods of gestation. 
 
 The divisions and subdivisions of this species of deformity have 
 been unnecessarily multiplied. In practice, these subdivisions are 
 useless ; they only serve to embarrass the pupil. I shall, therefore, 
 limit myself to the description of the two principal forms of con- 
 tracted pelvis. I shall insist, however, on the causes and diagno- 
 sis, which will enable me to point out more particularly the indi- 
 cations. 
 
 Pelvic deformities from diminished capacity are divided into 
 two kinds: deformity from absolute diminution, and deformity from 
 relative diminution. 
 
 1. Absolute Diminution (Velpeau). 
 
 This species of deformity is distinguished by the regularity of 
 form ; it is in all respects similar to a well-conformed female adult 
 pelvis, except that the dimensions are not the same ; but the tex- 
 ture of the bones, their form, colour, and general solidity do not 
 differ from the healthy state. But there is a remarkable difference 
 in the pelves of rachitic individuals. 
 
 M. Naegele has four in his collection, taken from women in whom 
 it was necessary to perform the Caesarean section, or embryotomy. 
 
 Three of these pelves belonged to women of ordinary stature ; 
 the fourth to a dwarf thirty-one years of age, well conformed, and 
 measuring in height thirty-nine inches. 
 
 M. Nsegele admits several kinds of this deformity, and for farther 
 details I refer the reader to his work, entitled Principal Deformi- 
 ides of the Pelvis, of which M. Danyau has just made an excellent 
 translation. 
 
 A. Causes of this Variety. — Most writers have heretofore suppo- 
 sed that a deformed pelvis with absolute diminution was produced 
 by an arrest of growth, in consequence of which the pelvis pre- 
 serves after puberty the characters of infancy. But the descrip- 
 tion I have given of this pelvis, according to Naegele, shows that 
 it is in every respect similar to the female adult pelvis, the same 
 conformation of the straits, pubic arch, and separated bones. It 
 differs only in its diameters, and is far from resembling the pelvis 
 of an infant. Neither has it anything in common with the pelves 
 of rachitic persons ; and it is met with in women whose skeletons 
 present no trace of this disease. The cause of its production we 
 do not know. 
 
118 
 
 DISEASES INCIDENT TO PREGNANCY. 
 
 2. Relative Diminution (Velpeau). 
 
 M. P. Dubois has reduced all deformed pelves of the contract- 
 ed character to three types : flattening from before backward ; 
 sinking down of the anterior and lateral parts ; compression from 
 one side to the other. 
 
 These deformities may affect the straits separately or simulta- 
 neously. 
 
 A. Flattening from before backward. — In this form of pelvis, it 
 is generally the sacrum that sinks down, rarely the symphysis pu- 
 bis. This contraction may affect the superior strait, and present 
 this form. The diminution in the antero-posterior diameter of the 
 superior strait (A I) is almost always accompanied with an in- 
 crease of the corresponding diameter of the inferior strait (A B), 
 unless the concavity of the sacrum should be very marked, in 
 which case both these diameters would be deformed ; that of the 
 cavity (A C) would gain in extent from before backward. 
 
 (Fig. 62.) (Fig. 63.) 
 
 ~JQD 
 
 Although the sinking down of the symphysis is rare, yet it may 
 coincide with that of the sacrum, and then the pelvis presents the 
 figure of 8. 
 
 (Fig. 64.) (Fig. 65.) 
 
 CO 
 
 If the symphysis be too long vertically (fig. 67), the antero-posteri- 
 or diameter of the inferior strait is deformed, and this deformity is still 
 more remarkable when the symphysis is oblique inwardly (fig. 66). 
 
 (Fig. 66.) (Fig. 67.) 
 
 / 
 
 (: 
 
 Profile view. 
 
 Profile view. 
 
DISEASES INCIDENT TO PREGNANCY. 119 
 
 It is rare that the immobility of the coccyx constitutes a seri- 
 ous obstacle to delivery, when the pelvis is otherwise well con- 
 formed. 
 
 B. Sinking down of the Anterior and Lateral Walls. — The com- 
 pression of the antero-lateral walls contracts the oblique diameters ; 
 this species of deformity is not very rare, yet it is more so than 
 the preceding. The pelvis, in this case, may be deformed on one 
 side, or on both sides at once. 
 
 In all cases, it is the point corresponding to the cotyloid cavity 
 which has been depressed. 
 
 If this depression have taken place on both sides, the pelvis pre- 
 sents the form of a club at cards (fig. 68) ; but usually the deform- 
 ity is greater on one side than the other, and gives to the superior 
 strait this form (69) ; the oblique diameter (A I) is very much con- 
 tracted ; but the antero-posterior diameter (B C), although having 
 lost nothing of its length, and presenting sometimes even more than 
 four inches, will not permit the descent of the head. In fact, this 
 latter cannot be contained in the space presented by the symphy- 
 sis pubis. 
 
 (Fig. 68.) (Fig. 69.) 
 
 ÇP 
 
 It is to this species of contraction that we are to refer the ob- 
 lique pelvis of M. Nsegele ; the characters of 1 his pelvis are as fol- 
 low : anchylosis of one of the iliac bones with the sacrum, arrest 
 of growth, or defective growth of half the sacrum, and the sacral 
 foramina of this side small. 
 
 (Fig. 70.) 
 
 The other side, which appears to be naturally formed, is, how- 
 ever, not so. Thus, in removing the deformed portion of the pel- 
 ves of this kind, we cannot, with the other two halves which ap- 
 pear well formed, make a normal pelvis. There remains a space 
 of more or less extent between the pubic bones. 
 
120 DISEASES INCIDENT TO PREGNANCY. 
 
 (Fig. 71.) 
 
 The strength of the bones, their size, and internal structure are the 
 same as those of the healthy bones. 
 
 This species of conformation presents a great advantage, for 
 one side gains in extent what the other has lost, and this will per- 
 mit the accomplishment of labour. Moreover, in this case, if any 
 circumstance should render extraction of the fœtus necessary at 
 the time of labour, the accoucheur will be enabled to deliver by 
 the feet, although, in general, a pelvic deformity contra-indicates 
 this operation. 
 
 C. Compression of the Lateral Walls. — The lateral compression 
 of the pelvis affects the configuration of the inferior strait and cav- 
 ity more frequently than that of the superior strait. The tuberos- 
 ities of the ischium approximate, and the pubic arch assumes the 
 form of the male pelvis. When this compression has altered the 
 form of the superior strait, it is the transverse or bis-iliac diam- 
 eter which becomes contracted. The antero-posterior diameter, 
 on the contrary, increases,, the pubes project forward, and the 
 sacrum falls backward. When the effect has been slight, the su- 
 perior strait is round ; if the compression has been greater, it is 
 oval (fig. 72) ; finally, this compression may have been more con- 
 siderable on one side than on the other ; in this case, the strait as- 
 sumes this form (fig. 73). 
 
 (Fig. 72.) (Fig. 73.) 
 
 I have now given all the details with regard to the three species of 
 malformation by relative diminution necessary to establish the prac- 
 tical deductions which I shall hereafter make. I should, however, 
 add, that these three types sometimes become united, and then all the 
 diameters of the pelvis are deformed, which explains why each au- 
 thor has admitted a multitude of divisions and subdivisions alto- 
 gether useless in practice. In most cases, it is not the exact de- 
 gree of contraction, unless it should be very marked, that will vary 
 
DISEASES INCIDENT TO PREGNANCY. 121 
 
 the means to be employed, but rather the difficulties of expulsion, 
 for we must take into account also the size of the child's head. 
 One woman, for example, will be delivered by means of forceps, 
 having but three inches and a quarter, because her children are 
 small ; while in another, delivery cannot be accomplished by these 
 means, and it will be necessary, after unavailing efforts, to have 
 recourse to another operation, because the female brings forth 
 large children.* 
 
 § 4. Causes of Pelvic Deformities. 
 
 For a long time, rachitis and malacosteon were regarded as the 
 only causes of pelvic deformity. The researches, however, of 
 Nsegele, P. Dubois, Guérin, Bouvier, Sédillot, &c, have shown 
 that, in cases in which rachitis does not exist, certain mechanical 
 causes have produced malformation of the pelvis, when its powers 
 of resistance were slight, in infancy or in feeble subjects. M. Nse- 
 gele has also pointed out causes the intimate nature of which is as 
 yet unknown. 
 
 1. Rachitis and Malacosteon. 
 
 Rachitis and malacosteon, although very distinct in their ana- 
 tomical characters, produce, however, the same results. We shall 
 examine their influence on the deformities of the pelvis, without 
 distinction. Rachitis and malacosteon have not altogether the 
 same influence on the osseous structure ; the first, which is pecu- 
 liar to infancy, is often accompanied by a certain degree of soften- 
 ing, but its principal characteristic is an arrest of growth ; while in 
 malacosteon, which only occurs in the adult, the softening is much 
 more evident, but the bones have acquired their full development. 
 These two affections are, therefore, the original causes of the va- 
 rious pelvic deformities ; but to these causes we must add the 
 action of an external force, without which no malformation would 
 exist. 
 
 In rachitis, the softening is never so great as to produce de- 
 formity in the bones by their own proper weight. This, how- 
 ever, may occur in some rare cases of malacosteon. Thus, the 
 deformities are to be attributed to an external force acting as a 
 secondary cause, the muscular force, for example, and, so far as the 
 pelvis individually is concerned, the weight which it has to sustain. 
 
 In the erect position, the weight of the body transmitted from the 
 lumbar vertebrae to the heads of the thigh bones, following two di- 
 verging lines, the resistance which the inferior extremities oppose 
 to this weight has a tendency to depress from above downward 
 
 * Occasionally, when there is no contraction of the pelvis, there is a delay in the de- 
 livery, for which'the accoucheur cannot at first account. This delay may be due to a pe- 
 culiar conformation of the spine of the ischium ; and if it should escape attention, serious 
 consequences may ensue. This spine is occasionally (though I believe rarely) curved in- 
 ward, and forms a hook, which offers an irresistible barrier to spontaneous delivery. By 
 an attentive exploration of the pelvis, the accoucheur will be enabled to detect the cause of 
 the difficulty ; and as this difficulty does not manifest itself until the head has well descend- 
 ed into the pelvic cavity, the indication is to deliver by the forceps.— Ed. 
 
 Q 
 
122 DISEASES INCIDENT TO PREGNANCY. 
 
 the posterior portion of the bony circle of the pelvis, and to elevate 
 the anterior portion ; and again, this force, at the same time that it 
 pushes the sacrum downward, pushes it also forward, and the por- 
 tion of the pubic bones near the cotyloid cavity, under the influ- 
 ence of this cause, approximates the sacro-vertebral angle. This 
 will explain why the deformities are so much more frequent and 
 marked at the superior strait, and why the antero-posterior and 
 oblique diameters are more frequently contracted than the others. 
 
 If the weight should act more particularly upon one side, the de- 
 formity will be much more evident in this direction. Such will be 
 the case when one of the lower extremities is shorter than the 
 other. If to this be added the influence of habit, and the nature of 
 the duties the woman performs, it will be readily understood how 
 the deformity may affect more especially one side of the pelvis, 
 and thus constitute the oblique pelvis of Naegele. 
 
 In this latter case, however, in explaining how the sacro-verte- 
 bral prominence approximates one of the cotyloid cavities by be- 
 ing directed from above downward and from behind forward, and 
 how, likewise, one of the cotyloid cavities may approximate the 
 sacrum and be elevated or depressed at the same time, nothing 
 has lpeen said of the anchylosis of the sacro-iliac symphysis of the 
 affected side ; and this, according to Naegele, is the pathognomon- 
 ic character of the oblique pelvis. Is this anchylosis congenital ? 
 Is it determined by an inflammatory action of the articular sur- 
 faces, supervening after infancy ? M. Naegele has not yet satis- 
 factorily explained this point ; he thinks, however, that this anchy- 
 losis is occasioned by an arrest of growth. The lateral compres- 
 sion, or the contraction of the transverse diameter, is rare ; it is 
 combined almost always with the antero-posterior compression, in 
 order to produce malformation of the oblique diameters. It is oc- 
 casioned by the children lying for a length of time on the same 
 side, or by the pressure exerted on one of the hips by nurses, who 
 carry the child always on the same arm ; this circumstance may 
 also determine the elevation and the inward compression of the 
 tuberosity of the ischium. Finally, if the child remains habitually 
 in the sitting posture, the sacrum curves upon itself, the coccyx ap- 
 proaches the sacro-vertebral prominence, which likewise is pushed 
 down, and the two antero-posterior diameters of the two straits are 
 deformed. 
 
 2. Previous Malformation of some other Portion of the Skeleton. 
 A. Curvature of the Spinal Column. — Curvature of the spine is 
 rarely accompanied with marked deformity of the pelvis. In six- 
 ty-nine cases of deformity of the spine noticed by M. Bouvier, 
 fifty-seven women presented a perfectly natural pelvis ; in twelve 
 only was it malformed ; and, moreover, in these twelve, the in- 
 ferior extremities were more or less curved. This latter circum- 
 stance, on the contrary, is intimately connected with deformity of 
 the pelvis, and the fact is so constant that we may, on the inspec- 
 tion alone of the legs, ascertain the condition of the pelvis, while 
 
DISEASES INCIDENT TO PREGNANCY. 123 
 
 the majority of women who are affected with curvature of the spine 
 only, bring forth their children with as much facility as others. I 
 have frequently had occasion to notice this circumstance. 
 
 Although curvatures of the spinal column cannot be regarded as 
 a cause of pelvic deformity, and although this rarely accompanies 
 these contractions, it is, however, true that they may exert an un- 
 happy influence on the degree of contraction, and on the form of 
 the pelvis. Thus the curvature of the vertebral column may cause 
 the pelvis to be thrown from before backward, particularly at the 
 angle formed by the junction of this column with the sacrum. 
 
 B. Lesions of the Inferior Extremities. — As I have already re- 
 marked, incurvation of the inferior extremities almost always ac- 
 companies deformity of the pelvis, and, moreover, it may occasion, 
 or at least increase them. Thus, when the limbs are of unequal 
 length, the pressure which they exert on the cotyloid cavities is 
 unequal, and may increase the deformity of one side of the pelvis. 
 When there has been no previous malformation of the pelvis, 
 shortening of one of the limbs may determine deformity, whether 
 the shortening be the result of a fracture, luxation, or of atrophy, 
 more particularly if any of these accidents should occur before the 
 pelvis has attained its full development. 
 
 Congenital Luxations of the Femur. — It cannot be denied that 
 congenital luxations of the femur ordinarily exert a certain influ- 
 ence on the configuration of the pelvis ; but this influence is so 
 slight in most cases, that parturition is not affected by it ; and there 
 does not exist a solitary example of a congenital luxation of the fe- 
 mur without rachitis, producing a deformity of the pelvis requiring 
 the use of instruments. 
 
 § 5. Diagnosis of Pelvic Deformities. 
 
 The accoucheur may be consulted by a mother anxious to know 
 whether the pelvis of her daughter is such as to justify marriage. 
 His opinion may also be desired by a female pregnant for the first 
 time, in whose mind there may exist fears as to the formation of her 
 pelvis. In this case, he will have to reply to the following ques- 
 tions : 
 
 Is delivery at full term compatible with the safety of the child ? 
 What influence will the deformity have on pregnancy? What 
 precautions are necessary to guard against accident until the com- 
 pletion of gestation, and to facilitate delivery ? 
 
 When the accoucheur states that delivery will not be possible 
 without the interference of art, he will then be asked whether this 
 interference will compromise the life of the mother or child ; and 
 whether this operation cannot be avoided by some process during 
 pregnancy, either saving the life of both mother and child, or sac- 
 rificing the child for the benefit of the mother ? 
 
 In order to answer these questions satisfactorily, and to furnish 
 himself with a rule of conduct in advance, it will be necessary for 
 the accoucheur to know precisely the condition of the pelvis, and 
 the dimensions of the diameters, &c. 
 
124 DISEASES INCIDENT TO PREGNANCi. 
 
 However, it must not be supposed that this mensuration can be 
 made with mathematical accuracy ; our means will not enable us 
 to obtain this precision ; but even if we could, the object we have 
 in view would not be completely accomplished, for, in order to ar- 
 rive at a rigorous appreciation of the consequences of the deform- 
 ity and the operations it might require, it would be necessary also 
 to know the exact size of the fcetus, which is not possible. 
 
 Happily, in practice, an approximation as to the absolute condi- 
 tion of the pelvis will suffice, and it is easy to arrive at this result. 
 With this view, the accoucheur should, in the first place, learn the 
 previous history of the patient in infancy and youth, and afterward 
 proceed to an external and internal examination. 
 
 When the accoucheur is called upon to pass an opinion as to 
 the natural or unnatural conformation of a female, he should, says 
 M. P. Dubois, inquire minutely into the antecedent condition of this 
 woman during her infancy and youth. The history of early life 
 will often, of itself, cause him to suspect the state of the pelvis. He 
 should address the following questions to the parent : 
 
 What diseases was the infant affected with ? At what age did 
 they manifest themselves ? At what age did the child walk ? After 
 walking, did it appear weak in the inferior extremities ? Was the 
 erect position possible ? Was it easy ? Were the articulations 
 large ? 
 
 If all these phenomena appeared in infancy, it is highly probable 
 that the pelvis is deformed ; and, moreover, it may be affirmed that 
 the symptoms arose from rickets, a disease peculiar to infancy. It 
 commences rarely before eighteen or twenty months, and very 
 seldom after thirteen or fourteen years of age. If there should be 
 curvatures of the spinal column and extremities, it will be almost 
 certain that the pelvis is deformed; and if the curvature com- 
 menced in the inferior extremities, we may conclude that it is 
 owing to rachitis, for this disease exerts its influence first on the 
 tibias, then on the bones of the thighs, pelvis, and vertebral column. 
 On the contrary, if the first ten years have been passed without 
 disturbance of the general health, then curvatures must be attrib- 
 uted to malacosteon, especially if the curvature of the spine has 
 preceded that of the lower limbs. Deformity of the spine may ex- 
 ist alone ; then we may legitimately hope that the pelvis is not con- 
 tracted. Experience, indeed, proves that the vertebral column 
 may be considerably curved without the pelvis participating in the 
 deformity, when the inferior extremities are straight ; and that, in 
 general, curvatures of the extremities alone accompany pelvic mal- 
 formations. 
 
 2. External Examination. 
 The preliminary researches terminated, the accoucheur will 
 commence the external examination with becoming decency and 
 circumspection. This examination may be made while the patient 
 is either in the standing or recumbent position, but always through 
 her linen. According to M. Velpeau, if the carriage of the woman 
 
DISEASES INCIDENT TO PREGNANCY. 125 
 
 be easy, free, and steady ; the inferior extremities straight ; the hips 
 on the same level, wider than the base of the thorax, and well 
 rounded (the width of the hips is double the transverse diameter 
 of the superior strait) ; the great trochanters well separated ; if 
 there be no falling in of the sacrum at its point of junction with the 
 vertebral column ; if the symphysis pubis is neither too compressed, 
 nor too prominent, nor too long, there will be good reason to infer 
 a proper conformation. If the patient should be lame, the ac- 
 coucheur will examine whether this depends on the greater curva- 
 ture of one limb than the other, on the flattening of the anterolat- 
 eral wall, or an old or recent disease of the coxo-femoral articula- 
 tion, or on a former fracture, &c. If this examination should enable 
 the accoucheur to recognise some of the symptoms of pelvic de- 
 formity, he should not be content with those which afford merely 
 presumptive evidences, but should have recourse to other means, 
 by which he will arrive at more precise knowledge. 
 
 Indeed, it is not on simple probabilities that the accoucheur is to 
 interdict the marriage of a young girl, or determine, during preg- 
 nancy, to perform an operation, more or less hazardous to the child, 
 with the view of protecting the mother against the dangers of de- 
 livery at full term. He will likewise require much more positive 
 data at the time of labour, to guide him in the choice of the opera- 
 tion necessary to be performed. 
 
 To arrive at this result, authors have proposed a variety of in- 
 struments, which are applied either externally or internally; but 
 the finger is undoubtedly the best pelvimeter. However, the cal- 
 lipers of Baudelocque, in skilful hands, will enable us to arrive at 
 very satisfactory results, although they do not furnish an absolute 
 certainty. 
 
 (Fig. 74.) 
 
 In this examination, the woman should be placed on her side, if 
 we wish to ascertain the extent of the antero-posterior diameter 
 of the inferior strait ; the extremity of one branch of the instrument 
 should be placed in front of the superior portion of the symphysis 
 pubis, having taken the precaution of separating the soft parts ; the 
 other extremity is held by an assistant on the spinous process of the 
 first false vertebra of the sacrum. 
 
 If the pelvis be well formed, the distance between the extremi- 
 ties of the instrument will be seven inches. 
 
 We must then deduct half an inch for the thickness of the pubes, 
 
126 DISEASES INCIDENT TO PREGNANCY. 
 
 and about two and a half inches for that of the sacrum, and we shall 
 have four inches for the diameter at the superior strait. If the dis- 
 tance, however, between the extremities should be only six inches 
 instead of seven, the antero-posterior diameter will be short by one 
 inch, and, consequently, will measure but three inches, and so on 
 successively. 
 
 If we wish to measure the oblique diameters, one point of the 
 instrument must be placed on the external surface of the great tro- 
 chanter, and the other on the prominent part of the sacro-iliac ar- 
 ticulation of the opposite side. The distance should be nine inches, 
 from which are to be deducted two and three quarter inches for 
 the thickness of the trochanter, neck of the femur, and cotyloid 
 cavity, and one and three quarters for the posterior symphysis. 
 There will remain for the oblique diameter four and a half inches. 
 If the distance be less than nine inches, the deduction made for 
 the thickness of the parts will give the amount of deformity that 
 may exist. 
 
 Two circumstances, however, may lead the accoucheur into 
 error : 1st. The difficulty of fixing firmly the extremities of the 
 instrument on the parts indicated ; 2d. The variations in the thick- 
 ness of the parts. 
 
 In a well-formed pelvis, it is easy to place one extremity on the 
 pubes, and the other on the first tubercle of the sacrum, &c. But in 
 a deformed pelvis, the parts no longer preserving their natural rela- 
 tions, it will be extremely difficult to determine the points on which 
 to fix the instrument. I have often met with this difficulty alone, and 
 also when assisting M. P. Dubois in his investigations at La Clinique ; 
 I have sometimes known M. Dubois to abandon the instrument, and 
 substitute for it his finger. If the extremities of the instrument be 
 not properly placed, there will be an inaccurate measurement. I 
 will suppose now that the instrument is suitably adjusted. In a 
 deformed pelvis, the thickness of the bones is not always the same ; 
 it varies extremely ; in the antero-posterior diameter, for example, 
 we obtain seven inches with the instrument, and yet there will not 
 be four inches between the pubes and sacrum. 
 
 Nevertheless, Baudelocque's pelvimeter is a useful instrument, 
 especially in young girls, in whom an internal examination is not 
 permitted. 
 
 In order to ascertain the condition of the diameter of the inferior 
 strait, the finger applied to the exterior will suffice. 
 
 The female sits on the edge of a chair, or stands up. 
 
 In the measurement of the antero-posterior diameter, the pulp 
 of the index finger of the accoucheur should be placed on the 
 point of the coccyx, and the summit of the thumb on the edge of 
 the sub-pubic ligament, after which the two fingers, kept in this 
 fixed position, should be applied to a graduated rule, in order to 
 ascertain the precise distance. 
 
 In the transverse diameters, the index finger should be placed 
 on one tuberosity of the ischium, and the thumb on the other. 
 
 The external measurement of the pelvis, as can readily be ima- 
 
DISEASES INCIDENT TO PREGNANCY. 127 
 
 gined, does not afford results sufficiently positive to be relied on 
 alone, when an internal measurement is admissible. In a married 
 woman, for example, it is indispensable to measure accurately, by 
 means of the touch, the various dimensions of the pelvis. 
 
 3. Internal Examination. 
 
 In the internal measurement of the pelvis, instruments have been 
 proposed, the use of which is so inconvenient and painful that they 
 have been abandoned : such is the intro-pelvimeter of Coutouly, 
 and that of Madame Boivin. 
 
 Practitioners of the present day employ the finger ; it is the best 
 and most certain of all pelvimeters. 
 
 To ascertain the measurement of the antero-posterior diameter 
 of the superior strait, the index finger should be introduced into the 
 vagina in the direction of the axis of the inferior strait, towards 
 the sacro- vertebral angle, the radial border of the finger being ap- 
 plied immediately under the pubes. If the pulp of the finger does 
 not reach the sacro-vertebral angle, it is because the diameter has 
 its normal dimensions ; or, if it be contracted, it is so slight that 
 delivery can still be accomplished. 
 
 But, if the finger reach the sacro-vertebral angle, we still have 
 reason to apprehend greater or less difficulty. In order to meas- 
 ure, in this case, the extent of the sacro-pubic diameter, we must 
 mark with the nail of the index finger of the other hand, being 
 careful to separate the external and internal labia below the pubes, 
 on the finger introduced ; this finger is then withdrawn, and it is 
 applied to a measure. 
 
 (Fig. 75.) 
 
 But the oblique line represented by the length of the finger in- 
 troduced does not give exactly the length of the antero-posterior 
 diameter, which, passing from the sacro-vertebral angle, proceeds 
 to the upper portion of the symphysis pubis ; this oblique line is 
 somewhat longer. In order to obtain the precise measurement 
 of the antero-posterior diameter, we must deduct half an inch 
 (fig. 75). 
 
 We must also take into account the greater or less obliquity of 
 the symphysis pubis. If, for example, its summit be thrown in- 
 ward (fig. 76), we might suppose the diameter to be much greater 
 than it really is. If it be thrown outward, it might be considered 
 smaller (fig. 77). 
 
128 
 
 DISEASES INCIDENT TO PREGNANCY. 
 (Fig. 76.) (Fig. 77.) 
 
 The finger will ascertain readily whether the concavity of the 
 sacrum is increased or diminished, and this will enable us to de- 
 cide as to the condition of the antero-posterior diameter of the 
 cavity. 
 
 The antero-posterior diameter of the inferior strait is measured 
 in the same manner as the corresponding diameter of the superior 
 strait. The extremity of the index finger being applied to the ex- 
 tremity of the coccyx, the accoucheur will raise his wrist until the 
 radial border of the finger touches the lower portion of the sym- 
 physis pubis, and will mark this point with the other index finger. 
 He will, moreover, ascertain more or less the mobility of the sacro- 
 coccygeal articulation by pressing slightly on the point of the 
 coccyx. 
 
 (Fig. 78.) • 
 
 It is much more difficult to ascertain the oblique and transverse 
 diameters of the superior strait ; but the diameters of the inferior 
 strait may be determined by the fingers. It is by the touch alone 
 that we can recognise the existence of exostoses or other tumours 
 obstructing the pelvis. 
 
 Authors have recommended to make this examination by means 
 of the entire hand introduced into the vagina ; but it is only during 
 labour that this could be had recourse to. 
 
 As it is often of great importance to ascertain the extent of the 
 oblique diameters, I shall add to the means already proposed the 
 directions which M. Nsegele has indicated for the exploration of 
 the oblique pelvis. 
 
 To arrive at this result, we must compare the measurements of 
 the two sides of an oblique pelvis ; the difference will give the ex- 
 tent of the contraction. I shall now, with this view, repeat cer- 
 tain measurements, made by M. Naegele, between points easy to 
 determine in ihe most deformed pelves. 
 
 When the pelvis is well formed, from the ischiatic tuberosity of 
 
DISEASES INCIDENT TO PREGNANCY. 129 
 
 one side to the posterior superior iliac spine of the opposite side, the 
 ordinary distance is six inches and a half. It is about the same on 
 the one side as on the other. 
 
 In the oblique pelvis, there may be, between the two measure- 
 ments made on each side, a difference of from one to two inches. 
 
 In a well-formed pelvis, from the anterior superior iliac spine of 
 one side to the posterior superior iliac spine of the other side, the 
 distance is about seven inches and three quarters. 
 
 In the oblique pelvis, there may be, between the two sides, a dif- 
 ference of from nine to twenty-two lines. 
 
 In a well- formed pelvis, from the superior apophysis of the last 
 lumbar vertebra to the anterior superior iliac spine on both sides, 
 the distance is six inches and a half. 
 
 In the oblique pelvis, the smallest difference between one side 
 and the other is from eight lines to one inch five lines. 
 
 In a well-formed pelvis, from the great trochanter of one side to 
 the posterior superior iliac spine of the other side, there are eight 
 inches and a half. 
 
 In the oblique pelvis, the smallest difference is seven lines ; the 
 greatest, nineteen lines. 
 
 In a well-formed pelvis, from the middle of the inferior border 
 of the symphysis pubis to the posterior superior iliac spine on both 
 sides, there are six inches three lines. 
 
 In the oblique pelvis, the smallest difference between this same 
 distance, taken from the two sides, is seven lines; the greatest, 
 nine lines. 
 
 It is evident, therefore, that it will be easy to recognise a well- 
 formed pelvis, because the measurements between the same points 
 will be the same on each side ; while in the oblique oval pelvis, 
 there will be, for each measurement taken from one side to the 
 other, a marked difference, which will enable us to recognise the 
 oblique pelvis, and even the degree of contraction. 
 
 6. Influence of Pelvic Deformities on Pregnancy ; and Prognosis, 
 so far as Delivery is concerned. 
 
 I have already stated that an excess of capacity may exert a 
 serious influence on pregnancy ; such is not the fact with contract- 
 ed pelves ; they rarely compromise gestation ; and yet, in certain 
 cases of marked contraction, abortion would be desirable. This 
 alone might avoid the perils of delivery at term, which would call 
 for operations most dangerous to the mother. 
 
 This influence would be especially felt during labour ; the diffi- 
 culties would be proportioned to the deformity. As has already 
 been remarked, in order precisely to appreciate these difficulties, 
 it would be necessary to take into account the size of the child, its 
 position, the reducibility of its parts, and the energy of the uterine 
 contractions — circumstances not possible to know during pregnan- 
 cy, and some of which only are appreciable at the time of labour.. 
 
 Pelvic contractions expose the fetus and mother to other dan- 
 gers : the portion of the fetus which presents does not close up 
 
 R 
 
130 DISEASES INCIDENT TO PREGNANCY. 
 
 entirely the superior strait ; the liquor amnii escapes, and the 
 fœtus is exposed during the whole labour to the immediate com- 
 pression of the uterus. Frequently, also, the first escape of liquid, 
 after the rupture of the membranes, brings with it a portion of the 
 umbilical cord, and the child dies from the consequences of this 
 compression. The operations necessary for its extraction frequent- 
 ly, too, compromise its safety. I shall again speak of these cir- 
 cumstances in detail, when I treat of pelvic deformities during la- 
 bour. 
 
 The mother's life may be endangered by the contusions, lacera- 
 tions, and fistulse of every kind, caused either by the head of the 
 child, by instruments, by the separation of the symphyses, or by 
 serious operations. I shall allude to these points hereafter. 
 
 7. Indications presented by Pelvic Deformities during Pregnancy. 
 
 Is it not possible, during pregnancy, for art to interfere profit- 
 ably in order to prevent the serious consequences of pelvic de- 
 formities both for mother and child ? This question is no longer 
 doubtful. In order more definitely to point out the indications to 
 be fulfilled by the accoucheur during pregnancy, I shall first enu- 
 merate the difficulties which may take place at the time of labour. 
 
 Moreover, as regards these difficulties, and the indications to be 
 fulfilled, I shall arrange, according to M. P. Dubois, the various 
 deformities of the pelvis in three principal classes. 
 
 The first class embraces pelves in which the passage measures 
 three inches and a half. 
 
 The second, in which the pelves vary from three and a half to 
 two and a half inches. 
 
 In the third are embraced all the cases in which the contraction 
 is less than two inches and a half. 
 
 Three inches and a half. — Spontaneous delivery in this case, al- 
 though more protracted, difficult, and dangerous, is, however, pos- 
 sible. 
 
 Meriman, Baudelocque, and M. Moreau have advised, under 
 ;these circumstances, to subject the woman to a regimen calculated 
 to diminish the volume of the foetus, with a view to render deliv- 
 ery at term more easy. Repeated bleedings, light diet, frequent 
 warm baths, and active exercise will attain this object. M. Mo- 
 reau speaks of having succeeded in this several times, and I have 
 heard him cite the case of a woman who was delivered at full 
 term of a living child, after having been subjected to this kind cf 
 regimen, while in her previous pregnancies it became necessary to 
 mutilate the child in order to extract it. I have myself noticed 
 only one fact which will sustain this view ; # but I have observed 
 
 * It is a fact well known to the profession, that pregnant women not only sustain them- 
 selves well under active antiphlogistic treatment, but that, notwithstanding severe inflam- 
 matory disease during gestation, and the consequent depletion to which they have been 
 subjected, they bring forth at term healthy, vigorous children. How often are we called 
 upon to attend ladies in their confinement emaciated by phthisis, and who bring into the 
 world foetuses as large as under ordinary circumstances ? These facts, therefore, go directly 
 ■o invalidate the views of Baudelocque, Meriman, and Moreau.— Ed. 
 
DISEASES INCIDENT TO PREGNANCY. 131 
 
 so many of a contrary nature that I do not concur in this opinion. 
 M. P. Dubois does not believe that the regimen of the mother can 
 influence the development of the foetus, and this is the opinion most 
 generally admitted. 
 
 The pelvis measuring at least two and a half inches, and also 
 measuring from three and a half to three inches. — The spontane- 
 ous expulsion of the fœtus is here even possible. However, the 
 uterine contractions must be very expulsive, and the reduction 
 of the head considerable, for the smallest diameter of the head is 
 three and a quarter inches ; and yet the life of the child will be 
 often compromised. But in a contraction less than three inches 
 art will have to interfere, unless the fœtus be dead, and softened 
 by putrefaction. 
 
 The dietetic means recommended by M. Moreau might be em- 
 ployed here, but we possess, in these cases, a much more precious 
 resource, premature artificial delivery. 
 
 1. Premature Artificial Delivery. 
 Thanks to the efforts of MM. Stoltz, Dezeimeris, P. Dubois, and 
 Velpeau, delivery brought on before the full term is an operation 
 hereafter recognised in French midwifery. For a long time it 
 proved useful to our neighbours in England and Germany, while 
 a foolish prejudice caused it to be rejected by French practitioners, 
 who did not hesitate even to have recourse to the Csesarean sec- 
 tion, and symphyseotomy. 
 
 And what object is proposed in this operation? To save the 
 child, and protect the mother from the perils of an operation at the 
 full period of utero-gestation. And this object, be it remembered, 
 is attained in the majority of cases. 
 
 If we consult the statistics published in 1838 by M. Stoltz, it 
 will be seen that, in 211 premature artificial deliveries, more than 
 one half of the children survived, and scarcely one woman in fif- 
 teen died ; now compare these results with those obtained from the 
 Csesarean section and symphyseotomy, and then decide. 
 
 We have not within the walls of Paris one solitary example of 
 a woman who has survived the Caesarean section. She who lived 
 the longest was one of those on whom I assisted M: P. Dubois to 
 operate. She died on the 17th day of a tetanic affection, when 
 everything promised a most successful result. — (Bull, of the Acad, 
 of Med., t. hi., p. 694 ; t. v., p. 25.) 
 
 To obtain the result proposed in premature artificial delivery, it 
 should not be attempted until a period of pregnancy at which the 
 viability of the fœtus is certain, and only when delivery at the full 
 term cannot be accomplished without a cutting operation for the 
 fœtus or mother. 
 
 The viability of the fœtus is not constant until after the revolu- 
 tion of the seventh month ; and it is at this period that artificial de- 
 livery should be attempted. But as the fœtus may not be viable 
 at the seventh month, and the longer it sojourns in the uterus 
 the more apt it will be to live, with a view of affording it the 
 
132 DISEASES INCIDENT TO PREGNANCY. 
 
 best chance of viability, we should not practise this operation until 
 the latest possible period, depending upon the degree of contrac- 
 tion. 
 
 So far as the safety of the mother is concerned, the question is 
 less easy to determine ; the limits within which this operation may 
 be performed must be established with precision. 
 
 It should not be attempted while the degree of contraction af- 
 fords hope that delivery may take place at term, even if this deliv- 
 ery should require assistance. In a word, while there is a chance 
 to extract the foetus alive, recourse should not be had to it. When 
 the contraction is such that a living foetus cannot be brought forth, 
 premature delivery should not be attempted; and the accoucheur 
 has then to choose between the Caesarean section or miscarriage. 
 
 At the period of viability (seven months), in comparing the di- 
 mensions of the bi-parietal diameter of the head with the dimen- 
 sions of the pelvis, we may ascertain the degree of contraction in 
 which it would be proper to practise artificial delivery. At seven 
 months and one week, the bi-parietal diameter measures from two 
 and a quarter inches to two inches and nine lines. 
 
 It is necessary, therefore, that the diameter of the pelvis should 
 be at least two inches and nine lines ; a farther contraction than 
 this does not allow premature artificial delivery. 
 
 Now the less the contraction, the longer should we delay, in or- 
 der to afford a greater chance to the foetus. But when the diam- 
 eter of the pelvis is above three inches and two lines, which is the 
 other extreme limit, this operation should not be performed, for 
 spontaneous delivery is possible at term, the bi-parietal diameter 
 at this period not measuring more than from three inches two lines 
 to three inches four lines. However, if the woman had been in the 
 habit of bringing forth very large children, artificial delivery 
 would be justifiable when the superior strait measures three inches 
 and a half. £ 
 
 Certain practitioners have recommended not to perform this op- 
 eration in primiparae, and to wait until the difficulties of a first la- 
 bour shall have pointed out its necessity in subsequent pregnan- 
 cies. 
 
 M. P. Dubois does not concur in this opinion ; for he contends 
 that, when the pelvis measures only from two inches nine lines to 
 three inches and a quarter, spontaneous delivery is merely an ex- 
 ception, while difficult, and often fatal labours, result. 
 
 He, moreover, recommends this operation when the pelvis is ob- 
 structed by the presence of a tumour, and when the female is af- 
 fected with acute disease. 
 
 He does not sanction the operation when there are twins, for, in 
 such cases, the children are smaller, and may pass the straits at 
 term ; and, moreover, they are rarely viable before this period. 
 
 In all instances, the accoucheur should be assured of the life of 
 the foetus before resorting to the operation. 
 
DISEASES INCIDENT TO PREGNANCY. 133 
 
 2. Mode of Operating, 
 
 The consequences of an artificial delivery may be quite differ- 
 ent from what is anticipated. And in order not to assume un- 
 necessary responsibility, the accoucheur, before performing the 
 operation, should take the counsel of several colleagues. The oper- 
 ation being decided upon, the woman should be put in a state of 
 preparation several days in advance, by baths, and emollient vagi- 
 nal injections. Finally, before the operation, the bladder and rec- 
 tum should be evacuated. 
 
 The woman is placed transversely on the edge of the bed, the 
 breech on a firm cushion, and the legs supported by two assistants. 
 
 After having again ascertained the condition of the pelvis, and 
 not the presentation and position, which would be entirely useless, 
 and in most cases very uncertain,* the operator introduces a spec- 
 ulum. As soon as the neck of the uterus corresponds to the cen- 
 tre of this instrument, he then introduces into the vaginal orifice of 
 this organ, which, at this period of pregnancy, is always open, a 
 small cone of prepared sponge. This cone should be about eigh- 
 teen lines in length, and six lines at its base. It should be well lu- 
 bricated, and retained externally by a string, and then carried to 
 the orifice by means of the tampon forceps. The operator then 
 introduces a soft sponge, moistened with warm water, as far as 
 the neck of the womb, and withdraws the speculum gradually, be- 
 ing careful to retain the sponges in place with the extremity of the 
 forceps. The second sponge should be large enough to fill the 
 whole vagina. 
 
 This being done, the whole is maintained in situ by means of 
 long compresses, and a T bandage. 
 
 Such is the mode of procedure adopted by M. P. Dubois, but 
 he likewise administers ergot, in the dose of fifty to sixty centi- 
 grammes, three times. I have almost always remarked that ute- 
 rine contraction comes on one or two hours after these means have 
 been employed ; the neck of the uterus, irritated by the prepared 
 sponge, dilates ; and it acts sympathetically on the muscular fibres 
 of the fundus of the organ, and solicits its contraction. The ergot 
 increases the activity of this contraction. 
 
 When, by the lapse of time, and the intensity of the pains, it is 
 judged that the dilatation is sufficient to permit the easy rupture of 
 the membranes, escape must be given to the liquor amnii by per- 
 forating the membranes with an ordinary writing pen ; and then 
 real labour declares itself. 
 
 Sometimes, however, several hours may pass by before any ap- 
 pearance of labour exhibits itself; sometimes, also, it becomes 
 necessary to introduce a larger cone of sponge, and repeat the 
 ergot. 
 
 The ergot, however, must be administered with caution, for fear 
 it should occasion permanent contractions, fatal to the fœtus ; it 
 
 * The delivery would be most favourable in the presentation of the summit, but any other 
 presentation would not be a contra-indication. 
 
134 DISEASES INCIDENT TO PREGNANCY. 
 
 would, indeed, be advisable not to give it at the commencement, 
 but reserve it, in case the prepared sponge did not prove sufficient. 
 
 Some authors have recommended to bring on premature deliv- 
 ery by external manipulations, the rupture of the membranes only, 
 &c, &c. But the best and least hazardous plan is the one I have 
 just noticed. The rupture of the membranes is often very difficult 
 at this period before the dilatation of the neck, and the manipula- 
 tions are frequently useless. 
 
 When the contraction of the pelvis is less than two and a half 
 inches, spontaneous delivery at term is physically impossible ; the 
 accoucheur, in this case, has not the resource of premature delivery, 
 for a living child cannot be extracted. When the full period of 
 utero-gestation is completed, there will be but one of two alter- 
 natives : diminish the volume of the child, or enlarge the passage, 
 or open for it a new place of escape. 
 
 During pregnancy, abortion will present an extreme and last 
 resource. And it would seem more humane to sacrifice, before the 
 period of viability, an embryo whose existence is so uncertain, in 
 order to protect the mother from the perilous chances of symphys- 
 eotomy and the Csesarean section. 
 
 I must confess that, if such an alternative were presented to me, 
 the diameter of the pelvis being only two inches, I should not hes- 
 itate to propose this means. 
 
 The abuse and criminal extension of such a resource is repre- 
 hensible, but not its proper and authorized employment. This op- 
 eration should always be undertaken with great care, and all ne- 
 cessary precaution used to satisfy the public mind of its necessity : 
 it should never be performed without previously having a consult- 
 ation of three medical men, and the opinion should have their writ- 
 ten signatures.* 
 
 * Premature artificial delivery I cannot but regard as one of the most precious aids of 
 which, under certain trying circumstances, the accoucheur can possibly avail himself. Why 
 enlightened France, a country which has done so much for the sound advancement of ob- 
 stetric science, has for so long a period rejected this operation, I cannot understand. And I 
 participate entirely in the feelings of pleasure expressed by our author, that the attention of 
 his countrymen should at last have become awakened to the importance of this subject. In 
 Germany and Holland, premature artificial delivery has been had recourse to of late years 
 with the most satisfactory and marked results. According to Kilian (Die Operat. Geburts- 
 hulfe, p. 298), this operation, up to the year 1831, had been performed 161 times, viz., 
 In England .... 72 
 In Germany . . . .79 
 
 In Italy 7 
 
 In Holland . _3 
 
 161 
 
 Of these 161 cases, 46 foetuses were bom dead and 115 living, 73 df which continued to 
 live. Eight only of the mothers died after delivery, and five of these succumbed from causes 
 entirely unconnected with the operation. 
 
 Now, supposing that these cases absolutely called for this operation, here are results, be- 
 tween which and the results of the Csesarean section, symphyseotomy, or craniotomy, either 
 as regards the ultimate safety of the mother or child, no comparison can be instituted ; the 
 chances of safety both to mother and child being in favour of artificial delivery at least as 
 five to one. 
 
 While I heartily concur in the views entertained by Drs. Dubois and Chailly as to the 
 value and importance of this operation, when absolutely indicated, yet there are some points of 
 practice suggested by them from which I cannot but dissent, and I do so with great def- 
 cr6nc6. 
 
 1st. I do not think the introduction of the speculum at all necessary ; the operation can 
 be performed not only with facility, but entire safety, without this instrument. Again, I hold 
 
DISEASES INCIDENT TO PREGNANCY. 135 
 
 J 
 
 Art. VIII. — Deformities of the Soft Parts during Pregnancy. 
 
 Deformities of the organs of generation, either accidental or 
 congenital, which have not been of a nature to prevent conception, 
 
 it to be a rule, which the pupil should ever keep in memory, that the feelings of his patient 
 are always to be sacredly guarded, and on no account should there be an unnecessary expo- 
 sure of her person. 
 
 2d. The promiscuous administration of ergot, as an auxiliary in this operation, must occa- 
 sionally be attended with serious consequences to both mother and child. For, in the first 
 place, the justification of premature artificial delivery is founded on the fact that there is 
 such a contraction in the bony or soft structures of the mother as seriously to endanger 
 her life, as also that of her child, if she be permitted to pass on to her full term. Now, if one 
 of the extremities of the foetus should not present at the superior strait (and this cannot be 
 positively ascertained before the dilatation of the uterine orifice), to administer ergot would 
 be to ensure the death of the fœtus, and not unlikely serious lacerations might ensue to the 
 mother. For example, if the child should present crosswise, or in any other manner so as 
 to cause a disproportion between it and the parts through which it has to pass, ergot would 
 certainly be contra-indicated. 
 
 3d. Instead of introducing a piece of prepared sponge into the orifice of the uterus, and af- 
 terward plugging up the vagina, I greatly prefer to use a simple gum-elastic bougie. Let 
 the index finger of one hand be introduced as far as the neck of the womb ; having reached 
 this organ, the end of the finger should rest on the posterior lip ; the bougie, being well lu- 
 bricated with oil, is then to be carried along the finger, and when it reaches the os tinea?, the 
 finger previously introduced should give the instrument a direction, not from before backward., 
 but from below upward, in the line of the axis of the superior strait ; the instrument, thus di- 
 rected, should be made merely to enter the orifice, and not be introduced higher, and by the 
 finger already in the vagina the end of the instrument should be pushed gently backward and 
 forward ; and with this careful titillation, the uterus will often be thrown into contraction. 
 Should this, however, not prove sufficient to cause the action of the womb, after the lapse of 
 twelve hours the instrument should be again introduced, and carried sufficiently high to rup- 
 ture the membranes. This being done, the contractions usually proceed, and delivery is ef- 
 fected. Should, however, the womb become inert, I should much prefer awakening its en- 
 ergies by the gentle and cautious introduction of the finger into the uterine orifice than by 
 the use of ergot, at least until the absolute position of the foetus had been ascertained. 
 
 I have been obliged to have recourse to premature artificial delivery twice in the same 
 iady, and with entire success. In both instances I pursued the course just recommended. 
 
 This lady was a native of Canada. Her husband, some months after marriage, took her 
 to South America, where she was delivered of a child. He stated to me that she had been 
 suffered to remain in labour for five days ; and after experiencing the most agonizing pains, 
 she was spontaneously delivered of a putrid foetus, of immense size. In about a month after 
 her delivery she began to walk about her room, and although weak, she was otherwise in 
 tolerable health. The first intimation she had that there was anything wrong was the ex- 
 cessive pain in any attempt at sexual intercourse ; this proved to be impossible. In the 
 course of a few weeks they sailed for New-York, and as soon as they arrived, my late la- 
 mented friend, Dr. Bushe, was sent for, and was requested to take charge of the case. At 
 this time his health was so infirm as to disqualify him from attending to general practice. 
 He sent a note to me by her husband, requesting that I would take this lady under my pro- 
 fessional charge. On visiting her, and making an examination, I found that the entire vulva 
 was in a state of adhesion, allowing only a small opening for the meatus urinarius. After 
 hearing the account of her labour, this condition of things was easily explained. From the 
 long and severe pressure of the head of the foetus against the walls of the vagina, violent in- 
 flammation ensued, resulting in sloughing, and a consequent adhesion of the vaginal parietes. 
 The indication in this case was obvious — the vagina needed restoration. Accordingly, I com- 
 menced an incision just below the meatus urinarius, and extended it about an inch down- 
 ward ; the scalpel soon came in contact with cicatrices so resisting that it appeared almost 
 as if I was cutting on iron. As soon as I completed the incision, I introduced a small sponge 
 covered with oil silk, and retained it in situ with the T bandage. By occasionally with- 
 drawing the sponge and renewing it, I found that the vagina yielded slowly to this sort of 
 pressure. With the aid of a small-sized rectum bougie, carefully introduced twice a week, 
 and, after being withdrawn, replaced by the sponge, the vagina, in the course of a month, 
 permitted the introduction of the finger ; then I had an opportunity of ascertaining its con- 
 dition. It was filled with hard and unyielding cicatrices, in the form of rings. Having suc- 
 ceeded in dilating the vagina to this extent, I then recommended this lady to continue the 
 sponge, and occasionally to introduce the bougie. In the course of three months, I was vis- 
 ited by her husband, who seemed somewhat chagrined, and he stated that it pained him to 
 say that his wife thought she was again pregnant. This I found really to be the case, though 
 it is manifest, from what has been said, that sexual intercourse must have been attended 
 with great difficulty. With this, however, I had nothing to do ; the mischief had been done, 
 and it was my duty to provide in the best possible manner for my patient's safety. The 
 sponge and bougie (gradually increasing the size of both) were constantly used, and the va- 
 
136 
 
 DISEASES INCIDENT TO PREGNANCY. 
 
 may, however, occasion fears at the time of delivery, and require 
 some attention during pregnancy : the union of the labia majora 
 and minora, permanence of the hymen, &c. 
 
 As is readily imagined, this adhesion cannot take place except 
 in a certain extent of the vulva, for if it were complete, impregna- 
 tion could not be accomplished. Most frequently it is not until the 
 time of labour that the accoucheur is called upon to separate these 
 parts. It would be better, even, to wait until this period, when the 
 accident has been suspected during pregnancy, for nature, in most 
 cases, will be sufficient to destroy this adhesion at the time of ex- 
 pulsion. 
 
 The same is true as regards the presence of the hymen. 
 
 Narrowness and Rigidity of the Vagina. — The vagina may be 
 divided transversely by bridles, and cross-pieces pierced with 
 holes ; or longitudinally by a partition, extending from the vulva 
 to the uterus, and penetrating sometimes the interior of the cavity 
 of this organ. Nature will suffice in the majority even of these 
 cases. I witnessed at La Clinique a remarkable fact of this kind. 
 A young girl, sixteen years of age, presented herself a little before 
 her full term ; the sage-femme, in examining her, found her finger 
 arrested in the middle of the vagina by a resisting membrane, in 
 which no opening could be detected. 
 
 M. P. Dubois examined her with the speculum, and requested me 
 
 (Fig. 79.) 
 Lateral view. 
 
 (Fig. 80.) 
 Before delivery, seen with the speculum. 
 
 1. Anterior chamber. 
 
 2. Posterior chamber. 
 
 3. Diaphragm. 
 
 4. Uterus. 
 
 5. Sound penetrating the diaphragm. 
 
 gina seemed to yield slightly to this continued pressure; this lady having passed six months 
 and a half of her gestation, I deemed it prudent to hold a consultation as to the propriety of 
 resorting to premature delivery, feeling in my own mind that (although contractions of the 
 soft parts do sometimes yield to the combined influence of pregnancy and labour) in her sit- 
 uation it would, to say the least, be hazardous to the child to allow her to proceed to her 
 full term. On proposing the consultation to her husband, he was anxious that a particular 
 friend of his, Dr. Richardson, of Havana, then on a visit to this city, should be called in. 
 This was accordingly done; and after a full examination of all the circumstances, it was 
 deemed prudent to bring on artificial delivery. This I did in the manner above indicated, and 
 delivered the lady of a fine, healthy girl. This lady again became pregnant, and went to the 
 city of Baltimore, where she was delivered at full term, with the forceps, of a dead child after 
 a labour of six days ! ! In consequence of the contraction of the soft parts, the vagina was 
 lacerated ; vesico-vaginal fistulee followed, and again the vagina became considerably con- 
 tracted. About three years from her last delivery, I was again consulted in her case. She 
 was pregnant, and I resorted to premature artificial delivery, the soft parts not being in a 
 condition to justify delay until the completion of gestation. In this instance, too, the child 
 was born alive, and lived for three months.— Ed. 
 
DISEASES INCIDENT TO PREGNANCY. 137 
 
 to make a drawing of this anomaly ; I did so, and it is here given 
 to the reader. In the centre of the partition there was a small or- 
 ifice, through which an ordinary sound could scarcely be passed. 
 The sound penetrated a posterior free chamber. 
 
 Notwithstanding the difficulties which an anomaly like this might 
 have justly caused to be apprehended at the time of delivery, yet 
 M. P. Dubois, confiding in the infinite resources of nature, and, 
 moreover, thinking it would always be in time to interfere during 
 labour, did not perform any operation. 
 
 The event justified his hopes ; for one morning a messenger in- 
 formed him that the woman had been delivered alone, almost with- 
 out pain. 
 
 Fifteen days after delivery, the finger readily penetrated the 
 opening, and reached the posterior chamber ; but it was pressed 
 on all sides by the diaphragm or partition. At the time of de- 
 livery, the diaphragm was not lacerated ; its opening was merely 
 distended, to allow the passage of the foetus ; but it again contracted 
 or returned upon itself like the neck of the womb after delivery. 
 
 (Fig. 81.) 
 After delivery, seen with the speculum. 
 
 However, in the case of extreme contraction of the entire vagi- 
 na, would it not be prudent to favour the dilatation of this canal by 
 the introduction of prepared sponge, or some other dilating body, 
 as was done in a similar instance by my friend M. Maher, Sur- 
 geon of Marines at Rochefort ; or should we trust entirely to na- 
 ture? 
 
 M. Moreau also cites a case in which the vagina would scarce- 
 ly admit the introduction of a writing-quill. This disposition, 
 which gave rise to much uneasiness, yielded to the progress of 
 pregnancy, and to the modifications induced in the soft parts by 
 labour. 
 
 Art. IX. — Displacements of the Uterus during Gestation. 
 
 The displacements of the uterus during gestation may occur at 
 various periods, and in various ways. 
 
 During the first months, while the uterus is yet in the pelvic cav- 
 ity, it may descend, incline forward or backward ; these deviations 
 are called descent, ante-version, and retro-version. 
 
 At a later period, when the uterus has ascended above the supe- 
 rior strait, it may likewise descend, incline forward, to the right 
 and to the left, but not backward. These displacements have re- 
 
 S 
 
138 DISEASES INCIDENT TO PREGNANCY. 
 
 ceived more particularly the names of anterior and lateral obliqui- 
 ties. 
 
 § 1. Descent. 
 
 As was observed, when treating of the diagnosis of pregnancy, 
 that the uterus descends at certain periods of gestation, and this de- 
 scent should be considered physiological ; but if the pelvis*be very 
 capacious, the ligaments extensible, and the tissue of the organ pre- 
 sent less resistance than in the ordinary state, the entire uterus 
 may descend, and the cervix repose on the floor of the pelvis ; 
 sometimes, even, it projects through the vulva. In this case, the 
 resources of art will be called for, with a view to sustain the ute- 
 rus, otherwise very serious evils may result from this disposition, 
 such as acute pain in the groins, constipation, retention of urine, &c. 
 
 The best means to employ in this case is a fine sponge introdu- 
 ced into the vagina in order to support the organ; the pessary 
 should be proscribed. I have not omitted any of the indications 
 which these displacements present, in the article Deformed Pelvis 
 by Excess of Amplitude, 
 
 § 2. Retro-version and Ante-version. 
 
 These accidents, less frequent than the former, are also much 
 more grave, if they are not remedied in time. (See the same arti- 
 cle, Deformities by Excess of Amplitude.)* 
 
 * The inconveniences arising from displacements of the uterus in the unimpregnated state, 
 although occasionally serious, are not to be compared with the grave results growing out of 
 this condition of things during gestation, especially if the actual cause of the difficulty should 
 escape the attention of the accoucheur. In order that labour may be spontaneous or natu- 
 ral, among other conditions necessary, it is essential that the long axis of the uterus should 
 be parallel, or nearly so, to the axis of the superior strait of the pelvis. Any departure, there- 
 fore, from this parallelism, which would so displace the womb as to occasion an absolute 
 retro-version of its orifice, or an excessive right or left obliquity, would necessarily not only 
 retard, but frequently render delivery physically impossible, until the mal-position had been 
 overcome. The following case will elucidate this principle : 
 
 On Friday, the 17th of July, 1835, 1 was requested by Dr. Elwes, of the United States 
 Army, to visit Mrs. B. at Fort Hamilton, Long Island, distant twelve miles from the city. I 
 was informed by Drs. Carpenter and Elwes, the former of whom saw her at the commence- 
 ment of her sickness, that she had been in labour, not, however, accompanied by very strong 
 pain, for eight days, and that the liquor amnii had been passing from her, in small quantities, 
 for the four days previous to my visiting her. Dr. Carpenter, who was the family physician, 
 and who had attended her in two former accouchements, stated that he had been unable to 
 reach the mouth of the womb, and that, from the commencement of her labour up to the 
 period at which I arrived, he had been completely foiled in every attempt to effect this ob- 
 ject. Dr. Elwes had experienced the same difficulty. At the request of these gentlemen, I 
 proceeded to make an examination. On introducing my finger into the vagina, I discovered 
 a large resisting tumour, which I recognised to be the head of the foetus, the womb inter- 
 vening between it and the finger. In examining very cautiously the surface of the tumour, 
 I was unable to discover the os tincse. It occurred to me that this was a case of retro-ver- 
 sion of the neck of the womb, and in gently sliding my finger under the foetal head, and car- 
 rying it towards the posterior part of the pelvis, I felt the os tinea?, which was turned so en- 
 tirely backward as to regard the concavity of the sacrum. It was now quite apparent why 
 the labour had been so protracted, and it was certain that while the uterus retained its pres- 
 ent position, delivery would be out of the question. In consequence of the mal-position of 
 the womb, the whole force of the uterine contraction was directed in such way as to ren- 
 der it physically impossible (without laceration of this viscus) for the child to pass through 
 the pelvis. The position of the uterus, under ordinary circumstances, is parallel, or nearly 
 so, to the axis of the superior strait, so that the whole force of the contractile effort being 
 directed from above downward, it is evident, should there be no impediment to a natural 
 delivery, that the child must be propelled through the maternal pelvis. In this case, how- 
 ever, in consequence of the mal-position of the womb, the force of the contractions was cen- 
 
DISEASES INCIDENT TO PREGNANCY. 139 
 
 § 3. Obliquities of the Uterus. 
 
 In speaking of the diagnosis of pregnancy, I remarked that the 
 uterus was more or less inclined in front, and to the right, rarely 
 to the left ; such is the normal condition of pregnancy. But when 
 this disposition is considerable, it becomes, during the latter months, 
 the cause of inconveniences and pain, which it is important to rem- 
 edy. 
 
 The abdomen should be supported at an early period with an 
 appropriate bandage. If this precaution should be neglected, 
 when there is a disposition to separation in the linea alba, the ute- 
 rus may escape out of the abdominal cavity, and occasion a pro- 
 trusion under the integuments of the abdomen. 
 § 4. Hernia of the Uterus. 
 
 Facts well authenticated of hernia of the uterus during a state 
 of vacuity and the first month of pregnancy, fully establish the pos- 
 sibility of this occurrence ; but we cannot admit the passage of the 
 
 tred against the posterior wall of the cervix uteri, and the point of resistance was found to 
 be the internal surface of the sacrum. This, then, accounts at once for the difficulty of 
 the labour, and shows most conclusively that it could not have been otherwise than pro- 
 tracted. As soon as I had discovered the position of the uterus, and thus assured myself of 
 the entire cause of the delay, I withdrew my hand, and suggested to Drs. Carpenter and 
 Elwes, in which suggestion they both coincided, that this case presented two indications, viz. : 
 
 1st. To rectify, as far as practicable, the mal-position of the cervix uteri. 
 
 2d. To turn, and deliver by the feet. 
 
 I should have remarked that the mouth of the womb was quite soft and dilatable. It will, 
 I apprehend, be unnecessary for me to enter into any argument to show the paramount neces- 
 sity of the first indication ; and if it be recollected that the patient was in a state of danger- 
 ous exhaustion, the propriety of the second will be evident. But why, it may be asked, not 
 apply the forceps ? My answer to this question shall be brief. The head of the foetus was 
 still at the superior strait, and, without reference to the opinions of others on this subject, I 
 can aver, for myself, that, where immediate delivery is indicated, I should always prefer (pro- 
 vided the parts were in a proper condition) turning by the feet, to the delay which must ne- 
 cessarily attend delivery by the forceps before the head has begun to descend into the 
 excavation of the pelvis. The operation being agreed upon, Mrs. B. was placed on her back, 
 with her breech on the edge of the bed, her legs flexed on her thighs, and her feet resting on 
 the hands of Drs. C. and E., who were seated one on each side of me. I introduced my right 
 hand, and, with the other applied to the abdomen, I reached the os tincae ; I then succeeded 
 in fixing my index finger within the circle of the anterior lip, which was cautiously brought 
 towards the centre of the pelvic excavation, at the same time gently pushing back the fundus 
 with the hand applied to the abdomen. In this way I succeeded in overcoming the mal-po- 
 sition of the uterus ; and in fulfilling the second indication I proceeded as follows : Before 
 determining on which hand to employ in order to effect the version, I first acquainted my- 
 self with the precise situation of the fcetal head, which I found to be placed in the second 
 position of the vertex, the posterior fontanelle corresponding to the right acetabulum, and 
 the anterior to the left sacro-iliac symphysis ; consequently, I introduced the right hand for 
 the purpose of performing the version, in order that the natural curve might be given to the 
 child's body. The hand was carried up in the usual manner until the feet were reached ; 
 these were gently grasped and brought into the vagina. The patient, at this time, became 
 alarmingly exhausted; she rallied under the influence of a little brandy and water, and I 
 proceeded to complete the delivery without delay. The child was alive and vigorous, and 
 both parent and offspring recovered from their perilous position, and are, I believe, at this 
 time in the enjoyment of good health. 
 
 The above case is interesting on two accounts. In the first place, that the child should 
 not have been sacrificed by the great length of time Mrs. B. was in labour ; and, secondly, the 
 possibility of mistaking the retro-version for an imperforate condition of the os tineas. Cases 
 are recorded in which the orifice of the womb was completely obliterated in women in labour. 
 Lauverjat's case, in this particular, is interesting : it is cited by Sabatier in his Médecine 
 Opératoire. Lauverjat, not being able to detect the mouth of the womb, during labour, in a 
 woman pregnant for the first time, made an incision into the portion of the uterus corre- 
 sponding with the orifice. M. Gautier, a Parisian surgeon, had a similar case. Instances 
 of the same kind are likewise quoted by Hammond and others. And in another part of this 
 work I will give the particulars of a case in which, in consequence of injuries inflicted on 
 the os tincae by the introduction of instruments to promote miscarriage, it became neces- 
 sary for me, at the time of labour, to incise the orifice, which resulted favourably to both 
 mother and child. — Ed. 
 
140 DISEASES INCIDENT TO PREGNANE i. 
 
 uterus through the inguinal ring in an advanced period of gesta- 
 tion. 
 
 This pretended hernia of the uterus, which can be reduced by sus- 
 taining this viscus during labour, is nothing more than eventeration 
 or protrusion of the womb, more or less developed, through the 
 separation of the linea alba. 
 
 The only indication to fulfil, during pregnancy, is to return the 
 organ, and maintain it by means of a bandage. 
 
 It will be seen that I have placed in the same chapter the ante- 
 rior and lateral obliquities. During gestation, they require one and 
 the same treatment. As to posterior obliquities, they cannot be 
 admitted. The abnormal insertion of the neck of the uterus on 
 the anterior parts of the organ has led to the belief of a posterior 
 obliquity. (See the same article during labour.) 
 
 Art. X.— Tumefaction and Pain in the Breasts. 
 During the first period of pregnancy, the reaction towards the 
 breasts may be such as frequently to produce a feeling of painful 
 tension. In order to moderate this, it will be sufficient to apply 
 emollient cataplasms to the breasts, and to keep the bowels free by 
 injections or mild laxatives. This condition, however, is merely 
 temporary ; it disappears as pregnancy advances. I am at this 
 time attending a lady who has presented all these phenomena. 
 Sometimes this pain in the breasts does not appear until a late pe- 
 riod of gestation. 
 
 Art. XL — Tension of the Abdominal Walls, and especially 
 of the Integuments. 
 
 In proportion as the uterus becomes developed, the abdominal 
 walls, and especially the integuments, are forced to distend in or- 
 der to afford room to the encroaching organ ; often even they yield 
 under these efforts, and become corrugated. The integuments of 
 the thighs are also called upon to contribute to the development of 
 the abdomen. 
 
 When these walls offer very great resistance, they become much 
 distended ; the woman experiences pain, and the uterus, impeded 
 in its evolution, sometimes contracts prematurely, and expels the 
 foetus. 
 
 This resistance is best overcome by embrocations with the oil 
 of sweet almonds, and general baths ; and the consequences of this 
 reaction of the abdominal walls on the uterus must be controlled 
 by anodyne injections, small bleedings, &c. 
 
 Art. XII. — Pruritus. 
 In order to omit none of the inconveniences to which the preg- 
 nant woman is exposed, I shall speak of that excessive pruritus 01 
 itching about the external genitals during the first months of preg- 
 nancy. I have seen it so insupportable that women affected with 
 it could neither sleep, walk, nor eat ; they were in a state of con- 
 tinual excitement, and could not resist scratching themselves. 
 
DISEASES INCIDENT TO PREGNANCY. 141 
 
 General baths, emollient lotions, frequent lotions with the ve- 
 geto-mineral water, will usually relieve this condition. However, 
 the pruritus is sometimes very obstinate ; in a poor woman whom 
 I was several times called upon to attend, after the employment of 
 general bloodletting, and all the other remedies, it yielded only to 
 Zhe application of leeches to the vulva.* 
 
 This latter means I have heard M. Desormeaux recommend, 
 and, in this case, I had no scruples in using it, so important was it, 
 at any price, to relieve the patient. 
 
 The pruritus was so excessive, that I apprehended every moment 
 the occurrence of convulsions. 
 
 The pregnancy, however, went on to the full time ; she was de- 
 livered of a dead child, which a circumstance unconnected with 
 the leeching had deprived of life — the interruption of the circula- 
 tion in the cord by a clot of blood formed around the umbilical 
 vein. The suffering of this patient during pregnancy had been so 
 intense that she was attacked with metro-peritonitis after delivery, 
 from which she had the good fortune to recover. 
 
 Art. XIII. — Miscarriage and Hemorrhage during Gestation. 
 Hemorrhage during pregnancy is a phenomenon which almost 
 always precedes, accompanies, or follows miscarriage. These two 
 accidents have, in their causes, progress, diagnosis, and especially 
 in their treatment, such intimate relations, that it is almost impos- 
 sible to separate them without exposing ourselves to numerous rep- 
 etitions ; so that I have preferred treating of them in the same arti- 
 cle, and at the same time considering hemorrhage during preg- 
 nancy only as one of the symptoms of miscarriage.f 
 
 * A more annoying affection than pruritus of the vulva in pregnant women can scarcely 
 be imagined ; and if, in certain aggravated forms, it is not relieved, it will be very apt to lead 
 to abortion. The application of leeches I have, on several occasions, had recourse to, and 
 with the happiest effects. A solution composed of 51. of borat. sodae to gxij aquae bullient. ap- 
 plied to the parts cold and frequently, I have found of great value in this affection. — Ed. 
 
 t Our author has certainly omitted to state one important exception,' which clearly estab- 
 lishes the possibility of hemorrhage during gestation as entirely unconnected with miscar- 
 riage. Now, under certain circumstances, it may happen that between the seventh and 
 eighth month, a pregnant female may be attacked with slight flooding, without any predis- 
 position on her part to miscarry, and if the cause of the hemorrhage be not promptly under- 
 stood, serious, and, indeed, often fatal consequences may ensue. Supposing, therefore, that 
 a female has passed to her seventh month of pregnancy without encountering any trouble, 
 or without being subjected to any cause ordinarily capable of inducing miscarriage, and she 
 should at this period flood, the accoucheur will at once have ground to suspect that the hem- 
 orrhage is in consequence of an insertion of the placenta on the mouth of the womb. Now 
 what connexion is there between hemorrhage at this period of gestation, and the presence of 
 the placenta over the uterine orifice ? The connexion is manifest. For example, at this 
 period the internal orifice begins to open, and, consequently, some of the bloodvessels by which 
 the maternal portion of the placenta is united to the internal surface of the womb hecome 
 lacerated, and occasion a discharge of blood. Should the presence of the placenta be the 
 true cause of the hemorrhage in this case, and be overlooked by the accoucheur, and he 
 treat the matter lightly, the gravest consequences may result both to mother and child. 
 The most perfect repose should be enjoined ; the patient should be kept in the recumbent 
 posture on a mattrass in preference to a feather bed, with her hips slightly elevated above 
 the plane of the body. She should be free from all excitement, both physical and mental ; 
 iced drinks should be administered, and the bowels kept gently relaxed. The following 
 will be found well adapted to this case : 
 
 R-. Sulphat. of Magnesiae, ^i. 
 Infus. Rosar., gviij. 
 
 A tablespoonful to be given twice or thrice a day, depending on its action. 
 
 In addition to these means, cloths saturated with ice-water should be placed on the lower 
 
142 DISEASES INCIDENT TO PREGNANCY. 
 
 Abortion may be said to be the expulsion of the fœtus before 
 the period of its legal viability, which has been fixed at six months. 
 It has been generally divided into ovular miscarriage, when it takes 
 place before the end of the first month ; embryonic miscarriage, 
 before the end of the third month ; and foetal miscarriage, from 
 the third to the sixth month. 
 
 This accident, which people in general, and certain physicians, 
 consider as of little moment, requires, however, under ordinary 
 circumstances, as much care, if, indeed, not more, than a delivery 
 at term, on account of the serious consequences it may have on 
 the economy. Either because the small size of the fœtus seems to 
 favour its expulsion, or the slight development of the circulatory 
 apparatus occasions but little hemorrhage from the female, mis- 
 carriage is much more frequent during the first two months than 
 at a more advanced period of pregnancy. If a contrary opinion 
 has been entertained, it is because great attention is necessary to 
 ascertain this accident in the first two months, the embryo being, 
 in most instances, in the cloths with which the female has protect- 
 ed herself, or in the garde-robe. Miscarriage sometimes takes 
 place without the woman's being conscious of it, and the hemor- 
 rhage which accompanies it is mistaken for profuse menstruation ; at 
 other times, if the indisposition she experiences be slight, even when 
 miscarriage occurs, she takes but little care of herself, and the 
 miscarriage passes unperceived ; it is, in general, only in cases in 
 which the symptoms accompanying miscarriage are grave enough 
 to require urgent attention that the physician is called in, and that 
 he can take cognizance of the fact ; and he frequently is in doubt 
 as to whether the accident has taken place or not. We can, there- 
 fore, readily see the difficulty of furnishing an exact statistical ta- 
 ble of city practice ; and in hospitals much error must ensue, for 
 women scarcely ever apply for admission in cases of early mis- 
 carriage. 
 
 It is generally supposed that male miscarriages are more fre- 
 quent than female ; but this opinion, I believe, is owing to the fact 
 that, during the first months, the clitoris, in consequence of its de- 
 velopment, may be mistaken for the penis. However, the returns, 
 giving sixteen male births to eleven female, serve to confirm this 
 opinion. 
 
 § 1. Causes of Miscarriage. 
 The death of the embryo precedes or follows the expulsion ; 
 these two facts are intimately connected. Thus, when some cause 
 
 portion of the abdomen and thighs. Should the patient be plethoric, a bleeding from the 
 arm from *x to jxij, aijd repeated according to the judgment of the accoucheur^Will be in- 
 dicated. Should the hemorrhage continue, notwithstanding all these remedies, Çhe tampon 
 should then be had recourse to. The object of the tampon in this case is to make gentle 
 but firm pressure on the mouth of the uterus, and this will often succeed in arresting the 
 hemorrhage. The tampon may consist of pieces of soft sponge, or of old linen,:with which 
 the vagina must be completely filled, care being taken to make exact pressure* on the ute- 
 rine or.fce ; and it should be retained in place by the T bandage. 1 have, on several occa- 
 sions, been enabled to arrest the bleeding in this way, and with proper care, thé patient can 
 be conducted to the full term;— Ed. ► " •'■ 
 
DISEASES INCIDENT TO PREGNANCY. 143 
 
 or other has determined the death of the fœtus, according to the 
 established laws of nature, it should be expelled ; also, if the influ- 
 ence of the same agents or any other cause should throw the womb 
 into contraction, the fœtus is expelled, and it ceases to live because 
 it has not attained its development. 
 
 We are, therefore, naturally led to admit as causes of miscar- 
 riage all those influences which may induce uterine contractions 
 before the term of viability, or occasion the death of the fœtus. 
 
 A. Predisposing Causes. — Certain opposite temperaments, but 
 which have strong relations by their effects, predispose women to 
 hemorrhage, and, consequently, to miscarriage. Such are the ple- 
 thoric and nervous temperaments. The consequence of the for- 
 mer is an abundant menstrual evacuation and a hemorrhagic ten- 
 dency, which is renewed at each period ; the latter determines 
 towards the uterus a local congestion, and either of these two cir- 
 cumstances may prove fatal to the fœtus by destroying the vascu- 
 lar connexions which unite it to its mother. 
 
 All the predisposing causes of hemorrhage, that is to say, all 
 those which are of a nature to determine an afflux of blood to the 
 uterus, will be likewise causes of miscarriage : such as inflamma- 
 tion of the uterus or the adjoining organs ; their organic altera- 
 tions, hemorrhage occurring in preceding pregnancies, and which 
 have a tendency to be renewed at each subsequent gestation. 
 
 A sedentary, idle, inactive life, luxurious habits, and, finally, la- 
 borious occupations, are so many predisposing causes to hemor- 
 rhage and miscarriage. 
 
 B. Causes which tend to produce Uterine Contractions before 
 the full Period. — All mechanical irritations, such as falls, efforts, 
 coughs, vomiting, and contusions, may bring on contractions of the 
 uterus. It is the same with repeated vaginal examinations, the 
 presence of a pessary, coitus, cauterizing the neck of the womb, and 
 criminal attempts. Uterine rheumatism is a very frequent cause 
 of miscarriage.* The too great rigidity of the uterine fibres, and 
 the resistance they offer to dilatation, and the deficiency of tone in 
 the inferior segment of the uterus, have also been regarded as 
 causes of miscarriage. Miscarriages are more frequent in primi- 
 pares, in whom the uterine fibre, less easy to distend, is always 
 ready to react. This resistance of the uterine fibre may explain 
 how miscarriage has a tendency to be repeated in the same wom- 
 an, not always at the same period, but at a term somewhat more 
 advanced at each successive occurrence, so that, after several 
 miscarriages, the woman finally reaches her full period. In this 
 case, the resistance of the organ is gradually weakened by the pre- 
 ceding pregnancies, and the second is a little more prolonged than 
 the first, the third more than the second, &c, &c. 
 
 Frequently, too, the uterus tends to contract at the same period ; 
 
 * 1 am at this moment attending a lady who had always miscarried, several times from 
 this cause, before I was called to her. 1 have succeeded in carrying her to her seventh 
 month, and have hopes that she may attain her full period. 
 
144 DISEASES INCIDENT TO PREGNANCY. 
 
 but then it is on account of habit, or of the disposition which or- 
 gans have of reproducing the same acts at the same period. 
 
 The presence of two foetuses, dropsy of the amnios, in conse- 
 quence of the excessive distension of the uterus, frequently induce 
 premature contractions. 
 
 Adhesions, displacements of the uterine annexée, such as the 
 fallopian tubes, ovaries, broad ligaments ; the presence of a fibrous 
 tumour in or near the uterus, the pressure of corsets, and, in a 
 word, all the circumstances which oppose a free increase of the or- 
 gan, may determine early action. 
 
 Some authors have cited as a cause the influence which pelvic 
 deformities exert on pregnancy ; but this is far from being proved ; 
 as to the influence of the insertion of the placenta, that, too, re- 
 mains to be demonstrated. 
 
 Sympathies depending on irritation of the bladder and rectum, 
 in cases in which an operation has been performed on these or- 
 gans, may also excite uterine contraction. It is the same, too, 
 with uterine affections, with changes in the tissue of the organ, in 
 consequence of disease or the advanced age of the woman, or of 
 its incomplete development in youth. 
 
 A strong electric shock may likewise produce the same result. 
 Although it has been denied, yet it is evident that vivid moral im- 
 pressions may occasion miscarriage. Thus, we see every day 
 women who, much affected at the theatre, or seized with sud- 
 den fright on beholding some alarming object, have not time, fre- 
 quently, to reach their homes before they are delivered. If this 
 influence prevail at full term, its possibility at a less advanced 
 period must certainly be admitted. In fine, this cause should also 
 be capable of determining contractions during pregnancy, since it 
 can moderate them during labour, a fact which cannot be ques- 
 tioned. 
 
 There are other causes, which appertain to the entire organism : 
 acute and chronic affections of the mother, measles, scarlet fever, 
 epidemic fever, and particularly jaundice and phthisis pulmonalis, 
 and eclampsia or convulsions promote uterine action ; but convul- 
 sions are very rare at an early period of gestation. The influence 
 of certain atmospheric conditions appear to produce real epidemics 
 of miscarriage, which can be explained in no other way. This 
 observation has been frequently made in large establishments des- 
 tined to receive lying-in women. Saucerotte mentions that the 
 women who inhabit the summit of the Vosges are much exposed 
 to miscarriage, and that, in order to protect themselves from this 
 accident, they leave the mountain after they have conceived. 
 
 C. Causes which operate fatally on the Fœtus.— Most of the 
 causes which I have enumerated in the preceding chapter will like- 
 wise obtain here. Thus, all external violences, besides determin- 
 ing premature contraction, may also destroy the foetus, either in- 
 directly or directly : indirectly, by occasioning congestion of the 
 organ, which gives rise to hemorrhage fatal to the foetus ; directly, 
 by injuring the foetus through the uterine walls. 
 
DISEASES INCIDENT TO PREGNANCY. 145 
 
 Repeated vaginal examinations, the presence of a pessary, coi- 
 tus, cauterization of the cervix uteri, operations performed near the 
 uterus, and criminal attempts, which I have regarded as causes of 
 premature contraction, often occasion the death of the fœtus, sec- 
 ondarily, by determining hemorrhage. The same will result from 
 remaining too long in warm baths ; exciting food, disturbance of 
 the digestive functions, any obstacle to the free development of the 
 womb, may also affect directly the fœtus ; so, likewise, with an 
 electric shock or violent mental emotion. The possibility of this 
 latter circumstance has been contested. But should we doubt this 
 fact, of which authors have presented so many examples, merely 
 because the most minute dissection has not enabled us to detect 
 nervous communications between the fœtus and its parent ? More- 
 over, would not the liquor amnii be an excellent conductor of elec- 
 tricity ? 
 
 The causes appertaining to the entire organism, acute and chron- 
 ic affections, &c, which are capable of exciting uterine contrac- 
 tion, may also destroy the child. I should likewise add to these, 
 diseases of the skin, and especially syphilis, with which the mother 
 may be affected. It is generally supposed that the diseases of the fa- 
 ther are not communicated to the fœtus ; however, science possesses 
 several facts which overthrow this assertion. M. Guillemot cites 
 one very conclusive case. A young woman, whose husband had 
 been much diseased, miscarried several times ; but, having become 
 a widow and the wife of another husband, she went to her full 
 term. I have now under my care two children who bear evident 
 traces of a constitutional affection of their father. 
 
 Eclampsia almost immediately destroys the fœtus, as well as 
 causes its expulsion. 
 
 In a word, there are several special causes which destroy the 
 child in utero, and the most of them escape us. For example, it 
 may be affected while in utero with numerous diseases, and become 
 the more easily destroyed as it is less developed. Foetuses die 
 with all the evidences of a variolous disease, &c. Certain diseases 
 of the membranes and umbilical vesicle, which occur at the com- 
 mencement of intra-uterine life, the cause and nature of which are 
 entirely unknown to us, may also arrest the fœtus in its develop- 
 ment. There are other causes better understood, which have been 
 well described by MM. Cruveilhier, P. Dubois, and Jacquemier ; 
 such as apoplexy of the placenta to a greater or less extent ; ab- 
 scesses of this organ, its ossification and atrophy, affections which 
 seem to be different degrees of the same disease, and which may 
 invade so much of the placenta as entirely to destroy its functions. 
 I have often seen in the same placenta a multitude of these dis- 
 eased points, some of which were recent, and others in a state of 
 suppuration ; while others, again, are ossified.* M. P. Dubois has 
 
 * I have repeatedly been consulted by ladies who have had several successive miscar- 
 riages, and who have not been enabled to carry the foetus to the full term. Such a condition 
 of things, if permitted to continue, not only strikes at the very foundation of health, but it is 
 apt to give rise to unhappiness and discontent. These cases usually prove rebellious to the 
 means employed for their relief, and they not unfrequently throw discredit on the accou- 
 
 T 
 
146 DISEASES INCIDENT TO PREGNANCY. 
 
 frequently exhibited to his class placentas presenting these different 
 modifications. I had one in my practice, the parenchyma of which 
 was entirely cartilaginous. The abnormal insertion of the placenta 
 over or near the mouth of the womb cannot, in any way, be con- 
 sidered a cause of abortion, not even in consequence of the hem- 
 orrhage, which always necessarily takes place. In a word, hem- 
 orrhage does not manifest itself, in this case, until an advanced pe- 
 riod of pregnancy ; it will determine then, not a miscarriage, but 
 a premature delivery ; for whether the placenta be inserted over 
 the mouth of the womb, centre for centre, or by one of its borders, 
 it will nevertheless preserve its vascular connexions with the cer- 
 vix until the end of seven months and a half, often even of eight 
 months ; and as the internal orifice does not dilate before this peri- 
 od, it would only be from this time that the progressive dilatation 
 of the orifice would gradually destroy the vascular connexions 
 which unite it to the placenta, and thus occasion hemorrhage. 
 
 Deformed foetuses and monsters rarely reach the full term. 
 
 The shortness of the cord may determine its rupture, or the sep- 
 aration of the placenta (Mauriceau, Montgomery) ; it may encircle 
 with force the extremities or neck of the fœtus, impede the de- 
 velopment of these parts, and produce undue pressure on itself. 
 M. Guillemot reports the case of a foetus of three months, which 
 had on its neck deep marks caused by the pressure of the cord, 
 and this latter, very much stretched, was partly lacerated at its 
 root. 
 
 Hemorrhage may occur in the sheath of the cord, and the coag- 
 ulum resulting from it may compress the vessels and intercept the 
 
 cheur. I could detail numerous instances of success in my own practice, where others had 
 failed ; and I ascribe my success entirely to the fact that, in treating these obstinate cases, I 
 have been fortunate enough to reach the cause of the difficulty. If a female miscarry once, 
 she is apt, from the mere influence of habit, to miscarry again; and this premature action of 
 the uterus often begets a morbid and irritable condition of this organ. Now, if a female mis- 
 carry several times successively, without being enabled to assign any particular cause, and 
 the ovum be examined, in numerous instances it will be found that the placenta presents an 
 unusual appearance; that it is, in fact, diseased. In consequence of this morbid condition of 
 the after-birth, it is prematurely detached from the womb ; the death of the embryo, and its 
 expulsion, are the consequences. This disease of the placenta may depend on the number of 
 previous miscarriages (thus, as it were, debilitating the natural powers of the uterus), or on 
 a venereal or scrofulous taint ; no matter on what cause it may depend, if the accoucheur 
 wish to carry his patient to the full term, he must first remove the cause of the disease, 
 which determines the early separation of the after-birth. I have never failed in relieving this 
 difficulty, when traceable to a diseased placenta, by the following treatment. In the first 
 place, after the miscarriage all sexual intercourse must be interdicted for a given period, de- 
 pending upon the action of the remedies. The patient should then be placed under the in- 
 fluence of mercury, and ptyalism should be produced. 
 
 I am in the habit of ordering the following formula : 
 #. Massae Hydrar., 3J. 
 Pulv. Opii, gr. iij. 
 Ft. massa in pil., xij. 
 Dividenda. 
 
 One of these pills should be taken every other night, and continued until the mouth is 
 touched. As soon as the ptyalism has passed off, I order half a wine-glass of the compound 
 sirup of sarsaparilla to be taken twice a day, until two pint bottles have been used. 
 
 These means, together with horseback exercise, sea-bathing, and a cheerful mind, have 
 usually, in my hands, been sufficient to overcome this morbid condition of the system, and 
 prepare it for a successful fecundation. A most important direction after pregnancy ensues, 
 is to enjoin a separation until the fifth month has passed, for where there have been antecedent 
 miscarriages, there is more or less predisposition to the same accident previous to this pe- 
 riod— Ed. 
 
DISEASES INCIDENT TO PREGNANCY. 147 
 
 circulation. M. Deneux has published a fact of this kind ; and I 
 have a portion of cord which, I believe, presents an analogous le- 
 sion. It belonged to the foetus which died fifteen days before de- 
 livery, at the ninth month, of which I spoke in the article Pruri- 
 tus, page 141. 
 
 If the patient should be predisposed to miscarriage, all the above 
 causes act with much more force. Some women miscarry under 
 the influence of the slightest cause ; while others, on the contrary, 
 encounter severe moral and physical disturbances without annoy- 
 ance. A woman, some months pregnant, arrived from Moscow 
 and came to La Clinique to be confined, after having travelled sev- 
 eral hundred miles in sleds over the most frightful roads, exposed 
 to all the privations and fatigues of so long a journey, and yet she 
 was delivered at her full term. 
 
 § 2. Progress of Miscarriage (hemorrhage). 
 
 The first phenomenon which manifests itself is, in general, hem- 
 orrhage. At an advanced period, the point of the uterus corre- 
 sponding to the placenta is the only one which has vascular con- 
 nexions with the ovum ; hence the rarity of hemorrhage ; while at 
 an earlier period the entire ovum adheres to the uterus by the ca- 
 duca, and very important vascular connexions unite all the parts ; 
 hence the necessity of hemorrhage. Also, hemorrhage is less abun- 
 dant as the miscarriage takes place nearer the full term. It is 
 considerable for the first three months, less after this period, and 
 rare after the fourth month. It is also less abundant when the foe- 
 tus is expelled a long time after its death, for the uterine circula- 
 tion being no longer necessary for the life of the foetus, it becomes 
 modified ; the utero-placental vessels obliterate in part, and furnish 
 but little blood at the time of the separation of the placenta. This 
 hemorrhage may be internal, latent, or concealed, that is to say, it 
 may take place either between the external surface of the ovum 
 and internal of the uterus, or even in the membranes (which, how- 
 ever, is rare) ; it may also be external ; in this case, the blood es- 
 capes through the genital organs. This is the most frequent form. 
 
 At a period bordering on full term, the uterus, entirely developed, 
 enjoys a force of contraction capable of determining the dilatation 
 of the neck, and this latter is thinner, more supple, and more easy 
 of dilatation as the period of delivery approaches ; and as soon as 
 the mouth of the womb is opened, all the obstacles will be re- 
 moved. 
 
 At an earlier period, the neck of the womb is long, rigid, and 
 thick ; it will require more force to overcome its resistance ; be- 
 sides, the tissue of the organ being less developed, is not endowed 
 with sufficient contractile power to counterbalance advantageously 
 the resistance of the orifice. 
 
 At a period near the full term, the ovum divides before its ex- 
 pulsion. 
 
 At a less advanced period, the ovum does not always divide, and 
 although it is smaller than at a more advanced period, its expulsion 
 
148 DISEASES INCIDENT TO PREGNANCY. 
 
 is not the less difficult, in consequence of its integrity, joined to the 
 preceding causes — the resistance of the neck of the womb, and its 
 want of proper contractile power. 
 
 At an advanced period, the annexae, smaller than the foetus, do 
 not present any difficulty in their expulsion. Except in rare cases, 
 the annexée come away with facility. 
 
 At an earlier period, the annexae, larger in proportion as the em- 
 bryo is less advanced, will themselves constitute the entire diffi- 
 culty of the expulsion. Sometimes the delivery is protracted, pain- 
 ful, and alarming ; sometimes, even, it is impossible, and the pla- 
 centa passes off in a fluid state, or is absorbed. 
 
 § 3. Prognosis of Miscarriage (hemorrhage). 
 
 I place the prognosis immediately after the preceding article, be- 
 cause it is intimately connected with it. 
 
 So far as the foetus is concerned, the prognosis of miscarriage is 
 always unfavourable, for it is either its death which determines the 
 miscarriage, or its death is the consequence of it ; but in cases in 
 which the miscarriage has not yet taken place, the prognosis will 
 be the more alarming, in proportion as the hemorrhage is more 
 abundant. However, women occasionally lose considerable quan- 
 tities of blood during their pregnancy, without having the life of 
 the fœtus compromised ;* this circumstance, it must be remem- 
 bered, is rare. As to the mother, the prognosis will be more se- 
 rious in proportion as pregnancy is less advanced. 
 
 This proposition, admitted since the time of Hippocrates, is con- 
 firmed every day, and it is with regret that I find myself obliged 
 to differ in opinion with M. Desormeaux. It is certainly true, 
 however, that in some cases of miscarriage, at three or four weeks, 
 the consequences are in general very trifling ; but from this period 
 to four months, as I have already remarked in the preceding arti- 
 cle, miscarriage is accompanied by hemorrhage the more serious 
 as the embryo is less developed. The expulsion being more diffi- 
 
 * A most extraordinary instance of profuse loss of blood in the sixth month of pregnancy- 
 occurred in a patient of Dr. A. D. Clement, of this city. A messenger came for me early one 
 morning, requesting that I would hasten to visit a lady who had been taken suddenly ill. 
 On reaching the house, I found the patient lying on the floor, in an exceedingly debilitated 
 condition. I learned the following particulars of her case. Early in the morning, in at- 
 tempting to leave her bed, she stumbled and fell to the ground. She was immediately at- 
 tacked with most alarming hemorrhage from her womb ; it was so profuse that in a few 
 minutes after the attack she fainted, and it was with difficulty she could be rallied. Finding 
 her in this situation, and learning that Dr. Clement was the family physician, I urged the 
 necessity of immediately sending for him, and in the mean time I proceeded to meet the indi- 
 cations of the case. The patient was laid on the bed, her hips gently elevated, and the most 
 perfect repose enjoined. On introducing my finger into the vagina, I discovered that the 
 mouth of the womb was not only considerably dilated, but it was quite soft and yielding. 
 Cold applications were made use of to the abdomen and thighs, and a drachm of laudanum 
 administered. This patient could not have lost less than two quarts of blood from her 
 womb ; and from the dilated condition of the orifice, together with the presence of actual 
 pains, it was reasonable to suppose that premature labour was inevitable. The profuseness 
 of the hemorrhage now ceased, and was reduced to an occasional oozing of blood per vagi- 
 nam. The pains seemed, however, to increase in violence ; and with the hope of checking 
 them, I introduced into the rectum two opium pills, containing a grain each ; this had the 
 desired effect. In the mean time Dr. Clement arrived, and I left the patient in his charge. 
 I heard nothing more of the case for three or four months, when the doctor informed me that 
 the lady had gone to her full term, and had been delivered of a healthy living son. — Ed. 
 
DISEASES INCIDENT TO PREGNANCY. 149 
 
 cult, painful, and protracted, the woman continues for a longer pe- 
 riod exposed to the consequences of this hemorrhage. The diffi- 
 culty or impossibility of extracting the placenta subjects the woman 
 to the same hazard, and, moreover, exposes her to the consecutive 
 dangers of the manipulations employed to bring away the after- 
 birth, and to the consequences of a retention of this organ, and 
 of its putrid absorption, when it cannot be delivered. 
 
 The rapidity of the hemorrhage, the strength of the patient, the 
 profusion of the discharge, will also influence the danger of this 
 accident. However, some women lose large quantities of blood 
 without being much weakened. My friend, Dr. Devilliers, is now 
 attending a lady who has lost a considerable quantity of blood, 
 without having her pregnancy interrupted, or her health much af- 
 fected by it. 
 
 As to the remote effects of miscarriage, such as chronic affec- 
 tions of the genital organs, which appear at an advanced age, they 
 are perhaps more serious after miscarriage than after delivery at 
 full term. But the immediate consequences are as grave in the 
 one case as in the other. All things being equal, I have a larger 
 number of cases of women affected with metro-peritonitis after 
 miscarriage than after delivery at full term. 
 
 The cause of miscarriage will modify its danger ; it is more 
 alarming when it is occasioned by violence, when accompanied by 
 uterine congestion, or when it supervenes in the course of an acute 
 inflammation. I have known it prove fatal in a few hours in jaun- 
 dice ; finally, the most dangerous miscarriage is that excited by 
 internal medicines or culpable manipulations. After the expulsion 
 of the foetus, although the milk fever and lochial discharge are pro- 
 portionally slight in the earlier periods of pregnancy, yet the after 
 treatment generally requires much more care. 
 
 § 4. Diagnosis of Miscarriage. 
 
 The diagnosis of miscarriage is divided into three periods : be- 
 fore it has taken place, during its occurrence t and after it has taken 
 place. 
 
 A. Before it has taken place. — The symptoms which will enable 
 us to foresee a miscarriage will vary according to the period of preg- 
 nancy, and the cause which produces it. As I have already ob- 
 served, it is sometimes accompanied by such slight pain, that it 
 passes unperceived, and the entire ovum, covered with blood, is 
 lost in the dejections, or cloths, or is mistaken for a clot. Under 
 such circumstances, we cannot ascertain, in time to prevent it, that 
 miscarriage is threatened. 
 
 However, the attention of the accoucheur should always be 
 awakened with reference to women who are subject to profuse 
 menstruations, who experience a sensation of fulness in the pelvis, 
 pain in the loins, and especially a slight sanguineous discharge ; in 
 a word, all the symptoms of local plethora. General plethora and 
 premature contractions should always be objects of special mo- 
 ment to the accoucheur ; but, unfortunately, most of the precur- 
 
150 DISEASES INCIDENT TO PREGNANCY. 
 
 sory symptoms are not, in general, very evident until after the mis- 
 carriage is inevitable. How, in a word, can we distinguish wheth- 
 er the uterine pains and sanguineous discharge are owing to a re- 
 turn of the menstrual evacuation, or to a miscarriage, when there 
 is no symptom establishing the existence of pregnancy ? For the 
 pains which accompany a difficult menstruation very closely simu- 
 late those of childbirth, although authors have mentioned as a dis- 
 tinctive sign, that in miscarriage the discharge precedes the pains, 
 while the contrary occurs in relation to the menses ; but this does 
 not always take place, and the distinction is not so readily made as 
 to justify, in cases of doubtful miscarriage, other means than repose 
 and laudanum, with a view of preventing the accident ; for blood- 
 letting and refrigerants may determine very serious consequences 
 in cases of simple return of the menses. 
 
 But at a more advanced period, pregnancy being no longer 
 doubtful, the symptoms of threatened miscarriage are more easily 
 appreciated ; for it is rare that the menses, when they occur during 
 pregnancy, continue beyond the period of four or five months, 
 besides, we should apprehend miscarriage when a discharge of 
 blood takes place in a woman who has passed the first half of her 
 pregnancy without being troubled with it. The various symptoms 
 of local plethora, too, will be certain indices of threatened miscar- 
 riage. When the bad health of the mother, or some slow cause 
 acting upon the ovum, determines miscarriage, we will observe, 
 according to M. P. Dubois, chills followed by heat, loss of appe- 
 tite, nausea, thirst, coldness of the extremities, lassitude, palpitation, 
 a sensation of sorrow and depression, a painful feeling of cold and 
 weakness in the abdomen, bearing down in the pelvic excavation, 
 and an illusory desire to urinate ; under these circumstances, we 
 should expect every moment to see a miscarriage without our be- 
 ing able to prevent it. Also, when the female perceives an incon- 
 venient weight in her abdomen, moving according to the move- 
 ments of the body ; a febrile action in the evening ; and joined to 
 these symptoms, all the other signs indicating the death of the 
 foetus, milk fever, secretion of milk, falling away of the breasts, 
 cessation of the active fœtal movements, and of the pulsations of 
 the heart. 
 
 If miscarriage be apprehended in consequence of violence, the 
 woman experiences an acute pain either in the loins or in some 
 point of the abdomen ; this pain diminishes, and reappears again 
 with more intensity. If the fœtus have died, the woman expe- 
 riences all the symptoms I have just enumerated, and labour de- 
 clares itself, ordinarily, nine days after the accident. But there is 
 nothing fixed about this rule, foetuses having remained in the womb 
 several months after their death. 
 
 But how are we to prevent a threatened miscarriage, where the 
 cause is internal hemorrhage, and pregnancy is but little advanced ? 
 If the blood is effused in the interior of the ovum, the quantity will 
 be too small to be appreciated by any increase in the volume of 
 the uterus, or to occasion any serious effects on the health of the 
 
DISEASES INCIDENT TO PREGNANCY. 151 
 
 mother ; the death even of the fœtus will often be unknown, and 
 the hemorrhage will pass altogether unperceived. 
 
 Should the blood be accumulated between the placenta and 
 uterus, when a part of the membranes are separated in order 
 to allow the blood to collect, the coagulum which would result 
 would be too small to make its presence perceptible. Certain 
 general effects, such as slight tension of the abdomen, and a dull 
 feeling of fulness in the pelvis, will alone denote the formation of 
 it ; its effects on the fœtus will sometimes not be appreciable. 
 When pregnancy is more advanced in the first case of hemor- 
 rhage in the membranes, the uterus assumes an unusual develop- 
 ment, which may be recognised either by an abdominal examina- 
 tion or the vaginal touch ; it will be at once perceived that this 
 development is not in correspondence with the period of preg- 
 nancy. The death of the fœtus being the common consequence 
 of this accident, all the usual symptoms will manifest themselves. 
 If the blood be accumulated between the membranes and uterus, 
 the development of the organ will be readily appreciated ; it will 
 be irregular and bilobed ; we may sometimes distinguish the point 
 in which the sanguineous collection has taken place, because in 
 one spot we will feel an evident fluctuation, without perceiving the 
 fœtal movements. This hemorrhage may also become manifest by 
 the death of the fœtus and its effects on the health of the mother ; 
 and yet it may be considerable without either the one or the other 
 suffering the slightest inconvenience. However, most frequently, 
 in both instances, the woman will complain of weight in the rec- 
 tum, pains in the loins, and dragging about the groins ; this condi- 
 tion of things may continue until the quantity of blood becomes so 
 considerable as to force the womb to contract, when there will be 
 a discharge of blood externally. But, in many cases, there will 
 be much doubt. 
 
 When the fœtus has ceased to live, its prolonged sojourn in the 
 uterus is harmless to the mother while the membranes are entire ; 
 it is, on the contrary, often very serious when the membranes are 
 ruptured. In the former case, the species of decomposition which 
 it undergoes, although it is so called, does not resemble a veritable 
 putrefaction ; the cadaver has no smell, the soft parts are flaccid, 
 the head sinks under its own proper weight, the ribs are seen 
 through the soft parts, and the front of the chest is very much flat- 
 tened ; the sunken abdomen, almost hollow at the umbilicus, forms 
 on the sides two rounded prominences ; the skin, especially that of 
 the abdomen, is of a brownish-red colour, without any appearance 
 of a green tinge ; the cord is no longer twisted upon itself ; it is 
 soft, reddish, and filled with a brownish fluid ; the epidermis peals 
 off with facility, and leaves the dermis bare, which is glutinous, and 
 of a lively red colour. The epidermis of the feet and hands is white, 
 and in folds. 
 
 In the latter case, on the contrary, the access of air into the cav- 
 ity of the uterus, aided by the elevated temperature of the organ, 
 causes decomposition to proceed very rapidly. There passes from 
 
152 DISEASES INCIDENT TO PREGNANCY. 
 
 the genital organs a blackish fluid, a solution of the putrid tissues, 
 possessing extreme fetor ; the uterus becomes a centre of infection ; 
 the patient is attacked with a low fever, to which she rapidly yields 
 if nature or art do not relieve her. 
 
 Signs indicating the Presence of Miscarriage. 
 
 In the commencement of pregnancy, when it cannot be ascer- 
 tained by any certain signs, how are we to distinguish the reappear- 
 ance of the menses, accompanied by uterine pains, from miscar- 
 riage ? This diagnosis is extremely difficult to establish, as I ob- 
 served in the preceding chapter. 
 
 Until the third month, if the existence of pregnancy be well estab- 
 lished, the diagnosis becomes extremely easy. The appearance of 
 the menses being rare in pregnancy, any discharge of blood which 
 may manifest itself at this period should be watched with solicitude 
 by the accoucheur. But it may happen that, at this term, preg- 
 nancy cannot be detected ; under these circumstances, we will oft- 
 en be in doubt. However, if, in a woman who is not subject to ir- 
 regularities in her menstruation, a sanguineous discharge take place 
 after a delay of some weeks ; if this discharge be accompanied with 
 pains ; if the pains be not modified by the discharge, and become 
 more and more acute and separated by intervals of calm ; and if 
 the neck, slightly dilated, permits the introduction of the extremity 
 of the finger, we should apprehend a miscarriage. From the end 
 of the third month, the diagnosis of pregnancy, more easy to estab- 
 lish, will enable us also more readily to recognise the signs of mis- 
 carriage. All the phenomena of a real labour declare themselves ; 
 they are accompanied by a discharge of blood more or less abun- 
 dant, according to the period. The escape of a liquid similar to the 
 liquor amnii is, in most cases, a certain sign of threatened miscar- 
 riage. However, this phenomenon may' take place without the 
 rupture of the membranes, and then it ceases to be an indication of 
 an approaching miscarriage. The following is M. Nsegele's expla- 
 nation of this phenomenon, which, according to him, is not rare : 
 "A serous exhalation takes place gradually between the external 
 surface of the membranes and the internal surface of the uterus, 
 and collects in different points ; and, when these collections have 
 become sufficiently large to excite the action of the uterus, this or- 
 gan contracts ; the liquid, in detaching the inferior portion of the 
 membranes, reaches the lower point of the uterus, and escapes 
 through the orifice. If the contractions which determine this evac- 
 uation are perceived, this phenomenon simulates the more closely 
 the escape of the liquor amnii ; but frequently this expulsion takes 
 place in consequence of contractions of which the patient is not 
 conscious." 
 
 If, after the third month, to the preceding signs should be joined 
 those which characterize the death of the foetus, the diagnosis will 
 be more certain. However, the death of the fœtus does not al- 
 ways involve the cessation of pregnancy. One of my patients, to 
 whom I called M. P. Dubois, presented a very remarkable case of 
 
DISEASES INCIDENT TO PREGNANCY. 153 
 
 this kind. This lady, already the mother of two children, became 
 pregnant a third time, and reached the third week of her pregnancy 
 without inconvenience ; but at this period she experienced a feel- 
 ing of lassitude, accompanied by pains in the loins ; she complain- 
 ed of pricking sensation in the breast. This condition of malaise 
 continued for several months, without any reappearance of the 
 menses. The patient, who, for the rest, had experienced, from the 
 commencement, all the feelings of her first two pregnancies, and 
 having no doubt that she was again pregnant, although her abdo- 
 men did not become developed, requested my advice. She w T as, 
 at this time, five months and a half pregnant. I noticed the devel- 
 opment of the uterus, but it was far from being in correspondence 
 with the presumed term of gestation. The active motions of the 
 fœtus were not perceived, and auscultation afforded no sign. 
 
 At six months and a half, 23d December, 1838, 1 was again sum- 
 moned to this patient, and delivered her, after a regular labour, ac- 
 companied with tolerable hemorrhage, of an ovum four inches in 
 length, which contained an embryo at most not more than four 
 lines. It was reddish, and floated in a liquid of a brick-red colour. 
 As is evident, the foetus, in this case, ceased to live at fifteen days 
 or three weeks, while the placenta continued to grow in the uterus. 
 
 In case of twins, one may be expelled before term, and the other 
 continue to live. M. P. Dubois noticed this fact in a lady who lived 
 at Sèvres, and also in a female in the Maternité. 
 
 Signs indicating that Miscarriage has taken place. 
 
 It is of great importance to ascertain, in the first place, whether, 
 in miscarriage, the foetus and membranes have been expelled, or 
 whether the placenta still remains in the uterus. 
 
 The first precaution for the accoucheur to take, on arriving at 
 the bedside of a woman threatened with miscarriage, after having 
 learned from her all the facts calculated to enlighten his mind, is 
 to examine the evacuations and bed-clothing, in order to ascertain, 
 if possible, whether the foetus has been expelled. If he observe 
 any coagula of blood, he should have them washed and separated, 
 in order that they may be distinguished from a foetus. The woman 
 should be recommended to use a vessel for her evacuations, in or- 
 der that the embryo may not be lost ; and the clothes should be put 
 one side, so as to be examined on his return. 
 
 Without these precautions, it will often be very difficult to as- 
 certain whether miscarriage has taken place or not. The degree 
 of dilatation of the neck of the womb cannot, in most cases, de- 
 termine this question. Before miscarriage, the neck may be dila- 
 ted without our being able to feel anything ; often, it will be found 
 quite closed. After the expulsion of the foetus, it may remain open 
 if the placenta be still retained in the organ, or if a coagulum be 
 formed there ; but it may also close on these substances. Frequent- 
 ly even, immediately after the expulsion, it closes, and where preg- 
 nanes is but little advanced, it assumes the form it had before the 
 
 U 
 
154 DISEASES INCIDENT TO PREGNANCY. 
 
 accident. How, then, can it be ascertained that miscarriage has 
 taken place ? 
 
 So far as the pains are concerned, there is the same doubt and 
 uncertainty ; they may be continued by the presence of the placen- 
 ta and of a coagulum ; or, after the complete expulsion, they may 
 loe determined by a peculiar morbid condition, and continue for a 
 longer or shorter period. 
 
 We must, therefore, search carefully for the fœtus, and endeav- 
 our to distinguish it from the membranes and coagula. 
 
 § 5. Treatment. 
 The treatment consists in preventing and arresting miscarriage, 
 and in remedying the accidents which may attend it. 
 
 The Prevention of Miscarriage. 
 
 If miscarriage should be occasioned by weakness or the general 
 bad health of the patient, we should avail ourselves of the interval 
 between her pregnancies to endeavour to combat these causes. 
 
 Thus, weak, cachectic women, whose constitution has been in- 
 jured by protracted disease — those especially in whom the inferior 
 segment of the womb participates in this general state of atony 
 and relaxed condition of the tissues, should be put upon a tonic 
 regimen ; preparations of iron, cold sea-bathing, mineral waters, 
 &c. These means should be continued during pregnancy, avoid- 
 ing, however, such as cannot be used without fatigue to the pa- 
 tient. It will sometimes be necessary to enjoin rest during the first 
 months. The circumstances which accompanied the preceding 
 miscarriages, if there should have been any, will guide the accou- 
 cheur in this particular. For example, if the expulsion of the foe- 
 tus should have previously taken place without any appreciable 
 cause other than the laxity of the fibres about the neck of the 
 womb, repose will be indicated. Another circumstance frequently 
 determines miscarriage in debilitated women who menstruate irreg- 
 ularly, and are affected with leucorrhœa ; it is a sanguineous exhala- 
 tion, sometimes even a profuse hemorrhage, which destroys the foetus. 
 In this case, the same means are to be employed ; and, moreover, we 
 should endeavour to combat all the causes of local congestion, and 
 prevent especially constipation by frequent enemata ; and a few 
 days before the expected return of the menstrual evacuation, if the 
 patient should not be too weak, it would be proper to make a small 
 revulsive bleeding from the arm of one or two ounces at most : should 
 the bleeding not be advisable, mustard cataplasms should be placed 
 upon the back and arms, and everything should be avoided which 
 can possibly accelerate the circulation in the inferior extremities. 
 
 The rigidity of the fibres of the body of the uterus, its excess of 
 contractility, must be treated by entirely opposite measures : warm 
 baths, a mild regimen, general bleeding, and laudanum injections. 
 
 In case of prolapsus of the womb, the organ should be supported, 
 but it must be remembered that the presence of a pessary may de- 
 termine miscarriage ; its employment should be closelv watched. 
 
DISEASES INCIDENT TO PREGNANCY. 155 
 
 It would, however, be better to depend upon absolute repose du- 
 ring the first months, until the uterus ascends above the superior 
 strait, it being understood that the woman should sedulously avoid 
 all fatigue and' violent effort. 
 
 The general vices of the constitution must be treated by their 
 appropriate remedies, and, as far as possible, in the interval be- 
 tween the pregnancies ; or, at an advanced period of gestation, es- 
 pecially when there is a syphilitic affection, for the mercurial treat- 
 ment has been regarded by some authors as fatal to the fœtus. 
 
 The causes which are connected with the diseases of the ovum 
 or fœtus are beyond the pale of art. 
 
 Finally, the hemorrhagic tendency, which manifests itself in wom- 
 en whose menstrual evacuation is very abundant, and which is a 
 frequent cause of miscarriage, should be treated during the ab- 
 sence of pregnancy by spare regimen ; and during gestation, es- 
 pecially when the female has already miscarried several times at 
 the menstrual periods, and when there are symptoms of general or 
 local plethora, we should abstract each month from the arm a 
 small quantity of blood a few days before the menstrual epoch, and 
 this should be continued until the period of the former miscarria- 
 ges has passed. I insist that only small bleedings should be prac- 
 tised during pregnancy, although more copious venesection is 
 sometimes called for when the plethora is great ; but I have often 
 known profuse bleedings occasion effects the reverse of those an- 
 ticipated ; and I am aware that the majority of physicians are not 
 sufficiently guarded against the effects of these copious depletions. 
 
 Desormeaux, in cases of large hemorrhoidal tumours, and in 
 phlegmasia? of the neighbouring organs, the bladder and rectum, 
 recommends local bleeding. I have often obtained good results 
 from it, and M. Gendrin observes that the application of leeches 
 to the groins in local plethora will be followed by the happiest ef- 
 fects. I must admit, however, that in this case I prefer the general 
 abstraction of blood. In a word, judicious bloodletting is a pow- 
 erful means by which I have been enabled to carry to their full 
 term a number of women who, until they had been confided to my 
 care, had miscarried several times. I might cite many instances, 
 but I refer the reader to the memoir which I published on this 
 subject.* 
 
 As useful precautions, which should be employed, no matter what 
 may have been the cause of preceding miscarriages, or what circum- 
 stances may induce us to apprehend their recurrence, we should 
 recommend the woman to avoid, at the commencement of pregnan- 
 cy, constipation ; and with this view, she should make frequent use 
 of warm enemata. Should these prove insufficient, she must not 
 have recourse to any drastic purgative, but a slight laxative should 
 be administered — castor oil, for example. Physical and mental ex- 
 citement, violence, horseback exercise, riding in a carriage, warm 
 bathing frequently repeated and prolonged, should all be sedulous- 
 
 * On Miscarriage, and the Means of preventing and arresting it. 
 
156 DISEASES INCIDENT TO PREGNANCY. 
 
 ly avoided. If some disease foreign from pregnancy should re- 
 quire an operation, it would be indispensable, especially if there be 
 reason to fear miscarriage, to defer it until after delivery, if pos- 
 sible ; such, for example, as the extraction of a tooth, the break- 
 ing up of a stone in the bladder, cauterization of the neck of the 
 uterus, &c, &c. 
 
 The Means of arresting Miscarriage. 
 The mode of treatment adopted by Professor P. Dubois, and 
 which I have frequently found successful in his hands at La CK 
 nique, in cases in which miscarriage appeared inevitable, consists k 
 the employment of two agents, which I have already recommend- 
 ed in the preventive treatment. 
 
 Bleeding and Laudanum. — The opportunities which my father- 
 in-law, M. Honoré and myself have had of employing this method 
 of treatment at the Hôtel Dieu and La Clinique, as also in our city 
 practice, have resulted most satisfactorily to both of us. 
 
 But before proceeding farther, it will be proper, in order to un- 
 derstand the modus operandi of these remedies, to consider briefly 
 the contractile properties with which the uterus is endowed at all 
 periods of life, and which it possesses in a higher degree during 
 gestation. 
 
 Like all the hollow viscera of organic life, the uterus possesses 
 two kinds of contractility: the first is the organic contractility 
 proper ; the second is the contractility of tissue, or retractility. 
 
 The action of these two kinds of contractility, much more man- 
 ifest in the uterus than in all the other organs subjected to the 
 same influence, enables us to establish clearly its distinctive char- 
 acters. 
 
 A. The proper Organic Contractility of the Uterus. — The action 
 of the organic contractility of the uterus consists in a rapid con- 
 traction of the organ, almost always accompanied by pain, return- 
 ing by paroxysms, and acomplished with violence, in order to ex- 
 pel from the uterine cavity the fœtus and annexa? : this property of 
 the uterus is the most powerful agent in parturition. 
 
 This contractile power resides in all parts of the uterus ; but as 
 the womb is an organ of expulsion, nature has concentrated the 
 greatest amount of its expulsive forces in the superior portion of 
 this organ, in the point opposite to that which affords passage to 
 the child. 
 
 Ergot can increase this property ; opium and bloodletting may 
 arrest its action. 
 
 B. Organic Contractility of the Tissue. — Distinct from the for- 
 mer, the organic contractility of the tissue exists in the whole ex- 
 tent of the walls of the organ, but exhibits itself more especially in 
 certain points. It is in virtue of this property that the uterus con- 
 tracts, after it has expelled the foetus. But as an essential condi- 
 tion for its exercise, it is necessary that the emptying of the uterus 
 be accomplished gradually. 
 
 This property, which appertains to all the other organs, is much 
 
DISEASES INCIDENT TO PREGNANCY. 157 
 
 more marked in the uterus ; in proportion as the foetus is expelled, 
 the tissues return gradually upon themselves, and finally close up 
 the mouths of the bloodvessels. Without this wise provision of 
 nature, the vascular system, excessively developed during preg- 
 nancy, would have preserved the same conditions ; and, after deliv- 
 ery, the mouths of the vessels, remaining open upon the internal 
 surface of the uterus, would have poured out blood abundantly 
 and death would soon have followed this hemorrhage. 
 
 Moreover, the fundus of the organ is, in the majority of cases, 
 the seat of the insertion of the placenta, and with this view, it is 
 provided with a most active vascular apparatus, and is endowed 
 with this property of contraction in a much higher degree than the 
 inferior portions ; it is this absence of retraction in the cervix of the 
 womb that renders hemorrhage so frequent in cases of insertion of 
 the placenta over the orifice or in its vicinity. 
 
 Immediately after delivery, it is easy to appreciate this differ- 
 ence ; the fundus presents in the hypogastric region a hard and 
 globular body ; the neck, on the contrary, is soft, relaxed, and open. 
 
 Unconnected with parturition during life, the contractility of 
 tissue, always going on without pain, and also without conscious- 
 ness to the patient, will sometimes be sufficient to determine deliv- 
 ery a short time after the death of the mother. Bichat thinks that 
 putrefaction alone can destroy this faculty. 
 
 Finally, this property is increased by ergot; but it resists all 
 moral influences, and, what is very important, the influence of 
 bloodletting and opium. 
 
 These properties are so distinct, that one may exist without the 
 other. Thus, after a rapid expulsion, effected under the influence 
 of energetic contractions, the uterus does not always return on it- 
 self ; while, on the contrary, after the extraction of the foetus has 
 become necessary, in consequence of inertia of the womb, this or- 
 gan, gradually emptied, contracts. 
 
 The study of these different properties will show us that agents 
 which may suspend the exercise of the organic contractility with- 
 out at all impeding the retractility of tissue, will become precious 
 remedies in cases of threatened abortion, not the result of disease 
 of the ovum, or of the death of the foetus, but merely of a prema- 
 ture action of the organic contractility. 
 
 These agents are opium and bloodletting, separately or united. 
 
 As one circumstance which will vary the treatment, authors 
 have made a distinction between the signs of abortion caused 
 by the death of the foetus, and those which characterize a miscar- 
 riage depending on a cause which may be remedied ; and this dis- 
 tinction is based upon the fact that we must abstain from all treat- 
 ment which has for its object to arrest labour, and that even we 
 should favour the expulsory process when the child has ceased to 
 live ; and when it is living, we must endeavour to prevent it. But 
 this distinction, which is sometimes easily made when pregnancy 
 is sufficiently advanced to permit auscultation, cannot be arrived 
 at when we have only uncertain signs for a guide. 
 
158 DISEASES INCIDENT TO PREGNANCY 
 
 In all cases of doubt as to the life of the foetus, the accoucheur 
 should act in reference to the preservation of the child. These rem- 
 edies, applicable in all cases, will preserve the fœtus if that be pos- 
 sible, and will not prevent miscarriage if it be inevitable, only the 
 expulsion will sometimes be a little more retarded ; but the delay 
 which these remedies will occasion in the termination of the mis- 
 carriage, if it be inevitable, must be viewed as a very slight disad- 
 vantage in comparison with the success that attends them in pre- 
 serving the life of the fœtus and the health of the mother. In ca- 
 ses of failure even, this medication would still be beneficial, for 
 moderates the acute pains which accompany, and so often follow 
 miscarriage. This practice is generally adopted in England. 
 
 For the sake of clearness as to the indications to be fulfilled, I 
 will divide miscarriage into three periods. 
 
 First Period. 
 
 Uterine pains, passing from the umbilicus towards the pelvic 
 cavity, accompanied with hardness of the abdomen, and often with 
 pain in the loins, with a sensation of weight about the rectum, and 
 with general lassitude. 
 
 The uterine portion of the neck is softened and open ; and ten- 
 sion of the membranes at each contraction, when pregnancy is 
 advanced. 
 
 Treatment. — Absolute repose, horizontal posture, spare diet, and 
 bleeding from the arm, if there should be general or local plethora ; 
 a laxative enema, and after it has operated, a gill of fluid in lave- 
 ment with 18 or 20 drops of the laudanum of Sydenham, which 
 the patient must retain. If the contractions should cease, do no- 
 thing more ; if not, continue the anodyne injection in 1 5 and 20 
 drop doses every half hour until the labour ceases. We will rare- 
 ly be obliged to employ it often, or increase the quantity ; the first 
 administration will ordinarily suffice, if the fœtus be viable and 
 alive, and if the woman be in a normal state. 
 
 Second Period. 
 
 The same symptoms as in the first period ; and, in addition, mu- 
 co-sanguineous discharge, more or less hemorrhage, thinning of 
 the orifice, greater degree of dilatation, and protrusion of the mem- 
 branous sac. 
 
 Treatment. — Just the same as in the preceding case; and be- 
 sides, cold lemonade, and cold compresses on the thighs ; but, in 
 general, the treatment here is less efficacious. However, there 
 are numerous successful cases cited. Velpeau states that Mau- 
 riceau, Puzos, Nsegele, and Stoltz have seen instances in which, 
 after abundant hemorrhage, miscarriage did not follow. 
 
 Third Period. 
 All the preceding symptoms ; in addition, profuse hemorrhage, 
 and rupture of the sac. Here no treatment will avail. 
 
 However, M. Desormeaux mentions a case in which the woman 
 
DISEASFS INCIDENT TO PREGNANCY. 159 
 
 went on to full term after hemorrhage, the formation and rupture 
 of the membranous sac. 
 
 May not this fact, observed by a man who is great authority, 
 be explained differently ? May it not have been one of those ca- 
 ses in which there is abundant discharge of water during preg- 
 nancy, to which I have already alluded, and of which M. Nœgele 
 has given a very satisfactory explanation? (De Hydrorrhea 
 Gravidarum, 1822, auct. J. B. Geil.) 
 
 May not, in this case, the pains, which have caused the expul- 
 sion of one or more watery collections, have been more violent 
 than usual, and may others not have been accompanied by a san- 
 guineous discharge caused by the separation of a part of the mem- 
 branes, and by the tension of the amniotic sac, w r hich remains in 
 tact, although supposed to be ruptured, in consequence of the great 
 quantity of liquid that escapes ? 
 
 This explanation is alone admissible, for it is physically impos- 
 sible that a rupture of the membranes, especially if accompanied by 
 contractions, should not terminate in the expulsion of the foetus. 
 
 The administration of laudanum in so large a dose may inspire 
 apprehension in the minds of some practitioners, but I have never 
 known it followed by any serious consequences ; sometimes slight 
 somnolence and headache, and general numbness, a passing nar- 
 cotism. w T hich cold lemonade in a weak infusion of cold coffee will 
 quickly remove. M. P. Dubois has never known this mode of 
 treatment prove injurious to the child. 
 
 Be this as it may, it wall always be proper to admonish the as- 
 sistants that these symptoms may possibly follow the administra- 
 tion of opium, in order that they may not become alarmed should 
 they occur. 
 
 Treatment of the Accidents which may complicate Miscarriage. 
 
 Hemorrhage is one of the accidents which most usually accom- 
 pany miscarriage ; it may precede, accompany, or follow the ex- 
 pulsion of the fœtus. Most frequently, hemorrhage occasions mis- 
 carriage ; sometimes, however, it is only the consequence of it. 
 It may be slight or very abundant. In the former case, we may 
 content ourselves with the means indicated in the preceding para- 
 graph (second period). But should the hemorrhage continue so 
 profuse as to endanger the life of the mother, miscarriage becomes 
 inevitable, and the accoucheur should employ all the remedies 
 proper to arrest the hemorrhage, when even these remedies might 
 be of a nature to determine the death and expulsion of the foetus. 
 In fine, hemorrhage is one of those accidents which, by its sudden 
 occurrence and the rapidity of its progress, may compromise most 
 seriously the responsibility of the accoucheur, and which requires 
 on his part a prompt judgment, great prudence, and especially self- 
 possession. He should have recourse to refrigerants ; but no mat- 
 ter how alarming the hemorrhage, these should never be applied 
 over the whole surface of the body. They should be limited to the 
 thighs and lower portion of the abdomen ; and care should be taken 
 
160 DISEASES INCIDENT TO PREGNANCY. 
 
 to keep the superior portions of the body warm. In this way, a 
 useful derivation will be obtained, and we will thus concentrate 
 towards the organs essential to life the quantity of blood necessa- 
 ry for the maintenance of their functions. 
 
 If, on the contrary, cold applications should be employed all over 
 the body, they may be suddenly followed by a fatal chill ; and in 
 all cases they are accompanied by pain and great anguish. 
 
 A cold lavement may be employed ; but vaginal injections of 
 this nature are not to be used ; they only serve to dilute the clots 
 and increase the hemorrhage. The accoucheur should constantly 
 direct his attention to the pulse and countenance, and, if it becomes 
 necessary, he should apply the tampon. 
 
 Each author has recommended a peculiar kind of tampon ; some 
 suggest that a fine linen handkerchief be introduced into the vagi- 
 na, commencing with one of the corners, until the vagina is com- 
 pletely filled ; others advise to introduce with the finger a com- 
 press, and afterward to secure it with cotton, lint, &c, &c. Some 
 also recommend to have these substances saturated with vinegar 
 or some astringent liquid. Tamponing in this manner is very pain- 
 ful, and frequently it does not completely close up the vagina. 
 The best mode of applying the tampon is, undoubtedly, as fol- 
 lows : introduce, up to the neck of the womb, a number of dossils 
 of lint or cotton connected by a thread, which is to be withheld ex- 
 ternally ; these dossils must be lubricated with cerate. In order to 
 introduce them, I use the speculum and the tampon forceps. These 
 instruments are not indispensable, but they enable us to place the 
 tampon much more accurately ; after having well filled the upper 
 portion of the vagina with dossils, I then introduce lint in sufficient 
 quantity to fill the entire vagina, and the speculum is gradually 
 withdrawn ; when the speculum is out of the vulva, the vagina is 
 completely filled up. Nothing now remains but to maintain the 
 tampon in situ by means of compresses and a T bandage. 
 
 The tampon, thus applied, will oppose effectually the escape of 
 blood ; it forces it to coagulate, by absorbing its serous portion ; a 
 coagulum is formed, and the mouths of the vessels are thus closed. 
 
 But with the undoubted advantages for the mother, it cannot be 
 denied that this procedure is attended by serious inconveniences 
 for the foetus ; it irritates the cervix by its presence, and solicits the 
 reaction of this portion upon the fundus of the^organ; the uterus 
 contracts, the cervix softens and dilates, and if the hemorrhage be 
 arrested when the tampon is removed, the miscarriage will be found 
 imminent. Notwithstanding this, however, the tampon is not the 
 less valuable; for, when the hemorrhage is serious, everything 
 should be sacrificed to the safety of the mother. There are some 
 women who cannot endure, even for a few minutes, the introduc- 
 tion of the tampon. In them, it occasions a most painful distension 
 of the vagina and weight in the rectum. In cases of the insuffi- 
 ciency of the tampon, or where its introduction cannot be borne, 
 we are then compelled to do all in our power to promote the evac- 
 uation of the contents of the womb. 
 
DISEASES INCIDENT TO PREGNANCY. 161 
 
 To facilitate Miscarriage. 
 Most of the remedies which the accoucheur will find himself 
 forced to employ in order to arrest hemorrhage will frequently 
 compromise pregnancy; such, for example, as the tampon and 
 ergot. If, therefore, it should become necessary to promote mis- 
 carriage, it will be sufficient, for the first month, to insist on these 
 same means. But care must be taken not to rupture the mem- 
 branes with a view to favour the expulsion of the fœtus, for it is 
 very important, on the contrary, that the ovum be expelled entire. 
 It is only at a more advanced period of pregnancy that we will be 
 authorized to separate the ovum in order to facilitate the expulsion 
 of the foetus, because then, if the placenta should not come away, 
 the size of the uterus will permit the introduction of the hand for 
 the purpose of extracting it 
 
 Delivering the Placenta. 
 During the first months, the placenta will frequently be expelled 
 at the same time as the foetus, and the ovum then passes out entire ; 
 but often the membranes rupture under the influence of uterine 
 contraction, the waters escape, and the foetus is expelled ; then the 
 contractions cease, the cervix returns gradually on itself, and the 
 placenta is retained within the cavity of the uterus. After a few 
 hours the contractions recommence, and the expulsion of the an- 
 nexai is effected. However, most usually the cause that has re- 
 tained the placenta in the first instance continues to retain it for 
 several days ; the complete separation then takes place, and the 
 placenta is expelled. But from the time the foetus has been deliv- 
 ered until the final expulsion of the placenta, there is constantly a 
 discharge of blood, more or less abundant. The presence of the 
 placenta in the cavity of the uterus has caused this hemorrhage, by 
 opposing the complete contraction of the organ, and by favouring 
 the afflux of blood into its walls. The accoucheur is frequently 
 obliged to aid the delivery of the placenta, in order to save the 
 woman from the danger of bleeding, at the same time that he em- 
 ploys the proper means to combat this accident. If the placenta 
 should be detached, it will be found more or less engaged in the 
 neck of the uterus, and two fingers will then suffice to extraet it: 
 if necessary, the false conception forceps may be employed. Vu- 
 thors have recommended, in this case, the use of the specuiun. us 
 a means proper to facilitate the attempts at delivery, but the blood 
 and clots constantly passing out of the vagina will materially inter- 
 fere with the utility of this instrument. If the placenta should still 
 be adhering to the womb, and if the condition of the cervix will 
 not permit it to be seized, its extraction cannot be accomplished ; 
 and we must then depend upon refrigerants, ergot, and the tampon.* 
 This is the course to be pursued in cases in which the accoucheur, 
 having been present from the commencement of the miscarriage, 
 
 * The tampon may be used at this period, notwithstanding the rupture of the membranes, 
 without any fear of serious internal hemorrhage ; for the development of the uterus is not 
 such as to warrant apprehension on this ground. 
 
 X 
 
162 DISEASES INCIDENT TO PREGNANCY. 
 
 is positive that the fœtus alone has been expelled, and that the pla- 
 centa is yet retained. But when he is called in after the efforts of 
 the womb have continued for some time, and cannot examine the 
 clots of discharged blood, he will necessarily be in doubt as to the 
 cause of the hemorrhage, notwithstanding all the assurances of the 
 assistants. If, however, on making a vaginal examination, he 
 should recognise the presence of the placenta, he should endeavour 
 to extract it ; but should the neck of the womb be closed, and thus 
 prevent him from ascertaining the presence of this body in the cav- 
 ity of the uterus, what should then be his conduct ? If the hem- 
 orrhage be slight, as he does not know whether the miscarriage has 
 taken place or not, and if the latter, he may hope yet to save the 
 foetus, he should limit himself to the means I have already indica- 
 ted (refrigerants, laudanum, &c.) ; if the hemorrhage be serious, he 
 ought to do everything to arrest it. Thus, he will administer er- 
 got, apply the tampon, &c. 
 
 However, whatever may be the points of the case, no forcible 
 attempt must ever be made to overcome the resistance of the cer- 
 vix ; this would be the most certain means of aggravating the 
 hemorrhage, without in the least facilitating the delivery. 
 
 When the placenta is completely separated, and retained in the 
 uterus, frequently there will be no hemorrhage ; but there is an- 
 other series of accidents to combat. The introduction of a small 
 quantity of air, and the heat in the uterine cavity, will cause rapid 
 putrefaction of the placenta ; the lochise become fetid, and all the 
 phenomena of the absorption of this putrid mass declare them 
 selves. These results must be opposed by injections and antisep- 
 tics internally. 
 
 Injections into the vagina should be composed of a decoction of 
 quinine, one to three grammes to one hundred grammes of water ; 
 or of the chloride of sodium, a spoonful to one hundred grammes 
 of water. 
 
 The decoction of quinine, sweetened and acidulated, must be ad- 
 ministered internally ; potions of the acetate of ammonia, in the dose 
 of one to two grammes in a hundred grammes of some aromatic in- 
 fusion ; and if nervous symptoms should manifest themselves, cam- 
 phor should be given in pills, in the dose of thirty to sixty centi- 
 grammes, or musk, in the dose of ten to twenty centigrammes. 
 But we should especially insist on the employment of ergot, and, 
 if it be possible, the uterus should be cleansed with emollient injec- 
 tions, thrown up gently by means of a canula ; and if the mouth 
 should be closed, we must abandon this method, and limit ourselves 
 to simple vaginal injections frequently repeated. 
 
 Sometimes, however, these serious results do not take place, and 
 the placenta is thrown off in a fluid state, or is gradually absorbed. 
 Examples of this absorption are cited by authors. This absorption 
 may take place during the first months, in consequence of the small 
 size of the placenta; but the development acquired by this body at 
 a more advanced period, if it does not entirely exclude the possi- 
 bility, should at least render the occurrence of this phenomenon 
 
PREMATURE LABOUR. 163 
 
 extremely rare ; and in this latter case, it is always attended with 
 very severe symptoms, which we should endeavour to prevent by 
 all means of extraction reconcilable with the safety of the mother. 
 In fine, whenever the miscarriage takes place at a period of gesta- 
 tion which will permit the introduction of the hand into the uterus, 
 the extraction of the placenta should always be effected. 
 
 CHAPTER V. 
 
 PREMATURE LABOUR. 
 
 We understand by premature labour the expulsion of the foetus 
 from the period of viability to the full term of utero-gestation. 
 Most of the causes capable of determining miscarriage may also 
 occasion the expulsion of a viable fœtus before term. 
 
 The progress of this accident is more regular, and it resembles 
 more delivery at the full period, in proportion as pregnancy is more 
 advanced ; but previous to the eighth and a half month, the changes 
 in the cervix necessary to the accomplishment of a normal deliv- 
 ery have not taken place ; its progress, therefore, presents some 
 irregularities. Thus the first stage of the labour, during which the 
 dilatation of the neck is effected, will be longer than at full term. 
 Before the cervix dilates, it must become completely effaced, and 
 most frequently this demands considerable time, and is accom- 
 plished only under the influence of energetic contractions, which 
 are frequently accompanied by a febrile paroxysm. 
 
 When the dilatation is once effected, the second period of ex- 
 pulsion will be more rapid than at term, which is explained by the 
 small size of the fœtus. 
 
 The same means recommended for the arrest of miscarriage 
 are to be employed with a view to prevent premature delivery. 
 
 The patient will require the same attention as if delivered at full 
 term ; with the exception, however, that as the delivery ordinarily 
 proceeds with more rapidity, it will be proper to retard the expul- 
 sion in order to prevent inertia of the womb, which might result 
 from too quick an escape of the fœtus. 
 
 CHAPTER VI. 
 
 ATTENTIONS DURING PREGNANCY. 
 
 The pregnant woman is more excitable and sensitive than she 
 is under ordinary circumstances. She should therefore avoid all 
 atmospheric changes, which might cause in her acute affections of 
 
164 ATTENTIONS DURING PREGNANCY. 
 
 the lungs ; cough, as I have already observed, is a frequent cause 
 of miscarriage. 
 
 She should wear a corset without whalebone, in order to give 
 support to the breasts and abdomen, without, however, compress- 
 ing them. 
 
 If she intend to suckle her child, it will be proper to recom- 
 mend her to use a nipple shield, in which the nipple may lodge ; 
 this will be a proper means of preventing the flattening of the nip- 
 ples, and will favour their projection. The child will experience 
 much less difficulty in seizing the breast, if this precaution be at- 
 tended to. 
 
 In respect to her person, the patient should avoid baths, general 
 ablutions, and warm lavements. 
 
 She should never put her feet into water ; their cleanliness may 
 be preserved by simply washing them. 
 
 If constipation should not yield to simple injections, gentle lax- 
 atives must be administered. 
 
 In a word, the female should avoid riding in carriages, espe- 
 cially during the first months ; and also crowded assemblies, and all 
 physical and moral excitement. She should exercise moderately, 
 without fatiguing herself, and partake of wholesome and abundant 
 food ; she should not be permitted to live exclusively on diet that 
 is not nourishing, because she fancies it ; but, at the same time, she 
 must not be altogether deprived of it. 
 
 Thus, she may be permitted to eat solids and fruits ; she may 
 take coffee and liquor if she desires. But the repeated use of spir- 
 ituous drinks must be interdicted. 
 
 It must not be supposed that this interdiction is necessary only 
 among the poorer classes. I have known women in the highest 
 walks of society who, when not pregnant, drank nothing but wa- 
 ter, upon whom it became absolutely necessary to enjoin this re- 
 striction during their gestation. 
 
 CHAPTER VII. 
 
 CIRCUMSTANCES WHICH WILL GIVE US REASON TO SUPPOSE THAT A 
 WOMAN WILL MAKE A GOOD NURSE. 
 
