Class Book COPYRIGHT DEPOSIT A TREATISE THE SCIENCE AND PRACTICE MIDWIFERY. • BY W. S.TLAYFALR, M.I).,F.R.CP., PHYSICIAN-ACCOPCHEUR TO H. I. AND R. H. THE DCCHESS OF EDINBURGH ; PROFESSOR OF OBSTETRIC MEDICINE IN KING'S COLLEGE ; PHYSICIAN FOR THE DISEASES OF WOMEN AND CHILDREN TO KINO'S COLLEGE HOSPITAL J CONSULTING PHYSICIAN TO THE GENERAL LYING-IN HOSPITAL, AND TO THE EVELINA HOSPITAL FOR CHILDREN ; PRESIDENT OF THE OBSTETRICAL SOCIETY OF LONDON J LATE EXAMINER IN MIDWIFERY TO THE UNIVERSITY OF LONDON, AND TO THE ROYAL COLLEGE OF PHYSICIANS. THIRD AMERICAN EDITION, REVISED AND CORRECTED BY THE AUTHOR. WITH NOTES AND ADDITIONS BY ROBERT P. HARRIS, M.D WITH TWO PLATES AND ONE HUNDRED AND EIGHTY-THREE ILLUSTRATIONS. - PHILADELPHIA: HEKEY C. LE 1880. ■fix l8do Entered according to Act of Congress, in the year 1880, by HENRY C. LEA, in the Office of the Librarian of Congress. All rights reserved. COLLINS, PRINTER, TO T. GAILLARD THOMAS, M.D., PROFESSOR OF OBSTETRICS IN THE COLLEGE OF PHYSICIANS AND SURGEONS, NEW YORK. Dear Dr. Thomas : I am desirous of marking my gratitude for the kind reception of my book in America, where so much valuable obstetric work has been done, by associating with the Second Edition the name of one whose many important contributions to the branch of Medicine of which it treats have gained for him so great and so well-deserved a reputation. I could wislt that it were more worthy of the honor you do me in allowing me to dedicate it to you ; but, such as it is, I beg you to accept it as a mark of the high esteem in which you, as well as your fellow laborers in obstetric science, are held in the mother country. I am, very faithfully yours, W. 8. PLAYFAIR. 31 George Street, Hanover Square, 1878. (iii) AMERICAN PUBLISHER'S NOTICE It will be seen that this edition has been carefully revised by the author specially for this country, thus presenting the subject in its latest aspect from a trans-atlantic stand-point. There still remained some matters in which American opinion and practice differ from those of England, and these it has been the effort of the Editor to present, as before, in a manner as concise as possi- ble. They chiefly relate to the use of forceps and to the Cesarean section. The statistics of the latter, as far as regards the United Kingdom, have been compiled especially for this work, while those of the United States will be found the most complete that have hitherto been collected. Besides these, a number of other points have been briefly alluded to, such as the progress of the Porro operation ; the possibility of life in utero after the death of the mother; the management of occipito-posterior positions; the results, in the United States, of the abdominal section after ruptured uterus, etc. In all cases the text of the Author has been left intact, and the additions have been distinguished by inclosure in brackets [ — ]. Philadelphia, December, 1879. CO 2- JffOL rREFACE TO THE THIRD AMERICAN EDITION. The Second American Edition of my work on Midwifery being exhausted before the corresponding English Edition, I cannot better show my appreciation of the kind reception my book has received in the United States, than by acceding to the Publisher's request that I should myself undertake the issue of a third edition. As little more than a year has elapsed since the second edition was issued, there are naturally not many changes to make ; but I have, nevertheless, subjected the entire work to careful revision, and introduced into it a notice of most of the more important recent additions to obstetric science. To the operation of Gastro-Elvtrot- omy, formerly briefly discussed along with the Cesarean section, I have now devoted a separate chapter. In the preparation of this I have to acknowledge my indebtedness to Dr. (xarrigues's exhaustive article on the operation, recently published in the New York Med- ical Journal, of which, indeed, it is little more than an abstract. The Editor of the Second American Edition, Dr. Harris, enriched it with many valuable notes, of which, it will be observed, I have freelv availed mvself. 31 George Street, Haxover Square, London, September, 1S79. (vii) PREFACE TO THE FIRST EDITION. Those who have studied the progress of Midwifery know that there is no department of medicine in which more has been done of late years, and none in which modern views of practice differ more widely from those prevalent only a short time ago. The Author's object has been to place in the hands of his readers an. epitome of the science and practice of midwifery which embodies all recent advances. He is aware that on certain important points he has recommended practice which not long ago would have been considered heterodox in the extreme, and which, even now, will not meet with general approval. He has, however, the satisfaction of knowing that he has only done so after very deliberate reflection, and with the profound conviction that such changes are right, and that they will stand the test of experience. He has endeavored to dwell especially on the practical part of the subject, so as to make the work a useful guide in this most anxious and responsible branch of the profession. It is admitted by all that emergencies and difficulties arise more often in this than in any other branch of practice; and there is no part of the practitioner's work which, requires more thorough knowledge or greater experience. It is, moreover, a lamentable fact that students generally leave their schools more ignorant of obstetrics than of any other subject. So long as the absurd relations exist, which oblige the lecturer on midwifery to attempt the impossible task of teaching obstetrics in a short three months' course — an absurdity which has over and over again been pointed out — such must of necessity be the case. This must be the Author's excuse for dwelling on many topics at greater (ix) X PREFACE TO THE FIRST EDITION. length than some will doubtless think their importance merits, since he desires to place in the hands of his students a work which may in some measure supply the inevitable defects of his lectures. Many of the illustrations are copied from previous authors, while some are original. The following quotation from the preface to Tyler Smith's " Manual of Obstetrics" will explain why the source of the copied woodcuts has not been in each instance acknowledged: " When I began to publish, I determined to give the authority for every woodcut copied from other works ; I soon found, however, that obstetric authors of all countries, from the time of Mauri- ceau downwards, had copied each other so freely without acknowl- edgment as to render it difficult or impossible to trace the originals." The Author has to express his acknowledgments to many friends for their kind assistance by the loan of illustrations and otherwise, and more especially to his colleague, Dr. Hayes, for his valuable aid in passing the work through the press. 31 GrEORGE STREET, HANOVER SQUARE, March, 1876 CONTENTS. PAET I ANATOMY AND PHYSIOLOGY OF THE ORGANS CONCERNED IN PARTURITION. CHAPTER I. ANATOMY OF THE PELVIS. PAGE Its importance — Formation of Pelvis — The os innominatum : its three divisions — Separation between the True and False Pelvis— the Sacrum and Coccyx — Me- chanical relations of the Sacrum — Pelvic articulations and ligaments — Move- ments of the Pelvic joints — The Pelvis as a whole — Differences in the two sexes — Measurements of the Pelvis — Its diameters, planes, and axes — Development of the Pelvis — Soft parts in connection with the Pelvis 25 CHAPTER II. THE FEMALE GENERATIVE ORGANS. Division according to Function: 1. External or Copulative ; 2. Internal or Form- ative Organs — -Mons Veneris — Labia majora and minora — The Clitoris — The vestibule and orifice of Urethra — Passing of the female catheter — Orifice of Vagina — The Hymen — The glands of the Vulva — The Perineum — The'Vagina — The Uterus ; its position and anatomy — The ligaments of the Uterus — The Parovarium — The Fallopian Tubes — The Ovaries — The Graafian Follicles, and the Ova 41 CHAPTER III. OVULATION AND MENSTRUATION. Functions of the Ovary— Changes in the Graafian Follicle: 1. Maturation; 2. Escape of the Ovum — Formation of the Corpus Luteum — Quality and source of the Menstrual blood— Theory of Menstruation — Purpose of the Menstrual loss -Vicarious Menstruation — Cessation of Menstruation 73 (xi) Xll CONTENTS. PAET II. PREGNANCY. CHAPTER I. CONCEPTION AND GENERATION. PAGE The Semen — Site and mode of Impregnation — Changes in the Ovum — Cleavage of the Yelk — The Decidua and its formation — Formation of the Amnion — The Umbilical Vesicle and Allantois — The Liquor Amnii and its uses — The Chorion — The Placenta ; its formation, anatomy, and functions . . . . .86 CHAPTER II. THE ANATOMY AND PHYSIOLOGY OF THE FOETUS. Appearance of the Foetus at various stages of development — Anatomy of the Foetal Head — The Sutures and Fontanelles — Influence of Sex and Race on the Foetal Head — Position of the Foetus in utero — Functions of the Foetus — The Foetal Circulation 109 CHAPTER III. PREGNANCY. Changes in the form and dimensions of the Uterus — Changes in the Cervix — Changes in the texture of the Uterine Tissues, the Peritoneal, Muscular, and Mucous Coats — General modifications in the Body produced by Pregnancy . 125 CHAPTER IV. SIGNS AND SYMPTOMS OF PREGNANCY. Signs of a fruitful Conception — Cessation of Menstruation — Sympathetic disturb- ances: Morning Sickness, etc. — Mammary Changes — Enlargement of the Ab- domen — Quickening — Intermittent Uterine Contractions — Vaginal Signs of Pregnancy — Ballottement, etc. — Auscultatory Signs of Pregnancy — Foetal Pul- sations — Uterine Souffle, etc. .......... 135 CHAPTER V. THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY SPURIOUS PREGNANCY THE DURATION OF PREGNANCY SIGNS OF RECENT PREGNANCY. Adipose enlargement of the Abdomen — Distension of the Uterus by retained Menses, etc. — Congestive enlargement of Uterus — Ascites — Uterine and Ovarian Tumors — Spurious Pregnancy: its Causes, Symptoms, and Diagnosis — The duration of Pregnancy — Sources of Fallacy — Methods of Predicting Date of De- livery — Protraction of Pregnancy — Signs of recent Delivery . . . .150 ^ CONTENTS. Xlll CHAPTER VI. ABNORMAL PREGNANCY, INCLUDING MULTIPLE PREGNANCY, SUPER- FCETATION, EXTRA-UTERINE FCETATION, AND MISSED LABOR. PAGE Plural Births, their frequency ; Relative frequency in different Countries : Causes, etc. — Super^fcetation and Super-fecundation — Nature — Explanation — Objections to admission of such cases — Their possibility admitted — Extra- Uterine Pregnancy — Classification — Causes — Tubal Pregnancies — Changes in the Fallopian Tubes — Condition of Uterus — Progress and Termination — Diag- nosis — Treatment — Abdomin al Pregnancy : Description; Diagnosis; Treatment — Missed Labor : its Symptoms, Causes, and Treatment . . . . .160 CHAPTER VII. DISEASES OF PREGNANCY. Some only Sympathetic, others Mechanical or Complex in their Origin — Derange- ments of the Digestive Organs : Excessive Nausea and Vomiting ; Diarrhoea ; Constipation ; Hemorrhoids ; Ptyalism ; Toothache and Caries of Teeth ; Affec- tions of Respiratory Organs ; Dyspnoea, etc. — Palpitation — Syncope — Anaemia and Chlorosis — Albuminuria .......... 188 CHAPTER VIII. DISEASES OF PREGNANCY (continued). Disorders of the Nervous System : Insomnia ; Headaches and Neuralgia ; Paraly- sis ; Chorea ; Disorders of the Urinary Organs ; Retention of Urine ; Irritability of the Bladder ; Incontinence of Urine ; Phosphatic Deposits ; Leucorrhcea ; Effects of Pressure ; Laceration of Veins ; Displacements of the Gravid uterus ; Prolapse, Anteversion, Retroversion — Diseases coexisting with Pregnancy : Eruptive Fevers ; Smallpox, Measles, Scarlet Fever, Continued Fever ; Phthisis ; Cardiac Disease ; Syphilis : Icterus ; Carcinoma ; Pregnancy complicated with Ovarian and Fibroid Tumors 201 CHAPTER IX. PATHOLOGY OF THE DECIDUA AND OVUM. Pathology of the Decidua — Hydrorrhoea Gravidarum — Pathology of the Chorion ; Vesicular Degeneration, Myxoma Fibrosum — Pathology of the Placenta ; Blood Extravasations, Fatty Degeneration, etc. — Pathology of the Umbilical Cord — Pathology of the Amnion, Hydramnios ; Deficiency of Liquor Amnii, etc. — Pathology of the Foetus ; Blood Diseases transmitted through the Mother, Small- pox, Measles, and Scarlet Fever, Intermittent Fevers, Lead-poisoning, Syphilis — Inflammatory Diseases — Dropsies — Tumors — Wounds and Injuries of the Foetus — Intrauterine Amputations — Death of the Foetus . . . . .211 Xll CONTENTS. PAET II. PREGNANCY. CHAPTER I. CONCEPTION AND GENERATION. PAGE The Semen — Site and mode of Impregnation — Changes in the Ovum — Cleavage of the Yelk — The Decidua and its formation — Formation of the Amnion — The Umbilical Vesicle and Allantois — The Liquor Amnii and its uses — The Chorion — The Placenta ; its formation, anatomy, and functions . . . . .86 CHAPTER II. THE ANATOMY AND PHYSIOLOGY OF THE FOETUS. Appearance of the Foetus at various stages of development — Anatomy of the Foetal Head — The Sutures and Fontanelles — Influence of Sex and Race on the Foetal Head — Position of the Foetus in utero — Functions of the Foetus — The Foetal Circulation ............. 109 CHAPTER III. PREGNANCY. Changes in the form and dimensions of the Uterus — Changes in the Cervix — Changes in the texture of the Uterine Tissues, the Peritoneal, Muscular, and Mucous Coats — General modifications in the Body produced by Pregnancy . 125 CHAPTER IV. SIGNS AND SYMPTOMS OF PREGNANCY. Signs of a fruitful Conception — Cessation of Menstruation — Sympathetic disturb- ances: Morning Sickness, etc. — Mammary Changes — Enlargement of the Ab- domen — Quickening — Intermittent Uterine Contractions — Vaginal Signs of Pregnancy — Ballottement, etc. — Auscultatory Signs of Pregnancy — Foetal Pul- sations — Uterine Souffle, etc. .......... 135 CHAPTER V. THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY SPURIOUS PREGNANCY THE DURATION OF PREGNANCY SIGNS OF RECENT PREGNANCY. Adipose enlargement of the Abdomen — Distension of the Uterus by retained Menses, etc. — Congestive enlargement of Uterus — Ascites — Uterine and Ovarian Tumors — Spurious Pregnancy: its Causes, Symptoms, and Diagnosis — The duration of Pregnancy — Sources of Fallacy — Methods of Predicting Date of De- livery — Protraction of Pregnancy — Signs of recent Delivery .... 150 CONTENTS. Xlll CHAPTER VI. ABNORMAL PREGNANCY, INCLUDING MULTIPLE PREGNANCY, SUPER- FCETATION, EXTRA-UTERINE FtETATION, AND MISSED LABOR. PAGE Plural Births, their frequency ; Relative frequency in different Countries ; Causes, etc. — Super-foetation and Super-fecundation — Nature — Explanation — Objections to admission of such cases — Their possibility admitted — Extra- Uterine Pregnancy — Classification — Causes — Tubal Pregnancies — Changes in the Fallopian Tubes — Condition of Uterus — Progress and Termination — Diag- nosis — Treatment — Abdominal Pregnancy : Description ; Diagnosis ; Treatment — Missed Labor : its Symptoms, Causes, and Treatment 160 CHAPTER VII. DISEASES OF PREGNANCY. Some only Sympathetic, others Mechanical or Complex in their Origin — Derange- ments of the Digestive Organs : Excessive Nausea and Vomiting ; Diarrhoea ; Constipation ; Hemorrhoids ; Ptyalism ; Toothache and Caries of Teeth ; Affec- tions of Respiratory Organs ; Dyspnoea, etc. — Palpitation — Syncope — Anaemia and Chlorosis — Albuminuria .......... 188 CHAPTER VIII. diseases of pregnancy (continued). Disorders of the Nervous System : Insomnia ; Headaches and Neuralgia ; Paraly- sis ; Chorea ; Disorders of the Urinary Organs ; Retention of Urine ; Irritability of the Bladder ; Incontinence of Urine ; Phosphatic Deposits ; Leucorrhcea : Effects of Pressure ; Laceration of Veins ; Displ acements of the Gravid uterus ; Prolapse, Anteversion, Retroversion — Diseases coexisting with Pregnancy : Eruptive Fevers ; Smallpox, Measles, Scarlet Fever, Continued Fever ; Phthisis ; Cardiac Disease ; Syphilis ; Icterus ; Carcinoma ; Pregnancy complicated with Ovarian and Fibroid Tumors 201 CHAPTER IX. PATHOLOGY OF THE DECIDUA AND OVUM. Pathology of the Decidua — Hydrorrhoea Gravidarum — Pathology of the Chorion ; Vesicular Degeneration, Myxoma Fibrosum — Pathology of the Placenta ; Blood Extravasations, Fatty Degeneration, etc. — Pathology of the Umbilical Cord — Pathology of the Amnion, Hydramnios ; Deficiency of Liquor Amnii, etc. — Pathology of the Foetus ; Blood Diseases transmitted through the Mother, Small- pox, Measles, and Scarlet Fever, Intermittent Fevers, Lead-poisoning, Syphilis — Inflammatory Diseases — Dropsies — Tumors — Wounds and Injuries of the Foetus — Intrauterine Amputations — Death of the Foetus . . . . .218 XIV CONTENTS. CHAPTER X. ABORTION AND PREMATURE LABOR. PAGE Importance and Frequency — Definition and Classification — Frequency — Recur- rence— Causes— Causes Referable to Foetus— Changes in a Dead Ovum retained in Utero— Extravasations of Blood— Moles, etc.— Causes depending on Maternal State— Syphilis ; Causes acting through Nervous System, Physical Causes, etc. —Causes depending on Morbid States of Uterus— Symptoms— Preventive Treat- ment — Prophylactic Treatment — Treatment when Abortion is inevitable — After- treatment 235 PAET III LABOR. CHAPTER I. THE PHENOMENA OF LABOR. Causes of Labor — Mode in which the Expulsion of the Child is effected — The Uterine contraction — Mode in which the Dilatation of the Cervix is effected — Rupture of the Membranes — Character and source of Pains during Labor — Effect of Pains on Mother and Foetus — Division of Labor into Stages — Prepara- tory Stage — False Pains — First Stage — Second Stage — Third Stage — Mode in which the Placenta is expelled — Duration of Labor ..... 248 CHAPTER II. MECHANISM OF DELIVERY IN HEAD PRESENTATIONS. Importance of Subject— Frequency of Head Presentations— The different positions of the Head— First Position— Division of Mechanical Movements into Stages- Flexion — Rotation — Extension — External Rotation — Second Position — Third Position— Fourth Position— Caput Succedaneum— Alteration in shape of Head from moulding .... ....... 261 CHAPTER III. MANAGEMENT OF NATURAL LABOR. Preparatory Treatment— Dress of Patient during Pregnancy — The Obstetric Bag — Duties on first visiting Patient — False Pains — Their Character and Treatment — Vaginal Examination — The Position of Patient — Artificial Rupture of Mem- branes — Treatment of Propulsive Stage — Relaxation of the Perineum — Treat- ment of Lacerations — Expulsion of Child — Promotion of Uterine Contraction — Ligature of the Cord — Management of the Third Stage of Labor — Application of the Binder — After-treatment 274 ■v CONTENTS. XV CHAPTER IV. * ANAESTHESIA IN LABOR. PAGE Agents employed — Chloral : its Object and Mode of administration — Ether — Chloroform: its Use, Objections to, and Mode of administration . . .288 CHAPTER V. PELVIC PRESENTATIONS. Frequency— Causes— Prognosis to Mother and Child— Diagnosis by Abdominal Palpation and by Vaginal Examination— Differential Diagnosis of Breech, Knee, and Feet— Mechanism— Treatment— Management of Impacted Breech Presenta- tions 292 CHAPTER VI. PRESENTATIONS OF THE FACE. Erroneous Views formerly held on the Subject — Frequency — Mode of Production — Diagnosis — Mechanism — Four Positions of the Face — Description of Delivery in First Face Position — Mento-posterior Positions in which Rotation does not take place — Prognosis — Treatment 303 CHAPTER VII. DIFFICULT OCCIPITO-POSTERIOR POSITIONS. Causes of Face to Pubis Delivery — Mode of Treatment — Upward Pressure on Forehead — Downward Traction on Occiput — Use of Forceps — Peculiarities of Forceps Delivery .'........... 313 CHAPTER VIII. PRESENTATIONS OF SHOULDER, AR)I, OR TRUNK COMPLEX PRESENTATIONS PROLAPSE OF THE FUNIS. Position of the Foetus— Division into Dorso-anterior and Dorso-posterior Posi- tions—Causes—Prognosis and Frequency— Diagnosis— Mode of distinguishing Position of Child— Differential Diagnosis of Shoulder, Elbow, and Hand- Mechanism— The Two possible Modes of Delivery by the Natural Powers- Spontaneous Version— Spontaneous Evolution— Treatment— Complex Presenta- tion : Foot or Hand with Head, Hand and Feet together— Dorsal Displacement of the Arm— Prolapse of the umbilical Cord— Frequency— Prognosis— Causes- Diagnosis— Postural Treatment— Artificial Reposition— Treatment when Repo- sition fails ........••••• 317 CHAPTER IX. PROLONGED AND PRECIPITATE LABORS. Evil effects of Prolonged Labor— Influence of the Stage of Labor in Protraction — Delay in First Stage rarely serious — Temporary Cessation of Pains — Symptoms XVI CONTENTS. PAGE of Protraction in the Second Stage — State of the Uterus in Protracted Labor — Cases of Protraction due to Morbid condition of the expulsive powers — Causes of Protraction — Treatment — Oxytocic remedies — Ergot of Rye, etc. — Manual Pres- sure — Instrumental Delivery — Precipitate Labor — Its Causes and Treatment . 332 CHAPTER X. LABOR OBSTRUCTED BY FAULTY CONDITION OF THE SOFT PARTS. Rigidity of the Cervix : its Causes, Effects, and Treatment — Bands and Cicatrices in the Vagina — Extreme rigidity of the Perineum — Labor complicated with Tumor — Vaginal Cystocele — Calculus — Hernial Protrusions — (Edema of Vulva — Haematic Effusions, etc. . . . . . . . . . . 346 CHAPTER XI. DIFFICULT LABOR DEPENDING ON SOME UNUSUAL CONDITION OF THE FCETUS. Plural Births, Treatment of — Locked Twins — Conjoined Twins — Intra-uterine Hydrocephalus : Its Dangers, Diagnosis, and Treatment — Other dropsical Effu- sions — Foetal Tumors — Excessive Development of Foetus 359 CHAPTER XII. DEFORMITIES OF THE PELVIS, Classification — Causes of Pelvic Deformity — Rickets and Osteo-malasia — The Equally enlarged Pelvis — The Equally contracted Pelvis — The Undeveloped Pelvis — Masculine or Funnel-shaped Pelvis — Contraction of Conjugate Diameter of the Brim — Figure-of-eight deformity — Spondylolithesis — Narrowing of the Oblique Diameters — Obliquely contracted Pelvis — Kyphotic Pelvis — Robert's Pelvis — Deformity from old-standing Hip-joint disease — Deformity from Tumors, Fractures, etc. — Effects of Contracted Pelvis on Labor — Risks to the Mother and Child — Mechanism of Delivery in Head Presentation ; a, in Contracted Brim ; b, in Generally contracted Pelvis — Diagnosis — External Measurements — Internal Measurements — Mode of estimating the Conjugate diameter of the brim — Mode of Diagnosing the Oblique Pelvis — Treatment— The Forceps — Turning — The Induction of Premature Labor — Induction of Abortion ..... 371 CHAPTER XIII. HEMORRHAGE BEFORE DELIVERY : PLACENTA PRiEVIA. Definition — Causes — Symptoms — Sources and Causes of Hemorrhage— Prognosis — Treatment 393 CHAPTER XIV. HEMORRHAGE FROM SEPARATION OF A NORMALLY SITUATED PLACENTA Causes and Pathology— Symptoms and Diagnosis — Prognosis — Treatment . . 405 CONTENTS. XV11 CHAPTER XY. HEMORRHAGE AFTER DELIVERY. PAGE Its frequency — Generally a preventable accident — Causes — Nature's method of Controlling Hemorrhage — Uterine Contraction — Thrombosis — Secondary Causes of Hemorrhage — Irregular Uterine Contraction — Placental Adhesions — Consti- tutional Predisposition to Flooding — Symptoms — Preventive treatment — Cura- tive treatment — Secondary post-partum Hemorrhage — Its Causes and Treatment 408 CHAPTER XVI. RUPTURE OF THE UTERUS, ETC. Its Fatality — Seat of Rupture — Causes, predisposing and exciting — Symptoms — Prognosis — Treatment : when the Foetus remains in Utero ; when the Foetus has escaped from the Uterus — Recapitulation — Lacerations of the vagina — Vesico and Recto-vaginal Fistula? — Their mode of Formation — Treatment . . . 426 CHAPTER XVII. INVERSION OF THE UTERUS. Division into Acute and Chronic forms — Description — Symptoms — Diagnosis — Mode of production — Treatment . 435 PAET IV. OBSTETRIC OPERATIONS. CHAPTER I. INDUCTION OF PREMATURE LABOR. History — Objects — May be performed either on account of the Mother or Child — Modes of Inducing Labor — Puncture of Membranes — Administration of Oxyto- cics — Means acting indirectly on the Uterus — Dilatation of Cervix — Separation of Membranes — Vaginal and Uterine douches — Introduction of Flexible Ca- theter 442 CHAPTER II. TURNING. History — Turning by External Manipulation — Object and Nature of the Opera- tion — Cases Suitable for the operation — Statistics and Dangers — Method of performance — Cephalic Version — Method of performance — Podalic Version — Position of Patient — Administration of Anaesthetics — Period when the opera- tion should be undertaken — Choice of Hand to be used — Turning by Bi-polar method — Turning when the Hand is introduced into the Uterus — Turning in Abdomino-anterior Positions — Difficult cases of Arm Presentation . . . 449 2 XV111 CONTENTS. CHAPTER III. THE FORCEPS. PAGE Frequent use of the Forceps in Modern practice*— Description of the Instrument — The Short Forceps — Its Varieties — The Long Forceps — Suitable to all cases alike — Action of the Instrument — Its power as a Tractor, Lever, and Compres- sor — Preliminary considerations before operation — Use of Anaesthetics — De- scription of the Operation — Low Forceps Operation — High Forceps Operation — Possible Dangers of Forceps Delivery — Possible Risks to the Child . . . 465 CHAPTER IV. THE VECTIS. THE FILLET. Nature of the Vectis — Its use as a Lever or Tractor — Cases in which it is appli- cable — Its use as a Rectifier of Malpositions — The Fillet — Nature of the Instru- ment — Objection to its use ' . . . . 489 CHAPTER V. OPERATIONS INVOLVING THE DESTRUCTION OF THE FCETUS. Their Antiquity and History — Division of Subject — Nature of Instruments em- ployed — Perforator — Crotchet — Craniotomy Forceps — Cephalotribe — Forceps- saw — Ecraseur — Cases requiring Craniotomy — Method of Perforation — Extrac- tion of the Head — Comparative merits of Cephalotripsy and Craniotomy— Extraction by the Craniotomy Forceps — Extraction of the Body — Embryotomy — Decapitation and Evisceration 491 CHAPTER VI. THE CESAREAN SECTION SYMPHYSEOTOMY AND LAPARO-ELYTROTOMY. History of the Operation — Statistics — Results to Mother and Child — Causes re- quiring the Operation — Post-mortem Cesarean Section — Causes of Death after the Cesarean Section — Peliminary Preparations — Description of the Operation — Subsequent Management — Substitutes for the Csesarean Section — Symphyse- otomy — Laparo-elytrotomy . . . . .... . . . 506 CHAPTER VII. LAPARO-ELYTROTOMY. History — Nature of the Operation — Advantages over the Csesarean Section — Cases suitable for the operation — Anatomy of the parts concerned in the opera- tion — Method of performance — Subsequent treatment . . . . . 525 CHAPTER VIII. THE TRANSFUSION OF BLOOD. History — Nature and Object of the Operation — Use of Blood taken from the Lower Animals — Difficulties from Coagulation of Fibrine — Modes of Obviating them — Immediate Transfusion — Addition of Chemical Agents to prevent Coagulation — Defibrination of the Blood — Statistical Results — Possible Dangers of the Opera- tion — Cases suitable for Transfusion— Description of the Operation — Effects of Successful Transfusion — Secondary Effects of Transfusion .... 530 CONTENTS. XIX PAET y. THE PUERPERAL STATE. CHAPTER I. THE PUERPERAL STATE AND ITS MANAGEMENT. PAGE Importance of Studying the Puerperal State — The Mortality of Childbirth — Alte- rations in the Blood after Delivery — Condition after Delivery — Nervous Shock — Fall of the Pulse — The Secretions and Excretions — Secretion of Milk — Changes in the Uterus after Delivery — The Lochia — The After-pains — Manage- ment of Women after Delivery — Treatment of Severe After-pains — Diet and Regimen .............. 540 CHAPTER II. MANAGEMENT OF THE INFANT, LACTATION, ETC. Commencement of Respiration after the Birth of the Child — Apparent Death of the new-horn Child — Its Treatment — Washing and Dressing the Child — Ap- plication of the Child to the Breast — The Colostrum and its Properties — Secre- tion of Milk — Importance of Nursing — Selection of a Wet-nurse — Management of Lactation — Diet and Regimen of Nursing Women — Period of Weaning — Disorders of Lactation — Means of Arresting the Secretion of Milk — Defective Secretion of Milk — Depressed Nipples — Fissures and Excoriations of the Nipples — Excessive Flow of Milk — Mammary Abscess — Hand-feeding — Causes of Mor- tality in Hand-feeding — Various kinds of Milk — Method of Hand-feeding . 551 CHAPTER III. PUERPERAL ECLAMPSIA. Its Doubtful Etiology — Premonitory Symptoms — Symptoms of the Attack — Con- dition between the Attacks — Relation of the Attacks to Labor — Results to Mother and Child — Pathology — Treatment — Obstetric Management . . 568 CHAPTER IV. PUERPERAL INSANITY. Classification — Proportion of Various forms — Insanity of Pregnancy — Predispos- ing Causes — Period of Pregnancy at which it occurs — Type of Insanity — Prognosis — Transient Mania during Delivery — Puerperal Insanity (Proper) — Type of Insanity — Causes — Theory of its dependence on a Morbid State of the Blood — Objections to the theory — Prognosis — Post-mortem signs — Duration — Insanity of Lactation — Type — Symptoms — Of Mania — Of Melancholia — Treat- ment — Question of Removal to Asylum — Treatment during Convalescence . 577 XX CONTENTS. CHAPTER V. PUERPERAL SEPTICAEMIA. PAGE Differences of opinion — Confusion from this cause — Modern view of this Disease — History — Its Mortality in Lying-in Hospitals — Numerous Theories as to its Nature — Theory of Local Origin — Theory of an Essential Zymotic Fever — Theory of its identity with Surgical Septicaemia — Nature of this view — Channels through which Septic Matter may be absorbed — Character and Origin of Septic Matter often obscure — Division into Auto-genetic and Hetero-genetic case3 — Sources of Self-infection — Sources of Hetero-genetic Infection — Influence of Cadaveric Poison — Infection from Erysipelas — Infection from other Zymotic Diseases — Contagion from other Puerperal Patients — Mode in which the Poison may be conveyed to the Patient — Conduct of the Practitioner in relation to the Disease — Nature of the Sej)tic Poison — Local changes resulting from the ab- sorption of Septic Material — Channels through which Systemic Infection is produced — Pathological Phenomena observed after general Blood Infection — Four principal Types of Pathological Change — Intense cases without marked Post-mortem Signs — Cases characterized by Inflammation of the Serous Mem- branes — Cases characterized by the impaction of Infected Emboli, and Secondary Inflammation and Abscess — Description of the Disease — Duration — Varieties of Symptoms in different cases — Symptoms of Local Complications — Treatment . 589 CHAPTER VI. PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. Puerperal Thrombosis and its Results — Conditions which favor Thrombosis — Con- ditions which favor Coagulation in the Puerperal State — Distinction between Thrombosis and Embolism — Is primary Thrombosis of the Pulmonary Arteries possible ? — History — Symptoms of Pulmonary Obstruction — Is recovery pos- sible ? — Causes of Death — Post-mortem appearances — Treatment . . . 613 CHAPTER VII. PUERPERAL ARTERIAL THROMBOSIS AND EMBOLISM. Causes — Symptoms — Treatment .......... 624 CHAPTER VIII. OTHER CAUSES OF SUDDEN DEATH DURING LABOR AND THE PUERPERAL STATE. Organic and Functional causes — Idiopathic Asphyxia — Pulmonary Apoplexy — Cerebral Apoplexy — Syncope — Shock and Exhaustion — Entrance of Air into the Veins 626 CHAPTER IX. PERIPHERAL VENOUS THROMBOSIS (SYN. : CRURAL PHLEBITIS PHLEGMASIA DOLENS ANASARCA SEROSA GEDEMA LACTEUM AVHITE LEG, ETC) Nature — Symptoms — History and Pathology — Anatomical form of the Thrombi in the Veins — Detachment of Emboli — Treatment 629 >: CONTENTS. XXI CHAPTER X. PELVIC CELLULITIS AND PELVIC PERITONITIS. PAflE Two Forms of Disease — Variety of Nomenclature — Importance of Differential Diagnosis — Etiology — Connection with Septicaemia — Seat of Inflammation — Relative Frequency of the two forms of Disease — Symptomatology — Results of Physical Examination — Terminations — Prognosis — Treatment . . . 63(i INDEX 645 A. ILLUSTRATIONS. Section of a Frozen Body in the last months of Pregnancy (after Branne). Illus- trating the Relations of the uterus to the surrounding Parts, and the attitude of the Foetus, which is lying in the second Cranial Position. . . Plate I. Section of a Frozen Body at the termination of the first stage of Labor (after Braune) . The bag of membranes is still unbroken, the cervix is fully dilated, and the head (in the second position) is in the pelvic cavity . . Plate II. FIG. PAGB 1. Os innominatum 26 2. Sacrum and Coccyx ........... 27 3. Section of Pelvis and heads of Thigh-bones, showing the Suspensory Action of the Sacro-iliac Ligaments. (After Wood.) . . . .29 4. Outlet of Pelvis 32 5. The Female Pelvis 32 6. The Male Pelvis 33 7. Brim of Pelvis, showing Antero-posterior, Oblique, and Conjugate Diameters 34 8. Transverse section of Pelvis, showing the Diameters . . . . .34 9. Planes, of the Pelvis, with Horizon . . . .. . . . 36 10. Axes of the Pelvis 37 11. Representing general Axis of the Parturient Canal, including the Uterine Cavity and Soft Parts 38 12. Side view of Pelvis 38 13. Pelvis of a Child 39 14. Vascular supply of Vulva. (After Kobelt.) ...... 45 15. Longitudinal section of Body, showing Relation of Generative Organs . 46 16. Transverse section of Bod} r , showing Relations of the Fundus Uteri . . 48 17. Transverse section of Uterus ......... 49 18. Uterus and Appendages in an Infant . . . . . . . .49 19. Portion of Interior of Cervix. (Enlarged nine diameters.) ... 51 20. Muscular Fibres of unimpregnated Uterus. (After Farre.) ... 52 21. Developed Muscular Fibres from the Gravid Uterus. (After Wagner.) . 52 22. Lining Membrane of Uterus, showing network of Capillaries and orifices of Uterine Glands. (After Farre.) ........ 54 23. The Course of the Glands in the fully developed Mucous Membrane of the Uterus. (After Williams.) 54 24. Villi of Os Uteri stripped of Epithelium 55 25. Villi of Uterus, covered with Pavement Epithelium and containing Looped Vessels. (After Tyler Smith and Hassall.) 56 26. Bifid Uterus. (After Farre.) 58 [27. Partitioned Uterns 59] 28. Adult Parovarium, Ovary, and Fallopian Tube. (After Kobelt.) . . 61 29. Posterior view of Muscular and Vascular arrangements. (After Rouget.) . 62 ( xxiii ) XXIV ILLUSTRATIONS. Fid. PAGE 30. Fallopian Tube laid open. (After Richard.) . . . . . .64 31. Ovary enlarged under Menstrual Nisus 65 32. Longitudinal Section of Adult Ovary. (After Farre.) ... .66 33. Section through the cortical part of the Ovary. (After Turner.) . . 67 34. Vertical Section through the Ovary of the Human Foetus. (After Foulis.) 68 35. Diagrammatic Section of Graafian Follicle ....... 69 36. Bulb of Ovary . .70 37. Mammary Gland . .71 38. Section of Ovary, Showing Corpus Luteum three weeks after Menstruation. (After Dalton.) 75 39. Corpus Luteum at the fourth month of Pregnancy. (After Dalton,) . . 76 40. Corpus Luteum of Pregnancy at Term. (After Dalton.) .... 76 41. Sperm Cells and Nuclei 86 42. Ovum of Rabbits containing Spermatozoa ....... 88 43. Formation of the " Polar Globule" 90 44. Segmentation of the Yelk . . . . . ... . . .90 45. Formation of the Blastodermic Membrane. (After Joulin.) ... 91 46. Aborted Ovum (of about forty days), showing the Triangular Shape of the Decidua (which is laid open), and the Aperture of the Fallopian Tube. (After Coste.) 93 47. ^ 48. > Formation of the Decidua. (After Dalton.) ...... 94 49. ) 50. An Ovum removed from the Uterus, and part of the Decidua Vera cut away. (After Coste.) . . . . .94 51. Diagram of Area Germinativa, showing the primitive trace and Area Pel- lucida 96 52. Development of the Amnion . . . . . . . .97 53. Development of the Umbilical Vesicle and Amnion ..... 98 54. An Embryo of about twenty-five days laid open. (After Coste.) . . 98 55. Development of the Chorion 99 56. Placental Villus, greatly magnified. (After Joulin.) ..... 104 57. Terminal Villus of Foetal Tuft, minutely injected. (After Farre.) . . 105 58. Diagram representing a Vertical Section of the Placenta. (After Dalton.) 105 59. Diagram illustrating the Mode in which a Placental Villus derives a Cover- ing from the Vascular System of the Mother. (After Priestley.) . . 106 60. The Extremity of a Placental Villus. (After Goodsir.) . . . .106 61. Anterior and Posterior Fontanelles ........ 113 62. Bi-parietal diameter, Sagittal and Lambdoidal Sutures, with Posterior Fon- tanelle . . . . . . . . . . • • 113 63. Diameters of the Festal Skull 114 64. Mode of ascertaining the Position of the Foetus by Palpation . . .116 65. Diagram illustrating the Effect of Gravity on the Foetus. (After Duncan.) 118 66. Illustrating the greater Mobility of the Foetus and the larger relative amount of Liquor Amnii in Early Pregnancy. (After Duncan.) • • • 118 67. Diagram of Foetal Heart. (After Dalton.) I 22 68. Diagram of Heart of Infant. (After Dalton.) I 23 69. Size of Uterus at various Periods of Pregnancy ...-•• I 26 70. -\ 71. ( Supposed Shortening of the Cervix at the third, sixth, eighth, and ninth 72. ( months of Pregnancy, as figured in Obstetric works . . . .129 73. J ILLUSTRATIONS. XXV FIG. PAGE 74. Cervix of a Woman Dying in the eighth Month of Pregnancy. (After Duncan.) 129 75. Appearance of the Areola in Pregnancy ....... 139 76. Illustrating the Cavity between the Decidua Vera and. the Decidua Reflexa during the early Months of Pregnancy. (After Coste.) . . . 160 77. Tubal Pregnancy, with the Corpus Luteum in the Ovary of the opposite side ............. 169 78. Tubal Pregnancy. (From a specimen in the Museum of King's College.) . 170 79. Extra-uterine Pregnancy at term of the Tubo-Ovarian Variety. (After a case of Dr. A. Sibley CanipbelUs.) 172 80. Uterus and Foetus in a case of Abdominal Pregnancy .... 179 SI. Litkopaedion. (From a preparation in the Museum of the Pioyal College of Surgeons.) ISO 82. Contents of the Cyst in Dr. Oldham's case of Missed Labor . . . 186 83. Hypertrophied Decidua laid open, with the Ovum attached to its Fundal Portion. (After Duncan.) . . . .~ . . . . 219 84. Imperfectly developed Decidua Vera, with the Ovum. (After Duncan.) . 219 85. Hydatiform Degeneration of the Chorion 221 86. Double Placenta, with Single Cord 225 87. Fatty Degeneration of the Placenta 226 88. Knots in the Umbilical Cord ........ 227 89. Intra-uterine Amputation of both Arms and Legs ..... 232 90. An apoplectic Ovum, with Blood effused in masses under the Fcetal Surface of the Membranes ........... 238 91. Blighted Ovum, with Fleshy Degeneration of the Membranes . . . 238 92. Mode in which the Placenta is Naturally Expelled. (After Duncan.) . 259 93. Attitude of Child in first position. (After Hodge.) 264 94. First Position : Movement of Flexion 265 95. First Position : Occiput in Cavity of Pelvis. (After Hodge.) . . .267 96. First Position : Occiput at Outlet of Pelvis. (After Hodge.) . . .267 97. First Position : Head Delivered. (After Hodge.) 269 98. External Rotation of Head in first position. (After Hodge.) . . . 269 99. Third Position of Occiput at Brim of Pelvis 270 100. Fourth Position of Occiput at Pelvic Brim 273 101. Examination during the First Stage of Labor ...... 278 102. Mode of effecting Relaxation of the Perineum ...... 282 103. Usual Method of Removing the Placenta by Traction on the Cord . . 285 104. Illustrating Expression of the Placenta 286 105. First, or left Sacro-cotyloid position of the Breech 296 106. Passage of the Shoulders and partial Rotation of the Thorax . . .297 107. Descent of the Head 298 108. Second position in Face Presentation ........ 303 109. Rotation Forwards of Chin 30S 110. Passage of the Head through the External Parts in Face Presentation . 309 111. Illustrating the position of the Head when Forward Rotation of the Chin does not take place 309 112. Dorso- anterior Presentation of the Arm 318 113. Dorso-posterior Presentation of the Arm . . . . . . . 31 S 114. Commencing Spontaneous Evolution 323 115. Spontaneous Evolution further Advanced 324 116. Dorsal Displacement of the Arm 326 XXVI ILLUSTRATIONS. F' fl ' PAGE 117. Dorsal Displacement of the Arm in Footling Presentations. (After Barnes.) 326 118. Prolapse of the Umbilical Cord 327 119. Postural Treatment of Prolapse of the Cord 329 120. Braim's Apparatus for Replacing the Cord ...... 331 121. Labor complicated by Ovarian Tumor ....... 354 122. Twin Pregnancy, Breech and Head presenting ...... 359 123. Head Locking, both Children presenting Head first. (After Barnes.) . 361 124. Head Locking, first Child coining Feet first : Impaction of Heads from wedging in Brim. (After Barnes.) 362 125. Labor impeded by Hydrocephalus 367 126. Adult Pelvis retaining its Infantile Type 375 127. Rickety Pelvis, with backward depression of Symphysis Pubis . .376 128. Flatness of Sacrum, with narrowing of Pelvic Cavity .... 377 129. Pelvis deformed by Spondylolithesis. (After Killian.) . . . . 377 130. Osteo-malacic Pelvis 378 131. Extreme degree of Osteo-malacic Deformity . ... . . . 379 132. Obliquely Contracted Pelvis, (After Duncan.) 379 133. Robert's, or double obliquely Contracted Pelvis 380 134. Bony Growth from Sacrum obstructing the Pelvic Cavity .... 381 135. Greenhalgh's Pelvimeter .......... 386 136. Section of Foetal Cranium, showing its Conical Form .... 389 137. Showing the greater Breadth of the biparietal Diameter of the Foetal Cra- nium. (After Simpson.) . . . . . . . . 389 138. Showing the greater Space for the biparietal Diameter in certain Cases of Deformity. (After Simpson.) 390 139. Irregular Contraction of the Uterus, with Encystment of the Placenta . 412 140. Partial Inversion of the Fundus ........ 436 141. Illustrating the Commencement of Inversion at the Cervix. (After Duncan.) 439 142. Barnes's Bag for Dilating the Cervix ....... 446 143. First Stage of Bi-polar Version . . . . • . . . . .456 144. Second Stage of Bi- polar Version . . 457 145. Third Stage of Bi-polar Version ........ 457 146. Fourth Stage of Bi-polar Version ........ 458 147. Seizure of the Feet when the Hand is introduced into the Uterus . . 460 148. Drawing down of the Feet and Completion of Version . . . . 461 149. Showing the Completion of Version. (After Barnes.) .... 462 150. Showing the Use of the Right Hand in Abdomino-anterior positions . . 463 151. Denman's Short Forceps .......... 466 152. Zeigler's Forceps . . .467 153. Simpson's Forceps 468 154. Tarnier's Forceps 469 155. Position of Patient for Forceps Delivery, and Mode of Introducing the Lower Blade 473 156. Introduction of the Upper Blade . . . . • • • .415 157. Forceps in position ; Traction in the Axis of the Brim, downwards and backwards ............. 476 158. Last Stage of Extraction ; the Handles of the Forceps turned upwards towards the Mother's Abdomen 477 [159. Hodge Forceps 481] [160. Wallace " 482] [161. Davis " 482] . ILLUSTRATIONS. XXV11 Fig. PAGE [1G2. Elliot Forceps 483] [163. Sawyer " 484] [164. Application of Forceps at Inferior Strait 485] [165. Application of Forceps in the Head at Superior Strait, the left Blade held in place by an Assistant 487] [166. Direction of Forceps as Head is being delivered 488] 167. Vectis with Hinged Handle 489 168. Wilmot's Fillet 490 169. ^ 170. > Various forms of Perforators . . . . * . . .493 171. ) 172 and 173. Crotchets 493 174. Craniotomy Forceps 494 175. Simpson's Cranioclast 494 176. Hicks's Cephalotribe 496 177. Perforation of the Skull 499 178. Foetal Head crushed by the Cephalotribe ....... 502 [179. Straight Craniotomy Forceps ......... 503] [180. Curved " " 503] 181. Method of Transfusion by Aveling's Apparatus ..... 537 182. Section of a Uterine Sinus from the Placental Site nine weeks after delivery. (After Williams.) 545 183. Hayes's Tube for Intra-uterine Injections 608 PLATE I . Os Pubis Eladdei Clitoris. Section of a Frozen Body in the last month of Pregnancy (after Braune), illustrating the Relations of the Uterus to the surronnrling-parts, and the Attitude of the Foetus, which is lying in the Second Cranial " : Mon. PLATE II. M— M : Sup. Mescnt. Sup. Mescnt.A V. Porta) stomach Ext. Os Uteri Rectum v'%v£»| Liquor Amnii ectiou of a Frozen Body at the termination of the First Stage of Labor (after Braune). The Bag of Mem- branes is still unbroken, the Cervix is fully dilated, and the Head (in the second position) is iu the Pelvic Cavity. THE SCIENCE AND PRACTICE OF MIDWIFERY. PART I. ANATOMY AND PHYSIOLOGY OF THE ORGANS CONCERNED IN PARTURITION. CHAPTER I. ANATOMY OF THE PELVIS. The pelvis is the bony basin situated between the trunk and the lower extremities. To the obstetrician its study is of paramount importance, for it not only contains, in the unimpregnated state, all the organs connected with the function of reproduction, but through its cavity the foetus has to pass in the process of parturition. An accurate knowledge, therefore, of its anatomical formation may be said to be the very alphabet of obstetrics, without which no one can practise midwifery, either with satisfaction to himself, or safety to his patient. In a treatise on obstetrics, however, any detailed account of the purely descriptive anatomy of the pelvis would be out of place. A knowledge of that must be taken for granted, and it is only necessary to refer to those points which have a more or less direct bearing on the study of its obstetrical relations. The pelvis is formed of four bones. On either side are the ossa innominata, joined together by the sacrum ; to the inferior extremity of the sacrum is attached the coccyx, which is, in fact, its continuation. The os innominatum (Fig. 1) is an irregularly shaped bone origi- nally formed of three distinct portions, the ilium, the ischium, and the pubes, which remain separated from each other up to and beyond the period of puberty. They are united at the acetabulum by a Y-shaped cartilaginous junction, which does not, as a rule, become ossified until about the twentieth year. The consequence is that tlw; 3 ( 25 ) jBm i 26 ORGANS CONCERNED IN PARTURITION. pelvis, during the period of growth, is subject to the action of various mechanical influences to a far greater extent than in adult life ; and these, as we shall presently see, have an important effect in deter- mining the form of the bones. The external surface and borders of the os innominatum are chiefly of obstetric interest from giving attachment to muscles, many of which have an important accessory influence on parturition, such as the muscles forming the abdominal wall, which are attached to its crest, and those closing its outlet and Os Innominatum. forming the perineum, which are attached to the tuberosity of the ischium. On the anterior and posterior extremities of the crest of the ilium are two prominences (the anterior and posterior spinous processes) which are points from which certain measurements are sometimes taken. The internal surface of the upper fan-shaped portion of the os innominatum gives attachment to the iliacus muscle, and contributes to the support of the abdominal contents ; along with its fellow of the opposite side it forms the false pelvis. The false is separated from the true pelvis by the ilio-pectineal line, which, with the upper margin of the sacrum, forms the brim of the pelvis. This is of especial obstetric importance, as it is the first part of the pelvic cavity through which the child passes, and that in which osseous deformities are most often met with. At one portion of the ilio- pectineal line, corresponding with the junction of the ilium and pubes, is situated a prominence, which is known as the ilio-pectineal eminence. Internal Surface. — The internal smooth surface of the innominate bone below the linea ilio-pectinea forms the greater portion of the pelvis proper. In front, with the corresponding portions of the opposite bone, it forms the arch of the pubes, under which the head of the child passes in labor. Behind this we observe the oval obturator foramen, and below that the tuberosity and spine of the ischium, the latter separating the great .<*ind lesser sciatic notches, and giving attachment to ligaments of im- ANATOMY OF THE PELVIS. 27 Fig. 2. &±j&> r^A portance. The rough articulating surface posteriorly, by which the junction with the sacrum is effected, may be noted, and above this the prominence to which the powerful ligaments joining the sacrum and os innominatum are attached. The sacrum (Fig. 2) is a triangular and somewhat spongy bone forming the continuation of the spinal column, and binding together the ossa innominata. It is originally composed of five separate portions, anal- ogous to the vertebrae, which ossifv and unite about the period of puberty, leaving on its internal surface four prominent ridges at the points of junction. The upper of these is sometimes so well marked as to be mistaken on vaginal examination, for the promontory of the sacrum itself. The base of the sacrum is about 4J inches in width, and its sides rapidly ap- proximate until they nearly meet at its apex, giving the whole bone a triangular or wedge shape. The anterior and pos- terior surfaces also approximate in the same way, so that the bone is much thicker at the base than at the apex. The sacrum, in the erect position of the body, is directed from above downwards and from before backwards. At its upper edge it is joined, the lumbo-sacral cartilage intervening, with the fifth lumbar vertebra. The point of junction, called the promontory of the sacrum, is of great importance, as on its undue projection many deformities of the brim of the pelvis depend. The anterior surface of the bone is concave, and forms the curve of the sacrum; more marked in some cases than in others. There is also more or less concavity from side to side. On it we observe four apertures on each side, the intervertebral foramina giving exit to nerves. The posterior surface is convex, rough and irregular for the attachment of ligaments and muscles, and showing a ridge of vertical prominences, corresponding to the spinous processes of the vertebrae. Mechanical Relations of the Sacrum. — The sacrum is generally de- scribed as forming a keystone to the arch constituted by the pelvic bones, and transmitting the weigkt of the body, in consequence of its Avedge-like shape, in a direction which tends to thrust it downwards and backwards, as if separating the ossa innominata. Dr. Duncan, 1 however, has shown, from a very careful consideration of its mechanical relations, that it should rather be regarded as a strong transverse beam, curved on its anterior surface, the extremities of which are in contact with the corresponding articular surfaces of the ossa innominata. The weight of the body is thus transmitted to the innominate bones, and through them to the acetabula and the femurs. Sacrum and Coccyx. 1 Researches in Obstetrics, p. 67. '? ZO ORGANS CONCERNED IN PARTURITION. (Fig. 3.) There counter-pressure is applied, and the result is, as we shall subsequently see, an important modifying influence on the de- velopment and shape of the pelvis. The coccyx (Fig. 2) is composed of four small separate bones, which eventually unite into one, but not until late in life. The uppermost of these articulates with the apex of the sacrum. On its posterior surface are two small cornua, which unite with corresponding points at the tip of the sacrum. The bones of the coccyx taper to a point. To it are attached various muscles which have the effect of imparting considerable mobility. During labor, also, it yields to the mechanical pressure of the presenting part, so as to increase the antero-posterior diameter of the pelvic outlet to the extent of an inch or more. Ossification of Coccyx. — If, through disease or accident, as sometimes happens, the articular cartilages of the coccyx become prematurely ossified, the enlargement of the pelvic outlet during labor may be prevented, and considerable difficulty may thus arise. This is most apt to happen in aged primiparae, or in women who have followed sedentary occupations ; and not infrequently, under such circum- stances, the bone fractures under the pressure to which it is subjected by the presenting part. Pelvic Articulations. — The pelvic bones are firmly joined together by various articulations and ligaments. The latter are arranged so as to complete the canal through which the foetus has to pass, and which is in great part formed by the bones. On its internal surface, where the absence of obstruction is of importance, they are every- where smooth ; while externally, where strength is the desideratum, they are arranged in larger masses, so as to unite the bones firmly together. The pelvic articulations have been generally described as symphyses or amphiarthrodia, a term which is properly applied to two articulating surfaces, united by fibrous tissue in such a way as to prevent any sliding motion. It is certain, however, that this is not the case with the joints of the female pelvis during pregnancy and parturition. Lenoir found that in 22 females, between the ages of 18 and 35, there was a distinct sliding motion. Therefore, the pelvic articulations are, strictly speaking, to be considered examples of the class of joints termed arthrodia. Lumbosacral Joint. — The last lumbar vertebra is united to the sacrum by ligamentous union similar to that which joins the vertebrae to each other. The intervening fibro- cartilage forms a disk, which is thicker in front than behind, and this, in connection with a similar peculiarity of the fifth lumbar vertebra, tends to increase the sloped position of the sacrum, and the angle which it forms with the verte- bral column. It constitutes the most prominent portion of the pro- montory of the sacrum, and is the part on which the finger generally impinges in vaginal examinations. The anterior common vertebral ligament passes over the surface of the joints, and we also find the ligamenta sub-flava and the inter-spinous ligaments, as iu the other vertebrae. The articular processes are joined together by a fibrous capsule, and there is also a peculiar ligament, the lumbo-sacral, nding from the transverse process of the vertebra on each side, extendi ANATOMY OF THE PELVIS. 29 and attaching itself to the sides of the sacrum and the sacro-iliac synchondrosis. Ligaments of Coccyx. — The sacrum is joined to the coccyx, and, in some cases at least, the separate bones of the coccyx to each other, by small cartilaginous disks like that connecting the sacrum with the last lumbar vertebra. They are farther united by anterior and posterior common ligaments, the latter being much the thicker and more marked. In the adult female a synovial membrane is found between the sacrum and coccyx, and it is supposed that this is formed under the influence of the movements of the bones on each other. Sacro-iliac Synchondrosis. — The opposing articular surfaces of the sacrum and ilium are each covered by cartilages, that of the sacrum, being the thickest. These are firmly united, but, in the female, according to Mr. Wood, 1 they are always more or less separated by an intervening synovial membrane. Posterior to these cartilaginous convex surfaces there are strong interosseous ligaments, passing directly from bone to bone, filling up the interspace between them, and uniting them firmly. There are also accessory ligaments, such as the superior and anterior sacro iliac, which are of secondary con- sequence. The posterior sacro-iliac ligaments, however, are of great Fig 3. Section of Pelvis and Heads of Thisrh-bones, showing the Suspensory Action of the Sacro-iliac Ligaments. (After Wood.) obstetric importance. They are the very strong attachments which unite the rough surfaces on the posterior iliac tuberosities to the posterior and lateral surfaces of the sacrum. They pass obliquely downwards from the former points, and suspend, as it were, the 1 Todd's Cyclopaedia of Anatomy and Physiology, article " Pelvis" p. 123. m* 30 ORGANS CONCERNED IN PARTURITION. sacrum from them. According to Duncan, the sacrum has nothing to prevent its being depressed by the weight of the body but these ligaments, and it is mainly through them that the weight of the body is transmitted to the sacro- cotyloid beams and the heads of the femur. Sacro-sciatic Ligaments. — The sacro-sciatic ligaments are instru- mental in completing the canal of the pelvis. The greater sacro- sciatic ligament is attached by a broad base to the posterior spine of the ilium, and to the posterior surfaces of the ilium and coccyx. Its fibres unite into a thick cord, cross each other in an X-like manner, and again expand at their insertion into the tuberosity of the ischium. The lesser sacro-sciatic ligament is also attached with the former to the back parts of the sacrum and coccyx, its fibres passing to their much narrower insertion at the spine of the ischium, and converting the sacro-sciatic notch into a complete foramen. Obturator Membrane. — The obturator membrane is the fibrous aponeurosis that closes the large obturator foramen. Joulin 1 supposes that, along with the sacro-sciatic ligaments, it may, by yielding some- what to the pressure of the foetal head, tend to prevent the contusion to which the soft parts would be subjected if they were compressed between two entirely osseous surfaces. Symphysis Pubis. — The junction of the pubic bones in front is effected by means of two oval plates of fibro-cartilage, attached to each articular surface by nipple-shaped projections, which fit into corresponding depressions in the bones. There is a greater separa- tion between the bones in front than behind, where the numerous fibres of the cartilaginous plates intersect, and unite the bones firmly together. At the upper and back part of the articulation there is an interspace between the cartilages, which is lined by a delicate membrane. In pregnancy this space often increases in size, so as to extend even to the front of the joint. The juncture is further strengthened by four ligaments, the anterior, the posterior, the supe- rior, and the sub-pubic. Of these, the last is the largest, connecting together the pubic bones and forming the upper boundary of the puoic arch. Movements of Pelvic Joints. — The close apposition of the bones of the pelvis might not unreasonably lead to the supposition that no movement took place between its component parts; and this is the opinion which is even jet held by many anatomists. It is tolerably certain, however, that even in the unimpregnated condition there is a certain amount of mobility. Thus Zaglas has pointed out 2 that in man there is a movement in an antero-posterior direction of the sacro-iliac joints, which has the effect, in certain positions of the body, of causing the sacrum to project downwards to the extent of about a line, thus narrowing the pelvic brim, tilting up the point of the bone, and thereby enlarging the outlet of the pelvis. This movement seems habitually brought into play in the act of straining during defecation. 1 Traite d'Accouchements, p 11. 2 Monthly Journal of Med. Science, Sept. 1851. ANATOMY OF THE PELVIS. 31 Observations in the Lower Animals. — During pregnancy in some of the lower animals there is a very marked movement of the pelvic articulations, which materially facilitates the process of parturition. This, in the case of the guinea-pig and cow, has been specially pointed out by Dr. Matthews Duncan. 1 In the former, during labor, the pelvic bones separate from each other to the extent of an inch or more. In the latter the movements are different, for the symphysis pubis is fixed by bony anchylosis, and is immovable ; but the sacro- iliac joints become swollen during pregnancy, and extensive move- ments in an antero-posterior direction take place in them, which materially enlarge the pelvic canal during labor. Mode in which the Movements are effected. — It is extremely probable that similar movements take place in women, both in the symphysis pubis and in the sacro-iliac joints, although to a less marked extent. These are particularly well described by Dr. Duncan. They seem to consist chiefly in an elevation and depression of the symphysis pubis, either by the ilia moving on the sacrum, or by the sacrum itself undergoing a forward movement on an imaginary transverse axis passing through it, thus lessening the pelvic brim to the extent of one or even two lines, and increasing, at the same time, the diameter of the outlet by tilting up the apex of the sacrum. These movements are only an exaggeration of those which Zaglas describes as occurring normally during defecation. The instinctive positions which the parturient woman assumes find an explanation in these observations.. During the first stage of labor, when the head is passing through the brim, she sits, or stands, or walks about, and in these erect positions the symphysis pubis is depressed, and the brim of the pelvis enlarged to its utmost. As the head advances through the cavity of the pelvis, she can no longer maintain her erect position, and she lies down and bends her body forward, which has the effect of causing a nutatory motion of the sacrum, with corresponding tilting up of its apex, and an enlargement of the outlet. Alterations in the Pelvic Joints during Pregnancy. — These move- ments during parturition are facilitated by the changes which are known to take place in the pelvic articulations during pregnancy. The ligaments and cartilages become swollen and softened,, and the synovial membranes existing between the articulating surfaces become greatly augmented in size and distended with fluid. These changes act by forcing the bones apart, as the swelling of a sponge placed between them might do after it had imbibed moisture. The reality of these alterations receives a clinical illustration from those eases, which are far from uncommon, in which these changes are carried to so extreme an extent, that the power of progression is materially interfered with for a considerable time after delivery. Pelvis as a Whole. — On looking at a pelvis as a whole, we are at once struck with its division into the true and false pelvis. The latter portion (all that is above the brim of the pelvis) is of compara- tively little obstetric importance, except in giving attachments to 1 Researches in. Obstetrics, p. 19, T 32 ORGANS CONCERNED IN PARTURITION, the accessory muscles of parturition, and need not be further con- sidered. The brim of the pelvis is a heart-shaped opening, bounded by the sacrum behind, the linea ilio-pectinea on either side, and the symphysis of the pubes in front. All below it forms the cavity, which is bounded by the hollow of the sacrum behind, by the inner surfaces of the innominate bones at the sides and in front, and by the posterior surface of the symphysis pubis. It is in this part of the pelvis that the changes in direction which the foetal head undergoes Fig. 4. Outlet of Pelvis. in labor are imparted to it. The lower border of this canal, or pelvic outlet (Fig. 4), is lozenge- shaped, is bounded by the ischiatic tuberosities on either side, the tip of the coccyx behind, and the under surface of the pubic symphysis in front. Posteriorly to the tuberosities of the ischia the boundaries of the outlet are completed by the sacro-sciatic ligaments. Differences in the two Sexes. — There is a very marked difference Fig. 5. The Female Pelvis. between the pelvis in the male and the female, and the peculiarities of the latter all tend to facilitate the process of parturition. In the ANATOMY OF THE PELVIS. 33 female pelvis (Fig. 5) all tlie bones are lighter in structure, and have the points for muscular attachments much less developed. The iliac bones are more spread out, hence the greater breadth which is ob- served in the female figure, and the peculiar side-to-side movement which all females have in walking. The tuberosities of the ischia are lio-hter in structure and further apart, and the rami of the pubes also converge at a much less acute angle. This greater breadth of the pubic arch gives one of the most easily appreciable points of Fig. 6. The Male Pelvis. contrast between the male and female pelvis ; the pubic arch in the female forms an angle of from 90° to 100°, while in the male (Fig. 6) it averages from TCP to 75°. The obturator foramen are more triangular in shape. The whole cavity of the female pelvis is wider and less funnel- shaped than in the male, the symphysis pubis is not so deep, and, as the promontory of the sacrum does riot project so much, the shape of the pelvic brim is more oval than heart-shaped. These differences between the male and female pelves are probably due to the presence of the female genital organs in the true pelvis, the growth of which increases its development in width. In proof of this, Schrceder states that in women with congenitally defective internal organs, and in women who have had both ovaries removed early in life, the pelvis has always more or less of the masculine type. Measurements of the Pelvis. — The measurements of the pelvis that are of most importance from an obstetric point of view, are taken between various points directly opposite to each other, and are known as the diameters of the pelvis. Those of the true pelvis are the dia- meters which it is especially important to fix in our memories, and it is customary to describe three in works on obstetrics — the antero- posterior or conjugate, the oblique, and the transverse — although of course the measurements may be taken at any opposing points in the circumference of the bones. The a?itero-posterior (sacro-pubic), at the brim (Fig. 7), is taken from the upper part of the posterior 34 ORGANS CONCERNED IN PARTURITION, Fig. 7. Brim of Pelvis, showing Antero-posterior, Oblique, and Conjugate Diameters. Fig. 8. Transverse Section of Pelvis, showing the Diameters. surface of the symphysis pubis to the centre of the promontory of the sacrum ; in the cavity, from the centre of the symphysis pubis to a corresponding point in the body of the third piece of the sacrum ; and at the outlet (coccy-pubic), from the lower border ofthe symphysis pubis to the tip of the coccyx. The oblique, at the brim, is taken from the sacro-iliac joint on either side to a point of the brim corres- ponding with the ilio- pectineal em- inence (that starting from the right sacro-iliac joint being called the right oblique, that from the left, the left oblique) ; in the cavity a similar measurement is made at the same level as the conjugate; while at the outlet an oblique diameter is not usually measured. The trans- verse is taken at the brim, from a point midway between the sacro- iliac joint and the ilio-pectineal eminence to a corresponding point at the opposite side of the brim ; in the cavity from points in the same plane as the conjugate and oblique diameters ; and at the outlet from the centre of the inner border of one ischial tuberosity to that of the other. The measure- ments given by various writers IH ANATOMY OF THE PELVIS. differ considerably, and vary somewhat in different pelves. Taking the average of a large number, the following may be given as the standard measurements of the female pelvis : — Aiuero-posteilor. Oblique. Transverse. in. in. in. Brim . . . . . 4.25 4.8 5.2 Cavity 4.7 5.2 4.75 Outlet 5.0 — 4.2 It will be observed that the lengths of the corresponding dia- meters at different places vary greatly ; thus while the transverse is longest at the brim, the oblique is longest in the cavity, and the antero-posterior at the outlet. It will be subsequently seen that this fact .is of great practical importance in studying the mecha- nism of delivery, for the head in its descent through the pelvis alters its position in such a way as to adapt itself to the largest diameter of the pelvis; thus as it passes through the cavity it lies in the oblique diameter, and then rotates so as to be expelled in the antero- posterior diameter of the outlet. Diameters as altered by Soft Parts. — In thinking of these measure- ments of the pelvis, it must not be forgotten that they are taken in the dried bones, and that they are considerably modified during life by the soft parts. This is especially the case at the brim, where the projection of the psoas and iliacus muscles lessens the transverse diameter about half an inch, while the antero-posterior diameter of the brim, and all the diameters of the cavity, are lessened by a quarter of an inch. The right oblique diameter of the brim is, even in the dried pelvis, found to be, on an average, slightly longer than the left ; probably on account of the increased development of the right side of the pelvis from the greater use made of the right leg; but in addition to this, the left oblique diameter is somewhat lessened during life by the presence of the rectum on the left side. The advantage gained by the comparatively frequent passage of the head through the pelvis in the right oblique diameter is thus explained. Other Measurements. — There are one or two other measurements of the true pelvis which are sometimes given, but which are of sec- ondary importance. One of these, the sacro-cotyloid diameter, is that between the promontory of the sacrum and a point immediately above the cotyloid cavity, and averages from 3.4 to 3.5 inches. An- other, called by Wood the lower or inclined conjugate diameter, is that between the centre of the lower margin of the symphysis pubis and the promontory of the sacrum, and averages half an inch more than the antero-posterior diameter of the brim. These measurements are chiefly of importance in relation to certain pelvic deformities. External Measurements. — The external measurements of the pelvis are of no real consequence in normal parturition, but they may help us, in certain cases, to estimate the existence and amount of deformi- ties. Those which are generally given are : Between the anterior- superior iliac spines, 10 inches ; between the central points of the crests of the ilia, 10 J inches; between the spinous process of the last lumbar vertebra and the upper part of the symphysis pubis (external conjugate), 7 inches. M 86 ORGANS CONCERNED IN PARTURITION, Planes of the Pelvis. — By the planes of the pelvis are meant imagi- nary levels at any portion of its circumference. If we were to cut out a piece of cardboard so as to fit the pelvic cavity, and place it either at the brim or elsewhere, it would represent the pelvic plane at that particular part, and it is obvious that we may conceive as many planes as we desire. Observation of the angle which the pelvic planes form with the horizon shows the great obliquity at which the pelvis is placed in regard to the spinal column. Thus the angle abi (Fig. 9) represents the inclination to the horizon of Pianos of the Pelvis with. Horizon. A b. Horizon. c d. Vertical line. A b r. Angle of inclination of pelvis to horizon, equal to 60°. B i c. Angle of inclination of pelvis to spinal column, equal to 150°. c i j. Angle of inclination of sacrum to spiual column, equal to 130°: e F. Axis of pelvic inlet. L m. Mid plane in the middle line n. Lowest point of mid plane of ischium. the plane of the pelvic brim, I B, and is estimated to be about 60°, while the angle which the same plane forms with the vertebral column is about 150°. The plane of the outlet forms, with the coccyx in its usual position, an angle with the horizon of about 11°, but which varies greatly with the movements of the tip of coccyx, and the degree to which it is pushed back during parturition. These figures must only be taken as giving an approximative idea of the inclination of the pelvis to the spinal column, and it must be remem- bered that the degree of inclination varies considerably in the same female at different times, in accordance with the position of the body. During pregnancy especially, the obliquity of the brim is lessened by ANATOMY OF THE PELVIS 37 the patient throwing herself backwards in order to support more easily the weight of the gravid uterus. The height of the promon- tory of the sacrum above the upper margin of the symphysis pubis is on an average about 3J inches, and a line passing horizontally backwards from the latter point would impinge on the junction of the second and third coccygeal bones. Axes of the Parturient Canal. — By the axis of the pelvis is meant an imaginary line which indicates the direction which the foetus takes during its expulsion. The axis of the brim (Fig. 10) is a line Fig. 10. Axes of the Pelvis. A. Axis of a superior plane. b. Axis of mid plane. D. Axis of canal. c. Axis of inferior plant Horizon. drawn perpendicular to its plane, which would extend from the um- bilicus to about the apex of the coccyx ; the axis of the outlet of the bony pelvis intersects this, and extends from the centre of the pro- montory of the sacrum to midway between the tuberosities of the ischia. The axis of the entire pelvic canal is represented by the sum of the axes of an indefinite number of planes at different levels of the pelvic cavity, which forms an irregular parabolic line, as repre- sented in the accompanying diagram (Fig. 10, A d). It must be borne in mind, however, that it is not the axis of the bony pelvis alone that is of importance in obstetrics. We must always, in considering this subject, remember that the general axis of the parturient canal (Fig. 11) also includes that of the uterine cavity above, and of the soft parts beloAV. These are variable in direction according to circumstances ; and it is only the axis of that portion of the parturient canal extending between the plane of the pelvic brim and a plane between the lower edge of the pubic sym- physis and the base of the coccyx that is fixed. The axis of the 88 ORGANS CONCERNED IN PARTURITION, lower part of the canal will vary according to the amount of disten- sion of the perineum during labor ; but when this is stretched to its utmost, just before the expulsion of the head, the axis of the plane Fig. 11. Representing General Axis of Parturient Canal, including the Uterine Cavity and Sift Parts. Fig. 12. between the edge of the distended perineum and the lower border of the symphysis, looks nearly directly forwards. The axis of the ute- rine cavity generally corresponds with that of the pelvic brim, but it may be much altered by abnor- mal positions of the uterus, such as ante version from laxity of the abdo- minal walls. The foetus, under such circumstances, will not enter the brim in its proper axis, and diffi- culties in the labor arise. A knowl- edge of the general direction of the parturient canal is of great im- portance in practical midwifery in guiding us to the introduction of the hand or instruments in ob- stetric operations, and in showing us how to obviate difficulties aris- ing from such accidental deviations of the uterus as have been just Side View of Pelvis. alluded to. / x ANATOMY OF THE PELVIS. 39 Cavity of the Pelvis. — The arrangements of the bones in the interior of the pelvic canal (Fig. 12) are important in relation to the mechanism of delivery. A line passing between the spine of the ischium and the ilio-pectineal eminence divides the inner surface of ischial bone into two smooth plane surfaces, which have received the name of the planes of the ischium. Two other planes are formed by the inner surfaces of the pubic bones in front and by the upper portion of the sacrum be- hind, both having a direction downwards and backwards. In study- ing the mechanism of delivery, it will be seen that many obstetricians attribute to these planes, in conj unction with the spine of the ischium, a very important influence in effecting rotation of the foetal head from the oblique to the antero-posterior diameter of the pelvis. Development of the Pelvis. — The peculiarities of the pelvis during infancy and childhood are of interest as leading to a knowledge of the manner in which the form observed during adult life is impressed upon it. The sacrum in the pelvis of the child (Fig. 13) is less cle- Fig. 13. Pelvis of a Child. veloped transversely, and is much less deeply curved than in the adult. The pubes is also much shorter from side to side, and the pubic arch is an acute angle. The result of this narrowness of both the pubes and sacrum is that the transverse diameter of the pelvic brim is shorter instead of longer than the antero-posterior. The sides of the pelvis have a tendency to parallelism, as well as the antero- posterior walls ; and this is stated by "Wood to be a peculiar charac- teristic of the infantile pelvis. The iliac bones are not spread out as in adult life, so that the centres of the crests of the ilium are not more distant from each other than the anterior superior spines. The eavity of the true pelvis is small, the tuberosities of the ischia are proportionately nearer to each other than they afterwards become ; the pelvic viscera are consequently crowded up into the abdominal cavity, which is, for this reason, much more prominent in children than in adults. The bones are soft and semi-cartilaginous until after the period of puberty, and yield readily to the mechanical influences 40 ORGANS CONCERNED IN PARTURITION. to which they are subjected ; and the three divisions of the innomi- nate bone remain separate until about the twentieth year. As the child grows older the transverse development of the sacrum increases, and the pelvis begins to assume more and more of the adult shape. The mere growth of the bones, however, is not sufficient to account for the change in the shape of the pelvis, and it has been well shown by Duncan that this is chiefly produced by the pressure to which the bones are subjected during early life. The iliac bones are acted upon by two principal and opposing forces. One is the weight of the body above, which acts vertically upon the sacral ex- tremity of the iliac beam through the strong posterior sacro-iliac ligaments, and tends to throw the lower or acetabular ends of the sacro-cotyloid beams outwards. This outward displacement, how- ever, is resisted, partly by the junction between the two acetabular ends at the front of the pelvis, but chiefly by the opposing force, which is the upward pressure of the lower extremities through the femurs. The result of these counteracting forces is that the still soft bones bend near their junction with the sacrum ; and thus the greater transverse development of the pelvic brim characteristic of adult life is established. In treating of pelvic deformities it will be seen that the same forces applied to diseased and softened bones ex- plain the peculiarities of form that they assume. Pelvis in Different Races. — The researches that have been made on the differences of the pelvis in different races prove that these are not so great as might have been expected. Joulin pointed out that in all human pelves the transverse diameter was larger than the anteroposterior, while the reverse was the case in all the lower animals, even in the highest simias. This observation has been more recently confirmed by Von Franque, 1 who has made careful measure- ments of the pelvis in various races. In the pelvis of the gorilla the oval form of the brim, resulting from the increased length of the conjugate diameter, was very marked. In certain races there is so far a tendency to animality of type, that the difference between the transverse and conjugate diameters is much less than in European women, but is not sufficiently marked to enable us to refer any given pelvis to a particular race. Yon Franque makes the general obser- vation that the size of the pelvis increases from South to North, but that the conjugate diameter increases in proportion to the transverse in southern races. Soft Parts in Connection with Pelvis. — In closing the description of the pelvis, the attention of the student must be directed to the mus- cular and other structures which cover it. It has already been pointed out that the measurements of the pelvic diameters are con- siderably lessened by the soft parts, which also influence parturition in other ways. Thus attached to the crests of the ilia are strong muscles which not only support the enlarged uterus during pregnancy, but are powerful accessory muscles in labor : in the pelvic cavity are the obturator and pyriformis muscles lining it on either side ; the 1 Scanzoni's Beitrage, 1867. THE FEMALE GENERATIVE ORGANS. 41 pelvic cellular tissue and fasciae ; the rectum and bladder ; the vessels and nerves, pressure on which often gives rise to cramps and pains during pregnane}^ and labor ; while below the outlet of the pelvis is closed, and its axis directed forwards by the numerous muscles form- ing the floor of the pelvis and perineum. CHAPTEE II. THE FEMALE GENERATIVE ORGANS. Division according to Function. — The reproductive organs in the female are conveniently divided, according to their function, into : 1, The external or copulative organs, which are chiefly concerned in the act of insemination, and are only of secondary importance in par- turition : they include all the organs situated externally which form the vulva ; and the vagina, which is placed internally and forms the canal of communication between the uterus and the vulva, 2, The internal or formative organs : they include the ovaries, which are the most important of all, as being those in which the ovule is formed ; the Fallopian tubes, through which the ovule is carried to the uterus; and the uterus, in which the impregnated ovule is lodged and de- veloped. 1. The external organs consist of: — ■ Mons Veneris. — The mons veneris, a cushion of adipose and fibrous tissue which forms a rounded projection at the upper part of the vulva. It is in relation above with the lower part of the hypogas- tric region, from which it is often separated by a furrow, and below it is continuous with the labia majora on either side. It lies over the symphysis and horizontal rami of the pubes. After puberty it is covered with hair. On its integument are found the openings of numerous sweat and sebaceous glands. Labia Majora. — The labia majora form two symmetrical sides to the longitudinal aperture of the vulva. They have two surfaces, one external, of ordinary integument, covered with hair, and another internal, of smooth mucous membrane, in apposition with the corre- sponding portion of the opposite labium, and separated from the ex- ternal surface by a free convex border. They are thicker in front, where they run into the mons veneris, and thinner behind, where they are united, in front of the perineum, by a thin fold of integu- ment called the fourchette, which is almost invariably ruptured in the first labor. In the virgin the labia are closely in apposition, and conceal the rest of the generative organs. After child-bearing they become more or less separated from each other, and in the aged they waste, and the internal nymphse protrude through them. Both their 4 42 ORGANS CONCERNED IN PARTURITION. cutaneous and mucous surfaces contain a large number of sebaceous glands, opening either directly on the surface or into the hair folli- cles. In structure the labia are composed of connective tissue, con- taining a varying amount of fat, and parallel with their external surface are placed tolerably close plexuses of elastic tissue, inter- spersed with regularly arranged smooth muscular fibres. These fibres are described by Broca as forming a membranous sac, resembling the dartos of the scrotum, to which the labia majora are analogous. Towards its upper and narrower end this sac is continuous with the external inguinal ring, and in it terminate some of the fibres of the round ligament. The analogy with the scrotum is further borne out by the occasional hernial protrusion of the ovary into the labium, corresponding to the normal descent of the testis in the male. Labia Minora. — The labia minora, or nymphae, are two folds of mucous membrane, commencing below, on either side, about the centre of the internal surface of the labium externum ; they converge as they proceed upwards, bifurcating as they approach each other. The lower branch of this bifurcation is attached to the clitoris, while the upper and larger unites with its fellow of the opposite side, and forms a fold round the clitoris, known as its prepuce. The nymphas are usually entirely concealed by the labia majora, but after child- bearing and in old age they project somewhat beyond them ; then they lose their delicate pink color and soft texture, and become brown, dry, and like skin in appearance. This is especially the case in some of the negro races, in whom they form long projecting folds called the apron. The surfaces of the nymphae are covered with a tesselated epithe- lium, and over them are distributed a large number of vascular papillae, somewhat enlarged at their extremities, and sebaceous glands, which are more numerous on their internal surfaces. The latter secrete an odorous, cheesy matter, which lubricates the surface of the vulva, and prevents its folds adhering to each other. The nymph a3 are composed of trabiculte of connective tissue, containing muscular fibres. Clitoris. — The clitoris is a small erectile tubercle situated about half an inch below the anterior commissure of the labia majora. It is the analogue of the penis in the male, and is similar to it in struc- ture, consisting of a corpus cavernosum, the two halves of which are separated by a fibrous septum. The crura are covered by the ischio- cavernous muscles, which serve the same purpose as in the male. It has also a suspensory ligament. The corpora cavernosa are composed of a vascular plexus with numerous transversing muscular fibres. The arteries are derived from the perineal artery, and give a branch, the cavernous, to each half of the organ ; there is also a dorsal artery distributed to the prepuce. According to Gussenbauer these caver- nous arteries pour their blood directly into large veins, and a finer venous plexus near the surface receives arterial blood from small arterial branches. By these arrangements the erection of the organ which takes place during sexual excitement is favored. The nervous supply of the clitoris is large, being derived from the internal pudic t) THE FEMALE GENERATIVE ORGANS. 43 nerve, which supplies branches to the corpora cavernosa, and termi- nates in the glands and prepuce, where Paccinian corpuscles and ter- minal bulbs are to be found. On this account the clitoris has been supposed by some to be the chief seat of voluptuous sensation in the female. Vestibule. — The vestibule is a triangular space, bounded at its apex by the clitoris, and on either side by the folds of the nymphse. It is smooth, and, unlike the rest of the vulva, is destitute of sebaceous glands, although there are several groups of muciparous glands open- ing on its surface. At the centre of the base of the triangle which is formed by the upper edge of the opening of the vagina, is a promi- nence, distant about an inch from the clitoris, on which is the orifice of the urethra. This prominence can be readily made out by the finger, and the depression upon it — leading to the urethra — is of im- portance as our guide in passing the female catheter. This little operation ought to be performed without exposing the patient, and it is done in several ways. The easiest is to place the tip of the index finger of the left hand (the patient lying on her back) on the apex of the vestibule, and slip it gently down until we feel the bulb of the urethra, and the dimple of its orifice, which is generally readily found. If there is any difficulty in finding the orifice, it is well to remember that it is placed immediately below the sharp edge of the lower border of the symphysis pubis, which will guide us to it. The catheter (and a male elastic catheter is always the best, especially during labor, when the urethra is apt to be stretched) is then passed under the thigh of the patient, and directed to the orifice of the urethra by the finger of the left hand, which is placed upon it. We must be careful that the instrument is really passed into the urethra, and not into, the vagina. It is advisable to have a few feet of elastic tubing attached to the end of the catheter, so that the urine can be passed into a vessel under the bed without uncovering the patient. If the patient be on her side, in the usual obstetric position, the ope- ration can be more readily performed by placing the tip of the finger in the vagina and feeling its upper edge. The orifice of the urethra lies immediately above this, and if the catheter be slipped along the palmar surface of the finger, it can generally be inserted without much trouble. If, however, as is often the case during labor, the parts are much swollen, it may be difficult to find the aperture, and it is then always better to look for the opening than to hurt the patient by long-continued efforts to feel it. [In this country, the instrument is almost always introduced when possible, with the woman on her back. — Ed.] Urethra. — The urethra is a canal 1J inches in length, and it is in- timately connected with the anterior wall of the vagina, through which it may be felt. It it composed of muscular and erectile tissue, and is remarkable for its extreme dilatability, a property which is turned to practical account in some of the operations for stone in the female bladder. Orifice of the Vagina. — The orifice of the vagina is situated imme- diately below the bulb of the urethra. In virgins it is a circular 44 ORGANS CONCERNED IN PARTURITION. opening, but in women who have borne children or practised sexual intercourse, it is, in the undistended state, a vertical fissure. In virgins it is generally more or less blocked up by a fold of mucous membrane, containing some cellular tissue and muscular fibres, with vessels and nerves, which is known as the hymen. This is most often crescentic in shape, with the concavity of the crescent looking upwards ; sometimes, however, it is circular with a central opening, or cribriform ; or it may even be entirely imperforate, and this gives rise to the retention of the menstrual secretion. These varieties of form depend on the peculiar mode of development of the fold of vaginal mucous membrane which blocks up the orifice of the vagina in the foetus, and from which the hymen is formed. The density of the membrane also varies in different individuals. Most usually it is very slight, so as to be ruptured in the first sexual approaches, or even by some accidental circumstance, such as stretching the limbs, so that its absence cannot be taken as evidence of want of chastity. A knowledge of this fact is of considerable importance from a medi- co-legal point of view. Sometimes it is so tough as to prevent inter- course altogether, and may require division by the knife or scissors before this can be effected ; and at others it rather unfolds than rup- tures, so that it may exist even after impregnation has been effected, and it has been met with intact in women who have habitually led unchaste lives. In a few rare cases it has even formed an obstacle to delivery, and has required incision during labor. Carunculse Myrtiformes. — The carunculae myrtiformes are small fleshy tubercles, varying from two to five in number, situated round the orifice of the vagina, and which are generally supposed to be the remains of the ruptured hymen. Schroeder, however, maintains that they are only formed after child-bearing in consequence of parts of the hymen having been destroyed by the injuries received during the passage of the child. Vulvo-vaginal Glands. — Near the posterior part of the vaginal orifice, and below the superficial perineal fascia, are situated two conglomerate glands which are the analogues of Cowper's glands in the male. Each of these is about the size and shape of an almond, and is contained in a cellular fibrous envelope. Internally they are of a yellowish- white color, and are composed of a number of lobules separated from each other by prolongations of the external envelope. These give origin to separate ducts which unite into a common canal, about half an inch in length, which opens in front of the attached edge of the hymen in virgins, and in married women at the base of one of the carunculse myrtiformes. According to Huguier, the size of the glands varies much in different women, and they appear to have some connection with the ovary, as he has always found the largest gland to be on the same side as the largest ovary. They secrete a glairy, tenacious fluid, which is ejected in jets during the sexual orgasm, probably through the spasmodic action of the peri- neal muscles. At other times their secretion serves the purpose of lubricating the vulva, and thus preserves the sensibility of its mucous membrane. THE FEMALE GENERATIVE ORGANS. 45 Fossa Navicular is. — Immediately behind the hymen in the unmar- ried, and between it and the perineum, is a small depression called the fossa navicularis, which disappears after childbearing. Perineum. — The periDeurn separates the orifice of the vagina from that of the rectum. It is about 1J inches in breadth, and is of great obstetric interest, not only as supporting the internal organs from below, but because of its action in labor. It is largely stretched and distended by the presenting part of the child ; and if unusually tough and unyielding, may retard deliverj r , or it may be torn to a greater or less extent, thus giving rise to various subsequent troubles. Vascular Supply of the Vulva. — The structures described above together form the vulva, and they are remarkable for their abundant vascular and nervous supply. The former constitutes an erectile tissue similar to that which has already been described in the cli- toris, and which is especially marked about the bulb of the vestibule (Fig. 14). From this point, and extending on either side of the Fig. 14. Vascular Supply of Vulva. (Aftpr Kobelt.) a, Bulb of vestibule. 6. Muscular tissue of vagiua. c, d, c,f. The clitoris and its muscles, g, h, i, k, I, to, n. Veius of the nymphae aud clitoris communicating with the epigastric aud obturator veins. vagina, there is a well-marked plexus of convoluted veins, which, in their distended state, are likened by Dr. Arthur Farre to a filled leech. The erection of the erectile tissue, as well as that of the clitoris, is brought about under excitement, as in the male, by the compression of the efferent veins by the contraction of the ischiocavernous mus- cles, and by that of a thin layer of muscular tissues surrounding the orifice of the vagina, and described as the constrictor vaginae. 46 ORGANS CONCERNED IN PARTURITION Vagina.— The vagina is the canal which forms the communication between the external and internal generative organs, through which the semen passes to reach the uterus, the menses flow, and the foetus is expelled. Roughly speaking, it lies in the axis of the pelvis, but its opening is placed anterior to the axis of the pelvic outlet, so that its lower portion is curved forwards. It is narrow below, but dilated above, where the cervix uteri is inserted into it, so that it is more or less conoidal in shape. Generally speaking, its anterior and posterior walls lie closely in contact, but they are capable of very wide dis- tension, as during the passage of the foetus. The anterior wall of the vagina is shorter than the posterior, the former measuring on an average 2 J inches, the latter 3 inches ; but the length of the canal varies greatly in different subjects and under certain circumstances. In front the vagina is closely connected with the base of the bladder, so that when the vagina is prolapsed, as often occurs, it drags the bladder with it (Fig. 15) ; behind, it is in relation with the rectum, Fig. 15. Longitudinal Section of Body, showing Kelations of Generative Organs. but less intimately ; laterally with the broad ligaments and pelvic fascia ; and superiorly with the lower portion of the uterus and folds of peritoneum both before and behind. The vagina is composed of mucous, muscular, and cellular coats. The mucous lining is thrown into numerous folds. These start from longitudinal ridges which exist on both the anterior and posterior walls, but most distinctly on the anterior. They are very numerous in the young and unmarried, THE FEMALE GENERATIVE ORGANS. 47 and greatly increase the sensitive surface of the vagina. After child- bearing, and in the aged, they become atrophied, but they never completely disappear, and towards the orifice of the vagina, where they exist in greatest abundance, they are always to be met with. The whole of the mucous membrane is lined with tesselated epithe- lium, and it is covered with a large number of papillae either conical or divided, which are highly vascular and project into the epithelial layer. Unlike the vulvar mucous membrane, that of the vagina seems to be destitute of glands. Beneath the epithelial layer is a submucous tissue containing a large number of elastic and some muscular fibres, derived from the muscular walls of the vagina. These are strong and well-developed, especially toward the ostium vaginae. They consist of two layers — an internal longitudinal, and an external circular — with oblique decussating fibres connecting the two. Below they are attached to the ischio-pubic rami, and above they are con- tinuous with the muscular coat of the uterus. The muscular tissue of the vagina increases in thickness during pregnancy, but to a much less degree than that of the uterus. Its vascular arrangements, like those of the vulva, are such as to constitute an erectile tissue. The arteries form an intricate network around the tube, and eventually end in a submucous capillary plexus, from which twigs pass to supply the papillae ; these again give origin to venous radicles which unite into meshes freely interlacing with each other, and forming a well- marked venous plexus. 2. Internal Organs of Generation. — The internal organs of gene- ration consist of the uterus, the Fallopian tubes, and the ovaries ; and in connection with them we have to study the various ligaments and folds of peritoneum which serve to maintain the organs in posi- tion, along with certain accessory structures. Physiologically, the most important of all the generative organs are the ovaries, in which the ovules are formed, and which dominate the entire reproductive life of the female. The Fallopian tubes which convey the ovule to the uterus, and the uterus itself — whose main function is to receive, nourish and eventually expel the impregnated product of the ovary — may be said to be, in fact, accessory to these viscera. Practically, however, as obstetricians, we are chiefly concerned with the uterus, and may conveniently commence with its description. Uterus. — The uterus is correctly described as a pyriform. organ, flattened from before backwards, consisting of the body, with its rounded fundus, and the cervix which projects into the upper part of the vaginal canal. In the adult female it is deeply situated in the pelvis, being placed between the bladder in front and the rectum behind, its fundus being below the plane of the pelvic brim (Fig. 16). It only assumes this position, however, towards the period of puberty ; and in the foetus it is placed much higher, and lies, indeed, entirely within the cavity of the abdomen. It is maintained in this position partly by being slung by its ligaments, which we shall subsequently study, and partly by being supported from below by the pelvie cel- lular tissue and the fleshy column of the vagina. The result is that the uterus, in the healthy female, is a perfectly movable body, alter- 48 ORGANS CONCERNED IN PARTURITION ing its position to suit the condition of the surrounding viscera, especially the bladder and rectum, which are subjected to variations of size according to their fulness or emptiness. When from any cause — as, for example, some peri-uterine inflammation producing adhesions to the surrounding textures — the mobility of the organ is interfered with, much distress ensues, and if pregnancy supervenes more or less serious consequences may result. Generally speaking, the uterus may be said to lie in a line roughly corresponding with the axis of the pelvic brim, its fundus being pointed forwards and its cervix lying in such a direction that a line drawn from it would impinge on the junction between the sacrum and coccyx. According Fig. 16. Transverse Section of the Body, showing Relations of the Fundus Uteri, m. Pubes. a, a (in front). Remainder of hypogastric arteries, a, a (behind). Spermatic vessels and nerves. B. Bladder. L, L. Round, ligaments. U. Fundus uteri, t, t. Fallopian tubes, o, o. Ovaries, r. Rectum, g. Right ureter, res. ing on the psoas muscle, c. Utero-sacral ligaments, v. Last lumbar vertebra. to some authorities, the uterus in early life is more curved in the anterior direction, and is, in fact, normally in a state of ante-flexion. Sappey holds that this is not necessarily the case, but that the amount of anterior curvature depends on the emptiness or fulness of the bladder, on which the uterus, as it were, moulds itself in the unim- pregnated state. It is believed also that the body of the uterus is very generally twisted somewhat obliquely, so that its anterior sur- face looks a little towards the right side, this probably depending on the presence and frequent distension of the rectum in the left side of the pelvis. The anterior surface of the uterus is convex, and is covered in three-fourths of its extent by the peritoneum, which is intimately adherent to it. Below the reflection of that membrane it is loosely connected by cellular tissue to the bladder, so that any THE FEMALE GENERATIVE ORGANS. 49 downward displacement of the uterus drags the bladder along with it. The posterior surface is also convex, but more distinctly so than the anterior, as may be observed in looking at a transverse section of the organ (Fig. 17). It is also covered by peritoneum, the reflection Fig. 17. Transverse Section of Uterus. of which on the rectum forms the cavity known as Douglas's pouch. The fundus is the upper extremity of the uterus, lying above the points of entry of the Fallopian tubes. It is only slightly rounded in the virgin, but becomes more decidedly and permanently rounded in the woman who has borne children. Dimensions. — Until the period of puberty the uterus remains small and undeveloped (Fig. 18); after that time it reaches the adult size, at which it remains until menstruation ceases, when it again atrophies. If the woman has borne children, it always remains larger than in Fig. 18. Uterus and Appendages in an Infant. (After Farre the nullipara. In the virgin adult the uterus measures 2 J inches from the orifice to the fundus, rather more than half being taken up by the cervix. Its greatest breadth is opposite the insertion of the Fallopian tubes ; its greatest thickness, about 11 or 12 lines, oppo- 50 ORGANS CONCERNED IN PARTURITION. site the centre of its body. Its average weight is about 9 or 10 drachms. Independently of pregnancy, the uterus is subject to great alterations of size towards the menstrual period, when on account of the congestion then present, it enlarges, sometimes, it is said, con- siderably. This fact should be borne in mind, as this periodical swelling might be taken for an early pregnancy. Regional Divisions. — For the purpose of description the uterus is conveniently divided into the fundus, with its rounded upper ex- tremity, situated between the insertions at the Fallopian tubes ; the body, which is bounded above by the insertion of the Fallopian tubes, and below by the upper extremity of the cervix, and which is the part chiefly concerned in the reception and growth of the ovum ; and the cervix, which projects into the vagina, and dilates during labor to give passage to the child. The cervix is conical in shape, measur- ing 11 to 12 lines transverely at the base, and 6 or 7 in the antero- posterior direction ; while at the apex it measures 7 to 8 transversely, and 5 antero-posteriorly. It projects about 4 lines into the canal of the vagina, the remainder of the cervix being placed above the reflection of the vaginal mucous membrane. It varies much in form in the virgin and nulliparous married woman, and in the woman who has borne children ; and the differences are of importance in the diagnosis of pregnancy and uterine disease. In the virgin it is regularly pyramidal in shape. At its lower extremity is the opening of the external os uteri, forming a small transverse fissure, sometimes difficult to feel, and generally described as giving a sensation to the examining finger like the extremity of the cartilage at the tip of the nose. It is bounded by two lips, the anterior of which is apparently larger on account of the position of the uterus. The surface of the cervix, and the borders of the os, are very smooth and regular. Changes after Childbirth. — In women who have borne children these parts become considerably altered. The cervix is no longer conical, but is irregular in form and shortened. The lips of the os nteri become fissured and lobulated, on account of partial lacerations which have occurred during labor. The os is larger and more irregu- lar in outline, and is sometimes sufficiently patulous to admit the tip of the finger. In old age the cervix atrophies, and after the change of life it not uncommonly entirely disappears, so that the orifice of the os uteri is on a level with the roof of the vagina. Internal Surf ace of the Uterus. — The internal surface of the uterus comprises the cavities of the body and cervix — the former being rather less than the latter in length in virgins, but about equal in women who have borne children — separated from each other by a constriction forming the upper boundary of the cervical canal. The cavity of the body is triangular in shape, the base of the triangle being formed by a line joining the openings of the Fallopian tubes, its apex by the upper orifice of the cervix or internal os, as it is sometimes called. In the virgin its boundaries are somewhat convex, projecting inwards. After chiklbearing they become straight or slightly concave. The opposing surfaces or the cavity are always in THE FEMALE GENERATIVE ORGANS 51 contact in the healthy state or are only separated from each other by a small quantity of mucus. Cavity of the Cervix. — The cavity of the cervix is spindle-shaped or fusiform, narrower above and below, at the internal and external os uteri, and somewhat dilated between these two points. It is flat- tened from before backwards, and its opposing surfaces also lie in contact, but not so closely as those of the body. On the mucous lining of the anterior and posterior surfaces is a prominent perpen- dicular ridge, with a lesser one at each side, from which transverse ridges proceed at more or less acute angles. These have received the name of the arbor vitas. According to Guyon the perpendicular ridges are not exactly opposite, so that they fit into each other, and serve more completely to fill up the cavity of the cervix, especially towards the internal os (Fig. 19). The arbor vita3 is most distinct in the virgin, and atrophies considerably after childbearing. Fig. 19. Portion of Interior of Cervix. Enlarged nine diameters. (After Tyler Smith, and Hassall.) The superior extremity of the cervical canal forms a narrow isthmus separating it from the cavity of the body, and measuring about fthsofan inch in diameter. Like the external os, it contracts after the cessation of menstruation, and in old age sometimes becomes entirely obliterated. Structure of the Uterus. — The uterus is composed of three principal structures — the peritoneal, muscular, and mucous coats. The peri- toneum forms an investment to the greater part of the organ, ex- tending downwards in front to the level of the os internum, and behind to the top of the vagina, from which points it is reflected 52 ORGANS CONCERNED IN PARTURITION, upwards on the bladder and rectum respectively. At the sides the peritoneal investment is not so extensive, for a little below the level of the Fallopian tubes the peritoneal folds separate from each other, forming the broad ligaments (to be afterwards described) ; here it is that the vessels and nerves supplying the uterus gain access to it. At the upper part of the organ the peritoneum is so closely adherent to the muscular tissue that it cannot be separated from it ; below the connection is more loose. The mass of the uterine tissue, both in the body and cervix, consists of unstriped muscular fibres, firmly united together by nucleated con- nective tissue and elastic fibres. The muscular fibre cells are large and fusiform, with very attenuated extremities, generally containing in their centre a distinct nucleus. These cells, as well as their nuclei, become greatly enlarged during pregnancy (Fig. 21) ; according to Strieker, this is only the case with the muscular fibres which }3lay an important part in the expulsion of the foetus,, those of the outermost and innermost layers not sharing in the increase of size. 1 In addi- tion to these developed fibres there are, especially near the mucous coat, a number of round elementary corpuscles, which are believed Muscular Fibres of unimpregnated Uterus (After Farre.) a. Fibres united by connective tissue. Separate fibres and elementary corpuscles. Fig. 21. Developed Muscular Fibres from the Gravid Uterus. (After Wagner.) by Dr. Farre 2 to be the elementary form of the muscular fibres, and which he has traced in various intermediate states of development. Dr. John Williams 3 believes that a great part of the muscular tissue of the uterus, rather more indeed than three-fourths of its thickness, is an integral part of the mucous membrane, analogous to the mus- cularis mucosae of the mucous membrane of the alimentary canal. This he describes as being separated from the rest of the muscular tissue by a layer of rather loose connective tissue, containing nume- rous vessels. In early foetal life, and in the uteri of some of the 1 Comparative Histology, vol. iii., Syd. Soc. Trans., p. 2 The Uterus and its Appendages, p. 632. 477. :< 0n the Structure of the Mucous Membrane of the Uterus," Obstet. Journ., 1875. THE FEMALE GENERATIVE ORGANS. 53 lower animals, this appearance is very distinct ; in the adult female uterus, however it cannot be readily made out. Arrangement of the Muscular Fibres. — On examining the uterine tissue in an unimpregnated condition no definite arrangement of its muscular fibres can be made out, and the whole seem blended in in- extricable confusion. By observation of their relations when hyper- trophied during pregnancy, Helie 1 has shown that they may, speaking roughly, be divided into three layers : an external ; a middle, chiefly longitudinal ; aud an internal, chiefly circular. Into the details of their distribution, as described by him it is needless to enter at length. Briefly, however, he describes the external layer as arising posteriorly at the junction of the body and cervix, and spreading upwards and over the fundus. From this are derived the muscular fibres found in the broad and round ligaments, and more particularly described by Kouget. The middle layer is made up of strong fasciculi, which run upwards, but decussate and unite with each other in a remarkable manner, so that those which are at first superficial become most deeply seated, and vice versa. The muscular fasciculi which form this coat curve in a circular manner around the large veins, so as to forma species of muscular canal through which they run. This arrangement is of peculiar importance, as it affords a satisfactory ex- planation of the mechanism by which hemorrhage after delivery is prevented. The internal layer is mainly composed of circular rings of muscular fibres, beginning round the . openings of the Fallopian tubes, and forming wider and wider circles which eventually touch and interlace with each other. They surround the internal os, to which they form a kind of sphincter. In addition to these circular fibres on the internal uterine surface, both anteriorly and posteriorly, there is a well-marked triangular layer of longitudinal fibres, the base being above and the apex below, which sends muscular fasciculi into the mucous membrane. Its Mucous Membrane. — The anatomy of the lining membrane of the uterus has been the subject of considerable discussion. Its exist- ence has been denied by many authorities, most recently by Snow Beck, 2 who maintains that it is in no sense a mucous membrane, but only a softened portion of true uterine tissue. It is, however, pretty generally admitted by the best authorities that it is essentially a mucous membrane, differing from others only in being more closely adherent to the subjacent structures, in consequence of not possessing any definite connective tissue framework. It is a pale pink membrane of considerable thickness, most marked at the centre of the body, where it forms from Jth to Jth of the thickness of the whole uterine walls. At the internal os uteri it terminates by a distinct border, which separates it from the mucous membrane lining the cervical cavity. The Utricular Glands. — On the surface of the mucous membrane may be observed a multitude of little openings, about -g^th of a line 1 Recbercbes sur la disposition des Fibres musculaires de 1'Uterus. Paris, 1869. 2 Obst. Trans., vol. xiii. p. 294. 54 ORGANS CONCERNED IN PARTURITION. in width (Fig. 22). These are the orifices of the utricular glands, which are found in immense numbers all over the cavity of the Lining Membrane of Uterus, showing network of Capillaries and Orifices of Uteriue Glands. (After Farre.) From the body. From orifice of Fallopian tube. de-sac, narrower at their Fig. 23. uterus, and very closely agglomerated together. They are little culs- mouths than in their length, the blind ex- tremities of which are found in the sub- jacent tissues. Williams describes them as running obliquely towards the surface at the lower third of the cavity, perpen- dicularly at its middle, while towards the fundus they are at first perpendicular, and then oblique in their course (Fig. 23). By others they are described as being often twisted and corkscrew-like. One or more may unite to form a common orifice, several of which may open together in little pits or depressions on the surface of the mucous membrane. These glands are composed of structureless membrane lined with epithelium, the precise character of which is doubtful. By some it is described as columnar, by others tessellated, and by some again as ciliated. The most gener- ally received opinion is that it is columnar, but not ciliated; therein differing from the epithelium covering the surface of the membrane, which is undoubtedly ciliated, the movements of the cilia being from within outwards. Williams, however, has observed cilia in active movement on the columnar epithelium lining the glands, and also states that at the deep-seated extremi- ties of the glands, which penetrate between the muscular fibres for some distance, the columnar epithelium is replaced by rounded cells. The capillaries of the mucous mem- brane run down between the tubes, form- ing a lacework on their surfaces, and round their orifices. No true papillae exist in the membrane lining the uterine cavity. The The course of the Glands in the fully developed Mucous Mem- brane of the Uterus, viz., just be- fore the onset of a menstrual period. (After Williams ) THE FEMALE GENERATIVE ORGANS. 55 mucous membrane of the uterus is peculiar in being always in a state of change and alteration, being thrown oft* at each menstrual period in the form of debris, in consequence of fatty degeneration of its structures, and, reformed afresh by proliferation of the cells of the muscular and connective tissues, probably from below upwards, the new membrane commencing at the internal os.» Hence its appearance and structure vary considerably according to the time at which it is examined. This subject, however, will be more particu- larly studied in connection with menstruation. . Mucous Membrane of the Cervix. — The mucous membrane of the cervix is much thicker and more transparent than that of the body of the uterus, from which it also differs in certain structural peculiari- ties. The general arrangements of its folds and surface have already been described. The lower half of the membrane lining the cavity of the cervix, and the whole of that covering its external or vaginal por- tion, are closely set with a large number of minute filiform, or clavate papillas (Fig. 24). Their structure is similar to that of the mucous Fig. 24. Villi of Os Uteri stripped of Epithelium, (After Tyler Smith and Hassall.) membrane itself, of which they seem to be merelv elevations. They each contain a vascular loop (Fig. 25), and they are believed by Kilian and Far re to be mainly concerned in giving sensibility to this part of the generative tract. All over the interior of the" cervix, both on the ridges of the mucous membrane and between their folds, are a very large number of mucous follicles, consisting of a structure- less membrane lined with cylindrical epithelium, and intimately united with the connective tissue. They cease at the external orifice 56 ORGANS CONCERNED IN PARTURITION. of the cervix, and they secrete the thick, tenacious, and alkaline mucus which is generally found filling the cervical cavity. The transparent follicles, known as the " ovula Nabothii," which are some- times found in considerable numbers in the cavity of the cervix con- sist of mucous follicles the mouths of which have become obstructed and their canals distended by mucous secretion. The lower third of the cervical canal as well as the exterior of the cervix, are covered with pavement epithelium ; while on its upper portion is found a columnar and ciliated epithelium similar to that lining the uterine cavity. Fig. 25. Villi of uterus covered with Pavement Epithelium, and containing Looped Vessels. (After Tyler Smith and Hassall.) Vessels of the Uterus. — The arteries of the uterus are derived from the internal iliac, and from the ovarian. They enter the uterus be tween the folds of the broad ligaments, and, penetrating its muscular coat, anastomose freely with each other and with the corresponding vessels of the opposite side. Their walls are thick and well-devel- oped, and they are remarkable for their very tortuous course, forming spiral curves, especially in the upper part of the uterus. They end in minute capillaries which form the fine meshes surrounding the glands, and in the cervix, give off the loops entering the papillae. Beneath the uterine mucous membrane these capillaries form a plexus, terminating in veins without valves^ which unite with each other to form the large veins traversing the substance of the uterus, known during pregnancy as the uterine sinuses, the walls of which are closely adherent to the uterine tissues. These veins, freely anastomosing with each other, pass outwards to the folds of the broad ligaments, THE FEMALE GENERATIVE ORGANS. 57 where they unite to form, with the ovarian and vaginal veins, a large and well -developed venous network, known as the pampiniform plexus. Lymphatics of the Uterus. — The lymphatics of the uterus are large and well developed, and they have recently, and with much proba- bility, been supposed to play an important part in the production of certain puerperal diseases. A more minute knowledge than we at present possess of their course and distribution will probably throw much light on their influence in this respect. According to the re- searches of Leopold, 1 who has studied their minute anatomy care- fully, they originate in lymph spaces between the fine bundles of connective tissue forming the basis of the mucous lining of tne uterus. Here they are in intimate contact with the utricular glands and the ultimate ramifications of the uterine bloodvessels. . As they pass into the muscular tissue they become gradually narrowed into lymph- vessels and spaces, which have a very complicated arrangement, and which eventually unite together in the external muscular layer, espe- cially on the sides of the uterus, to form large canals which probably have valves. Immediately under the peritoneal covering these lymph- vessels form a large and characteristic network covering the anterior and posterior surfaces of the uterus, and present, in various parts of their course, large ampullae. They then spread over the Fallopian tubes. The lymphatics of the body of the uterus unite with the lumbar glands, those of the cervix with the pelvic glands. Nerves of the Uterus. — The distribution and arrangement of the nerves of the uterus have been the subject of much controversy. They are derived mainly from the ovarian and hypogastric plexuses, inosculatiing freely with each other between the folds of the broad liga- ment, from which they enter the muscular tissue of the uterus gene- rally, but not invariably, following the course of the arteries. They are chiefly derived from the sympathetic ; but, as the hypogastric plexus is connected with the sacral nerves, it is probable "that some fibres from the cerebrospinal system are distributed to the cervix. It is now generally admitted that nervous filaments are distributed to the cervix, even as far as the external os although their existence in this situation has been denied by Jobert and other writers. The ultimate distribution of the nerves is not yet made out. Polle de- scribes a nerve filament as entering the papillae of the cervical mu- cous membrane along with the capillary loop, and Frankenhauser says the nerve fibres surround the muscles of the uterus in the form of plexuses and terminate in the nuclei of the muscle cells. Anomalies of the Uterus. — Various abnormal conditions of the uterus and vagina are occasionally met with, which it is necessary to mention, as they may have an important practical bearing on parturition. The most frequent of these is the existence of a double,. or partially double, uterus (Fig. 26), similar to that found normally in many of the lower animals. This abnormalitv is explained by the development of the organ during foetal life. The uterus is formed 1 Arch. f. Gynak. Bd. vi. Heft i. 58 ORGANS CONCERNED IN PARTURITION out of structures existing only in early foetal life, known as the Wolfian bodies. These consist of a number of tubes, situated on either side of the vertebral column, and opening internally into an excretory duct. Along their external border a hollow canal is formed, termed the canal of Miiller, which like the excretory ducts, proceeds to the common cloaca of the digestive and urinary organs which then exists. The canal of Miiller unites with its fellow of the opposite side to form the uterus and Fallopian tubes in the female, and subsequently the central partition at their point of junction dis- appears. If, however, the' progress of development be in any way checked, the central partition may remain. Then we have produced Fig. 26. Bifid Uterus. (After Farre.) either a complete double uterus or the uterus bicornis, which is bifid at its upper extremity only ; or a double vagina, each leading to a separate uterus. Pregnancy in cases of Bifid Uterus. — If pregnancy occur in any of these anomalous uteri, and many such cases are recorded, serious troubles may follow. It may happen that one horn of a double uterus is not sufficiently large to admit of pregnancy going on to term, and rupture may occur. It is supposed that some cases, pre- sumed to be tubal gestation, were really thus explicable. Impreg- nation may also occur in the two cornua at different times, leading to superfcetation. It is, however, quite possible that impregnation may occur in one horn of a bind uterus, and labor be completed with- out anything unusual being observed. A remarkable case of this sort has been recorded by Dr. Eoss of Brighton, 1 in which a patient miscarried of twins on July 16, 1870, and on October 31, fifteen weeks later, she was delivered of a health} 7 " child. Careful examination showed the existence of a complete double uterus, each side of which had been impregnated. Curiously enough, this patient had formerly given birth to six living children at term, nothing remarkable having been observed in her labors. It can only rarely happen, that, under such circumstances, so favorable a result will follow, and more or less difficulty and danger may generally be expected. Occasionally 1 Lancet, August, 1871. THE FEMALE GENERATIVE ORGANS. 59 the vagina only is double, the uterus being single. Dr. Matthews Duncan has recorded some cases of this kind, 1 in which the vaginal septum formed an obstacle to the birth of the child, and required division. [As there have been reported in the United States, within a short period, no less than five cases of pregnancy, four of them within two years, in which it has been claimed that a tubal foetal cyst discharged its contents into the uterine cavity, and from this through the vagina, I have thought it well to introduce here, the illustration of Kuss- maul, which is in itself a proof, that the uterus although to the sense of touch and external manipulation of normal form, may be in fact as decidedly duplex as a bifid organ. Partitioned Uterus A much less rare form than this, is the half developed uterus, one side being in a rudimentary state. Such an organ may become im- pregnated in its rudimentary cornu, which will either burst as it develops, or, what more rarely happens, discharge its contents per vaginam. To distinguish such a form of pregnancy, from the Fallo- pian variety at the proximal end of the tube, has been generally claimed as impossible during life, and difficult even after death, cer- tain anatomical points being required in proof. Although we have high American authorities in [New York and Philadelphia who claim to have diagnosed true tubal pregnancies in 1 Researches in Obstetrics, p. 443. 60 ORGANS CONCERNED IN PARTURITION. the cases referred to, we know that the most celebrated gynaecolo- gists have been at times mistaken, and that their errors have been revealed under the knife of the surgeon, or anatomist. J T\vo of the reports are illustrated by drawings, representing a normal uterus and a dilated Fallopian tube, just such as we should expect to burst eventually into the abdominal cavity. I should like to believe a per vaginam delivery possible in such a case, and should be glad to have a post-mortem proof to this effect : but certainly our studies of tubal and interstitial specimens have not prepared the medical profession to anticipate so fortunate a termination. When the uterus is perfectly normal, the Fallopian cyst if close to it is found to be developed in the least resisting direction, which is of course toward the distal extremity of the tube. If then the tubal sac contracts as has been claimed, with pains like those of labor, we should not expect it to exert an amount of muscular force sufficient to overcome the resistance at the utero-tubal orifice, but to empty its contents if at all, through a rent at its weakest part. If it be possible that an ovum can develop itself in the proximal end of the Fallopian tube, without as it usually does, penetrating its wall and becoming interstitial, then such a delivery might be possible, provided the wall of the cyst next to the uterine cavity, shall not as is quite common in the true interstitial variety, become its thickest portion. I can easily form in theory just such a cyst, as would of necessity empty itself into the uterine cavity ; but would it be true to nature in any case? Having now five of these remarkable subjects in our two largest cities, it is to be hoped for the good of science, and the settlement of a doubtful question, that at some future day their pelvic organs may be examined after death. — Ed.] Ligaments of the Uterus. — The various folds of peritoneum which invest the uterus serve to maintain it in position, and they are de- scribed as its ligaments. They are the broad, the vesico-uterine, and sacro-uterine ligaments ; the round ligaments are not peritoneal folds like the others. Broad Ligaments. — The broad ligaments extend from either side of the uterus, where their laminae are separated from each other, transversely across to the pelvic wall, and thus divide the cavity of the pelvis into two parts; the anterior containing the bladder, the posterior the rectum. Their upper borders are divided into three subsidiary folds, the anterior of which contains the round ligament, the middle the Fallopian tube, and the posterior the ovary. This arrangement has received the name of the ala vespertilionis, from its fancied resemblance to a bat's wing. Between the folds of the broad ligaments are found the uterine vessels and nerves, and a certain amount of loose cellular tissue continuous with the pelvic fasciae. Here is situated that peculiar structure called the organ of Eosen- miiller, or the parovarium (Fig. 28), which is the remains of the Wolffian body, and corresponds to the epididymis in the male. This f 1 N. Y. Med. Jour. vol. xxvii. p. 273 ; vol. xxviii. 1S78, p. 595.] THE FEMALE GENERATIVE ORGANS. 61 may best be seen in young subjects, by holding up the broad liga- ments and looking through them by transmitted light ; but it exists at all ages. It consists of several tubes (eight or ten according to Farre, eighteen or twenty according to Bankes 1 ), which are tortuous Fig. 28. SSi Adult Parovarium, Ovary, antl Fallopian Tube. (After Kol^elt.) in their course. They are arranged in a pyramidal form, the base of the pyramid being towards the Fallopian tube, its apex being lost on the surface of the ovary. They are formed of fibrous tissue, and lined with pavement epithelium. They have no excretory duct, or communication with either the uterus or ovary, and their function, if they have any, is unknown. Muscular Fibres between its Folds. — A number of muscular fibres are also found in this situation, lying between the meshes of the connective tissue. They have been particularly studied by Rouget, who describes them as interlacing with each other, and forming an open network, continuous with the muscular tissue of the uterus (Fig. 29). They are divisible into two layers, the anterior of which is continuous with the muscular fibres of the anterior surface of the uterus, and goes to form part of the round ligament ; the posterior arises from the posterior wall of the uterus, and proceeds transversely outwards, to become attached to the sacro-iliac synchondrosis. A continuous muscular envelope is thus formed, which surrounds the whole of the uterus, Fallopian tubes, and ovaries. Its function is not yet thoroughly established. It is supposed to have the effect of retracting the stretched folds of peritoneum after delivery, and more especially of bringing the entire generative organs into harmonious action during menstruation and the sexual orgasm ; in this way explaining, as we shall subsequently see, the mechanism by which the fimbriated extremity of the Fallopian tube grasps the ovary prior to the rupture of a Graafian follicle. Round Ligaments. — The round ligaments are essentially muscular in structure. They extend from the upper border of the uterus, 1 Bankes, On the Wolffian Bodies. 62 ORGANS CONCERNED IN PARTURITION. with the fibres of which their muscular fibres are continuous, trans- versely and then obliquely downwards, until they reach the inguinal Fig. 29. Posterior View of Muscular and Vascular Arrangements. (After Rouget.) Vessels. — 1, 2, 3. Vaginal, cervical, and uterine plexuses. 4. Arteries of body of uterus. 5. Arteries supp'ying ovary. Muscular fasciculi. — 6,7. Fibres attached to vagina, symphysis pubis, aud sacro-iliac joint. 8. Muscular fasciculi from uterus aud broad ligaments. 9,10,11,12. Fasciculi attached to ovary and Fallopian tubes. rings, where they blend with the cellular tissue. In the first part of their course the muscular fibres are solely of the unstriped variety, but soon they receive striped fibres from the transversalis muscles, and the columns of the inguinal ring, which surround and cover the unstriped muscular tissue. In addition to these structures they con- tain elastic and connective tissue, and arterial, venous, and nervous branches ; the former form the iliac or cremasteric arteries, the latter the genito-crural nerve. According to Mr. Eainey the principal function of these ligaments is to draw the uterus towards the sym physis pubis during sexual intercourse, and thus to favor the ascent of the semen. Vesico -uterine Ligaments. — The vesico-uterine ligaments are two folds of peritoneum passing in front from the lower part of the body of the uterus to the fundus of the bladder. Utero-sacral Ligaments. — The utero-sacral ligaments consist of folds of peritoneum of a crescentic form, with their concavities look- THE FEMALE GENERATIVE ORGANS. 68 ing inwards : they start from the lower part of the posterior surface of the uterus, and curve backwards to be attached to the third and fourth sacral vertebne. Within their folds exist bundles of muscu- lar fibres, continuous with those of the uterus, as well as connective tissue, vessels, and nerves. The experiments of Savage, as well as of other anatomists, show that these ligaments have an important influence in preventing downward displacement of the womb. Alterations during Pregnancy. — During pregnancy all these liga- ments become greatly stretched and unfolded, rising out of the pelvic cavity and accommodating themselves to the increased size of the gravid uterus ; and they again contract to their natural size, possibly through the agency of the muscular fibres contained within them, after delivery has taken place. Fallopian Tubes. — The Fallopian tubes, the homologues of the vasa deferentia in the male, are structures of great physiological interest. They serve the double purpose of conveying the semen to the ovar}^, and of carrying the ovule to the uterus. From the latter function they may be looked on as the excretory ducts of the ovaries ; but, unlike other excretory ducts, they are movable, so that they may apply themselves to the part of the ovaries from which the ovule is to come; and so great is their mobility, that there is reason to believe that a Fallopian tube may even grasp the ovary of the opposite side. [This has been established by a case where impregnation took place in an ovary, the Fallopian tube corresponding to which was imper- vious and immovable. — Ed.] Each tube proceeds from the upper angle of the uterus at first transversely outwards, and then down- wards, backAvards, and inwards, so as to reach the neighborhood of the ovary. In the first part of its course it is straight, afterwards it becomes flexuous and twisted on itself. It is contained in the upper part of the broad ligament, where it may be felt as a hard cord. It commences at the uterus by a narrow opening, admitting only the passage of a bristle, known as the ostium uterinum. As it passes through the muscular walls of the uterus the tube takes a somewhat curved course, and opens into the uterine cavity by a dilated aper- ture. From its uterine attachment the tube expands gradually until it terminates in its trumpet-shaped extremity; just before its distal end, however, it again contracts slightly. The ovarian end of the tube is surrounded by a number of remarkable fringe-like processes. These consist of longitudinal membranous fimbriae, surrounding the aperture of the tube, like the tentacles of a polyp, varying consider- ably in number and size, and having their edges cut and subdivided. On their inner surface are found both transverse and longitudinal folds of mucous membrane, continuous with those lining the tube itself (Fig. 30). One of these fimbria? is always larger and more de- veloped than the rest, and is indirectly united to the surface of the ovary by a fold of peritoneum proceeding from its external surface. Its under surface is grooved so as to form a channel, open below. The function of this fringe-like structure is to grasp the ovary during the menstrual nisus; and the fimbria which is attached to the ovary would seem to guide the tentacles to the ovary which they are in- 64 ORGANS CONCERNED IN PARTURITION, tended to seize. One or more supplementary series of fimbriae some- times exist, which have an aperture of communication with the canal of the Fallopian tube, beyond its ovarian extremity. Fig. 30. Fallopian Tube laid open. (After Richard.) a, b. Uterine portion of Tube, c, d. Plicae of Mucous Membrane, e. Tubo-ovarian Ligaments and Fringes. /. Ovary, g. Round Ligaments. Their Structure. — The tubes themselves consist of peritoneal, mus- cular, and mucous coats. The peritoneum surrounds the tube for three-fourths of its calibre, and comes into contact with the mucous lining at its fimbriated extremity, the only instance in the body where such a junction occurs. The muscular coat is principally composed of circular fibres, with a few longitudinal fibres inter- spersed. Its muscular character has been doubted by Eobin and JRichard, but Farre had no difficulty in demonstrating the existence of muscular fibres, both in the human female and many of the lower .animals. According to Eobin the muscular tissue of the Fallopian tubes is entirely distinct from that of the uterus, from which he describes it as being separated by a distinct cellular septum. The mucous lining is thrown into a number of remarkable longitudinal folds, each of which contains a dense and vascular fibrous septum, with small muscular fibres, and is covered with columnar and ciliated epithelium. The apposition of these produces a series of minute capillary tubes, along which the ovules are propelled, the action of the cilia, which is towards the uterus, apparently favoring their progress. The Ovaries. — The ovaries are the bodies in which the ovules are formed, and from which they are expelled, and the changes going on in them in connection with the process of ovulation, during the whole period between the establishment of puberty and the cessation of menstruation, have an enormous influence on the female economy. Normally, the ovaries are two in number ; in some exceptional cases a supplementary ovary has been discovered ; or they may be entirely TIIE FEMALE GENERATIVE ORGANS. 65 absent. The} 7 are placed in the posterior fold of the broad ligament, usually below the brim of the pelvis, behind the Fallopian tubes, the left in front of the rectum, the right in front of some coils of the small intestine. Their situation varies, however, very much under different circumstances, so that they can scarcely be said to have a fixed and normal position. In pregnancy they rise into the abdomi- nal cavity with the enlarging uterus ; and in certain conditions they are dislocated downwards into Douglas's space, where they may be felt through the vagina as rounded and very tender bodies. Tlteir Connections. — The folds of the broad ligament, between which the ovaries are placed, form for them a kind of loose mesentery. Each of them is united to the upper angle of the uterus by a special ligament called the utero-ovarian. This is a rounded band of organic muscular fibres, about an inch in length, continuous with the super- ficial muscular fibres of the posterior wall of the uterus, and attached to the inner extremity of the ovary. It is surrounded by peritoneum, and through it the muscular fibres, which form an important integral part in the structure of the ovaries, are conveyed to them. The ovary is also attached to the fimbriated extremity of the Fallopian tube in the manner already described. The ovary is of an irregular oval shape (Fig. 31), the upper bor- der beino- convex, the lower — throuo-h which the vessels and nerves enter — -being straight. The anterior surface, like that of the uterus, is less convex than the posterior. The outer extremity is more A A. Ovary enlarged under Menstrual Nisus. B. Ripe Follicle projecting on its surface, o, a, a. Traces of previously ruptured Follicie. rounded and bulbous than the inner, which is somewhat pointed and eventually lost in its proper ligament. By these peculiarities it is possible to distinguish the left from the right ovary, after they have been removed from the body. The ovar} r varies much in size under different circumstances. On an average, in adult life, it measures from one to two inches in length, three-quarters of an inch in width, and about half an inch in thickness. It increases greatly in size QQ ORGANS CONCERNED IN PARTURITION during each menstrual period ; a fact which has been demonstrated in certain cases of ovarian hernia, where the protruded ovary has been seen to swell as menstruation commenced ; also during preg- nancy, when it is said to be double its usual size. After the change of life it atrophies, and becomes rough and wrinkled on its surface. Be- fore puberty, the surface of the ovary is smooth and polished, and* of a whitish color. After menstruation commences, its surface becomes I scarred by the rupture of the Graafian follicles (Fig. 31, a a), each of which leaves a little linear or striated cicatrix, of a brownish color; and the older the patient the greater are the number of these cicatrices. Structure. — The structure of the ovary has been made the subject of many important observations. It has an external covering of epithelium, originally continuous with the peritoneum, called by some the germ-epithelium, in consequence of the ovules being formed from it in early foetal life. In the adult it is separated from the peri- toneum at the base of the organ by a circular white line, and it con- sists of columnar epithelium, differing only from the epithelium lining the Fallopian tubes, with which it is sometimes continuous through the attached fimbria uniting the tube and the ovary, in being destitute of cilia. Immediately beneath this covering is the dense coat known as the tunica alhuginea, on account' of its whitish color. It consists of short connective-tissue fibres, arranged in laminae, among which are interspersed fusiform muscular fibres. At the point where the vessels and nerves enter the OA^ary this membrane is raised into a rido-e, which is continuous with the utero- ovarian ligament. The tunica albuginea is so intimately blended with the stroma of the ovary, as to be inseparable on dissection ; it does not, however, exist as a distinct lamina, but is merely the external part of the proper structure of the ovary, in which more dense connective tissue is developed than elsewhere. The Stroma. — On making a longitudinal section of the ovary (Fig. 32), it will be seen to be composed of two parts, the more internal of which is of a reddish color from the num- ber of vessels that ramify in it, and is called the medullary or vascular zone ; while the external, of a whitish tint, receives the name of the cortical or parenchymatous substance. The former consists of loose connective tissue interspersed with elastic, and a considerable number of muscular fibres. According to Kouget 1 and His 2 the muscular structure forms the greater part of the ovarian stroma. The latter de- scribes it as consisting essentially of inter- woven muscular fibres, which he terms the "fusiform tissue," and which he be- lieves to be continuous with the muscular layers of the ovarian vessels. The former believes that the mus- cular fasciculi accompany the vessels in the form of sheaths, as in Fig. 32. Longitudinal section of adult ovary. (After Farre.) 1 Journal de Physiol, i. p. 737. 2 Scliultze's Arch. f. Mikrocop. Anat. 1865. THE FEMALE GENERATIVE ORGANS 67 erectile tissues. Both attribute to the muscular tissues an important influence in the expulsion of the ovules, and in the rupture of the Graafian follicles. Waldeyer and other writers, however, do not consider it to be so extensively developed as Eouget and His believe. The cortical substance is the more important as that in which the Graafian follicles and ovules are formed. It consists of interlaced fibres of connective tissue, containing a large number of nuclei. The muscular fibres of the medullary substance do not seem to penetrate into it in man. In it are found the Graafian follicles, which exist in enormous numbers from the earliest periods of life, and in all stages of development (Fig. 33). Fig. 33. tSSSffife :»£? 7A Section through the Cortical part of the Ovary. e. Surface epithelium. $■?. Ovarian Stroma. 11. Large-sized Graafian Follicles. 2 2. Middle- sized, and 33. Small sized Graafian Follicles, o. Ovule within Graafian Follicle, v v. Bloodvessels in the Stroma, g. Cells of the Membraua Granulosa. (After Turner.) The Graafian Follicles. — According to the researches of Pfluger, Waldeyer, and other German writers, the Graafian follicles are formed in early foetal life by cylindrical inflections of the epithelial covering of the ovary, which dip into the substance of the gland. These tubular filaments anastomose with each other and in them are formed the ovules, which are originally the epithelial cells lining the tubes. Portions become shut off from the rest of the filaments, and form the Graafian follicles. The ovules, on this view, are highly developed epithelial cells, originally derived from the surface of the ovary, and not developed in its stroma. These tubular filaments disappear shortly after birth, but they have recently been detected by Slavyansky 1 in the ovaries of a woman thirty years of age. These observations have been modified by Dr. Poulis. 2 He reco.o:- 1 Annales de Grynak. Feb. 1871. 2 Proceedings of the Royal Soc. of Edinb., April, Pliys. vol. xiii., 1879. 18' and Journ. of Anat. and 68 ORGANS CONCERNED IN PARTURITION. nizes the origin of the ovules from the germ-epithelium covering the surface of the ovary, which is itself derived from the Wolffian body. He believes all the ovules to be formed from the germ -epi- thelium corpuscles, which become embedded in the stroma of the ovary, by the outgrowth of processes of vascular connective tissue, fresh germ-epithelial corpuscles being constantly produced on the surface of the organ up to the age of 2J years, to take the place of those already embedded in its stroma. He believes the Graafian follicles to be formed by the growth of delicate processes of connec- tive tissue between and around the ovules, but not from tubular inflections of the epithelium covering the gland, as described by Waldeyer (Fig. 34:). This view is supported by the researches of Fig. 34. Vertical Section through the Ovaiy of the Human Foetus. gg. Germ-epithelium, with oo, developing ovule9 in it. s s. Ovarian Stroma, containing ccc, Fusiform Connective tissue Corpuscles, vv. Capillary Bloodvessels. In the centre of the Figure an Involution of the Germ-epithelium is shown; and at the left lower side a Primordial Ovule, with the Connective-tissue Corpuscles ranging themselves round it. (After Foulis.) Balfour, 1 who arrives at the conclusion that the whole egg- contain- ing part of the ovary is really the thickened germinal epithelium, broken up into a kind of mesh work by growths of vascular stroma. According to this theory Pfluger's tubular filaments are merely trabe- cule of germinal epithelium, modified cells of which become de- veloped into ova. The greater proportion of the Graafian follicles are only visible with the high powers of the microscope, but those which are ap- proaching maturity are distinctlv to be seen by the naked eye. The quantity of these follicles is immense. Foulis estimates that at birth each human ovary contains not less than 30,000. No fresh follicles appear to be found after birth, and as development goes on some only grow, and, by pressure on the others, destroy them. Of those that grow of course only a few ever reach maturity; they are scat- tered through the substance of the ovary, some developing in the 1 P. M. Balfour. "Structure and Development of Vertebrate Ovary." Quarterly Journal of Microscopical Science, vol. xviii., 1878. THE FEMALE GENERATIVE ORGANS. 69 stroma, others on the surface of the organ, where they eventually burst, and are discharged into the Fallopian tube. Structure. — A ripe Graafian follicle has an external investing mem- brane (Fig. 35), which is generally described as consisting of two Fig. 35. Diagrammatic Section of Graafian Fol icle. 1. Ovum. 2. MemV>rana granulosa. 3. External membrane of Graafian follicle. 4. Itsvessels. 5. Ovarian stroma. t>. Cavity of Graafian follicle. 7. External covering of ovary. distinct layers; the external, or tunica fibrosa, highly vascular and formed of connective tissue ; the internal, or tunica propria, composed of young connective tissue, containing a large number of fusiform or stellate cells, and numerous oil-globules. These layers, however, appear to be essentially formed of condensed ovarian stroma. Within this capsule, is the epithelial lining called the membrana (jranulosa, consisting of stratified columnar epithelial cells, which, according to Foulis, are originally formed from the nuclei of the fibro-nuclear tissue of the stroma of the ovary. At one part of the circumference of the ovisac is situated the ovule, around which the epithelial cells are congregated in greater quantity, constituting the projection known as the discus proligerus. The remainder of the cavity of the follicle is filled with a small quantity of transparent fluid, the liquor foil iculi, traversed by three or four minute bands, the retinacula of Barry, which are attached to the opposite walls of the follicular cavity, and apparently serve the purpose of suspending the ovule and main- taining it in a proper position. In many young follicles this cavity does not at first exist, the follicle being entirely filled by the ovule. According to Waldeyer, the liquor foiliculi is formed by the disinte- gration of the epithelial cells, the fluid thus produced collecting, and distending the interior of the follicle. Ovule. — The ovule is attached to some part of the internal surface of the Graafian follicle. It is a rounded vesicle about ^\q of an inch in diameter, and is surrounded by a layer of columnar cells, distinct from those of the discus proligerus in which it lies. It is invested by a transparent elastic membrane, the zona pellucida, or vitelline membrane. In most of the lower animals the zona pellucida is per- forated by numerous very minute pores, only visible under the TO ORGANS CONCERNED IN PARTURITION. highest powers of the microscope; in others there is a distinct aper- ture of a larger size, the micropyle, allowing the passage for the spermatozoa into the interior of the ovule. It is possible that similar apertures may exist in the human ovule, but they have not been demonstrated. Within the zona pellucida some embryologists de- scribe a second fine membrane, the existence of which has been denied by Bischoff. The cavity of the ovule is filled with a viscid yellow fluid, the yelk, containing numerous grannies. It entirely iills the cavity, to the walls of which it is non-adherent. In the centre of the yelk in young, and at some portion of its periphery in mature ovules, is situated the germinal vesicle, which is a clear cir- cular vesicle, refracting light strongly, and about g^th of a line in diameter. It contains a few granules, and a nucleolus, or germinal spot, which is sometimes double. From within outwards, therefore, we find: — 1. The germinal spot; round this 2. The germinal vesicle, contained in 3. The yelk, which is surrounded by the 4. Zona pellucida, with its layers of columnar epithelial cells. These constitute the ovule. The ovule is contained in — ■ The Graafian follicle, and lies in that part of its epithelial lining called the — Discus "proligerus, the rest of the follicle being occupied by the liquor folliculi. Bound these we have the epithelial lining or mem- hrana granulosa, and the external coat consisting of the tunica pro- pria and the tunica fibrosa-. Vessels and Nerves of the Ovary. — The vascular supply of the ovary is complex. The arteries enter at the hilum, penetrating the stroma Fig. 36. Bulb of Ovary. v. Uterus, o. Ovary and utero-ovarian ligament, r. Fallopian tube. 1. Utero-ovarian vein. 2. Pampiniform ovarian plexus. 3. Commencement of spermatic vein. in a spiral curve, and are ultimately distributed in a rich capillary plexus to the follicles. The large veins unite freely with each other, and form a vascular and erectile plexus, continuous with that sur- rounding the uterus, called the bulb of the ovary (Fig.86). Lym- phatics and nerves exist, but their mode of termination is unknown. THE FEMALE GENERATIVE ORGANS 71 The Mammary Glands. — To complete the consideration of the generative organs of the female we must study the mammary glands, which secrete the fluid destined to nourish the child. In the human subject they are two in number, and instead of being placed upon the abdomen, as in most animals, they are situated on either side of the sternum, over the pectoralis major muscles, and extend from the third to the sixth ribs. This position of the glands is obviously intended to suit the erect position of the female in suckling. They are con- vex anteriorly, and flattened posteriorly where they rest on the muscles. They vary greatly in size in different subjects, chiefly in proportion to the amount of adipose tissue they contain. In man, and in girls, previous to puberty, they are rudimentary in structure ; while in pregnant women they increase greatly in size, the true glandular structures becoming much hypertrophied. Anomalies in shape and position are sometimes observed. Supplementary mammas, one or more in number, situated on the upper portion of the mam- mie, are sometimes met with, identical in structure with the normally situated glands ; or, more commonly, an extra nipple is observed by the side of the normal one. In some races, especially the African, the mammas are so enormously developed, that the mother is able to suckle her child over her shoulder. Their Structure. — The skin covering the gland is soft and supple, and during pregnancy often becomes covered with fine white lines, while large blue veins may be observed coursing over. Underneath it is a quantity of connective tissue, containing a considerable amount of fat, which extends between the true glandular structure. This is composed of from fifteen to twenty lobes, each of which is formed of a number of lobules. The lobules are produced by the aggrega- tion of the terminal acini in which the milk is formed. The acini are minute culs-de-sac opening into little ducts, which unite with each other until they form a large duct for each lobule ; the ducts of Fig. 37. 1. Galucrophorous ducts 2. Lohuli of the mammary gland. each lobule unite with each other, until they end in a still larger duct common to each of the fifteen or twenty lobes into which the gland is divided, and eventually open on the surface of the nipple. These terminal canals are known as the c/alactojihorus ducts (Fig. 37). They become widely dilated as they approach the nipple, so as to 72 ORGANS CONCERNED IN PARTURITION. form reservoirs in which milk is stored until it is required, but when they actually enter the nipple they again contract. Sometimes they give oft' lateral branches, but, according to Sappey, they do not anas- tomose with each other, as some anatomists have described. These excretory ducts are composed of connective tissue, with numerous elastic fibres on their external surface. Sappey and Eobin describe a layer of muscular fibres, chiefly developed near their terminal extremities. They are lined with columnar epithelium, continuous with that in the acini; and it is by the distension of its cells with, fatty matter, and their subsequent bursting, that the milk is formed. Nipple. — The nipple is the conical projection at the summit of the mamma, and it varies in size in different women. Not very unfre- quently, from the continuous pressure to which it has been subjected by the dress, it is so depressed below the surface of the skin as to prevent lactation. It is generally larger in married than in single women, and increases in size during pregnancy. Its surface is covered with numerous papillae, giving it a rngous aspect, and at their bases the orifices of the lactiferous ducts open. Here are also the openings of numerous sebaceous follicles, which secrete an unctuous material supposed to protect and soften the integument during lactation. Beneath the skin are muscular fibres, mixed with connective and elastic tissues, vessels, nerves, and lymphatics. When the nipple is irritated it contracts and hardens, and by some this is attributed to its erectile properties. The vascularity, however, is not great, and it contains no true erectile tissue : the hardening is, therefore, due to muscular contraction. Surrounding the nipple is the areola, of a pink color in virgins, becoming dark from the development of pig- ment cells during pregnancy, and always remaining somewhat dark after childbearing. On its surface are a number of prominent tuber- cles, sixteen to twenty in number, which also become largely de- veloped during gestation. They are supposed by some to secrete milk, and to open into the lactiferous tubes ; most probably they are- composed of sebaceous glands only. Beneath the areolar is a circular band of muscular fibres, the object of which is to compress the lactif- erous tubes which run through it, and thus to favor the expulsion of their contents. The mammae receive their blood from the internal mammary and intercostal arteries, and they are richly supplied with lymphatic vessels, which open into the axillary glands. The nerves are derived from the intercostal and thoracic branches of the brachial plexus. The secretion of milk in women who are nursing is accompanied by a peculiar sensation, as if milk were rushing into the breast, called the " draught," which is excited by the efforts of the child to suck, and by various other causes. The sympathetic relations be- tween the mammae and the uterus are very well marked, as is shown in the unimpregnated state by the fact of the frequent occurrence of • sympathetic pains in the breast in connection with various uterine diseases, and, after delivery, by the well-known fact that suction pro- duces reflex contraction of the uterus, and even severe after-pains. OVULATION AND MENSTRUATION. 73 CHAPTER III. OVULATION AND MENSTRUATION. Functions of the Ovary. — The main function of the ovary is to supply the female generative element, and to expel it, when ready for impregnation into the Fallopian tube, along which it passes into the uterus. This process takes place spontaneous in all viviparous animals, and without the assistance of the male. In the lower animals this periodical discharge receives the name of the oestrus or rut, at which time only the female is capable of impregnation and admits the approach of the male. In the human female the periodical dis- charge of the ovule, in all probability, takes place in connection with menstruation, which may therefore be considered to be the analogue of the rut in animals. After each menstrual period Graafian folli- cles undergo changes which prepare them for rupture and the dis- charge of their contained ovules. After rupture, certain changes occur which have for their object the healing of the rent in the ovarian tissue through which the ovule has escaped, and the filling np of the cavity in which it was contained. This results in the for- mation of a peculiar body in the substance of the ovary, called the corpus luteum which is essentially modified should pregnancy occur, and is of great interest and importance. During the whole of the childbearing epoch the periodical maturation and rupture of the Graafian follicles are going on. If impregnation does not take place, the ovules are discharged and lost ; if it does, ovulation is stopped, as a general rule, during gestation and lactation. Theory of Menstruation. — This, broadly speaking, is an outline of the modern theory of menstruation which was first broached in the year 1821 by Dr. Power, and subsequently elaborated by Negrier, Bischoff, Raciborski, and many other writers. Although the se- quence of events here indicated" may be taken to be the rule, it must be remembered that it is one subject to many exceptions, for un- doubtedly ovulation may occur without its outward manifestation, menstruation, as in cases in which impregnation takes place during lactation or before menstruation has been established, of which many examples are recorded. These exceptions have led some modern writers to deny the ovular theory of menstruation, and their views will require subsequent consideration. In order to understand the subject properlv it will be necessary to study the sequence of events in detail. Changes in the Graafian Follicle. — The changes in the Graafian follicle which are associated with the discharge of the ovules com- prise — 1. Maturation. As the period of puberty approaches a cer- 74 ORGANS CONCERNED IN PARTURITION. tain number of the Graafian follicles, fifteen to twenty in number, increase in size, and come near the surface of the ovary. Amongst these one becomes especially developed, preparatory to rupture, and upon it for the time being all the vital energy of the ovary seems to be concentrated. A similar change in one, sometimes in more than one, follicle takes place periodically during the whole of the child- bearing epoch, in connection with each menstrual period, and an examination of the ovary will show several follicles in different stages of development. The maturing follicle becomes gradually larger, until it forms a projection on the surface of the ovary, from five to seven lines in breadth, but sometimes even as large as a nut (Fig. 31). This growth is due to the distension of the follicle by the in- crease of its contained fluid, which causes it so to press upon the ovarian structures covering it, that they become thinned, separated from each other, and partially absorbed, until they eventually readily lacerate. The follicle also becomes greatly congested, the capillaries coursing over it become increased in size and loaded with blood, and being seen through the attenuated ovarian tissue, give it, when mature, a bright red color. At this time some of these distended capillaries in its inner coat lacerate, and a certain quantity of blood escapes into its cavity. This escape of blood takes place before rupture, and seems to have for its principal object the increase of the tension of the follicle, of which it has been termed the menstruation. Pouchet was of opinion that the blood collects behind the ovule, and carries it up to the surface of the follicle. By these means the follicle is more and more distended, until at last it ruptures either sponta- neously or, it may be, under the stimulus of sexual excitement. "Whether the laceration takes place during, before, or after the men- strual discharge is not yet positively known : from the results of post-mortem examination in a number of women who died shortly before or after the period, Williams believes that the ovules are ex- pelled before the monthly flow commences. 1 In order that the ovule may escape, the laceration must, of course, involve not only the coats of the Graafian follicles, but also the superincumbent structures. Laceration seems to be aided by the growth of the internal layer of the follicle, which increases in thickness before rupture, and assumes a characteristic yellow color from the number of oil-globules it then contains. It is also greatly facilitated, if it be not actually produced, by the turgescence of the ovary at each menstrual period, and by the contraction of the muscular fibres in the ovarian stroma. As soon as the rent in the follicular walls is produced, the ovule is discharged, surrounded by some of the cells of the membrana granu- losa, and is received into the fimbriated extremity of the Fallopian tube, which grasps the ovary over the site of the rupture. ^ By the vibratile cilia of its epithelial lining, it is then conducted into the canal of the tube, along which it is propelled, partly by ciliary action and partly by muscular contraction in the walls of the tube. Obliteration of the Graafian Follicle.— After the ovule has escaped, i Proceedings of the Royal Society, 1875. OVULATION AND MENSTRUATION 75 Ficx. 38. certain characteristic changes occur in the empty Graafian follicle, which have for their object its cicatrization and obliteration. There are great differences in the changes which occur when impregnation has followed the escape of the ovule, and they are then so remarkable that they have been considered certain signs of pregnancy. They are, however, differences of degree rather than of kind. It will be well, however, to discuss them separately. Changes undergone by the Follicle where Impregnation does not occur. — As soon as the ovule is discharged, the edges of the rent through which it has escaped become agglutinated by exudation, and the fol- licle shrinks, as is generally believed, by the inherent elasticity of its internal coat, but according to Eobin, who denies the existence of this coat, from compression by the muscular fibres of the ovarian stroma. In proportion to the contraction that takes place, the inner layer of the follicle, the cells of which have become greatly hyper- trophied and loaded with fat granules previous to rupture, is thrown into numerous folds. The greater the amount of contraction the deeper these folds become, giving to a section of the follicle an appearance similar to that of the convolutions of the brain (Fig. 38). These folds in the human subject are generally of a bright yellow color, but in some of the mam- malia they are of a deep red. The tint was formerly ascribed by Raciborski to absorption of the coloring matter of the blood-clot contained in the follicular cavity, a theory he has more recently abandoned in favor of the view main- tained by Coste that it is due to the in- herent color of the cells of the lining membrane of the follicle, which, though not well marked in a single cell, becomes very apparent en masse. The existence of a contained blood-clot is also denied by the latter physiologist, except as an unusual pathological dition ; and he describes the cavity as containing a gelatinous and plastic fluid, which becomes absorbed as contraction advances. The more recent researches of Dalton, 1 however, show the existence of a central blood clot in the cavity of the follicle, and he considers its occasional absence to be connected with disturbance or cessation of* the menstrual function. The folds into which the membrane has been thrown continue to increase in size, from the proliferation of their cells, until they unite and become adherent, and eventually fill the follicular cavity. By the time that another Graafian follicle is matured and ready for rupture the diminution has advanced con- siderably, and the empty ovisac is reduced to a very small size. The cavity is now nearly obliterated, the yellow color of the convolutions Section of ovary, urn three weeks (After Daltou.) showing corpus lute- after menstruation. con- Report on the Corpus Luteum. American Gynsec. Trans, vol. ii., 187£ 76 ORGANS CONCERNED IN PARTURITION. is altered into a whitish tint, and on section the corpus lutenm has the appearance of a compact white stellate cicatrix, which generally disappears in less than forty days from the period of rupture. The tissue of the ovary at the site of laceration also shrinks, and this, aided by the contraction of the follicle, gives rise to one of those per- manent pits or depressions which mark the surface of the adult ovary. Slavyansky 1 has recently shown that only' a few of the immense number of Graafian follicles undergo these alterations. The greater proportion of them seem never to discharge their ovules, but, after increasing in size, undergo retrogressive changes exactly similar in their nature, but to. a much less extent, to those which result in the formation of a corpus luteum. The sites of these may afterwards be seen as minute striae in the substance of the ovary. Changes undergone by the Follicle when Impregnation has taken place. — Should pregnancy occur, all the changes above described take place, but, inasmuch as the ovary partakes cf the stimulus to which all the generative organs are then subjected, they are much more marked and apparent. Instead of contracting and disappearing in a few weeks, the corpus luteum continues to grow until the third or fourth month of pregnancy ; the folds of the inner layer of the ovisac become large and fleshy, and permeated by numerous capillaries, and ultimately become so firmly united that the margins of the convolu- tions thin and disappear, leaving only a firm fleshy yellow mass, averaging from 1 to 1} inches in thickness, which surrounds a central cavity, often containing a whitish fibrillated structure, believed to be the remains of a central blood clot. This was erroneously sup- Fig. 39. Fig. 40. Corpus luteum at the fourth month cf pregnancy. Corpus luteum of pregnancy at (After Dalton.) term. (After Dalton. ; posed by Montgomery to be the inner layer of the follicle itself, and he conceived the yellow substance to be a new formation between it and the external layer, while Eobert Lee thought it was placed ex- ternal to both the external and internal layers. i Archiv de Phys. March, 1874. OVULATION AND MENSTRUATION. 77 Between the third and fourth months of pregnancy, when the corpus luteum has attained its maximum of development (Fig. 89), it forms a firm projection on the surface of the ovary, averaging about 1 inch in length, and rather more than J an inch in breadth. After this it commences to atrophy (Fig. 10), the fat-cells become absorbed, and the capillaries disappear. Cicatrization is not com- plete until from one to two months after deliver}'. Its Value as a Sign of Pregnancy. — On account of the marked appearance of the corpus luteum it was formerly considered to be an infallible sign of pregnancy ; and it was distinguished from the cor- pus luteum of the non-pregnant state by being called a " true'" as opposed to a " false'' corpus luteum. From what has been said it will be obvious that this designation is essentially wrong, as the difference is one of degree only. Dalton 1 applies the term ''false corpus luteum" to a degenerated condition sometimes met with in an unruptured Graafian follicle consisting in re-absorption of its contents, and thickening of its walls. It differs from the "true"' corpus luteum in being deeply seated in the substance of the ovarv, in having no central clot, and in being unconnected with a cicatrix on the surface of the ovary. Xor do obstetricians attach by any means the same importance as they did formerly to presence of this corpus luteum as indicating impregnation; for even when well marked, other and more reliable signs of recent delivery, such as enlargement of the uterus, are sure to be present, especially at the time when it has reached its maximum of development : while after delivery at term it has no longer a sufficiently characteristic appearance to be depended on. Menstruation. — By the term menstruation (eatamenia, periods, etc.\ is meant the periodical discharge of blood from the uterus, which occurs, in the healthy woman, every lunar month, except during pregnancy and lactation, when it is, as a rule, suspended. Period of Establish ment — The first appearance of menstruation coin- cides with the establishment of puberty, and the physical changes that accompany it indicate that the female is capable of conception and childbearing, although exceptional cases are recorded in which pregnancy occurred before menstruation had begun. In temperate climates it generally commences between the 14th and 16th years, the largest number of cases being met with in the loth year. This rule is subject to many exceptions, it being by no means very rare for menstruation to become established as earlv as the 10th or 11th years, or to be delayed until the 18th or 20th. Beyond these physio- logical limits a few cases are from time to time met with in which it has begun in early infancy, or not until a comparatively late Period of life. Influence of Climate, Pace, etc. — Various accidental circumstances have much to do with its establishment. As a rule, it occurs some- what earlier in tropical, and later in very cold, than in temperate climates. The influence of climate has been unduly exaggerated. It 1 Op. cit., p. 75. 78 ORGANS CONCERNED IN PARTURITION. used to be generally stated that in the Arctic regions women did not menstruate until they were of mature age, and that in the tropics girls of 10 or 12 years of age did so habitually. The researches of Eoberton, of Manchester, 1 first showed that the generally received opinions were erroneous ; and the collection of a large number of statistics has corroborated his opinion. There can be no doubt, how- ever, that a larger proportion of girls menstruate early in warm cli- mates. Joulin found that in tropical climates, out of 1635 cases, the largest proportion began to menstruate between the 12th and 13th years ; so that there is an average difference of more than two years between the period of its establishment in the tropics and in tempe- rate countries. Harris 2 states that among the Hindoos 1 to 2 per cent, menstruate as early as nine years of age ; 3 to 4 per cent, at ten ; 8 per cent, at eleven ; and 25 per cent, at twelve ; while in London or Paris probably not more than one girl in 1000 or 1200 does so at nine years. The converse holds true with regard to cold climates, although we are not in possession of a sufficient number of accurate statistics to draw very reliable conclusions on this point ; but out of 4715 cases, including returns from Denmark, Norway and Sweden Russia and Labrador, it was found that menstruation was established on an average a year later than in more temperate countries. It is probable that the mere influence of temperature has much to do in producing these differences, but there are other factors, the action of which must not be overlooked. Raciborski attributes considerable importance to the effect of race; and he has quoted Dr. Webb, of Calcutta, to the effect that English girls in India, although subjected to the same climatic influence as the Indian races, do not, as a rule, menstruate earlier than in England ; while in Austria, girls of the Magyar race menstruate considerably later than those of Grer man pa- rentage. 3 The surroundings of girls, and their manner of education and living, have probably also a marked influence in promoting or retarding its establishment. Thus, it will commence earlier in the children of the rich, who are likely to have a highly developed ner- vous organization, and are habituated to luxurious living, and a pre- mature stimulation of the mental faculties by novel-reading, society, and the like ; while amongst the hard-worked poor, or in girls brought up in the country, it is more likely to begin later. Premature sexual excitement is said also to favor its early appearance, and the influ- ence of this among the factory girls of Manchester, who are exposed in the course of their work, to the temptations arising from the pro- miscuous mixing of the sexes, has been pointed out by Dr. Clay. 4 Changes Occurring at Puberty. — The first appearance of menstrua- tion is accompanied by certain well-marked changes in the female system, on the occurrence of which we say that the girl has arrived at the period of puberty. The pubes become covered with hair, the breasts enlarge, the pelvis assumes its fully developed form, and the ' Edin. Med. and Surg. Journ., 1832. 2 Amer. Journ. of Obst. 1871. R. P. Harris, on early puberty. , 3 Op. cit., p. 227. 4 Brit. Record of Obst. Med. vol. i. OVULATION AND MENSTRUTA ION . 79 general contour of the body fills out. The mental qualities also alter; the girl becomes more shy and retiring, and her whole bearing indi- cates the change that has taken place. The menstrual discharge is not established regularly at once. For one or two months there may be only premonitory symptoms: a vague sense of discomfort, pains in the breasts, and a feeling of weight and heat in the back and loins. There then may be a discharge of mucus tinged with blood, or of pure blood, and this may not again show itself for several months. Such irregularities are of little consequence on the first establishment of the function, and need give rise to no apprehension. Period of Duration and Recurrence. — As a rule, the discharge re- curs every twenty-eight days, and with some women with such regu- larity that they can foretell its appearance almost to the hour. The rule is, however, subject to very great variations. It is by no means uncommon, and strictly within the limits of health, for it to appear every twentieth day, or even with less interval ; while in other cases, as much as six weeks may habitually intervene between two periods. The period of recurrence may also vary in the same subject. I am acquainted with patients who sometimes have only twenty-eight days, at others as many as forty-eight days, between their periods, without their health in any way suffering. joulin mentions the case of a lady who only menstruated two or three times in the year, and whose sister had the same peculiarity. The duration of the period varies in different women, and in the same woman at different times. In this country its average is four or five days, while in France, Dubois and Brierre de Boismont fix eight days as the most usual length. Some women are only unwell for a few hours, while in others the period may last many daj's be- yond the average without being considered abnormal. Quantity of Blood lost. — The quantity of blood lost varies in dif- ferent women. Hippocrates puts it at ^xviij, which, however, is much too high an estimate. Arthur Farre thinks that from 5ij to siij is the full amount of a healthy period, and that the quantity cannot habitually exceed this without producing serious constitu- tional effects. Eich diet, luxurious living, and anything that un- healthily stimulates the body and mind, will have an injurious effect in increasing the flow, which is, therefore, less in hard-worked countrywomen than in the better classes and residents in towns. It is more abundant in warm climates, and our countrywomen in India habitually menstruate over-profusely, becoming less abundantly unwell when they return to England ; the same observation has been made with regard to American women residing in the Gulf States, who improve materially by removing to the Lake States. Some women appear to menstruate more in summer than in winter. I am acquainted with a lady who spends the Avinter in St. Petersburgh, where her periods last eight or ten days, and the summer in Eng- land, where they never exceed four or five. The difference is prob- ably due to the effect of the over-heated rooms in which she lives in Kussia. [I have known insanity to result from the exhaustion produced by this excessive menstrual loss in the far south. One 80 ORGANS CONCERNED IN PARTURITION. Louisiana lady came in this condition on three occasions to Philadel- phia for treatment, being cured upon each occasion. After the third recovery, she accepted the advice given her to remain north, and by so doing has been perfectly well for several years. Two young ladies under my care, born in this city, have on several occasions resided in Florida ; they were always in poor health from menstrual excess while there, but had the function restored to its normal character after their return to a cool climate. A winter's checking influence has often a marvellous effect in cases of southern patients, made thin and miserable by this oft-repeated and long-continued drain. — Ed.] The daily loss is not the same during the continuance of the period. It generally is at first slight, and gradually increases so as to be most profuse on the second or third day, and as gradually diminishe. To- wards the last days it sometimes disappears for a few hours, and then conies on again, and is apt to recur under any excitement or emotion. Quality of Menstrual Blood. — As the menstrual fluid escapes from the uterus it consists of pure blood, and, if collected through the speculum, it coagulates. The ordinary menstrual fluid does not coagulate unless it is excessive in amount. Various explanations of this fact have been given. It was formerly supposed either to contain no fibrine, or an unusually small amount. Eetzius attributes its non-coagulation to the presence of free lactic and phosphoric acids. The true explanation was first given by Mandl, who proved that even small quantities of pus or mucus in blood were sufficient to keep the fibrine in solution ; and mucus is always present to greater or less amount in the secretions of the cervix and vagina, which mix with the menstrual blood in its passage through the genital tract. If the amount of blood be excessive, however, the mucus present is insufficient in quantity to produce this effect, and coagula are then formed. On microscopic examination the' menstrual fluid exhibits blood corpuscles, mucous corpuscles, and a considerable amount of epithelial scales, the last being the debris of the epithelium lining the uterine cavity. According to Virchow the form of the epithelium often proves that it comes from the interior of the utricular glands. The color of the blood is at first dark, and as the period progresses it generally becomes lighter in tint. In women who are in bad health it is often very pale. These differences doubtless depend upon the amount of mucus mingled with it. The menstrual blood has always a characteristic, faint, and heavy odor, which is analogous to that which is so distinct in the lower animals during the rut. Kaciborski mentions a lady who was so sensitive to this odor that she could always tell to a certainty when any woman was menstruating. It is attributed either to decomposing mucus mixed with the blood, which, when partially absorbed, may cause the peculiar odor of the breath often perceptible in menstruating women ; or to the mixture with the fluid of the sebaceous secretion from the glands of the vulva- It probably gave rise to the old and prevalent prejudices as to the "ovulation and menstruation. 81 deleterious properties of menstrual blood, which, it is needless to say, are altogether without foundation. Source of the Blood. — It is now universally admitted that the source of the menstrual blood is the mucous membrane lining the interior of the uterus, for the blood may be seen oozing through the os uteri by means of the speculum, and in cases of prolapsus uteri ; while in cases of inverted uterus L may be actually observed escaping from the exposed mucous membrane, and collecting in minute drops upon its surface. During the menstrual nisus the whole mucous lining becomes congested to such an extent that, in examining the bodies of women who have died during menstruation, it is found to be thicker, larger, and thrown into folds, so as to completely fill the uterine cavity. The capillary circulation at this time becomes very marked, and the mucous membrane assumes a deep red hue, the net- work of capillaries surrounding the orifices of the utricular glands being especially distinct. These facts have an unquestionable con- nection with the production of the discharge, but there is much dif- ference of opinion as to the precise mode in which the blood escapes from the vessels. Coste believed that the blood transudes through the coats of the capillaries without any laceration of their structure. Farre inclines to the hypothesis that the uterine capillaries terminate by open mouths, the escape of blood through these, between the menstrual periods, being prevented by muscular contraction of the uterine walls. Pouchet believed that during each menstrual epoch the-entire mucous membrane is broken down and cast off in the form of minute shreds, a fresh mucous membrane being developed in the interval between two periods. During this process the capillary network would be laid bare and ruptured, and the escape of blood readily accounted for. Tyler Smith, who adopted this theory, states that he has frequently seen the uterine mucous membrane, in women who have died during menstruation, in a state of dissolution, with the broken loops of the capillaries exposed. The phenomena at- tending the so-called membranous dysmenorrhoea, in which the mucous membrane is thrown off in shreds, or as a cast of the uterine cavity — the nature of which was first pointed out bj- Simpson and Oldham — have been supposed to corroborate this theory. This view is, in the main, corroborated by the recent researches of Engelman, 1 Williams, 2 and others. Williams describes the mucous lining of the uterus as undergoing a fatty degeneration before each period, which commences near the inner os, and extends over the whole mucous membrane, and down to the muscular wall. This seems to bring on a certain amount of muscular contraction, which drives the blood into the capillaries of the mucosa, and these, having become degene- rated, readily rupture, and permit the escape of the blood. The mucous membrane now rapidly disintegrates, and is cast off in shreds with the menstrual discharge, in which masses of epithelial cells may always be detected. Engelman, however, holds that the fatty de- 1 American Journal of Obstetrics, May, 187.". 2 On the Structure of the Mucous Membrane of the Uterus, Obst. Journ., 1875. 82 ORGANS CONCERNED IN PARTURITION. generation is limited to the superficial layers, and that a portion only of the epithelial investment is thrown off. As soon as the period is over the formation of a new mucous membrane is begun, from pro- liferation of the elements of the muscular coat, and at the end of a week the whole uterine cavity is lined by a thin mucous membrane. This grows until the advent of another period, when the same de- generative changes occur unless impregnation has taken place, in which case it becomes further developed into the decidua. Theory of Menstruation. — That there is an intimate connection be- tween ovulation and menstruation is admitted by most physiologists, and it is held by many that the determining cause of the discharge is the periodic maturation of the Graafian follicles. There is abundant evidence of this connection, for we know that when, at the change of life, the Graafian follicles cease to develop, menstruation is arrested ; and when the ovaries are removed by operation, of which there are now numerous cases on record, or when they are eongenitally absent, menstruation does not generally take place. A few cases, however, have been observed in which menstruation continued after double ovariotomy, and these have been used as an argument by those physiologists who doubt the ovular theory of menstruation. Slav- yansky has particularly insisted on such cases, which, however, are probably susceptible of explanation. It may be that the habit of menstruation may continue for a time even after the removal of the ovaries, and it has not been shown that menstruation has continued permanently after double ovariotomy, although it certainly has occa- sionally, although quite exceptionally, clone so for a time. It is possible, also, that, in such cases, a small portion of ovarian tissue may have been left unremoved, sufficient to carry on ovulation. Roberts, a traveller quoted by Depaul and Gueniot in their article on Menstruation in the " Dictionnaire cles Sciences Meclicales," relates that in certain parts of Central Asia it is the custom to remove both ovaries in young girls who act as guards to the harems. These women, knoAvn as hedjeras, subsequently assume much of the virile type, and never menstruate. The same close connection between ovulation and the rut of animals is observed, and supports the conclusion that the rut and menstruation are analogous. The chief difference be- tween ovulation in man and the lower animals is that in the latter the process is not generally accompanied by a sanguineous flow. To this there are exceptions, for in monkeys there is certainly a discharge analogous to menstruation occurring at intervals. Another point of distinction is that in animals connection never takes place except during the rut, and that it is then only that the female is capable of conception; while in the human race conception only occurs in the interval between the periods. This is another argument brought against the ovular theory, because, it is said, if menstruation depend on the rupture of a Graafian follicle and the emission of an ovule, then impregnation should only take place during or immediately after menstruation. Coste explains this by supposing that it is the maturation and not the rupture of the follicle which determines the occurrence of menstruation; and that the follicle may remain unrup- OVULATION AND MENSTRUATION. 83 tared for a considerable time after it is mature, the escape of the ovule being subsequently determined by some accidental cause, such as sexual excitement. However this may be, there is good reason to believe that the susceptibility to conception is greater during the menstrual epochs. Eaciborski believes that in the large proportion of cases impregnation occurs in the first half of the menstrual interval, or in the few days immediately preceding the appearance of the dis- charge. There are, however, very numerous exceptions, for in Jewesses, who almost invariably live apart from their husbands for eight clays after the cessation of menstruation, impregnation must constantly occur at some other period of the interval, and it is certain that they are not less prolific than other people. This rule with them is very strictly adhered to, as will be seen by the accompanying in- teresting letter from a medical friend who is a well-known member of that community, and which I have permission to publish. 1 This fact is of itself sufficient to disprove the theory advanced bv Dr. Avrard, 2 that impregnation is impossible in the latter half of the menstrual interval. This, and the other reasons referred to, un- doubtedly throw some doubt on the ovular theory, but they do not seem to be sufficient to justify the conclusion that menstruation is a physiological process altogether independent of the development and maturation of the Graafian follicles. All that they can be fairly held to prove is that the escape of the ovules may occur independently of menstruation, but the weight of evidence remains strongly in favor of the theory which is generally received. 1 10 Bernard Street, Russell Square, July 28, 1873. My dear Sir. 1. To the best of my knowledge and belief, the law which prohibits sexual intercourse amongst Jews for seven clear days after the cessation of menstruation, is almost universally observed ; the exceptions not being sufficient to vitiate statistics. The law has perhaps fewer exceptions on the Continent — especially Russia and Poland, where the Jewish population is very great — than in England. Even here, however, women who observe no other ceremonial law observe this, and cling to it after everything else is thrown overboard. There are doubtless many exceptions, especially among the better classes in England, who keep only three days after the cessation of the menses. 2. The law is — as you state — that should the discharge last only an hour or so, or should there be only one gush or one spot on the linen, the five days during which the period might continue are observed ; to which must be superadded the seven clear days = twelve days per mensem in which connection is disallowed. Should any dis- charge be seen in the intermenstrual period, seven days would have to be kept, but not the five, for such irregular discharge. 3. The "bath of purification," which must contain at least eighty gallons, is used on the last night of the seven clear days. It is not used till after a bath for cleansing purposes ; and, from the night when such " purifying" bath is used, Jewish women are accustomed to calculate the commencement of pregnancy. That you should not have heard it is not strange ; its mention would be considered highly indelicate. 4. Jewish women reckon their pregnancy to last nine calendar or ten lunar months, 270 to 280 days. There are no special data on which to reckon an average, nor do I know of any books on the subject, except some Talmudic authorities which I will look up for you if you desire it. Pray make no apologies for writing to me ; any information I possess is at your service. I am, dear Sir, yours very truly, Dr. Playfair. A. Asher. P. S. The Biblical foundation for the law of the seven clear days is Leviticus xv., verse 19 till the end of the chapter— especially verse 28. 2 Rev. de Therap. Med. Chir., 1867. 81 ORGANS CONCERNED IN PARTURITION. Purpose of the Menstrual Loss. — The cause of the monthly perio- dicity is quite unknown, and will probably always remain so. Goodman 1 has suggested what he calls the " cycical theory of men- struation,"which refers the phenomena to a general condition of the vascular system, specially localizing itself in the generative organs, and connected with rhythmical changes in their nerve centres. It does not seem to me, however, that he has satisfactorily proved the re- currence of the conditions which his ingenious theory assumes. The purpose of the loss of so much blood is also somewhat obscure. To a certain extent it must be considered an accident or complication of ovulation, produced by the vascular turgescence. Nor is it essen- tial to fecundation, because women often conceive during lactation, when menstruation is suspended ; or before the function has become established. It may, however, serve the negative purpose of relieving the congested uterine capillaries which are periodically filled with a supply of blood for the great growth which takes place Avhen concep- tion has occurred. Thus immediately before each period the uterus may be considered to be placed by the afflux of blood in a state of preparation for the function it may be suddenly called upon to per- form. That the discharge relieves a state of vascular tension which accompanies ovulation is proved by the singular phenomenon of vicarious menstruation, which is occasionally, though rarely, met with. It occurs in cases in which, from some unexplained cause, the discharge does not escape from the uterine mucous membrane. Under such circumstances a more or less regular escape of blood may take place from other sites. The most common situations are the mucous membranes of the stomach, of the nasal cavities, or of the lungs; the skin, not uncommonly that of the mammas, probably on account of their intimate sympathetic relation with the uterine organs; from the surface of an ulcer; or from hemorrhoids. It is a noteworthy fact that in all these cases the discharge occurs in situa- tions where its external escape can readily take place. This strange deviation of the menstrual discharge may be taken as a sign of general ill-health, and it is usually met with in delicate young women of highly mobile nervous constitution. It may, however, begin at puberty, and it has even been observed during the 'whole sexual life. The recurrence is regular, and always in connection with the men- strual nisus, although the amount of blood lost is much less than in ordinary menstruation. Cessation of Menstruation. — After a certain time changes occur, showing that the woman is no longer fitted for reproduction ; men- struation ceases, Graafian follicles are no longer matured, and the ovary becomes shrivelled and wrinkled on its surface. Analogous alterations take place in the uterus and its appendages. The Fallo- pian tubes atrophy, and are not unfrequently obliterated. The uterus decreases in size. The cervix undergoes a remarkable change which is readily detected on vaginal examination. The projection of the cervix into the vaginal canal disappears, and the orifice of the os 1 American Journal of Obstetrics, Oct. 1878. OVULATION AND MENSTRUATION. • 85 uteri in old women is found to be flush with the roof of the vagina. In a large number of cases there is after the cessation of menstrua- tion, an occlusion both of the external and internal os; the canal of the cervix, however, between them remains patulous, and is not un- frequentlv distended with a mucous secretion. Period of Cessation. — The age at which menstruation ceases varies much in different women. In certain cases it may cease at an unusu- ally early age, as between 30 and 10 years, or it may continue far beyond the average time, even up to 60 years ; and exceptional, though perhaps hardly reliable instances, are recorded in which it has continued even to 80 or 90 years. These, are, however, strange anomalies, which, like cases of unusually precocious menstruation, cannot be considered as having any bearing on the general rule. Most cases of so-called protracted menstruation will be found to be really morbid losses of blood depending on malignant or other forms of organic disease, the existence of which, under such circumstances, should always be suspected. In this country menstruation usually ceases between 10 and 50 years of age. Eaciborski says that the largest number of cases of cessation are met with in the 16th year. It is generally said that women who commence to menstruate when very young, cease to do so at a comparatively early age, so that the average duration of the function is about the same in all women. Cazeaux and Eaciborski, whose opinion is strengthened by the observations of Guy in 1500 cases, 1 think, on the contrary, that the earlier menstruation com- mences, the longer it lasts, earty menstruation indicating an excess of vital energy which continues during the whole child-bearing life. Climate and other accidental causes, do not seem to have as much effect on the cessation as on the establishment of the function. It does not appear to cease earlier in warm than in temperate climates. The change of life is generally indicated by irregularities in the recurrence of the discharge. It seldom ceases suddenly, but it may be absent for one or more periods, and then occur irregularly ; or it may become profuse or scanty, until eventually it entirely stops. The popular notions as to the extreme danger 'of the menopause are probably much exaggerated ; although it is certain that at that time various nervous phenomena are apt to be developed. So far from having a prejudicial effect on the health, however, it is not an un- common observation to see an hysterical woman, who has been for years a martyr to uterine and other complaints, apparently take a new lease of life when her uterine functions have ceased to be in active operation, and statistical tables abundantly prove that the general mortality of the sex is not greater at this than at any other time. > Med. Times and Gaz., 1845. PART II PREGNANCY. CHAPTER I. CONCEPTION AND GENERATION. Generation in the human female, as in all mammals, requires the congress of the two sexes, in order that the semen, the male element of generation, may be brought into contact with the ovule, the female element of generation. Semen. — The semen secreted by the testicle of an adult male is a viscid, opalescent fluid, forming an emulsion when mixed with water, and having a peculiar faint odor, which is attributed to the secretions which are mixed with it, such as those from the prostate and Cowper's glands. On analysis it is found to be an albuminous fluid, holding in solution various salts, principally phosphates and chlorides, and an animal substance, spermatine, analogous to fibrine. Examined under a magnifying power of from 400 to 500 diameters, it consists of a transparent and homogeneous fluid, in which are float- ing a certain number of grannies and epithelial cells, derived from the secretions mixed with it, and the characteristic sperm cells and spermatozoa which form its essen- tial constituents (Fig. 41). The sperm cells are large spherical vesicles, each containing from two to eight smaller cells, within which the spermatozoa are developed ; and, as these soon escape and be- come free, the sperm cells are only to be detected in the testicles themselves, while in semen that has been ejaculated they are rarely visible. The large parent cell, termed by Robin the male ovule, forms within it several subsidiary cells by the segmentation of its granular contents. Within these secondary cells, or vesicles of evo- lution, which are believed by Kolliker to be developed from the nuclei of the parent cell, the spermatozoa are formed, and before ejaculation they may be seen coiled spirally in their interior. The external envelope then disappears, and a number of spermatozoa, one (86) a, b. Sperm cells containing- nnclei, each nu- cleus having within a spermatozoon, c. Nucleus, with nucleoli. d. Nucleus, with spermato- zoon, e. A cell, with a bundle of spermatic filaments. /, g, h. Spermatozoa. CONCEPTION AND GENERATION. 87 being formed in each of the secondary cells, may be observed in the interior of the original parent cell. Eventually that also is absorbed, and the contained spermatozoa become liberated, and move about freely in the seminal fluid. As seen under the microscope, the sper- matozoa, which exist in healthy semen in enormous numbers, present the appearance of minute particles, not unlike a tadpole in shape. The head is oval and flattened, measuring about e x?oir °f an i ncR in breadth, and attached to it is a delicate filamentous expansion or tail, which tapers to a poiut so fine that its termination cannot be seen by the highest powers of the microscope. The whole sperma- tozoon measures from ^ n to g^ of an inch in length. The spermatozoa are observed to be in constant motion, sometimes very rapid, sometimes more gentle, which is supposed to be the means by which they pass upwards through the female genital organs. They retain their vitality and power of movement for a consider- able time after emission, provided the semen is kept at a temperature similar to that of the body. Under such circumstances they have been observed in active motion from forty-eight to seventy-two hours after ejaculation, and they have also been seen alive in the tes- ticle as long as twenty -four hours after death. In all probability they continue active much longer within the generative organs, as many physiologists have observed them in full vitality in bitches and rabbits, seven or eight da^vs after copulation. The recent ex- periments of Haussman, however, show that they lose their power of motion in the human vagina within twelve hours after coitus, although they doubtless retain it longer in the uterus and Fallopian tubes. Abundant leucorrhoeal discharges and acrid vaainal secretions cle- stroy their movements, and may thus cause sterility in the female. On account of their mobility, the spermatozoa were long considered to be independent animalcules, a view which is by no means exploded, and has been maintained in modern times by Pouchet, Joulin, and other writers, while Coste, Eobin, Kolliker, etc., liken their motion to that of ciliated epithelium. There can be no doubt that the fer- tilizing power of the semen is due to the presence of the spermatozoa, although some of the older physiologists assigned it to the spermatic fluid. The former view, however, has been conclusively proved by the experiments of Prevost and Dumas, who found that on carefully removing the spermatozoa by filtration the semen lost its fecundating properties. Sites of Impregnation. — -There has been great difference of opinion as to the part of the genital tract in which the spermatozoa and the ovule come into contact, and in which impregnation, therefore, occurs. Spermatozoa have been observed in all parts of the female genital organs in animals killed shortly after coitus, especially in the Fallo- pian tubes, and even on the surface of the ovary. The phenomena of ovarian gestation, and the fact that fecundation has been proved to occur in certain animals within the ovary, tend to support the idea that it may also occur in the human female before the rupture of the Graafian follicle. In order to do so, however, it is necessary for the spermatozoa to penetrate the proper structure of the follicle and the 88 PHEGNANCY, epithelial covering of the ovary, and no one has actually seen them doing so. Most probably the contact of the spermatozoa and the ovule occurs very shortly after the rupture of the follicle, and in the outer part of the Fallopian tubes. Coste mentions that, unless the ovale is impregnated, it very rapidly degenerates after being expelled from the ovary, partly by inherent changes in the ovule itself, and partly because it then soon becomes invested by an albuminous covering which is impermeable to the spermatozoa. He believes, therefore, that impregnation can only occur either on the surface of the ovary, or just within the fimbriated extremity of the tube. Mode in which the ascent of the Semen is effected. — The semen is probably carried upwards chiefly by the inherent mobility of the spermatozoa. It is believed by some that this is assisted by other agencies; amongst them are mentioned the peristaltic action of the uterus and Fallopian tubes ; a sort of capillary attraction effected when the walls of the uterus are in close contact, similar to the move- ment of fluid in minute tubes ; and also the vibratile action of the cilia of the epithelium of the uterine mucous membrane. The action of the latter is extremely doubtful, for they are also supposed to effect the descent of the ovule, and they can hardly act in two opposite ways. The movement of the cilia being from within outwards, it would cer- tainly oppose, rather than favor, the progress of the spermatozoa. It must, therefore, be admitted that they ascend chiefly through their own powers of motion. They certainly have this power to a remarkable extent, for there are numerous cases on record in which impregnation has occurred without penetration, and even when the hymen was quite entire, and in which the semen has simply been de- posited on the exterior of the vulva ; in such cases, which are far from uncommon, the spermatozoa must have found their way through the whole length of the vagina. It is probable, however, that under ordinary circumstances the passage of the spermatic fluid into the uterus is facilitated by changes which take place in the cervix during the sexual or- gasm, in course of which the os uteri is said to dilate and close again in a rhythmi- cal manner. 1 Mode of Impregnation. — The precise method in which the spermatozoa effect impregnation was long a matter of doubt. It is now, however, certain that they actually penetrate the ovule, and reach its interior. This has been conclusively proved by the observations of Barrj^, Meissner, and others, who have seen the spermatozoa within the external mem- brane of the ovule in rabbits (Fig. 42). In some of the invertebrata a canal or open- Fig. 42. Ovum of Rabbit containing sperma- tozoa. 1. Zona pellucida. 2. The germs, consisting of two large cells, several smaller cells, and spermatozoa. How do the Spermatozoa enter the Uterus ? by J. Beck, M.D. CONCEPTION AND GENERATION. 89 ing exists in the zona pellucida, through which the spermatozoa pass. ]STo such aperture has yet been demonstrated in the ovules of mam- mals, but its existence is far from improbable. According to the observations of Newport, several spermatozoa enter the ovule, and the greater the number that do so the more certain fecundation be- comes. After the spermatozoa penetrate the zona pellucida they disintegrate and mingle with the yelk, having, while doing so, im- parted to the ovule a power of vitality, and initiated its development into a new being. Progress of the Impregnated Ovule towards the Uterus. — The length of time which lapses before the fecundated ovule arrives in the cav- ity of the uterus has not yet been ascertained, and it probably varies under different circumstances. It is known that in the bitch it may remain eight or ten days in the Fallopian tube, in the guinea-pig- three or four. In the human female the ovum has never been dis- covered in the cavity of the uterus before the tenth or twelth day after impregnation. Changes immediately before and after Impregnation. — The changes which occur in the human ovule immediately before and after im- pregnation, and during its progress through the Fallopian tube, are only known to us by analogy, as, of course, it is impossible to study them by actual observation. We are in possession, however, of ac- curate information of what has been made out in the lower animals, and it is reasonable to suppose that similar changes occur in man. Immediately after the ovule has passed into the Fallopian tube, it is found to be surrounded by a layer of granular cells, a portion of the lining membrane of the Graafian follicle, which was described as the discus proligerus. As it proceeds along the tube these surrounding- cells disappear, partly, it is supposed, by friction on the walls of the tube, and partly by being absorbed to nourish the ovule. Be this as it may, before long they are no longer observed, and the zona pellu- cida forms the outermost layer of the ovule. "When the ovule has advanced some distance along the tube, it becomes invested with a covering of albuminous material, which is deposited around it in suc- cessive layers, the thickness of which varies in different animals. It is very abundant in birds, in whom it forms the familiar white of the egg. In some animals it has not been detected, so that its presence in the human ovule is uncertain. Where it exists it doubtless con- tributes to the nourishment of the ovule. Coincident with these changes is the disappearance of the germinal vesicle. At the same time the yelk contracts and becomes more solid ; retiring, in one spot, from close contact with the zona pellucida, and thus forming a species of cavity called by Newport the respiratory chamber, which in some animals is filled with a transparent liquid. After this occurs the very peculiar phenomenon known as the cleavage of the yelk, which results in the formation of the membrane from which the foetus is developed. It is preceded by the formation at one point of the surface of the yelk of a minute transparent globule of a bluish tint, sometimes of three or four separate globules which subsequently unite into one. This has received the name of the polar globule (Fig. 43), 7 90 PREGNANCY Fig. 43. and seems to be formed from the "hya- line substance of the yelk, from which it soon becomes entirely separated, and remains attached to the inner surface of the zona pellucida. It indicates the point at which the segmentation of the yelk begins, and where the cephalic ex- tremity of the foetus will subsequently be placed. According to Robin these changes occur in all ovules, whether they are impregnated or not, but if the ovule is not fecundated, no further alterations occur. Supposing impregnation has taken place, a bright clear vesicle, called the vitelline nucleus, very similar in appearance to a drop of oil, appears in the centre of the yelk. The segmentation of the yelk (Fig. 44) commences at the point where the polar globule is situated ; it begins to divide into two halves, and at Formation of the "Polar Globule." 1. Zona Pellucida, containing sperma- tozoa. Vesicl 2. Yeik. 3 and 4. Germinal 5. The Polar Globule. Fig. 44. Segmentation of the Yelk. A. Ovum with first Embryo cell. B. Division of embryo cell and cleavage of the yelk around it. C, I), E. Further division of the yelk. the same time the vitelline nucleus becomes constricted in its centre, and separates into two portions, one of which forms a centre for each of the halves into which the yelk has divided. Each of these im- mediately divides into two, as does its contained portion of the vitel- line nucleus, and so on in rapid succession until the whole } T elk is divided into a number of spheres, each of which consists of a clump of nucleated protoplasm. By these continuous dichotomous divisions the whole yelk is formed into a granular mass which, from its supposed resemblance to a mulberry, has been named the muriform body. When the sub- division of the yelk is completed, its separate spheres become con- verted into cells, consisting of a fine membrane with granular CONCEPTION AND GENERATION. 91 contents. These cells unite by their edges to form a continuous membrane (Fig. 45), which, through the expansion of the muriform body by fluid which forms in its interior, is distended until it forms a lining to the zona peilucida. This is the blastodermic membrane from which the foetus is developed. By this time the ovum has reached the uterus, and, before proceeding to consider the further _1^2 X,,'.'.'- ■- ■■;'.■.-. :-."'■.-,■. . Formation of the Blastodermic Membrane from the cells of the Muriform Body. (After Joulin.) 1. Luyer of albuminous material surrounding 2. The Zona peilucida. changes which it undergoes it will be well to study the alteration which the stimulus of impregnation has set on foot in the. mucous membrane of the uterus, in order to prepare it for the reception and growth of its contents. Changes in the Uterine Mucous Membrane consequent on Pregnancy. — Even before the ovum reaches the uterus, the mucous membrane becomes thickened and vascular, so that its opposing surfaces entirely fill the uterine cavity. These changes may be said to be the same in kind, although more marked and extensive in degree, as the alter- ations which take place in the mucous membrane in connection with each menstrual period. The result is the formation of a distinct membrane, which affords the ovum a safe anchorage and protection, until its connections with the uterus are more fully developed.- After delivery, this membrane, which is bv that time quite altered in appearanc3, is at least partially thrown off with the ovum ;■ on which account it has received the name of the decidua, or caduca. Divisions of the Decidua. — The decidua consists of two principal portions, which, in early pregnancy, are separated from each other by a considerable interspace. One of these, called the decidua vera, lines the entire uterine cavity, and is, no doubt, the original mucous lining of the uterus greatly hypertrophied. The second, the decidua reflexa, is closely applied round the ovum ; and it is probably formed by the sprouting of the decidua vera around the ovum at the point 92 PREGNANCY. on which the latter rests, so that it eventually completely surrounds it. As the ovum enlarges, the decidua reflexa is necessarily stretched, until it comes everywhere into contact with the decidua vera, with which it firmly unites. After the third month of pregnancy true union has occurred, and the two layers of decidua are no longer separate. The decidua serotina, which is described as a third portion, is merely that part of the decidua vera on which the ovum rests, and where the placenta is eventually developed. Views of William and John Hunter. — It is needless to refer to the various views which have been held by anatomists as to the struc- ture and formation of the decidua. That taught by John Hunter was long believed to be correct, and down to a recent date it received the adherence of most physiologists. He believed the decidua to be an inflammatory exudation which, on account of the stimulus of pregnancy, was thrown out all over the cavity of the uterus, and soon formed a distinct lining membrane to it. When the ovum reached the uterine orifice of the Fallopian tube it found its entrance barred by this new membrane, which accordingly it pushed before it. This separated portion formed a covering to the ovum, and became the decidua reflexa ; while a fresh exudation took place at that portion of the uterine wall which was thus laid bare, and this became the decidua vera. William Hunter had much more correct views of the decidua, the accuracy of which was at the time much contested, but which have recently received full recognition. He describes the decidua in his earlier writings as an hypertrophy of the uterine mucous membrane itself, a view which is now held by all physiologists. Structure of the Decidua. — When the decidua is first formed it is a hollow triangular sac lining the uterine cavity (Fig. 46), and having three openings into it, those of the Fallopian tubes at its upper angles, and one, corresponding to the internal os uteri, below. If, as is generally the case, it is thick and pulpy, these openings are closed up and can no longer be detected. Id early pregnancy it is well developed, and continues to grow up to the third month of utero-gestation. After that time it commences to atrophy, its adhe- sion with the uterine walls lessens, it becomes thin and transparent, and is ready for expulsion when delivery is effected. When it is most developed, a careful examination of the decidua enables us to detect in it all the elements of the uterine mucous membrane greatly hypertrophied. Its substance chiefly consists of large round or oval nucleated cells and elongated fibres, mixed with the tubular uterine gland ducts, which are much elongated and filled with cylindrical epithelium cells, and a small quantity of milky fluid. According to Friedlander the decidua is divisible into two layers: the inner being formed by a proliferation of the corpuscles of the sub-epithelial con- nective tissue of the mucous membrane; the deeper, in contact with the uterine walls, out of flattened or compressed gland ducts. In an early abortion the extremities of these ducts may be observed by a lens on the external or uterine surface of the decidua, occupying the summit of minute projections, separated from each other by depres- CONCEPTION AND GENERATION 93 sions. If these projections be bisected they will be found to contain little cavities, filled with lactescent fluid, which were first described by Montgomery of Dublin, and are known as Montgomery^ cups. Fig. 46. Aborted Ovum of about forty days, showing the Triangular Shape of the Decidua (which is laid open), and the Aperture of the Fallopian Tube. (After Coste.) They are in fact the dilated canals of the uterine tubular glands. On the internal surface of such an early decidua a number of shallow depressions may be made out, which are the open mouths of these ducts. Formation of the Decidua Reflexa. — "When the ovum reaches the uterine cavity it soon becomes imbedded in the folds of the hvper- trophied mucous membrane, which almost entirely fills the uterine cavity. As a rule it is attached to some point near the opening of a Fallopian tube, the swollen folds of mucous membrane preventing its descent to the lower part of the uterus; in exceptional circum- stances, however, as in women who have borne many children, and have a more than usually dilated uterine cavity, it may fix itself at a point much nearer the internal os uteri. According to the now generally accepted opinion of Coste, the mucous membrane at the base of the ovum soon begins to sprout around it and gradually ex- tends until it eventually completely covers the ovum (Figs. 47-^9), and forms^ the decidua reflexa, Coste describes, under the name of the umbilicus, a small depression at the most prominent part of the ovum, which he considers to be the indication of the point where the closure of the decidua reflexa is effected. There are some objections to this theory, for no one has seen the decidua reflexa incomplete and in the process of formation, and on examining its internal surface, that is, the one furthest from the ovum, its microscopical appearance 94 PREGNANCY is identical with, that of the inner surface of the decidua vera. To meet these difficulties, Weber and Goodsir, whose views have been adopted by Priestley, contended that the decidua reflexa is " the primary lamina of the mucous membrane, which when the ovum Fig. 47. Fig. 48. Fig. 49. Formation of Decidua. (The decidua is colored "black, the ovum is repre- sented as engaged between two projecting folds of membrane.) Projecting Folds of Membrane- growing up around the ovum. (After Dal ton.)- Showing Ovum completely surrounded by the Decidua Reflexa. enters the uterus, separates in two-thirds of its extent from the layers beneath it, to adhere to the ovum ; the remaining third remains attached, and forms a centre of nutrition." According to this view the decidua vera would be a subsequent growth over the separated Fig. 50. An Ovum removed from Uterus, and part of the Decidua Vera cut away. (After Coste.) a. Decidua vera, showing the follicles opening on its inner surface, b. Inner extremity of Fallo- pian tube. c. Flap of decidua reflexa. d. Ovum. portion, and the decidua serotina the portion of the primary lamina which remained attached. In this way the fact of the opposed sur- faces of the decidua vera and reflexa being identical in structure CONCEPTION AND GENERATION. 95 would be accounted for. The difficulty which this theory is intended to meet, does not seem so great as is supposed, for if, as is likely, it is only the epithelial or internal surface of the mucous membrane which sprouts over the ovum, and not its deeper layers, the facts of the case would be sufficiently met by Coste's view. Up to the third month of pregnancy the decidua reflexa and vera are not in close contact, and there may even be a considerable interspace between them, which sometimes contains a small quantity of mucous fluid, called the hydroperione. This fact may account for the curious circumstance, of which many instances are on record, that a uterine sound may be passed into a gravid uterus in the early months of pregnancy without necessarily producing abortion, and also for the occasional occurrence of menstruation after conception (Figs. 50 and 76). Eventually, by the growth of the ovum, the decidua reflexa comes closely into contact with the vera, and the two become inti- mately blended and inseparable. Decidua at the end of Pregnancy and after Delivery. — As pregnancy advances the decidua alters in appearance and becomes fibrous and thin. In the later months of utero-gestation fatty degeneration of its structure commences, its vessels and glands are obliterated, and its adhesion to the uterine walls is lessened, so as to prepare it for separation. As we shall subsequently see, this fatty degeneration was assumed by Simpson to be the determining cause of labor at term. Views of Robin. — It was long believed that the entire decidua was thrown off after labor, leaving the muscular coat of the uterus bare and denuded, and that a new mucous membrane was formed during convalescence. According to Robin, 1 whose views are corroborated by Priestley, no such denudation of the muscular tissue of the uterus ever occurs, but a portion of the decidua always remains attached after delivery. After the fourth month of pregnancy they believe that a new mucous membrane is formod under the decidua, which remains in a somewhat imperfect condition till after delivery, when it rapidly develops and assumes the proper functions of the mucous lining of the uterus. Robin also believes that that portion of the decidua which covers the placental site, the so-called decidua serotina, is not thrown off with the membranes, like the decidua vera and reflexa, but remains attached to the uterine walls, a thin layer of it only being expelled with the placenta, on which it may be observed. Duncan 2 entirely dissents from these views, and does not admit the formation of a new mucous membrane during the later months of utero-gestation. He believes that the greater portion of the decidua is thrown off, but that part remains, and from this the fresh mucous membrane is developed. This view is similar to that of Spiegelberg, who holds that the portion of the decidua that is expelled is the more superficial of the two layers described by Friedlander, composed chiefly of the epithelial elements, while the deeper or glandular 1 Memoires de l'Acad. Imp. de Med. 1860. 2 Researches in Obstetrics, p. 18(3 et seq. 96 PREGNANCY. layer remains attached to the walls of the uterus. From the epithe liura of the glands a new epithelial layer is rapidly developed after delivery. This theory bears on the well-known analogy of the uterus after delivery to the stump of an amputated limb; an old simile, principally based on the erroneous theory that the whole muscular tissue of the uterus was laid bare. This, as we have seen, is not the case, but the simile so far holds good in that the mucous lining is deprived of its epithelial covering; and this fact, together with "the existence of numerous open veins on the interior of the uterus, readily explains the extreme susceptibility to septic absorption which forms so peculiar a characteristic of the puerperal state. Changes in the Ovum. — Before we commenced the studv of the decidna we had traced the impregnated ovum into the uterine cavity, and described the formation of the blastodermic membrane by the junction of the cells of the muriform body. We must now proceed to Consider the further changes which result in the development of the foetus, and of the membranes that surround it. It would be quite out of place in a work of this kind to enter into the subject of embryology at any length, and we must therefore be content with such details as are of importance from a practical point of view. Division of the Blastodermic Membrane into Layers. — The blasto- dermic membrane, which forms a complete spherical lining to the ovum, between the yelk and the zona pellucida, soon divides into two layers, the most external, called the epiblast, and an internal, the hypoblast, and between them is subsequently developed a third known as the mesoblast. From these three layers are formed the entire foetus; the epiblast giving origin to the bones, muscles, and integu- ments, the nervous system, the serous membranes, and the amnion; the hypoblast forming the mucous membranes and the alimentary canal; and the mesoblast the circulating system. The Area Germinativa. — Almost immediately after the separation of the blastodermic membrane into layers, one part of it becomes . Fig. 51. Diagram of area germinativa, showing the primitive trace and area pellucida. thickened by the aggregation of cells, and is called the area (jermina- iiva. This is at first round and then oval in shape, and in its centre CONCEPTION AND GENERATION 97 Fig. 52 the first trace of the foetus may be detected in the form of a narrow straight line, the primitive trace. Surrounding it are some cells more translucent than those of the rest of the area germinativa, and hence called the area pellucida (Fig. 51). On each side of the primitive trace two elevated ridges soon arise, the laminae, dor sales, which grad- ually unite posteriorly to form a cavity within which the cerebro- spinal column is subsequently developed. Anteriorly they join to form the thoracic and abdominal cavities, inclosing portions of the epiblast, from which the serous membranes of the body are devel- oped. The minute embryo thus formed soon curves on itself, with its convexity outwards, and a distinct thickening is observed at one end, which is subsequently developed into the cephalic extremity of the foetus, while, at its other end, a thickening less marked in degree forms the caudal extremity. Formation of the Amnion.