MIDWIFERY] 
 
 OR 
 
 PRINCIPLES OF TOKOLOGY AND EMBRYOLOGY. 
 
 ALP. A. L. IKL VELPEAU, 3YC.D. 
 
 ETC. ETC. 
 
 TRANSLATED FROM THE FRENCH BY 
 
 OH. D. MEIGS, M.D. 
 
 Member of the American Philosophical Society ; Lecturer on Midwifery and the 
 Diseases of Women and Children, &c. &c. 
 
 JOHN GRIGG, No. 9, N. FOURTH STREET. 
 1831.
 
 Eastern District of Pennsylvania, to wit : 
 
 Be it remembered, that on the ninth day of February, in the fifty-fifth 
 year of the independence of the United States of America, A.D. 1831, 
 John Grigg, of the said district, has deposited in this office the title 
 of a book, the right whereof he claims as proprietor, in the words 
 following, to wit : 
 
 An Elementary Treatise on Midwifery : or Principles of Tokology 
 and Embryology. By Alf. A. L. M. Velpeau, M.D. &c. &c. Trans- 
 lated from the French by Charles D. Meigs, M.D. Member of the 
 American Philosophical Society; Lecturer on Midwifery and the 
 Diseases of Women and Children, &c. &c. 
 
 In conformity to the act of the congress of the United States, enti- 
 tled, " an act for the encouragement of learning, by securing the 
 copies of maps, charts and books to the authors and proprietors of such 
 copies during the times therein mentioned ;" and also to the act, en- 
 titled, " an act supplementary to an act, entitled, ' an act for the en- 
 couragement of learning, by securing the Copies of maps, charts and 
 books to the authors and proprietors of such copies during the times 
 therein mentioned,' and extending the benefits thereof to the arts oi 
 designing, engraving and etching historical and other prints." 
 
 D. CALDWELL, 
 Clerk of the Eastern District of Pennsylvania. 
 
 Philadelphia . 
 
 Printed by James Kay, Jun. & Co. 
 
 Printer* to the Philadelphia Medical and American Philosophical Societies 
 No. 4, Minor Street.
 
 TO 
 
 THOMAS C. JAMES, M.D. 
 
 PROFESSOR OF MIDWIFERY AND THE DISEASES OF WOMEN AND 
 CHILDREN IN THE UNIVERSITY OF PENNSYLVANIA. 
 
 Respected Sir: 
 
 I take the liberty of addressing the following work to you, 
 not only for the purpose of showing my sense of your high rank 
 and authority in the science and art so ably treated of by M. 
 Velpeau, but also as a testimonial of my gratitude for many 
 acts of kindness received at your hands. 
 
 I was induced to undertake the preparation of it for 
 the American press, by a sincere desire to see so excel- 
 lent a book in the hands of the profession in this country, a 
 book which, as I think, cannot be read without exciting in 
 the mind sentiments of great respect for the science of 
 Tokology, as M. Velpeau denominates it, and a correspond- 
 ing desire to see it advanced in all the relations of its real useful- 
 ness and dignity. I am willing to admit that we have, already, 
 a good book in the American edition of Baudelocque's work, 
 which, however, is but an abridgement. We have no transla- 
 tions of the works of Capuron, Maygrier, Gardien, Duges, 
 Flamant, or those admirable writings of Mesdames Lacha- 
 pelle and Boivin. It did not seem improper, therefore, to
 
 j v DEDICATION. 
 
 add to our stock one of the most enlightened and recent of 
 the French authorities. 
 
 M. Velpeau will readily be admitted, by those who read 
 this volume, to be a man of talents and industry of a high 
 order; an admission, confirmed not merely by reference to his 
 writings, but also by the sentiments of public journalists in 
 his own country, where the competition among men of letters 
 is so great and stirring, that he who attains to distinction, will 
 be, ipso facto, considered as having deserved it. In the re- 
 public of letters in France palmam qui meruitjerat,raaybe 
 regarded as a maxim in daily use and practice. 
 
 The admirable composition of Dr Denman, of which Pro- 
 fessor Francis has lately furnished the public with an improved 
 edition, and the systems of Burns, Ashwell, and Ryan, cannot 
 be regarded as completely filling the chasm which has opened in 
 the last half century between the old limits of the science and 
 its present advanced- station. I ought not in this enumera- 
 tion to omit a reference to the work of Dr Dewees, which, 
 rich as it is in business details, and valuable for the soundness 
 of its practical precepts, may, nevertheless, without the fear of 
 disparagement, be considered less full and complete in regard to 
 its anatomical and physiological features, and the ample collation 
 of good authorities, than the volume which I have the honor 
 to present to you. To say that Dr Dewees's " System of Mid- 
 wifery" is creditable to the science and to himself, is not 
 enough, where it is universally admitted to be honourable to 
 the country. 
 
 Denman, Burns, Dewees and Velpeau, will, I trust, be con- 
 sidered as a collection of authorities, at the least, small enough 
 for any student or any practitioner of the delicate, difficult 
 and responsible art of Midwifery: if so, I shall be absolved 
 from the charge of adding to the number of authors, one 
 whose works are useless or superfluous. 
 
 In relation to the manner in which I have executed my 
 humble task, nothing ought to be said by me, further than 
 that I have aimed to give a transcript of the author's perform-
 
 DEDICATION. V 
 
 ance, and not to substitute one of my own under his name and 
 authority. 
 
 There are some slight errors which I shall not point out, 
 because I presume every reader of such a work is as com- 
 petent as I am to correct them: I have no excuse to offer to 
 those who may detect them, except that the proofs have been 
 read with much attention, and a desire to attain a great degree 
 of correctness. 
 
 You, I hope, sir, who know how much of my time is absorb- 
 ed in the business of my profession, will have the goodness to 
 overlook all such minor faults of the translation as might na- 
 turally occur, under the circumstances in which I am placed, 
 and accept it, and with it the assurance of my profound 
 
 respect. 
 
 CH. D. MEIGS. 
 Jan. 28th, 1831.

 
 AUTHOR'S PREFACE. 
 
 Confounded with the other branches of medicine, and pur- 
 sued almost exclusively by mere medicasters during a long 
 series of ages, the Art of Midwifery has advanced with ex- 
 treme slowness. Among the Egyptians, the Hebrews, the 
 Greeks, and the Romans, it was reduced in some sort to what 
 concerns the cutting of the umbilical cord; and even at the 
 present time^ in countries that are imperfectly civilized, those 
 who make a profession of it inspire so little confidence, that 
 the husband is still compelled to imitate the conduct of the 
 first man, that is to say, he becomes the accoucheur of his wife. 
 These primitive notions have doubtless long ceased to exist 
 amongst us; in our day the Art of Midwifery is especially seen 
 to acquire a rapid movement, and to progress equally with the 
 other departments of the art of curing; it would, however, 
 be wrong to conclude from hence, that every thing has been 
 already done, and that no further improvements can be made: 
 the Science of Obstetrics ought to follow the movements of the 
 age, and advance if it would not retreat. It seems to me 
 that it may be defined, the ensemble of knowledge relative 
 to the reproduction of the human species. By studying it 
 under this extensive and philosophic view, and by doing away 
 the absurd and vulgar prejudice, that it is impossible to be 
 at the same time a skilful accoucheur and an able physician, 
 we shall succeed in establishing it upon a basis worthy of 
 the subject! 
 
 In this book I have endeavoured not to be unjust to any
 
 viii PREFACE. 
 
 one. I have spoken on all occasions without being influenced 
 by hatred or prejudice, and I may add, without enthusiasm, 
 and with absolute independence. The sciences compose a re- 
 public in which every man is at liberty to make researches, 
 to examine and think for himself, as well as to say what he 
 thinks. Truth is the avowed object of all who cultivate 
 them: it may be reached by a hundred different routes, and 
 I never could understand how any reasonable man could be 
 offended because his ideas fail to be received as laws for other 
 men. 
 
 In adopting a course somewhat different from that pursued 
 by the modern classic writers, I was not misled as to its 
 merits. No person attaches less importance to classifications 
 than I do, or is more fully convinced that every one has an 
 equal right to choose for himself. The course I have chosen 
 appeared to me to be more natural than any other; I found 
 that one was necessary for my purposes, and I preferred this 
 one; I shall therefore make no further attempt to justify it; 
 it belongs to the public to decide whether it be good or bad. 
 
 I have given a name to the science of the accoucheur; in 
 the first place, because it is a substitute for a periphrasis; and 
 in the next, because it is quite extraordinary that that science 
 should have remained until the present day without any 
 special qualification in France. From the earliest years of 
 my studies, I employed the term (obstetricie) obstetrics, de- 
 rived from the Latin obstetrix, midwife. I think it more uni- 
 form in acceptation than the word obstetrique, which is used 
 in Germany, and which M. Duges has desired to establish 
 among us. But the word tokology, derived from ro*oc, child- 
 birth, and from xoyee, study, out of which may be constructed 
 the terms tokological, tokologist, tokologue, tokograph, &c. 
 and which present nothing hard or difficult in their pronunci- 
 ation, has seemed to me more conformable to the habits of 
 our language and the rules of grammar. 
 
 It is of the nature of a preface to set forth the motives of 
 the author of a doctrinal book, and the advantages which he
 
 PREFACE. ix 
 
 supposes himself to enjoy over his predecessors. I hope that 
 I may be permitted to dispense with this common form. 
 Since the time of Baudelocque very good treatises on mid- 
 wifery have been composed; I am the first to proclaim it, and 
 have not the smallest intention to contest the rights which 
 their authors may have acquired to the enjoyment of the pub- 
 lic esteem. But at the present day, every thing proceeds 
 with such rapidity, that each moment is, so to speak, marked 
 by new wants. Besides, as the last speaker, I might hope that 
 I could produce a work, if not better, at least equally useful 
 with others; it remains to be seen whether I have succeeded. 
 
 In composing it, I have attempted to make a profitable use, 
 not only of the works of my own countrymen, whether an- 
 cients or contemporaries, but also of all such foreign writers as 
 I could have access to. Numerous materials have also been 
 furnished by between one thousand and twelve hundred la- 
 bours, examined with care either at the Maternite at Tours, 
 and the hospital Saint Louis, while I was a student there, or 
 at the hospital de Perfectionnement, while I was in service 
 there as chef de Clinique, or at my amphitheatre and in my 
 private practice, since I began to teach tokology; lastly, I have 
 thought it best to embody in the work a detailed extract of a 
 treatise on Embryology, which I have been preparing for a 
 long time past. 
 
 I may be permitted to make an appeal to my brethren upon 
 this subject. If, in the space of six years, I have been enabled 
 to make dissections of nearly one hundred and forty products 
 of conception within the third month of gestation, I am in- 
 debted for those opportunities to the kindness of a great 
 many physicians and female practitioners of midwifery. I 
 shall testify my thankfulness to them in another work, but in 
 the mean time, I cannot express the amount of obligations they 
 will confer by continuing to send me such specimens. 
 B
 
 CONTENTS. 
 
 CHAPTER I. 
 
 Of the Parts that are concerned in Generation, Pregnancy, and Labour, 17 
 
 Of the Pel vis, - - 17 
 
 ARTICLE T. 
 
 SECTION 1. 
 
 Of the Bones of the Pelvis, - 18 
 
 . I. Of the sacrum, - 18 
 
 . II. Of the coccyx, - 19 
 
 . III. Of the coxal bones, 20 
 
 SECTION 2. 
 
 Of the Articulations or Symphyses of the Pelvis, 21 
 
 SECTION 3. 
 
 Of the Pelvis in General, - 23 
 
 . I. External surface, - 23 
 
 . II. Internal surface, ... 23 
 
 . III. Straits of the pelvis, - 25 
 
 . IV. Dimensions of the excavation, - 27 
 
 . V. Base of the pelvis, - 28 
 . VI. Dimensions of the pelvis unconnected with its axes or straits, 29 
 . VII. Differences of the pelvis in respect to ages, sexes, and species, 29 
 
 . VIII. Of the recent pelvis, - 32 
 
 . IX. Uses of the pelvis, - 33 
 
 SECTION 4. 
 
 Of the Deformed Pelvis, 34 
 
 . I. Deformity from excess of amplitude, - 35 
 
 . II. Deformity from want of amplitude, - 35 
 
 . III. Faulty direction of the axes, 40 
 
 . IV. Causes of deformities of the pelvis, 40 
 
 . V. Of the mensuration of the pelvis, 42 
 
 ARTICLE II. 
 
 Of the Sexual Organs, ... 43
 
 xii CONTENTS. 
 
 SECTION 1. 
 
 Of the External Parts of Generation, - 49 
 . I. Of the raons veneris, - .49 
 . II. Of the labia, - 49 
 . III. Of the lesser labia, 50 
 . IV. Of the clitoris, 51 
 . V. Of the vestibule, 52 
 . VI. Of the urethra, 53 
 . VII. Of the hymen, 53 
 . VIII. Of the myrtiform or vaginal caruncles, 54 
 . IX. Of the perineum, fossa navicularis, fourchette, froeuum, com- 
 missure, - .... 55 
 . X. Differences between the external organs of generation in wo- 
 men and those of brutes, .... 56 
 . XI. Anomaly of the external organs of generation, - 57 
 
 SECTION 2. 
 
 Internal Genital Organs, - - ' 58 
 
 . I. Of the uterus, - 58 
 
 A. External surface, 58 
 
 B. Internal surface, - 60 
 
 C. Dimensions of the womb, - 61 
 
 D. Structure, 62 
 . II. Fallopian tubes, 67 
 . III. Ovaries, 68 
 . IV. Ligaments of the uterus, 69 
 . V. Of the vagina, ... 71 
 . VI. Of the sexual organs in general, 
 
 . VII. Varieties in the internal organs of generation in animals, 74 
 
 . VIII. Difference according to ages, - - 75 
 
 . IX. Anomalies, 76 
 
 . X. Hermaphrodism, 80 
 
 CHAPTER II. 
 
 Functions of the Sexual Organs, . 82 
 
 ARTICLE I. 
 
 Of Menstruation, or the Catamenial Discharge, 82 
 
 ARTICLE II. 
 Of Reproduction, 9J 
 
 SECTION 1. 
 
 Of the Generation or Procreation of Germs, - 94 
 
 . I. Of the female germ, 94 
 
 . II. Of the male germ, 95
 
 CONTENTS. xiii 
 
 SECTION 2. . 
 Of Fecundation, 98 
 
 SECTION 3. 
 Of Conception, ... - 101 
 
 CHAPTER HI. 
 
 History of Gestation, - 102 
 
 ARTICLE I. 
 
 Of True Pregnancy, - 103 
 
 SECTION 1. 
 
 Of Uterine Pregnancy, - 103 
 
 . I. Local phenomena, - 103 
 
 . II. Sympathetic phenomena and rational signs, 115 
 
 . III. Sensible signs, - 120 
 
 . IV. Of touching, 120 
 
 . V. Ofballottement, - 125 
 
 . VI. Of auscultation, - - 127 
 
 SECTION 2. 
 
 Of Extra-uterine Pregnancy, - 132 
 
 . I. Of ovarian pregnancy, - 132 
 
 . II. Of abdominal pregnancy, - - 133 
 
 . III. Of tubal pregnancy, 134 
 
 . IV. Of interstitial pregnancy, - 135 
 
 . V. Causes of extra-uterine pregnancy, 136 
 
 . VI. Signs and terminations of preternatural pregnancy, 137 
 
 ARTICLE II. 
 
 Of False Pregnancy, 142 
 
 ARTICLE HI. 
 
 Of Pregnancy as it regards the sex of the Foetus, - 144 
 . I. Is it possible to ascertain the sex of the foetus during preg- 
 nancy? - - 144 
 . II. Is it possible to procreate either sex at pleasure? 147 
 . III. Of the influence of the seasons and of public prosperity upon 
 the production of the sexes and the proportion of concep- 
 tions, - --- - 149
 
 XIV 
 
 CONTENTS. 
 
 CHAPTER IV. 
 
 150 
 
 ARTICLE I. 
 
 Of the Appendages of the Foetus, - - 150 
 SECTION 1. 
 
 Of the Membranes, - 150 
 
 . I. Of the caduca or connecting membrane, 150 
 
 . II. Of the proper membranes of the ovum, - 157 
 
 A. Of the chorion, 157 
 
 B. Of the amnios, 161 
 . III. Of the water of the amnios, - - 163 
 
 SECTION 2. 
 
 Of the Vesicles of the Embryo, 166 
 
 . I. Of the umbilical vesicle, 166 
 
 . II. Of the allantois, - 171 
 
 SECTION 3. 
 
 Of the Cord and Placenta, - - 175 
 
 . I. Of the umbilical cord, - 175 
 
 . II. Of the placenta, - 179 
 
 ARTICLE II. 
 
 Of the Foetus, 188 
 
 SECTION 1. 
 
 Development of the Embryo and of the Foetus, 188 
 
 . I. Of the embryo in general, 190 
 
 . II. Of the head and organs of the senses, - 192 
 
 . III. Of the members and lower parts of the trunk, - 194 
 
 . IV. Of the foetal head at term, 201 
 . V. Of the attitude and position of the foetus during pregnancy, 206 
 
 . VI. Of superfoetalion, 208 
 
 SECTION 2. 
 
 Functions of the Foetus, 212 
 
 . I. Of the nourishment of the foetus, 212 
 
 . II. Circulation of the foetus, 220 
 
 . III. Of the respiration of the foetus, - 224 
 
 $. IV. Of the viability of the foetus, - 226 
 
 ARTICLE III. 
 
 Of Abnormil Expulsions of the Human Ovum, 229
 
 CONTENTS. xv 
 
 SECTION 1. 
 Of Abortion, - - - 229 
 
 SECTION 2. 
 Of the Term of Gestation and of Retarded Births, - - 244 
 
 SECTION 3. 
 Of Precocious or Early Births, - ... 247 
 
 CHAPTER V. 
 
 Of Labour, - - .... 248 
 
 ARTICLE I. 
 
 Of Labour in General, ..... 251 
 
 SECTION 1. 
 
 Of the Causes of Labour, - .... 252 
 
 . I. Efficient causes, - ... 252 
 
 . II. Determining or occasional causes, - . 258 
 
 SECTION 2. 
 
 Of Labour, - .... 262 
 
 . I. Precursory or preliminary symptoms of labour, - 263 
 
 . II. First stage, or period of dilatation, ... 265 
 
 . III. Second stage, or period of expulsion, - . 266 
 
 . IV. Qf labour-pains, . - . . 270 
 
 . V. Of the dilatalion of the os uteri, - - - 275 
 
 . VI. Of the discharge of glairy mucus, - . 278 
 
 . VII. Of the bag of waters, ..... 280 
 
 ARTICLE II. 
 
 Of Eutocia or Simple Labour, .... 282 
 
 SECTION 1. 
 
 Of Natural Eutocia, ..... 287 
 
 . I. Presentation of the vertex, ... 288 
 
 First, or occipito-anterior position, - ... 290 
 
 A. First variety. 
 
 Left occipilo-acetabular position, - - . 291 
 
 B. Second variety. 
 
 Right occipito-acetabular position, ..... 294 
 
 C. Third variety. 
 
 Occipito-pubic position, - .... 297 
 
 Second, or occipito-posterior position, - - 299 
 
 A. First variety. 
 
 Left fronto-acetabular position, ... 300
 
 xv i CONTENTS. 
 
 B. Second variety. 
 
 Right fronto-acetabular position, 302 
 
 C. Third variety. 
 
 Fronto-pubic position. 304 
 
 . II. Presentation of the face, 307 
 
 A. Right inento-iliac position, 310 
 
 B. Left mento-iliac position, 311 
 
 C. Mento-sacral position. - 311 
 
 SECTION 2. 
 
 Of Unnatural Eutocia, - 312 
 
 . I. Presentation of the feet, - 317 
 
 First ; Calcaneo-anterior position, 318 
 
 A. First variety. 
 
 Loins in front and towards the left, 318 
 
 B. Second variety. 
 
 Loins in front and towards the tight, 320 
 
 C. Third variety. 
 
 Loins directly in front, 820 
 Second ; Calcaneo-posterior position, - 
 
 Presentation of the knees, 326 
 
 Presentation of the breech, - 326 
 
 SECTION 3. 
 
 Of the Conduct of the Accoucheur during Labour, 328 
 
 . I. Of the diagnosis, - 329 
 
 . II. To determine the position, 332 
 
 . III. Of the prognosis, 335 
 
 . IV. Of the attentions necessary for the woman in labour, - 336 
 
 ARTICLE III. 
 
 Of Dystocia, - 363 
 
 SECTION 1. 
 
 Accidental Dystocia, 364 
 
 . I. Of hemorrhagic dystocia, 364 
 
 . II. Of convulsive dystocia, - 381 
 . III. Dystocia caused by premature descent of the umbilical cord, 390 
 . IV. Dystocia from excessive length or shortness of the umbilical 
 
 cord, 393 
 
 . V. Aneurismal dystocia, - 895 
 
 . VI. Dytitocia from asthma, hydrothorax, gibbosity, dropsy, - 395 
 
 . VII. Hernial dystocia, 396 
 
 . VIII. Dystocia from syncope, 396 
 
 SECTION 2. 
 
 Essential Dystocia, - 398 
 
 . I. Dystocia occasioned by the state of the female organs, 398 
 
 f. II. Dystocia depending on the foetus, 406 
 
 SECTION 8. 
 
 Dyitocia from Wrong Presentations of the Foetus, - 412
 
 CONTENTS. 
 
 . I. Deviated positions of the head, - 413 
 
 . II. Deviated breech positions, 413 
 
 . III. Deviated positions of the trunk of the body, 414 
 
 CHAPTER VI. 
 
 Obstetric Operations, - 421 
 
 ARTICLE I. 
 
 Of Turning, 421 
 
 SECTION 1. 
 
 Of Turning in General, - .... 422 
 
 SECTION 2. 
 
 Of Version by the Head, .... 423 
 
 SECTION 3. 
 
 Of Turning by the Feet or Pelvis, ... 430 
 
 . I. Of bringing down the feet when the head is at the orifice, 435 
 
 A. Left occipito-iliac position, - ... 435 
 
 B. Right occipito-iliac position, .... 442 
 . II. Of turning by the feet in presentations of the trunk, - 443 
 
 A. Positions of the shoulder nnd side, ... 444 
 First ; positions of the left shoulder, - ... 445 
 Second ; positions of the right shoulder, .... 447 
 
 B. Presentation of the sternum, ... 443 
 
 C. Presentation of the back, - . . 449 
 
 SECTION 4. 
 
 01 the Maneuvre in Presentations of the Pelvis, - - 450 
 
 A. Positions of the feet, - ... 450 
 
 B. Positions of the breech, - ... 452 
 
 SECTION 5. 
 
 Presentation of the Arm, - .... 455 
 
 General Recapitulation on the Maneuvre, - - 459 
 
 ARTICLE II. 
 
 Of the Forceps, - . 459 
 
 SECTION 1. 
 
 The Forceps in itself considered, . . 459 
 
 SECTION 2. 
 
 Of the Use of the Forceps, - . 462 
 
 . I. Oceipito-anterior position, .. 467 
 
 . II. Occipito posterior position, - - 471 
 
 . III. Left occipito-iliac position, - - . 471
 
 CONTENTS. 
 
 . IV. Right occipito-iliac position, 472 
 
 . V. Positions of the pelvis, 472 
 
 . VI. The child is completely or partially double, - 474 
 
 . VII. The head separated from the body remains alone in the pelvis, 474 
 . VIII. Recapitulation on the employment of the forceps, 475 
 
 ARTICLE III. 
 
 Of the Lever, 477 
 
 SECTION 1. 
 Of the Lever in itself considered, - 477 
 
 SECTION 2. 
 
 Use of the Lever, - 478 
 
 . I. Use of the lever as a crotchet, - 479 
 
 II. Of the lever used as a lever, - 480 
 
 ARTICLE IV. 
 
 Of the Fillet, - 481 
 
 ARTICLE V. 
 
 Of the Locked Head, 482 
 
 ARTICLE VI. 
 
 Of the Measures rendered necessary by Narrowness of the Pelvis, - 487 
 
 SECTION 1. 
 
 Of Regimen as a means of enabling Women with Contacted Pelvis to 
 
 be delivered without the assistance of any surgical operation, - 489 
 
 SECTION 2. 
 
 Of Abortion brought on for the purpose of rendering Symphyseotomy or 
 
 the Cesarean Operation unnecessary, - 490 
 
 SECTIONS. 
 Of Symphyseotomy, 497 
 
 SECTION 4. 
 Of the Ceaareau Operation, &c. 506 
 
 SECTION 5. 
 Vaginal Cesarean Operation, - 520 
 
 SECTION 6. 
 Of Cephalotomy and Embryotomy, - 521 
 
 SECTION 7. 
 Of Crotchet* and their Use, 524 
 
 SECTION 8. 
 Of the Extraction of the Bead when it has been left alone in the Genital 
 
 Pamagei, 628
 
 CONTENTS. 
 
 CHAPTER VII. 
 
 Of the Natural Phenomena which follow the Delivery of the Foetus, 530 
 
 ARTICLE I. 
 
 Of the Delivery of the After-birth, - - 530 
 
 SECTION 1. 
 Of Simple or Natural Delivery of the After-birth, - - 530 
 
 SECTION 2. 
 Of Complicated Delivery of the After-birth, - 537 
 
 ARTICLE II. 
 
 Management of the Child, 552 
 
 SECTION 1. 
 
 Of the Foetus in a Healthy State, . . 552 
 
 SECTION 2. 
 
 . I. Of tying and cutting the cord, - - - 553 
 
 . II. Of cleansing the child, - . 557 
 
 . III. Of dressing the child, - - - . . 559 
 
 SECTION 3. 
 
 Of the Foetus in a State of Disease, - - - - 561 
 
 . I. Of asphyxia, . . - 561 
 
 Of the apoplectic state, . 565 
 
 . III. Of some other states of the new born child, 567 
 
 ARTICLE III. 
 
 Management of the Lying-in Woman, - 569
 
 AN ELEMENTARY 
 
 CHAPTER I. 
 
 Of the Parts that are concerned in Generation, Preg- 
 nancy, and Labour. 
 
 ARTICLE I. 
 -Of the Pelvis, 
 
 1. The pelvis, a sort of bony girdle or cavity, which constitutes 
 the inferior termination of the trunk of the body, is found, in the 
 human species, between the spine, which it supports posteriorly, 
 and the thigh bones, on which it rests anteriorly. Its shape, which 
 is very irregular and difficult to describe, resembles in some mea- 
 sure that of a cone with its apex and base strongly inclined towards 
 each other, on their anterior face. Regarding it as an appendage 
 both of the vertebral column and of the inferior extremities, the ana- 
 tomists who lived antecedently to the time of Vesalius, gave no par- 
 ticular description of it. Diemerbroeck, Dionis, Saint Hilaire, Mau- 
 riceau, and De La Motte scarcely dwell for a moment upon it in 
 their works : and even at the present day, the learned who aim to 
 promote the honour of what is called philosophical anatomy, have, 
 for the major part, returned in this respect to the same way of think- 
 ing as the ancient naturalists. But although the development of 
 the skeleton might, in a system of general zoology, permit us to take 
 C
 
 IS 
 
 OF THE PELVIS. 
 
 such a view of it, it does not follow that we ought to do so in toko- 
 locry. The accoucheur must necessarily study the pelvis as a por- 
 tion distinct from, and, as far as connected with his art, independent 
 of the rest of the body. Hence it is, that all authors since the time 
 of Smellie and Levret have followed this course; which I shall ac- 
 cordingly adopt. 
 
 SECTION 1. 
 Of the Bones of the Pelvis. 
 
 2. There are four bones in the adult pelvis : the sacrum and coc- 
 cyx posteriorly, and on the median line; and the coxal bones in front, 
 and on the sides. As he who is destined to engage in the practice 
 of midwifery ought to be made acquainted with the entire pelvis, I 
 do not deem it necessary to dwell at length upon the graphic details 
 that are to be found in most of the classical works upon each con- 
 stituent portion of it. On this subject there exists, even in our most 
 modern works, quite a faulty mode of exposition, which it is proper 
 to reform : after the manner of Baudelocque, the pubis, the ilium 
 and ischium are minutely described as so many separate bones, 
 while, for the most part, the coxal bone is almost entirely lost sight 
 of; and yet it alone possesses any considerable interest in relation 
 to midwifery, inasmuch as the throe pieces of" which it. is composed 
 are united into one before the individual is liable lo become preg- 
 nant. 
 
 . I. Of the sacrum (ox AY/CH/???, .v dun him). 
 3. The sacrum, a single hone, situated between the last lurnbai 
 vertebra and the coccyx, is looked in, MS it were, between (lie two 
 
 ilia. 
 1. <>i"a triangulai 01 pyramidal shape, curved forwards on its an 
 
 i Mil-face, il presents lo (lie examiner, successively, an int. 
 <ir pelvic, region, and external or jio-icrior region, \v>- 
 and an apex. 
 
 Its (interior .vM/;/I;/r, someu hal concave, presents I. Along ils 
 middle, lour or five cjimdraii'Milar laeelles, and (lie MIMIC number i 
 
 tmntrene lines; ". < MituMrdlv, <li- f. ral holes, ter- 
 
 mmatin" in an e.|ii;i] unmix 
 
 of UK- :inl. -nor brand,, M ()IV ,,n|\van)lv 
 
 and between tlie--e op. I,. mie\eii 
 
 uidal inn 
 u in. -li i convex ami verv uneven, e\hi
 
 OF THE PELVIS. 19 
 
 bits, along its middle, a series of protuberances which, by their union, 
 constitute the crista of the sacrum; above this crest is seen the open- 
 ing of the sacral canal; below are the two branches formed by its 
 bifurcation, the triangular space which terminates the spinal canal, 
 and the tubercles or points called the horns of the sacrum. On 
 either side of the false vertebral spines, are seen the sacral grooves, 
 the posterior sacral holes, and still nearer to the edges of the bone 
 are to be found certain rough surfaces that serve for the attachment 
 of the posterior sacro-iliac ligaments. 
 
 7. Its edges may be divided into two portions : one, superior, 
 very thick, exhibits, on its anterior half, a semilunar articular facette 
 which unites it to the coxal bone; on its posterior half, a hollow, and 
 certain rough protuberances for the attachment of the sacro-iliac 
 ligaments; the other, inferior, thin, almost sharp, serves for the in- 
 sertion of the sacro-sciatic ligaments. 
 
 8. Its base, very broad, looks upwards. On its middle may be 
 seen a plain elliptical surface, situated transversely, inclined more or 
 less backwards, and which is articulated with the last lumbar verte- 
 bra; outwards, and a little forwards, a triangular surface, the lesser 
 wing of the sacrum, which is slightly depressed towards its anterior 
 face, and concurs in forming the internal iliac fossa; lastly, we ob- 
 serve on the posterior surface, the opening of the sacral canal, and 
 the two articular apophyses of the first piece of the sacrum. 
 
 9. Its apex, thin, elliptical, slightly convex, is received into the 
 base of the coccyx. 
 
 10. The sacrum, a simple prolongation of the spine, is formed by 
 the union of five vertebra?. Near forty points of ossification maybe 
 observed in it; at birth it is still formed of fifteen pieces, three for 
 each vertebra; but soon afterwards it only exhibits five, which, also, 
 always coalesce before the age of puberty. 
 
 . II. Of the coccyx (oxsa coccygis). 
 
 11. The coccyx is a sort of rudimental sacrum, whose anterior 
 face, almost plane, supports the end of the rectum, while its pos- 
 terior surface, slightly convex, is only separated from the skin by 
 the posterior sacro-coccygeal ligament. Its edges serve as points 
 of attachment for the small sciatic ligament, and ischio-coccygeus 
 muscle; its base, somewhat concave, surmounted laterally by two 
 prolongations resembling horns, is articulated with the apex and cor- 
 nua of the sacrum. Its apex, tubercular and rounded, gives inser- 
 tion to the external sphincter of the anus. 
 
 1 -. The three or four pieces of which it is composed, mere ves- 
 tiges of an equal number of vertebral bodies, remain for a long
 
 20 OF THE PELVIS. 
 
 while movable upon each other; however, they at length coalesce; 
 but, in most women, the bone, as a whole, loses its power of moving 
 upon the sacrum only at a very advanced age. 
 
 . III. Of the coxal bone (os coxaliurri). 
 
 13. The bone of the ilium, the hip bone, the nameless bone, or 
 more property, as was long ago indicated by Celsus, the coxal bone, 
 situated between the femur and the sacrum, alone forms the two an- 
 terior and lateral thirds of the pelvis. 
 
 14. Of an irregular quadrangular shape, looking as if strangula- 
 ted at its middle, and twisted in two opposite directions, the coxal 
 bone exhibits two surfaces and four edges. 
 
 15. On its internal or pelvic surface, which is divided into two 
 nearly equal portions, we distinguish, above, a large excavation 
 called the internal iliac fossa, which is filled by a muscle of the same 
 name; behind, an articular surface, of a semilunar shape, called the 
 articular facette; still farther behind, certain rugosities, similar to 
 those observed on the edge of the sacrum, with which they unite. 
 
 On its inferior half, and posteriorly, is seen a plane, almost trian- 
 gular surface, which corresponds to the cotyloid cavity, and to the 
 body of the ischium; in its middle, the sub-pubal opening; in front, 
 the internal face of the pubis, and of the ischio-pubal ramus. 
 
 16. A semicircular edge, thick, smooth, and rounded posteriorly, 
 thin and sharper in front where it terminates in the crista of the 
 pubis, an edge which forms the greatest part of the superior strait, 
 and unites these two halves of the pelvic surface of the coxal bone. 
 
 1 7. Its external or femoral surface exhibits, on its upper half, what 
 is called the external iliac fossa, filled by the three glutei muscles; 
 below, the sub-pubal hole, the external face of the ischium and isehio- 
 pubic ramus; in the middle, the cotyloid cavity. 
 
 1 8. Its upper edge, or the iliac crista, thicker both posteriorly and 
 anteriorly than in the middle, twisted like an italic s, divided by the 
 anatomists into an external lip, an internal lip, arxl an interstice, for 
 more conveniently describing the attachment of muscles, terminates 
 in front, by the antcro-superior spine of the ilium, and behind, by 
 tin: postero-supcrior spine of the ilium. 
 
 19. lis lain r i'dge, presents three portions : superiorly, an oval 
 
 . i In: articulation of the pubes; inferiorly, the tuberosity of 
 the ischium; and in tlu; middle, the edge of the ischio-pubic ramus, 
 turned somewhat outwai 
 
 MI its tnitir/or nl^(\ proceeding from above, downwards, 
 iroiii the ilium innards the pubis, we remark the superior iliac 
 ; a small -umlun.ir notch; the inferior iliac spine; the groove
 
 OF THE PELVIS. 21 
 
 for the psoas and iliac muscles; the ileo-pectineal eminence, for the 
 insertion of the lesser psoas; a triangular surface, smooth, inclined 
 forwards, and concealed by the pectinalis muscle; the crest; then 
 the spine of the pubis; and, lastly, the angle of the pubis. 
 
 21. On its posterior edge, in proceeding from above downwards, 
 is seen the posterior superior spine of the ilium; a small irregular 
 notch ; the postero-inferior spine of the ilium, which articulates 
 with the sacrum; the great ischiatic notch; the ischiatic spine; the 
 small ischiatic notch, and the most posterior portion of the tubero- 
 "sity of the ischium. 
 