 It is very difficult, during pregnancy, to ascertain positively 
 whether a female will make a good wet-nurse. I have known 
 women to present all the appearances of excellent nurses : large, 
 strong, with their breasts well developed, and yet have no milk ; 
 while others, weak and delicate in appearance, and who, being 
 desirous of nursing, notwithstanding all representations to the con- 
 trary, proved capital nurses. In general, it is rare that a woman 
 cannot nurse if she be in good health, and observes all the precau- 
 
INFLUENCE OF PREGNANCY ON DISEASE. 165 
 
 tions of which I shall speak more in detail in a special article on 
 lactation. 
 
 We may, therefore, conclude that a female will be able to nurse 
 her child if she be in good health, if she be not labouring under dis- 
 ease which may be transmitted, and if the breasts, of the ordinary 
 size, be marked on their surface with bluish veins ; if the areola be 
 elevated, the nipple prominent and well pierced, and especially if 
 a sero-lactescent fluid be discharged on slight pressure. She 
 should also possess a good disposition, and avoid sudden and fre- 
 quent emotions ; she should live in a healthy position, and particu- 
 larly in the country. But if she should possess a lymphatic tem- 
 perament, an irritable disposition, or be endowed with too great a 
 degree of sensibility, she should be dissuaded from nursing, even 
 if she present all the necessary physical characteristics. 
 
 And the absolute impossibility of nursing her child should be 
 pointed out if she cannot leave the city, and if she reside in a 
 confined and damp section, where the sun cannot penetrate. 
 
 CHAPTER VIII. 
 
 INFLUENCE OF PREGNANCY ON DISEASE. 
 
 Several diseases occur, become suspended, or disappear during 
 pregnancy, such as headache, toothache, and nervous affections of 
 the face. I saw at La Clinique, in a female named Aglaé Masson, 
 a goitre become developed under the influence of pregnancy, in- 
 crease during labour, and gradually disappear after delivery. 
 
 Other diseases existing before conception, and which until then 
 present nothing serious, frequently assume an alarming character 
 under the influence of gestation ; some slight affections disappear 
 completely. Phthisis pulmonalis frequently becomes modified du- 
 ring pregnancy, and is succeeded, apparently, by perfect health; 
 but this, for the most part, is but temporary. After delivery the 
 symptoms manifest themselves again, and proceed, with frightful 
 rapidity, to a fatal termination. 
 
166 DELIVERY IN GENERAL. 
 
 PART THIRD. 
 
 DELIVERY IN GENERAL. 
 
 By delivery is meant the spontaneous expulsion or an artificial 
 extraction of a viable fœtus and its annexée through the maternal 
 organs, and the return of these organs to their primitive condition. 
 
 Delivery has received different denominations. When it is 
 achieved by the sole efforts of nature, and happily for both mother 
 and child, it is called natural; but when it has been effected by 
 the efforts of nature, without being also favourable to mother and 
 child, it is called simply spontaneous. In a word, it is not natural 
 when the object of nature is not fulfilled. It is called difficult, ar- 
 tificial, whenever it cannot be accomplished without the interfe- 
 rence of art. It is also called precocious delivery, and delivery at 
 term, according to the periods of pregnancy at which it occurs. 
 
 Precocious and Tardy Births. 
 
 In the human female, the duration of labour is ordinarily nine 
 months, or two hundred and seventy days. However, this period 
 is not so rigorous that fetuses cannot be born before term, and be 
 viable and strong, while others, having exceeded this period, are 
 born weak and scarcely viable. 
 
 Two circumstances may determine precocious and tardy births : 
 
 1st. The fœtus, although not having arrived at the full term, 
 may, however, have acquired a development and perfection of or- 
 ganization which qualify it for external existence before the period 
 fixed by nature, and then it is expelled before term. 
 
 It is easy to distinguish this expulsion from premature delivery 
 resulting from any other cause, by the appreciation of the particu- 
 lar cause, by the strength of the fœtus, and by the perfection of its 
 organs. 
 
 2d. The development of the fetus may be incomplete, although 
 at term, and then it is necessary that pregnancy be prolonged, in 
 order that the fetus may attain its degree of perfection. 
 
 These two phenomena are determined by that property which the 
 uterus possesses, of acquiring, before the end of the ninth month, the 
 conditions which enable it to contract, and expel a fetus the devel- 
 opment of which is premature, or of attaining these modifications 
 only after the prescribed term, in order that the organization of 
 the fetus may become perfected. This fact is perfectly reason- 
 able, and it is, moreover, proved by experiments made on animals. 
 Do we not see, for example, in domestic animals, in which it is al- 
 ways easy to ascertain the time of impregnation, bring forth their 
 young, strong and large, some days before term, and simply be- 
 cause the perfection of the fetuses has occasioned their expulsion ? 
 
SPONTANEOUS DELIVERY AT TERM. 167 
 
 And, also, do we not see the young expelled after term, because 
 they have not attained the degree of necessary development ? In 
 cows, for instance, which go nine months, the same as the human 
 female, these variations are very striking : some calve thirty days 
 before their time, others thirty days after.* Why should not the 
 human species be subject to the same irregularities ? 
 
 It will be in vain objected that these facts cannot be ascertained 
 without great difficulty ; analogy will suffice to admit them. They 
 are, moreover, proved by numerous examples cited by authors, 
 and, among others, by one mentioned by Desormeaux, of a lunatic 
 who was not delivered until nine months and fifteen days after 
 conception. 
 
 The law has also interfered in the settlement of this question ; 
 and it has declared that, after the three hundredth day, or tenth 
 month, the legitimacy of the child may be contested by the hus- 
 band. 
 
 TITLE I. 
 
 SPONTANEOUS DELIVERY AT TERM. 
 
 The spontaneous expulsion of the fœtus is a very complex func- 
 tion, in which, theoretically, we should distinguish two orders of 
 phenomena: 1st, the physiological phenomena, which are only the 
 manifestation of the vital action of the uterus and organs concern- 
 ed in parturition. Such are the precursory signs ; the contraction 
 and pain, the dilatation of the neck of the uterus, the muco-san- 
 guineous discharge, the formation of the membranous sac, its rup- 
 ture, &c. 2d, the mechanical phenomena of labour, and the en- 
 semble of the laws which govern in the spontaneous expulsion of 
 the fœtus. 
 
 CHAPTER I. 
 
 CAUSES OF LABOUR. 
 
 The causes of labour have been distinguished into the determi- 
 nate and efficient. 
 
 Art. I. — Determinate Causes. 
 Most authors have generally agreed to place the determinate 
 causes of labour in the uterus, but all do not explain this phenome- 
 
 * For some articles on this subject, see Velpeau, second edition, Paris, 1835, t. i , p. 382. 
 
168 CAUSES OF LABOUR. 
 
 non in the same manner. According to some, the uterus com- 
 mences its action after it has undergone all the modifications ne- 
 cessary for it to experience at the full period of gestation. This 
 explanation, insufficient as it may appear, is still the most rea- 
 sonable. According to others, it is the excessive distension of the 
 uterus which forces it to contract upon the fœtus. The opinion 
 of M. Desormeaux seems to be that adopted by most modern ac- 
 coucheurs. " The fundus and body of the uterus," he observes, 
 " are the first to become distended, in order to form the cavity 
 destined to contain the fœtus. The cavity of the cervix does not 
 participate until a later period in the increase of the uterus, and 
 the resistance which its orifice opposes to the escape of the ovum 
 diminishes .in proportion as pregnancy advances to its termination. 
 At this period, the fibres of the cervix no longer possessing resist- 
 ance sufficient to prevent an antagonistic effect to the action of the 
 fibres of the fundus, these last contract, and the fœtus is expelled." 
 M. P. Dubois has adopted, in his lectures, the theory proposed 
 by Jones Sower in 1819. I will transcribe it as I find it in my 
 notes : 
 
 The uterus, at the completion of pregnancy, may be compared 
 to most of the hollow and muscular organs, the rectum and blad- 
 der. It is composed, like these organs, of two planes of muscu- 
 lar fibres, the most external of which are longitudinal, the most 
 internal, circular. Like them, it presents a contractile cavity, and 
 a sphincter or orifice, with circular fibres. Like them, too, the ute- 
 rus receives two orders of nerves ; the one, coming from the gan- 
 glionic system, distributes itself upon the body ; the other, coming 
 from the system of animal life, go to the cervix of the organ. 
 
 Besides, there exist between the cervix and body of the ute- 
 rus the same sympathies as between the rectum and sphincter, be- 
 tween the bladder and its neck ; and, just as the mechanical irrita- 
 tion produced on the sphincter by the presence of foecal matter de- 
 termines the contraction of the intestine, so, also, when at the end 
 of pregnancy, there remains at the inferior portion of the uterus 
 merely a ring composed of the circular fibres of the external ori- 
 fice, this ring or sphincter, which, receiving nerves of animal life, is 
 endowed with great sensibility, becomes irritated by the contact of 
 the membranes and fœtus to which it had not been accustomed, 
 and reacts sympathetically on the fibres of the fundus, which con- 
 tract. I do not insist upon these various causes ; for none of the 
 theories advanced is entirely satisfactory, and we are compelled 
 to return, with M. Velpeau, to the opinion of Avicenna : " At the 
 proper time, delivery takes place by the grace of God." 
 
 Art. II. — Efficent Causes. 
 Hippocrates, and some ancient accoucheurs, and, indeed, some 
 moderns too, such as Harvey, regard the fœtus as the principal 
 agent of its expulsion ; and this opinion they founded on the follow- 
 ing facts : that delivery is more protracted and painful when the 
 fœtus has ceased to live ; that foetuses have been expelled after the 
 
CAUSES OF LABOUR. 169 
 
 death of their mother ; and, finally, that the young of some of the 
 larger animals execute movements proper to facilitate their expul- 
 sion. It is true, that, after the death of the foetus, the expulsion is 
 more slow ; but this is not because the dead fœtus cannot aid in its 
 expulsion, but simply because the fœtus, sunk upon itself, does not 
 present to the uterus a point of support, and no longer stimulates 
 it by its active movements ; and because then the uterus loses its vi- 
 tality, its walls fall into a state of atony, and its organic contrac- 
 tility is deprived of its ordinary energy. These circumstances, 
 which, it is true, depend upon the death of the fœtus, will suffice to 
 explain the delay in the delivery when the fœtus has ceased to ex- 
 ist, without our having any right to attribute this protraction to the 
 simple fact that the fœtus is not alive. In order to prove that the 
 fœtus co-operates in its expulsion, authors have cited the example 
 of children being born spontaneously after the death of the mother ; 
 but in most of these instances the fœtus had died before its parent ; 
 and, moreover, it is well known that a dead fœtus may be expelled 
 in virtue of the tonicity of the uterus. 
 
 Bichat has demonstrated that all the organs do not die at the 
 same time, and that the uterus may expel the fœtus by the force of 
 its contractions some moments after the last pulsation of the 
 heart. 
 
 Leroux has felt this organ contract fifteen minutes after the last 
 breath. Osiander, having performed the Cassarean operation on a 
 cadaver, saw the uterus contract as in the living subject. 
 
 As to the movements executed by the young of some of the larger 
 animals at the time of their expulsion, they cannot be doubted. 
 And if it be reasonable to admit that the fœtus is not the principal 
 agent of its expulsion, the opinion of those who think from analogy 
 that it may contribute directly to it, at least to a certain extent, 
 does not appear entirely void of foundation. 
 
 But what is this efficient cause ? Evidently it is found in the 
 contraction of the uterine walls, aided by that of the diaphragm 
 and abdominal muscles. However, the contraction of the uterus 
 alone will suffice, in many cases, to effect delivery. In fact, expul- 
 sion occurs in females where the abdominal parietes are open, and 
 also in those where these parietes are paralyzed. But if, most gen- 
 erally, the uterus will suffice at the commencement of labour, it is 
 not always so after the head has passed the superior strait, and 
 rests on the floor of the pelvis. The simultaneous action of the dia- 
 phragm and abdominal muscles is frequently indispensable to as- 
 sist the uterus, and terminate the expulsion. However, the dia- 
 phragm is not, like the abdominal muscles, a direct agent of partu- 
 rition ; it does not exert any compression upon the uterus ; but, sus- 
 tained by the air inspired by the lungs, it gives to the base of the 
 chest an immobility, which affords a point of firm support to the 
 muscles, and it thus indirectly aids the uterus in its contractions. 
 
 Y 
 
170 PHYSIOLOGICAL PHENOMENA OF DELIVERY. 
 
 CHAPTER II. 
 
 PHYSIOLOGICAL PHENOMENA OF DELIVERY. 
 
 Art. I. — Precursory Signs of Delivery. 
 
 When pregnancy is near the completion of its term, a few days 
 in advance delivery is announced by a train of symptoms called 
 the precursory signs. Thus, the uterus descends and becomes 
 prominent ; the sides of the abdomen are more hollow ; respiration 
 and digestion become more easy. It is said that, at this period, 
 the woman becomes more active and gay ; but it is not so with all, 
 for I have frequently observed the contrary. In a word, she is dis- 
 turbed by want of sleep, and experiences a general malaise ; she 
 very frequently has an aversion for all active exercise. The lips 
 of the vulva relax and become painful. The situation of the head 
 at the superior strait causes the compression of the neck of the blad- 
 der and rectum, and the woman experiences frequent desire to pass 
 her urine and fasces, and a sensation of cramp in her thighs. These 
 latter symptoms, occasioned by the pressure excited by the foetus 
 on the maternal organs, do not, in general, exist when any other 
 portion than the head presents, for the vertex alone can by its form 
 descend sufficiently in the excavation, pushing before it the inferior 
 segment of the undilated uterus, while such is not the case with 
 the other portions of the foetus. Thus these symptoms, besides 
 announcing that delivery is at hand, will enable us to predict that 
 the vertex presents. 
 
 Walking and standing also become more difficult, either in con- 
 sequence of the preceding causes, or because of a slight softening 
 of the symphyses. (Edema, and enlargement of the veins of the low- 
 er extremities and parts of generation, do not often appear before 
 this period, or increase if they have previously existed. It is the 
 same with regard to hemorrhoidal tumours. 
 
 Finally, the uterus, as if to prelude an important act which it is 
 about to accomplish, contracts almost insensibly, and these success- 
 ive contractions are painful to the mother ; primiparœ are more 
 subject to them than others. They feel their abdomen becoming 
 hard, and if the uterine orifice is open, the touch will enable the ac- 
 coucheur to recognise the distension of the membranes. 
 
 After these first symptoms labour commences, which Desor- 
 meaux has divided into three principal periods : the first compre- 
 hends all the phenomena observed from the commencement of la- 
 bour to the complete dilatation ; the second embraces the period 
 from the dilatation to the expulsion of the fœtus ; and the third 
 comprehends the delivery of the placenta. 
 
FIRST AND SECOND PERIODS OF LABOUR. 171 
 
 Art. II. — First Period of Labour. 
 
 Labour is composed of a succession of phenomena, which are 
 varied by a multitude of circumstances. 
 
 Thus, it presents differences in primiparae and in women who 
 have already borne children ; it is also influenced by the physical 
 and moral energy, and by the physiological and pathological con- 
 dition of the woman. Notwithstanding these varieties, the rapid 
 sketch which I am about to make will represent, with all possible 
 precision, the different phases of labour in a primipara. 
 
 At the commencement of labour, the patient experiences a kind 
 of interior constriction, which troubles her, and which she has diffi- 
 culty to express ; her whole body trembles ; the respiration is op- 
 pressed ; the pulse becomes slower, and all the vital forces seem to 
 concentrate on the organ destined to accomplish the great act of 
 the birth of man : thus the stomach ceases its functions ; nausea, and 
 sometimes excessive thirst, occur ; the face becomes pale, and the 
 skin is covered with a viscid perspiration. The patient experiences 
 a feeling of lassitude ; frequently she is tormented with distressing 
 presentiments ; she weeps, becomes agitated, or remains immova- 
 ble. During this time, other phenomena present themselves. To 
 the slightest pain which she has thus far experienced, now succeed 
 uterine contractions of a more marked character. The cervix be- 
 gins to dilate, and there is a muco-sanguineous discharge ; during 
 the contraction, through the borders of the orifice are felt the mem- 
 branes, which advance under the form of a spherical sac, the di- 
 mensions of which increase with the dilatation, and its form varies 
 according to different circumstances, which I will mention hereaf- 
 ter ; the pains become more and more active, and the interval be- 
 tween them is much shorter ; the patient is irritable, and difficult to 
 govern. Sometimes a chill, with chattering of the teeth, precedes 
 the pain ; the pulse is accelerated ; the mouth and tongue are dry ; 
 the teeth and lips become sooty ; vomiting takes place ; the mind 
 wanders, and the woman appears delirious. During the interval 
 between the contractions, the orifice is supple, thick, and rounded ; 
 the membranes do not protrude, but are applied immediately upon 
 the part of the foetus which presents. Each pain brings on the 
 same series of phenomena, until, the dilatation of the cervix being 
 complete, the uterine cavity and vagina form but one uninterrupted 
 canal. Thus terminates the first stage of labour, the most fatigu- 
 ing and protracted, but, at the same time, the least dangerous and 
 difficult. 
 
 Art. III. — Second Period of Labour. 
 At this epoch the woman begins to feel conscious of the impor- 
 tant act that is about taking place. The muscles of the abdomen 
 extend assistance to the uterus ; the woman increases her efforts ; 
 the respiration is hurried and panting; the skin is covered with 
 perspiration ; the pulse becomes quicker and more full. Each con- 
 traction is followed by an interval of calm sufficiently marked, du- 
 
172 PHYSIOLOGICAL PHENOMENA OF DELIVERY. 
 
 ring which the woman, overcome by a desire to repose, falls asleep, 
 but is soon awakened by a recurrence of the pains. Under the 
 influence of these successive contractions, the bag of waters pro- 
 trudes more and more, and, too feeble to sustain the pressure it 
 experiences, it bursts. The liquor amnii now escapes in more or 
 less quantity, and immediately the portion of the fœtus which pre- 
 sents closes up the orifice, especially if it be the head. There now 
 succeeds a calm of short duration, and the uterus seems to repose 
 only to acquire new energy. Soon the contractions recommence 
 with a power and force which they had not previously exhibited ; 
 the fœtus passes the orifice, and penetrates the vagina, which di- 
 lates by degrees in order to receive it, and it soon reaches the floor 
 of the pelvis. During this time, the compression of the crural nerves 
 and some nervous twigs, which pass through the thyroid foramen, 
 occasions cramps and a dragging sensation at the anterior and 
 internal portion of the thighs. 
 
 The pains become more and more violent ; the woman seizes 
 hold of anything that is near her ; she throws herself backward, 
 fixes her feet against the point of support which has been provided 
 for her, takes a deep inspiration, and, drawing in her lips, throws 
 all the muscles of her body into contraction. Much more frequent- 
 ly, however, the cries she utters in consequence of the intensity of 
 the pain nullify a portion of the effect, by the movements of inspi- 
 ration and expiration which they determine. 
 
 The head at each contraction, resting on the perineum, begins 
 to press forward ; at each pain the floor of the pelvis projects 
 more and more ; the anus becomes prominent, and opens ; the 
 vulva also opens, the labia minora separate, and the hair of the 
 child's head is brought to view ; the labia majora become effaced ; 
 the integuments on the superior portion of the thighs also contrib- 
 ute to the enlargement of the vulva, which, forced forward by the 
 head, forms a circular ring, thin especially at its inferior commis- 
 sure, which appears ready to burst. This latter accident would 
 certainly take place if the contraction did not immediately cease ; 
 the head then retires within the excavation ; the perineum returns 
 upon itself; the vulva closes, but the woman experiences constant- 
 ly a feeling of tenesmus in the bladder and rectum, which torments 
 her with an incessant desire to void her urine and fasces, and causes 
 her to bear down ; also, although she does not experience pain, yet 
 she frequently makes an effort to expel the child ; finally, after a suc- 
 cession of contractions and intervals of calm necessary to habitu- 
 ate the maternal organs to the excessive dilatation they experience, 
 the head, which advances gradually at each contraction, and retires 
 a little during the moment of calm, is pushed forward by a strong 
 expulsive pain, which draws a shriek from the woman, and passes 
 the tuberosities of the ischium ; but it is arrested for some time by 
 the soft parts, and finally clears them. Ordinarily the trunk fol- 
 lows the head immediately ; sometimes, however, it is not expelled 
 for some seconds afterward. 
 
PHYSIOLOGICAL PHENOMENA OF LABOUR. 173 
 
 Art. IV. — Duration of Labour. 
 
 The duration of labour is extremely variable, depending upon 
 climate, the degree of civilization, and constitution of the woman ; 
 it is more protracted in a primipara, on account of the resistance 
 of the perineum ; but the progress of age does not exert on its du- 
 ration the detrimental influence supposed by most accoucheurs, 
 even in a primipara. 
 
 In a word, the numerous observations made by travellers, and 
 the experience of every day, prove, in the first place, that the fa- 
 cility of childbirth is in an inverse ratio to the state of civilization ; 
 and, secondly, that the mean duration of labour in our climate is 
 from eight to ten hours. 
 
 The numerous circumstances capable of varying the epoch of 
 delivery may be easily appreciated ; we may predict the probable 
 duration of labour by the degree of dilatation and suppleness of 
 the cervix, its hardness and resistance ; by the frequency, intensi- 
 ty, and prolonged character of the pains ; by the greater or less 
 resistance of the perineum and vulva. But, whatever may be his 
 skill, the accoucheur should never attempt to state exactly the time 
 at which delivery will take place, for fear of exposing himself to 
 error. In a word, there is nothing certain as to the progress of the 
 dilatation, nor is there any regularity in the succession of the con- 
 tractions ; and I have frequently known labours, which experi- 
 enced persons have supposed near their termination, become pro- 
 longed far beyond the period they had imagined. 
 
 Art. V. — Physiological Phenomena of Labour. 
 The physiological phenomena of labour, of which I have just 
 presented a condensed description, do not always proceed with 
 regularity ; numerous exceptions might be noted, especially as re- 
 gards the principal of these phenomena, such as uterine contrac- 
 tion or pain, dilatation of the cervix, muco-sanguineous discharge, 
 and the formation and rupture of the membranous sac. 
 
 § 1. Pain or Contraction. 
 In obstetric language, we employ as synonymous the words pain 
 and contraction, because, in most women, the pain is caused by the 
 contraction, and is inseparable from it. However, every contrac- 
 tion is not productive of pain ; and we must not confound cause 
 and effect ; for we see some women bring forth their children al- 
 most without pain, and yet, as there was expulsion, there must 
 have been uterine contraction. Among other examples, I may 
 mention that of a young primipara, aged sixteen years, whose 
 vagina was separated by a partition pierced by a small opening, 
 and of which M. Dubois requested me to make a drawing, in or- 
 der that the student might have a precise idea of it. (See article 
 Dystocia, Deformities of the Vagina.) She was awakened by slight 
 pains at four o'clock in the morning, and was delivered alone at 
 six, without demanding any assistance. 
 
174 PHYSIOLOGICAL PHENOMENA OF DELIVERY. 
 
 As the contraction does not always occasion pain, so, in like 
 manner, the vivacity of the pain does not always enable us to meas- 
 ure the force of the contraction ; for some women, very sensitive, 
 complain of great pain when the contractions are quite moderate. 
 
 A. Character of the Contractions. — The pains commence in the 
 lumbar region, encircle the pelvis, and terminate sometimes in 
 front, and sometimes on the fundament, occasioning a desire to 
 pass the faeces. They are accompanied by a hardening and prom- 
 inence of the abdomen ; if the finger, as has already been observed, 
 be applied to the orifice, it will be found dilated, and the mem- 
 branes protrude. The uterine souffle becomes suspended, but the 
 pulsations of the heart preserve their integrity. 
 
 Sometimes these pains are only felt in the lumbar and sacral re- 
 gions ; the pains in the loins, to use the common expression, are 
 much more distressing than the others, and have a less marked in- 
 fluence on the labour. It is impossible to state the particular pe- 
 riod during which they occur ; I have observed them at all the pe- 
 riods ; but it is certain that they depend on the great sensibility of 
 the orifice, which receives nerves only of animal life, through the 
 lumbar and hypogastric plexuses. 
 
 The pains have received different names, according to the pe- 
 riod of labour to which they appertain. 
 
 The first, those which accompany the precursory phenomena of 
 labour, are called cutting pains ; they are marked by a distinct in- 
 terval of labour, and, in general, possess but little interest. 
 
 The second, stronger and nearer together, and which are not 
 separated by a complete calm, are called preparative, because they 
 determine the dilatation of the orifice. Finally, they soon take the 
 name of expulsive, and just at the termination of labour they are 
 called conquessant. 
 
 B. Seat of the Pain. — Some authors contend that the seat of the 
 pain is exclusively in the neck of the uterus, because this portion 
 is supplied with nerves from the system of animal life. Others 
 suppose that the body of the uterus is also capable of transmitting 
 to the nervous centre the pain which results from its contraction. 
 M. P. Dubois has united these two opinions, and admits that the 
 pain is produced by the contraction of the whole organ, adding, 
 however, that at the commencement of labour the dilatation of 
 the neck is the principal cause of this pain ; that later, it appears to 
 be specially due to the compression of the body ; and that, at the 
 last moment of expulsion, the compression of the vagina, the ex- 
 cessive dilatation of the vulva and perineum, give to these pains a 
 peculiar character, which the preceding ones did not possess. 
 
 The calm or relaxation which is observed between each con- 
 traction is the result of that law which is found to govern the or- 
 ganism, in virtue of which a contraction is not permanent, and is 
 interrupted by fatigue, in order that it may be followed by an in- 
 terval of calm, which permits it to preserve its activity. 
 
PHYSIOLOGICAL PHENOMENA OF LABOUR. 175 
 
 § 2. Dilatation of the Orifice. 
 
 The phenomena of dilatation are not the same in primiparse and 
 in women who have already had children. In primiparse, the in- 
 ternal orifice is closed, thin, and sharp, and requires more or less 
 time for it to acquire the degree of dilatation present in a woman 
 who has borne children, and in whom, before labour commences, 
 the orifice is already open. Then, from this moment, in both, the 
 dilatation is gradual ; slow until it equals in extent a two-shilling 
 piece, it then proceeds much more rapidly, and particularly at the ex- 
 pense of the anterior lip, which thickens and forms a pad, which is 
 felt between the head of the foetus and the lower portion of the 
 symphysis pubis. The state of relaxation or rigidity of the neck, 
 the presenting portion of the foetus, the period of labour at which 
 the membranous sac ruptures, will all have an influence on the 
 progress of dilatation. In fine, irregularity in the uterine contrac- 
 tions, or the pathological contractions, as M. P. Dubois calls them, 
 and of which I shall speak more in detail hereafter, may, much 
 more than the obliquities of the uterus, prolong this dilatation. 
 
 It is easily understood how the rigidity or relaxation of the ori- 
 fice may influence the dilatation, and why the dilatation will take 
 place more rapidly in a presentation of the vertex, which, by its 
 form, engages easily in the orifice, than in a presentation of the 
 shoulder, when the part remains a long time high up, and does not 
 press upon the orifice Until a later period. So, also, if the mem- 
 branous sac be prematurely ruptured, its aid in dilating the orifice 
 will be lost. The causes, therefore, of dilatation of the neck of the 
 womb are uterine contraction, descent of the membranous sac, and 
 the presenting portion of the foetus. 
 
 § 3. Muco-sanguineous Discharge. 
 The mucous discharge is a secretion from the womb and vagina, 
 which takes place at the time of labour, and sometimes before ; it 
 is mixed with blood proceeding from the slight laceration of the 
 orifice during its dilatation, and particularly from the rupture of the 
 small vessels which, passing from the internal surface of the ute- 
 rus, distribute themselves on the membranes ; and, finally, from the 
 separation of a small portion of the placenta. 
 
 § 4. Membranous Sac. 
 
 In proportion as the cavity of the uterus becomes smaller in 
 consequence of the contractions, the amniotic fluid, in gaining the 
 point of the uterus offering the least resistance, that is to say, the 
 neck, pushes before it the membranes, and in proportion as the or- 
 ifice dilates, the membranes protrude so as to constitute the bag of 
 waters ; and, as the cavity of the ovum is not distended by the 
 liquor amnii, a portion of this fluid may pass from it in consequence 
 of the contraction of the uterus. And it is not necessary, in order 
 to explain this phenomenon, to admit the extensibility of the mem- 
 branes, or the transudation of the liquid from the cavity of the 
 
176 PHYSIOLOGICAL PHENOMENA OF DELIVERY. 
 
 ovum. The form of this bag undergoes no appreciable change in 
 configuration so far as the orifice is concerned, but it varies ac- 
 cording to the portion of the foetus which presents. 
 
 (Fig. 82.) 
 
 Thus, in the presentation of the vertex, it is flat ; the membranes 
 are almost applied to the head of the fœtus, and between them and 
 the head there is but a small quantity of fluid. 
 
 (Fig. 83.) 
 
 In the presentation of the face and of the pelvic extremity (fig. 
 83), the sac becomes elongated, and contains much more liquid. 
 
 Division of the Ovum. — When the dilatation is complete, and 
 often even when the neck measures only eighteen to twenty lines 
 in diameter, the membranous sac is ruptured under the influence of 
 an energetic contraction, sometimes with a sound, sometimes with- 
 out any apparent indication. 
 
 A. Premature Rupture. — The rupture of the sac may be prema- 
 ture ; it may take place before any uterine contractions have been 
 perceived, or during the first sensible contractions, and it is gener- 
 ally supposed that this occurrence is followed by serious conse- 
 quences in all cases. I am of opinion that authors have exagger- 
 ated the unfavourable influence of this accident upon labour; it is 
 true, however, that in presentations which do not completely close 
 up the orifice, the escape of too much liquor amnii will render the 
 labour more long and difficult, and especially dangerous for the 
 child, since it ceases to be protected during the contractions by a 
 layer of fluid interposed between it and the uterus. But in pre- 
 sentations of the vertex, this unfavourable influence is scarcely 
 felt in the majority of cases ; I will go farther, and remark, that 
 frequently this premature rupture permits the uterus, when it is 
 too much distended, to return upon itself, and thus favours the con- 
 tractions. 
 
 B. Tardy Rupture. — The density of the membranes, and the 
 
PRESENTATIONS AND POSITIONS OF THE FŒTUS. 177 
 
 presence of the head of the fœtus, which sometimes opposes the im- 
 pulsion of the fluid, will cause a delay in the rupture of the sac. 
 
 C. Rupture above the Orifice. — The rupture of the sac above the 
 orifice is favourable to the retention of the fluid. It occasionally 
 happens in this case, that a portion of the sac ruptured above the 
 orifice, and separated from the internal surface of the uterus, accom- 
 panies the foetus in its expulsion, and covers its head ; it is then 
 said that the child is born with a caul ; but it is difficult to imagine 
 that the child could be thus expelled without previous rupture of 
 the sac. This can only happen when the foetus has not attained 
 the full term of its development. In similar circumstances, I have 
 sometimes seen the sac pushed forward by the head of the child 
 even into the vagina, the ovum having remained thus far intact ; 
 but at this period the sac became ruptured. It will be readily con- 
 ceived that this propulsion of the membranes may determine seri- 
 ous results, such as the premature separation of the placenta, hem- 
 orrhage and its consequences. 
 
 D. The Point at which the Sac is ruptured. — The rupture of the 
 sac may take place in the centre, or in some point remote from the 
 orifice. In this latter case, after the escape of a small quantity of 
 fluid, the head closes up the orifice, and the inferior portion of the 
 sac fills again with liquid, and forms what is termed a supernumer- 
 ary bag : this is of rather common occurrence. 
 
 E. Escape of the Fluid. — As soon as the sac is ruptured, all the 
 liquid it contains escapes ; but the head of the child then closes 
 the orifice, and prevents, for the time, the flow of the remaining 
 portion of the liquor amnii. Soon, however, new contractions suc- 
 ceed, and then the head, slightly raised up by the fluid, allows a 
 small quantity to escape, and this occurs at each pain, as long as 
 the head has not passed the orifice. 
 
 In the flat sac, the quantity of fluid that escapes is small, and the 
 uterus thus not being permitted readily to return upon itself, the 
 labour is somewhat retarded. In this case, it will suffice to raise 
 gently the head of the foetus, which will allow an additional quan- 
 tity of fluid to pass out, and the contractions will then become 
 more effective. In the other variety of sac, the liquid escapes in 
 great abundance and constantly, especially if the shoulder or feet 
 present. The flow is less when there is a complete pelvic pre- 
 sentation. 
 
 Art. VI. — Presentations and Positions of the Fœtus. 
 
 The foetus is expelled in virtue of certain laws, which vary ac- 
 cording to the presentations and positions it affects at the superior 
 strait. The presentation is the presence of some particular part of 
 the foetus at the upper strait ; the position is the relation which the 
 part bears to the different points of the strait. 
 
 Before the time of Solayres, practitioners never attempted to do 
 more than ascertain the presentations ; it was he, and his pupil 
 Baudelocque, who first classified the positions. But they suffered 
 themselves to exaggerate a good principle. Thus, Baudelocque, 
 
178 PHYSIOLOGICAL PHENOMENA OF DELIVERY. 
 
 predicating on the fact that all parts of the foetus could be felt at 
 the uterine orifice, admitted twenty-two presentations ; on the same 
 principle, and supposing that each presentation might be in rela- 
 tion with the various points of the upper strait, he admitted sev- 
 enty-four positions. However, notwithstanding this great number 
 of presentations and positions, he has not been true to his principle 
 in admitting only twenty-two presentations and seventy-four posi- 
 tions ; for on the foetus we may distinguish more than twenty-two 
 principal points, and around the superior strait there are a thou- 
 sand points with which each presentation may be in relation : he 
 therefore felt the necessity of limiting himself to a certain number 
 of presentations and positions ; but this limit has not been as com- 
 plete as it might have been. 
 
 Authors soon discovered that these subdivisions were useless in 
 practice, and, moreover, difficult to be remembered by the pupil ; 
 they therefore endeavoured to simplify this classification. 
 
 Madame Lachapelle, MM. Naegele, Stoltz, A. Dubois, and P. 
 Dubois, have successively improved this important part of the ob- 
 stetric art, and have thus rendered a signal service to the science, 
 and especially to the students. I shall not contrast the ancient 
 classifications and those which followed them, but shall content 
 myself simply with stating that proposed by M. P. Dubois, for it 
 embraces all the successive improvements introduced since the 
 time of Baudelocque. 
 
 § 1. Presentations. 
 
 The principle with which Baudelocque started, that all the parts 
 of the foetus at term can be felt at the orifice of the uterus, if it can 
 be admitted theoretically, will not, certainly, be recognised in prac- 
 tice ; for certain portions of the foetal surface have never presented 
 directly in a foetus at the full period. Madame Lachapelle, in forty 
 thousand cases, never met with them. Such are the portions of 
 the dorsal region, from the first dorsal vertebra to the last lumbar ; 
 so, also, the anterior region, from the neck to the umbilicus, and the 
 lateral regions of the neck. Hence the necessity of admitting in 
 the classification those regions of the foetus which alone may oc- 
 cupy the superior strait. Again, certain presentations, even among 
 those which exist from the commencement of labour, soon disap- 
 pear to give place to others, which continue during the whole de- 
 livery. M. P. Dubois, therefore, has admitted real presentations 
 and their varieties. 
 
 For this purpose he has divided the foetus into three principal 
 regions, which may present at the upper strait, the cephalic ex- 
 tremity, the pelvic extremity, and trunk. 
 
 But the head may present flexed or extended ; it is, therefore, 
 necessary to distinguish a presentation of the vertex and a presen- 
 tation of the face. 
 
 The vertex does not always present directly ; it may be some- 
 what inclined : a parietal protuberance, or even a portion near the 
 
PRESENTATIONS AND POSITIONS OF THE FŒTUS. 179 
 
 ear, may occupy the superior strait. Variety of Parietal Presen- 
 tation, two in number. 
 
 The vertex may be very much flexed, occipital variety ; it may 
 not be flexed, frontal variety. 
 
 There are, therefore, one full presentation of the vertex, and four 
 varieties of presentation. 
 
 It is the same with the face, which has a frontal variety when 
 the os frontis presents ; two malar varieties when one or other 
 cheek occupies the strait ; a mento- cervical variety when the chin 
 and a small portion of the neck present. 
 
 When the pelvic extremity presents, the legs are habitually 
 flexed on the thighs, and the thighs on the abdomen ; but these 
 parts may be separated : thus the thighs, the feet, or the knees may 
 present alone. But as these various circumstances cause no change 
 in the expulsion, they should not be considered distinct presenta- 
 tions, but merely different modes of one and the same presentation ; 
 and we admit, then, but one presentation for the pelvic extremity. 
 
 Moreover, the pelvic extremity, whether it presents entire or 
 not, does not always occupy the strait directly. It may, like the 
 vertex and face, be inclined in four different directions : two iliac 
 varieties, when one or other hip presents ; a sacral variety, when 
 the sacrum presents ; an anterior variety, when the pelvic extrem- 
 ity presents by the front of the tibias, if it be complete, or by the 
 posterior portion of the thighs,, if the breech alone descends. 
 
 It must be remembered that these varieties of presentation can- 
 not be recognised except in the complete presentation and in those 
 of the breech ; the knees and feet being much too movable to allow 
 the accoucheur, by their direction, to appreciate the inclinations of 
 the foetus. 
 
 Madame Lachapelle had long since remarked that, in presenta- 
 tions of the trunk, the sides only of the trunk occupied the supe- 
 rior strait ; and, after her example, M. P. Dubois has divided the 
 trunk into two lateral halves, which will give the two presenta- 
 tions ; one for the right lateral region, the other for the left lateral 
 region. In the full presentation, the shoulders and acromion oc- 
 cupy the centre of the superior strait ; but these presentations may 
 be like the others, full or irregular. Thus, a small portion of the 
 back may be felt at the orifice at the same time with the shoulders, 
 dorsal variety ; a small portion of the chest, sternal variety ; a 
 small portion of the inferior part of the neck, cervical variety ; the 
 portion of the side on which rests the elbow of the fœtus, cubital 
 variety ; and irregular presentations, which, like corresponding 
 ones of the vertex, are included in the presentation of the right and 
 left shoulders. 
 
 In a word, M. P. Dubois has admitted five full presentations, and 
 four varieties of presentations for each full one. But he has not 
 arranged these last in the same class with the full presentations : 
 1st. Because they only exist at the commencement of labour ; 2d. 
 Because they do not in any respect modify the mechanism of spon- 
 taneous delivery; 3d. Because they scarcely alter the principal 
 
180 PHYSIOLOGICAL PHENOMENA OF DELIVERY. 
 
 manipulations. But we must not forget them in practice, because 
 they are sometimes felt at the orifice, and because, in certain cases, 
 rare it is true, they render it necessary for the accoucheur to inter- 
 fere, in consequence of their not changing to the full presentation. 
 The mechanism of labour will make this better understood. 
 
 Positions, 
 
 The older accoucheurs, as I have already remarked, predicating 
 on the fact that the presentations may be in relation with all the 
 points at the upper strait, admitted a great number of positions, in 
 each of which -the mechanism of delivery varied. 
 
 M. Naegele and M. P. Dubois, on the ground that delivery is ac- 
 complished according to the same laws, in the majority of cases, 
 whatever may be the position, have divided the pelvis into two 
 lateral halves, and have admitted for each presentation only two 
 positions, a left and a right. But as the parts which serve as the 
 indicating point in the presentation, the occiput, for example, in the 
 vertex, may correspond with all the points of these two halves, we 
 add to this definition of left or right occipito-iliac position, the words 
 anterior, transverse, or posterior, as the occiput is in front, trans- 
 versely, or posteriorly. These varieties of position have only a 
 secondary influence in practice, since the delivery, as will be seen, 
 is the same in each presentation, no matter what the position. But 
 it is well to remember them, for they serve to explain certain rare 
 anomalies in the movements of the head during its passage through 
 the pelvic canal, and their exact knowledge guides the accoucheur 
 in cases in which it becomes necessary to interfere. 
 
 MM, Nœgele and P. Dubois have also admitted for the face 
 two positions, right mento-iliac and left mento-iliac. The chin at 
 the right or left, always with the same varieties of anterior, trans- 
 verse, or posterior. There are likewise two positions for the pel- 
 vic extremity, the left sacro-iliac and right sacro-iliac, anterior, 
 transverse, or posterior. 
 
 Two positions for the left lateral region of the trunk or left 
 shoulder, left cephalo-iliac, right cephalo-iliac. The head is to the 
 left or to the right. And two for the right lateral region, left cephalo- 
 iliac, right cephalo-iliac, accordingly as the head is to the left or 
 to the right. But we do not meet, in these presentations of the 
 trunk, with the same varieties of position ; their situation is almost 
 always transverse. 
 
 All these presentations and positions are not equally frequent, 
 nor equally favourable to the mother and child. In the first three 
 spontaneous termination is usual ; in the presentations of the trunk, 
 on the contrary, this spontaneous termination is of rare occurrence. 
 I have taken nearly all I have said with regard to the classifica- 
 tion from the learned lectures of M. P. Dubois. I am indebted to 
 him, also, for the elements of the following synopsis : 
 
PRESENTATIONS AND POSITIONS OF THE FŒTUS. 
 
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182 PRESENTATION OF THE VERTEX. 
 
 TITLE II. 
 
 PRESENTATION OF THE VERTEX, OR OF THE HEAD FLEXED. 
 
 The presentation of the vertex is much more frequent than all 
 the other presentations combined.* Thus, M. P. Dubois had nine- 
 teen hundred and thirteen presentations of the vertex in two thou- 
 sand and twenty cases of delivery. (For the cause of this fre- 
 quency, see Attitude of the Fœtus at Term). Moreover, he has 
 shown that, in these nineteen hundred and thirteen presentations 
 of the vertex, the occiput was found on the left thirteen hundred 
 and seventy-seven times, thirteen hundred and fifty-five times in 
 front (left occipito-iliac, or left anterior or cotyloid position), and 
 twelve times posteriorly (left posterior occipito-iliac, or left sacro- 
 symphysien). Finally, in these nineteen hundred and thirteen pres- 
 entations of the vertex, he has found five hundred and forty-six 
 right occipito-iliac positions, in four hundred and ninety-one of 
 which the occiput corresponded with the right sacro-iliac symphy- 
 sis, and in fifty-five only was the occiput turned forward behind 
 the right cotyloid cavity. 
 
 M. Naegele, in one hundred presentations of the vertex, found 
 the occiput seventy times to the left and in front, and thirty times 
 posteriorly and to the right. These results are in every respect 
 conformable to those obtained by M. P. Dubois, and the opinion 
 now generally admitted is, that the head, when it presents, assumes 
 in preference the diagonal position, the occiput in front and to the 
 left, or posteriorly and to the right ; that the right anterior occip- 
 ito-iliac, and left posterior occipito-iliac, that is to say, the two op- 
 posite positions of the other diagonal, are very rare, and particu- 
 larly the left position, which is itself much less frequent than the 
 transverse positions ; at least such is the case if my own observa- 
 tions and those of Madame Lachapelle be correct, f 
 
 * To afford the pupil some idea of the relative frequency of vertex presentations, I subjoin 
 precise calculations made on this subject by Madame Lachapelle. Of 15,652 children born 
 during a period of nine years, 14,677 presented the vertex, 349 the breech, 235 the feet, 72 
 the face, 68 one or other shoulder, and 2 the knees. It will thus be seen that the presenta- 
 tions of the vertex formed nearly 15-16ths of the whole.— Ed. 
 
 t There must be some error here. If Dr. Chailly makes a faithful record of the observa 
 tions of Naegele and M. P. Dubois in reference to the relative frequency of occiput presenta- 
 tions at the left anterior and right posterior points of the pelvis, these gentlemen must have 
 laboured under some miscalculation ; for their tables are not only at variance with those of 
 the most accurate of their predecessors, but they will, I think, be found to differ widely from 
 Nature herself. For example, Naegele, it is said, in 100 presentations of the vertex, found 
 the occiput directed to the left and in front 70 times, and to the right and posteriorly 30 
 times. According to Dr. Chailly, in 1913 presentations of the vertex, M. P. Dubois has found 
 the occiput situated at the left and in front 1377 times, and 491 times to the right and pos- 
 teriorly. And Dr. Chailly, moreover, adds, that the opinion now generally admitted is, that 
 the head, when it presents, has the occiput either in front and to the left, or posteriorly and 
 to the right. This statement is undoubtedly erroneous : so far from being the admitted opin- 
 ion, it will be seen that, in the presentations of the vertex at the superior strait, the occiput 
 will be found at the left and in front of the pelvis some seven to eight times more frequently 
 than at the right and anterior portion ; and that these anterior and lateral positions of the oc- 
 
PRESENTATION OF THE VERTEX. 183 
 
 Why is the head found more frequently in the left diagonal, the 
 occiput to the left and in front, or to the right and posteriorly ? 
 The situation of the rectum, and its repletion during the latter 
 periods of pregnancy, appear to be the cause of this preference. 
 The right diagonal diameter is diminished by the development of 
 the rectum, and the head finds itself forced to seek the diameter 
 which presents the greatest space for its descent, and, in this case, 
 it is the left diagonal diameter. 
 
 Finally, it appears to me impossible to say to what causes is to be 
 attributed the great frequency of the anterior left occipito-iliac po- 
 sition ; and I cannot admit that it depends on the same circumstan- 
 ces as those which authors have regarded as determining the pre- 
 sentation of the vertex, namely, the weight of the back of the fœ- 
 tus ; for this weight would act much more frequently on the right 
 
 ciput occur from 80 to 100 times more frequently than the posterior and lateral. I cannot 
 account for this discrepancy between the calculations of Dubois and Naegele, and those of 
 Madame Lachapelle and Baudelocque, to say nothing of numerous other observers ; and I 
 wish especially to direct the attention of the student to the fact of this error, as laid down by 
 Dr. Chailly, because it involves a most important practical direction, to which allusion shall 
 be made presently. Madame Lachapelle gives the following table as the result of her expe- 
 rience in the Maternité at Paris : In 15,652 cases, 11,634 presented the occiput in front and 
 to the left of the pelvis ; 2853 presented the occiput in front and to the right ; 112 posteriorly 
 and to the right, and 78 posteriorly and to the left. In not one of these instances was there a 
 complete transverse position of the head. Now, what is the experience of Baudelocque on 
 this subject, a man whose opportunities for accurate observation were most ample? In 
 10,322 cases, the occiput was to the left and anterior portion of the pelvis 8522 times ; to the 
 right and anterior portion, 1754 times ; to the right and posterior portion, 25 times ; to the left 
 and posterior portion, 19 times. I might present the pupil with other tables, made under cir- 
 cumstances to forbid error, all showing the same result ; but it can scarcely be necessary. I 
 must repeat, I cannot account for the statement of M. P. Dubois, usually so accurate and just 
 in his opinions. 
 
 Indeed, if his statements were to pass without notice, it might give rise to serious conse- 
 quences both to mother and child. For example, the depth of the anterior wall of the pelvis, 
 consisting of the length of the symphysis pubis, is about one third the length of the posterior 
 wall, consisting of the length of the sacrum and coccyx. Now, when the occiput is situated 
 at either the left or right acetabulum, the head, before being delivered, will have to traverse 
 only one third the distance (the length of the anterior wall) that it will be required to do 
 when situated at either the left or right sacro-iliac symphysis, for then it must travel the 
 whole length of the sacrum and coccyx. Therefore, all things being equal, when the occi- 
 put is at one of the anterior and lateral points of the pelvis, the labour will be two thirds 
 shorter than when it is situated at one of the posterior and lateral points. Again, when the 
 occiput is in one of these latter positions, it sometimes occurs that nature spontaneously 
 brings it to one of the anterior and lateral points during the movement of rotation, and thus 
 overcomes all difficulty ; but this is not the course ordinarily pursued by nature in these pos- 
 terior positions of the occiput (as Dr. Chailly alleges — see mechanism of natural delivery 
 in the right posterior occipito-iliac position), but it constitutes an exception ; and in these posi- 
 tions, the occiput, instead of being under the symphysis pubis, is found in the concavity of 
 the sacrum. Nature, by the very fact that she sometimes spontaneously changes the pos- 
 terior positions of the occiput to the anterior, clearly indicates what should be the course 
 pursued by the accoucheur under these circumstances. He cannot have a more faithful 
 guide than nature — she is full of wisdom and benevolence — always vigilant and prompt, 
 when not circumvented by difficulty, in overcoming obstacles to the free and safe passage of 
 the child. Now, the course I would seriously recommend to the pupil is this ; it is the 
 practice inculcated by Baudelocque, Capuron, &c, and I have availed myself of it with the 
 best results : When he arrives at the bedside, and, in making a vaginal examination, ascer- 
 tains 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 dilated to permit 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 right acetabulum ; for ex- 
 ample, 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 effected, nature will usually be competent to accomplish the delivery, and the 
 foetus will not be exposed to the severe hazard of a protracted birth. Indeed, if this change 
 be not made, it will often be necessary to resort to the forceps to terminate the delivery ; and 
 if the labour be submitted to nature, the child will frequently be sacrificed. — Ed. 
 
184 PRESENTATION OF THE VERTEX. 
 
 than on the left, the inclination of the uterus being much more 
 marked on the right side, and I have just remarked that the right 
 anterior occipito-iliac positions are rather rare. I will content my- 
 self with admitting the fact, without endeavouring to ascertain the 
 cause, the nature and extent of this work not permitting me to pur- 
 sue researches purely theoretical. 
 
 § 1 . Diagnosis of the Presentation. 
 
 At an advanced period of pregnancy, and before the neck of the 
 uterus will allow the introduction of the finger, it is frequently pos- 
 sible to ascertain the presentation by the touch. The vertex, for 
 example, adapting itself by its form to the superior strait, descends 
 by pushing before it the inferior segment of the uterus ; there is 
 then felt through the anterior wall of this segment a regular, solid 
 tumour, which is raised by means of the finger with the more 
 difficulty as pregnancy is farther advanced (see Diagnosis of 
 Pregnancy, Eighth and Ninth Month) ; and the sensation is per- 
 ceived so usually in this presentation when the pelvis is well formed, 
 and no other cause prevents the head from descending, that, when 
 it is not perceived, we have reason to apprehend a presentation 
 less favourable than that of the vertex: either the face, pelvic ex- 
 tremity, or trunk. 
 
 These parts, by their irregular forms, cannot, in fact, descend 
 prematurely at the superior strait, and be felt there, as the vertex is. 
 The accoucheur, in this case, should watch attentively the com- 
 mencement of the labour, in order to remedy at once the accidents 
 which may manifest themselves. 
 
 After the labour has fairly begun, the finger introduced into the 
 orifice more or less dilated may very readily recognise this pre- 
 sentation ; before the rupture of the membranes, there is felt at the 
 superior strait a large, smooth, solid tumour, exhibiting an elastic, 
 bony resistance, on which are observed membranous spaces of 
 various forms, representing the sutures and fontanelles. After the 
 rupture of the membranes, these characters are still more evident. 
 Yet, most usually the sutures lose their membranous appearance in 
 consequence of the overlapping of the bones of the scull, and pre- 
 sent to the finger of the accoucheur the feeling of longitudinal 
 prominences. This fact depends on the compression produced on 
 the head in descending. 
 
 § 2. Diagnosis of the Position. 
 In order to ascertain the position, it will be necessary to know 
 the relation of the fontanelles with the different points at the supe- 
 rior strait. Before the rupture of the sac, it is sometimes pos- 
 sible to recognise the position, but often this cannot be done ; 
 for most frequently the diagnosis cannot be arrived at until after 
 the rupture of the membranes. When this takes place, the ac- 
 coucheur seeks with his finger for the sagittal suture, which trav- 
 erses the superior strait diagonally from left to right, or from 
 right to left. This suture terminates at the fontanelles ; so that, 
 
PRESENTATION OP THE VERTEX. 185 
 
 whether the finger passes forward or backward, it will reach one 
 of the two fontanelles, according to the position. I will sup- 
 pose that the finger touches in front and to the left, at the extrem- 
 ity of the sagittal suture, the posterior fontanelle, a slightly mem- 
 branous and triangular space, formed by three prominent angles 
 (the parietal angles and point of the occiput), and three other an- 
 gles (the junction of the two branches of the lamdoidal suture, 
 and the extremity of the sagittal suture ) ; this will be the left an- 
 terior occipito-iliac position ; but in order to be positive that we 
 feel the posterior and not the anterior fontanelle, we must endeav- 
 our to reach the other fontanelle, which is behind and to the right. 
 In order to do this, the finger is made again to pass along the sa- 
 gittal suture posteriorly, and the anterior fontanelle will be felt — a 
 quadrilateral membranous space, formed by four osseous angles, and 
 the junction of four sutures ; this, of course, will remove all doubt 
 as to the nature of the position — the left anterior occipito-iliac. It 
 can scarcely be necessary to add that, in the right posterior occip- 
 ito-iliac position, the situation of the head is inverse ; that the pos- 
 terior fontanelle will be felt posteriorly, and to the right ; and that, 
 in following the same course, the occiput being taken as the start- 
 ing-point, we shall be enabled to ascertain the other positions of 
 the vertex. 
 
 § 3. Difficulty of Appreciation. 
 
 When the vertex has been for some time exposed to the uterine ef- 
 fort at the superior strait, the scalp becomes the seat of a sero-san- 
 guineous engorgement, which may be sufficiently marked to form a 
 large sanguineous tumour, which may conceal the characters of 
 the presentation, and much more frequently those of the position. 
 The finger will feel, in this case, a tumour more or less soft, and 
 more or less prominent, which, at first, might be supposed to be 
 the breech, an error which has been committed more than once 
 under these circumstances. But, in carrying the finger under the 
 orifice, we should endeavour to reach a portion of the head, the 
 bony resistance of which will make the diagnosis complete ; we 
 shall then recognise the presentation of the vertex. The position 
 
 (Fiff. 84.) 
 
 Aa 
 
186 PRESENTATION OF THE VERTEX. 
 
 is much more difficult to define in this case ; the engorgement of 
 the scalp sometimes entirely conceals the fontanelles. Happily, in 
 this presentation, delivery being most generally spontaneous, no 
 matter what the position, it will be sufficient to know that the ver- 
 tex presents, and we can then commit the labour to nature. 
 
 A defective ossification (I) in the length of the sagittal suture may 
 be mistaken for a fontanelle, and lead to error as to the direction of 
 the head, especially when it is possible to reach only one of the two 
 real fontanelles. The advanced ossification of the fontanelles, and 
 their disappearance in consequence of the overlapping of the bones 
 at the time of the descent of the head, are also capable of mislead- 
 ing the accoucheur. It is proper, however, to add, that only the 
 posterior fontanelle can lose its character by this overlapping of 
 the bones or the advanced ossification ; while the anterior, which 
 is much larger, preserves almost always, at least in part, its pecu- 
 liar marks. 
 
 Art. I. — Mechanism of Spontaneous Delivery. 
 
 The mechanism of spontaneous delivery is precisely the same in 
 all the positions of the vertex, whether the occiput looks to one of 
 the points of the left lateral half, or of the right lateral half of the 
 pelvis. A slight difference exists, however, between the anterior 
 and posterior positions : in the posterior, the movement of rotation 
 which brings the occiput under the pubes is more extended ; and, 
 moreover, these positions may sometimes, though very rarely, be 
 
 (Fig. 85.) 
 Before Flexion. 
 
PRESENTATION OF THE VERTEX. 187 
 
 converted into the posterior positions.* This exception, however, 
 does not prevent our stating, as a general rule, that natural deliv- 
 ery is effected according to the same laws, whatever may be the 
 point at the superior strait with which the occiput is in contact. 
 
 Thus it will be sufficient to describe this mechanism in the left 
 anterior occipito-iliac position, and in the right posterior occipito- 
 iliac position. 
 
 § 1. Mechanism of Spontaneous Delivery in the Presentation of 
 
 the Vertex, and in the Left Anterior Occipito-iliac Position: 
 
 first Position. — (See Fig. 85.) 
 
 Before the rupture of the membranes, the head is demi-flexed on 
 the chest ; the anterior parietal protuberance is more accessible to 
 the finger of the accoucheur, and appears lower than the posterior, 
 whether this depends on a lateral inclination of the head, deter- 
 mined by the ordinary ante-version of the organ, or on the inclina- 
 tion of the plane of the superior strait. 
 
 The two fontanelles are nearly on the same plane ; however, 
 the posterior is somewhat lower, and the finger reaches it more 
 easily, particularly in this position, in which this fontanelle is situ- 
 ated in front of the pelvis. 
 
 The posterior fontanelle is situated in front and to the left ; the 
 occiput corresponding with the posterior portion of the cotyloid 
 cavity, the anterior fontanelle being in relation with the right sacro- 
 iliac symphysis. It results from this, that the occipito-frontal diam- 
 eter (OF)f and the sagittal suture are parallel to the left oblique 
 diameter, and the bi-parietal diameter is parallel to the right ob- 
 lique diameter.J After the rupture of the membranes, commence 
 the mechanical phenomena of the expulsion of the ovum, which 
 have been divided into five principal periods, in order to facilitate 
 their study. It must not, however, be supposed that these five 
 periods are executed successively with the regularity with which 
 I am about to describe them : often, two or three periods are com- 
 bined ; and, again, a third commences before the entire accomplish- 
 ment of the two first, &c, &c. 
 
 A. First Period, Flexion. — After the rupture of the membranes, 
 the uterine contractions are exerted on the fœtus, compress it, and 
 cause it to descend into the superior strait ; but the head, which 
 presents by a diameter having nearly four inches (O F), experien- 
 ces a certain resistance on the part of the orifice and the soft parts 
 which line the superior strait. It is true that, by the aid of the 
 continued contractions of the uterus, the head may overcome this 
 resistance without changing its situation ; but it will do so much 
 more readily by flexing : thus the head, which presents demi-flex- 
 ed, is solicited to complete its flexion, in order that a more favour- 
 
 * As I have already remarked in a preceding note, Dr. Chailly here mistakes the excep- 
 tions for the rule. — Ed. 
 
 t The diameter which presents is not altogether the occipito-frontal ; it is somewhat less. 
 
 % According to M. Naegele, in consequence of the lateral inclination of the head, these 
 two diameters should not be parallel. 
 
188 PRESENTATION OF THE VERTEX. 
 
 able diameter, the occipito-bregmatic (O B), may replace the oc- 
 cipitofrontal, which is larger, and thus the descent becomes more 
 easy. 
 
 (Fig. 86.) 
 Flexion, First Period. 
 
 This flexion, therefore, favours the descent of the head ; but it 
 may not be accomplished, and yet delivery be effected ; it is use- 
 ful, but not indispensable. Thus, sometimes, in presentation of the 
 vertex, it does not always precede the descent ; sometimes even it 
 fails altogether. Frequently the head presents, at the commence- 
 ment, already flexed. The mechanism of this flexion will be read- 
 ily understood, if it be remembered that the force of the uterine 
 contraction, exerted on the trunk of the foetus through the spinal 
 column, falls on the foramen occipitale, that is to say, nearer the 
 occiput than the chin ; the occiput, in consequence, tends to de- 
 scend, and the chin approaches the chest. Add to this, that the 
 fœtus, which already presents the head demi-flexed on the chest, 
 has exhibited a great tendency to flex itself still more. I shall 
 content myself with this short explanation, without entering into 
 mathematical details, which would only take me from my object. 
 
 After flexion, the relations of the head change : of the two fon- 
 tanelles, which were on the same level and on the same plane, the 
 posterior descends and becomes more accessible, while the ante- 
 rior ascends, and frequently is out of reach. Thus, the accoucheur 
 is surprised at not being able to feel the anterior fontanelle, which 
 he readily recognised at the commencement of the labour. The 
 sub-occipito-bregmatic diameter takes the place of the occipito- 
 frontal, and the head passes the superior strait presenting its small- 
 est diameters. 
 
PRESENTATION OF THE VERTEX. 
 
 189 
 
 (Fig. 87.) 
 Descent. Second Period. 
 
 B. Second Period, Descent. — In proportion as the head descends, 
 its inclination ceases ; the parietal protuberances are on the same 
 plane, and the change in their position is complete when the descent 
 of the head is perfected. The head is always flexed. 
 
 «# . (Fig. 88.) 
 
 Rotation, Third Period. 
 
 C. Third Period, Rotation. — When the head reposes on the 
 floor of the pelvis, the fœtus executes, in totality, a movement of 
 rotation, which carries the occiput under the ischio-pubic branch ; 
 then the sagittal suture becomes parallel to the great diameter of 
 the vulva, the occiput descends along the pubic arch, and the 
 shoulders pass the superior strait. Figure 88 represents this 
 movement. 
 
190 
 
 PRESENTATION OF THE VERTEX. 
 
 D. Fourth Period, Extension. — Now the fourth period commen- 
 ces. The extension, the expulsive force, which, until now, acted 
 upon the occiput, is directed upon the chin, because the posterior 
 portion of the neck, in being placed behind the symphysis pubis, 
 has destroyed, by its resistance, the sum of contractile effort which 
 was exerted upon the occiput ; the chin leaves, little by little, the 
 chest, and passes along the concavity of the sacrum ; we then see, 
 successively, at the vulva the occiput under the pubes, then at the 
 anterior commissure of the perineum (B), the anterior fontanelle 
 (B), the forehead, the nose, and, finally, the chin. The diameters 
 which measure the extension are the sub-occipito-bregmatic (S.o.-B), 
 the sub-occipito-frontal (S.o.-F), the sub-occipito-mental (S.o.-M). 
 
 (Fig. 89.) 
 Extension, Fourth Period. 
 
 In figure 89, the sub-occipito-bregmatic (S.o.-B) is already out 
 of the soft parts. In figure 90, the sub-occipito-frontal (S.o.-F) 
 has just escaped ; and, finally, the head has descended by its sub- 
 occipito-mental diameter (S.o.-M), the chin is out of the soft parts, 
 and the perineum upon the neck of the fœtus. 
 
 E. Fifth Period, Restitution and External Rotation. — As soon 
 as the head has passed the vulva it falls towards the anus, remains 
 a few seconds with its face backward, and then executes a slight 
 movement of rotation, almost imperceptible, which carries the oc- 
 ciput towards the left groin of the mother ; then there is a much 
 more extended movement of rotation, which carries the occiput to- 
 
PRESENTATION OF THE VERTEX. 
 
 191 
 
 .vards the internal portion of the thigh of the same side. The first 
 movement should be called the movement of restitution ; the sec- 
 ond, which has improperly received this name, should be called 
 the movement of external rotation. This suggestion is due to M. 
 Gerdy. In fine, the first of these movements is determined by the 
 necessity which the head feels of resuming its natural relations 
 with the trunk ; it is, however, not constant : the second is nothing 
 more than the external representation of the movement of internal 
 rotation of the shoulders. 
 
 (Fig. 92.) 
 •External Rotation, Fifth Period. 
 
 Although, in the majority of cases, the trunk follows precisely 
 the different movements of rotation executed by the head, yet 
 sometimes, at the moment the occiput is about passing under the 
 pubes in an antero-posterior situation, the shoulders remain slightly 
 diagonal, the neck of the child being somewhat twisted. The 
 head once extended, and freed from the soft parts, and the neck 
 of the child relieved from its torsion, the head resumes its proper 
 relations with the trunk, and the occiput looks to the groin of the 
 mother (movement of restitution). But the shoulders, not being 
 able to pass the inferior strait in this nearly transverse situation, 
 execute a movement of internal rotation, which places them in an 
 antero-posterior direction ; the head follows externally this move- 
 ment, and the occiput becomes in relation with the left thigh (move- 
 ment of external rotation). 
 
 This last movement, however, is often the only one that is appre- 
 ciable ; the first either is not necessary, because the neck of the in- 
 fant has not been twisted, or it passes unperceived, so slight is it 
 when it occurs. 
 
 It is, therefore, in a situation slightly diagonal that, in most cases, 
 the shoulders pass the inferior strait. This rarely occurs when 
 the head is situated in the antero-posterior diameter: the right 
 shoulder is placed under the right ischio-pubic branch, the left in 
 
192 PRESENTATION OF THE VERTEX. 
 
 front of the left sacro-ischiatic ligament, so that their bis-acro- 
 mial diameter is in relation with the right oblique diameter of the 
 inferior strait. The anterior shoulder, according to some, the pos- 
 terior, according to others, descends the first. There is no gen- 
 eral rule with regard to this point ; and it may, moreover, be 
 added, that frequently the two shoulders pass the vulva at the 
 same time. After the passage of the shoulders, the trunk is im- 
 mediately expelled, curving itself on its right lateral region, in or- 
 der to accommodate the curvature of the excavation. 
 
 § 2. Mechanism of Natural Labour in the Right Posterior Occipito- 
 iliac Position : second of M. P. Dubois, fourth of Baudelocque. 
 
 (Fig. 93.) 
 
 In this position, which is the opposite of the preceding, the occi- 
 put is in relation with the right sacro-iliac symphysis. The fore- 
 head is situated behind the left cotyloid cavity ; but the other rela- 
 tions of the head are the same. Thus, the sagittal suture and the 
 occipito-frontal diameter are parallel to the left oblique diameter ; 
 the bi-parietal diameter is parallel to the other right oblique diam- 
 eter. The parietal protuberance, which is in front, appears also 
 lower ; the two fontanelles are nearly on the same plane, but the 
 posterior is much more difficult to reach than in the preceding po- 
 sition, because it is behind ; the anterior, on the contrary, is more 
 readily accessible. I have already remarked that the mechanism 
 of labour in this position is accomplished according to the same 
 laws, in the great majority of cases, as that I have just described. 
 It is composed also of five periods, some of which present pecu- 
 liarities important to note. 
 
 A. First Period, Flexion. — Before, as after the movement of the 
 head, the diameters have the same relations with those of the pel- 
 
PRESENTATION OF THE VERTEX. 
 
 193 
 
 vis as in the preceding case. After flexion, the posterior fonta- 
 nelle becomes more accessible ; the anterior, on the contrary, re- 
 mains less so, but it may be reached by the finger, because it is in 
 front of the pelvis. 
 
 B. Second Period, Descent — Nothing tc^note. 
 
 C. Third Period, Rotation. — The head executes the same move- 
 ment of rotation as in the preceding case, only the rotation is much 
 more extended ; the occiput traverses the whole right lateral half 
 of the pelvis, and it gets under the pubes in order to pass out. 
 
 D. Fourth Period, Extension. — Nothing to note. 
 
 E. Fifth Period, Restitution and External Rotation. — The re- 
 mainder of the expulsion is exactly the same as if the occiput were 
 in front and to the right. 
 
 It is now easy to comprehend this mechanism in the other posi- 
 tions, the right anterior and left posterior occipito-iliac, as also in 
 the transverse positions ; so I shall pass them over in silence. 
 
 § 3. Mechanism of Spontaneous Delivery in the Varieties of Pres- 
 entation of the Vertex. 
 
 Causes of these Varieties. 
 
 I have already remarked, in the classification of the presenta- 
 tions, that these varieties depend on the different inflexions of the 
 head of the foetus on the trunk, and were not determined by the 
 inclination of the organ. Such is the opinion of M. P. Dubois. 
 But, although this is the case in most instances, yet I am satisfied 
 that, under certain circumstances, rare it is true, these inclinations 
 of the head depend on those of the trunk of the fcetus, which has 
 been effected itself by the inclinations of the uterus. 
 
 Thus, taking the frontal variety of the vertex for example, see 
 what would be the condition of the foetus without an inclination 
 of the womb (fig. 94) ; the head not flexed on the trunk, the ante- 
 rior fontanelle felt by the finger, and occupying the centre of the 
 superior strait. 
 
 (Fig. 94.) (Fig. 95.) 
 
 On the contrary (fig. 95), in this variety, caused by an incfina- 
 
 Bb 
 
194 PRESENTATION OF THE VERTEX. 
 
 tion, the head would present flexed, as in the complete presenta- 
 tion of the vertex, and the anterior fontanelle would also be felt 
 in the centre of the superior strait. In a word, the diagnosis of 
 the presentation of the head would be precisely the same in these 
 two cases. 
 
 This distinction is not without profit in practice ; for if, in the 
 immense majority of cases, the varieties of presentations which are 
 not determined by the inclinations become reduced almost always 
 by themselves without the interference of art, it is not so with those 
 due to these inclinations or obliquities. In this case, the uterus 
 should be supported, and brought to its natural position during 
 the contraction ; in this way. two objects will be attained : 1st, the 
 contractions of the uterus will be in the direction of the axis of the 
 superior strait ; 2d, the portions of the foetus which are oblique will 
 be placed in relation with this axis, and if the head follows the 
 righting of the trunk, it will present, after the reduction, with its 
 most favourable diameters. (See Obliquities of the Uterus during 
 Labour.) 
 
 Parietal Varieties. 
 
 The parietal varieties of presentation are two in number ; one 
 for the left parietal bone, the other for the right. 
 
 A. Diagnosis of the Parietal Varieties. — At the superior strait, 
 a tumour is felt, which has all the characters of the vertex ; but 
 the finger passes directly upon a more solid and prominent portion, 
 which is the parietal protuberance (1). The sagittal suture (2) is 
 quite under the pubes, when the posterior parietal protuberance, 
 which is behind, occupies the centre of the pelvis ; this is repre- 
 sented in the subjoined figure. This suture is in the concavity 
 of the sacrum when the anterior parietal protuberance presents. 
 
 (Fig. 96.) 
 
 
 E. Diagnosis of the Positions in these Varieties. — It is precisely 
 the same as in the positions of the full presentation. In a word, 
 whether the head be inclined to the right or the left, the occiput 
 will be in relation with all the points of the superior strait. 
 
PRESENTATION OF THE VERTEX. 195 
 
 C. Mechanism of Expulsion. — The mechanism of expulsion is 
 likewise the same as in the presentation of the vertex ; only there 
 is a period which precedes all the others, the period of reduction 
 of the head to its proper position. After the reduction, the pres- 
 entation of the vertex is complete, and the expulsion is accom- 
 plished as if the head had not presented in the first instance ob- 
 liquely. 
 
 This occurs in most cases ; sometimes, however, the head may 
 descend inclined, without any previous change ; the labour is then 
 composed of five periods, as in the presentation of the vertex. After 
 the descent, the head is righted in making the movement of exten- 
 sion. The vertex, however, has been delivered without being 
 righted. Nature will almost always suffice, and it is very rare, 
 as I shall have occasion hereafter to remark, that art is obliged to 
 interfere in these parietal varieties. 
 
 I have never known but one unreduced parietal variety to pre- 
 vent the descent of the head. The records of the midwifery clin- 
 ique of Paris do not contain one example of necessity for inter- 
 ference ; and even in three cases in which the ear was felt at the 
 mouth of the uterus, the delivery terminated spontaneously, with- 
 out any change in the head. I might also mention a number ot 
 cases of parietal varieties, in which the head became righted be 
 fore its descent ; this is not uncommon. 
 
 Frontal Variety. 
 
 This variety of presentation of the vertex results from the head 
 not presenting flexed, although it may not be extended, as occurs 
 in the presentation of the face. 
 
 A. Diagnosis of the Presentation. — The finger arrives immediate- 
 ly at the anterior fontanelle, which occupies the centre of the supe- 
 rior strait, and it sometimes even reaches the root of the nose ; but 
 the posterior fontanelle cannot be felt, unless it should correspond 
 with the anterior half of the pelvis, and even in this case it is diffi- 
 cult to reach it. The diameter which presents is nearly the occip- 
 itofrontal ; it measures four inches. For the rest, all the other 
 characters are those of the vertex presenting demi-flexed. 
 
 (Fig. 97.) 
 
 B. Diagnosis of the Position. — The same as in the full present- 
 ation of the vertex, but it is more difficult to ascertain, in conse- 
 quence of the elevation of the posterior fontanelle. 
 
196 PRESENTATION OF THE VERTEX. 
 
 C. Mechanism of Expulsion. — The mechanism of expulsion, m 
 this case, is composed of five periods, as in the full presentation, 
 the period of flexion being somewhat more protracted. Should 
 the period of flexion fail, the descent will nevertheless take place, 
 provided the pelvis is well formed, and the head possesses its or- 
 dinary dimensions. The width of the superior strait of a well-form- 
 ed pelvis being at least four inches and three lines for the oblique 
 diameters, in which the head always tends to descend, and the head 
 measuring but four inches when it presents by its frontal variety, 
 there can be no difficulty in the descent. If the uterus should con- 
 tract, and the head not descend, there will be some obstacle entire- 
 ly independent of the presentation ; an excessive head, for exam- 
 ple, or a contracted pelvis, which would not allow the head to pass 
 even if flexed. The frontal variety, therefore, never forms an im- 
 pediment to delivery when the pelvis is natural. I have even 
 seen delivery accomplished in one case in which the pelvis was 
 sensibly contracted. A female named Vanesse, at full term, was 
 brought to La Clinique 10th of October, 1840, at 4 o'clock in the 
 evening. She had been in labour since Friday, 9th of October, at 
 8 o'clock in the evening. The head, which presented in the first 
 position of the frontal variety, did not descend, notwithstanding en- 
 ergetic uterine action. The child had ceased to live. A short 
 time after this woman was brought to the ward, the delivery made 
 some progress, but the contractions of the uterus becoming slower, 
 the sage-femme in chief, Madame Callé, sent for me. On my arri- 
 val, I found the head so low down that I did not think it necessary 
 to do anything. In fine, notwithstanding the slight contractions, 
 the head had executed its movement of rotation ; it was resting on 
 the floor of the pelvis, and the occiput, placed under the pubes, had 
 already commenced to distend the vulva, so that in a few minutes 
 after my arrival the delivery took place spontaneously, the 10th, at 
 8 o'clock in the evening, after twenty-four hours' labour. 
 
 The pelvis of this woman was contracted ; and this circumstance 
 alone retarded the descent of the head ; and yet, with the frontal 
 variety, the descent took place, although the pelvis was not natu- 
 ral. From this we may judge what will occur in a well-form- 
 ed pelvis. I only cite this case to prove the facility of descent by 
 the occipitofrontal diameter in a normal pelvis, and not with a 
 view of encouraging inaction in similar cases. If, in a word, the 
 person who had charge of this patient had interfered at the proper 
 time, after having ascertained the insufficiency of the uterine con- 
 tractions, and the prolonged sojourn of the head at the superior 
 strait, this delivery would not have been followed by such seri- 
 ous results both to mother and child. The child perished in 
 consequence of the delay in the delivery ; and the continued so- 
 journ of the head at the superior strait produced an eschar, from 
 which resulted a vesico-vaginal fistula. However, it must be ad- 
 mitted that these accidents are not always the necessary conse- 
 quences of a prolonged delivery : children are frequently born alive, 
 without injury to the soft parts of the mother, after a much longer 
 
PRESENTATION OF THE VERTEX. 197 
 
 and more painful labour than that I have just described. Moreover, 
 if the pelvis had been well formed, it is manifest that these accidents 
 would not have occurred to mother and child. In this case, the 
 child having ceased to live, and the head being low down when I 
 w T as called in, I congratulated myself for not having interfered ; for 
 the forceps would certainly have been blamed for the consequen- 
 ces resulting merely from delay in the delivery. 
 
 Occipital Variety. 
 A. Diagnosis of the Presentation. — In this presentation, which 
 is the reverse of the preceding, the head presents very much flex- 
 ed, and the posterior fontanelle occupies the centre of the orifice ; 
 the anterior fontanelle is very difficult to reach if it be in front, and 
 impossible if behind. The diameter of this presentation is favour- 
 able to the descent of the head ; it extends from the lower portion 
 of the occiput to the vertex, and measures three inches six lines. 
 
 B. Diagnosis of the Position. — The diagnosis is the same as in 
 the full presentation, but more difficult to recognise, because only 
 one fontanelle can be reached. 
 
 C. Mechanism of Expulsion. — There is only one peculiarity 
 worthy to be mentioned in spontaneous delivery — the first period of 
 flexion is entirely wanting, for the head presents already very much 
 flexed ; it even becomes slightly extended in proportion as it de- 
 scends. The expulsion is as easy as in the full presentation. (For 
 the exceptions, see Manipulations.) 
 
 Prognosis. 
 
 In the great majority of cases, the prognosis is as favourable as 
 in the full presentation of the vertex. In the early contractions, 
 the head is righted, or descends, strongly flexed, and the delivery 
 is as rapid and fortunate as if the head presented in full. 
 
 If I insist somewhat on these varieties of presentation, it is less on 
 account of their practical importance than a desire to omit nothing 
 which bears on the presentations of the fœtus. These varieties 
 scarcely ever constitute a difficulty ; and when they do, they must 
 be greatly exaggerated, which is very rare in a fœtus at full term. 
 When the ear is felt at the superior strait, or the posterior portion 
 of the neck occupies the centre of this strait, or even the forehead, 
 nature will suffice in most cases, and will much better correct these 
 obliquities than the hand. (See Manipulations?) In a word, what- 
 
198 PRESENTATION OF THE VERTEX. 
 
 ever may be the presentation, when the head occupies the superior 
 strait, provided the pelvis and head are both well formed, nature 
 will almost always be sufficient to effect the descent.* 
 
 Art. II. — Anomalies in the Mechanism of Spontaneous 
 Delivery. 
 
 1. Flexion. 
 
 I have already stated, when speaking of the movement of flex- 
 ion, that this first period frequently took place simultaneously with 
 the descent. It may, however, fail, either because the head pre- 
 sents already flexed, or because it descends without undergoing flex- 
 ion. This movement sometimes is not effected until the head has 
 reached the floor of the pelvis. The movement of flexion also ex- 
 hibits some irregularities ; it is not rare, especially in the occipito- 
 posterior positions, for the chin, instead of approximating the chest, 
 to become more remote from it, and the head is consequently ex- 
 tended, so that the anterior fontanelle approaches by degrees the 
 centre of the pelvis, as if the frontal variety of the vertex present- 
 ed. This variety is ordinarily temporary, and the head becomes 
 flexed after reaching the floor of the pelvis. In some cases still 
 more rare, and which are the reverse of the preceding, whether the 
 flexion of the head has exceeded its ordinary limits, or the trunk of 
 the fœtus becomes thrown back on its posterior region, the occipital 
 fontanelle occupies the centre of the excavation, as in a variety of 
 occipital presentation. Having descended to the floor of the pel- 
 vis, the resistance which the head encounters there gradually pla- 
 ces it in its natural position. 
 
 * It will be found, I think, that nature is not always competent to overcome the difficulty 
 of these mal-positions. For example, when the side of the head presents at the superior 
 strait, the relation which the occipito-mental diameter of the head bears to the oblique diam- 
 eter of the strait is such as to render it physically impossible that the head can pass, unless 
 the position should be changed either by the spontaneous efforts of nature, or the manipula- 
 tion of the accoucheur. Should it, therefore, prove that nature is unable to right the head, 
 and it be suffered to remain in this position after strong uterine contractions, the child will 
 inevitably be sacrificed, and the mother herself incur serious hazard. I should, therefore, 
 recommend the pupil to ascertain early the condition of things at the superior strait : if he 
 find such a position of the head as to require redressing either by nature or himself, let him 
 be vigilant, and not yield too much time to nature ; for if the neck of the womb should be 
 well dilated, and the membranous sac ruptured, and yet no alteration in the head, the womb, 
 in consequence of the escape of the liquor amnii, firmly grasps the head and surface of the 
 child's body : the contractions only tend to wedge the head (if I may so speak) at the superior 
 strait, and the difficulty of manipulating will generally be proportionate to the time elapsed since 
 the escape of the amniotic fluid. Let the pupil, therefore, not lose time precious to the safety 
 of the child, but proceed, while the womb is soft and dilatable, to correct the mal-position. 
 In this case, there will be one of two indications : either to right the head and commit the 
 achievement of the delivery to nature, or have recourse at once to version, and bring down the 
 feet. The choice of these operations will depend on the condition of the patient. Should 
 nothing untoward present itself, save the mal-position, the mere righting of the head will be 
 sufficient. Should the patient, however, be exhausted, or suffer under any other serious com- 
 plication of natural labour, the operator should at once proceed to turn, and thus complete the 
 delivery. In order to correct the mal-position, it will be necessary to introduce the hand into 
 the vagina, pass it up to the superior strait, and gently place the fingers on the side of the 
 head, the other hand steadying the uterus through the abdomen ; the hand thus placed at 
 the superior strait will cautiously elevate the head, and at the same time incline the vertex 
 downward, thus converting the position into an ordinary one of the vertex. The manner of 
 acting when the forehead or occiput presents will be indicated hereafter ; and the reader is 
 referred for the rules of version to the excellent precepts of our author, which will be found 
 under their appropriate head. — Ed. 
 
ANOMALIES OF SPONTANEOUS DELIVERY. 199 
 
 § 2. Descent 
 The anomalies during the time of descent depend on circum- 
 stances unconnected with the presentation, and which require the 
 intervention of art. I shall not, therefore, for the present, occupy 
 myself with them. 
 
 § 3. Rotation. 
 
 The movement of rotation most generally does not take place 
 until the head has reached the floor of the pelvis ; however, it may 
 be executed, in part, during the period of descent, and be com- 
 pleted after the head has passed to the perineum. Likewise, it may 
 not be accomplished until the head, having passed the inferior 
 strait diagonally, is about protruding through the soft parts. I have 
 often noticed this in primiparse. The head can readily descend 
 through the inferior strait diagonally, accommodating its occipito- 
 frontal diameter to one of the oblique diameters of this strait ; then, 
 having reached the vulva, the great diameter of which is the an- 
 teroposterior, it is forced to complete its movement of rotation, in 
 consequence of the resistance of the soft parts. 
 
 There is another anomaly which I have observed. The occi- 
 put having been at the right or left, may pass from the opposite 
 side without stopping under the symphysis pubis, and the accou- 
 cheur is surprised to find a position different from what he recog- 
 nised at the commencement of labour. After this excess in its 
 movement of rotation, the occiput returns, and finally passes out 
 under the pubes. This anomaly rarely occurs in an opposite direc- 
 tion. However, I observed it once at La Clinique : the occiput, 
 which was transverse and to the left, placed itself in relation with 
 the sacro-iliac symphysis of the same side ; then, passing in front 
 and below the sacro=vertebral angle, it traversed the whole right 
 lateral wall of the pelvis, and passed out under the pubes, as would 
 have been the case in a right posterior occipito-iliac position, re- 
 duced to an anterior. 
 
 A. Descent of the Vertex in the Occipito-posterior Position. — 
 Finally, this movement of rotation, which I have just represented 
 as taking place either prematurely or tardily, and as being com- 
 plete or excessive, may also occur in a contrary direction : thus, 
 for example, in a right posterior occipito-iliac position, the occiput, 
 by a rare exception, instead of passing under the symphysis pubis, 
 may be turned into the concavity of the sacrum ; and, in this case, 
 the expulsion is terminated most frequently by the sole efforts of the 
 uterus ; an opinion which was not generally received in the last 
 century. 
 
 The head becomes considerably flexed, descends diagonally in 
 the superior strait, and in proportion as it passes this strait, the occi- 
 put gets into the cavity of the perineum ; or the head descends diag- 
 onally in the superior strait, and then passes out of the inferior strait 
 in the same direction, without going to the concavity of the sacrum. 
 Be it as it may, the perineum, greatly distended, becomes elongated, 
 
200 
 
 PRESENTATION OF THE VERTEX. 
 
 the occiput traverses its concavity, appears at its anterior commis- 
 sure at the same time that the forehead is under the pubes, and 
 the head passes out by its occipitofrontal diameter. The perine- 
 um requires, in this case, very particular attention (see fig. 99). 
 
 (Fig. 99.) 
 Side View of the Pelvis. 
 
 It is thus, in most cases, that the occipito-posterior descent is 
 effected, and not as has usually been described. The occiput does 
 not descend first, and, after its expulsion, the anterior fontanelle, 
 coronal suture, forehead, nose, mouth, and chin, do not pass suc- 
 cessively under the symphysis pubis. 
 
 However, although this delivery is spontaneous in most instances, 
 it does not terminate so easily as in the occipito-anterior positions. 
 In a word, in the occipito-anterior positions, the inflexible line (O I) 
 which extends from the lower portion of the occiput to the at- 
 loido-axoid articulation, is very small, and accommodates itself read- 
 ily to the posterior part of the symphysis pubis, and permits the oc- 
 ciput to pass the symphysis without difficulty ; while, in the poste- 
 rior positions, this inflexible line (1 2, fig. 99) extends from the oc- 
 ciput to the first dorsal vertebra ; it is, therefore, more extended, 
 and, as it is straight, it accords badly with the crooked canal to be 
 traversed by the fœtus ; for, in order that the occiput may reach 
 the anterior commissure of the perineum, this line must traverse 
 the posterior wall of the excavation, which is much longer than the 
 
 (Fig. 100.) 
 Side View of the Pelvis. 
 
ANOMALIES OF SPONTANEOUS DELIVERY. 201 
 
 anterior, and it must also right the floor of the pelvis (3). Now, 
 in order that these things may be accomplished, the anterior flex- 
 ion of the fœtus should be very marked, and the resistance of the 
 perineum overcome. This expulsion, in most cases, is longer and 
 more painful to the mother, and requires energetic and continued 
 uterine action. 
 
 But this difficulty in the expulsion is not because the contrac- 
 tions of the uterus fall indirectly upon the fœtus. I believe, on the 
 contrary, that the fœtus, by its situation, constitutes in the occipito- 
 posterior position an uninterrupted line, which transmits the force 
 of the contractions to the occiput much better than in the anterior 
 position, where the line represented by the fœtus is broken at the 
 articulation of the neck. In order to be satisfied of this, it will only 
 be necessary to examine the two preceding figures (99, 100), and 
 compare them. 
 
 The spontaneous expulsion may be effected in another way, in 
 the posterior positions. The presentation of the vertex, in conse- 
 quence of the extension of the head, may be changed in the exca- 
 vation into a presentation of the face. The chin then passes out 
 first under the pubes ; but for this change of presentation to take 
 place in the excavation, the diameters of the latter must be very 
 large, or those of the head considerably reduced, for the occipito- 
 mental diameter, measuring at least five inches, cannot be in rela- 
 tion with the diameters of the excavation, which in the natural 
 state measure at most four inches and a half. 
 
 This movement of rotation may fail altogether ; and art, in this 
 case, is often forced to interfere, not, as I have remarked, because 
 the head cannot pass the inferior strait when it is diagonal, but 
 because the resistance of the perineum, especially in primiparae, 
 opposes the passage of the head through the vulva, unless the rota- 
 tion is complete. 
 
 § 4. External Rotation of the Head, Internal of the Shoulders. 
 
 The rotation of the shoulders may also offer some varieties : it 
 may be incomplete, or be wanting altogether, as I shall hereafter 
 explain, in consequence of the more or less resistance of the peri- 
 neum ; and, in this case, the external rotation of the head is executed 
 imperfectly or not at all, which confirms in every particular the 
 opinion of M. Gerdy with regard to the movement of rotation. 
 
 Finally, the rotation of the shoulders may also be excessive : thus, 
 in the left anterior occipito-iliac position, after the expulsion of the 
 head, the shoulders are transverse ; the shoulder which is to the 
 left should pass in the concavity of the sacrum, in order that the 
 bis-acromial diameter may be placed in an antero-posterior situa- 
 tion. But, instead of going to the concavity of the sacrum, this 
 shoulder may pass under the pubes, while the right shoulder gets 
 to the concavity of the sacrum, and the back, which corresponded 
 to the left, is in relation with the right side. The rotation of the 
 head, which, as I have remarked, is the consequence of the rota- 
 tion of the shoulders, is also executed in this case in an inverse di- 
 
 Cc 
 
202 PRESENTATION OF THE VERTEX. 
 
 rection, and the occiput, in lieu of regarding the left thigh, turns 
 towards the right. Another confirmation of the opinion of M. 
 Gerdy. 
 
 § 5. Cause of the Movement of Rotation. 
 As is readily seen from the description which I have just given 
 of spontaneous delivery, the occiput, no matter with what point of 
 the superior strait it may have been in relation, passes under the 
 pubes. What is the cause of this movement of rotation ? Be- 
 fore the time of M. P. Dubois, it was supposed that this cause was 
 due to the inclined planes, the anterior and the posterior, which 
 conducted the occiput under the pubes, when it corresponded 
 to the anterior half of the pelvis ; and to the concavity of the sa- 
 crum, when it was originally in relation with the posterior half of 
 the excavation. Neither was the conversion of a posterior posi- 
 tion into an anterior admitted. However, if the inclined planes 
 had such a direct action on the rotation of the head, this movement 
 could not be executed below these planes beyond their sphere of 
 action ; and we know very well that this movement, in the major- 
 ity of cases, does not commence until the head rests on the floor 
 of the pelvis, and after it has already passed the planes. Again, 
 if the inclined planes determined the movement of rotation, the 
 two anterior planes would always place the occiput in front, when 
 this portion of the fcetal head corresponded to one of the points on 
 the anterior of the pelvis, while the two posterior planes would 
 throw the occiput backward, when in relation with the posterior 
 portion of the pelvis. Experience, however, proves that the occi- 
 put always comes in front, no matter to what point of the upper 
 strait it may correspond. Where, therefore, is the influence of the 
 posterior inclined planes ? M. P. Dubois, on the contrary, is of 
 opinion that this cause is owing to a number of circumstances, 
 viz., on the one hand, to the volume, form, and mobility of the parts 
 expelled ; and, on the other hand, to the capacity and shape of the 
 pelvic canal. And such is the influence of this combination, that 
 the different parts of the fœtus are placed in situations the most 
 favourable to their expulsion. From the occipito-pubic position 
 being the most favourable, all the positions reduce themselves to 
 this type during their passage. The floor of the pelvis in this ro- 
 tation undoubtedly exerts the greatest influence ; the rotation is 
 evidently produced by the resistance the floor offers to the various 
 portions of the foetus. The observations which M. P. Dubois 
 made at the Maternité render this explanation simple and intelligi- 
 ble. I will allow the professor to speak for himself: " In a wom- 
 an who had died some time after delivery, the uterus was opened 
 to within a short distance of the orifice. The fœtus was placed at 
 the orifice, which was dilated and soft, in the right posterior occip- 
 ito-iliac position of the vertex. Several sages-femmes compress- 
 ing and pushing the fœtus from above downward, caused it to de- 
 scend without difficulty into the excavation of the pelvis. Much 
 greater effort, however, was necessary to make it traverse the pe- 
 
 I 
 
DELIVERY OF THE VERTEX IN TWIN CASES. 203 
 
 rineum, and pass the vulva ; and it was not without surprise that 
 we saw, during three successive attempts, when the head traversed 
 the external genitals, that the occiput turned forward and to the 
 right, and the face backward and to the left. We repeated the ex- 
 periment the fourth time ; but on this occasion the head passed the 
 vulva, the occiput remaining posteriorly. We next took a fœtus 
 which had died the preceding night, and much larger than the for- 
 mer ; we placed it in the same situation as the first twice succes- 
 sively, and the head passed through the vulva, after having execu- 
 ted its movement of rotation : in the third and following attempts, 
 it descended without executing the movement. Thus the move- 
 ment of rotation did not cease to take place until the perineum and 
 vulva had lost the resistance necessary for its accomplishment." 
 The daily observations of practitioners tend likewise to confirm 
 the views of M. P. Dubois. Thus, for example, when twins are 
 expelled, the first which presents is expelled regularly ; the rota- 
 tion of the head and shoulders is accomplished ; the perineum op- 
 poses a proper resistance ; but the dilatation of the genitals, in con- 
 sequence of its expulsion, is such, that the second fœtus, especially 
 if it be smaller than the other, not experiencing on the part of the 
 perineum sufficient resistance, is frequently expelled in the situation 
 in which it was originally placed, without any movement of rota- 
 tion. It is for the same reason that, in delivery of the vertex, rota- 
 tion is effected the more regularly as the head is larger, and the 
 perineum more resisting. This is observed in primiparae ; and if, 
 after the expulsion of the head, the shoulders are so frequently ob- 
 served to pass out irregularly, is it not because they have been 
 preceded by the head? Finally, when the perineum has been rup- 
 tured by preceding deliveries, particularly if the fœtus is very 
 small, it is expelled in most cases without undergoing any of the 
 movements usually observed in spontaneous delivery. Every- 
 thing goes to show that the rotation of the head and shoulders de- 
 pends upon the exact relation of the fœtus with the parts of the 
 mother through which it has to pass. 
 
 Art. III. — Delivery of the Vertex in Twin Cases. 
 It is very rare to find two foetuses presenting simultaneously by 
 the vertex ; but if, as an exception, it should so happen, the expul- 
 sion is effected according to the same laws as in the case of a sin- 
 gle birth ; only, as I have already remarked, the expulsion of the 
 second would be accomplished less regularly, because it would 
 successively traverse passages already dilated by the other fœtus 
 (see the preceding paragraph) ; the second is, in general, expelled 
 a few moments after the first. Sometimes, however, the delivery 
 maybe delayed several hours, and even days. In these cases, un- 
 less there should be some accident, the accoucheur should do 
 nothing. 
 
204 ATTENTIONS REQUIRED DURING LABOUR. 
 
 Art. IV. — Prognosis. 
 
 The prognosis of the presentation of the vertex is very favoura- 
 ble both for mother and child, especially in primary or secondary 
 occipito-anterior positions ; it is less favourable in occipito-poste- 
 rior positions remaining such; the descent is more difficult; and 
 sometimes even, though rarely, art is obliged to interfere, and both 
 these circumstances are of a nature to compromise the life of the 
 child and the health of the mother. Thus, notwithstanding the 
 greatest possible care, the perineum may be more or less lacera- 
 ted ; it may even have the central perforation, the foetus escaping 
 between the anterior commissure of the perineum and anus. M. 
 Moreau has recorded some examples of this. In a word, the pro- 
 longed sojourn of the head in the excavation may determine sloughs, 
 and urinary or stercoral fistulae. 
 
 The life of the infant is compromised in this presentation about 
 once in fifty deliveries. 
 
 CHAPTER I. 
 
 ATTENTIONS REQUIRED BY THE WOMAN DURING LABOUR* 
 
 § 1. Instruments to he provided by the Accoucheur, 
 When the accoucheur is called upon to give his assistance to a 
 woman in labour, he should always supply himself with the for- 
 ceps. In fact, the life of the child, and sometimes even that of the 
 
 * The first entrance of the young accoucheur into the lying-in chamber is a matter of no 
 little importance. In the first place, he has popular prejudice to contend with — he is not an 
 " old gentleman, and therefore he knows nothing of his business." The only means left him 
 of putting an end to this prejudice, and of demonstrating that, although not a patriarch in 
 years, yet that he is fully competent to the discharge of his duties, is his conduct after he 
 crosses the threshold of the parturient chamber. One mistake at his début in obstetric prac- 
 tice may exert a singularly unhappy influence over his future prospects; but should he, on 
 the contrary, make a " favourable impression" in his first case, the best consequences may 
 ensue to him. Something more is required of the accoucheur, if he wish to succeed, than a 
 profound knowledge of his subject : with this must be blended an intimate acquaintance 
 with all the details of the sick-room ; he must understand human nature ; he must distin- 
 guish between a harmless concession to popular whim and caprice, and a concession which 
 may compromise his own character and the dignity of his art ; in a word, he must constantly 
 bear in memory the full measure of his responsibilities, and never, for the purposes of self- 
 aggrandizement, prove recreant to the high trusts confided to his care. 
 
 Punctuality and promptness in responding to professional calls are especially important in 
 the practice of obstetric medicine. We will now suppose that a messenger has arrived, re- 
 questing the immediate attendance of the accoucheur. The latter proceeds, without delay, 
 to the residence of the patient— he rings the bell— he is admitted, and if this should be his 
 first professional visit to the family, all eyes are naturally turned towards him, surveying him 
 with marked care, and if he falter under the scrutinizing gaze, it will be attributed to want 
 of professional skill ! The accoucheur's general bearing, as soon as he enters the house of 
 his patient, should be that of a well-bred gentleman : he should manifest no excitement ; but 
 his general conduct should be such as to show that he is accustomed to these calls, and un- 
 derstands how to comport himself. Soon after he has been introduced into the parlour, the 
 nurse will probably leave the patient for the purpose of having a little chat with the doctor. 
 In this interview with the nurse, much can be learned as to the general condition of the pa- 
 tient — whether she is much alarmed — whether she has suffered much from her pains — 
 whether it is her first child— whether she is nervous and irritable— whether she is agitated 
 
TO ASCERTAIN THAT THE FEMALE IS PREGNANT. 205 
 
 mother, will often depend upon immediate delivery, and the time ne- 
 cessary to procure the instrument will expose both mother and child 
 to serious danger. He should also have with him an ordinary fe- 
 male catheter, and one of gum-elastic (No. 9), in case the intro- 
 duction of the silver catheter should be impracticable ; in addition, 
 he should be provided with an instrument to push up the cord, in 
 case of necessity (see figures 107, 108) ; a laryngeal tube, lan- 
 cets, &c. ; these instruments are indispensable. I am also in the 
 habit of taking with me a speculum, lint, waxed thread, and a tam- 
 pon forceps, in case hemorrhage should render the tampon neces- 
 sary ; a small syringe, in order to inject the rectum in asphyxia of the 
 infant, and a feather quill to remove any mucus which may collect 
 in the throat, and cut in the shape of a toothpick to pierce the 
 membranes, should it become necessary ; also, a small box contain- 
 ing the extract of belladonna, and another containing cerate. 
 
 Although most of these articles may be readily procured after 
 arriving at the bedside, they increase so triflingly the volume of 
 the forceps, that it is better to have them provided in advance. 
 I have never regretted this precaution. I am always particular in 
 concealing from view the instruments, after taking from the case 
 those which may be absolutely necessary during natural labour ; 
 such as the sound, stethoscope, &c. 
 
 2. To ascertain that the Female is Pregnant and in Labour. 
 
 Arrived at the bedside of his patient, the first duty of the ac- 
 coucheur should be to ascertain that she is really pregnant ; and if 
 pregnant, that she is in actual labour. 
 
 So many circumstances may induce the belief that pregnancy 
 
 at the doctor's arrival, &c, &c. These preliminary inquiries over, the nurse then leaves, 
 with the promise that, in a few minutes, she will return and conduct the doctor to the sick- 
 room. As soon as he enters the room, his presence will be privately announced to the lady, 
 who has already been prepared by the nurse for his reception. He then advances towards 
 the bed, and enters into conversation with his patient, talking of any and every thing except 
 of the subject directly connected with the object of his visit. In this way, she becomes ac- 
 customed to his presence — the first interview has passed, and she finds that, after all, it is 
 not such a dreadful thing to talk to a doctor, and, if he is adroit, he will have impressed her 
 very favourably, merely by his manner. During this conversation with the patient, the ac- 
 coucheur will probably notice (if the labour has really commenced) that she is suffering oc- 
 casionally from pain, which she may endeavour to conceal, but which she cannot effectually 
 do. If these pains are severe, having the character of undoubted labour pains, he should 
 mention privately to the nurse that the labour appears to be advancing, and that it now be- 
 comes necessary for him to ascertain the exact condition of things by an examination. This 
 the nurse will immediately understand, and she mentions the fact to the lady, who, of course, 
 will generally assent without any difficulty. The accoucheur then asks the nurse for a nap- 
 kin, which he has carefully pinned upon the arm of the hand which he intends to introduce 
 into the vagina. The hand is then well lubricated with sweet oil, flaxseed, or some muci- 
 laginous substance. If the accoucheur has the choice of position, he will find an advantage 
 in examining the patient upon her back. Everything being thus prepared, he then proceeds 
 to the examination without the slightest exposure of the patient, with all the gentleness and 
 delicacy due to the situation of the lady who has confided herself to his skill and honour. 
 I cannot concur in opinion with Dr. Chailly, that the accoucheur should make the vaginal 
 examination before obtaining the consent of his patient — in this country, at least, such conduct 
 would not be tolerated. Nor do I see the necessity for providing himself with the numerous 
 instruments detailed by our author. A lancet and catheter are all the instruments absolutely 
 necessary for the accoucheur to have about him until there is a positive indication that others 
 are required. I hold it to be indiscreet, to say the least, to carry the forceps with him to 
 every case of midwifery he may be called upon to attend ; if this instrument should be re- 
 quired, there will generally be sufficient time allowed to procure it ; and, moreover, it is well 
 not to have temptation in our way. — Ed. 
 
206 ATTENTIONS REQUIRED DURING LABOUR. 
 
 exists and labour has commenced, that we cannot be too much on 
 our guard against error ; not that this error would be prejudicial to 
 the woman, but it would occasion a loss of time, and might com- 
 promise the reputation of the accoucheur. 
 
 The touch is the most certain means of arriving at this knowl- 
 edge ; but the accoucheur should not practise it immediately, un- 
 less, on his arrival, he should judge, from the nature of the pains, 
 that the labour is considerably advanced ; he should allow time 
 sufficient for the patient to become familiar with his presence. 
 
 He must commence by inquiring into the different circumstan- 
 ces of her pregnancy ; he calculates with her whether she is at term ; 
 and if she has had children, he must question her as to her prece- 
 ding labours. This conversation may lead to useful indications for 
 his conduct, and he may be admonished of accidents which, hav- 
 ing complicated her former deliveries, may also present themselves 
 in the present accouchement. The accoucheur should also assure 
 himself that the woman has perceived the active movements of the 
 foetus ; and if she is in a proper position, he may ascertain, by 
 means of auscultation, whether the infant is alive or dead. 
 
 During this time, he observes at each pain the nature, duration, 
 and energy of the contractions, and if he has some little tact, this 
 examination alone will suffice to enable him to fix the particular 
 period of the labour ; he will also, in this examination, distinguish 
 the true from the false pains. In the normal contractions, the pains 
 ordinarily commence in the back, and encircle the abdomen like a 
 band ; they expend their force on the abdomen and towards the gen- 
 ital organs, return at regular intervals, and are separated by a per- 
 fect calm. Those, on the contrary, which merely simulate labour, 
 are more or less continuous, and are produced by intestinal colic. 
 They are recognised by the irregularity of their return, and of 
 their seat, and by heartburn and diarrhoea, which sometimes accom- 
 pany them. 
 
 Occasionally, there are pains which have their seat in the ute- 
 rus, returning at regular intervals, and which resemble the pains 
 of childbirth, without the presence of any other sign of labour. 
 The most skilful practitioners may, in this case, be deceived by 
 these appearances. The touch is the only means of removing all 
 doubt ; yet it does not always destroy the uncertainty, for these 
 pains may determine the commencement of labour. The neck of 
 the uterus opens, the membranes become tense, and the contractions 
 continue for some hours ; then everything again becomes calm, 
 and after a few days real labour is declared. I have often observ- 
 ed these premature contractions manifest themselves, called, ordi- 
 narily, false labour. I have known them, in some women, reappear 
 at different times during the last two weeks of pregnancy. How 
 then, it may be asked, are we to distinguish, at first, this commence- 
 ment of labour from a regular labour, which continues until com- 
 pletion? I do not think it possible to guard against the error, time 
 alone being able to enlighten the accoucheur in this particular. 
 
THE TOUCH DURING LABOUR. 207 
 
 § 3. The Touch during Labour, 
 
 These preliminary preparations once accomplished, it is neces- 
 sary to proceed to the touch. I prefer, for this operation, that 
 the woman should be lying down ; this position is less disagree- 
 able ; moreover, it allows the finger to penetrate farther forward. 
 However, there is no objection to the standing position ; but in this 
 case the back of the patient should be supported by a wall, or some 
 solid piece of furniture. 
 
 In general, I do not inform the patient of the kind of investiga- 
 tion I am about making ; and, under pretext of listening to the pul- 
 sations of the heart, I cause her to assume the recumbent posture ; 
 then, after finishing the auscultation, I immediately practise the 
 touch. 
 
 Frequently, there is a very natural resistance on the part of the 
 woman; then, without withdrawing the hand, she should be in- 
 formed of the positive necessity of the examination, both as re- 
 gards herself and her child ; the finger, previously lubricated with 
 lard, once introduced, the first object of inquiry should be whether 
 the patient is pregnant, and this is to be ascertained by aid of the 
 ballottement, &c. (see Diagnosis of Pregnancy), in case, in conse- 
 quence of the contractions, the ear should not be able to detect 
 the pulsations of the fœtal heart ; then it should be ascertained if 
 the pregnancy has arrived at its full term, in order that the labour 
 may be resisted, if premature. The dilatation of the uterine ori- 
 fice, the tension of the membranes during a pain, the relaxation of 
 these parts when the pain has ceased, will indicate whether or not 
 the patient is in labour. The frequency and duration of the con- 
 tractions, the thinning of the neck of the uterus, and its degree of 
 dilatation, will enable us to form an opinion as to the probable dura- 
 tion of the labour. The particular conformation of the pelvis, the 
 state of the genital organs, the nature of the presentation, and the 
 position of this presentation, should likewise be ascertained. It will 
 not be necessary, however, to insist too rigidly on these investiga- 
 tions, when the position is difficult to recognise, for it will suffice, 
 in the majority of cases, to ascertain the presentation, in order to 
 know whether the delivery is to be committed to the natural efforts, 
 or whether it will become necessary to interfere ; it would only be 
 in the case of an improper presentation, which required the aid of 
 the accoucheur, that he would be authorized to insist on the diagno- 
 sis of position. 
 
 § 4. Choice of Place for the Delivery of the Woman. 
 
 As soon as these important points are settled, it will be necessa- 
 ry to prepare the chamber and bed for the delivery, as also all the 
 auxiliaries which may be needful. The chamber should be, as far 
 as practicable, spacious, quiet, and well ventilated ; the tempera- 
 ture should be moderate, for heat predisposes to hemorrhage and 
 inertia of the womb, and cold to peritoneal inflammations. 
 
 All useless persons should be dispensed with, and especially 
 
208 ATTENTIONS REQUIRED DURING LABOUR. 
 
 those whose presence may be displeasing to the patient ; some- 
 times the husband is of the number ; he should then be requested 
 to leave, under pretext of soothing his sensibility. Most women, 
 on the contrary, are anxious to have their husbands near them at 
 this time. The sagacity of the accoucheur will enable him to 
 judge of the course to be pursued in these matters. 
 
 § 5. Regimen. 
 It is proper for a woman in labour to abstain from nourishment. 
 In fact, all the vital forces appear to concentrate upon the uterus, 
 and, as it were, abandon the other organs ; digestion is not per- 
 formed, and most frequently the food is rejected. However, if the 
 labour should be protracted, some broth may be given. As to 
 drinks, they should be mild and refreshing ; and we should rigidly 
 proscribe the use of warm wine and spirituous liquors, by the aid 
 of which some women imagine that their strength is sustained, but 
 which are more likely to determine inflammations and active hem- 
 orrhages, and tend rather to weaken than invigorate the system. 
 
 § 6. Attention to the Rectum and Bladder. 
 
 The accoucheur should be very particular to have the rectum 
 evacuated ; the woman should be advised to take a lavement ; and 
 if it prove ineffectual, a second should be administered, with the ad- 
 t dition of a small quantity of common honey. In order to facilitate 
 the passage of the head, the rectum should be completely emptied ; 
 and this precaution has the advantage of avoiding the involuntary 
 expulsion of the faeces at the moment the head presses upon the 
 perineum. 
 
 The woman should be requested to void her urine, and during 
 this time the accoucheur should leave the room. But if the emis- 
 sion of urine be impossible, the catheter should be introduced, and 
 without uncovering the patient. The catheter, placed on the 
 palmar face of the index finger of the right hand, should be intro- 
 duced into the vagina ; the extremity of the finger, extending be- 
 yond the catheter, will feel for the small tubercle, which is situated 
 at the anterior extremity of the urethro-vaginal septum, and but 
 a very short distance from the orifice of the urethra. The finger, 
 without leaving this point, will raise the extremity of the sound, 
 and cause it to penetrate without difficulty, provided the operator 
 has some little skill. It must be admitted, however, that the intro- 
 duction of the catheter is sometimes impracticable in this manner, 
 and the accoucheur is under the necessity of uncovering the pa- 
 tient. This difficulty is in consequence of the bladder being push- 
 ed up above the superior strait, and drawing with it the urethra ; 
 the meatus urinarius is carried upward, and is lost behind the bor- 
 der of the symphysis pubis. In this case, it is absolutely necessary 
 that the parts be exposed to view. It sometimes is necessary, in 
 order to penetrate the bladder more readily, to use a flexible gum- 
 elastic sound. 
 
PREPARATION OF THE BED. 209 
 
 § 7. Dress, 
 The patient need not be undressed, but she should be attired ac- 
 cording to the season, in order that she may leave her bed, and 
 walk if necessary ; the dress should be loose, and garters dispensed 
 with, 
 
 § 8. Objects necessary to Reanimate the Infant 
 There should be placed on a table near a window, easy to open, 
 a flannel folded in several doubles to receive the infant, in case it 
 should require reanimation, and the impression of the atmosphere. 
 There should also be provided some napkins, vinegar, cold water, 
 compresses, and a feather quill ; also a ligature for the cord about 
 seven inches in length, and knotted at its two extremities ; scissors, 
 a compress, and bandage for the umbilicus. 
 
 § 9. Preparation of the Bed. 
 
 These precautions being completed, by which all confusion will 
 be avoided at the moment of the birth of the infant, the preparation 
 of the bed should next be attended to. The construction of the 
 bed varies according to the particular country. In France, a cot 
 is used, on which is placed a mattress, the upper portion of which 
 is raised by means of chairs reversed. This bed has always ap- 
 peared to me to be very inconvenient for the patient. I have sub- i 
 stituted for it an ordinary bed, with mattress, counterpane, pillows, 
 and the usual covering. The woman finds herself at ease on this 
 bed ; she can readily change her position, and sleep during the in- 
 tervals of pain. I am careful to place under the mattress, at the 
 point corresponding with the breech of the patient, a hard cushion, 
 in order that the breech may not sink into the bed, and to afford 
 an opportunity to give proper support to the perineum, as also that 
 the head of the fœtus, at the moment of its expulsion, may be suf- 
 ficiently elevated to avoid the fluid which necessarily escapes at 
 the time. 
 
 Moreover, this bed, by its arrangement, allows the patient to re- 
 main quiet for some time after delivery, so that when she is re- 
 moved to her ordinary bed, she is clean and comfortable, it being 
 understood that care be taken to place a piece of oil-cloth on the 
 first mattress, in order to protect it. 
 
 If the woman should not have sufficient persons around her to 
 furnish a point of support during the contractions of the womb, a 
 bar of wood should be placed across the foot of the bed, which 
 will afford the feet a proper support. 
 
 Before the rupture of the membranes, the woman may be either 
 in the standing or recumbent position ; but after the rupture, she 
 should be placed on the bed, and should not be permitted to leave 
 it, unless walking about the room should be deemed necessary to 
 give activity to the pains. The accoucheur sits on the right of 
 the bed ; he ascertains from time to time, by means of the touch, the 
 progress of the labour, and gives encouragement to his patient, and 
 
 Dd 
 
210 ATTENTIONS REdUIRED DURING LABOUR. 
 
 directs her efforts. He should not read, nor fall asleep, unless over- 
 come by fatigue : the suffering woman requires all his attention. 
 As a matter of policy, the accoucheur should be particular on this 
 subject, for I have known women discharge their medical attend- 
 ants from motives as slight as this. Most women, from the com- 
 mencement of labour, make strong efforts, with a view to hasten 
 the expulsion. But they exhaust themselves without profit, as long 
 as the neck of the uterus is not dilated, and the bag of waters un- 
 ruptured. The patient should be instructed to bear down only at 
 the proper time, and during the presence of pain. If she should 
 experience severe pain in the back, she may be relieved by passing 
 under her loins a napkin folded lengthwise, the extremities of 
 which should be raised by a person on each side of the bed. 
 
 All these little attentions should be shown without uncovering 
 the patient ; even at the moment of the expulsion of the child, this 
 is rarely necessary, unless the perineum should require some par- 
 ticular care, &c. 
 
 Finally, when the latter period of labour arrives, and the head 
 compresses the inferior portion of the rectum, the woman experi- 
 ences an imaginary desire to evacuate the bowels, and requests to 
 be permitted to go to the garde-robe ; but this request is not to be 
 assented to, and she should be informed that the desire is illusory ; 
 for women have been known to be delivered while at the garde- 
 robe, and the hazard both to mother and child under such circum- 
 stances is apparent. Should she insist, and even if there should be 
 an involuntary evacuation, the accoucheur, in order to soothe her 
 delicacy, should still affirm that she is mistaken, and at the same 
 time pass under her a clean napkin. Should she not credit the as- 
 sertion, and be perfectly aware of the accident, it will be well for 
 the accoucheur to appear to be ignorant of what has occurred. 
 This inconvenience takes place often at the time of the passage of 
 the head, while the accoucheur is supporting the perineum ; he 
 should be careful to interpose between this part and his hand a 
 linen folded several doubles. 
 
 § 10. Support of the Perineum. 
 
 In order to support the perineum, the accoucheur places himself 
 on the right side of the patient ; the right arm is passed under her 
 right thigh, and he presses the perineal surface, especially on the 
 side of the anus, with the palmar face of the hand, and the radial 
 border of the index finger is placed on the anterior border of the 
 perineum, and the thumb extended on the right thigh. 
 
 But this precaution would be useless, and the perineum fre- 
 quently ruptured, if the woman were not requested to moderate 
 her efforts during this time. For fear that the request should not 
 be complied with, and the head be too rapidly expelled, I pass my 
 left arm on the right thigh of the patient, and place my fingers on 
 the vertex of the head, in order to support it. Thus I allow the 
 head to pass at my pleasure between this hand and the perineum, 
 when the parts are in a condition to allow it without laceration. 
 
SUPPORT OF THE PERINUEM. 
 (Fig. 101.) 
 
 211 
 
 As soon as the head is expelled, it is to be simply supported in 
 raising it towards the pubes ; then the finger is to be passed be- 
 tween the symphysis pubis and neck of the infant, in order to as- 
 certain whether the cord encircles this latter. Should it be found 
 around the neck, a sufficient length of the cord should be drawn 
 out to allow it to pass over the head, or, if this is not possible, it 
 should be cut, and slight tractions made on the head, which will 
 suffice in most cases to determine the expulsion of the shoulders ; 
 but should these tractions not prove sufficient, the accoucheur 
 should, without delay, hook, with his index finger, the shoulder 
 which is situated posteriorly, and bring it down. 
 
 It is generally supposed that the perineum is in no danger after 
 the passage of the head, and it is rarely supported at the time the 
 shoulders are expelled. I am satisfied, however, that most of the 
 lacerations of the perineum are produced by the passage of the 
 bis-acromial diameter, simply because the perineum is not support- 
 ed at this moment ; hence the passage of the shoulders should be 
 carefully looked after. S 
 
 CHAPTER II. 
 
 ATTENTIONS TO THE CHILD AND MOTHER AFTER DELIVERY. 
 
 As soon as the child is born, the covering should be raised at the 
 foot of the bed, and the child placed on its side, at some distance 
 from, and with its back to the vulva, in order that it may breathe 
 freely, and not be suffocated with the discharge from the vagina. 
 
212 ATTENTIONS TO CHILD AND MOTHER AFTER DELIVERY. 
 
 The accoucheur should then ascertain that the uterus contracts 
 properly, and that it does not contain a second fœtus ; # the woman 
 is then to be covered, and requires for the moment no other care, 
 but should be left to the delightful emotions which she must neces- 
 sarily experience. 
 
 § 1. The Sex of the Child should not be immediately told. 
 
 The accoucheur is generally urgently solicited to tell the sex of 
 the infant, but he should be careful not to comply with the request, 
 but should dissemble the matter, even to the assistants, for fear of 
 indiscretion ; for the joy which the mother would experience if her 
 wishes were realized, would be as dangerous as the chagrin occa- 
 sioned by disappointment. 
 
 She should not be informed of the sex of her child until she has 
 somewhat recovered from her fatigue. 
 
 § 2. Tying the Cord. 
 If the child be healthy, if it cry, and the respiration be well es- 
 tablished, we should see that the base of the cord does not contain 
 any portion of the intestine, and then a ligature should be applied 
 two or three fingers' breadth from the umbilicus, in order that 
 the integuments, which extend some lines on the cord, may not be 
 included in the ligature ; the ligature should be drawn sufficiently 
 tight to obliterate completely the vessels, especially if the cord be 
 much infiltrated. It is, indeed, proper, in this latter case, before 
 applying the ligature, to press out with the fingers the lymph it 
 contains ; for, without this precaution, after the spontaneous evac- 
 »,tion of the fluid, the ligature would no longer compress suffi- 
 ently the vessels, and the blood might escape through the arter- 
 s, and endanger the life of the child. Thé cord is afterward to 
 • cut with the scissors. 
 
 M. P. Dubois recommends to apply two ligatures, and make 
 e section between them ; I usually adopt this rule.f It has the 
 
 There is no direction more important for the accoucheur scrupulously to observe than 
 one here indicated. As soon as the child is delivered, before separating it from its 
 
 .jther, he should place one hand on the abdomen to ascertain the condition of the uterus ; 
 whether it contracts, and is converted into a hard tumour occupying the hypogastric region, or wheth- 
 er it remains in a state of inertia, filling up more or less the abdominal cavity. In the former 
 case, the accoucheur feels secure against hemorrhage ; and, in the latter, he is admonished 
 sufficiently early of the danger to which the woman is exposed from inevitable flooding to 
 enable him to apply the proper remedies to induce uterine contraction, and thus rescue his 
 patient. How many women have perished from the neglect of this simple, yet most impor- 
 tant rule ! The accoucheur, for example, heedless of the condition of the uterus, attends 
 to the child ; cuts the cord, applies the ligature ; walks to the fireplace, sits down, and en- 
 ters into familiar conversation with the nurse. In the course of a few minutes he approaches 
 the bed of his patient ; he is terrified at the change ! She has the pallor of death on her 
 countenance — pulseless — speechless — moribund ! She has flooded to death ! This is not a 
 heightened picture. It is one, however, of fearful contemplation. We shall again allude to 
 this topic. — Ed. 
 
 t Under ordinary circumstances, there is no necessity for two ligatures. I am in the habit 
 of applying only one ; and I think there is much advantage derived from this practice. In al- 
 lowing the placental extremity of the cord to be free, there is an escape of blood, which, in 
 my judgment, facilitates the expulsion of the after-birth, in consequence of the disgorgement 
 which this escape of blood occasions in it. As for the objection urged by M. P. Dubois, that 
 the blood will soil the bed, &c, this is of little moment, for the bed is already soiled. Even 
 in twin cases, two ligatures are not always necessary, for usually there is no vascular con- 
 nexion between the two placentas. — Ed. 
 
APOPLEXY OF THE NEWBORN INFANT. 213 
 
 advantage of avoiding, at the time the cord is cut, the abundant 
 effusion of blood on the bed, &c. ; and if, in multiple pregnancy, 
 the presence of a second child has not been recognised, this addi- 
 tional ligature on the placental portion of the cord will prevent 
 hemorrhage, which would often prove fatal to the second child. 
 There sometimes exist between the two placentas vascular com- 
 munications, through which the blood, passing from one placenta to 
 the other, might escape externally by the cord of the first child. 
 
 Some accoucheurs are in the habit of dividing the cord before 
 tying it ; this practice I reserve for cases in which the life of the 
 infant is in danger. 
 
 It has been asked, whether the ligature on the cord is indispen- 
 sable, and if, after the regular establishment of respiration, the cir- 
 culation in the vessels is not arrested ? It is true that, in a great 
 number of cases, such is the fact ; but as experience has shown 
 that hemorrhages fatal to the child have occurred where the cord 
 has not been tied, it is our duty never to omit this precaution. 
 
 Such is the course I am in the habit of pursuing when the infant 
 is healthy ; but if I have the slightest fear of its life, I immediately 
 cut the cord seven or eight fingers' breadth from the abdomen, and 
 compress the extremity with the thumb and index finger; the 
 child is then removed to a table prepared for this purpose near a 
 window, which I cause to be opened. In order that I may carry 
 the child properly in this case, I place the thumb and index finger 
 which compress the cord between the upper portion of the thighs, 
 the three other fingers support the breech, while with the other 
 hand I support the shoulders and head ; I then proceed actively to 
 administer to the infant all necessary attention. 
 
 Art. I. — Apoplexy of the Newborn Infant. 
 Frequently, after a long and tedious labour, the infant is born 
 apoplectic ; the surface of the body is swollen, the face bluish, and 
 there is an absence of all motion ; the limbs are flexible, and the 
 body preserves its heat ; the pulsations of the cord and heart are 
 obscure, and even imperceptible. The first indication, in this case, 
 is to remove the engorgement from the brain and lungs. For this 
 purpose, a few teaspoonfuls of blood should be allowed to escape 
 from the extremity of the cord. Often, in order to determine this 
 escape, it will be necessary to make several successive sections 
 of the end of the cord. Hence the utility of dividing it at first 
 seven or eight fingers' breadth from the umbilicus. At the same 
 time, the posterior fauces should be cleared of the mucosities, eithei 
 with the little finger, or with the feathers of a quill prepared for 
 this purpose. During these operations, the infant should be ex- 
 posed naked to the action of the air. The respiration is thus estab- 
 lished, and the blue aspect of the body is succeeded by a rosy tint. 
 
 Art. II.— Asphyxia. 
 
 Extreme paleness of the surface, flaccidity and softness of the 
 flesh, absence of respiration especially, and general coldness, with, 
 
214 ATTENTIONS TO CHILD AND MOTHER AFTER DELIVERY. 
 
 however, persistance of the pulsations of the heart, characterize as- 
 phyxia. This accident manifests itself in a child born weak or be- 
 fore term, and after manual or prolonged deliveries. In this case, 
 we must be careful not to allow any blood to escape by the cord, 
 and a temporary ligature should be immediately applied. The 
 window before which the infant is placed should be wide open ; 
 and the head, face, and chest of the child exposed, in order that 
 they may receive the direct impression of the air ; all the other 
 parts of the body must be enveloped in warm cloths, which should 
 be frequently renewed. Frictions should be made on the chest 
 with the hand, or a piece of linen or flannel saturated with cold 
 vinegar and water, or brandy ; a few drops of ether may be placed 
 on the chest, while with the other hand the nose and throat may 
 be gently irritated by means of a feather, and any mucus which 
 may have collected removed. Percussion with the hand on the 
 breech is likewise useful, and the blows may be given with some 
 little force. Desormeaux has also suggested a means, from which 
 I have derived great advantage : it consists in throwing, with a 
 brisk movement, from the mouth a jet of brandy on the chest of the 
 child. While these different remedies are being administered, a 
 small lavement may be given ; and a bath is to be prepared, into 
 which the child should be plunged as soon as it begins to make 
 a few inspirations. Frequently, a few minutes will suffice to re- 
 store the child to life ; but sometimes it becomes necessary to per- 
 sist for a long time in the use of these remedies ; we should not re- 
 lax, but, on the contrary, persevere in our attempts, with renewed 
 energy, for some children are not resuscitated until an hour or two 
 of well-directed effort. It is especially in this case that insufflation 
 is indicated, either by direct means, the mouth of the accoucheur 
 being applied over the mouth of the infant, or through the agency 
 of Chaussier's laryngeal tube. I have frequently succeeded in this 
 way ; and frequently, too, entirely failed. 
 
 This operation requires a certain degree of skill, and it should 
 be performed with great precaution, for a too rapid or prolonged 
 insufflation may rupture the pulmonary vesicles. 
 
 The following is the mode of proceeding : 
 
 The extremity of the tube should be introduced into the larynx 
 with the right hand, the left being employed in giving proper direc- 
 tion to it through the anterior wall of the neck ; then the two angles 
 of the mouth are to be closed, in order to prevent the escape of 
 air ; a small quantity of air is now gently introduced, and pressure 
 is to be made on the chest to simulate expiration. Finally, these 
 attempts at insufflation and expiration must be renewed as often 
 as may be deemed necessary. 
 
 It is rare for these two accidents, apoplexy and asphyxia, to 
 manifest themselves separately ; they are almost always combined. 
 In this case, the various means of treatment suggested must be 
 employed. 
 
CONGENITAL WEAKNESS. 215 
 
 Art. III. — Congenital Weakness. 
 
 Children bora before term, or after serious disease of the mother, 
 require great attention ; they should be enveloped in soft cotton, 
 and exposed to a warm temperature. The best means of effecting 
 the latter would be to place around them bottles of warm water, 
 or, still better, to put them in a metallic cradle, to be surrounded 
 by boiling water. 
 
 Instances are mentioned of children born extremely weak, and 
 scarcely arrived at the period of viability, whose lives have been 
 preserved by means of this species of incubation. 
 
 § 1. Dressing the Infant. 
 
 Before dressing the mfant, and after being assured that there is 
 no malformation, the albuminous matter which ordinarily covers 
 the surface of the body should be removed. To do this most ef- 
 fectually, the body should be lubricated with sweet oil, cerate, or 
 fresh butter, and then wiped with a piece of linen ; but, in order to 
 leave no impurity, the child should be placed in warm soap-water, 
 and properly washed. 
 
 This being done, the infant is then to be placed on warm linen 
 spread on the knees of the nurse, who will carefully dry it. 
 
 The head must be covered, in the first place, with a cap of fine 
 linen, and then with one of flannel; also a shirt of linen, open 
 behind, and then a second and third of some warmer material, ac- 
 cording to the temperature ; these should be fastened with strings. 
 In general, pins should not be used, for they may injure the child. 
 Moreover, when the child cries without any known cause, the 
 nurse is very apt to suppose that it is in consequence of a pin 
 pricking it, and she is constantly undressing the infant. 
 
 Before finishing the toilet of the infant, the cord should be dress- 
 ed with a linen compress, with a hole in the centre, through which 
 the cord is to be drawn : the whole should be raised above the um- 
 bilicus. A second compress should be placed over the first ; then 
 there should be two or three turns of a bandage, to be fastened 
 with a needle and thread: a loose dress is to be put on the 
 infant, and it must be protected against cold. It should then be 
 placed in the cradle on its side, and on no account laid on a sofa 
 or arm-chair, for fear some one might sit on it. Infants have fre- 
 quently been sacrificed in this way, and too much caution cannot 
 be used. 
 
 As soon as the accoucheur has completed his duties to the in- 
 fant, he should return to the mother, and give her his attention. In 
 simple pregnancy, he will proceed to deliver the placenta ; but if 
 there should be a second infant in the uterus, he must first await its 
 expulsion. 
 
 Art. IV. — Natural Delivery of the After-birth. 
 Immediately after the expulsion of the foetus, the uterus, in vir- 
 tue of its organic contractility of tissue, returns upon itself; the 
 
21 G ATTENTIONS TO CHILD AND MOTHER AFTER DELIVERY. 
 
 cellular attachments which unite it to the placenta are broken, and 
 this latter organ, separated, presents itself at the orifice of the 
 womb. The neck of the uterus is short, soft, and unequal ; it can 
 be easily penetrated, but the internal orifice is more resisting. 
 However, it is not necessary for the neck to become again effaced 
 in order to afford a passage to the placenta ; it opens readily, and 
 the after-birth passes it in totality or in part, and enters the vagi- 
 na ; it is rarely found expelled out of the vulva. The placenta 
 once delivered, the neck becomes firmer and increases in length, 
 but it still dilates, to allow the coagula to pass. As a general rule, 
 it is not until thirty days that it resumes its natural dimensions. 
 
 Should the delivery of the after-birth be left to the spontaneous 
 efforts of nature, or should it always be aided ? Experiments made 
 byM. P. Dubois at La Clinique will enable us to decide this ques- 
 tion without difficulty. If the expulsion of the placenta be commit- 
 ted to the uterine and vaginal contraction in a certain number of 
 women, it will be observed that in very few it is expelled sponta- 
 neously, and with rapidity ; but in the others, in whom the expul- 
 sion takes place, it requires a longer or shorter time — one, two, 
 and even five to six hours after the birth of the child ; that in some 
 the expulsion does not take place at all ; and that, generally, in 
 these latter cases, artificial delivery, now become necessary, will 
 be the more difficult in proportion to the delay, the retraction of 
 the internal orifice becoming more and more energetic. 
 
 It results, from these facts, that the delivery should always be aid- 
 ed. From fifteen to twenty minutes after the birth of the child, 
 the accoucheur should ascertain whether the patient has felt any 
 pains, for these indicate the separation of the placenta ; he then ex- 
 amines per vaginam, to discover whether this organ has reached 
 the mouth of the womb, while, with the other hand placed on the 
 abdomen, he assures himself of the condition of the uterus, wheth- 
 er it forms a globular body, and is hard in the right hypogastric 
 region. If the separation has taken place, he proceeds at once to 
 the extraction of the placenta. He envelops the cord with a piece of 
 linen, in order to prevent its slipping from the fingers ; he then pla- 
 ces two or three folds of it around the index finger, and makes 
 traction first in the direction of the axis of the superior strait ; and 
 afterward, in proportion as the placenta descends, he pulls in the 
 direction of the axis of the inferior strait. During this time, he 
 should take the precaution of placing the other hand on the fundus 
 of the womb, in order to see that it is not drawn down, which 
 would be likely to happen if the placenta were not completely de- 
 tached.* 
 
 * The management of the placenta constitutes one of the most important duties of the 
 accoucheur. As a general rule, the real dangers of parturition are directly connected more 
 or less with the delivery of the after-birth. Hemorrhage, inversion of the womb, prolapsus of 
 this organ, laceration of the placenta, tearing away the umbilical cord, are all so many accidents, 
 most of them fearful in their consequences, resulting from the mismanagement of the placen- 
 ta. Let the student, therefore, be on his guard, and not suppose that his duties are termina- 
 ted, or that his patient's safety is secured by the mere delivery of the child. As "I have re- 
 marked in a preceding note, as soon as the foetus is expelled the accoucheur should place his 
 hand on the abdomen of the mother, to ascertain the condition of the uterus— whether it is con- 
 
DELIVERY OF THE AFTER-BIRTH. 217 
 
 In proportion as the placenta presents at the vulva, the accou- 
 cheur should rotate it between the two hands, in order to form a 
 cord of the membranes, and thus give them more consistence. 
 Without this precaution, some portion of them may remain in the 
 uterus, and occasion difficulties of which we shall speak hereafter. 
 
 If the separation has not been completed, he must wait ; frictions 
 are to be made on the uterus, and slight tractions on the cord. If, 
 in the course of an hour, the separation should not have taken 
 place, it would not be prudent to delay any longer, as much on ac- 
 count of the patient, as for fear the extraction of the after-birth 
 should become more and more difficult. The hand should be in- 
 troduced into the womb, in order to effect artificial delivery. (See 
 Artificial Delivery.) 
 
 Immediately after the extraction of the placenta, it should be as- 
 certained that it is entire, and that no portion of it or of the mem- 
 branes remains in the uterus. Should this occur, the accoucheur 
 should proceed at once to remove it. 
 
 tracted. If this be the case, he may remain easy, for there is no danger of hemorrhage. In ten, 
 fifteen, or twenty minutes after the delivery of the child, the mother will complain of pains, 
 simulating in their character labour-pains ; these are nothing more than the contractions of 
 the womb, which will speedily result in the separation of the placenta from its internal sur- 
 face. The patient, especially if it be her first child, often becomes alarmed by these pains, 
 supposing that she is again to encounter all the agony of childbirth. The accoucheur should, 
 therefore, explain the nature of the pains, their object, &c. In proportion as the placenta 
 becomes detached from the internal surface of the womb, there will be a slight discharge of 
 blood, and this usually takes place immediately after the pain. The pains, therefore, togeth- 
 er with the discharge of blood, will indicate that nature is engaged in detaching the placenta. 
 When the patient has experienced several of these pains, and a discharge of blood has fol- 
 lowed, and, above all, the accoucheur feels the uterus well contracted in the hypogastric re- 
 gion, he is then assured that the placenta is completely separated from the uterus, and if he 
 introduce his finger, he will find it lying over the mouth of the womb, and sometimes pro- 
 jecting in part through this orifice. Under these circumstances, he can proceed to extract it 
 as follows. The cord being enveloped with linen, he makes two or three twists of it around 
 the fingers of the right hand, while he introduces the index finger of the other hand into the 
 vagina, carrying it up to the mouth of the uterus ; this finger then seizes the cord close to 
 the after-birth, and makes traction downward and backward in the direction of the axis of 
 the superior strait : when the placenta passes out of the womb and is in the vagina, the ex- 
 traction is to be made in the line of the inferior strait, always remembering to withdraw the 
 placenta by rotating it, in order that the membranes may be twisted into a cord, and not be 
 left in the uterine cavity, which would often result seriously. As soon as the after-birth has 
 come away, the accoucheur should carefully introduce his finger into the vagina, and re- 
 move any coagula of blood that may be there, and he should particularly ascertain whether 
 there is a clot of blood keeping the mouth of the womb open ; if so, it should be immediately re- 
 moved. Should this coagulum be suffered to remain, hemorrhage will frequently be the re- 
 sult, and the patient, under any circumstances, will be exposed to much unnecessary suffer- 
 ing by the severe contractions of the uterus, occasioned by the presence of the coagulum. 
 
 When the placenta is still high up in the womb and not completely detached, the accoucheur 
 should not make traction on the cord ; for he will either lacerate the placenta or cord, or, if the 
 adhesions between the placenta and womb be sufficient to resist the force of the traction, 
 the womb itself will often be inverted. In this case, he should endeavour to stimulate the 
 uterus to contractions by frictions on the abdomen. Should these not be sufficient to sep- 
 arate the after-birth, he must then have recourse to the artificial delivery of this organ, the 
 rules for which will be given under the appropriate head. 
 
 As soon as the placenta has been removed, the accoucher should have a bandage applied 
 around the body of" his patient. This bandage should consist of a fold of linen about fourteen 
 inches wide, and sufficiently long to enciicle the body. It should be applied without moving 
 the patient, and should be placed next to the surface of the body. It should be drawn down 
 well under the hips, and secured with pins ; the pressure of the bandage must be gentle 
 and uniform. Many fashionable women are in the habit of using variously-constructed cor- 
 sets for this purpose : these corsets are usually stiff and unyielding, like the prejudices of 
 their patrons, and often prove injurious. — Ed. 
 
 E E 
 
218 ATTENTIONS TO CHILD AND MOTHER AFTER DELIVERY. 
 
 § 1 . Delivery in case of Twins. 
 
 I have already observed, and I now repeat it, that, in cases of 
 twins, we should be careful not to remove the placenta of the first 
 child until after the birth of the second. There almost always 
 exist vascular communications between the placentas ; and any trac- 
 tions exerted on the first would almost certainly result in the pre- 
 mature separation of the other, which would expose both mother and 
 child to the danger of hemorrhage.* 
 
 Finally, after the birth of the twins, in order to extract the after- 
 births, we should make tractions on one of the cords, first on the 
 one which offers the least resistance, and afterward on the other, 
 before pulling upon both cords. In this way the placental mass de- 
 scends by one of its extremities, and is more readily extracted. 
 
 § 2. Attentions to the Woman immediately after the Delivery 
 of the Placenta. 
 