— At each of these points, very soon after the formation of the embryo, two hollow processes may be observed which gradually arch over the dorsal surface of the foetus, until they meet each other and form a complete en- velope to it. At the ventral surface these processes are separated by the whole length of the embryo, but they here also gradually approach each other, and eventually surround what is subsequently the umbilical cord, and blend with the integument of the foetus at the point of its insertion. In this way is formed the amnion (Fig. 52), consisting of two layers ; the in- ternal, derived from the epiblast, is formed of tessellated epithelial cells, the external arising from the meso- blast, is formed of cells like those of young connective tissue. Before the folds of the amnion unite, the free edge of each is bent outwards and spreads around the ovum, immediately within the zona pellucida, forming a lining to it, termed by Turner the sub-zonal membrane, which is con- nected with the development of the chorion. The amnion is the most internal of the membranes surrounding the foetus, and will presently be studied more in detail. It soon becomes distended with fluid, the liquor amnii, and as this increases in amount it separates the amnion more and more from the uterus. Changes in the Mucous Layer. — During this time the innermost layer of the blastodermic membrane or hypoblast is also developing two projections at either extremity of the "foetus, and these gradually approach each other anteriorly. As the hypoblast is in contact with the yelk, when these meet they have the effect of dividing the yelk into two^ portions. One, and the smaller of the two, forms eventu- ally the intestinal canal of the foetus ; the other, and much the larger, Development of the Amnion. 1. Vitelline membrane. 2. External layer of blastodermic membrane. 3. Internal layers forming the umbilical vesicle. 4. t'mbilical vessels. 5. l'rojections forming amnion. 6. Allautois. 98 PREGNANCY. contains the greater portion of the yelk, and forms the ephemeral structure known as the umbilical vesicle, from which the foetus derives most of its nourishment during the early stage of its existence. Its communication with the abdominal cavity of the foetus is through the constricted portion at the point of division called the vitelline duct (Fig. 53). An artery and vein, the om/phalo-mesenteric, ramify on the vesicle and its duct. 1. Exo-chorion. 2. External layer of blastodermic membrane. 3. Umbilical vesicl 5. Amnion. 6. Embryon. 7. Allantois increasing in size. 4. Its vessels. Fig. 54. As the amnion increases in size, it pushes back the umbilical vesical towards the external membrane of the ovum, between which and the amnion it lies (Fig. 54) ; and when the allantois is developed, it ceases to be of any rise, and rapidly shrinks and dwindles away. In most mammals no trace of it can be found after the fourth month of utero-gestation ; in some, including the human female, it is said to exist as a minute vesicle at the placental end of the umbilical cord at the full period of pregnancy. The umbilical vesicle is filled with a yellowish fluid, containing many oil and fat globules, simi- lar to the yelk of an egg. The Allantois. — Somewhere about the twen- tieth day after conception a small vesicle is formed toward the caudal extremity of the foetus, which is called the allantois. It is well developed and persistent in many of the lower animals, but in man it is merely a temporary structure, and disappears after it has fulfilled its functions. Its study, therefore, in the human race has been a matter of difficulty, and it was long before we were possessed of any very reliable information regarding it. There has been some difference of opinion as to its precise mode of origin. An Embryo of about twenty-five days laid open. (After Coste.) a. Chorion, b. Amnion. c. Cavity of chorion, d. Umbilical vesicle, e. Pedi- cle of allantois. /. Em- biyo. CONCEPTION AND GENERATION. 99 The most generally received opinion is that it begins as a divertic- ulum from the lower part of the intestinal canal. This, at first spherical, rapidly develops and becomes pyriform in shape, while, by a process of constriction, similar to that which occurs in the vitellus to form the umbilical vesical, it becomes divided into two parts, com- municating with each other, the smaller of them being eventually developed into the urinary bladder. The larger portion, leaving the abdominal cavity along with the vitelline duct, rapidly grows until it comes into contact with the most external ovular membrane, the chorion, over the entire inner surface of "which it spreads. In this part vessels soon develop : namely, the two umbilical arteries, de- rived from the abdominal aorta, and two umbilical veins, one of which subsequently disappears; these, along with the vitelline duct and the pedicle of the allantois, form the umbilical cord. The main and very important function of the allantois, therefore, is to carry the foetal vessels up to the inner surface of the sub-zonal membrane. Fig. 55. 1. Exo-chorion. 2. External layer of the blastodermic membrane. 3. Allantois. 4. Umbilical vesical. 5. Amnion. 6. Embryon. 7. Pedicle of Allantois. Besides this purpose, the allantois, at a very early period, may receive the excretions of the foetus, and serve as an excrementitious organ. According to Cazeaux, scarcely a trace of the allantois can be seen a few days after its formation. Its lower part or pedicle, however, long remains distinct, and forms part of the umbilical cord ; and traces of it may be found even in adult life in the form of the urachus, which is really the dwindled pedicle, and forms one of the ligaments of the bladder. The Corps Reticule or Yitriform Body. — Between the chorion and amnion is often found a gelatinous fluid, with minute filamentous processes traversing it, called by Velpeau the corps reticule which is not met with until the allantois comes into contact with the chorion, and which seems to be formed out of the tissues of that vesicle. It is analogous to the so-called Wharton's jelly found in the umbilical 100 PREGNANCY. cord. "When first formed it is highly vascular, but the vessels entirely disappear after the placenta is formed, and the remainder of the chorionic villi atrophy. Sometimes it exists in considerable quantities, and should the chorion rupture at the end of pregnancy, it may escape and give rise to an erroneous impression that the liquor amnii has been discharged. Recapitulation. — Before proceeding to consider the foetal envelopes more at length, it may be useful to recapitulate the structures already alluded to as forming the ovum. In this we find : — ■ 1. The embryo itself. 2. A fluid, the liquor amnii, in which it floats. 3. The amnion, a purely fcetal membrane surrounding the embryo, and containing the liquor amnii. 4. The umbilical vesicle, containing the greater portion of the yelk, serving as a source of nutrition to the early embryo through the vitelline duct, and in which ramify the omphalo-mesenteric vessels. 5. The allantois, a vesicle proceeding from the caudal extremity of the embryo, spreading itself over the interior of the ovum, and serving as a channel of vascular communication between the chorion and the foetus, through the umbilical vessels. 6. An interspace between the outer layer of the ovum and the amnion, in which is contained the umbilical vesicle and allantois, and the corps reticule of Yelpeau. 7. The outer layer of the ovum, along with the sub-zonal mem- brane, forming the chorion and placenta. Amnion. — The amnion is the most internal of the two membranes surrounding the foetus ; its origin at an early period of foetal life has already been described. It is a perfectly smooth, transparent, but tough membrane, continuous with the integument of the foetus at the insertion of the umbilical cord, round which it forms a sheath. Soon after it is formed it becomes distended with a fluid, the liquor amnii, in which the foetus is suspended and floats. This fluid increases gradually in quantity, distending the amnion as it does so, until this is brought into contact with the inner surface of the chorion, from which it was at first separated by a considerable interspace. Structure.- — The internal surface of the amnion is smooth and glistening, and on microscopic examination it is found to consist of a layer of flattened cells, each containing a large nucleus. These rest on a stratum of fibrous tissue which gives to the membrane its toughness, and hj which it is attached to the inner surface of the chorion. It is entirely destitute of vessels, nerves, and lymphatics. The quantity of the liquor amnii varies much at different periods of pregnancy. In the early months it is relatively greater in amount than the foetus, which it outweighs. As pregnancy advances, the weight of the foetus becomes four or five times greater than that of the "liquor amnii, although the actual quantity of fluid increases dur- ing the whole period of gestation. The amount of fluid varies much in different pregnancies. Sometimes there is comparatively little ; while at others the quantity is immense, reaching several pounds CONCEPTION AND GENERATION. 101 in weight, greatly distending the uterus, and thus, it may be : pro- ducing difficulty in labor. Its Quality.— AX first the liquid is clear and limpid. As pregnancy advances it becomes more turbid and dense, from the admixture of epithelial debris derived from the cutaneous surface of the foetus. In some cases, without actual disease, it may be dark green in color, and thick. and tenacious in consistency. It has a peculiar heavy odor, and it consists chemically of water containing albumen, with various salts, principally phosphates and chlorides. Its Source. — The source of the liquor amnii has been much disputed. Some maintain that it is derived chiefly from the foetus, a view suffi- ciently disproved by the fact that the liquor amnii continues to in- crease in amount after the death of the foetus. Burclach believed that it is secreted by the internal surface of the uterus, and arrives in the cavity of the amnion by transudation through the membrane. Priestley — and this seems the most probable hypothesis — thinks that it is secreted by the epithelial cells lining the membrane, which become distended with fluid, burst, and pour their contents into the amniotic cavity. Functions and Uses. — -The most obvious use of the liquor amnii is to afford a fluid medium in which the foetus floats, and so is protected from the shocks and jars to which it would otherwise be subjected, and from undue pressure from the uterine walls. By distending the uterus it saves the uterus from injury, which the movements of the foetus might otherwise inflict, and the foetus is thus also enabled to change its position freely. The facility with which version by ex- ternal manipulation can be effected depends entirely on the mobility of the foetus in the fluid which surrounds it. Some have also supposed that it prevents the foetus, in the early months of pregnancy, from forming adhesions to the amnion. In labor it is of great service, by lubricating the passages, but chiefly by forming, with the membranes, a fluid wedge, which dilates the circle of the os uteri. Chorion. — The chorion is the more external of the truly foetal mem- branes, although external to it is the decidua, having a strictly ma- ternal origin. It is a perfectly closed sac, its external surface, in contact with the decidua, being rough and shaggy from the develop- ment of villi (Fig. 51), its internal smooth and shining. As the ovum passes along the Fallopian tube it receives, as we have seen, an albuminous coating, and this, with the zona pellucida, is devel- oped into a temporary structure, the primitive chorion. On its exter- nal surface villous prominences soon appear, which have no ascer- tained structure, and which seem to supply the early ovum with nutriment by endosmotic absorption from the mucous membrane of the uterus. This primitive chorion, however, has not been observed in the human subject, although it may be readily seen in the ova of some of the lower animals, such as the dog and the rabbit. Some twelve days after conception, when the blastodermic membrane is formed, the true chorion appears. This is, in fact formed by the epiblast layer of the blastodermic membrane, which everywhere lines the zona pellucida or primitive chorion, and, by pressure, causes its 102 PREGNANCY. absorption and disappearance. On the surface of the true chorion thus formed, which is now the external envelope of the ovum, villi soon appear. Formation of the Villi. — These villi are hollow projections like the fingers of a glove, which are raised up from the surface of the cho- rion (the hollows looking into the chorionic cavity), and they cover the whole external surface of the ovum, giving it the peculiar "shaggy appearance observed in early abortions. They push themselves into the substance of the decidua, with which they soon become so firmly united that they cannot be separated without laceration. At first they are absolutely non-vascular, but soon the allantois, previously described, reaches the inner surface of the chorion, and spreads itself over the whole of it. Each villus now receives a separate artery and vein, which gives off a branch to each of the sub- divisions into which the villus divides. These vessels are encased in a fine sheath of the allantois which enters the villus along with them and forms a lining to it, described by some as the endochorion; the external epithelial membrane of the villus, derived from the epiblast layer of the blasto- dermic membrane, being called the exo-chorion. The artery and vein lie side by side in the centre of the villus and anastomose at its extremity ; each villus thus having a separate circulation. Growth and Atrophy of the Villi. — As soon as the union of the allantois with the chorion has been effected, the villi grow very rapidly, give off branches, which, in their turn, give off secondary branches, and so form root-like processes of great complexity. In the early months of gestation they exist equally over the whole sur- face of the ovum. As pregnancy advances, however, those which are in contact with the decidua reflexa shrivel up, and, by the end of the second month, disappear, being no longer required for the nutrition of the ovum. The chorion and decidua thus come into close contact, being united together by fibrous shreds, which, on microscopic ex- amination, are found to consist of the atrophied villi. A certain number of the villi, viz., those which are in contact with the decidua serotina, instead of dwindling away increase greatly in size, and eventually develop into the organ by which the foetus is nourished —the placenta. Form of the Placenta. — -This important organ serves the purpose of supplying nutriment to, and aerating the blood of the foetus, and on its integrity the existence of the foetus depends. It is met with in all mammals, but is very different in form and arrangement in different classes. Thus, in the sow, mare, and in the cetacea, it is diffused over the whole interior of the uterus ; in the ruminants, it is divided into a number of separate small masses, scattered here and there over the uterine walls ; Avhile in the carnivora and elephant, it forms a zone or belt round the uterine cavity. In the human race, as well as in rodentia, insectivora, etc., the placenta is in the form of a circular mass, attached generally to some part of the uterus near the orifices of the Fallopian tubes ; but it may be situated anywhere in the uterine cavity, even over the internal os uteri. As it is ex- pelled after delivery with the foetal membranes attached to it, and as CONCEPTION AND GENERATION. 103 the aperture in these corresponds to the os uteri, we can generally determine pretty accurately the situation in which the placenta was placed, by examining them after expulsion. The maternal surface of the placenta is somewhat convex, the foetal concave. Its size varies greatly in different cases, and it is usually largest when the child is big, but not necessarily so. Its average diameter is from six to eight inches, its weight from 18 to 24 oz., but, in exceptional cases, it has been found to weigh several pounds. Abnormalities of form are not very rare. Thus, the placenta has been found to be divided into distinct parts, a form said by Professor Turner to be normal in certain genera of monkeys; or smaller supplementary placentas [placentae succentariae), may exist round a central mass. These variations of shape are only of importance in consequence of a risk of part of the detached placenta being left in utero after delivery, and giving rise to septicaemia or secondary hemorrhage. Attachment of the Membranes. — The foetal membranes cover the whole foetal surface of the placenta, being reflected from its edges so as to line the uterine cavity, and being expelled with it after delivery. They also leave it at the insertion of the cord, to which they form a sheath. The cord is generally attached near the centre of the placenta, and from its insertion the umbilical vessels may be seen dividing and radiating over the whole foetal surface. Its Maternal Surface. — The maternal surface is rough and divided by numerous sulci, which are best seen if the placenta is rendered convex, so as to resemble its condition when attached to the uterus. A careful examination shows that a delicate membrane covers the entire maternal surface, unites the sulci together, and dips down be- tween them. This is, in fact, the cellular layer of the decidua sero- tina, which is separated and expelled with the placenta, the deeper layer remaining attached in utero. Numerous small openings may be seen on the surface, which are the apertures of the veins torn off from the uterus, as also those of some arteries, which, after taking several sharp turns, open suddenly into the substance of the organ. Minute Structure of the Placenta. — As regards the minute structure of the placenta it is certain that it consists essentially of two dis- tinct portions, one foetal, consisting of the greatly hypertrophied chorionic villi, with their contained vessels, which carry the foetal blood so as to bring it into intimate relation with the maternal blood, and thus admit of the necessary changes occurring in it connected with the nutrition of the foetus; and the other maternal, formed out of the decidua serotina and the maternal bloodvessels. These two portions are in the human female so intimately blended as to form the single deciduous organ which is thrown off after delivery. These main facts are admitted by all, but considerable differences of opinion still exist among anatomists as to the precise arrangement of these parts. In the following sketch of the subject I shall describe.the views most generally entertained, merely briefly indicating the points which are contested by various authorities. Foetal Portion of the Placenta. — The foetal portion of the placenta consists essentially of the ultimate ramifications of the chorion villi, 104 PREGNANCY. which may be seen on microscopic examination in the form of clnb- shaped digitations which are given off at every possible angle from the stem of a parent trunk, just like the branches of a plant. With- in the transparent walls of the villi the capillary tubes of the con- tained vessels may be seen lying, distended with blood, and present- ing an appearance not unlike loops of small intestine. The capilla- ries are the terminal ramifications of the umbilical arteries and veins, which, after reaching the site of the placenta, divide and subdivide until they at last form an immense number of minute capillary vessels, with their convexities looking towards the maternal portion of the placenta, each terminal loop being contained in one of the digitations of the chorionic villi. Each arterial twig is accompanied by a corresponding venous branch, which unites with it to form the terminal arch or loop (Fig. 56). The foetal blood is carried through Placental Villus, greatly magnified. (After Joulin.) 1 2. Placental vessels, forming terminal loops. .".Chorion tissue, forming external walls of villus. 4. Tissue surrounding vessels. these arterial twigs to the villi, where it comes into intimate contact with the maternal blood, in consequence of the anatomical arrange- ments presently to be described ; but the two do not directly mix, as the older physiologists believed, for none of the maternal blood escapes when the umbilical cord is cut, nor can the minutest injections through the foetal vessels be made to pass into the maternal vascular system, or vice versa. In addition to the looped terminations of the umbilical vessels, Farre and Schroecler van der Kolk have described another set of capillary vessels in connection with each villus (Fig. CONCEPTION AND GENERATION. 105 57). This consists of a very fine network covering each villus, and very different in appearance from the convoluted vessels lying in its Fig. 57. a. Terminal villus of foetal tuft, minutely injected. 6. Its nucleated non- vascular sheath. (After Farre.) interior, which are the only ones which have been usually described. Dr. Farre believes that these vessels only exist in the early months of Fig. 58. Diagram representing a Vertical Section of the Placenta. (After Dalton.) a., a. Chorion, b, b. Decidua. c, c, c, c. Orifices of uteriue sinuses. pregnancy, and that they disappear as pregnancy advances. Priestlev 1 suggests that they may not be vessels at all, but lymphatics, which 1 The Gravid Uterus, p. 52. 106 PREGNANCY. ma j possibly absorb nutrient material from the mother's blood, and throw it into the foetal vascular system. The existence of lymphatics, or nerves, in the placenta, however, has never been demonstrated, and they are believed not to exist. Maternal Portion of the Placenta. — As generally described, the maternal portion of the placenta consists of large cavities, or of a single large cavity, which contain the maternal blood, and into which the villi of the chorion penetrate (Fig. 58). Into this maternal part of the viscus the curling arteries of the uterus pour their blood, which is collected from it by the uterine sinuses. The villi of the chorion, therefore, are suspended in a sac filled with maternal blood, which penetrates freely between them, and with which they are brought into very intimate contact. Dr. John Keid believed that only the delicate internal lining of the maternal vessels entered the substance of the placenta, to form the sac just spoken of. Into this the villi project, pushing before them the membrane forming the limiting wall of the placental sinuses, each of them in this way re- ceiving an investment, just as the fingers of a hand are covered by a glove (Fig. 59). Fig. 59. Fig. 60. C— --. Diagram illustrating the mode in which a pla- cental villus derives a covering from the vascu- lar system of the mother. (After Priestley.) o. Villus having three terminal digitations pro- jecting into b. Cavity of the mothers vessel, c. Dotted lines representing coat of vessel. The Extremity of a Placental Villus. (After Goodsir.) a. External membrane of villus (the lining membrane of vascular system of Weber). b. External cells of villus derived from decidua. c. c. Nuclei of ditto. d. The space between the maternal and fcctal portions of villus. e. Its internal membrane. /. Its internal cells. g. The loop of umbilical vessels. Theory of Goodsir.— Schroeder van der Kolk and Gooclsir (Fig. 60) were of opinion that not only were the maternal bloodvessels con- tinued into the substance of the placenta, but also the processes of the decidua, which accompanied the vessels and were prolonged over each villus, so as to separate it from the limiting membrane of the maternal sinuses. Each villus would thus be covered by two layers of fine tissue, one from the internal lining membrane of the maternal bloodvessels, the other from the epithelial cells of the decidua. Theory of Turner. — Turner, whose valuable researches on the com- parative anatomy of the placenta have thrown much light on its CONCEPTION AND GENERATION. 107 structure, points out that the placentoe of all animals are formed on the same fundamental type. 1 in which the foetal portion consists of a smooth, plane-surfaced vascular membrane, covered with pavement epithelium, which is brought into contact with the maternal portion^ consisting of a smooth, plane-surfaced vascular membrane, covered with columnar epithelium. The foetal capillaries are separated from the maternal capillaries only by two opposed layers of epithelium. In various animals the placentae are more or less specialized from the generalized form, in some to a much greater extent than others. In the human placenta the maternal vessels have lost their normal cylindrical form, and are dilated into a system of freely intercom- municating placental sinuses, which are, in fact, maternal capillaries enormously enlarged, with their walls so expanded and thinned out that they eannot be recognized as a distinct layer limiting the sinus. Each foetal chorionic villus projecting into these sinuses is covered with a layer of cells distinct from those of the epithelial layer of the villus, and readily stripped from it. These are maternal in their origin, and are derived from the decidua, which sends prolongations of its tissue into the placenta. These cells, he believes form a secret- ing epithelium which separates from the maternal blood a secretion for the nourishment of the foetus, which is, in its turn, absorbed by the villi of the chorion. Theory of Ercolani. — A view not very dissimilar to this has been advanced, by Professor Ercolani of Bologna, who maintains that the maternal portion of the placenta is a new formation, strictlv glandu- lar, and not vascular, in its structure. It is formed, he thinks, by the submucous connective tissue of the decidua serotina, and it dips down into the placenta and forms a sheath to each of the chorion villi, which it separates from the maternal blood. This new glandu- lar structure he describes as secreting a fluid, termed the " uterine milk," which is absorbed by the villi of the chorion, just as the mother's milk is absorbed by the villi of the intestines, and it is with this fluid alone that the chorion villi are in direct contact. The sheath, thus formed to each villus is doubtless analogous to the laver of cells which Goodsir described as encasing each villus, but is attributed to a new structure formed after conception. Theory of Braxton Hicks. — The existence of the maternal sinus system in the placenta, is altogether denied by anatomists of emi- nence whose views are worthy of careful consideration. Prominent amongst these is Braxton Hicks. 2 who has written an elaborate paper on the subject. He holds that there is no evidence to prove that the maternal blood is poured out into a cavity in which the chorion villi float, and he believes that the curling arteries, instead of entering the so-called maternal portion of the placenta, terminate in the de- cidua serotina. The hypertrophied chorion villi at the site of the placenta are firmly attached to the decidual surface, into which their tips are imbedded. The line of junction between the decidua reflexa and serotina forms a circumferential margin to, and limits the pla- 1 Introduction to Human Anatomy, part 2. 2 Obst. Trans., vol. xiv. 108 PREGNANCY. centa. The arrangement of the foetal portion of the placenta on this view is very similar to that generally described, but the villi are not surrounded by maternal blood at all, and nothing exists between them, unless it be a small quantity of serous fluid. The change in the foetal blood is effected by endosmosis, and Hicks suggests that follicles of the decidua may secrete a fluid, which is poured into the intervillous spaces for absorption by the villi. Functioiis of the Placenta. — It will thus be seen that anatomists of repute are still undecided as to important points in the minute ana- tomy of the placenta, which further investigation will doubtless clear up. The main functions of the organ are, however, sufficiently clear. During the entire period of its existence it fills the important office of both stomach and lungs to the foetus. Whatever view of the arrangement of the maternal bloodvessels be taken, it is certain that the foetal blood is propelled by the pulsations of the foetal heart into the numberless villi of the chorion, where it is brought into very intimate relation Avith the mother's blood, gives off its carbonic acid, absorbs oxygen, and passes back to the foetus, through the um- bilical veins, in a fit state for circulation. The mode of respiration, therefore, in the foetus is analogous to that in fishes, the chorion villi representing the gills, the maternal blood the water in which they float. Nutrition is also effected in the organ, and, by absorption through the chorion villi, the pabulum for the nourishment of the foetus is taken up. It also probably serves as an emunctory for the products of excretion in the foetus. Picard found that the blood in the placenta contained an appreciably larger quantity of urea than that in other parts of the body, this urea probably being derived from the foetus. Claude Bernard also attributed to it a glycogenic function, 1 supposing it to take the place of the foetal liver until that organ was sufficiently developed. Degenerative Changes previous to Expulsion. — Finally, we find that the temporary character of the placenta is indicated by certain degen- erative changes, which take place in it previous to expulsion. These consist chiefly in the deposit of calcareous patches on its uterine sur- face, and in fatty degeneration of the villi, and of the decidual layer between the placenta and the uterus. If this degeneration be carried to excess, as is not unfrequently the case, the foetus may perish from a want of a sufficient number of healthy villi through which its respiration and nutrition may be effected. Umbilical Cord.- — The umbilical cord is the channel of communi- cation between the foetus and placenta, being attached to the former at the umbilicus, to the latter generally near its centre, "but some- times, as in the battledore placenta, at its edge. It varies much in length, measuring on an average from 18 to 24 inches, but in excep- tional cases being found as long as 50 or 60, and as short as 5 or 6 inches. When fully formed it consists of an external membranous layer formed of the amnion, two umbilical arteries, one umbilical vein, and 1 Acad, des Sciences, April, 1859. ANATOMY AND PHYSIOLOGY OF THE FCETUS. 109 a considerable quantity of transparent gelatinous substance surround- ing the vessels, called Wharton's jelly, which is contained in a fine network of fibres, and is formed out of the tissue of the allantois. At an early period of pregnancy, in addition to these structures, the cord contains the pedicle of the umbilical vesicle, with the omphalo mesenteric vessels ramifying on it, and two umbilical veins, one of which soon atrophies and disappears. No nerves or lymphatics havt been satisfactorily demonstrated in the cord, although such have been described as existing. The vessels of the cord are at first straight in their course, but shortly they become greatly twisted, the arteries being external to the vein, and in nine cases out of ten the twist is from left to right. Various explanations have been given of this peculiarity, none of them entirely satisfactory. Tyler Smith attributed it to the movements of the foetus twisting the cord, its attachment to the placenta being a fixed point ; this would not, how- ever, account for the frequency with which the spiral turns occur in one direction. Mr. John Simpson attributed it to the greater pres- sure of the blood through the right hypogastric artery, on account of that vessel having a more direct relation to the aorta than the left. The umbilical arteries give off no branches, and the vein con- tains no valves, nor can any vasa vasorum be detected in their coats after they have left the umbilicus. The umbilical arteries increase in size after they leave the cord, to divide on the surface of the pla- centa. This is the only example in the body in which arteries are larger near their terminations than their origin, and the object of this arrangement is probably to effect a retardation of the current of the blood distributed to the placenta. The tortuous course of the vein probably compensates for the absence of valves, and moderates the flow of blood through it. Distinct knots are not unfrequently observed in the cord, but they rarely have the effect of obstructing the circulation through it. They no doubt form when the foetus is very small. They may sometimes also be produced in labor by the child being propelled through a coil of the cord lying circularly round the os uteri. The so called false knots are merely accidental nodosi- ties due to local enlargements of the vessels. CHAPTER II. THE ANATOMY" AND PHYSIOLOGY OF THE FCETUS. It is obviously impossible to attempt anything like a full account of the development of the various foetal structures, or of their growth during intra-uterine life. To do so would lead us far beyond the scope of this work, and would involve a study of complex details 110 PREGNANCY. only suitable in a treatise on Embryology. It is of importance, how- ever, that the practitioner should have it in his power to determine approximately the age of the foetus in abortions or premature labor, and for this purpose it is necessary to describe briefly the appear- ance of the foetus at various stages of its growth. 1st Month. — The foetus in the first month of gestation is a minute gelatinous, and semi-transparent mass, of a grayish color, in which no definite structure can be made out, and in which no head nor ex- tremities can be seen. It is rarely to be detected in abortions, being- lost in surrounding blood clots. In the few examples which have been carefully examined it did not measure more than aline in length. It is, however, already surrounded by the amnion, and the pedicle of the umbilical vesicle can be traced into the unclosed abdominal cavity. 2d Month. — The embrj^o becomes more distinctly apparent, and is curved on itself, weighing about 62 grains, and measuring 6 to 8 lines in length. The head and extremities are distinctly visible — ■ the latter in the form of rudimentary projections from the body. The eyes are to be seen as small black spots on the side of the head. The spinal column is divided into separate vertebrae. The indepen- dent circulatory system of the foetus is now beginning to form, the heart consisting of only one ventricle and one auricle, from the former of which both the aorta and pulmonary arteries arise. On either side of the vertebral column, reaching from the heart to the pelvis, are two large glandular structures, the corpora Wolffiania, which consists of a series of convoluted tubes opening into an excre- torv duct, running along their external borders, and connected below with the common cloaca of the genito- urinary and digestive tracts. They seem to act as secreting glands, and fulfil the functions of the kidneys before these are formed. Towards the end of the second month they atrophy and disappear, and the only trace of them in the foetus at term is to be found in the parovarium lying between the folds of the broad ligaments. At this stage of development there are met with in the human embryo, as in that of all mammals, four transverse fissures opening into the pharynx, which are analo- gous to the permanent branchiae of fishes. Their vascular supply is also similar, as the aorta at this time gives off four branches on each side, each of which forms a branchial arch, and these afterwards unite to form the descending aorta. By the end of the sixth week these, as well as the transverse fissures to which they are distributed, disappear. By the end of the second month the kidneys and supra- renal capsules are forming, and the single ventricle is divided into two by the growth of the inter-ventricular septum. The umbilical cord is quite straight, and is inserted into the lower part of the ab- domen. Centres of ossification are showing themselves in the infe- rior maxillary bones and the clavicle. M Month.— The embryo weighs from 70 to 300 grains, and meas- ures from 2 J to 3J inches in length. The forearm is w r ell formed and the first traces of the fingers can be made out. The head is large in proportion to the rest of the body, and the eyes are promi- ANATOMY AND PHYSIOLOGY OF THE FCETUS. Ill nent. The umbilical vesicle and allantois have disappeared, the greater portion of the chorion villi have atrophied, and the placenta is distinctly formed. 4:th Month. — The weight is from 4 to 6 oz., and the length about 6 inches. The convolutions of the brain are beginning to develop. The sex of the child can now be ascertained on inspection. The muscles are sufficiently formed to produce distinct movements of the limbs. Ossification is extending, and can be traced in the occipital and frontal bones, and in the mastoid processes. The sexual organs are differentiated. 5th Month. — Weight about 10 oz. Length, 9 or 10 inches. Hair is observed covering the head, which forms about one-third of the length of the whole foetus. The nails are beginning to form, and ossification has commenced in the ischium. 6th Month. — Weight about 1 lb. Length, 11 to 12J inches. The hair is darker. The eyelids are closed, and the membrana papillaris exists ; eyelashes have now been formed. Some fat is deposited under the skin. The testicles are still in the abdominal cavity. The clitoris is prominent. The pubic bones have begun to ossify. 7th Month. — -Weight, from 3 to 4 lbs. Length, 13 to 15 inches. The skin is covered with unctuous, sebaceous matter, and there is a more considerable deposit of subcutaneous fat. The eyelids are open. The testicles have descended into the scrotum. 8th Month. — Weight, from -1 to 5 lbs. Length, 16 to 18 inches, and the foetus seems now to grow in thickness rather than in length. The nails are completely developed. The membrana pupillaris has disappeared. Foetus at Term. — At the completion of pregnancy the foetus weighs on an average 6 J lbs., and measures about 20 inches in length. These averages are, however, liable to great variation. Eemarkable his- tories are given by many writers of foetuses of extraordinary weight, which have been probably greatly exaggerated. Out of 3000 chil- dren delivered under the care of Cazeaux at various charities, one only weighed 10 lbs. There are, however, several carefully recorded instances of weight far exceeding this; but. they are undoubtedly much more uncommon than is generally supposed. Dr. Kamsbotham mentions a foetus weighing 16 J lbs., Cazeaux tells of one which he delivered by turning which weighed 18 lbs., and measured 2 feet 1J inches, and the birth of one weighing 21 lbs. has been recently re- corded. 1 Such overgrown children are almost invariably stillborn. On the other hand, mature children have been born and survived which have not weighed more than 5 lbs. [Probably the largest foetus on record was that of Mrs. Captain Bates, the Nova Scotia giantess, a woman of 7 ft. 9 in., whose husband is also of gigantic build, reaching 7ft. 7 in. in height. This child, born in Ohio, was their second, and was lost in its birth, as no forceps could be procured of sufficient size to grasp the head. The foetus weighed 23 J lbs., and was 30 in. in length. Their first infant weighed 1 Brit. Med. Journ. Feb. 1, 1879. 112 PREGNANCY. 19 lbs. We have had children born in this city at maturity and live, that weighed but one pound. The well-remembered " Pincus babv" weighed a pound and an ounce. 1 — Ed.J The average size of male children at birth, as in afterlife, is some- what greater than that of female. Thus Simpson 2 found that out of 100 cases the male children averaged 10 oz. more in weight than the female, and § an inch more in length. A new-born child at term is generally covered to a greater or less extent with a greasy, unctuous material, the vernix caseosa, which is formed of epithelial scales and the secretion of the sebaceous glands, and which is said to be of use in labor, by lubricating the surface of the child. The head is gene- rally covered with long dark hair, which frequently falls off or changes in color shortly after birth. Dr. Wiltshire 3 has called attention to an old observation, that the eyes of all new-born children are of a peculiar dark steel-gray color, and that they do not acquire their permanent tint until some time after birth. The umbilical cord is generally inserted below the centre of the body. Anatomy of the Foetal Head. — The mostimportant part of the foetus from an obstetrical point of view is the head, which requires a sepa- rate study, as it is the usual presenting part, and the facility of the labor depends on its accurate adaptation to the maternal passages. The chief anatomical peculiarity of interest, in the head of the foetus at term, is that the bones of the skull, especially of its vertex ■ — Avhich, in the vast majority of cases, has to pass first through the pelvis — are not firmly ossified as in adult life, but are joined loosely together by membrane or cartilage. The result of this is, that the skull is capable of being moulded and altered in form to a very con- siderable extent by the pressure to which it is subjected, and thus its passage through the pelvis is very greatly facilitated. This, how- ever, is chiefly the case with the cranium proper, the bones of the face and of the base of the skull being more firmly united. By this means the delicate structures at the base of the brain are protected from pressure, while the change of form which the skull undergoes during labor implicates a portion of the skull where pressure on the cranial contents is least likely to be injurious. The divisions between the bones of the cranium are further of ob- stetric importance in enabling us to detect the precise position of the head during labor, and an accurate knowledge of them is therefore essential to the obstetrician. The Sutures and FontaneU.es. — We talk of them as sutures and fontanelles, the former being the lines of junction between the sepa- rate bones which overlap each other to a greater or less extent during labor ; the latter membranous interspaces where the sutures join each other. The principal sutures are: 1st. The sagittal, which separates the two parietal bones, and extends longitudinally backwards along the vertex of the head. 2d. The frontal, which is a continuation of the 1 [It was remarkable for the strength of its cry.] 2 Selected Obst. Works, p. 327. 3 Lancet, February 11, 1871. ANATOMY AND PHYSIOLOGY OF THE FCETUS 113 sagittal, and divides the two halves of the frontal bone, at this time separate from each other. 3d. The coronal, which separates the frontal from the parietal bones, and extends from the squamous por- tion of the temporal bone across the head to a corresponding point on the opposite side ; and 4th, the lamhdoidal, which receives its name from its resemblance to the Greek letter a, and separates the occipital from the parietal bones on either side. The fontanelles (Fig. 61) are the membranous interspaces where the sutures join — the anterior and larger being lozenge-shaped, and formed by the junc- tion of the frontal, sagittal, and two halves of the coronal sutures. It will be well to note that there are, therefore, four lines of sutures running into it, and four angles, of which the anterior, formed by Fig. 61. Fig. 62. Anterior and Posterior Fontanelles Bi-parietal Diameter, Sagittal or Lambdoidal Sutures, with. Posterior Fontanelles. the frontal suture, is most elongated and well marked. The posterior fontanelle (Fig. 62) is formed by the junction of the sagittal suture with the two legs of the lambdoidal. It is, therefore, triangular in shape, with three lines of suture entering it in three angles, and is much smaller than the anterior fontanelle, forming merely a depres- sion into which the tip of the finger can be placed, while the latter is a hollow as big as a shilling, or even larger. As it is the posterior fontanelle which is generally lowest, and the one most commonly felt during labor, it is important for the student to familiarize himself with it, and he should lose no opportunity of studying the sensations imparted to the finger by the sutures and fontanelles in the head of the child after birth. The Diameter of the Foetal Skull. — For the purpose of understand- ing the mechanism of labor, we must study the measurements of the foetal head in relation to the cavity through which it has to pass. They are taken from corresponding points opposite to each other, and are known as the diameters of the skull (Fig. 63). Those of most importance are: 1st. The occi^i to-mental, from the occipital protuberance to the point of the chin, 5.25" to 5.50". 2d. The occi- pitofrontal from the occiput to the centre of the forehead, 4.50" to 114 PREGNANCY. Fig. 63. 5". 3d. The sub-occipito-bregmatic, from a point midway between the occipital protuberance and the margin of the foramen magnum to the centre of the anterior fontanelle, 3.25". 4th. The cer- vico-bregmatic, from the anterior margin of the foramen magnum to the centre of the anterior fon- tanelle, 3,1b". 5th. Transverse or bi-parielal, between the parietal protuberances, 3.75" to 4". 6th. 1 & 2. Occipitofrontal diameter. 3 & 4. Occipito mental. 5 & 6. Cervico-bregmatic. 7 & S. Frou to-mental. JBi-temporal, 3.50". 7th. the apex of chin, 3.25". Alteration between the ears, Fronto-mental, from the forehead to the of Diameter during Labor. — The length of these respective diameters, as given by differ- ent writers, differs considerably — a fact to be explained by the meas- urements having been taken at different time's; by some just after birth, when the head was altered in shape by moulding it had under- gone ; by others when this had either been slight, or after the head had recovered its normal shape. The above measurements may be taken as the average of those of the normally shaped head, and is to be noted that the first two are most apt to be modified during labor. The amount of compression and moulding to which the head may be subjected, without proving fatal to the foetus, is not certainly known, but it is doubtless very considerable. Some interesting ex- amples of the extent to which the head may be altered in shape in difficult labors have been given by Barnes, 1 who has shown by trac- ings of the shape of the head taken immediately after delivery, that in protracted labor the occipito-mental and occipitofrontal diameters may be increased more than an inch in length, while lateral compres- sion may diminish the bi- parietal diameter to the same length as the inter-auricular. The foetal head is movable on the vertical column to the extent of a quarter of a circle ; and it seems probable that the laxity of the ligaments admits with impunity a greater circular move- ment than would be possible in the adult. Influence of Sex and Race on the Foetal Head. — On taking the ave- rage of a large number of measurements, it is found that the heads of male children are larger and more firmly ossified than those of females, the former averaging about half an inch more in circum- ference. Sir James Simpson attributed great importance to this fact, and believed that it was sufficient to account for the larger proportion of still-births in male than in female children, as well as for the greater difficulty of labor and the increased maternal mortality that are found to attend on male births. His well-known paper on this subject, which has given rise to much controversy, is full of the most elaborate 1 Obst. Trans., vol. vii. ANATOMY AND PHYSIOLOGY OF THE FCETUS. 115 details, and so great did he believe the foetal influence to be, that he calculated that between the years 1831 and 1837 there were lost in Great Britain, as a. consequence of the slightly larger size of the male than of the female head at birth, about 50,000 lives, including those of about -16,000 or 47,000 infants, and of between 3000 and 4000 mothers who died in childbed. 1 It is probable that race and other conditions, such as civilization and intellectual culture, have con- siderable influence on the size of the foetal skull, but we are not in possession of sufficiently accurate data to justify any very positive opinion on these points. Position of the Foetus in Utero. — In the very large majority of cases the foetus lies in utero with the head downwards, and is so placed as to be adapted in the most convenient way to the cavity in which it is placed. The uterine cavity is most roomy at the fundus, and narrowest at the cervix, and the greatest bulk of the foetus is at the breech, so that the largest part of the child usually lies in the part of the uterus best adapted to contain it. The various parts of the child's body are further so placed, in regard to each other, as to take up the least possible amount of space. (See frontispiece.) The body is bent so that the spine is curved with its convexity outwards,. this curvature existing from the earliest period of development ; the chin is flexed on the sternum ; the forearms are flexed on the arms, and lie close together on the front of the chest ; the legs are flexed on the thighs, and the thighs drawn up on the abdomen ; the feet are drawn up towards the legs; the umbilical cord is generally placed out of reach of injurious pressure, in the space between the arms and the thighs. Variations from this attitude, however, are not uncommon, and are not, as a rule, of much consequence. Although the cranial presentations are much the most common, averaging: 96 out of every 100 cases, other presentations are bv no means rare, the. next most frequent being either that of the breech, in which the long diameter of the child lies in the long diameter of the uterine cavity, or some variety of transverse presentation, in which the long diam- eter of the foetus lies obliquely across the uterus, and no longer corresponds to its longitudinal axis. Changes of Foetal Position during Pregnancy. — It was long believed that the head presentation was only assumed towards the end of pregnancy, when it was supposed to be produced by a sudden move- ment on the part of the foetus, known as the culbute. It is now well known that, in the large majority of cases, the head is lowest during all the latter part of pregnancy, although changes in position are more common than is generally believed to be the case, and presen- tation of parts other than the head is much more frequent in pre- mature labor than in delivery at term. In evidence of the last statement, Churchill says that in labor at the seventh month the head presents only 83 times out of 100 when the child is living, and that as many as 53 per cent, of the presentations are preternatural when the child is still-born. The frequency with which the foetus 1 Selected Obstet. Works, p. 363. 116 PREGNANCY. changes its position before delivery has been made the subject of investigation by various German obstetricians, and the fact can be readily ascertained by examination. Valenta 1 found that out of nearly 1000 cases, carefully and frequently examined by him, in 57.6 per cent, the presentation underwent no change in the latter months of pregnancy, but in the remaining 42.4 per cent, a change could be readily detected. These alterations were found to be most frequent in multiparas, and the tendency was for abnormal presentations to alter into normal ones. Thus it was common for transverse presenta- tions to alter longitudinally, and but rare for breech presentations to change into head. The ease with which these changes are effected no doubt depends, in a considerable degree, on the laxity of the uterine parietes, and on the greater quantity of amniotic fluid, by both of which the free mobility of the foetus is favored. Detection of Foetal Position by Abdominal Palpatio?!. — The facility with which the position of the foetus in utero can be ascertained by abdominal palpation has not been generally appreciated in obstetric works, and yet, by a little practice, it is easy to make it out. Much information of importance can be gained in this way, and it is quite possible, under favorable circumstances, to alter abnormal presen- tations before labor has begun. For the purpose of making this Fig. 64. Mode of ascertaining the Position of the Fcetus hy Palpation. examination, the patient should lie at the edge of the bed, with her shoulders slightly raised, and the abdomen uncovered. The first observation to make is to see if the longitudinal axis of the uterine tumor corresponds with that of the mother's abdomen ; if it does, the presentation must be either a head or a breech. By spreading the hands over the uterus (Fig. 64), a greater sense of resistance can bs 3 Mon. f. Geburt., 1866. ANATOMY AND PHYSIOLOGY OF THE FOETUS 117 felt, in most cases, on one side than on the other, corresponding to the back of the child. By striking the tips of the fingers suddenly inward^ at the fundus, the hard breech can generally be made out, or the head, still more easily, if the breech be downwards. When the uterine walls are unusually lax, it is often possible to feel the limbs of the child. These observations can be generally corroborated by auscultation, for in head presentations the foetal heart can usually be heard below the umbilicus, and in breech cases above it. Trans- verse presentations can even more easily be made out by abdominal palpation. Here the long axis of the uterine tumor does not corre- spond with the long axis of the mother's abdomen, but lies obliquely across it. By palpation the rounded mass of the head can be easily felt in one of the mother's flanks, and the breech in the other, while the foetal heart is heard pulsating nearer to the side at which the head is detected. Explanation of the Position of the Foetus in Utero. — The reason why the head presents so frequently has been made the subject of much discussion. The oldest theory was, that the head lay over the os uteri as the result of gravitation, and the influence of gravity, although contested by many obstetricians, prominent among whom were Du- bois and Simpson, has been insisted upon as the chief cause by others, Dr. Duncan being one of the most strenuous advocates of this view. The objections urged against the gravitation theory were drawn partly from the result of experiments, and partly from the frequency with which abnormal presentations occurred in premature labors, when the action of gravity could not be supposed to be suspended. The experiments made by Dubois went to show that when a foetus was suspended in Avater gravitation caused the shoulders, and not the head to fall lowest. lie, therefore, advanced the hypothesis that the position of the foetus was due to instinctive movements, which it made to adapt itself to the most comfortable position in which it could lie. It need only be remarked that there is not the slightest evidence of the foetus possessing any such power. Simpson proposed a theory which was much more plausible. He assumed that the foetal position was due to reflex movements produced by physical irrita- tions to which the cutaneous surface of the foetus is subjected from changes of the mother's position, uterine contractions, and the like. The absence of these movements, in the case of the death of the foetus, would readily explain the frequency of mal-presentation under such circumstances. The obvious objection to this theory, complete as it seems to be, is the absence of any proof that such constant extensive reflex movements really do occur in utero. Dr. Duncan has very conclusively disposed of the principal objections which have been raised against the influence of gravitation, and when an obvious ex- planation of so simple a kind exists, it seems useless to seek further for another. He has shown that Dubois's experiments did not accu- rately represent the state of the foetus in utero, and that during the greater part of the day, when the woman is upright, or lying on her back, the foetus lies obliquely to the horizon at an angle of about 30°. The child thus lies, in the former case, on an inclined plane, formed 118 PREGNANCY. "by the anterior uterine wall and by the abdominal parietes, in the latter by the posterior uterine wall and the vertebral column. Down the inclined plane so formed the force of gravity causes the foetus to slide, and it is only when the woman lies on her side that the foetus is placed horizontally, and is not subjected in the same degree to the action of gravity (Fig. 65). The frequency of mal-presenta- Diagram illustrating the Effect of Gravity on the Foetus. (After Duncan ) a, b, is parallel to the axis of the pregnant uterus and pelvic brim, c, d, e, is a perpendicular line. e, the centre of gravity of the foetus, d, the centre of flotation, tions in premature labors is explained by Dr. Duncan partly by the fact that the death of the child (which so frequently precedes such Fig. Illustrating the greater Mobility of the Foetus and the Larger relative Amount of Liquor Amnii in Early Pregnancy. (After Duncan.) o, h. Axis of pregnant uterus. ft, h. A horizontal line. cases) alters its centre of gravity, and partly by the greater mobil- ity of the child and the greater relative amount of liquor amnii (Fig. 66). The influence of gravitation is probably greatly assisted ANATOMY AND PHYSIOLOGY OF THE FCETUS. 119 by the contractions of the uterus which are going on during the greater part of pregnancy. The influence of these was pointed out by Dr. Tyler Smith, who distinctly showed that the contractions of the uterus preceding delivery exerted a moulding or adapting influ- ence on the foetus, and prevented undue alterations of its position. Dr. Hicks proved 1 that these uterine contractions are of constant occurrence from the earliest period of pregnancy, and there can be little doubt that they must have an important influence on the body contained within the uterus. The whole subject has been recently considered by Pinard 2 who shows that many factors are in action to produce and maintain the usual position of the foetus in utcro, which may be either of an active or a passive character : the former being chiefly the active movements of the foetus and the contractions of the uterus and the abdominal muscles ; the latter, the form of the uterus and the foetus, the slippery surface of the amnion, pressure of the amniotic fluid, etc. When any of these factors are a»t fault, mal-pre- sentation is apt to occur. Functions of the Foetus. — The functions of the foetus are in the main the same, with differences depending on the situation in which it is placed, as those of the separate being. It breathes, it is nourished, it forms secretions, and its nervous system acts. The mode in which some of these functions are carried on in intra-uterme life requires separate consideration. 1. Nutrition.- — -During the early period of pregnancy, and before the formation of the umbilical vesicle and the allantois, it is certain that nutritive material must be supplied to the ovum by endosmosis through its external envelope. The precise source, however, from which this is obtained is not positively known. By some it is believed to be derived from the granulations of the discus proligerus which surround it as it escapes from the Graafian follicle, and sub- sequently from the layer of albuminous matter which surrounds the ovum before it reaches the uterus; while others think it probable that it may come from a special liquid secreted by the interior of the Fallopian tube as the ovum passes along it. As soon as the ovum has reached the uterus, there is every reason to believe that the umbilical vesicle is the chief source of nourishment to the embryo, through the channel of the omphalo-mesenteric vessels, which convey matters absorbed from the interior of the vesicle to the intestinal canal of the foetus. At this time the exterior of the ovum is covered by the numerous fine villosities of the primitive chorion, which are imbedded in the mucous membrane of the uterus, and it is thought that they may absorb materials from the maternal system, which may be either directly absorbed by the embryo, or which may serve the purpose of replacing the nutritive matter which has been removed from the umbilical vesicle by the omphalo-mesenteric vessels. This point it is, of course, impossible to decide. Joulin, however, thinks that these villi probably have no direct influence on the nourishment 1 Obst. Trans, vol. xiii. p. 216. 2 Annal. de Gryn., May and July, 1878. 120 PREGNANCY. of the foetus, which is at this time solely effected by the umbilical vesicle, but that they absorb fluid from the maternal system, which passes through the amnion and forms the liquor amnii. As soon as the allantois is developed, vascular communication between the foetus and the maternal structures is established, and the temporary func- tion of the umbilical vesicle is over; that structure, therefore, rapidly atrophies and disappears, and the nutrition of the foetus is now solely carried on by means of the chorion villi, lined as they now are by the vascular endo-chorion, and chiefly by those which go to form the substance of the placenta. This statement is opposed to the views of many physiologists, who believe that a certain amount of nutritive material is conveyed to the foetus through the channel of the liquor amnii, itself derived from the maternal system, which is supposed either to be absorbed through the cutaneous surface of the foetus, or carried to the intesti- nal canal by deglutition. The reasons for assigning to the liquor amnii a nutritive function are, however, so slight, that it is difficult to believe that it has any appreciable action in this way. They are based on some questionable observations, such as those of Weydlich, who kept a calf alive for fifteen days by feeding it solely on liquor amnii, and the experiments of Burdach, who found the cutaneous lymphatics engorged in a foetus removed from the amniotic cavity, while those of the intestine were empty. The deglutition of the liquor amnii for the purposes of nutrition, has been assumed from its occasional detection in the stomach of the foetus, the presence of which may, however, be readily explained by spasmodic efforts at respiration, which the foetus undoubtedly often makes before birth, especially when the placental circulation is in any way interfered with, and during which a certain quantity of fluid would necessarily be swallowed. The quantity of nutritive material, however, in the liquor amnii is so small — not more than 6 to 9 parts of albumen in 1000 — that it is impossible to conceive how it could have any appre- ciable influence in nutrition, even if its absorption, either by the skin or stomach, were susceptible of proof. That the nutrition of the foetus is effected through the placenta is proved by the common observation that ivhenever the placental circulation is arrested, as by disease of its structure, the foetus atro- phies and dies. The precise mode, however, in which nutritive materials are absorbed from the maternal blood is still a matter of doubt, and must remain so until the mooted points as to the minute anatomy of the placenta are settled. The various theories enter- tained on this subject by the upholders of the Hunterian doctrine of placental anatomy, and 'by those who deny the existence of a sinus system, have already been referred to in the chapter on the Anatomy of the Placenta, to which the reader is referred (pp. 106-108). 2. Respiration. — One of the chief functions of the placenta, besides that of nutrition, is the supply of oxygenated blood to the foetus. That this is essential to the vitality of the foetus, and that the pla- centa is the site of oxygenation, are shown by the facts that when- ever the placenta is separated, or the access of foetal blood to it ANATOMY AND PHYSIOLOGY OF TIIE FCETUS. 121 arrested oy compression of the cord, instinctive attempts at inspira- tion are made, and if aerial respiration cannot be performed, the foetus is expelled asphyxiated. Like the other functions of the foetus during intra- uterine life, that of respiration has been made the subject of numerous more or less ingenious hypotheses. Thus many have believed that the foetus absorbed gaseous material from the liquor amnii, which served the purpose of oxygenating its blood, St. Hilaire thinking that this was affected by minute openings in its skin, Beclard and others through the bronchi, to which they believed the liquor amnii gainad access. Independently of the entire want of evidence of the absorption of gaseous materials by these channels, the theory is disproved by the fact that the liquor amnii contains no air which is capable of respiration. Serrcs attributed a similar func- tion to some of the chorion villi, which he believed penetrated the utricular glands of the decidua reflexa, and absorbed gas from the hvdroperione, or fluid situated between it and the decidua vera, and in this manner he thought the foetal blood was oxygenated until the fifth month of intra-uterine life, when the placenta was fully formed. This hypothesis, however, rests on ncraccurate foundation, for it is certain that the chorion villi do not penetrate the utricular glands in the manner assumed ; or, even if tliey did, the mode in which the oxygen thus absorbed by the chorion villi reaches the foetus, which is separated from them by the amnion and its contents, would still remain unexplained. The moile in which, the oxygenation of the foetal blood is effected before the formation of the placenta remains, therefore, as yet un- known. After the development of that organ, however, it is less difficult to understand, for the foetal blood is everywhere brought into such close contact with the maternal, in the numerous minute ramifications of the umbilical vessels, that the interchange of gases can readily be effected. The activity of respiration is doubtless much less than in extra-uterine life, for the waste of tissue in the foetus is necessarily comparatively small, from the fact of its being suspended in a fluid medium of its own temperature, and from the absence of the processes of digestion and of respirator}' movements. The quan- tity of carbonic acid formed would, therefore, be much less than after birth, and there would be a correspondingly small call for oxygena- tion of venous circulation. 3. Circulation, — The functions of the lungs being in abeyance, it is necessary that all the foetal blood should be carried to, the placenta to receive ox^vgen and nutritive materials. To understand the mode in which this is effected, we must bear in mind certain peculiarities in the circulatory system which disappear after birth. 1. The two sides of the foetal heart are not separate, as in the adult. The right ventricle in the adult sends also the venous blood to the lungs, through the pulmonary arteries, to be aerated by con- tact with the atmosphere. In the foetus, however, only sufficient blood is passed through the pulmonary arteries to insure their being pervious and ready to carry blood to the lungs immediately after birth. 9 122 PEEGNANCY. An aperture of communication, the foramen ovale, exists between the two auricles, which is arranged so as to permit the blood reach- ing the right auricle to pass freely into the left, but not vice versa. By this means a large portion of the blood reach- FlG - 6 ?. ing the heart through the venae cava?:, instead of passing, as in the adult, into the right ventricle, is directed into the left auricle. 2. Even with this arrangement, however, a larger portion of blood would pass into the pul- monary arteries than is required for transmission to the lungs, and a further provision is made to prevent its going to them by means of a foetal vessel, the ductus arteriosus (Fig. 67), which arises Diagram of Foetai Heart, from the point of bifurcation of the pulmonary (Alter Daiton.) arteries, and opens into the arch of the aorta. I' ^°" a ' , In consequence of this arrangement only a very 2. Pulmonary artery. -L . o J J 3,3. Pulmonary brauches. small portion ot the blood reaches the lungs at ail. 4. Ductus arteriosus. 3. The fcetal hypogastric arteries are con- tinued into two large arterial trunks, which pass- ing into the cord, form the umbilical arteries, and carry the impure fcetal blood into the placenta. 4. The purified blood is collected into the single umbilical vein, through which it is carried to the under surface of the liver, from which point it is conducted, by means of another special foetal vessel the ductus venosus, into the ascending vena cava, and the right auricle. Course of the Fcetal Circulation. — In order to understand the course of the fcetal blood, it may be most conveniently traced from the point where it reaches the under surface of the liver through the umbilical vein. Part of it is distributed to the liver itself, but the greater quantity is carried directly into the vena cava, through the ductus venosus. The vena cava also receives the blood from the foetal veins of the lower extremities, and that portion of the blood of the nm bilical vein which has passed through the liver. This mixed blood is carried up to the right auricle, from which by far the greater part of it is immediately directed into the left auricle, through the fora- men ovale. From thence it passes into the left ventricle, which sends the greater part of it into the head and upper extremities through the aorta, a comparatively small quantity being transmitted to the inferior extremities. The blood which is thus sent to the upper part of the body is collected into the vena cava superior, by which it is thrown into the right auricle. Here the mass of it is probably di- rected into the right ventricle, which expels it into the pulmonary arteries, and from thence through the ductus arteriosus into the descending aorta. By this arrangement it will be seen that the de- scending aorta conveys to the lower part of the body the compara- tively impure blood which has already circulated through the head, neck, and upper extremities. From" the descending aorta a small quantity of blood is conveyed to the lower extremities, the greater part of "it being carried for purification to the placenta through the umbilical arteries. ANATOMY AND PHYSIOLOGY OF THE FCETUS. 123 Establishment of Independent Circulation. — As soon as the child is born it generally cries loudly, and inflates its lungs, and, in conse- quence, the pulmonary arteries are dilated, and the greater portion of the blood of the right ventricle is at once sent to the lungs, from whence, after being arterialized, it is returned to the left auricle, through the pulmonary veins. The left auricle, therefore, receives more blood than before, the right less, and the placental circulation being arrested, no more passes through the umbilical vein. In con- sequence of this, the pressure of the blood in the two auricles is equalized, the mass of the blood in the right auricle no longer passes into the left (the valve of the foramen ovale being closed by the equal pressure on both sides), but directly into the right ventricle and from thence into the pulmonary arteries, and the ductus arte- riosus soon collapses and becomes impervious. The mass of blood in the descending aorta no longer finds its way into the hypogastric arteries, but passes into the lower extremities, and the adult circu- lation is established. Changes after Birth. — The changes which take place in tempo- rary vascular arrangements of the foetus, prior to their complete dis- appearance, are of some practical interest. The ductus arteriosus, as has been said, Fig. 68. collapses, chiefly because the mass of blood is drawn to the lungs, and partly, perhaps, by its own inherent contractility. Its walls are found to be thickened, and its canal closes, first in the centre, and subse- quently at its extremities, its aortic end remaining longer pervious on account of the greater pressure of blood from the left side of the heart (Fig. 68). Practical clos- ure occurs within a few days after birth, although Flourens states that it is not completely obliterated until eighteen months or two years have elapsed. 1 Ac- cording to Schroeder, its walls unite with- out the formation of any thrombus. The tus arteriosus becoming obliterated. foramen ovale is soon closed by its valve, which contracts adhesion with the edges of the aperture, so as effect- ually to occlude it. Sometimes, however, a small canal of commu- nication between the two auricles may remain pervious for many months, or even a year and more, without, however, any admixture of blood occurring. A permanently patulous condition of this aper- ture, however, sometimes exists, giving rise to the disease known as cyanosis. The umbilical arteries and veins, and the ductus venosus soon also become impermeable, in consequence of concentric hypertrophy of their tissues and collapse of their Avails. The closure of the former is aided bv the formation of coagula in their interior. According to i. 3.3. Diagram of Heart of Infant. (After Dalton.) Aorta. 2. Pulmonary Artery. Pulmonary branches. 4. Duc- Acad. des Sciences, 1854. 124 PREGNANCY. Eobin, a longer time than is usually supposed elapses before they become completely closed, the vein remaining pervious until the twentieth or thirtieth day after delivery, the arteries for a month or six weeks. He has also described 1 a remarkable contraction of the umbilical vessels within their sheaths, at the point where they leave the abdominal walls, which takes place within three or four days after birth, and seems to prevent hemorrhage taking place when the cord is detached. Function of the Liver. — The liver, from it proportionately large size, apparently plays an important part in the foetal economy. It- is not until about the fifth month of utero-gestation that it assumes its characteristic structure, and forms bile, previous to that time its texture being soft and undeveloped. According to Claude Bernard, after this period one of its most important offices is the formation of sugar, which is found in much larger amount in the foetus than after birth. Sugar is, however, found in the foetal structures long before the development of the liver, especially in the mucous and cutaneous tissues, and it seems probable that these, as well as the placenta itself, then fulfil the glycogenic function, afterwards chiefly performed by the liver. The bile is secreted after the fifth' month of pregnancy, and passes into the intestinal canal, and is subsequently collected in the gall-bladder. By some physiologists it has been supposed that the liver, during intra-uterine life, was the chief seat of depuration of the carbonic acid contained in the venous blood of the foetus. It is, however, more generally believed that this is accomplished solely in the placenta. The bile, mixed with the mucous secretion of the intestinal tract, forms the meconium which is contained in the intes- tines of the foetus, and which collects in them during the whole period of intra-uterine life. It is a thick, tenacious, greenish substance, which is voided soon after birth in considerable quantity. The Urine. — Urine is certainly formed during intra-uterine life, as is proved by the fact familiar to all accoucheurs, that the bladder is constantly emptied instantly after birth. It has generally been supposed that the foetus voided its urine into the cavity of the am- nion, and the existence of traces of urea in the liquor amnii, as well as some cases of imperforate urethra, in which the bladder was found to be enormously distended, and some congenital hydronephrosis associated with impervious ureters, have been supposed to corrobo- rate this assumption. The question has been very fully studied by Joulin, who has collected together a large number of instances in which there was imperforate urethra without any undue distension of the bladder. He holds also that the amount of urea found in the liquor amnii is far too minute to justify the conclusion that the urine of the foetus was habitually poured into it, although a small quantity may, he thinks, escape into it from time to time ; and he, therefore, believes that the urine of the foetus is only secreted regularly and abundantly after birth, and that during intra-uterine life its retention is not likely to give rise to any functional disturbance. 2 ' Acad, des ScieiTces, 1860. 2 Acad, des Sciences, p. 301. PREGNANCY. 125 Function of the Nervous System. — There is no doubt that the nervous system acts to a considerable extent during intra-uterine life, and some authors have even supposed that the foetus was en- dowed with the power of making instinctive or voluntary movements for the purpose of adapting itself to the form of the uterine cavity. There can be no question, however, that the movements the foetus performs are purely reflex and automatic. That it responds to a stimulus applied to the cutaneous nerves is proved by the experi- ments of Tyler Smith, who laid bare the amnion in pregnant rabbits, and found that the foetus moved its limbs when these Avere irritated through it. Pressure on the mother's abdomen, cold applications, and similar stimuli, will also produce energetic foetal movements. The gray matter of the brain in the new-born child is, however, quite rudimentary in its structure, and there is no evidence of intelligent action of the nervous system until some time after birth, and a fortiori during pregnane}*. CHAPTEE III. PREGNANCY. As soon as conception has taken place a series of remarkable changes commence in the uterus, which progress until the termina- tion of pregnancy, and are well worthy of careful study. They pro- duce those marvellous modifications which effect the transformation of the small undeveloped uterus of the non-pregnant state into the large and fully-developed uterus of pregnancy, and have no parallel in the whole animal economy. A knowledge of them is essential for the proper comprehension of the phenomena of labor, and for the diagnosis of pregnancy which the practitioner is so frequently called upon to make. Excluding the varieties of abnormal pregnancy, which will be noticed in an- other place, Ave shall 'here limit ourselves to a consideration of the modifications of the maternal organism Avhich result from simple and natural gestation. Changes in the Uterus. — The unimpregnated uterus measures 2 J inches in length, and weighs about 1 oz., while at the full term of pregnancy it has so immensely grown as to AA'eigh 24, oz., and meas- ure 12 inches. This groAvth commences as soon as the ovum reaches the uterus, and continues uninterruptedly until delivery. In the early months the uterus is contained entirely in the cavity of the pelvis, and the increase of size is only apparent on vaginal examina- tion, and that with difficulty. After the third month the enlarge- ment is chiefly in the lateral direction, so that the Avhole bodA* of the 126 PREGNANCY. Fig. 69. uterus assumes more of a spherical shape than in the non- pregnant state. If an opportunity of examining the gravid uterus post mor- tem should occur at this time, it will be found to have the form of a sphere flattened somewhat posteriorly, and bulging anteriorly. After the ascent of the organ into the abdomen, it develops more in the vertical direction, so that at term it has the form of an ovoid, with its large extremity above and its narrow end at the cervix uteri, and its longitudinal axis corresponds to the long diameter of the mother's abdomen, provided the presentation be either of the head or breech. The anterior surface is now even more distinctly pro- jecting than before — a fact which is explained b^v the proximity of the posterior surface to the rigid spinal column behind, while the anterior is in relation with the lax abdominal parietes, which yield readily to pressure, and so allow of the more marked prominence of the anterior uterine wall. Change in Situation. — Before the gravid uterus has risen out of the pelvis no appreciable increase in the size of the abdomen is percep- tible. On the contrary, it is an old observation that at this early stage of pregnancy the abdomen is flatter than usual, on account of the partial descent of the uterus in the pelvic- cavity as a result of its increased weight. As the growth of the organ advances it soon be- comes too large to be contained any longer within the pelvis, and about the middle of the third or the beginning of the fourth month the fundus rises above the pelvic brim ■ — not suddenly, as is often errone- ously thought, but slowly and gradu- ally — when it may be felt as a smooth rounded swelling. Size at various Periods of Prey- nancy. — It is about this time that the movements of the foetus first become appreciable to the mother, when " quickeninc/" is said to have taken place. Towards the end of the fourth month the uterus reaches to about three fingers' breadth above the symphysis pubis. About the fifth month it occupies the hypo- gastric region, to which it imparts a marked projection, and the altera- tion in the figure is now distinctly perceptible to visual examination. About the sixth month it is on a level with, or a little above, the um- bilicus. About the seventh month it is about two inches above the umbilicus, which is now projecting and prominent, instead of de- pressed, as in the non-pregnant state. During the eighth and ninth months it continues to increase until the summit of the fundus is immediately below the ensiform cartilage (Fig. 69). A knowledge Size of Uterus at various Periods of Pregnancy. PREGNANCY. 127 of the size of the uterine tumor at various periods of pregnancy, as thus indicated, is of considerable practical importance, as forming the only guide by which we can estimate the probable period of delivery in certain cases in which the usual data for calculation are absent, as, for example, when the patient has conceived during lacta- tion. The Uterus Sinks before Delivery. — For about a week or more before labor the uterus generally sinks somewhat into the pelvic cavity, in consequence of the relaxation of the soft parts which pre- cedes delivery, and the patient now feels herself smaller and lighter than before. This change is familiar to all child-bearing women, to whom it is known as kk the lio-htenins; before labor." The Direction of the Uterus. — While the uterus remains in the pelvis its longitudinal axis varies in direction, much in the same way as that of the non-pregnant uterus, sometimes being more or less vertical, at others in a state of anteversion or partial retroversion. These variations are probably dependent on the distension or empti- ness of the bladder, as its state must necessarily affect the position of the movable organ poised behind it. After the uterus has risen into the abdomen its tendency is to project forwards against the ab- dominal wall, which forms its chief support in front. In the erect position the long axis of the uterine tumor corresponds with the axis of the pelvic brim, forming an angle of about 30° with the horizon. In the semi-recumbent position, on the other hand, as Duncan 1 has pointed out, its direction becomes much more nearly vertical. In women who have borne many children, the abdominal parietes no longer afford an efficient support, and the uterus is displaced ante- riorly, the fundus in extreme cases even hanging downwards. Lateral Obliquity of the Uterus. — In addition to this anterior ob- liquity, on account of the projection of the spinal column, the uterus is very generally also displaced laterally, and sometimes to a very marked degree, so that it may be felt entirely in one flank, instead of in the centre of the abdomen. In a large proportion of cases this lateral deviation is to the right side, and many hypotheses have been brought forward to explain this fact, none of them being satis- factory. Thus, it has been supposed to depend on the greater fre- quency with which women lie on their right side during sleep, ^n the greater use of the right leg during walking, on the supposed com- parative shortness of the right round ligament, which drags the tumor to that side, or on the frequent distension of the rectum on the left side, which prevents the uterus being displaced in that direction. Of these the last is the cause which seems most constantly in opera- tion, and most likely to produce the effect, Changes in the Direction of the Cervix. — The cervix must obviously adapt itself to the situation of the body of the uterus. We find, therefore, that in the early months, when the uterus lies low in the pelvis, it is more readily within reach. After the ascent of the uterus, it is drawn up, and frequently so much so as to be reached 1 Researches in Obstetrics, p. 10. 128 PREGNANCY. with difficulty. When the uterus is much ante verted, as is so often the case, the os is displaced backwards, so that it cannot be felt at all by the examining ringer. Relation of the Uterus to the Surrounding Parts. — Towards the end of pregnancy the greater part of the anterior surface of the uterus is in contact with the abdominal wall, its lower portion resting on the posterior surface of the symphysis pubis. The posterior surface rests on the spinal column, while the small intestines are pushed to either side, the large intestines surrounding the uterus like an arch. Changes in the Uterine Parietes.- — -The great distension of the uterus during pregnancy was formerly supposed to be mainly clue to the mechanical pressure of the enlarging ovum within it. If this were so, then the uterine walls would be necessarily much thinner than in the non-pregnant state. This is well known not to be the case, and the immense increase in the size of the uterine cavity is to be ex- plained by the hypertrophy of its Avails. At the full period of preg- nancy the thickness of the uterine parietes is generally about the same as that of the non-pregnant uterus, rather more at the placental site, and less in the neighborhood of the cervix. Their thickness, however, varies in different cases, and in some women they are so thin as to admit of the foetal limbs being \ery readily made out by palpation. Their density is, however, always much diminished, and, instead of being hard and inelastic, they become soft and yielding to pressure. This change coincides with the commencement of preg- nancy, of which it forms, as recognizable in the cervix, one of the earliest diagnostic marks. At a more advanced period it is of value as admitting a certain amount of yielding of the uterine walls to movements of the foetus, thus lessening the chance of their being injured. Changes in the Cervix during .Pregnancy. — Very erroneous views have long been taught, in most of our standard works on midwifery, as to the changes which occur in the cervix uteri during pregnancy. It is generally stated that, as pregnancy advances, the cervical cavity is greatly diminished in length, in consequence of its being gradually drawn up so as to form part of the general cavity of the uterus, so that in the latter months it no longer exists. In almost all midwifery works accurate diagrams are given of this progressive shortening of the cervix (Figs. 70 to 73). The cervix is generally described as having lost one-half of its length at the sixth month, two-thirds at the seventh, and to be entirely obliterated in the eighth and ninth. The correctness of these views was first called in question in recent times by Stoltz, in 1826, but Dr. Duncan, 1 in an elaborate historical paper on the subject, has shown that Stoltz was anticipated by Weit- brech in 1750, and, to a less degree, by Eoederer and other writers. This opinion is now pretty generally admitted to be correct, and is upheld by Cazeaux, Arthur Farre, Duncan, and most modern obstet- ricians. Indeed, various postmortem examinations in advanced pregnancy have shown that the cavity of the cervix remains in 1 Resecarches in Obstetrics. PREGNANCY. 129 reality of its normal length of one inch, and it can often be measured during life by the examining finger, on account of its patulous state Figs. 70, 71, 72, 73. Supposed Shortening of the Cervix at the Third, Sixth, Eighth, and .Ninth Months of Pregnancy, as Figured in Obstetric Works. (Fig. 74). During the fortnight immediately preceding delivery, however, a real shortening or obliteration of the cervical cavity takes Fig. 74. Cervix from a Woman Dying in the Eighth Month of Pregnancy. (After Duncan.) place; but this, as Duncan has pointed out, seems to be due to the incipient uterine contractions, which prepare the cervix for labor. 130 PREGNANCY. Apparent Shortening. — There is, no doubt, an apparent shortening of the cervix always to be detected during pregnancy, but this is a fallacious and deceptive feeling, due to the softness of the tissue of the cervix, which is exceedingly characteristic of pregnancy, and which to an experienced finger affords one of its best diagnostic marks. Shortening of the Cervix. — In the non-pregnant state the tissue of the cervix is hard, firm, and inelastic. When conception occurs, softening begins at the external os, and proceeds gradually and slowly upwards until it involves the whole of the cervix. By the end of the fourth month both lips of the os are thick, softened, and velvety to the touch, giving a sensation, likened by Cazeaux to that produced by pressing on a table through a thick, soft cover. By the , sixth month at least one-half of the cervix is thus altered, and by the eighth the whole of it, and so much so that at this time those unac- customed to vaginal examination experience some difficulty in dis- tinguishing it from the vaginal walls. It is this softening, then, which gives rise to the apparent shortening of the cervix so gene- rally described, and it is an invariable concomitant of pregnancy except in some rare cases in which there has been antecedent morbid induration and hypertrophic elongation of the cervix. If, -therefore, on examining a woman supposed to be advanced in pregnancy, we find the cervix to be hard and projecting into the vaginal canal, we may safely conclude that pregnancy does not exist. The existence of softening, however, it must be remembered, will not of itself justify an opposite conclusion, as it may be produced, to a very con- siderable extent, by various pathological conditions of the uterus. The Os Uteri is generally Patulous. — At the same time that the tissue of the cervix is softened, its cavity is widened, and the external os becomes patulous. This change varies considerably in primiparse and multiparse. In the former the external os often remains closed until the end of pregnancy ; but even in them it generally becomes more or less patulous after the seventh month, and admits the tip of the examining ringer. In women who have borne children this change is much more marked. The lips of the external os are in them generally fissured and irregular, from slight lacerations of its tissue in former labors. It is also sufficiently open to admit the tip of the finger, so that in the latter months of pregnancy it is often quite possible to touch the membranes, and through them to feel the presenting part of the child. Changes in the Texture of the Uterine Tissues.- — The remarkable increase in size of the uterus during pregnancy is, as we have seen, chiefly to be explained by the growth of its structures, all of which are modified during gestation. The peritoneal covering is consider- ably increased, so as still to form a complete covering to the uterus when at its largest size. William Hunter supposed that its extension was affected rather by the unfolding of the layers of the broad liga- ment, than by growth. That the layers of the broad ligament do unfold during gestation, especially in the early months, is probable ; but this is not sufficient to account for the complete investment of PREGNANCY. 131 the uterus, and it is certain that the peritoneum grows pari passu with the enlargement of the uterus. In addition there is a new for- mation of fibrous tissue between the peritoneal and the muscular coats, which affords strength, and diminishes the risk of laceration during labor. Muscular Coat. — The hypertrophy of the muscular tissue of the uterus is, however, the most remarkable of the changes produced by pregnancy. Not only do the previously-existing rudimentary fibre- cells become enormously increased in size — so as to measure, accord- ing to Kolliker, from seven to eleven times their former length, and from two to live times their former breadth — but new unstriped fibres are largely developed, especially in the inner layers. These new cells are chiefly found in the first months of pregnancy, and their growth seems to be completed by the sixth month. The con- nective tissue between the muscular layers is also largely increased in amount. The weight of the muscular tissue of the gravid uterus is, therefore, much increased, and ft has been estimated by Heschl that it weighs at term from 1 to 1.5 lbs., that is, about sixteen times more than in the unimpregnated state. This great development of the muscular tissue admits of its dissection in a way which is quite impossible in the unimpregnated state, and the recent researches of Helie (p. 53) enable us to understand much better than before how the muscles forming the walls of the gravid uterus act during the expulsion of the child./ The changes in the mucous coat of the uterus, which result in the formation of the decidua, have already been discussed at length else- where (p. 91). Circulatory Apparatus. — The circulatory apparatus of the uterus during pregnane}' has been described when the anatomy of the pla- centa was under consideration (p. 105). Lymphatics. — The lymphatics are much increased in size : and re- cent theories on the production of certain puerperal diseases attribute to them a more important action than has been commonly assigned to them. Nerves. — The question of the growth of the nerves has been hotly discussed. Eobert Lee took the foremost place among those who maintain that the nerves of the uterus share the general growth of its other constituent parts. Dr. Snow Beck, however, believed that they remain of the same size as in the unimpregnated state, and this view is supported by Hirchfeld, Eobin,' and other recent writers. Eobin thought that there was an apparent increase in the size of the nerve- tubes, which, however, is really due to increase in the neuri- lemma, Kilian describes the nerves as increasing in length but not in thickness ; while Schroeder states that they participate equally with the lymphatics in the enlargement the latter undergo. TV hich- ever of these views may ultimately be found to be correct, it is cer- tain that analogy would lead us to expect an increase of nervous, as well as of vascular supply. General Modification in the Body produced hy Pregnancy. — It is not in the uterus alone that pregnancy is found to produce modifications 132 PREGNANCY. of importance. There are few of the more important functions of the body which are not, to a greater or less extent, affected ; to some of these it is necessary briefly to direct attention, inasmuch as, when carried to excess, they produce those disorders which often compli- cate gestation, and which prove so distressing and even dangerous to the patients. Such of them as are apparent and may aid us in diagnosis are discussed in the chapter which treats of the signs and symptoms of pregnancy ; in this place it is only necessary to refer to those which do not properly fall into that category. Changes in the Blood. — Amongst those which are most constant and important are the alterations in the composition of the blood. The opinion of the profession on this subject has, of late years, under- gone a remarkable change. Formerly in was universally believed that pregnancy was, as the rule, associated with a condition analogous to plethora, and that this explained many characteristic phenomena of common occurrence, such as headache, palpitation, singing in the ears, shortness of breath, and the like. As a consequence it was the habitual custom, not }-et by any means entirely abandoned, to treat pregnant women on an antiphlogistic system ; to place them on low diet, to administer lowering remedies, and very often to practise venesection, sometimes to a surprising extent. Thus it was by no means rare for women to be bled six or eight times during the latter months, even when no definite symptoms of disease existed ; and many of the older authors record cases where depletion was practised every fortnight, as a matter of routine, and, when the symptoms were well marked, even from fifty to ninety times in the course of a single pregnancy. Composition of the Blood in Pregnancy. — Numerous careful analyses have conclusively proved that the composition of the blood during pregnancy is very generally — perhaps it would not be too much to say always — profoundly altered. Thus it is found to be more watery, its serum is deficient in albumen, and the amount of colored globules is materially diminished, averaging, according to the analyses of Becquerel and Eoclier, 111.8 against 127.2 in the non-gravid state. At the same time the amount of fibrine and of extractive matter is considerably increased. The latter observation is of peculiar im- portance as it goes far to explain the frequency of certain thrombotic affections, observed in connection with pregnancy and delivery ; this hyperinosis of the blood is also considerably increased after labor by the quantity of effete material thrown into the mother's system at that time, to be got rid of by her emunctories. The truth is, that the blood of the pregnant woman is generally in a state much more nearly approaching the condition of amemia than of plethora, and it is certain that most of the phenomena attributed to plethora may be explained equally well and better on this view. These changes are much more strongly marked at the latter end of pregnancy than at its commencement, and it is interesting to observe that it is then that the concomitant phenomena alluded to are most frequently met with. Cazeaux, to whom we are chiefly indebted for insisting on the practical bearing of these views, contends that the pregnant state is PREGNANCY. 138 essentially analogous to chlorosis, and that it should be so treated. Objection has not unnaturally been taken to this theory, as implying that a healthy and normal function is associated with a morbid state, and it has been suggested that this deteriorated state of the blood may be a wise provision of nature instituted for a purpose we are not as yet able to understand. It may certainly be admitted that preg- nancy, in a perfectly healthy state of the system, should not be associated with phenomena in themselves in any degree morbid. It must not be forgotten, however, that our patients are seldom, we might safely say never, in a state that is physiologically healthy. The influence of civilization, climate, occupation, diet, and a thousand other disturbing causes that, to a greater or less degree, are always to be met with, must not be left out of consideration. Making every allowance, therefore, for the undoubted fact that pregnancy ought to be a perfectly healthy condition, it must be conceded, I think, that in the vast majority of cases coming under our notice it is not entirely so; and the deductions drawn by Cazeaux, from the numerous analyses of the blood of pregnant women, seem to point strongly to the conclusion that the general blood-state is one of poverty and ansemia, and that a depressing and antiphlogistic treatment is dis- tinctly contra-indicated. Modification in certain Viscera. — Closely connected with the al- tered condition of the blood is the physiological hypertrophy of the heart, which is now well known to occur during pregnancy. This was first pointed out by Lurcher in 1828, and it has been since veri- fied by numerous observers. It seems to be "constant and considera- ble, and to be a purely physiological alteration intended to meet the increased exigencies of the circulation, which the complex vascular arrangements of the gravid uterus produce. The hypertrophy is limited to the left ventricle ; the right ventricle, as well as both au- ricles, being unaffected. Blot estimates that the whole weight of the heart increases one-fifth during gestation. The more recent re- searches of Lohlein 1 render it probable that the hypertrophy is less than those authors have supposed. According to Duroziez 2 the heart remains enlarged during lactation, but diminishes in size immediately after delivery in women who do not suckle, while in women who have borne many children it remains permanently somewhat larger than in nulliparae. Similar increase in the size of other organs has been pointed out by various writers, as, for example, in the lym- phatics, the spleen, and the liver. Tarnier states that in women who have died after delivery, the organs always show signs of fatty de- generation. According to Gassner the whole body increases in weight during the latter months of pregnancy, and this increase is somewhat beyond that which can be explained by the size of the womb and its contents. Formation of Osteophytes. — Irregular bony deposits between the skull and the dura mater, in some cases so largely developed as to line the whole cranium, have been so frequently detected in women i Zeitschrift fur Geburtshulfe, etc., 1876. 2 Gaz. des Hopit. 1868. 134 PREGNANCY. who have died during parturition, that they are believed by some to be a normal production connected with pregnancy. Ducrest found these osteophytes in more than one-third of the cases in which he performed post-mortem examinations during the puerperal period. Rokitansky, who corroborated the observation, believed this peculiar deposit of bony matter to be a physiological, and not a pathological condition connected with pregnancy ; but whether it be so, or how it is produced, has not yet been satisfactorily determined. Changes in the Nervous System.— More or less marked changes con- nected with the nervous system are generally observed in pregnancy, and sometimes to a very great extent. When carried to excess they produce some of the most troublesome disorders which complica f e gestation, such as alterations in the intellectual functions, changes in the disposition and character, morbid cravings, dizziness, neuralgia, syncope, and many others. They are purely functional in their char- acter, and disappear rapidly after delivery, and may be best de- scribed in connection with the disorders of pregnancy. Changes in the Respiratory Organs. — Respiration is often inter- fered with, from the mechanical results of the pressure of the en- larged uterus. The longitudinal dimensions of the thorax are lessened by the upward displacement of the diaphragm, and this necessarily leads to some embarrassment of the respiration, which is, however, compensated, to a great extent, by an increase in breadth of the base of the thoracic cavity. Changes in the Urine. — Certain changes, which are of very con- stant occurrence, in the urine of pregnant women have attracted much attention, and have been considered by many writers to be pathognomonic. They consist in the presence of a peculiar deposit, formed when the urine has been allowed to stand for some time, which has received the name of hiestein. Its presence was known to the ancients, and it was particularly mentioned by Savonarola in the fifteenth century, but it has more especially been studied within the last thirty years by Eguisier, Golding Bird, and others. If the urine of a pregnant woman be allowed to stand in a cylindrical ves- sel, exposed to light and air, but protected from dust, in a period, varying from two to seven days, a peculiar flocculent sediment, like fine cotton-wool, makes its appearance in the centre of the fluid, and soon afterwards rises to the surface and forms a pellicle, which has been compared to the fat on cold mutton-broth. In the course of a few days the scum breaks up and falls to the bottom of the vessels. On microscopic examination it is found to be composed of fat parti- cles, with crystals of ammoniaco-magnesium phosphatesand phosphate of lime, and a large quantity of vibriones. These appearances are generally to be detected after the second month of pregnancy, and up to the seventh or eighth month, after which they are rarely pro- duced. Regnauld explains their absence during the latter months of gestation by the presence in the urine, at that time, of free lactic acid, which increases its acidity, and prevents the decomposition of the urea into carbonate of ammonia. He believes that kiestein is produced by the action of free carbonate of ammonia on the phos- SIGNS AND SYMPTOMS OF PREGNANCY. 135 phate of lime contained in the urine, and that this reaction is pre- vented by the excess of acid. Golding Bird believed kiestein to be analogous to casein, to the presence of which he referred it, and he states that he has found it in twenty-seven out of thirty cases. Braxton Hicks so far corrobo- rates his view, and states that the deposit of kiestein can be much more abundantly produced if one or two teaspoonfnls of rennet be added to the urine, since that substance has the property of coagu- lating casein. Much less importance, however, is now attached to the presence of kiestein than formerly, since a precisely similar sub- stance is sometimes found in the urine of the non-pregnant, especially in anaemic women, and even in the urine of men. Parkes states that it is not of uniform composition, that it is produced by the decompo- sition of urea, and consists of the free phosphates, bladder mucus, infusoria, and vaginal discharges. Neugebauer and Vogel give a similar account of it, and hold that it is of no diagnostic value. That it is of interest, as indicating the changes going on in connection with pregnancy, is certain ; but inasmuch as it is not of invariable occur- rence, and may even exist quite independently of gestation, it is obviously quite undeserving of the extreme importance that has been attached to it. [Although not a reliable test of pregnancy, it is a remarkable fact, that in all the cases of suspected impregnation in private practice in which I have employed it, I never found a woman pregnant who had not shown it in her urine. — Ed.] CHAPTER IV. SIGNS AND SYMPTOMS OF PREGNANCY r . Importance of the Subject. — In attempting to ascertain the presence or absence of pregnancy, the practitioner has before him a problem which is often beset with great difficulties, and on the proper solution of which, the moral character of his patient, as well as his own pro- fessional reputation, may depend. The patient and her friends can hardly be expected to appreciate the fact, that it is often far from easy to give a positive opinion on the point; and it is always advis- able to use much caution in the examination, and not to commit ourselves to a positive opinion, except on the most certain grounds. This is all the more important, because it is just in those cases in which our opinion is most frequently asked, that the statements of the patient are of least value, as she is either anxious to conceal the existence of pregnancy, or, if desirous o( an affirmative diagnosis, 136 PREGNANCY. unconscious] j colors her statements, so as to bias the judgment of the examiner. Constant attempts have been made to classify the signs of preg- nancy; thus some divide them into the natural and sensible signs, others into the presumptive, the probable, and the certain. The latter classification, which is that adopted by Montgomery in his classical work on the "Signs and Symptoms of Pregnancy," is no doubt the better of the two, if any be required. The simplest way of studying the subject, however, is the one, now generally adopted, of considering the signs of pregnancy in the order in which they occur, and attaching to each an estimate of its diagnostic value. Signs of a fruitful Conception. — From the earliest ages authors have thought that the occurrence of conception might be ascertained by certain obscure signs, such as a peculiar appearance of the ej'es, swelling of the neck, or by unusual sensations connected with a fruitful intercourse. All of these, it need hardly be said, are far too uncertain to be of the slightest value. The last is a symptom on which many married women profess themselves able to depend, and one to Avhich Cazeaux is inclined to attach some importance. Cessation of Menstruation. — The first appreciable indication of pregnancy, on which any dependence can be placed, is the cessation of the customary menstrual discharge, and it is of great importance, as forming the only reliable guide for calculating the probable period of delivery. In women who have been previously perfectly regular, in whom there is no morbid cause which is likely to have produced suppression, the non-appearance of the catamenia may be taken as strong presumptive evidence of the existence of pregnancy ; but it can never be more than this, unless verified and strengthened by other signs, inasmuch as there are many conditions besides pregnancy which may lead to its non-appearance. Thus exposure to cold, mental emotion, general debility, especially when connected with incipient phthisis, may all have this effect. Mental impressions are peculiarly liable to mislead in this respect. It is far from uncommon in newly-married women to find that menstruation ceases for one or more periods, either from the general disturbance of the system con- nected with the married life, or from a desire on the part of the patient to find herself pregnant. Also in unmarried women, who have subjected themselves to the risk of impregnation, mental emo- tion and alarm often produce the same result. Menstruation during Pregnancy. — A' further source of uncertainty exists in the fact, that in certain cases menstruation may go on for one or more periods after conception, or even during the whole pregnancy. The latter occurrence is certainly of extreme rarity, but one or two instances are recorded by Perfect, Churchill, and other writers of authority, and therefore its possibility must be admitted, The former is much less uncommon, and instances of it have probably come under the observation of most practitioners. The explanation is now well understood. During the early months of gestation, when the ovum is'not yet sufficiently advanced in growth to fill the whole uterine cavity, there is a considerable space between SIGNS AND SYMPTOMS OF PREGNANCY. 137 the decidua reflexa which surrounds it, and the decidua vera lining the uterine cavity. It is from this free surface of the decidua vera that the periodical discharge comes, and there is not only ample surface for it to come from, but a free channel for its escape through the os uteri. After the third month the decidua reflexa and the decidua vera blend together, and the space between them disappears. Menstruation after this time is, therefore, much more difficult to •account for. It is probable that, in many supposed cases, occasional losses of blood from other sources, such as placenta prsevia, an abraded cervix uteri, or a small polypus, have been mistaken for true men- struation. If the discharge really occurs periodically after the third month, it can only come from the canal of the cervix. The occurrence, however, is so rare, that if a woman is menstruating regularly and normally, who believes herself to be more than four months advanced in pregnancy, we are justified ipso facto in negativing her supposition. In an unmarried woman all statements as to regularity of menstrua- tion are absolutely valueless, for, in such cases, nothing is more common than for the patient to make false statements for the express purpose of deception. Pregnancy tulien Menstruation is Normally Absent. — Conception may unquestionably occur when menstruation is normally absent. This is far from uncommon in women during lactation, when the function is in abeyance, and who therefore have no reliable data for calculating the true period of their delivery. Authentic cases are also recorded in which young girls have conceived before menstrua- tion is established, and in which pregnancy has occurred after the change of life. Estimate of its Diagnostic Value. — Taking all these facts into ac- count, we can only look upon the cessation of menstruation as a fairly presumptive sign of pregnancy in women in whom there is no clear reason to account for it, but one which is undoubtedly of great value in assisting our diagnosis. Sympathetic Disturbances. — Shortly after conception various sym- pathetic disturbances of the system occur, and it is only very excep- tionally that these are not established. They are generally most developed in women of highly nervous temperament ; and they are, therefore, most marked in patients in the upper classes of society, in whom this class of organization is most common. Morning Sickness. — -Amongst the most frequent of these are various disorders of the gastro-intestinal canal. Nausea or vomiting is very common; and as it is generally felt on first rising from the recum- bent position, it is popularly known amongst women as the " morn- ing sickness." It sometimes commences almost immediately after conception, but more frequently not until the second month, and it rarely lasts after the fourth month. Generally there is nausea rather than actual vomiting. The woman feels sick and unable to eat her breakfast, and often brings up some glairy fluid. In other cases, she actually vomits ; and sometimes the sickness is so excessive as to resist all treatment, seriously to affecfrihe patient's health, and even 138 PREGNANCY. imperil lier life. These grave forms of the affection will require separate consideration. Cause of the Sickness. — Very different opinions have been held as to the cause of morning sickness. Dr. Henry Bennet believes that, when at all severe, it is always associated with congestion and inflam- mation of the cervix uteri. Dr. Graily Hewitt maintains that it de- pends entirely on flexion of the uterus, producing irritation of the uterine nerves at the seat of the flexion, and consequent sympathetic vomiting. This theory, when broached at the Obstetrical Society, was received with little favor ; it seems to me to be sufficiently dis- proved by the fact, which I believe to be certain, that more or less nausea is a normal and nearly constant phenomenon in pregnancy, for it is difficult to believe that nearly every pregnant woman has a flexed uterus. The generally received explanation i's, probably, the correct one, viz., that nausea, as well as other forms of sympathetic disturbance, depends on the stretching of the uterine fibres by the growing ovum, and consequent irritation of the uterine nerves. It is, therefore, one, and only one, of the numerous reflex phenomena naturally accompanying pregnancy. It is an old observation that when the sickness of pregnancy is entirely absent, other, and gene- rally more distressing, sympathetic derangements are often met with, such as a tendency to syncope. Dr. Eedford 1 has laid especial stress on this point, and maintains that under such circumstances women are peculiarly apt to miscarry. Other derangements of the digestive functions, depending on the same cause, are not uncommon, such as excessive or depraved appe- tite, the patient showing a craving for strange and even disgusting articles of diet. These cravings may be altogether irresistible, and are popularly known as "longings." Of a similar character is the disturbed condition of the bowels frequently observed, leading to constipation, diarrhoea, and excessive flatulence. Other Sympathetic Phenomena. — Certain glandular sympathies may be developed, one of the most common being an excessive secretion from the salivary glands. A tendency to syncope is not infrequent, rarely proceeding to actual fainting, but rather to that sort of partial syncope, unattended with complete loss of consciousness, which the older authors used to call "lypothemia." This often occurs in women who show no such tendency at other times, and, when developed to any extent, it forms a very distressing accompaniment of pregnancy. Toothache is common, and is not rarely associated with actual caries of the teeth. When any of these phenomena are carried to excess it is more than probable that some morbid condition of the uterus exists, which increases the local irritation producing them. Mental Peculiarities.— Mental phenomena are very general. An undue degree of despondency, utterly beyond the patient's control, is far from uncommon ; or a change which renders the bright and good-tempered woman fractious and irritable ; or even the more for- tunate, but less common change, by which a disagreeable disposition becomes altered for the better. 1 Diseases of Women and Children, p. 551. SIGNS AND SYMPTOMS OF PREGNANCY. 139 Diagnostic Value. — All these phenomena of exalted nervous suscep- tibility are but of slight diagnostic value. They may be taken as corroborating more certain signs, but nothing more ; and they are chiefly interesting from their tendency to be carried to excess and to produce serious disorders. Mammary Changes. — Certain changes in the mammas are of early occurrence, dependent, no doubt, on the intimate sympathetic rela- tions at all times existing between them and the uterine organs, but chiefly required for the purpose of preparing for the important func- tion of lactation, which, on the termination of pregnancy, they have to perform. Changes in the Areolae. — Generally about the second month of preg- nancy the breasts become increased in size and tender. As preg- nancy advances the}' become much larger and firmer, and blue veins may be seen coursing over them. The most characteristic changes are about the nipples and areohe. The nipples become turgid, and are frequently covered with minute branny scales, formed by the desiccation of sero-lactescent fluid oozing from them. The areohe be- come greatly enlarged and darkened from the deposit of pigment (Fig. 75). The extent and degree of this discoloration vary much in Fig. 75. y Appearance of the Areola ia Pres-n ancy. different women. In fair women it may be so slight as to be hardly appreciable; while in dark women it is generally exceedingly charac- teristic, sometimes forming a nearly bTack circle extending over a great part of the breast. The areola becomes moist as well as dark in appearance and is somewhat swollen, and a number of small tuber- cles are developed upon it, forming a circle of projections around the nipple. These tubercles are described by Montgomery as being inti- 140 PREGNANCY. mately connected with the lactiferous ducts, some of which may oc- casionally be traced into them and seem to open on their summits. As pregnancy advances they increase in size and number. During the latter months what has been called " the secondary areola" is produced, and when well marked presents a very characteristic ap- pearance. It consists of a number of minute discolored spots all round the outer margin of the areola where the pigmentation is fainter, and which are generally described as resembling spots from which the color had been discharged by a shower of water-drops. This change, like the darkening of the primary areola, is most marked in brunettes. At this period, especially in women whose skin is of fine texture, whitish silvery streaks are often seen on the breasts. They are produced by the stretching of the cutis vera, and are per- manent. By pressure on the breasts a small drop of serous-looking fluid can very generally be pressed out from the nipple often as early as the third month, and on microscopic examination milk and cholos- trum globules can be seen in it. Diagnostic Value of Mammary Changes. — The diagnostic value of these mammary changes has been variously estimated. When well marked they are considered by Montgomery to be certain signs of pregnancy. To this statement, however, some important limitations must be made. In women who have never borne children they, no doubt, are so ; for, although various uterine and ovarian diseases produce some darkening of the areola, they certainly never produce the well-marked changes above described. In multiparas, however, the areolae often remain permanently darkened, and in them these signs are much less reliable. In first pregnancies the presence of milk in the breasts may be considered an almost certain sign, and it is one which I have rarely failed to detect even from a comparatively early period. It is true that there are authenticated instances of non-pregnant women having an abundant secretion of milk estab- lished from mammary irritation. Thus Bauclelocque presented to the Academy of Surgery of Paris a young girl, eight years of age, who had nursed her little brother for more than a month. Dr. Tan- ner states — I do not know on what authority — that " it is not uncom- mon in Western Africa for young girls who have never been preg- nant to regularly employ themselves in nursing the children of others, the mammas being excited to action by the application of the juice of one of the euphorbiaceas." Lacteal secretion has even been noticed in the male breast. But these exceptions to the general rule are so uncommon as merely to deserve mention as curiosities ; and I have almost never been deceived in diagnosing a first pregnancy from the presence of even the minutest quantity of lacteal secretion in the breasts, although even then other corroborative signs should always be sought for. In multiparas the presence of milk is by no means so valuable, for it is common for milk to remain in the mammas long after the cessation of lactation, even for several years. Tyler Smith correctly says that " suppression of the milk in persons who are nursing and liable to impregnation is a more valuable sign of preg- SIGNS AND SYMPTOMS OF PREGNANCY. 141 nancy than the converse condition." This is an observation I have frequently corroborated. As a diagnostic sign, therefore, the mammary appearances are of great importance in primiparae, and when well marked they are sel- dom likely to deceive. They are specially important when we sus- pect pregnancy in the unmarried, as we can easily make an excuse to look at the" breast without explaining to the patient the reason ; and a single glance, especially if the patient be dark-complexioned, may so far strengthen our suspicion as to justify a more thorough examination. In married multiparas they are less to be depended upon. Other Pigmentary Changes. — In connection with this subject may be mentioned various irregular deposits of pigment which are fre- quently observed. The most common is a dark-brownish or yellow- ish line starting from the pubes and running up to the centre of the abdomen, sometimes as far as the umbilicus only, at others forming an irregular ring round the umbilicus, and reaching to the epigas- trium. [It is well marked in pregnant women of the African race, even in those of quite a dark shade of skin. This line is narrower as a rule, than in the white, but darker. — Ed.] It is, however, of very uncertain occurrence, being well marked in some women, while in others it is entirely absent. Patches of darkened skin are often observed about the face, chiefly on the forehead, and this bronzing sometimes gives a very peculiar appearance. Joulin states that it only occurs on parts of the face exposed to the sun, and that it is therefore most frequently observed in women of the lower order who are freely exposed to atmospheric influences. These pigmentary changes are of small diagnostic value, and may continue for a con- siderable time after delivery. Enlargement of the Abdomen. — The progressive enlargement of the abdomen, and the size of the gravid uterus at various periods of pregnancy, as well as the method of examination by means of ab- dominal palpation, have already been described (pp. 116 and 126). We will now consider the well-known phenomena produced by the movements of the foetus in utero, which are so familiar to all pregnant women. These, no doubt, take place from the earliest period of foetal life at which the muscular tissue of the foetus is suffi- ciently developed to admit of contraction, but they are not felt by the mother until somewhere about the sixteenth week of utero-ges- tation, the precise period at which they are perceived varying con- siderably in different cases. The error of the law on this subject, which supposes the child not to be alive, or "quick," until the mother feels its movements, is well known, and has frequently been protested against by the medical profession. The so-called quickening — which certainly is felt very suddenly by some women — is believed to depend on the rising of the uterine tumor sufficiently high to permit of the impulse of the foetus being transmitted to the abdominal walls of the mother, through the sensory nerves of which its movements become appreciable. The sensation is generally described as being a feeble fluttering, which, when first felt, not unfrequently causes unpleasant 142 PKEGNANCY. nervous sensations. As the uterus enlarges, the movements become more and more distinct, and generally consist of a series of sharp blows or kicks, sometimes quite appreciable to the naked eye, and causing distinct projections of the abdominal walls. Their force and frequency will also vary during pregnancy according to circum- stances. At times they are very frequent and distressing; at others, the foetus seems to be comparatively quiet, and they may even not be felt for several days in succession, and thus unnecessary fears as to the death of the foetus often arise. The state of the mother's health has an undoubted influence upon them. They are said to increase in force after a prolonged abstinence from food, or in certain positions of the body. It is certain that causes interfering with the vitality of the foetus often produce very irregular and tumultuous movements. They can be very readily felt by the accoucheur on palpating the abdomen, and sometimes, in the latter months, so dis- tinctly as to leave no doubt as to the existence of pregnancy. They can also generally be induced by placing one hand on each side of the abdomen and applying gentle pressure, which will induce foetal motion, that can be easily appreciated. The Diagnostic Value of Foetal Movements.— As a diagnostic sign the existence of foetal movements has always held a high place, but care should be taken in relying on it. It is certain that women are themselves very often in error, and fancy they feel the movements of a foetus when none exists, being probably deceived by irregular contractions of the abdominal muscles, or flatus within the bowels. They may even involuntarily produce such intra-abdominal move- ments as may readily deceive the practitioner. Of course, in advanced pregnancy, when the foetal movements are so marked as to be seen as well as felt, a mistake is hardly possible, and they then constitute a certain sign. But in such cases there is an abundance of other indi- cations and little room for doubt. In questionable cases, and at an earlier period of pregnancy, the fact that movements are not felt must not be taken as a proof of the non-existence of pregnancy, for they may be so feeble as not to be perceptible, or they may be absent for a considerable period. Intermittent Uterine Contractions. — Braxton Hicks 1 has directed attention to the value, from a diagnostic point of view, of intermittent contractions of the uterus during pregnancy. After the uterus is sufficiently large to be felt by palpation, if the hand be placed over it, and be grasped for a time without using any friction or pressure, it will be observed to distinctly harden in a manner that is quite characteristic. This intermittent contraction occurs every five or ten minutes, sometimes oftener, rarely at longer intervals. The fact that the uterus did contract in this way had been previously described, more especially by Tyler Smith, who ascribed it to peristaltic action. But it is certain that no one, before Dr. Hicks, had pointed out the fact that such contractions were constant and normal concomitants of pregnancy, continuing during the whole period of utero-gestation, i Obst. Trans, v. 13. SIGNS AND SYMPTOMS OF PREGNANCY. 143 and forming a ready and reliable means of distinguishing the uterine tumor from other abdominal enlargements. Since reading Dr. Hicks's paper I have paid considerable attention to this sign, which I have never failed to detect, even in the retroverted gravid uterus contained entirely in the pelvic cavity, and I am disposed entirely to agree with him as to its great value in diagnosis. If the hand be kept steadily on the uterus, its alternate hardening and relaxation can be appreciated with the greatest ease. The advantages which this sign has over the foetal movements are that it is constant, that it is not liable to be simulated by anything else, and that it is independent of the life of the child, being equally appreciable when the uterus con- tains a degenerated ovum or dead foetus. The only condition likely to give rise to error is an enlargement of the uterus in consequence of contents other than the results of conception, such as retained menses, or a polypus. The history of such cases — which are more- over of extreme rarity — would easily prevent any mistake. As a corroborative sign of pregnancy, therefore, I should give these inter- mittent contractions a high place. [I once attended the wife of a physician in her second pregnancy, who had lost her first child by abortion, and was supposed to be again threatened with the same misfortune. I found her suffering pain with each intermittent con- traction, but beyond this, there were no symptoms to indicate an ex- pulsive design on the part of the uterus. These painful intermittent contractions persisted for three weeks, and then gradually assumed their normal character under an opiate treatment. The lady went to the full term of gestation and bore a child which lived. — Ed.] Vaginal Signs of Pregnancy. — The vaginal signs of pregnancy are of considerable importance in diagnosis. They are chiefly the changes which may be detected in the cervix, and the so-called bal- lottement, which depends on the mobility of the foetus in the liquor amnii. Softening of the Cervix. — The alterations in the density and appa- rent length of the cervix have been already described (p. 12S). When pregnancy has advanced beyond the fifth month the peculiar velvety softness of the cervix is very characteristic, and affords a strong corroborative sign, but one which it would be unsafe to rely on by itself, inasmuch as very similar alterations may be produced by various causes. When, however, in a supposed case of preg- nancy advanced beyond the period indicated, the cervix is found to be elongated, dense, and projecting into the vaginal canal, the non- existence of pregnancy may be safely inferred. Therefore the nega- tive value of this sign is of more importance than the positive. Ballottement, when distinctly made out, is a very valuable indica- tion of pregnancy. It consists in the displacement, by the examin- ing finger, of the foetus, which floats up in the liquor amnii, and falls back again on the tip of the finger with a slight tap which is exceedingly characteristic. Method of Examination. — In order to practise it most easily, the patient is placed on a couch or bed in a position midway between sitting and lying, by which the vertical diameter of the uterine 144 PREGNANCY. cavity is brought into correspondence with that of the pelvis. Two fingers of the right hand are then passed high up into the vagina in front of the cervix. The uterus being now steadied from without by the left hand, the intravaginal fingers press the uterine wall suddenly upwards, when, if pregnancy exist, the foetus is displaced, and in a moment falls back again, imparting a distinct impulse to the fingers. When easily appreciable it may be considered as a certain sign, for although an ante- flexed fundus, or a calculus in the bladder, may give rise to somewhat similar sensations, the absence of other indications of pregnancy would readily prevent error. Bal- lottement is practised between the fourth and seventh months. Be- fore the former time the foetus is too small, while at a later period it is relatively too large, and can no longer be easily made to rise upwards in the surrounding liquor amnii. The absence of ballotte- ment must not be taken as proving the non-existence of pregnancy, for it may be inappreciable from a variety of causes, such as abnor- mal presentations, or the implantation of the placenta upon the carvix uteri. Vaginal Pulsation. — There are also some other vaginal signs of pregnancy of secondary consequence. Amongst these is the vaginal pulsation, pointed out by Osiander, resulting from the enlargement of the vaginal arteries, which may sometimes be felt beating at an early period. Often this pulsation is very distinct, at other times it cannot be felt at all, and it is altogether unreliable, as a similar pul- sation may be felt in various uterine diseases. Uterine Fluctuation. — Dr. Easch has drawn attention to a pre- viously undescribed sign which he believes to be of importance in the diagnosis of early pregnancy. 1 It consists in the detection of fluctuation through the anterior uterine wall, depending on the pres- ence of the liquor amnii. In order to make this out, two fingers of the right hand must be used, as in ballottement, while the uterus is steadied through the abdomen. Dr Easch states that by this means the enlarged uterus in pregnancy can easily be distinguished from the enlargement depending on other causes, and that fluctuation can always be felt as early as the second month. If it is associated with suppressed menstruation and darkened areolae, he considers it a cer- tain sign. In order to detect it, however, considerable experience in making vaginal examinations is essential, and it can haidly be depended on for general use. Alteration in Color of the Vagina. — A peculiar deep violet hue of the vaginal mucous membrane was relied on by Jacquemier and Kltige as affording a readily-observed indication of pregnancy. In most cases it is well marked; sometimes, indeed, the change of color is very intense, and it evidently depends on the congestion produced by pressure of the enlarged uterus. The same effect, however, is constantly seen where similar pressure is affected by large fibroid tumors of the uterus, and, therefore, for diagnostic purposes it is valueless. » Drit. Med. Journ., vol. ii. 1873. SIGNS AND SYMPTOMS OF PREGNANCY. 145 Auscultatory Signs of Pregnancy. — By far the most important signs are those which can be detected by abdominal auscultation, and one of these — the hearing of the foetal heart-sounds — forms the only sign which per se, and in the absence of all others, is per- fectly reliable. Discovery of Foetal Auscultation. — The fact that the sounds of the fuetal heart are audible during advanced pregnancy was first pointed out by Mayor of Geneva in 1818, and the main facts in connection with foetal auscultation were subsequently worked out by Kerga- radec, Naegele, Evory Kennedy, and other observers. The pulsations first become audible, as a rule, in the course of the fifth month, or about the middle of the fourth month. In exceptional circumstances, and by practised observers, they have been heard earlier. Depaul believes that he detected them as early as the eleventh week, and Routh has also detected them at an early period by vaginal stetho- scopy, which, however, for obvious reasons, cannot be ordinarily employed. Naegele never heard them before the eighteenth week, more generally at the end of the twentieth, and for practical purposes the pregnancy must be advanced to the fifth month before we can reasonably expect to detect them. From this period up to term they can almost always be heard, if not at the first attempt, at least after- wards, to a certainty, if we have the opportunity of making repeated examinations. Accidental circumstances, such as the presence of an unusual amount of flatus in the intestines, may deaden the sounds for a time, but not permanently. Depaul only failed to hear them in 8 cases out of 906 examined during the last three months of pregnane v ; and out of 180 cases, which Dr. Anderson of Glasgow carefully ex- amined, he only failed in 12, and in each of these the child was still- born. They, therefore, form not only a most certain indication of pregnancy, but of the life of the foetus also. Description of the Sound. — The sound has been always likened to the double tic-tac of a watch heard through a pillow, which it closeiv resembles. It consists of two beats, separated by a short interval, the first being the loudest and most distinct, the second being some- times inaudible. The rapidity of the foetal pulsations forms an important means of distinguishing them from transmitted maternal pulsations, with which they might be confounded. Their a\^erage number is stated by Slater, who made numerous observations on this point, to be 132, but sometimes they reach as high as 110, and some- times as low as 120. It will thus "be seen that the pulsations are always much more rapid than those of the mother's heart, unless, indeed, the latter be unduly accelerated by transient mental emotion or disease. To avoid mistakes, whenever the foetal heart is heard its rate of pulsation should be carefully counted, and compared with that of the mother's pulse; if the rate differ, Ave may be sure that no error has been made. The rapidity of the foetal pulsations, re- mains, as a rule, the same during the whole period of pregnancy, while their intensity gradually increases. They may, however, be temporarily increased or diminished in frequenc}^ by disturbing causes, such as the pressure of the stethoscope, which, exciting 146 PREGNANCY. tumultuous movements of the foetus, may induce greatly-increased frequency of its heart- beats. So also during labor, after the escape of the liquor amnii, when the contractions of the uterus have a very distinct influence on the foetus, they may be greatly modified. An acceleration or irregularity of the pulsations, made out in the course of a prolonged labor, may thus be of great practical importance, by indicating the necessity for prompt interference. Similar alterations, associated with tumultuous and unusual foetal movements felt by the mother towards the end of pregnancy, may point to danger to the life of the foetus during the latter months, and may even justify the induction of premature labor. This is especially the case in women who have previously given birth to a succession of dead children owing to disease of the placenta, and, in them, careful and frequently repeated auscultations may warn us of the impending danger. Supposed difference of Rapidity according to the Sex of the Foetus. — The rapidity of the foetal heart has been supposed by some to afford a means of determining the sex of the child before birth. Franken- hauser, who first directed attention to this point, is of opinion that the average rate of pulsations of the heart is considerably less in male than in female children, averaging 124 in the minute in the former, as against 144 in the latter. Steinbach makes the difference somewhat less, viz., 131 for males, and 138 for females. He pre- dicted the sex correctly by this means in 45 out of 57 cases, while Frankenhauser was correct in the whole 50 cases which he specially examined with reference to the point. Dr. Hutton, of New York, 1 was also correct in 7 cases he fixed on for trial. Devilliers found the difference in the sexes to be the same as Steinbach ; he attributes it, however, to the size and weight, rather than to the sex of the child, and believes the pulsations to be least numerous in large and well-developed children. As male children are usually larger than female, he thus explains the relatively less frequent pulsations of their hearts. Dr. Gumming, of Edinburgh, also believes that the weight of the child has considerable influence on the frequency of its cardiac pulsations, so that a large female child may have a slower pulse than a small male. 2 The point, however is more curious than practical, and the rapidity of the pulsations certainly would not justify any positive prediction on the subject. Circumstances in- fluencing the maternal circulation seem to have no influence on that of the foetus. Site at which the Sounds are heard. — The foetal heart-sounds are generally propagated best by the back of the child, and are, there- fore, most easily audible when this is in contact with the anterior wall of the uterus, as is the case in the large majority of pregnancies. When the child is placed in the dorso-posterior position, the sounds have to traverse a larger amount of the liquor amnii, and are further modified by the interposition of the foetal limbs. They are, there- fore, less easily heard in such cases, but even in them they can almost always be made out. As the foetus most frequently lies with the 1 New York Med. Journ., Julv, 1872. 2 Edin. Med. Journ., 1875. SIGNS AND SYMPTOMS OF PREGNANCY. 147 occiput over the brim of the pelvis, and the back of the child towards the left side of the mother, the heart-sounds are usually most dis- tinctly audible at a point midway between the umbilicus and the left anterior superior spine of the ilium. In the next most common posi- tion, in which the back of the child lies to the right lumbar region of the mother, they are generally heard at a corresponding point at the right side, but in this case they are frequently more readily made out in the right flank, being then transmitted through the thorax of the child, which is in contact with the side of the uterus. In breech cases, on the other hand, the heart-sounds are generally heard most distinctly above the umbilicus, and either to the right or left, accord- ing to the side towards which the back of the child is placed. It' will thus be seen that the place at which the foetal heart-sounds are heard varies with the position of the foetus ; and this, when combined with the information derived from palpation, affords a ready means of ascertaining the presentation of the child before labor. The sounds are only audible over a limited space, about two to three inches in diameter ; therefore, if we fail to detect them in one place, a careful exploration of the whole uterine tumor is necessary before we are satisfied that they cannot be heard. Sources of Fallacy. — The only mistake that is likely to be made is taking the maternal pulsations, transmitted through the uterine tumor, for those of the foetal heart. A little care will easily prevent this error, and the frequency of the mother's pulse should always be ascertained before counting the supposed foetal pulsations. If these are found to be 120 or more, while the mother's pulse is only 70 or 80, no mistake is possible. If the latter is abnormally quickened greater care may be necessary, but even then the rate of pulsation of each will be dissimilar. Braxton Hicks 1 has pointed out that in tedious labor, when the muscular powers of the mother are exhausted, the muscular subsurrus may produce a sound closely resembling the foetal pulsation ; but error from this source is obviously very improbable. Mode of practising Auscultation. — In listening for the foetal heart- sound the patient should be placed on her back, with the shoulders elevated and the knees flexed. The surface of the abdomen should be uncovered, and an ordinary stethoscope employed, the end of which must be pressed firmly on the tumor, so as to depress the ab- dominal walls. The most absolute stillness is necessary, as it is often far from easy to hear the sounds. Sometimes, after failing with the ordinary stethoscope, I have succeeded with the bin-aural, which re- markably intensifies them. When once heard they are most easily counted during a space of five seconds, as, on account of their frequency, it is not always possible to follow them over a longer period. [The double stethoscope in use in the United States is the invention of the late Dr. Gr. P. Cammann, of New York, a celebrated and ingenious physi- cian who devoted his life to the study of the diseases of the chest. — Ed.] Value of this Sign of Pregnancy. — When the foetal heart-sounds are heard distinctly, pregnancy may be absolutely and certainly diag- 1 Obst. Trans., vol. xv. 148 PREGNANCY. nosed. The fact that we do not hear them does not, however, pre- clude the possibility of gestation, for the foetus may be dead, or the sounds temporarily inaudible. Umbilical Souffle. — There are some other sounds heard in ausculta- tion which are of very secondary diagnostic value. One of these is the so-calied umbilical or funic souffle, which was first pointed out by Evory Kennedy. It consists of a single blowing murmur, synchro- nous with the foetal heart-sounds, and most distinctly heard in the immediate vicinity of the point where these are most audible. Most authors believe it to be produced by pressure on the cord, either when it is placed between a hard part of the foetus and the uterine walls, or is twisted round the child's neck. Schroeder and Hecker detected it in fourteen or fifteen per cent, of all cases, and the latter believed it to be caused by flexure of the first portion of the cord near the umbilicus. For practical purposes it is quite valueless, and need only be mentioned as a phenomenon which an experienced aus- cultator may occasionally detect. Uterine Souffle. — The uterine souffle is a peculiar single whizzing murmur which is almost always audible on auscultation. It varies very remarkably in character and position. Sometimes it is a gentle blowing or even musical murmur; at others it is loud, harsh, and scrap- ing ; sometimes continuous, sometimes intermittent. It may also be heard at any point of the uterus, but most frequently low down, and" to one or other side ; more rarely above the umbilicus, or towards the fun- dus ; and it often changes its position so as to be heard at a subsequent auscultation at a point where it was previously inaudible. It may be heard over a space of an inch or two only, or in some cases, over the whole uterine tumor ; or again, it may sometimes be detected simultaneously over two entirely distinct portions of the uterus. It is generally to be heard earlier than the foetal heart-sounds, cften as soon as the uterus rises above the brim of the pelvis, and it can almost always be detected after the commencement of the fourth month. The sound becomes curiously modified by the uterine contractions during labor, becoming louder and more intense before the pain comes on, disappearing during its acme, and again being heard as it goes off. Hicks attributes to a similar cause, viz., the uterine contractions during pregnancy, the frequent variations in the sound which are characteristic of it. 1 The uterine souffle is also audible after the death of the foetus, and it is believed by some to be modified and to become more continuously harsh when that event has taken place. Theories as to its Cause. — Very various explanations have been given of the causes of this sound. For long it was supposed to be formed in the vessels of the placenta, and hence the name " placental souffle" by which it is often talked of; or if not in the placenta, in the uterine vessels in its immediate neighborhood. The non-placental origin of the sound is sufficiently demonstrated by the fact that it may be heard for a considerable time after the expulsion of the pla- centa. Some have supposed that it is not formed in the uterus at all, » Op. cit. p. 233. SIGNS AND SYMPTOMS OF PREGNANCY. 149 but in the maternal vessels, especially the aorta and the iliac arteries, owing to the pressure to which they are subjected by the gravid uterus. The extreme irregularity of the sound, its occasional disap- pearance, and its variable site, seem to be conclusive against this view. The theory which refers the sound to the uterine vessels is that which has received most adherents, and which best meets the facts of the case ; but it is by no means easy or even possible to account for the exact mode of its production in them. Each of the explanations which have been given is open to some objection. It is far from unlikely that the intermittent contractions of the uterine fibres, which are known to occur during the whole course of preg- nancy, may have much to do with it, by modifying, at intervals, the rapidity of the circulation in the vessels. Its production in this manner may also be favored by the chlorotic state of the blood, to which Cazeaux and Scanzoni are inclined to attribute an important influence, likening it to the anaemic murmur so frequently heard in the vessels in weakly women. Diagnostic Value. — From a diagnostic point of view the uterine souffle is of very secondary importance, because a similar sound is very generally audible in large fibroid tumors of the uterus, and even in some few ovarian tumors; it is, therefore, of little or no A*alue in assisting us to decide the character of the abdominal enlarge- ment. The supposed dependence of the sound on the placental cir- culation has caused its site to be often identified with that of the placenta. It is, however, most frequently heard at the lower part of the uterus, while the placenta is generally attached near the fundus, so that its position cannot be taken as any safe guide in determining the situation of that viscus. Sounds produced by the Movements of the Foetus. — Occasionally, in practising auscultation, irregular sounds of brief duration may be heard, which are not susceptible of accurate description, and which doubtless depend on the sudden movements of the foetus in the liquor amnii, or on the impact of its limbs on the uterine walls. When heard distinctly they are characteristic of pregnancy ; and they may be sometimes heard when the other sounds cannot be de- tected. They are, however, so irregular, and so often entirely absent that they can hardly be looked upon in any other light than as occa- sional phenomena. Sounds referred to Decomposition of the Liquor Amnii and to sepa- ration of the Placenta. — Two other sounds have been described as being sometimes audible, which may be mentioned as matters of interest, but which are of no diagnostic value. One is a rustling sound, said by Stoltz to be audible in cases in which the foetus is dead, and which he refers to gaseous decomposition of the liquor amnii; its existence is, however, extremely problematical. The other is a sound heard after the birth of the child, and referred by Caillant to the separation of the placental adhesions. He describes it as a series of rapid short scratching sounds, similar to those pro- duced by drawing the nails across the seat of a horse-hair sofa. Simp- 150 PREGNANCY. son 1 admits the existence of the sound, but believed that it is pro- duced by the mere physical crushing of the placenta, and artificially imitated it out of the body by forcing the placenta through an aper- ture the size of the os uteri. Relative Value of the Signs and Symptoms of Pregnancy. — It will be seen, then, that although there are numerous signs and symptoms accompanying pregnancy, many of them are unreliable by themselves, and apt to mislead. Those which may be confidently depended on are the pulsations of the foetal heart, which, however, fail us in cases of dead children ; the fecial movements when distinctly made out ; baliottement ; the intermittent contractions of the uterus ; and to these Ave may safely add the presence of milk in the breasts, provided we have to do with a first pregnancy. The remainder are of importance in leadingus to suspect pregnancy, and in corroborating and strengthening other symptoms, but they do not, of themselves, justify a positive diagnosis. CHAPTER Y. THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. SPURIOUS PREG- NANCY. THE DURATION OF PREGNANCY. SIGNS OF RECENT PREGNANCY. Importance of the Subject. — The differential diagnosis of pregnancy has of late years assumed much importance on account of the advance of abdominal surgery. The cases are so numerous in which even the most experienced practitioners have fallen into error, and in which the abdomen has been laid open in ignorance of the fact that pregnancy existed, that the subject becomes one of the greatest con- sequence. Fortunately it is less so from an obstetrical than from a gynaecological point of view, inasmuch as the converse error, of mis- taking some other condition for pregnancy, is of far less consequence, as it is one which time will always rectify. But even in this way carelessness may lead to very serious injury to the character, if not to the health of the patient ; and it will be well to refer briefly to some of the conditions most liable to be mistaken for pregnancy, and to the mode of distinguishing them. Adipose enlargement of the abdomen may obscure the diagnosis by preventing the detection of the uterus ; and if, as is not uncommon in women of great obesity, it is associated with irregular menstruation, the increased size of the abdomen might be supposed to depend on pregnancy. The absence of corroborative signs, such as auscultatory 1 Selected Obstet. Works, p. 151. DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 151 phenomena, mammary changes, and the hardness of the cervix as felt per vagi nam, make it easy to avoid this error. [We are sometimes consulted in cases of women in whom fatness of body has commenced, by the formation of an adipose cake, which covers the centre of the abdomen, and gives the infra-umbilical por- tion a protruding roundness very much like that observed in preg- nancy. In one case that my attention was called to in a young mar- ried woman, I found the rest of the body but very slightly covered with fat, although in time the deposit became general, her weight then increasing from 120, to 1(30 pounds. Such subjects either sus- pect themselves pregnant, or affected with a tumor, according to cir- cumstances. These discoid deposits are thick in the centre, and thin toward the ilia, being in some instances several inches thick at a point midway between the umbilicus and pubes. — Ed.] Distension of the uterus by retained menstrual fluid, or watery secretion, is an occurrence of rarity that could seldom give rise to error. Still it occasionally happens that the uterus becomes enlarged in this way, sometimes reaching even to the level of the umbilicus, and that the physical character of the tumor is not unlike that of the gravid uterus. The best safeguard against mistakes will be the previous history of the case, which will always be different from that of ordinary pregnancy. Retention of the menses almost always occurs from some physical obstruction to the exit of the fluid, such as imperforate hymen; or if it occur in women who have already menstruated, we may usually trace a history of some cause, such as inflammation following an antecedent labor, which has produced occlusion of some part of the genital tract. The existence of a pelvic tumor in a girl who has never menstruated will of itself give rise to suspicion, as pregnancy under such circumstances is of extreme rarit}^. It will also be found that general symptoms have existed for a period of time considerably longer than the supposed duration of pregnancjr, as judged of by the size of the tumor. The most characteristic of them are periodic attacks of pain due to the addition, at each monthly period, to the quantity of retained menstrual fluid. Whenever, from any of these reasons, suspicion of the true character of the case has arisen, a careful vaginal examination will generally clear it up. In most cases the obstruction will be in the vagina, and is at once detected, the vaginal canal above it, as felt per rectum, being greatly distended by fluid ; and Ave may also find the bulging and imperforate hymen protruding through the vulva. The absence of mammary changes, and of ballottement, will materially aid us in forming a diagnosis. Congestive Hypertrophy of the Uterus. — The engorged and enlarged uterus, frequently met with in women suffering from uterine disease, might readily be mistaken for an early pregnancy, if it happened to be associated with amenorrhcea. A little time would, of course, soon clear up the point, by showing that progressive increase in size, as in pregnancy, does not take place. This mistake could only be made at an early stage of pregnancy, when a positive diagnosis is never 152 PBEGNANCY. possible. The accompanying symptoms — pain, inability to walk, and tenderness of the uterus on pressure — would further prevent such an error. Ascitic Distension of the Abdomen. — Ascites, per se, could hardly be mistaken for pregnancy ; for the uniform distension and evident fluctuation, the absence of any definite tumor, the site of resonance on percussion changing in accordance with alteration of the position of the woman, and the unchanged cervix and uterus, should be suffi- cient to clear up any doubt. Pregnancy may, however, exist with ascites, and this combination may be difficult to detect, and might readily be mistaken for ovarian disease, associated with ascites. The existence of mammary changes, the presence of the softened cervix, ballottement, and auscultation — provided the sounds were not masked by the surrounding fluid — would afford the best means of diagnosing such a case. Uterine and Ovarian Tumors.— One of the most frequent sources of difficulty is the differential diagnosis of large abdominal tumors, either fibroid or ovarian, or of some enlargements due to malignant disease of the peritoneum or abdominal viscera. The most expe- rienced have been occasionally deceived under such circumstances. As a rule, the presence of menstruation will prevent error, as this generally continues in ovarian disease, while in fibroids it is often excessive. The character of the tumor — the fluctuation in ovarian disease, the hard nodular masses in fibroid — and the history of the case — especially the length of time the tumor has existed — will aid in diagnosis, while the absence of cervical softening, and of ausculta- tory phenomena will further be of material value in forming a con- clusion. Some of the most difficult cases to diagnose are those in which pregnancy complicates ovarian or fibroid disease. Then the tumor may more or less completely obscure the physical signs of pregnancy. The usual shape of the abdomen will generally be altered considerably, and we may be able to distinguish the gravid uterus, separated from the ovarian tumor by a distinct sulcus, or with the fibroid masses cropping out from its surface. Our chief reliance must then be placed in the alteration of the cervix, and in the aus- cultatory signs of pregnancy. Spurious Pregnancy. — The condition most likely to give rise to errors is that very interesting and peculiar state, known as spurious pregnancy. In this most of the usual phenomena of pregnancy are so strangely simulated, that accurate diagnosis is often far from easy. There are hardly any of the more apparent symptoms of pregnancy which may not be present in marked cases of this kind. The abdo- men may become prominent, the areolae altered, menstruation arrested, and apparent foetal motions felt; and, unless suspicion is aroused, and a careful physical examination made, both the patient and the practitioner may easily be deceived. Cases in which Spurious Pregnancy Occurs. — There is no period of the child-bearing life in which spurious pregnancy may not be met with; but it is most likely to occur in elderly women about the DIFFERENTIAL DIAGNOSIS OS PREGNANCY. 153 climacteric period, when it is generally associated with ovarian irrita- tion connected with the change of life ; or in younger women, who are either very desirous of finding themselves pregnant, or who, being unmarried, have subjected themselves to the chance of being so. In all cases the mental faculties have much to do with its production, and there is generally either Yery marked hysteria, or even a condi- tion closely allied to insanity. Spurious pregnancy is by no means confined to the human race. It is well known to occur in many of the lower animals. Harvey related instances in bitches, either after unsuccessful intercourse, or m connection with their being in heat, even when no intercourse had occurred. In such cases the abdomen swelled, and milk appeared in the mammte. Similar phenomena are also occasionally met with in the cow. In these instances, as in the human female, there is probably some morbid irritation of the ova- rian system. Its Siy?2s and Symptoms. — The physical phenomena are often very well marked. The apparent enlargement is sometimes very great, and it seems to be produced by a projection forward of the abdomi- nal contents due to depression of the diaphragm, together with rigidity of the abdominal muscles, and may even closely simulate the uterine tumor on palpation. After the climacteric it is frequently associated, as Gooch pointed out, with an undue deposit of fat in the abdominal walls and omentum, so that there may be even some dul- ness on percussion, instead of resonance of the intestines. The foetal movements are curiously and exactly simulated, either by involun- tary contractions of the abdominal walls, or by the movement of flatus in the intestines. The patient also generally fancies that she suffers from the usual sympathetic disorders of pregnancy, and thus her account of her symptoms will still further tend to mislead. Sometimes followed by Spurious Labor. — Not only may the supposed pregnane}' continue, but, at what would be the natural term of de- livery, all the phenomena of labor may supervene. Many authentic cases are on record in which regular pains came on, and continued to increase in force and frequency until the actual condition was diagnosed. Such mistakes, however, are only likely to happen when the statements of the patient have been received without further inquiry. When once an accurate examination has been made, error is no longer possible. Methods of Diagnosis. — We shall generally find that some of the phenomena of pregnancy are absent. Possibly menstruation, more or less irregular, may have continued. Examination per vaginam will at once clear up the case, by showing that the uterus is not enlarged, and that the cervix is unaltered. It may then be very difficult to convince the patient or her friends that her symptoms have misled her, and for this purpose the inhalation of chloroform is of great value. As consciousness is abolished, the semi- voluntary projection of the abdominal muscles is prevented, the large apparent tumor vanishes, and the bystanders can be readily convinced that none exists. As the patient recovers the tumor again appears. 11 154 PREGNANCY. Duration of Pregnancy. — The duration of pregnancy in .the human female has always formed a fruitful theme for discussion amongst obstetricians. The reasons which render the point difficult of deci- sion are obvious. As the large majority of cases occur in married women, in whom intercourse occurs frequently, there is no means of knowing the precise period at which conception took place. The only datum which exists for the calculation of the probable date of delivery is the cessation of menstruation. It is quite possible, how- ever, and indeed probable, that conception occurred, in a considerable number of instances, not immediately after the last period, but im- mediately before the proper epoch for the occurrence of the next. Hence, as the interval between the end of one menstruation and the commencement of the next averages 25 days, an error to that extent is always possible. Another source of fallacy is the fact, which has generally been overlooked, that even a single coitus does not fix the date of conception, but only that of insemination. It is well known that in many of the lower animals the fertilization of the ovule does not take place until several days after copulation, the spermatozoa remaining in the interval in a state of active vitality within the genital tract. It has been shown by Marion Sims that living sper- matozoa exist in the cervical canal in the human female some days after intercourse. It is very probable, therefore, that in the human female, as in the lower animals, a considerable, but unknown interval, occurs between insemination and actual impregnation, which may render calculations as to the precise duration of pregnancy altogether unreliable. Average Time between Cessation of Menstruation and Delivery. — A large mass of statistical observations exist, respecting the average duration of gestation, which have been drawn up and collated from numerous sources. It would serve no practical purpose to reprint the voluminous tables on this subject that are contained in menstrual works. They are based on two principal methods of calculation. First, we have the length of time between the cessation of menstru- tion and delivery. This is found to vary very considerably, but the largest percentage of deliveries occurs between the 274th and 280th day after the cessation of menstruation, the average day being the 278th ; but, in individual instances, very considerable variations both above and below these limits are found to exist. Next we have a series of cases, from various sources, in which only one coitus was believed to have taken place. These are naturally always open to some doubt, but, on the whole, they may be taken as affording tole- rably fair grounds for calculation. Here, as in the other mode of calculation, there are marked variations, the average length of time, as estimated from a considerable collection of cases, being 275 days after the single intercourse. It may, therefore, be taken as certain that there is no definite time which we can calculate on as being the proper duration of pregnancy, and, consequently, no method of esti- mating the probable date of delivery on which we can absolutely rely. ■ DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 155 Methods of Predicting the probable Date. — The prediction of the time at which the confinement may be expected is, however, a point ©f considerable practical importance, and one on which the medical attendant is always consulted. Various methods of making the calculation have been recommended. It has been customary in this country, according to the recommendation of Montgomery, to fix upon ten lunar months, or 280 days, as the probable period of gesta- tion, and, as conception is supposed to occur shortly after the cessa- tion of menstruation, to add this number of clays to any day within the first week after the last menstrual period as the most probable period of delivery. As, however, 278 days is found to be the average duration of gestation after the cessation of menstruation, and as this method makes the calculation vary from 281 to 287 days, it is evi- dently liable to fix too late a date. Naegele's method was to count 7 days from the first appearance of the last menstrual period, and then reckon backwards three months as the probable date. Thus, if a patient last commenced to menstruate on August 10, counting in this way from August 17 would give May 17 as the probable date of the deliver} 7 . Matthews Duncan has paid more attention than any one else to the prediction of the date of delivery. His method of calculating is based on the fact of 278 days being the average time between the cessation of menstruation and parturition ; and he claims to have had a greater average of success in his predictions than on any other plan. His rule is as follows : — " Find the day on which the female ceased to menstruate, or the first day of being what she calls ' well.' Take that clay nine months forward as 275, unless February is included, in which case it is taken as 273 days. To this add three days in the former case, or five if February is in the count, to make up the 278. This 278th day should then be fixed on as the middle of the week, or, to make the prediction the more accurate, of the fortnight in which the confinement is likely to occur, by which means allowance is made for the average variation of either excess or deficiency." Various periodoscopes and tables for facilitating the calculation have been made. The periodoscope of Dr. Tyler Smith (sold by Messrs. John Smith, 52 Long Acre) is very useful for reference in the consulting room, giving at a glance a variety of information, such as the probable period of quickening, the dates for the induc- tion of premature labor, etc. The following table, prepared by Dr. Protheroe Smith, is also easily read, and is very serviceable : — 156 PREGNANCY. Table for Calculating the Period of Utero-gestation. 1 IN ir le Calendar Months. Ten Lunar Months. From To Days. To Days. January 1 September 30 273 October 7 280 February 1 October 31 273 November 7 280 March 1 November 30 275 December 5 280 April 1 December 31 275 January 5 280 May 1 January 31 276 February 4 280 June 1 February 28 273 March 7 280 July 1 March 31 274 April 6 280 August 1 April 30 273 May 7 280 September 1 May 31 273 June 7 280 October 1 June 30 273 July 7 280 November 1 July 31 273 August 7 280 December 1 August 31 274 September 6 280 Quickening a Fallacious Guide in estimating Date of Delivery. — The elate at which the quickening has been perceived is relied on by- many practitioners, and still more by patients, in calculating the probable date of delivery, as it is generally supposed to occur at the middle of pregnancy. The great variations, however, in the time at which this phenomena is first perceived, and the difficulty which is so often experienced of ascertaining its presence with any certainty, render it a very fallacious guide. The only times at which the per- ception of quickening is likely to prove of any real value are when impregnation has occurred during lactation (when menstruation is normally absent), or when menstruation is so uncertain and irregular that the date of its last appearance cannot be ascertained. As quick- ening is most commonly felt during the fourth month, more frequently in its first than in its last fortnight, it may thus afford the only guide we can obtain, and that an uncertain one, for predicting the date of delivery. Is Protraction of Gestation Possible? — From a medico-legal point of view the question of the possible protraction of pregnancy beyond the average time, and of the limits within which such protraction can be admitted, is of very great importance. The law on this point varies considerably in different countries. Thus in France it is laid down that legitimacy cannot be contested until 300 days have elapsed from the death of the husband, or the latest possible opportunity for sexual intercourse. This limit is also adopted by Austria, while in Prussia it is fixed at 302 days. In England and America no fixed date is admitted, but while 280 days is admitted as the "^ legitimism tempus pariendi," each case, in which legitimacy is questioned, is to 1 The above obstetric " Ready Reckoner" consists of two columns, one of calendar, the other of lunar months, and may be read as follows : — A patient has ceased to menstruate on July 1 : her confinement may be expected at soonest about March 31 (the end of nine calendar months) ; or at latest on April 6 (the end of ten lunar months). Another has ceased to menstruate on January 20 ; her confinement may be expected on September 30, plus 20 days (the end of nine calendar months) at soonest ; or on October 7, plus 20 days (the end of ten lunar months) at latest. DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 157 be decided on its own merits. At the early part of the century the question was much discussed by the leading obstetricians in connec- tion with the celebrated Gardner peerage case, and a considerable difference of opinion existed among them. Since that time many apparently perfectly reliable cases have been recorded, in which the duration of gestation was obviously much beyond the average, and in which all sources of fallac}^ were carefully excluded. Reliable Cases of Protraction. — Not to burden these pages with a number of cases, it may suffice to refer, as examples of protraction, to four well-known instances recorded by Simpson, 1 in which the pregnancy extended respectively to 336, 332, 319, and 324 days after the cessation of the last menstrual period. In these, as in all cases of protracted gestation, there is the possible source of error that im- pregnation may have occurred just before the expected advent of the next period. Making an allowance of 23 days in each instance for this, we even then have a number of days much above the average, viz. r 313, 309, 296, and 301. Numerous instances as curious may be found scattered through obstetric literature. Indeed, the experience of most accoucheurs will parallel such cases, which may be more common than is generally supposed, inasmuch as they are only likely to attract attention when the husband has been separated from the wife beyond the average and expected duration of the pregnancy. Protraction common in the Lower Animals. — The evidence in favor of the possible prolongation of gestation is greatly strengthened by what is known to occur in the lower animals. In some of these, as in the cow and the mare, the precise period of insemination is known to a certainty, as only a single coitus is permitted. Many tables of this kind have been constructed, and it has been shown that there is in them a very considerable variation. In some cases in the cow it has been found that delivery took place 45 days, and in the mare 43 days after the calculated date. Analogy would go strongly to show, that what is known to a certainty to occur in the lower animals, may also take place in the human female. The fact, indeed, is now very generally admitted ; but we are still unable to fix, with any degree of precision, on the extreme limit to which protraction is possible. Some practitioners have given cases in which, on data which they believe to be satisfactory, pregnancy has been extremely protracted; thus Meigs and Adler record instances which the}^ believed to have been prolonged to over a year in one case, and over fourteen months in the other. These are, hoAvever, so problematical that little weight can be attached to them. On the whole it would hardly be safe to conclude that pregnancy can go more than three or four weeks be- yond the average time. This conclusion is justified by the cases we possess in which pregnancy followed a single coitus, the longest of which was 295 days. Evidence from Size of Child. — Dr. Duncan 2 is inclined to refuse credence to every case of supposed protraction unless the size and 1 Obstet. Memoirs, p. 84. 2 Fecundity and Fertility, p. 348. 158 PREGNANCY. weight of the child are above the average, believing that lengthened gestation must of necessity cause increased growth of the child. The point requires further investigation, and it cannot be taken as proved that the foetus necessarily must be large because it has been retained longer than "usual in utero ; or, even if this be admitted, it may have been originally small, and so, at the end of the protracted gestation, be little above the average weight. There are, however, many cases which certainly prove that a prolonged pregnancy is at least often associated with an unusually developed foetus. Dr. Duncan himself cites several, and a very interesting one is mentioned by Leishman, in which delivery took' place 295 days after a single coitus, the child weighing 12 lbs. 3 oz. In some Cases Labor may commence and he Arrested. — It seems possible that, in some cases of protracted pregnancy, labor actually came on at the average time, but, on account of faulty positions of the uterus, or other obstructing cause, the pains were ineffective and ultimately died away, not recurring for a considerable time. Joulin relates some instances of this kind. In one of them the labor was expected from the 20th to the 25th of October. He was summoned on the 23d, and found the pains regular and active, but ineffective ; after lasting the whole of the 24th and 25th they died away, and delivery did not take place until November 25th, after the lapse of a month. In this instance the apparent cause of difficulty was extreme anterior obliquity of the uterus. A precisely similar case came under my own observation. The lady ceased to menstruate on March 16, 1870. On December 12th, that is, on the 273d day, strong labor pains came on, the os dilated to the size of a florin, and the membranes became tense and prominent with each pain. After last- ing all night they gradually died away, and did not recur until Jan- uary 12th, 304 days from the cessation of the last period. Here there was no assignable cause of obstruction, and the labor, when it did come on, was natural and easy. The curious fact that, in both these cases, as in others of the same kind that are recorded, labor came on exactly a month after the pre- vious ineffectual attempt at its establishment, affords, so far as it goes, an argument in favor of the view maintained by many that labor is apt to come on at what would have been a menstrnal period. Siyns of Recent Delivery. — From a forensic point of view it often becomes of importance to be able to give a reliable opinion as to the fact of delivery having occurred, and a few words may be here said as to the signs of recent delivery. Our opinion is only likely to be sought in cases in which the fact of delivery is denied, and in which we must, therefore, entirely rely on the results of a physical exami- nation. If this be undertaken within the first fortnight after labor, a positive conclusion can be readily arrived at. At this time the abdominal walls will still be found loose and flaccid, and bearing very evident marks of extreme distension in the cracks and fissures of the cutis vera. These remain permanent for the rest of the patient's life, and may be safely assumed to be signs of an antecedent pregnancy, provided we can be certain that no other DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 159 cause of extreme abdominal distension has existed, such as ascites, or ovarian tumor. Within the first few days after delivery, the hard round ball formed by the contracted and empty uterus can easily be felt by abdominal palpation, and more certainly by combined external and internal examination. The process of involution, however, by which the uterus is reduced to its normal size, is so rapid, that after the first week it can no longer be made out above the brim of the pelvis. In cases in which an accurate diagnosis is of importance, the increased length of the uterus can be ascertained by the uterine sound, and its cavity will measure more than the normal 2J inches for at least a month after delivery. It should not be forgotten that the uterine parietes are now undergoing fatty degeneration, and that they are more than usually soft and friable, so that the sound should be used with great caution, and only when a positive opinion is essential. The state of the cervix and of the vagina may afford useful in- formation. Immediately after delivery the cervix hangs loose and patulous in the vagina, but it rapidly contracts, and the internal cs is generally entirely closed after the eighth or tenth day. The re- mainder of the cervix is longer in returning to its normal shape and consistency. It is generally permanently altered after delivery, the external os remaining fissured and transverse, instead of circular with smooth margins, as in virgins. The vagina is at first lax, swollen, and dilated, but these signs rapidly disappear and cannot be satisfac- torily made out after the first few days. The absence of the fourchette may be recognized, and is a persistent sign. The presence of the lochia affords a valuable sign of recent deliv- ery. For the first few days they are sanguineous, and contain numer- ous blood-corpuscles, epithelial scales, and the debris of the decidua. After the fifth day they generally change in color, and become pale and greenish, and from the eighth or ninth day till about a month after delivery, they have the appearance of a thick opalescent mucus. They have, however, a peculiar, heavy, sickening odor, which should prevent their being mistaken for either menstruation or ieucorrhoeal discharge. The appearance of the breasts will also aid the decision, for it is impossible for the patient to conceal the turgid swollen condition of the mammas, with the darkened areolae, and, above all, the presence of milk. If, on microscopic examination, the milk is found to con- tain colostrum corpuscles, the fact of very recent delivery is certain. In women who do not nurse it should be remembered that the secre- tion of milk often rapidly disappears, so that its absence cannot be taken as a sign that delivery has not taken place. On the whole, there should be no difficulty in deciding that a woman has been de- livered, as some of the signs are persistent for the rest of her life ; but it is not so easy unless we see the case within the first eight or ten days, to say how long it is since labor took place. 160 PREGNANCY. CHAPTER VI. ABNORMAL PREGNANCY, INCLUDING MULTIPLE PREGNANCY, SUPER- FCETATION, EXTRA-UTERINE FCETATION, AND MISSED LABOR. Plural Births an abnormal variety of Pregnancy. — The occurrence of more than one foetus in utero is far from uncommon, but there are circumstances connected with it which justify the conclusion that plural births must not be classified as natural forms of pregnancy, The reasons for this statement have been well collected by Dr. Arthur Mitchell, 1 who conclusively shows that not only is there a direct increase of risk both to the mother and her offspring, but that many abnormalities, such as idiocy, imbecility, and bodily deformity, occur with much greater frequency in twins than in single-born children, He concludes that " the whole history of twin births is exceptional, indicates imperfect development and feeble organization in the product, and leads us to regard twinning in the human species as a departure from the physiological rule, and therefore injurious to all concerned." Frequency of multiple Births. — The frequency of multiple births varies considerably under different circumstances. Taking the aver- age of a large number of cases collected by authors in various countries, we find that twin pregnancies occur about once in 87 labors ; triplets once in 7679. A certain number of quadruple preg- nancies, and some cases of early abortion in which there were five foetuses, are recorded, so that there can be no doubt of the possibility of such occurrences ; but they are so extremely uncommon that they may be looked upon as rare exceptions, the relative frequency of which can hardly be determined. Relative frequency in different Countries. — The frequency of mul- tiple pregnancy varies remarkably in different races and countries. The following table 2 will show this at a glance : — 1 Med. Times and Gaz., Nov. 18B2. 2 Puech, Des Naissances Multiples. ABNORMAL PREGNANCY 161 Relative Frequency of Multiple Pregnancies in Europe. Countries. England Austria . Grand Duchy of Baden Scotland France . Ireland . Mecklenburg-Schwerin Norway . Prussia . Russia . Saxony . Switzerland . Wurteniberg . Proportion of Twin to Single Births. 116 94 89 95 99 64 68.9 81.62 89 50.05 79 102 862 Proportion of Triplets. 6,720 6,575 8,256 4,995 6,436 5,442 7,820 4,054 1,000 6,464 Proportion of Quadruplets. 1 : 2,074,306 1 : 167,296 1 : 183,236 1 : 394,690 1 : 400,000 1 : 110,991 It will be seen that the largest proportion of multiple births occurs in Russia, and that the number of triple births is greatest where twin pregnancies are most frequent. Puech concludes that the number of multiple pregnancies is in direct proportion to the general fecundity of the inhabitants. Dr. Duncan has deduced some interesting laws, with regard to the production of twins, from a large number of statistical observations; 1 especially that the tendency to the production of twins increases as the age of the woman advances, and is greater in each succeeding pregnancy, exception being made for the first pregnancy, in which it is greater than in any other. Newly married women appear more likely to have twins the older they are. There can be no doubt that there is often a strong hereditary tendency in individual families to multiple births. A remarkable instance of this kind is recorded by Mr. Curgenven, 2 in which a woman had four twin pregnancies, her mother and aunt each one, and her grandmother two. Simpson mentions a case of quadruplets, consisting of three males and one female, who all survived, the female subsequently giving birth to triplets. 3 Sex of Children. — In the largest number of cases of twins the children are of opposite sexes, next most frequently there are two females, and twin males are the most uncommon. Thus out of 59,178 labors, Simpson calculates that twin male and female occurred once in 199 labors, twin females once in 226, and twin males once in 258. The proportion of male to female births is also notably less in twin than in single pregnancies. Size of Foetuses. — Twins, and ci fortiori triplets, are almost always smaller and less perfectly developed than single children. Hence the chances of their survival are much less, and Clarke calculates the mortality amongst twin children as one out of thirteen. Of triplets, indeed, it is comparatively rare that all survive ; while in 1 On Fecundity, Fertility, and Sterility 2 Obstet. Trans., vol. xi. p. 99. s Obstet. Works, p. 830. 162 PREGNANCY. quadruplets, premature labor and the death of the foetuses are almost certain. It is a common observation that twins are often unequallv developed at birth. By some this difference is attributed to one of them being of a different age to the other. It is probable, however, that in most of these cases the full development of one foetus has been interfered with by pressure of the other. This is far from uncom- monly carried to the extent of destroying one of the twins, which is expelled at term, mummified and flattened between the living child and the uterine wall. In other cases when one foetus dies it may be expelled without terminating the pregnancy, the other being retained in utero and born at term ; and those who disbelieve in the possi- bility of superfoetation explain in this way the cases in which it is believed to have occurred. Causes.— Multiple pregnancies depend on various causes. The most common is probably the simultaneous, or nearly simultaneous, maturation and rupture of two Graafian follicles, the ovules becoming impregnated at or about the same time. It by no means necessarily follows, even if more than one follicle should rupture at once, that both ovules should be impregnated. This is proved by the occur- rence of cases in which there are two corpora lutea with only one foetus. There are numerous facts to prove that ovules thrown' off within a short time of each other, may become separately impreg- nated, as in cases in which negro women have given birth to twins, one of which was pure negro, the other half-caste. It may happen, however, that a single Graafian follicle contains more than one ovule, as has actually been observed before its rup- ture ; or, as is not uncommon in the egg of the fowl, an ovule may contain a double germ, each of which may give rise to a separate foetus. Arrangement of the Foetal Membranes and Placentae. — The various modes in which twins may originate explain satisfactorily the varia- tions which are met with in the arrangement of the foetal membranes, and in the form and connections of the placentas. In a large propor- tion of cases there are two distinct bags of membranes, the septum between them being composed of four layers, viz., the chorion and amnion of each ovum. The placentae are also entirely separate. Here it is obvious that each twin is developed from a distinct ovum, having its own chorion and amnion. On arriving in the uterus it is probable that each ovum becomes fixed independently in the mucous membrane, and is surrounded by its own decidua reflexa. As growth advances, the decidua reflexa generally atrophies from pressure, as it is not usual to find more than four layers of membrane in the septum separating the ova. In other cases there is only one chorion, within which are two distinct amnions, the septum then consisting of two layers only. Then the placentas are generally in close apposi- tion, and become fused into a single mass ; the cords, separately attached to each foetus, not infrequently uniting shortly before reach- ing the placental mass, their vessels anastomosing freely. In other more rare instances both foetuses are contained in a common amni- but, as the amnion is a purely foetal membrane, it is prob- ABNORMAL PREGNANCY. 163 able that, when this arrangement is met with, the originally existing septum between the amniotic sacs has been destroyed. In both these latter cases the twins must have been developed from a single ovule containing a double germ, and Schroeder states that they are then always of the same sex. Dr. Brunton 1 has started a precisely opposite theory, and has tried to prove that twins of the same sex are contained in separate bags of membrane, while twius of opposite sexes have a common sac. He says that out of twenty-live cases coming under his observation, in iifteen the children contained in different sacs were of the same sex, but in the remaining ten, in which there was only one sac, they were of opposite sexes. It is difficult to believe that there is not an error in these observations, since twins contained in a single amniotic sac do not occur nearly as often as ten times out of twenty-live cases, and no distinction is made between a common chorion with two amnions and a single chorion and amnion. The facts of double monstrosity also disprove this view, since conjoined twins must of necessity arise from a single ovule with a double germ, and there is no instance on record in which they were of opposite sexes. Membranes and Placentw in Triplets. — In triplets the membranes and placentae may be all separate, or as is commonly the case there is one complete bag of membranes, and a second having a common chorion, with a double amnion. It is probable, therefore, that trip- lets are generally developed from two ovules, one of which contained a double germ. Diagnoses of Multiple Pregnancy. — It is comparatively seldom that twin pregnancy can be diagnosed before the birth of the first child, and even when suspicion has arisen, its indications are very defective. There is generally an unusual size and an irregularit}^ of shape of the uterus, sometimes even a distinct depression or sulcus between the two foetuses. When such a sulcus exists it may be possible to make out parts of each foetus by palpation on either side of the uterus. The only sign, however, on which the least reliance can be placed is the detection of two foetal hearts. If two distinct pulsa- tions are heard at different parts of the uterus ; if, on carrying the stethoscope from one point to another, there is an interspace where pulsations are no longer audible, or when they become feeble, and again increase in clearness as the second point is reached ; and, above all, if we are able to make out a difference in frequency between them, the diagnosis is tolerably safe. It must be remembered, how- ever, that the sounds of a single heart may be heard over a larger space than usual, and hence a possible source of error. Twin preg- nancy, moreover, may readily exist without the most careful auscul- tation enabling us to detect a double pulsation, especially if one child lie in the dorso- posterior position, when the body of the other may prevent the transmission of its heart's beat. The so-called placental souffle is generally too diffuse and irregular to be of any use in diagnosis, even when it is distinctly heard at separate parts of the uterus. i Obst. Trans., vol. x. 164 PREGNANCY. Superfcetation and Superfecundation. — Closely connected with the subject of multiple pregnancies are the conditions known as super- fecundation and swperfoetation, regarding which there has been much controversy and difference of opinion. By the former is meant the fecundation, at or near the same period of time, of two separate ovules before the decidaa lining the uterus has been formed, which by many is supposed to form an insuperable obstacle to subsequent impregnation. The possibility of this occur- rence has been incontestably proved by the class of cases already referred to, in which the same woman has given birth to twins bear- ing evident traces of being the offspring of fathers of different races. By super fetation is meant the impregnation of a second ovule, when the uterus already contains an ovum which has arrived at a considerable degree of development. The cases which are supposed to prove the possibility of this occurrence are very numerous. They are those in which a woman is delivered simultaneously of foetuses of very different ages, one bearing all the marks of having arrived at term, the other of prematurity ; or of those in which a woman is delivered of an apparently mature child, and, after the lapse of a few months, of another equally mature. The possibility of superfcetation is strongly denied by many practitioners of eminence, and explana- tions are given, which doubtless seem to account satisfactorily for a large proportion of the supposed examples. In the former class of cases it is supposed, with much probability, that there is an ordinary twin pregnancy, the development of one foetus being retarded by the presence in utero of another. That this is not an uncommon occur- rence is certain, and the fact has already been alluded to in treating of twin pregnancy. In cases of the latter kind it is possible that some of them may be due to separate impregnation in a bilobed uterus, the contents of one division being thrown off a considerable time before those of the other. Numerous authentic examples of this occurrence are recorded, but by far the most remarkable is that related by Dr. Eoss, of Brighton, which has been already referred to (p. 58.) In this case the patient had previously given birth to many children without any suspicion of her abnormal formation having arisen, and, had it not been detected by Dr. Eoss, the case might fairly enough have been claimed as an indubitable example of super- fcetation. Making every allowance for these explanations, there remain a considerable number of cases which it is very difficult to account for, except on the supposition that the second child has been conceived a considerable time after the first. Those interested in the subject will find a large number of examples collected in a valuable paper by Dr. Bonnar, of Cupar. 1 He has adopted the ingenious plan of consulting the records of the British peerage, where the exact date of the birth of successive children of peers is given, without, of course, any reasonable possibility of error, and he has collected numerous examples of births rapidly succeeding each other, which i Edin. Med. Journ., 1864-65. ABNORMAL PREGNANCY. 165 are apparently inexplicable on any other theory. In one case he cites, a child was born September 12, 1849, and the mother gave birth to another on January 21, 1850, after an interval of only 127 days. Subtracting from that 11 days, which Dr. Bonnar assumes to be the earliest possible period at which a fresh impregnation can occur after delivery, we reduce the gestation to 113 days, that is, to less than four calendar months. As both these children survived, the second child could not possibly have been the result of a fresh impregnation after the birth of the first ; nor could the first child have been a twin prematurely delivered, for if so it must have only reached rather more than the fifth month, at which time its survival would have been impossible. Besides the numerous examples of cases of this kind recorded in most obstetric works, there are one or two of miscarriage in the early months, in which, in addition to a foetus of four or five months' growth, a perfectly fresh ovum of not more than a month's develop- ment was thrown off. One such case was shown at the Obstetrical Society in 1862, which was reported on by Drs. Harley and Tanner, who stated that in their opinion it was an example of superfoetation. A still mere conclusive case is recorded by Tyler Smith. 1 " A young married woman, pregnant for the first time, miscarried at the end of the fifth month, and some hours afterwards a small clot was dis- charged, inclosing a perfectly healthy ovum of about one month. There were no signs of a double uterus in this case. The patient had menstruated regularly during the time she had been pregnant." This case is of special interest from the fact of the patient having men- struated during pregnancy— a circumstance only explicable on the same anatomical grounds which render superfoetation possible. So far as I know, it is the only instance in which the coincidence of superfoetation and menstruation during early pregnancy has been observed. Objections. — The objections to the possibility of superfoetation are based on the assumptions that the decidua so completely fills up the uterine cavity that the passage of the spermatozoa is impossible ; that their passage is prevented by the mucous plug which blocks up the cervix ; and that when impregnation has taken place ovulation is suspended. It is, however, certain that none of these are insupera- ble obstacles to a second impregnation. The first was originally based on the older and erroneous view which considered the decidua to be an exudation lining the entire uterine cavity, and sealing up the mouths of the Fallopian tubes and the aperture of the internal os uteri. The decidua reflexa, however, does not come into apposition with the decidua vera until about the eighth week of pregnancy, and, therefore, until that time there is a free space between the two mem- branes through which the spermatozoa might pass to the open mouths of the Fallopian tube, and in which a newly impregnated ovule might graft itself. A reference to the accompanying figure of a pregnancy in the third month, copied from Coste's work, will 1 Manual of Obstetrics, p. 112. 166 PREGNANCY readily show that, as far as the decidua is concerned, there is no mechanical obstacle to the descent and lodgment of another impreg- nated ovule (Fig. 76). Then, as regards the plug of mucus, it is pretty certain that this is in no way different from the mucus filling Fig. 76. Illustrating the Cavity between the Decidua Vera and the Decidua Reflexa during the early months of Pregnancy. (After Coste.) the cervix in the non-pregnant state, which offers no obstacle at all to the passage of the spermatozoa. Lastly, respecting the cessation of ovulation during pregnancy, this, no doubt, is the rule, and proba- bly satisfactorily explains the rarity of super fcetation. There are, however, a sufficient number of authenticated cases of menstruation during pregnancy to prove that ovulation is not always absolutely in abeyance; and, as long as it occurs, there is unquestionably' no positive mechanical obstruction, at least in the early months of preg- nancy, in the way of the impregnation and lodgment of the ovules that are thrown off. The reasonable conclusion, therefore, seems to be that, although a large majority of the supposed cases are explica- ble in other ways, it cannot be admitted that superfcetation is either physiologically or mechanically impossible. Extra-uterine Pregnancy. — The most important of the abnormal varieties of pregnancy, if Ave consider the serious and very generally fatal results attending it, is the so-called extra-uteri?ie foetation, which consists in the arrest and development of the ovum outside the cavity of the uterus. Of late years this subject has received much well-merited attention, which, it is to be hoped, may lead to the establishment of some definite rules for the management of this most anxious and dangerous class of cases ABNORMAL PREGNANCY. 167 Site of Extra-uterine Pregnancy. — The ovum may be arrested and developed in various situations on its way to the uterus, most com- monly in some part of the Fallopian tube, or it may be in the cavity of the abdomen, or even quite beyond it, as in a few rare cases in which the ovum has found its way into a hernial sac. Classification. — Extra-uterine gestation may be subdivided into the following classes: 1st, and most common of all, tubal gestation and as varieties of this, although by some made into distinct classes (a) interstitial and (I)) tubo-ovarian gestation. In the former of these subdivisions the ovum is arrested in the part of the Fallopian tube that is situated in the substance of the uterine parietes ; in the latter, at or near the fimbriated extremity of the tube — so that part of its cyst is formed by the tube and part by the ovary. 2d. Abdominal gestation, in which an ovum, instead of finding its way into the tube, falls into the peritoneal cavity and there becomes attached and de- veloped ; or the so-called secondary abdominal gestation, in which an extra-uterine pregnancy, originally tubal, becomes ventral, through rupture of its cysts and escape of its contents into the abdominal cavity. 3d. Ovarian gestation, the existence of which is denied by many writers of eminence, such as Velpeau and Arthur Farre, while it is maintained by others of equal celebrity, such as Kiwisch, Coste, and Hecker. It must be admitted that it is extremely difficult to understand how an ovarian pregnancy, in the strict sense of the word, can occur, for it implies that the ovule has become impregnated before the laceration of the Graafian follicle, through the coats of which the spermatozoa must have passed. Coste, indeed, believes that this frequently occurs ; but, while spermatozoa have been detected on the surface of the ovary, their penetration into the Graafian follicle has never been demonstrated. Farre has also clearly shown that in many cases of supposed ovarian pregnancy the surrounding structures were so altered that it was impossible to trace their exact origin, and to say, to a certainty, that the foetus was really within the substance of the ovary. Kiwisch gives a reasonable explanation of these cases by supposing that sometimes the Graafian follicle may rupture, but that the ovule may remain within it without being discharged. Through the rent in the walls of the follicle the spermatozoa may reach and impregnate the ovule, which may develop in the situation in which it has been detained. The subject has been recently ably considered by Puech, * who admit two varieties of ovarian pregnancy, according as the foetus has developed in a vesicle which has remained open, or in one which has closed immediately after fecundation. He considers that most cases of so-called ovarian pregnancy are either dermoid cysts, ovario-tubal pregnancies, or abdominal pregnancies in which the placenta is attached to the ovary, and that even in the rare cases of true ovarian pregnancies, the progress and results do not differ from that of abdominal pregnancy. While, therefore, it is impossible to deny the existence of ovarian pregnancy, it must be considered to be a very rare and exceptional variety, which, as far 1 Armal. de Grnaec, July, 1878. 168 PREGNANCY. as treatment and results are concerned, does not differ from tubal or abdominal gestation. 4th. There are two rare varieties in which an ovum is developed either in the supplementary horn of a bi-lohed uterus, or in a hernial sac. For the sake of clearness, we may place these varieties of extra- uterine gestation in the following tabular form : — 1st. Tubal — ■ (a) Interstitial, (b) Tubo-ovarian. 2d. Abdominal — ■ (a) Primary, (b) Secondary. 3d. Ovarian. 4th. In bi-lobed uterus, hernial, etc. Causes. — The etiology of extra-uterine foetation in any individual case must necessarily be almost always obscure. Broadly speaking, it may be said that extra- uterine foetation may be produced by any condition which prevents, or renders difficult, the passage of the ovule to the uterus, while it does not prevent the access of the spermatozoa to the ovule. Thus inflammatory thickening of the coats of the Fallopian tubes by lessening their calibre, but not suffi- ciently so to prevent the passage of the spermatozoa, may interfere with the movements of the tube which propel the ovum forward, and so cause its arrest. A similar effect may be produced by various morbid conditions, such as inflammatory adhesions, from old-stand- ing peritonitis, pressing on the tube ; obstruction of its calibre by inspissated mucus or small polypoid growths ; the pressure of uterine or other tumors, and the like. The fact that extra-uterine preg- nancies occur most frequently in multiparas, and comparatively rarely in women under thirty years of age, tends to show that these con- ditions, which are clearly more likely to be met with in such women than in young primiparaa, have considerable influence in its causation. A curiously large proportion of cases occur in women who have either been previously altogether sterile, or in whom a long interval of time has elapsed since their last pregnancy. The disturbing effects of fright, either during coition or a few days afterwards, have been insisted on by many authors as a possible cause. Numerous cases of this kind are recorded ; and, although the influence of emotion in the production of this conditiou is not susceptible of proof, it is not difficult to imagine that spasms of the Fallopian tubes might be produced in this way, which would either interfere with the passage of the ovum, or direct it into the abdominal cavity. The oc- currence of abdominal pregnancy is probably less difficult to account for if we admit, with Coste, that the ovule becomes impregnated on the surface of the ovary itself, for there must be very many conditions which prevent the proper adaptation of the fimbriated extremity of the tube to the surface of the ovary, and failing this, the ovum must of necessity drop into the abdominal cavity. Kiwisch has pointed out that this is particularly apt to occur when the Graafian follicle de- velops on the posterior surface of the ovary ; and, indeed, it is proba- ble that it may be of common occurrence, and that the comparative rarity of abdominal pregnancy is due to the difficulty with which the ABNORMAL PREGNANCY 169 impregnated ovale engrafts itself on the surrounding viscera. Im- pregnation may actual iy occur in the abdominal cavity itself, of which Keller 1 relates a remarkable instance. In this case Koeberle had re- moved the body of the uterus and part of the cervix, leaving the ovaries. In the portion of the cervix that remained there was a fistu- lous aperture opening into the abdominal cavity, through which semen passed and produced an abdominal gestation. Several curious cases are also recorded, which have given rise to a good deal of discussion, in which a tubal pregnancy existed while the corpus luteum was on the opposite side (Fig. 77). The most probable explanation, however, is Fig. Tubal Pregnaocy, -with the Corpus Luteum in the Ovary of the opposite side. The Decidua is represented in the process of detachment from the Uterine Cavity. that the fimbriated extremity of the tube in which the ovum was found had twisted across the abdominal cavity and grasped the opposite ovary, in this way, perhaps, producing a flexion which impeded the progress of the ovum it had received into its canal. Tyler Smith suggested that such cases might be explained by supposing that the ovum, after reaching the uterus, failed to graft itself in the mucous membrane, but found its way into the opposite Fallopian tube. Kussmaul 2 thinks that such a passage of the ovum across the uterine cavity may be caused by muscular contraction of the uterus, occurring shortly after conception, squeezing the yet free ovum upwards towards the opening of the opposite tube, and possibly into the tube itself. The history and progress of cases of extra-uterine pregnancy are materially different according to their site, and, for practical pur- poses, we may consider them as forming two great classes : the tubal (with its varieties), and the abdominal. Tubal Pre'/nancies. — When the ovum is arrested in any part of the Fallopian tube the chorion soon commences to develop villi, just as in ordinary pregnancy, which engraft themselves into the mucous tube, and fix the ovum in its new position. The lining of the 1 Dps Gross^ses Extra-nterines, Paris, 1872. 2 Mon. f. Geburt, Oct. 1862. 12 170 PREGNANCY mucous membrane becomes hypertropliied, much in the same way as that of the uterus under similar circumstances ; so that it becomes developed into a sort of pseudo-decidua. Inasmuch, however, as the mucous coat of the tubes is not furnished with tubular glands, a true decidua can scarcely be said to exist, nor is there any growth of membrane around the ovum analogous to the decidua reflexa. The ovum is, therefore, comparatively speaking, loosely attached to its abnormal situation, and hence hemorrhage from laceration of the chorion villi can very readily take place. It is seldom that any development of the chorion villi into distinct placental structure is observed ; this is probably owing to the fact, that laceration and death generally occur before the period at which the placenta is normally formed. The muscular coat of the tube soon becomes hypertropliied, and, as the size of the ovum increases, the fibres are separated from each other, so that the ovum protrudes at certain points through them, and at these it is only covered by the stretched and attenuated mucous and peritoneal coats of the tube. At this time the tubal pregnancy forms a smooth oval tumor, which, as a rule, has not formed any adhesions to the surrounding structures (Fig. 78). The part of the tube unoccupied by the ovum may be Fig. 78. Tubal Pregnancy. (From a Specimen in the Museum of King's College.) found unaltered, and permeable in both directions; or, more fre- quently, it becomes so stretched and altered that its canal cannot be detected. Most frequently it is that part of the tube nearest the uterus which cannot be made out. The condition of the uterus in this, as in other forms of extra-uterine pregnancy, has been the sub- ject of considerable discussion. It is now universally admitted that ABNORMAL PREGNANCY. . 171 the uterus undergoes a certain amount of sympathetic engorgement, the cervix becomes softened, as in natural pregnancy, and the mucous membrane develops into a true decidua. In many cases the decidua is found on post-mortem examination, in others it is not ; and hence the doubts that some have expressed as to its existence. The most reasonable explanation of its absence is that given by Duguet, 1 who has shown that it is far from uncommon for the uterine decidua to be thrown off en masse during the hemorrhagic dis- charges which so frequently precede the fatal issue of extra-uterine gestation. Interstitial and False Ovarian Pregnancy. — When the ovum is arrested in that portion of the tube passing through the uterus, in so-called interstitial pregnancy, the muscular fibres of the uterus become stretched and distended, and form the outer covering of the ovum. When, on the other hand, the site of arrest is in the fimbri- ated extremity of the tube, the containing cyst is formed partly of the fimbriae of the tube, partly of ovarian tissue ; hence it is much more distensible, and the pregnancy may continue without laceration to a more advanced period, or even to term, so that when the ovum is placed in this situation, the case much more nearly resembles one of abdominal pregnancy. Period at which Rapture Occurs. — The termination of tubal preg- nancy, in the immense majority of cases, is death, produced by lace- ration giving rise either to internal hemorrhage, or to subsequent intense peritonitis. Rupture usually occurs at an early period of pregnancy, most generally from the fourth to the twelfth week, rarely later. However, a few instances are recorded in which it did not take place until the fourth or fifth month, and Saxtorph and Spiegel- berg have recorded apparently authentic cases in -which the preg- nancy advanced to term without laceration. It is generally effected by distension of the tube, which at last yields at the point which is most stretched; and sometimes it seems to be hastened or deter- mined by accidental circumstances, such as a blow or fall, or the excitement of sexual intercourse. Symptoms of Rupture. — The symptoms accompanying rupture are those of intense collapse, often associated with severe abdominal pain, produced by the laceration of the cyst. The patient will be found deadly pale, with a small, thready, and almost imperceptible pulse, perhaps vomiting, but with mental faculties clear. If the hemorrhage be considerable, she may die without any attempt at re- action. Sometimes, however — and this generally occurs in cases in which the tube tears, the ovum remaining intact — the hemorrhage may cease on account of the ovum protruding through the aperture, and acting as a plug. The patient may then imperfectly rally, to be again prostrated by a second escape of blood, which proves fatal. If the loss of blood is not of itself sufficient to cause death from shock and anosmia, the fatal issue is generally only postponed, for the effused blood soon sets up a violent general peritonitis, which rapidly 1 Annales de Gynecologie, May, 1874. 172 PREGNANCY carries off the patient. If she should survive the second danger, the case is transformed into one of abdominal pregnancy, the foetus becoming surrounded by a capsule produced by inflammatory exuda- tion (Fig. 79). The case is then subjected to the rules of treatment presently to be discussed when considering that variety of extra- uterine gestation. Fig. 79. Extra-uierinc Pregnancy at term of the Tubo-Ovarian variety. Campbell's.) (After a Case of Dr. A. Sibley Diagnosis. — The possibility of diagnosing tubal gestation before rupture occurs is a question of great and increasing interest, from the fact that, could its existence be ascertained, we might very fairly hope to avert the almost certainly fatal issue which is awaiting the patient. Unfortunately, the symptoms of tubal pregnancy are always obscure, and too often death occurs without the slightest suspicion as to the nature of the case having arisen. In the first place, it is to be observed that all the usual sympathetic disturbances of pregnancy exist : the breasts enlarge, the areolae darken, and morning sickness is present. There is also an arrest of menstruation ; but, after the absence of one or more periods, there is often an irreg- ular hemorrhagic discharge. This is an important symptom, the value of which in indicating the existence of tubal pregnancy has of late years been much dwelt upon by various authors, both in this ABNORMAL PREGNANCY. 173 country and abroad. Barnes attributes it to partial detachment of the chorion villi, produced by the ovum growing out of proportion to the tube in which it is contained. Whether this is the correct explanation or not, it is a fact that irregular hemorrhage very gene- rally precedes the laceration for several days or more. Accompanying this hemorrhage there is almost always more or less abdominal pain, produced by the stretching of the tissues in which the ovum is placed, and this is sometimes described as being of very intense and crampy character. If, then, wc meet with a case in which the symp- toms of early pregnancy exist, in which there are irregular losses of blood, possibly discharge of membranous shreds, and abdominal pain, a careful examination should be insisted on, and then the true nature of the case may possibly be ascertained. Should extra-uterine foetation exist, we should expect to find the uterus somewhat enlarged, and the cervix softened, as in early pregnancy, but both these changes are doubtless generally less marked than in normal pregnancy. This fact of itself, however, is of little diagnostic value, for slight difference of this kind must always be too indefinite to justify a positive opinion. Presence of a Peri-uterine Tumor. — The existence of a peri-uterine tumor, rounded or oval in outline, and producing more or less dis- placement of the uterus, in the direction opposite to that in which the tumor is situated, may point to the existence of tubular foetation. By bimanual examination, one hand depressing the abdominal wall, while the examining finder of the other acts in concert with it either through the vagina or rectum, the size and relations of the growth may be made out. There are various conditions, which give rise to very similar physical signs, such as small ovarian or fibroid growths, or the effusion of blood around the uterus ; and the differential diag- nosis must always be very difficult, and often impossible. A curious example of the difficulties of diagnosis is recorded by Joulin, in which Huguier, and six or seven of the most skilled obstetricians of Paris, agreed on the existence of extra- uterine pregnancy, and had, in con- sultation, sanctioned an operation, when the case terminated by abortion, and proved to be a natural pregnancjr. The use of the uterine sound, which might aid in clearing up the case, is necessarily contra-indicated unless uterine gestation is certainly disproved. Hence it must be admitted that positive diagnosis must almost always be very difficult. So that the most we can say is, that when the general signs of early pregnancy are present, associated with the other symptoms and signs alluded to, the suspicion of tubal preg- nancy may be sufficiently strong to justify us in taking such action as may possibly spare the patient the necessarily fatal consequence of rupture. Treatment. — If the diagnosis were quite certain, the removal of the entire Fallopian tube and its contents by abdominal section would be quite justifiable, and probably would neither be more difficult, nor more dangerous, than ovariotomy ; for, at this stage of extra-uterine foetation, there are no adhesions to complicate the 174 PREGNANCY. operation. As yet, however, the uncertainty of the diagnosis has prevented the adoption of the practice. [In 1816, Dr. John King, 1 ol Edisto Island, South Carolina, ope- rated upon a case of extra-uterine pregnancy by the vaginal section, and saved both mother and child. The placenta was removed, but there does not appear to have been any hemorrhage. — Ed.] Opening of the Sac by the Galvano- caustic Knife. — Dr. Thomas, of New York, 2 has recently recorded a most instructive case, in which he saved the life of the patient by a bold and judicious operation. The nature of the case was rendered pretty evident by the signs above described, and Thomas opened the cyst from the vagina by a platinum knife, rendered incandescent by a galvano-caustic battery, by which means he hoped to prevent hemorrhage. Through the opening thus made he removed the foetus. In subsequently attempt- ing to remove the placenta very violent hemorrhage took place, which was only arrested by injecting the cyst with a solution of persulphate of iron. The remains of the placenta subsequently came away piecemeal, after an attack of septicaemia, which was kept within bounds by freely washing out the cyst with antiseptic lotion, the patient eventually recovering. If I might venture to make a criticism on a case followed by so brilliant a success, it would be that, in another instance of this kind, it would be safer to follow the rule so strictly laid down with regard to gastrotomy in abdominal pregnancies, and leave the placenta untouched, trusting to the injec- tion of antiseptics, and the thorough drainage of the cyst, to prevent mischief. [In a second operation, performed on May 10, 1876, in a case of secondary abdominal pregnancy, Dr. Thomas 3 operated through the linea alba, and removed a female foetus weighing six pounds, fifteen ounces. The funis was traced to the left iliac fossa, where it was apparently inserted into the peritoneum, and no placenta was dis- cernible. The cord was cut off at its origin, and the wound closed, except at its lower part, which was kept open by a glass tube. The woman's pulse before the operation was 120, and fell to 107 at the end of the first week ; temperature was always 100° and upwards, but in the middle of the fourth week it rose to 103°-104°, and the pulse to 130. The placenta was found presenting at the opening in the abdomen, and was removed with dressing forceps. It was of the ordinary diameter, and had a shrivelled appearance. The removal afforded a decided relief, and the temperature fell within three hours. Antiseptic injections were freely used in the treatment of the case, and the patient made a good recover}^. The success of this operation, 4 may be said to have been in a meas- ure, the saving of a similar case in this city, for when Dr. "Walter F. Atlee was shown the report, he finally decided to operate in the case of a woman who had carried a foetus for thirteen months, and in P New York Med. Repos., 1817, p. 388.] 2 New York Med. Journ., June, 1875. [ 3 Am. Journ. of Obstetrics, vol. ix. p. 655, 1876.] [4 Am. Jour, of Med. Sci. Oct. 1878, p. 321, reported by Ed.] ABNORMAL PREGNANCY. 175 whom certain nervous and vascular disturbances were indicative of danger, although she bore the appearance of good health. Laparot- omy was performed on May 18th, 1878, and the patient went home six miles, at the end of twenty-six days. I have seen her repeatedly, and she now weighs more than at any time in her life. This is the only instance of the operation in Philadelphia. The advice given by the author in regard to the non-removal of the placenta was first urged upon the medical profession in 1791, by Mr. William Trumbull in a paper read before the Medical Society of London ; and again in 1795, in a letter 1 from the late Dr. James Mease, of Philadelphia, to Dr. Lettsom, of London, in which he reported an operation by Dr. Charles McKnight, of New York, very similar to this of Dr. Thomas, and ending favorably to the woman. The remarks of Dr. Mease on the impropriety of removing the placenta were read before the same society, and concurred in by some of the members present. It is a little remarkable, that the opinion of Dr. Mease originated in an accident which occurred in the operation of Dr. McKnight, by which the funis was ruptured, and in consequence of which, the placenta, which was outside of the cyst, could not be found for removal. The value of this discovery, appears to have been lost to the profession for a long term of years, as many authors have ob- jected to the operation because of the danger of removing the pla- centa. Prof. T. Gaillard Thomas 2 before mentioned, has perhaps had as successful an experience in the operation of laparotomy for the re- moval of extra-uterine foetuses, as any man either in Europe or America : having operated in this form three times since the begin- ning of May, 1876, with a favorable result in each case. This shows that the operation is much less dangerous to life than was for a long period believed. The day of " waiting for imposthumation to take place 11 is in a measure passing away, and the wiser plan of removing the foetus where the condition of the woman is indicative of clanger is becoming recognized as proper and advisable. It is very well to wait for a pointing to take place in some cases, but we must remem- ber that in many, to delay is to lose the patient. There have been several cases illustrating this latter experience within a few years in Philadelphia, and the actors engaged, have in consequence very ma- terially changed their conservative views.— Ed.] Means of Destroying the Vitality of the Foetus. — Another mode of managing these cases is to destroy the foetus, so as to check its further growth, in the hope that it may remain inert and passive within its sac. Various operations have been suggested and prac- tised for this purpose. Thus needles have been introduced into the tumor, through which currents of electricity have been passed, either the continuous current, or, as has been suggested by Duchenne, a spark of Franklinic electricitv Hicks, Allen and others have en- P Memoirs of Med. Soc. London, vol. iv. p. 342, 1795.] P Am. Jour, of Med. Sci., Oct. 1878, p. 321, and Jan. 1879, p. 17-— Ed.] 176 PREGNANCY. deavored to destroy the foetus by passing an electro-magnetic cur- rent through it by means of a needle. In a case reported by Dr. Bachetti, in which the continuous current was used, the growth of the ovum was arrested, and the patient recovered. The same result, however, would probably have followed the simple puncture of the cyst. This has been successfully practised on several occasions either with a small trocar and canula, or with a simple needle. A very interesting case, in which the development of a two months' tubal gestation was arrested in this way, is recorded by Greenhalgh, 1 and another by Martin, of Berlin. 