 22. At birth, the coxal bone is composed of three distinct pieces: 
 one superior, the ilium, which constitutes the hip and the two iliac 
 fossa; one inferior, the ischium, which supports the weight of the 
 body when seated; the third, anterior, the pubis, to which are ap- 
 pended, as it were, the organs of generation. It is in the cotyloid 
 cavity, at the ileo-pectineal eminence, and "in the middle of the 
 ischio-pubal ramus, that these three bones at length are blended into 
 one about the period of puberty; but there are commonly added in 
 childhood, a plate for the crest of the ilium, one for the tuberosity of 
 the ischium, another point of ossification for the antero-inferior spine, 
 and a fourth for the spine of the pubis; which sometimes do not 
 coalesce with the principal pieces until a very late period. 
 
 SECTION 2. 
 Of the Articulations, or Symphyses of the Pelvis. 
 
 23. There are three principal articulations of the pelvis: one for 
 the two pubes in front, and two for the bones of the ilium and the 
 sacrum behind. 
 
 24. At the anterior or median symphysis, the bones are kept in 
 contact by a fibro-cartilaginous substance called the interpubal liga- 
 ment, and whose thickness is far from being uniform at every point 
 of the kind of ring or oval circle which it represents. Its thickness, 
 which is very considerable on the upper part, a little less so in front, 
 and much less so behind, becomes suddenly much greater below, 
 where the fibrous body assumes the name of sub-pubal or triangular 
 ligament. In the centre, the articular surfaces are separated by a 
 very thin 1 plate of cartilage, which in early life, and even in a good 
 many adult women, is moistened by a small quantity of synovial 
 fluid. 
 
 A portion of the periosteum lines the posterior surface, a fibrous 
 lamina of the same material is observed in front, and these two layers
 
 22 OF THE PELVIS. 
 
 have received the names of anterior and posterior ligaments of the 
 symphysis pubis. 
 
 25. The sacro-iliac or posterior symphyses are much more com- 
 plex than the preceding. There the sacrum is locked, like a double 
 wedge, between the coxal bones, so that it offers a very efficient re- 
 sistance to the weight of the body, which presses it from above down- 
 wards, and to the efforts of the pelvic viscera, which tend to force 
 it backwards; its articular surfaces, although uneven, are nevertheless 
 covered with a very thick diarthrodial cartilage, while those of the 
 iliac bones are wholly destitute of them. 
 
 26. The name of posterior sacro-iliac ligament is given to a col- 
 lection of fibrous bundles, that are yellow, elastic, mixed with small 
 lumps of fat which fill up the uneven and rugous excavation that is 
 seen behind the cartilaginous surfaces. These fibrous bundles, of 
 the same nature with the yellow ligaments of the vertebra;, are com- 
 posed of fibres decussating in every direction, and are united almost 
 intimately with the sacrum and coxal bones. Being of considerable 
 strength, they give an extraordinary solidity to the articulation which 
 they concur in forming. There is not, rigorously speaking, any an- 
 terior sacro-iliac ligament: a simple lamella of the pelvic periosteum 
 serves in its stead. 
 
 27. Other small fibrous bands also serve, but less immediately, 
 to unite the bones of the pelvis behind. These are the sacro-sciatic, 
 and sacro-spinal ligaments; which, by passing from the posterior 
 spines of the ilium, and from the inferior half of the edge of the sa- 
 crum to the spine, and tubcrosity of the ischium, convert the two 
 ischiatic notches into holes. 
 
 20. The connexions of the pelvis with the vertebral column and 
 with the coccyx, arc effected by two amphiarthroses. 
 
 2f>. One, the sacro-coccygeal articulation, is composed, 1. Of an 
 elliptical librn-cartilaginous lamina, which unites the point of the sa- 
 crum to the base of the coccyx; 2. Of the posterior sacro-coccygeal 
 liniment, a sort of prolongation or extension of the supra-spinal 
 Mient of the vcrtebnc, which closes the lower extremity of the 
 sacral canal; and '3. Of the anterior sacro-coccygeal ligament, 
 formed of two lateral bands united at their point on (he front of the 
 second or third piece of the coccyx. Naturally very movable in 
 women, this articulation permits the coccyx to turn backwards, from 
 half an inch to an inch, while the child is passing through the lower 
 
 Tin: oilier, the sacro -r< //< f/rtit (irticiilution, differs from the 
 
 uplii;iithro.-< 9, only in <hc thiduie.ss of its fibro-cartilage; 
 
 MI the obliquity oi' the articular faces of the last lumbar vertebra, and
 
 OF THE PELVIS. 23 
 
 of the sacrum, an obliquity which produces the sacro-vertebral angle, 
 or the promontory ; and by the presence of the ilio-lumbar ligament, 
 which extends from the last transverse vertebral apophysis to the 
 posterior extremity, and not to the posterior spine of the iliac crest, 
 as is incorrectly asserted by several modern authors. 
 
 31. The obturator membrane, and the ligament of Fallopius, 
 which extends from the anterior superior spine of the ilium to the 
 spine of the pubis, constituting the crural arch, and separating, be- 
 fore it terminates, into two columns to form the inguinal ring, com- 
 pletes the ligamentous apparatus of the pelvis. 
 
 SECTION 3. 
 Of the Pelvis in general. 
 
 . I. External surface. 
 
 32. The principal use of the external surface of the pelvis, which 
 is very uneven, is to give attachment to the muscles which surround 
 the coxo-femoral articulation; it may be divided into four regions. 
 
 33. The first, anterior, bounded on the sides by the cotyloid ca- 
 vities, presents, in its middle, the front of the symphysis of the pubis, 
 and laterally, the external obturator fossa, filled with the correspond- 
 ing muscle. 
 
 34. The second, posterior, bounded by the projection of the coxal 
 bones, is formed almost wholly by the posterior surfaces of the sa- 
 crum and coccyx. Consequently, we may observe in this region 
 the sacral crista and the lower orifice of the spinal canal; the sacral 
 portion of the vertebral grooves filled with the point of the sacro-spi- 
 nal muscle, and in the bottom of which are seen the ten posterior 
 sacral holes, from whence pass the nerves of the same name. 
 
 35. The two last, lateral, enclosed by the preceding, present the 
 external iliac fossa? above; below and behind, the posterior surlan 
 of the sacro-ischiatic ligaments, and the plane of the notches or 
 holes of the same name; below and forwards, the cotyloid cavity 
 which receives the hoed of the femur. 
 
 . II. Internal surface. 
 
 36. The ancient author? have compared the pelvis to a barber's 
 basin. Although trivial, this comparison, nevertheless, gives a pretty 
 exact idea of it. We may, with the modems, divide its inner face 
 into two parts: one, superior, which bears the nnme of greater b 
 sin, upper basin, or abdominal basin, on account of its dimensions, 
 its situation, or the parts it enclose?; the other, inferior, .-MM! 
 
 is also known as the leaser basin, or the pfJmr cj'car<ii'ion.
 
 24 OF THE PELVIS. 
 
 37. The abdominal basin constitutes part of the belly. Of an 
 elliptical form, largely notched in front, where it corresponds to the 
 hypogastrium, notched also behind, in order to receive the lower end 
 of the spine, this cavity is composed of the two internal iliac fossae, 
 which belong to the coxal bones, as well as to the lesser wings of the 
 sacrum, and which are occupied by the sigmoid flexure of the colon 
 on the left, the coecum on the right, and by some folds of the small 
 intestines on both sides. 
 
 38. The lesser basin may be considered as part of a canal larger 
 in the middle than at its two extremities, curved anteriorly, and des- 
 tined to contain the internal genito-urinary organs, the rectum, and 
 the hypogastric and sacral vessels and nerves. In order to obtain 
 a clearer idea of it, it is well to follow the advice of M. Chaussier, 
 that is to say, to remove the greater basin by a horizontal section 
 with a saw. Like the external surface, it may be divided into four 
 regions, and circumscribed in the same way, always excepting the 
 lateral regions, which leave the internal face of the ilium above 
 them. 
 
 39. The anterior region of the lesser basin, very greatly notched 
 below -by the pubic arch, slightly convex from above downwards, 
 and concave transversely, comprises the posterior face of the bodies 
 of the pubes, of the ischio-pubal rami, and of the obturator mem- 
 branes. We may remark, 1. On the median line a perpendicular 
 crest, more or less salient, formed by the posterior part of the sym- 
 physis pubis; 2. Outwardly, the internal obturator fossa, surmount- 
 ed by a canal, (and not a simple hole,) oblique from behind forwards, 
 and from without inwards; through this, which is called the sub-pubal 
 or obturator canal, the obturator vessels and nerves proceed from 
 the interior of the pelvis to the inner side of the thigh. 
 
 40. The posterior region, very much excavated, is represented 
 by the anterior surface of the sacrum, of the coccyx, and of the root 
 of the sacro-ischiatic ligaments. 
 
 4 1 . The lateral regions, formed in front by the internal face of 
 the cotyloid portion and the rest of the ischium, behind by the in- 
 ner face of the sacro-ischiatic ligaments, arc largely opened by the two 
 sciatic holes. Of these two openings, one, superior and the largest, 
 is of an oval shape, and gives from within the pelvis, 1. To 
 the pyramidal muscle, which is inserted into the great trochanter; 
 2. To the ureal sciatic nerve, wind) proceeds to he distributed on 
 the back part of tlie thigh, the outer and back part of the leg, and 
 to the whole foot; :<. To the gluteal artery, and to the internal 
 pubic vessels and nerves : the other, inferior, much smaller, of a tri- 
 
 <ihr shape, is filled by the internal obturator muscle, which pro-
 
 OF THE PELVIS. 35 
 
 ceeds to join the tendon of the pyramidalis in the digital cavity of 
 the great trochanter, and by the pudic vessels and nerves which re- 
 enter the pelvis to be distributed in the perineum. 
 
 42. Suppose a vertical cut, which should divide the lesser basin 
 into four equal parts, there would be found four planes inclined to- 
 wards each other at their points. The two anterior inclined planes 
 comprise a portion of the lateral regions and the whole of the an- 
 terior region of the excavation; the two posterior are formed by the 
 front of the sacrum and coccyx, by the sciatic ligaments and notches, 
 and the sacro-iliac articulations. It is always on two of these 
 four surfaces that the extremities of the diameters of the foetal head 
 glide, during parturition. 
 
 . III. Straits of the pelvis. 
 
 43. A. Superior strait. The sort of horizontal circle which se- 
 parates the internal surface of the pelvis into two parts, is called 
 the superior or abdominal strait, greater strait, or margin of the 
 pelvis : formed behind by the sacro-vertebral angle and the ante- 
 rior edge of the lesser wings of the sacrum, outwardly by the rim 
 which limits the iliac fossa below, in front hy the superior posterior 
 edge of the body of the pubis; it is thick or rounded in the first por- 
 tion described, while in the second it, on the contrary, grows thin, and 
 is transformed, so to speak, into a crest. 
 
 44. Its form in the dried pelvis approaches more or less to that 
 of an oval, of the heart on a card, or of an ellipse; but with the soft 
 parts it represents a triangle, with the base in front. 
 
 45. Its inclination downwards and forwards, when the woman is 
 on foot, varies from thirty-five to fifty degrees. This inclination is 
 less in the sitting posture, and when the person lies down or bends 
 forwards; it increases in pregnant women, in those who make use of 
 their abdomen to support heavy burthens, as is the case at Paris 
 with the women who sell fruit, vegetables, fish, &c.; also while on 
 the knees; and whenever, for the purpose of preserving the equili- 
 brium, we attempt to throw the upper end of the central line of the 
 body backwards. 
 
 46. Its axis, is an imaginary line extending from the umbilical 
 region to the lower two-thirds of the front of the sacrum. Every 
 degree of inclination of which the 'plane of the strait is susceptible, is 
 equally applicable to its axis, since the latter must pass through the 
 former. The upper extremity of this may rise higher or fall lower, 
 according as its lower extremity recedes from or approaches towards 
 the point of the coccyx. In this respect there arc infinite shades of 
 difference, which must not be lost sight of in practice, whether the 
 
 D
 
 26 OF THE PELVIS. 
 
 labour be terminated spontaneously, whether the child must be turned, 
 sought for by the hand, or delivered with instruments. 
 
 47. Its principal diameters are four in number : the sacro-pubal, 
 or antero-posterior, which extends from the most salient point of the 
 sacro-vertebral angle to the posterior surface of the symphysis pubis ; 
 the transverse'or bis-iliac, which passes from the lower edge of one 
 iliac fossa to a point diametrically opposite; the two oblique or mean 
 diameters, which proceed from the sacro-iliac symphysis, and termi- 
 nate behind the ileo-pectineal eminence of the opposite side. 
 
 48. The length of the first or small diameter is, according to 
 Madame Boivin, and most of the French authors, four inches, and 
 four inches and four lines according to Meckel ; that of the second 
 is five inches; that of the third from four inches and four lines to four 
 inches and a half: so that their union gives a circumference of 
 about thirteen inches and a half. But these dimensions are subject 
 to great variety, and ought not to be understood here except in a 
 very general manner. 
 
 49. B. Inferior strait. The inferior strait, lesser strait, perineal 
 strait, or apex of the pelvis, is formed by the point and edges of the 
 coccyx, the edges of the sacro-sciatic ligaments, of the tuberosities 
 of the ischium, and the ischio-pubal rami ; it accordingly presents 
 three triangular projections, the coccyx behind, and the two ischia 
 on the sides ; as well as three indentations, one anterior, very deep, 
 known as the arch of the pubis, and two others, posterior, still deep- 
 er and very irregular when the sciatic ligaments are removed, but, 
 on the contrary, quite superficial when these fibrous bands are in 
 their natural situation. Its form is precisely like that of the heart 
 on a playing-card; only it may become oval by the retreat back- 
 wards or the removal of 'the coccygeal triangle; it being in the mean 
 while understood that the widest, most open part of these figures is 
 always turned backwards. 
 
 50. Like the abdominal strait, the inferior strait has four diame- 
 ters : one, the coccy-pubal, or antero-posterior, is measured from the 
 point of the coccyx to the top of the arch of the pubis ; another, the 
 transverse, or foVischiatic, from the posterior and interior part of 
 one tuberosity of the ischium to that of the opposite side; the two 
 last, or the oblique diameters, reach from the point where the rami 
 of tho pubes and ischia meet, to the middle of the edge of the 
 sacro-sciatic ligaments. 
 
 51. These diameters are generally found to he four inches each ; 
 however, M. Meckel gives to the first four inches and four lines, 
 and four inches six lines to the second. M. Delpcch is surely incor- 
 rect in giving as the mean term four inches and a half to one, arid
 
 OF THE PELVIS. 27 
 
 five inches to the other. The mobility of the coccyx, and the elas- 
 ticity of the sciatic ligaments, render the antero-posterior diameter 
 capable of being prolonged four, six, eight, or even twelve lines, 
 while the oblique diameters are also evidently capable of being elon- 
 gated ; the transverse, on the contrary, 1 have always found to be 
 a few lines less than four inches. Thus the circumference of the 
 perineal strait should be about twelve inches. 
 
 52. In general, the plane of the inferior strait is inclined slightly 
 upwards, s6 that the line that represents it crosses that of the supe- 
 rior strait in front of the symphysis of the os pubis; however, it is 
 sometimes found to be horizontal, and even below the level of the 
 coccyx. 
 
 53. The axis of the inferior strait is represented by a straight line 
 drawn from the interior of the pelvis, and cutting the middle of the 
 coccy-pubal diameter at right angles; the upper extremity of this 
 line most commonly rises as high as the sacro-vertebral angle, and 
 sometimes is found to be even parallel with the spinal column, and 
 may approach even nearer to the axis of the superior strait in very 
 many instances, as is proved by the late researches of professor 
 Naegele, and as I have ascertained for myself. 
 
 54. In order to obtain correct notions on this subject, it is neces- 
 sary to suppose the coccyx depressed, as it is by the head of the 
 fetus at the moment of delivery; the posterior extremity of the 
 coccy-pubal diameter will 'then be found lower than its anterior 
 extremity, and the axis of the strait descends obliquely from behind 
 forwards, under an angle of from fifteen to twenty degrees, passing 
 from the anterior face of the first or second piece of the sacrum, 
 through the middle of the space which separates the anterior parts 
 of the tuberosities of the ischia; it is requisite, further, not to forget 
 that in the living subject, and particularly during the passage of the 
 head, the obliquity of this line is so much increased, that it becomes 
 almost parallel with the plane of the superior strait. 
 
 . IV. Dimensions of the excavation. 
 
 55. The anterior wall of the pelvic cavity, opposite to the sym- 
 physis of the pubis, is only eighteen inches high, but more outwardly it 
 is near three inches: the depth of the middle portion of the lateral 
 regions is at least three inches and a half; the posterior wall is at 
 least five along the median line, following the curve of the sacrum; 
 and only four in a straight line, from the promontory to the point of 
 the coccyx. From these differences it is manifest that the inclina- 
 tion of the straits will always be about two inches and a half, and in 
 an inverse proportion, in each case; for the pubis cannot be depress-
 
 28 OF THE PELVIS. 
 
 ed towards the horizon without an equal or apparent degree of ele- 
 vation of .the coccyx. The sacro-pubal diameter is increased, by de- 
 scending to the centre of the excavation, from six to ten lines, on 
 account of the concavity of the sacrum; the transverse diameter, on 
 the contrary, diminishes gradually as it approaches the ischiatic, 
 where it is only four inches. The oblique diameters alter but very 
 little, and I arn ignorant of the facts that might warrant Mr Meckel 
 in assigning to them a length of five inches and four lines. 
 
 56. As the anterior face of the sacrum presents us with a cavity 
 that is irregular and of greater or less depth, it is easy to understand 
 that a series of right lines that should fall perpendicularly upon it 
 could not be parallel; that they would all converge towards each 
 other, and cross at angles more or less acute in front of the articu- 
 lation of the pubis, with the exception of one that would be exactly 
 horizontal. For the same reason, we may imagine that the plane 
 represented by each of these lines must have an axis as well as those 
 of the straits, and consequently, that we cannot refuse to admit an 
 axis of the excavation. The union of all these axes would give a 
 curve, concave anteriorly, and whose two extremes would be repre- 
 sented by the central lines of the superior and inferior straits. By 
 viewing the axes of the pelvis in this light, the accoucheur will always 
 have before him the direction of the plane of the anterior face of the 
 sacrum, of the coccyx, and even of the perineum; and as this is the 
 plane that directs the head of the foDtus, such a mode of regarding 
 it seems to me more simple, and much more useful for practice, 
 than the method indicated by certain authors, and which is burthened 
 with geometrical formulas*. 
 
 . V. Base of the pelvis. 
 
 57. The great circumference or base of the pelvis looks upwards 
 and forwards. Its plane is parallel to that of the abdominal strait. 
 It is formed posteriorly by a notch, in the bottom of which is seen 
 the base of the sacrum, and which is naturally filled by the last ver- 
 tebra, the ileo-lumbar ligaments, and the quadratus lumborum mus- 
 cles; outwardly, by the superior edge of the coxal bone, which affords 
 
 * Vide Devcnter (Observ. Sur le Manuel des Jlccouchcmens, 1734), who 
 appears to have been the first to indicate that the cavity of the pelvis is not paral- 
 lel to the axis of the body; Muller ( Collect, de Holler); Rocderer (DeJlrispcl- 
 vii, tfc. Gott. 1751); Smellio (Treatise on the Theory, Sfc. 1771); Levrct 
 (Jlrt dot Jlccouchcnif.nl, 1766); Camper (Translation of Mauriceau, 1759); 
 i jJ>t ,r.'lrn>nchcr, 1804); Lobstein (Bulletin dc la Facultc de Medccine 
 Thise. dc M. Guillemot, Paris, 182-1, No. 164), 
 nod Memoir of M. N:r-Mc (Das IVcib- 
 .nd in Jlrthivr* <1r Mfdirinc, Tune 1827)
 
 OF THE PELVIS. 29 
 
 attachment to the three broad muscles of the abdomen; that is to 
 say, to the external oblique by its outer lip, to the transversalis by 
 its inner lip, and to the internal oblique by its interstice; in front by 
 the great hypogastric notch which looks from above downwards, and 
 from without inwards ; by the antero-superior spine of the ilium, to 
 which are attached Poupart's ligament, the sartorius muscle, and a 
 part of the iliac muscle and the fascia lata; a small semilunar de- 
 pression for the passage of some nervous filaments going to the 
 thigh; the antero-inferior spine of the ilium, which gives insertion to 
 one of the roots of the rectus femoris muscle; a second depression 
 for the passage of the united psoas and iliacus muscles; the linea 
 iteo-pectinea, sometimes scarcely discernible, and sometimes very 
 salient, and which receives the attachment of the psoas parvus ; a 
 third depression or triangular space filled up by the origin of the 
 pectineus muscle, and corresponding to the crural vessel and nerves; 
 the pectineal crista or postero-superior edge of the pubis, oblique 
 from without inwards, which forms part of the superior strait, and 
 terminates in the spine of the pubis, to which is attached the outer 
 pillar of the abdominal ring and the rectus abdominis muscle; lastly, 
 by the upper edge of the symphysis pubis. 
 
 . VI. Of the dimensions of the pelvis, unconnected with its axes 
 or straits. 
 
 58. The space comprised between the two. anterior inferior spines 
 of the ilia measures eight or nine inches; that between the antero- 
 superior, from nine to ten; and from ten to eleven between the middle 
 portions of the crista? of the ilia. The length of the crest of the 
 ilium, following its course from the postero-superior spine to the 
 antero-superior tuberosity is eight inches, and six inches in a straight 
 line. The base of the sacrum is four inches across, and two inches 
 and a half from front to rear. From the middle of the iliac crista 
 to the tuberosity of the ischium is seven inches, and the margin of 
 the excavation cuts this line into two nearly equal portions; the sym- 
 physis p^ubis, which is eighteen lines high, is only half an inch thick. 
 The arch of the same name is from three and a half to four inches 
 wide at its base where it blends with the bis-ischiatic diameter, and 
 only ten or twelve lines at its apex; its height is two inches and a 
 half, and the bony semicircle of which it is composed is folded for- 
 wards and outwards, as if it had been turned in this way by the pas- 
 sage of some hard and rounded body, while still in a soft and plastic 
 state. 
 
 . VII. Differences of the pelvis, in respect to ages, sexes and 
 species.
 
 30 OF THE PELVIS. 
 
 59. At birth the pelvis is extremely narrow and very much elon- 
 gated; the curves of the iliac crista arc scarcely begun, and the 
 position of the ilium is almost vertical; the pelvic cavity is conoidal 
 and not excavated; the sacrum is so much elevated that a horizontal 
 line passes under the point of the coccyx at the same time that it 
 rests on the top of the pubis; its transverse are much shorter than 
 its antero-posterior diameters. The bones are still bordered with 
 thick layers of temporary cartilages, and the whole is so compress- 
 ible that the dimensions of the pelvic extremity of the foetus may 
 easily accommodate themselves to those of the maternal pelvis dur- 
 ing labour. After two or three years, some new osseous points 
 are produced, but they do not always coalesce entirely with the rest 
 of the coxal bone until the age of fifteen or twenty years. The 
 spine of the pubis has even been seen to acquire a length of six 
 or eight lines, and remain movable like an independent piece, which 
 has caused it to be compared to the marsupial bones of the didel- 
 phic animals. 
 
 60. It is therefore not until the fifteenth or eighteenth year that 
 the evolution and union of the several osseous points of the pelvis 
 are entirely completed; so that previously to this age it is not the 
 height of prudence to expose a woman to become pregnant. 
 
 61. In men the pelvis always retains, in respect to its form, the 
 same characters it had in infancy. All its parts are narrower and 
 deeper than they are in women; the coccy-pubal diameter, is only 
 three inches and a quarter, the bis-ischiatic three inches, and the 
 bis-iliac four and a half. There are only seven or -eight inches be- 
 tween the antcro-superior spinous processes, and eight or nine from 
 the middle of one iliac crista to the opposite one. The arch of the 
 pubis is straight, not wide in front, and almost triangular; the sym- 
 physis of these bones is at least two inches long, and the thyroid for- 
 amen approaches also to tire form of a triangle; the sacrum is much 
 less curved, the excavation not so deep, and the superior strait more 
 inclined, rounder, more like an oval or a circle; the iliac fossae are 
 more hollow, the great trochanters are not so far apart, tb/J bones 
 in general thicker, and especially more uneven on their outer sur- 
 faces; in the male pelvis, every thing bespeaks strength and solidity, 
 and is HO arranged as to render progression easy. 
 
 !n women, on the contrary, the articulations are not so com- 
 pact, they nre thinner; the iliac cristii: arc wider, and turned outwards 
 inoro than the base of the thorax, which gives a greater breadth to 
 the hips. The trodianler.s widely separated, by increasing the 
 transverse extent of the base of support of the body, also render 
 walking more dillicult, and give to the sex a gait that is altogether
 
 OF THE PELVIS. 31 
 
 peculiar; in a word, nature seems here to have sacrificed strength 
 and ease of motion to the advantage of pregnancy and parturition. 
 
 63. In the male pelvis the coccyx early unites with the point of 
 the sacrum, and the three symphyses frequently anchylose in old 
 age; in women the sacro-coccygeal articulation remains movable 
 even until the period of decrepitude; the sacro-iliac and pubic arti- 
 culations are rarely anchylosed, even at the most advanced age. 
 
 64. In thin women, and in those who are aery tall, the pelvis is 
 not so wide, and resembles more nearly that of the male, than in 
 persons of a short and well proportioned stature; which, in the opi- 
 nion of the common people, causes the former to bear children with 
 more difficulty than the latter. 
 
 65. The pelvis of animals is notably different from that of the 
 human species. If Roussel and some other philosophers had paid 
 attention to this circumstance, they doubtless would not have 
 maintained that labour requires no aid, because brutes are delivered 
 of their young without needing assistance, and almost without pain. 
 In fact, in most quadrupeds, the pelvis, scarcely curved, in reality 
 presents only one single axis; the sacrum is almost parallel with the 
 spine; the straits are only slightly inclined, and the walls of the pel- 
 vic canal are nearly all of the same length; the coxal bones are so 
 narrow, straight and elongated, that there is, so to speak, no iliac 
 fossa; so that delivery is not exposed, in these species, to the same 
 hazards as in man. 
 
 66. It must not be thought, however, that nature changes thus 
 suddenly, and without gradation, the forms of organs in a series of 
 creatures ; in the monkeys, the pelvis, by differing from that of the 
 inferior animals, is found already to approximate somewhat to the 
 character of the human pelvis ; it is only by ascending the zoological 
 scale, that we find it gradually becoming more perfect ; its various 
 shades may be traced in the ourang-outang, the Bosjesmans, who 
 from their organization seem to constitute the connecting link be- 
 tween the monkey and man, in the Ethiopian or Negro, and the 
 Malay or Japanese races, before coming up to the Caucasian race, 
 in which it is removed as far as possible from the form observed in 
 the other mammifera?* ; whence we have a right to presume that 
 parturition is so much the more painful, as the species is more per- 
 
 * On this subject the reader may consult an interesting work by Dr Wro- 
 lick, who had in Holland an opportunity of comparing the pelvis of the Negro, 
 the Javanese, Bosjesmans, Mustee, an^the Hottentot Venus, who was seen by 
 many persons at Paris, and who was a veritable Howzouanasse. Le Bulletin 
 des Sciences Medicales for February 1827 contains an extract from this memoir, 
 which is also to be found in the bookstores at Paris.
 
 32 OF THE PELVIS. 
 
 feet, and vice versa: a compensation as admirable as it is singular, 
 and which occasions danger in some measure to multiply and accu- 
 mulate around an animal in proportion as his intelligence becomes 
 more perfect. 
 
 67. In the kangaroo and other marsupial animals, the pelvis is 
 prolonged in front by means of the spines of the pubes, which form 
 two separate bones, and support the pouch, in which the second 
 gestation of these animals is effected ; its narrowness in the cabiai 
 and the mole would not admit of the escape of the young ; but during 
 gestation the pieces are disjoined, and separate considerably from 
 each other. In the cetacean there are only some traces of a pelvis ; 
 and in birds, reptiles and fishes, where it serves only in depositing 
 the egg, we find it gradually decomposed, until it disappears. 
 
 . VIII. Of the recent pelvis. 
 
 68. The soft parts which naturally cover the interior of the pelvis, 
 produce certain changes in its form and dimensions, the knowledge 
 of which is indispensable to the accoucheur. 
 
 69. The inferior strait, for example, is shut up by a kind of par- 
 tition, which is called the floor of the pelvis ; a partition which 
 diminishes the height of the excavation, and seems to be the anta- 
 gonist of the diaphragm, or rather of the abdominal muscles, during 
 the efforts of inspiration, defecation, and the emission of urine, and 
 during parturition. 
 
 70. This floor is composed of two fleshy layers: one, superior, 
 concave above, is formed by the levator ani and ischio-coccygeal 
 muscles; the other, inferior, concave below, is composed of the 
 sphincter ani, transversus pcrinei, ischio-cavernosus, and constrictor 
 vaginae muscles. There also arc found the lower hemorrhoidal and 
 the internal pudic vessels and nerves, with fat and cellular tissue in 
 greater or less abundance. 
 
 71. Lastly, it is pierced, as it were, on the medium line by the 
 urethra, the vagina, and the termination of the rectum. Its lower 
 face is lined by an aponeurosis which seems to rise from the great 
 sciatic ligament, and the inner lip of the pubic arch, and the strength 
 of which, although very variable, will be found greatest as it is exa- 
 mined nearest to its origin. A portion of the pelvic aponeurosis 
 covers its upper region, and I think with Camper and M. Dcsor- 
 mcaux, that the disposition of the fibrous lamina' may exert some in- 
 fluence on the promptitude or tardiness of labour, particularly in 
 women who have never hud childf* 
 
 72. The superior strait is more elevated in the recent than in 
 the dried skeleton, by ilic cntnc tliir.kru^.s of the psoas muscles,
 
 OF THE PELVIS. 33 
 
 which, with the iliac vessels, form a sort of column, extending from 
 the sides of the sacro-vertebral angle, to the linea ilio-pectinea, so 
 as in a considerable degree to contract the bis-iliac diameter, and 
 also to, increase the inclination of the strait very much. Instead of 
 being elliptical, or representing an oval whose large extremity should 
 be turned backwards, this strait is now almost circular, or in the 
 shape of a triangle with the base forwards; the sacro-iliac notches 
 scarcely exist, and the sacro-vertebral angle is much less prominent 
 than is commonly supposed, from the idea formed of it upon inspec- 
 tion of the dried pelvis. 
 
 73. From the researches to which I have devoted myself, and 
 whose results have been already made known, I find that the en- 
 trance of the pelvis is widest between the ilio-pectineal eminences: 
 at this point its transversal diameter is four inches and some lines, 
 while the bis-iliac diameter, properly so called, is only three inches 
 and a half to four inches. Beneath the promontory and the psoas 
 muscles, the transverse diameter is really five inches, and the con- 
 cavity of the sacrum gives quite as great a length to the antero-pos- 
 terior diameter. 
 
 74. The bottom of the excavation is of a lozenge shape, with an- 
 gles corresponding on the one hand to the ischiatic spines, and on the 
 other to the middle line of the sacrum and posterior surface of the 
 pubic symphysis. These four angles indicate the place of union of 
 the four inclined planes, which thus represent four triangles, tend- 
 ing to approach each other at their points. 
 
 75. The sacral vessels and plexus, as well as the pyramidalis mus- 
 cle, are found in the posterior triangles : the anterior planes enclose 
 the internal obturator muscles and part of the levator ani. The 
 pelvic fascia is exactly applied over all these parts ; an abundant 
 layer of cellular tissue, in which are imbedded the internal iliac ves- 
 sels, the hypogastric flexus and arteries, a layer which, by the de- 
 position of fat, sometimes becomes so thick as to diminish the cavity, 
 and thus render labour more difficult, lines the whole, and is sepa- 
 rated from the viscera by the intermediate peritoneum. 
 
 . IX. Uses of the pelvis. 
 
 76. The different bony pieces which compose the pelvis are sus- 
 ceptible of only a very slight movement upon each other; notwith- 
 standing assertions to the contrary, the kind of sliding that takes 
 place between the sacrum and coxal bones, as well as between the 
 ossa pubis, in consequence of a fall upon the feet, for example, can- 
 not in any manner be compared to articular motion of whatsoever 
 species. 
 
 E
 
 34 OF THE PELVIS. 
 
 77. The pelvis is the base of the trunk ; it forms a complete ring,, 
 the posterior half of which, says M. Desormeaux, supports the en- 
 tire weight of the body, while the anterior serves as its abutment, so 
 that the weight of the trunk and thoracic members, transmitted 
 through the vertebral column to the sacrum, expends itself first on 
 the ossa ilia, and next on the pubes, which press against each other 
 with more or less force. 
 
 78. To the lateral parts of this circle are attached the pelvic 
 members, which in certain postures, in their turn, support the whole 
 of this burthen, whether conjointly or separately. This use of the 
 pelvis, though interesting to the physiologist, is still more so to the 
 accoucheur, for it accounts for the vicious and singular forms that 
 are sometimes assumed by the pelvic cavity, when ossification either 
 proceeds too slowly or retrogrades. Another use of the pelvis is 
 to enclose and protect the bladder, the rectum, the uterus, the tubes, 
 and ovaries. During pregnancy it supports the womb, and main- 
 tains it in a proper attitude. During labour it gives passage to the 
 infant, by impressing upon it the most favourable direction, and by 
 affording a point d'appui to the soft parts of generation, 
 
 SECTION 4. 
 Of the Deformed Pelvis. 
 
 79. It would perhaps be more rational not to speak of dcformi' 
 ties of the pelvis, until we should come to treat of difficult labour ; 
 but the custom of examining them immediately after treating of the 
 natural conformation having prevailed for so long a time, I have not 
 felt myself at liberty to deviate from it. 
 
 80. The pelvis is deformed whenever it is sufficiently altered, ei- 
 ther in its natural form or dimensions, to render parturition difficult, 
 dangerous, or impossible. In this view, a pelvis may be mal-formcd 
 although its conformation be regular, and it may have a mal-confor- 
 mation, although it bo not deformed. Nevertheless, these two con- 
 ditions being almost always united, it has happened that the books 
 have commonly confounded them both together. Sacombe, it is true, 
 desired to sec a distinction made between mal-configuration and 
 mal-confortnation; but this distinction being purely grammatical, has 
 not been adopted, and scarcely deserves to be combated. 
 
 81. The direction of the axes and planes of the pelvis, the di- 
 mensions of ils diameters, and even its form, arc doubtless far from 
 being, in all pelves, exactly similar to those; I have mentioned above ; 
 but a few lines more or less, an inclination more or less derided, ;i
 
 OF THE PELVIS 85 
 
 slight mal-cqnformation, not sufficient to prevent a labour from ter- 
 minating without danger it may be conceived that these deformities, 
 properly so called, must be pretty rare. 
 
 All deformities of the pelvis may be referred to its excess of am- 
 plitude, its narrowness, or the faulty direction of its axes. 
 
 . I. Deformity from excess of amplitude. 
 