 Immediately after the removal of the after-birth, the accoucheur 
 should ascertain, by a vaginal and abdominal examination, that the 
 fundus of the womb has not been drawn down by the placenta ; 
 for it should be remedied at once, by introducing into the uterus 
 one hand, which would push up the inverted fundus ; then frictions 
 on the abdomen should be made, in order to facilitate the action of 
 the uterus, which should form a hard tumour on the right side. 
 This being done, the woman should be permitted to repose for 
 about a quarter of an hour, in order that the blood, which the womb 
 furnishes abundantly just after delivery, may be discharged. Du- 
 ring this interval, articles necessary for her toilet should be pre- 
 pared ; the clothes and linen, as also her bed, should be well warm- 
 ed, and a dry and warm fold of linen should be passed under her. 
 The genital organs and upper portion of the thighs should then be 
 gently and cautiously washed with a sponge wet with warm wa- 
 ter, and afterward dried with soft, warm linen. The clean chemise 
 should then be placed over the head of the patient, and she should 
 be assisted in removing the other, without subjecting her to cold ; 
 then her ordinary nightgown should be furnished, and all the soiled 
 clothes removed from her. All this should be done as much as 
 possible under cover, and with due celerity. The patient should 
 be protected with a light covering, and then removed to her bed, 
 previously warmed : under no circumstances should she be per- 
 mitted to walk to it. It will require more address than strength 
 to transport the patient from one bed to another ; and, in general, 
 the accoucheur should charge himself with this duty. For this pur- 
 pose, he should pass the right arm under the limbs of the patient, 
 support the back with the left, and allow her to keep herself in a 
 fixed position, by throwing her arms around his neck. She will 
 thus be carried without difficulty, and placed on the bed prepared 
 for her. 
 
 * Dr. Chailly is certainly wrong in the assertion that there almost always exist vascular 
 connexions between the two placentas. Such, at all events is not the experience of other 
 practitioners.— Ed. 
 
REGIMEN, ETC. 219 
 
 Art. V. — Attentions necessary to the Puerperal Woman 
 
 and Infant. 
 The chamber of the parturient female should have a proper ven- 
 tilation, and be of a moderate temperature ; the labour-bed and soil- 
 ed linen should be removed as soon as possible, and but little light 
 admitted into the room. 
 
 § 1. The Accoucheur should not leave the Patient immediately after 
 
 her Delivery. 
 
 Soon after the patient has been put into her bed, she sometimes 
 experiences inexpressible comfort ; at other times she is attacked 
 with a chill and chattering of the teeth ; but this chill is ordinarily 
 of short duration, and she has a desire to sleep. 
 
 Whether she sleeps or not, the accoucheur should remain for 
 some time with his patient after the birth of her child. He should 
 examine carefully the pulse, and condition of the uterus. Some 
 women, left to themselves, have been attacked with serious hem- 
 orrhage during their sleep, and have passed from sleep to death ; 
 others, taken with flooding at the moment the accoucheur left 
 them, have expired before it was possible to recall him. There- 
 fore, the patient should not be committed to the charge of the nurse 
 until after the lapse of two hours. 
 
 § 2. Regimen. 
 
 If the patient complain of hunger, she may take some warm 
 broth ; she should be advised to avoid all emotions, either sad or 
 gay ; and no one should be permitted to visit her except her im- 
 mediate family, and the visits of these should be short. The most 
 absolute quiet should be observed by the nurse. For drink, sugar 
 and water, the infusion of linden, and orange leaf, and sirup of gum, 
 &c, may be prescribed. Finally, after being assured that the pa- 
 tient does not flow, and having given general directions, the ac- 
 coucheur may retire. 
 
 During the first five or six hours which succeed the delivery, 
 the pulse, from being corded and frequent as it was, becomes soft 
 and full ; the skin is soft and humid, and there escapes from the 
 womb blood sufficient to soil three or four napkins. 
 
 § 3. First Visit of the Accoucheur. 
 
 At his first visit, which should be made as early as possible, the 
 accoucheur should inquire whether his patient has urinated, and he 
 should examine the chamber for himself, in order that he may see 
 the quantity. Frequently the pressure exerted upon the bladder 
 and urethra, during the passage of the head, renders the emission 
 of water difficult, and sometimes impossible ; the catheter then be- 
 comes necessary. 
 
 It has very often happened that accoucheurs, having neglected 
 to inform themselves whether or not the urine has been voided, 
 have supposed the pains caused by the retention of urine, and which 
 
220 ATTENTIONS TO CHILD AND MOTHER AFTER DELIVERY. 
 
 would have ceased at once if the catheter had been introduced, to 
 be the commencement of peritonitis, or inflammation of the womb, 
 and leeches, bleeding, baths, cataplasms, &c, have been directed. 
 Happy, indeed, if the error is soon discovered ; for women, through 
 an inconceivable ignorance of their medical attendants, have been 
 known to succumb with the most excruciating suffering, and all 
 owing to extreme distension of the bladder. It is proper to remark 
 that death, in this case, is occasioned by gangrene of the bladder, 
 or rupture of this organ, which is followed by a most frightful per- 
 itonitis ; this latter accident has been more than once mistaken for 
 rupture of the womb. 
 
 It must not be supposed that this is a heightened picture ; these re- 
 tentions of urine after labour are sufficiently frequent; and during the 
 fourteen years I have been in practice, I have been more than once 
 called to administer in similar cases. In one instance, I was called 
 to a lady who had been attended by an excellent practitioner, but 
 who was a stranger to these important little details, which persons 
 alone remember who are constantly in the habit of attending the 
 lying-in chamber. 
 
 The merited consideration which this honourable confrère en- 
 joyed in other respects rendered my position very embarrassing, 
 for I was aware that, on introducing the catheter, I should at once 
 remove all the alarming symptoms, and deprive my honourable 
 compeer of the reputation of the cure. I therefore approved of 
 all that had been done, leeches, &c, &c, and assured the friends 
 that the remedies employed had brought the disease to that point 
 that it could be subdued almost instantly ; but I observed to my 
 confrère that I thought the catheter should be used. This was a 
 ray of light to him. I retired ; the patient was removed from the 
 bath in which she was when I was called, the catheter was imme- 
 diately introduced, and the cure was as prompt as I had promised. 
 I have often heard M. P. Dubois relate analogous cases. 
 
 § 4. General Examination of the Patient. 
 After being satisfied that the urine has been voided, the accou- 
 cheur should examine the napkins that have been soiled ; he should 
 ascertain the condition of the abdomen by placing his hand under 
 the bedclothes, and without in any way exposing the patient ; he 
 should press lightly on each iliac region, and if there should be no 
 tenderness, he will have no cause for uneasiness ; the state of the 
 pulse will be an excellent guide in this case, for there is always 
 frequency of the pulse with the commencement of peritoneal in- 
 flammation. 
 
 § 5. Prescriptions. 
 Ablutions with warm water, or with an infusion of chervil, 
 should be recommended two or three times a day ; but great care 
 should be taken not to expose the patient. Whenever she desires 
 to pass her urine or fasces, a bed pan must be used. The most 
 absolute repose should be again enjoined ; the bed of the patient 
 
EXAMINATION OF THE INFANT, ETC. 221 
 
 should not be disturbed, and an interdict put upon visiters ; the 
 mother and husband alone should be admitted, and these but for a 
 short time. The patient requires the most complete silence and 
 repose, and she should be alone with the nurse. 
 
 § 6. Examination of the Infant 
 
 The accoucheur should inform himself as to the state of the 
 child, whether the meconium and urine have been expelled; if 
 necessary, the evacuation of the intestines may be aided by a little 
 sugar and water, in which may be put a teaspoonful of the sirup of 
 rhubarb ; or small lavements may be administered. If the mother 
 nurses her child, all these means will be unnecessary, for the colos- 
 trum, or first milk, will be sufficient to open the bowels of the in- 
 fant. I am in the habit of having it put to the breast as soon as 
 the patient has had a few hours' repose. Some accoucheurs rec- 
 ommend to wait until the milk fever ; I do not concur in this opin- 
 ion; for the child has, at this period, difficulty of seizing the nip- 
 ple, which is effaced by the tension of the breasts ; and, moreover, 
 the artificial feeding, to which recourse must be had, does more or 
 less injury to the child. 
 
 § 7. Death of the Infant from Starvation. 
 
 Some infants, after their birth, do not exhibit the slightest desire 
 for food ; they sleep continually, will not suck the finger when put 
 into their mouth, nor will they take the breast. If it should be 
 supposed, from this, that the child does not need nourishment, and 
 proper care be not taken to awake it from this lethargic sleep, fa- 
 tal consequences will soon ensue. It will be necessary to place 
 the child before the fire, and use frictions over the whole surface 
 of its body, and apply small mustard sinapisms to the feet ; warm 
 milk with sugar and water should be given by the mouth. I have 
 seen children who, without these precautions, would have died of 
 absolute starvation. 
 
 § 8. First and Second Day of lying in. 
 
 During the first and second day, the bowels of the patient will 
 not require any attention, unless they should not have been evac- 
 uated before the labour ; in this case, it will suffice to administer a 
 simple lavement. The nourishment should consist of gruel, toast- 
 water, tea, &c. Until after the milk fever, the patient should be 
 visited twice a day. 
 
 After-pains. 
 
 The accoucheur should not confound a physiological result, the 
 after-pains, with that morbid distress which announces the inva- 
 sion of inflammation ; the after-pains are not accompanied with 
 fever, and are intermittent. They result from the effort made by 
 the uterus to discharge the coagula it contains, and press out the 
 blood still in its walls ; and, during these contractions, the accou- 
 
222 ATTENTIONS TO CHILD AND MOTHER AFTER DELIVERY. 
 
 cheur can feel, through the abdominal parietes, the uterus, which 
 forms a round tumour. The patient will be conscious that a small 
 quantity of blood flows at each contraction. The after-pains, 
 more frequent and intense in women who have had children than 
 in primiparse, who, indeed, are often exempt from them, commence 
 most generally after the expulsion of the after-birth ; at first, feeble 
 and rare, they become more frequent, and cease during the milk 
 fever ; but sometimes they are reproduced afterward. It is un- 
 usual, however, for them to continue during the first eight or nine 
 days. These pains are sometimes so severe as to require inter- 
 ference on the part of the accoucheur. The application of a flax- 
 seed poultice to the abdomen and vulva will be found useful, should 
 there be no disposition to hemorrhage ; in the latter case, lotions of 
 laudanum to the lower portion of the abdomen, or 10, 15, to 20 
 drops in lavement should be administered.* Should the uterus be 
 of more than usual volume, and the pains appear to be occasioned 
 by coagula of blood, an attempt should be made to remove them 
 with the finger ; and if this is impracticable, ergot should be admin- 
 istered, as recommended by M. Velpeau. 
 
 b. Lochice, 
 
 The term lochia is applied to the discharge which takes place 
 from the vagina from delivery until the restoration of the womb 
 to its normal volume. Immediately after the removal of the pla- 
 centa and the flow of blood which accompanies it, a small quan- 
 tity of pure blood escapes from the uterus. After twelve or fif- 
 teen hours, the blood loses its consistence, its colour becomes light- 
 er, and there is merely a discharge of sanguineous serum ; but usu- 
 ally all discharge ceases during the milk fever. As soon as this 
 is terminated, the lochiae reappear, but they are of a yellowish- 
 white colour. The duration of this discharge is sometimes fifteen 
 days, three weeks, or a month ; sometimes even, in women who 
 do not nurse, and only in such, it will continue for six weeks, or 
 even longer. The lochia is also more abundant in the latter 
 
 * Many patients object to enemata, and the indication can, in my judgment, be as well, 
 if not more effectually met, by the administration of a calming potion by the mouth. I 
 am in the habit, when the after-pains are severe, of ordering the following mixture, which 
 will scarcely ever fail in producing the desired effect : 
 
 # Sirup Papav., 31J. 
 Mucil. Acacias, §ij. 
 
 Sol. Sulph. Morphias, gtt. x. 
 Ft. mist. 
 One half to be given, and if the suffering is not allayed, the remaining half in two 
 hours. 
 
 Also, instead of having recourse to enemata for the purpose of relaxing the bowels, 
 I would recommend, on the third day after delivery, the administration of castor oil or 
 magnesia. If these should be objectionable, the common black draught will be found 
 useful. 
 
 # Infus. Sennae, ^ijss. 
 Sulphat. Magnesias, 3ÙJSS. 
 Mannae, 3iij. 
 
 Tinct. Jalapae, 3L 
 Ft. haust. 
 This prescription has been long in favour, and will generally be found to answer the pur- 
 pose.— Ed. 
 
MILK FEVER, ETC. 223 
 
 than in those who nurse their children. Frequently the sanguine 
 ous discharge continues much longer than the ordinary period, 
 and is often reproduced after having ceased, when the patients 
 leave their beds too soon after delivery. However, it must be re- 
 marked that, in almost all women, this discharge often assumes a 
 reddish hue the first time they attempt to leave their bed, even 
 after the fifteenth day ; lactation diminishes both its duration and 
 quantity. In consequence of the changes which this discharge un- 
 dergoes, the lochia is distinguished by the names of sanguineous, 
 and serous, or puriform ; it has an odour sui generis, which varies 
 according to the patient. When it becomes fetid, no matter what 
 the cause may be, weak aromatic injections with chamomile should 
 be prescribed, and the parts frequently bathed. 
 
 The abundance of this discharge varies very much during the 
 first twenty-four hours ; women soil, ordinarily, from eight to ten 
 napkins, and this number diminishes every day.* 
 
 c. Milk Fever, 
 
 The milk fever generally appears between the fortieth and six- 
 tieth hour. The breasts become tumid and hard, the subcutane- 
 ous veins are engorged, and the patient is troubled, more or less, 
 with cephalalgia ; the skin is hot and dry at first, and then abun- 
 dant perspiration ensues ; the pulse, at first small and corded, soon 
 becomes full and soft ; the tongue is slightly coated, and the face 
 flushed. 
 
 Rarely, a slight chill precedes the invasion of this fever ; the 
 breasts swell more and more ; the patient cannot bring her arms 
 to her body ; but, at the end of twenty- four or thirty-six hours, all 
 these symptoms disappear. 
 
 The accoucheur, during this period, should watch the patient 
 with great attention, and see that his directions are strictly enfor- 
 ced. The chest should be covered with a handkerchief of thick 
 muslin ; and, for fear of cold, all ablutions and lavements should 
 be dispensed with, unless especially indicated. 
 
 The patient must be put upon rigid diet. The milk fever is 
 often very light in women who nurse ; it sometimes even does not 
 make its appearance. 
 
 § 9. Regimen after the Milk Fever. 
 The fever once passed, nourishment may be allowed. Howev- 
 er, if the breasts continue engorged, broths alone should be given ; 
 
 * The lochial discharge is sometimes very small in quantity ; at other times it becomes 
 arrested, and continues so for several days ; and this circumstance, especially in plethoric 
 women, may lead to serious consequences if neglected by the accoucheur. In either case, 
 when the lochial discharge is slight, or arrested beyond the period of the milk fever, I usually 
 order warm flaxseed poultices, containing about 3 ij of powdered camphor, to be placed over 
 the vulva and lower portion of the abdomen. The poultices should be renewed as soon as they 
 lose their heat, and should be continued until the return of the discharge, which usually will 
 take place after one or two applications of these cataplasms. They will be found admirably 
 adapted to such cases. If, however, the discharge should not return, and there should be 
 fulness of the head, or congestion elsewhere, it will be proper to abstract blood from the 
 arm, &c— Ed. 
 
224 ATTENTIONS TO CHILD AND MOTHER AFTER DELIVERY. 
 
 a gentle laxative, either by the mouth or in lavement, may also 
 become necessary. 
 
 The quantity of food may be cautiously increased, but it should 
 be of easy digestion. The twelfth or eighteenth day the patient 
 may begin to indulge in her ordinary diet. 
 
 a. Separation of the Cord. 
 In general, the cord separates and falls off about the fourth or 
 fifth day, although it may happen before or after this period. The 
 accoucheur should examine the umbilicus with attention ; if it sup- 
 purates after the separation of the cord, a compress, smeared with 
 cerate or fresh butter, should be applied until the tenth or twelfth 
 day, when the cicatrization is complete, and the compress should be 
 kept in place by a bandage drawn sufficiently tight. Should there 
 be an exomphalos, graduated compresses, or a cotton pad of proper 
 resistance, should be put under the bandage. 
 
 b. Making the Bed. 
 The bed of the patient should not be made until after the milk 
 fever, and then this should be done every day ; the patient should 
 be placed in another bed, where she should remain until her own 
 is properly prepared. From the ninth to the fifteenth day, and not 
 before, due regard being had to the temperature and the different 
 circumstances of the patient, she may be permitted to sit in an 
 arm-chair for an hour or two for two or three consecutive days, 
 after which she may gradually attempt to walk about her room. 
 
 § 10. First Going out of the Patient. 
 She should not venture out until between the twentieth and 
 thirtieth day, especially in winter. Indeed, it would be more pru- 
 dent, in this case, to postpone it until the end of six weeks. She 
 should not be permitted togo to church too soon to return thanks 
 to God for her happy delivery ; for, generally, the temperature is 
 cold and humid, even in summer, and the patient would be exposed 
 to serious danger. 
 
 11. Attention to the Bowels of the Patient. 
 Each day, after the milk fever, the patient should have a lave- 
 ment administered. If simple water is insufficient, a small quan- 
 tity of mercurialized honey may be added to it. If this should not 
 take effect, some castor oil, either in warm herb or chicken broth, 
 may be given ; I like this mode of administering the oil. In the 
 first place, the oil itself is gentle, and, in the majority of cases, 
 purges without producing pain, and never occasions excessive ac- 
 tion ; secondly, given in very warm broth — as warm, indeed, as it 
 can be taken — it loses much of its disagreeable taste, which is not 
 the case when mixed, as is generally advised, with lemon sirup. 
 
 § 12. Specifics to prevent Milky Deposites. 
 Some females believe in milky deposites, and have an extreme 
 
COMPLICATIONS INCIDENT TO LABOUR. 225 
 
 dread of them ; they are in the habit of asking the accoucheur for 
 some specific, and also for purgative medicine. Unless there 
 should be some contra-indication, laxatives should be allowed ; 
 they cannot but prove useful ; and, moreover, if denied by the ac- 
 coucheur, he will be blamed for any disease that may occur for 
 fifty years afterward, for it certainly will be attributed to his ob- 
 stinacy. Castor oil or seidlitz powders I prefer in such cases. 
 
 Complications which may manifest themselves during the Pe- 
 riod of Accouchement, when the Vertex presents. 
 
 In most cases, delivery is a natural function, capable of being ac- 
 complished by the resources of the organism. The accoucheur is 
 then but a simple spectator of the parturient process ; but a multi- 
 tude of circumstances may occur to impede the progress of de- 
 livery, render it dangerous, or altogether impossible. It then be- 
 comes necessary to aid nature, and rescue the mother and child 
 from the dangers with which they are menaced. 
 
 In the enumeration of these complications, I will not pursue the 
 plan usually adopted, but will arrange them as nearly as possible 
 in reference to the difficulties they may occasion, and to the oper- 
 ations which may become necessary from the commencement to 
 the termination of the labour. I will likewise indicate, after each 
 complication, the necessary treatment, reserving what I shall have 
 to say of version, the forceps, &c, &c. Moreover, the indications 
 and the manner of operating not being the same in all the present- 
 ations, I shall arrange them, first, in reference to the presentation 
 of the vertex, then of the face, pelvic extremity, and trunk. 
 
 CHAPTER I. 
 
 COMPLICATIONS WHICH MAY RETARD OR PREVENT LABOUR. 
 Art. I. — Inefficient Contractions — Inertia of the Uterus. 
 
 Inefficient uterine contraction manifests itself especially in wom- 
 en of frail constitution, and who have been debilitated by serious 
 disease. In these, the contractions are not only feeble, but of very 
 short duration ; they do not tell, as is vulgarly said. The dilata- 
 tion of the orifice of the womb is slow, and the membranous sac 
 makes but little pressure upon it. If the membranes are ruptured, 
 the head scarcely rests on the orifice. 
 
 The accoucheur should, as far as possible, support the strength 
 of the patient by slight tonics, wine, &c. ; and if these means are 
 insufficient, ergot should be administered, but only when the dila- 
 tation is nearly completed. 
 
 F F 
 
226 COMPLICATIONS WHICH MAY RETARD OR PREVENT LABOUR. 
 
 § 1. Debility peculiar to the Uterus. 
 
 The debility peculiar to the uterus, although the constitution of 
 the patient is otherwise good, may likewise determine the same phe- 
 nomena. Frequently the whole energy of the uterus is exhausted 
 at the commencement of labour in producing powerful contrac- 
 tions ; these contractions soon lose their intensity, and cease alto- 
 gether. 
 
 It then becomes necessary to apply frictions to the abdomen, titil- 
 late the neck of the uterus, recommend the patient to walk about 
 the room, and administer ergot. 
 
 Ergot. 
 
 Ergot should be pulverized at the moment it is to be used, other- 
 wise it loses its virtues. 
 
 This medicament possesses the property of increasing and ex- 
 citing uterine contraction ; no one at the present day seems to 
 doubt this fact. But it is not so generally admitted that it is capa- 
 ble of determining these contractions before they have manifested 
 themselves. For myself, I believe it can bring on contractions at 
 any time, but more particularly at an advanced period of pregnan- 
 cy.* I have never administered it previous to the occurrence of 
 uterine contraction, until after the period of fœtal viability, and in 
 no instance, in these cases, have I known it to fail. 
 
 Besides its efficacy in inertia uteri, ergot possesses certain hem- 
 ostatic properties, which render it of great value in uterine hem- 
 orrhages. In this case, it acts on the proper organic contractility 
 of the tissue of the uterus ; while, in the former case, it awakens 
 and develops the organic contraction. 
 
 The contractions which it determines differ somewhat from the 
 natural contractions, which circumstance enables us to distinguish 
 whether or not the return of the pains is due to the action of the 
 ergot. They usually manifest themselves ten or fifteen minutes 
 after the administration of the medicine, and their effects continue 
 about an hour and a half. They are permanent, progress by ex- 
 acerbation, and there is no perfect calm between them, as in the 
 natural contractions; the uterus continues constantly contracted 
 upon the foetus. These contractions resemble very much certain 
 morbid contractions, to which I shall allude presently; they are 
 also fatiguing to the patient, but very different in their results, for 
 they determine the labour, while the morbid contractions have no 
 influence upon it. 
 
 This permanent uterine effort is sometimes followed by serious 
 inconveniences to the child. Some accoucheurs, supposing that 
 ergot may cause the death of the infant, have abandoned its use. 
 
 It is unfortunately true that this medicine is very much abused. 
 
 * A dwarf, of whom I shall speak more particularly hereafter, and whom M. P. Dubois 
 was obliged to deliver the first time with forceps, became again pregnant. In order to avoid 
 an operation, he resolved to bring on premature delivery. Ergot was administered before 
 any pain had commenced, at about the eighth month, and regular labour soon followed. 
 
ADMINISTRATION OP ERGOT. 227 
 
 I have often seen it administered in cases in which it was entirely- 
 useless ; and in some instances in which I have been called to 
 change an unnatural presentation, I have found the fœtus dead, and 
 the uterus so contracted upon itself, that the version was extremely 
 difficult ; and all this simply because, mistaking the indication, er- 
 got had been administered, instead of changing the presentation, as 
 should have been done. 
 
 This abuse, and these unfortunate results, have contributed to 
 throw discredit upon this medicine in the minds of many respecta- 
 ble practitioners ; but should we deprive ourselves of a precious 
 remedy because, when improperly prescribed, it is followed by- 
 serious inconvenience ? Certainly not. 
 
 I shall now mention the circumstances which, according to M. 
 P. Dubois, will justify or contra-indicate the use of ergot. 
 
 It should not be given, during labour, in case of feeble uterine 
 contractions or of complete inertia of the womb, except when the 
 pelvis is well formed, the head of the fœtus has its natural dimen- 
 sions, and the presentation such as to admit of spontaneous deliv- 
 ery. Thus, it should not be given in presentations of the trunk, or 
 where there is any serious difficulty about the neck of the womb, 
 either in consequence of a morbid condition or want of dilatation ; 
 nor should it be prescribed until after the rupture of the mem- 
 branes, and the proper dilatation or dilatability of the neck. Care 
 should likewise be taken not to administer it when the head is in 
 the pelvic cavity, or at the vulva, and when the fœtus is in danger. 
 It is necessary, under these circumstances, to have recourse to the 
 forceps. 
 
 It should not, if possible, be given to women with their first chil- 
 dren, for fear of a too rapid delivery, which might endanger the 
 perineum ; nor to nervous and very irritable women, nor to those 
 who are labouring under symptoms of congestion or plethora, or 
 whose uterine sensibility is very much heightened, and who are 
 disposed to inflammation. 
 
 Ergot is most generally administered in powder mixed in a 
 small glass of sugar and water ; the dose is one drachm divided 
 into three parts, which are to be taken at an interval of ten min- 
 utes, depending upon the effects produced. It has also been given 
 in decoction, infusion, tincture, &c. ; but, as its action is the more 
 efficacious in proportion as it is more recently pulverized, it is bet- 
 ter to administer it in powder. 
 
 Ergot, no matter in what form it may be given, is frequently 
 thrown off the stomach. In this case, it should be administered in 
 enemata ; and it is thus more rapidly absorbed than by the stom- 
 ach, and acts more directly upon the uterus. Hence, care must 
 be taken not to increase the dose.* 
 
 * Our author's remarks on ergot, and the indications for its employment, are most excel- 
 lent ; let them be attentively considered. The abuse of this agent has given rise in our 
 country to the most fearful results. Both mother and child have frequently been sacrificed 
 by the improper administration of this drug. I have now in my museum two ruptured wombs 
 taken from women to whom ergot had been given, and on whom attempts at version had 
 been made ! ! I was called to one of these cases about six months since ; I found the unfor- 
 
228 COMPLICATIONS WHICH MAY RETARD OR PREVENT LABOUR. 
 
 § 2. Plethora. 
 General or local plethora may also dimmish or suspend the 
 pains ; bloodletting is indicated in this case. 
 
 § 3. Moral Impressions. 
 Strong moral impressions, occasioned by the presence of per- 
 sons who are displeasing, the presence of an accoucheur different 
 from the one expected, &c, may produce similar effects. It is 
 the same with regard to any severe pain, foreign from uterine con- 
 traction ; no matter what the cause may be, the accoucheur should 
 endeavour to ascertain it, and, if possible, remove it. 
 
 § 4. Death of the Infant. 
 The death of the infant does not influence the contractions of 
 the womb, as some accoucheurs have supposed. The expulsion 
 of an infant, after it has ceased to live, takes place sometimes, it is 
 true, slowly ; at other times, art is obliged to interfere in order to 
 promote its delivery. But it must not be supposed that the death 
 of the infant occasions these obstacles ; for if the woman and uterus 
 are endowed with sufficient energy, the expulsion will take place 
 as rapidly as if the child were living ; and when the delivery is 
 protracted after the death of the infant, it does not depend on want 
 of action in the foetus, but rather because that the same causes 
 that have determined its death have also influenced the constitution 
 of the mother, and the energy of the uterus. 
 
 § 5. Extreme Distension of the Uterus. 
 The extreme distension of the uterus, whether it be occasioned 
 by the presence of several foetuses, or by an excessive accumula- 
 tion of fluid, may also induce debility — a suspension or complete 
 cessation of the pains. In fact, in ordinary cases, the ovum is not 
 entirely filled with amniotic fluid, and the uterus is not distended ; 
 thus, before the rupture of the membranes, it can press upon the 
 faetus, and cause a portion of it to descend into the orifice. When, 
 on the contrary, this organ has been forced to distend itself beyond 
 its ordinary limits in consequence of the abnormal increase of the 
 ovum, it loses, in part, its contractile property. This difficulty 
 may be remedied by rupturing the membranes, thus affording es- 
 cape to a portion of the liquor amnii. The uterus then finds itselî 
 
 tunate woman moribund ; about two hours before I saw her, she had been attacked with 
 vomiting. When I arrived she was nearly pulseless and speechless, with pallor of coun- 
 tenance, cold extremities, and a clammy perspiration. This woman had been in labour 
 about twenty hours, and the above symptoms manifested themselves about two hours before 
 my arrival. In looking at the woman, I pronounced it to be a case of ruptured womb, and 
 stated at the time that she must die. The physician in attendance did not concur in either 
 of these opinions. Nothing could be done in the case. The poor creature sunk before we 
 left the house; a post-mortem examination was requested, but refused. At 11 o'clock the 
 same evening the husband came for me, and said he was willing that the examination should 
 be made. Dr. Bu steed accompanied me, and the autopsy revealed the truth of the previous 
 opinion ; the womb was lacerated to the extent of six inches in its left lateral wall, and the 
 child had been thrown into the abdomen ! This was one of the beautiful results of the im- 
 proper use of ergot, followed by attempts at forced version. — Ed. 
 
RUPTURE OF THE MEMBRANES. 229 
 
 in a natural condition, and its organic contractility is then freely 
 exercised. 
 
 § 6. Resistance of the Membranes. 
 
 The membranes are occasionally so thick and resisting that the 
 energetic and continued contractions of the womb cannot easily rup- 
 ture them, although the dilatation may have been complete for some 
 time, and the membranous sac project into the vagina. If the ac- 
 coucheur does not interfere in this case, the rupture of the sac may 
 be delayed for a considerable period ; sometimes even the contrac- 
 tions will be altogether insufficient to produce it. The uterus then 
 falls into a state of inertia, and it becomes necessary to rupture the 
 sac artificially. 
 
 % 
 § 7. Rupture of the Membranes. 
 
 After having ascertained that the dilatation is complete, that the 
 presentation is favourable, and that there is no other mechanical obsta- 
 cle than the resistance of the membranes, it becomes the duty of the 
 accoucheur to rupture them. For this purpose, he should select the 
 moment of a strong contraction ; and while the sac is projected for- 
 ward, he should push against it the extremity of the index finger ; this 
 will frequently suffice ; but it sometimes becomes necessary to lacer- 
 ate the membranes with the finger nail, in order to weaken them, and 
 even occasionally to employ a pointed instrument; an ordinary 
 pen, for example, will answer the purpose. It must be introduced 
 on the index finger as far as the sac ; then, at the moment of a con- 
 traction, it should be slightly pushed with the other hand, and the 
 sac is thus penetrated without difficulty. The pen is the instrument 
 which, of all others, should be preferred ; it is flexible and harm- 
 less. It will sometimes be proper to curve it, in order to reach the 
 membranes more readily. 
 
 I have stated, as a principle, that the membranes should not be 
 ruptured until the dilatation is complete ; because, if done earlier, the 
 neck of the womb, not yet dilated, could not give passage to the 
 fœtus. The amniotic fluid having passed off, the contractions ne- 
 cessary to achieve this dilatation will be exerted directly upon the 
 fœtus, which, no longer protected by the fluid, is exposed, until the 
 dilatation is completed, to the contractile efforts of the uterus, and 
 may be destroyed by this compression. 
 
 But there are exceptions to this rule : thus, when the neck, with- 
 out being entirely dilated, is effaced, soft, and dilatable, if the rupture 
 becomes necessary in order to facilitate delivery, it may be accom- 
 plished without danger to the fœtus. The inconveniences of this 
 premature rupture, whether performed by the accoucheur or by 
 the efforts of nature, have been much exaggerated. For, in most 
 of the cases in which the rupture is necessary, the head of the 
 fœtus fills up so exactly the orifice, that, in general, but a small 
 quantity of the fluid escapes ; and, indeed, we are often obliged to 
 promote its discharge in order to increase the uterine action. 
 With this view, but only when the dilatation is nearly complete^ 
 
230 COMPLICATIONS WHICH MAY RETARD OR PREVENT LABOUR. 
 
 the head should be gently raised above the orifice, and, in propor- 
 tion as the fluid escapes, the contractions become stronger. 
 
 Rigidity of the neck of the uterus, its obliquity and agglutination 
 the resistance of the perineum, the deformities of the pelvis and 
 fœtus, and unnatural presentations, are so many circumstances 
 capable indirectly of retarding labour, and enfeebling the contrac- 
 tions. In these cases, the uterus contracts, at first, with more or 
 less energy ; then, fatigued, as it were, by repeated efforts against 
 obstacles it cannot overcome, it becomes exhausted, the contrac- 
 tions grow gradually more feeble, and finally cease altogether. I 
 should therefore, perhaps, treat of these complications in this place, 
 but as they constitute by themselves obstacles to the expulsion of 
 the fcetus, a special chapter will be devoted to them. 
 
 FinaHy, whatever may be the cause of the inertia, if the means 
 recommended do not excite uterine contraction, the foetus must be 
 delivered by the feet (turning), if the head be situated at the supe- 
 rior strait ; or the forceps should be used if the contractions at the 
 commencement of labour have brought the head into the cavity, 
 and inertia has supervened after this descent. (See forceps, turn- 
 ing, at the end of this article.) 
 
 Art. II. — Irregular or Morbid Contractions. 
 
 The organic contractility of the uterus is subject to irregularities 
 in its mode of action, and to a particular state of exacerbation, 
 which it is important to note. The uterus, as may be seen in the 
 diagrams in this work, is composed of several fibrous plexuses and 
 muscular fasciculi, which constitute distinct and veritable muscles. 
 In natural labour, all these muscles contract at once, and act upon 
 the fcetus, and the result of this contraction is a lively pain, soon 
 followed by a perfect calm. If, on the contrary, the different mus- 
 cles contract one after the other, there results from this circum- 
 stance a series of alternate contractions extremely painful and fa- 
 tiguing, and very irregular in the mode and intervals of their pro- 
 duction. The hand, applied to the abdomen, soon ascertains, by 
 the irregularities of the surface of the uterus, the hardness of cer- 
 tain points, and the softness of others, that the contractions are 
 partial, and that the foetus, tossed about by these alternate contrac- 
 tions, instead of descending by the combined action of all the mus- 
 cles of the organ, advances with great slowness, and most fre- 
 quently makes no progress. 
 
 At other times the pains are continuous. In this case, all the 
 portions of the organ contract simultaneously, and although this 
 contraction may determine the descent of the foetus, yet the im- 
 pulse it receives is not in relation with the violence of the pain. 
 In both cases, the patient is extremely agitated, and becomes truly 
 despondent ; the pulse is frequent and hard ; the skin hot ; the face 
 flushed ; all the muscles of the body appear to participate in the 
 contraction of the uterus ; the mind even becomes somewhat af- 
 fected. Finally, if this peculiar condition of the womb, to which 
 
EXHAUSTION. UTERINE RHEUMATISM. 231 
 
 the name of uterine tetanus has been given, be not controlled, it 
 will soon be followed by convulsions — puerperal eclampsia. 
 
 In this case, proper treatment is most frequently followed by 
 happy results ; it terminates the anguish to which the woman has 
 been exposed, and prevents the fatal consequences which might 
 otherwise ensue. 
 
 The treatment consists, in general, of bloodletting, baths, and 
 narcotics, according to the temperament of the patient. If she be 
 plethoric, bleeding will sometimes suffice alone ; but if, in ten or 
 fifteen minutes after the abstraction of blood, the sedative effect ex- 
 pected from it be not manifested, recourse must be had to opiates. 
 If nervous and irritable, baths, and especially narcotics, should be 
 employed. An enema, consisting of fifteen drops of the laudanum 
 of Sydenham in only a wine-glass of water, in order that it may be 
 the more easily retained, should be administered ; the patient should 
 then be put into a bath ; and if, on leaving the bath, the effect is 
 not produced, small enemata should be given every quarter of an 
 hour, with the addition of fifteen drops of laudanum in each. The 
 quantity of laudanum, however, should not exceed sixty to eighty 
 drops. 
 
 In general, a few minutes after the first enema, the pains be- 
 gin to diminish. The extreme agitation she has suffered is succeed- 
 ed by perfect tranquillity, during which the patient falls into re- 
 freshing sleep ; after this, the pains recommence, but they are reg- 
 ular, and are followed by intervals of rest. The patient recovers 
 her energy and courage, and the labour makes rapid progress. 
 
 I have frequently, both in city and hospital practice, had occa- 
 sion to employ this treatment, and I have always found it success- 
 ful. M. P. Dubois was the first practitioner I ever knew have re- 
 course to it. 
 
 Art. III. — Exhaustion. 
 Exhaustion may occur at any period of labour ; attempts should 
 be made to strengthen the patient by tonics, but these means are 
 frequently unavailing, when the exhaustion is in consequence of an- 
 tecedent disease, or of excessive fatigue. The accoucheur must 
 then extract the fœtus ; by turning, if the head is yet at the supe- 
 rior strait ; by the forceps, if it has descended, and delivery by 
 turning is impracticable. 
 
 Art. IV. — Uterine Rheumatism. 
 
 Uterine rheumatism is also an obstacle to the regular accomplish- 
 ment of parturition ; sometimes, even, it renders delivery impossi- 
 ble without the interference of art. 
 
 The symptoms of this affection are nearly the same as those of 
 the morbid contractions ; each contraction is not separated by a 
 distinct interval ; the contraction, when it manifests itself, is nothing 
 more than the exacerbation of a pain, which has not ceased ; more- 
 over, each of these exacerbations is distressing to the woman during 
 its entire duration. The pain resides in the uterine contraction, 
 
232 COMPLICATIONS WHICH MAY RETARD OR PREVENT LABOUR. 
 
 while, in the natural contraction, the pain is not felt at the com- 
 mencement ; it is perceived only at the moment the effort of the 
 body of the uterus is communicated to the neck. 
 
 In uterine rheumatism, the pain does not commence at the fun- 
 dus of the organ, as is the case in the normal contraction ; but it is 
 felt at first at the point in which the patient habitually suffers, and 
 thence it extends to the neck. 
 
 The violence of the pains is sometimes so great in this malady 
 that the contraction is suddenly arrested, and is replaced by per- 
 manent pain, which exerts no influence whatever on the progress 
 of the labour ; for fear of increasing her sufferings, the woman 
 avoids contracting her abdominal muscles, and the labour then pro- 
 ceeds with extreme tardiness, or ceases altogether, notwithstand- 
 ing the intensity and continued character of the pains. The patient 
 is in a state of extreme anxiety, accompanied by tenesmus of the 
 bladder ; the thirst is excessive, the pulse frequent, and the skin hot 
 and dry. The continuance of this state, entirely analogous to the 
 morbid contractions of which I have already spoken, may give rise 
 to eclampsia, or determine inflammation of the uterus : it is impor- 
 tant, therefore, to make every effort to moderate it. Embrocations 
 should be made on the abdomen of equal parts of the oil of sweet 
 almonds and laudanum ; a small enema, with ten, fifteen, to twenty 
 drops of the laudanum of Sydenham, should be administered, ac- 
 cording to the intensity of the symptoms ; should there be plethora, 
 a small bleeding may be practised. Finally, if these remedies 
 should not suffice, and the labour makes no progress, the fcetus 
 should be delivered either by turning or by the forceps. In this 
 case, however, turning can rarely be performed ; in fact, the first 
 contractions are often sufficient to render this operation impossible, 
 in consequence of the retreat of the uterus, and to place the head 
 within reach of the forceps. 
 
 Art. V. — Obliquities of the Uterus. 
 In the article Diseases of Pregnancy, I spoke of the obliquities 
 of the uterus ; it remains now for me to speak of their influence on 
 labour. 
 
 § 1. Anterior Obliquity. 
 The anterior obliquity, when inconsiderable, is nothing more, as 
 I have already observed, than the normal condition of the uterus 
 arrived at full term, and requires no particular attention ; but when 
 it is very marked, it may sensibly retard the labour. It becomes 
 necessary, therefore, to correct it ; for, in consequence of the forced 
 ante-version of the fundus, the neck of the uterus is thrown back- 
 ward, and rests against the anterior surface of the sacrum (figure 
 102) ; the dilatation of the neck is accomplished with extreme diffi- 
 culty, or is not accomplished at all ; and if the pelvis is large, the 
 head, not being able to pass the uterine orifice, pushes before it, as 
 far as the vulva, the anterior and inferior segment of the uterus. 
 The dotted curved line of figure 102 represents this condition of 
 
POSTERIOR OBLIQUITY. 
 
 233 
 
 things. Should the pelvis be contracted, the difficulty is much in- 
 creased, and the consequences may be more serious. Thus, the 
 anterior and inferior portion of the uterus, distended by the head, 
 may be lacerated, or fall into gangrene. 
 
 Diagnosis. 
 It is easy, in the former case, when the head has descended into 
 the cavity, to ascertain whether it is covered by the womb ; for 
 the finger, carried posteriorly, will feel the uterine orifice ; and, 
 moreover, the ante-version of the body of the organ will point out 
 sufficiently the cause which retards the labour. 
 
 (Fig. 102.) (Fig. 103.) 
 
 Ante-version of the Uterus. Posterior Position of the Cervix. 
 
 The neck, however, may be thrown far backward, without an 
 anterior inclination of the fundus, in consequence of its abnormal 
 situation on the uterus (figure 103) ; and this disposition will occa- 
 sion the difficulties I have just stated. It will be easy to distinguish 
 these two conditions from each other. 
 
 When the head is still at the superior strait, the abdominal ex- 
 amination and the touch will enable us to recognise the malposi- 
 tion ; and the orifice of the uterus will often, in this case, be more 
 accessible than when the inferior portion of the uterus has been 
 pushed into the cavity. 
 
 § 2. Posterior Obliquity. 
 After the example of Baudelocque, Gardien, Desormeaux, and M. 
 P. Dubois, I do not admit the posterior obliquity as at all possible 
 at the full period of pregnancy ; and, moreover, if it should exist, 
 it never could be sufficiently marked to prove an obstacle to de- 
 livery. The body of the uterus, limited by the vertebral column, 
 could never incline sufficiently backward to remove the uterine 
 orifice from the superior strait : this orifice, at most, could be placed 
 behind the pubes, but it would always be so related to the pelvic 
 cavity as to render the passage of the head possible. 
 
 (Fig. 104.) 
 
 (Fig. 105.) 
 
 G G 
 
231 COMPLICATIONS WHICH MAY RETARD OR PREVENT LABOUR. 
 
 Certain authors, however, record cases of posterior inclination 
 at full term, but these are nothing more, in my opinion, than in- 
 stances of abnormal insertion of the neck on the anterior portion of 
 the uterus (fig. 105). In looking at the observations reported by 
 Meriman and Velpeau, the reader will find the truth of what I say. 
 In fact, they have by no means demonstrated that there was pos- 
 terior inclination of the organ ; the situation of the neck seems to 
 have particularly attracted their attention, and it is this circum- 
 stance which most probably has caused them to admit the pos- 
 terior obliquity of the body of the uterus. In a word, whatever 
 may be the cause of this accident, the consequences are always the 
 same, as is also the treatment. 
 
 Diagnosis, 
 The situation of the orifice will suffice to characterize this acci- 
 dent. 
 
 § 3. Lateral Obliquities, 
 
 As I remarked in treating of pregnancy, the right lateral ob- 
 liquity is much more frequent than the left, and it is usually much 
 more marked than the latter. 
 
 This obliquity rarely interferes with the termination of labour. 
 However, it may slightly retard the delivery. I am also of the 
 opinion that it may exert an influence on the character of the 
 foetal presentation. I have already cited the case of a lady in 
 whom this forced obliquity occasioned a frontal variety of the 
 vertex, which the reduction of the uterus to its usual position, im- 
 mediately corrected ; and I agree also with Dugès, that it may 
 likewise determine, in certain cases, the presentation of the trunk. 
 
 Treatment, 
 
 The obliquities of the uterus rarely occasion a serious obstacle 
 to the expulsion of the foetus. If they be not very marked, they 
 may retard the labour, but nature overcomes, sooner or later, the 
 difficulties. However, the accoucheur should not remain a pas- 
 sive spectator ; he should support the uterus during each contrac- 
 tion, place it in its natural situation, and keep it so, if possible, by 
 the position given to the woman. In this way the axis of the ute- 
 rus is placed in relation with that of the superior strait, and the 
 entire expulsive force being directed upon the foetus, the dilatation 
 of the neck, and the descent of the head, are accomplished more 
 rapidly. 
 
 In some rare cases, too. of excessive obliquity, nature alone may 
 suffice ; but here art, of necessity, should interfere. The uterus 
 should be reduced to its position, and maintained in it. 
 
 In the anterior obliquity, the patient should be placed on her 
 back ; and in the lateral obliquities, on the side opposite to the ob- 
 liquity. Then, with the hands placed on the exterior, the uterus is 
 brought straight, and kept so, especially during the uterine contrac- 
 tion ; a bandage will most usually fulfil this object, but it is better to 
 
HERNIA OF THE UTERUS. 235 
 
 employ the hands at the moment of the contraction. In most cases 
 these means will suffice. In some instances, however, it becomes 
 necessary to draw the neck of the uterus forward with the fin- 
 gers of one hand, while the uterus is supported with the other. 
 This reduction of the neck should be made during the absence of 
 ^ain, but the fingers should keep it reduced during the contraction. 
 In a word, if these means prove insufficient, which would not be 
 unlikely in case of the abnormal insertion of the neck of the ute- 
 rus, and if the delivery should be impossible, it will become neces- 
 sary, if the head be above the superior strait, to introduce the 
 hand into the vagina, seek for the orifice, and endeavour to pen- 
 etrate the uterine cavity, in order to perform the version of the 
 fœtus. 
 
 If the head should be in the excavation, this operation would not 
 be applicable ; it would be necessary then to make an artificial pas- 
 sage for the fœtus, by incising the anterior and inferior wall of the 
 uterus. (See Vaginal Ccesarean Operation.) This would likewise 
 be the only alternative, if version be impossible when the head is 
 situated above the superior strait. 
 
 Art. VI. — Hernia op the Uterus. 
 
 By hernia of the uterus is meant the passage of the organ 
 through the separation of the linea alba ; this is eventration, with 
 excessive anterior obliquity. Hernia of the uterus through the 
 inguinal or crural ring is likewise possible during the commence- 
 ment of pregnancy, and it may continue to develop itself in this 
 manner until full term, out of the abdomen. The Memoirs of the 
 Academy of Surgery contain some very curious cases of uterine 
 hernia, which, at the completion of gestation, required that the tu- 
 mour should be opened. 
 
 Should there be nothing more than simple eventration, the re- 
 duction of the uterus is the only indication to be fulfilled. If there 
 should be a positive hernia, the Csesarean operation may be neces- 
 sary ; but it should not be hastened, in order that sufficient time 
 may be allowed to test the inefficiency of the uterine contractions 
 to effect the delivery ; for, even in this case, some women have 
 been delivered without aid. But there should not be too much de- 
 lay, for fear of compromising the life of the fœtus, thus destroy- 
 ing the mother by the operation, and the fœtus by unnecessary 
 procrastination. 
 
 Art. VII. — Prolapsus Uteri. 
 Prolapsus of the womb, at the full term of gestation, is of very 
 frequent occurrence, but I have never known it to offer any obsta- 
 cle to delivery. On the contrary, I have always observed that, in 
 this case, the expulsion of the fœtus was more easy and rapid. In- 
 deed, before labour, the head has already descended ; sometimes, 
 even, it rests on the floor of the pelvis. In order, therefore, to be 
 expelled through the vulva, it only awaits the dilatation of the 
 neck of the womb. The accoucheur then simply supports the 
 
236 COMPLICATIONS WHICH MAY RETARD OR PREVENT LABOUR. 
 
 orifice, and places his finger on the anterior lip, endeavouring 
 to bring it forward at each contraction. I never find it neces- 
 sary to have recourse to any other means, unless there should be 
 adhesion of the neck, or alteration of its tissue. 
 
 It is proper that the young accoucheur should be apprized of the 
 possibility of this propulsion of the uterus, even as far as the vulva, 
 by the head of the fœtus, in order that he may be guarded against 
 an error which has been often committed. 
 
 Suppose, for example, that an inexperienced accoucheur should 
 be called to a woman who has suffered for several days, but who, 
 to the present time, has experienced merely those dull pains which 
 often precede labour. 
 
 A vaginal examination satisfies him that, in the pelvic excava- 
 tion, a few lines from the vulva, there is a solid tumour presenting 
 the resistance of the head, on which he feels the sutures and fon- 
 tanelles. It is really the head that he feels, with its sutures and 
 fontanelles ; but they are felt through the anterior and inferior 
 segment of the uterus, which covers the head of the fœtus. The 
 head is not naked ; it has not yet passed the orifice. Thus, con- 
 sidering the duration and intensity of the pains, which, no doubt, 
 have been exaggerated to him, and likewise the great descent of 
 the head, he at once imagines the labour to be near its completion, 
 and so informs the friends. He may suppose that the membranes 
 have been ruptured, not having inquired of the patient whether or 
 not this has really taken place. Indeed, should he take this pre- 
 caution, he will not always, in this case, become more enlightened, 
 for the rupture of the membranes may occur without the knowl- 
 edge of the patient ; and, again, if she should feel herself wet by 
 the flow of urine or the vaginal mucosities, she may suppose that 
 it is in consequence of the discharge of the amniotic fluid. 
 
 Judge, therefore, of the astonishment of the accoucheur, who, 
 supposing that the labour is near at hand, finds that it continues 
 for several days. His reputation is compromised, and his error 
 may give rise to serious consequences. Thus, let us suppose that, 
 believing the labour nearly completed, the accoucheur, after some 
 hours of watching, finds that the head makes no progress, notwith- 
 standing the tolerably active pains which have occurred, but which 
 merely announce the commencement, and not the termination of 
 labour (I have already observed that each stage of labour is mark- 
 ed by the different character of the pain). Under the persuasion 
 that the head has passed the uterine orifice, he refers the delay in 
 the delivery to the resistance of the membranous sac, supposing, 
 as he does, that the membranes have not been ruptured. He also 
 imagines he understands why the sensations offered to his finger 
 were confused, and why he did not distinctly feel the fontanelles 
 and sutures ; he mistakes the inferior segment of the uterus for the 
 membranes. With this conviction, he again inquires of the pa- 
 tient whether the waters have come away, and he directs his 
 questions in such manner as to have his suspicions confirmed ; he 
 
VOMITING. SYNCOPE. 237 
 
 then proceeds to rupture the pretended membranes with his finger 
 nail ; he even attempts to perforate them with the pen. 
 
 The failure of these attempts, and the pain they occasion the 
 patient, may inform the accoucheur as to the nature of the ob- 
 stacle, or induce him to suppose that the rupture of the membranes 
 has been accomplished, and that the head rests naked in the cav- 
 ity. Under this latter idea, he attributes the difficulty which he 
 experiences in ascertaining exactly the characters of the presenta- 
 tion of the vertex to the swelling of the scalp, which, by a pro- 
 longed sojourn in the cavity of the pelvis, has become the seat of 
 a sero-sanguineous tumour. Then, believing that the labour has 
 continued for a long time, because he has felt the head at the in- 
 ferior strait, and under an apprehension that this prolongation of 
 the labour may prove injurious to the infant, tormented, too, by the 
 assistants, to whom he has stated that the labour would be of short 
 duration, and alarmed by the cries of the patient, he resolves to 
 extract the fœtus by means of the forceps, attributing the delay to 
 the resistance of the perineum, or to an excess of volume in the 
 head, or, finally, to a contraction of the inferior strait, while the 
 true cause of the difficulty is the last which presents itself to his 
 mind. Judge, therefore, of the serious consequences resulting from 
 the application of the forceps, the uterus being comprised between 
 the head and the blades of the instrument. 
 
 It must not be supposed that this case is at all exaggerated. All 
 experienced practitioners will confirm the necessity of this caution, 
 *and the pupils will thank me for having admonished them of a 
 danger to which no author has as yet particularly alluded. 
 
 I have frequently been sent for, in similar cases, to apply the 
 forceps, while all that was necessary was patience, and encourage- 
 ment to the woman and assistants. 
 
 Art. VIII. — Vomiting. 
 It is not unusual, during labour, to see women attacked with 
 vomiting, thus rejecting the nourishment or drinks they have taken, 
 or simply throwing mucosities from the stomach. In the former 
 case, as soon as the contents of the stomach are removed, the vom- 
 iting ceases ; in the latter, the attempts to vomit, depending upon 
 an oppression of the stomach, or the sympathetic reaction of the 
 uterus, occur more or less frequently. There is nothing serious 
 about this symptom, and it may be easily moderated, by giving 
 sugar and water cold, with a few drops of orange-flower water, 
 taken in spoonful doses. The female should take no nourishment, 
 for digestion cannot be performed during the labour, because all 
 the forces of the organism are concentrated upon the uterus. How- 
 ever, should it be necessary to sustain the strength, some light broth, 
 taken cold, may be allowed. 
 
 Art. IX. — Syncope. 
 Feeble, nervous women, who, in a state of health, readily faint, 
 are very liable to syncope during labour. If this should depend 
 
238 DISEASES UNCONNECTED WITH LABOUR. 
 
 upon the debility of the patient, her strength should be supported 
 by tonics ; but if it be often repeated, and so prolonged as to endan- 
 ger her safety, the labour should be at once terminated. 
 
 Although Desormeaux cites a case in which delivery terminated 
 spontaneously in a woman who fainted at each pain, during the 
 whole labour, yet I do not think it advisable to abandon the patient 
 to the consequences of these repeated syncopies. 
 
 Art. X. — Cramps. 
 
 I have spoken, in describing the phenomena of labour, of cramps, 
 which take place in the thighs, legs, or certain parts of the abdo- 
 men ; frictions constitute the only remedy. 
 
 CHAPTER II. 
 
 DISEASES UNCONNECTED WITH LABOUR, AND WHICH REQUIRE THE 
 PARTICULAR ATTENTION OF THE ACCOUCHEUR, AND SOMETIMES 
 HIS INTERFERENCE. 
 
 Certain affections, unconnected with pregnancy and delivery, 
 but which exist at the time of labour, sometimes oblige the accou- 
 cheur to interfere : such as phthisis pulmonalis, diseases of the heart, 
 asthma, hemoptysis, hematemesis, hernia, paraplegia. 
 
 In phthisis pulmonalis, the resources of the organism are gener- 
 ally sufficient to expel the foetus ; however, when the disease is 
 advanced, it is frequently impossible for the patient to make proper 
 effort to second the action of the uterus ; these efforts, too, may 
 prove injurious to her, and hasten her death, and especially render 
 it more painful. It is, therefore, the duty of the accoucheur to 
 give his aid in this case ; but as the first pains, which determine 
 the descent of the head, are not severe, and as interference is not 
 admissible until after the dilatation of the neck of the womb, ver- 
 sion would rarely be indicated, unless the woman should be ex- 
 tremely enfeebled, and the first pains had not sufficed to cause the 
 head to descend ; the forceps, therefore, is the instrument usually 
 employed under these circumstances. In fact, it is only after the 
 head has reached the excavation that those expulsive and fatigu- 
 ing pains declare themselves, which call forth such strong effort 
 on the part of the woman, and which, if possible, she should be 
 spared. 
 
 The conduct of the accoucheur should be precisely the same in 
 an advanced affection of the heart, or in the case of an aneurismal 
 tumour, which threatens to burst ; the descent of the head should 
 be committed to the first pains, if they be not of such a character 
 as to endanger the life of the mother ; and when the head is in the 
 excavation, the accoucheur should proceed to deliver. 
 
PROCIDENTIA OF THE UMBILICAL CORD. 239 
 
 Asthma, and all affections interfering with free respiration, pre- 
 sent the same indications. 
 
 In slight hemoptysis or hematemesis, it will suffice to employ- 
 remedies proper to arrest the hemorrhage, such as a small bleeding, 
 revulsives to the inferior extremities, cold drinks, and sinapised 
 maniluvia ; but if the hemorrhage should be profuse, and increased 
 by the contractions, it will be necessary to proceed at once to de- 
 livery, either by turning or the forceps, depending upon the situa- 
 tion of the head. The hemorrhage almost always ceases immedi- 
 ately after the extraction of the foetus. Indeed, the discharge of 
 blood, which takes place through the vulva, produces a very salu- 
 tary revulsion. 
 
 If the patient should have an unreduced hernia, care should be 
 taken to effect its reduction as soon as possible during an interval 
 of calm, and maintain it reduced during the contraction of the ute- 
 rus. If the reduction should be impossible, the accoucheur should 
 prevent, by the pressure of the fingers during a pain, the protrusion 
 of additional parts. If, in a word, there should be danger of stran- 
 gulation, the labour must be immediately terminated. 
 
 I attended, at La Clinique, two paraplegic women in their la- 
 bour, but they did not require any particular attention. However, 
 this affection, as also hemiplegia, might offer an obstacle to the reg- 
 ular contractions of the womb. 
 
 CHAPTER III. 
 
 ACCIDENTS CAPABLE OF COMPROMISING THE LIFE OF THE MOTHER 
 
 OR CHILD. 
 
 Certain accidents, such as procidentia of the cord, escape of the 
 meconium, too short a cord, hemorrhage, eclampsia, rupture of the 
 uterus or vagina, which, although for the most part permitting the 
 spontaneous expulsion of the fœtus, yet require the interference of 
 art, because they are of a nature to endanger, more or less rapidly, 
 the life of mother or child. 
 
 Art. I.^-Procidentia of the Umbilical Cord. 
 
 By procidentia of the cord is meant the escape of that portion oi 
 the fœtal appendage below the presenting part of the fœtus. Pro- 
 cidentia most usually manifests itself in those presentations which 
 do not completely close up the superior strait, such as presentation 
 of the face, and especially of the shoulder. It may take place at 
 any stage of labour, but it is much more frequent at its commence- 
 ment, and at the moment of the rupture of the membranes. How- 
 ever, this accident may occur when the presenting portion of the 
 fœtus already occupies the excavation, or has passed the inferior 
 
240 ACCIDENTS COMPROMISING THE LIFE OF MOTHER OR CHILD. 
 
 strait. M. Nsegele once remarked the descent of the cord by the 
 side of the shoulder, the head having already escaped through the 
 vulva. Finally, this procidentia may precede the rupture of the 
 membranes, and the cord may descend in the amniotic sac by 
 passing between the presenting part and the superior strait. 
 
 This variety, which some authors have thought proper to desig- 
 nate by a particular name, I consider nothing more than the first 
 degree of the same accident, and I shall, therefore, call it proci- 
 dentia ; however, in the diagnosis and treatment I shall establish an 
 important distinction between these two varieties. 
 
 Procidentia of the cord is not of very rare occurrence. Ac- 
 cording to the statistical observations of M. Schuré, of Strasbourg, 
 one case of procidentia presents itself in two hundred and sixty-five 
 cases of delivery. The observations made in La Clinique have 
 given nearly the same results ; and I am, therefore, induced to be- 
 lieve that there must be some error in the calculation of Madame 
 Lachapelle, for she states that she has met with this accident only 
 41 times in 15,652 cases. 
 
 § 1. Causes. 
 
 Predisposing Causes. — The predisposing causes are, the abun- 
 dance of the liquor amnii ; the length of the umbilical cord ; the 
 small size of the foetus ; a want of contraction in the inferior seg- 
 ments of the uterus, or a defective application of this latter over 
 the descending portion of the fœtus ; unnatural presentations of the 
 foetus, principally those of the trunk, because they do not fill up 
 the pelvic cavity ; deformities of the superior strait ; insertion of 
 the placenta over the mouth of the uterus, or in its vicinity ; the 
 insertion of the cord into the membranes likewise predisposes to 
 procidentia, by maintaining this organ near the orifice. Finally, 
 it is the same with regard to procidentia of the foot or hand, which, 
 by keeping the presenting part distant from the pelvic circle, leaves 
 a space through which the cord escapes. 
 
 Determining Causes. — The determining causes are, the sudden 
 or premature rupture of the membranes, and the rapid discharge 
 of a large quantity of liquor amnii ; it is often, also, the result of 
 manipulations, either necessary or ill-timed. 
 
 § 2. Diagnosis. 
 The diagnosis of procidentia of the cord will vary, depending 
 upon whether the membranes are ruptured or not. In the former 
 case, it will be quite easy : the finger feels, through the membranes, 
 a soft, small body, readily displaced, having active and frequent 
 pulsations, which the accoucheur will not confound, on account of 
 their rhythm, with the pulsations of his own arteries, or with those 
 of the mother. It is proper, however, to observe that, even before 
 the rupture of the membranes, the cord may sometimes be so com- 
 pressed between the presenting portion of the foetus and the supe- 
 rior strait as to change the character of these pulsations, and thus 
 lead the accoucheur into error. The abnormal insertion, too, of 
 
PROCIDENTIA OF THE UMBILICAL CORD. 241 
 
 the cord into the membranes may likewise be mistaken for proci- 
 dentia. In this case, the finger would immediately feel the pulsa- 
 tions of one of the ramifications of the cord, which are distributed 
 over the membranes before passing to the placenta. 
 
 (Fig. 106.) 
 
 After the rupture of the membranes, the diagnosis is extremely 
 simple, for the cord is readily felt ; sometimes, even, it appears at 
 the vulva. 
 
 § 3. Prognosis. 
 
 Procidentia of the cord is one of the most serious accidents that 
 can befall the foetus. Indeed, if the accoucheur do not interfere 
 at the proper time, death is most frequently the consequence ; and, 
 with the best-directed effort, the child cannot always be rescued 
 from the danger with which it is menaced. Certain circumstan- 
 ces which I have mentioned in speaking of the causes, and on 
 which I shall rely in order to establish the treatment, may vary the 
 prognosis : such as the integrity or rupture of the membranes, 
 the actual condition of the prolapsed cord, the time which has 
 elapsed from its first occurrence, the degree of pressure exerted 
 upon it, the period of labour, the condition of the uterus and exter- 
 nal organs, &c, &c. 
 
 As regards the mother, procidentia can exert no influence, for 
 the labour is not retarded by it. However, there is one case in 
 which delivery may be delayed, and occasion some inconvenience 
 to the mother : it is the premature detachment of the placenta, and 
 consequent hemorrhage, occasioned by too short a cord. Finally, 
 under ordinary circumstances, procidentia of the cord can only in- 
 directly prove injurious to the mother, either in consequence of the 
 operations necessary to save the infant, or of the effort which the 
 patient makes to accelerate her labour ; and, indeed, she may be 
 seriously affected by the apprehension she experiences with regard 
 to the safety of the child ; hence, care should be taken to keep her 
 ignorant of the fact that the cord is prolapsed. 
 
 H H 
 
242 ACCIDENTS COMPROMISING THE LIFE OF MOTHER OR CHILD. 
 
 § 4. Consequences of Procidentia of the Cord. 
 
 The compression of the cord, and, consequently, the interruption 
 of the circulation in this organ, is the sole cause of the death of the 
 fœtus. Guillemot and M. Velpeau think that the mere chilling of 
 the cord, when it hangs out of the vagina, will often occasion the 
 death of the fœtus, without any compression of the organ ; but 
 I do not concur in this opinion, and regard it only as an aggrava- 
 ting circumstance. Madame Lachapelle, who denies the influ- 
 ence of cold on the umbilical circulation, has seen the cord remain 
 out of the vulva for several hours, and still the pulsations were felt. 
 Baudelocque and Delamotte cite similar cases. I witnessed at La 
 Clinique a case of this kind. A female in whom procidentia of the 
 cord had occurred simultaneously with the rupture of the mem- 
 branes, at eight o'clock in the morning, did not arrive at La Cli- 
 nique until ten o'clock ; about eight inches of the chilled cord were 
 out of the vulva, and yet the pulsations preserved all their force ; 
 the reduction of the cord was effected by the sage-femme in chief, 
 and the child was born spontaneously, and in a healthy condition ; 
 the cord was two feet in length. 
 
 But authors, who regard the compression of the cord as the prin- 
 cipal, if not the only cause of the death of the fœtus, explain differ- 
 ently the influence of this compression ; some suppose that the in- 
 terruption in the circulation deprives the fœtus of the aliments ne- 
 cessary for its nutrition, and that it thus dies of inanition. Accord- 
 ing to others, the fœtus becomes a victim to apoplexy, because the 
 blood, continuing to flow abundantly through the umbilical vein, 
 cannot return to the placenta by the umbilical arteries. This opin- 
 ion deserves no comment ; for if the arteries be compressed, the 
 vein will be so likewise, and the blood could not reach the fœtus, 
 because it could not return to the placenta. For the same reason, 
 the fœtus could not die of syncope ; in fact, in order that the blood 
 may return freely to the placenta, and not to the fœtus, we must 
 admit that the vein alone could be compressed. Finally, most ac- 
 coucheurs at the present day regard asphyxia as the chief cause 
 of the death of the fœtus, admitting always that this condition is 
 often complicated with a fulness of the brain, heart, lungs, and liv- 
 er, circumstances which only show a plethoric state of these or- 
 gans, but which do not constitute a veritable apoplectic condition. 
 
 According to the opinion most generally received, the placenta 
 is, as I have already remarked, during intra-uterine life, the only 
 organ from which the fœtus derives its blood. If, therefore, the 
 fœto-placental circulation become interrupted by the compression 
 of the cord, the blood of the fœtus cannot be taken to the placenta 
 in order to be vivified by the mediate contact of the maternal 
 blood, and the fœtus is placed in the condition of an adult deprived 
 of atmospheric air, and dies of asphyxia. 
 
 The body of an infant that has died in consequence of the com- 
 pression of the cord is livid, rarely pale and discoloured ; the face, 
 and especially the lips, bear principally the traces of the venous 
 engorgement in the capillaries. 
 
PROCIDENTIA OF THE UMBILICAL CORD. 243 
 
 In the autopsy, I have sometimes found the vessels and mem- 
 branes of the brain injected ; but this is by no means constant. As 
 to the accumulation of blood in the lungs, it is so uniformly met 
 with, that it may be said to be the necessary consequence of as- 
 phyxia ; the entire venous system is engorged with blood, while 
 the arteries are nearly deprived of it. Lastly, the liver is much 
 more frequently congested than the brain ; and this is explained by 
 the fact that the liver participates in the purification of the blood. 
 
 § 5. Treatment. 
 Procidentia of the cord left to itself is almost always fatal to the 
 foetus ; and, therefore, interference becomes necessary. Delay is 
 permitted only in a very few cases, which I will state as precisely 
 as possible. 
 
 a. Before the Rupture of the Membranes. 
 
 If the presence of the cord below the head be ascertained before 
 the rupture of the membranes, the accoucheur should await the 
 complete dilatation of the orifice before attempting anything, not 
 that he could calculate on the spontaneous reduction, for this is 
 extremely rare, but because any interference might result in the 
 premature rupture of the membranes, a serious occurrence for the 
 foetus, as it would remain exposed to the dangers of compression 
 until the dilatation permitted the accoucheur to do something ef- 
 fectually. But when the orifice is completely dilated, and the con- 
 tractions have attained a certain intensity, the accoucheur should 
 introduce two or three fingers, and even the whole hand, if the con- 
 dition of the external parts will permit, in order to push up the 
 cord through the membranes ; then, profiting by an energetic con- 
 traction, he will rupture the amniotic sac, either with the hand in- 
 troduced, or by means of an ordinary pen, carried along the hand 
 supporting the cord, and pushed forward with the other; at the 
 moment the fluid escapes, the head places itself exactly over the 
 uterine orifice, while the cord, sustained by the extremity of the 
 fingers, is carried above the superior strait, and is protected from 
 compression.* 
 
 If the pelvis should be very capacious, the head small, and the 
 membranous sac so distensible as readily to permit the descent oi 
 the head into the excavation, care should be taken not to rupture 
 the membranes ; and the accoucheur should wait, before rupturing 
 the sac, until the external parts are sufficiently relaxed to permit the 
 application of the forceps without inconvenience to the mother, in 
 case the use of this instrument should become necessary. The 
 parts, then, being in proper condition, the sac should be ruptured. 
 
 * The 17th of July, at three o'clock in the afternoon, a female, by name Delaporte, entered 
 the lying-in apartment at La Clinique. The presence of the cord was detected through the 
 membranes. As soon as the dilatation was complete, M. P. Dubois effected the reduction 
 of the cord with entire success, in rupturing the membranes, and the child was born alive : a 
 circumstance unusual in compression of the cord, and to which I shall allude hereafter ; the 
 incomplete rotation of the head, in consequence of the descent of the arm, rendered the ap- 
 plication of the forceps necessary in the cavity. 
 
244 ACCIDENTS COMPROMISING THE LIFE OF MOTHER OR CHILD. 
 
 Frequently at this time, the head, being near the vulva, is expelled 
 spontaneously, and no compression being exerted on the cord, es- 
 pecially if this latter have become prolapsed at the posterior por- 
 tion of the pelvis, all interference becomes unnecessary ; or if the 
 child should be in danger, it will be easy to extract it with the 
 forceps. 
 
 It is, therefore, evident that the circumstances in which delay is 
 permitted before the rupture of the membranes are exceedingly 
 limited, and they are reduced to the following : integrity of the 
 membranes when auscultation does not indicate any suffering of the 
 fœtus; pelvis capacious ; head small ; contractions energetic; poste- 
 rior prolapsion of the cord; the accoucheur always remembering to 
 exercise a strict supervision, and to be prepared to act in case the 
 touch or auscultation should announce any difficulty in the fœital 
 circulation. 
 
 b. After the Rupture of the Membranes. 
 
 After the rupture of the membranes, the accoucheur should not 
 be inactive, unless the head should still be high up in the pelvis, and 
 an absence of the conditions indicating a speedy delivery, such as 
 a capacious pelvis, a small foetus, relaxed state of the external or- 
 gans, and energetic contractions ; the condition of the cord should 
 be attentively watched, so that the forceps may be applied without 
 delay, in case the safety of the child should be endangered. If, in 
 consequence of the great descent of the head, the cord can no long- 
 er be felt, the accoucheur should carefully ascertain, by means of 
 auscultation, the actual condition of the fœtus ; and if the restless- 
 ness of the patient render this impossible, and especially if the 
 amniotic fluid should be mixed with meconium, the fœtus should be 
 delivered immediately. But when none of the circumstances which 
 justify delay present themselves, the accoucheur should make every 
 effort to replace the cord, and, in case of failure, he should termi- 
 nate the delivery either by turning or the forceps, depending upon 
 the stage of the labour. 
 
 The reduction of the cord is not a very difficult operation, nor is 
 it always successful ; and, moreover, it is not subjected to any 
 fixed rule. A great number of instruments have been recom- 
 mended, the use of which is more or less inconvenient and ineffect- 
 ual. The hand should always be preferred to them ; it acts with 
 much more certainty, and possesses the important advantage of 
 enabling the accoucheur to ascertain by the touch the condition of 
 the fœtus. Although we cannot recommend any very positive 
 rule, yet it may be observed, that this reduction should be attempt- 
 ed with the left hand if the cord is to the right, and vice versa; 
 and, as much as possible, towards one of the two sacro-iliac sym- 
 physes, where, generally speaking, there will be found more space. 
 The accoucheur must not be content to push the cord into the 
 uterus ; he should be careful that it is carried sufficiently high up to 
 be free from all compression ; and, moreover, he should keep it in 
 place with the hand until the head, forced by the uterine contrac- 
 
PROCIDENTIA OF THE UMBILICAL CORD. 
 
 245 
 
 tions, fills up the superior strait. For this purpose, a piece of fine 
 sponge has been recommended to fill the space through which the 
 prolapsus has occurred ; I have often used it, but prefer the hand. 
 
 Some authors, to avoid the procidentia of the cord, have advi- 
 sed to introduce the hand into the uterus, and wind the cord around 
 one of the limbs of the foetus ; but this manœuvre is admissible only 
 in cases where the pelvis is so malformed as to prevent pelvic 
 turning, although the head might descend spontaneously. 
 
 If the state of the uterine orifice, and the narrowness of the ex- 
 ternal organs, prevent the introduction of the whole hand, and, con- 
 sequently, the reduction of the cord, we may use with advantage 
 a gum-elastic catheter, armed with its stylet and a narrow riband, 
 as was frequently employed successfully by M. Champion. 
 
 The mode of proceeding is, first, to tie the cord very loosely 
 with the riband, then introduce the part (O) of the riband into the 
 eye (I) of the catheter, where we observe the extremity of the 
 stylet ; the stylet then passes through the part (O) of the riband, is 
 pushed to the end of the catheter, and carries with it the umbilical 
 cord. 
 
 (Fig. 107.) (Fig. 108.) 
 
 This sound is guided by two fingers, and introduced into the 
 neck of the uterus, and pushed as far as possible into the organ. 
 When once the reduction is complete, and the head has entered 
 into the superior strait, the stylet is first withdrawn, so that the 
 cord and the fold of riband are left in the uterus, and the catheter 
 is then removed 
 
 This reduction, as I have remarked, is frequently useless, either 
 because the cord cannot be returned, and is reduced imperfectly, 
 or will not continue. The course of the accoucheur varies in each 
 
 case. 
 
 1. Where the Reduction is impossible, or the Cord cannot remain 
 reduced. — As this case seldom occurs, except where the dilatation is 
 perfect, we can interfere with advantage. If the head be above the 
 superior strait, and if the life of the child be in danger, the accou- 
 cheur should deliver by pelvic turning ; and, in this case, he should 
 
246 ACCIDENTS COMPROMISING THE LIFE OF MOTHER OR CHILD. 
 
 be careful to push the cord into the uterus, so that it may not be com- 
 pressed by the parts of the fœtus, as they descend into the pelvis. If 
 the life of the child do not seem endangered, if the pulsations of 
 the cord continue regular, if all the circumstances indicating a 
 rapid descent coexist, we may delay acting till the descent takes 
 place, being ready, however, to apply the forceps in case of need. 
 Finally, if the head has come into the cavity, it would not be wise 
 to trust its final delivery to the efforts of nature. The forceps 
 should always be applied, especially in a first confinement. In 
 fact, at this period of labour, we cannot ascertain directly by the 
 cord the sanitary state of the child, as it is impossible .to reach the 
 umbilical fold ; and, farther, auscultation throws no light on the 
 subject, because of the cries and distress of the female. 
 
 2. The Reduction having been performed, the Cord is beyond the 
 reach of the Finger. — Auscultation, and the discharge of the waters 
 tinged with meconium, can alone demonstrate, in this case, whether 
 the reduction be perfect or imperfect ; whether the cord be or be 
 not compressed ; and, consequently, whether we must remain quiet 
 or act. 
 
 These are the only general rules for this severe and difficult case. 
 It is impossible to state precisely the indications : their appreciation 
 must be left to the sagacity of the accoucheur. 
 
 Here, in these cases, auscultation is extremely valuable. If the 
 pulsations of the heart be feeble and slow, after having been exces- 
 sively frequent ; particularly if their rhythm be irregular, intermit- 
 tent, the life of the child is certainly in danger, and the accoucheur 
 ought to interfere ; but will this interference always be in time ? and 
 does not experience oblige us to admit, with M. P. Dubois, that a 
 fœtus, in whom the pulsations have some force and regularity, 
 who lives the intra-uterine life, may be unfitted by some unknown 
 injuries for an extra-uterine existence, and expire on coming into 
 the world ? How, then, can the exact moment for interference be 
 defined ? No man can decide in advance. I repeat it, the accou- 
 cheur must depend on auscultation, and the different circumstances 
 attending the labour. 
 
 Art. II. — Discharge of Waters tinged with Meconium. 
 The discharge of the waters tinged with meconium in present- 
 ations of the head, is a certain sign that the fœtus suffers, or has 
 suffered ; and ought, therefore, to excite the anxiety of the accou- 
 cheur. In fact, whenever the circulatory relations between the 
 fœtus and the mother are interrupted by the compression of the 
 cord, the fœtus attempts to accomplish the acts of extra-uterine 
 life. Thus it urinates, and this act cannot be perceived, because it 
 is impossible to distinguish the urine from the water of the amnios ; 
 the meconium is passed, and gives to the water the characteristic 
 greenish tinge. We must not confound this with the discharge of 
 the meconium in pelvic presentation : here, the excrementitious mat- 
 ter is discharged by the mechanical compression of the parts, but 
 yet the life of the fœtus is not endangered. This circumstance is 
 
SHORTNESS OF THE CORD. 247 
 
 even a characteristic sign of the presentation. What, then, must 
 the accoucheur do when the head presents, and the waters tinged 
 with meconium are discharged ? He must first ascertain if a fold 
 of the cordhavenot passed below the head : if this accident do not 
 appear, he must examine, by auscultation, if the compression of the 
 head in a remote point be not the cause of this phenomenon : if the 
 pulsations be normal, there is nothing to be done ; for if the dis- 
 charge of the meconium have been caused by a derangement of the 
 circulation, it has been but momentary, and no longer exists. 
 
 If the rhythnvof the pulsations be altered, if they grow weaker, 
 after a marked period of acceleration, the cord is compressed in 
 some point which cannot be reached, and we must then interfere 
 by the forceps or by turning. 
 
 Art. III. — Shortness of the Cord. 
 Shortness of the cord operates unfavourably on the progress of 
 labour, the life of the fœtus, and that of the mother ; this shortness 
 may be natural, that is, the umbilical cord may be very short ; it 
 may be accidental, in consequence of the cord, naturally very long, 
 becoming shorter, by making turns around the limbs, neck, or 
 trunk of the child. Farther, whatever may be the cause, this short- 
 ness may occasion many accidents: such as slowness of the labour, 
 the death of the fœtus, the premature separation of the placenta, 
 the inversion of the uterus, &c, &c. 
 
 § 1. Influence of Shortness of the Cord on the Progress of Labour. 
 
 Some authors admit that shortness of the cord, by retaining the 
 fœtus fixed to the wall of the uterus, may retard the descent of the 
 head to the superior strait and in the cavity. Finally, that this 
 shortness may prevent its descent into the inferior strait. 
 
 It is easy to explain the symptoms caused by this circumstance, 
 when the membranes are once ruptured : but how admit that this 
 shortness may produce the slightest accident, manifest externally, 
 when the bag of waters is entire ? I admit that I cannot under- 
 stand the effects of this shortness, before the rupture of the mem- 
 branes. In fact, the cord cannot be so short as to prevent the de- 
 scent of the head a few lines : besides, if no cord existed, if the full- 
 grown fœtus were attached to the placenta by the umbilicus, which 
 would bring the uterus with it, it would rest on the superior strait ; 
 and, farther, what influence could the non-descent of the fœtal part 
 have on labour, while the membranes were entire ? Farther, can 
 we admit, also, that this non-descent can retard the labour by pre- 
 venting the rupture of the membranes, when every one knows that 
 the membranes are ruptured prematurely, precisely in those cases 
 where the fœtal part cannot descend ? Ought we not, in this case, 
 when there are contractions, attribute the delay rather to the re- 
 sistance of the membranes than to another cause which is still 
 more rare ? The effects of this shortness may be so easily attrib- 
 uted to many other causes, that it is extremely difficult to estab- 
 lish the diagnosis of this accident. Authors, however, have at- 
 
248 ACCIDENTS COMPROMISING THE LIFE OF MOTHER OR CHILD. 
 
 tempted to lay down signs, by the aid of which we can detect this 
 circumstance at all periods of labour ; but every practitioner will 
 see in most of these characters the result merely of a theoretical 
 study of the effects which may be produced by this accident. 
 
 Thus, it is said before the rupture of the membranes it will be 
 easy to see, in the case of shortness, that the elevation of the head 
 after contraction does not resemble its habitual elevation during 
 pain, when the cord is not drawn down, &c., &c. 
 
 Then, after this rupture, the depression of the fundus of the uterus 
 during contraction, its elevation after the pain, which may be de- 
 tected by applying the hand to the abdomen, may serve to charac- 
 terize this symptom, &c, &c. ; certainly, in some cases, which, 
 however, are very rare, it will be possible, by great tact, to ascer- 
 tain that the delay in parturition depends on the shortness of the 
 cord ; but we must also admit that, in most cases, the cause of the 
 delay will remain completely unknown, especially in the first pe- 
 riod of labour ; adding, however, that the shortness at this period 
 may cause some apparent symptom : thus, before the rupture of 
 the bag of waters, who would pretend to ascribe the slowness of 
 the labour to the shortness of the cord rather than to the resist- 
 ance of the membranes, especially when it is universally known 
 that this resistance of the membranes is much more common than 
 the shortness of the cord ? It is only after the spontaneous or arti- 
 ficial rupture of the membranes that the head could be retained at 
 the superior strait by the shortness of the cord ; and yet this cir- 
 cumstance is very rare ; and even in this case, we should be more 
 disposed to attribute the delay of the head to its excessive size (a 
 fact very difficult to be ascertained), or to any other cause rather 
 than to the shortness of the cord. 
 
 Finally, when the head is in the cavity, when it is at the inferior 
 strait, even when the signs which characterize this accident are as 
 evident as they can be, the accoucheur will refer the delay in the 
 labour to anomalies in the rotation of the head, resistance of the 
 perineum, insufficiency of the contractions of the uterus, rather than 
 to the true cause. In fact, the shortness of the cord can exercise 
 no influence on the progress of the labour until after the rupture of 
 the membranes, and this cause cannot be ascertained until the head 
 has descended into the cavity, and then the diagnosis will be very un- 
 certain ; but it will be proper to attribute delay in the labour to the 
 shortness of the cord, if the accoucheur have ascertained, by exam- 
 ination, that the head is small and movable, have performed its rota- 
 tory motion, that the perineum is very extensible, that the head does 
 not rest upon it during the pains, and that his finger feels, at each 
 contraction, the depression of the head, which returns to its former 
 position when the pain has ceased ; and, finally, if this phenomenon be 
 noticed at every pain, without any advancement of the head. The 
 pain felt by the female in a definite point, corresponding to the 
 place of insertion of the placenta, also serves as an indication ; and, 
 finally, the cause of the delay of the head is indicated most clearly 
 by hemorrhage following the rapid descent of the head, which had 
 
SHORTNESS OF THE CORD. 249 
 
 hitherto remained stationary, by the rapid progress of the head 
 under the influence of each pain, when these pains had previously 
 been inefficient. The accoucheur can no longer be in doubt as to 
 the true cause, when nature uses one of her resources (rupture of 
 the cord, or premature separation of the placenta) to overcome the 
 obstacle. Hence, the true cause of the slowness of the labour is 
 most frequently detected at the moment when another symptom, 
 hemorrhage, requires interference. We will, however, remark, 
 that although it may be impossible to form a correct diagnosis, yet 
 the means to be employed to remedy shortness of the cord will, in 
 most cases, be the same as those adopted to remedy the accident 
 erroneously thought to retard the labour. In short, whatever may 
 be the cause of delay, the mode of action will be nearly the same. 
 
 § 2. Influence of the Shortness of the Cord on the Health of the 
 Fœtus and Mother. 
 
 The shortness of the cord may endanger the health of the moth- 
 er and fœtus, by prolonging the labour, by the operations which 
 are necessary, by the premature separation of the placenta and its 
 consequences, by the laceration of the umbilicus, or by the inversion 
 of the uterus, caused by the adhesions of the placenta. When the 
 umbilical cord is not ruptured, the child may suffer from asphyxia, 
 during labour, by the constriction of the folds of the cord on its 
 limbs and neck. Here, death results from the compression of the 
 cord ; the fœtus also may be strangled by folds constricting the 
 neck, a fact seldom witnessed during labour, but sometimes occur- 
 ring during intra-uterine life. M. Taxil has seen a child, in whom 
 the neck was so much constricted by three turns of the cord as to 
 measure only two or three lines in thickness. Montgomery, in his 
 excellent treatise on the " Signs of Pregnancy" mentions several 
 cases of strangulation of the limbs, and we present two drawings 
 made by this gentleman from nature. 
 
 (Fig. 109.) (Fig. 110.) 
 
 He attributes these spontaneous amputations, as he terms them, 
 to the constriction of the cord; in fact, in figure 110 we see the 
 remnant of this cord going from one limb which is entirely sep- 
 arated to another which still remains attached. Formerly, these 
 
 1 1 
 
250 ACCIDENTS COMPROMISING THE LIFE OF MOTHER OR CHILD. 
 
 spontaneous amputations were generally thought to be caused only 
 by partial gangrene. 
 
 § 3. Treatment: 
 
 In these cases, the indications of treatment vary with the period 
 of labour. But most generally they are fulfilled while remedying 
 accidents other than the shortness of the cord, and, very happily, 
 the result is the same. 
 
 Thus, before the rupture of the membranes, the dilatation being 
 perfect, if, by a rare exception, the labour is delayed by the short- 
 ness of the cord, the accoucheur would certainly attribute this de- 
 lay to the resistance of the membranes, and would rupture them : 
 the waters would then pass off, the uterus would contract, and per- 
 mit the foetus to come down still more ; but if the shortness of the 
 cord could retard the descent at the superior strait, it will delay it 
 much more in the cavity, as the uterus cannot descend and permit 
 the fœtus to come down ; new difficulties will then appear ; then, 
 whether we can or cannot ascertain the true cause of the delay 
 in the progressive and retracting motions of the foetus, when it is 
 evident that delivery cannot be accomplished, although the pains 
 are very strong, the forceps must be used. If the head be detain- 
 ed at the inferior strait, the forceps must still be employed, wheth- 
 er the delay is attributable to the resistance of the perineum or to 
 the shortness of the cord. 
 
 But in all cases, as soon as the cord can be reached, if it be 
 twined around the neck of the child, we must relax the folds and 
 disengage the head, or we must cut it, holding the foetal end of the 
 divided cord firmly in the fingers, and deliver the child with rapid- 
 ity. If the cord be naturally short, we cannot reach it until the 
 shoulders are delivered, and we divide it with the same care. 
 
 The assistance to be given to the mother and child will vary 
 with the circumstances which may complicate labour. (See Hem- 
 orrhage, Inversion of the Uterus, &c.) 
 
 Art. IV. — Uterine Hemorrhage during Labour. 
 Under the term uterine hemorrhage I include all discharges of 
 blood from the genital organs, coming either from the vessels of the 
 uterus or umbilical cord. This form of hemorrhage, which is alone 
 to be treated of here, is one of the most formidable accompani- 
 ments of labour. 
 
 § 1. Causes of Uterine Hemorrhage. 
 These causes are either predisposing, determining, or special. 
 
 Predisposing Causes. 
 
 Pregnancy, in consequence of the modifications it causes in the 
 circulation, is the principal predisposing cause of hemorrhage. 
 Thus, during gestation, the circulation and nutrition become more 
 active, the pulse is fuller and more frequent, the skin is redder ; in 
 
UTERINE HEMORRHAGE DURING LABOUR. 251 
 
 fact, general plethora exists ; but the circulation is most active in 
 and near the uterus. The uterus becomes a circulatory centre, and 
 this state, in which the adjacent organs participate, is singularly 
 increased by all the circumstances which can quicken the circula- 
 tion: such as a sanguineous temperament, profuse menstruation, 
 and even a lymphatic temperament, which often attends uterine 
 congestion, and predisposes certain females to a kind of hem- 
 orrhagic diathesis at each menstrual period. Of this character, 
 also, are moral and physical excitements ; finally, all causes which 
 can maintain great activity in the general circulation, and especial- 
 ly which may determine a considerable afflux of blood towards 
 the uterus, such as rich food, the repeated use of spirituous drinks, 
 attendance at balls, the use of very hot baths, revulsions on the 
 lower limbs, physical excitements, and diseases of the uterus and 
 adjacent organs. The anatomical arrangements of the circulation 
 of the uterus and appendages of the fœtus at an advanced period 
 of pregnancy, so well described by Dubois and Jacquemier, ex- 
 plain the mode of production and frequency of hemorrhages. 
 
 If we examine the organs when their development is perfect, 
 when the placenta is the seat of a double circulation, we are struck 
 with the enlargement of the sanguineous apparatus of the uterus 
 and adjacent organs. 
 
 The four arteries which supply blood to the uterus (the hypo- 
 gastric and the ovarian) enlarge considerably as they approach this 
 organ. Before giving off their first divisions, they enlarge, dilate 
 as they advance between the peritoneum and the external surface 
 of the uterus, and then ramify, ad infinitum, in the tissue of the 
 uterus, doubling in size. Others, which are invisible in the unim- 
 pregnated state, are successively developed, and likewise present 
 a large calibre. 
 
 If we examine the veins, from their leaving the uterus till their 
 opening into the hypogastric and ascending vena cava, we see 
 that they are much enlarged. Thus, considered in the uterine 
 parietes, the veins seem like canals situated in the centre of the 
 muscular tissue ; they anastomose and form large sinuses, into some 
 of which the little finger can be inserted. These veins are much 
 broader at the point of insertion of the placenta, open on the inner 
 surface of the uterus, and empty into the sinuses of the placenta. 
 
 We can see, from this arrangement, how all the influences which 
 can produce congestion in the organ, and, consequently, cause a rup- 
 ture of the vessels, will occasion hemorrhage. But what class ol 
 vessels will be ruptured most easily, and will most generally supply 
 the effused blood ? M. Jacquemier thinks that the venous system 
 is the first to yield. The arteries, on the contrary, unless they are 
 diseased, and even those which are protected only by the decidu- 
 ous membrane, are ruptured much more rarely than the utero- 
 placental veins, the soft tissue of which does not present much re- 
 sistance. Farther, although it may be proper to attribute hemor- 
 rhage to the arterial circulation, since plethora commences by the 
 arterial system, it is still true that most of the blood in uterine hem- 
 
252 ACCIDENTS COMPROMISING THE LIFE OF MOTHER OR CHILD. 
 
 orrhages comes from the venous system, and this fact confirms the 
 opinion of M. Jacquemier. 
 
 In fact, what occurs ? plethora appears in the arterial system, 
 but the utero-placental arteries resist it. The plethora then passes 
 from the arterial to the venous system, where it finds less resist- 
 ance. 
 
 Determining Causes. 
 
 All the preceding causes, when they act for a certain time, may 
 become determining causes ; farther, the various physical and moral 
 emotions which I have already enumerated under the article Abor- 
 tion, may also occasion this accident. 
 
 Special Causes. 
 The special determining causes are, the premature separation of 
 the placenta, in consequence of the too rapid retraction of the ute- 
 rus ; the lacerations of the neck of the uterus, the insertion of the 
 placenta on or near the orifice, the spontaneous laceration of the 
 inner coat of the uterus, the complete rupture of its parietes, the 
 bursting of a thrombus of the vagina or vulva, the abnormal inser- 
 tion of the cord on the membranes, and the rupture of one of the 
 vessels ; finally,' rupture of the umbilical cord. 
 
 A. Premature Separation of the Placenta. — The irregular patho- 
 logical contractions, the too sudden and rapid normal contractions 
 of the uterus, and its too rapid retraction, may separate the pla- 
 centa prematurely from the inner surface of the organ, and pro- 
 duce a hemorrhage, which is the more dangerous, in proportion as 
 the labour is less advanced ; and, as is known, these phenomena 
 are particularly manifest in cases where the uterus has been dis- 
 tended by dropsy of the amnios, at the moment when the rupture 
 of the membranes permits a large quantity of the water to escape, 
 or in cases of twins. 
 
 In the latter case, hemorrhage may occur after the birth of the 
 first child, and then the life of the mother and that of the second 
 child, which is contained in the uterus, may be compromised ; or it 
 may appear after the birth of the two children ; then only the life 
 of the mother is endangered. 
 
 The separation of the placenta may also be caused by the short- 
 ness of the umbilical cord ; often, also, by the descent of the entire 
 ovum, or of a part of the membranes, covering the head of the 
 child. 
 
 B. Lacerations of the Neck of the Uterus. — The foetus can rarely 
 pass through the maternal organs without lacerating the neck ot 
 the uterus to a greater or less extent, and if, in this case, only a lit- 
 tle blood escape, it is because the foetus obliterates the patulous 
 mouths of the vessels which are exposed by the laceration of the 
 neck in its passage. Hence, although this accident occurs fre- 
 quently, serious hermorrhage is rare. 
 
 C. Insertion of the Placenta on the Neck of the Uterus. — The in- 
 sertion of the placenta on the neck of the uterus is an almost con- 
 
UTERINE HEMORRHAGE DURING LABOUR. 253 
 
 stant cause of uterine hemorrhage. Authors, however, mention 
 cases of this insertion without hemorrhage. M. Moreau explains 
 this fact satisfactorily. He remarks, that these instances of inser- 
 tion of the placenta without hemorrhage are all referrible to cases 
 where the foetus had died, often long before its expulsion. In this 
 case, in fact, the uterine circulation is modified as follows : of all 
 the blood going to the uterus to nourish the foetus, only as much 
 reaches it as is necessary to the uterine circulation, properly so call- 
 ed ; the vessels diminish, some even are effaced ; in fact, the stimulus 
 which solicited the blood to the uterus having ceased, the circula- 
 tion is so modified that but little or no hemorrhage occurs when 
 the placenta separates ; or, in all cases, if hemorrhage occur, it is 
 very slight. 
 
 How can we explain the production of hemorrhage in cases 
 where the placenta is inserted on or near the orifice? In the 
 latter weeks of gestation and during labour, this phenomenon is 
 readily explained. In fact, at this time, as I have remarked when 
 treating of the diagnosis of pregnancy (eighth and ninth month), 
 the inner orifice begins to open in the primipara ; and, in females 
 who have borne children, it frequently dilates several weeks sooner. 
 Then, as the placenta cannot participate in this dilatation, the vas- 
 cular connexions between the placenta and the uterus are partially 
 destroyed, and the blood escapes externally. 
 
 This opinion is confirmed by the period of pregnancy when 
 these hemorrhages occur ; viz., from the eighth to the ninth month. 
 
 The abnormal insertion of the placenta on the neck of the ute- 
 rus, however, may cause hemorrhage at an earlier period of ges- 
 tation ; but this is rare, and cannot occur before the end of the 
 sixth month ; and then we must find another explanation of this 
 circumstance. The following appears to me to be the most ration- 
 al : before the end of the sixth month, the uterus is developed, espe- 
 cially at its fundus ; the lower part, on the contrary, is not equally 
 developed, but its enlargement coincides with that of the placenta ; 
 hitherto these two parts, the placenta and neck of the uterus, pre- 
 served their relations of connexion ; but, after the end of the sixth 
 month, the lower part of the organ increases in proportion to the 
 increase of the fundus, while the placenta, which has acquired near- 
 ly its entire development, can no longer participate in this rapid 
 increase ; then the inter-utero-placental tissue is lacerated, exposing 
 the open orifices of the utero-placental vessels, and hemorrhage en- 
 sues. 
 
 D. Rupture of the uterus, and thrombus of the vulva and vagina 
 are rare accidents, which I shall treat of in a special chapter. 
 
 E. Finally, the rupture of one of the vessels of the cord, or of the 
 cord itself, may cause a serious hemorrhage, especially for the foe- 
 tus. In this case, the discharge may be intra-ovular, intra- uterine, 
 or external. 
 
 This accident may depend on a disease of the tunics of the cord, 
 the special arrangement of its vessels, and, finally, on the shortness 
 of the cord. 
 
254 ACCIDENTS COMPROMISING THE LIFE OF MOTHER OR CHILD. 
 
 I have, as already remarked, a cord where the vein is varicose 
 in many parts, and presents, especially in one of its points, a swell- 
 ing, which seems to be a collection of blood, the organized clot of 
 which around the vein compresses it on all sides. I attributed the 
 death of the fœtus to this compression. Several similar facts are 
 cited by authors, but they are not common. 
 
 We can then see, that if the vein may rupture and permit blood 
 to be effused into the sheath of the cord, this sheath also may be 
 ruptured, and give rise to a hemorrhage which is serious to the 
 child and mother. 
 
 Velpeau relates several similar cases. M. Deneux has observed 
 one where the vein was very varicose in almost the whole of its 
 course, and had discharged a great quantity of blood. 
 
 This accident may also cause a hemorrhage within the ovum, 
 and an external or intra-uterine hemorrhage, according as the 
 membranes are entire or broken, according as the neck of the ute- 
 rus is or is not closed by clots. 
 
 (Fig. 111.) 
 
 The vessels of the cord may sometimes separate or ramify on 
 the surface of the ovum, before going to the placenta. I have twice 
 noticed this arrangement, and one of these placentas has been pre- 
 pared by M. Voillemier. 
 
 We then easily understand that if the membranes are ruptu- 
 red at the point where the vessel is inserted, this vessel may be 
 broken and give rise to severe hemorrhage, which will generally 
 be extra-ovular ; but which may be internal, if the flow of blood 
 through the neck of the uterus be prevented by some obstacle. 
 
 In a similar case, observed by Nsegele, one of the vessels was 
 ruptured, and the foetus died of hemorrhage. This fact is unique. 
 
 When the cord is short, hemorrhage may occur from its rup- 
 ture. 
 
UTERINE HEMORRHAGE DURING LABOUR. 255 
 
 § 2. Diagnosis of Uterine Hemorrhage. 
 The symptoms of uterine hemorrhage are distinguished into pre- 
 cursory symptoms and symptoms of actual hemorrhage. 
 
 Precursory Symptoms. 
 Hemorrhage sometimes appears suddenly, even when not caused 
 by external violence ; but most commonly the female feels a weight 
 and sensation of heat, trembling in the pelvis, dull pain in the loins 
 and thighs, and uneasiness in all the limbs ; sometimes, also, the 
 local symptoms of plethora are attended by general symptoms. 
 Thus, the patient's face is flushed ; she feels a dizziness and head- 
 ache ; the pulse is full, developed, slow, &c, &c. The active mo- 
 tions of the foetus are slow, dull, or have ceased altogether. 
 
 Symptoms of actual Hemorrhage. 
 The precursory symptoms appear a longer or shorter period 
 before hemorrhage occurs ; the symptoms which announce the 
 actual existence of this accident are distinguished into general and 
 local. 
 
 A. General Signs. — Weakness of the pulse, paleness of the face, 
 coldness of the extremities, ringing in the ears ; finally, all the 
 symptoms of hemorrhage, which generally occur. 
 
 B. Local Signs. — The local signs are also distinguished into two 
 classes : according as the hemorrhage is apparent externally, exter- 
 nal hemorrhage, or when the discharge of blood does not appear 
 externally, internal hemorrhage. 
 
 External Hemorrhage. 
 
 The hemorrhage itself is its own symptom. Accoucheurs gen- 
 erally attempt to ascertain exactly the cause of hemorrhage, in order 
 to establish the diagnosis. This seems to me perfectly useless ; for 
 whether the hemorrhage be occasioned by the insertion of the pla- 
 centa over the orifice, or its premature separation, &c, &c, the in- 
 dications will be varied only by the lightness or severity of the 
 accident ; farther, this persistence in establishing the diagnosis may 
 be attended with serious consequences : examinations by the finger 
 may separate the coagula and increase the hemorrhage, or renew 
 it if had been checked. 
 
 Nevertheless, if, by great care in his investigations, the accou- 
 cheur detect in the neck of the uterus a spongy and soft body ; 
 if the membranes be entire, and the hemorrhage increase during 
 uterine contraction, it must be attributed to abnormal insertion of 
 the placenta on the neck of the uterus. 
 
 If, on the contrary, it arise from the separation of this body, the 
 hemorrhage increases only between the pains ; it is less during 
 contraction, and the placenta is not felt at the orifice. 
 
 After the rupture of the membranes, these differences in the in- 
 crease or diminution of the flow cease to be perceptible. In both 
 cases, the pressure produced by the head of the child prevents the 
 
256 ACCIDENTS COMPROMISING THE LIFE OF MOTHER OR CHILD. 
 
 blood from escaping during contraction. Farther, we understand 
 the equivocal character of these signs, and why that which seems 
 the most positive, the presence of the placenta, may lead into error, 
 because it is difficult for the accoucheur to distinguish the placenta 
 from the clots which obstruct the uterine orifice. But happily, in 
 this case, an exact diagnosis is not material. 
 
 The difficulty of the diagnosis, in cases where the external hem- 
 orrhage comes from the umbilical vessels, is explained with equal 
 facility. 
 
 Hemorrhage from the separation of the placenta, and even that 
 arising from the insertion of the placenta over the orifice, may be 
 confounded with that coming from a tumour of the hairy scalp, or 
 from any other part of the fœtus which may be ruptured. At the 
 hospice of La Maternité, at Paris, this was seen by M. P. Dubois, 
 in an encephalic child : at first view, this tumour was mistaken 
 for a separated placenta. 
 
 Internal Hemorrhage. 
 
 At an advanced period of pregnancy, even during labour, a 
 small quantity of blood may accumulate in the uterus and remain 
 unobserved ; but most generally, especially if the hemorrhage oc- 
 cur to any extent, it appears externally by general signs, which I 
 have mentioned, and by the following local signs : there is greater 
 resistance of the mass of the uterus, irregularity of its form, coin- 
 cident with its unusual and rapid development, and the cessation 
 of active motions. 
 
 During labour, internal hemorrhage is most frequently preceded, 
 attended, or followed, by a slight discharge of blood externally : 
 in this case, the hemorrhage is both internal and external. 
 
 In short, the more advanced the pregnancy, the more serious and 
 easily distinguished will be the hemorrhage. Sufficient blood to 
 endanger the life of the child may, however, be effused between the 
 uterus and the separated ovum, although the accoucheur may be 
 ignorant of it, from any effects on the state of the mother. 
 
 This accident may be confounded with dropsy of the amnios or 
 tympanitis, but the absence of the other signs of internal hemor- 
 rhage soon removes all doubts. 
 
 Seat of the Effusion. 
 
 The seat of the effusion in internal hemorrhages varies accord- 
 ing to the cause of the hemorrhage. Thus, in cases of separation 
 of the placenta : 
 
 1. The blood may accumulate between the placenta and the 
 uterus, and the placenta, separated at its centre, may adhere to the 
 uterus at its circumference ; but most frequently, the blood from 
 the placenta, the adhesions of which are destroyed in one point, 
 separates the membranes, and is effused around the ovum : in 
 this case, the internal hemorrhage may be fatal to the mother and 
 child. In fact, the uterus, in the usual state of pregnancy, is not so 
 much enlarged as not to allow room for farther distension, by a 
 
UTERINE HEMORRHAGE DURING LABOUR. 257 
 
 quantity of blood sufficient to be fatal to the mother and child, al- 
 though'some authors have denied this. 
 
 2. The blood may also be effused between the folds of the differ- 
 ent membranes ; M. C. Baudelocque mentions several cases of this, 
 and sometimes the quantity of blood may be so large as to occasion 
 anxiety. Most frequently, however, these hemorrhages are slight, 
 and are not observed. 
 
 3. Effusion may take place within the membranes by the rupture 
 of the cord (intra-ovular hemorrhage) ; numerous cases cited by 
 Baudelocque, Delamotte, Peu, Nsegele, Deneux, Guillemot, estab- 
 lish incontestably the possibility of these hemorrhages. 
 
 4. Finally, the blood may be effused within the placenta, but this 
 internal hemorrhage, or apoplexy of the placenta, cannot be consid- 
 ered in the same point of view as the preceding : in fact, it never 
 endangers the life of the mother ; and if the child die, it is not from 
 the loss of blood, but because the apoplectic sinuses, when numer- 
 ous, cause the degeneration of the placenta, and disturb or nullify 
 its functions. 
 
 § 3. Prognosis. 
 
 The severity of the prognosis varies in a ratio with the quantity 
 of blood lost, according to the period of the labour when hemor- 
 rhage occurs, its nature, and the causes which produce it. 
 
 Thus, hemorrhage will be more serious to the mother and child 
 as the accident appears at a period of labour more remote from the 
 moment when the dilatation of the uterine orifice or that of the ex- 
 ternal parts wiJl permit the spontaneous expulsion of the fœtus, or 
 its extraction. In fact, during the time required by these parts to 
 become properly prepared for delivery, the quantity of blood dis- 
 charged may endanger the lives of both mother and child. 
 
 It is much more serious for the child during labour than for the 
 mother ; it is more serious also for both in cases where the placen- 
 ta is inserted over the orifice, when this insertion occurs in the cen- 
 tre : the almost perfect separation of the placenta causes, at the 
 moment of labour, a considerable hemorrhage, which is the more 
 alarming for the mother as she may have been already enfeebled 
 by hemorrhages which appeared in the latter months of pregnan- 
 cy ; much more dangerous for the foetus, as the relations which 
 unite the placenta to the uterus are more completely destroyed. 
 
 We understand, also, that this accident is much more serious in 
 cases of the premature separation of the placenta, according as this 
 separation is more complete. 
 
 The internal hemorrhage is much more dangerous than the ex- 
 ternal, because it may give rise to a considerable loss of blood be- 
 fore it is indicated by any external symptoms ; and then, when it is 
 detected, it is often too late to remedy it efficiently. 
 
 Internal hemorrhage is less serious before than after the rup- 
 ture of the membranes : thus, before this rupture, the dilated ute- 
 rus contains a smaller quantity of blood than when the ovum is 
 ruptured. Besides, after the rupture, art is deprived of a saluta- 
 
 K K 
 
258 ACCIDENTS COMPROMISING THE LIFE OF MOTHER OR CHILD. 
 
 ry resource — the artificial perforation of the membranes. This 
 operation stimulating, in fact, the contraction of the uterus, will oft- 
 en arrest the hemorrhage, especially in cases where it arises from 
 a premature separation of the placenta, inserted on the fundus of the 
 uterus, this part possessing more power of contracting than the 
 neck. 
 
 Hemorrhage is a much more serious thing for the mother in the 
 hospital than in the city, especially when metro-peritonitis is epi- 
 demic, as discharges of blood singularly predispose to this terrible 
 disease. 
 
 If the profuseness of the hemorrhage be equally fatal to the moth- 
 er and child, we must not think that the loss of blood operates in the 
 same manner on both. 
 
 The mother dies anemic ; but the quantity of blood which is lost 
 rarely endangers the life of the foetus, unless the blood comes from 
 the umbilical cord. The child dies from asphyxia, as if the cord 
 were compressed. Instead of being anemic and pale, it is, on the 
 contrary, red and violet : at the autopsy, we find all the veins gor- 
 ged with blood, as occurs in asphyxia. 
 
 When the hemorrhage has been very great, without, however, 
 destroying the life of the mother, it affects the system severely. 
 The female becomes much enfeebled, she presents all the symp- 
 toms of chlorosis, and indigestion and the sight and hearing are af- 
 fected ; but she rarely escapes those nervous headaches which are 
 so permanent and painful. I have often had occasion to observe 
 this fact, which seems to me to be a natural consequence of profuse 
 hemorrhage. Farther, all remedies for this are useless, and it con- 
 tinues till the strength of the patient is restored by proper regimen. 
 
 § 4. Treatment. 
 The treatment of uterine hemorrhage is preventive or curative ; 
 the whole preventive treatment is found in the article Hemorrhage 
 and Abortion during Pregnancy. The curative treatment is gen- 
 eral and special. 
 
 General Treatment. 
 
 When the accoucheur is called to a female affected with hem- 
 orrhage, he must cause the patient to lie down in the horizontal 
 posture ; remove the pillows, and elevate the hips on a firm cush- 
 ion, so that the chest may be lower than the hips. The chamber 
 should be well aired and ventilated, yet it should not be very light. 
 The most perfect repose of body and mind is indispensable. 
 
 Hence the female should be encouraged, and the utmost silence 
 and complete quiet should be preserved around her. 
 
 The patient should be lightly covered at the upper part of the 
 body ; the feet and legs should be uncovered, or protected only by 
 a sheet ; the rectum should previously be emptied by a cold enema, 
 or mild laxative if the enema be insufficient, and the drink should 
 be cold lemonade, currant-jelly water, &c. 
 
UTERINE HEMORRHAGE DURING LABOUR. 259 
 
 Special Treatment. 
 
 The special treatment also varies according to the lightness or 
 severity of the accident, and according, also, to the period of la- 
 bour. The remedies, however, do not depend at all on the causes 
 producing it. 
 
 The following table, which belongs entirely to M. Dubois, em- 
 braces all the modifications which this state can present. (See 
 Table, p. 260, 261.) 
 
 Remarks on the Indications in the Table. 
 
 It will be seen that the indications rest on the lightness or sever- 
 ity of the hemorrhage, and not on the insertion or non-insertion of 
 the placenta on the neck. This circumstance, however, is not im- 
 material ; the hemorrhage produced by the separation of the pla- 
 centa inserted over the orifice is most generally severe, and then 
 demands the remedies indicated for profuse hemorrhages. At 
 times, however, the insertion of the placenta on the neck of the 
 uterus occasions only slight bleeding. I do not think, then, with 
 most accoucheurs, that the insertion of the placenta on the neck 
 requires the labour in all cases to be terminated rapidly and 
 promptly. It may, however, modify the employment of the reme- 
 dies indicated. Thus, in a case of severe hemorrhage, if the pla- 
 centa cover the orifice entirely, we cannot have recourse to the 
 simple rupture of the membranes, as we should if this did not occur. 
 If the orifice be not sufficiently dilated nor dilatable to admit the 
 hand, the tampon should be used ; on the contrary, if the hand can 
 be introduced, we must separate one of the sides of the placenta 
 to open a passage into the uterine cavity, and terminate labour by 
 turning. But if a portion only of the placenta be inserted on the 
 orifice, and leaves a part of the membranes exposed, we may 
 proceed as if the placenta was not inserted on the orifice. 
 
 In no case is it proper to pierce the placenta, as some authors 
 recommend. 
 
 Finally, if the placenta be crowded by the head or pelvic ex- 
 tremity of the foetus, and be entirely, or almost entirely, separated, 
 and have passed through the o-rifice of the uterus, we must remove 
 it before the fœtus ; for the organ in this case is useless, and its 
 presence in the vagina obstructs the free use of the hand and in- 
 struments. 
 
 In the article Abortion I have mentioned the mode of applying 
 the tampon.* This is a valuable remedy, and acts first by pre- 
 
 * In 1841 I was called, by Dr. Cazalis, to see a young female in her first labour, in the 
 Rue de Seine, St. Germain, and who was affected with hemorrhage. She had gone the full 
 term ; the thick neck was resisting and not dilated, and would not allow any measures to be 
 taken to relieve the mother and child from the dangers of hemorrhage, although this was 
 very profuse, and the female seemed much debilitated. Touching per vaginam readily dis- 
 covered the presence of the placenta at the orifice ; the membranes were entire ; the pains 
 were feeble. Through the placenta was felt a firm, hard body, which I regarded as the head. 
 Auscultation might perhaps have thrown some light on the subject, but I considered it as 
 most important to ascertain the existence of the child, whether it was alive, and to check 
 the hemorrhage as soon as possible ; I had to choose between the rupture of the membranes 
 
260 ACCIDENTS COMPROMISING THE LIFE OF MOTHER OR CHILD. 
 
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262 ACCIDENTS COMPROMISING THE LIFE OF MOTHER OR CHILD. 
 
 venting the flow of blood ; then its presence on the neck of the ute- 
 rus irritates this lower part of the organ, and solicits the reaction of 
 the upper portion, which contracts, and causes the orifice to dilate. 
 Then, when the tampon is withdrawn, we find the passages pre- 
 pared, and the membranes may be ruptured. The latter operation 
 alone will often arrest the hemorrhage, and if not, the foetus must 
 be extracted. If the tampon do not cause the dilatation of the 
 neck, it would certainly favour its thinness, and then it would still 
 be possible to rupture the membranes, because, if this rupture be 
 inefficient, the neck, although not dilated nor dilatable, will permit 
 delivery to take place, in cases of imminent danger, by first cut- 
 ting the sides of this thin orifice. 
 
 But to obtain these results, the tampon must remain in the vagi- 
 na at least an hour or two, and until it has induced strong con- 
 tractions. Farther, the longer it is applied the more advanced 
 shall we find the labour. The length of time for its application 
 should be based on the state of the neck at the time it is tampon- 
 ned, and on the strength of the contractions while it is applied. 
 
 Unfortunately, the remedy cannot always be borne by females. 
 Sometimes it causes an insupportable feeling of tenesmus in the 
 rectum and bladder, and soon after its application the female will 
 beg you to remove it. In those cases, however, where the tampon 
 is indispensable, we must encourage them to bear it for a few mo- 
 ments, by pointing out the necessity of its application, and not with- 
 draw it until its presence becomes intolerable, and leads to symp- 
 toms more dangerous than hemorrhage, which is fortunately very 
 rare. I have enlarged, also, on the mode in which ergot is admin- 
 istered. Dubois much prefers the dilatation of the orifice by lat- 
 eral incisions of the neck to forced parturition, but they cannot 
 
 and the tampon ; the state of the neck, which, notwithstanding the ergot, would not allow 
 me to expect a rapid dilatation under the influence of the rupture of the membranes, decided 
 me in favour of the tampon, which I applied with a speculum. Pledgets of lint, tied with 
 thread, were pushed into the vagina as I withdrew the speculum. Finally, when the vagina 
 was entirely filled, I applied a T bandage firmly to keep it in place. We then administered 
 a drachm of ergot in two doses: by means of these remedies the external hemorrhage did 
 not cease entirely, but powerful contractions supervened, and in an hour or less the efforts 
 of the female partially expelled the tampon, and the membranes were ruptured : we removed 
 the lint and bandage, but found the pelvic extremity at the orifice instead of the head, as I 
 had imagined. The dilatation being almost complete, I introduced the hand immediately, 
 and grasped the fe^of the child ; the delivery was rapid, but the hemorrhage had compro- 
 mised its life, andWf fer a ^ ew inspirations, it died. The mother recovered perfectly, the 
 hemorrhage ceasing^with the delivery of the child. 
 
 February 2, at half past nine o'clock, Madame Mozanot, thirty-five years old, having borne 
 seven children at the full term, and had one miscarriage at three months, which had requi 
 red the tampon for three days, was attacked with repeated hemorrhages in the last thret 
 months of this eighth pregnancy. When eight months advanced, the hemorrhage was se 
 vere, and in this state she was brought, at half past nine A.M., to the salle des accouche 
 mens. The neck was soft, dilated to the size of a five-franc piece, and the placenta was 
 inserted on the left of the os tincae. M. Dubois immediately tamponned her, say about ten 
 o'clock : at twelve, in consequence of frequent faintings, he administered a drachm of ergot 
 in Malaga wine, but as the female continued to grow feeble, and farther hoping, from the na- 
 ture of the contractions and their duration, that the neck was dilated, he withdrew the tam- 
 pon ; and, in fact, the neck was sufficiently enlarged to permit the labour to be terminated : 
 twenty minutes after twelve, M. Dubois turned by the feet; the child was dead, but the 
 mother recovered. 
 
 In a case almost similar, April 29, the rupture of the membranes brought on labour, the 
 hemorrhage ceased, and the child was dead. If my limits permitted, I could adduce many 
 more cases, showing that this symptom is more fatal to the child than to the mother. 
 
ECLAMPSIA DURING LABOUR. 263 
 
 be had recourse to unless the undilated neck is thin. On the con- 
 trary, where the neck preserves its thickness, these incisions are 
 useless. Dubois recommends them to be made, also, only on the 
 sides of the orifice ; an extremely important precept. In fact, the 
 bladder and rectum might be endangered by the prolongation of 
 these incisions, during the delivery of the fœtus, were they made 
 anteriorly and posteriorly. Farther, they should not be deep, ex- 
 tending only a few lines ; the passage of the hand and the child 
 will do the rest. 
 
 In making these incisions, Dubois uses a convex-shaped, probe- 
 pointed bistoury, with a long handle ; the instrument glides along 
 the index finger of the left hand, which answers for a guide, for an 
 incision on the right and left side. A straight, probe-pointed bistoury 
 might be used, but in this case the blade should be protected by a 
 thin strip of linen, and should be left exposed only for two or three 
 lines at its extremity. 
 
 This precaution is as necessary for the parts of the mother as 
 for the finger of the accoucheur. 
 
 Refrigerants, as I have already stated when speaking of abor- 
 tion, should not be used over the whole body, but only on the lower 
 extremities, while the upper parts should be warmed, to keep as 
 much blood as possible in the organs essential to life ; this produces, 
 at the same time, a very useful revulsive action. 
 
 The membranes, as has been seen, should not be ruptured, ex- 
 cept in cases where the neck, although not dilated nor dilatable, is, 
 however, thin enough for us to expect dilatation soon. If, on the 
 contrary, the neck be thick, and a long time must elapse before its 
 dilatation, it is better to use the tampon immediately. In fact, sup- 
 pose the neck of the uterus was thick, and the membranes were 
 ruptured without arresting the hemorrhage ; as the state of the neck 
 does not permit us to penetrate into the uterus, the female will re- 
 main exposed to the dangers of hemorrhage until the mouth is dila- 
 ted, for we can hardly use the tampon in this case without fear of 
 substituting internal for external hemorrhage. We could not, as I 
 have said, prefer the tampon to forced labour, after the rupture of 
 the membranes, except in cases where the uterus is powerfully 
 contracted, when strong pains exist, and- a very small quantity of 
 water has escaped from the uterus : here its application requires 
 great care. 
 
 Art. V. — Eclampsia during Labour. 
 I have stated, when treating of convulsions during pregnancy 
 the nature, causes, diagnosis, prognosis, and treatment of this acci- 
 dent, and shall now mention the special modifications produced by 
 labour in the prognosis, and the indications to be fulfilled. Thus, 
 as in hemorrhage, the prognosis is much more serious in propor- 
 tion as the orifice and external organs are less dilated, and ac- 
 cording as the spontaneous or forced delivery is more remote and 
 difficult : here the danger of the prognosis applies to the mother 
 more than to the fœtus, whose life is almost always compromised 
 
264 ACCIDENTS COMPROMISING THE LIFE OF MOTHER OR CHILD. 
 
 long before it is possible to act. The termination of the labour, 
 however, is not always followed with so immediate a result for the 
 mother as in hemorrhage ; most frequently the convulsions con- 
 tinue after the expulsion or extraction of the foetus. 
 
 § 1. Treatment. 
 The treatment consists, first, during the paroxysm, as we have 
 already said when treating of convulsions during pregnancy, in 
 keeping the tongue in the mouth, so that it may not be bitten ; then, 
 after the paroxysm, in employing the means already enumerated, 
 as general and local bleeding, purgative enemata, antispasmodic 
 potions, revulsives to the extremities, &c.,&c. ; and especially, while 
 all these remedies are used, the accoucheur should deliver the 
 foetus, if possible ; in these cases, this is the surest remedy ; but, as 
 we shall state hereafter, this delivery ought not to be made at all 
 risks ; we may frequently fail, and where we succeed the remedy 
 might be worse than the evil. The violence requisite might aggra- 
 vate the convulsive symptoms in most cases. The special treat- 
 ment consists in delivering the foetus : the processes for this vary 
 according to the frequency, duration, and intensity of the par- 
 oxysms, and according, also, to the period of labour at which the 
 paroxysms appear. 
 
 SYNOPTICAL TABLE OF THE TREATMENT OF CONVULSIONS 
 DURING LABOUR. 
 
 Slight.... < 
 
 Neck not dila- 
 ted, not dilatable, 
 thick. 
 
 j Membranes 
 I entire. 
 
 Membranes 
 V ruptured. 
 
 k Neck dilated, dilatable. 
 
 ( Membranes 
 Neck not dila- j entire, 
 ted, not dilatable, < 
 thick. Membranes 
 
 V ruptured. 
 
 [ Membranes 
 .Severe... <( Neck not dila- J entire. 
 
 ted, but thin. \ Membranes 
 ^ruptured. 
 
 f Membranes 
 Neck dilated or J entire. 
 ^ dilatable. ) Membranes 
 
 V ruptured. 
 
 Rupture the membranes ; distension 
 being one of the principal causes of 
 convulsions, we may expect to termi- 
 nate them by producing contraction of 
 the organ. 
 
 Anoint the os tincae with extract of 
 belladonna, and wait. 
 
 Confide the delivery to nature, and 
 do not administer ergot ; it may aggra- 
 vate the symptoms ; and, farther, it is 
 useless, convulsions causing, in most 
 cases, very powerful contractions of 
 the uterus. 
 
 £ Rupture them, belladonna, and wait. 
 
 ( Belladonna ; forced delivery has been 
 urged ; but this remedy is often more 
 dangerous to the mother than the con- 
 vulsions ; therefore abstain from it. 
 
 Rupture them, belladonna, wait. 
 
 Belladonna, then incisions on the 
 sides of the orifice, and deliver the foe- 
 tus by turning or the forceps. 
 
 Rupture them and deliver the foetus. 
 Deliver. 
 
 Remarks on the Treatment. 
 In most cases, we may say that the general indications of 
 cure, and the special treatment laid down in the above table, are 
 attended, most frequently, with a fortunate result for the mother, 
 but much less fortunate for the child. 
 
RUPTURE OF THE UTERUS. 265 
 
 I have verified this fact by observations in the city, and in thir- 
 teen cases of convulsions at La Clinique, I have also noticed other 
 cases, the details of which are not without interest. 
 
 In November, 1841, 1 was requested by Dr. Clair and a midwife, 
 in my neighbourhood, to visit a female in labour with her first child, 
 attacked with convulsions. When I arrived, the female was in a 
 coma, which had followed the third paroxysm ; the child was living ; 
 prompt action was important, and very fortunately the head had 
 descended into the cavity, and had nearly completed its rotation : 
 the occiput, however, was a little on the left. The application of 
 the forceps was very easy (1 began with the pivot blade), and the 
 child, a female, was delivered alive, and did well. The mother, 
 however, had frequent paroxysms the whole of the next day, not- 
 withstanding the attentions of Dr. Devilliers, who was likewise 
 called to her. The second night was passed in a state of furious 
 delirium, followed by profound coma, which continued till the next 
 morning. After this she recovered completely. In this case, the 
 termination of the labour saved the child ; but the convulsions 
 continued, and even increased. In eleven other cases, noticed 
 at La Clinique,* I observed the same thing seven times. I also 
 remarked that in the thirteen females, nine were primiparae, seven 
 dropsical ; two pregnant with twins ; one was attacked during 
 pregnancy ; ten during labour ; two after parturition ; one at five 
 months ; one at seven months ; three at eight months ; one at term. 
 In three only the precursory signs were noticed ; in eight the for- 
 ceps were used ; in one manual delivery was practised ; four were 
 delivered spontaneously ; only two died ; ten children died ; one 
 came into the world putrefied, and two lived. 
 
 Art. VI. — Rupture of the Uterus. 
 Rupture of the uterus is the most formidable accident which can 
 occur to the female in the puerperal state ; it is sometimes followed 
 by instant death. The uterus may be ruptured at its fundus or 
 supra-vagjnal portion. 
 
 § 1. Predisposing Causes. 
 We may regard as predisposing every cause which increases 
 the distension of the uterus, or diminishes the resistance of its pari- 
 etes ; such as twin pregnancies, dropsy of the amnios, debility of 
 certain parts of the organ without any known cause, or which may 
 be produced by gangrenous alterations, by atrophy, apoplexy, acute 
 or chronic inflammation of the organ, or scirrhous alteration. 
 
 § 2. Efficient Causes. 
 
 The efficient causes are, powerful contractions of the uterus to 
 
 overcome a mechanical obstacle to labour, such as the contraction 
 
 of the pelvis, a bad presentation of the fœtus, lesions by external 
 
 causes, as falls, blows, wounds ; finally, lesions by internal causes, 
 
 * Biron, f. Prunet; Cossard, f. Jaquin ; Bourson, f. Judaine; Nachon, Geoffroi, f. Her- 
 baux, Lesson, Raboutet (Bl., M. M. 14 Septembre, 1840.) (27 Septembre, 1840.) 
 
 L L 
 
26G ACCIDENTS COMPROMISING THE LIFE OF MOTHER OR CHILD. 
 
 among which we must place in the first rank unskilful obstetrical 
 manipulations. In fact, how many times has this last circumstance 
 caused the death of the female, who would have survived in 
 skilful hands ! M. Voillemier and M. Cazeaux found once, in an 
 autopsy, a laceration of two thirds of the uterus after the applica- 
 tion of the cephalotribe. An old interne of the hospitals twice de- 
 tected the same thing after the use of this instrument. It is not 
 surprising, therefore, that unskilful operators condemn this instru- 
 ment, which is so valuable when properly used. 
 
 § 3. Symptoms. 
 
 The female suddenly utters a piercing cry, and complains of a 
 most intense pain, like a cramp, in the place where the rupture oc- 
 curs ; she becomes pale, the pulse flags, is almost imperceptible, 
 general insensibility follows this state of inexpressible anguish, and 
 the female faints. The pains suddenly cease, the abdomen be- 
 comes supple, depressible, and frequently the fundus of the uterus 
 cannot be felt at its usual height ; but we feel in its place the parts 
 of the foetus, while the contracted uterus is depressed into the hy- 
 pogastric region. 
 
 If we examine per vaginam if the bag of waters be unbroken, 
 and were prominent before the accident, we feel that it is flaccid, 
 although the waters have not escaped ; we ascertain also that the 
 foetal part, which occupied the superior strait, is no longer there ; 
 it seems to me impossible to feel the displaced fœtal parts through 
 the cul-de-sac of the vagina. But if the dilatation of the orifice 
 permit the introduction of the hand into the cavity of the uterus, 
 this hand often ascertains that the foetus has disappeared, that in its 
 place are folds of the intestines ; but most frequently there are some 
 parts of the fœtus within the cavity of the organ, and we can follow 
 those which have escaped into the abdominal cavity through the 
 fissure of the uterus. If, however, the fluids alone are diffused into 
 the peritoneal cavity, if the fœtus be not displaced, the fissure of 
 the organ is closed by its contraction, and no light is thrown on the 
 question by touching ; but the external phenomena and rapid death 
 establish a diagnosis in this case which is confirmed by autopsy. 
 
 § 4. Prognosis. 
 
 The prognosis of rupture of the uterus is very alarming ; this 
 accident is often followed by instant death, but most generally 
 death occurs after a few hours, in consequence of hemorrhage oi 
 peritonitis. This accident is much more serious before than after 
 the rupture of the membranes ; in fact, after the discharge of the 
 waters, we need not dread their effusion into the cavity of the peri- 
 toneum ; the blood which comes from the wound, or the separation 
 of the placenta, can alone be effused into it. 
 
 Some females, however, escape all these dangers. Dubois was 
 sent for one day to La Maternité in a case of this kind. The pa- 
 tient, mother of seven children, had been only an hour in the salle 
 d'accouchement, when suddenly she uttered a piercing cry, and 
 
RUPTURE OF THE UTERUS. 267 
 
 complained of pain in her right side. Her face was pallid, and 
 suddenly sunk, her eyes were suffused, the pulse was depressed ; 
 and the head, which had previously presented at the os tincse, 
 could no longer be felt. M. P. Dubois turned the child, but found 
 the feet in the abdomen ; the operation was performed easily; after 
 removing the fœtus, he again introduced his hand, penetrated more 
 anteriorly into the cavity of the peritoneum, and even pushed back 
 some folds of intestine which tended to engage in the opening. On 
 the fifteenth day the patient was discharged cured. 
 
 § 5. Treatment. 
 The rupture of the uterus is serious only from the alarming acci- 
 dents it causes, and which result from the effusion of the amniotic 
 fluid and blood into the cavity of the organ, and thence into the 
 peritoneum. The accoucheur, as soon as he detects the accident, 
 should immediately deliver the fœtus, and thus permit the uterus 
 to contract, and, consequently, the union of the laceration, conform- 
 ing, however, to the following rules : 
 
 1. If the fœtal parts be not displaced, we should deliver by turn- 
 ing or by the forceps ; in case of contraction of the superior strait or 
 excessive size of the fœtus, as the mother will almost certainly die, 
 gastrotomy should be performed to extract the fœtus if it be alive ; 
 if dead, or if we think it is not viable, the size of the fœtal parts 
 must be diminished in order to extract them. 
 
 2. When a part of the child is still within the uterus, if it be the 
 feet, we must draw on them, and remove the fœtus. If these parts 
 have passed into the peritoneal cavity, the hand must reach them ; 
 and in this case, the contraction of the uterus will never be power- 
 ful enough to prevent the hand, when it has entered this organ, 
 from following the parts of the child through the rupture which 
 these parts still keep open. I cannot think that the proposition to 
 introduce the hand into the uterus with a bistoury to enlarge the 
 opening, and thus overcome its contraction, was made seriously. 
 
 3. When the whole fœtus has passed into the peritoneal cavity, 
 we must "still attempt to reach it through the laceration, and re- 
 move it through the natural passages. In all cases, after the re- 
 moval of the fœtus, the hand should be introduced into the uterus, 
 to ascertain that no hernia of the intestines exists, and to reduce it 
 in case it has occurred. 
 
 The rest of the treatment is embraced in that of uterine hemor- 
 rhage and peritonitis.* 
 
 * Within the last twenty months I have seen^ve cases of rupture of the uterus. This is 
 a fearful number, and the proportion is far too great for them all to have been spontaneous 
 or unavoidable. Unfortunately, several of them were the direct consequences of gross mis- 
 management. Never can I forget the melancholy scene which I witnessed about eighteen 
 months since in a case of this kind. I was requested to visit, about five miles from the city, 
 a poor woman, who had been in labour thirty-six hours. From the commencement of her 
 labour she had two medical gentlemen with her, and, for reasons which I trust were satis- 
 factory to themselves and their consciences, they determined on the use of the perforator. 
 This instrument was accordingly thrust into the brain of a living child ; the labour, howev- 
 er, did not advance, and they proceeded to remove the foetus piecemeal. After four hours' 
 work they succeeded in bringing away the whole of the fœtus in a mangled condition, ex- 
 cept the head, which was still in the womb. The friends of the unfortunate sufferer became 
 
268 ACCIDENTS COMPROMISING THE LIFE OF MOTHER OR CHILD. 
 
 Art. VII. — Rupture of the Vagina. 
 The rupture of the vagina is much less formidable than that of 
 the uterus ; if, however, it occur at the upper part, near the inser- 
 tion of the uterus, it may give rise to accidents almost as fatal. 
 On the contrary, the lacerations of the central and lower part of 
 this canal, or vesico and recto-vaginal fistulse, are not of a char- 
 alarmed ; their confidence was lost ; and the serious apprehensions entertained for the safety 
 of the woman induced them to call in additional aid. I was sent for ; and, hearing the par- 
 ticulars of the case as far as the messenger could communicate them, I hastened to the 
 house, accompanied by Dr. Busteed and two of my pupils, Messrs. Burtsell and Cook. On 
 entering the room of the unhappy woman, a scene disclosed itself at which the heart sickens. 
 "Hie patient was pale and exhausted ; her countenance was that of a dying woman ; she 
 was almost pulseless, with cold extremities, and the perspiration of death on her. She beg- 
 ged us to relieve her, and said she was willing to undergo any suffering if she could only be 
 spared to her children ! Poor creature ! had she known that she was about being removed 
 from her children by the atrocious butchery of men to whom she had confided her life, she 
 would not have made the appeal she did. In approaching the bed of this murdered woman, 
 and in attempting to make a vaginal examination, to ascertain the condition of the womb 
 (the head of the fœtus being still within its cavity, having been separated from the trunk), 
 the reader may imagine my feelings on finding a mass of small intestines protruding from 
 the vagina, and lying between the thighs ! Such was the fact. The operators had not con- 
 tented themselves with slaughtering the infant, but they ruptured the uterus, through which 
 the intestines had protruded, and in this condition had abandoned the woman ! ! From what 
 I could learn, she lay in this situation for three hours before I saw her, the doctors having 
 left the house, stating that nothing more could be done ! ! Verily, death does terminate all 
 human effort. 
 
 Why was embryotomy had recourse to in this case ? I never could ascertain. There 
 must have been some secret reason for it ; perhaps the burning love which some men have 
 for the eclat of bloody deeds. There was no deformity of the pelvis ; the head of the foetus 
 was of the ordinary size ; and, as far as I could learn, it was nothing more than an ordinary 
 protracted labour; the pains had not been severe, and there was not sufficient expulsive 
 force to deliver the child ; the doctors judged it advisable to do something, and they determined 
 to turn and deliver by the feet. They accordingly proceeded ; and, mistaking a hand for a 
 foot, pulled it down into the vagina. They were then foiled ; and, in order to complete the 
 tragedy, they commenced the horrid business of cutting up the foetus, and extracting it 
 piecemeal ! Thus were two lives wantonly sacrificed. The poor woman died in about two 
 hours after I arrived, and, half an hour before she sunk, she observed, " My poor baby was 
 alive, for I felt it move when the doctors were tearing it away from me." Such language, uttered 
 under such circumstances, was indeed calculated to awaken the reflections of the actors 
 in this scene of carnage, and point out to them the magnitude of their guilt. This may seem 
 a harsh expression on my part, but, in the name of justice, is it not merited ? 
 
 Rupture of the womb sometimes occurs spontaneously. Dr. William Power, a gentle- 
 man extensively engaged in the practice of midwifery, requested me, about a year since, to 
 see a case of this kind with him. The female had previously borne several children. She 
 sent for the doctor at the commencement of her labour, and everything appeared to be going 
 on favourably. The delivery was not much advanced ; the doctor left her, stating that he 
 would return in two hours. He did so, and found a marked alteration in the condition of 
 his patient. She was vomiting, almost pulseless, with clammy perspiration and cold extrem- 
 ities. I arrived soon after the doctor's second visit, and our opinion was that these symp- 
 toms were induced by rupture of the uterus. Indeed, the child could be distinctly felt 
 through the abdominal walls, having escaped through the rent into the cavity of the abdo- 
 men. The woman died in three hours from the time I saw her. At the request of the doc- 
 tor, and assisted by one of my former pupils, Dr. Busteed, I opened the abdomen as soon as 
 she expired, with the remote hope of saving the child, but it was dead. 
 
 Dr. Bernhisel, of this city, sent for me, about ten months since, to see Mrs. M., who like- 
 wise had spontaneous rupture of the womb. She was the mother of several children, and 
 had been much enfeebled by antecedent ill health. The doctor arrived about three hours 
 after the commencement of her labour ; he made an examination, and found the head descend- 
 ing in the pelvic cavity, and everything promised a favourable delivery. He informed me 
 that, while sitting by the bedside, he distinctly heard something snap ; immediately vom- 
 iting and symptoms of collapse ensued. I was sent for, and the doctor and I concurred in 
 opinion as to the nature of the case, he having previously expressed to the friends his fears 
 that rupture had taken place. The indication in this instance was to deliver immediately 
 with the forceps (the head being in the pelvic excavation) ; and the doctor assenting, I delivered 
 her without difficulty of a foetus of ordinary size. The child was dead, and, from its ap- 
 pearance, must have been so for several days. The mother succumbed ten hours after de- 
 livery. In a preceding note, I mentioned a case of rupture of the uterus in consequence of 
 the administration of ergot, and the subsequent attempts of the physician to produce version. 
 —Ed. 
 
RUPTURE OF THE VAGINA. 269 
 
 acter to endanger the physical existence of the patient, but they 
 compromise her happiness. I shall attend to these accidents when 
 speaking of the consequences of lying-in. 
 
 Lacerations of the Superior Part of the Vagina, or Rupture of 
 the Natural Relations which unite it to the Uterus. 
 
 A. Causes. — The passage of the foetal parts, in cases of dispro- 
 portion of the foetus with the pelvis, the application of the forceps 
 where the blades have been badly guided, and which have perfo- 
 rated the cul-de-sac of the vagina, the too rapid* and violent repul- 
 sion of the parts of the child at the moment of entering the uterus 
 to turn, especially when we have not taken the precaution to sup- 
 port the fundus of the organ with the other hand applied exter- 
 nally. 
 