2 Joulin suggested that not only should the cyst be punctured, but that a solution of morphia should be injected into it, which, by its toxic influence, would insure the destruction of the foetus. Other means proposed for effecting the same object, such as pressure, or the administration of toxic remedies by the mouth, are too far uncertain to be relied on. The simplest and most effectual plan would be to introduce the needle of an aspirator, by which the liquor amnii would be drawn oft', and the further growth of the foetus effectually prevented. Parry, 3 indeed, is opposed to this practice, and has collected several eases in which the puncture of the cyst was followed by fatal results, either from hemorrhage or septicaemia. In these, however, an ordinary trocar and canula were probably empk^ed, which would necessarily admit air into the sac. It is difficult to imagine that a fine hair-like aspi- rating needle, rendered properly antiseptic by carbolic acid, could have any injurious results; and it could do no harm, even if an error of diagnosis had been made, and the suspected extra-uterine foetation turned out to be some other sort of growth. If the aspi- rator proves that an extra-uterine foetation exists, then, if the cyst be of any considerable size, and the pregnancy advanced beyond the second month, we might, if deemed advisable, resort to a more radical operation, such as that so successfully practised by Thomas. Treatment when Rupture has Occurred. — When the chance of arrest- ing the growth of a tubular foetation has never arisen, and we first recognize its existence after laceration has occurred, and the patient is collapsed from hemorrhage, what course are we to pursue? Hith- erto all that ever has been done is to attempt to rally the patient by stimulants, and, in the unlikely event of her surviving the imme- diate effects of laceration, endeavoring to control the subsequent peritonitis, in the hope that the effused blood may become absorbed, as in pelvic hematocele. This is, indeed, a frail reed to rest upon, and when laceration of a tubal gestation, advanced beyond a month, has occurred, death has been the most certain result. It is supposed by Bernutz, and his opinion is shared by Barnes, that rupture which does not prove fatal, is probably not very rare in the first few days of extra-uterine gestation, and that it is not an uncommon cause of certain forms of pelvic hematocele. It has more than once been sug- gested that it would be perfectly justifiable when laceration has oc- « Lancet, 1867. 2 Monat. f. Geburt, 1868. 3 Parry on Extra-Uterine Pregnancy, p. 204. ABNORMAL PREGNANCY. 177 curred to perform gastrotomy, to sponge away the effused blood, and to place a ligature around the lacerated tube and remove it, with its contents. This would no doubt be a bold and heroic procedure, but no one who is acquainted with the triumphs of modern abdominal surgery can say that it would be either impossible or hopeless. The sponging out of effused blood from the abdominal cavity is an every- day procedure in ovariotomy, nor is there any apparent difficulty in ligaturing and removing the sac of the extra-uterine pregnancy, for, as a rule, there are no adhesions formed to the surrounding parts. The history of these cases shows that death does not generally follow rupture for some hours, so that there would be usually time for the operation, and the extreme prostration might be, perhaps, tempo- rarily counteracted by transfusion. Pressure on the abdominal aorta, resorted to when the patient is ficst seen, might possibly be employed with advantage to check further hemorrhage, until the question of operation is decided. We must remember that the alternative is death and hence any operation which would afford the slightest hope of success would be perfectly justifiable. I cannot, therefore, agree with those who hold that because the chances of success are so small, the operation should not be tried ; and I do not doubt that it will yet fall to the lot of some one, by this means, to snatch a patient from the jaws of death, and still further to extend the successes of abdominal surgery. [The great obstacle to such a procedure, is the difficulty or un- certainty of diagnosis. One man of large experience in gynaecological operations may be quite positive of the condition, and be willing to operate, when he is opposed in opinion and decision by a consultation of several medical brethren. A case in point occurred recently in one of our large cities, where the patient was examined by several physicians, one of whom was anxious to operate but was overruled — the lady died in sixty hours, of a slowly oozing hemorrhage from a small ruptured Fallopian cyst as proved by autopsy, and the gynae- cologist proposing to operate was confident that the bleeding might have been readily arrested by laparotomy, and a clamp or ligation. —Ed.] Abdominal Pregnancy. — In the second of the two classes into which, for practical convenience, we have divided extra-uterine -gestation the ovum is developed in the abdominal cavity. It is as yet an open question whether in some cases the pregnancy is primarily abdominal or not. Barnes believes that it probably never is so, on account of the difficulty of admitting that so minute a body as the ovum should be able to fix itself on the smooth peritoneal surface. He therefore thinks that all abdominal pregnancies are primarily either tubal or ovarian, the sac in which they were contained having given way, and the ovum having retained its vitality through partial attach- ment to the original sac. This theory is opposed to that of the ma- jority of writers, and, although it may perhaps render the facts less difficult to understand, it is purely hypothetical. There is no evi- dence to show that in most cases there is an early laceration of a tubal or ovarian sac. That the chorion villi do graft themselves 178 PREGNANCY. upon the surrounding peritoneum is certain, and is observed in all cases of abdominal gestation. It is not more difficult to imagine them doing this from their very first development than a little later; for it must be allowed that if such laceration does occur, in most cases it can only be when pregnancy is very slightly advanced. On the whole, therefore, it seems not unreasonable to admit the usual explanation of these cases, that the ovule, already impregnated, escaped the grasp of the Fallopian tube, and fell into the abdominal cavity, where it rooted itself and developed. Some have, indeed, supposed that abdominal pregnancy may occasionally arise in conse- quence of spermatozoa finding their way into the peritoneal cavity, and there meeting and impregnating an ovule discharged from the Graafian follicle. Such an event one would suppose to be almost im- possible, but Koeberle's case, already quoted, proves that it has actu- ally occurred. The probability is that it is by no means rare for im- pregnated ovules to drop into the peritoneal cavity, and that the majority of those that do so perish without doing any harm. When they do survive, however, the chorion villi sprout, attach themselves to the surrounding structures, and eventually develop into a placenta. The mode in which the chorion villi are attached, and the arrange- ment of the maternal bloodvessels, have never yet been, worked out, and would form a very interesting subject for investigation. The precise seat of attachment varies, and the placenta has been found fixed to most of the abdominal viscera, either those contained in the pelvis proper, or it may be the intestines, or to the iliac fossa ; most frequently, apparently, the ovum finds its way into the retro-uterine cul-de-sac. Formation of a Cyst round the Ovum. — The subsequent changes vary much. In the large majority of cases the ovum produces con- siderable irritation, resulting in the exudation of plastic material, which is thrown round it, so as to form a secondary cj^st or capsule, in which maternal vessels are largely developed, and which stretches, pari passu, with the growth of the ovum (Fig. 80). The density and strength of this cyst are found to be very different in different cases ; sometimes it forms a complete and strong covering to the ovum, at others it is very thin and only partially developed, but it is rarely entirely absent. As there is ample space for the development of the ovum, and as the secondary cyst generally stretches and grows along with it, most cases of abdominal pregnancy progress without any very remarkable symptoms, beyond occasional severe attacks of pain, until the full term of pregnancy has been reached. Sometimes, how- ever, the cyst lacerates, and there is an escape of blood into the abdominal cavity, accompanied by more or less prostration and col- lapse, which may prove fatal, but from which the patient more gen- erally rallies. The foetus, now dead, will remain in the abdomen, and will undergo changes and produce results similar to those which we shall presently described as occurring in cases progressing to the full period. Pseudo-lahor sometimes comes on. — In most cases at the natural termination of pregnancy, a strange series of phenomena occur ; ABNORMAL PREGNANCY 179 pseudo-labor comes on, there are more or less frequent and strong uterine contractions, possibly an escape of blood from the vagina, the discharge of the broken down uterine decidua, and even the estab- lishment of lactation. Sometimes the contractions of the abdominal Uterus and Fcetus iu a Case of Abdominal Pregnancy. muscles, produced by this ineffective labor, have been so strong as to cause the laceration of the adventitious cyst surrounding the foetus. and the escape of blood and liquor amnii into the abdominal cavity, with a rapidly fatal result. More frequently laceration does not occur, and the spurious labor pains continue at intervals, until the fcetus dies, possibly from pressure, but more often from effusion of blood into the tissue of the placenta, and consequent asphyxia. Occa- sionally the foetus has apparently lived a considerable time, in some cases even for several mouths, after the natural limit of pregnancy has been reached. Changes after the Death of the Foetus. — It is after the death of the fcetus that the dangers of abdominal pregnancy generally commence, and they are numerous and various. The subsequent changes that occur are well worthy of study. Occasionally the foetus has been retained for a length of time, even until the end of a long life, with- out producing any serious discomfort, and in many cases of this kind several normal pregnancies and deliveries have subsequently taken place. Even when the extra- uterine gestation appears to be tolerated, and has remained for long without producing any bad effects, serious symptoms may be suddenly developed ; so that no woman, under such circumstances, can be considered safe. The condition of these retained foetuses varies much. Most commonly the liquor amnii is absorbed, the foetus shrinks and dies, all its soft structures are changed into adipocere, and the bones only remain unaltered. Sometimes this change occurs with great rapidity. I have elsewhere 1 recorded 1 Obst. Trans, vii. 180 PREGNANCY a case of extra-uterine foetation in which at the full term of pregnancy the foetus was alive, and the woman died in less than a year after- wards. On post-mortem the foetus was found entirely transformed into a greasy mass of adipocere, studded with foetal bones, in which not a trace of any of the soft parts could be detected. On the other hand the foetus may remain unchanged ; in the Museum of the College of Surgeons there is one which was retained in the abdomen for fifty-two years, and which was found to be as fresh and unaltered as a new-born child. In other cases the sac and its contents atrophy and shrink, and calcareous matter is de- posited in them, so that the whole be- Fig. 81. Lithopsedion. (From a preparation in (he Museum of the College of Surgeons. ; comes converted into a solid mass known as a lithopsedion (Fig. 81). The cases, however, in which the retention of the foetus gives rise to no mischief are quite exceptional. Generally the foetus putre- fies, and this may either immediately cause fatal peritonitis or septicaemia ; or, as more commonly happens, secondary inflammation and suppuration of the sac. Under the influence of the latter the sac opens externally, either directly at some point of the abdominal walls, or indi- rectly through the vagina, the bowels, or even the bladder. Through the aper- ture or apertures thus formed (for there are often several fistulous openings), pus, and the bones and other parts of the broken-down foetus, are discharged ; and this may go on for months, and even years, until at last, if the patient's strength does not give way, the whole contents of the cyst are expelled, and recovery takes place. From various statistical observations it appears, that the chances of recovery are best when the cyst opens through the abdominal walls, next through the vagina or bladder, and that the foetus is discharged with most difficulty and danger when the aperture is formed into the bowel. At the best, however, the process is long, tedious, and full of dangers ; and the patient too often sinks, during the attempt at expulsion, through the irritation and exhaustion produced by the abundant and long-continued discharge. Diagnosis. — The diagnosis of abdominal gestation is by no means so easy as might be thought, and the most experienced practitioners have been mistaken with regard to it. The most characteristic symptom, although this isnot so common as in tubal gestation, is metrorrhagia combined with the general signs of pregnancy. Very severe and frequently repeated attacks of abdominal pain are rarely absent, and should at once cause sus- picion, especiallv if associated with hemorrhage. They are supposed by some to depend on intercurrent attacks of peritonitis, by which the foetal cyst is formed. Parry doubts this explanation, and attrib- ABNORMAL PREGNANCY. 181 utes them partly to the distension of the cyst by the growing foetus, and partly to pressure on the surrounding structures. On palpation the form of the abdomen will be observed to differ from that of nor- mal pregnancy, being generally more developed in the transverse direction, and the rounded outline of the gravid uterus cannot be detected. When development has advanced nearly to term, the ex- treme distinctness with which the foetal limbs can be felt will arouse suspicion. Per vagi nam the os and cervix will be felt softened as in ordinary pregnancy, but often displaced by the pressure of the cyst, and sometimes fixed by peri-metritic adhesions ; either of these signs is of great diagnostic value. By bimanual examination it may be possible to make out that the uterus is not greatly enlarged, and that it is distinctly separate from the bulk of the tumor; these facts, if recognized, would of them- selves disprove the existence of uterine gestation. The diagnosis, if the foetal limbs or heart-sounds could be detected, would be cleared up in any case by the uterine sounds, which would show that the uterus was empty and only slightly elongated. But we must be care- ful not to resort to this test unless the existence of uterine gestation is positivelv disproved by other means. As, however, it places the diagnosis beyond a doubt, it should always be employed whenever operative procedure is in contemplation. Quite recently I have seen a remarkalDle case which illustrates the importance of this rule. The case had been diagnosed as abdominal pregnancy by no less than six experienced practitioners, and was actually on the operating table for the performance of laparotomy. As a precaution, having some doubts of the diagnosis, I suggested the passage of the sound, which entered into a gravid uterus, the case proving to be one of small ovarian tumor jammed clown into Douglas's space, and displacing the cervix forwards. Had it not been for this precaution its true nature would certainly not have been detected. Treatment. — The treatment of abdominal gestation will always be a subject of anxious consideration, and there is much difference of opinion as to the proper course to pursue. It is pretty generally admitted that it is not advisable to adopt any active measures until the full term of development is reached. Puncturing the cyst, with the view of destroying the foetus and arresting its further growth, has been practised, but there are good grounds for rejecting it, for there is not the same imminent risk of death from rupture of the cyst as in tubal foetation ; and even if the destruction of the foetus could be brought about, there would still be formidable dangers from subsequent attempts at elimination, or from internal hemorrhage. Primary Gastrotomy. — When the full period has arrived, the child being still alive, as proved by auscultation, we have to consider whether it may not be advisable to perform gastrotomy before the foetus perishes, and so at least save the life of the child. There are few questions of greater importance, and more difficult to settle. The tendency of medical opinion is rather in favor of immediate opera- tion, which is recommended by Velpeau, Kiwisch, Koeberle, Schroe- der, and many other writers, whose opinion necessarily carries great 182 PREGNANCY. weight. The arguments used in favor of immediate operations are that, while it affords a probability of saving the child, the risks to the mother, great though they undoubtedly are, are not greater than those which maybe anticipated by delay. If we put off interference the cyst may rupture during the ineffectual efforts at labor, and death at once ensae ; or, if this does not take place, other risks, which can never be foreseen, are always in store for the patient. She may sink from peritonitis, or from exhaustion, consequent on the efforts at elimination, which in the majority of cases are sooner or later set up, so that, as Barnes properly saj^s, " the patient's life may be said to be at the mercy of accidents, of which we have no sufficient warn- ing." On the other hand, if we delay, while we sacrifice all hope of saving the child, we at least give the mother the chance of the foeta- tion remaining quiescent for a length of time, as certainly not infre- quently occurs. Thus, Campbell collected 62 cases of ultimate re- covery after abdominal gestation, in 21 of which the foetus was retained without injury for a number of years. Then there is the question of secondary gastrotomy, which consists in operating after the death of the foetus when urgent symptoms. have arisen, a course which is advocated by Mr. Hutchinson. In favor of this procedure it is urged, that by delay the inflammation taking place about the cyst will have greatly increased the chance of adhesions having formed between it and the abdominal parietes, so as to shut off its contents from the cavity of the peritoneum. The more effectually this has been accomplished, the greater are the patient's chances of recovery. When the foetus has been dead for some time the vascu- larity of the cyst will also be lessened, and the placental circulation will have ceased, so that the danger of hemorrhage will be much diminished. It will be seen, therefore, that there are arguments in favor of each of these views. The results of the primary operation are far less favorable than we should have, a priori, supposed. Since the first edition of this work appeared the subject has been carefully studied by Dr. Parry in his exhaustive treatise on Extra-Uterine Foetation. He has there shown that when the case is left until nature has shown the channel through which elimination is to be effected, the mortality is 17.35 less than in the cases in which the primary operation was performed. His conclusion is, that "the pri- mary operation cannot be too forcibly condemned. It is not too much to say that this operation adds only another danger to a life already trembling in the balance, which the delusive hope of saving the un- certain life of a child does not warrant us in assuming." It is only just to remember, as is forcibly pointed out by Keller, that in these days of advanced abdominal surgery a better result might be antici- pated than when gastrotomy was performed in the haphazard way which was usual before we had gained experience from ovariotomy. No doubt minute care in the performance of the operation, a due attention to its details, studiously avoiding, as much as possible, the passage of blood and the contents of the cyst into the peritoneal cavity, and a free use of antiseptics would materially lessen its peril. ABNORMAL PREGNANCY. 183 This conclusion is well illustrated in a recent interesting paper by Thomas, who relates three successful cases of laparotomy in abdomi- nal pregnancy. 1 Mode of performing the Operation. — The operation, then, should be performed with all the precaution with which we surround ovari- otomy. The incision, best made in the linea alba, should not be greater than is necessary to extract the foetus, and may be lengthened as occasion requires. It has been suggested that should the head be felt presenting above the vagina, the intervening structures should be divided, and the foetus withdrawn by the forceps. This procedure was actually adopted with success in 1816, by Dr. John King, of Edisto Island, South Carolina. If there are no adhesions the walls of the cyst should be stitched to the margin of the incision, so as to shut it off as completely as possible from the peritoneal cavity. This has been specially insisted on by Braxton Hicks, and should never be omitted. The special risk is not so much the wounding of the peritoneum, as the subsequent entrance of septic matter from the cyst into its cavity. Another cardinal rule, both in primary and secondary gastrotomy, is to make no attempt to remove the placenta. Its attachments are generally so deep seated and diffused, that any endeavor to separate it is likely to be attended with profuse and un- controllable hemorrhage, or with serious injury to the structure to which it is attached. Many of the failures after operating can be traced to a neglect of this rule. The best subsequent course to pur- sue, after removing the foetus and arresting all hemorrhage, either by ligature or the actual cautery, is to sponge out the cyst as gently as possible, and then to bring the upper part of the wound into appo- sition with sutures, leaving the lower open, with the cord protruding so as to insure an outlet for the escape of the placenta as it slips down. The subsequent treatment must be specially directed to favor the escape of the discharge, and to prevent the risk of septicaemia. These objects may be much aided by injections of antiseptic fluids, such as a solution of carbolic acid, or diluted Condy's fluid ; and it would perhaps be advisable to place a drainage tube in the lower angle of the wound. It may be well to point out that there is no operation in which a scrupulous following of the antiseptic method, on Mr. Lister's principles, is so likely to be useful. Treatment when the Foetus is Dead. — -As long as the placenta is re- tained the danger is necessarily great, and it may be many clays or even weeks before it is discharged. "When once this is affected the sac may be expected to contract, and eventually to close entirely. AVhen the foetus is dead, or when we have determined not to attempt primary gastrotomy, it is advisable to wait, verj^ carefully watching the patient, until either the gravity of her general symptoms, or some positive indication of the channel through which nature is about to attempt to eliminate the foetus, shows us that the time for action has arrived. If there be distinct bulging of the cyst in the vagina, or in the retro- vaginal cul-de-sac, especially if an opening has formed there, 1 Am. Journ. of Med. Sci., Jan. 1879. 184 PREGNANCY. we may properly content ourselves with aiding the passage of the foetus through the channel thus indicated, and removing the parts that present piecemeal as they come within reach, cautiously enlarg- ing the aperture if necessary. If the sac have opened into the intes- tines, the expulsion of the foetus through this channel is so tedious and difficult, the exhaustion attending it so likely to prove fatal, and the danger from decomposition of the foetus through passage of in- testinal gas so great, that it would probably be best to attempt to remove it by gastrotomy, especially if it is only recently dead, and the greater portion is still retained. Mode of Performing Secondary Gastrotomy. — If an opening forms at the abdominal parietes, or if the symptoms determine us to resort to secondary gastrotomy before this occurs, the operation must be performed in the same way, and with the same precautions, as primary gastrotomy. Here, as before, the safety of the operation must greatly depend on the amount and firmness of the adhesions ; for if the cyst be not completely shut off from the peritoneal cavity, the risks of the operation will be little less than those of primary gastrotomy. It would obviously materially influence our decision and prognosis if we could determine this point before operating. Unfortunately it is impossible, as the experience of ovariotomists proves, to ascertain the existence of adhesions with any certainty. If, however, we find that the abdominal parietes do not move freely over the cyst, and if the umbilicus be depressed and immovable, the presumption is that considerable adhesions exist. If they are found not to be present, the cyst walls should be stitched to the margin of the incision, in the manner already indicated, before the contents are removed. If the foetus has been long dead, and its tissues greatly altered, its removal may be a matter of difficulty. In the case under my own care, already alluded to, the foetal structures formed a sticky mass of such a nature, that I believe it would have been impossible to empty the cyst had an operation been attempted. This possibility would be, to some extent, a further argument in favor of the primary operation. Opening of Cyst by Caustics. — The importance of adhesion has led some practitioners to recommend the opening of the cyst by potassa fusa or some other caustic, in the hope that it would set up adhesive inflammation around the apertures thus formed. Several successful operations by this method are recorded, and it would be worth trving, should the extreme mobility of the cyst lead us to suspect that no adhesions existed. If we have to deal with a case in which fistulous openings leading to the cyst have already formed, it may, perhaps, be advisable to dilate the apertures already existing, rather than make a fresh incision ; but, in determining this point, the sur- geon will naturally be guided by the nature of the case, and the character and direction of the fistulous openings. General Treatment. — It is almost needless to say anything of general treatment in these trying cases ; but the administration of opiates to allay the sufferings of the patient, and the endeavor to ABNORMAL PREGNANCY. lbO support the severely taxed vital energies by appropriate food and medication, will form a most important part of the management. Gestation in a Bi-lobed Uterus. — -A few words may be said as to gestation in the rudimentary horn of a bi-lobecl uterus, to which considerable attention has of late years been directed by the writings of Kussmaul and others. It appears certain that many cases of supposed tubal gestation are really to be referred to this category. Although such cases are of interest pathologically, they scarcely re- quire much discussion from a practical point of view, inasmuch as their history is pretty nearly identical with that of tubal pregnancy. The rudimentary horn is distended by the enlarging ovum, and after a time, when further distension is impossible, laceration takes place. As a matter of fact, all the 13 cases collected by Kussmaul termi- nated in this way ; and even on post-mortem examination it is often extremely difficult to distinguish them from tubal pregnancies. The best way of doing is probably by observing the relations of the round ligaments to the tumor, for, if the gestation be tubal, they will be found attached to the uterus on the inner or uterine side of the cyst; whereas, if the pregnancy be in a rudimentary horn of the uterus, they will be pushed outwards and be external to the sac. hi the latter case, moreover, the sac will be probably found to contain a true decidua, which is not the case in tubal pregnancy. The only point in which they differ is that in cornual pregnancy rupture may be delayed to a somewhat later period than in tubal, on account of the greater distensibility of the supplementary horn. Missed Labor. — The term " missed labor 11 is applied to an exceed- ingly rare class of cases in which, at the full period of pregnancy, labor has either not come on at all, or, having commenced, the pains have subsequently passed off, and the foetus is retained in utero for a very considerable length of time. Under such circumstances it has usually happened that the membranes have ruptured at or about the proper term, and the access of air to the foetus in utero has been followed by decomposition. A putrid and offensive discharge has then com- menced, and eventually portions of the disintegrating foetus have been expelled per vaginam. This discharge may go on until the en- tire foetus is gradually thrown off; or, more frequently, the patient dies from septicaemia, or other secondary result of the presence of the decomposing mass in utero. Thus McClintock relates one case, 1 in which symptoms of labor came on in a woman, 45 years of age, at the expected period of de- livery, but passed off without the expulsion of the foetus. For a period of sixty-seven weeks a highly offensive discharge came away, with some few bones, and she eventually died with symptoms of pyaemia. He also cites another case in which the patient died in the same way, after the foetus had been retained for eleven years. [Two very remarkable cases have occurred in the United States, which are especially Avorthy of note as the women became the sub- jects of the Cesarean section. The first 2 occurred in a mulatto of 25 3 : Dublin Quart. .Tonrn., Feb. and May, 1864. ,o [ 2 Am. Jour. Med. Sci. vol. xviii. page 257.] 18b PREGNANCY. the mother of three or four children, a native of Virginia, who car- ried her foetus two years, and was in labor at intervals during fifteen months. She was affected with occlusion of the cervix, and had a calcareous incrustation over and around the internal os. Gastro-hys- terotomy was performed in 1828 and a putrid foetus removed. The woman was doing well until the middle of the second week when she was seized with peritonitis after a meal of meat and cider. The second 1 woman was black, set. 33 ; mother of one child ; car- ried her foetus three and a half years ; had a partial rupture of the uterus at four months and nearly died ; was in labor a tterm, but foetus did not descend ; pains at intervals for a month ; an abscess opened near umbilicus in about twenty months ; Csesarean section in 1860, in Louisiana; abdominal cavity not opened; foetus putrid; one foot and hand found secured by bands in a pouch on the left side of the uterus ; woman recovered. She had been attended in her labor by a midwife. — Ed.] Ulceration of the Uterine Walls. — Sometimes, when the foetus has been retained for a length of time, a further source of danger has Fig. 82. Contents of the Cyst in Dr. Oldham's case of Missed Labor. been added by ulceration or destruction of the uterine walls, proba- bly in consequence of an ineffectual attempt at its elimination. This occurred in Dr. Oldham's case (Fig. 82), in which the contained mass is said to have nearly worn through the anterior wall of the uterus; [» N. 0. Med. and Surg. Jour., July, 1877, p. 35.] ABNORMAL PREGNANCY. 187 and also in one reported by Sir James Simpson, 1 in which a patient died three months after term, the foetus having undergone fatty meta- morphosis, an opening the size of half-a-crown having formed between the transverse colon and the uterine cavity. It is also stated that " the uterine walls were as thin as parchment." In some few cases, however, probably when the entrance of air has been prevented, the foetus has been retained for a length of time without decomposing, and without giving rise to any troublesome symptoms. Such a case is reported by Dr. Cheston, 2 in which the foetus remained in utero for fifty -two years. Its Causes. — The causes of this strange occurrence are altogether unknown. Generally the foetus seems to have died sometime before the proper term for labor, and this may have influenced the character of the pains. It is probably also most apt to occur in women of feeble and inert habit of body, possibly where there was some obsta- cle to the dilatation of the cervix, which the pains were unable to overcome. Barnes suggests 3 that some presumed examples of missed labor " were really cases of interstitial gestation, or gestation in one horn of a two-horned uterus." In several of the cases, however, the details of the post-mortem examination are too minute to admit of the possibility of mistake having been made. Miiller, of Nancy, has recently attempted to prove, by a critical examination of published cases, that most examples of so-called " mixed labor" were in reality cases of extra-uterine foetation, in which an ineffectual attempt at parturition took place, the foetus being subsequently retained. From what has been said, it will be seen that the dangers arising from this state are very considerable, and when once the full term has passed beyond doubt, especially if the presence of an offensive discharge shows that deconiDOsition of the foetus has commenced, it would be proper practice to empty the uterus as soon as possible. The necessary precaution, however, is not to decide too quickly that the term has really passed ; and, therefore, we must either allow sufficient time to elapse to make it quite certain that the case really falls under this category, or have unequivocal signs of the death of the foetus, and injury to the mother's health. If we had to deal with the case before any extensive decomposition of the foetus had occur- red, we probably should find little difficulty in its management, for the proper course then would be to dilate the cervix with the fluid dilators, and remove the foetus by turning; or, before doing so, we might endeavor to excite uterine action by pressure and ergot. If the case did not come under observation until disintegration of the foetus had begun, it would be more difficult to deal with. If the foetus had become so much broken up that it was being discharged in pieces, Dr. McClintock says that " in regard to treatment, our measures should consist mainly of palliatives, viz., rest and hip-baths to subdue uterine irritation; vaginal injections to secure cleanliness i Edin. Med. Journ., 1865. 2 Me d. C hir. Trans., 1814. 3 Diseases of Women, p. 445. 188 PREGXANCY. and prevent excoriation ; occasional digital examination, so as to de- tect any fragments of bone that might be presenting at the os, and to assist in removing them. These are plain rational measures, and beyond them we shall scarcely, perhaps, be justified in venturing. Nevertheless, under certain circumstances, I would not hesitate to dilate the cervical canal so as to permit of examining the interior of the womb, and of extracting any fragments of bone that may be easily accessible ; but unless they could thus be easily reached and removed, the safer course would be to defer, for the present, interfer- ing with them. 1 It may be doubted, I think, whether, considering the serious results which are known to have followed so many cases, it would not, on the whole, be safer to make at least one decided effort, under chloroform, to remove as much as possible of the putrefying uterine contents, after the os has been fully dilated. Such a procedure would be less irritating than frequently repeated endeavors to pick away detached portions of the foetus, as they present at the os uteri. When once the os is dilated, antiseptic intra-uterine injections, as of diluted Condy's fluid, might safely and advantageously be iised. Unquestionably, it would be better practice to interfere and empty the uterus as soon as we are quite satisfied of the nature of the case, rather than to delay, until the foetus has been disintegrated. CHAPTEE VII. DISEASES OF PKEGNANCY. The diseases of pregnancy form a subject so extensive that they might well of themselves furnish ample material for a separate treatise. The pregnant woman is, of course, liable to the same diseases as the non-pregnant ; but it is only necessary to allude to those whose course and effects are essentially modified by the exist- ence of pregnancy, which have some peculiar effect on the patient in consequence of her condition. There are, moreover, many dis- orders which can be distinctly traced to the existence of pregnancy. Some of them are the direct results of the sympathetic irritations which are then so commonly observed ; and, of these, several are only exaggerations of irritations which may be said to be normal accompaniments of gestation. These functional derangements may be classed under the head of neuroses, and they are sometimes so slight as merely to cause temporary inconvenience, at others so grave as seriously to imperil the life of the patient. Another class of 1 Dublin Quart. Journ.. vol. xxxvii. p. 314. DISEASES OF PREGNANCY. 189 disorders are to be traced to local causes in connection with the gravid uterus, and are either the mechanical results of pressure, or of some displacement, or morbid state of the uterus; while the origin of others may be said to be complex, being partly due to sympathetic irritation, partly to pressure, and partly to obscure nutritive changes produced by the pregnant state. Derangements of the Digestive System,. — Among the sympathetic derangements there are none which are more common, and none which more frequently produce distress, and even danger, than those which affect the digestive system. Under the heading of " The Signs of Pregnancy," the frequent occurrence of nausea and vomiting has already been discussed, and its most probable causes considered (p. 137). A certain amount of nausea is, indeed, so common an accom- paniment of pregnancy, that its consideration as one of the normal symptoms of that state is fully justified. We need here only discuss those cases in which the nausea is excessive and long-continued, and leads to serious results from inanition, and from the constant distress it occasions. Fortunately a pregnant woman may bear a surprising amount of nausea and sickness without constitutional injury, so that apparently almost all aliments may be rejected, without the nutrition of the body very materially suffering. At times the vomiting is limited to the early part of the day, when all food is rejected, and when there is a frequent retching of glairy transparent fluid, in severe cases mixed with bile, while at the latter part of the day the stomach may be able to retain a sufficient quantity of food, and the nausea disappears. In other cases the nausea and vomiting are almost incessant. The patient feels constantly sick, and the mere taste or sight of food may bring on excessive and painful vomiting. The duration of this distressing accompaniment of pregnancy is also variable. Generally it commences between the second and third months, and disappears after the woman has quickened. Sometimes, however, it begins with conception, and continues unabated until the pregnancy is over. Symptoms of the Graver Coses. — In the worst class of cases, when all nourishment is rejected, and when the retching is continuous and painful, symptoms of very great gravity, which may even prove fatal, develop themselves. The countenance becomes haggard from suffering, the tongue dry and coated, the epigastrium tender on pres- sure, and a state of extreme nervous irritability, attended with rest- lessness and loss of sleep, becomes established, In a still more aggra- vated degree, there is general feverishness, with a rapid, small, and thready pulse. Extreme emaciation supervenes, the result of wast- ing from lack of nourishment. The breath is intensely fetid, and the tongue dry and black. The vomited matters are sometimes mixed with blood. The patient becomes profoundly exhausted, a low form of delirium ensues, and death may follow if relief is not obtained. Prognosis. — Symptoms of such gravity are fortunately of extreme rarity, but they do from time to time arise, and cause much anxiety. Gueniot collected 118 cases of this form of the disease, out of which 190 PREGNANCY. 46 died ; and out of the 72 that recovered, in 42 the symptoms only- ceased when abortion, either spontaneous, or artificially produced, had occurred. When pregnancy is over the symptoms occasionally cease with marvellous rapidity. The power of retaining and assimi- lating food is rapidly regained, and all the threatening symptoms disappear. Treatment. — In the milder forms of obstinate vomiting, one of the first indications will be to remedy airy morbid state of the primal viae. The bowels will not infrequently be found to be obstinately constipated, the tongue loaded, and the breath offensive ; and when attention has been paid to the general state of the digestive organs by general aperient medicines, and antacid remedies, such as bismuth and soda, and pepsine after meals, the tendency to vomiting may abate without further treatment. Regulation of Diet. — The careful regulation of the diet is yery im- portant. Great benefit is often derived from recommending the patient not to rise from the recumbent position in the morning until she has taken something. Half a cup of milk and lime-water, or a cup of strong coffee, or a little rum and milk, or cocoa and milk, or even a morsel of biscuit, taken on waking, often has a remarkable effect in diminishing the nausea. When any attempt at swallowing solid food brings on vomiting, it is better to give up all pretence at keeping to regular meals, and to order such light and easily assimi- lated food, at short intervals, as can be retained. Iced milk with lime or soda-water, given frequently, and not more than a mouthful at a time, will frequently be retained when nothing else will. Cold beef jelly, a spoonful at a time, will also be often kept down. Spark- ling koumiss has been strongly recommended as very useful in such cases, and is worthy of trial. It is well, however, to bear in mind, in regulating the diet, that the stomach is fanciful and capricious, and that the patient may be able to retain strange and apparently unlikely articles of food ; and that, if she express a desire for such, the experiment of letting her have them should certainly be tried. Medicinal Treatment.— The medicines that have been recommended are innumerable, and the practitioner will often have to try one after the other unsuccessfully ; or may find, in an individual case, that a remedy will prove valuable which, in another, may be altogether powerless. Amongst those most generally useful are effervescing draughts, containing from three to five minims of dilute hydrocyanic acid; the creasote mixture of the Pharmacopoeia; tincture of mix vomica, in doses of five or ten minims ; single minim doses of vinum ipecacuanhas, every hour in severe cases, three or four times daily in those which are less urgent; salicine, in doses of three to five grains three times a day, recommended by Tyler Smith ; oxalate of cerium, in the form of pill, of which three to five grains may be given three times a day — a remedy strongly advocated by Sir James Simpson, and which occasionally is of undoubted service, but more often fails ; the compound pyroxylic spirit of the London Pharmacopoeia in doses, of five minims every four hours, with a little compound tincture of cardamoms, a drug which is comparatively little known, but which DISEASES OF PREGNANCY. 191 occasionally has a very marked and beneficial effect in checking vomiting ; opiates in various forms — which sometimes prove useful, more often not — maybe administered either by the mouth or in pills containing from half a grain to a grain of opium, or in small doses of the solution of the bimeconate of morphia or of Battley's sedative solution, or subcutaneously, a mode of administration which is much more often successful. If there is much tenderness about the epigas- trium, one or two leeches may be advantageously applied, or one- third of a grain of morphia may be sprinkled on the surface of a small blister, or cloths saturated in laudanum may be kept over the pit of the stomach. The administration per rectum of twenty grains of chloral, combined with the same amount of bromide of potassium, in a small enema, is said to be very useful. In many cases I have found that the application of a spinal ice-bag to the cervical vertebrae, in the manner recommended by Dr. Chapman, has checked the vom- iting when all drugs have failed. The ice may be placed in one of Chapman's spinal ice-bags, and applied for half an hour or an hour, twice or three times a clay. It invariably produces a comforting- sensation of warmth, which is always agreeable to the patient. Ice may be given to suck ad libitum, and is very useful ; while, if there be much exhaustion, small quantities of iced champagne may also be given from time to time. Local Treatment. — Inasmuch as the vomiting unquestionably has its origin in the uterus, it is only natural that practitioners should endeavor to check it by remedies calculated to relieve the irritability of that organ. Thus morphia in the form of pessaries per vaginam, or belladonna applied to the cervix, has been recommended, and — ■ the former especially — are often of undoubted service. A pessary containing one-third to half a grain of morphia may be introduced night and morning, without interfering with other methods of treat- ment. Dr. Henry Bennet directs especial attention to the cervix, which, he says, is almost always congested and inflamed, and covered with granular erosions. This condition he recommends to be treated by the application of nitrate of silver through the speculum. Dr. Clay, of Manchester, corroborates this view, and strongly advocates, especially when vomiting continues in the latter months, that one or two leeches should be applied to the cervix. Exception may fairly be taken to both these methods of treatment as being somewhat hazardous, unless other means have been tried and failed. I have little doubt, however, that, in many cases, a state of uterine con- gestion is an important factor in keeping up the unduly irritable condition of the uterine fibres, and an endeavor should always be made to lessen it by insisting on absolute rest in the recumbent pos- ture. Of the importance of this precaution in obstinate cases there can be no question. Dr. Chapman, of Norwich, strongly recommends dilation of the cervix by the finger, and states that he has found it very serviceable in checking nausea. It is obvious that this treat- ment must be adopted with great caution, as, roughly performed, it might lead to the production of abortion. Dr. Hewitt's views as to the dependence of sickness on flexions of the uterus have already 192 PREGNANCY. been adverted to, and reasons have been given for doubting the general correctness of his theory. It is quite likely, however, that well-marked displacements of the uterus, either forwards or back- wards, may serve to intensify the irritability of the organ. Cazeaux mentions an obstinate case immediately cured by replacing a retro- verted uterus. A careful vaginal examination should, therefore, be instituted in all intractable cases, and if distinct displacement be de- tected, an endeavor should be made to support the uterus in its normal axis. If retroverted, a Hodge's pessary may be safely em- ployed ; if anteverted, a small air-ball pessary, as recommended by Hewitt, should be inserted. I believe, however, that such displace- ments are the exception rather than the rule in cases of severe sick- ness. The importance of promoting nutrition by every means in our poAver should always be borne in mind. The effervescing koumiss, which can now be readily obtained, I have found of great value, as it can often be retained when all other aliment is rejected. The ex- haustion produced by want of food soon increases the irritable state of the nervous system, and, if the stomach will not retain anything, Ave can only combat it by occasional nutrient enemata of strong beef tea, yolk of egg, and the like. The production of Artificial Abortion. — Finally, in the worst class of cases, when all treatment has failed, and when the patient has fallen into the condition of extreme prostration already described, we may be driven to consider the necessity of producing abortion. For- tunately cases justifying this extreme resource are of great rarity, but nevertheless there is abundant evidence that, every now and then women do die from uncontrollable vomiting, whose lives might have been saved had the pregnancy been brought to an end. The value of artificial abortion has been abundantly proved. Indeed, it is re- markable how rapidly the serious symptoms disappear AA'hen the uterus is emptied, and the tension of the uterine fibres lessened. It has fortunately but rarely fallen to my lot to have to perform this operation for intractable vomiting. In one such case the patient Avas reduced to a state of the utmost prostration, having kept hardly any food on her stomach for many Aveeks, and when I first saw her she was lying in a state of low muttering delirium. Within a few hours after abortion was induced all the threatening symptoms had disap- peared, the vomiting had entirely ceased, and she Avas next day able to retain and absorb all that Avas given to her. The value of the operation, therefore, I believe to be undoubted. Where it has failed, it seems to have been on account of undue delay. Owing to the natural repugnance Avhich all must feel toAvards this plan, it has gene- rally been postponed until the patient has been too exhausted to rally. If, therefore, it is done at all, it should be before prostration has ad- vanced so far as to render the operation useless. In these cases the obvious indication is to lessen the tension of the uterus at once, and therefore the membranes should be punctured by the uterine sound, so as to let the liquor amnii drain aAvay, and this may of itself be sufficient to accomplish the desired effect. It is almost needless to DISEASES OF PREGNANCY. 193 add, that no one would be justified in resorting to this expedient without having his opinion fortified by consultation with a fellow- practitioner. Other disorders of the digestive system may give rise to considerable discomfort but not to the serious peril attending obstinate vomiting. Amongst them are loss of appetite, acidity and heartburn, flatulent distension and sometimes a capricious appetite, which assumes the form of lono-ing for strange and even disgusting articles of diet. As- sociated with these conditions there is generally derangement of the whole intestinal tract, indicated by furred tongue and sluggish bowels, and they are best treated by remedies calculated to restore a healthy condition of the digestive organs, such as a light easily digested diet, mineral acids, vegetable bitters, occasional aperients, bismuth and soda, and pepsine. The indications for treatment are not different from those which accompany the same symptoms in the non-pregnant state. Diarrhoea is an occasional accompaniment of pregnancy, often de- pending on errors of diet. When excessive and continuous it has a decided tendency to induce uterine contractions, and I have frequently observed premature labor to follow a sharp attack of diarrhoea. It should, therefore, not be neglected ; and, if at all excessive, should be checked by the usual means, such as chalk mixture with aromatic confection, and small doses of laudanum or chlorodyne. The possi- bility of apparent diarrhoea being associated with actual constipation, the fluid matter finding its way past the solid materials blocking up the intestines, should be borne in mind. Constipation is much more common, and is indeed a very general accompaniment of pregnancy, even in women who do not suffer from it at other times. It partly depends on the mechanical interference of the gravid uterus with the proper movements of the intestines, and partly on defective innervation of the bowels resulting from the altered state of the blood. The first indication will be to remedy this defect by appropriate diet, such as fresh fruits, brown bread, oat- meal porridge, etc. Some medicinal treatment will also be necessary, and, in selecting the drugs to be used, care should be taken to choose such as are mild and unirritating in their action, and tend to improve the tone of the muscular coats of the intestine. A small quantity of aperient mineral water in the early morning, such as the Hunyadi, Frederickshalle, or Pullna water, often answers very well; or an oc- casional dose of the confection of sulphur ; or a pill containing three or four grains of the extract of colocynth, with a quarter of a grain of the extract of nux vomica, and a grain of extract of hyoscyamus at bedtime; or a teaspoon ful of the compound liquorice powder in milk at bedtime. Constipation is also sometimes effectually com- bated by administering, twice daily, a pill containing a couple of grains of the inspissated ox-gall, with a quarter of a grain of extract of belladonna. Enemata of soap and water are often very useful, and have the advantage of not disturbing the digestion. In the latter months of pregnancy, especially in the few weeks preceding delivery the irritation produced by the collection of hardened feces in the 194 PREGNANCY. bowel is a not infrequent cause of the annoying false pains which then so commonly trouble the patient. In order to relieve them, it will be necessary to empty the bowels thoroughly by an aperient, 'such as a good dose of castor oil, to which fifteen or twenty minims of laudanum may be advantageously added. Should the rectum become loaded with scybalous masses, it may be necessary to break down and re- move them by mechanical means, provided we are unable to effect this by copious enemata. Hemorrhoids. — The loaded state of the rectum so common in preg- nancy, combined with the mechanical effect of the pressure of the gravid uterus on the hemorrhoidal veins, often produces very trou- blesome symptoms from piles. In such cases a"" regular and gentle evacuation of the bowels should be secured daily, so as to lessen as much as possible the congestion of the veins. Any of the aperients already mentioned, especially the sulphur electuary, may be used. Dr. Fordyce Barker 1 insists that, contrary to the usual impression, one of the best remedies for this purpose is a pill containing a grain or a grain and a half of powdered aloes, with a quarter of a grain of extract of nux vomica, and that castor oil is distinctly prejudicial, and apt to increase the symptoms. I have certainly found it answer well in several cases. When the piles are tender and swollen, they should be freely covered with an ointment consisting of four grains of muriate of morphia to an ounce of simple ointment, or with the Ung. Gallae c. opio of the Pharmacopoeia ; and, if protruded, an at- tempt should be made to push them gently above the sphincter, by which they are often unduly constricted. Belief may also be ob- tained by frequent hot fomentations, and sometimes, when the piles are much swollen, it will be found useful to puncture them, so as to lessen the congestion, before any attempt at reduction is made. Ptyalism. — A profuse discharge from the salivary glands is an occasional distressing accompaniment of pregnancy. It is generally confined to the early months, but it occasionally continues during the whole period of gestation, and resists all treatment, only ceasing when delivery is over. Under such circumstances the discharge of saliva is sometimes enormous, amounting to several quarts a day, and the distress and annoyance to the patient are very great. In one case under my care the saliva poured from the mouth all day long, and for several months the patient sat with a basin constantly by her side, incessantly emptying her mouth, until she was reduced to a condition giving rise to really serious anxiety. This profuse saliva- tion is, no doubt, a purely nervous disorder, and not readily con- trolled* by remedies. Astringent gargles, containing tannin and chlorate of potass, frequent sucking of ice, or of tannin lozenges, in- halation of turpentine and creasote, counter-irritation over the sali- vary glands by blisters or iodine, the bromides, opium internally, may all be tried in turn, but none of them can be depended on with any degree of confidence. Toothache and Caries of the Teeth. — Severe dental neuralgia is also 1 The Puerperal Diseases, p. 33. DISEASES OF PREGNANCY. 195 a frequent accompaniment of pregnancy, especially in the early months. When purely neuralgic, quinine in tolerably large doses is the best remedy at our disposal ; but not infrequently, it depends on actual caries of the teeth, and attention should always be paid to the condition of the teeth, when facial neuralgia exists. There is no doubt that pregnancy predisposes to caries, and the observation of this fact has given rise to the old proverb, ''for every child a tooth." Mr. Oakley Coles, in an interesting paper 1 on the condition of the mouth and teeth during pregnancy, refers the prevalence of caries to the coexistence of acid dyspepsia, causing acidity of the oral secre- tions. There is much unreasonable dread amongst practitioners as to interfering with, the teeth during pregnancy, and some recommend that all operations, even stopping, should be postponed until after delivery. It seems to me certain that the suffering of severe tooth- ache is likely to give rise to far more severe irritation than the opera- tion required for its relief, and I have frequently seen badly decayed teeth extracted during pregnancy, and with only a beneficial result. Affections of the Respiratory Organs. — Amongst the derangements of the respiratory organs, one of the most common is spasmodic cough, which is often excessively troublesome. Like many other of the sympathetic derangements accompanying gestation, it is purely nervous in character, and is unaccompanied by elevated temperature, quickened pulse, or any distinct auscultatory phenomena. In char- acter it is not unlike whooping-cough. The treatment must obviously be guided by the character of the cough. Expectorants are not likely to be of service, while benefit may be derived from some of the anti- spasmodic class of drugs, such as belladonna, hydrocyanic acid, opi- ates, or bromide of potassium. Such remedies may be tried in suc- cession, but will often be found to be of little value in arresting the cough. Dyspnoea may also be nervous in character, and sometimes symptoms, not unlike those of spasmodic asthma, are produced. Like the other sympathetic disorders, it, as well as nervous cough, is most frequently observed during the early months. There is an- other form of dyspnoea, not uncommonly met with, which is the me- chanical result of the interference with the action of the diaphragm and lungs by the pressure of the enlarged uterus. Hence this is most generally troublesome in the latter months, and continues unre- lieved until delivery, or until the sinking of the uterine tumor which immediately precedes it. Bej^ond taking care that the pressure is not increased by tight lacing or injudicious arrangement of the clothes, there is little' that can be done to relieve this form of breath- lessness. [In some instances, the difficulty of respiration is particularly dis- tressing when the patient attempts to lie clown in bed; and sleep is rendered broken and unrefreshing. In such cases two points are indicated: we must elevate the chest, and at the same time relieve the tension of the abdomen. This is best accomplished by the use of an inclined plane, in the form of a wide board padded with pillows, J Trans, of the Odontological Society. 196 PREGNANCY. resting on the head and middle of the bed at its two ends. The patient is to rest her back upon this, in a half-reclining position, and have her knees elevated with a pillow under them, on which she virtually, as it were, sits. This I have found to give great relief, especially to primiparse, who are apt to suffer from diaphragm- atic pressure and abdominal resistance. Inunction of the abdomen will also be found of value. — Ed.] Palpitation, like dyspnoea, may be due either to sympathetic dis- turbance, or to mechanical interference with the proper action of the heart. "When occurring in weakly women it may be referred to the functional derangements which accompany the chlorotic condition of the blood often associated with pregnancy, and is then best reme- died by a general tonic regimen, and the administration of ferruginous preparations. At other times anti- spasmodic remedies may be indi- cated, but it is seldom sufficiently serious to call for much special treatment. Syncope. — Attacks of fainting are not rare, especially in delicate women of highly -developed nervous temperament, and are perhaps most common at or about the period of quickening, although some- times lasting through the whole pregnancy. In most cases these attacks cannot be classed as cardiac, but are more probably nervous in character, and they are rarely associated with complete abolition of consciousness. They rather, therefore, resemble the condition described by the older authors as lypothemia. The patient lies in a semi-unconscious condition with a feeble pulse and widely-dilated pupils, and this state lasts for varying periods, from a few minutes to half an hour or more. In one very troublesome case under my care they often recurred as frequently as three or four times a day. I have observed that they rarely occur when the more common sym- pathetic phenomena of pregnancy, especially vomiting, are present. Sometimes they terminate with the ordinary symptoms of hysteria such as sobbing. The treatment should consist during the attack in the administration of diffusible stimulants, such as ether, sal-volatile, and valerian, the patient being placed in the recumbent position with the head low. If frequently repeated it is ^inadvisable to attempt to rally the patient by the too free administration of stimulants. In the intervals a generally tonic regimen, and the administration of ferru- ginous remedies, are indicated. If they recur with great frequency the daily application of the spinal ice-bag has proved of much service. Extreme Anaemia and Chlorosis. — In connection with disorders of the circulatory system may be noticed those which depend on the state of the blood. The altered condition of the blood, which has already been described as a physiological accompaniment of pregnancy (p. 132), is sometimes carried to an extent which may fairly be called morbid; and, either on account of the deficiency of blood-corpuscles, or from the increase in its watery constituents, a state of extreme anaemia and chlorosis may be developed. This may be sometimes carried to a very serious extent. Thus Gusserow 1 records five cases J Arch. f. Gyn., ii. 2, 1871. DISEASES OF PREGNANCY. 197 in which nothing but excessive anaemia could be detected, all of which ended fatally. Generally when such symptoms have been carried to an extreme extent, the patient has been in a state of chlorosis before pregnancy. The treatment must, of course, be calculated to improve the general nutrition, and enrich the impoverished blood ; a light and easily assimilated diet, milk, eggs, beef- tea, and animal food — if it can be taken — -attention to the proper action of the bowels, a due amount of stimulants, and abundance of fresh air, will be the chief indications in the general management of the case. Medicinally, fer- ruginous preparations will be required. Some practitioners object, apparently without sufficient reason, to the administration of iron during pregnancy, as liable to promote abortion. This unfounded prejudice may probably be traced to the supposed emmenagogue prop- erties of the preparations of iron ; but, if the general condition of the patient indicate such medication, they may be administered without any fear. Preparations of phosphorus, such as the phosphide of zinc, or free phosphorus in capsules, also promise favorably, and are well worthy of trial. (Edema associated with Hydrsemia. — Some of the more aggravated cases are associated with a considerable amount of serous effusion into the cellular tissue, generally limited to the lower extremities, but occasionally extending to the arms, face, and neck, and even producing ascites and pleuritic effusion. Under the latter circum- stances this complication is, of course, of great gravity, and it is said that after delivery the disappearance of the serous effusion may be accompanied by metastasis of a fatal character to the lungs or the nervous centres. This form of oedema must be distinguished from the slight oedematous swelling of the feet and legs so commonly ob- served as a mechanical result of the pressure of the gravid "uterus, and also from those cases of oedema associated with albuminuria. The treatment must be directed to the cause, while the disappearance of the effusion may be promoted by the administration of diuretic drinks, the occasional use of saline aperients, and rest in the hori- zontal position. Albuminuria. — The existence of albumen in the urine of pregnant women has for many j^ears attracted the attention of obstetricians, and it is now well known to be associated, in wa^vs still imperfectly understood, with many important puerperal diseases. Its presence in most cases of puerperal eclampsia was long ago pointed out by Lever in this country and Bayer in France, and its association with this disease gave rise to the theory of the dependence of the convul- sion on uremia, which is still generally entertained. It has been shown of late years, especially by Braxton Hicks, that this associa- tion is by no means so universal as was supposed; or rather that, in some cases, the albuminuria follows and does not precede the convul- sions, of which it might therefore be supposed to be the consequence rather than the cause; so that further investigations as to these par- ticular points are still required. Modern researches have shown that there is an intimate connection between many other affections and albuminuria; as, for example, certain forms of paralysis, either of 198 PREGNANCY. special nerves, as puerperal amaurosis, or of the spinal system; cephalalgia and dizziness ; puerperal mania ; and possibly hemor- rhage. It cannot, therefore, be doubted that albuminuria in the pregnant woman is liable, at any rate, to be associated with grave disease, although the present state of our knowledge does not enable us to define very distinctly its precise mode of action. Causes of Puerperal Albuminuria. — The presence of albumen in the urine of pregnant women is far from a rare phenomenon. Blot and Litzman met with albuminuria in 20 per cent, of pregnant women, which is, moreover, far above the estimate of other authors ; Fordyce Barker 1 thinks it occurs in about 1 out of 25 cases, or 4 per cent., while Hofmier 2 found it in 137 out of 5000 deliveries in the Berlin Gncekolical Institution, or 2.71 per cent. As in the large majority of these cases, it rapidly disappears after delivery, it is obvious that its presence must, in a large proportion of cases, depend on temporary causes, and has not always the same serious importance as in the non-pregnant state. This is further proved by the undoubted fact that albumen, rapidly disappearing after delivery, is often found in urine of pregnant women who go to term, and pass through labor without any unfavorable symptoms. Pressure by the Gravid Uterus. — The obvious fact that in pregnancy the vessels supplying the kidneys are subjected to mechanical pres- sure from the gravid uterus, and that congestion of the venous circu- lation of those viscera must necessarily exist to a greater or less degree, suggests that here we may find an explanation of the frequent occurrence of albuminuria. This view is further strengthened by the fact that the albumen rarely appears until after the fifth month, and, therefore, not until the uterus has attained a considerable size ; and also that it is comparatively more frequently met with in primiparas, in whom the resistance of the abdominal parietes, and consequent pressure, must be greater than in women who have already borne children. It is, indeed, probable that pressure and consequent venous congestion of the kidneys have an important influence in its produc- tion ; but there must be, as a rule, some other factor in operation, since an equal, or even greater amount of pressure is often exerted bv ovarian and fibroid tumors, without any such consequences. Altered State of the Blood. — This is probably to be found in the altered condition of the blood, which, on account of the unusual call for nutritive supply on the part of the foetus, contains an excess of albuminous material. Hence we have two factors ahvays at work in the pregnant woman, both predisposing to the escape of albumen, viz., a turgid state of the renal venous system, and a super-albumi- nous condition of the blood. But in the large majority of cases, although these conditions are present, no albuminuria exists, and they must, therefore, be looked upon as predisposing causes, to which some other is added before the albumen escapes from the vessels. What this is generally escapes our observation, but probably any condition 1 American Journal of Obstetrics, July, 1878. 2 Berlin Klin. Woch., Sept. 1878. DISEASES OF PREGNANCY. 199 producing sudden hyperemia of the kidneys, and giving rise to a state analogous to the first stage of Bright's disease — such, for ex- ample, as sudden exposure to cold and impeded cutaneous action — may be sufficient to set a light to the match already prepared by the existence of pregnancy. In addition to these temporary causes it must not be forgotten that pregnancy may supervene in a patient already suffering from Bright's disease, when of course the albumen will exist in the urine from the commencement of gestation. The Effects of Puerperal Albuminuria. — The various diseases asso- ciated with the presence of albumen in the urine will require sepa- rate consideration. Some of these, especially puerperal eclampsia, are amongst the most dangerous complications of pregnancy. Others, such as paralysis, cephalalgia, dizziness, may also be of considerable gravity. The precise mode of their production, and whether they can be traced, as is generally believed, to the retention of urinary elements in the blood, either urea or free carbonate of ammonia produced by its de- composition, or whether the two are only common results of some undetermined cause, will be considered when we come to discuss puerperal convulsions. Whatever view may ultimately be taken on these points, it is sufficiently obvious that albuminuria in a pregnant woman must constantly be a source of much anxiety, and must induce us to look forward with considerable apprehension to the termination of the case. Prognosis. — We are scarcely in possession of a sufficiently large number of observations to justify any very accurate conclusions as to the risk attending albuminuria during pregnancy, but it is certainly by no means slight. Hofmeir believes that albuminuria is a most severe complication both for woman and child, even when uncom- plicated with eclampsia. The prognosis, he thinks, depends on whether it is acute in its onset, that is, coming on within a few davs of labor, or is extended over several weeks. The former is more likely to pass entirely away after delivery, while in the latter there is more risk of the morbid state of the kidneys becoming permanent, and leading to the establishment of Bright's disease after the preg- nancy is over. Groubeyre estimated that 49 per cent, of primipara? who have albuminuria, and who escape eclampsia, die from morbid conditions traceable to the albuminuria. This conclusion is prob- ably much exaggerated, but if it even approximate to the truth, the danger must be very great. Tendency to produce Abortion. — Besides the ultimate risk to the mother, albuminuria strongly predisposes to abortion, no doubt on account of the imperfect nutrition of the foetus by blood impoverished by the drain of albuminous materials through the kidneys. This fact has been observed by many writers. A good illustration of it is given by Tanner, 1 who states that four out of seven women he at- tended suffering from Bright's disease during pregnancy, aborted, one of them three times in succession. Symptoms. — The symptoms accompanying albuminuria in preg- 1 Signs and Diseases of Pregnancy, p. 428. 200 PREGNANCY. nancy are by no means uniform or constantly present. That which most frequently causes suspicion is the anasarca- — -not only the cede- matous swelling of the lower limbs which is so common a consequence of the pressure of the gravid uterus, but also of the face and upper extremities. Any puffiness or infiltration about the face, or any oedema about the hands or arms, should always give rise to suspicion, and lead to a careful examination of the urine. Sometimes this is carried to an exaggerated degree, so that there is anasarca of the whole body. Anomalous nervous symptoms — such as headache, transient dizzi- ness, dimness of vision, spots before the eyes, inability to see objects distinctly, sickness in women not at other times suffering from nausea, sleeplessness, irritability of temper — are also often met with, sometimes to a slight degree, at others very strongly developed, and should always arouse suspicion. Indeed, knowing as we do that many morbid states may be associated with albuminuria, w T e should make a point of carefully examining the urine of all patients in whom any unusually morbid phenomena show themselves during pregnancy. Character of the Urine. — The condition of the urine varies con- siderably, but it is generally scanty and highly colored, and, in addi- tion to the albumen, especially in cases in which the albuminuria has existed for some time, we may find epithelium cells, tube casts, and occasionally blood corpuscles. Treatment. — The treatment must be based on what has been said as to the causes of the albuminuria. Of course it is out of our power to remove the pressure of the gravid uterus, except by inducing labor ; but its effects may at least be lessened by remedies tending to promote an increased secretion of urine, and thus diminishing the congestion of the renal vessels. The administration of saline diure- tics, such as the acetate of potash, or bitartrate of potash, the latter being given in the form of the well-known imperial drink, will best answer this indication. The action of the bowels may be solicited by purgatives producing watery motions, such as occasional doses of the compound jalap powder. Dry cupping over the loins, frequently repeated, has a beneficial effect in lessening the renal hyperemia. The action of the skin should also be promoted by the use of the vapor bath, and with this view the Turkish bath may be employed with great benefit and perfect safety. Jaborancli and pilocarpi^ have been given for this purpose, but have been found by Fordyce Barker to produce a dangerous degree of depression. The next indication is to improve the condition of the blood by appropriate diet and medi- cation. A very light and easily assimilated diet should be ordered, of which milk should form the staple. Tarnier 1 has recorded several cases in which a purely milk diet was very successful in removing albuminuria. With the milk, which should be skimmed, we may allow white of egg 1 or a little white fish. The tincture of the per- chloride of iron is the best medicine we can give, and it may be ad- 1 Annal. de Gynec, Jan. 1876. DISEASES OF PREGNANCY. 201 vantageously combined with small doses of tincture of digitalis, which acts as an excellent diuretic. Question of Inducing Labor. — Finally, in obstinate cases we shall have to consider the advisability of inducing premature labor. The propriety of this procedure in the albuminuria of pregnancy has of late rears been much discussed. Spiegelberg 1 is opposed to ]t, while Barker 2 thinks it should only be resorted to " w hen treatment has been thoroughly and perseveringly tried without success for the re- moval of symptoms of so grave a character that their continuance would result in the death of the patient." Hofmeir, 3 on the other hand, is in favor of the operation which he does not think increases the risk of eclampsia, and may avert it altogether. I believe that, having in view the undoubted risks which attend this complication, the operation is unquestionably indicated, and is perfectly justifiable, in all cases attended with symptoms of serious gravity. It is not easy to lav down any definite rules to guide our decision ; but I should not hesitate to adopt this resource in all cases in which the quantity of albumen is considerable and progressively increasing, and in which treatment has failed to lessen the amount ; and, above all, in every case attended with threatening symptoms, such as severe headache, dizziness, or loss of sight. The risks of the operation are infinitesimal compared to those which the patient would run in the event of puerperal convulsions supervening, or chronic Bright's dis- ease becoming established. As the operation is seldom likely to be indicated until the child has reached a viable age, and as the albu- minuria places the child's life in danger, we are quite justified in considering the mother's safety alone in determining on its perform- ance. CHAPTER Till. DISEASES OF PREGNANCY (CONTINUED). Disorders of the Nervous System. — There are many disorders of the nervous system met with during the course of pregnancy. Among the most common are morbid irritability of temper, or a state of mental despondency and dread of the results of the labor, some- times almost amounting to insanity, or even progressing to actual mania. These are but exaggerations of the highly susceptible state of the nervous system generally associated with gestation. Want of sleep is not uncommon, and, if carried to anv great extent, may pro- duce serious trouble from the irritability and exhaustion it produces 1 Lehrbuch. des Geburt. 2 Amer. Jour, of Obstet., July, 1S78. 3 Up. cit. 14 202 PREGNANCY. In such cases we should endeavor to lessen the excitable state of the nerves, by insisting on the avoidance of late hours, over-much society, exciting amusements, and the like ; while it may be essential to promote sleep by the administration of sedatives, none answering so well as the chloral hydrate, in combination with large closes of the bromide of potassium, which greatly intensifies its hypnotic effects. [I have for several years made use of the bromide of sodium very extensively for the purpose of quieting nervous excitability and securing sleep. This salt is more soluble than that of potash ; has a larger equivalent of bromine, and hence more hypnotic power ; is more grateful to the stomach, and more purely salt-like in character. Its price in the United States, is no longer an obstacle to its extensive use. — Ed.] Headaches and Neuralgias. — Severe headaches and various intense neural giae are common. Amongst the latter the most frequently met with are pain in the breasts due to the intimate sympathetic connection of the mamma? with the gravid uterus; and intense inter- costal neuralgia, which a careless observer might mistake for pleu- ritic or inflammatory pain. The thermometer, by showing that there is no elevation of temperature, would prevent such a mistake. Neu- ralgia of the uterus itself, or severe pains in the groins or thighs — the latter being probably the mechanical results of dragging on the attachments of the abdominal muscles- — are also far from uncommon. In the treatment of such neuralgic affections attention to the state of the general health, and large doses of quinine and ferruginous pre- parations whenever there is much debility, will be indicated. Locally sedative applications, such as belladonna and chloroform liniments ; friction with aconite liniment when the pain is limited to a small space ; and, in the worst cases, the subcutaneous injection of mor-- phia, will be called for. Those pains which apparently depend on mechanical causes may often be best relieved by lessening the trac- tion on the muscles, by wearing a well-made elastic belt to support the uterus. Paralysis depending on Pregnancy .—Among the most interesting of the nervous diseases are various paralytic affections. Almost all varieties of paralysis have been observed, such as paraplegia, hemi- plegia (complete or incomplete), facial paralysis, and paralysis of the nerves of special sense, giving rise to amaurosis, deafness, and loss of taste. Churchill records 22 cases of paralysis during pregnancy, collected by him from various sources. A large number have also been brought together by Imbert Goubeyre, 1 in an interesting memoir on the subject, and others are recorded by Fordyce Barker, Joulin, and other authors ; so that there can be no doubt of the fact that paralytic affections are common during gestation. In a large propor- tion of the cases recorded the paralyses have been associated with albuminuria, and are doubtless ursemic in origin. Thus in 19 cases, related by Goubeyre, albuminuria was present in all; Darcy, 2 how- ever, found no albuminuria in 5 out of 14 cases. The dependency of i Mem. de l'Acad. de Med., 1801. 2 These de Paris, 1877. DISEASES OF PREGNANCY. 203 the paralysis on a transient cause, explains the fact that in the large majority of these cases the paralysis was not permanent, but disap- peared shortly after labor. In every case of paralysis, whatever be its nature, special attention should be directed to the state of the urine, and, should it be found to be albuminous, labor should be at once induced. This is clearly the proper course to pursue, and we should certainly not be justified in running the risk that must attend the progress of a case in which so formidable a symptom has already developed itself. When the cause has been removed, the effect will also generally rapidly disappear, and the prognosis is therefore, on the whole, favorable. Should the paralysis continue after delivery, the treatment must be such as we would adopt in the non-pregnant state; and small doses of strychnia, along with faradization of the affected limbs, would be the best remedy at our disposal. Paralyses which are not Uraemic in their Origin. — There are, how- ever, unquestionably some cases of puerperal paralysis which are not uremic in their origin, and the nature of which is somewhat obscure. Hemiplegia may doubtless be occasioned by cerebral hemorrhage, as in the non-pregnant state. Other organic causes of paralysis, such as cerebral congestion, or embolism, may, now and again, be met with during pregnancy, but cases of this kind must be of compara- tive rarity. Other cases are functional in their origin. Tarnier relates a case of hemiplegia which he could only refer to extreme anaemia. Some, again, may be hysterical. Paraplegia is apparently more frequently unconnected with albuminuria than the other forms of paralysis; and it may either depend on pressure of the gravid uterus on the nerves as they pass through the pelvis, or on reflex action, as is sometimes observed in connection with uterine disease. When, in such cases, the absence of albuminuria is ascertained by frequent examination of the urine, there is obviously not the same risk to the patient as in cases depending on uroemia, and therefore it may be justifiable to allow pregnancy to go on to term, trusting to subsequent general treatment to remove the paralytic symptoms. As the loss of power here depends on a transient cause, a favorable prognosis is quite justifiable. Partial paralysis of one lower ex- tremity, generally the left, sometimes occurs, from pressure of the foetal occiput, and may continue for some days or weeks, with a gradual improvement, after parturition. Chorea is not infrequently observed, and forms a serious complica- tion. It is generally met with in young women of delicate health, and in the first pregnancy. In a large proportion of the cases the patient has already suffered from the disease before marriage. On the occurrence of pregnancy, the disposition to the disease again becomes evoked, and choreic movements are re-established. This fact may be explained partly by the susceptible state of the nervous system, partly by the impoverished condition of the blood. Prognosis. — That chorea is a dangerous complication of pregnancy is apparent by the fact that out of 56 cases collected by Dr. Barnes, 1 1 Obst. Trans., vol. x. 204 PREGNANCY. no less than 17, or 1 in 3, proved fatal. Nor is it danger to life alone that is to be feared, for it appears certain that chorea is more apt to leave permanent mental disturbance when it occurs during pregnancy, than at other times. It has also an unquestionable tendency to bring on abortion or premature labor, and in most cases the life of the child is sacrificed. Treatment. — The treatment of chorea during pregnancy does not differ from that of the disease under more ordinary circumstances; and our chief reliance will be placed on such drugs as the liquor arsenicalis, bromide of potassium, and iron. In the severe form of the disease, the incessant movements, and the weariness and loss of sleep, may very seriously imperil the life of the patient, and more prompt and radical measures will be indicated. If, in spite of our remedies, the paroxysms go on increasing in severity, and the patient's strength appears to be exhausted, our only resource is to remove the most evident cause by inducing labor. Generally the symptoms lessen and disappear soon after this is clone. There can be no question that the operation is perfectly justifiable, and may even be essential under such circumstances. ' It should be borne in mind that the chorea often recurs in a subsequent pregnancy, and extra care should then always be taken to prevent its development. Disorders of the urinary organs are of frequent occurrence. Re- tention of urine may be met with, and this is often the result of a retroverted uterus. The treatment, therefore, must then be directed to the removal of the cause. This subject will be more particularly considered when we come to discuss that form of displacement (p. 209); but we may here point out that retention of urine, if long con- tinued, may not only lead to much distress, but to actual disease of the coats of the bladder. Several cases have been recorded in which cystitis, resulting from urinary retention in pregnancy, eventually caused the exfoliation of the entire mucous membrane of the blad- der, 1 which was cast off, sometimes entire, sometimes in shreds, and occasionally with portions of the muscular coat attached to it. The possibility of this formidable accident should teach us to be careful not to allow any undue retention of urine, but, by a timely use of the catheter, to relieve the symptoms, while we, at the same time, endeavor to remove the cause. Irritability of the bladder is of frequent occnrrence. In the early months it seems to be the consequence of sympathetic irritation of the neck of the bladder, combined with pressure, while in the later months it is, probably, solely produced by mechanical causes. When severe it leads to much distress, the patient's rest being broken, and disturbed by incessant calls to micturate, and the suffering induced may produce serious constitutional disturbances. I have elsewhere pointed out, 2 that irritability of the bladder in the latter months of pregnancy is frequently associated with an abnormal position of the foetus, which is placed transversely or obliquely. The result is either that undue pressure is applied to the bladder, or that it is drawn out 1 Obst. Trans., vol. xi. 2 Obst. Trans., vol. xiii. DISEASES OF PREGNANCY. 205 of its proper position. The abnormal position of the foetus can readily be detected by palpation, and as readily altered by external manipu- lation. In some of the cases I have recorded, altering the position of the foetus was immediately followed, by relief; the symptoms re- curring after a time, when the foetus had again assumed an oblique position. Should the foetus frequently become displaced, an endeavor may be made to retain it in the longitudinal axis of the uterus by a proper adaptation of bandages or pads. In cases not referable to this cause we should attempt to relieve the bladder symptoms by appro- priate medication, such as small doses of liquor potassse, if the urine be very acid ; tincture of belladonna ; the decoction of triticum repens, an old but very serviceable remedy; and vaginal sedative pessaries containing morphia or atropine. [In one case where a lad}' had borne two children with very little inconvenience, I found great suffering from the pressure of the foetus on the bladder, commencing as early as the fifth month. This con- tinued for a period of two months, when she very fortunately mis- carried. In making a digital exploration, I recognized that the fuetus was anencephalus, and for this reason descended too low in the pelvis. — Ed.] Incontinence of Urine. — Women who have borne many children are often troubled with incontinence of urine during pregnancy, the water dribbling away on the slightest movement. Through, this much irritation of the skin surrounding the genitals is produced, at- tended with troublesome excoriations and eruptions. Relief may be partially obtained by lessening the pressure on the bladder by an abdominal belt, while the skin is protected by applications of simple ointment or glycerine. Phosphatic Deposit. — Dr. Tyler Smith has directed attention to a phosphatic condition of the urine occurring in delicate women, whose constitutions are severely tried by gestation. This condition can easily be altered by rest, nutritious diet, and a course of restorative medicines, such as steel, mineral acids, and the like. Leucorrhaea. — A profuse whitish leucorrhoeal discharge is very common during pregnancy, especially in its latter half. The discharge frequently alarms the patient, but, unless it is attended with disa- greeable symptoms, it does not call for special treatment. When at all excessive, it may lead to much irritation of the vagina and ex- ternal generative organs. The labia may become excoriated and covered with small aphthous patches, and the whole vulva may be hot, swollen, and tender. Warty growths, similar in appearance to syphilitic condylomata, are occasionally developed in pregnant women, unconnected with any specific taint, and associated with" the presence of an irritating leucorrhoeal discharge. According to Thibierge, 1 these resist local applications, such as sulphate of copper or nitrate of silver, but spontaneously disappear after delivery. Inasmuch as the leucorrhoeal discharge is dependent on the congested condition of the generative organs accompanying pregnancy, we can hope to do 1 Arch. Gen. de Med.. 1656. 206 PREGNANCY. little more than alleviate it. In tlie severer forms, as has been pointed out by Henry Bennet, the cervix will be found to be abraded or covered with granular erosion, and it may be, from time to time, cautiously touched with the nitrate of silver, or a solution of carbolic acid. Generally speaking, we must content ourselves with recom- mending the patient to wash the vagina out gently with diluted Condy's fluid; or with a solution of the sulpho-carbolate of zinc, of the strength of four grains to the ounce of- water ; or with plain tepid water. For obvious reasons frequent and strong vaginal douches are to be avoided, but a daily gentle injection, for the purpose of ablution, can do no harm. Pruritis. — A very distressing pruritis of the vulva is frequently met with along with leucorrhoea, especially when the discharge is of an acrid character, which in some cases leads to intense and protracted suffering, forcing the patient to resort to incessant friction of the parts. Pruritis, however, may exist without leucorrhoea, being apparently sometimes of a neuralgic character, at others associated with aphthous patches on the mucous membrane, ascarides in the rectum, or pediculi in the hairs of the mons veneris and labia. Cases are even recorded in which the pruritic irritation extended over the whole body. The treatment is difficult and unsatisfactory. Various sedative applica- tions may be tried, such as weak solutions of Goulard's lotion ; or a lotion composed of an ounce of the solution of the muriate of morphia, with a drachm and a half of hydrocyanic acid, in six ounces of water ; or one formed by mixing one part of chloroform with six of almond oil. A very useful form of medication consists in the insertion into the vagina of a pledget of cotton-wool, soaked in equal parts of the glycerine of borax and sulphurous acid. This may be inserted at bedtime, and withdrawn in the morning by means of a string attached to it. In the more obstinate cases, the solid nitrate of silver maybe lightly brushed over the vulva ; or, as recommended by Tarnier, a solution of bichloride of mercury, of about the strength of two grs. to the ounce, may be applied night and morning. The state of the digestive organs should always be attended to, and aperient mineral water may be usefully administered. When the pruritis extends beyond the vulva, or even in severe local cases, large doses of bromide of potassium may perhaps be useful in lessening the general hyper- sesthetic state of the nerves. Effects of Pressure. — Some of the disorders of pregnancy are the direct results of the mechanical pressure of the gravid uterus. The most common of these are oedema and a varicose state of the veins ot the lower extremities,, or even of the vulva. The former is of little consequence, provided we have assured ourselvesthat it is really the result of pressure, and not of albuminuria, and it can generally be relieved by rest in the horizontal position. A varicose state of the veins of the lower limbs is very common, especially in multiparas, in whom it is apt to continue after delivery. Occasionally the veins of the vulva, and even of the vagina, are also enlarged and varicose, producing considerable swelling of the external genitals. Eest in the recumbent position, and the use of an abdominal belt, so as to DISEASES OF PREGNANCY. 207 take the pressure off the veins as much as possible, are all that can bj done to relieve this troublesome complication. If the veins of the legs are much swollen, some benefit may be derived from an elastic stocking or a carefully applied bandage. Occasional serious results from Laceration of the Veins. — Serious and even fatal consequences have followed the accidental laceration of the swollen veins. When laceration occurs during or immediately after delivery — a not uncommon result of the pressure of the head — it gives rise to the formation of a vaginal thrombus. It has occa- sionally happened from an accidental injurj' during pregnancy, as in the cases recorded by Simpson, in which death followed a kick on the pudenda, producing laceration of a varicose vein, or in one men- tioned by Tarnier, where the patient fell on the edge of a chair. Severe hemorrhage has followed the accidental rupture of a vein in the leg. The only satisfactory treatment is pressure, applied directly to the bleeding parts by means of the finger, or by compresses satu- rated in a solution of the perchloricle of iron. The treatment of vaginal thrombns following labor must be considered elsewhere. Occasionally the varicose veins inflame, become very tender and painful, and coagula form in their canals. In such cases absolute rest should be insisted on, while sedative lotions, such as the chloro- form and belladonna liniments, should be applied to relieve the pain. Displacements of the Gravid Uterus. — Certain displacements of the gravid uterus are met with, which may give rise to symptoms of great gravity. Prolapse, which is rare, is almost always the result of pregnancy occurring in a uterus which had been previously more or less proci- dent. Under such circumstances the increasing weight of the uterus will at first necessarily augment the previously existing tendency to protrusion of the womb, which may come to protrude partially or entirely beyond the vulva. In the great majority of cases, as preg- nancy advances, the prolapsus cures itself, for at about the fourth or fifth month the uterus will rise above the pelvic brim. It has been said, that, in some cases of complete procidentia, pregnancy has gone on even to term, with the uterus lying entirely outside the vulva. Most probably these cases were imperfectly observed, the greater part of the uterus being in reality above the pelvic brim, a portion only of its lower segment protruding externally ; or, as has some- times been the case, the protruding portion has been an old standing hypertrophic elongation of the cervix, the external os uteri and fundus being normally situated. Should a prolapsed uterus not rise into the abdominal cavity as pregnancy advances, serious symptoms will be apt to develop themselves ; for, unless the pelvis be unusually capacious, the enlarging uterus will get jammed within its bony walls, the rectum and urethra will be pressed upon, defecation and micturition will be consequently impeded, and severe pain and much irritation will result. In all probability such a state of things would lead to abortion. The possibility of these consequences should, there- fore, teach us to be careful in the management of every case of prolap- sus, however slight, in which pregnancy occurs. Absolute rest, in the 208 PREGNANCY. horizontal position, should be insisted on ; while the uterus should be supported in the pelvis by a full-sized Hodge's pessary, which should be worn until at least the sixth month, when the uterus would be fully within the abdominal cavity. After delivery, prolonged rest should be recommended, in the hope that the process of involu- tion may be accompanied by a cure of the prolapse. There can be no doubt that pregnancy carried to term affords an opportunity of curing even old-standing displacements, which should not be neg- lected. Antcversion of the gravid uterus seldom produces symptoms of consequence. In all probability it is common enough when preg- nancy occurs in a uterus which is more than usually anteverted, or is anteflexed. Under such circumstances, there is not the same risk of incarceration in the pelvic cavity as in cases in which pregnancy exists in a retroflexed uterus, for, as the uterus increases in size, it rises without difficulty into the abdominal cavity. In the early months the pressure of the fundus on the bladder may account for the irritability of that viscus then so commonly observed. It will be remembered that Graily Hewitt attributes great importance to this condition as explaining the sickness of pregnancy — a theory, however, which has not met with general acceptation. Extreme anteversion of the uterus, at an advanced period of preg- nancy, is sometimes observed in multiparas with very lax abdominal Avails, occasionally to such an extent that the uterus falls completely forwards and downwards, so that the fundus is almost on a level with the patient's knees. This form of pendulous belly may be associated with a separation of the recti muscles, between which the womb forms a ventral hernia, covered only hj the cutaneous textures. When labor comes on this variety of displacement may give rise to trouble by destroying the proper relation of the uterine and pelvic axes. The treatment is purely mechanical, keeping the patient lying on her back as much as possible, and supporting the pendulous abdo- men by a properly adjusted bandage. A similar forward displace- ment is observed in cases of pelvic deformity, and in the worst forms, in rachitic and dwarfed women, it exists to a very exaggerated de- gree. .Retroversion.- — The most important of the displacements, in conse- quence of its occasional very serious results, is retroversion of the gravid uterus. It was formerly generally believed that this was most commonly produced by some accident, such as a fall, which dislocated a uterus previously in a normal position. Undue dis- tension of the bladder was also considered to have an important influence in its production, by pressing the uterus backwards and downwards. Its Causes. — It is now almost universally admitted that, although the above-named causes may possibly sometimes produce it, in the very large proportion of cases it depends on pregnancy having occurred in a uterus previously retroverted or retroflexed. The merit of pointing out this fact unquestionably belongs to the late DISEASES OF PREGNANCY. 209 Dr. Tyler Smith, and further observations have fully corroborated the correctness of his views. In the large majority of cases in which pregnancy occurs in a uterus so displaced, as the womb enlarges, it straightens itself, and rises into the abdominal cavity, without giving any particular trouble; or, as not infrequently happens, the abnormal position of the organ interferes so much with its enlargement as to produce abortion. Sometimes, however, the uterus increases without leaving the pelvis until the third or fourth month, when it can no longer be retained in the pelvic cavity without inconvenience. It then presses on the urethra and rectum, and eventually becomes completely in- carcerated within the rigid walls of the bony pelvis, giving rise to characteristic symptoms. Symptoms. — The first sign which attracts attention is generally some trouble connected with micturition, in consequence of pressure on the urethra, On examination, the bladder will often be found to be enormously distended, forming a large, fluctuating abdominal tumor, which the patient has lost all power of emptying. Fre- quently small quantities of urine dribble away, leading the woman to believe that she has passed water, and thus the distension is often overlooked. Sometimes the obstruction to the discharge of urine is so great as to lead to dropsical effusion into the cellular tissue of the arms and legs. This was very well marked in one of my casus, and disappeared rapidly after the bladder had been emptied. Difficulty in defecation, tenesmus, obstinate constipation, and inability to empty the bowels, becomes established about the same time. These symp- toms increase, accompanied by some pelvic pain and a sense of weight and bearing down, until at last the patient applies for advice, and the true nature of the case is detected. When the retroversion occurs suddenly, all these symptoms develop with great rapidity and are sometimes very serious from the first. Progress and Termination. — The further progress is various. Sometimes, after the uterus has been incarcerated in the pelvis for more or less time, it may spontaneously rise into the abdominal cavity, when all threatening symptoms will disappear. So happy a termination is quite exceptional, and if the practitioner should not interfere and effect reposition of the organ, serious and even fatal consequences may ensue, unless abortion occurs. Termination if Reduction is not Effected. — The extreme distension of the bladder, and the impossibility of relieving it, may lead to lacerations of its coats, and fatal peritonitis: or the retention of urine may produce cystitis, with exfoliation of the coats of the bladder; or, as more commonly happens, retention of urinary elements may take place, and death occur with all the symptoms of uremic poison- ing. At other times the impacted uterus becomes congested and inflamed, and eventually sloughs, its contents, if the patient survive, being discharged by nstulous"communications into the rectum and vagina. It need hardly be said that such terminations are only possi- ble in cases which have been grossly mismanaged, or the nature of which has not been detected till a late period. 210 PREGNANCY. Diagnosis. — The diagnosis is not difficult. On making a vaginal examination, the finger impinges on a smooth rounded elastic swell- ing, filling up the lower part of the pelvis, and stretching and de- pressing the posterior vaginal wall, which occasionally protrudes beyond the vulva. On passing the finger forwards and upwards we shall generally be able to reach the cervix, high up behind the pubes, and pressing on the urethral canal. In very complete retroversion it may be difficult or impossible to reach the cervix at all. On ab- dominal examination the fundus uteri cannot be felt above the pelvic brim ; this, as the retroversion does not give rise to serious symp- toms until between the third and fourth months, should, under natural circumstances, always be possible. By bi- manual examina- tion we can make out, with due care, the alternate relaxation and contraction of the uterine parietes characteristic of the gravid uterus, and so differentiate the swelling from any other in the same situa- tion. The accompanying phenomena of pregnane? will also prevent any mistake of this kind. Retroversion [joimj on to Term. — In some few cases retroversion has been supposed to go on to term. Strictly speaking, this is impossi- ble^ but in the supposed examp]es, such as in the well-known case recorded by Oldham, part of a retroflexed uterus remained in the pelvic cavity, while the greater part developed in the abdominal cavity. The uterus is, therefore, divided, as it were, into two por- tions; one, which is the flexed fundus, remaining in the pelvis, the other, containing the greater part of the foetus, rising above it. Under these circumstances, a tumor in the vagina would exist in combination with an abdominal tumor, and pregnancy might go on to term. Considerable difficulty may even arise in labor, but the malposition generally rectifies itself before it gives rise to any serious results. Treatment. — The treatment of retroversion of the gravid uterus should be taken in hand as soon as possible, for every day's delay involves an increase in the size of the uterus, and, therefore, greater difficulty in reposition. Our object is to restore the natural direc- tion of the uterus, by lifting the fundus above the promontory of the sacrum. The first thing to be clone is to relieve the patient by emp- tying the bladder, the retention of urine having probably originally called attention to the case. For this purpose it is essential to use a long elastic male catheter of small size, as the urethra is too elon- gated and compressed to admit of the passage of the ordinary silver instrument. Even then it may be extremely difficult to introduce the catheter, and sometimes it has been found to be quite impossible. Under such circumstances, provided reposition cannot be effected without it, the bladder may be punctured an inch or two above the pubes by means of the fine needle of an aspirator, and the urine drawn off. Dieulafoy's work on aspiration proves conclusively that this may be done without risk, and the operation has been successfully performed by Schatz and others. It very rarely happens, however, and in long-neglected cases only, that the withdrav/al of the urine is found to be impossible. DISEASES OF PREGNANCY. 211 Mode of Effecting Reduction. — The bladder being emptied, and the bowels being also opened, if possible, by copious enemata, we pro- ceed to attempt reduction. For this purpose various procedures are adopted. If the case is not of very long standing, I am inclined to think that the gentlest and safest plan is the continuous pressure of a caoutchouc bag, filled with water, placed in the vagina. The good effects of steady and long-continued pressure of this kind were proved by Tyler Smith, who effected in this way the reduction of an inverted uterus of long standing, and it is not difficult to understand that it may succeed when a more sudden and violent effort fails. I have tried this plan successfully in two cases, a pyriform India-rub- ber bao' beinc- inserted into the vagina, and distended as far as the patient could bear by means of a syringe. The water must be let out occasionally to allow the patient to empty the bladder, and the bag immediately refilled. In both my cases reposition occurred within twenty-four hours. Barnes has failed with this method ; but it succeeded so \\ T ell in my cases, and is so obviously less likely to prove hurtful than forcible reposition with the hand, that [ am in- clined to consider it the preferable procedure, and one that should be tried first. Failing with the fluid pressure, we should endeavor to replace the uterus in the following way. The patient should be placed at the edge of the bed, in the ordinary obstetric position, and thoroughly anaesthetized. This is of importance, as it relaxes all the parts, and admits of much freer manipulation than is otherwise pos- sible. One or more fingers of the left hand are then inserted into the rectum ; if the patient be deeply chloroformed, it is quite possi- ble, with due care, even to pass the whole hand, and an attempt is then made to lift or push the fundus above the promontory of the sacrum. At the same time reposition is aided by drawing down the cervix with the fingers of the right hand per vaginam. It has been insisted that the pressure should be made in the direction of one or other sacro-iliac synchondrosis rather than directly upwards, so that the uterus may not be jammed against the projection of the promon- tory of the sacrum. Failing reposition through the rectum, an at- tempt may be made per vaginam, and for this some have advised the upward pressure of the closed fist passed into the canal. Others recom- mend the hand and position as facilitating reposition, but this pre- vents the administration of chloroform, which is of more assistance than any change of position can possibly be. Various complex in- struments have been invented to facilitate the operation, but they are all more or less dangerous, and are unlikely to succeed when manual pressure has failed. As soon as the reduction is accomplished, subsequent descent of the uterus should be prevented by a large-sized Hodge's pessary, and the patient should be kept at rest for some days, the state of the bladder and bowels being particularly attended to. When reposi- tion has been fairly effected, a relapse^is unlikely to occur. Treatment ichen Reduction is found Impossible. — In cases in which reduction is found to be impossible, our only resource is the artificial induction of abortion. Under such circumstances this is impera- 212 PREGNANCY. tively called for. It is best effected by puncturing the membranes, the discharge of the liquor amnii of itself lessening the size of the uterus, and thus diminishing the pressure to which the neighboring parts are subjected. After this reposition may be possible, or we wait until the foetus is spontaneously expelled. It is not always easy to reach the os uteri, although we can generally do so with a curved uterine sound. If we cannot puncture the membranes, the liquor amnii may be drawn off through the uterine walls by means of the aspirator, inserted through either the rectum or vagina. The injury to the uterine walls thus inflicted is not likely to be hurtful, and the risk is certainly far less than leaving the case alone. Naturally so extreme a measure would not be adopted until all the simpler means indicated have been tried and failed. Diseases coexisting with Pregnancy. — The pregnant woman is, of course, liable to contract the same diseases as in the non-pregnant state, and pregnancy may occur in women already the subject of some constitutional disease. There is no doubt yet much to be learned as to the influence of coexisting disease on pregnancy. It is certain that some diseases are but little modified by pregnancy, and that others are so to a considerable extent ; and that the influence of the disease on the foetus varies much. The subject is too exten- sive to be entered into at any length, but a few words may be said as to some of the more important affections that are likely to be met with. Eruptive Fevers. Smallpox. — The eruptive fevers have often very serious consequences, proportionate to the intensity of the attack. Of these variola has the most disastrous results, which are related in the writings of the older authors, but which are, fortunately, rarely seen in these days of vaccination. The severe and confluent forms of the disease are almost certainly fatal to both the mother and child. In the discrete form, and in modified smallpox after vaccination, the patient generally has the disease favorably, and, although abortion frequently results, it does not necessarily do so. Scarlet Fever. — If scarlet fever of an intense character attacks a pregnant woman, abortion is likely to occur, and the risks to the mother are very great. The milder cases run their course without the production of any untoward symptoms. Should abortion occur, the well-known dangerous effect of this zymotic disease after delivery will gravely influence the prognosis. Cazeaux was of opinion that pregnant women are not apt to contract the disease ; while Mont- gomery thought that the poison when absorbed during pregnancy might remain latent until delivery, when its characteristic effects were produced. Measles, unless very severe, often runs its course without seriously affecting the mother or child. I have myself seen several examples of this. De Tourcoing, however, states that out of 15 cases the mother aborted in 7, these being all very severe attacks. Some cases are recorded in which the child was born with the rubeolous eruption upon it. DISEASES OF PREGNANCY. 213 Continued Fevers. — The pregnant woman may be attacked with any of the continued fevers, and, if they are at all severe, they are apt to produce abortion. Out of 22 cases of typhoid, 16 aborted, and the remaining 6, who had slight attacks, went on to term ; out of 63 cases of relapsing fever, abortion or premature labor oecurred in 23. According to Schwedeu the main cause of danger to the foetus in continued fevers is the hyperpyrexia, especially when the maternal temperature reaches 101° or upwards. The fevers do not appear to be aggravated as regards the mother, and the same ob- servation has been made by Cazeaux with regard to this class of disease occurring after delivery. Pneumonia seems to be specially dangerous, for of 15 cases collected by Grisolie 1 11 died — a mortality immensely greater than that of the disease in general. The larger proportion also aborted, the children being generally dead, and the fatal result is probably due, as in the severe continued fevers, to hyperpyrexia. The cause of the maternal mortality does not seem quite apparent, since the same danger does not appear to exist in severe bronchitis, or other inflammatory affections. Phthisis. — Contrarv to the usually received opinion it appears certain that pregnancy had no retarding influence on coexisting phthisis, nor does the disease necessarily advance with greater rapidity after delivery. Out of 27 cases of phthisis, collected by Grisolie, 2 21 showed the first symptoms of the disease after pregnancy had commenced. Phthisical women are not apt to conceive; a fact which may probably be explained by the frequent coexistence, -in such cases, of uterine disease, especially severe leucorrhoea. The entire duration of the phthisis seems to be shortened, as it averaged only nine and a half months in the 27 cases collected — a fact which proves, at least, that pregnancy has no material influence in arresting its progress. If we consider the tax on the vital powers which pregnancy naturally involves, we must admit that this view is more physiologically probable than the one generally received, and appa- rently adopted without any due grounds. Heart-disease. — The evil effects of pregnancy and parturition on chronic heart-disease have of late received much attention from Speigelberg, Fritsch, Peter, and other writers. The subject has been ably discussed 3 in a series of elaborate papers by Dr. Angus Mac- Donald, which are well worthy of study. Out of 28 cases collected by him, 17, or 60 per cent., proved fatal. This, no doubt, is not altogether a reliable estimate of the probable risk of the complica- tion ; but, at any rate, it shows the serious anxiety which the occur- rence of pregnancy in a patient suffering from chronic heart-disease must cause. Dr. MacDonald refers the evils resulting from pregnancy in connection with cardiac lesions to two causes : First, destruction of that equilibrium of the circulation, which has been established 1 Arch. Gen. de Mod. vol. xiii. p. 298. 2 t^, vo i # xxii> 3 Obstet. Journ. 1877. 214 PREGNANCY. by compensatory arrangements ; secondly, the occurrence of fresh inflammatory lesions upon the valves of the heart already diseased. The dangerous symptoms do not usually appear until after the first half of the pregnancy has passed, and the pregnancy seldom advances to term. The pathological phenomena generally met with in fatal cases are pulmonary congestion, especially of the bronchial mucous membrane, and pulmonary oedema, with occasional pneu- monia and pleurisy. Mitral stenosis seems to be the form of cardiac lesion most likely to prove serious, and next to this aortic incompe- tency. The obvious deduction from these facts is that heart-disease, especially when associated with serious symptoms, such as dyspnoea, palpitation, and the like, should be considered a strong contra-indica- tion of marriage. When pregnane}^ has actually occurred, all that can be done is to enjoin the careful regulation of the life of the patient, so as to avoid exposure to cold, and all forms of severe exertion. Syphilis. — The important influence of syphilis on the ovum is fully considered elsewhere. As regards the mother, its effects are not different from those at other times. It need only, therefore, be said that, whenever indications of syphilis in a pregnant woman exist, the appropriate treatment should be at once instituted and carried on during her gestation, not only with the view of checking the pro- gress of the disease, but in the hope of preventing or lessening the risk of abortion, or of the birth of an infected infant. So far from pregnancy contra-indicating mercurial treatment, there rather is a reason for insisting on it more strongly. As to the precise medica- tion, it is advisable to choose a form that can be exhibited continu- ously for a length of time without producing serious constitutional results. Small doses of the bichloride of mercury, such as one-six- teenth of a grain, thrice daily, or of the iodide of mercury, answer this purpose well; or, in the early stages of pregnancy, the mercurial vapor bath, or cutaneous inunction, may be employed. Dr. Weber, of St. Petersburg, 1 has made some observations show- ing the superiority of the latter methods, which he found did not interfere with the course of pregnancy ; the contrary was the case when the mercury was administered by the mouth, probably, as he supposes, from disturbance of the digestive system. It must be borne in mind, that in married women it may sometimes be expedient to prescribe an anti-syphilitic course without their knowledge of its nature, so that inunction is not always feasible. Epilepsy. — The influence of pregnancy on epilepsy does not appear to be as uniform as might perhaps be expected. In some cases the number and intensity of the fits have been lessened, in others the disease becomes aggravated. Some cases are even recorded in which epilepsy appeared for the first time during gestation. On account of the resemblance between epilepsy and eclampsia there is a natural apprehension that a pregnant epileptic may suffer from convulsions 1 Allgem. Med. Cent. Zeit. Feb. 1875. DISEASES OF PREGNANCY. 215 during delivery. Fortunately, this is by no means necessarily the case, and labor often goes on satisfactorily without any attack. Jaundice, the result of acute yellow atrophy of the liver, is occa- sionally observed, and is said to have been sometimes epidemic. Independently of the grave risks to the mother, it is most likely to produce abortion or the death of the foetus. According to Davidson, it originates in catarrhal icterus, the excretion of the bile-products being impeded in consequence of pregnancy, and their retention giving rise to the foetal blood-poisoning which accompanies the severer forms of the disease. Slight and transient attacks of jaun- dice may occur, without being accompanied by any bad consequences. Their production is probably favored by the mechanical pressure of the gravid uterus on the intestines and the bile- ducts. Carcinoma. — The occcurrence of pregnancy in a woman suffering from malignant disease of the uterus is by no means so rare as might be supposed, and must naturally give rise to much anxiety as to the result. The obstetrical treatment of these cases will be dis- cussed elsewhere. Should Ave be aware of the existence of the dis- ease during gestation, the question will arise Avhether Ave should not attempt to lessen the risks of delivery by bringing on abortion or premature labor. The question is one which is by no means easy to settle. AYe have to deal with a disease which is certain to proA^e fatal to the mother before long, and the progress of which is proba- bly accelerated after labor, Avhile the manipulations necessary to in- duce delivery may A T ery unfavorably influence the diseased structures. Again, by such a measure Ave necessarily sacrifice the child, Avhile Ave are by no means certain that Ave materially lessen the danger to the mother. The question cannot be settled except on a considera- tion of each particular case. If we see the patient early in pregnancy, by inducing abortion Ave may saA'e her the dangers of labor at term - — possibly of the Cesarean section — if the obstruction be great. Under such circumstances, the operation Avould be justifiable. If the pregnancy have advanced beyond the sixth or seventh month, unless the amount of malignant deposit be very small indeed, it is probable that the risks of labor Avould be as great to the mother as a term, and it would then be advisable to giA r e her the advantage of the feAV months' delay. Ovarian Tumor. — Cases are occasionally met with in Avhich preg- nancy occurs in women who are suffering from OA^arian tumor, and their proper management has giA^en rise to considerable discussion. There can be no doubt that such cases are attended with very dauger- ous and often fatal consequences, for the abdomen cannot Avell ac- commodate the gravid uterus and the ovarian tumor, both increasing simultaneously. The result is that the tumor is subject to much contusion and pressure, Avhich have sometimes led to the rupture of the cyst, and the escape of its contents into the peritoneal cavity; at others to a low form of inflammation, attended with much exhaustion, the death of the patient supervening either before or shortly after delivery. The danger during delivery from the same cause, in the cases which go on to term, is also very great. Of 13 cases of delivery 216 PREGNANCY. by the natural powers, which I collected in a paper on "Labor Com- plicated with Ovarian Tumor," 1 far more than one-half proved fatal. [In one instance in this city, a lady well known to the editor, gave birth to three of her four children, during the existence of an ovarian tumor. The children all lived to grow up, and their mother died of her disease at the age of 75, after being repeatedly tapped during fifty years. The ovarian tumor was discovered by Dr. Benjamin Kush soon after her first child was born in 1809. and she was first tapped by Dr. Physick in 1811. In 1812, 1815, and 1818 she gave birth to the children mentioned, the third being delicate, sickly, and weighing six pounds. Thigf last died of phthisis when 45 ; the others still live. 2 — Ed.] Another source of danger is twisting of the pedicle, and consequent strangulation of the cyst, of which several instances are recorded. It is obvious, then, that the risks are so manifold that in every case it is advisable to consider whether they can be lessened by surgical treatment. Methods of Treatment. — The means at our disposal are either to induce labor prematurely, to treat the tumor by tapping, or to per- form ovariotomy. The question has been particularly discussed by Spencer Wells in his works on " Ovariotomy," and by Barnes in his " Obstetric Operations." The former holds that the proper course to pursue is to tap the tumor when there is any chance of its being materially lessened in size by that procedure, but that when it is multilocular, or when its contents are solid, ovariotomy should be performed at as early a period of pregnancy as possible. Barnes, on the other hand, maintains that the safer course is to imitate the means by which nature often meets this complication, and bring on premature labor without interfering with the tumor. He thinks that ovariotomy is out of the question, and that tapping may be insuffi- cient and leave enough of the tumor to interfere seriously with labor. So far as recorded cases go, they unquestionably seem to show that tapping is not more dangerous than at other times, and that ovario- tomy may be practised during pregnancy with a fair amount of suc- cess. Wells records 10 cases which were surgically interfered with. In 1 tapping was performed, and in 9 ovariotomy; and of these 8 recovered, the pregnancy going on to term in 5. On the other hand, 5 cases were left alone, and either went to term, or spontaneous pre- mature labor supervened ; and of these 3 died. The cases are not sufficiently numerous to settle the question, but they certainly favor the view taken by Wells rather than that by Barnes. It is to be observed that, unless we give up all hope of saving the child, and induce abortion, the risk of induced premature labor, when the preg- nancy is sufficiently advanced to hope. for a viable child, would almost be as great as that of labor at term ; for the question of interference will only have to be considered with regard to large tumors, which would be nearly as much affected by the pressure of a gravid uterus at seven or eight mouths, as by one at term. Small tumors, gene- 1 Obst. Trans., vol. ix. [ 2 Trans. Phila. Obstet. Soc. vol. i. 1873, p. 64.— reported by Ed.] DISEASES OF PREGNANCY. 217 rally escape attention, and are more apt to be impacted before the presenting part in delivery. The success of ovariotomy during pregnancy has certainly been great, and we have to bear in mind that the woman must necessarily be subjected to the risk of the operation sooner or later, so that we cannot judge of the case as one in which abortion terminates the risk. Even -it the operation should put an end to the pregnancy — and there is at least a fair chance that it will not do so — there is no certainty that that would increase the risk of the operation to the mother, while as regards the child we should only have the same result as if we intentionally produced abortion. On the whole, then, it seems that the best change to the mother, and certainly the best to the child, is to resort to the appa- rently heroic practice recommended by Wells. The determination mustj however, be to some extent influenced by the skill and ex- perience of the operator. If the medical attendant has not gained that experience which is so essential for a successful ovariotomist, the interests of the mother would be best consulted by the induction of abortion at as early a period as possible. One or other procedure, is essential ; for, in spite of a few cases in which several successive pregnancies have occurred in women who have had ovarian tumors, the risks are such as not to justify an expectant practice. Should rupture of the cyst occur, there can be no doubt that ovariotomy should at once be resorted to, with the view of removing the lacerated cyst and its extravasated contents. * Fibroid Tumors. — Pregnancy may occur in a uterus in which there are one or more fibroid tumors. If these are situated low down and in a position likely to obstruct the passage of the foetus, they may very seriously complicate delivery. When they are situated in the fundus or body of the uterus they may give rise to risk from hemor- rhage, or from inflammation of their own structure. Inasmuch as they are structurally similar to the uterine walls they partake of the growth of the uterus during pregnancy, and frequently increase re- markably in size. Cazeaux says — " I have known them in several instances to acquire a size in three or four months which the} 7 would not have done in several years in the non-pregnant condition." Con- versely, they share in the involution of the uterus after delivery, and often lessen greatly in size, or even entirely disappear. Of this fact I have elsewhere recorded several curious examples ; l and many other instances of the complete disappearance of even large tumors have been described by authors whose accuracy of observation cannot be questioned. Treatment. — The treatment will vary with the position of the tumor. "If it is such as to be certain to obstruct the passage of the child, abortion should be induced as soon as possible. If the tumor is well out of the way, this is not so urgently called for. The princi- pal danger then is that the tumor will impede the post-mortem con- traction of the uterus, and favor hemorrhage. Even if this should happen, the flooding could be controlled by the usual means, espe- 1 Obst. Trans, vols. v. xiii. and xix. 15 218 PREGNANCY. ciallj by the injection of the perchloride of iron. I have seen several cases in which delivery has taken place under such circumstances without any untoward accident. The danger from inflammation and subsequent extrusion of the fibroid masses would probably be as great after abortion or premature labor, as after delivery at term. It seems, therefore, to be the proper rule to interfere when the tumors are likely to impede delivery, and in other cases to allow the preg- nancy to go on, and be prepared to cope with any complications as they arise. The risks of pregnancy should be avoided in every case in which uterine fibroids of any size exist, the patients being advised to lead a celibate life. CHAPTEK IX, PATHOLOGY OF THE DECIDUA AND OVUM. Comparatively little is, unfortunately, known of the pathological changes which occur in the mucous membrane of the uterus during pregnancy. It is probable that they are of much more consequence than is generally believed to be the case; and it is certain that they are a frequent cause of abortion. Endometritis. — One of the most generally observed probably de- pends on endometritis antecedent to conception. When the impreg- nated ovule reached the uterus, it engrafted itself on the inflamed mucous membrane, which was in an unfit condition for its reception and growth. A not uncommon result, under such circumstances, is the laceration of some of the decidual vessels, extravasation of blood between the decidua and the uterine walls, and consequent abortion at an early stage of pregnancy. As this morbid state of the uterine mucous membrane is likely to continue after abortion is completed, the same history repeats itself on each impregnation, and thus we may have constant early miscarriages produced. It does not neces- sarily follow, however, that the pregnancy is immediately terminated when this state of things is present. Sometimes a condition of hyperplasia of the decidua is produced, the membrane becomes much thickened and hypertrophied, and the decidual cells are greatly in- creased in size (Fig. 83). In other instances the internal surface of the decidua becomes studded with rough polypoid growths, 1 depend- ing on proliferation of its interstitial tissue. Duncan has found that the hypertrophied decidua is always in a state of fatty degeneration, more advanced in some places than in others. 2 The result of these alterations is frequently to produce dwindling or death of the ovum, 1 Virchow's Archiv fur Path. 1868. 2 Researches in Obstetrics, p. 293. PATHOLOGY OF THE DECIDUA AND OVUM. 219 which, however, retains its connection with the decidua, until, after a lapse of time, the deciclua is expelled in the form of a thick tri- Fig. 83. \ Hypertrophiert Decidua laid open, with the Ovum attached to its Fundal Portion. (After Duncan.) angular fleshy substance, with the atrophied ovum attached to some part of its inner surface. In other cases, in which the hyperplasia has advanced to a less extent, the nutrition of the foetus is not interfered with, and pregnancy may continue to term, the changes in the decidua beino- recognizable after de- livery. Other diseases besides endometritis may give rise to similar alterations in the de- cidua, one of these being as Virchow maintains, syphilis. The converse condition, and im- perfect development of the de- cidua, especially of the decidua reflexa, has also been noted as Fig. 84. Imperfectly developed Decidua Vera, with the Ovum. (After Duncan.) 220 PREGNANCY. a cause of abortion. The ovum will then hang loosely in the ute- rine cavity, without the support which the growth of the decidua re- flexa around it ought to afford, and its premature expulsion readily follows (Fig. 81). Hydrorrhea Gravidarum. — The peculiar condition known as hy- drorrhea gravidarum most probably depends on some obscure morbid state of the uterine mucous membrane. By this is meant a discharge of clear watery fluid at intervals during pregnancy. It may happen at any period of gestation, but is most commonly met with in the latter months. It may commence with a mere dribbling, or there may be a sudden and copious discharge of fluid. Afterwards the watery fluid, which is generally of a pale yellowish color, and trans- parent like the liquor amnii, may continue to escape at intervals for many weeks, and sometimes in very great abundance, so as to satu- rate the patient's clothes. Very frequently it is expelled in gushes, and at night, when the patient is lying quietly in bed; its escape is then probably due to uterine contraction. Many theories have been held as to its cause. By some it is attributed to the rupture of a cyst placed between the ovum and the uterine w r alls ; Bauclelocque referred it to a transudation of the liquor amnii through the membranes ; while Burgess and Dubois believed it to depend on a laceration of the membranes at a distance from the os uteri. Mattei more recently has attributed it to the existence of a sac between the chorion and the amnion. It may be that in some instances a single discharge of fluid may come from one of the two last-mentioned causes. But if it be continuous or repeated, another source must be sought for. Hegar 1 maintains that it is the result of abundant secretion from the glands of the mucous membrane, which accumulates between the decidua and chorion, and escapes through the os uteri. If this occur the decidua is probably in an hypertro- phied and otherwise morbid state. Hyclrorrhoea is chiefly of interest from the error of diagnosis it is likely to give rise to ; for, on being summoned to a case in which watery discharge has occurred for the first time, we are naturally apt to suppose that the membranes have ruptured, and that labor is imminent. Nor is there any very certain means of deciding if this be so. In hydrorrhea, we find that pains are absent, the os uteri unopened, and ballottement may be made out. Even if the membranes be ruptured, there will be no indica- tion for interference unless labor has actually commenced ; and the repetition of the discharge, and the continuance of the pregnancy, will soon clear up the diagnosis. Ilydrorrhoea, although apt to alarm the patient, need not give rise to any anxiety. The pregnancy generally progresses favorably to the full period; although, in excep- tional cases, premature labor may supervene. No treatment is neces- sary, nor is there any that could have the least effect in controlling the discharge. Pathology of the. Chorion.— -The only important disease (rf the chorion, with which we are acquainted, 'is the well-known condition ' Monat. f. Geburt., 1863. PATHOLOGY OF THE DECIDUA AND OVUM. 221 Fig. which is variously described as uterine hydatids, cystic disease of the ovum, hydatiform defeneration of the chorion, or vesicular mole. The name of uterine hydatids was long given to it on the supposition that the grapelike vesicles, which characterize the disease, were true hyda- tids, similar to those which develop in the liver and other structures. This idea has long been exploded, and it is now known as a certainty that the disease originates in the villi of the chorion. The precise mode and the causes of its production, are, however, not yet satisfac- torily settled. The disease is character- ized by the existence in the cavity of the uterus of a large number of translucent vesicles, containing a clear limpid fluid, which has been found on analysis to bear close resemblance to the liquor amnii. These small bladder like bodies, which vary in size from that of a millet-seed to an acorn, are often described as resem- bling; a bunch of grapes or currants. On more minute examination, they are found not to be each attached to independent pedicles, as is the case in a bunch of grapes, but some of them grow from other vesicles, while others have distinct pedicles attached to the chorion, the pedi- cles themselves sometimes being; dis- tended by fluid (Fig. So). This peculiar arrangement of the vesicles is explained by their mode of growth. Causes of Cystic Defeneration. — There has been considerable discussion as to the etiology of this disease. Bv some it is supposed always to follow death of the foetus ; and the whole developmental energy being expended on the chorion, which retains its attachment to the decidua. the result is its abnormal growth and cystic degenera- tion. This is the view maintained by Grierse and Graily Hewitt, and it is favored by the undoubted fact that in almost all cases the foetus has entirely disappeared ; and by the occasional occurrence of cases of twin conceptions in which one chorion has degenerated, the other remaining healthy until term. On the other hand, it is maintained that the starting-point is connected with the maternal organism. Virchow thinks it originates in a morbid state of the decidua; while others have attributed it to some blood dyscrasia on the part of the mother, such as syphilis. There are many reasons for believing that causes of this nature may originate the affection. Thus it is often found to occur more than once in the same person ; and alterations of a simi- lar kind, although limited in extent, are not unfrequently found in connection with the placenta and membranes of living children. On this theory the death of the foetus is secondary, the consequence of impaired nutrition from the morbid state of the chorion. The prob- Hydatitbrm Degeneration of the Chorion. 222 PREGNANCY. ability is that both views may be right, the disease sometimes fol- lowing the death of the embryo, and at others being the result of obscure maternal causes. Pathology. — The degeneration of the chorion villi generally com- mences at an early period of pregnancy, before the placenta has com- menced to form. In that case the entire superficies of the chorion becomes affected. The disease, however, may not begin until after the greater part of the chorion villi has atrophied, and then it is lim- ited to the placenta. The epithelium of the villi appears to be the part first affected, and the whole interior of the diseased villus becomes filled with cells. The connective tissue of the villus under- goes a remarkable proliferation, and collects in masses at individual spots, the remainder of the villus being unaffected. By the growth of these elements the villus becomes distended, and many of the cells liquefy, the intercellular fluid, thus produced, Avidely separating the connective tissue, so as to form a network in the interior of the vil- lus. 1 Thus are formed the peculiar grapelike bodies which charac- terize the disease. When once the degeneration has commenced, the diseased tissue has a remarkable power of increase, so that it some- times forms a mass as large as a child's head, and several pounds in weight. The nutrition of the altered chorion is maintained by its connec- tions with the decidua, which is also generally diseased and hypertro- phied. Sometimes the adhesion of the mass to the uterine walls is very firm, and may interfere with its expulsion ; while, in a few rare cases, it has been found that the villi have forced their way into the substance of the uterus, chiefly through the uterine sinuses, and thus caused atrophy and thinning of its muscular structure. Cases of this kind are related by Volkmann, Walcleyer, 2 and Barnes, and it is obvious that the intimate adhesion thus effected must seriously add to the gravity of the prognosis. Medico-legal Questions. — Taking this view of the etiology of this disease, it is obvious that it is essentially connected with pregnancy, and that there is no valid ground for maintainig, as has sometimes been done, that it may occur independently of conception. It is just possible, however, that true entozoa may form in the substance of the uterus, which being expelled per vaginam, might be taken for the results of cystic disease, and thus give rise to groundless suspi- cions as to the patient's chastity. Hewitt has related one case in which true hydatids, originally formed in the liver, had extended to the peritoneum, and were about to burst through the vagina at the time of death. This occurred in an unmarried woman. One or two other examples of true hydatids forming in the substance of the ute- rus are also recorded. A very interesting case is also related by Hewitt, 3 in which undoubted acephalocysts were expelled from the uterus of a patient who ultimately recovered. A careful examina- 1 Braxton Hicks, Guy's Hospital Reports, vol. ii. Third Series, p. 183. 2 Virchow's Archiv, vol. xliv. p. 88. 3 Obstet. Trans,, vol. xii. PATHOLOGY OF THE DEdDUA AND OVUM. 223 tion of the cyst and its contents would show their true nature, as the echinococci heads, with their characteristic hooklets, would be dis- coverable by the microscope. It is also possible that unfounded suspicions might arise from the fact of a patient expelling a mass of hydatids long after impregnation. In the case of a widow, or woman living apart from her husband, serious mistakes might thus be made. This has been specially pointed out by McClintock, 1 who says, "Hydatids maybe retained in utero for many months or years, or a portion only may be expelled, and the residue may throw out a fresh crop of vesicles, to be dis- charged on a future occasion.'' Symptoms and Progress of the Disease. — The symptoms of cystic disease of the ovum are by no means well marked. At first there is nothing to point to the existence of any morbid condition, but as pregnancy advances its ordinary course is interfered with. There is more general disturbance of the health than there ought to be, and the reflex irritations, such as vomiting, may be unusually developed. The first physical sign remarked is rapid increase of the uterine tumor, which soon does not correspond in size to the supposed period of pregnane}^. Thus, at the third month, the uterus may be found to reach up to, or beyond the umbilicus. About this time there generally are more or less profuse watery and sanguineous dis- charges, which have been described as resembling currant juice. They no doubt depend on the breaking down and expulsion of the cysts, caused by painless uterine contractions. They are sometimes excessive in amount, recur with great frequency, and often reduce the patient extremely. Portions of cysts may now generally be found mingled with the discharge, and sometimes large masses of them are expelled from time to time. Indeed, the discovery of portions of cysts is the only certain diagnostic sign. Vaginal examination, before the os has dilated, will give no information, except the absence of ballottement. An unusual hardness or densit}^ of the uterus — ■ described by Leishman, who attributes much importance to it, as " a peculiar doughy, boggy feeling" — has been pointed out by several writers. The contour of the uterine tumor, moreover, is often irregu- lar. In addition, we, of course, fail to discover the usual ausculta- tory signs of pregnancy. All this may aid in diagnosis, but nothing, except the presence of cysts in the watery bloody discharge, will enable us to pronounce with certainty as to the nature of the disease. Treatment. — As soon as the diagnosis is established, the indications for treatment are obvious. The sooner the uterus is cleared of its contents the better. Ergot may be given with advantage to favor uterine contraction, and the expulsion of the diseased ovum. Should this fail, more especially if the hemorrhage be great, the fingers, or the whole hand, must be introduced into the uterus, and as much as possible of the mass removed. As the os is likely to be closed, its preliminary dilatation by sponge or laminaria tents, or by a Barnes's bag, if it be already opened to some extent, will in most cases be 1 McClintock's Diseases of Women, p. 398. 224 PREGNANCY. required. If chloroform be then administered, the remaining steps of the operation will be easy. On account of the occasional firm adhesion of the cystic mass to the uterus, too energetic attempts at complete separation should be avoided. Any severe hemorrhage after the operation can be controlled by swabbing out the uterine cavity with the perchloride of iron solution. Under the name of Myxoma fibrohim, a more rare degeneration of the chorion has been described by Virchow and Hildebrandt, 1 char- acterized, not by vesicular, but fibroid degeneration of the connective tissue of the chorion. This is, however, too little understood to require further observation. Pathology of the Placenta. — The pathology of the placenta has of late years attracted much attention, and it has an important practical bearing in consequence of its effects on the child. Placentas vary considerably in shape. They may be crescentic, or spread over a considerable surface, in consequence of the chorion villi entering into communication with a larger portion of the de- cidua than usual {Placenta membranacea). Such forms, however, are merely of scientific interest. The only anomaly of shape of any practical importance is the formation of what have been called pla- centse succenturise. These consist of one or more separate masses of placental tissue, produced by the development of isolated patches of chorion villi. Hohl believes that they always form exactly at the junction of the anterior and posterior walls of the uterus, which in early pregnancy is a mere line. As the uterus expands, the portions of placenta, on each side of this, become separated from each other. They are only of consequence from the possibility of their remain- ing unnoticed in the uterus after delivery, and giving rise to second- ary post-partum hemorrhage. The rare form of double placenta with a single cord, figured in the accompanying woodcut (Fig. 86), was probably formed in this way, and the supplementary portion, in such a case, might readily escape notice. The placenta may also vary in dimensions. Sometimes it is of excessive size, generally when the child is unusually big ; but not infrequently in connection with hydramnios, the child being dead and shrivelled. In other cases it is remarkably small, or at least appears to be so. If the child be healthy, this is probably of no pathological importance, as its smallness may be more apparent than real, depending on its vessels not being distended with blood. When true atrophy of the placenta exists, the vitality of the foetus may be seriously interfered with. This condition may depend either on a diseased state of the chorion villi, or of the clecidua in which they are implanted. 2 The latter is the more common of the two ; and it generally consists in hyperplasia of the connective tissue of the de- cidua, which presses on the villi and vessels, and gives rise to gen- eral or local atrophy. This change is similar in its nature to that observed in cirrhosis of the liver, and certain forms of Bright's dis- » Monat. f. Geburt, May, 1865. 2 Wlnttaker, Amer. Journ. of Obst., vol. iii. , p. 229. PATHOLOGY OF THE DECIDUA AND OVUM. ZZD ease. It has generally been ascribed to inflammatory changes, and, under the name of -placentitis, has been described by many authors, and has been considered to be a common disease. To it are attributed many of the morbid alterations which are commonly observed in placentas, such as hepatizations, circumscribed purulent deposits, and adhesions to the uterine vails. Many modern pathologists have doubted whether these changes are in any proper sense inflammatory. Whittaker observes on this point: "The disposition to reject pla- centitis altogether increases in modern times. Indeed, it is impos- sible to conceive of inflammation on the modern theory (Cohnheim) Fig. 86. Double Placenta, with single cord. of that process, since there are no capillaries, in the maternal portion at least, through whose walls a 'mioration' misfit occur, and there are no nerves to regulate the contractility of the vessel-walls in the entire structure." Eobin thus explains the various pathological changes above alluded to : " "What has been taken for inflammation of the placenta is nothing else than a condition of transformation of blood clots at various periods. What has been regarded as pus is only fibrine in the course of disorganization, and in those cases where true pus has been found the pus did not come from the pla- centa, but from an inflammation of the tissue of the uterine vessels and an accidental deposition in the tissue of the placenta." The extravasations of blood here alluded to are of very common occur- rence, and they are found in all parts of the organ ; in its substance. 226 PREGNANCY on its decidual -surface, or immediately below the amnion, where they serve as points of origin for the cysts that are there often observed. The fibrine thus deposited undergoes retrograde meta- morphosis as in other parts of the body ; it becomes decolorized, it undergoes fatty degeneration or becomes changed into calcareous masses ; and in this way, it is supposed, may be explained the vari- ous pathological changes which are so commonly observed. The amount of retrograde metamorphosis, and the precise appearance presented will, of course, depend on the time that has elapsed since the blood extravasations took place. Fatty degeneration of the placenta, and its influence on the nutri- tion of the foetus, have been specially studied in this country by Barnes and Druitt. Yellowish masses of varying size are very com- monly met with in placentas, and these are found to consist, in great Fatty Degeneration of the Placenta. part, of molecular fat, mixed with a fine network of fibrous tissue. The true fatty degeneration, however, specially affects the chorion villi (Fig. 87). On microscopic examination they are found to be altered and misshaped in their contour, and to be loaded with fine granular fat-globules. Similar changes are observed in the cells of the decidua. The influence on the foetus will, of course, depend on the extent to which the functions of the villi are interfered with. The probable cause of this degeneration, is, no doubt, some obscure alteration in the nutrition of the tissue, depending on the state of the PATHOLOGY OF THE DECIDUA AND OVUM. 227 Fig. 88. mother's health. Barnes believes that syphilis has much influence in its production. Druitt has pointed out that some amount of fatty degeneration is always present in a mature placenta, and is probably connected with the physiological separation of the organ ; and Good- ell has more recently suggested that an unusual amount of this change may be merely an anticipation of the natural termination of the life of the placenta. 1 Other morbid states of the placenta, of greater rarity, are occasion- ally met with, as an cedematous infiltration of its tissue, always occur- ring, according to Lange, in cases of hvdrainnios; pigmentary and calcareous deposits ; and tumors of various kinds ; but these require only a passing mention. Pathology of the Umbilical Cord. — The umbilical cord may be of excessive length, varying from 18 to 20 inches, which is its average measurement, up to 50 or 60 inches, and a case is recorded in which it even reached the extraordinary length of 9 feet. If unusually long it may be twisted round the limbs or neck of the child, and the latter position may, in ex- ceptional instances, prove injurious dur- ing labor. Some authors refer cases of spontane- ous amputation of fuetal limbs in utero to constrictions by the umbilical cord, bat this accident is more probably pro- duced by filamentous adnexa of the amnion. Knots in the cord are not un- common, and they result from the foetus, in its movements, passing through a loop of the cord (Fig. 88). If there is an average amount of AYharton's jelly in the cord the ves- sels are protected from pressure, and no bad effects follow. Gery, in a recent paper on this subject, 2 attempts to show that such knots are more important than is generally believed, and relates two cases in which he believes them to have caused the death of the foetus. Extreme torsion of the cord, an exaggeration of the spiral twists generally observed, may prove injurious, and even fatal, to the child by obstructing the circulation in the vessels. Spaeth mentions three cases in which this caused the death of the foetus, the cord being twisted until it was reduced to the thickness of a thread. Anomalies in the distribution of the vessels of the cord are of common occurrence. The cord may be attached to the edge, instead of to the centre, of the placenta (battledore placenta). It may break up into its component parts before reaching the placenta, the vessels running through the membranes ; and if, in such a case, traction on Kuots of the Umbilical Cord. 1 American Journal of Obstetrics, vol. ii. p. 535. 2 L'Union Meclicale, Oct. 1876. 228 PREGNANCY. the cord be made, the separate vessels may lacerate, and the cord be- come detached. There may be two veins and one artery, or only- one vein and one artery, or there may be two separate cords to one placenta. These, and other anomalies that might be mentioned, are of little practical importance. The principal pathological condition of the amnion with which we are acquainted is that which is associated with excessive secretion of liquor amnii, and is generally known under the name of hydramnios, which term Kidd 1 limits to cases in which more than two quarts of amniotic fluid exist. Its precise cause is still a matter of doubt. By some it is referred to inflammation of the amnion itself; at other times it is apparently connected with some morbid state of the decidua, which may be found diseased and hypertrophied. The foetus is very often dead and shrivelled, and the placenta enlarged and cedematous. It does not necessarily follow, however, that hydramnios causes the death of the child. Out of 33 cases McClincock found that 9 children were born dead ; 2 and of the 19 born alive, 10 died within a few hours, the remainder survived. There does not appear to be any marked relation between the state of the mother's health and the occurrence of this disease ; and it is certainly not necessarily present when the mother is suffering from dropsical effusions in other parts of the body. The theory that the disease is of purely local origin is favored by the fact, that when hydramnios occurs in twin pregnancy, one ovum only is generally affected. Its effects, as regards the mother, are chiefly mechanical. It rarely begins to show itself before the fifth or sixth month of pregnancy, but, when once it has commenced, it rapidly produces a feeling of discomfort and enlargement, alto- gether beyond that which should exist at the period of pregnancy which has been reached. In advanced stages the distress produced is often very great, the enlarged uterus pressing upon the diaphragm, and producing much embarrassment of respiration. Premature ex- pulsion of the foetus very often supervenes. Four out of McClintock's patients died after labor, showing that the maternal mortality is high, a result which he refers to the debilitated state of the women who were the subjects of the disease. Diagnosis. — The diagnosis is not, as a rule, difficult. It has to be distinguished from ascitic distension of the abdomen, from enlarge- ment of the uterus from twin pregnancy, and from ovarian tumor, or pregnancy complicated with ovarian tumor. The first will be rec- ognized by the superficial position of the fluid ; the difficulty of feel- ing the contour of the uterus, which is obscured by the surrounding fluid, and the results of percussion which show that the fluid is free in the peritoneal cavity ; and by the coexistence of dropsical effusions in other parts of the body. The second may be difficult, and even impossible, to diagnose from it : general^, however, in hydramnios the uterine tumor is more distinctly tense or fluctuating ; the foetal ' On the Diagnosis of Dropsy of the Amnion. Proceedings of the Obstetrical So- ciety of Dublin, May 11, 1878. 2 Diseases of Women, p. 383. PATHOLOGY OF THE DECIDUA AND OVUM. 229 limbs cannot be felt on palpation; and the lower segment of the uterus, as felt per vaginam, is unusually distended, the presenting part not being appreciable. Ovarian tumors alone, or complicating pregnancy, may also be difficult to distinguish from dropsy of the amnion. The general history of the case, and the presence or ab- sence of signs of pregnancy, may enable us to arrive at a diagnosis ; and Kidd points out that the position of the uterus, whether gravid or not, is usually low down in the pelvis in ovarian dropsy, while in drops}' of the amnion it is drawn high up, and reached with difficulty on vaginal examination. Its effect on Labor. — During labor an excessive amount of liquor amnii is often a cause of deficient uterine action and delay, the pains being feeble and ineffective. This, of course, tells chiefly in the first stage, which is often much prolonged, unless the membranes are punctured early, and the superabundant fluid allowed to escape. Treatment. — -No treatment is known to have any effect on the disease.' If the discomfort and distension are very great, it may be absolutely necessary to puncture the membranes, and allow the water to escape. This inevitably brings on labor. If the pregnancy be not sufficiently advanced to give hope for the birth of a living child, we would not, of course, resort to this expedient unless the mother's health was seriously imperilled. It is possible that in such cases the patient might be relieved by inserting the minute needle of an aspi- rator through the os, and removing a certain quantity of the liquor amnii by aspiration, without inducing the labor. I have never had an opportunity of trying this expedient, but it seems a possibility. Deficiency/ of Liquor Amnii — A defective amount of liquor amnii is said to favor certain malformations, by allowing the uterus to compress the foetus unduly. It certainly occasionally gives rise to adhesion between the foetus and the membranes, and to the formation of amniotic bands which are capable of producing certain foetal de- formities (p. 227). Appearance of the Liquor Amnii. — The liquor amnii itself varies much in appearance. It is sometimes thick and treacly, instead of limpid, and it may be offensive in odor. The cause of these varia- tions is not well understood. Pathology of the Foetus. — There is abundant evidence that the foetus in utero is subject to many diseases, some of which cause its death, and others leave distinct traces of their existence, although not proving fatal. The subject is of great importance, and is well worthy of study. There is still much to be done in this direction, which may lead to important practical results. I can, however, do little more than enumerate some of the principal affections which have been observed. Blood Diseases transmitted through the Mother. Smallpox. — It is a well-established fact that the various eruptive fevers, from which the mother may suffer, may be communicated to the foetus in utero. When the mother is attacked with confluent smallpox, she almost always aborts, but not necessarily so when it is discrete or modified. In such cases it has often happened that the foetus has been born 230 PREGNANCY. with evident marks of smallpox. Cases are on record which prove that the foetus was attacked subsequently to the mother. Thus a mother attacked with smallpox has miscarried, and has given birth to a living child showing no trace of the disease, which, however, showed itself in two or three days; proving that it had been con- tracted, and had run through its usual period of incubation, when the foetus was still in utero. It does not follow, however, that the foetus is affected, as Serres has collected 22 cases in which women, suffering from smallpox, gave birth to children who had not con- tracted the disease. It has been supposed that, in such cases, the child is protected from smallpox, though it has shown no symptom of having had the disease. Tarnier, however, cites two instances in which such children had smallpox two years after birth. Madge and Simpson record cases in which vaccination performed on the mother during pregnancy protected the foetus, on whom all subse- quent attempts at vaccination failed. There is evidence also to prove that the disease may be transmitted to the foetus through a mother, who is herself unsusceptible of contagion; the child having been covered with smallpox eruption, the mother being quite free from it. It is probable, that the same facts which have been ob- served with regard to smallpox, hold true with reference to other zjnriotic diseases, such as scarlet fever and measles, although there is not sufficient evidence to justify a positive assertion to that effect. Measles and Scarlet Fever. — Amongst other maternal diseases, mala- rious and lead poisoning are known to affect the foetus in utero. Dr. Stokes relates cases in which the mother suffered from tertian ague, the child having also attacks, as evidenced by its convulsive move- ments, appreciable by the mother, which took place at the regular intervals, but at a different time from the mother's paroxysms. In other cases the febrile paroxysm comes on at the same time in the foetus as in the mother; and the fact has been verified by the observa- tion that the paroxysms continued to recur simultaneously after delivery. The foetus has also been born with distinct malarious enlargement of the spleen. From the frequency w r ith which largely hypertrophied spleens are seen in mere infants in malarious districts, I imagine that the intra-uterine disease must be common. I have frequently observed this fact in India, although, of course, without any possibility of ascertaining if the mothers had suffered from inter- mittent fever during pregnancy. Lead-poisoning is also known to have a most prejudicial effect on the foetus, and frequently to lead to abortion. M. Paul has collected 81 cases, 1 in ivhich it caused the death of the foetus, in some not until after birth; and occasionally it seems to have affected the foetus even when the mother escaped. Syphilis. — Of all blood dyscrasiae transmitted to the foetus, the most important is syphilis. Its influence in producing repeated abortion has been elsewhere described. It may unquestionably be transmitted to the foetus without producing abortion, and at term the mother may be either delivered of a living child, bearing evi- i Arch. Gen. de Med., 1860. PATHOLOGY OF THE DECIDUA AND OVUM. 231 dent traces of tlie disease ; of a dead child similarly affected ; or of an apparently healthy child in whom the disease develops itself after a lapse of a month or two. These varying effects piobably de- pend on the intensity of the poison, and the longer the time that has elapsed since the origin of the disease in the infected parents, the better will be the chance for the child. The disease is,, no doubt, generally transmitted through the mother, and if she be affected at the time of conception, the infection of the foetus seems certain. If, however, she contracts the disease at an advanced period of preg- nancy the child may entirely escape. Eicord even believes that syphilis, contracted after the sixth month of pregnancy, never affects the child. The father alone may transmit the disease to the ovum ; and Hutchinson has recorded cases to show that the mother may become secondarily affected through the diseased foetus. The evi- dences of syphilitic taint in a living or dead child are sufficiently characteristic. The child is generally puny and ill-developed. An eruption of pemphigus is common, either fully developed bullae, or their early stage, when they form circular copper-colored patches. This eruption is always most marked on the hands and feet, and a child born with such an eruption may be certainly considered syphi- litic. On post-mortem examination the most usual signs are small patches of suppuration in the thymus, similar localized suppurations in the tissues of the lungs, indurated yellowish patches in the liver, and peritonitis, the importance of which in causing the death of syphilitic children has been specially dwelt on by Simpson. 1 inflammatory Diseases. — The most important of the inflammatory diseases affecting the foetus is peritonitis. Simpson has shown that traces of it are very frequently met with, and that it is not always syphilitic. Sometimes it has been observed when the mother has been in bad health during pregnancy, and at others it seems to have resulted from some morbid condition of the foetal viscera. Pleurisy with effusion, is another inflammatory affection which has been noticed. Dropsies. — The dropsical affections most generally met with are ascites and hydrocephalus, which may both have the effect of im- peding delivery. Of these hydrocephalus is the more common, and may give rise to much difficulty in labor. Its causes are uncertain but it probably depends on some altered state of the mother's health, as it is apt to recur in several successive pregnancies, and is not in- frequently associated with an imperfectly developed vertebral column and spina bifida. The fluid collects in the ventricles, which it greatly distends, and these then produce expansion and thinning of the cranium, the bones of which are widely separated from each other at the sutures, which are prominent and fluctuating. In a few cases internal hydrocephalus may be complicated, and the diag- nosis in labor consequently obscured, by the coexistence of what has been called " external hydrocephalus." This consists of a collec- tion of fluid between the skull and the scalp, which may be either » Obst. Works, vol. i. p. 117. 232 PREGNANCY Fig. 89. formed there originally, or may collect from a rupture of one of the sutures or fontanelles during labor, through which the intra cranial fluid escapes. Ascites is generally associated with hydramnios, and sometimes with hydro- thorax, or other dropsical effusions. It is a rare affec- tion, and according to Depaul 1 extreme distension of the bladder is not infrequently mistaken for it. Tumors of different kinds may be met with in various parts of the child's body, which sometimes grow to a great size and impede 'de- livery. Tarnier records cases of meningocele larger than a child's head, and large cystic growths have been observed attached to the nates, pectoral region, or other parts of the body. Cancerous tumors of considerable size, either external, or of the viscera, have also been met with. Other fcetal tumors may be produced by congenital de- formities, such as projection of the liver or other abdominal viscera through a deficiency of the abdominal wall ; or spina bifida, from imperfectly developed vertebrae. The amount of dystocia produced by such causes will, of course, vary much in proportion to the size, consistency, ancl'accessibility of the tumor. Wounds and Injuries of the Foetus. — Accidents of serious gravity to the foetus may happen from violence, to which the mother has been subjected, such as falls or blows, with- out necessarily interfering with gestation. Many curious examples of this kind are on record. Thus a child has been born pre- senting a severe lacerated wound extending the whole length of the spine, where both the skin and the muscles had been torn, and which seems to have resulted from the mother having fallen in the last month of preg- nancy. Similar lacerations and contusions have been observed in other parts of the body, the wounds being in various stages of cicatrization, corresponding to the lapse of time since the accident had occurred. Intra-uterine fractures are not rare, appa- rently arising from similar causes. In some of these cases the broken ends of the bones had united, but, from want of accurate ap- position, at an acute angle, so as to give rise to much subsequent deformity. Chaus- sier records two cases in which there were many fractures in the same child, in one 113, and in another 42, which were in different stages of repair. He attributes this curious occurrence to some congenital defect in the nutrition of the bones, possibly allied to mollities ossium. 2 Intra-uterine amputations of fcetal limbs have not infrequently been observed. Children are occasionally born with one extremity more Intia-uteriae Amputation of both. Aims and Le°rs. 1 Tarnier's Cazeaux, p. 855. 2 Gazette Hebdom., 1860. TATIIOLOGY OF THE DECIDUA AND OVUM. 233 or less completely absent, and cases are known in which the whole four extremities were wanting (Fig. 89). The mode in which these malformations are produced has given rise to much discussion. At one time it was supposed that the deficiency of the limb was due to o-angrene of the extremity, and subsequent separation of the spha- celated parts. Ejuss, who has studied the whole subject very minutely, 1 considers gangrene in the unruptured ovum to be an im- possibility, for that change cannot occur unless there is access of oxygen, and when portions of the separated extremity are found in utero, as is often the case, they show evidences of maceration, but not of decomposition. The general belief is that these intra-uterine amputations depend on constriction of the limb by folds or bands of the amnion — most often met with when the liquor amnii is deficient in quantity — -which obstruct the circulation, and thus give rise to atrophy of the part below the constriction. It has been supposed that the umbilical cord might, by encircling the limb, produce a like result. It appears doubtful, however, whether this cause is sufficient to produce complete separation of the limb, as any great amount of constriction would interfere with the circulation through the cord. Sometimes, when intra-uterine amputation occurs, the separated portion of the limb is found lying loose in the amniotic cavity, and is expelled after the child. Cases of this kind have been recorded by Martin, Chaussier, and Watkinson. More often no trace of the separated extremity can be found. The explanation probably de- pends upon the period of utero-gestation at which amputation took place. If it occurred at a very early period of pregnancy, before the third month, the detached portion would be minute and soft, and would easily disappear by solution. If at a later period, this could hardly happen, and the detached portion would remain in utero. In cases of the latter kind cicatrization of the stump has often been ob- served to be incomplete. Simpson pointed out the occasional exist- ence of rudimentary fingers or toes on the stump of an amputated limb, such as are seen on the thighs in Fig. 89. These he attributed to an abortive reproduction of the separated extremity, analogous to what is observed in some of the lower animals. This explanation has been contested with much show of reason. Martin believes that the reproduction is only apparent, and that the rudimentary ex- tremities are, in reality, instances of arrested development. The constricting agents interfered with the circulation sufficiently to arrest the growth of the limb below the site of constriction, but not sufficiently to effect complete separation. If constriction occurred at a very early stage of development an appearance similar to that observed by Simpson would be produced. It does not follow, how- ever, that all cases of absence of limbs depend on intra-uterine ampu- tations. In some cases they would appear to be the result of a sponta- neous arrest of development, or of congenital monstrosity^. Mr. Scott 2 relates a case in which a distinct hereditary tendency was evident, 1 Scanzoni's Beitrage, 1869. 2 Obstet. Trans., vol. xiii. p. 94. 16 234 PREGNANCY. and here the deformity certainly could not have resulted from the constriction of amniotic bands. In this family the grandfather had both forearms wanting, with rudimentary fingers attached ; the next generation escaped;. but the grandchild had a deformity precisely similar to the grandfather. Death of Foetus.— When from any cause, the foetus has died during pregnane}^, it may either be soon expelled, or it may be retained in utero for a longer or shorter time, or even to the full period. The changes observed in such foetuses vary considerably according to the age of the foetus at the time of death, or the time that it has been retained in utero. If it die at an early period, when the tissues are very soft, it may entirely dissolve in the liquor amnii, and no trace of it may be found when the membranes are expelled. Or it may shrivel or mummify ; and if this happen in a twin pregnancy, as sometimes occurs, the growing foetus may compress and flatten the dead one against the uterine wall. Appearance. — At a later period of pregnancy a dead foetus under- goes changes ascribed to putrefaction, but which produce appearances different from those of decomposition in animal textures exposed to the atmosphere. There is no offensive smell, as in ordinary decay. The tissues are all softened and flaccid. The more manifest changes are in the skin, the epidermis of which is separated from the cutis vera, which has a deep reddish color. This is especially apparent on the abdomen, which is flaccid, and hollow in the centre. The inter- nal organs are much altered. The brain is diffluent and pulpy, and the cranial bones loose within the scalp. The structures of the mus- cles and viscera are in various stages of transformation, many having undergone fatty changes, and containing crystals of margarin and cholesterin. The extent to which these changes. occur depends, to a great extent, on the length of time the foetus has been dead, but they do not admit of our estimating with any degree of accuracy what that time has been. The symptoms and diagnosis of the death of the foetus may here be considered. They are, unfortunately, not very reliable. The cessa- tion of the foetal movements cannot be depended on, as they are frequently unfeit for days or weeks, when the child is alive and well. Sometimes the death of the foetus is preceded by its irregular and tumultuous movements, and, in women who have been delivered of several dead children in succession, this sensation may guide us in our diagnosis. This suspicion may be confirmed by auscultation. The mere fact that we are unable, at any given time, to hear the foetal heart will not justify an opinion that the foetus is dead. If, however, the foetal heart has been distinctly heard, and after one or two careful examinations, repeated at separate times, it cannot again be made out, the probability of the child being dead may be assumed. Certain changes in the mother's health have been noted in connec- tion with the death of the foetus, such as depression and lowness of spirits, a feeling of coldness and weight about the lower parts of the abdomen, paleness of the face, a livid circle round the eyes, irregular shiverings and feverishness, shrinking of the breasts, and diminution ABORTION AND PREMATURE LABOR. 235 in the size of the abdominal tumor. All these, however, are too in- definite to justify a positive diagnosis, and they are not infrequently altogether absent. At most they can do no more than cause a sus- picion as to what has happened. CHAPTBE X. ABORTION AND PREMATURE LABOR. Importance and Frequency of Abortion. — The premature expulsion of the foetus is an event of great frequency. The number of foetal lives thus lost is enormous. There are few multiparas who have not aborted at one time or other of their lives. Hegar estimates that about one abortion occurs to every 8 or 10 deliveries at term. White- head has calculated that at least 90 per cent, of married woman, who lived to the change of life, had aborted. The influence of this acci- dent on the future health of the mother is also of great importance. It rarely, indeed, proves directly fatal, but it often produces great debility from the profuse loss of blood accompanying it; and it is one of the most prolific causes of uterine disease in after life, possibly because women are apt to be more careless during convalescence than after delivery, and the proper involution of the uterus is thus more frequently interfered with. Definition. — A not uncommon division of the subject is into abor- tion, miscarriage, and premature labor, the first name being applied to expulsion of the ovum before the end of the fourth month of utero- gestation ; miscarriage to expulsion from the end of the fourth to the end of the sixth month; and premature labor to expulsion from the end of the sixth month to the term of pregnancy. This is, however, a needless and confusing subdivision, which leads to no practical result. It suffices to apply the term abortion or miscarriage indis- crimately to all cases in which pregnancy is terminated before the foetus has arrived at a viable age, and premature labor to those in which there is a possibility of its survival. There is little or no hope of a foetus living before the 28th week or seventh lunar month, and this period is therefore generally fixed on as the limit between premature labor and abortion. The rule, is however, not without an occasional, although very rare, exception. Dr. Keiiler, of Edin- burgh, has recorded an instance in which a foetus was born alive at the fourth month, nine days after the mother had experienced the sensation of quickening. I myself recently attended a lady who mis- carried in the fifth month of pregnancy, the child being born alive, and living for three hours. Several cases are on record in which after delivery at the sixth month the child survived and was reared. 236 PREGNANCY. The possibility of the birth of a living child under such circum- stances should be recognized, at it may give rise to legal questions of importance ; but the exceptions to the ordinary rule are so rare, that they need not interfere with the division of the subject usually made. Abortion is most Common in Multipara?. — Multiparas abort far more frequently than primiparse. This is contrary to the statement in many obstetrical works. Thus, Tyler Smith says " there seems to be a greater danger of this accident in the first pregnancy." Schroeder, 1 however, states that 23 multiparae abort to 3 primiparse ; and Dr. Whitehead, of Manchester, who has particularly studied the subject, believes that abortion is more apt to occur after the third and fourth pregnancies, especially when these take place towards the time for the cessation of menstruation. Liability to a recurrence of Abortion. — There can be no doubt that women who have aborted more than once are peculiarly liable to a recurrence of the accident. This can generally be traced to the exist- ence of some predisposing cause which, persists through several preg- nancies, as, for example, a syphilitic taint, a uterine flexion, or a morbid state of the lining membrane of the uterus. It is probable that in many women a recurrence of the accident induces a habit of abortion, or, perhaps it might be more accurate to say, a peculiar irritable condition of the uterus, which renders the continuance of pregnancy a matter of difficulty, independently of any recognizable- organic cause. Very early Abortions are often Unrecognized. — The frequency of abortion varies much at different periods of pregnancy ; and it occurs much more often in the early months, because of the comparatively slight connection then existing between the chorion and the decidua. At a very early period of pregnancy the ovum is cast off with such facility, and is of such minute size, that the fact of abortion having occurred passes unrecognized. Very many cases, in which the patient goes one or two weeks over her time, and then has what is supposed to be merely a more than usually profuse period, are probably in- stances of such early miscarriages. Velpeau detected an ovum, of about fourteen days, which was not larger than an ordinary pea, and it is easy to understand how so small a body should pass unnoticed in the blood which escapes along with it. Abortions before the Third Month and between the Third and Sixth. — Up to the end of the third month, when miscarriage occurs, the ovum is generally cast off en masse, the decidua subsequently coming away in shreds, or as an entire membrane. The abortion is then comparatively easy. From the third to the sixth month, after the placenta is formed, the amnion is, as a rule, first ruptured by the uterine contractions, and the foetus is expelled by itself. The pla- centa and membranes may then be shed as in ordinary labor. It often happens, however, that on account of the firmness of the pla- cental adhesion at this period, the secundines are retained for a 1 Schroeder, Manual of Midwifery, p. 149. ABORTION AND PREMATURE LABOR. 237 greater or less length of time. This subjects the patient to many risks, especially to those of profuse hemorrhage, and of septicaemia. For this reason, premature termination of the pregnancy is attended by much greater danger to the mother between the third and sixth months, than at an earlier or later date. After the sixth month the course of events is not different from that attending ordinary labor. The prognosis to the child is more unfavorable in proportion to the distance from the full period of gestation at which premature labor takes place. Causes. — The causes of abortion may conveniently be subdivided into the predisposing and exciting, the latter being often slight, and such as would have no effect in inducing uterine contractions in women unless associated with one or more of the former class of causes. The predisposition to abortion may depend on some condi- tion interfering with the vitality of the ovum, or its relation to the maternal structures, or on certain conditions directly affecting the mother's health. Causes referable to the Foetus. — One of the most common antece- dents of abortion is the death of the foetus, which leads to secondary changes, and ultimately produces the uterine contractions which end in its expulsion. The precise causes of death in any given case can not always be accurately ascertained, as they sometimes depend on conditions which are traceable to the maternal structures, at others to the ovular, or, it may be, to a combination of the two. Xor does it by any means follow that the death of the ovum immediately results in its expulsion. The mode in which death of the ovum pro- duces abortion is not difficult to understand, for it necessarily leads to changes in the relations between the ovular and maternal structures; these changes cause hemorrhages — partly external, and partly into the membranes — which, in their turn, excite uterine contraction. Extravasations of blood may take place in various positions. One of the most common is into the decidual cavity, between the decidua vera and the decidua reflexa — or between the decidua vera and the uterine walls. If the hemorrhage is only slight, and especially if it comes from that portion of the decidua near the internal os, and at a distance from the ovum, there need be no material separation, and pregnancy may continue. This explains the cases occasionally met with, in which there is more or less hemorrhage, without subsequent abortion. When the amount of extra vasated blood is at all great, separation and abortion necessarily result, and the decidua will be found on expulsion to have coagula on its surface, and between its various layers which are found to project into the cavity of the amnion (Fig. 90). In other cases hemorrhage is still more extensive, and, after breaking through the decidua reflexa, it forms clots between it and the chorion, and even in the cavity of the amnion. Supposing expulsion to take place shortly after coagula are deposited among the membranes, the blood is little altered, and we have an ordinary abortion. If, however, the ovum is retained, the coagulated fibrine, and the placenta or membranes, undergo secondary changes, which lead to the formation of moles. The so-called fleshy mole (Fig. 91) 238 PREGNANCY. is often retained for many weeks or months after the death of the foetus, and during this time there may be but little modification of An Apoplectic Ovum, with Blood effused in Masses under the Fcetal Surface of the Membrane. the usual symptoms of pregnancy ; or, as is frequently the case, it gives rise to occasional hemorrhage, until at last uterine contractions Blighted Ovum, with Fleshy Degeneration of the Membrane. come on, and it is cast off in the form of a thick fleshy mass, having but little resemblance to the ordinary products of conception. The ABORTION AND PREMATURE LABOR. 239 most probable explanation of its formation is, that when hemorrhage originally took place, the effusion of blood was not sufficient to effect the entire separation and expulsion of the ovum. Part of the mem- branes, or of the placenta — if that organ had commenced to form — retained its organic connection with the uterus, while the foetus perished. The attached portion of the placenta or membranes con- tinues to be nourished, although abnormally. The foetus generally entirely disappears, especially if it has perished at an early period of utero-gestation, when it becomes dissolved in the liquor amnii. Or it may become macerated, shrivelled, and greatly altered in appear- ance. The effused blood becomes decolorized from the absorption of the corpuscles ; and, according to Scanzoni, fresh vessels are developed in the fibrine, which increase the vascular attachment of the mole to the uterine walls. The placenta and membranes may go on increasing in thickness, until they form a mass of considerable size. Careful microscopic examination will almost always enable us to discover the villi of the chorion, altered in appearance, often loaded with granular fatty molecules, but sufficiently distinct to be readily recognizable. Causes depending on the Maternal State. — Important as are the causes of abortion arising from some morbid condition of the ovum, they are not more so than those which depend on the maternal state, and it is to be observed that the former are often indirect causes, produced by primary maternal changes. Many of these maternal causes act by causing hyperemia of the uterus, which leads to ex- travasation of blood. Thus abortion is apt to occur in women who lead unhealthy lives, such as those who occupy over-heated and ill- ventilated rooms, or indulge to excess in the fatigues and pleasures of society, in the use of alcoholic drinks, and the like. Over-frequent coitus has been, for the same reason, observed to produce a remark- able tendency to abortion, and Parent-Duchatelet has noted that it is of very frequent occurrence amongst women of loose life. Many diseases strongly predispose to it, such as fevers, zymotic diseases of all kinds, measles, scarlet fever, smallpox ; and diseases of the respiratory organs, such as bronchitis and pneumonia. Syphilis is well known to be one of the most frequent causes, and one that is likely to act in successive pregnancies. It may act so that the preg- nancy is brought to a premature termination, time after time, until the constitutional disease is eradicated by appropriate treatment, It acts in some cases through the influence of the father in producing a diseased ovum ; and it is the only cause which can with certainty be traced to the state of the father's health. Many other morbid condi- tions of the blood also dispose to abortion. It has been observed to be a frequent result of lead-poisoning ; also of the presence of noxious gases in the atmosphere, such as an excess of carbonic acid. Causes acting through the Nervous System. — Many causes act through the nervous system, such as fright, anxiety, sudden shock, and the like. Thus there are numerous instances on record in which women aborted suddenly after the receipt of some bad news, and it is said to have been of frequent occurrence in women immediately before exe- 240 PREGNANCY. cation. The influence of irritation propagated through the nervous system from a distance, tending to produce uterine contraction and abortion through the agency of reflex action, has been specially dwelt upon by Tyler Smith. Thus he points out that abortion not unfrequently occurs from the irritation of constant suckling in women who become pregnant during lactation. The effect of suckling in producing uterine contraction is, indeed, well known, and the ap- plication of the child to the breast, for this purpose, has long been recognized as a method of treatment in post-partum hemorrhage. The irritation of the trifacial in severe toothache ; of the renal nerves in cases of gravel, in albuminuria, etc. ; of the intestinal nerves in excessive vomiting, in diarrhoea, obstinate constipation, ascarides, etc., all act in the same way. We may, perhaps, also explain, by this hypothesis, the fact, that women are more apt to abort at what would have been the menstrual epoch, than at other times, as the ovarian nerves may then be subject to undue excitement. It is prob- able, however, that there may be also at these times more or less active congestion of the decidua, which may predispose to laceration of its capillaries and blood extravasation. Such congestion exists in those exceptional cases in which menstruation continues for one or more periods after conception, the blood probably escaping from the space between the decidua vera and reflexa ; and, therefore, there is no reason to question its also happening even when such abnormal menstruation is not present. Physical Causes. — Certain physical causes may produce abortion by separating the ovum. Thus it may follow a fall, a blow, or other accidents of a trivial character. On the other hand, women may be subjected to injuries of the severest kind without aborting. The probabilitv, therefore, is that these apparently trivial causes only operate in women who, for some other reason, are predisposed to the accident. Tins is borne out by the fact — which is well known in these clays, when the artificial production of abortion is, unhappily, far from a very rare event — that it is by no means easy to destroy the vitality of the foetus. I myself know of a case, in which the uterine sound was passed several times into a pregnant uterus with- out producing abortion, the pregnancy proceeding to term. Oldham has related a similar case in which he in vain attempted to induce abortion by the sound in a case of contracted pelvis ; and Duncan has mentioned an instance in which an intra-uterine stem pessary was unwittingly introduced, and worn for some time by a pregnant woman, without any bad effect. The fact that pregnancy is with difficulty interfered with when there is a healthy relation between the ovum and the uterus, no doubt, explains the disastrous effects of criminal abortion, which have been especially insisted on by many of our American brethren. Causes depending on Morbid States of the Uterus. — Morbid states of the uterus have an important influence in the production of abortion. Any condition which mechanically interferes with the proper develop- ment of the uterus is apt to operate in this way. Amongst these may be mentioned fibroid tumors ; the presence of old peritoneal ABORTION AND PREMATURE LABOR. 211 adhesions, rendering the womb a more or less fixed organ ; but, above all, flexion and displacement of the uterus. Retroflexion of the uterus is, unquestionably, one of the most frequent factors in its production, not only on account of the irritation which the abnormal position sets up, but from interference with the uterine circulation, which leads to the effusion of blood, and the death of the ovum. An inflamed condition of the cervical and uterine mucous mem- branes will act in the same way, should pregnancy have occurred ; although such a condition more often prevents conception taking place. Symptoms. — Oue of the earliest indications of impending abortion is more or less hemorrhage. This may at first be slight, and may last for a short time only, recurring after an interval of time; or it may commence with a sudden and profuse discharge. Occasionally it is very abundant, and its continuance and amount form one of the gravest symptoms of the accident. After the loss of blood has con- tinued for a i>reater or less leno-th of time — it may be even for some days— uterine contractions come on, recurring at regular intervals, and eventually lead to the expulsion of the ovum. More rarely the impending miscarriage commences with pains, which lead to lacera- tion of vessels and hemorrhage. When Pain and Hemorrhage coexist. — As long as one or other of these symptoms exists alone, we may hope to avert the threatened miscarriage; but when both occur together there is little or no chance of its being arrested. Certain premonitory symptoms are de- scribed by authors as common in abortion, such as feverishness, shivering, a sensation of coldness; all of which are obscure and un- reliable, and are certainly much more frequently absent than present. If the pregnancy be early it is probable that the entire ovum will be shed with little trouble, and it often passes unperceived in the clots which surround it. It is, therefore, of importance that all the discharges should be very carefully examined. After the second month the rigid and undilated cervix presents a formidable obstacle to the escape of the ovum, and it may be a considerable time before there is sufficient dilatation to admit of its passage. This is gradually effected by the continuance of pains, but not without a severe loss of blood. It may be that the amnion is ruptured, and the fetus ex- pelled first. After a lapse of time the secundines are also shed, but there may be a considerable delay, amounting even to days, before this is effected. As long as any portions of the membranes are retained in utero, the patient is necessarily subjected to considerable risk, not only from the continuance of hemorrhage, but also from septicaemia. Hence it may be laid down as a rule, that we can never consider our patient out of danger until we have satisfied ourselves that the whole of the uterine contents have been expelled. Treatment. — Our first endeavor in any case of impending miscar- riage will be, of course, to avert the threatened accident. If hemor- rhage has not been excessive, and if, on vaginal examination, which o JO should always be practised, we find no dilatation of the os, we may entertain a reasonable hope of success. If. on the contrary, we find 242 PREGNANCY. the os beginning to open, if we are able to insert the linger through it so as to touch the ovum, especially if pains also exist, we are justified in considering abortion to be inevitable, and the indication will then be to have the ovum expelled, and the case terminated as soon as possible. In the former case, the most absolute rest is the first thing to insist on. The patient should be placed in bed, not overburdened with clothes, in a cool temperature, and she should have a light and easily assimilated diet. All movements, even rising out of bed to empty the bladder or bowels, should be absolutely pro- hibited. To avert the tendency to the commencement of uterine contraction there is no remedy so useful as opium, which must be given freely, and frequently repeated. It may be administered either in the form of laudanum, or of Battley's sedative solution, which has the advantage of producing less general disturbance. It may be advantageously exhibited in doses of from 20 to 80 minims, and re- peated after a few hours. A still better preparation is chlorodyne, which I have found of extreme value in arresting impending mis- carriage, in doses of 15 minims, repeated every third or fourth hour. If, from any cause, it is considered unadvisable to give the sedative by the mouth, it may be administered in a small starch enema per rectum. In all cases it will be necessary to keep the patient more or less under the influence of the drug for several days, and until all symptoms of miscarriage have passed away. Care should be taken that the bowels do not become locked up by the action of the opiates — as this might of itself be a cause of irritation — and their constipat- ing effects ought to be obviated by small doses of castor oil, or other gentle aperient. Various subsidiary methods of treatment have been recommended, such as bleeding from the arm, or the local applica- tion of leeches in supposed plethoric states of the system ; revulsives, such as dry cupping to the loins; the application of ice, to check hemorrhage; astringents, such as acetate of lead or gallic acid, for the same purpose. Most of these, if not hurtful, will be, at least, useless. The cases in which venesection would be beneficial are ex- tremely rare, and the local applications, especially cold, are much more apt to favor, than to prevent, uterine action. [ Value of Opium.— As an instance of the value of opium in arrest- ing abortion under unfavorable circumstances, I refer to the follow- ing case. Mrs. E., a young married lady in affluent circumstances, the mother of two children, and of apparently a phthisical tendency, the disease being in her family, was taken in labor at 4 J months; the intermittent pains being very decided, and the loss of blood con- siderable. Under the effects of morphia given at intervals, the jaains became gradually less frequent and severe, until at the end of ten hours they ceased entirely. The uterine development advanced without any more interruption, and the patient gave birth to a living- female child at the end of nine months. The foetus was a little below the average in weight, but lived. Viburnum Prunifolium, in the form of a fluid extract, has recently come into notice as a preventive of abortion, especially in cases ABORTION AND PREMATURE LABOR. 243 where there appears to be a habit to abort at short intervals. Great claims are made for the remedy, which is under trial as yet. — Ed.] Prophylactic Treatment. — In cases of repeated miscarriage in suc- cessive pregnancies, a special course of prophylactic treatment is indicated, and is often attended with much success. In cases of this kind the first indication, and one which ought to be carefully attended to, is to seek for and, if possible, to remove or mitigate the cause which has given rise to the former abortions. Those causes which depend on constitutional states must first be carefully investigated, and treated according to the indications present. These may be obscure and not easily discovered ; but it is certainly unwise to assume too readily the existence of what has been called ''a habit of abortion," which further inquiry may prove to be only an indication of constitutional debility, degeneracy of the placental structures, or a latent and unsuspected syphilitic taint. If constitutional debility be present to a marked extent, a generous diet and a restorative course of treatment (preparations of iron, quinine, and other suitable tonics), may effect the desired object. Treatment in cases depending on Local Causes. — Local congestion of the uterus, or a general plethoric state of the patient, have often been supposed to be efficient causes of recurring abortion. Dr. Henry Bennet has especially dwelt on the influence of congestion and abra- sions of the cervix in causing premature expulsion of the foetus, 1 and recommends the topical application of nitrate of silver, or other caustics, to the inflammatory abrasions existing on the neck of the womb. Formerly venesection was a favorite remedy ; and many authors have recommended the local abstraction of blood by leeches applied to the groin, or round the anus, or even to the cervix. The influence of general plethora is more than doubtful ; and although local congestions are, probably, much more effective causes, still it would seem more judicious to treat them by rest, and local sedatives, rather than by topical applications which, injudiciously applied, might produce the very accident they were intended to prevent. [Advantages of a Pure Atmosphere. — In one plethoric woman who aborted repeatedly at about six weeks after impregnation, and in whom depletion failed and opium was inadmissible from cerebral disturbance, I at last succeeded in saving the seventh foetus. The lady was somewhat rheumatic, and subject to attacks of spasmodic asthma, for which she occasionally went to a dry mountainous region. Finding her pregnant when at this retreat, I kept her there until she had long passed the usual time for aborting, when I had her brought home. During the period from the third to the eighth month she was at times affected with uterine pains, when she was kept still in bed until they subsided. In the eighth and ninth months there was no trouble, and she was delivered at the full period of gestation. Before the sixth abortion, when at home, I had succeeded in check- ing the action of the uterus until the end of the second month, but 1 On Inflammation of the Uterus, p. 432. 244 PREGNANCY. with the effect of producing such extreme prostration, that I was glad to learn that the foetus had been expelled. — Ed.] The position of the uterus should be carefully investigated. If it be found to be retroflexed, a well-fitting Hodge's pessary should be applied, so as to support it until it has completely risen out of the pelvis. Treatment in Cases depending on Syphilis. — The possibility of syphilitic infection should always be inquired into, for this poison may act on the product of conception long after all appreciable traces of it have disappeared from the infected parent. Should there be recurrent abortions in a patient who had formerly suffered from syphilis, or whose husband bad at any time contracted the disease, no time should be lost in using appropriate anti-syphilitic remedies, which should invariably be administered both to the husband and wife. Diday especially insists that in such cases it is not sufficient to submit the father and mother to a mercurial course in the absence of pregnancy, but that, as each successive impregnation occurs, the mother should again commence anti-syphilitic treatment, even though she has no visible traces of the disease. 1 In this way there is reason- able ground for hoping that infection of theovum may be prevented. I think, too, that we may be the more encouraged to persevere in the treatment of these unfortunate cases, from the fact that the syphilitic poison tends to wear itself out. I have seen several cases in which this taint, at first produced early abortion, then each suc- cessive pregnancy was of longer duration, until eventually a living child was born. In fatty degeneration of the chorion villi, and in other morbid states of the placenta, which act by preventing the proper nutrition of the foetus, and the due aeration of its blood, there is no reliable means of treatment except the general improvement of the mother's health. Simpson strongly recommended the administration of chlorate of potash in cases in which the child habitually dies in the latter months of pregnancy, on the supposition that it supplied to the blood a large amount of oxygen, and thus made up for any deficiency in the supply of that element through the placental tufts. The theory is, at best, a doubtful one, although I believe the drug to be unques- tionably beneficial in cases of the kind. It probably acts by its tonic properties rather than in the manner Simpson supposed. It may be given in doses of 15 to 20 grains three times a day, and may be advantageously combined with small closes of dilute hydrochloric acid. In frequently recurring premature labors with dead children, Simpson strongly recommended the induction of premature labor a little before the time at which we had reason to believe that the foetus has usually perished ; or, in other words, before the placental disease had advanced sufficiently far to interfere with its nutrition. The practice has constantly been adopted with success, and is per- fectly legitimate, but the difficulty, of course, is to fix on the right time. Careful auscultation of the' foetal heart may be of some use in » Diday, Infantile Syphilis, Syd. Soc. Trans, p. 207. ABORTION AND PREMATURE LABOR. 245 guiding us to a decision, as the death of the foetus is generally pre- ceded for some days by irregular, tumultuous, and intermittent action of the heart, There will always remain a certain number of cases in which no appreciable cause can be discovered. Under such circumstances prolonged rest, at least until the time has passed at which abortion formerly took place, will afford the best chance of avoiding a recur- rence of the accident.. There must always be some difficulty in carrying out this indication, inasmuch as the patient's health is apt to suffer in other ways from the confinement, and the want of fresh air and exercise which it entails. The strictness with which rest should be insisted on must vary in different cases, but it should be specially attended to at what would have been the menstrual periods. At these times the patient should remain in bed altogether; at others she may lie on a sofa, and, if circumstances permit, spend part of the day, at least, in the open air. Sexual intercourse should be pro- hibited. Should actual symptoms of abortion come on, the pre- ventive treatment, already indicated, may be resorted to. Great care, however, should be used in prescribing opiates as preventives, and they should be given for a specified time only. I have seen, more than once, an incurable habit of opium-eating originate from the incautious and too long continued exhibition of the drug in such cases. When we have satisfied ourselves that abortion is inevitable, we must proceed to employ treatment that favors the expulsion of the ovum. Removal of the Ovum, ivhen within reach. — If the os be sufficiently dilated, and the pains strong, we may find the ovum separated and protruding from the os. We may then be able to detach it by the finger. For this purpose the uterus is depressed from without by the left hand, while an endeavor is made to scoop out the ovum with the examining finger. If it be out of reach, and yet appears de- tached, chloroform should be administered, the whole hand intro- duced into the vagina, and the finger into the uterine cavity. The complete detachment of the ovum can, in this way, be far more readily and safely effected than by using any of the many ovum-for- ceps which have been invented for the purpose. Plugging of the Vagina. — If the ovum be not sufficiently sepa- rated, or the os be undilated, means must be taken to control the hemorrhage until the former can be removed or expelled. It is here that plugging of the vagina finds its most useful application. This may be done in various ways. That most usually employed is filling the vagina with a tolerably large sponge, in the^interstices of which the blood coagulates. A better plan is to soak a number of pledgets of cotton-wool in water and tie a string round each. The vagina can be completely and effectively packed with these ; and this is best done through a speculum. Each pledget should be covered with glycerine, which completely prevents the offensive odor which other- wise always arises. The pledgets can be removed by traction on the strings, but if these are not used much pain is caused in getting them 246 PREGNANCY. out of the vagina. The plug should never be left in for more than six or eight hours, after whieh a fresh one may be inserted if neces- sary. Two or three full doses of the liquid extract of ergot, of 5ss to 5j each, or a subcutaneous injection of ergotine, may be given while the plug is in position. The plug itself is a strong excitant of uterine action, and the two combined often effect complete detach- ment, so that, on the removal of the tampon, the ovum may be found lying loose in the os uteri. If the os be undilated and the ovum en- tirely out of reach, the former may be opened by means of sponge or laminaria tents. I think a well prepared sponge tent the most ef- fectual, and it can be maintained in situ by a vaginal plug below it. It also acts as a most efficient plug, effectually controlling all hemor- rhage. In a few hours it opens up the os sufficiently to admit the fino-er. Retention of the Membranes. — The most troublesome cases are those in which the foetus is first expelled, and the placenta and membranes remain in utero. As long as this is the case the patient can never be considered safe from the occurrence of septicaemia. Dr, Priestley has strongly insisted on the importance of removing the secundines as soon as possible. There can be no doubt that this should be done whenever it is feasible. Cases, however, are frequently met with in which any forcible attempt at removal would be likely to prove very hurtful, and in which it is better practice to control hemorrhage by the plug or sponge tent, and wait until the placenta is detached, which it will generally be in a day or two at most. Under such circumstances fetor and decomposition of the secundines may be pre- vented by intra- uterine injections of diluted Condy's fluid. Provided the os be sufficient^ patulous to prevent the collection of the fluid in the uterine cavity, and not more than a drachm or two of fluid be injected at a time, so as simply to wash away and disinfect decom- posing detritus, they can be used with perfect safety. Sometimes cases are met with in which the oshas entirely closed, and in which we can only suspect the retention of the placenta by the history of the case, the continuance of hemorrhage, or the presence of a fetid discharge. Should Ave see reason to suspect this the os must be dilated with sponge or laminaria tents, and the uterine cavity thoroughly explored under chloroform. This condition of things is for from uncommon in women who have not had medical assistance from the first, and it often gives rise to very troublesome and anxious symptoms. It has been said that placentae thus retained have been completely absorbed, and cases of the kind have been related by Naegele and Osiander. The spontaneous absorption, however, of so highly organized a body as the placenta would be a phenomenon of the most remarkable character; and it seems more natural to suppose that, in most cases of the kind, the placenta has been cast off without the knowledge of the patient. Sometimes the placenta never becomes entirely de- tached, and, retaining organic connection with the uterine walls, forms Avhat has been called a ' placental poly pus. ,' This may produce secondary hemorrhages, in the same way as an ordinary fibroid poly- pus. Barnes recommends the removal of these masses by means of ABORTION AND PREMATURE LABOR. 247 the wire ecraseur. Before their detection the os uteri must be opened up. Retention in utero of a Blighted Ovum. — The cases, previously alluded to, m which an ovum has perished in earlj^ pregnancy and is retained in utero, are often puzzling, and may give rise to serious moral and medico-legal questions. The blighted ovum may be retained for many months, the outside limit according to MeClintock, 1 by whom the subject has been ably discussed, being nine months. The appear- ance of the ovum when thrown off will give no reliable clue to the length of time which has elapsed since it perished. The symp- toms are often very obscure. Generally there have been the usual indications of pregnancy which, with or without signs of impending miscarriage, disappears or are modified, and then follows a period of ill health, with pelvic uneasiness, and irregular metrorrhagia, which may be mistaken for menstruation. Occasionally, but by no means necessarily, there is a fetid discharge, and this probably exists only when the membranes have broken, and air has access to the ovum. In some cases obscure septicemic symptoms have been observed. Such symptoms are obviously too indefinite to lead to an accurate diagnosis. In the course of time the ovum is generally thrown off, with more or less hemorrhage. If the nature of the case is detected ergot maybe given to promote the expulsion of the uterine contents, and it may even be advisable to dilate the cervix with sponge or laminaria tents, and remove them artificially. Subsequent Management. — The frequenc}" with which abortion leads to chronic uterine disease should lead us to attach much more im- portance to the subsequent management of the patient than has been customary. The usual practice is to confine the patient to bed for two or three days only, and then to allow her to resume her ordinary avocations, on the supposition that a miscarriage requires less sub- sequent care than a confinement The contrary of this is, however, most probably the case ; for the uterus has been emptied when it is unprepared for involution, and that process is often very imperfectly performed. We should, therefore, insist on at least as much atten- tion being paid to rest as after labor at term. 1 Sydenham Society's edition of Smellie's Midwifery, vol. i. p. 169. PART III. LABOR. CHAPTER I. THE PHENOMENA OF LABOR. Deliver!/ at Term. — In considering delivery at term we have to dis- cuss two distinct classes of events. One of these is the series of vital actions brought into play in order to effect the expulsion of the child ; and the other consists of the movements imparted to the child — the body to be expelled — in other words, the mechanism of delivery. Causes of Labor. — Before proceeding to the consideration of these important topics, a few words may be said as to the determining causes of labor. This subject has been from the earliest times a qusestio vexata among physiologists ; and many and various are the theories which have been broached to explain the curious fact that labor spontaneously commences, if not at a hxed epoch, at any rate approximately so. It must be admitted that, even yet, there is no explanation which can be implicitly accepted. Foetal or Maternal Causes. — The explanations which have been given may be divided into two classes — those which attribute the advent of labor to the foetus, and those which refer it to some change connected with the maternal generative organs. The former is the opinion which was held by the older accou- cheurs, who assigned to the foetus some active influence in effecting its own expulsion. It need hardly be said that such fanciful views have no kind of physiological basis. Others have supposed that there might be some change in the placental circulation, or in the vascular system of the foetus, which might solve the mystery. The latest hypothesis of this kind, which, however, is not fortified by any evidence, is by Barnes, who savs : " I rather incline to the opinion that when the foetus has attained its full development, when its organs are prepared for external life, some change takes piace in its circulation, which involves a correlative disturbance in the maternal circulation, which excites the attempt at labor." 1 The majority of obstetricians, however, refer the advent of labor to purely maternal causes. Among the more favorite theories is one, which was originally started in this country by Dr. Power, and 1 Diseases of Women, p. 434. (243) THE PHENOMENA OF LABOR. 249 adopted and illustrated by Depaul, Dubois, and other writers. It is based on the assumption that there is a sphincter action of the fibres of the cervix, analogous to that of the sphincters of the bladder and rectum, and that when the cervix is taken up into the general uterine cavity as pregnancy advances, the ovum presses upon it, irri- tates its nerves, and so sets up reflex action, which ends in the estab- lishment, of uterine contraction. This theory was founded on erro- neous conceptions of the changes that occurred in the neck of the uterus; and, as it is certain that obliteration of the cervix does not really take place in the manner that Power believed when his theory was broached, it is obvious that its supposed result cannot follow. Distension of the Uterus. — Extreme distension of the uterus has been held to be the determining cause of labor, a view lately revived by Dr. King, of Washington, 1 who believes that contractions are in- duced because the uterus ceases to augment in capacit} r , while its contents still continue to increase. This hypothesis is sufficiently disproved by a number of clinical facts which show that the uterus may be subject to excessive and even rapid distension — as in cases of hydra mnios, multiple pregnancy, and hydatiform degeneration of the ovum — without the supervention of uterine contractions. Fatty Defeneration of the Decidua. — Another inciter of uterine action has been supposed to be the separation of the ovum from its connections to the uterine parietes, in consequence of fatty degenera- tion of the decidua occurring at the end of pregnancy. The sup- posed result of this change, which undoubtedly occurs, is that the ovum becomes so detached from its organic adhesions as to be some- what in the position of a foreign body, and thus incites the nerves so largely distributed over the interior of the uterus. This theorv, which has been widely accepted, was originally started by Sir James Simpson, who pointed out that some of the most efficient means of inducing labor (such, for example, as the insertion of a gum-elastic catheter between the ovum and the uterine Avails) probably act in the same way, viz., by effecting separation of the membranes and detachment of the ovum. Barnes instances, in opposition to this idea, the fact that ineffect- ual attempts at labor come on at the natural term of gestation in cases of extra-uterine pregnancy, when the foetus is altogether inde- pendent of the uterus, and therefore, he argues, the cause cannot be situated in the uterus itself. A fair answer to this argument would be that although, in such cases, the womb does not contain the ovum, it does contain a decidua, the degeneration and separation of which might suffice to induce the abortive and partial attempts at labor then witnessed. Objections to these Theories. — A serious objection to all these theories, which are based on the assumption that some local irritation brings on contraction, is the fact, which has not been generally appreciated, that uterine contractions are always present during pregnancy as a 1 American Journal of Obstetrics, vol. iii. 17 250 LABOR, normal occurrence, and that they may be, and often are. readily in- tensified at any time, so as to result in premature delivery. It is, indeed, most likely that, at or about the full term, the ner- vous supply of the uterus is so highly developed, and in so advanced a state of irritability, that it more readily responds to stimuli than at other times. If by separation of the decidua, or in some other way, stimulation of the excitor nerves is then effected, more frequent and forcible contractions than usual may result, and, as they become stronger and more regular, terminate in labor. But, allowing this, it still remains quite unexplained why this should occur with such regularity at a definite time. Tyler Smith's Ovarian Theory. — Tyler Smith tried, indeed, to prove that labor came on naturally at what would have been a menstrual epoch, the congestion attending the menstrual nisus acting as the ex- citer of uterine contraction. He, therefore, refers the onset of labor to ovarian, rather than to uterine, causes. Although this view is ■upheld with all its author's great talent, there are several objections to it difficult to overcome. Thus, it assumes that the periodic changes in the ovary continue during pregnancy, of which there is no proof. Indeed there is good reason to believe that ovulation is suspended during gestation, and with it, of course, the menstrual nisus. Be- sides, as has been well objected by Cazeaux, even if this theory were admitted, it would still leave the mystery unsolved, for it would not explain why the menstrual nisus should act in this way at the tenth menstrual epoch, rather than at the ninth or eleventh. In spite, then of the many theories at our disposal, it is to be feared that we must admit ourselves to be still in entire ignorance of the reason why labor should come on at a fixed epoch. Mode in which the Expulsion of the Child is effected. — The expulsion of the child is effected by the contractions of the muscular fibres of the uterus, aided by those of some of the abdominal muscles. These efforts are in the main entirely independent of volition. So far as regards the uterine contractions, this is absolutely true, for the mother has no power of originating, lessening, or increasing the action of the uterus. As regards the abdominal muscles, however, the mother is certainly able to bring them into action, and to increase their power by voluntary efforts ; but, as labor advances, and as the head passes into the vagina and irritates the nerves supplying it, the abdominal muscles are often stimulated to contract, through the influ- ence of reflex action, independently of volition on the part of the mother. The Chief Factor in Expulsion. — There can be little doubt that the chief agent in the expulsion of the child is the contraction of the uterus itself. This opinion is almost unanimously held by accouch- eurs, and the influence of the abdominal muscles is believed to be purely accessory. Dr. Haughton, however, maintains a view which is directly contrary to this. From an examination of the force of the uterine contractions, arrived at by measuring the amount of mus- cular fibre contained in the walls of the uterus, he arrives at the conclusion that the uterine contractions are chiefly influential in rup- THE PHENOMENA OF LABOR. 