 82. It would seem at the first glance, that a very large pelvis 
 ought to be rather advantageous than unfavourable in pregnancy 
 and labour ; but observation and reason prove that this is not always 
 the case. 
 
 During gestation, the womb, being less completely supported, 
 may be upset, either backwards or forwards, as long as its dimen- 
 sions do not exceed those of the abdominal strait, and it may in- 
 cline in any direction after the fourth month. 
 
 A large pelvis favours the descent of the womb anil the prompt 
 termination of labour, and, consequently, exposes the woman to all 
 those accidents which occasionally follow rapid delivery ; that is to 
 say, to inertia, inversion of the uterus, and hemorrhage. 
 
 I agree, nevertheless, with Madame Lachapelle, that these incon- 
 veniences have been exaggerated, that it is generally easy to prevent 
 them, and that the falling of the child, the premature detachment of 
 the placenta, and the rupture of the cord have perhaps never been 
 produced by this cause rather than by some other. 
 
 . II. Deformity from want of amplitude. 
 
 83. It has been incorrectly maintained that the pelvis cannot be 
 contracted in one direction without becoming larger in another, and 
 that, consequently, the circumferences of its straits never vary. 
 Observation has superabundantly demonstrated that in a consider- 
 able number of women, the pelvis retains, after the age of puberty, 
 most of the characters it had in infancy, and that its form ap- 
 proaches more or less to that of the male; and so far, its absolute 
 capacity remains less than it ought to be in the normal state. 
 
 Besides, since it is fully admitted that there may be excessive 
 capacity, I sec not wuy there should be any repugnance to assert 
 that it may also be too small in all its directions at once ; however, 
 this general and regular narrowness is pretty rare, and I have not yet 
 learned that it has ever involved the necessity of a serious operation. 
 
 84. It may be said, therefore, that relative or partial smallness is 
 the only kind that involves real danger ; it is most commonly met with 
 at the superior strait, less common at the perineal strait, and met with 
 ^till loss frequently in the excavation ; it may affect the antero-pos
 
 
 36 OF THE PELVIS 
 
 terior, transverse or oblique diameters, either taken separately, or 
 several of them conjointly. 
 
 85. According to my researches I find that it most frequently 
 affects the oblique diameters of the superior strait, and more generally 
 one than both of them at once ; shortening of the transverse dia- 
 meter is the rarest of all, and has perhaps never been met with 
 alone. 
 
 86. These different deformities give to the entrance of the pelvis 
 forms as various as they are easy to conceive of. Shortening of the 
 antero-posterior diameter may depend on too great a saliency of the 
 sacro-vertebral angle, and then the strait is cordiform ; jf, at the same 
 time, the symyphysis of the pubis is driven backwards, the pelvis 
 exhibits the appearance of the figure oo, lying in a horizontal posi- 
 tion. When both of the oblique diameters are affected, the bodies 
 of the pubis, by approaching the promontory, may, if there be no 
 derangement of the symphysis, give to the strait the shape of a tri- 
 angle^ trapezium, or a trefoil, according as the ends of the bis-iliac 
 diameter shall forna^angles more or less acute or rounded. These 
 pelves, which have been denominated trilobated or trifoliated, also 
 present this peculiarity, that the three segments are sometimes 
 equal, while at other times the anterior portion, or the right, or left, 
 is much smaller than the other two. ft may also happen, that the 
 two acetabula may tend to approach each other, in proportion as 
 they approximate towards the sacrum ; the pubes in this case, bent 
 at a right angle tothe ileo-pectineal eminences, project from one 
 inch and a half to two inches in front, become parallel to the antero- 
 posterior diameter, and have between them a space of only a few 
 lines. The figures of two pelves of this sort may be seen in a dis- 
 sertation by Weidcman. Madame Boivinhas given a design of one 
 that belongs to the same category ; but the most extraordinary one 
 is that belonging to M. JeufFrion, and a model of which in plaister 
 was deposited by M. Maygrier in the Museum of the Ecole de Me- 
 decine. In this pelvis the two pubes proceed directly backwards to 
 the points whore they unite with the ilia, that is, to the extent of a 
 full inch and a half; near the acetabnla, a$ well as immediately 
 behind the symphysis, the interval between them is only three lines ; 
 all this portion, therefore, is completely foreign to the circle of the 
 strait, and the antero-posterior diameter measures in reality only two 
 inches and a hall', in.sie.id ot'fivo, an would have been supposed had 
 it been UK :i-urcd externally during life. 
 
 87. When only one ol'ilic oblique diameters is deformed, it com- 
 monly produces, a di position ilint it is hi-jlily important, to notice. 
 If, for example, the contraction occurs on the right side, the left
 
 OF THE PELVIS. 37 
 
 may present an excess of amplitude. In this case, it is clear, that 
 if the head presents with the occiput turned to the right, the labour 
 mi^ht not come to a conclusion without assistance; whereas if it had 
 presented to the left, nature would have sufficed for her own relief. 
 This remark indicates with sufficient clearness, that in order to pro- 
 cure an easy delivery for a woman with such a conformation, it is 
 only necessary to turn, and bring down the child in the first or se- 
 cond position of the feet ; so that the occiput may correspond to the 
 largest side of Hhe strait. It also explains why a woman who has 
 been spontaneously delivered of her first child, may not perhaps get 
 through, in a second labour, without symphysiotomy or the Caesarian 
 section, and vice versa. 
 
 88. In 1825 I was requested to attend a woman who had been 
 in labour for two days ; the bead would not engage; I sought for the 
 feet, and terminated the labour. In 1826, the same woman was 
 brought to the hospital de la Faculte, having been four days in labour. 
 The waters were gone off, and the head was strongly engaged ; the 
 womb, being very closely applied to the fetus, would not allow the 
 operation of turning ; the application of the forceps was attempted 
 by MM. Desormeaux, Deneux and myself, but nothing could induce 
 the head to descend. This woman, who became pregnant again in 
 1827, gave me timely notice when her labour came on ; I felt for 
 the feet, and every thing was promptly and happily terminated. The 
 different issue of these thlree labours depended upon this, that in one 
 case, the back part of the head presenting to the right, where the 
 pelvis was greatly contracted, could not pass through the strait, 
 while in the other, by turning the occiput to the left, where the 
 natural dimensions were preserved, the passage of the head was not 
 impossible. 
 
 89. Unless the sacrum itself be contracted, it is rarely that a les- 
 sening of the transverse diameter of the abdominal strait is capable 
 of interfering with the escape of the child. There are almost always 
 to be found more than four inches between the iliac fossae, and this 
 kind* of deformity only, occasions an increase of the sacro-pubal 
 diameter, by giving to the strait the form of an oval, or a greatly 
 elongated heart. 
 
 90. Sometimes the narrowing affects only one side of the pelvis, 
 as is seen in a specimen in the museum of the Faculte : in that case 
 the deformity comprises both the greater 'and lesser basin. 
 
 91. All these deformities maybe combined in various ways, or 
 exist singly, and in very different degrees. Charles Bell tells us 
 that in the pelvis of a woman who had been long affected with osteo- 
 tnalacia, there remained a space of about three lines only in the
 
 OF THE PELVIS. 
 
 ; 
 
 antero-posterior diameter, and only about half an inch betwixt th 
 iliac fossae*. Baudelocque cites a case in which there were only 
 nine lines from the sacrum to the pubis. A contraction almost as 
 great as the one just mentioned, is observable in a specimen that I 
 saw in the Museum de 1'Ecole de Medecine ; however, any body 
 can understand how many shades there may be between these ex- 
 treme contractions and the normal dimensions of the pelvis. 
 
 92. The inferior strait is perhaps more frequently enlarged than* 
 contracted; when the base of the sacrum is depressed towards the 
 pubis, or the pubis driven backwards towards the sacrum, it almost 
 always is in the direction of a see-saw movement, which separates 
 the coccyx more or less from the top of the pubic arch. Although 
 it may be laid down as a general rule that the inferior strait enlarges 
 while the superior strait contracts, it is, nevertheless, possible that 
 they may both be narrowed at the same time, and that too in their 
 corresponding d'iameters. 
 
 93. The approximation of the tuberosities of the ischia towards 
 each other, too great a straightness, or a triangular form of the pubic 
 arch, coinciding almost always with a long symphysis pubis, give 
 birth to what is called barrurc, the most common and dangerous of 
 all the deformities of the perineal strait ; for as the foetal head must 
 pass through the pubic arch, rather than behind the ischia where 
 the soft parts arrest it, the barrure renders the delivery extremely 
 difficult; the retrovcrsion of the coccyx does no good in this case, 
 and if the child is born at last, it is at the expense of an extensive 
 laceration of the perineum. 
 
 94. The coccyx, also, very often becomes almost horizontaWinJ 
 may, by rising upwards, more or less affect the coccy-pubal diame- 
 ter, especially where the base ofcthc sacrum is thrown back/ It 
 also pretty frequently happens that one of the ischia with its ramus 
 inclines towards the centre of the strait, while the opposite ischium 
 and the coccyx do not alter their position. In fine, the varieties oi 
 form are here less numerous than, in the superior strait; but t! ( < 
 degrees of contraction should be understood in the same manner. 
 
 95. Faults of the excavation coincide almost always with the con- 
 tractions of one or the other strait, and sometimes with both of them 
 simultaneously. They depend cither on too great, or on an insuffi- 
 cient curvature of the sacrum. 
 
 9G. In the former case the bone is bent, as it were, upon its an- 
 
 * In a woman who had already had six children, M. Nx-gcle saw such a de- 
 formity of the pelvis as to leave only two lines on iln l.-li, ami .-ax lines on the 
 light between the fourth lumbar vertebra and the superior brim of the symphysifc 
 pubis.
 
 OF THE PELVIS. 39 
 
 terior face, and the sacro-pubal or coccy-pubal diameters are to a 
 greater or less degree diminished, while the antcro-posterior diame- 
 ter is found to be larger than natural ; in other instances, although 
 very greatly curved, it is not the less removed to a great distance 
 from the pubis, whether at its base or apex. 
 
 tn the second case, the anterior face of the sacrum being actually 
 plane, or even slightly convex, as may be seen in a specimen belong- 
 ing to the collection of the Ecole, the pelvic cavity, instead of dilating 
 betwixt its straits, becomes smaller, or on the other hand, it enlarges 
 regularly, from the promontory to the point of the coccyx, according 
 as the base of the sacrum seems to have see-sawed forwards or 
 backwards. 
 
 97. When the sacrum is too concave, and when both the straits 
 are narrowed, if the head, by means of great efforts, comes down to 
 the excavation, it stops there, becomes locked, can neither advance 
 nor retreat, and renders the labour so dangerous that even the Ca> 
 sarian operation itself might be insufficient for its termination. If 
 it be too straight, and the lower strait is too much contracted, the 
 head will descend at first very promptly, but as it passes through a 
 conical canal,. it will soon be arrested, and with difficulty clear the 
 apex. 
 
 98. Whenever narrowness of one of the straits coincides with ex- 
 cessive amplitude of the other, the progress of the labour is neces- 
 sarily perplexed. Is the abdominal strait faulty through insufficient 
 amplitude ? the head will long repiain arrested at it, but will pass 
 through at last ; then, meeting almost no resistance, it will traverse 
 the apex of the pelvis with great celerity, at a moment perhaps when 
 the accoucheur, judging of the duration of the labour by the time 
 that has been already occupied, is informing the assistants that seve- 
 ral hours must elapse before it can be concluded. Has the inferior 
 strait, on the contrary, lost its dimensions ? the foetus engages with 
 extreme quickness, and the practitioner, who does not suspect the 
 i-cal condition of the pelvis, announces that the woman will speedily 
 be relieved, whilst perhaps the very best planned succours are be- 
 coming indispensably necessary. 
 
 99. If the symphysis pubis forms a crest projecting backwards a 
 few lines, as I have seen it do in two instances, it does not prevent 
 the delivery from being accomplished ; but during the passage of the 
 head it may contuse the bladder and the uterus, and favour the 
 laceration of these organs . Sometimes one of the acctabula projects 
 into the excavation, or it may be one of the sciatic spines, turned 
 very much inwards, that deforms the cavity, as was observed both 
 by Levret and Madame Lachapelle ; exostoses of every sort ami
 
 40 OF THE PELVIS. 
 
 
 
 shape have been met with ; scirrhus, fibrous tumours, &c. may also 
 be developed so as to interfere with parturition ; but it must be 
 acknowledged that a majority of the faults of the excavation depend 
 upon too great or too small a curve of the sacrum. 
 
 BP 
 . III. Faulty direction of the axes. 
 
 100. Nearly all these faults of conformation change, to a greater 
 or less degree, the planes and axes of the pelvis. When the sacro- 
 vertebral angle projects too much towards the pubis, the hollowness 
 of the lumbar region being necessarily augmented, it happens that 
 the angle between the spine and sacrum, instead of being one hun- 
 dred and thirty-five degrees, may yield only one hundred and thirty, 
 or even one hundred and twenty degrees ; the axis of the superior 
 strait, therefore, inclines forwards, and approaches the horizontal 
 line ; if the coccyx and the point of the sacrum, restrained by the 
 sacro-sciatic ligaments, are not drawn away by this see-saw, the 
 plane of the inferior strait is depressed to the level, or below the 
 level of the horizontal line, and may -even become parallel to the 
 plane of the superior strait, which in some measure justifies the 
 opinion of Messrs Scemmering, Carus, Nasgele, &c., who think 
 that even in the natural state the perineal strait inclines downwards 
 and not upwards. But this disposition, far ftton bringing the axis 
 of the apex of the pelvis towards the perpendicular, or from inclin- 
 ing it backwards, as at the first glance might be supposed, carries it, 
 on the contrary, considerably in front, inasmuch as the anterior face 
 of the coccyx must determine its direction. When the pubis rises 
 and the promontory becomes obtuse, the axis of the superior strait 
 approaches towards the vertical line, and in some cases becomes 
 parallel to the axis of the trunk of the body ; if, in this case, the pos- 
 terior wall of the excavation fails in being sufficiently concave, the 
 two pelvic axes may become parallel, although the plane of the in- 
 ferior strait be much inclined "forward. This conformation, which 
 especially favours the laceration of the perineum, gives ris^jduring 
 labour, to difficulties that have not been sufficiently dwelt fttt in our 
 classical works, and to which M. Lobstein endeavoured to direct the 
 attention of the profession in 1817. 
 
 . IV. Causes of deformities of the pelvis. 
 
 101. In order correctly to understand the causes of faulty con- 
 formations of the pelvis, it is right to study them as they act in in- 
 fancy, during puberty, or at the adult age. Until the sixth or seventh 
 year, they are very well explained by a reference to rachitis, which 
 is almost the only causg of them. Tho bones that are chiefly affected
 
 OF THE PELVIS. 41 
 
 in this disease, being constantly pressed between two opposing forces, 
 must give way in that direction in which the strongest force operates, 
 or towards the point where there is the least resistance. 
 
 102. Thus, admitting that the softening of the bones is every 
 where equally great, that the child is standing on its feet, and rests 
 with the same pressure on both legs, it is evident that the base of 
 the sacrum will be depressed towards the pubis, and the cotyloid 
 cavities will be pushed upwards towards the promontory. Hence, 
 there will be shortening of the sacro-pubic, as well as of the oblique 
 diameters: if the child stands on its feet, but leans more on one foot 
 than on the other, the oblique diameter of one side only will be 
 contracted ; if he remains seated, the hollow of the sacrum will be- 
 come deeper, while the antero-posterior diameters of the two straits 
 will be lessened ; if he be habitually laid upon his back, the curve 
 of the sacrum, instead of augmenting, will disappear, as well as the 
 pelv-i-vertebral angle, and the coccy-pubic diameter will generally 
 lose somewhat of its dimensions ; a lateral posture will influence the 
 transverse diameters, &.c. 
 
 103. Although the weight of the body then will account for most 
 of the vicious forms of the pelvis, it must,nevertheless, be admitted 
 that their production is in certain cases singularly favoured by the 
 active power of the muscles that surround the coxo-femoral articu- 
 lation ; so much the more, as the bones, most commonly softened 
 only at some particular points, retain every where else all the solidity 
 that is desirable. 
 
 104. After the first periods of childhood, the deformities of the 
 pelvis are almost always the result of a disease, as that malacosteon, 
 either general or partial, which is so common in England, of osteo- 
 malacia, of irregular action of the muscles, and of bad habits in 
 respect to attitude. It is thus that young girls, who, for the purpose 
 of increasing the prominence of their hips and the depth of the 
 lumbar hollow, keep the pelvis and head thrown strongly backwards 
 while they project the abdomen and breast as far forwards as possi- 
 ble, never think that for the purpose of obtaining some elegance of 
 form, they run the risk of being never able to become mothers, 
 without exposure to the greatest danger. 
 
 105. In a diseased hip joint the head of the femur has been seen 
 to push the bottom of the acetabulum into the pelvis, and even to 
 pierce through the acetabulum. Madame Lachapelle gives the case 
 of a woman who was affected with a spontaneous luxation of the 
 thigh bone, and in which the false acetabulum projected so far into 
 the pelvic excavation as to interfere with the labour ; the amputation 
 of a thigh, but not of a leg, in an adult woman, and a fortiori in a 
 
 F
 
 42 OF THE PELVIS. 
 
 young girl, is also capable of vitiating the pelvis, and in the following 
 manner: The artificial limb, being obliged to bear upon the ischium, 
 the acetabulum of the sound side has alone to support the weight of 
 the body. Now the laws of mechanics teach us that in this state of 
 things, the oblique diameter corresponding to the natural limb may 
 become contracted so much, as to render delivery dangerous, as has 
 been proved by the observations made by D'Herbiniaux and Madame 
 Lachapelle. ) * * '4f"* **w 
 
 106. Fractures and luxations, unequally consolidated, caries, 
 syphilis, &c. have also sometimes given rise to obstacles to partu- 
 rition. To recapitulate, it may be said that rickets almost always 
 occasions deformed pelvis in young children, for at that age the 
 members, of which the coxal bones constitute a part, generally par- 
 ticipate in the diseased condition ; while later in life, as for example 
 at the approach of puberty, as osteo-malacia almost solely affects 
 the spinal column, the curves of the spine may be carried to the 
 greatest extent without the pelvis, in reality, suffering any change. 
 For further details on this subject the reader may consult, with ad- 
 vantage, the works of M. Portal, of Choulant, Shaw, Bamfield, of 
 MM. La Chaise, Pravaz,- &c. on spinal deformity and the diseases 
 of the spine and pelvis. 
 
 . V. Of the mensuration of the pelvis. 
 
 107. When called upon to ascertain the state of a woman's pel- 
 vis, we ought to begin by interrogating the parents, or persons about 
 her, as to the manner in which her childhood had been passed ; 
 whether her first steps were slow and difficult, and whether she 
 remained for a long time weakly ; when we learn that the joints had 
 been large and as if swelled ; that she had been ricketty or phthisical, 
 we may infer that rachitis had existed, and that her pelvis is pro- 
 bably deformed. We should next examine very attentively the 
 other parts of her body, and if there be any preternatural curve in 
 the spine, if the knees are large and turned inwards, if the lower 
 jaw projects too much forwards, if the teeth are blueish and ex- 
 hibit transverse striae, the same inference may be drawn ; while we 
 may suppose the contrary if none of the above circumstances should 
 exist. 
 
 108. The theory of homologues, a theory which, as is well known, 
 teaches that in animals, not only is the right side an exact repeti- 
 tion of the left, but also that the lower half of the trunk repre- 
 
 the superior hall'; that the anterior half encloses the same 
 elements as the posterior, has very naturally given rise to an idea, 
 that the pelvis ought only to be a repetition of the head. In Ger-
 
 OF THE PELVIS. 43 
 
 many, therefore, where this doctrine has numerous partisans, there 
 appeared some years since a work in which Dr Weber endeavoured 
 to demonstrate that the head and the pelvis are subject to the same 
 laws of evolution; that the good or bad conformation of one of these 
 parts always corresponds exactly with a similar state of the other ; 
 that the narrowness and depth of the male pelvis for example are 
 in exact accordance with the form of the male head, whose vertical 
 and antero-posterior diameters, in general, exceed the transversal, 
 while the opposite condition is observable in the female, &.c. 
 
 109. Consequently, M. Weber desires that the inspection of the 
 head should give us an exact idea of the condition of the pelvis. His 
 method is very simple : the occipito frontal, bi-parietal, and fronto- 
 mastoid diameters of the head, exactly represent the sacro-pubic, 
 bis-iliac and oblique diameters of the pelvis. 
 
 The superior strait is proportioned to the cranium, and the face 
 is proportioned to the inferior strait. 
 
 Although Mr Weber cites cases in support of his system, I am 
 obliged, nevertheless, to say that I have seen the very best shaped 
 pelvis coincide with the -most deformed crania, and vice versa ; 
 however, it has appeared to me as it did to Madame Lachapelle, 
 that the more the upper part of the face projects, the larger is the 
 pelvis. 
 
 1 10. These preliminary researches being completed, we pass on 
 to the examination of the pelvis itself, with all possible decency and 
 circumspection. If the woman's gait is easy, free and unconstrained; 
 if the hips are on the same level, wider than the base of the thorax, 
 and well rounded, the great trochanters properly separated from 
 each other ; if she is not hollow backed ; if the sacrum has neither too 
 much nor too little convexity; if the symphysis of the pubis is neither 
 sunk in nor protuberant, nor too long, there will be some good rea- 
 son for reporting a good conformation ; by placing the fingers be- 
 tween the labia and the root of the thighs we can ascertain whether 
 or not the pubic arch is narrow, whether it forms a sufficiently large 
 arc of a circle, and whether the ischia are too near each other. 
 
 111. It is not necessary, for the purpose of correctly appreciating 
 all these circumstances, to uncover the woman, or to make her lie 
 down ; if there be any fear of alarming her modesty, the examina- 
 tion may be made through her chemise. When all the characters 
 of a good conformation are met with, it is common to dispense with 
 any farther examination ; but if some of those characters be want- 
 ing, we should endeavour to determine the kind of deformity that 
 does exist : a hollow back, with a very decided saliency of the pubis, 
 indicates an extreme degree of inclination, and a trilobated form of
 
 44 OF THE PELVIS. 
 
 the superior strait. If the symphysis be at the same time depressed, 
 we may affirm that the sacro-pubic diameter is shortened, and that 
 the strait is bilobated, or of the figure of an 00. Hips uneven or 
 too much elevated, and depressed external iliac fossae disclose a 
 fault of the bis-iliac diameter. The approximation of the ischia, 
 the convexity of the sacrum, and the forward inclination of the coc- 
 cyx need only to be hinted at to render it easy even to the least skil- 
 ful person to recognise them in an instant. 
 
 112. As it is essential to the happiness of families that we should 
 arrive at mathematical results, and as the employment of the hand 
 yields them only in a vague and approximative manner, the ac- 
 coucheurs have invented an infinity of instruments for the purpose 
 of exactly measuring the pelvis, whether externally or internally ; 
 these instruments are called pelvimeters or mecometers. 
 
 1 13. Only two of them can be applied externally ; one, the (com- 
 pas d' epaisseur) calliper of Baudelocque, which is almost exclu- 
 sively employed, on account of its simplicity ; and the other, the 
 mecometer of Chaussier, which is scarcely used except at the 
 Maternite of Paris. The calliper serves to measure, 1. The sa- 
 cro-pubic diameter, by placing one of the buttons in front of the 
 symphysis pubis, and the other on the first spinous process of the 
 sacrum ; 2. The oblique diameters, by placing one of the ends of 
 the calliper on the external surface of the great trochanter, and the 
 other on the projecting portion of the opposite sacro-iliac junction. 
 In the first situation, the cursor must measure seven inches; so that by 
 deducting two inches and a half for the sacrum and half an inch for 
 the pubis, there may remain four inches for the antero-posterior 
 diameter of the superior strait. For the oblique diameters, it should 
 measure nine inches, for we must deduct two inches and three quar- 
 ters for the trochanter, the neck of the femur and the acetabulum, 
 and one inch and three-quarters for the posterior symphysis. 
 
 114. Baudelocque has asserted that the thickness of the bones 
 rarely varies more than one or two lines in the antero-posterior 
 diameter, and that the results obtained by the calliper may be relied 
 on. Madame Lachapelle, on the contrary, regards this mode of 
 proceeding as very deceptive, and thinks the thickness of the sacrum 
 may vary from four to five lines. Madame Boivin goes still farther, 
 for she says the thickness indicated by Baudelocque varies from four 
 to twelve lines. One thing certain is, that leanness or fatness does not 
 diminish or increase in a sensible degree the thickness of the soft 
 parts, on the points to be touched by the instrument, and that the 
 differences of thickness of the sacrum and pubis mentioned by 
 Mesdames Lar.hapHln nml Boivin, are at least extremely rare.
 
 OF THE PELVIS. 45 
 
 115. As to the measurement of the oblique diameters, the length 
 of the neck of the femur has appeared to vary too much to permit 
 practitioners to repose much confidence in it ; but I think, on this 
 subject there has been a very general misapprehension : for among 
 a pretty considerable number of well formed pelves I have never 
 found in this direction a difference exceeding a quarter of an inch, 
 more or less, than the one indicated. 
 
 As the cristae of the ilia may be considerably raised or much de- 
 pressed, without the straits having undergone any modification, we 
 should be exposed to too many and too serious mistakes, were we 
 to take half the distance between them as the measure of the bis- 
 iliac diameter. This last is surrounded by too many muscles, and 
 moreover is of too little importance for us to measure it in any 
 other way than with the hand. 
 
 116. The fingers suffice for ascertaining the state of the inferior 
 strait. According to the authors, the woman should be seated upon 
 the edge of a chair, but she may also be examined while standing 
 up. The ball of the fore finger is placed upon the point of the coc- 
 cyx, and the point of the thumb on the edge of the sub-pubic liga- 
 ment, after which the two fingers, being held at the same distance 
 apart, are referred to a graduated scale to ascertain the degree of 
 separation. While the extremity of the index is pressed against the 
 point of the coccyx, the radial edge of the finger, instead of the thumb, 
 may be pressed against the top of the pubic arch ; but there is more 
 danger in this method of painfully pressing against the external sexual 
 organs, if their sensibility happens to be excited. To measure the 
 ischiatic diameter, we must press the points of two fingers against the 
 lips of the ischia, at the spot where the great sacroscatic ligament is 
 inserted, taking care to push the fat aside by gentle pressure. 
 
 117. Although it is true that this exterior exploration does not 
 enable us to pronounce with confidence as to the nature and degree 
 of deformity of the pelvis, it is nevertheless the only one we can have 
 recourse to in virgins ; in other women it is permissible to attempt 
 the internal mensuration, which it has been proposed to perform in 
 a great many different ways. 
 
 118. Coutouly was the first to propose measuring the interior 
 of the pelvis by means of a pelvimeter, which bears his name. It 
 is impossible to convey a clearer idea of such an instrument, fre- 
 quently modified by its inventor, than by comparing it to the shoe 
 maker's rule employed in measuring the length of the foot. It is 
 introduced, closed, into the vagina, after which it is opened, and one 
 of its branches rests against the pubis while the other is applied to 
 the sacro-vertebral projection. Now, the movable or sliding branch
 
 46 OF THE PELVIS, 
 
 being graduated externally, it is easy to estimate the distance that 
 
 separates the two vertical pieces. In this manner we can measure 
 
 the sacro-pubic diameter with the most rigid exactness on the dried 
 
 pelvis, but in living women, Coutouly's instrument is rarely applicable, 
 
 except in the case of pregnancy ; it is not so, however, in a woman 
 
 in labour, if the summit of the head be engaged in the strait ; besides, 
 
 when it can be made use of, its introduction must always be very 
 
 painful, and its results will be most generally fallacious. This pel- 
 
 vimeter therefore deserves the neglect into which it has sunk. 
 
 Many accoucheurs have endeavoured to find a substitute, but as 
 
 those they have proposed have not fulfilled the ends intended by their 
 
 authors any better than Coutouly's, they have been quite as little 
 
 employed as his. The thimble with which Asdrubali armed the 
 
 fore finger in order to increase its length ; the sort of foot-rule, 
 
 in the shape of a compass or pincers, with branches of unequal 
 
 lengths, which can be opened in the pelvis; those made with the arms 
 
 straight, hollow, or full and graduated, according to the plans of 
 
 Stein, Creve, and Aitken, afford us results not at all more precise 
 
 than the others. 
 
 119. The internal mensuration may be well effected by the fingers 
 or hand. When the woman is not in labour, or when the head is not 
 as yet engaged, the point of the fore finger may readily be carried 
 to the promontory : the root of the finger is then raised up against 
 the arch of the pubis, and the place where it touches is marked with 
 a finger nail of the other hand. Nothing can be easier after this 
 than to ascertain the distance from pubis to sacrum. Unlike other 
 pelvimeters, the finger is a feeling instrument, the 'point of which 
 will not slip away from the promontory of the sacrum without the 
 operator knowing it; thus one of the most frequent causes of error 
 is at once obviated. It is true, that as the line represented by the 
 finger falls below, and not on a level with the top of the symphysis, 
 as it ought to do, we commonly find the length greater than it ought 
 in reality to be, but by subtracting four or five lines on account of 
 this obliquity, we shall have for the remainder pretty exactly the 
 measurement of the space between the sacro- vertebral angle and 
 the top of the symphysis pubis. There are two circumstances, how- 
 ever, that may easily lead us into error. The first is where the 
 upper edge of the symphysis seems to have fallen backwards ; and 
 the second, where the contrary obtains. Here indeed the antero- 
 postcnor diameter of the .superior strait mi-rlit appear very great, 
 although in fact it were very small, and reciprocally. But the appli- 
 cation of the calliper externally would readily correct the mistake 
 likely to arise from such a disposition of the bones.
 
 OF THE PELVIS. 47 
 
 120. During labour, we can, if needful, pass the whole hand into the 
 vagina ; the thumb and forefinger are then separated, so as to place 
 one on the sacro-vertebral angle, and the other behind the pubis ; 
 the hand is withdrawn in that position, and we can, with the assis- 
 tance of a foot-rule, determine, within one or two lines, the dimen- 
 sions of the sacro-pubic diameter, without having recourse to the 
 loop of thread proposed by Storck, the armed hand of Koep, or any 
 other of the thousand inventions for that purpose. Instead of using 
 the thumb and index finger, I have sometimes availed myself of the 
 index and medius fingers passed high up into the vagina ; after hav- 
 ing separated them as far as possible, and placed the points of them 
 on each extremity of the diameter, which it is designed to measure, 
 two fingers of the other hand are to be placed between their roots 
 in order too keep them apart, and then they should be withdrawn 
 from the female organs. 
 
 121. With the finger we have the advantage of appreciating all 
 sorts of deformities of the pelvis, whatever be their seat, their nature 
 or degree, the straightness of the sacrum, as well as excess of its 
 curve; also, exostoses and tumours of whatsoever nature, the trans- 
 verse as well as the antero-posterior diameters. By pressing with 
 a certain degree of force against the point of the coccyx, it is pos- 
 sible even to learn how much may be gained in the coccy-pubic 
 diameter, by the retreat of the coccyx backwards. Those who have 
 objected that the finger is not always long enough to reach the angle 
 of the sacrum, have forgotten that a pelvis, in which the forefinger 
 cannot reach to the promontory, is thereby proved to be so spa- 
 cious, that the accoucheur need not trouble himself to* examine it 
 any farther. Moreover, it cannot be denied that, although it is never 
 very difficult to discriminate between a deformed pelvis and one that 
 is not so, it is nevertheless impossible, in certain cases, to determine 
 the exact nature and degree of each particular deviation ; it is there- 
 fore no more than right to give the praise they deserve to the efforts 
 lately made by Madame Boiviri to obtain more precise results : the 
 instrument which she has invented, and which she has named intro- 
 pelvimeter, although founded on the same principles as Coutouly's, 
 differs from it, nevertheless, very considerably. As its branches are 
 separately introduced, one into the rectum, and .the other into the 
 vagina, and as the curve of the rectal branch is very deep, it may be 
 used in the virgin as well as in the pregnant woman, and at any 
 stage of labour ; it may even be employed in ascertaining the oblique 
 and transverse diameters, and by altering its vaginal branch it could 
 easily be converted into a calliper. Nevertheless, I doubt we shall
 
 48 OF THE PELVIS. 
 
 not be able to obtain from this apparatus such exact results as its in- 
 ventor seems to hope for. 
 
 122. However multiplied the means of measuring the pelvis, it 
 must have been seen from the foregoing, that even the most skilful 
 accoucheur will never be able to attain to the mathematical precision 
 that is desirable ; but is this a reason for rejecting them entirely, and 
 asserting with Puzos that the operation itself is of no use ? This 
 author, otherwise so correct, has assuredly gone too far, in saying that 
 a young woman ought to be forbidden to marry, if she had ever been 
 affected with rickets, or if she have a spinal deviation, and humanity 
 and justice both appeal from his judgment. How many ill-shaped 
 women bring large robust children with the greatest ease into the 
 world? Another serious inconvenience might attach to such a 
 general proscription : many women would pay no respect to the 
 prohibition, and not be slow in convincing themselves that they had 
 been frightened with dangers wholly chimerical. Hence, what al- 
 most always occurs when the effect does not follow the threat, those 
 who run some risks upon being married, and those who run no risks 
 at all would equally turn a deaf ear to advice. On the other hand, 
 it would be absurd to deny the importance of pelvimetry, in labour, 
 when a decision must be made between embryotomy, and the dan- 
 gerous operations that may be performed upon the mother. Finally, 
 by citing, for the purpose of proving the uselessness of pelvic men- 
 suration, the cases of women who were not afraid to become preg- 
 nant again after having once undergone the Cassarian operation, 
 Puzos seems to me to have misunderstood their true position : is it 
 really the attraction of pleasure that always induces them to yield 
 to the brutal husband that the law has given to them : is it fair to 
 compare a woman who fears above all things to lose the affections 
 of a man to whom she is united for life, to a young girl, who, free 
 from all entanglements, ought to think first, and above all, of her 
 own safety ? 
 
 ARTICLE II. 
 Of the Sexual Organs. 
 
 In women as in men, the organs of reproduction are partly 
 wirloMul within the pelvis, and partly exposed on the exterior sur- 
 face of that cavity.
 
 OF THE SEXUAL ORGANS. 49 
 
 SECTION 1. 
 Of the External Parts of Generation. 
 
 124. Under the title of external genital organs are generally com- 
 prehended the mons Veneris, the vulva, and the perineum. 
 
 Mere appendages of the internal organs, these parts perform 
 only a secondary office in the great generative function ; but during 
 the expulsion of the ovum, they undergo changes and are exposed 
 to dangers which render the^gct knowledge of them very useful 
 to the physician-accoucheur.^ 
 
 . I. Of the Mons Venens. 
 
 125. The Mount of Venus (the sur-pubal eminence, pules) is a 
 sort of relief formed by the soft parts that cover the front of the 
 pubis ; it is principally composed of fat, fibrous filaments, and cel- 
 lular tissue. In fat women it is sometimes separated from the 
 belly by a transverse groove of considerable depth ; the degree of 
 its projection also varies on the same account, but much more on 
 account of the projection of the bones which support it being dif- 
 ferent in different subjects. 
 