 B. The rupture of the upper part of the vagina is marked by the 
 same phenomena as those showing a rupture of the uterus, only 
 the symptoms are less intense ; sometimes even the pain pro- 
 duced by the laceration is so slight that it is confounded with that 
 caused by the contraction of the organ. If the rupture occur at 
 the upper and back part of the vagina, the foetus also may pass 
 partially into the peritoneal cavity ; as the peritoneum covers, at 
 this point, a large part of this canal, the neck of the organ then 
 ascends and leaves the foetal parts. Thus, when the head has 
 passed into the cavity, and occupies the lower part of the vagina, 
 if a rupture occur at the upper part, the lower extremities of the 
 foetus may escape through the rupture, and penetrate into the peri- 
 toneum. The same may be the case with the head, when the 
 breech has passed into the cavity: finally, the head or the feet 
 may enter there when the shoulder presents ; but the touch can 
 hardly recognise this accident before the extraction of the foetus. 
 If it occur when one of the foetal parts occupies the lower part of 
 the vagina, it would not be possible to detect it, except in cases 
 where the rupture is caused by mechanical violence before the 
 descent of the foetus. 
 
 C. The prognosis is much less serious than in the preceding 
 case. 
 
 D. The treatment consists in extracting the foetus and control- 
 ling the complications. 
 
 * This repulsion should always be made slowly and carefully : in most cases, especially 
 in presentations of the shoulder, the hand can enter the uterus, between the superior strait 
 and the parts which are in it, without this repulsion. 
 
270 DIFFICULTIES RESULTING FROM ANOMALIES IN LABOUR. 
 
 CHAPTER IV. 
 
 DIFFICULTIES RESULTING FROM ANOMALIES IN THE MECHANISM OF 
 
 LABOUR. 
 
 Art. I. — Anomalies in the first period of Flexion. 
 
 The two fontanelles are always on the same plane ; the anterior 
 fontanelle is not very difficult to reach, nor, in fact, inaccessible, 
 as occurs after flexion. 
 
 I have stated, in the article Anomaly in the Mechanism of Spon- 
 taneous Delivery by the Vertex, that the period of flexion is very sel- 
 dom deficient; that when it does not occur, the descent of the 
 head still takes place in most cases. I will add, that in order for 
 the descent of the vertex not to occur, flexion having failed, either 
 the head must be excessively large, or the diameters of the pelvis 
 small. Even in this case, the flexion will not always be deficient, 
 because it will be the more disposed to take place as it is more neces- 
 sary to the descent. Finally, if, by a very rare exception, it be defi- 
 cient, and the descent, in consequence of a slight disproportion 
 between the pelvis and the head of the fœtus, cannot occur, after 
 w r aiting for uterine pains as long as is proper, after quickening 
 them, if necessary, with ergot, if they be slight, we must intro- 
 duce several fingers of the hand, the palm of which looks to the face 
 of the child, and try to raise the forehead in order to flex the head. 
 In case we fail, the forceps should be used. But I repeat it, this 
 coincidence of defect in flexion, with a contraction of the superior 
 strait, or an excessive size of the head, is very rare : flexion will 
 occur more readily, the greater the obstacle to its descent ; and if 
 action be necessary, it must be ascribed rather to the mechanical 
 obstacle at the superior strait than to an anomaly in the period of 
 flexion. 
 
 Art. II. — Anomaly in the second period of the Descent. 
 
 The period of descent cannot fail by itself, and its accomplish- 
 ment can be obstructed only by foreign circumstances. 
 
 Such are, inertia of the uterus, deformities of the superior strait, 
 inordinate size of the foetal head, the resistance of the os tineas, or 
 mal-presentation of the head (rare), &c, &c. All these accidents 
 will be discussed separately in the chapter on mechanical obsta- 
 cles to parturition. 
 
 Art. III. — Anomalies in the third period of Rotation. 
 I have already dwelt at length on the anomalies of this period 
 of rotation. We have seen that, in presentations of the vertex, na- 
 ture alone is sufficient in most cases ; that the head can be expelled 
 when its rotatory motion is not entirely effected ; that when the oc- 
 ciput is posterior, spontaneous delivery of the fœtus is still the rule. 
 But if the head be arrested in its rotatory movement, diagonally, the 
 occiput on one of the two sacro-iliac symphyses, or behind one of 
 
ANOMALIES IN THE FOURTH AND FIFTH PERIODS OF DESCENT. 271 
 
 the two cotyloid cavities, and if the head be not small, nor the 
 pelvis large, the head cannot descend. The difficulty would be still 
 greater were the head to be arrested transversely. When there 
 are powerful contractions, and we cannot, consequently, attribute 
 to inertia the defect in rotation, we are very much embarrassed to 
 ascertain its cause : it may depend on an excessive size of the head, 
 the resistance of the perineum, a particular position of the head, 
 &c. Farther, whatever may be its cause, art is obliged to inter- 
 fere with the forceps, which alone can complete this movement of 
 rotation. 
 
 Art. IV. — Anomalies in the fourth period of Descent. 
 
 As we may well suppose, this fourth period cannot fail of itself; 
 the want of rotation to which I have alluded, the resistance of the 
 external parts, the inertia of the uterine contractions, the contrac- 
 tion of the inferior strait, are circumstances which alone can pre- 
 vent the delivery of the head. I have already spoken of uterine 
 inertia : the other causes will be treated of particularly in the fol- 
 lowing chapter. 
 
 Art. V. — Anomalies in the fifth period : External Rotation 
 of the Head, Internal of the Shoulders. 
 It is rare, as we have remarked in the same article when speak- 
 ing of spontaneous delivery by the vertex, that art is obliged to 
 interfere for a want of rotation in the shoulders. When they pre- 
 sent diagonally, they descend readily, and often are even delivered 
 transversely ; but if a disproportion exist between the bis-acro- 
 mial diameter of the shoulders and the transverse diameter of the 
 inferior strait ; if to this circumstance be added too great resist- 
 ance of the perineum, or, as frequently happens, a deficiency in 
 the expulsory efforts, the accoucheur should rotate the shoulders 
 and bring them down. He should first wait a few minutes, unless 
 the child appears in danger, and then should pull slightly on the 
 head of the child, directing the occiput to the left, if, before the 
 delivery of the head, the position were the left occipito-iliac ; to 
 the right, if the position were opposite. If these slight tractions be 
 insufficient, in cases where the occiput was originally on the left, 
 the accoucheur introduces the index finger of the right hand as 
 deeply as possible on the shoulder, which is on the left of the pel- 
 vis, so as to hook the finger, if possible, in the axilla, and the index 
 of the left hand under the right shoulder, which looks to the right 
 of the pelvis : then, by depressing the right index finger, and ele- 
 vating the left, he moves the shoulders in opposite directions, bring- 
 ing that on the left into the cavity of the sacrum, that on the right 
 under the pubes ; then the index finger of the right hand impresses 
 on the shoulder, on which it remains fixed, a motion of traction and 
 elevation, by which the fœtus is delivered. If the occiput were 
 primitively on the right, the left index finger should be placed over 
 the shoulder on the right of the pelvis, the right index finger under 
 that on the left of the pelvis. 
 
272 MECHANICAL OBSTACLES TO PARTURITION. 
 
 CHAPTER V. 
 
 MECHANICAL OBSTACLES TO PARTURITION. 
 
 Art. I. — Resistance of the Membranes. 
 I have already shown that the resistance of the membranes may 
 retard parturition indirectly, by causing inertia of the uterus. This 
 resistance of the bag of waters may be, of itself, a mechanical ob- 
 stacle to parturition. Thus, sometimes the membranes are so 
 thick and solid that they resist the contractions of the uterus, al- 
 though these may be very strong, and then parturition is singular- 
 ly retarded : sometimes, but rarely, nature is unable to surmount 
 this obstacle, and art is then compelled to interfere. 
 
 Rupture of the Membranes. 
 As soon as the uterus is perfectly dilated, the accoucheur takes 
 advantage of a pain, grates the membranes with the nail of the 
 index finger, and ruptures them ; but this can seldom be accom- 
 plished in the case we are speaking of, viz., when the membranes 
 are very firm. Most generally we are obliged to use the process 
 of M. P. Dubois, which is certain, safe, and easily performed. A 
 quill pen is introduced on the index finger of the right hand to the 
 membranes, and at the moment the membranes project very con- 
 vexedly, the pen is pushed with the left hand, and the bag of wa- 
 ters is torn at this point. This is all that is necessary, and the 
 membranes will never be so firm or thick as to require the use of 
 any other instrument, as a bistoury, or sharp-pointed probe, &c, 
 which should be carefully avoided. These instruments are man- 
 aged less easily than the pen, and if a fistula should be formed by 
 the long-continued pressure of the head of the fœtus on the vesical 
 or recto-vaginal wall, it would naturally be attributed to the use of 
 the instrument. 
 
 Art. II. — Obstacles dependant on the Neck of the Uterus. 
 
 § 1. Agglutination of the External Orifice. 
 
 The agglutination of the external orifice of the uterus is much 
 more frequent than is generally supposed. If it be often unnoticed, 
 it is because nature most usually overcomes it. This aggluti- 
 nation seems to be caused by the inflammation of the surfaces in 
 contact, which are frequently united by a more or less resisting 
 pseudo-membranous or fibrous tissue. 
 
 This agglutination may be detected by the following signs: 1st. 
 There is no orifice for the introduction of the finger, but in place 
 of this orifice there is a small hollow fold, depressed in its centre, 
 which is filled with cellular tissue. 2d. This agglutination may 
 
OBSTACLES DEPENDANT ON THE NECK OF THE UTERUS. 273 
 
 also be suspected by the propulsion of the lower segment of the 
 uterus into the cavity of the pelvis, at the commencement of labour. 
 
 In fact, if nature generally conquer this obstacle, and the orifice 
 of the uterus finally open, it is not till after violent and long-con- 
 tinued pains, by which the lower part of the organ is often forced 
 low down into the cavity of the pelvis. This distended part fre- 
 quently becomes so thin that we imagine that only the membranes 
 of the ovum are interposed between the finger and the head. 
 
 The distension is so great that the uterus would finally be rup- 
 tured if the agglutination of the neck were not destroyed by nature 
 or in some other way. In cases where nature is insufficient, these 
 adhesions may often be removed by the end of the finger. Hence, 
 this state % of things should be remedied at the beginning of labour, 
 or as soon as recognised, in order to spare the female those severe 
 pains which might, of themselves, possibly remove the difficulty. 
 By this wise course, also, we avoid the troublesome consequences 
 of the propulsion of the lower segment of the uterus. 
 
 § 2. Complete Obliteration of the Neck of the Uterus. 
 
 The neck of the uterus may be completely obliterated, in conse- 
 quence of the intimate union of the two lips of the orifice. This 
 union may be caused by an inflammation of the neck supervening 
 after impregnation, and may be so intimate, that the uterus will be 
 ruptured in some other point, sooner than give way at the place of 
 this adhesion. As soon as we ascertain that the contractions of 
 the uterus will not overcome this obstacle, and that the symptoms 
 do not depend on a posterior position of the neck, but are caused 
 by the accidental absence of this orifice, an incision should be made 
 in the anterior part of the lower segment of the uterus. (See Va- 
 ginal C cesarean Operation.) 
 
 § 3. Rigidity of the Orifice. 
 
 From the commencement of labour, the orifice of the uterus is 
 sometimes firm, rigid, and painful to the touch ; hot, although very 
 thin, and apparently easy to be dilated : nevertheless, it does not 
 open, and the female is annoyed by very sharp pains in the loins ; a 
 symptom most generally attending rigidity of the neck of the ute- 
 rus, and seemingly a consequence of it. 
 
 Sometimes this state of rigidity does not appear till at a more ad- 
 vanced stage of labour. The orifice, which had begun to dilate, 
 contracts little by little, closes, and prevents the descent of the head 
 of the fœtus ; or it manifests itself when the head has entered the 
 cavity of the pelvis, either before the contraction of the neck, or in 
 overcoming its resistance ; the orifice then contracts on the neck 
 oî the child, and prevents the passage of the shoulders. 
 
 This phenomenon, termed spasm of the neck, spasmodic contrac- 
 tion, as also rigidity of the orifice, is often connected with a state 
 of plethora, and yields frequently to general bloodletting and baths. 
 Emollient injections and fumigations are useless : I have always 
 known them to fail. Belladonna, however, is frequently very use- 
 
 M M 
 
274 MECHANICAL OBSTACLES TO PARTURITION. 
 
 ful, and should be employed in the form of the extract, about 
 the consistence of soft wax : of this, a small mass should be placed 
 on the nail of the index finger, and introduced to the neck of the 
 uterus. The heat and mucus liquefy the extract, which may then 
 be spread over the whole inner surface of the orifice. When this 
 remedy succeeds, its effect is generally instantaneous ; ten or fif- 
 teen minutes after it has been used, the neck loses its rigidity, and 
 dilates. I remember very distinctly the first time it was used by 
 M. P. Dubois, on account of another important fact connected with 
 it. At this time, I accompanied Dubois to the Maternité hospital. 
 Two females were in the parturition ward ; in one, the uterine or- 
 ifice had been dilated to the size of a two-shilling piece since the 
 morning, and had resisted very powerful contractions. Dubois 
 used the belladonna in this case, and then came to the second fe- 
 male to observe the mechanism of spontaneous evolution, the foetus 
 being from the sixth to the seventh month. # The child was putre- 
 fied and softened ; the pains were strong ; the parts in a good state ; 
 and this spontaneous expulsion, the shoulder presenting, required 
 only a few minutes for its termination. During this short space of 
 time, the dilatation in the first female was nearly complete. 
 
 October 22, 1840, Guilleron was taken in labour at 7 A.M. ; in 
 the evening, at twenty minutes before 9, the orifice had not dila- 
 ted, although the pains were very severe ; it was rigid, tense, pro- 
 jecting far backward, so that it was very difficult to introduce the 
 finger. The midwife used belladonna, as directed by M. P. Du- 
 bois ; in ten minutes the dilatation was complete, and the head pass- 
 ed the orifice. 
 
 This remedy, however, is not infallible : I have frequently used 
 it unsuccessfully, and whenever I have known it to succeed, it has 
 acted immediately. 
 
 The rigidity may depend on a morbid alteration of the neck of 
 the uterus, which has destroyed the extensibility of the fibres of 
 this part ; in this case, nature herself is sufficient. Dilatation takes 
 place at the expense of the sound portion ; the other splits and tears 
 to give passage to the foetus. If the whole neck be fibrous or scir- 
 rhous, the same effect may still' be produced ; but in this case, the 
 lacerations may extend, and affect the body of the organ, which, 
 as is well known, is a very serious accident. Therefore, if this 
 state resist baths, bleeding, belladonna, as will generally be the 
 case, incisions must be made on the sides of the orifice with a con- 
 vex bistoury, or a straight, probe-pointed bistoury, which should be 
 guided by the finger into the neck of the uterus. In these cases, it 
 is expedient to make many incisions, in order that sufficient dilata- 
 tion may exist, without danger of their extending too far. To 
 avoid the consequences of this accident also, these incisions should 
 not be made at the anterior and posterior parts of the orifice. In 
 fact, if extended in this direction, they might affect the bladder or 
 the rectum. I have seen this slitting of the orifice followed by 
 
 * It was under the impression of the possibility of expulsion by the trunk that I drew for 
 Dubois the figures of spontaneous evolution published in this work. 
 
DESCENT OF SOME OTHER PART WITH THE HEAD. 275 
 
 the best effect, either in females where the only obstacle was a 
 pure and simple rigidity of the neck, or in those where the parts 
 were more or less diseased. 
 
 In a young female, seventeen years old, who was confined at 
 La Clinique, the neck was healthy, but so rigid that incisions were 
 required. The child was born in an unreduced posterior occipital 
 position. 
 
 The incisions also were indispensable in a case of parturition in 
 an aged female, the mother often children ; the neck was so much 
 diseased, that at first it was thought the placenta was inserted on 
 the orifice.* 
 
 In fact, a spongy, tender, friable, bleeding substance could alone 
 be felt. 
 
 § 4. Faulty Direction of the Orifice. 
 
 It frequently happens that the orifice of the uterus does not oc- 
 cupy the centre of the pelvis, and this depends on the forced incli- 
 nation of the body of the organ, or on the abnormal insertion of the 
 orifice on the lower segment of the uterus. When speaking of 
 Uterine Obliquities, p. 250, I have stated the course to be pursued 
 in both cases. 
 
 The body of the organ should be carried into its natural direc- 
 tion at the same time that the neck is brought to the centre of the 
 pelvis. Where the insertion of the neck is abnormal, we are fre- 
 quently obliged to support at each pain the anterior lip, which op- 
 poses the passage of the head. 
 
 Art. III. — Descent of some other Part of the Fœtus, at the 
 
 SAME TIME WITH THE HEAD. 
 
 § 1. Descent of the Head and Forearm. 
 
 Sometimes an arm loses its natural relations, leaves the anterior 
 part of the chest, and enters the superior strait with the head. 
 This occurrence is not extremely rare, and, in most cases, it does 
 not prevent the spontaneous termination of the case. As the ex- 
 pulsion of the foetus takes place as rapidly as if this accident did 
 not exist, it may pass unnoticed until the moment when the head 
 and arm are expelled simultaneously. 
 
 M. P. Dubois was once obliged to go to Bellevue, and left in my 
 charge, in the parturition ward, a female in whom the arm pre- 
 sented simultaneously with the head, and where every effort to re- 
 duce the arm was unsuccessful. This was the first parturition, and 
 she had been in labour for three hours : it was then one o'clock in 
 the day. At four, Dubois returned, and found the labour termi- 
 nated without any interference on my part, so easy had been the 
 descent of the head and arm. 
 
 In another case, I observed the same result, but the labour was 
 longer and more difficult. 
 
 * I have frequently found the best effects from emet. tart., given in solution to tolerance, 
 in overcoming rigidity of the uterine orifice, where the rigidity is not dependant on disease, 
 but simply a resistance of the muscular fibre.— Ed. 
 
276 MECHANICAL OBSTACLES TO PARTURITION. 
 
 I might cite may instances of presentation of the arm which 
 were not recognised until the head passed through the vulva. 
 
 Sometimes, however, this presentation of the arm retards the 
 progress of the head, but nature finally triumphs over all difficul- 
 ties, and the head comes down. Not unfrequently, however, when 
 it reaches the floor of the pelvis, its rotatory motion is impeded by 
 the presence of the arm, and, consequently, it cannot be expelled. 
 Art is then obliged to interfere. 
 
 May 7, 1835, I assisted, at La Clinique, at a labour where this 
 occurred ; the peculiar position of the arm, and the readiness with 
 which it passed down, prevented this presentation from being de- 
 tected, or even suspected. The head remained for a long time on 
 the floor of the pelvis, but it did not execute its rotatory motion. 
 As the real cause of the delay was unknown, it was naturally at- 
 tributed to the weakness of the contractions of the uterus (they 
 were feeble), or to the resistance of the perineum. M. Dubois ap- 
 plied the forceps. 
 
 The blades were introduced easily ; the delivery was readily 
 performed, and all were surprised to see, when the head passed 
 through the vulva, that the arm was engaged in the instrument ; 
 and it was then found that the presentation of the arm alone pre- 
 vented the movement of rotation. 
 
 Finally, from these cases, and others which we cannot insert 
 here for want of space, we may say that the coming down of the 
 arm is an accident not very serious in itself, and that, if it offer a 
 serious obstacle to the progress of the head, it is only from a con- 
 traction of the superior strait, or from the excessive size of the foe- 
 tus. In fact, the bi-parietal diameter, the extent of which is at 
 most three inches and a half, is generally increased seven lines by 
 the presence of the arm, and this diameter, in a well-formed pelvis, 
 may pass through the superior strait, notwithstanding this increase, 
 which does not make it in all more than four inches. 
 
 We must admit, that if, in most cases, the entrance of the head 
 into the pelvis and its delivery may take place spontaneously, they 
 are also sometimes retarded : the delivery even may be entirely 
 prevented in consequence of the impediment presented by the arm 
 to the rotation of the head. 
 
 § 2. Diagnosis. 
 
 When the descent of the arm is complete, it is easily recognised ; 
 but when the head and arm are locked, and occupy together the 
 edge of the superior strait, it is often impossible to ascertain the 
 presence of the arm ; and, farther, as we have already said, the 
 readiness with which the head passes down most generally gives 
 no cause to suspect this accident. 
 
 But it is necessary to establish a correct diagnosis, and, in fact, 
 it is very important not to confound this accident with the descent 
 of the arm in presentations of the trunk ; for, in the former case, 
 nature will almost always suffice, even when art has been unable to 
 effect the reduction. 
 
DESCENT OF OTHER PARTS WITH THE HEAD. 277 
 
 In the latter case, on the contrary, we must never rely on na- 
 ture, which will almost always prove impotent, and we must con- 
 sider the interference of the accoucheur as a rule to be observed 
 always, with very few exceptions. 
 
 Happily, the distinction between the two cases is easy. In the 
 former, the head occupies the superior strait, and is detected by its 
 elastic, bony resistance, its size, and the presence of sutures and 
 fontanelles. 
 
 In the latter, the shoulder follows the arm immediately, and is 
 recognised by its characters ; it is irregular, and we can feel the 
 hollow of the axilla, the intercostal spaces, or the scapula, &c. 
 (See Diagnosis of Trunk Presentations.) 
 
 § 3. Manual Operation. * 
 
 When the presentation of the arm is detected, the accoucheur 
 should first attempt to return the arm above the head, which is fre- 
 quently practicable. Sometimes, on the contrary, this is utterly 
 impossible ; we must then support the arm at every pain, in order 
 that the head may come down alone. This descent of the head 
 will generally occur, even in cases where we cannot support the 
 hand and fore-arm. If the descent of the head be impossible in con- 
 sequence of narrowness of the pelvis, or if, after its descent, the ro- 
 tation of the head be impeded, although the pelvis may be well 
 formed, the forceps alone should be applied. It is impossible to 
 give very exact rules for the return of the arm ; except that the 
 right hand should be used to reduce the arm which is on the left, 
 and vice versa. 
 
 § 4. Descent of the two Hands and two Fore-arms. 
 
 Sometimes nature may overcome this obstacle also ; but this case 
 is more serious than the preceding, and requires the aid of art, 
 whenever the fœtus has attained its natural dimensions, and the 
 pelvis is not abnormally large. In short, for the fœtus to be expel- 
 led in this instance, it must be very small, or the pelvis must be very 
 capacious. If neither of these requisites exist, the contractions 
 will frequently be unable to effect the descent, and particularly the 
 rotation of the head, supposing it to have descended into the cav- 
 ity of the pelvis. 
 
 Here the accoucheur, who has detected the presence of the two 
 arms at the superior strait with the head, must first attempt to re- 
 turn them both : if he can reduce one of them, the case becomes 
 similar to that just mentioned in the preceding section ; if neither 
 can be returned, he must not wait for spontaneous delivery, un- 
 less it should appear very easy, but he must turn as soon as pos- 
 sible, lest the uterus should contract, render this operation impos- 
 sible, and require the application of the forceps on the head at the 
 superior strait. (This application, as I shall show hereafter, is 
 much more difficult and dangerous than turning when the head is 
 so high.) 
 
 The modes of reduction are the same as in the preceding case. 
 
278 MECHANICAL OBSTACLES TO PARTURITION. 
 
 § 5. Descent of one Foot, or of both Feet. 
 
 One foot or both feet may present at the same time with 
 the head ; in most cases, the head alone passes through the supe- 
 rior strait, and the feet remain behind ; but the descent of one or 
 of both feet may prevent that of the head. In this case, the course 
 to be pursued by the accoucheur is as follows : if the head be high 
 up, he should attempt to return these two extremities ; if this be 
 impossible, which is rare, after waiting for nature to accomplish all 
 that he can expect, the right hand should be introduced; if the 
 foot or feet be on the left, or vice versa, he will pull on them while 
 the other hand pushes back the head of the foetus : by means of 
 this motion in opposite directions, the pelvic extremity will be 
 brought down in place of the head, and the rest may be left to 
 spontaneous efforts, if the life of the foetus be not endangered ; if 
 otherwise, the delivery should be terminated quickly. 
 
 If the head be low, it should be delivered with the forceps, being 
 careful not to embrace the displaced limbs in the blades, in order 
 that these may remain behind, as the head is brought into the infe- 
 rior strait. 
 
 The course of the accoucheur should be exactly the same if a 
 foot and arm present together. Thus, first attempt to return them; 
 then, if unsuccessful, and nature is impotent, draw upon the foot 
 or feet, pushing back the head when it is high up, and delivering 
 it with the forceps when it is low. 
 
 In December, 1835, we saw at La Clinique a female in whom 
 the head, left arm, and one foot presented at the superior strait. 
 The pelvis was manifestly contracted, and these parts had been 
 brought to the superior strait with the head, by improper attempts 
 at turning ; the uterus was contracted so firmly, that even if the 
 pelvis had been well formed, turning should not have been attempt- 
 ed : the child was dead ; cephalotripsy was promptly performed, 
 and without injuring the genital organs of the mother; but she was 
 exhausted by her long labour and sufferings, and expired a few 
 days after her delivery. 
 
 Art. IV. — Varieties of Presentation.* 
 In describing the mechanism of spontaneous parturition, in the 
 varieties of presentation of the vertex, I have stated as a principle, 
 that when the vertex occupies the superior strait, nature alone is 
 almost always sufficient to effect the descent, whatever may be 
 the mode of presentation (whatever may be its variety of present- 
 ation). I have taken it for granted that the pelvis and head 
 were well formed. Hence we can understand how seldom art is 
 called upon to interfere in these varieties of presentation of the 
 vertex. In fact, to require this intervention, we must admit a 
 forced inclination of the head, and nature would most generally 
 conquer this obstacle, if the pelvis were well formed, or abnormally 
 large. Even a deformity does not always prevent the passage of 
 
 * Termed, very improperly, inclined positions. 
 
VARIETIES OF PRESENTATION. 279 
 
 the head. I have already mentioned the case of Vanesse, who 
 was delivered while alone, although there was evidently a contrac- 
 tion of the superior strait. If, however, nature be unable to bring 
 down the head, and art is obliged to interfere to save the female 
 from the consequences of a long-continued labour, what course must 
 be pursued by the accoucheur to effect delivery ? The processes 
 vary according to the variety. 
 
 § 1. Parietal Varieties. 
 In the varieties of this presentation, the entire ear never occu- 
 pies the centre of the orifice, but the ear can frequently be reached 
 anteriorly or posteriorly, according to the position of these varie- 
 ties of presentation. 
 
 a. Anterior Parietal Varieties. 
 
 I will suppose, first, the parietal bone is forward, and occupies 
 the superior strait, and that the occiput is to the left or to the 
 right. 
 
 In such a case, the accoucheur must first ascertain that the va- 
 riety is not caused by a very marked anterior obliquity, which may 
 certainly occur. If this obliquity be ascertained to exist, the ute- 
 rus must be kept in its normal position during the whole of the la- 
 bour. This alone will often correct the variety, or, at least, will 
 facilitate the descent. If, after taking this precaution, the variety 
 continue, it is independent of the inclination of the uterus. What, 
 then, should the accoucheur do ? 
 
 1. He must wait for the spontaneous descent, which will take 
 place in an immense majority of cases. 2. If, however, the dilata- 
 tion have been complete for seven or eight hours, and the descent 
 have not occurred, notwithstanding the power of the contractions, 
 he must interfere. 
 
 There are several modes of proceeding: the position of the 
 head may be righted, or the child may be turned, or the forceps 
 may be used. 
 
 A. Manual righting of the Head. — This is recommended in this 
 case by every writer. Madame Lachapelle alone, while suggest- 
 ing this course, remarks, that the execution of it is very difficult, 
 and even impossible, in most cases, and that Baudelocque himself, 
 who was very favourable to this operation, finally renounced it, 
 on account of its difficulties. I have satisfied myself of the truth 
 of Madame Lachapelle's opinions, and Dubois thinks that this man- 
 œuvre is not only almost impossible, but is attended with serious 
 inconvenience. 
 
 In fact, in order to its success, we must act from the commence- 
 ment of labour till the membranes are ruptured ; and in this case 
 even we may frequently fail, for the hand has not a sufficiently 
 firm purchase on the vertex to right it readily. But suppose the 
 manœuvre to be successful, it is not free from inconvenience nor 
 danger. 
 
 L The introduction of the hand into the organs of the mother at 
 
280 MECHANICAL OBSTACLES TO PARTURITION. 
 
 the commencement of labour, when the external parts are not in a 
 proper state, will be extremely painful. Added to this, the neces- 
 sary manipulations will cause immense suffering to the patient. 
 
 2. When the hand is once introduced, the displacement of the 
 head at the superior strait will favour the discharge of all the am- 
 niotic fluid ; and in case the position of the head is righted, the foetus, 
 during the rest of the labour, will be exposed directly to the pressure 
 of the uterus. In fact, it will be deprived of that protecting mass 
 of fluid interposed between it and the expulsory organ, in cases 
 where parturition is spontaneous. Nor is this all ; the umbilical 
 cord and one or both arms may pass down under the head at the 
 moment when it is raised, and this descent is also favoured by the 
 rapid discharge of the amniotic fluid. It is readily seen that these 
 complications may require the immediate interference of the ac- 
 coucheur, and become very serious to the fœtus, and more or less 
 dangerous to the mother. 
 
 I have settled as a principle, that art should never interfere till 
 the spontaneous efforts of nature are found insufficient. In this 
 case, if the uterine contractions do not force down the head, as is 
 generally the case in a well-formed pelvis, it will fix the head at 
 the superior strait so firmly that it cannot be displaced unless the 
 uterus becomes inert. 
 
 B. Pelvic Turning. — To attempt pelvic turning at the com- 
 mencement of labour would not be rational in a case where so 
 much may be expected from the contractions of the uterus. We 
 must therefore wait, before practising this operation, till the im- 
 potence of nature is evident, and then turning is just as imprac- 
 ticable as righting the position of the head, in consequence of the 
 too powerful contraction of the womb. The forceps must then 
 be used, unless the uterus ceases to act, and permits turning to be 
 performed. 
 
 C. Forceps.— In this case, the forceps may act in two modes : by 
 righting the head, or by bringing it down. 
 
 a. Righting. — The blades of the forceps can be placed only on 
 the sides of the pelvis, as we shall see hereafter, on giving rules 
 for applying the forceps at the superior strait : the head will then 
 be embraced in the diagonal position from one frontal prominence 
 to an opposite occipital protuberance. Then, during the first trac- 
 tions, it may become righted by turning on an axis, the two ex- 
 tremities of which terminate in each of the two ovals. 
 
 b. Descent. — Or the head may be seized in the same manner, 
 and if not righted, will be brought directly into the cavity of the 
 pelvis.* 
 
 * It haê been asserted that the application of one of the two blades will be much more 
 difficult than that of the other, because it is impeded by the depressed shoulder. This would 
 be true, were the forceps applied regularly at the superior strait ; but as it can only be pla- 
 ced on the sides, the inclination of the head cannot, in any manner, impede the application 
 of the instrument. 
 
VARIETIES OF PRESENTATION. 
 
 281 
 
 b. Posterior Parietal Varieties. 
 If it be the parietal bone which is posterior, which presents at 
 
 (Fig. 112.) 
 
 the superior strait, whatever may be the position of the vertex 
 (whether the occiput be on the right or left), we cannot suppose 
 that in this case the parietal variety is caused by a posterior incli- 
 nation of the uterus, as this inclination cannot be admitted. The 
 accoucheur then will regard this variety as the result of an inclina- 
 tion of the head on the trunk, and then the manœuvre will be the 
 same as in the preceding case. 
 
 First wait, then attempt to right the head ; and if this cannot be 
 done, do not urge it, but have recourse to the forceps, or turning, 
 according to circumstances. 
 
 § 2. Frontal Variety. 
 The frontal variety is reduced spontaneously like the preceding, 
 
 (Fig. 113.) 
 
 and assistance is required less frequently; for if the head con- 
 tinue to present without flexing, or remain slightly flexed, it will 
 come down ; the size of the diameters by which it presents justi- 
 fies the possibility of this result (the occipito-frontal diameter being 
 four inches) ; and if it do not occur, we must ascribe it to a cause 
 foreign to the presentation, as, obliquity of the uterus, weak pains, 
 or a disproportion between the head and the superior strait. 
 
 N N 
 
282 MECHANICAL OBSTACLES TO PARTURITION. 
 
 Uterine Obliquity, 
 In most cases, the frontal variety occurs because the head pre- 
 sents at the superior strait, not flexed, and its continuance depends 
 also on the fact that flexion does not take place in the first period 
 of labour ; it is certain, however, that a very marked lateral obli- 
 quity may cause this variety and retard the descent, as I have re- 
 cently observed. 
 
 (Fig. 114.) 
 
 It is readily seen, in this case, that the first thing to do is to re- 
 store the uterus to its normal position : this alone will remedy the 
 variety, and the descent will not be tardy. 
 
 Insufficiency of the Uterine Contractions. 
 If the pains be not strong enough, we must try to make them 
 more active. 
 
 Disproportion between the Head and Pelvis. 
 
 In the absence of other causes, it is proper to attribute delay in 
 the descent of a frontal variety to disproportion between the head 
 and the superior strait, even when this cannot be detected by the 
 touch. In this case, manual reduction or the application of the 
 forceps may be useful : I do not speak of turning, for whenever 
 we suspect a contraction of the superior strait or excessive size of 
 the head, this operation should not be performed. 
 
 A. Manual Righting. — If the pelvis be well shaped, the head may 
 descend without flexing ; but in consequence of the disproportion 
 between it and the pelvis, the movement of flexion, which substi- 
 tutes a more favourable diameter for one less favourable (see Spon- 
 taneous Delivery), becomes necessary, and we must then attempt 
 to accomplish this flexion. Two modes have been recommended 
 in this case : in one, the forehead is supported by two fingers during 
 the contraction, in order to force the head to flex ; this is performed 
 the most easily, and, farther, is by no means inconvenient, but, un- 
 fortunately, it is not always successful. The cause which prevents 
 the flexion of the head is frequently more powerful than the ac- 
 coucheur, whose efforts are frustrated, as was the case with me in 
 a face presentation, of which we shall speak hereafter. The sec- 
 ond process is more difficult than the first ; it seldom succeeds, is 
 very painful, and not free from danger. 
 
VARIETIES OF PRESENTATION. 283 
 
 This process consists in depressing the occiput, and thus forcing 
 the head to flex. For this purpose, the accoucheur introduces the 
 left hand into the uterus, if the occiput be on the right, and vice 
 versa ; then the fingers are crooked, and an attempt is made to 
 hook the occiput, and bring it to the superior strait. 
 
 The difficulties of this manœuvre are readily seen ; in fact, the 
 contraction of the uterus, in most cases, will oppose the introduction 
 of the hand ; and, farther, it is difficult for the fingers to get sufficient 
 hold on the occiput, and the cause which determines the presenta- 
 tion acts constantly to reproduce it in spite of the efforts of the 
 accoucheur. 
 
 The dangers are the same as those stated when speaking of the 
 manœuvre for the parietal varieties (discharge of the amniotic 
 fluid, descent of the cord, and of one or both arms). Thus this 
 manœuvre is seldom employed, and hence the forceps should be 
 used when the pains are weak. 
 
 B. Forceps. — This instrument should be applied from one occipi- 
 tal protuberance to the opposite frontal prominence. The head 
 cannot be flexed by this instrument, but it may be brought down ; 
 but in this case, the descent will be more difficult than in the parie- 
 tal variety, on account of the disproportion between the head and 
 the pelvis. (See Deformities of the Pelvis, and Application of 
 the Forceps.) 
 
 (Fig. 115.) 
 
 Occipital Variety. 
 
 The defect in the descent of the head which presents itself in the 
 occipital variety, can only be explained by an abnormal flexion of 
 the head, which places the posterior part'of the neck of the child 
 in relation with the superior strait, and then this would be no lon- 
 ger an occipital variety. Farther, this presentation, if it were pos- 
 sible in the fœtus at term, would terminate sooner or later by de- 
 scending into the superior strait, in consequence of the spontaneous 
 depression of the occiput. What is to be done when this anomaly 
 is seen at the superior strait ? First, the uterus must be righted if 
 it be inclined, and then we must examine attentively if the defect 
 in the descent do not depend on some cause other than the presen- 
 tation ; and when we are satisfied that everything contributes to fa- 
 vour the descent, and that it cannot take place, we should attempt 
 to correct the presentation. For this, a manœuvre has been 
 recommended which is the inverse of that described to bring the 
 
284 MECHANICAL OBSTACLES TO PARTURITION. 
 
 occiput into the frontal variety : it consists in acting on the fore- 
 head with the right hand, if the forehead be to the left and recipro- 
 cally, and depress the forehead, to bring the vertex to the centre 
 of the superior strait. This operation is, perhaps, still more diffi- 
 cult than the preceding ; it is attended with the same pain and the 
 same danger : hence pelvic turning is preferable. 
 
 Remarks on all the Varieties of Presentation of the 
 
 Vertex. 
 
 To conclude, all the varieties of presentation of the vertex should 
 permit, sooner or later, the descent of the head, either by correct- 
 ing the position, or by descending in an inclined direction ; when 
 this is not the case, it must generally be ascribed to some foreign 
 cause, as the inclination of the uterus, the feebleness of the pains, 
 and particularly a marked disproportion between the size of the 
 head and the dimensions of the superior strait. 
 
 The irregularity of the pains, when it exists with these varieties, 
 may lead to the belief that the slowness of the descent depends on 
 the presentation. In fact, a person unaccustomed to these things 
 would be astonished to see the head remain at the superior strait, 
 notwithstanding the continued energy and constancy of the con- 
 tractions, and would naturally think it correct to attribute the de- 
 lay to the presentation, which seems abnormal, when, in fact, there 
 is neither inclination of the uterus nor contraction of the pelvis. 
 
 These irregular contractions, however, move the foetus to the right 
 and left, but do not cause its descent, although the pains are severe 
 and constant. I am even satisfied that if disadvantages have been 
 attributed to the occipital variety, it is because difficulties depend- 
 ant on the circumstance we have mentioned, and which have been 
 ascribed to other presentations, as we have seen, are entirely dis- 
 connected with it. Hence, in these cases, the accoucheur should 
 ascertain the type of the contractions, to regulate them as required. 
 (See Morbid Contractions.) 
 
 Art. V. — Separate Multiple Fœtuses. 
 
 In case there is a plurality of foetuses, the labour is generally 
 more rapid than where there is only one. In fact, twins are usual- 
 ly born before term, and are then expelled more rapidly on ac- 
 count of their small size. Farther, the foetuses are generally de- 
 livered without delay, one after another. 
 
 Sometimes the uterus, after expelling the first foetus, contracts, 
 and ceases to act ; labour is suspended for a time, which is seldom 
 more than half an hour, the pains return, and the second child is ex- 
 pelled : the same would be the case in a third and fourth foetus, if 
 they existed in the uterus. 
 
 This, however, does not always take place, and the expulsion of 
 the other foetuses may be deferred for hours, or even days. Should 
 the accoucheur wait for the spontaneous birth of these, or should 
 he interfere ? 
 
SEPARATE MULTIPLE FŒTUSES. 285 
 
 In my opinion, in these cases, the accoucheur should not remain 
 inactive. Thus, when the mother has not been fatigued by the first 
 labour, if the presentation of the foetuses be natural at the superior 
 strait, he should rupture the amniotic bag, rub the uterus to excite 
 its contractions, and hasten the delivery of the other foetuses, which 
 will be accomplished more readily, because the genital organs 
 have been dilated very recently by the first child. 
 
 When the delivery of the first child has been long and difficult, 
 or has required the interference of art, and the mother is weak and 
 exhausted, the labour should be terminated, taking care, however, 
 not to empty the uterus too rapidly, in order that this organ, which 
 has been considerably distended during pregnancy, may not be- 
 come inert. 
 
 All those conditions which may endanger the life of the mother 
 or children need the interposition of art in this as well as in other 
 cases. We must, however, define the indications required by cer- 
 tain symptoms peculiar to a plurality of foetuses. 
 
 Thus, two foetuses may present themselves simultaneously at 
 the superior strait by the head, and mutually impede the delivery : 
 this case is very rare, and it may be remedied by raising the most 
 movable head, and permitting the descent of the other. One head 
 may present at the superior strait, accompanied by the feet ; if na- 
 ture do not overcome this obstacle, which is hardly supposable, 
 and we are obliged to use some slight force on the lower extrem- 
 ities, care must be taken to pull only on one foot, lest the two feet 
 do not belong to the same child. The same thing should be ob- 
 served when turning is performed in a case of twins. 
 
 Without this wise precaution, we should be in danger of bring- 
 ing down simultaneously parts which cannot be extracted together. 
 
 In this case, also, the head of the second child may descend with 
 the trunk of the first, of which the pelvic extremity has presented, 
 the head being situated at the superior strait. Thus, the head of 
 the first child brings down the head of the second, as a cord draws 
 a cork from a bottle (if I may be allowed the simile). If the foetus- 
 es be very small, they may be extracted or expelled in this man- 
 ner ; but if they be of ordinary size, inasmuch as the two cannot 
 descend together, art must interfere. In this case, we must be care- 
 ful not to pull upon the feet of the first one, but on the head of the 
 second, if the head cannot be pushed back. In fact, the first foetus, 
 the feet of which have descended, represents a cone, the apex of 
 which has come down before the base ; as the parts descend they 
 increase in size, and become more difficult to extract. The second 
 child, on the contrary, represents a cone where the base has de- 
 scended before the apex, and then, as the parts to be extracted be- 
 come smaller, they will yield to tractions more readily. Hence, 
 the forceps should be applied to the head of the second child : in 
 case these means fail, the head may be opened, and its delivery thus 
 facilitated. 
 
286 MECHANICAL OBSTACLES TO PARTURITION. 
 
 Art. VI. — Monstrosities. 
 I shall not speak here of acephalous, anencephalous foetuses, &c, 
 as their delivery is as easy as that of a well-formed child. 
 
 § 1. Plurality of Adherent Foetuses. 
 
 Although it may be possible to ascertain the existence of twin 
 pregnancy, we cannot determine whether the foetuses are attached 
 until after the membranes are ruptured. But, after the rupture of 
 the first bag, if a second break directly before the descent of the 
 first foetus, we must infer that the children are separate, especial- 
 ly if the head and feet be felt at the same time at the orifice. In 
 fact, if the twins be separate, each foetus generally has its distinct 
 ovum, and then two ruptures occur ; and, farther, the feet and the 
 head of one, or the feet of one and the head of another, may de- 
 scend simultaneously when the foetuses are distinct ; but when they 
 are united, they are contained in one ovum ; there is then only 
 one rupture of the bag ; and as they never adhere by the head, if 
 several parts present at the superior strait, it must be the heads or 
 lower extremities. 
 
 Now, if two heads and two pelvic extremities present simulta- 
 neously, which might readily occur in cases of separate foetuses, 
 the introduction of the hand into the uterus can alone discover the 
 facts of the case. 
 
 But where we suspect the foetuses are united, we must not be- 
 gin by introducing the hand into the uterus, but must wait until na- 
 ture fails, as these products are frequently born spontaneously. 
 The mode of expulsion and the operative processes vary accord- 
 ing to the kind of monstrosity. 
 
 A. Foetuses united by the Head or Breech. — When the point of 
 union is flexible, the two children may adapt themselves one to the 
 other, and thus be expelled readily. In the opposite case, especial- 
 ly if the foetuses be at term, art must interfere. The accoucheur 
 must pull one part and push back the other, and thus produce an 
 overlapping : if this manoeuvre fail, he must attempt to remove all 
 these parts simultaneously with the hands or forceps. Finally, if 
 these fail, the fœtus may be mutilated without hesitation. It is 
 unnecessary to state that in this case no operation should be per- 
 formed on the mother to remove a monstrosity, as this practice 
 ought not to be pursued even for a well-formed foetus. 
 
 B. Two Heads and one Trunk. — If the two heads be sufficient- 
 ly movable to descend successively, the labour may terminate 
 spontaneously ; but if the two heads descend simultaneously, we 
 should proceed as in the previous case. 
 
 C. One Head and two Trunks. — The size of the head alone may 
 impede delivery. 
 
 D. Each Head with a separate Trunk, the Trunks united. — The 
 overlapping of one part on the other will alone permit the expul- 
 sion. In case this do not occur, we should act as before in A. 
 
OBSTACLES PRESENTED BY THE SOFT PARTS 287 
 
 Art. VII. — Obstacles presented by the soft Parts. 
 
 § 1. Union of the External and Internal Labia. 
 
 If this union be congenital, it must be imperfect, as otherwise 
 conception could not occur ; and if it be perfect, it could not take 
 place till after impregnation, and then as the result of accident. 
 
 In most of these cases, nature triumphs over the obstacles. If, 
 however, this adhesion of the labia impede the termination of la- 
 bour, they must be separated by the bistoury. 
 
 § 2. Continuance of the Hymen. 
 The hymen seldom obstructs labour ; when it does, it should be 
 divided. 
 
 § 3. Narrowness and Rigidity of the Vulva. Resistance of the Peri- 
 neum. 
 
 The resistance of the external organs is generally overcome by 
 labour-pains ; sometimes, however, art is compelled to interfere, 
 lest nature, by removing these obstacles, should cause more or less 
 serious trouble. In fact, if the perineum be less resistant than the 
 vulva, it may be torn, and give passage to the child. Moreau has 
 cited several instances of these central perforations of the peri- 
 neum ; the vulva, perineum, and even the anus, may be more or 
 less injured. 
 
 Finally, the parts may resist so firmly as to prevent the expul- 
 sion of the foetus, and then art interferes. 
 
 It will readily be seen that the forceps must not be used in these 
 cases, except when the parts are not too resistant or rigid. In 
 most instances, in fact, notwithstanding the utmost precautions, its 
 use causes accidents which it is desirable to avoid, such as laceration 
 of the perineum and anus. In these cases, we must follow the ex- 
 ample of Dubois, and make, on one of the lower sides of the dis- 
 tended vulva, an oblique incision of one or two lines in extent : 
 this will be sufficient to permit the spontaneous expulsion of the 
 foetus, and in case it enlarges and extends, it never affects the parts 
 it is so important to preserve, the anus and rectum ; for this pro- 
 longation will in fact occur obliquely, while a laceration on the 
 median line* may, by its extension, involve the sphincter ani muscle. 
 
 In this manner, then, delivery will occur, and the evil conse- 
 quences of the forced expulsion of the foetus will be avoided. 
 
 This incision is also preferable to lacerations, because it heals 
 rapidly, and the union is perfect (while this is not the case with 
 lacerations of the perineum). This arises from the fact that the 
 lateral incision is not moistened constantly with the fluids from the 
 genital organs. 
 
 * This was the case with Madame Leroi, in her first labour, and Dubois was obliged to per- 
 form this operation. This female, in whom, beside extreme narrowness of the external or- 
 gans, there was a contraction of the superior strait, was delivered, December 7th, of a liv 
 ing child, weighing seven pounds. She left the hospital, well, December 21. 
 
288 MECHANICAL OBSTACLES TO PARTURITION. 
 
 If the resistance be slight, and the arrest of labour depend on 
 the fact that the contractions are not powerful enough to overcome 
 the resistance of the soft parts, the forceps must be used without 
 making an incision, but very slowly and carefully. 
 
 Finally, if, in case of very evident narrowness of the parts, or 
 too great resistance of the perineum, the pains cease, after employ- 
 ing means to bring them on, the forceps must be used, but then 
 a lateral incision should be made in the vulva. 
 
 It is very difficult to determine exactly the precise moment for 
 action, where there is excessive resistance in the perineum and soft 
 parts. In fact, the indications are regulated by the strength of the 
 patient, the time that has elapsed since the descent of the head, the 
 intensity of the uterine pains, &c. 
 
 Generally, however, we must act after a labour has continued 
 from thirty to thirty-six hours, and the head, having come into the 
 cavity of the pelvis, has remained four 1 or five hours on the peri- 
 neum without overcoming its resistance. This is the only mode of 
 preventing the various accidents which depend on the prolonged 
 continuance of the head in the cavity, viz., compression of the ma- 
 ternal organs, gangrene of these parts, vesico or recto-vaginal fistu- 
 las ; the death of the fœtus in consequence of derangement in the 
 utero-foetal circulation by pressure, exhaustion of the mother, ute- 
 rine inertia after the birth of the foetus, and consequent hemorrhage, 
 &c. 
 
 But although timely aid is indispensable, we must not follow 
 the example of those who constantly interfere, and use too lightly 
 and quickly remedies which are apt to be attended with incon- 
 venience. 
 
 The sagacity of the accoucheur, however, will note all the cir- 
 cumstances which may affect his course. 
 
 I insist on this point, because I have very frequently been called 
 by young practitioners and inexperienced midwives to use the for- 
 ceps in cases where it was thought necessary to terminate the la- 
 bour, and this a few hours after it had really commenced ; while 
 it was only necessary to wait quietly for the delivery, which was 
 effected spontaneously shortly after my arrival, and without any 
 action on my part. 
 
 Another circumstance which often presents, and which frequent- 
 ly leads young accoucheurs to anticipate a long-continued la- 
 bour and the necessity of interference, is the premature descent 
 of the head before the dilatation of the neck of the' uterus, and, 
 consequently, before labour ; the accoucheur finds the head on 
 the perineum, and refers the commencement of labour to this pe- 
 riod ; he relies on this fact alone ; all other circumstances, such as 
 the character of the pains, the dilatation of the neck, are unnoticed, 
 and he thinks himself obliged to terminate a labour which he ima- 
 gined was commenced longer than was really the case. 
 
 Narrowness of the Vagina. 
 Nature alone is generally sufficient in this case ; the head is the 
 
OBSTACLES PRESENTED BY THE SOFT PARTS. 289 
 
 best dilating body imaginable ; it acts gradually and slowly, pro- 
 ceeding from the upper part of the vagina, which is the broadest 
 portion of this canal. When the pains are not strong enough to force 
 down the head, they should be made more active ; finally, if neces- 
 sary, the forceps should be used. 
 
 Adhesion of the Parietes of the Vagina and Transverse Bands. 
 
 (Fig. 116.) (Fig. 117.) 
 
 As we have stated in the article on Pregnancy, these defects in 
 formation generally present no indication during pregnancy, nor 
 at the time of labour. I have mentioned the case of the young fe- 
 male who was delivered spontaneously at La Clinique, although in 
 her the vagina was divided transversely by a firm membrane, pre- 
 senting a small orifice, and, before labour, when seen by the spec- 
 ulum, presented the form as delineated in fig. 116, and after labour 
 appeared as in fig. 117. But things do not always terminate so 
 fortunately. The adhesions of the parietes of the vagina, the bands 
 and congenital membranes, which might not impede conception, 
 may obstruct parturition. In this case, having experienced the in- 
 efficiency of uterine contractions, the accoucheur should remove 
 the obstacle. 
 
 A. Treatment. — The bands and membranes should be divided 
 crucially. If they be near the vulva, after emptying the bladder 
 and rectum, the labia should be separated in order to make the 
 section. If they be situated deeply, the speculum will be indis- 
 pensable. In all cases, we must act very slowly, and divide the 
 tissues layer after layer. We must be still more careful if the ob- 
 stacle be caused by the adhesion of the parietes of the vagina. In 
 fact, in these cases, the bistoury often acts blindly. It is very difficult 
 to determine exactly if one of these two layers be not more divided 
 than the other. Thus, when the tissues are once cut, we should 
 attempt to destroy the adhesions by a blunt medium, the finger, 
 for instance, and avoid as much as possible the bladder and rec- 
 tum. These operations are, as may well be imagined, extremely 
 difficult and dangerous ; very happily, nature generally relieves 
 the accoucheur from the troubH of performing them. 
 
 Art. VIII. — Treatment in Deformities of the Pelvis and ex- 
 cessive Size of the Fœtus. 
 When the pelvis is contracted by the approximation of its pari- 
 
 o 
 
290 MECHANICAL OBSTACLES TO PARTURITION. 
 
 êtes, or by the development of firm tumours attached to the osse- 
 ous tissue, the treatment will vary with the degree of the deformity, 
 the force of the pains, the abnormal size of the foetus, the reducibil- 
 ity of the head ; but, unfortunately, we cannot point out very exactly 
 the course to be pursued by the accoucheur, as the volume of the 
 child cannot be estimated before birth with any degree of precision ; 
 in fact, it is in hydrocephalus only that we can judge of the size of 
 the head by the separation of the sutures, and even in this case it 
 will be difficult to decide, à priori, upon the kind of operation. 
 
 However, we shall first suppose that the deformity can be detect- 
 ed, and that the size of the head is normal, and shall point out the 
 course to be pursued in each of the degrees of contraction, on 
 which I have already established indications to be fulfilled during 
 pregnancy. 
 
 § 1. Treatment when the smallest Diameter of the Pelvis measures 
 at least three Inches and a half. 
 When the vertex presents in a pelvis which measures, in its 
 smallest diameter, at least three inches and a half, we must wait 
 and intrust the delivery to the efforts of nature, which will proba- 
 bly be sufficient ; thus, after the rupture of the membranes and per- 
 fect dilatation, we may remain inactive six or seven, or even eight 
 hours, according to the strength of the patient ; the head is pushed 
 on by the pains, its extremity descends, the bones lap over each 
 other, the occiput elongates, a considerable sero-sanguineous tu- 
 
 (Fig.118.) 
 
 mour forms on it ; and, finally, the base of the scull, measuring three 
 inches, passes through the superior strait. But if constant and 
 powerful contractions, during this period, cannot overcome the ob- 
 stacle, if the head make no progress, the forceps must be applied. 
 So, too, if the head remain a long time in the cavity, being retain- 
 ed at the inferior strait, which may be badly formed, or, if well 
 formed, if the shoulders cannot overcome the obstacle at the supe- 
 rior strait, through which the head has passed, we must act more 
 promptly. # 
 
 § 2. Treatment when the Pelvis is at most three Inches and a half 
 and at least two Inches and a half 
 We shall first consider the indications required by this degree 
 of contraction, the child being alive, and shall admit, with M. Du- 
 bois, two subdivisions. 
 
DEFORMITY OF PELVIS AND EXCESSIVE SIZE OF FŒTUS. 291 
 
 From three and a half to three Inches. 
 We must wait, as in the preceding case, six, seven, or eight 
 hours, during which the pains may be strong ; for there are nu- 
 merous cases of spontaneous delivery in this degree of contraction ; 
 but after this time, if the pains be insufficient, the forceps should 
 be used.* If tractions made properly be not sufficient, the instru- 
 ment should be withdrawn, and the case left to the powers of nature 
 for one or two hours, and then the forceps should be again applied ; 
 i£ the second application be unsuccessful, and delivery with them 
 is found to be impossible, the head should be opened, even if the 
 fœtus be living. In fact, having done everything possible to save 
 the child, we must now attend to the mother. Parturition cannot 
 take place, unless the pelvis is enlarged or the size of the fœtus 
 diminished. One cannot hesitate ; and although it is painful to sac- 
 rifice a living child, yet, if we follow the advice of some French 
 writers, and delay until the child dies, we do not destroy life, it is 
 true, but permit the child to die, which, I think, is the same thing. 
 But to wait for the death of the child may cause a long delay, and 
 during this time the female is exposed to the pains and suffering of 
 an unavailing labour, and her life may be endangered, if not imme- 
 diately, at least by the consequences of too prolonged parturition ; 
 hence, she ought not to be exposed to so many dangers in order 
 to preserve the life of a child whose viability is already compro- 
 mised, and whose death is constantly looked for. 
 
 In fact, the course of the English physicians seems to me more 
 judicious : when the delivery is thought to be impracticable, when 
 all the means compatible with the safety of the mother and child 
 have been tried in vain, they do not hesitate to operate on the 
 child in season, and, through an unintelligible degree of sensibility, 
 they do not sacrifice the mother by culpable delay. Under these 
 circumstances, however, it is always well to have the advice of 
 several medical men. 
 
 Pelvis measuring three to two Inches and a half. 
 If the child be living, we should delay ; for if the pelvis measure 
 a few lines less than three inches, children may be born alive, 
 under the following circumstances: strong pains, extreme redu- 
 cibility of the head, smallness of the fœtus, which may be not 
 fully grown: the forceps also should be used, as in the prece- 
 ding case, before we follow the English practice ; but even when 
 the forceps can be applied, which is not always the case, the in- 
 strument is not safe for the fœtus, and it may endanger more 01 
 
 * The dwarf Lepratt, twenty-one years old, well known at our minor theatres, having 
 gone her full time, could not be delivered by her four physicians. The pelvis measured about 
 three inches. M. Dubois delivered her with forceps while in a comatose state, preceded by 
 convulsions. The child was dead. 
 
 This female recovered perfectly under my charge, and was seen shortly after by M. Mont- 
 gomery in Paris. 
 
 Being again pregnant, Dubois was called in early, and she was delivered prematurely of a 
 little girl, who was suckled for a short time by the mother. This case has been published 
 by Dubois. (Bulletin de l'Académie Royale de Médecine, Paris, 1840, vol. v., p. 35, &c. 
 
292 MECHANICAL OBSTACLES TO PARTURITION. 
 
 less the soft parts situated around the edge of the superior strait. 
 Hence, we ought not to insist too much on the instrument, and 
 after using some force, and for some time unsuccessfully, the for- 
 ceps should be withdrawn and the head perforated. 
 
 Now in these two cases, the pelvis measuring from three to two 
 inches and a half, if the child be dead, we should act immediately, 
 in order to spare the mother all the dangers of a painful and long 
 labour. In this degree of contraction, also, symphyseotomy has 
 been recommended, but, thanks to artificial premature delivery and 
 the invention of the cephalotribe, this operation has fallen into dis- 
 use. While symphyseotomy is nearly as severe for the mother as 
 the Caesarean section, it is by no means so advantageous to the 
 child, which generally dies. Farther, when the pelvis measures 
 less than two inches and a half, this operation is impracticable. In 
 fact, if the symphysis be separated to the utmost, say two inches, 
 the antero-posterior diameter is only increased four lines, and al- 
 lowing three lines for the descent of the parietal protuberance in 
 this separation, we have seven lines as the total increase. 
 
 Now suppose the pelvis measures only two inches and a quarter, 
 this would afford a passage of two inches and three quarters at 
 the maximum : hence there could be no spontaneous delivery, and 
 the forceps would be always necessary, and sometimes even the 
 perforation of the cranium. 
 
 § 3. Pelvis measuring less than two Inches and a half. 
 
 In this case, the spontaneous or artificial delivery of the foetus 
 is physically impossible ; we have then to choose between the 
 mutilation of the fœtus and the Cesarean operation. I never hes- 
 itate : whether the foetus be living or dead, it seems rational to act 
 on it, whenever by so doing we can give the mother any chance 
 of recovery. Thus, I put aside entirely the question of the life or 
 death of the child. 
 
 In this case, also, the indications vary according to the degree " 
 of contraction. 
 
 The smallest Diameter of the Pelvis from two to two Inches and 
 
 a half 
 
 In this degree of contraction we can diminish the size of the foe- 
 tus and remove it by the cephalotribe forceps of Baudelocque, Jr., 
 without exposing the mother to very imminent danger; but we 
 must carefully avoid the sharp crotchets which are found in most 
 forceps ; they are murderous instruments, which the accoucheur 
 cannot guide safely, and which do not find a firm hold on those 
 parts of the foetus to which we attempt to apply them. They slip 
 as soon as any force is employed, and lacerate, to a greater or less 
 extent, the parts of the unfortunate mother, who often dies from 
 the injuries of this distressing operation, even before it is termi- 
 nated. 
 
 The cephalotribe, on the contrary, is a very valuable instrument, 
 although it is condemned by those who have used it unsuccessfully, 
 
DEFORMITY OP PELVIS AND EXCESSIVE SIZE OF FŒTUS. 293 
 
 and those who had no part in its invention. But still it is appreciated 
 by all men of enlightened minds as an extremely important instru- 
 ment, which has already, and will render, immense service in 
 obstetrics. I have frequently seen it used by Dubois, in cases 
 where, formerly, the mother would certainly have been much la- 
 cerated by removing the child piecemeal", and where even the Ce- 
 sarean section would have been thought necessary. I believe in the 
 wisdom of Velpeau's remark : " When it shall be proved," says he, 
 K that the cephalotribe has done more injury than good to society, 
 I shall still consider it as the most important discovery in the art of 
 obstetrics." 
 
 This instrument has doubtless serious inconveniences : it is diffi- 
 cult to direct it w T ell. The points which perforate the hairy scalp 
 may lacerate the organs of the mother; but who will dare say, 
 that, even in skilful hands, the cephalotribe is a murderous instru- 
 ment, which ought to bring disgrace on its inventor, and that it is as 
 dangerous as the Cœsarean section, if not more so ? We admit that, 
 in unskilful hands, the cephalotribe may be as fatal as the Cesa- 
 rean section : in two cases, where it was used by the same ac- 
 coucheur since its invention, autopsy has shown that a part of the 
 uterus was grasped at the same time as the head of the child ; but 
 this is not the rule ; it is only the exception. From such failures, 
 it is easily seen why some men, whose opinions have weight with 
 those pupils who cannot judge for themselves, exclaim so loudly 
 against the cephalotribe, and totally condemn an instrument to 
 which they ascribe accidents arising from their own want of skill. 
 
 In short, if many cases of failure have contributed to bring the 
 instrument into disrepute, it is because it has often been directed 
 by unskilful hands, or because it is seldom used until the life of the 
 mother has been endangered by the length of the labour, or by the 
 various manœuvres performed. 
 
 In a word, females have been brought to La Clinique when at 
 the point of death ; and we cannot expect that the use of this in- 
 strument, even in the hands of a person as skilful as Dubois, will 
 be as successful as if the operation had been performed in season.* 
 
 In conclusion, notwithstanding the danger of this instrument to 
 
 * A female, whose pelvis measured only two inches and a half, and who had been in la- 
 bour for five days, was brought to La Clinique in a dying state. Dubois performed cepha- 
 lotripsy, and removed the trunk with great difficulty. 
 
 Another female, who had been three days in labour, was brought to La Clinique, also dying. 
 
 The superior strait, which was evidently narrowed, was occupied by the face, left arm, 
 and one toot. These parts had been brought to the superior strait by ineffectual attempts to 
 turn. Dubois perforated the forehead, and used the cephalotribe. The foetus had been dead 
 for some time, and was very large. 
 
 In another case, Du bois was called to the Hôtel Dieu, to a female who had been twenty-four 
 hours in labour, and from whom neither the head of the child, nor the instrument which had 
 remained in the sexual organs, could be removed. Dubois found the patient in this state ; 
 he began by removing the forceps, and then diminished the head by the cephalotribe ; but the 
 child was softened and putrefied, the head came off, and it was then necessary to apply the 
 cephalotribe on the chest. 
 
 These three females, selected from many others, died almost immediately after their de- 
 livery ; but their death could in no wise be attributed to the cephalotribe, directed by so skil- 
 ful an operator as Dubois, but to the length of the labour, and the constant efforts made be- 
 fore applying to a more expert accoucheur. 
 
294 MECHANICAL OBSTACLES TO PARTURITION. 
 
 the mother, it will give her more chances of recovery than the 
 Caesarean section. 
 
 Thus, whenever the cephalotribe can be introduced at the supe- 
 rior strait, it should always be preferred to the Caesarean section, 
 which has failed in Paris, and but seldom succeeded in other coun- 
 tries. 
 
 M. Dubois performed it twice, while I was at La Clinique, with 
 success to the child, but the mother sunk. The last, however, sur- 
 vived seventeen days, and died with tetanus, when entire success 
 was expected from the state of the wound and the general condi- 
 tion of the patient. This operation was performed a third time, in 
 the absence of Dubois, by M. Moreau ; the child died at its birth, 
 and the mother sunk in a few hours after the operation. 
 
 The Pelvis less than two Inches. 
 
 In this case, we cannot think of extracting the fœtus through the 
 natural passages ; for, supposing even that the instrument could be 
 introduced, it would then not always be possible to remove the 
 child, and this removal would require immense efforts, which lacer- 
 ate and bruise the organs of the mother, and expose her to nearly 
 the same danger as the Caesarean section. 
 
 In this event, one of the two individuals would be sacrificed, and 
 the other would have a very slight chance for life, while the Caesa- 
 rean operation saves the life of the child, and leaves the mother near- 
 ly as many chances of safety as cephalotripsy. 
 
 § 4. Uncertainty as to the Degree of Narrowness and the Size of 
 
 the Head. 
 
 There are cases where neither the finger nor the pelvimeter can 
 ascertain the degree of deformity in the pelvis, and which, howev- 
 er, have required the mutilation of the foetus. It is very difficult, if 
 not impossible, for this to occur when the pelvis is less than three 
 inches, as, from the facility with which the finger can reach the 
 sacro-vertebral prominence, the extent of the superior strait can be 
 very closely estimated, and the course to be pursued is readily seen. 
 When the pelvis measures more than three inches, the exact de- 
 gree of the narrowness is not easily estimated ; and, farther, in con- 
 sequence of our inability to ascertain the size of the head unless hy- 
 drocephalus exist, we might often at first be mistaken as to the 
 means to be employed. 
 
 In these cases, the accoucheur should begin by the most innocent 
 means, and not employ those which are more energetic until the 
 former have been found to fail. Suppose, for instance, that an ac- 
 coucheur is called to a female in whom the pelvis measures three 
 inches and a half, and that there is no ground for suspecting that it 
 is contracted : the female may have been confined once or twice 
 easily, which might readily occur with this degree of contraction, 
 because the heads of the first children were small, and the pains 
 strong.* 
 
 * A female in the Rue Vieille-du-Temple, who sent for me, was a case of this kind. She 
 
TUMOURS IN THE PELVIC CAVITY. 295 
 
 But in the third pregnancy the child is large, and the head ossi- 
 fied : after seven, eight, or even ten hours of fruitless effort, the ac- 
 coucheur determines to aid nature ; at first he employs the forceps, 
 and, after successive unavailing attempts, he is obliged to have re- 
 course to the perforator; should this fail, he resorts to cephalo- 
 tripsy. 
 
 It must be admitted that these cases are not rare in practice ; 
 and the conduct of the accoucheur must be regulated by the diffi- 
 culties he meets with after the successive use of each remedy. 
 
 Art. IX. — Tumours in the Pelvic Cavity. 
 
 Tumours, varying in nature and form, may diminish the capaci- 
 ty of the pelvic excavation, and occasion a serious obstacle to de- 
 livery, which often compromises the safety of the mother. 
 
 " There are," observes M. P. Dubois, " in these cases, numerous 
 complications, which it is not possible to foresee, which exceed all 
 our conjectures, and leave us often without a remedy." These tu- 
 mours may be developed in the osseous tissue itself, and be attached 
 to the parietes of the excavation : such as exostoses, periostoses, 
 carcinomatous and fibrous tumours. Others are contained in the 
 substance of the vaginal walls, and more particularly in the recto- 
 vaginal septum, and are more or less movable. They are of a 
 cancerous or fibrous nature ; and sometimes are in the form of cysts 
 of various composition, containing either fluids, encephaloid or 
 fleshy masses, or, finally, extra-uterine foetuses.* 
 
 § 1. Attached Tumours, 
 
 Periostoses, exostoses, and other solid and adhering tumours, de- 
 form the pelvis, and present as serious complications as when this 
 cavity is contracted. 
 
 Indications, — The conduct of the accoucheur, therefore, will be 
 
 was small, the pelvis manifestly narrowed, but with regularity. The antero-posterior diame- 
 ter was not more than three and a half inches. In her first labour, she was delivered by in- 
 troducing the forceps, and withdrawing them several times, and this continued from 5 P.M. 
 till midnight. The child was dead ; the mother was dangerously ill, but finally recovered. 
 
 In the next two pregnancies, she was delivered, after a long and tedious labour, of living 
 children, which were small, and had very compressible heads. Finally, in 1842, eighteen 
 years after the third labour, she became pregnant, but things were not so favourable as in the 
 last labour. After going her fall term, and perhaps a little over it, she sent for me, and after 
 a labour of twenty-four hours, and twelve hours of severe pain, as the head did not advance 
 an inch, I applied the forceps above the superior strait, and was aided by M. Brazier. The 
 head was in the left anterior occipito-iliac position. The blades were readily applied, and 
 they were locked with some difficulty. The head being held firmly, powerful traction was 
 made, which brought it into the strait ; but feeling that the instrument had slipped, I with- 
 drew it, and applied it again. The head was now brought down, the periifeum was support- 
 ed by M. Brazier, and was uninjured ; the child, however, breathed a few times and expired. 
 The operation did not continue more than twenty minutes. The death of the child might 
 have been hastened by the forceps, and also by the cord, which slipped below the head after 
 the first application of the instrument. 
 
 The mother recovered perfectly, and more rapidly than after the two spontaneous labours. 
 She is now well. The difficulties in the fourth labour depended upon the narrowness of the 
 superior strain and the enormous head of the child and its firmness, it being so ossified that 
 the sutures and fontanelles were barely perceptible. 
 
 * Larrey, Jr., communicated a case of this character to the Medical Society of Emulation. 
 From a patient in La Clinique he removed a vesical calculus as large as a pigeon's egg, 
 and also a similar tumour situated on the bladder. The extirpation was performed through 
 a fistulous opening which had existed for many months in the hypogastric region, and from 
 which projected a tuft of hair like that of the head This operation succeeded perfectly. 
 
296 
 
 MECHANICAL OBSTACLES TO PARTURITION. 
 
 precisely the same. When the volume of the tumour, however, 
 renders it necessary to have recourse to an operation, which may 
 be more or less serious for the mother and child, we should, after 
 having ascertained the nature of the tumour through the vagina 
 and rectum, puncture it, and thus diminish its size, by affording an 
 escape to the fluid it contains. 
 
 These tumours are sometimes partly solid and partly fluid ; and 
 this puncture will frequently suffice to allow the delivery to pro- 
 ceed. 
 
 It must be remembered that great caution is called for in this 
 operation, and that it should not be resorted to until the nature and 
 seat of the tumour are perfectly understood, in order that no risk 
 may be incurred of injuring any important organ. 
 
 § 2. Movable Tumours, 
 
 The movable tumours met with in the pelvic cavity are not de- 
 veloped there ; they are composed, for the most part, of ovarian 
 cysts, and pediculated tumours of various kinds, originating in the 
 abdomen; of vesical calculi, and of the bladder itself distend- 
 ed by urine, and which are pushed into the cavity below the fœ- 
 tus, thus affording an obstacle to its passage. When these tumours 
 are small, parturition may be accomplished, but the friction of the 
 tumour, and its contusion, frequently give rise to serious consecu- 
 tive trouble. In all cases, we should endeavour to place the ab- 
 dominal tumours above the superior strait. 
 
 Indications. — When the accoucheur ascertains, at the commence- 
 ment of labour, the presence of one of these growths ât the superior 
 strait, he should support it constantly with the extremity of his fin- 
 gers, especially during a pain, in order that the head may descend 
 while the tumour is kept in its place. If by these means the head 
 do not descend, he should then introduce his hand into the vagi- 
 na, and raise the tumour above the superior strait ; then, if the 
 membranes should be entire, he must rupture them immediately, 
 in order to facilitate the descent of the head. If, on the arrival of 
 the accoucheur, the tumour have already passed into the cavity, he 
 should still attempt its reduction during the interval of contraction ; 
 but should the head have descended into the superior strait, and 
 become firmly fixed by the uterine contractions, the reduction 
 will be impossible. Under these circumstances, the accoucheur, 
 after being well assured of the insufficiency of nature, is left no 
 other alternative than to extirpate the tumour or reduce the size 
 of the head. The nature of the tumour will decide him as to the 
 course to be pursued. 
 
 A. Abdominal Tumours.* — If the tumour have descended into the 
 
 * On the 2d of June, 1837, 1 was requested to visit Mrs. B., aged twenty-seven years, from 
 whom I heard the following particulars : She had been married nine months and a half. 
 Previous to her marriage she had always enjoyed good health, and her "monthly courses" had 
 observed a marked regularity. About six weeks prior to marriage, she thought she observed 
 a very slight swelling in the iliac region ; it produced no uneasiness, but actuated, no doubt, 
 by a proper feeling of delicacy, Mrs. B. consulted a physician, to know whether, under the 
 circumstances, it would be proper for her to marry. She was assured that the swelling 
 would amount to nothing, and, therefore, felt no farther anxiety in regard to it. Her 
 
TUMOURS IN THE PELVIC CAVITY. 297 
 
 posterior cul-de-sac of the peritoneum, there will be every reason 
 to believe that it consists of an ovarian cyst, or of some other organ, 
 
 " courses" never returned after marriage, and the various presumptive and probable s}Tnp- 
 toms of pregnancy soon manifested themselves. With the exception of frequent indisposi- 
 tion to sleep at night, and torpid bowels, nothing remarkable occurred until about eight and 
 a half months after her marriage. At this period, the pain in her back was at times exces- 
 sively severe, and the abdominal enlargement had increased so rapidly, that she found it 
 necessary to seek medical advice. A surgeon was accordingly sent for, and, after reflect- 
 ing on her case for some days, told the husband of Mrs. B. that, if his wife would consent, 
 he would remove the tumour. To this proposition she, in common with her husband and 
 friends, objected. Another medical gentleman was then requested to meet the first in con- 
 sultation. Nothing, so far as I could learn, of professional interest was agreed on by them. 
 The husband, naturally anxious to know the precise condition of his wife, called on these 
 gentlemen, and requested them to say whether they considered her pregnant. They de- 
 clined giving an opinion, and said they would prefer waiting, as a few days would decide 
 the nature of the case. Dissatisfied at not receiving more encouragement than was imbod- 
 ied in the above conversation, the gentlemen were told that their services were no longer 
 required. 
 
 This is the purport of what transpired previous to my seeing the case, and the facts are 
 stated as taken down by me at the time from the lips of Mrs. B., in the presence of Dr. 
 Washington. On visiting the patient, I found her excessively enlarged, and labouring 
 under very acute distress ; the integuments on the abdomen appeared ready to burst ; she 
 was feverish, and much troubled with constipation ; her respiratory and digestive organs 
 suffered greatly from pressure, and her general appearance of emaciation evidenced much 
 internal trouble. 
 
 For the last two weeks Mrs. B. had been compelled, such was her distress, to leave her 
 bed frequently during the night and walk the room. After a very rigid investigation, by 
 way of question and answer, as to the history of the case, I was unable to elicit any facts 
 other than those which have already been mentioned. Mrs. B. being then arranged in bed 
 on her back, with the thighs flexed on the pelvis, I made an abdominal examination of the 
 tumour. It was very evident that the enlargement was wanting in uniformity, and it 
 assumed somewhat a diagonal position as regarded the abdomen. There was no pain when 
 the tumour was pressed upon ; and, in percussing the abdomen, a very distinct fluctuation 
 was perceptible. It was plain that this was not a case of ascites, for the fluctuation, though 
 tolerably diffused from the great size of the tumour, was certainly circumscribed ; and 
 ascites, we know, at least in a majority of cases, is preceded by such symptoms of disease 
 as will at once enable the careful practitioner to detect the malady. From the previous 
 history, therefore, of the case, together with the symptoms present, I had no hesitation in 
 concluding that the patient laboured under ovarian dropsy. An examination, per vaginam, 
 was next made, and it was discovered that the womb was enlarged. There was nothing 
 remarkable about the cervix uteri — no pain on pressure, and its structure appeared perfect- 
 ly natural, nor was there the slightest vaginal discharge. The finger being introduced into 
 the rectum, the posterior surface of the womb evinced a decided development of this vis- 
 cus, and this latter examination fortified me in opinion as to the probable amount of 
 uterine enlargement. The question now to be decided was an exceedingly important one. 
 Did the enlargement of the womb depend upon pregnancy, or was it the result of disease, 
 or might it be owing to the presence of something in its cavity other than a foetus ? That 
 it was not disease, the perfect absence of pain, and of all the symptoms ordinarily attend- 
 ing a morbid condition of this viscus, seemed clearly to demonstrate. The patient was 
 fully under the impression that she was pregnant, and had, together with her female friends, 
 attributed all her distress to this condition. She, however, had never felt the motion of 
 the fœtus. It will thus be seen that I had arrived at a portion only of my diagnosis, and 
 the duty devolved on me to endeavour to account for the enlargement of the womb. Ac- 
 cordingly, I resorted, as the only means now left, to auscultation. I made repeated 
 attempts, simply with my ear applied to the abdomen, to detect the pulsations of the fœtal 
 heart, or the " bruit placentaire." I did not succeed. On the following day, I requested 
 my friend, Dr. Washington, to visit the patient with me. She was again examined with 
 great care, and repeated attempts were made, both with the ear and stethoscope, but with- 
 out success. Under all the circumstances of the case, we felt ourselves justified in giving 
 the following opinion, which was stated to the patient and her friends, viz., that Mrs. B. 
 laboured under ovarian dropsy, complicated, most probably, with early pregnancy. The 
 distension of the abdomen was now so great, and the distress from injurious pressure so 
 marked, that it became my duty to urge on Mrs. B., as a means of temporary relief, the ne- 
 cessity of being tapped. The suggestion was not assented to, and palliatives were directed 
 — keeping the bowels in a relaxed state, and ordering such articles of diet as were most easy 
 of digestion. Morphine procured her comparative rest at night. She continued in this 
 state until 15th July, when I operated on her in the presence of Dr. Washington, Professor 
 Alban Goldsmith, Drs. Caldwell and Hibbard. One gallon and a half of amber-coloured 
 fluid, of the consistence of melted calf's foot jelly, were drawn off. She experienced 
 such- immediate relief as to elicit the expression that " she felt as if she were in heaven." 
 On the following day Dr. Washington and myself again had recourse to the stethoscope, 
 
 Pp 
 
298 
 
 MECHANICAL OBSTACLES TO PARTURITION. 
 
 the removal of which might determine the immediate death of the 
 mother : in this case, he will be obliged to act on the foetus ; and it 
 is here that the perforator, and especially the cephalotribe, will be 
 of essential service. 
 
 The following is a case in point : A female named Bernet, while 
 in labour, 27th February, 1839, at 5 o'clock P.M. was brought to 
 La Clinique ; the membranes had been ruptured since the 20th, and 
 
 (Fig. 119.) 
 
 and the pulsations of the foetal heart were distinctly heard. This was most gratifying, so 
 far as it confirmed the diagnosis. It is highly probable that the great size of the tumoui 
 had materially interfered with our arriving at this result earlier. On the 20th of July Mrs. 
 B. quickened. From the period of the operation until the following October, Mrs. B. en 
 joyed comparatively excellent health ; her digestion was much improved, and she gained 
 flesh. In October, however, it again became necessary to draw off the accumulated fluid. 
 One gallon was taken away ; in two days afterward the distension was much increased, 
 and on the 19th of October half a gallon of fluid was drawn off. It is worthy of remark, 
 that, in performing this last operation, not more than an ounce of fluid passed through the 
 canula. A probe was introduced to remove the obstruction, but none was found to exist. 
 It was, however, very evident that there was yet a great quantity of fluid in the ovarium, 
 and the distress of the patient obviously indicated the removal of at least a portion of it. 
 The trocar was therefore introduced into another part of the tumour, when not more than 
 two ounces passed away. The instrument was then withdrawn, and, on looking attentive- 
 ly at the ovarium, a pouting was observed at its upper portion, immediately under the last 
 rib. The trocar being introduced at this point, sufficient fluid escaped to make the pa- 
 tient quite comfortable. The cause of the difficulty was owing to the fluid being enclosed 
 in cysts, each distinct in itself; and it seems to me that a useful lesson can be derived 
 from the recollection of this fact. For example, in hydatid dropsy of the ovarium, post- 
 mortem examinations reveal to us that the various cysts, or compartments, vary in size, 
 some containing a gallon or more, while others are so small as not to yield, when punc- 
 tured, an ounce of fluid. Now, let us suppose our opinion to be formed as to the existence 
 of ovarian dropsy in any given case, and, in the event of an operation, if, in puncturing one 
 of the small cysts, not more than a large spoonful of liquid escaped, we might at first sup- 
 pose that we had failed in our diagnosis. The bare mention of the fact will, I apprehend, 
 be sufficient to put practitioners on their guard against the possibility of such an error, in 
 volving, as it certainly would, their professional reputation, if, indeed, it did not compro- 
 mise the safety of the patient. 
 
 After the last tapping, Mrs. B. passed on with more or less distress to the period of her 
 confinement, which took place on the 29th of October. She was in labour only two hours, 
 and was delivered of a still-born, unnatural, and sickly-looking infant. The placenta fol- 
 lowed almost immediately the expulsion of the foetus, and the uterus was well contract- 
 ed. In two hours after the birth of the child, the ovarium commenced enlarging, and in 
 thirty-six hours after delivery this poor woman breathed her last, the abdomen being al- 
 most ready to burst, from the gaseous distension of the intestines The husband and friends 
 had been fully admonished of the almost certain result of the case soon after we had first 
 visited the patient. In the post-mortem examination, in which I was kindly assisted by 
 Dr. Caldwell, the uterus was found to be perfectly healthy, the left ovarium was im- 
 mensely large, and filled with a number of hydatid cysts. The right ovarium preserved 
 its natural character in every respect. The preparation is now in my museum. — Ed. 
 
 
TUMOURS IN THE PELVIC CAVITY. 299 
 
 the labour commenced the 21st. I examined this woman as soon 
 as she arrived, but the head was so far above the superior strait 
 that it was impossible for me to reach it. Posteriorly, and deeply- 
 descended into the excavation, I felt a resisting, smooth, immovable, 
 and large tumour, which, at first, might have been mistaken for the 
 head. On introducing my finger into the narrow passage between 
 the tumour and posterior surface of the symphysis pubis, I detected 
 a sanguineous and flattened protuberance, which, at each contrac- 
 tion, made an effort to descend. I made several attempts at re- 
 duction, which Professor P. Dubois also renewed on his arrival, 
 but without effect. The woman was excessively debilitated, with 
 frequent pulse and sunken countenance, and M. Dubois resolved 
 to break down the head of the child, which, however, had been 
 dead some time. The cephalotribe was introduced without dif- 
 ficulty, and after the head was diminished, powerful tractions 
 were required in order to deliver it. Immediately afterward, on 
 examining the parts, M. Dubois was very much surprised to find 
 nothing in the vagina, the tumour having descended into the left 
 iliac fossa, where it could be distinctly felt. The abdomen was 
 meteoric and very painful ; pulse frequent and small ; and such com- 
 plete prostration that the patient could scarcely articulate. These 
 alarming symptoms, however, yielded to the influence of antiphlo- 
 gistic treatment. The patient, as soon as she recovered, left the 
 hospital, but was compelled soon to return, and in a few days died 
 of peritonitis. Unfortunately, there was no autopsy ; the patient, 
 being a Jewess, was claimed by her friends. 
 
 A careful examination at the commencement of labour would 
 have enabled the accoucheur to ascertain the presence of the tu- 
 mour, which, if he had supported during each pain, would have 
 permitted the descent of the head. The facility with which the 
 tumour was reduced after the operation leaves no doubt that this 
 might have been accomplished. 
 
 B. Vesical Calculi. — Should the tumour be composed of a calcu- 
 lus contained in the bladder, and its reduction prove impracticable, 
 it would then be necessary to practise vaginal lithotomy. Lithot- 
 omy above the pubes has been suggested in this case, but I cannot 
 see with what reason ; for it seems to be impossible to remove the 
 stone by the high operation, after it has descended into the excava- 
 tion, and become firmly fixed there by the head. Moreover, the 
 reasons which usually render this operation necessary do not obtain 
 here ; for the stone, no matter what its volume may be, can de- 
 scend into the pelvic cavity. It can also pass the inferior strait, 
 and, therefore, the only mode of extracting it is to perform vaginal 
 lithotomy. 
 
 C. Distension of the Bladder. — If it be a distended bladder which 
 offers an obstacle to the head, it will be recognised by the follow- 
 ing circumstances : The tumour will, in general, be situated on one 
 of the sides of the pelvis ; a fluctuation is felt in it during the ab- 
 sence of pain, and it becomes resisting and elastic during a con- 
 traction. In addition, the introduction of the catheter, which should 
 
300 MECHANICAL OBSTACLES TO PARTURITION. 
 
 always be attended to the first thing when there is a tumour in 
 the pelvis, will immediately remove the cause of difficulty in this 
 case. 
 
 D. Fulness of the Rectum. — Indurated fecal matter may collect 
 in the rectum to such a degree as to render delivery impossible. 
 My father had a case of this kind, in which injections and purga- 
 tives entirely failed ; he was obliged to empty the rectum with a 
 scoop. 
 
 Art. X. — Tumours in the Vulva and Vagina. 
 (Edema of the external labia, varicose development of their veins, 
 thrombus of the vulva and vagina, cancerous and fibrous tumours, 
 cysts, vegetations in the parietes of the vagina, are all so many 
 circumstances which may prove more or less serious to the moth- 
 er. These tumours, when much developed, may also obstruct par- 
 turition. 
 
 § 1. (Edema of the External Labia. 
 
 When the external labia become the seat of œdematous swell- 
 ings, the expulsion of the head at the latter period of labour may 
 be retarded, and the pressure it occasions may induce gangrene or 
 rupture of the labia ; such results, however, are exceedingly rare. 
 I have always observed that females, even those in whom the 
 vulva was extremely infiltrated, were delivered without trouble, and 
 without experiencing any difficulty from this oedema. Should the 
 swelling, however, be considerable, it would be advisable to afford 
 escape to the fluid by a few punctures with the lancet. 
 
 § 2. Varices and Thrombus of the Labia and Vagina. 
 
 A. Varices. — A varicose condition of the labia and vagina, de- 
 termined by the obstructed venous circulation in the lower extrem- 
 ities, in consequence of the enlargement of the uterus, requires, of 
 itself, no particular care ; but the serious accidents which some- 
 times result from these varices call for great circumspection on 
 the part of the accoucheur. During pregnancy, for example, but 
 more especially during labour, the tumefied veins may rupture, and 
 give rise to an effusion in the cellular tissue of a greater or less 
 quantity of blood ; sometimes, even, after gangrene of the parts, 
 this effusion may take place externally, and thus the female may 
 perish from hemorrhage. 
 
 B. Thrombus. — The varicose veins rarely rupture in the early 
 months of pregnancy ; for, in general, 'they are not sufficiently 
 developed to become ruptured spontaneously, or even under the 
 influence of some external cause.* Thrombus, therefore, usually 
 does not manifest itself until the latter period of gestation, and par- 
 
 * A female aged thirty years came to La Clinique to be confined February 12, 1835 ; she 
 had been affected with varicose tumours of the labia majora and vagina during the whole of 
 
 Îregnancy, and was much less incommoded by them in the fortnight preceding parturition, 
 hiring labour, however, on April 27th, they resumed the appearance they presented du- 
 ring pregnancy ; but their rupture was prevented by supporting them with the fingers until 
 the head entered the genital organs and compressed them, and the labour terminated well. 
 
EXCESSIVE SIZE OF THE FŒTUS. 301 
 
 ticularly at the time of labour ; sometimes, also, the varices do not 
 appear until after delivery, and in this case they are the more alarm- 
 ing, because of their greater development in the relaxed tissues, 
 and also because frequently their presence is not detected at the 
 moment they exhibit themselves. 
 
 The formation of the thrombus commences with an acute pain, 
 felt in the part affected ; this part swells, and becomes suddenly 
 engorged, or increases very gradually. 
 
 Occasionally, the thrombus occupies the entire extent of one of 
 the labia, and then extends to the excavation, containing a quantity 
 of blood so considerable as measurably to enfeeble the patient. 
 
 The tissues are violet and tense, with a very distinct fluctuation ; 
 often, even, the tissues rupture in consequence of the effusion, fol- 
 lowed by more or less hemorrhage. Sometimes these sanguineous 
 collections terminate by resolution ; they may also terminate by 
 absorption. 
 
 Indications. — If the tumour should impede delivery, escape 
 should be afforded to the blood by an incision, but this should never 
 be done until the head has sufficiently descended to threaten se- 
 rious pressure on the tumour in proportion as it disengages. With- 
 out this precaution, dangerous hemorrhage might ensue. 
 
 If the tumour manifest itself during pregnancy, or after parturi- 
 tion, and should not be much developed, we should attempt the 
 resolution of the effused blood ; but if, on the contrary, it be large, 
 and especially if the tissues be thin, and in a condition to cause us 
 to apprehend gangrene, free incisions should be made, in order that 
 the coagula and blood contained in the tumour may be evacuated. 
 The coagula should be removed with the finger, leaving those 
 which adhere too firmly, for fear of renewing the hemorrhage. In 
 this case, it has been advised not to open the tumour as soon as it 
 is formed, and I concur entirely in this opinion ; for, if the effused 
 fluid be permitted to escape before a coagulum is formed, we ex- 
 pose the patient to severe hemorrhage. Therefore, as a general 
 rule, we should delay several days before making the incision. But 
 should the tumour assume a very rapid development, and give 
 ground to fear an internal hemorrhage, it should be opened imme- 
 diately, and then recourse be had to the tampon. 
 
 Art. XL — Excessive Size of the Fœtus. 
 The foetus rarely acquires such a size as to render delivery im- 
 possible, when the pelvis is well formed ; most frequently, this ex- 
 cess of volume only retards parturition. However, unusual devel- 
 opment of the foetus has been known to offer an insurmountable 
 obstacle to delivery, even when the pelvis possessed its ordinary 
 dimensions ; and this cavity being contracted, the same difficulty 
 would of course obtain to a greater degree. In both cases, this 
 disproportion between the pelvis and foetus should be overcome by 
 tractions made with the forceps ; this instrument will alone suffice, 
 if the pelvis and head be well formed. , In the contrary case, we 
 should proceed as has been mentioned in the article Deformities of 
 the Pelvis, 
 
302 MECHANICAL OBSTACLES TO PARTURITION. 
 
 Art. XII. — Abnormal Development of certain Parts of the 
 
 Fœtus. 
 
 § 1. Hydrocephalus. 
 Hydrocephalus is distinguished into external and internal. The 
 former, consisting of an accumulation of fluid under the scalp and 
 pericranium, never offers any impediment to delivery, and has been 
 termed more especially the sero-sanguineous tumour. The latter, 
 a collection of serum within the cranium, which alone should be 
 called hydrocephalus, is entitled to particular attention, not only on 
 account of the difficulty it occasions in parturition, but because it 
 involves the safety of the child after its birth. I shall now allude 
 to it merely in connexion with its influence on labour. 
 
 Diagnosis. 
 
 At the time of labour, hydrocephalus is distinguished by the 
 following circumstances: the head forms a large tumour, which 
 occupies the entire contour of the superior strait, without descend- 
 ing. This tumour is resisting during a contraction ; soft and fluc- 
 tuating in the intervals of pain, particularly at the points corre- 
 sponding with the sutures and fontanelles, which are more or less 
 open ; the bones themselves are likewise, in a greater or less degree, 
 separated. Finally, in cases of very marked hydrocephalus, the 
 bones float, as it were, in the midst of the soft parts. 
 
 Indications. — When hydrocephalus is slight, and even in cases 
 where the cranium contains a certain quantity of fluid, spontaneous 
 delivery may be accomplished. The head, being extremely soft, 
 elongates, and adapts itself to the cavity of the pelvis, and finally 
 is expelled. But most frequently the accoucheur is obliged to aid 
 the expulsion by the application of the forceps. Sometimes even 
 this instrument proves unavailing ; and it then becomes necessary 
 to puncture the tumour. Under these circumstances, great care 
 should be had not to involve the brain, but merely to evacuate the 
 serum ; for, although the life of the child will almost always be 
 compromised by this puncture, yet infants have sometimes survi- 
 ved the operation. The puncture should be made with a trocar 
 or a pointed bistoury enveloped in a piece of linen, except the ex- 
 tremity of the blade. 
 
 § 2. Ascites and Hydrothorax. 
 
 After the delivery of the head, the labour may be obstructed by 
 the thorax and abdomen, if they be the seat of an effusion. Hy- 
 drothorax will be recognised by the separation of the intercostal 
 spaces, and the fluctuation perceived by the finger at these points. 
 This fluctuation, together with the enlargement of the abdomen, 
 characterizes ascites. 
 
 Nature may, indeed, overcome these obstacles ; however, art is 
 most frequently obliged to interfere. The accoucheur should make 
 tractions on the head, and, if these be insufficient, he should punc- 
 ture the thorax or abdomen. 
 
A CASE OF OBLITERATION OF THE ORIFICE. 303 
 
 A female, in whom these two complaints existed, came to La 
 Clinique to be confined ; after the puncture of the chest, it requir- 
 ed the united efforts of M. P. Dubois and myself to extract the rest 
 of the trunk. 
 
 § 3. Tumours developed on the Fœtus. 
 
 Tumours of various kinds and size may develop themselves on 
 the surface of the fœtus, and retard parturition, or occasion a se- 
 rious obstacle to its accomplishment. It is extremely difficult to 
 ascertain the existence of these tumours in advance ; generally, we 
 do not suspect their presence until the difficulties which they oc- 
 casion in parturition become manifest. If they be accessible, they 
 should be removed by an instrument ; if not, we must proceed as 
 in contraction of the pelvis. # 
 
 * The following case should have been inserted in another place, under the head of ob- 
 literation of the oriiice ; but its recent occurrence prevented this. 
 
 December 19th, 1843, Drs. Vermeule andHolden requested me to meet them in consulta- 
 tion, in the case of Mrs. M., who had been in labour for twenty -four hours. On arriving at 
 the house, I learned the following particulars from the medical gentlemen : Mrs. M. was 
 the mother of two children, and had been suffering severely, for the last fourteen hours, 
 from strong expulsive pains, which, however, had not caused the slightest progress in the 
 delivery. I was likewise informed that, about four hours before I saw the case, Dr. Miner, 
 an experienced physician, had been sent for, and, after instituting a vaginal examination, 
 remarked to the attending physicians that, " in all his practice, he had never met with a 
 similar case." Dr. Miner suggested the administration of an anodyne, and, having other 
 professional engagements, left the house. Mrs. M. was taken in labour Monday, December 
 18th, at seven o'clock P.M., and on Tuesday, at seven P.M., I first saw her. Her pains 
 were then almost constant, and such had been the severity of her suffering that her cries 
 for relief, as her medical attendants informed me, had attracted crowds of persons about the 
 door. As soon as I entered her room she exclaimed, " For God's sake, doctor, cut me open, 
 or I shall die ; I never can be delivered without you cut me open." I was struck with this 
 language, especially as I had already been informed that she had previously borne two 
 children. At the request of the médical gentlemen, I proceeded to make an examination 
 per vaginam, and I must confess that I was startled at what 1 discovered, expecting every 
 instant, from the intensity of the contractions of the uterus, that this organ would be rup- 
 tured in some portion of its extent. I could distinctly feel a solid, resisting tumour at the 
 superior strait, through the walls of the uterus ; but I could detect no os tincce. In carrying 
 my finger upward and backward towards the cul-de-sac of the vagina, I could trace two 
 bridles, extending from this portion of the vagina to a point of the uterus, which was quite 
 rough and slightly elevated ; this roughness was transverse in shape, but with all the cau- 
 tion and nicety of manipulation I could bring to bear, I found it impossible to detect any 
 opening in the womb. In passing my finger, with great care, from the bridles to the rough 
 surface, and exploring the condition of the parts with an anxious desire to afford the dis- 
 tressed patient prompt and effectual relief, I distinctly felt cicatrices, of which this rough 
 surface was one. Here, then, was a condition of things produced by injury done to the soft 
 parts at some previous period, resulting in the formation of cicatrices and bridles, and like- 
 wise in the closure of the mouth of the womb. At this stage of the examination, I knew no- 
 thing of the previous history of the patient more than I have already stated, and the first 
 question I addressed to her was this : Have you ever had any difficulty in your previous 
 confinements? have you ever been delivered with instruments? &c, &c. She distinctly 
 replied that her previous labours had been of short duration, and that she had never been 
 delivered with instruments, nor had she ever sustained any injury in consequence of her 
 confinements. Dr. Vermeule informed me that this was literally true, for he had attended 
 her on those occasions. This information somewhat puzzled me, for it was not in keeping 
 with what any one might have conjectured, taking into view her actual condition, which 
 was undoubtedly the result of direct injury done to the parts. 
 
 I then suggested to Drs. Vermeule and Holden the propriety of questioning the patient 
 still more closely, with the hope of eliciting something satisfactory as to the cause of her 
 present difficulty ; remarking, at the same time, that it would be absolutely necessary to 
 have recourse to an operation for the purpose of delivering her. On assuring her that she 
 was in a most perilous situation, and, at the same time, promising that we would do all 
 in our power to rescue her, she voluntarily made the following confession : About six 
 weeks after becoming pregnant, she called on the notorious Madame Restell, who, learn- 
 ing her situation, gave her some powders with directions for use ; these powders, it ap- 
 pears, did not produce the desired effect. She returned again to this woman, and asked 
 her if there were no other way to make her miscarry. " Yes" says Madame Restell, " i" 
 
304 MECHANICAL OBSTACLES TO PARTURITION. 
 
 can probe you; but I must hare my price for this operation." "What do you probe with?" 
 "A piece of whalebone." "Well," observed the patient, " I cannot afford to pay your price, 
 and I will probe myself." She returned home, and used the whalebone several times; it 
 
 Sroduccd considerable pain, followed by discharge of blood. The whole secret was now 
 isclosed. Injuries inflicted on the mouth of the womb by these violent attempts had re- 
 sulted in the circumstances as detailed above. It was evident, from the nature of this poor 
 woman's sufferings and the expulsive character of her pains, that prompt artificial delivery 
 was indicated. As the result of the case was doubtful, and it was important to have the 
 concurrent testimony of other medical gentlemen, and as it imbodied great professional in- 
 terest, I requested my friends, Drs. Detmold, Washington, and Doane, to see it. They 
 reached the house without delay, and, after examining minutely into all the facts, it was 
 agreed that a bi-lateral section of the mouth of the womb should be made. Accordingly, 
 without loss of time, I performed the operation in the following manner : The patient was 
 brought to the edge of the bed, and placed on her back. The index finger of my left hand 
 was introduced into the vagina as far as the roughness, which I supposed to be the seat of the 
 os tincœ ; then a probe-pointed bistoury, the blade of which had been previously covered with 
 a band of linen to within about four lines of its extremity, was carried along my finger until 
 the point reached the rough surface. I succeeded in introducing the point of the instru- 
 ment into a very slight opening which I found in the centre of this surface, and then made 
 an incision of the left lateral portion of the mouth, and, before withdrawing the bistoury, I 
 made the same kind of incision on the right side. I then withdrew the instrument, and in 
 about five minutes it was evident that the head of the child made progress; the mouth of 
 the womb dilated almost immediately, and the contractions were of the most expulsive 
 character. There seemed, however, to be some ground for apprehension that the mouth of 
 the uterus would not yield with sufficient readiness, and I made an incision of the posterior 
 lip through its centre, extending the incision to within a line of the peritoneal cavity. In 
 ten minutes from this time, Mrs. M. was delivered of a strong, full-grown child, whose bois- 
 terous cries were heard with astonishment by the mother, and with sincere gratification by 
 her medical friends. The expression of that woman's gratitude, in thus being preserved 
 from what she and her friends supposed to be inevitable death, was an ample compensation 
 for the anxiety experienced by those who were the humble instruments of affording her re- 
 lief. This patient recovered rapidly, and did not, during the whole of her convalescence, 
 present one unpleasant symptom. It is now ten weeks since the operation, and she and 
 her infant are in the enjoyment of excellent health. 
 
 I omitted to mention that the urethra was preternaturally dilated. I introduced my finger 
 as far as the bladder without any consciousness on her part, such was the degree of its en- 
 largement. 
 
 About ten days after the operation, Dr. Forry visited this patient with me, and heard 
 from her own lips the narrative of her case, so far as her visit to Madame Restell is con- 
 cerned, and which I have already stated. On Saturday last, January 20th, Dr. Forry again 
 accompanied me on a visit to this woman, and a vaginal examination was made. The mouth 
 of the womb is open, and will permit the introduction of the end of the forefinger, and the 
 two bridles are distinctly felt, extending from the upper and posterior portion of the vagina 
 to the posterior lip of the os tincœ, which they seem firmly to grasp. The urethra is still very 
 much enlarged, and somewhat tender to the touch. 
 
 At my last visit to this patient with Dr. Forry, she made some additional revelations, 
 which I think should be given not only to the profession, but to the public, in order that it 
 may be known that in our very midst there is a monster who speculates with human life with 
 as much coolness as if she were engaged in a game of chance. This patient, with unaffect- 
 ed sincerity, and apparently ignorant of the moral turpitude of the act, stated most unequivo- 
 cally, to both Dr. Forry and myself, that Madame Restell, on previous occasions, had caused 
 her to miscarry five times, and that these miscarriages had, in every instance, been brought 
 about by drugs administered by this trafficker in human life. The only case in which the 
 medicines failed was the last pregnancy, when, at the suggestion of Madame Restell, she 
 probed herself, and induced the condition of things described, and which most seriously in- 
 volved her own safety, as well as that of her child. In the course of conversation, this wom- 
 an mentioned that she knew a great number of persons who were in the habit of applying to 
 Madame Restell for the purpose of miscarrying, and that she scarcely ever failed in afford- 
 ing the desired relief; and, among others, she cited the case of a female residing in Hous- 
 ton-street, who was five months pregnant ; Madame Restell probed her, and she was deliv- 
 ered of a child, to use her own expression, "that kicked several times after it was put into the 
 bowl." 
 
 It indeed seems too monstrous for belief that such gross violations of the laws of both God 
 and man should be suffered in the very heart of a community professing to be Christian, 
 and to be governed by law and good order. Yet these facts are known to all who can read. 
 This creature's advertisements are to be seen in most of our daily papers ; there she invites 
 the base and the guilty, the innocent and the unwary, to apply to her. She tells publicly what 
 she can do, and, without the slightest scruple, urges all to call on her who may be anxious to 
 avoid having children. Here, then, is a premium offered for vice, to say nothing of the prod- 
 igal destruction of human life that must necessarily result from the abominations of this mer- 
 cenary and heartless woman. 
 
 With all the vigilance of the police of our city, and with every disposition, I am sure, on 
 the part of the authorities to protect public morals, and bring to merited punishment those 
 who violate the sanctity of the law, this Madame Restell, as she styles herself, has as yet 
 escaped with impunity. 
 
THE FORCEPS. 
 
 305 
 
 Occupying the position I do, and fully appreciating the important trusts confided to my 
 care in connexion with the department over which I have the honour to preside in the Uni- 
 versity, I have felt it to be a duty I owe to the community, to the profession, and to myself, 
 publicly to expose the facts of this case ; and I fervently hope that the disclosures here 
 made may tend to the arrest of this woman, and the infliction of the severest penalty of the 
 law. 
 
 In a professional point of view, this case is not without interest. It must be evident to 
 all that, without the operation, the patient must have sunk. She had been in labour precise- 
 ly twenty-nine hours when I made the section of her womb ; and for twenty hours pre- 
 viously the contractions were most energetic, possessing all the characteristics of true ex- 
 pulsive pains. But yet, with all this suffering, not the slightest change had been effected in 
 the parts. If nature, therefore, had been competent to overcome the resistance, sufficient 
 time was allowed for this purpose. Longer delay would undoubtedly have placed the lives 
 of both mother and child in extreme peril ; for, from the reiterated, but unavailing efforts of the 
 womb, there was reason to anticipate rupture of this viscus, which would most probably 
 have compromised the life of the mother ; while, at the same time, the child was exposed to 
 congestion from constant pressure exerted on its head by the contractile force of the uterus. 
 
 I am not aware that this operation has ever been performed in this country ; at least, I 
 have found no record of it. It has, on several occasions, been resorted to in Europe, but not 
 always with success. — Ed. 
 
 CHAPTER VI. 
 
 OBSTETRICAL OPERATIONS. 
 
 After having reviewed in detail the various accidents capable 
 of complicating labour in presentation of the vertex, and having 
 mentioned the particular rules applicable to each especial case, it 
 now remains for me to enumerate the operations called for in the 
 different conditions of the female, and likewise furnish a description 
 of the instruments necessary in the performance of these operations. 
 
 Art. I. — Forceps. 
 
 The forceps is an instrument composed of two 
 branches, which articulate by means of a pivot and 
 mortise ; it is a species of pincers with which we 
 extract the head of the fœtus from the maternal 
 organs. (Fig. 120.) 
 
 Some authors have also advised the application 
 of the forceps on the pelvic extremity ; but this 
 would be attended with great inconvenience. If 
 the foetus be living, the blades of the instrument, 
 by the pressure they exert on the abdominal or- 
 gans, would certainly endanger its life. And, 
 again, whether it be living or not, the forceps can- 
 not take a sufficiently strong hold on the pelvic 
 extremity, and would consequently slip from the 
 vagina This instrument, therefore, should not be 
 applied except on the head. 
 
 The forceps, originally introduced by Chamber- 
 lain, an English accoucheur, was at first straight, 
 and could only be used after the head had descend- 
 ed into the pelvic excavation. Since the time of 
 
 (Fig. 120.) 
 
306 
 
 OBSTETRICAL OPERATIONS. 
 
 Chamberlain, Levret and Smellie have suggested important modi- 
 fications in this instrument ; the most valuable of which is that 
 which enables us to employ it when the head is at the superior 
 strait* 
 
 With this view, the borders of the instrument have been curved, 
 the upper border being concave, while the lower is convex. This 
 curve, or concavity, must begin at the pivot. Thus arranged, the 
 forceps accommodates itself to the two axes of the pelvic canal, and 
 may be carried to the womb for the purpose of reaching the head. 
 Each branch is composed of a blade, concave internally, and hol- 
 lowed in its centre ; and of a handle, by means of which the accou- 
 cheur introduces the blade. These two branches are in every 
 respect similar, except at their middle portion, where they articu- 
 late ; the one has a pivot, and the other a mortise. These serve 
 as a means of union after the branches have been introduced. 
 
 (Fig. 121.) The extremity of the handle of each branch is 
 
 (r^ curved in the form of a hook, in order to afford a 
 
 1 U tr§& firm hold to the hand of the accoucheur. This 
 also enables us to. employ one of the branches as 
 a blunt hook, when we wish to bring down the 
 hips in the pelvic presentation, they being inacces- 
 sible to the finger. 
 
 Some forceps present, at the extremity of each 
 handle (2), a perforator on one side, and a crotch- 
 et (3) on the other. These two crotchets may, in 
 fact, serve as blunt hooks, but the screw is apt 
 to turn when it is fixed on the handles ; but this is 
 comparatively a slight inconvenience. A much 
 more serious one is this : after the application of 
 each blade, in difficult cases, in order to articulate 
 them, it sometimes becomes necessary to impress 
 on each handle, and with a certain degree of en- 
 ergy, force in an opposite direction, and the mo- 
 bility of the extremity of the instrument may inter- 
 fere with the certainty of these motions. 
 
 Besides, since the invention of the cephalotribe, 
 should not the crotchet be confined to the museums, and entirely 
 banished from practice?! It is a murderous instrument for the 
 
 * The forceps figured in plate 120 is that of Baudelocque modified by Dubois. It is the 
 only one used at the Maternité and La Clinique. 
 
 t The crotchet is, indeed, a murderous instrument ; and its use has been followed by the 
 most melancholy results. Under the most favourable circumstances, and in the most dexter- 
 ous hands, it often does harm. It is well understood that it is never to be applied except on 
 a dead child, or where the operation of embryotomy is called for. Its chief danger, therefore, 
 regards the mother ; for the purchase which this instrument takes on the child almost al- 
 ways gives way, and if the accoucheur be not particularly guarded, the soft parts of the 
 mother, the bladder, rectum, or vagina, will be lacerated, often giving rise to the most disas- 
 trous consequences. To obviate this injurious tendency of the instrument, I have caused 
 a guard crotchet (figure 4 in the adjoining plate) to be constructed, which I offer to the at- 
 tention of the profession, allowing its merits to rest upon the judgment they may form of 
 its utility. The adaptation of this instrument to the particular indications to be fulfilled in 
 the use of the crotchet will, I think, be found to be all that can be desired. Fig. 3 presents 
 a front view, and in the centre of the blade is a groove for the reception of the guard, which 
 slides with great facility to the point of the crotchet. The extremity of the guard, on its ex- 
 
308 OBSTETRICAL OPERATIONS. 
 
 mother ; it can take no firm hold on the fœtal body ; it slips at the 
 very first tractions, and lacerates the maternal organs. In the ex- 
 traction of the foetus by the crotchet, the operator is guided by no 
 particular rule, nor can the duration of the operation be limited. 
 The cephalotribe, on the contrary, which can in all cases be sub- 
 stituted for the crotchet, can be much more promptly applied, is 
 more certain, and attended with far less danger. 
 
 The perforator may be retained merely to take the place of Smel- 
 lie's scissors : I should observe, however, that it is not so useful. 
 
 The pivot branch of the forceps is called the pivot branch, male 
 branch, left branch ; the other, the mortise branch, female branch, 
 right branch. 
 
 Objections have been made to the designations of left and right 
 branch, because, it is said, one branch may be confounded with 
 the other. I cannot, I must confess, understand how this error 
 can be committed, if it be well understood previously that the pivot 
 branch is called the left branch, because it is always introduced 
 with the left hand, and on the left side of the pelvis ; and the mortise 
 branch the right, because it is held with the right hand, and is pla- 
 ced on the right of the pelvis. Either of these three names may 
 be given to the instrument ; I prefer, however, the terms pivot and 
 mortise branch, in order to avoid all error. 
 
 ternal surface, is convex and smooth, and so completely conceals the sharp point of the 
 crotchet as entirely to protect the soft parts from injury, even if the crotchet should slip 
 during the tractions made on it by the accoucheur ; for, in this event, instead of the bladder, 
 rectum, or vagina being torn by the point of the crotchet, these parts will suffer no injury, 
 for the smooth surface only of the guard comes in contact with them. It will be seen that, 
 at the other extremity of the guard, there is the ordinary blunt hook. This is important 
 only as a matter of economy. 
 
 Fig. 1 represents my forceps, which I believe imbodies some important improvements ; 
 whether profitable or not, must also depend on the judgment of my professional brethren. 
 The curve of the blades, their lightness and thinness (sufficiently strong, however, for all 
 ordinary purposes), I regard as very essential improvements. The blades of the forceps are 
 usually too thick, unnecessarily so ; for this circumstance frequently prevents their intro- 
 duction, especially if the head be unusually large, or the pelvis somewhat contracted. In my 
 judgment, therefore, the thinner the blades, consistently with the strength required, the more 
 advantageous will the instrument be found. Instead of the pivot lock, my forceps has the 
 button joint, and the advantage of this mode of articulation over the pivot will be at once 
 conceded on testing the relative facility of locking the branches. It appears to me that ac- 
 coucheurs generally have paid too little attention to the handles of the forceps. I certainly do 
 attach great value to this portion of the instrument, and I am well satisfied that the indiffer- 
 ence of practitioners to this point has frequently led to failure in its application. In order to 
 extract the head of the fœtus safely, something more is required than the mere adjustment 
 of the blades ; and if proper traction be not made, and proper direction given to the traction, 
 the child will often be sacrificed, and severe injury ensue to the soft parts of the mother. 
 To obviate these difficulties, therefore, and to furnish every facility for the safe extraction of 
 the child, 1 have provided a handle (fig. 2) of sufficient length and curve. The curve at the 
 extremity of the handle will afford greater facility to the operator, and give him more power 
 that any forceps I have yet seen. To be satisfied of this fact, it is only necessary to apply 
 the instrument on the manikin. The length of the handles likewise affords a proper lever 
 for the tractions. The two rings will enable the operator to give proper direction to the force 
 he employs, and will, at the same time, facilitate very much the lateral motions so essential 
 to impart to the child's head during the stages of its delivery. Fig. 7 represents my pierce 
 crane, or perforator. Fig. 5 is the ordinary vectis. 
 
 It is due to myself to state, that these instruments are not presented to the consideration 
 oi the profession from any fondness that I have for fame as an inventor — my ambition lies in a 
 different channel. But they are the result of much reflection ; and all I ask is, that they 
 may receive that degree of favour to which, on fair trial, they may be found to be legitimately 
 entitled. 
 
 * Mr. Goulding, 35£ Chatham-street, is the manufacturer of these instruments ; and 1 
 take this opn^r'.^mty of bearing my testimony to his superior skill and finished workman- 
 ship.— Ed. 
 
THE FORCEPS. 309 
 
 § 1. General Rules. 
 
 (1.) The forceps must be applied only on the head of the fœtus, 
 whether the head be flexed (vertex), extended (face), or remain in 
 the maternal organs after the extraction of the trunk. I have al- 
 ready stated why this instrument should never be applied to the 
 pelvic extremity. 
 
 (2.) The head should not be too large, nor the pelvis too con- 
 tracted, and especially, in this case, its deformity should not be reg- 
 ular ; for the forceps diminishes but very slightly the volume of the 
 head. It is not, properly speaking, an instrument of compression ; 
 it is rather an instrument of traction. If, therefore, the resistance 
 which it has to overcome be very considerable, the soft parts cov- 
 ering the bones might be violently contused, and also rupture of the 
 ligaments and relaxation of the symphysis take place, thus com- 
 promising the life of the mother without any useful result. 
 
 (3.) Above all, the position of the head should be ascertained, 
 both by the touch and auscultation. 
 
 (4.) It is necessary, as nearly as possible, that the blades be ap- 
 plied on the sides of the head, so that it may be embraced in its 
 bi-parietal diameter. In the course of this article it will be shown 
 that there are some exceptions to this rule. The concavity of 
 the borders should regard that portion of the head which is to be 
 brought under the symphysis pubis. 
 
 (5.) This concavity of the borders should likewise, at the time 
 of the introduction of the blades, regard the anterior half of the 
 pelvis, whether directly to the left or to the right ;. but it should 
 never look towards the posterior half. At the moment of delivery, 
 it should regard directly the lower surface of the symphysis pubis. 
 I shall mention hereafter some exceptions to this precept. It should 
 never, however, regard the posterior half of the pelvis. 
 
 (6.) As an invariable rule, the pivot branch should always be 
 held with the left hand, and placed on the left of the pelvis ;. hence 
 the propriety of the name left branch. The mortise branch should 
 always be introduced with the right hand, and placed on the right 
 of the pelvis ; hence the term right branch. 
 
 (7.) The hand opposite to that which guides the handle of the 
 forceps should always be introduced, with the exception of the 
 thumb, into the maternal organs, in order to give proper direction 
 to the blade, and protect the vagina from the contact of the instru- 
 ment. 
 
 Whatever may be the situation of the head and its elevation, 
 this precaution should never be omitted ; it is essentially important. 
 Two or three fingers may, indeed, suffice to guide the branches 
 on the sides of the head after it has descended into the pelvic ex- 
 cavation, and passed the mouth of the uterus. But when the head 
 is still comprised within a portion of the womb, although it may 
 have come into the excavation, and more especially if it be at the 
 superior strait, it is very important to guide the blades into the 
 uterine orifice with the hand, taking care to insinuate the extremity 
 
 \ 
 
310 OBSTETRICAL OPERATIONS. 
 
 of the fingers between the orifice and head. With this precaution, 
 the blade glides along the palmar surface of the hand, and penetrates 
 the cavity of the uterus without passing on the outside of the neck, 
 and pressing against the cul-de-sac of the vagina, which it might 
 perforate if the instrument were pushed with much force, which, 
 however, should never be attempted. Special rules will demon- 
 strate the value of these precepts. 
 
 (8.) The second branch is always introduced above the one first 
 applied, for the presence of the perineum, and its resistance, render 
 this necessary in most cases. 
 
 (9.) Which branch should be introduced the first? We may com- 
 mence indifferently with one or the other ; but if it be the mortise, as 
 the pivot branch must almost always be introduced over it, because, 
 in this case, the pivot branch is the second introduced, this latter 
 will be placed over the mortise, and in order to articulate them, 
 and bring the pivot branch under the mortise, we will be under the 
 necessity of separating the handles of the forceps. This separa- 
 tion will not be attended by any inconvenience if the head have com- 
 pletely passed from the orifice, but it will contuse and lacerate, 
 more or less seriously, this part, if the head should still be retained 
 within the neck of the uterus. In order, therefore, to avoid this 
 result, we should always commence with the pivot branch. With 
 some few exceptions, this method is adopted by M. P. Dubois and 
 myself. 
 
 Whenever the branches are to be placed on the sides .of the pel- 
 vis, at the two extremities of the transverse diameter, there can be 
 no objection to the pivot branch being introduced first. But, in the 
 diagonal positions, when the head is in the pelvic cavity, in order to 
 grasp it properly in its bi-parietal diameter, one branch must be in 
 front, and the other posteriorly (fig. 122). If, therefore, we com- 
 
 (Fig. 122.) 
 
 mence with the pivot branch, and this branch be introduced posteri- 
 orly, its application will be quite easy ; but it occupies space in the 
 pelvis, will push the head under the pubes, and render the introduc- 
 tion of the second much more difficult, and sometimes impossible. 
 
THE FORCEPS. 311 
 
 And, moreover, after unavailing attempts to introduce the mortise 
 branch, we shall be compelled to withdraw the pivot branch in order 
 to allow more space for the introduction of the mortise (fig. 122).* 
 Crossing will be the necessary consequence of this application, 
 since the pivot branch, being applied second, will be placed on the 
 mortise. If the perineum, however, should be very distensible, or 
 should have been lacerated in previous deliveries, we may endeav- 
 our to place the pivot branch under that of the mortise, and thus 
 avoid the crossing. 
 
 With a view to render more easy the application of the branch 
 which should be in front, Madame Lachapelle has recommended 
 to introduce it always the first, because it is the most difficult ;f as 
 we shall see when describing the rules proper for each application, 
 we are rarely obliged to follow the excellent precept of Madame 
 Lachapelle ; for we can almost always commence with the pivot 
 branch, and thus dispense with the crossing. It will also be seen 
 that there is only one case (the left anterior occipito-iliac position) 
 in which my directions vary from those of this celebrated sage- 
 fern me ; and, in consulting the treatise of Madame Lachapelle, it 
 will be found that she herself very frequently departs from the 
 precept she has inculcated. In fine, we may commence with ei- 
 ther branch, but it is preferable, if it can be done, to commence 
 with the pivot branch, in order to avoid the crossing. If the appli- 
 cation of the pivot branch, introduced first, should obstruct the in- 
 troduction of the mortise branch, .it must be withdrawn, in order 
 to give place to the latter ; and we shall then be obliged to have 
 recourse to crossing, unless the perineum allows the pivot branch 
 to pass under the mortise. This method is generally adopted by 
 all accoucheurs, and M. P. Dubois is constantly in the habit of fol- 
 lowing it himself. 
 
 (10.) Towards what point of the pelvis should the branches be 
 directed ? Should they be carried directly to the place they are 
 intended ultimately to occupy? or should they be directed first to 
 the posterior part of the pelvis, to be afterward brought to their 
 proper situation by the hand introduced into the maternal organs, 
 and by a vibratory movement imparted to the handle of the in- 
 strument ? J I adopt this latter mode, after the example of M. P. 
 Dubois. 
 
 * In this figure, and in all those which present a front view of the application of the for- 
 ceps, the head being in the cavity, the forceps is situated too perpendicularly ; but we can- 
 not represent it in a more horizontal position without producing a shortening as difficult to 
 express as to comprehend, and which would frequently give only a very incorrect represent- 
 ation of the fact I wish to express. An exact idea of the direction of the forceps can only 
 be had by figures seen in profile, excepting, however, those front views where the forceps 
 is represented reversed on the abdomen of the female, when the head descends, which are 
 extremely correct, and also those showing the application of the forceps at the superior 
 strait. 
 
 t I cannot understand why it should be laid down as a precept to apply first the blade 
 which should be at the posterior part of the pelvis on account of its difficulty, when every 
 one knows it is the most easy of application. The precept of Madame Lachapelle is much 
 more natural, and is readily understood. 
 
 1 I can see no advantage in this rule ; but, on the contrary, trouble may arise from it. 
 Suppose, for example, the head is in the pelvic cavity, and it becomes necessary to apply 
 the forceps. If the head be situated directly in the pelvis, with either the occiput or fore- 
 
312 0B3T ETHICAL OPERATIONS. 
 
 However, as will be shown hereafter, it may become necessary, 
 in the diagonal or transverse applications, to carry at first to the 
 point it is intended to occupy, the branch which is to be placed 
 above ; this will depend on special and respective dispositions of 
 the head and pelvis, which it is not possible to know in advance. 
 
 The sagacity of the accoucheur will alone enable him to appre- 
 ciate these circumstances ; but the exceptions do not destroy the 
 rule. 
 
 (11.) The branches should never be pushed with force; they 
 should, as it were, place themselves. 
 
 (12.) The orifice of the uterus must be dilated or dilatable. 
 
 (13.) We should articulate the instrument with great care, in or- 
 der not to injure the orifice ; and, in case of crossing, before artic- 
 ulating we should separate the branches from each other as little 
 as possible, always with the view of protecting the uterine orifice. 
 
 (14.) As soon as the articulation is completed, we should ascertain 
 that the head is properly seized, and that the maternal organs are 
 not comprised between the head and the forceps. The head is 
 well seized when, in making slight tractions on it, we feel that it 
 becomes, as it were, a part of the instrument. In order to be cer- 
 tain that the parts of the mother are not held by the forceps, it will 
 be sufficient, after having articulated it, to exert a certain pressure 
 on the extremity of the branches in approximating the handles to- 
 wards each other ; if the pressure do not occasion pain, the oper- 
 ation may be proceeded with ; in the contrary case, the instrument 
 should be disarticulated, without withdrawing it, and an effort 
 should be made with the finger to detach the part that has been 
 included within it. 
 
 (15.) It has been generally advised, in order to ascertain that 
 each branch is well applied, to push the respective branches gently 
 inward before articulating them. If the branch meet with an ob- 
 stacle, it is in consequence of its improper application ; it should be 
 withdrawn, and again introduced properly. If it should not be 
 impeded, and in slightly pulling it outward it experience resist- 
 ance, then we know the head is judiciously seized. 
 
 This precept, excellent in itself when the head has not passed 
 the uterine orifice, is not applicable without some restriction to ca- 
 ses in which the head has completely freed the orifice, this latter 
 encircling the shoulders of the fœtus. To make it, therefore, ab- 
 solute, would be to lead young accoucheurs into grave error, and 
 cause them to imagine difficulties which do not exist. 
 
 In fine, when the head has arrived in the cavity, in the seconda- 
 ry antero-posterior positions, the occiput or forehead corresponding 
 to the posterior portion of the pubes, the forceps is applied directly 
 according to the axis of the inferior strait only (fig. 123, No. 1), 
 
 head regarding the pubes, nothing would be easier than to introduce the instrument, taking 
 the hand previously passed into the vagina as a guide, on the sides of the head at once, with- 
 out previously carrying the blades to the posterior part of the pelvis. This latter procedure 
 migh^result in injury to the scalp of the child, in consequence of the efforts made to bring the 
 blades to the lateral portions of the head. But if carried to these points when first intro- 
 duced, no such difficulty would follow. — Ed. 
 
THE FORCEPS. 313 
 
 and then the extremity of the blades always passes to the posterior 
 wall of the cavity ; in this case, even, we may employ the straight 
 forceps ; if, therefore, we should conclude that, because the branch 
 meets with an obstacle, it is badly applied, we withdraw it in or- 
 der to give it a better direction; but it always encounters the 
 same impediment, no matter what may be done, for if the branch 
 be properly introduced, it cannot be directed otherwise. 
 
 (Fig. 123.) 
 
 In the diagonal positions, the extremity of the branch which is 
 situated in front, enters the uterus, because the anterior wall of the 
 pelvis is much shorter than the posterior ; the branch which is sit- 
 uated posteriorly, for the contrary reason, penetrates the uterus 
 less deeply than in the antero-posterior positions. The rule, 
 therefore, will be applicable in this case only to the branch which 
 is in front, and not to that which is posteriorly, since this latter 
 will always encounter the posterior wall of the cavity. 
 
 But when the head has not entirely passed the uterine orifice, 
 and when it is above the superior strait, the application of the rule 
 is useful. In fact, the forceps must then accommodate itself to 
 the direction of the two axes of the pelvis, by pushing the perine- 
 um backward (fig. 123, No. 2), and, consequently, the branches 
 must of necessity penetrate the uterus. 
 
 (16.) The tractions, as far as possible, should be made during 
 the pain, and always in the direction of the pelvic axes (fig. 123, 
 Nos. 1 and 2). 
 
 All these general rules will be more readily comprehended and 
 recollected when viewed in connexion with the special rules 
 adapted to each position of the head. 
 
 § 2. Position of the Female, and preliminary Precautions. 
 
 When the operation has been decided upon, the patient should 
 be placed in a convenient position. This varies according to 
 different countries ; the one usually adopted in France is the fol- 
 lowing : the female is placed across the bed, one of the sides of 
 which should be supported against the wall. Several pillows or 
 
 Rr 
 
314 OBSTETRICAL OPERATIONS. 
 
 cushions are piled between her back and the wall ; a board or 
 hard cushion is introduced under the upper mattress, so that the 
 breech may rest on it. It will also be well to place under the 
 breech, in order that it may not sink into the mattress, a linen fold- 
 ed eight double ; then we put under the patient a cloth extending 
 to the ground, which will receive the fluids that may escape from 
 the organs. The anterior commissure of the perineum should cor- 
 respond exactly with the border of the bed ; and if there should 
 be difficulty, the breech should be brought even beyond this point. 
 The inferior extremities are flexed, and covered each with a sheet, 
 and the heels rest on the knees of two assistants, seated on each side 
 of the patient, but sufficiently remote not to incommode the opera- 
 tor. A third assistant is placed near the patient, for the purpose 
 of encouraging her, and administering whatever may be necessary. 
 If the patient should be restless or intractable, another assistant 
 must steady the pelvis, to prevent any movements which might 
 interfere with the operation. This position is indispensable in most 
 cases ; and it is the more necessary, as the head is higher up in the 
 pelvis. When, however, the head is at the inferior strait, the ap- 
 plication of the forceps being generally very easy, any of the ar- 
 rangements calculated to alarm the patient may be dispensed with. 
 It will be sufficient to bring her to the extremity of the bed on 
 which she lies, taking the precaution to place a support under this 
 extremity, or directing the assistant to keep it steady. In this way, 
 the feet of the patient rest on the bed itself, and do not, therefore, 
 require to be supported. 
 
 In England, the female is delivered on her side, as in spontane- 
 ous labour. 
 
 In all cases, it will be the duty of the assistant to present the 
 branches of the forceps to the operator. 
 
 Finally, everything must be prepared which may be necessary 
 for the mother during the operation, or for the infant after its ex- 
 traction ; such as vinegar, salts, cold and warm water, a feather, 
 &c. (See Spontaneous Delivery.) 
 
 Napkins, oil, or some mucilaginous substance, together with a 
 pair of scissors, should also be placed at the side of the operator. 
 
 After all these precautions have been taken, the operation should 
 be commenced. 
 
 Almost all writers recommend a rule which I do not think it is 
 wise always to observe. They suggest that, before applying the 
 instrument, it should be shown to the patient, and its ingenious 
 mechanism explained to her. M. P. Dubois always adopts a con- 
 trary course ; and as for myself, I must confess that I do not fol- 
 low this precept in practice.* I think it is much more likely to 
 
 * The general precepts of our author with regard to the application of the forceps are 
 truly admirable, and well deserve the attention of the pupil. But I most decidedly differ 
 from him in regard to the furtive use of the instrument. Nothing, in my opinion, can jus- 
 tify the application of the forceps without previously obtaining the consent of the patient, 
 unless it should be that she is in a state of unconsciousness. I have never found any diffi- 
 culty in overcoming the prejudices or fears of my patient ; and when the use of the forceps 
 is indicated, it is far better that she should be apprized of the fact, and receive from the ac- 
 
THE FORCEPS. 315 
 
 alarm the patient than to tranquillize her, unless her mind should 
 be unusually firm. The sight of the instrument alone terrifies 
 most women ; they revolt at the idea of its application, and cannot 
 appreciate the perfection of an instrument which is to be employed 
 on themselves. Some, even, on beholding it, fall into convulsions. 
 
 The course which experience has taught me to be the most rea- 
 sonable is the following : keep the patient in ignorance of what 
 you are about to do, assure her that the hand alone will suffice, 
 conceal the instrument from her sight, and be careful not to make 
 any noise in locking the branches. With this view, the forceps 
 should be enveloped in a cloth, and placed on the floor at the foot 
 of the bed. 
 
 However, as Madame Lachapelle observes, this course will not 
 tranquillize a woman of great moral energy. The accoucheur, 
 therefore, must decide, from the character of his patient, the course 
 to be pursued. 
 
 Before placing the instrument in the cloth, the blades should be 
 properly warmed by putting them in warm water ; but it must be 
 ascertained that the temperature is not too high ; then they should 
 be well lubricated with some oily material. 
 
 § 3. Cases in which the Forceps should be employed. 
 
 In the enumeration which I have already made of the various 
 accidents capable of complicating labour, it will have been seen 
 that the use of the forceps is indicated under the following cir- 
 cumstances : 
 
 Disproportion between the dimensions of the head and those of 
 the pelvis, whether this disproportion refer to the size of the head 
 or to the contraction of the pelvis. 
 
 Accidents of a nature to compromise the life of the mother or 
 infant, when version is not practicable. 
 
 Inclined and irregular presentations of the vertex, which are not 
 corrected spontaneously, or which cannot be reduced by the hand 
 of the accoucheur. 
 
 Finally, anomalies in the movement of rotation of the head, inertia 
 of the womb, resistance of the external genital organs, whether the 
 head present first, or after the delivery of the trunk. 
 
 This instrument may, moreover, be applied when the head is 
 situated at the superior strait, after it has descended into the pelvic 
 cavity, or become arrested at the inferior strait, and also in all the 
 positions which the head can assume. Its application being the more 
 easy in proportion as the head has advanced, I will commence 
 with the vertex, the head being at the inferior strait, after having 
 executed its movement of rotation; and thence I shall proceed 
 
 coucheur an explanation of its modus operandi. Let her be assured that it is not a cutting 
 instrument, that it will prove harmless to her child, and that she herself will not be injured 
 by its judicious employment. I am in the habit of adopting a rule which I heard suggested 
 by my old master, the venerable Capuron ; it is this : I request the patient to put her two 
 hands together ; I then embrace them within the branches of the forceps, and make gentle 
 traction, and when she is informed that this is the manner in which the instrument will act 
 on the head of the child, she becomes quite easy in her mind, and consents at once to the 
 application. — Ed. 
 
316 OBSTETRICAL OPERATIONS. 
 
 with the use of the instrument, and point out its application in the 
 cavity, and at the superior strait. In this way, I will pass from 
 the simple to the more complex indications.* 
 
 § 4. Application of the Forceps in Presentation of the Vertex, the 
 Bead being at the Inferior Strait. 
 When the head has descended into the cavity, it may be in re- 
 
 * The pupil must remember that, occasionally, the use of the forceps will be indicated 
 when there is not the slighest disproportion between the foetus and maternal pelvis. The 
 labour, for example, may have been perfectly natural, and all things have gone on well 
 until the head reaches the inferior strait. At this stage of the labour, either convulsions, 
 hemorrhage, exhaustion, hernia, hemoptysis, rupture of the womb, &c., &c, may occur, 
 and render immediate delivery absolutely necessary. It is important that the rule for arti- 
 ficial delivery, under these circumstances, should be clearly understood, and that the les- 
 sons inculcated by some of the latest English writers on the subject should be suffered to 
 pass unheeded. I cannot but view the directions given by these authors, with regard to the 
 time of applying the forceps, as fraught with evil not only to the safety of both mother and 
 child, but also to the reputation of the accoucheur. Now, for example, let us take Dr. 
 Ramsbotham, one of the most recent authorities on the subject, and whose work is, no doubt, 
 in the hands of many of our American students. In speaking of the rules for the application 
 of the forceps (page 216), he says, " Before the forceps can be applied, the os uteri must be 
 entirely dilated, and the head must have come down into the pelvis sufficiently low to en- 
 able us to feel one or both ears distinctly. It is necessary to touch one or both ears, because they be- 
 come the guide to the proper adaptation of the blades." Again, at page 228, the same author ob- 
 serves, " If no progress have been made for a number of hours, and, especially, if impaction 
 should have existed for four hours, then, provided an ear can be felt, and the parts are not so 
 rigid as to endanger laceration, we are justified in employing the forceps." The underli- 
 ning here is my own, and I wish particularly to call the attention of the pupil to the words 
 as italicised. According to Dr. Ramsbotham, and almost all English authors agree with 
 him, the ear of the child's head must be felt before it would be justifiable to apply the for- 
 ceps. In the first place, I would observe that my own experience teaches me that it is not 
 an easy thing to reach the ear, even when the head is at the inferior strait ; and, secondly, 
 if the rule, as laid down by Dr. Ramsbotham, be adopted, fatal consequences must inevita- 
 bly frequently ensue to both mother and child. 
 
 To illustrate this point, let us suppose that the head is in the pelvic cavity ; the mother 
 suddenly becomes exhausted, either from hemorrhage, or the fatigue of antecedent effort. 
 No matter what the cause may be, she is exhausted, and immediate delivery is indicated. 
 The accoucheur introduces the finger, and endeavours to reach the ear ; he does not suc- 
 ceed ; the patient's situation becomes more and more alarming ; he again makes the at- 
 tempt to find the ear ; he fails ; he feels in his heart, indeed, everything clearly indicates 
 that the forceps should be applied, but he cannot reach the ear ; he delays, in the hope that " the 
 head may come down into the pelvis sufficiently low to enable him to feel one or both ears distinctly." 
 Alas ! this proves fallacious. The assistants supplicate him to do something to relieve the 
 patient, for they see she is dying ; and what will it avail, under these melancholy circum- 
 stances, for him to exclaim, " I can do nothing, for the ear of the child cannot be felt !" His 
 patient, of course, sinks, and here are two lives sacrificed because of a precept in which I 
 can see neither propriety nor meaning. Let it not be supposed that this is an overdrawn pic- 
 ture. Such results must inevitably ensue from an adherence to the rule to which I have 
 just alluded. When Dr. Ramsbotham says that " it is necessary to touch one or both ears, be- 
 cause they become the guide to the proper adaptation of the blades," he makes use of language 
 that, I must confess, surprises me not a little. If there be any meaning in what he says, 
 it is simply this, that unless the ears are felt, it will be impossible to know how to arrange 
 the blades of the forceps, because of the ignorance of the accoucheur as to the position of 
 the head. Admitting the truth of this author's reasoning, when the head is at the inferior 
 strait, which I most unequivocally deny, how is the position to be ascertained when the 
 head is still at the superior strait ? Certainly not by feeling the ears, for these cannot be 
 felt once in a thousand times, before the head has descended into the pelvic cavity. The 
 position of the head can be told both at the inferior and superior strait by the direction of 
 the fontanelles, sagittal suture, &c, &c. ; and these will indicate the manner of applying 
 the forceps, and of sel2mg*îh*e head in its bi-parietal measurement. 
 