251 taring the membranes, and dilating the os uteri, bringing into action, it' needful, a force equivalent to 54 lbs.; but when this is effected, and the second stage of labor has commenced, he thinks the remain- der of the labor is mainly completed by the contractions of the ab- dominal muscles, to which he attributes enormous powers, equiva- lent, if needful, to a pressure of 5 W 23.65 lbs. on the area of the pelvic canal. These views bear on a topic of primary consequence in the phy- siology' of labor. They have been fully criticized by Duncan, who has devoted much experimental research to the study of the powers brought into action in the expulsion of the child. His conclusions are that, so far from the enormous force being employed that Haughton estimated, in the large majority of cases the effective force brought to bear on the child by the combined action of both the uterine and abdominal muscles is less than 50 lbs. — that is, less than the force which Haughton attributed to the uterus alone. In extremely severe labors, when the resistance is excessive, he thinks that extra power may be employed; but he estimates the maximum as not above 80 lbs., including in this total the action of both the uterine and abdominal muscles. Joulin arrived at the conclusion that the uterine contractions were capable of resisting a maximum force of about one hundred weight. Both these estimates, it will be observed, are much under that of Haughton, which Duncan de- scribes as representing "a strain to which the maternal machinery could not be subjected without instantaneous and utter destruction." There are many iacts in the history of parturition which make it certain that the chief factor in the expulsion of the child is the uterus. Among these may be mentioned occasional cases in which the action of the abdominal muscles is materially lessened, if not annulled — as in profound anaesthesia, and in some cases of para- plegia — in which, nevertheless, uterine contractions suffice to affect delivery. The most familiar example of its influence, however, and one that is a matter of everyday observation in practice, is when inertia of the uterus exists. In such cases no effort on the part of the mother, no amount of voluntary action that she can bring to bear on the child, has any appreciable influence on the progress of the labor, which remains in abeyance until the de- fective uterine action is re-established, or until artificial aid is given. The contraction of the uterus, then, being the main agent in de- livery, it is important for us to appreciate its mode of action, and its effect on the ovum. Uterine Contractions at the Commencement of Labor. — We have seen that intermittent and generally painless uterine contractions exist during pregnancy. As the period for delivery approaches, these become more frequent and intense, until labor actually com- mences, when they begin to be sufficiently developed to effect the opening up of the os uteri, with the view to the passage of the child. They are now accompanied by pain, which increases as labor advances, and is so characteristic that "pains 17 are universally used 252 LABOR. as a descriptive term for the contractions themselves. It does not necessarily follow that uterine contractions are painless until they commence to effect dilatation of the os uteri. On the contrary, during the last days or even weeks of pregnancy, women constantly have irregular contractions, accompanied by severe suffering, which, however, pass off without producing any marked effect on the cer- vix. When labor has actually begun, if the hand is placed on the uterus, when a pain commences, the contraction of its muscular tissue is very apparent, and the whole organ is observed to become tense and hard, the rigidity increasing until the pain has reached its acme, the uterine walls then relaxing, and remaining soft until the next pain comes on. At the commencement of labor these pains are few, separated from each other by a considerable interval, and of short duration. In a perfectly typical labor the interval between the pains becomes shorter and shorter, while, at the same time, the dura- tion of each pain is increased. At first they may occur only once in an hour or more, while eventually there may not be more than a few minutes' interval between them. Mode in which Dilatation of the Cervix is Effected. — If, when the pains are fairly established, a vaginal examination be made, the os uteri will be found to be thinned and dilated in proportion to the progress of the labor. Luring the contraction' the bag of membranes will be felt to bulge, to become tense from the downward pressure of the liquor amnii within it, and to protrude through the os if it be sufficiently open. The membranes, with the contained liquor amnii, thus form a fluid wedge, which has a most important influence in dilating the os uteri (see Frontispiece). This does not, however, form the sole mechanism by which the os uteri is dilated, for it is also acted upon by the contractions of the muscular fibres of the uterus, which tend to pull it open. It is probable that the muscu- lar dilatation of the os is effected chiefly by the longitudinal fibres, which, as they shorten, act upon the os uteri, the part where there is least resistance. Partly then by muscular contraction, partly by mechanical pres- sure, the cervical canal is dilated, and as it opens up it becomes thin- ner and thinner, until it is entirely taken up into the uterine cavity. Rupture of the Membranes. — There is no longer any obstacle to the passage of the presenting part of the child into the cavity of the pslvis, and the force of the pains now generally effects the rupture of the membranes, and the escape of the liquor amnii. There is often observed, at this time, a temporary relaxation in the frequency of the pains, which had been steadily increasing ; but they soon re- commence with increased vigor. If the abdomen be now examined it will be observed to be much diminished in size, partly in conse- quence of the escape of the liquor amnii, partly from the descent of the foetus into the pelvic cavity. Change in the Character of the Pains. — The character of the pains soon changes. They become stronger, longer in duration, separated by a shorter interval, and accompanied by a distinct forcing effort, being generally described as " the bearing -down" pains. Now is the THE PHENOMENA OF LABOR. 253 time at which, the accessory muscles of parturition come into opera- tion. The patient brings them into play in the manner which will be subsequently described, and the combined action of the uterine and abdominal muscles continues until the expulsion of the child is effected. Mode of Action of the Uterus. — The precise mode of uterine con- traction is still somewhat a matter of dispute. It is generally de- scribed as commencing in the cervix, passing gradually upwards by peristaltic action, the wave then returning downwards towards the os uteri. This view was maintained by Wigand, and has been en- dorsed by Eigby, Tyler Smith, and many other writers. In support of it they instance the fact that, on the accession of a pain, the pre- senting part first recedes, the bag of membranes then becomes tense and protrudes through the os, and it is not until some time that the presenting part of the child itself is pushed down. It is very doubt- ful if this view is correct; and a careful examination of the course of the pains would rather lead to the belief that the contractions commence at the fundus, where the muscular tissue is most largely developed, and gradually proceed downwards to the cervix ; the waves of contraction being, however, so rapid that the whole organ seems to harden en masse. The apparent recession of the presenting part, and the bulging of the bag of membranes, are certainly no proof that the contractions begin at the cervix ; for the commencing contraction would necessarily push down the fluid in front of the head, and cause the membranes to bulge, and the os to become tense, before its force was brought to bear on the foetus itself. Indeed did the contraction commence at the lower part of the uterus, we should expect the opposite of what takes place to occur, and the waters to be pushed upwards, and away from the cervix. The fundal origin of the contraction is further illustrated by what is observed when the hand of the accoucheur is placed in the uterine cavity, as often happens in certain cases of hemorrhage or turning ; for if a pain then comes on, it will be felt to start at the fundus, and gradually compress the hand from above downwards. Value of the Intermittent Character of the Pains. — The intermittent character of the contractions is of great practical importance. Were they continuous, not only would the muscular powers of the patient be rapidly exhausted, but, by the obliteration of the vessels produced by the muscular contraction, the circulation through the placenta would be interfered with, and the life of the child imperilled. Hence one of the chief dangers of protracted labor, especially after the es- cape of the liquor amnii, is that the uterine fibres may enter into a state of tonic rigidity, a condition that cannot be long continued without serious risks both to the mother and child. The fact that the uterine contractions are altogether involuntary proves them to be excited — as indeed we would a priori infer from our knowledge of the anatomical arrangement of the nerves of the uterus — solely by the sympathetic system. Still it is a fact of every- day observation that they can be largely influenced by emotions. Various stimuli applied to the spinal system of nerves (as for exam- 254 LABORo pie when the mammae are irritated) have also a marked effect in in- ducing uterine contraction. The precise mode in which such influ- ence is conveyed to the uterus, in spite of the numerous experiments which have been made for the purpose of determining how far labor is affected by destruction of the spinal cord, is still a matter of doubt. After the foetus has passed through the cervix, the spinal nerves distributed to the vagina and perineum are excited by the pressure of the presenting part, and through them, the accessory powers of parturition are chiefly brought into play. The contraction of the muscles of the vagina itself is supposed to have some influence in favoring the expulsion of the foetus after the birtli of part of the body, and also in promoting the expulsion of the placenta. In the lower animals the vagina has a very marked contractile property, and is, in some of them, the main agent by which the young are ex- pelled. In the human subject this influence is certainly of very secondary importance. Character and Source of Pains during Labor. — The amount of suf- fering experienced during labor varies much in different cases, and is in direct proportion to the nervous susceptibility of the patient. There are some women who go through labor with little or no pain at all. This is proved by the cases (of which there are numerous authentic instances recorded) in which labor has commenced during sleep, and the child has been actually born without the mother awaking. I am acquainted with a lady, who has had a large family, who assures me that, though the labor is accompanied by a sense of pressure and discomfort, she experiences nothing which can be called actual pain. Such a happy state of affairs is, however, extremely exceptional, and, in the vast majority of cases, parturition is accom- panied by intense suffering during its whole course, in some cases amounting to anguish, which has probably no parallel under any other condition. The precise cause of the pain has been much discussed, and is, no doubt, complex. In the First Stage. — In the early stage of labor, and before the di- latation of the os, it is chiefly seated in the back, from whence it shoots round the loins and down the thighs. It is then probably pro- duced, partly by pressure on the nerve filaments caused by contrac- tion of the muscular fibres to which they are distributed, and partly by stretching and dilatation of the muscular tissue of the cervix. M. Beau believes that in this stage the pain is not produced, strictly speaking, in the uterus itself, but is rather a neuralgia of the lumbo- abdominal nerves. The pains at this time are generally described as "acute" and "grinding," terms which sufficiently well express their nature. In highly nervous women these pains are often much less well borne than those of a later stage, and the suffering they undergo is indicated by their extreme restlessness and loud cries as each contraction supervenes. As the os dilates, and the labor advances into the expulsive stage, other sources of suffering are added. In the Second Stage. — The presenting part now passes into the va- gina and presses on the vaginal nerves, as well as on the large ner- THE PHENOMENA OF LABOR. ZDD vous plexuses lying in the pelvis. As it descends lower it stretches the perineum and vulva, and presses on the bladder and rectum. Hence cramps are produced in the muscles supplied by the nerve plexuses, as well as an intolerable sense of tearing and stretching in the vulva and perineum, and often a distressing feeling of tenesmus in the bowels. By this time the accessory muscles of parturition are brought into action, and they, as veil as the uterine muscles, are thrown into frequent and violent contractions, which, independently of the other causes mentioned, are sufficient of themselves to produce great pain, likened to that of colic, produced by involuntary and repeated contraction of the muscles of the intestines. Taking all these causes into consideration, there is no lack of suf- ficient explanation of the intolerable suffering which is so constant an accompaniment of child-birth. Effect of the Pains on the Mother and Foetus. — The effect of the pains on the mother's circulation is well marked. The rapidity of the pulse increases distinctly with each contraction, and, as the pain passes off* it again declines to its former state. A similar observation has been made with regard to the sounds of the foetal heart, especially after the expulsion of the liquor amnii. Hicks has pointed out that during a pain the muscular vibrations give rise to a sound which often resembles that of the foetal heart, and which completely disap- pears when the muscular tissue relaxes. The effect of the pain in intensifying the uterine souffle has been already mentioned. The strong muscular efforts would naturally lead us to expect a marked elevation of temperature during labor. Further observations on this point are required; but Squire asserts that there is generally only a very slight increase in temperature during delivery, rapidly passing- off as soon as labor is over. Division of Labor into Stages. — Such being the physiological facts in connection with the labor pains, we may now describe the ordinary progress of a natural labor — that is, one terminated by the natural powers, and with a head presenting. For facility of description obstetricians have long been in the habit of dividing the course of labor into stages, which correspond pretty accurately with the natural sequence of events. For this purpose we generally talk of three stages : viz., 1, from the commencement of regular pains until the complete dilatation of the cervix; 2, from the complete dilatation of the cervix until the expulsion of the child; 3, the concluding stage, comprising the permanent contraction of the uterus, and the separation and expulsion of the placenta. To these we may conveniently add a preparatory stage, antecedent to the regular commencement of the labor. Preparatory Stage. — For a short time before deliverv. varying from a few days to a week or two, certain premonitory symptoms gene- rally exist, which indicate the approaching advent of labor. Some- times they are well marked, and cannot be mistaken: at others they are so slight as to escape observation. Amongst the most common is a sinking of the uterus into the pelvic cavity, resulting from the relaxation of the soft parts preceding delivery. The result is, that 256 LABOR. the upper edge of the uterine tumor is less high than before, and, in consequence, the pressure on the respiratory organs is diminished, and the woman often feels lighter, and altogether less unwieldy, than in the previous weeks. If a vaginal examination be made at this time, the lower segment of the uterus will be found to have sunk lower into the pelvic cavity; and the consequence of this is that, while the respiration is less embarrassed, and the patient feels less bulky, other accompaniments of pregnancy, such as hemorrhoids, irritability of the bladder and bowels, and oedema of the limbs, be- come aggravated. The increased pressure on the bowels often induces a sort of temporary diarrhoea, which is so far advantageous that it empties the bowels of feces which may have collected within them. As has already been pointed out, the contractions which have been going on at intervals during the latter months of pregnancy now get more and more marked, and they have the effect of producing a real shortening of the cervix, which is of great value preparatory to its dilatation. More marked mucous discharge from the cavity of the cervix also generally occurs a short time before labor, and it is not infrequently tinged with blood from the laceration of minute capillary vessels. This discharge, popularly known as the "shoivs" is a pretty sure sign that labor is not far oft'. It may, however, be entirely absent, even until the birth of the child. When copious it serves to lubricate the passages, and is generally coincident with rapid dilata- tion of the parts, and a speedy labor. False Pains. — During this time (premonitory stage) painful uterine contractions are often present, which, however, have no effect in dilating the cervix. In some cases they are frequent and severe, and are very apt to be mistaken for the commencement of real labor. Such u false pains" as they are termed, are often excited and kept up by local irritations, such as a loaded or disordered state of the in- testinal canal ; and they frequently give rise to considerable distress, and much inconvenience both to the patient and practitioner. They are, it should be remembered, only the normal contractions of the uterus, intensified and accompanied with pain. First Stage, or Dilatation. — As labor actually commences, the uterine contractions become stronger, and the fact that they are "true" pains can be ascertained by their effect on the cervix. If a vaginal examination be made during one of these, the membranes will be felt to become tense and bulging during the pain, and the os uteri will be found partially dilated, and thinned at its edges. As labor advances this effect on the os becomes more and more marked. At first the dilatation is very slight, perhaps not more than enough to admit the tip of the examining finger, and both the upper and lower orifices of the cervix can be made out. As the pains get stronger and more frequent, dilatation proceeds in the way already described, and the cervix gets more thin and tense, until we can feel a thin circular ring (which is lax between the pains, but becomes rigid and tense during the contraction when the bag of water bulges through it), without any distinction between the upper and lower orifices. During this time the patient, although she may be suffer- THE PHENOMENA OF LABOR. ZD i ing acutely, is generally able to sit up and walk about. The amount of pain experienced varies much according to the character of the patient. In emotional women of highly-developed nervous suscepti- bilities it is generally very great. They are restless, irritable, and desponding, and when the pain comes on cry out loudly. The character of the cry is peculiar and well marked during the first stage and has constantly been described by obstetric writers as charac- teristic. It is acute and high, and is certainly very different from the deep groans of the second stage, when the breath is involuntarily retained to assist the parturient effort, When dilatation is nearly completed various reflex nervous phenomena often show themselves. One of these is nausea and vomiting, another is uncontrollable shivering, which is not accompanied by a sense of coldness, the patient being often hot and perspiring. Both these symptoms indi- cate that the propulsive stage will shortly commence; and they may be regarded as favorable rather than otherwise, although they are apt to alarm the patient and her friends. By this time the osis fully dilated, the membranes generally rupture spontaneously, and a con- siderable portion of the liquor amnii flows away. The head, if pre- senting, often acts as a sort of ball-valve, and, falling down on the aperture of the cervix, prevents the complete evacuation of the liquor amnii, which escapes by degrees during the rest of the labor, or may be retained in considerable quantity until the birth of the child. It not infrequently happens, if the membranes are somewhat tougher than usual, and the pains frequent and strong, that the foetus is pushed through the pelvis, and even expelled, surrounded by the membranes. When this occurs the child is said to be born with a " caul" and this event would doubtless happen more fre- quently than it does, were it not the custom of the accoucheur to rupture the membranes artificially as soon as the os is completely opened up, after which time their integrity is no longer of any value. Second Stage, or Propulsion. — The os is now entirely retracted over the presenting part, and is no longer to be felt, the vagina and the uterine cavity forming a single canal. Now the mucous discharge is generally abundant, so that the examining finger brings away long strings of glairy transparent mucus, tinged with blood. The pains after a short interval of rest, become entirely altered in character. The uterus contracts tightly round the foetus, the presenting part de- scends into the pelvis, and the true propulsive pains commence. The accessory muscles of parturition now come into play. With each pain the patient takes a deep inspiration, and thus fills the chest, so as to give a point oVappui to the abdominal muscles. For the same reason she involuntarily seizes hold of some point of support, as the hand of a bystander or a towel tied to the bed, and, at the same time, pushes with her feet against the end of the bed, and so is able to bear down to advantage. The cries are no longer sharp and loud, but consist of a series of deep suppressed groans, which correspond to a succession of short expirations made during the straining effort. In this way the abdominal muscles contract forcibly on the uterus, 258 > LABOR. which they further stimulate to action by pressing upon it. It is to be observed that these straining efforts are, to a considerable extent, under the control of the patient. By encouraging her to hold her breath and bear down they can be intensified ; while if we wish to lessen them we can advise her to call out, and when she does so the abdominal muscles have no longer a fixed point of action. Although the patient may thus lessen the effect of these accessory muscles, it is entirely out of her power to stop their action altogether. As labor advances the head descends lower and lower, receding somewhat in the intervals between the pains, until eventually it comes down in the perineum, which it soon distends. Distension of the Perineum and Birth of the Child. — The pains now get stronger and more frequent, often with scarcely a perceptible in- terval between them, until the perineum gets stretched by the ad- vancing head. In the interval between the pains elasticity of the perineal structures pushes the head upwards, so as to diminish the tension to which the perineum is subjected, the next pain again put- ting it on the stretch, and protruding the head a little further than before. By this alternate advance and recession, the gradual yield- ing of the structures is favored, and risk of laceration greatly dimin- ished. During this time the pressure of the head mechanically empties the bowel of its contents. During the last pains, when the perineum is stretched to the utmost, the anal aperture is dilated, sometimes to the size of a five- shilling piece ; and in this way the perineum is relaxed, just as the distension, and consequent risk of laceration, are at their maximum. The apex of the head now pro- trudes more and more through the vulva, surrounded b^y the orifice of the vagina, and eventually it glides over the perineum and is expelled. The intensity of the suffering at this moment generally causes the patient to call out loudly. The force of the abdominal muscles is thus lessened at the last moment, and this, in combination with the relaxation of the sphincter ani, forms an admirable con- trivance for lessening the risk of perineal injury. The rest of the body is generally expelled immediately by a single pain, and with it are discharged the remains of the liquor amnii, and some blood-clots from separation of the placenta ; and so the second stage of labor terminates. The Third Stage. Its Importance. — The third stage commences after the expulsion of the child. It is of paramount importance to the safety of the mother that it should be conducted in a natural and efficient manner ; for it is now that the uterine sinuses are closed, and the frail barrier by which nature effects this may be very readily interfered with, and serious and even fatal loss of blood ensue. Un- fortunately, it is too often the case that the practitioner's entire at- tention is fixed on the expulsion of the child, so that the natural history of the rest of delivery is very generally imperfectly studied and understood. Contraction of the Uterus and Detachment of the Placenta. — As soon as the child is expelled, the uterine fibres contract in all directions, and the hand, following the uterus down, will find that it forms a THE PHENOMENA OF LABOR. 259 Fis firm rounded mass lying in the lower part of the abdominal cavity. By retraction of its internal surface, the placental attachments are generally separated, and the after-birth remains in the cavity of the uterus as a foreign body. Mode in which Hemorrhage is Prevented. — The escape of blood from the open mouths of the uterine sinuses is now prevented in two ways; viz., (1) by the contraction of the uterine Avails, and the more firm, persistent, and tonic this is, the more certain is the immunity from hemorrhage ; (2) by the formation of eoagula in the mouths of the vessels. Any undue haste in promoting the expulsion of the pla- centa tends to prevent the latter of these two hemostatic safeguards, and is apt to be followed by loss of blood. After a certain time, averaging from a quarter to half an hour, the uterus will be felt to harden, and, if the case be solely left to nature, what has been aptly called a miniature labor occurs. Pains come on, and the placenta is spontaneously expelled from the uterus, either into the canal of the vagina, or even externally. In most obstetric works it is stated that the after-birth may be separated either from its centre or edge, and that it is very generally expelled through the os in an inverted form, with its foetal surface down- wards, and folded transversely on itself. That this is the mode in which the placenta is often expelled, when traction on the cord is practised, is a matter of certainty. It then passes through the os very much in the shape of an inverted umbrella. It is certain, however, that this is not the natural mechanism of its delivery. What this is has been well illustrated bv Dun- can, 1 who has very clearly shown that, when this stage of labor is left entirely to nature, the sepa- rated placenta is expelled edgeways, its uterine and detached surface gliding along the inner sur- face of the uterus, the foldings of its structure being parallel to the long diameter of the ute- rine cavity (Fig. 92). In this way it is expelled into the vagina, and during the process little or no hemorrhage occurs. When the placenta is drawn out in the way too generally practised, it obstructs the aperture of the os, and, acting like the piston of a pump, tends to promote hemorrhage. The corol- laries as to treatment drawn from these facts will be subsequently considered. I am anxious, however, here to direct attention to na- ture's mechanism, because I believe there is no part of labor about the management of which erroneous views are more prevalent than that of this stage, and none in which they are more apt to lead to serious consequences ; and unless the mode in which nature effects the expulsion of the placenta, and prevents hemorrhage, is thorough!}?- understood, we shall certainly fail in assisting her in a proper man- Mode iu which the Placenta is Naturally Expelled. (After Duncan.) * Edin. Med. Jour., April, 1871. 260 LABOR. ner. In the large proportion of cases, when left entirely to them- selves, the placenta would be retained, if not in the uterus, at any rate in the vagina, for a considerable time — possibly for several hours — ■ and such delay would very unnecessarily tire the patience of the practitioner, and be prejudicial to the patient. It is, therefore, our duty in the majority of cases, to promote the expulsion of the after- birth ; and when this is properly and scientifically clone, we increase, rather than diminish the patient's safety and comfort, But, in order to do this, we must assist nature, and not act in opposition to her method, as is so often the case. After-pains. — When once the placenta is expelled, the uterus con- tracts still more firmly, and in a typical case, is felt just within the pelvic brim, hard and firm, and about the size of a cricket ball. Generally for several hours, or even for one or two days, it occasion- ally relaxes and contracts, and these contractions give rise to the " after-pains" from which women often suffer much. The object of these pains is, no doubt, to expel any coagulathat may remain in the litems, and therefore, however unpleasant they may be to the patient, they must be considered, unless very excessive, to be salutary rather than otherwise. Duration of Labor. — The length of labor varies extremely in dif- ferent cases, and it is quite impossible to lay down any definite rules with regard to it. Subject to exceptions, labor is longer in primi- parae than in multiparas, on account of the greater resistance of the soft parts in the former, especially of the structures about the vagina and vulva. It is also generally stated that the difficulty of labor increases with the age of the patient, and that in elderly primiparae it is likely to be unusually tedious from rigidity of the soft parts. It is very doubtful if this opinion has any real basis, and in such cases the practitioner often finds himself agreeably disappointed on the result. Mr. Eoper, 1 indeed, argues that the wasting of the tissues which occurs after forty years of age diminishes their resistance, and that first labors, after that age, are easier, as a rule, than in early life. The habits and mode of life of patients have, no doubt, a con- siderable influence on the duration of labor, but we are not in pos- session of any very reliable facts with regard to this subject. It is reasonable to suppose that the tissues of large, muscular, strongly developed women will offer more resistance than those of slighter build. On the other hand, women of the latter class, especially in the upper ranks of life, more often develop nervous susceptibilities, which may be expected to influence the length of their labors. The average duration of labor, calculated from a large number of cases, is from eight to ten hours ; even in primiparae, however, it is con- stantly terminated in one or two hours from its commencement, and may be extended to twenty-four hours without any symptoms of urgency arising. In multiparas it is frequently over in even a shorter time. Indications calling for interference may arise at any time during the progress of labor, independently of its length. The pro- i Obst. Trans., v. 7. DELIVERY IN HEAD PRESENTATIONS. 261 portion between the length of the first and second stages also varies considerably. The first stage is generally the longest ; and it is stated by Cazeaux to be normally about twice the length of the second. This is probably under the mark, and I believe Joulin to be nearer the truth in stating that the first stage should be to the second as four or five to one, rather than as two to one. Often when the first stage has been very prolonged, the second is terminated rapidly. Necessity of Caution in expressing an Opinion as to the possible .Duration of labor. — The practitioner is constantly asked as to the probable length of labor, and the uncertainty cf this should always lead him to give a most guarded opinion. Even when labor is pro- gressing apparently in the most satisfactory manner, the pains fre- quently die away, and delivery may be delayed for many hours. In the first stage a cervix that is apparently rigid and unyielding may rapidly and unexpectedly dilate, and delivery soon follow. In either case, if the practitioner has committed himself to a positive opinion he is apt to incur blame, and it is far better always to be extremely cautious in our predictions on this point. Period of the Day at ivhich Labor Occurs. — A somewdiat larger pro- portion of deliveries occur in the early hours of the morning than at other times. Thus West 1 found that out of 2019 deliveries, 780 took place from 11 P.M. to 7 A.M., 662 from 7 A.M. to 8 P.M., and 577 from 3 P.M. to 11 P.M. CIIAPTEE II. MECHANISM OF DELIVERY IN HEAD PRESENTATIONS. Importance of the Subject. — It is quite impossible to over-estimate the importance of thoroughly understanding the mechanism of the passage of the foetus through the pelvis. This dominates the whole scientific practice of midwifery, and the practitioner cannot acquire more than a merely empirical knowdedge, such as may be possessed by an uneducated midwife, or to conduct the more difficult cases requiring operative interference, with safety to the patient or satis- faction to himself, unless he thoroughly masters the subject. In treating of the physiological phenomena of labor, it w r as assumed that we had to do with an ordinary case of head presenta- tion, the description being applicable, with slight variations, to pre- sentations of other parts of the foetus. So in discussing the mechanical phenomena of delivery, I shall describe more in detail the mechanism 1 Amer. Med. Jcmrn. 1854. 262 LABOR. of head presentations, reserving any account of the mechanism of other presentations until they are separately studied. Head presen- tation is so much more frequent than that of any other part — amounting to 95 per cent, of all cases — that this mode of studying the subject is fully justified ; and, when once the student has mastered the phenomena of delivery in head presentations, he will have little difficulty in understanding the mechanism of labor when other parts of the foetus present, based, as it always is, on the same general plan. Position of the Head by its Sutures and Fontanelles. — In entering on this study we come to appreciate the importance of the sutures and fontanelles in enabling us to detect the position of the foetal head, and to watch its progress through its canal: and unless the "tactus eruclitus" by which these can be distinguished from each other has been acquired, the practitioner will be unable to satisfy himself of the exact progress of the labor. Nor is this always easy. Indeed, it requires considerable experience and practice before it is possible to make out the position of the head with absolute certainty ; but this knowledge should always be aimed at, and the student will never regret the time and trouble he spends in acquiring it. Position of the Head at the commencement of Labor. — At the com- mencement of labor the long diameter of the head lies in almost any diameter of the pelvic brim, except in the antero-posterior, where there is not space for it. In the large majority of cases, however, it enters the pelvis in one or other of the oblique diameters, or in one between the oblique and transverse : but until it has fairly passed through the brim, it more frequently lies directly in the transverse diameter than has been generally supposed. Hence obstetricians are in the habit of describing the head as lying in four positions, accord- ing to the parts of the pelvis to which the occiput points ; the first and third positions being those in which the long diameter of the head occupies the right oblique diameter of the pelvis, the second and fourth those in which it lies in the left oblique. Many sub- divisions of these positions have been made, which only complicate the subject, and render it more difficult to understand. The positions, then, of the foetal head after it has entered the brim, which it is of importance to be able to distinguish in practice are : — - First (or left occipito- cotyloid). — The occiput points to the left fora- men ovale, the sinciput to the right sacro-iliac synchondrosis, and the long diameter of the head lies in the right oblique diameter of the pelvis. Second (or right occipito-cotyloid). — The occiput points to the right foramen ovale, the forehead to the left sacro-iliac synchondrosis, and the long diameter of the head lies in the left oblique diameter of the pelvis. Third {or right occi pi to -sacro-iliac). — The occiput points to the right sacro-iliac synchondrosis, the forehead to the left foramen ovale, and the long diameter of the head lies in the right oblique diameter of the pelvis. This position is the reverse of the first. Fourth (or left occipito-sacro-iliac). — The occiput points to the left sacro-iliac synchondrosis, the forehead to the right foramen ovale, DELIVERY IN HEAD PRESENTATIONS 263 unci the long diameter of the head lies in the left oblique diameter of the pelvis. This position is the reverse of the second. Frequency of these Positions. — The relative frequenc} r of these positions has long been, and still is, a matter of discussion among obstetricians. According to Naegele, to whose classical essay we owe the greater part of our knowledge of the subject, the head lies in the right oblique diameter in 99 per cent, of all cases. More re- cent researches have thrown some doubt on the accuracy of these figures, and many modern obstetricians believe that the second posi- tion, which Naegele believed only to be observed as a transitional stage in the natural progress of the third position, is much more common than he supposed. This question will be more fully dis- cussed when we treat of the mechanism of occipito-posterior delivery, and, in the meantime, it may serve to show the discrepancy which exists in the opinions of modern writers, if we append the following- table of the relative frequency of the various positions, 1 copied from Irishman's \Vork : — First Position. Second Position. Naegele . Naegele, Jim. . Simpson and Ba' Dubois Murphy . Sway ne . TV 70. 64.G4 76.45 70.83 63.23 8(^.36 .29 2.87 16.18 9.79 Third Position. 29. 32.88 22.68 25.66 16.18 1.04 Fourth Position Xot Classified. .58 .132 4.42 2.8 Here it will be seen that all obstetricians are agreed as to the im- mensely greater frequency of the first position — the only point at issue being the relative frequency of the second and third. Explanation. — Various explanations have been given of the greater frequency with which the head lies in the right oblique diameter. Ry some it is referred to the natural tendency of the back of the foetus, as shown by the experimental researches of Honing and other writers, to be directed, in consequence of gravitation, for- wards and to the left side of the mother in the erect attitude, and backwards and to her right side in the recumbent. The explanation given by Simpson was that the head lay in the right oblique diame- ter m consequence of the measurement of the left oblique being more or less lessened hy the presence of the rectum. When the rectum is collapsed, indeed, the narrowing of the diameter is slight ; but it is so often distended by fascal matter — sometimes, when constipation exists, to a very great extent — that it may really have a very important influence in determining the position of the foetal head. In describing the mechanism of delivery, it will be well for us to concentrate our attention on the first, or most common position, dwelling subsequently more briefly on the differences between it and the less common ones. 1 Irishman's System of Midwifery, p. 341. 264 LABOR. Description of the First Position.- — In this position, when the head commences to descend, the occiput lies in the brim pointing to the left ileo-pectineal eminence, the forehead is directed to the right sacra-iliac synchondrosis, and the sagittal suture runs obliquely across the pelvis in the right-oblique diameter. The back of the child is turning towards the left side of the mother's abdomen, the right shoulder to her right side, the left to her left side (Fig. 93). If Fig. 93. Attitude of Child in First Position. (After Hodge.) a vaginal examination be now made (the patient lying in the ordinary obstetric position), and the os be sufficiently open, the finger will impinge upon the protuberance of the right parietal bone, which is described as the " presenting part," a term which has received various definitions, the best of which is probably that adopted by Tyler Smith, viz., "that portion of the foetal head felt most prominently within the circle of the os uteri, the vagina, and the os tincse, in the successive stages of labor." If the tip of the examining finger be passed slightly upwards, it will feel the sagittal suture running obliquely across the pelvis and, if this be traced downwards and to the left, it will come upon the triangular posterior fontanelle, with the lambdoiclal sutures diverging from it. If the finger could be passed sufficiently high in the opposite direction, upwards and to the right, it would come upon the large anterior fontanelle ; but, at this time, that is too high up to be within reach. The chin is slightly flexed upon the sternum, this flexion, as we shall presently see, being greatly increased as the head begins to descend. The head, at the commencement of labor, generally lies within the pelvic brim, especially in primiparce. In multiparas, owing to the DELIVERY IN HEAD PRESENTATIONS 265 relaxation of the abdominal parietes, the uterus is apt to fall some- what forwards, and the head consequently is more entirely above the brim, but is pushed within it as soon as labor actually commences. Naeyles Views. — Xaegele — and his description has been adopted by most subsequent writers — describes the head, at this period, as lying obliquely in relation to the brim, the right parietal bone, on which the examining finger impinges, being supposed by him to be much lower than the left. The accuracy of this vievv has, of late years, been contested, and it is now pretty generally admitted that this obliquity does not exist, and that the head enters the brim of the pelvis with both parietal bones on the same level, and with its bi-parietal diameter parallel to the plane of the inlet (Fig. 94). Xae- Fig. 94. rirst Position: Movement of Flexion. gele's view was adopted, partly because the finger always felt the right parietal protuberance lowest, and partly because it was at that point that the " caput succedaneurn" or swelling observed on the head after delivery, was always formed. Both arguments are, however, fallacious ; for the right parietal bone is the part which would natu- rally be felt lowest, on account of the oblique position of the pelvis to the trunk; while, with regard to the caput succedaneum, it has been conclusively proved by Duncan, that it does not form on the point most exposed to pressure, as Kaegele assumed, but on the part of the head where there is least pressure, that is the part lying over the axis of the vaginal canal. Division of Mechanical Movements into Stages. — In tracing the pro- gress of the head from the position just described, obstetricians have been in the habit of dividing the movements it undergoes into vari- ous stages, which are convenient for the purpose of facilitating de- scription. It must be borne in mind that these are not evident and distinct stages, which can always be made out in practice, but that is 266 LABOR. the j run insensibly into one another, and often occur simultaneously, or nearly so, in rapid labor. They may be described as : 1. Flexion. 2. First movement of descent. 3. Levelling or adjusting movement. 4. Rotation. 5. Second movement of descent and extension. 6. Ex- ternal rotation. 1. Flexion, the first movement of the head consists of a rotation on its bi-parietal diameter, by which the chin of the child becomes bent on the sternum, and the occiput descends lower than the front part of the head. By this there is a clear gain of at least a half inch, for the occipito-bregmatic diameter (3J inches) becomes substituted for the occipitofrontal (4 inches) (Fig. 94). The movement is most marked when the pelvis is narrow, and, in some cases of pelvic deformity, it takes place to an extreme degree ; while, in unusually large and roomy pelves, it occurs to a very slight extent, or not at all. The reason of this flexion is twofold. Solayres and the majority of obstetricians explain it by saying that the ex- pulsive force is communicated to the head through the vertebral column, and, inasmuch as the head is articulated much nearer the occiput than the sinciput, the resistance being equal, the former must be pushed down. This is doubtless the correct explanation of the flexion after the membranes are ruptured ; but, before that happens, the ovum is practically a bag of water, which is equally compressed at all points by the uterine contractions, and is pushed downwards through the os en masse, the expulsive force not being transmitted through the vertebral column at alb Under such circumstances flexion is probably effected in the following way : the head being articulated nearer the occiput than the forehead, and being equally pressed upon from below by the resisting structures, the pressure is more effectual on the forehead— consequently that is forced upwards, and the occiput descends. This explanation would also hold good after the rupture of the membranes, and probably both causes assist in effecting the movement. 2 and 3. Descent and Levelling Movement.- — The movements of descent and levelling may be described together. As soon as the head is liberated from the os uteri, it descends pretty rapidly through the pelvis, until the occiput reaches a point nearly opposite the lower part of the foramen ovale (Fig. 95), and the sinciput is opposite the second bone of the sacrum. A levelling movement now occurs, the anterior fontanelle comes to be more easily within reach, more on a level with the posterior, and the chin is no longer so much flexed on the sternum. This change is due to the fact that the anterior end of the ovoid experiences greater resistance than the posterior, and as soon as this resistance counterbalances and exceeds that applied to the latter, the sinciput must descend. The right side of the head also descends 'more than the left from a similar cause, so that the head becomes, as it were, slightly flexed on the right shoulder. This obliquity of the head on its transverse diameter in the lower part of the pelvis has been denied by Kiineke, 1 who maintains that the head i Die Vier Factoren der Geburt, Berlin, 1869. DELIVERY IN HEAD PRESENTATIONS. 267 passes through the entire pelvis in the same position as it enters the brim, that is, with both parietal bones on a level, so that the point of intersection of the transverse and antero-posterior diameters of the pelvis would correspond with the sagittal suture. There is, Fig. 95. First Position ; Occiput in the Cavity of the Pelvis. (After Hodge.) however, good reason to believe that, in the lower half of the pelvic cavity, the head is not truly synclitic, as Kuneke describes, but that the right parietal bone is on a somewhat lower level than the left. 4. Rotation. — The movement of rotation is very important. By it the long diameter of the head is changed from the oblique diameter of the pelvic cavity to the antero-posterior diameter of the outlet (Fig. 96), or to a diameter nearly corresponding to it, so that the Fig. 96. First Position : Occiput at outlet of Pelvis. (After Hodge.) long diameter of the head is brought into relation with the longest diameter of the pelvic outlet. This alteration almost always takes place, and may be readily observed by the accoucheur who carefully watches the progress of labor. Various explanations have been given of its causes. The one most generally adopted is, that it is due to the projection inwards of the ischial spines, which narrow the transverse diameter of the pelvic outlet. As the pains force the occiput downwards, its rotation backwards is prevented by the pro- jection of the left ischial spine, while its rotation forwards is favored by the smooth bevelled surface of the ascending ramus of the ischium. Similarly the ischial spine on the opposite side prevents the rotation forwards of the forehead, which is guided backwards to the cavity of the sacrum by the smooth surface of the sacro-ischi- 268 LABOR. atic ligaments. These arrangements, therefore, give a screwlike form to the interior of the' pelvis ; and as the pains force the head downwards, they are effectual in imparting to it the rotatory move- ment which is of such importance in adapting it to the longest measurement of the outlet. By most of the German obstetricians the influence of the ischial spines, and of the smooth pelvic planes in producing rotation is not admitted. They rather refer the change of direction to the in- creased resistance the head meets from the posterior wall of the pelvis, and from the perineal structures. Whichever part of the head first meets this resistance, which is much greater than that of the anterior part of the pelvis, must necessarily be pressed forwards ; and as, in the large majority of cases, the posterior fontanelle de- scends first, it is thus pressed forwards until rotation is effected. This view has the advantage of accounting equally well for ihe rota- tion in occipito-posterior as in occipitoanterior positions, the former of which, on the more ordinarily received theory, are not quite satis- factorily explicable. It does not follow that the smooth surfaces of the pelvic planes are without influence in favoring the rotation. On the contrary, they probably greatly facilitate it; but it is more sim- ply and effectually explained by the latter theory than by that which attributes so important an action to the ischial spines. In some rare cases the head escapes rotation and reaches the per- ineum still lying in the oblique diameter. Even here, however, rotation is generally effected, often suddenly, just as the head is about to pass the vulva, and it is very rarely expelled in the oblique posi- tion. The movement at this stage may be explained by the peri- neum, which is attached at its sides, and grooved in its centre : to the hollow so formed the long diameter of the head accommodates itself, and is thus rotated into the antero-posterior diameter of the outlet. 5. Extension — By the process just described the face is turned back into the hollow of the sacrum ; but the head docs not lie abso- lutely in the antero-posterior diameter of the pelvic outlet, but rather in one between it and the oblique. The occiput is still forced down by the pains, and, in consequence of its altered position, is en- abled to pass between the rami of the pubis, and advances until its further descent is checked by the nape of the neck, which is pressed under and against the arch of the pubes. By this means the occiput is fixed, and the pains continuing, the uterine force no longer acts on the occiput, but on the anterior part of the head, which is now pushed down and separated from the sternum. This constitutes extension. As the head descends, the soft structures of the perineum are stretched, and the coccyx pushed back so as to enlarge the out- let. The pains continue to distend the perineum more and more, the head advancing and receding with each pain. As the forehead descends, the sub-occipito-bregmatic, the sub- occipitofrontal, and the sub-occipito-mental diameters successively present ; the occiput turns more and more upwards in front of the pubes (Fig. 97), and, at last, the face sweeps over the perineum and is born. The mechanical cause of this movement may be readily explained. DELIVERY IN HEAD PRESENTATIONS. 269 As soon as the occiput has passed under the arch of the pubis, and is no longer resisted by the anterior pelvic walls, the head is sub- jected to the action of two forces: that of the uterine pressure act- ind that, of the resistance of the ing downwards and backwards ; Fig. 9^ First position : Head delivered. (After Hodge.) posterior walls of the pelvis and the soft parts, acting almost directly forwards. The necessary result is that the head is pushed in a direc- tion intermediate between these two opposing forces — that is, down- wards and forwards in the axis of the pelvic outlet. In addition to the slight obliquity which exists as regards the direct relation of the long diameter of the head to the antero- poste- rior diameter of the outlet at the moment of its expulsion, the head also lies somewhat obliquely in relation to its own transverse diame- ter, so that, in the majority of cases, the right parietal bone is ex- pelled before the left. 6. External Rotation. — Shortly after the head is expelled, as soon as renewed uterine action commences, it may be observed to make a Fig 98. External Rotation of Head in First Position. (After Hodee.) distinct rotatory movement, the occiput turning to the left thigh of the mother, and the face turning upward to the right thigh (Fig. 98). The reason of this is evident. When the head descends In the right 270 LABOR. oblique diameter the shoulders lie in the opposite or left oblique diam- eter, and as the head rotates into the antero-posterior diameter, they are necessarily placed more nearly in the transverse. As soon as the head is expelled the shoulders are subjected to the same uterine force and pelvic resistance as the head has just beeu, and they are acted on in precisely the same way. Consequently they too rotate, but in the opposite direction, into the antero-posterior diameter of the out- let, or nearly so, just as the head did, and as they do so, they neces- sarily carry the head with them, and cause its external rotation. The two shoulders are soon expelled, the left shoulder generally the first, sweeping over the perineum in the same manner as the face. This is, however, not always the case, and they are often expelled simultaneously, or the right shoulder may come first. The body soon follows, and the second stage of labor is completed. Second Position.- — In the second position (right occipito-cotyloid) the long diameter of the head lies in the left oblique diameter of the pelvis. On making a vaginal examination, in the ordinary obstetric position, the finger, passing upwards and to the right, feels the small posterior fontanelle ; downwards and to the left, it feels the anterior. The sagittal suture lies obliquely across the pelvis in the left oblique diameter. The description of the mechanism of delivery is precisely the same as in the first position, substituting the word left for right. Thus the finger impinges on the left parietal bone, the occiput turns from right to left during rotation. After the birth of the head the occiput turns to the right thigh of the mother, the face to the left thigh. Third, or Right Occi/pito-sacro-iliac Position. — In the third position the head enters the pelvic brim with the occiput directed backwards Fig. 99. Third Position of Occiput, at Brim of Pelvis. to the right sacro-iliac synchondrosis, and the sinciput forwards to the left foramen ovale (Fig. 99). The posterior fontanelle is directed DELIVERY IN HEAD PRESENTATIONS. Z < 1 backwards, the anterior fontanelle forwards, while the examining finger impinges on the left parietal bone. The mechanism of de- livery in these cases is of much interest. In the large majority of cases, daring the progress of delivery, the occiput rotates forwards along the right side of the pelvis, until it comes to lie almost in the antero-posterior diameter of the outlet, and passes under the pubic arch, the forehead passing over the perineum. It will be seen that during part of this extensive rotation the head must lie in the second position, and the case terminates just as if it had been in the second position from the commencement of labor. Manner in which the Occiput is Rotated Forwards. — How is it that this rotation is effected, and that the sinciput, occupying the posi- tion of the occiput in the first position, should not be rotated for- wards to the pubes as that is? This, no doubt, may be explained by the fact, that the uterine force transmitted through the vertebral column causes the occiput to descend lower than the sinciput, so that in most cases, in making a vaginal examination, the posterior fonta- nelle can be readily felt, while the anterior is high up and out of reach. The head is, therefore, extremely flexed, and so descends into the pelvic cavity, until the occiput, being now below the right ischial spine, experiences the resistance of the pelvic floor, opposite the right sacro-ischiatic ligament, by which it is directed forwards. The forehead is, at this time, supposing flexion to be marked, too high to be influenced by the anterior pelvic plane. Pressure continuing, the occiput rotates forwards, the forehead passes round the left side of the pelvis, and labor is terminated as in the second position. The period of labor at which rotation takes place varies. In the majority of cases it does not occur until the head is on the floor of the pelvis, for it is then that resistance is most felt; but the greater the resistance, the sooner will rotation be produced. Hence it is more likely to occur early when the head is large, and the pelvis comparatively small. The facility with which this movement is effected obviouslv de- pends upon the complete flexion of the chin on the sternum, by which the anterior fontanelle is so elevated that its rotation backwards is not resisted by the inward projection of the left ischial spine, and the occiput is correspondingly depressed. If, however, this flexion is not complete, and the anterior fontanelle is so low as to be readily within reach of the finger, considerable difficulty is likely to be ex- perienced. In many such cases rotation is still eventually effected, but in others it is not ; and the labor is then terminated with the face to the pubes, but at the expense of considerable delay and diffi- culty. According to Dr. Uvedale West, of Alford, who devoted much careful study to the subject, this termination occurs in about 4 per cent, of occipito-posterior positions. When it is about to happen the anterior fontanelle may be felt very low down, and, sometimes, even the forehead and superciliary ridges. The uterine force pushes down the occiput, the sinciput being fixed behind the pubes, which it ob- viously cannot pass under, as does the occiput in the first position. The sinciput, therefore, becomes more flexed and pushed upwards, 272 LABOR. while tlie resistance of the pelvic floor directs the occiput forwards. The perineum now becomes enormously distended by the back part of the head, and is in great danger of laceration. The occiput is even- tually, bat not without much difficulty, expelled. A process of ex- tension now occurs, the nape of the neck being fixed, as it were, against the centre of the perineum, the expelling force now acting on the forehead, and producing rotation of the head on its transverse axis. The forehead and face are thus protruded, and the body fol- lows without difficulty. It is said that, in a few exceptional cases, where the anterior fon- tanelle is much depressed, the labor may terminate by the conversion of the presentation into one of the face, the head rotating on its trans- verse axis, the forehead passing to the posterior part of the pelvis, and the chin emerging under the perineum. It is obvious, however, that this change can only occur when the head is unusually small, and it must of necessity be extremely rare. Relative frequency of Second and Third Positions. — Reference has already been made to Naegele's views as to the rarity of the second position, and to his opinion that cases in which the occiput was found to point to the right foramen ovale were only transitional stages in the rotation of occipito-posterior positions. Such an assumption, however, is unwarrantable, unless the case has been watched from the very commencement of labor. Many perfect^ qualified ob- servers have arrived at the conclusion that second positions are far more common than Naegele supposed ; and in the table already quoted it will be seen that while Murphy estimates the second and third as being equally frequent, Swayne believes the second to be much more common than the third. It is probable that the weight of Naegele's authority has induced many observers to classify second positions as third positions in which partial rotation has already been accomplished. My own experience would certainly lead me to think that second positions are very far from uncommon. The ques- tion, however, must be considered to be in abeyance, until further observations by competent authorities enable us to decide it conclu- sively. Fourth or Left Occipito-sacro-ischiatic— -The fourth position is just as much the reverse of the second as the third is of the first. The occiput points to the left (Fig. 100) sacro-iliac synchondrosis, and the finger impinges on the right parietal bone. The mechanism is pre- cisely the same as in the third position, the rotation taking place from left to right. Formation of the Caput Succedaneum. — The formation of the caput succedaneum has been already alluded to. This term is applied to the oedematous swelling which forms on the head, and is produced by effusion from the obstruction of the venous circulation caused by the pressure to which the head is subjected. It follows that the size of the swelling is in direct proportion to the length of the labor. In rapid deliveries, in which the head is forced through the pelvis quickly, it is scarcely, if at all, developed; while after protracted labors, it is large and distinct, and may obscure the diagnosis of the DELIVERY IN HEAD PRESENTATIONS. 273 position, by preventing the sutures and fontanelles being felt. Its situation varies according to the position of the head : thus, in the first and fourth positions it forms on the right parietal bone, in the second and third on the left ; and we may, therefore, verify, by speetion of its site, the accuracy of our diagnosis. m- Fig. 100. Fourth Position of Occiput at Pelvic Brim. An ordinary mistake which has been made by obstetricians is to regard the caput succedaneum as formed at the point where the head has been most subjected to pressure; while, in fact, it forms on that part which is most unsupported by the maternal structures, and where the swelling may consequently most readily occur. There- fore, in the early stages of the labor, it always forms on the part of the head which lies in the circle of the os uteri ; while, in subsequent stages, it forms on that which lies in the axis of the vaginal canal, and eventually is most prominent on the part that is first expelled from the vulva. Alteration in the Shape of the Head from Moulding. — A few words may be said as to the alteration in the form of the foetal head which occurs in tedious labors, and results from the moulding which it has undergone in its passage through the pelvis. The smaller the pelvis, and the greater the pressure applied to the head during delivery, the more marked this is. The result is, that in vertex presentations the occipito- mental and occipitofrontal diameters are elongated to the extent of an inch, or even more, while the transverse diameters are lessened, from compression of the parietal bones. This moulding is of unquestionable value in facilitating the birth of the child. The amount of apparent deformity is very considerable, and may even give rise to some anxiety. It is well to remember, therefore, that it is always transient, and that in a few hours, or days at most, the elasticity of the soft cranial bones causes them to resume their natural form. The caput succedaneum also disappears rapidly, therefore no amount of deformity from either of these causes need give rise to anxiety, or call for any treatment. 274 LABOR. CHAPTER III. MANAGEMENT OF NATURAL LABOR. Although labor is a strictly physiological function, and in a large majority of cases, might, no doubt, be safely accomplished without assistance from the accoucheur, still medical aid, properly given, is always of value in facilitating the process, and is often absolutely essential for the safety of the mother and child. Preparatory Treatment. — The management of the pregnant woman before delivery is a point which should always receive the attention of the medical attendant, since it is of consequence that the labor should come on when she is in as good a state of health as possible. For this purpose ordinary hygienic precautions should never be neglected in the latter months of gestation. The patient should take regular and gentle exercise, short of fatigue, and, if the weather permit, should spend as much of her time as possible in the open air, Hot rooms, late hours, and excitement of all kinds should be strictly avoided. The diet should be simple, nutritious, and unstimulating. The state of the bowels should be particularly attended to. During the few days preceding labor the descent of the uterus often causes pressure on the rectum, and prevents its evacuation. Hence it is customary to prescribe occasional gentle aperients, such as small doses of castor oil, for a few days before the expected period of de- livery. Some caution, however, is necessary, as it is certainly not very uncommon for labor to be determined rather sooner than was anticipated, in consequence of the irritation of too large a purgative dose. The state of the bowels should always be inquired into at the commencement of labor, and, if there be any reason to suspect that they are loaded, a copious enema should be administered. This is always a proper precaution to take, for a loaded rectum is a common cause of irregular and ineffective uterine action ; and even when it does not produce this result, the escape of the feces, in consequence of pressure on the bowel during the propulsive stage, is always dis- agreeable both to the patient and practitioner. Dress of Patient during Pregnane//. — The dress of the patient dur- ing pregnancy may be here adverted to ; for much discomfort may arise, and the satisfactory progress of labor may even be interfered with, from errors in this respect. After the uterus has risen out of the pelvis the ordinary corset, which most women wear, is apt to produce very injurious pressure; still more so when attempts are made to conceal the increased size by tight lacing. After the fourth or fifth month, therefore, the comfort of the patient is much increased by wearing a specially con- MANAGEMENT OF NATURAL LABOR. 275 structed pair of stays, with elastic let into the sides and front, so that they accommodate themselves to the gradual increase of the figure. Such are made by all stay-makers, and should be worn whenever the circumstances of the patient permit. Failing this it is better to avoid the use of the corset altogether, and to have as little pressure on the uterus as possible ; although many women cannot do without the support to which they are accustomed. To multipara, especially if there be much laxity of the abdominal parietes, a well-fitting elas- tic abdominal belt is often a great comfort. This is constructed so that it can be tightened when the patient is walking and in the erect position, when such support is most required, and readily loosened when desired. Necessity of Attending to the First Summons. — It is hardly neces- sary to insist on the necessity of the practitioner attending imme- diately to the first summons to the patient. It is true that he may verj^ often be sent for long before he is actually required. But on the other hand, it is quite impossible to foresee what may be the. state of any individual case. By prompt attention he may be able to rectify a malposition, or prevent some impending catastrophe, and thus save his patient from consequences of the utmost gravity. Articles to be taken by the Accoucheur. — The practitioner should always be provided with the articles which he may require. The ordinary obstetric cases, containing one or two bottles and a catheter, such as are sold by most instrument-makers, are cumbrous and use- less: while "obstetric bags" are expensive luxuries not within the reach of all. Every one can manufacture an excellent obstetric bag for himself, at a small expense, by having compartments for holding bottles stitched on to the sides of an ordinary leather bag, such as is sold for a few shillings at any portmanteau- maker's. It is a great comfort to have at hand all that may be required, and the bag should contain chloroform or other anaesthetic, chloral, laudanum, the liquor ferri perchloridi of the Pharmacopoeia, the liquid extract of ergot, and a hypodermic syringe, with a bottle containing a solution of ergotine for subcutaneous injection. If it also contain a Higginson's syrine, a small elastic catheter, a good pair of forceps, and one or two suture needles, with some silver wire or carbolized cato-ut, the practitioner is provided against any ordinary contingency. Other articles that may be required, such as thread, scissors, and the like, are generally provided by the nurse or patient. Duties on first Visiting the Patient. — On arriving at the house the practitioner should have his visit announced to the patient, and he will very often find that the first effect of his presence is to arrest the pains that have been hitherto progressing rapidly ; thereby af- fording a very conclusive proof of the influence of mental impres- sions on the progress of labor. If the pains be not already propulsive, it is well that he should occupy himself at first in general inquiries from the attendants as to the progress of the labor, and in seeing that all the necessary arrangements are satisfactorily carried out, so as to allow the patient time to get accustomed to his presence. If he have any choice in the matter, he should endeavor to secure a 276 LABOR. large, airy, and well-ventilated apartment for the lying-in room, as far removed as possible from without. He may also see to the bed which should be without curtains, and prepared for the labor by having a water-proof sheeting laid under a folded blanket or sheet on which the patient lies. These receive the discharges during labor, and can be pulled from under the patient after delivery, so as to leave the dry clothes beneath. Among the lower classes, the lying-in chamber is considered a legitimate meeting-place for nu- merous female friends to gossip, whose conversation is often distress- ing, and is certainly injurious, to a woman in the excitable condition associated with labor. The medical attendant should, therefore, insist on as much quiet as possible, and should allow no one in the room except the nurse and some one friend whose presence the patient may desire. The husband's presence must be left to the wishes of the patient. Some women like their husbands to be with them, while others prefer to be without them, and the medical attendant is bound to act in accordance with the patient's desire. Vaginal Examination. — If pains be actually present a vaginal ex- amination is essential, and should not be delayed. It enables us to ascertain whether the labor has commenced or not, and whether the presentation is natural or otherwise. The pains, although apparently severe, may be altogether spurious, and labor may not have actually commenced. It is of much importance, both for our own credit and comfort, that we should be able to diagnose the true character of the pains; for if they be so-called "false" pains, we might wait hours in fruitless expectation of progress, while delivery is still far off. The necessity of ascertaining, therefore, the actual state of affairs need not further be insisted on. Character of False Pains. — False pains are chiefly characterized. by their irregularity, sometimes coming on at short intervals, sometimes with many hours between them ; they also vary much in intensity, some being very sharp and painful, while others are slight and tran- sient. In these respects they differ from the true pains of the first stage, which are at first slight and short, and gradually recur with increased force and regularity. The situation of the two kinds of pains also varies, the false pains being chiefly situated in front, while the true pains arc felt most in the back, and gradually slioot round to- wards the abdomen. Nothing short of a vaginal examination will enable us to clear up the diagnosis satisfactorily. If the labor have actually commenced, the os will be more or less dilated, and its edges thinned ; while with each pain the cervix will become rigid, and the membranes tense and prominent. The false pains, on the contrary, have no effect on the cervix, which remains flaccid and undilated; or, if the os be sufficiently open to admit the tip of the finger, the membranes will not become prominent during the contraction. Un- der such circumstances we may confidently assure the patient that the pains are false, and measures should be taken to remove the irri- tation which produces them. In the large majority of cases the cause of the spurious pains will be found to be some disordered state of the intestinal tract ; and they will be best remedied by a gentle ape- MANAGEMENT OF NATURAL LABOR. 277 r i en t such as castor oil, or the compound coloeynth pill with hyos- cyamus followed by, or combined with, a sedative, such as twenty minims of laudanum or chlorodyne. Shortly after this has been administered the false pains will die away, and not recur until true labor commences. Mode of conducting a Vaginal Examination. — For a vaginal exami- nation the patient is placed by the nurse on her left side, close to the edge of the bed, with the legs flexed on the abdomen. The prac- titioner being seated by the edge of the bed, passes the index finger of the right hand, previously lubricated with lard or cold cream, up to the vulva, and gently insinuates it into the orifice of the vagina, then pushes it backwards in the axis of the vaginal outlet, and finally turns it upwards and forwards so as to more readily reach the cervix. This it may not always be easy to do, for at the commence- ment of labor the cervix may "be so high as to be reached with clif- ficultv, or it may be directed backwards so as to point towards the cavity of the sacrum. The exploration is often much facilitated by depressing the uterus from without, by the left hand placed on the abdomen. Our subject is not only to ascertain the state of the cervix as to softness and dilatation, but also the presentation, the condition of the vagina, and the capacity of the pelvis. The examination is generally commenced during a pain, at which time it is less distress- ing to the patient ; but in order to be satisfactory, the finger must remain in the vagina until the pain is over, the examination being concluded in the interval between this pain and J:he next. In head presentations the round mass of the cranium is generally at once felt through the lower part of the uterus, and then we have the satisfaction of being able to assure the patient that all is right. If the os be sufficiently dilated, we can also feel through it the occi- put covered by the membranes. It is impossible at this time to make out the exact position of the head by means of the sutures and fontanelles, which are too high up to be within reach. Nor should any attempt be made to do so, for fear of prematurely rupturing the membranes. The fact that the head is presenting is all that we require to know at this stage of the labor. The Condition of the Os as indicating the Progress of Labor. — The condition of the os itself, as to rigidity and dilatation will materially assist us in forming an opinion as to the progress and probable dura- tion of the labor; but, although the friends will certainly press for an opinion on this point, the cautious practitioner will be careful not to commit _him self to a positive statement, which may so easily be falsified. It will suffice to assure the friends that everything is satis- factory, but that it is impossible to say with any certainty how rapidly, or the reverse, the case may progress. If the pains be not very frequent or strong, and the os not dilated to more than the size of a shilling, a considerable delay may be antici- pated, and the presence of the medical attendant 'is useless. He may, therefore, safely leave the patient for an hour or more, provided he be within easy reach. It is needless to say that this should never be done unless the exact presentation be made out. If some part, 278 LABOR other than the head, be presenting, it will probably be impossible to make it out until dilatation has progressed further ; and the prac- titioner must be incessantly on the watch until the nature of the case be made out, so as to be able to seize the most favorable moment for interference, should that be necessary. Position of Patient during First Stage. — The position of the patient is a matter of some moment in the first stage. It is a decided ad- vantage that she should not be then in a recumbent position on her side, as is usual in the second stage; for it is of importance that the expulsive force should act in such a way as to favor the descent of the head into the pelvis, i. e.^ perpendicularly to the plane of its brim, and also that the weight of the child should operate in the same way. Therefore, the ordinary custom of allowing the patient to walk Fig. 101. Examination during the first stage. about, or to recline in a chair, is decidedly advantageous ; and it will often be observed that the pains are more lingering and ineffective if she lie in bed. If the patient be a multipara, or if the abdomen be somewhat pendulous, an abdominal bandage, by supporting the uterus, will greatly favor the progress of this stage. Keeping the patient out of bed has the further advantage of preventing her be- ing unduly anxious for the termination of the labor ; and a little cheerful conversation will keep up her spirits, and obviate the mental depression which is so common. Good beef- tea may be freely ad- ministered, with a little brandy and water occasionally, if the patient be weak, and will be useful in supporting her strength. Vaginal Examinations. — Over-frequent vaginal examinations at this period should be avoided, for they serve no useful purpose, and MANAGEMENT OF NATURAL LABOR. 279 are apt to irritate the cervix. It will be necessary, however, to as- certain the progress of the dilatation at intervals. Artificial Rapture of the Membranes. — When once the os is fully di- lated the membranes may be artificially ruptured if they have not broken spontaneously, for they no longer serve any useful purpose, and only retard the advent of the propulsive stage. This can be easily done by pressing on them, when they are rendered tense dur- ing a pain, by some pointed instrument, such as the end of a hair- pin, which is always at hand. In some cases, indeed, it is even expedient to rupture the membranes before the os is fully dilated. Thus it not infrequently happens, when the amount of liquor amnii is at all excessive, that the os dilates to the size of a five-shilling- piece or more ; but, although it is perfectly soft and flaccid, it opens up no further until the liquor amnii is evacuated, when the propul- sive pains rapidly complete its dilatation. Some experience and judgment are required in the detection of such cases, for if we evacu- ated the liquor amnii prematurely the pressure of the head on the cervix might produce irritation, and seriously prolong the labor. This manoeuvre is most likely to be useful when the pains are strong and the os perfectly flaccid, but when the membranes do not protrude through the os and effect further dilatation. It is sometimes not easy to ascertain whether the membranes are ruptured or not. This is most likely to be the case when the head is low down, and the amount of liquor amnii is so small that the pouch does not become prominent during the pains. A little care, however, will enable us, if the membranes be ruptured, to feel the rugosities of the scalp covered with hair, and to distinguish it from the smooth polished surface of the membranes. Treatment of the Propulsive Stage. — -After the evacuation of the liquor amnii there is generally a lull in the progress of the labor, the pains, however, soon recurring with increased force and frequency, and propelling the head through the pelvic cavity. The change in the character of the pains is soon appreciated by the bearing clown efforts by which they are accompanied, as well as by their increased length and intensity. Position of the Patient during the Second Stage. — It is now advisa- ble that the patient be placed in bed ; and in this country it is usual for her to lie on her left side, with her nates parallel to the edge of the bed, and her body lying across it. This is the established ob- stetric position in England, and it would be useless to attempt to in- sist on any other, even if it were advisable. Although the dorsal position is preferred on the Continent, it is difficult to see wherein its advantages consist. It certainly leads to unnecessary exposure of the person, and it is, on the whole, less easy to reach the patient, so placed, for the necessary manipulations. Moreover, the dorsal position increases the risk of laceration of the perineum, by bringing the weight of the child's head to bear more directly upon it. Thus Schroeder found that lacerations occurred in 37.6 per cent, of cases delivered on the back, as against 24.4 per cent, in other positions. The patient usually remains in bed during the whole of this stage, 280 LABOR. and it is customary for the nurse to tie to the foot of the bed a jack- towel, which is laid hold of and used as a support in making bearing down efforts. If the pains be few and far between, and the patient finds it more comfortable to get up occasionally, there is no reason why she should not do so. On the contrary, as Ave shall subsequently see in treating of lingering labor, the pains under such circumstances are often increased m the sitting posture, in consequence of the weight of the child producing increased pressure on the nerves of the vagina. Detection of the Position of the Head — At this time vaginal exami- nation, which should be more frequently repeated than in the first stage, enables us to ascertain precisely the position of the head, by means of the sutures and fontanelles, as well as to watch its progress. Management of the Anterior Lip of Cervix ivhen impacted beticeen the Head and Pelvis. — It not infrequently happens that the head descends into the pelvis, even to its floor, without the os having entirely disappeared. The anterior lip especially is apt to get caught between the head and pubis, to become swollen by the pressure to which it is subjected, and then to retard the progress of the labor. There can be no reasonable objection to attempting to prevent this cause of delay by pressing on the incarcerated lip during the inter- val of the pains, so as to push it above the head, and maintain it there during the pains until the head descends below it. This manoeuvre, if clone judiciously, and without any undue roughness or force, is certainly not liable to be attended by any of the evil con- sequences which many obstetricians have attributed to it ; it is indeed a matter of common sense that the injury to the cervix is likely to be less if it be pushed gently out of the way, than if it be left to be tightly jammed for hours between the presenting part and the bony pelvis. This mode of assistance is very different from the digital dilatation of a rigid cervix, which was formerly much prac- tised, especially in Edinburgh, in consequence of the recommendation of Hamilton, and which was properly objected to by the great ma- jority of obstetricians. If the pains be producing satisfactory progress, no further inter- ference is required. The medical attendant should, however, see that the bladder is evacuated ; and if it have not been so for some hours, it may be necessary to draw off the urine by the catheter. When- ever the labor is lengthy, he should occasionally practise auscultation, so as to satisfy himself that the foetal circulation is being satisfactorily carried on. Regulation of the Voluntary Bearing-down Efforts.— -The regulation of the bearing-down efforts at this time is of importance. It is com- mon for the nurse to urge the patient to help herself by straining, and it is certain that by voluntary exertion of this kind she can materially increase the action of the accessory muscles of parturition. If the pains be strong, and the labor promise to be rapid, such voluntary exertions are not likely to be prejudicial. On the other hand, if the case be progressing slowly, they only unnecessarily fatigue the patient, and should be discouraged. When the perineum MANAGEMENT OF NATURAL LABOR. 28l is distended we may even find, it advisable to urge the patient to cease all voluntary effort, and to cry out, for the express purpose of lessening the tension to which the perineum is subjected. This is the stage in which anaesthesia is most serviceable, but its employment must be separately discussed. Distension of the Perineum. — As the head descends more and more the perineum becomes distended, and there is considerable difference of opinion amongst accoucheurs as to the management of the case at this time. In most obstetric works the practitioner is advised to endeavor to prevent laceration by the manoeuvre that is described as " supporting the perineum." By this is meant, laying the palm of the hand on the distended structures, and pressing firmly upon them during the acme of the pain, with the view of mechanically preventing their tearing. There can be little doubt that this, or some modification of it, is the practice now followed by the large majority of practitioners. Of late years the evil effects likely to follow it have been specially dwelt upon by Graily Hewitt, Leishman, Groodell, and other writers, who maintain that by pressure exerted in this fashion we not only fail to prevent, but actually favor laceration, in consequence of the pressure producing increased uterine action, just at the time when forcible distension of the perineum is likely to be hurtful. Therefore some hold that the perineum ought to be left entirely alone, and that the head should be allowed gradually to dis- tend it, without any assistance on the part of the practitioner. Much error may be traced to a misconception of what is required. The term "supporting the perineum" conveys an unquestionably erroneous idea, and it is certain that no one can prevent laceration by mechanical support. If the term " relaxation of the perineum'' were employed, Ave should have a far more accurate idea of what should be aimed at, and if this be borne in mind, I think it cannot be questioned that nature may "be most usefully assisted at this stage. Dr. GoodelFs Method. — Dr. Goodell, of Philadelphia, has specially studied this subject, and has recommended a method, the object of which is to relax the perineum. His advice is, that one or two fingers of the left hand should be inserted into the rectum, by which the perineum should be hooked up and pulled forward over the head, towards the pubis, the thumb of the same hand being placed on the advancing head, so as to restrain its progress if needful. I have adopted this plan frequently, and believe that it admirably answers its purpose, especially when the perineum is greatly distended, and laceration is threatened. It must be admitted that the insertion of the fingers into the anal orifice, in the manner recommended, is re- pugnant both to the practitioner and patient, and the same result can be obtained in a less unpleasant way. I mention it, however, to sIioav what it is that the practitioner must aim at. If, when the head is distending the perineum greatly, the thumb and forefinger of the right hand are placed along its sides, it can be pushed gently forward over the head at the height of the pain, while the tips of the fingers may, at the same time, press upon the advancing vertex, so as to retard its progress if advisable (Fig. 102). By this means the sud- 19 282 LABOR. den and forcible stretching of the perineal structures is prevented, and the chance of laceration reduced to a minimum, while nature's mode of relaxing the tissues, by dilatation of the anal orifice, is favored. This is very different from the mechanical support that is usually recommended, and the less pressure that is applied directly Fig. 102. Mode of effectiug relaxation of the Perineum. to the perineum the better. Nor is it either needful or advisable to sit by the patient with the hand applied to the perineum for hours, as is so often practised. Time should be given for the gradual dis- tension of the tissues by the alternate advance and recession of the head, and we need only intervene to assist relaxation when the stretching has reached its height, and the head is about to be ex- pelled. A napkin may be interposed between the hand and the skin, for the purpose of cleanliness. Should the perineum be excessively tough and resistant, assiduous fomentation with a hot sponge may be resorted to, and will be of some service in promoting relaxation. Incision of the Perineum. — -When the tension is so great that lace- ration seems inevitable, it is generally recommended that a slight incision should be made on each side of the central raphe, with the view of preventing spontaneous laceration. This may no doubt be done with perfect safety, but I question if it is likely to be of use. The idea is that an incised wound is likely to heal more readily than a lacerated one. When, however, a distended perineum ruptures, its structures are so thinned that the tear is always linear ; and, as a matter of fact, the edges of the tear are always as clean, and _ as closely in apposition, as if the cut had been made with a knife. Moreover, the laceration invariably heals perfectly, if only the edges be brought into contact at once with one or two metallic sutures. I believe therefore, that Goodell is right in stating that incision of the perineum is rarely, if ever, necessary, unless it is hardened by pre- MANAGEMENT OF NATURAL LABOR. 283 vious cicatrization. In almost all first labors, the fourchette is torn, but requires no treatment of any kind. In some cases, do what we will, more or less laceration occurs, and the perineum should always be examined after the expulsion of the child, to see if any tear has taken place. Treatment of Lacerations. — If it has given way to any extent, I believe that it is good practice to insert one or two interrupted sutures of silver wire or carbolized gut at once. Immediately after delivery the sensibility of the tissues is deadened by the distension to which they have been subjected, and the sutures can be inserted with little or no pain. It is quite true that lacerations of an inch or less will generally heal perfectly well of themselves ; but this is not invariably the case, while healing almost certainly follows if the edo-es be brought together at once. In the severer forms of lacera- tion, extending back to, or even through the sphincter, the precaution is all the more necessary, and a subsequent operation of gravity may in this way be avoided. The sutures can be removed without diffi- culty in a week or so, when complete adhesion has taken place. Expulsion of the Child. — The head, when expelled, should be re- ceived in the palm of the right hand, while the left hand is placed upon the abdomen to follow down the nterus as it contracts and expels the body. There is generally some little delay after the ex- pulsion of the head, and we should now see if the cord surround the neck, and, if it does so, it should be drawn over the head. The ex- pulsion of the body should be left entirely to the uterine contrac- tions. If there be undue delay we may endeavor to excite uterine action by friction on the fundus, and it will rarely happen that sufficient contraction does not now come on. If we display undue haste in withdrawing the body, Ave run the risk of emptying the uterus while its tissues are relaxed, and so favor hemorrhage. If however, there seem serious danger of the child being asphyxiated, its expulsion may be favored by gently passing the forefinger of each hand within the axillae, and using traction; but it is only very exceptionally that such interference is required. Promotion of Uterine Contraction after the Birth of the Child.— Ah the uterus contracts, it should be carefully followed down through the abdominal parietes by the left hand, which should grasp it as the body is expelled, with the view of seeing that it is efficiently con- tracted. This is a point of vital importance in preventing hemorrhage, which will presently be more especially considered. Ligature of the Cord. — As soon as the child cries we may proceed to tie and separate the cord. For this purpose the nurse usually provides ligatures composed of several strands of whitey-brown thread; but tape, or any other suitable material, may be employed. It is important, especially if the cord be very thick and gelatinous, to see that it is thoroughly compressed, so that the vessels are ob- literated, otherwise secondary hemorrhage might occur. The cord is tied about an inch and a half from the child, and it is usual, though of course not essential, to place a second ligature about two inches nearer the placental extremity of the cord. The latter is, perhaps, 284 LABOR. of some use by retaining the blood, and thus increasing the size, of the placenta, and favoring its more ready expulsion by uterine con- traction. The cord is then divided with scissors between the liga- tures, the child wrapped up in flannel, and given to the nurse, or a bystander, to hold, while the attention of the practitioner is concen- trated on the mother, with a view to the proper management of the third stage of labor. Importance of Proper Management of Third Stage. — There is un- questionably no period of labor where skilled management is more important, and none in which mistakes are more frequently made. By proper care at this time the risk of post-partum hemorrhage is reduced to a minimum, the efficient contraction of the uterus is secured, the amount and intensity of after pains are lessened, and the safety and comfort of the patient greatly promoted. Moreover, the general practice, as to the management of this stage, is opposed to the natural mechanism of placental expulsion, and is far from being well adapted to secure the important objects which we ought to have in view. Let us see what is the practice usually recommended and followed, and then we shall be in a position to understand in what respects it is erroneous. For this purpose! cannot do better than copy the directions contained in one of our most deservedly popular obstetric text-books, which undoubtedly expresses the usual practice in the management of this stage. "When the binder is applied, the patient may be allowed to rest a while, if there is no flooding ; after which, when the uterus contracts, gentle traction may be made by the funis, to ascertain if the placenta be detached. If so, and especially if it be in the vagina, it may be removed by continuing the traction steadily in the axis of the upper outlet at first, at the same time making pressure on the uterus." 1 Objections to Ordinary Practice. — This may fairly be taken as a sufficiently accurate description of the practice usually followed. 2 The objections I have to make are: (1) That it inculcates the common error of relying on the binder as a means of promoting uterine contraction, advising its application before the expulsion of the placenta; while I hold that the binder should never be applied until after the placenta is expelled, and not even then, unless the uterus is perfectly and permanently contracted. (2) That it teaches that traction on 'the cord should be used as a means of withdraw- ing the placenta; whereas the uterus itself should be made to expel the after-birth, and, in nineteen cases out of twenty, the finger need never be introduced into the vagina after the birth of the child, nor the cord touched. This may seem an exaggerated statement to those who have accustomed themselves to the usual method of dealing with the placenta; but I feel confident that all who have learnt the method of expression of the placenta would testify to its accuracy. Expression of the Placenta. — The cardinal point to bear in mind is, that the placenta should be expelled from the uterus by a vis a tergo, 1 Churchill's Theory and Practice of Midwifery, p. 162. 2 This practice is further illustrated by the annexed diagram, contained in most MANAGEMENT OF NATURAL LABOR 285 not drawn out by a vis a fronte. That uterine pressure after the birth of the child has been recommended by many English writers is certain, and the Dublin school especially have dwelt on its import- ance as a preventive of post-partum hemorrhage ; but the distinct enunciation of the doctrine that the placenta should be pressed, and not drawn, out of the uterus, we owe to Crede and other German writers; and it is only of late years that this practice has become at all common. Those who have not seen placental expression prac- tised, find it difficult to understand that, in the large majority of cases, the uterus may be made to expel the placenta out of the va- gina; but such is unquestionably the fact. A little practice is no doubt necessary to effect this satisfactorily ; but when once the knack has been learnt, there is little difficulty likely to be ex- perienced. Importance of not Removing the Placenta Hurriedly. — Before de- scribing the method of placental expression, a word of caution may be said against undue haste in attempting expression of the placenta, a mistake that is often made, and which, I believe, tends to increase the risk of post-partum hemorrhage. So long as we satisfy our- selves that the uterus is fairly contracted, so as to avoid the possi- bility of its distension with blood, a certain delay after the birth of the child is useful, from its giving time for coagula to form within the uterine sinuses, by which their open mouths are closed up. The importance of this point has been special^ dwelt upon by McClin- tock, who lays down the rule that 15 or 20 minutes should be allowed to elapse, after the birth of the child, before any attempt to remove obstetric works, which represents the accoucheur as withdrawing the placenta by traction, and which I insert as an illustration of what ought not to be done (Fig. 103). Fig. 103. Usual Method of Removing the Placenta by Traction on the Cord. 286 LABOR the after-birth is made. This is a good and safe practical rule, as it gives ample time for the complete detachment of the placenta, and the coagulation of the blood in the uterine sinuses. Mode of Effecting Expression of the Placenta. — During this inter- val the practitioner or nurse should sit by the bedside, with the hand on the uterus to secure contraction and prevent distension ; but not kneading or forcibly compressing it. When Ave judge that a suffi- cient time has elapsed, we may proceed to effect expulsion. For this purpose the fundus should be grasped in the hollow of the left hand, the ulnar edge of the hand being well pressed down behind the fundus, and when the uterus is felt to harden, strong and firm pres- sure should be made downwards and backwards in the axis of the pelvic brim. If this manoeuvre be properly carried out, and suffi- cientl}^ firm pressure made, in almost every case the uterus may be made to expel the placenta into the bed, along with any coagula that may be in its cavity (Fig. 104). The uterine surface of the pla- Fig. 104. Illustrating Expression of the Placenta. centa is generally expelled first, as is represented in the diagram, the cord being within the membranes; whereas the foetal surface, and root of the cord, are the parts which appear first when the placenta is removed by traction (Fig. 103). If we do not succeed at the first effort, which is rarely the case if extrusion be not attempted too soon after the birth of the child, Ave may wait until another contrac- tion takes place, and then reapply the pressure. I repeat that, after a little practice, the placenta may be entirely expelled in this Avay, in nineteen cases out of twenty, without even touching the cord, and the bugbear of retained placenta will cease to be a source of dread. Management of the Membranes. — Should we fail in causing the uterus to expel the placenta, a vaginal examination may be made, and, if the placenta be found lying entirely in the vagina, it may be MANAGEMENT OF NATURAL LABOR. 287 carefully withdrawn. If, however, the cord can be traced up through the os, showing that the placenta is still within the uterine cavity, we must again resort to pressure to effect its expulsion, and not at- tempt to withdraw it by traction. Such cases may fairly be classed as retained placenta, but they should be very rarely met with, and are discussed elsewhere. When they do occur often in the hands of the same practitioner, it is fair to conclude that he has not properly acquired the art of managing this stage of labor. Generally speak- ing, the placenta should be expelled within twenty minutes after the birth of the child; but no doubt, in the large majority of cases, expulsion might be effected sooner were it advisable to attempt it. When the mass of the placenta is expelled, the membranes gene- rally still remain in the vagina, and they should be twisted into a rop?, and very gently withdrawn, so as not to leave any portion behind. This is a precaution the importance of which I would strongly urg3. for I believe that the chance of part of the membranes being torn off and left in utero is the one objection to the method recommended. With due care, however, this accident may be avoided, and the risk will be lessened if the placenta is received into the palm of the right hand, on expression, so as to avoid any strain on the membranes. Compression of the Uterus after the Expulsion of the Placenta. — The duties of the medical attendant are not even now over. For at least ten minutes after the extrusion of the placenta, he should keep his haul on the firmly contracted uterus, gently kneading it, without any force, for the purpose of promoting firm and equable contraction, and causing it to throw off' any coagula that may form in its cavity. Administration of Er 'jot of Rye. — The subsequent comfort and safety of the patient may be promoted by administering, at this time, a full dose of ergot of rye, such as a drachm, or more, of the liquid extract. The property possessed by this drug of producing tonic and persistent contraction of the uterine fibres, which renders it of doubtful utility as an oxytocic during labor, is of special value after delivery, when such contraction is precisely what Ave desire. I have long been in the habit of administering the drug at this period, and believe it to be of great value, not only as a prophylactic against hemorrhage, but as a means of lessening after-pains. Application of the Binder. — When we are satisfied that the uterus is permanently contracted we may apply the binder, but this should rarely be done until at least half an hour after the birth of the child. The soiled clothes should be gently withdrawn from under the patient, moving her as little as possible, and the binder should be, at the same time, slipped under the body, taking care that it is passed well below the hips, so as to secure a firm hold. Xo kind of bandage is better than a piece of stout jean, of sufficient breadth to extend from the trochanters to the ensiform cartilage ; a jack-towel or bolster slip answers the purpose very well. These are preferable, at any rate at first, to the shaped binders that are often used. One or two folded napkins are generally placed over the uterus, so as to form a pad to keep up pressure. Once in position, the binder is 288 LABOR. palled tight, and fastened by pins. The utility of careful bandaging after delivery can scarcely be doubted, although some years ago it became the fashion to dispense with it. It gives a comfortable sup- port to the lax abdominal walls, keeps up a certain amount of pres- sure on the uterus, and tends to restore the figure of the patient. After the bandage is applied, a warm napkin should be placed on the vulva, as a means of estimating the quantity of the discharge and the patient may be allowed to rest. After-treatment. — Unless the labor have been very long and fatigu- ing, an opiate, often exhibited as a matter of routine, is unadvisable; although it may be well to leave one with the nurse, to be given if the patient cannot sleep, or if the after-pains be very troublesome. The practitioner may now leave the room, but not the house, and at least an hoar should elapse after delivery before he takes his depart- ure. Before doing so he should visit the patient, inspect the napkin to see that there is not too much discharge, and satisfy himself that the uterus is contracted, and not distended with coagula. He should also count the pulse, which, if the patient be progressing satisfac- torily, will be found at its normal average. If, however, it be beat- ing over 100 per minute, he should on no account leave, for such a rapidity of the circulation renders it extremely probable that hemor- rhage is impending. This is a good practical rule, laid down by M'Clintock in his excellent paper "On the Pulse in Child-bed," attention to which may often save the patient from disastrous con- sequences. Before leaving, the practitioner should see that the room is dark- ened, all bystanders excluded, and the patient left as quiet as possible to recover from the shock of labor. CHAPTER IV. A^vESTHESIA IN" LABOR. A few words may be said as to the use of anaesthetics during labor, a practice which has become so universal that no argument is required to establish its being a perfectly legitimate means of as- suaging the sufferings of childbirth. Indeed, the tendency in the present clay is in the opposite direction ; and a common error is the administration of chloroform to an extent which materially interferes with the uterine contractions, and predisposes to subsequent post- partum hemorrhage. Af/ents Employed. — Practically speaking the only agent hitherto employed in this country is chloroform, although the bi-chloricle of methylene, and ether, have been occasionally tried. Of late years, ANAESTHESIA IN LABOR. 289 cliloral has been extensively used by some ; and as I believe it to be an ao-ent of very great value, I shall first indicate the circumstances under which it may be employed. Chloral. — The peculiar value of chloral in labor is, that it may be safely administered at a time when chloroform cannot be generally employed. The latter, while it annuls suffering, very frequently tends, in a marked degree, to diminish uterine action. This is a familiar observation to all who have employed it much during labor, as the diminution of the force and intensity of the pains, and the consequent retardation of the labor, often oblige us to suspend its in- halation, at least temporarily. Indeed, this very property of annul- ling uterine action is one of its most valuable qualities in obstetrics, as in certain cases of turning. For such purposes it is necessary to give it to the surgical extent, which we endeavor to avoid when it is used simply to lessen the suffering of ordinary labor. Still it is not always easy to limit its action in this way, and thus it very frequently does more than we wish. Such diminution in the intensity of uterine contraction is comparatively of less consequence in the propulsive stage, and it is generally more than counterbalanced by the relief it affords. In the first s'age it is otherwise, and, practically speaking, chloroform is generally not admissible until the head is in the pelvic cavity. Chloral on the other hand, has no such relaxing effects on uterine contraction. It cannot, it is true, compete with chloroform in its power of relieving pain, but it produces a drowsy state in which the pain is not felt nearly so acutely as before. It is, therefore, in the first stage of labor, while the pains are cutting and grinding, and during the dilatation of the cervix, that it finds its most useful application. It is especially valuable in those cases, so frequently met with in the upper classes, in which the pains produce intolerably acute suffering, with but little effect on the progress of the labor. In them the os is often thin and rigid, and the pains very frequent and acute, but little or no dilatation is effected. When the patient is brought under the influence of chloral, however, the pains become less frequent but stronger, nervous excitement is calmed, and the dilatation of the cervix often proceeds rapidly and satisfactorily. Indeed I know of nothing which answers so well in cases of rigid, undilatable cervix, and I believe its administration to be far more effective, under such circumstances, than any of the remedies usually employed. Object and Mode of Administration. — The object is to produce a somnolent condition, which shall be protracted as long as possible. For this purpose 15 grains of chloral may be administered every twenty minutes, until three doses are given. This generally suffices to produce the desired effect. The patient becomes very drowsy, dozes between the pains, and wakes up as each contraction com- mences. It may be necessary to give a fourth dose, at a longer in- terval, say an hour after the third dose, to keep up and prolong the soporific action, but this is seldom necessary, and I have rarely given more than a drachm of chloral during the entire progress of labor. Another advantage of this treatment is that, while it does not inter- 290 LABOR. fere with the use of chloroform in the second stage, it renders it necessary to give less than otherwise would be called for, and thus its action can be more easily kept within bounds. On the whole therefore, I am inclined to consider chloral a very valuable aid in the management of labor, and believe that it is destined to be much more extensively used than is at present the case. So far as my experi- ence has yet gone I have not met with any symptoms which" have led me to think that it has produced bad effects ; and I have known many patients sleep quietly through labor, without expressing any excessive suffering, or asking for chloroform, who, under ordinary circumstances, would have been most urgently calling for relief. It occasionally happens that the patient cannot retain the chloral from its tendency to produce sickness ; it may then be readily given per rectum in the form of enema. Chloroform. — Generally speaking, we do not think of giving chloro- form until the os is fully dilated, the head descending, and the pains becoming propulsive. It has often, indeed, been administered earlier, for the purpose of aiding the dilatation of a rigid cervix, and there is no doubt that it often succeeds well when employed in this way ; but I have already stated my belief that chloral answers this purpose better. Should only he given during the Pains. — There is one cardinal rule to be remembered in giving chloroform during the propulsive stage, and that is, that it should be administered intermittently, and never continuously. When the pain comes on a few drops may be scattered over a Skinner's inhaler, which affords one of the best means of administering it in labor, or placed within the folds of a handkerchief twisted into the form of a cone. During the acme of the pain the patient inhales it freely, and at once experiences a sense of great relief; and, as soon as the pain dies away, the inhaler should bs removed. In the interval between the pains the effect of the drug passes off, so that the higher degree of anaesthesia should never be produced. Indeed, when properly given, consciousness should not be entirely abolished, and the patient, between the pains, should be able to speak, and understand what is said to her. This intermittent administration constitutes the peculiar safety of chloroform admin- istered in labor, and it is a fortunate circumstance that, as yet, there is, I believe, no case on record of death during the inhalation of chloroform for obstetric purposes. This is obviously due to the effect of each inhalation passing off before a fresh dose is admin- istered. The effect on the pains should be carefully watched. If they become very materially lessened in force and frequency, it may be necessary to stop the inhalation for a short time, commencing again when the pains get stronger, which effect may be often completely and easily prevented by mixing the chloroform with about one-third of absolute alcohol, which, originally recommended, I believe, by Dr. Sansom, increases the stimulating effects of the chloroform, and thus diminishes its tendency to produce undue relaxation. The amount administered must vary, of course, with the peculiarities of ANESTHESIA IN LABOR. 291 each individual case and the effect produced, but it need never be large. As the head distends the perineum, and the pains get very strono* and forcing, it may be given more freely and to the extent of inducing even complete insensibility just before the child is born. Filter as a Substitute for Chloroform. — In cases in which chloroform has lessened the force of the pains ether may be given instead with great advantage. It certainly often acts well when chloroform is inadmissible on account of its effects on the pains, and, so far as my experience goes, it has not the property of relaxing the uterus, but, on the contrary, has sometimes seemed to me distinctly to intensify the pains. Of late I have nsed a mixture of one part of absolute alcohol, two of chloroform, and three of ether. This is less disagree- able than ether, and has not the over-relaxing effects of chloroform. Precautions. — Bearing in mind the tendency of chloroform to pro- duce uterine relaxation, more than ordinary precautions should always be taken against post-partum hemorrhage in all cases in which it has been freely administered. In cases of operative midwifery it is often given to the extent ot producing complete anaesthesia. In all such cases it should be admin- istered, when possible, by another medical man, and not by the operator, because the giving of chloroform to the surgical degree requires the undivided attention of the administrator, and no man can do this and operate at the same time. I once learnt an import- ant lesson on this point, I had occasion to apply the forceps in the case of a lady who insisted on having chloroform. AVhcn commenc- ing the operation I noticed some suspicious appearances about the patient, who was a large stout woman, with a feeble circulation. I therefore stopped, allowed her to regain consciousness, and delivered her without anaesthesia, much to her own annoyance. Just one month after labor she went to a deutist to have a tooth extracted, and took chloroform, during the inhalation of which she died. This impressed on my mind the lesson that no man can do two things at the same time. The partial unconsciousness of incomplete aniesthesia, in which the patient is restless and tossing about, renders the applica- tion of forceps, as well as all other operations, very difficult. There- fore, unless the patient can be completely and fully anaesthetized, it is better to operate without chloroform being given at all [In the United States chloroform is rarely used in obstetric practice, as compared with pure sulphuric ether, such as that prepared by Dr. Squibb, of New York; and aniesthesia is much less frequently prac- tised than it was soon after its introduction. With some women, ether acts as a stimulant, increasing their power of expulsion, while at the same time the suffering is greatfy lessened ; the whole pro- cess of labor is perfect; the placenta extruded almost without blood, and there is no subsequent uterine relaxation. But unfortu- nately such cases are exceptional. With some patients the anaesthetic produces a species of intoxication, with hysterical excitement, and the pains, which are at first diminished, at last cease entirely, or are rendered of no value, and the ether has to be withheld, as I have frequently seen. Some women complain that they have a night- 292 LABOR. mare, or are made to "feel wild," and are not relieved of pain, and request to have the anaesthetic withheld. But the chief cause for the infrequent resort to ether has been the production of uterine inertia after delivery, and consequent post-partum hemorrhage. In turning, the remedy is for the time important, but the delivery need not be completed under it. The use of fluid ext. ergot is a valuable prophylactic, but more to be relied upon in most instances where there has been no anaesthesia. — Ed.] CHAPTER Y. PELVIC PRESENTATIONS. Under the head of 'pelvic presentations it is customary to include all cases in which any part of the lower extremities of the child pre- sents. By some these are further subdivided into breech, footling % and hnee presentations ; but, although it is of consequence to be able to recognize the feet and the knee when they present, so far as the mechanism and management of delivery are concerned, the cases are identical, and, therefore, may be most conveniently considered to- gether. Frequency. — Presentations corning under this head are far from uncommon ; those in which the breech alone occupies the pelvis are met with, according to Churchill, once in 52 labors, while Rams- botham estimates that it presents more frequently, viz., once in 38.8 labors. Footling presentations occur only once in 92 cases. They are probably often the mere conversion of original breech presenta- tions, the feet having come down during the labor, either in conse- quence of the sudden escape of the liquor amnii, when the breech was still freely movable above the brim, or from some other cause. Knee presentations are extremely rare, as may be readily understood if it be borne in mind that to admit them the thighs must be ex- tended, hence the vertical measurement of the child must be greatly increased, and therefore it could not be readily accommodated within the uterine cavity, unless of unusually small size. As a matter of fact, Mine. La Chapelle found only one knee presentation in upwards of 3000 cases. Causes. — The causes of pelvic presentations are not known. They are probably the same as those which produce other varieties of mal- presentations ; and it is not unlikely that, in certain women, there may be some peculiarity in the shape of the uterine cavity which favors their production. It would be difficult otherwise to explain such a case as that mentioned by Yelpeau, in which the breech pre- sented in six labors. PELVIC PRESENTATIONS. 293 Prognosis. — The results, as regards the mother, are in no way more unfavorable than in vertex presentation. The first stage of the labor is generally tedious, since the large rounded mass of the breech does not adapt itself so well as the head to the lower segment of the uterus, and dilatation of the cervix is consequently apt to be retarded. The second stage is, however, if anything, more rapid than in vertex cases ; and even when it is protracted, the soft breech does not pro- duce such injurious pressure on the maternal structures as the hard and unyielding head. The Infantile Mortality in Pelvic Presentations. — The result is very different as regards the child. Dubois calculated that 1 out of 11 children was still-born. Churchill estimates the mortality as much higher, viz., 1 in Si. The latter certainly indicates a larger num- ber of still-births than is consistent with the experience of most practitioners, and more than should occur if the cases be properly managed ; but there can be no doubt that the risk to the child is, even under the most favorable circumstances, very great. Even when the child is not lost it may be seriously injured. Dr. Kuge has tabu- lated a series of 29 cases in which there were found to be fractures of bones or other injuries. 1 Causes of Foetal Mortality. — The chief source of danger is pressure on the umbilical cord, in the interval elapsing between the birth of the body and the head. At this time the cord is very generally com- pressed between the head of the child and the pelvic walls, so that circulation in its vessels is arrested. Hence the aeration of the fcetal blood cannot take place ; and, pulmonary respiration not having been yet e-stablished, the child dies asphyxiated. There are other condi- tions present which tend, although in a minor degree, to produce the same result. One of these is that the placenta is probably often separated by the uterine contractions when the bulk of the body is being expelled, as, indeed, takes place, under analogous circum- stances, when the vertex presents; the necessary result being the arrest of placental respiration. Joulin thinks that the same effect may be produced by the compression of the placenta between the contracted uterus and the hard mass of the fcetal skull. Probably all these causes combine to arrest the functions of the placenta ; and, if the delivery of the head, and consequently the establishment of pulmonary respiration, be delayed, the death of the child is almost inevitable. The corolkny is that the danger to the child is in direct proportion to the length of time that elapses between the birth of the body and that of the head. The risk to the child is greater in footling than in breech cases, because in the former the maternal structures are less perfectly di- lated, in consequence of the small size of the feet and thighs, and, therefore, the birth of the head is more apt to be delayed. Diagnosis. — Inasmuch as the long axis of the child corresponds with the long axis of the uterus, in pelvic as in vertex presentations, there is nothing in the shape of the uterus to arouse suspicion as to 1 Bui. Gen. de Therap., August, 1875. 294 LABOR. the character of the case. Still, it is often sufficiently easy to recog- nize a pelvic presentation by abdominal examination, if we have occasion to make one. The facility with which it may be done de- pends a good deal on the individual patient. If she be not very stout, and if the abdominal parietes be lax and non-resistant, we shall generally be able to feel the round head at the upper part of the uterus much firmer, and more defined in outline than the breech. The conclusion will be fortified if we hear the foetal heart beating on a level with, or above, the umbilicus. The greater resistance on one side of the abdomen will also enable us to decide, with tolerable ac- curacy, to which side the back of the child is placed. Information thus acquired is, at the best, uncertain ; and we can never be quite sure of the existence of a pelvic presentation until we can corrobo- rate the diagnosis by vaginal examination. Results of Vaginal Examination. — The first circumstance to ex- cite suspicion on examination per vaginam, even when the os is nu- cleated, is the absence of the hard globular mass felt through the lower segment of the uterus, which is so characteristic of vertex presentations. When the os is sufficiently open to allow the mem- branes to protrude, although the presenting part is too high up to be within reach, we may be struck with the peculiar shape of the bag of membranes, which, instead of being rounded, projects a consider- able distance through the os, like the finger of a glove. This is a peculiarity met with in all malpresentations alike, and is, indeed, much less distinct in breech than in footling presentations, because in the former the membranes are more stretched, just as they are in vertex cases. When the membranes rupture, instead of the waters dribbling away by degrees, they often escape with a rush, in conse- quence of the pelvic extremity not filling up the lower part of the uterus so accurately as the head, which acts as a sort of ball-valve, and prevents the sudden and complete discharge of the waters. Diagnosis of the Breech. — Often, on first examining, even when the membranes are ruptured, the presentation is too high up to be made out accurately. All that we can be certain of is, that it is not the head; and the case must be carefully watched, and examinations frequently repeated, until the precise nature of the presentation can be established. If the breech present, the finger first impinges on a round, soft prominence, on depressing which a bony protuberance, the trochanter major, can be felt. On passing the finger upwards it reaches a groove, beyond which a similar fleshy mass, the other buttock, can be felt. In this groove various characteristic points, diagnostic of the presentation, can be made out. Towards one end we can feel the movable tip of the coccyx, and above it the hard sacrum, with rough projecting prominences. These points, if accu- rately made out, are quite characteristic, and resemble nothing in any other presentation. In front there is the anus, in which it is sometimes, but by no means always, possible to insert the tip of the finger. If this can be done it is easy to distinguish it from the mouth, with which it might be confounded, by observing that the hard alveolar riclsres are not contained within it. Still more in front PELVIC PRESENTATIONS. 295 we may find the genital organs, the scrotum in male children being often much swollen if the labor has been protracted. Thus it is often possible to recognize the sex of the child before birth. Differential Diagnosis. — The breech might be mistaken for the face, especially if the latter be much swollen ; but this mistake can readily be avoided by feeling the spinous processes of the sacrum. The knee is recognized by its having two tuberosities with a de- pression between them. It might be confounded with the heel, the elbow, or the shoulder. From the heel, it is distinguished by having two tuberosities instead of one ; from the elbow, by the latter havino" one sharp tuberosity, with a depression on each side, instead of a central depression and two lateral prominences; and from the shoulder, by the latter being more rounded, having only one promi- nence, running from which the acromion and clavicle can be traced. Diagnosis of the Foot. — -The foot may be mistaken for the hand. This error will be avoided by remembering that all the toes are in the same line, and that the great toe cannot be brought into apposi- tion with the others, as the thumb can with the fingers. The inter- nal border of the foot is much thicker than the external, whereas the two borders of the hand are of the same thickness. Moreover, the foot is articular at right angles to the leg, and cannot be brought into a line with it, as the hand can with the arm. Finally, the pro- jection of the calcaneum is characteristic, and resembles nothing in the hand. Mechanism. — As is the case in other presentations, obstetricians have very variously subdivided breech presentations, with the effect of needlessly complicating the subject. The simplest division, and that which will most readily impress itself on the memory of the student, is to describe the breech as presenting in four positions, anal- ogous to those of the vertex, the sacrum being taken as representing the occiput, and the positions being numbered according to the part of the pelvis to which it points. Thus Ave have — First, or left sacro-anterior (corresponding to the first position of the vertex). The sacrum of the child points to the left foramen ovale of the mother. Second, or right sacro-anterior (corresponding to the second vertex position). The sacrum of the child points to the right foramen ovale of the mother. Third or right sacro-posterior (corresponding to the third vertex position). The sacrum of the child points to the right sacro-iliac synchondrosis of the mother. Fourth or left sacro-posterior (corresponding to the fourth vertex position). The sacrum of the child points to the left sacro-iliac syn- chonclrosis of the mother. Of these, as with the corresponding vertex positions, the first and third are the most common, their comparative frequency, no doubt, depending on the same causes. The mechanical conditions to which the presenting part is subjected are also identical, but the alterations of positions of the breech in its progress are by no means so uniform as those of the head, on account of its less perfect adaptation to the 296 LABOR pelvic cavity. The mechanism of the delivery of the shoulders and head in breech presentations, moreover, is of much greater practical importance than that of the body in vertex presentations, inasmuch as the safety of the child depends on its speedy and satisfactory ac- Fiq. 105. First or left Sacro-cotyloid Position of the Breech. complishment. Bearing these facts in mind, it will suffice to describe briefly the phenomena of delivery in the first and third breech positions. Position of the Child at Brim. — In the first position the sacrum of the child points to the left foramen ovale, its back is consequently placed to the left side of the uterus and anteriorly, and its abdomen looks to the right side of the uterus and posteriorly. The sulcus between the buttocks lies in the right oblique diameter of the pelvis, while the transverse diameter of the buttocks lies in the left oblique diameter, the left buttock being most easily within reach. As in vertex presentations the hips of the child lie on the same level at the pelvic brim, although Naegele describes the left hip as placed lower than the right. Descent. — As the pains act on the body of the child, the breech is gradually forced through the pelvic cavity, retaining the same relations as at the brim, its progress being generally more slow than that of the head, until it reaches the lower pelvic strait, when the same mechanism which, produces rotation of the occiput comes to operate upon it. The result is a rotation of the child's pelvis, so that its transverse diameter comes to lie approximately in the antero- posterior diameter of the outlet, its antero-posterior diameter corre- sponds to the transverse diameter of the mother's pelvis, the left hip lies behind the pubis, and the right towards the sacrum. This rota- PELVIC PRESENTATIONS. 297 tion, which is admitted by the majority of obstetricians, is altogether denied by Naegele. There can be no doubt, however, that it does generally take place, but by no means so constantly as the corre- sponding rotation of the vertex ; and it is not uncommon for it to be entirely absent, and for the hips to be born in the oblique diam- eter of the outlet. The body of the child is said frequently not to follow the movement imparted to the hips, so that there is more or less of a twist in the vertebral column. Expulsion of the Hips and Body. — The left hip now becomes firmly fixed behind the pubis, and a movement of extension, analogous to that of the head in vertex presentations, takes place. The right, or posterior, hip revolves round the fixed one, gradually distends the perineum, and is expelled first, the left hip rapidly following. As soon as both hips are born, the feet slip out, unless the legs are com- pletely extended upon the child's abdomen. The shoulders soon follow, lying in the left oblique diameter of the pelvis. The left shoulder rotates forwards behind the pubis, where it becomes fixed, the right shoulder sweeping over the perineum, and being born first. The arms of the child are generally found placed upon its thorax, and are born before the shoulders. Sometimes they are ex- tended over the child's head, thus causing considerable delay, and greatly increasing the risk to the child. It is now generally ad- mitted that such extension is most apt to occur when traction has been made on the child's body with the view of hastening delivery, and that it is rarely met with when the expulsion of the body is left entirely to the natural powers. Delivery of the Head.— When the shoulders are expelled the head enters the pelvis in the opposite, or right oblique diameter, the face looking to the right sacro-iliac synchondrosis. As the greater part Fig. 106. of the Shoulders and Partial Rotation of the Thorax. of the child is now expelled, and as the head has entered the vagina, the uterus, having a comparatively small mass to contract upon^ must obviously act at a mechanical disadvantage. Still the pressure of the head on the vagina is a powerful inciter, the accessorv muscles 20 298 LABOR. of parturition are brought into strong action, and there is usually quite sufficient force to insure expulsion of the head without artificial aid. On account of the great resistance to the descent of the occiput from its articulation with the spinal column, the pains have the Fig. 107. Descent of the Head. effect of forcing down the anterior portion of the head, and this insures the complete flexion of the chin upon the sternum. This is a great advantage from a mechanical point of view, as it causes the short occipito-mental diameter of the head to enter the pelvis in the axis of the uterus and the brim. If the head should be in a state of partial extension — as sometimes happens when the pelvis is un- usually roomy — the occipital frontal diameter is placed in a similar relation to the brim, a position certainly less favorable to the easy birth of the head. As the head descends it experiences a movement of rotation, the occiput passing forwards and to the right, behind the pubic arch, the face turning backwards into the hollow of the sacrum. The body of the child will be observed to follow this movement, so that its back is turned towards the mother's abdomen, its anterior surface to the perineum. The nape of the neck now becomes firmly fixed under the arch of the pubis, the pains act chiefly on the ante- rior portion of the head, and cause it to sweep over the perineum, the chin being first born, then the mouth and forehead, and lastly the occiput. Sacroposterior Positions. — It is needless to describe the differences between the mechanism of the second and first positions, which the student, who has mastered the subject of vertex presentations, will readily understand. It is necessary, however, to say a few words as to sacro-posterior positions, choosing for that purpose the third, which is the more common of the two. This is exactly the opposite of the first position. The sacrum of the child points to the right sacro- iliac synchondrosis, its abdomen looks forward and to the left side of the mother. The transverse diameter of the child's pelvis lies in the left oblique diameter, the right hip being anterior. The birth of PELVIC PRESENTATIONS. 299 tlie body generally takes place exactly in the way that has been already described, the right hip being towards the pubis. As the head descends into the pelvis the occiput most usually rotates along its right side — the rotation Laving been often already partially effected when that of the hips had been made — until it comes to rest behind the pubis, the face passing backwards along the left side of the pelvis into the hollow of the sacrum. This change cor- responds exactly to the anterior rotation of the occiput in occipito- posterior positions, and is the natural and favorable termination. Sometimes, forward rotation does not take place, and the occiput then turns backwards into the hollow of the sacrum. What then generally occurs is that the pains continue, for the reason already mentioned, to depress the chin and produce strong flexion of the face on the sternum the occiput becoming fixed on the anterior border of the perineum. The pains continuing to act chiefly on the anterior part of the head, the face is born first behind the pubis, the occiput only slipping over the perineum after the forehead has been ex- pelled. Second Mode in which such Cases occasionally End. — A second mode of termination of such positions is mentioned in most works, on the authority of one or two recorded cases; but although mechanically possible, it is certainly an event of extreme raritv. The chin, in- stead of being flexed on the sternum, is greatly extended, so that the face of the child looks upwards towards the pelvic brim. The chin then hitches over the upper edge of the pubis and becomes fixed there, while the force of the uterine contractions is expended on the posterior part of the head, which descends through the pelvis, dis- tending the perineum, and is born first, the face subsequently fol- lowing. Mechanism of Feet Presentation. — The mechanism of the delivery of the body and head in cases in which the feet originally present, does not differ, in any important respect, from that which has been already described, and requires no separate notice. Treatment. — From what has been said of the natural mechanism, it is evident that one of the most fruitful causes of difficulty and complication is undue interference on the part of the practitioner. It is, no doubt, tempting to use traction on the partially born trunk in the hope of expediting delivery ; but when it is remembered that this is almost certain to produce extension of the arms above the head, and subsequently extension of the occiput ou the spine, both of which seriously increase the difficulty of delivery, the necessity of leaving the case as much as possible to nature will be apparent. Having once, therefore, determined the existence of a pelvic pre- sentation, nothing more should be done until the birth of the breech. The membranes should be even more carefully prevented from pre- maturely rupturing than in vertex presentations, since the}'' serve to dilate the genital passages better than the presenting part/ Hence they should be preserved intact, if possible, until they reach the floor of the pelvis, instead of being punctured as soon as the os is fully 300 LABOR. dilated. The breech when born should be received and supported in the palm of the hand. Danger to Child. — When the body is expelled as far as the umbili- cus, the dangers to the child commence: for now the cord is apt to be pressed between the body of the child and the pelvic walls. To obviate this risk as much as possible, a loop of the cord should be pulled down, and carried to that part of the pelvis where there is most room, which will generally be opposite one or the other sacro- iliac synchondrosis. As long as the cord is freely pulsating we may be satisfied that the life of the child is not gravely imperilled, al- though delay is fraught with danger, from other sources which have been already indicated. In most cases the arms now slip out ; but it may happen, even without any fault on the part of the accoucheur, that they are extended above the head, and it is of great importance that we should be thoroughly acquainted with the best means of liberating them from their abnormal position. Management token the Arms are extended above the Head. — They must, of course, never be drawn directly downwards, or the almost certain result would be fracture of the fragile bones. We should endeavor to make the arm sweep over the face and chest of the child, so that the natural movements of its joints should not be opposed. If the shoulders be within easy reach, the finger of the accoucheur should be slipped over that which is posterior — because there is likely to be more space for this manoeuvre towards the sacrum — ■ and gently carried downwards towards the elbow, which is drawn over the face, and then onwards, so as to liberate the forearm. The same manoeuvre should then be applied to the opposite arm. It may be that the shoulders are not easily reached, and then they may be depressed by altering the position of the child's body. If this be carried well up to the mother's abdomen, the posterior shoulder will be brought lower down; -and, by reversing this procedure and carry- ing the body back over the perineum, the anterior shoulder may be similarly depressed. It is only very exceptionally, however, that these expedients are required. Birth of the Head. — The arms being extracted, some degree of ar- tificial assistance is, at this time, almost always required. If there be much delay, the child will almost certainly perish. Attempts have been made, in cases in which delivery of the head could not be rapidly effected, to establish pulmonary respiration by passing one or two fingers into the vagina, so as to press it back and admit air to the child's mouth, or by passing a catheter or tube into the mouth. Neither of these expedients are reliable, and we should rather seek to aid nature in completing the birth of the head as rap- idly as possible. The first thing to do, supposing the face to have rotated into the cavity of the sacrum, is to carry the body of the child well up towards the pubis and abdomen of the mother without applying* any traction, for fear of interfering with the all-important flexion of the chin on the sternum. If now the patient bear down strongly, the natural powers may be sufficient to complete delivery. If there be any delay, traction must be resorted to, and we must en- PELVIC PRESENTATIONS. 301 deavor to apply it in such a way as to insure flexion. For this pur- pose, while the body of the child is grasped by the left hand, and drawn upwards towards the mother's abdomen, the index and middle fingers of the right hand are placed on the back of the child's neck, so that their tips press on either side of the base of the occiput, and push the head into a state of flexion. In most works we are advised to pass the index and middle Angers of the left hand at the same time over the child's face, so as to depress the superior maxilla. Dr. Barnes insists that this is quite unnecessary, and that extraction in the manner indicated, by pressure on the occiput, is quite sufficient. Should it not prove so, flexion of the chin may be very effectually assisted by downward pressure on the forehead through the rectum. One or two fingers of the left hand can readily be inserted into the bowel, and the expulsion of the head is thus materially facilitated. Value of Pressure through the Abdomen. — By far the most power- ful aid, however, in hastening delivery of the head, should delay occur, is pressure from above. This has been, strangely enough, almost altogether omitted by writers on the subject. It has been strongly recommended by Professor Penrose, and there can be no question of its utility. Indeed, as the uterus contracts tightly round the head, uterine expression can be applied almost directly to the head itself, and without any fear of deranging its proper relation to the maternal passages. It is very seldom, indeed, that a judicious combination of traction on the part of the accoucheur, with firm pressure through the abdomen applied by an assistant, will fail in effecting delivery of the head before the delay has had time to prove injurious to the child. Amplication of the Forceps to the After-coming Head. — Many accou- cheurs — among others Meigs, and Pigby — advocate the application of the forceps when there is delay in the birth of the after-coining head. If the delay be due to want of expulsive force in a pelvis of normal size, manual extraction, in the manner just described, will be found to be sufficient in almost every case, and preferable, as being more rapid, easier of execution, and safer to the child. The forceps may be quite properly tried, if other means have failed; especially if there be some disproportion between the size of the head and the pelvis. Management of Sacroposterior Positions. — Difficulties in delivery may also occur in sacro-posterior positions. Up to the time of the birth of the head the labor usually progresses as readily as in sacro- anterior positions. If the forward rotation of the hips do not take place, much subsequent difficulty may be prevented bv gently favor- ing it by traction applied to the breech during the pains, the finger being passed for this purpose into the fold of the groin. It is after the birth of the shoulders that the absence of rotation is most likely to prove troublesome. It has been recommended that the body should then be grasped, in the interval between the pains, and twisted round so as to bring the occiput forward. It is by no means certain, however, that the head would follow the movement imparted to the body, and there must be a serious danger of giving 302 LABOR. a fatal twist of the neck by such a manoeuvre. The better plan is to direct the face backwards, towards the cavity of the sacrum, by pressing on the anterior temple during the continuance of a pain. In this way the proper rotation will generally be effected without much difficulty, and the case will terminate in the usual way. Management of Cases in which Forward Rotation does not occur. — If rotation of the occiput forwards do not occur, it is necessary for the practitioner to bear in mind the natural mechanism of delivery under such circumstances. In the majority of cases the proper plan is to favor flexion of the chin by upward pressure on the occiput, and to exert traction directly backwards, remembering that the nape of the neck should be fixed against the anterior margin of the perineum. If this be not remembered, and traction be made in the axis of the pelvic outlet, the delivery of the head will be seriously impeded. In the rare cases in which the head becomes extended, and the chin hitches on the upper margin of the pubis, traction directly forwards and upwards may be required to deliver the head; but before resort- ing to it care should be taken to ascertain that backward extension of the head has really taken place. Management of Impacted Breech Presentations. — It remains for us to consider the measures which may be adopted in those very troublesome cases in which the breech refuses to descend, and be- comes impacted in the pelvic cavity, either from uterine inertia, or from disproportion between the breech and the pelvis. Here, un- fortunately, the peculiar shape of the presenting part, which is un- adapted for the application of the forceps, renders such cases very difficult to manage. Two measures have been chiefly employed: 1st, bringing down one or both feet, so as to break up the presenting part, and convert it into a footling case ; 2d, traction on the breach, either by the fingers, a blunt hook, or fillet passed over the groin. Barnes insists on the superiority of the former plan, and there can be no question that, if a foot can be got down, the accoucheur has a complete control over the progress of the labor, which he can gain in no other way. If the breech be arrested at or near the brim, there will generally be no great difficulty in effecting the desired object. It will be necessary to give chloroform to the extent of complete anaesthesia, and to pass the hand over the child's abdomen in the same manner, and with the same precautions, as in performing podalic version, until a foot is reached, ivhich is seized and pulled down. If the feet be placed in the usual way close to the buttocks, no great difficulty is likely to be experienced. If, however, the legs be ex- tended on the abdomen, it will be necessary to introduce the hand and arm very deeply, even up to the fundus of the uterus, a proced- ure which is always difficult, and which may be very hazardous. Nor do I think that the attempt to bring down the feet can be sa.'e when the breech is low down and fixed in the pelvic cavity. A certain amount of repression of the breech is possible, but it is evident that this cannot be safely attempted when the breech is at all low clown. PRESENTATIONS OF THE FACE. 303 Traction on the Groin. — Under such circumstances traction is our only resource, and this is always difficult and often unsatisfactory. Of all contrivances for this purpose none is better than the hand of the accoucheur. The index finger can generally be slipped over the groin without difficulty, and traction can be applied during the pains. Failing this, or when it proves insufficient, an attempt should be made to pass a fillet over the groins. A soft silk handkerchief, or a skein of worsted, answers best, but it is by no means easy to apply. The simplest plan, and one which is far better than the ex- pensive instruments contrived for the purpose, is to take a stout piece of copper wire and bend it double into the form of a hook. The extremity of this can generally be guided over the hips, and through its looped end the fillet is passed. The wire is now with- drawn, and carries the fillet over the groins. I have found this simple contrivance, which can be manufactured in a few moments, very useful, and by means of such a fillet very considerable tractive force can be employed. The use of a soft fillet is in every way pref- erable to the blunt hook which is contained in most obstetric bags. A hard instrument of this kind is quite as difficult to apply, and any strong traction employed by it is almost certain to seriously injure the delicate foetal structures over which it is placed. As an auxiliary the employment of uterine expression should not be forgotten, since it may give material aid when the difficulty is only due to uterine inertia. After a difficult breech labor is completed the child should be carefully examined to see that the bones of the thighs and arms have not been injured. Fractures of the thigh are far from uncom- mon in such cases, and the soft bones of the newly born child will readily and rapidly unite if placed at once in proper splints. Embryotomy. — Failing all endeavors to deliver by these expedients, there is no resource left but to break up the presenting part by scis- sors, or by craniotomy instruments ; but fortunately so extreme a measure is but rarely necessary. CHAPTER VI. PRESENTATIONS OF THE FACE. Presentation's of the face are by no means rare ; and, although in the great majority of cases they terminate satisfactorily by the unassisted powers of nature, yet every now and again they give rise to much difficulty, and then they may be justly said to be amongst the most formidable of obstetric complications. It is, therefore, essential that the practitioner should thoroughly understand the 304 LABOR. natural history of this variety of presentation, with the view of enabling him to intervene with the best prospect of success. Erroneous Views formerly held on the Subject. — The older accou- cheurs held very erroneous views as to the mechanism and treatment of these cases, most of them believing that delivery was impossible by the natural efforts, and that it was necessary to intervene hy version in order to effect delivery. Smellie recognized the fact that spontaneous delivery is possible, and that the chin turns forwards and under the pubis ; but it was not until long after his time, and chiefly after the appearance of Mme. La Chapelle's essay on the subject, that the fact that most cases could be naturally delivered was fully admitted and acted upon. Frequency. — The frequency of face presentations varies curiously in different countries. Thus, Collins found that in the Eotunda Hos- pital there was only 1 case in 497 labors, although Churchill gives 1 in 249 as the average frequency in British practice ; while in Ger- many this presentation 'is met with once in 169 labors. The only reasonable explanation of this remarkable difference is, that the dorsal decubitus, generally followed abroad, favors the transforma- tion of vertex presentations into those of the' face. The mode in which this change is effected — for it can hardly be doubted that, in the large majority of cases, face presentation is due to a backward displacement of the occiput after labor has actually commenced, but before the head has engaged in the brim — has been made the subject of various explanations. Mode in which Face Presentations are produced. — It has generally been supposed that the change is induced by a hitching of the occiput on the brim of the pelvis, so as to produce extension of the head, and descent of the face ; the occurrence being favored by the oblique position of the uterus so frequently met with in preg- nancy. Hecker attaches considerable importance to a peculiarity in the shape of the foetal head generally observed in face presenta- tions, the cranium having the dolicho-cephalous form, prominent posteriorly, with occiput projecting, which has the effect of increas- ing the length of the posterior cranial lever arm, and facilitating extension when circumstances favoring it are in action. Dr. Dun- can 1 thinks that uterine obliquity has much influence in the produc- tion of face presentation, but in a different way from that above referred to. He points out that, when obliquity is very marked, a curve in the genital passages is produced, the convexity of which is directed to the side towards which the uterus is deflected. When uterine contraction commences, the foetus is propelled downwards, and the cavity of the curve is acted on to the greatest advantage by the propelling force, and tends to descend. Should the occiput happen to lie in the convexity of the curve so formed, the tendency will be for the forehead to descend. In the majority of cases its descent will be prevented by the increased resistance it meets with, in consequence of the greater length of the anterior cranial lever 1 Edin. Med. Jour., vol. xv. PRESENTATIONS OF THE FACE. 305 arm ; but if the uterine obliquity be extreme, this may be -counter- balanced, and a face presentation ensues. The influence of this obliquity is corroborated by the observation of Baudelocque, that the occiput in face presentations almost invariably corresponds to the side of the uterine obliquity. A further corroboration is afforded by the fact, that in face presentation the occiput is much more fre- quently directed to the right than to the left ; while right lateral obliquity of the uterus is also much more common. These theories assume that face presentations are produced during labor. In a few cases they certainly exist before labor has com- menced. It is possible, however, as we know that uterine contrac- tions exist independently of actual labor, that similar causes may also be in operation, although less distinctly, before the commence- ment of labor. Diagnosis. — The diagnosis is often a matter of considerable diffi- culty at an early period of labor, before the os is fully dilated and the membranes ruptured, and when the face has not entered the pelvic cavity. The finger then impinges on the rounded mass of the forehead, which may very readily be mistaken for the vertex. At this stage the diagnosis may be facilitated by abdominal palpation in the way suggested by Hecker. If the face is presenting at the brim, palpation will enable us to distinguish a hard, firm, and rounded body, immediately above the pubis, which is the forehead and sinciput ; on the other side will be felt an indistinct soft sub- stance, corresponding to the thorax and neck. When labor is ad- vanced, and the head has somewhat descended, or when the membranes are ruptured, we should be able to make out the nature of the presentation with certainty. The diagnostic marks to be relied on are the edges of the orbits, the prominence of the nose, the nostrils (their orifices showing to which part of the pelvis the chin is turned), and the cavity of the mouth, with the alveolar ridges. If these be made out satisfactorily, no mistake should occur. The most difficult cases are those in which the face has been a consider- able time in the pelvis. Under such circumstances the cheeks be- come greatly swollen and pressed together, so as to resemble the nates. The nose might then be mistaken for the genital organs, and the mouth for the anus. The orbits, however" and the alveolar ridges, resemble nothing in the breech, and should be sufficient to prevent error. Considerable care should be 'taken not to examine too frequently and roughly, otherwise serious injury to the delicate structures of the face might be inflicted. When once the presenta- tion has been satisfactorily diagnosed, examinations should be made as seldom as possible, and only to assure ourselves that the case is progressing satisfactorily. Mechanism. — If we regard face presentations, as we are fully justi- fied, in doing, as being generally produced by the extension' of the occiput in what were originally vetex presentations, we can readilv understand that the position of' the face in relation to the pelvis must correspond to that of the vertex. This is, in fact, what is found to 306 LABOR. be the case, the forehead occupying the position in which the occiput would have been placed had extension not occurred. The Positions of the Face correspond to those of the Vertex. — 'The face, then, like the head, may be placed with its long diameter corresponding to almost any of the diameters of the brim, but most generally it lies either in the transverse diameter, or between this and the oblique, while, as it descends in the pelvis, it more generally occupies one or other of the oblique diameters. It is common in obstetric works to describe two principal varieties of face presenta- tion, viz., the right and left mento-iliac, according as the chin is turned to one or other side of the pelvis. It is better, however, to classify the positions in accordance with the part of the pelvis to which the chin points. We may, therefore, describe four positions of the face, each being analogous to one of the ordinary vertex presentations, of which it is the transformation. First position. — The chin points to the right sacro-iliac synchon- drosis, the forehead to the left foramen ovale, and the long diameter of the face lies in the right oblique diameter of the pelvis. This corresponds to the first position of the vertex, and, as in that, the back of the child lies to the left side of the mother. Second position. — The chin points to the left sacro-iliac synchon- drosis, the forehead to the right foramen ovale, and the long diameter Fig. 108. Second Position in esentations. of the face lies in the left oblique diameter of the pelvis. This is the conversion of the second vertex position. Third position. — The forehead points to the right sacro-iliac syn- chondrosis, the chin to the left foramen ovale, and the long diameter PRESENTATIONS OF THE FACE. 307 of the face lies in the right oblique diameter of the pelvis. This is the conversion of the third vertex position. Fourth position. — The forehead points to the left sacro-iliac syn- chondrosis, the chin to the right foramen ovale, and the long diam- eter of the face lies in the left oblique diameter of the pelvis. This is the conversion of the fourth vertex position. Relative Frequency of these Positions. — The relative frequency of these presentations is not yet positively ascertained. It is certain that there is not the preponderance of first facial that there is of first vertex positions, and this may, no doubt, be explained by the suppo- sition that an unusual vertex position may of itself facilitate the transformation into a face presentation. Winckel concludes that, cseteris paribus, a face presentation is more readily produced when the back of the child lies to the right than when it lies to the left side of the mother; the reason for this being probably the frequency of right lateral obliquity of the uterus. We shall presently see that, with very rare exceptions, it is absolutely essential that the chin should rotate forwards under the pubis before delivery can be accomplished; and, therefore, we may regard the third and fourth face positions, in which the chin from the first points anteriorly, as more favorable than the first and second. Mechanism. — The mechanism of delivery in face is practically the same as in vertex presentations; and we shall have no difficulty in understanding it if we bear in mind that in Dice cases the forehead takes the place, and represents the occiput in vertex presentations. For the purpose of description we will take the first position of the face — ■ Description of Delivery in the First Position of the Face. — 1. The first step consists in the extension of the head, which is effected by the uterine contractions as soon as the membranes are ruptured. By this the occiput is still more completely pressed back on the nape of the neck, and the fronto-mental, rather than the mento-bregmatic, diameter is placed in relation to the pelvic brim. This corresponds to the stage of flexion in vertex presentations. The chin descends below the forehead, from precisely the same cause as the occiput in vertex presentations. On account of the ex- tended position of the head the presenting face is divided into por- tions of unequal length in relation to the vertebral column, through which the force is applied, the longer lever arm being towards the forehead. The resistance is, therefore, greatest towards the fore- head, which remains behind while the chin descends. 2. Descent. — -As the pains continue, the head (the chin being still in advance) is propelled through the pelvis. It is generally said that the face cannot descend, like the occiput, down to the floor of the pelvis, its descent being limited by the length of the neck. There is here, however, an obvious misapprehension. The neck, from the chin to the sternum, when the head is forcibly extended, measures from 3 J to 4 inches, a length. that is more than sufficient to admit of the face descending to the lower pelvic strait. As a matter of fact the chin is frequently observed in mento-posterior positions to de- 808 LABOR. scend so far that it is apparently endeavoring to pass the perineum before rotation occurs. At the brim the two sides of the face are on a level, but as labor advances, the right cheek descends somewhat, the caput succedaneum forms on the malar bone, and, if a secondary caput succedaneum form, on the cheek. 3. Rotation is by far the most important point in the mechanism of face presentations; for unless it occurs, delivery, with a full-sized head and an average pelvis, is practically impossible. There are, no doubt, exceptions to this rule, which must be separately considered, but it is certain that the absence of rotation is always a grave and formidable complication of face presentation. Fortunately it is only very rarely that it is not effected. The mechanical causes are pre- cisely those which produce rotation of the occiput forwards in vertex presentations. As it is accomplished, the chin passes under the arch of the pubis, and the occiput rotates into the hollow of the sacrum (Fig. 109); and then commences — Fig. 109. Rotation Forwards of Chin. 4. Flexion, a movement which corresponds to extension in vertex cases. The chin passes as far as it can under the pubic arch, and there becomes fixed. The uterine force is now expended on the oc- ciput which revolves, as it Avere, on its transverse axis (Fig. 110), the under surface of the chin resting on the pubis as a fixed point. This movement goes on until, at last, the face and occiput sweep over the distended perineum. 5. External Rotation is precisely similar to that which takes place in head presentations, and, like it, depends on the movements im- parted to the shoulders. Such is the natural course of delivery in the vast majority of PRESENTATIONS OF THE FACE. 309 cases ; but, in order fully to understand the subject, it is necessary to study those rare cases in which the chin points backwards, and Fig. 110. Passage of the Head through the External Parts in Face Presentation. forward rotation does not occur. These maybe taken to correspond to the occipito-posterior positions, in which the face is born looking Fig. 111. Illustrating the Position of the Head when Forward Potation of the Chin does not take place. to the pubes ; but unlike them, it is only very exceptionally that delivery can be naturally completed. The reason of this is obvious, for the occiput gets jammed behind the pubis, and there is no space 310 LABOR. for the fronto-mental diameter to pass the antero-posterior diameter of the outlet (Fig. 111). Cases are indeed recorded, in which delivery has been effected with the chin looking posteriorly ; but there is every reason to believe that this can only happen when the head is either unusually small, or the pelvis unusually large. In such cases the forehead is pressed down until a portion appears at the ostium vagi- nae, when it becomes firmly fixed behind the pubis, and the chin, after many efforts, slips over the perineum. When this is effected, flexion occurs, and the occiput is expelled without difficulty. The forehead is probably always on a lower level than the chin. Dr. Hicks 1 has published a paper, in which he attempts to show that this termination .of face presentations is not so rare as is gene- rally supposed, and he gives a single instance in which he effected delivery with the forceps ; but he practically admits that special conditions are necessary, such as the "antero-posterior diameter of the outlet particularly ample," and a diminished size of the head. When delivery is effected it is probable, as Cazeaux has pointed out, that the face lies in the oblique diameter of the outlet, and that the chin depresses the soft structures at the side of the sacro-ischiatic notch, which yield to the extent of a quarter of an inch or more, and thereby permit the passage of the occipito-mental diameter of the head. It must, however, be borne well in mind, that spontane- ous delivery in mento-posterior positions is the rare exception, and that supposing rotation does not occur — and it often does so at the last moment — artificial aid in one form or another will be almost certainly required. Prognosis of Face Presentations. — As regards the mother, in the great majority of cases the prognosis is favorable, but the labor is apt to be prolonged, and she is, therefore, more exposed to the risks attending tedious delivery. As regards the child, the prognosis is much more unfavorable than in vertex presentations. Even when the anterior rotation of the chin takes place in the natural way, it is estimated that 1 out of 10 children is stillborn ; while if not, the death of the child is almost certain. This increased infantile mor- tality is evidently clue to the serious amount of pressure to which the child is subjected, and probably depends in many cases on cere bral congestion, produced by pressure on the jugular veins, as the neck lies in the pelvic cavity. Even when the child is born alive, the face is always greatly swollen and disfigured. In some cases the deformity produced in this way is excessive, and the features are often scarcely recognizable. This disfiguration passes away in a few clays ; but the practitioner should be aware of the probability of its occurrence, and should warn the friends, or they might be unne- cessarily alarmed, and possibly might lay the blame on him. Treatment. — After what has been said as to the mechanism of de- livery in face presentation, it is obvious that the proper course is to leave the case alone, in the expectation of the natural efforts being 1 Obst. Trans., vol. vii. PRESENTATIONS OF THE FACE. 311 sufficient to complete delivery. Fortunate!)', in the large majority of cases, this course is attended by a successful result. The older accoucheurs, as has been stated, thought active inter- ference absolutely essential, and recommended either podalic version, or the attempt to convert the case into a vertex presentation, by in- serting the hand and bringing down the occiput. The latter plan was recommended by Baudeloeque, and is even yet followed by some accoucheurs. Thus 'Dr. Hodge 1 advises it in all cases in which face presentation is detected at the brim ; but although it might not have been attended with evil consequences in his experienced hands, it is certainly altogether unnecessary, and would infallibly lead to most serious results if generally adopted. It may, however, be allowable in certain cases in which the face remains above the brim, and re- fuses to descend into the pelvic cavity. Even then it is questionable whether podalic version should not be preferred, as being easier of performance, giving, when once effected, a much more complete con- trol over delivery, and being less painful to the mother. Version is certainlv preferable to the application of the forceps, which are in- troduced with difficulty in so high a position of the face, and do nut take a secure hold. When once the face has descended into the pelvis, difficulties may arise from two chief causes; uterine inertia, and non-rotation for- wards of the chin. The treatment of the former class must be based on precisely the same general principles as in dealing with protracted labor in vertex presentations. The forceps may be applied with advantage, bearing in mind the necessity of getting the chin under the pubis, and, when this has been effected, of directing the traction forwards, so as to make the occiput slowly and gradually distend and sweep over the perineum. Difficulties arising ■ from Non-rotation of Chin Forwards. — The second class of difficult face cases are much more important, and may try the resources of the accoucheur to the utmost. Our first en- deavor must be, if possible, to secure the anterior rotation of the chin. For this purpose various manoeuvres are recommended. By some, we are advised to introduce the finger cautiously into the mouth of the child, and draw the chin forwards during a pain ; by others, to pass the finger up behind the occiput and press it backwards during the pain. Schroeder points out that the difficult}' often depends on the fact of the head not being sufficiently extended, so that the chin is not on a lower level than the forehead ; and that rotation is best promoted by pressing the forehead upwards with the finger during a pain, so as to cause the chin to descend. Penrose 2 believes that non-rotation is generally caused by the want of a point tfappui be- low, on account of the face being able to descend to the floor of the pelvis, and that, if this is supplied, rotation will take place. In such cases he applies the hand, or the blade of the forceps, so as to 1 System of Obstetrics, p. 335. 2 Amer. Supplement to Obst. Journ., April, 1876. 312 LABOR. press on the posterior cheek. By this means the necessary " point d'appui" is given ; and he relates several interesting cases in which this simple manoeuvre was effectual in rapidly terminating a pre- viously lengthy labor. Any, or all, of these plans may be tried. We must bear in mind, in using them, that rotation is often delayed until the face is quite at the lower pelvic strait, so that we need not too soon despair of its occurring. If, however, in spite of these manoeuvres, it do not take place, what is to be done ? If, the head be not too low down in the pelvis to admit of version, that would be the simplest and most effectual plan. I have succeeded in delivering in this way, when all attempts at producing rotation had failed ; but generally the face will be too decidedly engaged to render it possible. An attempt might be made to bring down the occiput by the vectis, or by a fillet ; but if the face be in the pelvic cavity, it is hardly possible for this plan to succeed. An endeavor may be made to pro- duce rotation by the forceps; but it should be remembered that rota- tion of the face mechanically in this way is very difficult, and much more likely to be attended with fatal consequences to the child, than when it is effected by the natural efforts. In using forceps for this purpose, the second or pelvic curve is likely to prove injurious, and a short straight instrument is to be preferred. If rotation be found to be impossible, an endeavor may be made to draw the face down- wards, so as to get the chin over the perineum, and deliver in the mento-posterior position ; but, unless the child be small, or the pelvis very capacious, the attempt is unlikely to succeed. Finally, if all these means fail, there is no resource left but lessening the size of the head by craniotomy, a dernier ressort which, fortunately, is very rarely required. Brow Presentations. — It sometimes happens that the head is par- tially extended, so as to bring the os frontis into the brim of the pelvis, and form what is described as a " brow presentation." Should the head descend in this manner, the difficulties, although not insupera- ble, are apt to be very great, from the fact that the long cervico- frontal diameter of the head is engaged in the pelvic cavity. The diagnosis is not difficult, for the os frontis will be detected by its rounded surface; while the anterior fontanelle is within reach in one direction, the orbit, and root of the nose, in another. Spontaneously converted into either Face or Vertex Presentations. — Fortunately, in the large majority of cases brow presentations are spontaneously converted into either vertex or face presentations, according as flexion or extension of the head occurs; and these must be regarded as the desirable terminations and the ones to be favored. For this purpose upward pressure must be made on one or other ex- tremity of the presenting part during a pain, so as to favor flexion, or extension; or, if the parts be sufficiently dilated, an attempt may be made to pass the hand over the occiput and draw it down, thus performing cephalic version. The latter is the plan recommended by Hodge, who describes the operation as easy. It is questionable> however, if a well-marked brow presentation be distinctly made out while the head is still at the brim, whether podalic version would DIFFICULT OCCIPITO-POSTERIOR POSITIONS. ol3 not be the easiest and best operation, If the forehead have descended too low for this, and if the endeavor to convert it into either a face or vertex presentation fail, the forceps will, probably, be required. In such cases the face generally turns towards the pubes, the supe- rior maxilla becomes fixed behind the pubic arch, and the occiput sweeps over the perineum.- Very great difficulty is likely to be ex- perienced, and if conversion into either a vertex or face presentation cannot be effected, craniotomy is not unlikely to be required. CHAPTER VII. DIFFICULT OCCIPITO-POSTERIOK POSITIONS. A FEW words may be said in this place as to the management of occipito-posterior positions of the head, especially of those in which forward rotation of the occiput does not take place. It has already been pointed out that, in the large majority of these cases, the occiput rotates forward without any particular difficulty, and the labor termi- nates in the usual way, with the occiput emerging under the arch of the pubis. Rotation Fomcards of the Occiput. — In a certain number of cases such rotation does not occur, and difficult}^ and delay are apt to fol- low. The proportion of cases in which face to pubis terminations of occipito-posterior positions occurs has been variously estimated, and they are certainly more common than most of our text-books lead us to expect. Dr. Uvedale "West, 1 who studied the subject with great care, found that labor ended in this way in 79 out of 2585 births, all these deliveries being exceptionally difficult. Causes of Face to Puhis Delivery. — He believed that forward rota- tion of the head is prevented by the absence of flexion of the chin on the sternum, so that the long occipito-frontal, instead of the short sub-occipito-bregmatic, diameter of the head is brought into contact with the pelvic diameter ; hence the occiput is no longer the lowest point, and is not subjected to the action of those causes which pro- duce forward rotation. Dr. Macdonald, who has written a thoughtful paper on the subject, 2 believes that the non-rotation forward of the occiput is chiefly due to the large size of the head, in consequence of which "the forehead gets so wedged into the pelvis anteriorly that its tendency to slacken and rotate forward does not come into play." Dr. West's explanation, which has an important bearing on the management of these cases, seems to explain most correctly the non-occurrence of the natural rotation. 1 Cranial Presentations, p. 33. 2 Edin. Med. Jour., Oct. 1874. 21 314 LABOR. The important question for us to decide is, how can we best assist in the management of cases of this kind when difficulties arise, and labor is seriously retarded? Mode of Treatment. — Dr. West, insisting strongly on the necessity of complete flexion of the chin on the sternum, advises that this should be favored by upward pressure on the frontal bone, with the view of causing the chin to approach the sternum, and the occiput to descend, and thus to come within the action of the agencies which favor rotation. Supposing the pains to be strong, and the fontanelle to be readily within reach, we may, in this way, very possibly favor the descent of the occiput; and without injuring the mother, or in- creasing the difficulties of the case in the event of the manoeuvre failing. The beneficial effects of this simple expedient are some- times very remarkable. In two cases in which I recently adopted it, labor, previously delayed for a length of time without any appa- rent progress, although the pains were strong and effective, was in each instance rapidly finished almost immediately after the upward pressure was applied. The rotation of the face backwards may at the same time be favored by pressure on the pubic side of the fore- head during the pains. Traction on the Occiput. — Others have advised that the descent of the occiput should be promoted by downward traction, applied by the vectis or fillet. The latter is the plan specially advocated by Hodge ; l and the fillet certainly finds one of its most useful applications in cases of this kind, as being simpler of application, and probably more effective, than the vectis. Over-active Endeavors at Assistance should be avoided. — Although any of these methods may be adopted, a word of caution is necessary against prolonged and over-active endeavors at producing flexion and rotation when that seems delayed. All who have watched such cases must have observed- that rotation often occurs spontaneously at a very advanced period of labor, long after the head has been pressed clown for a considerable time to the very outlet of the pelvis, and when it seems to have been making fruitless endeavors to emerge; so that a little patience will often be sufficient to overcome the difficulty. [ Version by the Vertex. — In order to adapt this section to American practice, I addressed letters of inquiry upon the management of occipito-posterior positions to several obstetrical professors and teachers, and have prepared this article accordingly. 1. " In primitive oblique occipito-posterior positions of the head, nature will almost, without exception, cause spontaneous rotation of the occiput to the symphysis pubis; but to favor this movement the bag of waters should be preserved." 2. "Spontaneous rotation, as a rule, does not begin until the head meets with resistance from the floor of the pelvis ; hence no effort to force rotation should be made until nature has proved herself inadequate." 3. Where rotation forward is prevented, it is probablj- clue to the 1 System of Obstetrics, p. 308. DIFFICULT OCCIPITO-POSTERIOR POSITIONS. 315 position of the occiput having been originally directly backward, and only becoming oblique after the descent of the head into the pelvis, the position of the child's body preventing the anterior move- ment of its occiput. That is, the sixth position of Hodge has changed into a fourth or fifth, but will not without assistance become a first or second. •i. If, then, rotation is not spontaneous after the head reaches the floor of the pelvis, version by the vertex will not take place except it be forced by the vectis or forceps. One professor writes, "I have thus far succeeded so well" (i. e., by the vectis and forceps), "that I recall but one instance in which the head was born with the occiput looking to the sacrum.' 1 Another says he applies the forceps and lets " the progress of the head deter- termine the mode by which it shall make its exit ; not trying to turn by the forceps." In the "primitive occipito- sacral position changed to oblique, or in the more rare unchanged sixth position of Hodge, if the head is large or the pelvis in any way obstructed, the case may require to be termi- nated by craniotomy. It is even possible to rotate the occiput from the sacrum to the pubes and save the child, as this was once done by the late Dr. William Harris, of Philadelphia. Of course, the body must have partly rotated. Use of the Hand in Occipito -posterior Positions. — The introduction of the hand for the purpose of effecting version by the vertex, under an anesthetic, was strongly advocated by the late Dr. John S. Parry, 1 of Philadelphia, who certainly used his own, which was small and thin, to very great advantage. Several very small-handed accoucheurs in this city have found their hands of very great value in some cases of obstetrics ; and it is said that a celebrated Neapolitan obstetrician owes his great popularity to the advantage thus derived. It will not do to advocate a general use of the hand in obstetric practice, as few have such as it would be safe to use, especially in primiparas. I have known a primipara labor for hours to deliver herself of a foetus in an occipito-posterior position, when all that was needed was the assistance of a suitable hand during three pains to bring the occiput fairly under the arch of the pubis. — Ed.] When necessary the Forceps may be Used. — In the event of assist- ance being absolutely required, there is no reason why the forceps should not be used. The instrument is not more difficult to apply than under ordinary circumstances, nor, as a rule, is much more trac- tion necessary. Dr. Macdonald, indeed, in the paper already alluded to, maintains that in persistent occipito-posterior positions there is almost always a want of proportion between the head and the pelvis, and that, therefore, the forceps will be generally required, and he prefers them to any artificial attempts at rectification. Some pecu- liarities in the mode of cleliveiy are necessary to bear in mind. In most works it is taught, that the operator should pay special atten- tion to the rotation of the head, and should endeavor to impart this \} Am. Jour. Obstetrics, May, 1875.] 316 LABOR. movement by turning the occiput forward during extraction. Thus Tyler Smith says, "In delivery with the forceps in occipito-posterior presentations, the head should be slowly rotated during the process of extraction so as to bring the vertex towards the pubic arch, and thus convert them into occipitoanterior presentations." The clanger accompanying any forcible attempt at artificial rotation will, how- ever, be evident on slight consideration. It is true that in many cases, when simple traciion is applied, the occiput will, of itself, ro- tate forwards, carrying the instrument with it. But that is a very different thing from forcibly twisting round the head with the blades of the forceps, without any assurance that the body of the child will- follow the movement. It is impossible to conceive that such violent interference should not be attended with serious risk of injury to the neck of the child. If rotation do not occur, the fair inference is, that the head is so placed as to render delivery with the face to the pubis the best termination, and no endeavor should be made to pre- vent it. This rule of leaving the rotation entirely to nature, and using traction only, has received the approval of Barnes and most modern authorities, and is the one which recommends itself as the most scientific and reasonable. Objection to Curved Instruments in such Cases. — These are cases in which the pelvic curve of the forceps is of doubtful utility. When applied in the usual way the convexity of the blades points back- wards. If rotation accompany extraction, the blades necessarily follow the movement of the head, and their convex edges will turn forwards. It certainly seems probable that such a movement would subject the maternal soft parts to considerable risk. I have how- ever, more than once seen such rotation of the instrument happen without any apparent bad result ; but the dangers are obvious. Hence it would be a wise precaution, either to use a pair of straight forceps for this particular operation, or to remove the blades and leave the case to be terminated by the natural powers, when the head is at the lower strait, and rotation seems about to occur. When there is no rotation, more than usual care should be taken with the perineum, which is necessarily much stretched by the rounded occiput. Indeed the risk to the perineum is very considerable, and, even with the greatest care, it may be impossible to avoid laceration. Bearing these precautions in mind, delivery with the forceps in occipito-posterior positions offers no special difficulties or dangers. PRESENTATIONS OF SHOULDER, ETC. 317 CHAPTER VIII. PRESENTATIONS OF THE SHOULDER, ARM, OR TRUNK — COMPLEX PRESENTATIONS — PROLAPSE OF THE FUNIS. In the presentations already considered the long diameter of the foetus corresponded with that of the uterine cavity, and, in all of them, the birth of the child by the maternal efforts was the general and normal termination of labor. We have now to discuss those important cases in which the long diameter of the foetus and uterus do not correspond, but in which the long foetal diameter lies ob- liquely across the uterine cavity. In the large majority of these it is either the shoulder, or some part of the upper extremity, that presents; for it is an admitted fact that although other parts of the body, such as the back, or abdomen, may, in exceptional cases, lie over the os at an early period of labor, yet, as labor progresses, such presenta- tions are almost always converted into those of the upper extremity. For all practical purposes we may confine ourselves to a considera- tion of shoulder presentations; the further subdivision of these into elbow or liand presentations being no more necessary than the division of pelvic presentations into breech, knee, and footling cases, since the mechanism and management are identical, whatever part of the upper extremity presents. Delivery by the Natural Powers is quite Exceptional, — There is this great distinction between the presentations we are now considering and those already treated of, that, on account of the relations of the foetus to the pelvis, delivery by the natural powers is impossible, except under special and very unusual circumstances that can never be relied upon. Intervention on the part of the accoucheur is, there- fore, absolutely essential, and the safety of both the mother and child depends upon the early detection of the abnormal position of the foetus ; for the necessary treatment, which is comparatively easy and safe before labor has been long in progress, becomes most diffi- cult and hazardous if there have been much delay. Position of the Foetus. — Presentations of the upper extremity or trunk are often spoken of as "transverse preservations" or " cross births ;" but both of these terms are misleading, as they imply that the foetus is placed transversely in the uterine cavity, or that it lies directly across the pelvic brim. As matter of fact, this is never the case, for the child lies obliquely in the uterus, not indeed in its long axis, but in one intermediate between its long and transverse diameters. Divided into Dorso-anterior and Dor so- posterior Positions. — Two great divisions of shoulder presentations are recognized; the one in which the back of the child looks to the abdomen of the mother 318 LABOR. (Fig. 112), and the other in which the back of the child is turned towards the spine of the mother (Fig. 113). Each of these is sub- Fig. 112. Borso-anterior Presentation of the Arm. divided into two subsidiary classes, according as the head of the child is placed in the right or left iliac fossa. Thus in dorso-anterior Fig. 113. Dorso-posterior Presentation of the Arm. positions, if the head lie in the left iliac fossa, the right shoulder of the child presents ; if in the right iliac fossa, the left. So in dorso- posterior positions, if the head lie in the left iliac fossa, the left PRESENTATIONS OF SHOULDER, ETC. 319 shoulder present ; if in the right, the right. Of the two classes the dorso-anterior positions are more common, in the proportion, it is said, of two to one. Causes. — The causes of shoulder presentation are not well known. Amongst those most commonly mentioned are prematurity of the foetus, and excess of liquor amnii ; either of these, by increasing the mobility of the foetus in utero, would probably have considerable influence. The fact that it occurs much more frequently amongst premature births has long been recognized. Undue obliquity of the uterus has probably some influence, since the early pains might cause the presenting part to hitch against the pelvic brim, and the shoulder to descend. An unusually low attachment of the placenta to the inferior segment of the uterine cavity has been mentioned as a predisposing cause. In consequence of this the head does not lie so readily in the lower uterine segment, and is apt to slip up into one of the iliac fossae. This is supposed to explain the frequency of arm presentation in cases of partial or complete placenta prsevia. Danyou and Wigand believe that shoulder presentations are favored by irregularity in the shape of the uterine cavity, especially a rela- tive increase in its transverse diameter. This theory has been gene- rally discredited by writers, and it is certainly not susceptible of proof; but it seems far from unlikely that some peculiarity of shape may exist, not capable of recognition, but sufficient to influence the position of the foetus. How otherwise are we to explain those remark- able cases, many of which are recorded, in which similar malpositions occurred in many successive labors? Thus Joulin refers to a patient who had an arm presentation in three successive pregnancies, and to another who had shoulder presentation in three out of four labors. Certainly, such constant recurrences of the same abnormality could only be explained on the hypothesis of some very persistent cause, such as that referred to. Pinard 1 states that shoulder presentations are seven times more common in multiparas than in primiparoe, in consequence, as he believes, of the laxity of the abdominal walls in the former, which allows the uterus to fall forwards, and thus prevents the head entering the pelvic brim in the latter weeks of pregnancy. It is probable that merely accidental causes have most influence in the production of shoulder presentation, such as falls, or undue pres- sure exerted on the abdomen by badly fitting or tight sta^ys. Partially transverse positions during pregnancy are certainly much more com- mon than is generally believed, and may often be detected by abdominal palpation. The tendency is for such malpositions to be righted either before labor sets in, or in the early period of labor ; but it is quite easy to understand how any persistent pressure, applied in the manner in- dicated, may perpetuate a position which otherwise would have been only temporary. Prognosis and Frequency. — According to Churchill's statistics, shoulder presentations occur about once in 260 cases, that is only slightly less frequently than those of the face. The prognosis to 1 Aimal. d'hyg. pub. et de med., Jan. 1879. 320 LABOR. both the mother and child is much more unfavorable ; for he esti- mates that out of 235 cases 1 in 9 of the mothers, and half the chil- dren were lost. The prognosis in each individual case will, of course, vary much with the period of delivery at which the malposition is recognized. If detected early, interference is easy, and the prognosis ought to be good ; whereas there are few obstetric difficulties more trying than a case of shoulder presentation, in which the necessary treatment has been delayed until the presenting part has been tightly jammed into the cavity of the pelvis. Diagnosis. — Bearing this fact in mind, the paramount necessity of an accurate diagnosis will be apparent ; and it is specially important that we should be able not only to detect that a shoulder or arm is presenting, but that we should, if possible, determine which it is, and how the body and head of the child are placed. The existence of a shoulder presentation is not generally suspected, until the first vaginal examination is made during labor. The practitioner -will then be struck with the absence of the rounded mass of the foetal head, and, if the os be open and the membranes protruding, by their elongated form, which is common to this and to other malpresentations. If the presenting part be too high to reach, as is often the case at an early period of labor, an endeavor should at once be made to ascer- tain the fcetal position by abdominal examination. This is the more important, as it is much more easy to recognize presentations of the shoulder in this way than those of the breech or foot ; and, at so early a period, it is often not only possible, but comparatively easy, to alter the position of the foetus by abdominal manipulation alone, and thus avoid the necessity of the more serious form of version. The method of detecting a shoulder presentation by examination of the abdomen has already been described (p. 116), and need not be repeated. The chief points to look for are, the altered shape of the uterus, and two solid masses, the head and the breech, one in either iliac fossa. The facility with which these parts may be recognized varies much in different patients. In thin women, with lax abdomi- nal parietes, they can be easily felt ; while in very stout women, it may be impossible. Failing this method, we must rely on vaginal examinations ; although, before the membranes are ruptured, and when the presenting part is high in the pelvis, it is not always easy to gain accurate information in this way. The difficulty is increased by the paramount importance of retaining the membranes intact as long as possible. It should be remembered, therefore, that when a presentation of the superior extremity is suspected, the necessary examinations should only be made in the intervals between the pains when the membranes are lax, and never when they are rendered tense by the uterine contractions. As either the shoulder, the elbow, or the hand, may present, it will be best to describe the peculiarities of each separately, and the means of distinguishing to which side of the body the presenting part belongs. 1. The shoulder is recognized as a round smooth prominence, at one point of which may often be felt the sharp edge of the acromion. PRESENTATIONS OF SHOULDER. ETC. 321 If the finger can be passed sufficiently high, it may be possible to feel the clavicle, and the spine of the scapula. A still more complete examination may enable us to detect the ribs and the intercostal spaces, which would be quite conclusive as to the nature of the presentation, since there is nothing resembling them in any other part of the body. At the side of the shoulder, the hollow of the axilla may generally be made out. Mode of Diagnosing the Position of the Child. — In order to ascer- tain the position of the child we have to find out in which iliac fossa the head lies. This may be done in two ways : 1st. The head may be felt through the abdominal parietes by palpation ; and 2d, since the axilla always points towards the feet, if it point to the left side the head must lie in the right iliac fossa, if to the right, the head must be placed in the left iliac fossa. Again, the spine of the scapula must correspond to the back of the child, the clavicle to its abdomen; and, by feeling one or other, we know whether we have to do with a dorso-anterior or dorso- posterior position. If we cannot satisfac- torily determine the position by these means, it is quite legitimate practice to bring down the arm carefully, provided the membranes are ruptured, so as to examine the hand, which will be easily recog- nized as right or left. This expedient will decide the point ; but it is one which it is better to avoid, if possible, for it not only slightly increases the difficulty of turning, although perhaps not very mate- rially, but the arm might possibly be injured in the endeavor to bring it down. Differential Diagnosis of the Shoulder. — The only part of the body likely to be taken for the shoulder is the breech; but in that its larger size, the groove in which the genital organs lie, the second prominence formed by the other buttock, and the sacral spinous processes are sufficient to prevent a mistake. 2. The elbow is rarely felt at the os, and may be readily recognized by the sharp prominence of the olecranon, situated between two lesser prominences, the condyles. As the elbow always points towards the feet, the position of the foetus can be easily ascertained. 3. The hand is easy to recognize, and can only be confounded with the foot. It can be distinguished by its borders being of the same thickness, by the fingers being wider apart and more readily sepa- rated from each other than the toes, and above all by the mobility of the thumb, which can be carried across the palm, and placed in apposition with each of the fingers. Mode of Detecting which Hand is Presenting. — It is not difficult to tell which hand is presenting. If the hand be in the vagina, or be^yoncl the vulva, and within easy reach, we recognize which it is by laying hold of it as if we were about to shake hands. If the palm lie in the palm of the practitioner's hand, with the two thumbs in apposition, it is the right hand; if the back of the hand, it is the left. Another simple way is, for the practitioner to imagine his own hand placed in precisely the same position as that of the foetus ; and this will readily enable him to verify the previous diagnosis. A simple rule tells us how the body of the child is placed, for, provided we 322 LABOR. are sure the hand is in a state of supination, the back of the hand points to the back of the child, the palm to its abdomen, the thumb to the head, and the little finger to the feet. Mechanism. — It is perhaps hardly proper to talk of a mechanism of shoulder presentations, since, if left unassisted, they almost inva- riably lead to the gravest consequences. Still, nature is not entirely at fault even here, and it is well to study the means she adopts to terminate these malpositions. Terminations. — There are two possible terminations of shoulder presentation. In one, known as " spontaneous version" some other part of the foetus is substituted for that originally presenting ; in the other, "spontaneous evolution" the foetus is expelled by being squeezed through the pelvis, without the originally presenting part being withdrawn. It cannot be too strongly impressed on the mind that neither of these can be relied on in practice. Spontaneous version may occasionally occur before, or immediately after, the rupture of the membranes, when the foetus is still readily movable within the cavity of the uterus. A few authenticated cases are recorded in which the same fortunate issue took place after the shoulder had been engaged in the pelvic brim for a considerable time, or even after prolapse of the arm ; but its probability is neces- sarily much lessened under such circumstances. Either the head or the breech may be brought down to the os in place of the original presentation. The precise mechanism of spontaneous version, or the favoring circumstances, are not sufficiently understood to justify any positive statement with regard to it. Cazeaux believed that it is produced by partial or irregular con- traction of the uterus, one side contracting energetically, while the other remains inert, or only contracts to a slight degree. To illus- trate how this may effect spontaneous version, let us suppose that the child is lying with the head in the left iliac fossa. Then if the left side of the uterus should contract more forcibly than the right, it would clearly tend to push the head and shoulder to the right side, until the head "came to present instead of the shoulder. A very in- teresting case is related by Geneuil, 1 in which he was present during spontaneous version, in the course of which the breech was substi- tuted for the left shoulder more than four hours after the rupture of the membranes. In this case the uterus was so tightly contracted that version was impossible. He observed the side of the uterus opposite the head contracting energetically, the other remaining flac cid, and eventually the case ended without assistance, the breech pre- senting. The natural moulding action of the uterus, and the greater tendency of the long axis of the child to lie in that of the uterus, no doubt assist the transformation, and much must depend on the mo- bility of the foetus in any individual case. That such changes often take place in the latter weeks of preg- nancy, and before labor has actually commenced, is quite certain and 1 Ann. de Gynecologie, v. v. 1876. PRESENTATIONS OF SHOULDER, ETC. 323 they are probably much more frequent than is generally supposed. Wiien spontaneous version does occur, it is, of course, a most favor- able event ; and the termination and prognosis of the labor are then the same as if the head or breech had originally presented. Spontaneous Evolution. — The mechanism of spontaneous evolution, since it was first clearly worked oat by Douglas, has been so often and carefully described, that we know precisely how it occurs. Al- though every now and then a case is recorded in which a living child has been born by this means, such an event is of extreme rarity ; and there is no doubt of the accuracy of the general opinion, that spontaneous evolution can only happen when the pelvis is un- usually roomy and the child small : and that it almost necessarily involves the death of the foetus, on account of the immense pressure to which it is subjected. Two varieties are described, in one of which the head is first born, in the other the breech ; in both the originally presenting arm re- mained prolapsed. The former is of extreme rarity, and is believed only to have happened with very premature children, whose bodies were small and flexible, and when traction had been made on the presenting arm. Under such circumstances it can hardly be called a natural process, and we may confine our attention to the latter and more common variety. What takes place is as follows : The presenting arm and shoulder are tightly jammed down, as far as is possible, by the uterine con- tractions, and the head becomes stronglv flexed on the shoulder. As Fig. 114. Commencing Spontaneous Evolution. much of the body of the foetus as the pelvis will contain becomes engaged, and then a movement of rotation occurs, Avhich brings the body of the child nearly into the antero-posterior diameter of the pelvis (Fig. 114). The shoulder projects under the arch of the pubis, the head lying above the symphysis, and the breech near the 324 LABOR. sacro-iliac synchondrosis. It is essential that the head should lie forwards above the pubes, so that the length of the neck may per- mit the shoulder to project under the pubic arch, without any part of the head entering the pelvic cavity. The shoulder and neck of the child now become fixed points, round which the body of the child rotates, and the whole force of the uterine contractions is ex- pended on the breech. The latter, with the body, therefore, becomes more and more depressed, until, at last, the side of the thorax reaches the vulva, and, followed by the breech and inferior extremities, is slowly pushed out (Fig. 115). As soon as the limbs are born the head is easily expelled. Fig. 115. Spontaneous Evolution further advanced. The enormous pressure to which the body is subjected in this process can readily be understood. As regards the practical bearings of this termination of shoulder presentations, all that need be said is, that, if we should happen to meet with a case in which the shoulder and thorax were so strongly depressed that turning was impossible, and in which it seemed that nature was endeavoring to effect evolution, we would be justified in aiding the descent of the breech by traction on the groin, before resorting to the difficult and hazardous operation of embryotomy or decapitation. Treatment. — It is unnecessary to describe specially the treatment of shoulder presentation, since it consists essentially in performing the operation of turning, which is fully described elsewhere. It is only needful here to insist on the advisability of performing the operation in the way which involves the least interference with the uterus. Hence if the nature of the case be detected before the mem- branes are ruptured, an endeavor should be made — and ought gen- erally to succeed — to turn by external manipulation only- If we can succeed in bringing the breech or head over the os in this way, the case will be little more troublesome than an ordinary presentation of these parts. Failing in this, turning by combined external and PRESENTATIONS OF SHOULDER, ETC. 325 internal manipulation should be attempted ; and the introduction of the entire hand should be reserved for those more troublesome cases in which the waters have long drained away, and in which both these methods are inapplicable. Should ah these means fail, we must resort to the mutilation of the child by embryulcia or decapitation, probably the most difficult and dangerous of all obstetric operations. 1 Complex Presentations. — There are various so-called complex pre- sentations in which more than one part of the foetal body presents. Thus we may have a hand or a foot presenting with the head, or a foot and hand presenting simultaneously. The former do not neces^ sarily give rise to any serious difficult)', for there is generally suffi- cient room for the head to pass. Indeed it is unlikely that either the haud or foot should enter the pelvic brim with the head, unless the head was unusually small, or the pelvis more than ordinarily capacious. As regards treatment, it is, no doubt, advisable to make an attempt to replace the hand or foot by pushing it gently above the head in the intervals between the pains, and maintaining it there until the head be fully engaged in the pelvic cavity. The engage- ment of the head can be hastened by abdominal pressure, which will prove of great value. Failing this, all we can do is to place the presenting member at the part of the pelvis where it will least im- pede the labor, and be the least subjected to pressure ; and that will generally be opposite the temple of the child. As it must obstruct the passage of the head to a certain extent, the application of the forceps may be necessary. When the feet and hands present at the same time, in addition to the confusing nature of the presentation from so many parts being felt together, there is the risk of the hands coming down, and converting the case into one of arm presentation. It is the obvious duty of the accoucheur to prevent this bv insuring the descent of the feet, and traction should be made on them, either with the fingers or with a lac, until their descent, and the ascent of the hands, are assured. Dorsal Displacement of the Arm. — In connection with this subject may be mentioned the curious dorsal displacement of the arm first described by Sir James Simpson, 2 in which the forearm of the child becomes thrown across and behind the neck. The result is the for- mation of a ridge or bar, which prevents the descent of the head into the pelvis by hitching against the brim (Fig. 116). The difficulty of diagnosis is very great, for the cause of obstruction is too high up to be felt. But if we meet with a case in which the pelvis is roomy and the pains strong, and yet the head does not descend after an adequate time, a full exploration of the cause is essential. For this purpose we would naturally put the patient under chloroform, and 1 [In nine instances in the United States, the Cesarean section has been performed under these circumstances with a successful result to the mother in six. One who died was three days under a midwife ; another twenty-six hours, the woman having ruptured the membranes early and given ergot ; and the third was exhausted bv long labor. All three died of exhaustion. — Ed.] 2 Selected Obst. Works, vol. i. 326 LABOR. pass the hand sufficiently high. We might then feel the arm in its abnormal position. That was what took place in a case under my own care, in which I failed to get the head through the brim with the forceps, and eventually delivered by turning. The same course was Fig. 116. Fig. 117. Dorsal Displacement of the Arras. Dorsal Displacement of the Arms in Footling Presentations. (After Fames.) adopted by my friend Mr. Jardin Murray in a similar case. 1 Simp- son advises that the arm should be brought down so as to convert the case into an ordinary hand and head presentation. This, if the arm be above the brim, must always be difficult, and I believed the simpler and more effective plan is podalic version. A similar dis- placement may cause some difficulty in breech presentations, and after turning (Fig. 117). Delay here is easier of diagnosis, since the obstacle to the expulsion will at once lead to careful examination. By carrying the body of the child well backwards, so as to enable the finger to pass behind the symphysis pubis and over the shoulder, it will generally be easy to liberate the arm. Prolapse of the Umbilical Cord. — It occasionally happens that the umbilical cord falls clown past the presenting part (Fig. 118), and is apt to be pressed between it and the walls of the pelvis. The conse- quence is, that the foetal circulation is seriously interfered with, and 1 Med. Times and Gaz., 1861. PRESENTATIONS OF SHOULDER, ETC. 327 the death of the child from asphyxia is a common result. Hence prolapse of the funis is a very serious complication of labor in so far as the child is concerned. Prolapse of the Umbilical Cord. Frequency. — Fortunately it is not a very frequent occurrence. Churchill calculates that out of over 105,000 deliveries it was met with once in 240 cases, and Scanzoni once in 254. Its frequency varies much under different circumstances, and in different places. "We find from Churchill's figures a remarkable difference in the pro- portional number of cases observed in France, England, and Germany, viz., 1 in 446 J, 1 in 2 07 J, and 1 in 156, respectively. Great as is the proportion referred to Germany in these figures, it has been found to be exceeded in special districts. Thus Engelman records 1 case out of 94 labors in the Lying-in Hospital at Berlin, and Michaelis 1 in 90 in that of Kiel. These remarkable differences are at first sight not easy to account for. Dr. Simpson suggests, with consider- able show of probability, that the difference in frequency in England, France, and Germany, may depend on the varjnng positions in which lying-in women are placed during labor in each county. In France, where, although the patient is laid on her back, the pelvis is kept elevated, the complication occurs least frequently; in England, where she lies on her side, more often; and in Germany, where she is placed on her back with her shoulders raised, most often. The special frequency of prolapsed funis in certain districts, as in Kiel, is supposed by Engelman 1 to depend on the prevalence of rickets, and consequently of deformed pelvis, which we shall presently see is 1 Amer. Journ. of Obst., vol. vi. 828 LABOR. probably one of the most frequent and important causes of the accident. Prognosis. — With regard to the danger attending prolapsed funis, as far as the mother is concerned, it may be said to be altogether unimportant ; but the universal experience of obstetricians points to the great risk to which the child is subjected. Scanzoni calculates that 45 per cent, only of the children were saved ; Churchill estimated the number at 47 per cent.; thus, under the most favorable circum- stances, this complication leads to the death of more than half the children. Engelman found that out of 202 vertex presentations only 36 per cent, of the children survived. The mortality was not nearly so great in other presentations ; 68 per cent, of the cases in which the child presented with the feet were saved, and 50 per cent, in original shoulder presentations. The reason of this remarkable dif- ference is, doubtless, that in vertex presentations the head fits the pelvis much more completely, and subjects the cord to much greater pressure; while in other presentations the pelvis is less completely filled, and the interference with the circulation in the cord is not so great. Besides, in the latter case, the complication is detected early, and the necessary treatment sooner adopted. The foetal mortality is considerably greater in first labors; a result to be expected on account of the greater resistance of the soft parts, and the consequent prolongation of the labor. Causes. — The causes of prolapse of the funis are any circumstances which prevent the presenting part accurately fitting the pelvic brim. Hence it is much more frequent in face, breech, or shoulder, than in vertex presentations, and is relatively more common in footling and shoulder presentations than in any other. Amongst occasional acci- dental predisposing causes may be mentioned early rupture of the membranes, especially if the amount of liquor amnii be excessive, as the sudden escape of the fluid washes down the cord ; undue length of the cord itself; or an unusually low placental attachment. Engel- man attaches great importance to slight contraction of the pelvis, and states that in the Berlin Lying-in Hospital, where accurate measurements of the pelvis were taken in all cases, it was almost invariably found to exist. The explanation is evident, since one of the first results of pelvic contraction is to prevent the ready engage- ment of the presenting part in the pelvic brim. Diagnosis. — The diagnosis of cord presentation is generally devoid of difficulty ; but if the membranes are still unruptured, it may not always be^ quite easy to determine the precise nature of the soft structures felt through them, as they recede from the touch. If the pulsations of the cord can be felt through the membranes, all diffi- culty is removed. After the membranes are ruptured, there is nothing that it can well be mistaken for. Importance of Determining the Pulsatio7is of the Cord. — The im- portant point to determine in such a case is whether the cord be pulsating or not ; for if pulsations have entirely ceased, the inference is that the child is dead, and the case may then be left to nature without further interference. It is of importance, however, to be PRESENTATIONS OF SHOULDER, ETC 329 careful ; for, if the examination be made during a pain, the circula- tion might be only temporarily arrested. The examination, there- fore, should be made during an interval, and a loop of the cord pulled down, if necessary, to make ourselves absolutely certain on this point. Amount of Cord Prolapsed. — The amount of the prolapse varies much. Sometimes only a knuckle of the cord, so small as to escape observation, is engaged between the pelvis and presenting part. Under such circumstances the child may be sacrificed without any suspicion of danger having arisen. More often the amount pro- lapsed is considerable ; sometimes so as to lie in the vagina in a long- loop, or even to protrude altogether beyond the vulva. Treatment. — In the treatment the great indication is to prevent the cord from being unduly pressed on, and all our endeavors must have this object in view. If the presentation be detected before the full dilatation of the cervix, and when the membranes are unruptured, we must try to keep the cord out of the way ; to preserve the mem- branes intact as long as possible, since the cord is tolerably protected as long as it is surrounded by the liquor amnii ; and to secure the complete dilatation of the os, so that the presenting part maj^ engage rapidly and completely. Postural Treatment. — Much may be done at this time by the pos- tural treatment, which we chiefly owe to the ingenuity of Dr. T. (rail- lard Thomas, of New York, whose writings familiarized the profession with it, although it appears that a somewhat similar plan had been Fig. 119. Postural Treatment of Prolapse of the Cord. occasionally adopted previously. Dr. Thomas's method is based on the principle of causing the cord to slip back into the uterine cavity by its own weight, For this purpose the patient is placed on her hands and knees, with the hips elevated, and the shoulders resting on a lower level (Fig. 119). The cervix is then no longer the most dependent portion of the uterus, and the anterior wall of the uterus 22 330 LABOR. forms an inclined plane down which the cord slips. The success of this manoeuvre is sometimes very great, but by no means always so. It is most likely to succeed when the membranes are unruptured. If, when adopted, the cord slip away, and the os be sufficiently dilated, the membranes may be ruptured, and engagement of the head pro- duced by properly applied uterine pressure. Sometimes the position is so irksome that it is impossible to resort to it. Postural treatment is not even then altogether impossible, for by placing the patient on the side opposite to that of the prolapse, so as to relieve the cord as much as possible from pressure, and at the same time elevating the hips by a pillow, it may slip back. Even after the membranes are ruptured, postural treatment in one form or another may succeed; and, as it is simple and harmless, it should certainly be always tried. Attempts at reposition, by one or other of the methods described below, may also occasionally be facilitated by trying them when the patient is placed in the knee-shoulder position. Artificial Reposition. — Failing by postural treatment, or in combi- nation with it, it is quite legitimate to make an attempt to place the cord beyond the reach of dangerous pressure by other methods. Unfortunately reposition is too often disappointing, difficult to effect, and very frequently, even when apparently successful, shortly fol- lowed bv a fresh descent of the cord. Provided the os be fully dilated, and the presenting head engaged in the pelvis (for reposition may be said to be hopeless when any other part presents), perhaps the best way is to attempt it by the hand alone. Probably the simplest and most effectual method is that recommended by McClin- tock and Hardy, who advise that the patient should lie on the oppo- site side to the prolapsed cord, which should then be drawn towards the pubis as being the shallowest part of the pelvis. Two or three fingers may then be used to push the cord past the head, and as high as they can reach. They must be kept in the pelvis until a pain comes on, and then very gently withdrawn, in the hope that the cord may not again prolapse. During the pain external pressure may very properly be applied to favor descent of the head. This manoeu- vre may be repeated during several successive pains, and may event- ually succeed. The attempt to hook the cord over the foetal limbs, or to place it in the hollow of the neck, recommended in many works, involves so deep an introduction of the hand that it is obvi- ously impracticable. Instruments used for Reposition.- — Various complex instruments have been invented to aid reposition (Fig. 120), but even if we pos- sessed them they are not likely to be at hand when the emergency arises. A simple instrument may be improvised out of an ordinary male elastic catheter, by passing the two ends of a piece of string through it, so as to leave a loop emerging from the eye of the cathe- ter. This is passed through the loop of prolapsed cord, and then fixed in the eye of the catheter by means of the stilette. The cord is then pushed up into the uterine cavity by the catheter, and liber- ated by withdrawing the stilette. Another simple instrument may PRESENTATIONS OF SHOULDER, ETC. 331 be made by cuttting a bole in a piece of wbale- Fig. 120. bone. A piece of tape is tben passed tbrougb tbe loop of tbe cord, and the ends threaded tbrougb tbe eye cut in tbe whalebone. By tightening tbe tape the whalebone is held in close apposition to the cord, and the whole is passed as high as possi- ble into the uterine cavity. The tape can easily be liberated by pulling one end. If preferred, the cord can be tied to tbe whalebone, which is left in utero until the child is born. Nothing need be said as to the various other methods adopted for keeping up the cord, such as the insertion of pieces of sponge, or tying tbe cord in a bag of soft leather, since they are generally admitted to be quite useless. Treatment when Reposition Fails. — It only too often happens that all endeavors at reposition fail. The subsequent treatment must then be guided by the circumstances of the case. If the pelvis be roomy, and the pains strong, especially in a multipara, we may often deem it advisable to leave tbe case to nature, in the hope that tbe head may be pushed through before pressure on tbe cord has had time to prove fatal to the child. Under such circumstances the patient should be urged to bear down, and the descent of the bead pro- moted by uterine pressure, so as to get the second stage completed as soon as possible. If the head be within easy reach, the application of the forceps is quite justi- fiable, since delay must necessarily involve the death of the child. During this time the cord should be placed, if possible, opposite one or other sacro-iliac synchondrosis, according to the position of the head, as the part of the pelvis where there is most room, and where the pressure would consequently be least prejudicial. If we have to do with a case in which the head has not descended into the pelvis, and postural treatment and reposition have both failed, provided the os be fully dilated, and other circumstances be favorable, turning would undoubtedly offer the best chance to the child. This treat- ment is strongly advocated by Engelman, who found that 70 per cent, of the children delivered in this way were saved. There can be no question that, so far as the interests of tbe child are concerned, it is, under the circumstances indicated, by far tbe best expedient. Turning, however, is by no means always devoid of a certain risk to the mother, and the performance of the operation, in any particu- lar case, must be left to the judgment of the practitioner." A fully dilated os, with membranes unruptured, so that version could be performed by the combined method without the introduction of the hand into the uterus, would be unquestionably tbe most favorable state. If it be not deemed proper to resort to it, all that can be done is to endeavor to save the cord from pressure as much as possible, by one or other of the methods already mentioned. Braun's Apparatus for Replacing the Cord. 332 LABOR. CHAPTER IX. PROLONGED AND PRECIPITATE LABORS. Among the difficulties connected with parturition there are none of more frequent occurrence, and none requiring more thorough knowledge of the physiology and pathology of labor, than those arising from deficient or irregular action of the expulsive powers. The importance of studying this class of labors will be seen when we consider the numerous and very diverse causes which produce them. Evil Effects of Prolonged Labor. — That the mere prolongation of labor is in itself a serious thing, is becoming daily more and more an acknowledged axiom of midwifery practice ; and that this is so is evident when we contrast the statistical returns of such institutions as the Rotunda Lying-in Hospital of late years, with those which were published some twenty or thirty years ago. It may be fairly assumed that the practice of the distinguished heads of that well- known school represents the most advanced and scientific opinion of the day When we find that, less than thirty years ago, the forceps were not used more than once in 310 labors, while according to the report for 1873 the late Master applied them once in 8 labors, it is apparent how great is the change which has taken place. Causes of Prolonged Labor. — Labor may be prolonged from an immense number of causes, the principal of which will require sepa- rate study. Some depend simply on defective or irregular action of the uterus ; others act by opposing the expulsion of the child, as, for example, undue rigidity of the parturient passages, tumors, bony deformity, and the like. Whatever the source of delay, a train of formidable symptoms are developed, which are fraught with peril both to the mother and the child. As regards the mother, they vary much in degree, and in the rapidity with which they become estab- lished. In many cases, in which the action of the uterus is slight, it may be long before serious results follow ; while in others, in which a strongly-acting organ is exhausting itself in futile endeavors to overcome an obstacle, the worst signs of protraction may come on with comparative rapidity. The Influence of the Stage of Labor in Protraction. — The stage of labor in which delay occurs has a marked effect in the production of untoward symptoms. It is a well-established fact that prolongation is of comparatively small consequence to either the mother or child in the first stage, when the membranes are still intact, and when the soft parts of the mother, as well as the body of the child, are pro- tected by the liquor amnii from injurious pressure ; whereas if the membranes have ruptured, prolongation becomes of the utmost im- PROLONGED AND PRECIPITATE LABORS. 333 portance to both as soon as the head has entered the pelvis, when the uterus is strongly excited by reflex stimulation, when the mater- nal soft parts are exposed to continuous pressure, and when the tightly-contracted uterus presses firmly on the foetus and obstructs the placental circulation. It is in reference to the latter class of cases that the change of practice, already alluded to, has taken place, with the most beneficial results both to the mother and child. It must not be assumed, however, that prolongation of labor is never of any consequence until the second stage has commenced. The fallacy of such an opinion was long ago shown by Simpson, who proved, in the most conclusive way, that both the maternal and foetal mortality were greatly increased in proportion to the entire length of the labor; and all practical accoucheurs are familiar with cases in which symptoms of gravity have arisen before the first stage is concluded. Still, relatively speaking, the opinion indicated is un- doubtedly correct. In the present chapter we have to do only with those causes of delay connected with the expulsive powers. Inasmuch, however, as the injurious effects of protraction are similar in kind, whatever be the cause, it will save needless repetition if we consider, once for all, the train of symptoms that arise whenever labor is unduly prolonged. Delay in the First Stage. — As long as the delay is in the first stage only, with rare exceptions, no symptoms of real gravity arise for a length of time ; it may be even for days. There is often, however, a partial cessation of the pains, which in consequence of temporary exhaustion of nervous force, may even entirely disappear for many consecutive hours. Under such circumstances, after a period of rest, either natural or produced by suitable sedatives, they recur with renewed vigor. Symptoms of Protraction in the Second Stage. — A similar temporary cessation of the pains may often be observed after the head has passed through the os uteri, to be also followed by renewed vigorous action after rest. But now any such irregularity must be much more anxiously watched. In the majority of cases any marked alteration in the force and frequency of the pains at this period indicates a much more serious form of delay, which in no long time is accom- panied by grave general symptoms. The pulse begins to rise, the skin to become hot and dry, the patient to be restless and irritable. The longer the delay, and the more violent the efforts of the uterus to overcome the obstacle, the more serious does the state of the patient become. The tongue is loaded with fur, and in the worst cases, dry and black ; nausea and vomiting often become marked ; the vagina feels hot and dry, the ordinary abundant mucous secre- tion being absent ; in severe cases it may be much swollen, and if the presenting part be firmly impacted, a slough may even form. Should the patient still remain undelivered, all these symptoms be- come greatly intensified ; the vomiting is incessant, the pulse is rapid and almost imperceptible, low muttering delirium supervenes, and the patient eventually dies with all the worst indications of profound irritation and exhaustion. 