 126. The skin that covers it is very thick, elastic, not very ex- 
 tensible, and covered with hair in the adult ; it contains a great 
 number of sebaceous follicles, and the whole represents a sort of 
 cushion, the uses of which are, according to many authors, connect- 
 ed with the business of copulation. The composition of the mons 
 Venerig very fully explains the violent pain which accompanies phleg- 
 monous inflammation of the part, and enables us to comprehend 
 why abscesses formed within it should be promptly opened. 
 
 . II. Of the Labia (labia pudendi externa). 
 
 127. A sort of cutaneous folds which seem to result put of the 
 bifurcation of the lower part of the mons Veneris, the two labia sepa- 
 rate farther and farther from each other, for about half their length, 
 and then approach to be united again about an inch in front of the 
 anus, exhibiting two commissures, one superior or pubic, the other 
 inferior or perineal. Their external surface, formed by the skin of 
 the thighs, is, like the pubes, covered with hair, at puberty. Their 
 internal surface is smooth, glabrous, and of a rose colour ; a con- 
 siderable number of sebaceous or mucous follicles are observed 
 upon it. The accoucheur ought to be aware that the matter furnish- 
 ed by these follicles may become acrid, and irritating to such a 
 
 G
 
 50 OF THE SEXUAL ORGANS. 
 
 degree, as to give rise to a discharge that has often been mistaken 
 for blennorrhagia, particularly in uncleanly women. 
 
 In young girls, the thickness of the labia is greater above than 
 below. In women who have borrfe children the contrary com- 
 monly obtains. Moreover, before the age of puberty, they are very 
 close together, and pretty firm. After marriage they separate 
 from each other, become flaccid, bluish, and lose the regularity of 
 their form. 
 
 Composed, like the mons Veneris, of filamentous cellular tissue and 
 fat, they are also, like it, subject to phlegmonous inflammation, at- 
 tended with violent pain, and which^ught to be opened early, taking 
 care to plunge the instrument to ^ponsiderable depth if it is de- 
 sired to avoid relapses and sinuses. 
 
 128. As the tissue of which they acomposed is much looser 
 than that of the mons, and they are exposed to more friction, they 
 are subject not only to purulent collections, but also to bloody ex- 
 travasations, serous effusions, &c. which may acquire a consider- 
 able size. 
 
 129. The great labia may also become the seats of hernia, and 
 other tumours, which should not be confounded with those above 
 mentioned. T.he slit which they circumscribe, and which is placed 
 in the direction of the coccy-pubic diameter, is called the vulva, 
 while the whole of the external genitals is specially designated by 
 the word pudendum. This slit contains several parts, situated in 
 a direction from above downwards : these are the lesser labia and 
 the clitoris, the vestibule, the meatus urinarius, the vulvar orifice of 
 the vagina, the hymen, the fossa navicularis, and the fourchette. 
 
 . III. Of the lesser labia (labia pudendi interna). 
 
 130. Thus denominated because they are, in fact, much smaller 
 than the preceding, known also as the nympha; the lesser labia have 
 been compared to a young cock's comb. They arise, superiorly, 
 by two branches, which are continuous with the prepuce of the 
 clitoris : they then descend, divergingly, on the inner face of the 
 greater labia, and terminate insensibly about the middle of these 
 latter, opposite to the orifice of the vagina. They arc of a firm 
 consistence, and a reddish colour; they are formed cf a tegumen- 
 tary fold of a mucous character, very delicate and very sensible, and 
 also of an erectile or spongy tissue, very closely resembling that of 
 the corpus cavernosum in men. 
 
 i:U. At birth the nymphfR generally protrude beyond the level 
 of the greater labia ; in young virgins, on the contrary, the labia al- 
 most entirely conceal the nymphce ; and in adult women who have
 
 OF THE SEXUAL ORGANS. 51 
 
 had children, the lesser labia again become very salient, while they 
 lose their firmness and their rosy hue. 
 
 132. In this respect numerous varieties are to be observed : some- 
 times, indeed, their appearance undergoes no alteration ; at other 
 times they acquire a considerable length, either as regards their 
 whole extent, or only near their posterior extremity.* This hyper- 
 trophy, which is in some cases natural, but most commonly acci- 
 dental, is some times carried to such an extent as to interfere \vith 
 coition ; so that it was formerly not uncommon to amputate the 
 nymphae. In some countries they are naturally much longer than 
 in our European regions. In Persia and Turkey, for instance, if 
 we may believe the reports of travellers, it is frequently found 
 necessary to excise them. 
 
 133. From the time of Kolbe all the naturalists have spoken of a 
 peculiar fold, known as the Hottentot apron, and on which Tackard, 
 Sparman, Banks, Peron, Le Vaillant, Lesueur, and several others 
 have emitted very different notions. Evidently depending on the 
 prolongation of the lesser labia, as was seen by Ten Rhyne, it is 
 not among the civilized Hottentots that it is met with, but among the 
 
 savage tribes of the environs of tne cape, discovered by the Dutch, 
 who call them Bosgismans or Bochismans, that is to say Bushmen. 
 On this subject no further doubt can be entertained, since an indi- 
 vidual of this species came to be exhibited at Paris, under the title 
 of the Hottentot Venus. In fact, the drawing of it furnished by 
 M. Flourens, and the descriptions published by MM. Cuvier and 
 Virey, show that, instead of being three or four lines, the nymphs 
 of this woman were several inches in length. It is true, there is a 
 wide difference between these dimensions and those attributed by 
 certain travellers to the Hottentot apron ; but it is easy to conceive 
 of an extent of six or eight in an organ which has been seen actually 
 to measure three inches, provided if by means resorted to in that 
 country they are subjected to continual tractions, always increasing 
 in force, from childhood up to adult age. 
 
 134. The uses of the nymphre are little known ; the ancients be- 
 lieved that they served to direct the course of the urine, whence 
 tUeir name of nymphae. Smellie and all the writers who have fol- 
 lowed him, pretend that they unfold, or disappear in labour, so as 
 to favour the enlargement of the vulva ; but this assertion is wholly 
 false ; it is said, lastly^ that being endowed with an exquisite degree 
 of sensibility, their use is to augment the pleasure of the veneral act. 
 
 . IV. Of the Clitoris (coles feminarum). 
 
 135. The clitoris is a tubercle which authors have compared to the
 
 52 OF THE SEXUAL ORGANS. 
 
 uvula, and which represents, on a small scale, the penis of the male. 
 In the clitoris are distinguishable a loose extremity, round, and of 
 an acorn shape, and a body which is attached by two roots to the 
 ischio-pubic rami ; but it has not a canal as is the case in the male 
 yard. A fold of skin covers it, serves as a prepuce, and then 
 proceeds to Disappear in each of the lesser labia, of which it seems 
 to be the root. 
 
 136. During the first months of uterine life the clitoris is as long 
 and large as the penis ; at birth its dimensions are still considerable. 
 But from that time it ceases to grow, if it does not even diminish, 
 so that at the age of puberty it is in general not more than four or 
 five lines in length. There are, however, some women in whom it 
 obtains a much greater development. It has been on some occa- 
 sions seen to reach the length of from one to five inches; in such 
 cases it scarcely differs from its analogue in the other sex. 
 
 137. Such a disposition as the above is further remarkable, inas- 
 much as it coincides wjth certain characteristics which have even 
 led to the belief that individuals of such conformation belonged to 
 neither sex peculiarly ; that is to say, these women generally have 
 very small breasts, hard features, a beard, and a temper which leads 
 them -to prefer labour and occupations foreign to the pursuits of the 
 sex. They are stout women, and arc fond of procuring illicit en- 
 joyments with persons of their own sex. In a word, such are the 
 individuals who have generally given rise to the questions relative 
 to hermaphrodism. 
 
 138. Such is the intimate structure of the clitoris, that during 
 coition, the blood accumulates within, swells it, and occasions its 
 erection; the delicate membrane that invests it being of the same 
 nature as that of the nympha?, and very sensitive, it has in consequence 
 been concluded, that with nymphiu it is the chief seat of venereal plea- 
 sure. The clitoris rarely exhibits any morbid affections ; but as 
 its size, when excessive, may incommode during copulation, and as 
 its uses are not very essential, it has in several instances been subject- 
 ed to the operation of amputation. 
 
 . V. Of the Vestibule. 
 
 139. Circumscribed by the clitoris, the inner face of the nym- 
 
 ph.T, am! (he meat us urinarius, the vestibule, is a small triangular 
 space, depressed, corresponding to the uppc^part of the arcli of the 
 pubis, through which Cclsus and M. Lislram; have recommended 
 that (lie bladder should be opened, for the purpose of extracting the 
 stone in females, and which performs no special function relative to 
 reneration.
 
 OF THE SEXUAL ORGANS. 53 
 
 . VI. Of the Urethra. 
 
 140. Beneath the vestibule is perceived the orifice of the urethra; 
 this opening is separated from the vagina only by a kind of tubercle, 
 which projects more or less in different persons, and which termi- 
 nates its anterior. middle column. On account of this tubercle, no- 
 thing is so easy as to sound a woman's bladder without uncovering 
 her, for after a very little practice, the finger suffices for distinguish- 
 ing it and guiding the sound. In women the urethra is large, coni- 
 cal, about twelve or fifteen lines long, scarcely curved ; it has nei- 
 ther prostate gland nor bulb ; its lower wall may be said to be con- 
 founded with the anterior wall of the vagina, and would be rubbed, 
 contused, and lacerated much more frequently than it is, were it 
 not that it is situated at the very top of the pubic arch, in a free 
 space, which is so narrow that neither the occiput nor forehead of 
 the child can reach it to lodge in it. Its natural direction, short- 
 ness, extensibility, and width, readily explain the ease with which the 
 catheter is introduced, the rare occurrence of urinary calculi in 
 women, and the fact that even fecundation has sometimes taken 
 place where the womb opened only into the bladder. 
 
 141. The orifice of the vagina, irregular, and of greater or less 
 size in women who have borne children, more rounded, but of 
 equally variable dimensions in married women who have never yet 
 become mothers, is in virgins contracted by the hymen. 
 
 . VII. Of the Hymen (valvula vaginalis}. 
 
 142. Admitted by some and rejected by others during the seven- 
 teenth and eighteenth centuries, the hymen, and not \ the mem- 
 brane of the hymen, as it is denominated in several French works, is a 
 fold which always exists, provided it have not been destroyed, in young 
 girls. In shape resembling a half moon with its concave and sharp 
 edge turned forwards, its extremities are sometimes so much pro- 
 longed as to unite under the urethra, and thus form a circular valve, 
 whose breadth, however, diminishes as it approaches the meatus 
 urinarius : being on its convex edge continuous with the mucous 
 membrane of the vagina and vulva, the hymen may contract the en- 
 trance of the vulvo-uterine canal in very various degrees, and even 
 close it entirely. Its circle always contracts from behind forwards. 
 I have sometimes detected muscular fibres in it, which were arranged 
 in a decussating manner as in the womb ; in such cases, it was 
 thick, strong, elastic, and very much developed ; at other times I 
 have seen it thin, transparent as a pellicle, and very easily broken ; 
 in general it is thicker at birtli than at any other period of life. In
 
 54 OF THE SEXUAL ORGANS. 
 
 new born infants it often presents the shape, the rosy tint, and soft- 
 ness of the lesser labia. 
 
 143. Regarded as the seal of virginity by the vulgar, and for a 
 long time so considered by medico-jurists and magistrates, the hymen 
 has on more than one occasion been the cause of an iniquitous de- 
 cision by .the tribunals, either in condemning an innocent woman, or 
 on the contrary, in absolving one who was scandalously guilty. But 
 at present it is universally admitted that a thousand causes foreign 
 to the act of coition may destroy it, and that copulation itself does 
 not always occasion its rupture. If this membrane be thin, delicate 
 and broad, a sudden or extensive movement of the limbs, excoria- 
 tions, the appearance of the menses, &c., may cause it to disappear. 
 If it be thick, muscular, elastic, but narrow, the sexual union would 
 not be prevented, and the hymen might remain whole until labour 
 should take place, as is proved by the cases mentioned by Pare, 
 Nasgele and others ; but I believe it incapable in any case of furnish- 
 ing a real obstacle to the escape of the child. If the hymen be broad 
 and resisting, while at the same time it either partially or completely 
 closes the canal of the vagina, it might form an insurmountable ob- 
 stacle to the flow of the menses outwards, and by retaining the 
 blood in the vagina or womb, give rise to symptoms that would be 
 more or less important, according to circumstances. Smellie, Den- 
 man, &,c., report the cases of women in whom this state of things 
 produced all the general symptoms of pregnancy, and who reco- 
 vered their ordinary health as soon as an incision into the hymen 
 had allowed of the escape of the blood with which the parts 
 were filled. I have been consulted on account of one young lady 
 twenty-two years of age, whose hymen had prevented the consum- 
 mation of marriage. I met with another specimen, in the corpse 
 of a woman about forty years of age, who had cohabited with her 
 husband for a long time, but without having any children. As a 
 general rule, however, the hymen is ruptured at the first sexual ap- 
 proach, wjiich in consequence of this laceration is accompanied with 
 more or less p%in, and a slight discharge of blood. When once 
 torn, its shreds contract, and give rise to one or more tubercles, 
 known by the name of myrtiform caruncles. 
 
 . ,. VIII. Of the Myrtiform or Vaginal Caruncles. 
 
 I'M. There arc still a great many physiologists who think that the 
 
 myrtiform caruncles are special organs, and independent of the hy- 
 
 thcy found their opinion on the circumstance that they are 
 
 sometimes found even whore the hymen is whole, and that their 
 
 number and situation do not appear to be accounted for on any other
 
 OF THE SEXUAL ORGANS. 55 
 
 hypothesis. The opposite opinion tends, it is true, to predominate ; 
 but as its supporters have not refuted their antagonists so convin- 
 cingly as to dissipate all doubts on the subject, I have sought for the 
 cause of such a discrepancy of sentiment, and believe I have disco- 
 vered it. Of the four caruncles commonly observed at the entrance 
 of the vulvo- uterine canal, and which correspond to the four extre- 
 mities of the vertical and transverse^ameters of this opening, two, 
 namely, that which is near the mewls urinarius, and that which is 
 near the fourchette, belong to the midale columns of the vagina, 
 while the other two only are the remains of the hymen. The for- 
 mer, therefore, exist even in virgins, while the latter ought only to 
 be met with after coition. It is clear, moreover, that these latter, 
 or the lateral caruncles, may vary in number, size and situation, 
 accordingly as the hymen is broken into two, three, or four shreds, 
 of equal or unequal sizes, in this or that direction, and according as 
 the hymen itself was of greater or less thickness and breadth ; these 
 latter caruncles are altered in form, and sometimes disappear entirely 
 in consequence of labour, while, on the other hand, the median car- 
 uncles enlarge, rather than diminish with the progress of age. 
 
 . IX. Perineum, fossa navicularis, fourchette, froenum, commis- 
 sure. 
 
 145. Between the perineal commissure of the vulva, or greater 
 labia, and the convex edge of the hymen, or posterior semi-cir- 
 cumference of the outer orifice of the vagina, is seen the fossa 
 navicularis ; the fourchette or the frcenum forms its anterior edge, 
 and ought not to be confounded with its posterior edge, which 
 is the commissure itself. It most commonly happens that the 
 fourchette is torn in a first labour, and the fossa navicularis is there- 
 by forever destroyed. 
 
 146. The perineum, which separates the vulva from the anus, is 
 scarcely an inch, or an inch and a half in length ; its inferior surface 
 is composed of skin ; it happens, but rarely, that it is covered with 
 hairs, which, if they be cut off, produce, while growing again, the 
 effect of a brush, and sometimes occasion intolerable pain, the 
 cause of which it is well to understand. Above, that is, between 
 the skin and the point where the rectum and vagina come into im- 
 mediate contact, there is a triangular space filled with fleshy fibres, 
 cellular tissue, fat, nerves and vessels, and which, constituting a part 
 of the perineum, allow it to elongate itself very considerably during 
 labour ; to such a degree, indeed, as will be seen in the sequel, that 
 from being only an inch long, as in its natural state, it may be extended
 
 56 OF THE SEXUAL ORGANS. 
 
 even to four or five inches in length, when most strongly pressed 
 upon by the head. 
 
 147. Without repeating on this occasion what I have elsewhere 
 said, of the arrangement of the parts that compose the' female peri- 
 neum, I think it may be, nevertheless, useful to recal to mind the 
 mean dimensions, which, after a great number of observations, I 
 have been enabled to establish Delation to the various objects which 
 I have now examined. 
 
 It is found : 
 
 . That from the upper part of the pubis to the clitoris is two 
 inches and a half. 
 
 2. From the anterior commissure of the vulva to the anus, three 
 inches and a half. 
 
 From the clitoris to the posterior commissure of the vulva, one 
 inch and a half. 
 
 . From the posterior commissure of the vulva to the point of the 
 coccyx, three inches. 
 
 5. From the coccyx to the anus, about eighteen lines. 
 
 6. From the anus to the vulva, fifteen lines, allowing only a few 
 lines besides for the orifice of the rectum. 
 
 It is also useful to know that the constrictor vaginfe muscle, 
 which is analogous to the accelerator urinse of the male, is inclosed 
 within the body of the greater labia, and that it is so strong in some 
 individuals, as to contract with energy during coition, and consider- 
 ably lessen the size of the orifice of the vagina ; that the only im- 
 portant artery in the neighbourhood of these parts, the pudic artery, 
 is confined as it were entirely towards the circumference of the 
 penneal strait, and consequently, that it is not on account of he- 
 morrhage that lacerations of this region are likely to prove dan- 
 gerous. 
 
 . X. Difference between the external organs of generation of 
 women, and those of brutes. 
 
 In reviewing the principal zoological classes, it is easy to 
 perceive that the external sexual parts, mere organs of coition, as 
 i the human species, are far from exhibiting the same characters, 
 and the same completeness in all cases. 
 
 ! 's, reptiles and birds, the cloaca supplies their place, ex- 
 'iucsilial havo a clitoris ; in the maminiforaj, the 
 lloll/ "" l:! rs ;i iiioiw Vcncris useless, ;md accordingly, 
 
 not ii Iracp ..I'n |IM ,J. 
 
 Accoi. \I. Cuviur, neither do the nympluc exist in any
 
 OF THE SEXUAL ORGANS. 57 
 
 family ; however I have reason to think I observed it in the giraffe 
 which is now in the Jardin du Roi. 
 
 149. The vulva and greater labia are met with in all classes, but 
 with very various forms. The interior is almost always wrinkled, 
 as in the cow, the tiger, &c. Placed lengthwise in the majority of 
 animals, it is in some cases transverse as in the hyena, or circular 
 as in the rabbit and in most of the rodentia ; very shallow as in 
 women ; it forms in the guinea pig a canal as long as, or even longer 
 than the vagina of the bear and some species of the monkey ; all of 
 them have a clitoris, which in some is very small, and very large in 
 others, the monkey for example, where it is connected as to size with 
 an excessively lascivious disposition. The hymen, attributed by most 
 authors to woman alone, is certainly to be found in a great number 
 of animals. Is the plait or circle that separates the vagina from 
 the vulva in the she goat, the ewe, and the bitch any thing else ? 
 M. Cuvier has noticed it in the hyena and the daman. It is im- 
 possible to mistake it in the semi-lunar membrane which contracts 
 the vagina of the virgin mare and she ass, or in that which was no- 
 ticed by Steller in the lamantin of the north : I think the giraffe has 
 it also. The greater labia, the clitoris, and the hymen are there- 
 fore the most constantly met with of all the external organs of 
 generation ; and in all the species, these parts of coition are, there- 
 fore, rather destined to augment the pleasure of the venereal con- 
 gress than to play any fundamental part in the great act of repro- 
 duction. 
 
 . XI. Anomaly of the external organs of generation. 
 
 150. I have already spoken of the preternatural development 
 of the clitoris and nymphae, as well as the extreme length of these 
 parts among certain nations ; I have now to remark, that the greater 
 labia have been in some instances found wholly wanting, in conse- 
 quence of malformation of the individual ; sometimes they adhere 
 to each other, either at one spot or throughout their whole extent, 
 as in the three examples cited by Madame Boivin, as was seen by 
 Cassan and M. Willaume, who saw one case each, and as is fre- 
 quently met with in Persia, Egypt, Turkey, and throughout almost 
 the whole of Africa, where the barbarous custom of infibulation is 
 still practised. Borelli says he saw, in the hospital of Castro, a little 
 girl who had two vulvas, one above the other. It might also be 
 said that where the vagina is completely double, there are two 
 lateral vulvas. The same anomalies are found to occur in the 
 nymphae, which Neubauer in one case found to be triple, and which 
 
 H
 
 58 OF THE SEXUAL ORGANS. 
 
 depend, too, more frequently on an acquired disease than on a pri- 
 mitive fault of the conformation. 
 
 SECTION II. 
 Internal Genital Organs. 
 
 The internal parts of generation in women consist of the womb, 
 the vagina, the fallopian tubes, the ovaries, and the ligamentous at- 
 tachments. 
 
 . I. Of the Uterus (matrix}. 
 
 151. The uterus or womb is a hollow muscle, destined to lodge 
 and nourish the ovum during pregnancy, arid expel it by the process 
 of labour. It is therefore essentially the organ of gestation, and not 
 of generation, as has been erroneously repeated by several authors. 
 
 152. Situation. Situated in the pelvic excavation, behind the 
 bladder, in front of the rectum, beneath the sma-11 intestines, and 
 continuous below with the vagina, the uterus, in its unimpregnated 
 state, is generally placed in the direction of the axis of the superior 
 strait. 
 
 153. Configuration. Its shape is that of a pear or a small flat- 
 tened gourd, or further, of a truncated cone, compressed antero-pos- 
 teriorly, its base being turned upwards, its apex downwards. 
 
 154. Division. For the purpose of explaining the phenomena of 
 pregnancy, the womb is divided into fundus, body, and neck. The 
 
 fundus comprises all that portion that is found above a horizontal 
 line drawn from one fallopian tube to the other ; the body extends 
 from this same line to the contracted portion which marks the com- 
 mencement of the neck ; and the latter, more or less swelled, con- 
 stitutes the lower portion of the organ. 
 
 A. External Surface. 
 
 156. The external surface of the womb has been divided into, 1. 
 An anterior region, which is slightly convex, its upper half being 
 covered with peritoneum, and the remainder being in contact with 
 the basfond of the bladder ; 2. A. posterior region, much more convex 
 than the preceding, covered in its whole extent witli peritoneum, 
 and separated from the rectum by a space or chink in which the 
 intestines may become strangulated ; 3. Three edges, one of which, 
 superior, convex, and smooth, corresponds to tlic fundus, and two 
 others, lateral, convex on their superior half, and concave be- 
 low, are lost, as it were, in the broad ligaments; 4. Three angles,
 
 OF THE SEXUAL ORGANS. 59 
 
 the two first, superior and lateral, unite the three edges, and seem to 
 give origin to the tubes, the ligaments of the ovaries, and the round 
 ligaments ; the third, inferior, far more important than the others, 
 is seen in the upper part of the vagina, and deserves very special 
 attention. 
 
 It exhibits an orifice resembling a transverse slit, dividing it into 
 two lips, and has received the name of the tench's mouth (os tinea?). 
 Of these two lips, the anterior, which is thicker and broader than 
 the posterior, is also, indeed, somewhat the longest. Nevertheless, 
 as the vagina ascends higher behind than in front, it seems when a 
 woman is carefully touched, that the posterior is longer than the 
 anterior lip. To this peculiarity, doubtless, ought to be attributed 
 the error into which many accoucheurs have fallen, who, not con- 
 tent with asserting that the anterior lip is the shortest, have also 
 represented it as being the thinnest in drawings which in other re- 
 spects were most carefully made. To convince any one of the pro- 
 portional length of the two lips of the neck, it is only necessary to 
 separate the womb from the vagina in the dead subject. It will 
 then be seen that the posterior lip is at the same time the thinnest, 
 the narrowest, and the shortest. However, this difference is not 
 to be seen, except in women who have borne children. In virgins 
 the lips are very near to each other, and we can scarcely feel 
 with the finger the line-like slit that separates them ; but it may be 
 distinguished, as has been judiciously remarked by M. Dubois, by 
 comparing the sensation produced by touching it, to that experi- 
 enced by touching the point of the nose with the end of a finger. 
 Sometimes, however, instead of such a narrow slit, we meet with a 
 circular orifice ; a modern author has even taken occasion from this 
 circumstance, to advance the opinion, that such is the natural ar- 
 rangement of the part : but this is evidently an error. M. Desor- 
 meaux thinks that this last mentioned form is particularly to be met 
 with in women who are not apt for fecundation ; but this is an opi- 
 nion which requires to be supported by additional evidence. Be- 
 sides, we must take care not to confound this circular form with 
 that which is pretty often observed at a certain stage of pregnancy, 
 in women who have borne children before ; which it is not always 
 an easy matter, however, to avoid. 
 
 156. Before women become mothers, the lips of the os tineas 
 are smooth, regular and pretty firm, although supple ; the whole neck 
 terminates in an extremity which is rather acuminated than bulging. 
 After one or two confinements, its slit is wider, more uneven ; the 
 free extremities of the lips are farther apart ; the anterior is elon- 
 gated, often ends in a point, and exhibits tubercles or bumps, which
 
 60 OF THE SEXUAL ORGANS. 
 
 are also found on the posterior lip, and separated from each other 
 by crevices of greater or less depth, and in greater or less number, 
 chiefly in the left. It is true, however, that this last mentioned dis- 
 position does not demonstrate with mathematical certainty that there 
 have been several pregnancies, for it may be occasioned by disease. 
 It should also be understood, that the contrary state persists in some 
 women, after a great many lyings in. Thus, in a woman in her 
 seventh pregnancy, I have seen the vaginal angle of the womb more 
 regular than in another whom I examined by way of comparison, and 
 who was in her first pregnancy : but in this, as in every thing else, 
 we should remember the rule without forgetting the exceptions. 
 
 B. Internal Surface. 
 
 157. The womb presents an internal surface, which is also called 
 its cavity, and which the accoucheurs divide into superior portion or 
 cavity of the body, and inferior portion or cavity of the neck. 
 
 158. Cavity of the body. The first, of a triangular shape, with 
 sides separated from each other only by a layer of mucus which is 
 more or less thick, sometimes exhibits, on the median line, a sort of 
 raphe or crest, which runs through its whole length, and is joined 
 by other oblique or transverse lines. The sides of this cavity, as 
 well as its bottom, are almost straight, sometimes slightly convex in 
 young girls, while they generally remain pretty concave after a 
 lying-in. Its two superior angles are continuous with the origin of 
 the fallopian tubes, which are sometimes'expanded like a funnel, and 
 ought, according to M. Geoffroi St Hilaire, to be regarded as the 
 rudiment of the aduterum, which is remarked in most of the rnam- 
 mifera? ; its inferior angle is called the superior, uterine or internal 
 orifice of the neck, and is the point by which the two cavities of the 
 womb communicate with each other. 
 
 159. Cavity of the neck. The cavity of the neck, of an oval 
 shape, is twelve or fifteen lines in length, and five or six lines in 
 width at its widest part, and one or two lines from front to rear. 
 On its two walls, and particularly on the posterior one, are found 
 certain plaits or lines, which have been carefully studied of late by 
 Madame Boivin. This is a sort of gathering, which seems to be only 
 a continuation of that which is found in the womb itself, but much 
 more developed. The median crest, the largest of all, more salient 
 in the middle than at either end, is formed, as it were, by the approxi- 
 mation of many small secondary folds crowded together. The trans- 
 verse lines are all oblique from above downwards, and from the 
 sides inwards, towards the preceding line, on which they terminate,
 
 OF THE SEXUAL ORGANS. 61 
 
 like the barbs of a feather, on their stem. Slightly concave upwards, 
 they leave pretty deep grooves between each other, in which a good 
 many mucous follicles are to be found, and occasionally, some small 
 round transparent vesicles, a sort of hydatids, formerly regarded as 
 germs, and for a long time known as the eggs of Naboth. More 
 deeply seated, that is, beneath this network, which constitutes what 
 is called the arbor vitce. there is another one, somewhat differently 
 disposed, but which cannot be examined until we corne to speak of 
 the structure of the organ. At the place where the two walls of 
 the neck unite, and where the transverse lines too are confounded, 
 are also seen two longitudinal lines. 
 
 160. The superior opening of the neck having been above indi- 
 cated as the uterine orifice, it is useless to return again to the consi- 
 deration of it. The inferior orifice divides the lips of the os tincae 
 from each other ; and as it opens into the vagina, it may very pro- 
 perly be called the vaginal orifice of the womb. From what has 
 been said, and which ought to be understood of the cervix of a young 
 woman, previously to being fecundated, it is evident that the inferior 
 angle of the uterus ought to be quite acute, that a little higher up 
 the size of the neck should be greater, and that this part ought to 
 be again contracted, and as it were, strangulated at the place where 
 it unites with the body of the organ. 
 
 C. Dimensions of the Womb. 
 
 161. In women who have never had children, the womb, measured 
 from the most salient point of the fundus to the end of the anterior 
 lip of the neck, I have found to be of an average length of from 
 twenty-six to twenty-eight lines ; from one fallopian tube to the other, 
 from seventeen to twenty lines ; from front to rear, in the thickest 
 part, nine to eleven lines ; at the neck I have found that there were, 
 transversely, ten to twelve lines, five or six lines from front to rear, 
 eight or ten lines across at the place where it is strangulated, and 
 that there were four lines of thickness at the same point. The pa- 
 rietes of the womb are four lines in thickness at the body, and two 
 or three at the neck ; the lips project two or three lines into the 
 vagina, and the slit that separates them is of about the same extent. 
 
 162. After several pregnancies the uterus is from two and a half 
 to three inches in its- entire length ; twenty to twenty-four lines wide 
 at the fundus, fifteen to sixteen at the widest part of the cervix, 
 twelve to fourteen lines thick at the body, eight to ten at the neck, 
 and each of the walls are six lines in thickness : the vaginal orifice 
 is half as large again as in a virgin. 
 
 In the first named state, the womb weighs from eight to twelve
 
 62 OF THE SEXUAL ORGANS. 
 
 drachms, and in the second about two ounces. It will be seen that 
 these dimensions are very near those given by Rcederer ; and they 
 are the results of a considerable number of measurements taken on 
 the dead subject. 
 
 D. Structure. 
 
 163. An external membrane, an internal membrane, a peculiar 
 tissue, numerous vessels, nerves and cellular tissue enter into the 
 composition of the womb. 
 
 164. a. The external membrane, of a serous character, belongs 
 to the peritoneum ; posteriorly, it descends lower than the cervix, on 
 to the posterior surface of the vagina, while, in front, it is reflected 
 upon the bladder after having invested the anterior surface of the body 
 of the uterus, and before it reaches the cervix. Very closely adhe- 
 rent along the upper edge and median line of the uterus, it becomes 
 less so nearer the sides, and in the neighbourhood of the broad liga- 
 ments maybe easily detached. Observers have not agreed in rela- 
 tion to its thickness, doubtless because it has often been confounded 
 with the layer immediately beneath it, but which in reality ought to 
 be distinguished from it. On the whole, it is thin and very dense. 
 
 165. Sub-peritoneal layer. This is kind of doubling which gives to 
 the peritoneal layer a borrowed thickness, covers every part of the 
 uterus, extends itself into the broad ligaments, and is, indeed, only 
 a portion of the common sub-peritoneal fascia, which at this point 
 assumes most of the characters of the yellow fibrous tissue ; that is 
 to say, it is elastic, strong, dense, and may be converted into real 
 muscular tissue, as has been remarked by Madame Boivin, and as I 
 have several times observed myself. 
 
 166. b. The existence of the internal membrane is not admitted 
 by all anatomists. Gordon, Chaussicr, M. Ribes, &c. reject it ; 
 the most careful dissections, putrefaction, ebullition, chemical re- 
 agents, have all failed in demonstrating its existence to these observers, 
 except towards the close of pregnancy ; but at that period it con- 
 stitutes, according to them, a pellicle of new formation, and not a 
 natural membrane. Beclard also taught that the internal membrane 
 of the uterus is not a complete mucous membrane, and that it has no 
 epithelium. It is true, that except during pregnancy, we cannot 
 always demonstrate the existence of an uterine mucous membrane, 
 but in several women who died while pregnant, or shortly after deli- 
 very, I have succeeded in raising very distinct portions of it. But 
 even could we not succeed in separating it mechanically, analogy 
 would sullice to convince us of its presence : the mucous membranes 
 are exclusively provided with villi ; they alone furnish mucus in the
 
 OF THE SEXUAL ORGANS. 63 
 
 healthy state, and muco-purulent matters in a state of disease ; it is 
 on their surfaces that we meet with polypi and sanguine exhalations. 
 Hence, the glairy discharge that occurs during labour, the leucor- 
 rhoeal discharges, the menstrual function, &c. all prove that the 
 inner surface of the womb performs the same functions and is sub- 
 ject to the same diseases as the mucous membranes. I conclude, 
 therefore, that, if we can in reality refuse to admit the existence of a 
 membrane, we shall at least be forced to admit that the uterus pos- 
 sesses a mucous surface. During several weeks, no organ of the 
 foetus is, properly speaking, invested with a mucous membrane ; not 
 one of them can be divided into lamella? of different natures ; they 
 are all formed of a homogenous tissue ; the intestines, like the other 
 hollow organs, are possessed not of internal and external membranes, 
 but of surfaces ; it is only at a later period, little by little, and in the 
 same situations where they are observed after birth, that the distinc- 
 tion of tissues established by the zoologists are effected. Thus, the 
 interior of all the cavities, of all the canals that communicate nearly 
 or remotely with the atmosphere, exhibit the aspect of villous sur- 
 faces ; but to this fundamental character are added others which 
 differ according to the organ, and reduce every portion into har- 
 mony with the uses of the parts it helps to constitute. Sometimes 
 it is a movable lamina, thick and wrinkled, as in the alimentary 
 canal ; in other instances it is a thin smooth layer, difficult to sepa- 
 rate from the subjacent tissues, as in the ureters, the vasa deferen- 
 tia, &c. Although follicular and villous, this element may adhere 
 so intimately to the substance of the organs, that it is impossible to 
 separate it ; and this is the case with the womb. Nature, true to 
 her great principle, seems here to take pleasure in varying forms 
 without multiplying means ; on some points she is content with a 
 mere rudiment, while at other points she at once attains p'erfection ; 
 but on the other hand, that which, so to speak, she leaves incomplete 
 in the normal state, is rendered complete by a disease, or by some 
 eventual condition ; in this way it happens that a pregnancy, a poly- 
 pus, or some other lesion, have, in more than one instance, rendered 
 the mucous membrane of the uterus altogether evident. 
 
 167. e. Peculiar tissue, or parenchyma. Situated between the two 
 preceding layers, and alone constituting almost the entire essential 
 and fundamental part of the organ, the proper tissue of the womb 
 has been the subject of the researches of a great many very able 
 anatomists. Bonacciolus, Swammerdam, Meckel and Ruysch, 
 Noorthwyck, Sue, Hunter, Loder, Weisse, M. Lobstein, Belloni, 
 and very recently Madame Boivin, have striven to demonstrate its 
 texture, before, during, and after pregnancy ; but in spite of so many
 
 64 OF THE SEXUAL ORGANS. 
 
 exertions, opinions are still far from being unanimous in regard to 
 its nature. 
 