 The rule, therefore, for the pupil to adopt, is to pay no regard either to the ear or the 
 length of time the head may have been in the excavation, but to proceed to artificial deliv- 
 ery the moment the life of either mother or child becomes seriously endangered. The very 
 essence of forceps delivery, that which commends it so strongly to the consideration of the 
 profession, is the ability with which it enables us to save both mother and child. There- 
 fore, if artificial delivery be indicated, have recourse to it before the life of the child has been sac- 
 rificed, or the vital force of the mother so far expended as to render her recovery extremely doubtful. 
 I do not advocate a meddlesome midwifery, but I do most strenuously recommend such an 
 application of the means put into our hands of affording relief as will achieve the maximum 
 of good to both mother and child. — Ed. 
 
THE FORCEPS. 317 
 
 lation with all the points of the circumference of this cavity. As, 
 in each of these positions, the particular rules for the application 
 of the forceps vary, we shall treat successively of the eight prin- 
 cipal positions : occipito-pubic, occipito- sacral, left anterior occipito- 
 iliac, right posterior occipito-iliac, right anterior occipito-iliac, left 
 posterior occipito-iliac ; finally, the transverse left and right occipi- 
 to-iliac. Before attempting to apply the forceps in the pelvic cavi- 
 ty, we should first ascertain whether the head has completely 
 passed the orifice of the uterus, or whether it has descended into 
 the cavity entirely covered by the inferior segment of this organ. 
 
 This precept is of essential moment, and yet it has been omitted 
 by certain authors ; and even those who have spoken of it have 
 done so without sufficiently insisting on its value. It frequently 
 happens that, from the commencement of labour, the head pushes 
 before it the inferior segment of the uterus, which is thin, and 
 the orifice of which is not dilated ; it moulds this segment on 
 itself, and if the accoucheur should not be aware of the possibility 
 of this accident, he may readily imagine that the head is naked, in- 
 asmuch as the thinness of the inferior wall of the uterus, which fa- 
 vours its propulsion and descent, enables him to feel distinctly the 
 bony resistance of the head, and often, even, the sutures and fonta- 
 nelles. 
 
 Now, if the accoucheur should arrive at the bedside of his pa- 
 tient at this period, he might suppose, in consequence of the descent 
 of the head, which he believes to be free or naked, that the labour is 
 much farther advanced than it is in reality ; and, again, the sojourn 
 of the head in the cavity until the dilatation shall have become 
 complete, may induce him to imagine that the labour is prolonged 
 by the resistance of the parts ; and he resolves on the use of the 
 forceps. Judge, therefore, of the evils that must result, if he seize 
 at the same time the head and inferior segment of the uterus. It 
 is only necessary to be advised of the possibility of this accident 
 to avoid it. If the accoucheur pass his finger carefully over the 
 tumour, he will readily perceive whether the head is naked or cov- 
 ered ; he will find the orifice thin and flattened on the head, and the 
 finger may enter it ; it will then be necessary to await its com- 
 plete dilatation. As soon, however, as this is accomplished, all in- 
 terference will be useless, for the head will pass the inferior strait 
 without difficulty. 
 
 Finally, the head may have partially passed the orifice, and be 
 encircled by it. In this case, the orifice is also very thin ; we must 
 be assured of this circumstance in order to guide properly the blades 
 within the orifice, and not carry them in the cul-de-sac of the 
 vagina. 
 
 In a word, before applying the forceps in the cavity, the condi- 
 tion and situation of the uterine orifice must be known. If it can 
 be readily reached with the extremity of the fingers, the branches 
 should be carefully directed to it ; then the blade should be passed 
 over the scalp of the head in order that it may penetrate the orifice. 
 If the extremity of the blade should engage in a fold of the scalp, 
 
318 OBSTETRICAL OPERATIONS. 
 
 it should be carried slightly outward, and then its introduction 
 should be continued. It' the orifice cannot be reached, it must be 
 ascertained whether the head is entirely free, or whether it has 
 pushed before it the thin and undilated inferior segment of the 
 uterus. 
 
 Operation in the Occipito-pubic Position. 
 
 The finger can readily distinguish the situation of the head ; the 
 posterior fontanelle occupies the centre of the vulva ; the sagittal 
 suture is directed from above downward and from before back- 
 ward ; the occiput is consequently under the pubes, and the forehead 
 in the concavity of the sacrum ; the two sides of the head corre- 
 spond to the sides of the pelvis. 
 
 The head is retained in the genital organs, either in consequence 
 of inertia of the womb, a slight contraction of the inferior strait 
 (rare), or of the resistance of the parts themselves. This circum- 
 stance is, of all others, the most frequent. 
 
 In order that the head may be grasped by its bi-parietal diame- 
 ter, the two blades should be placed on the sides of the pelvis, along 
 the two extremities of the transverse diameter. As they occupy 
 an analogous situation, one to the left, and the other to the right, 
 it is a matter of indifference which is introduced first ; one is as 
 easily applied as the other ; but, in order to avoid crossing, we 
 should commence with the pivot branch. 
 
 The operator rests himself on one knee ;* he then oils the pal- 
 mar and dorsal surface of the right hand, and introduces it entire, 
 except the thumb, into the maternal organs, posteriorly in the con- 
 cavity of the sacrum, and in the direction of the left sacro-ischiatic 
 ligament ; with this hand he again satisfies himself as to the situa- 
 tion of the head and uterine orifice ; and if the orifice have accom- 
 panied the head low down, which is rare when it is retained in the 
 genital organs, the extremity of the fingers should be carefully in- 
 troduced within it. In order to conduct the extremity of the blade 
 within the orifice, the pivot branch must be held with the left hand, 
 as we would hold a pen ; then resting it obliquely on the right groin 
 of the patient, it should be made to penetrate the vulva in the di- 
 rection of its axis, sliding along the palmar surface of the right 
 hand, and supporting the extremity of the blade on the head of the 
 foetus ; in proportion as the branch is introduced, the handle of the 
 instrument must be gradually depressed between the thighs of the 
 patient, bringing it towards the median line, and, at the same time, 
 with the hand already introduced, the extremity of the blade should 
 be made to execute a slight movement of the fourth of a circle, 
 which will place it on the side of the pelvis, where it is to remain. 
 
 This branch thus applied is to be intrusted to an assistant, who 
 maintains it in its situation with one hand passed under the thigh 
 
 * It will be found much more convenient for the accoucheur, and certainly much more 
 agreeable to the patient, if he will seat himself on a chair instead of resting on his knee. 
 The chair should stand so as to enable the accoucheur to be placed between the thighs 
 of the patient ; and the assistants, seated on each side, must take care not to crowd him. 
 —Ed. 
 
THE FORCEPS. 
 (Fig. 124.) 
 
 319 
 
 of the patient, and arranged in such manner as not to embarrass 
 the operator. 
 
 The assistant must be instructed not to approximate the handle 
 of the blade introduced to the left thigh, for it would then act as 
 a lever, throwing the head to the right, and preventing the adjust- 
 ment of the second blade, which should be directed to the right 
 side. 
 
 Before proceeding to the application of the second or mortise 
 branch, the accoucheur should lubricate his left hand, and not for- 
 get to dry properly his right hand, which is to hold the branch, in 
 order that the handle of the instrument may not slip between his 
 fingers. 
 
 The left hand introduced into the vagina serves as a conductor 
 for the mortise branch, which is held with the right hand, and in- 
 troduced, like the preceding, at first posteriorly and to the right, 
 then brought to the side of the pelvis by the left hand, which ele- 
 vates the blade, while the right hand depresses the handle. 
 
 Occasionally, in applying the second branch, we can only intro- 
 duce a few fingers of the left hand, which renders the adjustment 
 of this branch less certain. The accoucheur, under these circum- 
 stances, should be exceedingly guarded, and glide as exactly as 
 possible the extremity of the blade over the scalp of the foetus. 
 The mortise branch being properly introduced, the accoucheur 
 rises and stands up ; # he then seizes the branches with the corre- 
 sponding hands (the pivot branch with the left hand, the mortise 
 branch with the right), and places them parallel to each other, 
 bringing the pivot towards the mortise, and articulating them. 
 
 * There is no necessity for the accoucheur to rise. He should, on the contrary, retain 
 his seat, and proceed to the completion of the operation with as little disturbance as possible. 
 Many patients are very easily alarmed ; and the more tranquilly the accoucheur performs 
 his duties, the more gratefully will they be acknowledged. — Ed. 
 
320 
 
 OBSTETRICAL OPERATIONS. 
 (Fig. 125.) 
 
 When the two branches are placed at the same height, exactly- 
 parallel to each other, and the mortise branch is over the pivot 
 branch, the articulation is quite easy ; as soon as the pivot has en- 
 tered the mortise, the assistant turns it, and the junction of the two 
 branches is complete. 
 
 The accoucheur then seizes the forceps, the left hand being above 
 and near the articulation, the right hand below, at the extremity of 
 the handles, with the thumb to the right of the patient; then, by the 
 aid of slight lateral movements, combined with a movement of direct 
 traction, following the axis of the inferior strait, he draws on the 
 head from below upward, elevating the handle of the instrument 
 towards the pubes,from to I, in proportion as the head engages 
 in the inferior* strait ; these tractions should be made during the 
 
 * I have seen persons apply the forceps ; and, after having introduced them with tolerable 
 dexterity, fail in extracting the head, simply because of the rude and unskilful manner in 
 which they attempted to pull upon it. The lateral movement imparted to the forceps by the 
 accoucheur is most important, and should never be omitted ; for if only direct force be em- 
 ployed, the delivery will not only be tedious and unnecessarily painful, but the head of the 
 child may be seriously endangered. Therefore, after the instrument has been properly ap- 
 plied, and the joint articulated, the accoucheur should, during a pain, commence his tractions 
 with a lateral sweep of the forceps, at the same time using a certain degree of direct force ; 
 and this lateral and extractive traction must be combined until the delivery of the head is 
 completed. The force employed should be two thirds lateral and one third extractive. The 
 advantage of this degree of combination will be made manifest when practising on the man- 
 akin. And I cannot too strongly impress on the pupil the value of this machine. To become 
 a dexterous and safe obstetric operator, two things are necessary, and they are so essentially 
 material that, if they be neglected, failure must often be the result. In the first place, the 
 accoucheur should have a clear perception of the principles on which rests the mechanism 
 of natural labour. And, secondly, he should reduce those principles to practice on the man- 
 akin. The manakin is as important to the obstetricianas the cadaver to the operative surgeon ; 
 and if practitioners could be made to appreciate the benefits to be derived from practising on 
 it, much good would necessarily result to those who, in the hour of their peril, need not onto 
 the sympathy, but the consummate skill of their medical attendant. — Ed. 
 
THE FORCEPS. 
 
 321 
 
 pains, if there be any ; the patient, too, should be requested to bear 
 down in order to assist in the extraction of the head. But when 
 the perineum begins to distend, it should be well supported, and the 
 patient desist from all effort, and the accoucheur himself should 
 cease his tractions ; indeed, if the contractions be energetic, and 
 the female experience an uncontrollable necessity to bear down, 
 the forceps should retain the head in place, and not extract it. 
 
 Without these indispensable precautions, the head might be ex- 
 pelled too rapidly, and more or less injury occur to the genital or- 
 gans. 
 
 (Fig. 126.) 
 
 In this operation, we should simulate the course of nature in spon- 
 taneous delivery, in which the head does not pass the orifice of the 
 vulva suddenly, but after repeated and successive efforts, thus pro- 
 ducing a gradual dilatation of the orifice. This wise provision of 
 nature should serve as a guide to the operator in all cases, and 
 more especially in a primipara. 
 
 Thus, after this first period of repose, the accoucheur should 
 
 The direction of our author with regard to the elevation of the handle of the forceps in 
 proportion as the head distends the perineum should, on no account, be lost sight of. The 
 object of the elevation is to bring the chin from the sternum, or, in other words, to effect the 
 movement of extension, and this can only be done (when the occiput is under the symphysis 
 pubis) by raising the handle of the instrument as the head advances ; and when the head is 
 completely out of the vulva, the handle of the forceps will describe a right angle with the 
 abdomen of the mother. — Ed. 
 
 Ss 
 
322 
 
 OBSTETRICAL OPERATIONS. 
 
 renew his tractions, or permit the efforts of the uterus to cause the 
 head to progress ; then he must again support it, and recommend 
 the patient not to press down ; the perineum should also be prop- 
 erly sustained. Finally, after four or five successive periods of 
 rest like this, during which the parts become gradually accustom- 
 ed to the presence of the head, which dilates them little by little, 
 the operator should complete the extraction with great care. With 
 this view, he should raise the handle of the forceps towards the 
 abdomen of the mother ; and at this moment the perineum requires 
 to be very accurately supported by an assistant. 
 
 If there should be no one present of sufficient intelligence to 
 perform this duty, the forceps should be held with the left hand 
 passed over the right thigh of the patient ; and the accoucheur, 
 standing on the right side, should, with the other hand carried under 
 the right thigh, support the perineum himself. 
 
 (Fig. 127.) 
 
 
 It is only with these wise precautions and careful manner of pro- 
 ceeding that the soft parts can be protected from harm. If the 
 head be extracted too rapidly, the perineum, even if it should be 
 supported, will still be more or less seriously injured ; the external 
 fibres of the sphincter ani, and even the intestine itself, may par- 
 ticipate in this laceration. I have already alluded to the melan- 
 choly consequences of this accident, rendering the unfortunate suf- 
 ferer an object loathsome to herself and friends, and at once de- 
 
■ 
 
 THE FORCEPS. 323 
 
 stroying all physical and moral comfort. Thus, these precautions 
 cannot be too rigidly insisted upon, in order that the patient may 
 be protected against these effects, and the young practitioner saved 
 the mortification of occasioning them. Unfortunately, these oc- 
 currences are not rare, and yet in no work are they sufficiently 
 set forth. 
 
 All practitioners know, however, the difficulty they encountered, 
 in their first use of the forceps, in resisting the impatience they 
 experienced to terminate the delivery rapidly ; an impatience in- 
 creased by the cries and supplications of the female, and the im- 
 portunities of the assistants. They understand, too, how impor- 
 tant it is to admonish young practitioners on this subject. 
 
 It must also be admitted that, notwithstanding all imaginable 
 care, lacerations of the perineum will sometimes occur. The peri- 
 neum is occasionally so weak, inelastic, and, if I may be permitted 
 the expression, so friable, that it has no power of itself to resist the 
 passage of the head ; and we should, in this case, be the more vigi- 
 lant. In a female whom M. P. Dubois was obliged to deliver with 
 instruments, on account of inertia of the womb, the perineum ex- 
 hibited all these characters ; and, in defiance of every precaution, 
 it was lacerated in a small portion of its extent. 
 
 Sometimes, also, the perineum is so resisting that extraction of 
 the fœtus, rendered necessary by inertia, cannot possibly be ac- 
 complished without resulting in laceration. Under these circum- 
 stances, it would be proper, since the passage must be enlarged, to 
 make a small incision on the right or left side of the perineum, rath- 
 er than expose it to rupture. In fact, spontaneous laceration of 
 the perineum always takes place on the median line, and if it should 
 extend to a certain distance in this direction, it may involve the 
 anus ; while a lateral incision may be enlarged by the passage of 
 the head, without compromising any essential part. I have seen 
 M. P. Dubois have recourse to this alternative ; the incision healed 
 perfectly, without leaving the slightest trace, and this is what usu- 
 ally occurs. 
 
 After the head is delivered, the instrument should be removed 
 by separating the blades. If there should be contractions, the 
 expulsion of the shoulders will not be long delayed ; but should 
 there be inertia, it will be necessary to make slight tractions on the 
 head, favouring the movement of external rotation, the occiput to- 
 wards the left thigh, if the primitive position were the left occipito- 
 iliac, towards the right thigh in the contrary case. 
 
 If this rotation cannot be effected without great difficulty, or if, 
 notwithstanding its accomplishment, the shoulders resist the trac- 
 tions, the accoucheur must introduce the index finger of the right 
 hand over the hollow of the axilla situated on the left of the wom- 
 an, and the index finger of the left hand under the hollow of the 
 axilla on the right ; then the index finger of the right hand should 
 be depressed, while that of the left is elevated. By this contrary 
 movement, the right index finger will bring into the concavity of the 
 sacrum the shoulder situated on the left of the pelvis, while the left 
 
324 
 
 OBSTETRICAL OPERATIONS. 
 
 index finger places under the pubes the shoulder, which was on the 
 right of the pelvis. The delivery, in this case, must be the more 
 expeditious, as the labour may have been more protracted, or the 
 danger of the child more imminent. 
 
 Operation in the Occipito-sacral Position. 
 
 The occiput, in this position, is in the cavity of the sacrum ; the 
 forehead is placed under the pubes, and the two sides of the head 
 correspond to the two sides of the pelvis. 
 
 In this case, the occiput should be disengaged posteriorly. The 
 application is precisely the same as in the preceding position ; the 
 disengagement alone varies. 
 
 In this position, at the moment of spontaneous expulsion, the 
 head is very much flexed ; the occiput and forehead pass out si- 
 multaneously, the forehead under the pubes, the occiput in the an- 
 terior commissure of the perineum. To arrive at this result in the 
 extraction of the head, the accoucheur must commence by raising 
 the handle of the forceps from O to I, at the same time that he 
 makes direct tractions ; and when the occiput is about passing 
 the commissure of the perineum, he must cease his tractions, and 
 depress the instrument from I to A, in order to disengage the fore- 
 head and face from under the symphysis pubis. 
 
 The perineum should be strictly attended to, for it encounters 
 much more danger here than in the preceding case. 
 
 (Fig. 128.) 
 
 Operation in the Left Anterior Occipito-iliac Position. 
 
 In this position, the occiput is to the left and in front, behind the co- 
 tyloid cavity ; the forehead rests on the right sacro-iliac symphy- 
 sis ; the right side of the head corresponds to the right cotyloid 
 cavity ; the left side to the left sacro-iliac symphysis. 
 
 In order to seize the head in its bi- parietal diameter, one branch 
 should be placed in front and to the right, the other posteriorly and 
 to the left. To avoid all error, the accoucheur should ask himself 
 which part of the head is to be brought under the pubes. In the 
 presentation of the vertex, that portion of the head corresponding 
 to the front of the pelvis should always be brought under the pubes ; 
 now, as the occiput lies behind the cotyloid cavity, it is to the left 
 and in front, and should, therefore, be placed under the pubes. For 
 
THE FORCEPS. 325 
 
 this purpose, the concavity of the borders of the instrument, after 
 being applied, should regard the occiput and the left cotyloid 
 cavity. 
 
 But, before introducing the branches, in order exactly to under- 
 stand how they should be placed (which in front, and which pos- 
 teriorly), we should present the instrument already articulated in 
 the situation it is to assume after it is applied. In this case, the 
 concavity of the borders must look to the left and in front. Then, 
 without changing the direction of the forceps, we disarticulate the 
 instrument, and see that the pivot branch should be placed pos- 
 teriorly and to the left of the pelvis, and the mortise branch in 
 front and to the right. 
 
 After previously introducing the right hand into the concavity 
 of the perineum, the accoucheur seizes the pivot branch with the 
 left hand, and introduces it by gliding it on the right hand, and 
 directs it to the left sacro-iliac symphysis. This branch must not 
 be brought on the side of the pelvis, as in the preceding cases. In 
 proportion as the branch penetrates, he depresses slowly the han- 
 dle, and confides it to an assistant, who must retain it carefully in 
 this exact situation. 
 
 The mortise branch must be placed in front, and to the right of 
 the pelvis, behind the right cotyloid cavity, with which the right 
 side of the head corresponds. This branch is seized with the right 
 hand, and glided on the left hand previously introduced into the 
 parts, towards the right sacro-iliac symphysis. In proportion as 
 it enters, the left hand, on which the blade is applied, must bring it, 
 by a spiral movement, from below upward, to the situation it is de- 
 finitively to occupy, behind the right cotyloid cavity. During this 
 time, the right hand, changing gradually its situation and grasping 
 the branch above, depresses the handle of the instrument towards 
 the left thigh of the female. The mortise branch having been ap- 
 plied the second on the pivot branch, the articulation is easy, for 
 there is no crossing. The articulation should always be made 
 with great caution, and not in a hurried manner; as soon as it is 
 accomplished, a rotatory movement* from left to right should be 
 
 * When the head is in the diagonal position, and the use of the forceps is indicated, it is of 
 essential moment to bear in mind the direction of Dr. Chailly as to the rotatory movement to 
 be effected on it. Indeed, if direct traction were made as soon as the instrument is applied, 
 without previously changing the position of the head, it would not only be physically impos- 
 sible to extract it (for, occupying as it does the diagonal position, its disproportion to the di- 
 mensions of the pelvis renders its delivery a thing out of the question), but the soft parts of the 
 mother would be more or less lacerated, and the severe pressure exerted on the head by 
 the unavailing efforts of the accoucheur would most probably sacrifice the child. It occa- 
 sionally occurs that labour proceeds auspiciously, and there is no difficulty until the head 
 has descended into the pelvic cavity ; here, in consequence of some impediment to the 
 movement of rotation, the head becomes arrested ; and, notwithstanding the strong expul- 
 sive efforts of the womb, there is no progress in the delivery. The strength of the mother 
 becomes exhausted, and the undue pressure on the soft parts may result in recto or vesico- 
 vaginal fistulae, in severe inflammation of the vagina, &c, &c, to say nothing of the al- 
 most certain death of the child, should the cause of the difficulty escape the attention of 
 the accoucheur. If, therefore, a case of this kind should present itself, and after delaying 
 a reasonable time for nature to overcome the difficulty, should she fail, the accoucheur 
 should proceed at once to instrumental delivery. Do not wait until the child is sacrificed, 
 and the soft parts of the mother seriously injured ; but as soon as nature has declared her 
 incompetence to afford the necessary relief, let the accoucheur demonstrate that, in the 
 hour of need, he can act as nature's substitute, and rescue both mother and child from 
 
326 OBSTETRICAL OPERATIONS. 
 
 gently imparted to the instrument, in order to bring simultaneously 
 under the pubes the occiput and the concavity of the borders of the 
 instrument, and the head is then disengaged in the occipito-pubic 
 position. 
 
 (Fig. 129.) 
 
 
 Exceptions. — Two exceptions may be noted in this case. It 
 may happen that, in introducing the pivot branch first, which is 
 the most easy to apply, because it is posteriorly, we may render 
 more difficult the spiral movement which the second branch should 
 execute, in order to place itself in front and to the right. It must 
 be remembered that the branch which is to be in front is much 
 more difficult to place than that which is to be posterior. 
 
 It may also occur that this difficulty will be experienced even in 
 commencing with the branch which is to be above. In this case, 
 it will sometimes be found more easy to pass this branch directly 
 to the point which it is ultimately to occupy. Should this attempt 
 prove useless, we shall then be compelled to withdraw the pivot 
 branch, which has been introduced first posteriorly and to the left, 
 
 their perils. To do this, however, requires a profound knowledge, an intimate acquaintance 
 with the principles of his art. 
 
 February 23d, 1842, I was requested by a gentleman of this city to hasten to his house, 
 to meet his family physician, Dr. Andreas, in consultation. This gentleman's wife had 
 been in severe labour for thirty hours, and had received from the doctor every mark of 
 kindness and attention. Her pains had been severe ; and at the commencement of labour 
 the mouth of the womb dilated, the head began to descend, and there was reason to be- 
 lieve (as the .doctor informed me) that the delivery would soon be completed. When, how- 
 ever, the head reached the pelvic cavity, it became arrested there, although there was no 
 diminution in the pains, or in the force of uterine contraction. The lady, naturally of a 
 delicate constitution, suffered severely from the constant action of the womb, and her 
 strength began to fail her. On making an examination per vaginam, I found the head occu- 
 pying the cavity diagonally ; there was much heat in the vagina, and the scalp somewhat 
 corrugated. Immediate delivery was indicated ; for it was evident that nature had been 
 foiled in rotating the head, and the exhausted condition of the mother, together with the 
 hazard incurred by the child, evidently pointed out the indication to be fulfilled. The doc- 
 tor concurred in this view, and, at his request, I introduced the forceps. As soon as the 
 instrument was articulated, I brought the occiput under the pubes by rotating the head, and 
 delivered the lady of a living daughter ; a circumstance which, although unexpected, was 
 welcomed with all that warmth of love which only a mother can exhibit. 
 
 At this period puerperal fever prevailed to an alarming extent in this city ; and this lady, 
 on the second day after delivery, was attacked with it ; she was dangerously ill, but recov- 
 ered. She and her little daughter are now in excellent health. — Ed. 
 
THE FORCEPS. 327 
 
 in order that more space may be gained in the cavity to place 
 the mortise branch first in front and to the right. 
 
 But then, the pivot branch being applied the second will be found 
 above the mortise branch, and it will be necessary to cross the 
 branches in order to articulate them ; that is, to pass under the 
 mortise the pivot branch, which is above it ; unless, however, we 
 are enabled to introduce the pivot branch under the mortise branch, 
 which is rarely possible, on account of the resistance of the peri- 
 neum. 
 
 Madame Lachapelle establishes the general rule, that the branch 
 which is to be in front of the pelvis should always be introduced 
 first, because it is the most difficult. This precept, excellent in 
 itself, has, however, the inconvenience of rendering it necessary to 
 cross the branches in all cases in which the part to be brought 
 under the pubes corresponds to the left anterior fourth of the pelvis. 
 Moreover, this procedure, to which we are seldom obliged to have 
 recourse, differs from the general rule I have given (to introduce 
 the pivot branch first) only where the occiput or forehead corre- 
 sponds to the left and front of the pelvis ; with this exception, there 
 is perfect agreement between the general precepts of this celebra- 
 ted sage-femme and myself, in all cases in which the part to be 
 brought under the pubes corresponds to the right anterior fourth of 
 the pelvis. In this case, also, when the introduction of the forceps 
 has stimulated the uterine contractions, or when art has been obli- 
 ged to interfere for some irregularity in the movement of rotation, 
 or for any other accident, without inertia uteri, Madame Lacha- 
 pelle has recommended, in order to protect the perineum, to with- 
 draw the instrument after the rotation has been completed, and 
 to commit the expulsion of the head to the spontaneous efforts of 
 nature. 
 
 This suggestion is excellent where the head, badly seized, pre- 
 sents at the vulva with unfavourable diameters ; but it is without 
 value when the head is grasped in its bi-parietal diameter. In a 
 word, if the perineum have such little power of resistance as to rup- 
 ture when the head is regularly seized, and notwithstanding the 
 precautions I have already indicated, it would also rupture with 
 equal facility if the head were expelled naturally. The recommend- 
 ation of Madame Lachapelle is also attended with inconvenience 
 to the accoucheur. Thus, suppose, for example, that after the for- 
 ceps is withdrawn, and the rotation of the head shall have been com- 
 pleted, the contractions should cease or become insufficient (which 
 will often happen under these circumstances), it will become ne- 
 cessary to reapply the instrument, in order to extract the fœtus. 
 
 This second operation may give rise to suspicion in the minds 
 of the assistants, not always competent to judge rightly of these 
 matters, that the first failed, and may induce them to speak dispar- 
 agingly of the accoucheur. 
 
 It therefore appears to me, in view of these facts, much more 
 proper, in this case, to increase our vigilance and usual caution, 
 rather than withdraw the forceps. 
 
328 OBSTETRICAL OPERATIONS. 
 
 However, if there should be strong uterine contraction, on which 
 we might calculate with certainty, we might, although the head 
 was properly seized, remove the instrument, and confide the ex- 
 pulsion to nature. In withdrawing the branches, they must be 
 made to pursue the same route as when introduced. 
 
 Operation in the Right Posterior Occipito-iliac Position. 
 
 The application of the forceps is exactly the same as in the pre- 
 ceding case, although the position is precisely the reverse. The 
 occiput being posteriorly and to the right, cannot be brought in 
 front, which, however, occurs in spontaneous expulsion ; but it is 
 the forehead which, being to the left and in front, is to be conducted 
 under the pubes. 
 
 The curvature of the borders of the instrument should, there- 
 fore, be directed to the left and in front, &c. The forehead is to be 
 brought under the pubes by the same movement of rotation that ser- 
 ved to place the occiput there in the preceding case. Finally, the 
 head must be disengaged, as in the occipito-posterior position, that is 
 to say, by making traction at first upward, and then slightly down- 
 ward, in order to bring the forehead and face from under the pubes. 
 So far, in the application of the forceps, it will be seen that, in order 
 to extract the foetus, I have imitated, artificially, the process which 
 nature employs to expel it. Here commences the first exception, 
 for the means which I have at my disposition, in the present case, 
 are insufficient to reproduce exactly the natural mechanism. 
 
 In a word, in the spontaneous expulsion, the occiput leaves the 
 right sacro-iliac symphysis, and passes in front by means of an 
 extended rotatory movement, in which the trunk participates almost 
 entirely. Now, if I endeavour, by means of the forceps, to accom- 
 plish tho same object, I would contort the neck in most cases, be- 
 cause the trunk, held by the retraction of the uterus, would not fol- 
 low the rotation of the head, and this torsion, exceeding the fourth 
 of a circle, would compromise the infant's life. Again, to bring the 
 occiput forward by causing it to traverse the entire right lateral 
 wall of the pelvis, it would be necessary, at the time of applying 
 the forceps, in order to seize the head in its bi-parietal diameter, 
 to direct the curvature of the instrument posteriorly, which is im- 
 possible ; or to embrace the head very irregularly, by placing one 
 branch under the pubes, the other in the cavity of the sacrum, 
 which is scarcely ever practicable, even in the cavity (see Trans- 
 verse Positions), and which would also be attended with inconve- 
 nience to the mother. 
 
 The disengagement in the occipito-posterior position being much 
 more natural, easy, and advantageous to the child, we should de- 
 part from the rules traced out by nature, and carry the occiput pos- 
 teriorly ; we do this in bringing under the pubes the forehead, which 
 is to the left and in front. 
 
 Operation in the Right Anterior Occipito-iliac Position. 
 The occiput is to the right and in front, behind the right coty- 
 
THE FORCEPS. 
 (Fig. 130.) 
 
 329 
 
 loid cavity ; the forehead is posteriorly and to the left, on the left 
 sacro-iliac symphysis ; the occiput, in this case, must be brought 
 in front. We should, therefore, direct the curvature of the borders 
 of the instrument towards the occiput, that is, to the right and in 
 front, and the pivot branch should be grasped with the left hand, 
 and introduced on the left sacro-iliac symphysis, and then brought 
 by a spiral movement, above and to the left, behind the left cotyloid 
 cavity ; the mortise branch, held with the right hand, is introduced 
 to the right and posteriorly on the sacro-iliac articulation, and re- 
 mains there. The mortise being placed on the pivot, there is no 
 crossing ; the movement of rotation will be from right to left, &c. 
 Hence Madame Lachapelle's rule is followed : to apply first the 
 branch which is to be placed above. 
 
 (Fig. 131.) 
 
 Operation in the Left Posterior Occipito-iliac Position. 
 In this position, which is the reverse of the preceding, the fore- 
 head corresponds to the right cotyloid cavity, and the occiput to 
 the left sacro-iliac symphysis. The application of the forceps will 
 be the same as in the preceding case ; the movement of rotation, 
 
 Tt 
 
330 
 
 OBSTETRICAL OPERATIONS. 
 
 also, will be accomplished in the same manner, from right to left, 
 only the forehead is brought under the pubes instead of the occiput, 
 which passes to the concavity of the sacrum. 
 
 (Fig. 132.) 
 
 U. v k ) 
 
 But the disengagement of the head varies, as in all cases in 
 which the occiput is posteriorly ; elevate, in the first place, in order 
 to disengage the occiput, then depress to bring the forehead and 
 face under the pubes. 
 
 Operation in the Left Transverse Occipito-iliac Position. 
 In this position, one of the sides of the head is in exact relation 
 with the posterior portion of the symphysis pubis, the other side 
 regards the sacrum ; the occiput corresponds to the left of the pel- 
 vis, the forehead to the right. Which portion of the head should 
 be brought under the pubes ? Is it the occiput or forehead ? These 
 two parts are at equal distances from the symphysis pubis ; and 
 whether the forehead or occiput be placed under the pubes, the 
 movement of rotation will be as extensive in one case as in the 
 other; but the occipito-anterior disengagement being easier, and 
 more favourable for both mother and child, as we have the choice, 
 we should certainly bring the occiput under the pubes. 
 
 (Fig. 133.) 
 
THE FORCEPS. 
 
 331 
 
 The occiput corresponds to the left of the pelvis ; the concavity 
 of the borders must be directed to the left of the mother. Then, 
 in disarticulating the instrument, the accoucheur will perceive that 
 the mortise branch is above, and the pivot branch below. Now, in 
 order to seize the head in its bi-parietal diameter, one of the blades, 
 that of the mortise branch, must be placed under the pubes, while 
 the other is introduced in the concavity of the sacrum. 
 
 The pivot branch, therefore, is taken with the left hand and car- 
 ried directly to the concavity of the sacrum ; so far, the operation is 
 extremely easy. Then the mortise branch, held with the right hand, 
 is at first introduced to the right, in the direction of the sacro-iliac 
 symphysis of this side, and brought gradually, by a very extended 
 spiral movement, directly under the pubes. This second part of 
 the operation is extremely difficult to perform ; it is often impossible 
 to place this mortise branch under the pubes, no matter what plan 
 may be adopted, whether by a spiral movement, or by attempts to 
 introduce it directly under the pubes. 
 
 If, however, we should succeed in embracing the head in its bi- 
 parietal diameter, as soon as the forceps is articulated, we should 
 rotate the head from left to right, by which means the occiput will 
 be brought under the pubes ; then we proceed with the extraction. 
 
 Operation in the Right Transverse Occipito-iliac Position. 
 In this position, the opposite of the preceding, the occiput corre- 
 sponds to the right of the pelvis ; the concavity of the borders will 
 be directed to the right ; the pivot branch, introduced on the left 
 sacro-sciatic ligament, is brought under the pubes ; the mortise 
 branch is placed immediately in the concavity of the sacrum ; the 
 movement of rotation will be from right to left. 
 
 (Fig. 134.) 
 
 Exceptions. — The application of the forceps in these positions 
 can scarcely ever be made regularly, even when the head has 
 descended low in the pelvic cavity ; and. as I have just remarked, 
 this difficulty depends on the introduction of the branch which 
 should be under the pubes. It is so embarrassing that, in the ma- 
 jority of cases, it cannot be accomplished. Two circumstances 
 may then arise: 
 
332 OBSTETRICAL OPERATIONS. 
 
 1st. If this anterior branch can be brought only behind one of the 
 cotyloid cavities, as in the diagonal positions, it will not correspond 
 with the other branch, which has been placed directly in the con- 
 cavity of the sacrum ; therefore, to make them parallel, this pos- 
 terior branch must be reduced to a diagonal position. Suppose 
 that, in this case, the head should be placed in the left transverse 
 occipito-iliac position, the mortise branch being behind the right 
 cotyloid cavity, it will be necessary to bring to the left sacro-iliac 
 symphysis the pivot branch, which is posteriorly, otherwise the in- 
 strument could not be articulated. The head, although transverse, 
 will then be seized as if it were diagonal, the mortise branch cor- 
 responding to one of the sides of the os frontis, and- the pivot to the 
 opposite lamdoidal suture ; the head is embraced in the forceps 
 from one frontal protuberance to the opposite occipital protuberance 
 (fig. 135), and by a diameter less favourable to the delivery than 
 the bi-parietal diameter. However, in most cases, the disengage- 
 ment will be accomplished. In a word, one of two things may 
 take place : either the head may turn in the instrument at the time 
 of its articulation, and, from being transverse, become diagonal, 
 and then the delivery will be as easy as in a diagonal position ; or 
 it remains transverse (fig. 135), while the forceps can only be ap- 
 plied diagonally. Then, after having articulated the branches, a 
 movement of rotation is imparted to the forceps, which brings the 
 concavity of the borders of the instrument under the pubes, but only 
 places the occiput behind the left cotyloid cavity. It is rare, how- 
 ever, for the disengagement of the head to take place in the diagonal 
 position ; for this purpose, the rotation of the occiput must be com- 
 plete ; it must, therefore, be accomplished. For this, the accou- 
 cheur increases the rotation of the forceps, in order to complete 
 that of the head ; that is, he directs the concavity of the borders 
 of the instrument to the right. If the perineum should offer much 
 resistance, and there be energetic uterine contractions on which we 
 may rely, it will be prudent to withdraw the instrument, if the head 
 have nothing to overcome but the resistance of the external parts. 
 If, in this same case, there should be no uterine effort, after having 
 brought the occiput under the pubes by an exaggerated movement 
 of rotation, the branches should be disarticulated, in order that they 
 may be withdrawn and reapplied on the sides of the head ; or, 
 after separating, but without withdrawing them, they may be placed 
 in this situation by depressing one, and elevating the other. 
 
 2d. Finally, it may happen, in the transverse positions, as it often 
 does in the diagonal, that it is not possible to place the forceps di- 
 agonally ; and that the instrument can only be applied as if the head 
 were in the antero-posterior position, one branch to the left, the 
 other to thé right. It will be evident that, in this case, the head 
 being transverse, it will be seized from the forehead to the occiput 
 (fig. 136). 
 
 In order, then, to bring the occiput under the pubes, we should 
 direct the concavity of the borders of the instrument to the right, in 
 the left transverse occipito-iliac position, and to the left in the oppo- 
 
THE FORCEPS. 
 (Fig. 135.) 
 
 site position ; then, if there be contractions, the instrument should be 
 withdrawn, and the expulsion confined to nature ; for, in this case, it 
 would be hazardous to disengage the head, having one branch under 
 the pubes, and the other in the concavity of the sacrum. If there 
 should be no contractions, we may reapply the forceps regularly 
 on the sides of the pelvis, either by first withdrawing the instru- 
 ment, or conducting the branches to this situation without remo- 
 ving them : this latter mode of procedure will often present difficul- 
 ties, and the branches cannot be introduced with the same certainty. 
 Finally, we should never extract the head, in this irregular appli- 
 cation of the forceps, unless the parts should be very extensible, 
 and the head small and reducible. 
 
 (Fig. 136.) 
 
 Particular Rules for the Application of the Forceps, the Head being 
 in the Pelvic Cavity, and the Position unknown. 
 
 The accoucheur may be called to apply the forceps when the 
 head, having remained for a long time in the cavity, has become 
 the seat of a large sanguineous tumour, which conceals the char- 
 acters of the position. Under these circumstances, auscultation 
 
334 OBSTETRICAL OPERATIONS. 
 
 will prove of great value ; for, if the summum of intensity of the 
 pulsations of the fœtal heart should be heard directly in front, it will 
 be either an occipito-pubic or an occipito-sacral position ; and, in this 
 case, the application of the forceps will be the same. If the sum- 
 mum of intensity be to the left, there will be every reason to believe 
 that it is a left anterior occipito-iliac position, which is much more 
 frequent than the left posterior ; if to the right, it is more than prob- 
 able that it is a right anterior occipito-iliac position, for this, after 
 the descent of the head, is more frequent than the posterior posi- 
 tion ; the contrary, however, is observed at the superior strait. In 
 a word, it will also, in some cases, be possible to ascertain more 
 exactly the position, and to know whether the occiput is in front 
 and to the left, posteriorly and to the left, in front and to the right, 
 or posteriorly and to the right. I must admit, however, that this 
 has always appeared to me very difficult ; and I am of opinion 
 that it will be impossible to distinguish, in most cases, the diagonal 
 from the transverse positions. 
 
 If, therefore, the pulsations of the foetal heart should be heard in 
 front, the forceps must be applied in the direct position. If they 
 should be heard to the left, without being able to determine wheth- 
 er the greatest intensity is in front or posteriorly, the forceps should 
 be applied in the most frequent position, the left anterior occipito- 
 iliac. Should the intensity be to the right, the instrument must be 
 introduced in the right anterior occipito-iliac position, which is the 
 most common after the descent of the head. But let us see what 
 will be the consequence if the accoucheur should be led into error, 
 not as to the right or left position, for this is scarcely possible ; 
 but if, on hearing the pulsations on one side, he should imagine it to 
 be an anterior, while it is a posterior of the same side. 
 
 (Fig. 137.) 
 
 I will now suppose that the position is a right posterior occipito- 
 iliac, and that it has been mistaken for a right anterior ; the forceps 
 will be applied as in a right anterior position, the curvature of the 
 
THE FORCEPS. 335 
 
 borders of the instrument regarding the posterior surface of the 
 right cotyloid cavity, the pivot branch in front and to the left, the 
 mortise branch posteriorly and to the right. The head will be 
 seized in its occipitofrontal diameter (fig. 137). " If the head should 
 be resisting and irreducible, the separation of the branches of the 
 instrument will indicate to the operator that it is grasped in its un- 
 favourable diameters, and will at once point out to him his error. 
 He then proceeds as in cases in which the position is altogether 
 unknown : he will apply one branch on the left, the other on the 
 right, and will seek, by inclining the instrument either to the right 
 or to the left, the direction most favourable for the delivery. (See, 
 farther on, Unknown Position.) But if the head be reducible and 
 small, the separation of the instrument will not take place, and the 
 accoucheur will still be of the opinion that the head is in the right 
 anterior occipito-iliac position, while, in fact, it is a right posterior 
 occipito-iliac ; he then believes it to be necessary to bring the oc- 
 ciput under the pubes, by a movement of rotation from right to 
 left, which will place the concavity of the borders of the forceps 
 under the pubic arcade, but which will bring the occiput only to 
 the right extremity of the transverse diameter. The head not 
 yielding to the direct tractions exerted upon it, the accoucheur 
 continues the movement of rotation, by directing the concavity of 
 the borders of the instrument towards the left cotyloid cavity. 
 This movement will not suffice to complete the rotation of the 
 head ; it only brings the occiput behind the right cotyloid cavity ; 
 finally, the head still resisting the tractions, the operator inclines 
 the concavity of the borders entirely to the left, and thus conducts 
 the occiput under the pubis. He now perceives that the head 
 yields readily to the force he employs ; but as it would not be pru- 
 dent to effect this disengagement with the present situation of the 
 forceps, for fear of injury to the external organs, he withdraws the 
 instrument, places it on the sides of the pelvis, and completes the 
 extraction ; should there be efficient uterine contraction, he com- 
 mits the expulsion to the spontaneous efforts of nature. 
 
 It may also frequently occur, under these circumstances, that the 
 branches cannot be adjusted, one in front and to the left, the other 
 posteriorly and to the right (fig. 137), and that they turn on the 
 sides of the pelvis (fig. 138) ; then the occiput will be more remote 
 from the concavity of the borders of the forceps, and the rotation 
 of the head cannot be accomplished with one application of the 
 instrument only, as would be possible in the preceding case. The 
 head will be seized by one occipital protuberance and the opposite 
 frontal protuberance. The operator, still supposing that it is a 
 right anterior sacro-iliac position, in order to bring the ociput 
 under the pubis, rotates the forceps from right to left, which di- 
 rects the concavity of the borders of the instrument towards the 
 left cotyloid cavity, and brings the occiput in the transverse posi- 
 tion ; the head continuing to resist, he increases the rotation of the 
 instrument, notwithstanding which, he can only bring the occiput 
 behind the right cotyloid cavity, and he still feels that the head 
 
336 
 
 OBSTETRICAL OPERATIONS. 
 
 docs not yield. Finding that it is impossible to extract the head, 
 and not being able to carry the rotation farther, since to do this 
 it would be necessary to place the concavity of the borders in re- 
 lation with the left sacro-iliac symphysis, which cannot be done, 
 he withdraws the instrument, and again applies it on the sides of 
 the pelvis. But the head, the rotation of which is not complete, 
 still resists the tractions, and, in order to extract it, the accoucheur, 
 in directing the concavity of the borders of the instrument either to 
 the right (and in this case the result would be fruitless) or to the 
 left (the only direction favourable to the disengagement), succeeds, 
 ultimately, by repeated efforts, in delivering the head. 
 
 (Fig. 138.) 
 
 It is evident from these examples, more of which might be ad- 
 duced, that auscultation, though of precious value, may, however, 
 occasionally lead to error, and prove prejudicial to the life of the 
 foetus, in consequence of the torsion of its neck, which results from 
 the extended movement of rotation the head undergoes, and which 
 is contrary to the rules for the application of the forceps in present- 
 ations of the vertex. However, this is an error into which the 
 most skilful practitioners may fall, and which, happily, does not al- 
 ways involve the safety of the fœtus. Madame Lachapelle cites 
 instances in which children have survived this degree of torsion. 
 
 Auscultation, in cases of doubtful diagnosis, may, therefore, be 
 of great value, but it will in some instances occasion error; so 
 that if, after the use of the stethoscope, we should still be in doubt 
 as to the position, it will be much better to pursue the course I 
 shall now point out. 
 
 If the pulsations of the heart cannot be heard, either because the 
 foetus has ceased to live, or because the agitation of the mother 
 renders auscultation impossible, and the position should be alto- 
 gether unknown or doubtful, the accoucheur should apply the for- 
 ceps on the sides of the pelvis. 
 
 Then, making slight tractions on the instrument, he will ascertain 
 whether the head resists or yields to his efforts. If it yield to 
 
THE FORCEPS. 
 (Fig. 139.) 
 
 337 
 
 direct traction, it is because it has executed its movement of rota- 
 tion ; if it resist, he should then direct the concavity of the instru- 
 ment to the right, the left occipito-iliac position being the most 
 frequent ; then he continues his tractions. If, indeed, it should 
 be a left anterior occipito-iliac position, or a right posterior oc- 
 cipito-iliac, the application being the same in both cases, the head 
 will yield to the efforts of the operator ; moreover, he will soon 
 perceive that his tractions are more availing, whether made above 
 or below, according as the position is an occipitoanterior or an 
 occipito-posterior, and the head will soon be disengaged in one or 
 other of these two positions. 
 
 If these tractions, the concavity of the branches regarding the 
 right side of the woman, produce no result, the accoucheur should 
 conclude that he is deceived, and that it is a right anterior or left 
 posterior occipito-iliac position ; he then directs the concavity of 
 the borders to the left, and immediately, in increasing more or less 
 this movement of rotation, he perceives that the head yields to the 
 tractions that he makes upon it ; and he then elevates or depresses 
 the instrument, according as the facility he experiences of effecting 
 one or other of these movements indicates to him that it is an ante- 
 rior-occipital or posterior-occipital position. 
 
 (Fig. 140.) 
 
 In a word, when the position is unknown, as the occiput or fore- 
 head, which should always be brought under the pubes in the present- 
 ation of the vertex, corresponds always in front either to the left 
 
 U u 
 
338 OBSTETRICAL OPERATIONS. 
 
 or to the right, it will be sufficient, in order to disengage the head, 
 to employ at first direct tractions ; and if resistance should offer, it 
 will be necessary to direct the concavity of the instrument either to 
 the right or to the left, by increasing more or less the rotation, 
 according to the direction in which this rotation may appear most 
 favourable to the extraction. But, in this case, it will be very impor- 
 tant to employ only limited tractions ; the perineum, too, should be 
 carefully supported, and the accoucheur should be ready to delay 
 the delivery of the head, rather than extract it ; for if, after having 
 resisted the direct tractions, the movement of rotation should have 
 placed the head in a position more favourable to its expulsion, it 
 may pass too suddenly from the maternal organs, and injure them 
 to a greater or less extent. Finally, if the parts be very friable, 
 and there be present strong uterine contractions, after having 
 brought under the pubes the part which should be placed in front, 
 the accoucheur should withdraw the forceps, and leave the delivery 
 to nature. If there should be no contractions, the instrument must 
 be reapplied on the bi-parietal diameter. 
 
 § 5. Application of the Forceps in the Presentation of the Vertex, 
 when the Head is engaged in the Superior Strait. 
 
 When the head is half engaged in the superior strait, the rules 
 for the application of the forceps are precisely the same as when 
 it has descended into the cavity. The operation, however, is more 
 difficult and dangerous for both mother and child.* It should, 
 
 * Too much attention cannot be given to the opinion of Dr. Chailly in reference to the 
 difficulty and danger of applying the forceps when the head is at the superior strait. I 
 have already insisted on this point, and it is one of great practical interest. A short time 
 since, 1 requested two of my students, Messrs. Guernsey and Blodgett, to attend one of my 
 clinique patients who was in labour. This woman was twenty-four years of age, healthy 
 and robust, and pregnant with her first child. She had been suffering more or less pain 
 for two days before these gentlemen visited her; and, after the lapse of thirty-six hours 
 •from their first visit, Mr. Guernsey stated to me that, notwithstanding strong uterine con- 
 tractions, there was no progress in the delivery, and that the friends were becoming impa- 
 tient. He also remarked (I had not yet seen the patient) that she was strong and muscu- 
 lar, with a bounding pulse. I suggested to him to bleed her to the amount of §xij., and to 
 inform me in the course of two hours whether any progress had been made. At this time 
 I was sent for, and was accompanied with another pupil, Mr. De Courcy. When I arrived, 
 the gentlemen in charge of the case remarked that the head was still at the upper strait, 
 and they did not believe that the pains, although severe, had occasioned any progress in 
 the delivery. On making a vaginal examination, I found their representations to be literal- 
 ly true : the mouth of the uterus was dilated, but the head, enormously large and resisting, 
 had not begun to disengage. The occiput lay on the left acetabulum, and the anterior fon- 
 tanelle on the opposite sacro-iliac symphysis, and the head was in a demi-flexed position. 
 There was considerable heat about the vagina, and the scalp was evidently corrugated, 
 manifesting that unusual pressure (all, however, unavailing) had been exerted on the head, 
 and that the child was in more or less danger. The woman herself fervently supplicated 
 that we should deliver her, her only anxiety being the safety of her child. It was no easv 
 matter to decide upon the course to be adopted in this case ; it was evident, however, that 
 artificial delivery was indicated ; but whether by version or the forceps was a question of 
 some delicacy to determine. Under ordinary circumstances, there would have been no 
 hesitation, for the head being at the superior strait, and artificial delivery becoming neces- 
 sary, version would be preferable. But, in this instance, the head was unusually large, 
 and turning would, of course, have been attended not only with great difficulty to the oper- 
 ator, but with serious results, most probably, to both mother and child. Add to this, that 
 the uterus was contracting with great energy, and it will be seen that the question natu- 
 rally arose, Which would afford the best chance to the mother and child, the forceps or 
 turning ? I decided on the former, and, in consequence of the peculiar circumstances of the 
 case, departed, in this preference, from a rule which I hold to be almost universally proper : 
 to turn rather than attempt delivery by the forceps when the head is still at the superior strait. Pro- 
 
THE FORCEPS. 
 
 therefore, never be had recourse to, except where version is im- 
 practicable in consequence of the excessive ascent of the uterus 
 (rare in presentation of the vertex), and when the pelvis is mal- 
 formed or the size of the head is very large. Yet, if the pelvis be 
 deformed in its oblique diameter (see fig. 70), version may be prac- 
 tised. The regular application of the branches at the superior 
 strait is exceedingly difficult ; indeed, it may be said to be impos- 
 sible in most cases. To what is this difference attributable ? In the 
 application of the instrument when the head has descended into 
 the cavity, it has to accommodate itself only to one axis. The ap- 
 plication could be accomplished with a straight as well as with a 
 curved forceps. At the superior strait, on the contrary, the instru- 
 ment must penetrate the uterus, and adapt itself to the combined 
 axes of the inferior and superior straits : consequently, it is neces- 
 sary that it be curved on its borders, and that the concavity of the 
 borders of the blades correspond with the posterior portion of the 
 symphysis pubis, in order that the instrument may accommodate 
 itself to the curvature of the pelvic canal. If this direction be depart- 
 ed from, it will be impossible to apply the instrument. The branch 
 which should be posteriorly may possibly be introduced ; but the 
 one which is to be in front cannot be applied properly, and it will 
 be found altogether impracticable to articulate the branches, which 
 do not correspond with each other. The perineum, which still in- 
 creases the curvature of the pelvis, opposes the handles of the in- 
 strument in passing backward, and, consequently, prevents the for- 
 ceps, the concavity of whose borders regards one of the sides of 
 the pelvis, from accommodating itself to the axis of the superior 
 strait. In fine, to attempt to articulate a forceps the concavity 
 of whose borders does not regard the posterior portion of the pubes 
 when the head is at the superior strait, would be like endeavouring 
 to pass an inflexible straight line through a crooked canal, which is 
 impossible. The forceps thus applied leaves so little space be- 
 tween the blades, that the smallest head cannot be embraced be- 
 tween them. 
 
 In two positions only can the forceps be applied regularly at the 
 superior strait, in taking the head by its bi-parietal diameter ; the 
 positions are those in which the occiput or forehead is at the sym- 
 physis pubis, because, the sides of the head corresponding with the 
 sides of the pelvis, the branches will be placed on the sides of the 
 pelvis and head, and their concavity will be in front. Unfortu- 
 nately, these positions are very rare, if even they exist at all ; while 
 the diagonal positions, in which it is not possible to seize the head 
 regularly by its bi-parietal diameter, since to do this the concavity 
 of the borders of the instrument should regard one of the sides of 
 
 ceeding with great caution, and after some little difficulty, I succeeded in adjusting the 
 blades of the instrument, but found it utterly impossible to approximate the handles of the 
 forceps, in consequence of the great size of the head. I carefully held the handles, guard- 
 ing against the possibility of the blades slipping, and commenced my tractions downward 
 and backward (loosening, but not withdrawing the instrument during the intervals of pain), 
 and succeeded, in about twenty minutes, in delivering the patient of an enormous living 
 child. The head of this infant was excessivelv large, and the dimensions of the body were 
 proportionate. — Ed. 
 
340 OBSTETRICAL OPERATIONS. 
 
 (Fig. 141.) 
 
 the pelvis, are the most frequent. In fine, the forceps can scarcely 
 ever be applied regularly when the head is at the superior strait. 
 Whatever the position of the head may be at this strait, the pivot 
 branch should be placed on the left, and the mortise branch on the 
 right, without regard to the position. This has been called the 
 German method. It is seen now that, in the diagonal positions, 
 the head must be seized by one frontal prominence, and the oppo- 
 site occipital protuberance ; that, in the transverse positions, it is 
 seized from the forehead to the occiput ; it may even be said that 
 such is the rule, and that those cases in which the forceps can be 
 applied regularly constitute the exceptions. 
 
 It must be understood, moreover, that the application of the for- 
 ceps will be the less regular as the head is more elevated. 
 
 The more the head is elevated, the more necessary it will be to 
 observe the precautions I have already mentioned in reference to 
 the orifice. Thus, it is essential that the branches be safely guided 
 within the orifice on the extremity of the fingers of the other hand. 
 
 The branches should be introduced in the direction of the two 
 axes, in order to penetrate the uterus. They should be applied 
 with great gentleness, and no violence should be used to overcome 
 any obstacle that may oppose their adjustment. 
 
 It is especially here that the precept of which I spoke a short 
 time since will find a useful application. 
 
 After having introduced one branch, in order to be certain that it 
 is well applied, we should endeavour to carry it a little farther ; and 
 if it meet with no obstacle, this will indicate that it has entered the 
 uterus. In attempting to withdraw it, also, there should be resist- 
 ance, which is determined by the head. If an obstacle be encounter- 
 ed which prevents the farther introduction of the branches, it is 
 because the branches have not penetrated the uterus, but are im- 
 bedded in the cul-de-sac of the vagina. They must then be with- 
 drawn, in order that they may be carried within the uterine orifice. 
 However, notwithstanding one branch may have entered the ute- 
 rus, the presence of some portion of the fœtus may present an im- 
 pediment to its farther ingress. In this case, after having well 
 
THE FORCEPS. 341 
 
 ascertained, with the extremity of the finger, that the end of the 
 blade passes into the uterus, we should endeavour to overcome the 
 obstacle by varying the direction of the extremity of the blade, and 
 endeavouring to remove the impediment by gentle efforts. But 
 we should never push the instrument violently, especially if we 
 have any doubt as to the proper situation of the blade. If, in fact, 
 the obstacle were due to the cul-de-sac of the vagina, it could not 
 resist this violence, and, consequently, the extremity of the blade 
 would penetrate the peritoneum. 
 
 The blades should be introduced higher in proportion as the 
 head is more elevated, so that this latter may be embraced by them. 
 After the head has been once seized, the two handles, grasped with 
 the hand corresponding to them, should be approximated so that 
 the mortise may be over the pivot. If these two points of articula- 
 tion do not correspond exactly, the handles should be gently moved 
 in an opposite direction, and should then be strongly bound by a 
 napkin.* The tractions must be made in the axis of the superior 
 strait, that is, downward, as much as the perineum will sanction ; 
 it is on this account that it is important, in this application of the 
 instrument, to place the patient on the border of a solid bed, which 
 is sufficiently elevated. If the bed, on the contrary, should be 
 low, the accoucheur cannot use much force, and will encounter 
 great fatigue. From time to time he must cease his efforts, and 
 ascertain, with the finger introduced between the two blades, wheth- 
 er the head passes down with the forceps, or whether the forceps 
 descends alone. If the instrument should lose its hold, it must be 
 withdrawn, and again introduced more deeply, and the handles 
 should be still more firmly bound. 
 
 The accoucheur must be careful never to abandon himself to the 
 forceps ; and when very energetic tractions are required, whatever 
 force he may employ, he should always be ready to arrest the de- 
 livery of the head, if it should threaten to be too rapid. A neglect 
 of this precaution has sometimes subjected accoucheurs to ridi- 
 cule ; they have abandoned themselves to the instrument, have 
 
 * I am aware that it is generally recommended to place a cord or folded napkin around 
 the handles of the forceps, after the blades are adjusted, and before the accoucheur com- 
 mences his tractions. But I regard this as bad practice in most cases, and, in my opinion, 
 it should be dispensed with. In the first place, when the handles are approximated, the 
 accoucheur can retain them in situ without the aid of the band ; and, secondly, if they 
 cannot be brought in contact in consequence of the large size of the head, to apply a band- 
 age under these circumstances would almost certainly ensure the child's death, for the 
 forced pressure employed could not but result prejudicially. I am well satisfied that the in- 
 fant is often sacrificed by the long-continued pressure made on its head after the application 
 of the instrument ; and to avoid this, 1 always pursue the following method, which I am in 
 the habit of recommending to my class, and to which I attach great value : As soon as the 
 instrument is properly applied, and the patient has a labour-pain (for, as a general rule, the 
 tractions are to be employed only during the pains), I then commence extracting, with the 
 particular kind of force already indicated in a previous note, and when the pain ceases, of 
 course my efforts cease, and at the same time / cautiously loosen the lock of the instrument, 
 still retaining it on the head ; thus, during the period when I cannot make tractions, relieving 
 the head of the fœtus from all undue pressure. As soon as the pain recommences, the in- 
 strument is again cautiously locked, and the tractions proceeded with. Every practitioner 
 knows that occasionally it requires great effort and some considerable time to achieve de- 
 livery with the forceps. To exert, therefore, constant, and frequently severe pressure on 
 the head during the whole of this period, must inevitably prove serious, if not fatal to the 
 infant.— Ed. 
 
342 OBSTETRICAL OPERATIONS. 
 
 (Fig. 142.) 
 
 thought of nothing but the forceps, and this latter suddenly losing 
 its hold, they have fallen backward with only the forceps in their 
 hands. 
 
 In proportion as the head descends in the cavity, the handles of 
 the instrument must be raised, and the tractions made in the axis 
 of the inferior strait. But the head, which has been seized from 
 one frontal protuberance to the opposite occipital protuberance in 
 the diagonal positions, and from the forehead to the occiput in the 
 transverse positions, cannot pass the inferior strait, in presenting 
 these unfavourable diameters, as if it had been regularly seized. 
 The concavity, therefore, of the borders of the instrument must be 
 directed to the right side, if that portion of the head which we 
 wish to bring in front be to the left, and vice versa. In this way 
 the rotation of the head is accomplished. If the parts are very 
 extensible, we may deliver, although the head should be grasped 
 in its unfavourable diameters, and the concavity of the borders of 
 the forceps regards one of the sides of the pelvis, instead of being 
 placed under the symphysis pubis. But we should be careful how 
 we extract the head, the instrument being placed in this manner ; 
 if the genital organs be narrow, friable, and inelastic, we should, 
 if there be no uterine contractions, place the branches on the sides 
 of the head, either by withdrawing for the purpose of reintrodu- 
 cing them, or by sliding them on the sides of the pelvis, without 
 removing them, but, well understood, they must have been pre 
 viously disarticulated. If, in this case, the uterus should contract 
 with energy, we withdraw the instrument, and confide the expulsion 
 of the head to nature. 
 
 Same Application of the Forceps, but the Position being unknown. 
 
 It sometimes happens that the prolonged sojourn of the head at 
 the superior strait occasions on the scalp a sero-sanguineous tu- 
 mour, which conceals the characters of the position. This circuit 
 
THE FORCEPS. 343 
 
 stance modifies in no respect the application of the forceps, since 
 one branch must be to the left, and the other to the right, no mat- 
 ter what the position ; but it leaves the accoucheur in doubt at the 
 moment he attempts to disengage the head, after it has arrived in 
 the cavity. With a view to render the disengagement more easy, 
 on which side should the movement of rotation be made? on which 
 side, in a word, should the concavity of the borders of the instru- 
 ment be directed ? It is impossible to know. 
 
 We should, therefore, as I have already remarked, the forehead 
 and occiput always regarding one of the two anterior fourths of 
 the pelvis, pass the concavity of the borders, at first to the right, 
 and if the head should not appear to yield, then to the left. In 
 acting thus, we shall not fail to discover the most favourable direc- 
 tion for the disengagement. 
 
 § 6. Operation when the Head is movable above the Superior Strait. 
 
 The operation is precisely the same in this case as in the pre- 
 ceding, except the difficulties are much greater. Moreover, the 
 mother and child incur much more serious hazard. We should 
 not have recourse to the forceps, in this case, unless version is im- 
 possible. This impossibility could only be in consequence of a dis- 
 proportion between the head and pelvis. If, therefore, the head 
 should be excessively large, or the pelvis much contracted, it will 
 be necessary to use the perforator.* (See article Deformities of 
 the Pelvis.) 
 
 The height of the head, as in the preceding case, renders the 
 regular application impossible ; and this height, which is still more 
 considerable, occasions great difficulty in guiding the branches with 
 the extremity of the fingers, which are impeded in attempting to 
 reach this elevation. Again, the mobility of the head exposes to 
 three kinds of inconvenience, which were not met with in the pre- 
 ceding application: 1st. The branch first applied moves the head 
 to the opposite side by acting on it as a lever, and there is no room 
 to introduce the other branch between the edge of the superior 
 strait and the head ; its extremity strikes against the head. Add to 
 this, that frequently the assistant, who holds the handle of the 
 branch first applied (pivot branch), increases the difficulty by ap- 
 proximating the handle to the left thigh, which circumstance aug- 
 ments the effort which the blades make on the head. This in- 
 convenience may be remedied by fixing the head at the superior 
 strait, with the hands of an assistant applied firmly on the hypogas- 
 trium, and in taking care that the handle of the pivot branch is 
 drawn towards the right thigh by the aid to whom it is confided. 
 2d. On account of this mobility, the head is pushed before the in- 
 strument, and can only be seized by the extremity of the forceps, 
 or merely by one of its borders ; so that, during the very first trac- 
 tions, it slips between the blades. This may occur in two different 
 
 * Let not the pupil thoughtlessly decide on the use of this instrument of death. He must 
 be fully satisfied of his inability to deliver with the forceps, or by version, before he resorts 
 to this fatal extreme. — Ed. 
 
344 
 
 OBSTETRICAL OPERATIONS. 
 
 ways : when the head is grasped by the extremities of the blades 
 only, it escapes from below upward (fig. 143) ; when it is grasped 
 by one of the borders of the instrument, which is common in all 
 cases in which the pelvis is deformed, on account of the very 
 marked ante-version of the uterus, it escapes horizontally from the 
 blades, and rests on the pubes (fig. 144). 
 
 This difficulty will be overcome by causing an assistant to main- 
 tain the head at the superior strait, and reducing, as far as possible, 
 the ante- version. 
 
 (Fig. 143.) 
 
 (Fig. 144.) 
 
 The dangers of this application will be avoided, the head being 
 movable, by introducing the fingers as high as practicable, in order 
 to guide the extremity of the blade within the orifice. Our vigi- 
 lance and caution must be increased ; the tractions should be slow 
 and guarded, and we should always be prepared to desist if the 
 instrument should loose its hold, in order that we may prevent the 
 unpleasant consequences of a violent extraction of the forceps. 
 
 Circumstances which exclude the use of the Forceps when the Head 
 is arrested at the Superior Strait. 
 It will have been seen, from what I have so far said respecting 
 the presentation of the vertex, that a deformity of the pelvis, or an 
 increase in the diameters of the head (but not an excessive size), 
 the descent of some other part, whether foetal or maternal, with 
 the head, when the uterus is retracted on the foetus, are the only 
 circumstances which require the application of the forceps in this 
 presentation, when the head is at the superior strait. In order to 
 overcome all the other accidents, version should be preferred. It 
 scarcely ever happens, when the vertex presents in a well-formed 
 pelvis, and the head possesses its normal dimensions, that the ute- 
 rine retraction is such as to oppose the introduction of the hand ; 
 for if this violent retraction existed, it could only occur after ener- 
 getic efforts of the womb, which would certainly cause the head 
 
THE FORCEPS. 345 
 
 to descend into the cavity, whatever might be its position, and then, 
 instead of version, the forceps would be indicated. It may, how- 
 ever, be urged, that a very inclined variety of presentation may 
 prevent the descent of the head, notwithstanding strong and ener- 
 getic contractions ; and that, in this case, the retraction of the ute- 
 rus might be such as to prevent the introduction of the hand. But 
 these forced inclinations are extremely rare ; and, in most cases, I 
 am satisfied that nature can overcome them. It is only, therefore, 
 a disproportion between the head and pelvis that renders the ap- 
 plication of the forceps necessary above the superior strait. 
 
 However, in this case, even, the application of the forceps has 
 certain limits, beyond which it would be useless, and positively 
 dangerous for both mother and child. The pelvis should not be 
 too much contracted, nor too regular in its deformity ; nor should 
 the head be of an excessive volume, as, for example, in hydroceph- 
 alus, the only case in which we can appreciate the size of the head 
 before birth. 
 
 Baudelocque (vol. ii., p. 22) has fixed an extreme limit beyond 
 which this instrument cannot be employed with safety to the moth- 
 er: this limit is three inches. He has also made some experiments 
 as to the degree of reduction which the head can undergo, and 
 as to the effects of this reduction on the life of the fœtus and the 
 organs of the mother ; I shall draw some practical deductions from 
 these experiments, taking the liberty, however, of adding a few 
 observations, which I think important, and which have been omit- 
 ted by this celebrated accoucheur. 
 
 The forceps is merely an instrument of traction ; it cannot re- 
 duce the volume of the head sufficiently to allow it to pass through 
 a pelvis of less than three inches ; moreover, I am well satisfied 
 that the compression caused by this instrument, even admitting 
 that it does not slightly increase the diameter perpendicular to that 
 on which it acts, never exerts any influence on the diameter op- 
 posing the disengagement, but on that which crosses it. In fact, 
 in the case before us, it is easy to appreciate the unfavourableness 
 of this circumstance. Thus, in a contraction of the antero-posterior 
 diameter of the superior strait, which is the most common, the 
 head is placed transversely, its bi-parietal diameter being in relation 
 with the antero-posterior diameter, while the occipito-frontal corre- 
 sponds with the bis-iliac or transverse diameter. And as the for- 
 ceps can only be applied on the sides of the pelvis, it seizes the head 
 from the forehead to the occiput (fig. 145), diminishes the occipito- 
 frontal diameter, which does not require it, and increases the bi- 
 parietal, which really stands most in need of diminution ;*' and the 
 forceps acts, in this case, evidently as an instrument of traction, 
 
 * Baudelocque supposes that, in applying the forceps above the superior strait, the head may 
 be seized by its bi-parietal diameter, in which he is universally followed, without thinking that, 
 on account of the transverse position assumed by the head at the contracted superior strait, 
 to take it by its bi-parietal diameter, we must apply one blade under the pubes and the other 
 on the sacro-vertebral angle, which cannot be done in a pelvis well formed at the superior 
 strait, and still less when the pelvis is deformed. In order that the head may be seized in 
 this case regularly, the forceps should be applied antero-posteriorly, and all practitioners 
 know the rarity of this position, particularly in a contracted pelvis. 
 
 X x 
 
346 
 
 OBSTETRICAL OPERATIONS. 
 
 and not by determining a reduction favourable to the disengage- 
 ment, since it would be more capable of augmenting than diminish- 
 ing the bi-parietal diameter. ^ 
 
 (Fig. 145.) 
 
 Supposing that, in an antero-posterior position of the head (which 
 is rare), no matter whether this position be spontaneous or be pro- 
 duced by the application of the forceps, the instrument could act 
 on the bi-parietal diameter, this diameter has no occasion for re- 
 duction ; indeed, it can present no obstacle to the descent, for it is 
 no longer in relation with the contracted antero-posterior diameter, 
 but with the bis-iliac. The occipitofrontal diameter, therefore, 
 would now be in need of reduction, since it is in relation with the 
 smallest diameter of the pelvis. 
 
 (Fig. 146.) 
 
 I have just demonstrated that the compression of the head scarce- 
 ly ever determines its reduction in a sense favourable to the disen- 
 gagement ; and experience shows that it is difficult for this com- 
 pression to exceed four or five lines without destroying the foetus, 
 
THE FORCEPS. 347 
 
 and often endangering more or less the life of the mother. In a 
 word, the violent tractions necessary to be made upon the head in 
 order to cause its descent into a pelvis of less than three inches, 
 bruise and lacerate the soft parts which line the pelvic cavity ; and 
 the mother often falls a victim to this violence, while the child, 
 already destroyed, cannot be extracted. If, therefore, this reduc- 
 tion be necessary in order to deliver the foetus, and as the reduc- 
 tion must sacrifice it, and involve the safety of the mother, it ap- 
 pears to me far more rational, after having ascertained the capa- 
 city of the pelvis, and delayed a necessary time, according to the 
 strength of the patient, twelve or eighteen hours, during which the 
 energetic contractions of the womb have been unable to effect the 
 descent ; it would, I repeat, be more rational to diminish the vol- 
 ume of the head by the perforator or cephalotribe, and thus save 
 the mother, since the child must inevitably perish. We may have 
 recourse to these means with the less scruple, because, in most ca- 
 ses, the child has been sacrificed before we attempt the operation. 
 
 Authors, it is true, report cases of spontaneous delivery where 
 the pelvis has measured less than three inches ; but such records, 
 which are not extremely rare, tend only to prove the infinite re- 
 sources of nature, but do not in any way fortify those who recom- 
 mend the extraction with the forceps of the head at full term, when 
 the pelvis is less than three inches. 
 
 In fine, because the expulsive and long-continued efforts of the 
 uterus may, in one, two, or three days, cause the delivery of the 
 head, when the superior strait measures not quite three inches, is 
 this any justification for the accoucheur to attempt the accomplish- 
 ment of the same thing by instruments ? Certainly not. In the first 
 case, if children have been expelled alive, it is because the compres- 
 sion resulting from the contractions of the womb is gentle, gradu- 
 al, and continuous, and is not followed by the same unhappy conse- 
 quences as when it is sudden and rapid, which is more or less the 
 case with the compression produced by the violent efforts of the 
 accoucheur, and which always destroys the infant. 
 
 And, moreover, what object can there be in applying the for- 
 ceps, when it must sacrifice the child, and seriously endanger the 
 life of the mother, and which, in most cases, proves entirely use- 
 less? 
 
 There would be an apology for adopting this course only in cases 
 in which the deformity of the pelvis cannot be readily ascertained, 
 and which certainly would not be admissible when the contraction 
 is so well marked ; and in cases, also, in which a slighter contraction 
 coexists with an excessively large head, a circumstance, except in 
 hydrocephalus, which it is not possible to appreciate ; but, in con- 
 sequence of the great effort necessary to make,* and the insufficien- 
 cy of the uterine contractions to effect the passage, we should have 
 
 * In no case can we appreciate, by the approximation of the handles of the instrument, the 
 degree of compression exercised on the head ; for if the forceps be badly tempered, the han- 
 dles may touch, although the blades are not approximated in the same proportion. This re- 
 duction is also very limited and very variable ; it depends, in fact, on the solidity of the 
 bones and sutures, and the manner in which the head is seized. 
 
348 OBSTETRICAL OPERATIONS. 
 
 reason to suspect that the obstacle is due to the large size of the 
 head, which it is not possible to reduce, except with the perforator 
 or cephalotribe. 
 
 § 7. Accidents which may follow the Application of the Forceps, 
 
 The accidents which may depend on the use of the forceps may be 
 in consequence of its application, although the instrument be directed 
 by a skilful hand, or they may result from the inexperience of the 
 operator. 
 
 In the first class are embraced contusions of the soft parts which 
 line the margin of the superior strait, laceration of the perineum, 
 and death of the foetus, whether produced by compression of the 
 brain or umbilical cord. In the application of the forceps above 
 the superior strait, there will be procidentia of the cord at least 
 two out of five times. 
 
 In the second class are embraced contusions and lacerations of 
 the neck of the uterus, which, in general, are not very serious ; per- 
 forations of the cul-de-sac of the vagina by the extremity of the 
 blade pushed with too much violence, or badly introduced ; acci- 
 dents which are of the most formidable character, because the in- 
 strument penetrates the peritoneal cavity ; contusions of the mar- 
 gin of the superior strait in cases in which the application of the 
 forceps should not have been attempted. Laceration of the peri- 
 neum, sphincter ani, and of a portion of the rectum ; all of which 
 are more or less grave, and to which I shall hereafter allude. 
 
 As to vesico, urethro, and recto vaginal fistulse,* which have 
 been so often ascribed to the forceps, I cannot regard them as 
 being ordinary consequences of the application of this instrument, 
 even when this application has not been without blame. In truth, 
 these accidents are much more frequently observed after spontane- 
 ous deliveries than as the results of artificial interference. They 
 are occasioned by the prolonged sojourn of the head at the superior 
 strait, by the pressure exerted by the head on the parts which are 
 first contused, and then fall into gangrene. When they occur 
 after the use of the forceps, we should attribute them rather to the 
 pressure which the head has exerted on the parts for a long time 
 previous to the operation, than to any injury from the tractions 
 made with the instrument, or to any improper direction given to the 
 blades at the moment of their introduction. 
 
 Art. II. — Turning. 
 Turning is an operation by which the accoucheur proposes to 
 bring down to the superior strait one of the two extremities of the 
 fœtus — the head or pelvic extremity. Hence there are two spe- 
 cies of turning : cephalic turning and pelvic turning. 
 
 ■*■ These fistulae are common consequences resulting from the too frequent use of the 
 crotchet. I am now attending a poor creature, who has entailed upon her the most dis- 
 tressing disease, not only from the unskilful, but, I am sorry to say, the unnecessary use 
 of this fatal instrument. Her child was taken from her fragment by fragment, and yet her 
 pelvis and organs are perfectly well formed ! When will conscience preside over the acts 
 of certain practitioners ? — Ed. 
 
TURNING. 349 
 
 The ancients, labouring under the false notion that delivery could 
 not terminate favourably to the mother and child except in cases 
 in which the fœtus presents the head, laid down as a principle, that 
 the vertex should always be brought to the superior strait. 
 >j[ From the time of Hippocrates to that of Celsus, cephalic version 
 was exclusively recommended. 
 
 Celsus, struck with the difficulties, frequently insuperable, expe- 
 rienced in the performance of this operation, and with the dangers 
 incurred by the mother, recommended the extracting of the fœtus 
 by the pelvic extremity, but only after it had ceased to live. This 
 precept prevailed until the time of Ambrose Paré, and especially 
 of his pupil Guillemeau. They were the first who suggested pelvic 
 version on the living fœtus. Experience has since proved the ex- 
 cellence of this suggestion, and the practice has been universally 
 adopted. 
 
 Cephalic version had completely fallen into oblivion, when, at 
 the end of the last century, Flamant in France, and Osiander in 
 Germany, endeavoured to revive it ; they contended that delivery 
 by the vertex is more favourable than by the pelvic extremity ; 
 and, in order to give value to their opinion, they exaggerated the 
 difficulties and dangers of the extraction of the fœtus by the feet, 
 and the advantages of cephalic version. 
 
 If we may reproach the Germans, and, among ourselves, M. 
 Velpeau, for having spoken too favourably of this practice, we 
 must at the same time admit that it has been too severely con- 
 demned by Baudelocque, Madame Lachapelle, and most modern 
 accoucheurs. If the principles inculcated by the advocates of this 
 practice be not altogether true (as I shall demonstrate) ; if this op- 
 eration be not applicable to all cases ; if it be accompanied by diffi- 
 culties and dangers not met witb in pelvic version ; and if this lat- 
 ter should be preferable in cases in which it is possible to choose 
 the one or the other, it is nevertheless certain that it is, under cer- 
 tain circumstances, capable of proving highly useful. But this is 
 not the place to institute a parallel ; this discussion will be more 
 proper when speaking of the presentations of the trunk, in which 
 cephalic version should be specially practised. 
 
 In the presentation of the vertex, which occupies us at this mo- 
 ment, it is not necessary to say anything about bringing the head 
 to the superior strait, for it is there already ; it is to pelvic version 
 that we must have recourse in order to extract the fœtus. 
 
 § 1. Pelvic Version. 
 It is proposed, in pelvic version, to bring the feet or knees of the 
 child to the superior strait, and deliver the fœtus by means of trac- 
 tions made on these parts. 
 
 Necessary Conditions. 
 In order that pelvic version may be practised, it is necessary, 
 1st. That there should be no disproportion between the head of 
 the fœtus and the superior strait ; that the pelvis, in a word, be not 
 
\ 
 350 OBSTETRICAL OPERATIONS. 
 
 contracted, or, if mal-formed, only slightly so, and especially that 
 it be not regularly small in its deformity. Among the deformed 
 pelves, there is only one species which will permit the performance 
 of this operation — it is the oblique pelvis of Naegele. In fact, in 
 this case, one side of the pelvis generally increases as much as it 
 loses on the other side, and, by bringing the fœtus to the extended 
 portion, it is possible to extract it readily, and without much dan- 
 ger. 
 
 Hydrocephalus, it must be understood, would be a positive con- 
 tra-indication. 
 
 If, notwithstanding these sage precepts, the accoucheur should 
 attempt pelvic version in a pelvis presenting less than three inches 
 and a half, it would be easy to engage the pelvic extremity, the 
 diameters of which are small, but insurmountable difficulties would 
 be encountered in extracting the head. In fine, the head most fre- 
 quently reaches the superior strait in a state of extension more or 
 less marked, and then presents those diameters which oppose its 
 descent. This circumstance is exceedingly dangerous to the child, 
 not in consequence of the application of the forceps, which has 
 been erroneously recommended in this case, for it is impracticable, 
 inasmuch as the head being at the superior strait, the trunk closes 
 up the pelvic cavity ; but the danger arises from the tractions which 
 are made on the fœtus, and the murderous operations had recourse 
 to when the head cannot be flexed, or extracted as it presents. 
 
 2d. The orifice should be sufficiently dilated and dilatable, not 
 only to permit the easy introduction of the hand, but also the ready 
 extraction of the fœtus. In pelvic version, the fœtus represents a 
 cone, the summit of which engages before the base, and the parts 
 which present successively at the orifice become more and more 
 voluminous. If, therefore, the orifice be imperfectly dilated, the 
 first portions of the fœtus, the fee?, descend readily, but the shoul- 
 ders and head offer a resistance more or less marked, and while 
 the orifice is undergoing the necessary dilatation, the child may 
 be sacrificed by compression of the cord. 
 
 3d. Finally, the head should not be too much descended into the 
 pelvic cavity, and especially it must not have passed the mouth of 
 the womb. If, indeed, the head were deeply engaged in the cavi- 
 ty, even if it should not have passed the orifice, great difficulty 
 would be experienced in pushing it above the superior strait : and 
 if it should have passed the orifice, it would be impossible again to 
 carry it into the uterus without rrsking the destruction of the natu- 
 ral relations which unite this organ to the vagina, and likewise in- 
 curring the danger of rupture of the womb. 
 
 Preliminary Precautions. 
 As soon as the operation is decided upon, we should carefully 
 conceal from the patient the true nature of it ; she should be told 
 that only a slight change is to be effected in the situation of the 
 fœtus, and, at the same time, assured that the consequences both to 
 her and the child will not be serious ; but the accoucheur should 
 
TURNING. 351 
 
 never, delay the operation of turning because he has not obtained 
 the consent of the patient. Indeed, when he has determined to per- 
 form an operation on which often immediately depends the safety 
 of both mother and child, the accoucheur should not even ask con- 
 sent, for it only alarms the patient, and frequently causes her to 
 object positively to the operation. He should be the sole judge in 
 the case. But if it be proper, and even indispensable, to conceal 
 the fact from the patient, it is also most important to communicate 
 with those around, and explain to them the dangers to which the 
 mother and child will be exposed by the operation ; such conduct 
 will in no way change the result, but it will have the great advan- 
 tage of relieving the accoucheur of much unnecessary responsibil- 
 ity. If an unfortunate result should follow, much less censure will 
 be attached to the accoucheur, he having previously prepared the 
 friends for the possibility of such an occurrence. But he must be 
 guarded in his communication, lest he should infuse alarm into the 
 minds of the assistants which they cannot conceal, and which might 
 possibly affect the patient.* 
 
 This being done, the accoucheur should see that everything 
 which may be necessary to resuscitate the child, in case of need, 
 is previously arranged near a window easy to open (cold and 
 warm water, vinegar, napkins, a feathered quill, &c, &c). Then 
 he should have himself provided with what he may find neces- 
 sary during the operation ; cerate, if it can be procured, and if 
 not, fresh butter or lard. These substances will be preferable to 
 oil in facilitating the introduction of the hand ; finally, napkins, a 
 fillet, and small compresses should be in readiness. The prelim- 
 inary preparations should be made very quietly, for fear of alarm- 
 ing the patient. 
 
 * 1 differ in opinion from our author, that the necessity of the operation should be con- 
 cealed from the patient. On the contrary, I think she should not only be informed of it, and 
 her assent obtained, but she should likewise know that her child will incur more or less haz- 
 ard in consequence of the operation ; but, at the same time, she should be given to under- 
 stand that it is an alternative presenting the best chance of safety both to herself and offspring. 
 Turning is an operation too delicate in itself, and too grave in its possible results, ever to be 
 attempted heedlessly, and without the entire approbation of the patient. Dr. Chailly, it 
 seems to me, does not view this question with his usual acumen ; and I am sure he will 
 agree with me that no sane surgeon would attempt a surgical operation of any import — for 
 example, the putting a ligature around the femoral artery, the extraction of a cataract, or the 
 amputation of a limb — without previously conferring with his patient, and obtaining a full and 
 cordial consent. Suppose, however, he were to proceed without this conference ; the first 
 stroke of his knife would infuse terror into his patient, and the agitation consequent on this 
 alarm might cause that knife to be plunged into an artery, from which would flow his life- 
 blood in streams too copious to be arrested by the affrighted surgeon ! What is turning ? It 
 is the introduction of the hand and arm into one of the most important viaAra of the human 
 economy, and the slighest violence on the part of the operator, or undue effort on the part oi 
 the patient, may occasion rupture of this organ, and thus produce instantaneous death. 
 Suppose, for example, the accoucheur attempts the operation without previously informing 
 his patient ; he pulls off his coat ; lubricates his hand and arm ; passes them into the womb -, 
 peradventure, he may have reached the feet at the fundus ; the patient becomes suddenly 
 terrified ; she is awakened as if from a dream ; she exclaims, " Doctor, what are you doing ?'" 
 the fearful suspicion crosses her mind that something is wrong; the doctor is busy with the 
 operation ; his bare arm is completely within the cavity of the womb ; the patient again ex- 
 claims, "Good God! doctor, what are you doing?" intent on his work, he makes no reply; 
 the patient, phrensied with alarm, attempts suddenly to tear herself from his grasp ; this ef- 
 fort thrusts the operator's arm through the walls of the uterus ; she sickens ; becomes faint, 
 pulseless, speechless ; she dies ; and dies, perhaps, with that arm still in her womb ! ! Such 
 may be the consequences of turning, if the patient be not previously informed of the accou- 
 cheur's intention.— Ed. 
 
352 OBSTETRICAL OPERATIONS. 
 
 With as little disturbance as possible, the female should be placed 
 in a proper position, and the assistants should have their stands as- 
 signed them, and the duties they are to perform pointed out. 
 
 The patient should take the same position as in the application 
 of the forceps ; she is placed across the bed, the breech brought to 
 the edge of the mattress, under which must be inserted a hard cush- 
 ion ; the feet must rest on the knees of two assistants placed on 
 either side. She must be supported by pillows placed between her 
 back and the wall ; an assistant will stand by her, as much to en- 
 courage and afford her any aid which may be required during the 
 operation, as to hold her should it become necessary. All this 
 should be done promptly, quietly, and without confusion ; this pre- 
 caution cannot be too rigidly insisted on. Let all these prepara- 
 tions be so simplified as to pass unperceived. Such is the point to 
 which the efforts of the accoucheur should be directed. 
 
 He should then take off his coat, unless the sleeves should be 
 so large as to enable him to roll them up above his elbow ; the 
 coat of the accoucheur should always be made in this manner, for 
 it will spare the patient the alarm occasioned by removing the en- 
 tire coat. 
 
 On the other hand, he should not content himself with rolling up 
 his sleeves partially, for it is absolutely necessary that the fore-arm 
 be completely naked, not that we are always obliged to intro- 
 duce it entirely into the parts, but because, if this should become 
 indispensable, the sleeve of the coat interfering with the introduc- 
 tion of the arm, it will become necessary to withdraw the arm from 
 the maternal organs, in order to lay it bare. 
 
 This circumstance will have the triple inconvenience of occa- 
 sioning suffering to the patient, retarding the operation, and inspi- 
 ring doubts as to the skill of the operator. 
 
 The position of the fœtus should then be ascertained, both by the 
 touch and auscultation, if the touch be not sufficient to point out 
 the diagnosis. In a word, the choice of the hand will depend on 
 the knowledge of the position ; it is, therefore, essential that this 
 latter should be understood. 
 
 It is not, however, necessary to distinguish between an anterior 
 and a posterior position ; this is useless. It will suffice to know 
 that the occiput and back are to the left, or to the right. These 
 two circumstances alone will determine the choice of the hand. 
 When the oxciput is to the left, whether posteriorly or in front, the 
 left hand is to be employed. When to the right, either in front 01 
 posteriorly, the right hand must be selected. 
 
 This choice of the hand is useful, because it enables the accou- 
 cheur to introduce his hand with the palm regarding the anterior 
 surface of the foetus, and reach more readily the parts after which 
 he is searching ; it also facilitates the movement of flexion of the 
 child on its anterior plane, an indispensable condition, in order that 
 turning may be practised without the fœtus being exposed to un- 
 necessary danger, and the womb to lacerations. 
 
 But it must not be supposed that this choice is rigorously neces- 
 
 
TURNING. 353 
 
 sary, and that a neglect of the precept will always result seriously. 
 Every one knows, on the contrary, that when the foetus is movable, 
 that is to say, when the membranes are intact at the time version 
 is practised, this operation may be performed as well with one 
 hand as the other. The hand, which then enjoys great liberty, 
 can reach the parts it seeks with entire facility. 
 
 Thus, in cases in which it is impracticable to recognise the posi- 
 tion, in consequence of the integrity of the membranes, and the ab- 
 solute impossibility, from particular circumstances, of ascertaining 
 the position by auscultation, the accoucheur should not despair of 
 success in the operation. He introduces the right hand, the use of 
 which is most familiar to him ; and in most instances, even when 
 the other would have been indicated, he will succeed as complete- 
 ly as if he had made a rigorous selection of the hand. 
 
 After the rupture of the membranes, a sanguineous tumour may 
 disguise the position ; it may also occur that the agitation of the 
 patient will prevent the accoucheur from having recourse to aus- 
 cultation. In this case, too, he will introduce the right hand. But 
 if this hand, oppressed by the contractions of the uterus, and not 
 finding itself in relation with the anterior plane of the fœtus, cannot 
 easily seize the feet or knees, it should be withdrawn, and the other 
 introduced. Nevertheless, the accoucheur should, as far as possi- 
 ble, insist on the choice of the hand. Occiput being to the left, left 
 hand ; occiput to the right, right hand. 
 
 The whole of the fore-arm and the dorsal surface only of the 
 hand should be well greased. In fine, the parts of the fœtus are, in 
 general, very slippery, and we should not increase the chance of fail- 
 ure by lubricating the internal portion of the hand which is to seize 
 these parts.* 
 
 Operation. - 
 
 All these precautions having been observed, and being assured 
 that the urine has been voided, and the bladder empty, and introdu- 
 cing the catheter, if it should be necessary, the operation should be 
 commenced. I will describe the operation in the left occipito-iliac 
 position, and it will be easy to understand it in the other, right oc- 
 cipito-iliac position. 
 
 Pelvic version is composed of three periods : the introduction of 
 the hand, the evolution of the fœtus, and its extraction. 
 
 First Period. — The accoucheur, placed in front of the patient, 
 stands up or rests on his knees, depending on the elevation of the 
 bed, and, before proceeding, he places the hand not to be introdu- 
 
 * This advice I cannot consider judicious. If the dry hand of the accoucheur come in 
 contact with the organs of the mother, or the surface of the foetal body, there will, undoubt- 
 edly, be risk of injury to these parts, to say nothing of the want of facility which the dryness 
 of the hand will occasion in the performance of the operation. The objection urged by Dr. 
 Chailly why the palm of the hand should not be lubricated is (admitting its validity, which, 
 in most cases, I do not) of far less importance than the injury which might result if this rule 
 were neglected. One of the essential points, in my opinion, to be kept constantly in view 
 by the accoucheur, is to have the entire hand and arm thoroughly anointed before attempt- 
 ing the operation of turning. The soft parts of the mother as well as the body of the fœtus 
 are thus guarded, and the facility of introduction vastly increased. — Ed. 
 
 Y Y 
 
354 
 
 OBSTETRICAL OPERATIONS. 
 
 ced upon the fundus of the womb, in order to compress it when ne- 
 cessary. I am in the habit of recommending this precaution thus 
 early, not that it is necessary at the commencement of the opera- 
 tion, but because my experience teaches me that it is the only cer- 
 tain means of not forgetting it at the moment it becomes indispen- 
 sable, that is, when the hand is penetrating the uterine orifice. The 
 observance of this rule is exceedingly important, for its omission 
 may occasion alarming consequences to the mother, such as rup- 
 ture of the points of attachment between the orifice and vagina, and 
 laceration of the uterus in other portions of its extent. 
 
 If there should be an intelligent assistant, to whom this duty may 
 be confided, it may be intrusted to him, although the accoucheur 
 may do it very well himself; for the use of the two hands is not re- 
 quired in the extraction of the fœtus, except when it is no longer 
 necessary to maintain in place the fundus of the womb. 
 
 The hand which is to penetrate the organs of the mother must 
 be introduced slowly and gently into the vulva, except the thumb, 
 which is to be united to the other fingers as soon as the hand is in- 
 troduced as far as the wrist, rotating it at the same time, and dimin- 
 ishing as much as possible its volume. These precautions cannot 
 be too scrupulously observed, especially in primiparae. The intro- 
 
 (Fig. 147.) 
 
TURNING. 355 
 
 daction of the hand is, in general, the most painful part of the 
 operation. 
 
 What time should be selected to penetrate the external organs ? 
 Authors are not agreed on this point. It has been recommended 
 to select the period of pain, in order that the patient may attribute 
 to the contraction of the womb the suffering occasioned by the in- 
 troduction of the hand. But it is well known that the contrary al- 
 ways takes place, and that women are much more disposed to as- 
 cribe the uterine pain to the accoucheur, no matter how simple his 
 investigation may be. Thus, after the example of M. P. Dubois, 
 my advice is to introduce the hand only during an interval of calm ; 
 the patient can then distinguish between the pain occasioned by the 
 introduction of the hand and that resulting from uterine contraction. 
 
 The hand must be introduced in the direction of the axis of the 
 vulva and inferior strait ; as soon as it has entered the excavation, 
 it must change its direction in order to penetrate the orifice of the 
 womb ; and, therefore, it must pursue the axis of the superior 
 strait. To enter the cavity of the uterus, the accoucheur must 
 avail himself of an interval of calm when this organ does not con- 
 tract. If this rule be neglected, by attempting to force the resist- 
 ance of the contracted womb, he may cause its rupture. Finally, 
 at this moment the fundus of the organ should be properly com- 
 pressed, either by the hand of the accoucheur or by that of an 
 assistant. 
 
 All these precautions being taken, if the membranes be rup- 
 tured, the hand can enter the cavity of the uterus. If it be well 
 dilated, the hand penetrates without difficulty between the head 
 and maternal parts, without being obliged to push these aside. 
 Should the orifice, without being dilated, be in a dilatable condition, 
 the fingers will penetrate gradually and cautiously, and very care- 
 fully move the head of the infant, which reposes on the orifice, but 
 not by seizing it with the full hand, the thumb placed here, the four 
 fingers there, êfc, fyc., in order to place it in the iliac fossa cor- 
 responding with the occiput ; for we can enter the uterus without 
 being obliged to bring the thumb by the side of the index finger, and 
 follow minutely a multitude of precepts, which are entirely useless, 
 and which, in my opinion, are not put into practice even by those 
 who have recommended them. It frequently happens that the ute- 
 rus is thrown into contraction by the irritation produced on the 
 orifice in consequence of the introduction of the hand. In this case, 
 the accoucheur should desist, but not withdraw the hand ; he should 
 continue it there in order to be ready to introduce it the moment 
 the contraction ceases. 
 
 As soon as the hand is introduced, he must assure himself that he 
 is not deceived as to the position of the fœtus, and, consequently, 
 that he has selected the proper hand. If, however, he discovers 
 that he has been mistaken, he should still continue the operation, if 
 the uterus should not be firmly contracted ; and this contraction 
 rarely occurs when we practise version in the presentation of the 
 vertex. But if it should happen that the uterus be in a state of 
 
356 OBSTETRICAL OPERATIONS. 
 
 contraction, and the hand encounter difficulty in passing between 
 this organ and the foetal body, it should be withdrawn, and again 
 introduced with the palm regarding the anterior surface of the 
 fœtus. Occiput being to the left, left hand ; occiput to the right, 
 right hand. 
 
 If the membranes be intact at the moment the hand reaches the 
 orifice, what course is to be pursued ? Under these circumstances, 
 should the accoucheur rupture the membranes at the centre of the 
 orifice in order to penetrate the uterus ; or, rather, should he pass 
 his hand into the orifice, gradually separating the membranes from 
 the internal surface of the womb, then carrying his hand up to the 
 feet, seize them, and break the membranes ? 
 
 Those accoucheurs who have recommended this latter mode, 
 allege in favour of their opinion that the hand, in thus passing be- 
 tween the membranes and uterus, reaches the upper portion of the 
 foetus without there being an escape of one drop of amniotic fluid, 
 and that thus the hand, traversing the uterus, which is not con- 
 tracted, can, at the moment it ruptures the membranes, very readily 
 bring down the feet, and in this way complete the second period, 
 or that of evolution. While, on the contrary, in rupturing the mem- 
 branes in the centre, the fluid is allowed to escape, the uterus con- 
 tracts, and the operation becomes very difficult. 
 
 The advantages of the previous separation of the membranes 
 before their rupture have always appeared to me more speculative 
 than real, and the inconveniences of the rupture in the centre very 
 much exaggerated. 
 
 When the hand breaks the membranes at the moment it pene- 
 trates the neck of the uterus, there is a discharge of fluid ; but the 
 wrist, and then the arm, which immediately follows the hand, com- 
 pletely closes up the orifice, and sufficient fluid remains in the womb 
 to permit the ready evolution of the fœtus. Again, the small quan- 
 tity of liquid that has escaped does not produce immediate contrac- 
 tion of the organ, and the hand still enjoys great freedom. 
 
 In the second process, on the contrary, the operation is long- 
 er, more difficult, often impracticable, and dangerous. Thus, the 
 separation is not always possible, and to accomplish it will re- 
 quire more or less time, during which the suffering and danger 
 incurred by the patient are prolonged, and the safety of the child 
 involved. Besides, even when the separation is easy, it may be 
 followed by certain inconveniences : the placenta may be encoun- 
 tered by the hand during its passage, and its partial or complete 
 detachment be effected, which might cause the death of the fœtus, 
 and seriously endanger the life of the mother by inducing hemor- 
 rhage. It is in vain to urge that the placenta can be easily distin- 
 guished from the membranes ; for it is certain that this distinction 
 cannot be made as readily as authors contend ; and it is, therefore, 
 wise not to expose the mother and child simply for the purpose of 
 obtaining so slight an advantage. 
 
 In fine, we should rupture the membranes in the centre, at the 
 moment of penetrating the uterus, and the separation of the mem- 
 
TURNING. 
 
 357 
 
 branes should be reserved for those cases in which, being partly 
 effected, it will be found easy to accomplish ; but we should not 
 insist on this separation, in order to reach the feet, if the slightest 
 obstacle should present itself, and we should then rupture the mem- 
 branes as soon as the obstacle is encountered. 
 
 Whether the membranes have been ruptured in advance, or 
 whether they are perforated the moment the hand enters the womb, 
 the mode of proceeding to arrive at the feet is always the same : 
 the accoucheur introduces his hand gently between the uterus and 
 head, and following the anterior plane of the foetus, he passes over 
 the face and chest, and carries the hand as far as the knees, which 
 he finds nearer the head, in proportion as the contractions of the 
 womb have increased the flexion of the fœtus. This mode of pro- 
 ceeding is the most easy, prompt, and least painful, because it does 
 not require such a complete introduction of the hand into the organs. 
 
 Some authors recommend to follow the back of the fœtus, or the 
 side which regards the posterior portion of the pelvis, and, during 
 the progress, search for the arms and hips, and on reaching the 
 breech, to seize the feet and bring them down. In this way, they 
 observe, we will avoid confounding the arms with the legs ; the 
 road is longer, but it is more certain'. Indeed, one is almost tempt- 
 ed to believe that those who give this counsel have never had their 
 hand in the uterus, or that they simply repeat, on the faith of an- 
 other, a precept which they have never carried in practice them- 
 selves, as is- too often the case. 
 
 (Fig. 148.) 
 
358 OBSTETRICAL OPERATIONS. 
 
 In the first place, this rule cannot be followed except in cases in 
 which the hand has great facility of motion in the womb. Then 
 only can it make lateral movements and penetrate deeply, and then 
 all is possible. But every accoucheur knows that it is extremely 
 difficult, in most cases, to proceed this long distance, when the ute- 
 rus is contracted on the fœtus ; and that, in adopting this rule, which 
 requires much of the arm to be introduced, and manipulations 
 painful to the mother, we will be as likely to mistake a hand for a 
 foot as by the method I advise. The accoucheur should, by all 
 means, practise on a dead infant in order to distinguish the hand 
 from the foot ; this preliminary knowledge every practitioner should 
 possess. If, in fact, this mistake were made, nothing serious would 
 arise from it. It would only be necessary to let go the hand as 
 soon as the error was detected, and proceed to search for a foot or 
 a knee. 
 
 This circumstance is of too secondary a character to authorize 
 the precept generally given. I regard it as useless, painful, and 
 tedious under the most favourable circumstances, and impossible in 
 cases of difficulty ; whereas, in carrying the hand along the ante- 
 rior surface of the fœtus, the feet and knees will be found at a very 
 short distance from the head. The distance traversed by the hand 
 is shorter and more direct, and the operation is much less painful. 
 
 Farther, this is the only mode to be adopted when the contracted 
 uterus will not permit the hand to pass directly towards the parts 
 it seeks, and opposes its lateral movements. 
 
 1 remember that the first case of version which I saw performed 
 by M. P. Dubois, the foot of the infant was already seized and 
 brought into the vagina, before it appeared to me the operation had 
 been commenced. His hand and wrist only were introduced into 
 the maternal organs, and directed to the anterior surface of the fœ- 
 tus. It is always in this way that I have since noticed this excel- 
 lent master proceed, and I have entirely adopted his method, so 
 far preferable to the absurd precepts I had imbibed previously to 
 becoming his pupil ; precepts which I had always followed until 
 this period, and which often led me into difficulties from which I 
 could not well extricate myself. How often have I attributed the 
 obstacles which I encountered to my own want of skill, while they 
 were due altogether to my adherence to rules often impossible to 
 put in practice ! 
 
 While the hand is passing up between the uterus and body of the 
 fœtus, if this organ should contract, the hand should be applied flat 
 on the fœtus, and remain perfectly quiet during the period of con- 
 traction ; in the interval of calm, the accoucheur again proceeds. 
 
 Evolution of the Fœtus. — When the hand has reached the infe- 
 rior extremities, it seizes whatever it meets with, whether a knee 
 or a foot, and brings it down by giving to the fœtal body its natural 
 flexion. This movement of evolution should always be effected in 
 the absence of pain : such are the only rules to be observed during 
 this period of the operation. I have often seen them reduced to 
 practice by M. P. Dubois, and my own experience has for many 
 
359 
 
 years satisfied me of their excellence. Most authors, however, 
 enter into much more minute details, but they are more or less 
 useless and impracticable. 
 
 Thus, they recommend that both feet shall be grasped at once, 
 and that when only one can be reached, it should be brought down, 
 and the accoucheur should proceed to search for the other. 
 
 Others concede that, strictly speaking, we may be content with 
 one limb, when it is the sub-pubic which has been seized ; but should 
 it be the posterior, we should immediately search for the other ; and 
 these precepts are laid down without any principle, nor are we told 
 why one extremity should be preferred to another. 
 
 Finally, these authors go so far as to indicate the exact manner 
 of seizing the limbs, the respective situation of each of the fingers of 
 the hand, and the points of the foetal body to which they are to be 
 applied. 
 
 This is precision, indeed, but there is but one answer to it, viz., 
 to seize the limbs as we can, grasp both at once, which is rarely 
 possible ; and when we can only take hold of one, which is the rule, 
 we do not know, in most cases, whether it is an anterior or poste- 
 rior extremity ; and even if we could distinguish the extremities, 
 the result would in no way be changed, for we must pull on the 
 limb that has been grasped, without feeling that it is necessary to 
 search for the other. In a word, in the great majority of cases, 
 turning is accomplished as well with one as with both extremities. 
 The limb that has not been seized lies on the anterior surface of 
 
360 
 
 OBSTETRICAL OPERATIONS. 
 
 the fœtus (see fig. 150), and the pelvic extremity descends with 
 facility. It will be understood that, since the entire pelvic extrem- 
 ity may descend spontaneously, it will pass down the more readily 
 when it is partly delivered, and we are enabled to make tractions on 
 it. If we are sometimes obliged to seek for the other extremity, this 
 will depend on particular circumstances, which I have heard stated 
 only by M. P. Dubois, and to which I shall allude immediately. 
 
 Extraction. — As soon as the knees, feet, or even one foot, or one 
 knee, shall have been brought into the vagina, moderate and gentle 
 tractions must be made on this part, taking care always to do this 
 during a contraction of the uterus. The contraction aids, in the 
 first place, the extraction ; then it keeps the head flexed on the chest, 
 and the arms in their natural relations ; in no case should the trac- 
 tions be continuous and rapid. No matter what may be the severi- 
 ty of the accident for which version is had recourse to, there will 
 always be time to extract the fœtus with that care and delicacy 
 so necessary to guard both itself and the organs of the mother. 
 It will be necessary, also, to impart to that portion of the fœtus on 
 which tractions are made a movement of torsion, in order to bring 
 as much as possible the back behind the right cotyloid cavity. In 
 the position of which we now speak, this precaution should be ta- 
 ken at the time of the first tractions, in order that the various por- 
 tions of the fœtus may participate in this movement before their 
 descent. On the contrary, if we delay until the parts have de- 
 scended too far, this torsion may fall on some determinate point of 
 the fœtal axis, and thus injure its organs. 
 
 (Fig. 150.) 
 
TURNING. 
 
 361 
 
 But as soon as it is possible to hook the groin of the other limb, 
 the index finger should be carried there, not with a view to bring 
 down this extremity, as all the pupils endeavour to do when they 
 operate on the manikin for the first time, but merely to draw on 
 this part, and thus aid the tractions which are exerted on the limb 
 first seized. 
 
 If, by chance, both extremities have been brought down at once, 
 we should make tractions more particularly on the anterior, in or- 
 der to endeavour to bring the back of the fœtus in front ; and for 
 this purpose, both limbs must be grasped, taking care not to injure 
 them with the ends of the fingers. It is also advised, in this case, 
 to place carefully the thumb on the posterior surface of the limb, 
 the index and middle fingers on the external surface, the ring and 
 little fingers on the anterior surface. What precision ! It requires 
 no comment from me, for the reader will readily perceive its utter 
 inutility. The only precaution, I repeat, for the accoucheur to ob- 
 serve, when he determines on the extraction of the fœtus, is not to 
 bruise the parts ;* to embrace them by broad surfaces, and not al- 
 
 (Fig. 151.) 
 
 * The rules indicated by Dr. Chailly are well worthy the consideration of the pupil ; and, 
 if observed, will render the operation of turning comparatively trifling, so far as the safety of 
 the mother and child is concerned. There is, however, one suggestion I have to make ; it 
 is this : as soon as the feet protrude through the vulva, instead of seizing them with the naked 
 hind and making tractions on them, it would be better to envelop them in pieces of soft lm- 
 
 Z z 
 
3152 
 
 OBSTETRICAL OPERATIONS. 
 
 ways to press on the same points. Thus, in proportion as the fœ- 
 tus is delivered, the accoucheur should place his hands as near as 
 possible to the vulva, and, as far as practicable, let the bones be his 
 point of support. 
 
 In all cases, as soon as the finger can reach the umbilicus, he 
 should make slight traction on the placental extremity of the um- 
 bilical cord, in order to relax it ; he will in this manner avoid rup- 
 turing it in the event of its being tense. If the foetus be across the 
 cord, the posterior limb should be disengaged from the loop formed 
 by the cord, and this latter should be placed in the concavity of 
 the sacrum, where it will be less likely to be compressed than 
 at any other part. 
 
 If care have been taken not to make tractions except during the 
 contractile efforts of the womb, the arms often pass down crossed 
 on the chest before the head, and their descent is effected alone, in 
 proportion as the trunk is extracted. But if the tractions have 
 been continuous, and often even when the rule has not been de- 
 parted from, the arms, in proportion as the trunk is delivered, be- 
 come applied against the two sides of the head, and oppose the 
 extraction of this latter ; we must then proceed to their delivery. 
 
 (Fig. 152.) 
 
 en, and thus continue the tractions, the linen intervening between the hand of the accou- 
 cheur and the extremities of the foetus. Without this precaution, there will be danger of 
 injuring the delicate, soft parts of the infant. This is a rule which I always observe.— Ed. 
 
TURNING. 
 
 363 
 
 We commence with the arm which is behind, because there is 
 more space in the concavity of the sacrum to effect this disen- 
 gagement. The back being to the right, the index and middle fin- 
 ger of the left hand are glided together along the humerus, the thumb 
 serving as a support below ; then the arm is depressed in the di- 
 rection of its flexion, bringing it over the face and chest : we next 
 proceed to the extraction of the arm which is in front ; the pro- 
 cedure is the same, except that we employ in preference the right 
 hand when the back is to the right. 
 
 (Fi ff . 153.) 
 
 It sometimes happens that the delivery of the arm which is in 
 front is extremely difficult ; in this case, we must have recourse 
 to the rule of M. P. Dubois ; I have often seen him employ it with 
 success, and I have already experienced great service from follow- 
 ing it ; it consists in imparting to the trunk a movement of rota- 
 tion from behind forward, and from right to left with the left hand, 
 while we depress the shoulder which is in front into the concavity 
 of the sacrum with the right hand. This slight torsion on the neck of 
 the infant is without inconvenience, and it renders the descent much 
 more easy. 
 
 The head ordinarily enters the cavity flexed, the occiput corre- 
 sponding to one of the points on the anterior portion of the pelvis, 
 and then it will be sufficient to give to the trunk a slight movement 
 of rotation, which brings the back of the fœtus quite forward, in or- 
 
364 
 
 OBSTETRICAL OPERATIONS. 
 
 der to complete the movement of internal rotation of the head. This 
 being accomplished, the trunk of the foetus is raised, and the deliv- 
 ery of the head is generally effected by itself, or under the influ- 
 ence of a very slight effort. 
 
 But if the descent of the head should not take place, we must 
 hasten to extract it. For this purpose, the entire hand is car- 
 ried along the sacrum ; two fingers of this hand are introduced 
 into the mouth of the foetus, and flex the head by depressing the 
 under jaw, while the other hand, placed above the shoulders of 
 the foetus, makes tractions on them ; to these partial movements of 
 the two hands must be joined a movement of elevation, from A to 
 I ; a movement which is executed simultaneously by the two arms. 
 It is in this way only that the head can be extracted when it re- 
 
 (Fig. 154. 
 
 i 
 
 sists, and not by placing two fingers on the sides of the nose, and 
 two on the occiput, as some authors have recommended. 
 
 I know for myself that, whenever I have been obliged to deliver 
 the head after the extraction of the trunk, I have never been able 
 to obtain a sufficiently firm hold on the sides of the nose, which 
 are smooth and slippery ; and I have always been obliged to have 
 recourse to the rule laid down by Madame Lachapelle, and which 
 is adopted exclusively by all accoucheurs who are familiar with 
 the practice of the obstetric art. 
 
 How often has the life of the child been sacrificed by consuming 
 precious time in these vain attempts ! 
 
 On two occasions I had an opportunity of witnessing this fact, as 
 also the excellence of the mode I advise, and the inutility of the 
 other. 
 
 I was called by Dr. A. Robert to see a female living in the Place 
 des Italiens. A physician, whose name I could not learn, had been 
 endeavouring for an hour to extract the head of an infant, the trunk 
 
TURNING. 
 
 365 
 
 of which was delivered : the child was dead. He tried in vain 
 to flex the head by pushing up the occiput, and seek to depress 
 the sides of the nose ; all these attempts proved ineffectual. In 
 two seconds I completed the delivery. 
 
 I arrived one day at the salle des accouchemens, in the absence 
 of M. P. Dubois ; a female was in labour, and had just been deliver- 
 ed of a fœtus that presented by the pelvis ; the trunk was entirely 
 out of the vulva, but for fifteen minutes two persons had been en- 
 deavouring, without success, to extract the head, which was solidly 
 fixed in the pelvic cavity. One of them, for whom I entertain 
 great esteem, was about applying the forceps, when, on seeing me, 
 he begged that I would attempt to deliver the head. There were a 
 number of pupils present, and I was therefore anxious to terminate 
 the delivery. I introduced two fingers firmly on the inferior jaw, 
 and two on the shoulders, and by means of a movement of ele- 
 vation and direct traction, I extracted the head in less time than it 
 has taken me to describe the case. Unfortunately, the child was 
 dead. The head was so firmly fixed, that I was obliged to make 
 very considerable effort, and I retained for several days the marks 
 of the contusion which the under jaw had produced on the middle 
 finger of my right hand. 
 
 Far be it from me to censure those who had given assistance 
 to this patient ; they failed because of too much confidence in a 
 procedure which almost always is ineffectual. 
 
 If the fœtus cannot be rotated on its axis, by which the back 
 is brought in front, and should have been delivered with its face 
 above, and the occiput in the concavity of the sacrum, still the ex- 
 traction may be accomplished ; however, it would be more diffi- 
 cult. 
 
 (Figr. 155.) 
 
 I-—.. 
 
366 
 
 OBSTETRICAL OPERATIONS. 
 
 Two cases may then present in which the head descends flex- 
 ed, because care has been observed in making the tractions. Then 
 the forehead and occiput present together at the inferior strait ; 
 and it is the full sub-occipito-frontal diameter which measures the 
 delivery of the head ; if it should not be accomplished, it must be 
 facilitated by endeavouring to depress the under jaw with two fin- 
 gers, while with the other hand direct traction is made on the 
 trunk (from O to B), slightly depressing it (fig. 155) ; should too 
 much difficulty be experienced, we should, without loss of time, 
 elevate the trunk from A to I (fig. 156), in order to make the 
 forehead pass under the pubes, and to disengage the occiput at the 
 commissure of the perineum. Or the head may reach the pelvic 
 cavity in a state of extension ; and in this case, it cannot be ex- 
 tracted except by raising considerably the trunk from A to I, thus 
 causing the occiput to pass out first posteriorly. ' It is very rare 
 that these means alone will not suffice to deliver the head, without 
 recourse being had to the forceps. 
 
 (Fig. 156.) 
 
 i^. 
 
 Turning in case of Twins. 
 If the fœtus be contained in the uterine cavity, we must be care- 
 ful not to seize both feet if they should present themselves, for we 
 should incur the risk of pulling on a foot of each foetus at the same 
 time. Hence the difficulties to which I have already alluded in 
 speaking of the accidents connected with multiple pregnancy. 
 
 § 2. Difficulties encountered in Pelvic Version. 
 Version is not always performed as easily as I have just stated ; 
 occasionally, difficulties more or less serious are met with in this 
 operation ; I shall now enumerate them in the order of their oc- 
 currence. 
 
 Contraction of the Vulva. 
 The vulva, unless there should be an abnormal conformation, is 
 never so contracted as to offer a serious obstacle to the introduc- 
 
TURNING. 367 
 
 tion of the hand, especially if, before attempting the operation, we 
 delay until the orifice is entirely dilated. In fine, the vulva, to- 
 gether with the neck of the womb, undergoes a sort of preparatory 
 relaxation or softening, which permits the hand to pass it readily 
 enough when the neck itself is permeable. It must be remember- 
 ed, however, that in primiparse especially, the introduction of the 
 hand must be effected with great gentleness and care. 
 
 Rigidity of the Orifice of the Uterus. 
 
 When the orifice is rigid, undilated, and undilatable, we should 
 employ, in order to overcome this resistance, the various means I 
 have already suggested : bleeding, if the patient be plethoric, baths, 
 unctions on the cervix, with the extract of belladonna ; but if these 
 remedies fail, and the accident calling for version be of a nature 
 rapidly to compromise the safety of the mother or child, the ac- 
 coucheur should make several small incisions on the orifice before 
 attempting to penetrate it. 
 
 But these incisions will not readily afford passage to the hand, 
 unless the orifice, although rigid and undilated, be thin. In the 
 contrary case, if it be thick, after making the incisions with a view 
 to overcome the resistance of the orifice, almost as much effort 
 should be employed as in forced delivery. 
 
 Exclusive Rigidity of the Internal Orifice. 
 Sometimes, when the external orifice is dilated and supple, the 
 hand experiences great difficulty in surmounting the resistance of 
 the internal orifice, which contracts spasmodically upon it, and ob- 
 structs its passage to the feet. Often this contraction does not 
 manifest itself until after the hand has been introduced into the 
 womb, and it then acts only on the arm of the accoucheur. But 
 this constriction is sometimes so severe, that the extremity is par- 
 alyzed, and the fingers are deprived of all action ; they touch the 
 parts of the foetus, but are unable to grasp them. To have some 
 idea of this inability of motion, and of the painful pressure which 
 the arm and hand undergo, it is necessary to have experienced it. 
 This circumstance is often a serious obstacle, which, in retarding 
 the labour, exposes the mother and child to all the consequences 
 of the accidents requiring version. In this case, what course is to 
 be pursued ? Withdraw the hand, and introduce the other ; if this 
 should encounter the same difficulty, we should endeavour to ex- 
 cite its motion by putting it into cold water ; and, at the same time, 
 administer to the patient 15, 20, or 30 drops of laudanum in in- 
 jection, and embrocations of equal parts of laudanum and the oil oi 
 sweet almonds should be made on the abdomen. 
 
 Bloodletting should also be practised if there be symptoms of 
 vascular fulness. If, notwithstanding these measures, the resistance 
 is not overcome, which is rare, the accoucheur should request a 
 consultation, in order that his colleague, whose arm has not been 
 suffering from the pressure, may terminate the delivery. This will 
 be an unpleasant alternative ; for people, not being able to appreci- 
 
368 OBSTETRICAL OPERATIONS. 
 
 ate the motive of the accoucheur, will interpret it as an evidence 
 of want of skill. It is, however, an extremity to which the most 
 dexterous practitioners are obliged sometimes to resort. 
 
 Uterine Contraction. 
 It is not usual, in presentation of the vertex, for the contraction 
 of the uterus to be so energetic as to interfere with turning. In 
 fine, unless we have reason to suspect a very inclined presentation 
 of the head, or some mechanical obstacle to its descent, if the ef- 
 forts of the womb have been so powerful as to be followed by a 
 violent retraction of the organ, the head may have descended, un- 
 der the influence of these contractions, so low as to forbid version, 
 and render the application of the forceps necessary. 
 
 Mobility of the Body of the Uterus. 
 M. P. Dubois is the only one who has pointed out another spe- 
 cies of difficulty, which is met with not unfrequentiy, and which 
 proves an obstacle to the introduction of the hand into the cavity 
 of the womb : I allude to the mobility of this organ. In this case, 
 the hand, uterus, and fœtus form but one whole ; the hand cannot 
 pass between the womb and foetus, and it embraces in its motions 
 both the uterus and infant. It will be seen that, under these cir- 
 cumstances, the only indication to fulfills to have the womb main- 
 tained steadily by an assistant. 
 
 Descent of the Head simultaneously with the Feet. 
 When we have seized only one foot or one knee, the other 
 foot or knee which has not descended performs, with regard to 
 the head, the office of a knotted cord which draws the cork from 
 a bottle, and it brings down the head with it to the superior strait. 
 This same thing may occur when both feet have been grasped, 
 but this is more rare. This accident is to be remedied by pushing 
 up the head with one hand, while tractions are made on the feet 
 with the other ; these two movements should be made simultane- 
 ously. 
 
 Only one Foot can be grasped. 
 
 Those cases in which only one foot can be reached, constitute 
 the rule ; those in which both are seized, the exception. As I have 
 already remarked, version is effected, in most cases, equally well 
 with one as when both feet are grasped ; and we cannot settle, as 
 a general rule, that, having brought down only one foot, the other 
 must be searched for. It is rare, on the contrary, that we are 
 obliged to resort to this expedient. 
 
 What circumstances, however, may render it necessary ? There 
 is but one ; it sometimes happens that the internal orifice, which 
 has allowed the hand to pass freely, contracts on the various parts 
 of the foetus in proportion as we endeavour to extract them, and 
 the contraction is occasionally so powerful, that the amount of force 
 necessary to employ in order to overcome this resistance may be 
 such as to lacerate and injure the extremity on which the force is 
 
369 
 
 used. Therefore, to obviate this inconvenience, we should seek for 
 the other extremity of the foetus ; and in making tractions on both 
 extremities at the same time, we shall be less liable to injure them 
 than if we concentrated our effort on one only. 
 
 But it cannot be admitted, as some authors have contended, that 
 the obstacle to the extraction of the foetus in this case is due to the 
 fact that it is placed with its extremities crosswise on the symphy- 
 sis pubis, one foot resting on the border of the superior strait. How, 
 in a word, can we admit that such causes are capable of opposing 
 the extraction of the foetus, when we know that the inferior seg- 
 ment of the uterus presents a smooth infundibulum, on which the 
 fœtus easily glides along to the orifice ; and that the superior strait, 
 on which the segment reposes, is itself covered with soft parts, 
 which conceal all its asperities? 
 
 In seeking for the extremity which he has not been able to bring 
 down, the accoucheur attaches a fillet to the extremity already in 
 the vulva, in order to retain it externally ; he then introduces the 
 right hand when the part he seeks is on the left, and the left hand 
 in the contrary case, and, grasping the extremity as he can, he ex- 
 tracts it from the womb (fig. 158). 
 
 Difficulties in bringing down the Arms. 
 During the extraction of the trunk, the arms may ascend on 
 the sides of the head, and then their delivery is not very diffi- 
 
 A A A 
 
370 
 
 OBSTETRICAL OPERATION! 
 
 (Fig- 158.) 
 
 cult : all authors agree on this point. The arm in front may of- 
 fer some little obstacle. I have indicated the rule laid down in 
 this case by M. P. Dubois, which consists in conducting the ante- 
 rior shoulder in the concavity of the sacrum. But the righting of 
 this arm is not always effected on one of the sides of the head ; if 
 it should not have participated in the movement of rotation pro- 
 duced on the trunk, it passes behind the occiput : this accident can 
 only take place in the occipito-pubic position. In the occipito- 
 sacral, on the contrary, it is unimportant, for the descent will be 
 easy in the concavity of the sacrum. 
 
 Again, the arm may right itself in two different directions: 
 either in passing the right side of the head over the chest, or in 
 following the back of the infant and the posterior part of the neck. 
 In order, then, to disengage the arm without injuring its articula- 
 tion with the shoulder, it should be brought down in the direction 
 in which the righting has taken place. Thus, it will be perceived 
 that the difficulty does not consist merely in the descent, but in 
 distinguishing these two modes of righting the one from the other. 
 
 Some authors have given precepts by which, they contend, it is 
 very easy to recognise these two species of righting : if it occur 
 in the anterior and superior direction, the inferior angle of the 
 
TURNING. 371 
 
 scapula is very remote from the spine ; it is, on the contrary, very 
 near the spine when the crossing is effected from below upward 
 and posteriorly. 
 
 It is far from being easy to distinguish these two accidents from 
 each other when the accoucheur feels the chest palpitating be- 
 tween his two hands, and with imminent risk of life unless there 
 be prompt action. Under such circumstances, we cannot make 
 these minute distinctions ; the delay of a few seconds, and the in- 
 fant ceases to live ; we must, therefore, act promptly and decided- 
 ly. In all cases, the descent will be very long and difficult to ef- 
 fect, even when the nature of the righting has been ascertained ; 
 often, it will be impracticable. In a word, how can we cause the 
 arm to pass with facility between the occiput and symphysis pubis, 
 when these two parts are in immediate contact ? 
 
 But it must also be admitted that the means of diagnosis are not 
 so certain that they may not give rise to error ; and if we be de- 
 ceived as to the direction of the righting, which may frequently be 
 the case, we will be exposed to the blunder of disengaging in one 
 direction an arm which has been righted in another, and then the 
 articulation may be twisted. 
 
 In view of the difficulties of descent and of its delays, in conse- 
 quence of the impossibility, in most cases, of accurately ascertain- 
 ing the diagnosis, and on account of the danger of a descent in a 
 contrary direction, it will be much better to have recourse imme- 
 diately to the method of Madame Lachapelle. " If great diffi- 
 culty," she observes, " be experienced in disengaging the arm 
 placed between the occiput and symphysis pubis, we should not 
 lose time in endeavouring to effect an impossibility, but the arm 
 should be brought down with the head. The arm may possibly 
 be fractured ;t but this latter circumstance should not deter the 
 accoucheur ; for, in forcing the descent, in the majority of cases the 
 fracture will be produced much more frequently than in disenga- 
 ging it with the head." 
 
 We might also, in this instance, employ the rule of M. P. Du- 
 bois, and carry the shoulder which is above into the concavity of 
 the sacrum ; then the disengagement of the arm will be effected 
 with tolerable facility, whatever may be the direction of the right- 
 ing. 
 
 Application of the Forceps when the Delivery of the Head, arrested 
 at the Inferior Strait, cannot be accomplished by the Hand of 
 the Accoucheur. 
 
 It is extremely rare that the delivery of the head, when delayed 
 at the superior strait, cannot be effected by the hand alone, and 
 that the use of the forceps becomes necessary ; and, indeed, I am 
 satisfied that, in a majority of cases in which this instrument has 
 
 * Fracture of the arm is a slight accident in a newly-born child, but the accoucheur 
 should not mention it, lest the parents be alarmed. A compress, containing a piece of paste- 
 board soaked in water, and a bandage to envelop the arm, are all that is necessary in this 
 case. In eight or ten days it must be removed, and the union is perfect. 
 
372 
 
 OBSTETRICAL OPERATIONS. 
 
 been supposed necessary, if a proper mode of extraction had been 
 resorted to, and sufficient force applied, the head might have been 
 delivered with the hand alone. 
 
 The inferior strait, however, may be so contracted, and the re- 
 sistance of the external parts so great, as to render the application 
 of the forceps necessary. 
 
 In this case, the head may assume four principal positions, and 
 present flexed or extended. 
 
 A. Occipito-pubic Position. — Whether the head be flexed or ex- 
 tended, the application of the forceps will be precisely the same. 
 Moreover, the general rules for the application of the instrument 
 will be likewise the same as when the head presents first in a sim- 
 ilar position ; there is, however, one invariable precept here, which 
 is always to be observed when the forceps is applied after the de- 
 livery of the trunk. 
 
 The forceps must always be applied at the anterior part of the 
 fœtus, whatever may be its position. 
 
 Promptitude is one of the first rules to be observed in this appli- 
 cation. Thus, after having enveloped the fœtus in warm linen, 
 the trunk should be elevated as high as possible by an assistant, 
 and the forceps applied below the trunk. The pivot branch, held 
 with the left hand and guided with the right, previously introduced 
 into the maternal organs, is placed on the left of the pelvis ; the 
 mortise branch, held with the right hand and directed with the 
 left, is placed on the right. The head is then seized by its bi- 
 parietal diameter ; and when the articulation of the blades is com- 
 pleted, the accoucheur lays hold of the two inferior extremities of 
 the infant at the same time that he grasps the extremity of the for- 
 ceps, and an assistant supports the trunk of the fœtus. He then 
 delivers the head, elevating the instrument from A to I (fig. 159). 
 
 (Fig. 159.) 
 
 B. Occipito-sacral Position. — In this position, the forceps is ap- 
 plied in precisely the same manner as in the preceding case, 
 
TURNING. 
 
 373 
 
 whether the head be flexed or extended ; but the mode of delivery- 
 varies according to one or other of these circumstances. The 
 trunk of the fœtus, in either case, should be depressed as low as 
 possible, in order to permit the introduction of the instrument. 
 
 (Fig. 160.) 
 
 ai -**- 
 
 These precautions being taken, and the forceps applied, if the 
 head be flexed, tractions must be made from A to I, and the for- 
 ceps slightly depressed, in order to disengage the forehead from 
 under the pubes (fig. 160). 
 
 If the head be extended, the delivery will be accomplished by 
 elevating the instrument from A to I (fig. 161), the assistant being 
 always careful, in these two cases, to support the trunk according 
 to the movements of the accoucheur. 
 
 (Fig. 161.) 
 
 The application of the forceps is a little more difficult in these 
 two cases, when the occiput is posteriorly, than when it was in 
 
374 
 
 OBSTETRICAL OPERATIONS. 
 
 front. But in the left occipito-iliac or right occipito-iliac, always 
 after the delivery of the trunk, great difficulty is experienced in 
 the adjustment of the branches. And Madame Lachapelle has 
 recommended very wisely to bring the face into the concavity of 
 the sacrum by means of the hand, and thus apply the forceps in 
 the occipito-pubic position. For this purpose, the right hand of the 
 accoucheur if the back be to the left, the left hand if the back be 
 to the right, must be introduced into the concavity of the sacrum, 
 and the fingers, united in the form of a crotchet, turn the face into 
 the sacrum, while the other hand imparts to the trunk an analo- 
 gous movement. 
 
 (Fig. 162.) 
 
 This being accomplished, the head is extracted with the hand 
 (fig. 151); it would only be in case of failure that we should be 
 obliged to resort to the forceps. For this purpose, the trunk of 
 the foetus should be held towards the left thigh ; if the occiput be 
 to the left, the forceps should be applied to the anterior part of the 
 infant, the concavity of the borders regarding the occiput, that is, 
 the left, and we should commence with the pivot branch. 
 
 When the instrument is articulated, the accoucheur rotates it 
 from left to right, which will bring, simultaneously, the concavity 
 
TURNING. 
 
 375 
 
 of the borders of the instrument and the occiput under the pubes. 
 The delivery is then effected as in an occipito-pubic position. 
 
 (Fig. 163.) 
 
 In the right occipito-iliac position, the trunk must be kept to- 
 wards the right thigh, the concavity of the borders of the instru- 
 ment being directed to the right ; the rotation must be from right to 
 left, &c, &c. (fig. 164). 
 
 These applications, whether the head be diagonal or transverse, 
 are extremely difficult ; but happily, in most cases, we will be able 
 to bring the face into the concavity of the sacrum by means of the 
 hand (fig. 162), when it corresponds to one of the two sides of the 
 pelvis. 
 
 This manipulation has also been recommended when the face is 
 above ; but it is entirely impracticable : the hand and wrist cannot 
 penetrate deep enough to turn the head, and the fingers, therefore, 
 cannot reach the face. In order that this operation may be per- 
 formed, the pelvis should be very capacious and the head very 
 small ; in this case, the operation would be useless, for the head 
 would readily follow the rotation imparted to the trunk, and the 
 face would be thus brought into the concavity of the sacrum with- 
 out the introduction of the hand, and without the forceps. 
 
376 
 
 OBSTETRICAL OPERATIONS. 
 (Fig. 164.) 
 
 The Head may he retained at the Superior Strait. 
 
 A. Well-formed Pelvis. — We must, in the first place, suppose 
 that there is no disproportion between the pelvis and the head of 
 the foetus. In this case, the head cannot be arrested at the supe- 
 rior strait if proper tractions have been made, and especially if 
 we have been careful to employ them only during the contractions 
 of the uterus. The head will readily pass this strait in presenting 
 its occipito-frontal diameter ; but if the tractions have been con- 
 tinuous, the head, being no longer retained in its position of natural 
 flexion by the contractions of the uterus, becomes extended, and 
 then presents at the superior strait its occipito-mental diameter. 
 
 This accident may occur in two principal positions : occipito- 
 pubic, and occipito-sacral. 
 
 a. Occipito-pubic. — The occiput rests on the pubes, the chin on 
 the sacro-vertebral angle. The accoucheur introduces his hand 
 under the trunk of the foetus, and passes it high enough to place 
 his index and middle fingers in the mouth of the infant, and, in thus 
 bringing down the chin first, he substitutes for the occipito-mental 
 diameter, measuring five inches, the occipito-frontal diameter, 
 which measures four inches. This operation is not very difficult : 
 the trunk does not so completely occupy the pelvic cavity as to 
 prevent the introduction of a small hand between the chest and the 
 concavity of the sacrum. 
 
377 
 
 b. Occipito-sacral. — The occiput rests on the sacro-vertebral 
 angle, the chin on the symphysis pubis. Here it is not possible to 
 introduce the hand between the symphysis pubis and the chest of 
 the fœtus, in order to depress the mouth, and, consequently, the 
 chin. There is not sufficient space between these parts to permit 
 the passage of the smallest hand. We must, therefore, abandon 
 this method. The accoucheur should carry the right hand poste- 
 riorly, in order to embrace the occiput and direct it to the left, and, 
 consequently, the face to the right ; this should be combined with 
 a motion of elevation of the wrist, to flex the head, in supporting 
 the occiput. This being accomplished, that is, the face regarding 
 
 (Fig. 166.) 
 
 Bbb 
 
378 OBSTETRICAL OPERATIONS. 
 
 one of the points of the right side, the hand endeavours to reach 
 the face, as in fig. 162, and directs it posteriorly. Two fingers are 
 then introduced into the mouth, and they complete the flexion of 
 the head, if it be not sufficient, and deliver it. 
 
 This manipulation, as must be evident, is extremely difficult to 
 execute ; it is, however, the only innocent plan to be resorted to 
 in a similar case. If the delivery of the head cannot be effected 
 in this way, we have no other alternative than the method I shall 
 indicate farther on. 
 
 B. Malformed Pelvis. — I have mentioned, among the contra-in- 
 dications for turning, two circumstances of equal value : excessive 
 size of the head, and contraction of the pelvis. It is often in our 
 power, before attempting version, to ascertain the condition of the 
 pelvis ; but this is not always possible, and it frequently happens 
 that, in performing version in a pelvis which we suppose to be 
 well formed, we are surprised at meeting obstacles to the descent 
 of the head. These obstacles reveal to us the fact that the pelvis 
 is contracted, but so regularly that the circumstance escaped our 
 observation. 
 
 Again, in consequence of the difficulties of ascertaining the size 
 of the fœtal head before birth, unless the infant be affected with 
 hydrocephalus, we are often exposed to the error, after extracting 
 the trunk, of bringing to the superior strait a head of excessive vol- 
 ume. 
 
 This accident is the most serious for the fœtus of all those ca- 
 pable of complicating version. The almost insurmountable diffi- 
 culties encountered in the extraction of an extended head, when 
 the superior strait is contracted, will often compromise the life of 
 the child by the delay occasioned in its delivery, and also by the 
 manipulations, more or less murderous, to which we are obliged to 
 have recourse. 
 
 The extended head may be arrested in the two positions, oc- 
 cipito-pubic and occipito-sacral, which I have admitted in the case 
 of a well-formed pelvis. The accoucheur must endeavour to in- 
 terfere in the same manner (see figs. 165 and 166) ; he will succeed 
 sometimes in the occipito-pubic position, but very rarely in the 
 occipito-sacral. In case these efforts should fail, what is to be 
 done ? Shall the forceps be applied, as some have recommended, 
 when the head is situated above the superior strait, and the trunk 
 of the fœtus filling up the pelvic excavation ? Is this even possi- 
 ble ? Experience proves that, under these circumstances, the for- 
 ceps is of no use, for there is not sufficient space in the cavity to 
 permit the instrument to reach the head ; and that, even admitting 
 that each branch might possibly be introduced, yet it would not 
 be practicable to unite or articulate them. Certainly this is one 
 of the most embarrassing and painful situations in which the ac- 
 coucheur can be placed. He sees that the infant is in extreme 
 danger, and he cannot attempt to afford it relief without incurring 
 the hazard of destroying it by the very means he resorts to for its 
 
TURNING. 379 
 
 safety. This situation is, indeed, an unpleasant one, but it must be 
 accepted. 
 
 The first indication, in the occipito- sacral position, is to rotate 
 forcibly the trunk of the foetus with the left hand, so as to bring 
 the face posteriorly, while with the right hand, the fingers of 
 which are introduced into the mouth, we must attempt to flex and 
 extract the head. 
 
 We are often, in this case, obliged to be aided by an assistant, 
 who rotates the trunk of the infant, and makes, at the same time, 
 tractions on it proportionate to the resistance. We should be 
 guarded in exercising these tractions on the fœtus, not so much 
 through fear of destroying it — for, in the majority of cases, it has 
 already been sacrificed by the torsion practised on its trunk — but in 
 order not to exhibit the sad spectacle of a violent detruncation, 
 which often covers with ridicule the operator, who falls on the 
 ground with the body of the fœtus in his hands ! ! Violence should 
 never be suffered to characterize an obstetric operation, no matter 
 what may be its nature. If the section of the neck of the child be 
 necessary, it is far preferable to perform it with a cutting instru- 
 ment than forcibly to tear the trunk from the head. The soft parts 
 of the mother, too, frequently suffer from these violent tractions. 
 