334 LABOR. So formidable a train of symptoms, or even the slighter degrees of them, should never occur in the practice of the skilled obstetrician ; and it is precisely because a more scientific knowledge of the process of parturition has taught the lesson that, under such circumstances, prevention is better than cure, that earlier interference has become so much more the rule. Those who taught that nothing should be done until nature had had every possible chance of effecting delivery, and who, therefore, allowed their patients to drag on in many weary hours of labor, at the expense of «great exhaustion to themselves, and imminent risk to their offspring, made much capital out of the time-honored maxim that "meddlesome midwifery is bad." When this proverb is applied to restrain the rash interference of the ignorant, it is of undeniable value; but, when it is quoted to prevent the scientific action of the experienced, who know precisely when and why to interfere, and who have accquired the indispensable mechanical skill, it is sadly misapplied. State of the Uterus in Protracted Labor. — The nature of the pains and the state of the uterus, in cases of protracted labor, are peculiarly worthy of study, and have been very clearly pointed out by Dr. Braxton Hicks. 1 He shows that, when the pains have apparently fallen off and become few and feeble, or have entirely ceased, the uterus is in a state of continuous or tonic contraction, and that the irritation resulting from this is the chief cause of the more marked symptoms of powerless labor. If, in a case of the kind, the uterus be examined by palpation, it will be found firmly contracted between the pains. The correctness of this observation is beyond question, and it will, no doubt, often be an important guide in treatment. Under such circumstances instrumental interference is imperatively demanded. Conditions and Causes affecting the Expulsive Powers. — In consider- ing the causes of protracted labor, it will be well first to discuss those which affect the expulsive powers alone, leaving those depending on morbid states of the passages for future consideration; bearing in mind, however, that the results, as regards both the mother and the child, are identical, whatever may be the cause of delay, Constitution of the Patient. — The general constitutional state of the patient may materially influence the force and efficiency of the pains. Thus it not unfrequently happens that they are feeble and ineffective in women of very weak constitution, or who are much exhausted by debilitating disease. Cazeaux pointed out that the effects of such general conditions are often more than counterbalanced by flaccidity and Avant of resistance of the tissues, so that there is less obstacle to the passage of the child. Thus in phthisical patients reduced to the last stage of exhaustion, the labor is not unfrequently surprisingly easy. Influence of Tropical Climates. — Long residence in tropical climates causes uterine inertia, in consequence of the enfeebled nervous power 1 Obst. Trans., vol. ix. PROLONGED AND PRECIPITATE LABORS. 335 it produces. It is a common observation that European residents in India are peculiarly apt to suffer from past-partum hemorrhage from this cause. The general mode of life of patients has an unquestion- able effect ; and it is certain that deficient and irregular uterine action is more common in women of the higher ranks of society, who lead luxurious, enervating lives, than in women whose habits are of a more healthy character. Frequent Child-bearing. — Tyler Smith lays much stress on frequent child-bearing as a cause of inertia, pointing out that a uterus which has been very frequently subjected to the changes connected with pregnancy, is unlikely to be in a typically normal condition. It is doubtful, however, whether the uterus of a perfectly healthy woman is affected in this way ; certainly, if child-bearing had undermined her general health, the labors are likely to be modified also. Age of Patient. — Age has a decided effect. In the very young the pains are apt to be irregular, on account of imperfect development of the uterine muscle. Labor taking place for the first time in women advanced in life is also apt to be tedious, but not by any means so invariably as is generally believed. The apprehensions of such patients are often agreeably falsified, and where delay does occur, it is probably more often referable to rigidity and toughness of the parturient passages than to feebleness of the pains. Disorders of the Intestines. — Morbid states of the primas viae fre- quently cause irregular, painful, and feeble contractions. A loaded state of the rectum has often a remarkable influence, as evidenced by the sudden and distinct change in the character of the labor which often follows the use of suitable remedies. Undue distension of the bladder often acts in the same way, more especially in the second stage. When the urine has been allowed to accumulate unduly, the contraction of the accessory muscles of parturition often causes such intense suffering, by compressing the distended viscus, that the pa- tient is absolutely unable to bear down. Hence the labor is carried on by uterine contractions alone, slowly, and at the expense of much suffering. A similar interference with the action of the accessory muscles is often produced by other causes. Thus if labor comes on when the patient is suffering from bronchitis or other chest disease, she may be quite unable to fix the chest by a deep inspiration, and the diaphragm and other accessory muscles cannot act. In the same way they may be prevented from acting Avhen the abdomen is occu- pied by an ovarian tumor, or by ascitic fluid. Mental conditions have a very marked effect. This is so commonly observed that it is familiar to the merest beginner in midwifery prac- tice. The fact that the pains often dimmish temporarily on the entrance of the accoucheur is known to every nurse ; and so also undue excitement, the presence of too many people in the room, over-much talking, have often the same prejudicial effect. Depres- sion of mind, as in unmarried women, and fear and despondency in women who have looked forward with apprehension to their labor, are also common causes of irregular and defective action. 336 LABOR. Excessive Amount of Liquor Amnii. — Undue distension of the uterus from an excessive amount of liquor amnii not unfrequently retards the first stage, by preventing the uterus from contracting efficiently. When this exists, the pains are feeble and have little effect in dilating the cervix beyond a certain degree. This cause may be suspected, when undue protraction of the first stage is associated with an unusu- ally large size and marked fluctuation of the uterine tumor, through which the foetal limbs cannot be made out on palpation. On vaginal examination, the lower segment of the uterus will be found to be very rounded and prominent, while the bag of membranes will not bulge through the os during the acme of the pain. Malpositions of the Uterus. — A somewhat similar cause is undue obliquity of the uterus, which prevents the pains acting to the best mechanical advantage, and often retards the entry of the presenting part into the brim. The most common variety is anteversion, result- ing from excessive laxity of the abdominal parietes, which is espe- cially found in women who have borne many children. Sometimes this is so excessive that the fundus lies over the pubis, and even projects downwards towards the patient's knees. The consequence is that, when labor sets in, unless corrective means be taken, the pains force the head against the sacrum, instead of directing it into the axis of the pelvic inlet. Another common deviation is lateral obliquity, a certain degree of which exists in almost all cases, but sometimes it occurs to an excessive degree. Either of these states can readily be detected by palpation and vaginal examination com- bined. In the former the os may be so high up, and tilted so far backwards, that it may be at first difficult to reach it at all. Irregular and Spasmodic Pains. — Besides being feeble, the uterine contractions, especially in the first stage, are often irregular and spasmodic, intensely painful, but producing little or no effect on the progress of the labor. This kind of case has been alreadj^ alluded to in treating of the use of anoBsthetics (p. 289), and is very com- mon in highly nervous and emotional women of the upper classes. Such irregular contractions do not necessarily depend on mental causes alone, and they are often produced by conditions producing irritation, such as loaded bowels, too early rupture of the membranes, and the like. Dr. Trenholme, of Montreal, 1 believes that such irregu- lar pains most frequently depend on abnormal adhesions between the decidua and the uterine walls, which interfere with the proper dilatation of the os, and he has related some interesting cases in support of this theory. Treatment. — The mere enumeration of these various causes of pro- tracted labor will indicate the treatment required. Some of them, such as the constitutional state of the patient, age, or mental emotion, it is, of course, beyond the power of the practitioner to influence or modify ; but in every case of feeble or irregular uterine action, a careful investigation should be made with the view of seeing if any removable cause exist. For example, the effect of a large enema, ' Obst. Trans. 1873. PROLONGED AND PRECIPITATE LABORS. 337 when we suspect the existence of a loaded rectum, is often very re- markable ; the pams frequently almost immediately changing in character, and a previously lingering labor being rapidly terminated. Excessive distension of the uterus can only be treated by artificial evacuation of the liquor amnii ; and after this is done, the character of the pains often rapidly changes. This expedient is indeed often of considerable value in casts in which the cervix has dilated to a certain extent, but in which no further progress is made, especially if the bag of membranes does not protrude through the os during the pains, and the cervix itself is soft, and apparently readily dilata- ble. Under such circumstances, rupture of the membranes, even before the os is fully dilated, is often very useful. Adherent Membranes. — If we have reason to suspect morbid adhe- sions between the membranes and the uterine walls, an endeavor must be made to separate them by sweeping the finger or a flexible catheter round the internal margin of the os, or puncturing the sac. The former expedient has been advocated by Dr. Inglis, 1 as a means of increasing the pains when the first stage is very tedious, and I have often practised it with marked success. Trenholme's observa- tion affords a rationale of its action. The manoeuvre itself is easily accomplished, and, provided the os be not very high in the pelvis does not give any pain or discomfort to the patient. Uterine Deviations. — Attention should always be paid to remedy- ing any deviations of the uterus from its proper axis. If this be lateral, the proper course to pursue is to make the patient lie on the opposite side to that towards which the organ is pointing. In the more common anterior deviation she should lie on her back, so that the uterus may gravitate towards the spine, and a firm abdominal bandage should be applied. This prevents the organ from falling- forwards, while its pressure stimulates the muscular fibres to in- creased action ; hence it is often very serviceable when the pains are feeble, even if there be no anteversion. Temporary Exhaustion. — In a frequent class of cases, especially in the^ first stage, the pains diminish in force and frequency from fatigue, and the indication then is to give a temporary rest, after which they recommence with renewed vigor. Hence an opiate, such as 20 minims of Battley's solution, which often acts quickest when given in the form of enema, is frequently of the greatest possible value. If this secure a few hours' sleep, the patient will generally awake much refreshed and invigorated. It is important to distinguish this variety of arrested pain from that dependent on actual exhaustion; and this can be done by attention to the general condition of the patient, and especially by observing that the uterus is soft and flaccid in the intervals between the pains, and that there is none of the tonic contraction, indicated by persistent hardness of the uterine parietes. When the pains are irregular, spasmodic, and excessively painful, without producing any real effect, opiates, are also of great service; and it is under such circumstances that chloral is especially valuable. 1 Sydenham Society's Year-Book, 1869. 338 LABOR. Oxytocic Remedies. — Still a large number of cases will arise in which the absence of all removable causes has been ascertained, and in which the pains are feeble and ineffective. We must now proceed to discuss their management. The fault being the want of sufficient contraction, the first indication is to increase the force of the pains. Here the so-called oxytocic remedies come into action ; and, although a large number of these have been used from time to time, such as borax, cinnamon, quinine 1 , and galvanism, practically, the only one in which any reliance is now placed is the ergot of rye. This has long been the favorite remedy for deficient uterine action, and it is a powerful stimulant of the uterine fibres. It has, however, very serious disadvantages, and it is very questionable whether the risks to both mother and child do not more than counterbalance any ad- vantages attending its use. The ergot is given in doses of 15 or 20 grains of the freshly powdered drug diffused in warm water, or in the more convenient form of the liquid extract in doses of from 20 to 30 minims, or, still better, in the form of ergotine injected hypo- dermically, 3 to 4 minims of the hypodermic solution being used for the purpose. In about fifteen minutes after its administration the pains generally increase greatly in force and frequency, and if the head be low in the pelvis, and if the soft parts offer no resistance, the labor may be rapidly terminated. Objections to its Use.- — Were its use always followed by this effect there Avould be little or no objection to its administration. The pains, however, are different from those of natural labor, being strong, per- sistent, and constant. Its effect, indeed, is to produce that yery state of tonic and persistent uterine contraction, which has been already pointed out as one of the chief dangers of protracted labor. Hence if, from any cause, the exhibition of the drug be not followed by rapid delivery, a condition is produced which is serious to the mother; and which is extremely perilous to the child, on account of the tonic contraction of the muscular fibres obstructing the utero-placental circulation. Dr. Hardy found that soon the foetal pulsations fall to 100, and, if delivery be long delayed, they commence to intermit. He also observed that when this occurred the child was always born 1 [Quinia as an oxytocic deserves more than a passing notice, having been very carefully tested by several leading obstetricians of Philadelphia within a few years. According to the observations of Dr. Albert H. Smith, in 42 cases of parturition, it presents the following peculiar characteristics. It has no power in itself to excite uterine contractions, but simply acts as a general stimulant, and promoter of vital energy, and functional activity. In normal labor at full term, its administration in a dose of fifteen grains, is usually followed in as many minutes by a decided increase in the force and frequency of the uterine contractions, changing in some instances a tedious exhausting labor into one of rapid energy, advancing to an early completion. It promotes the permanent tonic contraction of the uterus, after the expulsion of the placenta ; women that had flooded in former labors escaping entirely, there not having been an instance of post-partum hemorrhage in the whole 42 cases. It also diminishes the lochial flow where it had been excessive in former labors, the change being remarked upon by the patients ; and consequently lessens the severity of the after-pains. Cinchonism is very rarely observed as an effect of large doses in parturient women. —Ed.— Trans. Coll. Phys. Philad. 1875, p. 183.] PROLONGED AND PRECIPITATE LABORS. 339 dead, and found that the number of still-born children after ergot has been exhibited was very large ; for out of 30 cases in which he gave it in tedious labor, only 10 of the children were born alive. Nor is its use by any means free from danger to the mother ; a not inconsiderable number of cases of rupture of the uterus have been attributed to its incautious use. Hence, if it is to be given at all, it is obvious that it must be with strict limitations, and after careful con- sideration. It is worthy of note that in the Bethesda Hospital in Dublin, the use of ergot as an oxytocic before delivery, has been pro- hibited by the present trustees. Limitations to its Use. — The cardinal point to remember is that it is absolutely contraindicated unless the absence of all obstacles to rapid delivery has been ascertained. Hence, it is only allowable when the first stage is over, and the os fully dilated ; when the ex- perience of former labors has proved the pelvis to be of ample size ; and when the perineum is soft and dilatable. Perhaps, as has been suggested, the administration of small doses of from 5 to 10 minims of the liquid extract every ten minutes, until more energetic action set in, might obviate some of these risks. Manual Pressure as a Means of Increasing the Uterine Co?itraetions. — If Ave had no other means of increasing defective uterine contrac- tions at our disposal, and if the choice lay only between the use of ergot and instrumental delivery, there might not be so much objec- tion to a cautious use of the drug in suitable cases. We have, how- ever, a means of increasing the force of the uterine contractions so much more manageable, and so much more resembling the natural process, that I believe it to be destined to entirely supersede the ad- ministration of ergot. This is the application of manual pressure to the uterus through the abdomen, an expedient that has of late years been much used in Germany, and has begun to be employed in English practice. I believe, therefore, that ergot should be chiefly used for the purpose of exciting uterine contraction after delivery, when its pecu- liar property of promoting tonic contraction is so valuable, and that it should rarely, if at all, be employed before the birth of the child. The systematic use of uterine pressure as an oxytocic Avas first prominently brought under the notice of the profession by Kristeller, under the name of " Expressio Foetus," although it has been used in various forms from time immemorial. Albucasis, for example, Avas clearly acquainted Avith its use, and referred to it in the folloAving terms : Cum ergo vides ista signa, tunc oportet, ut comprimatur uterus ejus ut descendat embryo velociter." There are some curious obstetric customs among various nations, which probably arose from a recognition of its value ; as, for example, the mode of deliA r ery adopted among the Kalmucks, Avhere the patient sits at the foot of the bed, Avhile a Avoman seated behind her, seizes her round the Avaist and squeezes the uterus during the pains. Amongst the Japanese, Siamese, North American Indians, and many other nations, pressure, applied in various ways is habitually used. Kristeller maintains that it is possible to effect the comp"!ete ex- pulsion of the child by properly applied pressure, even Avhen the 340 LABOR. pains are entirely absent. Strange as this may appear to those who are not familiar with the effects of pressure, I believe that, under ex- ceptional circumstance, when the pelvis is very capacious, and the soft parts offer but slight resistance, it can be done. I have delivered in this way a patient whose friends would not permit me to apply the forceps, when I could not recognize the existence of any uterine contraction at all, the foetus being literally squeezed out of the uterus. It is not, however, as replacing absent pains, but as a means of in- tensifying and prolonging the effects of deficient and feeble ones, that pressure finds its best application. Its effects are often very remarkable, especially in women of slight build, where there is but little adipose tissue in the abdominal walls, and not much resistance in the pelvic tissues. If the finger be placed on the head while pressure is applied to the uterus, a very marked descent can readily be felt, and not infrequently two or three appli- cations will force the head on to the perineum. There are, however, certain conditions when it is inapplicable, and the existence of which should contraindicate its use. Thus if the uterus seem unusually tender on pressure, and, a fortiori, if the tonic contraction of exhaus- tion be present, it is inadmissible. So also if there be any obstruction to rapid delivery, either from narrowing of the pelvis or rigidity of the soft parts, it should not be used. The cases suitable for its application are those in which the head or breech is in the pelvic cavity, and the delay is simply due to a want of sufficiently strong expulsive action. Mode of Application. — It may be applied in two ways. The better is to place the patient on her back at the edge of the bed, and spread the palms of the hands on either side of the fundus and body of the uterus, and, when a pain commences, to make firm pressure during its continuance downwards and backwards in the direction of the pelvic inlet. As the contraction passes off' the pressure is relaxed, and again resumed when a fresh pain begins. In this way each pain is greatly intensified, and its effect on the progress of the foetus much increased. It is not essential that the patient should lie on her back. A useful, although not so great, amount of pressure can be applied when she is lying in the ordinary obstetric position on her left side, the left hand being spread out over the fundus, leaving the right free to watch the progress of the presenting part per vaginam. Special Value of Uterine Pressure. — The special value of this method of treating ineffective pains is, that the amount and fre- quencv of the pressure are completely within the control of the practitioner, and are capable of being regulated to a nicety in ac- cordance with the requirements of each particular case. It has the peculiar advantage of closely imitating the natural means of delivery, and of being absolutely without risk to the child : nor is there any reason to think that it is capable of injuring the mother. At least I may safely say that, out of the large number of cases in which I have used it, 1 have never seen one in which I had the least reason to think that it had proved hurtful. Of course, it is essential not to use undue roughness: firm and even strong pressure may be em- PROLONGED AND PRECIPITATE LABORS. 341 ployed, but that can be done without being rough ; and, as its appli- cation is always intermittent, there is no time lor it to inflict any injury on the uterine tissues. Pressure is specially valuable when it is desirable to intensify feeble pains. It may be serviceably employed when the pains are altogether absent, to imitate and replace them, provided there be nothing but the absence of a vis a tergo to prevent speedy delivery. In such cases an endeavor should be made to imitate the pains as closely as possible, by applying the pressure at intervals of four or five minutes, and entirely relaxing it after it has been applied for a few seconds. Change of Professional Opinion as to Instrumental Delivery. — When all these means fail we have then left the resource of instru- mental aid, and we have now to consider the indications for the use of the forceps under such circumstances. It has been already pointed out that professional opinion on this point has been undergoing a marked change ; and that it is now recognized as an axiom by the most experienced teachers that, when we are once convinced that the natural efforts are failing, and are unlikely to effect delivery, except at the cost of long delay, it is far better to interfere soon rather than late, and thus prevent the occurrence of the serious symptoms ac- companying protracted labor. The recent important debate on the use of the forceps at the Obstetrical Society of London remarkably illustrated these statements, for, while there was much difference of opinion as to the advisability of applying the forceps when the head was high in the pelvis, a class of cases not now under consideration, it was very generally admitted that the modern teaching was based on correct scientific grounds. This is, of course, directly opposed to the view so long taught in our standard works, in which instrumental interference was strictly prohibited unless all hope of natural delivery was at end ; and in which the commencement at least, if not the complete establishment, of symptoms of exhaustion, was considered to be the only justification for the application of forceps in lingering labor. Views of Dr. Johnston on the Use of the Forceps. — The reasons which have led the late distinguished Master of the Eotunda Hospital to a more frequent use of the forceps are so well expressed in his report for 1872, that I venture to quote them, as the best justification for a practice that many practitioners of the older school will, no doubt, be inclined to condemn as rash and hazardous. He says : l " Our established rule is that so long as nature is able to effect its purpose without prejudice to the constitution of the patient, danger to the soft parts, or the life of the child, Ave are in duty bound to allow the labor to proceed ; but as soon as Ave find the natural efforts are be- ginning to fail, and after having tried the milder means for relaxing the parts or stimulating the uterus to increased action, and the de- sired effects not being produced, Ave consider we are in duty bound 1 Fourth Clinical Report of tlie Rotunda Lying-in Hospital for the ye^vr ending 1872. 342 LABOR. to adopt still prompter measures, and by our timely assistance relieve the sufferer from her distress and her offspring from an imminent death. Why, may I ask, should we permit a fellow creature to undergo hours of torture when we have the means of relieving her within our reach? Why should she be allowed to waste her strength, and incur the risks consequent upon long pressure of the head on the soft parts, the tendency to inflammation and sloughing, or the danger of rupture, not to speak of the poisonous miasm which emanates from au inflammatory state of the passages, the result of tedious labor, and which is one of the fertile causes of puerperal fever and all its direful effects, attributed by some to the influence of being confined in a large maternity, and not to its proper source, z. y far the most common variety of pelvic deformity. In its slighter degrees it is not necessarily dependent on rickets, although when more marked it almost invariably is so. When unconnected with rickets, it probably can be traced to some injurious influence before the bones have ossified, such as increased pressure of the trunk from carrying weights in early childhood, and the like. By this means the sacrum is unduly depressed, and projects forwards, so as to slightly narrow the conjugate diameter. Mode of production in Rickets. — When caused by rickets the amount of the contraction varies greatly, sometimes being very slight, some- times sufficient to prevent the passage of the child altogether, and necessitate craniotouw or the Cesarean section. The sacrum, softened by the disease, is pressed vertically downwards by the weight of the body, its descent being partially resisted by the already ossified por- tions of the bone, so that the result is a downward and forward movement of the promontory. The upper portion of the sacral con- cavity is thus directed more backwards ; but, as the apex of the 876 LABOR. bone is drawn forwards by the attachment of the perineal muscles to the coccyx, and by the sacro-ischiatic ligaments, a sharp curve of its lower part in a forward direction is established. 1 Occasional Increase of Transverse Diameter.- — -The depression of the sacral promontory would tend to produce strong traction, through the sacroiliac ligaments, on the posterior ends of the sacro-cotyloid beams, and thus induce expansion of the iliac bones, and consequent increase of the transverse diameter of the brim. So an unusual length of the transverse diameter is very often described as accom- panying this deformity, but probably it is not so often apparent as might otherwise be expected, on account of the imperfect develop- ment of the bones generally accompanying rickets ; and Barnes 2 says that in the parts of London where deformities are most rife, any enlargement of the transverse diameter is exceedingly rare. Fre- quently the sacrum is not only depressed, but displaced more or less to one side, most generally to the left, thus interfering with the regu- lar shape of the deformed brim. This is often the result of a lateral flexion of the spinal column, depending on the rachitic diathesis. Cavity of Pelvis is generally not Affected. — In most cases of this kind the cavity of the pelvis is not diminished in size, and is often even more than usually wide. The constant pressure on the ischia, which the sitting posture of the child entails, tends to force them apart, and also to widen the pubic arch. Considerable advantage results from this in cases in which we have to perform obstetric operations, as it gives plenty of room for manipulation. Figure-of-eight Deformity. — In a few exceptional cases the narrow- ing of the conjugate diameter is increased by a backward depression of the symphysis pubis, which gives the pelvic brim a sort of figure- of-eight shape (Fig. 127). The most reasonable explanation of this Fig. 127. Rickety Pelvis, with Iback ward depression of the Symphysis Pubis. peculiarity seems to be, that it is the result of the muscular contrac- tion of the recti muscles, at their point of attachment, when the [ ] In the State of Louisiana, where there have been nineteen Cesarean sections, and where rickets among the blacks has in certain localities been very prevalent, I am informed that renification of the pelvis is increased by the habit of the sound children carrying the rachitic ones pig-a-back. — Ed.] 2 Lectures on Obst. Operations, p. 280. DEFORMITIES OF THE PELVIS centre of gravity of the body is thrown backwards, on account of the projection of the sacral promontory. Sometimes also the antero- posterior diameter of the cavity is unusually loosened by the disap- pearance of the vertical curvature of the sacrum, which, instead of forming a distinct cavity, is nearly flat (Fig. 128). Fig. 128. Fig. 129. Flatness of Sacram vrith Narrowing of Pelvic Cavity. Pelvis deformed by Spoudylolithesis. (After Kilian.) Spondyloh 'thesis. — In a few rare cases, to which attention was first called in 1853 by Kilian of Bonn, a very formidable narrowing of the conjugate diameter of the pelvic brim is produced by a down- ward displacement of the fourth and fifth lumbar vertebrae, which become dislocated forward, or if not actually dislocated, at least separated from their several articulations to a sufficient extent to encroach very seriously on the dimensions of the pelvic inlet. This condition is known as spondf/IoJilhesis. (Fig. 1*29.) The effect of this is sufficiently obvious, for the projection of the lumbar vertebrae prevents the passage of the child. To such an ex- tent is obstruction thus produced, that, in the majority of the recorded cases, the Cesarean section was necessary. The true conjugate diam- eter, that between the promontory of the sacrum, and the symphysis pubis, is increased rather than diminished ; but, for all practical pur- poses, the condition is similar to extreme narrowing of the conju- gate from rickets, for the bodies of the displaced vertebras project into and obstruct the pelvic brim. The cause of this deformity seems to be different in different cases. In some it seems to have been congenital, and in others to have de- pended on some antecedent disease of the bones, such as tuberculosis or scrofula, producing inflammation and softening of the connection between the last lumbar vertebra and the sacrum, thus permitting downward displacement of the bones. Lambl believed that it gene- rally folloAved spina bifida, which had become partially cured, but which had produced deformity of the vertebras, and favored their 25 378 LABOR, dislocation. Brodhurst, 1 on the other hand, thinks that it most prob- ably depends on rachitic inflammation and softening of the osseous and ligamentous structures, and that it is not a dislocation in the strict sense of the word. Narrowing of the Oblique Diameter. — The most marked examples of narrowing of both oblique diameters depend on osteo-malacia. In this disease, as has already been remarked, the bones are uniformly softened ; and the alterations in form are further influenced by the fact that the disease commences after union of the separate portions of the os innominatum has been completely effected. The amount of deformity in the worst cases is very great, and frequently renders delivery impossible without the Cesarean section. Sometimes the softening of the bones proves of service in delivery, by admitting of the dilatation of the contracted pelvic diameter by the pressure of the presenting part, or even by the hand. Some curious cases are on record in which the deformity was so great as to apparentl}' re- quire the Cesarean section but in which the softened bones eventu- ally yielded sufficiently to render this unnecessary. Mode of Production in Osteo-malacia. — The weight of the body de- presses the sacrum in a vertical direction, and at the same time com- presses its component parts together, so as to approximate the base and apex of the bone, and narrow the conjugate diameter of the brim, Osteomalacic Pelvis. by causing the promontory to encroach upon it. The most charac- teristic changes are produced by the pushing inwards of the walls of the pelvis at the cotyloid cavities, in consequence of pressure exerted at these points through the femurs. The effect of this is to dimm- ish both oblique diameters, giving the brim somewhat the shape of a trefoil, or an ace of clubs. The sides of the pubis are at the same time approximated, and may become almost parallel, and the true conjugate may be even lengthened (Fig. 130). The tuberosities of i Obst. Trans., vol. vi. p. 97. DEFORMITIES OF THE PELVIS 379 the ischia are also compressed together, with the rest of the lateral pelvic wall, so that the outlet is greatly deformed as well as the brim (Fig. 181). Fig. 131. Extreme Degree of Osteomalacic Deformity. Obliquely Contracted Pelvis. — That form of deformity in which one oblique diameter only is lessened, has received considerable attention, from having been made the subject of special study by Naegele, and is generally known as the obliquely contracted pelvis (Fig. 132). It is a condition that is very rarely met with, although it is interesting from Fig. 132. an obstetric point of view, as throw- ing considerable light on the mode in which the natural development of the pelvis is effected. It is difficult to diagnose, inasmuch as there is no apparent external deformity, and probably it has never, in fact, been detected before delivery. It has a very serious influence on labor ; Litz- mann found that out of 28 cases of this deformity, 22 died in their first labors, and 5 more in subsequent de- liveries. The prognosis, therefore, is very formidable, and renders a knowl- edge of this distortion, rare though it be, of importance. Its essential characteristic is flattening and want of development of one side of the pelvis, associated with anchylosis of the correspond- ing sacro-iliac synchondrosis. The latter is probably always present, and it seems to be most generally a congenital malformation. The lateral half of the sacrum on the same side, and the entire innominate bone are much atrophied. The promontory of the sacrum is directed towards the diseased side, and the symphysis pubis is pushed over towards the healthy side. The main agent in the production of this deformity is the absence of the sacro-iliac joint, which prevents the proper lateral expansion of Obliquely Contracted Pelvis. Duncan.) (After 380 LABOR the pelvic brim on that side, and allows the counter-pressure, through the femur, to push in the atrophied os innominatum to a much greater extent than usual. The chief diminution in the length of the pelvic diameter is between the ilio-pectineal eminence of the affected side and the healthy sacro-iliac joint; while the oblique diameter between the anchylosed joint and the healthy os innominatum is of normal length. Narrowing of the Transverse Diameter. — Transverse contraction of the pelvic brim is very much less common than narrowing of the conjugate diameter. It most frequently depends on backward curv- ature of the lower parts of the spinal column, in consequence of disease of the vertebrae. This form of deformed pelvis is generally known as the kyphotic. The effect of the spinal curvature is to drag the promontory of the sacrum backwards, so that it is high up and out of reach. By this means the antero-posterior diameter of the brim is increased, while the transverse is lessened ; the relative pro- portion between the two is thus reversed. While the upper propor- tion of the sacrum is displaced backwards, its lower end is projected forward, so that the antero-posterior diameters of the cavity and outlet are considerably diminished. The ischial tuberosities are also nearer to each other, and the pubic arch is narrowed. Obstruction to delivery will be chiefly met with at the lower parts and outlet of the pelvic cavity; for, although the transverse diameter of the brim is narrowed, there is generally sufficient space for the passage of the head. Roberts Pelvis. — Another form of transversely contracted pelvis is known as Roberts pelvis (Fig. 133), having been first discovered by Robert, of Coblentz. It is in fact a double obliquely contracted pelvis, depending on anchylosis of both sacro-iliac joints, and consequent defective development of the innom- inate bones. The shape of the pelvic brim is markedly oblong, and the sides of the pelvis are more or less parallel with each other. The outlet is also much contracted trans- versely. The amount of obstruction is very great, so that, according to Schroeder, out of 7 well-authenti- cated cases the Cesarean section was required in 6. Deformity from Old- standing Hip- joint Disease. — Another cause of transverse deformity, occasionally met with, is luxation of the head of the femur, depending on old- standing joint disease. The head of the femur, in this case, presses on the innominate bone at the site of dislocation, and the result is that the iliac fossa on the affected side, or both if the accident hap- pens on both sides, is pushed inwards, the transverse diameter of the brim being lessened. The tuberosity of the ischium is, however, Fig. 133. Robert's or Double Obliquely Contracted Pelvis. (After Duncan.) DEFORMITIES OF THE PELVIS 381 Fig. 134. projected outwards, so that the outlet of the pelvis is increased rather than diminished. Deformity from Tumors, Fractures, etc. — Obstruction of the pelvic cavitj from exostosis or other forms of tumors growing from the bones is of great rarity (Fig. 134). It may, however, produce very serious dystocia. Several curious ex- amples are collected in Mr. Wood's article on the pelvis, in some of which the obstruction was so great as to necessitate the Cesarean section. 1 Some of these growths were true exostoses ; and, according to Stadt- feldt, 2 these are commonly found in pelves that are otherwise contracted ; others osteo-sarcomatous tumors attached to the pelvic bones, most generally the upper part of the sacrum ; and others were malignant. In some cases spiculae of bone have developed about the linea ilio-pec- tinea or other parts of the pelvis, which may not be sufficient to pro- duce obstruction, but which may injure the uterus, or even the foetal head, when they are pressed upon them. Irregular projections may also arise from the callus of old fractures of the pelvic bones. All such cases defy classification, and differ so greatly in their extent, and in their effect on labor, that no rales can be laid down for them, and each must be treated on its own merits. Effects of Contracted Pelvis in Labor. — The effects of pelvic con- tractions on labor vary, of course, greatly with the amount and nature of the deformity; but they must always give rise to anxiety, and, in the graver degrees, they produce the most serious difficulties we have to contend with in the Avhole range of obstetrics. Nature of Uterine Action in Pelvic Deformity. — In the lesser degrees, in which the proportion between the presenting part and the pelvis is only slightly altered, we may observe little abnormal beyond a greater intensity of the pains, and some protraction of the labor. It is generally observed that the uterine contractions are strong and forcible in cases of this kind, probably because of the increased resistance they have to contend against ; and this is obviously a desirable and conservative occurrence, which may, of itself, suffice to overcome the difficulty. The first stage, however, is not infre- quently prolonged, and the pains are ineffective, for the head does Bony Growth from Sacrum Obstructing Pelvic Cavity. the \} Pelvic exostosis has been the obstacle to delivery in eight American Cesarean cases. One woman was operated upon three times, and died after the last operation. Five of the children were born alive. Fonr women recovered. Two died after labors of three days each, and one, of two. — Ed.] 2 Obstetrical Journ., July, 1S79. 882 LABOR. not readily engage in the brim, the uterus is more mobile than in ordinary labors, and it probably acts at a disadvantage. Risk to the Mother. — In the more serious cases, the mother is sub- jected to many risks, directly proportionate to the amount of obstruc- tion and the length of the labor. The long-continued and excessive uterine action, produced by the vain endeavors to push the child through the contracted pelvic canal, the more or less prolonged con- tusion and injury to which the maternal soft parts are necessarily subjected (not unfrequently ending in inflammation and sloughing with all its attendant dangers), and the direct injury which may be inflicted by the measures we are compelled to adopt for aiding de- liver}^ (such as the forceps, turning, craniotomy, or Cesarean sec- tion), all tend to make the prognosis a matter of grave anxiety. Risk to the Child. — Nor are the clangers less to the child ; and a very large proportion of still-births will always be met with. The infantile mortality may be traced to a variety of causes, the most important being the protraction of the labor, and the continuous pressure to which the presenting part is subjected. For this reason, even in cases in which the contraction is so slight that the labor is terminated by the natural powers, it has been estimated that 1 out of every 5 children is still-born ; and as the deformity increases in amount, so, of course, does the prognosis to the child become more unfavorable. Freouent Occurrence of Prolapse of the Cord. — Prolapse of the umbilical cord is of very frequent occurrence in cases of pelvic de- formity, the tendency to this accident being traceable to the fact of the head not entering and occupying the upper strait of the pelvis as in ordinary labors, and thus leaving a space through which the cord may descend. So frequently is this complication met with in pelvic deformity that Stanesco 1 found it had happened as often as 59 times in 414 labors ; and when the dangers of prolapsed funis are added to those of protracted labors, it is hardly a matter of surprise that the occurrence should, under such circumstances, almost always prove fatal to the child. Injury to Child's Head. — The head of the child is also liable to injury of a more or less grave character from the compression to which it is subjected, especially by the promontory of the sacrum. Independentlv of the transient effects of undue pressure (temporary alteration of the shape of the bones and bruising of the scalp), there is often met with a more serious depression of the bones of the skull, produced by the sacral promontory. This is most marked in cases in which the head has been forcibly dragged past the projecting bone by the forceps, or after turning. The amount of depression varies with the degree of contraction; but sometimes, were it not for the yielding of the bones of the foetal skull in this Avay, delivery, with- out lessening the size of the head by perforation, would be impossi- ble. Such depressions are found at the spot immediately opposite the promontory, generally at the side of the skull near the junction i Op. cit. p. 94. DEFORMITIES OF THE PELVIS. 383 of the frontal and parietal bones. Sometimes there is a slight per- manent mark, but more often the depression disappears in a few days. The prognosis to the child is, however, grave, when the con- traction has been sufficient to indent the skull ; for it has been found that 50 per cent, of the children thus marked died either immediately or shortly after labor. 1 Course of Labor. — The means which nature takes to overcome these difficulties are well worthy of study, and there are certain peculiari- ties in the mechanism of delivery when pelvic deformities exist, which it is of importance to understand, as they guide us in deter- mining the proper treatment to adopt. Frequency of Malpresentation. — Mai presentations of the foetus are of much more frequent occurrence than in ordinary labors ; partly because the head does not engage readily in the brim, but, remaining free above it, is apt to be pushed away by the uterine contractions, and partly because of the frequent alteration of the axis of the uterine tumor. The pendulous condition of the abdomen in cases of pelvic deformity is often very obvious, so that the fundus is sometimes almost in a line with the cervix, and thus transverse or other abnormal positions are very frequently met with. It is to be noted, however, that we cannot regard breech presentations as so unfavorable as in ordinary labors, for the pressure from the con- tracted pelvis is less likely to be injurious when applied to the body than to the head of the child; and indeed, as we shall presently see, the artificial production of these presentations is often advisable as a matter of choice. Mechanism of Delivery in Head Presentations. — The mode in which the head passes naturally through a contracted pelvis is in some respects different from the ordinary mechanism of delivery in head presentations, and has be^n carefully worked out by Spiegelberg, and other German obstetricians. The means which nature adopts to overcome the difficulty are dif- ferent in cases in which there is a marked narrowing of the conju- gate diameter of the brim, and in those in which there is a generally contracted pelvis. In Contracted Brim. — In the former, and more common deformitv, when the head enters the brim, in consequence of the resistance it meets with, the expelling power of the uterus acts more on the ante- rior part of the head than in ordinary cases, the chin becomes in some degree separated from the sternum, and the anterior fontanelle descends somewhat lower than the posterior. At this stage, on ex- amination, it will be found — -supposing we have to do with a case in which the occiput points to the left side of the pelvis — that the ante- rior fontanelle is lower than the posterior, and to the right, the bi- temporal diameter of the head is engaged in the conjugate diameter of the brim (as the smallest diameter of the skull, there is manifest advantage in this), the bi-parietal diameter and the largest portion of the head points to the left side. The sagittal suture will be felt 1 Schroeder, op. cit. p. 256. 884: LABOR. running across in the transverse diameter of the brim, but nearer to the sacrum, the head being placed obliquely. As the head is forced down by the uterine contractions, the parietal bone, which is resting on the promontory, is pushed against it, so that the sagittal suture is forced more into the true transverse diameter of the pelvic brim, and approaches nearer to the pubis. The next step is the depression of the head, the occiput -undergoing a sort of rotation on its trans- verse axis, so that it reaches a plane below the brim. When this is accomplished, the rest of the head readily passes the obstruction. The forehead now meets with the resistance of the pelvic Avails, the posterior fontanelle descends to a lower level, and, as the cavity of the pelvis in cases of antero-posterior contraction of the brim is generally of normal dimensions, the rest of the labor is terminated in the usual way. In generally Contracted Pelvis. — In the generally contracted pelvis the head enters the brim with the posterior fontanelle lowest, and it is after it has engaged in it that the resistance to its progress becomes manifest. The result is, therefore, an exaggeration of what is met with in ordinary cases. The resistance to the anterior or longer arm of the lever is greater than that to the occipital or shorter; and, therefore, the flexion of the head becomes very marked. The pos- terior fontanelle is consequently unusually depressed, and the ante- rior quite out of reach. So the head is forced down as a wedge, and its further progress must depend upon the amount of contraction. If this be not too great the anterior fontanelle eventually descends, and delivery is completed in the usual way. Should the contraction be too much to permit of this, the head becomes jammed in the pelvis, and diminution of its size may be essential. In cases of deformity of the conjugate diameter, combined with general contraction of the pelvis, the mechanism partakes of the pe- culiarities of both these classes, to a greater or less extent, in propor- tion to the preponderance of one or other species of deformity. Diagnosis. — It rarely happens that deformities of the pelvis, except of the gravest kind, are suspected before labor has actually com- menced ; and, therefore, we are not often called upon to give an opin- ion as to the condition of the pelvis before delivery. Should we be so, there are various circumstances which may aid us in arriving at a correct conclusion. Prominent among them is the history of the patient in childhood. If she is known to have suffered from rickets in early life, more especially if the disease has left evident traces in deformities of the limbs, or in a dwarfed and stunted growth, or in curvature of the spine, there will be strong presumptive evidence of pelvic deformity; a markedly pendulous state of the abdomen may also tend to confirm the suspicion. Nothing short of a careful ex- amination of the pelvis itself will, however, clear up the point with certainty ; and, even by this means, to estimate the precise degree of deformity with accuracy requires considerable skill and practice. The ingenuity of practitioners has been much exercised, it might perhaps be justly said, wasted, in the invention of various more or less complicated pelvimeters for aiding us in obtaining the desired DEFORMITIES OF THE PELVIS. 385 object. It is, however, pretty generally admitted by all accoucheurs, that the hand forms the best and most reliable instrument for this purpose, at any rate as regards the interior of the pelvis ; although a pair of callipers, such as Baudelocque's well-known instrument, is essential for accurately determining the external measurements. The objections to all internal pelvimeters, even those most simple in their construction, are their cost and complexity, and the impossibility of using them without pain or injury to the patient. External Measurements. — It was formerly thought that by meas- uring the distance between the spinous processes of the sacrum and the symphysis pubis, and subtracting from it what we judge to be the thickness of the bones and soft parts, we might arrive at an ap- proximate estimate of the measurement of the conjugate diameter of the pelvic brim. It is now admitted that this method can never be depended on, and that, taken by itself, it is practically useless. A change in the relative length of other external measurements of the pelvis is, however, often of great value in showing the existence of deformity internally, although not in judging of its amount. The measurements which are used for this purpose are between the anterior superior spines of the ilia, and between the centres of their crests, averaging respectively 10 and 11 inches. According to Spie- gelberg these measurements may give one of three results. 1. Both may be less than they ought to be, but the relation of the one to the other remains unchanged. 2. That between the crests is not, or is at most very little, dimin- ished, but that between the spines is increased. 3. Both are diminished, but at the same time their mutual relation is not normal, the distance between the spines being as long, if not longer, than that between the crests. No. 1 denotes a uniformly contracted pelvis. No. 2, a pelvis simply contracted in the conjugate diameter of the brim, and not otherwise deformed. No. 3, a pelvis with narrowed conjugate and also uniformly contracted, as in the severe type of rachitic deformity. If, however, both these measurements are of average length, and the distance between the crests is about one inch greater than between the spines, the pelvis is normal. Besides the above some information may be obtained by the measurement of the external conjugate diameter, which averages 7f inches. This may be taken by placing one point of the callipers in the depression below the spine of the last lumbar vertebra, the other at the centre of the upper edge of the s} r mphysis pubis. If the measurement be distinctly below the average, not more, for example than 6.3 in., we mav conclude that there is a narrowing of the an- tero-posterior diameter of the brim, the extent of which we must endeavor to ascertain by other means. For the purpose of making these measurements Baudelocque's compas d'epaisseur can be used, or Dr. Lazarewitch's elegant universal pelvimeter, which can be adopted also for internal pelvimetry ; but, in the absence of these special contrivances, an ordinary pair of calli- pers, such as are used by carpenters, can be made to answer the desired object. 386 LABOR. Fig. 135. Greenhalgh's Pelv Internal Measurements. — These external measurements must be corroborated by internal, chiefly of the antero-posterior diameter, by which alone Ave can estimate the amount of the deformity. We en- deavor to find, in the first place, the length of the diagonal conju- gate, between the lower edge of the symphysis pubis and the prom- ontory of the sacrum, which aver- ages about half an inch more than the true conjugate. This is best done by placing the patient on her back, with the hips well raised. The index and middle ringer of the right hand are then intro- duced into the vagina, and the perineum is pressed steadily back- wards, so as to overcome the re- sistance it offers. If the tip of the second finger can reach the prom- ontory of the sacrum, the radial side of the first finger is raised so as to touch the lower edge of the pubis. A mark is made with the nail of the index of the left hand on that part of the examining finger which rests under the symphysis, and then the distance from this to the tip of the finger, less half an inch, may be taken to indicate the measurement of the true conjugate of the brim. Various pelvimeters are meant to make the same meas- urements, such as Lumley Earle's, Lazare witch's, which is similar in principle, and Van Huevel's ; the best and simplest, I think, is that invented by Dr. Green halgh (Fig. 135). It consists of a movable rod, attached to a flexible band of metal which passes around the palm of the examining hand. At the distal end of the rod is a curved portion, which passes over the radial edge of the index finger. The examination is made in the usual way, and when the point of the finger is resting on the promontory of the sacrum, the rod is with- drawn until it is arrested by the posterior surface of the symphysis, the exact measurement of the diagonal conjugate being then read off on the scale. It is to be remembered that this procedure is useless in the slighter degrees of contraction, on which the promontory of the sacrum cannot be easily reached. Dr. Eamsbotham proposed to measure the con- jugate by spreading out the index and middle fingers internally, the tip of one resting on the promontory, the other behind the symphysis pubis ; and then drawing them, in the same position, and measuring the distance between them. This manoeuvre I believe to be imprac- ticable. Whenever, in actual labor, we wish to ascertain the condition of the pelvis accurately, the patient should be anesthetized, and the DEFORMITIES OF THE PELVIS. 887 whole hand introduced into the vagina (which could not otherwise be done without causing great pain), and the proportions of the pelvis, and the relations of the head to it, thoroughly explored ; and, if what has been said as to the mechanism of delivery in these cases be borne in mind, this may aid us in determining the kind of de- formity existing. In this way contractions about the outlet of the pelvis can also be pretty generally made out. Mode of Dicujnosiruj "the Oblique Pelvis. — The obliquely contracted pelvis cannot be determined by any of these methods, but certain external measurements, as Naegele has pointed out, will readily enable us to recognize its existence. It will be found that measure- ments, which in the healthy pelvis ought to be equal, are unequal in the obliquely distorted pelvis. The points of measurement are chiefly ; 1. From the tuberosity of the ischium on one side to the posterior superior spine of the ilium on the other ; 2. From the anterior superior iliac spine on the one side to the posterior superior on the opposite; 3. From the trochanter major of one side to the posterior superior iliac spine on the other ; -i. From the lower edge of the symphj'sis pubis to the posterior superior iliac spine ; 5. From the spinous process of the last lumbar vertebra to the anterior superior spine of the ilium on either side. If these measurements differ from each other by half an inch to an inch, the existence of an oblique deformed pelvis may be safely diagnosed. The diagnosis can be corroborated by placing the patient in the erect position, and letting fall two plumb lines, cue from the spines of the sacrum, the other from the symphysis pubis. In a healthy pelvis these will fall in the same plane, but in the oblique pelvis the anterior line will deviate considerably towards the un- affected side. Treatment. — The proper management of labor in contracted pelvis is, even up to this time, one of the most vexed questions in midwifery, notwithstanding the immense amount of discussion to which it has given rise ; and the varying opinions of accoucheurs of equal expe^ rience afford a strong proof of the difficulties surrounding the subject. This remark applies, of course, only to the lesser degrees of deformity, in which the birth of a living child is not hopeless. When the antero- posterior diameter of the brim measures from 2 j to 8 inches, it is universally admitted that the destruction of the child is inevitable, unless the pelvis be so small as to necessitate the performance of the Cesarean section. But when it is between 3 inches and the normal measurement, the comparative merits of the forceps, turning and. the induction of premature labor, form a fruitful theme for discus- sion. With one class of accoucheurs the forceps is chiefly advocated, and turning admitted as an occasional resource when it has failed ; and this indeed, speaking broadly, may be said to have been the general view held in this country. More recently we find German authorities of eminence, such as Schroeder and Spiegelberg, giving turning the chief place, and condemning the forceps altogether in contracted pelvis, or at least, restricting its use within very narrow limits. More strangely still we find, of late, that the induction of 388 LABOR. premature labor, on the origination and extension of which British accoucheurs have always prided themselves, is placed without the pale, and spoken of as injurious and useless in reference to pelvic deformities. To see our way clearly amongst so many conflicting opinions is by no means an easy task, and perhaps we may best aid in its accomplishment by considering separately the three operations in so far as they bear on this subject, and pointing out briefly what can be said for and against each of them. The Forceps. — In England and in France it is pretty generally admitted that in the slighter degrees of contraction the most reliable means of aiding the patient is by the forceps. It should be remem- bered that the operation, under such circumstances, is always much more serious than in ordinary labors simply delayed from uterine inertia, when there is ample room, and the head is in the cavity of the pelvis ; for the blades have to be passed up very high, often when the head is more or less movable above the brim, and much more traction is likely to be required. For these reasons artificial assist- ance, when pelvic deformity is suspected, is not to be lightly or hurriedly resorted to. Nor fortunately is it always necessary; for if the pains be sufficiently strong, and the contraction not too great to prevent the head engaging at all, after a lapse of time it will be- come so moulded in the brim as to pass even a considerable obstruc- tion. In all cases, therefore, sufficient time must be given for this ; and if no suspicious symptoms exist on the part of the mother — no elevation of temperature, dryness of the vagina, rapid pulse, and the like, and the foetal heart-sounds continue to be normal — labor may be allowed to go on for some hours after the rupture of the mem- branes, so as to give nature a chance of completing the deliver}^. When this seems hopeless, the intervention of art is called for. Cases Suitable for the Forceps. — The forceps is generally considered to be applicable in all degrees of contraction, from the standard measurement, down to about 3 J inches in the conjugate of the brim. There can be no doubt that, in such cases, traction with the forceps often enables us to effect delivery, when the natural efforts have proved insufficient, and holds out a very fair hope of saving the child. Out of 17 cases in which the high forceps operation was re- sorted to for pelvic deformity, reported by Stanesco, in 13 living- children were born. If the length of the labor, and the long-con- tinued compression to which the child has been subjected, be borne in mind, this result must be considered very favorable. Objections that have been raised to the Forceps. — AYhat are the ob- jections which have been brought against the operation? These have been principally made by Schroeder and other German writers. They are, chiefly the difficulty of passing the instrument ; the risk of injuring the maternal structures; and the supposition that, as the blades must seize the head by the forehead and occiput, their com pressive action will diminish its longitudinal and increase its trans- verse diameter (which is opposed to the contracted part of the brim), and so enlarge the head just where it ought to be smallest. There is little doubt that these writers much exaggerate the compressive DEFORMITIES OF THE PELVIS 389 Fig. 136. power of the forceps. Certainly with those generally used in this country, any disadvantage likely to accrue from this is more than counterbalanced by the traction on the head; and the fact, that minor degrees of obstruction can be thus overcome, with safety both to the mother and child, is abundantly proved by the numberless cases in which the forceps have been used. It is not equally Suitable in all kinds of Deformity. — It is very likely that the forceps do not act equally well in all cases. When the head is loose above the brim ; when the contraction is chiefly limited to the antero-posterior diameter, and there is abundance of room at the sides of the pelvis for the occiput to occupy after version; and when, as is usual in these cases, the anterior fontanelle is depressed and the head lies transversely across the brim, it is probable that turning may be the safer operation for the mother, and the easier performed. When, on the other hand, the head has engaged in the brim, and has become more or less impacted, it is obvious that version could not be performed without pushing it back, which may neither be easy nor safe. In the generally contracted pelvis, in which the head enters in an exaggerated state of flexion and lies obliquely, the posterior fon- tanelle being much depressed, the forceps are' more suitable. Mechanical Advantage of Turning in certain Cases. — The special reasons why version sometimes succeeds when the forceps fails, or why it may be elected from the first as a matter of choice, have been by no one better pointed out than by Sir James Simpson. Although the operation was performed by many of the older obstetricians, its revival in modern times, and the clear enunciation of its principles, can undoubtedly be traced to his writings. He points out that the head of the child is shaped like a cone, its narrowest portion the base of the cranium (Fig. 136, bb), measuring, on an average, from J to § of an inch less than the broadest portion (Fig. 13(3, aa), viz., the bi-parietal diameter. In ordi- nary head presentations the latter part of the head has to pass first ; but if the feet are brought down, the narrow apex of the cra- nial cone is brought first into apposition with the contracted brim, and can be no more easily drawn through than the broader base can be pushed through bv the uterine con- tractions. Nor is this the onlv advantage, for after turning the narrower bi- temporal diameter (Fig. 137, bb) — which measures, on an average, half an inch less than the bi- parietal (Fig. 137, aa) — is brought into con- tact With the Contracted Conjugate, While the Showing the greater breadth of broader bi-parietal lies in the comparatively the BU P arietal diameter of • T j. j.1 -1 j? ^ -\ ■ /tt -i or>\ tne Foetal Cranium. (After wide space at the side oi the pelvis (Fig. 138). Simpson.) Section of Foetal Cranium, show- ing its Conical Form. 390 LABOR. These mechanical considerations are sufficiently obvious, and fully explain the success which has often attended the performance of the operation. Limits of the Operation. — -It is generally admitted that it may be possible, for the reasons just mentioned, to deliver a living child by turning, through a pelvis contracted beyond the point which would permit of a living child being extracted by the forceps. Many ob- stetricians believe that it is possible to deliver a living child by turn- ing in a pelvis contracted even to the extent of 2} inches in the conjugate diameter. Barnes maintains that, although an unusually compressible head may be drawn through a pelvis contracted to 3 inches, the chance of the child being born alive under such circum- stances must necessarily be small, and that from 3J inches to the normal size must be taken as the proper limits of the operation. Fig. 138. Showing the greater space for the Bi-parielal Diameter at the side of the Pelvis in certain cases of Deformity. (After Simpson.) That delivery is often possible by turning, after the forceps and the natural powers have failed, and when no other resource is left but the destruction of the child, must, I think, be admitted by all ; for the records of obstetrics are full of such cases. To take one ex- ample only, Dr. Braxton Hicks 1 records four cases in which the for- ceps were tried unsuccessfully, in all of which version was used, three of the children being born alive. Here are the lives of three children rescued from destruction, within a short period, in the practice of one man ; and a fact like this would, of itself, be ample justification of the attempt to deliver by turning, when the child was known to be alive, and other means had failed. The possibility that craniotomy may still be required is no argument against the opera- tion ; for although perforation of the after-coming head is certainly not so easy as perforation of a presenting head, it is not so much more difficult as to justify the neglect of an experiment by which it may possibly be altogether avoided. Comparative Estimate of the Two Operations. — The original choice of turning is a more difficult question to decide. My own impression is that the use of the forceps will generally be found to be preferable. An exception should, I think, be made for those cases in which the i Guy's Hosp. Rep. 1870. DEFORMITIES OF THE PELVIS. 391 head refuses to enter the brim, and cannot be sufficiently steadied by external pressure to admit of an easy application of the instru- ment. Under these circumstances increasing experience leads me to prefer turning as decidedly the simpler and safer operation, and the passage of the head through the contracted brim can be very mate- rial ly°faeilitated by strong pressure from above, as has been so well pointed out by Gooclell. 1 An argument used by Martin, of Berlin, 2 in reference to the two operations, should not be lost sight of, as it seems to be a valid reason for giving a preference to the forceps. He points out that moulding may safely be applied for hours to the vertex ; but that when pres- sure is applied to the important structures about the base of the brain, as after turning, moulding cannot be continued beyond five minutes without proving fatal. This, however, is no reason why turning should not be used after the forceps and the natural efforts have proved ineffectual. Craniotomy or the Csesarean Section is required. — When the con- traction is below 3 inches in the conjugate, or when the forceps and turning; have failed, no resource is left but the destruction of the foetus, or the Cesarean section. The induction of premature labor as a means of avoiding the risks of delivery at term, and of possibly saving the life of the child, must now be studied. The established rule, in this country, is, that in all cases of pelvic deformity, the existence of which has been ascertained either by the experience of former labors, or by accurate examina- tion of the pelvis, labor should be induced previous to the full period so that the smaller and more compressible head of the premature foetus may pass, where that of the foetus at term could not. The gain is a double one, partly the lessened risk to the mother, and partly the chance of saving the child's life. The practice is so thoroughly recognized as a conservative and judicious one, that it might be deemed unnecessary to argue in its favor, were it not that some most eminent authorities have of late years tried to show, that it is better and safer to the mother to leave the labor to come on at term ; and that the risk to the child is so great in artificially induced labor as to lead to the conclusion that the operation should be altogether abandoned, except, perhaps, in the extreme distortion in which the Cesarean section might other- wise be necessary. Prominent amongst those who hold these views are Spiegelberg and Litzmann, and they have been supported, in a modified form, by Matthews Duncan. Spiegelberg 3 tries to show, by a collection of cases from various sources, that the results of in- duced labor in contracted pelvis are much more unfavorable than when the cases are left to nature ; that in the latter the mortality of the mothers is 6 6 per cent., and of the children 28.7 per cent., whereas in the former the maternal deaths are 15 per cent., and the infantile 66.9 per cent. Litzmann 4 arrives at not very dissimilar results, 1 Amer. Journ. of Obst., vol. viii. 2 Mon. f. Geburt. 1867. * Arch. f. Gryn. b. i. s. 1. « lb. b. ii. s. 169. 392 LABOR. namely, 6.9 per cent, of the mothers and 20.3 per cent, of the children in contracted pelvis at term, and 14.7 per cent, of the mothers and 55.8 per cent, of the children, in artificially induced premature labor. If these statistics were reliable, inasmuch as they show a very decided risk to the mother, there might be great force in the argu- ment that it would be better to leave the cases to run the chance of delivery at term. It is, however, very questionable whether they can be taken, in themselves, as being sufficient to settle the question. The fallacy of determining such points by a mass of heterogeneous cases, collected together without a careful sifting of their histories, has over and over again been pointed out ; and it would be easy enough to meet them by an equal catalogue of cases in which the maternal mortality is almost nil. The results of the practice of many authorities are given in Churchill's work, where we find, for example, that out of 46 cases of Merriman's, not one proved fatal. The same fortunate result happened in 62 cases of Eambotham's. His conclusion is, that "there is undoubtedly some risk incurred by the mother, but not more than by accidental premature labor," and this conclusion, as regards the mother, is that which has long ago been arrived at by the majority of British obstetricians, who un- doubtedly have more experience of the operation than those of any other nation. With regard to the child, even if the German statis- tics be taken as reliable, they would hardly be accepted as contra- indicating the operation, inasmuch as it is intended to save the mother from the dangers of the more serious labor at term, and, in many cases, to give at least a chance to the child, whose life would other- wise be certainly sacrificed. The result, moreover, must depend to a great extent on the method of operation adopted, for many of the plans of inducing labor recommended are certainly, in themselves, not devoid of danger both to the mother and the child. It may, I think, be admitted, as Duncan contends, 1 that the operation has been more often performed than is absolutely necessary, and that the higher degrees of pelvic contraction are much more uncommon than has been supposed to be the case. That is a very valid reason for insisting on a careful and accurate diagnosis, but not for rejecting an operation which has so long been an established and favorite re- source. Determination of Period for Inducing labor. — When the induc- tion of labor has been determined on, the precise period at which it should be resorted to becomes a question for anxious consideration, for the longer it is delayed the greater, of course, are the dangers for the child. Many tables have been constructed to guide us on this point, which are not, on the whole, of so much service as they might appear to be, on account of the difficulty of determining with minute accuracy the amount of contraction. The following, however, which is drawn up by Kiwisch, may serve for a guide in settling this ques- tion : — 1 Eclin. Med. Journ., July, 1S73, p. 339. HEMORRHAGE BEFORE DELIVERY. 393 Inches. Lines. When the sacro-pubic diameter is 2 and fa' or 7 induce labor at 30th week. 2 ' ' 8 " 9 " " 31st 2 ' ' 10 " 11 " a 32d 3 ' ; it " 33d 3 " 1 " 33d 3 ' i 2 " 3 " a 34th 3 < ' 4 " 5 " a 35th 3 < < 5 " 6 " a 36th In cases of moderate deformity, when labor pains have been in- duced, the further progress of the case may be left to nature ; but in the more makecl cases, as in those below 3 inches, it will often be found necessary to assist delivery by turning or by the forceps, the former being here specially useful, on account of the extreme pliability of the head, and the facility with which it ma}' be drawn through the contracted brim. By thus combining the two operations it may be quite possible to secure the birth of a living child even in pelves very considerably deformed. Production of Abortion in extreme Deformity. — When the contraction is so great as to necessitate the induction of the labor before the sixth month, or, in other words, before the child has reached a viable age, it would be preferable to resort to a very early production of abor- tion. The operation is then indicated, not for the sake of the child, but to save the mother from the deadly risk to which she would otherwise be subjected. As in these cases, the mother alone is con- cerned, the operation should be performed as soon as we have posi- tively determined the existence of pregnancy. ISIo object can be gained by waiting until the development of the child is advanced to any extent, and the less the foetus is developed, the less will be the pain and risks the mother has to undergo. There is no amount of deformity, however great, in which we could not succeed in bringing on miscarriage by some of the numerous means at our disposal; and, in spite of Dr. Eadford's objections, who maintains that the obstetri- cian is not justified in sacrilicing the life of a human being more than once, when the mother knows that she cannot give birth to a viable child, there are few practitioners who would not deem it their duty to spare the mother the terrible clangers of the Coesarean section. CHAPTER XIII. HEMORRHAGE BEFORE DELIVERY: PLACENTA PR. E VIA. The hemorrhages which are the result of an abnormal situation of the placenta, partially or entirely, over the internal os uteri, have formed a most fruitful theme for discussion. The causes producing the abnormal placental site, the sources of the blood, and the causes 26 39-4 LABOR. of its escape, the means adopted by nature for its arrest, and the proper treatment, have, each and all of them, been the subject of endless controversies, which are not yet by any means settled. It must be admitted, too, that the extreme importance of the subject amply justifies the attention which has been paid to it ; for there is no obstetric complication more apt to produce sudden and alarming effects, and none requiring more prompt and scientific treatment. B y placenta prvevia we mean the insertion of the placenta at the lower segment of the uterine cavity, so that part of it is situated, wholly or partially, over the internal os uteri. In the former case there is complete or central placental presentation, in the latter an incomplete or marginal presentation. Causes. — The causes of this abnormal placental site are not fully understood. It was supposed by Tyler Smith to depend on the ovale not having been impregnated until it had reached the lower part of the uterine cavity. Cazeau suggests that the uterine mucous mem- brane is less swollen and turgid than when impregnation occurs at the more ordinary place, and that, therefore, it offers less obstruction to the descent of the ovule to the lower part of the uterine cavity. An abnormal size, or unusual shape, of the uterine cavity may also favor the descent of the impregnated ovule; the former probably explains the fact, that placenta prasvia more general^ occurs in women who have borne several children. 1 These are merely interest- ing speculations having no practical value, the fact being undoubted that, in a not inconsiderable number of cases — estimated by Johnson and Sinclair as 1 out of 573 — -the placenta is grafted partially or entirely over the uterine orifice. History. — Placenta previa was not unknown to the older writers, who believed that the placenta had originally been situated at the fundus, from which it had accidentally fallen to the lower part of the uterus. Portal, Levret, Roederer, and especially our own country- man Rigby, where among those whose observations tended to improve the state of obstetrical knowledge as to its real nature. To Rigby we owe the term " unavoiolahle hemorrhage" as a synonym for placenta proevia, and as distinguishing hemorrhage from this source from that resulting from separation of the placenta at its more usual position, termed by him, in contra-distinction, " accidental hemorrhage." These names, adopted by most writers on the subject, are obviously mis- leading, as they assume an essential distinction in the etiology of the hemorrhage in the two classes of cases, which is not alway warranted. 1 [In the statistical tables of Trask 1 and King, 2 which collectively furnish the cases of 245 women, the number of whose pregnancies is noted, we find that the largest number of placentae prsevise occurred in the second pregnancy, after which they grad- ually declined. Thus we find 23 placental presentations in primiparse, 49 in second labors, 31 in third, 30 in fourth, and 29 in fifth. One-fifth then of all the cases were second pregnancies ; and nearly one-third, first and second. The sixth pregnancies in both Trash's and King's record, are almost exactly the same as the proportion in primiparse. The belief in the greater frequency, after several pregnancies is, there- fore, not well founded. — Ed.] [i Prize essay of Dr. James D. Trask. of N. Y., Trans. Am. Med. Ass. ISo/i, p. 663.') [ 2 Statistics of Placenta Prsevia, collected from the practice of physicians iu the State of Indiana by Dr. Enoch W. King, of Galena, Ind., 1S79, 8vo. pp. 50, cases, 11*2.] HEMORRHAGE BEFORE DELIVERY. 395 It is of the utmost importance to a right understanding of the nature and treatment of placenta prasvia that we should fully under- stand the source of the hemorrhage, and the manner of its produc- tion ; but we shall be able to discuss this subject better after a description of the symptoms. Symptoms. — Although the placenta must occupy its unusual site from the earliest period of its formation, it rarely gives rise to appre- ciable symptoms before the last three months of utero- gestation. It is far from unlikely, however, that such an abnormal situation of the placenta may produce abortion in the earlier mouths, the site of its attachment passing unobserved. Sudden Flow of Blood. — The earliest symptom which causes suspi- cion is the sudden occurrence of hemorrhage, without any appreciable cause. The amount of blood lost varies considerably. In some cases the first hemorrhage is comparatively slight, and is soou spontaneously arrested ; but, if the case be left to itself, the flow after a lapse of time — it may be a few days, or it may be weeks — again commences in the same unexpected way, and each successive hemorrhage is more profuse. The losses show themselves at different periods. They rarely begin before the end of the sixth month, more often nearer the full period, and sometimes not until labor has actually com- menced. The hemorrhage very often coincides with what would have been a menstrual period ; doubtless on account of the physio- logical congestion of the uterine organs then present. Should the first loss not show itself until at or near the full time, it may be tremendous, and a few moments may suffice to place the patient's life in jeopardy. Indeed it may be safely accepted as an axiom, that once hemorrhage has occurred, the patient is never safe ; for excessive losses may occur at any moment without warning, and when assist- ance is not at hand. It often happens that premature labor comes on after one or more hemorrhages. In any case of placenta prsevia, when labor lias commenced, whether premature or at the full time, the hemorrhage may become excessive, and with each pain fresh portions of placenta may be de- tached, and fresh vessels torn and left open. Under these circum- stances the blood often escapes in greater quantity with each suc- cessive pain, and diminishes in the Intervals. This has long been looked upon as a diagnostic mark by which we can distinguish be- tween the so-called " unavoidable" 'and " accidental" hemorrhage ; in the latter the flow being arrested during the pains. The distinc- tion, however, is altogether fallacious. The tendency of uterine contraction in placenta praevia, as in all other forms of uterine hemorrhage, is to constrict the vessels from which the blood escapes, and so to lessen the flow. The apparently increased flow during 'the pains depends on the pains forcing out blood which has already escaped from the vessels. In one way up to a certain point, the pains do favor hemorrhage, by detaching fresh portions of placenta; but the actual loss takes place chiefly during the intervals, and not during the continuance of contraction. 896 LABOR. Results of Vaginal Examination. — On vaginal examination, if the os be sufficiently open to admit the finger, which it generally is on account of the relaxation produced by the loss of blood, we shall almost always be able to feel some portion of presenting placenta. If it be a central implantation, we shall find the upper aperture of the cervix entirely covered by a thick, boggy mass, which is to be distinguished from a coagulum by its consistence, and by its not breaking down under the pressure of the finger. Through the pla- cental mass we may feel the presenting part of the foetus ; but not as distinctly as when there is no. intervening substance. In partial placental presentations the bag of membranes, and above it the head or other presentation, will be found to occupy a part of the circle of the os, the rest being covered by the edge of the placenta. In mar- ginal presentations we may only be able to make out the thickened edge of the after-birth, projecting at the rim of the os. If the cer- vix be high, and the gestation not advanced to term, these points may not be easy to make out, on account of the difficulty of reaching the cervix; and, as accurate diagnosis is of the utmost importance, it is proper to introduce two fingers, or even the whole hand, so as thoroughly to explore the condition of the parts. The lower portion of the uterine ovoid may be observed to be more than usually thick and fleshy ; and Gendrin has pointed out that ballottement cannot be made out. The accuracy of our diagnosis may be confirmed, in doubtful cases, by finding that the placental bruit is heard over the lower part of the uterine tumor. Dr. Wallace 1 has suggested that vaginal auscultation may be ser- viceable in diagnosis, and states that, by means of a curved wooden stethoscope, the plaeental bruit may be heard with startling distinct- ness. This is, however, a manoeuvre that can hardly be generally carried out in actual practice. The Source of Hemorrhage. — It is now generally admitted by au- thorities that the immediate source of the hemorrhage is the lacerated utero-placental vessels. Only a few years ago Sir James Simpson advocated with his usual energy, the theory, sustained by his pre- decessor, Dr. Hamilton, that the chief, if not the only, source of hemorrhage was the detached portion of the placenta itself. He argued that the blood flowed from the portion of the placenta which was still adherent into that which was separated, and escaped from the surface of the latter; and on this supposition he based his prac- tice of entirely separating the placenta, having observed that, in many cases in which the after-birth had been expelled before the child, the hemorrhage had ceased. The fact of the cessation of the hemorrhage, when this occurs, is not doubted ; but Simpson's expla- nation is contested by most modern writers, prominent among whom is Barnes, who has devoted much study to the elucidation of the sub- ject, He points out that the stoppage of the hemorrhage is not clue to the separation of the placenta, but to the preceding or accompany- ing contraction of the uterus, which seals up the bleeding vessels, J Edin. Med. Journ., Nov. 1872. HEMORRHAGE BEFORE DELIVERY. 397 just as it does in other forms of hemorrhage. The site of the loss was actually demonstrated by the late Dr. Mackenzie in a series of experiments, in which he partially detached the placenta in pregnant bitches, and found that the blood flowed from the walls- of the uterus, and not from the detached surface of the placenta. The arrange- ment of the large venous sinuses, opening as they do on the uterine mucous membrane, favors the escape of blood when they are torn across; and it is from them, possibly to some extent also from the uterine arteries, that the blood comes, just as in post-partuin hemor- rhage, when the whole, instead of a part, of the placental side is bared. Causes of Hemorrhage. — Various explanations have been given of the causes of the hemorrhage. For long it was supposed to depend on the gradual expansion of the cervix during the latter months of pregnancy, which separated the abnormally placed placenta. It has been seen, however, that this shortening of the cervix is apparent only, and that the cervical canal is not taken up into the uterine cavity during gestation, or, at all events, only during the last week or so. This, therefore, cannot be admitted as an explanation of pla- cental separation. Jacquemier proposed another theory which has been adopted by Cateaux. He maintains that during the first six months of utero-gestation the superior portion of the uterus is more especially developed, as shown by the pyriform shape of the fundus during the time; and that, as the placenta is usually attached in that situation, and then attains its maximum of development, its relations to its attachments are undisturbed. During the last three months of pregnancy, on the contrary, the lower segment of the uterus develops more than the upper, while the placenta remains nearly stationary in size; the inevitable result being a loss of proportion between the cervix and the placenta, and the detachment of the latter. There are various objections which can be brought against this theory; the most important being that there is no evidence at all to show that the lower segment of the uterus does expand more in proportion than the upper during the lattsr months of pregnancy. Barnes's theory is based on the supposition that the loss of relation between the uterus and placenta is caused by excess of growth on the part of the placenta itself over that of the cervix, which is not adapted for its attachment. The placenta, on this hypothesis, grows away from the site of its attachment, and hemorrhage results. It will be observed that neither this theory, nor that propounded by Jacque- mier, are readily reconcilable with the fact that hemorrhage fre- quently does not begin until labor has commenced at term. Inasmuch as the loss of relation between the placenta and its attachments, which they both presuppose, must exist in every case of placenta previa, hemorrhage should always occur during" some part of the last three months of pregnancy. Matthews Duncan 1 has recently in- vestigated the whole subject at length, and maintains that the hemor- rhages are accidental, not unavoidable, being due to precisely similar 1 Edin. Med. Journ., Xov. 1873, and Brit. Med. Journ., Nov. 1S73. 398 LABOR, causes are those which give rise to the occasional hemorrhages when the placenta is normally placed. The abnormal situation of the pla- centa, of course, renders these causes more apt to operate ; but in their action he believes them to be precisely similar to those of acci- dental hemorrhage, properly so called. Separation of the placenta from expansion of the cervix, he believes to be the cause of hemor- rhage after labor has begun, and then it may strictly be called una voidable: but hemorrhage is comparatively seldom so produced during the continuance of pregnancy. "There are," says Duncan, "four ways in which this kind of hemorrhage may occur: — " 1. By the rupture of a utero-placental vessel at or about the in- ternal os uteri. " 2. By the rupture of a marginal utero-placental sinus within the area of spontaneous premature detachment, when the placenta is in- serted not centrally or covering the internal os, but with a margin at or near the central os. u 8. By partial separation of the placenta from accidental causes, such as a jerk or fall. "4. By a partial separation of the placenta, the consequence of uterine pains producing a small amount of dilatation of the internal os. Such cases may be otherwise described as instances of miscar- riage commencing, but arrested at a very early stage." I see no reason to doubt the possibility of hemorrhage being due, in many cases, to the first three causes, and in its production it would strictly resemble accidental hemorrhage. The fourth heading refers the hemorrhage to partial separation, in consequence of commencing dilatation of the cervix, but it explains the dilatation by the suppo- sition of commencing miscarriage. This latter hypothesis seems to be as needless as those which presuppose a want of relation between the placenta and its attachments. We know that, quite independ- ently of commencing miscarriage, uterine contractions are constantly occurring during the continuance of pregnancy. There is reason to suppose that these contractions do not affect the cervical, as well as the fundal portions of the uterus ; and in cases in which the placenta is situated partially or entirely over the os, one or more stronger contractions than usual may, at any moment, produce laceration of the placental attachments in that neighborhood. Pathological Changes in the Placenta. — A careful examination of the placenta may show pathological changes at the site of separation, such as have been described by Gendrin, Simpson, and other writers. They probably consist of thrombosis in the placental cotyledons, and effused blood-clots, variously altered and discolorized, according to the lapse of time since separation took place. Changes occur in the portion of the placenta overlying the os uteri, whether separation has occurred or not. There may be atrophy of the placental struc- ture in this situation, as well as changes of form, such as complete or partial separation into two lobes, the junction of which overlies the os uteri. 1 » Sinelius, Arch. Gen. ole Med., vol. ii. 1861. HEMORRHAGE BEFORE DELIVERY. 399 Natural Termination when Placenta presents. — The history of de- livery, if left to nature, is specially worthy of study, as guiding to proper rules of treatment. It sometimes happens, when the pains are very strong and the delivery rapid, that labor is completed with- out any hemorrhage of consequence. ''Although,' 1 says Cazeaux, ''hemorrhage is usually considered to be inevitable under such cir- cumstances, yet it may not appear even during the labor; and the dilatation of the os uteri may be effected without the loss of a drop of blood." Again, Simpson conclusively showed, that when the placenta was expelled before the birth of the child, all hemorrhage ceased. Barnes's theory of placenta prsevia, which has been pretty gene- rally adopted, explains satisfactorily both these classes of cases. He describes the uterine cavity as divisible into three zones or regions. When the placenta is situated in the upper or middle of these zones, no separation or hemorrhage need occur during labor. When, however, it is situated partially or entirely in the lower or cervical zone, the expansion of the cervis during labor must produce more or less separation, and consequent loss of blood. As soon as the previous portion of the placenta is sufficiently separated, provided contraction of the uterine tissue be present to seal up the mouths of the vessels, hemorrhage no longer takes place. The placenta may not be entirely detached, but no further hemorrhage occurs, in con- sequence of the remaining portion being engrafted on the uterus bevond the region of unsafe attachment. In the former, then, of these classes of cases, the absence of hemor- rhage is explained on this theory, by the pains being sufficiently rapid and strong to complete the separation of the placental attach- ment from the lower cervical zone before flooding had taken place ; in the latter, it ceases, not necessarily because the entire placenta is expelled, but because of its detachment from the area of dangerous implantation. The amount of cervical expansion required for this purpose varies in different cases. Dr. Duncan 1 estimates the limit of the spontaneous detaching area to be a circle of -IJ inches diameter, and that, after the cervix has expanded to that extent, no further separation or hemorrhage takes place. To admit of the passage of a full-sized head, Barnes estimates that expansion to about a circle of 6 inches diameter is necessary; on the other hand he has sometimes observed "that the hemorrhage has completely stopped when the os uteri had opened to the size of the rim of a wineglass, or even less." It will be seen then that in this, as in every other form of puer- peral hemorrhage, the tendency of uterine contraction is to check the hemorrhage ; and that, provided the pains are sufficiently ener- getic, nature -may be capable of stopping the flooding without arti- ficial aid. It is but rarely, however, that she can be trusted for the purpose ; and we shall presently see that these theoretical views have an important practical bearing on the subject of treatment. 1 Obst. Trans., vol. xv. 400 LABOR. Prognosis. — The prognosis to both the mother and child is cer- tainly grave in all cases of placenta previa. Bead, in his treatise on placenta previa, estimates the maternal mortality, from the statis- tics of a large number of cases, as 1 in 4 J cases, and Churchill as 1 in 3. This is unquestionably too high an estimate, and based on statistics the accuracy of which cannot be relied on. The mortality will, of course, greatly depend on the treatment adopted. Doubtless, if cases were left to nature, the result would be quite as unfavorable as Bead supposes. But if properly managed, much more successful results may safely be anticipated. Out of 64 cases, recorded by Barnes, the deaths were 6, or 1 in 10J. Under any circumstances the risks to the mother are very great. Churchill estimates that more than half the children are lost. The reasons for the great danger to the child are very obvious, subjected as it is to the risk of asphyxia from the loss of the maternal blood, and from its respira- tion being carried on during labor by a placenta which is only par- tially attached ; many children also perish from prematurity, or from mal- presentation. Treatment. — Whenever, in the latter months of pregnancy, a sudden hemorrhage occurs, the possibility of placenta previa will naturally suggest itself; and, by a careful vaginal examination, which under such circumstances should always be insisted on, the existence of this complication will generally be readily ascertained. It is seldom that the os is not sufficiently dilated to enable us to satisfy ourselves when the placenta is presenting. Is it justifiable to allow the Pregnancy to Continue ?■ — The first ques- tion that will arise is, are we justified in temporizing, using means to check the hemorrhage, and allowing the pregnancy to continue ? This is the course which has generally been recommended in works on midwifery. We are told to place the patient on a hard mattress, not to heat or overburden her with clothes, to keep her absolutely at rest, to have the room cool and well-aired, to apply cold cloths to the vulva and lower part of the abdomen, to administer cold and acidulated drinks in abundance, and to prescribe acetate of lead and opium, or gallic acid, on account of their supposed hemostatic effect. Of late years the judiciousness of these recommendations has been strongly contested. Not long ago an interesting discussion took place at the Obstetrical Society of London, 1 on a paper in which Dr. Greenhalgh advised the immediate induction of labor in all cases of placenta previa. 2 No less than six metropolitan teachers of mid- wifery took part in it, and, although they differed in details, they all agreed as to the inaclvisability of allowing pregnancy to progress when the existence of placenta previa had been distinctly ascer- tained. The reasons for this course arc obvious and unanswerable. The labor, indeed, verv often comes on of its own accord ; but should it not do so, the patient's life must be considered to be always in » Obst. Trans., vol. vi. p. 188. [ 2 That oases of premature delivery have no special element of danger, will also appear from Dr. King's record; as there were 23 recoveries in 29 cases. Eleven chil- dren, two at 6^ months, were also saved. — Ed.] HEMORRHAGE BEFORE DELIVERY. 401 jeopardy until the case is terminated, for no one can be sure that most dangerous, or even fatal flooding may not at any moment come on ; and the nearer to term the patient is, the greater the risk to which she is subjected. Nor is the safety of the child likely to be increased by delay. Provided it has arrived at a viable age, the chances of its being born alive may be said to be greater if preg- nancy be terminated at once, than if repeated floodings occur. I think, therefore, that it may be safely laid down as an axiom, that no attempt should be made to prevent the termination of pregnancy, but that our treatment should rather contemplate its conclusion as soon as possible. An exception may, however, be made to this rule wjien the hemorrhage occurs for the first time before the seventh month of utero-gestation. The chances of the child surviving would then be very small, and if the hemorrhage be not alarming, as at that early period is likely to be the case, the measures indicated above may be employed, in the hope of carrying on the pregnancy umtil there is a prospect of the patient being delivered of a living child. But little benefit is likely to accrue from astringent drugs. Perfect rest in bed is more likely to be beneficial than anything else ; and astringent vaginal pessaries, of matico or perchloride of iron, might be used with advantage as local haemostatics. Various Metltods of Treatment. — When the period of pregnancy, or the urgenc} T of the case, determines us to forego any attempt at tem- porizing, there are various plans of treatment to be considered. These are chiefly — 1. Puncture of the membranes. 2. Phila- centa acting as an obstacle to contraction over the seat of union, while the rest of the organ was free to contract. Some men of very extensive experience still hold to this view. Others having equal advantages claim that the body of the organ contracts uniformly ; that the internal os may be spasmodically constricted ; and the cervix at the same time remain dilated as a flaccid bag, or funnel-shaped vestibule. This latter view is based upon the belief that the arrangement of the circular muscular fibres is such that a violent linear contraction in the body of the uterus must be an anatomical impossibility. The recent discussions upon " tetanoid constriction of the uterus," as a most obstinate form of dystocia, have revived the question as to the exact seat of spasm, and may lead eventually to an exact determination of the zone of fibres in- volved. — En.] 2 Rigby's Midwifery, p. 225. HEMORRHAGE AFTER DELIVERY. 413 ahove the contraction are in a state of inertia ; were the higher parts of the uterus even in moderate action, the hour-glass contrac- tion would soon be overcome." 1 If placental expression were always employed, if it were the rule to effect the expulsion of the placenta by a vis a tergo, instead of extracting by a vis a fronte, I feel con- fident that these irregular and spasmodic contractions — of the influ- ence of which in producing hemorrhage there can be no question — would rarely, if ever, be met with. It is to be observed that even in these cases, it is not because the uterus is in a state of partial con- traction, but because it is in a state of partial relaxation, that hemor- rhage ensues. Placental Adhesions. — Adhesions of the placenta to the uterine parietes may cause hemorrhage, especially if they be partial, and the remainder of the placentae be detached. The frequency of these has been over-estimated. Many cases believed- to be examples of adherent placentae are, in reality, only cases of placentae retained from uterine inertia. The experience of all avIio see much midwifery will probably corroborate the observation of Braun, that "abnormal adhesion and hour-glass contraction are more frequently encountered in the experience of the young practitioner, and they diminish in frequency in direct ratio to increasing years.'' 2 The cause of adhe- sion is often obscure, but it most probably results from a morbid state of the decidua, which is produced by antecedent disease of the uterine mucous membrane : then the adhesion is apt to recur in sub- sequent pregnancies. The decidua is altered and thickened, and patches of calcareous and fibrous degeneration may be often found on the attached surface of the placenta. Most frequently the placenta is only partially adherent; patches of it remain firmly attached to the uterus, while the rest is separated : hence the uterine walls re- main relaxed, and hemorrhage frequently follows. The diagnosis and management of these very troublesome cases will be found de- scribed under the head of treatment (p. -117). Constitutional Predisposition to Fhoding. — Finallv I think it must be admitted that there are some women who really merit the appel- lation of "Flooders, 1 ' which has been applied to them, and who, do what we may, have the most extraordinary tendency to hemorrhage after delivery. I do not think that these cases, however, are by any means so common as some have supposed. 3 I have attended several patients who have nearly lost their lives from post-partum hemor- rhage in former labors, some who have suffered from it in every pre- ceding confinement, and I have only met with two cases in which the assiduous use of preventive treatment failed to avert it. In these (one of which I have elsewhere published in detail 4 ), in spite of all my efforts, I could not succeed in keeping up uterine contraction, and the patients would certainly have lost their lives were it not for the means which modern improvements have fortunately placed at our disposal for producing thrombosis in the mouths of the bleeding 1 Researches in Obstetrics, p. 389. 2 Braun's Lectures, 1869. [ 3 See remarks on quinia, p. 338. — Ed.] 4 Obst. Journ., vol. i. 414 LABOR. vessels. The nature of these rare cases requires farther investiga- tion ; possibly they may, to some extent, be the subjects of the so- called hemorrhagic diathesis. Sians and Symptoms. — The loss of blood may commence immedi- ately atter the birth of the child, before the expulsion of the placenta, or not until some time afterwards, when the contracted uterus has again relaxed. It may commence gradually, or suddenly ; in the latter case, it may begin with a gush, and in the worst form the bed- clothes, the bed, and even the floor, are deluged with the blood which, it is no exaggeration to say, is pouring from the patient. If now the hand be placed on the abdomen, we shall miss the hard round ball of the contracted uterus, which will be found soft and flabby, or we may even be unable to make out its contour at all. If the hemor- rhage be slight, or if we succeed in controlling it at once, no serious consequences follow ; but if it be excessive, or if we fail to check it, the gravest results ensue. Exhaustion in Extreme Cases. — There are few sights more appal- ling to witness than one of the worst cases of post partum hemorrhage. The pulse becomes rapidly affected, and may be reduced to a mere thread, or it may become entirely imperceptible. Syncope often comes on, not in itself always an unfavorable occurrence, as it tends to promote thrombosis in the venous sinuses. Or, short of actual syncope, there may be a feeling of intense debility and faintness. Extreme restlessness soon supervenes, the patient throws herself about the bed, tossing her arms wildly above her head ; respiration becomes gasping and sighing, the "besoin de respirer" is acutely felt, and the patient cries out for more air ; the skin becomes deadly cold, and covered with profuse perspiration ; if the hemorrhage continue unchecked, we next may have complete loss of vision, jactitation, convulsions, and death. Formidable as such symptoms are, it is satisfactory to knoAv that recovery often takes place, even when the powers of life seem reduced to the lowest ebb. If we can check the hemorrhage -while there is still some power of reaction left, however slight, we may not unrea- sonably hope for eventual recovery. The constitution, however, may have received a severe shock, and it may be months, or even years, before the patient recovers from the effects of only a few minutes' hemorrhage. A death-like pallor frequently follows these excessive losses, and the patient often remains blanched and exsanguine for a long time. Preventive Treatment. — The preventive treatment of post-partum hemorrhage should be carefully practised in every case of labor, however normal. If the practitioner make a habit ot never remov- ing his hand from the uterus after the birth of the child until the placenta is expelled, and of keeping up continuous uterine contrac- tion for at least half an hour after delivery is completed, not neces- sarily by friction on the fundus, but by simply grasping the contracted womb with the palm of the hand and preventing its undue relaxation, cases of post- partum flooding will seldom be met with. As a rule we should, I think, not apply the binder until at least that time has HEMORRHAGE AFTER DELIVERY. 415 elapsed. The hinder is an effective means of keeping up, but not of producing, contraction, and it should never be trusted to for the latter purpose. If it be put on too soon, the uterus may relax under it, and become filled with, clots without the practitioner knowing any- thing about it ; whereas this cannot possibly take place as long as the uterine globe is held in the hollow of the hand. I have seen more than one serious case of concealed hemorrhage result from the too common habit of putting on the binder immediately after the removal of the placenta. I believe also, as I have formerly said, that it is thoroughly good practice to administer a full dose of the liquid extract of ergot in all cases after the placenta has been ex- pelled, to insure persistent contraction, and to lessen the chance of blood-clots being retained in utero. These are the precautions which should be used in all cases alike ; but when we have reason to fear the occurrence of hemorrhage, from the history of previous labors or other cause, special care should be taken. The ergot should be given, and preferably in the form of the subcutaneous injection of ergotine, before the birth of the child, when the presentation is so far advanced that we estimate that labor will be concluded in from ten to twenty minutes, as we can hardly expect the drug to produce any effect in less time. Particular atten- tion, moreover, should then be paid to the state of the uterus. Every means should be taken to insure regular and strong contraction, and it is advisable to rupture the membranes early, as soon as the os is dilated or dilatable, to insure stronger uterine action. If any tend- ency to relaxation occur after delivery, a piece of ice should be passed into the vagina, or into the uterus. Should coagnla collect in the uterus, they may be readily expelled by firm pressure on the fundus, and the finger should be passed occasionally up to the cervix, and any which arc felt there should be gently picked away. We should be specially on our guard in all cases in which the pulse does not fall after delivery. If it beat at 100 or more some ten minutes or a quarter of an hour after the birth of the child, hemorrhage not nnfrequently follows; anil, hence, it is a good prac- tical rule, which may save much trouble, that a patient should never be left unless the pulse has fallen to its natural standard. Curative Treatment. — As there are only two means which nature adopts in the prevention of post-partum hemorrhage, so the remedial measures also may be divided into two classes. 1. Those which act by the production of uterine contraction. 2. Those which act by producing thrombosis in the vessels. Of these the first are the most commonly used ; and it is only in the worst cases, in which they have been assiduously tried and have failed, that we resorted to those com- ing under the second heading. Uterine Pressure. — The patient should be placed on her back, in which position Ave can more readily command the uterus, as well as attend to her general state. If the uterus be found relaxed and full of clots, by firmly grasping it in the hand contraction may be evoked, its contents expelled, and further hemorrhage at once arrested. Should this fortunately be the case, we must keep up contraction by 416 LABOR. gently kneading the uterus, until we are satisfied that undue relaxa- tion will not recur. The powerful influence of friction in promoting contraction cannot be doubted, and nothing will replace it ; no doubt it is fatiguing, but as long as it is effectual it must be kept up. No roughness should be used, as we might produce subsequent injury, but it is quite possible to use considerable pressure without any violence. Another method of applying uterine pressure has been strongly advocated by Dr. Hamilton, of Falkirk, and it may be serviceable where there is a constant draining from the uterus, and a capacious pelvis. It consists in passing the fingers of the right hand high up in the posterior cul-de-sac of the vagina, so as to reach the posterior surface of the uterus, while counter-pressure is exercised by the left hand through the abdomen. The anterior and posterior walls of the uterus are thus closely pressed together. Administration of Ergot. — During the time that pressure is being npplied, attention can be paid to general treatment; and in giving his directions to the by-standers the practitioner should be calm and collected, avoiding all hurry and excitement. A full dose of ergot should be adminstered, and if one have already been given, it should, be repeated. We cannot, however, look upon ergot as anything but a useful accessory, and it is one which requires considerable time to operate. The hypodermic use of ergotine offers the double advan- tage, in severe cases, of acting with greater power, and much more rapidly than the usual method of administration. It should, there- fore, always be used in preference. Stimulants. — The sudden flow will probably have produced ex- haustion and a tendency to syncope, and the administration of stimu- lants will be necessary. The amount must be regulated by the state of the pulse, and the degree of exhaustion. There is no more ab- surd mistake, however, than implicitly relying on the brandy bottle to check post-partum hemorrhage. In the worst cases absorption is in abeyance, and brandy may be poured down in abundance, the prac- titioner believing that he is rousing his patient, while he is, in fact, only filling the stomach with a quantity of fluid, which is eventu- ally thrown up unaltered. I have more than once seen symptoms, produced by the over-free use of brandy in slight floodings, which were certainly not those of hemorrhage. I remember on one occa- sion being summoned by a practitioner, with a view to transfusion, to a patient who was said to be insensible and collapsed from hemor- rhage. I found her, indeed, unconscious ; but with a flushed face, a bounding pulse, a firmlv contracted uterus, and deep stertorous breathing. On inquiry I ascertained that she had taken an enor- mous quantity of brandy, which had brought on the coma of pro- found intoxication, while the hemorrhage had obviously never been excessive. Hypodermic Injection of Ether. — The hypodermic injection of sul- phuric ether has been recommended as a powerful stimulant in cases in which exhaustion is very great. A fluid rachm may be in- HEMORRHAGE AFTER DELIVERY. 417 jected, and the remedy is worthy of trial, when the tendency to syn- cope is extreme. Fresh Air, etc. — The windows should be thrown widely open, to allow a current of fresh cold air to circulate freely through the room. The pillows should be removed, the head kept low, and the patient should be assiduously fanned. Emptying of Uterus.— -If bleeding continue, or if it commence be- fore the placenta is expelled, the hand should be carefully and gently passed into the uterus, and its cavity cleared of its contents. The mere presence of the hand within the uterus is a powerful incitor of uterine action. When the placenta is retained it is the more essen- tial, as the hemorrhage cannot possibly be checked as long as the uterus is distended by it, During the operation the uterus should bd supported by the left hand externally, and, by using the two hands in concert, the chances of injuring the textures are greatly lessened. Treatment of Hour-glass Contraction. — If the so-called " hour-glass contraction"' be present, or if the placenta be morbidly adherent, the operation will be more difficult, and will require much judgment and care. The spasmodic contraction of the inner os in the former case may generally be overcome by gentle and continuous pressure of the fingers passed within the contraction, while the uterus is supported from without. By this means, too, further hemorrhage can in most cases be controlled, until tlie spasm is sufficiently relaxed to admit of the passage of the hand. Signs of Adherent Placenta. — There are no very reliable signs to indicate morbid adhesion of the placenta, previous to the introduc- tion of the hand. The following are the symptoms as laid down by Barnes, any of which might, however, accompany non-detachment of the placenta, unaccompanied by adhesion : " You may suspect mor- bid adhesion, if there have been unusual difficulty in removing the placenta in previous labors ; if, during the third stage, the uterus contracts at intervals firmly, each contraction being accompanied by blood, and yet, on following up the cord, you feel the placenta in titer o ; if on pulling on the cord, two fingers being pressed into the placenta at the root, you feel the placenta and uterus descend in one mass, a sense of dragging pain being elicited ; if, during a pain the uterine tumor does not present a globular form, but be more promi- nent than usual at the place of placental attachment,'' 1 Treatment of Adherent Placenta. — The artificial removal of an ad- herent placenta is always a delicate and anxious operation, which, however carefully performed, must of necessity expose the patient to the risk of injury to the uterine structures, and of leaving behind portions of placental tissue, which may give rise to secondary hemor- rhage, or septicaemia. The cord will guide the hand to the site of attachment, and the fingers must be very gently insinuated between the lower edge of the placenta and the uterine wall ; or, if a portion be already detached, we may commence to peel off the remainder at 1 Obstetric Operations, p. 440. 418 LABOR. that spot. Supporting the uterus externally, we carefully pick off as much as possible, proceeding with the greatest caution, as it is by no means easy to distinguish between the placenta and the uterus. " At the best it is far from easy to remove all, and it is wiser to separate only what we readily can, than to make too protracted efforts at com- plete detachment. When it is found to be impossible to detach and remove the whole, or a great part of the placenta, Ave cannot but look upon the further progress of the case with considerable anxiety. The retained portions may be, ere long, spontaneously detached and expelled, or they may decompose and give rise to fetid discharge and septic infection. Such cases must be treated by antiseptic intra- uterine injections, so as to lessen the risk of absorption as much as possible ; but until the retained masses have been expelled, and the discharge has ceased, the patient must be considered to be in consider- able clanger. In a few rare cases, there is reason to believe that considerable masses of retained placental tissue have been entirely absorbed. It is difficult to understand so strange a phenomenon, but several well-authenticated cases are recorded, in which there seems no reason to doubt that the retained placenta was removed in this way. 1 [The placenta may be retained for a long period, and finally be sus- pected of being a malignant growth. I saw one case recently in which the uterus had been inverted for three years and had a mass like a malignant growth upon its fundus. When etherized, and placed in the knee- chest position, the uterus replaced itself, as soon as air was introduced into the vagina. — Ed.] Excitement of Reflex Action by Cold, etc. — Various means are used for exciting uterine contraction by reflex stimulation. Amongst the most important of these is cold. In patients who are not too ex- hausted to respond to the stimulus applied, it is of extreme value. But, to be of use, it should be used intermittently, and not continu- ously. Pouring a stream of cold water from a height on the abdomen is a not uncommon, but bad, practice, as it deluges the patient and the bedding in water, which may afterwards act injuriously. Flap- ping the lower part of the abdomen with a wet towel is less objec- tionable. Ice can generally be obtained, and a piece should be in- troduced into the uterus. This is a very poAverful haemostatic, and often excites strong action when other means fail. I constantly em- ploy it, and have never seen any bad results follow. A large piece of ice may also be held over the fundus, and removed, and re-applied from time to time. Iced water may be injected into the rectum. A very powerful remedy is washing out the uterine cavity with a stream of cold water, by means of the vaginal pipe of a Higginson's syringe carried up to the fundus. Another means of applying cold, said to be ver}^ effectual, is the application of the ether spray, such as is used for producing local anaesthesia, over the loAver part of the abdomen. 2 All these remedies, however, depend for their good re- 1 See an interesting paper by Dr. Thrush on " Retention of the Placenta in Labor at Term." Am. Journ. of Obstet., July, 1877. 2 Griffiths, Practitioner, March, 1877. HEMORRHAGE AFTER DELIVERY. 419 suits on the fact of the patient being in a condition to respond to stimulus ; and their prolonged use, if they fail to excite contraction rapidly, will certainly prove injurious. Kigby used to look upon the application of the child to the breast as one of the most certain in- citors of uterine action. It may be of service, after the hemor- rhage has been checked, in keeping up tonic contraction, and should therefore not be omitted; but we certainly cannot waste time in in- ducing the child to suck in the face of the actual emergency. Intra-uterine Injections of Warm Water. — Of late, intra-uterine in- jections of warm Avater, at a temperature of from 100° to 120 3 , have been highly recommended as a powerful means of arresting post- partum hemorrhage, often proving effectual Avhen all other treatment has failed. The number of published cases in which it has proved of great value is now considerable. The present master of the Kotunda, Dr. Lornbe Atthill, has recorded 16 cases 1 in which it checked hemorrhage at once, in many of which ergot, ice, and other means had failed. He speaks of it as especially useful in those troublesome cases in which the uterus alternatelv relaxes and hardens, and resists all our efforts to produce permanent contraction. My own experience of this treatment is very favorable. I have now used it in several cases, in some of which the tendency to hemor- rhage was very great, and in every instance it has at once produced strong uterine action, and instantly checked the flow. It is, more- over, much more agreeable to the patient than cold applications. I think it cannot be doubted that we have in these warm irrigations a valuable addition to our methods of treating uterine hemorrhage. State of the Bladder. — The late Dr. Earle pointed out 2 that a dis- tended bladder often prevents contraction, and to avoid the possi- bility of this the catheter should be passed. Plugging of the Vagina. — Plugging of the vagina has often been used. It is only necessary to mention it for the purpose of insisting on its absolute inapplicability in all cases of post-partum hemorrhage ; the only effect it could have would be to prevent the escape of blood externally, which might then collect to any extent in the cavity of the uterus. Compression of the abdominal aorta is highly thought of by many continental authorities, but is little known or practised in this countiy. It has been objected to by some on the theoretical ground that the hemorrhage is chiefly venous, and not arterial, and that it would only favor the reflux of venous blood into the vena cava. Cazeaux points out that, on account of the close anatomical relations between the aorta and the vena cava, it is hardly possible to compress one vessel without the other. The backward flow of blood, therefore, through the vena cava may also be thus arrested. There is strong evidence in favor of the occasional utility of compression. Its chief recommendation is, that it can be practised immediately, and by an assistant who can be shown how to apply the pressure. It is most 1 Lancet, February 9, 1S78. 2 Earle's Flooding after Delivery, p. 163. 420 LABOR. likely to prove useful in sudden and severe hemorrhage, and, if it only control the loss for a few moments, it gives us time to apply other methods of treatment. As a temporary expedient, therefore, it should be borne in mind, and adopted when necessary. It has the great advantage of supplementing, without superseding, other and more radical plans of treatment. The pressure is very easily applied, on account of the lax state of the abdominal walls. The artery can readily be felt pulsating above the fundus uteri, and can be compressed against the vertebrae by three or four fingers applied lengthways. Baudelocque, who was a strong advocate of this pro- cedure, states that he has, on several occasions, controlled an other- wise intractable hemorrhage in this way, and that he, on one occasion, kept up compression for four consecutive hours. Cazeaux believes that compression of the aorta may have a further advantageous effect in retaining the mass of the blood in the upper part of the body, and thus lessening the tendency to syncope and collapse. If an aortic tourniquet, such as is used for compressing the vessel in cases of aneurism, could be obtained, it might be used with advantage in serious cases. Bandaging of the Extremities. — When the hemorrhage has been excessive, and there is profound exhaustion firm bandaging of the extremities, by preference with Esmarch's elastic bandages if they can be obtained, may be advantageously adopted, with the view of retaining the blood as much as possible in the trunk, and thus lessen- ing the tendency to syncope. As a temporary expedient in the worst class of cases it may occasionally prove of service. Infection of Styptics. — Supposing these means fail, and the uterus obstinately refuses to contract in spite of all our efforts — and, do what we may, cases of this kind will occur — the only other agent at our command is the application of a powerful styptic to the bleeding surface to produce thrombosis in the vessels. "The latter," says Dr. Ferguson, 1 alluding to this means of arresting hemorrhage, "appears to be the sole means of safety in those cases of intense flooding in which the uterus flaps about the hand like a wet towel. Incapable of contraction for hours, yet ceasing to ooze out a drop of blood, there is nothing apparently between life and death but a few soft coagula plugging iip the sinuses." These form but a frail barrier indeed, but the experience of all who have used the injection of a solution of perchloride of iron in such cases, proves that they are thoroughly effectual, and its introduction into practice is one of the greatest improvements in modern midwifery. Although this method of treating these obstinate cases is not new, since it was practised long ago in Germany, its adoption in this country is unquestionably due to the energetic recommendation of Dr. Barnes. Although the dangers of the practice have been strongly insisted on, and with a degree of acrimony that is to be regretted, I know of only one pub- lished case in which its use has been followed by any evil effects. Its extraordinary power, however, of instantly checking the most 1 Preface to Gooch On Diseases of Women, p. xlii. HEMORRHAGE AFTER DELIVERY. 421 formidable hemorrhage, has been demonstrated by the unanimous testimony of all who have tried it. As it is not proposed by any one that this means of treatment should be employed until all ordinary methods of evoking contraction have failed, and as, in cases of this kind, the lives of the patients are of necessity imperilled, we should be fully justified in adopting it, even if its possible injurious effects had been much more certainly proved. It is surely at any time justifiable to avoid a great and pressing peril by running a possible chance of a less one. Whenever, therefore, we have tried the plans above indicated in vain, no time should be lost in resorting to this expedient. No practitioner should attend a case of midwifery with- out having the necessary styptic with him. The best and most easily obtainable form of using the remedy is the "liquor ferri per- chloridi fortior" of the London Pharmacopoeia, which should be diluted for use with six times its bulk, of water. This is certainl}^ better than a weaker solution. The vaginal pipe of a Higginson's syringe, through which the solution has once or twice been pumped to exclude the air, is guided by the hand to the fundus uteri,-and the fluid injected gently over the uterine surface. The loose and flabby mucous membrane is instantaneously felt to pucker up, all the blood with which the fluid comes in contact is coagulated and the hemorrhage is immediately arrested. I think it is of importance to make sure that the uterus and vagina are emptied of clots before injection. In the only cases in which I have seen any bad symptoms follow, this precaution had been neglected. The iron hardened all the coagula, which remained in utero, and septicaemia supervened ; which, however, disappeared after the clots had been broken up and washed away by intra-uterine antiseptic injections. After we have resorted to this treatment, all further pressure on the uterus should be stopped. We must remember that we have now abandoned con- traction as an haemostatic, and are trusting to thrombosis, and that pressure might detach and lessen the coagula which are preventing the escape of blood. Other local astringents may be eventually found to be of use. Tincture of matico possibly might be serviceable, although I am not aware that it has been tried. Dupierris has advocated tincture of iodine, and has recorded 24 cases in which he employed it, in all without accident and with a successful issue. Penrose strongly re- commends common vinegar, which has the advantage of being always readily obtainable. But nothing seems likely to act so immediately or so effectual^, as the perchloride of iron. Hemorrhage from Laceration of Maternal Structures. — A word may here be said as to the occasional dependence of hemorrhage after delivery on laceration of the cervix, or other injury to the maternal soft parts. Duncan has narrated a case in which the bleeding came from a ruptured perineum. If hemorrhage continue after the uterus is permanently contracted, a careful examination should be made to ascertain if any such injury exist. Most generally the source of bleeding is the cervix, and the flow can be readily arrested by swab- 422 LABOR. bing the injured textures with a sponge saturated in a solution of the perchloride. Secondary Treatment. — The secondary treatment of post-partum hemorrhage is of importance. When reaction commences, a train of distressing symptoms often show themselves, such as intense and throbbing headache, great intolerance of light and sound, and general nervous prostration ; and, when these have passed away, we have to deal with the more chronic effects of profuse loss of blood. Nothing is so valuable in relieving these symptoms as opium. It is the best restorative that can be employed, but it must be administered in larger doses than usual. Thirty to forty drops of Battley's solution should be given by the mouth, or in an enema. At the same time the patient should be kept perfectly still and quiet, in a darkened room, and the visits of anxious friends strictly forbidden. Strong beef essence or gravy soup, milk, or eggs beat up with milk, and similar easily absorbed articles of diet, should be given frequently, and in small quantities at a time. Stimulants will be required ac- cording to the state of the patient, such as warm brandy and water, port wine, etc. Rest in bed should be insisted on, and continued much beyond the usual time. Eventually the remedies which act by promoting the formation of blood, such as the various prepara- tions of iron, will be found useful, and may be required for a length of time. • Transfusion. — Under the head of transfusion I have separately treated the application of that last resource in those desperate cases in which the loss of blood has been so excessive as to leave no other hope. Secondary Post-partum Hemorrhage. — In the majority of cases, if a few hours have elapsed after delivery without hemorrhage, we may consider the patient safe from the accident. It is by no means very rare, however, to meet with even profuse losses of blood coming on in the course of convalescence, at a time varying from a few hours, or clays, up to several weeks after delivery. These cases are de- scribed as examples of " secondary hemorrhage" and they have not received at all an adequate amount of attention from obstetric writers, inasmuch as they often give rise to very serious, and even fatal, results, and are always somewhat obscure in their etiology, and difficult to treat. We owe almost all our knowledge of this condition to an excellent paper by Dr. McClintock, of Dublin, who has collected characteristic examples from the writings of various authors, and accurately described the causes which are most apt to produce it. Profuse Lochial Discharge. — We must, in the first place, distin- guish between true secondary hemorrhage and profuse lochial dis- charge, continued for a longer time than usual. The latter is not a very uncommon occurrence, and is generally met with m cases m which involution of the uterus has been checked ; as by too early exertion, general debility, and the like. The amount of* the lochial discharge varies in different women. In some patients it habitually continues during the whole puerperal month, and even longer, but HEMORRHAGE AFTER DELIVERY. 423 not to an extent which justifies us in including it under the bead of hemorrhage. In such cases prolonged rest, avoidance of the erect posture, occasional small doses of ergot, and, it may be, after the lapse of some weeks, astringent injections of oak bark, or alum, will be all that is necessary in the way of treatment. True secondary hemorrhage is often sudden in its appearance and serious in its effects. McClmtock mentions 6 fatal cases, and Mr. Bassett, of Birmingham, 1 has recorded 13 examples which came under his own observation, 2 of which ended fatally. The Causes are either Constitutional or Local. — The causes may be either constitutional, or some local condition of the uterus itself. Among the former are such as produce a disturbance of the vascu- lar system of the body generally, or of the uterine vessels in particu- lar. The state of the uterine sinuses, and the slight barrier which the thrombi formed in them offer to the escape of blood, readily explain the fact of any sudden vascular congestion producing hemor- rhage. Thus mental emotions, the sudden assumption of the erect posture, any undue exertion, the incautious use of stimulants, a loaded condition of the bowels, or sexual intercourse shortly after delivery, may act in this way. McClintock records the case of a lady in whom very profuse hemorrhage occurred on the twelfth day after labor, when sitting up for the first time. Feeling faint after suckling, the nurse gave her some brandy, whereupon a gush of blood ensued, "deluging all the bed-clothes and penetrating through the mattress so as to form a pool on the floor." Here the erect posi- tion, the exquisite pain caused by nursing, and the stimulating drink, all concurred to excite the hemorrhage. In another instance the flooding Avas traced to excitement produced hy the sudden return of an old lover on the eighth day after labor. Moreau especially dwells on the influence of local congestion produced by a loaded con- dition of the rectum. Constitutional affections producing general debility, and an impoverished state of the blood, probably also may have the same effect. Blot specially mentions albuminuria as one of these, and Saboia states that in Brazil secondary hemorrhage is a common symptom of miasmatic poisoning, and can only be cured by change of air and the free use of quinine. 2 Local Causes. — Local conditions seem, however, to be more fre- quent factors in the production of secondary hemorrhage. These may be generally classed under the following heads : — ■ 1. Irregular and inefficient contraction of the uterus. 2. Clots in the uterine cavity. 3. Portions of retained placenta or membranes. 4. Betroflexion of the uterus. 5. Laceration or inflammatory state of the cervix. 6. Thrombosis or hematocele of the cervix or vulva. 7. Inversion of the uterus. 8. Fibroid tumors pr polypus of the uterus. 1 Brit. Med. Jour., 1872. 2 Saboia, Traite des Accouchements, p. 819. 424 LABOR. The first four of these need only now be considered, the others being described elsewhere. Relaxation of and Clots in, the Uterus. — Relaxation of the uterus and distension of its cavity by coagula may give rise to hemorrhage, although not so readily as immediately after delivery, for coagula of considerable size are often retained m utero for many days after labor. The uterus will be found larger than it ought to be, and tender on pressure. Usually the coagula are expelled with severe after-pains ; but this may not take place, and hemorrhage may ensue several days after delivery. Or there may be only a relaxed state of the uterus without retained coagula. Bassett relates 4 cases traced to these causes, and several illustrations will be found in McClin- tock's paper. Portions of retained placenta or membranes are more frequent causes. The retention may be due to carelessness on the part of the practitioner, especially if he have removed the placenta by traction, and failed to satisfy himself of its integrity. It may, however, often be due to circumstances entirely beyond his control; such as adherent placenta, which it is impossible to remove without leaving portions in utero, or more rarely placenta succenturia. In the latter case there is a small supplementary portion of placental tissue developed entirely separate from the general mass, and it may remain in utero without the practitioner having the least suspicion of its existence. Portions of the membranes are very apt to be left in utero. It is to prevent this that they should be twisted into a rope, and extracted very gently after expression of the placenta. Hemorrhage from these causes generally does not occur until at least a week after delivery, and it may not do so until a much longer time has elapsed. In 4 cases, recorded by Mr. Bassett, it commenced on the twelfth, tenth, fourteenth, and thirty-second day. It may come on suddenly and continue ; or it may stop, and recur frequently at short intervals. In my experience retention of portions of the pla- centa is very common after abortion, when adhesions are more gene- rally met with than at term. In addition to the hemorrhage there is often a fetid discharge, due to decomposition of the retained por- tion, and possibly more or less marked septicemic symptoms, which may aid in the diagnosis. The placenta or membranes may simply be lying loose as foreign bodies in the uterine cavity ; or they may be organically attached to the uterine walls, when their removal will not be so easily effected. Retroflexion. — Barnes has especially pointed out the influence of retroflexion of the uterus in producing secondary hemorrhage, 1 which seems to act by impeding the circulation at the point of flexion, and thus arresting the process of involution. In everv case in which secondary hemorrhage occurs to any extent, careful investigation into the possible causes of the attack, and an accurate vaginal examination, are imperatively required. If it be due to general and constitutional causes only, Ave must insist on the most absolute rest on a hard bed in a cool room, and on the absence 1 Obstetric Operations, p. 492. HEMORRHAGE AFTER DELIVERY. 425 of all causes of excitement. The liquid extract of ergot will be very generally useful in 5j closes repeated every six hours. McClintock strongly recommends the tincture of Indian hemp, which may be ad- vantageously combined with the ergot, in doses of 10 or 15 minims, suspended in mucilage. Astringent vaginal pessaries of matico or perchloride of iron may be used. Special attention should be paid to the state of the bowels, and, if the rectum be loaded, it should be emptied by enemata. In more chronic cases a mixture of ergot, sulphate of iron, and small doses of sulphate of magnesia, will prove very serviceable. This is more likely to be effectual when the bleed- ing is of an atonic and passive character. McClintock speaks strongly in favor of the application of a blister over the sacrum. When the hemorrhage is excessive, more effectual local treatment will be re- quired. Cazeaux advises plugging of the vagina. Although this cannot be considered so dangerous as immediately after delivery, inasmuch as the uterus is not so likely to dilate above the plug, still it is certainly not entirely without risk of favoring concealed internal hemorrhage. If it be used at all, a firm abdominal pad should bo applied, so as to compress the uterus ; and the abdomen should be examined, from time to time, to insure against the possi- bility of uterine dilatation. With these precautions the plug may prove of real value. In any case of really alarming hemorrhage I should be disposed rather to trust to the application of st} r ptics to the uterine cavity. The injection of fluid in bulk, as after delivery, could not be safely practised, on account of the closure of the os and the contraction of the uterus. But there can be no objection to swabbing out the uterine cavity with a small piece of sponge attached to a handle, and saturated in a solution of the perchloride of iron. There are few cases which will resist this treatment. If we have reason to suspect retained placenta or membranes, or if the hemorrhage continue or recur after treatment, a careful ex- ploration of the interior of the womb will be essential. On vaginal examination, we may possibly feel a portion of the placenta protrud- ing through the os, which can then be removed without difficulty. If the os be closed, it must be dilated with, sponge or laminaria tents, or by a small-sized Barnes's bag, and the uterus can then be thoroughly explored. This ought to be done under chloroform, as it cannot be effectually accomplished without introducing the whole hand into the vagina, which necessarily causes much pain. If the placenta or membranes be loose in the uterine cavity, they may be removed at once ; or, if they be organically attached, they may be carefully picked off. The uterus should at the same time, and as long as the os remains patulous, be thoroughly washed out with Condy's fluid and water, to diminish the risk of septicaemia. Retroflexion can readily be detected by vaginal examination, and the treatment consists in careful reposition with the hand, and the application of a large-sized Hodge's pessar} r . [In managing the convalescence after excessive hemorrhage it is of great importance to replace the loss as rapidly as possible, in order to avoid serious diseases resulting from exhaustion. To accomplish 28 426 LABOR. this, I am usually in the habit of giving the essence of from three to seven pounds of beef per diem, for the first two weeks, and have given as high as eleven. It is remarkable how soon this restores the health and strength of the woman. — Ed.] CHAPTEE XYI. RUPTURE OF THE UTERUS, ETC. Rupture of the uterus is one of the most dangerous accidents of labor, and until of late years it has been considered almost necessarily fatal, and beyond the reach of treatment. Fortunately it is not of very frequent occurrence, although the published statistics vary so much that it is by no means easy to arrive at any conclusion on this point. The explanation is, no doubt, that many of the tables con- found partial and comparatively unimportant lacerations of the cer- vix and vagina, with rupture of the body and fundus. It is only in large lying-in institutions, where the results of cases are accurately recorded, that anything like reliable statistics can be gathered, for in private practice the occurrence of so lamentable an accident is likely to remain unpublished. To show the difference between the figures given by authorities, it may be stated that, while Burns cal- culates the proportion to be 1 in 940 labors, Inglebv fixes it as 1 in 1300 or 1400, Churchill as 1 in 1331, and Lehmann as 1 in 2433. Dr. Jolly, of Paris, has published an excellent thesis containing much valuable information. 1 He finds that out of 782,741 labors, 230 rup- tures, excluding those of the vagina or cervix, occurred, that is, 1 in 3403. Seat of Rupture. — Lacerations may occur in any part of the uterus — the fundus, the body, or the cervix. Those of the cervix are comparatively of small consequence, and occur, to a slight ex- tent, in almost all first labors. Only those which involve the supra- vaginal portion are of really serious import. Ruptures of the upper part of the uterus are much less frequent than of the portion near the cervix ; partly, no doubt, because the fundus is beyond the reach of the mechanical causes to which the accident can, not unfrequently be traced, and partly because the lower third of the organ is apt to be compressed between the presenting part and the bony pelvis. The site of placental insertion is said by Madame La Chapelle to be rarely involved in the rupture, but it does not always escape, as numerous recorded cases prove. The most frequent seat of rupture is near the junction of the body and neck, either anteriorly or posteriorly, op- 1 Rupture uterine pendant le Travail, Paris, 1873. RUPTURE OF THE UTERUS. 427 posite the sacrum, or behind the symphysis pubis, but it may occur at the sides of the lower segment of the uterus. In some cases the entire cervix has been torn away, and separated in the form of a ring. Rapture may be Partial or Complete. — The laceration may be partial or complete ; the latter being the more common. The mus- cular tissue alone may be torn, the peritoneal coat remaining intact; or the converse may occur, and then the peritoneum is often fissured in various directions, the musular coat being unimplicated. The extent of the injury is very variable: in some cases being only a slight tear, in others forming a large aperture, sufficiently extensive to allow the foetus to pass into the abdominal cavity. The direction of the laceration is as variable as the size, but it is more frequently vertical than transverse or oblique. The edges of the tear are irregu- lar and jagged ; probably on account of the contraction of the mus- cular fibres, which are frequently softened, infiltrated with blood, and even gangrenous. Large quantities of extravasated blood will be found in the peritoneal cavity ; such hemorrhage, indeed, being- one of the most important sources of danger. Causes are either Predisposing or Exciting. — The causes are divided into predisposing and exciting ; and the progress of modern research tends more and more to the conclusion that the cause which leads to the laceration could only have operated because the tissue of the uterus was in a state predisposed to rupture, and that it would have had no such effect on a perfectly healthy organ. What these pre- disposing changes are, and how they operate, is yet far from being known, and the subject offers a fruitful field for pathological investi- gation. Said to he more Common in Multiparse. — It is generally believed that lacerations are more common in multiparse than in primiparse. Tyler Smith contended that raptures are relatively as common in first as in subsequent labors. Statistics are not sufficiently accurate or extensive to justify a positive conclusion, but it is reasonable to suppose that the pathological changes, presently to be mentioned as predisposing to laceration, are more likely to be met with in women whose uteri have frequently undergone the alteration attendant on repeated pregnancies. Age seems to have considerable influence, as a large proportion of cases have occurred in women between thirty and forty years of age. Alterations in the tissues of the uterus are probably of very great importance in predisposing to the accident, although our information on this point is far from accurate. Among these are morbid states of the muscular fibres, the result of blows and contusions during preg- nancy; premature fatty degeneration of the muscular tissues, an anticipation, as it were, of the normal involution after deliveiy ; fibroid tumors, or malignant infiltration of the uterine walls, which either produce a morbid state of the tissues, or act as an impediment to the expulsion of the foetus. The importance of such changes has been specially dwelt on by Murphy in this country, and by Lehmann in Germany, and it is impossible not to concede their probable influ- 428 LABOR. ence in favoring laceration. However, as yet these views are founded more on reasonable hypothesis than on accurately observed patho- logical facts. Another and very important class of predisposing causes are those which lead to a want of proper proportion between the pelvis and the foetus. Deformity in Pelvis is a Frequent Cause. — Deformity of the pelvis has been very frequently met with in cases in which the uterus has raptured. Thus out of 19 cases, carefully recorded by Eadford, 1 the pelvis was contracted in 11, or more than one-half. Eadford makes the curious observation that ruptures seem more likely to occur when the deformity is only slight ; and he explains this by supposing that in slight deformities the lower segment of the uterus engages in the brim, and is, therefore, much subjected to compression, while in extreme deformity the os and cervix uteri remain above the brim, the body and fundus of the uterus hanging down between the thighs of the mother. This explanation is reasonable; but the rarity with which ruptured uterus is associated with extreme pelvic deformity may rather depend on the infrequency of advanced degrees of con- traction. Malpresentation. — Amongst causes of disproportion depending on the foetus are either malpresentation, in which the pains cannot effect expulsion, or undue size of the presenting part. In the latter way may be explained the observation that rupture is much more fre- quently met with male than with female children, on account,, no doubt, of the larger size of the head in the former. The influence of intra-uterine hydrocephalus was first prominently pointed out by Sir James Simpson, 2 who states that out of 74 cases of intra-uterine hydrocephalus the uterus ruptured in 16. In all such cases of dis- proportion, whether referable to the pelvis or foetus, rupture is pro- duced in a twofold manner, either by the excessive and fruitless uterine contractions, which are induced by the efforts of the organ to overcome the obstacle ; or by the compression of the uterine tissue between the presenting part and the bony pelvis, leading to inflam- mation, softening, and even gangrene. Mechanical Injury of Rupture. — The proximate cause of rupture mav be classed under two heads — mechanical injury, and excessive uterine contraction. Under the former are placed those uncommon cases in which the uterus lacerates as the result of some injury in the latter months of pregnancy, such as blows, falls, and the like. Not so rare, unfortunately, are lacerations produced by unskilled attempts at delivery on the part of the medical attendant, such as by the hand during turning, or by the blades of the forceps. Many such cases are on record, in which the accoucheur has used force and violence, rather than skill, in his attempts to overcome an obstacle. That such unhappy results of ignorance are not so uncommon as they ought to be is proved by the figures of Jolly, who has collected 71 cases of rupture during podalic version, 37 caused by the forceps, 10 i Obsc. Trans., vol. viii. 2 Selected Obst. Works, p. 385. RUPTURE OF THE UTERUS. 429 by the ceplialotribe, and 30 during other operations, the precise nature of which is not stated. 1 The modus operandi of protracted and in- effectual uterine contractions, as a proximate cause of rupture, is sufficiently evident, and need not be dwelt on. It is necessary to allude, however, to the effect of ergot, incautiously administered, as a producing cause. There is abundant evidence that the injudicious exhibition of this drug has often been followed by laceration of the unduly stimulated uterine fibres. Thus, Trask, talking of the sub- ject, says that Meigs had seen three cases, and Bedford four, distinctly traceable to this cause. Jolly found that ergot had been administered largely in 33 cases in which rupture occurred. Premonitory Symptoms. — Some have believed that the impending occurrence of rupture could frequently be ascertained by peculiar premonitory symptoms, such as excessive and acute crampy pains about the lower part of the abdomen, due to the compression of part of the uterine wails. These are far too indefinite to be relied on, and it is certain that the rupture generally takes place "without any symptoms that would have afforded reasonable grounds for suspicion. General Symptoms. — The symptoms are often so distinct and alarm- ing as to leave no doubt as to the nature of the case ; not infrequently, however, especially if the laceration be partial, they are by no means so well marked, and the practitioner may be uncertain as to what has taken place. In the former class of cases a sudden excruciating pain is experienced in the abdomen, generally during the uterine contractions, accompanied by a feeling, on the part of the patient, of something having given way. In some cases this has been accom- panied by an audible sound, which has been noticed by the by- standers. At the same time there is generally a considerable escape of blood from the vagina, and a prominent symptom is the sudden cessation of the previously strong pains. Alarming general symp- toms soon develop, partly due to shock, partly to loss of blood, both external and internal. The face exhibits the greatest suffering, the skin becomes deadly cold and covered with a clammy sweat, and fainting, collapse, rapid feeble pulse, hurried breathing, vomiting, and all the usual signs of extreme exhaustion quickly follow. Results of Abdominal and Vaginal Examinations. — Abdominal pal- pation and vaginal examination both afford characteristic indications in well-marked cases. If the child, as often happens, has escaped entirely, or in great part, into the abdominal cavity, it may be readily felt through the abdominal walls ; while in the former case, the par- tially contracted uterus may be found separate from it in the form of a globular tumor, resembling the uterus after delivery. Per vaginam it may generally be ascertained that the presenting part has suddenly receded, and can no longer be made out ; or some other part of the foetus may be found in its place. If the rupture be ex- tensive, it may be appreciable on vaginal examination, and, some- times, a loop of intestine may be found protruding through the tear. Other occasional signs have been recorded, such as an emphysema- 1 Op. cit., p. 38. 430 LABOR. tous state of the lower part of the abdomen, resulting from the entrance of air into the cellular tissue ; or the formation of a san- guineous tumor in the hypogastrium, or vagina. These are too un- common, and too vague, to be of much diagnostic value. Symptoms are somewhat Obscure. — Unfortunately the symptoms are by no means always so distinct, and cases occur in which most of the reliable indications, such as the sudden cessation of the pains, the external hemorrhage, and the retrocession of the presenting part, may be absent. In some cases, indeed, the symptoms have been so obscure that the real nature of the case has only been detected after death. It is rarely, however, that the occurrence of shock and pros- tration is not sufficiently distinct to arouse suspicion, even in the absence of the usual marked signs. In not a few cases distinct and regular contractions have gone on after laceration, and the child has even been born in the usual way. Of course, in such a case, mistake is very possible. So curious a circumstance is difficult of explana- tion. The most probable way of accounting for it is, that the lacera- tion has not implicated the fundus of the uterus, which contracted sufficiently energetic to expel the foetus. Hence it will be seen that the symptoms are occasionally obscure, and the practitioner must be careful not to overlook the occurrence of so serious an accident, because of the absence of the usual and characteristic symptoms. Prognosis. — The prognosis is necessarily of the gravest possible character, but modern views as to treatment perhaps justify us in saying that it is not so absolutely hopeless as has been generally taught in our obstetric works. When we reflect on what has oc- curred — the profound nervous shock ; the profuse hemorrhage, both external, and especially into the peritoneal cavity, where the blood coagulates and forms a foreign body ; the passage of the uterine contents into the abdomen, with the inevitable result of inflamma- tion and its consequences, if the patient survive the primary shock ; — the enormous fatality need cause no surprise. Jolly has found that out of 580 cases 100 recovered, that is, in the proportion of 1 out of 6. This is a far more favorable result than we are generally led to anticipate ; and as many of the recoveries happened in apparently the most desperate and unfavorable cases, we should learn the lesson that wo need not abandon all hope, and should at least en- deavor to rescue the patient from the terrible dangers to which she is exposed. As regards the child the prognosis is almost necessarily fatal ; and indeed, the cessation of the foetal heart-sounds has been pointed out by McClintock as a sign of rupture in doubtful cases. The shock, the profuse hemorrhage, and the time that must necessarily elapse before the delivery of the child, are of themselves quite sufficient to explain the fact that the foetus is almost always dead. Treatment. — From what has been said of the impossibility of fore- telling the occurrence of rupture, it must follow that no reliable pro- phylactic treatment can be adopted, beyond that which is a matter of general obstetric principle, viz., timely interference when the RUPTURE OF THE UTERUS. 431 uterine contractions seem incapable of overcoming an obstacle to delivery, either on the part of the pelvis or foetus. Indications after Rupture has taken place. — After rupture the main indications are to effect the removal of the child and the placenta, to rally the patient from the effects of the shock, and, if she survives so lono-, to combat the subsequent inflammation and its consequences. By far the most important point to decide is the best means to be adopted for the removal of the child ; for it is admitted by all that the hopeless expectancy that was recommended by the older accou- cheurs, or, in other words, allowing the patient to die without making any effort to save her, is quite inadmissible. If the foetus be entirely within the uterine cavity, no doubt the proper course to pursue is to deliver at once per vias naturales, either by turning, by forceps, or by cephalotripsy. If any part other than the head present turning will be best, great care being taken to avoid further increase of the laceration. If the head be in the cavity or at the brim of the pelvis, and within easy reach of the forceps, it may be cautiously applied, the child being steadied by abdominal pressure, so as to facilitate its application. If there be, as is often the case, some slight amount of pelvic contraction, it may be preferable to perforate and apply the cephalotribe, so as to avoid any forcible attempts at extraction, which might unduly exhaust the already prostrate patient, and turn the scale against her. This will be the more allowable since the child is, as we have seen, almost always dead, and we might readily ascer- tain if it be so by auscultation. Removal of the Placenta. — After delivery extreme care must be taken in removing the placenta, and for this it will be necessary to introduce the hand. The placenta will generally be in the uterus, for if the rent be not large enough for the child to pass through, it may be inferred that the placenta will not have done so either. If it has escaped from the uterus, very gentle traction on the cord may bring it within reach of the hand, and so the passage of the hand through the tear to search for it will be avoided. Treatment when the Foetus has Escaped out of the Uterus. — There can be but little doubt that, in the cases indicated, such is the proper treatment, and that which affords the mother the best chance. Un- fortunately, the cases in which the child remains entirely in utero are comparatively uncommon, and generally it will have escaped into the abdomen, along with much extravasated blood. The usual plan of treatment recommended, under such circumstances, is to pass the hand through the fissure (some have even recommended that it should be enlarged by incision if necessary), to seize the feet of the foetus, to drag it back through the torn uterus, and then to reintro- duce the hand to search for and remove the placenta. Imagine w T hat occurs during the process. The hand gropes blindly among the ab- dominal viscera, the forcible dragging back of the foetus necessarily tears the uterus more and more, and, above all, the extravasated blood remains as a foreign body in the peritoneal cavity, and neces- sarily gives rise to the most serious consequences. It is surely hardly 432 LABOR. a matter of surprise that there is scarcely a single case on record of recovery after this procedure. Reasons favoring Gastrolomy. — Of late years a strong feeling has existed that, whenever the child has entirely, or in great part, escaped into the abdominal cavity, the operation of gastrotomy affords the mother a far better chance of recovery ; and it has now been per- formed in many cases with the most encouraging results. It is easy to see why the prospects of success are greater. The uterus being already torn, and the peritoneum opened, the only additional danger is the incision of the abdominal parietes, which gives us the oppor- tunity of sponging out the peritoneal cavity, as in ovariotomy, and of removing all the extravasated blood, the retention of which so seriously adds to the dangers of the case. Another advantage is that, if the patient be excessively prostrate, the operation may be delayed until she has somewhat rallied from the effects of the shock, whereas delivery by the feet is generally resorted to as soon as the rupture is recognized, and when the patient is in the worst possible condition for interference of any kind. 1 Comparative Results of Various Methods of Treatment. — Jolly has carefully tabulated the results of the various methods of treatment, and, making every allowance for the unavoidable errors of statistics, it seems bevond all question that the results of gastrotomy are. so greatly superior to those of other plans, that I think its adoption may fairly be laid clown as a rule whenever the foetus is no longer within the uterine cavity. Comparative Results of Various Methods of Treatment after Rupture of Uterus. Treatment. No. of cases Deaths. Kecoveries. Per cent, of recoveries. Expectation ..... Extraction per vias naturales Gastrotomy ..... 144 382 38 142 310 12 2 72 26 1.45 10 68.4 Of course this table will not justify the conclusion that 68 per cent, of the cases of ruptured uterus in which gastrotomy is per- formed will recover ; but it may fairly be taken as proving that the chances of recovery are at least three or four times as great as when the more usual practice is adopted. [According to Dr.. Trask's report 2 of cases of rupture of the uterus, 27 women recovered out of 115 that were not delivered, and 77 out of 207 delivered ; 29 operations by laparotomy saved 22 women. [American Puerperal Laparotomies . — After a search of several years, I 1 I am fully of the opinion that we ought to go much further than this, and ope- rate in cases even where the child can be readily delivered per vias naturales, if there is a decided rupture with escape of blood and liquor amnii into the abdominal cavity, for the removal of these fluids is only second in importance to that of the foetus. In eervico-vaginal rupture this is not so important, as there is generally a natural drain- age ; but where the body or fundus have been freely rent, there is no security equal to that of opening the abdomen and cleaning it out. — Ed.] [ 2 Am. Journ. Med. Sci., vol. xv. N. S. 1848, pp. 104, 383 ; vol. xxxii. p. 81.] RUPTURE OF THE UTERUS. 483 I have thus far collected 40 cases in the United States, with 21 women and 2 children saved. One mother and child were saved by an immediate operation with a pocket-knife, in 1869. I presume that a general record of American operations published and unpub- lished would show a saving of about 50 per cent., which is much lower than that claimed by Trask and Jolly, collected from published reports, and less than I thought myself a year ago. Take Trask's foreign cases, 20, and our own 40, and we have, native and foreign, 60, with 37 recoveries and 23 deaths. I look upon our own statistics as much more reliable, because many of the unpublished cases were searched out by correspondence. — Ed.] Necessity of Care in Performing the Operation. — It is perhaps need- less to say that the operation must be performed with the same minute care that has raised ovariotomy to its present pitch of per- fection, and that especial attention should be paid to the sponging out of the peritoneum, and the removal of foreign matters. Recapitulation. — To recapitulate, I think what has been said jus- tifies the following rules of treatment after rupture : — 1. If the head or presenting part be above the brim, and the foetus still in utero — forceps, turning, or cephalotripsy, according to circum- stances. 2. If the head be in the pelvic cavity — forceps or cephalotripsy. 3. If the foetus have wholly, or in great part, escaped into the abdominal cavity — gastrotomy. [I know that these rules are those which have been given in ob- stetrical works of high authority, but still I believe them to be based upon the errors of the past, and the cause of a high degree of mor- tality. Let any one examine Dr. Trask's tables, and he will learn how few are likely to be saved under these rules. Children entirely escaped into the abdominal cavity have been drawn back into the uterus and the women have recovered. So also of the same condi- tions, where the foetus has been left intact. But Ave are not to ex- pect such results. What we are to look for is death in frightful proportion under any of these rules. I do not object to the manner of delivery, but I do to the closing of the case here. In all cases where the state of the woman will warrant it, I believe that the abdomen should be opened and sponged out, and where the uterine wound gapes, that it should be closed by sutures. — Ed.] Subsequent Treatment. — As to the subsequent treatment little need be said, since in this we must be guided by general principles. The chief indication will be to remove shock and rally the patient by stimulants, etc., and to combat secondary results by opiates and other appropriate remedies. Lacerations of the vagina occasionally take place, and in the great majority of cases, they are produced by instruments, either from a want of care in their introduction, or from undue stretching of the vaginal Avails during extraction with the forceps. Slight vaginal lacerations are probably much more common after forceps delrvery than is generally believed to be the case. As a rule, they are pro- ductive of no permanent injury, although it must not be forgotten 434 LABOR. that every breach of continuity increases the risk of subsequent septic absorption. When the laceration is sufficiently deep to tear through the recto-vaginal septum, or the anterior vaginal wall, the passage of the urine or feces is apt to prevent its edges uniting ; then that most distressing condition, recto-vaginal, or vesico- vaginal fistula is established. It must not be supposed that fistulas are often the result of injury during operative interference. That is a common but yevy erroneous opinion both among the profession and the public. In the vast majority of cases the fistulous opening is the consequence of a slough resulting from inflammation, produced by long-continued pressure of the vaginal walls between the child's head and the bony pelvis, in cases in which the second stage has been allowed to go on too long. In most of these cases instruments were doubtless eventually used, and they get the blame of the accident ; whereas the fault lay, not in their being employed, but rather in their not having been used soon enough to prevent the contusion and inflammation which ended in sloughing. When vesico- vaginal fistulas are the result of lacerations during labor, the urine must escape at once, but this is rarely the case. In the large majority of cases the urine does not pass per vaginam until more than a week after delivery, showing that a lapse of time is necessary for inflammatory action to lead to sloughing. In order to throw some light on these points, on which very erroneous views have been held, I have carefully examined the histories, from various sources, of 63 cases of vesico- vaginal fistula. 1st. In 20 no instruments were employed. Of these, there were in labor under 24 hours ..... 2 from 24 to 48 hours u 48 to 70 " " 70 to 80 " l ' 80 hours and upwards 8 1 2 7 1 20 Therefore out of these 20 cases one-half were certainly more than 48 hours in labor, and 6 of the remaining 10 were probably so also. In only 1 of them is the urine stated .to have escaped per vaginam immediately after delivery. In 7 it is said to have clone so within a week, and in the remainder after the seventh day. 2d. In 34 cases instruments were used, but there is no evidence of their having produced the accident. Of these, there were in labor under 24 hours ....... 2 from 24 to 48 hours ... 8 " 48 to 72 . . 10 " 72 hours and upwards . • 14 34 1 But of these in 7 no precise time is stated. 6 of them are marked very tedious, therefore they prohahly exceeded the limit. INVERSION OF THE UTERUS. 435 The urine escaped within 24 hours in 2 cases only, within a week in 16. and after the seventh day in 15. So that here again Ave have the history of unduly protracted delivery, 24 out of the 34 having been certainly more than 48 hours in labor. 3d. In 9 cases the histories show that the production of the fistula may fairly be ascribed to the unskilled use of instruments. Of these, there were in labor under 24 hours ... 7 from 24 to 48 hours ... 1 " 48 to 72 " ... 1 9 The urine escaped at once in 7 cases, and in the remaining 2 after the seventh day. These statistics seem to me to prove, in the clearest manner, that, in the large majority of cases, this unhappy accident may be directly traced to the bad practice of allowing labor to drag on many hours in the second stage without assistance, and not to premature instru- mental interference. This question has recently been elaborately studied by Emmet, who gives numerous statistical tables which fully corroborate these views. His conclusion, the result of much prac- tical experience of vesico- vaginal fistula?, is Avorthy of being quoted: "I do not hesitate." he says, "to make the statement that I have never met with a case of vesico-vaginal fistula which, without doubt, could be shown to have resulted from instrumental delivery. On the contrarjr, the entire weight of evidence is conclusive in showing that the injury is a consequence of delay in delivery." 1 Treatment. — As to the treatment of vaginal laceration little can be said. In the slighter cases vaginal injections of diluted Conchy's fluid will be useful to lessen the risk of septic absorption ; and the graver, when vesico-vaginal or recto- vamnal fistula? have actually formed, are not within the domain of the obstetrician, but must be treated surgically at some future date. CHAPTER XYII. INVERSION OF THE UTERUS. Inversion of the uterus shortly after the birth of the child is one of the most formidable accidents of parturition, leading to symptoms of the greatest urgency, not rarely proving fatal, and requiring prompt and skilful treatment. Hence it has obtained an unusual amount of 1 The Principles and Practice of Gynaecology, p. 669. 436 LABOR. Fig. 140. attention, and there are few obstetric subjects which have been more carefully studied. An Accident of Great Rarity. — Fortunately, the accident is of great rarity. It was only observed once in upwards of 190,800 deliveries at the Eotunda Hospital since its foundation in 1745 ; and many practitioners have conducted large midwifery practices for a lifetime without ever having witnessed a case. It is none the less needful, however, that we should be thoroughly acquainted with its natural history, and with the best means of dealing with the emergency when it arises. Division into Acute and Chronic Forms.— Inversion of the uterus may be met with in the acute or chronic form ; that is to say, it may come under observation either immediately or shortly after its occur- rence, or not until after a considerable lapse of time, when the invo- lution following pregnancy has been completed. The latter falls more properly under the province of the gynaecologist, and involves the consideration of many points that would be out of place in a work on obstetrics. Here, therefore, the acute form alone is con- sidered. Description of Inversion. — Inversion consists essentially in the en- larged and empty uterus being turned inside out, either partially or entirely ; and this may occur in various degrees, three of which are usually de- scribed, and are practically useful to bear in mind. In the first and slightest degree there is merely a cup-shaped depression of the fundus (Fig. 140) ; in the second the depression is greater, so that the inverted portion forms an introsusception, as it were, and projects downwards through the os in the form of a round ball, not unlike the body of a polypus, for which, indeed, a careless observer might mistake it ; and, thirdly, there is the complete variety, in which the whole organ is turned inside out and may even project beyond the vulva. Its Symptoms. — The symptoms are generally very characteristic, although, when the amount of inversion is small, they may entirely escape observation. They are chiefly those of profound ner- vous shock, viz., fainting, small, rapid, and feeble pulse, possibly convulsions and vomiting, and a cold, clammy skin. Occasionally severe ab- dominal pain, and cramp and bearing down are felt. Hemorrhage is a frequent accompaniment, sometimes to a very alarming extent, especially if the placenta be partially or entirely detached. The loss of blood depends to a great extent on the condition of the uterine parietes. If there be much contraction of the part that is not in- Partial Inversion of the Fundus. (From a preparation in the museum of Guy's Hospital.) INVERSION OF THE UTERUS. -137 verted, the introsuscepted part may be sufficiently compressed to pre- vent any great loss. If the entire organ be in a state of relaxation, the loss may be excessive. Results of Physical Examination. — The occurrence of such symp- toms shortly after delivery would of necessity lead to an accurate examination, when the nature of the case may be at once ascertained. On passing the finger into the vagina, we either find the entire uterus forming a globular mass, to which the placenta is often attached ; or, if the inversion be incomplete, the vagina is occupied by a firm, round, and tender swelling, which can be traced upwards through the os uteri. The hand placed on the abdomen will detect the absence of the round ball of the contracted uterus, and bi-manual examina- tion may even enable us to to feel the cup-shaped depression at the site of inversion. Differential Diagnosis. — When such signs are observed immedi- ately after delivery, mistake is hardly possible. Numerous instances, however, are recorded in which the existence of inversion was not immediately detected, and the tumor formed by it only observed after the lapse of several days, or even longer, when the general symptoms led to vaginal examination. It is probable that, in such cases, a partial inversion had taken place shortly after delivery, which, as time elapsed, became gradually converted into the more complete variety. In a case of this kind, as in a chronic inversion, some care is necessary to distinguish the inversion from a uterine polypus, which it closely resembles. The cautious insertion of the sound will render the diagnosis certain, since its passage is soon ar- rested in inversion, while, if the tumor be polypoid, it readily passes in as far as the fundus. Manner in which Inversion is Produced. — The mechanism by which inversion is produced is well worthy of study, and has given rise to much difference of opinion. Occasionally produced by Accidental Mechanical Causes. — A yqty general theory is, that it is caused, in many cases, by mismanage- ment of the third stage of labor, either b}~ traction on the cord, the placenta being still adherent, or by improperly applied pressure on the fundus ; the result of both these errors being a cup-shaped de- pression of the fundus, which is subsequently converted into a more complete variety of inversion. That such causes may suffice to start the inversion cannot be doubted, but it is probable that their fre- quency has been much exaggerated. Still there are numerous re- corded cases in which the commencement of the inversion can be traced to them. Improperly applied pressure (as when the whole body of the uterus is not grasped in the hollow of the hand, but when a monthly nurse, or other uninstructed person, presses on the lower part of the abdomen, so as simply to push down the uterus en masse) is often mentioned in histories of the accident. Thus in the " Edinburgh Medical Journal" for June, 1848, a case is related in which the patient would not have a medical man, but was attended by a midwife, who, after the birth of the child, pulled on the cord, while the patient herself clasped her hands and pushed down her 433 LABOR. abdomen, at the same time straining forcibly, when the uterus be- came inverted and the patient died of hemorrhage before assistance could be procured. Here both of the mechanical causes mentioned were in operation. In several cases it is mentioned that the accident occurred while the nurse was compressing the abdomen. That the accident is practically impossible when firm and equable contraction has taken place, cannot be questioned. Hence it is of paramount importance that the practitioner should himself carefully attend to the conduct of the third sta^c of labor. Often Occurs Spontaneously. — In a large proportion of cases no mechanical causes can be traced, and the occurrence of spontaneous inversion must be admitted. There are various theories held as to how this occurs. Partial and irregular contraction of the uterus is generally admitted to be an important factor in its production : but it is still a matter of dispute whether the inversion is produced mainly by an active contraction of the fundus and body of the uterus, the lower portion and cervix being in a state of relaxation ; or whether the precise reverse of this exists, the fundus being relaxed and in a state of quasi-paralysis, while the cervix and lower portion of the uterus are irregularly contracted. The former is the view main- tained by Bad ford and Tyler Smith, while the latter is upheld by Matthews Duncan. Evidence in Favor of Duncan's Theory. — -There are good clinical reasons for believing that Duncan's view more nearly corresponds with the true facts of the case ; for, if the fundus and body of the uterus be really in a state of active contraction, while the cervix is relaxed, we have, as Duncan points out, the very condition which is normal and desirable after delivery, and that which we do our best to produce. If, however, the opposite condition exist, and the fundus be relaxed, while the lower portion is spasmodically contracted, a state exists closely allied to the so-called hour-glass contraction. Supposing now any cause produces a partial depression of the fundus, it is easy to understand how it may be grasped by the contracted portion, and carried more and more clown, in the manner of an intro- susception, until complete inversion results. That such partial paraly- sis of the uterine walls often exists, especially about the placental site was long ago pointed out by Rokitansky, and other pathologists. This theory supposes the original partial depression and relaxation of the fundus. How this is often produced by mismanagement of the third stage has already been pointed out; but, even in the absence of such causes, it may result from strong bearing-down efforts on the part of the patient, or, as Duncan holds, from the absence of the retentive power of the abdomen. Indeed the incompatibility of an actively contracted state of the fundus with the partial depression which is essential, according to both views, for the production of inversion, is the strongest argument in favor of Duncan's theory. Taylor's Theory. — A totally different view has more recently been sustained by Dr. Taylor, of New York, who maintains that " spon- taneous active inversion of the uterus rests upon prolonged natural and energetic action of the body and fundus; the cervix, the lower INVERSION OF THE UTERUS 439 Fig. 141. part, yielding first, is thus rolled out, or everted, or doubled up, as there 'is no obstruction from the contractility of the cervix, which is at rest or functionally paralyzed ; the body is gradually, sometimes instantaneously, forced lower and lower, or inveited." 1 That partial inversion may commence at the cervix was pointed out by Duncan in his paper, who depicts it in the accompanying diagram (Fig. 141), and states it to be of not unfrequent occurrence. It is not impossible that occasionally such a state of things should be carried on to com- plete inversion. But there are serious ob- jections to the acceptance of Dr. Taylor's view that such is the principal cause of inversion, since the process above described would be of necessity a slow and long- continued one, whereas nothing is more cer- tain than that inversion is generally sudden and accompanied by acute symptoms of shock, and is often attended b^v severe hem- orrhage, which could not occur when such excessive contraction was taking place. Treatment. — The treatment of inversion consists in restoring the organ to its natural condition as soon as possible. Every moment's delay only serves to render res- toration more difficult, as the inverted por- tion becomes swollen and strangulated ; whereas if the attempt at reposition be made immediately, there is generally com- paratively little difficulty in effecting it. Therefore it is of the utmost importance that no time should be lost, and that we should not overlook a partial or incomplete inversion. Hence the occurrence of any unusual shock, pain, or hemorrhage after delivery, without any readily ascertained cause, should always lead to a careful vaginal examination. A want of attention to this rule has too often resulted in the existence ot partial inversion being overlooked, until its reduction was found to be difficult or impossible. Mode of Attempting Reduction.- — In attempting to reduce a recent inversion, the inverted portion of the uterus should be grasped in the hollow of the hand and pushed gentl}^ and firmly upwards into its natural position, great care being taken to apply the pressure in the proper axis of the pelvis, and to use counter-pressure, by the left hand, on the abdominal walls. Barnes lays stress on the import- ance of directing the pressure towards one side, so as to avoid the promontory of the sacrum. The common plan of endeavoring to push back the fundus first has been well shown by McClintock 2 to have the disadvantage of increasing the bulk of the mass that has to be reduced, and he advises that, while the fundus is lessened in size by compression, we should, at the same time, endeavor to push Illustrating the Commencement of Inversion, at the Cervix. (After Duncan.) 1 New York Med. Journ., 1872. 2 Diseases of Women, p. 79. 440 LABOR. up first the part that was less inverted, that is to say, the portion nearest the os uteri. Should this be found impossible, some assist- anee may be derived from the manoeuvre, recommended by Merriman and others, of first endeavoring to push up one side or wall of the uterus, and then the other, alternating the upward pressure from one side to the other as we advance. It often happens as the hand is thus applied, that the uterus somewhat suddenly rein verts itself, sometimes with an audible noise, much as an India-rubber bottle would do under similar circumstances. When reposition has taken place the hand should be kept for some time in the uterine cavity to excite tonic contraction ; or Barnes's suggestion of injecting a weak solution of perchloride of iron may be adopted, so as to constrict the uterine walls, and prevent a recurrence of the accident. It is hardly necessary to point out how much these manoeuvres will be facilitated by placing the patient fully under the influence of an anoesthetic. Management of the Placenta. — There has been much difference of opinion as to the management of the placenta in cases in which it is still attached wdien inversion occurs. Should, we remove it before attempting reposition, or should we first endeavor to reinvert the organ, and subsequently remove the placenta ? The removal of the placenta certainly much diminishes the bulk of the inverted portion, and, therefore, renders reposition easier. On the other hand, if there be much hemorrhage, as is so frequently the case, the removal of the placenta may materially increase the loss of blood. For this reason, most authorities recommend that an endeavor should be made at reduction before peeling off the after-birth. But if any delay or difficulty be experienced from the increased bulk, no time should be lost, and it is in every way better to remove the placenta and en- deavor to reinvert the organ as soon as possible. Management of Cases detected some time after Delivery. — Supposing we meet with a case in which the existence of inversion has been overlooked for days, or even for a week or two, the same procedure must be adopted ; but the difficulties are much greater, and the longer the delay, the greater they are likely to be. Even now, however, a well-conducted attempt at taxis is likely to succeed. Should it fail, we must endeavor to overcome the difficulty by con- tinuous pressure applied by means of caoutchouc bags, distended with water, and left in the vagina. It is rarely that this will fail in a comparatively recent case, and such only are now under considera- tion. It is likely that by pressure, applied in this Avay for twenty- four or forty-eight hours, and then followed by taxis, any case detected before the involution of the uterus is completed may be successfully treated. [Siwntaneous Reposition of the Inverted Uterus. — After all attempts have failed to replace an inverted uterus, already too much contracted to yield to the pressure employed, nature sometimes accomplishes the' work herself, as proved beyond question, from quite a number of well-established cases, several of which belong to our own country. Quite recently I saw one of the most remarkable on record. A INVERSION OF THE UTERUS. 441 woman of 29, mother of three, miscarried at six and a half months fiom lifting. From the time of her delivery she was subject to weep- ings of blood, and at times to more or less severe hemorrhages, one of which a few weeks ago nearly proved fatal. This condition of dis- ease had lasted three years, when Dr. Waiter F. Atiee was called in to relieve her in her worst hemorrhagic attack, and found her uterus inverted, and a nodular growth upon the fundus which gave out an offensive odor. Thinking the disease possibly malignant, and be- lieving in any event, that to save the woman he would be obliged to remove the uterus, he called a consultation, and prepared for the operation ; but when the patient was etherized, placed in the knee- chest position, and Sims's speculum introduced, behold there was nothing to be seen in the vagina but a soft dilated cervix, the uterus having become replaced by atmospheric pressure, aided perhaps by traction on the uterine attachments within. When explored, the uterus was found to be very soft and thin, and to contain some hard nodular masses, which on removal proved to be portions of an adhe- rent placenta. The hemorrhage ceased upon the reposition and clean- ing out of the uterus, and the patient made a good recover}*. This woman was anremic to a marked degree, and her abdominal walls so thin that a finger in the uterus could readily be felt above the pubes. There is not the slightest doubt about the inversion, which was proved to exist a short time before the change of posture by Dr. Agnew, who made a finger in the rectum meet another above the pubes, and there was no fundus between them. Two 1 cases are upon record where reposition was the result of falls, One at eight months, and the other after as many years. Dr. Mcehr- ing, Meigs, Hodge, and Warrington of this cit\ r , failed to replace a uterus, and the woman became again pregnant in about six years, aborting with a three months' foetus under the care of Dr. Warring- ton. Dr. Meigs saw a second case with Dr. Levis, in which there was violent flooding followed by hemorrhages which gradually de- clined. After her return from a journey West, she became pregnant and bore a child. Dr. John L. Atlee, of Lancaster, failed to replace a uterus in a woman who bore a child a year afterwards. 2 Dr. John- son F. Flatch, of Kent, Connecticut, reported a case in a letter to Dr. Meigs, in which inversion occcurred spontaneously, fourteen or fif- teen hours after labor. After being under the care of several physi- cians, she had, at the end of eighteen months, two severe hemorrha- gic attacks after which she improved, and finally at the end of two years and nine months, bore a child of 9 pounds and 6 ounces. In all cases, spontaneous reposition appears to result from a soft- ening and thinning of the uterine walls, as the result of anaemia brought on by hemorrhages. This was particularly noticed by Boivm and Duges, in autopsies of women dying of repeated hemor- rhages. — Ed.] [' See Dailliez, Essai sur le reuversement de la matrice, Paris, 1805, pp. 105-107.] [ 2 Meigs's Obstetrics, 1852, Phila. p. 60S.] 29 PART IV. OBSTETRIC OPERATIONS. CHAPTER I. INDUCTION OF PEEMATURE LABOR. The first of the obstetric operations we Lave to consider is the induction of premature labor, an operation which, like the use of for- ceps, was first suggested and practised m this -country, and the recog- nition of which, as a legitimate procedure, Ave also chiefly owe to the labor of our fellow-countrymen, in spite of much opposition both at home and abroad. It is not known with certainty to whom we owe the original suggestion ; but we are told by Denman that in the year 1756 there was a consultation of the most eminent physicians at that time in London, to consider the advantages which might be expected from the operation. The proposal met with formal approval, and was shortly after carried into practice by Dr. Macaulay, the patient being the wife of a linendraper in the Strand. From that time it has flourished in Great Britain, the sphere of its application has been largely increased, and it has been the means of saving many mothers and children, who would otherwise, in all probability have perished. On the Continent, it was long before the operation was sanctioned or practised. Although recommended by some of the most eminent German practitioners, it was not actually performed until the year 1804. In France the opposition was long- continued and bitter. Many of the leading teachers strongly denounced it, and the Academy of Medicine formally discountenanced it so late as the year 1827. The objections were chiefly based on religious grounds, but partly, no doubt, on mistaken notions as to the object proposed to be gained. Although frequently discussed, the operation was never actually car- ried into practice until the }^ear 1831, when Stoltz performed it with success. Since that time opposition has greatly ceased, and it is now employed and highly recommended by the most distinguished ob- stetricians of the French schools. Objects of the Operation. — In inducing premature labor, Ave propose- to avoid or lessen the risk to which, in certain cases, the mother is exposed by delivery at term, or to save the life of the child which might otherwise be endangered. Hence the operation may be indi- cated either on account of the mother alone, or of the child alone, or, as not unfrequently happens, of both together. (442) INDUCTION OF PREMATURE LABOR. 443 Defective Proportion between the Child and Pelvis is the most Fre- quent Indication. — In by far the largest Dumber of cases the operation is performed on account of defective proportion between the child and the maternal passages, due to some abnormal condition on the part of the mother. This want of proportion may depend on the presence of tumors either of the uterus or growing from the pelvis. But most frequently it arises from deformity of the pelvis (p. 389), and it is needless to repeat what has been said on that point. I shall, therefore, only briefly refer to a few more uncommon causes, which occasionally necessitate its performance. Habitually Large Size of the Foetal Head. — One of these is an habit- ually large, or over-limly ossified, foetal head. Should we meet with a case in which the labors are always extremely difficult, and the head apparently of unusual size, although there is no apparent want of space in the pelvis, the induction of labor would be perfectly justifiable, and in all probability would accomplish the desired ob- ject. In such cases the full period of delivery would require to be anticipated by a very short time. A week or a fortnight might make all the difference between a labor of extreme severity, and one of comparative ease. Condition of the Mothers Health calling for the operation. — There is a large class of cases in which the condition of the mother indi- cates the operation. Many of these have already been considered when treating of the diseases of pregnancy. Amongst them may be mentioned vomiting which has resisted all treatment, and which has produced a state of exhaustion threatening to prove fatal ; chorea, albuminuria, convulsions, or mania ; excessive anasarca, ascites, or dyspnoea connected with disease of the heart, lungs, or liver, may be, in a great measure, caused by the pressure of the enlarged uterus ; in fact, any condition or disease affecting the mother, provided only we are convinced that the termination of pregnancy would give the patient relief, and that its continuance would involve serious danger. It need hardly be pointed out that the induction of labor for any such causes involves grave responsibility, and is decidedly open to abuse; no practitioner would, therefore, be justified in resorting to it, especially if the child have not reached a viable age, without the most anxious consideration. 1S0 general rules can be laid down. Each case must be treated on its own merits. It is obvious that the nearer the patient is to the full period, the greater will be the chance of the child surviving, and the less hesitation need then be felt in consulting the interests of the mother. Conditions affecting the Safety of the Child alone. — In another class of cases the operation is indicated by circumstances affecting the life of the child alone. Of these the most common are those in which the child dies, in several successive pregnancies, before the termina- tion of utero-gestation. This is generally the result of fatty, calcare- ous, or syphilitic degeneration of the placenta, which is thus rendered incapable of performing its functions. These changes in the placenta seldom commence until a comparatively advanced period of preg- nancy ; so that if labor be somewhat hastened, we may hope to 444 OBSTETRIC OPERATIONS. enable the patient to give birth to a living and healthy child. The experience of the mother will indicate the period at which the death of the foetus has formerly taken place, as she would then have appre- ciated a difference in her sensations, a diminution in the vigor of the foetal movements, a sense of weight and coldness, and similar signs. For some weeks before the time at which this change has been expe- rienced, we should carefully auscultate the foetal heart from day to day, and, in most cases, the approach of danger will be indicated sufficiently soon to enable us to interfere with success, by tumultuous and irregular pulsations, or a failure in their strength and frequency. On the detection of these, or on the mother feeling that the move- ments of the child are becoming less strong, the operation should at once be performed. Simpson also induced premature labor with success in a patient who twice gave birth to hydrocephalic children. In the third pregnancy, which he terminated before the natural period, the child was well-formed and healthy. Induction of Labor zuhen the Mother, is mortally III. — Some obstetri- cians have proposed to induce labor, with the view of saving the child, when the mother was suffering from - mortal disease. This indication is, however, so extremely doubtful, from a moral point of view, that it can hardly be considered as ever justifiable. Various Methods of Inducing Labor; their mode of Action. — The means adopted for the induction of labor are very numerous. Some of them act through the maternal circulation, as the administration of ergot, and other oxytocics; others by their power of exciting reflex action, or by interfering with the integrity of the ovum, or by a com- bination of both, as the vaginal douche, separation of the membranes from the uterine walls, puncture of the ovum, dilatation of the os, stimulating enemata, or irritation of the breasts. The former class are never employed in modern obstetric practice. Of the latter, some offer special advantages in particular cases, but none are equally adapted for all emergencies. Often a combination of more methods than one will be found most useful. I shall mention the various methods in use, and discuss briefly the relative advantages and dis- advantages of each. Puncture of Membranes. — The evacuation of the liquor amnii, by the puncture of the membranes, was the first method practised, and was that recommended by Denman and all the earlier writers. It is the most certain which can be employed, as it never fails, sooner or later, to induce uterine contractions There are, however, several disadvantages connected with it, which are sufficient to contra-indi- cate its use in the majority of cases. It is uncertain as regards the time taken in producing the desired effect, pains sometimes coming on within a few hours, but occasionally not until several days have elapsed. The contracting walls of the uterus press directly on the body of the child, which, being frail and immature, is less liable to bear the pressure than at the full period of pregnancy. Hence it involves great risk to the foetus. Besides, the escape of the water does away with the fluid wedge so useful in dilating the os, and should version be necessary from mal-presentation — a complication INDUCTION OF PREMATURE LABOR. 445 more likely to occur than in natural labor — the operation would have to be performed under very unfavorable conditions. These objections are sufficient to justify the ordinary opinion that this pro- cedure should not be adopted, unless other means had been tried and failed. Every now and then cases are met with in which it is ex- tremely difficult to arouse the uterus to action, and under such circumstances, in spite of its drawbacks, this method will be found to be very valuable. When the operation has to be performed before the child is viable, that is, before the seventh month, these objections do not hold, and then it is the simplest and readiest procedure Ave can adopt. Indeed, in producing early abortion, no other is prac- ticable. The operation itself is most simple, requiring only a quill, stiletted catheter, or other suitable instrument, to be passed up to the os, carefully guarded by the ringers of the left hand previously introduced, and to be pressed against the membranes until perfora- tion is acomplished. Meissner, of Leipsic, has proposed, as a modi- fication of this plan, that the membranes should be punctured obliquely, three or four inches above the os, so as to admit of a gradual and partial escape of the amniotic fluid, thus lessening the risk to the child from pressure by the uterus. For this purpose he employed a curved silver canula, containing a small trocar, which can be projected after introduction. The risk of injuring the uterus, by such an instrument, would be considerable, and we have other and better means at our command which render it unnecessary. When we require to produce early abortion, it would be well not to attempt to puncture the membranes with a sharp-pointed instrument. The objection can be effected with certainty, and greater safety, by passing an ordinary uterine sound through the os, and turning it round once or twice. Administration of Oxytocics. — The administration of ergot of rye, either alone, or combined with borax and cinnamon, has been some- times resorted to. This practice has been principally advocated by Kamsbotham, who was in the habit of exhibiting scruple doses of the powdered ergot every fourth hour, until delivery took place. Sometimes he found that as many as thirty or forty doses were re- quired 'to effect the object; occasionally labor commenced after a single dose. Finding that the infantile mortality was very great when this method was followed, he modified it, and administered two or three doses only, and, if these proved insufficient, he punc- tured the membranes. There can be no doubt that ergot possesses the power of inducing uterine contractions. The risk to the child is, however, quite as great as when the membranes are punctured ; for not only is it subject to injurious pressure from the tumultous and irregular contractions which the ergot produces, but the drug itself, when given in large doses, seems to exert a poisonous influence on the foetus. For these reasons ergot may properly be excluded from the available means of inducing labor. Methods acting Indirectly on the Uterus. — Various methods have been recommended which act indirectly on the uterus, the source of irritation being at a distance. Thus D'Outrepont used frequently 416 OBSTETRIC OPERATIONS. Fig. 142. repeated abdominal frictions and tight bandages. Scanzoni, remem- bering the intimate connection between the mammae and uterus, and the tendency which irritation of the former has to induce contraction of the latter, recommended the frequent application of cupping- glasses to the breasts. Radford and others have employed galvanism. Stimulating enemata have been employed. All these methods have occasionally proved successful, and unlike the former plans we have mentioned, they are not attended by any special risk to the child. They are, however, much too uncertain to be relied on, besides being irksome both to the patient and practitioner. The artificial dilatation of the os uteri, in imitation of its natural opening in labor, was first practised by Kliige. He was in the habit of passing within the os a tent made of compressed sponge, and allowing it to dilate by imbibition of fluid. If labor were not pro- voked within twenty- four hours he removed it, and introduced one of larger dimensions, changing it as often as was necessary until his object was accomplished. Although this operation seldom failed to induce labor, it had the disadvan- tage of occupying an indefinite time, and the irrita- tion produced was often painful and annoying. Dr. Keiller, of Edinburgh, was the first to suggest the use of caoutchouc bags, distended by air, as a means of dilating the os. This plan has been perfected by Dr. Barnes in his well-known dilators, which are of great use in many cases in which artificial dilatation of the cervix is necessary. They consist of a series of India-rubber bags of various sizes, with a tube at- tached (Fig. 142), through which water can be in- jected by an ordinary Higgin son's syringe. They have a small pouch fixed externally, in which a sound can be placed, so as to facilitate their intro- duction. When distended with water the bags as- sume somewhat of a fiddle shape, bulging at both extremities, which insures their being retained within the os. When first introduced into practice as a means of inducing labor, it was thought that this method gave a complete control over the process, so that it could be concluded within a definite time at the will of the operator. The experience of those who have used it nruch has certainly not justified this anticipa- tion. It is true that, occasionally, contractions supervene within a few hours after dilatation has been commenced; but, on the other hand, the uterus often responds very imperfectly to this kind of stimulus, and the bags may be inserted for many consecutive hours without the desired result supervening; the puncture of the mem- branes being eventually necessary in order to hasten the process. Indeed, my own experience would lead me to the conclusion that, as a means of evoking uterine contraction, cervical dilatation is very unsatisfactory. Dr. Barnes himself has evidently seen reason to modify his original views, for, while he at first talked of the bags as enabling us to induce labor with certainty at a given time, he has Barnes's Bag Dilating the Cerv INDUCTION OF PREMATURE LABOR. 447 since recommended that uterine action should be first provoked by other means, the dilators being subsequently used to acccelerate the labor thus brought on. The bags thus employed find, as I believe, their most useful and a very valuable application ; but when used in this way they cannot be considered a means of originating uterine action. A subsidiary objection to the bags is the risk of displacing the presenting part. I have, for example, introduced them when the head was presenting, and, on their removal, found the shoulder lying over the os. It is not difficult to understand how the continu- ous pressure of a distended bag in the internal os might easily push away the head, which is so readily movable as long as the mem- branes are unruptured. Still, if labor be in progress, and the os in- sufficiently dilated, the possibility of this occurrence is not a sufficient reason for not availing ourselves of the undoubtedly valuable assist- ance which the dilators are capable of giving. Separation of the Membranes. — Some processes for inducing labor act directly on the ovum, by separating the membranes, to a greater or less extent, from the uterine walls. The first procedure of the kind was recommended by Dr. Hamilton, of Edinburgh, and con- sisted in the gradual separation of the membranes for one or two inches all round the lower segment of the uterus. To reach them, the finger had to be gently insinuated into the interior of the os, which was gradually dilated to a sufficient extent by a series of suc- cessive operations, repeated at intervals of three or four hours. When this had been accomplished, the fore-finger was inserted and swept round between the membranes and the uterus, but it was fre- quently found necessary to introduce the greater part of the hand to effect the object, and, sometimes, even this was not sufficient, and a female catheter or other instrument had to be used for the purpose. The method was generally successful in bringing on labor, but it now and then failed, even in Dr. Hamilton's hands. It is certainly based on correct principles, but it is tedious and painful both to the practitioner and the patient, and very uncertain in its time of action. For these reasons it has never been much practised. Vaginal and Uterine Douches. — In the year 1836 Kiwisch suggested a plan which, from its simplicity, has met with much approval. It consists in projecting, at intervals, a stream of warm or cold water against the os uteri. Its action is doubtless complex. Kiwisch him- self believed that relaxation of the soft parts, through the imbibition of water, was the determining cause of labor. Simpson found that the method failed, unless the water mechanically separated the mem- branes from the uterine Avails. Besides this effect, it probably di- rectly induces reflex action, bv distending the vagina and dilating the os. In using it, it has been customary to administer a douche twice daily, and more frequently if rapid effects be desired. The number required varies in different cases. The largest number Kiwisch found it necessary to use was 17, the smallest 4. The average time that elapses before labor sets in is four days. Hence the method is obviously useless when rapid delivery is required. Dr. Cohen, of Hamburgh, introduced an important modification of 448 OBSTETRIC OPERATIONS. the process, which has been considerably practised. It consists in passing a silver or gum-elastic catheter some inches within the os, between the membranes and the uterine walls, and injecting the fluid through it directly into the cavity of the uterus. He used creasote, or tar-water, and injected, without stopping, until the patient com- plained of a feeling of distension. Others have found the plan equally efficacious when they only employed a small quantity of plain water, such as 7 or 8 ounces. Professor Lazarewitch, of Char- koff, is a strong advocate of this method. He believes that uterine action is evoked much more rapidly and certainly if the water be injected near the fundus, and he has contrived an instrument for the purpose, with a long metallic nozzle. Dangers of these Plans. — So many fatal cases have followed these methods, that it cannot be doubted that, in spite of their certainty and simplicity, there is an element of risk in them that should not be overlooked. Many of these are recorded in Barnes's work, and he comes to the conclusion, which the facts unquestionably justify, that "the douche, whether vaginal or intra-uterine, ought to be ab- solutely condemned as a means of inducing labor." The precise rea- son of the danger is not very obvious. Sudden stretching of the uterine walls, producing shock, has been supposed to have caused it; but in many of the fatal cases the sjmiptoms have been rather those attending the passage of air into the veins, and it is easy to under- stand how air may have been introduced, in this way, into the large uterine sinuses. Injection of Carbonic Acid Gas. — Simpson and Scanzoni have both tried with success the injection of carbonic acid gas into the vagina. Fatal results have, however, followed its employment, and Simpson has expressed an opinion that the experiment should not. be re- peated. Simpson's Mode of Operating. — Simpson originally induced labor by passing the uterine sound within the os, and up towards the fun- dus, and, when it had been inserted to a sufficient extent, moving it slightly from side to side. He was led to adopt this procedure in the belief that we might thus closely imitate the separation of the decidua, which occurs previous to labor at term. Uterine contrac- tions were induced with certainty and ease, but it was found impossi- ble to foretell what time might elapse between the commencement of labor and the operation, which had frequently to be performed more than once. He subsequently modified this procedure by introducing a flexible male catheter, without a stilette, which he allowed to re- main in the uterus until contractions were excited. This plan is much used in Germany, and is now that which is also most fre- quently adopted in this country. It is simple and very efficacious, pains coming on, almost invariably, within 24 hours after the cathe- ter or bougie is introduced. A theoretical objection is the possi- bility of the catheter separating a portion of the placenta and giving rise to hemorrhage ; but in practice this has not been found to occur, and the risk might generally be avoided by introducing the catheter at a distance from the placenta, the probable situation of which has TURFING. 449 been ascertained by auscultation. The more deeply the catheter is introduced, the more certain and rapid is its effect, and not less than 7 inches should be pushed up within the os. It is not always easy to insert it so far, especially if a flexible catheter be used, which is apt to be too pliable to pass upwards with ease. A solid bougie — male urethral bougie — should, therefore, be employed, and I have found its introduction greatly facilitated by anaesthetizing the patient, and passing the greater part of the hand into the vagina. In this way it can be pushed in very gently, and without any risk of injury to the uterus. There is some chance of rupturing the membranes while pushing it upwards. This accident, indeed, cannot always be avoided, even when the greatest care is taken ; but, when it occurs, the puncture will be at a distance from the os, so that a small portion only of the liquor amnii will escape, and this can scarcely be con- sidered a serious objection. It is always an advantage to allow the pains to come on gradually, and in imitation of natural labor. There- fore, if, after the bougie has been inserted for a sufficient time, uterine contractions come on sufficiently strongly, we may leave the case to be terminated naturally ; or, if they be comparatively feeble, we may resort to accelerative procedures, viz., dilatation of the cervix by the fluid bags, and subsequently the puncture of the membranes. In this way we have the labor completely under control ; and I believe this method will commend itself to those who have experience of it, as the simplest and most certain mode of inducing labor yet known, and the one most closely imitating the natural process. The Child is Immature and Difficult to Bear. — It should not be for- gotten that the child is immature, and that unusual care is likely to be required to rear it successfully. We should, therefore, be careful to kave at hand all the usual means of resuscitation ; and, as the mother may not be able to nurse at once, it would be a good pre- caution to have a healthy wet nurse in readiness. CHAPTER II TURXIXG. Turxixg, by which we mean the alteration of the position of the foetus, and the substitution of some other portion of the body for that originally presenting, is one of the most important of obstetric operations, and merits careful study. It is also one of the most ancient, and was evidently known to the Greek and Roman physi- cians. Up to the fifteenth century, cephalic version — that in which the head of the foetus is brought over the os uteri — was almost exclusively practised, when Pare and his pupil Guillemeau taught 450 OBSTETRIC OPERATIONS. the propriety of bringing the feet clown first. It was by the latter physician especially that the steps of the operation were clearly defined ; and the French have undoubtedly the merit both of per- fecting its performance, and of establishing the indications which should lead to its use. Indeed, it was then much more frequently performed than in later times, since no other means of effecting arti- ficial delivery were known, which did not involve the death of the child ; and practitioners, doubtless, acquired great skill in its per- formance, and were inclined to overrate its importance, and extend its use to unsuitable cases. An opposite error was fallen into after the invention of the forceps, which for a time led to the abandonment of turning in certain conditions for which it was well adapted, and in which it has only of late years been again practised. Cephalic version has, since Pare wrote, been recommended and practised from time to time, but the difficulty of performing it satis- factorily was so great that it never became an established operation. Dr. Braxton Hicks has perfected a method by which it can be ac- complished with greater ease and certainty, and which renders it a legitimate and satisfactory resort in suitable cases. To him Ave are also indebted for introducing a method of turning without passing the entire hand into the cavity of the uterus, which, under favorable circumstances, is not only easy of performance, but deprives the operation of one of its greatest dangers. Turning hy External and Internal Manipulation. — The possibility of effecting version by external manipulation has been long known, and was distinctly referred to and recommended by Dr. John Pechey, 1 so far back as the year 1698. Since that time it has been strongly advocated by Wigand and his followers ; and various authors in thic country, notably Sir James Simpson, have referred to the advantage to be derived from external manipulation assisting the hand in the interior of the uterus. In 1854 Dr. Wright, of Cincinnati, advocated the application of the bi-manual method in arm and shoulder pre- sentations, chiefly with the view of effecting cephalic version. To Dr. Hicks, however, incontestably belongs the merit of having been the first distinctly to show the possibility of effecting complete version in all cases in which the operation is indicated by combined external and internal manipulation, of laying down definite rules for its prac- tice, and of thus popularizing one of the greatest imDrovements in modern midwifery. Object and Nature of the Operation. — The operation is entirely dependent for success on the faet that the child in utero is freely movable, and that its position may be artificially altered with facility As long as the membranes are unruptured, and the foetus is floating in the surrounding fluid medium, it is liable to constant changes in position, as may be readily demonstrated in the latter months of pregnancy; and the operation, under these circumstances, may be performed with the greatest facility. Shortly after the liquor amnii has escaped there is still, as a rule, no great difficulty in effect-^ 1 The Complete Midwife's Practice, p. 142. TURNING. 451 ing version; but, as the body-is no longer floating in the surround- in^ liquid, its rotation must necessarily be attended with some increased risk of injury to the uterus. If the liquor amnii have been lono* evacuated, and the muscular structure of the uterus be strongly "contracted, the foetus may be so firmly fixed, that any attempt to move it is surrounded with the greatest difficulties, and may even fail entirelv, or be attended with such risks to the maternal structures as to be quite unjustifiable. Cases Suitable for the Operation. — Version may be required either on account of the mother or child alone; or it may be indicated by some condition imperilling both, and rendering immediate delivery necessary. The chief cases in which it is resorted to are those of transverse presentation, where it is absolutely essential; accidental or unavoidable hemorrhage; certain cases of contracted pelvis; and some complications, especially prolapse of the funis. The special indications for the operation have been separately discussed under these subjects. Statistics and Dangers of the Operation. — The ordinary statistical tables cannot be depended on as giving any reliable results as to the risks of the operation^ Taking all cases together, Dr. Churchill esti- mates the maternal mortality as 1 in 16, and the infantile as 1 in 3. Like all similar statistics, they are open to the objection of not dis- tinguishing between the results of the operation itself, and of the cause which necessitated interference. Still they are sufficient to show that the operation is not free from grave hazards, and that it must not be undertaken without due reflection. The principal dangers will be discussed as we proceed. It may suffice to mention here that those to the mother must vary with the period at which the operation is undertaken. If version be performed early, before the rupture of the membranes, or, in favorable cases, without the introduction of the hand into the interior of the uterus, the risk must of course be infinitely less than in those more formidable cases in which the waters have long escaped, and the hand and arms have to be passed into an irritable and contracted uterus. But even in the most unfavorable cases accidents may be avoided, if the operator bear constantly in mind that the principal clanger consists in lace- ration of the uterus or vagina from undue force being employed, or from the hand and arm not being introduced in the axis of the pas- sages. There is no operation in which gentleness, absence of all hurry, and complete presence of mind are so essential. A certain number of cases end fatally from shock or exhaustion, or from sub- sequent complications. As regards the child, the mortality is little, if at all, greater than in original breech and footling presentations. Nor is there any good reason why it should be so, seeing that cases of turning 3 after the feet are brought through the os, are virtually reduced to those of feet presentation, and that the mere version, if effected sufficiently soon, is not likely to add materially to the risk to which the child is exposed. Version by External Manipulation. — The possibility of effecting version by external manipulation has been recognized by various 452 OBSTETRIC OPERATIONS. authors, and was made the subject of an excellent thesis by Wigand who clearly described the manner of performing the operation. In spite of the manifest advantages of the procedure, and the extreme facility with which it can be accomplished in suitable cases, it has by no means become the established custom to trust to it, and prob- ably most practitioners have never attempted it, even under the most favorable conditions. The possibility of operation is based on the extreme mobility of the foetus before the membranes are ruptured. After the waters have escaped, the uterine walls embrace the foetus more or less closely, and version can no longer be readily performed in this manner. Gases suitable for the Operation. — It may, therefore, be laid down as a rule that it should only be attempted when the abnormal posi- tion of the foetus is detected before labor has commenced, or in the early, stage of labor, when the membranes are ruptured. It is also unsuitable for any but transverse presentations, for it is not meant to effect complete evolution of the foetus, but only to substi- tute the head for the upper extremity. It is useless whenever rapid delivery is indicated, for, after the head is brought over the brim, the conclusion of the case must be left to the natural powers. Method of Performance. — The manner of detecting the presentation by palpation has been already described (p. 116), and the success of the operation depends on our being able to ascertain the positions of the head and breech through the uterine walls. Should labor have commenced, and the os be dilated, the transverse presentation may be also made out by vaginal examination. Should the abnormal pre- sentation be detected before labor has actually begun, it is, in most cases, easy enough to alter it, and to bring the foetus into the longi- tudinal axis of the uterine cavity. Pinard 1 recommends that after this has been done the foetus should be maintained in position by a well-fitting elastic abdominal belt. It is seldom, however, discovered until labor has commenced, and even if it be altered, the child is ex- tremely apt to resume, in a short time, the faulty position in which it was formerly lying. Still there can be no harm in making the attempt, since the operation itself is in no way painful, and is abso- lutely without risk either to the mother or child. When the trans- verse presentation is detected early in labor, I believe it is good practice to endeavor to remedy it by external manipulation, and, if it fail, we may at once proceed to other and more certain methods of operating. The procedure itself is abundantly simple. The pa- tient is placed on her back, and the position of the foetus ascertained by palpation as accurately as possible, in the manner already indi- cated. The palms of the hands being then placed over the opposite poles of the foetus, by a series of gentle gliding movements, the head is pushed towards the pelvic brim, while the breech is moved in the opposite direction. The facility with which the foetus may some- times be moved in this way can hardly be appreciated by those who have never attempted the operation. As soon as the change is De la version par manoeuvres externes- Paris-, 1878.. TURNING. 