 168. Nature of the peculiar tissue of the ivomb. The same thing 
 has taken place in regard to the womb, as always occurs in anatomy, 
 whenever the analogies and comparisons, which authors are obliged 
 to draw for the purpose of illustrating their ideas, are rigorously 
 construed according to the letter. When Vesalius asserted that the 
 womb is a muscle, Walter, taking the muscles of the skeleton, and 
 even the heart or the intestines as his type, found no difficulty in 
 proving that Vesalius had made a mistake. Although, on the one 
 hand, Malpighi, Ruysch, Noorthwyck, Wrisberg, Meckel, Lobstein, 
 and the major part of modern anatomists, have arranged themselves 
 on the side of Vesalius, we see on the other, Boehmer, Blumenbach, 
 &c., alleging reasons, that are apparently very plausible, to prove 
 that it is at least not founded on the state of the organ when unim- 
 pregnated. Both sides have often been right; but, by referring to 
 forced approximations, they have too often lost sight of the object 
 to render it possible to reconcile so many various observations. 
 
 Previously to asserting that the womb does or does not contain 
 muscular tissue, it would have been proper to determine what are 
 the characters of that tissue in general ; to show that the red colour 
 is not essential to it, since it is wanting in the muscles of fishes, 
 reptiles, and even in the muscular coat of the'human intestines ; and 
 that the same is true of the fibrous appearance, since it is met with 
 in the tendons, aponeuroses, &c., but that it alone enjoys the faculty 
 of contractility, and contains fibrine. 
 
 In the second place, it should be considered indispensable to re- 
 cognize a truth that is too much overlooked in our days : which is, 
 that the fleshy fibre must necessarily pass through several less perfect 
 gradations of development; that, in some organs, it remains in the 
 rudimental condition, and is developed only by accident. Thus, 
 the trachea, and the bronchia, even the arteries of large animals, the 
 elephant among others, evidently exhibit muscular fibres, \vliilc the 
 same organs in the human species rarely exhibit them with any dis- 
 tinctness. The gall bladder, the vcsiculac scminales, &c. are not 
 furnished with them, according to most of the modern anatomists ; 
 but let these organs be examined when their coats, strongly hyper- 
 tropbied, have been long distended, and we shall be soon forced to 
 admit that they possess a muscular coat, as the ancients believed, 
 and as I h.-ivc MTII myself. The womb, previously to puberty, is 
 only a rudimental muscle ; when not gravid, its ori>ani/ation, it is 
 true, is but a sketch, but it is only towards the end of pregnancy 
 that wo can possibly test its nature. Every circumstance tends to
 
 OF THE SEXUAL ORGANS. 65 
 
 establish that the cellule-fibrous, elastic yellow tissue which com- 
 poses the basis of the inter-laminar and inter-spinal ligaments of the 
 vertebras, constitutes also the web of a very great variety of other 
 organs. It is no where more abundant than in the uterus. Hence 
 it appears that this element holds a middle place, and serves in some 
 sort as a passage between the cellular and muscular systems ; the 
 chemists have detected fibrine in it, and I have seen it, on various 
 points, transformed into real contractile tissue. I am scarcely afraid 
 to assert that wherever it is met with, -.it may accidentally develope 
 muscular fibres, and that these fibres exist naturally in some zoolo- 
 gical species. 
 
 169. In order, therefore, to understand the essence of the uterine 
 tissue, it ought to be studied during its gravid state : then only is it 
 red, contractile, formed of tomentose fibres ; then only does it con- 
 tain a great proportion of the fibrine ; and presents, in a word, 
 all the characters of the most perfect muscular tissue. 
 
 170. Disposition of the fibres. Vesalius, Malpighi, and the first 
 anatomists who admitted their existence, contented themselves 
 with saying that the fibres of the womb are so interlaced, that 
 it is impossible to trace out their direction. Ruysch and some 
 others advanced, that being principally collected about the fun- 
 dus of the organ, they compose an orbicular muscle, a sort of disc, 
 the use of which is to detach the placenta at the period of labour. 
 Hunter, Sue, &c. admit that it forms a number of layers variously 
 crossed ; A. Leroy teaches that they give rise to two layers of 
 muscles, one internal and one external ; and M. Meckel, who in 
 common with several German anatomists, partially adopts this sen- 
 timent, thinks that each of the two principal, layers ought to be di- 
 vided into several other secondary layers. Baudelocque, and most 
 of the French anatomists, abandoning all hopes of assigning to these 
 fibres a determinate direction, have contented themselves with teach- 
 ing that they are disposed in loops, parallel to the axis of the uterus, 
 or in horizontal circles ; that the body and fundus of the womb* are 
 chiefly composed of the former, while the latter are found more 
 especially in the neck. Indeed it will be hereafter seen that great 
 stress has latterly been laid on this idea, which is relied on for the 
 Explanation of the process by which the cervix is effaced during 
 pregnancy, and dilated in labour, &c., and also the occasional 
 causes of parturition. Lastly, Madame Boivin, to whom we are 
 indebted for some valuable researches on this subject, has observed 
 a much greater number of fleshy layers in the womb than any pre- 
 ceding author. She admits, 1 . A longitudinal fascicle, which oc- 
 cupies the median line in front and rear ; and extends from the fun- 
 
 I
 
 66 OF THE SEXUAL ORGANS. 
 
 dus to the neok ; 2. On each surface of the organ, and on both sides 
 of the vertical column three layers of transverse fibres, which pro- 
 ceed to lose themselves, outwards, in the tubes, the ligaments of the 
 ovaries, the round ligaments, and the posterior ligaments ; 3. At 
 the superior angles of the uterus, and deeply seated, a circular layer, 
 the centre of which corresponds to the origin of the tubes, and which 
 interlaces and confounds itself with the opposite one ; 4. And lastly, 
 Very near the mucous surface, a layer that is thinner than any of the 
 others. > 
 
 I have myself dissected a very great number of wombs, at every 
 period of age, both unimpregnated and during the gravid state, and I 
 am convinced that each of these modes of regarding the subject has 
 some foundation. The imbrication noticed by Malpighi and his 
 predecessors is not to be disputed, and does not exclude the exis- 
 tence of the muscle spoken of by Ruysch. This last author, although 
 opposed by Heister, Haller, &c. was almost entirely right : it suf- 
 fices merely to examine the inner surface of the womb, at the close 
 of pregnancy, to recognize the stratum of muscular fibres he men- 
 tions ; only, instead of one orbicular disc admitted by the celebrated 
 Dutch anatomist, there are two. The two layers spoken of by A. 
 Leroy, Rosenberger, M. Meckel, &c. are completely apparent in 
 the last month of gestation ; but it must not be expected that they 
 can be found independent of each other. Considered in a general 
 manner, all these peculiarities agree together very well, and further, 
 they agree with the sentiment of those \vlio insist upon it that the 
 womb contains none but fibres arranged in loops or vertically, and 
 in circles or horizontally. 
 
 171. Conclusions. _ Upon, the whole, the following are what I 
 have most invariably observed on this subject. 1. Beneath the peri- 
 toneum there is a first stratum that is thin, dense, elastic, cellulo- 
 fibrous, and sometimes, but not always, muscular, in which the 
 fibres have no determinate direction ; 2. A thicker layer of transverse 
 fibres,' which, united in different planes, and imbricated like the con- 
 strictor muscles of the pharynx, all tend outwards, and converge 
 towards the four principal points mentioned by Madame Boivin ; 
 3. More deeply seated, are found other transverse fibres ; but the 
 longitudinal and oblique fibres predominate, especially at the neck, 
 where they constitute the basis of the ridges observed on the inner 
 surface of the organ ; lastly, above is seen the pretended detrusor 
 placenta of Ruysch, which seems to be nothing more than an ex- 
 pansion of the circular fibres of the Fallopian tubes. 
 
 The basis of all these strata is the yellow cellulo-fibrous tissue, 
 surcharged with fibrine ; the fleshy tissue developes itself in this pri- 
 mitive web as in the intestines ; but inasmuch as the womb seems to
 
 OF THE SEXUAL ORGANS. 67 
 
 be composed by the union of two cylindrical canals, and as it is 
 necessary that it should be endowed with great strength, it is not as- 
 tonishing that its multiplied fibres should affect the most complex 
 and varied directions. 
 
 172. d. Blood-vessels. Two orders of arteries are appropriated 
 to the gestative organs : one, known as the uterine arteries, furnish- 
 ed by the hypogastrics, penetrate into the substance of the womb at 
 the cervix ; the others, the ovarian, given off by the aorta or the 
 emulgents, pass along in the broad ligaments, and after being partly 
 distributed in the ovaries, proceed to the sides of the body of the 
 womb itself. In ramifying, those of the left side inosculate with 
 those of the right, those from above'witji those from below, and as 
 all of them are strongly compressed in the substance of the tissue in 
 which they creep, they are doubled and redoubled a great many 
 times. The veins, distributed in the same manner as the arteries, 
 go to the internal iliac vein from one part, and to the ovarian veins 
 from the other. During pregnancy, these various carials, partially un- 
 folded and largely dilated, run chiefly between the two fleshy strata 
 so much insisted upon by A. Leroy. 
 
 173. e. Its lymphatic vessels pass into the pelvic and iliac gang- 
 lions ; its nerves come from the sacral plexus, and from the gangli- 
 onic system by the renal and hypogastric plexuses. The former 
 are distributed almost exclusively upon the cervix, and if is natural 
 to attribute to them the excessive sensibility enjoyed by this part ; 
 while the latter, being here destined to furnish only the vegetative 
 sensibility, must be more regularly distributed to all parts of the 
 womb. 
 
 . II. Fallopian tubes (tuba Fallopiana}. 
 
 174. The uterine tubes, or Fallopian tubes, (seminiferous ducts} 
 are two small, hollow cylinders, four or five inches long, as large 
 as the barrel of a quill, and extending from the lateral angles of the 
 womb, with which they are continuous, to near the iliac fossae, 
 where they terminate in a laciniated and loose extremity, called th*e 
 devil's-bit (morsus diaboli,} or fimbriated extremity of the tube. 
 This tortuous tube is inclosed in the upper edge of the broad liga- 
 ment ; its cavity, which, at the womb, is large enough to admit of a 
 middle sized probe, at first contracts by degrees, so that near its 
 middle a bristle can scarcely be passed through it, it then enlarges, 
 and soon acquires a. diameter of two or three lines. Among the 
 fringes which terminate its loose extremity is one that is harder and 
 longer than the rest, which fixes itself to the ovary, and seems to be 
 the real continuation of the tube.
 
 68 OF THE SEXUAL ORGANS. 
 
 175. Structure. The composition of the seminiferous tubes is in 
 all respects similar to that of the uterus itself. They are enveloped 
 externally by the peritoneum, which adheres closely to them, and a 
 mucous membrane, folded in the direction of their length, lines them 
 within. A pretty thin layer of fleshy fibre is found betwixt these 
 two laminas ; its fibres are of two sorts, like as in the small intes- 
 tines : one sort, longitudinal, are only a prolongation of the trans- 
 verse stratum of the surface and fundus of the uterus ; the others, 
 which are circular, cut the former at right angles, and seem to be 
 appendages of the orbicular muscle of Ruysch. As to the internal 
 coat, its existence has been denied ; but to the proofs related above, 
 (166) I may add, that in a woman of middle age, I and M. Baude- 
 locque, Jun. saw the mucous membrane of the Fallopian tube as. 
 movable, and as easily separable, as it is in the oasophagus ; its valvu- 
 lar folds, mentioned by those authors who assert that the ovule may 
 easily pass to the womb, but cannot possibly retrograde towards the 
 ovary, and especially, that the semen masculinum cannot pass 
 through the tube, have been the products only of the imagination of 
 those who needed them for the defence of their preconceived theories. 
 The tubes receive all their vessels from the ovarian branches ; their 
 nerves belong to the great sympathetic, and like the uterus, their 
 basis is an elastic, fibrous, cellular tissue. 
 
 . III. Ovaries (ovaria) . 
 
 176. The ovaries, long known as the testes muliebres, and which 
 may be called the female seminal glands, are situated in the upper 
 part of the broad ligaments, behind, and a little below the tubes, 
 near the superior angles of the uterus, to which they are attached 
 by the ligament of the ovary. Oblong, slightly flattened from front 
 to rear, being of the size and almost of the shape of an almond or a 
 large bean, the ovaries have a superior, convex and loose edge, while 
 their inferior edge is straight, receives vessels, and proceeds to join 
 the ovarian fringe of the tube. Their surface even, or scarcely 
 botryoidal in women who have never been fecundated, presents, on 
 the contrary, in those who have had children, inequalities, fissures 
 and reliefs in a greater or less degree. Differing as much both in 
 appearance and nature from the salivary glands to which Pean com- 
 pared them, as they do from the seminal glands of the male, the 
 ovaries possess a structure which is peculiar lo themselves, as is the 
 case in all the special organs. A sort of parenchyma of a. reddish 
 grey colour, composed of lamellae and lilamrnts variously interlaced, 
 constitute their principal tissue. Since the time of 11. De Graaf, it is 
 admitted that there really do exist in this parenchyma certain
 
 OF THE SEXUAL ORGANS. 69 
 
 transparent vesicles, from twelve to twenty in number, and which 
 are denominated ovules or germs. In it also we occasionally meet 
 with accidental vesicles, true hydatids, which should not be con- 
 founded with the former, but which may possibly be only degene- 
 rated ovules. According to De Graaf, " vessels and preparative 
 nerves enter into these vesicles, on the tunics of which several of 
 their branches, after various divarications, distribute themselves, as 
 occurs in the yolk of the egg while it is still attached to its ovary." 
 A strong, thick, and very tough membrane serves as the shell or 
 envelope of this tissue; and according to my observations, this fibrous 
 membrane is only an appendage of the ligament of the ovary ; that 
 is to say, the ligament of the ovary, which is one or two inches in 
 length, and one or two lines thick, is formed by a fascicle, from the 
 transverse layer of the posterior surface of the uterus, and when it 
 reaches the point of the seminal gland, its fibres separate in order to 
 envelope the parenchyma in question. It is evident that the proper 
 tunic of the ovary is altogether distinct from the peritoneal layer, 
 from which, however, it is impossible to separate it. In naming it 
 dartos, it is probable that the ancients did not suppose that like the 
 dartos of the male, it approaches by its nature very nearly to the 
 contractile or muscular tissue. 
 
 177. Until the time of Fallopius, it was generally taught that the 
 germ was carried from the ovary to the uterus by different canals, 
 of which the tube did not constitute any part ; the ligament of the 
 ovary was supposed to be the principal one ; it formed th deferent 
 canal. Warthon and Mauriceau admitted one or two others, which 
 passed from the edge of the ovarium arid opened into the vagina ; 
 but it was long ago demonstrated that the ligamentous cord of the 
 ovary is solid, and contains no canal ; however, the other passage, 
 also forgotten for a whole age, has just been recalled to the attention 
 of naturalists by M. Gartner of Copenhagen, who looks upon it as 
 an organ that is always to be met with in the large quadrupeds. I 
 have vainly sought for it in the human subject, and found nothing 
 even remotely resembling it. The ovary is the essential organ of 
 generation, the organ in which germs are formed. 
 
 . IV. Ligaments of the uterus. 
 
 178. In investing the internal organs of generation, the peri- 
 toneum gives birth to several ligamentous folds, "which it is proper 
 now to describe. 
 
 Of these, the chief are the broad ligaments, which constitute a 
 transverse partition, and divide the whole depth of the pelvis into 
 two cavities, one anterior and the other posterior ; in the former the
 
 70 OF THE SEXUAL ORGANS. 
 
 bladder is situated, and in the latter, which is deepest, is found the 
 rectum ; the two lamina of the peritoneum, of which the broad 
 ligaments are composed, separate when they reach the sides of the 
 womb, in order to spread out on its surfaces ; downwards and out- 
 wardly, they also deploy so as to be continuous with the peritoneum 
 which lines the cavity of the pelvis ; their superior border, which is 
 loose, extending from the angles of the uterus to the iliac fossa, is 
 divided, as it were, into two or three secondary folds, which are 
 called its lesser wings : one of these, the posterior, encloses the 
 ovary and its ligaments ; another (the middle one according to M. 
 Dubois and the other authors who admit three of them ; but the 
 anterior one, according to Baudelocque, M. Desormeaux, and all 
 the accoucheurs who contend that there are only two) contains the 
 Fallopian tube, and is the highest ; the third, mentioned by some 
 and rejected by others, and which is in fact scarcely distinguishable 
 in the natural state, is found in front of, and lower down than either 
 of the preceding ones, and encloses the round ligament. The two 
 serous laminae of the broad ligament are not in immediate contact ; 
 they are separated by a layer of cellular tissue, of various thickness 
 in different individuals, and this layer, which downwards and out- 
 wards becomes blended with the sub-peritoneal cellular tissue or the 
 fascia propria of the pelvis and iliac fossae, is sometimes found to 
 contain muscular fibres ; so that we find, in the broad ligaments, 
 nearly the same elements as in the womb itself. 
 
 179. The round ligaments or sur-pubic cord*, fibrous bundles, 
 which take their rise in front of and a little below the Fallopian tubes, 
 follow the outline of the anterior semi-circumference of the superior 
 strait, and proceed, after passing through the inguinal rings, to ter- 
 minate in the groins and mons Veneris, are the only ones which have 
 been deemed, with the broad ligaments, worthy of attention. Formed 
 of reddish and wavy fibres, which rise from the anterior and middle 
 transverse layers of the womb, the round ligaments are evidently of 
 a muscular nature. Dionis asserted that the use of the round liga- 
 ments was to depress the os tineas by contracting during the sexual 
 embrace, and thus to bring it closer to the male organ ; but as their 
 origins are lower than their insertions, it is manifest that their con- 
 traction in that case would produce a rather contrary effect. But 
 further, the womb without them would be always retrovertcd by the 
 bladder, which 4s -repeatedly distended with ..urine in the course of 
 every twenty-four hours : they also" uphold it until towards the mid- 
 dle OT pregnancy; but further than this nothing is certainly known in 
 regard to their uses, and there is no occasion for me to enter into an 
 argument against (he opinion of the ancients, especially of Spigelius,
 
 OF THE SEXUAL ORGANS. 71 
 
 who supposed that the semen passed through them in its passage to 
 the clitoris. Being put on the stretch by the ascent of the womb, 
 it is possible that they may, when the woman is on foot, and parti- 
 cularly when on her knees, occasion pretty smart pains in the groins 
 and thighs. 
 
 180. Douglass, A. Petit, Sue, &c. have noticed four other liga- 
 ments, two anterior (utero-vesical of Madame Boivin), and two pos- 
 terior (utero-sacral, id.) ; the two former,' very small in most women, 
 passing from the sides of the cervix uteri to the lateral parts of the 
 bas-fond of the bladder, are occasionally composed, in addition to 
 their peritoneal coat, of a few fleshy fibres, that seem to be detach- 
 ed from the antero-inferior transverse layer of the neck of the womb. 
 The latter, which are much stronger and more constantly observed, 
 originate a little lower down, from the posterior surface of the cer- 
 vix, run backwards, each forming a crescent, the concavity of which 
 looks towards thfe median line, and are attached to the sides of the 
 rectum, where they are lost in the cellular tissue and peritoneum 
 which invests the front of the sacrum ; from numerous facts that 
 have come under my notice, I am of the opinion that they are of 
 the same nature as the round ligaments, and that their fleshy fibres 
 are furnished by the postero-inferior transverse layer of the uterus; 
 consequently, it may be conceived that they may tend to prevent the 
 retroversion of the womb, and be in this respect congeners of the 
 round ligaments ; that their use is to prevent the os tincse from being 
 carried forwards ; and that the knowledge of them is far from being 
 unimportant to the accoucheur. 
 
 . V. Of the Vagina. 
 
 181. The vagina or vulvo-uterine canal, an organ for eduction 
 and copulation, is a cylindrical canal, four o*r five inches long, by 
 about an inch in diameter, which extends from the vulva, where it is 
 continuous with the labia and hymen, up to the neck of the uterus, 
 to whose circumference it is attached. Its direction is nearly paral- 
 lel to that of the posterior walLof the'excavation, that is to say, it is 
 concave in front, and convex posteriorly, is situated in the axis of 
 the inferior strait, and' forms an angle of about sixty-five degrees 
 with the great diameter of the womb. From this disposition, it 
 happens that its posterior wall is much longer than the anterior, and 
 its two extremities being inclined towards each other in front, re- 
 present pretty correctly the planes of the two straits of the pelvis. 
 
 1 82. Connexions. Thfe posterior region of its external surface, 
 resting for the middle three-fifths of its whole extent on the fore part of 
 the rectum, assists in forming the recto-vaginal septum ; in approach-
 
 72 OF THE SEXUAL ORGANS. 
 
 
 
 ing the vulva its lower fifth leaves the rectum, at a distance equal to 
 the whole thickness of the perineum ; its superior fifth, loose in the 
 pelvis, is invested by the peritoneum. Its anterior region is con- 
 nected by means of a dense and firm cellular tissue, first to the bas- 
 fond of the bladder, so as to form the vesico-vaginal septum, then to 
 the urethra, which gives rise to the urethro-vaginal septum. The 
 sides of the vagina are surrounded with vessels, nerves, and a very 
 abundant cellular tela. 
 
 183. The interior of the vagina presents a number of wrinkles or 
 folds, analogous to those which are met with in the cavity of the 
 .cervix : the middle column of its parietes, sometimes divided into 
 two, three, or four small parallel columns, increases in thickness as 
 we approach nearer to the vulva ; the same is true of the transverse 
 folds ; so that the vagina, which is smooth, or almost smooth above, 
 is most commonly rugose and plaited below, like the palate in the 
 ruminating animals. I have already stated (1 44)", that below the 
 meatus urinarius and at the fourchette, these two middle columns 
 constitute the anterior and posterior myrtiform caruncles. Larger 
 in young persons who have never cohabited, and in brunettes with a 
 dry fibre, than in women who are in an opposite condition, all these 
 wrinkles are effaced during labour, but in general, reappear soon 
 afterwards. W&- + ^Mfr 
 
 184. The vaginal cavity terminates above in a circular groove, 
 or cul de sac, much deeper behind than in front. Supple, thin, and 
 situated between organs liable to alternate dilatation and contraction, 
 the sides of the vagina are habitually in almost complete contact; 
 but, as they are endowed with great sensibility, it happens that the 
 capacity of the vulvo-uterine canal varies considerably. Sometimes 
 it is found to be wider at its middle than in any where else, and 
 that is because the wdmb is too much depressed ; at other times it 
 is only the superior ,portion, especially in women who have had 
 children, that is found dilated as it Were ; which depends on the 
 neck of the uterus having remained after delivery lower than it was 
 before marriage. In fine, we shall .hardly find it of equal dimen- 
 sions throughout, except in those who have scarcely ever, as yet, 
 yielded themselves up to venereal enjoyments. 
 
 185. Structure. Two layers enter into its composition: one, ex- 
 ternal, a real prolongation of the external laminae of the uterus, has, 
 for its basis, the yellow cellulo-fibrous tissue, and contains a small 
 number of interlaced, very pale muscular fibres, which must not be 
 confounded with the elliptical muscular rings of its vulvar orifice, 
 and which belong to the constrictor vagina muscle. These latter, 
 indeed, act under obedience to the will ; the former, on the contrary,
 
 OF THE SEXUAL ORGANS. 73 
 
 are not brought into play except by the gratifications of love. Ar- 
 teries, and more especially numerous veins, pass through this tissue, 
 and form, particularly below, a real spongy or erectile stratum, which 
 swells under the frictions of coition, and may then contract so much 
 as manifestly to diminish the width of the vagina. 
 
 186. The other, internal, is continuous with the mucous mem- 
 brane of the vulva, and is blended, on the lips of the cervix, with 
 that which lines the cavity of the womb ; that half which is nearest 
 the pudendum presents all the characters of the most perfect mu- 
 cous lamina: ; in it are found an epithelium, follicles, villi, &c. Near 
 the neck it cannot be separated from the subjacent tissues, and, at 
 that point, nothing demonstrates the existence of follicles and villi. 
 It covers all the duplicatures of the vagina, but does not compose 
 them, whatever may have been said to the contrary by a crowd of 
 authors. The mucous follicles are principally seated at the bot- 
 tom of these folds, where also the venereal chancre is found to be 
 occasionally concealed. 
 
 187. Two small glands, noticed from time immemorial by the 
 anatomists, under the name of vaginal glands, or prostates of Bar- 
 tholin, and which have been erroneously classed among the simple 
 follicles, are to be seen under the lateral myrtiform caruncles, be- 
 twixt the mucous membrane and the muscular coat : their uses are 
 little understood ; M. Gartner, however, thinks they may serve as 
 the point of origin or termination of the canal discovered by him. 
 
 . VI. Of the sexual organs in general. 
 
 188. The sexual organs, taken as a whole, and regarded in a 
 philosophical light, may be considered as a dependency of the tegu- 
 mentary laminaa; that is to say, the mucous membrane consti- 
 tutes the most important and constantly present portion of them. In 
 the lower animals, as well as in those whose sexual system is in the 
 highest degree complex, the germs are always created at the bot- 
 tom of a mucous cavity, whether it consist of a simple excavation, 
 or constitutes a canal that is straight, tortuous, &.c. However, the 
 generative cavity is sometimes composed of a doubled homogeneous 
 lamina, of equal thickness throughout its whole extent, as in worms, 
 and the species that have no uterus ; sometimes, on the contrary, this 
 duplicaturc is at first very thin in one portion of its extent, becomes 
 in the next place very thick at another point, and gradually becomes 
 thin again in a third, as is the case in women. 
 
 189. Although, in the human species, the generative apparatus 
 forms, as it does in brutes, only a long canal reaching from the 
 ovary to the vulva, it exhibits to us, nevertheless, one of the most 
 
 K
 
 74 OF THE SEXUAL ORGANS. 
 
 perfect of tfie secretory apparatuses. The ovaries constitute its 
 glandular portion, the uterus is the reservoir, and the vagina the 
 excretory duct ; so that they may, in respect to their peculiar func- 
 tions, be divided into formative, productive, and transmitting organs 
 (the ovaria and tubes'), into gestative organ, (the womb), and into 
 eductive, conjunctive, or copulative organs (the vagina and vulva). 
 
 . VII. Varieties in the internal organs of generation in ani- 
 mals. 
 
 190. A long tube, extremely thin, double, wound upon itself 
 within the body of the animal, and terminating in a sort of vagina, 
 performs all the generative functions in the lumbricoid worms. 
 Fishes possess enormous ovaries, which contain as many as two 
 hundred thousand ovula, are continued without interruption into the 
 oviducts or tubes, and have a directly external opening. The ova- 
 ries of reptiles resemble bunches of grapes, but of various lengths ; 
 in birds they present numerous cells, in which the eggs are lodged ; 
 the oviduct, always open and trumpet shaped at its superior extre- 
 mity, terminates, below, in the cloaca, which supplies the place of a 
 vagina. The mammiferse alone possess an uterus, but with the ex- 
 ception of that of the monkey, it is very different from the human 
 womb ; yet their fallopian tubes and ovaries differ only by slight 
 shades from those of women. Almost all the rodentia, the rumi- 
 nantia, the solipedes, the amphibia, &c. possess a womb divided into 
 three cavities; a middle one, which represents the neck, and two 
 lateral ones, called the horns, which must not be confounded with 
 the Fallopian tubes. These horns, or aduterwn, are generally very 
 long, and sometimes are two, three, or four times as long as the cervix, 
 which in the Guinea pig, the hare, &c. can scarcely be said to exist 
 at all. Hence it may be said, that there are in reality two wombs, 
 two tubes, and two ovaries for one single vagina. 
 
 191. Separated in some instances by a very decided contraction 
 from the vulva, and in others continuous, without any line of demar- 
 cation, with the vulva, sometimes twice or thrice as long as the vul- 
 var canal, as in the bitch, sometimes, on the other hand shorter, as 
 in the bear, the vagina of the mammiferie exhibits numerous varie- 
 ties, in respect to its dimensions, the arrangement of its folds, and 
 its connexion with the womb. 
 
 But the most remarkable genital system is that of the didelphic 
 or marsupial animals : besides the tubes, their womb is composed 
 of two horns, each of which opens by an orifice furnished with a 
 valvular cushion into a third cavity, largely expanded, of the shape 
 of a cul dc sac. This cul do eac rests upon the vagina, and sepa-
 
 OF THE SEXUAL ORGANS. 75 
 
 rates it from its horns, but does not open into its cavity. It sends 
 off a small canal which proceeds downwards and backwards, then 
 mounts upwards in a semicircular manner to the orifice of the vagina, 
 where it opens. Further, on the lower part of the belly, they have 
 a very complicated kind of sac, which contains small teats, and 
 where their young are deposited at a very early period ; as if for a 
 second gestation. 
 
 192. Careful dissections of most of the large animals confirm 
 what I have now advanced, touching the nature of the peculiar tis- 
 sue of the sexual organs of the human female (168): the muscular 
 fibres are very evidently seen in the uterine horns of the cow, the 
 mare, &c. where they affect the same arrangement as the small in- 
 testines : the same is true of the cervix, where their direction is 
 chiefly transversal, and of the broad ligaments, where they consti- 
 tute several distinct bundles. 
 
 . VIII. Difference according to ages. 
 
 193. In the early periods of uterine life, the ovary, very large, 
 and particularly very much elongated, forms a sort of yellowish sac, 
 which is uninterruptedly continuous with the Fallopian tube, as in 
 fishes. Very small in proportion, very slender, and almost lost in the 
 middle of the broad ligaments, it is thicker the nearer we come to the 
 vagina, above which it terminates by a neck that is soft, very pro- 
 jecting, and of a considerable size ; at the ninth month the vagina 
 is very long, and wide enough to admit of the introduction of the 
 finger ; its mucous membrane, as well as that of the cervix, is very 
 evident ; but the body of the womb is so firm, that it would be diffi- 
 cult to separate its different tissues. From birth to puberty the 
 genital organs of the young girl undergo no special change ; nothing 
 in them discloses the great part they are destined at some period to 
 play in the economy, and they merely follow in their evolution the 
 progress of that of the constitution. At the age of from twelve to 
 eighteen years, they awake from their long stupor. The womb 
 rapidly attains to double the size it had previously acquired, both in 
 breadth and thickness ; the base of the wedge, which it resembles, 
 instead of remaining low down, rises higher up, and thenceforth the 
 woman commences a new aera. Although not so marked, yet the 
 changes that take place in the ovaries and Fallopian tubes are not the 
 less undeniable. 
 
 As long as a woman has had no children, the genital organs re- 
 main in this state ; after one or more pregnancies, the ovaria become 
 covered with protuberances, wrinkles or cicatrices, and they still 
 increase a little in size. The tubes, almost strangers to the great
 
 76 OF THE SEXUAL ORGANS. 
 
 revolution operated in the general system, scarcely differ from their 
 condition previously to the first pregnancy, or from what they will be 
 at a ripe age, unless affected by diseases, of which they often become 
 the seat ; the form and proportions of the uterus remain unaltered, 
 only it continues of a rather increased size. The vagina becomes 
 shorter and wider, while the strength of the round ligaments is more 
 or less augmented. In old age the ovaria are atrophied, become 
 elongated, and of a very irregular shape ; the womb tends again 
 back to its original size ; the cavity of its body becomes so contract- 
 ed, that the stricture which connects it with the neck is sometimes 
 found to close it completely up, as has been very judiciously indicated 
 by M. Mayer. 
 
 I 
 
 . IX. Anomalies. 
 
 194. The anomalous conditions of the sexual apparatus, which 
 are as numerous as they are diversified, all seem to depend upon a 
 want, an arrest, or an aberration of development, or on a disease 
 occurring anteriorly or posteriorly to the period of birth. 
 
 195. No authentic case exists of a complete and simultaneous 
 absence of all the internal female organs of generation ; but Chaus- 
 sier, Madame Boivin, M. Duges and Cassan, have made mention of 
 a person who had only one ovary, one tube, and so to speak, only one 
 half of the uterus. The absence of the ovaria has been ascertained, 
 in more than one instance, although the other parts of generation 
 were in a natural state : only one was absent in the case mentioned 
 by M. Jadelot. M. Renauldin has seen them reduced to the smallest 
 possible size in a woman about forty years of age ; the Graafian 
 vesicles may fail to become developed in them, and that necessarily 
 occasions sterility. 
 
 1915. The tubes are rarely found wanting, nor do they often de- 
 viate from their ordinary direction ; but they occasionally become 
 accidentally closed, sometimes near the ovary, and at others at a 
 point nearer to the uterus. 
 
 197. M. Renauldin gives a very remarkable case of absence of 
 the uterus : the cervix alone existed in a rudimental state. This 
 fact is confirmatory of those previously reported by Bousquct, The- 
 den, Engcl, Lieutaud, M. Caillot, and of the one recently made 
 public by M. Breschet. Sometimes the womb is very much elon- 
 gated, as in the monkeys ; it is oftencr found divided into two equal 
 or unequal portions, either partially or completely, internally or only 
 externally, and sometimes on both surfaces at once. Sometimes 
 there i.s a sort of accidental sac superadded to the natural organ, 
 into which it opens, as in the case related by Dionis ; or, on the
 
 OF THE SEXUAL ORGANS. 77 
 
 contrary, with which it has no communication, as in the example 
 given by Canestrini. Most generally, the division is at the median 
 line, either externally and at the fundus, as in one instance furnished 
 in the Leipsic Commentaries and another related by Eisenmann, 
 or on the posterior surface, as in Morgagni's case, or on the fundus 
 and both surfaces at the same time ; and then the womb, really two- 
 horned, resembles more or less that of the quadrupeds. Sometimes 
 the division comprises only the superior part of the organ, which at 
 other times is separated quite down, into two portions ; sometimes 
 the two horns unite at an acute angle, and touch at their corres- 
 ponding surfaces ; in other cases they affect a transverse position, 
 and only unite at the upper end of the vagina, so as to form the cer- 
 vix. Internally, the septum is also far from being always of the 
 same magnitude. At times it is only a little spur that divides the 
 fundus of the uterine cavity into two sinuses, as in the example cited 
 by Eisenmann. In the specimen deposited at the Museum of the 
 Faculty, by M. Dupuytren, it is simply represented by a double me- 
 dian crest, attributable to an hypertrophy of the natural vertical 
 columns of the cavities of the body and cervix. This septum may 
 stop at the superior part of the cervix uteri, or descend as low as 
 into the vagina ; it may be complete, and divide the womb into two 
 perfectly distinct cavities, or may be pierced in some portion of its 
 length, and allow one of the cavities to communicate freely with the 
 other. The neck itself may be single, as in the instances related by 
 Bauhin, Sylvius, Riolan, Celti, Purcell, Marquet, Ferlan, Tiedemann, 
 Madame Boivin ; or double, as in the cases of 'Grosel, Mademoseille 
 De la Marche, Cruger, Bartholin, Haller, Litre, De Tressan, Eisen- 
 mann, Callisen, Boehmer, Tiedemann, MM. Lallemant, Dupuytren, 
 Dumeril, Dubois, West, Cassan, Recamier, Gamier and Ollivier 
 D' Angers, and in a case that I saw in a womb, the account of which 
 was recently published by M. A. Berard. 
 