 Unfortunately, as a last resort, the accoucheur will be obliged 
 to have recourse to detruncation, and afterward to the forceps, in 
 order to deliver the mother. M. P. Dubois performs the section 
 of the neck by means of large curved scissors. This operation 
 cannot be completed with two or three cuts, as has been supposed. 
 The scissors can only act by their extremity and by small sections, 
 for otherwise the soft parts of the mother would be exposed to in- 
 jury. 
 
 In order to perform this operation, we should, in the first place, 
 depress the trunk of the fœtus in drawing from above, and the 
 section should be made commencing from before backward. We 
 may, indeed, employ a bistoury, but the scissors appear to me to 
 fulfil more completely the indication in view. The trunk being 
 removed from the pelvic excavation, it is possible then to change 
 the direction of the head, and to remove it in all cases by the for- 
 ceps or the cephalotribe, if this instrument should become indispen- 
 sable. 
 
 This is an extremity to which the prudent accoucheur will not 
 often be reduced, if he examine closely into the condition of the 
 pelvis before he attempts to act, and be careful to make moderate 
 tractions only during the contractions of the uterus. If, however, 
 the accoucheur sometimes finds himself compelled to resort to this 
 alternative, it is always after the life of the child has been sacri- 
 ficed by improper attempts at version, and when the pelvis is con- 
 tracted. The safety of the mother, therefore, is his only care. 
 
 I have not mentioned, in this article, shortness of the cord as a 
 complication in version, for I have already treated this subject in 
 detail. The indications, however, are precisely the same, whether 
 this accident complicates version or spontaneous delivery. 
 
380 
 
 OBSTETRICAL OPERATIONS. 
 
 Art. III. — Cephalotomy. 
 Cephalotomy comprises the following operations: 1st, perfora- 
 tion of the cranium ; 2d, breaking down the base of the scull. 
 
 § 1 . Perforation of the Cranium. 
 This operation is performed with Smellie's scissors : it is the in- 
 strument that should be preferred. We may, however, employ a 
 bistoury, or the perforator attached to the extremity of one of the 
 branches of certain forceps ; but this latter instrument especially 
 is far from presenting the advantages of Smellie's scissors. 
 (Fig. 167.) The patient being situated as for the application of the 
 a forceps or version, the accoucheur lubricates properly his 
 / \ left hand, and introduces it entire, except the thumb, into 
 \ / the maternal organs ; he then takes the scissors in his right 
 hand, having previously guarded the point with a small ball 
 of wax, and guides them on the palmar surface of the left 
 hand until they reach the head ; in order to perforate more 
 readily, he selects a suture or fontanelle, if practicable ; but 
 the important point is, to direct the instrument perpendic- 
 ularly, in order that it may not slip and wound the organs 
 of the mother. If, therefore, it should become necessary to 
 depart from this perpendicular line in his attempt to reach a 
 suture or fontanelle, the accoucheur should at once abandon 
 the idea of perforating in one of these membranous spaces, and 
 should select that portion of the head which presents most directly 
 to the point of the instrument. A few movements of rotation will 
 suffice, together with a slight effort, to overcome the resistance of 
 the bones of the cranium, and the accoucheur will know that he 
 has penetrated the cerebral mass as soon as the resistance ceases. 
 He then separates the branches of the instrument, turns them in 
 different directions, and thus breaks down the brain ; the branches 
 are now brought together, and, holding them between the thumb 
 and index finger of the right hand, he again separates them suf- 
 ficiently to widen the opening as the scissors are withdrawn. The 
 scissors represent a kind of lancet, the external borders of which 
 are cutting. At the moment they are withdrawn from the cra- 
 nium, directing them cautiously on the left hand, which must re- 
 main in the vagina during the whole operation, the scalp should 
 be incised in order to afford a more easy escape to the brain. 
 
 It has been recommended, in this case, to throw injections into 
 the cranium, with a view to favour the evacuation of the cerebral 
 mass ; but I have satisfied myself that they are entirely useless ; 
 they complicate and render more disagreeable an operation, the 
 consequences of which we should, as far as possible, conceal. 
 Thus, after the scissors are withdrawn, if we do not employ injec- 
 tions, the contractions of the uterus, or the cephalotribe, if the de- 
 gree of contraction should require it, will suffice to bring away 
 the brain, which the accoucheur should receive in a cloth, and care- 
 fully remove from thé observation of the assistants ; while, on the 
 
CEPHALOTOMY. 
 
 381 
 
 contrary, the water of the injections, mixed with blood and brain, 
 passes abundantly from the organs, and gives to this operation the 
 appearance of barbarity. 
 
 If the degree of contraction will permit the spontaneous expul- 
 sion of the head after it is reduced, the patient should be covered 
 and removed to her bed, and the delivery of the foetus committed 
 to nature ; whenever this course can be adopted, it will certainly 
 be the most desirable ; for the application of the forceps, and still 
 more the cephalotribe, will be accompanied with more or less dan- 
 ger, from which, as far as possible, the patient should be protected. 
 But should the woman be exhausted, or if there be inertia of the 
 womb, we must have recourse to the forceps (see rules for this 
 application when the head is above the superior strait). The in- 
 strument, in this case, will be more likely to slip than when the 
 head has not been perforated. It will, therefore, be necessary to 
 bind very accurately the handles of the forceps with a napkin, in 
 order to prevent this accident. If the pelvis measure less than 
 three inches, the cephalotribe must be employed. 
 
 § 2. The Cephalotribe. 
 The cephalotribe, or compressing forceps of the head, invent- 
 ed by M. Baudelocque, nephew of the celebrated accoucheur, is a 
 most precious instrument, which cannot be too positively defended 
 against its traducers. It advantageously replaces all the sharp 
 crotchets, and the entire arsenal of cutting instruments, armed with 
 teeth, &c. ; instruments almost as fatal to the mother as to the child, 
 and which, I am happy to say, are completely banished from prac- 
 tice. 
 
 (Fig. 168.) 
 
382 OBSTETRICAL OPERATIONS. 
 
 This instrument, composed of two branches, is applied, like the 
 forceps, at the superior strait, on the two sides of the pelvis. In 
 fact, even when it can be applied regularly tc the head, it becomes 
 altogether useless, if the size of the head must be reduced. 
 
 The important point in this operation is, carefully to guide the 
 instrument into the uterus, and to be well assured that the organs 
 of the mother have not been included within the grasp of the cephal- 
 otribe. Its weight, although much reduced since its invention, 
 renders it much less manageable than the ordinary forceps. 
 
 The head being seized, the branches must be articulated, and 
 then brought together by turning the manivelle. The firmest and 
 most thoroughly ossified heads readily yield under the pressure of 
 this instrument. As soon as the reduction is effected, the accou- 
 cheur should proceed to the extraction with all possible care ; for 
 spiculse of bone frequently pass through the scalp, and may lacer- 
 ate the maternal organs. To avoid these accidents, the accou- 
 cheur must give to the cephalotribe a proper direction ; he should 
 endeavour to place the largest diameter of the crushed head in 
 apposition with the largest of the pelvis. For this purpose, he di- 
 rects the concavity of the borders of the instrument either to the 
 right or to the left, as he may experience more facility in bring- 
 ing down the head in one or the other direction ; he should also 
 introduce the fingers of the left hand, in order to protect, as much 
 as possible, the organs from the spiculas of bone which may have 
 protruded through the scalp. 
 
 Some authors have recommended always to perforate the cra- 
 nium before applying the cephalotribe ; but it seems to me that this 
 precept should not be absolute. In my opinion, we should com- 
 mence by perforating when we have reason to hope that this alone 
 will suffice ; but when we know in advance that we must resort 
 to the cephalotribe, notwithstanding the perforation, there can be 
 no motive in performing two operations when one will be suf- 
 ficient. In a word, the most solid heads cannot resist the cephalo- 
 tribe ; the scalp is perforated spontaneously, and the brain escapes 
 of itself ; this, at least, is what I have always observed in the living 
 female, in the manikin, and in the dead infant. The operation is 
 more rapid, less dangerous for the mother, and is not so repulsive 
 to the assistants ; and I believe that the opinion that perforation 
 of the cranium should always of necessity precede the use of the 
 cephalotribe has been advanced with no other object than to make 
 it appear that this instrument is incomplete. 
 
 Art. IV. — Operations on the Mother. 
 Thanks to premature artificial delivery and the cephalotribe, 
 operations which were formerly supposed necessary to be per- 
 formed on the mother for the purpose of extracting the child, are 
 now resorted to only in very rare cases. These operations are 
 symphyseotomy and the Caesarean section. 
 
SYMPHYSEOTOMY. 383 
 
 § 1. Symphyseotomy. 
 
 The section of the symphysis pubis has been advised in cases 
 in which the pelvis measures from three inches and a quarter to 
 two inches and a half; but premature artificial delivery during 
 pregnancy, and cephalotripsy, if, unfortunately, the aid of the ac- 
 coucheur has not been called for in time to provoke premature 
 delivery, have caused this operation to fall entirely into disuse. 
 Almost as serious for the mother as the Csesarean section, it does 
 not present the same advantages for the child ; the efforts almost 
 always necessary to make on the infant to extract it compromise 
 its life. 
 
 In fine, the division of the symphysis pubis does not present such 
 an increase in the pelvis as to enable a fœtus of normal size to pass 
 without injury both to itself and mother. 
 
 I do not, for example, speak of a contraction of three inches 
 and a quarter ; for the forceps will answer in this case without the 
 section of the pubes ; but under this, symphyseotomy offers no ad- 
 vantages. 
 
 It is not possible to separate the symphysis more than two inch- 
 es, which will augment the antero-posterior diameter only four 
 lines ; if to this be added the three lines gained by the descent of 
 the parietal protuberance in the separation of the pubes, the antero- 
 posterior diameter will present an increase of seven lines. If this 
 diameter measures three inches, its increase will give it only three 
 inches and a quarter. 
 
 It will now be seen that this result will still require considerable 
 effort to be made on the head by means of the forceps. 
 
 If, now, the pelvis measured only two inches and a half, its 
 maximum of increase would be three inches one or two lines ; and, 
 in this case, the forceps would often prove insufficient, and perfora- 
 tion of the cranium and cephalotripsy would be indicated, notwith- 
 standing the operation of symphyseotomy had been performed : in 
 other words, the mother would have been sacrificed without profit 
 to the child. 
 
 In fact, when symphyseotomy will permit the extraction of the 
 child without violence, premature delivery in such cases will prove 
 much more advantageous. If, called in too late, the accoucheur 
 has not been able to provoke delivery before term (the infant being 
 viable), he has only to choose between symphyseotomy and perfo- 
 ration or cephalotripsy. Reduced to this extremity, of seriously 
 involving the safety of the mother without knowing whether the 
 child is alive, or of sacrificing the child with the view of protect- 
 ing the parent, the accoucheur must take counsel of his conscience. 
 As for myself, the choice would not be doubtful. 
 
 Nevertheless, I shall now, in a few words, give a history of this 
 operation, and the modes of performing it. 
 
 In 1773, Sigault, at that time a student of medicine, struck with 
 the idea that the abnormal softening of the pelvic articulations ren- 
 dered parturition more easy, proposed to separate the svmphysis 
 
3S1 OBSTETRICAL OPERATIONS. 
 
 pubis to arrive at the same result. The Academy of Surgery re- 
 jected this proposition ; but Sigault was not discouraged, and, as- 
 sisted by Alphonse Leroy, he performed his first operation in 1777. 
 Both mother and child were saved. This success secured for him 
 a number of partisans. The faculty of medicine presented him with 
 a medal, but he raised up against himself numerous and bitter ad- 
 versaries. The physicians divided themselves into two classes, the 
 one advocating symphyseotomy, the other the Csesarean section. 
 Much was written for and against ; recrimination followed recrim- 
 ination, and the controversy at last terminated by the general con- 
 sent that each operation had its own peculiar advantages. 
 
 Operation. 
 
 Symphyseotomy should not be practised except when the infant 
 is living, and especially where there is no doubt of its viability. 
 When, therefore, auscultation has decided this question, the accou- 
 cheur can proceed with the operation, which is simple enough. Af- 
 ter evacuating the bladder, the patient is placed as for the applica- 
 tion of the forceps, and firmly held by assistants. A sound is in- 
 troduced into the bladder ; it will serve at the same time to evac- 
 uate the urine, and direct, during the operation, the meatus urinarius 
 downward and to the right, remote from the cutting instrument. 
 An assistant holds the sound in this situation, while another makes 
 tense the integuments above the pubes. The operator, after hav- 
 ing ascertained the precise position of the symphysis, makes an 
 incision, -embracing all the soft parts, commencing about half an 
 inch above the pubes, and extending a little to the left, above the 
 clitoris. This incision brings to view the inter-pubic cartilage, 
 which must be cut through with great care, to avoid injuring the 
 bladder. This being accomplished, the bones separate, and if the 
 contractions "be energetic, the delivery may terminate spontaneous- 
 ly. In the contrary case, we must have recourse to the forceps. 
 After the delivery, the bones must be brought together, the integu- 
 ments united by adhesive straps, and the whole maintained in place 
 by a body bandage. If any vessels should be cut during the oper- 
 ation, they must be secured by ligature. 
 
 But a multitude of evils follow this operation, and frequently 
 destroy the patient. When she survives, the consolidation of the 
 bones is not ordinarily completed for three or four months ; in some 
 instances it neyer takes place, and the patient cannot walk during 
 the remainder of her life. 
 
 § 2. Cœsarean Section. 
 
 The Cesarean section, or the extraction of the foetus by means 
 of an incision into the abdominal and uterine walls, should not be 
 performed on the living woman except in cases in which the con- 
 traction of the pelvis is so marked as to proscribe the use of the 
 cephalotribe. 
 
 This operation may also be practised on a female who has just 
 expired after the period of viability, and when auscultation shows 
 
CESAREAN SECTION. 385 
 
 that the foetus is still living, and that it is possible to extract it 
 alive. 
 
 But if the female should succumb during labour, it would be bet- 
 ter, if the condition of the organs would permit, to extract it by 
 means of the forceps, or by version. 
 
 How often, after the death of the mother, has this operation been 
 practised ; and practised, too, even when auscultation has not de- 
 tected the pulsations of the fœtal heart ? 
 
 Some accoucheurs recommend always to perform this operation, 
 whether the pulsations of the heart are heard or not, and even 
 after the lapse of ten, fifteen, or twenty-four hours from the death 
 of the mother, children having survived the death of their parent 
 for this period. There can be no objection to this precept as a 
 general rule of conduct, being always careful to ascertain that the 
 female has positively expired, and careful, too, to perform the oper- 
 ation with as much vigilance as if she were living, for fear that she 
 really were so. When, however, this rule was originally laid down, 
 its utility was undoubted, for at that period there were no certain 
 signs by which the death or life of the foetus could be established. 
 But we are now, perhaps, not so well convinced of its necessity, 
 since auscultation furnishes the certain means of ascertaining the 
 pulsations of the heart ; a means the more infallible, as all the other 
 organs in which life is extinct are in the most absolute repose, so 
 as not in any way to interfere with auscultation. 
 
 As for myself, I do not hesitate to state that, unless the friends 
 should urgently desire the operation, I would not perform it, unless 
 I had distinctly heard the pulsations of the foetal heart. And I 
 should pursue this course for the reason that the death of the moth- 
 er might be only apparent ; and if the operation be performed only 
 ten or fifteen minutes after it was supposed she had expired, her 
 death would certainly be caused on the spot, while, without the 
 operation, she might have been restored to life. 
 
 The Caesarean operation is one of the most serious that can be 
 practised on the living woman : five sixths, at least, die.* With 
 
 The Caesarean section is, undoubtedly, a dread alternative for the accoucheur to choose, 
 but I cannot agree with Dr. Chailly, that its fatality is as great as he represents ; nor am I 
 disposed to adopt the opinion, unfortunately too general, that craniotomy is almost always to 
 be preferred to the Caesarean section. In truth, it needs some nerve, and, for a man of 
 high moral feeling, much evidence as to the necessity of the operation, before he can bring 
 himself to the perpetration of an act which requires, for his own peace of mind, the fullest 
 justification. The man who would wantonly thrust an instrument of death into the brain 
 of a living fœtus, would not scruple, under the mantle of night, to use the stiletto of the as- 
 sassin. Yet, how often has the foetus been recklessly torn from its mother's womb piece- 
 meal, and its fragments held up to the contemplation of the astonished and ignorant 
 spectators as testimony undoubted of the operator's skill ! Oh ! could the grave speak, how 
 eloquent, how momentous, how damning to the character of those who speculate in human 
 life would be its revelations ! 
 
 Independently of the abuse of this operation (craniotomy), of its unjustifiable frequency, 
 let us for a moment look at its relative fatality when compared with the Caesarean section. 
 
 According to the statistics gathered by Dr. Churchill, among British practitioners, crani- 
 otomy is resorted to 1 in 219 cases ; among the French, 1 in 1205§ ; among the Germans, 1 in 
 1944^ : the average, therefore, of these three nations will be 1 in 896^. In 252 cases, 50 
 mothers died, or about 1 in every 5. As regards the Caesarean section, the same author 
 states, that since 1750 he has collected 321 operations, from which 149 mothers recovered ; 
 and that in 187 cases, where the result is mentioned, 130 children were saved, and 57 lost. 
 
 Hence, then, we have a calculation showing that in craniotomy, where, of necessity, all 
 
 Ccc 
 
386 OBSTETRICAL OPERATIONS. 
 
 such results, it is difficult to conceive how a practitioner can de* 
 cide to perform it on a living woman, when, by sacrificing the child, 
 
 the children must be sacrificed, one woman ont of every five died ; while in the Caesarean 
 section, one mother recovered out of two and a fraction, and the success to the child was 
 certainly most fortunate. 
 
 But, again, we only hear of the deaths in the proportion of 1 to 5 of women who have been 
 subjected to the hazards of craniotomy ; nothing is said of the dreadful lacerations and de- 
 struction of the soft parts, which often entail on the sufferer distress and anguish to which 
 death itself would be preferable. 1 do not believe it is possible to remove a child by embry- 
 otomy when the antero-posterior diameter of the superior strait measures less than two inch- 
 es, without subjecting the mother to severe hazard, provided the child be of the ordinary size. 
 My opinion on this subject is not a speculative one ; it is based on repeated experiments made 
 on a wooden pelvis constructed for this purpose ; and 1 am satisfied that, even with the 
 space of two and one fourth inches, all the dexterity which the operator can bring to his aid 
 will be required to protect the mother from serious, if not fatal injury. Authors, therefore, I 
 think, must have laboured under some error on this subject. For example, Dr. Davis states 
 that craniotomy is admissible when the diameter is only one inch ; Dr. Burns, when it is one 
 and three fourths ; and Dr. Osborne, when it is one and a half inches. I cannot but protest 
 against anv such deductions, and, therefore, without hesitation, would prefer the Caesarean 
 section (if I had certain evidence that the child lived) to any attempt to extract it per vias 
 naturalea, if the antero-posterior diameter measured less than two and one eighth inches. The 
 reject of craniotomy is to save the life of the mother by sacrificing that of the child. This 
 object cannot, in my judgment, be attained without occasioning the most serious results 
 (even admitting she survives the operation) in a contracted pelvis such as is described by Drs. 
 Burns, Osborne, &c. 
 
 A case occurred in Philadelphia, unique in its character, and one that is full of profes- 
 sional interest. Mrs. R., twenty-six years of age, was married 16th of May, 1830, and on 
 the 14th of June, 1831, was in labour with her first child. Dr. George Fox was called to 
 her assistance, and finding that there was deformity of the pelvis, requested the counsel 
 of Profs. James and Meigs, and Drs. Lukens, Hewson, and J. R. Barton. It was concluded, 
 after repeated examination, that the antero-posterior diameter did not exceed two inches. 
 " The question arose as to what was to be done. The Caesarean operation was thought to 
 be attended with so much risk to the mother as almost to be necessarily fatal, some of the 
 most distinguished surgeons being entirely opposed to its performance; and Dr. Physic, 
 who was called upon for his opinion on the propriety of this operation, was decided and 
 positive in his opposition to it ; under the weight of such authority, the idea of the Caesarean 
 •operation was abandoned."* It was then determined to perform cephalotomy, and Prof. 
 Meigs agreed to undertake it. Before he commenced the operation, however. Prof. M. 
 conceiving, after farther examination, that " cephalotomy would be attended with as much 
 risk to the life of the mother as the Caesarean operation, thought it better to call another 
 consultation, to reconsider the propriety of performing the Caesarean operation."! The 
 consultation resulted in the opinion that the child was dead. Cephalotomy, therefore, was 
 performed. On the 22d of June, 1833, this same female was again in labour with her second 
 child. Prof. Meigs was called in, and performed a second time the operation of cephalot- 
 omy. But we are not told that in this case the child was dead ; therefore, it is to be pre- 
 sumed it was alive. 
 
 On March 25, 1835, this heroic woman was taken in labour with her third child. Dr. Jo- 
 seph G. Nancrede was her physician ; and, after mature deliberation, decided that the Cae- 
 sarean section was the only appropriate operation in her case. Dr. Nancrede requested the 
 counsel of Professor Gibson, who concurred in opinion with him. Accordingly, in the pres- 
 ence of Dr. Nancrede, Professor Deweese, Dr. Dove of Richmond, Professor Horner, Dr. 
 Beattie, Dr. William Coxe, Dr. Theodore Deweese, and Dr. Charles Bell Gibson, the dis- 
 tinguished professor performed the operation with entire success, saving both mother and 
 child. 
 
 Nov. 5th, 1837, Professor Gibson was summoned to this patient, who was again in labour 
 with her fourth child ! ! He again performed the Caesarean section, and with the same 
 success, saving both mother and child. These facts must carry with them their own com- 
 ment ; but it does seem that they establish, without doubt, the truth of the views I have al- 
 ready expressed on the subject of the two operations, craniotomy and the Caesarean section. 
 Dr. Richard K. Hoffman, a distinguished surgeon of this city, reported the following case 
 of successful Caesarean section in the New- York Journal of Medicine and Surgery for July, 
 1839 ; and, from its interest, I take the liberty of transcribing it in his own words. 
 
 " Dr. H. was called at 8 P.M., August 12, 1838, by Dr. Cockcroft, Jr., to visit with him a 
 Mrs. Day, at No. 5 Allen-street, then in labour with her first child. He found her a dwarf, 
 four feet high, forty-two years of age ; her spine and body seemed of ordinary length, but ly- 
 ing on her side in bed, she appeared to have no legs, the length of her lower extremities not 
 being greater than that of an ordinary thigh, and her upper extremities equally dispro- 
 portioned. On examination per vaginam, the anterior surface, or what should be the hollow 
 of the sacrum, was felt bulging forward with a regular, smooth, convex prominence that had 
 
 * Relation of a Case of Labour, in a Female with deformed Pelvis, by George Fox, M.D., in North. 
 American Medical and Surgical Journal, No. xxiv., October, 1831, p. 485. t Ibid. 
 
 
CESAREAN SECTION. 387 
 
 it is possible to save the mother. Thus, when the pelvis measures 
 more than two inches, cepl^krtripsy should be had recourse to. It 
 
 been mistaken for the head of the foetus at the full time. To prove that the sacrum project- 
 ed forward, the forefinger was introduced up the rectum, and found to pass anteriorly to the 
 projection ; at the base or promontory, the sacrum approached so near the symphysis pubis 
 as to admit with difficulty the passage of two fingers between them, reducing that space to 
 about an inch and a quarter. Laterally there was more space, but not in the antero-posterior 
 diameter. The head of the child could be reached by the finger through this narrow aper-, 
 ture, lying above the brim of the pelvis, and its outlines could be distinctly felt through the 
 parietes of the abdomen, pressing on and projecting forward over the os pubis. A catheter 
 was introduced, and the bladder found nearly empty. Drs. Belcher, Cockcroft, and the re- 
 porter concluded that there was no resource but the section of the womb. Dr. A. L. Ander- 
 son, so well known for his obstetric skill and experience, was called in, who thought that, by 
 care and very patient waiting, it would be practicable to deliver by embryotomy. Dr. Hoff- 
 man was unwilling to resort to this, from the conviction that, with a space not wider than an 
 inch and a half at most, with the rectum behind, and the bladder in front, together with the 
 relaxed os tincse in the way, and the head hardly within reach of the finger, it would be al- 
 most impracticable, and would endanger wounding the bladder or rectum, and lacerating the 
 cervix uteri. vHe, however, went home to procure instruments, and requested his neighbour, 
 Dr. John Watson, to accompany him to the patient, who, after an examination of the case, 
 decided in favour of the Cesarean section. Dr. Cockcroft (whose patient she was), and Dr. 
 Belcher, who had seen her in consultation, agreeing in this decision, and requesting Dr. 
 Hoffman to perform the operation, the patient having then been in labour twenty-four hours, 
 Dr. H. proceeded as follows : placing the patient on her back, on a cot, with the thighs flex- 
 ed on the pelvis, an incision from six to seven inches in length was made through the skin 
 from near the os pubis to the umbilicus, in the course of the linea alba. Being much 
 stretched by the distended uterus, the integuments receded to the extent of three or four 
 inches as they were separated by the scalpel, and were easily divided by slight touches of 
 the knife. On dividing the exposed peritoneum, some fluid gushed out, which it was 
 thought might be urine from an over-distended bladder, though the catheter had been intro- 
 duced two hours before. To remove any apprehension of this kind, that instrument (a long, 
 flexible one) was again introduced, and very little urine was found in the bladder, showing 
 that the fluid came from the cavity of the peritoneum. The uterus, thus laid bare, was di- 
 vided, by one stroke of the knife, about five inches in length ; the head of the child, the occi- 
 put presenting, was at once protruded through the incision, and, with a little assistance, was 
 delivered, followed by the shoulders, &c. ft evinced signs of life by gasping and moving 
 the arms. Dr. Belcher took it in charge. With the umbilical cord as a guide, Dr. H. then 
 introduced his left hand through the incision into the uterus (which was not felt to con- 
 tract), and, on gently pressing the placenta, it was found to be detached, and was removed. 
 
 " There was not more hemorrhage than usually attends a natural delivery. The small in- 
 testines, which had protruded to a considerable extent, were carefully replaced, and the 
 wound brought together by six or eight sutures, not including the peritoneum. Adhesive 
 straps, compress, and bandage were then applied. The pulse was good, and did not flag du- 
 ring or after the operation ; twenty drops of solution of sulphate of morphine were given, and 
 repeated during the night. 
 
 " 13th. Second day, 7 A.M., nine hours after the operation, patient had slept, and had 
 passed a tolerably good night ; felt comfortable ; had not voided urine ; pulse 120 ; some heat 
 of skin ; no distension of abdomen ; an enema of infusion of flaxseed was prescribed. 5 
 P.M., nineteen hours after operation, had voided urine twice. The enema, which had been re- 
 peated, had not come away ; abdomen more tense, and somewhat tympanitic, tender to the 
 touch, and pain darting from one lumbar region to the other ; pulse 104, and strong. She 
 was freely bled, and fifteen grains of calomel were ordered, to be followed at bedtime by cas- 
 tor oil ; hop fomentations to be applied to the whole abdomen. 14th. Third day, abdomen 
 tumid and tender ; no discharge from bowels had taken place ; an enema, containing ol. tere- 
 binth., was then given, and was followed by a free evacuation of the bowels ; eighteen leech- 
 es were then applied to the abdomen, and the fomentations continued. 15th. Fourth day, 
 venesection repeated to ten or twelve ounces, and fomentations persevered in. 16th. Sixth 
 day, wound was dressed, leaving the sutures, union being incomplete ; pulse 110 ; ordered 
 castor oil.* By confining her to a very small quantity of light nourishment, by the occasion- 
 al use of aperients or enemata, and by fomentations assiduously applied to the abdomen, the 
 soreness and uneasiness were gradually removed, and on the 2d of September, three weeks 
 after the operation, the patient was sitting up in a chair, ' feeling smart,' with a good appe- 
 tite, and her bowels regular. The wound had closed, with the exception of a very small 
 space at its lower part ; a probe introduced into this could be felt at the os tincae, showing 
 that the incision into the uterus was not entirely closed. Four weeks after the operation, 
 the patient (who was a very estimable and industrious little woman) set out on her journey 
 home on Long Island, at a distance of thirty miles, with the wound completely closed, and 
 in good health. In October following, she was heard of as continuing in good health. 
 
 " The child was deformed in the lower extremities, and did not long survive its delivery." 
 —Ed. 
 
 * We here annex the account of the progress and the result of the case, as subsequently furnished 
 by D. H. , for the purpose of giving a continuous view of it. 
 
388 OBSTETRICAL OPERATIONS. 
 
 will be in vain objected that the use of the cephalotribe is mur- 
 derous, when the pelvis measures but^trifle over two inches. 
 
 To this it may be replied, that this instrument, even in these con- 
 ditions, presents a much better chance of life to the mother than 
 the Caesarean section ; and if the cephalotribe has not yet rendered 
 all the service it will one day show itself capable of doing, it is be- 
 cause accoucheurs are not sufficiently familiar with its use, and be- 
 cause, in most cases, it is not employed until the female, already 
 exhausted by a prolonged labour, and by attempts of every de- 
 scription to relieve her, is about expiring. 
 
 While the Caesarean operation, on the contrary, is, and should 
 always be performed under favourable circumstances, such as will 
 rarely be absent when the fœtus is living. 
 
 Time alone will decide this question ; the invention of the cephal- 
 otribe is too recent to enable us to compare the results which it 
 furnishes with those of the Caesarean section. 
 
 But I am fully of opinion that the period will arrive when the 
 generation which succeeds us, judging without prejudice, will ren- 
 der proper justice to the cephalotribe, and proscribe the Caesarean 
 operation in cases in which, by destroying the foetus, it will be pos- 
 sible to save the mother. 
 
 At present, I will not practise the abdominal and uterine section, 
 in order to extract the foetus, except when the pelvis is so con- 
 tracted as to render the mutilation of the foetus impossible. But 
 when the contraction is less than two inches, the Caesarean opera- 
 tion must be resorted to : this is the only resource left to the moth- 
 er ; and if the operation be performed at the proper time, the child 
 too may be saved. 
 
 As soon as the necessity of this alternative is made manifest, it 
 is important not to delay it until the protraction of the labour has 
 compromised the life of the foetus, for in this case we should risk 
 sacrificing both mother and child, a most melancholy result. All 
 the efforts of the accoucheur should be directed to extracting the 
 child alive, as the mother will almost certainly perish. 
 
 Unfortunately, we are often called too late to perform this oper- 
 ation at an advantageous period of labour. 
 
 But if the accoucheur should have been sent for at the com- 
 mencement of the labour, and more particularly if he have attend- 
 ed the patient during the last few days of her pregnancy, she may 
 be prepared for the operation by baths, bloodletting, &c, &c, and 
 the moment favourable for its performance may be selected. The 
 time of choice is that in which the neck of the womb is sufficiently 
 dilated to afford a ready passage to the fluids which will escape du- 
 ring and after the operation, the ovum being still intact. This lat- 
 ter precept, not to rupture the membranes before operating, is of 
 great importance. The distension of the organ facilitates the oper- 
 ation, and especially the retraction of the uterus, after the dis- 
 charge of the liquid. Formerly, it was recommended to rupture 
 the membranes, in order to oppose the escape of the amniotic 
 fluid into the peritoneum ; but this effusion can be easily prevent- 
 
CESAREAN SECTION. 
 
 ed by an assistant accurately compressing with his hands the two 
 sides of the abdomen. 
 
 The apparatus for the operation consists of two bistouries, one 
 convex, the other probe-pointed, and with a narrow blade ; of for- 
 ceps, ligatures, curved needles, threaded with waxed ligatures ; of 
 small bandages, adhesive plaster, straight silver needles, a large piece 
 of agaric, pledgets of lint smeared with cerate, soft lint, a linen band, 
 compresses, a body bandage ; and, finally, warm and cold water, 
 vinegar, and fine sponges ; and, at every hazard, a pair of forceps. 
 This apparatus being properly arranged, and an assistant being 
 charged with the duty of handing the instruments and different 
 dressings to the operator, and another with sponges, the patient is 
 placed on a bed somewhat elevated, as in the application of the for- 
 ceps : she is held by the assistants. One assistant steadies with his 
 two hands the uterus on the median line ; this precaution will 
 also prevent the effusion of fluids in the peritoneum. Finally, an- 
 other assistant places his hand on the fundus of the womb, with 
 a view to keep the intestinal mass above, and oppose its interposi- 
 tion between the uterine and abdominal walls. 
 
 The operator then makes with a convex bistoury, on the me- 
 dian line, the first incision, which includes the integuments and 
 sub-cutaneous cellular tissue, beginning a little below the umbilicus, 
 and extending within an inch and a half of the pubes. This incis- 
 ion, therefore, should extend from four and a half to five and a half 
 inches. If the short stature of the female should prevent this length 
 of incision, limiting it to the points designated, it should be prolong- 
 ed a little to the left of the umbilicus, and above. The surgeon then 
 divides, layer by layer, the aponeurotic planes of the linea alba, and 
 thus reaches the peritoneum. He makes a slight opening in this 
 membrane, through which he passes, on the index finger of the left 
 hand, a probe-pointed bistoury, with which he extends the incision. 
 
 The operator, after this, incises the uterus, layer by layer, be- 
 coming more and more cautious, until he arrives at the surface of 
 the ovum, which he likewise incises ; then, with the index finger of 
 the left hand and the probe-pointed bistoury carried through this 
 opening, he completes the incision of the uterus, passing towards 
 the superior angle of the wound. 
 
 The fcetus must then be immediately extracted by the part it 
 presents ; the uterus contracts, the placenta is sépara- (fi* wo.) 
 ted, and the accoucheur extracts it through the incis- 
 ion, as also the membranes, which must be rotated, in 
 order to give them more solidity. 
 
 The finger should then be introduced into the mouth 
 of the womb to ascertain that no foreign body is there. 
 
 The uterus, in contracting, closes the wound which 
 has been made in its walls, and, therefore, this incision 
 does not need any particular dressing. The wound in 
 the abdominal walls is brought together by means of a 
 figure of 8 suture, made with silver needles passed into 
 the lips of the incision, and around which is placed a 
 
390 
 
 PRESENTATION OF THE FACE. 
 
 ligature. These needles should be situated about one inch and a 
 quarter from each other, and each should have an independent lig- 
 ature. Between each suture there should be a strip of adhesive 
 plaster, then lint, and the whole to be kept in place by compresses 
 and a body bandage. 
 
 The treatment consists in combating the accidents that may 
 manifest themselves. At the end of four or five days the lint 
 should be renewed, without touching the needles or adhesive strips ; 
 it will not be until the fifteenth day that, the cicatrization being com- 
 plete, we will be enabled gradually to remove the needles. Unfor- 
 tunately, it is most generally from the cadaver that we remove the 
 first dressings. 
 
 TITLE III. 
 
 PRESENTATION OF THE FACE. 
 
 If I were to follow the order of frequency, I should place im- 
 mediately after the presentation of the vertex that of the pelvic 
 extremity ; but I have thought it more useful not to separate the 
 presentation of the face from that of the vertex, in order to make 
 more striking the analogies between these two presentations, which, 
 moreover, are merely two subdivisions of the presentation of the 
 head. 
 
 Before the time of P. Portal, the opinion was generally received 
 that the presentation of the face was not susceptible of spontaneous 
 
 (Fig. 170.) 
 
CAUSES OF FACE PRESENTATIONS. 
 
 termination ; it was he, therefore, who first laid down the princi- 
 ple, that not only could the expulsion, in this case, be terminated 
 by nature alone, but that this presentation is favourable to the 
 mother and child, and should be placed in the category of natural 
 labours. At a later period, Deleurie also adopted this doctrine ; 
 but Deventer, Roederer, and almost all authors who preceded 
 Madame Lachapelle, rejected it. Baudelocque himself, Gardien, 
 Maygrier, although regarding delivery by the face as possible by 
 the spontaneous efforts of nature, have recommended to endeavour 
 to prevent this presentation or to change it, on the assumption 
 that it is one of those cases presenting more or less danger. 
 
 Impressed with the facility with which delivery by the face is 
 most usually terminated without any serious complication, Madame 
 Lachapelle stated as a principle, that the face presentation should 
 be confided to nature. She predicates her opinion upon the fact 
 that, in seventy- two cases of delivery by the face, forty-two termi- 
 nated favourably. — {Pratique des Accouchemens, t. i., p. 369.) 
 
 Velpeau observed six cases in which the children were born 
 alive. MM. Nsegèle, Stoltz, and Moreau agree in opinion with 
 Madame Lachapelle. Finally, M. P. Dubois, in eighty-five cases 
 observed by him at La Maternité, was obliged to interfere eight 
 times ; twice because the arm was about to descend simultaneous- 
 ly with the face, five times on account of the resistance of the ex- 
 ternal genital organs, and once because the foetus was dead. I 
 have myself observed several cases at La Clinique, in which face 
 presentations terminated favourably for both mother and child. 
 On one occasion only, M. P. Dubois was obliged to apply the for- 
 ceps, in a right posterior mental position, incompletely reduced. 
 
 In truth, if we merely consult experience, and consider the diame- 
 ters concerned in the descent and delivery of the face and vertex, 
 which have nearly the same dimensions, we shall naturally be in- 
 duced to admit the spontaneous termination as possible, provided 
 always the chin passes under the pubic arcade ; for it would be oth- 
 erwise if it passed into the concavity of the sacrum. Thus, although 
 I concur with Madame Lachapelle as to the manner in which things 
 take place in the majority of cases, yet I cannot consent to class this 
 delivery among natural labours ; I should fear, in doing so, that I 
 might inspire young practitioners with too great security ; and as 
 this expulsion, although most usually spontaneous, frequently com- 
 promises the life of the fœtus, and calls for the interference of art, 
 it has appeared to me more rational to comprise it among labours 
 that are spontaneous, and often natural. 
 
 §1. Causes of Face Presentations. 
 Obliquity of the uterus has been regarded by most accoucheurs 
 as the principal cause of the presentation of the face. According 
 to Deventer and Gardien, this presentation would be secondary to 
 a presentation of the vertex, and this substitution is accomplished 
 in this way : in consequence of the inclination of the uterus, the 
 axis of this organ and that of the superior strait not being in rela- 
 
392 
 
 PRESENTATION OP THE FACE. 
 
 tion, the uterine contractions, acting on the fœtus, would tend to 
 engage it in the axis of this viscus, that is, obliquely, and not per- 
 pendicularly, according to the axis of the superior strait. Under 
 these circumstances, the fœtus would rest against the border of 
 this strait, the occiput would be thrown backward, and the face 
 take the place of the vertex. 
 
 M. P. Dubois is of opinion that things do not pass in this manner 
 ordinarily. According to him, these presentations are almost al- 
 ways primitive, and not occasioned by the obliquity of the uterus. 
 In eighty-five cases, he has not met with a single well-characterized 
 instance of obliquity. Moreover, how can it be supposed that the 
 parts of the fœtus could become arrested at the superior strait, 
 when it is remembered that this strait is lined by soft and yielding 
 organs, and that the uterine walls present to the fœtus a smooth 
 plane, lubricated and contractile, on which it glides into the strait ? 
 M. P. Dubois admits, therefore, that these presentations are primi- 
 tive at labour, and that yet they are the result of the deflexion of 
 presentations of the vertex — a deflexion occasioned, most probably, 
 by the active movements of the fœtus, and the following is his expla- 
 nation : " At an indeterminate period of gestation, the chin may sep- 
 arate from the chest ; if the fœtus remain in this attitude until full 
 term, it will find itself definitively placed in this position at the com- 
 mencement of labour by the rupture of the membranes and the 
 contractions of the uterus." However, we cannot positively assert 
 that uterine obliquities may not sometimes cause this presentation. 
 
 (Fig. 171.) 
 
 (Fig. 172.) 
 
DIAGNOSIS OF THE FULL PRESENTATION. 393 
 
 Whatever may be the cause of the presentation, it is evident 
 that it is the result of the presentation of the vertex extended. The 
 order in which the positions of this presentation are classed prove 
 this fact: the right posterior mento-iliac position (fig. 171), the first 
 of the face, corresponds to the left anterior occipito-iliac (fig. 172), 
 the first of the vertex. The left anterior mento-iliac (fig. 174), the 
 second of the face, corresponds to the right posterior occipito-iliac 
 (fig. 173), the second of the vertex, &c, &c. 
 
 Diagnosis. 
 
 I have already remarked, in the classification of presentations 
 and positions, that the face may present at the superior strait, ei- 
 ther full or inclined, in four different ways. Thus, in the full pre- 
 sentation, the front of the face is felt at the orifice ; in the varieties 
 of malar presentations, one or other cheek is felt ; a large portion 
 of the forehead in the frontal variety ; and, finalty, the chin and a 
 small part of the neck in the mento-cervical variety : the frontal 
 variety is the most frequent, the malar the least so, and the mento- 
 cervical is rare. 
 
 As to the positions, I have also shown that, although the chin may 
 be in relation with all the points of the superior strait, yet the face 
 generally assumes but two principal positions : the right posterior 
 mento-iliac, the left anterior mento-iliac. These two positions 
 have been sufficiently proved to enable us to establish their order 
 of frequency ; but such is not the case with the two opposite diag- 
 onal positions. They are so rare, that it is only in the way of an- 
 alogy that they can be admitted. In fact, if the vertex should pre- 
 sent in the diagonal position, in order to descend readily at the su- 
 perior strait — and it would be still more so with the face, the diam- 
 eters of which exceed somewhat those of the vertex — it should be 
 solicited to assume this situation. Thus, I cannot admit that the 
 transverse positions are the most frequent, and I think that authors 
 have been led to suppose that the extent of the transverse diame- 
 ter rendered the transverse positions more frequent, simply because 
 they have measured this diameter in the dry pelvis, which is long- 
 er, instead of viewing it in a pelvis covered with the soft parts, 
 in which case this transverse diameter is smaller and less favoura- 
 ble than the oblique. 
 
 § 2. Diagnosis of the Full Presentation. 
 
 The diagnosis of the presentation of the face is not, in general, 
 difficult ; it is, however, more so before the rupture of the mem- 
 branes, especially if they be tense. The finger of the accoucheur, 
 in this case, most usually reaches the forehead, the face not being 
 yet completely extended, and then he may suppose it to be a pre- 
 sentation of the vertex ; sometimes, even, the part is so elevated 
 that he cannot reach it. 
 
 After the rupture of the membranes, at the commencement of 
 labour, the orifice being but slightly dilated, only a small portion 
 of the forehead is felt, together with the orbits and nose ; but in 
 
 Ddd 
 
394 PRESENTATION OF THE FACE. 
 
 proportion as the dilatation increases, and the movement of exten- 
 sion is completed, the mouth and chin also descend in the orifice. 
 The diagnosis then becomes evident ; but very often, when the face 
 has remained for some time at the superior strait, these characters 
 are somewhat concealed by the tumefaction which they undergo, 
 and it might be possible to mistake the face for the presence of a 
 pelvic extremity ; for only a large tumour is felt, partly solid, and 
 partly soft, in which prominences and infractuosities are distin- 
 guished. We should, under these circumstances, endeavour to 
 recognise the presence of the nose, because the nostrils will pre- 
 vent our confounding it with any other part. The nose, in this 
 case, is situated in a fissure formed by the tumefaction of the cheeks, 
 and it is this disposition which may cause us to believe that the 
 breech presents; and the mouth should be searched for, which 
 cannot, without great carelessness, be mistaken for the anus. The 
 buccal cavity, much wider than the anus, presents the alveolar 
 processes, and likewise contains within it the tongue ; the anus, on 
 the contrary, contracts on the finger of the accoucheur, and the 
 coccyx may be distinctly recognised ; add to this that, in this case, 
 the finger is always covered with meconium. Finally, the osseous 
 contour of the orbits, and the presence of the chin, will remove all 
 doubt. 
 
 § 3. Diagnosis of the Position. 
 The direction of the nostrils at the commencement of labour, and 
 that of the chin when the dilatation permits us to feel this part, will 
 serve to determine the position. Thus, if the nose or chin be felt 
 to the right and posteriorly, it is a right posterior mento-iliac posi- 
 tion ; to the left and in front, it is a left anterior mento-iliac posi- 
 tion, &c, &c. 
 
 Art. I. — Mechanism of Spontaneous Delivery. 
 
 § 1. Mechanism of Spontaneous Delivery in the Full Presentation 
 of the Face. — Right Posterior Mento-iliac Position. 
 
 The mechanism of spontaneous delivery by the face may be 
 divided, like that of the vertex, into five periods for the full pre- 
 sentation. 
 
 Before the rupture of the membranes, the face is moderately ex- 
 tended, and may become more so ; in this situation, it presents at 
 the superior strait by a diameter intermediate between the mento- 
 occipital and mento-bregmatic, the length of which is four inches 
 seven or eight lines (fig. 170). This diameter is parallel to the left 
 oblique diameter of the superior strait, the chin corresponding with 
 the right sacro-iliac symphysis. The bi-temporal diameter is paral- 
 lel to the right oblique diameter ; and the cheek, which is in front, 
 is more readily accessible, whether, as I have said in speaking of 
 the vertex, it be owing to the anterior inclination of the face, or to 
 that of the plane of the superior strait. 
 
MECHANISM OF SPONTANEOUS DELIVERY. 
 
 395 
 
 (Fig. 175.) 
 Extension, First Period. 
 
 But after the rupture of the sac, the face completes its extension 
 (first period, fig. 175), and then presents a more favourable diame- 
 ter, the mento-bregmatic, which measures from three and a quarter 
 to four inches, and by which it descends (second period). Then, 
 when the face has penetrated the excavation, sometimes only in pro- 
 portion as it enters, it undergoes a movement of rotation, by which 
 the chin, brought to the right and in front, is soon conducted under 
 the ischio-pubic branch, and, finally, directly under the symhysis 
 pubis (third period). This rotation of the chin in front almost al- 
 ways occurs, no matter how remote it may be from the pubes, and 
 it is only as an exception when it passes into the concavity of the 
 sacrum. 
 
 (Fig. 176.) 
 Descent and Commencement of Rotation, Second Period. 
 
396 
 
 PRESENTATION OP THE FACE. 
 
 Finally, the chin soon passes the symphysis pubis, and descends 
 towards the mons veneris ; the head then flexes, and the front of 
 the trachea is under the pubic arch, and from the anterior commis- 
 sure of the perineum we see successively disengaged the forehead, 
 the bregma, and the occiput (fourth period). The front of the 
 trachea and the lower portion of the symphysis pubis serve as a 
 central point for all the diameters, which successively measure the 
 
 (Fig. 177.) 
 
 Complete Rotation, Third Period. 
 
 Delivery, Fourth Period. 
 
 (Fig. 178.) 
 Profile View of Delivery. 
 
MECHANISM OF SPONTANEOUS DELIVERY. 
 (Fig. 179.) (Fig. 180.) 
 
 397 
 
 delivery of the face : these diameters are, the trachelo-frontal (three 
 and a half inches), trachelo-bregmatic (three and three quarter 
 inches), trachelo-occipital (four inches one or two lines). 
 
 If now we compare these diameters with that of the inferior 
 strait, the antero-posterior, which measures four inches four or five 
 lines, we can easily understand the facility with which the face 
 passes in this mento-anterior position. 
 
 (Fig. 181.) 
 External Rotation, Fifth Period. 
 
 The fifth period, that of external rotation, is the same as in the 
 presentation of the vertex. 
 
 § 2. Mechanism of Spontaneous Delivery in the other Positions of 
 
 the Face. 
 The mechanism of spontaneous delivery in the other positions 
 of the face is exactly the same as in the preceding, except that the 
 movement of rotation, which carries the chin under the pubes, is 
 the more extended as the chin is situated more posteriorly ; and 
 we may establish, as a general rule, that, in the positions of the 
 face, whatever may be the point at the upper strait with which 
 the chin corresponds, the latter will almost always descend in 
 front, and the delivery will be spontaneous ; but should the chin 
 remain posteriorly, which, happily, is very rare, the delivery will 
 be far from terminating so favourably. 
 
398 
 
 PRESENTATION OF THE FACE. 
 
 § 3. Mechanism of Spontaneous Delivery in the Inclined Presenta- 
 tions of the Face, or Varieties of Presentation. 
 
 Malar Varieties. — Diagnosis and Mechanism. 
 
 When the face is inclined at the superior strait, one or other 
 cheek occupies more particularly the centre of the orifice : if it be 
 the cheek which is in front of the pelvis, we often feel an ear be- 
 hind the pubes ; and the other parts of the face, the nose and 
 mouth, are towards the sacrum. If it be the cheek which is pos- 
 teriorly that occupies the orifice, the nose and mouth are nearer 
 the anterior portion of the pelvis. 
 
 What I have said of the varieties of the presentation of the ver- 
 tex is equally applicable to those of the face. During the first con- 
 tractions of the uterus these varieties correct themselves, the head 
 becomes righted, and the full face occupies the superior strait ; in 
 a word, the variety gives place to the full presentation, and the 
 labour is terminated as favourably as if this variety had not pre- 
 sented. It is precisely the same with the malar varieties : they 
 can even descend, like the parietal varieties of the vertex, without 
 previous righting. 
 
 Frontal Variety. — Diagnosis and Mechanism. 
 In this variety, the full forehead occupies the superior strait ; the 
 (Fig. 182.) finger can feel the orbits on one side and the 
 
 anterior fontanelle on the other. This variety 
 of presentation is very frequent, and it cor- 
 rects itself, like the others, immediately after 
 the rupture of the membranes. The first pe- 
 riod of delivery, extension, takes place ; the 
 face, which presented itself imperfectly ex- 
 tended, now extends, and occupies, in full, the 
 superior strait. It is rare, although it may oc- 
 cur, that the face, instead of becoming com- 
 pletely extended, flexes, and thus a presenta- 
 tion of the vertex is substituted spontaneously 
 for one of the face. 
 
 Mento-cervical Variety. — Diagnosis and Mechanism. 
 The chin is placed almost in the centre, and a small portion of 
 the neck of the foetus occupies the orifice 
 with it. The mouth may also be reach- 
 ed ; but by degrees the face descends, 
 and the mouth, nose, orbits, and a por- 
 tion of the forehead unite with the chin, 
 and descend into the superior strait, the 
 neck having ascended on the opposite 
 side. 
 
 It is very unusual for these substitu- 
 tions of presentation not to be accomplish- 
 ed, and that art is obliged to interfere. 
 
 
 (Fig. 183.) 
 
ANOMALIES IN SPONTANEOUS DELIVERY. 399 
 
 As to the position, it remains the same ; for, whether the pre- 
 sentation be full or inclined, the chin is still either on the right or 
 the left. 
 
 Art. II. — Anomalies in the Mechanism of Spontaneous De- 
 livery. 
 All the anomalies which I have mentioned as being capable of 
 manifesting themselves during the expulsion of the foetus in the 
 presentation of the vertex, are equally met with in delivery by the 
 face ; but things do not pass as happily in the latter as in the for- 
 mer presentation. 
 
 § 1. First Period, Deflexion or Extension. 
 Thus, the movement of flexion may fail in the presentation of 
 the vertex (a circumstance not very rare), and yet this will not 
 prevent the descent of the head, for, as I have already remarked, 
 this flexion is only useful, and not indispensable to the descent. 
 In the presentation of the face, on the contrary, if the period of 
 extension, which is analogous to flexion of the vertex, be n-jt ac- 
 complished, the descent is singularly retarded, and may sometimes 
 not be effected, and art is obliged to interfere ; but it is very rare 
 that, extension does not occur, for it has for its object to substitute 
 a favourable for an unfavourable diameter. (See Manipulations 
 in Case of Anomaly.) 
 
 § 2. Second Period, Descent. 
 The descent in this presentation, as in every other, cannot fail 
 of itself; when it does not take place, it is because some circum- 
 stance interferes with its execution, such as a want of extension, 
 deformity, &c, &c. 
 
 § 3. Third Period, Rotation. 
 As has been seen in the mechanism of spontaneous expulsion, 
 the rotation of the chin most usually is effected in front ; but the 
 rotation, in this case, may very readily be incomplete, and the face 
 then descends diagonally without much difficulty. Madame La- 
 chapelle has noticed this descent take place transversely. But if 
 the rotation of the chin in front should fail entirely, and it remain, 
 therefore, in relation with the sacro-iliac symphyses (which is very 
 rare), the accoucheur will almost always be obliged to render as- 
 sistance. The spontaneous expulsion, however, may still occur, 
 but in virtue of certain conditions, and by means of a very com- 
 plicated mechanism. 
 
 Descent in the Mento-posterior Position remaining such. 
 In this situation, the occiput is supported behind the symphysis 
 pubis, and the chin is arrested by the sacrum ; the face presents, 
 therefore, in the antero-posterior diameter of the inferior strait, 
 which measures only four inches four or five lines, by its occipito- 
 mental diameter, measuring five inches. This will render delivery 
 
400 
 
 PRESENTATION OF THE FACE. 
 
 impossible unless the head should change its situation, which may 
 take place in two ways : the labour may terminate, the face con- 
 tinuing to present ; or, by a movement of flexion, the vertex may 
 replace the face. 
 
 (Fig. 184.) 
 
 <S£> 
 
 In the former case, the neck of the infant elongates under the 
 influence of very energetic contractions ; a small portion of the 
 chest also descends in the superior strait, and the occiput is turned 
 backward. These various combined movements enable the chin 
 to advance diagonally, gliding along the concavity of the sacrum 
 as far as the sacro-sciatic ligament, which it passes by pushing it 
 posteriorly. The chin being thus situated in the concavity of the 
 perineum, the trachea rests on the point of the sacrum. It is not 
 the occipito-mental diameter which now presents at the moment 
 of the disengagement, for, if it were, the disengagement could not 
 be effected ; but it is the trachelo-occipital, which allows the vertex 
 to pass under the symphysis pubis in presenting, successively, to 
 the cocci-pubic diameter, the trachelo-frontal (three inches and a 
 half), trachelo-bregmatic (three inches and three quarters), and 
 trachelo-occipital (four inches and a few lines). 
 
 (Fig. 185.) 
 
 After the vertex has thus passed under the symphysis pubis, the 
 face, having remained in the concavity of the perineum, which it has 
 pushed backward, soon disengages, by a movement of progression, 
 in front. It will be seen that the diameters which measure the ex- 
 pulsion of the face beyond the osseous parts in this instance, are the 
 same as in the preceding case ; so that we are not to ascribe the 
 
ANOMALIES IN SPONTANEOUS DELIVERY. 401 
 
 difficulties of this delivery to the length of these diameters, but 
 rather to the circumstances which render possible the previous dis- 
 engagement of the chin, in order that the occipito-mental diameter 
 may be avoided. In fact, for the chin to traverse the entire con- 
 cavity of the sacrum, in order to pass the sacro-sciatic ligament, it 
 becomes necessary that the neck of the infant should elongate con- 
 siderably, in order that a portion of the chest may descend in the 
 superior strait, and that the contractions of the uterus be very en- 
 ergetic, and the perineum not too resisting. 
 
 These are the conditions, rarely met with, which constitute the 
 difficulty of the expulsion. They cannot exist except when the 
 pelvis is very capacious, or the foetus very small. Thus, whenever 
 the foetus and pelvis present their ordinary dimensions, delivery, in 
 most cases, will be impossible without the aid of the accoucheur. 
 
 In the second case, the face, having arrived in the pelvic excava- 
 tion, presents at the inferior strait its occipito-mental diameter, 
 which cannot pass this strait ; then the chin, instead of approach- 
 ing the perineum, as in the preceding instance, becomes more re- 
 mote from it, ascends towards the sacro-vertebral angle, and be- 
 comes flexed on the chest, which permits the occiput to descend 
 and pass under the pubes. In a word, the occipito-anterior present- 
 ation of the vertex replaces, in the excavation the presentation of 
 the face. 
 
 But this circumstance can only be explained by admitting that 
 the fœtus is very small and the pelvis very large ; for, in order that 
 the head, being extended in the excavation, that is to say, having 
 its occipito-mental diameter perpendicular, may become flexed, it 
 becomes necessary that this diameter should move in the excava- 
 tion. Now, this diameter measuring five inches, and the excava- 
 tion four and a half inches, this flexion cannot be accomplished, un- 
 less there should be a diminution in the diameters of the head, or an 
 increase in those of the pelvis. 
 
 § 4. Fourth Period, Delivery. 
 
 The fourth period of delivery, like that of the descent, cannot fail 
 of itself; it is prevented by other circumstances, such as resistance 
 of the parts, inertia, &c, &c. 
 
 Sometimes, in the secondary mento-anterior position, that is, 
 when the chin corresponds with the posterior portion of the sym- 
 physis pubis, the head may become flexed in the excavation, and the 
 chin, instead of passing under the pubes, ascends behind the sym- 
 physis pubis ; the forehead is placed under the arch, and the delivery 
 terminates as in the occipito-posterior position of the vertex. (See 
 fig. 99.) I had occasion, in January, 1841, to observe this mecha- 
 nism in a female at La Clinique. The primitive position had been 
 a right posterior mento-iliac, which was completely reduced to an 
 anterior. The head of the foetus was small, and the pelvis capa- 
 cious, which explains this anomaly during the period of descent. 
 
 E E E 
 
402 PRESENTATION OF THE FACE. 
 
 § 5. Fifth Period, External Rotation. 
 
 Finally, the fifth period, or that of external rotation of the head 
 and internal of the shoulders, is subject to the same irregularities 
 as that of the vertex. 
 
 Art. III. — Prognosis for the Mother. 
 
 I remarked, in the first article of this chapter, that delivery by the 
 face should be regarded as spontaneous in the majority of cases ; 
 but, as not being always natural, for the labour is sometimes long- 
 er, more painful for the mother, and dangerous for the child than 
 in delivery by the vertex ; it requires also more frequently the in- 
 terference of art. In fact, as has already been observed, the anom- 
 alies, in the different movements the face should execute during its 
 progress, have a much more serious influence than when the head 
 presents flexed ; and the right or left mento-posterior position, re- 
 maining such after its descent, or which becomes altogether poste- 
 rior, constitutes a most grave accident ; but it is absolutely untrue, 
 as some authors contend, that the primitive right or left mento- 
 posterior position is more serious than the anterior ; for the mento- 
 posterior positions almost always are reduced to the secondary an- 
 terior (that is, after the descent) ; and- as, moreover, they are the 
 most frequent, as every day's practice demonstrates, they give rise 
 to the largest proportion of spontaneous deliveries. 
 
 If the labour be occasionally longer than in the presentation of 
 the vertex, it is not because the face presents at the superior strait 
 diameters unfavourable to the descent, for I have shown precisely 
 the contrary; the trachelo-bregmatic, measuring three and three 
 quarter to four inches at most, corresponds with the oblique diam- 
 eter of the pelvis, which measures four inches ; but it is because the 
 face, which is at the superior strait, accommodates itself badly by its 
 inequalities to the regular and uniform contour of this strait, and re- 
 mains separated from the uterine orifice by a mass of fluid, instead 
 of resting, as the vertex does, on this orifice, and thus favouring its 
 dilatation. 
 
 As to the movement of rotation, it is executed with as much reg- 
 ularity as in delivery by the vertex, no matter how remote the chin 
 may be from the symphysis pubis. The delivery, however, will be 
 much more serious when, instead of coming in front, the chin pass- 
 es posteriorly, for, in this case, the woman will exhaust herself in 
 vain efforts ; and whether the accoucheur is obliged to interfere, 
 or the expulsion be spontaneous, which is exceedingly rare, the 
 prolonged sojourn of the head behind the symphysis and on the rec- 
 tum may occasion vesico and recto-vaginal fistulse. Moreover, ai 
 the moment the head passes the external parts, the perineum, not- 
 withstanding every care, may be lacerated. 
 
 As to the delivery at the inferior strait, when the chin passes un- 
 der the pubes, it is accomplished as rapidly as that of the occiput. 
 Experience demonstrates this fact, and it is evident, although the 
 contrary has recently been maintained. 
 
PROGNOSIS FOR THE INFANT, ETC. 403 
 
 Art. IV. — Prognosis for the Infant. 
 
 A protracted labour, when the face occupies the superior strait, 
 may occasion cerebral plethora of the foetus, and all the grave con- 
 sequences resulting from it. The same thing may occur in the 
 mento-anterior rotation, in consequence of the too prolonged so- 
 journ of the anterior part of the neck of the infant under the pubes. 
 The compression of the jugular veins, in this case, compromises the 
 life of the child once in ten or twelve deliveries. Unfortunately, 
 it is difficult to affix a limit beyond which delay is dangerous. We 
 see, indeed, foetuses remaining for a long time in this attitude with- 
 out injury ; others, on the contrary, die after a short and easy la- 
 bour. According to Madame Lachapelle, if the infant move its 
 tongue and lips, we must remain inactive ; but if these motions 
 cease, we must then act. It would be well to add to these indica- 
 tions the evidence furnished by auscultation, in order that we may 
 be assured of the state of the foetal circulation. 
 
 Procidentia of the cord is a grave complication which frequently 
 accompanies this presentation, the superior strait not being entirely 
 occupied by the part which engages. 
 
 The tumefaction of the face should be taken into account in the 
 prognosis ; it also occurs, although in a less degree, in the other 
 presentations ; it is occasioned by a sero-sanguineous afflux, which 
 a few days will suffice to dissipate. It is the same with the ten- 
 dency which the head has to be thrown backward, in consequence 
 of its forced position in traversing the pelvis. 
 
 CHAPTER I. 
 
 THE CONDUCT OF THE ACCOUCHEUR IN DELIVERY BY THE FACE. 
 
 The accoucheurs of the last century, and Madame Lachapelle 
 herself, in the commencement of her practice, recommended to con- 
 vert the presentation of the face at the superior strait into the pre- 
 sentation of the vertex. For this purpose, before the descent of the 
 face, the hand, the palm of which corresponded with the occiput, 
 was introduced between the border of the superior strait and head ; 
 then the four fingers, being fixed in the form of a crotchet on the 
 occiput, bring this part down to the superior strait. 
 
 In giving this direction, those authors contended that delivery by 
 the vertex is as favourable as possible to the foetus, while, by the 
 face, it terminates spontaneously only in cases in which the chin 
 corresponds to the front of the pelvis, and often, even in this case, 
 the life of the child is sacrificed. 
 
 They likewise allege in favour of their opinion, that the right and 
 left posterior mento-iliac positions always giving rise to the direct 
 
404 PRESENTATION OF THE FACE. 
 
 mento-posterior, it becomes necessary to prevent this rotation of 
 the chin posteriorly by acting on the vertex, for the mento-posterior 
 position will always require the interference of art, and is more or 
 less fatal to the foetus and mother. 
 
 It would be easy for me to demonstrate that these fears are, for 
 the most part, without foundation ; and that, if the accoucheur were 
 formerly often called upon to render assistance, and the life of the 
 child and mother were frequently compromised in this presenta- 
 tion, it was because practitioners were too hasty in disturbing the 
 march of nature, instead of permitting her to proceed quietly in 
 her work, and thus establish the true prognosis of this species of 
 delivery. 
 
 It is also evident that these erroneous notions have prevailed, 
 because authors have attributed to presentation of the face acci- 
 dents which have resulted directly from the attempts made to 
 change this presentation. 
 
 There is no doubt, however, that delivery by the vertex is much 
 more favourable to the mother, and especially to the child, than by 
 the face. I have established this fact in the prognosis ; for the 
 mother, in presentation of the face, the labour is more protracted 
 and dangerous, if certain anomalies should manifest themselves 
 during the progress of the labour. For the infant, besides the dan- 
 gers incurred by these anomalies in the most favourable circum- 
 stances, death takes place once in ten or twelve cases ; and if rota- 
 tion of the chin occur posteriorly, the sacrifice of the child is al- 
 most certain. 
 
 Thus, if, in acting on the vertex instead of the face, we can ob- 
 viate all these inconveniences, without substituting others equally 
 or still more serious, and if, in most cases, this operation were prac- 
 ticable, we should certainly have recourse to it. But, in the first 
 place, in admitting that we could succeed in bringing down the 
 vertex instead of the face, there would be no similarity between a 
 labour when the vertex had been acted upon forcibly at the supe- 
 rior strait, and one occurring in a primitive presentation of the 
 vertex. In fact, when the vertex presents of itself, and the rup- 
 ture of the membranes occurs, the orifice is completely closed up 
 by the presenting part, and the amniotic fluid escapes but partially 
 during the entire labour, and, consequently, the foetus is not expo- 
 sed to the immediate compression of the uterus ; this favourable 
 condition does not exist when the vertex has been brought down 
 by the accoucheur. The introduction of the hand, and the at- 
 tempts made to grasp the occiput, permit the whole of the liquor 
 amnii to escape. Moreover, this discharge of the fluid may bring 
 down a loop of the umbilical cord below the head of the foetus. 
 This accident is rare in the primitive presentation of the vertex, 
 because, as I have remarked, the vertex closes up the orifice ; but 
 it often takes place during these attempts at cephalic version, at 
 the moment the hand seeks to push up the face and bring down 
 the vertex. If procidentia of the cord should occur, we should 
 attempt its reduction, in order to prevent compression ; and if we 
 
 I 
 
CONDUCT OF THE ACCOUCHEUR. 405 
 
 do not succeed in placing it above the. superior strait, we shall be 
 obliged, with a view of protecting the foetus from the consequen- 
 ces of this accident, to perform pelvic version or have recourse 
 to the forceps, depending on whether the head has descended 
 more or less ; operations which are not without inconvenience to 
 the child. One or both arms may likewise be brought down to the 
 superior strait at the same time with the vertex. Hence the neces- 
 sity of attempting their reduction, and, in case of failure, to resort 
 to version, or the application of the forceps, according to the partic- 
 ular circumstances. These attempts at reduction, extremely pain- 
 ful in themselves, aggravate the serious condition in which we find 
 the mother and child placed. 
 
 But the dangers of this operation to both mother and child are 
 not the only reasons which should make us proscribe it ; the diffi- 
 culties in its execution are very great, and those accoucheurs who 
 have attempted this operation can fully appreciate its embarrass- 
 ments. The warmest advocates of this method, even Baudelocque 
 himself, have acknowledged numerous failures. Madame Lacha- 
 pelle, at the time her mind was imbued with these false notions with 
 regard to the presentation of the face, also very frequently expe- 
 rienced insurmountable difficulties. The experience of M. P. Du- 
 bois has likewise given the same results in cases in which he was 
 induced, in consequence of pelvic deformity, to attempt to change 
 the presentation. It may, indeed, be affirmed that, in presenta- 
 tions of the head, it is sometimes possible to place nature in the 
 channel she should pursue ; but we can rarely overcome these de- 
 partures from her standard, except in changing the presentation 
 by pelvic version. 
 
 One circumstance only, strictly speaking, will render the reduc- 
 tion of the presentation possible. It is this : when, on rupturing the 
 membranes at the moment of introducing the hand, we find the 
 face movable at the superior strait ; but even in this case we will 
 sometimes encounter considerable difficulty. Again, it would only 
 be when the superior strait is deformed that it would be admis- 
 sible to practise this operation in order to save the foetus the dan- 
 gers of an irregular application of the forceps when the head is 
 extended. But if recourse be had to the operation after the rup- 
 ture of the membranes, the contractions of the uterus will almost 
 always oppose its execution. Most usually, therefore, the attempts 
 at reduction will be useless in two ways: 1st. Either there will be 
 complete failure, after reiterated and long-continued efforts ; and 
 after having occasioned great suffering to the patient, we will be 
 compelled to abandon the face at the superior strait; and, under 
 these circumstances, the labour will be much more unfavourable 
 than if we had done nothing. 
 
 2d. Or these attempts at reduction may prove unavailing, be- 
 cause the vertex, once brought down, may be again removed from 
 the superior strait, and the face take its place, notwithstanding all 
 the efforts of the accoucheur to maintain it in position. This ef- 
 
 . 
 
406 PRESENTATION OF THE FACE. 
 
 feet is the result of the natural tendency of this presentation to 
 occupy the superior strait after it has once taken place there. 
 
 If, now, instead of resorting to this operation, we permit the pre- 
 sentation of the face to continue, the rotation of the chin in front 
 will be executed in the great majority of cases, no matter what 
 may be the point of the superior strait with which the chin cor- 
 responds, and the delivery will, as regards the mother, be nearly 
 as favourable as in the expulsion by the vertex ; less favourable, 
 however, for the infant, for its life is sacrificed once in ten or twelve 
 times. This spontaneous delivery, however, will present it a bet- 
 ter chance than the operation, for, in the latter case, the child suc- 
 cumbs once in seven or eight times. In addition, the mother will 
 be spared the pains consequent upon these attempts, and the accou- 
 cheur the difficulties and disappointment of failure. 
 
 But the partisans of this method, who believe, for the most part, 
 that the mento-anterior or transverse positions are the only ones 
 which are reduced to the direct mento-anterior, and that the right 
 or left mento-posterior, on the contrary, less frequent than the 
 former, are necessarily changed to the direct posterior, insist that, 
 in the right or left posterior mento-iliac position, we should have 
 recourse to cephalic version, in order to prevent the mento-poste- 
 rior rotation, much more serious than all the dangers connected 
 with the operation they recommend. My reply is, that experience 
 proves that the primitive mento-posterior positions are the most 
 frequent, that the anterior rotation of the chin occurs as readily in 
 these positions as in the anterior, and that the chin very rarely 
 passes into the concavity of the sacrum. Madame Lachapelle has 
 never met with an instance of this kind. And that, moreover, to 
 prevent this posterior rotation, which probably would not take 
 place, we are not justified in attempting, at the superior strait, an 
 operation which will often endanger the safety of the child, and 
 which is very painful for the mother. 
 
 I will even add that, in admitting, as authors contend, that the 
 direct mento-posterior position is a necessary consequence of the 
 right or left primitive posterior mento-iliac, it is not by cephalic 
 version that we are to prevent this posterior rotation, but by pel- 
 vic version, which is much less protracted, easier, and less painful, 
 and which is more favourable both to mother and child. It is true 
 that, during the operation of this pelvic version, the same accidents 
 wh'.ch complicate cephalic version may manifest themselves ; but 
 the difference is very great, for the feet of the infant being seized 
 in pelvic version, it may be immediately protected from the conse- 
 quences of these accidents in proportion as they occur ; an advan- 
 tage not possessed by cephalic version, where we are obliged to 
 abandon the head as soon as it is brought to the superior strait. 
 
 In conclusion, we should not interfere with the presentation of 
 the face at the superior strait, when even in a mento-posterior po- 
 sition (for this is the most commonly met with), because experience 
 has shown, in our day, that the delivery will be spontaneous in 
 most cases, and natural under many circumstances, and that we 
 
CONDUCT OF THE ACCOUCHEUR. 407 
 
 only aggravate the condition of the mother and child in operating 
 at the superior strait when the labour is not complicated by any 
 accident ; and this fact must be kept constantly in view, that if, for 
 a long period, it was supposed to be necessary to change this pre- 
 sentation, it is because authors have attributed to it the difficulties 
 and accidents which result only from their own rash attempts to 
 save the mother and child from the consequences of these acci- 
 dents ; and it must also be remembered that it is more rational to 
 confide this expulsion to the efforts of nature. 
 
 In most cases, therefore, the duties of the accoucheur will be 
 limited to supporting the perineum ; but, in this case, it must not 
 be forgotten that the anterior portion of the neck, at the moment 
 of the delivery, rests on the border of the pubic arcade, and that 
 too much force must not be employed in this support, for fear of 
 increasing the compression of the jugulars. 
 
 If, indeed, in consequence of certain anomalies during the prog- 
 ress of labour, after the face has passed the superior strait, the chin 
 should remain posteriorly and to the right, or pass entirely behind, 
 we shall then be under the necessity of doing the best that circum- 
 stances will permit. I shall speak of these indications in the fol- 
 lowing chapters. 
 
 Accidents which may occur during the Progress of Labour, when the 
 
 Face presents. 
 
 The accidents capable of calling for the assistance of the accou- 
 cheur in the presentation of the face, from its engagement in the 
 superior strait until its final passage through the inferior strait, are 
 the same as in the presentation of the vertex, and require the same 
 treatment. 
 
 Again, these complications being much more serious in the pre- 
 sentation of the face, require more prompt action. The presence 
 of the face, too, at the superior strait indicates certain modifica- 
 tions in the means to be employed. 
 
 In the first place, the accoucheur should always prefer version to 
 the forceps, whenever this operation is possible, for the application 
 of the forceps may result much more seriously to the child when 
 the head is extended (face presentation), than when it is flexed 
 (vertex presentation), one of the blades of the instrument being al- 
 most invariably applied to the face when the application is irregu- 
 lar. Secondly, when some accident manifests itself, the face occu- 
 pying the superior strait, it will be necessary to interfere earlier 
 than in the presentation of the vertex, in order to prevent the de- 
 scent of the head, and the too violent contraction of the uterus ; 
 circumstances which, rendering version impossible, will oblige us 
 to have recourse to the forceps. 
 
 For the accidents capable of retarding or preventing delivery, 
 and likewise for the complications foreign to labour, and requiring 
 the particular attention of the accoucheur, and sometimes his in- 
 terference, as also for those which may compromise the safety of 
 mother or child, the reader is referred to w T hat is said under the 
 head of Vertex Presentations, 
 
408 ANOMALIES IN THE MECHANISM OF LABOUR. 
 
 CHAPTER I. 
 
 DIFFICULTIES OCCASIONED BY ANOMALIES IN THE MECHANISM OF 
 
 LABOUR. 
 
 The various anomalies during the different periods of labour, 
 have a much more alarming influence in presentation of the face 
 than in that of the vertex, nature being, in the latter case, gener- 
 ally sufficient of herself. 
 
 Art. I. — Anomalies of the First Period, Deflection. 
 
 As was remarked in presentation of the vertex, the descent of 
 the flexed head may very readily take place without previous 
 flexion ; and if this flexion occur, it is only to facilitate the descent, 
 and not because it is indispensable. It is not the same, however, 
 with deflection or extension in the presentation of the face. With- 
 out the accomplishment of this first period, the descent cannot be 
 effected ; thus, when extension does not take place, art must inter- 
 fere. 
 
 The accoucheur should endeavour to draw the chin to the cen- 
 tre of the superior strait ; and if this be impossible, it will be neces- 
 sary to perform pelvic version. 
 
 Art. II. — Anomalies in the Second Period of Descent. 
 This period cannot fail of itself; adventitious circumstances alone 
 can oppose its accomplishment ; such as, the anomaly in the first 
 period, inertia of the uterus, excessive size of the head, contractions 
 of the pelvis, &c. 
 
 Art. III. — Anomalies in the Third Period of Rotation. 
 This is one of the gravest complications which can possibly oc- 
 cur in presentation of the face. In fact, rotation of the chin for- 
 ward is absolutely necessary, for without it spontaneous expulsion 
 cannot take place ; therefore, the chin must be brought in front, 
 which can only be effected by the forceps. 
 
 Art. IV. — Anomalies in the Fourth Period of Delivery. 
 This fourth period cannot fail of itself; inertia, resistance of the 
 soft parts, &c, &c, can alone prevent it. 
 
 Art. V. — Anomalies of the Fifth Period, External Rotation. 
 (See Vertex Presentations.) 
 
VARIETIES OF PRESENTATION. 409 
 
 CHAPTER II. 
 
 MECHANICAL OBSTACLES TO DELIVERY. 
 
 (See Vertex Presentations.) 
 
 For all the complications in this chapter, the indications are pre- 
 cisely the same as in the presentation of the vertex. The varieties 
 of presentation alone present some peculiarities worthy of note. 
 
 Art. I. — Varieties of Presentation. 
 
 Varieties of Malar Presentations. 
 It is very rare that we are obliged to interfere for varieties of 
 presentation in general. What I have said with regard to the 
 presentations of the vertex is equally applicable here. Thus, in the 
 first place, in those cases in which one or other cheek occupies the 
 superior strait (malar varieties), as was stated in the article Sponta- 
 neous Delivery by the Face, the malar varieties almost always right 
 themselves during the first contractions of the womb, and are suc- 
 ceeded by the full presentation. Now, if the righting should not 
 take place, the face may still descend inclined as far as the excava- 
 tion, and the righting is not accomplished until it reaches the inferior 
 strait, simultaneously with its delivery ; if, however, which is very 
 rare, one or other malar variety persist in presenting, and the descent 
 do not take place, the accoucheur must assist. Unfortunately, the 
 manual righting, the bringing the face to the centre of the superior 
 strait, is not more practicable in this case than in the parietal vari- 
 eties of the vertex. Moreover, it will be impossible, in most cases, 
 to bring the vertex into the position of .the face .by fixing the fingers 
 upon the occiput (see Conduct in Delivery by the Face and Cepha- 
 lic Version), for we must delay a certain period in order to test the 
 insufficiency of the uterine contractions, which will ordinarily suf- 
 fice to effect this righting ; and, by this time, the energies of the 
 womb will have become so violent, that, in the majority of instances, 
 they will render useless all attempts at reduction. Pelvic version, 
 even in these cases, will not always be possible ; and the application 
 of the forceps will, unfortunately, be too often the only resource. 
 Nevertheless, every legitimate effort should be made to practise ce- 
 phalic or pelvic version, in order to avoid the danger of applying 
 the forceps on the face. I repeat, however, that these presenta- 
 tions are rare, and the necessity for interference is still more so. 
 
 Variety of Frontal Presentation. 
 The variety of frontal presentation, as has been remarked in the 
 article Spontaneous Delivery by the Face, is the most frequent, 
 
 Fff 
 
410 
 
 MECHANICAL OBSTACLES TO DELIVERY. 
 
 and is almost always converted into the full presentation; the 
 head presents, in this case, demi-flexed by an unfavourable diam- 
 eter (four inches seven to eight lines) ; but the first period of 
 spontaneous delivery, the complete extension, which rarely fails, is 
 accomplished, and the face, thus perfectly extended, occupies in full 
 the superior strait. If the frontal variety should continue without 
 becoming reduced, the descent will not be possible, unless the head 
 is small and the pelvis very large. Two methods have been recom- 
 mended in this case in order to determine the 
 descent : the first consists in flexing the head, 
 with a view to bring down the vertex, by en- 
 deavouring to cause the chin to ascend and ap- 
 proximate the chest, which is next to impos- 
 sible. The second method may sometimes 
 prove successful : it consists in supporting the 
 foreheard during the contraction, in order that 
 the face may descend, or in bringing down the 
 chin with two fingers in the form of a crotchet. 
 Madame Lachapelle has often succeeded in 
 this way ; often, too, she has failed. In case 
 of failure with these partial manipulations, 
 should the contraction of the uterus oppose version, we must have 
 recourse to the forceps. 
 
 Mento-cervical Variety of Presentation. 
 Finally, the mento-cervical variety, that in which the chin and a 
 small portion of the neck are felt at the 
 orifice, is reduced, like the preceding, to 
 a full presentation ; it is, nevertheless, 
 very rare. Should this reduction not 
 take place (which is still more rare), we 
 should endeavour to depress the face, by 
 means of two fingers introduced into the 
 mouth, while with the other hand placed 
 on the iliac fossa, to which corresponds 
 the occiput, we endeavour to cause the 
 head to descend. This operation is dif- 
 ficult ; and if the face does not descend, 
 or cannot be depressed, we must act as in the preceding varieties. 
 
 Art. II. — Deformities of the Pelvis. 
 Although a deformity of the pelvis at the superior strait does not 
 exclude the spontaneous termination of a face presentation, yet we 
 cannot disguise the fact that this termination must necessarily be 
 rare, and that, when it does occur, the infant is in great danger. 
 Thus, pelvic version being proscribed in this case, M. P. Dubois 
 advises to bring down the vertex in the place of the face, if this be 
 possible, before applying the forceps, in order to save the child 
 from the dangers of an application which cannot but be irregular. 
 (For the other indications, see Presentation of the Vertex.) If the 
 
 (Fig. 187.) 
 
PARTICULAR RULES FOR APPLICATION OF FORCEPS. 411 
 
 inferior strait be contracted, the forceps alone will be applicable ; 
 such, also, will be the fact when the face is retained by the resist- 
 ance of the external genital organs. 
 
 CHAPTER III. 
 
 GENERAL RULES FOR THE APPLICATION OF THE FORCEPS IN THE 
 PRESENTATION OF THE FACE. 
 
 The general rules for the application of the forceps in face pre- 
 sentations are the same as for the vertex; as for the particular 
 rules, they, too, are the same, with some few exceptions, and I shall 
 now enumerate them, commencing, as I did for the vertex, with the 
 most simple, and then passing to the more complicated cases. 
 
 Art. I. — Particular Rules for the Application of the Forceps 
 when the Head is in the Pelvic Cavity. 
 Whatever may be the cause requiring the application of the for- 
 ceps, this application will vary according to the position of the head. 
 The rules for the use of this instrument when the head is in the 
 cavity, the chin corresponding to the anterior half of the pelvis, are 
 the same as in the presentation of the vertex, the occiput corre- 
 sponding also in front ; they vary according to the positions.* 
 
 * Although it is undoubtedly true that the foetus, under ordinary circumstances, can be 
 delivered by the spontaneous efforts of nature when the face presents, yet it should not be 
 forgotten that, in this form of presentation, as soon as the active efforts of the womb prove 
 insufficient to effect the delivery, much delay on the part of the accoucheur may result fatally 
 to the child, and, at the same time, inflict serious injury on the mother. I have repeatedly 
 been called to cases of face presentation (and from the number I have seen, 1 should not be 
 inclined to consider them as rare as has been supposed), in which the child was suffering se- 
 riously from the excessive pressure exerted on it by the contractile power of the uterus, and 
 where immediate delivery was indicated. 
 
 In June, 1840, Dr. Oatman sent for me in haste to visit Mrs. J., who had been in active 
 labour for twenty-four hours. Her pains from the commencement had been expulsive, and 
 she suffered from their constant and violent recurrence. The membranous sac had ruptured 
 three hours after the commencement of the labour; but the mouth of the womb had previ- 
 ously become well dilated. Dr. Oatman, on making a vaginal examination, ascertained that 
 the face presented ; the efforts of the womb caused the head to descend, but its progress was 
 extremely slow ; after the face had pressed partially into the excavation, it became arrested, 
 and notwithstanding the continued and powerful action of the womb, it made no farther 
 progress. The mother's strength was yielding under the influence of these repeated and 
 fruitless contractions, and the life of the child was in great peril from the pressure exerted 
 on it. Dr. Oatman having decided in his own mind that artificial delivery was absolutely 
 indicated, requested my attendance. On arriving, I found the condition of things as de- 
 scribed above, and at the request of the doctor proceeded to deliver Mrs. J. with the forceps. 1 
 encountered but little difficulty in the operation, and in a few moments presented her with 
 a fine iiving daughter. A few hours' delay in this case would have rendered this agreeable 
 result impossible. 
 
 In September, 1842, Dr. Graham sent for me in consultation in the case of a young married 
 lady in labour with her first child. She had been in labour six hours before the doctor visited 
 her, and when he arrived the mouth of the womb was but slightly dilated, and the pains had 
 not been severe. He left her, and was again sent for in the evening, about fourteen hours from 
 the commencement of her labour. The orifice was then dilated to the size of a four-shilling 
 piece, and he recognised the presentation to be that of the face. The pains continued with 
 more or less force during the night, but although the uterus became completely dilated, there 
 was very little progress in the delivery. The patient was exceedingly frail, and became 
 very much exhausted. It was at this time that I first saw her, being twenty-eight hours 
 
412 APPLICATION OF FORCEPS IN FACE PRESENTATION. 
 
 § 1. Secondary Mento-pubic Position. 
 Thus, in the direct mento-pubic position, the concavity of the bor- 
 ders of the forceps should regard the lower portion of the symphysis 
 pubis, one branch to the left, the other to the right, as in the corre- 
 sponding occipito-pubic position of the vertex ; after the same man- 
 ner, direct tractions should be made, combined with the lateral mo- 
 tion ; then, raising the instrument in front of the symphysis pubis, a 
 movement of flexion is imparted to the head, which enables the fore- 
 head, bregma, and occiput to pass the anterior commissure of the peri- 
 neum. 
 
 § 2. Left Anterior Mento-iliac Secondary Position. 
 If I were to follow the order of frequency of face presentations, I 
 should, immediately after the mento-pubic, speak of the right mento- 
 iliac ; but the application being precisely the same in the cases in 
 which the occiput and chin regard the same points in the anterior half 
 of the pelvis, I shall describe first the mode of applying the instru- 
 ment in the left anterior mento-iliac position, corresponding with the 
 left anterior occipito-iliac. The concavity of the borders of the instru- 
 ment being directed to the left and in front, will be in relation with 
 the chin, which is to be brought under the pubes; the pivot branch is 
 introduced first posteriorly and to the left, the mortise branch in front 
 and to the right, and, by a movement of rotation, the concavity of the 
 borders and the chin are brought under the pubes, and the delivery is 
 effected as in the preceding case. 
 
 § 3. Right Anterior Mento-iliac Secondary Position. 
 In this position, the application is the reverse of the preceding ; the 
 pivot branch is placed above and to the left, the mortise branch be- 
 low and to the right; the chin must be brought under the pubes, and 
 the delivery will be the same. 
 
 § 4. Secondary Transverse Positions. 
 In the transverse positions, we should direct the concavity of the 
 borders to the left, if the chin be on this side; and in order to -seize 
 the head as nearly as possible on the sides, the pivot branch should be 
 carried quite into the concavity of the sacrum, the other under the pu- 
 bes, if this be possible, &c. ; if the chin correspond to the right, the 
 concavity should be directed to this side ; the pivot branch above un- 
 der the pubes, the mortise in the hollow of the sacrum, &c. This reg- 
 
 from the period her labour commenced. I found the face partially descended in the excava- 
 tion ; it was very tumid from the pressure it had undergone, and the patient herself in a state 
 of great exhaustion. The indication here no one could mistake ; and at the request of Dr. 
 Graham I introduced the forceps, and delivered her of a living child. The mother had an 
 average convalescence, but died six months afterward from consumption. 
 
 I might cite other cases illustrating the necessity of prompt and effective action on the part 
 of the accoucheur, when, from the inability of nature, both mother and child would be more 
 or less compromised by unreasonable delay. I cannot too impressively inculcate the fact that 
 we are frequently deprived of exhibiting the real benefits of judicious interference, by unjustifi- 
 able procrastination. Why delay until the child is sacrificed? why hesitate to act the mo- 
 ment nature shows that she is incompetent to discharge her duty ? There is a broad dis- 
 tinction between that prompt and opportune action by which two precious lives are saved, 
 and a rash and meddlesome midwifery, which looks not to consequences. — Ed. 
 
PARTICULAR RULES. 413 
 
 ular application, even in the excavation, is not always possible ; often 
 we will not be able to apply the instrument except in the diagonal 
 position, and the curvature will not be entirely in relation with the 
 chin. Under these circumstances, we will be obliged, in order to 
 bring the chin from under the pubes, to increase somewhat the rota- 
 tion of the forceps. 
 
 § 5. Right or Left Posterior Secondary Mento-iliac Positions. 
 
 Will the rules for the application of the forceps be the same for the 
 face when the chin regards the posterior half of the pelvis, as for the 
 vertex in the corresponding positions ? 
 
 I will remark, in the first place, that it is extremely rare that the 
 face, having entered the excavation, remains in the diagonal position, 
 right or left posterior mento-iliac ; it is even more rare for the chin to 
 pass entirely backward. Madame Lachapelle has never observed this 
 position, and regards it as impossible. It. must, therefore, be very 
 rare. However, there are some examples of it mentioned by authors. 
 
 I will suppose, therefore, that the chin, sliding on the right or left 
 sacro-iliac symphysis, remains in this position, or that some accident 
 manifests itself; the application of the forceps then becomes indispen- 
 sable. In this case, should the chin be brought forward, or carried 
 into the concavity of the sacrum ? Before proceeding farther, we 
 must return to the presentation of the vertex, and examine why, in 
 ♦his presentation, we should bring the occiput under the pubes when 
 it corresponds in front ; why, on the contrary, it must be carried poste- 
 riorly when it corresponds with this portion of the pelvis, by acting 
 on the forehead, which is brought under the pubes. It is because, 
 when we apply the forceps in the excavation, the trunk of the foetus 
 is steadied by the contractions of the uterus, and, by imparting a 
 movement of rotation on the occiput, which is posteriorly, with a view 
 to bring it in front, most commonly the head alone would be rotated, 
 while the trunk would remain immovable and the neck contorted. 
 This does not take place in spontaneous delivery, in which the head 
 and trunk execute the same movements, preserving nearly their nat- 
 ural relations. This torsion of the neck in the application of the for- 
 ceps, when it exceeds the fourth of a circle, being capable of compro- 
 mising the life of the foetus, we should abstain from bringing the occi- 
 put in front. In fact, the delivery in the direct occipito-posterior posi- 
 tion, if cautiously managed, is not of a nature to endanger either the 
 life of the foetus or the soft parts of the mother. And, moreover, the 
 occiput can be brought in front only by a very irregular and difficult 
 application of the forceps. 
 
 Would the delivery progress as favourably in the presentation of 
 the face, if, fearing torsion of the neck, we were to conduct the chin 
 posteriorly ? Certainly not. If the chin be retained posteriorly, to 
 the right or to the left, and if we carry it entirely backward, or if it 
 assume this situation itself, the case will be fatal to the child, and the 
 soft parts of the mother, and even her life, seriously involved. 
 
 Would it not, under these circumstances, be wise to conform to the 
 precepts of Smellie, and bring the chin forward, notwithstanding the 
 
414 
 
 APPLICATION OF FORCEPS IN FACE PRESENTATION. 
 
 inconveniences connected with the torsion of the neck of the infant 1 
 This, at least, is the advice of Madame Lachapelle, and she holds this 
 language : " The chin, under no pretext whatever, should be carried 
 and delivered posteriorly ; such practice icould only result in insur- 
 mountable obstacles, and cause the death of the infant." But also, 
 regarding the application of the forceps in this case as very difficult, 
 she prefers version whenever this operation is practicable. "If by 
 chance," she observes, " a circumstance which my experience causes 
 me to regard as impossible, I should find the chin turned entirely 
 backward towards the sacrum, and the infant was presumed to be 
 living, I believe I should make every effort to reach the feet, even if 
 the head were in the lower part of the excavation, and partly passed 
 the uterine orifice.* This alternative appears to me preferable to the 
 direct tractions, and to the method of Smellie. If the head, how r ever, 
 had entirely escaped through the orifice, we should then be compelled 
 to select between the two modes of applying the forceps, for version is 
 not to be thought of." 
 
 We can add nothing to these wise precepts ; but supposing, in this 
 case, version being impossible, we resort to the forceps, how is the in- 
 strument to be applied ? The face is in the excavation, and the chin 
 corresponds with the right or left sacro- iliac symphysis. If I employ 
 here the same rules as in the vertex, I would bring the forehead under 
 the pubes, and the chin in the concavity of the sacrum ; and, in order 
 to disengage the face, I would be obliged to flex the head in the ex- 
 cavation, by depressing the forceps to bring the occiput under the 
 symphysis pubis; and I have already sufficiently established the fact 
 that this delivery is impossible w T ith a foetus at full term in a pelvis 
 which has only its normal dimensions ; for, in order that the head may 
 
 become flexed after it has reached the 
 excavation in a state of extension, it will 
 be necessary that the occipito-mental di- 
 ameter, measuring five inches, should 
 move in the excavation, all the diam- 
 eters of which are four inches and a half; 
 tar the head being once seized, with a 
 view to disengage it, 1 should proceed 
 by a movement of elevation and direct 
 traction, until the chin, which I would 
 direct towards one of the sacro-sciatic 
 ligaments, by inclining the forceps of this 
 side, had passed this ligament. The trachea rests on the point of the 
 
 (Fig. 188.) 
 
 sacrum. 
 
 * With all the respect I entertain for the opinions of that extraordinary woman, Madame 
 Lachapelle, on subjects connected with obstetric science, yet I am compelled to dissent 
 from her in the principle which she here so emphatically lays down : " I should make every 
 effort to reach the feet, even if the head were in the lower part of the excavation, and partly pass' 
 ed the uterine orifice." This is a rule of practice dangerous to the mother, often fatal to the 
 child, and hazardous to the reputation of the accoucheur. It is a precept which surpri- 
 ses me the more, considering the high source from which it emanates. To attempt to push 
 the head into the womb after being •' low in the excavation, and partly through the orifice," 
 would, in the first place, subject the mother to the severe hazard of rupture of this organ ; 
 and, secondly, it would almost certainly involve the safety of the child, in consequence of the 
 
PARTICULAR RULES. 
 Fig. 189.) 
 
 415 
 
 And then, by a movement of depression and repulsion posteriorly, I 
 would disengage gradually the occiput from the pubes, the chin push- 
 ing the perineum downward and backward ; then, with the aid of a 
 slight direct traction, I would deliver the face, which remains fixed 
 on the perineum ; this latter traction, in most cases, will be useless. 
 But delivery in this way is truly painful, and dangerous to both moth- 
 er and child. 
 
 Let us now examine what will be the course of things, if, in the 
 same position, we attempt to bring the chin forward, and what method 
 must be pursued. 
 
 In the first place, it is rare that the chin is exactly in relation with 
 the sacro-iliac symphysis ; the neck, in this case, experiences great 
 difficulty in measuring the posterior wall of the excavation ; the chin 
 will be solicited to approximate the anterior part, and it will then be 
 found near the extremity of the transverse diameter. It was in a case 
 of this kind that I saw M. P. Dubois bring the chin under the pubes. 
 He found it sufficient, in order to effect the disengagement of the chin, 
 to incline the concavity of the borders of the forceps on the side oppo- 
 site to that with which the chin corresponded. If even the chin were 
 in relation with the sacro-iliac symphysis, it would be still necessary, 
 for the purpose of affording some chance to the child and protecting 
 the mother, to bring the chin forward. Farther, I would conform to 
 this precept if the chin has passed quite posteriorly in the concavity of 
 the sacrum. 
 
 But I have already established as a principle, in the general rules 
 for the application of the forceps, that we should always place the 
 concavity of the borders of the instrument in correspondence with the 
 part which we wish to bring in front ; this part is the chin, and it is 
 posteriorly ; therefore, I should direct this concavity backward, which 
 is contrary to the rules of art. (See Vertex.) Now, what is to be 
 done ? Shall we, after the example of Smellie, employ a straight for- 
 ceps, or admit a mento-transverse instead of a mento-posterior, and ap- 
 ply the instrument as in a transverse position 1 if the chin be to the 
 right, introducing the pivot branch first, and conducting it, as nearly 
 as possible, under the symphysis pubis, and the mortise branch in the 
 
 force necessary to return the head and bring down the feet. If I may be permitted to state 
 a principle on this subject, I would say, whenever artificial delivery is indicated, if the head be 
 low in the pelvic excavation, and entirely or even partially through the orifice cf the womb, there 
 must be no election between version and the forceps ; the latter must always be resorted to. — Ed. 
 
416 
 
 APPLICATION OF FORCEPS IN FACE PRESENTATION. 
 
 concavity of the sacrum ? The contrary of this, if the chin be to the 
 left. I suppose the most common position, right posterior mento-iliac ; 
 the head being once seized, the chin will not be found entirely in re- 
 lation with the concavity of the border of the forceps ; it will be some- 
 what more posteriorly, and then, when the movement of rotation will 
 
 (Fig. 190.) 
 
 
 be complete for the forceps, that is, when the curvature is entirely un- 
 der the symphysis pubis, the chin will only be behind the cotyloid cav- 
 ity ; and, in order to bring it under the pubes, we must increase the 
 rotation of the forceps so that the concavity of the borders, at the mo- 
 ment of delivery, regards the opposite cotyloid cavity. It must, how- 
 ever, be understood here, as in all irregular applications of the forceps, 
 that it will be necessary, should the parts be too resisting, to disarticu- 
 late the instrument in order to apply it again more regularly ; or, if 
 there should be uterine contractions, commit the expulsion to the nat- 
 
 (Fig. 191.) 
 
PARTICULAR RULES. 417 
 
 ural efforts. Finally, the rules pointed out above must be conformed 
 to (Presentation of the Vertex). 
 
 It is rare, as was remarked with regard to the vertex, that we can 
 apply one branch entirely under the symphysis pubis, even in the ex- 
 cavation ; and we can only place the forceps diagonally, and, unfortu- 
 nately, on the face and occiput ; then, after the movement of rotation, 
 which must be increased as much as possible in order to bring the 
 chin very near the pubes, the instrument should be disarticulated, and 
 reapplied in the diagonal position, and thus complete the rotation of 
 the chin and its delivery. It will be the same if the forceps have been 
 applied on the sides of the pelvis. Finally, two successive applica- 
 tions will become absolutely indispensable if we desire to bring in front 
 the chin, which is quite posteriorly. The first application must be 
 made as diagonally as possible in order to bring the chin transversely ; 
 the second, made in the same direction, conducts it under the pubes, 
 and, always increasing slightly the movement of rotation, the delivery 
 is achieved. These methods appear to me much preferable to those 
 by which the head is disengaged in the direct mento-posterior posi- 
 tion; for they only endanger the life of the child by the torsion of its 
 neck, and even in this case, it may be hoped that the trunk will par- 
 ticipate, if not in totality, at least in part, in this movement of rotation 
 imparted to the head, and that, if the torsion of the neck should oc- 
 cur, it may not exceed the fourth of a circle. Madame Lachapelle 
 cites, under these circumstances, cases in which children were born 
 alive with the chin resting on the back ; and they were extracted in 
 the mento-anterior position with almost as much facility as in the oc- 
 cipitoanterior of the vertex ; while the violent tractions necessary to 
 make on the head, in order to draw the chin to the extremity of the 
 sacrum, always compromise the life of the foetus in consequence of the 
 compression experienced by the head, but more particularly from the 
 forced extension of the vertebral column, and the lesions of the spinal 
 marrow resulting from it. These energetic efforts, too, which are oft- 
 en long continued, while they contuse and lacerate the parts of the 
 mother on which the vertex and chin have rested for a considerable 
 time, cause also a rupture of the perineum, more or less extensive, du- 
 ring the passage of the head, notwithstanding every precaution. This 
 rupture may sometimes extend to the rectum ; and these accidents may 
 not only endanger the life of the mother, but expose her to infirmities 
 (vesico and recto vaginal fistula?) which strike at her very moral ex- 
 istence. 
 
 Art. II. — Particular Rules for the Application of the Forceps 
 when the Face is at the Superior Strait. 
 When the face is detained at the superior strait, we should insist on 
 pelvic version; and it is only when this operation is impracticable 
 that we should resolve on the application of the forceps. We should 
 employ every means to enable us to apply the branches regularly on 
 the sides of the head, for fear of endangering the life of the child, by 
 placing one of the branches on the face. But, unfortunately, these 
 precepts, which are the same as when the face is in the excavation, 
 
 Ggg 
 
418 PRESENTATION OF THE PELVIC EXTREMITY. 
 
 excellent as they are, cannot be followed at the superior strait ; and 
 most generally, no matter what may be the consequences, the applica- 
 tion will be very irregular, as in the presentation of the vertex : one 
 branch is placed to the left of the pelvis, and the other to the right, 
 without any regard to the position. Direct tractions are made in the 
 axis of the superior strait, and as soon as the descent is effected, the 
 delivery must be conducted in the same way as when the face is in 
 the excavation. 
 
 Art. III. — Particular Rules for the Application of the Forceps 
 when the Face is Movable above the Superior Strait. 
 
 In this case, version being possible, it must be preferred to the for- 
 ceps ; but if a pelvic deformity should interfere with the employment 
 of this means, we must- endeavour, before applying the forceps, to 
 bring, by means of the hand, the vertex in the situation of the face ; or, 
 at least, to turn the chin forward, if it correspond to the right and pos- 
 teriorly, as is usually the case. In either case, the application will 
 be much more favourable for the fœtus. But, unhappily, the difficulties 
 to be encountered in executing these precepts are very great ; and 
 we shall, therefore, often be obliged to apply the forceps to the face, 
 regardless of the consequences of this application. 
 
 In conclusion, nature generally suffices in presentation of the face ; 
 therefore, we should not be too eager to manipulate at the superior 
 strait, either for the purpose of substituting for this presentation that 
 of the vertex or pelvic extremity. But the anomalies in the progress 
 of the labour require, much more frequently than in the presentation 
 of the vertex, the intervention of art ; and the means to be employed, 
 in this case, are less innocent, especially to the fœtus, than in vertex 
 presentations. 
 
 If it be possible, we should attempt version ; and if the application 
 of the forceps be the only resource, we should not hesitate to bring 
 the chin in front, with whatever point of the pelvis it may corre- 
 spond. 
 
 Version in Presentation of the Face. 
 The rules for extraction by the pelvic extremity are exactly the 
 same, whether the vertex or face occupy the superior strait. (See 
 Version.) 
 
 TITLE IV. 
 
 PRESENTATION of the pelvic extremity. 
 
 M. P. Dubois, as may be seen in his synoptical classification of pre- 
 sentations and positions, has united under the same denomination of 
 presentation of the pelvic extremity, the four breech presentations of 
 
VARIETIES OF PELVIC PRESENTATION. 
 
 419 
 
 the ancient authors, viz., the complete pelvic extremity, the hips, the 
 knees, and feet. 
 
 In fact, whether this extremity be composed of all its parts, or 
 whether they be separate, that is, whether the breech, knees, or feet 
 present alone, or simply one foot or one knee, the other being on the 
 abdomen, spontaneous delivery is effected precisely in the same man- 
 ner. Thus, I shall unite them all in the same description, not omit- 
 ting, however, so far as diagnosis and prognosis are concerned, to 
 establish the difference which exists between these various modes of 
 presentation. 
 
 (Fig. 192.) 
 
 Like the presentation of the vertex and face, the pelvic extremity 
 does not always present in the same position at the superior strait ; it 
 may be inclined in four different directions : thus, at the commence- 
 ment of labour, we may feel at the orifice one hip (iliac variety), a 
 part of the sacrum (sacral variety), the anterior part of the pelvic ex- 
 tremity (anterior variety). 
 
 These varieties disappear as soon as the pelvic extremity rights it- 
 self and begins to descend, and have but little influence in mod- 
 ifying the mechanism of spontaneous delivery ; they do not deserve to 
 be mentioned, except as regards the diagnosis. 
 
 Again, it will be readily understood that, on account of the mobili- 
 ty of the feet and knees, it is impossible to distinguish the varieties of 
 presentation of the breech properly so called, when the feet and knees 
 present ; and the varieties can only be appreciated in the complete 
 presentation of the extremity, or in that of the hips. Two principal 
 positions have been admitted by M. P. Dubois : the first, left sacro- 
 iliac ; the second, right sacro-iliac (the sacrum regarding the left or 
 the right). 
 
420 PRESENTATION OF THE PELVIC EXTREMITY. 
 
 Finally, in the left sacro-iliac position, the sacrum is almost al- 
 ways directed in front ; in the right sacro-iliac position it regards the 
 sacro-iliac symphysis. 
 
 The positions of the left oblique diameter are the most frequent, and 
 in this respect we find a perfect analogy between the presentation of 
 the vertex and that of the face. 
 
 This presentation, much less frequent than that of the vertex, has 
 been observed by M. P.Dubois only eighty-five times in twenty thousand 
 labours, but it is much more common than that of the face. As to 
 the relative frequency of these different modes of presentation, it is as 
 follows : in eighty-five cases of the presentation of the pelvic ex- 
 tremity, the breech is observed fifty-four times, the feet twenty-six, the 
 knees once. 
 
 § 1. Causes. 
 
 According to Madame Lachapelle, the most probable cause of this 
 presentation is thus explained : during the greater portion of gesta- 
 tion, while the foetus still enjoys much mobility in the uterine cavity, 
 and its long diameter is easily put in relation with the transverse diam- 
 eter of the organ, the position of the foetus not being stationary, it 
 may, in virtue of its active motion, present at the orifice almost all 
 the points of its surface, but especially the head and pelvic extremity. 
 I suppose that, at some indeterminate period, this latter part is brought 
 down to the superior strait by the movements of the foetus, and re- 
 mains there for a longer or shorter period ; it may happen that the 
 foetus, during this period, acquires such development as to prevent its 
 leaving the strait ; in a word, its long diameter cannot pass the trans- 
 verse diameter of the uterus, and its pelvic extremity, therefore, re- 
 mains permanently fixed at the superior strait. 
 
 This explanation, although the most rational, is still not altogether 
 free from objection. 
 
 § 2. Diagnosis. 
 
 Diagnosis of the Presentation. 
 
 At an advanced period of pregnancy, it is possible to distinguish a pre- 
 sentation of the pelvic extremity, by abdominal percussion, auscultation, 
 and the touch. At the fundus of the womb there is felt a rounded, 
 hard, solid tumour, which is the head ; the intensity of the pulsations 
 of the foetal heart is heard above the umbilicus, and the finger does 
 not recognise at the superior strait the solid spherical surface, repre- 
 sented by the vertex; most frequently it can feel no portion of the 
 foetus at this point; sometimes it is enabled to reach a small mova- 
 ble portion, a foot or a knee. 
 
 During labour, before the rupture of the membranes, there is a soft, 
 irregular tumour felt, composed of several parts, some of which are 
 movable, and others stationary. The membranous sac gradually 
 elongates, and finally ruptures ; more or less amniotic fluid escapes, 
 because the superior strait is but imperfectly closed by the parts which 
 present 
 
VARIETIES OF PRESENTATION. 421 
 
 It is only at this time that the diagnosis can be made with precision. 
 
 Complete Presentation. — When the pelvic ex- (Fig- 193.) 
 
 tremity is composed of all its elements, and the ori- 
 fice but slightly dilated, we feel at first one buttock ; 
 then, in proportion as the orifice opens, the heels 
 and the other buttock descend, and the fissure separ- 
 ating the two buttocks is distinctly recognised. The 
 finger is also able to reach the irregular surface of 
 the sacrum and anus, a small, circular orifice, which 
 contracts on the finger of the accoucheur, and in the 
 vicinity of which there is a small, pointed, elastic 
 prominence — the coccyx, an organ which can be felt in the fattest in- 
 fants, and which is the essential character of the presentation. In fol- 
 lowing the median fissure, which separates the buttocks, we also feel the 
 genital organs, and we can ascertain in advance the sex of the child ; we 
 should, in this case, employ the touch very delicately if it be a female 
 infant ; for if, mistaking the vulva for the anus, the finger should be 
 introduced deeply, the hymen may be destroyed. Finally, the fin- 
 ger of the accoucheur is generally covered more or less with meco- 
 nium. 
 
 Presentation of the Breech. — The characters of this presentation 
 are the same, except the feet, which cannot be felt. 
 
 Presentation of the Feet. — When the two feet present, it is difficult 
 to confound them with any other part. If only one should engage, it 
 is distinguished from the hand by the presence of the os calcis, and by 
 the difference of length between the toes and fingers of the hand. In 
 the foot, the large toe is of the same length as the others; in the 
 hand, the thumb is shorter, and is more separated from the other fin- 
 gers. The foot forms with the leg an angle more or less acute ; the 
 hand is directly continuous with the arm. 
 
 Presentation of the Knees. — This very rare presentation is easily rec- 
 ognised; the finger encounters two round tumours, but somewhat 
 pointed ; it can pass beyond these tumours, and reach the bend of 
 the knee. 
 
 Differential Diagnosis of the Presentation. 
 At first, one buttock presenting alone, may be mistaken for the pa- 
 rietal protuberance of the vertex, and, in this case, the fissure separa- 
 ting the buttocks may also be mistaken for the sagittal suture. If 
 this error may be pardoned at the commencement of labour, there is 
 no excuse for it at a more advanced period. When the cheeks, in the 
 presentation of the face, by a prolonged sojourn at the superior strait, 
 have become the seat of a sero-sanguineous afflux, they may likewise, 
 at the first aspect, impose on us the belief that the breech presents. 
 But if care be taken to pass the finger in the fissure which separates 
 these two projections, instead of feeling the anus, the coccyx and gen- 
 ital organs, the finger simply penetrates an open cavity, furnished with 
 a tongue and alveolar processes ; it recognises the orbits, and especially 
 the nose, a small, pointed, flexible organ, pierced with two openings, 
 and which characterizes the presentation of the face. 
 
422 PRESENTATION OF THE PELVIC EXTREMITY. 
 
 Finally, in the pelvic presentation, the amniotic fluid escapes usual- 
 ly mixed with the meconium, and the finger of the accoucheur is like- 
 wise covered with this excretion. 
 
 Diagnosis of the Position. 
 
 In the complete presentation, the direction of the point of the coc- 
 cyx, that of the heels, genital organs, and rugosities of the sacrum, 
 enable us to establish with what point of the superior strait the sa- 
 crum is in relation. Example : the heels and rugosities of the sacrum 
 directed to the left and in front, the point of the coccyx and genital 
 organs to the right and posteriorly, indicate a left anterior sacro-iliac 
 position. 
 
 It will, after this, be perfectly easy to complete the diagnosis of the 
 positions in the other presentations. I should, however, remark, that 
 the positions in the presentation of the knees cannot possibly be recog- 
 nised when we can only reach the sacrum, for the anterior portion of 
 these organs cannot be distinguished from the posterior. 
 
 For the rest, the principal object to bear in mind is to establish the 
 diagnosis of the presentation, in order that it may be ascertained 
 whether the labour is to be confided to the spontaneous efforts of na- 
 ture ; the diagnosis of the position is useful only in cases in which the 
 intervention of art is called for. 
 
 Art. I. — Mechanism of Spontaneous Delivery 
 
 I will describe the mechanism of spontaneous delivery in the pres- 
 entation of the breech, which is the most common ; and in the two 
 left anterior and right posterior sacro-iliac positions, which are like- 
 wise the most frequent. I will say nothing of the other positions, in 
 which the mechanism is precisely the same. 
 
 § 1. Mechanism of Spontaneous Delivery in the Full Presentation of 
 the Breech, and in the Left Anterior Sacro-iliac Position. 
 
 The fœtus presents with the legs lying on the anterior portion of 
 the trunk, the breech alone occupying the superior strait. 
 
 The back is in front and to the left ; the anterior plane of the fœtus 
 regards the posterior right side of the pelvis ; the sacro-pubic diame- 
 ter of the fœtus corresponds with the left oblique diameter ; the bis- 
 iliac of the fœtus with the other right oblique diameter. Before the 
 complete dilatation, the buttock in front presents first to the finger of 
 the accoucheur, whether this depend on the position of this part, on 
 the inclination of the pelvic extremity itself, or on that of the plane of 
 the superior strait. But when the orifice is perfectly dilated, the but- 
 tocks right themselves, become compressed, and are reduced in size. 
 This first period, which M. P. Dubois calls the lessening of the parts, 
 corresponds to the first period of flexion in the vertex, and extension in 
 the face : finally, they descend simultaneously. If the contractions 
 be energetic, on account of the small volume of the breech, it descends 
 promptly into the excavation (second period). In the contrary case, 
 they pass down gradually, without changing the situation they affect- 
 
MECHANISM OF SPONTANEOUS DELIVERY. 423 
 
 ed at the superior strait. Having reached the floor of the pelvis, and 
 only when the perineum begins to distend, they execute a movement 
 of rotation (third period), which carries the left buttock behind the 
 right ischio-pubic branch, and the right in front of the left sacro-sciat- 
 ic ligament. The left buttock descends gradually into the inferior 
 strait and reaches the vulva first, remaining immovable below the 
 right ischio-pubic branch, while the right buttock traverses the con- 
 cavity of the perineum, and disengages first at the anterior commissure 
 of the perineum. 
 
 The left buttock disengages in its turn (fourth period), and the en- 
 tire breech executes a movement of rotation, which places the bis-iliac 
 diameter of the fœtus in exact relation with the antero-posterior di- 
 ameter of the vulva. 
 
 (Fig 194.) 
 
 In proportion as the buttocks disengage at the inferior strait, the 
 arms, applied on the sides and front of the chest, together with the 
 shoulders, enter the excavation in the diagonal position which they 
 affected, as also the pelvic extremity, at the superior strait. The trunk 
 of the foetus, therefore, is slightly turned on its own axis. They arrive 
 in this way at the inferior strait, and pass it in the same manner as the 
 breech : the left shoulder under the right ischio-pubic branch ; the 
 right shoulder on the left sacro-sciatic liagament ; they then finally as- 
 sume the antero-posterior position at the moment they leave the soft 
 parts. 
 
 The posterior shoulder, which appears the last, is ordinarily deliv- 
 ered the first. 
 
 The head passes the superior strait in the left diagonal position, the 
 occiput behind the left cotyloid cavity. When the head is completely 
 flexed, it presents, at the superior strait, its sub-occipito-bregmatic di- 
 ameter, and the occipito-mental diameter is parallel to the axis of the 
 inferior strait. If it be only moderately flexed, which is most usually 
 the case, it is the sub-occipito frontal diameter which presents, and the 
 trachelo-bregmatic diameter is parallel to the axis of the inferior strait. 
 The head then becomes flexed, and often passes the inferior strait di- 
 agonally ; often, also, it executes a movement of rotation, which pla- 
 ces the forehead in the concavity of the sacrum, and the occiput im- 
 
424 
 
 PRESENTATION OF THE PELVIC EXTREMITY. 
 
 mediately behind the pubes ; the shoulders become transverse at the 
 vulva (internal rotation of the head, external of the shoulders, fifth pe- 
 riod); the forehead and bregma disengage successively at the com- 
 missure of the perineum; and the sub-occipito-frontal diameter is in 
 relation with the antero-posterior diameter of the inferior strait. 
 
 (Fig. 195.) 
 
 This delivery of the head frequently requires, on the part of the ac- 
 coucheur, an elevation of the trunk, together with gentle direct tractions. 
 In a word, the head has passed the uterus ; it is beyond the reach of the 
 contractions of this organ, and those of the vagina cannot always ex- 
 pel it. 
 
 § 2. Mechanism of Spontaneous Delivery in the Full Presentation of 
 the Breech : the Right Posterior Sacro-iliac Position. 
 
 The back of the fœtus is posteriorly, and to the right ; its anterior 
 surface in front, and to the left. The mechanism is precisely the same 
 as in the preceding case, only the movement of rotation, which brings 
 the back forward, is much more complete ; and here we find a perfect 
 analogy between what takes place in the presentation of the vertex 
 and that of the face, in which, as has been seen, the occiput and chin, 
 when situated posteriorly, still disengages in front. 
 
 This rotatkn of the back forward is most usually followed by the 
 head, so that the occiput, which has been brought simultaneously with 
 the back to the anterior portion of the pelvis, likewise disengages un- 
 der the pubes. Sometimes, however, the back alone rotates, and the 
 head enters the excavation in the occipito-posterior position ; then, af- 
 ter the expulsion of the trunk, at the moment it is about to disengage, 
 the occiput passes under the pubes. 
 
 Such are the laws which most commonly govern the spontaneous 
 expulsion in the presentation of the vertex ; but there are some excep- 
 tions, which I will mention in the article Anomalies. 
 
 § 3. Spontaneous Delivery in the Varieties of Presentation of the Pel- 
 vic Extremity. 
 The varieties of iliac, sacral, and anterior presentations do not affect, 
 
 
AInOMALIES IN THE MECHANISM OF SPONTANEOUS DELIVERY. 425 
 
 or at least very slightly, the mechanism of spontaneous expulsion. 
 Thus, during the first contractions, the pelvic extremity rights itself, 
 and descends. There is here an additional period, the period of 
 righting. 
 
 ART. II. ANOMALIES IN THE MECHANISM OF SPONTANEOUS DELIVERY. 
 
 We find, in the mechanism of spontaneous expulsion by the pelvic 
 extremity, perfect analogies with spontaneous delivery in the two pres- 
 entations of the head. 
 
 1st. Thus, the^r^ period, the lessening of the parts, which is mere- 
 ly the analogue of the periods of flexion and extension of the vertex 
 and face, is scarcely ever appreciable except when the pelvic extrem- 
 ity presents complete, and when, consequently, it undergoes its reduc- 
 tion of size. The first period, therefore, is less constant than in the 
 two preceding presentations. 
 
 2d. The second period, descent, cannot fail of itself. 
 
 3d. The third period, rotation, is exactly the same as in the vertex 
 and face, and is subject to the same irregularities. Thus, the back 
 does not commence its movement of rotation until the pelvic extremity 
 rests on the floor of the pelvis. This rotation, however, of the back, 
 like that of the occiput and chin, may be executed, in part, before the 
 complete descent ; and, again, it may not be accomplished until the 
 breech, having passed the inferior strait diagonally, disengages from 
 the soft parts. 
 
 § 1. Disengagement of the Pelvic Extremity, the Back and Occiput 
 being Posteriorly. 
 
 In fact, the movement of rotation may fail altogether ; the back, ori- 
 ginally situated posteriorly, remains in this position, instead of placing 
 itself under the pubes. 
 
 In this case, the expulsion most frequently terminates spontaneous- 
 ly; for the shoulders, when their bis- acromial diameter is not very 
 long, and the vulva dilatable, and, especially, if the perineum have 
 been ruptured in preceding deliveries, may pass the vulva in a trans- 
 verse position ; the back then glides along the point of the coccyx and 
 the perineum, and the occiput lodges in the concavity of the sacrum. 
 The head may then disengage in two ways : in the first, it becomes 
 firmly flexed, and the entire head disengages by a movement of pro- 
 gression forward, the forehead being placed under the pubes, and the 
 whole occipitofrontal diameter measuring the expulsion of the head. 
 In the second case, the head presents at the inferior strait extended, 
 the chin fixed behind the pubes ; the occiput disengages first at the 
 anterior commissure of the perineum, then, successively, the bregma, 
 forehead, and face. But this disengagement, which is rare, can only 
 be accomplished by the assistance of the accoucheur, who supports the 
 trunk of the foetus, and raises it from A to I. 
 
 The disengagement of the head, the back and occiput being poste- 
 riorly, presents in general such little difficulty, that an author, found- 
 ing his opinion on a series of these cases met with in practice, pre- 
 sented to the Academy a memoir, in which he considered this occip- 
 
 Hhh 
 
426 
 
 PRESENTATION OF THE PELVIC EXTREMITY. 
 (Fig. 196.) 
 
 ito-posterior disengagement as the most favourable. He inferred, also, 
 from these observations, that, in practising pelvic version, we should 
 endeavour to place the back posteriorly, in order to make the deliv- 
 ery more easy. 
 
 Evidently this author has fallen into error ; but still we may derive 
 from the facts he states this practical deduction, that the occipito-pos- 
 terior disengagement is not so difficult as is generally imagined, and 
 that when, in version, this rotation of the back forward is difficult to 
 execute, and cannot be effected without danger to the infant, we must 
 not persist in performing it. 
 
 4th. Delivery, Fourth Period. — This period cannot fail, except from 
 peculiar circumstances, inertia of the womb, resistance of the peri- 
 neum, anomaly in the rotation of the hips, shoulders, head, &c, &c. 
 
 5th. External Rotation of the Shoulders, Internal of the Head, Fifth 
 Period. — This period is the analogue of the external rotation of the 
 head in presentations of the face and vertex, a movement which some 
 authors term restitution. 
 
 It presents, also, some varieties in the presentation of the pelvic ex- 
 tremity ; thus, after the disengagement of the breech and shoulders in 
 the antero-posterior position, if the head, which is retained fc in the ex- 
 cavation, be of small volume, it is not solicited to execute the move- 
 ment of rotation by which the occiput is brought in front, and the head 
 remains diagonally ; it is disengaged in this situation, and the shoul- 
 ders do not execute externally the movement, which carries the back 
 directly forward. The back remains in relation with one or other 
 thigh. 
 
 This movement of the shoulders may take place, but in an opposite 
 direction, the back passing posteriorly, because the occiput in the pel- 
 vis goes to the concavity of the sacrum. Nature most usually triumphs 
 over these anomalies. I will mention, in the article Accidents, the 
 means by which they are to be remedied. 
 
PROGNOSIS OF DELIVERY BY THE PELVIC EXTREMITY. 427 
 
 Art. III. — Prognosis of Delivery by the Pelvic Extremity. 
 
 § 1. Relative to the Mother. 
 
 Delivery by the pelvic extremity is somewhat less favourable than 
 delivery by the cephalic extremity flexed. With regard to the prog- 
 nosis, the pelvic presentation occupies nearly the same rank as the 
 presentation of the face. 
 
 The size of the parts composing the pelvic extremity, particularly 
 when it is complete, retards their descent until, under the effort of the 
 contractions, they are reduced in volume. The dilatation of the ori- 
 fice is also slower, especially if the rupture of the membranes occur 
 prematurely. But M. P. Dubois has never observed, as has been im- 
 puted to him, that the delivery will be the more favourable to the 
 mother in proportion as the volume of these parts is more considerable. 
 It was in reference to the child that M. Dubois made this observation. 
 
 § 2. Relative to the Child. 
 
 It is particularly to the infant that delivery by the pelvic extremity 
 proves serious. M. P. Dubois, putting out of question all the cases in 
 which infants seem to have perished under the influence of causes for- 
 eign to this presentation, has established the fact that one out of 
 twelve is sacrificed, while only one in fifty succumbs in presentation 
 of the vertex. 
 
 What is the cause of this difference ? It was for a long time sup- 
 posed that the death of the foetus was occasioned, in this case, by the 
 determination of fluids towards the superior parts. This determination 
 could have but very slight influence in producing the death of the 
 foetus. In a word, the neck of the womb does not contract constantly 
 on the foetus ; there are alternations of relaxation and contraction, du- 
 ring which the circulation can resume its ordinary course. More- 
 over, the large vessels contained in the great cavities and thickness of 
 the extremities are in part protected from this compression. How- 
 ever, although the parts exposed to the hollow of the pelvis most usu- 
 ally become the seat of this afflux, aud the parts contained in the cav- 
 ity of the uterus cannot become congested on their surface, yet we 
 cannot exactly deny that the internal portion of the parts thus liable 
 to this uterine compression do not become the seat of a slight sero- 
 sanguineous engorgement. The autopsy of children who have suc- 
 cumbed during this form of delivery has almost always enabled us 
 to detect traces of cerebral congestion. 
 
 Nevertheless, while we do not altogether assert that this determina- 
 tion does not bear some part in these accidents, it should be kept in 
 mind that the compression of the cord is the principal, if not the only 
 cause of the death of the foetus. In order thoroughly to understand 
 the influence of this cause, let us, in the first place, see what takes 
 place in the presentation of the vertex, and why the cord cannot be 
 compressed unless it descends below the head or is comprised between 
 the foetus and womb, in some point remote from the orifice ; circum- 
 stances which present themselves only as exceptions. During the 
 whole period of labour in the presentation of the vertex, even after 
 
428 
 
 PRESENTATION OF THE PELVIC EXTREMITY. 
 
 the head has passed the maternal organs (fig. 197), the cord floats in 
 the midst of the liquor amnii. Again, after the delivery of the head, 
 the parts which follow it in the pelvic canal, diminishing in size, pass 
 the straits rapidly, and the cord, which accompanies them, cannot in 
 any way be compressed. 
 
 (Fig. 197.) 
 
 In the presentation of the pelvic extremity, before the umbilicus has 
 passed the superior strait and orifice, the conditions are the same for 
 
 (Fig. 198.) 
 
PROGNOSIS OF DELIVERY BY THE BELVIC EXTREMITY. 
 
 429 
 
 the foetus as in the presentation of the vertex ; the cord is free, and 
 floating above the superior strait (fig. 198) j but as soon as the root of 
 the cord has passed the superior strait (fig. 199), the portions of the 
 foetus which engage and become more and more voluminous, compress 
 the cord, and the life of the child is thus often compromised, especial- 
 ly if the labour is protracted. 
 
 "When the pelvic extremity presents incompletely (as in fig. 198, 
 199), the gravity of this mode of delivery is enhanced. 
 
 In a word, if the child present by the feet or knees, these parts ex- 
 hibit but little volume, and can pass the uterine orifice, although still 
 incompletely dilated. The foetus, indeed, represents a cone, the sum- 
 mit of which engages before the base. Parts more and more volu- 
 minous present successively at the orifice, and are obliged, before they 
 descend, to sojourn at the superior strait for a longer or a shorter 
 time, until the dilatation is sufficient to enable them to pass. Thus, 
 after the inferior extremities, come the hips, then the shoulders and 
 head. As long as the hips have not passed the orifice, there is no 
 danger of the infant (fig. 198), the cord being entirely out of the 
 reach of compression ; but as soon as the umbilicus has freed the ori- 
 fice, it is compressed, and this compression is the more exact and pro- 
 longed as the portions of the foetus which follow the hips are more 
 voluminous, and the orifice more resisting. 
 
 (Fig. 199.) 
 
 The foetus is, therefore, deprived of the vascular relations which unite 
 it to its mother, and perishes from asphyxia. 
 
 It will now be readily understood, contrary to the opinion formerly 
 received, and which at the present day some accoucheurs profess, that 
 
430 
 
 PRESENTATION OF THE PELVIC EXTREMITY. 
 
 delivery by the pelvic extremity is the more favourable as this ex- 
 tremity engages more completely (fig. 192). In this case, indeed, these 
 combined parts presenting at the orifice a volume almost as consider- 
 able as that of the head, although more reducible than the pelvic ex- 
 tremity, sojourn above the superior strait until the mouth of the womb 
 is fully dilated. The first period of the delivery is the longest ; but 
 after the descent of this complete extremity, the shoulders and head, 
 "which have been preceded at the orifice by a part nearly as volumi- 
 nous as themselves, find this orifice permeable, and pass through it rap- 
 idly. This second period of delivery is much more rapid than in the 
 incomplete presentation of the extremity ; and it is in this circum- 
 stance that rests all the difference in the prognosis between the two 
 modes of presentation. In fine, as the cord is usually compressed du- 
 ring the second period of delivery, if this period be rapid, the chance 
 of compression will be much diminished. Statistical facts prove in- 
 contestably the truth of this assertion. In the complete presentation 
 of the pelvic extremity, the life of the child is much less endangered 
 than in that of the breech ; and this latter is more favourable than 
 that of the knees or feet. 
 
 (Fig. 200.) 
 
 Finally, the delivery is more favourable when it terminates spon- 
 taneously than when art is obliged to interfere. In pelvic version, in 
 a word, one child succumbs in seven. 
 
 § 3. Conduct of the accoucheur during this Delivery. 
 After what has preceded, the conduct which the accoucheur should 
 pursue in delivery by the pelvic extremity is already pointed out, since 
 the labour will be the more favourable as art interferes less. This de- 
 livery should be confided to nature, no matter what the mode of pre- 
 sentation of the pelvic extremity, unless peculiar circumstances should 
 
ACCIDENTS. 431 
 
 render the assistance of the accoucheur necessary. In fact, tractions 
 made on the presenting parts, with the object of hastening their de- 
 scent, only accelerate the period at which the umbilicus enters the 
 excavation, and becomes compressed. 
 
 If the complete pelvic extremity present, since this circumstance is 
 favourable to the fœtus, we should be careful not to remove it from 
 the superior strait by attempting to introduce the hand for the purpose 
 of bringing down the feet and knees through an orifice but imperfect- 
 ly dilated. 
 
 This practice, generally adopted for a period of thirty years, has 
 not so entirely fallen into disuse as not to justify an opposition to it, as 
 being repugnant to the laws of nature. 
 
 So far from interfering with this complete presentation of the pelvic 
 extremity, as I have often heard M. P. Dubois remark, we should en- 
 deavour even to increase its size if possible, in order that the parts 
 may not pass before the full dilatation. 
 
 If the knees or feet present, we must still be on our guard against 
 the temptation we naturally feel to hasten the delivery, by making 
 tractions on parts affording so ready a purchase. We should learn to 
 resist this impatience of both ourselves, the female, and assistants ; it 
 is a difficulty rarely overcome by the young accoucheur at the com- 
 mencement of his career. In fine, if we do not interfere with this incom- 
 plete presentation, the umbilicus will engage in the superior strait 
 much less rapidly than if tractions be made on the feet; and the 
 chances of compression will be retarded as long as possible, until the 
 dilatation is entire ; whereas, in drawing on these extremities, the pe- 
 riod for this compression will be hastened. 
 
 Although we may establish as a principle that, in most cases, the 
 accoucheur should remain a simple spectator, it must, however, be 
 added, that if this rule should never be infringed during the first pe- 
 riod of delivery, it is not always so with the second period. The ac- 
 coucheur should, on the contrary, hold himself prepared to act in case 
 the pelvic extremity, deeply descended in the excavation, should not 
 be expelled with sufficient rapidity by the uterine contractions, in or- 
 der that the compression, which takes place at this stage of labour, 
 may not prove fatal to the child. 
 
 CHAPTER I. 
 
 ACCIDENTS WHICH MAY OCCUR DURING THE WHOLE PROGRESS OF 
 LABOUR WHEN THE PELVIC EXTREMITY PRESENTS. 
 
 The description of these accidents, whether the vertex, face, or pel- 
 vic extremity presents, is precisely the same ; neither do the general 
 methods of proceeding vary : there are some special rules, however, 
 which undergo certain modifications. For the most part of these ac- 
 cidents, I refer to the presentation of the vertex ; I will speak partie- 
 
432 PRESENTATION OF THE PELVIC EXTREMITY. * 
 
 ularly of those only which are modified by the pelvic extremity, and 
 which call- for certain peculiar manipulations. After this enumera- 
 tion, I will give the general rules for the extraction of the fœtus ap- 
 plicable to all the accidents which require this operation. 
 
 Art. I. — Accidents capable of Retarding or Preventing De- 
 livery. 
 
 The accidents contained in this article need no other care than 
 in the presentation of the vertex. (See Accidents in Presentation of 
 the Vertex.) 
 
 Art. II. — Diseases Foreign to Labour, and which require the Par- 
 ticular Attention of the Accoucheur, and sometimes his Inter- 
 vention. {See Vertex.) 
 
 Art. III. — Accidents capable of Compromising the Life of Mother 
 and Child. (See Vertex.) 
 
 § 1. Escape of Liquor Jimnii tinged with Meconium. 
 
 In the presentation of the pelvic extremity, the discharge of the me- 
 conium which commingles with the liquor amnii is far from possessing 
 the same importance as in the two preceding presentations. This ex- 
 pulsion of meconium is occasioned by a mechanical cause, the compres- 
 sion of the parts. It may occur, also, without leading us to conclude 
 that the life of the child is in danger. As this accident, however, as 
 in presentation of the vertex, may depend on compression of the cord, 
 it is indispensable to ascertain carefully the condition of the fœtal cir- 
 culation. 
 
 If the rhythm of the pulsations be altered, if they become enfeebled 
 after a period of marked acceleration, it is because the life of the child 
 is in peril. It therefore must be extracted. For the rules of this ex- 
 traction, see, at the end of this chapter, Obstetric Operations. 
 
 § 2. Brevity of the Cord. (See Vertex.) 
 
 The consequences of brevity of the cord are less serious than in the 
 presentations of the vertex, because they can be remedied more 
 promptly. Thus, as soon as the pelvic extremity is sufficiently de- 
 scended in the excavation to permit the umbilicus to be reached, we 
 may ascertain, by making tractions on the cord, whether the delay in 
 the descent is owing to the brevity of the cord ; and then, as soon as 
 the orifice, which has permitted the passage of the pelvic extremity, is 
 sufficiently dilated to permit the ready extraction of the shoulders and 
 head, we should pull gently on the parts which present until we are 
 enabled to make a section of the cord ; the delivery must then be 
 promptly terminated. (See, at the end of this chanter, Obstetric Op- 
 erations.) 
 
ANOMALIES. 433 
 
 Art. IV. — Difficulties occasioned by Anomalies in the Mechanism 
 
 of Labour. 
 
 § 1. Anomaly of the First Period. 
 
 When the parts are so large as not to have their size reduced, the 
 descent may be retarded, but will never be prevented by this anoma- 
 ly, unless the pelvic extremity should possess excessive dimensions. 
 Under these circumstances, the dilatation being complete, we should 
 proceed to the extraction of this extremity, either by seeking the feet, 
 or by making tractions on the hips, according to the peculiarities of 
 the case. 
 
 § 2. Anomaly in the Descent. 
 Excessive size of the parts, inertia of the womb, resistance of the 
 orifice, &c, &c, occasion this anomaly. (See article Mechanical Ob- 
 stacles to Delivery.) 
 
 § 3. Anomaly in Rotation. 
 
 When rotation of the sacrum forward is incomplete, the delivery, in 
 most cases, is effected with facility, even if the sacrum should pass pos- 
 teriorly. This period of rotation is subjected to the same irregularities 
 as its analogue in presentations of the head, only that in, presentation, 
 of the pelvic extremity, it scarcely requires the intervention of the ac- 
 coucheur. Such is not the case in presentation of the vertex ; art is 
 often obliged to interfere when the rotation of the head is incomplete, 
 and sometimes even when the occiput is posteriorly; and it will be 
 seen, from what I have said of the gravity of the posterior mento-iliac 
 positions of the face, what the difference is between this anomaly in 
 the presentation of the face and the sacro-sacral position of the pelvic 
 extremity, when nature almost uniformly suffices. 
 
 For the mode of proceeding in this case, in the event of the delivery 
 not taking place, see Obstetric Operations at the end of this chapter. 
 
 § 4. Anomalies in the Delivery. 
 This period- cannot fail of itself. 
 
 § 5. Anomalies in the Fifth Period : Internal Rotation of the Head, 
 External of the Shoulders. 
 Immediately after the expulsion of the trunk, the head executes in- 
 ternally a movement of rotation, which places the occiput behind the 
 pubes, or in the concavity of the sacrum* Externally, this movement 
 is followed by the shoulders, which become transverse to the vulva. 
 This movement of rotation is necessary to the delivery of the head. In 
 case it should not be accomplished, we must produce it by introducing 
 the right hand, if the occiput be to the left, and vice versa, under the 
 head, and place the fingers on the face, in order to bring it into the 
 hollow of the sacrum. (See fig. 201.) 
 
 In 
 
434 
 
 PRESENTATION OF THE PELVIC EXTREMITY. 
 (Fig. 201.) 
 
 Art. V. — Mechanical Obstacles to Delivery. 
 
 I have nothing particular to remark with regard to the resistance of 
 the membranes, the agglutination of the external orifice, the rigidity of 
 the orifice, or its improper direction. These accidents are the same 
 as in presentation of the vertex, and are to be remedied in the same 
 manner. 
 
 It has been recommended, in a work recently published, to over- 
 come the spasmodic contraction of the orifice of the womb on the neck 
 of the child, after the expulsion of the trunk, by dividing the orifice 
 with a cutting instrument. To recommend the section of the uterine 
 orifice with a bistoury, w r hen the trunk of the foetus completely fills the 
 excavation, cannot but excite astonishment ; and my readers will ap- 
 preciate whether such a thing is possible. 
 