453 effected, the long diameters of the foetus and of the uterus will cor- respond, and vaginal examination will show that the shoulder is no longer presenting, and that the head is over the pelvic brim. If the os be sufficiently dilated, and labor in progress, the membranes should now be punctured, and the position of the foetus maintained for a short time by external pressure, until Ave are certain that the cephalic presentation is permanently established. If labor be not in progress, an attempt may at least be made to effect the same object b.ypads and a binder ; one pad being placed on the side of the uterus in the situation of the breech, and another on the opposite side in the situation of the head. Cephalic Version. — On account of the difficulty of performing cepha- lic version in the manner usually recommended, it has practically scarcely been attempted, and with the exception of some more recent authors, it is generally condemned by writers on systematic mid- wifery. Still the operation offers unquestionable advantages in those transverse presentations in which rapid delivery is not necessary, and in which the only object of interference is the rectification of malposition ; for, if successful, the child is spared the risk of being drawn footling through the pelvis. The objections to cephalic ver- sion are based entirely on the difficulty of performance ; and, un- doubtedly, to introduce the hand within the uterus, search for, seize, and afterwards place the slippery head in the brim of the pelvis, could not be an easy process, even under the most favorable circum- stances, and must always be attended by considerable risk to the mother. Velpeau, who strongly advocated the operation, was of opinion that it might be more easily accomplished by pushing up the presenting part, than by seizing and bringing down the head. Tv i- gand more distinctly pointed out that the head could be brought to a proper position by external manipulation, aided by the fingers of one hand within the vagina. Braxton Hicks has laid down clear rules for its performance, which render cephalic version easy to ac- complish under favorable conditions, and will doubtless cause it to become a recognized mode of treating- malpositions. The number of cases, however, in which it can be performed must always be limited since, as in turning by external manipulation alone, it is necessary that the liquor amnii should be still retained, or at least have only recently escaped; that the presentation be freely movable above the pelvic brim; and that there be no necessity for rapid delivery. Dr. Hicks does not believe protrusion of the arm to be a contra-indica- tion, and advises that it should be carefully replaced within the uterus. When, however, protrusion of the arm has occurred, the thorax is so constantly pushed clown into the pelvis that replacement can neither be safe nor practicable, except under unusually favorable conditions, and podalic version will be necessary. Method of Performance. — It is impossible to describe the method of performing cephalic version more concisely and clearly than in Dr. Hicks's own words. "Introduce," he says, "the left hand into the vagina, as in podalic version ; place the right hand on the out- side of the abdomen, in order to make out the position of the foetus, 454 OBSTETRIC OPERATIONS. and the direction of its head and feet. Should the shoulder, for instance, present, then push it with one or two fingers in the direc- tion of the feet. At the same time pressure with the other hand should be exerted on the cephalic end of the child. This will bring the head down to the os ; then let the head ba received on the tips of the inside fingers. The head will play like a ball between the two hands; it will be under their command, and can be placed in almost any part at will. Let the head then be placed over the os, taking care to rectify any tendenc}^ to face presentation. It is as w T ell, if the breech will not rise to the fundus readily after the head is fairly in the os, to withdraw the hand from the vagina, and with it press up the breech from the exterior. The hand which is re- taining gently the head from the outside should continue there for some little time till the pains have insured the retention of the child in its new position and the adaptation of the uterine walls to its new form. Should the membranes be perfect, it is advisable to rupture them as soon as the head is at the os uteri ; during their flow and after the head will move easily into its proper position." The procedure thus described is so simple, and would occupy so short a time, that there can be no objection to trying it. Should we fail in our endeavors, we shall not be in a worse position for effecting delivery by podalic version, which can be proceeded with without withdrawing the hand from the vagina, or in any way altering the position of the patient. Podalic Version. — The method of performing podalic version varies with the nature of each particular case. In describing the operation, it has been usual to divide the cases into those in which the circum- stances are favorable, and the necessary manoeuvres easily accom- plished : and those in which there are likely to be considerable diffi- culties, and increased risk to the mother. This division is eminently practicable, since nothing can be more variable than the circum- stances under which version may be required. Before describing the steps of the operation, it may be well to consider some general conditions applicable to all cases alike. Position of the Patient. — In this country the ordinary position on the left side is usually employed. On the Continent and in America the patient is placed on her back, with the legs supported by assist- ants, as in lithotomy. The former position is preferable, not only as a matter of custom, and as involving much less fuss and exposure of the person, but because it admits of both the operator's hands being more easily used in concert. In certain difficult cases, when the liquor amnii has escaped, and the back of the child is turned towards the spine of the mother, the dorsal decubitis presents some advantages in enabling the hand to pass more readily over the body of the child ; but such cases are comparatively rare. The patient should be brought to the side of the bed, across which she should be laid, with the hips projecting over, and parallel to, the edge, the knees being flexed towards the abdomen, and separated from each other by a pillow, or by an assistant. Assistants should also be placed so as to restrain' the patient if necessary, and prevent her TURNING. 455 involuntarily starting from the operator, as this might not only embarrass his movements, but be the cause of serious injury. Administration of Anaesthetics. — The exhibition of anaesthetics is peculiarly advantageous. There is nothing which tends to facilitate the steps of the process so much, as stillness on the part of the patient, and the absence of strong uterine contraction. When the vagina'is very irritable and the uterus firmly contracted round the body of the child, complete anaesthesia may enable us to effect ver- sion, when without it we should certainly fail. Period when the Operation should he Undertaken. — The most favor- able time for operating is when the os is fully dilated, before, or im- mediately after, the rupture of the membranes and the discharge of the liquor amnii. The advantage gained by operating before the waters have escaped cannot be overstated, since we can then make the child rotate with great facility in the fluid medium in which it floats. In the ordinary operation, in which the hand is passed into the uterus^ it is essential to wait until the os is of sufficient size to admit its being introduced with safety. This may generally be done when the os is the size of a crown-piece, especially if it be soft and yielding. Choice of Rand to he used. — The practice followed with regard to the hand to be used in turning varies considerably. Some accoucheurs always employ the right hand, others the left, and some one or other, according to the position of the child. In favor of the right hand, it is said that most practitioners have more power with it, and are able to use it with greater gentleness and delicacy. In transverse presentations, if the abdomen of the child be placed anteriorly, the right hand is said to be the proper one to use, on account of the greater facility with which it can be passed over the front of the child; and in difficult cases of this kind, when we are operating with the patient on her back, it certainly can be employed with more pre- cision than the left. In all ordinary cases, however, the left hand can be introduced much more easily in the axis of the passages, the back of the hand adapts itself readily to the curve of the sacrum, and, even when the child's abdomen lies anteriorly, it can be passed -forwards without difficulty so as to seize the feet. These advantages are sufficient to recommend its use, and ver} r little practice is re- quired to enable the practitioner to manipulate with it as freely as with the right. If, in addition, we remember that the right hand is required to operate on the foetus through the abdominal walls — and this is a point which should never be forgotten — we shall have abundant reasons for laying it down as a rule that the left hand should generally be employed. Before passing the hand and arm they should be freely lubricated, with the exception of the palm, which is left untouched to admit of a firm grasp being taken of the foetal limbs. It is also advisable to remove the coat, and bare the arm as high as the elbow. As it should be a cardinal rule to resort to the simplest procedure when practicable, it will be well to consider first the method by com- bined external and internal manipulation, without passing the hand 456 OBSTETRIC OPERATIONS into the uterus, and subsequently that which involves the introduc- tion of the hand. Turning by Combined External and Internal Manipulation.- — To effect podalic version by the combined method it is an essential pre- liminary to ascertain the situation of the foetus as accuratelv as pos- sible. It will generally be easy, in transverse presentation, to make out the breech and the head by palpation ; while, in head presenta- tions, the fontanelles will show to which side of the pelvis the face is turned. The left hand is then to be passed carefully into the vagina, in the axis of the canal, to a sufficient extent to admit of the fingers passing freely into the cervix. To effect this, it is not always necessary to insert the whole hand, three or four fingers being gen- erally sufficient. Fig. 143. First Stage of Bipolar Version —Elevation of the Head and Depression of the Breech. (Alter Barnes.) If the head lie in the first or fourth position, push it upwards and to the left; while the other hand, placed externally on the abdomen, depresses the breech towards the right (Fig. 144). By this means we act simultaneouslv on both extremities of the child's body, and easilv alter its position. The breech is pushed down gently but firmly, by gliding the hand over the abdominal wall. The head will now pass out of reach, and the shoulder will arrive at the os, and will lie on the tips of the fingers. This is similarly pushed upwards in the same direction as the head (Fig. 144), the breech at the same TURNING 457 time being still farther depressed, until the knee comes within reach of the fingers, when (the membranes being now ruptured, if still Fig. 144. Second Stage of Bi-polar Version.— Elevation of the Shoulders and Depression of the Breech. (After Barnes.) unbroken) it is seized and pulled down through the os (Fig. 145). Occasionally the foot comes immediately over the os, when it can be seized instead of the knee. Version may be facilitated by changing Fig. 145. Third Stage of Bi-polar Version.— Seizure of the Kuee and partial Elevation of the Head. (After Barnes.) the position of the external hand, and pushing the head upwards from the iliac fossa, instead of continuing the attempt to depress the 458 OBSTETRIC OPERATIONS. breech (Figs. 145 and 146). These manipulations should always he carried on in the intervals, and desisted from when the pains come on ; and when the pains recur with great force and frequency, the advantage of chloroform will be particularly apparent. In the Fig. 146. Fourth Stage of Bi-polar Version. — Drawing down of the Legs and completion of versiou. (After Barnes.) second and third positions, the steps of the operation should be re- versed ; the head is pushed upwards and to the right, the breech, downwards and to the left. When the position cannot be made out with certainty, it is well to assume that it is the first, since that is the one most frequently met with ; and even if it be not, no great inconvenience is likely to occur. If the os be not sufficiently open to admit of delivery being concluded, the lower extremity can be retained in its new position with one finger, until dilatation is suffi- cientlv advanced, or until the uterus has permanently adapted itself to the altered position of the child, either of which results will gene- rally be effected in a short space of time. In transverse presentations the same means are to be adopted, the shoulder being pushed upwards in the direction of the head, while the breech is depressed from without. This is frequently sufficient to bring the knees within reach, especially if the membranes are entire, but version is much facilitated by pressing the head upwards from without, alternately with depression of the breech. If the liquor amnii has escaped, and the uterus is firmly contracted round the body of the child, it will be found impossible to effect an altera- tion in its position without the introduction of the hand, and the TURNING. 459 ordinary method of turning must be employed. The peculiar advan- tage of the combined process is, that it in no way interferes with the latter, for, should it not succeed, the hand can be passed on into the uterus without withdrawal from the vagina (provided the os be sufficiently dilated), and the feet or knees seized and brought down. Podalic Version when the Hand is introduced into the Uterus.— Turn- ing, with the hand introduced into the uterus, provided the waters have not or have only recently escaped, and the os be sufficiently dilated, is an operation generally performed with ease. Introduction of the Hand. — The first step, and one of the most important, is the introduction of the hand and arm. The fingers having been pressed together in the form of a cone, the thumb lyiug between the rest of the fingers, the hand, thus reduced to the smallest possible dimensions, is slowly and carefully passed into the vagina, in the axis of the outlet, in an interval between the pains, and passed onwards in the same cautious manner, and with a semi-rotatory motion, until it lies entirely within the vagina, the direction of in- troduction being gradually changed from the axis of the outlet to that of the brim. If uterine contractions come on, the hand should remain passive until they are over. It should ever be borne in mind, as one of the fundamental rules in performing version, that we should act only in the absence of pains, and then with the utmost gentleness — all force and violent pushing being avoided. The hand, still in the form of a cone, having arrived at the os, if this be suffi- ciently dilated, may be passed through at once. If the os be not quite open, but dilatable, the points of the fingers may be gently insinuated, and occasionally expanded, so as to press it open suffi- ciently to permit the rest of the hand to pass. While this is being done, the uterus should be steadied by the other hand placed exter- nally, or by an assistant. If the presentation should not previously have been made out with accuracy, we can now ascertain how to pass the hand onwards, so that its palmar surface may correspond with the abdomen of the child. Rupture of the Membranes. — The membranes should now be rup- tured — if possible during the absence of pain — so as to prevent the waters being forced out. The hand and arm form a most efficient plug, and the liquor amnii cannot escape in any quantity. Some practitioners recommend that, before rupturing the membranes, the hand should b3 passed onwards between them and the uterine walls, until we reach the feet. By so doing we run the risk of separating the placenta ; besides we have to introduce the hand much further than may be necessary, since the knees are often found lying quite close to the os. As soon as the membranes are perforated, the hand can be passed on in search of the feet (Fig. 147). At this stage of the operation increased care is necessary to avoid anything like force ; and should a pain come on, the hand must be kept perfectly flat and still, and rather pressed on the body of the child than on the uterus. If the pains be strong, much inconvenience may be felt from the compression ; and, were the onward movement continued, or the hand even kept bent in the conical form in which it was introduced, 4G0 OBSTETRIC OPERATIONS. rupture of the uterine walls might easily be caused. This is not likely to occur in the class of cases now under consideration, for it is chiefly when the waters have long escaped that the progress of the hand is a matter of difficulty. Valuable assistance may now be given Fig. 147. Seizure of the Feet when the Hand is Introduced into the Uterus. by pressing the breech downwards from without, so as to bring the knees or feet more easily within the reach of the internal hand. Having arrived at the knees or feet, they may be seized between the fingers, and drawn downwards in the absence of a pain (Fig. 148). This will cause the foetus to revolve on its axis, the breech will de- scend, and, at the same time, the ascent of the head may be assisted by the right hand from without. It is a question with many ac- coucheurs which part of the inferior extremities should be seized and brought clown. Some recommend us to seize both feet, others prefer one only, while some advise the seizure of one or both knees. In a simple case of turning, before the escape of the waters, it does not matter much which of these plans is followed, since version is accomplished with the greatest ease by any one of them. The seizure of the knee, however, instead of the feet, offers certain advantages which should not be overlooked. It is generally more accessible, affords a better hold (the fingers being inserted in the flexure of the ham), and, being nearer the spine, traction acts more directly on the body of the child. Any danger of mistaking the knee for the elbow TURNING. 461 may be obviated by remembering the simple rule that the salient angle of the former looks towards the head of the child, of the latter Fig. 148. Drawing down of the Feet and Completion of Version. towards its feet. Certain advantages may also be gained by bring- ing down one foot or knee only, instead of both. When one inferior extremity remains flexed on the body of the child, the part which has to pass through the os is larger than when both legs are drawn down, and consequently the os is more perfectly dilated, and less difficulty is likely to be experienced in the delivery of the rest of the body, so that the risk to the child is materially diminished. Choice of Leg to be brought down in Transverse Presentations. — Simpson, whose views have been adopted by Barnes and other writers, recommends the seizing if possible, in arm presentations, of the knee farthest from and opposite to the presenting arm, as by this means the body is turned round on its longitudinal axis, and the presenting arm and shoulder more easily withdrawn from the os. Dr. Galabin has carefully investigated this point in a recent paper, 1 and contends that there is a greater mechanical advantage in seizing the leg which is nearest to, and on the same side as, the presenting arm, and this, moreover, is generally more readily done. 1 Obst. Trans., vol. xix. 1877. 462 OBSTETRIC OPERATIONS, Management of the Case after Version. — As soon as the head has reached the fundus, and the lower extremity is brought through the os, the case is converted into a foot or knee presentation, and it comes to be a question whether delivery should now be left to nature or terminated by art. This must depend to a certain extent on the case itself, and on the cause which necessitated version, but generally, it will be advisable to finish delivery without unnecessary delay. To accomplish this, downward traction is made during the pains, and desisted from in the intervals (Fig. 149). As the umbilical cord Fig. 149. \D/T$ Showing the Completion of Version. (After Barnes.) appears, a loop should be drawn down ; and if the hands be above the head, they must be disengaged and brought over the face, in the same manner as in an ordinary footling presentation. The manage- ment of the head, after it descends into the cavity of the pelvis, must also be conducted as in labors of that description. Turning in Placenta Prsevia. — In cases of placenta praevia the os will, as a rule, be more easily dilatable than in transverse presenta- tions. Hicks's method offers the great advantage of enabling us to perform version much sooner than was formerly possible, since it only requires the introduction of one or two fingers into the os uteri. Should we not succeed by it, and the state of the patient indicates that delivery is necessary, we have at our command, in the fluid dilators, a means of artificially dilating the os uteri which can be TURNING 463 employed with ease and safety. If we have to do with a ease of entire placental presentation, the hand should be passed at that point where the placenta seems to be least attached. This will alwaj's be better than attempting to perforate its substance, a measure some- times recommended, but more easily performed in theory than in practice. If the placenta only partially present, the hand should, of course, be inserted at its free border. It will frequently be advisable not to hasten delivery after the feet have been. brought through the os, for they form of themselves a very efficient plug, and effectually prevent further loss of blood ; while, if the patient be much ex- hausted, she may have her strength recruited by stimulants, etc., before the completion of delivery. Turning in Ahdomino- anterior Positions.- — In abdomino-anterior positions, in which the waters have escaped, and in which, therefore, some difficulty may be reasonably anticipated, the operation is gener- ally more easily performed with the patient on her back ; the right hand is then introduced in the uterus, and the left employed exter- nally (Fig. 150). In this way the internal hand has to be passed a Fig. 150. Showing the TT se f the Right Hand in Abdomino-anterior Position. shorter distance, and in a less constrained position. The operator then sits in front of the patient, who is supported at the edge of the bed in the lithotomy position with the thighs separated, and the right hand is passed up behind the pubis, and over the abdomen of the child. Difficult Cases of Arm Presentation. — The difficulties of turning culminate in those unfavorable cases of arm presentation in which the membranes have been long ruptured, the shoulder and arm pressed down into the pelvis, and the uterus contracted round the 464 OBSTETRIC OPERATIONS. body of the child. The uterus being firmly and spasmodically con- tracted, the attempt to introduce the hand often only makes matters worse, by inducing more frequent and stronger pains. Even if the hand and arm be successfully passed, much difficulty is often ex- perienced in causing the body of the child to rotate ; for we have no longer the fluid medium present in which it floated and moved with ease, and the arm of the operator may be so cramped and pained, by the pressure of the uterine walls, as to be rendered almost power- less. The risk of laceration is also greatly increased, and the care necessary to avoid so serious an accident adds much to the difficulty of the operation. Value of Anaesthesia in Relaxing the Uterus. — In these perplexing cases various expedients have been tried to cause relaxation of the spasmodically contracted uterine fibres, such as copious venesection in the erect attitude until fainting is induced, warm baths, tartar emetic, and similar depressing agents. None of these, however, are so useful as the free administration of chloroform, which has practi- cally superseded them all, and often answers most effectually when given to its full surgical extent. Mode of Procedure. — The hand must be introduced with the pre- cautions already described. If the arm be completely protruded into the vagina, we should pass the hand along it as a guide, and its palmar surface will at once indicate the position of the child's abdo- men. No advantage is gained by amputation, as is sometimes recom- mended. When the os is reached, the real difficulties of the operation commence, and, if the shoulder be firmly pressed down into the brim of the pelvis, it may not be easy to insinuate the hand past it. It is allowable to repress the presenting part a little, but with extreme caution, for fear of injuring the contracted uterine parietes. It is better to insinuate the hand past the obstruction, which can generally be done by patient and cautious endeavors. Having succeeded in passing the shoulder, the hand is to be pressed forward in the intervals, being kept perfectly flat and still on the body of the foetus when the pains come on. It is much safer to press on it than on the uterine walls, which might readily be lacerated by the projecting knuckles. When the hand has advanced sufficiently far, it will be better, for the reasons already mentioned, to seize and bring down one knee only. Management of Cases in which the Foot is brought down but the Foetus will not Revolve. — Even when the foot has been seized and brought through the os, it is by no means always easy to make the child revolve on its axis, as the shoulder is often so firmly fixed in the pelvic brim as not to rise towards the fundus. Some assistance may be derived from pushing the head upwards from without, which, of course, would raise the shoulder along with it. If this should fail, me may effect our object by passing a noose of tape or wire ribbon round the limb, by which traction is made downwards and back- wards ; at the same time, the other hand is passed into the vagina to displace the shoulder and push it out of the brim. It is evident that this cannot be done as long as the limb is held by the left hand, as THE FORCEPS. 465 there is no room for both hands to pass into the vagina at the same time. By this manoeuvre version may be often completed, when the foetus cannot be turned in the ordinary way. Various instruments have been invented, both for passing a lac round the child's limb, and for repressing the shoulder, but none of them can compete, either in facility of use or safety, with the hand of the accoucheur. Should all attempts at version fail, no resource is left but the mutilation of the child, either by evisceration or decapitation. This extreme measure is, fortunately, seldom necessary, as with due care version may generally be effected, even under the most unfavorable circumstances. CHAPTER III. THE FORCEPS. Of all obstetric operations the most important, because the most truly conservative both to the mother and child, is the application of the forceps. In modern midwifery the use of the instrument is much extended, and it is now applied by some of our most expe- rienced accoucheurs with a frequency which older practitioners would have strongly reprobated. That the injudicious and unskilful use of the forceps is capable of doing much harm, no one will for a moment deny. This, however, is not a reason for rejecting the recommenda- tion of those who advise a more frequent resort to the operation, but rather for urging on the practitioner the necessity of carefully study- ing the manner of performing it, and of making himself familiar with the cases in which it is easy or the reverse. Nothing but practice — at first on the dummy, and afterwards in actual cases — can impart the operative dexterity which it should bo the aim of every obstetri- cian to acquire, and without which there can be no assurance of his doing his duty to his patient efficiently. Description of the Instrument. — The forceps may best be described as a pair of artificial hands, by which the foetal head may be grasped and drawn through the maternal passages by a vis a fronte, when the vis a tergo is deficient. This description will impress on the mind the important action of the instrument as a tractor, to which all its other powers are subservient. The forceps consists of two separate blades of a curved form, adapted to fit the child's head ; a lock by which the blades are united after introduction ; and handles which are grasped by the operator, and by means of which traction is made. It would be a wearisome and unsatisfactory task to dwell on all the modifications of the instrument which have been made, which are so numerous as to make it almost appear as if no one could practise 466 OBSTETRIC OPERATIONS, Fig. 151. midwifery with the least pretension to eminence, unless lie has attached his name to a new variety of forceps. The Short Forceps. — The original instrument, invented by the Chamberlens, may be looked upon as the type of the short straight forceps, which has been more employed than any other, and which, perhaps, finds its best representative in the short forceps of Denman (Fig. 151). Indeed the only essential difference between the two is the lock of the latter, originally in- vented by Smellie, which is so excellent that it has been adopted in all British forceps; and which, for facility of junc- ture, is much superior to either the French pivot, or the German lock, while for firmness it is, for all practical purposes, as good as either. In this instrument the blades are 7, the handles 4| inches in length ; the extremities of the blades are exactly 1 inch apart, and the space between them, at their widest part, is 2| inches. The blades measure If inches at their greatest breadth, and spring with a regular sweep directly from the lock, there being no shank. The blades are formed of the best and most highly tempered steel, to resist the strain to which they are occasionally subjected, and they are smooth and rounded on their inner sur- face, to obviate the risk of injury to the scalp of the child. Advantages claimed for this Form, rf Instrument. — The special advantage claimed for this form of instrument is, that, the two halves being precisely similar, no care or forethought is required on the part of the practi- tioner as to which blade should be introduced uppermost — an ad- vantage of no great value, since no one should undertake a case of forceps delivery who has not sufficient knowledge of the operation, and presence of mind enough to obviate any risk from the intro- duction of the wrong blade first. On account of its shortness, and the want of the second or pelvic curve, it is only adapted for cases in which the head is low down in the pelvis, or actually resting on the perineum. The Pelvic Curve, its Advantages. — The question of the second or pelvic curve is one on which there is much difference of opinion. The forceps we are now considering, and the many modifications formed on the same plan, is constructed solely with reference to its grasp on the child's head, and without regard to the axes of the maternal passages. Consequently were we to introduce it when the head was at the upper part of the pelvis, we could not fail to expose Denman's Short Forcepa. THE FORCEPS. 46T Fig. 152. the soft parts to the risk of contusion, and (in consequence of the necessity of drawing more directly backwards) unduly stretch and even lacerate the perineum. Hence it is now admitted by obstetri- cians, with few exceptions, that the second curve is essential before the complete descent of the head, although it is not absolutely so after this has taken place. The only circumstances under which a straight blade can possess any superiority are in certain cases of occipito-posterior position, in which it is found necessary to rotate the head round a large extent of the pelvis, when the circular sweep of a strongly-curved instrument might prove injurious. Such cases, however, are of rare occurrence, and need in no way influence the general employment of the pelvic curve. Zeiglers Forceps. — The short forceps, usually employed in Scot- land, is the invention of the late Zeigler (Fig. 152), 1 and is useful from the facility with which the blades may be introduced in accurate apposition to each other, a point which in practice is of no little value. In general siza and appearance it closely resembles Den man's forceps, but the fenestrum of the lower blade is continued down to the handle. In intro- ducing, the lower blade is slipped over the handle of the other blade already in situ, and thus it is guided with great certainty into a proper position, locking itself as it passes on. This instrument has the disadvantage of not having the second curve, but the facility of introduction has rendered it a great favorite with many who have been in the habit of employing it. The Long Forceps. — For cases in which the head is not on the perineum, or at least not quite low in the pelvis, a longer instrument is essential. To meet this indication Smellie invented the long forceps, which, like the shorter instrument, has been very variously modified. The most perfect instrument of the kind employed in this country is that known as Simpson's forceps (Fig. 153), which combines many excellent points selected from the forceps of various obstetricians, as well as some original additions, and which, as a whole, has never been surpassed. The curved portions of the blades are 6J inches long, the fenestrum measuring 1^ at its widest part. The extremities of the blades are 1 inch asunder when the handles are closed, and 3 inches at their widest part. The object of this somewhat unusual width is to lessen the compressing power of the instrument, without in any way interfering with its action as a tractor. The pelvic curve is less than in most long forceps, so as to admit of the rotation of the head when necessary, without the risk of injuring the maternal structures. Between the curve of the blade and the lock is a straight portion or shank, measuring 2| inches, which, before joining the handle, is bent at right angles into a knee. Zeipler's Forceps. P It lias been made here, but is not regarded -rc-itli any favor. — Ed.] 468 OBSTETRIC OPERATIONS Fig. 153. This shank is a useful addition to all forceps, and is essential in the long forceps to insure the junction of the blades beyond the parts of the mother, which might otherwise be caught in the lock and injured. The knees serve the purpose of preventing the blades from slipping from each other after they have been united. They also admit of one finger being introduced above the lock, and used as an aid in traction ; a provision which is made in some other varieties of long forceps by a semicircular bend in each shank. The handles which in most British forceps are too small and smooth to afford a firm grasp, are serrated at the edge, and flattened from before backwards, so as to fit the closed fist more accurately. At their extremities, near the lock, there are a pair of projecting rests, over which the fore and middle fingers may be passed in traction, and which greatly increase our power over the instrument. Although this, and other varieties of the long forceps, are specially constructed for application when the head is high in the pelvis, it answers quite as well as the short forceps — in- deed, in most respects better — when the head has descended low down. It is a decided advantage for the practitioner to habituate himself to the use of one instru- ment, with the application and power of which he becomes thoroughly familiar. It is a mere waste of space and money for him to incumber himself with a number of instruments of various shapes and sizes, and he may be sure that a good pair of long forceps, such as Simpson's, will be suitable for every emergency, and in any position of the head. Disadvantages of a Weak Instrument. — The chief argument against the use of such an instrument in simple cases is its great power. This, however, is entirely based on a misconception. The existence of power does not involve its use, and the stronger instru ment can be employed with quite as much delicacy and gentleness as the weaker. The remarks of Dr. Hodge 1 on this point are extremely apposite, and are well worthy of quotation. He says, " Certainly no man ought to apply the forceps who has not sufficient discretion to use no more force than is absolutely requisite for safe delivery ; if, e Simpson's Forceps. 1 System of Obstetrics, p. 242. THE FORCEPS. 469 therefore, there is more power at command, he is not obliged to use it ; while, on the contrary, if much power be demauded, he can, within the bounds of prudence, exercise it by the long forceps, but with the short forceps his efforts might be unavailing ; moreover, in cases of difficulty, the short forceps being used, the practitioner would be forced to make great muscular efforts ; while with the long forceps, owing to the great leverage, such effort will be compara- tively trifling, and, of course, the whole force demanded can be much more delicately, and at the same time efficiently applied, and with more safety to the tissues of the child and its parent." Continental Forceps. — The forceps usually employed on the Con- tinent, and in America, differ considerably, both in appearance and construction, from those in use in this country. As a rule it is a larger and more powerful instrument, joined by a pivot or button joint, and it always possesses the second or pelvic curve. Of late years Simpson's forceps has been much employed in some parts of Germany. The chief objection to the Continental instruments is their Fie. 154. cumbrousness. This is chiefly in the handles, which in many of them are forged in a piece with the blades, the part introduced within the maternal structures not being materially differ- ent from the corresponding part of the English instrument. The forceps invented by Professor Tarnier (Fig. 154) have recently at- tracted considerable attention. In this instrument traction is not made on the handles by which the blades are intro- duced, as in ordinary forceps, but on a supplementary handle (a) subsequently attached to the blades near the lower opening of their fenestra (b). The object claimed for this arrangement is that less force is required in traction, Tanner's Forceps. which can alwaj^s be made in the proper axis of the pelvis ; that the blades are not likely to slip ; and that rotation of the head is not interfered with. The instrument, however, is much more complex than that usually employed in this country, and does not seem to possess sufficient advantages to coun- terbalance this defect. 1 Action of the Instrument. — The forceps is generally said to act in three different ways : — 1st. As a tractor. 2d. As a lever. 3d. As a compressor. [} Professor Tarnier lias adopted, in this instrument, the blades of Davis. It has beenmnch simplified recently, by Dr. Richard A. Cleemann, of Philadelphia, by taking away the long curve of the handles, dispensing -with the tongue, and bending for- ward the shanks. — Ed.] 470 OBSTETRIC OPERATIONS, The Chief Use of the Forcejis as a Tractor. — It is more especially as a tractor that the instrument is of value, and it is used with the great- est advantage when it is employed merely to supplement the action of the uterus, which is insufficient of itself "to effect delivery, or when, from some complication, it is necessary to complete labor with greater rapidity than can be accomplished by the unaided powers of nature. In most cases traction alone is sufficient ; but, in order that it may act satisfactorily, and that the instrument may not slip, a proper con- struction of the forceps, and a sufficient curvature of the blades, are essential. The want of these is the radical fault of many of the short, straight instruments in common use, which have a tendency to slip during our efforts at extraction. As a Lever. — -The forceps acts also as a lever, but this action has been greatly exaggerated. It is generally described as a lever of the first class, the power being at the handles, the fulcrum at the lock, and the weight at the extremities. There may possibly be some leverage power of this kind when the instrument is first introduced, and the handles held so loosely that one blade is able to work on the other. But, as ordinarily used, the handles are held with a suffi- ciently firm grasp to prevent this 1 movement, -and then the two blades practically form a single instrument. Galabin, who has studied this subject in detail, points out 1 that: "1. The lever is formed by both blades of the forceps and the foetal head united in one immovable mass. As soon as the blades begin to slip over the head, the lever is decomposed, and the swaying move- ment ceases to have any mechanical advantage. 2. The power is applied to the handles in a slanting direction. The resistance or weight does not act at a point either between the former and the fulcrum, or beyond the fulcrum, but at a point in a plane nearly at right angles to the line joining these two points; and its direction is a line perpendicular to that plane of the pelvis in which the greatest section of the head is engaged, that is to say, in the case of straight forceps, nearly parallel to the handles. The lever formed does not, therefore, strictly speaking, belong to any one of the three orders into which levers are commonly divided. 3. The fulcrum is fixed partly by friction, partly by the combination of traction with oscil- latory movement — in other words, by the power being directed in great measure downwards, and only slightly to one side." He further shows that the pendulum motion of the forceps is super- fluous in all ordinary forceps operations, in which traction alone is amply sufficient for delivery; but that when the head is impacted, and great force is required for its extraction, a mechanical advantage may be gained from having recourse to an oscillatory movement, which should, however, be very limited, and only continued if found to effect distinct advance of the head. As a Compressor. — Eegarcling the compressive power of the instru- ment there has been much difference of opinion. There is no doubt » Galabin, "Action of Midwifery Forceps as a Lever," Obstetrical Journal, November, 1876. THE FORCEPS. 471 that the forceps, especially some of the foreign instruments in which the points nearly approach each other, is capable of exerting con- siderable compression on the head. It is, however, extremely prob- lematical if this action be of real value. It is to be borne in mind that in cases of protracted labor the head has been already moulded and compressed, and the bones have been made to overlap each other to their utmost extent, by the sides of the pelvis; we can scarcely, therefore, expect to diminish the head much more by the forceps, without employing an amount of force that will seriously endanger the life of the" child. It is in cases of disproportion between the head and the pelvis, depending on slight antero- posterior contraction of the pelvic brim, that diminution of the child's head by compres- sion wouid be most useful. Then, however, the pressure of the forceps is exerted on that portion of the head which lies in the most roomy diameter of the pelvis, where there is no want of space. If this pressure do not increase the opposite diameter, which is in appo- sition to the narrower portion of the pelvis, it can at least do nothing towards lessening it ; and diminution of any other part of the child's head is not required. Dynamical Action of the Forceps. — The mere introduction of the forceps sometimes excites increased uterine action, through the reflex irritation induced by the presence of a foreign body in the vagina. This has been called the dynamical action of the forceps ; but it can- not be looked upon in any other light than that of an occasional accidental result. The circumstances indicating the use of the forceps have been separately considered elsewhere, and to recapitulate them here would only lead to needless repetition. I shall therefore now merely de- scribe the mode of using the instrument. Difference between the High and Low Operations. — Before doing so it is well to repeat what has alreadjr been said as to the difference between what may be termed the high and low forceps operations. The application of the instrument, when the head is low in the pelvis, is extremely simple; and when there is no disproportion between the head and the pelvis, and some slight traction is alone required to supplement deficient expulsive power, the operation, in the hands of any ordinarily well-instructed practitioner, ought to be perfectly safe both to the mother and child. It is very different when the head is arrested at the brim, or high in the pelvis. Then the application of the forceps is an operation requiring much dexterity for its proper performance, and must never be undertaken without anxious con- sideration. It is because these tAvo classes of operations have been confused that the use of the instrument is regarded by many with such unreasonable dread. Preliminary Considerations. — Before attempting to introduce the forceps, there are several points to which attention should be di- rected : — 1st. The membranes must, of course, be ruptured. 2dly. For the safe and easy application of the instrument, it is also advisable that the os should be fullv dilated, and the cervix re- 472 OBSTETRIC OPERATIONS. tracted over the head. Still, these two points cannot be regarded, as many have laid down, as being sine qua non. Indeed we are often compelled to use the instrument when, although the os is fully dilated, the rim of the cervix can be felt at some point of the contour of the head, especially in cases in which the anterior lip is jammed between the head and the pubis. Provided due care be taken to guard the cervical rim with the fingers of one hand, as the instrument is slipped past it, there need be no fear of injury from this cause. If the os be not fully dilated, but is sufficiently open to admit of the passage of the forceps, the operation, under urgent circumstances, may be quite justifiable, but it must necessarily be a somewhat anxious one. 3dly. The position of the head should be accurately ascertained by means of the sutures and fontanelles. Unless this be done, the operation will always be hap-hazard and unsatisfactory, as the prac- titioner can never be in possession of accurate knowledge of the pro- gress of the case. It may be that the occiput is directed backwards; and, although that does not contra-indicate the application of the forceps, it involves special precautions being taken. 4th ly. The bladder and bowels should be emptied. Question of Administering Anaesthetics. — Before proceeding to ope- rate, the question of anaesthesia will arise. In any case likely to be difficult it is of the greatest assistance to have the patient completely under the influence of an anaesthetic to the surgical degree, so as to have her as still as possible ; but, whenever this is deemed necessary, another practitioner should undertake the responsibility of the admin- istration. In simple cases I believe it is better to dispense with anaes- thetics altogether, partly because they are apt to stop what pains there are, which is in itself a disadvantage, but chiefly because, under partial anaesthesia, the patient loses her self-control, is restless, and twists herself into awkward positions, which give rise to the utmost difficulty and inconvenience in the use of the instrument. Moreover, if no anaesthetic be given, the patient can assist the operator by placing herself in the most convenient attitude. Description of the Operation. — In describing the method of apply- ing the forceps, I shall assume that we have to do with the simpler variety of the operation, when the head is low in the pelvis. Sub- sequently I shall point out the peculiarities of the high operation. Position of the Patient. — As to the position of the patient, I believe there can be no doubt of the superiority of that which is usually adopted in this country. On the Continent and in America the for- ceps is always employed with the patient lying on her back, a posi- tion involving much needless exposure of the person, and requiring more assistance from others. In certain cases of unusual difficulty the position on the back is of unquestionable utility, but we may, at least, commence the operation in the usual way, and subsequently turn the patient on her back if desirable. Importance of a Suitable Position. — Much of the facility with which the blades are introduced depends on the patient's being properly placed. Hence, although it gives rise to a little more trouble at first, THE FORCEPS 473 I believe that it is always best to pay particular attention to this point, whether the high or low forceps operation be about to be per- formed. The patient should be brought quite to the side of the bed, with her nates parallel to, and projecting somewhat over its edge. The body should lie almost directly across the bed, and nearly at right angles to the hips, with the knees raised towards the abdomen Fig. 155. Position of Patient for Forceps Delivery and Mode of Introducing Lower Blade. (Fig. 155). In this way there is no risk of the handle of the upper blade, when depressed in introduction, coming in contact with the bed. The blades should be warmed in tepid Avater, lubricated with cold cream or carbolic oil, and placed ready to hand. These preliminaries having been attended to, we proceed to the in- troduction of the blades, sitting by the side of the bed, opposite the nates of the patient. Direction in which the Blades are to be Introduced. — The important question now arises, in what direction are the blades to be passed? The almost universal rule in our standard works is, that they must be passed as nearly as possible over the child's ears, without any re- ference to the pelvic diameters. Hence, if the head have not made its turn, but is tying in one oblique diameter, the blades would re- quire to be passed in the opposite oblique diameter ; in short, the position of the forceps, as regards the pelvis, must vary according to the position of the head. Some have even laid down the rule, that the forceps is contra-indicated unless an ear can be felt ; a rule that would veiy seriousty limit its application, as in many cases in which it is urgently required it is a matter of great difficulty, and even impossibility, to feel the ear at all. It is admitted that in the high forceps operation the blades must be introduced in the trans- 31 474 OBSTETRIC OPERATIONS. verse diameter of the pelvis, without relation to the position of the head. On the Continent it is generally recommended that this rule should be applied to all cases of forceps delivery alike, whether the head be high or low, and I have now for many years adopted this plan, and passed the blades in all cases, whatever be the position of the head, in the transverse diameter of the pelvis, without any at- tempt to pass them over the bi-parietal diameter of the child's head. Dr. Barnes points out with great force that, do what we will, and attempt as we may, to pass the blades in relation to the child's head, they find their way to the sides of the pelvis, and that the marks of the fenestra on the head always show that it has been grasped by the brow and side of the occiput. 1 Of the perfect correctness of this ob- servation I have no doubt ; hence it is a needless element of com- plexity to endeavor to vary the position of the blades in each case, and one which only confuses the inexperienced practitioner, and renders more difficult an operation which should be simplified as much as possible. While, therefore, it is of importance that the precise position of the head should be ascertained in order that we may have an intelligent notion of its progress^ I do not think that it is essential as a guide to the introduction of the forceps. Method of Introducing the Lower Blade.- — -As a rule the lower blade, lightly grasped between the tips of the index and middle fingers and thumb, should be introduced first. Poised in this way, we have per- fect command over it, and can appreciate in a moment any obstacle to its passage. Two or more fingers of the left hand are introduced into the vagina, and by the side of the head, as a guide ; the greatest care must be taken, if the cervix be within reach, that they are passed within it, so as to avoid the possibility of injury. Necessity of Gentleness in Passing the Instrument. — The handle of the instrument has to be elevated, and its point slid gently along the palmar surface of the guiding fingers, until it touches the head (Fig. 155). At first the blade should be inserted in the axis of the outlet, but as it progresses, the handle must be depressed and carried back- wards. As it is pushed onwards it is made to progress by a slight side- to -side motion, and it is of the utmost importance to bear in mind that the greatest gentleness must always be used. If any ob- struction be felt, we are bound to withdraw the instrument, partially or entirely, and attempt to manoeuvre, not force, the point past it. As the blade is guided on in this way, it is made to pass over the convexity of the head, the point being ahvays kept lightly in contact with it, until it finally gains its proper position. When fully inserted the handle is drawn back towards the perineum, and given in charge to an assistant. The insertion must be carried on only in the inter- vals between the pains, and desisted from during their occurrence; otherwise there would be a serious risk of injuring the soft parts of the mother. Introduction of the Upper Blade. — The second blade is passed di- P This is not the case when the forceps used is made to adapt itself to the sides of the child's head, such as the Wallace, Davis, or Hodge instruments. — Ed.] THE FORCEPS. 475 rectly opposite to the first, and is generally somewhat more difficult to introduce, in consequence of the space occupied by the latter. It is passed along two fingers directly opposite the first blade, and with exactly the same precautious as to direction and introduction except that at first its handle has to be depressed instead of elevated (Fig. 156). Fig. ]56. Introduction of the Upper Blade. Locking of the Handles. — The handle wjiich was in charge of the assistant is now laid hold of by the operator, and the two handles are drawn together. If the blades have been properly introduced, there should be no difficulty in locking ; but, should we be unable to join them easily, we must withdraw one or other, either partially or entirely, and reintroduce it with the same precautions as before. We must also assure ourselves that no hairs, nor any of the maternal structures are caught in the lock. Method of Traction. — When once the blades are locked we may commence our efforts at traction. To do this we lay hold of the handles with the right hand, using only sufficient compression to give a firm grasp of the head, and to keep the blades from slipping. The left hand may be advantageously used in assisting and support- ing the right during our efforts at extraction, and, at a late stage of the operation, may be employed in relaxing the perineum when stretched by the head of the child. Traction must always be made in reference to the pelvic axes ; being at first backwards towards the perineum (Fig. 157), in the direction of the axis of the brim, and as the head descends and the vertex protrudes through the vulva, it must be changed to that of the outlet. We must extract only during the pains ; and, if these should be absent, we must imitate them by acting at intervals. This is a point which deserves special attention, for there is no more common error than undue hurry in delivery. 476 OBSTETRIC OPERATIONS. The only valid objection I know of against a more frequent resort to the forceps in lingering labors is, that the sudden emptying of the Fig. 157. Forceps in Position. Traction in the Axis of the Brim, downwards and backwards . nterus, in the absence of pains, may predispose to hemorrhage ; and it cannot be denied that it is one of some weight. However, if due care be taken to operate slowly, and to allow several minutes to elapse between each tractive effort, while at the same time uterine contractions be stimulated by pressure and support, this need not be considered a contra-indication. Besides direct traction we may im- part to the instrument a gentle waving motion from handle to handle, which brings into operation its power as a lever ; but this must not be done to any great extent, and must always be subservient to direct traction. Descent of the Head. — Proceeding thus in a slow and cautious manner, carefully regulating the force employed according to the exigencies of the case, we shall perceive that the head begins to descend ; and its progress should be determined, from time to time, by the fingers of the unemployed hand. The Rotation from the Oblique Diameter. — When the head lies in the oblique diameter, as it descends, in consequence of its perfect adaptation to the pelvic cavity, it will turn into the antero- posterior diameter without any effort on the part of the operator, provided only that the traction be sufficiently slow and gradual. As the head is about to emerge, it is necessary to raise the handles towards the mother's abdomen. More than usual care is required to prevent laceration of the perineum, which is always much stretched (Fig. 158). If, as often happens, the pains have now increased, and the perineum be very thin and tense, it may even be desirable to remove TFIE FORCEPS. 477 the blades gently, and leave the case to be terminated by the natural powers : bat if due precautions are used this need not be necessary. Fig. 158 Last Stage of Extraction. The Handles of the Forceps are being gradually turned upwards towards the Mother's Abdomen. The peculiarities of forceps delivery in occipito-posterior positions have already been discussed (p. 313), and need not be repeated. High Forceps Operations.— When the high forceps operation has been decided on, the passage of the blades will be found to be much more difficult from the height of the presenting part, the distance which they must pass, and, in some cases, from the mobility of the head interfering with their accurate adaptation. The general prin- ciples of introduction and of traction are, however, identical. If the operation be attempted before the head has entered the pelvic brim, it must be fixed, as much as possible, by abdominal pressure. In guiding the blades to the head special care must be taken to avoid any injury of the soft parts, especially if the cervix be not com- pletely out of reach. For this purpose' it may even be advisable to introduce the entire left hand as a guide, so as to avoid any possi- bility of injuring the cervix, from not passing the instrument under its edge. Peculiar Method of Introducing the Blades. — Some authors advise that, in such cases, the blade should be introduced at first opposite the sacrum, until the point approaches its promontory. It is then made to sweep round the pelvis, under the protecting fingers, till it reaches its proper position on the head. This plan is advocated by 478 OBSTETRIC OPERATIONS. Ramsbotham, Hall Davis, and other eminent practical accoucheurs, and it is certainly of service in some cases of difficulty ; especially when, from any reason, it is not possible to draw the nates over the edge of the bed, when the necessary depression of the handle of the upper blade is difficult to effect. It involves, however, a somewhat complicated manoeuvre, and it is seldom that the blades cannot be readily introduced in the usual Avay. Necessity of Care in Locking. — In locking the slightest approach to roughness must be carefully avoided, for the extremities of the blades are now within the cavity of the uterus, and serious injury might easily be inflicted. If difficulty be met with, rather than em- ploy any force, one of the blades should be withdrawn, and reintro- duced in a more favorable direction. If the blades have shanks of sufficient length, there should be no risk of including the soft parts of the mother in the lock, which, in a badly constructed instrument, is an accident not unlikely to occur. Method of Traction. — After junction traction must at first be alto* gether in the axis of the brim, and to effect this the handles must be pressed well backwards towards the perineum. • As the head descends it will probably take the usual turn of itself, without effort on the part of the operator, and the direction of the tractive force may be gradually altered to that of the axis of the outlet. If the pains be strong and regular, and there be no indication for immediate delivery, we may remove the forceps after the head has descended upon the perineum, and leave the conclusion of the case to nature. This course may be especially advisable if the perineum and soft parts be unusually rigid ; but generally it is better to termi- nate labor without removing the instrument. Possible Dangers of Forceps Delivery. — Before concluding this sub- ject, reference may be made to the possible dangers of the operation. I would here again insist on the importance of distinguishing be- tween the high and Ioav forceps operations, which have been so unfor- tunately and 'unfairly confounded. Reasons have already been given for'rejecting the statistics of the risks attending forceps delivery in the latter class of cases (p. 3 A 3). A formidable catalogue of dangers, both to the mother and child, might easily be gathered from our standard works on obstetrics. Among the former the principal are lacerations of the uterus, vagina, and perineum; rupture of varicose veins, giving rise to thrombus ; pelvic abscess, from contusion of the soft parts ; subsequent inflammation of the uterus or peritoneum ; tearing asunder of the joints and symphyses; and even fracture of the pelvic bones. A careful analysis of these, such as has been so well made by Drs. Hicks and Philips, 1 proves beyond doubt that the application of the instrument is not so much concerned in their pro- duction, as the protraction of the labor, and the neglect of the practi- tioner in not interfering sufficiently soon to prevent the occurrence of the evil consequences afterwards attributed to the operation itself. Many of these will be found to arise from the prolonged pressure on 1 Obst. Trans., vol. xiii. TIIE FORCEPS. 479 the soft parts within the pelvis, and the subsequent inflammation or sloughing. To these causes may be referred with propriety most cases of vesico- vaginal fistula (p. 434), peritonitis, and metritis fol- lowing instrumental labor. Lacerations and similar accidents may, however, result from an incautious use of the instrument. Slight lacerations of the mucous membrane of the vagina are probably far from uncommon. But if these cases were closely examined, it would be found that the fault lay not in the instrument, but in the hand that used it. Either the blades were introduced without due regard to the axes of the pelvis, or they were pushed forwards with force and violence, or an instru- ment was employed unsuitable to the case (such as a short straight forceps when the head was high in the pelvis), or undue haste and force in delivery were used. It would be manifestly unfair to lav the blame of such results upon the forceps, which, in the hands of a more judicious and experienced practitioner, would have effected the desired object with perfect safety. The instrument is doubtless unsafe in the hands of any one who does not understand its use, just as the scalpel or amputating knife would be in the hands of a rash and inexperienced surgeon. The lesson to be learnt seems to be clearly, not that the dangers should deter us from the use of the forceps, but that they should induce us to study more carefully the cases in which it is applicable, and the method of using it with safety. Possible Risks to the Child. — The dangers to the child are princi- pally, lacerations of the integuments of the scalp and forehead ; con- tusion of the face ; partial, but temporary, paralysis of the face from pressure of a blade on the facial nerve ; depression or fracture of the cranial bones ; injury to the brain from undue pressure of the blades. These evils are of rare occurrence, and when they do happen, gene- rally result from improper management of the operation — such as undue compression, the use of improper instruments, or excessive and ill-directed efforts at traction— and cannot, therefore, be con- sidered as in any way contra-indicating the use of the instrument. Many of the more common results, such as slight abrasions of the scalp, or paralysis of the face, are transitory in their nature and of no real consequence. [The Forceps in America. — Although obstetrical forceps were first used in England, other countries in the march of improvement have made great changes, not only in the original forms, but in their man- ner of use : and different shapes, as well as different positions of the woman in application, have become in a measure almost national. With the exception of having adopted almost exclusively the Erench and German dorsal decubitus in making use of the instruments, we have become in a measure eclectic in the selection of the latter ; medi- cal schools, accoucheurs, and local obstetrical societies influencing students and the junior members of the profession, to adopt the French, German, English, or American styles, as the case may be, the forceps themselves bearing the names of their several inventors, 480 OBSTETRIC OPERATIONS. or compilers ; for some are a true compilation, the blade, from one contriver ; fenestral openings, another ; pelvic curve, a third ; width, a fourth ; shanks, a fifth ; method of locking, a sixth ; etc. etc. For this reason the late Prof. Hodge named his forceps the eclectic, al- though in some respects entirely original, particularly in the long superimposed shanks, a great improvement for operating at the supe- rior strait, and avoiding the painful stretching of the posterior com- missure. Dr. Hodge expended a great deal of thought and money in perfecting his forceps, and the various steps in the process were marked by a new form, until, from a heavy, clumsy instrument, he grad- ually evolved what was at one time regarded as a wonderful improve- ment upon the forceps of France and England. A contemporary of Prof. Hodge, the late Prof. David D. Davis, of London, was equally anxious to perfect the instrument, and turned his attention especially to making the blades light, open, and to so fit the sides of the foetal head as to enable traction to be made with- out much pressure, or leaving any mark on the child's scalp. There is a principal of mechanics involved in his instrument, which he studied to perfect, by moulding the blades so as to obtain consider- able coaptating surface, and thus by increase of friction avoid undue and dangerous pressure. The Davis blade soon began to effect changes in the form of American forceps, and by the addition of long handles, and some alterations of shape, weight, and curve, be- came a leading feature in those bearing the names of William Harris, Prof. Wallace, of the Jefferson Medical College, Dr. Bethel, and Albert H. Smith, all of this city. The short Davis instrument was a great favorite of the late Prof. Meigs, and Dr. William Harris, both largely engaged in obstetrical practice, as well as teaching, and many a delicate woman, with wasting forces, was aided in her delivery at their hands, and surprised to find no mark on the baby's head, and that her own sufferings could be so gently and safely relieved. Although such was the estimation of the Davis blade, and still is in many parts of our country, it does not appear to have retained its popularity or been adopted, as its mechanical perfection would lead one who appreciates it to suppose it would have been. In Great Britain, the favorite forms now in use are but a very slight improve- ment upon the forceps of a hundred years ago, except in finish and material, the open fenestra and bevelled blades of Davis being de- clined in favor of the looped fenestras and flat-edged blades in use when he made his experiments and changes. This appears to have grown out of a practice which has been largely adopted in Germany, Great Britain, and many parts of the United States, in applying the forceps to the foetal head, the blades being introduced at the sides of the pelvis, without much reference to the position which the head occupies. As compression is objected to, the blades are made long and widely separated (3J to 8 J), and the handles short, so as not to allow of much leverage. As the blades do not fit the head, the mechanism of labor as taught by Hodge has been much simplified, as it is not necessary to learn all the oblique fittings of the fenestra over the parietal protuberances or ears. Dr. Meigs used to tell the THE FORCEPS. 481 students that the forceps was the " child's instrument,'' and should be used as a tractor ; and it was as a well-applied mechanical tractor that he advocated the use of the Davis blades against those of Sie- bold, Levret, Baudelocque, and Haigliton, employed generally in our country forty years ago. His language is not very complimentary to what he denominates by distinction "the mothers instrument" the form being better adapted for saving the woman than the foetus. ("Obstetrics,'' p. 540.) At the present clay we have two general varieties of forceps in use in the United States ; under each of which may be placed a vast number of special forms, which are simply changes Upon one or the other general type, according to the Fig. 159. fancy of the inventor. At the head of one type, may be placed the long forceps of Prof. Hodge, de- signed to be adapted to the sides of the child's head in all possible cases: and of the other, those of Prof. Simpson, of Edinburgh, or their modification by Profs. Elliot and Bedford, of New York, intended to be used as tractors, and applied in reference to the sides of the mother's pelvis, rather than to those of the in- fant's head. Taking the long forceps of Levret and Baudelocque as improved and modified by Hodge ; with the blades of Prof. Davis as a substitute, and handles of less curve than those of Hodge ; and we have the long forceps of Prof. Ellerslic Wallace, of the Jefferson College, the favorite instrument with those who pur- chase forceps of the manufacturers in this city. Next in popularity are the instruments of Hodge, Davis, and Simpson, Elliot, Bedford, and a few others, in all about a dozen forms that are kept in stock. The improvement of the late Prof. Elliot upon the instru- ment of Simpson, consists in narrowing and length- ening the shanks; widening somewhat the fenestras; elongating the blades ; giving greater security against slipping in the handles; and gauging the distance between the blades b} r a milled-head screw-stop in the end of the handles : the shanks and blades are an exact counterpart of the Miller -forceps of England, which appeared about the same time, 1858. The Hodtje forceps were based in their contrivance Hodge Forceps, upon the following points : 1. The instrument should be shaped to the contour of the foetal head, and have sufficient play to allow of compression, where the pelvis is too narrow for the head to pass in its normal condition. 2. The blades should be so arranged in reference to the shanks and handles as to enable them to seize the head of the foetus in its bi-parietal diameter at the superior straight, and be drawn upon in the direction of the curve of the pelvic canal until the delivery is complete. 3. The long forceps ought to be competent to act either at the superior strait of the pelvis, in its 482 OBSTETRIC OPERATIONS. cavity or at its outlet, so as to avoid a multiplicity of instruments and their attendant expense. And 4. The instrument should not cat the scalp of the child if properly adjusted, or injure the soft parts of the mother. It would be folly to claim that all this could or has been accom- plished ; as there must necessarily be exceptional cases in all the points given ; hence the contrivance of the forceps of Tarnier and Cleemann for certain presentations above the superior strait ; and the long and short convertible instruments of a few inventors. There are many cases of labor in the higher walks of life where, although there is no obstruction, still the women re- Fig. 160. Fig. 161. quire manual or instrumental as- sistance, as they cannot deliver themselves for want of sufficient contractile muscular force. Such women require that the forceps used should be easily introduced ; should act simply as tractors ; control the movement of the foetal head by being well fitted to its shape, and leave no effect upon the scalp or vulva. Although these requisites may be filled by the Hodge instrument, it is this class of cases that has demanded a lighter and more roomy pair of forceps, such as that devised by Davis. As the teaching of the Jefferson Medical College under Dr. Meigs, favored as we have stated the for- ceps of Davis, so his successor in carrying out in a measure the same views, has combined the blades of the Davis pattern, with the long handles of Hodge, in con- triving the Wallace forceps, now so much in use by the large number of graduates of this school. As Wallace Forceps. Davis Forceps. compared with the Hedge instru- ment, it is one inch shorter (15 inches against 1(3) ; the blades are of the same length (6 inches) the fenestra are more open; the shanks are only half the length, giving a much greater compressing power ; and the handles are of the same measurement from pivot to hooks. Both have the Siebold lock, over which we believe the broad-topped button and notch to possess some advantages; and the Wallace is somewhat heavier than the Hodge which should weigh 17 ounces. The short Davis instrument made for Prof. Meigs under direction of the inventor weighed lOf ounces, and measured 12 inches in THE FORCEPS. 483 Fig. 162. length; fenestra 5 inches long, 2 inches wide; blades separated 2} inches. Handles 4J inches to lock, which was of the Smellie or English pattern. A recently purchased pair in possession of the editor is 13J inches long, with 5 inch handles, a button lock, 2 inch close set shanks, and (5 J inch blades. I believe the changes are decided improvements, especially the lock and elongated handles. It has answered admirably in adynamic cases, requiring only a few pounds of tractile assistance. The Davis blades have been added to long handles, and the whole made of steel and marvellously light, at the special request of a few accoucheurs, who wished them to aid in some cases of arrest at the perineum. The late Prof. George T. Elliot, of New York, who received much of his practical obstetrical training in the Dublin Lying-in Hospital, imbibed the teachings of the English school, and be- came impressed with the value of the system as taught by Simpson ; after the principle of whose forceps, modelled somewhat after that of the late Prof. Gun- ning G. Bedford, of New York, he in 1858, presented to the medical profession the instrument that bears his name. The forceps of Prof. Bedford has a trac- tion ring on each side, where the Elliot has a cornu, has a button joint, instead of a Smellie, has no screw stop, and has diverging instead of superim- posed shanks. These points have generally been considered as improvements, and hence the Elliot has taken precedence in large measure over the Bedford instrument in New York sales, the two being the leading forceps in demand. The instru- ment of White, of Buffalo, is perhaps next, and then Hodge's. But few of Prof. Wallace's forceps, the leading instrument in the Philadelphia trade, are ordered. The White is a long forceps, a compound of the Elliot blade, long superimposed shanks of Hodg-e, Siebold lock, and short corrugated steel handles bowed out like dental forceps, and ending in thin blunt hooks. The Sawj^er and Simpson short forceps are about equally in demand in New York. The former is unknown to the trade here ; and but comparatively few of the Simpson are sold, although the system of their application has several advocates in Phila- delphia. We have here a representation of one of the lightest of all the varieties of the short forceps, weighing but 5 ounces, and measuring 9f inches in length ; the handle being 3 inches, shank 1J, and chord of blade-curve b\. The blades are 1J inches wide, with oval fenestra?. -J inch w r ide, and separated 2| inches at their widest part, and f inch at the tips. This instrument was invented about three years and a half ago, by Prof. Edw. Warren Sawyer, of Push Medical College, Chicago, and Elliot Forceps. 484 OBSTETRIC OPERATIONS Fig. 163. has been highly commended by Prof. By ford and others. The for- ceps has the blades of Davis, superimposed shanks of Hodge, and lock of Smellie, with hard-rubber plates moulded hot upon the handles. The several parts have been somewhat modified ; the object being to secure a tractor for cases of deficient expulsive force, where the foetal head is low in the pelvis. Professor Sawyer says: "In the labors to which my forceps is applicable it is not necessary for the operator's body to be in line with the pelvic axis. My mode of procedure is the following : the woman is placed upon her back and drawn to the edge of the bed, the outside leg is now flexed ; beneath this flexed extremity and the bed covering, I apply the forceps — often using but one hand in the operation. When the instrument is locked, I grasp the handle in such a manner that the palm of the hand looks upward; one hook then rests naturally upon the extensor surface. of the first phalanx of the index finger, while the other hook rests upon a corresponding part of the thumb. When thus adjusted, I lift the head from the pelvic outlet, at the same time invoking the pendulum movement if desired. At this moment the advantage of the hooked handle is very apparent to the operator. 1 ' . . . " All practitioners must have often felt, during the last moments of labor, when the uterus and the mother seemed fatigued, the need of a little help to the expansive powers. The ordinary instruments are too formidable to be used at the last moment, and it is then that this little forceps is useful." I have given the names and characters of the various forceps most in use in New York and Philadelphia ; and b}^ the large num- ber of graduates of their respective schools as shown by their pre- ferences in making purchases of the leading instrument makers of the two cities. The mechanism of instrumental delivery is much simplified by applying the forceps to whatever parts of the foetal head may be opposite the sides of the pelvis; but it is very ques- tionable whether it is the scientific method, or the safer for the child. With one blade over the side of the occiput, and the other over that of the forehead, which is the manner of seizure in oblique positions of the vertex, we certainly have not a very secure hold, and run some risk of injury to the foetus. The advocates of this system claim that they use no compression, onl}^ a simple traction ; which may be true in one sense, but amounts to the same in effect, else how could Dr. Elliot, by traction with great force, straighten out one of the blades of his Simpson forceps, as related in the "K Y. Journ. of Med." for September, 1858, page 1(31, in the paper which he pre- Sawyer Forceps. THE FORCEP! 485 sentecl, describing his new forceps and a number of cases in which he had tested them. It makes but little difference whether we com- press the head before we begin to pull, or pull so as to wedge the head between the blades and thus compress it, except as to the differ- ence of fit in the two instances; the adjusted and even pressure, being the less likely to injure the foetus. I have always believed that the forceps should fit the head, and that the student should be taught how to accomplish it correctly in the various positions of the foetus. If the student has a mechanical turn of mind, a delicate sense of touch, and a clear head, he will soon learn ; if he is not a mechanic, he will be forced to adopt a more simple method of de- livery. In a large city, there are but few first class obstetrical manipulators as a general rule, and they are usually well known as Fig. 164. V Application of the Forceps at the Inferior Strait. such, for the reason that but few have all the requisites to enable them to achieve notoriety; and yet there are hundreds who can de- liver a woman with forceps moderately well. To one, the mechan- ism of Hodge is a simple matter, and soon mastered ; to another, it is 486 OBSTETRIC OPERATIONS. a useless complication, and lie prefers the more simple system. Hence the great differences between obstetricians, as to the best in- strument, and the best method of application. Some of the vast array of patterns have decided merit, and display much mechanical skill ; while others serve only to amuse the educated examiner. One obstetrician, like Elliot, uses a variety of forceps one after another in the same case, and pulls with great force ; while another confines his work almost to one instrument, adjusts it easily, pulls moderately, and seldom fails. There are no doubt exceptions, but certainly the most delicate manipulators we have seen, believed in and practised the teachings of Hodge and Meigs. There may be cases where it might be well to practise the method of Simpson, as is done occa- sionally by some of our leading practitioners ; but we cannot see why his plan of delivery should be exclusively used on any mode of scientific reasoning. I present a series of plates in illustration of the American method of delivery with the forceps ; the position, as will be seen, being that of France and Germany- — on the back. When it is de- cided to use the forceps, in almost all case's in the United States, the patient is brought to the edge of the bed on her back, with her nates close to the edge, her feet on two chairs, and her knees widely sepa- rated, as in the plate above. The patient is covered with a sheet, or heavier covering if in winter, and there is no necessity of exposure, as the whole manipulation may be done by the sense of touch. The position is by far the most convenient for the obstetrician, and enables him much more easily to keep in his mind all the anatomical rela- tions of the foetus and pelvis, than when in the English decubitus. We study the anatomy, with the subject on the back, and the mechanism of labor in front of the pelvis, or manikin, then why complicate matters by a change of position, which to say the least, is a very awkward one, particularly in introducing the long forceps, setting them according to the instructions of Hodge, and carrying them forward between the thighs as the head emerges ? I have used the short forceps in an exhausted case, with the woman on her side, but found it much less convenient for the various movements, although I soon delivered the foetus. As to the question of exposure, there is less in appearance than in fact, in the English position, in many cases. If the patient and nurse are fastidious and careful during the use of the forceps, the accoucheur can manage without his eyes in a large proportion of cases ; but the fault of exposure lies more frequently in the temporary reckless indifference begotten of pain and suffering in the woman, than in any act of the accou- cheur, if inclined to spare the feelings of his patient as much as possible. The long forceps, with its pelvic curve, was specially designed for use at the superior strait of the pelvis, the curve of the blades, as in the Davis instrument modified by Wallace, being intended to cor- respond with the direction of the occipito-mental diameter of the foetal head. The long superimposed shanks of several varieties of the long forceps will here be found valuable, as the lock is not intro- THE FORCEPS. 487 duced, or the posterior commissure of the vulva widely stretched. If the head is entirely above the strait, the line of the blades must be changed correspondingly, in order to apply them properly, and keep the line of traction within the coccyx ; and even then, to draw Fig. 165, Application of the Forceps with the Head at the Superior Strait ; the left blade held in place by an Assistant. in the proper direction, the left hand must act at first in a backward direction from the lock ; while the right brings the handles down- ward, forward, and then upward ; both hands describing a curve, but that of the right being much the greater. The peculiar forceps of Tarnier, or of Cleemann, being designed to meet this form of exi- gency, may be brought into requisition. In latter years it has become much more common than formerly to introduce the forceps into the uterus, before it is fully dilated, in consequence of the success claimed for the plan as carried out in the 488 OBSTETRIC OPERATION Dublin Lying-in Hospital. As this should never be done where the os is not readily dilatable, and requires much skill in execution, it is not safe to recommend its general adoption in cases of delay in pri- vate practice, The forceps should not be introduced with any force, but the left blade 'should be slid in gently, and with a spiral motion, and then the right ; care being taken that they should also lock without force, which they will do if properly adjusted. Traction is to be exerted slowly, and during a pain, the whole movement being made to cor- respond with the natural as closely as possible. Fig. 166. Direction of the Forceps as the Head is being Delivered. As the foetal head comes under the arch of the pubes, the handles of the forceps must rise more and more from the bed 7 until at last they are over the abdomen, as the head emerges from the perineum. This last movement of instrumental delivery should be a very slow one, for fear of rupture. It has been proposed to remove the blades before delivery is complete ; but there is no occasion for this, if the forceps is applied to the sides of the head over the parietal protru- berances ; as where these protrude, and the blades are flat and thin, there is verv little additional space required. With such instruments as the old Levret, Baudelocque, and Rohrer forceps, with looped or kite-shaped fenestras, and thick edges, this was a much more impera- THE VECTIS THE FILLET, 489 tive direction, than with the better instruments of the present day. With a Sawyer forceps the perineum ought to be safer, and under better control than without. When the perineum is thought to be in danger, the process of distension should be retarded through two or three pains, or even more if required, instead of drawing the head through at once. After the head is delivered, if the cord is not around the neck, and, therefore, in danger from pressure, the body should be allowed to remain until the uterus has well contracted upon it, for fear of hemorrhage after delivery from uterine inertia. — Ed.] CHAPTEE IT. THE VECTIS — THE FILLET. Fig. 16 < In connection with the subject of instrumental delivery it is essen- tial to say something of the use of the vectis, on account of the value which was formerly ascribed to it, which was at one time so great in this country that it became the favorite instrument in the metropolis ; Denman saying of it that even those who employed the forceps were " very willing to admit the equal, if not superior, utility and convenience of the vectis." Even at the present day, there are practitioners of no small experience who believe it to be of occa- sional great utility, and use it in preference to the forceps in cases in which slight assistance only is required. In spite, however, of occasional attempts to recommend its use, the instrument has fallen into disfavor, and may be said to be practically obsolete. Nature of the Instrument. — The vectis, in its most approved form, consists of a single blade, not unlike that of a short straight forceps, attached to a wooden handle. A variety of modifications exist in its shape and size. The handle has been occasionally manu- factured, for the convenience of carriage, with a hinge close to the commencement of the blade (Fig. 167), or with a screw at the point where the handle and blade join. The power of the instrument, and the facility of introduction, depend very much on the amount of curvature of the blade. If this be decided, a firmer hold of the head is taken and greater tractive force is obtained, but the difficulty of introduction is increased. The vectis is used either as a lever or a tractor. When employed in the former way, the fulcrum is intended to be the hand of the ope- 32 Vectis with Hinged Handle. 490 OBSTETRIC OPERATIONS rator ; but the risk of using the maternal structures as & point d'cppui, and the inevitable danger of contusion and laceration which must follow, constitute one of the chief objections to the operation. Its value as a tractor must always be limited and quite inferior to that of the forceps, while it is as difficult to introduce and manipulate. Cases in which- it is Applicable. — The vectis has been recommended in cases in which the low forceps operation is suitable, provided the pains have not entirely ceased. There is no doubt that it may be quite capable of overcoming a slight impediment to the passage of the head. It is applied over various parts of the head, most com- monly over the occiput, in the same manner, and with the same precautions, as one blade of the forceps. Dr. Eamsbotham says "we shall find it necessarjr to apply it to different parts of the cranium, and perhaps the face also, successively, in order to relieve the head from its fixed condition, and favor its descent. 1 ' Such an operation obviously requires quite as much dexterity as the application of the forceps; while, if we bear in mind its comparatively slight power, and the risk of injury to the maternal structures, we must admit that the disuse of the instrument in modern practice is amply justified. The vectis may, however, find a useful application when employed to rectify malpositions, especially in certain occipito-posterior present- ations. This action of the instrument has already been considered (p. 314), and, under such circumstances, it may prove of service where the forceps is inapplicable. When so employed it is passed carefully over the occiput, and, while the maternal structures are guarded from injury, downward traction is made during the con- tinuance of a pain. So used, its applica- tion is perfectly simple and free from dan- ger, and for this purpose may be retained as a part of the obstetric armamentarium. The fillet is the oldest of obstetric in- struments, having been frequently em- ployed before the invention of the forceps, and even in the time of Smellie it was much used in the metropolis. It has since completely fallen out of favor as a scientific instrument, although its use is every now and again advocated, and it is certainly a favorite instrument with some practition- ers. This is to be explained by the appa- rent simplicity of the operation, and the fact that it can generally be performed without the knowledge of the patient; the latter, however, is one strong reason why it should not be used. Nature of the Instrument. — The fillet con- sists, in its most improved form (that which is recommended by Dr. Eardley Wilmot 1 (Fig. 168), of a slip of whalebone fixed Fig. 168. 1 Obst. Trans., vol. xv. OPERATIONS INVOLVING DESTRUCTION OF FCETUS. 491 into a handle, composed of two separate halves, which join into one. The whalebone loop is slipped over either the occiput or face, and traction used at the handle. Objections to its Use. — When applied over the face, after the head has rotated, it would probably do no harm, but if it were so placed when the head was high in the pelvis, traction would necessarily produce extension of the chin before the proper time, and would thus interfere with the natural mechanism of delivery. If placed over the occiput, it is impossible to make traction in the direction of the pelvic axes, as the instrument will then infallibly slip. If traction be made in any other direction, there must be a risk of in- juring the maternal structures, or of changing the position of the head. Hence there is every reason for discarding the fillet as a trac- tor, or as a substitute for the forceps, even in the simplest cases. It is quite possible that it may find a useful application in certain cases in which the vectis may also bo used, viz., as a rectifier of mal- position, and, from the comparative facility of its introduction, it would probably bo the preferable instrument of the two. CHAPTER V. OPERATIONS INVOLVING DESTRUCTION OF THE FCETUS. Operations involving the destruction and mutilation of the child were among the first practised in midwifery. Craniotomy was evi- dently known in the time of Hippocrates, as he mentions a mode of extracting the head by means of hooks. Celsus describes a similar operation, and was acquainted with the manner of extracting the foetus in transverse presentations by decapitation ; similar procedures were also practised and described by Aetius and others among the ancient writers. The physicians of the Arabian school not only emploj^ed perforators for opening the head, but were acquainted with instruments for compressing and extracting it. Religious Objections to Craniotomy. — Until the end of the seven- teenth century this class of operation was not considered justifiable in the case of living children ; it then came to be discussed whether the life of the child might not be sacrificed to save that of the mother. It was authoritatively ruled by the Theological Faculty of Paris, that the destruction of the child in any case was mortal sin. " Si Ton ne peut tirer l'enfant sans le tuer, on ne peut sans peche mortel le tirer." This dictum of the Roman Church had great influence on Continental midwifery, more especially in France, where, up to a recent date, the leading obstetricians considered craniotomy to be only justifiable when the death of the foetus had been positively 492 OBSTETRIC OPERATIONS. ascertained. Even at the present day there are not wanting practi- tioners who, in their praiseworthy objection to the destruction of a living child, counsel delay until the child has died ; a practice thor- oughly illogical, and only sparing the operator's feelings at the cost of greatly increased risk to the mother. In England, the safety of the child has always been considered subservient to that of the mother ; and it has been admitted that, in eyery case in which the extraction of a living foetus by any of the ordinary means is impos- sible, its mutilation is perfectly justifiable. Unjustifiable Frequency. — It must be admitted that the frequency with which craniotomy has been performed in this country constitutes a great blot on British Midwifery. Duriug the mastership of Dr. Labbat, at the Eotunda Hospital, the forceps was never once applied in 21,867 labors. Even in the time of Clarke and Collins, when its frequency was much diminished, craniotomy was performed three or four times as often as forceps delivery. These figures indicate a destruction of foetal life which we cannot look back to without a shudder, and which, it is to be feared, justify the reproaches which our Continental brethren have cast upon our practice. Fortunately, professional opinion has now completely recognized the sacred duty of saving the infant's life, whenever it is practicable to do so ; and British obstetricians now teach, as carefully as those of any other nation, the imperative necessity of using every endeavor to avoid the destruction of the foetus. Division of the Subject. — The operation now under consideration may be necessary : 1st, when the head requires either to be simply perforated, or afterwards more completely broken up and extracted ; an operation which has received various names, but is generally known in this country as craniotomy, and which may or may not require to be followed by further diminution of the trunk. 2dly, when the arm presents, and turning is impossible; this necessitates one of two procedures, decapitation with the separate extraction of the body and head, or evisceration. In both classes of cases similar instruments are employed, and those generally in use at the present time may be first briefly described. Description of Instruments Employed. — 1. The object of the perfo- rator is to pierce the skull of the child, so as to admit of the brain being broken up, and the consequent collapse and diminution in size of the cranium. The perforator invented by Denman, or some modi- fication of it, has been principally employed. It requires the handles to be separated in order to open the blades, and this cannot be done bv the operator himself. This difficulty is overcome in the modifi- cation of Naegele's perforator used in Edinburgh, in which the handles are so constructed that they open the points when pressed together, and are separated by a steel rod, with a joint at its centre, to prevent their opening too soon. By this arrangement the instru- ment can be manipulated by one hand only. The sharp-pointed portion has an external cutting edge, with projecting shoulders at its base, to prevent its penetrating too far into the cranium. Many modifications of these arrangements have since been contrived (Figs. OPERATIONS INVOLVING DESTRUCTION OF F03TUS 493 169, 170, 171). In some parts of the Continent a perforator is used constructed on the principle of the trephine ; but this is vastly more Fig. 169. Fig. 170. Fig. 171. Various forms of Perforators. difficult to work, and has the great disadvantage of simply boring a hole in the skull, instead of split- ting it up as is done by the sharp-pointed instru- ment. The instruments for extraction are the crotchet and craniotomy forceps. Crotchets and Craniotomy Forceps. — The crotchet is a sharp-pointed hook of highly-tempered steel, which can be fixed on some portion of the skull, either internal or external, traction being made by the handle. The shank of the instrument is either straight or curved (Figs. 172 and 173), the latter being preferable, and it is either at- tached to a wooden handle or forged in a single piece of metal. A modification of this instrument is known as Oldham's vertebral hook. It consists of a slender hook, measuring, with its handle, 13 inches in length, which, is passed through the. foramen magnum, and fixed in the vertebral canal, so as to secure a firm hold for traction. 1 All forms of crotchets are open to the serious objection of being liable to slip, or break through the bone to which they are fixed, so wounding either the soft parts of the mother, or the fingers of the operator placed as Figs. 1 Crotchet?. 1 [The American guarded crotchet is constructed like a pair of forceps, the end of one blade guarding the hook on the other, so that if the hold of the latter should give way and slip, it cannot injure the soft parts or hand of the operator as it immediately shuts against the guard. — Ed.] 494 OBSTETRIC OPERATIONS. a guard. Hence they are discountenanced by most recent writers, and may with propriety be regarded as obsolete instruments. Craniotomy Forceps are preferable for Extraction. — Their place as tractors is well supplied by the more modern craniotomy forceps (Fig. 174). These are intended to lay hold of the skull, one blade being introduced within the cranium, the other externally, and, when a firm grasp has been obtained, downward traction is made. A second object it fulfils is, to break away and remove portions of the skull, when per- foration and traction alone are insufficient to effect delivery. Many forms of craniotomy forceps are in use ; some armed with formidable teeth, others, of simpler construction, depending on their roughened and serrated internal surfaces for firmness of grasp. For general use, there is no better instrument than the cranioclast of Sir James Simpson (Fig. 175), which admirably fulfils both these indications. It consists of two separate blades, fastened by a button joint. The extremities of the blades are of a duck-billed shape, and are suffi- ciently curved to allow of a firm grasp of the skull being taken; the upper blade is deeply grooved to allow the lower to sink into it, and this gives the instrument great power in fracturing the cranial bones, when that is found to be necessary. It need not, however, be em- ployed for the latter purpose, and, the blades being serrated on their under surface, form as perfect a pair of craniotomy forceps as any in ordinary use. Provided with it, Ave are spared the necessity of pro- curing a number of instruments for extraction. Fig. 174. Craniotomy Forceps, Simpson's Cranioclast. Cephalotribe. — Amongst modern improvements in midwifery there are few which have led to more discussion than the use of the cepha-* lotribe. The instrument, originally invented by Baudelocque, was long employed on the Continent before it was used in this country, the prejudice against it being no doubt due to its formidable size and OPERATIONS INVOLVING DESTRUCTION OF FCETUS. 495 appearance. Of late years many of onr leading obstetricians have used it in preference either to the crotchet or craniotomy forceps, and have materially modified and improved its construction, so that the most objectionable features of the older instruments are not entirely removed. Object of the Instrument. — The cephalotribe consists of two power- ful solid blades, which are applied to the head after perforation, and approximated by means of a screw so as to crush the cranial bones, and after this it may be also used for extraction. The peculiar value of the instrument is, that, when properly applied, it crushes the firm basis of the skull, which is left untouched by craniotomy, or, if it does not, it at least causes the base to turn edgeways within the blades, so as to be in a more favorable position for extraction. An- other and specially valuable property is, that it crushes the bones within the scalp, which forms a most efficient protective covering to their sharp edges ; in this way one of the principal dangers of crani- otomy — the wounding of the maternal passages by spiculse of bone — is entirely avoided. The cephalotribe, therefore, acts in two ways ; as a crusher, and as a tractor. Some obstetricians believe the former to be its more important use, and even maintain that the cephalotribe is unsuited for traction. This view is specially maintained by Pajot, who teaches that, after the size of the skull has boen diminished by repeated crushings, its expulsion should be left to the natural powers. There are some grounds for believing that in the greater degrees of obstruc- tion the tractile power of the instrument should not be called into use ; but, in the large majority of cases, the facility with which the crushed head may be withdrawn by it constitutes one of its chief claims to the attention of the obstetrician. No one who has used it in this way, and experienced the rapid and easy manner in which it accomplishes delivery, can have any doubt on this point. Its Value. — There is every reason to believe that cephalotripsy will be much extended in this country, and that it will be considered, as I believe it unquestionably deserves to be, the ordinary operation in cases requiring destruction of the foetus. The comparative merits of cephalotripsy and craniotomy will be subsequently considered. Description of the Instrument. — The most perfect cephalotribe is probably that known as Braxton Hicks's (Fig. 176), which is a modi- fication of Simpson's. It is not of unwieldy size, but sufficiently powerful for any case, and not extravagant in price. The blades have a slight pelvic curve, which materially facilitates their intro- duction, yet not sufficiently marked to interfere with their being slightly rotated after application. Dr. Kidd, of Dublin, prefers a straight blade ; while Dr. Matthews Duncan thinks it better to use a somewhat bulkier instrument, modelled on the type of the Conti- nental cephalotribes. The principle of action of all these is identical and their differences are not of very material importance. Section of the Skull by the Forceps-saiv, or Ecraseur. — Another mode of diminishing the foetal skull is by removing it in sections. The object 496 OBSTETRIC OPERATIONS. Fig. 176. is aimed at in the forceps-saiu of Van Huevel, which consists of two large blades, not unlike those of the cepha- lotribe in appearance. Within these there is a complicated mechanism, working a chain saw from below up- wards, which cuts through the foetal skull ; the separated portions are sub- sequently withdrawn piecemeal. This instrument is highly spoken of by the Belgian obstetricians, who believe that it affords by far the safest and most effectual way of reducing the bulk of the foetal skull. In this country it is practically unknown ; ancl^ although it must be admitted to be theoretic- ally excellent, the complexity and cost of the apparatus have always stood in the way of its being used. Dr. Barnes has suggested that the same results may be obtained by dividing the head with a strong wire ecraseur. So far as I know, this sug- gestion has never yet been carried out in practice, not even by himself, and, therefore, it is not possible to say much about it. I should imagine, however, that there would be consid- erable difficulty in satisfactorily pass- ing the loop of wire over the skull, in a pelvis in which there is any well-marked deformity. Cases requiring Craniotomy. — The most common cause for which craniotomy or cephalotripsy is performed, is a want of proper pro- portion between the head and the maternal passages. This may arise from a variety of causes. The most important, and that most often necessitating the operation, is osseous deformity. This may exist either in the brim, cavity, or outlet, and it is most often met with in the antero- posterior diameter of the brim. Obstetric au- thorities differ considerably as to the precise amount of contraction which will prevent the passage of a living child at term. Thus Clarke and Burns believe that a living child cannot pass through a pelvis in which the antero-posterior diameter at the brim is less than 3 \ inches. Kamsbotham fixes the limit at 3 inches, and Osborne and Hamilton at 2f inches. The latter is the extreme limit at which the birth of a living child is possible; but there can be no doubt that, under favorable circumstances, it may be possible to draw the foetus, after turning, through a pelvis of that size. The opposite limit of the operation is still more open to discussion. Various authorities have considered it quite possible to draw a mutilated foetus through a pelvis in which the antero-posterior diameter does not exceed 1J Hicks's Cephalotribe. OPERATIONS INVOLVING DESTRUCTION OF FCETUS. 497 inches, and, indeed, have succeeded in doing so. Bat then there must be a fair amount of space in the transverse diameter of the pelvis to admit of the necessary manipulations. If there be a clear space here of 3 inches and upwards, it is no doubt possible to deliver per was naturales; but in such extreme deformities, the difficulties are so great and the bruising of the maternal structures so extensive, that it becomes an operation of the greatest possible severity, with results nearlv as unfavorable to the mother as the Cesarean section. Hence some" Continental authorities have not scrupled to prefer the latter operation in the worst forms of pelvic deformity. The rule in English practice always has been that craniotomy must be performed whenever it is practicable; and there can be no doubt that it is the right one. 1 Limits of the Operation. — Between from 2f to 3 inches anteropos- terior diameter in the one direction, and If inches hi the other, may be said to be the limits of craniotomy, provided, in the latter case, there be a fair amount of space in the transverse diameter. The same limits may be laid down with regard to tumors or other sources of obstruction. Other Causes justifying Craniotomy . — There are a few other con- ditions in which craniotomy is justifiable, independently of pelvic contraction, such as certain conditions of the soft parts which are supposed to render the passage of the head peculiarly dangerous to the mother. Among them may be mentioned swelling and inflam- mation of the vagina from the length of the previous labor, bands and cicatrices in the vagina, and occlusion and rigidity of the os. It is hardly too much to say that with a proper use of the resources of midwifery, the destruction of a living foetus for any of these condi- tions might be obviated. The most common of them is undoubtedly swelling of the soft parts causing impaction of the head ; an occur- rence which ought to be invariably prevented by a timely use of the forceps. Should interference unfortunately be delayed until impac- tion has actually taken place, doubtless no other resource but crani- otomy would be left ; but such cases, it is to be hoped, are now of rare occurrence in British practice. Undue rigidity of the os can be overcome by dilatation with the caoutchouc bags, or, in more serious cases, by incision, which would certainly be less perilous to the mother than dragging even a mutilated foetus through the small and rigid aperture. In the case of bands and cicatrices in the vagina, dilatation or incision will generally suffice to remove the obstruction ; but even were this not so, here, as in excessive rigidity of the peri- neum, it would be better that slight lacerations should take place, than that the child should be killed. Complications of Labor justifying Craniotomy. — Certain complica- tions of labor are held to justify craniotomy, such as rupture of the uterus, convulsions, and hemorrhage. The application of the forceps [ J The operation may be practicable, and still be more dangerous than the Cesarean section. Where experience sho-vvs this to be the case, ^re should in the United States elect the latter and perform it early. — Harris's note to 2d American edition.] 498 OBSTETRIC OPERATIONS. or turning will generally answer our purpose equally well, especially as we have the means of dilating the os sufficiently to admit of one or other of them being performed, when the natural dilatation is not sufficient. Craniotomy in rupture of the uterus will also be rarely indicated, as we have seen that gastrotomy appears to afford a better chance to the mother in those cases in which the foetus has partially or entirely escaped from the uterine cavity. Excessive Size of the Foetus. — -Want of proportion between the foetus and the pelvis, depending on undue size of the head, either natural, or the result of disease, may render the operation essential. In the former of these cases we shall generally have first attempted delivery with the forceps, and, if it has failed, there can be no doubt as to the propriety of lessening the bulk of the head by perforation. Craniotomy when the Child is believed to be Dead. — In most obstetric works we are recommended to perforate, rather than apply the for- ceps, when we are convinced that the child has ceased to live. This advice is based on the greater facility with which craniotomy can be performed, and its supposed greater safety to the mother. There can be no doubt of the ease with which the child can be extracted after perforation, when the pelvis is not contracted ; and, if we could always be sure of our diagnosis, the rule might be a good one. Be- fore acting on it, however, we must bear in mind the extreme diffi- culty of positively ascertaining the death of the foetus. Of the signs usually relied on for this purpose, there are scarcely any which are not open to fallacy, except peeling of the scalp, and disintegration of the cranial bones (which do not take place unless the child has been dead for a length of time), and they are, therefore, useless, in most instances. Discharge of the meconium constantly takes place when the child is alive ; a cold and pulseless prolapsed cord may belong; to a twin ; and the foetal heart may become temporarily inaud- ible, although the child is not dead. If, indeed, we have carefully watched the foetal heart all through the labor, and heard it become more and more feeble, and finally stop altogether, we might be cer- tain that the child has died ; but surely such observations would rather indicate an early recourse to the forceps or version, so as to obviate the fatal result we know to be impending. In certain breech presentations, or after turning, it may be found impossible to extract the head, without diminishing its size by per- forating behind the ear. In such cases we know to a certainty whether the child be alive or dead, before resorting to the operation. The first step, whether Ave resort to cephalotripsy or craniotomy, is perforation, which will, therefore, be first described. In the former the desirability of first perforating the head is not always recognized. To endeavor to crush the head without perforating is needlessly to increase the difficulties of the case, and it should be remembered, as a cardinal rule, that perforation is an essential preliminary to the proper use of the cephalotribe. Method of Perforation. — Before perforating we must carefully as- certain the exact" relation of the os to the presenting part, since, in OPERATIONS INVOLVING DESTRUCTION OF FCETUS. 499 many cases, the operation is per- Fig. V formed before the os is fully, di- lated, when there is a risk of wounding the cervix. Two or more fingers of the left hand should be passed up to the head, and placed against the most promi- nent part of the parietal bone. Under these, used as a guard (Fig. 177), the perforator should be cau- tiously introduced until the scalp is reached. It is important to fix on a bony part of the skull, and not on a suture or fontanelle, for puncture, because our object is to break up the vault of the cranium as much as possible, so as to allow the skull to collapse. When the instrument has reached the point we have selected, it should be made to penetrate the scalp and skull with a semi-rotatory boring mo- tion, and advanced until it has sunk up to the rests, which will oppose its further progress. Occasionally ■considerable force w ill be necessary to effect penetration, more espe- cially if the scalp be swollen by long-continued pressure ; and this stage of the operation will be facilitated by causing an assistant to steady the head by pressure on the foetus through the abdomen more especially if it be still free above the pelvic brim. We must then press together the handles of the instrument, which will have the effect of widely separating the cutting portion, and making an incision through the bones. After this the point should be turned round, and again opened at right angles to the former incision, so as to make a free crucial opening. During this process care must be taken to bury the perforator in the skull up to the rests, so as to avoid the possi- bility of injuring the maternal soft parts. The instrument should now be introduced within the skull and moved freely about, so as to thoroughly and completely break up the brain. Especial care must be taken to reach the medulla oblongata and base of the brain, for, if these were not destroyed, we might subject ourselves to the distress of extracting a child in whom life was not extinct. If this part of the operation be thoroughly performed, there will be no necessity for washing out the brain by the injection of warm water as is sometimes recommended, for the broken-up tissue will escape freely through the opening made by the perforator. Perforation of the After-coming Head. — The perforation of the after-coming head does not generally offer any particular difficulty. Perforation of the Skull. 500 OBSTETRIC OPERATIONS. It is accomplished in the same manner, the child's body being well drawn out of the way by an assistant. The point of the perforator, carefully guarded by the finger, is guided up to the occiput, or behind the ear, where it is inserted. It is sometimes useful to Postpone Extraction. — If there be no neces- sity for very rapid delivery, and the pains be still present, it is often advisable to wait ten minutes or a quarter of an hour before pro- ceeding to extract. This delay will allow the skull to collapse and become moulded to the cavity of the pelvis, when forced clown by the pains, and possibly the natural efforts may suffice to finish the labor in that time ; or, at least, the head will have descended further, ani will be in a better position for extraction. Should perforation be required after having failed to deliver with the forceps — and this is only likely to be the case when the obstruction is comparatively slight — it is certainly a good plan to perforate without removing the forceps, which may then be used as tractors. "We have now to decide on the method of extraction, and our choice lies between the cephalotribe and the craniotomy forceps. Comparative merits of Cephalotripsy and Craniotomy. — Those who have used both must, I think, admit that in any ordinary case, in which the obstruction is not great, and only a comparatively slight diminution in the size of the head is required, cephalotripsy is infi- nitely the easier operation. The facility with which the skull can be crushed is sometimes remarkable, and those who will take the trouble to read the reports of the operation published by Braxton Hicks, Kidd, and others, cannot fail to be struck with the rapidity with which the broken-down head may often be extracted. This is far from being the case with the craniotomy forceps, even when the obstruction is moderate only ; for it may be necessary to use consid- erable traction, or the blades may take a proper grasp with difficulty, or it may be essential to break down and remove a considerable portion of the vault of the cranium before the head is lessened suffi- ciently to pass. During the latter process, however carefully per- formed, there is a certain risk of injuring the maternal structures, and, in the hands of a nervous or inexperienced operator, this dan- ger, which is entirely avoided in cephalotripsy, is far from slight. The passage of the blades of the cephalotribe is by no means difficult, and I think it must be admitted that the possible risks attending it are comparatively small. On account, therefore, of its simplicity and safety to their maternal structures, I believe cephalotripsy to be de- cidedly the preferable operation in all cases of moderate obstruction. When we approach the lower limit, and have to do with a very marked amount of pelvic deformity, the two operations stand on a more equal footing. Then the deformity may be so great as to render i!: difficult to pass the blades of even the smallest cephalotribe suffi- ciently deep to grasp the head firmly, and, even when they are passed, the space is often so limited as to impede the easy working of the instrument. Besides this, repeated crushings may be required to diminish the skull sufficiently. I attach but little importance to the argument that the diminution of the skull in one diameter increases OPERATIONS INVOLVING DESTRUCTION OF FG3TUS. 501 its bulk in another. The necessity of removing and replacing the blades on another part of the skull, and of repeating this perhaps several times, in the manner recommended by Pajot, is a far more serious objection. To do this in a contracted pelvis iuvolves, of necessity, the risk of much contusion. Fortunately cases of this kind are of extreme rarity, much more so than is generally believed, but when they do occur they tax the resources of the practitioner to the utmost. On the whole, the conclusion I would be inclined to arrive at with regard to the two operations is, that in all ordinary cases, cephalo- tripsy is safer and easier, whereas in cases with considerable pelvic deformity, the advantages of cephalotripsy are not so well marked, and craniotomy may even prove to be preferable. Description of the Operation. — The first step in using the cephalo- tribe is the passage of the blades. These are to be inserted in pre- cisely the same manner, and with the same precautions as in the high forceps operation. In many cases the os is not fully dilated, and it is absolutely essential to pass the instrument within it. Special care should, therefore, be taken to avoid any injury to its edges, and, for this purpose, two or three fingers of the left hand, or even the whole hand, should be passed high up, so as thoroughly to protect the maternal structures. In. order that the base of the skull maybe reached and effectually crushed, the blades must be deeply inserted, and, in doing this, great care and gentleness must be used. As the projecting promontory of the sacrum generally tilts the head for- wards, the handles of the instrument, after locking, must be well pressed back towards the perineum. If the blades do not lock easily, or if any obstruction to their passage be experienced, one of them must be withdrawn and re-introduced, just as in forceps operations. Care must be taken, as the instrument is being inserted, to fix and steady the head by abdominal pressure, since it is generally far above the brim, and would readily recede if this precaution were neglected. When the blades are in situ, Ave proceed to crush bv turning the screw slowly, and as the blades are approximated, the bones yield, and the cephalotribe sinks into the cranium. The crushed portion then measures of course, no more than the thickness of the blades, that is about 1J inches. This is necessarily accompanied by some bulging of the part of the cranium that is not within the grasp of the instrument (Fig. 178), but in slight deformity this is of "no con- sequence, and we may proceed to extraction, waiting, if possible, for a pain, and drawing downwards in the axis of the pelvic outlet, as in forceps delivery. The site of perforation should be examined to see that no spiculce of bone are projecting from it, and if so they should be carefully removed. In such cases the head often descends at once, and with the greatest ease. Should it not do so, or should the obstruction be considerable, a quarter turn should be given to the handles of the instrument, so as to bring the crushed portion into the narrowed diameter, and the uncrushed portion into the wider transverse diameter. It may now be advisable to remove the 502 OBSTETRIC OPERATIONS. Fig. 178. blades carefully, and to reintroduce them with the same precautions, so as to crush the unbroken portion of the skull. This adds materially to the difficulties of the case, since the blades have a tendency to fall into the deep channel already made in the cranium, and so it is by no means always easy to seize the skull in a new direction. Before reapplying them, if the condition of the patient be good and pains be present, it may be well to wait an hour or more, in the hope of the head being moulded and pushed down into the pelvic cavity. This was the plan adopted by Dubois, and, according to Tarnier, was the secret of his great success in the oper- ation. Pajot's method of repeated crush - ings, in the greater degrees of contraction, is based on the same idea, and he recom- mends that the instrument should be rein- troduced at intervals of two, three, or four hours, according to the state of the patient, until the head is thoroughly crushed ; no attempts at traction being used, and ex- pulsion being left to the natural powers. This, he says, should always be clone when the contraction is below 2J inches, and he maintains that it is quite possible to effect delivery by this means when there is only 1J inches in the antero-posterior diameter. The repeated introduction of the blades in this fashion must necessarily be hazardous, except in the hands of a very skilful operator ; and I believe that if a second application fail to overcome the difficulty, which will only be very exceptionally the case, that it would be better to resort to the measures presently to be described. Should we elect to trust to the craniotomy forceps for extraction, one blade is to be introduced through the perforation, and the other, in apposition to it, on the outside of the scalp. In moderate deformi- ties, traction applied during the pains may of itself suffice to bring down the head. Should the obstruction be too great to admit of this, it is necessary to break down and remove the vault of the cranium. For this purpose Simpson's cranioclast answers better than any other instrument. One of the blades is passed within the cranium, the other, if possible, between the scalp and the skull, and the portion of bone grasped between them is then broken off; this can generally be accomplished by a twisting motion of the wrist, without using much force. The separated portion of bone is then extracted, the greatest care being taken to guard the maternal struc- Fcetal Head crushed by the Cephalotribe. OPERATIONS INVOLVING DESTRUCTION OF FCETUS. 503 tures, during its removal, by the fingers of the left hand. The instrument is then applied to a fresh part of the skull, and the same pro- cess repeated, until as much of the vault of the cranium as may be necessary is broken up and removed. [The craniotomy forceps chiefly in use with us were devised by the late Prof. Charles D. Meigs, for his second operation upon Mrs. Keybold, of Philadelphia, in 1833, and have been used repeatedly since, either as tractors, or for reducing the size of the fuetal head, in cases of deformity of the pelvis. 1 Some obste- tricians prefer the less curved, and broader- bladed instrument of Great Britain, as a trac- tor ; but for the general purposes of picking away the cranial bones, and drawing down the base of the skull, in cases of extreme pelvic deformity, there is no more simple appliance than that of Dr. Meigs. To act upon an oval bodv like the foetal head, Dr. M. was obliged to prepare two forms of forceps — straight and curved — to be mod as might be required, according to the part of Fig. 179. Fig. 180. Straight Craniotomy Forceps. th. SX nil to be broken down, or drawn upon. These are lightly made, serrated, and 12 J inches in length. — Ed.] Advantages of bringing down the Face in Difficult Cases.- — Dr. Braxton Hicks 2 has conclusively shown that in difficult cases, after the removal of the cranial vault, the proper procedure is to bring down the face; since the smallest measurement of the skull after the removal of the upper part of the cranium, is from the orbital ridge to the alveolar edge of the superior maxillary bone. This alteration in the presentation he proposes to effect by a small blunt hook, made for the purpose, which is forced into the orbit, by means of which the face is made to descend. Barnes recommends that this should be done by fixing the craniotomy forceps over the forehead and face, and making traction in a backward direction, so as to get the face past the projecting promontory of the sacrum. The importance of bringing down the face was long ago pointed out by Burns, but it has been lost sight of, until Hicks again drew attention to it in the paper referred to. In the class of cases in which this procedure is valuable, the risk to the maternal passages, from the removal of fractured portions of bone, must always be considerable, and it is of great importance not only to preserve the scalp as entire as possible, so as to protect them, but to use the utmost possible care in removing the broken pieces of bone. Extraction of the Body. — "When the extraction of the head has [' The illustration given is taken from the instruments devised by Dr. Meigs as an improvement upon his original pattern, and will be seen to differ from that here- tofore given in American obstetrical publications. — Ed.] 2 Obst. Trans., vol. vii. 504 OBSTETRIC OPERATIONS. been effected, either by the cephalotribe or the craniotomy forceps, there is seldom much difficulty with the body. By traction on the head one of the axillae can easily be brought within reach, and if the body do not readily pass, the blunt hook should be introduced, and traction made until the shoulder is delivered. The same can then be done with the other arm. If there be still difficulty, the cephalotribe may be used to crush the thorax. The body is, however, so com- pressible that this is rarely required. Embryotomy where Turning is Impossible. — There only remains for us to consider the second class of destructive operations. These may be necessary in long-neglected cases of arm presentation, in which turning is found to be impracticable. Here fortunately the question of killing the foetus does not arise, since it will, almost necessarily, have already perished from the continuous pressure. We have two operations to select from, decapitation and evisceration. Decapitation. — The former of these is an operation of great an- tiquity, having been fully described by Gelsus. It consists in sever- ing the neck, so as to separate the head from the body ; the body is then withdrawn by means of the protruded arm, leaving the head in utero to be subsequently dealt with. If the neck can be reached without great difficulty — and, in the majority of cases, the shoulder is sufficiently pressed clown into the pelvis to render this quite possi- ble — there can be no doubt, that it is much the simpler and safer operation. Methods of dividing the Neck. — The whole question rests on the possibility of dividing the neck. For this purpose many instruments have been invented. The one generally recommended in this country is knoAvn as Eamsbotham's hook, and consists of a sharply curved hook, with an internal cutting edge. This is guided over the neck, which is divided by a sawing motion. There is often considerable difficulty in placing the instrument over the neck, although, if this were done, it would doubtless answer well. Others have invented instruments, based on the principle of the apparatus for plugging the nostrils, by means of which a spring is passed round the neck, and to the extremity of the spring a short cord, or the chain of an ecraseur, is attached ; the spring is then withdrawn and brings the chain or cord into position. The objection to any of these appa- ratuses is, that they arc unlikely to be at hand when required, for few practitioners provide themselves with costly instruments which they may never require. It is of importance, therefore, that we should have at our command some means of dividing the neck, which is available in the absence of any of these contrivances. Dubois re- commends for this purpose a strong pair of blunt scissors. The neck is brought as low as possible by traction on the prolapsed arm, and the blades of the scissors guided carefully up to it. By series of cautious snipping movements it is then completely divided from below upwards. This, if the neck be readily within reach, can gen- erally be effected without any particular difficulty. Dr. Kidd, of Dublin, 1 who strongly advocates this operation, recommends that an i Dublin Quart. Journ., May, 1871. OPERATIONS INVOLVING DESTRUCTION OF FCETUS. 505 ordinary male elastic catheter, strongly curved and mounted on a firm stilet, or, still better, on a uterine sound, should be passed round the neck. Previous to introduction a cord should be attached to the ex- tremity of the catheter, which is left round the neck when it is with- drawn. By means of this cord a strong piece of whipcord, or the wire of an ecraseur, can easily be drawn round the neck and used for dividing it. The former, to protect the maternal structures, may be worked through a speculum, and by a series of lateral movements the neck is easily severed. The ecraseur, however, offers special advantages, since it entirely does away with any risk of in- juring the mother. Withdrawal of the Body and Delivery of the Head. — After the neck is divided the remainder of the operation is easy. The body is withdrawn without difficulty by the arm, and we then proceed to deliver the head. By abdominal pressure this, in most cases, can be pushed down into the pelvis, so as to come easily within reach of the cephalotribe, which is by far the best instrument for extraction. Preliminary perforation is not necessary, since the brain can escape through the severed vertebral canal. The secret of doing this easily is to fix and press down the head sufficiently from above, otherwise it would slip away from the grasp of the instrument. The perfora- tor and craniotomy forceps may be used, if the cephalotribe be not at hand. Perforation is, however, by no means always easy, on ac- count of the mobility of the head. After it is accomplished one blade of the craniotomy forceps is passed within the skull, the other externally, and the head slowly drawn down. Evisceration. — The alternative operation of evisceratron is a much more troublesome and tedious procedure, and should only be used when the neck is inaccessible. The first step is to perforate the thorax at its most depending part, and to make as wide an opening into it as possible, in order to gain access to its contents. Through this the thoracic viscera are removed piecemeal, being first broken up as much as possible by the perforator, and then, the diaphragm being penetrated, those in the abdomen. The object is to allow the body to collapse, and the pelvic extremities to descend, as in sponta- neous evolution. This can be much facilitated by dividing the spinal column with a strong pair of scissors, introduced into the opening made in the thorax, so that the body may be doubled up as on a hinge. Here the crotchet may find a useful application, for it can be passed through the abdominal cavity, and fixed on some point in the interior of the child's pelvis ; and thus strong traction can be made without any risk of injury to the mother. It can be readily understood that this process is so lengthy and difficult as to render it probably the most trjdng of obstetric operations : it is certainly inferior in every respect to decapitation, and is only to be resorted to when that is impracticable. 1 [' In nine instances of impaction of the foetus in a transverse position, in the United States, the Csesarean operation has been performed, owing to great difficulty in accom- plishing either decapitation or evisceration, and six of the women were saved. The three deaths were from exhaustion. — Ed.1 33 506 OBSTETRIC OPERATIONS CHAPTER VI. THE CESAREAN SECTION — SYMPHYSEOTOMY — AND LAPARO- ELYTROTOMY. History. — The Cesarean section has perhaps given rise to more discussion than any other subject connected with midwifery, and there is yet much difference of opinion as to the limits of, and indica- tions for, the operation. The period at which the Cesarean section was first resorted to is not known with accuracy. It seems to have been practised by the Greeks, after the death of the mother ; and Pliny mentions that Scipio Africanus and Manlius were born in this way. The name of Caesar is said to have been given to children so extracted, and afterwards to have been assumed as a family patro- nymic. These children were dedicated to Apollo ; whence arose the practice of things sacred to that god being taken under the special protection of the family of the Caesars. Many celebrities have been supposed to owe their lives to the operation ; among the rest iEscula- pius, Julius Caesar, and our own Edward VI. Regarding the two latter, there is conclusive proof that the tradition is without founda- tion. There is no doubt that the operation was constantly practised on women who had died at an advanced period of pregnancy, and indeed it has, at various times, been enforced by law. Thus among the Romans it was decreed by Numa, that no pregnant woman should be buried until the foetus had been removed by abdominal section. The Italian laws also made it necessary, and the operation has always received the strong support of the Roman Church. So lately as the middle of the eighteenth century, the King of Sicily sentenced to death a physician who had neglected to practise it. The first authentic case in which the operation was performed on a living woman occurred in 1191. It was afterwards practised by Nufer in 1500; and in 1581 Rousset published a work on the subject, in which a number of successful cases were related. In English works of that time it is not alluded to, although it was undoubtedly performed on the Continent, and to such an extent that its abuse became almost proverbial. We have evidence in Shakespeare, however, that the operation was familiarly known in this country, since he tells us that— . . . . Macduff was from his mother's womb Untimely ripped. Pare* and Guillemeau, amongst the writers of the period, were noted for their hostility to the operation, while others equally strongly upheld it. In this country it has scarcely ever been performed in a manner CESAREAN SECTION. 507 which offers even the faintest hope of success. It has been looked upon as almost necessarily fatal to the mother, and it has, therefore, been delayed until the patient has arrived at the utmost stage of exhaustion. For example, in looking over the records of British cases, it is no uncommon thing to find that the Cesarean section was resorted to, two, three, or even six days after labor had begun, 1 and when the patient was almost moribund. With rare exceptions within the last few years, the operation has been performed in what may be called a hap- hazard way. In mam- cases long and fruitless attempts at delivery by craniotomy had already been made, so that the pas- sages had been subjected to much contusion and violence. Little or no attempt has been made to obviate the well-known risks of ab- dominal operations; no care has been taken to prevent blood and other fluids finding their way into the peritoneal cavity, and no means have been adopted subsequently to remove them. It is, therefore, not so much a matter of surprise that the mortality has been so great, but rather that any cases have recovered. Mortality. — From what we know of the history of ovariotomy, its early fatality, and the extreme and even apparently exaggerated precautions which are essential to its success, it is fair to conclude that, if the Cesarean section were performed, as it is to be hoped it always will be in future, with the same careful attention to minute details as ovariotomy, the results would not be so disastrous. Making every allowance for these facts, it must be admitted that the Cesa- rean section is necessarily almost a forlorn hope; and in making thess observations I have no intention of contesting the well-estab- lished rule of British practice, that it is not admissible as an opera- tion of election, and must only be resorted to when delivery per vias naturales is impossible. Statistical Eetums are not Reliable. — The mortalitv, as given in statistical returns from various sources, differs so greatly as to make them but little reliable. Radford tabulates 77 operations performed in this country, of which 60, or 85.71 per cent., proved fatal, and 11, or 14.28 per cent., recovered. Michaelis and Kayscr found that out of 258 and 338 operations, 54 and 64: per cent, respectively were fatal. These include operations performed under all sorts of condi- tions, even when the patient was almost moribund ; and until Ave are in possession of a sufficient number of cases performed under con- ditions showing that the result is obviously due to the operation — in which it was undertaken at an early period of labor, and performed with a reasonable amount of care — it is obviously impossible to arrive at any reliable conclusions as to the mortality of the operation. 2 That it is. necessarily hopeless is certainly not the case, and we know that on the Continent, Avhere it is resorted to much oftener and earlier in labor than in this country, there are authentic cases in which it has been performed twice, thrice, and even, in one instance, four times on the same patient. Kayser thinks that a second operation on the 1 See Radford on Csesarean Section, p. 15. [ 2 See American Statistics, by the editor, p. 522.] 508 OBSTETRIC OPERATIONS. same patient affords a better prognosis than a first, probably because peritoneal adhesions, resulting from the first operation, have shut oft* the general abdominal cavity from the uterine wound ; and he believes that in second operations the mortality is not more than 29 per cent. \_The Csesarean Operation in the United Kingdom. — It is impossible to state with any satisfactory degree of accurac}^ how many times the operation has been performed in England, Ireland, and Scotland ; for the statistics collected are with very few exceptions confined to the cases that have been published, when we know that there must be many that have never appeared in print. If 48 out of 112 in our own country were not reported through the medical journals it is not at all likely that nine will cover this class of cases in Great Britain. Dr. Thomas Radford, of Manchester, continuing and embracing the work of Dr. Hull, published two sets of tables, one in 1865, con- taining the records of 77 operations; and another in 1868, with 21 additional cases, making in all 98. Of this number, 82 died, and only 16 recovered : 46 women were deformed by osteomalacia, and 16 bv rickets. Several British authors, one even residing in Man- Chester, appear not to be aware of the fact, that Dr. Badford issued the supplementary pamphlet, of which I am the fortunate possessor of a copy. Taking up the record where Dr. Baclford left it, I have added 20 more operations as the result of the work of the last decade, with a favorable issue in six cases, or the same number saved as in the pre- vious period of the same length. It may be that I have failed to secure several cases, as there were thirty collected by Dr. Radford for the previous decade, although it is true that only seventeen were found for the ten years ending with 1858. Of the 118 cases 22 sur- vived, and 96 died. That is, 12 saved out of 50, in the last twenty years, against 10 out of 68 in the preceding 120 years, which is some- Avhat of an improvement in the results attained, provided we have all the cases. Of the recovered cases, 5 had malignant disease of the cervix uteri, 6 pelvic obstruction from osteomalacia, 5 ditto from rickets, 1 ditto from fracture, 2 from pelvic exostosis, and 1 from coxalgic ancliylosis and spinal curvature. One woman had her uterus erroneously punc- tured in an operation of ovariotomy, and in one the cause of difficulty is not stated, = 22. The time in labor of the 22 cases was as follows, viz. : Within twenty-four hours, 5 ; on the second day, 4 ; on the third day, 5 ; four days, 1 ; five days, 1 ; six days, 1 ; twelve days, 1 ; labor not yet commenced, 2 ; and not stated, 2, = 22. Dr. Baclford gives 56 as the number of children "preserved," but this includes many that must have died within a very short period. Of the 20 cases in my supplement, the children were living in 12. Of these, 2 died in a few moments, 1 lived four hours, 1 nine days, 1 seven months, and 1 seven and a half months, so that but 6 appear as having lived to a later period. One-half of the children were dead when removed from the six women who recovered in the past CESAREAN SECTION. 509 ten years. In the whole 22 successful operations, 15 children were removed alive, of whom 2 died in a few moments, leaving 13 to be counted as " saved." In the whole 118 operations, about one in five may be said to have been performed in a reasonably good season. With the best of care in England, the success in the operation must always be below that in the United States, provided our own subjects are promptly subjected to the knife. This is shown by a comparison between the timely operations of the two countries. I have selected out 21 British cases, recorded as follows: in 3, labor was artificially induced ; 3 are denominated simply as " early" and in 15, the pains had lasted from three or four hours to thirteen. These 21 cases, therefore, may be classed as "early;" and notwith- standing the measure of promptness, but 5 recovered, or less than the proportion of the published cases of all grades, for the past ten years. Take the same number of operations performed in the United States within the same measure of time, and wc may reverse the figures of saved and lost. It is no wonder then, that English obstetricians regard the Cesar- ean operation as the " last resort" the " forlorn hope" etc., and turn their attention to devising all kinds of expedients where possible to avoid the necessity for its performance. Xow, while I have every respect for British opinion in matters of surgery, I do not wish our own obstetricians and surgeons to form their opinion of the risks of this particular operation from English obstetrical works, which are correct according to their own experience, but all wrong in the light of American success. \Ye have of late been following too much in the line of their opinion, and as a consequence have postponed the use of the knife until too late to employ it except with fatal effect. Promptness in action, then, does not appear to have much influence over the result in Great Britain, although all important and quite encouraging here — for of six early British cases in the last ten years, with the greatest care in management, but one was saved. I attri- bute this difference to the great poverty and consequent want of stamina in the subjects operated upon, the injurious effects upon their tissues, of the use of malt drinks, and the vomiting and uterine inertia produced by inhaling chloroform when administered to such subjects. The remarkable results of ovariotomy under Spencer ATells, Keith, and others, show that it is largely the character of the subject that makes the Cesarean section so much more dangerous ; for, al- though some of the ovarian cases may belong to the same impover- ished class, the great majority do not, and, besides, there is generally an opportunity of improving their condition by proper hygienic and dietetic treatment preparatory to the operation, which is very rarely the case with reference to the subjects for gastro-hysterotomv, who must endure the operation while still under the depressing effects of poverty, exposure to dampness, and it may be, disease resulting from it in the form of pelvic softening, an affection which we never see in our native population. — Ed.] Results to the Child. — The mortality of the children likewise cannot be ascertained from statistical returns since, in the large majority of 510 OBSTETRIC OPERATIONS. cases in which dead children were extracted, the result had nothing to do with the operation. Indeed, there is nothing in the operation itself which can reasonably be supposed to affect the child. If, there- fore, the child be alive when the operation is commenced, there is every probability of its being extracted alive ; and Eadford's conclu- sion that, "the risk to infants in Cesarean births is not much greater than that which is contingent on natural labor, provided correct prin- ciples of practice are adopted," probably very nearly represents the truth. Causes requiring the Operation. — The Cesarean section is required when there is such defective proportion between the child and the maternal passages, that even a mutilated foetus cannot be extracted. This in by far the greatest number of cases is due to deformity of the pelvis arising from rickets or mollitis ossium. The latter may occur in a patient who had been previously healthy, and who has given birth to living children. It is a more common cause of the extreme varieties of deformity than rickets, and out of 77 British cases, tabulated by Eadford, in 48 the deformity was produced by osteomalacia and in 1-i only by rickets. In certain cases the pelvis itself may be of normal size, but has its cavity obstructed by a solid tumor of the ovary, of the uterus itself, or one growing from the pelvic wall. The obstruction may also depend on morbid conditions of the maternal soft parts, of which the most common is advanced malignant disease of the cervix. Other conditions may, however, render it essential. Thus Dr. Newman 1 records a case in which he performed the operation for insurmountable resistance and obstruc- tion of the cervix, which was believed at the time to be malignant. The patient recovered, and was subsequently delivered naturally, and without anything abnormal being made out. This renders it probable that the disease was not malignant, and it may possibly have been an extensive inflammatory exudatory into the tissues of the cervix, subsequently absorbed. I myself was present at a Cesar- ean section performed in Calcutta in the year 1857, when the pelvis was so uniformly blocked up with exudation, probably due to exten- sive pelvic cellulitis or hematocele, that the operation was essential. Limits of Obstruction justifying the Operation. — Different accou- cheurs have fixed on various limits for the operation. Most British authorities are of opinion that it need not be resorted to, if the smallest diameter of the pelvis exceed 1J inch. 2 This question has already been considered in discussing craniotomy, and it has been shown that a mutilated foetus may be drawn through a pelvis of 1J inch antero-posterior diameter, provided there be a space of 8 inches in the transverse diameter. If sufficient space for using the neces- sary instruments do not exist, the Cesarean section may be required, even when there is a larger antero-posterior diameter than 1J inch. This is especially likely to occur when we have to do with deformity 1 Obst. Trans., vol. iii. p. 343. [ 2 In Dr. Parry's table of 70 craniotomies, there are 34 cases of 2 to 1\ inches con- jugate, and still the mortality (27) amounts to 37 f per cent. Am. Journ. Obstetrics, N. Y. vol. v. 1873, p. 644.] CESAREAN SECTION. 511 arising from mollities ossium, in which the obstruction is in the sides and outlet of the pelvis, the true conjugate being sometimes even elongated. On the Continent the Cesarean section is constantly practised, as an operation of election, when the smallest diameter measures from 2 to 2 J inches ; and when the child is known to be alive, some foreign authors recommend it when there are as much as 8 inches in the antero- posterior diameter. In this country, where the life of the child is most properly considered of secondary import- ance to the safety of the mother, we cannot fix one limit for the ope- ration when the child is living, and another when it is dead. Nor, I think, can we admit the desire of the mother to run the risk, rather than sacrifice the child, as a justification of the operation, although, this is laid clown as an indication by Schroeder. 1 Great as are the dangers attending craniotomy in extreme deformity, there can be no doubt that we must perform it whenever it is practicable, and only resort to the Cesarean section when no other means of delivery are possible. For this reason I think it unnecessary to discuss the question, whether we are justified in destroying the foetus in several successive pregnancies, when the mother knows that it is impossible for her to give birth to a living child. Denman was the first to question the advisability of repeating craniotomy on the same patient. Amongst modern authors Eadford takes the most decided view on this point, and distinctly teaches that even when delivery by craniotomy is pos- sible, it "can be justified on no principle, and is only sanctioned by the dogma of the schools, or by usage," and that, therefore, the Cesarean section should be performed with the view of saving the child. Doubtless much can be said from this point of view ; but, nevertheless, he would be a bold man who would deliberately lecte to perform the Cesarean section on such grounds. 2 It is to be hoped, however, that in these days the induction of premature labor or abortion would always spare us the necessity of deciding so delicate a point. Post-mortem Csesarean Operation.- — The Cesarean section may also be required in cases in which death has occurred during pregnancy or labor. This was the indication for which it was first employed, and it has constantly been performed when a pregnant woman has died at an advanced period of utero-gestation. There is no doubt that a prompt extraction of the child under these circumstances has frequently been the means of saving its life, but by no means so often as is generally supposed. Thus Schwartz 3 showed that out of 107 cases not one living child was extracted. Duer 4 has written an inte- resting paper on this subject in which he has tabulated 65 cases of 1 Manual of Midwifery, p. 202. [ 2 This was done twice successfully by Prof. William Gibson in the case of Mrs. Reybold, of Philadelphia, in 1835, and 1837, after she had twice been delivered by craniotomy under Prof. Charles D. Meigs, who declined destroying any more children for her. Mrs. P. still lives at the age of 70, and the daughter and son likewise, with their six children. — Ed.] 3 Monat. f. Geburt., suppl. vol., 1861, p. 121. 4 Post-mortem Delivery, Am. Journ. of Obst., Jan. 1879. 512 OBSTETRIC OPERATIONS. post-mortem Coesarean section. In 40 a living child was extracted, the time elapsing after the death of the mother being as follows: "Between 1 and 5 minutes, including 'immediately,' and 'in a few minutes,' there were 21 cases; between 5 and 10 minutes, none; between 10 and 15 minutes, 13 cases ; between 15 and 23 minutes, 2 cases ; after 1 hoar, 2 cases ; and after 2 hours, 2 cases." In those extracted, however, after the lapse of an hour, the children did not ultimately survive, and the cases themselves seem open to some doubt. Want of Success in Post-mortem Operation. — The reason that the want of success has been so great, is doubtless the delay that must necessarily occur before the operation is % resorted to, for, inde- pendently of the fact that the practitioner is seldom at hand at the moment of death, the very time necessary to assure ourselves that life is actually extinct will generally be sufficient to cause the death of the foetus. Considering the intimate relations between the mother and child, we can scarcely expect vitality to remain in the latter more than a quarter, or at the outside, half an hour, after it has ceased in the former. The recorded instances in which a living child was extracted ten, twelve, and even forty hours after death, were most probably cases in which the mother fell into a prolonged trance or swoon, during the continuance of which the child must have been removed. A few authentic cases, however, are known in which there can be no reasonable doubt that the operation was performed successfully several hours after the mother was actually dead. An often-quoted and interesting example is that of the Princess of Schwartzenburgh, who perished one evening in a fire at Paris, and from whose body a living infant is said to have been removed on the morning of the following day. The authenticity of this case, however, is open to grave doubt. 1 [The Storij of the Princess of Schwarzenberg is based upon the authority of Prof. Gardien, of Paris, who introduced it into his work on obstetrics in 1816, and Prof. Yelpeau, who quotes him in his own in 1829 ; and this is all the authenticity it ever had. The statement is not even " open to a grave doubt," for it is the purest of all fabri- cations, as I can readily prove. The Princess was burned at a court-ball, on the night of Sunday, July 1, 1810, and under circumstances which made her name famous as a self-sacrificing heroine. This fact has made it a comparatively easy matter to secure the whole of the truth required. The Gazette Rationale ou Moniteur Universal, the official journal of the empire, of Tuesday, July 3, 1810, gives the facts of her death, and states that at day-break, on July 2, a disfigured body was discovered in the debris of the hall, which Dr. Gall believed to be that of the Princess, about which there was no doubt, when an ornament known to have been worn by her, was found upon the neck. This paper also states, that "the Princess was the mother of eight children," and n See article by Ed. in Am. Jour, of Med. Sci., Oct. 1879, p. 389.] CESAREAN SECTION. 513 that she was "four months pregnant." The Journal de l'Empire, of July 4, gives virtually the same account. Besides this we have statements 1 to the effect that her body was almost entirely burned to a crisp mass, so that an operation was an impossibility. In the Journal de Medicine, by Drs. Corvisart, Leroux, and Boyer, there is no reference to the case in the monthly numbers from Jul}-, 1810, to Jan. 1811. I hope, therefore, as I have proved that the women was only pregnant four months, and that her body was burned beyond the possibility of an operation, that no future obstetrical writer will record the case, as " perhaps the best authenti- cated" of all this class of historical marvels, or express any doubt about it ; let the record be dead and buried historically. — Ed.] Since, then, there is a chance, however slight, of saving the child's life, we are bound to perform the operation, even when so much time has elapsed as to render the chances of success extremely small. It might be considered almost superfluous to insist on the necessity of assuring ourselves of the mother's death before commencing the neces- sary incisions ; but, unfortunately, numerous instances are known in which mistakes in diagnosis have been made, and in which the iirst steps of the operation have shown that the mother was still alive. The operation should, therefore, always be performed with the same care and caution as if the mother were living. If death have occurred during labor, some have advised version as a preferable alternative. This can only be resorted to, with any hope of success, if the passages be in a condition to admit of delivery with rapidity ; otherwise the delay required for dilatation, even when forcibly accomplished, and the drawing of the child through the pelvis, will be almost necessarily fatal. The only argument in favor of version is, that it is less painful to the friends ; and, if the}' manifest a decided objection to the Caesarean section, there can be no reason why an attempt to save the child in this way should not be made. Causes of Death after Caesarean Section. — The causes of death after the Cesarean section may, speaking generally, be classed under four principal heads ; hemorrhage, peritonitis and metritis, shock, septi- caemia, and exhaustion from long delay. These are pretty much the same as those following ovariotomy and the resemblance between the two operations is so great that modern experience as to the best mode of performing ovariotomy, as well as regards the after treat- ment, may be taken as a guide in the management of cases of Cesar- ean section. Hemorrhage is Frequent, although Seldom Fatal. — Hemorrhage to an alarming extent is a frequent complication, although seldom the cause of death. Thus out of 88 operations, the particulars of which have been carefully noted, severe hemorrhage occurred in 14, 6 of which terminated successfully, and in 4 only could the fatal result be ascribed to the loss of blood. In 1 of these the source of the hemor- rhage is not mention in another it came from the wound in the [' Alison's "History of Europe,"" Mad. Junot's "Memoirs of Xapoleon, his Court and Family."] 514 OBSTETRIC OPERATIONS. abdominal wall, and in the other 2 from the uterine incision being made directly over the placenta. In neither of the 2 latter was the loss of blood immediately fatal ; for it was checked by uterine con- traction, and only recurred after many hours had elapsed. The divided uterine sinuses, and the open mouths of the vessels at the placental site, are the most common sources of hemorrhage. Means of avoiding the Risk. — Much may be done to diminish the risk of bleeding, but even with every precaution, it must be a source of danger. Hemorrhage from the abdominal wall may be best prevented by making the incision as nearly as possible in the line of the linea alba, so as not to wound the epigastric arteries, and by tying any bleeding vessels as Ave proceed. The principal loss of blood will be met with in dividing the uterus ; and this will be greatest when the incision is near or over the placental site, where the largest vessels are met with. We are recommended to ascertain the position of the placenta by auscultation, and thus, if possible, to avoid opening the uterus near its insertion. But even if we admit the placental souffle to be a guide to its situation, if the placenta be attached to the anterior walls of the uterus, a knowledge of its posi- tion would not always enable us to avoid opening the uterus in its immediate vicinity. We must, in the event of its lying under the incision, rather hope to control the hemorrhage by removing it at once from its attachments, and rapidly emptying the uterus. When the child has been removed there may be a large escape of blood ; but this will generally be stopped by the contraction of the uterus, in the same manner as after natural labor. Should contraction not take place, the uterus may be firmly grasped for the purpose of exciting it. This plan is advocated by Winckel, who had a large experience in the operation ; and by using free compression in this way, and making a point of not closing the wound until the uterus is firmly contracted, he has never met with any inconvenience from hemorrhage. If bleeding continue, styptic applications may be used, as in a case reported by Hicks, who was obliged to swab out the uterine cavity with a solution of perchloride of iron. Peritonitis and Metritis are frequent Causes of Death. — Among the most frequent causes of death are peritonitis and metritis. Kayser attributes the fatal result to them in 77 out of 123 unsuccessful cases. The mere division of the peritoneum will not account for the fre- quency of this complication, since its occurrence is considerably more frequent than after ovariotomy, in which the injury to the peritoneum is quite as great, and indeed greater, if we take into account the adhesions which have to be divided or torn in that operation. The division of the uterus must be regarded as one source of this danger. Dr. West lays great stress on its unfavorable condition after delivery for reparative action. Ho believes that the process of involution or fatty degeneration which commences in the muscular fibres previous to delivery, renders them peculiarly unfitted to cica- trize ; and he points out that, on post-mortem examination, the edges of the incision have been found dry, of unhealthy color, gaping, and showing no tendency to heal. On this account Hicks and others CESAREAN SECTION. 515 have operated ten days or more before the full period of labor, in the hope that the risk from this source might be avoided. It is by no means certain, however, that the change in the uterine fibres is the cause of the wound not healing, and involution will commence at once when the uterus is emptied, even if the full period of preg- nancy have not arrived. As a point of ethics, moreover, it is question- able if we are justified in anticipating the date of so dangerous an operation, even by a few weeks, unless the benefit to be derived is very decided indeed. Escape of Lochia and other Fluids into the Peritoneal Cavity. — One important cause of peritonitis is the escape of the lochia through the uterine incision into the cavity of the peritoneum, which there de- compose and act as an unfailing source of irritation. This may be prevented, to a great extent, by seeing that the os uteri is patulous, so as to afford a channel for the escape of discharges, and by closing the uterine wound by sutures. In addition there is the danger arising from blood and liquor amnii escaping into the peritoneum, and subsequently decomposing. There is little evidence that " la toilette du peritoine," on Avhich ovariotomists now lay so much stress, has ever been particularly atttended to in Cesarean operations. The Unhealthy Condition of the Patient is the Chief Source of Danger. — The chief predisposing cause of these inflammations, however, must be looked for in the condition of the patient, just as asthenic inflam- mation in ovariotomy is most frequently met with in those whose ganeral health is broken down by the long continuance of the disease. We are fully justified, therefore, in assuming that peritonitis and metritis will be more likely to occur after the Cesarean section when that operation has been unnecessarily delayed, and when the patient is exhausted by a protracted labor. In proof of this we find that, in the large proportion of the cases above mentioned, peritonitis oc- curred when the operation was performed under unfavorable con- ditions. Septicaemia. — -The sources of septicaemia are abundantly evident, not the least, probably, being absorption by the open vessels in the uterine incision. Nervous Shock. — -The last great danger is general shock to the ner- vous system. In Kayser's 123 cases, 30 of the deaths are referred to this cause. In the large majority of these the patient was pro- foundly exhausted before the operation Avas begun. It is in predis- posing to these nervous complications, that we should, a priori, expect that vaccillation and delay would be most hurtful ; and in operating when the patient's strength is still unimpaired, we afford her the best chance of bearing the inevitable shock of an operation of such mag- nitude. Secondary Dangers. — In addition a few cases have been lost from accidental complications, which are liable to occur after any serious operation, and which do not necessarily depend on the nature of the procedure. Danger to Child from, Portions of its Body heing caught by the Con- trading Uterus. — There is only one source of danger, special to the 516 OBSTETRIC OPERATIONS. child, which is worthy of attention. As the infant is being removed from the cavity of the uterus, the muscular parietes sometimes con- tract with great rapidity and force, so as to seize and retain some part of its body. This occurred in 2 of Dr. Eadford's cases, and in 1 of them it is stated that " the child was vigorously alive when first taken hold of, but, from the length of time occupied in extracting the head, it became so enfeebled as to show only slight signs of life," and subsequently all attempts at resuscitation failed. I have myself seen the head caught in this way, and so forcibly retained that a second in- cision was required to release it. . In Dr. Eadford's cases the placenta happened to be immediately under the incision, and he attributes the inordinate and rapid contraction of the uterus to its premature sepa- ration. It is difficult to believe that this was more than a coinci- dence, because the contraction does not take place until the greater part of the child's body has been withdrawn, and because numerous cases are recorded in which the uterus was opened directly over the placenta, or in which it was lying loose and detached, in none of which this accident occurred. The true explanation may, I think, be found in the varying irritability of the uterus in different cases. Irrespective of the risk of portions of the child being caught and detained, rapid contraction is a distinct advantage, since the danger of hemorrhage is thereby much diminished. Serious consequences may be best avoided by removing, when practicable, the head and shoulders of the child first, or by employing both, hands in extrac- tion, one being placed near the head, the other seizing the feet. Either of these methods is preferable to the common practice of lay ing hold of the part that may chance to lie most conveniently near the line of incision. If this point were properly attended to, al- though the detention of the lower extremities might occasionally occur, the life of the child would not be imperilled. The preparation of the patient for the operation should seriously oc- cupy the attention of the practitioner, and this is the more essential, since almost all patients requiring the Caesarean section are in a wretchedly debilitated condition. If the patient be not seen until she is actually in labor, of course this is out of the question. But this will rarely be the case, since the deformed condition of the patient must generally have attracted attention. Every possible means should be taken, therefore, when practicable, to improve the general health by abundance of simple and nourishing diet, plenty of fresh air, and suitable tonics (amongst which preparations of iron should occupy a prominent place), while the state of the secretions, the bowels, skin, and kidneys, should be specially attended to. Whenever it is possible a large, airy apartment should be selected for the operation, which should never be done in a hospital, if other arrangements be practicable. These details may seem trivial and unnecessary; but to insure success in so hazardous an under- taking, no care can be considered superfluous, and probably the want of attention to such points has had much to do with increasing the mortality. [In the United States, where osteo-malacia has on no one occasion CESAREAN SECTION. 51T been the cause of deformity requiring the operation of section, the patients are generally in a fair condition of health, although not usually either strong or plethoric. So far from there being an op- portunity to put them under preparatory treatment, the trouble is, that the operator seldom sees them until entirely too late. In the class of patients to be operated upon here, there is rarely sought, until frightened into the necessity of doing it, either an accoucheur or sur- geon of the requisite skill and experience. — Ed.] Question of Time to be Selected for the Operation. — The question arises whether we should operate before labor has commenced. By selecting our own time, as some have advised, we certainly have the advantage of operating under the most favorable conditions, instead of possibly hurriedly. There are, however, numerous advantages in waiting until spontaneous uterine action has commenced, which seem to me to more than counterbalance the advantages of choosing our own time. Prominent among these is the partial opening of the os uteri, so as to afford a channel for the escape of the lochia, and the certainty of active contraction of the uterus, to arrest hemor- rhage. Barnes recommends that premature labor should be first induced, and then the operation performed. This seems to me to introduce a needless element of complexity ; and besides, in cases of great deformity, it is by no means always easy to reach the cervix with the view of bringing on labor. All needful arrangements should be made, so as to avoid hurry and excitement when the operation is commenced, and Ave may then wait patiently until labor has fairly set in. The Administration of Anesthetics. — The operation itself is simple. The patient should be placed on a table, in a good light, and with the temperature of the room raised to about 60 J . Chloroform has so frequently been followed by severe vomiting, that it is probably better not to administer it. For the same reason Mr. Spencer Wells has long given up using it in ovariotomy, and finds that chloro- methyl answers admirably; ether also is devoid of the disadvantages of chloroform. In one or two cases local anaesthesia has been used, by means of two spray producers acting simultaneously ; and this plan, if the patient have sufficient fortitude to dispense with general anaesthesia, has the further advantage of stimulating; the uterus to powerful contraction. Description of the Operation. — The incision should be made as much as possible in the line of the linea alba, so as to avoid wounding the epigastric arteries. On account of the deformity, the configuration of the abdomen is often much altered, and some have advised that the incision should be made oblique or transverse, and on the most prominent part of the abdomen. The risk of hemorrhage being thus much increased, the practice is not to be recommended. The incision, commencing a little above the umbilicus, is carried down for about three inches below it. The skin and muscular fibres are carefully divided, layer by layer, until the shining surface of the peritoneum is reached, and any bleeding vessels should be secured as we proceed. A small opening is now made in the peritoneum, which should be 518 OBSTETRIC OPERATIONS. laid open along the whole length of the incision, upon two fingers of the left hand introduced as a guide. Before incising the uterus an assistant should carefully support it in a proper position, and push it forward by the hands placed on either side of the incision, so as to bring its surface into apposition with the external wound, and pre- vent the escape of the intestines. If we have reason to believe that the placenta is situated anteriorly, we may incise the uterus on one or other side ; otherwise the line of incision should be as nearly as possible central. The substance of the uterus is next divided until the membranes are reached, which are punctured, and divided in the same way as the peritoneum. The uterine incision should be of the same length as that in the abdomen, and it should not be made too near the fundus ; for not only is that part more vascular than the body of the uterus, but wounds in that situation are more apt to gape, and do not cicatrize so favorably. After the uterus is opened, Dr. Winckel recommends that the fingers of an assistant should be placed in the two terminal angles of the wound, so that the ends of the incision may be hooked up, and brought into close apposition with the abdominal opening. By this means he prei r ents not only the escape of blood and liquor, amnii into the cavity of the perito- neum, but also the protrusion of the abdominal viscera. Removal of the Child. — The child should now be carefully removed, the head and shoulders being taken out (if possible) at first ; the placenta and membranes are afterwards extracted. Should the pla- centa be unfortunately found immediately under the incision, a con- siderable loss of blood is likely to take place, which can only be checked by removing it from its attachments, and concluding the operation as rapidly as possible. Importance of securing Uterine Contraction. — As soon as the child and the secundines have been extracted, the sooner the uterus con- tracts the better. It will usually do so of itself, but should it remain lax and flabby, it should be pressed and stimulated by the hand. We are specially warned against handling the uterus by Bamsbo- tham and others ; but there seems no valid reason why we should not restrain hemorrhage in this way, as after a natural labor. The in- tervention of the abdominal parietes, in their lax condition after delivery, can make very little difference between the two cases. Er- gotine administered hypoclermically, will also be useful in promoting efficient contraction. Closure of the Uterine and Ahdominal Wounds. — The advisability of closing the uterine wound by sutures is a mooted point. The balance of evidence is certainly in favor of this practice, as tending to prevent the escape of the lochia into the peritoneal cavity. 1 Inter- [' Sutures, chiefly of silver wire have "been used in 17 operations out of 112 in the United States. The catgut suture, whether plain or carbolized, cannot be too strongly condemned, as it has signally failed on the continent, and has been decided to be unreliable by the Obstetrical Society of London, for it does not hold even when treble- knotted. It has only been used once in the United States, and the wound gaped open. Tho material stretches as well as becomes untied. The fisbing-gut suture has taken its place abroad, as it does not elongate, and is not rapidly dissolved. The wire- suture has saved life in some cases of complete uterine atony in our country.— Ed.] CESAREAN SECTION. 519 rupted sutures of silver wire or carbolized gut may be used, and cut short ; or, as successfully practised by Spencer Wells, a continuous silk suture may be applied, one end being passed through the os into the vagina, by which it is subsequently withdrawn. Before closing the uterine wound one or two fingers should be passed through the cervix, to insure its being patulous. A free escape of the lochia in this direction is of great consequence, and AVinckel even advises the placing of a strip of lint, soaked in oil, in the os so as to keep up a free exit for the discharge. A point of great importance, and not sufficiently insisted on, is the advisability of not closing the abdominal wound until we are thor- oughly satisfied that hemorrhage is completely stopped, since airy escape of blood into the peritoneum would very materially lessen the chances of recovery. In a successful case reported by Dr. New- man, 1 the wound was not closed for nearly an hour. Before doing so all blood and discharges should be carefully removed from the peritoneal cavity, by clean soft sponges dipped in warm water. The abdominal wound should be closed from above downwards, by hare- lip pins, wire or silk sutures, which should be inserted at a distance of an inch from each other, and passed entirely through the abdomi- nal walls and the peritoneum, at some little distance from the edges of the incision, so as to bring the two surfaces of the peritoneum into contact. By this means we insure the closure of the peritoneal cavity, the opposed surfaces adhering with great rapidity. The sur- face of the wound is then covered with pads of folded lint, kept in position by long strips of adhesive plaster, and the whole covered with a soft flannel belt. Subsequent Management. — Into the subsequent treatment it is un- necessary to enter at any length, since it must be regulated by general principles, each symptom being met as it arises. It has been cus- tomary to administer opiates freely after the operation ; but they seem to have a tendency to produce sickness and vomiting, and ought not to be exhibited unless pain or peritonitis indicate that they are required. In fact, the treatment should in no way differ from that usual after ovariotomy, and the principles that should guide us will be best shown by the following quotation from Mr. Spencer "Wells's description of that operation : " The principles of after-treatment are — to obtain extreme quiet, comfortable warmth, and perfectly clean linen to the patient ; to relieve pain by warm applications to the abdomen, and by opiate enemas ; to give stimulants when they are called for by failing pulse or other signs of exhaustion; to relieve sickness by ice, or iced drinks; and to allow plain, simple, but nour- ishing food. The catheter must be used every six or eight hours, until the patient can move without pain. The sutures are removed on the third day, unless tympanitic distension of the stomach or in- testines endanger re-opening of the wound. In such circumstances they may be left for some clays longer. The superficial sutures may remain until union seems quite firm." 1 Obst. Trans., vol. viii. 520 OBSTETRIC OPERATIONS. Potto's Operation. — Porro of Pavia has recently suggested and car- ried into practice a modification of the Cesarean section, which con- sists in the removal of the uterus and ovaries, after the extraction of the child. The advantages are the removal of the wounded organ from the abdominal cavity, thus lessening the chances of septicaemia and haemorrhage, and leaving a smaller traumatic surface, which is fixed externally in the abdominal incision. The operation has now been performed 25 times, with 10 recoveries and 15 deaths. Although it is not easy, in an operation so recently introduced, to give a very positive opinion as to its merits, it obviously offers some advantages worthy of careful consideration. The fact that it renders future pregnancies impossible, need certainly not act as argument against its adoption, considering the class of cases in which the Cesarean section is required. The operation itself is simple. As performed by Spaeth the hemorrhage was controlled by the chain of an ecra- seur thrown round the uterus, which was then cut off, along with the ovaries, and attached to the abdominal wound, as in ovariotomy. Four drainage tubes were inserted, two in Douglas's space, and two higher up on either side. The whole operation was performed anti- septically and offered no difficulties. 1 [As the author's record is not complete, I will state that up to this time as far as ascertainable, the operation has been performed 32 times, with 15 recoveries ; viz., United States 1, Italy 12, Austria 9, Germany 2, France 3, Belgium 2, Denmark 1, Switzerland 1, and Russia 1. This operation of removing the uterus and ovaries as supplemental to the Cesarean section, is of English origin, and was first recom- mended as an improvement upon the old method because believed to be less dangerous, by Dr. James Blundell of London, in his Guy's Hospital Lectures in 182 8. 2 After a series of experiments in abdom- inal surgery upon the lower animals, Prof. Blundell became con- vinced that this method of operating should be adopted with reference to the human female, and urged it upon his class as well worthy of trial and adoption. The first actual operation of removing the uterus of a woman in labor was performed in Boston, July 21st, 1869, by Prof. Horatio E. Storer, 3 for the arrest of an uncontrollable hemorrhage following the Cesarean section, in a case where pregnancy was complicated with fibro-cystic disease, the sides of the uterine incision being two inches thick : the woman lived 68 hours. The operation of Edoardo Porro was performed with success on May 21st, 1876 ; and was succeeded with the same result by Prof. Spath, at the Lying-in Hospital of Vienna, twelve days later. This gave an impetus to the expedient as a hospital improvement, and now the method has been tried on more than a score of hospital cases on the Continent, in a number of localities. The fact that four ope- 1 Werner Med. Wochenschrift. 1878. [ 2 Lancet, vol. ii., p. 167, London, 1828J [ 3 Jour. Gynecol. Soc. Boston, Oct. 1869, page 223.] CESAREAN SECTION. 521 rations have succeeded out of seven, in the Vienna Hospital, where all the Cesarean cases had proved fatal for a century, under the old method ; and that Prof. Tarnier succeeded also at the Maternite of Paris, where there had been nothing but failures since 1787, has made a very decided impression on the minds of the leading Euro- pean professors of Obstetrics. The Midler Method. — This consists in the elevation of the gravid uterus from the abdominal cavity by the long incision ; then con- stricting the cervix to prevent all hemorrhage; then evacuating the uterus so as to prevent all entrance of fluid into the abdomen, and finally cutting through the cervix. This was devised by Prof. Miiller, of Berne, Switzerland, and has been performed several times with a fair prospect of success. The foetus is readily resuscitated. Prof. Litzman, of Kiel, Denmark, tried the apparatus of his col- league Esmark in one case which he lost ; and then in a short time the plan of Miiller, but the woman died of peritonitis on the sixteenth day. Prof. \Vasseige, of Liege, proposes to use a ribbon, instead of a wire constrictor, as in one of his cases the wire opened an artery in the cervix. The chain-eeraseur, serre-noeud of Cintrat, wire ecraseur, and clamp, have all had their advocates. As we have had but 4 hospital Cesarean operations in 112 cases in the United States, there is no demand for the Porro method as a hospital improvement with us. We have had cases in which I believe the plan might be of value ; such as those with uterine fibroids, and some similar to the second case of Prof. Tarnier, i. e., women long in labor, and with a putrid foetus in utero. His patient was four feet high, and the waters had been broken three days. Such patients have occasionally lived with us, but the great majority have died. If all our Cesarean operations were early, there would be but a very limited use for the Porro method here. Where there is a uterine tumor and a prospective danger of hemorrhage, I believe that Muller's method would offer the best hope of success — Ed.] Substitute for the Csesarean Section ; Symphyseotomy. — Bearing in mind the great mortality attending the Csesarean section, it is not surprising that obstetricians should have anxiously considered the possibility of devising a substitute, which should afford the mother a better chance of recovery. The first proposal of the kind was one from which great results were at first anticipated. In 1768 Sigault, then a student of medicine in Paris, suggested symphyseotomy, which consists in the division of the symphysis pubis, with a view of allow- ing the pubic bones to separate sufficiently to admit of the passage of the child. Although at first strongly opposed, it was subsequently ardently advocated by many obstetricians, and was often performed on the Continent, and in a few cases in this country. The Operation is Admitted to be Useless^ — It is generally admitted that it is quite impossible to make this a substitute for the Cesarean section, since the utmost gain which even a wide separation of the symphysis pubis would give would be altogether insufficient to admit of the passage of even a mutilated foetus. Dr. Churchill concludes that, even if it were possible to separate it to the extent of four 34 522 OBSTETRIC OPERATIONS. inches, we should only have an increase of from four lines to half an inch in the anteroposterior diameter, in which the obstruction is generally most marked. In the lesser degrees of deformity this might possibly be sufficient to allow the foetus to pass ; but the risk of the operation itself, and the subsequent ill effects, altogether contra-indi- cate it in cases of this description. [The Csesarean Operation in America. — The changes in my record since the publication of the last edition of this work have necessi- tated the remodelling of this entire article. Ten years of research have satisfied me that few Europeans yet understand our exact posi- tion with reference to this critical operation, made, however, far more dangerous than it ought to be, by an almost criminal delay in operating. Statistics have often been very much decried, and deservedly so, because they do not in general represent the whole truth. Few men have the patience to hunt up the unpublished records of anything, much less of a rarely performed operation, in a country as vast as this. And then when we do hunt them out, the cases, as a whole, do not properly represent the mortality and dangers of the operation. We must sift and condemn until we separate the bad surgery from the good, and the properly conducted from the improperly managed cases. We average the whole collection to learn what the ratio of deaths has been; and we do the same with the properly managed cases, to find out what it might and should have been. Acting on this, I present 119 American Csesarean cases, with 54 women saved. Of these, 112 belong to the United States, out of which 48 women recovered ; 52 children were delivered alive, of whom 9 soon perished, leaving 43 saved. The published cases, such as statistical records are usually made up from, number 64, of which 35 women recovered, or an average of 59y\ per cent. The unpublished cases, some of them older than any of the published, number 48, of which 13 were saved, or an average of 27 per cent,, making the average in the 112, 42 f per cent, of women saved. Dr. Playfair remarks on page 507, "Until we are in possession of a sufficient number of cases performed under conditionsshowing that the result is obviously due to the operation, in which it was under- taken at an early period of labor, and performed with a reasonable amount of care," it is obviously impossible to arrive at any reliable conclusions as to the mortality of the operation." By the sifting process, carefully and conscientiously performed, I am able to furnish just this character of record, the operations having been done in good season, and when the patients were not endangered by previous in- termeddling and too long delay. This list of timely operations numbers 27, and the results are as follows, viz.: women saved, 20; lost, 7; children delivered alive, 22, of whom 18 were ultimately saved; and children found dead in utero, 5. The causes of death in the seven were as follows, viz.: peritonitis, 3; septicemia, 1; shock and ex- haustion (in a dwarf), 1 ; irritative fever, 1 ; and intestinal obstruc- tion, 1. CESAREAN SECTION. DZo We have, then, 27 operations of the class called for by the author, and these are all that can be claimed out of the 112, on the data found ; there may possibly have been one or two more in the cases where the time in labor has not been ascertained, judging from their saving both, mother and child, but such have been excluded from the list, as the object of its preparation has been to show facts without reference to result. The percentage then reads: women saved under seasonably performed Cassarean operations in the United States, 74/ f ; children saved, 67^ ; children rescued alive, and dead within a week, 4 ; whole percentage of children rescued alive, 81 Jf . To show how these 27 cases represent the percentage of mortality, I have just looked back in my record eight years, when the list of operations numbered 59, and by the same rule of exclusiveness have selected out 1G timely operations. By these, the percentage of women saved amounts to 68}, and children 75. During the eight years, I have added 53 more operations, only 11 of which were performed in due season, either as to time or condition, and we find an improvement instead of a diminution in the favorable result. The diminution of the proportion of timely cases is explainable from the fact that 36 of the 53 additional operations had been withheld from publication, and were obtained by correspondence. One of the most celebrated American obstetrical writers, in a speech before a learned medical association, delivered a year ago, claimed that the Cesarean section was "the most dangerous operation in surgery." Is this borne out by the facts just given? Take the capital operations of surgery, and hunt them everywhere, frontier settlements and all, and how many will show 42 per cent, of re- coveries? One of the fallacies which is contradicted by ovariotomy every day is, that the great danger of gastro-hysterotomy is the opening of the abdominal cavity. When Prof. Byford performed ovariotomy on a young lad}-, 1 and followed it by the removal of a seven and a half months' foetus from her uterus, having thrown it into contractile action by erroneously tapping it, why did the patient make a good recovery? Why, also, do so manv more women recover after an early than a late operation ? It is not exhaustion of bodily forces, for we see this in many ovariotomy cases that do well. There is but one way to account for it, and that is the danger of opening the uterus after it has been long in action. Uterine muscular fatigue favors atony of the organ, gaping of the incision in it, the escape of blood and lochia into the abdominal cavity, the production of second- ary hemorrhage, metro- peritonitis, and septicaemia, and the condi- tions proving fatal under the names of shock, exhaustion, and heart- clot. We hear laparo-elytrotomy commended because it avoids opening the, abdominal cavity, when its real value is in avoiding the uterine incision where the organ has been permitted to exhaust itself by delay. In laparotomy for the removal of an extra-uterine foetus, the abdomen is opened, and many cases recover, provided the [i Am. Jour. Obstetrics, N. Y., 1879, p. 31.] 524 OBSTETRTC OPERATIONS. placenta is not removed in the operation. What has made the success of the Porro method, but the recognition of the fact that the uterus is the seat of danger ? Up to ten or twelve years ago, the general result of the Cesarean operations of the United States put us very much in advance of the success attained in Great Britain; but within this period we have been decidedly retrograding and England slightly improving. Judg- ing from the past, we have now about an average of three cases a year. In the whole United States, we have saved 7 women in the last decade, out of 32, thereby diminishing the percentage, which stood at 53 in 1869, down to 42f. Having become frightened at the "dreadful" operation, we are reaping the fruits of making it the " forlorn hope." With the exception of 7 operated on early, the women were in labor from one day to fifteen, a number being two, three, and four days. What is the best indication of the character of the cases, is the fact that 21 of the 32 children were lost. In New York City, one surgeon performed the operation three times in as many consecutive years, and lost all the cases because of the time wasted before he was called in. Nos. 1 and 2 were Germans, in labor three days each, and affected with pelvic exostosis; both died, and one child lived. No. 3 was black, with a deformed pelvis, and in labor four days; she had a conjugate of If inch. Of these six lives, but one was saved. These are fair examples of the way in which time is wasted in useless delay on the part of accoucheurs and midwives. The Cesarean operation has a twofold character as respects the mortality which follows it. In early cases it is an expedient of medium gravity; but is almost hopeless in late ones. What our accoucheurs require, is to realize the clanger of delay and the abso- lute necessity of haste. The erroneous estimate of the fatality of the operation has an effect to insure this fatality by causing delay in its performance. I was recently struck with the remarkable success of an operation performed by Dr. Olcott, of Brooklyn, upon a woman in whom the obstruction to delivery was a large uterine fibroid, because almost all such cases had proved fatal, and wrote to him to know exactly how long it was after the commencement of labor that he began to operate. His answer, " nine and a half hours," revealed the great basis of his success. — Ed.] LAPARO-ELYTROTOMY. 525 CHAPTEE VII. LAPARO-ELYTROTOMY. In the former editions of this work laparo-elytrotoray was briefly considered as one of the suggested substitutes for the Ciesarean section which merited careful study, and appeared to be of a promising character, but of which too little was known to justify any positive conclusions with regard to it. The subject naturally attracted con- siderable attention, and several interesting papers have appeared in which its indications, difficulties, and advantages have been carefully considered. Since Thomas's first case was published, several operations have been performed, with results so encouraging that I cannot but believe that the operation has a great future before it, and that it will be the duty of the accoucheurs to resort to it instead of the more hazardous Ciesarean section, unless some special contra-indication exists. Under these circumstances it seems proper no longer to consider it as an addendum to his description of the Ciesarean sec- tion, but to study it more in detail in a separate chapter. History. — The history of the operation is curious and interesting. The earliest suggestion of a procedure of this character seems to have been made by Joerg in the year 1806, who proposed a modi- lied Ciesarean section, without incision of the uterus, by the division of the linea alba, and of the upper part of the vagina, the foetus being extracted through the cervix. This suggestion was never carried into practice, and it is obvious that it misses the one chief advantage of laparo-elytrotomy, the leaving of the peritoneum intact. In 1820 R'tgen proposed, and actually attempted, an operation much resembling Thomas's, in which section of the peritoneum was avoided. He failed, however, to complete it, and was eventually compelled to deliver his patient by the Cesarean section. In 1823 Baudelocque, the younger, independently conceived the same idea, and actually carried it into practice, although without success. Lastly, in 1837, Sir Charles Bell suggested a similar operation, clearly perceiving its advantages. Hence it appears that previous to Thomas's recent work in the matter, the operation was independently invented no less than three times. It fell, however, entirely into oblivion, and was onlv occasionally mentioned in systematic works as a matter of curious obstetric history, no one apparently appreciating the promising char- acter of the procedure. In the year 1870, Dr. T. Gaillard Thomas, of New York, read a paper before the Medical Association of the town of Yonkers on the Hudson Biver entitled "Gastro-elytrotomy, a substitute for the Csesa- "' in which he described the operation as he had per- 526 OBSTETRIC OPERATIONS. formed it three times on the dead subject, and once on a married woman in 1870, with a successful issue as regards the child. It seems beyond doubt that Thomas invented the operation for himself, being ignorant of Bitgen's and Baudelocque's previous attempts, and it is certain, to quote Grarrigues, 1 that to him " belongs the glory of having been the first who performed gastro-elytrotomy so as to extract a living child from a living mother in his first operation, and of having brought both mother and child to complete recovery in his second operation." Since Thomas's first case, the operation has been performed three times by Dr. Skene of Brooklyn, and has found its way across the Atlantic, having been twice performed in England, by Himes in Sheffield, and by Edis in London. Nature of the Operation. — The object of gastro-elytrotomy is to reach the cervix by incision through the lower part of the abdominal wall, and upper part of the vagina, and through it to extract the foetus as may most easily be done. Advantages over the Cesarean Section. — If this procedure is found practicable, the enormous advantages it offers over the Cesarean section are at once apparent in dividing the abdomen, the abdominal wall only is incised, and the peritoneum is left intact. The vagina is divided, "but incision of the uterine parietes, which forms one of the chief risks of the Cesarean section, is entirely avoided. Now there is nothing in either of these procedures alarming in itself, and if farther experience proves that the practical difficulties of the opera- tion do not stand in the Avay of its adoption, Dr. Thomas will have introduced by his able advocacy of the operation, probably the greatest improvement in modern obstetrics. Cases suitable for the Operation. — It may be broadly stated that gastro-elytrotomy is applicable in all cases calling for the Cesarean section, when the mother is alive. In post-mortem extractions of the foetus, the Cesarean section, being the most rapid procedure, would certainly be preferable. Exceptions must be made for certain cases of morbid conditions of the soft parts which render delivery per vias naturales impossible, and in which gastro-elytrotomy could not be performed, where it would be impossible in cases of tumor obstruct- ing the pelvic cavity, also in carcinoma or fibroid of the uterus. When the head is firmly impacted in the pelvic brim, and cannot be dislodged, the operation would be impossible, as the vagina could not be incised. Unlike the Cesarean section, the operation cannot be performed twice on the same patient, at least on the same side, since adhesions left by the former incisions would prevent the sepa- ration of the peritoneum, and division of the vagina. It remains to be seen whether in certain cases of extreme deformity, with pendu- lous abdomen and distorted thighs, the site of the incision might not be so difficult to reach, as to render the necessary manoeuvres impos- sible. Anatomy of the Parts Concerned in the Operation. — It will facilitate 1 New York Med. Journ., Nov. 1878. LAPARO-ELYTROTOMY. 527 the proper comprehension of the operation, and render an avoidance of its possible dangers more easy, if the anatomical relations of the parts concerned are briefly described. Abdominal Incision. — The abdominal incision extends from a point an inch above the anterior superior iliac spine, and is carried, with a slight downward curve, parallel to Poupart's ligament, until it reaches a point one inch and three-quarters above, and to the outside of, the spine of the pubes. Beyond the latter point it must not extend, so as to avoid the risk of wounding the round ligament and the epi- gastric artery. In this incision the skin, the aponeurosis of the external oblique, and the fibres of the internal oblique, and trans- versalis muscles, are divided. The rectus is not implicated. After the muscles are divided, the transversalis fascia is reached. It is fortunately rather dense in this situation, and is separated from the peritoneum by a layer of connective tissue containing fat. Arteries. — The superficial epigastric artery is necessarily divided, but is too small to give any trouble. The internal epigastric is fortu- nately not divided, but is so near the inner end of the incision, that it may accidentally be so. In one of Dr. Skene's operations it was laid bare. Starting from the external iliac, about a quarter of an inch above Poupart's ligament, it runs downwards, forwards, and inwards to the ligament, thence it turns upwards and inwards, in front of the round ligament and inside the internal abdominal ring, behind the posterior layer of the sheaths of the rectus muscle, which it finally enters. The circumflex ilii artery also rises from the ex- ternal iliac a little below the epigastric. It ruus between the perito- ueum and Poupart's ligament until it reaches the crest of the ilium, inside which it runs. It thus lies altogether below the line of the incision, and is not likely to be injured. Peritoneum. — After the transversalis fascia is divided, the perito- neum is reached, and is readily lifted up intact, so as to expose the upper parts of the vagina, through which the foetus is extracted. It is fortunate, as facilitating this manoeuvre, that the peritoneum is much more lax than in the non- pregnant state, and it has been found very easy to lift it out of the way in all the operations hitherto per- formed. Vaginal Incisions. — The division of the vagina is the part of the operation likely to give rise to most trouble "and risk. It is to be noted, that in cases of pelvic contraction calling for this operation, the uterus, with its contents, will be abnormally high and altogether above the pelvic brim ; the vagina is, therefore, necessarily elongated and brought more readily within reach. It is enlarged in its upper part during pregnane}-, and thrown into folds ready for dilatation during the passage of the child. It is loosely surrounded by another tissue, and is composed of muscular fibres, easily separable, and an internal mucous layer. Its vascular arrangements are very complex, and the risk of hemorrhage is. one of the prominent difficulties of the operation. In Baudelocque's attempt, in which the vagina was cut instead of torn, the loss of blood was so great as to lead to a discontinuance of 528 OBSTETRIC OPERATIONS. the operation. The arteries are numerous, consisting of branches from the hypogastric, inferior vesical, internal pudic, and haemor- rhoidal arteries. The veins form a network surrounding the whole canal, but are largest at its extremities, so that it is desirable to open the vagina as low down as possible. Relations of the Vagina. — Behind the vagina lies the pouch of peritoneum known as Douglas's space, and below that the rectum. In front of it lies the bladder, and the risk of injuring that viscus, or the ureter entering it, constitutes another of the dangers of the operation. The relations of these parts have been specialty studied by Garrigues, 1 with the view of facilitating the safe performance of the operation, and I quote his description. " The anterior superior surface of the vagina is, in its upper part, bound by loose connective tissue to the bladder on a surface that has the shape of a heart. In the lower or anterior part, the boundary line of this surface runs parallel to, and a little outside of the trigo- nam vesicale. In the upper part it follows the outline of the vagina, from which it passes over to the cervix. The distance from the internal opening of the urethra to the neck of the womb is one inch and a quarter (3.2 centimetres). The bladder extends five-eighths of an inch (1.5 centimetres) upon the cervix. It is very liable to be reached by the vaginal rent, if the latter is made too high up or too horizontal. The lower part of the antero-superior wall carries in the middle line the urethra. In the uppermost part, a little outside of, and behind the bladder, lies the ureter. In order to avoid the ureter and the bladder, the incision of the vagina should be made nearly an inch and a half (3.8 centimetres) below the uterus, and in a direction parallel to the ureter and the boundary line between the bladder and the vagina." The Operation. — The operation has hitherto been performed on the right side only. In consequence of the position of the rectum on the left, it seems doubtful if the difficulties of performing it on that side would not render the operation impossible. This point can only be cleared up by experience, and, in the mean time, the right side should certainly be selected. For the proper performance of the operation four assistants are necessary, besides one who administers the anaes- thetic. The patient is placed on her back on the operating table, with pelvis raised, and in the same position for ovariotomy. In con- sequence of access of air per vaginam strict antiseptic precautions cannot be adopted. Before commencing the operation the cervix is dilated as much as possible by Barnes's bags, assisted, if necessary, by digital dilatation. The operator stands on the right side of the patient, while an assistant, standing on her left, lays his hands on the uterus and draws it upwards and to the left, so as to put the skin on the stretch. The incision is commenced at a point one inch above the anterior superior spine of the ilium, and is carried inwards, in a slightly curved direc- tion, until it reaches a point one and three-quarter inch above and i Loc. cit., p. 479. LAPARO-ELYTROTOMY. 529 outside the spine of the pubes. The skin and muscular and aponeu- rotic tissues are carefully divided, layer by layer, any arterial branches being secured as they are severed, until the trans versalis fascia is reached. This is raised by a fine tenaculum, and an aperture is made in it, through which a director is introduced, and on this the fascia is divided in the whole length of the superficial incision. The opera- tor now separates the peritoneum from the transversalis and iliac fascia with his fingers, and an assistant, placed on his left, elevates it. as well as the contained intestines, by means of a fine warmed napkin and keeps it well out of the way during the rest of the opera- tion. A third assistant now introduces a silver catheter into the bladder, and holds it in the position of the boundary line between it and the vagina, and below the uterus. A blunt wooden instrument like the obturator of a speculum is introduced into the vagina, which is pushed up by it above the ilio- pectineal line. On this an incision is made by Paquelin's thermo- cautery heated to a red heat only, as far below the uterus as possible, and parallel to the ilio-pectineal line and the catheter felt in the bladder. When the vagina has been burnt through, the index fingers of both hands are pushed through the incision, and the vagina torn through as far forward as is deemed safe by the guide of the catheter in the bladder, and as far backward as possible. When this has been done the uterus is depressed to the left, and the cervix lifted into the incision by the fingers, and the membranes are ruptured. Through the cervix thus elevated the child is extracted, according to the pre- sentation, either by simple traction, by the forceps, or by turning. Before concluding the operation the bladder should be injected with milk, to make sure that it has not been wounded. Should it be so, the laceration may be at once united by carbolized gut. The prin- cipal risk at this stage is hemorrhage from the vaginal vessels, which, however, fortunately did not give rise to much trouble in any of the recent operations. If it occurs it must be dealt with as best we can, either by ligature, by the actual cautery, or by thoroughly plugging the vaginal wound with cotton-wool both through the incision and per vagi nam. If the latter is not necessary the wound should be cleaned by injecting a warm solution of weak carbolized water (2 per cent.), its edges united by interrupted sutures, and dressed as is deemed best. The subsequent treatment must be conducted on general sur- gical principles, and will much resemble that necessary after other severe abdominal operations, such as ovariotomy- The vagina should be gently syringed two or three times daily with a weak antiseptic lotion. The diet should be mild and nutritious, chiefly consisting of milk, beef- tea, and the like. Pain, pyrexia, etc., must be treated as they arise. [I have little to add in reference to this scientific, but difficult operation, which must be necessarily limited in its adoption, because of the skill and number of assistants which it requires, and the many cases in which it is inadmissible. In 45 out of the 112 Cesarean cases in my record, it could not have been performed. Seven opera- tions in nine years is very slow progress, compared with the Porro 530 OBSTETRIC OPERATIONS. method, as shown by the reports of the latter from the Continent, where it is now being performed on an average of about once a month, and with a degree of success more satisfactory than is shown by the record of the Thomas method. The anatomical skill demanded, together with its other requirements, will necessarily confine Laparo- elytrotomy to our large cities, and limit the great future which has been anticipated for it. It has by no means as yet had a full trial. — Ed.] CHAPTER VIII. THE TRANSFUSION OF BLOOD. The transfusion of blood in desperate and apparently hopeless cases of hemorrhage, offers a possible means of rescuing the patient which merits careful consideration. It has a^ain and asrain attracted the attention of the profession, but has never become popularized in obstetric practice. The reason of this is not so much the inherent defects of the operation itself — for quite a sufficient number of suc- cessful cases are recorded to make it certain that it is occasionally a most valuable remedy — but the fact that the operation has been con- sidered a delicate and difficult one, and that it has been deemed necessary to employ complicated and expensive apparatus, which is never at hand when a sudden emergency arises. Whatever may be the difference of opinion about the value of transfusion, I think it must be admitted that it is of the utmost consequence to simplify the process in every possible way, and it is above all things neces- sary to show that the steps of the operation are such as can be readily performed by any ordinarily-qualified practitioner, and that the ap- paratus is so simple and portable as to make it easy for any obstetri- cian to have it at hand. There are comparatively few who would consider it worth while to carry about with them, in ordinary every- day work, cumbrous and expensive instruments which may never be required in a life-long practice ; and hence it is not unlikely that, in many cases in which transfusion might have proved useful, the op- portunity of using it has been allowed to slip. Of late years the operation has attracted much attention, the method of performing it has been greatly simplified, and I think it will be easy to prove that all the essential" apparatus may be purchased for a few shillings, and in so portable a form as to take up little or no room ; so that it may be always carried in the obstetric bag ready for any possible emergency. The history of the operation is of considerable interest. In Villari's " Life of Savonarola" it is said to have been employed in the case of Pope Innocent VIII., in the year 1492, but I am not aware on what THE TRANSFUSION OF BLOOD. 531 authority the statement is made. The first serious proposals for its performance do not seem to have been made until the latter half of the seventeenth century. It was first actually performed in France, by Denis, of Montpellier, although Lower, of Oxford, had previously made experiments on animals which satisfied him that it might be undertaken with success. In November, 1(307, some months after Denis's case, he made a public experiment at Arundel House, in which twelve ounces of sheep's blood Ave re injected into the veins of a healthy man, who is stated to have been very well after the opera- tion, which must, therefore, have proved successful. These nearly simultaneous cases gave rise to a controversy as to priority of inven- tion, which was long carried on with much bitterness. The idea of resorting to transfusion after severe hemorrhage does not seem to have been then entertained. It was recommended as a means of treatment in various diseased states, or with the extrava- gant hope of imparting new life and vigor to the old and decrepit. The blood of the lower animals only Avas used ; and, under these cir- cumstances, it is not surprising that the operation, although practised on several occasions, Avas never established as it might ha\^e been had its indications been better understood. From that time it fell almost entirely into oblivion, although ex- periments and suggestions as to its applicability Avero occasionally made, especially by Dr. Harwood, Professor of Anatomy at Cam- bridge, avIio published a thesis on the subject in the year 1785. He, however, never carried his suggestions into practice, and, like his predecessors, only proposed to employ blood taken from the loAver animals. In the year 182-1 Dr. Blundell published his Avcll-knoAvn Avork, entitled " Kesearches, Physiological and Pathological," which detailed a large number of experiments ; and to that distinguished physician belongs the undoubted merit of haAdng brought the subject prominently before the profession, and of pointing out the cases in Avhicli the operation might be performed with hopes of success. Since the publication of this work, transfusion has been regarded as a legitimate operation under special circumstances ; but, although it has frequently been performed with success, and in spite of many in- teresting monographs on the subject, it has never become so estab- lished, as a general resource in suitable cases, as its advantages would seem to Avarrant. Within the last feAV years more attention has been paid to the subject, and the writing of Panum, Martin, and dc Belina, abroad, and of Hio-o-mson, McDonnell, Hicks, and Avelino; at home, OO 7 7 7 O _ 7 amongst many others, have thrown much light on many points con- nected with the operation, and it is to be hoped that the committee appointed by the Obstetrical Society, in their forthcoming report, may still more increase our knoAA T leclge. N'ature and Object of the Operation. — Transfusion is practically only employed in cases of profuse hemorrhage connected with labor, al- though it has been suggested as possibly of A^alue in certain other puerperal conditions, such as eclampsia, or puerperal fever. Theo- retically it may be expected to be useful in such diseases ; but, inas- much as little or nothing is knoAvn of its practical effects in these 532 OBSTETRIC OPERATIONS. diseased states, it is only possible here to discuss its use in cases of excessive hemorrhage. Its action is probably twofold. 1st, the actual restitution of blood which has been lost. 2d, the supply of a sufficient quantity of blood to stimulate the heart to contraction, and thus to enable the circulation to be carried on until fresh blood is formed. The influence of transfusion as a means of restoring lost blood must be trivial, since the quantity required to produce an effect is generally very small indeed, and never sufficient to counterbalance that which has been lost.. Its stimulant action is no doubt of far more importance ; and if the operation be performed before the vital energies are entirely exhausted, the effect is often most marked. Use of Blood taken from the Lower Animals. — In the earliest opera- tions the blood used was always that of the lower animals, generally of the sheep. Dr. Blundell believed that such blood could not be employed with success. Recent cases, such as those published by Keene, who used lamb's blood in 12 cases. 1 have conclusively proved this idea to be erroneous. Brown-Sequard has shown that Blundell's experiments with animal blood failed, partty because he used too large a quantity and injected too quickly, and partly because he used blood too rich in carbonic acid and too poor in oxygen. He has shown that the success of the operation must depend to a great ex- tent on these points, and that blood, containing sufficient carbonic acid to be black, proves directly poisonous, unless it is injected in very small quantity, and with great slowness. Although, then, it is certain that the blood of some of the lower animals, especially of those in which the corpuscles are of less size than in man, as in sheep, can be employed with safety, still the operation, of late 3-ears, has been almost always performed with human blood alone, and, for many obvious reasons, is always likely to be so. Difficulties from Coagulation of Fibrine. — The great practical diffi- culty in transfusion has always been the coagulation of the blood very shortly after it has been removed from the body. When fresh drawn blood is exposed to the atmosphere, the fibrine commences to solidify rapidly, generally in from three to four minutes, sometimes much sooner. It is obvious that the moment fibrillation has com- menced the blood is, ipso facto, unfitted for transfusion, not only be- cause it can be no longer passed readily through the injecting appa- ratus, but because of the great danger of propelling small masses of fibrine into the circulation, and thus causing embolism. Hence, if no attempt be made to prevent this difficulty, it is essential, no matter what apparatus is used, to hurry on the operation so as to inject be- fore fibrillation has begun. This is a fatal objection, for there is no operation in the whole range of surgery in which calmness and de- liberation are so essential, the more so as the surroundings of the patient in these unfortunate cases are such as to tax the presence of mind and coolness of the practitioner and his assistants to the utmost. Methods of Obviating Coagulation. — All the recent improvements 1 London Med. Record, Dec. 31, 1873. THE TRANSFUSION OF BLOOD. 538 have had for their object the avoidance of coagulation, and practi- cally this has been- effected in one of three ways. 1st, by immediate transfusion from arm to arm, without allowing the blood to be ex- posed to the atmosphere, according to the methods proposed by Aveling and Roussel. 2d, by adding to the blood certain chemical reagents which have the property of preventing coagulation. 3d, removal of the fibrine entirely, by promoting its coagulation and straining the blood, so that the liquor sanguinis and blood corpuscle alone are injected. Inasmuch as the success of the operation altogether depends on the method adopted, it will be well, before going further, to consider briefly the advantages and disadvantages of each of these plans. Immediate Transfusion. — 1. The method of immediate transfusion has been brought prominently before the profession by Dr. Aveling, who has invented an ingenious apparatus for performing it. The apparatus consists essentially of a miniature Higginson's syringe, without valves, and with a small silver canula at either end. One canula is inserted into the vein of the person supplying blood, the other into a vein of the patient, and by a peculiar manipulation of the syringe, subsequently to be described, the blood is carried from one vein into the other. It must be admitted that, if there were no practical difficulties, this instrument would be admirable, and it is therefore not surprising that it should have met with so much favor from the profession. I cannot but think, however, that the opera- tion is not so simple as it at first sight appears, and that therefore it wants one of the essential elements required in any procedure for performing transfusion. One of my objections is, that it is by no means easy to work the apparatus without considerable practice. Of this I have satisfied myself by asking members of my class to work it after reading the printed directions, and finding that they are not always able to do so at once. Of course it may be said that it is easy to acquire the necessary manipulative skill; but. when the necessity for transfusion arises, there is no time left for practising with the instrument, and it is essential that an apparatus, to be uni- versally applicable, should be capable of being used immediately, and without previous experience. Other objections are the necessity of several assistants, the uncertainty of there being a sufficient circu- lation of blood in the veins-of the donor to afford a constant supply, and the possibility of the whole apparatus being disturbed by rest- lessness or jactitation on the part of the patient. For these reasons, it seems to me that this plan of immediate transfusion is not so simple, nor so generally applicable, as defibrination. Still, it is im- possible not to recognize its merits, and it is certainly well worthy of further study and investigation. Another method of immediate transfusion is that recommended by E-oussel, 1 whose apparatus has recently attracted considerable attention. It possesses many undoubted advantages, and is, beyond doubt, a valuable addition to our means of performing the opera- 1 Obstetrical Transactions, vol. xviii. 534 OBSTETRIC OPERATIONS. tion. It lias, however, the great disadvantage of being costly and complicated, and hence I do not believe that it is likely to come into general use. Addition of Chemical Agents to Prevent Coagulation. — 2. The second plan for obviating the bad effects of clotting is the addition of some substance to the blood which shall prevent coagulation. It is well known that several salts have this property, and the experiments made in the case of cholera patients prove that solutions of some of them may be injected into the venous system without injury. This method has been specially advocated by Dr. Braxton Hicks, who uses a solution of three ounces of fresh phosphate of soda in a pint of water, about six ounces of which are added to the quantity of blood to be injected. He has narrated 4 cases 1 in which this plan was adopted successfully, so far as the prevention of coagulation was concerned. It certainly enables the operation to be performed with deliberation and care, but it is somewhat complicated; and it may often happen that the necessary chemicals are not at hand. A further objection is the bulk of fluid which must be injected, and there is reason to believe that this has, in some cases, seriously embarrassed the heart's action, and interfered with the success of the operation. In many of the successful cases of transfusion the amount of blood injected has been very small, not more than two ounces. Dr. Richardson proposes 'to prevent coagulation by the addition of liquor ammonite to the blood, in the proportion of two minims, diluted with twenty minims of water, to each ounce of blood. Defibrination of the Blood. — 3. The last method, and the one which, on the whole, I believe to be the simplest and most effectual, is defi- brination. It has been chiefly practised in this country by Dr. McDonnell, of Dublin, who has published several very interesting cases in which he employed it, and abroad by Martin, of Berlin ; de Belina, of Paris [and Thomas G. Morton, of Philadelphia. 