 198. In all these cases, the uterine orifices opened into a simple 
 or double vagina, according to circumstances ; but in a subject 
 dissected by Saviard and Duverney, one of them opened into the 
 rectum, while the other maintained its natural disposition. A simi- 
 lar case may be found in the works of Valisnieri ; at any rate, whe- 
 ther the os tineas be simple or compound, whether it be the termi- 
 nation of a two horned womb, or of one of a perfectly natural form, 
 it is not extremely uncommon to see it terminate in the rectum, the 
 bladder, or urethra, or even in the hypogastrium, above the pubis. 
 
 199. Is it now necessary to remark that the question so long 
 debated, as to double uteri, resolves itself into a mere logomachy ? 
 If by double uterus we are to understand the simultaneous existence
 
 78 OF THE SEXUAL ORGANS. 
 
 of two wombs, each possessed of two tubes and two ovaries, it is 
 clear that none such have been met with ; if, on the contrary, to 
 constitute this condition it is only necessary to have a more or less 
 complete division of the natural uterus into two equal or unequal 
 parts, each one having its own tube, ovary, cavity and cervix, there 
 are too many examples, it is an anomaly too often observed, and too 
 easy to be explained according to the laws of the animal economy, 
 to permit us to entertain the shadow of a doubt about it at the pre- 
 sent day. 
 
 200. The gestative organ is subject to other irregularities. M. 
 Baudelocque discovered, and had a drawing made of a preternatural 
 canal, which extended from the right tube to the cavity of the neck, 
 passing in the substance of the parietes of the womb. Madame 
 Boivin also makes mention of a kind of irregular canal which seemed 
 to form a communication betwixt the ovary and the superior part of 
 the vagina ; and perhaps there is no great difference between this 
 anomaly and the canal mentioned by M. Gartner. Several authors 
 have spoken of wombs obliterated either wholly, or in part j either 
 by a primitive faultiness of the development, or accidentally ; the 
 cervix uteri rnay present a considerable length and size, as in the 
 remarkable cases cited by Bichat, MM. Lallemant, Segard, Gar- 
 dien, &c., and its position may be deranged by preternatural adhe- 
 sions, which fix one of its faces or edges too near the margin of the 
 pelvis, either in front, on one side, or backwards. The ovaries may 
 escape from the pelvis through the openings at the groins, descend 
 into the upper part of the labia pudendi, or pass over to the side 
 opposite to that they ought to occupy, and become entangled with 
 the tubes in such a manner as to be extricated with difficulty, as in 
 a case that fell under my own notice. 
 
 201. Vicious conformations of the vagina are not less frequent 
 than those of the womb. Its total absence is pretty common. MM. 
 Boyer, Caillot, Willaumc, and an infinity of others, have seen it ter- 
 minate in a cul de sac above the vulva, and not open externally 
 at all ; in some cases its vulvar opening exists, but is obliterated 
 above, and does not extend to the uterus. All the students of the 
 school of Paris may have seen a woman of this conformation a few 
 months since in the wards of the Hotel-Dieu. I have observed a 
 similar disposition in a woman of about thirty years of age, who had 
 been delivered of a child five years previously, and had not had her 
 menses since that period. In M. Sue's case the rectum opened 
 into the vagina, and the vagina into the bladder ; nevertheless, the 
 vulvo-utcrinc passage may open into the bladder of urine, without 
 the bowel being at all deviated from its natural course, as is proved
 
 OF THE SEXUAL ORGANS. 79 
 
 in the cases related by Maret, Palfin and Cassan ; the vagina is more 
 frequently found to terminate in the rectum, at various distances 
 from the anus. The septum which divides it is pretty often com- 
 posed either of a simple fr.cenum, connate or accidental, situated 
 transversely, or parallel to its axis, near the vulva or cervix, or 
 towards the .middle of the canal; or, of a valvular fold, more or less 
 strong ; or, of a real diaphragm. I .have observed all these differ- 
 ences both in the living and dead subject. This septum may give 
 to the vagina the appearance of two united cylindrical canals, each 
 having a hymen, as occurred twice to Callisen and once to Eisen- 
 mann, or a single external opening, as noticed by Bartholin and Hal- 
 ler ; sometimes it exists only above and below, and allows the two 
 vaginas to communicate with each other, about their middle or near 
 the neck ; most frequently, as remarked by Majocchi, Bcehmer, 
 Cassan, &c., it does not reach to the vulva, and further, is in general 
 only the continuation of a similar disposition of the womb. 
 
 202. If such observations were good for nothing but to satisfy an 
 idle curiosity, I should not have dwelt so long on them ; but many 
 of them are closely concerned with the practice of tokology ; others 
 explain several phenomena, of which it would be otherwise difficult 
 to give any account : sterility, several kinds of extra-uterine preg- 
 nancy, superfetation, retention of the menses, fecundation and de- 
 livery through the anus, and want of menstruation, are cases in 
 point. When the womb is double, if the woman becomes preg- 
 nant in one side only, and there are, meanwhile, two orifices, quite 
 separate from eacli other in the vagina, two different persons, al- 
 though equally learned, may establish a very different diagnosis, 
 even during labour. Two distinguished physicians, says Tiedemann, 
 met together to see a woman who supposed herself on the point of 
 lying in ; having touched her, one declared that the neck was in a 
 natural state ; the other found it dilated, and said that the head was 
 engaged. Another examination showed them that the neck was 
 double. M. West laid before the Academy of Medicine a nearly 
 similar case, collected at the Maternite of Paris : at the commence- 
 ment of the labour one of the pupils not only thought that dilata- 
 tion had not begun, but that the neck was not quite effaced ; the 
 other found it dilated nearly one inch ; the woman having died in 
 labour, the post mortem examination showed the reason of this dif- 
 ference of opinion ; the womb, which was double, terminated by a 
 double os tincae in the vagina. 
 
 203. If by imagining laws we could compel nature to obey them, 
 I should be content to say with Tiedemann and Meckel, that a ma-
 
 30 OF THE SEXUAL ORGANS. 
 
 
 
 jority of the irregular conformations of the genitalia are only in- 
 stances of a persistence of their primitive, but natural state of organ- 
 ization ; that the uterus bicornis, for example, depends upon this, that 
 the two half cylinders which are said to.constitute its first rudiments, 
 have disobeyed the laws of conjunction discovered by M. Serres: 
 but, unfortunately, it happens in this as in most other cases, the mo- 
 tives, the causes escape our research, and these brilliant concep- 
 tions have but one fault, and that is they do not agree with actual 
 observation. I am bold to affirm, from numerous researches, that 
 the womb and vagina in reality present from their very first appear- 
 ance, the same form and the same general characters, as those they 
 possess after their complete development. 
 
 . X. Hermaphrodism. 
 
 204. A being in whom two sexes are united is called an herma- 
 phrodite; this name, according to fable, is derived from Hermaphro- 
 dite, the son of Mercury (gf) and Venus (A$5o<f/Tc), who was 
 condemned by the gods to unite his body to that of Salmacis, for 
 having despised the charms of that nymph. Often debated in the 
 courts of justice in times past, and by the physiologists of all ages, 
 the question of hermaphrodism or androgyny, almost wholly aban- 
 doned towards the close of the last century, seems on the point of 
 coming up again to divide the opinions of the learned. In the mo- 
 noecious plants, in zoophytes, and various molusca, such as the oys- 
 ter and snail, the two germs are found to exist in the same indivi- 
 dual ; but the sexes are observed to be separate in the dioecious 
 vegetables, and in the animal kingdom, in worms,- insects, and also 
 in fishes, reptiles, birds, and mammiferous animal.s. So that her- 
 maphrodism in the human species is, at least to all appearance, 
 contrary to those laws that preside over the grand distinctions of 
 living beings. Notwithstanding this, M. Tiedemann, setting out on 
 the principle that the embryo is at the beginning neither male nor 
 female, admits the possibility of hermaphrodism, and his opinion is 
 maintained in Germany by M. Meckel and several other physiolo- 
 gists. It is true that a strange assemblage of organs has been fre- 
 quently noticed, which, though in the same subject, appeared to 
 belong to diiU-rent sc.xos.; but all cases of this sort, when divested 
 of the marvellous with which ignorance or the love of the marvel- 
 lous h;is cldthcil them, may be. easily c.l:isscd with some kind of 
 monstrosity of one or the other of (lie sexes. No individual has 
 9 both I ho male and female genital organs. 
 
 On -inn.- orr.iMons ;m mormons clitoris lias induced the belief that 
 individual wa.-> at once male and female, and, like some of the
 
 OF THE SEXUAL ORGANS. 81 
 
 gasteropoda, capable both of fecundating and being fecundated. 
 Sometimes it is a slightly developed penis, an hypospadiaeos, a slit in 
 the scrotum, that have been mistaken for a vulva and clitoris, as in 
 the case recently presented to the Academy by M. Rullier, and 
 that which all the physicians in Paris may have had an oppor- 
 tunity to examine in a man who exhibited himself for a long time 
 here to the public. At other times it is either a prolapsion or a pro- 
 longation of the cervix uteri which inexperienced observers have 
 mistaken for a penis, as happened with the judges of Toulouse in 
 the famous affair of Margaret Malaure. 
 
 In certain cases, however, one might be considerably embarrassed 
 in forming an opinion : a person who possessed all the external 
 characters of a pretty woman, presented herself to M. Marjolin, and 
 begged him to examine her and inform her to which sex she be- 
 longed : in the labia of a pretty well formed vulva, the professor 
 felt two oblong tumours, which were of the size of the male tes- 
 ticles ; there was a vagina which terminated in a blind sac behind 
 the pubis, and the bladder opened under the root of a body, which 
 bore a much stronger resemblance to the penis than to the clitoris. 
 Professor Mayer dissected a child six months old, that had no vulva, 
 but a penis perforated with an urethra, and on the sides of which 
 were observed two small roundish tumours inclosed in a fold of skin, 
 and yet it had an uterus. 
 
 205. I think, without, however, being able to affirm it, that the 
 person examined by M. Marjolin was a female, with congenital her- 
 nia of the ovaries and preternatural development of the clitoris ; 
 M. Mayer's case was certainly a girl, also affected with hernia of 
 the ovaries, and whose vagina opening into the bladder, was con- 
 tinuous with the urethra. 
 
 206. It may therefore be admitted, agreeably to the sentiments of 
 M. Marc, that hermaphrodism is only apparent, and its species may 
 be divided into three genera : one in which there is monstrosity in the 
 male ; the second, in which the feminine sex cannot be mistaken ; 
 and the third, in which it is not so easy to characterise the individual. 
 The Memoirs of the Academy of Sciences, those of the Academy of 
 Dijon, the Philosophical Transactions, the Bulletins of the Faculty 
 of Medicine of Paris, a Memoir by M. Pierquin, almost all the sci- 
 entific collections, a work by the learned German professor Bur- 
 dach, contain numerous cases more or less analogous to those I have 
 above analyzed. 
 
 L
 
 82 
 
 CHAPTER II. 
 
 Functions of the Sexual Organs. 
 
 . i 
 
 ARTICLE I. 
 Of Menstruation, or the Catamenial Discharge. 
 
 207. Puberty, or the marriageable age, is announced in girls, as 
 it is in boys, by numerous changes. The general organization, 
 which, until that period, had progressed alike in both beings, seems 
 suddenly to take an opposite direction in each. The young girl be- 
 comes more timid and reserved ; her form becomes more rounded, 
 her voice alters, but to take on a softer and more harmonious tone ; 
 her bosom is developed ; the cellular tissue extends from the front 
 of the breast and the hypogastrium, as from two centres, towards the 
 neck, while it at the same time proceeds to form a soft cushion for 
 the upper part of the limbs. Her eyes, which are at once brilliant 
 and languishing, express commingled desires, fears, and tenderness ; 
 the sensations she experiences, and the sense of her own weakness, 
 are the causes why she no longer dares to approach the companions 
 of her childhood but with a downcast look. On the other hand, the 
 gentle modesty that animates her countenance, and the seductive 
 graces of her demeanour, soon disclose a power whose existence 
 she never suspected, and which renders it true to say that the mar- 
 riageable age in the softer sex is the spring tide of nature and the 
 season of the pleasures ; but a new function, the catamenial, the abso- 
 lute compass of good or bad health in women, is established with 
 more or less difficulty in the naidst of this great revolution, and by 
 the disorders or accidents which it involves, sometimes dashes with 
 bitterness those happy seasons to which it should naturally serve as 
 the prelude. 
 
 208. Definition. Menstruation consists in a sanguineous dis- 
 charge from the sexual parts. It is a natural function, to which 
 women have in all ages of the world been subject. The supposi-
 
 OF MENSTRUATION. 83 
 
 tions of Emmet, of Roussel, of M. Aubert, &c. who think that the 
 menses are the result of civilization, appear to me wholly unfounded. 
 Neither is it true that the women of the arctic pole, the aborigines of 
 Brazil, and of some other countries in America, are exempt from 
 them. Nothing, however, of the kind exists in animals, with the 
 exception of the ourang-outang, some of the monkeys, and the bat, 
 which, according to some naturalists, are subject to a periodical dis- 
 charge. If, in other species, such as the quadrupeds, the cetaceae, 
 birds, &c. we sometimes find that a coloured mucus escapes from 
 the cloaca or vulva, it will be, in general, only at the approach of the 
 season for copulation, and it would be unreasonable to compare this 
 phenomenon with the function of menstruation. 
 
 209. The menses, still known among the common people as the 
 regies,* lunes, mois, Jleurs or flueurs, purgation, affaires, and epo- 
 ques, appear at puberty, and cease with fecundity, during pregnancy, 
 and while the woman gives suck. As soon as they appear, fecunda- 
 tion is possible, and as long as they continue to return at the natural 
 period, we may conclude that the woman has not conceived. Ob- 
 servers have often made mention of women who were not regulated, 
 and had never been so, but who enjoyed, nevertheless, a good state 
 of health ; it is to be observed, however, as remarked by Linnasus, 
 that they were sterile. I am acquainted with a lady who is not re- 
 gulated, ruddy, and of a good size, in blooming health, married for 
 ten years, whose greatest desire is to become a mother, but who has 
 lost all hope of becoming so ; her husband, moreover, is young, loves 
 her tenderly, and before he married her had begotten a child by an- 
 other woman. I have seen another at the hospital of Tours, who 
 had never seen any thing, as she expressed it, but who, notwith- 
 standing, was the mother of a strong and healthy son of fifteen or 
 eighteen years of age. It seems to me to be almost certain that 
 the absence of the menses generally depends upon some faulty con- 
 formation of the womb or its appendages ; so that it may be easily 
 conceived that it is generally a sign of sterility. Deventerand Bau- 
 delocque have known women who were never regular except during 
 pregnancy, and I have collected several similar cases. 
 
 210. Eruption. In our temperate climes the menses commence 
 between the twelfth and sixteenth year ; a little earlier, from eight 
 to twelve years, in southern climates ; and a little later, from fifteen 
 to twenty years, in the north. Some travellers even pretend that the 
 
 * I have left the French terms in this place untranslated, for they are unsus- 
 ceptible of translation. I have preferred to give in a note the English names in 
 common use. They are menses, flowers, monthly discharge, show, regular dis- 
 charge, monthly*, time, and most commonly they are alluded to with a nod. M.
 
 84 OF MENSTRUATION. 
 
 Turkish women are capable of becoming mothers at the age of seven 
 or eight years. Dr Prideaux, for example, relates that Cadijah, 
 aged five years, was regular when Mahomet espoused her. But 
 this story, like most others that come from countries of whose man- 
 ners and customs we know so little, is only a popular tale, for I 
 find in a faithful translation of the Koran, that Cadijah was upwards 
 of forty years old when she married the prophet. Others tell us, 
 that near the poles, and on the northern slopes of mountains, it is 
 not uncommon for the menses not to appear until the twenty-third 
 or twenty-fourth year. 
 
 211. The discrepancies presented by opposite climates in mass, 
 is found to be true in the details in every country, and occasionally 
 in every province and city. A country life and occupations, sim- 
 plicity of manners, a frugal regimen, like the temperature of northern 
 regions, procrastinate the first menstrual epoch ; a life of leisure, the 
 imitative arts, such as painting and music, the habit of frequenting 
 balls, the theatre, lascivious books and pictures, good living, the use 
 of stimulating drinks, and living in populous cities, tend on the other 
 hand, like the temperature of the equatorial latitudes, to accelerate its 
 appearance. It is less precocious also in a robust woman, of a 
 lymphatico-sanguine temperament, very fat, and whose sensibility is 
 not very acute, than in those who are thin, delicate, nervous, irri- 
 table and sanguine. Even at Paris, girls are occasionally observed 
 to become regular at ten, eleven and twelve years : I know two who 
 were so, one at nine and a half, and the other at ten and a half years ; 
 and I am in the habit of visiting a family where the young lady, who at 
 fourteen, is as tall and robust as a majority of women at twenty, has 
 been entirely in a state of puberty since she was eight years and a 
 half old. Children are also spoken of who were regular at birth, or 
 between the first and fifth year of their age, but it is reasonable to 
 suppose that this discharge must have been owing to some disease, 
 or at least had nothing in common with the catamenial flow. On 
 this subject I cannot however withhold a case recently made public; 
 it is that of a young girl at Havannah, whose menses appeared first 
 when she was eighteen months old, and have since that continued to 
 return once a month ; the child, moreover, has a bosom, a very de- 
 cided character of countenance, and all the marks of anticipated 
 puberty. Other persons also are seen at this capital, who did not 
 menstruate until their seventeenth, eighteenth, nineteenth, or twen- 
 tieth years. Osiander noticed at Gottingen, that of one hundred 
 and thirty-seven women, nine became regular at twelve years of 
 age, eight at thirteen, twenty-one at fourteen, thirty-two at fifteen, 
 twenty-four at sixteen, eleven at seventeen, eighteen at eighteen, ten
 
 OF MENSTRUATION. 85 
 
 at nineteen, eight at twenty, one at twenty-one, and one other at 
 twenty-four years of age. 
 
 Preceded, commonly, by a sense of general lassitude, of uneasiness 
 in the limbs, of weight in the loins, of heat, of tension in the epigas- 
 trium and perineum, by a slight pruritus of the sexual parts, by a mu- 
 cous discharge, that is clear or yellow, and more or less abundant, it 
 happens also that the first eruption of the menses is in many women 
 effected without its being announced by any precursory symptoms ; it 
 is then rarely abundant, nor does it commonly last more than two or 
 three days. In general they do not become regular until after three 
 or four periods ; in the succeeding appearances, the discharge lasts 
 variously from a few hours to a week, but the average term is four 
 or five days. 
 
 212. The quantity of blood that escapes amounts, according to 
 Hippocrates, to two cotylae, or to eighteen ounces according to 
 Galen. Haller computes it at six, eight, or twelve ounces, and Bau- 
 delocque at only three or four ounces ; in general it is more profuse 
 in persons and places where its appearance is most precocious, so 
 that. European women who go to inhabit a warm climate, as for 
 example Batavia or Java, often perish in consequence of their pro- 
 fuse menstrual evacuations. M. Desormeaux has remarked, and I 
 have also had occasion to observe it, that country girls who come to 
 Paris to go to service, not unfrequently find that their menses are 
 stopped or considerably diminished. As the different periods are 
 not always alike in the same woman, as they are sometimes more 
 abundant or less so every second or third period, alternately, it 
 is impossible to have any certain data on this subject. Again, as 
 the blood that flows from the organs can only be collected on cloths 
 or in water, it is manifest the observer must frequently make up an 
 erroneous opinion, and that he ought to count upon obtaining merely 
 approximative results. 
 
 213. Nature. The minds of the ancient physiologists were 
 strongly exercised in regard to the catamenial blood. It is similar, 
 says Hippocrates, to that of a slaughtered animal ; or again, accord- 
 ing to Aristotle, to that which flows from a simple wound. There 
 are now but few opponents of this system among medical men. But 
 very different ideas prevailed at Rome in the time of Pliny, and are 
 still very commonly upheld among the public. If we might believe 
 the celebrated Roman naturalist, the menstrual fluid, endowed with 
 the most noxious qualities, would be considered as a dangerous poison, 
 whose exhalations alone are sufficient to turn all the sauces of a whole 
 kitchen, the cheeses of a whole dairy, to make a whole family sick, and 
 wilt all the flowers of a parterre ; travellers inform us that even now,
 
 86 OF MENSTRUATION. 
 
 in some parts of America, women are so much dreaded during their 
 menstrual periods, that they are forbidden to go out of doors except 
 in cases of urgent necessity ; and further, that they are obliged to 
 wear a mark that advertises people of their situation, so that they 
 may flee out of their way. While ridiculing, as they deserve, such 
 fables as these, the moderns have perhaps too much neglected that 
 portion which may be true. It is very rarely that a vulgar prejudice 
 does not contain some truth. If we reflect on the odour derived 
 from the different secretions of animals, or the aroma exhaled from 
 the skin of certain women, is it fair to reject without distinction all 
 that has been said in relation to the menstrual excretion ? I am 
 certainly far from giving credit to the peculiarities related by Pliny, 
 Columella and the Arabians ; but I do not see why the miasms that 
 escape from a female during the flow of her menses, should be in- 
 capable of turning a fluid so easily affected as milk, nor why it could 
 not possibly have the same effect on certain sauces. Besides, it is 
 evident that blood retained for some time within the sexual organs, 
 particularly of women who are inattentive to cleanliness, may, by 
 being decomposed, acquire certain deleterious properties. 
 
 Its odour is too variable to permit us to compare it to the marigold, 
 rather than to any thing else. From its being found fluid, although 
 long retained in the womb, we are not authorised to conclude with 
 M. Lavagna, that it contains no fibrine ; we too frequently see it 
 escape in clots from women who get up to walk about after having 
 bsen long in a sitting posture, to be able to say with Dionis, that 
 menstrual blood never coagulates. According to all appearances, 
 it contains less fibrine than that from other parts of the body, but is not 
 entirely without it. Being mixed with the mucous and serous mat- 
 ters naturally furnished by the internal surface of the genital organs, 
 the menstrual blood is thus rendered more viscous, and ought not to 
 exhibit the same characters as that which escapes from a wound. 
 
 214. Progress. The menstrual fluid is, in most women, at first 
 very liquid, serous, scanty, and not high coloured ; its consistence 
 and quantity increase on the second day ; on the third it is in almost 
 every respect similar to the blood that escapes from the nose in 
 epistaxis ; the fourth restores to it the characters of the second, and 
 on the fifth its appearances are analogous to those of the first ; some- 
 times, on the contrary, the evacuation has a slower course, and is 
 not really abundant until the fourth or fifth, while in others the blood 
 flows from the commencement in as great a quantity as on the second 
 or third days. In some cases it appears one day, does not return 
 the next, and flows in abundance afterwards. It most commonly 
 comes away in the shape of simple small drops, which flow fast,
 
 OF MENSTRUATION. 87 
 
 and some women are obliged to be very careful to prevent it from 
 falling in quantities to the ground. 
 
 215. The periodical return of the menses ordinarily takes place 
 every month, as their name indicates, or rather every-twenty-eight or 
 twenty-nine days, which brings them into relation with the lunar 
 periods ; in an infinity of people they are observed to recur at nearer 
 or remoter periods ; sometimes only twenty-two, twenty, eighteen, 
 and even fifteen days elapse between each catamenial revolution ; I 
 know a person who is never more than twelve days free from it ; 
 and I have the care of another who is almost always affected with it, 
 but who in other respects is in good health, only she is thin, and of 
 an extreme sensibility. These frequent returns of the menses, with- 
 out any peculiar change in the health, are particularly to be ob- 
 served in warm countries, and in nervous women. The emaciation 
 which attends this state is at the critical period frequently succeeded 
 by plumpness more or less decided, as if the sanguine discharges to 
 which nakire had become accustomed were now turned to the 
 benefit of the whole organism ! 
 
 Others are regular every thirty-second, thirty-fifth, or fortieth day, 
 and even every two or three months, without being in the least in- 
 commoded, as is pretty frequently observed to be the case in Green- 
 land, Lapland and other cold countries ; and neither is it uncommon 
 to observe the same thing in our own country places ; but none of 
 these anomalies contradict the principles established by physiolo- 
 gists in all ages. 
 
 216. Without daring to set up the simple results of my own ob- 
 servations, in opposition to those who assert that all women are 
 regular in the first fortnight of the month, half from the first to the 
 eighth, and the rest from the eighth to the fifteenth, I cannot refrain 
 from stating that I have seen as many who were menstruating at 
 the close as at the beginning of each month in the year ; I therefore 
 do not believe it possible to establish any thing certain on this head. 
 
 217. Causes. Physiologists have been for a long time divided in 
 regard to the causes of menstruation, and at the present day even, 
 every thing seems to indicate that there will not be a unity of senti- 
 ment very soon on this point. Some authors have stated, with Aris- 
 totle and Galen, Simson, Astruc, and M. Lobstein, that the menses 
 depend upon a general or local plethora, upon a superabundance of 
 blood: others, with Osiander, pretend that the menses are occasion- 
 ed by too large a proportion of carbon and azote being contained in 
 the blood of the uterus. Dr Clifton refers them to the relative 
 weakness of the venous parietes, and to the perpendicular effort of
 
 88 OF MENSTRUATION. 
 
 the blood. Paracelsus, Sylvius, and De Graaf think they are pro- 
 duced by a principle of fermentation ; Stahl and M. Duges suppose 
 they arise under the influence of an irritamentum or peculiar moli- 
 men ; Ernmett, who attributes them to an erection, and Lecat, who 
 qualifies them as an amorous phlogosis, suppose them to be the 
 effect of venereal desires. But who does not herein perceive that 
 vain show of words so prodigally made use of in ancient physiology, 
 or, that such suppositions as these only serve to protract, without 
 solving the problem ? 
 
 218. The periodicity of the menses has not been explained any 
 better than their general cause. Aristotle, Vanhelmont, Mead, and 
 even our elegant Roussel, attributed it to the influence of the moon. 
 From the physicians, this opinion has passed among the people, and 
 the poets have converted it into a proverb by the following verse : 
 
 Luna vetus tetulas, juvenes nova luna repurgat. 
 
 But to show its fallacy, we need only recollect that the same 
 woman may be regular at different lunar phases, once in the space 
 of several, or even of one single year ; however, this is a point on 
 which there is need for new researches, and for the complete clear- 
 ing up of which, numerous observations would be required. 
 
 219. Many attempts have been also made with the view to ascer- 
 tain the final causes of menstruation, but it must be confessed with 
 equally ill success. What in fact is proved by saying that this func- 
 tion disposes and maintains the uterus in a state apt for fecundation; 
 that its suppression during pregnancy permits the ovum to grow and 
 be developed without weakening the female ? It is generally quite 
 well known that conception does not take place until the menses 
 have appeared, nor after they have ceased to return ; but the why 
 and the how are not known : they are the sign and not the cause of 
 fecundity ; the absence of the menses does not produce sterility ; but 
 women who do not menstruate, are often found to be sterile, because, 
 in either case, something is wrong in the state of the genital organs. 
 
 220. Seat. The seat of the menstrual discharge is another sub- 
 ject on which the naturalists continue still to dispute. The Greeks, 
 the Arabians, and a majority of writers of all ages place it in the ute- 
 rus ; but Columbus, Severin Pineau, Bohn, as well as a crowd of 
 moderns, and among them M. Desormeaux, have seen the menses 
 escaping immediately from the vagina, or the different parts which 
 constitute the vulva ; the uterus, it is said, cannot furnish them when 
 they flow during pregnancy. 
 
 221. It appears to me to be easy to reconcile these opinions. 
 The blood of the menses undeniably comes from the uterine cavity
 
 OF MENSTRUATION. 89 
 
 in the majority of instances ; facts the most multiplied and authentic 
 prove it incontestably. Thus, in persons whose menses had been 
 long suppressed, in consequence of disease, or had never appeared, 
 in consequence of some faulty organization of the vagina or vulva, 
 the womb has an hundred times been found full and distended with 
 blood ; in others who died while menstruating, the cavity of the 
 womb has been seen covered with ecchymoses, and sometimes filled 
 with clots of blood. If the os tinea? be confined in the cupule of a 
 pessary with a cylindrical opening passing through it, the blood will 
 be found to escape therefrom ; when there is a prolapsus, it may be 
 seen distilling from the cervix ; and in the natural state, we find by 
 placing the finger between the lips of the os tinea?, that the fluid 
 escapes from the part. 
 
 222. On the other hand it is equally certain that it has sometimes 
 been seen to exude from the interior of the vagina or vulva ; I 
 do not perceive, indeed, how it can be otherwise in a woman who 
 continues to menstruate during her whole gestation. But these cases 
 are exceptions, anomalies, and do not invalidate the general rule : 
 menstruation is then deviated from its general route, as is the case 
 when it takes place from the urethra, the rectum, the pulmonary 
 passages, the breasts, or some portion of the tegumentary surfaces. 
 These irregularities, moreover, are rare, and appear to have been 
 in more than one instance the effect of real disease. 
 
 223. Source. Attempts have been made, also, to ascertain the 
 immediate source of the menses, one party placing it in the veins, 
 along with Vesalius, in the arteries, with Ruysch, or the capillaries, 
 with Winslow and'Meibomius ; others think it is to be found in cer- 
 tain particular gRindules, as Lister, or in peculiar little receptacles, 
 as Simson, or lastly, with Astruc, in a supposed set of venous sinu- 
 ses. There are as many gratuitous suppositions as there are opi- 
 nions, all of them referring to a question as idle as it is difficult of 
 solution. The menstrual blood escapes from the womb by exhala- 
 tion or by perspiration, as in all the hemorrhagies of the mucous 
 membranes, but without our being able to learn whether it trans- 
 udes from the venous rather than from the arterial capillaries, and 
 vice versa. In this respect, whether the discharge be derived from 
 the body or cervix of the womb, from the vagina, or elsewhere, the 
 mechanism of the function is always the same, and that is what it 
 imports us to know. 
 
 224. Cessation. The age at which the menses cease to appear 
 is not less variable than that of their first eruption. Most generally 
 it is from forty-five to fifty years ; but some women are exempted 
 at the age of forty, or even at thirty-six, thirty, twenty-six, or twen- 
 
 M
 
 90 OF MENSTRUATION. 
 
 ty-four, as in the instances cited by Haller and others ; and of which 
 I also have known several. Some continue to menstruate without any 
 inconvenience until fifty-five, sixty, sixty-five, and even seventy years 
 of age. Cases are related of persons who have lost them at the 
 usual period, and become regular again at eighty, ninety, ninety- 
 five, or, according to the report of Blancardi, even at one hundred and 
 five years of age. But, as M. Desormeaux remarks, although these 
 kinds of return are not rare at sixty, seventy, or seventy-five years, 
 it is at least certain they ought rather to be considered as the sign 
 of some disease, than as a real resumption of the menstrual function. 
 However, in the fact itself, there is nothing which the laws of the 
 animal economy render incomprehensible. In the same manner as 
 certain plants sometimes flourish a second time in autumn, after 
 having been withered at the close of spring, so, also, a woman may, 
 under certain circumstances, return, as it were, to her young age 
 again, when she is just touching the decline of life. It is a last ef- 
 fort of nature to restore a more prosperous season, but which serves, 
 unhappily, only to hasten a dissolution which she in vain desires to 
 retard. Thus it appears that, in the natural order, the menses ought 
 to cease between the fortieth and fiftieth years in our temperate 
 climes ; between thirty and forty in warm climates, and from forty- 
 five to fifty under the colder zones : in other words, their whole 
 duration is, every where, near about thirty years; where they are 
 precocious they disappear sooner, and where their appearance is more 
 tardy they are also prolonged to a later period of life. All cases 
 that are in opposition to this general rule, ought, in my opinion, to 
 be registered as among the exceptions, or regarded as pathological. 
 225. The change of life (age du retour) is mark*ed by the gradual 
 disappearance of the charms of puberty; the bosom and the cheeks 
 become flaccid, the skin is wrinkled, appears to be too large, and 
 loses its delicateness ; the eyes sink in the orbits ; the carnation of 
 the cheeks is supplanted by a yellowish tint ; that empurpled blush 
 which once, amidst smiles, sat on her rosy lips, is chased away by a 
 bluish and leaden hue ; every circumstance proclaims that the sea- 
 son of the pleasures is past, and that she can no longer rely on the 
 ;itti notions peculiar to the sex. It is, therefore, very properly, that 
 this period is called the critical time, or critical age ; but attempts 
 have been erroneously made to justify these epithets, by reference 
 to the numberless dangers with which, according to the general opi- 
 nion, women nre nt this period surrounded. In fact, the statistical 
 rchrs published by Moret and Finlayson, MM. Chateauncuf 
 and I.acli.Yi-r, prove that not more women than men die between 
 the ages of forty and fifty years. Nevertheless, the menses rarely 
 cease suddenly, or without Occasioning some disorder : on some occa-
 
 OF MENSTRUATION. 91 
 
 sions their suppression is preceded by a gradual diminution of the 
 duration of each period, and of the quantity of blood lost ; or on the 
 contrary, by an increase which sometimes converts them into a 
 pretty abundant hemorrhage ; sometimes they cease, return again to 
 cease and return, before a final stop is put to them ; they become 
 irregular in character ; a mucous discharge is established ; lassitude, 
 sense of suffocation, nervous complaints, even severe diseases occur 
 in some cases ; but in others, also, nothing of all this is observed to 
 happen, and the health, which up to that period had been precarious, 
 becomes quite confirmed ; strength is restored ; the emaciated indi- 
 vidual grows fat, and finds nothing but benefits in the loss of her 
 catamenial discharges. 
 
 ARTICLE II. 
 Of Reproduction. 
 
 226. Designed for the perpetuation of species, reproduction is a 
 function peculiar to living beings. Inert bodies are produced, but 
 never reproduce. Without contradiction, reproduction constitutes 
 one of the most astonishing phenomena of animated nature : and 
 how many efforts have been made, from the beginning of time until 
 now, to ascertain its mechanism ! Indeed, ought not man, whose 
 prerogative it is to think, first to endeavour to understand himself? 
 Can any thing in the universe interest him so much as his own ori- 
 gin ? Yet these efforts so multiplied, these researches so ably con- 
 ducted, and these labours, of all sorts, pursued so perseveringly by 
 the most celebrated men, have hitherto scarcely served to any 
 other end than to show him how deep is, the mystery that veils the 
 commencement of his existence. 
 
 227. Pythagoras and his disciples said that the embryo is formed 
 out of the menstrual blood, and a kind of moisture that descends 
 from the brain during coition, and that it is developed according to 
 the laws of harmony. 
 
 228. Empedocles and Hippocrates, who are not less obscure 
 than the former on this subject, thought that both the male and fe- 
 male enclosed the molecules of embryos of both sexes, and that these 
 molecules were united in the womb during the sexual union. 
 
 229. Aristotle, with certain modifications, reproduced the idea of 
 Pythagoras, and by an ingenious metaphor, made of the womb a real 
 sculptor's shop, where the woman furnished the marble, the man 
 brought the workman, and the embryo represented the statue.
 
 92 OF REPRODUCTION. 
 
 230. Galen set forth an opinion diametrically opposite to that of 
 the celebrated naturalist of Stagyra ; he insists that the embryo is 
 produced from the semen of the male, and that the material furnish- 
 ed by the woman serves solely for its nourishment. 
 