 Opiates, bloodletting, and tractions are the only means of overcom- 
 ing this resistance. 
 
 § 1. Descent of some other Portion of the Fœtus. 
 
 If the hands should descend simultaneously with the pelvic extrem- 
 ity, this complication will be of no consequence. In proportion as this 
 extremity descends, the hands remain above, and when, even, they pass 
 down with the pelvis, they scarcely ever oppose its descent. 
 
 If, however, it should become necessary to reduce these parts, all 
 
MECHANICAL OBSTACLES TO DELIVERY. 
 
 435 
 
 that will be required is to support them during the contraction of the 
 uterus. 
 
 But it is different when the head descends simultaneously with the 
 pelvic extremity ; this accident, which is very rare, and scarcely ever 
 occurs except in pelvic version, requires the assistance of the accou- 
 cheur. With the extremity of one hand he pushes up the head, while 
 with the other he exerts tractions on the pelvic extremity (fig. 202). 
 
 §2. Varieties of Presentation. 
 
 I have already remarked that the varieties of presentation are ap- 
 preciable only when the pelvic extremity is complete, or when the 
 breech presents. In fact, the mobility of the feet or knees is such 
 that their inclinations can have no influence on those of the breech. 
 
 These varieties require interference much less frequently than those 
 of the vertex. Thus, if one hip occupy the superior strait, the pelvic 
 extremity becomes righted, and then descends. 
 
 (Fig. 202.) 
 
 If the sacrum present, the same movement of righting takes place ; 
 and it is the same with the anterior variety. If, however, one of these 
 varieties should continue, we must aid the descent of the pelvic ex- 
 tremity by righting it ; and in this case the righting will be as difficult 
 as in the presentations of the vertex, and then proceed to the ex- 
 traction of the fœtus. (See the following chapter : Obstetric Opera- 
 tions.) 
 
436 PRESENTATION OF THE PELVIC EXTREMITY. 
 
 § 3. Multiple Isolated Fœtuses. (See Vertex.) 
 
 If two foetuses should present simultaneously at the superior strait by 
 the extended pelvic extremity, one passes first, and the other follows ; 
 however, in this case, the two may descend simultaneously ; the infe- 
 rior extremities pass into the excavation without difficulty, but the hips, 
 presenting at the superior strait, prevent the descent of the rest of the 
 trunk. Under these circumstances, certainly of rare occurrence, what 
 is to be done 1 We should push up one foetus, and make tractions on 
 the other ; and we should be careful to seize one of the feet only, in 
 order that we may not make tractions on two extremities appertaining 
 to different foetuses. 
 
 While, therefore, we pull on one foot or one knee, we support with 
 the other hand the parts that remain stationary, and do not yield to 
 these tractions. 
 
 § 4. Monstrosities. (See Vertex.) 
 
 If two pelvic extremities should present, and the foetuses be united 
 (which cannot be known in advance), we should make tractions on 
 one foot only, as in the preceding paragraph ; but it will be perceived 
 that these tractions cause both foetuses to descend, and their bodies 
 being pressed one on the other, may thus pass through the pelvis. In 
 case, however, this cannot be done, we must proceed as in the pres- 
 entation of the vertex. 
 
 I will not speak of the obstacles occasioned by the soft parts. 
 
 In order to remedy the adhesion of the labia, the persistance of the 
 hymen, the narrowness and rigidity of the vulva, and the resistance of 
 the perineum, w T e must fulfil the same indications as in the presenta- 
 tion of the vertex. 
 
 § 5. Indications in Deformities of the Pelvis. 
 
 Deformities of the pelvis constitute very serious complications in the 
 presentation of the pelvic extremity ; for even when nature is compe- 
 tent to effect delivery, or only slight tractions are needed, the child is 
 most usually sacrificed. In a word, when the head presents first, it 
 can more readily overcome the resistance to its descent ; and .while it 
 is performing this object, the cord is free in the uterine cavity, and re- 
 moved from all compression. But, on the contrary, in the pelvic pres- 
 entation, when the trunk has been expelled without difficulty, the 
 head, especially if it be extended, presents at the deformed superior 
 strait extremely unfavourable diameters ; and it will require some time 
 for it to remove the obstacles to its descent, during which the foetus 
 will be sacrificed from compression of the cord. In this case, cephal- 
 ic version has been recommended ; but, as will be seen in presenta- 
 tions of the trunk, even when the head is near the orifice, this opera- 
 tion is surrounded with so much difficulty, that we are frequently 
 obliged to renounce it ; the difficulty, therefore, will be considerably 
 increased if we attempt to bring down the head in the pelvic presenta- 
 tion, when, of course, it is situated in the fundus of the organ ; should 
 
MECHANICAL OBSTACLES TO DELIVERY. 437 
 
 we, even in this presentation, attempt the operation, and would it be 
 more reasonable to confine ourselves to the ordinary methods of ex- 
 traction ? 
 
 If, however, we shall have ascertained positively, before the rupture 
 of the membranes, that the pelvic extremity presents at the superior 
 strait, we may endeavour to bring down the vertex instead of the 
 breech. M. Colomb has mentioned that he has often succeeded in 
 similar cases. 
 
 The manner of effecting this substitution consists in passing up the 
 breech with the finger through the membranes, at the same time that 
 we attempt to depress the head with the other hand placed in the ab- 
 dominal walls, or by means of external manipulations with both 
 hands. 
 
 The conditions favourable to the performance of this operation are 
 rarely met with ; for, in order that it may be accomplished, the uterus 
 should not be distended with amniotic fluid, and the abdominal and 
 uterine walls should be relaxed, thin, and free from pain. 
 
 In case we should be enabled to achieve this manipulation, we 
 should then confide the delivery to nature, and abstain as much as 
 possible from making tractions on the parts ; these tractions in the 
 pelvic extremity will be indicated only when the efforts of the womb 
 prove insufficient. 
 
 Should, however, the contraction of the pelvis be such as to occa- 
 sion great difficulty in the descent of the incomplete pelvic extremity, 
 the life of the child will certainly be sacrificed ; and the mother can- 
 not be delivered but by detruncating the foetus, in order to remove its 
 body from the excavation, and thus be enabled to seize the head 
 with the forceps, perforate, or break it down by means of the cephalo- 
 tribe. 
 
 § 6. Movable or fixed Tumours in the Excavation, Vagina, and 
 Labia Majora, $*c, fyc. 
 
 The conduct of the accoucheur here will be the same as in the pres- 
 entation of the vertex, except as to the modes of extraction, which 
 will vary. 
 
 § 7. Excessive Size of the Fœtus. 
 
 After being satisfied that the uterine contractions are insufficient to 
 determine the descent, we should endeavour to effect it ; for this pur- 
 pose, the dilatation being complete, the hand is introduced, and an at- 
 tempt made to seize the feet or one of the hips, and thus bring down 
 the pelvic extremity. For the management of the extraction of the 
 trunk and head in the excavation, see the following chapter. 
 
 If the excessive size of the foetus should depend upon the abnormal 
 development of a tumour on the breech, hydrocephalus, hydrothorax, 
 ascites, &c, &c, we must employ the same means as indicated in the 
 presentation of the vertex. To reduce the size of the part by puncture 
 or the cephalotribe is the only resource of the operator. 
 
438 OBSTETRIC OPERATIONS IN PRESENTATION OF PELVIC EXTREMITY. 
 
 CHAPTER II. 
 
 OBSTETRIC OPERATIONS PROPER IN PRESENTATION OF THE PELVIC 
 
 EXTREMITY. 
 
 Whatever may be the complication requiring the extraction of the 
 foetus when it presents its pelvic extremity, the means to be employed 
 are always the same ; they vary only according to the period of labour, 
 that is, according to the degree of elevation or descent of the part to 
 be seized, according to the mode of presentation, and the size of the 
 part, together with the diameter of the pelvis. 
 
 Art. I. — Complete Presentation of the Pelvic Extremity. 
 Whether it be excessive size of the parts, or any other complica- 
 tion I have enumerated, that hinders the extraction of the fœtus, this 
 extraction must be effected according to circumstances, either with the 
 hand or the crotchet. 
 
 § 1. Manual Delivery. 
 
 Pelvic Extremity at the Superior Strait. 
 If the pelvic extremity be above the superior strait, after placing 
 the female as for the operation of version, and having previously ar- 
 ranged everything that may be necessary during or after the opera- 
 tion (see Version), the hand, the palm of which regards the anterior 
 surface of the fœtus, is introduced with all possible care ; it penetrates 
 with great delicacy the uterine orifice, ruptures the membranes if still 
 intact, then passing to the feet, which will be found quite near the ori- 
 fice, they are both grasped, if this be practicable ; if not, one only is 
 seized and brought down ; the remaining part of the operation is in 
 every respect similar to the rest of pelvic version. (See Version.) The 
 same observation applies to the difficulties which may be met with in 
 the extraction, and the means of overcoming them. 
 
 The Pelvic Extremity half engaged in the Excavation. 
 
 In this case, if the hand can reach the feet without difficulty, they 
 should be brought down ; if not, the index finger should be hooked in 
 the groin, and thus pull the breech into the excavation. 
 
 On which hip should traction be made ? We should in preference 
 act on the one in front ; and, for this purpose, the index finger should 
 be introduced between the pubes and hip ; but sometimes there is not 
 sufficient space between these two parts to enable us to do this ; and 
 most commonly we are compelled to proceed from behind forward, 
 hooking the anterior groin with the finger passed between the root of 
 the thighs ; this hip is thus seized and brought down into the excava- 
 tion ; the finger, still remaining between the root of the thighs, is then 
 
COMPLETE PRESENTATION. 439 
 
 turned towards the posterior portion of the pelvis, and brings down 
 the posterior hip by fixing itself in the fold of the groin. This hip is 
 more readily seized, because it is depressed simultaneously with the 
 first ; the finger, still continuing its tractions, draws it into the inferior 
 strait, slightly elevating as it descends. In fine, it is made to traverse 
 the concavity of the sacrum, while the anterior hip remains fixed be- 
 hind the pubes. 
 
 This being accomplished, the remaining part of the traction is the 
 same as in version. 
 
 § 2. Blunt Hook. 
 
 If, however, the finger should not succeed in reaching the hip, 
 either on account of its being too elevated or too large, we must then 
 employ the blunt hook, in order to bring down the hips. M. Cham- 
 pion has modified, for this purpose, the crotchet of Smellie ; this instru- 
 ment appears to me to combine all the necessary advantages. 
 
 The blunt hook is applied precisely in the same man- 
 ner as the finger. Thus, we should endeavour, in the 
 first place, to hook the groin of the hip in front by pass- 
 ing the instrument along the symphysis pubis, at the 
 root of the thighs ; this hip should then be brought 
 down, and afterward the other ; but it is not possible to 
 pursue exactly the same course. 
 
 In fine, when the operator feels that the hook is prop- 
 erly applied, and that it cannot injure the maternal or- 
 gans, he should introduce the hand to ascertain that its 
 extremity is not placed on any parts that may be in- 
 jured during the tractions. If we should succeed in 
 passing the instrument under the pubes, it would be pos- 
 sible to ascertain this fact with the hand introduced 
 along the root of the thighs ; but, as the instrument can 
 ordinarily be introduced only between the thighs on the 
 anterior hip, the hand will not be able to recognise its 
 proper situation, for it cannot pass between the pubes 
 and hip. 
 
 On the contrary, as the hand can very readily enter 
 the concavity of the sacrum, we should fix the hook on the posterior 
 hip, proceeding from before backward between the root of the thighs. 
 The extremity of the fingers will then distinctly feel whether the hook 
 is so applied as not to endanger the parts of the mother. 
 
 It must not be supposed that these precautions are unnecessary ; 
 the best possible blunt hook, if improperly guided, may be followed 
 by serious inconveniences. 
 
 The Complete Pelvic Extremity deeply descended in the Excavation. 
 In this case, it is always easy to hook the hip with the index finger, 
 unless a circumstance similar to that mentioned in the preceding page 
 should present itself. 
 
440 OBSTETRIC OPERATIONS IN PRESENTATION OF PELVIC EXTREMITY. 
 
 Art. II. — The Pelvic Extremity presents incompletely by the 
 
 Hips. 
 
 § 1. Manual Operation, 
 
 Superior Strait. 
 The hand, the palm of which regards the anterior surface of the 
 foetus, being introduced, the index finger passes along the root of the 
 thighs, and fixes itself in the bend of the hip, and is not carried up 
 for the purpose of seizing the feet, which are placed at the fundus of 
 the organ. This hip will be brought into the excavation, and thence 
 into the inferior strait ; then the finger, pronated, grasps the posterior 
 hip, and brings it down along the concavity of the sacrum, and thus 
 to the vulva. The rest of the extraction is the same as in pelvic ver- 
 sion. 
 
 Inferior Strait. 
 
 When the back is to the left, the index finger of the right hand is 
 introduced into the hollow of the sacrum, and fixed on the posterior 
 groin ; and the index of the left hand, applied under the pubes, is car- 
 ried to the anterior groin ; then the two hands impart to the pelvic 
 extremity a movement of traction and elevation. In proportion as the 
 parts are delivered they are rotated, so that when the extraction of 
 the trunk is completed, the occiput will be in front. 
 
 Finally, if the feet or knees present alone, the rules will be precisely 
 the same as in the latter period of extraction by version. 
 
 § 2. Forceps. 
 
 Some authors have recommended to apply the forceps on the pelvic 
 extremity; but should the foetus be alive, great inconveniences will 
 arise, for the compression exerted by the end of the blades on the ab- 
 dominal organs will certainly endanger the life of the child ; and, 
 whether it be dead or alive, the instrument cannot obtain on the pel- 
 vic extremity a sufficiently firm hold to enable it to extract the foetus. 
 It should, therefore, not be employed in this case on the breech, but it 
 sometimes becomes necessary to apply it to the head, which has been 
 arrested at the inferior strait, after the expulsion of the trunk, and not 
 at the superior strait. The application in this case is impossible, un- 
 less the detruncation of the child has previously been effected. 
 
 § 3. The Cephalotribe. 
 
 The cephalotribe may be employed on the pelvic extremity in order 
 to diminish its size, in case of deformity of the pelvis. This instrument 
 is not, like the forceps, liable to lose its hold, for the parts are firmly 
 held by the teeth of the cephalotribe. 
 
 After the extraction of the pelvis by means of the cephalotribe, this 
 instrument may also be applied to the chest, and, finally, to the head, 
 when it. is arrested at the superior strait ; but not until the trunk of 
 the foetus has been previously removed from the excavation. 
 
PRESENTATIONS OF THE TRUNK. 441 
 
 TITLE V. 
 
 PRESENTATIONS OF THE TRUNK. 
 
 I have already stated, in speaking of the classification of the present- 
 ations and positions, that the foetus, at full term, can present at the 
 superior strait only by the lateral regions of the trunk ; and that nei- 
 ther the back, nor anterior surface of the chest, has ever been felt di- 
 rectly over this strait.* 
 
 These presentations, therefore, are two in number, one for the right, 
 the other for the left side ; they are called full when the acromial por- 
 tion of the shoulder occupies the centre of the orifice; but, at the 
 commencement of labour, this part is not always felt at the superior 
 strait ; the finger recognises the shoulder, and a small portion of the 
 anterior surface of the chest — this is the sternal variety ; or the shoul- 
 der and a small portion of the posterior surface of the chest are felt— 
 dorsal variety. The shoulder and hollow of the neck may also be felt 
 at the superior strait — cervical variety ; finally, the finger may pass on 
 the side, properly so called, on the portion of the chest on which rests 
 the elbow of the infant — cubital variety. 
 
 The varieties in the presentation have no great importance in prac- 
 tice; for even if they manifest themselves at the commencement of la- 
 bour, they do not continue a long time ; and, under the influence of 
 uterine contractions, these varieties disappear to give place to the full 
 presentation (acromial), as occurs in the corresponding varieties of 
 the vertex, face, and pelvic extremity. 
 
 * August 16th, 1835, I was requested by Dr. Carrrman, of this city, to visit with him a 
 patient, who had been in labour twelve hours. He informed me that her sufferings had been 
 very severe, and the expulsive efforts of the uterus constant and vigorous. He remarked to 
 me the peculiarity of the presentation, and requested that I would accompany him for the 
 purpose of attempting the version of the fœtus. On arriving at the bedside, we found Mrs. 
 W. labouring under considerable mental excitement, from the fears she entertained as to her 
 safety, which, together with the strong expulsive efforts of her womb, rendered her an object 
 rather unfit for a successful operation. She was extremely opposed to any attempt being 
 made to deliver her ; but, on being assured that every care would be taken not to harm her, 
 and that we did not intend to use instruments, she finally consented to an examination. At 
 the request of Dr. Camman, I proceeded to ascertain the exact condition of things ; on car- 
 rying my finger into the vagina, I encountered several folds of the umbilical cord, but all 
 pulsation had ceased. At the superior strait I distinctly felt the abdomen of the foetus ; there 
 could be no error here, for the umbilicus of the infant lay immediately over the centre of the 
 strait. Resting on the posterior surface of the cervix uteri, I discovered another portion of 
 the fœtus, which, after a cautious examination, I recognised to be the elbow ; the forearm 
 was flexed on the arm, and in this way the elbow had descended — rather a singular present- 
 ation. Now, what was to be done? The obvious indication was to proceed at once to 
 delivery by attempting to bring the feet into the vagina. The membranous sac had ruptured 
 about three hours before we arrived ; and the escape of the amniotic fluid had much en- 
 hanced the expulsive character of the pains, and the uterus was contracting firmly on the 
 fœtus as it lay at the superior strait. The difficulty, therefore, of the operation was mani- 
 fest. The patient was strong, and of rather a rigid muscular fibre, and we abstracted from 
 her arm twelve ounces of blood. This was followed by a partial relaxation ; and, placing the 
 patient in the ordinary position for turning, I proceeded to deliver. With much less diffi- 
 culty than I had anticipated, I succeeded in bringing down the feet, and the extraction of 
 the fœtus was accomplished without any delay, and without the occurrence of any untoward 
 accident. The mother soon recovered. — En. 
 
 Kkk 
 
442 PRESENTATIONS OF THE TRUNK. 
 
 (Fig. 204.) 
 
 Moreover, interference being necessary in the presentations of the 
 trunk, it matters little whether they are full or inclined, for the mode 
 of proceeding will always be the same in all these cases. 
 
 These varieties are converted into full presentations in the following 
 manner : if the neck of the infant occupy the orifice simultaneously 
 with the acromion, the head ascends little by little, while the acro- 
 mion descends alone. In the cubital variety, on the contrary, the pel- 
 vic extremity ascends, and the acrorainion passes down to the centre 
 of the superior strait. Finally, in the dorsal and sternal varieties, the 
 fcetus rights itself, and the acromion again occupies the centre of the 
 superior strait. 
 
 Also, when we recognise a presentation of the shoulder before the 
 rupture of the membranes, or at the moment the membranes rupture, 
 we may frequently recognise one of these varieties of presentation ; 
 while, if we make the examination after the contractions have acted 
 on the fcetus, we most frequently find the shoulder fixed at the supe- 
 rior strait (full acromial presentation), the change having taken place. 
 
 It sometimes happens that, at the commencement of the rupture of 
 the membranes, the arm which follows the shoulder descends in the 
 orifice, and presents even at the vulva. This occurrence is constant 
 in these presentations when the interference of art has been a long 
 time delayed. The contractions gradually cause the shoulder to de- 
 scend, and then the arm. Certain accoucheurs, regarding this pres- 
 entation of the arm, in the presentation of the shoulder, as more se- 
 rious than the acromial presentation, have made it a distinct presenta- 
 tion, under the name of presentation of the arm and hand ; I look 
 upon it more as requiring intervention than occasioning an obstacle. 
 
 As to the positions which the fcetus may assume in each of the pres- 
 entations of the trunk, they are two in number for each lateral region 
 of the trunk (whether the presentation be full or a variety). 
 
 Presentation of the Right Side or of the Right Shoulder. (Two 
 
 Positions.) 
 
 The head is to the left (left cephalo-iliac), back in front ; or the 
 head is to the right (right cephalo-iliac), and the back posteriorly. 
 
SPONTANEOUS DELIVERY. 443 
 
 Presentation of the Left Side or Left Shoulder. (Two Positions.) 
 
 The head is to the left (left cephalo-iliac), the back posteriorly ; the 
 head is to the right (right cephalo-iliac), the back in front. 
 
 § 1. Causes. , 
 
 The causes of presentations of the trunk cannot be very well appre- 
 ciated. But it is generally supposed that small size and mobility of 
 the fœtus, and obliquity of the womb, may occasion them. I cannot 
 believe, however, that they are produced by sudden fright. 
 
 The presentations of the trunk are more frequent than those of the 
 face ; Madame Lachapelle has observed sixty-eight in fifteen thousand 
 six hundred and fifty-two labours, and M. P. Dubois thirteen in twen- 
 ty-two hundred labours. The presentation of the right lateral region 
 is also more frequent than that of the left. 
 
 The left cephalo-iliac positions are more common than the others, 
 probably in consequence of the greater frequency of the left occipito- 
 iliac position. 
 
 I shall not treat of the diagnosis of the presentations and positions 
 until I speak of the rules for interference. 
 
 In fine, spontaneous expulsion, in these presentations, constituting 
 an exception, and taking place, in most cases, without the knowledge 
 of the accoucheur, and without nature receiving any assistance, it is 
 only when it becomes necessary to change the presentation or extract 
 the fœtus that it becomes important to know which shoulder presents, 
 and in what positions. 
 
 § 2. Spontaneous Delivery in Presentation of the Trunk. 
 
 Art should always interfere in presentations of the trunk; it is a 
 rule from which the accoucheur should never depart, except under pe- 
 culiar circumstances, which 1 shall mention hereafter. 
 
 In a word, although nature will sometimes suffice in these cases, 
 yet this spontaneous expulsion must be considered as altogether an ex- 
 ception, the accomplishment of which requires a combination of cir- 
 cumstances not often met with. 
 
 This expulsion may also be very happy for the mother and child ; 
 but it most frequently compromises the safety of the child, and is more 
 or less dangerous for the mother. 
 
 Spontaneous expulsion may take place in three ways: 
 
 A. Before the period of viability, and especially when the fœtus is 
 dead and softened by putrefaction, it may be expelled folded double, 
 and thus, expulsion not being governed by any rule, the fœtus is 
 thrown off from the maternal organs like an amorphous mass. 
 
 B. From the period of viability until full term, the fœtus may be 
 expelled by two different mechanisms : 
 
 1st. The shoulder, under the influence of uterine contractions, or 
 tire active motions of the fœtus, may pass from the superior strait, in 
 order to give place either to the head or the pelvic extremity. This 
 change of presentation has received the name of spontaneous version. 
 
444 PRESENTATIONS OF THE TRUNK. 
 
 2d. The shoulder, pushed by the contractions of the womb, may de- 
 scend in the excavation, and become fixed- under the pubes, while the 
 trunk progresses, passing, as it were, into the concavity of the sacrum, 
 and glides between the shoulder and posterior wall of the pelvis, and 
 disengages at the anterior commissure of the perineum. This is what 
 is termed spontaneous evolution. 
 
 Spontaneous Version. 
 
 Spontaneous version is nothing more than a change of presentation, 
 by which the head or pelvic extremity replaces the shoulder, which 
 gradually leaves the superior strait. 
 
 It is not, therefore, a delivery by the shoulders, but by the head or 
 pelvic extremity ; a very different thing from spontaneous evolution. 
 
 This spontaneous version may occur, whatever the period and dimen- 
 sions of the fœtus, but it can only take place while the membranes are 
 intact, and the foetus enjoys great mobility. It will also be seen, from 
 these circumstances, that the delivery for the mother and child will be 
 as favourable as if it had occurred in the presentation which replaced 
 the shoulder. 
 
 Although M. Velpeau had occasion to observe a case of spontaneous 
 version after the rupture of the membranes, it is, nevertheless, certain 
 that this change of presentation is scarcely possible after the escape of 
 the waters ; and that, when the fœtus is expelled spontaneously in 
 this case, it is only by the mechanism of spontaneous evolution. 
 
 Spontaneous version almost always takes place without the knowl- 
 edge of the accoucheur ; also, we but imperfectly understand its mech- 
 anism and causes. 
 
 Prognosis. 
 The prognosis in this expulsion is extremely favourable to both moth- 
 er and child. As soon as the presentation is changed, the membranes 
 rupture, and the delivery will pass on as happily as if it had been a 
 presentation of the vertex or pelvic extremity. 
 
 Spontaneous Evolution. 
 
 The spontaneous evolution or expulsion of the fœtus in the present- 
 ation of the shoulder, much better understood than spontaneous ver- 
 sion, is accomplished nearly by the same laws as all the other mecha- 
 nism of spontaneous expulsion, and this regularity in the expulsion is 
 the more perfect as the fœtus approaches more nearly the dimensions 
 at term. Thus, we have the analogue of the first period of flexion, 
 also descent, rotation, and extension, and, finally, even external rota- 
 tion. But this mechanism is the more difficult and the more danger- 
 ous for both mother and child, as the size of the latter is more consid- 
 erable. 
 
 In order to describe this mechanism, I will suppose a presentation 
 of the right shoulder, left cephalo-iliac position. 
 
 Immediately after the rupture of the membranes, the parts diminish 
 in size by the compression they undergo. The first period is the ana- 
 logue of flexion in the presentation of the vertex, of extension in that 
 
SPONTANEOUS EVOLUTION. 
 
 445 
 
 of the face, and of the lessening of the parts in the presentation of the 
 pelvic extremity. Then the shoulder descends gradually, and, in pro- 
 portion as it enters the excavation, it executes a movement of rotation, 
 which places the head on the horizontal branch of the left pubes, and 
 thence under the pubic arcade. After this movement, the arm disen- 
 gages, and passes out of the vulva ; sometimes the expulsion of the 
 arm takes place before this period. When the rotation is performed, 
 the period of the descent of the trunk is complete ; the side of the fœ- 
 tus is pushed into the excavation by gliding on the right sacro-iliac 
 symphysis, while the shoulder remains immovable. After the side, the 
 pelvic extremity descends, which also pursues the same direction. Fi- 
 nally, the perineum distends, and there successively pass out at the an- 
 terior commissure of the perineum, the lateral and superior portion of 
 the chest, the side, properly so called, the hip, and pelvic extremity. 
 In proportion as these parts are delivered, the head and left arm enter 
 the excavation, but they are soon expelled ; and, in most cases, the 
 head does not undergo its movement of internal rotation. In a word, 
 it presents at parts which have been excessively dilated, and it is not 
 solicited by them to perform this movement of rotation. 
 
 (Fig. 205.) 
 
 (Fig. 206.) 
 
446 
 
 PRESENTATIONS OF THE TRUNK. 
 (Fig. 208.) 
 
 v^> 
 
 Such is the course pursued when the dorsal surface of the foetus 
 corresponds to the front of the pelvis. When the anterior surface of 
 the infant is in relation with the anterior part of the female, the ex- 
 pulsion is exactly the same ; but it is also more easy, in this case, to 
 recognise the regularity with which is accomplished the movement of 
 its external rotation, which, in every presentation, brings the pos- 
 terior surface of the fœtus forward. This movement is effected here 
 with perfect regularity; in proportion as the foetus passes the vulva, 
 a movement of torsion is exercised upon it, which brings the back of 
 the child in front. M. P. Dubois was the first to notice this circum- 
 stance. 
 
 (Fig. 209.) 
 
 I have twice had occasion to observe the mechanism of spontaneous 
 evolution, once at La Maternité, and once at La Clinique, in a twin 
 
SPONTANEOUS EVOLUTION. 447 
 
 pregnancy. In the first case, the foetus was not viable. In the sec- 
 ond, the twin which was expelled in this way was exceedingly small, 
 and had attained only its eighth month ; it survived its birth. M. 
 Velpeau has reported a great number of similar cases. In some of 
 these, the foetuses had attained the full period of gestation. Denman, 
 also, mentions several cases ; but it will readily be understood that, in 
 the great majority of instances, this expulsion cannot take place at 
 term when the foetus and pelvis possess their normal dimensions ; and 
 that the mother, if art should not interfere, will often succumb without 
 achieving the object. The dangers, likewise, to which both mother 
 and child are exposed are manifest. The length of the labour, and 
 the compression exerted on the infant, almost always cause its death, 
 and the forced passage of the foetus contuses and lacerates more or less 
 the organs of the mother; and, again, the distressing and continued 
 suffering occasioned by this species of labour in the entire economy, 
 gives rise to a general disturbance, which often sacrifices the patient. 
 
 The prognosis, therefore, of this labour at term is extremely unfa- 
 vourable ; and we cannot too strongly condemn the practice of Den- 
 man, who confides the most of these expulsions to nature. In 137 spon- 
 taneous evolutions, according to M. Velpeau, 125 children were sacri- 
 ficed ; and how many mothers succumbed before the termination of the 
 delivery, or soon afterward ! how many, also, had entailed on them, 
 during their life, the most deplorable maladies, to which death itself 
 would be preferable ! 
 
 Before term, spontaneous evolution may be accomplished without 
 the same hazard to the mother and child, especially if the pelvis be 
 capacious, the contractions energetic, the foetus small, and the parts 
 relaxed. In a primipara, the difficulties will be much increased. 
 
 In conclusion, as this form of delivery cannot be accomplished ex- 
 cept under peculiar circumstances, and as it almost invariably compro- 
 mises the safety of mother and child, when even it is effected, the ac- 
 coucheur, whenever he can interpose, should never remain a simple 
 spectator, unless the foetus should not have attained its period of via- 
 bility. 
 
 CHAPTER I. 
 
 OPERATIONS. 
 
 Art being always obliged to interfere in this presentation, I shall 
 not speak of the accidents capable of complicating it, as I have done 
 in the three preceding presentations, for the necessary intervention 
 for the presentation of the shoulder itself will remedy, at the same 
 time, whatever complications may arise. 
 
 But I will treat of these accidents in regard to the difficulties which 
 they may occasion in the performance of the operations indicated in 
 
44S OPERATIONS. 
 
 presentation of the shoulder, and in regard to the modification? they 
 may render necessary in the different methods. 
 
 After the period of viability, and even before, if it be possible to 
 interpose usefully, the accoucheur should aid nature. 
 
 Art. I. — Assisting Nature. 
 The rules pursued by the accoucheur in assisting nature will vary 
 according as the membranes are intact or ruptured, and according to 
 other circumstances, to which I shall allude in proportion as they pre- 
 sent themselves. 
 
 § 1. Before the Rupture of the Membranes. 
 
 A. Diagnosis of the Presentation. — Before the rupture of the mem- 
 branes, what are the symptoms indicating the presentation of the 
 trunk, and what should be the conduct of the accoucheur? Previous 
 to the rupture of the amniotic sac, the presence of a shoulder at the 
 superior strait may be recognised by the following signs : 
 
 In percussing the abdomen, it will be found that the long diameter 
 of the uterus is not perpendicular, but transverse ; and that the head of 
 the foetus, a rounded, solid tumour, is situated in one of the iliac fossse. 
 
 The vaginal touch will enable us to recognise the presentation ; in 
 the first place, we will not feel at the superior strait either the vertex, 
 face, or pelvic extremity ; and, moreover, the part reached by the fin- 
 ger will be very elevated and pointed, presenting at its summit an 
 osseous prominence, formed by the acromion. Again, if the presenta- 
 tion be not full, we will be enabled to feel the elbow scapula and 
 intercostal spaces. 
 
 All these characters cm be easily traced through the membranes, 
 and will enable us to distinguish readily the presence of the shoulder 
 at the superior strait. But the sac being intact, it will be extremely 
 difficult to recognise which shoulder presents, and the exact position 
 of this shoulder. This latter part of the diagnosis is happily not in all 
 cases absolutely indispensable. 
 
 Such, however, is not the case with regard to the diagnosis of the 
 presentation ; it is necessary that the presence of the trunk be ascer- 
 tained at the superior strait, and, as far as possible, before the rupture 
 of the membranes, in order that we may endeavour to operate, if prac- 
 ticable, before their rupture ; and, under any circumstances, to be pre- 
 pared to proceed as soon as the rupture occurs, and the dilatation is 
 complete. 
 
 The infrequency of these presentations obliges us to familiarize our- 
 selves with them by exercising with a dead foetus on the manikin. 
 This, insufficient as it may appear, is the only means the pupil can 
 command, and it is too important to be neglected. 
 
 This kind of manipulation has enabled several of my pupils to rec- 
 ognise very promptly presentations of the trunk, which certainly they 
 would otherwise have mistaken. An error in diagnosis, in this case, 
 will have a serious effect on both mother and child. 
 
 This error, however, is often committed by practitioners otherwise 
 skilful, but who, not having had an opportunity of feeling a shoulder 
 
ASSISTING NATURE. 449 
 
 at the superior strait, cannot recognise it even when it presents itself 
 to their observation. An accoucheur, for example, may practise ten, 
 and even twenty years, and have, too, a tolerable share of obstetric 
 business, without once meeting with this presentation.* 
 
 In most of the cases in which I have been called to terminate de- 
 livery in the presentations of the trunk, there has been a mistake with 
 regard to the presentation ; for it was not known until after the escape 
 of the arm, when error is no longer possible. Almost uniformly, even, 
 the practitioner, supposing that it was a presentation of the vertex, 
 the descent of which should be promoted by stimulating the womb, 
 had, before my arrival, administered ergot, which, of course, added to 
 the difficulties and dangers of the operation. 
 
 This subject appears to me to be one of so much importance that I 
 will mention, at the end of this article, some cases exemplifying the 
 serious consequences of this mistake. 
 
 B. Differential Diagnosis. — We may, in the first place, confound 
 the full presentation of the shoulder, that in which the acromion occu- 
 pies the centre of the superior strait, with a variety of parietal present- 
 ation of the vertex ; but the form of the abdomen, the difficulty ex- 
 perienced in reaching the presenting part, and the peculiar configura- 
 tion of this part, will enable us to distinguish the presentation of the 
 shoulder from that of the parietal, which is lower, and near which are 
 to be felt the sutures, fontanelles, and that resistance which character- 
 izes the head. When, therefore, we are assured that the shoulder oc- 
 cupies the superior strait, we should interfere. In this case, the mem- 
 branes being intact, two methods may be adopted : cephalic or pelvic 
 version. 
 
 * Dr. Kirby sent for me October 18th, 1843, to see, in consultation with him, Mrs. E., who 
 had been in severe labour for three days. Mrs. E. was twenty-six years of age, and in labour 
 with her first child. Her uterus had acted with great vigour, but there was no progress in 
 the delivery. She was becoming weak under the continued efforts of the womb, and it was 
 very evident that some obstacle must have prevented the birth of the child, for the doctor 
 assured me that her pains had been abundantly sufficient to effect delivery under ordinary 
 circumstances. He likewise expressed his conviction that the shoulder occupied the superior 
 strait ; for, making a vaginal examination, 1 found his judgment perfectly correct on this 
 point ; and I moreover distinctly felt a loop of the umbilical cord, which had passed down 
 between the shoulder and the uterine orifice. I could, however, detect no pulsations in it ; 
 and it was to be presumed, even in the absence of this fact, that the child had succumbed in 
 consequence of the vigorous and long-continued, yet unavailing efforts of the womb. The 
 waters had passed away about ten hours before I saw the patient. Concurring in opinion 
 with Dr. Kirby as to the course to be adopted, at his request I proceeded to perform version, 
 and bring down the feet. I encountered great difficulty in introducing my hand into the 
 orifice (so strongly did it contract on the shoulder). 1 then desisted for twenty minutes, 
 during which a solution of emetic tartar was administered to the patient. A tablespoonful 
 of a solution containing two grains to the ounce was given every five minutes. Three 
 doses produced nausea ; and I again attempted the introduction of the hand, which was ac- 
 complished with ordinary facility. The feet were seized and brought into the vagina without 
 difficulty, and I proceeded to complete the extraction. I encountered no obstacle until the 
 head had reached the superior strait ; in carrying my finger to this point, I discovered that 
 the occipito-mental diameter of the head occupied the strait. My index finger was then 
 introduced into the mouth of the foetus, and with great difficulty 1 succeeded in bringing the 
 chin upon the sternum, thus producing the movement of flexion. But, from the unusual size 
 of the head, and its disproportion to the dimensions of the pelvis, I found it utterly impossi- 
 ble to extract it. From its excessive volume, the forceps could not be introduced, and the 
 only alternative left was to diminish the head with the perforator, which was the more will- 
 ingly resorted to, as ample evidence of the child's death had been furnished even before I 
 commenced turning ; but even with the aid of the perforator, much difficulty was experienced 
 in completing the delivery. The head was truly enormous. 1 am under obligations to Dr. 
 Kirby for his valuable assistance. The mother had a rapid convalescence. — Ed. 
 
 Lll 
 
450 OPERATIONS. 
 
 Cephalic Version. 
 
 Cephalic version is an operation by which we propose to bring the 
 head of the fœtus to the superior strait when some other portion occu- 
 pies this strait. It has been recommended both before and after the 
 rupture of the membranes. It is, under both these circumstances, dif- 
 ficult to execute ; it is favourable to mother and child in the former, 
 but not so in the latter case. It will be readily understood that spon- 
 taneous version, the description of which I gave in the commencement 
 of this chapter, has caused authors to attempt the same result by means 
 of external manipulations, when the membranes are intact. If the 
 operation should prove successful in this case, it would render essen- 
 tial service to both mother and child. 
 
 In a word, as soon as the vertex is brought to the superior strait, 
 the membranes should be ruptured, and the delivery will be as happy 
 for the infant and mother as if the vertex had originally presented. 
 We thus substitute for a presentation which, left to itself, would have 
 sacrificed the child, and often, too, the mother, or which, being con- 
 verted into a pelvic version, would destroy the child once in seven 
 times — a cephalic version, artificial, it is true, but which, effected 
 during the integrity of the membranes, admits of a perfectly natural 
 expulsion. 
 
 In what way are we to obtain this result ? M. Velpeau recom- 
 mends that this substitution should be performed by external manipu- 
 lations. I have seen M. P. Dubois and M. Colomb effect it in this 
 manner ; and I myself have succeeded, with my friend Dr. Devilliers, 
 in a female in whom the foetus enjoyed remarkable mobility. But, to 
 perform this operation, there is required a combination of circumstan- 
 ces rarely found : the fœtus must possess great freedom of motion, the 
 abdominal and uterine walls must be relaxed, thin, and free from pain, 
 and the quantity of amniotic fluid small, in order that the hands may 
 readily embrace the parts, and change their position with facility. 
 
 As soon as the accoucheur ascertains that the shoulder presents, he 
 should at once cause the patient to assume the recumbent posture, and 
 request her to moderate her efforts, in order that the membranes may 
 not be ruptured until the complete dilatation, which would interfere 
 with cephalic version, and which, also, in the event of failure, would 
 render the conditions for pelvic version less favourable, in consequence 
 of the discharge of the liquor amnii and the contraction of the womb. 
 
 This precaution being taken, an effort should then be made to as- 
 certain the position ; for, in order to bring down the head, we must 
 know how it is situated. But I have already remarked that, before 
 the rupture of the membranes, the vaginal touch cannot settle this 
 point. What, then, is to be done ? Happily, the circumstances which 
 favour the operation will likewise enable us to ascertain the position ; 
 the hands, applied to the abdomen, can distinguish, in one of the iliac 
 fossse, a round, solid tumour, which is the bead, and, in an opposite 
 point of the uterus, and above, small movable parts, which are the 
 feet. Auscultation, too, will be of service here : thus, we will hear 
 the intensity of the pulsations of the heart in front and directly down- 
 
ASSISTING NATURE. 451 
 
 ward, and they will also be heard in the iliac fossa opposite to the 
 one in which the head is felt, while they cannot be distinguished near 
 this latter. 
 
 When the accoucheur thinks that he has recognised the position, if 
 the dilatation of the neck be complete, he can proceed. But why de- 
 lay until the dilatation be complete, since the hand is not to be intro- 
 duced into the parts for the purpose of extracting the fœtus ? The 
 external manipulations, and especially the efforts necessary to be em- 
 ployed on the shoulder, with two fingers applied on the membranes, 
 may induce contractions, under the influence of which the membranes 
 may rupture ; and if the dilatation be not complete, and cephalic ver- 
 sion prove impossible, the escape of the amniotic fluid will render any 
 attempts at pelvic version extremely difficult. Therefore, only when 
 the dilatation is complete and the membranes intact, must the operator, 
 by means of external manipulations, attempt to bring the head to the 
 superior strait, and push up the pelvic extremity; such is the rule 
 given by M. Velpeau. He advises, also, to endeavour to engage the 
 head with one hand, while, with the fingers of the other, an effort is 
 made to remove the shoulder from the superior strait. This method 
 is, in general, the easiest, and most frequently successful. 
 
 As soon as the change of presentation is accomplished, that is, when 
 the head has taken the place of the shoulder, the hand of the accou- 
 cheur, applied externally, should maintain the foetus in this position, 
 while with the other hand, during a contraction of the uterus, he rup- 
 tures the membranes ; the waters discharge, the head descends, and 
 the delivery is as favourable as if the vertex had presented. But it is 
 possible that the accoucheur may be in error as to the position, and, 
 mistaking the pelvic extremity for the head, he may bring down the 
 pelvis instead of the head. In this case, the same advantage would 
 not be obtained as if the head had been made to pass to the superior 
 strait ; for, in delivery by the pelvis, one infant in eleven or twelve 
 succumbs, whereas only one in fifty dies in delivery by the vertex. 
 There is not, however, much to regret; if the pelvis had not been 
 brought down, the membranes being intact, we would have been obli- 
 ged to seek for the feet by introducing the hand and rupturing the 
 membranes, and the life of the child would have been compromised 
 once in seven times by this manual extraction. Therefore, when we 
 cannot accurately recognise the position, we must not attempt cephal- 
 ic version through the abdominal walls and membranes. 
 
 This operation is not always practicable, even under circumstances 
 which appear to favour its execution ; and when these circumstances 
 do not present themselves, we shall often meet with insurmountable 
 difficulty ; it is, therefore, in such cases, preferable to have recourse to 
 pelvic version. 
 
 Pelvic Version. 
 Pelvic version, practised at the moment the membranes are rup- 
 tured, is of easy execution, and extremely favourable to the child. 
 Which hand is to be employed in this operation ? The choice w T ill 
 depend on our knowledge of the position. But I have stated that it 
 
452 OPERATIONS. 
 
 is rarely possible to ascertain which shoulder presents, and the posi- 
 tion of the shoulder, before the rupture of the membranes ; how, there- 
 fore, are we to make choice of the hand 1 
 
 In all cases in which the position is unknown, the right hand must 
 be employed ; it is introduced with proper care, and, having reached 
 the membranes, it ruptures them, and penetrates as far as the feet, 
 which it brings down into the vagina. If, which is rare when the foe- 
 tus enjoys much mobility, the hand experience difficulty in reaching 
 the inferior extremities, and if it adapt itself imperfectly to the foetus, 
 we should endeavour to ascertain the exact position of the child, then 
 withdraw the hand and introduce the other. 
 
 § 2. After the Rupture of the Membranes. 
 After the rupture of the membranes, w T e must not think of cephalic 
 version ; pelvic version is the only resource. * 
 
 Parallel between Cephalic and Pelvic Version. 
 
 In fine, as the conditions capable of favouring cephalic version do 
 not exist, the foetus has lost much of its mobility in consequence of 
 the more or less complete escape of amniotic fluid, and then it would 
 be extremely difficult, if not impossible, to remove the shoulder from 
 the superior strait, and bring down the head. Moreover, the force 
 which the accoucheur would be obliged to employ in this operation 
 would frequently occasion the most serious accidents : rupture of the 
 attachments of the vagina and uterus, and even rupture of the uterus it- 
 self. 
 
 And, again, are we to suppose that the foetus would be in a more 
 favourable condition, admitting that we could bring the head to the 
 superior strait, than if we at once practised pelvic version ? Assured- 
 ly not. The escape of the liquor amnii, and the complications which 
 might accompany cephalic version, do not render it more favourable 
 than pelvic version. In a word, delivery after the discharge of the 
 waters, and after the multiplied and forcible efforts to bring the head 
 to the superior strait, will not be as favourable to the child as spon- 
 taneous delivery by the vertex. Notwithstanding the opinion of 
 Flamant, it is impossible to conceive that there is any parity between 
 these two modes of delivery by the vertex. 
 
 In spontaneous expulsion by the vertex, the foetus is protected from 
 the force of the contractions by the interposition of the liquor amnii 
 until the delivery is completed. In the delivery which follows cephal- 
 ic version, the foetus, during the entire period of the expulsion, is ex- 
 posed to the immediate compression of the uterus ; but this is not all. 
 Procidentia of the cord, which so rarely complicates spontaneous pres- 
 entation of the vertex, is often produced by the attempt made to bring 
 down the head ; and supposing we should succeed in this operation, 
 we cannot confide the expulsion to nature, for the foetus would suc- 
 cumb from compression of the cord. We should resort to pelvic ver- 
 sion if the head have not descended in the excavation ; and, in this lat- 
 ter case, to the forceps. 
 
 One or both arms may also be brought down at the same time with 
 
ASSISTING NATURE. 453 
 
 the head ; and certainly, in this event, the accoucheur could not re- 
 main a simple spectator. The descent of only one arm with the head 
 may, it is true, not impede spontaneous delivery under favourable cir- 
 cumstances; but this accident requires the assistance of the accou- 
 cheur in the case which now occupies us, for the labour has already 
 been sufficiently embarrassed by a combination of circumstances dan- 
 gerous to both mother and child, without adding this additional diffi- 
 culty, and we should, therefore, perform pelvic version. It is scarce- 
 ly necessary to observe, that the presence of both arms would render 
 this alternative still more imperative. 
 
 Again, after numerous efforts, painful and dangerous to the mother, 
 and which often, by their consequences, prove fatal to the child, we 
 are frequently obliged to abandon cephalic version, and substitute for 
 it pelvic version ; this is what most commonly occurs. It cannot, in- 
 deed, be supposed that the circumstances under which we practise 
 pelvic version will, then, be as favourable as if we had proceeded at 
 once without loss of time, during which the uterus, firmly contracting 
 on itself, opposes the introduction of the hand, and compresses the um- 
 bilical cord. 
 
 Supposing, also, that the head had been brought to the superior 
 strait, the first contractions of the womb might cause it to leave the 
 strait to give place again to the shoulder, in consequence of the ten- 
 dency which a presentation has to reproduce itself, when it has once 
 occurred. 
 
 But even if the head should remain at the superior strait, the 
 contractions may be insufficient to terminate the delivery, and the ac- 
 coucheur must then interpose, either by pelvic version, or by the for- 
 ceps, according to the situation of the head. 
 
 In view of all these considerations, which must appear to every one 
 full of reason, I do not hesitate to recommend, under these circumstan- 
 ces, pelvic version, resorting, after the example of MM. Velpeau, Du- 
 bois, and Moreau, to cephalic version only in cases in which there is 
 deformity of the pelvis. In truth, pelvic version should always be 
 preferred, because it is applicable to all cases ; it is more easily per- 
 formed than cephalic version, even when all the conditions favourable 
 to the latter are present, and it is more favourable both to mother and 
 child. It may be performed at all the periods of labour ; it will alone 
 suffice to determine the expulsion of the foetus, and it remedies all the 
 accidents which may complicate it. Thus, procidentia of the cord 
 may manifest itself during the progress of this operation, as in cephal- 
 ic version ; but what a difference ! In pelvic version, as soon as the 
 feet are seized, the accoucheur terminates the delivery at once, and 
 protects the child from the perils w T hich menace it. Does the same 
 thing occur in cephalic version 1 
 
 Cephalic Version in Pelvic Deformities. 
 After the rupture of the membranes, this operation should be resort- 
 ed to only when the pelvis is deformed. Between the two evils, the 
 choice should be for the least, and it is in this case alone that the per- 
 formance of this operation becomes proper. When the contracted pel- 
 
454 PRESENTATIONS OF THE TRUNK. 
 
 vis will permit the spontaneous descent of the head, the life of the foe- 
 tus will be less frequently endangered than if it be brought down by 
 the pelvic extremity ; and the difficulties of the delivery will also be 
 less for the mother. But the mother will derive important benefit 
 from cephalic version when the contraction is very marked, and the per- 
 foration of the cranium and cephalotribe become indispensable. It will 
 enable us to act on the head, and thus more promptly and certainly 
 save the mother, than by mutilation of the foetus while it presents the 
 shoulder. 
 
 A. Operation in Cephalic Version. — The rules laid down by Flamant 
 and M. Velpeau for version when the shoulder is yet at the superior 
 strait, are the following : When the position of the head has been ac- 
 curately ascertained by the abdominal percussion and the touch, the 
 accoucheur introduces two or three fingers into the maternal organs, 
 and fixes them on the shoulder ; he raises the shoulder, and endeav- 
 ours to remove it from the superior strait by directing it towards the 
 side corresponding with the pelvic extremity, in order to allow the 
 head to descend, while, at the same time, he endeavours to bring the 
 head to the superior strait, with the left hand applied to it, through the 
 abdominal walls. This method is the most simple, least painful, and 
 safest ; it is the one recommended, under these circumstances, by M. 
 P. Dubois, and which I have already suggested previous to the rupture 
 of the membranes ; unfortunately, it is very rarely successful after the 
 rupture. The fcetus does not enjoy sufficient mobility to allow itself to 
 be displaced in this manner, and we are then obliged to have recourse 
 to pelvic version. As to the second method, it merits all that I have 
 said of cephalic version ; its execution is accompanied with all the 
 difficulties and dangers which I have enumerated above. 
 
 The hand, the palm of which regards the back of the fœtus (the 
 choice of the hand is not strictly indicated), penetrates entire the ma- 
 ternal organs; when it reaches the uterine orifice, it raises the shoul- 
 der, pushes it towards the iliac fossa, in which are situated the inferior 
 extremities ; it then seizes the head by the occiput, and engages it in 
 the superior strait, and maintains it there until the contractions of the 
 uterus have firmly fixed it in this point. The rest of the delivery is to 
 be intrusted to the spontaneous effort, and in the absence of uterine 
 contraction, the forceps must be applied. Finally, we must proceed as 
 in cases in which a deformity of the pelvis complicates the presentation 
 of the vertex. 
 
 If all the difficulties encountered in this operation be duly consider- 
 ed, it will not seem strange that, in our day, the operation should have 
 been abandoned, even in cases of pelvic deformity, and that the at- 
 tempts of the German school again to restore it to confidence have not 
 met many admirers among us. 
 
 It is not, however, right entirely to proscribe it, as some accoucheurs 
 have done ; for it is evident that, if it be practicable in a case of pel- 
 vic contraction, both the infant and mother will be placed in more fa- 
 vourable circumstances than if pelvic version be resorted to (see Pelvic 
 Version) ; and, therefore, it should be attempted in this instance. 
 
OPERATIONS. 455 
 
 Pelvic Version in Presentations of the Trunk. 
 
 The first care of the accoucheur, when called to a female in whom 
 the shoulder presents, should be to ascertain precisely whether it be a 
 presentation of one of the lateral regions of the trunk ; whether it be 
 the acromion that occupies the centre of the superior strait (full present- 
 ation) ; whether it be a small portion of the side of the neck and 
 acromion (cervical variety) ; whether the portion of the side on which 
 rests the elbow of the infant (cubital variety) ; whether a small portion 
 of the back and acromion (dorsal variety) ; or, finally, the anterior 
 portion of the chest and acromion (anterior variety) ; it matters not 
 which of these presentations may occur, for the manner of interfering 
 is the same. The diagnosis, however, of the presentation is easier in 
 the varieties than in the acromial presentation. It being well ascer- 
 tained which of the two lateral regions of the trunk presents — and this 
 is never difficult after the rupture of the membranes — we should next 
 inform ourselves of the relations of the fœtus to the womb, in order to 
 know which shoulder presents, for the choice of the hand and the di- 
 rection to give it in pelvic version are based on the exact knowledge of 
 the position of the shoulder which presents. 
 
 A. To ascertain which Shoulder presents from the Relations of the 
 Fœtus with the Pelvis. — To recognise the particular shoulder, we must 
 understand accurately the position of the foetus ; for this purpose, the 
 accoucheur examines the parts which occupy the superior strait, en- 
 deavours to distinguish them from each other, and to establish their 
 positive relations. 
 
 If the finger encounter on the left of the acromion a hollow into 
 which it passes with facility, especially if it can reach the ear, which 
 is sometimes possible, the accoucheur should conclude that the hollow 
 he feels is the space which separates the shoulder from the head, and 
 that the head is to the left ; if he succeed in passing his finger on the 
 other side of the acromion into another hollow (the axillary space), 
 this hollow always regarding the side in which the feet of the infant 
 are situated, he concludes also, from this circumstance, that the head 
 is to the left. 
 
 But this will not suffice to point out the particular shoulder which 
 presents. In a word, in figures 210 and 212 the head is to the left, 
 and yet in one it is the right shoulder, and in the other it is the left, 
 which occupies the superior strait. Therefore, in order that the diag- 
 nosis may be complete, we should also know the situation of the back 
 of the infant. If the intercostal spaces be felt posteriorly, if the scapu- 
 la be in front, the back will also be in front, and in combining these 
 two facts with the first, we shall have, 
 
 £wnE eft '!^^-( %2 10). 
 
 If now, the head being still to the left, we feel the scapula posteri- 
 orly, and the sternum in front, the back will be posteriorly, and we 
 shall have, 
 
 K ^5'. S Left shoulder (fig. 212). 
 
456 PRESENTATIONS OF THE TRUNK. 
 
 If, finally, the hollow of the neck be felt to the right of the shoulder, 
 if the hollow of the axilla regard the left, the head is to the right ; and 
 as the scapula may be behind or in front, we shall have, 
 
 SL°*o e „t dght '! Leftshoulder ^- 2l3) - 
 
 Head to the right, R; fc shoulder (fi 2n) 
 Back posteriorly. ) 
 
 In order more perfectly to recognise the particular shoulder which 
 presents, as soon as we have been enabled to appreciate the different 
 relations I have just enumerated, we should, in thought, place our- 
 selves in the position we suppose the foetus to assume. 
 
 But it is not always easy to recognise the relations of the fœtus with 
 the womb, and, consequently, to know which shoulder presents. For- 
 tunately, in those cases in which the shoulder is slightly engaged, or 
 version easy, so accurate a diagnosis is not indispensable. In fine, all 
 authors do not agree as to the choice of the hand : some recommend 
 to employ the one corresponding with the shoulder that presents ; oth- 
 ers, on the contrary, the other. In view of this difference of opinion, 
 it may be inferred that, when the operation is not difficult, we may 
 proceed as well with one as the other hand, and, in contrary cases, 
 we must do as well as circumstances will permit. If, however, I had 
 an opinion, I should choose that corresponding with the presenting 
 shoulder, for it seems to me to accommodate itself better with the 
 parts we wish to seize. 
 
 If, therefore, we know that a shoulder occupies the superior strait, 
 but do not know which, we should introduce the hand the use of 
 which is the most familiar to us ; if we encounter great difficulty in 
 reaching the feet, we withdraw this hand, but not without previously 
 exploring the foetus, in order to ascertain its position, and to guide 
 more accurately the other. Madame Lachapelle has given a precept 
 on this subject which is altogether feasible ; it consists in bringing 
 down the arm with a view to learn more positively which shoulder 
 presents. Then the diagnosis is perfectly simple, as I shall explain in 
 a moment. 
 
 B. Operation. — Suppose we discover which shoulder occupies the 
 superior strait, how are we to proceed 1 
 
 Presentation of the Right Shoulder, Left Cephalo-iliac Position. 
 
 The left hand being placed on the fundus of the womb in order to 
 maintain it in position, the right hand, properly lubricated, is introdu- 
 ced with care into the maternal organs, pursuing the axes of the straits, 
 which it traverses. Arrived at the uterine orifice, it enters between 
 the shoulder and sacro-vertebral prominence, without it becoming ne 
 cessary to push aside the shoulder. Then, passing the hand along the 
 anterior surface of the foetus and the posterior wall of the womb, it 
 penetrates as far as the feet, which are situated to the right ; both of 
 these are seized, if possible ; but, in most cases, we can only bring 
 down one. If a knee should offer itself to the hand of the operator, 
 he should be content, and bring it down. The rest of the extraction is 
 the same as in the second and third period of pelvic version ; except 
 
OPERATIONS. 
 
 457 
 
 that the version is much more easy, and the head has not the same 
 tendency to descend simultaneously with the pelvic extremity as in 
 the presentation of the vertex. 
 
 (Fig. 210.) 
 
 Presentation of the Right Shoulder, Right Cephalo-iliac Position. 
 
 In this presentation, the position of which is the opposite of the 
 preceding, the right hand must still be introduced ; it must not pass 
 behind the shoulder, but rather between the pubes and shoulder ; the 
 version here is somewhat more difficult, for the hand, being thrown 
 back on the fore-arm, is in a more oppressive position than in the pre- 
 ceding case. It is to obviate this difficulty that certain authors have 
 advised to pass the hand posteriorly, and arrive at the feet by rotating 
 the pelvic extremity. In order that this advice may be followed, the 
 uterus should not be too much contracted in the child ; for, in this 
 case, the hand could not be introduced between the foetus and womb; 
 but, in this case, if we raise the uterus with the left hand, with a view 
 to reduce its anterior obliquity, we will succeed much better in pass- 
 ing directly to the feet with the right hand introduced in front, than 
 by attempting to traverse so long a route. 
 
 Moreover, when this contraction is very violent, we can only reach 
 the feet by a movement of direct progression, and by rotating the 
 breech of the foetus. (See fig. 211.) 
 
 In simple cases, however, we can succeed, no matter what method 
 we adopt. 
 
 M MM 
 
458 
 
 PRESENTATIONS OF THE TRUNK. 
 (Fig. 211.) 
 
 Presentation of the Left Shoulder, Left Cephalo-iliac Position. 
 The left hand is introduced between the pubes and anterior surface 
 of the foetus, and directed to the right, where it seizes the inferior ex- 
 tremities, and brings them in front 
 
 (Fig. 212.) 
 
OPERATIONS. 
 
 459 
 
 Presentation of the Left Shoulder, Right Cephalo-iliac Position. 
 
 The left hand is introduced posteriorly between the shoulder and 
 sacro-vertebral prominence ; the feet are seized to the left, and brought 
 down posteriorly (fig. 213). 
 
 (Fig. 213.) 
 
 The Shoulder deeply descended in the Excavation, and the Arm out of 
 
 the Vulva. 
 
 Pelvic version may be performed from the moment the shoulder oc- 
 cupies the superior strait, until it rests on the floor of the pelvis. But 
 it must be remembered that the operation will be the more difficult in 
 proportion as the descent is more complete. 
 
 For the methods to be employed, see the preceding article. 
 
 But what are we to do with the arm when it protrudes externally ? 
 Should we agree with some authors in considering its presence an ob- 
 stacle to version, and then endeavour to return or amputate it ? Be- 
 fore touching this very delicate question, which occasioned grave dis- 
 cussions in the medical world in 1825, in consequence of a method 
 proposed by Doctor Hélie, of Domfront, in Normandy, it is indispen- 
 sable to establish the differential diagnosis of the presence of the arm 
 which accompanies the head, and of the procidentia of that accompa- 
 nying the shoulder. 
 
 A. Differential Diagnosis of the Presence of the Arm in the Pres- 
 entation of the Head, and in that of the Shoulder. — When the arm 
 accompanies the head, as I have remarked, it descends at first much 
 less profoundly ; then, in following this arm, we recognise the vertex 
 or face by their proper characters ; while, in the presentations of the 
 trunk, the arm, deeply descended, protrudes through the vulva, and the 
 
460 PRESENTATIONS OF THE TRUNK. 
 
 shoulder is still tolerably high up. Finally, the signs characterizing 
 the shoulder after the rupture of the membranes being easily recog- 
 nised, it is scarcely possible to confound these two accidents. 
 
 When it is once established that the descended arm belongs to a 
 particular shoulder, we should then, by means of this arm, proceed to 
 ascertain the position. 
 
 B. Recognition of the Shoulder which presents by the Direction of 
 the Thumb. — An infallible rule for recognising the presenting shoulder 
 is the following : the palm of the hand which protrudes externally is 
 turned upward towards the pubes, and the side which the thumb re- 
 gards is the side corresponding with the shoulder which presents. 
 
 Thus, if the thumb look to the right, it is the right shoulder which 
 occupies the superior strait, and vice versa. 
 
 It is impossible that this rule should lead us into error, whatever 
 degree of torsion the arm may undergo ; whenever the palm is brought 
 in front, the side which corresponds with the thumb will be that of 
 the shoulder. 
 
 C. But what is to be done with this arm ? Should it be considered 
 an obstacle, and its reduction or amputation attempted 1 
 
 The presence of the arm will very rarely interfere with the opera- 
 tor. It would, therefore, be useless to attempt its reduction, even 
 when this is practicable. It is scarcely worth while to allude to a 
 precept, formerly promulged, and observed even in our day by certain 
 ignorant matrons, of making tractions on the arm. These tractions, 
 unless the fœtus should be extremely small and softened by putrefac- 
 tion, and the pelvis unusually capacious, would have no other result 
 than to render version more difficult, and even impossible, by bringing 
 down the shoulder into the excavation. Monteggia is said, by means 
 of this method, to have succeeded in bringing the head to the superior 
 strait ; although this be not impossible, yet the practice is altogether 
 censurable ; and, as M. Champion observes, we may conclude that 
 most authors who have sanctioned this precept have confounded the 
 presence of the arm accompanying the head with that of the arm 
 which precedes the shoulder. 
 
 As to the amputation of the arm, although, in the immense majori- 
 ty of cases, we may practise version without being obliged previously 
 to amputate the arm of the infant, it may, however, happen that the 
 neck of the uterus, contracted spasmodically, may oppose the introduc- 
 tion of the hand, and thus oblige us to remove the arm for the purpose 
 of affording more space. 
 
 Authors report some cases in which this amputation seemed indis- 
 pensable ; I have also found several observations of this kind, which 
 are full of interest, in a very remarkable work published by M. Cham- 
 pion on this subject, and which he had the kindness to present to 
 me. 
 
 It is true, however, that we are but rarely obliged to amputate the 
 arm ; and, moreover, far from proving an obstacle to version, its pres- 
 ence frequently facilitates it. In fine, the arm enables us to establish 
 the diagnosis with precision ; it serves as a guide to the hand of the ac- 
 coucheur, and, by securing it with a fillet, we prevent its return, and, 
 
OPERATIONS. 461 
 
 consequently, we are not obliged to bring it down ; and when we 
 have succeeded in bringing the feet into the vagina, the tractions we 
 make on the arm simultaneously with the feet facilitate the descent 
 and rotation of the shoulders. 
 
 We should, therefore, place on the wrist of the infant a woollen fil- 
 let (it is less likely to bruise than a linen one), and the extremity of 
 this fillet is to be intrusted to an aid ; and then version is to be per- 
 formed as if the arm did not occupy the vagina and uterine orifice. 
 
 As soon as the inferior extremities are seized, the assistant holds the 
 fillet loosely during the period of evolution, so that the arm may enter 
 partially the organs, and thus follow the movement imparted to the 
 trunk. When both or only one foot has descended into the vagina, 
 the operator then seizes the fillet with one hand and the foot with the 
 other, and makes tractions on these two parts. The arm is thus 
 brought out on the side of the trunk of the foetus, and cannot pass up 
 along the sides of the head, &c, &c. 
 
 Pelvic Version is Impracticable. 
 
 But the contraction of the body of the uterus, and the spasmodic 
 contraction of the neck of this organ, may be so violent as to prevent 
 the introduction of the hand, and the evolution of the foetus, even after 
 the hand has penetrated as far as the feet. 
 
 What, then, is to be done, in order to save the foetus and mother, and 
 ender version practicable? It is, in this case, that anodyne injec- 
 tions, composed of fifteen, twenty, or thirty drops of the laudanum of 
 Sydenham, embrocations on the abdomen, with equal parts of the oil of 
 sweet almonds and laudanum, general bloodletting, and the warm 
 bath, may prove useful.* M. Champion has also proposed, under 
 
 * I have frequently experienced the best effects from bloodletting and tartar emetic in 
 solution, in cases of obstinate contraction of the womb ; and this condition of the organ is 
 not at all unusual in shoulder presentations, and for this reason : it may often happen that 
 the practitioner is not called to the case until the arm has already descended into the vagina, 
 and frequently, on his arrival, he finds it protruding through the vulva. The membranes, of 
 course, have been previously ruptured, and the liquor amnii having escaped in greater or less 
 quantity, the uterus is most usually, under these circumstances, found firmly contracting on 
 the shoulder at the superior strait, preventing the introduction of the hand of the accoucheur. 
 Ignorant midwives, too, in these presentations, are very apt to take hold of the arm, and 
 make tractions on it, supposing that in this way they can succeed in accomplishing the ex- 
 traction of the fœtus. It is, therefore, most important, in presentations of the shoulder, that 
 the accoucheur should early understand the nature of the case, and proceed, as soon as the 
 mouth of the womb is in a proper condition, to the delivery of the child by version. As to 
 cephalic version or spontaneous evolution, they are to be classed among the possibilities of 
 the lying-in chamber, and should never be suffered to take the place of pelvic version when 
 this operation is practicable. This latter operation is sometimes attended with fatal conse- 
 quences to the mother, resulting in rupture of the womb ; and it often proves fatal to the 
 child, in consequence of the rude and unskilful manner in which it is performed. In judi- 
 cious hands, it is, under ordinary circumstances, a perfectly safe operation for both mother 
 and child. 
 
 In consequence of the great pressure of the womb after the protrusion of the arm through 
 the vulva, we will sometimes find the arm of a livid colour, and hence, if we were hastily to 
 conclude from this circumstance that the child had succumbed, we might be induced to have 
 recourse to embryotomy, and thus mutilate the infant ; and the first evidence we should have 
 of the error of our diagnosis, and that we were really cutting on the body of a living child, 
 would be the motion of the fœtus in its feeble attempt to withdraw itself from the murderous 
 grasp of the operator ! I have on several occasions been called to cases in which it has been 
 supposed that the child was dead, simply from the circumstance of the livid colour of the 
 protruded arm. 
 
 A few months since, Dr. Shanks had an interesting case of this kind. He was in attend- 
 ance on a strong, muscular Scotch woman, with her first child. She had been in labour 
 
462 PRESENTATIONS OF THE TRUNK. 
 
 these circumstances, to inject a mucilaginous decoction of flaxseed and 
 poppy heads into the uterus, as much for the purpose of tranquillizing 
 as of lubricating the uterine walls ; and also to place the patient on 
 the side, or even on her knees and hands at the moment of operating, 
 in order to protect the womb from the action of the abdominal mus- 
 cles, and particularly to enable the accoucheur to pass the superior 
 strait in a direct line, without bending the wrist and fore-arm, as is in- 
 dispensable when the feet of the infant are in front and the patient on 
 her back. If, by the aid of these means, version cannot be accom- 
 plished, the accoucheur, when the foetus is living, should profit by the 
 examples which nature furnishes us, and endeavour to produce arti- 
 ficially what she effects spontaneously. (Spontaneous Evolution.) 
 
 For this purpose, the shoulder being depressed and fixed under the 
 pubes, the trunk of the infant resting on one of its lateral surfaces 
 (fig. 205), the hand must be introduced into the concavity of the sa- 
 crum, and we should endeavour to draw down the breech by making 
 tractions with the fingers fixed in the duplicature of the trunk, or, in 
 other words, determine artificially the evolution of the fœtus in the con- 
 cavity of the sacrum (see figs. 206, 207, 208, 209). If we fail with 
 the fingers, we may employ the blunt hook, which we fix in the same 
 place. 
 
 This method, which has often been followed by Peu and Monteggia, 
 of Milan, and which is also advocated by Drs. Douglass and Robert 
 Lee, is the only chance of safety to the infant. 
 
 We can very well understand, however, how uncertain this chance 
 is ; and, moreover, all the conditions necessary to facilitate this evolu- 
 tion should be present, otherwise we should not attempt the operation, 
 nor should we suffer spontaneous evolution to occur, for the most se- 
 rious results may ensue to the mother. 
 
 In fine, if the foetus be of large size, and the pelvis possess only its 
 normal dimensions, the forced passage of the infant, under these cir- 
 cumstances, will endanger more or less the organs of the mother, and 
 even her life. 
 
 some hours before the doctor had been summoned. On his arrival, he found the uterus con- 
 tracting with great energy, and, in making an examination, he discovered that the mem- 
 branous sac was ruptured, and the shoulder occupied the superior strait. The doctor 
 abstracted from the patient's arm about ^xii. of blood ; this seemed to induce some 
 slight relaxation about the uterus, but not sufficient to allow him to introduce his hand for 
 the purpose of turning. In a short time the arm was expelled into the vagina, and the con- 
 tractions of the uterus became very violent. At this period I was requested by the doctor to 
 see the patient with him. She had then been in labour about twenty-two hours. The arm 
 was quite livid, and, as the doctor informed me, had been so for the last three hours. In car- 
 rying my finger up to the orifice of the womb, I found this organ most firmly contracted on 
 the foetus, and it was impossible to introduce my hand. The patient was immediately bled 
 to the extent of *x. ounces, and a solution of tartar emetic, in the proportion of two grains 
 to the zi. prepared, of which she took a tablespoonful every five minutes until nausea 
 was produced. The third dose caused slight vomiting, and the general relaxation which 
 followed enabled me to introduce my hand and deliver by the feet. In a short time I ex- 
 tracted a healthy living child. 
 
 1 have also seen cases in which, notwithstanding the protrusion of the arm and the escape 
 of the liquor amnii, the uterus remained quite relaxed, offering very little impediment to the 
 operation of version. 
 
 In September last, I was requested by Drs. Pratt and Leo-Wolfe to meet them in consult- 
 ation in the case of Mrs. E., who had been in labour for twenty hours. The arm had passed 
 into the vagina, and the uterus, although contracting with ordinary force, still permitted the 
 easy introduction of the hand. At the request of these gentlemen, I proceeded to bring down 
 the feet, and soon delivered the patient of a living daughter. — Ed. 
 
OPERATIONS. 463 
 
 § 
 
 The desire to save the infant should yield to the paramount im- 
 portance of preserving the life of the mother ; and, again, this evolu- 
 tion is so often fatal to the infant, that, in resorting to it, we should 
 compromise the safety of the mother for the object of bringing into the 
 world a dead fœtus ! 
 
 Happily, also, in this case, it is very rare that the child survives the 
 protracted labour ; in the majority of instances it will have suc- 
 cumbed, and then the course to be pursued is plain. The accoucheur 
 should make a section of the neck of the fœtus, thus separating it 
 from the trunk, which will enable him successively to extract these two 
 divided parts. 
 
 I would even remark that, in a similar case, the impossibility of 
 version being clearly established, I should not hesitate to perform em- 
 bryotomy even if the child had resisted this contraction of the uterus ; 
 for although it may live while in the womb, in consequence of the cir- 
 culatory relations by which it is united to its mother, yet it could not 
 survive externally, on account of serious alteration of its organs. 
 
 In acting thus, we perform the operation at a proper time, while the 
 mother has sufficient strength to encounter it, and to resist the acci- 
 dents which may follow ; and we abridge the sufferings of the 
 mother. 
 
 Some authors have recommended, before resorting to embryotomy, 
 when the child is living, to amputate the arm, in order to reach the 
 uterine orifice more readily, and then practise version, and endeavour 
 thus to extract the fœtus alive. In several cases cited by M. Cham- 
 pion in the excellent work which he sent me, it became possible, after 
 the amputation, to extract the fœtus alive and save the mother ; while 
 before the amputation, it w T as impossible even to reach the feet. But 
 after perusing these cases, I am inclined to attribute the difficulties of 
 version rather to the contraction of the uterus than to the presence of 
 the arm ; and we may also conclude that if, after the removal of the 
 arm, it was sometimes possible to reach the feet, this introduction of 
 the hand was not in consequence of the amputation of the limb, but 
 because the spasm of the uterine orifice had ceased spontaneously, un- 
 der the influence of the means employed. But M. Champion himself 
 is far from saying that the facts he reports will justify this practice as 
 one to be generally adopted ; but he simply asks whether the accou- 
 cheur cannot perceive in this method an extreme resource in very rare 
 cases ? 
 
 As for myself, basing my opinion on the authority of Madame La- 
 chapelle and M. P. Dubois, I cannot admit that, under any circum- 
 stances, the presence of the arm can oppose version ; and, moreover, 
 having employed all the means proper to facilitate this operation, if it 
 should still prove impracticable, I would ascribe the difficulty, not to 
 the presence of the arm, but to the contraction of the uterus ; and then 
 I should not amputate the arm, but resort to embryotomy. 
 
 In fine, if the accoucheur perform embryotomy in order to save the 
 life of the mother, he will not have a legal action brought against him ; 
 but let him, with the same object, bring into the world a living child 
 deprived of a limb, and his reputation and whole existence will pay 
 the penalty of such an act. 
 
364 PRESENTATIONS OF THE TRUNK. 
 
 And, moreover, as I have already remarked, in these cases the via- 
 bility of the foetus is almost invariably compromised, when we have 
 ascertained that version is not practicable. The conscience, therefore, 
 of the accoucheur should be at rest; he may perform embryotomy; 
 but, in this latter case, it sometimes becomes necessary to amputate 
 the arm, in order to reach more readily the neck of the infant. I once 
 saw M. P. Dubois under the necessity of adopting this alternative. 
 
 But, then, this amputation, which is to be followed by detruncation, 
 is not accompanied by all the inconveniences I have just mentioned. 
 We should, however, be careful not to have recourse to it, unless it 
 become absolutely necessary ; for we deprive ourselves, in removing 
 the arm, of an excellent means of extraction as soon as the neck is 
 separated. 
 
 Embryotomy in Presentation of the Trunk. 
 
 Two methods have been recommended in this case : either to per- 
 form the section of the neck, or that of the trunk through the centre. 
 
 A. Section of the Neck of the Infant. — The method of detruncation 
 attributed to Celsus, and which I have, on several occasions, seen put 
 in practice by M. P. Dubois, appears to me to combine the most ad- 
 vantages. I shall describe it as I have seen it performed by this skil- 
 ful operator. 
 
 After having accurately ascertained the situation of the foetus, he 
 introduces the left hand into the maternal organs, whether the head 
 be to the left or to the right ; then, seizing a blunt hook with the 
 right hand, he glides it along the hand that is introduced as far as the 
 neck of the infant, on which he endeavours to fasten it. The left 
 hand is now withdrawn, and he grasps the arm and hook with his 
 two hands, and makes tractions, with the view of bringing the neck 
 of the child as low down as possible. When the neck has descended 
 far enough to become accessible to a cutting instrument, he confides 
 the handle of the hook to an assistant, who is charged with holding 
 it firmly ; he then again introduces the left hand into the maternal or- 
 gans, and fixes the extremity of the fingers on the point at which he 
 intends to divide the neck. This being done, he seizes with the right 
 hand the large curved scissors, of which I have already spoken, and 
 passes them along the left hand as far as the integuments of the foetus, 
 which he cuts, little by little, in separating very slightly the blades of 
 the instrument ; an indispensable precaution, in order to avoid embra- 
 cing the parts of the mother in the scissors. When the decollation 
 has been completed, tractions on the arm will suffice to extract the 
 trunk ; then the head alone remains, which can be brought away by 
 introducing a finger into the mouth, and bringing it through the lar- 
 gest diameters of the pelvis; or the forceps may be employed ; but this 
 instrument is very rarely necessary. It is in this way that I have seen 
 M. P. Dubois practise the section of the neck, and not by fixing the 
 neck of the infant with the hand in form of a crotchet ; for it is quite 
 impossible to bring the head sufficiently low with the hand alone to 
 enable us to divide it. I am not surprised that this method should 
 have proved unsuccessful. 
 
OPERATIONS. 465 
 
 It may, however, happen that, even with the aid of the blunt hook, 
 we cannot depress the neck sufficiently to operate on it with certain- 
 ty ; in this case, the rule laid down by Davis should be adopted. I 
 once assisted M. P. Dubois in performing this latter operation. After 
 having fixed the hook on the middle of the trunk, he incised the trunk 
 through its centre with the curved scissors. The successive section of 
 the walls of the chest was made at first very gradually. Then, on 
 reaching the spinal column, this was divided with one cut of the scis- 
 sors ; and after that he again proceeded slowly and gradually, being 
 careful to place the extremity of the left hand behind the fœtal parts, 
 in order not to wound the organs of the mother with the scissors while 
 terminating the section of the wall of the chest situated behind the 
 pelvis. This operation, performed with extraordinary skill, was so 
 prompt and harmless to the mother, that she did not utter a complaint ; 
 and she was delivered before some of the assistants, remote from the 
 bed, were aware that it was commenced. 
 
 I shall insist, in terminating this important chapter, on the necessity 
 of exercising on the dead foetus, especially in reference to the diagno- 
 sis of the presentations. How can we, with any degree of security, 
 attempt to operate, when at any moment we are liable to commit an 
 error which may destroy both mother and child 1 
 
 How often is the accoucheur called to cases of presentation of the 
 trunk which have been altogether mistaken from their commencement, 
 after precious time had been lost in useless delay, and in the employ- 
 ment of violent measures ! 
 
 It must not be supposed that these errors are confined to young men 
 in the profession ; I have seen them committed by respectable prac- 
 titioners, who had mistaken this presentation, because they had never 
 met with it in several years' extensive practice. 
 
 I was called during the last year to a lady, in whom the shoulder 
 presented ; the physician in attendance, an educated man, and one 
 who enjoyed a certain reputation as an accoucheur in the quarter in 
 which he resided, supposed at first that it was the vertex, and he wait- 
 ed three days for its descent, which, of course, did not take place, not- 
 withstanding several doses of ergot, and the application of the forceps, 
 which was likewise resorted to ! 
 
 Evidently, this practitioner supposed the vertex presented, otherwise 
 it would be difficult to explain his conduct. Administer ergot, when 
 a mechanical obstacle existed at the superior strait, an obstacle which 
 could only be removed by a change of presentation ; and, finally, ap- 
 ply the forceps on the shoulder ! As may be imagined, only one 
 branch could be introduced, the pivot branch, posteriorly ; as to the 
 mortise branch, which he endeavoured to apply to the left and in front, 
 after several successive and violent attempts, it was abandoned. Du- 
 ring these efforts the child succumbed, but, fortunately for the mother, 
 notwithstanding the time thus consumed and the administration of the 
 ergot, the uterine contraction was not so violent as to oppose version, 
 and the mother was thus saved. But, after a year of suffering, she 
 was not restored to health, although attended by the most eminent ac- 
 coucheurs. 
 
 N N N 
 
466 PRESENTATIONS OF THE TRUNK. 
 
 i 
 
 After a phlegmon, which terminated in resolution, she was trouble» 
 for many months with a severe pain in the right iliac fossa, similar to 
 that experienced during the attempts to introduce the right branch of 
 the forceps. The true cause of these pains, which resisted every cura- 
 tive measure, and which for a long time prevented all motion of the 
 right lower extremity, remained entirely unknown. 
 
 It may be alleged, in extenuation of similar errors, that the vertex 
 may be removed from the superior strait, and give place to the shoul- 
 der, founding this opinion on the fact that the opposite of this occurs 
 in the presentation of the shoulder (spontaneous cephalic version). But 
 between these two cases there is a wide difference : the head, when it 
 occupies the superior strait, accommodates itself to the form of this 
 strait, and the foetal ovoid to the form of the uterus ; it cannot, there- 
 fore, be solicited to change its situation to give place to the shoulder. 
 Such, however, is not the case with the presentation of the trunk. In 
 this case, the fœtus, situated almost transversely, is obliged to accom- 
 modate its large diameter to the transverse diameter of the uterus ; 
 this organ permits this distension, but sometimes, also, it may react on 
 the fœtus, and cause it to change its presentation. Again, the shoul- 
 der adapts itself badly to the superior strait ; during a long time it is 
 not fixed firmly there, and then, especially when it presents in the cer- 
 vical or cubital variety, that is, when the head or pelvic extremity is 
 near the superior strait, spontaneous or cephalic, or pelvic version may 
 take place. 
 
 It therefore appears to me impossible that the vertex, when it oc- 
 cupies the superior strait alone, can yield its place to the shoulder, al- 
 though the shoulder may give its place to the head. I do not believe 
 that there is one authenticated case of the kind. 
 
 Such is not absolutely the case when the head is at the superior 
 strait conjointly with the arm. This simultaneous presentation of the 
 tirm and head may gradually be converted into a cervical variety of 
 •presentation of the shoulder. 
 
 A fact which occurred to myself, and which I cite because I believe 
 it will be instructive to others, although I am not exempt from re- 
 proach, has satisfied me of the possibility .of this substitution of pres- 
 entation. 
 
 About eleven years ago, in a lady who resided in the Rue Rivoli, 
 and on whom I was in attendance as accoucheur, I recognised, through 
 the membranes, the presence of the vertex : the result proved that I 
 was not mistaken. The dilatation being complete, I ruptured the 
 membranes, and immediately the arm descended with the head. At 
 this period my mind was not imbued with the excellent precepts which 
 I have since learned from the example and instruction of my learned 
 master, and I thought that I was bound, at every hazard, to effect the 
 reduction of the arm. This reduction not being always easy, particularly 
 for one inexperienced in the obstetric art, I failed in it. I could not re- 
 turn the arm. Then, hoping that something might be gained by the con- 
 tractions of the womb, I administered ergot with the view of stimu- 
 lating the uterus to action. But whether my attempts at reduction, 
 probably badly directed, had removed the head somewhat from the 
 
ARTIFICIAL DELIVERY OF THE PLACENTA. 467 
 
 superior strait, or whether this was effected spontaneously, the arm 
 extended quite into the vagina. 
 
 Justly alarmed at this circumstance, I again introduced my hand, 
 and endeavoured to reach the feet, but, owing to the strong contrac- 
 tions of the uterus, and too much timidity on my part, together with the 
 intractable character of the patient, I could not succeed. 
 
 It became necessary to seek more skilful assistance. M. Moreau, 
 my father, M. Taillefer, all successively attempted the version ; but the 
 contractions were so violent that they could not accomplish it. M. 
 Moreau requested me to send for M. P. Dubois, of whose skill at that 
 time I was entirely ignorant ; M. Deneux, who was also present, feel- 
 ing the head partially engaged at the superior strait, for it had not left 
 it entirely, thought, with reason, that the only mode of terminating the 
 delivery was to act on the head ; he endeavoured, therefore, to bring 
 it down with the forceps, but all his efforts proved useless. Finally, 
 M. P. Dubois succeeded in applying this instrument, and effected the 
 delivery ; the child had succumbed, but the mother recovered per- 
 fectly. 
 
 ei If ours were the period of honest admissions," truly observes M. 
 Champion, " what honourable practitioner, and, particularly, what ac- 
 coucheur is there who would not have some revelation of this kind to 
 make?" 
 
 It is, therefore, because I am convinced that the admission of a fault 
 is more useful to the pupil than the recital of success, that I have not 
 attempted to conceal my errors : 1st. In wishing, at all hazards, to ac- 
 complish the reduction of the arm, instead of relying on nature, as soon 
 as I failed in my first efforts. 2d. In mistaking at first the substitution 
 of presentation which I had occasioned, and confiding in nature when 
 I should have practised version at tne proper time. 
 
 This circumstance, however, will always be mentioned by me with 
 pleasure, for it was on this day that I first had an opportunity to ap- 
 preciate the great skill of M. P. Dubois, became his pupil, and com- 
 pleted under his guidance my obstetric education. 
 
 CHAPTER II. 
 
 ARTIFICIAL DELIVERY OF THE PLACENTA. 
 
 I have already treated of the natural delivery of the after-birth ; and 
 it now remains for me to speak of the accidents capable of opposing its 
 expulsion, and of those which sometimes complicate it. 
 
 Art. I. — Uterine Inertia. 
 In order that the relations which unite the placenta to the uterus 
 may cease, it is necessary that the uterus should contract on itself, and 
 its walls become diminished. When this separation does not take 
 
468 ARTIFICIAL DELIVERY OF THE PLACENTA. 
 
 place in consequence of inertia of the womb, what is to be done ? We 
 should be extremely particular not to take away the placenta until we 
 shall have stimulated the contractility of the uterus by frictions on the 
 abdomen, titillations on the lips of the organ, and by sustaining the 
 strength of the patient. 
 
 In fact, if we remove the after-birth before having awakened the 
 contractility of the uterus, we shall expose the patient to the conse- 
 quences of a frightful hemorrhage. 
 
 It is rare that the inertia is protracted ; in all cases we should de- 
 lay until it has been overcome before removing the placenta, even 
 when several hours shall have passed. This precept may appear to be 
 in contradiction to that already given of bringing away the placenta 
 artificially when one hour shall have elapsed after the expulsion of the 
 child ; but this rule is liable to certain exceptions, and uterine inertia 
 is one of them. In fine, when the uterus remains inert, there is no 
 danger that the neck, in contracting, will oppose the delivery of the 
 after-birth if it be deferred. And it is especially to avoid this difficul- 
 ty that M. P. Dubois recommends to effect its expulsion artificially, if 
 the natural efforts be not sufficient at the end of an hour. 
 
 Art. II. — Debility of the Cord. 
 
 Weakness of the cord, whether it depend on its slight resistance, 
 or the abnormal insertion of its vessels on the membranes, is a circum- 
 stance which prevents our effecting the delivery by means of the cord. 
 We are admonished of this fact, because the hand feels that, at every 
 step, the cord gives way. This consciousness of the laceration of the 
 cord is very manifest. 
 
 In this case, should we delay and confide the delivery to nature, or 
 should we accomplish it artificially ? We should at first intrust it to 
 nature, but not for a period exceeding an hour; after this time, it 
 might be followed by serious inconvenience ; for if the contractions 
 did not suffice for the expulsion of the placenta during the time we 
 delayed for this natural effort, the neck of the uterus would contract 
 on itself, and we should experience . great difficulty in accomplishing 
 the delivery, besides occasioning much suffering to the patient. Thus 
 it appears to me to be much more wise in this case, when the pains 
 felt by the mother, the contraction of the uterus, and the descent of a 
 portion of the placenta give us reason to suppose that it is completely 
 detached, not to delay longer than an hour, and introduce the hand 
 along the cord, grasp the placenta, which we find partly descended, 
 and extract it. By pursuing this mode, we often avoid much diffi- 
 culty, prevent a too considerable discharge of blood, kept up by the 
 presence of the placenta, and, finally, we complete the labour, and al- 
 low the patient to be changed, and placed in her bed to seek repose. 
 If the resistance should be very great, for fear it may depend on an 
 adhesion of the placenta, we should wait one hour; and, at the expi- 
 ration of this time, the hand should be introduced, and the cause of 
 the obstacle ascertained. 
 
 In all cases, when the cord is frail, we should not make use of trac- 
 tions on it, not that the rupture of the cord would be followed by incon- 
 
SPASMODIC CONTRACTION OF THE UTERUS. 469 
 
 venience — for whether it be attached or not to the placenta, it is per- 
 fectly useless so far as the delivery is concerned, on account of its 
 weakness — but because this separation of the cord is always consid- 
 ered as an evidence of want of skill on the part of the accoucheur, 
 and it also creates alarm among the assistants. 
 
 Art. III. — Spasmodic or Irregular Contraction of the Uterus. 
 
 After the expulsion of the foetus, the organic contractility of the 
 uterus is much less intense ; it is more particularly the contractility of 
 tissue, or the retraction of the organ, which accomplishes the separa- 
 tion of the placenta and its expulsion. It is, however, true that there 
 are slight uterine contractions, which contribute to the expulsion of 
 the after-birth. 
 
 This organic contraction, and this contractility of tissue, manifest 
 themselves in every viscus under ordinary circumstances. But things 
 do not always pass in this manner ; certain portions of the uterus, for 
 example, may remain inert, while others may be acted on by the two 
 species of contractility combined ; and then, according to the portion 
 of the organ which is the seat of this anomaly, the placenta may be 
 thrown from its cavity, or it may be retained there. 
 
 The external orifice of the uterus never presents this spasmodic con- 
 dition; it is always found soft and relaxed after the expulsion of the 
 foetus. 
 
 But it is not so with the internal orifice, which almost invariably 
 retracts after the delivery of the child, and often even is affected with 
 spasm. The body of the uterus may also participate in this state of 
 spasmodic contraction. It will be seen that, in this latter case, the 
 spasmodic contraction of the entire body of the organ, when the in- 
 ternal orifice is not contracted, far from opposing the delivery of the 
 placenta, will, on the contrary, determine it. In order that this spas- 
 modic condition of the body may prevent the delivery, it becomes ne- 
 cessary that all the parts of the organ should not be simultaneously 
 affected ; that one part should be relaxed, while the other contracts 
 spasmodically. 
 
 Thus, therefore, spasmodic contractions of the internal orifice, partial 
 and spasmodic contractions of the body of the uterus, are two compli- 
 cations, the first of which will retain the placenta in the cavity of the 
 uterus, and the second will cause its confinement to a certain part of 
 this organ. 
 
 § 1. Spasmodic Contractions of the Internal Orifice. 
 When all the signs wdfich announce the separation of the placenta 
 become manifest, when the time has passed in which we should sup- 
 pose this separation had taken place, and when strong tractions made 
 on the cord have no effect, we should proceed at once to discover the 
 cause of the difficulty. If it be occasioned by the spasmodic condition 
 of the internal orifice, the finger of the accoucheur, after passing the 
 external orifice, which is soft and open as it were, encounters the supe- 
 rior portion of the uterine neck, which is strongly contracted and closed. 
 Sometimes, however, when this condition is not manifested until after 
 
470 
 
 PRESENTATION OF THE PELVIC EXTREMITY. 
 
 the descent of a portion of the placenta, we reach the internal orifice 
 less readily, but we feel very distinctly that this portion of the placenta 
 is strangulated circularly. 
 
 The condition of the neck is, in general, only temporary ; time will 
 ordinarily be all that is required to overcome it. But if, after four or 
 five hours' delay, it should still continue, and even before this time in 
 the event of any accident, we should act. Ten, fifteen, twenty drops 
 of laudanum should be administered in injection, narcotic embrocations 
 on the abdomen, and bloodletting if there be plethora; finally, if these 
 measures fail, we should introduce the hand, well lubricated with bel- 
 ladonna ointment (one fifth of the extract to four fifths of hog's lard), 
 entering very gradually one finger at a time, and forcing with great 
 care the resistance of the neck, and, at the same time, compressing the 
 uterus with the other hand placed externally ; then we should extract 
 the placenta. 
 
 § 2. Irregular and Spasmodic Contractions of the Body of the Uterus. 
 The separation of the placenta and its expulsion are accomplished 
 by a contraction of the whole of the uterus ; but, as I have already 
 remarked, certain portions of the organ may remain relaxed while 
 others contract ; and thus, if the portion on which the placenta is in«- 
 serted remains inert, while all the other parts of the uterus contract 
 spasmodically, the placenta becomes enclosed in this uncontracted por- 
 tion ; this is what is called the enchatonnement of the placenta. This 
 may be produced likewise in another manner, by the contraction of 
 only one portion of the uterus, which constricts the organ in its cen- 
 tre. The disposition of the uterine fibres explains very accurately this 
 fact. We see, in fig. 214, on each side of the organ, concentric cir- 
 cular fibres at the orifice of the fallopian tube. 
 
 (Fig. 214.) Now let us suppose that the placenta is 
 
 inserted on one of these muscles, which is 
 not at all uncommon, and that the circular 
 fibres, the most remote from the orifice of 
 the tube, should contract spasmodically, the 
 after-birth will be enclosed in this species of 
 cavity, as a stone in the beazle of a ring 
 (dans le chaton d'une bague). 
 
 It may very well happen, in this case, 
 that this circular ring is the only part of the 
 organ that contracts, while all the other por- 
 tions are in a state of relaxation. 
 
 The conduct to be pursued is the same as in the preceding case ; 
 except that, if the spasmodic condition resist the opiates, &c, &c, and the 
 use of the hand be indicated, we should not, if possible, force the con- 
 tracted portion with the whole hand ; one or two fingers only should be 
 introduced into it for the purpose of withdrawing the placenta.* 
 
 * I do not think this advice of Dr. Chailly will always be found useful in these cases ; at 
 least, my experience points out the necessity of a different practice. In this peculiar spas- 
 modic condition of the uterus, I have never found anything answer so promptly and effect- 
 ually as breaking down, if I may so speak, the spasm of the affected part by fatiguing the 
 muscular fibres, and this object can be accomplished in the following manner : the hand is 
 
ABNORMAL ADHESIONS. 
 
 471 
 
 This accident is often complicated with ad- 
 hesion of the placenta ; and, under these cir- 
 cumstances, it becomes necessary to introduce 
 the hand into the constricted portion, in or- 
 der to effect the separation of the placenta 
 with the extremity of the fingers. 
 
 Art. II. — Abnormal Adhesions. 
 
 The abnormal adhesions, which unite the 
 placenta to the uterus, may be more or less 
 extensive, and more or less solid. This acci- 
 dent is known by the following signs : notwith- 
 standing the combination of all the other circum- 
 stances favouring the expulsion of the after-birth 
 (such as contractions of the uterus, &c, &c), tractions made on the cord 
 do not produce any result ; and the hand applied to the hypogastrium 
 during these tractions, distinctly perceives that the uterus is drawn 
 down. If the uterine contraction were less active, this hand, instead 
 of perceiving that the whole uterus had descended, would, on the con- 
 trary, find that only a portion of the organ had become depressed. 
 
 When, by these signs, we suspect an adhesion of the placenta, we 
 should, before verifying the fact by the introduction of the hand, en- 
 deavour to excite the contractions by frictions on the abdomen, titilla- 
 ting the neck of the organ, and then resorting again to tractions, pro- 
 portioning them to the firmness of the cord. 
 
 It is not until these repeated attempts have failed, and after the 
 lapse of an hour, that we should introduce the hand into the uterus for 
 the purpose of ascertaining precisely the nature of the obstacle, and 
 immediately remedying it before withdrawing the hand. 
 
 The hand is introduced into the organs with all possible precaution, 
 following the umbilical cord made tense by the other hand : in this 
 way we shall arrive directly at the placenta, without groping in the 
 dark. 
 
 As soon as the hand has reached the placenta, it endeavours to dis- 
 cover whether a portion of this organ is detached, and it is at this point 
 that it commences the completion of the separation. 
 
 The method which, in this case, should be employed, consists in 
 
 to be introduced into the cavity of the uterus in a conical form, and this form is to be main- 
 tained while the hand remains in the cavity ; it is to be passed up to the constricted portion, 
 and the fingers, representing the summit of the cone, are made to push gently, but firmly, 
 against the centre of the contracted orifice ; equable and continued pressure will thus break 
 the force of the spasm, and the after-birth can then be removed without difficulty. But it 
 occasionally happens that the hand becomes so severely cramped, and the resistance of the 
 constricted portion is so great, that the accoucheur is under the necessity of withdrawing the 
 hand without accomplishing the object. Under these circumstances, I have twice had 
 recourse to a method, which I do not remember to have seen mentioned by any author, and 
 to which I attach very great importance. It is this : I take a small piece of burnt sponge, of 
 a conical shape, well enveloped with patent lint, and completely saturated with sweet oil, 
 and afterward covered with belladonna ointment ; this I enclose in the hollow of my hand, 
 and then carrying the hand into the uterus, I apply the apex of this sponge to the constricted 
 orifice, and by firm and properly -directed pressure, allowing the sponge to act on the princi- 
 ple of a wedge, the spasm is overcome, and all difficulty is at an end. I submit this method 
 to the test of future trial, believing, as I do, that it will be found to answer a valuable end. — 
 Ed. 
 
472 
 
 ARTIFICIAL DELIVERY OF THE PLACENTA. 
 
 (Fig. 216.) 
 
 seizing the detached portion with the full hand, 
 and drawing on it, in order to detach the rest ; 
 or, if the adhesions do not yield to these efforts, 
 they must be broken up by the nails, in acting 
 always on the. placenta, and keeping as remote 
 from the tissue of the uterus as possible. This 
 is the only mode of effecting the separation.* 
 
 In this operation, we should be careful not to 
 detach the parts which adhere too firmly, and 
 which would be separated from the rest of the 
 placenta, for fear, in extracting them, we should 
 lacerate the tissue of the womb. These isolated 
 cotyledons become gradually detached themselves, 
 and are expelled in fragments, or with the lo- 
 chia?. 
 
 If the adhesions should be intact, we must introduce the hand be- 
 tween the membranes and the surface of the uterus ; and if we be 
 positive as to the point at which the placenta commences, we should 
 effect the separation by beginning at the circumference of this organ ; 
 if there be any doubt, it would be more advisable to commence from 
 the centre to the circumference : for this purpose, we should lacerate 
 the placenta in the neighbourhood of the insertion of the cord, intro- 
 duce the fingers into this laceration, and thus, little by little, accomplish 
 the detachment of the placenta. 
 
 If, in consequence of too intimate an adhesion, we should be obli- 
 ged to leave some portions of the after- birth in the uterus, we should for 
 several days examine the patient, and ascertain whether their parts 
 are detached ; and if so, they should be seized with the fingers. We 
 should also endeavour to provide against the dangers of the absorp- 
 tion of these putrified masses. With this view, there should be fre- 
 quent vaginal injections with a weak solution of the chloride of lime. 
 Injections into the womb should be composed of a decoction of marsh- 
 mallows, and should be administered with great caution, and in small 
 quantity, by the accoucheur himself. Indeed, without an absolute ne- 
 cessity, I should abstain from these latter injections. M. Housman 
 has reported several cases in which serious accidents were occasioned 
 by the passage of the fluid into the abdominal cavity through the fal- 
 lopian tube. I also observed, at La Clinique, a similar fact, from an 
 injection thrown into the womb ; the patient experienced of a sudden 
 severe pain in the right iliac fossa ; all the symptoms of local peritoni- 
 tis manifested themselves at this point ; but they were combated, and 
 the patient recovered. 
 
 * Let me here caution the student not to fall into a common error in regard to the reten- 
 tion of the placenta. It is not unusual for the inexperienced practitioner in midwifery to 
 refer every case of detained placenta to morbid adhesions, hour-glass contractions, &c, &c. I 
 have repeatedly been sent for to remove the placenta, when one of the above conditions was 
 supposed by the physician in attendance to be the cause of the difficulty ; and on introducing 
 my finger into the vagina, I found the placenta protruding through the mouth of the womb, 
 and all that was necessary to effect its expulsion was to take it away with the hand. Hour- 
 glass contraction and morbid adhesions are comparatively rare, and it will be well to keep this 
 fact in memory. — Ed. 
 
ACCIDENTS m THE DELIVERY OF THE PLACENTA. 473 
 
 Art. V. — Accidents in the Delivery of the Placenta. 
 Hemorrhage, inversion of the womb, and laceration of the tissue of 
 the uterus, are the principal accidents capable of complicating the de- 
 livery of the after-birth. 
 
 § 1. Hemorrhage. 
 Hemorrhage, after the expulsion of the foetus, may precede, accom- 
 pany, or follow the extraction of the placenta ; it is always occasion- 
 ed by uterine inertia.' It is a most formidable accident, which, in a 
 few minutes, may cause the death of the patient. The accoucheur, 
 therefore, as has been remarked, should not leave his patient imme- 
 diately after the delivery of the after-birth ; for two hours afterward he 
 should remain with her, in order that in an instant he may be readv to 
 arrest the hemorrhage if it should occur. 
 
 a. Diagnosis. 
 Hemorrhage may be external or internal. 
 
 A. External Hemorrhage. — The diagnosis of external hemorrhage 
 is very simple ; in fact, the discharge of blood externally sufficiently 
 characterizes the nature of the accident. We should, however, be ac- 
 customed to appreciate the quantity of blood which a female ordina- 
 rily loses after the removal of the placenta (it is considerable), in or- 
 der that we may not mistake this normal discharge for hemorrhage, 
 and not, on the contrary, remain passive in consequence of regarding 
 a veritable flooding as nothing more than a physiological result. If, 
 after the discharge of blood which follows the placenta, there should 
 still be an abundant flow, if the pulse become weak, and the face pale, 
 it is not possible to misunderstand that there is really hemorrhage, 
 which requires prompt treatment. 
 
 B. Internal Hemorrhage. — When coagula, closing up the mouth of 
 the womb or vagina, prevents the blood from passing out externally, it 
 accumulates in the cavity, which it distends, and the female becomes 
 pale, her pulse falls, and she grows more or less faint. In this case, we 
 must distinguish accurately as to the cause of these symptoms. Thus, 
 for example, the abdomen may become enlarged from an over-distend- 
 ed bladder, and the weakness of the pulse, pallor of countenance, and 
 syncope, may also depend on the rapidity with which the blood leaves 
 the head, in order to pass, immediately after delivery, into the vessels 
 of the lower portion of the abdomen. 
 
 The touch and abdominal percussion will soon point out the true 
 cause of these troubles. 
 
 In fact, whether the hemorrhage be internal or external, the only 
 mode of ascertaining its nature, before it has become very alarming, 
 is to pursue the course I have already indicated, and which I shall 
 again call to the mind of the pupil. 
 
 Immediately after the expulsion of the foetus or placenta, we take a 
 cautious survey of the patient, and inquire whether or not she feels any 
 blood passing in abundance from her ; and we should also watch the 
 pulse. If there should be the slightest ground for apprehension, we 
 
 o o 
 
474 ARTIFICIAL DELIVERY OF THE PLACENTA. 
 
 should at once proceed to examine the nature of the case, by inspect- 
 ing the napkin which has been applied to the vulva, and seeing wheth- 
 er or not it is saturated with blood. 
 
 The condition of the uterus should also be an object of particular 
 attention with the accoucheur ; with the hand applied to the hypo- 
 gastrium, he will ascertain whether this organ is globular, resisting, 
 and but little developed, or whether it is not properly contracted. 
 
 b. Treatment. 
 When hemorrhage takes place after delivery, the cause is the first 
 object to be combated. For this purpose, while we send for some 
 ergot,* we should provide napkins, compresses, a bucket of water with 
 
 * Ergot should never be considered among the heroic remedies in the treatment of uterine 
 hemorrhage after the birth of the child. Some practitioners are in the habit of relying on it 
 as an all-sufficient agent in these cases, but they are in error. In profuse hemorrhage, death 
 may ensue before the ergot can act. Something else, therefore, must be done in these trying 
 emergencies. Hemorrhage, after the expulsion of the child, is either external or internal. In 
 either case the indication is the same ;■ the uterus must be made to contract. This object will 
 be best effected by introducing one hand into the cavity of the womb, carrying it, if possible, 
 to the point of the organ, to which the placenta is yet partially attached, or from which it has 
 been separated. Then with the broad surface of the posterior portion of the fingers pressure 
 is to be made directly on the bleeding vessels, while, with the other hand applied to the ab- 
 domen, counter pressure is to be employed. In this way, the uterus will frequently be made 
 to contract, and the hemorrhage will at once cease. Together with the pressure, the cold 
 dash is an invaluable remedy. Let iced water be thrown from a height on the abdomen ; and 
 this is to be repeated successively until contraction is induced. I have occasionally found 
 great benefit from grasping a small piece of ice, and introducing it into the womb ; the con- 
 tact of cold thus suddenly applied will sometimes produce immediate contraction of the organ. 
 
 It has been remarked by a writer on midwifery, that no physician should have the hardi- 
 hood to cross the threshold of the lying-in chamber who is not prepared promptly and effec- 
 tively to manage every placenta case that may by any possibility present itself. This is the 
 language of that emphatic, lucid, and practical author, Dr. Gooch. I respond most heartily, 
 with all consciousness of its truth, to the value of this sentiment ; and I would say to those 
 who have never yet been engaged in the practice of the profession, that if there be any one 
 thing more than another, in the whole routine of professional duty, calculated to strike terror 
 into the heart of the practitioner, and for a moment paralyze his best energies, it is a case of 
 flooding after the birth of the child. One moment's hesitation or doubt on the part of the 
 practitioner, and death speedily terminates the scene. Nature has opened her floodgates, 
 and if they be not instantly and skilfully closed, all chance of rescue is at an end. Never, 
 since I have been a practitioner of medicine, have I had my feelings so wrought upon, and my 
 sympathies so freely excited, as in a case in which I was recently engaged. It is a sorrow- 
 ful, melancholy tale ; yet it is so full of instruction, that I cannot forbear narrating it, in 
 order that wholesome admonition may be derived from its recital. 
 
 A short time since, I was sent for in great haste by a gentleman to meet him in consult- 
 ation in the case of a lady who had just been delivered of a child. As soon as I reached the 
 house, he informed me that half an hour before my arrival he had delivered his patient of a 
 fine son ; and he observed that there was another foetus in the womb. Finding his patient 
 growing weak, he thought it advisable to send for assistance. This was all the information 
 I received, when, on being introduced into the room, I witnessed a scene which I have not 
 language to describe. The husband and relatives were gathered around the bed of the dying 
 woman ; her two little children, who had been asleep in an adjoining room, awakened by the 
 confusion of the night, became alarmed, and rushed into their mother's chamber. As soon 
 as I beheld the patient, I became convinced that all was over. There she lay, pulseless and 
 speechless, with death written upon her countenance. In placing my hand on the abdomen, 
 I found it immensely distended ; it was soft on pressure, and in an instant 1 arrived at my 
 diagnosis. It was a case of internal uterine hemorrhage. Without a moment's delay, I intro- 
 duced my hand, for the purpose, if possible, of bringing on contraction of the womb. I found 
 the placenta detached, and lying immediately over the mouth of the uterus, thus effectually 
 preventing the escape of blood externally, and leading the practitioner to a fatal error as to 
 the actual condition of his patient. As soon as I had introduced my hand into the womb, the 
 unfortunate woman seemed to experience a momentary revival. She opened her eyes wildly, 
 gazed on those around, asked for her children, and instantly expired ! 
 
 Comment here can scarcely be necessary. Error of judgment as to the nature of the diffi- 
 culty had thus suddenly swept from earth an interesting woman ; it had converted a house 
 of joy into one of mourning, and had deprived the young and helpless of a mother's love and 
 devotion. Such scenes are indeed agonizing, and are calculated to make a lasting impres- 
 sion on the minds of all who appreciate the necessity of accurate knowledge and the fulness 
 of professional responsibility.— Éd. 
 
ACCIDENTS IN THE DELIVERY OF THE PLACENTA. 475 
 
 a pitcher; and, if the hemorrhage be internal, we should immediately 
 introduce the hand into the uterus and remove the coagula and blood 
 which it contains. This introduction of the hand likewise has the ad- 
 vantage of soliciting the contraction of the walls of the uterus. At 
 the same time, the other hand, applied to the hypogastrium with the 
 same object in view, makes frictions on the womb. 
 
 As soon as the hemorrhage has become external, or if it were so 
 from the first, such is the conduct which the accoucheur is to pursue. 
 
 The pillows and bed-covering should be immediately removed, the 
 breech should be slightly raised by a sheet folded several doubles ; the 
 upper portion of the body alone should be kept warm, in order to in- 
 vite as much as possible blood to the organs essential to life ; but the 
 inferior portion of the body should be covered simply with a sheet, 
 and the windows should be open. 
 
 While the accoucheur is making frictions on the hypogastrium, he . ^ . 
 should administer ./si. of ergot in a small quantity of water. At the "' pf\ 
 same time, he directs the assistants to place cold compresses on the u 
 legs and thighs ; and if the frictions should be insufficient to bring on 
 uterine contraction, he must not wait for the action of the ergot, but 
 immediately, with the extremity of the fingers of one hand, press on 
 the abdominal aorta before its bifurcation; and he thus exerts with 
 this hand, on which is superposed the other, a compression, which, 
 when well made, almost invariably arrests the hemorrhage. 
 
 This means, which we owe to M. Baudelocque, nephew, and wheth- 
 er he originated it or not matters little, is one of the most precious 
 discoveries with which the obstetric art has been enriched. 
 
 M. d'Ornelas has quite recently cited in his thesis several cases of 
 success obtained by this remedy. 
 
 My father had recourse to it once with the happiest result ; and in 
 two instances I have also been enabled to preserve the lives of two 
 women, who certainly would have died had it not been for this valu- 
 able agent. 
 
 In one of these patients I made use of this compression for nearly 
 two hours, when M. P. Dubois, whom J had sent for, arrived and wit- 
 nessed the fact. « 
 
 The effect produced by this compression is so manifest, that the 
 flow of blood is immediately checked ; and if, by a movement of the 
 patient, the aorta should escape from the hand, the hemorrhage re- 
 commences immediately. 
 
 This compression, as is well understood, is not a curative remedy ; 
 but it permits us to gain time, a result the more important in an acci- 
 dent so fearfully rapid as uterine hemorrhage. 
 
 Finally, while this compression is faithfully persevered in, and the 
 flooding is thus checked, we must employ with activity the other 
 means which are calculated to arrest it definitively. Cold water should 
 be thrown into the rectum ; two or three drachms of ergot, in two or 
 three doses; the cold compresses to the legs and thighs should be 
 constantly renewed, and an assistant should make continued frictions 
 on the uterus. 
 
 The compression of the aorta will be the more easy in proportion 
 
476 ARTIFICIAL DELIVERY OF THE PLACENTA. 
 
 as the patient is less loaded with fatty matter ; but, even when the 
 female is very corpulent, it still may be practised with facility, and 
 successfully. In fine, immediately after the expulsion of the fœtus, 
 the uterus descends, and there is a space between the fundus of this 
 organ and the intestines, which, for a period of nine months, having 
 been pressed up towards the superior portion of the abdomen, do not 
 immediately after the delivery resume the place they occupied before 
 pregnancy. It is into this space that the hand passes with facility for 
 the purpose of making the compression. 
 
 It is sometimes extremely fatiguing to continue this compression, 
 and we are occasionally obliged to be relieved by ari assistant. 
 
 C. Before the delivery of the placenta, a very serious flooding, if 
 not remedied, may take place from the placental extremity of the cord. 
 
 This accident is, however, very rare, and the mode of arresting it 
 perfectly simple ; it consists in placing a ligature on the cord. 
 
 § 2. Inversion of the Uterus. 
 
 Inversion of the uterus may be occasioned by the spontaneous de- 
 livery of the placenta ; but, much more frequently, this accident results 
 from tractions made on the cord while adhesion still exists between 
 the placenta and uterus. This inversion may be incomplete, and then 
 the touch and abdominal percussion will disclose the nature of the 
 difficulty. If, on the contrary, it be complete, we feel and see be- 
 tween the lips of the vulva a round, rugous, blackish tumour, composed 
 of the inverted uterus. 
 
 When the inversion is incomplete, the hand should be introduced 
 cautiously, for the purpose of raising the fundus of the inverted organ. 
 
 If it be complete, the extremity of the fingers, covered with a linen, 
 must be applied to the fundus of the organ, and gradually return it, 
 until the reduction be accomplished. If, in this case, the placenta 
 were still adhering to the uterus, it should be immediately detached, 
 and the w r omb reduced ; but we .should not attempt the reduction of 
 the uterus and placenta together, for the reduction, in most cases, 
 would be impossible, or, at lease, would require great effort. Finally, 
 what motive could there be for the simultaneous reduction, when we 
 should afterward be obliged to introduce the entire hand for destroy- 
 ing, artificially, the adhesions 1 
 
DERANGEMENTS OF THE MILKY SECRETION. 477 
 
 FOURTH PART. 
 CHAPTER I. 
 
 ACCIDENTS FOLLOWING DELIVERY. 
 
 In this fourth part I shall treat of the accidents which may compli- 
 cate the puerperal period, and of the diseases incident to the infant 
 soon after its birth ; but, in a work like this, it will be at once seen 
 that I cannot give a full description of these accidents ; and that I 
 must, therefore, limit myself simply to certain views, which will en- 
 able the young practitioner to establish the diagnosis of these maladies, 
 and combat them by proper treatment. 
 
 Art. I. — Derangements of the Milky Secretion. 
 
 Derangements in this secretion are much more common in women 
 who nurse than in those who do not. The contrary opinion, however, 
 prevails ; but experience every day proves that it is entirely unfounded. 
 
 These derangements are, galacterrhea, agalaxy, excoriations, fis- 
 sures, engorgement of the breast, inflammation, abscess, and indura- 
 tions, which are the consequences of inflammation. 
 
 § 1. Galacterrhea. 
 
 A. In the Female who does not nurse. — Galacterrhea, or excessive 
 milky secretion, in a female who does not nurse, is an accident which 
 merits all the attention of the accoucheur. 
 
 This accident, however, is never so marked the first day of the milk 
 fever as to require any other treatment than the means usually resort- 
 ed to during this fever : the most absolute repose of body and mind, 
 cold drinks, diet, and warmth applied to the breasts by means of cards 
 of cotton. But if the fever should continue the second day, and the 
 breasts be very tense, tumefied, and painful, it will be necessary to 
 moderate the activity of this secretion. 
 
 The patient must be placed on absolute diet, and flaxseed poultices 
 applied to the breasts ; then, in order to increase the other secretions, 
 the patient should be kept warm, for the purpose, if possible, of pro- 
 moting perspiration ; but the secretion of the mucous membrane of the 
 intestines must particularly be kept up by gentle laxatives, such as 
 castor oil, or calomel (one drachm divided into ten powders), every 
 two hours. Seidlitz water may also be employed with advantage. 
 It would even be useful to administer a purgative injection ; for drink, 
 the patient should take nitrate of potash and warm water, ten grains to 
 the pint. 
 
 This regimen must be continued as long as we have any apprehen- 
 sions about the breasts. 
 
4? S ACCIDENTS FOLLOWING DELIVERY. 
 
 B. In a Female who nurses her Child. — Galacterrhea in a female 
 who nurses never constitutes a disease, except under circumstances 
 which I shall immediately mention. 
 
 In a word, it is very rare that the secretion of milk is more abundant 
 than is required by the wants of the infant, if care should be taken to 
 put the child to the breast before the milk fever. It is always prudent 
 to put the child to the breast a few hours after its birth, whether the 
 secretion of milk be sufficient or not. If it cannot extract the necessa- 
 ry nourishment, other can be supplied ; but the very suction exerted 
 by the mouth of the infant will determine an easy action in the mam- 
 mary gland, which would not otherwise have manifested itself for 
 forty or sixty hours afterward, and which would then have been ex- 
 cessive. 
 
 What follows when, according to the advice of some physicians, the 
 child is not put to the breast until the secretion of milk has occurred ? 
 In the first place, the breasts swell, then the nipple becomes effaced, 
 and the child cannot take hold of it in order to nourish itself, and, at 
 the same time, diminish the quantity of milk. 
 
 This accident, notwithstanding all precautions, may manifest itself 
 in women who nurse, and especially in those whose nipple does not 
 present sufficient prominence to enable the child to seize it. Thus, 
 with a view to obviate all these inconveniences, and to facilitate as 
 much as possible the natural secretion. I have adopted a plan which 
 has proved very successful : it consists in taking, for the first few days, 
 a nurse whose child is more vigorous than the newly-born infant. 
 When we desire to put the latter to the breast, we place, in the first 
 instance, to it the infant of the nurse, which, being stronger, brings out 
 the nipple, causes the milk to flow to the breasts, or disgorges them, 
 depending on circumstances ; and when everything is thus properly 
 prepared, this child is removed, and the other applied to the breast in 
 its place; it then takes the nipple without difficulty. If the secretion 
 of milk be not sufficiently established to afford ample nourishment to 
 the infant, the nurse puts it immediately to her own breast as soon as 
 it has left that of the mother. 
 
 This very simple method, and which can be resorted to by any one, 
 prevents the engorgement of the breasts, and does away with the ne- 
 cessity of artificial nourishment. It should be continued until the moth- 
 er is perfectly able to nurse her infant ; generally five or six days will 
 suffice. 
 
 If, however, no precautions should have been taken to prevent this 
 excessive secretion of milk, or if means are not adopted to make this 
 activity of the glands useful, galacterrhea may become a disease, 
 when, from certain circumstances, the child ceases to take the breast, 
 or cannot extract a sufficient quantity of milk. A succulent regimen, 
 constipation, and gastric derangement, serve to favour this excessive 
 secretion of milk, which, in some women, may also be produced by ir- 
 ritation of the mammary gland, frequently followed by a considerable 
 engorgement, if the milk should not escape externally, either natural- 
 ly or by the suction of the child. 
 
 But there is one case particularly in which galacterrhea may mani- 
 
DERANGEItfENTS OF THE MILKY SECRETION. 479 
 
 fest itself; when, for example, a female, having nursed her infant for 
 the first few days, finds herself under the necessity of abandoning it ; 
 thus, the excitement already occasioned by the suction of the child 
 continues after this latter has been withdrawn from the breast, and the 
 milk which has been secreted, being no longer taken from the breast, 
 causes a painful engorgement. 
 
 The treatment for galacterrhea consists, in the first place, when 
 there is merely a superabundance of milk, in extracting the superflu- 
 ous part by means of a pump, or by the application of young pups, as 
 is often done in the country ; then the quantity of nourishment should 
 be diminished, and, in severe cases, absolute diet enjoined, and the oth- 
 er secretions increased, &c, &c. 
 
 Agalaxy is much more serious, especially when the female is obli- 
 ged to nourish her infant. Agalaxy, or defective milky secretion, may 
 be occasioned by the following circumstances : an unnatural conforma- 
 tion or absence of the nipple, schirrus or morbid atrophy of the breasts, 
 a too abundant secretion of the lochiae, diarrhoea, immoderate secretion 
 of urine, copious perspiration, impoverished diet, irritation of the im- 
 portant viscera, excesses of all kinds, venereal and other affections, pro- 
 tracted nursing, excessive youth or age of the female, appearance of 
 the menses, and, finally, pregnancy. 
 
 On the part of the infant, improper conformation of the lips, tongue, 
 or velum palati, any other bad conformation and great debility, which 
 prevents the child from taking hold of the nipple, are also causes of 
 agalaxy. And it is to these causes that we must direct our attention, 
 if we wish to bring the milk to the breasts. In the first place, a mild 
 regimen, and even abstraction of blood, when the female is plethoric, 
 or affected with inflammation of some of her viscera, will be indicated. 
 If, on the contrary, she be debilitated, it will be necessary to prescribe 
 a tonic regimen, and repose, moral as well as physical. Should the 
 nipple be badly formed, we must ascertain whether it is capable of 
 erection, so as to afford the child an opportunity to seize it, for very 
 frequently it may develop itself under the influence of slight titilla- 
 tions and the suction of the child. As to the deformities of the child, 
 they should be remedied, if possible. But there are cases where the 
 evil is irremediable for both mother and child. When, for example, 
 the deformity of the latter is so marked as to prevent the possibility 
 of suction ; then the only resource will be artificial nourishment, of 
 which we shall speak hereafter.. Should the mother labour under 
 some organic affection of the breasts, be too old, become pregnant, or 
 have a return of the menses,* it will then be necessary to provide a 
 nurse for the child. 
 
 § 2. Engorgement of the Breasts. 
 Engorgement of the breasts, or, as it is commonly called, morbus 
 pilaris, which takes place during lactation, is characterized by swell- 
 
 * The mere return of the menses during the period of lactation cannot, of itself, render it 
 necessary either to wean the infant or procure another nurse ; for, in many instances, this 
 function appears regularly, without in any way affecting the ability of the mother to suckle 
 her child. But should the menses occasion derangement either in this secretion or in the 
 general system of the mother, the alternative must then be resorted to. — Ed. 
 
4S0 ACCIDEiNTS FOLLOWING DELIVERY. 
 
 ing of one or other breast, and more rarely of both. The breast be- 
 comes painful, hard, tense, irregular, and presents a slight redness on 
 its surface, with inequalities, which sometimes extend to the axilla. 
 Although this engorgement may occur at different periods of lactation, 
 and return again, yet it ordinarily manifests itself a few days after de- 
 livery, and most usually is not attended with danger. The causes of 
 this engorgement are, cold, blows, pulling of the nipple, excessive 
 sensibility from the too active suction of the child, excess in nourish- 
 ment, sudden cessation of nursing, excoriations and fissures of the 
 breasts, &c., &c. 
 
 Engorgement of the breasts usually terminates by resolution at the 
 end of a few days, and it is not followed by induration except when 
 it has been considerable, continued for a long time, or been badly 
 treated. We should, in the first place, as soon as this accident occurs, 
 disgorge the breast by artificial suction, or by the application of the 
 child, if the mother nurse ; if not, we should limit ourselves to diet or 
 a light regimen, to emollient applications, which should be accompa- 
 nied with the internal administration of saline purgatives, diuretics, 
 and diaphoretics. 
 
 Inflammation. 
 
 Inflammation of the breasts is a more advanced degree of the mal- 
 ady, and may determine serious consequences ; it invades the subcuta- 
 neous cellular tissue, the fascise, or even the tissue of the gland itself. 
 Like the preceding, it may occur at any period of lactation, but most 
 frequently manifests itself during the first month. It is occasioned by 
 the same causes as the engorgement, and more especially by cold, 
 fissures of the nipple, lively moral affections, &c, &c. If the subcu- 
 taneous inflammation be circumscribed, it differs in no respect from 
 ordinary phlegmon. In feeling the breast, it will be discovered to be 
 hard, tense, and painful in a certain point ; the surface of the skin is 
 smooth, red, and painful, and its thickness appears to be increased. 
 If the affection do not terminate in resolution, the most sensible point 
 soon softens, becomes of a livid red colour, and is the seat of an evi- 
 dent superficial fluctuation ; finally, the skin becomes so attenuated 
 that it bursts, and allows the pus to escape more or less externally. 
 
 If the inflammation should be more deep-seated, and invade the 
 aponeuroses, the pain is more obscure, and becomes acute only when 
 the subcutaneous cellular tissue or the gland itself is attacked, which 
 is ordinarily the case. The engorgement then increases considerably ; 
 the breast becomes hard and irregular to the touch ; the pain is very 
 acute, profound, and pulsative, with lancinating sensations. The 
 fever is the more violent as the inflammation occupies a greater ex- 
 tent of the gland, or its totality ; and it must be remembered that the 
 inflammation commences habitually at the superior and external por- 
 tion of the breast ; there is anorexia, thirst, cephalalgia, all the symp- 
 toms, in fine, of intense irritation. If the inflammation do not cease 
 or limit itself, the secretion of milk becomes gradually suppressed, and 
 we then observe, on the points which were first most indurated, the 
 commencement of a deep fluctuation, which may involve several por- 
 
DERANGEMENTS OF THE MILKY SECRETION. 481 
 
 tions, or even the entire organ ; then collections of pus are formed in 
 the milk-tubes, and in the areolae of the gland. If the collection of 
 pus be small, or if it be not near the surface, it will be very difficult 
 to distinguish the fluctuation. It sometimes happens that, when the 
 accoucheur does not possess great nicety of touch, he may suppose 
 there is a deep-seated fluctuation, when, in fact, he feels healthy and 
 soft portions of the gland, which, in most women, impart the sensa- 
 tion of effused fluid ; this is an error which, occasionally, experienced 
 practitioners have committed, and having made incisions into the part, 
 instead of pus, only blood escaped. We should, however, open an 
 abscess as soon as we believe it to be formed ; for, if left to itself, the 
 inflammation of the gland may give rise to a number of abscesses, 
 which open at different points of the surface of the breast, often causing 
 excessive pain ; or they unite beneath the aponeuroses, and destroy a 
 portion of the gland, involving the cellular tissue and the neighbour- 
 ing glands of the axilla. In all cases, it is difficult to prevent sup- 
 puration, no matter what means may be employed; and these means 
 consist in emollient applications, in general and local bloodletting, 
 &c, &c. Laxatives, diaphoretics, and warm baths should not be neg- 
 lected. As to the methodical compression of the entire gland, advi- 
 sed by M. Trousseau, who says he has derived the best effects from 
 it, I would not hazard to recommend it even at the commencement. 
 When, notwithstanding these means, the inflammation continues and 
 extends, and the pain becomes pulsative, anodyne cataplasms, unctions 
 with the tranquillizing balsam or with the tincture of safron, will be 
 useful. In fine, if the abscess become inevitable, as is usually the 
 case, and fluctuation begin to be felt, no matter how deep-seated it 
 may be, we should not hesitate to make an early and free incision ; it 
 is the best mode of putting an end to the inflammation, of destroying 
 the tension of the parts, and diminishing the pain. This plan will 
 likewise prevent the extension of the purulent collection, and thus pro- 
 tect a large portion of the gland. Inflammation of the breasts is a 
 serious complication for the mother, for it prevents her nursing the 
 child, either during the progress of the disease, if it have not involved 
 too large a portion of the gland, or, if the gland be destroyed or indu- 
 rated, which is not uncommon, the breast is entirely deprived of its 
 function. In a word, the inflammation is easily reproduced in certain 
 women, and requires the complete cessation of nursing. As has been 
 seen, the disease may terminate in resolution, suppuration, or indura- 
 tion. 
 
 The resolution of the inflammatory engorgement is often accompa- 
 nied with diarrhoea, abundant perspiration, and a remarkable increase 
 in the quantity of urine. 
 
 After the abscesses have been opened, they should be continued so 
 for some time by means of a dossil of lint, in order to favour the escape 
 of the pus ; and emollient cataplasms must still be applied with a view 
 of completely disgorging the breast, and they may gradually be follow- 
 ed by astringents. 
 
 Induration of the gland may occur as well when suppuration has not 
 formed as when it has taken place ; it is a serious termination, and 
 
 Ppp 
 
482 ACCIDENTS FOLLOWING DELIVERY. 
 
 every effort should be made to prevent it by employing absorbent and 
 alkaline lotions, either with mercurial ointment, or with the ointment 
 of the hydriodate of potash ; and when the engorgements are consid- 
 erable, the iodide should be taken internally. 
 
 § 3. Fissures or Excoriations of the Breast 
 
 In women who nurse for the first time, sometimes even in each suc- 
 cessive lactation, the efforts of suction occasion fissures of the nipple 
 more or less profound, which are always extremely painful, and which, 
 although they are ordinarily not dangerous, frequently render all efforts 
 at nursing unsuccessful. 
 
 Sometimes, however, when they are superficial, they heal sponta- 
 neously, the infant still continuing to nurse ; but, for this to take place, 
 the woman must be endowed with great energy, and with an anxious 
 desire to nurse her child, for the suffering caused by the suction on the 
 nipple, deprived of its epithelium, is almost intolerable. 
 
 This distress is often so great, when the excoriations are deep, that 
 even in using all the remedies proper to tranquillize the pain, it re- 
 quires almost superhuman courage to support it. Moreover, in these 
 cases, the patient is often obliged to cease nursing in order to avoid se- 
 rious accidents, such as loss of the nipple, inflammation of the breasts, 
 abscesses, &c., &c. 
 
 It has been recommended, as preventive treatment, to prepare, be- 
 fore delivery, the nipple by gentle and often-repeated suction, with a 
 view to harden the epithelium which covers the nipple. This plan 
 will also have the advantage of rendering the nipple more fit to fulfil 
 its functions, in consequence of the elongation it undergoes. 
 
 This is the only preventive means, as inefficacious as it may be, that 
 we can propose. 
 
 The curative treatment is also extremely uncertain. I have seen all 
 the remedies fail and succeed alternately ; such as the mucilage of 
 quince (five to six grains of quince to a spoonful of boiling water) ap- 
 plied to the breast immediately after nursing by means of a leaf of 
 ivy ; the butter of cocoa, cauterization with the nitrate of silver, &c. 
 Finally, the only means presenting a positive advantage is mediate 
 nursing, by means of the artificial breast (made of a cow's teat) of Ma- 
 dame Lebreton. This does not entirely preserve the nipple from the 
 irritation occasioned by the suction, but it tempers it ; and while the 
 child continues to suck, without having its mouth immediately in con- 
 tact with the breast, this latter gradually heals, and becomes restored. 
 
 As a means proper to facilitate this suction, and in order to cause 
 the child to take the breast with more relish, the small cup of the nip- 
 ple should be filled with warm sweetened milk. 
 
 The infant readily sucks the milk filling the little cup ; a vacuum is 
 soon effected, and the mother's milk soon replaces the other. I have 
 often succeeded with this little artifice. 
 
 But if the infant should be feeble, it would be impossible to have re- 
 course to this ; we would then be obliged to obtain a nurse, whose 
 child, being stronger, would suck the patient from the end of the arti- 
 ficial breast, while the nurse would provide nourishment for the infant ; 
 
LACERATIONS OF THE SOFT PARTS. 483 
 
 for it is very important, under these circumstances, not to allow the 
 breasts to become engorged, for this would be a complication which 
 .would certainly oblige the patient to renounce altogether the idea of 
 nursing her child. 
 
 It often occurs too, that, in this artificial lactation, the efforts the 
 child is obliged to make in suction causes inflammation of its mouth, 
 and then this method must be discontinued, although the child may not 
 refuse to take the breast. 
 
 These precautions are to be employed as long as the fissures are not 
 entirely cicatrized ; however, it would be w r ell, from time to time, to 
 try immediate lactation, in order to ascertain whether it may again be 
 renewed. 
 
 Such is the conduct I pursue in these cases. I have almost always 
 found the specifics so much lauded fail entirely. 
 
 Art. II. — Lacerations of the Soft Parts. 
 
 § 1. Elongation and Lacerations of the Neck. 
 
 In some women the uterine orifice and neck itself, pushed down jy 
 the infant during labour, become so elongated that the presenting part 
 of the foetus draws them before it so as to form a species of sheath ; 
 most generally it is the anterior lip of the orifice which is elongated, 
 and presents, behind the pubes and near the vulva, a resisting tumour, 
 which must not be confounded with some portion of the foetus. 
 
 The neck, thus stretched and violently compressed, sometimes occa- 
 sions an acute pain, and is often lacerated in some point of its extent. 
 This point, according to M. Stoltz, corresponds most commonly to the 
 passage of the occiput when the foetus presents the vertex, of the fore- 
 head or abdomen when the face presents, and of the occiput and fore- 
 head when the pelvis presents. These lacerations are often multiple, 
 and may extend beyond the borders of the orifice, and involve the 
 neck itself; and they may divide these parts into several irregular 
 flaps, which, soon after delivery, retract, and become converted into 
 small tubercles, which result in nothing serious, and do not require any 
 treatment. 
 
 We must content ourselves, during labour, with preventing the elon- 
 gation of the neck by pushing it, if possible, behind the presenting 
 part ; but this manipulation should be performed with great care, and 
 without injuring the orifice with the hand. 
 
 § 2. Laceration of the Vagina. 
 The walls of the vagina also are exposed, during delivery, to nu- 
 merous lesions, more serious, and much less easily remedied than the 
 preceding ; they may be produced by the too violent and prolonged 
 pressure of the head in the pelvic cavity, by the excessive distension 
 it causes at the inferior portion of the recto-vaginal septum, by the en- 
 ergetic contraction of the longitudinal fibres of the uterus, which draw 
 upward the walls of the vagina, and by the violent efforts of the wom- 
 an to aid these contractions ; and, finally, by the injudicious interfe- 
 rence of the accoucheur. These lacerations will be the more common 
 
484 ACCIDENTS FOLLOWING DELIVERY. 
 
 as the narrowness and deformities of the pelvis, the bony prominences 
 and tumours of the excavation and size of the infant, are more consid- 
 erable, or as the position it occupies distends more completely the 
 vulva-uterine canal ; the bridles and contractions of the vagina or vul- 
 va, and too great rigidity of the parts, are also causes of these lesions. 
 It is worthy of remark, that most commonly they have their seat in 
 the upper portion of the vagina when they proceed from unskilful ma- 
 nipulations, and particularly from the application of instruments ; while 
 the lacerations of the inferior portion of this canal originate from the 
 violent passage and dragging of the head of the foetus. 
 
 Vesico-vaginal Perforations. 
 Fistulas, which result from the communication of the bladder with 
 the vagina, are easily recognised by the passage of the urine into the 
 vagina, by the touch, by the use of the speculum, or by introducing 
 into the bladder a sound, which will pass through the perforation. 
 These fistulas are not uncommon, and are difficult to treat. It is for- 
 tunate, however, that a large number of them heal spontaneously. It 
 should be, nevertheless, observed, that it is much more difficult to ef- 
 fect the cicatrization of the vesico-vaginal fistulas, or of the bas-fond 
 of the bladder, than of those between the urethra and vagina. Be it 
 as it may, it is true the surgical means employed have been undoubt- 
 edly successful ; such as sutures, with needles differently shaped, cau- 
 terization with the actual or potential cautery, approximation of the 
 borders of the wound by the method of Dessault, and the various modes 
 of union suggested by different authors. 
 
 Recto-vaginal Perforations. 
 Besides the causes we have already enumerated as being capable of 
 producing them, there is one on which M. Danyau has insisted, and 
 which should be known to the profession When the head is of large 
 size and has descended on the floor of the perineum, and the exter- 
 nal parts of generation offer resistance, if the accoucheur, with the 
 view of supporting the perineum and preventing its rupture, exert 
 with the hand too violent pressure on this part, the inferior portion of 
 the recto-vaginal septum, excessively distended, ruptures without being 
 perceived ; it is, therefore, important merely to support the perineum, 
 without forcibly pushing it back. The recto-vaginal fistulas are, in 
 general, extremely difficult to cure; occasionally, spontaneous cica- 
 trization takes place, but we should not depend on such exceptions. 
 The means used to remedy these fistulas are, sutures, with paring the 
 edges, as in the method of Diffenbach for laceration of the perineum, 
 compression of the rectum, &c, &c. 
 
 § 3. Lacerations of the Perineum. 
 We embrace under lacerations of the perineum, lesions which in- 
 volve either the commissure of the vulva or the substance of the peri- 
 neum itself, or, finally, those two parts together, and the sphincter of 
 the anus. It is much more rational, with MM. Velpeau and Moreau, 
 to term lacerations, or slits of the vulva, those which involve the labia 
 
- LACERATIONS OF THE SOFT PARTS. 485 
 
 majora or fourchette only ; and lacerations or rupture of the perineum 
 those which affect a part of this region ; involving also the fourchette, 
 and sometimes the sphincter ani ; finally, central perforation of the pe- 
 rineum — a rupture of this region exclusively, the commissure of the 
 perineum and the sphincter remaining intact, a perforation through 
 which the foetus may be expelled. 
 
 Lacerations of the Vulva. 
 Lesions of this nature, which merely comprise the fourchette, and 
 which extend only three or four lines on the perineum, or which even 
 affect the labia majora and minora, and which are transverse or lon- 
 gitudinal, do not, in general, demand any special attention. Ablution 
 with marshmallows and tents of lint interposed between the labia will 
 alone suffice. 
 
 Lacerations or Rupture of the Perineum. 
 