2 Dr. Morton has transfused defibrinated blood fourteen times in twelve subjects; in one of them with an interval of a month between the two operations. The cases were exhaustion after hemorrhage, pro- found anaemia, exhaustion at close of typhoid fever, purpura hemor- rhagica, and opium poisoning. — Ed.]. The process of removing the fibrine is simple in the extreme, and occupies a few minutes only. Another advantage is that the blood to be transfused may be pre- pared quietly in an adjoining apartment, so that the operation may be performed with the greatest calmness and deliberation, and the donor is spared the excitement and distress which the sight of the apparently moribund patient is apt to cause, and which, as Dr. Hicks has truly pointed out, may interfere with the free flow of blood. The researches of Panum, Brown-Sequard, and others, have proved that the blood corpuscles are the true vivifying element, and that defibrinated blood acts as well, in every respect, as that containing 1 Guy's Hosp. Reports, vol. xiv. [2 See Am. Jour. Med. Sci., July, 1874, p. 110, Article VII., by Dr. Thomas G. Morton ; with reports of cases and designs of apparatus employed. — Ed.] THE TRANSFUSION OF BLOOD. 535 fibrine. It has been proved that the fibrine is reproduced within a short time, 1 and the whole tendency of modern research is to regard it, not as an essential element of the blood, but as an excrementitious product, resulting from the degradation of tissue, which may, there- fore, be advantageously removed. Another advantage derived from defibrination is, that the corpuscles are freely exposed to the atmo- sphere, oxygen is taken up, and carbonic acid given oft', and the dangers which Brown-Sequard has shown to arise from the use of blood containing too much carbonic acid are thereby avoided. There can be, therefore, no physiological objection to the removal of the fibrine, which, moreover, takes away all practical difficulty from the operation. The straining to which the defibrinated blood is sub- jected entirely prevents the possibility of even the most minute particle of fibrine being contained in the injected fluid; the risk from embolism is, therefore, less than in any of the other processes already referred to. My own experience of this plan is limited to 3 cases, but in 2 it answered so well that I can conceive no reasonable objection to it. I should be inclined to say that transfusion, thus performed, is amongst the simplest of surgical operations — an opinion which the experience of McDonnell and others fully confirms. Transfusion of Milk. — Recently the intra- venous injection of freshly drawn warm milk has been recommended as a substitute for blood, chiefly in America. It was first used by Dr. Hodder of Toronto, but has been introduced and strongly advocated by Thomas of New York, who has used it twice after ovariotomy. Brown -Se'quard in experi- menting on the lower animals found that it answered as well as either fresh or defibrinated blood, and about half an hour after the injection no trace of the milk-corpuscles could be found in the blood. It pos- sesses the advantage of being more easily obtained, and more readily manipulated than blood, but future researches are required before its perfect efficacy can be considered established. About ,?viij of milk are sufficient for ordinary cases, and it should be fresh drawn, warm, and free from acidity. [In the last edition, I introduced a long article upon the "intra- venous injection of milk," in place of which the author has prepared the above. As he gives no account of the process, I reproduce the statement of Dr. Charles T. Hunter, of the University of Pennsylvania, who has performed the operation ten times on four subjects. The milk is drawn into a double vessel, with warm water in the interspace, and the temperature regulated to about 99° Fahr. The fluid is strained through fine- wire-gauze, to exclude any foreign matters that might be injurious. Attached to the funnel and tube Dr. Hunter has a perforating canula with a small stopcock to cut off the flow of milk. After the vein is fully exposed, the milk is run through the tube, the cock closed, which keeps the canula full by capillary attraction, and the vessel perforated by the cutter on the end of the canula; the cock is then opened, funnel elevated, and milk carried in by its own weight. — Ed.] 1 Paimm, Virchow's Arch., vol. xxvii. 536 OBSTETRIC OPERATIONS. Statistical Results. — The number of cases of transfusion are perhaps not sufficient to admit of completely reliable conclusions. It is cer- tain, however, that transfusion has often been the means of rescuing the patient when apparently at the point of death, and after all other means of treatment had failed. Professor Martin records 57 cases, in 43 of which transfusion was completely successful, and in 7 tem- porarily so ; while in the remaining 7 no reaction took place. Dr. Higginson, of Liverpool, has had 15 cases, 10 of which were success- ful. Figures such as these are encouraging, and they are sufficient to prove that the operation is one which at least offers a fair hope of success, and which no obstetrician would be justified in neglecting, when the patient is sinking from the exhaustion of profuse hemor- rhage. It is to be hoped also that further experience may prove it to be of value in other cases, in which its use has been suggested, but not, as yet, put to the test of experiment. Possible Dangers of the Operation. — The possible risks of the opera- tion would seem to be the danger of injecting minute particles of fi brine which form emboli, of bubbles of air, or of overwhelming the action of the heart by injecting too rapidly, or in too great quantity. These may be, to a great extent, prevented by careful attention to the proper performance of the operation, and it does not clearly appear, from the recorded cases, they have ever proved fatal. We must also bear in mind that transfusion is seldom or ever likely to be attempted until the patient is in a state which would otherwise almost certainly preclude the hope of recovery, and in which, there- fore, much more hazardous proceedings would be fully justified. Cases Suitable for Transfusion. — The cases suitable for transfusion are those in which the patient is reduced to an extreme state of exhaustion from hemorrhage during or after labor or miscarriage, whether by the repeated losses of placenta prasvia, or the more sudden and profuse flooding of post-partum hemorrhage. The opera- tion will not be contemplated until other and simpler means have been tried and failed, or until the symptoms indicate that life is on the verge of extinction. If the patient should be deadly pale and cold, with no pulse at the wrist, or one that is scarcely perceptible ; if she be unable to swallow, or vomits incessantly ; if she lie in an unconscious state; if jactitation, or convulsions, or repeated fainting should occur; if the respiration be laborious, or very rapid and sighing; if the pupil do not act under the influence of light, it is evident that she is in a condition of extreme danger, and it is, under such circumstances, that transfusion, performed sufficiently soon, offers a fair prospect of success. It does not necessarily follow be- cause one or other of these symptoms is present, that there is no chance of recovery under ordinary treatment, and indeed it is within the experience of all, that patients have rallied under apparently the most hopeless conditions. But when several of them occur together, the prospect of recovery is much diminished, and transfusion would then be fully justified, especially as there is no reason to think that a fatal result has ever been directly traced to its employment. In- deed, like most other obstetric operations, it is more likely to be THE TRANSFUSION OF BLOOD 537 postponed until too late to be of service, than to be employed too earlv ; and in some of the cases reported as unsuccessful, it was not performed until respiration had ceased, and death had actually taken place. It has been sometimes said that transfusion can never be employed if the uterus be not firmly contracted, so as to prevent the injected blood again escaping through the uterine sinuses. The cases in which this is likely to occur are few ; and if one were met with, the escape of blood could be prevented by the injection into the uterus of the perchloride of iron. Description of the Operation. — In describing the operation I shall limit myself to an account of Aveling's method of immediate trans- fusion, and to that of injecting defibrinated blood. I consider myself justified in omitting any account of the numerous apparatuses which have been invented for the purpose of injecting pure blood, since I believe the practical difficulties are too great ever to render this form of operation serviceable. The great objection to most of the instru- ments used is their cost and complexity : and as long as any special apparatus is considered essential, the full benefits to be derived from transfusion are not likely to be realized. The necessity for employ- ing it arises suddenly ; it may be in a locality in which it is impossi- ble to procure a special instrument ; and it would be well if it were understood that transfusion may be safely and effectually performed by the simplest means. In many of the successful cases an ordinary syringe was used ; in one, in the absence of other instruments, a child's toy syringe was employed. I have myself performed it with a simple syringe purchased at the nearest chemist's shop, when a special transfusion apparatus failed to act satisfactorily. Method of performing Immediate Transfusion. — In immediate trans- fusion (Fig. 181), the donor is seated close to the patient, and the Fig. 181. < D Method of Transfusion by Aveling's Apparatus. veins in the arms of each having been opened, the silver canula at either end of the instrument in introduced into them (a b). The tube between the bulb and the patient is now pinched (u), so as form a vacuum, and the bulb becomes filled with blood from the donor. 35 538 OBSTETRIC OPERATIONS. The finger is now removed so as to compress the distal tube (d'), and the bulb being compressed (c), its contents are injected into the patient's vein. The bulb is calculated to hold about two drachms, so that the amount injected can be estimated by the number of times it is emptied. The risk of injecting air is prevented by filling the syringe with water, which is injected before the blood. Injection of Defibrinated Blood.— For injecting defibrinated blood various contrivances have been used. McDonnell's instrument is a simple cylinder with a nozzle attached, from which the blood is pro- pelled by gravitation. When the propulsive power is insufficient, increased pressure is applied by breathing forcibly into the open end of the receiver. De Belina's instrument is on the same principle, only atmospheric pressure is supplied by a contrivance similar to Kichardson's spray -producer, attached to one end. The idea is simple, but there is some doubt of a gravitation instrument being sufficiently powerful, and it certainly failed in my hands. I have had valves applied to Aveling's instrument, so that it works by compression of the bulb, like an ordinary Higginson's syringe. This, with a single silver canula at one end, for introduction into the vein, forms a per- fect and inexpensive transfusion apparatus, taking up scarcely any space. If it be not at hand, any small syringe, with a tolerably fine nozzle, may be used. Mode of Preparing the Blood. — The first step of the operation is defibrination of the blood, which should, if possible, be prepared in an apartment adjoining the patient's. The blood should be taken from the arm of a strong and healthy man. The quality cannot be unimportant, and, in some recorded cases, the failure of the operation has been attributed to the fact of the donor having been a weakly female. The supply from a woman might also prove insufficient ; and, although it has been shown that blood from two or more per- sons may be used with safety, yet such a change necessarily causes delay, and should, if possible, be avoided. A vein having been opened, eight or ten ounces of blood are withdrawn, and received into some perfectly clean vessel, such as a dessert finger-glass. As it flows it should be briskly agitated with a clear silver fork, or a glass rod, and very shortly, strings of fibrine begin to form. It is now strained through a piece of fine muslin, previously dipped in hot water, into* a second vessel which is floating in water at a tempera- ture of about 105°. By this straining the fibrine and air-bubbles resulting from the agitation are removed, and, if there be no exces- sive hurry, it might be well to repeat the straining a second time. If the vessel be kept floating in warm water, the blood is prevented from getting cool, and we can now proceed to prepare the arm of the patient for injection. Mode of Exposing the Veins selected for Transfusion. — This is the most delicate and difficult part of the operation, since the veins are generally collapsed and empty, and by no means easy to find. The best way of exposing them is that practised by McDonnell, who pinches up a fold of the skin at the bend of the elbow, and transfixes it with a fine tenotomy knife or scalpel, so making a gaping wound THE TRANSFUSION OF BLOOD. 589 in the integument, at the bottom of which they are seen lying. A probe should now be passed underneath the vein selected for opening, so as to avoid the chance of its being lost at any subsequent stage of the operation. This is a point of some importance, and from the neglect of this precaution I have been obliged to open another vein than that originally fixed on. A small portion of the vein being raised with the forceps, a nick is made into it for the passage of the can u la. Injection of the Blood. — The prepared blood is now brought to the bedside, and, the apparatus having been previously filled with blood to avoid the risk of injecting any bubbles of air, the canula is in- serted into the opening made in the vein, and transfusion commenced. It should be constantly borne in mind that this part of the operation should be conducted with the greatest caution, the blood introduced very slowly, and the effect on the patient carefully watched. The injection may be proceeded with until some perceptible effect is pro- duced, which will generally be a return of the pulsation, first at the heart, and subsequently at the wrist, an increase in the temperature of the body, greater depth and frequency of the respirations, and a general appearance of returning animation about the countenance. Sometimes the arms have been thrown" about, or spasmodic twitch- ings of the face have taken place, The quantity of blood required to produce these effects varies greatly, .but in the majority of cases has been very small. Occasionally 2 ounces have proved sufficient, and the average may be taken as ranging between 4 and 6 : although in a few cases between 10 and 20 have been used. The practical rule is to proceed very slowly with the injection until some per- ceptible result is observed. Should embarrassed or frequent respira- tion supervene, we may^suspect that we have been injecting either too great a quantity of blood, or with too much force and rapidity, and the operation should at once be suspended, and not resumed until the suspicious symptoms have passed away. It may happen that the effects of the transfusion have been highly satisfactory, but that in the course of time there is evidence of returning syncope. This may possibly be prevented by the administration of stimulants ; but if these fail there is ncreason why a fresh supply of blood should not again be injected, but this should be done before the effects of the first transfusion have entirely passed away. Sicondary Effects of Transfusion. — The subsequent effects in suc- cessful cases of transfusion merit careful study. In some few cases death is said to have happened within a few weeks, with symptoms resembling pyaemia. Too little is known on this point, however, to justify any positive conclusions with regard to it. PART Y. THE PUERPERAL STATE. CHAPTER I. THE PUERPEKAL STATE AND ITS MANAGEMENT. Importance of Studying the Puerperal State. — The key to the man- agement of women after labor, and to the proper understanding of the many important diseases which may then occur, is to be found in a study of the phenomena following delivery, and of the changes going on in the mother's system during the puerperal period. No doubt natural labor is a physiological and healthy function, and during recovery from its effects disease should not occur. It must not be forgotten, however, that none of our patients are under phy- siologically healthy conditions. The surroundings of the lying-in woman, the effects of civilization, of errors of diet, of defective clean- liness, of exposure to contagion, and of a hundred other conditions, which it is impossible to appreciate, have most important influences on the results of childbirth. Hence it follows that labor, even under the most favorable conditions, is attended with considerable risk. The Mortality of Childbirth. — It is not easy to say with accuracy what is the precise mortality accompanying childbirth in ordinary domestic practice, since the returns derived from the reports of the Registrar-General, or from private sources, are manifestly open to serious error. The nearest approach to a reliable estimate is that made by Dr. Matthews Duncan, 1 who calculates from figures derived from various sources, that not fewer than 1 out of every 120 women, delivered at or near the full time, dies within four weeks of child- birth. This indicates a mortality far above that which has been generally believed to accompany child-bearing under favorable cir- cumstances. It, however, closely approximates to a similar estimate made by McClintock, 2 who calculates the mortality in England and "Wales as 1 in 126 ; and in the upper and middle classes alone, where the conditions may naturally be supposed to be more favorable, at 1 in 146 ; more recently he has come to the conclusion from his own increased experience, and the published results of the practice of others, that 1 in 100 would more correctly represent the rate of puer- peral mortality. 3 In these calculations there are some obvious sources 1 The " Mortality of Childbed," Edin. Med. Journ., Nov. 1869. 2 Dublin Quarterly Journ., Aug. 1869. 3 Brit. Med. Journ., Aug. 10, 1878. (540) THE PUE11PERAL STATE AND ITS MANAGEMENT. 541 of error, since they include deaths from all causes within four weeks of delivery, some of which must have been independent of the puer- peral state. But it is not the deaths alone which should be considered. All practitioners know how large a number of their patients suffer from morbid states which may be directly traced to the effects of child- bearing. It is impossible to arrive at any statistical conclusion on this point, but, it must have a very sensible and important influence on the health of child-bearing women. Alterations in the Blood after Delivery.— -The state of the blood during pregnancy, already referred to, has an important bearing on the puerperal state. There is hyperinosis, which is largely increased by the changes going on immediately after the birth of the child : for then the large supply of blood, which has been going to the uterus, is suddenly stopped, and the system must also get rid of a quantity of effete matter thrown into the circulation, in consequence of the degenerative changes occurring in the muscular fibres of the uterus. Hence all the depurative channels, by which this can be eliminated, are called on to act with great activity. If, in addition, the peculiar condition of the generative tract be borne in mind — viz., the large open vessels on its inner surface — the partially bared inner surface of the uteras, and the channels for absorption existing in consequence of slight lacerations in the cervix or vagina — it is not a matter of surprise that septic diseases should be so common. Condition after Delivery. — It will be well to consider successively the various changes going on after delivery, and then we shall be in a better position for studying the rational management of the puer- peral state. Nervous Shock. — Some degree of nervous shock or exhaustion is observable after most labors. In many cases it is entirely absent ; in others it is well marked. Its amount is in proportion to the severity of the labor, and the susceptibility of the patient ; and it is therefore, most likely to be excessive in women who have suffered greatly from pain, who have undergone much muscular exertion, or who have been weakened from undue loss of blood. It is evidenced by a feeling of exhaustion and fatigue, and not uncommonly there is some shivering, which soon passes off, and is generally followed by refreshing sleep. The extreme nervous susceptibility continues for a considerable time after delivery, and indicates the necessity of keeping the lying-in patient as free from all sources of excitement as possible. Fall of the Pulse. — Immediately after delivery the pulse falls, and the importance of this, as indicating a favorable state of the patient, has already been alluded to. The condition of the pulse has been carefulty studied by Blot, 1 who has shown that this diminution, Avhich he believes to be connected with an increased tension in the arteries, due to the sudden arrest of the uterine circulation, continues, in a large proportion of cases, for a considerable number of days 1 Arch. Gen. de Med., 1864. 542 THE PUERPERAL STATE. after delivery; and, as a matter of clinical import, as long as it does, the patient may be considered to be in a favorable state. In many instances the slowness of the pulse is remarkable, often sinking to 50 or even 40 beats per minute. Any increase above the normal rate, especially if at all continuous, should always be carefully noted, and looked on with suspicion. In connection with this subject, how- ever, it must be remembered that in puerperal women the most trivial circumstances may cause a sudden rise of the pulse. This must be familiar to every practical obstetrician, who has constant opportunities of observing this effect after any transient excitement or fatigue. In lying-in hospitals it has generally been observed that the occurrence of any particularly bad case will send up the pulse of all the other patients who may have heard of it. Temperature in the Puerperal State.- — The temperature in the lying- in state affords much valuable information. Daring, and for a short time after labor, there is a slight elevation. It soon falls to, or even somewhat below, the normal level. Squire found that the fall oc- curred within twenty-four hours, sometimes within twelve hours, after the termination of labor. 1 For a few days there is often a slight increase of temperature, which is probably caused by the rapid oxidation of tissue in connection with the involution of the uterus. In about forty-eight hours there is a rise connected with the estab- lishment . of lactation, amounting to one or two degrees over the normal level ; but this again subsides as soon as the milk is freely secreted. Crecle has also shown 2 that rapid, but transient, rises of temperature may occur at any period, connected with trivial causes, such as constipation, errors of diet, or mental disturbances. But, if there be any rise of temperature which is at all continuous, especially to over 100° Fahr., and associated with rapidity of the pulse, there is reason to fear the existence of some complication. The Secretions and Excretions.- — The various secretions and excre- tions are carried on with increased activit}^ after labor. The skin especially acts freely, the patient often sweating profusely. There is also an abundant secretion of urine, but not uncommonly a diffi- culty of voiding it, either on account of temporary paralysis of the neck of the bladder, resulting from the pressure to which it has been subjected, or from swelling and occlusion of the urethra. For the same reason the rectum is sluggish for a time, and constipation is not infrequent. The appetite is generally indifferent, and the patient is often thirsty. Secretion of Milk. — Generally in about forty -eight hours the secre- tion of milk becomes established, and this is occasionally accompanied by a certain amount of constitutional irritation. The breasts often become turgid, hot, and painful. There may, or may not, be some general disturbance, quickening of pulse, elevation of temperature, possibly slight shivering, and a general sense of oppression, which are quickly relieved as the milk is formed, and the breasts emptied 1 "Puerperal Temperatures," Obstetrical Transactions, vol. ix. 2 Monat. f. Geburt, Dec. 1868. THE PUERPERAL STATE AND ITS MANAGEMENT. 543 by suckling. Squire says that the most constant phenomenon con- nected with the temperature is a slight elevation as the milk is secreted, rapidly falling when lactation is established. Barker noted elevation, either of temperature or pulse, in only 4 out of 52 cases which were carefully watched. There can be little doubt that the importance of the so-called ''milk fever" has been immensely ex- aggerated, and its existence, as a normal accompaniment of the puerperal state, is more than doubtful. It is certain, however, that, in a small minority of cases, there is an appreciable amount of dis- turbance about the time that the milk is formed. Out of 423 cases Macau 1 found that in 114, or about 27 per cent., there was no rise of temperature ; in 226 the temperature did rise to 100° and over, and of these in 32, or a little over 7 per cent., the only ascertainable cause was a painful or distended condition of the breast. Many modem writers, such as Winckel, Grunewaldt, and d'Espine, entirely deny the connection of this disturbance with lactation, and refer it to a slight and transient septicemia. Graily Hewitt remarks that it is most commonly met with when the patient is kept low and on defi- cient diet after delivery, especially when the system is below par from hemorrhage, or any other cause. This observation will, no doubt, account for the comparative rarity of febrile disturbance in connection with lactation in these days, in which the starving of puerperal patients is not considered necessan T . It is certain that anything deserving the name of milk fever is now altogether excep- tional, and such feverishness as exists is generally quite transient. It is also a fact, that it is most apt to occur in delicate and weakly women, especiallv in those who do not, or are unable to, nurse. There does not, however, seem to be any sufficient reason for refer- ring it, even when tolerably well marked, to septicemia. The relief which attends the emptying of the breasts seems sufficient to prove its connection with lactation, and the discomfort which is necessarily associated with the swollen and turgid mammae, is, of itself, quite sufficient to explain it. In the urine of women during lactation an appreciable amount of sugar may readily be detected. The amount varies according to the condition of the breasts. It increases when they are turgid and con- gested, and is, therefore, most abundant in women in whom the breasts are not emptied, as when the child is dead, or when lactation is not attempted. Contraction of the Uterus after Delivery. — Immediately after de- livery the uterus contracts firmly, and can be felt at the lower part of the abdomen as a hard, firm mass, about the size of a cricket ball. After a time it again relaxes somewhat, and alternate relaxations and contractions go on, at intervals, for a considerable time after the expulsion of the placenta. The more complete and permanent the contraction, the greater the safety and comfort of the patient ; for when the organ remains in a state of partial relaxation, coagula are apt to be retained in its cavity, while, for the same reason, air enters 1 Dublin Jonrn. of Med. Science, May, 1878. 544 THE PUERPERAL STATE. more readily into it. Hence decomposition is favored, and the chances of septic absorption are much increased ; while, even when this does not occur, the muscular fibres are excited to contract, and severe after-pains are produced. Subsequent Diminution in the Size of the Uterus. — After the first few days the diminution in the size of the uterus progresses with great rapidity. By about the sixth day it is so much lessened as to project not more than 1J or 2 inches above the pelvic brim, while bv the eleventh day it is no longer to be made out by abdominal palpa- tion. Its increased size is, however, still apparent per vaginam, and, should occasion arise for making an internal examination, the mass of the lower segment of the uterus, with its flabb^v and patulous cervix, can be felt for some weeks after delivery. This may some- times be of practical value in cases in which it is necessary to ascer- tain the fact of recent deliver} 7 -, and, under these circumstances, as pointed out by Simpson, the uterine sound would also enable us to prove that the cavity of the uterus is considerabty elongated. Indeed the normal condition of the uterus and cervix is not regained until six weeks or two months after labor. These. observations are cor- roborated by investigations on the weight of the organ at different periods after labor. Thus Heschl 1 has shown that the uterus, imme- diately after delivery, weighs about 22 to 24 oz. ; within a week, it weighs 19 to 21 oz. ; and at the -end of the second week, 10 to 11 oz. only. At the end of the third week, it weighs 5 to 7 oz. ; but it is not until the end of the second month that it reaches its normal weight. Hence it appears that the most rapid diminution occurs during the second week after delivery. Fatty Transformation of the Muscular Fibres.- — The mode in which this diminution in size is effected is by the transformation of the muscular fibres into molecular fat, which is absorbed into the mater- nal vascular system, which, therefore, becomes loaded with a large amount of effete material. Heschl has shown that the entire mass of the enlarged uterine muscles are removed, and replaced by newly- formed fibres, which commence to be developed about the fourth week after delivery, the change being complete about the end of the second month. Generally speaking, involution goes on without inter- ruption. It is, however, apt to be interfered with by a variety of causes, such as premature exertion, intercurrent disease, and, very probably, by neglect of lactation. Hence the uterus often remains large and bulky, and the foundation for many subsequent uterine ailments is laid. Changes in the Uterine Vessels. — Williams has drawn attention to changes occurring in the vessels of the uterus, some of which seem to be permanent, and may, should further observations corroborate his investigations, prove of value in enabling us to ascertain whether a uterus is nulliparous or the reverse ; a question which may be of medico-legal importance. After pregnancy he found all the vessels enlarged in calibre. The coats of the arteries are thickened and 1 Researches on the Conduct of the Human Uterus after Delivery. THE PUERPERAL STATE AND ITS MANAGEMENT. 545 hypertrophied, and this lie has observed even in the uteri of aged women who have not born children for many years. The venous sinuses, especially at the placental site, have their walls greatly thickened and convoluted, and contain in their centre a small clot of blood (Fig. 182). This thickening attains its greatest dimensions in Fig. 182. Section of a Uterine Sinus from the Placental Site nine weeks after Delivery. (After Williams.) the third month after gestation, but traces of it may be detected as late as ten or twelve weeks after labor. Changes in the Uterine Mucous Membrane. — The changes going on in the lining membrane of the uterus immediately after delivery are of great importance in leading to a knowledge of the puerperal state, and have already been discussed when describing the decidua (p. 96). Its cavity is covered with a reddish-gray film, formed of blood and fibrine. The open mouths of the uterine sinuses are still visible, more especially over the site of the placenta, and thrombi may be seen projecting from them. The placental site can be distinctly made out, in the form of an irregularly oval patch, where the lining mem- brane is thicker than elsewhere. Contraction of the Vagina, etc. — The vagina soon contracts, and, by the time the puerperal month is. over, it has returned to its normal dimensions, but after child-bearing it always remains more lax, and less rugose, than in nullipara?. The vulva, at first very lax and much distended, soon regains its former state. The abdominal pari- etes remain loose and flabby for a considerable time, and the white streaks, produced by the distension of the cutis, very generally be- come permanent. In some women, especially when proper support 546 THE PUERPERAL STATE. by bandaging lias not been given, the abdomen remains permanently loose and pendulous. The Lochial Discharge. — From the time of delivery, up to about three weeks afterwards, a diseharge escapes from the interior of the uterus, known as the lochia. At first this consists almost entirely of pure blood, mixed with a variable amount of coagula. If efficient uterine contraction have not been secured after the expulsion of the placenta, coagula of considerable size are frequently expelled with the lochia for one or two days after delivery. In three or four days the distinctly bloody character of the lochia is altered. They have a reddish watery appearance, and are known as the lochia rubra or cruenta. According to the researches of Wertheimer, 1 they are at this time composed chiefly of blood corpuscles, mixed with epithelium scales, mucous corpuscles, and the debris of the decidua. The change in the appearance of the discharge progresses gradually, and about the seventh or eight day it has no longer a red color, but is a pale greenish fluid, with a peculiar sickening and disagreeable odor, and is familiarly described as the "green waters." It now contains a smaller quantity of blood corpuscles, which .lessen in amount from day to day, but a considerable number of pus corpuscles, which re- main the principal constituent of the discharge until it ceases. Besides these, epithelial scales, fatty granules, and crystals of cholesterine, are observed. Occasionally a small infusorium, which has been named the "trichomena vaginalis," has been detected; but it is not of constant occurrence. Variation in its Amount and Duration. — The amount of the lochia varies much, and in some women it is habitually more abundant than in others. Under ordinary circumstances it is very scanty after the first fortnight, but occasionally it continues somewhat abundant for a month or more, without any bad results. It is apt again to become of a red color, and to increase in quantity, in consequence of any slight excitement or disturbance. If this red discharge con- tinue for any undue length of time, there is reason to suspect some abnormality, and it may not unfrequently be traced to slight lacera- tions about the cervix, which have not healed properly. This result may also follow premature exertion, interfering with the proper in- volution of the uterus; and the patient should certainly not be allowed to move about as long as much colored discharge is going on. Occasional Fetor of the Discharge. — Occasionally the lochia have an intensely fetid odor. This must always give rise to some anxiety, since it often indicates the retention and putrefaction of coagula, and involves the risk of septic absorption. It is not very rare, however, to observe a most disagreeable odor persist in the lochia without any bad results. The fetor always deserves careful attention, and an endeavor should be made to obviate it by directing the nurse to syringe out the vagina freely night and morning with Condy's fluid and water; while, if it be associated with quickened pulse and J Virchow's Arch., 1861. THE PUERPERAL STATE AND ITS MANAGEMENT. 547 elevated temperature, other measures, to be subsequently described, will be necessary. The after-pains, which many child-bearing women dread even more than the labor-pains, are irregular contractions, occurring for a varying time after delivery, and resulting from the efforts of the uterus to expel coagula which have formed in its interior. If. there- fore, special care be taken to secure complete and permanent con- traction after labor, they rarely occur, or to a very slight extent. Their dependence on uterine inertia is evidenced by the common observation that they are seldom met with in primiparse. in whom uterine contraction may be supposed to be more efficient, and are most frequent in women who have borne many children. They are a preventible complication, and one which need not give rise to any anxiety: they arc, indeed, rather salutary than the reverse, for if coagula be retained in utero, the sooner the}' are expelled the better. The after-pains generally begin a few hours after delivery, and con- tinue in bad cases, for three or four days, but seldom longer. They are generally increased when the mamma? are irritated by suction. When at their height they are often relieved by the expulsion of the coagula. In some severe cases they are apparently neuralgic in character, and do not seem to depend on the retention of coagula. Thcv may be readily distinguished from pains due to more serious causes, by feeling the enlarged uterus harden under their influence, by the uterus not being tender on pressure, and by the absence of any constitutional symptoms. Management of Women after Delivery.— -The management of women after child-birth has varied much at different times, according to fashion or theory. The dread of inflammation long influenced the professional mind, and caused the adoption of a strictly antiphlo- gistic diet, which led to a tardy convalescence. The recognition of the essentially physiological character of labor has resulted in more sound views, with manifest advantage to our patients. The main facts to bear in mind with regard to the puerperal woman are, her nervous susceptibility, which necessitates quiet and absence of all excitement ; the importance of favoring involution by prolonged rest; and the risk of septicaemia, which calls for perfect cleanliness and attention to hygienic precautions. The Administration of Ojiiatcs is generally Unadvisable. — As soon as we are satisfied that the uterus is perfectly contracted, and that all risk of hemorrhage is over, the patient should be left to sleep. Many practitioners administer an opiate; but. as a matter of routine, this is certainly not good practice, since it checks the contractions of the uterus, and often produces unpleasant effects. Still, if the labor have been long and tedious, and the patient be much exhausted. 15 or 20 drops of Battley's solution may be administered with advantage. Attention to the State of the Pulse, Bladder, and Uterus. — TTithin a few hours the patient should be seen, and at the first visit particular attention should be paid to the state of the pulse, the uterus, and the bladder. The pulse during the whole period of convalescence should be carefullv watched, and. if it be at all elevated, the tem- 548 THE PUERPERAL STATE. perature should at once be taken. If the pulse and temperature remain normal, we may be satisfied that things are going on well; but if the one be quickened and the other elevated, some disturbance or complication may be apprehended. The abdomen should be felt to see that the uterus is not unduly distended, and that there is no tenderness. After the first day or two this is no longer necessary. Treatment of Retention of Urine. — Sometimes the patient cannot at first void the urine, and the application of a hot sponge over the pubis may enable her to do so. If the retention of urine be due to temporary paralysis of the bladder, three or four 20- minim doses of the liquid extract of ergot, at intervals of half an hour, may prove successful. Many hours should not be allowed to elapse without re- lieving the patient by the catheter, since prolonged retention is only likely to make matters worse. Subsequently, it may be necessary to empty the bladder night and morning, until the patient regain her power over it, or until the swelling of the urethra subsides, and this will generally be the case in a few days. Occasionally the bladder .becomes largely distended, and is relieved to some degree by drib- bling of urine from the urethra. Such a state of things may deceive the patient and nurse, and may produce serious consequences by causing cystitis. Attention to the condition of the abdomen will prevent the practitioner from being deceived, for in addition to some constitutional disturbance, a large, tender, and fluctuating swelling will be found in the hypogastric region, distinct from the uterus, which it displaces to one or other side. The catheter will at once prove that this is produced by distension of the bladder. Treatment of Severe After-pains. — If the after-pains be very severe, an opiate may be administered, or, if the lochia be not over-abun- dant, a linseed -meal, poultice, sprinkled with laudanum, or with the chloroform and belladonna liniment, may be applied. If proper care have been taken to induce uterine contraction, they will seldom be sufficiently severe to require treatment. In America, quinine in doses of 10 grains twice daily, has been strongly recommended, espe- cially when opiates fail, and when the pains are neuralgic in char- acter, and I have found this remedy answer extremely well. The quinine is best given in solution with 10 or 15 minims of hydrobro- mic acid, which materially lessens the unpleasant head symptoms often accompanying the administration of such large closes. Diet and Regimen. — The diet of the puerperal patient claims care- ful attention, the more so as old prejudices in this respect are as yet far from exploded, and as it is by no means rare to find mothers and nurses who still cling tenaciously to the idea that it is essential to prescribe a low regimen for many days after labor. The erroneous- ness of this plan is now so thoroughly recognized, that it is hardly necessary to argue the point. There is, however, a tendency in some to err in the opposite direction, which leads them to insist on the patient's consuming solid food too soon after delivery, before she has regained her appetite, thereby producing nausea and intestinal de- rangement. Our best guide in this matter is the feelings of the pa- tient herself. If, as is often the case, she be disinclined to eat, there THE PUERPERAL STATE AND ITS MANAGEMENT. 549 is no reason why she should be urged to do so. A good cup of beef- tea, some bread and milk, or an egg beat up with milk, may gener- ally be given with advantage shortly after delivery, and many patients are not inclined to take more for the first day or so. If the patient be hungry there is no reason why she should not have some more solid, but easily digested food, such as white hsh, chicken, or sweet- bread ; and, after a day or two, she may resume her ordinary diet, bearing in mind that, being confined to bed, she cannot with advan- tage consume the same amount of solid food as when she is up and about. Dr. Oldham, in his presidential address to the Obstetrical Society, 1 has some apposite remarks on this point, which are worthy of quotation. "A puerperal month under the guidance of a monthly nurse is easily drawn out, and it is well if a love of the comforts of illness and the persuasion of being delicate, which are the infirmities of many women, do not induce a feeble life, which long survives after the occasion of it is forgotten. I know no reason why, if a woman is confined early in the morning, she should not have her breakfast of tea and toast at nine, her luncheon of some digestible meat at one, her cup of tea at five, her dinner with chicken at seven, and her tea again at nine, or the equivalent, according to the varia- tion of her habits of living."' [The practice in general in the United States has been to avoid the use of stimulating food for two or three days after delivery, on the same principle that low diet is used in the different forms of abdominal surgery. Full diet and animal food might possibly answer in many of our cases without risk ; and beef essence wc know is of much value after hemorrhage, but in healthy vigorous subjects I see no occasion to ignore the teaching of the past, when based upon sound reasoning. I believe in dieting the robust, and feeding up the delicate. By " dieting" I do not mean the old starvation sj'stem ; but plain, simple, nutritious food. — Ed.] "Of course, there is the common-sense selection of articles of food, guarding against excess, and avoiding stimulants. But gruel and slops, and all inter- mediate feeding, are to be avoided."' No one who has seen both methods adopted can fail to have been struck with the more rapid and satisfactory convalescence which takes place when the patient's strength is not weakened bv an unnecessarilv low diet. Stimulants, as a rule, are not required ; but, if the patient be weakly and ex- hausted, or if she be accustomed to their use, there can be no reason- able objection to their judicious administration. Attention to Cleanliness, etc, — Immediately after delivery a warm napkin is applied, to the vulva, and, after the patient has rested a little, the nurse removes the soiled linen from the bed, and washes the external genitals. It is impossible to pay too much attention during the subsequent progress of the case to the maintenance of perfect cleanliness. Perfectly antiseptic midwifery is no doubt an impossibility ; but a near approach to it may be made, and the greater the care taken, the more certainly will the safety of the patient be insured. It will be a wise precaution to advise the nurse 1 Obstet. Trans., vol. vi. 550 THE PUERPERAL STATE. never to touch the genitals for the first few days, unless her hands have been moistened in a 1 in 20 solution of carbolic acid, or lubri- cated with carbolized oil. The linen should be frequently changed, and all dirty linen and discharges immediately removed from the apartment. The vulva should be washed daily with Condy's fluid and water, and the patient will derive great comfort from having the vagina syringed gently out once a day with the same solution. The remarkable diminution of mortality which, has followed such anti- septic precautions in certain Lying-in Hospitals in Germany, well shows the importance of these measures. The room should be kept tolerably cool, and fresh air freely admitted. Action of the Bowels. — It is customary, on the morning of the second or third day, to secure an action of the bowels ; and there is no better way of doing this than by a large enema of soap and water. If the patient object to this, and the bowels have not acted, some mild aperient may be administered, such as a small dose of castor oil, a few grains of colocynth and henbane pill, or the popular French aperient, the " Tamar Indien." Lactation. — The management of suckling and of the breasts forms an important part of the duties of the monthly nurse, which the practitioner should himself superintend. This will be more conven- iently discussed under the head of lactation. Importance of Prolonged Best. — The most important part of the management of the puerperal state is the securing to the patient pro- longed rest in the horizontal position, in order to favor proper invo- lution of the uterus. For the first few days she should be kept as quiet and still as possible, not receiving the visits of any but her nearest relatives, thus avoiding all chance of undue excitement. It is customary among the better classes for the patient to remain in bed for eight or ten days ; but, provided she be doing well, there can be no objection to her lying on the outside of the bed, or slipping on to a sofa, someAvhat sooner. After ten days or a fortnight she may be permitted to sit on a chair for a little ; but I am convinced that the longer she can be persuaded to retain the recumbent position, the more complete and satisfactory will be the progress of involution, and she should not be allowed to walk about until the third week, about which time she may also be permitted to take a drive. If it be borne in mind that it takes from six weeks to two months for the uterus to regain its natural size, the reason for prolonged rest will be obvious. The judicious practitioner, however, while insisting on this point, will take measures at the same time, not to allow the patient to lapse into the habit of an invalid, or to give the necessary rest the semblance of disease. Subsequent Treatment. — -Towards the termination of the puerperal month some slight tonic, such as small doses of quinine with phos- phoric acid, may be often given with advantage, especially if conva- lescence be tardy. Nothing is so beneficial in restoring the patient to her usual health as change of air, and in the upper classes a short visit to the seaside may generally be recommended, with the certainty of much benefit. MANAGEMENT" OF THE INFANT, LACTATION, ETC. 551 CHAPTEE II. MANAGEMENT OF THE INFANT, LACTATION, ETC. Commencement of Respiration. — Almost immediately after its ex- pulsion, a healthy child cries aloud, thereby showing that respiration is established, and this may be taken as a signal of its safety. The first respiratory movements are excited, partially by reflex action resulting; from the contact of the cold external air on tire cutaneous nerves, and partly by the direct irritation of the medulla oblongata, in consequence of the circulation through it of blood no longer oxy- genated in the placenta. Apparent Death of the New-horn Child. — Not infrequently the child is born in an apparently lifeless state. This is especially likely to be the case when the second stage of labor has been unduly pro- longed, so that the head has been subjected to long-continued pres- sure. The utero- placental circulation is also apt to be injuriously interfered with before the birth of the child when a tardy labor has produced tonic contraction of the uterus, and consequent closure of the uterine sinuses; or, more rarely, from such causes as the injudi- cious administration of ergot, premature separation of the placenta, or compression of the umbilical corcl. In any of these cases it is probable that the arrest of the utero-placeutal circulation induces attempts at inspiration, which are necessarily fruitless, since air cannot reach the lungs, and the foetus may die asplryxiated ; the existence of the respiratory movement being proved on post-mortem examina- tion by the presence in the lungs of liquor amnii, mucus, and meco- nium, and by the extravasation of blood from the rupture of their engorged vessels. Appearance of the Child in such Cases. — In most cases, when the child is born in a state of apparent asphyxia, its face is swollen and of a dark livid color. It not infrequently makes one or two feeble and gasping efforts at respiration, without any definite cry ; on aus- cultation the heart may be heard to beat weakly and slowly. Under such circumstances there is a fair hope of its recovery.. In other cases the child, instead of being turgid and livid in the face, is pale, with flaccid limbs, and no appreciable cardiac action, then the prog- nosis is much more unfavorable. Treatment of Apparent Death. — No time should be lost in endeavor- ing to excite respiration, and, at first, this must be done by applying suitable stimulants to the cutaneous nerves, in the hope of exciting reflex action. The cord should be at once tied, and the child re- moved from the mother ; for the final uterine contractions have so completely arrested the utero-placental circulation, as to render it no 552 THE PUERPERAL STATE. longer of any value. If the face be very livid, a few drops of blood may with advantage be allowed to flow from the cord before it is tied, with the view of relieving the embarrassed circulation. Very often some slight stimulus, such as one or two sharp slaps on the thorax, or rapidly rubbing the body with brandy poured into the palms of the hands, will suffice to induce respiration. Failing this, nothing acts so well as the sudden and instantaneous application of heat and cold. For this purpose extremely hot water is placed in one basin, and quite cold water in another. Taking the child by the shoulders and legs, it should be dipped for a single moment into the hot water, and then into the cold ; and these alternate applica- tions may be repeated once or twice, as occasion requires. The effect of this measure is often very marked, and I have frequently seen it succeed when prolonged efforts at artificial respiration had been made in vain. Artificial Respiration. — If these means fail, an endeavor must be at once made to carry on respiration artificially. The Sylvester method is, on the whole, that which is most easily applied, and, on account of the compressibility of the thorax, it is peculiarly suitable for infants. The child being laid on its back, with the shoulders slightly elevated, the elbows are grasped by the operator, and alter- nately raised above the head, and slowly depressed against the sides of the thorax, so as to produce the effect of inspiration and expira- tion. If this do not succeed, the Marshall Hall method may be sub- stituted; and one or more of the plans of exciting reflex action through the cutaneous nerves may be alternated with it. Insufflation of the Lungs. — Other means of exciting respiration have been recommended. One of them, much used abroad, is the artificial insufflation of the lungs by means of a flexible catheter guided into the glottis. It is not difficult to pass the end of a catheter into the glottis, using the little finger as a guide ; and once in position, it may be used to blow air gently into the lungs, which is expelled by com- pression on the thorax, the insufflation being repeated at short inter- vals of about ten seconds. One advantage of this plan is, that it allows the liquor amnii and other fluids, which may have been drawn into the lungs in the premature efforts at respiration before birth, to be sucked up into the catheter, and so removed from the lungs. The same effect may be produced, but less perfectly, by placing the hand over the nostrils of the child, blowing into its mouth, and immediately afterwards compressing the thorax. 1 One of these methods should certainly be tried, if all other means have failed. Faradization along the course of the phrenic nerves is a promising means of inducing respiration, which should be used if the proper apparatus can be procured. Encouragement to persevere in our endeavors to resuscitate the child may be derived from the numerous authenticated instances of success after the lapse of a [• When this is done the oesophagus must he closed hy placing the thumh and fingers on opposite sides of the larynx, and pressing it backward, just before blowing in the mouth. When this is accomplished so as to fill the lungs, the thorax should be pressed, and the inflation repeated. — Ed.] etc. 553 considerable time, even of an hour or more. As long as the cardiac pulsations continue, however feebly, there is no reason to despair. Washing and Dressing of the Child. — When the child cries lustily from the first, it is customary for the nurse to wash and dress it as soon as her immediate attendance on the mother is no longer required. For this purpose it is placed in a bath of warm water, and carefully soaped and sponged from head to foot. With the view of facilitating the removal of the unctuous material with which it is covered, it is usual to anoint it with cold cream or olive-oil, which is washed off' in the bath. Nurses are apt to use undue roughness in endeavoring to remove ever y particle of the vernix caseosa, small portions of which are often firmly adherent. This mistake should be avoided, as these particles will soon dry up and become spontaneously detached. The cord is generally wrapped in a small piece of charred liuen, which is supposed to have some slight antiseptic property, and this is renewed from day to day until the cord has withered and separated. This generally occurs within a week ; and a small pad of soft linen is then placed over the umbilicus, and supported by a flannel belly- band, placed round the abdomen, which should not be too tight, for fear of embarrassing the respiration. By this means the tendency to umbilical hernia is prevented. [As the vernix caseosa is readily miscible with pure lard, and can be easily removed by its means, it has become the practice with many obstetricians in the United States to order the infant to be well anointed, and then wiped from head to foot with soft rags, until all the vernix disappears and the skin retains a slight oily trace, not enough to soil the clothing. By this means water is avoided, and with it much of the risk of taking cold; and the skin is left less sensitive after the sudden change which it is made to endure at birth than when subjected to hot water and soap. In the hot months water is preferable at the first dressing. — Ed.] Clothing, etc. — 'The clothing of- the infant varies according to fashion and the circumstances of the parents. The important points to bear in mind are that it should be warm (since newly-born children are extremely susceptible to cold), and at the same time light and suffi- ciently loose to allow free play to the limbs and thorax. All tight bandaging and swaddling, such as is so common in some parts of the Continent, should be avoided, and the clothes should be fastened by strings or by sewing, and no pins used. At the present day it is customary not to use caps, so that the head may be kept cool. The utmost possible attention should be paid to cleanliness, and the child should be regularly bathed in tepid water, at first once daily, and after the first few weeks both night and morning. After drying, the flexures of the thighs and arms, and the nates, should be dusted with violet powder or Fuller's earth, to prevent chafing of the skin. The excrements should be received in napkins wrapped round the hips, and great care is required to change the napkins as often as they are wet or soiled, otherwise troublesome irritation will arise. A neglect of this precaution, and the washing of the napkins with coarse soap or soda, are among the principal causes of the eruptions and excoriations so common in badly cared for children. When 36 554 THE PUERPERAL STATE. washed and dressed the child may be placed in its cradle, and covered with soft blankets or an eider-down quilt. Application of the Child to the Breast. — As soon as the mother has rested a little, it is advisable to place the child to the breast. This is useful to the mother by favoring uterine contraction. Even now there is in the breasts a variable quantity of the peculiar fluid known as colostrum. This is a viscid yellowish secretion, different in appear- ance from the thin bluish milk which is subsequently formed. Ex- amined under the microscope it is found to contain some milk globules, a number of large granular and small fat corpuscles. It has a purgative property, and soon produces with less irritation than any of the laxatives so generally used, a discharge of the meco- nium with which the bowels are loaded. Hence the accoucheur should prohibit the common practice of administering castor oil, or other aperient, within the first few days after birth, although there can be no objection to it. in special cases, if the bowels appear to act inefficiently and with difficulty. Over-frequent Suckling should be Avoided. — For the first few days, and until the secretion of milk is thoroughly established, the child should be put to the breast at long intervals only. Constant attempts at suckling an empty breast lead to nothing but disappointment, both to the mother and child, and, by unduly irritating the mamnue, some- times to positive harm. Therefore, for the first day or two, it is sufficient if the child be applied to the breast twice, or at most three times, in the twenty-four hours. Nor is it necessary to be apprehen- sive as many mothers naturally are, that the child will suffer from want of food. A few spoonfuls of milk and water being given from time to time, the child may generally wait without injury until the milk is secreted. This is generally about the third day, when the secretion is found to be a whitish fluid, more watery in appearance than coav's milk, and showing under the microscope an abundance of minute spherical globules, refracting light strongly, which are abundant in proportion to the quality of the milk. A certain number of granular corpuscles may also be observed shortly after the birth of the child, but, after the first month, these should have almost altogether disappeared, The reaction of human milk is decidedly alkaline, and the taste much sweeter than that of cow's milk. Importance of Nursing ivhen Practicable. — The importance to the mother of nursing her own child, whenever her health permits, on account of the favorable influence of lactation in promoting a proper involution of the uterus, has already been insisted on. Unless there be some positive contra-indication, such as a marked strumous, cachexia, an hereditary phthisical tendency, or great general debil- ity, it is the duty of the accoucheur to urge the mother to attempt lactation, even if it be not carried on more than a month or two. It is, however, the fact that in the upper classes of society a large number of patients are unable to nurse, even though willing and anxious to do so. In some there is hardly any lacteal secretion at all, in others there is at first an over-abundance of watery and innu- tritions milk, which floods the breasts, and soon dies away altogether. MANAGEMENT OF THE INFANT, LACTATION, ETC. 555 Whe?i the Mother cannot Nurse a Wet Nurse should he Procured. — ■ Whenever the mother cannot or will not nurse, the question will arise as to the method of bringing up the child. From many causes there is an increasing tendency to resort to bottle-feeding, instead of procuring the services of a wet nurse, even when the question of expense does not come into consideration. No long experience is required to prove that hand feeding is a bad and imperfect substitute for nature's mode, and one which the practitioner should discourage whenever it lies in his power to do so. It is true that, in many cases, bottle-fed children do well ; but there is good reason to believe that, even when apparently most successful, the children are not so strong in after-life as they would have been had they been brought up at the breast, When, in addition, it is borne in mind how much of the success of hand-feeding depends on intelligent care on the part of the nurse, what evils are apt to accrue from injurious selec- tion of food, and from ignorance of the commonest laws of dietetics, there is abundant reason for urging the substitution of a wet nurse, whenever the mother is unable to undertake the suckling of her child. It must be admitted that good hand-feeding is better than bad wet-nursing, and the success of the latter hinges on the proper selection of a wet nurse, As this falls within the duties of the prac- titioner, it will be well to point out the qualities which should be sought for in a wet nurse, before proceeding to discuss the mode of rearing the child at the breast, Selection of a Wet Nurse. — In selecting a wet nurse we should en- deavor to choose a strong, healthy woman, who should not be over 30, or 35 years of age at the outside, since the quality of the milk deteriorates in woman who are more advanced in life. For a similar reason a very young woman of 16 or 17 should be rejected. It is needless to say that care must be taken to ascertain the absence of all traces of constitutional disease, especially marks of scrofula, or enlarged cervical or inguinal glands, which may possibly be due to antecedent syphilitic taint. If the nurse be of good muscular de- velopment, healthy-looking with a clear complexion, and sound teeth (indicating a generally good state of health), the color of the hair and eyes are of secondary importance. It is commonly stated that brunettes make better nurses than blondes, but this is by no means necessarily the case ; and, provided all the other points be favor- able, fairness of skin and hair need be no bar to the selection of a nurse. The breasts should be pear-shaped, rather firm, as indicating an abundance of gland -tissue, and with the superficial veins well marked. Large, flabby breasts owe much of their size to an undue deposit of fat, and are generally unfavorable. The nipple should be prominent, not too large, and free from cracks and erosions, which, if existing, might lead to subsequent difficulties in nursing. On pressing the breast the milk should flow from it easily in a number of small jets, and some of it should be preserved for examination. It should be of a bluish -white color, and when placed under the microscope, the field should be covered with an abundance of milk corpuscles, and the large granular corpuscles of the colostrum should 556 THE PUERPERAL STATE. have entirely disappeared. If the latter be observed in any quantity in a woman who has been confined five or six weeks, the inference is that the milk is inferior in quality. It is not often that the prac- titioner has an opportunity of inquiring into the moral qualities of the nurse, although much valuable iiilormation might be derived from a knowledge of her previous character. An irascible, excit- able, or highly nervous woman will certainly make a bad nurse, and the most trivial causes might afterwards interfere with the quality of her milk. Particular attention should be paid to the nurse's own child, since its condition affords the best criterion of the quality of her milk. It should be plump, well nourished, and free from all blemishes. If it be at all thin and wizened, especially if there be any snuffling at the nose, or should any eruption exist affording the slightest suspicion of a syphilitic taint, the nurse should be unhesi- tatingly rejected. Management of Suckling. — The management of suckling is much the same whether the child is nursed by the mother or by a wet nurse. As soon as the supply of milk is sufficiently established, the child must be put to the breast at short intervals, at first of about two hours, and, in about a month or six weeks, of three hours. From the first few days it is a matter of the greatest importance, both to the mother and child, to acquire regular habits in this respect. If the mother get into the way of allowing the infant to take the breast whenever it cries, as a means of keeping it quiet, her own health must soon suffer, to say nothing of the discomfort of being incessantly tied to the child's side : while the child itself has not sufficient rest to digest its food, and, very shortty, diarrhoea, or other symptoms of dyspepsia, are pretty sure to folloAV. After a month or two the infant should be trained to require the breast less often at night, so as to enable the mother to have an undisturbed sleep of six or seven hours. For this purpose she should arrange the times of nursing so as to give the breast just before she goes to bed, and not again until the early morning. If the child should require food in the interval, a little milk and water, from the bottle, may be advan- tageously given. Diet of Nursing Women. — The diet of the nursing woman should be arranged on ordinary principles of hygiene. It should be abundant, simple, and nutritious, and all rich and stimulating articles of food should be avoided. A common error in the diet of wet nurses is over-feeding, which constantly leads to deterioration of the milk. Many of these women, before entering on their functions, have been living on the simplest and even sparest diet, and not uncommonly, in the better class of houses, they are suddenly given heavy meat meals three and even four times a day, and often three or four glasses of stout. It is hardly a matter of astonishment that, under such cir- cumstances, their milk should be found to disagree. For a nursing woman in good health two good meat meals a day, with two glasses of beer or porter, and as much milk and bread and butter as she likes to take in the interval, should be amply sufficient. Plenty of moderate exercise should be taken, and the more nurse and child are MANAGEMENT OF THE INFANT, LACTATION, ETC. 557 out in the open air, provided the weather be reasonably fine, the better it is for both. [As it is not the custom of American wet nurses to drink beer or stout, this part of their diet is undesirable. A healthy woman should have milk enough from her ordinary diet, which should be largely farinaceous. If milk agrees with her, it is far better than malt drinks in the production of a lacteal supply. — Ed.] Signs of Successful Lactation. — Carried on methodically in this manner, wet nursing should give but little trouble. In the intervals between its meals the child sleeps most of its time, and wakes with regularity to feed ; but if the child be wakeful and restless, cry after feeding, have disordered bowels, and, above all, if it do not gain, week by week, in weight (a point which should be, from time to time, ascertained by the scales), we may conclude that there is either some grave defect in the management of suckling, or that the milk is not agreeing. Should this unsatisfactory progress continue, in spite of our endeavors to remedy it, there is no resource left but the alter- ation of the diet, either by changing the nurse, or by bringing up the child by hand. The former should be preferred whenever it is practicable, and, in the upper ranks of life, it is by no means rare to have to change the wet nurse two or three times, before one is met with whose milk agrees perfectly. If the child have reached six or seven months of age, it may be preferable to wean it altogether, especially if the mother have nursed it, as hand-feeding is much less objectionable if the infant have had the breast for even a few months. Period of Weaning. — As a rule, weaning should not be attempted until dentition is fairly established, that being the sign that nature has prepared the child for an alteration of food; and it is better that the main portion of the diet should be breast milk until at least six or seven teeth have appeared. This is a safer guide than any arbi- trary rule taken from the age of the child, since the commencement of dentition varies much in different cases. About the sixth or seventh month it is a good plan to commence the use of some suita- ble artificial food once a day, so as to relieve the strain on the mother or nurse, and prepare the child for weaning, which should always be a very gradual process. In this way a meal of rusks, of the entire wheat flour, or of beef- or chicken-tea, with bread crumb in it, may be given with advantage; and, as the period for weaning arrives, a second meal may be added, and so eventually the child may be weaned without distress to itself, or trouble to the nurse. The Disorders of Lactation. — The disorders of lactation are nume- rous, and, as they frequently come under the notice of the practitioner, it is necessary to allude to some of the most common and important. Means of Arresting the Secretion of Milk. — The advice of the accou- cheur is often required in cases in which it has been determined that the patient is not to nurse, when we desire to get rid of the milk as soon as possible, or when, at the time of weaning, the same object is sought. The extreme heat and distension of the breasts, in the former class of cases, often give rise to much distress. A smart saline ape- 558 THE PUERPERAL STATE. rient will aid in removing the milk, and for this purpose a double Seidlitz powder, or frequent small doses of sulphate of magnesia, act well; while, at the same time, the patient should be advised to take as small a quantity of fluid as possible. Iodide of potassium in large doses, of 20 or 25 grains, repeated twice or thrice, has a remarkable effect in arresting the secretion of milk. This observation was first empirically made by observing that the secretion of milk was arrested when this drug was administered for some other cause, and I have frequently found it answer remarkably well. The distension of the breasts is best relieved by covering them with a layer of lint or cotton wool, soaked in a spirit lotion, or eau de cologne and water, over which oiled silk is placed, and by directing the nurse to rub them gently with warm oil, whenever they get hard and lumpy. Breast- pumps and similar contrivances only irritate the breasts, and do more harm than good. The local application of belladonna has been strongly recommended as a means for preventing lacteal secretion. As usually applied, in the form of belladonna plaster, it is likely to prove hurtful, since the breast often enlarges after the plasters are applied, and the pressure of the unyielding leather on which they are spread produces intense suffering. A better way of using it is by rubbing down a drachm of the extract of belladonna with an ounce of glyce- rine, and applying this on lint. In some cases it answers extremely well ; but it is very uncertain in its action, and frequently is quite useless. Defective, Secretion of Milk. — A deficiency of milk in nursing mothers is a yery common course of difficulty. In a wet nurse this drawback is, of course, an indication for changing the nurse ; but to the mother the importance of nursing is so great, that an endeavor must be made either to increase the flow of milk, or to supplement it by other food. Unfortunately, little reliance can be placed on any of the so-called galactagogues. The only one which in recent times has attracted attention is the leaves of the castor-oil plant, which, made into poultices and applied to the breast, are said to have a beneficial effect in increasing the flow of milk. More reliance must be placed in a sufficiency of nutritious food, especially such as con- tains phosphatic elements ; stewed eels, oyst:rs, and other kinds of shellfish, and the Eevalenta Arabica, are recommended by Dr. Routh, who has paid some attention to this point, 1 as peculiarly appropriate. If the amount of milk be decidedly deficient, the child should be less often applied to the breast, so as to allow milk to collect, and prop- erly prepared cow's milk from a bottle should be given alternately with the breast. This mixed diet generally answers well, and is far preferable to pure hand -feeding. [In the year 1870, 2 I prepared an article showing by three typical cases the value of milk as a diet for certain delicate mothers, who under their ordinary food, invariably fail to be able to nurse longer than a few weeks or months after parturition. This paper waspub- ! Routh on Infant-feeding. [2 Am. Jour. Obstet. Feb. 1870, p. 675.] MANAGEMENT OF THE INFANT, LACTATION, ETC. 559 lished by various periodicals during two years, and the plan has been brought largely into use, as the diet is capable of making a good nurse out of a mother, who but for it would make a complete failure, and of fattening her up during the time that she is secreting milk in abundance. When a delicate mother of 86 pounds weight, after failing in a month with each of three infants, is enabled by it to nurse a child 18 months, and gain at the same time 19 pounds, the diet must be an effective one. — Ed.] Depressed Nipples. — A not uncommon source of difficulty is a de- pressed condition of the nipples which is generally produced by the constant pressure of the stays. The result is, that the child, unable to grasp the nipple, and wearied with ineffectual efforts^ may at last refuse the breast altogether. An endeavor should be made to elon- gate the nipple before putting it into the child's mouth, either by the ringers, or by some form of breast-pump, which here finds a useful indication. In the worst class of cases, when the nipple is perma- nently depressed, it may be necessary to let the child suck through a glass nipple shield, to which is attached an India-rubber tube, similar to that of a sucking-bottle ; that it is generally well able to do. [In some instances this anatomical defect appears to be bej T ond remedy, unless a recently proposed surgical operation can be made effective. I have tried to prepare primiparae for several months be- fore labor, and then failed as soon as the breasts filled with milk. In some cases there is absolutely no nipple, and as a shield is of no value in protection, the escaping milk produces an eczema over the waist and upper part of the abdomen. This condition I have seen associated with a most obstinate galactorrhoea lasting several months. —Ed.] Fissures and excoriations of the nicies are common causes of suf- fering, in some cases leading to mammary abscess. Whenever the practitioner has the opportunity, he should advise his patient to prepare the nipple for nursing in the latter months of pregnancy ; and this may best be done by daily bathing it with a spirituous or astringent lotion, such as eau de cologne and water, or a weak solu- tion of tannin. After nursing has begun, great care should be taken to wash and dry the nipple after the child has been applied to it, and, as long as the mother is in the recumbent position, she may, if the nipples be at all tender, use zinc nipple-shields with advantage, when she is not nursing. In this way these troublesome complications may generally be prevented. The most common forms are either an abra- sion on the surface of the nipple, which, if neglected, may form a small ulcer, or a crack at some part of the nipple, most generally at its base. _ In either case, the suffering when the child is put to the breast is intense, sometimes indeed amounting to intolerable anguish, causing the mother to look forward with dread to the application of the child. Whenever such pain is complained of, the nipple should be carefully examined, since the fissure or sore is often so minute as to escape superficial examination. The remedies recommended are very numerous, and not always successful. Amongst those most 560 THE PUERPERAL STATE. commonly used are astringent applications, such as tannin, or weak solutions of nitrate of silver, or cauterizing the edges of the fissure with the solid nitrate of silver, or applying the flexible collodion of the Pharmacopoeia. Dr. Wilson, of Glasgow, speaks highly of a lotion composed of ten grains of nitrate of lead in an ounce of gly- cerine, which is to be applied after suckling, the nipple being care- fully washed before the child is again put to the breast. I have myself found nothing answer so well as a lotion composed of half an ounce of sulphurous acid, half an ounce of the glycerine of tannin, and an ounce of water, the beneficial effects of which are sometimes quite remarkable. Eelief may occasionally be obtained by inducing the child to suck through a nipple-shield, especially when there is only an excoriation ; but this will not always answer, on account of the extreme pain which it produces. Excessive Flow of Milk. — An excessive IIoav of milk, known as galactorrhosa, often interferes with successful lactation. It is by no means rare in the first weeks after delivery for women of delicate constitution, who are really unfit to nurse, to be flooded with a super- abundance of watery and innutritions milk, which soon produces disordered digestion in the child. Under such circumstances, the only thing to be clone is to give up an attempt which is injurious both to the mother and child. At a later stage the milk, secreted in large quantities, is sufficient^ nourishing to the child, but the drain on the mother's constitution soon begins to tell on her. Palpitation, giddiness, emaciation, headache, loss of sleep, spots before the eyes, and even amaurosis, indicate the serious effects which are being pro- duced, and the absolute necessity of at once stopping lactation. Whenever, therefore, a nursing woman suffers from such symptoms, it is far better at once to remove the cause, otherwise a very serious and permanent deterioration of health might result. Mammary Abscess. — There is no more troublesome complication of lactation than the formation of abscess in the breast ; an occurrence by no means rare, and which, if improperly treated, may, by long- continued suppuration and the formation of numerous sinuses in and about the breast, produce very serious effects on the general health. The causes of breast abscesses are numerous, and very trivial circum- stances may occasionally set up inflammation, ending in suppuration. Thus it may follow exposure to cold ; a blow, or other injury to the breast ; some temporary engorgement of the lacteal tubes ; or even sudden or depressing mental emotions. The most frequent cause is irritation from fissures or erosions of the nipples, which must, there- fore, always be regarded with suspicion, and cured as soon as possible. Signs and Symptoms. — The abscess majr form in any part of the breast, or in the areolar tissue below it ; in the latter case, the in- flammation very generally extends to the gland structure. Abscess is usually ushered in by constitutional symptoms, varying in severity with the amount of the inflammation. Pyrexia is always present ; elevated temperature, rapid pulse, and much malaise and sense of feverishness, followed, in many cases, by distinct rigor, when deep- MANAGEMENT OF THE INFANT, LACTATION, ETC. 561 seated suppuration is taking place. On examining the breast it will be found to be generally enlarged and very tender, while, at the site of the abscess, an indurated and painful swelling may be felt. If the inflammation be chiefly limited to the subglandular areolar tissue, there may be no localized swelling felt, but the whole breast will be acutely sensitive, and the slightest movement will cause much pain. As the case progresses, the abscess becomes more and more super- ficial, the skin covering it is red and glazed, and if left to itself, it bursts. In the more serious cases, it is by no means rare for multiple abscesses to form. These opening, one after the other, lead to the formation of numerous fistulous tracts, by which the breast may be- come completely riddled. Sloughing of portions of the gland-tissue may take place, and even considerable hemorrhage, from the de- struction of bloodvessels. The general health soon suffers to a marked degree, and, as the sinuses continue to suppurate for many successive months, it is by no means uncommon for the patient to be reduced to a state of profound and even dangerous debility. Treatment. — Much may be done by proper care to prevent the formation of abscess, especially by removing engorgement of the lacteal ducts, when threatened, by gentle hand friction in the manner alreadv indicated. When the general symptoms, and the local ten- derness, indicate that inflammation has commenced, we should at once endeavor to moderate it, in the hope that resolution may occur without the formation of pus. Here general principles must be attended to, especially giving the affected part as much rest as pos- sible. Feverishness may be combated hj gentle saline, minute doses of aconite, and large doses of quinine ; while pain should be relieved by opiates. The patient should be strictly confined in bed, and the affected breast supported by a suspensory bandage. Warmth and moisture are the best means of relieving the local pain, either in the form of hot fomentations, or of light poultices of linseed-meal or bread and milk, and the breast may be smeared with extract of bella- donna rubbed down with glycerine, or the belladonna liniment sprinkled over the surface of the poultices. Generally the pain and irritation produced by putting the child to the breast are so great as to contra-indicate nursing; from the affected side altogether, and we must trust to relieving the tension by poultices ; suckling being, in the mean time, carried on by the other breast alone. In favorable cases this is quite possible for a time, and it may be that, if the in- flammation do not end in suppuration, or if the abscess be small and localized, the affected breast is again able to resume its functions. Often this is not possible, and it may be advisable, in severe cases, to give up nursing altogether. Pus should be Removed as soon as Possible. — The subsequent man- agement of the case consists in the opening of the abscess as soon as the existence of pus is ascertained, either by fluctuation, or, if the site of the abscess be deep-seated, by the exploring needle. It may be laid down as a principle, that the sooner the pus is evacuated the better, and nothing is to be gained by waiting until it is superficial. 562 THE PUERPERAL STATE. On the contrary, such delay only leads to more extensive disorgani- zation of tissue and the further spread of inflammation. Antiseptic Treatment. — The method of opening the abscess is of primary importance. It has always been customary simply to open the abscess at its most depending part, without using any precaution against the admission of air, and afterwards to treat secondary ab- scesses in the same way. The results are well known to all practical accoucheurs, and the records of surgery fully show how many weeks or months generally elapse in bad cases before recovery is complete. The antiseptic treatment of mammary abscess, in the way first pointed out by Lister, afford results which are of the most remark- able and satisfactory kind. Instead of being weeks and months in healing, I believe that the practitioner who fairly and minutely car- ries out Mr. Lister's directions may confidently look for complete closure of the abscess in a few days; and I know nothing, in the whole range of my professional experience, that has given me more satisfaction than the application of this method to abscesses of the breast. The plan I first used is that recommended by Lister in the "Lancet" for 1867, but which is now superseded by his improved methods, which of course, will be used in preference by all who have made themselves familiar with the details of antiseptic surgery. The former, however, is easily within the reach of every one, and is so simple that no special skill or practice is required in its applica- tion ; whereas the more perfected antiseptic appliances will probably not be so readily obtained, and are much more difficult to use. I, therefore, insert Mr. Lister's original directions, which he assures me are perfectly aseptic, for the guidance of those who may not be able to obtain the more elaborate dressings: — -"A solution of one part of crystallized carbolic acid in four parts of boiled linseed oil having been prepared, a piece of rag from four to six inches square is dipped into the oily mixture, and laid upon the skin where the incision is to be made. The lower edge of the rag being then raised, while the upper edge is kept from slipping by an assistant, a common scalpel or bistoury dipped in the oil is plunged into the cavity of the ab- scess, and an opening about three-quarters of an inch in length is made, and the instant the knife is withdrawn the rag is dropped upon the skin as an antiseptic curtain, beneath which the pus flows out into a vessel placed to receive it. The cavity of the abscess is firmly pressed, so as to force out all existing pus as nearly as imay be (the old fear of doing mischief by rough treatment of the pyogenic membrane being quite ill-founded) ; and if there be much oozing of blood, or if there be considerable thickness of parts between the abscess and the surface, a piece of lint dipped in the antiseptic oil is introduced into the incision to check bleeding and prevent primary adhesion, which is otherwise very apt to occur. The introduction of the lint is effected as rapidly as may be, and under the protection of the antiseptic rag. Thus the evacuation of the original contents is accomplished with perfect security against the introduction of living germs. This, however, would be of no avail unless an anti- septic dressing could be applied that would effectually prevent the MANAGEMENT OF THE INFANT, LACTATION, ETC. 563 decomposition of the stream of pus constantly flowing out beneath it. After numerous disappointments, I have succeeded with the follow- ing, which may be relied upon as absolutely trustworthy : About six-teaspoonfuls of the above-mentioned solution of carbolic acid in linseed oil are mixed up with common whiting (carbonate of lime) to the consistence of a firm paste, which is, in fact, glazier's putty with the addition of a little carbolic acid, This is spread upon a piece of common tin-foil about six inches square, so as to form a laver about a quarter of an inch thick. The tin-foil, thus spread with putty, is placed upon the skin, so that the middle of it corre- sponds to the position of the incision, the antiseptic rag used in opening the abscess being removed the instant before. The tin is then fixed securely by adhesive plaster, the lowest edge being left free for the escape of the discharge into a folded towel placed over it and secured by a bandage. The dressing is changed, as a general rule, once in 24 hours, but, if the abscess be a very large one, it is prudent to see the patient 12 hours after it has been opened, when, if the towel should be much stained with discharge, the dressing should be changed, to avoid subjecting its antiseptic virtues to too severe a test. But after the first 24 hours a single daily dressing is sufficient. The changing of the dressing must be methodically done as follows: A second similar piece of tin-foil having been spread with the putty, a piece of rag is dipped in the oily solution and placed on the incision the moment the first tin is removed. This guards against the possibility of mischief occurring during the cleans- ing of the skin with a dry cloth, and pressing out any discharge which may exist in the cavity. If a plug of lint was introduced when the abscess was opened, it is removed under cover of the anti- septic rag, which is taken off at the moment when the new tin is to be applied. The same process is continued daily until the sinus closes." Treatment of Long -continued Suppuration and Fever. — If the case come under our care when the abscess has been Ions; discharg-ino* or when sinuses have formed, the treatment is directed mainly to pro- curing a cessation of suppuration and closure of the sinuses. For this purpose methodical strapping of the breast with adhesive plaster, so as to afford steady support and compress the opposing pyogenic surfaces, will give the best results. It may be necessary to lay open some of the sinuses, or to inject tinct. iodi or other stimulating lotions, so as to moderate the discharge, the subsequent surgical treatment varying according to the requirements of each case. As the drain on the system is great, and the constitutional debility general^ pro- nounced, much attention must be paid to general treatment ; and abundance of nourishing food, appropriate stimulants, and such medicines as iron and quinine, will be indicated. Hand-feeding. — In a considerable number of cases the inability of the mother to nurse the child, her invincible repugnance to a wet nurse, or inability to bear the expense, renders hand-feeding essen- tial. It is, therefore, of importance that the accoucheur should be thoroughly familiar with the best method of bringing up the child 564: THE PUERPERAL STATE. by hand, so as to be able to direct the process in the way that is most likely to be successful. Causes of Mortality in Hand- fed Children. — Much of the mortality following hand-feeding may be traced to unsuitable food. Among the poorer classes especially there is a prevalent notion that milk alone is insufficient ; and hence the almost universal custom of ad- ministering various farinaceous foods such as corn-flour or arrow- root, even from the earliest period. Many of these consist of starch alone, and are therefore absolutely unsuited for forming the staple of diet, on account of the total absence of nitrogenous elements. Independently of this, it has been shown that the saliva of infants has not the same digestive property on starch that it subsequently acquires, and this affords a further explanation of its so constantly producing intestinal derangement. Reason, as well as experience, abundantly prove that the object to be aimed at in hand-feeding is to imitate as nearly as possible the food which nature supplies for the new-born child, and therefore the obvious course is to use milk from some animal, so treated as to make it resemble human milk. as nearly as may be. Ass's Milk.' — Of the various milks used, that of the ass, on the whole, most closely resembles human milk, containing less casein and butter, and more saline ingredients. It is not always easy to obtain, and in towns is excessively expensive. Moreover, it does' not always agree with the child, being apt to produce diarrhoea. We can, however, be more certain of its being unadulterated, which in large cities is in itself no small advantage, and it maybe given with- out the addition of water or sugar. Goafs milk in this country is still more difficult to obtain, but it often succeeds admirably. In many places the infant sucks the teat directly, and certainly thrives well on the plan. [We reverse the order in this country, where the ass is seldom seen, and the goat quite common, particularly in the suburbs of our large cities where its milk is most required. I have seen marvellous results from feeding sick infants with its milk freshly drawn, and diluted with hot water. I do not believe its milk is as suitable as that of the cow, but it has the advantage that it can be obtained freshlv drawn in a city, by keeping the animal in the yard, or on a vacant lot. The goat" should be fed upon grass and other suitable diet, and not permitted to run at large, as it eats with impunity, stramonium and other noxious weeds. — Ed.] Cow's Milk audits Preparation.— In a large majority of cases we have to rely on cow's milk alone. It differs from human milk in containing less water, a larger amount of casein and solid matters, and less sugar. Therefore, before being given, it requires to be diluted and sweetened. A common mistake is over dilution, and it is far from rare for nurses to administer one- third cow's milk to two- thirds water. The result of this excessive dilution is, that the child becomes pale and puny, and has none of the firm and plump appear- ance of a well-fed infant. The practitioner should, therefore, ascer- tain that this mistake is not being made; and the necessary dilution MANAGEMENT OF THE INFANT, LACTATION, ETC. 565 will be "best obtained by adding to pure fresh cow's milk, one-third hot water, so as to warm the mixture to about 96°, the whole being slightly sweetened with sugar of milk, or ordinary crystallized sugar. After the first two or three months the amount of water may be lessened, and pure milk, warmed and sweetened, given instead. 1 Whenever it is possible, the milk should be obtained from the same cow, and in towns some care is requisite to see that the animal is properly fed and stabled. Of late years it has been customary to obviate the difficulties of obtaining good fresh milk by using some of the tinned milks now so easily to be had. These are already sweetened, and sometimes answer well, if not given in too weak a dilution. One great drawback in bottle-feeding is the tendency of the milk to become acid, and hence to produce diarrhoea. This may be obviated to a great extent by adding a tablespoonfui of lime-water to each bottle, instead of an equal quantity of water. Artificial Human Milk. — An admirable plan of treating cow's milk, so as to reduce it to almost absolute chemical identity with human milk, has been devised by Professor Frankland, to whom I am in- debted for permission to insert the receipt. I have followed this method in many cases, and find it far superior to the usual one, as it produces an exact and uniform compound. "With a little practice nurses can employ it with no more trouble than the ordinary mixing of cow's milk with water and sugar. The following extract from Dr. Frankland's work 2 will explain the principles on which the prep- aration of the artificial human milk is founded: "The rearing of infants who cannot be supplied with their natural food is notoriously dimcult and uncertain, owing chiefly to the great difference in the chemical composition of human milk and cow's milk. The latter is much richer in casein and poorer in milk-sugar than the former, whilst asses' milk, which is sometimes used for feeding infants, is too poor in casein and butter, although the proportion of sugar is nearly the same as in human milk. The relations of the three kinds of milk to each other are clearly seen from the following analytical numbers, which express the percentage amounts of the different constituents : — ■ Casein . . Butter Milk-sugar ...... Salts These numbers show that bv the removal of one-third of the casein from cow's milk and the addition of about one-third more milk-sugar a liquid is obtained which closely approaches human milk in compo- P I have been obliged with quite young infants in some instances, to change from Alderney to common cow's milk, as the larger proportion of butter in the former makes it too unlike that of the woman to agree with the child. It is well to recom- mend the milk of one cow, but many who claim to bring it, fill the little can out of the big one, on their round in the city. A very young cow and an old one are not suitable. In country practice, the selected cow system is often quite effective. — Ed.] 2 Frankland's Experimental Researches in Chemistry, p. 843. Woman. Ass. Cow. 2.7 1.7 4.2 3.5 1.3 3.8 5.0 4.5 3.8 .2 .5 .7 666 THE PUERPERAL STATE. sition, the percentage amounts of the four chief constituents being as follows : — ■ Casein ........... 2.8 Butter • ••........ 3.8 Milk-sugar . . . . . . . . # , 5 # q Salts . . . . . . . . . . t m # 7 The following is the mode of preparing the milk : Allow one-third of a pint of new milk to stand for about twelve hours, remove the cream, and add to it two-thirds of a pint of new milk, as fresh from the cow as possible. Into the one- third of a pint of blue milk left after the abstraction of the cream put a piece of rennet about one inch square. Set the vessel in warm water until the milk is fully curdled, an operation requiring from five to fifteen minutes accord- ing to the activity of the rennet, which should be removed as soon as the curdling commences, and put into an egg-cup for use on sub- sequent occasions, as it may be employed daily for a month or two. Break up the curd repeatedly, and carefully separate the whole of the whey, which should then be rapidly heated to boiling in a small tin pan placed over a spirit or gas lamp. During the heating a further quantity of casein technically called ' fleetings' separates, and must be removed by straining through muslin. Now dissolve 110 grains of powdered sugar of milk in the hot whey, and mix it with the two-thirds of a pint of new milk to which the cream from the other third of a pint was added as already described. The arti- ficial milk should be used within twelve hours of its preparation, and it is almost needless to add that all the vessels employed in its manufacture and administration should be kept scrupulously clean." Method of Hand-feeding. — Much of the success of bottle-feeding must depend on minute care and scrupulous cleanliness, points which cannot be too strongly insisted on. Particular attention should be paid to preparing the food fresh for every meal, and to keeping the feeding-bottle and tubes constantly in water when not in use, so that minute particles of milk may not remain about them and become sour. A neglect of this is one of the most fertile sources of the thrush from which bottle-fed infants often suffer. The particular form of bottle used is not of much consequence. Those now com- monly employed, with a long india-rubber tube attached, are prefer- able to the older forms of flat bottle, as they necessitate strong suc- tion on the part of the infant, thus forcing it to swallow the food more slowly. Care must be taken to give the meals at stated periods, as in breast-feeding, and these should be at first about two hours apart, the intervals being gradually extended. The nurse should be strictly cautioned against the common practice of placing the bottle beside the infant in its cradle, and allowing it to suck to repletion, a practice which leads to over-distension of the stomach, and conse- quent dyspepsia. The child should be raised in the arms at the proper time, have its food administered, and then be replaced in the cradle to sleep. In the first few weeks of bottle-feeding constipation is very common, and may be effectually remedied by placing as MANAGEMENT OF THE INFANT, LACTATION, ETC. 567 much phosphate of soda as will lie on a threepenny-piece in the bottle, two or three times in the twenty-four hours. Other kinds of Food. — If this system succeed, no other food should be given until the child is six or seven months old, and then some of the various infant's food may be cautiously commenced. Of these there are an immense number in common use ; some of which are good articles of diet, others are unfitted for infants. In selecting them we have to see that they contain the essential elements of nutri- tion in proper combination. All those, therefore, that are purely starchv in character, such as arrowroot, corn-flour, and the like, should be avoided ; while those that contain nitrogenous as well as starch elements, may be safely given. Of the latter the entire wheat flour, which contains the husks ground down with the wheat, generally answers admirably ; and of the same character are rusks, tops and bottoms, Xestle's or Liebig's infant's food, and many others. If the child be pale and flabby, some more purely animal food may often be given twice a day, and great benefit may be derived from a single meal of beef, chicken, or veal tea, with a little bread crumb in it, especially after the sixth or seventh month. Milk, however, should still form the main article of diet, and should continue to do so for many months. Management when Milk disagrees. — -If the child be pale, flabby, and do not gain flesh, more especially if diarrhoea or other intestinal dis- turbance be present, we may be certain that hand-feeding is not an- swering satisfactorily, and that some change is required. If the child be not too old, and will still take the breast, that is certainly the best remedy, but if that be not possible, it is necessary to alter the diet. "When milk disagrees, cream, in the proportion of one table- spoonful to three of water, sometimes answers as well. Occasionally also Liebig's infant's food, when carefully prepared, renders good service. Too often, however, when once diarrhoea or other intesti- nal disturbance has set in, all our efforts may prove unavailing, and the health, if not the life, of the infant becomes seriously imperilled. It is not, however, within the scope of this work to treat of the dis- orders of infants at the breast, the proper consideration of which re- quires a large amount of space, and I, therefore, refrain from making any further remarks on the subject. [As a general rule, children in this country are better kept exclu- sively on a milk diet for at least ten months, especially if it is in the summer season. The best addition then, is exsiccated wheat flour. prepared by the process of Hards, and known as Hards 1 farinaceous food, prepared wheat, imperial granum. etc. Ohio groats made of the oat kernel, and prepared barley flour, are sometimes useful where the habit of the child is constipated. — Ed.] 568 THE PUERPERAL STATE. CIIAPTEK III. PUERPERAL ECLAMPSIA. By the term puerperal eclampsia is meant a peculiar kind of epi- leptiform convulsions, which may occur in the latter months of preg- nancy, or during, or after parturition, and it constitutes one of the most formidable diseases with which the obstetrician has to cope. The attack is often so sudden and unexpected, so terrible in its nature, and attended with such serious danger both to the mother and child, that the disease has attracted much attention. Its Doubtful Etiology. — The researches of Lever, Braun, Frerichs, and many other writers who have shown the frequent association of eclampsia with albuminuria, have, of late years, been supposed to clear up to a great extent the etiology of the disease, and to prove its dependence on the retention of urinary elements in the blood. While the urinary origin of eclampsia has been pretty generally accepted, more recent observations have tended to throw doubt on its essential dependence on this cause ; so that it can hardly be said that we are yet in a position to explain its true pathology with cer- tainty. These points will require separate discussion, but it is first necessary to describe the character and history of the attack. Considerable confusion exists in, the description of puerperal con- vulsions from the confounding of several essentially distinct diseases under the same name. Thus, in most obstetric works, it has been customary to describe three distinct classes of convulsion ; the epi- leptic^ the hysterical, and the apoplectic. The two latter, however, come under a totally different category. A pregnant woman may suffer from hysterical paroxysms, or she may be attacked with apo- plexy, accompanied with coma, and followed by paralysis. But these conditions in the pregnant or parturient woman are identical with the same diseases in the non-pregnant, and are in no way special in their nature. True eclampsia, however, is different in its clinical history from epilepsy ; although the paroxysms while they last, are essentially the same as those of an ordinary epileptic fit. Premonitory Symptoms. — An attack of eclampsia seldom occurs without having been preceded by certain more or less well-marked precursory symptoms. It is true that, in a considerable number of cases, these are so slight as not to attract attention, and suspicion is not aroused until the patient is seized with convulsions. Still, sub- sequent investigations will very generally show that some symptoms did exist, which, if observed and properly interpreted, might have put the practitioner on his guard, and possibly enable him to ward off the attack. Hence a knowledge of them is of real practical value. PUERPERAL ECLAMPSIA. 569 The most common are associated with the cerebrum, such as severe headache, which is the one most generally observed, and is sometimes limited to one side of the head. Transient attacks of dizziness, spots before the eyes, loss of sight, or impairment of the intellectual facul- ties, are also not uncommon. These signs in a pregnant woman are of the gravest import, and should at once call for investigation into the nature of the case. Less marked indications sometimes exist in the form of irritability, slight headache or stupor, and a general feel- ing of indisposition. Another important premonitory sign is oedema of the subcutaneous cellular tissue, especially of the face or upper extremities, which should at once lead to an examination of the urine. Symptoms of the Attach. — Whether such indications have preceded an attack or not, as soon as the convulsion comes on there can no longer be any doubt as to the nature of the case. The attack is gene- rally sudden in its onset, and in its character is precisely that of a severe epileptic fit, or of the convulsions in children. Close observa- tion shows that there is at first a short period of tonic spasm, affecting the entire muscular system. This is almost immediately succeeded by violent clonic contractions, generally commencing in the muscles of the face, which twitch violently ; the expression is horribly altered; the globes of the eyes are turned up under the eyelids, so as to leave only the white sclerotics visible, and the angles of the mouth are retracted and fixed in a convulsive grin. The tongue is at the same time protruded forcibly, and, if care be not taken, is apt to be lacerated by the violent grinding of the teeth. The face, at first pale, soon becomes livid and cyanosecl, while the veins of the neck are distended, and the carotids beat vigorously. Frothy saliva collects about the mouth, and the whole appearance is so changed as to render the patient quite unrecognizable. The convulsive movements soon attack the muscles of the body. The hands and arms, at first rigidly fixed, with the thumbs clenched into the palms, begin to jerk, and the whole muscular system is thrown into rapidly-recurring convul- sive spasms. It is evident that the involuntary muscles are impli- cated in the convulsive action, as well as the voluntary. This is shown by a temporary arrest of respiration at the commencement of the attack, followed by irregular and hurried respiratory movements, producing a peculiar hissing sound. The occasional involuntary ex- pulsion of urine and feces indicates the same fact. During the attack the patient is absolutely unconscious, sensibility is totally suspended, and she has afterwards no recollection of what has taken place. For- tunately the convulsion is not of long duration, and, at the outside, does not last more than three of four minutes, generally not so long. In most cases, after an interval, there is a recurrence of the convul- sion, characterized by the same phenomena, and the paroxysms are repeated with more or less force and frequency according to the severity of the attack. Sometimes several hours may elapse before a second convulsion comes on ; at others the attacks may recur very often, with only a few minutes between them. In the slighter forms 37 570 THE PUERPERAL STATE. of eclampsia there may not be more than 2 or 3 paroxysms in all ; in the more serious as many as 50 or 60 have been recorded. Condition between the Attacks. — After the first attack the patient generally soon recovers her consciousness, being somewhat dazed and somnolent, with no clear perception of what has occurred. If the paroxysms be frequently repeated, more or less profound coma con- tinues in the intervals between them, which, no doubt, depends upon intense cerebral congestion, resulting from the interference with the circulation in the great veins of the neck, produced by spasmodic contraction of the muscles. The coma is rarely complete, the patient showing signs of sensibility when irritated, and groaning during the uterine contractions. In the worst class of cases, the torpor may become intense and continuous, and in this state the patient may die. When the convulsions have entirely stopped, and the patient has completely regained her consciousness, and is apparently conva- lescent, recollection of what has taken place during, and some time before, the attack, may be entirely lost, and this condition may last for a considerable time. A curious instance of this once came under my notice in a lady who had lost a brother to whom she was greatlv attached, in the week immediately preceding her confinement, and in whom the mental distress seemed to have had a good deal to do in determining the attack. It was many weeks before she recovered her memory, and during that time she recollected nothing about the circumstances connected with her brother's death, the whole of that week being, as it were, blotted out of her recollection. Relation of the Attacks to Labor. — If the convulsions come on during pregnancy, we may look upon the advent of labor as almost a certainty ; and if we consider the severe nervous shock and general disturbance, this is the result we might reasonably anticipate. If they occur, as is not uncommon, for the rlrst time during labor, the pains generally continue with increased force and frequency, since the uterus partakes of the convulsive action. It has not rarely happened that the pains have gone on with such intensity that the child has been born quite unexpectedly, the attention of the practi- tioner being taken up with the patient. In many cases the advent of fresh paroxysms is associated with the commencement of a pain, the irritation of which seems sufficient to bring on the convulsion. Results to the Mother and Child. — The results of eclampsia vary according to the severity of the paroxysms. It is generally said that about 1 in 3 or 4 cases- dies. The mortality has certainly lessened of late years, probably in consequence of improved knowledge of the nature of the disease, and more rational modes of treatment. This is well shown by Barker, 1 who found in 1855 a mortality of 32 per cent, in cases occurring before and during labor, and 22 per cent, in those after labor; while since that date the mortality has fallen to 14 per cent. The same conclusion is arrived at by Dr. Phillips, 2 who has shown that the mortality has greatly lessened since the practice of repeated and indiscriminate bleeding, long considered the 1 The Puerperal Disease, p. 125. 2 Guy's Hosp. Reps., 1870. PUERPERAL ECLAMPSIA. 571 sheet anchor in the disease, has been discontinued, and the adminis- tration of chloroform substituted. Cause of Death. — Death may occur during the paroxysm, and then it may be due to the long continuance of the tonic spasm producing asphyxia. It is certain that, as long as the tonic spasm lasts, the respiration is suspended, just as in the convulsive disease of children known as laryngismus stridulus ; and it is possible also that the heart may share in the convulsive contraction which is known to affect other involuntary muscles. More frequently, death happens at a later period, from the combined effects of exhaustion and asphyxia. The records of post-mortem examinations are not numerous; in those we possess the principal changes have been an anaemic condition of the brain, with some cedematous infiltration. In a few rare cases the convulsions have resulted in effusion of blood into the ventricles, or at the base of the brain. The prognosis as regards the child is also serious. Out of 36 children, Hall Davis found 26 born alive, 10 being still-born. There is good reason to believe that the con- vulsion may attack the child in utero ; of this several examples are mentioned by Cazeaux ; or it may be subsequently attacked with convulsions, even when apparently healthy at birth. Pathology of the Disease. — The precise pathology of eclampsia cannot be considered by any means satisfactorily settled. When, in the year 18-13, Lever first showed that the urine in patients suffering from puerperal convulsions was generally highly charged with albu- men — a fact which subsequent experience has amply confirmed — it was thought that a key to the etiology of the disease had been found. It was known that chronic forms of Bright's disease were frequently associated with retention of urinary elements in the blood, and not rarely accompanied by convulsions. The natural inference was drawn, that the convulsions of eclampsia w r ere also due to toxaemia resulting from the retention of urea in the blood, just as in the uraemia of chronic Bright's disease ; and this view was adopted and supported by the authority of Braun, Frcrichs, and many other writers of eminence, and was pretty generally received as a satisfac- tory explanation of the facts. Frerichs modified it so far, that he held that the true toxic element was not urea as such, but carbonate of ammonia, resulting from its decomposition; and experiments were made to prove that the injection of this substance into the veins of the lower animals produced convulsions of precisely the same char- acter as eclampsia. Dr. Hammond, 1 of Maryland, subsequently made a series of counter experiments, which were held as proving that there was no reason to believe that urea ever did become decom- posed in the blood in the way that Frerichs supposed, or that the symptoms of uraemia were ever produced in this way. Spiegelberg 2 has, more recently, again examined the question both clinically, in a patient suffering from convulsions, in whose blood an excess of ammonia and urea was found, and by experiments on dogs, and maintains the accuracy of French's views. Others have believed » Amer. Journ., 1861. 2 Arch. f. Gyn., 1870, 572 THE PUERPERAL STATE. that the poisonous elements retained in the blood are not urea or the products of its decomposition, but other extractive matters which have escaped detection. As time elapsed, evidence accumulated to show that the relation between albuminuria and eclampsia was not so universal as was supposed, or at least that some other factors were necessary to explain many of the cases. Numerous cases were observed in which albumen was detected in large quantities, without any convulsion following, and that, not only in women who had been the subject of Bright's disease before conception, but also when the albuminuria was known to have developed during pregnancy. Thus Imbert Groubeyre found that out of 164: cases of the latter kind, 95 had no eclampsia ; and Blot, out of 3 ° - 102' u I01 ' < ICO' 99' 08- " ft J [ \ I! !• payoJVti 1" y J 4* | 5- 1 ' 7'" s ,v 9 a IfV , 'Ok a long vaginal pipe attached. 1 The results are sometimes very re- markable, the threatening symptoms rapidly disappearing, and the temperature and pulse falling so soon after the use of the antiseptic injections as to leave no doubt of the beneficial effects of the treatment. I cannot better illustrate the advan- tages of this treatment than by the accompanying temperature chart, which is from a case which came under my observation in the out-door practice of King's College Hospital. It was that of a healthy woman, thirty- six years of age, who had an easy and natural labor. Nothing re- markable was observed until the 3d day after delivery, when the temper- ature was found to be slightly in- creased. On the morning of the 8th day the temperature had risen to 105.4°. She was delirious, with a rapid thready pulse, clammy perspiration, tympanitic abdomen, and her general condition indicated the most urgent danger. On vaginal examination a piece of com- pressed and putrid placenta was found in the os. This was removed by my colleague, Dr. Hayes, and the uterus thoroughly washed out with Condy's fluid and water. The same evening the temperature had sunk to 99° and the general symptoms were much improved. The next day there was a slight return of offensive discharge, and an aggravation of the symptoms. After again washing out the uterus the temperature fell, and from that date the patient conva- lesced without a single bad symptom. This is a very well-marked example of the value of local anti- septic treatment, and I have seen many cases of the same kind. It should, therefore, never be omitted in all cases in which self-infection is possible ; and, indeed, even when there is no reason to suspect the presence of a local focus of infection, the use of antiseptic lotions is 1 My colleague, Dr. Hayes, has invented a silver tube for the purpose of adminis- tering such infra-uterine injections (Fig. 183), which answers its purpose admirably. Fig. 183. Hayes's Tube for Tntra-uterine Injections. The numerous apertures at its extremity allow of a number of minute streams of fluid being thrown out in the form of a spray over the interior of the uterus, the complete bathing of its surface and washing out of its cavity being thus insured. It is, more- over introduced more easily than the ordinary vaginal pipe, and can be attached to a Higginson syringe. PUERPERAL SEPTICEMIA. 609 advisable, as a matter of precaution, since it can do no harm, and is generally comforting to the patient. Any antiseptic may be used, such as a weak solution of carbolic acid, 1 in 50, or of tincture of iodine, or Conchy's fluid largely diluted. I generally use the two latter alternately, the one in the morning, the other in the evening. The nozzle of the syringe should be guided well through the cervix, and the cavity of the uterus thoroughly washed out, until the fluid that issues from the vagina is no longer discolored. As the os is always patulous, there is no risk of producing the troublesome symptoms of uterine colic which occasionally follow the use of intra-uterine injec- tions in the unimpregnated state. It is quite useless to entrust the injec- tion to the nurse, and it should be performed at least twice daily by the practitioner himself, in all cases in which the discharges are offensive. Administration of Food and Stimulants. — In a disease characterized by so marked a tendency to prostration, the importance of sustaining the vital powers by an abundance of easily assimilated nourishment cannot be overrated. Strong beef-tea, or other forms of animal soup, milk, alone or mixed either with lime or soda water, and the yolk of eggs, beat up with milk and brandy, should be given at short inter- vals, and in as large quantities as the patient can be induced to take; and the value of thoroughly efficient nursing will be specially ap- parent in the management of this important part of the treatment. As there is frequently a tendency to nausea, the patient may resist the administration of food, and the resources of the practitioner will be taxed in administering it in such form and variety as will prove least distasteful. Generally speaking not more than one or two hours should be allowed to elapse without some nutriment being given . The amount of stimulant required will vary with the inten- sity of the symptoms, and the indications of debility. Generally, stimulants are well borne, prove decidedly beneficial, and require to be given pretty freely. In cases of moderate severity a tablespoonful of good old brandy or whiskey every four hours may suffice ; but when the pulse is very rapid and thready, when there is much low delirium, tympanites, or sweating (indicating profound exhaustion), it may be advisable to give them in much larger quantities and at shorter intervals. The careful practitioner will closely watch the effects produced, and regulate the amount by the state of the patient, rather than by any fixed rule ; but in severe cases, eight or twelve ounces of brandy, or even more, in the twenty-four hours may be given with decided benefit. Venesection not Admissible} — Venesection, both general and local, [' I believe that the entire abandonment of venesection lias been a grave error, and that where there is early in the attack, a high pulse, with great abdominal distension and tenderness, and a decided elevation of temperature, we ought to bleed the patient sitting, at once, and to such a degree as to produce a decided impression. One of the worst cases I ever saw, was cured in this way. The woman was delivered at 3^ P.M. of one day, and the disease manifested itself in twenty hours. At 9 the next morning she was apparently doing well : at 1 she was in great suffering, and could not bear her abdomen to be touched ; vs. i§xvj : at 9 P.M., symptoms more grave ; vs. f§xl in a sitting posture until she felt sick. At 10 P. M. pulse 150 : in twenty-four hours from this, no fever and very little pain : in three days, regarded as out of danger. Saw her in robust health, with her child living, a year later. — Ed.] CIO THE PUERPERAL STATE. was long considered a sheet anchor in this disease. Modern views are, however, entirely opposed to its use ; and in a disease character- ized by so profound an alteration of the blood, and so much prostra- tion, it is too dangerous a remedy to employ, although it is possible that it might alleviate temporarily the severity of some of the symptoms, especially in cases iu which peritonitis is well marked, and much local pain and tenderness are present. Medicinal Treatment. — The rational indications in medicinal treat- ment are to lessen the force of the circulation as much as is possible without favoring exhaustion; and to diminish the temperature. Use of Arterial Sedatives. — For the former purpose. Barker strongly advocates the use of veratrum viride, in doses of five drops of the tincture every hour, until the pulse falls to below 100, when its effects are subsequently kept up by two or three drops every second hour. Of this drug I have no personal experience; but I have ex- tensively used minute doses of tincture of aconite for the same pur- pose, and, when carefully given, I believe it to be a most valuable remedy. The way I have administered it is to give a single drop of the tincture, at first every half-hour, increasing the interval of ad- ministration according to the effect produced. Generally, after giving four or five doses at intervals of half an hour, the pulse begins to fall, and afterwards a few doses, at intervals of one or two hours, will suffice to prevent the heart's action rising to its former rapidity. The advantage of thus modifying cardiac action, with the view of preventing excessive waste of tissue, cannot be questioned. It is evident that so powerful a remedy must not be used without the most careful supervision, for, if continued too long, or given at too frequent intervals, it may unduly depress the circulation, and do more harm than good. It is necessary, therefore, that the practi- tioner should constantly watch the effect of the drug, and stop it if the pulse become very weak, or if it intermit. It is most likely to be useful at an early stage of the disease before much exhaustion is present, and then only when the pulse is of a certain force and volume. Barker says of the veratrum viride, what is also true of aconite, that "it should not be given in those cases in which rapid prostration is manifested by a feeble, thread-like irregular pulse, profuse sweats, and cold extremities. 1 ' Reduction of Temperature. — The reduction of temperature must form an important part of our treatment, and for this purpose many agents are at our disposal. Quinine in large doses, of from 10 to 20 grains, has been much used for this purpose, especially in Germany. After its exhibition the temperature frequentlv falls one or two degrees. It may be given morning and evening. Unpleasant head-symptoms, deafness, and ringing in the ears, often render its continuance for a length of time impossible; these may, however, be much lessened by the addition of 10 to 15 minims of hydrobromic acid to each dose. Salicylic acid, in doses of from 10 to 20 grains, or the salicylate of soda in the same doses, is a valuable antipyretic, which I have found PUERPERAL SEPTICEMIA. 611 on the whole more manageable than quinine. Under its use the tern perat are often falls considerably in a short space of time. It is, however, apt to depress the circulation, and thus requires to be care- fully watched while it is being administered, and should the pulse become very small and feeble, it should be discontinued. Warburg's Tincture. — In some cases, especially when the fever has assumed a remittent type, I have administered with marked benefit, a drug which is of high repute in India, in the worst class of mala- rious remittent fevers, and the almost marvellous effects of which in such cases I had myself witnessed in India many years ago. This is the so-called Warburg's tincture, the value of which has been testified to by many high authorities; among whom I may mention Dr. Mac- lean of Netley, Dr. Broadbent, and Sir Alexander Armstrong, the Director-General of the Medical Department of the Navy, who informs me that it is now supplied to all Pier Majesty's ships in the tropics, because it is found to be of the utmost value in cases in which quinine has little or no effect. Kscently its composition has been made public by Dr. Maclean. The basis is quinine, in combination with various aromatics and bit- ters, some of which probably intensify its action. Be this as it may, the testimony in favor of the anti-pyretic action of the remedy is very strong. I have found its exhibition followed by a profuse dia- phoresis (this being its almost invariable effect), and sometimes a rapid amelioration of the symptoms. In other cases in which I have tried it, like everything else, it has proved of no avail. Application of Cold. — Cold may be advantageously tried in suitable cases. The simplest mode of using it is by Thornton's ice-cap, by which a current of cold water is kept continuously running round the head. This has been found of great value in pyrexia after ova- riotomy, and I have also found it useful as a means of reducing tem- perature in puerperal cases. It is a comforting application, and gives great relief to the throbbing "headache, which often causes much suf- fering. Under its use the temperature often falls two or more de- grees, and it is easily continued day or night. In very serious cases, when the temperature reaches 105° and up- wards, the external application of cold to the rest of the body may be tried. I have elsewhere related a case of puerperal septicaemia with hyper-pyrexia, the temperature continuously ranging over 105°, in which I kept the patient for eleven days 1 nearly continuously covered with cloths soaked in iced water, by which means only was the temperature kept within moderate bounds, and life preserved. But this method of treatment is excessively troublesome, and is in no way curative. It is only of use in moderating the temperature when it has reached a point at which it could not continue long with- out destroying the patient. I should, therefore, never think of em- ploying it unless the temperature was over 105°, and then only as a temporary expedient, requiring incessant watching, to be desisted 1 A Lecture on a case of Puerperal Septicaemia, with Hyper-pyrexia, treated by the continuous application of Cold. — Brit. Med. Joum., Nov. 17, 1677. 612 THE PUERPERAL STATE. from as soon as the temperature had reached a more moderate height. It is clearly impossible to place a puerperal patient in a bath, as is practised in hyper-pyrexia associated with acute rheumatism. The same effect may, however, be obtained by placing her on Mackintosh sheeting, and covering the body with towels soaked in iced water, which are frequently renewed by the attendant nurses. During the application the temperature should be constantly taken, and as soon as it has fallen to 101°, the cold applications should be discontinued. Administration of Turpentine. — Amongst other remedies which have been used is turpentine, which was highly thought of by the Dublin school. In cases with much tympanitic distension, and a small weak pulse, it is sometimes of unquestionable value, and it probably acts as a strong nervine stimulant. Given in doses of 15 to 20 minims, rubbed up with mucilage, it can generally be taken in spite of its nauseous taste. Evacuant Remedies. — Purgatives, diaphoretics, or even emetics, have often been employed as eliminants of the poison. The former are strongly recommended by Schroeder and other German authori- ties, and in this country they were formerly amongst the most favorite remedies, and there is a general concurrence of opinion amongst our older writers as to their value. In the first volume of the " Obstetrical Journal," there is a paper by Mr. Morton, in which this practice is strongly advocated, and some interesting cases are recorded in which it apparently acted well. He administers calomel in doses of 3 or 4 grains with compound extract of colocynth, so as to keep up a free action of the bowels. It seems quite reasonable, when there is constipation, to promote a gentle action of the bowels by some mild aperient ; but, bearing in mind that severe and ex- hausting diarrhoea is a common accompaniment of the disease, I should myself hesitate to run the risk of inducing it artificially, espe- cially as there is no proof whatever that septic matter can really be eliminated in this way. At the commencement of the disease, how- ever, I have often given one or two aperient doses of calomel with decided benefit. Internal Antiseptic Remedies. — It is possible that further research will give us some means of counteracting the septic state of the blood, and the sulphites and carbolates have been given for this purpose, but as yet with no reliable results. Tincture of Perchloride of Iron. — The tincture of the perchloride of iron naturally suggests itself, from its well-known effects in surgi- cal pyaemia. In the less intense forms of the disease, especially when local suppurations exist, it is certainly useful, and may be given in doses of 10 to 20 minims every 3 or 4 hours. In very acute cases other remedies are more reliable, and the iron has the disadvantage of not unfrequently causing nausea or vomiting. Opiates. — When restlessness, irritation, and want of sleep are prominent symptoms, sedatives may be required. Under such cir- cumstances opiates may be given at night, and Battley's solution, nepenthe, or the hypodermic injection of morphia, are the forms which answer best. PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 613 Treatment of Local Complications. — Pain and tenderness, and local complications, must be treated on general principles. The distress from them is most experienced when peritonitis is well marked. Then warm and moist applications, in the form of poultices or fomen- tations, are very useful. Relief is also sometimes obtained from turpentine stupes, and, when the tympanites is distressing, turpentine enemata are very serviceable. I have found the free application over the abdomen of the flexible collodium of the pharmacopoeia, decidedly useful in alleviating the suffering from peritonitis. Such are the remedies most used in the treatment of this disease. It is needless to say that it is quite impossible to lay dowu fixed rules for the management of any individual case ; and it is obvious that, if puerperal septicaemia be not a special and distinct disease, its judi- cious management must depend on the general knoAvledge of the attendant, and on a careful study of the symptoms each separate case presents. CHAP TEE YI. PUERPERAL VEXOU3 THROMBOSIS AXD EMBOLISM.. Uxder the head of thrombosis we may class several important diseases connected with the puerperal state, which have received far less attention than they deserve. It is only of late years that some, we may probably safely say the majority, of those terribly sudden deaths which from time to time occur after delivery, have been traced to their true cause, viz., obstruction of the right side of the heart and pulmonary arteries from a blood-clot, either carried from a distance, or, as I shall hope to show, formed in situ. Although the result, and, to a great extent, the symptoms, are identical in both, still a careful consideration of the history of these two classes of cases tends to show that in their causation they are distinct, and that they ought not to be confounded. In the former, Ave have primarily a clotting of blood in some part of the peripheral venous system, and the sepa- ration of a portion of such a thrombus due to changes undergone during retrograde metamorphosis tending to its eventual absorption. In the latter we have a local deposition of flbrine, the result of blood changes consequent on pregnancy and the puerperal state. The formation of such a coagulum in vessels, the complete obstruction of which is incompatible with life, explains the fatal results. \Yhen, however, a coagulum chances to be formed in more distant parts of the circulation, the vital functions are not immediately interfered with, and we have other phenomena occurring, due to the obstruction. The disease known as phlegmasia dolens, I shall presently attempt 614 THE PUERPERAL STATE. to show, is one result of blood-clot forming in peripheral vessels. But from the evident and tangible symptoms it produces it has long been considered an essential and special disease, and the general blood dyserasia which produces it, as well as other allied states, has not been studied separately. I shall hope to show that all these various conditions, dissimilar as they at first sight appear, are yery closely connected, and that they are in fact due to a common cause • and thus, I think, we shall arrive at a clearer and more correct idea of their true nature, than if we looked upon them as distinct and separate affections, as has been commonly clone. I am aware that in phlegmasia dolens, the pathology of which has received perhaps more study than that of almost any other puerperal affection, some- thing beyond simple obstruction of the venous system of the affected limb is probably required to account for the peculiar tense and shining swelling which is so characteristic. Whether this be an obstruction of the lymphatics, as Dr. Tilbury Fox and others have maintained with much show of reason, or whether it is some as yet undiscovered state, further investigation is required to show. But it is beyond any doubt that the important and essential part of the disease is the presence of a thrombus in the vessels; and I think it will not be difficult to prove that in its causation and history it is precisely similar to the more serious cases in which the pulmonary arteries are involved. It will be Avell to commence the study of the subject by a consid- eration of the conditions which, in the puerperal state, render the blood so peculiarly liable to coagulation, and we may then proceed to discuss the symptoms and results of the formation of coagula in various parts of the circulatory system. Conditions which favor Thrombosis.- — The researches of Yirchow, Benj. Ball, Humphrey, Kicharclson, and others, have rendered us tolerably familiar with the conditions which favor the coagulation of the blood in the vessels. These are chiefly: 1. A stagnant or arrested circulation ; as, for example, when the blood coagulates in the veins which draw blood from the gluteal region in old and bed- ridden people, or as in some forms of pulmonary thrombosis, in which the clots in the arteries are probably the result of obstruction in the circulation through the lung-capillaries, as in certain cases of emphy- sema, pneumonia, or pulmonary apoplex}^. 2. A mechanical obstruc- tion around which coagula form, as in certain morbid states of the vessels, or, a better example still, secondary coagula which form around a travelled embolus impacted in the pulmonary arteries. 3. And most important of all, in which the coagulation is the result of some morbid state of the blood itself. Examples of this last condi- tion are frequently met with in the course of various diseases, such as rheumatism or fever, in which the quantity of fibrine is increased, and the blood itself is loaded with morbid material. Thrombosis from this cause is of by no means infrequent occurrence after severe surgical operations, especially such as have been attended with much hemorrhage, or when the patient is in a weak and anoemic condition. PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 615 This has been specially dwelt upon as a not infrequent source of death after operation by Fay re r and other surgeons. 1 Conditions -which favor Coagulation in the Puerperal State. — But little consideration is required to show why thrombosis plays so im- portant a part in the puerperal state, for there most of the causes favoring its occurrence are present. Probably there is no other con- dition in which they exist in so marked a degree, or are so frequently combined. The blood contains an excess of fibrine, which largely increases in the latter months of utero-gestation, until, as has been pointed out by Andral and Gravarret, it not unfrequently contains a third more than the average amount present in the non-pregnant state. As soon as delivery is completed, other causes of blood dys- crasia come into operation. Involution of the largely hypertrophied uterus commences, and the blood is charged with a quantity of effete material, which must be present, in greater or less amount, until that process is completed. It is an old observation that phlegmasia dolens is of very common occurrence in patients who have lost much blood during labor; thus Dr. Leishman says: "In no class of cases has it been so frequently observed as in women whose strength has been reduced to a low ebb by hemorrhage either during or after labor; and this, no doubt, accounts for the observation made by Merriman, that it is relatively a common occurrence after placenta previa." 2 An examination of the cases in which death results from pulmonary thrombosis shows the same facts, as in a large proportion of them severe post-partum hemorrhage has occurred. The exhaus- tion following the excessive losses so common after labor must of itself strongly predispose to thrombosis, and, indeed, loss of blood has been distinctly pointed out by Richardson to be one of its most common antecedents. "There is," he observes, "a condition which has been long known to favor coagulation and fibrinous deposition. I mean loss of blood, and syncope or exhaustion during impoverished states of the body." Since then so many of the predisposing causes of thrombosis are present in the puerperal state, it is hardly a matter of astonishment that it should be of frequent occurrence, or that it should lead to conditions of serious gravity. And yet the attention of the profession has been for the most part limited to a study of one only of the results of this tendency to blood-clotting after delivery, no doubt because of its comparative frequency and evident symptoms. True the balance of professional opinion has lately held that phlegmasia dolens is chiefly the result of some morbid condition of the blood producing plugging of the veins ; but the wider view which I am attempting to maintain, which would bring this disease into close relation with the more rarely observed, but infinitely important, obstructions of the pulmonary arteries, has scarcely, if at all, been insisted on. Doubtless further investigation will show that it is not in these parts of the venous system alone that puerperal thrombosis 1 Edin. Med. Jonrn., March, 1861 ; Indian Annals of Med., July, 1867. 2 Leishman, System of Obstetrics, p. 710. 616 THE PUERPERAL STATE. occurs ; but the symptoms and effects of venous obstruction else- where, important though they may be, are unknown. I propose then to describe the symptoms and pathology of blood- clot in the right side of the heart and pulmonary artery. It maybe useful here to repeat that this is essentially distinct from embolism of the same parts. The latter is obstruction due to the impaction of a separated portion of a thrombus formed elsewhere, and for its pro- duction it is essential that thrombosis should have preceded it. Em- bolism is in fact an accident of thrombosis, not a primary affection. The condition we are now discussing I hold to be primary, precisely similar in its causation to the venous obstruction which, in other situations, gives rise to phlegmasia dolens. At the threshold of this inquiry we have to meet the objection, started by several who have written on this subject, 1 that sponta- neous coagulation of the blood, in the right side of the heart and pulmonary arteries, is a mechanical and physiological impossibility. This was the view of Yircbow, who, Avith his followers, maintained that whenever death from pulmonary obstruction occurred, an em- bolus was of necessity the starting-point of the malady, and the nucleus round which secondary deposition of fibrine took place. Yirchow holds that the primary factor in thrombosis is a stagnant state of the blood, and that the impulse imparted to the blood by the right ventricle is of itself sufficient to prevent coagulation. It is to be observed that these objections are purely theoretical. Without denying that there is considerable force in the arguments adduced, I think that the clinical history of these cases strongly favors the view of spontaneous coagulation ; and I would apply to the theoretical objections advanced the argument used by one of their strongest upholders, with regard to another disputed point, " Je prefere laisser la parole aux faits, car devant eux la the'orie s'incline.'' 3 The anatomical arrangement of the pulmonary arteries shows how spontaneous coagulation may be favored in them; for, as Dr. Hum- phrey has pointed out, 3 " the artery breaks up at once into a number of branches, which radiate from it, at different angles, to the several parts of the lungs. Consequently, a large extent of surface is pre- sented to the blood, and there are numerous angular projections into the currents ; both which conditions are calculated to induce the spontaneous coagulation of the fibrine." We know also, that throm- bosis generally occurs in patients of feeble constitution, often debili- tated by hemorrhage, in whom the action of the heart is much weak- ened. These facts, of themselves, go far to meet the objections of those who deny the possibility of spontaneous coagulation at the roots of the pulmonary arteries Results of Post-mortem Examinations. — The records of post-mortem examinations show also, that in many of the cases the right side of the heart, as well as the larger branches of the pulmonary arteries, 1 See especially Berlin, Des Embolies, p. 46 et seq. 2 Bertin , Des Embolies, p. 149. 8 Humphrey, On the Coagulation of the Blood in the Venous System during Life. PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 617 contained firm, leathery, decolorized, and laminated coagula, which could not have been recently formed. The advocates of the purely embolic theory maintain that these are secondary coagula, formed around an embolus. But surely the mechanical causes which are sufficient to prevent spontaneous deposition of fibrine, would also suffice to prevent its gathering round an embolus ; unless, indeed, the obstruction was sufficient to arrest the circulation altogether, when death would occur before there was any time for secondary deposit. Before we can admit the possibility of embolism, we must haveat least one factor, that is, thrombosis in a peripheral vessel, from which an embolus can come. In many of the recorded cases nothing of the kind was found, and although, as is argued, this may have been overlooked, yet such an oversight can hardly always have been made. The strongest argument, however, in favor of the spontaneous origin of pulmonary thrombosis is one which I originally pointed out°in a series of papers k ' On thrombosis and embolism of the pul- monary artery as a cause of death in the puerperal state." 1 I there showed, from a careful analysis of 25 cases of sudden death after delivery in which accurate post-mortem examination had been made, that cases of spontaneous thrombosis and embolism may be divided from each other by a clear line of demarcation, depending on the period after delivery at which the fatal result occurs. In 7 out of these cases there was distinct evidence of embolism, and in them death occurred at a remote period after delivery ; in none before the nineteenth day. This contrasts remarkably with the cases in which the post-mortem examination afforded no evidence of embolism. These amounted to 15 out of the 25, and in all of them, with one exception, death occurred before the fourteenth day, often on the second or third. The reason of this seems to be that in the former, time is required to admit of degenerative changes taking place in the deposited fibrine leading to separation of an embolus ; while in the latter, the thrombosis corresponds in time, and to a great extent no doubt also in cause, to the original peripheral thrombosis from which, in the former, the embolus was derived. Many cases I have since collected illustrate the same rule in a very curious and instructive way. Another clinical fact I have observed points to the same conclusion. In one or two cases distinct signs of pulmonary obstruction have shown themselves without proving immediately fatal, and shortly afterwards, peripheral thrombosis, as evidenced by phlegmasia dolens of one extremity, has commenced. Here the peripheral thrombosis obviously followed the central, both being produced by identical causes, and the order of events, necessary to uphold the purely em- bolic theory, was reversed. I hold, then, that those who deny the possibility of spontaneous coagulation in the heart and pulmonary arteries do so on insufficient ground, and that we may consider -it to be an occurrence, rare no 1 Lancet, 1867. 40 618 THE PUERPERAL STATE. doubt, but still sufficiently often met with, and certainly of sufficient importance, to merit very careful study. History. — Dr. Chas. D. Meigs, of Philadelphia, was one of the first to direct attention to spontaneous coagulation of the blood in the right side of the heart and pulmonary arteries, as a cause of sudden death in the puerperal state. The occurrence itself, however, has been carefully studied by Paget, whose paper was published in 1855, four years before Meigs wrote on the subject. 1 ft is true that none of Paget's cases happened after delivery, but he none the less clearly apprehended the nature of the obstruction. In 1855, Hecker 2 at- tributed the majority of these cases to embolism proper; and since that date most authors have taken the same view, believing that spontaneous coagulation only occurs in exceptional cases, such as those in which, on account of some obstruction in the lung or in the debility of the last few hours before death, coagula form in the smaller ramifications of the pulmonary arteries, and gradually creep backwards towards the heart. Symptoms of Pulmonary Obstruction. — The symptoms can hardly be mistaken, and there seems to be no essential difference between the symptomatology of spontaneous and embolic obstructions, so that the same description will suffice for both. In a large proportion of cases the attack comes on with an appalling suddenness which forms one of its most striking characteristics. Nothing in the condition of the patient need have given rise to the least suspicion of impending mischief, when, all at once, an intense and horrible dyspnoea comes on; she gasps and struggles for breath; tears off the coverings from her chest in a vain endeavor to get more air; and, often, dies in a few minutes, long before medical aid can be had, with all the symp- toms of asphyxia. The muscles of the face and thorax are violently agitated in the attempt to oxygenate the blood, and an appearance closely resembling an epileptic convulsion may be presented. The face may be either pale or deeply cyanosed. Thus in one case I have elsewhere recorded, which was an undoubted example of true em- bolism, Mr. Pedler, the resident accoucheur at King's College Hos- pital, who was present during the attack, writes of the patient, 3 "She was suffering from extreme dyspnoea, the countenance was excessively pale, her lips white, the face generally expressing deep anxiety." In another, which was probably an example of sponta- neous thrombosis, 4 occurring on the twelfth day after delivery, it is stated " the face had assumed a livid purple hue, which was so re- markable as to attract the attention both of the nurse and of her mother, who was with her." The extreme embarrassment of the cir- culation is shown by the tumultuous and irregular action of the heart, in its endeavor to send the venous blood through the obstructed arteries. Soon it gets exhausted, as shown by its feeble and flutter- ing beat. The pulse is thread-like, and nearly imperceptible, the 1 Medico-Chir. Trans., vol. xxvii. p. 162, and vol. xxviii. p. 352; Philadelphia Medical Examiner, 1849. 2 Deutsche Klinicke, 1S55. 3 Brit. Med. Journ., March 27, 1869. 4 Obst. Trans., vol. xii. p. 194. PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 619 respirations short and hurried, but air may be heard entering the lungs freely. The intelligence during the struggle is unimpaired ; and the dreadful consciousness of impending death adds not a little to the patient's sufferings, and to the terror of the- scene. Such is an imperfect account of the symptoms, gathered from a record of what has been observed in fatal cases. It will be readily understood why, in the presence of so sudden and awful an attack, symptoms have not been recorded with the accuracy of ordinary clinical observation. A question of great practical interest, which has been entirely overlooked by writers on the subject is — Have we any ground for supposing that there is a possibility of recovery after symptoms of pulmonary obstruction have developed themselves? That such a result must be of extreme rarity is beyond question ; but I have little doubt that in some few cases, entirely inexplicable on any other hypothesis, life is prolonged until the coagulum is absorbed, and the pulmonary circulation restored. In order to admit of this it is, of course, essential that the obstruction be not sufficient to prevent the passage of a certain quantity of blood to the lungs, to carry on the vital functions. The history of mairy cases tends to show that the obstructing clot was present for a considerable time before death, and that it was only when some sudden exertion was made, such as rising from bod or the like, calling for an increased supply of blood which could not pass through the occluded arteries, that fatal symptoms manifested themselves. This was long ago pointed out by Paget, 1 who says, "The case proves that, in certain circumstances, a great part of the pulmonary circulation may be arrested in the course of a week (or a few days more or less), without immediate danger to life, or any indication of what had happened." And, after referring to some illustrative cases, "Yet in all these cases the characters of the clots by which the pulmonary arteries were obstructed, showed plainly that they had been a week or more in the process of forma- tion." If we admit the possibility of the continuance of life for a certain time, we must, I think, also admit the possibility, in a few rare cases, of eventual complete recovery. What is required is time for the absorption of the clot. In the peripheral venous system coagula are constantly removed by absorption. So strong, indeed, is the tendency to this, that Humphrey observes with regard to it, " It appears that the blood is almost sure to revert to its natural channel in process of time.'* 2 If then the obstruction be only par- tial, if sufficient blood pass to keep the patient alive, and a sudden supply of oxygenated blood is not demanded by any exertion which the embarrassed circulation is unable to meet, it is not inconceivable that the patient may live until the obstruction is removed. Illustrative Cases. — Such, I believe, to be the only explanation of certain cases, some of which, on any other hypothesis, it is impossible to understand. The symptoms are precisely those of pulmonary obstruction, and the description I have given above may be applied to them in every particular ; and, after repeated paroxysms, each of 1 Op. cit., p. 358. 2 Med. Chir. Trans., vol. xxvii. p. 14. 620 THE PUERPERAL STATE. which seems to threaten immediate dissolution, an eventual recovery takes place. What, then, I am entitled to ask, can the condition be, if not that which I suggest? As the question I am considering has never, so far as I am aware, been treated of by any other writer, I may be permitted to state, very briefly, the facts of one or two of the cases on which I found my argument, some of which I have already published in detail elsewhere. K. H., delicate young lady. Labor easy. First child. Profuse post-partum hemorrhage. Did well until the 7th day, during the whole of which she felt weak. Same day an alarming attack of dyspnoea came on. For several days she remained in a very critical condition, the slightest exertion bringing on the attacks. A slight blowing murmur heard for a few days at the base of the heart, and then disappeared. For two months patient remained in the same state. As long as she was in the recumbent position she felt pretty comfortable ; but any attempt at sitting up in bed, or any unusual exertion, immediately brought on the embarrassed respiration. During all this time it was found necessary to administer stimulants profusely to ward off the attacks. Eventually the patient recovered completely. Q. F., set. 44. Mother of twelve children. Confined on July 6. On the 11th day she went to bed feeling well. There was no swelling or discomfort of any kind about the lower extremities at this time. About half-past 3 A.M. she was sitting up in bed, when she was suddenly attacked with an indescribable sense of oppression in the chest, and fell back in a semi-unconscious state, gasping for breath. She re- mained in a very critical condition, with the same symptoms of embarrassed respira- tion, for three days, when they gradually passed away. Two days after the attack, phlegmasia dolens came on, the leg swelled, and remained so for several months. This case is an example of the fact I have already referred to, of phlegmasia dolens corning on after the symptoms of pulmonarv obstruction had manifested themselves; the inference being that both depended on similar causes operating on two distinct parts of the circulatory system. C. H., get. 24. Confined of her first child on August 20, 1867. Thirty hours after delivery she complained of great weakness and dyspnoea. This was alleviated by the treatment employed, but on the ninth day, after making a sudden exertion, the dyspnoea returned with increased violence, and continued unabated until I saw the patient on September 4, fourteen days after her confinement. The following are the notes of her condition made at the time of the visit : "I found her sitting on the sofa, propped up with pillows, as she said she could not breath in the recumbent position. The least excitement or talking brought on the most aggravated dyspnoea, which was so bad as to threaten almost instant death. Her sufferings during these paroxysms were terrible to witness. She panted and struggled for breath, and her chest heaved with short gasping respirations. She could not even bear any one to stand in front of her, waving them away with her hand, and calling for more air. These attacks were very frequent, and were brought on by the most trivial causes. She talked in a low suppressed voice, as if she could not spare breath for articulation. On auscul- tation air was found to enter the lungs freely in every direction, both in front and behind. Immediately over the site of the pulmonary arteries there was a distinct harsh, rasping murmur, confined to a very limited space, and not propagated either upwards or downwards. The heart-sounds were feeble and tumultuous." These symptoms led me to diagnose pulmonary obstruction, and I, of course, gave a most unfavorable prognosis, but to my great surprise the patient slowly recovered. I saw her again six weeks later, when her heart-sounds were regular and distinct, and the murmur had completely disappeared. E. E., set. 42, was confined for the first time on November 5, 1873, in the sixth month of utero-gestation. She had severe post-partum hemorrhage, depending on partially adherent placenta, which was removed artificially. She did perfectly well until the 14th day after delivery, when she was suddenly attacked with intense dyspnoea, aggravated in paroxysms. Pulse pretty full, 130, but distinctly inter- mittent. Air entered lun"S freely. The heart's action was fluttering and irregular, and, at the juncture of the fourth and fifth ribs with the sternum, there was a loud PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 621 blowing systolic murmur. This was certainly non-existent before, as tlie heart had been carefully auscultated before administering chloroform during labor. For two days the patient remained in the same state, her death being almost momentarily expected. On the 21st, that is two days after the appearance of the chest symptoms, phlegmasia dolens of a severe kind developed itself in the right thigh and leg. She continued in the same state for many days, lying more or less tranquilly, but having paroxysms of the most intense apnoea, varying from two to six or eight in the twenty- four hours. No one who saw her in one of these could have expected her to live throuo-h it. Shortly after the first appearance of the paroxysms it was observed that the cellular tissue of the neck and part of the face became swollen and cedematous, giving an appearance not unlike that of phlegmasia dolens. The attacks were always relieved bv stimulants. These she incessantly called for, declaring that she felt they kept her alive. During all this time the mind was clear and collected. The pulse varied from 110 to 130. Respirations about 60, temperature 101O to 102.5©. By slow degrees the patient seemed to be rallying. The paroxysms diminished in num- ber, and after December 1 she never had another, and the breathing became free and easy. The pulse fell to 80, and the cardiac murmur entirely disappeared. The patient remained, however, very weak and feeble, and the debility seemed to increase. Towards the second week in December she became delirious, and died, apparently exhausted, without any fresh chest symptoms, on the 19th of that month. No post- mortem examination was allowed. I have narrated this case, although, it terminated fatally,- because I hold it to be one of the class I am considering. The death was certainly not due to the obstruction, all symptoms of which had disappeared, but apparently to exhaustion from the severity of the former illness. It illustrates too the simultaneous appearance of symptoms of pulmonary obstruction and peripheral thrombosis. The swelling of the neck was a curious symptom, which has not been recorded in any other cases, and may possibly be a further proof of the analogy between this condition and phlegmasia dolens. Now, it may, of course, be argued that these cases do not prove my thesis, inasmuch as I only assume the presence of a coagulum. But I may fairly ask in return what other condition could possibly explain the symptoms? They are precisely those which are noticed in death from undoubted pulmonary obstruction. No one seeing one of them, or even reading an account of the symptoms, while ignorant of the result, could hesitate a single instant in the diagnosis. Surely, then, the inference is fair that they depended on the same cause? In the very nature of things my hypothesis cannot be veri- fied by post-mortem examination ; but there is at least one case on record, in which, after similar symptoms, a clot was actually found. The case is related by Dr. Richardson 1 . It was that of a man who for weeks had symptoms precisely similar to those observed in the cases I have narrated. In one of his agonizing struggles for breath he died, and after death it was found "that a fibrinous band, having its hold in the ventricle, extended into the pulmonary artery." This observation proves to a certainty that life may continue for weeks after the deposition of a coagulum ; and, moreover, this condition was precisely what we should anticipate, since, of course, the ob- structing coagulum must necessarily be small, otherwise the vital functions would be immediately arrested. 1 Clinical Essays, p. 224 et seq. 622 THE PUERPERAL STATE. Cardiac Murmurs in Pulmonary Obstruction. — There is a symptom noted in two of the above cases, and to less extent in a third, which has not been mentioned in any account of fatal cases occurring after delivery, viz., a murmur over the site of the pulmonary arteries. It is a sign we should naturally expect, and very possibly it would be met with in fatal cases if attention were particularly directed to the point. In both these instances it was exceedingly well marked, and in both it entirely disappeared when the symptoms abated. The probability of such a murmur being audible in cases of thrombosis of the pulmonary artery, has been recognized by one of our highest authorities in cardiac disease, who actually observed it in a non- puerperal case. In the last edition of his work on diseases of the heart, Dr. Walshe 1 says: "The only physical condition connected with the vessel itself would probably be systolic basic murmur fol- lowing the course of the pulmonary main trunk and of its immediate divisions to the left and right of the sternum. This sign I most certainly heard in an old gentleman whose life was brought to a sudden close, in the course of an acute affection, by coagulation in the pulmonary artery, and to a moderate extent in the right ven- tricle." Similar cases have, probably, been overlooked or misinterpreted. Many seem to have been attributed to shock, in the absence of a better explanation, a condition to which they bear no kind of re- semblance. Causes of Death. — The precise mode of death in pulmonary ob- struction, whether dependent on thrombosis or embolism, has given rise to considerable difference of opinion. Virehow attributes it to syncope, 2 depending on stoppage of the cardiac contraction. Panum, 3 on the other hand, contests this view, maintaining that the heart con- tinues to beat even after all signs of life have ceased. Certainly tumultuous and irregular pulsations of the heart are prominent symptoms in most of the recorded cases, and are not reconcilable with the idea of syncope. Pan urn's own theory is, that death is the result of cerebral anaemia. Paget seems to think that the mode of death is altogether peculiar, in some respects resembling syncope, in others anaemia. Bertin, who has discussed the subject at great length, attributes the fatal result purely to asphyxia. The condition, indeed, is in all respects similar to that state ; the oxygenation of the blood being prevented, not because air cannot get to the blood, but because blood cannot get to the air. The symptoms also seem best explained by this theory; the intense dyspnoea, the terrible struggle for air, the preservation of intelligence, the tumultuous action of the heart, are certainly not characteristic either of syncope or anaemia. Post-mortem Appearances of Clots. — The anatomical character of the clots seems to vary considerably. Ball, by whom they have been most carefully described, believes that they generally commence in the smaller ramifications of the arteries, extending backwards 1 Walshe, On Diseases of the Heart, 4th ed. 1873. 2 Gesamm. Abhandl., 1862, p. 316. 3 Vircliow's Archiv, 1863. PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 623 towards the heart, and filling the vessels more or less completely. Towards its cardiac extremity the coagulum terminates in a rounded head, in which respect it resembles those spontaneously formed in the peripheral veins. It is non-adherent to the coats of the vessels, and the blood circulates, when it can do so at all, between it and the vascular walls. Such clots are white, dense, and of a homogeneous structure, consisting of layers of decolorized fibrine, firm at the peri- phery, where the fibrine has been most recently deposited, and soft- ened in the centre, where amylaceous or fatty degeneration has commenced. Ball maintains that if the coagulum have commenced in the larger branches of the arteries, it must have first begun in the ventricle, and extended into them. According to Humphrey, the same changes take place in pulmonary as in peripheral thrombi, and they may become adherent to the walls of the vessels, or con- verted into threads or bands. When the obstruction is due to em- bolism, provided the case is a well-marked one, and the embolus of some size, the appearances presented are different. We have no longer a laminated and decolorized coagulum, with a rounded head, similar to a peripheral thrombus. The obstruction in this case generally takes place at the point of bifurcation of the artery, and we there meet with a grayish- white mass, contrasting remarkably with the more recently deposited fibrine before and behind it. It may be that the form of the embolus shows that it has recently been separated from a clot elsewhere ; and in many cases it has been pos- sible to fit the travelled portion to the extremity of the clot from which it has been broken. We may also, perhaps, find that the embolus has undergone an amount of retrograde metamorphosis corresponding with that of the peripheral thrombus from which we suppose it to have come, but differing from that of the more recently deposited fibrine around it. It must be admitted, however, that the anatomical peculiarities of the coagula will by no means always enable us to trace them to their true origin. In many cases emboli may escape detection from their smallness, or from the quantity of fibrine surrounding them. Treatment. — -But few words need be said as to the treatment of pulmonary obstruction. In a large majority of cases the fatal result so rapidly follows the appearance of the symptoms, that no time is given us even to make an attempt to alleviate the patient's suffer- ings. Should we meet with a case not immediately fatal, it seems that there are but two indications of treatment affording the slightest rational ground of hope. 1. To keep the patient alive by the administration of stimulants — brandy, ether, ammonia, and the like — to be repeated at intervals corresponding to the intensity of the paroxysms, and the results pro- duced. In the cases I have above narrated, in which recovery ensued, this took the place of all other medication. Possibly leeches, or dry cupping to the chest, might prove of some service in relieving the circulation. 2. To enjoin the most absolute and complete repose. The object of this is evident. The only chance for the patient seems to be, that 621 THE PUERPERAL STATE. the vital functions should be carried on until the coagulum has been absorbed, or, at least, until it has been so much lessened in size as to admit of blood passing it to the lungs. The slightest movements may give rise to a fatal paroxysm of dyspnoea, from the increased supply of oxygenated blood required. It must not be forgotten that in a large proportion of cases death immediately followed some exer- tion in itself trivial, such as rising out of bed. Too much attention, then, cannot be given to this point. The patient should be absolutely still ; she should be fed with abundance of fluid food, such as milk, strong soups, and the like ; and should on no account be permitted to raise herself in bed, or attempt the slightest muscular exertion. If we are fortunate enough to meet with a case apparently tending to recovery, these precautions must be carried on long after the severity of the symptoms has lessened, for a moment's imprudence may suffice to bring them back in all their original intensity. Bertin, 1 indeed, recommends a system of treatment very different from this. In the vain hope that the violent effort induced may cause the displacement of the impacted embolus (to which alone he attributes pulmonary obstruction), he recommends the administra- tion of emetics. Few, I fancy, will be found bold enough to attempt so hazardous a plan of treatment. Various drugs have been suggested in these cases. Eichardson recommended ammonia, a deficiency of which he at that time believed to be the chief cause of coagulation. He has since advised that liquor ammoniae should be given in large doses, 20 minims every hour, in the hope of causing solution of the deposited fibrine ; and he has stated that he has seen good results from the practice. Others advise the administration of alkalies, in the hope that they may favor absorption. The best that can be said for them is, that they are not likely to do much harm. CHAPTER VII. PUERPERAL AETEEIAL THROMBOSIS AND EMBOLISM. The same condition of the blood which so strongly predisposes to coagulation in the vessels through which venous blood circulates, tends to similar results in the arterial system. These, however, are by no means so common, and do not, as a rule, lead to such important consequences. The subject has been but little studied, and almost all our knowledge of it is derived from a very interesting essay by Sir James Simpson. 2 As I have devoted so much space to the con- i Op. cit. p. 393. 2 Selected Obst. Works, vol. i. p. 523. PUERPERAL ARTERIAL THROMBOSIS AND EMBOLISM. 625 sideration of venous thrombosis and embolism, I shall but briefly consider the effects of arterial obstruction. Causes. — In a considerable number of recorded cases the obstruc- tion has resulted from the detachment of vegetations deposited on the cardiac valves, the result of endocarditis, either produced by antecedent rheumatism, or as a complication of the puerperal state. Sometimes the obstruction seems to depend on some general blood dyscrasia, similar to that producing venous thrombosis, or on some local change in the artery itself. Thus Simpson records a case ap- parently produced by local arteritis, which caused acute gangrene of both lower extremities, ending fatally in the third week after de- livery. In other cases it has been attributed to coagulation follow- ing spontaneous laceration and corrugation of the internal coat of the artery. Symptoms. — The symptoms ot puerperal arterial obstruction must, of course, vary with the particular arteries affected. Those, with the obstruction of which we are most familiar, are the cerebral, the humeral, and the femoral. The effects produced must also be modi- fled by the size of the embolus, and the more or less complete ob- struction it produces. Thus, for example, if the middle cerebral artery be blocked up entirely, the functions of those portions of the brain supplied by it will be more or less completely arrested, and hemiplegia of the opposite side of the body, followed by softening of the brain-texture, will probably result. If the nervous symptoms be developed gradually, or increase in intensity after their first ap- pearance, it may be that an obstruction, at first incomplete, has in- creased by the deposition of fibrine around it. So the occasional sudden supervention of blindness, with destruction of the eyeball — cases of which are recorded by Simpson — not improbably depend on occlusion of the ophthalmic artery, the function of the organ de- pending on its supply through the single artery. The effects of ob- struction of the visceral arteries in the puerperal state are entirely unknown ; but it is far from unlikely that further investigation may prove them to be of great importance. In the extremities arterial obstruction produces effects which are well marked. They are classi- fied by Simpson under the following heads: 1. Arrest of p>ulse beloiv the site of obstruction. — This has been observed to come on either suddenly or gradually, and if the occlusion be in one of the large arterial trunks, it is a symptom which a careful examination will readily enable us to detect. 2. Increased force of pulsation in the ar- teries above the seat of obstruction. 3. Fall in the temperature of the limb. — This is a symptom which is easily appreciable by the ther- mometer, and, when the main artery of the limb is occluded, the coldness of the extremity is well marked. 4. Lesions of motor and sensory functions, paralysis, neuralgia, etc. etc. — 'Loss of power in the affected limb is often a prominent symptom, and when it comes on suddenly, and is complete, the main artery will probably be occluded. It may be diagnosed from paralysis depending on cerebral or spinal causes by the absence of head symptoms, by the history of the attack, and by the presence of other indications of arterial obstruction, such 626 THE PUERPERAL STATE. as loss of pulsation in the artery, fall of temperature, etc. The sen- sory functions in these cases are generally also seriously disturbed not so much by loss of sensation, as by severe pain and neuralgia. Sometimes the pain has been excessive, and occasionally it has been the first symptom which directed attention to the state of the limb. 5. Gangrene beloiv or beyond the seat of arterial obstruction. — Several interesting cases are recorded, in which gangrene has followed arte- rial obstruction, Generally speaking gangrene will not follow occlusion of the main arterial trunk of an extremity, as the collateral circulation becomes soon sufficiently developed to maintain its vitality. In many of the cases either thrombi have obstructed the channels of collateral circulation as well, or .the veins of the limb have also been blocked up. When such extensive obstructions occur they obviously cannot be embolic, but must depend on a local thrombosis, traceable to some general blood dyscrasia depending on the puerperal state. Treatment. — Little can be said as to the treatment of such cases, which must vary with the gravity and nature of the symptoms in each. Beyond absolute rest (in the hope of eventual absorption of the thrombus or embolus), generous diet, attention to the general health of the patient, and sedative applications to relieve the local pain, there is little in our power. Should gangrene of an extremity supervene in a puerperal patient, the case must necessarily be well- nigh hopeless. Simpson, however, records one instance in which amputation was performed above the line of demarcation, the patient eventually recovering. CHAPTER VIII. OTHER CAUSES OF SUDDEN DEATH DURING LABOR AND THE PUERPERAL STATE. A large number of the cases in which sudden death occurs during or after delivery find their explanation, as I have already pointed out, in thrombosis or embolism of the heart and pulmonary arteries. Probably, many cases of the so-called idiopathic asphyxia were in fact examples of this accident, the true nature of which had been misunderstood. Besides these there are, no doubt, many other con- ditions which may lead to a suddenly fatal result in connection with parturition. Some of these are of an organic, others of a functional nature. Organic Causes. — Among the former may be mentioned cases in which the straining efforts of the second stage of labor have pro- duced death in patients suffering from some pre-existent disease of CAUSES OF SUDDEN DEATH DURING LABOR. 627 the heart. Rupture of that organ has probably occurred from fatty degeneration of its walls. Dehous 1 narrates an instance in which the efforts of labor caused the rupture of an aneurism. Another case, from interference with the action of the heart in a patient who had pericardial effusion, is narrated by Ramsbotham. Dr. Devilliers re- lates an instance occurring in a young woman during the second stage of labor. The heart was found to be healthy, but the lungs were intensely congested, and blood was extensively extravasated all through their texture. This was probably caused by pulmonary congestion and apoplexy, produced by the severe straining efforts. Many cases from effusion of blood into the brain -substance, or on its surface, are on record, no doubt in patients who, from arterial de- generation or other causes, were predisposed to apoplectic effusions. The so-called apoplectic convulsions, formerly described in most works on obstetrics as a variety of puerperal convulsions, are evi- dently nothing more than apoplexy coming on during or after labor. As regards their pathology they do not seem to differ from ordinary cases of apoplexy in the non-pregnant condition. One example is recorded of death which was attributed to rupture of the diaphragm from excessive action in the second stage. Functional Causes. — Among the causes of death which cannot be traced to some distinct organic lesion, may be classed cases of syncope, shock, and exhaustion. Many instances of this kind are recorded. Thus in some women of susceptible nervous organization, the severity of the suffering appears to bring on a condition, similar to that pro- duced by excessive shock or exhaustion, which has not unfrequently proved fatal. Several examples of this kind have been cited by McClintock. 2 It is also not unlikely that sudden syncope sometimes produces a fatal result, during or after labor. Most cases of death, otherwise inexplicable, used to be referred to this cause ; but accu- rate autopsies were seldom made, and even when they were — the important effects of pulmonary coagula being unknown — it is more than probable that the true cause of death was overlooked. It has been supposed that the sudden removal of pressure from the veins of the abdomen, by the emptying of the gravid uterus after delivery, may favor an increased afflux of blood into the lower parts of the body, and thus tend to an anaemic condition of the brain, and the production of syncope. However this may be, the possibility of its occurrence, and its manifest danger in a recently delivered woman, are sufficient reasons for enforcing the recumbent position after labor is over. In some of the cases the syncope was evidently produced by the patient's suddenly sitting upright. Death from Air in the Veins. — Some cases of sudden death imme- diately after labor seem to be clue to the entrance of air into the veins. Six examples are cited by McClintock which were probably due to this cause. La Chapelle relates two. An interesting case is related by M. Lionet. 3 In this the patient died five and a half hours 1 Dehous, Sur les Morts suMtes. 2 Union Medic, 1853. 3 Dehous, op. cit. p. 58. 628 THE PUERPERAL STATE. after an easy and natural labor, the chief symptoms being extreme pallor, efforts at vomiting, and dyspnoea. Air was found in the heart and in the arachnoid veins. There can be no question that the ute- rine sinuses after delivery are nearly as Avell adapted as the veins of the neck for allowing the entrance of air. They are firmly attached to the muscular walls of the uterus, so that they gape open when that organ is relaxed, and it is easy to understand how air might enter. Indeed, in the post-mortem examination in one of the cases occurring in the practice of Mme. La Chapelle, it is stated that " the uterine sinuses opened in the interior of the uterus by large orifices (one line and a half in diameter), through which air could readily be blown as far as the iliac veins, and vice versa." The condition of the uterus after delivery also enables the air to have ready access to the mouths of the sinuses, for the alternate relaxation and contrac- tion of the uterus, occurring after the placenta is expelled, would tend to draw in the air as by a suction pump. Hence, an additional reason for insisting on firm contraction of the uterus, as this will lessen the risk of this accident. Cause of Death in such Cases. — The precise mechanism of death from air in the veins, has been a subject of dispute among patholo- gists. By Bichat, 1 it was referred to amemia and syncope from want of blood in the vessels of the brain, which are occupied by air; Nysten 2 attributed it to distension of the cavities of the heart by rarefied air, producing paralysis of its wall ; Leroy to a stoppage of the pulmonary circulation, and consequent want of proper blood- supply to the left heart ; while Leroy d'Etoilles thought it might depend on any of these causes, or a combination of all of them. These, and many other hypotheses on the subject, have been ad- vanced, to all of which serious objection could be raised. The most recent theory is one maintained by Virchow and Oppolzer, 3 and more recently by Feltz, which attributes the fatal results to impaction of the air-globules in the lesser divisions of the pulmonary arteries, where they form gaseous emboli, and cause death exactly in the same way as when the obstruction depends on a fibrinous embolus. The symptoms observed in fatal cases closely correspond to those of pul- monary obstruction, and it is not unlikely that some cases, attributed to other causes, may really depend on the entrance of air through the uterine sinuses. Such, for example, was most probably the explanation of a case referred to by Dr. Graily Hewitt in a discussion at the Obstetrical Society. 4 Death occurred shortly after the removal of an adherent placenta, during which, no doubt, air could readily enter the uterine cavity. The symptoms, viz., " severe pain in the cardiac region, distress as regards respiration, and pulselessness," are identical with those of pulmonary obstruction. Dr. Hewitt refers the death to shock, which certainly does not generally produce such phenomena. 1 Recherches sur la Vie et la Mort, 1853. 2 Nysten, Recherches de Phys. et Chem. Path., 1811. 3 Casuistics des Embolie ; Wiener Med. Woch., 1863. Des Embolies Capillaires, 1868. Op. cit. p. 115. 4 Obstet. Trans., vol. x. p. 28. PERIPHERAL VENOUS THROMBOSIS, ETC. 629 CHAP TEE IX. PERIPHERAL VENOUS THROMBOSIS — (SYN. : CRURAL PHLEBITIS — PHLEGMASIA DOLEXS — ANASARCA SEROSA — (EDEMA LACTEUM — WHITE LEG, ETC.). ATe now come to discuss the symptoms and pathology of the con- ditions associated with the formation of thrombi in the peripheral venous system, or rather in the veins of the lower extremities, since too little is known of their occurrence in other parts to enable us to say anything on the subject. The most important of these is the well-known disease which, under the name of phlegmasia dolens, has attracted much attention, and given rise to numerous theories as to its nature and pathology. In describing it as a local manifestation of a general blood-dyscrasia, and not as an essential local disease, I am making an assumption as to its pathology, that many eminent authorities would not consider justifiable. I have, however, already stated some of the reasons for so doing, and I shall shortly hope to show that this view is not in- compatible with the most probable explanation of the peculiar state of the affected limb. Symptoms. — The first symptom which usually attracts attention is severe pain in some part of the limb that is about to be affected. The character of the pain varies in different cases. In some it is extremely acute, and is most felt in the neighborhood of and along the course of the chief venous trunks. It may begin in the groin or hip, and extend downwards; or it may commence in the calf and proceed upwards towards the pelvis. The pain abates somewhat after swelling of the limb (which generally begins within twenty- four hours), but it is always a distressing symptom, and continues as long as the acute stage of the disease lasts. The restlessness, want of sleep, and suffering which it produces are sometimes excessive. Coincident with the pain, and sometimes preceding it, more or less malaise is experienced. The patient may for a day or two be rest- less, irritable, and out of sorts, without any very definite cause : or the disease may be ushered in by a distinct rigor. Generally there is constitutional disturbance, varying with the intensity of the case. The pulse is rapid and weak, 120 or thereabouts; the temperature elevated from 101° to 102°, with an evening exacerbation. The pa- tient is thirsty; the tongue glazed, or white and loaded: the bowels constipated. In some few cases, when the local affection is slight, none of these constitutional symptoms are observed. Condition of the Affected Limb. — The characteristic swelling rapidly follows the commencement of the symptoms. It generally begins in G30 THE PUERPERAL STATE. the groin, from whence it extends downwards. It may be limited to the thigh ; or the whole limb, even to the feet, may be implicated. More rarely it commences in the calf of the leg, extending upwards to the thigh, and downwards to the feet. The affected parts have a peculiar appearance, which is pathognomonic of the disease. Thev are hard, tense, and brawny ; of a shiny, white color ; and not yield- ing on pressure, except towards the beginning and end of the illness. The appearances presented are quite different from those of ordinary oedema. When the whole thigh is affected the limb is enormously increased in size. Frequently the venous trunks, especially the femoral and popliteal veins, are felt obstructed with coagula, and rolling under the finger. They are painful when handled, and in their course more or less redness is occasionally observed. Either leg may be attacked, but the left more frequently than the right. There is a marked tendency for the disease to spread, and we often find, in a case which is progressing apparently well, a rise of tem- perature and an accession of febrile symptoms, followed by the swell- ing of the other limb. Progress of the Disease. — After the acute stage has lasted from a week to a fortnight, the constitutional disturbance becomes less marked, the pulse and temperature fall, the pain abates, and the sleeplessness and restlessness are less. The swelling and tension of the limb now begin to diminish, and absorption commences. This is invariably a slow process. It is always many weeks before the effu- sion has disappeared, and it may be many months. The limb re- tains for a length of time the peculiar wooden feeling, as Dr. Churchill terms it. Any imprudence, such as a too early attempt at walking, may bring on a relapse and fresh swelling of the limb. This gradual recovery is by far the most common termination of the disease. In some rare cases suppuration may take place, either in the subcuta- neous cellular tissue, the lymphatic glands, or even in the joints, and death may result from exhaustion. The possibility of pulmonary obstruction and sudden death from separation of an embolus have already been pointed out, and the fact that this lamentable occurrence has generally followed some undue exertion should be borne in mind, as a guide in the management of our patient. Period of Commencement. — The disease usually begins within a short time after delivery, rarely after the second week. In 22 cases tabulated by Dr. Eobert Lee, 7 were attacked between the fourth and twelfth days, and 14 after the second week. Some cases have been described as eommencing even months after delivery. It is question- able if these can be classed as puerperal, for it must not be forgotten that phlegmasia dolens is by no means necessarily a puerperal disease. There are many other conditions which may give rise to it, all of them, however, such as produce a septic and hyperinosed state of the blood, such as malignant disease, dysentery, phthisis, and the like. My own experience would lead me to think that cases of this kind are much more common than is generally believed. History and Pathology. — The disease has long attracted the atten- tion of the profession. Passing over more or less obscure notices by ETC. 631 Hippocrates, De Castro, and others, we find the first clear account in the writings of Mauriceau, who not only gave a very accurate de- scription of its symptoms, but made a guess at its pathology, which was certainly more happy than the speculations of his successors ; it is, he says, caused, " by a reflux on the parts of certain humors which ought to have been evacuated by the lochia." Puzos ascribed it to the arrest of the secretion of milk, and its extravasation in the affected limb. This theory, adopted by Levret and many subsequent writers, took a strong hold on both professional and public opinion, and to it we owe many of the names by which the disease is known to this day, such as oedema lacteum, milk leg, etc. In 1784 Mr. White, of Manchester, attributed it to some morbid condition of the lymphatic glands and vessels of the affected parts ; and this, or some analogous theory, such as that of rupture of the lymphatics crossing the pelvic brim, as maintained by Tyre, of Gloucester, or general inflammation of the absorbents as held by Dr. Ferriar, was generally adopted. Phlebitic Theory. — It was not until the year 1823 that attention was drawn to the condition of the veins. To Bouillaud belongs the un- doubted merit of first pointing out that the veins of the affected limb were blocked up by coagula, although the fact had been previously observed by Dr. Davis, of University College. Dr. Davis made dissec- tions of the veins in a fatal case, and found, as Bouillaud bad done, that they were filled with coagula, which he assumed to be the results of inflammation of their coats; hence the name of "crural phlebitis" which has been extensively adopted instead of phlegmasia dolens. Dr. Eobert Lee did much to favor this view, and finding that thrombi were present in the iliac and uterine, as well as in the femoral, veins, he concluded that the phlebitis commenced in the uterine branches of the hypogastric veins, and extended downwards to the femorals. PEc pointed out that phlegmasia dolens was not limited to the puerperal state ; but that when it did occur independ- ently of it, other causes of uterine phlebitis were present, such as cancer of the os and cervix uteri. The inflammatory theory was pretty generally received, and even now is considered by many to be a sufficient explanation of the disease. Indeed the fact that more or less thrombus was always present could not be denied, and on the supposition that thrombus could only be caused by phlebitis, as was long supposed to be the case, the inflammatory theory was the natural one. Before long, however, pathologists pointed out that thrombosis was by no means necessarily, or even generally, the result of inflam- mation of the vessels in which the clot was contained, but that the inflammation was more generally the result of the coagulum. Theory of its Dejiendence on Septic Causes. — The late Dr. Mackenzie took a prominent part in opposing the phlebitic theory. He proved, by numerous experiments in the lower animals, that inflammation is not sufficient of itself to produce the extensive thrombi which are found to exist, and that inflammation originating in one part of a vein is not apt to spread along its canal, as the phlebitic theory assumes. His conclusion is, that the origin of the disease is rather 632 THE PUERPERAL STATE. to be sought in some septic or altered condition of the blood, pro- ducing coagulation in the veins. Dr. Tyler Smith 1 pointed out an occasional analogy between the causes of phlegmasia dolens and puer- peral fever, evidently recognizing the dependence of the former on blood dyscrasia. "1 believe," he says, "that contagion and infection play a very important part in the production of the disease. I look on a woman attacked with phlegmasia dolens as having made a fortunate escape from the greater clangers of diffuse phlebitis or puerperal fever." In illustration of this he narrates the following instructive history : "A short time ago a friend of mine had been in close attendance on a patient dying of erysipelatous sore-throat with sloughing, and was himself affected with sore-throat. Under these circumstances, he attended, within the space of twenty-four hours, three ladies in their confinements, all of whom were attacked with phlegmasia dolens." View of Tilbury Fox. — The latest important contribution to the pathology of the disease is contained in two papers by Dr. Tilbury Fox, published in the second volume of the " Obstetrical Transac- tions." He maintains that something beyond the mere presence of coagula in the veins is required to produce the phenomena of the disease, although he admits that to be an important, and even an essential, part of pathological changes present. The thrombi he be- lieves to be produced either by extrinsic or intrinsic causes : the former comprising all cases of pressure by tumor or the like ; the latter, and the most important, being divisible into the heads of — ■ 1. True inflammatory changes in the vessels, as seen in the epi- demic form of the disease. 2. Simple thrombus, produced by rapid absorption of morbid fluid. 3. Virus action and thrombus conjoined, the phlegmasia dolens itself being the result of simple thrombus, and not produced by dis- eased (inflamed) coats of vessels ; the general symptoms the result of the general blood-state ; the virus present. He further points out that the peculiar swelling of the limbs can- not be explained by the mere presence of oedema, from which it is essentially different. The white appearance of the skin, the severe neuralgic pain, and the persistent numbness indicating that the whole of the cutaneous textures, the cutis vera and even the epithelial layer, are infiltrated with fibrinous deposit. He concludes, there- fore, that the swelling is the result of oedema plus something else ; that something being obstruction of the lymphatics, by which the absorption of effused serum is prevented. The efficient cause which produces these changes he believes to be, in the majority of cases, a septic action originating in the uterus, producing a condition sim- ilar to that in which phlegmasia dolens arises in the non-puerperal state. There is no doubt much force in Dr. Fox's arguments, and it may, I think, be conceded that obstruction of the veins per se is not suffi- 1 Tyler Smith, Manual of Obstetrics, p. 538. PERIPHERAL VENOUS THROMBOSIS, ETC. 633 cient to produce the peculiar appearance of the limb. It is, more- over, certain that phlebitis alone is also an insufficient explanation not only of the symptoms, but even of the presence of thrombi so extensive as those that are found. The view which traces the disease solely to inflammation or obstruction of lymphatics is purely theoretical, has no basis of facts to support it, and finds, nowadays, no supporters. The experiments of Mackenzie and Lee, as well as the vastly increased knowledge of the causes of thrombosis which the researches of modern pathologists have given us, seem to point strongly to the view already stated, that the disease can only be explained by a general blood dyscrasia, depending on the puerperal state. It by no means follows that we are to consider Dr. Fox's speculations as incorrect. It is far from improbable that the lym- phatic vessels are implicated in the production of the peculiar swell- ing, only we are not as yet in a position to prove it. There is no inherent improbability in the supposition that the same morbid state of the blood which produces thrombosis in the veins, may also give rise to such an amount of irritation in the lymphatics as may interfere with their functions, and even obstruct them altogether. The essential and all-important point in the pathology of the disease, however, seems undoubtedly to be thrombosis in the veins; and the probability of there being some as yet undetermined pathological changes in addition to this, by no means militates against the view I have taken of the intimate connection of the disease with other results of thrombosis in different vessels. Changes Occurring in the Thrombi. — The changes which take place in the thrombi all tend to their ultimate absorption. These have been described by various authors as leading to organization or sup- puration. It is probable, however, that the appearances which have led to such a supposition are fallacious, and that they are really due to retrograde metamorphosis of the librine, generally of an amyla- ceous or fatty character. Detachment of Emboli. — The peculiarities of a clot that most favor detachment of an embolus are such a shape as admits of a portion floating freely in the blood-current, by the force of which it is de- tached and carried to its ultimate destination. When the accident has occurred, it is often possible to recognize the peripheral thrombus from which the embolus has separated, by the fact of its terminal extremity presenting a freshly fractured end, instead of the rounded head natural to it. Such detachment is unlikely to occur, even when favored by the shape of the clot, unless sufficient time have elapsed after its formation to admit of its softening and becoming brittle. The curious fact I have before mentioned, of true puerperal embo- lism occurring, in the large majority of cases, only after the nine- teenth day from delivery, finds a ready explanation in this theory, which it remarkably corroborates. Treatment. — On the supposition that phlegmasia dolens was the result of inflammation of the veins of the affected limb, an antiphlo- gistic course of treatment was naturally adopted. Accordingly, most writers on the subject recommended depletion, generally by the 41 634 THE PUERPERAL STATE. application of leeches, along the course of the affected vessels. We are told that if the pain continue the leeches should be applied a second, or even a third time. If we admit the septic origin of the disease we must, I think, see the impropriety of such a practice. The fact that it occurs, in a large majority of cases, in patients of a weakly and debilitated constitution, often in women who have already suffered from hemorrhage, is a further reason for not adopting this routine custom. If local loss of blood be used at all, it should be strictly limited to cases in which there is much tenderness and red- ness alongthe course of the veins, and then only in patients of ple- thoric habit and strong constitution ; cases of this kind will form a very small minority of those coming under our observation. Over-active Treatment Unadvisable. — What has been said of the pathology of the affection tends to the conclusion that active treat- ment of any kind, in the hope of curing the disease, is likely to be useless. Our chief reliance must be on time and perfect rest, in order to admit of the thrombi and the secondary effusion being ab- sorbed ; while we relieve the pain and other prominent symptoms, and support the strength and improve the constitution of the patient. Relief of Pain, etc. — The constant application of heat and moisture to the affected limb will do much to lessen the tension and pain. Wrapping the entire limb in linseed-meal poultices, frequently changed, is one of the best means of meeting this indication. If, as is sometimes the case, the weight of the poultices be too great to be readily borne, we may substitute warm flannel stupes, covered with oiled silk. Local anodyne applications afford much relief, and may be advantageously used along with the poultices and stupes, either by sprinkling their surface freely with laudanum, or chloroform and belladonna liniment, or by soaking the flannels in poppy-head fomen- tation. It is needless to say that the most absolute rest in bed should be enjoined, even in slight cases, and that the limb should be effectu- ally guarded from undue pressure by a cradle or some similar con- trivance. Local counter- irritation has been strongly recommended, and frequent blisters have been considered by some to be almost specific. I should myself hesitate to use blisters, as they would certainly not be soothing applications, and one hardly sees how they can be of much service in hastening the absorption of the effusion. Constitutional Treatment. — During the acute stage of the disease the constitutional treatment must be regulated by the condition of the patient. Light, but nutritious diet, must be administered in abundance, such as milk, beef-tea, and soups. Should there be much debility, stimulants, in moderation, may prove of service. With regard to medicines, we shall probably find benefit from such as are calculated to improve the condition of the blood and the general health of the patient. Chlorate of potash, with diluted hydrochloric acid, quinine, either alone or in combination with sesquicarbonate of ammonia, the tincture of the perchioride of iron, are the drugs that are most likely to prove of service. Alkalies and other medicines, which have been recommended in the hope of hastening the absorp- tion of coagula, must be considered as altogether useless. Pain must PERIPHERAL VENOUS THROMBOSIS, ETC. 635 be relieved and sleep produced by the judicious use of anodynes, such as Dover's powder, the subcutaneous injection of morphia, or chloral. Generally no form answers so well as the hypodermic in- jection of morphia. Subsequent Local Treatment. — When the acute symptoms have abated, and the temperature has fallen, the poultices and stupes may be discontinued, and the limb swathed in a flannel roller from the toes upwards. The equable pressure and support thus afforded ma- terially aid the absorption of the effusion, and tend to diminish the size of the limb. At a still later stage very gentle inunctions of weak iodine ointment may be used with advantage once a day before the roller is applied. Shampooing and friction of the limb, generally recommended for the purpose of hastening absorption, should be carefully avoided, on account of the possible risk of detaching a portion of the coagulum, and producing embolism. This is no merely imaginary danger, as the following fact narrated by Trousseau proves. "A phlegmasia alba dolens had appeared on the left side in a young woman suffering from peri-uterine phlegmon. The pain having ceased, a thickened venous trunk was felt on the upper and internal part of the thigh. Bather strong pressure was being made, when M. Demarquay felt something yield under his fingers. A few minutes afterwards the patient was attacked with dreadful palpita- tion, tumultuous cardiac action, and extreme pallor, and death was believed to be imminent. After some hours, however, the oppression ceased, and the patient eventually recovered. A slightly attached coagulum must have become separated, and conveyed to the heart or pulmonary artery." 1 Warm douches of Avater, of salt water if it can be obtained, may be advantageously used in the later stages of the disease, and they may be applied night and morning, the limb being bandaged in the interval. The occasional use of the electric current is said to promote absorption, and would seem likely to be a serviceable remedy. Change of Air, etc. — When the patient is well enough to be moved, a change of air to the seaside will be of value. Great caution, how- ever, should be recommended in using the limb, and it is far better not to run the risk of a relapse by any undue haste in this respect. It is well to warn the patient and her friends, that a considerable time must of necessity elapse, before the local signs of the disease have completely disappeared. 1 Trousseau, Clinique de l'Hotel-Dieu in Gaz. des Hop., 1860, p. 577. 636 THE PUERPERAL STATE. CHAPTEE X. PELVIC CELLULITIS AND PELVIC PERITONITIS. From the earliest time the occurrence after parturition of severe forms of inflammatory disease in and about the pelvis, frequently ending in suppuration, has been well known. It is only of late years, however, that these diseases have been made the subject of accurate clinical and pathological investigation, and that their true nature has begun to be understood. Nor is our knowledge of them as yet by any means complete. They merit careful study on the part of the accoucheur, for they give rise to some of the most severe and pro- tracted illnesses from which puerperal patients suffer. They are often obscure in their origin and apt to be overlooked, and they not rarely leave behind them lasting mischief. These diseases are not limited to the puerperal state. On the con- trary, many of the severest cases arise from causes altogether uncon- nected with child-bearing. These will not be now considered, and this chapter deals solely with such forms as may be directly traced to child-birth. Two Distinct Forms. — Eecent researches have demonstrated that there are two distinct varieties of inflammatory disease met with after labor, which differ materiall} 7 from each other in many respects. In one of these, the inflammation affects chiefly the connective tissue surrounding the generative organs contained within the pelvis, or extends up from beneath the peritoneum, and into the iliac fossae. In the other, it attacks that portion of the peritoneum which covers the pelvic viscera, and is limited to it. So much is admitted by all writers, but great obscurity in descrip- tion, and consequent difficulty in understanding satisfactorily the nature of these affections, have resulted from the variety of nomen- clature which different authors have adopted. Thus the former disease has been variously described as pelvic cellulitis, peri-uterine phlegmon, para-metritis, or pelvic abscess, while the latter is not unfrequently called peri-metritis, as contra- distinguished from para-metritis. The use of the prefix para or peri, to distinguish the cellular or peritoneal variety of inflammation, originally suggested by Virchow, has been pretty generally adopted in Germanv, and has 'been strongly advocated in this country by Matthews Duncan. It has never, however, found much favor with English writers, and the similarity of the two names is so great as to lead to confusion. I have, therefore, selected the terms u pelvic peri- tonitis" and "pelvic cellulitis" as conveying in themselves a fairly accurate notion of the tissues mainly involved. PELVIC CELLULITIS AND PELVIC PERITONITIS. 637 Importance of Distinguishing the Two Classes of Cases. — The im- portant fact to remember is that there exist two distinct varieties of inflammatory disease, presenting many similarities in their course, symptoms, and results, often occurring simultaneously, but in the main distinct in their pathology, and capable of being differentiated. Thomas compares them — and, as serving to fix the facts on the memory, the illustration is a good one — to pleurisy and pneumonia. "Like them," he says, "they are separate and distinct, like them affect different kinds of structure, and like them they generally com- plicate each other." It might, therefore, be advisable, as most writers on the disease occurring in the non -puerperal state have done, to treat of them in two separate chapters. There is, however, more difficulty in distinguishing them as puerperal than as non-puer- peral affections, for which reason, as well as for the sake of brevity, I think it better to consider them together, pointing out, as I pro- ceed, the distinctive peculiarities of each. Seat of Disease. — When attention was first directed to this class of diseases, the pelvic cellular tissue was believed to be the only struc- ture affected. This was the view maintained by Nonat, Simpson, and many modern writers. Attention was first prominently directed to the importance of localized inflammation of the peritoneum, and to the fact that many of the supposed cases of cellulitis were really peritonitic, by Bernutz. There can be no doubt that he here made an enormous step in advance. Like many authors, however, he rode his hobby a little too hard, and he erred in denying the occurrence of cellulitis in many cases in which it undoubtedly exists. Etiology. — The great influence of child-birth in producing these diseases has long been fully recognized. Courty estimates that about two-thirds of all the cases met with occur in connection with de- livery or abortion, and Duncan found that out of 40 carefully observed cases, 25 were associated with the puerperal state. The Inflammation is Secondary and never Idiopathic. — It is pretty generally admitted by most modern writers that both varieties of the disease are produced by the extension of inflammation from either the uterus, the Fallopian tubes, or the ovaries. This point has been especially insisted on by Duncan, who maintains that the disease is never idiopathic, and is " invariably secondary either to mechanical injury, or to the extension of inflammation of some of the pelvic vis- cera, or to the irritation of the noxious discharges through or from the tubes or ovaries." Often intimately connected with Septicemia. — Their intimate con- nection with puerperal septicaemia is also a prominent fact in the natural history of the diseases. Barker mentions a curious observa- tion illustrative of this, that when puerperal fever is endemic in the Bellevue Hospital in New York, cases of pelvic peritonitis and cel- lulitis are also invariably met with. Olshausen has also remarked that in the Lying-in Hospital at Halle, during the autumn vacation, when the patients are not attended by practitioners, and when, there- fore, the chance of septic infection being conveyed to them is less, these inflammations are almost always absent. As inflammation of 638 THE PUERPERAL STATE. the lining membrane of the uterus, of the vaginal mucous membrane, and of the pelvic connective tissue, are of very constant occurrence as local phenomena of septic absorption, the connection between the two classes of cases is readily susceptible of explanation. Schroeder, indeed, goes further, and includes his description of these dis- eases under the head of puerperal fever. They do not, however, necessarily depend upon it; for, although it must be admitted that cases of this kind form a large proportion of those met with, others unquestionably occur which cannot be traced to such sources, but are the direct result of causes altogether unconnected with the inflam- mation attending on septic absorption, such as undue exertion short! v after delivery, or premature coition. Mechanical causes may beyond doubt excite the disease in a woman predisposed by the puerperal process, but they cannot fairly be included under the head of puer- peral fever. Seat of the Inflammation in Pelvic Cellulitis. — Abundance of areolar tissue e-xists in connection with the pelvic viscera, which may be the seat of cellulitis. It forms a loose padding between the organs con- tained in the pelvis proper, surrounds the vagina, the rectum, and the bladder, and is found in considerable quantity between the folds of the broad ligaments. From these parts it extends upwards to the iliac fossae, and the inner surface of the abdominal parietes. In any of these positions it may be the seat of the kind of inflammation we are discussing. The essential character of the inflammation is similar to that which accompanies areolar inflammation in other parts of the body. There is first an acute inflammatory oedema, followed by the infiltration of the areolae of the connective tissue with exudation, and the consequent formation of appreciable swellings. These may form in any part of the pelvis. Thus we may meet with them, and this is a very common situation, between the folds of the broad ligaments, forming distinct hard tumors, connected with the uterus, and extending to the pelvic walls, their rounded outlines being readily made out by bi-manual examination. If the cellulitis be limited in extent, such a swelling may exist on one side of the uterus only, forming a rounded mass of varying size, and apparently attached to it. At other times the exudation is more extensive, and may com- pletely or partially surround the uterus, extending to the cellular tissue between the vagina and rectum, or between the uterus and the bladder. In such cases the uterus is imbedded and firmly fixed in dense hard exudation. At other times, the inflammation chiefly affects the cellular tissue covering the muscles lining the iliac fossae. There it forms a mass, easily made out by palpation, but on vaginal examination little or no trace of the exudation can be felt, or only a sense of thickness at the roof of the vagina on the same side as the swelling. Seat of the Inflammation in Pelvic Peritonitis. — In pelvic peritonitis the inflammation is limited to that portion of the peritoneum which invests the pelvic viscera. Its extent necessarily varies with the intensity and duration of the attack. In some cases there may be little more than irritation, while more often it runs on to exudation PELVIC CELLULITIS AND PELVIC PERITONITIS. 639 of plastic material. The result is generally complete fixation of the uterus, and hardening and swelling in the root of the vagina, and the lymph poured out may mat together the surrounding viscera, so as to form swellings, difficult, in some cases, to differentiate from those resulting from cellulitis. On post-mortem examination the pelvic viscera are found extensively adherent, and the agglutination may involve the coils of the intestine in the vicinity, so as sometimes to form tumors of considerable size. Relative Frequency of the Two Forms of Disease. — The relative fre- quency of these two forms of inflammation as puerperal affections is not easy to ascertain. In the non-puerperal state the peritonitic variety is much the more common, but in the puerperal state they very generally complicate each other, and it is rare for cellulitis to exist to any great extent without more or less peritonitis. Symptomatology, — The earliest symptom is pain in the lower part of the abdomen, which is generally preceded by rigor or chilliness. The amount of pain varies much. Sometimes it is comparatively slight, and it is by no means rare to meet with patients, who are the subjects of very considerable exudations, who suffer little more than a certain sense of weight and discomfort at the lower part of the abdomen. On the other hand the suffering may be excessive, and is characterized by paroxysmal exacerbations, the patient being com- paratively free from pain for several successive hours, and then having attacks of the most acute agony. Schroeder says that pain is always a symptom of peritonitis, and that it does not exist in uncomplicated cellulitis. The swellings of cellulitis are certainly sometimes remarkably free from tenderness, and I have often seen masses of exudation in the iliac fossae, which could bear even rough handling. On the other hand, although this is certainly more often met with in n on- puerperal cases, the tenderness over the abdomen is sometimes excessive, the patient shrinking from the slightest touch. The pulse is raised, generally from 100 to 120, and the thermometer shows the presence of pyrexia. During the entire course of the disease both these sjmiptoms continue. The temperature is often very high, but more frequently it varies from 100° to 101:°, and it generally shows more or less marked remissions. In some cases the temperature is said not to be elevated at all, or even to be sub-nor- mal, but this is certainly quite exceptional. Other signs of local and general irritation often exist. Among them, and most distinctly in cases of peritonitis, are nausea and vomiting, and an anxious pinched expression of the countenance, while the local mischief often causes distressing dysuria and tenesmus. The latter is especially apt to occur when there is exudation between the rectum and vagina, which presses on the bowel. The passage of feces, unless in a very liquid form, may then cause intolerable suffering. Such symptoms may show themselves within a few days after delivery, and then they can barely fail to attract attention. ".On the other hand, they may not commence for some weeks after labor, and then they are often insidious in their onset, and apt to be overlooked. It is far from rare to meet with cases six w T eeks or more after con* 64:0 THE PUERPERAL STATE. finement, in which tlie patient complains of little beyond a feeling of malaise and discomfort, and in which, on investigation, a consid- erable amount of exudation is detected, which had previously entirely escaped observation. Results of Physical Examination. — On introducing the finger into the vagina it will be found to be hot and swollen, in some cases dis- tinctly ©edematous, and on reaching the vaginal cul-de sac the exist- ence of exudation may generally be made out. The amount of this varies much. Sometimes, especially in the early stage of the disease, there is little more than a diffuse sense of thickness and induration at either side of, or behind, the uterus. More generally careful bi-manual examination enables us to detect a distinct hardening and swelling, possibly a tumor of considerable size, which may appa- rently be attached to the sides of the uterus, and rise above the pelvic brim, or may extend quite to the pelvic walls. The examina- tion should be very carefully and systematically conducted with both hands, so as to explore the whole contour of the uterus before, behind, and on either side, as well as the iliac fossae ; otherwise a considerable exudation might readily escape detection. When the exudation is at all great, more or less fixity of the uterus is sure to exist, and is a very characteristic symptom. The womb, instead of being freely movable by the examining finger, is firmly fixed by the surrounding exudation, and in severe forms of the disease is quite encased in it. More or less displacement of the organ is also of common occurrence. If the swelling be limited to one side of the pelvis or to Douglas's space, the uterus is displaced in the opposite direction, so that it is no longer in its usual central position. The Two Forms of Disease cannot always be Distinguished. — The differential diagnosis of pelvic cellulitis and pelvic peritonitis cannot always be made, and, indeed, in many cases it is impossible, since both varieties of disease coexist. The elements of differentiation generally insisted on are, the greater general disturbance, nausea, etc., in pelvic peritonitis, with an earlier commencement of the symp- toms after labor. The swellings of pelvic peritonitis are also more tender, with less clearly-defined outline than those of cellulitis. When the cellulitis involves the iliac fossa the diagnosis is, of course, easy, and then a continuous retraction of the thigh on the affected side (an involuntary position assumed with the view of keeping the muscles lining the iliac fossa at rest), is often observed. When the inflammation is chiefly limited to the cavity of the pelvis, the dis- tinction between the two classes of cases cannot be made with any degree of certainty. ^Terminations.— Both, forms of disease may end either in resolution or in suppuration. In the former case, after the acute symptoms have existed for a variable time, it may be for a few days only, it may be for many weeks, their severity abates, the swellings become less tender and commence to contract," become harder, and are gradu- ally absorbed; until, at last, the fixity of the uterus disappears, and it again resumes its central position in the pelvic cavity. This pro- cess is often very gradual. It is by no means rare to find a patient, PELVIC CELLULITIS AND PELVIC PERITONITIS. 641 even some months after the attack, when all acute symptoms have long disappeared, who is even able to move about without incon- venience, in whom the uterus is still immovably fixed in a mass of deposit, or is, at least, adherent in some part of its contour. More or less permanent adhesions are of common occurrence, and give rise to symptoms of considerable obscurity, which are often not traced to their proper source. Symptoms of Suppuration. — When the inflammation is about to terminate in suppuration, the pyrexial symptoms continue, and eventually well-marked hectic is developed, the temperature gene- rally showing a distinct exacerbation at night. At the same time rigors, loss of appetite, a peculiar yellowish discoloration of the face, and other signs of suppuration, show themselves. The relative fre- quency of this termination is variously estimated by authors. Duncan quotes Simpson as calculating it as occurring in half the cases of pelvic cellulitis, but states his own belief that it is much more frequent. West observed it in 23 out of 43 cases following delivery or abor- tion, and McClintock in 37 out of 70. Schroeder says that he has only once seen suppuration in 92 cases of distinctly demonstrable exudation, a result which is certainly totally opposed to common experience. Barker also states that in his experience suppuration in either pelvic peritonitis or cellulitis " is very rare, except when they are associated with pyaemia or puerperal fever." It is certain that suppuration is more likely to occur in pelvic cellulitis than in pelvic peritonitis, but it unquestionably occurs, in this country at least, much more frequently than the statements of either of these authors would lead us to suppose. Channels through which Pus may Escape. — The pus may find an exit through various channels. In pelvic cellulitis, more especially when the areolar tissue of the iliac fossa is implicated, the most common site of exit is through the abdominal wall. It may, how- ever, open at other positions, and the pus may find its way through the cellular tissue and point at the side of the anus, or in the vagina, or it may take even a more tortuous course and reach the inner sur- face of the thigh. Pelvic abscesses not uncommonly open into the rectum or bladder, causing very considerable distress from tenesmus or dysuria. According to Hervieux, it is chiefly the peritoneal varieties which open in this way. Not unfrequently more than one opening is formed; and when the pus has burrowed for any dis- tance, long fistulous tracts result, which secrete pus for a length of time, and are very slow to heal. Eupture of an abscess into the peritoneal cavity, especially of a peritonitic abscess, is a possible (but fortunately a very rare) termination, and will generally prove fatal by producing general peritonitis. In one case which I have recorded in the fifteenth volume of the "Obstetrical Transactions," suppuration was followed by extensive necrosis of the pelvic bones. Two similar cases are related by Trousseau in his " Clinical Medi- cine," but I have not been able to meet with any other examples of this rare complication, which was probably rather the result of some obscure septicemic condition than of extension of the inflammation. 