 231. R. De Graaf thought he could demonstrate that all animals 
 come from an egg, and says that in the human species itself, the 
 germs exist in the ovary, in the form of ovules, or little transparent 
 vesicles. The ancient doctrine, entitled the system of mixed germs, 
 was soon generally abandoned, while the new hypothesis, known as 
 the system of ovules, spread with the rapidity of lightning. This is 
 the doctrine that prevails at the present day ; but as may well be 
 supposed, it has not reached the nineteenth century without having 
 experienced numerous modifications. According to De Graaf, 
 Meckel, &c. the little ovule is only a kind of rudimental embryo, 
 which is only waiting for life in order then to commence its own de- 
 velopment ; and this life can only be imparted to it by the prolific 
 semen of the male ; according to Ruysch and Haller, the seminal 
 liquor is conveyed unaltered, by the Fallopian tube, to the ovary, while 
 others think that a very subtle vapour, an aura seminalis, only is de- 
 tached from it, and which produces the same effect ; several wri- 
 ters have advanced the opinion, that the semen, at first absorbed in 
 the vagina or uterus, and carried from thence into the torrent of the 
 circulation, does not return to the ovary to fecundate a vesicle until 
 it has undergone several elaborations. 
 
 232. Soon after the discovery of the ovules, Ham, Harstoecker, 
 and Lewenhoeck affirmed that the germs exist, quite formed, in the 
 reproductive fluid of the male ; that these germs, which they called 
 animalcules, are living ; that a single drop of sperm contains 
 many thousands of them ; that being projected in the act of coition 
 into the uterine cavity, they all perish with the exception of one, or 
 more, which are fortunate enough to reach the Fallopian tube ; that 
 one of them reaches the ovary, enters and lodges in a vesicle pre- 
 pared for that purpose, and afterwards returns to the womb in the 
 shape of a little ovum, &c. Hence is established a new system, since 
 called the system of animalcules, a system which gives to man an 
 immense share in the act of fecundation, while the ovular hypothe- 
 sis, as understood by De Graaf, attributes almost the whole of it to 
 the woman. 
 
 I. 1 1 awry, supported by the munificence of a great king ; Hal- 
 lor, with his extraordinary talents; Spallan/ani, with that good faith 
 and spirit nf oh-i i ration for which he was eo remarkable ; for the 
 purpose of clearing up this groat question, multiplied their experi- 
 nifiiis almost infinitely, and their labours have led, or seem to lead,
 
 OF REPRODUCTION. 93 
 
 to this common conclusion, to wit, that the union of germs takes 
 place in -the ovary, and that the development of the product of 
 fecundation is a simple evolution, and not an cpigenisis, as was for- 
 merly maintained. 
 
 234. Nevertheless, the doctrine of epigenisis has never been 
 wholly abandoned ; Maupertuis still defended it in his Venus Phy- 
 sique, published in 1754, asserting that the seed of the two sexes is 
 formed of particles that are never commingled save in the womb, 
 just as certain chemical elements mutually attract and combine with 
 each other. BufFon was even very near reviving it, by presenting 
 it in a new light : this celebrated writer supposed that at the moment 
 when the venereal enjoyment was at its greatest height, there were 
 separated from every portion of the body, and of the two conjoined 
 bodies at the same moment, a determinate number of organic mole- 
 cules ; that each of these molecules possessed a figure proportioned 
 to the part of the body from whence it was disengaged, but which 
 are similar in the two sexes ; that having reached the uterus, all the 
 similar molecules are mutually attracted towards each other, so that, 
 for example, those that were furnished by the eye, the nose, the ear, 
 or the arm, the lung, or the heart, or finger of the woman, can only 
 combine with the molecules from the eye, nose, ear, arm, lung, heart, 
 or finger of the man. 
 
 235. Not one of these opinions is wholly destitute of foundation ; 
 not one but has been defended with talent, and combated by very 
 good arguments ; none without its partisans and antagonists ; but the 
 nature of this work not admitting of my entering into very long de- 
 tails, so as to exhibit the just value of each of these doctrines, I shall 
 leave the subject with what has been above said. 
 
 236. Reproduction, in those beings that occupy a high grade on 
 the zoological scale, is an extremely complex act ; in order to a 
 good understanding of it as a whole, it ought to be analysed, in some 
 measure, in the several gradations of the animal kingdom . In the first 
 place, it is proper to remark, that the words reproduction, generation, 
 fecundation, conception, have each a distinct grammatical accepta- 
 tion, and it is wrong to employ them as synonyms, especially when 
 speaking of mammiferous animals. The word reproduction, for ex- 
 ample, is applicable to the whole function, while generation ought 
 to be understood as meaning the simple creation of germs ; the term 
 fecundation, in its turn, only expresses the act which unites the two 
 
 germs, or by which one of these germs vivifies the other ; the word 
 conception, which signifies to retain, can only be reasonably employ- 
 ed to designate the action which causes the fecundated germ to be 
 retained within the sexual organs ; lastly, the word reproduction is
 
 94 OF REPRODUCTION. 
 
 the general term, while the three others belong only to separate 
 phenomena, which may either exist unconjoined or altogether, ac- 
 cording to the class in which they happen to be observed. 
 
 237. Thus polypi, which reproduce themselves by germs, have 
 generation, but no fecundation nor conception. The batracian rep- 
 tiles also produce germs ; but these germs are of two species, those 
 of the male, and those of the female ; they must be mixed in order 
 for reproduction to take place, but as the mixture is effected exte- 
 riorly, the batracians have no conception, although they have both 
 a generation and a fecundation. In birds there is retention of the 
 fecundated germ, and consequently, generation, fecundation, and 
 conception. In the mammiferas and man, the vivified and conceived 
 germ is developed within the animal ; and there is, further, in these 
 cases, gestation, and even expulsion or parturition, at the end of 
 pregnancy. The function of reproduction then is composed, in the 
 human species, 1 . Of generation, or the formation of the germ ; 
 2. Of fecundation, or the vivification of the germ ; 3. Of conception, 
 or the retention of the vivified germ ; 4. Of gestation or pregnancy ; 
 5. Of parturition or the expulsion of the ovum. 
 
 SECTION 1. 
 
 Of the Generation or Procreation of Germs. 
 
 . 
 
 238. In the infusory animals which break to pieces of themselves, 
 and the zoophytes which we reduce to fragments that give birth to 
 an equal number of entire beings, germs are nothing more than 
 analogues of the general mass of the individuals from which they 
 have been separated. Their generation is, in this respect, analo- 
 gous to that of those plants that are multiplied by slips or grafts. 
 A little farther on in the scale, germs cannot be produced except by 
 peculiar organs which constitute the sexes, and in that case the 
 sexes are sometimes united in the same individual, sometimes they 
 exist in two different individuals. Snails, oysters, a pretty consi- 
 siderable number of other molusca, and all the monocccious plants 
 are in the first case, that is to say, they are hermaphrodites ; the 
 dubious plants, and almost all animals are found in the second ; so 
 that reproduction is here bi-sexual, and the male and female germs 
 are always furnished by different individuals. 
 
 . I. Of the female germ. 
 
 239. In ascending the scale from fishes up to women, the female 
 germ appears to be formed in the ovary (233) ; it is always found
 
 OF REPRODUCTION. 95 
 
 to present itself under the appearance of a vesicle, known by the 
 name of ovule. In reptiles and birds the ovule is very large, com- 
 paratively to that of women ; in all the mammiferae its reproduction 
 is extremely simple : the ovary is a gland whose special function it 
 is to secrete ovules, as the liver secretes bile, &c. MM. Prevost 
 and Dumas assure us that they have proved that the ovules are really 
 formed by the ovary, and by nothing but the ovary ; that they always 
 exist in this gland in adult females, who are capable of fecundation ; 
 that they are not developed until puberty, and are not found in old 
 age ; that animals that copulate at all seasons of the year also have 
 them without interruption until they become sterile, while on the 
 other hand they are only met with at the season of copulation in 
 those animals that have only one rutting time in each year. 
 
 240. These vesicles, at first very small, grow at last to the size of 
 a hempseed. As in fowls, they do not all grow at the same time ; 
 one or two generally exceeding the rest, and reaching the state of 
 maturity first. Their coats are then thick and opake, rise more or less 
 above the surface of the ovary, and seem as if they would burst its 
 investing membrane. At this period of its evolution the germ is 
 composed of two small coats, one, external, the largest, adheres to 
 the tissue of the ovary ; the other, internal, smaller, really constitutes 
 the ovule, while MM. Prevost and Dumas propose to restrict the 
 name of vesicle to the former. 
 
 241. After the discovery of the ovules, and particularly during the 
 last century, philosophers were desirous to know whether they are 
 transmitted from the mother to the daughter, together with the prin- 
 ciples of her organs ; or whether, on the other hand, they are not 
 formed until the age of puberty. This question, which gave rise 
 to the celebrated theory of the encasing of germs one within another, 
 has been especially argued by Swammerdam, Haller and Bonnet. 
 The latter insisted with great zeal, that we ought to carry back the 
 origin of the human beings that now cover, have covered, or will 
 hereafter cover the globe in all succeeding ages, to the ovary of the 
 first woman; that is to. say, that the evaries of the first woman must 
 have enclosed, shut up one within another, the germs of all the ge- 
 nerations that have succeeded, or will hereafter succeed ; in a word, 
 the whole human race. But these infinite divisions, in which the 
 imagination loses itself, have caused the idea of the pre-existence of 
 germs to be rejected, and at the present day they are regarded as the 
 results of a mere secretion. 
 
 . II. Of the male germ. 
 
 242. The germ furnished by male animals is a whitish, viscid
 
 96 OF REPRODUCTION. 
 
 liquor, called seed, prolific matter, or seminal fluid ; when this 
 liquid escapes from the urethra, it is composed of a substance se- 
 creted by the testicles, of the fluid exhaled from the vesiculse semi- 
 nales, and of the prostatic liquor. But which of all these various 
 elements is the fecundating principle ? It is not the aura seminalis; 
 for Spallanzani could never fecundate the eggs of frogs without 
 bringing them into immediate contact with the seminal liquor of the 
 male. Does it result from the mixture that I have just mentioned ? 
 No ; for the fluids furnished by the vesiculae seminales, the prostate 
 and the urethra, can only be regarded as the vehicle of that derived 
 from the testicles. Does it depend upon the animalcules named after 
 Lewenhoeck ? Several authors maintain the affirmative, and their 
 opinion has found numerous echoes in various parts of the learned 
 world. 
 
 243. According to Lewenhoeck, the animalcules are microscopic 
 corpuscles, endowed with the faculty of moving in a determinate di- 
 rection, and for a determinate end. Their large extremity, which 
 is also flattened, gives origin to their caudiform portion, which is 
 delicate and very much elongated. According to some of his parti- 
 sans, they may be divided into young, old, adult, weakly, strong, 
 male and female, &c.; and Plantade, of Montpellier, under the 
 assumed name ofDalempatius, refining still more on what had been 
 already advanced upon this subject, made out of a drop of prolific 
 liquor a well governed nation ; he imagined a king, princes, minis- 
 ters, magistrates, paupers, rich persons, merchants, soldiers, chil- 
 dren, old men, &c. Raillery produced on this occasion an effect 
 that could not be brought about by the most peremptory reasoning. 
 The animalcular hypothesis appeared to be absurd, and thenceforth 
 nobody dared to advocate it. 
 
 244. It is true that it had already been asserted that these corpus- 
 cles exist, and that they sometimes exhibit the form that had been 
 
 iied to them, but that they also appear on some occasions un- 
 der another form, and that they do not in any case belong more 
 peculiarly to the seminal liquor than to any other of the animal 
 fluids; in a word, that they do not play any special part in the act 
 of reproduction, or at the least, they are not the essential agents of 
 fecundation. 
 
 246. According to MM. Provost and Dumas, the animalcules de- 
 
 < <1 l>y Lcwenhocck do not exist except in the male organs of 
 
 ration, and dilFer from the mobile globules of the other fluids of 
 
 i|i. : . 'i-.-minin by their form, which is always the same in the same 
 
 ics ; by their mode of progression ; by the situation in 
 
 which they aic found, &,c.; they always have an enlarged extremity
 
 OF REPRODUCTION. 97 
 
 and an elongated portion ; their head, which is sometimes oval or 
 almost circular, sometimes lozenge-shaped, at others resembles the 
 catkin of the bul-rush ; but as it is at the same time flattened, it 
 cannot be recognized, except when seen in front. Their point, 
 sometimes straight, very long, and conical as in the dunghill cock, 
 sometimes short and fine as in the dog, at others very long and flex- 
 ous, pretty much resembles the tricocephalous worms, or the slen- 
 derest worms that inhabit the human body. Upon the whole, the 
 spermatic animalcula has a general resemblance to the tadpole of 
 the batracians ; its dimensions do not exceed one, two, or three 
 hundredths of a millimeter ; it is not to be seen in the seminal liquor 
 previous to the age of puberty, nor in old men, nor in the interval 
 of the seasons at which certain animals copulate, nor in the mule, 
 which, as is well known, is incapable of reproduction ; it is not met 
 with in the matter furnished by the urethra, the prostate, or the se- 
 minal vesicles, and it is to be found with the same characters in all 
 those animals that are wholly or partially deprived of these organs. 
 It is produced by the testicle which secretes it. Every prolific animal 
 contains it in its prolific gland, and frequently in its deferent duct. The 
 movement of these corpuscles seems to take place under the influence 
 of a will; they always move forwards ; they can be killed by an elec- 
 tric discharge, and thenceforth their motion ceases to be active. In 
 escaping from the formative gland, the viscous matter in which they 
 are enveloped is too thick to permit them to exercise any visible 
 motion ; but it is only necessary to mix them with some other liquid, 
 or permit them to become diluted in the seminal vesicle or urethra, 
 in order that their mobility should come immediately into play. 
 
 246. Simple microscopic globules, on the contrary, have neither 
 head nor tail, are round or of irregular shapes, sometimes larger 
 and sometimes smaller, and move only under the influence of some 
 external impression, and without any determinate end. They exist 
 in all the fluids of the economy, in the blood, in the serum, in the 
 milk, even in the spermatic liquor, before puberty, as well as at all 
 other periods of life, and in all animals. 
 
 247. MM. Prevostand Dumas by their numerous experiments on 
 artificial fecundation, became convinced that the animalcules alone 
 constituted the germ ; they never effected a vivification when the 
 liquid they made use of did not contain them, or when these living 
 molecules had been killed or destroyed in any way, whereas fecunda- 
 tion took place whenever the liquor they employed contained even 
 a few animalcules. 
 
 248. Although the experiments of these physiologists bear marks 
 of the greatest good faith and accuracy, I cannot, nevertheless, 
 
 N
 
 98 OF REPRODUCTION. 
 
 withhold all reference to the authorities which prevent us from 
 adopting, excepting in the most circumspect manner, the conclusions 
 that might be drawn from them. In Italy, Spallanzani has main- 
 tained that animalcules are completely foreign to the fecundative act ; 
 in spite of the assertions of Gleichen, the opinion of Spallanzani 
 prevails in Germany ; in France, MM. Bory de Saint Vincent 
 and Dutrochet are of nearly the same opinion; M. Virey regards them 
 as containing certain small balloons distended with a kind of pollen, 
 and which burst when they reach the organs of the other sex ; and 
 M. Raspail has very recently come out against the doctrine of ani- 
 malcules, which, according to him, are nothing more than certain 
 organic debris, or products of the decomposition of the sperm. 
 
 249. What, among so many contradictory assertions, are we to 
 believe ? what opinion must we adopt ? However it may be, we 
 may consider it as demonstrated that the female germ is an ovule, 
 and that that of the male is contained in his spermatic fluid, and 
 that this liquid contains such animalcules as were described by Lew- 
 enhoeck ; but that, in the present state of science, the relative im- 
 portance of each of these principles is unknown. 
 
 SECTION 2. 
 Of Fecundation. 
 
 250. When the germs have acquired their full size, a new pheno- 
 menon, by combining some of their principles, imparts to them mo- 
 tion and life ; this phenomenon is fecundation, which, as to its inti- 
 mate mechanism, is perhaps always effected in the same manner, but 
 which appears to be effected in different ways in different animated 
 beings. Although the snail has double sex, it cannot fecundate itself; 
 a copulation with another individual similar to itself is necessary, and 
 then each of them fecundates, and is at the same time fecundated. 
 
 251. Just as it happens in the monooccious plants, where, so to 
 speak, the pollen meets, by accident only, the ovary of the female 
 individual; so in many fishes and molusca, chance only seems to lead 
 the male to where the female had deposited her ova, so that he may 
 bedew it with his sperm. 
 
 252. In the batracian animals, such as the frog, although there is 
 no real copulation, copulation is, nevertheless, requisite, and fecun- 
 dation is effected while the female ova are in the act of escaping from 
 her organs. 
 
 263. Lastly, in the ophidian animals, birds, the mammiferae, and 
 man, it is necessary that the germ of the male should fecundate the 
 other in the interior of the female organs.
 
 OF REPRODUCTION. 99 
 
 254. Seat. But the point in the organs at which the two germs 
 meet is not yet completely ascertained. Is it in the ovary ? Is it 
 in the oviduct ? Is it in the womb ? All the ancients agreed that 
 the vivification of the germs takes place in the womb, whether, like 
 Pythagoras, they call to their aid an extremely subtle nervous prin- 
 ciple, whether they invoke, like Harvey, a magnetic impregnation, or 
 whether they content themselves with the seminal liquor of the male, 
 to explain the fact : almost all the ovarists, on the contrary, have 
 thought it could only be effected in the ovary, and a great majority 
 of the physiologists of the present day are of this way of thinking. 
 
 255. Among the animalculists, one party believed that fecundation 
 takes place in the womb without any participation by the ovule, or 
 with Maupertuis, that the animalcules attracted the ovarian vesicles 
 to the womb in order to effect their agglomeration or germifica- 
 tion. Others, with Andry, supposed that a single animalcule reaches 
 the ovary, enters an ovule by lifting a small valve, and that fecunda- 
 tion is effected at that moment. Finally, MM. Prevost and Dumas, 
 returning in' this respect to the idea of Buffon, of Maupertuis, of 
 Aristotle and Hippocrates, admit that the uterine cavity is the seat 
 of fecundation. 
 
 256. To maintain this last hypothesis, they rely on the circum- 
 stance that they were never, in their experiments, able to find any 
 animalcules in the Fallopian tubes, and, a fortiori, in the ovaries ; 
 while they frequently met with them in the womb or its horns ; on the 
 fact, that before the ovules can become impregnated^ they must be 
 enveloped in a coat of mucus, which they receive while in the tube on 
 their way to the womb ; that they could never succeed in the artificial 
 fecundation of ovules taken directly from the ovary, while nothing was 
 easier than to vivify such as had traversed the tube and the oviduct, 
 &c. But Ruysch saw the prolific matter in the Fallopian tubes of a 
 woman who was taken in adultery and killed on the spot by her hus- 
 band; Haller found semen in the seminiferous ducts of the female ani- 
 mals on which he experimented. Besides, are we authorised to deny 
 the existence of a fact observed by others, because we have ourselves 
 sought for it in vain ? Have we a right to infer, because the eggs 
 of frogs cannot be fecundated unless they have been previously more 
 or less thickly covered with a coating of mucus, that the same thing 
 holds true in women ? Further, these ovules which MM. Prevost 
 and Dumas found unfit for fecundation, could not have been forcibly 
 detached from the ovary without having been somewhat altered by 
 the instrument ; and that too, by the admission of the experimenters 
 themselves. Though the existence of ovarian pregnancies is far 
 from being demonstrated ; though the fact of an embryo half in the
 
 100 OF REPRODUCTION. 
 
 tube and half in the ovary, as reported by Bussiere, requires some 
 new evidence; though a great many cases of extra-uterine preg- 
 nancy, examined with care, are very far from being conclusive, the 
 experiments of Nuck, who placed a ligature on the tube, betwixt the 
 womb and ovary, directly after copulation, and upon killing the 
 animal some time afterwards, found that fecundation had taken place, 
 and that the ovum, stopped by the thread, had begun to develope 
 itself in the ovarian moiety of the seminiferous canal ; those of 
 Haighton, who found that fecundation did not take place in. rabbits 
 on that side where he had tied the tube, &c., appear to prove in- 
 contestably, that the union of the germs does not take place in the 
 womb. 
 
 257. Mechanism. As to the mechanism of this union, it is still 
 covered with an extremely thick veil. After coition, one of the 
 vesicles enclosed in the ovary enlarges with great rapidity, soon rises 
 above the surface of the organ, gradually thins its coat, which at 
 length bursts; when this vesicle bursts, a much smaller vesicle, 
 which is the real germ, escapes from it (239); this germ engages at 
 once in the tube, which meanwhile was spasmodically applied, like 
 a cupping-glass, to the portion of the ovary from which, during a 
 fruitful coition, the vesicle escapes. 
 
 258. The capsule which contained the germ before it was rup- 
 tured, constitutes what has by Valisnieri, Santorini, Cruikshank, 
 Buffbn and Home, been called the yellow body (corpus luteum); its 
 rupture occasions a small bleeding wound, which cicatrizes by de- 
 grees, and leaves in its place a wrinkle or depressed scar, more or 
 less deep, and which Littre, Haller, and some others mistook for the 
 real yellow body. 
 
 259. That which takes place in regard to a single ovule, may 
 also occur to two, to three, or a greater number. Supposing that 
 the evolution of the ovule is put in play by the commotion that ac- 
 companies coition, by a sort of electric commotion, by an aura 
 seminalis, by means of an animalcule, or by any principle whatsoever 
 of the prolific matter ; that this principle reaches the germ directly 
 from the woman, or that it reaches it only after having passed through 
 the general circulation, it always happens that after a fecundation 
 has been effected, there is detached from the ovary an ovule so modi- 
 fied, that it is soon recognized as a being similar to the one that 
 produced it. This is what is demonstrated by observation ; but we 
 know nothing further about it. The systems of preformation or 
 evolution, of cmboitcmcnt or panspermy, ofepigencsis and catagenesis, 
 expansive force, resisting force of the ancients ; the nisusformativus 
 of Blumenbach, reproduced under a new point of view, and clothed
 
 OF REPRODUCTION. 
 
 by M. Mayer with the philosophical jargon of the German schools, 
 teach us nothing in relation to the intimate nature of this work, which 
 is as extraordinary as it is curious. 
 
 SECTION 3. 
 Of Conception. 
 
 260. When the union of the germs is effected in the interior, the 
 new product resulting therefrom is commonly retained, or arrested in 
 some part of the sexual system. But this phenomenon constitutes 
 what is properly called conception. It is evidently distinct from 
 fecundation ; for wherever the latter is effected exteriorly to the 
 animal, as in fishes and many reptiles, conception cannot be truly 
 said to exist, while in the higher classes it always does exist. At a 
 first view, it might seem useless to make a distinct phenomenon of 
 it, and that it might without inconvenience be confounded with ges- 
 tation ; but upon a closer inspection, we are easily convinced of the 
 contrary. Indeed, the ophidians and birds have no gestation, and 
 yet they have a conception. Conception, therefore, comprehends 
 what takes place between the instant of vivification and the moment 
 when the fecundated germ begins to be developed ; whether it at- 
 taches itself for this purpose to some point of the generative pas- 
 sages, or whether it has to be expelled in order to undergo the pro- 
 cess of incubation exteriorly.
 
 102 
 
 CHAPTER III. 
 
 History of Gestation. 
 
 261. If the fecundated or conceived ovum passes out of the organs 
 of the mother before the germ begins its development, as in birds, . 
 there is no gestation, and the animal is called oviparous. If the 
 embryo is formed while passing through the oviduct, but so that it 
 cannot separate itself from its shell until after it is laid, as in certain 
 reptiles, there is still, properly speaking, no gestation, and such ani- 
 mals are called ovo-viviparous. Whenever, on the contrary, the egg 
 undergoes its entire incubation in the interior of the generative sys- 
 tem, and the foetus is not expelled until the development of its organs 
 enables it to live and grow in the external world, pregnancy or ges- 
 tation is said to exist ; this is observed to take place in the mammi- 
 ferae only ; in this case there exists a gestative organ, a single uterus, 
 or one womb and two ad uterum, destined to lodge the product of 
 fecundation until it attains its maturity, and such animals are deno- 
 minated viviparous. 
 
 Pregnancy, in the human species, is one of the phenomena of re- 
 production which it most imports us carefully to study. The words 
 pregnancy and gestation are not synonymous with the words preg- 
 nant woman, or woman with child. The former express a function, 
 and all that appertains thereto, from its origin until its termination. 
 The latter indicate merely the actual state of a woman who contains 
 within herself a fecundated or conceived ovum. 
 
 262. Division. If the fecundated ovum reaches, without being ob- 
 structed, the cavity of the womb, and maintains itself there, the preg- 
 nancy is said to be good, natural, or uterine; if it remains and is devel- 
 oped in the ovary, if it falls into the cavity of the peritoneum, stops in 
 the Fallopian tube, or becomes engaged in the substance of the womb 
 itself, it on the contrary receives the title of bad, preternatural, or 
 extra-uterine. The first species is then divided into three varieties. 
 
 1. Simple pregnancy, where the womb contains only a single ovum. 
 
 2. Double, triple, quadruple, or compound pregnancy, when there
 
 HISTORY OF GESTATION. 103 
 
 are two, three, or four foetuses. 3. Complicated pregnancy, where 
 a polypus, a great quantity of water, or any diseased state of the 
 product of the conception, or of the womb itself takes place. 
 
 The second comprises four varieties determined by the seat oc- 
 cupied by the fecundated germ ; so that authors admit, 1. An ova- 
 rian pregnancy ; 2. An abdominal or peritoneal pregnancy ; 3. A 
 tubal pregnancy ; and 4. A mixed or interstitial pregnancy. 
 
 After having observed that a great variety of diseases, sometimes 
 give rise to most of the symptoms of pregnancy, the French writers, 
 adopting a still more general first division, have established a true 
 and a. false or apparent pregnancy , differing from each other in this, 
 that the former is characterized by the presence, and the latter by 
 the absence of the fetus ; they have next described false pregnancy 
 as ventose, serous, sanguine, polypous, cancerous, nervous, molar, 
 hydatic, &c., accordingly as the increased size of the belly depends 
 on the presence of gas, water, blood, polypous or other tumours in 
 the womb, the existence of a scirrhus, an hydatiform or fleshy mole, 
 an undcfinable nervous state, &c. 
 
 ARTICLE I. 
 Of True Pregnancy. 
 
 SECTION 1. 
 Of Uterine Pregnancy. 
 
 263. As soon as pregnancy takes place, important and numerous 
 phenomena are manifested in the economy. Of these some are 
 local, physical, material : others are variable, transient, general : 
 some are common to all kinds of gestation, while others are peculiar 
 to some sorts only. 
 
 As uterine pregnancy comprises almost all of them, and further, 
 as it constitutes the only normal kind of gestation in the human 
 species, I shall speak, in the first place, only of those which belong 
 to it, and shall not treat of the special phenomena until I come to 
 the article in which I shall designate the means of distinguishing it 
 from all the rest. 
 
 264. The constitutional movement occasioned by copulation is 
 only momentary, both in women and in men, where fecundation is
 
 104 OF TRUE PREGNANCY. 
 
 not to result from it. In the opposite case, the state of turgescence, 
 of erection or spasm of the uterus and tubes, continues, ana* is the 
 prelude to a new kind of life in the former of these organs. Its 
 volume, its form, its situation, attitude, structure, its properties, all 
 are about to be changed. 
 
 265. Volume. After a conception takes place, the womb re- 
 mains in a state of fluxion, which gradually augments its size in 
 every direction : according to some accoucheurs, this growth is very 
 regular and uniform until the end of the pregnancy ; others assert 
 that it is irregular and by starts. M. Desormeaux thinks it is per- 
 formed very slowly in the first months, and on the contrary, with 
 great rapidity in the two or three last ; in the first case, at the ex- 
 pense of the walls of the organ alone, and in the last, of the walls 
 and cavity both. Not only does the body undergo this augmenta- 
 tion ; Madame Boivin maintains, that in the second month, the neck 
 is almost two inches in length. At the end of the third month, the 
 womb is nearly two inches and a half through in every direction, 
 and three inches and a half in the fourth month. At this last nam- 
 ed period, we observe in the dead subject, that the plaits near the 
 inner orifice are unfolded, and extended in long, very delicate 
 ridges. 
 
 266. At seven months, the superior third of the cervix has be- 
 come common with the inferior portion of the body, from which it 
 may however be distinguished by a rose-coloured zone, very differ- 
 ent from the deep red tint of the rest of the womb. Its inferior 
 portion, whiter, larger, and softer than the other, has still a dimen- 
 sion of about fifteen lines ; but we must not here confound the neck, 
 properly so called, with the os tineas, which is only five or six lines 
 long. The neck, which is thicker below than above, is still about 
 an inch long at eight months, and is not wholly lost in the uterine 
 ovoid, until in the course of the ninth month ; so that, from the 
 commencement of pregnancy until the eighth month, it grows thin- 
 ner, deploys, and is gradually widened, without losing meanwhile 
 much of its real length. 
 
 267. While admitting a part of these assertions to be true, I 
 think it nevertheless more correct to say with M. Desormeaux, that 
 if we leave the os tinea? out of the question, the neck loses about 
 one-third of its total length by the fifth month, one-half in the sixth, 
 two-thirds or three-fourths in the seventh, three-fourths or four- 
 filths in the eighth, and the remainder disappears in the course of the 
 ninth. 
 
 268. At full term the vertical diameter of the womb is twelve 
 inches in length, the antcro-posterior nine inches, and the trans-
 
 OF TRUE PREGNANCY. 105 
 
 verse eight and a half. At the level of the tubes, its circumference 
 is about twenty-six inches, and only thirteen at the uterine portion 
 of the cervix, which, according to Madame Boivin, ought then to be 
 five inches higher than the external orifice. Levret says that the 
 superficies of the womb, which, when unimpregnated, is only equal 
 to sixteen inches, is three hundred and thirty-nine at the commence- 
 ment of labour; that its cavity, which is four-fifths of an inch in the 
 former case, rises to four hundred and eight in the latter ; that its 
 mass, which is only four inches and a third before pregnancy begins, 
 is fifty-one at child-birth ; but the cavity of the womb is evidently 
 carried too far by Levret, for in this way it might hold seventeen 
 pounds of water, while the whole ovum in general does not weigh 
 more than from seven to ten pounds. 
 
 269. Form. Instead of remaining flattened on its two surfaces, 
 the womb becomes rounded, and soon grows of a pyriform shape. 
 The vaginal angle seems to contract ; to grow smaller; its orifice 
 sometimes becomes circular, or ceases to represent a simple linear 
 or transverse slit, particularly in first pregnancies ; on other occa- 
 sions it is pretty largely open, its lips become thicker and softer, 
 chiefly in those women who have borne several children. In some 
 instances of first pregnancy, it seems to close completely up, so that 
 it can scarcely be distinguished by the finger. 
 
 270. The womb next gradually assumes the form of an oval, with 
 its point downwards. Its posterior wall, which was, even before 
 impregnation (155), more protuberant than its anterior one, grows 
 so disproportionately that the tubes seem to descend considerably, 
 until their roots appear to answer to the point of union of the pos- 
 terior two-thirds, and anterior third of the uterine circumference. 
 Its fundus also enlarges very much. Of dimensions nearly equal in 
 every direction, about the fifth or sixth month the organ of gestation 
 exhibits the figure of a spheroidal vase terminated by a very short 
 neck ; it might be compared to a hog's bladder, with the urethral 
 extremity served round with thread for the space of an inch or two : 
 supposing that some one should now unwind the thread by degrees, 
 from above downwards, while another blows into the bladder from 
 the fundus, so as to distend it, we can acquire a pretty clear idea of 
 the gradual effacement of the apex of the womb. 
 
 271. At the close of pregnancy, the neck is nothing more than a 
 ring, formed merely by the lips of the os tincae, and the thickness of 
 which varies according as the woman is in her first pregnancy, or 
 as she has already had several children. In the former case, this 
 ring scarcely exists ; a circle that grows thinner and thinner, and 
 sometimes quite sharp at its edge, is ordinarily substituted for it ; 
 
 O
 
 106 OF TRUE PREGNANCY. 
 
 in the second, it pretty often retains a thickness of two, three, or 
 four lines, until labour comes on. Its orifice remains habitually 
 closed ; its lips are smooth, even and thin, even to the last, in those 
 who have never borne children ; in others it gapes a little at an early 
 period ; I have in many cases been able to introduce the end of my 
 finder into it, in women who were five and a half or six months 
 
 O ' 
 
 gone, and who were used for the purposes of the practical lessons 
 of my lying-in-room. Wider and softer below, it is then found to 
 be harder and narrower above ; its cavity resembles a pretty long 
 finger of a glove, so that we can touch the naked membranes, and 
 ascertain the position of the child several months before the end of 
 pregnancy. 
 
 272. Position. At the same time that the length and volume of 
 the womb are increasing, it undergoes other changes, both of its 
 posture and relations to other parts ; the cervix is depressed, and 
 approaches nearer to the vulva : this phenomenon, which is very de- 
 cided in some women, and scarcely appreciable in others, is'most fre- 
 quently met with, and is observable for a longer time in women who 
 have the pelvis large, and who are of a soft or naturally lax fibre ; and 
 less commonly in those of an opposite constitution, although it is not 
 a rare thing to find it in young and robust women, even in a first 
 pregnancy ; but the os tineas does not fail to rise up by degrees ; at 
 three months, it is about at the same place it occupied before im- 
 pregnation ; after this, continuing gradually to rise, it sometimes 
 gets as high as the sacro- vertebral angle, while, on the contrary, it 
 begins in other instances to descend again, at about the sixth, the 
 seventh or eighth month, and approaches pretty near the inferior 
 strait. 
 
 273. The fundus, which at the third month is not higher than 
 the level of the superior strait, rises two finger breadths above it in 
 the course of the fourth, approaches to the navel in the fifth, gets on 
 a level with that central point, or even above it, at the end of the 
 sixth, still goes upwards in the seventh and eighth, but never reaches 
 either the diaphragm or liver, nor does it ever fill up the epigastric 
 region, as has been hyperbolically or thoughtlessly stated by some 
 of the standard authors. I have observed that it often remains in 
 the meso-gastric region until labour takes place. Besides, with 
 some exceptions, it can scarcely happen otherwise, for in the last 
 UK mi Its of |n-(M_r|]fincy, the centre of I he pelvis is often from fifteen to 
 eighteen im-ln - (h.-stant from the navel. However, the womb, being 
 burl' t were with the weight of the ovum, scorns to sink or 
 in )) Mimcjwhut crushed downwards; which compel* it to enlarge
 
 OF TRUE PREGNANCY. 107 
 
 proportionably in the transverse and in the antero-posterior diame- 
 ters, which until then it fyad not done. 
 