 But those lacerations which involve a considerable portion of the 
 perineal region are much more important, and call for particular treat- 
 ment. The laceration takes place either on the median line and more 
 frequently on the side, and embraces only the sphincter of the vulva, 
 and more or less of the perineum, or, besides these parts, it involves 
 the sphincter of the anus itself in totality or in part ; an accident or- 
 dinarily without danger, but which always compromises the moral 
 existence of the unhappy woman. 
 
 These accidents are caused by narrowness, rigidity, or oedema of 
 the external parts of generation, which oppose too much resistance to 
 the passage of the child ; by the presentation of certain parts of the 
 foetus, which are either too large or in unfavourable positions, such, 
 particularly, as the occipito-sacral or posterior, those of the face, 
 Breech, the presentation of the shoulders, badly-conducted manipula- 
 tions ; finally, by the too precipitate expulsion of the infant, and neg- 
 lect in supporting the perineum. We should, especially, as M. Vel- 
 peau observes, be on our guard against the passage of the posterior 
 shoulder in the positions of the head, when the expulsion is rapid. 
 Lacerations of the perineum which are not extensive, those even which, 
 though complete, still leave the anus and sphincter intact, are not se- 
 rious ; such, however, is not the case with those which include the 
 sphincter of the anus and the inferior extremity of the rectum ; they 
 are followed by a loathsome infirmity, inability to retain the faecal 
 matter, thus converting the vagina into a veritable sink. Besides, 
 this may occasion prolapsus uteri, because the inferior floor of the va 
 gina failing, the organ is not naturally sustained, and, moreover, it 
 becomes impossible to maintain it in position by means of pessaries. 
 These lacerations are also troublesome, because, offering no resistance 
 to the foetus at the moment of delivery, they permit a too rapid expul- 
 sion, which may be followed, as I have already stated, by inertia of 
 the womb and hemorrhage, inversion of this organ, &c, &c. 
 
 Examples of the spontaneous cure of simple lacerations of the pe- 
 rineum are very rare, and, in this case, position alone will suffice. 
 The patient should be placed on one of her sides, and the thighs kept 
 
486 ACCIDENTS AFTER DELIVERY. 
 
 constantly approximated, or even they may be tied together, in order 
 to avoid any movement which might tend to separate the two lips of 
 the wound. But this is not always successful ; the discharge of the 
 lochias, the presence of which constantly irritates the wound, prevents 
 its adhesion ; unfortunately, it is impossible to obviate this inconveni- 
 ence, and we are constrained to delay until the female has recovered 
 from her confinement before undertaking a more certain operation. 
 And then, in order to direct the cicatrization, and prevent any loss of 
 substance, which might compromise some portions of the perineum, 
 we should, when the reunion has not taken place spontaneously du- 
 ring the three or four first days, abandon all hope of this occurring, 
 and place between the lips of the wound pledgets of lint saturated 
 with a decoction of marshmallows. In all cases, also, we should in- 
 troduce the catheter, to prevent the escape of urine into the womb. 
 
 As soon as the puerperal period has passed, we may resort to the 
 suture, which, from its success, has numerous advocates, but which is 
 not always infallible. The two kinds of suture most preferred are the 
 interrupted and twisted, which should not, however, be used until the 
 edges of the wound have been previously incised. When the lacera- 
 tions are very extensive, they must be treated by the method of Diffen- 
 bach, which consists in putting in several points of suture in order to 
 unite the borders of the wound, and afterward in making on the integ- 
 uments two incisions nearly parallel in the direction of the two borders 
 of the wound ; these are intended to prevent the giving way of the 
 points of the suture and the laceration of the parts embraced by them. 
 
 But the method of M. Roux is undoubtedly the most advantageous. 
 This skilful surgeon, by this means, has succeeded in restoring the peri- 
 neum in many remarkable instances. They are all recorded in a 
 memoir read before the Academy of Sciences. 
 
 With a view to present more accurately the details of the mode of 
 union adopted by this dexterous operator, I shall cite, in his own words, 
 the description of one of the operations in which he completely suc- 
 ceeded by means of the twisted suture. 
 
 " The paring of the parts having been regularly performed, so that 
 the two edges were similar to each other, I employed four ligatures, 
 introducing the needles, on the one side, from without inward, and, 
 on the other, from within outward; and I took care to encroach a lit- 
 tle on the walls of the vagina, but sufficient only to make on these 
 walls a slight traction, and place in contact the two wounds in all 
 portions of their extent. The ligatures being placed, I then used for 
 cylinders two pieces of gum-elastic bougie ; one of the pieces was pla- 
 ced in the folds which the twisted ligatures formed on one side, and 
 the other piece on the opposite side, between the separated portions of 
 all these ligatures. I finish by forming, with the two ends of each lig- 
 ature, on the second cylinder, at first a simple knot, but drawn very 
 tight, and afterward a double knot. I bring the lips of the wound 
 together somewhat firmly. 
 
 " I should mention that the twisted suture, from the manner in which 
 it acts, projects slightly beyond the borders of the wound, and that, in 
 consequence, the external coaptation is never so perfect as could be 
 
LACERATIONS OF THE SOFT FARTS. 487 
 
 desired. I have, therefore, thought of obviating this result, and place 
 the skin in contact with itself. I attain this object by means of small 
 ligatures, which I place in the different points of suture with the prin- 
 cipal ligatures, and which serve as so many points of simple suture ; 
 but I am careful not to draw them too firmly. Thus, I had so com- 
 pletely anticipated every difficulty, and made every appropriate cal- 
 culation, and the operation was so perfectly successful, that few things 
 in surgery have afforded me so much satisfaction as the result of this 
 method. The suture being completed, and the neighbouring parts 
 not appearing tense, I dispensed with the lateral incisions recommend- 
 ed by Diffenbach. 
 
 " At the commencement of the seventh day, I withdrew the liga- 
 tures, the parts being sufficiently united, and in a short time the con- 
 solidation of the perineum was complete. 
 
 " The perineum, thus restored, differed in no respect from this part 
 in its natural state ; it was two inches in length, and a raphe divided 
 it into two equal halves. In examining it, either through the vagina 
 or anus, it felt thick and solid ; and it was perfectly restored. 
 
 " This lady has since borne a child naturally, and the perineum 
 was not injured." 
 
 It is useless to add, that the patient should be subjected to a treat- 
 ment proper to combat all the inflammatory symptoms ; that she should 
 have the catheter introduced, and the bowels kept open by gentle 
 laxatives. 
 
 Destruction of the Perineum. 
 It sometimes happens that, in consequence of the severe and long- 
 continued pressure of the head of the fœtus on the perineum, this part 
 becomes mortified in almost its whole extent, and when the slough 
 falls off, there is a considerable loss of substance. This melancholy 
 result may also depend on the want of cleanliness, when the perineum 
 has been simply and regularly ruptured. A female, whose perineum 
 had been lacerated by the forceps, came to La Clinique in the most 
 deplorable condition, in order to be put under treatment ; but the loss 
 of substance was so great, and the rupture so extensive, that the anus 
 and vagina made one common cavity, and it was impossible to distin- 
 guish the different parts composing the genital organs ; M. P. Dubois 
 could do nothing for this unfortunate woman. It would be possible, 
 however, in certain cases in which this infirmity is less marked, to 
 remedy it by autoplasty. 
 
 Perforation of the Perineum. 
 I remarked that I would reserve this name, with M. Moreau, for 
 those rare cases in which, the vulva offering an obstacle to the passage 
 of the child, this latter is expelled through a perforation of the peri- 
 neum, the edges of the vulva and anus remaining most frequently in- 
 tact. The passage of the child through a part so thick as the peri- 
 neum is contested at the present day by M. Capuron, who absolutely 
 denies that it can take place. Instances, however, of the occurrence 
 of this accident are so numerous, and so well authenticated, that we 
 
488 ACCIDENTS AFTER DELIVERY. 
 
 cannot doubt them. If we observe attentively the last expulsive con- 
 tractions of the uterus in certain women, we shall notice that the head 
 of the infant distends and enlarges considerably the perineum before 
 passing between the lips of the vulva, and we may understand how, 
 under the influence of certain causes, the head may be capable of per- 
 forating the perineum. These causes are, too great prominence of 
 the sacro-vertebral angle, excessive inclination of the abdominal strait, 
 a diminished curvature of the sacrum, insufficient solidity of the sacro- 
 coccygeal articulation, increased capacity of the inferior strait, partic- 
 ularly at its posterior part, contraction of the pubic arcade, and ex- 
 cessive length of the symphysis pubis, rigidity of the vulva, length of 
 the perineum, absolute rectitude of the entire pelvis, violence of the 
 parturient effort, precipitate descent of the head, occipito-posterior 
 positions, and, finally, anything that may contribute to prevent the 
 parts, after having descended in the axis of the superior strait, to 
 change their direction when they rest on the floor of the pelvis. 
 
 It may be remarked here, that when the foetus passes through the 
 perineum, the laceration ordinarily takes place obliquely on the sides 
 of this region. 
 
 The treatment of this accident, which of itself is not very serious, 
 consists in keeping the patient on her side, the thighs brought togeth- 
 er by means of a bandage, in covering the wound with lint saturated 
 with a decoction of marshmallows, and in the introduction of the cath- 
 eter; and, finally, constipation must be guarded against. M. Mo- 
 reau, who reports a number of spontaneous cures, thinks that it re- 
 quires from thirty to forty days for the complete reunion of the parts. 
 This treatment will suffice to perfect the cicatrization of the wound ; 
 if the anterior band or bridle of the perforation be very thin, or unites 
 posteriorly, the wound will often be converted into a simple vulvo- 
 perineal laceration, and the cure will be less easy. 
 
 § 4. Injury of the Coccyx. 
 It occasionally occurs that, in women who are delivered for the 
 first time at an advanced age, the coccyx, whose articulation with the 
 sacrum becomes anchylosed, is fractured or dislocated. The conse- 
 quences may be severe pain, inflammation followed by suppuration, 
 caries, or necrosis. This accident is recognised by the displacement, 
 and the unusual mobility of the bone, by the suffering occasioned du- 
 ring the efforts of defecation, or during the slightest pressure. It is 
 to be treated by emollients, narcotics, leeches, incisions when abscess 
 exists, &c, &c. 
 
 § 5. Displacements of the Uterus. 
 Inversion. — I have already spoken of this accident. 
 
 Descent of the Uterus. 
 Descent of this organ, which I do not intend now to describe in de- 
 tail, is not unfrequent after delivery, especially during the first days, in 
 women w T hose tissues are relaxed, and with a large pelvis, and who 
 have had a protracted labour and difficult delivery of the after-birth ; 
 
LACERATIONS OF THE SOFT PARTS. 489 
 
 and in whom the perineum or recto-vaginal septum has been lacera- 
 ted, and who, during labour or after confinement, have made exces- 
 sive or premature efforts. 
 
 The touch will easily enable us to recognise this displacement of 
 the uterus ; the finger, in fine, encounters the neck a short distance 
 from the vulva, or immediately between the lips of the vulva ; and the 
 woman experiences a weight on the fundament, and dragging sensa- 
 tions in the groins and lower portion of the abdomen. These symp- 
 toms, which are also accompanied with constipation, and pain in go- 
 ing to stool, are more or less intense, depending on whether the descent 
 is incomplete, or whether there is procidentia of the organ. The 
 means to be employed, in order to combat this condition, are the same 
 in the two cases : thus, the female should be placed in the recumbent 
 position, with the hips raised above the level of the chest ; the accou- 
 cheur should endeavour to raise up the uterus with the fingers introdu- 
 ced into the vagina ; all effort should be interdicted, absolute repose 
 enjoined; the bowels should be kept open with injections, in order to 
 avoid the effort of defecation, and the patient should keep her bed for 
 four or five weeks. Ordinarily, these means will suffice ; but if, notwith- 
 standing their employment, the displacement be renewed, the uterus 
 must be sustained by mechanical means, a sponge or pessary, with 
 which may be united astringent injections, and a tonic regimen when 
 the lochias have disappeared. 
 
 Ante-version and retro-version, ante-flexion and retro-flexion, may 
 also occur after delivery ; the uterus, heavy and badly supported by 
 the liagments, becomes reversed horizontally, either forward [ante- 
 version) or backward [retro-version), or its walls, becoming more soft 
 in consequence of the distension they have undergone and their de- 
 fective contractility, permit the organ to become flexed, either anteri- 
 orly (ante-flexion) or posteriorly (retro-flexion), the fundus resting on 
 the pubes or sacrum, while the neck changes but slightly its direction, 
 or continues vertical. 
 
 We may include among the causes of these deviations, first, the lax- 
 ity of the suspensory ligaments, the size of the uterus, the capacity of 
 the superior strait, and all excessive effort ; the adhesions contracted 
 by the uterus with the adjoining parts, as the result of inflammation, 
 and the abridged length of the round ligaments, seem also to predis- 
 pose to ante- version. 
 
 The symptoms which indicate that these deviations have taken place 
 are, dragging sensations, pains in the loins or groins, particular sensi- 
 bility of the hypogastrium, sometimes symptoms of phlogosis of the 
 peritoneum and uterus, fever, constipation, and retention of urine ; then, 
 in ante-version, the vaginal touch shows that the neck is situated very 
 high in the excavation of the sacrum, while in retro-version it is placed 
 behind the pubes ; the body of the uterus lies almost horizontally, ei- 
 ther in front or posteriorly. In retro-flexion and ante-flexion, besides 
 the deviation of the neck anteriorly or posteriorly, the finger perceives 
 the fundus of the womb in the posterior or anterior cul-de-sac of the 
 vagina, but with more difficulty than in the preceding case. 
 
 In most instances, these deviations do not present any immediate 
 
 Qqq 
 
490 ACCIDENTS AFTER DELIVERY. 
 
 danger; sometimes, however, they give rise to severe inflammatory ac- 
 tion. The inconveniences which may result from displacement of the 
 uterus are, retention of urine, constipation, and sterility. Retro-flexion 
 of the uterus, especially, which is not very uncommon, exposes this or- 
 gan to chronic inflammation and adhesions, which, in subsequent preg- 
 nancies, render miscarriage almost inevitable. The treatment, as in 
 prolapsus, consists in placing the patient in the horizontal position, in 
 restoring the organ as much as possible to its normal situation, either 
 with the fingers which press on the neck or body, or with a small probe 
 covered with lint, as proposed by M. Evrat. When the reduction is 
 accomplished, we should place a tampon or piece of sponge between 
 the vagina and neck, on the side opposite to the deviation, or a pessary 
 of a proper form to maintain the organ in place. These means may 
 be aided by injections, astringent and cold washes, &c, &c. ; finally, 
 for weak and chlorotic women, we may prescribe the cold ferruginous 
 waters internally. 
 
 § 6. Effects of Delivery on the Intestines, Bladder, and Genital Organs. 
 
 The sudden changes which the depletion of the uterus occasions in 
 the relations of these viscera, those which take place in the circulation 
 of the pelvic organs by the contraction of the uterine vessels, and, 
 finally, the violent efforts, the prolonged pressure exerted during la- 
 bour, determine, occasionally, accidents worthy of attention. Thus, 
 the small intestines having been for a long time pushed up and com- 
 pressed by the impregnated uterus, finding themselves suddenly re- 
 lieved from this pressure, fall into a kind of inertia, in which the rec- 
 tum, also a long time compressed, participates. Women, therefore, 
 recently delivered, are most generally subject to constipation ; others, 
 on the contrary, are troubled with diarrhoea, which proceeds from an 
 irritation of the large intestine ; and this irritation, which sometimes 
 extends along the whole digestive tube, is to be attributed to nearly 
 the same causes. Finally, hemorrhoids, observed under the same cir- 
 cumstances, are produced by difficulty in the circulation, by the reiter- 
 ated efforts to expel the fœtus, and by the violent pressure exerted on 
 the inferior portion of the rectum. Emollient or slightly laxative in- 
 jections should at first be employed, in order to remove the constipa- 
 tion ; and if this do not prove effectual, we should administer castor 
 oil, glauber salts, or ipecacuanha, but not until five or six days after 
 delivery. The diarrhoea, the irritation of the intestines, and the hem- 
 orrhoids, should be treated, if they continue beyond the first week, 
 by emollients, either internally or externally, and even by local blood- 
 letting, depending on their degree of intensity. 
 
 It may, however, be remarked, that nature alone often overcomes 
 these difficulties, as she does those of which we shall speak. 
 
 The bladder, by the pressure of the uterus, is almost incessantly so- 
 licited to void itself; but, during labour, it is more or less violently 
 compressed by the foetus, which sometimes induces a temporary iner- 
 tia, or a veritable paralysis, which continues for a much longer time. 
 The retention of urine resulting from this condition of things, merits all 
 the attention of the practitioner, who should always be careful to as- 
 
LACERATIONS OF THE SOFT PARTS. 491 
 
 certain whether the patient has urinated. If, on the first day, she has 
 not passed her water, he should introduce à catheter into the bladder 
 for the purpose of emptying it, for its distension may occasion serious 
 accidents. The antiphlogistic regimen will also favour the restoration 
 of the contractility of the bladder. This inconvenience does not con- 
 tinue but a few hours, or, at most, a few days ; the longest period I 
 have known it to continue is fifteen days. 
 
 I would remind the reader how important it is to ascertain the ac 
 tual condition of the bladder, in order not to mistake symptoms of re- 
 tention for the commencement of a metro-peritonitis ; an error which 
 I have often seen committed. 
 
 Incontinence of urine is of short duration, and requires particularly 
 the employment of laxatives, and blisters to the hypogastrium. 
 
 Delivery may also have an unfavourable influence on the genital 
 organs. In addition to the various displacements and lacerations of 
 which we have spoken, it occasionally happens that the vagina, neck 
 of the uterus, fallopian tubes, ovaries, and even the cellular tissue 
 which surrounds these organs, are affected for some time with a de- 
 gree of irritation, and even become inflamed. Hence, there is at first 
 a sensation of heat, tension, pain on pressure, an habitual febrile par- 
 oxysm, loss of appetite, cephalalgia, nausea, suppression, diminution, 
 or change in the colour and odour of the lochias — symptoms not very 
 apparent at first, but which require great vigilance, and may become 
 very serious ; for they are frequently followed by unnatural adhesions, 
 indurations of the uterus or of its neck, metritis even, and those puru- 
 lent collections which, in our hospitals, so often occur in the iliac fossae 
 and pelvis. 
 
 The antiphlogistic treatment in these different cases should be rigid- 
 ly enforced. In fine, if, after emollient injections into the vagina, 
 baths, cooling drinks and diet, the symptoms still continue, we should 
 not hesitate to apply leeches in sufficient quantity, either to the vulva 
 or groins, and even abstract blood from the arm when the pulse and 
 general plethora of the system indicate it. Should abscesses form in 
 the vagina, iliac fossae, or in any other point, they should be opened 
 as soon as the fluctuation becomes evident, in order that they may 
 not extend and produce destructive ravages. But most commonly it 
 is not possible to afford escape to the pus, and then it is absorbed, or 
 finds a natural passage through the vagina or rectum. 
 
 Tympanitis. — One of the common effects of delivery is meteorism 
 of the abdomen ; this symptom is important, especially in refer- 
 ence to the diagnosis. It is caused either by cold, or by the relaxa- 
 tion of the fibres of the intestine and its inertia, or by deranged di- 
 gestion, and sometimes by slight irritation. It is necessary, therefore, 
 to look attentively at all the functions, with a view to ascertain that 
 the tympanitis is not connected with some more serious trouble either 
 of the intestines or peritoneum, and thus have recourse immediately 
 to the proper treatment. We might, in a word, confound this state 
 with peritonitis, metro-peritonitis, or gastro-enteritis, and employ local 
 bloodletting and emollient applications, which would only tend to in- 
 crease the meteorism ; while it could be readily removed by gentle 
 
492 ACCIDENTS AFTER DELIVERY. 
 
 laxatives, carminatives, embrocations with the oil of camphorated 
 chamomile, together with 'compression on the abdomen by means of 
 a moderately tight bandage. 
 
 Œdema of the Vulva. — We have already explained the causes of 
 this œdema, and how it should be treated during pregnancy and la- 
 bour ; delivery does not always dissipate it, and it may increase to 
 such an extent, and so completely close the labia majora, as to pre- 
 vent the escape of the lochial discharge. This condition arises either 
 from a simple serous infiltration without pain, or from an irritation, 
 accompanied with great sensibility of the parts which have been con- 
 tused during the passage of the infant. In the first case, slight scar- 
 ification will suffice to diminish the tension; in the second, it will be 
 necessary to apply leeches, and, if the inflammation be considerable, 
 we should recommend the use of emollient cataplasms and warm baths. 
 
 Thrombus of the Vulva. — If, during pregnancy, thrombus of the 
 vulva can occur, and be produced by the stagnation of fluids, and the 
 varicose condition of the veins of the vagina, we can readily compre- 
 hend how this disease may result from the contusion experienced by 
 the labia majora during the natural passage or artificial extraction of 
 the foetus. In a word, there forms in one or other labium, occa- 
 sionally in both, a sanguineous effusion, which is sometimes quite lim- 
 ited, and at other times involves a portion of the breech, and occasions 
 a large tumour, which is often accompanied with severe pain, espe- 
 cially if there be inflammation; it is known by the tumefaction and 
 fluctuation perceived in it. The prognosis of these tumours, in gen- 
 eral, is not alarming ; for they sometimes are removed spontaneously, 
 and their cure is not difficult, even if they should be converted into an 
 abscess. But, in some rare cases, the blood, infiltrated around the 
 rectum, bladder, &c, &c, has formed vast purulent collections, under 
 which the patients have succumbed. 
 
 In the treatment of thrombus, I have only to recall what I said in 
 speaking of the accidents of labour : 1st. The application of discutients ; 
 but they are without effect when the tumour fluctuates, is somewhat 
 large, and distinctly circumscribed ; it is only when it is very small 
 and resisting that they can be had recourse to. 2d. The evacua- 
 tion of the fluid contained in the tumour, by means of caustics, punc- 
 ture, or incision. The two former being either injurious or ineffectual, 
 we should employ incision. It should be made freely on the most 
 prominent and softest point as soon as there is manifest fluctuation in 
 the tumour, in order to prevent the effused fluid from extending too 
 far, and involving other parts. If the thrombus be recent, it would 
 be proper to delay twenty-four hours before opening it, that the lacera- 
 ted vessels in the tumour may have time to contract, and thus pre- 
 vent hemorrhage. It should be recollected that the opening of a 
 thrombus, which has become converted into an abscess in the vicinity 
 of the anus, will give rise to an escape of coagulated blood or a mix- 
 ture of pus, having the odour of fsecal matter, and which may be 
 attributed to a lesion of the intestine. After the incision, the wound 
 gradually cleanses, and cicatrizes without difficulty, if care be taken 
 
LACERATIONS OF THE SOFT PARTS. 493 
 
 to employ simple dressings with lint and compresses, and likewise 
 frequent ablutions of the part. 
 
 § 7. Bronchocele. 
 Tumefaction of the thyroid gland occurs more frequently after par- 
 turition than under other circumstances ; it appears two or three days 
 after delivery, and then it is attributed to cold, or even during the 
 efforts of labour; and, in the midst of her cries, the woman experien- 
 ces a sensation of rupture in the throat. This swelling may continue 
 small, indolent, and stationary, or it may increase gradually in size so 
 as materially to interfere with deglutition and respiration, and exert a 
 dangerous pressure on the surrounding organs. The gland sometimes 
 becomes inflamed, and is the seat of a large abscess, which bursts ex- 
 ternally. The treatment is the same as for goitre, and consists, first, 
 in emollient applications and leeches if there be inflammation ; then, 
 when this subsides, cold water and discutients should be employed. 
 If the tumour be hard and indolent, we should administer iodine in- 
 ternally in potion, or externally in the form of ointment, and frictions 
 on the part affected. The abscesses which may have a tendency to 
 form are to be treated on general principles. 
 
 § 8. Rheumatism of the Uterus. 
 
 If, during pregnancy and labour, the womb should be affected with 
 what is termed uterine rheumatism, this organ does not enjoy its usual 
 power of contraction ; it remains developed above the pubes, and the 
 female is exposed to hemorrhage. 
 
 The after-pains are then very severe and frequent, and the sensibil- 
 ity of the uterus, together with the general phenomena of reaction, 
 may induce us to suppose that peritoneal inflammation exists. 
 
 Often, indeed, a slight metro-peritoneal inflammation accompanies 
 this affection, and requires the application of leeches, cataplasms, laud- 
 anum, embrocations on the abdomen, and laudanum injections. 
 
 § 9. Puerperal Metro-peritonitis. 
 
 I have not made a separate article for puerperal metritis, because this 
 affection is so commonly accompanied with peritonitis that we can 
 scarcely separate it from this latter. 
 
 Puerperal metro-peritonitis may assume two very marked forms : 
 
 1st. Truly inflammatory form : in this case, in which the peritonitis 
 is the principal affection, or in consequence of the constitution of the 
 patient, the metritis presents the true character of the phlegmasiae of 
 parenchymatous organs. 
 
 2d. Typhoid form : metro-peritonitis never presents itself under this 
 form at the commencement; it corresponds with an anatomical lesion, 
 which, perhaps, itself is but a consequence of uterine phlebitis, and 
 which is characterized by putrescent softening of the organ. 
 
 I should mention here another form, much less alarming, but at the 
 same time very insidious, of metro-peritonitis ; I allude to that in 
 which, after the remarkable diminution, and sometimes even the ces- 
 sation of inflammatory symptoms, a most intense uterine neuralgia de- 
 velops itself. 
 
494 ACCIDENTS AFTER DELIVERY. 
 
 3d. The form to which has been applied the term puerperal fever. 
 Here the inflammation of the peritoneum and uterus is only one of the 
 pathological circumstances of the disease, and not the entire malady 
 itself. 
 
 Inflammatory Metro-peritonitis. 
 
 A. Causes. — Inflammation of the peritoneum and uterus may be oc- 
 casioned by the pains of childbirth, protracted labour, manipulations 
 necessary for the extraction of the foetus or placenta, cold, imprudence 
 in eating during the puerperal period, lively moral impressions, &c. 
 The suppression of the lochias must be regarded rather as an effect 
 than a cause of the disease. So, also, with the suppression of the 
 milky secretion. 
 
 B. Diagnosis. — I remarked, in speaking of the attention to the pu- 
 erperal patient, that the accoucheur should make particular inquiry as 
 to the functions of the bladder ; he should not content himself with ex- 
 amining the urine and ascertaining the quantity, but he should place 
 his hand on the hypogastrium, and assure himself that the bladder is 
 not distended ; for it may happen that, notwithstanding some urine 
 may escape from the great quantity collected, yet the bladder may still 
 be distended. If, in this case, we trust to the nurse, we may commit 
 serious error. 
 
 The attention of the accoucheur should next be directed to the 
 pulse; if he finds it natural, it is more than probable that the patient 
 is in a satisfactory condition, although she may complain of sharp pains 
 in the abdomen. When there is no frequency of the pulse, these pains 
 experienced by the patient are usually nothing more than the after- 
 pains occasioned by the return of the uterus to its primitive form. 
 Moreover, the regular return, the type of these pains, which simulates 
 those of labour, during which the uterus becomes hard, and which 
 commence in the loins and terminate in the lower portion of the ab- 
 domen, will serve also to distinguish them from those which character- 
 ize the commencement of a metro-peritonitis. Finally, all doubt will 
 be removed by an abdominal examination. Thus, we may press firm- 
 ly on the iliac fossae without occasioning any acute sensibility, if the 
 pains be determined by the physiological contraction of the uterus ; in 
 the contrary case, the slightest pressure on the iliac fossae causes acute 
 suffering. 
 
 We should, however, be on our guard against a very common cause 
 of error in diagnosis. If the patient have not urinated, or if she have 
 done so only partially, the pain which results from this repletion of 
 the bladder may induce us to believe that metro-peritonitis exists : in 
 fine, this pain extends to the groins, it is increased by pressure, and 
 has not the regularity of the after-pains ; it is accompanied with fre- 
 quency of pulse, extreme anxiety, cephalalgia, chills, enlargement of 
 the abdomen, and may simulate the meteorism of metro-peritoneal 
 inflammations. All error may be avoided by paying particular atten- 
 tion to the state of the bladder. 
 
 The invasion of metro-peritonitis, therefore, may be known by the 
 following symptoms : 
 
LACERATIONS OF THE SOFT PARTS. 495 
 
 Full, hard, frequent pulse, heat of skin, sensibility on pressure, es- 
 pecially in the iliac fossae ; this sensibility frequently extends to the 
 thighs ; more or less meteorism of the abdomen. The commencement 
 of the disease is often accompanied by a chill more or less prolonged, 
 followed by headache. During the milk fever, the milky secretion is 
 incompletely established, and there is no tumefaction of the breasts ; 
 frequently, too, from the very commencement, the lochial discharge 
 becomes suppressed, which has induced some to regard this symptom, 
 which ordinarily precedes all the others, as one of the causes of the 
 disease. 
 
 C. Progress. — This affection rarely resists an energetic antiphlogis- 
 tic treatment, especially when the strength of the patient permits a free 
 use of it, and the return to health is sufficiently rapid ; the physiolo- 
 gical functions, which had ceased, resume their activity. Thus, the 
 iochise reappear, the breasts swell, the fever subsides ; in a word, all 
 the other symptoms disappear. But, if the disease should have been 
 mistaken at its commencement, if the treatment have been inefficient, 
 either because it was had recourse to at too late a period, or because 
 the malady was beyond the resources of art, it may be modified in its 
 progress, but the result will be fatal. Sometimes to the inflammatory 
 period will succeed a period of collapse or adynamia, which will coin- 
 cide with the formation of a sero-purulent effusion in the peritoneum, 
 and occasion death in a few days ; sometimes the disease advances 
 with frightful rapidity ; although the effusion takes place, the period of 
 collapse fails, and the patient will sink in a few hours in the midst of 
 furious delirium, excruciating suffering, enormous distension of the ab- 
 domen, and, finally, constant suffocation, accompanied with vomiting, 
 hiccough, &c. At other times the pains completely cease, the distend- 
 ed abdomen is insensible, or, at all events, pressure occasions only an 
 obtuse and deep-seated uneasiness. 
 
 But, in all cases, the agony is often prolonged without symptoms of 
 ataxia ; consciousness remains perfect, the pulse gradually fails, gen- 
 eral coldness, commencing at the extremities, pervades the patient, and 
 she expires. This termination is happily rare in the inflammatory 
 form, when it is properly treated. Such, however, is not the case in 
 the typhoid form, and in puerperal fever. 
 
 D. Treatment. — At the commencement of the malady we should 
 insist on bloodletting, proportioned to the intensity of the disease, to 
 the strength and temperament of the patient. When the pulse is full, 
 if there be well-marked symptoms of inflammatory fever, twenty to 
 twenty-five ounces of blood should be abstracted from the arm, thirty 
 to forty leeches applied to the iliac fossae, succeeded by a warm cata- 
 plasm of flaxseed, while another is placed over the vulva ; these cata- 
 plasms must- be changed every three or four hours, and during this 
 change the abdomen should never be left naked or exposed, for the 
 fresh cataplasm should be applied the instant the other is removed. In 
 this way, the action of the air on the abdomen is prevented, and the 
 abdomen itself is kept warm and moist. 
 
 The cataplasms should also be sprinkled with laudanum, especially 
 if to the inflammatory symptoms sharp and frequent pains be added. 
 
496 ACCIDENTS AFTER DELIVERY. 
 
 Finally, the patient should take a cathartic of castor oil, or of calo- 
 mel, in order that a purgative effect may be produced ; for it is ex- 
 tremely important in this case, as also in the whole course of the dis- 
 ease, to avoid constipation. The most absolute repose should be en- 
 joined, and separation from all excitement ; every half hour a drink 
 should be administered of some warm and sweetened infusion. It is 
 rare for an affection really inflammatory to resist this treatment. Most 
 generally, these means will suffice to break the violence of the symp- 
 toms ; and repose, the use of warm drinks, emollient cataplasms and 
 injections, continued with care, will effect a speedy recovery. If, after 
 one general bleeding and the application of leeches, the symptoms do 
 not yield, we should again have recourse to leeches applied to the iliac 
 fossae, and their number must be proportioned to the intensity of the 
 disease and the strength of the patient. 
 
 But, should the inflammatory period pass without an amendment, 
 we must abandon bloodletting, and prescribe baths, laudanum injec- 
 tions, two a day, with the addition of eight to ten drops in each, and 
 embrocations to the abdomen composed of laudanum and camphorated 
 oil of chamomile ; finally, mercurial frictions on the abdomen and 
 thighs. I have often seen this succeed in desperate cases, and in 
 women who had been enfeebled by hemorrhages or distressing preg- 
 nancies. 
 
 When the patients recover from this disease, they frequently expe- 
 rience, during their convalescence, symptoms of gastric derangement ; 
 their strength and appetite do not return, and there is a slight febrile 
 action. In this case, vomiting by ipecacuanha will be found useful. 
 
 Neuralgic Form succeeding the Inflammatory Condition. 
 
 It is principally in those cases in which the metritis is the predom- 
 inant affection that w T e observe uterine neuralgia succeed metro-peri- 
 tonitis ; it will be recognised by the following symptoms : there is but 
 very little sensibility either in the hypogastrium or in any other point 
 of the abdomen ; the fever has ceased ; nor is there nausea, vomiting, 
 or constipation. In a word, everything announces a favourable ter- 
 mination, when the pains return after an interval of twelve or twenty- 
 four hours of perfect calm ; they soon become extremely distressing ; 
 the patient compares them to the pains of childbirth, so far as their 
 origin is concerned, but not as regards their severity, which, she says, 
 is much more intense. We might suppose that the metro-peritonitis 
 w T as returning, if the insensibility of the abdomen, the state of the pulse, 
 and the other negative signs which I have just mentioned, did not 
 suffice to establish the diagnosis. If, however, some doubts should 
 still remain, there is one symptom which will render the diagnosis 
 certain, and which, consequently, may be considered pathognomonic. 
 In metro-peritonitis, the patient carefully avoids all motion, because it 
 always increases her sufferings ; in uterine neuralgia, succeeding me- 
 tro-peritonitis, there is, on the contrary, continual jactitation, impossi- 
 bility of maintaining any given attitude, and hence there is change of 
 position every instant. 
 
 In this species, the treatment is simple and certain : laudanum in- 
 
LACERATIONS OF THE SOFT PARTS. 497 
 
 jections, repeated every two or three hours until the complete cessa- 
 tion of the pains, will dissipate them in twenty-four hours ; and the 
 termination of the metro-peritonitis is as rapid as if this complication 
 had not occurred during its progress. 
 
 I observed, the last year, a case of this kind in the service of M. 
 Honoré : a patient affected with puerperal metro-peritonitis had been 
 in one of the wards for six days ; her condition had gradually im- 
 proved, and on the seventh day she was considered cured ; but on the 
 following day M. Honoré was informed that this patient had been 
 seized with violent pain about 12 o'clock the previous night, and that 
 she would certainly die in consequence of the continued aggravation 
 of the pains. The diagnosis was not for a moment doubtful ; and the 
 prognosis itself was quite favourable ; and, finally, on the administra- 
 tion of the third anodyne injection, the pains completely ceased, and 
 the convalescence was rapid. 
 
 Typhoid Form. 
 Typhoid metro-peritonitis usually commences with a very intense 
 and prolonged chill, to which succeeds headache and somnolence ; the 
 pulse is small, hard, concentrated ; the skin is warm and dry, and cov- 
 ered with reddish spots, particularly on the fingers, wrists, and knees ; 
 the thirst is excessive ; there is abdominal meteorism, and sensibility, 
 on pressure, in the iliac fossae. Frequently to these first symptoms are 
 united a serous diarrhoea, frequent vomiting, and dyspnea, with more 
 or less suffocation ; the features are altered ; the eyes become sunken ; 
 the face is pale, or flushed only on the cheeks ; finally, there is com- 
 plete prostration of strength, with subsultus tendinum. This condi- 
 tion continues for a shorter or longer time ; but, in general, if the pa- 
 tient do not amend after thirty-six or forty-eight hours, the face be- 
 comes clayish, the features decompose more and more, a cold perspi- 
 ration covers the whole body, the abdomen enlarges, and presents dis- 
 tinct fluctuation ; sometimes the sensibility of the abdomen is extreme ; 
 sometimes it is obtuse, and the patient complains only of pain in the 
 loins ; the dyspnea increases considerably ; the urine and faeces escape 
 involuntarily ; and, finally, the patient succumbs, after prolonged suf- 
 fering. 
 
 A. Prognosis. — This form is more frequently fatal than the prece- 
 ding. Although generally less rapid in its progress, the symptoms 
 become more rapidly aggravated than in the inflammatory form. Thus, 
 the first inflammatory period is so short that it is often inappreciable, 
 and the sero-purulent effusion follows immediately the attack. This 
 circumstance explains why the antiphlogistic treatment is so rarely 
 successful. 
 
 B. Treatment. — During the first few hours of the attack, especially 
 if the inflammatory period is very decided, the treatment differs but 
 little from that recommended in the inflammatory form ; if, however, 
 certain symptoms should indicate in advance the typhoid form, we 
 must be reserved in the use of bloodletting; and, in this case, content 
 ourselves with one or two applications of leeches to the iliac fossae. 
 We shall find the mild laxatives of advantage, such as castor oil, espe- 
 
 R R R 
 
498 ACCIDENTS AFTER DELIVERY. 
 
 cially if there be constipation ; diarrhoea, even, would not contra-indi- 
 cate this medicine ; then we should administer small injections, with 
 ten or fifteen drops of laudanum, to which may be added with advan- 
 tage some camphor (a drachm triturated with the yolk of an egg) ; 
 mercurial frictions on the abdomen, and this latter should be constant- 
 ly covered with a large but light cataplasm. The drink, from the 
 commencement, should be gum-water and mild infusions ; but when 
 the typhoid symptoms fully manifest themselves, wine and water, qui- 
 nine, &c, will be indicated. 
 
 In some cases, blisters to the thighs and legs have been recom- 
 mended. 
 
 Epidemic Metro-peritonitis, or Puerperal Fever. 
 
 An affection, which partakes at the same time of these two inflam- 
 matory and typhoid forms, but which assumes more commonly the sec- 
 ond, is the epidemic puerperal fever, a frightful and rapid malady. 
 
 This fatal disease is still but little known, either as regards its na- 
 ture, forms, or treatment ; for, whenever it has prevailed in hospitals 
 devoted to parturient women, it has presented a peculiar character, 
 and often very dissimilar symptoms, the reasons of which will be found 
 in the singular atmospheric vicissitudes, so ably alluded to by writers. 
 This mysterious influence, which imparts to all diseases a variable 
 character, and often proves rebellious to all therapeutic agents, is es- 
 pecially manifest in puerperal fever ; thus, in the actual state of sci- 
 ence, we cannot give a complete history of this affection. It is only 
 by a series of observations collected under different circumstances of 
 time and place, and by comparing the progress, duration, termination, 
 and treatment of the principal phenomena of numerous epidemics, that 
 we shall be enabled to throw some light on the nature of this disease, 
 and the therapeutic methods most appropriate to oppose it. 
 
 I shall limit myself, therefore, to a brief history of the principal epi- 
 demics, the description of which has been transmitted to us, and of 
 those which I myself witnessed in 1836-38. 
 
 At the Hotel Dieu in Paris, in 1782, a most frightful epidemic ap- 
 peared. Doulcet, struck with the peculiar character of the disease, a 
 character attributed to the constipated condition of the bowels, admin- 
 istered ipecacuanha to all the patients, and from this moment the mal- 
 ady ceased its ravages. 
 
 In the epidemic which was so destructive, in 1790-91, in Aberdeen, 
 the peculiar type of the disease was an inflammatory condition, mani- 
 fested by intense headache, full pulse, &c. General and local bleed- 
 ing, carried even to syncope, enabled Gordon to save nearly all his 
 patients. 
 
 M. Tonnelle, under the guidance of Desormeaux, has given an ac- 
 count of the puerperal fever which prevailed in the Maternité of Paris 
 in the year 1829. In nearly all the cases which he has collected, we 
 find the various forms of this frightful malady : 
 
 1st. Inflammatory form. 2d. That typhoid form, often following 
 the suppuration of the vessels or the purulent absorption, and frequent- 
 ly accompanying uterine phlebitis and uterine putrescence, so w T ell de- 
 
EPIDEMIC METRO-PERITONITIS. 499 
 
 scribed by Dance. 3d. The ataxic form, which he has observed more 
 rarely. 
 
 It will readily be perceived that these varieties not having escaped 
 the sagacious observation of Desormeaux, this learned practitioner did. 
 not adopt any exclusive method of treatment. "He had," observes 
 M. Tonnelle, " conceived just notions of the treatment of this disease ; 
 he did not place any constant and positive value on the different ther- 
 apeutic methods ; their utility, in his opinion, was only relative, con- 
 trolled, on the one side, by the various forms of the disease, and, on the 
 other, by the different atmospheric conditions, which sensibly influence 
 it, without, however, modifying its general character. Thus, accord- 
 ing to Desormeaux, it is false to affirm, in an absolute and indetermi- 
 nate manner, that any particular medication will cure this disease. In 
 the actual condition of science, we should limit ourselves to saying 
 what remedies have succeeded at a given period and under given cir- 
 cumstances, and what have failed, until numerous and satisfactory ob- 
 servations, collected at different epochs and in different circumstances, 
 lay a solid basis for a general system, which, at the present day, w T e 
 do not possess. This skilful physician employed, according to indica- 
 tions, general and local bloodletting, mercurials, emetics, laxatives, 
 opiates, baths, cataplasms, blisters, sinapisms, quinine." 
 
 A. General Bloodletting. — In the inflammatory form, Desormeaux 
 derived undoubted advantages from general bleeding; employed at 
 the commencement, and repeated several times during the twenty-four 
 hours, it sometimes arrested the disease. In the second period, bleeds 
 ing was rarely useful ; however, it sometimes proved beneficial, when, 
 after the formation of the effusion, general reaction occurred, with a 
 hard, frequent pulse, increased heat, flushed countenance, &c. This 
 bleeding, under these circumstances, prevented secondary inflamma- 
 tions, particularly pleurisy and pneumonia. 
 
 Desormeaux and M. Tonnelle frequently noticed the inflammatory 
 type disguise itself under the delusive appearance of debility and pros- 
 tration : pale face, small pulse, and mediocre heat of surface. In this 
 insidious form, the exploration of the heart and lungs occasionally fur- 
 nished most valuable signs. If the pulsations were tumultuous, the 
 sound dull, and the impulsion strong, if the respiratory murmur were 
 feeble, Desormeaux had recourse to an experimental bleeding, and re- 
 peated or abandoned it, according to the effect produced, the state of 
 the pulse, and the character of the blood drawn from the vein. 
 
 B. Local bleeding was of great service in active inflammation of the 
 peritoneum and uterus, with high general reaction. 
 
 The leeches were applied to the abdomen, forty or fifty in number, 
 and frequently they were repeated in the evening and following morn- 
 ing, if there were not evident amelioration. It was found necessary 
 with some patients to apply as many as two hundred in the space of 
 thirty-six to forty-eight hours. 
 
 These local bleedings had a constant influence on the pain, and were 
 well borne by the patients, even by those who were enfeebled ; they 
 occasioned a sort of respite, during which the heat and agitation sub- 
 sided ; the skin became covered with perspiration, and frequently the 
 
500 ACCIDENTS AFTER DELIVERY. 
 
 lochiae reappeared. Such, however, was not the case with the general 
 bleeding, which was always followed by rapid debility, often without 
 affecting the local disease. 
 
 C. Mercurial Frictions. — When the effusion or suppuration had 
 formed, and, particularly, when there were symptoms that the pus had 
 been absorbed, Desormeaux abandoned bloodletting, and had recourse 
 to mercurial frictions, which frequently proved successful. 
 
 D. Ipecacuanha. — Since the time of Doulcet, physician of the Hôtel 
 Dieu, who gave popularity to this remedy and derived such brilliant 
 success from it, ipecacuanha has been alternately prescribed as an infal- 
 lible agent, and abandoned as useless or injurious, because attention 
 was not paid to the particular forms which the state of the atmosphere 
 imparted to the disease, and which would justify or contra-indicate the 
 use of this remedy. 
 
 Hufeland, Osiander, M. Recamier, and M. Cliet (of Lyons), deri- 
 ved great advantage from the administration of ipecacuanha. Desor- 
 meaux employed it for the first time in 1828 ; at first, his success was 
 undoubted, but in the course of the following year he succeeded 
 sometimes, and failed frequently. It was not until the commencement 
 of December, 1829, that the medical constitution, so to speak, favour- 
 ed its employment. 
 
 " For nearly two months that this remedy was administered," says 
 M. Tonnelle, " all the patients did not recover, but a large number 
 were saved as if by enchantment ; but, at the end of October, emetics 
 lost their influence. Desormeaux then suspended their use until favour- 
 able conditions should again present themselves." 
 
 Epidemic of January, 1836, observed at the Midwifery Clinique at 
 
 Paris. 
 The epidemic puerperal fever which prevailed at La Clinique in 
 183.6 presented the inflammatory type; and yet the antiphlogistic 
 treatment, which seemed the most rational, was attended with such 
 little success, that this circumstance furnishes an additional evidence 
 that there is in this disease an intangible principle, which escapes 
 analysis, and which, modified by circumstances, constitutes the verita- 
 ble malady. 
 
 How, in a word, can we otherwise comprehend the development of 
 a disease which assumes such different characters, laying waste a 
 whole section of country or an hospital, and prevailing at the same 
 time with the same intensity, and disappearing without any apprecia- 
 ble change in the conditions in which the patients are placed ? 
 
 Thus, if it were not true that essential fevers do not really exist, 
 and that all those fevers to which this name has been given are but a 
 symptom or evidence of a lesion of some organs inappreciable to our 
 senses, I should not hesitate to give epidemic puerperal fever the name 
 of essential fever. 
 
 Etiology. — Authors have considered as causes of puerperal fever af- 
 fections of different kinds which may present themselves in the female 
 during pregnancy : imprudence in eating, abuse of spirituous liquors, 
 exhaustion produced by exposure and poverty, laborious deliveries, or 
 
EPIDEMIC PUERPERAL FEVER. 501 
 
 those which have required long and painful manipulations. We can- 
 not but see in these different circumstances certain serious predisposi- 
 tions ; but the observations made in 1836 do not warrant us in attach- 
 ing much influence to them in the production of the disease, for the 
 epidemic attacked as frequently those women who had been previous- 
 ly in health as those who had been sick ; those who had been deliv- 
 ered spontaneously, as well as those who had been the subject of long 
 and painful operations. 
 
 Some authors have regarded suppression of the lochiœ as a cause of 
 puerperal fever. This view is not confirmed by experience ; the lo- 
 chial discharge always becomes suppressed after the cessation of the 
 disease, and we therefore see in this an effect, and not a cause. It is 
 the same as regards the secretion of milk. Indeed, almost all the pa- 
 tients were attacked before the establishment of this secretion. If we 
 cannot exactly admit, with some authors of the last century, that the 
 peritoneal effusion is occasioned by a metastasis of milk, yet there 
 may be something of truth in this opinion. Without saying that there 
 is really milk in the effusions of the peritoneum, it is very certain that 
 the absence or suppression of this secretion, if it do not determine the 
 disease, at least aggravates it. 
 
 Constipation cannot be considered a predisposition, but it is an 
 aggravating circumstance in the malady ; and hence good effects have 
 always been obtained from the use of laxatives, especially in conse- 
 quence of the increase they occasion in the intestinal secretion. 
 
 Diarrhoea, appearing after the invasion of the disease, can only be 
 regarded as an effect of the malady; and if, in some rare cases, it 
 manifests itself before any other symptom, it is because of a depar- 
 ture from the ordinary rule. 
 
 Fetor of the Lochiœ. — In this epidemic, the lochias assumed a re- 
 markably fetid character ; and M. P. Dubois also regards this circum- 
 stance as an effect, and not a cause. 
 
 Moral affections, imprudence in regimen, fyc, which have a di- 
 rect influence in the production of sporadic metro-peritonitis, consti- 
 tute, in epidemic peritonitis, only aggravating circumstances. 
 
 Low temperature, and cold, damp weather, have also been enumer- 
 ated among the causes of this affection ; but w r e see the disease ap- 
 pear with as much intensity in the warm and dry months of the year 
 as at any other time. Besides, according to the statistics collected on 
 this subject, we must admit that the mortality is less in northern than 
 in southern climates. If, however, cold cannot be regarded as an 
 essential cause of the epidemic, it is, nevertheless, a determining and 
 aggravating circumstance of the malady. 
 
 Changes in the Mir of Hospitals and Wards. — These changes can- 
 not be analyzed, and it is impossible to appreciate any difference in 
 the air of hospitals and that of the city ; and yet epidemic puerperal 
 fever is much more frequent and fatal in hospitals than in the city, 
 but the causes contributing to the development and gravity of the dis- 
 ease cannot, in any manner, be regarded as original causes ; for 
 occasionally the epidemic prevails in the city before a single case 
 shows itself at the hospital. 
 
502 ACCIDENTS AFTER DELIVERY 
 
 It is, however, well understood, from the observations made in the 
 different lying-in establishments, that the only mode of modifying the 
 disastrous effects of puerperal fever is to erect small, isolated hospitals, 
 the wards of which, being well ventilated, should contain but a few 
 beds. The Midwifery Clinique at Paris fulfils nearly all these con- 
 ditions. Thus, M. P. Dubois has caused small wards to be arranged, 
 properly warmed and ventilated, and containing each only four beds. 
 But all this solicitude by which M. P. Dubois has endeavoured to re- 
 move the slightest causes of mortality, is neutralized by the inatten- 
 tion of the administration as regards the circumstances connected with 
 the costly erection of this model hospital. The hospital buildings are 
 surrounded by very high houses, some of which were constructed be- 
 fore the hospital, but the greater number are built on a terrace pur- 
 chased by the faculty for this purpose, instead of having constructed 
 a low wall and spacious gardens, which would have permitted a free 
 circulation of air. 
 
 But this not all ; this hospital, erected at the expense of the state, 
 through the efforts of M. Orfila, forms a partition wall with the dis- 
 secting theatres, the influence of which, although less manifest during 
 the winter, is still obnoxious ; but in summer an odour so infectious is 
 exhaled, that at times it becomes necessary to close the windows look- 
 ing on that side. 
 
 Thus, it is very certain that, if the nourishment were better at La 
 Maternité, if the wards were more comfortably warmed, and the num- 
 ber of patients less, the mortality would also be much less considera- 
 ble than at La Clinique, in consequence of the great difference in the 
 hygienic situation of the buildings. Again, if the two hospitals en- 
 joyed the same topographical advantages, it is evident that the results 
 would be much more favourable at La Clinique, in consequence of 
 the greater excellence of its internal arrangements and regimen, and 
 of its more limited number of patients. 
 
 In 1829, when this epidemic was so fatal at La Maternité, M. P. 
 Dubois caused to be prepared without the building a small establish- 
 ment, to which all the newly-delivered patients were transported : two 
 only out of sixty died, although the epidemic continued to prevail in 
 the rest of the hospital. 
 
 Did these results depend on the new and favourable conditions in 
 which the patients found themselves placed, and on the fact that they 
 were removed from the contagion of which the hospital was the 
 centre 1 There can be no doubt of this ; but are we to admit that 
 these happy effects were obtained because the patients were out of 
 the reach of the contagion, determined by the contact of the women 
 themselves, and by the vicinity of those who had succumbed ? 
 
 The experience which I record would tend to invalidate the opin- 
 ion of the contagionists. In fact, the same nurses, the same sages- 
 femmes, and the same physicians attended both the large and small 
 establishment. 
 
 Some authors, however, are of opinion that the disease may be 
 transmitted by the clothes, bedding, nurses, and even by the physicians 
 themselves. If, indeed, the action of contagion be not proved, it is at 
 
EPIDEMIC PUERPERAL FEVER. 503 
 
 least doubtful ; and I think that, in this doubt, it will be extremely 
 wise to endeavour to prevent it. Such is the conduct pursued at La 
 Clinique Hospital, according to the orders of M. P. Dubois. When a 
 female is very ill, she is separated, as far as practicable, from the oth- 
 ers; should she die, the bed-clothing is purified, the curtains are 
 changed, and the apartment is ventilated for several days, and care- 
 fully cleansed before other patients are allowed to enter it. 
 
 Those who have studied the character of epidemic puerperal fever 
 will feel that these precautions are not useless. How often have I 
 seen, before these minute details were observed, the same bed prove 
 fatal to several women consecutively, while other women, sleeping in 
 the same ward, escaped with impunity ! Should this be considered 
 merely in the light of a coincidence 1 What, indeed, should be 
 thought of the following facts reported by M. P. Dubois, and recorded 
 in an excellent memoir by M. Voillemier ? 
 
 A young sage-femme of La Maternité, who was not pregnant, died 
 during the prevalence of a disastrous epidemic, presenting all the 
 symptoms and all the anatomical characters of puerperal fever ; and 
 the pupil who fulfilled the duties of interne at the same period, was 
 called to the city to attend a patient in labour just as he had comple- 
 ted the autopsy of a female who had died at La Maternité ; this pa- 
 tient, immediately after her delivery, w r as attacked with puerperal 
 fever, and sunk very rapidly. 
 
 M. Moreau himself is somewhat in doubt whether the disease which 
 occurs in the city at the same time that it does in the hospital, cannot 
 be traced to contagion transmitted by the physicians as well as to epi- 
 demic influence. Such, certainly, is my own experience. It was 
 rare, when an epidemic prevailed at La Clinique, that I had not also 
 patients in the city. Since I have ceased my duties there, I have had 
 but one case of sporadic metro-peritonitis, the determining cause of 
 which, unconnected with epidemic influence, was readily appreciated. 
 
 It is also very certain that accoucheurs not attached to the hospi- 
 tals have, during a series of years, attended a great number of wom- 
 en in labour, and have not met with a single case of puerperal fever. 
 
 The facts will not permit us to assert positively that the disease is 
 contagious, and yet they will not justify the unqualified rejection of 
 contagion. 
 
 Progress of the Disease. 
 
 The disease commenced most commonly between the twenty- 
 fourth, forty-eighth, or seventy-third hour. 
 
 It was generally preceded by a chill ; the pain commenced in 
 the iliac fossas or in the hypogastrium, and then extended rapidly 
 over the whole abdomen ; the pain was very much increased by 
 cough, pressure, vomiting, and even by respiration ; sometimes the 
 pain ceased a day before death, rather because the faculty of per- 
 ceiving it w r as lost, than because the disease had disappeared ; this 
 fact was the prelude to dissolution. All the patients were not troub- 
 led with pain in the loins, but those who were died more rapidly. 
 
 The pulse was very frequent, compressible, and became almost 
 
504 ACCIDENTS AFTER DELIVERY. 
 
 completely extinct under the finger; it was seldom above 120, and 
 reached as high as 150 ; in one patient it was 160. 
 
 The face was profoundly altered. 
 
 The lochial secretion was suppressed in some women, continued 
 in others, and sometimes only became diminished. 
 
 Frequently, the invasion of the milk fever coincided with that of 
 the puerperal fever, sometimes it continued or became suppressed ; 
 most usually, however, it was wanting from the commencement. 
 
 The tongue in the beginning was white, moist, and red on the 
 borders. 
 
 Diarrhoea was a constant attendant ; it was one of the first symp- 
 toms observed, and, at the commencement, was always grave, 
 while it was favourable at the decline of the disease. 
 
 The urine in some patients was small in quantity ; in others, it 
 was very highly coloured. 
 
 The patients were not, in general, affected with delirium ; the 
 intellectual faculties were preserved until the last moment. One 
 patient only had furious delirium ; in the two others it was slight 
 and temporary. 
 
 Before the second day, the distension of the abdomen was due 
 to meteorism ; from this period, the effusion began to form ; fre- 
 quently, it had already taken place in the first twenty-four hours. 
 
 The dyspnea was extreme ; neither the frequency of the pulse, 
 nor the pain on inspiration, nor the effusion of fluid, could explain 
 this excessive difficulty in breathing ; M. P. Dubois attributed it to 
 a peculiar nervous condition. Indeed, we see every day consider- 
 able effusion without this marked suffocation. 
 
 Almost all the patients were affected with vomiting, at first yel- 
 low, then greenish, and sometimes black. 
 
 Nearly all succumbed after a complete chill ; fifteen out of six- 
 teen patients died. 
 
 Treatment. * 
 
 The inflammatory character which the disease appeared to as- 
 sume caused hope that the energetic antiphlogistic treatment 
 would be attended with beneficial results. Thus, M. P. Dubois 
 prescribed bleeding from the arm at the commencement, sixteen 
 ounces from a large opening ; immediately afterward thirty to forty 
 leeches were applied to the iliac fossae and hypogastrium ; warm 
 vaginal injections were ordered ; cataplasms frequently renewed ; 
 and the patient had administered to her castor oil, and in the even- 
 ing the sirup of diacodium in a potion. 
 
 All these means were employed during the first period, that is, 
 during the first twenty-four hours. These results were obtained : 
 
 1st. When the remedies succeeded, the pulse became slow, and 
 the pain disappeared. 
 
 In the first case, the expectant mode was adopted. 
 
 2d. The disease not being broken, M. P. Dubois, if the pulse per- 
 mitted, had recourse again to leeches, rarely to general bleed- 
 ing, which was, then, small in quantity ; but he particularly en- 
 deavoured to prevent the abdominal effusion, by increasing the in- 
 
EPIDEMIC PUERPERAL FEVER. 505 
 
 testinal secretion, and with this object he administered calomel in 
 repeated doses until slight salivation was produced. 
 
 3d. During this period the meteorism was considerable ; there 
 was manifest fluctuation, small, frequent, depressible pulse, and the 
 face profoundly altered ; the patient was affected with frequent 
 vomiting. 
 
 Camphor was then administered in injection, combined with the 
 sulphate of quinine (a drachm of each). Rubefacients were applied 
 to the legs, and blisters to the thighs ; and, internally, the decoction 
 of quinine, wine and water, seltzer water, &c. 
 
 Post-mortem examination did not shed much light on this ob- 
 scure question ; we could not detect in the same organ always the 
 same lesion ; the lesions of the peritoneum, however, were the most 
 constant. Thus, this cavity was always distended by a considera- 
 ble quantity of turbid, yellowish-white fluid, in which floated floc- 
 culi of a concrete matter of the same colour. Pus was not once 
 detected in the vessels, although it was frequently found effused in 
 large quantity in the peritoneum, in the broad ligaments, and in small 
 masses in the tissue even of the uterus. This absence of pus in 
 the lymphatics and veins does not conflict with the observations of 
 Dance and Tonnelle on uterine phlebitis, but it goes to show how 
 variable are the alterations found in the various epidemics of puer- 
 peral fever; for M. Tonnelle, on the contrary, detected these 
 alterations almost constantly in the epidemic of which he has 
 given us an account. In 1829, in the two epidemics which ap- 
 peared during my sojourn at La Clinique, I noticed, with M. Lan- 
 douzy, a case evidently similar to those mentioned by Dance and 
 M. Tonnelle : pus was observed in the thoracic duct, and in the 
 uterine veins. Occasionally, also, we have met with that softening 
 of the womb called putrescence ; but, most generally, the uterus 
 was firm, its walls in a healthy state, and blood flowed from the 
 vessels as they were cut. 
 
 Finally, in a female who had exhibited, during the disease, all 
 the symptoms of the most intense and rapid puerperal fever, I 
 found in the autopsy, made with M. Landouzy, no lesion which could 
 explain the cause of death. All the organs were examined, the 
 muscles incised, the articulations opened, and we found neither ef- 
 fusion nor metastatic abscesses ; finally, there were none of the 
 changes ordinarily revealed by the autopsy in similar cases. This 
 woman, whose name was Boncelot, was delivered 27th June, 1839. 
 During the different phases of these epidemics of 1839, the diges- 
 tive apparatus seemed to be labouring under considerable derange- 
 ment ; and M. P. Dubois found the use of ipecacuanha very advan- 
 tageous ; but the mercurial frictions, employed in the third, period, 
 completely failed. 
 
 The epidemic which occurred at La Clinique in 1838, and 
 which was so accurately observed and described by M. Voillemier, 
 then interne of the establishment, presented likewise nearly the 
 same alterations. An analysis, unfortunately too brief, of the re- 
 markable memoir published by M. Voillemier, will complete the 
 
 S s s 
 
506 ACCIDENTS AFTER DELIVERY. 
 
 feeble outline I have given of this disease, so full of interest, and 
 the nature and treatment of which are, unhappily, so obscure. 
 
 The epidemic observed by M. Voillemier in 1838 assumed two 
 well-marked forms, the inflammatory and the typhoid. 
 
 In the first, intense chill, of variable duration, but less prolonged 
 than in the second ; shortly afterward, acute pain, but limited to 
 the hypogastric region ; sometimes it declared itself in one iliac 
 fossa, sometimes in the other. 
 
 General reaction, pulse small during the chill, from 110, 120, 
 130 per minute; the skin, at first pale, became red and burning; 
 then frontal headache, often very intense, accompanied with mark- 
 ed acceleration in the breathing. This first period terminated in 
 an extreme prostration of strength ; there was yet no diarrhoea, 
 meteorism, or vomiting. One general bleeding, thirty leeches to 
 the abdomen, and a purgative potion generally sufficed, in mild 
 cases, to remove all difficulty. This inflammatory nature of the 
 disease did not always show itself in so absolute a manner. Thus, 
 in some women who, after a chill of half an hour, appeared ex- 
 tremely prostrated, with pale countenance, rapid and concentrated 
 pulse, under the influence of the first bleeding the pulse rose, the 
 skin became moist with free perspiration, and severe headache en- 
 sued ; so that it became necessary again to resort to sanguineous 
 emissions, which, the first time, had been employed with some ap- 
 prehension. This type yielded ordinarily with rapidity to the an- 
 tiphlogistic treatment ; it was sometimes fatal, but it was far from 
 presenting the same gravity as the following form. 
 
 Typhoid Form. — This form, rapid in its development and inva- 
 sion, frightful by the number and severity of its symptoms, which, 
 resisting every therapeutic agent, and advancing most frequently 
 towards a fatal termination, commenced with a chill, sooner or 
 later after delivery ; this chill generally continued a long time, 
 notwithstanding all the means employed to keep the patient warm. 
 The pain commenced simultaneously with the chill, and extended 
 over the whole abdomen and loins ; it was so acute that the pa- 
 tients could not endure the weight of the cataplasms and bed- 
 clothing. Meteorism of the abdomen likewise manifested itself; 
 the pulse was sometimes 140 in the minute, often it was impossible 
 to count it ; the respiration was hurried, with extreme anxiety ; 
 the eyes without expression ; the face, pale and profoundly altered, 
 was covered with an abundant viscid perspiration ; then copious 
 fetid diarrhoea ensued, which rapidly exhausted the constitution ; 
 vomiting of green matter, which nothing could arrest; and, finally, 
 the patient succumbed after a few days, sometimes a few hours, 
 preserving her intelligence. 
 
 In twenty-four autopsies, the presence of pus in the lymphatic 
 vessels, and inflammation of the veins, were observed only in two 
 instances. In all the other cases, pus was infiltrated in the sub- 
 peritoneal cellular tissue, and likewise in that of the pelvis. 
 
 The uterus was most frequently exempt from all lesion, only its 
 size was more considerable than usual, and its internal surface 
 
PHLEGMASIA ALBA DOLENS. 507 
 
 was covered with a reddish sanious coat, often extremely offen- 
 sive ; but its tissue was rarely softened. Sometimes it contained 
 pus, collected in small masses the size of a pea, and which appeared 
 enclosed in a species of small cyst, to which there was no opening. 
 
 Inflammation of the veins was detected only three times, and 
 did not extend farther than the hypogastrium. In six cases, the 
 peritoneum was entirely exempt from any alteration. The quan- 
 tity of fluid contained in the peritoneum was sometimes not moi\ 
 than would fill a wine-glass ; at other times it equalled three pints. 
 On one occasion, M. Voillemier found the fluid coloured by blood ; 
 in most instances, the effusion was of a purulent nature. Finally, 
 perforation of the stomach was noticed only once, a circumstance 
 which had already been observed by Chaussier, M. Tonnelle, and 
 M. P. Dubois. 
 
 Once pus was detected in the humero-cubital and radio-carpal 
 articulations, six times in the pleura, but on no occasion in the lungs. 
 
 The treatment during this epidemic did not differ from that re- 
 sorted to in the preceding ; the baths, however, did not seem to be 
 of much efficacy ; often they appeared to aggravate the symp- 
 toms. Such was not the case with injections, which were con- 
 stantly followed by the happiest effect. 
 
 As to the mercurial preparations, M. P. Dubois did not employ 
 them except during the second period ; and, notwithstanding the 
 small number of women with whom mercury was used, there were, 
 undoubtedly, ten who owed their lives to this remedy. It was 
 employed in friction on the abdomen and thighs. 
 
 § 10. Phlegmasia Alba Dolens ((Edema of newly-delivered Women). 
 
 This name has been given to the acute and painful tumefaction 
 of the inferior extremities, which sometimes takes place as one of 
 the consequences of delivery. The début of the disease occurs 
 from the fifth to the fifteenth day after parturition. Sometimes the 
 symptoms of the malady are preceded by general distress, and, 
 again, the local symptoms appear the first. Thus, the patients are 
 attacked with fever, without being able to explain the cause ; then, 
 after a few days, swelling of the inferior extremities appears. At 
 other times, the swelling is preceded by violent chills, which occur 
 at several different periods. Occasionally, to these symptoms is 
 united a spasmodic metro-peritonitis, more or less grave ; but, 
 most generally, the phlegmasia occurs alone, and without any 
 other apparent precursory symptoms. The disease appears all 
 of a sudden on one of the extremities. The pain usually increases 
 as it advances ; at first, limited to the lower part of the leg, it 
 gradually extends itself as far as the groin, and sometimes even to 
 the hips. 
 
 Occasionally, also, the affection does not manifest itself in the 
 thigh, while it becomes seated in the two opposite extremities of 
 the limb, the lower portion of the leg, and the fold of the groin. 
 
 Sometimes the disease appears under the form of a simple stiff- 
 ness, a species of cramp ; at other times there are lancinating 
 
508 ACCIDENTS AFTER DELIVERY. 
 
 pains, excessively distressing, which draw shrieks from the patient. 
 This pain follows exactly the course of the vessels, which assume 
 the appearance of a knotted cord, very painful on pressure. The 
 temperature of the limb is increased. 
 
 The termination of this malady is ordinarily favourable. It has, 
 however, sometimes proved fatal. 
 
 The resolution of this engorgement is sometimes accompanied 
 with an enlargement of the superficial veins of the affected limb. 
 
 This affection may also terminate favourably after the formation 
 of purulent collections in different points of the extremity. 
 
 The fatal termination may be occasioned by numerous abscesses, 
 by purulent absorption, or by gangrene. 
 
 Treatment. — General bleeding, proportioned to the intensity of 
 the symptoms and to the strength of the patient ; application of 
 leeches to the groins, repeated as long as the pain shall continue ; 
 cataplasms. 
 
 Emollient drinks, mild purgatives ; if the pain be very acute, 
 anodynes may be employed. If the swelling should continue after 
 the cessation of the inflammatory symptoms, we must resort to 
 compression, by means of a roller bandage moistened with discu- 
 tient lotions ; alkaline baths, mercurial frictions, calomel internally 
 combined with digitalis. 
 
 § 11. Febrile Excitement, depending on the Condition of the Geni- 
 tal Organs. 
 
 Before completing this brief sketch of the diseases incident to 
 the parturient woman, there is one circumstance to which it will be 
 useful to call the attention of young practitioners. 
 
 At the moment of delivery, the external genital organs may, not- 
 withstanding every care, be contused and lacerated. These le- 
 sions often induce a febrile action, the cause of which will more 
 likely be unknown in proportion as the patient does not experience 
 pain in these parts, and does not, therefore, direct the attention of 
 the accoucheur to them. Thus, whenever there shall be fever, 
 without manifest cause, these organs should be examined, in order, 
 if necessary, that appropriate treatment may be employed. This 
 treatment consists in separating the labia from each other by means 
 of a piece of lint saturated with marshmallow, and renewed several 
 times during the day ; frequent ablutions and injections ; and, final- 
 ly, the parts should be covered with a cataplasm, having its sur- 
 face protected with gauze. 
 
 A few hours after the employment of these means the fever will 
 disappear, and the organs heal rapidly. 
 
 age under these circumstances would almost certainly ensure the child's death, for the 
 forced pressure employed could not but result prejudicially. I am well satisfied that the in- 
 fant is often sacrificed by the long-continued pressure made on its head after the application 
 of the instrument ; and to avoid this, I always pursue the following method, which I am in 
 the habit of recommending to my class, and to which I attach great value : As soon as the 
 instrument is properly applied, and the patient has a labour-pain (for, as a general rule, the 
 tractions are to be employed only during the pains), I then commence extracting, with the 
 
DISEASES OF NEW-BORN INFANTS. 509 
 
 CHAPTER II. 
 
 DISEASES OF NEW-BORN INFANTS. 
 
 Marks. 
 
 These consist of certain spots, of a brown, yellow, red, blue, or 
 black colour, which are observed on the skin, and which, resem- 
 bling in appearance certain objects or fruits, have induced the opin- 
 ion to prevail that they are the effect of various impressions ex- 
 perienced by the mother during pregnancy ; they are of variable 
 extent and form. They are the result of an alteration of a portion 
 of the skin, and of a disease which has its seat in the mucous body 
 of the integument, or in the rete-mucosum. They remain station- 
 ary after birth, assume nothing of a morbid character, and do not 
 require any treatment, which, on the contrary, would prove inju- 
 rious. 
 
 Fungus Hœmatodes. 
 
 Such, however, is not the case with certain vascular spots, red- 
 dish, more or less prominent, flattened, pediculated, which, being 
 occasioned by an aneurismal dilatation of the small sub-cutaneous 
 vessels, may, after birth, become the seat of a congestion, and of a 
 forced nutrition ; they may thus enlarge, ulcerate, and give rise to 
 fatal hemorrhages. The treatment which has been recommended 
 consists in cold and astringent applications, compression, extirpa- 
 tion by means of a cutting instrument, or by ligature, or placing a 
 ligature around the principal artery which supplies the varicose 
 vessels. 
 
 Ecchymoses and Bruises. 
 
 Most of the ecchymoses and bruises observed on the body of the 
 new-born infant are unimportant, and result most generally from 
 pressure experienced during a difficult labour, or from the neces- 
 sary obstetric manipulations. In the rest, the resolution of these 
 ecchymoses almost uniformly takes place spontaneously, and re- 
 quires to be facilitated by some discutient applications only in case 
 the integuments should become too much swelled. It should, how- 
 ever, be remembered that the bruises may result in erysipelatous 
 inflammation, and that, in this respect, they merit all the attention 
 of the accoucheur. 
 
 Sanguineous Tumours. 
 
 Very frequently, the parts of the infant which remain the long- 
 est exposed to the hollow of the pelvis become the seat of a sero- 
 sanguineous effusion, which shows itself more particularly on the 
 cranium, face, breech, shoulder, or knees, and is formed either by 
 
510 DISEASES OF NEW-BORN INFANTS. 
 
 effused blood, or by a reddish serosity. The tumour may be dif- 
 fused or circumscribed, hard, elastic, or soft, and fluctuating ; or- 
 dinarily it disappears of itself, after a few days ; but at other times, 
 the effused fluid, instead of being absorbed, becomes converted 
 into pus, and abscess, with excoriation of the subjacent parts, may 
 ensue, w r hich, however, most commonly only occurs on the cranium. 
 
 It is, therefore, much more important to study these sanguineous 
 tumours on the head, where their greater frequency is explained 
 by the presentations of the vertex. They present several varie- 
 ties. 
 
 1st. The most simple and common variety consists in an effu- 
 sion, more or less abundant, situated between the integuments of 
 the cranium and the subjacent aponeurosis (the caput succedaneum, 
 the external sanguineous tumour of the cranium) ; it is not danger- 
 ous, and subsides most frequently of itself, or under the influence 
 of some discutient ; it should not be opened with a bistoury, unless 
 the collection of fluid is so abundant that it cannot be absorbed. 
 
 Cephaïœmatome. 
 
 2d. Another important variety, described under the name of 
 cephaïœmatome, consists in a sanguineous effusion between the bones 
 and pericranium. Here the tumour is less prominent, and more 
 resisting than in the preceding case ; the fluctuation is not so man- 
 ifest, and if the finger be applied to the tumour, there will be a 
 slight depression, which lasts for a greater or less time. During the 
 first days after birth the tumour increases in elevation, fills, and 
 becomes more distended ; it then remains stationary for fifteen or 
 twenty days, at the end of which its volume gradually diminishes ; 
 for ordinarily the cure is effected without the aid of art, and par- 
 ticularly when the sub-pericranial tissue itself is not raised, the ab- 
 sorption proceeds with facility. It is then observed that the tu- 
 mour begins to make stronger resistance to pressure ; the finger 
 which compresses it feels a species of crackling, similar to that 
 produced by dry parchment. In proportion as it becomes hard, 
 it also becomes less elevated, flattens, and depresses towards its 
 centre, and there is felt around it a hard and bony ridge. The 
 cephalsematome is only met with on the parietal bone, and oftener 
 on the right than on the left (on account of the frequency of the 
 first positions of the head), and sometimes, also, on both at the 
 same time, but never on any other bone of the cranium. The 
 base of the tumour does not cross the sutures, and the blood which 
 it contains is extravasated between the pericranium and parietal 
 bone itself. This effusion, commonly without danger, may also, 
 although rarely, occasion necrosis or caries of the bone, which, as 
 a consequence, affects the dura mater, and causes the death of the 
 patient. 
 
 The principal cause of cephaïœmatome differs from those of the 
 preceding tumours, in the fact that the lateral and violent com- 
 pression exerted by the walls of the pelvis on the integuments and 
 bones of the cranium, after having produced an extreme overlap- 
 
CEPHALiEMATOME, ETC. 511 
 
 ping of the parietal bones, determines a fissure of thin substance, 
 and, consequently, a more or less considerable effusion of liquids, 
 formed also by the position of the parts exposed to the hollow of 
 the pelvis. 
 
 We observed that the cure generally takes place without the as- 
 sistance of the accoucheur. According to the researches of MM. 
 Nsegele and Valliex {Clinique of the Diseases of New-Born In- 
 fants, Paris, 1838, page 495), nature proceeds as follows in the 
 removal of the disease : 
 
 1st. The detached pericranium ossifies on its internal surface ; 
 
 2d. In proportion as the extravasated blood is absorbed, the os- 
 sified pericranium approximates the bone, and becomes perfectly 
 united to it ; 
 
 3d. After six months, and even a year, there is an eminence ob- 
 served on the portion of the cranium, which constituted the seat of 
 the tumour : 
 
 4th. In children who die at the end of six months or a year, on 
 making a section of the parietal bone, it will be found thicker at 
 the point of the tumour than at any other portion of its extent. 
 
 It will be seen that these tumours, left to themselves, or assisted 
 merely by some discutient applications, diminish, or disappear 
 completely after the lapse of a few weeks. If, however, after 
 twenty-five or thirty days, fluctuation was evident, and the tu- 
 mour very soft ; and if, in addition, the child presented symptoms 
 of cerebral disturbance, it would indicate that the absorption of the 
 effused fluid could not take place, and that the disease had reached 
 the bone, and penetrated even to the membranes of the brain. It 
 would then become necessary to practise an incision on the tu- 
 mour, in order to afford escape to the effused fluid, and avoid the 
 consecutive accidents. The cephalaematome has been observed 
 to heal very kindly after the incision. But it is particularly on 
 account of this small operation that it becomes necessary to distin- 
 guish accurately the sanguineous tumours of the cranium from the 
 cephalaematome. We shall see, farther on, what are the charac- 
 ters which accompany this latter affection. 
 
 5th. Finally, the third species of sanguineous tumour of the cra- 
 nium is deeper, and has its seat in the diploe of the parietal bones, 
 or between these bones and the dura mater. This, therefore, is 
 more dangerous than the others, since it is nearer the surface of 
 the brain. Resolution, however, may occur spontaneously with- 
 out occasioning serious results. As must be at once evident, no 
 special treatment can be resorted to. 
 
 Depression and Fracture of the Bones of the Cranium. 
 The depression of the frontal or parietal bone sometimes takes 
 place in new-born infants, in consequence of a difficult and pro- 
 longed labour, which has required the use of the forceps ; or in 
 consequence of the compression of the cranium against a too pro- 
 jecting sacro-vertebral prominence. This latter cause even seems 
 to be more frequent than the former, and is more likely to occasion 
 
512 DISEASES OF NEW-BORN INFANTS. 
 
 fracture of the bones. The peculiar kidney shape of the pelvis, 
 the too great resistance of the bony parts, the excessive size of the 
 fœtal head, will cause us to apprehend this lesion, the principal 
 consequences of which are coma, convulsions, and often death, if 
 there be effusion. 
 
 The depression usually has its seat in the frontal or parietal 
 bones, and is recognised by a very sensible sinking in under the 
 finger, broad, but not deep. 
 
 It may occur with or without fracture ; in either case, the acci- 
 dents are the same as those described above. These may also 
 occur when the head has been obliged to traverse a narrow pel- 
 vis ; and the bones having undergone considerable overlapping, 
 without either depression or fracture, have remained, after birth, in 
 the same situation. 
 
 The great compression exerted on the brain in pushing its fibres 
 in a sense opposite to their direction, according to M. Radfort, and 
 in oppressing the circulation of the longitudinal sinus, prevents the 
 establishment of respiration and circulation in a regular manner, 
 and produces sometimes a softening of the organ, and a sanguine- 
 ous effusion, which may become fatal. 
 
 There is no particular remedy for these different lesions, which 
 nature most usually cures herself. When, however, there appears 
 to be effusion in the brain and difficulty in the circulation, we should 
 hasten to cut the cord, in order that blood may flow from its open 
 vessels. 
 
 Paralysis of the Facial Nerve. 
 
 It occasionally happens that the branches of the forceps, in con- 
 sequence of the firm compression they exert on the lateral portions 
 of the head, and on the origin of the facial nerve, occasion a mo- 
 mentary paralysis of a portion of the muscles of the face. When 
 the child cries, the features become contracted only on one side, 
 and remain immovable on the other, and the eyelid of the com- 
 pressed side is perfectly passive. There is nothing alarming in 
 these symptoms ; after a few days the muscles regain their action 
 and the features their mobility ; if, however, this return to the nor- 
 mal state be too tardy, we may employ slight frictions on the fa- 
 cial nerve with a soft flannel and weak camphorated alcohol. I 
 have often observed this affection after the application of the for- 
 ceps. M. Landoftzy also reports several cases of this kind, ob- 
 served at La Clinique. 
 
 Diseases of the Skin in New-born Infants. 
 
 Among the principal diseases of the skin of new-born infants 
 we may mention the following : 
 
 Erythema, which may be caused by any species of irritation ap- 
 plied to the skin, by the contact of faecal matter, &c. In general, 
 the inflammation is very superficial, rarely accompanied with dis- 
 turbance of the system, and which disappears readily with clean- 
 liness and emollient lotions. 
 
DISEASES OF THE SKIN. 513 
 
 Erysipelas. — This is an affection which very frequently attacks 
 new-born infants, which is explained by the habitual sanguineous 
 congestion of their integuments. This eruption has its seat more 
 commonly on the abdomen, thorax, and extremities, than on the 
 face and head, and may terminate either by resolution, desqua- 
 mation, or suppuration of the sub-cutaneous cellular tissue, and 
 even by gangrene ; it is much less frequently than in adults ac- 
 companied with gastric symptoms, but enteritis is not very un- 
 usual ; finally, there is almost always acceleration of the pulse, 
 heat and dryness of the skin, together with pain and insomnolence. 
 Its duration varies from six to twelve days. The treatment con- 
 sists in emollient applications, especially when the erysipelas has a 
 tendency to become phlegmonous, and in local and cautious blood- 
 letting if the inflammation should be severe ; if not, diet and mild 
 drinks will alone suffice. We must, in a word, combat the symp- 
 toms of gastro-enteritis, and remove the causes capable of produ- 
 cing or continuing the irritation of the skin. 
 
 The erysipelas, which develops itself around the umbilicus of 
 new-born infants, and which is frequently produced by the irrita- 
 tion connected with the separation of the umbilical cord, requires 
 precisely the same treatment. 
 
 Pemphigus. — This eruption is sometimes observed on different 
 parts of the body of new-born infants, possessing the same charac- 
 ters as pemphigus of the adult ; but M. P. Dubois thinks he has 
 met with it in young infants who, presented also different symptoms 
 of a syphilitic affection, and who were born of syphilitic parents. 
 According, therefore, to this professor, it would seem that pemphi- 
 gus in new-born infants is an indication of venereal disease, and 
 that it requires a special treatment. 
 
 Variole. — Rare at birth. This affection, however, is observed 
 occasionally on the body of the young infant who has been affect- 
 ed with it in its mother's womb, in consequence of the latter hav- 
 ing the eruption. As singular as this fact may appear, it never- 
 theless has been observed several times by respectable practition- 
 ers, worthy of every confidence. Children, however, who have 
 contracted this malady during intra-uterine life, have generally 
 succumbed before their birth or a few days afterward. 
 
 Ichthyosis. — This is a congenital affection of the epidermis, which 
 appears under the form of blotches slightly thickened, separated 
 from each other by irregular lines. They are of a dull grayish 
 colour, become detached, and leave under them a thick and rough 
 epidermis. This disease, which may have its seat on one or all 
 the parts of the body at the same time, frequently continues for 
 several years, and cannot be confounded with the exfoliation of 
 the epidermis which takes place during the first days after birth. 
 The treatment consists in warm and emollient baths, gentle fric- 
 tions with olive oil or the oil of sweet almonds, acidulated drinks, 
 and especially personal cleanliness. 
 
 Syphilitic Vesicles. — When these vesicles are congenital, they 
 are tense, filled with a greenish yellow or sanguineous matter ; but 
 
 Ttt 
 
514 DISEASAS OF NEW-BORN INFANTS. 
 
 if they do not appear until after birth, they succeed inflamed spots ; 
 they are usually located on the feet, hands, heels, fingers, and toes. 
 They are of a few days' duration» and are followed by crusts and 
 ulcers, which continue for some time, and often occasion the death 
 of the infant. Pustules of a syphilitic nature are also observed in 
 new-born infants about the breech and genital organs ; they be- 
 come covered with crusts or scales, or are converted into ulcers, 
 and these then present all the characters of the syphilitic chancre. 
 It is, however, very difficult to distinguish these eruptions from 
 others similar in appearance, but which are much more readily 
 healed, and are not in any way dangerous. We must, therefore, 
 examine with care whether the parents of the child are not affect- 
 ed with syphilis ; and in this case, the mother must be subjected to 
 a mercurial treatment, as the only means of relieving the infant ; 
 but should this latter not nurse, it will then be necessary to put in 
 its milk the smallest quantity of the proto-iodide of mercury, or 
 any other suitable mercurial preparation. 
 
 Gangrene of New-born Infants, 
 This species of gangrene is remarked, particularly soon after 
 birth, in children whose circulation and respiration are imperfectly 
 performed. Congestion takes place, a sanguineous fulness of the 
 extremities, which, in consequence of the difficulty in the circula- 
 tion, become bluish, cold, decomposed, and sphacelate ; and then 
 either an inflammatory circle limits the ravages of the disease, or 
 death results. This gangrene usually commences on the toes or 
 fingers ; the skin becomes dark and tumefied, and is covered with 
 sero-sanguineous bullae, which excoriate ; the integuments assume 
 a brownish colour, become emphysematous, and emit a gangre- 
 nous odour, while the foetus, pale, immovable, breathing with dif- 
 ficulty, with scarcely strength to utter a cry, gradually sinks, its 
 body being emphysematous, and covered with scorbutic petechias. 
 It is necessary in this disease, most generally rapidly fatal, to di- 
 minish the sanguineous plethora by the application of leeches to 
 the anus, dry or aromatic frictions on the parts, in order to in- 
 crease the activity of the circulation, and to dress the eschars or 
 ulcers with the wine or decoction of quinine. These are the only 
 means we can employ, for internal remedies are impracticable in 
 infants so young, and whose digestive organs are so delicate. 
 
 (Edema, or Hardening of the Cellular Tissue in New-born Infants. 
 The hardening of the cellular tissue in new-born infants is 
 nothing more than simple oedema, entirely analogous to what is 
 observed in adults and old people ; it is, in a word, an abundant 
 infiltration of serum in the substance of the cellular tissue. This 
 affection is characterized by a very great resistance of one or sev- 
 eral portions of the surface of the body ; the integuments appear 
 to be hardened, swollen, tense, more or less red, and the impres- 
 sion made by the fingers continues for some time. The following 
 have been considered as capable of producing this disease : 
 
(EDEMA AND JAUNDICE. 515 
 
 1st, Natural debility of the infant; 2d, a condition of general or 
 congenital plethora ; 3d, superabundance of venous blood in the 
 tissues ; 4th, dryness of the skin before the exfoliation of the epi- 
 dermis ; 5th, obstruction in the circulation, occasioned by the abun- 
 dance of blood in the circulatory apparatus ; 6th, its excess in the 
 cellular tissue, to which it furnishes too many materials for secre- 
 tion ; 7th, the action of external agents on the skin, such as cold, 
 which, by checking the cutaneous perspiration, will favour the ac- 
 cumulation of serum in the cellular tissue. The sanguineous en- 
 gorgement of the liver, lungs, and heart, and the occlusion of the 
 natural openings, are not exclusive causes of this malady, but are 
 merely accompanying phenomena. 
 
 When the oedema is general, and the serous congestion is exces- 
 sive, all the parts of the body in which there is cellular tissue experi- 
 ence a disturbance in their functions ; thus, the glottis, having become 
 cedematous, renders the cry of the infant painful, acute, and cho- 
 ked. The slowness in the circulation explains the coldness of the 
 extremities and the prostration into which the patient falls. 
 
 The therapeutic indications consist in controlling the plethora 
 by sanguineous evacuations, and exciting the skin by irritating fric- 
 tions ; wool, applied directly to the surface, is one of the best 
 means of effecting this latter object. 
 
 The hardening of the adipose tissue takes place with or without 
 general infiltration of the sub-cutaneous cellular tissue. The cheeks, 
 breech, calves of the legs, and back, are its most ordinary seat. It 
 may or may not be accompanied with disturbed circulation or res- 
 piration. The adipose tissue in this affection is very firm, and is 
 like congealed tallow, which probably arises from the fact that the 
 animal heat has left the body of the infant. 
 
 Jaundice of New-horn Infants. 
 The icteric colour of the young infant is not always limited to 
 the integuments alone ; it may be partial or general. Thus, the 
 brain, spinal marrow (and it is tins condition which has been de- 
 scribed by Lobstein under the name Mrrho?wsis), lungs, heart, in- 
 testinal tube, kidneys, liver, muscles, cellular and adipose tissue, 
 have presented, either separately or simultaneously with the skin, 
 the peculiar yellow colour of jaundice ; but most commonly the 
 skin is affected, either in part or in totality ; and it is remarkable 
 that the yellow tint almost uniformly succeeds the red colour ex- 
 hibited by the skin of the new-born infant. It would, therefore, 
 seem probable that jaundice, being local, does not depend on any 
 general cause, such, for example, as disease of the liver, which, 
 moreover, scarcely ever is met with at this tender age ; and that the 
 yellow hue is occasioned by the deposite of the serum of the blood, 
 highly coloured, in certain organs, in which it finds itself placed 
 under peculiar conditions. It should, however, be remarked 
 that jaundice frequently coincides with a sanguineous congestion 
 of the liver and integuments. In all cases this species of icterus 
 is not a disease, and requires no particular treatment unless there 
 
516 DISEASES OF NEW-BORN INFANTS. 
 
 should be some complications, and nature generally removes the 
 yellow colour in a short time. 
 
 Leucorrhea. 
 Not unfrequently we observe in young infants a purulent dis- 
 charge from the vulva, which is sometimes quite abundant. In 
 general, it is a symptom of no importance, and will disappear in a 
 few days spontaneously, or by simple cleanliness and emollient lo- 
 tions. This discharge, however, will sometimes continue ; in this 
 case, we must employ astringents in the wash and in baths. It is 
 not usually a symptom of syphilis, as was for a long time sup- 
 posed, and it should not be ascribed to this disease except in cases 
 in which other positive symptoms on the part of the mother would 
 justify the opinion. The discharge, in a word, depends on an irri- 
 tation of the genito-urinary mucous membrane, analogous to that 
 of the conjunctiva in the ophthalmia of new-born infants. 
 
 Gangrene of the Vulva. 
 A disease of the genital organs, which is much more serious, and 
 which merits all the attention of the accoucheur, is gangrene of the 
 vulva. It coincides, almost always, with certain cutaneous phlegma- 
 sise, such as variola and rubeola ; it is a very grave affection, and is al- 
 ways complicated with gastric or cerebral symptoms, more or less se- 
 rious. The local treatment is the same as in other species of gangrene, 
 and consists in applications of powdered quinine, compresses wet with 
 the chloride of lime, &c, &c. 
 
 Swelling of the Breasts. 
 The breasts of new-born infants are sometimes the seat of a tume- 
 faction, caused by the accumulation, in the gland itself, of a sero-lac- 
 tescent fluid sometimes abundant, and which gives rise, in some rare 
 cases, to inflammation and abscess of the mamma?. But this turges- 
 cence is most generally temporary, and without danger ; however, 
 it will be proper to cover the breasts with cataplasms, to prevent acci- 
 dents. 
 
 Spotted Hemorrhagic Disease, and Hemorrhage of the Intestines. 
 
 I have classed these two diseases together, because they are almost 
 always combined, and proceed from the same cause. They are ob- 
 served in feeble children badly nourished, whose capillary circula- 
 tion is disturbed ; they present themselves under the form of spots of 
 a deep red, circumscribed and rounded, and which appear on the sur- 
 face of the body, and also in different points, and sometimes even 
 along the whole length of the digestive tube. In this latter case, there 
 is always hemorrhage of the gums, stomach, intestines, bladder, &c, 
 &c. This affection, however, ordinarily without fever, is sometimes 
 not accompanied with these alarming symptoms, and continues limited 
 to the skin. It is, nevertheless, often fatal ; and if we have the time, 
 we should endeavour to remove the danger by applying, for example, 
 one or two leeches to the breech in order to diminish the quantity of 
 
HEMORRHAGE. PURULENT OPHTHALMIA. 517 
 
 blood, but only in cases in which we suspect that the disease arises 
 from evident sanguineous congestion ; for if the disease be simple, and 
 the infant weak, we should confide the cure to nature. 
 
 Hemorrhage from the Umbilicus. 
 This may occur in an infant as soon as it is born, either in conse- 
 quence of not putting a ligature around the cord, or because the liga- 
 ture has become loose, or because violent tractions have torn the cord 
 from near the umbilicus. This is somewhat serious, and requires to be 
 remedied immediately, either by a ligature or compression, which may 
 be employed by placing above the wound lint, and graduated com- 
 presses, supported by a bandage. 
 
 Purulent Ophthalmia of New-born Infants. 
 
 The impression of cold air, the confinement of a number of children 
 in a badly-ventilated apartment, neglect of cleanliness, protracted and 
 difficult labour, as also the compression of the head of the infant, the 
 epidemic influence so manifest in hospitals, and, finally, syphilitic 
 blennorrhagia in the mother, are the principal causes of ophthalmia in 
 new-born infants. This disease may declare itself on the second or 
 third day after birth. At first, there is merely a slight redness and tu- 
 mefaction of the eyelids, which, however, are very sensible on pressure. 
 The child cannot endure the light, closes its eyes, and turns from it. 
 
 But if the irritation be left to itself, it soon passes to the second pe- 
 riod. The redness, pain, and tumefaction increase in intensity, and 
 suppuration is established. The conjunctiva of the ball of the eye be- 
 comes inflamed, tumefies, is covered with granulations, and the folds 
 which it forms give rise to an ectropium more or less marked, when 
 the child cries. The suppuration, which becomes more and more 
 abundant, varies in colour from a yellowish white to a green, and is 
 sometimes mixed with blood. When the inflammation has extended 
 over the globe of the eye, it occasions lesions, which may, in fact, de- 
 stroy the whole organ. The most common is inflammation of the 
 cornea, which may cause, 1st, opacity of this membrane, which usual- 
 ly subsides after the inflammation has yielded -, 2d, the softening of 
 the cornea, much more serious and frequent. The cornea loses its 
 polish, commonly towards the centre, presents in a given point a gray- 
 ish and slightly brown tint, becomes perforated, and allows the aque- 
 ous humour, crystalline lens, and also the vitreous humour to escape. 
 The eye is then sunken, and vision is lost. 3d. Ulceration, which 
 usually occurs on a level with the opaque portions of the cornea, and 
 presents tumefied borders, somewhat prominent and regular. It re- 
 sults in the same accidents. 
 
 The prognosis of ophthalmia, therefore, is the more alarming as the 
 inflammation extends more towards the globe of the eye, involving 
 more or less of its structures. In its simple state it lasts only a few 
 days; when the disease is more profound, its duration is very long. In 
 the first period of ophthalmia, the milk of the nurse, instilled between 
 the eyelids of the infant, will alone suffice. But when suppuration 
 has become established, the first thing to do in the treatment of this 
 
518 DISEASES OF NEW-BORN INFANTS. 
 
 disease is to combat the inflammation, if it be violent, by the applica- 
 tion of leeches to the external angle of each eye ; but it is rare that 
 we are obliged to have recourse to this alternative ; lotions with marsh- 
 mallow- water and rose-water will most generally suffice. We should 
 also use a collyrium composed of the nitrate of silver (two to five 
 grains to the ounce of water) ; this is the most efficacious remedy to 
 remove the inflammation, and oppose its melancholy results. Several 
 drops of this collyrium should be placed between the eyelids two or 
 three times a day. Finally, it is indispensable to keep the light from 
 the child's eyes, especially in serious ophthalmia, by placing a veil over 
 its face, turning it on the side opposite to the light, and surrounding its 
 cradle with thick green curtains. 
 
 A lady living in my neighbourhood brought to M. P. Dubois her 
 infant, affected w T ith purulent ophthalmia, and for which the only appli- 
 cation had been marshmallow-water. One eye was entirely destroy- 
 ed. M. Dubois requested me to take charge of this child, and with 
 the collyrium of the nitrate of silver I was fortunate enough to save 
 the other eye. 
 
 In general, sufficient attention is not paid in the city to this affection, 
 which, if left to itself, may often result in the most distressing conse- 
 quences. 
 
 Stomatitis with altered Secretion — Sprue. 
 
 This affection is characterized by the concretion of mucus on the 
 surface of the inflamed mucous membranes, whether these membranes 
 have an epithelium or not. This concretion may be observed in the 
 mouth, œsophagus, stomach, small and large intestines. We shall 
 here speak of it only when attacking the mouth. 
 
 The sprue presents itself under three forms : 1st, under the form of 
 very small white points, scattered over the tongue and the walls of 
 the mouth; 2d, it shows itself in layers of more or less extent; 3d, 
 under the form of a membrane, which covers the whole tongue, or ex- 
 tends on other portions of the buccal cavity. 
 
 This excretion is usually preceded by an erythematous inflammation 
 of the same parts, succeeded by small white points, which always 
 have their seat on the surface of the epithelium. These white points 
 soon unite under the form of a membrane, which gradually exfoliates, 
 to become again reproduced. The sprue, when composed of these 
 white points, usually occupies the extremity of the tongue ; when in 
 patches, the internal surface of the lips and cheeks ; and in a mem- 
 branous form, it is found at the base of the tongue, and on the velum 
 palati. 
 
 The presumed causes of sprue are early infancy, improper nourish- 
 ment, the accumulation of a number of children in the same apart- 
 ment, the peculiar constitution of each individual, which predisposes it 
 to inflammation of the mucous membrane, debility, quality of the nurse's 
 milk, and the repeated efforts at nursing which the child is occasion- 
 ally obliged to make. This disease is not considered contagious ; and 
 in very young infants it is not accompanied with much fever : the skin 
 is warm and dry, thirst ardent ; but it is often complicated with in- 
 
APTILE, ETC. 519 
 
 flammation of the digestive apparatus, and this circumstance renders 
 sprue so often fatal. 
 
 Treatment. — When sprue is simple, we should content ourselves 
 with washing the mouth of the infant several times during the day 
 with a camel's hair pencil, wet with the water of marshmallows and 
 honey with rose leaves, to which may afterward be added a little bo- 
 rax or alum. If the disease be complicated with inflammation of the 
 digestive tube, or of some other important organ, the inflammation 
 must be combated by appropriate treatment. The air should be 
 changed, the diet confined, and every cause capable of continuing the 
 disease removed. 
 
 Follicular Stomatitis, or Apthœ. 
 
 Apthae are nothing else than an inflammation of the muciparous 
 follicles of the mucous membrane, whether of the mouth, or of any 
 other portion of the digestive tube. 
 
 The mucous follicles, at first engorged and inflamed, soon afford 
 escape to a whitish matter through a laceration of their central 
 point, which promptly ulcerates. The small superficial ulcerations 
 sometimes have rounded borders, and secrete a pultaceous whitish 
 matter, which becomes detached. 
 
 The apthae most generally occupy the internal surface of the 
 lips, cheeks, the upper portion of the gums, the frenum, and sides 
 of the tongue. If they should be numerous and close together, 
 their borders become confounded, and the matter forms a more or 
 less broad layer, somewhat analogous to that of the sprue, which, 
 however, may be distinguished by remembering the development 
 of the inflamed follicles, and of their solutions of continuity, which 
 do not exist in sprue. 
 
 Apthae are remarked particularly in debilitated children, pale, 
 lymphatic, badly nourished, and breathing an impure air. 
 
 The general symptoms are of no account ; the skin is warm and 
 dry, and fever is observed only in children somewhat advanced in 
 age. But, if the apthse should be numerous, and extend along the 
 oesophagus and the rest of the digestive tube, which most frequently 
 is the case, the child grows pale and emaciated, is seized with vom- 
 iting and diarrhoea, and, finally, with all the symptoms of gastro- 
 enteritis. 
 
 The treatment is the same as has been recommended in sprue. 
 
 Two other species of stomatitis may affect the young infant : 
 the ulcerative and gangrenous. We shall not describe them here, 
 for they are ordinarily observed at a later period. 
 
 Principal Symptoms of the Diseases of the Digestive Organs in 
 New-born Infants. 
 Vomiting. — Vomiting, or, rather, the regurgitation of a portion 
 of the milk, is, in general, of not much moment ; the stomach re- 
 jects it because it is too much distended. But when the vomiting 
 causes the whole of the food to be thrown off, it will soon result in 
 the destruction of the infant ; it may depend on improper nourish- 
 
520 DISEASES OF NEW-BORN INFANTS. 
 
 ment, on oesophagitis, gastritis, enteritis, particularly about the ileo- 
 cecal region, on an obstruction to the course of the fsecal matter, 
 and on softening of the mucous membrane ; and it requires the 
 treatment appropriate to these different maladies, when they are 
 well characterized ; but, most generally, the alteration alone of the 
 diet, the use of a little magnesia, or of a slight laxative, will be all 
 that is required. 
 
 Diarrhoea. — It is not a constant sign of enteritis ; it may be pro- 
 duced by a veritable intestinal indigestion, improper diet, milk 
 which is too old, gestation or the affections of the nurse herself, too 
 precipitate weaning and premature use of solid food, irritation and 
 an increased secretion of the follicular structure, and, finally, by 
 colitis or enteritis. It varies in colour and in the consistence of 
 the matter discharged : the yellow diarrhoea, frothy and fluid, is 
 very often accompanied with inflammation ; the white and mucous 
 diarrhoea is mostly produced by an increased secretion of the mu- 
 ciparous follicles ; but, in general, the green evacuations are re- 
 garded as signs of gastro-intestinal inflammation. This symptom 
 is almost always accompanied with red spots about the anus, 
 whether there be inflammation of the intestines or not. The sirup 
 of gum, emollient cataplasms lubricated with oil, injections of mal- 
 lows, orange- water, and baths, will suffice in most cases to subdue 
 the diarrhoea. If the signs of intestinal irritation be very marked, 
 and resist these means, we must apply a leech to the stomach or 
 anus, according to the indication. In chronic diarrhoea, on the 
 contrary, which is accompanied by hectic fever, and which soon 
 destroys the infant, it often becomes proper to employ tonics and 
 astringents ; but what we must particularly attend to is the remo- 
 val of the causes of the disease, by changing the situation of the 
 child, giving it a more suitable nourishment, &c, &c. 
 
 Colic. — This is produced by the same causes as diarrhoea, and 
 may be spasmodic, or may depend on inflammation, intestinal in- 
 vagination, imperforate anus, gaseous distension during inflamma- 
 tion, or the sojourn of the food in the intestines without being 
 digested. Colic will be recognised by the cries and agitation of 
 the infant, and by its various contortions, in proportion as the pain 
 increases, and, finally, by the evacuation of the matter of diarrhoea. 
 It calls for the same treatment as this latter disease. 
 
 Tension of the Abdomen. — This frequently occurs in enteritis, 
 and is then accompanied by pains in the abdomen, and is continu- 
 ous, which distinguishes it from the passing distension of the intes- 
 tines by gas, when they are in a state of spasm, a condition which 
 is soon relieved when the gas escapes. 
 
 Eructations are rarely serious ; they often depend on the fre- 
 quent repletion of the stomach with food, and indicate a bad diges- 
 tion when abundant and repeated. It is a fact worthy of remark, 
 that, in young infants, the diseases of the digestive tube are not 
 accompanied by the same strongly-marked phenomena of reaction 
 as in the adult. Thus, with them, fever is rare, and the pulse, in most 
 cases, becomes weak ; the heat of the skin alone is increased. This 
 
CONGENITAL HERNIA OF THE ABDOMEN. 521 
 
 remark is the more important, as the digestive tube is the seat of 
 most of the diseases that prove fatal at this tender age. 
 
 Congenital Herniœ of the Abdomen. 
 
 These hernise may take place either through the natural open- 
 ings, or through the spaces formed by the imperfection of the ab- 
 dominal walls. 
 
 Umbilical Hernia. — This may occur at the moment of delivery, 
 or shortly afterward, and arises from the fact that the aponeurotic 
 ring, which is intended to circumscribe and bind the base of the 
 umbilical cord, is either too relaxed, or does not exist. Then, one 
 or more folds of the intestines pass into the species of expansion 
 formed by the umbilical cord at its insertion, and give rise to a her- 
 nia, the coverings of which are composed of integuments, cellular 
 tissue, and peritoneum. Two methods have been recommended 
 to relieve this hernia. 
 
 The ligature of Desault, which consisted in returning the intes- 
 tine, and seizing the integuments near the abdomen (a method 
 abandoned on account of its failures), and compression, which is 
 performed by applying to the umbilicus graduated compresses, 
 which are supported by means of a body bandage during the first 
 few days, and which is afterward replaced by an appropriate 
 bandage ; this will usually prove sufficient to effect a cure. 
 
 Congenital Inguinal Hernia. — When the testicles descend into 
 the scrotum, in the infant near term or after birth, they bring with 
 them a portion of the peritoneum, in the form of a cul-de-sac, the ab- 
 dominal opening of which becomes soon obliterated on a level with 
 the ring ; if this obliteration should not take place, the portion of 
 intestine may, simultaneously with the testicle, or at a later period, 
 and in consequence of the efforts of the infant, descend into the 
 scrotum, and form an inguinal hernia. It is very important not to 
 confound the testicle, which sometimes does not descend until after 
 birth, and which then would be placed at the inguinal ring, with 
 the portions of protruded intestine ; and we should be accurately 
 informed of the nature, volume, and presence of both one and the 
 other. 
 
 When we have ascertained that an intestinal fold, or a portion 
 of the epiploon has passed into the scrotum, we should endeavour 
 to return them by making gentle pressure through the inguinal 
 ring ; then, in very young infants, we should apply a temporary 
 bandage, with compresses, which should be changed frequently, in 
 order to prevent irritation of the skin ; and, finally, a permanent 
 bandage should be used as soon as the age and cleanliness of the 
 child will permit. 
 
 Compression should be made particularly over the opening of 
 the inguinal ring ; it will sometimes occasion the adhesion of the 
 peritoneal layers, and the réclusion of the ring itself. 
 
 In little girls, very rarely, it is true, the hernia through the ingui- 
 nal ring is composed of one of the ovaries. 
 
 Congenital Hydrocele. — The non-obliteration of the peritoneal 
 
 Uuu 
 
522 DISEASES OF NEW-BORN INFANTS. 
 
 sac, which descends with the testicle, may occasion the accumu- 
 lation of a certain quantity of serum in this sac, which may be 
 recognised by its regularly rounded form, by the transparency ob- 
 served through the coats of the testicle, and particularly by the 
 facility with which this fluid is returned to the abdomen, signs which 
 will prevent our confounding this affection with hernia. The treat- 
 ment consists in pushing the fluid into the abdomen, and in com- 
 pression on the opening of the ring for some time ; or, according 
 to Desault, the ring should be compressed, then puncture and in- 
 jection practised after the ordinary method. 
 
 Prolapsus of the Rectum, 
 The efforts which the child makes when it cries, or breathes 
 with difficulty, constipation, copious and hard evacuations render- 
 ed all of a sudden ; finally, the frequency of alvine discharges, 
 whether occasioned by a purgative or not, all tend to cause the 
 protrusion of the inferior extremity of the rectum, the internal 
 membrane of which, but slightly adhering to the two others by a 
 loose cellular tissue, gradually becomes detached and extends be- 
 yond the anus. In the first place, we must endeavour to return 
 the protruded membrane with the fingers smeared with butter or 
 cerate ; then the part reduced is to be kept in place with com- 
 presses saturated with cold water, and a T bandage. If the in- 
 firmity should continue, we will be obliged to use the precaution 
 of supporting the edges of the anus whenever the child has an 
 evacuation, and apply from time to time to the part lotions with a 
 solution of sulphate of zinc or alum, lime-water, astringents, and 
 tonics, which, however, must be aided by the application of a 
 bandage. 
 
 Principal Deformities in New-born Infants, 
 
 Absence of the Skin. — The skin may be wanting on one or more 
 parts of the body ; but its absence is almost always simultaneous 
 with that of the part it covers. This monstrosity is referred to two 
 causes : either the skin has originally existed, and has become de- 
 stroyed by a disorganization common in spina bifida ; or it has 
 never existed, because the parts for which it should serve as a 
 covering have been arrested in their development. 
 
 Excrescences. — The tegumentary covering may, on the contrary 
 sometimes present excrescences, particularly on the face, trunk, 
 and extremities ; it will be proper, when they are too prominent, 
 to remove them early. This is not the place to enter fully into all 
 the deformities which the skin may affect. 
 
 Astomia, or Absence of the Mouth. — This deformity occurs 
 when the bones of the face have been arrested in their growth, 
 and especially when the inferior maxillary bone is wanting. The 
 infant cannot survive with this irremediable defect, and soon sinks. 
 
 Atresia, or Obliteration of the Mouth. — The adhesion of the lips, 
 or the absence of the anterior opening of the mouth, is very rare ; 
 the treatment consists in making an incision of sufficient size on 
 
DEFORMITIER. 523 
 
 the point to which the mouth should correspond, and preventing 
 the cicatrization of the borders of the wound. 
 
 Hare-Lip. — The two lips, and more especially the upper, some- 
 times present in the new-born infant congenital divisions, situated 
 either in the middle or lateral portions of the raphe. This deform- 
 ity may consist in a partial division, a complete division, or in the 
 absence of a considerable portion of the lip and superior alveolar 
 arcade. When the division of the lip is simple, it is almost always 
 situated on the side of the raphe ; if it be double, it exists on each 
 side, and then the wings of the nose are drawn more or less out- 
 ward. Very frequently, it is accompanied with the division of the 
 alveolar border, either of one or of both sides, ordinarily between 
 the second incisor and canine. 
 
 Division of the Palate. — The palatine arch and the velum palati 
 may also present a separation more or less considerable in the me- 
 dian line. These deformities, which are produced, according to 
 some physiologists, by an arrest in the growth of the parts, require 
 surgical operations, for the hare-lip interferes with suction and the 
 taking the breast, while the division of the velum palati renders 
 deglutition very difficult, and even dangerous. The operation, 
 however, for hare-lip, or staphyloraphy, should not be performed 
 until the child is some months old ; and it should be nourished up 
 to this time by giving it the breast, or allowing it to drink from a 
 spoon or a biberon, holding it in a vertical position, particularly if 
 the child have a division of the velum palati. 
 
 Tongue-tie. — The length of the frenum of the tongue, commonly 
 called tongue-tie, limits the movements of this organ, and prevents 
 suction. We should, therefore, in this case, raise the tongue and 
 cut the frenum with a pair of scissors, being careful not to prolong 
 the incision too much, and directing the point of the scissors down- 
 ward, keeping them as far as possible from the base of the tongue, 
 in order to avoid cutting the veins. I prefer commonly making a 
 very slight section of the frenum of the tongue, and I then put the 
 child immediately to the breast. The efforts of suction complete 
 the freedom of this organ. I employ the middle and index fingers 
 of the left hand, with the pulp of which I raise the tongue. If the 
 hemorrhage, which sometimes occurs after the division of the ves- 
 sels, become alarming, we use either the nitrate of silver or ac- 
 tual cautery. 
 
 Imperforate Anus. — The inferior extremity of the intestine may 
 present a complete obliteration, which results from the imperfora- 
 tion of the skin over the centre of the anus, and then the rectum 
 terminates in a cul-de-sac at its inferior part, or a portion or the 
 whole of this intestine is wanting. In the first case, it contracts 
 adhesions with the sacrum ; in the second, it is the inferior extrem- 
 ity of the colon, which forms a cul-de-sac, and adheres to the sa- 
 crum near the vertebral prominence. It must not, however, be 
 supposed that imperforation of the anus always accompanies im- 
 perforation or absence of the rectum. This orifice occasionally 
 exists in children whose rectum is obliterated. This is a circum- 
 
524 DISEASES OF NEW-BORN INFANTS. 
 
 stance to which great attention should be paid when we are ex- 
 amining the signs of retention of the faeces. In the case in which 
 the rectum exists and the anus is imperforate, it will suffice, in order 
 to afford escape to the meconium, to make a puncture with a straight 
 bistoury in the point at which the anus should be found, and in the 
 summit of the small tumour, which distends at each effort made by 
 the infant. The closure of the external wound should be prevent- 
 ed by the introduction of meshes of lint. 
 
 But when the rectum is obliterated in great portion of its extent, 
 the operation, very difficult and dangerous, is rarely successful. 
 We have to choose between the formation of an artificial anus on 
 the anterior part of the abdomen, or at the point in which the anus 
 should have existed. The first operation is easier, but the disgust- 
 ing infirmity it occasions should cause us to prefer the method of 
 M. Amussat. I once carried to M. Amussat a young infant with 
 this imperforation, and this skilful surgeon performed one of those 
 bold operations which, in my opinion, should alone be attempted in 
 similar cases. It consisted in forming an artificial anus in the place 
 at which the natural orifice should have been originally situated. 
 For this purpose, after having dissected the parts as far as the in- 
 testine, he drew this towards him, opened, and attached it around 
 the anal orifice by means of sutures. M. Amussat had already 
 succeeded in the operation, but the infant of which I speak died. 
 It will be at once seen, notwithstanding its dangers, how prefera- 
 ble this operation is to the establishment of an artificial anus, 
 which consigns the unfortunate patient to a miserable existence. 
 
 Opening of the Foramen Ovale. — The opening of the inter-auricu- 
 lar orifice of the heart and ductus arteriosus does not occasion any 
 particular accidents during the first few days after birth, because 
 the quality of the blood at this period is in relation with the wants 
 of the organs; but if there be at the same time sanguineous ple- 
 thora, this malformation, joined to the impossibility or extreme dif- 
 ficulty of establishing respiration, produces sometimes cyanosis, for 
 the want of the proper oxygenation of the blood. This latter cir- 
 cumstance, however, may also occur without the opening of the 
 foramen ovale, when the blood, passing through the lungs, does 
 not undergo the necessary vital modifications. In the uncertainty, 
 therefore, in which we may be placed as to the cause of cyanosis, 
 we must proceed as if it depended on a sanguineous congestion 
 towards the heart and lungs. The infant should be kept near a 
 bright fire, and its head and whole body gently rubbed with warm 
 linen. 
 
 Deformity of the Spinal Marrow. 
 Complete absence of the spinal marrow always coincides with 
 that of the brain. In the case of acephalous children, the spinal 
 marrow is suddenly interrupted at about the fourth vertebra. The 
 anular protuberance still exists, so that the heart and lungs, which 
 receive nerves from the superior portion of the spine, may perform 
 their functions for some hours. 
 
DEFORMITIES. 525 
 
 Hydrorachie consists of one or more tumours situated along the 
 vertebral column, opposite the separation of the spinous apophyses, 
 and results from an accumulation of serosity contained in a sac 
 formed by the skin and membranes. The tumour, oblong, soft, 
 and disappearing on pressure, may be situated in different points of 
 the vertebral column. Sometimes the skin which covers it is un- 
 broken, and it can be distinguished only by the fluctuation and the 
 feeling of separation of the vertebras : children may then live a long 
 time with it. Sometimes the skin is very thin, transparent, mar- 
 bled, and soon ulcerates, and affords escape to the fluid ; some- 
 times, on the contrary, the tumour is open, the borders are ulcer- 
 ated, fungous, hard, and applied against the borders of the verte- 
 bral bifurcation, and the effused fluid escapes in variable quantity. 
 These two latter varieties are more common than the former. In 
 these cases, the inflammation of the membranes takes place prompt- 
 ly, and causes death. Thus, the symptoms of spina bifida are or- 
 dinarily unimportant as long as the tumour has no communication 
 with the air, and does not exert excessive pressure on the spinal 
 marrow and brain. We must, therefore, be careful not to open it, 
 and content ourselves with exerting a gentle and gradual pressure 
 on it. 
 
 Deformities of the Cranium and Brain. 
 
 Complete absence of the brain is met with only when the head, 
 face, and superior part of the neck are wanting at the same time. 
 
 Anencephalie consists in the absence of a portion of the brain, 
 with or without absence of the cranial cavity. It presents several 
 degrees : either the cerebral hemispheres are in a state of dropsy, 
 or the cerebellum and optic couches alone exist, or, what is still 
 more common, the cranium and brain are wanting at the same 
 time, and the forehead terminates on a level with the orbital 
 borders, giving to the head of the infant the appearance of that of 
 an animal. 
 
 Congenital Hydrocephalus is most usually distinguished by a 
 considerable enlargement of the cerebral mass and cranial bones, 
 caused, undoubtedly, by inflammation of the membranes, a very 
 abundant secretion of serum either within or without the ventricles, 
 or a species of nutritive hypertrophy. Hydrocephalus frequently 
 coexists with hydrorachitis. The infant then presents one or more 
 tumours along the vertebral column, with a very large head. The 
 disease does not give rise to any morbid symptom ; when it is not 
 considerable, it sometimes remains stationary until rather an ad- 
 vanced period of life, and produces in the infant singular activity 
 in the intellectual organs ; but if, in extensive hydrocephalus, the 
 disease increases, this activity is replaced by a destruction of the 
 cerebral organ, and death soon follows. 
 
 Mercurial frictions have been recommended in hydrocephalus, 
 but they are only useful when symptoms of acute or chronic men- 
 ingitis declare themselves. It would be proper, also, to employ 
 baths, derivatives on the digestive tube, revulsives to the extremi- 
 
526 DISEASES OF NEW-BORN INFANTS. 
 
 ties, diuretics, &c, &c. Stationary hydrocephalus demands only 
 hygienic attention, and particularly removal from all mental ex- 
 citement. 
 
 Encephalocele. — There occasionally exist between the bones of 
 the cranium intervals more or less considerable, caused either by 
 an arrest of development or by an excessive size of brain, as in 
 hydrocephalus, preventing their approximation. This organ is 
 then seen to form a real hernia through the separated fontanelles. 
 The character of the tumour is recognised by its softness, by its 
 being smaller than that of cephaloematome, by the general form of 
 the cranium, the separation of its bones, and particularly the situa- 
 tion of the hernia, which always occupies a point corresponding 
 with one of the fontanelles, principally the anterior and superior. 
 This diagnosis is important, in order not to confound the disease 
 with a sanguineous tumour of the cranium, into which we might 
 be tempted to plunge a bistoury, which must be guarded against 
 in this case ; the compression even would be injurious, and we 
 should content ourselves with simply covering the tumour, and 
 protecting it against external violence. This malady almost al- 
 ways coexists with hydrocephalus, and occasions, sooner or later, 
 the death of the infant. 
 
INDEX. 
 
 Page 
 
 A. 
 
 Abdomen, Pains in the .... 103 
 
 . Tension of the . . .140 
 
 Tension of, in the Infant . 520 
 
 Accoucheur, Conduct of, in Presentation 
 
 of the Face 403 
 
 Acidity 88 
 
 Adhesions, abnormal .... 471 
 
 After-pains 221 
 
 Agalaxy 479 
 
 Amnios 55 
 
 Hydropsy of the . . .94 
 
 Amniotic Fluid 58 
 
 Anencephalie 525 
 
 Annexa 87 
 
 Ante-flexion 115 
 
 Ante-version 138 
 
 Anus, imperforate 523 
 
 Apoplexy of the New-born Infant . .213 
 
 Apthae 519 
 
 Areola 27 
 
 Arms, Descent of, with the Head . . 275 
 Arms, Righting of the . . . . 369 
 
 Ascites 302 
 
 Astomia 522 
 
 Attentions to the Female during Labour 204 
 
 to the Female after the Deliv- 
 
 ery of the Placenta . .218 
 to Mother and Child after 
 
 Delivery . . . .211 
 
 Atresia 522 
 
 Auscultation in Pregnancy . . .47 
 
 B. 
 
 Ballottement 35 
 
 Births, tardy and precocious . . .166 
 
 Birth, Marks at 509 
 
 Bladder, Lesions in the Functions of . 98 
 
 Paralysis of . . . .490 
 
 Blood, Loss of 141 
 
 Blunt Hook 439 
 
 Bones, Cranial, Depression and Frac- 
 ture of the 511 
 
 Breast, Tissues of the . . . .482 
 
 Swelling of the, in the New-born 
 
 Infant 
 
 Breasts, Modifications of the . 
 
 Engorgement of the . 
 
 Inflammation of the . 
 
 Tumefaction and Pain in the 
 
 Bronchocele 
 
 C. 
 
 Caduca .54 
 
 Caesarean Operation .... 384 
 Cellular Tissues, (Edema and Harden- 
 ing of the 514 
 
 Cephalalgia 101 
 
 Cephalaeraatome 510 
 
 Cephalotomy 380 
 
 Cephalotnbe 381, 440 
 
 Cephalotripsy 381 
 
 Page 
 
 Cervix. Modifications of the . . . 45 
 
 Obliteration of the' . . .273 
 
 Elongation and Lacerations of the 483 
 
 ■ Obstacles occasioned by the . 273 
 
 Cervix of the Uterus . . . .13 
 Child, Dressing the .... 215 
 
 Chorion 54 
 
 Circulation, Foetal 67 
 
 Disturbance of the . . 90 
 
 Coccyx 2 
 
 Luxation of the .... 488 
 
 Colic in the Infant 520 
 
 Conception 20 
 
 Congenital Weakness .... 215 
 
 Constipation 89 
 
 Contraction 173 
 
 Contractions, Irregular or Pathological 
 
 230, 479 
 
 Uterine, Debility of the . 230 
 
 Convulsions 104, 263 
 
 Cord, Umbilical 57 
 
 Ligature of the . . 212 
 
 Debility of the . . 468 
 
 Procidentia of . . 239 
 
 Prolapsion of the . 224 
 
 Shortness of the . . 247 
 
 Cough 94 
 
 Cough, Nervous 103 
 
 Cramps 102, 238 
 
 Cranium, Perforation of the . . . 380 
 
 D. 
 
 Debility of the Uterine Contractions . 230 
 
 of the Cord . . . .468 
 
 of the Uterus . . . .226 
 
 Deformities, Pelvic .... 113 
 Indications during Pregnan- 
 cy 130 
 
 Indications during Labour 129 
 
 Indications in the Pelvic 
 
 Extremity . . .113 
 
 of the Soft Parts . . 135 
 
 Delivery in General . . . .166 
 
 Physiological Phenomena of . 170 
 
 Spontaneous . . . .186. 
 
 Premature .... 163 
 
 Premature Artificial . . 131 
 
 Spontaneous, at Term . . 167 
 
 Mento-posterior . . . 399 
 
 Occipito-posterior . . . 199 
 
 in Presentation of the Trunk . 443 
 
 Effects of, in the Intestines, 
 
 Bladder, &c. ... 490 
 
 Anomalies in . . . .198 
 
 Consequences of, attentions . 219 
 
 Attentions to Mother and Child 
 
 after 21J 
 
 Descent 13» 
 
 of the Head and Fore-arm . 275 
 
 of the Head and Feet . .368 
 
 Diarrhoea 89 
 
 of New-born Infant . . 520 
 
528 
 
 INDEX. 
 
 Digestive Functions, Disturbance of 
 
 Dilatation 
 
 Discharges, Mucous 
 
 Diseases of Pregnancy . 
 
 Diseases foreign to Labour 
 
 Dressing the Child 
 
 Dyspepsia 
 
 Dyspnoea 
 
 Page 
 
 26 
 
 45 
 
 98 
 
 85 
 
 238 
 
 215 
 
 94, 103 
 
 Ecchymoses 509 
 
 Eclampsia 104, 163 
 
 Embryo of one Month . . . .23 
 Embryotomy in the Presentation of the 
 
 Trunk 364 
 
 Encephalocele 526 
 
 Ergot 226 
 
 Eructations 520 
 
 Erysipelas 513 
 
 Erythema of the New-bom Infant . . 512 
 
 Eventrations 139, 235 
 
 Evolution, Spontaneous . . .444 
 
 Excrescences 522 
 
 Exhaustion 231 
 
 Face, Accidents 407 
 
 Presentation of the 390 
 
 Prognosis of . • 402 
 
 Varieties of . . 393 
 
 Facial Nerve, Paralysis of 512 
 
 Fallopian Tubes 12 
 
 Fever, Milk . . . . . .223 
 
 Puerperal 498 
 
 depending on the Condition of the 
 
 Genital Organs 
 
 Filet 
 
 Fistulae, Vesico-vaginal . 
 
 Recto-vaginal .... 
 
 Head, Delivery of the, after the Descent 
 of the Trunk . 
 
 Diameters of the . 
 
 Heart, foetal, Pulsations of the 
 
 Hemorrhages . 
 
 Hemorrhage during Pregnancy 
 
 after Delivery 
 
 Internal 
 
 Umbilical . 
 
 Uterine 
 
 Page 
 
 . 446 
 . 61 
 . 40 
 . 94 
 . 141 
 . 473 
 
 256, 516 
 . 517 
 . 250 
 . 93 
 . 521 
 
 139, 235 
 . 439 
 . 521 
 
 302, 525 
 . 81 
 . 94 
 . 525 
 . 96 
 . 302 
 . 287 
 
 508 
 
 523 
 
 484 
 
 484 
 
 Fluid, Amniotic 58 
 
 Foetal Circulation 67 
 
 Foetus at Term 59 
 
 Attitude of the . . . .63 
 
 Presentations and Positions of . 177 
 
 Excessive Size of the . 289, 301 
 
 Nutrition of the . . . .65 
 
 Head of the 60 
 
 Viability of the .... 69 
 
 Functions of the . . . . 65 
 
 Multiple, adherent . . .286 
 
 Multiple, separate . . .284 
 
 Fontanelles 61 
 
 Foramen Ovale, Persistance of . . 524 
 
 Forceps 305 
 
 Application of after Delivery of 
 
 the Trunk . . . .440 
 
 Application of in Presentation of 
 
 the Vertex . . . .316 
 
 Application of in Presentation of 
 
 the Face . . . .411 
 
 Accidents from Application of . 348 
 
 Fungus Haematodes .... 509 
 
 G. 
 
 Galacterrhea 477 
 
 Gangrene of the New-born Infant . . 514 
 
 of the Vulva in the New-born 
 
 Infant 516 
 
 Generation, Organs of . . . .11 
 
 H. 
 Hare-lip 523 | Membranes, Resistance of 
 
 Hemorrhoids 
 Hernia, Congenital . 
 
 of the Uterus 
 
 Hook, Blunt . 
 Hydrocele, Congenital . 
 Hydrocephalus 
 Hydrometry . 
 Hydropsy of the Amnios . 
 Hydrorachy . 
 Hydrorrhea 
 Hydrothorax . 
 Hymen, Persistance of . 
 
 I. 
 
 Ichthyosis 513 
 
 Impressions, Moral 228 
 
 Indications to be fulfilled in Pelvis of ex- 
 cessive Size 114 
 
 Inertia of the Uterus .... 225 
 
 Infant, Acephalous 525 
 
 : Death of the .... 228 
 
 Tumours developed on the . . 303 
 
 Colic in the 520 
 
 New-born, Diseases of . . 509 
 
 Apoplexy of . . 213 
 
 Asphyxia of the . . 213 
 
 Diarrhoea of the . . 520 
 
 Erythema of the . 512 
 
 Gangrene of the . 514 
 
 Jaundice of the . . 515 
 
 Leucorrhea in the . 516 
 
 Inferior Strait 7 
 
 Instruments with which the Accoucheur 
 
 should provide himself . . . 204 
 Itching 140 
 
 L. 
 
 Labia Majora, Union of . . . . 287 
 
 Labour Bed 209 
 
 Labour, Physiological Phenomena of . 173 
 
 Premature 163 
 
 Duration of . . . .173 
 
 Accidents of . . . .239 
 
 Causes of 167 
 
 Mechanism of, by the Vertex . 187 
 
 Anomalies in ... . 270 
 
 Attentions to the Female during 204 
 
 -Touch during . . . .207 
 
 Leucorrhea in the New-born Infant . 516 
 
 Lochia 222 
 
 Loins, Pains in 102 
 
 Longings 88 
 
 M. 
 
 Malacosteon 121 
 
 19 
 101 
 509 
 187 
 247 
 432 
 
 Mammae 
 
 Mania during Pregnancy 
 
 Marks at Birth .... 
 
 Mechanism of Labour by the Vertex 
 
 Meconium 
 
 Escape of 
 
 229, 272 
 
INDEX. 
 
 529 
 
 Membranes, Rupture of . 
 Membranous Sac . 
 Menses, Retention of 
 Mento-posterior Delivery 
 Metro-peritonitis, Epidemic . 
 
 Puerperal . 
 
 Inflammatory 
 
 Milk Fever .... 
 Miscarriage, Treatment of 
 
 Causes of . 
 
 during Pregnancy 
 
 Page 
 
 229 
 175 
 80 
 399 
 498 
 493 
 494 
 223 
 154 
 142 
 141 
 
 Mobility of the Uterus 
 
 Modifications of the Uterus and of the 
 
 Foetus, and Diagnosis of Pregnancy 21, 53 
 Modifications in the Breasts . . .26 
 
 Molar Pregnancy 82 
 
 Monstrosities 286 
 
 Moral Impressions 228 
 
 Movements, Active 33 
 
 Passive . . . .35 
 
 Mucous Discharges . . . .98 
 
 N. 
 
 Nausea 84 
 
 Neck, Elongation and Lacerations of the 483 
 Nerve, Facial, Paralysis of the . . 512 
 Nervous System, Disturbance of the 26, 101 
 Nursing, Circumstances favourable to . 164 
 Nutrition of the Fœtus . . . .65 
 
 O. 
 
 Obliquities of the Uterus . . 139,232 
 Obstetrical Operations .... 305 
 
 Odontalgia 101 
 
 OSdema 92 
 
 GEdema of the Vulva . . . .492 
 GEdema and hardening of the Cellular 
 
 Tissues 514 
 
 Ophthalmia, Purulent .... 517 
 Organs of Generation . . . .11 
 Orifice, External, Agglutination of the . 272 
 Orifice of the Uterus, Rigidity of . 273, 367 
 
 Os Innominatum 2 
 
 Ovaries 12 
 
 Ovule of twelve Days . . . .22 
 Ovum, Human, a* Term . . .54 
 
 P. 
 
 Pain 102 
 
 Palate, Division of 523 
 
 Palpitations 102 
 
 Parturition, Mechanical Obstacles to . 272 
 
 Pelvic Cavity 293 
 
 Tumours of the . . 295 
 
 Pelvic Extremity, Presentation of . .418 
 
 Accidents . . .431 
 
 Prognosis of . . 427 
 
 Manual Delivery of the 438 
 
 Pelvis 1 
 
 Bones of the 1 
 
 Articulations of the . . .3 
 
 in general 5 
 
 excessive Size of the . . . 114 
 
 Axes of the 10 
 
 Deformities of the . . .113 
 
 Oblique of Naegele . . .119 
 
 Diameters of the, compared with 
 
 those of the Foetus . . .60 
 
 Pemphigus 513 
 
 Perforation of the Cranium . . .380 
 
 Perineum 19 
 
 Perforation of the . . . 487 
 
 Perineum, Destruction of the 
 
 Lacerations of the 
 
 Resistance of the 
 
 Support of the 
 
 Page 
 
 487 
 484 
 287 
 210 
 498 
 507 
 84 
 55 
 
 Peritonitis, Puerperal 
 Phlegmasia Alba Dolens 
 Pica 
 
 Placenta ... 
 Accidents connected with De- 
 livery of the . . . . 473 
 
 Abnormal Adhesions of the . 471 
 
 Natural Delivery of the . . 215 
 
 Artificial Delivery of the . . 467 
 
 Attentions to the Female after 
 
 the Delivery of the . .218 
 
 Plethora 90 
 
 Pregnancy 21 
 
 . 47 
 
 Auscultation in 
 
 Miscarriage and Hemorrhage 
 
 during . . . .94 
 
 Abnormal Extra-uterine . 79 
 
 Compound . . . .72 
 
 Nervous . . . .82 
 
 Molar 82 
 
 Influence of on Disease .165 
 
 Diseases of . . . .85 
 
 Mania during . . .101 
 
 Presumptive Signs of . .24 
 
 Probable and certain Signs of 29 
 
 Attentions during . . . 163 
 
 Presentations and Positions, Classifica- 
 tion of 47, 53 
 
 Presentations and Positions, Diagnosis of 47 
 Presentations, Varieties of . . 278, 409 
 Presentation of the Face . . . 390 
 of the Head, Causes of . 63 
 
 of the Vertex 
 of the Trunk 
 
 Procidentia of the Cord . 
 Prognosis of Face Presentations 
 of Pelvic Extremity 
 
 Prolapsion of the Umbilical Cord 
 
 of the Rectum 
 
 of the Uterus . 
 
 182, 284 
 . 441 
 . 239 
 . 402 
 . 427 
 . 224 
 . 522 
 . 235 
 
 Pruritus 140 
 
 Ptyalism 89 
 
 Puerperal Fever 498 
 
 Neuralgic Form of . 504 
 
 Typhoid Form of . 506 
 
 R. 
 
 Rachitis 121 
 
 Recto-vaginal Fistulae .... 484 
 Rectum, Prolapsion of the . . . 522 
 
 Retro-flexion 138 
 
 Retro-version 138 
 
 Rotation, Causes of ... . 202 
 
 S. 
 
 Sac, Membranous 175 
 
 Sacrum 1 
 
 Signs of Pregnancy, Synopsis of . .53 
 
 Skin, Absence of 522 
 
 Souffle, Uterine 38 
 
 Spasms 103 
 
 Sprue 518 
 
 Stomatitis 518 
 
 Strait, Superior 6 
 
 Inferior 7 
 
 Sutures 60 
 
 Symphysis Pubis 4 
 
 Sacro-coccygeal ... 5 
 
530 
 
 INDEX. 
 
 Symphyses Sacro-iliac . 
 Relaxation of 
 
 99 
 
 Symphyseotomy 383 
 
 Syncope 102, 237 
 
 Syphilitic Vesicles 513 
 
 T. 
 
 Thrombus of the Vagina and Labia 300, 492 
 
 Tongue-tie 523 
 
 Touch 29 
 
 during Labour .... 207 
 
 Trunk, Presentation of .... 441 
 Tubercles, Papillary . . . .27 
 Tumours, Sanguineous .... 509 
 
 Turning 348 
 
 Twins 203 
 
 Diagnosis of .... 73 
 
 Delivery of Placentia in Case of . 218 
 
 Version in Case of . . .366 
 
 Tympanitis 491 
 
 
 U. 
 
 Umbilical Cord 
 
 Umbilical Vesicle . 
 Urine, Incontinence of 
 Uterine Souffle 
 Uterus . 
 
 ■ Structure of the 
 
 Cervix of the 
 
 Rupture of the 
 
 Cavity of the 
 
 Prolapsion of the 
 
 Descent of the 
 
 Distension of the 
 
 Debility of the 
 
 Inertia of the 
 
 Spasm of the 
 
 Retraction of the 
 
 Inversion of 
 
 Hernia of the 
 
 Rheumatism of the 
 
 103, 
 
 57 
 . 224 
 . 23 
 . 491 
 
 38 
 . 12 
 . 15 
 . 13 
 . 265 
 . 15 
 . 235 
 
 138, 488 
 . 228 
 . 226 
 
 225, 467 
 . 103 
 . 368 
 . 476 
 
 139, 235 
 236, 493 
 
 Uterus, Mobility of the . . . .368 
 
 Obliquities of the . . 139,232 
 
 Orifice of the, Contraction of . 230 
 
 Unnatural Direc- 
 
 tion of . .232 
 
 Rigidity of . 273, 367 
 
 V. 
 
 Vagina 16 
 
 Rupture of the . , . .268 
 
 Contraction of the . . .289 
 
 Lacerations of the . . . 483 
 
 Vagina and Labia, Tumours of the . 300 
 
 Varices 93 
 
 Variole 513 
 
 Vergetures 46 
 
 Version 348 
 
 Cephalic 450 
 
 Difficulties of Pelvic . . .366 
 
 Impossible 461 
 
 Pelvic 349 
 
 Pelvic, in Presentation of the 
 
 Trunk 451 
 
 Spontaneous .... 444 
 
 Vertex, Presentation of . . . • 182 
 
 Vertigo 102 
 
 Vesicle, Umbilical 23 
 
 Vesicles, Syphilitic .... 513 
 Vesico-vaginal Fistula? .... 484 
 
 Vomiting 237 
 
 in the Infant . . . .519 
 
 Vulva 18 
 
 Thrombus of the . . . .492 
 
 Contraction of the . . .366 
 
 Lacerations of the . . . 485 
 
 Gangrene of the, in the New-bom 
 
 Infant 514 
 
 (Edema of the . . . .492 
 
 Vulva and Vagina, Tumours in the . 300 
 
 W. 
 
 Water, Loss of 246 
 
 Weakness, Congenital .... 215 
 
 THE END. 
 
 
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