642 THE PUERPERAL STATE. Prognosis. — The prognosis is favorable as regards ultimate re- covery, but there' is great risk of a protracted illness which may seriously impair the health of the patient, especially if suppuration result. Hence it is necessary to be guarded in an expression of opinion as to the consequences of the disease. Secondary mischief is also far from unlikely to follow, from the physical changes pro- duced by the exudation, such as permanent adhesions or malpositions of the uterus, or organic alterations in the ovaries or Fallopian tubes. Treatment. — In the treatment of both forms of disease the import- ant points to bear in mind are the relief of pain, and the necessity of absolute rest ; and to these objects all our measures must be sub- ordinate, since it is quite hopeless to attempt to cut short the inflam- mation by any active medication. If the disease be recognized at a very early stage, the local abstrac- tion of blood, by the application of a few leeches to the groin or to the hemorrhoidal veins, may give relief; but the influence of this remedy has been greatly exaggerated, and when the disease is of any standing- it is quite useless. Leeches to the uterus, often recommended, are, I believe, likely to do more harm than good (unless in very skilful hands), from the irritation produced by passing the speculum. Opi- ates in large doses may be said to be our sheet anchor in treatment whenever the pain is at all severe, either by the mouth, in the form of morphia suppositories, or injected subcutaneously. In the not uncommon cases in which pain comes on severely in paroxysms, the opiates should be administered in sufficient quantity to lull the pain, and it is a good plan to give the nurse a supply of morphia supposi- tories (which often act better than any other form of administering the drug), with directions to use them immediately the pain threatens to come on. When there is much pyrexia large doses of quinine may be given with great advantage, along with the opiates. The state of the bowels requires careful attention. The opiates are apt to produce constipation, and the passage of hardened feces causes much suffering. Hence it is desirable to keep the bowels freely open. Nothing answers this purpose so well as small doses of castor oil, such as half a teaspoonful given every morning. Warmth and moisture, constantly applied to the lower part of the abdomen, give great relief either in the form of large poultices of linseed meal, or, if these prove too heavy, of spongio-piline soaked in boiling water. The poultices may be advantageously sprinkled with laudanum or belladonna liniment. I say nothing of the use of mercurials, iodide of potassium, and other so-called absorbent remedies, since I believe them to be quite valueless, and apt to divert attention from more useful plans of treatment, Importance of Rest. — The most absolute rest in the recumbent posi- tion is essential, and it should be persevered in for some time after the intensity of the symptoms is lessened. The beneficial effect of rest in alleviating pain is often seen in neglected cases, the nature of which has been overlooked, instant relief following the laying up of the patient. PELVIC CELLULITIS AND PELVIC PERITONITIS. 843 Counter -irritation. — When the acute symptoms have lessened ab- sorption of the exudation may be favored, and considerable reliei obtained, from counter-irritation, which should be gentle and lono*- continued. The daily use of tincture of iodine until the skin peels, perhaps best meets this indication ; but frequently repeated blisters are often very serviceable. This I believe to be a better plan than keeping up an open sore with savine ointment, or similar irritating applications. Opening of Pelvic Ahscesses. — When suppuration is established the question of opening the abscess arises. When this points in the groin, and the matter is superficial, a free incision may be made, and here, as in mammary abscess, the antiseptic treatment is likely to prove very serviceable. The abscess should, however, not be opened too soon, and it is better to wait until the pus is near the surface. The importance of not being in too great a hurry to open pelvic abscesses has been insisted on by West, Duncan, and other writers, and I have no doubt the rule is a good one. It is more especially applicable when the abscess is pointing in the vagina or rectum, where exploratory incisions are apt to be dangerous, and when the presence of pus should be positively ascertained before operating. We have in the aspirator a most useful instrument in the treatment of such cases, which enables us to remove the greater part of the pus without any risk, and the use of which is not attended with danger, even if employed prematurely. If it do not sufficiently evacuate the abscess, a free opening can afterwards be safely made with the bis- toury. The surgical treatment of pelvic abscess is, however, too wide a subject to admit of being satisfactorily treated here. Diet and Regimen. — The diet should be abundant, but simple and nutritious. In the early stages of the disease, milk, beef-tea, eggs, and the like, will be sufficient. After suppuration a large quantitv of animal food is required, and a sufficient amount of stimulants". The drain on the system is then often very great, and the amount of nourishment patients will require and assimilate, when a copious purulent discharge is going on, is often quite remarkable. A general tonic plan of medication will also be required, and such drugs as iron, quinine, and cod-liver oil, will prove useful. INDEX A BDOMEN, adipose enlargement of, 150, J\ [151] enlargement of, as a sign of preg- nancy, 141 state of, alter delivery, 544 Abdominal pregnancy. (See Extra-uterine pregnancy.) Abortion, 235 causes of, 237 difficulty in procuring artificial, 236 liability to recurrence of, 230 retention of secundines in, 241, 246 symptoms of, 241 treatment of, 241 production of, in vomiting of preg- nancy, 192 [value of opium in prevention of, 242] Abscess of niammse. (.See Mammary ab- scess.) Abscess, pelvic. (See Pelvic cellulitis.) After-pains, 547 treatment of, 548 Age, influence of, in labor, 335 Albuminuria in pregnancy, 197 relation of, to eclampsia, 568 relation of, to puerperal insanity, 581 Allantois, 98 Amnion, formation of, 97 pathology of, 229 structure of, 100 Amputations (intra-uterine), 232 Anaemia in pregnancy, 196 Anaesthesia in labor, 2S8 in forceps operations, 472 value of, in difficult cases of turning, 464 Anasarca in pregnancy, 199 Ante-version of the gravid uterus, 208 Apoplexy during or after labor, 568, 626 Arbor vitae, 51 Area germinativa, 96 Area pellucida, 97 Areola, 72 changes of, during pregnancy, 139 Arm, presentation of. (See Shoulder pre- sentation.) dorsal displacement of, 326 Artificial human milk, 565 Artificial respiration in cases of apparent still-birth, 552 Ascites as a cause of dystocia, 369 Asphyxia (idiopathic), 626 [Atmosphere, advantages of a pure, in preventing abortion, 243] Auscultatory signs of pregnancy, 145 BAGS (Barnes's). (See Dilators.) Ballottement, 143 Bi-lobed uterus, gestation in, 185 Binder, uses of, 287 Bladder, distension of, as a cause of pro- tracted labor, 335 state of, after delivery, 547 Blastodermic membrane, 91 division and layers of, 96 Blood, alteration in, after delivery, 541 Blood-diseases transmitted to foetus, 229 Blunt-hook in breech presentation, 303 Bowels, action of, after delivery, 550 Breech presentations. (See Pelvic pre- sentations.) Broad ligaments of uterus, 60 [Bromide of sodium preferred to bromide of potassium, 202] Bronchitis as a cause of protracted labor, 335 Brow presentations, 312 CESAREAN section, 325, 353, 381, 506 causes of mortality after, 513 causes requiring the operation, 510 description of, 517 history of, 506 post-mortem operation, 511 results to child in, 507 statistics of, 507 substitutes for, 521 [sutures in, 518] [Csesarean operation in America, 522] [in the United Kingdom, 508] [with fibroid tumor, 353] [transverse position of foetus, 325] [in pelvic exostosis, 381] Calculus of bladder obstructing labor, 356 Caput succedaneum, 272 Carcinoma in pregnancy, 215 obstructing labor, 349 Caries of teeth in pregnancy, 195 (645) 646 INDEX Carunculse myrtiformes, 44 [Catheter introduced in dorsal decubitus, 43] introduction of, 43 Caul, 257 Cellulitis, pelvic. (See Pelvic cellulitis.) Cephalotribe, 494 Cephalotripsy. (See Craniotomy.) Cervix uteri, 51 alterations of, after childbirth, 50 cavity of, 50 dilatation of, in labor, 252 impaction of, before foetal head, 280 incision of, for rigidity, 350 modification of, by pregnancy, 128 mucous membrane of, 55 organic causes of rigidity of, 348 rigidity of, as a cause of pro- tracted labor, 346 treatment of rigidity, 346 villi of, 55 Charlotte, Princess of Wales, death of, 344 Child (the new born). (See Infant.) Child, risks to, in forceps operations, 479 Childbirth, mortality of, 540 Chloral in labor, 289 in rigidity of cervix, 347 Chloroform in labor, 290 in difficult cases of turning, 464 in rigidity of cervix, 347 Chorea in pregnancy, 203 Chorion, 101 vesicular degeneration of, 221 Circulation of foetus, 121 Cleavage of yelk, 90 Clitoris, 42 Coccyx, 27, 28 ligaments of, 28 ossification of, 28 mobility of, 28 Cold in the treatment of puerperal hyper- pyrexia, 611 Colostrum, 554 Complex presentations, 325 Conception, signs of, 135 Constipation in pregnancy, 193 [Constriction of uterus, tetanoid, 256] Continued fever in pregnancy, 213 Convulsions (puerperal). (See Eclamp- sia.) Corps reticule, 99 Corpus luteum, 76 Cranioclast, 494 Craniotomy, 491 cases requiring, 496 comparative merits of, and cephalo- tripsy, 500 description of cephalotripsy, 501 extraction of head by craniotomy for- ceps, 502 method of perforating, 499 perforators, 492 perforation of after-coming head, 499 religious objections to, 491 Craniotomy forceps, 493 Crotchets, 493 Cystocele, obstructing labor, 355 DEATH, apparent, of new-born child. (See Infant.) Death, sudden, during labor and the puer- peral state, 626 from air in the veins, 627 functional causes of, 627 organic causes of, 626 Decapitation of foetus, 504 Decidua, 91 at end of pregnancy, and after de- livery, 95 cavity between d. vera and reflexa, 95 divisions of, 91 fatty degeneration of, as the cause of labor, 249 formation of d. reflexa, 93 structure of, 92 Delivery, state of patient after, 541 contraction of uterus after, 543 management of patient after, 547 nervous shock after, 541 prediction of date of, 155 signs of recent, ,158 state of pulse after, 541 weight of uterus after, 544 Diameters of foetal skull, 113 of pelvis, 33 Diarrhoea in pregnancy, 193 [Diet, milk, in nursing mothers, 558] of* lying-in women, 548 [wet-nurse, 557] Dilators (caoutchouc) in the induction of premature labor, 446 in rigidity of cervix, 348 Diphtheria in the puerperal state, 589 Diseases of pregnancy, 188 albuminuria, 197 anaemia and chlorosis, 196 carcinoma, 215 cardiac diseases, 213 chorea, 203 constipation, 193 diarrhoea, 193 disorders of the nervous system, 201 respiratory organs, 195 teeth, 194 urinary system, 204 displacements of the gravid ute- rus, 207 epilepsy, 214 eruptive fevers, 212 fibroid tumors, 217 haemorrhoids, 194 icterus, 215 leucorrhoea, 206 ovarian tumor, 215 palpitation, 196 paralysis, 202 pneumonia, 213 INDEX. 647 Diseases of pregnancy — pruritus, 206 ptyalism, 194 syncope, 196 syphilis, 214 varicose veins, 207 vomiting (excessive), 189 Dropsies affecting the foetus, 231 Ductus arteriosus, 122 venosus, 122 Dystocia from foetus, 357 ECLAMPSIA, 568 cause of death in, 571 condition of patient between the at- tacks, 570 confusion from defective nomencla- ture, 568 exciting causes of, 573 obstetric management in, 576 pathology of, 571 premonitory symptoms of, 568 relation of, to labor, 570 results to mother and child in, 570 symptoms of, 569 transfusion in, 531 Traube and Rosenstein's theorv of, 572 treatment of, 573 [venesection in, 575] uraemia theory of, 568 views of MacDonald, 573 Ecraseur, use of, as a substitute for crani- otomy. 496 Embolism. (See Thrombosis.) Embryotomy, 503 Emotion, mental, as a cause of protracted labor, 335 Epiblast, 96 Epilepsy, in pregnancy, 214 Epileptic convulsions, 568 Ergot of rye, 338 as a means of inducing labor, 445 objections to use of, 338 mode of administration, 338 value of, after delivery, 287 Eruptive fevers in pregnancy, 212 Erysipelas, as a cause of puerperal septi- cemia, 595 Ether in labor, 291 [in the United States, 291] Exhaustion, importance of distinguishing between temporary and permanent in labor, 337 Expression, uterine. (See Pressure.) of the placenta, 286 Extra-uterine pregnancy, 166 abdominal variety of, 177 causes of, 168 changes of the foetus in, 179 classification of, 167 diagnosis of abdominal variety, 180 Extra-uterine pregnancy — diagnosis of tubal variety, 172 gastrotomy in, [174], 175, 181 pseudo-labor in, 178 [vaginal section in, 174] symptoms of rupture in, 171 treatment after rupture, [177] treatment of abdominal variety, 181 tubal variety, 169 treatment of tubal variety, 173 Evisceration, 5U4 FACE presentation, 303 causes of, 304 diagnosis of, 305 difficulties connected with, 311 erroneous views formerly enter- tained of, 304 mechanism of delivery in, 305 mento-posterior positions in, 310 prognosis in, 310 treatment of, 310 Fallopian tubes, 63 False pains, character and treatment of, 276 Faradization in apparent still-birth, 552 Fibroid tumor in pregnancy. 217 obstructing labor, 352 Fillet, 489 in breech presentations, 303 nature of the instrument, 490 objections to its use, 491 Foetal head, anatomy of, 112 induction of premature labor, for large size of." 442 Foetal heart, sounds of, in pregnancy, 145 Foetus, anatomy and physiology of, 109 [anencephaious, causing enenresis, 205] appearance of a putrid, 234 appearance of, at various stages of de- velopment, 110 at term, 111 [cleaning of, without water, 553] circulation of, 121 changes in circulation of, as cause of labor, 248 changes in position of, during preg- nancv, 115 death of, 234 detection of position in utero by pal- pation, 115 early viability of, 235 excessive development of, as a cause of difficult labor, 370 explanation of its position in utero, 117 functions of, 119 nutrition of, 119 pathology of, 228 position of, in utero, 115 respiration of, 120 '648 INDEX Foetus- signs and diagnosis of death of, 234, 500 [gigantic, 111] Fontanelles, 112 Foot, diagnosis of, 295 Foot presentations. (See Pelvic presenta- tions.) Foramen ovale, 122 Forceps, 465 action of, 469 advantages of pelvic curve in, 466 [application at inferior strait, 487] [at superior strait, 487] application of, to after-coming head in breech presentations, 301 application of, within the cervix, 351 [carried over abdomen, to complete delivery of head, 488] cases in which a straight instrument should be used, 466 dangers of, 342, 478 dangers of, to child, 479 description of, 465 description of the operation, 472 difference between high and low ope- rations, 471 disadvantages of a weak instrument, 468 frequent use of, in modern practice, 340, 465 high operations, 477 [in America, 479] long, 467 preliminary considerations before using, 471 short, 466 use of anaesthetics in forceps deliverv, 472 use of in deformed pelvis, 387 use of in difficult occipito-posterior positions, 314 use of in protracted labor, 340 [Forceps, Bedford's, 483] [Clemann's, 469] [Davis's, 482] [Elliot's, 483] [Hodge's, 481] [Meigs's craniotomy, 503] [Sawyer's, 484] [Wallace's, 482] [White's, 483] Forceps-saw, 495 Fossa navicularis, 44 Funis. (See Umbilical cord.) GALACTAGOGUES, 558 Galactorrhcea, 560 Galvanism as a means of inducing labor, 445 Gangrene of limbs from arterial obstruc- tion, 613 Gastrotomy, after rupture of uterus, 432 in extra-uterine pregnancy, 174, 183 Gastro-elytrotomy. (See Laparo-elytrot- omy.) Generative organs, in the female, 41 division according to function, 41 Germinal vesicle, disappearance of, after impregnation, 89 Gestation. (See Pregnancy.) Graafian follicle, 67 structure of, 69 H HEMATOCELE, obstructing labor, 356 Haemorrhoids, in pregnancy, 194 [Hand, introduction of, in occipito-poste rior positions, 315] Hand-feeding of infants, 564 ass's milk in, 564 artificial human milk in, 565 causes of mortality in, 564 cow's milk in, and its prepara- tion, 564 goat's milk in, 564 method of, 566 Head presentations, 261 description of cranial positions in, 262 division of, 262 explanation of frequency of 1st position, 263 frequency of, 263 mechanism of 1st position, 265 2d position, 270 3d position, 270 4th position, 272 relative frequency of various po- sitions, 263 Heart, diseases of, in pregnancy, 213 hypertrophy of, in pregnancy, 132 Hemorrhage, accidental, 405 causes and pathology of, 406 concealed internal, 407 diagnosis, prognosis, and treatment of concealed internal, 406 prognosis of, 407 symptoms and diagnosis of, 406 treatment of, 408 Hemorrhage after delivery, 409 causes of, 409 constitutional predisposition to, 413 curative treatment of, 415 from laceration of maternal struc- tures. 421 nature's mode of preventing, 259, 409 preventive treatment of, 414 secondary causes of, 411 secondary treatment of, 421 symptoms of, 413 transfusion of blood in, 422 Hemorrhage after delivery (secondary ), 422 distinction between, and pro- fuse lochial discharge, 422 local causes of, 423 treatment of, 424 INDEX. 649 Hemorrhage, unavoidable. (See Placenta previa.) Hernia, in labor, 356 Hour-glass contraction of uterus, 411, [412] Hydatids of uterus, 221 Hydr amnios, 228 Hydrocephalus of foetus, as a cause of dif- ficult labor, 367 Hydrorrhea gravidarum, 221 Hymen, 43 [an obstacle to delivery, 44] Hypoblast, 96 Hysteria during labor, 568 FDUCTION of premature labor. (See Premature labor.) Inertia of the uterus, frequent child-bear- ing as a cause of, 334 Infant, apparent death of, 551 appearance of, in cases of apparent death, 551 clothing of, 553 evils of over-suckling, 554 management of, 556 management of, when food disagrees, 567 treatment of apparent death of, 551 various kinds of food of, 567 washing and dressing of, 553 Infantile mortality, diminution of, as a reason for more frequent use of forceps, 342 Inflammatory diseases affecting the foetus, 231 Insanity (puerperal), 577 classification of, 577 of lactation, 583 of pregnancy, 578 predisposing causes of, 578 puerperal (proper) 580 causes of, 581 form of, 579 prognosis of, 583 post-mortem signs of, 583 symptoms of, 584 transient mania during deliverv, 580 treatment of, 585 treatment during convalescence, 588 question of removal to an asylum, 588 Insomnia in pregnancy, 202 Intermittent fever affecting the foetus, 230 Intestines, disorders of, as influencing labor, 336 Inversion of uterus. (See Uterus.) Irregular uterine contractions after labor, 411 as a cause of lingering labor, 336 Irritable bladder in pregnancy, 204 Ischium, planes of the, 38. 42 AUNDICE in pregnancy, 215 KIESTEIN, 132, [135] Knots on the umbilical cord, 227 Knee presentation, 295 Kyphotic deformity of pelvis, 379 LABIA majora, 41 Labia minora, 42 Labor, 248 age, influence of, on 335 anaesthesia in, 288 arrest of, 158 causes of, 248 causes of precipitate, 336 causes of protracted, 333 character and source of pain in, 254 character of false pains, 276 dilatation of cervix in, 252 duration of, 260 effect of uterine contractions in, 251 evil effects of protracted, 332 induction of. (-See Premature labor.) influence of stage of, in protracted, 332 management of in deformed pelvis, 387 management of natural, 274 management of third stage of, 284 mechanism of, in head presentation, 261 obstructed by faulty condition of the soft parts, 341 period of day at which labor com- mences, 261 phenomena of, 248 position of patient during, 278 preparatory treatment, 274 precipitate, 346 prolonged and precipitate, 332 rupture of membranes in, 252 stages of, 255 symptoms of protracted, 333 treatment of protracted, 346 Lactation, defective secretion of milk in, 558 diet of nursing women during, 556 excessive flow of milk in, 559 importance of to mother, 554 importance of wet-nursing to child, 554 insanity of, 583 management of, 555 means of arresting secretion of milk in, 557 period of weaning in, 557 Lamina? dorsales, 97 Laparo-elytrotomy, 525 [Laparotomy, American puerperal, 432] Lead-poisoning, affecting the foetus, 230 as a cause of abortion, 240 Leucorrhcea, in pregnancy, 205 Lever. (See Vectis.) 650 INDEX [Line, dark abdominal, in negro, 141] Liquor amnii, 100 uses of, 101 source of, 101 deficiency of, 229 Lochia, 546 variation in amount and duration of, 546 occasional fetor of, 546 Lying-in hospitals, mortality in, 589 Lypotliemia, 196 MALPRESENTATIONS, peculiar form of bag of membranes m, 294 Mammary abscess, 560 antiseptic treatment of, 561 signs and symptoms of, 560 treatment of, 561 changes during pregnancy, 139 their diagnostic value, 140 glands, 71 their sympathetic relations with the uterus, 72 [McKnight's operation, 175] Measles, affecting the foetus, 230 in pregnancy, 212 Meconium, 124 Membranes, artificial rupture of, 279 puncture of, as a means of inducing labor, 444 Menstruation, 73 cessation of, 84 during pregnancy, 136 changes in Graafian follicle after, 73 [increased by change of residence to a hot climate, 79] period of, duration, and recurrence, 79 purpose of, 84 sources of blood in, 81 theory of, 82 quantity of blood lost in, 79 vicarious, 84 Mesoblast, 96 [Milk, Alderney, too rich for young in- fants, 565] artificial human, 565 ass's, 564 cow's, and its preparation, 564 defective secretion of, 558 excessive secretion of, 559 goat's, 564 [in cities, 564] means of arresting the secretion of, 557 secretion of, after delivery 554 Milk-fever, 543 Miscarriage. (See Abortion.) Missed labor, 185, [186] Moles, 237 Monstrosity (double), 363 classification of, 364 mechanism of delivery in, 364 Mons veneris, 41 Montgomery's cups, 93 Morning sickness, 137 Mortality of childbirth, 540 Mucous membrane of uterus. (See Ute- rus.) [Muller operation, 521] ATERVOUS shock after delivery, 542 ±\ Nervous system, changes in during pregnancy, 134 disorders of, in pregnancy, 201 excitability of, in puerperal wo- men, 573 Neuralgia in pregnancy, 202 Nipple, 72 Nipples, depressed, 59 [eczema from, 559] fissures and excoriations of, 559 Nursing. (See Lactation.) Nutrition of foetus, 119 Nymphse. (See Labia minora.) OBLIQUELY contracted pelvis, 378 Obstetric bag, 275 Occipito-posterior positions, difficult cases of, 313 causes of face- to pubis delivery in, 313 forceps in, 315 treatment of, 314 vectis or fillet in, 314 Omphalo-mesenteric artery and vein, 98 Opiates, use of, after delivery, 548 Os innominatum, 25 Osteomalacia, as a cause of deformity, 372 [not an American disease, 373] Osteophytes, formation of, during preg- nancy, 134 Os uteri, dilatation of, as a means of in- ducing labor, 446 occlusion of, in labor, 349 Ovarian pregnancy. (See Extra-uterine pregnancy.) tumor in pregnancy, 215 Ovariotomy in pregnancy, 216 Ovary, 64 functions of, 73 structure of, 64 vascular arrangements of, 68 Ovule, 69 changes in, after impregnation, 89 changes in, when retained in utero after its death, 238 formation of, 67. Ovum, blighted, retained in utero, 247 Oxytocic remedies, 338 PAINS, after, 547 false, 256 irregular and spasmodic as a cause of protracted labor, 336 labor, 251 INDEX. 651 Palpitation in pregnancy, 196 Pampiniform plexus, 56 Paralysis in pregnancy, 202 from embolism of the cerebral arte- ries, 619 from embolism of the main arteries of the limb, 619 Parovarium, 60 Parturient canal, axis of, 37 Pathology of decidua and ovum, 218 Pelvis, alterations in, articulations of, during pregnancy, 31 anatomy of, 25 articulations of, 28 axes of, 37 Cesarean section in deformities of, 391 causes of deformity of, 371 comparative estimate of turning and forceps in deformity of, 390 craniotomy in deformity of, 391 diagnosis of deformity, 384 deformities of, 371 development of, 39, 40 difference according to race, 40 difference in the two sexes, 32 division into true and false, 32 equally contracted, 374 equally enlarged, 374 forceps in deformity of, 388 induction of premature labor in de- formity of, 391 infantile, 39 kyphotic, 380 ligaments of, 28 masculine, 374 mechanism of delivery in deformed, 383 movements of the articulations of, 30 obliquely contracted, 379 planes of, 37 Robert's, 380 soft parts connected with, 40 tumors of, 381 turning in deformity of, 389 undeveloped, 375 Pelvic cellulitis and peritonitis, 636 etiology of, 637 importance of distinguishing the two forms of disease, 636 connection with septicemia, 637 opening of abscess in, 642 prognosis of, 642 relative frequency of the two forms of disease, 639 results of physical examina- tion, 640 seat of inflammation in cellu- litis, 637 seat of inflammation in peri- tonitis, 638 suppuration in, 641 symptomatology, 639 Pelvic cellulitis and peritonitis — terminations of, 640 treatment of, 641 two distinct forms of disease, 636 presentations, 292 application of forceps to the after- coming head in, 301 causes of, 292 danger to children in, 300 diagnosis of, 293 frequency of, 292 management of impacted breech in, 302 mechanism of, 295 prognosis in, 293 treatment of, 369 Pelvimeters, various forms of, 385 Perchloride of iron, injections of, in post- partum hemorrhage, 421 Perforators, 491 Perineum, distension of, in labor, 258, 281 incision of, 282 laceration of, 283 relaxation of, 281 rigidity of, as a cause of protracted labor, 351 Peritonitis, pelvic. {See Pelvic cellulitis.) Peritonitis, puerperal. {See Septicaemia.) Phlegmasia dolens. {See Thrombosis, peripheral venous.) Placenta, 102 adhesion of, after delivery, 413 degeneration of, 108 detachment of, in labor, 259 expression of, 286 foetal portion of, 103 form of, in man and animals, 102 functions of, 108 maternal portion of, 106 minute structures of, 103 pathology of, 224 [long-retained, 418] sinus system of, 105 sounds produced during separation of, 149 treatment of adherent, 417 Placenta membranacea, 224 Placenta prsevia 393, [394, 402] causes of, 394 causes of hemorrhage in, 397 natural termination of labor in, 399 pathological changes of placenta in 398 prognosis in, 394 sources of hemorrhage in, 396 summary of rules of treatment in, 404 symptoms of, 395 treatment of, 400 turning in, 462 Placenta succenturia, 224 Placentitis, 225 Plugging of vagina, 245 652 INDEX Plural births, 160, 359 arrangement of placentae and membranes in, 162 causes of, 162 diagnosis of, 163 relative frequency of, in different countries, 160 sex of children in, 161 treatment of, 360 Pneumonia in pregnancy, 213 "Polar globule," 89 [Polypus, an obstacle to delivery, 355] Porro operation, 520 Position of cranium in head-presentation. (See Head presentation.) Post-partum hemorrhage. {See Hemor- rhage.) Pregnancy, 125 abnormal, 160 affections of respiratory organs, 194, [195] alteration of color of vaginal mucous membrane as a sign of, 144 ballottement as a sign of, 143 changes in the blood during, 132 changes in the liver, lymphatics, and spleen during, 133 in the urine during, 134 [complicated with ovarian tumor, 216] deposits of pigmentary matter during, 141 differential diagnosis of, 150 dress of patient in, 274 duration of, 154 enlargement of abdomen as a sign of, 141 extra-uterine. (See Extra-uterine pregnancy.) foetal movements in, 141 formation of osteophytes during, 133 hypertrophy of the heart during, 133 in cases of double uterus, 57 in the absence of menstruation, 137 intermittent uterine contractions as a sign of, 142 ptyalism in, 194 prolapse of the uterus in, 207 protraction, 156 pruritis in, 206 quickening, 142 sickness of, 137 signs and diagnosis of, 136 sounds produced by the fcetal move- ments in, 149 spurious, 153 sympathetic disturbances of, 137 uterine fluctuation in, 144 vaginal signs of, 143 pulsation in, 144 Premature labor, 230 history of the operation of induc- tion of, 442 induction of, 442 Premature labor — in deformed pelvis, 393 injection of carbonic acid gas as a means of inducing, 448 insertion of flexible bougie as a means of inducing, 448 objects of the operation of induc- tion of, 442 oxytocics as a means of inducing, 445 period for the induction of, in de- formed pelvis, 393 precautions as regards the child in the induction of, 449 puncture of the membranes as a means of inducing, 445 separation of the membranes as a means of inducing, 447 vaginal and uterine douches as a means of inducing, 447 Pressure as a means of inducing uterine contractions, 339 mode of applying, 340 Prolapse of umbilical cord. (See Umbili- cal cord.) Ptyalisms in pregnancy, 194 Puerperal convulsions. (See Eclampsia.) fever. (See Septicaemia.) mania. (See Insanity.) state, 540 after-treatment in [549], 550 diet and regimen in, 548 diminution of uterus in, 543 importance of prolonged rest in, 550 secretions and excretions in, 542 temperature in, 542 Pulmonary arteries, anatomical arrange- ment of, as favoring thrombosis, 616 Pulse, state of, after delivery, 541 Q UICKENING, 142 [Quinine as an oxytocic, 338] RACE as influencing the size of the foetal skull, 114 Recto-vaginal fistula, 434 Respiration of foetus, 120 Retroversion of the gravid uterus, 208 Rickets as a cause of pelvic deformity, 373 Rosenmullor, organ of. (See Parovarium.) Round ligaments of the uterus, 61 Rupture of uterus. (*See Uterus.) | SACRUM, anatomy of, 27 mechanical relations of, 27 Salivation in pregnancy, 194 Scarlet fever affecting the foetus, 230 in pregnancy, 212 in the puerperal state, 596 Scvbalae in the rectum obstructing labor, 356 INDEX 653 Septicemia (puerperal), 589 bacteria in, 601 channels of diffusion in, 601 through which septic matter may be absorbed, 593 cold in treatment of, 611 conduct of practitioner in regard to, 599 contagion from other puerperal pa- tients as a cause of, 598 description of, 605 division into auto-genetic and hetero- genetic forms, 594 epidemics of, 590 history of, 589 importance of antiseptic precautions in, 600 influence of cadaveric poison as a cause of, 595 influence of zymotic disease in caus- ing, 595 its connection with pelvic cellulitis and peritonitis, 637 local changes in, 601 mode in which the poison maybe con- veyed to patients in, 599 nature of septic poison, 601 pathological phenomena in, 603 prevention of, 600 pyemic forms of, 604 sources of auto-infection in 594 of hetero-infection, 594, [599] symptoms of the intense forms, 605 theory of an essential zymotic fever, 591 of identity with surgical septi- caemia, 591 of local origin, 590 transfusion of blood in, 530 treatment of a, 607 [venesection in, 609] ^'arburg's tincture in the treatment of, 611 Sex, discovery of, of foetus during preg- nancy, 146 of foetus as influencing the size of the skull, 114 Shoulder presentations, 317 diagnosis of, 320 division of, 317 mechanism of, 322 prognosis and frequency of, 319 spontaneous version in, 322 treatment of, 329 [Siamese twins, how born, 364] Sickness of pregnancy, 137 [Silver uterine sutures, 519] [Sleep on inclined plane, for relief of dys pncea of pregnancy, 195] Smallpox affecting the foetus, 229 in pregnancy, 212 Smith's, Tyler, theory of labor, 250 Spondylolithesis, 377 Spontaneous evolution, 322 version, 320 Spurious pregnancy, 153 diagnosis of, 153 symptoms of, 153 [Story of the Princess of Swarzenberg, 512] Symphyseotomy, 520 Syncope during or after labor, 626 in pregnancy, 196 Syphilis affecting the foetus, 230 as a cause of abortion, 239 in pregnancy 214 [Stethoscope, Cammann's, 147] Super-fecundation and super-fcetation, 164 Sutures of fcetal head, 112 TEMPERATURE after delivery, 542 Thrombosis (peripheral venous), 629 changes in thrombi in, 637 condition of the affected limb, 629 detachment of emboli in, 634 history and pathology of, 630 progress of the disease, 630 symptoms of, 629 treatment of, 633 (puerperal), 613 arterial thrombosis and embo- lism, 624 cardiac murmur in pulmonary 622 cases illustrating recovery from pulmonary, 620 causes of death in pulmonary, 622 clinical facts in favor of pul- monary, 616 conditions which favor throm- bosis in the puerperal state, 614 distinction between thrombosis and embolism, 615 phlegmasia dolens a conse- quence of, 614 post-mortem apj>earance of clots in pulmonary, 622 question of primary thrombosis in the pulmonary arteries. 630 question of recovery from pul- monary, 615 symptoms of arterial, 624 of pulmonary obstruction in, 618 treatment of arterial, 626 of pulmonary, 623 Thrombus. (See Hematocele.) Toothache in pregnancy, 194 Transfusion of blood, 530 addition of chemical reagents to prevent coagulation of fibrin e, 534 cases suitable for the operation. 536 dangers of the operation, 536 654 INDEX, Transfusion of blood — defibrination of blood in, 534, [534] difficulties of the operation, 532 effects of successful transfusion, 539 history of the operation, 530, immediate transfusion, 533 method of injecting defibrinated blood, 539 method of performing immediate transfusion, 537 method of preparing defibrinated blood, 538 nature and object of the opera- tion, 531 secondary effects of, 539 statistical results of, 536 Tropics, influence of residence in, on labor, 334 Trunk, presentation of. (See Shoulder presentations.) Tumors, diagnosis of uterine and ovarian, 157 foetal, 232 obstructing labor, 370 Tunica albuginea, 66 Turning, 449 anaesthesia in, 455 by combined method, 453 by external manipulation only, 451 cases suitable for the operation, 451 for operating by combined method, 452 cephalic, 453 choice of hand to be used, 455 history of the operation, 449 in abdomino-anterior positions, 463 in deformed pelvis, 389 in placenta praevia, 402, 462 method of cephalic 450 of performing by external manip- ulation, 451 of podalic, 454 object and nature of the operation, 450 period when the operation should be performed, 455 podalic, 454, 459 position of patient in, 454 statistics and dangers of, 451 value of anaesthetics in difficult cases of, 464 Twins. (See Plural births.) [Carolina, how born, 366] conjoined, 361 locked, 360 UMBILICAL cord, 108 knots of, 109, 237 ligature of, 283 pathology of, 227 prolapse of, 326 causes of, 328 Umbilical cord, prolapse of — diagnosis of, 328 frequency of, 327 postural treatment of, 328 prognosis of, 329 reposition of, 330 Umbilical souffle, 147 vesicle, 97 Urachus, 99 Uraemia, in connection with eclampsia, 540 in connection with puerperal insanity, 581 Urethra, 43 Urine, changes in, during pregnancy, 134 retention of, after delivery, 548 Uterine fluctuation, as a sign of preg- nancy, 144 souffle, 147 Utero-sacral ligaments, 62 Uterus, 47 analogy of interior of, after delivery, and stump of an amputated limb, 95 anomalies of, 57 ante-partum hour-glass contraction, 351, [351] arrangement of muscular fibres of, 52 axis of, during pregnancy, 127 changes in cervix during pregnancy, 127, 143 changes in form and dimensions of, during pregnancy, 125 changes in mucous membranes of, after delivery, 545 changes in mucous membranes of, after impregnation, 91 changes in tissues of, during preg- nancy, 130 changes in the vessels of, after de- livery, 544 congestive hypertrophy of, 151 contractions of, in labor, 251 dimensions of, 49 diminution in size of, after delivery, 544 distension of, as a cause of labor, 249 distension of, by retained menses, 151 fatty transformation of, after delivery, 527 [hour-glass contraction, 412] intermittent contractions of, during pregnancy, 142, [143] internal surface of, 50 inversion of, 435 differential diagnosis of, 437 production of, 437 results of physical examination in, 437 symptoms of, 436 [spontaneous reposition, 440] treatment of, 439 ligaments of, 60 lymphatics of, 57 malposition of, as a cause of protracted labor, 336 INDEX 65o Uterus — mode of action in labor, 251 mucous membrane of, 53 muscular fibres of, 52 nerves of, 57 [partitioned, 59] [persistent intermittent contraction of, 143J regional division of, 50 relations of, 48 retroversion of gravid, 210 rupture of, 426 alterations of tissues in, 427 causes of, 427 comparative result of various methods of treatment in, 432 prognosis of, 430 seat of laceration in, 427 symptoms of, 430 treatment of, 430, 434 [gastrotoniy in, 433] size of, at various periods of preg- nancy, 126 state of, in protracted labor, 334 structures composing, 51 utricular glands of, 53 vessels of, 56 weight of, after delivery, 544 VAGINA, 45 bands and cicatrices of, obstructing VONA pellucida, Vagina — orifice of, 43 structure of, 46 Varicose veins in pregnancy, 207 Vectis, 489 action of, 489 cases in which it is applicable, 490 Veins, entrance of air into, as a cause of sudden death after delivery, 627 Venesection for rigidity of cervix, 347 Version. (See Turning.) [by tbe vertex, 314] Vesico-uterine ligaments, 61 Vesico-vaginal fistula, 433 Vestibule, 42 Vicarious menstruation, 84 Vomiting in pregnancy, 189 Vulva, 41 condition of, after delivery, 545 oedema of, obstructing labor, 356 vascular supply of. 45 Vulvo- vaginal glands, 44 WARBURG'S tincture, 611 Weaning. (See Lactation.) "Wet-nurse, selection of, 555 Wolffian bodies. 58, 110 Wounds of the foetus, 232 (19 delivery, 350 contraction of, after delivery, lacerations of, 433 543 affectins: the foetus Li Zymotic disease, 229 as a cause of septicsemia, 595 HENEY C. LIEN'S (LATE LEA k BLANCHARD'Sj CLASSIFIED O^T^I-jOGiTJIEJ OF MEDICAL AND SDEGIOAL PUBLICATIONS. In asking the attention of the profession to the works advertised in the following pages, the publisher would state that no pains are spared to secure a continuance of the confidence earned for the publications of the house by their careful selection and accuracy and finish of execution. The printed prices are those at which books can generally be supplied by booksellers throughout the United States, who can readily procure for their customers any works not kept in stock. Where access to bookstores is not convenient, books will be sent by mail post-paid on receipt of the price, and as the limit of m i ilable weight has been removed, no difficulty will be experienced in obtaining through the post-office any work in this catalogue. No risks, however, are assumed either on the money or the books, and no publications but my own are supplied, so that gentlemen will in most cases find it more convenient to deal with the nearest bookseller. An Illustrated Catalogue, of 64 octavo pages, handsomely printed, will be for- warded by mail, post-paid, on receipt of ten cents. HENRY C. LEA. Nos. 706 and 708 Sansom St., Philadelphia, January, 1880. INCREASED INDUCEMENT FOR SUBSCRIBERS TO THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, TWO MEDICAL JOURNALS, containing nearly 2000 LARGE PAGES, Free of Postage, for FIVE D0LLAKS Per Annum. TEEMS FOR 1880. The American Journal of the Medical Sciences, published ") Five Dollars quarterly (1150 pages per annum), with I per annum, The Medical News and Abstract, monthly (768 pp. per annum), J in advance. SEPARATE SUBSCRIPTIONS TO The American Journal of the Medical Sciences, when not paid for in advance, Five Dollars. The Medical News and Abstract, free of postage, in advance, Two Dollars and a half. *^* Advance-paying subscribers can obtain at the close of the year cloth covers, gilt-lettered, for each volume of the Journal (two annually), and of the News and Abstract (one annually), free by mail, by remitting ten cents for each cover. It will thus be seen that for the moderate sum of Five Dollars in advance, the subscriber will receive, free of postage, the equiva'ent of three or four large octavo volumes, etored with the choicest matter, original and selected, that can be furnished by the medical literature of both hemispheres. Thus taken to- gether, the "Journal," and the "News and Abstract" combine the advantages of the elaborate preparation that can be devoted to the Quarterly with the prompt conveyance of intelligence by the Monthly ; while, the whole being under a single editorial supervision, the subscriber is secured against the duplication of matter inevitabb when periodicals from different sources are taken together. The periodicals thus ofered at this unprecedented rate are universally known for For "The Obstetrical Journal,." see- p. 24) 2 Henry C. Lea's Publications — (Am. Journ. Med. Sciences). their high professional standing. I. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, Edited by I. MINIS HAYS, M.D., for more than half a century h^s maintained its position in the front rank of the medical literature of the world. Cordially supported by the profession of America, it circulates wherever the language is read, aad is universally regarded as a national exponent of American medicine — a position to which it is entitled by the distin- guished names from every section of the Union which are to be found among its collaborators.* It is issu d quarterly, in January, April, July, and October, each number containing about three hundred octavo pages, appropriately illustrated wherever necessary. A large portion of this space is devoted to Original Commu- nications, embracing papers from the most eminent members of the pro ession throughout the country. Following this is the Review Department, containing extended reviews by com- petent writers of prominent new works and topics of the day, together with numer- ous elaborate Analytical and BiDliogrt in which will be continued the series of Ortgtnal American Clinical Lectures, by gentlemen of the highest reputation throughout the United States, together w^h a choice selection of foreign Lectures and Hospital Notes and Gleanings. Then will follow the Monthly Abstract, sys- tematically arranged and classified, and presenting five or six hundred articles yearly ; and each number will conclude with a News Department, giving current profes- sional intelligence, domestic and foreign, the whole fully indexed at the close of each volume, rendering it of permanent value for refeierce. As stated above, the subscription price to the " News and Abstract" will be Two Dollars and a Half per annum, invariably in advance, at which rate it will rank as one of the cheapest medical periodicals in the country. But it will also be fur- nished, free of all charge, in commutation with the "American Journal of the Medical Sciences," to all who remit Five Dollars in advance, thus giving to the subscriber, for that very moderate sum, a complete record of medical progress throughout the world, in the compass of about two thousand large octavo pages. In this effort to furnish so large an amount of practical information at a price so unprecedentedly low, and thus place it within the reach of every member of the profession, the publisher confidently anticipates the friendly aid of all who feel an interest in the dissemination of sound medical literature. He trusts, e pecially, that the subscribers to the "American Medical Journal" will call the attention of their acquaintances to the advantages thus offered, and that he will be sustained in the endeavor to permanently establish medical periodical literature on a footing of cheapness never heretofore attempted. PREMIUM POR OBTAINING NEW SUBSCRIBERS TO THE "JOURNAL." Any gentleman who will remit the amount for two subscriptions for 1880, one of which at least must be for a new subscriber, will receive as a premium, free by mail, a copy of any one of the following rec nt works: "Barnes's Manual of Midwifery" (?ee p. 24), "Tilbury Fox's Epitome of Diseases of the Sk n," new edition, just ready, (see p. 18). " Fothergill's Antagonism of Medicines" (see p. lf>), " Holden's Landmarks, Medical and Surgical" (see p. 6), " Browne on the Use of the Ophthalmoscope" (seep. 29), "Flint's Essays on Conservative Medicine" (see p. 15), " Sturges's Clinical MEDiciNE"(see p. 14), "Swayne's Obstetric Aphorisms," new edition (see p. 21),. "Tanner's Clinical Manual" (see p. 5), "West on Nervous Disorders of Children" (see p. 20), %* Gentlemen desiring to avail themselves of the advantages thws offered will do well to forward their subscriptions at an early day, in order to insure the receipt of complete sets for the year 1880. Hgf* The safest mode of remittance is by bank check or postal money order, drawn to the order of the undersigned. Where these are not accessible, remittances for the "Journal" may be made at the risk of the publisher, by forwarding in registered letters. Address, HENRY C. LEA, Nos. 706 and 708 Sansom St., Philadelphia, Pa. Henry C. Lea's Publications — {Dictionaries). jnUNGLISON {ROBLEY), M.D., "^ Late Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. MEDICAL LEXICON; A Dictionary op Medical Science: Con- taining a concise explanation of the various Subjects and Terms of Anatomy, Physiology, Pathology, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence, and Dentistry, Notices of Climate and of Mineral Waters ; Formulae for Officinal, Empirical, and Dietetic Preparations ; with the Accentuation and Etymology of the Terms, and the French and other Synonymes ; so as to constitute a French as well as English Medical Lexicon. A New Edition. Thoroughly Revised, and very greatly Mod- ified and Augmented. By Richakd J. Dunglison, M.D. In one very large and hand- someroyaloctavo volume of over 1100 pages. Cloth, $6 50 j leather, raised bands, $7 50. {Just Issued.) The object of the author from the outset has not been to make the work a mere lexicon or dictionary of terms, but to afford, undereach, a condensed view of its various medical relations, and thus to render the work an epitome of the existing condition of medical science. Starting with this view, the immense demand which has existed for the work has enabled him, in repeated revisions, to augment its completeness and usefulness, until at length it has attained the position of a recognized and standard authority wherever the language is spoken. Special pains have been taken in the preparation of the present edition to maintain this en ■ viable reputation. During the ten years which have elapsed since the List revision, the additions to the nomenclature ofthe medical scienceshave been greater than perhaps in any similar period of the past, and up to the time of his death the author labored assiduously to incorporate every- thing requiring the attention of the student or practitioner. Since then, the editor has been equally industrious, so that the additions to the vocabulary are more numerous than in any pre- vious revision. Especial attention has been bestowed on the accentuation, which will be found marked on every word. The typographical arrangement has been much improved, rendering reference much more easy, and every care has been taken with the mechanical execution. The work has been printed on new type, small but exceedingly clear, with an enlarged page, so that the additions have been incorporated with an increase of but little over a hundred pages, and the volume now contains the matter of at least four ordinary octavos. A book well known to our readers, and of which every American ought to be proud. When the learned author of the work passed away, probably all of us feared lest the book should not maintain its place in the advancing science whose terms it defines. For- tunately, Dr. Richard J. Dunglison, having assisted his father in the revision of several editions of the work, a ad having been, therefore, trained in the methods and imbued with the spirit of the book, has been able to edit it, not in the patchwork manner so dear to the lieart of book editors, so repulsive to the taste of intel- ligent book readers, but to edit it as a work ofthe kind should be edited— to carry it on steadily, without jar or interruption, along the grooves of thought it has travelled during its lifetime. To show the magnitude of the task which Dr. Dunglison has assumed and car- ried through, it is only necessary to state that more than six thousand new subjects have been added in the present edition. —Phila. Med. Times, Jan 3, 1874. About the first book purchased by the medical stu- dent is the Medical Dictionary. The lexicon explana- tory of technical terms is simply a sine qua non. In a science so extensive, and with such collaterals as medi cine, it is as much a necessity also to the practising physician. To meet the wants of students and most physicians, the dictionary must be condensed while comprehensive, and practical while perspicacious. It was because Dunglison's met these indications that it became at once the dictionary of general use wherever medicine was studied in the English language. In no former revision have the alterations and additions been so great. More than six thousand new subjects and terms have been added. The chief terms have been set in black letter, while the derivatives follow in small caps; an arrangement which greatly facilitates reference. We may safely confirm the hope ventured by the editor " that the work, which possesses for him a filial as well is an individual interest, will be fouDd worthy a con- tinuance of the position so long accorded to it as a standard authority." — Cincinnati Clinic. Jan. 10, 1874. It has the rare meritthatit certainly has no rival in the English language for accnracyand extent of references. — London Medical Gazette As a standard work of reference, as one of the best, if not the very best, medical dictionary in the Eng- lish language, Dunglison's work has been well kDOwa for about forty years, and needs no words of praise on our part to recommend it to the members of the medical, and, likewise, of the pharmaceutical pro fession. The latter especially are in need of such a work, which gives ready and reliable information on thousands of subjects and terms which they are liable to encounter in pursuing their daily avoca- tions, but with which they cannot be expected to be familiar. The work before us fully supplies this want. — Am. Journ. of Pharm., Feb. 1S74. A valuable dictionary of the terms employed in medicine and the allied sciences, and of the rela- tions of the subjects treated under each head. It. re- flects great credit on its able American author, and well deserves the authority and popularity it has obtained.— British Med. Journ., Oct. 31, 1874. Few works of this class exhibit a grander monu- ment of patient research and of scientific lore The extent ofthe sale of this lexicon is sufficient to tes- tify to its u.-e ulness, and to the great service con- ferred by Dr. Kobley Dunglison on the profession, and indeed on others, by its issue.— London Lancet, May 13 1875. fJOBLYN {RICHARD D.), M.D *^A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. Revised, with numerous additions, by Isaac Hays, M. D., Editor of the " American Journal of the Medical Sciences." In one large royal 12mo. volume of over 500 double-columned pages ; cloth, $1 50 ; leather, $2 00 It is the best book of definitions we have, and ought always to be upon the student's table.— Southern Med. and Surg. Journal. ftOD WELL (G. F.), F.R.A.S.. frr.. A DICTIONARY OF SCIENCE: Comprising Astronomy, Chem- istry, Dynamics, Electricity, Heat, Hydrodynamics, Hydrostatics, Light, Magnetism, Mechanics, Meteorology, Pneumatics, Sound, and Statics. Preceded by an Essay on the History of the Physical Sciences, In one handsome octavo volume of 694 pages, and many illustrations: cloth, $5. Henry C. Lea's Publications — (Manuals^. A CENTURY OF AMERICAN ME DICINE. 1776-1876. By Doctors E. H. -£*~ Clarke, H. J. Bigelow, S. D. Gross, T. G. Thomas, and J. S. Billings. In one very hand- some 12mo. volume of about 350 pages : cloth, $2 25. {Just Ready.) This work appeared in the pages of the American Journal of the Medical 8ciencesduring the year 1876. As a detailed account of the development of medical science in America, by gentle- men of the highest authority in their respective departments, the profession will no doubt wel- come it in a form adapted for preservation and reference. -XTEILL {JOHN), M.D., and QfMITH {FRANCIS G.), M.D., "*~ Prof, of the Institutes of Medicine in the Univ. of Pen n c . AN ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE ; for the Use and Examination of Students. A new edition, revised and improved. In one very large and handsomely printed royal 12m < . volume, of about one thousand pages, with 374 wood-cuts, cloth, $4 ; strongly bound in leather, with raised bands, $4 75. H ARTSHORNE {HENRY), M.D., Professor of Rygiene in the University of Pennsylvania. A CONSPECTUS OF THE MEDICAL SCIENCES; containing Handbooks on Anatomy, Physiology, Chemistry, Materia Medica, Practical Medicine, Surgery, and Obstetrics. Second Edition, thoroughly revised and improved. In one large royal 12mo. volume of more than 1000 closely printed pages with 477 illustrations rn wood. Cloth, $4 25 ; leather, $5 00. {Lately Issued.) We can say with the strictest truth that it is the j worthy. If students mast have a coDspectus, tkey best work of the kind with which w< art acquainted, will be wise to procure that of Dr Hartshorne It embodies in a condensed form ail recent contiibu- | Detroit Rev. of Med and P/iarm., Aug 1874 tions to practical medicine ana is therefore useful Tb wnrk b f us howeve r, has many redeem- to every busy practitioner throughout our country besides being admirably adapted to the use of stu- dents of medicine. The book is faithfully and ably executed. — Charleston Med. Journ., April, 1875 The work is intended as an aid to the medical features not possessed by others, aud is the be-t we have seen. Dr. Hartshorne exhibits much hkill in condensation It is well adapted to the physician in active pracii.-e, who cau give but limited cime to the familiarizng of himself with the important changes stuient, and as such appears to admirably fulfil its ! which have teen made since he attended lectures object by itsexcellent arrangement, the full compi- | The manual of physiology has also l;een improved laiion >f facts, the perspicuity aud terseness of Ian guage, and the clear and instructive illustrations in some parts of the work — American Journ. of Pharmacy, Philadelphia, July, 1S74. The volume will be found useful, not only to stu- dents, but to many otherswhomay desire torefresh their memories with the smallest possible expendi- ture of time. — N. T. Med. Journal, Sept. 1874. The student will find this the most convenient and useful hoot of the kind on which he can lay his? hand.— Pacific Med. and Surg. Journ., Aug. 1S74. and gives the most comprehensive view of the late t advances in the science po-sible in the space devoted to the su v ject. The mechanical execution of the book leaves nothing to be wished for. — Peninsular Journal of Medicine, Sept 1874. After carefully looking through this conspectus, we are constraiued to say that it is the most com- plete work, especially in 'ts illustrations, of its kind that we have seen — ''incinnati Lancet, Sept. 1874. The favor with which the first edition of this Compendium was rece : ved, was an evidence of i;s Thisis the best book of its kind that we have ever | various excellences. The present edition bears evi- examined. It is an honest, accurate, and concii compend of medical sciences, as fairly as possible representing their present condition. The changes and the additions have been so judicious and tho- rough as to render it, so far as it goes, entirely trust- dence of a careful and thorough revision. Dr. Ham- horne possesses a happy faculty of seizing upon the salient points of each subject, and of presenting them in a concise and yet perspicuous manner.- Laav n- worth Med. Herald Oct. 1S74. rUDLOW {J.L.), M.D. A MANUAL OF EXAMINATIONS upon Anatomy, Physiology , Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised and greatly extended and enlarged. With 370 illustrations. In one handsome royal l2mo. volume of 816 large pages, cloth, $3 25 ; leather, $3 75. The arrangement of this volume in the form of question and answer renders it especially suit- able for the office examination of students, and for those preparing for graduation. rPANNER {THOMAS HAWKES), M.D., frc. A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAG- NOSIS. Third American from the Second London Edition. Revised and Enlarged by Tilbury Fox, M. D., Physician to the Skin Department in University College Hospita , Ac. In one neat volume small 12mo., of about 375 pages, cloth. $150. *.£* On page 4, it will be seen that this work is offered as a premium for procuring new subscribers to the "American Journal of the Medical Sciences." Henry C. Lea's Publications — (Anatomy). QRAY {HENRY), F.R.S., Lecturer on Anatomy at St. George's Hospital, London. ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by H. V. Carter, M.D., and Dr. Westmacott. The Dissecfcionsjointly by the Author and Br. Carter. With an Introduction on General Anatomy and Development by T. Holmes, M.A., Surgeon to St. George's Hospital. A new American, from the eighth enlarge*, and improved London edition. To which is added " Landmarks, Medical and Surgical," by Luther Holden, P.R.C.S., author of " Human Osteology," " A Manual of Dissections," etc. In one magnificent imperial octavo volume of 983 pages, with 522 large and elaborate engravings on wood. Cloth, $6; leather, raised bands, $7. (Just Ready.) The author has endeavored in this work to cover a more extendedrange of subjects than is cus- tomary in the ordinary text-books, by giving not only the details necessary for the student, but also the application of those details in the practice of medicine and surgery, thusrendering it both a guide for the learner, and an admirable work of reference for the active practitioner. The en- gravings form a special feature in the work, many of them being the size of nature, nearly all original, and having the names of the various parts printed on the body of the cut, in place of figures of reference, with descriptions at the foot. They thus form a complete and splendid series, which will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve to refresh the memory of tHose who may find in the exigencies of practice the necessity of recalling the details of the dissecting room ; while combining, as it does, a complete Atlas of Anatomy, with a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of essential use to all physicians who receive students in their offices, relieving both preceptor and pupil of much labor in laying the groundwork of a thorough medical education. Since the appearance of the last American Edition, the work has received three revisions at the hands of its accomplished editor, Mr. Holmes, who has sedulously introduced whatever has seemed requisite to maintain its reputation as a complete and authoritative standard text-book and work of reference. Still further to increase its usefulness, there has been appended to it the recent work by the distinguished anatomist, Mr. Luther Holden — "Landmarks, Medical and Surgical" which gives in a clear, condensed, and systematic way, all the information by which the prac- titioner can determine from the external surface of the body the position of internal parts. Thus complete, the work, it is believed, will furnish all the assistance that can be rendered by type and illustration in anatomical study. No pains have been spared in the typographical execution of the volume, which will be found in all respects superior to former issues. Notwithstanding the increase of size, amounting to over 100 pages and 57 illustrations, it will be kept, as heretofore, at a price rendering it one of the cheapest works ever offered to the American profession. The recent work of Mr Holden, which was no- ticed by us on p. 53 of this volume, has been added as an appendix, so that, altogether, this is the most practical and complete anatomical treatise available to American students and physicians. The former fluds in it the necessary guide in making dissec- tions; a very comprehensive chapter on minute anatomy ; and about all that can be taught him on general and special anatomy; while the latter, in its treatment of each region from a surgical point of view, and in the valuable edition of Mr Holden, will find all that will be essential to him in his practice —New Remedies, Aug. 1878. This work is as near perfection as one could pos- sibly or reasonably expect any book intended as a text-book or a genera) reference book on anatomy to be. The American publisher deserves the thanks of the profession for appending the recent work of Mr. Holden, "Landmarks, Medical and Surgical," which has already been commended as a separate book. The latter work— treating of topographical anatomy— has become an essential to the library of every intelligent practitioner. We know of no book that can take its place, written as it is by a most distinguished anatomist. It would be simply a waste of words to say anything further in praise of Gray's Anatomy, the text-book in almost every medical college in this country, and the daily refer ence book of every practitioner who has occasion to Cy^sult his books on anatomy. The work is simply indispensable, especially this present Amer- ican edition.— Fa. Med. Monthly, Sept. 187P. The addition of the recent work of Mr. Holden, as an appendix, renders this the most practical and complete treatise available to American students, who find in it a comprehensive chapter on minute anatomy, about all that can be taught on general and special anatomy, while its treatment of each region, from a surgical point of vie v, in the valu- able section by Mr Holden. is all that will be essen- tial to them in practice.— Ohio Medical Recorder, Aug 1S7S. It is difficult to speak in moderate terms of this new edition of "Gray." It seems to be as nearly perfect as it is possible to make a book devoted to any branch of medical science. The labors of the eminent men who have successively revised the eight editions through which it has passed, would seem to leave nothing for future editors to do. The addition of Holden's " Landmarks" will make it as indispensable to the practitioner of medicine and surgeryas it has been heretofore to the student. As regards completeness, ease of reference, utility, beauty, and cheapness, it has no rival. No stu- dent should enter a medical school without it ; no physician can afford to have it absent from his library.— St. Louis Clin. Record, Sept. 1878. R H Also for sale separate — 'OLDEN {LUTHER), F.R.C.S., Surgeon to St. Bartholomew's and the Foundling Hospitals. LANDMARKS, MEDICAL AND SURGICAL. From the 2d London Ed. In one handsome volume, royal 12mo., of 128 pages : cloth, 88 cents. (Now Ready.) EATE {CHRISTOPHER), F.R.C.S., Teacher of Operative Surgery in University College, London. PRACTICAL ANATOMY: A Manual of Dissections. From the Second revised and improved London edition. Edited, with additions, by W. W. Keen, M. D., Lecturer on Pathological Anatomy in the Jefferson Medical College, Philadelphia. Tn one handsome royal 12mo volume of 578 pages, with 247 illustrations. Cloth, $'6 50 ; leather, $4 00. Henry C. Lea's Publications — {Anatomy). A LLEN (HARRISON), M.D. -^-*- Professor of Physiology in the Univ. of Pa. A SYSTEM OF HUMAN ANATOMY: INCLUDING ITS MEDICAL and Surgical Relations. For the Use of Practitioners and Students of Medicine. With an Introductory Chapter on Histology. By E. 0. Shakespeare, M D., Ophthalmologistto the Phila. Hosp. In one large and handsome quarto volume, with several hundred original illustrations on lithographic plates, and numerous wood-cuts in the test. (Preparing.) In this elaborate work, which has been in active preparation for several years, the author has sought to give, not only the details of descriptive anatomy in a clear and condensed form, but also the practical applications of the science to medicine and surgery. The work thus has claims upon the attention of the general practitioner, as well as of the student, enabling him not only to re- fresh his recollections of the dissecting room, but also to recognize the significance of all varia- tions from normal conditions. The marked utility of the object thus sought bv the author is self-evident, and his long experience and assiduous devotion to its thorough development are a sufficient guarantee of the manner in which his aims have been carried out. No pains have been spared with the illustrations. Those of normal anatomy are from original dissections, drawn on stone by Mr. Hermann Faber, with the name of every part clearly engraved upon the figure, after the manner of " Holden" and "Gray," and in every typographical detail it will be the effort of the publisher to render the volume worthy of the very distinguished position which is anticipated for it. fLLIS (GEORGE V1NER). J~J Emeritus Proftssor of Anatomy in University College, London. DEMONSTRATIONS OF ANATOMY; Being a Guide to the Know- ledge of the Human Body by Dissection. By George Viner Ellis, Emeritus Professor of Anatomy in University College, London. From the Eighth and Revised London Edition. In one very handsome octavo volume of over 700 pages, with 256 illustrations. Cloth, $4.25 ; leather, $5.25. {Jvst Ready ) This work has long been known in England as the leading authority on practical anatomy, and the favorite guide in the dissecting-room, as is attested by the numerous editions through which it has passed. In the last revision, which has just appeared in London, the accomplished author has sought to bring it on a level with the most recent advances of science by making the necessary changes in his account of the microscopic structure of the different organs, as devel- oped by the latest researches in textural anatomy. Ellis's Demonstrations is the favorite text-book its leadership over the English manuals upon dis- of the English student of anatomy. In passiDg : secting. — Phila. Med. Times, May 24, 1879. throuah eight editions it has been >o revised and i adapted to the needs of the student hat it would ' As a dissector, or a work to have in haul and seem that it had almost reached perfection in this studied while one is engaged in dissecting, we re special line. The descii^tions are clear, and the ; S a,d " as tlie ve, T bftSt Wof k extant : which is cer- methods of pursuing anatomical investigations are tainly saying a very great deal. As a text-book to given wiih such detail -hat the book is honestly i be studied m the aissecung-room, it is superior to entitled to its name.— St. Louis Clinical Record, an 7 uf the w<"l™ upon anatomy.— Cincinnati Med. June, 1879. The success of this old manual seems to be as well deserved in the present as in the past volumes. The book seems destined to maintain yet for years News, May 21, 1879. We most unreservedly recommend it to every practitioner of medicine who can possitlv get it — Va. Med. Monthly, June, 1879. w ILSON (ERASMUS), F.R.S. A SYSTEM OF HUMAN ANATOMY, General and Special. Edited by W. H. Gobrecht, M.D , Professor of General and Surgical Anatomyin the Medical Col lege of Ohio. Illustrated with three hundred and ninety-seven engravings on wood . In one large and handsome octavo volume, of over 600 large pages ; cloth, $4 ; leather. $5. &MITH (HENRY H.), M.D., and JJORNER ( WILLIAM E.),M.D., Prof, of Surgery in the Univ. of Penna., &o. ' Late Prof . of Anatomyin the Univ. ofPevna. AN ANATOMICAL ATLAS ; illustrative of the Structure of the Human Body. In one volume, large imperial octavo, cloth, with about sis hundred and fifty beautiful figures. $4 50. s CHAFER (ED WA RD ALBERT), M.D., Assistant Professor of Physiology in University College, London. A COURSE OF PRACTICAL HISTOLOGY: Being an Introduction to the Use of the Microscope. In one handsome royal 12mo. volume of 304 pages, with numerous illustrations: cloth, $2 00. (Just Issued.) HORNER'S SPECIAL ANATOMY AND HISTOL- BELLAMY'S STUDENT'S GUIDE TO SURGICAL OGY. Eighth edition, extensively revised and modified. In 2 vol6. Svo., of over 1000 pages, with 320 wood cuts : cloth, $6 00 SHARPEY AND QUAIN'S HUMAN ANATOMY ANATOMY: A Text-bcok for Students prera for their Paes Examination. With ecg avin^.- oa wood In one handsome royal 12mo. volume Cloth, $2 25. Revised, by Joseph Leidt, M.D. , Prof of Anat. i CLELAND'S DIRECTORY FOR THE DISSECTION in Uaiv. of Penn. In two octavo vols, of about : OF THE HUMAN BODY. In one small volume 1300 pages, wiih 511 illustrations Cloth, $6 00.1 r.yal 12nio. of 182 pages: cloth $1 25. 8 Henry C. Lea's Publications — (Physiology). flARPENTER [WILLIAM B.), M.D., F.R.S., F.G.S., F.L.S., ^ Registrar to University of London, etc. PRINCIPLES OF HUMAN PHYSIOLOGY; Edited by Henry Power, M.B. Lond., F R.C.S., Examiner in Natural Sciences, University of Oxford. A new American from the Eighth Revised and Enlarged English Edition, with Notes and Addi- tions, by Francis G. Smith, M.D., Professor of the Institutes of Medicine in the Univer- sity ol Pennsylvania, etc. In one very large and handsome octavo volume, of 1083 pages, with twoplates and 373 engravings on wood ; cloth, $5 50 ; leather, $6 50. {Just Issued.) The great work, the crowning labor of the distinguished author, and through which so many generations of students have acquired their knowledge of Physiology, has been almost meta morphosed in the effort to aonpt it thoroughly to the requirements of modern science. Since the appearance of the last American edition, it has had several revisions at the experienced hand ol Mr. Power, who has modified and enlarged it so as to introduce all that is important in the investigation:- and discoveries of England, France, and Germany, resulting in an enlarge- ment of about one-fourth in the text. The series of illustrations has undergone a like revision , a large proportion of the former ones having been rejected, and the total number increased to nearly four hundred. The thorough revision which the work has so recently received in England, has rendered unnecessary any elaborate additions in this country but theAmerican Editor, Professor Smith, has introduced such matters as his long experience has shown him to be requisite for the student. Every care has been taken with the typographical execution , and the work is presented, with its thousand closely, but clearly printed pages, as emphatically the text-book for the student and practitioner of medicine — the onein which, asheretofore, especial care is directed to show the applications of physiology in the various practical branches of medical science. Notwithstanding its very great enlargement, the price has not been in- creased, rendering this one of the cheapest works now before the profession. We have been agreeably surprised to find the vol- ume so complete in regard to the structure and func- tions of the nervous system in all its relations, a subject that, in many respects, is one of the most diffi- cult of all, in the whole range of physiology, upon which to produce a full and satisfactory treatise of the class 10 which the one before us belongs. The additions by the American editor give to the work as it is a considerable value beyond that of the last English edition. In conclusion, we can give our cor- dial recommendation to the work as it now appears. The editors have, with their additions to the only work on physiology in our language that, in the full- est sen-e of the word, is the production of a philoso- pher as well as a physiologist, brought it up as fully as could be expected, if not desired, to the standard of our knowledge of its subject at the present day. It will deservedly maintain the place it has always had in the favor of ihe medical profession. — Journ. of Nervous and Mental Disease, April, 1S77. "Good wine needs no bush" says the proverb, and an old and faithful servant like the " big" Carpenter, as carefully brought down as this edition has been by Mr. Henry Power,\eeds little or no commendation by us. Such enormous advances have recently been made in our physiological knowledge, that what was perfectly new a year or two ago. looks now as if it had been a received and. established fact for years. In this ency- clopaedic way it is unrivalled. Here, as it seems to us, is thegreatvalue of the book; one is safe in sending a student to it for information on almost any given subject, perfectly certain of the fulness of information it will convey, and well satisfied of the accuracy with which it will there be found stated. — London Med. Times and Gazette, Feb. 17, 1877. The merits of " Carpenter's Physiology " are so widel y known and appreciated that we need only allude briefly to the fact that in the latest edition will be found a com- prehensive embodiment of the results of recent physic- logical investigation. Care has been taken to preserve the practical character of the original work. In fact the entire work has been brought up to date, and bears evidence of the amount of labor thathasbeen bestowed upon it by its distinguished editor, Mr. Henry Power. The American editor has made the latest additions, in order fully to cover the time that has elapsed since the last English edition. — N. Y. Med. Journal, Jan. 1877. LTOSTER {MICHAEL), M.D., F.R.S., i- Prof, of Physiology in Cambridge Univ., England. TEXT-BOOK OF PHYSIOLOGY. A new American, from the third English edition. Edited with notes and additions by Edward T. Reichert, M.D., Demonstrator of Experimental Therapeutics in Univ. of Penna. In one handsome royal 12mo. volume, with many illustrations, (hi Press.) The excellence of Mr. Foster's work as an exposition of functional physiology has long been recognized, while for the purposes of the student it has been somewhat deficient as re spects the details of jtructure so necessary to render intelligible the views and theories of the science. These it has been the effort of the editor to add in as concise a manner as possible, and in aid of this he has freely introduced illustrations from recognized authorities. In this improved form it is therefore hoped that the work may prove more than ever acceptable to the student as a clear and comprehensive text-book, presenting the science in its latest development. After a careful perusal of the entire work, we can It is not often that medical literature is euriched confidently recommend it, both to the student and by a book which promises to be of such permanent the practitioner, as being one of the best text-books value.— British Medical Journal. on physiology extant. — London Lancet. IZIRKES {WILLIAM SENHOUSE), M.D. A MANUAL OF PHYSIOLOGY. Edited by W. Morrant Baker, M.D., F.R.C.S. A new American from the eighth and improved London edition. "With about two hundred and fifty illustrations. In one large and handsome royal 12mo. vol- ume. Cloth, $3 25; leather, $3 75. (Lately Issued.) and Additions, by J. Cheston Morris, M.D. With illustrations on wood. In one octavo volrme of ?36 pages. Cloih, $2 25. LEHMANN'S PHYSIOLOGICAL CHEMISTRY. Com- plete in two large octavo volumes of 1200 pages, with 2l0 illustrations; cloth, $6. HARTSHORNE'S HANDBOOK OF ANATOMY AND PHYSIOLOGY. Second edition, revised. In one royal 12mo. vol., with 220 woodcuts ; cloth, LEHMANF'S MANUAL OF CHEMICAL PHYSIOL- OGY. Translated frciu the German, with ^otes Henry C. Lea's Publications — (Physiology, Chemistry). flALTON (J. C), M.D., •*-* Professor of Physiology in the College of Physicians and Surgeons, Nets York, Ac. A TREATISE ON HUMAN PHYSIOLOGY. Designed for the use of Studentsand Practitioners of Medicine. Sixth edition, thoroughly revised and enlarged, with three hundred and sixteen illustrations on wood. In one very beautiful octavo vol- ume, of over 800 pages. Cloth, $5 50; leather, $6 50. (Just Issued.) During the past few years several new works on phy- siology, and new editions of old works, have appeared, competing for the favor of the medical student, but none will rival this new edition of Dalton. As now en- larged, it will be found also to be. in general, a satisfac- tory work if reference for the practitioner. — Chicago Med. Journ. and Examiner, Jan. 1876. Prof. Dalton has discussed conflicting theories and conclusions regarding physiological questions with a fairness, a fulness, and a conciseness which lend fresh- ness and vigor to the entire hook. But his discussions have been so guarded by a refusal of admission to those speculative and theoretical explanations, which ai hest exist in the minds of observers themselves as only pro- babilities, that none of his readers need be led into grave errors while making them a study .— The Medical Record, Feb. 19, 1876. The revision of this great work has brought it forward with the physiological advances of the day. and renders it. as it has ever been, the finest work for students ex- tant.— Nashville Journ. of Med. and Surg., Jan. 1876. For clearness and perspicuity, Dalton's Physiology commended itself to the student years ago. and was a pleasant relief from the verbose productions which it supplanted. Physiology has, however, made many ad- vances since then — and while the style has been pre- served intact, the work in the present edition has been brought up fully abreast of the times. The new chemical notation and nomenclature have also been introduced into the present edition. Notwithstanding the multi- plicity of text-books on physiology, this will lose none of its old time popularity. The mechanical execution of the work is all that could be desired.— Peninsular Journal of Medicine, Dec. 1875. This popular tes-book on »hysiolog7 ernes to us in its sixth edition with the addition of ;i bout fifty per cent, of new matter, chiefly in the departments of patho- logical chemistry and the nervous system, where the principal advances 'nave been realized. With so tho- rough revision and additions, that keepthe work well up to the times, its continued popularity may be confi- dently predicted, notwithstanding the competition it may encounter. The publisher's work is admirably done. — St. Louis Med. and Surg. Journ , Dec. 1875 We heartily welcome this, the sixth edition of this admirable text book, than which there are none of equal brevity more valuable. It iscordially recommended by the Professor of Physiology in the University of Louisi- ana, as by all competent teachers in the United States, and wherever the English language is read, this bonk has been appreciated. The present edition, with its 31 6 admirably executed illustrations. has been carefully revised and very ruuch enlarged, although its bulk does not seem perceptibly increased. — New Orleans Medical and Surgical Journal, March, 1876. The present edition is very much superior to every other, not only in that it brings the subject up to the times, but that it do^s so more fully and satisfactorily than any previous edition. Take it altogether it remains in ourhumbleopinion.thebest text book on physiology in any land or language. — The Clinic, Nov. 6, 1875. As a whole, we cordially recommend the work as a text-book for the student, and as one of the best. — The Journal of Nervous and Mental Disease, Jan. 1876. Still holds its position as a masterpiece of lucid writ- ing, and is, we believe, on the whole, the best book to place in the hands of the student. — London Students' Journal. fjLASSEN {ALEXANDER), ^ Professorin the Royal Polytechnic School, Aix la-Chapelle. ELEMENTARY QUANTITATIVE ANALYSIS. Translated with notes and additions by Edgar F. Smith, Ph.D., Assistant Prof, of Chemistry in the Towne Scientific School, Univ. of Penna. In one handsome royal 12mo. volume, of 324 pages, with illustrations; cloth, $2 00. (Just Ready.) It is probably the best manual of an elementary 1 advancing to the analysis of minerals and such pro- nature extant, insomuch as its methods are the best. J ducts as are met with in applied chemistry It is It teaches by examples, commencing with single > an indispensable book for students in chemistry, determinations, followed by separations, and then »«•*'•*» -7w™~« r.t nh a ™ ;»+».*. n~> i. «x u i uu. i-"» (jo usa.Kj i\i u"«a iui .''Iumcuio ill Boston Journ. of Chemistry, Oct. 1S73. Q.ALLOWAY (ROBERT), F.G.S., ~* Prof of Applied Chemistry in the Royal College of Science for Treland, etc. A MANUAL OF QUALITATIVE ANALYSIS. From the Fifth Lon- don Edition. In one neat royal 12mo. volume, with illustrations ; cloth, $2 75. (Lately Issiied.) JDO WMAN (JOHN E.) , M.D. INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANALYSIS. Sixth American, from the sixth and revised London edition. With numer- ous illustrations. In one neat vol., royal 12mo., cloth, $2 25. G R REENE (WILLIAM H.), M.D., Demonstrator of Chemistry in Med. Dept , Univ. of Penna. A MANUAL OF MEDICAL CHEMISTRY. For the Use of Students. Based upon Bowman's Medical Chemistry. In one r >yal 12mo. volume of about 400 pages. With illustrations. (Shortly.) EMSEN(IRA), M. D., Ph.D^~ Professor of Chemistry in the Johns Hopkins University, Baltimore. PRTNCIPLESOF THEORETICAL CHKMrSTRY, with special reference to the Constitution of Chemical Compounds. In one handsome royal 12mo. vol. of over 232 pages: cloth, $1 50. (Just Issued.) TKTOHLER AND FITTIG. rr OUTLINES OF ORGANIC CHEMISTRY. Translated with Ad- ditions from the Eighth German Ed. By Ira. Remsen, M.D., Ph.D., Prof, of Chem andPhysics in Williams College, Mass. In one volume, royal 12mo.of 550 pp. , cloth, $3 10 Henry C. Lea's Publications — {Chemistry). ltfOWNES [GEORGE), Ph.D. A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and Practical. Revised and corrected by Henry Watts, B.A., F R.S., author of "A Diction- ary of Chemistry," etc. With a colored plate, and one hundred and seventy-seven illus- trations. A new American, from tht twelfth and enlarged London edition. Edited by Robert Bridges, M.D. In one large royal 12mo. volume, of over 1000 pages; cloth, $2 75 ; leather, $3 25. (Jtist Ready.) Two careful revisions by Mr. Watts, since the appearance of the last American edition of "Fownes," have so enlarged the work that in England it has been divided into two volumes. In reprinting it, by the use of a sraa'l and exceedingly clear type, cast for the purpose, it has been found possible to comprise the whole, without omission, in one volume, not unhandy for study and reference. The enlargement of the work has induced the American Editor to confine his additions to the narrowest compass, and he has accordingly inserted only such discoveries as have been an- nounced since the very recent appearance of the work in England, and has added the standards in popular use to the Decimal and Centigrade systems employed in the original. Among the additions to this edition will be found a very handsome colored plate, representing a number of spectra in the spectroscope. Every care has been taken in the typographical execu- tion to render the volume worthy in every respect of its high reputation and extended use, and though it has been enlarged by more than one hundred and fifty pages, its very moderate price will still maintain it as one of the cheapest volumes accessible to the chemical student. This work, inorganic and organic, is complete in one convenient volume. In its earliest editions it was fully up to the latest advancements and theo- ries of that time. In its present form, it presents, in a remarkably convenient and satisfactory man- ner, the principles and leading facts of the chemistry of to-day. Concerning the manner in which the various subjects are treated, much deserves to be said, and mostly, too, in praise of the book. A re- view of such a work as Fownes's Chemistry within the limits of a book-notice for a medical weekly is simply out of the question. — Cincinnati Lancet and Clinic, Dec. 14, 1878. When we state that, in our opinion, the present edition sustains in every respect the high reputation which its predecessors have acquired and eojoyed, we express therewith our fall belief in its intrinsic value as a text-book and work of reference. — Am. Journ. of Pharm., Aug. 1878. The conscientious care which has been bestowed upon it by the American and English editors renders it still, perhaps, the best book for the student and the practitioner who would keep alive the acquisitions of his student days. It has, indeed, reached a some- what formidable magnitude with its more than a thousand pages, but with less than this no fair repre- sentation of chemistry as it now is can be given. The type is small but very clear, and the sections are very lucidly arranged to facilitate study and reference. — Mtd. and Surg. Reporter, Aug. 3, 1878. The work is too well known to American students to need any extended notice; suffice it to say that the revision by the English editor has been faithfully done, and that. Professor Bridges has added some fresh and valuable matter, especially in the inor- ganic chemistry. The book has always been a fa- vorite in this country, and in its new shape bids fair to retain all its former prestige.— Boston Jour, of Chemistry, Aug. 1878. It will be entirely unnecessary for us to make any remarks relating to the general character of Fownes' Manual. For over twenty years it has held the fore- most place as a text-book, and the elaborate and thorough revisions which have been made from time to time leave little chance for any wide awake rival to step before it. — Canadian Pharm. Jour., Aug. 1878. As a manual of chemistry it is without a superior in the language. — Md. Med. Jour., Aug. 1S7S. A TTFIELD [JOHN), Ph.D., -^*- Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, Stc. CHEMISTRY, GENERAL, MEDICAL, AND PHARMACEUTICAL; including the Chemistry of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science, and their Application to Medicine and Pharmacy. Eighth edition revised by the author. In one handsome royal 12mo. volume of 700 pages, with illustrations. Cloth, $2 50 ; leather, $3 00. (Just Ready.) "We have repeatedly expressed our favorable opinion of this work, and on the appearance of a new edition of it, little remains for us to say, ex- cept that we expect this eighth edition to be as indispens?ble to us as the seventh and previous editions have been. While the general plan and arrangement have been adhered to, new matter has been added covering the observations made since the former edition The present differs from the preceding one chiefly in these alterations and in about ten pages of useful tables added in the appendix. —Am. Jour, of Pharmacy, May, 1879. A standard work like Attfield's Chemistry need only be mentioned by its name, without further comments The present ediiion contains such al terations and additions as seemed necessary for the demonstration of the latest developments of chemical principles, and the latent applications of chemistry to pharmacy. The author has bestowed arduous labor on the revision, and the extent of the information thus introduced may be estimated from the fact that the index contains three hun- dred new references relating to additional mate- rial.— Druggists' 1 Circular and Chemical Gazette, May, 1879. This very popular and meritorious work has now reached its eighth edition, which fact speaks in the highest terms in commendation of its excel- lence. It has now become the principal text-book of chemistry in all the medical colleges in the United States. The present edition contains such alterations and additions as seemed necessary for the demonstration of the latest developments of chemical principles, and the latest applications of chemistry to pdarmacy. It is scarcely necessary for us to say that it exhibits chemistry in its pre- sent advanced state. — Cincinnati Medical Ntws, April, 1S79. The popularity which this work has enjoyed is owing to the original and clear disposition of the facts of the science, the accuracy of the details, and the omission of much which freights many treatises heavily without bringing corresponding instruction to the reader. Dr. Attfield writes for students, and primarily for medical students; he always has an eye to the pharmacopoeia and its officinal prepara- tions; and he is continually putting the matter in the text so that it responds to the questions with which each section is provided. Thus the student learns easily, and can always refresh and test his knowledge.— Med andSurg. Reporter, April.19,'79. "We noticed only about two years and a half ago the publication of the preceding edition, and re- marked upon the exceptionally valuable character of the work. The work now includes the whole of the chemistry of the pharmacopoeia of the United States, Great Britain, and India.— New Remedies, May, 1S79. Henry C. Lea's Publications — {Chemistry). 11 B LOXAM {C.L.), Professor of Chemistry in King's College, London. CHEMISTRY, INORGANIC AND ORGANIC. From the Second Lon- don Edition. In one very handsome octavo volume, of 700 pages, with about 300 illus- trations. Cloth, $4 00; leather, $5 00. (Lately Issued.) We have in this work a complete and most excel- lent text-book for the use of schools, and can heart- ily recommend it as such. — Boston Med. and Surg. Journ., May 28, 1S74. The above is the title of a work which we can most conscientiously recommend to students of chemis- try. It is as easy as a work on cbemistry could be made, at the same time that it presents a full account of thatscience as it now stands. We have spoken of the work as admirably adapted to the wants of students ; it is quite as well suited to the require- ments of practitioners who wish to review their chemistry, or have occasion to refresh their memo- ries on any point re'ating to it. In a word, it is a book to be read by all who wish to know what is thechemistry of the presentday. — American Prac titioner, Nov. 1873. It would be difficult for a practical chemist and teacher to find any material fault with this most ad- mirable treatise. The author has given us almost a c\ clopaedia within the limits of a convenient volume, and has done so without penning the useless para- graphs too commonly making up a great part of the bulk of many cumbrous works. The progressive scientist is not disappointed when he looks for the record of new and valuable proces.-es at-d discover- ies, while the cautious conservative does not find its pages monopolized by uncertain theories and specu- lations. A peculiar point of excellence is the crys- tallized form of expression in which great truths are expressed in very short paragraphs. One is surprised at the brief space allotted to an important topic, and yet, after reading it, he feels that little, if any more should have been said. Altogether, it is seldom yoi see a text-book so nearly faultless. — Cincinnati Lancet Nov. 1S73. (1LO WES (FRANK), D.Sc, London. ^ Senior Science-Master at the High School, Newcastle-tinder Lyme, etc. AN ELEMENTARY TREATISE ON PRACTICAL CHEMISTRY AND QUALITATIVE INORGANIC ANALYSIS. Specially adapted for Use in the Laboratories of Schools and Colleges and by Beginners. From the Second and Revised English Edition, with about fifty illustrations on wood. In one very handsome royal 12mo. volume of 372 pages : cloth, $2 50. (Now Ready.) It is short, concise, and eminently practical. We i are so simple, and yet concise, as to be interesting therefore heartily commend it to students, and e-pe- and intellig'ble. The work is unincumbered with cially to those who are obliged to dispense with a : theoretical deductions, dealing wholly with the master. Of course a teacher is in every way desi- practical matter, which it is theaim of this compre- rable, but a good degree of technical skilland prac- hensive text-book to impart. The accuracy of the tical knowledge can be attained with no other analytical methods are vouched for from the fact instructor than the very valuable handbook now | that they have all been worked through by the under consideration. — St. Louis Clin. Record, Oct. ! author and the members of his class, from the 1877. I printed text. We can heartily recommend the work The work is so written and arranged that it can be to the student of chemistry as being a reliable and comprehended by the student without a teacher, and j comprehensive one.— Druggists Advertiser, Oct. the descriptions and directions for the various work 1 5 > 1*77. KNAPP'S TECHNOLOGY; or Chemistry Applied to the Arts, and to Manufactures. With American additions by Prof. Walter R. Johnson. In two very handsome octavo volumes, with 500 wood engravings, cloth, $6 00. ARRISH {ED WARD), Late Professor of Materia Medica in the Philadelphia College of Pharmacy. l TREATISE ON PHARMACY. Designed as a Text-Book for the Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. Fourth Edition, thoroughly revised, by Thomas S. Wiegand. In one handsome octavo volume of 977 pages, with 280 illustrations ; cloth, $5 50 ; leather, $6 50. (Lately Issued.) the work, not only to pharmacists, but also to the multitude of medical practitioners who are obliged to compound their own medicines. It -will ever hold an honored place on our own bookshelves. — Dublin Med. Press and Circular, Aug. 12, 1S74. Of Dr. Parrish's great work on pharmacy it only remains to be said that the editorhas accomplished his work so well as to maintain, in this fourth edi- tion, the high standard of excellence which it bad attained in previous editions, under the editorship of its accomplished author. This has not been accom- plished without much labor, and many additions and improvements, involving changes in the arrange- mentof the several parts of the work, and the addi- tion of much new matter. With the modifications thus effected it constitutes, as now presented, a com- pendium of the science and art indispensable to the pharmacist, and of the utmost value to every practitioner of medicine desirous of familiarizing himself with the pharmaceutical preparation of the articles which he prescribes for his patients. — Chi- cago Med. Journ., July, 1874. The work is eminently practical, and has the rare merit of being readable and interesting, while it pre- serves astrictly scientificcharacter. The whole work reflects the greatest credit on author, editor and pub We expressed our opinion of a former edition in | terms of unqualified praise, and we are in no mood j to detract from that opinion in reference to the pre- ! sent edition, the preparation of which has fallen into i competent hands. It is a book with which no pharma- ; cist can dispense, and from which no physician can | fail to derive much information of value to him in , practice. — Pacific M&.d and Surg. Jour n., June, '74. Perhaps one, if not the most important book upon I pharmacy which has appeared in the English lan- I guage has emanated from the transatlantic press. "Parrish"s Pharmacy" is a well-known work on this side of the water, and the fact shows us that a really useful work never becomes merely local in its fame. Thanks to the judicious editing of Mr. Wiegand, the Usher It will convey so me idea of the liberality which j posthumous edition of "Parrish" has been saved to has been bestowed upon its production when we men- 1 the public with all the mature experience of its ao- tion thatthereare no less than 2S0carefully executed thor. and perhaps none the worse for a dash of new illustrations. In conclusion, we hearuly recommend blood. — Lond. Pharm. Journal, Oct. 17, 1874. 12 Henry C. Lea's Publications — {Mat. Med. and Therapeutics), F 'ARQUHARSON [ROBERT), M.D., Lecturer on Materia Medica at St. Mary's Hospital Medical School. GUIDE TO THERAPEUTICS AND MATERIA MEDICA. Fe- cund American edition, revised by the Author. Enlarged and adapted to the U. S. M.D. In one neat royal 12mo. volume of 498 each article in health and disease are presented in parallel columns, not only rendering reference easier, but also impressing the facts more strongly upon the mind of the reader. The book has beeu adapted to the wants of the American student, and copious notes have been introduced, embodying the latest revision of tie Pharmacopoeia, together wi h the antidotes to the more promiuent poisons, and such of the newer remedial agents as seemed neces- sary to the completeness of the work. Tables of weights and measures, and a good alphabetical in- dex end the volume. — Druggists' Circular and Chemical Gazette, June, 1S79. It is a pleasure to think that the rapidity with which a second edition is demanded may be taken as an indication that the sense of appreciation of the value of reliable information regarding the use of remedies is notentirely overwhelmed in the cultivH- tion of pathological studies, characteristic of the pre- sent day. This work certainly merits the success it has so quickly achieved.™ New Remedies, July, '79. Pharmacopoeia. By Frank Woodbury pages: cloth, $2.25. {Just Ready.) The appearance of a new edition of this conve- nient and handy book in less than two years may certainly be taken as an indication of its useful ness. Ite convenient arrangement, and its terse- ness, and, at the same time, comoleteness of the information given, make it a handy book of refer- ence. — Am. Joum. of Pharmacy, June, 1879. The early appearance of a second eiition of Dr. Farquharson's work bears sufficient testimony to the appreciation of it by American readers. The plan is such as to bring the character and action of drugs to the eye and mind with clearness The care with which both author and ed tor have done their work is conspicuous on every page — Med. and Surg. Reporter, May 31, 1879. This work contains in moderate compass such well-digested facts concernirg the physiological and therapeutical action of remedies as are reason- ably established up to the present time. By a con- venient arrangement the corresponding effects of s TILLE (ALFRED), M.D., Professor of Theory and Practice of Medicine in the University of Penna. THERAPEUTICS AND MATERIA MEDICA ; a Systematic Treatise on the Action and Uses of Medicinal Agents, including their Description and History. Fourth edition, revised and enlarged. In two large and handsome 8vo. vols, of about 2000 pages. Cloth, $10; leather, $12. (Lately Issued.) It is unnecessary to do much more than to an- nounce the appearance of the fourth edition of this well known and excellent work. — Brit, and For. Med.-Chir. Review, Oct 1875. For all who desire a complete work on therapeutics and materia medica for reference, in casesinvolving medico-legal questions, as well as for information concerning remedial agents, Dr. Still^'s is "par ex- cellence" the work. The work being out of print, by the exhaustion of former editions, t he author has laid the profession under renewed obligations, by the careful revision, importantadditions, and timely re issuing a work not exactly supplemented by any other in the English language, if in any language. The mechanical execution handsomely sustains the well-known skill and good taste of the publisher. — St. Louis Med. and Surg. Journal, Dec 1874. From the publication of the first edition "Stille's Therapeutics" has been one of the classics; its ab- sence from our libraries would create a vacuum which could be filled by no other work in the lan- guage, and its presence supplies, in the two volumes of the present edition, a whole cyclopaedia of thera- peutics. — Chicago Medical Journal, Teh. 1875. The rapid exhaustion of three editions and the uni- versal favor with which the work has been received by the medical profession, are sufficient proof of its excellence as a repertory of practical and useful in- formation for the physician. The edition before us fully sustains this verdict, as the work has been care- fully revised and in some portions rewritten, bring- ing it up to the present time by the admission of chloral and croton-chloral. nitrite of amyl, bichlo- ride of methylene, methylic ether, lithium com- pounds, gelseminum, and other remedies. — Am. Joum. of Pharmacy, Feb. 1875. We can hardly admit that it has a rival in the multitnde of its citations and the fulness of its re- search into clinical histories, and we must assign it a place iu the physician's library; not, indeed, as fully representing the present state of knowledge in pharmacodynamics, but as by far the most complete treatise upon the clinical and practical side of the question. — Boston Med. and. Surg. Journal, Nov. o, 1874. flRIFFITH {ROBERT E.), M.D. A UNIVERSAL FORMULARY, Containing the Methods of Prepar- ing and Administering Officinal and other Medicines. The whole adapted to Physiciars and Pharmaceutists. Third edition, thoroughly revised, with numerous additions, bj John M. Maisch, Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large andhandsome octavo volume of about800pp., cl., $450; leather, $5 50. (Lately Issued.) To the druggist a good formulary is simply indis- pensable, and perhaps no formulary has been more extensively used than the well-known work before us. Many physicians have to officiate, also, as drug- gets. This is true especially of the country physi- cian, and a work which shall teach him the means by which to administer or combine his remedies in the most efficacious and pleasant manner, will al- ways hold its place upon his shelf A formulary of this kind is of benefit also to the city physician in liirjrest practice. — Cincinnati llinic, Feb. 21. 1874. A more complete formulary than it is in its pres- ent form the pharmacist or physician could hardly desire. To the first some such work is indispensa- ble, and it is hardly less essential to the practitioner who compounds his own medicines. Much of what is contained in the introduction ought to be com- mitted to memory by every student of medicine. As a help to physicians it will be found invaluable, and doubtless will make its way into libraries not already supplied with a standard work ofthe kind. — The American Practitioner , Louisville, July, '74. B RUiVTON (T. LA UDER), F.R.S., etc. PHARMACOLOGY AND THERAPEUTICS and Present (Preparing.) or, Medicine, Past Henry C. Lea's Publications — {Mat. Med. and Therapeutics). 13 UTILLE {ALFRED), M.D., LL.D., and JlfAlSCH {JOHN M.), Ph.D.. A3 Prof, of Theory and Practice of Medicine -*-'-*- Prof, of Mat. Med. and Bot. in Phila. and of Clinical Med. in Univ. of Pa. Coll. Pharmacy, Secy, to the American Pharmaceutical Association. THE NATIONAL DISPENSATORY: Containing the Natural History, Chemistry, Pharmacy, Actions and Uses of Medicines, including those recognized in the Pharmacopoeias of the United Stntes, Great Britain, and Germany, -with numer- ous references to the French Codex. Second edition, thoroughly revised, with numerous additions. In one very handsome octavo volume of 1692 pages, with 239 illustrations. Extra cloth, $6 75 ; leather, raised bands, $7 50. (Now Ready.) Preface to the Second Edition. The demand which has exhausted in a few months an unusually large edition of Ihe National Dispensatory is doubly gratifying to the authors, as showing that they were correct in thinking that the want of such a work was felt by the medical and pharmaceutical professions, and that their efforts to supply that want have been acceptable. This appreciation of their labors has stimulated them in the revision to render the volume more worthy of the very marked favor with which it has been received. The first edition of a work of . c uch magnitude must necessarily be more or less imperfect ; and though but little that is new and important has been brought to light in the short interval since its publication, yet the length of time during which it was passing through the press rendered the earlier portions more in arrears than the la'er. The opportunity for a revision has enabled th« authors to scrutinize the work as a whole, and to introduce alterations and additions whereve; there has seemed to be occasion for improve- ment or greater completeness. The principal changes to be noted are the introduction of seve- ral drugs under separate heading', and of a large number of drugs, chemicals, and pharma- ceutical preparations classified as allied drugs and preparations under the heading of more important or better known articles : these additions comprise in part nearly the entire German Pharmacopoeia and numerous articles from the French Codex. All new investigations which came to the authors'' notice up to the time of publication have received due consideration. The series of illustrations has undergone a corresponding thorough revision. A number have been added, and still more have been substituted for such as were deemed less satisfactory. The new matter embraced in the text is equal to nearly one hundred pages of the first edition. Considerable as are these changes as a whole, they have been accommodated by an enlargement of the page without increasing unduly the size of the volume. While numerous additions have been ma^e to the sections which relate to the physiological action of medicines and their use in the treatment of disease, great care has been taktn to make them as concise as was possible without rendering them incomplete or obscure. The doses have been expressed in the terms both of troy weight and of the metrical system, for the purpose of making those who employ the Dispensatory familiar With the latter, and paving the way for its introduction into general use. The Therapeutical Index has been extended by about 2250 new references, making the total number in the present edition ab ut 6000. The articles there enumerated as remedies for particular diseases are not only those which, in the authors' opinion, are curative, or even beneficial, but those also which have at any time been employed on the ground of popular belief or professional authority. It is often of as much consequence to be acquainted with the worthlessness of certain medicines or with the narrow limits of their power, as to know the we'l attested virtues of others and the conditions under which they are displayed. An additional value posse sed by such an Index is, that it contains the elements of a natural classification of medicines, founded upon an analysis of the results of experience, which is the only safe guide in the treatment of disease. This evidence of success, seldom paralleled, intend to let the grass grow under their feet, but to shows clearly how well the authors have met the keep the work up to the time. — New Remedies, Nov. existing needs of the pharmaceutical and medical I 1879. professions. Gratifying as it must be to them, they j have embraced the opportunity offered for a thor- This 13 a £ r ' at work by two of the ablest writers on ough ie vision of the whole work, striving to em- I materia medica in America The authors have pro- brace within it all that might have been omitted in j duced a work which, for accuracy and comprehensive the former edition, and all that has newly appeared of sufficient importance during the time of its col laboration, and the short interval elapsed since th< previous publication. After having gone carefully ness. is unsurpassed by any work on tb» subject. There is no book in the English language •which contains so much valuable information on the various articles of the materia medica. The work has cost the authors through the volume we must admit that the authors Z^™°P?*°*t™L S l^ll SU?!? ^I^w^-l '? have labored faithfully, and with success, in main- taining the high character of their work as a com- pendium meeting the requirements of the day, to which one can safely turn in quest of the latest in- formation concerning everything worthy of notice in producing a dispensatory which is not only national, but will be a lasting memorial of the learning and ability of the authors who produced it. — Edinburgh Medical Journal, Nov. 1879. A new edition of this great work, only a few connection with Pharmacy Materia Medica, and < raouths ;tfter the first, takes us by surprise. It .„ Theiapeutics.— Am. Jour, of Pharmacy, Nov. 1S79. : dicates the nigh appreciation of its value on the It is with great pleasure that we announce to our ' part of physicians and pharmacists, by which a readers the appearance of a second edition of the j large edition has been so soon exhausted. The pre- National Dispensatory. The total exhaustion of the ' sent is not merely a reprint but a revision, with first edition in the short space of six months, is a | important additions and modifications, requiringlOO sufficient testimony to the value placed upon the pages of new mat er, and an index increased by work by the profession. It appears that the rapid ' 2250 references. The doses are stated in both the sale of the first edition must have induced both the ! ordinary and metric terms. All the more important editors and the publisher to make preparations for | material of the German and French Pharmacopoeias a new edition immediately after the first had been ! is embodied. It is by far more international or uni- ssued, for we find a large amount of new matter versal than kvj other book of the kind in onr lan- added and a good deal of the previous text altered guagv and more comprehensive in every sense. — and improved, which proves that the authors do not Pacijic Mtd. a^id Sv.rg. Jown., Oct. 1S79. 14 Henry C. Lea's Publications — (Pathology, &c). fjORNIL {V.), Prof, in the Faculty of Med. AND T>ANVIER (L.), Paris. Prof, in the College of France. MANUAL OF PATHOLOGICAL HISTOLOGY. Translated, with Notes and Additions, by E. 0. Shakespeare, M.D., Pathologist and Ophthalmic Surgeon to Philada. Hospital, Lecturer on Refaction and Operative Ophthalmic Surgery in Univ. and by Henry C. Stmes. M.D., Demonstrator of Pathological Histology in In one very handsome octavo volume of about 700 pages, with over (Shortly.) So much has been done of late years in the elucidation of pathology by means of the micro- scope, and this subject now occupies so prominent a position as one of the most important branches of medical science, that the American profession cannot fail to welcome a translation of the pre- sent work, which, through its own merits and through the well-known reputation of its distin- guished authors, is regarded in Europe as the standard text-book and work of reference in its department. Such investigations and discoveries as have been made since its appearance will be introduced by the translator, and the work is confidently expected to assume in this country the same position which has been so universally accorded to it abroad. of Perm; the Univ. of Pa. 800 illustrations. TjiENWICK {SAMUEL), M.D., -*- Assistant Physician to the London Hospital, THE STUDENT'S GUIDE TO MEDICAL DIAGNOSIS. From the Third Revised and Enlarged English Edition. With eighty-four illustrations on wood. In one very handsome volume, royal 12mo. , cloth, $2 25. (Just Issued.) Of the many guide-books on medical diagnosis, claimed to be written for the special instruction of 8tudents,this is the best. Theauthor is evidently a well-read and accomplished physieian.and he knows how to teach practical medicine. The charm of sim- plicity is not the least interesting feature in the man- ner in which Dr. Fenwickconveysinstruction. There are few books of thissizeon practical medicine that contain so much and convey it so well as c he volume before us. It, is a book we can sincerely recommend to the student for direct instruction, and to the prac- titioner as a ready and useful aid to his memory. — Am. Journ. of Syphilography, Jan. 1874. o REEN (T. HENRY), M.D. , Lecturer on Pathology and Morbid Anatomy at Qharing-Oross Hospital Medical School, etc. PATHOLOGY AND MORBID ANATOMY. Third American, from the Fourth and Enlarged and Revised English Edition. In one very handsome octavo volume of 332 pages, with 132 illustrations; cloth, $2 25. (Just Ready.) This is unquestionably one of the hest manuals on the subject of pathology and morbid anatomy that can be placed in the student's hands, and we are glad to see it kept up to the times by new editions. Each edition is carefully revised by the author, with the view of makiug it include the most recent ad- vances in pathology, and of omitting whatever may have become obsolete.— N. Y. Med. Jour., Feb. 1879. The treatise of Dr. Green is compact, clearly ex- pressfd, up to the times, and popular as a text-book, both in England and America. The cuts are suffi- ciently numerous, and usual y well made. In the p-e-ent edition, such new matter has been added as was necessary to embrace the later resuits in patho- logical research. No doubt it will continue to enjoy the favor it has received at the hands of the profes- sion. — Med and Surg. Reporter, Feb. 1, 1S79. For practical, ordinary daily use, this is undoubt- edly the best treatise that is offered to students of pathology and morbid anatomy. — Cincinnati Lan- cet and Clinic, Feb. 8, 1879. D AVIS {NATHAN S.), Prof, of Principles and Practice of Medicine, etc., in Chicago Med. College. CLINICAL LECTURES ON VARIOUS IMPORTANT DISEASES; being acollection of the Clinical Lectures delivered in the Medical Wards of Mercy Hos- pital, Chicago. Edited by Frank H. Davis, M.D. Second edition, enlarged. In one handsome royal 12mo. volume. Cloth, $1 75. (Lately Issued.) CHRISTISON'S DISPENSATORY. With copious ad- ditions, and 213 large wood engravings. By R. Eolesfield Gkiffith, M.D. One vol. 8vo., pp. 1000, cloth. $4 00. CARPENTER'S PRIZE ESSAY ON THE USE OF Alcoholic Liquors in Health and Disease. New edition, with a Preface by D. F. Condie, M.D., and explanations of scientificwords. In oneneatl2mo. volume, pp. 178, cloth. 60 cents. GLUGE'S ATLAS of PATHOLOGICAL HISTOLOGY Translated, with Notes and Additions, by Joseph Leidy, M. D. In one volume, very large imperial quarto, with 320 copper-plate figures, plain and colored, cloth. $4 00. LA ROCHE ON YELLOW FEVER, considered in its Historical, Pathological. Etiological, and Thera- peutical Relations. In two large and handsome octavo volumes of nearly 1500 pp , cloth. $7 00. HOLLAND'S MEDICAL NOTES AND REFLEC- TIONS. 1 vol. 8vo., pp. 500, cloth. $3 60. BARLOW'S MANUAL OF THE PRACTICE OF MEDICINE. With Additions by D. F. Condie, M. D. 1 vol. 8vo., pp 600, cloth. $2 50. TODD'S CLINICAL LECTURES on CERTAIN ACUTB Diseases. In one neat octavo volume, of 320 pp., cloth. $2 50. STURGES'S INTRODUCTION TO THE STUDY OF CLINICAL MEDICINE. Being a Guide to the In- vestigation of Disease. In one handsome 12mo. volume, cloth, $1 25. (Lately Issued.) STOKES' LECTURES ON FEVER. Edited by John William Moore, M. D., Assistant Physician to the Cork Street Fever Hospital. In one neat 8vo. volume, cloth, $2 00. (Just Issued.) THE CYCLOPAEDIA OF PRACTICAL MEDICINE: comprising Treatises on the Nature and Treatment of Diseases, Materia Medica and Therapeutics, Dis- eases of Women and Children, Medical Jurispru- dence, etc. etc. By Dunglison, Forbes, Tweedie, and Conollt. In four large super-royal octavo volumes, of 3254 double-columned pages, strongly and handsomely bound in leather, $15; cloth, $11. Henry C. Lea's Publications — (Practice of Medicine), 15 &LINT {AUSTIN), M.D., •*- Professor of the Principles and Practice of Medicine in Bellevue Med. College, N. T. A TREATISE ON THE PRINCIPLES AND PRACTICE OF MEDICINE ; designed for the use of Students and Practitioners of Medicine. Fourth edition, revised and enlarged. In one large and closely printed octavo volume of about 1100 pp.; cloth, $6 00 ; or strongly bound in leather, with raised bands, $7 00. {Lately Issued.) By common consent of the English and American medical press, this work has been assigned to the highest position as a complete and compendious text-book on the most advanced condi- tion of medical science. At the very moderate price at which it is offered it will be found one of the cheapest volumes now before the profession. This excellent treatise on medicine has acquired : His own clinical studies and the latest contribu- tor itself in the United States a reputation similar to i tions to medical literature hoth in this country and that enjoyed in England by the admirable lectures I in Europe, have received careful attention, so that of Sir Thomas Watson. We have referred to many ( some portions have been entirely rewritten, and of the most important chapters, and find the revi- ; about seventy pages of new matter have been ad- >ion spoken of in the.preface is a genuine one, and thattheauthorhasvery fairly brought up hismatter to the level ofthe knowledge of the present day. The work has this great recommendation, that it is in on ded. — Chicago Mi-d Jour., June, 1873. Has uever been surpassed as a text-book for stu- dents and a book of ready reference for practition- volume, and therefore will not be so terrifving to the i ers The force of its logic its simple and practical student as the bulky volumes which several of our ! teachings, have left it without a rival in the field. N. Y.—Med. Record, Sept. 15, 1874. It is given to very few men to tread in the steps of Austin Flint, whose single volume on medicine, English text-books ofmedicinehavedevelopedinto —British and Foreign Me.d.-Chir. Rev., Jan. 1875 It is of course unnecessary to in trod uce or eulogize this now standard treatise. The pi esent edition j though here and there defective, is a masterpiece of has been enlarged aud revised to bring it up to the lucid condensation and of general grasp of an enor- author's present level of experience and reading. I mously wide subject. — Lond. Practitioner, Dec. '73- JDT THE SAME AUTHOR. CLINICAL MEDICINE; a Systematic Treatise on the Diagnosis and Treatment of Diseases. Designed for Students and Practitioners of Medicine. In one large and handsome octavo volume of 795 pages; cloth, $4 50; leather, $5 £0. {Now Ready.) It has been the object ofthe author in this volume to present tbe science and art of medicine in their most practical aspect, adapted to the necessities of the student and physician in the daily routine of duties at the bedside. By avoiding the discussion of questions relating to pathology and etiology, space is gained for the thorough consideration of diagnosis and treat- ment, embracing many points which escape attention in the ordinary text-books. In the arrange- ment of the work, diseases are classed according to the system of organs primarily affected ; and affections closely related are grouped together so as to elucidate their differentiation, and the appropriate treatment is poinded out for each. The preparation ofthe work has occupied the author for several years, and is presented as embodying the results of prolonged observation and experience under opportunities more extensive than often fall to the lot of the physician. jgT THE SAME AUTHOR. ESSAYS ON CONSERVATIVE MRDICTNE AND KINDRED TOPICS. In one very handsome royal 12rao. volume. Cloth, $1 38. {Just Issued.) fJARTSRORNE {HENRY), M.D., ■*•-"- Professor of Hygiene in the University of Pennsylvania ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEDI- CINE. A handy-book forStudents and Practitioners. Fourth edition, revised and im- proved. With about one hundred illustrations. In one handsome royal 12mo. volume, of about 550 pages, cloth, $2 63 ; half bound, $2 88. {Lately Iss?ied.) As a handbook, which clearly sets forth the essen- tials Of the PRINCIPLES AND PRACTICE OF MEDICINE, we do not know of its equal. — Fa. Med. Monthly. As a brief, condensed, but comprehensive hand- book, it cannot be improved upon. — Chicago Med. Examiner, Nov. 15, 1S74. Without doubt the best book of the kind published in the English language.— St.LouisMtd. and Surg. Journ., Nov. 1874. TXTATSON {THOMAS), M.D., frc. LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. Delivered at King's College, London. A new American, from the Fifth re- vised and enlarged English edition. Edited, with additions, and several hundred illustra- tions, by Henry Hartshorne, M.D., Professor of Hygiene in the University of Penn- sylvania. In two large and handsome 8vo. vols. Cloth, $9 00 ; leather, $11 00. {Lately Published.) It is a subject for congratulation and for thank- , cate and important pathological and practical ques- fuliess that Sir Thomas Watson, during a period of ; tions, the results of his. clear insight and his calm comparative leisure, after a long, laborious, and judgmentare now recorded for the benefit of man- most nonorableprofessional career, while retaining ' kind, in language which, for precision, vigor, aud full possession of his high mental faculties, should | classical elegance, has rarely been equalled) and have employed the opportunity to submit his Lee- j never surpassed The revision has evidently been tares to a more thorough revision than was possible | most carefully done, and the results appear in al- during the earlier and busier period of his life. ; most every page. — Brit. Med. Journ., Oct 14 1S71 Carefully passingin review some of the mostintri- | 16 Henry C. Lea's Publications — (Practice of Medicine). £)RISTOWE(JOHN SYER), M.D., F.R.C.P., J-J Physician and Joint Lecturer on Medicine, St. Thomas's Hospital. A TREATISE ON THE PRACTICE OF MEDICINE. Second American edition, revised by the Author. Edited, with Additions, by James H. Hutch- inson, M.D., Physiciiin to the Penna. Hospital. In one handsome octavo volume of nearly 1200 pages. With illustrations. Cloth, $550; leather, $6 50. (Just Ready ) In reprinting this work from the recent thoroughly revised second English edition, the author has made such corrections as seemed advisable, and has added a chapter on Insanity. The Editor has likewise revised his additions in the light of the latest experience, and the work is presented as reflecting in every way the most modern aspect of medical science, and as fully entitled to maintain the distinguished position accorded to it on both sides of the Atlantic as an authoritative guide for the student, and a complete though concise rook of reference for the practitioner. Notwithstanding the author's earnest effort at compression, the additions have amounted to abut one-tenth of the previous edition ; but by the use of an enlarged page these have been accommodated without increasing the size of the volume, while a reduction in the price renders it one of the cheapest works accessible to the profession. A few notices of the first edition are subjoined. This portly volume is a model of condensation. Upon the whole, we know of no work which we could more confidently recommend to the student or the practitioner, intending a review of the field of theory and practice, than this book of Dr. Bris towe's. We thus commend it, because the vast ar- ray of facts pertaining to the practice of medicine, as it is to-day, are here presenUd ably, and with that method, order, and perspicuity which, in all depart- ments of educaiion, distinguish the lessons of an ac- ceptable and profitable teacher. -Chicago Medical Journal and Examiner, Aug. 1877. In a style at once clear, interesting, and concise, Dr. Bristowe passes in review every conceivable subject connected with the practice of medicine. Those practitioners who purchase few books will find this a mot t opportune publication, because so many top- ics not usually embraced in a work on practice are adequately handled. Thebookis athoroughlygood one, and its usefulness to American readers has been increased by the judicious notes of the Editor. — Cincinnati Clinic, Jan. 7, 1877. ffiOQDBURY [FRANK), M.D., Physician to the German Hospital, Philadelphia, late Chief Assist, to Med. Clinic, Jeff. College Hospital, etc. A HANDBOOK OF THE PRINCIPLES AND PRACTICE OF Medicine ; for the use of Students and Practitioners. Based upon Husband's Handbook of Practice. In one neat volume, royal 12mo. (In Press.) LJABERSHON (S. <9.), M.5T J~L Senior Physician to and late Lecturer on the Principles and Practice of Medicine at Guy's Hospital, etc. ON THE DISEASES OF THE ABDOMEN, COMPRISING THOSE of the Stomach, and other parts of the Alimentary Canal, (Esophagus, Caecum, Intes- tines, and Peritoneum. Second American, from the third enlarged and revised Eng- lish edition. With illustrations. In one handsome octavo volume of over 500 pages. Cloth, $3 50. (Now Ready.) We can do very little to add to the favorable re- ception which has already been given by the medi- cal press of the world to this well kaown treatise We commend to all practitioners a careful perusal of Dr. Habershon's work More especially, we draw attention to the number of intestinal diseases re- corded in its pages, cases of extreme interest clini- cally and pathologically. This careful record shows that the work is no compilation but a careful exposi- tion of the author's personal experience. — Canadian Med. and Surg. Journ., May, 1879. This valuable treatise on diseases of the stomach and abdomen has been out of print for several years, and is therefore not so well known to the profession as it deserves to be. It will be found a cyclopadia of information, systematically arranged, on all dis- eases of the alimentary tract, from the mouth to the rectum A fair proportion of each chapter is devot- ed to symptoms, pathology, and therapeutics. The present edition is fuller man former ones in many particulars, and has been thoroughly revised and amended by the author. Several new chapters have been added, bringing the work fully up to the times, and makingit a volume of interest to the practitioner in every field of medicine and surgery. Perverted nutrition is in some form associated with all diseases we have to combat, and we need all the light that can be ohtained on a subject so broad and general. Dr Habershon's work is one that every practitioner should read and study for himself. — N. Y. Mtd. Journ., April, 1879. F< OTHERG1LL {J. MILNER),M.D. Edin., M.R.C.P. Lond., Asst. Phys. to the West Lond Hosp. : Asst. Phys. to the City of Lond. Hosp.,etc. THE PRACTITIONER'S HANDBOOK OF TREATMENT; Or, the Principles of Therapeutics. In one very neat octavo volume of about 550 pages : cloth, $4 00. (Now Ready.) he knew how suggestive and helpful it would be to him.— (Si. Louis Med. and Surg. Journ , April, 1877. We heartily commend his book to themedical student as an honest and intelligent guide through the mazes of therapeutics, and assure the practitioner who has grown gray in the harness that he will derive pleasure and in- Our friends will find this a very readable book; and that it sheds light upon every theme it touches, causing the practitiorer to feel more certain of his diagnosis in difficult cases. We confidently commend the work to our readers as one worthy of careful perusal. It lights the way over obscure and difficult passes in medical The chapter on the circulation of the blood j ^ practice, xne cnapier on me circmauon oi me umou i 9truction from its perusal. Valuable suggestions and is the most exhaustive and instructive to be found. It | materia i for thought abound throughout.- Boston Med. [would have, if ! _„,j o„„~ t„„„„„i m - a 1077 is a book every practitioner needs, and and Surg Journal, Mar. 8, 1877. T>T THE SAME AUTHOR. THE ANTAGONISM OF THERAPEUTIC AGENTS, AND WHAT IT TEACHES. Being the Fothergillian Prize Essay for 1878. In one neat volume, 12mo. of 156 pages; cloth, $1 00. (Just Ready.) royal Henry C. Lea's Publications — (Practice of Medicine). 17 REYNOLDS {J. RUSSELL). M.D.. -*•*' Prof, of the Principles and Practice of Medicine in Univ. College. London. A SYSTEM OF MEDICINE with Notes and Additions by Hwry Hapts- horne, M.D., late Professor of Hygiene in the University of Penna. Tn three large and handsome octavo volumes, containing ahout 3000 closely printed double-columned pages, with numerous illustrations. (In Press ) Volume I. (just ready) contains General Diseases and Diseases of the Nervous System. Volumk II. (nearly ready) will contain Diseases of Respiratory and Circulatory Systems. Volume IT!, (preparing for early publication) will contain Diseases of the Digestive and Blood Glandular Systems, of the Urinary Organs, of the Female Reproductive System, and of the Cutaneous System. Reynolds's System of Medicine, recently completed, has acquired, since the first appearance of the first volume, the well-deserved reputation of being the work in which modern British medicine is presented in its fullest and most practical form. This could scarce be otherwise in view of the fact that it is the result of the collaboration of the leading minds of the profession, each subject being treated by some gentleman who is regarded as its highest authority — as for instance, Diseases of the Bladder by Sir Henry Thompson, Malpositions of the Uterus by Graily Hewitt, Insanity by Henry Maudsley, Consumption by J. Hughes Bennet, Dis- eases of the Spine by Charges Bland Radcliffe, Pericarditis by Francis Sibson, Alcoholism by Francis E. Anstie, Renal Affections by William Roberts, Asthma by Hyde Salter, Cerebral Affections by t£ Charlton Bastian, Gout and Rheumatism by Alfred Baring Gar- rod, Constitutional Syphilis by Jonathan Hutchinson, Diseases of the Stomach by Wilson Fox, Diseases of the Skin by Balmanno Squire, Affections of the Larynx by Morell Mac- kenzie, Diseases of the Rectum by Blizard Curling, Diabetes by Lauder Brunton, Intes- tinal Diseases by John Syer Bristowe, Catalepsy and Somnambulism by Thomas King Cham • bers, Apoplexy by J. Hughlings Jackson, Angina Pectoris by Professor Gairdner, Emphy- sema of the Lungs by Sir William Jenner, etc. etc. All the leading schools in Great Britain have contributed their best men in generous rivalry, to build up this monument of medical sci- ence. St. Bartholomew's, Guy's, St Thomas's, University College, St Mary's in London, while the Edinburgh, Glasgow, and Manchester schools are equally well represented, the Army Medical School at Netley, the military and naval services, and the public health boards. That a work conceived in such a spiri*:, and carried out under such auspices should prove an indispensable treasury of facts and experience, suited to the daily wants of the practitioner, was inevitable, and the success which it has enjoyed in England, and the reputation which it has acquired on this side of the Atlantic, have sealed it with the approbation of the two pre-eminently practical nations. Its large size and high price having kept it beyond the reach of many practitioners in this country who desire to possess it, a demand has arisen for an edition at a price which shall ren- der it accessible to all. To meet this demand the present edition has been undertaken. The five volumes and five thousand pages of the original will, by the use of a smaller type and double columns, be compressed into three volumes of about three thousand pages, clearly and hand- somely printed, and offered at a price which will render it one of the cheapest works ever pre- sented to the American profession. But not only will the American edition be more convenient and lower priced than the English ; it will also be better and more complete. Some years having elapsed since the appearance of a portion of the work, additions will be required to bring up the subjects to the existing condition of science. Some diseases, also, which are comparatively unimportant in England, require more elaborate treatment to adapt the articles devoted to them to the wants of the American physi- cian ; and there are points on which the received pra2tice in this country differs from that adopted abroad. The supplying of these deficiencies has been undertaken by Henry Harts- horne, M.D., late Professor of Hygiene in the University of Pennsylvania, who will endeavor to render the work fully up to the day, and as useful to the American physician as it has proved to be to his English brethren. The number of illustrations will also be largely increased, and no effort will be spared to render the typographical execution unexceptionable in every respec. The first volume, containing more than 1100 pages, is now ready. Volume II. is far advanced in preparation, and the completion of the whole may be expected shortly. From Alfred Stille, M D., Pr f of Theory aud to ine ever since the publication of its first editi 'a, Practice of Medicino and of Clinical Medicine in , and I have always spoksn of it as a worthv succes- University of Pennsylvaoi*. sor to Forbes's celebrated Cvclopedia and Tweedie's Reynolds's System of Medicine has been familiar ! Library. w h : ch so long maintained their place in to me since the publication of its first volume. It j the esleem aad confidence of British and American was then the best work in English on the subjects ' physicians. The present production is an elaborate it comprised, and the succeeding volumes have more '. and exhaustive one, reflecting the latest learning, than borne out the promise of the first. Its distinc- ! science, and experience of a large number of the tire merit is that every article is a monograph pre- ; most matured and cultured minds of England. Ire- pared by an expert, and, for the most part, in a very ! land - aud Scotland ;_ it is a work of rare merit, in superior manner. I have always recommended it l whlch e7ery article is fully brought up to the exist- to advanced students in medicine and to phvsicians ; i in S state of the science of which it treats, and occu- although the cost of the English edition limited the P ie3 the sam9 h 'S h raak anQ o u g physicians that number of its purchasers. Mr. Lea deserves thanks Holmes's Surgery does among surgeons. The learn- for having rendered more accessible to American j ed American editor's additions contribute materially readers a work of such exceptionable merit. ! t0 the value of the work— nothing seems to have I escaped his critical eye The republication of such From J. M. DaCo^ta. M D , Prof, of Practice of '■ a work cannot fail to be of great benefit to our pro- Medicine in Jeff Med College Phila. I fession. I have been familiar with Reynolds's System of ! _ • _ „ _ _ , , _. L Medicine for several years, and know of no work in : From Roberts Bartholow, M D„ Prof, of Mate- the English language more thorough and complete, j " a M ' jdl <=a and General Therapeutics in Jeff. Med. College, Philadelphia. From ,S D. Gross M.D., LL.D D.C L Oxon., Prof Reynolds's System of Medicine represents the of Institutes and Practice of Surgery in Jeff Med. most advanced and scientific phase of medicine, and College, Pnila. | is a wor ij f suc h a high order that it ought to be in Reynolds's System of Medicine .has been familiar | the hands of all American physicians. 18 Henry C. Lea's Publications — {Practice of Medicine, &c). J^INLAYSON {JAMES), M.D., Physician avd Lecturer on Clinical Medicine in the Glasgow Western Infirmary, etc. CLINICAL DIAGNOSIS; A Handbook for Students and Prac- titioners of Medicine. In one handsome 12mo. volume, of 546 pages, with 85 illustra- Cloth, $2 63. (Just Ready.) tions. The book is an excellent one, clear, concise, conve- nient, practical. It is replete with the very know- ledge the student needs when he quits the lecture- room and the laboratory for the ward and sick-room, and does not lack in information that will meet the wants of experienced and older men. — Phila. Med. Times, Jan. 4, 1879. The aim of the author is to teach a student and practitioner how to examine a case so as to use "all his knowledge'" in arriving at a diagnosis. All the various symptoms of the several systems are grouped together in such a manner as to make their relations to a final diagnosis clear and easy of apprehension. This work has been done by men of large experience and trained observation, who have been long recog- nized as authorities upon the subjects which they treat. There is a profusion of illustrations to illus- trate subjects under discussion. The application of electricity, and instruments of precision in diagnosis, is fully discussed. This book is all good. We com- mend it to all students and practitioners of medicine as a work worthy of a place in their libraries. — Ohio Med. Recorder, Dec. 1878. This is one of the really useful books. It is attrac- tive from preface to the final page, and ought to be gi ven a place on every office table, because it contains in a condeused form all that is valuable in semeiology and diagnostics to be found in bulkier volumes, and because in its arrangement and complete index, it is unusually convenient for quick reference in any emergency that may come upon the busy practitioner. —N. C. Med. Journ., Jan. 1S79. TJAM1LTOS {ALLAN McLANE), M.D. Attending Physician at the Hospital for Epileptics and Paralytics, BlackwelV s Island, N. ¥., and at the Out- Patients' 1 Department of the New York Hospital. NERYOUSDISEASES;THEIR DESCRIPTION AND TREATMENT. In one handsome octavo volume of 512 pages, with 53 illus. ; cloth, $3 50. (Now Ready.) ctions, both acute and chronic, hemorrhages and This is unquestionably the best and most com- plete text-book of nervous diseases that has yet ap- peared, and were international jealousy in scientific affairs at all possible, we might be excused for a feeling of chagrin that it should be of American parentage. This work, however, has been performed in New York, and has been so well performed that no room is left for anything but commendation. "With great skill, Dr. Hamilton has presented to his readers a succinct and lucid survey of all that is known of the pathology of the nervous system, viewed in the light of the most recent researches. From the preliminary description of the methods of examination and study, and of the instruments of precision employed in the investigation of nervous diseases, up till the final collection of formula, the book is eminently practical. — Brain, London, Oct. 1878. The author tells us in his preface that it has been his object to produce a concise, practical book, and we think he has been successful, considering the ex- tent of the subject which he has undertaken. In fact, it is more extensive than the title properly or accurately indicates, embracing — besides what are usually regarded as nervous diseases— inflammatory tumors of the cerebrum and cerebellum, medul oblongata, spinal cord and nerves, with thrombosis and embolism of the arteries, sinuses, and veins. The reader may therefore expect information, more or less full and satisfactory, on almost everv point connected with the nervous system. We have no hesitation in saying that reliance may be placed on Dr. Hamilton's conscientious performance ot' his self- assigned task, on his soundness of judgment, and freedom from empiricism.— Edinburgh Med. Journ., Oct. 1S7S. From a very careful examination of the whole work, we car justly say that the author has not only clearly and fully treated of diagnosis and treatment, but, unlike most works of this class, it is very com- prehensive in regard to etiology, and exposes the pathology of nervous diseases i u the light of the very latest experiments and discoveries. The drawings are excellent and well selected. After this careful revision, we can heartily recommend this work to students and general practitioners in particular as being a full exposition of diseases of the nervous sys- tem, their pathology and treatment, to date. — iV. Y. Med. Record, Aug. 3, 1878. QHARCOT [J. 31.), Professor to the Faculty of Med. Paris, Phys. to La Salpetriere, etc. LECTURES ON DISEASES OF THE NERVOUS SYSTEM. Trans- lated from the Second Edition by George Sigerson, M.D., M.Ch., Lecturer on Biology, etc., Cath. Univ. of Ireland. With illustrations. 1 vol. 8vo. of 288 pages. Cloth, $1 75. (Just Ready.) CLINICAL OBSERVATIONS ON FUNCTIONAL NERVOUS DISORDERS By C. Handfield Jones. M.D., Physician to St. Mary's Hospital, &c. Sec- ond American Edition. In onehandsome octavo volumeof 318 pages.cloth, $3 25. IpOX {T1LBTJRF), M.D.,F.R.C.P.,and T. C. FOX, B.A., M.R.C.S., Physician to the Department for Skin Diseases, University College Hospital. EPITOME OF SKIN DISEASES. WITH FORMULAE. For Stu- dents and Practitioners. Second edition, thoroughly revised and greatly enlarged. In one very handsome 12mo. volume of 216 pages. Cloth, $1 38. (Just Ready.) The names of the authors are quite sufficient to The present edition of the Epitome considerably commend this book, Dr. Tilbury Fox being wefll known as occupying a place in the front rank of dermatologists of the day.— Canadian Journal of Med. Sci., May, 1878. exceeds in size, and surpasses in use, its predeces- sor. The work is certainly a valuable addition to the '"handy vjlume" department of medical litera- ture.— The Med. Bulletin, May, 1S78. , WILSON'S STUDENT'S BOOK OF CUTANEOUS MEDICINE and Diseases op the Skin. In one very handsome royal 12mo volume. $3 50. HILLTER'S HANDBOOK OF SKIN DISEASES, for Students and Practitioners. Second Am. Ed. In one roval 12mo. vol. of 358 pp. With illustrations. Cloth, '$2 25. M ORRIS (MALCHOM). M.D. Jnivt Lecturer on Dermatology, St. Mary's Hospital Med. School. SKIN DISEASES, Including their Definitions, Symptoms. Diagnosis, Prognos-is, Morbid Anatomy, and^reatment. A Manual for Students and Practitioners. In one 12mo. volume of over 300 pages. (Shortly.) Henry C. Lea's Publications — (Diseases of the Chest, &c). ' 19 ^ROWN {LENNOX), F.R.G.S. Ed., Senior Surgeon to the Central London Throat and Ear Hospital, etc., THE THROAT AND ITS DISEASES. With one hundred Typical Illustrations in colors, and fifty wood engravings, designed and executed by the author. In one very handsome imperial octavo volume of 351pages ; cloth, $5 00. (Now Ready.) The author's rare artistic skill hns been utilized in the production of one hundred beautiful illustra- tions in colors, rhe very best of the kind we have seen, and which have been distributed in ten plates. Fifty wood engravings, designed and executed by the author, appear in the body of the work — these are unusually accurate. In conclusion, we recom- mend this beautiful volume as an acceptable addi- tion to the library of those engaged in t v e treatment of diseases of the throat.— N. Y. Med. Record, Nov. 9, 1S7S. Chief of the Throat Dispensary at the CjElLEIl (GAEL), M.D., *~J Lecturer on Laryngoscopy at the Univ. of Penna. Univ. Hospital, Phila., etc. HANDBOOK OF DIAGNOSIS AND TREATMENT OF DISEASES OF THE TQROAT AND NASAL CAVITIES. In one handsome royal 12mo. volume, of 156 pages, with 35 illustrations; cloth, $1. (Just Ready.) We most heartily commend this book as showing I A convenient little handbook, claar. concise, and sound judgment in practice, and perfect familiarity with the literature of the spec alty it so ably epi- tomizes.— Philada. Mtd. Times, July 5, 1S79. accurate in its method, and admirably fulfilling rs purpo.-e of brincing the subject of which it treats within the comprehension of the general practi- tioner. — N. C. Med. Jour., June, 1S79. PLINT {AUSTIN), M.D., Professor of the Princivles and Practice of Medicine in Bellevue Hospital Med. College, N. Y. PHTHISIS: ITS MORBID ANATOMY, ETIOLOGY, SYMPTOM- ATIC EVENTS AND COMPLICATIONS, FATALITY AND PROGNOSIS, TREAT- MENT, AND PHYSICAL DIAGNOSIS; in a series of Clinical Studies. By Austin Flint, M.D., Prof, of the Principles and Practice of Medicine in Bellevue Hospital Med. College. New York. In one handsome octavo volume : $3 50. (Lately Issued.) This book contains an analysis, in the author's lucid I mend the book to the perusal of all interested in the style, of the notes which lie has made in several bun- study of this disease. — Boston Med. and Surg . Journal, dred cases in hospital and private practice. We com- | Feb. 10, 1876. JgY THE SAME AUTHOR. A MANUAL OF PERCUSSION AND AUSCULTATION; of the Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism, one handsome roj'al 12mo. volume : cloth, $1 75. (Just Issued.) In T>Y THE SAME AUTHOR. A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF DISEASES OF THE HEART. Second revised and enlarged edition. In one octavo volume of 550 pages, with a plate, cloth, $4. Dr. Flint chose a difficult subject for his researches , and clearest practical treatise on those subjects, and and has shown remarkable powers of observation ; should be in the hands of all practitioners and stu- and reflection, as well as great industry, in his treat- lents. It is a credit to America n medical literature. ment of it. His book must be considered the fullest I — Arner. Journ. of the Med. Sciences, July, 1S60. T> Y THE SAME AUTHOR. A PRACTICAL TREATISE ON THE PHYSICAL EXPLORA- TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE RESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume of 595 pages, cloth, $4 50. WILLIAMS'S PULMONARY CONSUMPTION; its Nature, Varieties, and Treatment. With an An- alysis of One Thousand Cases to exemplify its duration. In one neat octavo volume of about 350 pages ; cloth, $2 50. SLADE ON DIPHTHERIA; its Nature and Treat- ment, with an account of the History of its Pre- valence in various Countries. Secondand revised edition. In one neat royal 12mo. volume cloth. $1 25. WALSHE ON THE DISEASESOF THE HEART AND GREAT VESSELS. Third American Edition. In 1 vol. Svo., 420 pp., cloth, $3 00. LECTURES ON THE DISEASES OF THE STOMACH. With an Introduction on its Anatomy and Physio- logy. By William Brtnton, M.D., F.R.S. From the second and enlarged Londonedition. With il- lustrations on wood. In one handsome octavo volume of about 300 pages: cloth, $3 25. CHAMBERS'S MANUAL OF DIET AND REGIMEN IN HEALTH AND SICKNESS. In one handsome octavo volume. Cloth, $2 75. LA ROCHE ON PNEUMONIA. 1 vol. 8vo., cloth, of 500 pages. Price, $3 00. LINCOLN'S ELECTRO-THERAPEUTICS; a Concise Manual of Medical Electricity. In one very neat royal 12mo. volume, cloth, with illustrations, $1 50. FULLER ON DISEASES OF THE LUNGS AND AIR- PASSAGES. Their Pathology, Physical Diagnosis, Symptoms, and Treatment. From the second and revised English edition. In one handsome ocatvo volume of about 500 pages : cloth, $3 50. S>IITH ON CONSUMPTION ; ITS EARLY AND RE- MEDIABLE STAGES. 1 vol.8vo..pp.254. $2 2£. BASH AM ON RENAL DISEASES : a Clinical Guide to their Diagnosis and Treatment. With Illustra- tions. In onel2mo. vol. of 304 pages, clotb, $2 00. LECTURES ON THE STUDY OF FEVER. By A. Hudson, M.D., M.R.I. A., Physician to the Meath Hospital. In one vol. 8vo., cloth, $2 50. A TREATISE ON FEVER. By Robert D. Lyons, KCC. In one octavo volume of 362 pages, cloth. $2 25. 20 Henry C. Lea's Publications — (Venereal Diseases, &c). fPUMSTEAD [FREEMAN J.), M.D.,LL.D., '*-* Professor of Venereal Diseases at the Ool. of Phys. and Surg., New York, &c. THE PATHOLOGY AND TREATMENT OF VENEREAL DIS- EASES. Including the results of recent investigations upon the subject. Fourth edition, revised and largely rewritten with the co-operation of R. W. Taylor, M.D., of New York, Prof, of Dermatology in the Univ. of Vt. En one large and handsome octavo volume of 835 pages, with 138 illustrations. Cloth, $4 75 ; leather, $5 75 {Just Ready.) This work, on its first appearance, im-nediately took the position of a standard authority on its subject wherever the language is spoken, and the success of an Italian translation shows that it is regarded with equal favor on the Continent of Europe. In repeated editions the author labored sedulously to render it more worthy of its reputation, and in the present revision no pains have been spared to perfect it as far as possible. Several years having elapsed since the publication of the third edition, much material has been accumulated during the interval by the industry of syphilologists, and new views have been enunciated. All this so far as confirmed by observation and experience, has been incorporated; many portions of the volume been rewritten, the series of illustrations has been enlarged and improved, and the whole may be regarded rather ss anew work than as a new edition. It is confidently presented as fully on a level with the most advanced condition of syphilology, and as a work to which the practi- tioner may refer with the certainty of finding clearly and succinctly set forth whatever falls within the scope of such a treatise. However Taluable the previous eilitiotn have Veen, the present is, to our thinking, decidedly of more worth. An air of completeness — of having had gar- nered into its pages all the best fruit of the world's experience and research upon the subject of which it treats — has been given to the book, without in any way detracting from the peculiarly practical value of previous editions. Ncne the less clinical, the treatise seems much more cosmopolitan. The p ssession of old editions will be no excuse to the progressive physician for not purchasing this edi- tion, and we predict for it a very speedy sale. We congratulate Dr. Bumstead on the wisdom which led to the selection of Dr. Taylor as colleague, and we sinceraly congratulate the two coworkers upon the results of their labor. — Philadelphia Medical Times, Dec. 6, 1879. As it now stands, this is the only complete mod- ern work devoted exclusively to the discussion of venereal diseases. It was needed, and will be cor- dially welcomed by all who desire to keep abreast with the times in their knowledge of these subjects. It is one of the few really good books needed by every practitiocer of medicine or surgery, whether he be a general practitioner or specialist. — Detroit Lancet, December, 1879. Dr. Bumstead's successful labors entitle him now to rank pre-eminently as the authority in this coun try on venereal diseases. But not only does this fact make his present treatise of interest to practi- tioners ; the book is fully abreast with present literature on the subject of which it treats, is ex- tremely practical in descriptions of the several venereal diseases and modes of treatment, and hence should be in every doctor's library. — Va. Med. Monthly December, 1879. ffULLERIER (A.), and J?UMSTEAD (FREEMAN J.), *•/ Surgeon to the Hdpital du Midi. J-* Professor of Venereal Diseases in the College of Physicians and Surgeons, N. Y. AN ATLAS OF VENEREAL DISEASES. Translated and Edited by Freeman J. Bumstead. In one large imperial 4to. volume of 328 pages, double-columns, with 26 plates, containing about 150 figures, beautifully colored, many of them the size of life; strongly bound in cloth, $17 00 ; also, in five parts, stout wrappers, at $3 per part. Anticipating a very large sale for this work, it is offered at the very low price of Three Dol- lars a Part, thus placing it within the reach of all who are interested in this department of practice. Gentlemen desiring early impressions of the plates would do well to order it without delay. A specimen of the plates and text sent free by mail, on receipt of 25 cents. LEE'S LECTURES ON SYPHILIS AND SOME FORMS OF LOCAL DISEASE AFFECTING PRIN- CIPALLY THE ORGANS OF GENERATION. In one handsome octavo volume; cloth, $2 2"). HILL ON SYPHILIS AND LOCAL CONTAGIOUS DISORDERS. In one handsome octavo volume; cloth, $3 25. TO? (CHARLES), M.D., Phvsicianto the Hospital for Sick Children, London, &c. LECTURES ON THE DISEASES OF INFANCY AND CHILD- HOOD. Fifth American from the sixth revised and enlarged English edition. In one large and handsome octavo volume of 678 pages. Cloth, $4 50 ; leather, $5 50. {Lately Issued ) 73 F THE SAME AUTHOR. {Lately Issued.) ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILD- HOOD; being the Lumleian Lectures delivered at the Royal College of Physicians of London, in March, 1871. In one volume small l2mo., cloth, $1 00. T> Y THE SA WE A UTHO R. LECTURES ON THE DISEASES OF WOMEN. Third American, from the Third London edition. In one neat octavo volume of about 550 pages, clotfc, $3 75; leather, $4 75. CONDIE'S PRACTICAL TREATISE ON THE DIS- EASES OF CHILDREN. Sixth edition, revised and augmented, in one large octavo volume of nearly 80 closely printed pages, cloth. $5 25; leather $6 2J. SMITH'S PRACTICAL TREATISE ON THE WAST ING DISEASES OF INFANCY AND CH LDH "»OD. Second American, from the second revised and enlarged Easlish edition. In one handsome octa- vo voiume, cloth, $2 50. Henry C. Lea's Publications — (Diseases of Children, &c.). 21 &MITH{J. LEWIS), M.D., Clinical Professor of Diseases of Children in the Bellevue Hospital Med. College, N T. A COMPLETE PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Fourth Edition, revised and enlarged. In one handsome octavo volume of about 750 pages, -with illustrations. Cloth, $4 50 ; leather, $5 50. (JSoiv Ready.) The very marked favor with which this work has been received wherever the English lan- guage is spoken, has stimulated the author, in the preparation of the Fourth Edition, to spare no pains in the endeavor to render it worthy in every respect of a continuance of professional confidence. Many portions of the volume have been rewritten, and much new matter intro- duced, but by an earnest effort at condensation, the size of the work has not been materially increased. In the period which has elapsed since the third [ This excellent work is so well known that an edition of the woik, so extensive have been the ad- i exended notice at this time would be superfluous, vauces that whole chapters required to be rewiitten, j The author has tafeen advantage of the demand for and hardly a page could pass without som a ■"«'»"'" ' lateral correction or addition. This labor has occupied the writer closely, and he has performed it conscien- tiously, so that the book may be considered a faith- fuL portraiture of an exceptionally wide clinical experience in infantile diseases, corrected by a care- ful study of the recent literature of the subject. — Med. and Surg. Reporter, April 5, 1879. It is scarcely necessary for us to say the work be" fore us is a standard work upon diseases of children, and that no work has a higher standing than it upon those affections. Iu consequence of its thorough re- vision, the work has been made of more value than ever, and may be regarded as fully abreast of the times. We cordially couimend it to students and physicians. There is no better work in the language on diseases of children. — Cincinnati Med. News, March, 1879. the author has evidently determined that it ."-hall not lose ground in the esteem of the profession for another new edit on to revise in a most careful manner the entire book ; and the numerous correc- tions and additions evince a determination on his part to keep fully abreast with the rapid progress that is being ma de in the knowledge and treatment of children's diseases. By the adoption of a some- what closer type, an increase in size of only thirty paces has been necessitated by the new subject matter introduced.— Boston Mei. and Surg. Jour., May 29. 1S79. Probably no other work ever published in this country upon a medical subject has reached such a heighth of popularity as has this well-known trea- tise. As a text and reference-book it is pre emi- nently the authority upon diseases of children. It .-tands deservedly higher in the estimation of the profession than any other work upon the same sub- ject. — Nashville, Journ. of Med. and Surg., May, 1879. The author of this work has acquired an immense want of the latest knowledge on that important experience as physician to three of the large char- department of medicine. He has accordingly in- | ities of New York in which children are treated, corporated in the present edition the u-eful and j These asylums afford unsurpassed opportunities for practical results of the latest study aDd expeiiecce, observing the eff-cts of different plans of treatment, b th American and foreign. especially those beaiirg ' and the results as emb >died in this volume maybe on therapeutics. Altogether the book has been ; accepted with faith, and should be in the possession greatly improved, while it has not been greatly j of all practitioners now, in vi<>w of the approaching increased in size. — New York Mtdical Journal, season when the diseases of children alwavs increase. June, 1S79. 1 — Nat. M-. d. Stvitw, April, 1S79. ^ WAYNE {JOSEPH GRIFFITHS), M.I)., Physician-Accoucheur to the British General Hospital, d-c. OBSTETRIC APHORISMS FOR THE USE OF STUDENTS COM- MENCING MIDWIFERY PRACTICE Second American, from the Fifth and Revised London Edition, with Additions by E. R. Hutchins, M.D. With Illustrations. In one neat 12mo. volume. Cloth, $1 25. (Lately Issued.) *** See p. 4 of this Catalogue for the terms on which this work is offered as a premium to subscribers to the " Amebic ah Journal op the Medical Sciences." OHDRCHILL ON THE PUERPERAL FEYER AND MEIGS ON THE NATURE, SIGNS. AND TREAT OTHER DISEASES PECULIAR TO WOMEN. 1vol. Svo., pp. 450, cloth $2 50. DEWEES'S TREATISE ON THE DISEASES OF FE- MALES. With illustrations. Eleventh Edition, with the Author's lastimprovementsand correc- tions. In one octavo volume of 536 pages, with plates, cloth. $3 00. MENT OF CHILDBED FEVER. 1 vol. Svo , pp. 36S. cloth. $2 00. ASHWELL'S PRACTICAL TREATISE ONTHE DIS- EASES PECULIAR TO WOMEN. Third American, from the Third and revised London edition. 1 vol. 8vo., pp. 52S, cloth. $3 50. J^ODGE {HUGH L.), M.D., Emeritus Professor of Obstetrics, Ac, in the University of Pennsylvania. ON DISEASES PECULIAR TO WOMEN; including Displacements of the Uterus. With original illustrations. Second edition, revised and enlarged. In one beautifully printed octavo volume of 531 pages, cloth, $4 50. Professor Hodge'fc woik it crnly an original one j contribution to the study ofwomen'Fdif-ea6€8,itis rf from beginning to end, consequently no one can pe- great value, and is abundantly able to stand on its ruseits pageswithoat learning/something new. At a | own merits. — N. T. Mtdical Bee or d, Sept. 15, 186t. HURCHILL (FLEETWOOD), M.D., M.R.I.A. ON THE THEORY AND PRACTICE OF MIDWIFERY. A new American from the fourth revised and enlarged London edition. With notes and additiors by D. Francis Condie, M.D., author of a "Practical Treatise on the Diseases of Chil- dren," Ac. With one hundred and ninety four illustrations. In one very handsome octavo volume of nearly 700 large pages. Cloth, $4 00 ; "leather, $5 00. MONTGOMERY'S EXPOSITION OF THE SIGNS I RiGSY^fa SYSTEM OF MIDWIFERY. With notes AND SYMPTOMS OF PREGNANCY. With two j and Additional illustration 6. Second Ameri* an exquisitecolored plates, and numerous wood-euts. j a <*ition. Ons volume octavo, cloth 4S5 page6, In I vol. Svo. ,oinearly600pp., cloth, $375. I $2 50. C 22 Henry C. Lea's Publications— (ZKseases of Women). f'HOMAS (T. GAILLARD),M.D., Professor of Obstetrics, &c, in the College of Physicians and Surgeons, N. Y., Ac. A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. Fourth edition, enlarged and thoroughly revised. In one large and handsome octavo volume of 800 pages, with 191 illustrations. Cloth, $5 00; leather, $6 00. (Just Issued.) The author has taken advantage of the opportunity afforded by the call for another edition of fehis work to render it worthy a continuance of the very remarkable favor with which it has been received. Every portion has been subjected to a conscientious revision, and no labor has been spared to make it a complete treatise on the most advanced condition of its important subject. A work which has reached a fourth edition, and j is classical without beingpedaatic. full in thedetails that, too. in the short space of five years, has achieved of anatomy and pathology, without ponderous a reputation which places it almost beyond the reach translation of pages of German literature, describes of criticism, and the favorable opinions which we have distinctly the details and difficulties of each opera- ready expressed of the former editions seem to re- tion, without wearying and useless minutise, and quire that we should do little more than announce this new issue. We cannot refrain from saying that, as a practical work, this is second to none in the Eng- lish, or, indeed, in any other language. The arrange- ment of the contents, the admirably clear manner in which the subject of the differential diagnosis of several of the diseases is handled, leave nothing to be desired by the practitioner who wants a thoroughly clinical work, one to which he can refer in difficult cases of doubtful diagnosis with the certainty of gain- ing light and instruction. Dr. Thomas is a man with a very clear head and decided views, and there seems to be nothing which he so much dislikes as hazy notions of diagnosis and blind routine and unreasonable thera- peutics. The student who will thoroughly study this book and test its principles by clinical observation, will certainly not be guilty of these faults. — London Lancet, Feb. 13, 1875. Reluctantly we are obliged to close this unsatis- factory notice of so excellent a work, and in conclu- 8ion r would remark that, as a teacher ofgynsecology, both didactic and clinical, Prof. Thomas has certainly taken the lead far ahead of his confreres, and as an author he certainly has met with unusual and mer- ited success. — Am Journ. of Obstetrics, Nov. 1874. This volume of Prof. Thomas in its revised form in all respects a work worthy of confidence, justify- ing the high regard in which its distinguished au- thor is held by the profession. — Am. Supplement, Obstet. Journ., Oct. 1874. Professor Thomasfairly took the Profession of the United States by storm when his book first made its appearance early in 1S68. Its reception was simply enthusiastic, notwithstanding a few adverse criti- cisms from our transatlantic brethren, thefirstlarge edition was rapidly exhausted, and in six months a second one was issued, and in two years a third one was announced and published, and we are nowpro- mised the fourth. The popularity of this work was not ephemeral, and itssuccess wasunprecedentedin the annalsof American medical literature. Six years is a long period in medical scientific research, but Thomas's work on " Diseases of Women"is still the leading native production of the United States. The order, the matter, the absence of theoretical disputa tiveness, the fairness of statement, and the elegance of diction, preserved throughout the entire range of the book, indicate that Professor Thomas- did not overestimate his powers when he conceived the idea and executed the work of producing a new treatise upon diseases of women. — Prof. Pallen, in Louis- ville Med. Journal, Sept. 1874. B ARNES (ROBERT), M.D., F.R.G.P., Obstetric Physician to St. Thomas' s Hospital, &c. A CLINICAL EXPOSITION OF THE MEDICAL AND SURGI- CAL DISEASES OF WOMEN. Second American, from the Second Enlarged and Revised English Edition. In onp Handsome octavo volume, of 784 pages, with 181 illustrations. Cloth, $ 4 50 j leather, $5 50. (Just Ready.) The call for a new edition of Dr. Barnes's work on the Diseases of Females has encouraged the author to make it even more worthy of the favor of the profession than before. By a rear- rangement and careful pruning space has been found for a new chapter on the Gynaecological Relations of the Bladder ani Bowel Disorders, without increasing the size of the book, while many new illustrations have been introduced where experience has shown them to be needed. It is therefore hoped that the volume will be found to reflect thoroughly and accurately the present condition of gynaecological science. the work is a valuable one, and should be largely con -tilted by the profession. — Am. Svpp Obstetrical Journ. Gt. Britain and Ireland, Oct. 1878. No other gynaecological work holds a higher posi- tion, having become an authority everywhere in diseases of women. The work has been brought fully abreast of present knowledge. Every practi- tioner 'f medicine should have it upon the shelves of his library, and the student will find it a superior text-book.— Cincinnati Med. News, Oct. 1S7S. This second revised edition, of course, deserves all the commendation given to its predecessor, with the additional one that it appears to include all or nearly all the additions to our knowledge of its subject that have been made since the appearance of the first edi- tion The American references are, for an English work, especially full and appreciative, and we can cordially recommend the volume to American read- ers — Journ. of Nervous and Mental Disease, Oct. 1878. This second edition of Dr. Barnes's great work comes to us containing many additions and improve- ments which bring it up to date in every feature. The excellences of the work are too well known to require enumeration, aod we hazard the prophecy that they will for many years maintain its high po- sition as a standard text-book and guide book for students and practitioners. — N. O. Med. Journ., Oct. 1S78. Dr Barnes stands at the head of his profession in the old country, and it requires but scant scrutiny of his book to show that it has been sketched by a master. It is plain, practical common sense ; shows very deep research without being pedantic; is emi- nently calculated to inspire enthusiasm without in- culcating rashness; points out the dangers to be avoidpd as well as the success to be achieved in the various operations connected with this branch of medicine ; and will do much to smooth the rugged path of the young gynaecologist and relieve the per- plexity of the man of mature years. — Canadian Journ. of Med. Science, Nov. 1878. We pity the doctor who, having any consider- able practice in diseases of women, has no copy of " Barnes" for dailv consultation and instruction. It is at once a book of great learning, research, and individual experience, and at the same time emi- nently p 1 radical. That it has b?en appreciated by the profession, both in Great Britain and in this country, is shown by the second edition following so soon upon the first. — Am. Practitioner, Nov. 187S. Dr Barnes's work is one of a practical character, largely illustrated from cisesin his own experience, bit by uo means confined to such, as will be learned from the fact that he quotes from no less than 628 medical authors in numerous countries. Coming from such an author, it is not necessary to say that Henry C. Lea's Publications — (Diseases of Women). 23 TfMMET [THOMAS ADDIS), M.D. -*-* Surgeon to the Woman'' s Hospital, New York, etc. THE PRINCIPLES AND PRACTICE OF GYNAECOLOGY, for the use of Students and Practitioners of Medicine. In one large and very handsome octavo volume of 856 pages, with 130 illustrations. Cl.th, $5; leather, $6. {Just Ready.) It may be said that he has had opportunities for observation and experience, for unfettered and un- restrained experimentation, and for testing the value of the original and dazzling operations first proposed and performed by his illustrious predeces- sors before referred ro. and for devising new opera- tions and discovering pathological causes never before suspected or described, which no man in the profession has ever before secured. We also think that the readers of this work will agree with us, after its careful perusal, that he has a rare capacity for discriminating analysis, and generally for phi- losophical deduction and the equally important quality of patient, honest, continued work. For the work as a whole, we have only praise. It deserves and will receive the careful study of all who desire to keep on a level with the progress of Gynaecology. It embodies a larger amount of carefully analyzed personal experience in a unique field for observa- tion than any volume on Diseases of Women which has yet been published. Its great merit consists in this— coming as it does from a thoroughly honest, competent, and able specialist, who became a spe- cialist only after an « xcellent training and experi- ence as a general hospital physician and surgeon. The book is not one to be hastily glanced over, but will secure the critical study of Gynaecologists. Not only its style, which is individual and somewhat peculiar, but the new facts which it brings out, its original suggestions, its numerous and important statistical tables, and, in some instances, its unex- pected deductions, will compel attention, and will form the basis for a great deal of Gynaecological study and literature in the future. Allwhi make themselves familiar with the contents of this vol- ume, will feel assured that I>r Emmet has well earned and well deserved the reputation which he has already won, as one ofthe gre it Gynaecologists of the present age.— The Am. Journ. of Obstetrics, April, 1S79. We have examined this book with something more than ordinary care, and now lay it aside captivated by our impressions of it. From first to last, each page grows in interest, and one is struck with the practical tore of all that is said. It is indeed the gynaecological work for the practitioner. Its equal is not yet published, or at least we have not seen it. We cannot send 'his notice forward without reifcer- atirg that, in onr estimation, Emmet's Principles and Practice of Gynaecology is undoubtedly thebest book for the student, as well as the general practi- tioner, which is at present published. — Va. Med. Monthly, May, 1S79. nUXCAX [J. MATTHEWS), M.D., LLD., F.R.S.E.. etc. CLINICAL LECTURES ON THE DISEASES OF WOMEN, Delivered in Saint Bartholomew's Hospital. In one very neat octavo volume of about 200 pages. (Nearly Ready.) Prof. Matthews Duncan's originality and suggestiveness are sufficient guarantee that what- ever he may see fit to lay before the profe-sion is well worth attention ; while the importance ofthe subjects discussed'in the present volume will give it special attractiveness to the practising physician. CONTENTS. Lecture I. On Missed Abortion. IT. On Abnormal Pelvis. III. On Chronic Catarrh of the Cervix Uteri. IV. On Ovaritis. V. On Perimetritis and Parametritis. VI. On Kinds of Perimetritis. VII. On Forms of Parametritis. VIH. On Painful Sitting. IX. On Aching Kidney— Pyonephrosis — Stricture of Urethra. X. On Irri'nble Bladder. XL On Vaginismus. XII. On Spasmodic Dysmenorrhcea. XIII. On Hepatic Disease in Gynaecology and Obstetrics. XIV. On Fibrous Tumor of the Uterus flHADWICK [JAMES R.), A.M., M.D. A MANUAL OF THE DISEASES PECULIAR TO WOMEN. neat volume, royal 12mo , with illustrations. (Preparing.) In one JDAMSBOTHAM [FRANCIS H.), M.D. THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDI CINE AND SURGERY, in reference to the Process of Parturition. A new and enlarged edition, thoroughly revised by the author. With additions by W. V. Keating, M. D., Professor of Obstetrics, Ac, in the Jefferson Medical College, Philadelphia. In one Lrgre and handsome imperial octavo volume of 650 pages, strongly bound in leather, with raised bands ; with sixty-four beautiful plates, and numerous wood-cuts in the text, containing in all nearly 200 large and beautiful figures. $7 00. -U77XCKEL [F.], ' V Professor and Director ofthe Gynaecological Clinic in the University of Rostock. A COMPLETE TREATISE ON THE PATHOLOGY AND TREAT- MENT OF CHILDBED, for Students and Practitioners. Translated, with the consent of the author, from the Second German Edition, by James Read Chadwick, M.D. In one octavo volume. Cloth, $4 00. (Lately Issued.) /TANNER [THOMAS H.), M.D. ON THE SIGNS AND DISEASES OF PREGNANCY. First Amerienn from the Second and Enlarged English Edition. With four colored plates and illustra- tions on wood. In one handsome octavo volume of about 000 pages, cloth, $4 25. 24 Henry C. Lea's Publications — (Midwifery). pLAYFAIR ( W. S.), M.D., F.R.C.P., -*- Professor of Obstetric Medicine in King 's College, etc. etc. A TREATISE ON THE SCIENCE AND PRACTICE OF MIDWIFERY. Third American edition, revised by the author. Edited, with additions, by Robert P. Harris, M.D. In one handsome octavo volume of about 700 pages, with nearly 2(0 illustrations. {.Just Ready ) EXTRACT FROM THE AUTHOR'S PREFACE. The second American edition of my work on Midwifery being exhausted before the corre- sponding English edition, I cannot better show my appreciation of the kind reception my book has received in the United States than by acceding to the publisher's request that I should myself undertake the issue of a third edition. As little more than a year has elapsed since the second edition was issued, there are naturally not many changes to make, but I have, nevertheless, subjected the entire work to careful revision, and introduced into it a notice of most of the more important recent additions to obstetric science. To the operation of gastro- elytrotomy — formerly described along with the Csesarean section — I have now devoted a sepa- rate chapter. The editor of the Second American edition, Dr. Harris, enriched it with many valuable notes, of which, it will be observed, I have freely availed myself. A few notices of the previous edition are subjoined. The best work on the subject ever published in the English language. It is written in a clear, pleasant style, without that verbosity which characterizes some modern and highly pretentious works. The au thor is quite up with the times, both in practice and theory. It is the best text- book we have for students, snd sufficiently full of detail to supply all the wants of the practitioner. We would gladly see it in the hands of all who practise midwifery. — Canadian Journ. of Med. Set, Nov. 1878. There has been a general unanimity of opinion in the profession as to the high character of Dr. Play- fair's work, both as a manual for the student, and a book of reference for the practitioner ; and the revision and additions made to the second edition will not lower this favorable estimate of it. The additions made by Dr. Harris are of such a char- acter as to make us wish they were more in num- ber and greater in extent. — Am. Journ. of Med. Sciences, Jan. 1879. T)ARNES {FANCOURT), M.D., -U Physician to the General Lying-in Hospital, London. A MANUAL OF MIDWIFERY FOR MIDWIVES AND MEDICAL STUDENT 3. With 50 illustrations. In one neat royal 12mo. volume of 200 pages; cloth, $1 25. (Now Ready.) The book is written in plain, and as far as pos- sible in untechnical language. Any intelligent mid- wife or medical student can easily comprehend the directions It will undoubtedly fill a want, and will be popular with those for whom it has been prepared. The examining questious at the back will be found very useful.— Cincinnati Med. News. Aug 1879. The style is clear, and the book will, doubtless' be useful to the persons for whom it is intended. — London Med. Times and Gazette, Aug. 30, 1879. The book is written with as little technical lan- guage as possible. Any intelligent midwife or med- ical student can easily understand the directions. It will undoubtedly be found very useful. — Ohio Med. Recorder, Sept. 1879. In Monthly Summary, Gynecic 28 Articles " " Pediatric 4 " News 9 " rJIHE OBSTETRICAL JOURNAL. {Free of postage/or ]880.) THE OBSTETRICAL JOURNAL of Great Britain and Ireland: Including Midwifery, and the Diseases op Women and Infants. A monthly of 64 octavo pages, very handsomely printed. Subscription, Three Dollars per annum Single Numbers. 25 cents each. With the January number will terminae Vol. VII. of the Obstetrical Journal. The first No. of Vol. VIII. will be issued about Feb. 1st; the "American Supplement"' of 16 pages per No. will be discontinued, and the periodical will thenceforth consist of 64 pages per number, at the exceedingly low price of Three Dollars per annum, free of postage. For this trifling ) um the subscriber will then obtain more than 750 pages per annum, containing an extent and variety of information which may be estimated from the fact that Vol. VI. of the " Obstetri- cal Journal" contains in Original Communications . . 44 Articles Hospital Practice .... 4 " General Correspondence . . 5 " Reviews of Books 9 " Proceedings of Societies . . 101 " 241 In Monthly Summary, Obstetric 73 " and that it numbers among it? contributors the distinguished names of L>mbb Atthill, J. II. Aveling, Robert Barnes, J. Henry Bennet, Nathan Bozeman, Thomas Chambers, Fleet- wood Churchill, Charles Clay, John Clay, J. Matthews Duncan, Arthur Farre, Robert Greenhalgh, W. M. Graily Hewitt, J. Braxton Hicks, William Leishm\n, Angus Mac donald, Alfred Meadows, Alex. Simpson, J. G. Swayne, Lawson Tait, Edward J. Tilt, E. H. Trenholme, T. Spencer Wells, Arthur Wigglesworth, and many other distin- guished practitioners Under such nuspices it has amply fulfilled its object of presenting to the physician all that is new and interesting in the rapid development of obstetrical and gynae- cological science. As a very large increase in the subscription list is anticipated under this reduction in price, gentlemen who propose to subscribe, and subscribers intending to renew their subscriptions, are recommended to lose no time in making their remittances, as the limited number printed may at any time be exhausted. This is certainly a very excellent journal. It gives us the be*t obstetrical literature from across the water.— Ind. Journ. of Med., Nov. 1874. We cannot withhold the express'on of the admi- ration this elegant journal excites. — Western Lancet, .March, 1S75. Henry C. Lea's Publications — {Midwifery, Surgery). 25 TEISHMAN (WILLIAM), M.D., "^ Regius Professor of Midwifery in the University of Glasgow. &c. A SYSTEM OF MIDWIFERY, INCLUDING THE DISEASES OF PREGNANCY AND THE PUERPERAL STATE. Third American edition, revised by the Author, -with additions by John S. Parry, M.D., Obstetrician to the Philadelphia Hospital, &c. In one large and very handsome octavo volume, of 733 pages, with over two hundred illustrations. Cloth, $4 50; leather, $5 50. {Just Ready.) Author's Preface. The publication of a third American edition of his work affords the author an opportunity, of which he gladly avails himself, of expressing the great gratification which he has experienced in the generous appreciation of his labors by his colleagues in America. Of the many criticisms which have appeared, none have been more valuable or useful to him than those of the Ameri- can medical press. The methods of teaching on his side of the A lantic being somewhat differ- ent, it has been found necessary to make some modifications in order to make this and the previous edition quite intelligible. This has been ably done by Dr. John S. Parry ; and, without committirg himself to all that has been added, the author has much pleasure in acknowledging the courtesy and ability with which this task has been performed. In the preparation of the present edition, such alterations and modifications have been made as the progress of Obstetri- cal Science seems to require. The large circulation which the work has attained, has, indeed, imposed this duty upon the author as one to be conscientiously and carefully discharged, and in its performance he has been under many obligations to Dr. James Finlayson, which he has much pleasure in acknowledging. P ARRY (JOHN S.), M.D., Obstetrician to the Philadelphia Hospital, Vice-Prest of the O^stet. S ciety of Philadelphia. EXTRA-UTERINE PREGNANCY: ITS CLINICAL HISTORY, DIAGNOSIS, PROGNOSIS, AND TREATMENT. In one handsome octavo volume. Cloth, $2 50. {Lately Issued.) JJODGE [HUGH L.), M.D., Emeritus Professor of Midwifery, Ac, in the University of Pennsylvania, Ac. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Illns- trated with large lithographic plates containing one hundred and fifty-nine figures from original photographs, and with numerous wood-cuts. In one large and beautifully printed quarto volume of 550 double-columned pages, strongly bound in cloth. $14. The work of Dr. Hodge is something more than fact or principle is left unstated or unexplained. — Am Med Times, ^ept. 3, 1S64 It is very large, profusely and elegantly illnstrat ed, aad is fitted to take its place near the works of great obstetricians. Of the American works on the subject ifcie decidedly the best. — Edinb. Med. Jour., a simple presentation of hit particular views in the de -artment of Obstetrics ; it is something more than an >rdinarytreatise on midwifery; it is, in fact, a cyclopaedia of midwifery. He has aimed to em- body in a -.ingle volume the whole science and art of Obstetrics, in elaborate text is combined with ac- curate and varied pictorial illustrations, so that no Dec. 1S64. #*# Specimens of the plates and letter-press will be forwarded to any address, free by mail, on receipt of six cents in postage stamps. VT1MSON (LEWIS A), A.M., M.D., f^ Surgeon to the Presbyterian Hospital. A MANUAL OF OPERATIVE SURGERY. In one very handsome royal 12mo. volume of about 500 pages, with 332 illustrations ; cloth, $2 50. (Now Ready ) The work before us is a well printed, profu>ely performing them. The work is handsomely illus- illustrated manual of over four hundred and seventy ' trated, and the de< criptions are clear and well'drawn. pages. The novice, by a perusal of the work, will , It is a clever and useful volume; every student gain a good idea of the general domain of operative ! should possess one. The preparation of this work surgery, while the practical surgeon has presented does away with the necessity of pondering over to him within a very concise and intelligible form i larger works on surgery for descriptions of opera- the latest and most approved selections of operative I tions, as it presents in a nut-shell just whatis wanted procedure. Theprec : sion ar d conciseness with which ; by the surgeon without an elaborate search to find the different operations are described enable the : it— Md. Med Journal, Aug. 1S7S author to compress an immense amount of practical , The aathor - s conciseness and the repleteness of RStVViV-7 compass.-A. T. Meatcal \ the work with valuable illustrations entitle it ,o be decora, Aug. 6, i».& j classed with the tex t-books for students of operative This volume is devoted entirely to operative sur- : surgery, and as one of reference to the practitioner, gery, and is intended to familiarize the student with —Cincinnati Lancet and Clinic, July 27, 1S78. the details of operations and the different modes of] SKKT'S OPEKATIYE SURGERY. In 1 vol. 8vo. cl., of 650 pages ; withabout lOOwood-cuts. $3 25 COOPERS LECTURES ON THE PRINCIPLES AND Practice or Surgery. In lvol. Svo.cl'h, 750p. $2. GIBSON'S INSTITUTES AND PRACTICE OF SUR- GERY. Eighth edit'n, improved and altered. With thirty-four plates. In two handsome octavo vol- umes, about 1000 pp.. leather, raised bandi *P 50. THE PRINCIPLES AND PRACTICE OF SURGERY. By William Pirrib.F.R S E., Profes'r of Surgery in the University of Aberdeen. Edited by Jofh Neill, M.D., Professor of Surgery in the Penna. Medical College, Surg' n to the Pennsylvania Hos- pital, &c. In one very handsome octavo vol. of 780 pages, with 316 illustrations, cloth, $3 75. MILLER'S PRINCIPLES OF SURGERY. Fourth Ame- rican, from the Third Edinburgh Edition. In one large 8vo. vol. of 700 pages, with 340 illustrations, cloth, $3 75. MILLER'S PRACTICE OF SURGERY. Fourth Ame- rican, from the last Edinburgh Edition. Revisedbr the American editor. In one large 8vo. vol. of nearly 700 pages, with 364 illustrations: cht v , $3 7f . 26 Henry C. Lea's Publications — (Surgery). (1ROSS {SAMUEL D.), M.D., ^■A Professor of Surgery in the Jeferson Medical College of Philadelphia. SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, and Operative. Illustrated by upwards of Fourteen Hundred Engravings. Fifth edition carefully revised, and improved. In two large and beautifully printed imperial octavo vol- umes of about 2300 pp., strongly bound in leather, with raised bands, $15. (Just Issued.) The continued favor, shown by the exhaustion of successive large editions of this great work, proves that it has successfully supplied a want felt by American practitioners and students. In the present revision no pains have been spared by the author to bring it in every respect fully up tc the day. To effect this a large part of the work has been rewritten, and the whole en- arged by nearly one-fourth, notwithstanding which the price has been kept at its former very moderate rate. By the use of a close, though very legible type, an unusually large amount of matter is sondensed in its pages, the two volumes containing as much as four or five ordinary octavos. This, combined with the most careful mechanical execution, and its very durable bind- ing renders, it one of the cheapest works accessible to the profession. Every subject properly belonging to the iomain of surgery is treated in detail, so that the student who possesses this work may be said to have in it a surgical library. edition of Gross's " Surgery," will confirm his title of •' Primus inter Pares." It is learned, scbolar-like, me- thodical, precise, and exhaustive. We scarcely think any living man could write so complete and faultless a treatise, or comprehend more solid, instructive matter in the given number of pages. The labor must have been immense, and the work gives evidence of great We have now brought our task to a conclusion, and have seldom read a work wilh the practical value of which we have been moreimpressed. Every chapter is so concisely put together, that the busy practitioner, when in difficulty, can at once find the information he requires. His work, on the contrary, is cosmopolitan, the surgery of the world being fully represented in it. The work, in fact, is so historically unprejudiced, and so eminently practical, that it is almost a false compli- ment to say thatwe believe it to be destined to occupy a foremost place as a work of reference, while a system of surgery like the present system of surgery is the practice of surgeons. The printingand binding of the work is unexceptionable; indeed.it contrasts, in the latter respect, remarkably with English medical and surgical cloth-bound publications, which are generally so wretchedly stitched as to require re-binding before they are any time in use. — Dub. Joum. of Med. Sci.. March, 1874. Dr. Gross's Surgery, a great work, has become still greater, both in size and merit, in its most recent form. The difference in actual number of pages is not more than 13u, but. the size of the page having been in- creased to what we believe is technically termed '-ele- phant."there has been room for considerable additions, which, together with the alterations, are improve- ments. — Lond. Lancet, Nov. 16, 1872. It combines, as perfectly as possible, the qualities of a text-book and work of reference. We think this last powers of mind, and the highest order of intellectual discipline and methodical disposition, and arrangement of acquired knowledge and personal experience. — N.Y. Med. Joum., Feb. 1873. As a whole, we regard the work as the representative "System of Surgery" in the English language. — St. Louis Medical and Surg. Joum., Oct. 1872, The two magnificent volumes before us afford a very complete view of the surgical knowledge of the day. Some years ago we had the pleasure of presenting the first edition of Gross's Surgery to the profession as a work of unrivalled excellence; and now we have the result of years of experience, labor, and study, all con- densed upon the great work before us. And to students or practitioners desirousof enriching theirlibrary with a treasure of reference, we can simply commend the purchase of these two volumes of immense research — Cincinnati Lancet and Observer, Sept. 1872. A complete system of surgery — not a mere text-book of operations, but a scientific account uf surgical theory and practice in all its departments. — Brit, and For. Med. Chir. Rev., Jan. 1873. B Y THE SAME AUTHOR. A PRACTICAL TREATISE ON THE DISEASES, INJURIES, and Malformations of the Urinary Bladder, the Prostate Gland, and the Urethra. Third Edition, thoroughly Revised and Condensed, by Samuel W. Gross, M.D., Surgeon to the Philadelphia Hospital. In one handsome octavo volume of 574 pages, with 170 illus- trations : cloth, $4 50. (Just Iss7ied.) eases of the urinary organs. — Atlanta Med. Joum., Oct 1876. It is with pleasure we now again take up this old work in a decidedly new dress. Indeed, it must be re- garded as a new book in very many of its parts. The chapters on ''Diseases of the Bladder," "Prostate Body," and "Lithotomy," are splendid specimens of descriptive writing; while the chapter on •■ Stricture" is one of the most concise and clear that we have ever read. — New York Med. Joum., Nov. 1876. For reference and general information, the physician or surgeon can find no work that meets their necessities more thoroughly than this, a revised edition of an ex- cellent treatise, and no medical library should be with- out it. Replete with handsome illustrations and good ideas, it has the unusual advantage of being easily comprehended, by the reasonable and practical manner in which the various subjects are systematized and arranged We heartily recommend it to the profession as a valuable addition to the important literature of dis- T>Y THE SAME AUTHOR. A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR-PASSAGES. In 1 vol. 8vo., with illustrations, pp. 468, cloth, $2 75. D RUITT [ROBERT), M.R.C.S., frc. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new and revised American, from the eighth enlarged and improved London edition. Illue- trated with four hundred and thirty -two wood engravings. In one very handsome octavo volume, of nearly 700 large and closely printed pages, cloth, $4 00 ; leather, $5 00. practice of surgery are treated, and so clearly and perspicuously, as to elncidateeveryimporUnttopu . We nave examined thebook most thoroughly, and can say chat this success is well merited. Hie book moreover, possesses the inestimable advantages of aaving the subjects perfectly well arranged and classified and of being written in a style at once clear ind succinct. — Am. Journal of Med. Scieneee. All that the surgical student or practitioner could desire. — Dublin Quarterly Journal. It is a most admirable book. We do not know when we have examined one with more pleasure. — Boston Med. and Surg. Journal. In Mr. Druitt's book, though containingonly some even hundred pages, both the principles and the Henry C. Lea's Publications — (Surgery). 21 A SHHURST (JOHN, Jr.), M.D., -^-*- Prof, of Clinical Surgery, Univ of Pa., Surgeon to the Episcopal Hospital, Philadelphia THE PRINCIPLES AND PRACTICE OF SURGERY. Second edition, enlarged and revised. In one very large and handsome octavo volume of over 1000 pages, with 542 illustrations. Cloth, $6 ; leather, $7. (Just Ready.) Conscientiousness and thoroughness are two very marked trails of character in the author of this book. Out of these traits largely has grown the success of his mental fruit in the past, and the pre- sent offer seems in no wise an exception to what has gone before. The general arrangement of the vol- ume is the same as in the first edition, but every part has been carefully revised, and much new matter added.— Phila. Med. Times, Feb. 1, 1879. We have previously spoken of Dr. Ashhurst's work in terms of praise. We wish to reiterate those terms here, and to add that no more satisfactory representation of modern surgery has yet fallen from the press. In point of judicial fairness, of power of condensation, of accuracy and conciseness of expression and thoroughly good English, Prof. Ashhurst has no superior among i he surgical writers in America. — Am. Practitioner, Jan. 1S79. The attempt to embrace in a volume of 1000 pages the whole field of surgery, general and special, would be a hopeless ta>k unless through the most tireless industry in collating and arranging, and the wisest judgment in condensing and excluding. These facilities have been abundantly employed by the author, and he has given us a most excellent treatise, brought up by the revision for the second edition to the latest date. Of course this book is not designed for specialists, but as a course of general surgical knowledge and for general practitioners, and as a text-book for students it is not surpassed by any that has yet appeared, whether of home or foreign authorship. — N. Carolina Med. Journal, Jan. 1879. Ashhurst's Surgery is too well known in this country to require special commendation from us. This, its second edition, enlarged and thoroughly revised, brings it nearer our idea of a model text- book than any recently published treatise. Though numerous additions have been made, the size of the work is not materially increased The main trouble of text-books of modern times is that they are too cumbersome. The student needs a book which will furnish him the most information in the shortest time. In every respect this work of Ashhurst is the model text-book- full, comprehensive and com- pact.— Nashville Jour, of Med. and Surg., Jan. '79. The favorable reception of the first edition is a guarantee of the popularity of this edition, which is fresh from the editor's hands with many enlarge- ments and improvements. The author of this work is deservedly popular as an editor and writer, and his contributions to the literature of surgery have gained for him wide reputation. The volum'e now offered the profession will add new laurels to those already won by previous contributions. We can only add that the work is well arranged, filled with practical matter, and contains in brief and clear language all that is necessary to be learned by the student of surgery whilst in attendance upon lec- tures, or the general practitioner in his daily routine practice. — Md. Med. Journal, Jan. 1S79. The fact that this work has reached a second edi- tion so very soon after the publication of the first one, speaks more highly of its merits than anything we might say in the way of commendation. It seems to have immediately gained the favor of stu- dents and physicians.— Cincin. Med. News, Jan. '79. J>RYANT (THOMAS), F.R.C.S., •U Surgeon to Guy's Hospital. THE PRACTICE OF SURGERY. Second American, from the Sec- ond and Revised English Edition. With Six Hundred and Seventy two Engravings on Wood. In one large and very handsome imperial octavo volume of over 1000 large and closely printed pages. Cloth, $6 ; leather, $7. (Just Ready ) This work h;is enjoyed the advantage of two thorough revisions at the hand of the author since the appearance of the first American edition, resulting in a very notable enlargement of size and improvement of matter. In England this has led to the division of the work into two volumes which are here comprised in one, the size being increased to a large imperial octavo, printed on a condensed but clear type. The series of illustrations has undergone a like revision, and will be found correspondingly impro'. ed. The marked success of the work on both sides of the Atlantic shows that the author has suc- ceeded in the effort to give to student and practitioner a sou:id and trustworthy guide in the practice of Surgery; while the simultaneous appearance of the present edition in England and in this country affords to the American reader the benefit of the most recent advances made abroad in surgical science. Another edition of this manual having been called for, the author has availed himself of the opportunity to make no few alterations in the substance as wed as in the arrangement of the work, and, with a view to its improvement, has recast the materials and re- vised the whole. We ourselven are of the opinion that there is no better work on surgery extant Cincinnati Med. News, Match, 1S79 Bryaut's Surgery has been favorablyreceived from the first, and evidently grows in the esteem of the profession w.th each succeeding edition. Iu glanc- ing over the volume before us we fiud proof in almost every chapter of the thorough revision which the work has undergone, m*ny parts having been cut out and replaced by matter entirely fresh.— N Y ourn., April, 1879. Welcome as the new edition is, and as much as it is entitled to commendation, yet its appearance at this time is, in a certain sense, a matter of regret as it will be in competition with another work, lately issued from the same press. But, the difficult ta-k of British surgery it is perhaps without an equal, and I UrlZu^/ J l^TJ* l .o the relative merits of will doubtless always be a favorite text-book* ith the! ^^"t^S^L^^L^l* 1 *?^^ but pre- student and practitioner. — N. 1\ Med. Record, March 22, 1879. There are so many text-books of surgery, so many written by skilled and distinguished hands, that to ob tain the honor of a third edition in England is no light praise. Mr. Bryant merits this, by clearness of style, and good judgment in selecting the operations .he re- commends, in his new editions be goes carefully over the old grounds, in light of later research. On these and many allied points, Mr. Bryant is a calm and un- partisan observer, and his book throughout has the great merit of maintaining the true scientific, judicial tone of mind.— Med. and Surg. Peporttr, March 22, 1879. The work before us is the American reprint of the last London edition, and has the advantage over the latter in being of more convenient size, and in being compressed into one volume. The author has rewrit- i Med ten the greater part of the work, and has succeeded, in the amount of new matter added, in making it mark- edly distinctive from previous editions. A few extra pages have been added, and also a few new illustrations introduced. The publishers have presented the work in a creditable style. As a concise and practical manual j ^i.Ya.ui auu flsuuuiM we win not attempt but pre- dict that, considering the high excellence of both many others will likewise be rorced to hesitate lonz in making choice between them.— Cincinnati Lan. cet and Clinic, March 22, 1879. 28 Henry C. Lea's Publications — (Surgery). EJ RICES EN (JOHN E.), Professor of Surgery in University College, London, etc. THE SCIENCE AND ART OF SURGERY; being a Treatise on Sur- gical Injuries, Diseases, and Operations. Carefully revised by the author from the Seventh and enlarged English Edition. Illustrated by eight hundred and sixty two en- gravings on wood. In two large and beautiful octavo volumes of nearly 2000 pages: cloth, $8 50 ; leather, $10 50. {Now Ready.) In revising this standard work the authorhas spared no pains to render it worthy of a continu- ance of the very marked favor which it has so long enjoyed, by bringing it thoroughly on a level with the advance in the science and art of surgery made since the appearance of the last edition. To accomplish this has required the addition of about two hundred page? of text, while the illustrations have undergone a marked improvement A hundred and fifty additional wood-cuts have been inserted, while about fifty other new ones have been substituted for figures which were not deemed satisfactory. In its enlarged and improved form it is therefore pre- sented with the confident anticipation that it will maintain its position in the front rank of text-books for the student, and of works of reference for the practitioner, while its exceedingly moderate price places it within the reach of all. The seventh edition is before the world as the last word of surgical science. There may be monographs which excel it upon certain points, but as a con- spectus upon surgical principles and practice it is unrivalled. It will well reward practitioners to read it, for it has been a peculiar province of Mr. Erichsen to demonstrate the absolute interdepend- ence of medical and surgical science We need scarcely add, in conclusion, that we heartily com- mend the work to students that they may be grounded in a sound faith, and to praccitioners as an invaluable guide as the bedaide. — Am Practi- tioner, April, 1878. It is no idle compliment to say that this is the best edition Mr. Erichsen has ever produced of his well- known book. Besides inheriting the virtues of is predecessors, it possesses excellences quite its own. Having stated that Mr. Erichsen his incorporated into this edition every recent improvement in the science and art of surgery, it would be a supereroga- tion to give a detailed criticism. In short, we un- hesitatingly aver that we know of no other single work where the student and practitioner can gain at once so clear an insight into the principles of surgery, and so complete a knowledge of the exigencies of surgical practice. — London Lancet, Feb. 1-1, 1878 For the past twenty years Erichsen's Surgery has maintained its place as the leading text- book, not only in this country, but in Great Britain. That it is able to hold its ground, is abundantly proven by the tho- roughness with which the present edition has bean revised, and by the large amount of valuable mate- rial that has been added. Aside from this, one hun- dred and fifty new illustrations have been inserted, including quite a number of microscopical appear- ances of patholjgical processes. So marked is this change for the better, that the work almost appears as an entirely new one. — Med. Record, Feb. 23,1878 Of the many treatises on Surgery which it has* been our task to study, or our pleasure to read, there is none which in all points has satisfied us so well as the classic treatise of Erichsen. His polished, clear style, his free- dom from prejudice and hobbies, his unsurpassed grasp of his subject, and vast clinical experience, qualify him admirably to write a model text-book. When we wish, at the least cost of time, to learn the most of a topic in surgery, we turn, by preference, to his work. It is a pleasure, therefore, to see tliat the appreciation of it is general, and has led to the appearance of another edi- tion. — Med. and Surg. Reporter, Feb. 2, 1878. Notwithstanding the increase in size, we observe that much old matter has been omitted. The entire work has been thoroughly written up, and not merely amend- ed by a few extra chapters A great improvement has been made in the illustrations. One hundred and fifty new ones have been added, and many of the old ones have been redrawn The author highly appreciates the favor wiih which his work has been received by Ameri- can surgeons, and has endeavored to render bis latest edition more than ever worthy of their approval. That he has succeeded admirably, must, we think, be the general opinion. We heartily recommend the book to both student and practitioner. — N. T.Med. Journal, Feb. 1878. Erichsen has stood so prominently forward for years as a writer on Surgery, that his reputation is world wide, and his name is as familiar to the med- ical student as to the accomplished and experienced surgeon The work is not a reprint of former edi tions, but has in many places been entirely rewrit- ten. Eecent improvements in surgery have not es- caped his notice, various new operations have been thoroughly analyzed, and their merits thoroughly diocussed. One hundred and fifty new wood-cuts add to the value of this work. — N. O. Med. and Surg. Journal, March, 187 S. TIOLMES {TIMOTHY), M.D., J-J- Surgeon to St. George's Hospital, London. SURGERY, ITS PRINCIPLES AND PRACTICE. In one hand- some octavo volume of nearly 1000 pages, with 411 illustrations. Cloth, $6 ; leather, $7. (Just Isszied.) This is a work which has been looked for on both sides ofthe Atlantic with much interest. Mr. Holmes is a surgeon of large and varied experience, and one of the best known, and perhaps the most biilliant writer upon surgical subjects in England. It is a book for students — and an admirable one — and for the busy general practitioner. It will give a student all the knowledge needed to pass a rigid examina- tion. The book fairly justifies the high expectations that were formed of it. Its style is clear and forcible, even brilliant at times, and the conciseness needed to bringit withinitsproperlimitshas not impairea its force and distinctness. — N. Y. Med. Record, April 14, 1P76. It will be found a most excellent epitome of sur- gery by the general practitioner who has not the time togtveattentiou to more minute and extended works and to the medical student. In fact, we know of no one we can more cordially recommend. The author has succeeded well in giving a plain and practical account of each surgical injury and dis- ease, and of the treatment which is most com- monly advisable. It will no doubt become a popu- lar workin the profession, and especially as a text- book. — Cincinnati Med. News, April, 1S76. ASHTONONTHE DISEASES, INJURIES, and MAL- FORMATIONS OF THE RECTUM AND ANUS: with remarks on Habitual Constipation. Second American, from the fourth and enlarged London Edition. With illustrations. In one 8vo vol. ot 28/ pages, cloth, $3 25. iARGENT ON BANDAGING AND OTHER OPERA- TIONS OF MINOR SURGERY. New edition, with an additional chapter on Military Surgery. One 12mo. vol. ol 3SSpag3s wit h 18 i wood-cuts. Cloth, $175. Henry C. Lea's Publications — {Ophthalmology). 29 CJAMILTON {FRANK H.), 31. D., LA. Professor of Fractures and Dislocations, Ac, in Bellevue Hosp. Med. College, New York. A PRACTICAL TREATISE ON FRACTURES AND DISLOCA- TIONS. Fifth edition, revised and improved. In one large and handsome octavo volurre of nearly 800 pages, with 344 illustrations. Cloth, $5 75 : leather. $6 75. {Lately Issued.) This work is well known, abroad as well as at home, asthe highest authority on its important subject — an authority recognized in the courts as well as in the schools and in practice — and again manifested, not only by the demand for a fifth edition, but by arrangements now in pro- gress for the speedy appearance of a translation in Germany. The repeated revisions which the author has thus had the opportunity of making have enabled him to give the most careful consid- eration to every portion of the volume, and he has sedulously endeavored in the present issue, to perfect the work by the aid of his own enlarged experience, and to incorporate in it whatever of value has been added in this department since the issue of the fourth edition. It will there- fore be found considerably improved in matter, while the most careful attention has been paid to the typographical execution, and the volume is presented to the profession in the confident hope that it will more than maintain its very distinguished reputation. There is no better work on the subject in existence than that of Dr. Hamilton. It should be in the posses- sion of every general practitioner and surgeon. — The Am. Journ. of Obstetrics. Feb. 1876. The value of a work like this to the practical physi- cian and surgeon can hardly be over-estimated, and the necessity of having such a book revised to the latest dates, not mer^l yon account of tbepracticalimportance of its teachings, but also by reason of the medico-legal bearings of the cases of whichit treats, and which have recently been the subjectof usefulpapers by Dr. Hamil- ton and others, is sufficiently obvious to every one. The present volume seems to amply fill all the requisites. We can safely recommend it as the best of its kind in the English language, and not excelled in any other. Journ. of Xtrvous and Mental Disease, Jan 1S76. B ROWNE {EDGAR A.), Surgeon to the Liverpool Eye and Ear Infirmary, and to the Dispensary for Skin Distases. HOW TO USE THE OPHTHALMOSCOPE. Being Elementary In- structionsin Ophthalmoscopy, arranged for the Use of Students. With thirty-five illustra- tions. In one small volume royal l2mo. of 120 pages : cloth, $1. (Now Ready.) QARTER [R. BRUDENELL), F.R.CS., Ophthalmic Surgeon to St. George s Hospital, etc. A PRACTICAL TREATISE ON DISEASES OF THE EYE. Edit- ed, with test-types and Additions, by John Green, M.D. (of St. Louis, Mo.). In one handsome octavo volume of about 500 pages, and 124 illustrations. Cloth, $3 75. (Just Issued.) It would be difficult for Mr. Carter to write an unin- | manner, easy of comprehension, and hence the more Btructive book, and impossible for him to write an un- valuable. We would especially commend, however, as interesting one. Even on subjects with which he is not ; worthy of high praise, the manner in which the thera- bound to be familiar. hecandi>course with a rare degree | peutics of di.-ease of the e} e is elaborated, for here the of clearness and effect. Our readers will therefore not j author is particularly clear and practical, where other be surprised to learn that a work by him on the Diseases writers are unfortunately too often deficient. The final of the Eye makes a very valuable addition to ophthal- chapter is devoted to a discussion of the uses and selec- mic literature. . . . The book will remain one useful tion ofspectacles, and is admirably compact, plain, and alike to the general and thespecial practitioner. — Lon- useful, especially the paragraphs on the treatment of don Lancet, Oct. 30,1875. presbyopia and myopia. In conclusion, our thanks are _.. ....•, ... , ' '- , due the author for many useful hints in tbe trreat sub- It is with great pleasure that we can endorse the work j ject f ophthalmic surgery and therapeutics, afield as a most valuable contribution to practical ophthal- , where of late „ we g]eaT] but ft few * M ' f i0und mology. Mr. Carter neverdeviates from the end he has wheat f rom a mass of chaff — Aew; York Medical Record, in view, and presents the subjectin a clear and coucist , Q ct 23 1S75. y^ELLS {J.SOELBERG), Professor of Ophthalmology in King's College Hospital, Ac. A TREATISE ON DISEASES OF THE EYE. Third American, from the Fourth and Revised London Edition, with additions ; illustrated with numerous engravings on wood, and six colored plates. Together with selections from the Test-types of Jaeger and Snellen. In one large and very handsome octavo volume. (Preparing.) fJETTLESHIP [EDWARD), F.R.C.S., -*- * Ophthalmic Surg, and Led. on Ophth. Surg at St. Thomas' Hospital, Lor.don. MANUAL OF OPHTHALMIC MEDICINE. In one royal 12ino. volume of about 350 pages. (Shortly.) TAURENCE {JOHN Z.), F.R.CS., Editor of the Ophthalmic Review, &e. A HANDY-BOOK OF OPHTHALMIC SURGERY, for the use of Practitioners. Second Edition, revised and enlarged. With numerous illustrations. In one very handsome octavo volume, cloth, $2 75. A WSON {GEORGE), F.R.CS. Engl, Assistant Surgeon to the Royal London Ophthalmic Hospital, Moorfields , &e . INJURIES OF THE EYE, ORBIT, AND EYELIDS: their Imme- diate and Remote Effects. With about one hundred illustrations. In une very hand- some octavo volume, cloth, $3 50. 30 Henry C. Lea's Publications — {Medical Jurisprudence), ftURNETT {CHARLES H.), M.A., M.D., -*-' Aural Surg, to the Presb. Hosp., Surgeon-in-charge of the Infir . for His. of the Ear, Phila. THE EAR, ITS ANATOMY, PHYSIOLOGY, AND DISEASES. A Practical Treatise for the Use of Medical Students and Practitioners. In one hand- some octavo volume of 615 pages, with eighty-seven illustrations : cloth, $4 50 ; leather, $5 50. {Just Ready.) . Recent progress in the investigation of the structures of the ear, and advances made in the modes of treating its diseases, wouldseem to render desirable a new work in which all the re- sources of the most advanced science should dp placed at the disposal of the practitioner. This it has been the aim of Dr. Burnett to accomplish, and the advantages which he has enjoyed in the special study of the subject are a guarantee that the result of his labors will prove of service to the profession at large, as well as to the specialist in this department. Foremost among the numerous recent contribu- tions to aural literature -will be ranked this work of Dr. Burnett. It is impossible to do justice to this volume of over 600 pages in a necessarily brief notice. It must suffice to add that the book is pro- fusely and accurately illustrated, the references are conscientiously acknowledged, while the result has been to produce a treatise which will henceforth rank with the classic writings of Wilde and Von Tidlsch.— -The Lond. Practitioner, May, 1879. On account of the great advances which have been made of late years in otology, and of the increased interest manifested in it, the medical profession will welcome this new work, which presents clearly and concisely its present aspect, whilst clearly indi- cating the direction in which further researches can be most profitably carried on. Dr. Burnett from his own matured experience, and availing himself of the observations and discoveries of others, has pro- duced a work, which as a text-book, stands facile princeps in our language. We had marked several passages as well worthy of quotation and the atten- tion of the general practitioner, but their number and the space at our command forbid. Perhaps it is bet- ter, as the book ought to be in the hands of every medical student, and its study will well repay the busy practitioner in the pleasure he will derive from the agreeable style in which many otherwise dry and mostly unknown subjects are treated. To the specialist the work is of the highest value, and his sense of gratitude to Dr. Burneit will, we hope, be proportionate to the amount of benefit lie can obtain from the careful study of the book, and a constant reference to its trustworthy pages. — Edinbu gh Med. Jour., Aug. 1878. The book is designed especially for the use of stu- dents and general practitioners, and places at their disposal much valuable material. Such a book as the present one, we think, has long been needed, and we may congratulate the author on his success in filling the gap. Both student and practitioner can study the work with a great deal of benefit. It is profusely and beautifully illustrated.— N. Y. Hos~ pital Gazette, Oct 15, 1S77. Dr. Burnett is to be commended for having written the best book on .the subject in the English language, and especially for the care and attention he has given to the scientific side of the subject. — N. Y. Med. Journ., Dec. 1S77. BAYLOR [ALFRED S.),M.D., Lecturer on Med. Jurisp. and Chemistry in Quy'e Hospital. POISONS IN RELATION TO MEDICAL JURISPRUDENCE AND MEDICINE. Third American, from the Third and Revised English Edition. In one large octavo volume of 850 pages ; cloth, $5 50 ; leather, $6 50. {Just Issued.) The present is based upon the two previous edi- tions ; "butthecompleterevision rendered necessary by time has converted it into a new work." This statement from the preface contains all that it is de- sired to know in reference to the new edition. The works of this author are already in the library of every physician who is liable to be called upon for medico-legal testimony (and whatoneis not?), sothat all that is required to be known about the present book is that the author has kept it abreast with the times. What makes it now, as always, especially valuable to the practitioner is its conciseness and practical character, only those poisonous substances being described which give rise to legal investiga- tions.— The Clinic, .Nov. 6, 1875. Dr. Taylor has brought to bear on the compilation of this volume, stores of learning, experience, and practical acquaintance with his subject, probably far beyond what any other living authority on toxicol- ogy could have amassed or utilized. He has fully sustained his reputation by the consummate skill and legal acumen he has displayed in tne arrange- ment of the subject-matter, and the rer-ult is a work on Poisons which will be indispensable to every stu- dent or practitioner in law and medicine. — The Dub' lin Journ. of Med. Set., Oct. 1875. nr THE SAME AUTHOR. MEDICAL JURISPRUDENCE. Seventh American Edition. Edited by John J. Reese, M.D., Prof, of Med. Jurisp. in the Univ. of Penn. In one large octavo volume of nearly 900 pages. Cloth, $5 00; leather, $6 00. {Lately Issued.) To the members of the legal and medical profes- best authority on this specialty in our language. On sion, it is unnecessary to say anything commenda- tory of Taylor's Medical Jurisprudence. We might as well undertake to speak of the merit of Chitty's Pleadings.— Chicago Legal News, Oct. 16, 1873. It is beyond question the most attractive as well as most reliable manual of medical jurisprudence published in the English language.— Am. Journal of Syphilography, Oct. 1873. It is altogether superfluousfor us to offer anything in behalf of a work on medicaljurisprudence by an author who isalmost universally esteemed tobe the thispoint, however, we will&ay that wecousider Dr. Taylor to be the safest medico-legal authority to fol- low, in general, with which we areacqnaintedin any language. — Va Clin. Record. Nov. 1873. This last edition of the Manual is probably the best of all, as it contains more material and is w orked up to the latest views of the author as expressed iu the last edition of the Principles. Dr. Keese, the editor of the Manual, has done everything to make his workacceptable to his medical countrymen. — N. Y Med. Record, Jan. 15, 1874. T>Y THE SAME AUTHOR. THE PRINCIPLES AND PRACTICE OF MEDICAL JURISPRU- DENCE. Second Edition, Revised, with numerous Illustrations. In two large octavo volumes, cloth, $10 00 ; leather, $12 00 This great work is now recognized in England as the fullest and most authoritative treatise on every department of its important subject. In laying it, in its improved form, before the Amer- ican profession, the publisher trusts that itwill assume the same position in this country. Henry C. Lea's Publications — (Miscellaneous). 31 WHOMPSON [SIR HENRY), •*■ Surgeon and Professor of Clinical Surgery to University College Hospital . LECTURES ON DISEASES OF THE URINARY ORGANS. With illustrations on wood. Second American from the Third English Edition, octavo volume. Cloth, $2 25. (Just Issued.) In one neat JDY THE SAME AUTHOR. ON THE PATHOLOGY AND TREATMENT OF STRICTURE OF THE URETHRA AND URINARY FISTULA. With plates and wood-cuts. From the third and revised English edition. In one very handsome octavo volume, cloth, $3 50. (Lately Published.) ROBERTS {WILLIAM), M.D., -*-*' Lecturer on Medicine in the Manchester School of Medicine, etc. A PRACTICAL TREATISE ON URINARY AND RENAL DIS- EASES, including Urinary Deposits. Illustrated by numerous cases and engravings. Third American, from the ThirdRevised and Enlarged London Edition. In one largt and handsome octavo volume of over 600 pages. (Shortly.) T UKE {DANIEL HACK), M.D., Joint author of " The Manual of Psychological Medicine,''' 1 &c. ILLUSTRATIONS OF THE INFLUENCE OF THE MIND UPON THE BODY IN HEALTH AND DISEASE. Designed to illustrate the Action of the Imagination. In one handsome octavo volume of 416 pages, cloth, $3 25. (Lately Isszied.) jyLANDFORD (G. FIELDING), 31. D., F.R.C.P., JLJ Lecturer on Psychological Medicine at the School of St. George's Hospital, &c. INSANITY AND ITS TREATMENT: Lectures on the Treatment, Medical and Legal, of Insane Patients. With a Summary of the Laws in force in the United States on the Confinement of the Insane. By Isaac Ray, M. D. In one very handsome octavo volume of 471 pages; cloth, $3 25. It satisfies a want which must have been sorely actually seen in practice and the appropriate treat- feltby the busy generalpractitioners of thiscountry. ; rnent for them, we find in Dr. Blaudford's work a Lt takes the form of a manual of clinical description j considerable advance over previous writings on tl of the varions forms of insanity, with a description of the mode of examining persons suspected of in- sanity. We call particular attention to this feature of the book, as givingit a unique value to the gene- ral practitioner. If we pass from theoretical conside- rations to descriptions of the varieties of insanity as subject. His pictures of the various forms of mental disease are so clear and good that no reader can fail to be struck with their superiority to those given in >tdinary manuals in the English language or (so far as our own reading extends jin any other. — London Practitioner, Feb. 1871. EA {HENRY O.). SUPERSTITION AND FORCE: ESSAYS ON THE WAGER OF LAW, THE WAGER OF BATTLE, THE ORDEAL, AND TORTURE. Third Revised and Enlarged Edition. In one handsome royal 12mo. volume of 552 pages. Cloth, $2 50. (Just Ready.) The appearance of a new edition of Mr. Henry C. Lea's "Superstition and Force" is a sign that our highest scholarship is not without honor in its na- tive country. Mr. Lea has met every fresh demand for his wort with a careful revision of it, and the present edition is not only fuller and, if possible, more accurate than either of the preceding, but, from the thorough elaboration is more like a har- monious concert and less like a batcn of studies. — The Nation, Aug. 1, 187S. Many will be tempted to say that this, like the '•Decline and Fall," is one of the uucriticizable books Its facts are innumerable, its deductions simple and inevitable, and its chevaux-dt-frise of references bristling and dense enough to make the keenest, stoutest, and best equipped assailant think twice before advancing. Nor is there anything contro- versial in it to provoke assault. The author is no polemic. Though he obviously feels and thinks strongly, he succeeds in attaining impartiality. Whett er looked on as a picture or a mirror, a work such as this has a lasting value. — LippincotVs Magazine, Oct. 1S78. Mr. Lea's curious historical monographs, of which one of the most important is here reproduced in an enlarged form, have given him an unique position among English and American scholars. Be is dis- tinguished for his recondite and affluent learning, his power of exhaustive historical analysis, the breadth and accuracy of his researches among the rarer sources of knowledge, the gravity and temper- ance of his statements, combined with singular earnestness of conviction, and his warm attachment to the cause of human freedom and intellectual pro- gress.— N. Y. Tribune, Aug. 9, 1878. JDY THE SAME AUTHOR. (Lately Published.) STUDIES IN CHURCH HISTORY— THE RISE OF THE TEM- PORAL POWER— BENEFIT OF CLERGY— EXCOMMUNICATION. In one large royal 12mo. volume of 516 pp.; cloth, $2 75. The story was never told more calmly or with hasapeculiarimportancefortheEnglishstudent.and graater learning or wiser thought. We doubt, indeed if any other study of this field can be compared with this for clearness, accuracy, and power. — Chicago Examiner, Dec. 1870. Mr. Lea's latest work," 8tudiesin Church History," fully sustains the promise of the first. It deals with three subjects— the Temporal Power, Benefit of original books Clergy, and Excommunication, the record of which | is a chapter on Ancient Law likely to be regarded as final. We can hardly pass from our mention of such works as these — with which that on "Sacerdotal Celibacv" should be included — without notinc ♦he literary phenomenon that the head of one of the first American houses is also the writer of some of its most London Athenaum, Jan. 7 1871. 32 Henry C. Lea's Publications. INDEX TO CATALOGUE American Journal of the Medical Sciences Allen's Anatomy ..... Anatomical Atlas, by Smith and Horner Ashton on the Rectum and Anus Attneld's Chemistry .... Ashwellon Diseases of Females A.shhurst's Surgery .... Browne on Ophthalmoscope . Browne on the Throat .... Burnett on the Ear .... Barnes on Diseases of Women Barnes' Midwifery .... Bellamy's Surgical Anatomy Bryant's Practical Surgery Bloxani's Chemistry .... Blandford on Insanity . Basham on Renal Diseases ... Brinton on the Stomach Barlow's Practice oi Medicine . Bowman's (John E.) Practical Chemistry Brunton's Materia Medica and Therepeutics Bristowe's Practice Bumstead on Venereal Bumstead and Cullerier's Atlasof Venereal Carpenter's Human Physiology C lrpenter on the Use and Abuse of Alcohol Cornil and Ranvier .... Carter on the Eye Cleland's Dissector .... Classen's Chemistry .... Clowes' Chemistry .... Century of American Medicine . Chadwick on Diseases of Women Charcot on the Nervous System . Chambers on Diet and Regimen . Christisonand Griffith's Dispensatory Churchill's System of Midwifery Churchill on Puerperal Fever Condie on Diseases of Children . Cooper's (B. B.) Lectures on Surgery Callerier's Atlas of Venereal Diseases Cyclopaedia of Practical Medicine Duncan on Diseases of Women . Dalton's Human Physiology Davis's Clinical Lectures Dewees on Diseases of Females . Druitt's ModemSurgery Dunglison's Medical Dictionary Ellis's Demonstrations in Anatomy Erichsen's System of Surgery Emmet on Diseases of Womeu Farquharson's Therapeutics Foster's Physiology . . Fenwick's Diagnosis Finlayson's Clinical Diagnosis Flint on Respiratory Organs Flint on the Heart Flint's Practice of Medicine. Flint's Essays Flint's Clinical Medicine Flint on Phthisis . Flint on Percussion Fothergill's Handbook ofTreatment Fothergill's Antagonism of Therapeutic Age Fownes's Elementary Chemistry Fox on Diseases of the Skin Fuller on the Lungs, &c. . Green's Pathology and Morbid Anatomy Greene's Medical Chemistry Gibson's Surgery ..... Gluge's Pathological Histology, by Leidy Gray's Anatomy Galloway's Aualysis .... Griffith's (R. E.) Dniversal Formulary Gross on Urinary Organs Gross on Foreign Bodies in Air-Passages G ross's Principles and Practice of Surgery Habershon on the Abdomen . Hamilton on Dislocations and Fractures Hartshorne's Essentials of Medicine . Hartsnorne's Conspectus of the Medical Sciences 5 Hartshorne's Anatomy and Physiology . . 8 Hamilton on Nervous Diseases . . . .18 Heath's Practical Anatomy Hoblyn's Medical Dictionary . nts PAGE . 1 7 7 . 28 . 10 . 23 . 25 . 29 . 19 . 30 PAGE Hodge on Women 21 Hodge's Obstetrics ... ... 25 Holland's Medical Notes and Reflections . . 14 Holmes's Surgery . . . ... 28 Holden's Landmarks ..... 6 Horner's Anatomy and Histology ... 7 Hudson on Fever 19 Hill on Venerea] Diseases 20 Hillier's Handbook of Skin Diseases . . 18 Tones (C. Handfieid) on Nervous Disorders . 18 Kirkes' Physiology 8 Knapp's Chemical Technology . . . 11 Lea's Superstition and Force ... 31 Lea's Studies in Church History . .31 Lee on Syphilis 20 Lincoln on Electro-Therapeutics . . 1$ Leishman's Midwifery ...... 25 La Roche on Yellow Fever 14 La Roche on Pneumonia, &c 19 Laurence and Moon's Ophthalmic Surgery . 29 Lawson on the Eye ... .29 Lehmann'B Physiological Chemistry, 2 vols. . 8 Lehmann's Chemical Physiology ... 8 Ludlow's Manual of Examinations ... 5 Lyons on Fever 19 Medical News and Abstract .... 2 Morris on Skin Diseases 18 Meigs on Puerperal Fever X'2. Miller's Practice of Surgery . . . .25 Miller's Principles of Surgery . . . .25 Montgomery on Pregnancy .... 21 Nettleship's Ophthalmic Medicine . . .29 Neill and Smith's Compendium of Med. Science 5 Obstetrical Journal . ... 24 Parry on Extra-Uterine Pregnancy . . .25 Pavy on Digestion 18 Parrish's Practical Pharmacy . . . - . 11 Pirrie's System of Surgery . . 25 Playfair's Midwifery 24 Quain and Sharpey'B Anatomy, by Leidy . . 7 Reynolds' Practice of Medicine . . . .17 Roberts on Urinary Diseases . . . . .31 Ramsbotham on Parturition . . . .2.3 Remsen's Principles of Chemistry ... 9 Rigby's Midwifery 21 Rodwell's Dictionary of Science .... 5 Stimson's Operative Surgery . . .25 Swayne's Obstetric Aphorisms . . . .21 Seiler on the Throat 19 Sargent's Minor Surgery 28 Sharpey and Quain's Anatomy, by Leidy . . 7 Skey's Operative Surgery 25 Slade on Diphtheria 19 Schafer's Histology 7 Smith (J L.) on Children ... .21 Smith (H. H.) and Horner's Anatomical Atlas . 7 Smith (Edward) on Consumption . . . 19 Smith on Wasting Diseases in Children . . 20 Still6'6 Therapeutics 12 Stille & Maisch's Dispensatory . . . .13 Starges on CMnical Medicine . , . .14 Stokes on Fever 14 Tanner's Manual of Clinical Medicine . . 5 Tanner on Pregnancy 23 Taylor's Medical Jurisprudence . . .30 Taylor's Principles and Practice of Med Jnrisp 30 Taylor on Poisons ... 30 Tuke on the Influence of the Mind . . .31 Thomas on Diseases of Females . . . . 22 Thompson on Urinary Organs . . . .31 Thompson on Stricture 31 Todd on Acute Diseases .... Woodbury's Practice Walshe on the Heart Watson's Practice of Physic Wells on the Eye West on Diseases of Females . . West on Diseases of Children . . . West on Nervous Disorders of Children . Williams on Consumption .... Wilson's Human Anatomy . Wilson's Handbook of Cutaneous Medicine Wb'hler's Organic Chemistry Winckel on Childbed HENRY C. LEA— Philadelphia. 1