 274. Direction. While the womb remains unconstrained in the 
 excavation, and its funclus is not arrested by the base of the. sacrum, 
 its posterior half, forming a larger mass than its anterior half, tends 
 to make it turn over backwards, so that as the os tinea? sinks down- 
 wards, it inclines forwards, sometimes more, sometimes less, and 
 gets farther from the sacrum, and nearer to the pubis ; a deviation 
 that is favoured by the alternate fulness and emptiness of the urinary 
 bladder. Imperfectly supported in front by the abdominal parietes, 
 pressed upon through the medium of the viscera by the diaphragm, 
 and particularly as the woman in order to maintain her equilibrium 
 is obliged to carry her head and shoulders somewhat backwards, the 
 womb, as soon as it is sufficiently enlarged to touch the promontory, 
 can no longer rise except in the line of the axis of the superior strait. 
 Applied posteriorly against a solid, salient and rounded part, it witli 
 difficulty preserves its station on the median line, as it proceeds up- 
 wards into the abdomen, almost always deviates to one side or the 
 other, to the right eight times out often, so that one of its sides, the 
 left if the inclination is to the right, and the right if it is inclined to 
 the left, soon turns forwards ; whence it happens, that its anterior 
 region looks a little to the right in the former instance, and to the 
 left in the latter ; in a word, the womb seems to have turned on its 
 great axis. 
 
 275. The inclination of the womb to the right rather than to the 
 left, has been explained in a hundred different ways. The presence 
 of the rectum, habitually filled, in pregnant women, with hard ster- 
 coraceous matter, has appeared to some persons sufficient to account 
 for it ; but the right lateral obliquity is to be met with also in per- 
 sons who are not of a costive habit, and even in individuals labouring 
 under diarrhoea. M. Desormeaux adds, that while rising into the 
 abdomen, the organ of gestation is thrust to the right by the mass of 
 small intestines, and the sigmoid flexure of the colon ; which de- 
 pends, says he, on this, that the mesentery, fixed on the front of the 
 spine, descends obliquely from right to left. But there is an error 
 as to the fact here, for the mesentery is directed from left to right ; 
 and I am astonished that M. Desormeaux, in general so correct, 
 should have overlooked it ; besides, though the sigmoid flexure of 
 the colon is on the left, the caecum, which is still larger, is on the 
 right. Others have thought, with Lev-ret, that the insertion of the 
 placenta, by restricting the dilatation of one particular portion of 
 the womb, might occasion lateral obliquities to take place. Tn the 
 first place, it is not true that the portion of the womb in contact with
 
 108 OF TRUE PREGNANCY. 
 
 the placenta enlarges less than the other parts of the organ ; and 
 further, even if we could admit the fact, it would be necessary for 
 the placenta to be attached almost always to the right, which is con- 
 trary to what is found to be the case. Madame Boivin attributes 
 right lateral obliquity, to the excessive strength of the right round 
 ligament of the womb ; but in that case the right angle of the womb 
 ought not to be so distant as it is found to be from the right abdomi- 
 nal canal. I could more willingly admit, that being unable to rest 
 upon the front of the spine, the womb generally inclines to the right, 
 in consequence of the individual's habit of sleeping upon that side, 
 and of using the right arm rather than the left ; but it would be fur- 
 ther necessary to prove that in women who have the opposite habits, 
 the right obliquity is never met with. 
 
 276. While the fundus and body of the womb incline forwards 
 and to the right, the cervix generally tends backwards and to the 
 left ; however, it would be wrong to suppose it must be always so : 
 the orifice may remain in the centre of the excavation, although the 
 anterior or lateral obliquities may be very great, or it may even be 
 directed further backwards than is indicated by the position of the 
 fundus. I have frequently found its plane parallel to the anterior 
 surface of the sacrum in the last stages of pregnancy, although there 
 was not any anterior inclination ; it may also be turned to the right, 
 though the fundus is inclined to that side, which is a much rarer case. 
 
 277. Thickness of the walls. Galen, Paul ^Eginetta, and Mau- 
 riceau also have advanced that the uterus grows or distends only at 
 the expense of the thickness of its walls ; Riolan, Deventer, De La 
 Motte, and Roederer, on the other hand, have maintained that this 
 thickness increases during pregnancy, while the moderns admit that 
 it remains as it was previously to fecundation. Such discrepancy 
 of opinion upon a fact easy to be ascertained, looks, at a first view, 
 very strange; but let it, nevertheless, be explained with reference to 
 the situation in which the observers were placed. The ancients, 
 as they could not open dead bodies, were compelled to reason from 
 analogy ; seeing that the coats of the bladder grow thin in propor- 
 tion as they become more and more expanded, and that the same 
 thing, in a large number of animals, holds good as to the uterus and 
 its horns, they did not suppose it could happen otherwise in the 
 human species. Besides, they might found their opinions upon the 
 fact, that in women dying with uterine hemorrhage during labour, 
 or in the last three months of gestation, in those affected with hy- 
 drometry, or in whom the ovum contains too large a quantity of 
 amniotic fluid, the "muscular *oat of the womb is indeed very thin,
 
 OF TRUE PREGNANCY. 109 
 
 and sometimes reduced to one half, a third, and even a quarter of 
 its natural thickness. 
 
 Others might have been induced to defend a diametrically oppo- 
 site sentiment, because during the first eight days after parturition, 
 a period in which more childbed women die than in any other, the 
 parietes of the womb, in contracting, really thicken so much as to be 
 an inch, or even fifteen lines through, at the fundus. But, since nu- 
 merous opportunities have been enjoyed of interrogating nature in 
 a better way, hypotheses founded on false analogies or on excep- 
 tionable or badly explained cases, have given way before the truth. 
 
 278. It is now known that the womb preserves nearly the same 
 thickness during the whole course of pregnancy as it had when un- 
 impregnated ; (I say nearly, for sometimes it is a line or two thicker 
 or thinner ;) that this thickness, always greatest at the insertion of 
 the placenta, generally diminishes from the fundus towards the cer- 
 vix, where it is frequently found to be not more than two or three 
 lines, or even less ; that it increases a little in all parts of the organ 
 at the same time, until the third or fourth month, and then remains 
 rather below its primitive limits, except the cervix, which at that 
 period, especially, grows thinner, to exceed them again in the 
 last stages of pregnancy. It is, therefore, useless to argue against 
 the opinion of Jenty, who maintains that this thickness is much more 
 apparent than real, and that it is solely owing to the accumulation 
 of blood in the uterine vessels. 
 
 279. Structure. In its unimpregnated state, the organization of 
 the womb seems to be only incipient; it is perfected, or developed, in 
 pregnancy (169); its fibres, which were pale, dense, and inextrica- 
 bly tangled, soften, become redder, and soon represent layers and 
 bundles easy to detect and to follow. The cellular tissue, which 
 was before so firm, dense, and elastic, relaxes, becomes supple, 
 and indeed resembles the common cellular tela, and in this way 
 permits the other elements, which it held in bondage as it were, to 
 follow the impulse that animates the whole womb. The arterial 
 branches folded upon each other a thousand times, like the vas de- 
 ferens, and bridled in this condition by dense, elastic lamina?, cede 
 to the general relaxation, and gradually become lengthened ; their 
 angles, at first so sharp, with their doublings, grow blunter, enlarge, 
 and at last exhibit only certain zigzags of greater or less depth, 
 tortuosities which do not impede the circulation, and their calibre, 
 before the end of gestation, comes to be double, triple, and even 
 quadruple its diameter previous to fecundation. 
 
 280. The veins undergo the same metamorphoses : already, in the 
 natural state, larger and less tortuous, they enlarge, and are developed
 
 HO OF TRUE PREGNANCY. 
 
 still more rapidly than the, arteries ; at term they are observed to 
 furrow the fleshy layer in every direction, and form a net-work which 
 in some measure separates it into two planes. They are large 
 enough to admit a goose quill, and, in some instances, even the end 
 of the little finger ; near the mucous membrane they dilate so as to 
 constitute cones with inverted bases ; cones described by Astruc, 
 under the name of uterine sinuses, but which Haller restored to 
 their proper nature by denominating them venous sinuses; and to 
 which Hunter thinks no particular name should be given. 
 
 281. The lymphatic vessels are, according to Cruikshank, so 
 amplified that they may, by injecting them with mercury, be made as 
 large as crow-quills, and to form a kind of coating of silver to the sur- 
 face of the womb ; the nerves themselves, according to Hunter, also 
 increase sensibly in size ; which accounts for certain alterations of 
 function we shall have occasion to treat of in a subsequent page. 
 
 282. The mucous membrane, the existence of which it is so dif- 
 ficult to demonstrate in the uninipregnated state, becomes more 
 evident, redder, more villous ; distinct shreds of it can be separated; 
 the folds which it forms for the purpose of enclosing the ridges of 
 the cervix, relax and disappear, but not until the last half of preg- 
 nancy ; the serous coat also is far from being unaffected by all these 
 changes, and Bichat was evidently mistaken when he asserted that 
 the peritoneum, like the other diaphanous membranes, possesses 
 no extensibility. At the end of pregnancy, the meso-rectum re- 
 mains ; the broad ligaments, and other folds, though tightened, are 
 not effaced, yet lose some of their proportional dimensions, and even 
 somewhat of their absolute dimensions. Besides, admitting that 
 they do become completely unfolded, their laminae would be insuffi- 
 cient to cover a circumference of twenty-six inches. It is evident, 
 then, that the serous coat increases in the same proportion as the 
 fleshy coat of the womb ; that it is extensible, and remains in con- 
 tact with the same points of the subjacent layers, from the com- 
 mencement to the end of gestation. I have even remarked, as M. 
 Ristelhueber has, that, instead of becoming thinner, it rather in- 
 creases in thickness, and that its adherences scarcely relax at all 
 while it is undergoing this amplification. 
 
 283. Functions and properties. In proportion as the uterine 
 vessels deploy themselves, the blood is determined thither, and at 
 last the womb, like a sponge, is imnird with that fluid ; however, 
 the menses are suppressed as soon as frcinidatioii is effected, and 
 some physiologists IKIVC attributed to this circumstance most of the 
 modifications which am t|ir:ii experienced by the womb; but we 
 cannot adopt such an opinion, for the same changes arc observed
 
 OF TRUE PREGNANCY. Ill 
 
 in women who continue to be subject to a periodical discharge 
 during pregnancy, arid where the uterus is distended by a polypus, 
 while they are not met with in a case of simple amenorrhcca. Tra- 
 versed by larger nerves, and receiving a larger supply of vivifying 
 fluids, the uterus enjoys a livelier sensibility : in the unimpregnated 
 state it maybe touched, struck, pressed upon, without, so to speak, 
 causing the woman to feel any pain ; during the growth of the ovum, 
 on the contrary, the least jar, the least touch of the fo3tus are in- 
 stantly felt by the mother ; both its sensibility and contractility are 
 of a grade almost as high as that of the organs of relation. 
 
 284. To explain the extraordinary development of the uterine 
 cavity, the ancients taught that the ovum dilates k by growing, just 
 as we can dilate a glass tube by blowing into it, as we distend a 
 bladder by filling it with a fluid or air, or as we can spread out a 
 ball of soft wax. Puzos has not rendered this hypothesis more sus- 
 tainable, by calling to its support the laws observed by fluids in trans- 
 uding from without to the inner side of any inert vessel ; for as, in 
 physics, the force of impulsion of fluids is measured by the heighth 
 and thickness of the column, it is clear that in this case, the distend- 
 ing effort would increase in an inverse ratio to the resistance ; that, 
 from being very feeble at the beginning, when the density of the 
 organ is considerable, it would at the close be doubled ten times to 
 overcome a less difficulty. Would it be any better to say, with Van 
 Helmont, that the womb dilates spontaneously under the influence 
 of a bias m^teorisant^ or to admit, with Levret and the moderns, that 
 like the heart and the erectile tissues, it grows actively, and by the. 
 mere force of its vital properties ? But in reasoning thus, the fact 
 is explained without indicating the cause. It is at least certain that 
 the dilating force, altogether foreign to the product of conception, 
 exists in the gestative organ itself: a circumstance that beyond 
 question proves this to be the case, is, that in preternatural preg- 
 nancies, as remarked by Levret, Bertrandi, Meckel, Chaussier, &c. 
 the uterine cavity, though empty, dilates as it does in an ordinary 
 gestation. 
 
 285. To explain this dilatation, it is useless, with Malpighi, to refer 
 to a fermentative principle contained in the semen, or with Blumen- 
 bach, to a peculiar vital action ; the turgescence occasioned by fe- 
 cundation, and kept up by the ovum, affords a very satisfactory rea- 
 son for it : the congestion, of which the womb is the seat, invites to 
 it an excess of nutrition ; the new molecules incessantly deposited 
 there, necessarily elongate its fibres ; the vascular channels are both 
 uncoiled and enlarged at the same time, and as this unfolding and 
 elongation cannot take place without increasing the extent of the
 
 112 OF TRUE PREGNANCY. 
 
 curves or circles represented by each fibre and vessel in the organ, 
 it follows that the amplification of its cavity must be an inevitable 
 consequence of the augmented nutrition of its parietes. 
 
 286. Moreover, the ovum and the'womb enlarge both together; 
 and though the end or function of the thing contained is not to en- 
 force the distention of that which contains it, it at least serves to 
 support its parietes, and to keep up its due measure of irritation. 
 In this, as in all other cases, nature finds the means of multiplying 
 effects without augmenting the number of causes. 
 
 287. Appendages of the uterus. The changes effected in the 
 position, size, and weight of the womb will of necessity occasion 
 some alterations m the disposition of the circumjacent parts. 
 
 288. In consequence of the depression of the cervix during the 
 first months, the vagina becomes shorter and wider ; at a later pe- 
 riod, being drawn upwards along with the uterus, it becomes elon- 
 gated, and at length forms a kind of cone with the apex at the vulva. 
 By means of the fluids it imbibes it' becomes softened ; its anterior 
 and posterior columns sometimes acquire a very considerable size, 
 especially near their lower ends. 
 
 289. The Fallopian tubes, retained by the broad ligaments 
 against the sides of the womb, enlarge, become redder, more vascu- 
 lar, and, as it were, spongy on the inner surface of their funnel 
 shaped portion. 
 
 290. The ovaries, which are depressed in the same way, also in- 
 crease in size ; their vessels dilate, sometimes become varicose, so as 
 even to burst, and occasion a fatal hemorrhagy. 
 
 The fibres of the round ligaments are better expressed, enlarged and 
 redder, so that at the period of labour, they compose two real muscu- 
 lar cords,whose contraction is in certain cases so evident, that I have 
 in three different women observed it myself, and also pointed it out 
 to several persons during the contraction of the womb for expelling 
 the after birth. 
 
 21)1. The bladder rises above the superior strait ; the urethra is 
 concealed behind the symphysia of the pubis, becomes almost verti- 
 cal, its orifice retreats under the summit of the pubic arch, and the 
 introduction of the catheter in pregnant women, is thus rendered 
 more difficult ; it may also happen that the urinary bladder, being 
 more forcibly compressed above than below its fundus, may project 
 .iininst the upper part of the vagina, making a tumour there of 
 which I have often met with cases in the latter half of gestation. 
 
 Thr; fiTiinn being, as it were, strangulated above, and no 
 longer receiving any impulsion from the diaphragm, becomes dis- 

 
 OF TRUE PREGNANCY. 113 
 
 tended with stercoraceous matters, and in that way interferes with 
 the form of the posterior wall of the vagina. 
 
 293. The small intestines, being raised upwards by the fundus of 
 the uterus, in front of which they are sometimes partially placed, may 
 be in that way so compressed as to occasion colic pains of a more 
 or less violent character ; at other times their most movable por- 
 tions engage in the recto -vaginal excavation, where they are liable to 
 be strangulated and give rise to very serious affections ; but they are 
 most frequently thrust towards the lumbar regions, or else mount 
 directly up, pressing against the aich of the colon, the stomach and 
 liver. 
 
 The diaphragm itself being pushed upwards into the thorax, 
 whose base it enlarges, while its vertical diameter is lessened, is in 
 some degree hindered from executing its contractile movement. 
 
 294. The skin on the lower part of the beljy becomes thinner, is 
 covered with whitish blemishes and streaks, arranged in zigzag or 
 curved lines, with the convexity downwards ; its meshes enlarge like 
 that of a piece of stuff that yields upon being stretched, without, 
 however, tearing. After the lying-in it appears to be covered all 
 over with reticulated scars, and becomes wrinkled or covered with 
 plaits ; in short women, as observed by M. Desormeaux, and I will 
 add, in those where the abdomen attains to a very considerable size, 
 this state of the skin is propagated as far as the thighs and breech. 
 
 295. The aponeuroses become frayed ; the inguinal ring enlarges 
 a little, but the linea alba undergoes the greatest changes, because 
 it is more peculiarly charged with resisting the weight of the womb 
 and the viscera ; instead of one inch, it sometimes is four inches 
 wide at its middle ; towards the end of pregnancy we find in its 
 place nothing more than a tissue or net- work with meshes more or 
 less supple. 
 
 296. The navel opens a little, grows more salient and thinner, 
 which renders the occurrence of umbilical hernia very easy. In a 
 great many women there is such a separation of. the aponeurotic 
 fibres upon the median line, that it seems as if it were pierced with 
 a lozenge-shaped, or elliptical opening, the ends of which approach 
 sometimes nearer, sometimes less near to the epigastrium or pubis. 
 Further, in this case there is left, after the labour is over, an oblong 
 tumour, a kind of eventration, which is sometimes increased by sub- 
 sequent pregnancies to such a degree, as to permit the womb to 
 turn very much over in front, above the superior strait. 
 
 297. The pressure exercised by the womb upon the vessels of 
 the pelvic excavation necessarily impedes the venous circulation of 
 the surrounding parts; the external organs of generation, too, and 
 
 P
 
 U4 OF TRUE PREGNANCY. 
 
 the lower limbs, are often seen to be infiltrated, covered with varices, 
 and affected with considerable pain; pains that may depend upon the 
 compression of nerves belonging to the lumbar and sacral plexuses. 
 
 298. The pelvis relaxes, and its articulations, so firm and solid, 
 change so much, as in some women to become quite movable. 
 Avicenna, Aetius, Fernel, and most of the ancients had doubtless ob- 
 served it, for they placed rigidity of the symphyses among the causes 
 of difficult labour : this opinion however was pretty generally aban- 
 doned about the time of Pare ; for S. Pineau, vigorously opposed by 
 the surgeons of Paris for having maintained it, never could convince 
 them of it, until he exhibited the body of a newly delivered woman 
 who had been executed. Since then, Bertin and Bouvart, in a cele- 
 brated thesis ; Smellie, Levret, Plessman, Piet, Desault, M. Boyer, 
 Baudelocque, Beclard, Chaussier, Madame Boivin, &c. have ad- 
 mitted the softening of the pelvic articulations : some as a constant 
 occurrence ; others as an exception ; some as a state proper to 
 facilitate parturition, as a wise precaution of nature ; others as a 
 dangerous disease. At present the existence of the fact cannot be 
 doubted, and all the questions relating to this long debated point are 
 of easy solution. Reason indicates, and observation proves that the 
 ligamentous bands of the pelvis become more soft and supple in 
 many pregnant women ; and that, in common with all the surround- 
 ing parts, they contain a larger quantity of fluid ; but it is impossible 
 for such an afflux of fluids to take place without the articular surfaces 
 being separated. This process, however, is so moderate in a ma- 
 jority of cases, that neither the woman nor the accoucheur perceive 
 it. Smellie has seen it carried to such an extent that the bones 
 could be made to ride over each other ; Denman also mentions cases 
 of considerable separation ; Madame Boivin says it is not uncommon 
 to find a distance of four, six, eight, ten, and even twelve lines be- 
 tween the pubes, and naturalists are aware that in some of the mam- 
 mifersB, the bones of the pelvis, too narrow to permit the birth to 
 take place, separate so widely during gestation, as to be in a manner 
 lost in the soft parts. 
 
 299. In these cases of extreme softening, standing and walking, 
 which in some individuals are both fatiguing and painful at the close 
 of pregnancy, may produce inflammation and suppuration of the sym- 
 physes, numerous examples of which are upon record ; in these 
 cases too it is right } as Baudelocque teaches, to class their mobility 
 among the pathological alterations : on the other hand, we may con- 
 that in a slightly contracted pelvis, such a softening may to a 
 certain extent have a beneficial effect upon the labour, as has been 
 asserted by several authors ; but for promoting thia softening, is it
 
 OF TRUE PREGNANCY. 
 
 proper, in accordance with Pineau, to repose any confidence upon 
 the action of baths, cataplasms, and other means of the same nature ? 
 Is it possible, without any bad effect, to increase it by mechanical 
 efforts, such as dilating efforts for example ? Can we believe with 
 Denman and others, that the pressure exerted by the child's head 
 has something to do with its production, when the labour is violent, 
 and yet progresses slowly ? 
 
 According to Baudelocque, the ligaments alone share in this ope- 
 ration ; MM. Piet and Chaussier are wrong in teaching that the 
 cartilaginous plates are equally concerned in it. 
 
 The symphysis of the pubis, being in almost all respects similar to 
 the articulation of the bodies of two vertebras, explains why the soft- 
 ening affects it more frequently, and always to a greater degree 
 than the posterior symphyses ; and how it happens that in a majority 
 of women who have borne children, its surfaces are commonly rather 
 more distantly separated than they were before pregnancy took 
 place. 
 
 300. The consistency even of the bones of the pelvis is some- 
 times so altered, that they become flexible. Weidman relates a re- 
 markable instance of this kind : the inferior strait was so contracted,' 
 that the Caesarian operation appeared to be indispensably necessary; 
 but in attempting to pass up his hand, he perceived that the ischia 
 and the pubic arch yielded like cartilage, and the labour terminated 
 without an operation. M. Hofmeister has lately published a case 
 nearly similar, and not less curious. According to Burns and other 
 English accoucheurs, this state of things often exists as a symptom 
 of the dangerous disease they describe under the title of malacosteon. 
 
 . II. Sympathetic phenomena, and rational signs. 
 
 301. The numerous material modifications that have just been 
 enumerated, act more or less upon the rest of the system, and give 
 rise to what are by agreement denominated the general, common, 
 rational, vague, uncertain, and doubtful signs of gestation. 
 
 302. It is a common notion, long ago inculcated by Hippocrates 
 and Galen, that a fruitful copulation is accompanied with much live- 
 lier enjoyment than an ordinary coitus, and that it is felt at the same 
 moment by both the parties. According to Aristotle the copulative 
 organ of the male is withdrawn less moist than commonly from the 
 female organs, and the seminal fluid does not escape from them. 
 Immediately after coition the two beings fall into a state of languor, 
 of weakness, of uncommon sadness ; the woman feels a disposition 
 to faintness, to syncope, to have horripilation, colic, and a sort of 
 vermicular motion which seems to proceed from the womb and pass
 
 11 g OF TRUE PREGNANCY. 
 
 to the iliac fossae or flancs ; borborygmi, first in the uterus, which 
 seems to be full of gas, and then throughout the whole abdomen, and 
 sometimes a general shivering, beginning in the abdomen, complete 
 the series of symptoms which announce that fecundation has taken 
 place. 
 
 303. This first condition is succeeded by pregnancy, properly so 
 called. The eyes lose their vivacity, their brilliancy, have an ex- 
 pression of languor, and seem to sink into their orbits ; the eyelids 
 grow dark and are surrounded with a blackish, livid, or leaden circle; 
 the nose grows sharper and longer ; the mouth widens by the sepa- 
 ration of its corners ; all the features of the face seem to retire 
 backwards, which renders the chin more prominent ; the/ace be- 
 comes pale, is covered with spots of various sizes and numbers, 
 sometimes reddish, or of a more or less deep brown ; sometimes, 
 but more rarely, of a dead or milk white colour ; in a word, it be- 
 comes masked. 
 
 The neck swells, becomes softer, and is the seat of a congestion, 
 which, according to Diogenes, was formerly indicated by Democritus, 
 and which Catullus has mentioned in the following lines : 
 
 Non, illam nutrix, oriente luce, revisens, 
 Hestcruo collum, poterit circumdare filo ; 
 
 a congestion which Dumas says he has positively observed. The 
 breasts enlarge, become more tender, firmer ; sometimes a few drops 
 of whitish serosity can be extracted from them ; the nipple rises and 
 is more prominent ; the areola enlarges and grows visibly browner ; 
 the delicacy of their tegumentary layer increases, and they also occa- 
 sionally exhibit some whitish stains, analogous to those on the face. 
 
 304. The pulse, at first embarrassed, acquires a greater degree 
 of frequency, and then of force and hardness ; it becomes larger, 
 fuller, sometimes irregular, and somewhat bounding, quick and 
 feverish ; towards the term of labour, it is found to be, says Bordeu, 
 convulsive-like, intermittent and corded ; in fine, the artery seems 
 to be more tense, beats with more frequency and velocity ; the cir- 
 culation being more active, hemorrhages arc commoner and more 
 dangerous ; blood drawn from a vein, or escaping accidentally from 
 the organs, is found to be covered with a sizy coat, of variable 
 thickness, according as the fibrine or crassamcntum happens to be 
 above or below the natural proportions. The temperature of the 
 body rises, and enables pregnant women to bear cold better than 
 others ; Iho insensible transpiration is also more abundant, and at 
 the commencement yields an odour of prolific matter, but which 
 
 become.- acrid or of a peculiar nature. The urine flows
 
 OF TRUE PREGNANCY. 117 
 
 more abundantly, is cloudy, and contains a larger sediment ; all the 
 secretions are more energetically effected ; the saliva, in particular, 
 is often furnished in great quantity, so that some women are attacked 
 with a real ptyalism. The liper, being deranged in its secretions, is 
 said to occasion the stains or ephelides of the face and skin. 
 
 305. The sense of taste and the digestion are still more specially 
 perverted ; anorexia, nausea, and even vomiting supervene, and are 
 frequently followed with a complete loss of appetite ; the woman 
 now desires for food nope but the most singular and sometimes dis- 
 gusting objects. At one while her greatest happiness is to eat clay, 
 ashes, lime, or to craunch charcoal ; at another she places her de- 
 light in half putrid meat, spiders, or other unclean animals : in 
 general she is displeased with fat, and an animal regimen ; fruits and 
 vegetables suit her better ; some ardently desire sour drinks, and 
 love none but food prepared with vinegar, as salad, &c. 
 
 306. This state of inappetency and disgust is succeeded, after the 
 few first months, by a very decided appetite, in some cases almost 
 voracious, by easy digestion, fondness for wine and other spirituous 
 drinks ; but in the last third part of pregnancy, the digestive func- 
 tions again become disturbed, doubtless because the stomach, being 
 at that period too small, can only take in very small quantities of 
 food and drink. 
 
 307. The moral condition of the female is also subject to pretty 
 numerous changes: some women, naturally gay, good tempered, 
 and amiable, become sad, mechancholy, cross, unsociable, and vice 
 versa. In a good many women, the passions, although previously 
 moderate, acquire an extraordinary violence, cannot be subdued, 
 and cause the commission of the most atrocious crimes ; in others, 
 there are merely some singular desires, such as to eat a particular 
 kind of fruit or meat or game, or some particular dish, no matter 
 at what price ; an irresistible tendency to steal objects of small 
 value, or for which they have no use, and corruption of their man- 
 ners or character. There are some whose wit is never more lively, 
 more penetrating, more agreeable ; while others fall into a sort of 
 stupidity and apathy quite unnatural in them. In general the activity 
 of the intellectual faculties is augmented, whether in the whole, or 
 only in part ; in one case the memory, or a taste for the arts or 
 sciences, are modified; in others the judgment becomes exquisite, 
 or the imagination is exalted to such a degree, that some women 
 have, during their pregnancy, attained to a surprising degree of per- 
 fection in those works of genius, those arts or sciences, which they 
 had previously cultivated with indifference and without success ; 
 some lose their senses and become crazy, always at the same periods
 
 118 OF TRUE PREGNANCY. 
 
 of their pregnancy ; others are seen in whom mania never disap- 
 pears, and who never become composed except during this function. 
 
 308. Many diseases supervene, are suspended, or disappear ; 
 sometimes adontalgia, without any cajies of the teeth, is renewed 
 every time the woman becomes pregnant ; sometimes ' neuralgia, 
 whether suborbital, facial, or of any other sort ; chorea or St Vitus's 
 dance ; convulsions, or other motions, hysterical or epileptiform ; in 
 other cases, pulmonary consumption of a very advanced stage 
 seems to retrograde, or even gives place to a highly flourishing 
 state of health ; a pretty considerable number of different diseases, 
 such as chronic or obscure inflammation of the lungs or digestive 
 passages, and serious and profound organic lesions are affected in 
 the same manner. But although it is true that after parturition 
 some of the affections that are happily modified by gestation do not 
 return, it is but too certain that a major part of them thenceforth 
 progress towards a fatal termination with frightful rapidity. 
 
 309. Such is the series of sympathetic phenomena noticed in 
 pregnant women by accoucheurs : it has been seen that they are 
 numerous ; but unhappily, every one of them may exist ; they may 
 even be met with altogether, without the patient's being pregnant ; 
 while on the other hand, pregnancy often takes place without giving 
 rise to them. Besides, how can we rely upon those that depend 
 upon sensations experienced during or immediately after coition ? 
 Women, like all the rest of the human race, easily believe what they 
 desire, and are willing to conceal even from themselves what they 
 dread. They therefore will or will not experience such and such 
 symptoms, accordingly as they do or do not wish to be pregnant. 
 How can we subsequently recognize among the disturbances or dis- 
 orders of the mind that which appertains to pregnancy, and distin- 
 guish it from that which is occasioned by perverseness, or that which 
 depends upon actual disease ? 
 
 310. Be this as it may, there are a great many cases in which, by 
 proper attention, an able accoucheur can make excellent use of the 
 rational signs, in forming his opinion. For example, when the mask 
 on the face is rapidly manifested in a woman who has never had it 
 before, who lives in a large city, and is not exposed to tho-heat of 
 the sun, it becomes a very probable sign of pregnancy. The same 
 may be said of the violet circle round the eyes, and of the swelling 
 and sensibility of the breasts, when they are independent of the men- 
 strual function ; of the nausea, ptysalism, and disordered digestion, 
 perversion of the desires and appetite, when they are not results of a 
 morbid suppression of the catamenial discharge. As to the odour 
 given out by the skin ; as to the perspiration, the increased tempera- 
 
 I
 
 OF f RUE PREGNANCY. 119 
 
 ture, the condition of the pulse, the urine, the colour of the nipple 
 and its areola, the size of the neck, the changes in the aspect of the 
 face, &.c. their existence is too variable, too fugacious, or depends 
 upon too many different causes, or they are of too difficult determi- 
 nation, to permit us to repose the least confidence in them. They 
 are merely so many resources which the learned and ilpright physi- 
 cian abandons to the shameless quack, or to the credulous ignorant 
 vulgar who are duped by them. Upon the whole, the rational signs, 
 when united in a certain number, an$ properly weighed, most com- 
 monly suffice to make us believe in the existence of gestation, but 
 never to give us a mathematical certainty of it, to warrant us in 
 affirming to it before a court, even although in addition to these 
 there should be a suspension of the periodical flux. 
 
 31 1. Menses. However, in women who have no interest in de- 
 ceiving us, the last mentioned phenomenon deserves the greatest at- 
 tention ; it is the most conclusive, and sometimes the only one to be 
 met with ; but inasmuch as it is frequently the cause or the effect of 
 a great number of affections of more or less importance, and wholly 
 independent of pregnancy, it is not an easy matter to interpret it 
 correctly. If it happen suddenly, without being preceded by any 
 accident or disease that might account for it, and in a woman who 
 is commonly very regular, it may constitute an almost certain sign 
 of pregnancy, while in the contrary condition, its value, always much 
 lessened, can be determined only by a circumspect and experienced 
 practitioner. I have no occasion to remark that it is of no value 
 where pregnancy occurs before the first eruption of the menses. 
 Further, it is well known, that a woman whose menses have been 
 for some time suppressed, either from disease or merely from the 
 progress of age, may become pregnant ; that some women are 
 never regular except when they are pregnant ; and that the continu- 
 ance of the menses after fecundation is found occasionally to be al- 
 most epidemic, or at least, much more frequent in some years than 
 in others. 
 
 312. Size of the Belly. The enlargement of the abdomen in a 
 woman old enough to be fecundated, ordinarily suffices with the pub- 
 lic, to make them presume that she is pregnant. It is otherwise 
 with physicians. It is occasioned by so many diseases, that it ought 
 in this respect to be classed in the same category as the suppres- 
 sion of the menses. Nevertheless, its ordinary rate of progress is 
 such as to yield a very important sign, and one which, alone, is, in a 
 good many cases, sufficient to render it certain that there is preg- 
 nancy.
 
 120 OF TRUE PREGNANCY. 
 
 313. The belly often tumefies or swells by insensible degrees from 
 the first week after conception has taken place ; it afterwards dimi- 
 nishes or is even flattened about the beginning of the second month ; 
 whence the common proverb, a ventre plat, enfant il y a. It soon 
 afterwards grows again in a regular manner, and never stops until the 
 term of parturition. At first it projects along the median line and 
 lower part of the hypogastrium ; while the navel seems to sink be- 
 neath its natural level. Until the fourth month, the iliac regions ap- 
 pear to grow hollow instead of projecting in proportion with the hy- 
 pogastrium. About the end of the third month, the navel approaches 
 towards the level of the skin, which it soon surpasses, so as in some 
 women to form a protuberance of an inch or two, in the course of the 
 fifth, sixth or seventh month. Upon the whoFe, the special character 
 of a pregnant woman's abdomen is that it grows from below upwards, 
 and remains a long time flattened on its sides, although its middle 
 portion already projects considerably. I shall have further occasion 
 to advert to this point when I point out the means of distinguishing 
 true pregnancy from the affections with which we are liable to con- 
 found it. 
 
 . III. Sensible signs. 
 
 314. The sensible signs of pregnancy are obtained by means of 
 the touch, or of auscultation, and from the material changes effected 
 in the womb. 
 
 315. The touch. The introduction of one or two fingers into 
 the vagina, while the other hand is applied to the front of the abdo- 
 men, is called, in tokology, the touch. Recourse is had to it for the 
 purpose of ascertaining the diseases of the vulva, of the vagina, the 
 womb, the bladder, the rectum, and all the organs contained within 
 the pelvic cavity ; to learn the good or bad conformation of the pel- 
 vis, the nature, species, and degree of its contraction ; but especially 
 for appreciating the modifications of the cervix uteri, either in re- 
 gard to its size, its consistence, position, length or temperature ; 
 and the weight, form, extent, situation^ and dimensions of the womb 
 itself during the course of pregnancy. 
 
 3 1C. The touch has always been looked upon as the compass of 
 the accoucheur ; but this has not hindered some persons, Puzos 
 among others (122), from vigorously objecting to its employment, 
 llousscl says that " accoucheurs ought to expunge from their books 
 the impertinent directions that they give concerning the touch. 1 ' 
 According to him the operation is too {dunning to the modesty of a 
 " clable woman, too contrary to good morals, and gives signs 
 too vague for it ever to be had recourse to. But Roussel speaks
 
 OF TRUE PREGNANCY. 121 
 
 here more like a rhetorician than a physician ; his arguments, drawn 
 from its abuse, have no bearing on the rule. Though, in many cases, 
 the touch is insufficient, until two or three months have elapsed after 
 conception, to convince us either that pregnancy does or does not 
 exist, it is, nevertheless, the surest means of exploration in our power. 
 It not only serves to determine whether gestation exists, but it fur- 
 ther indicates the degree, the kind ; it alone can teach as whether 
 labour is near at hand or begun, whether it is in an advanced stage, 
 whether the child presents aright, whether the assistance of art is 
 useless or necessary, whether every thing is right after labour, &c. 
 The touch then is the principal lever, or at least one of the most 
 powerful resources of tokologic science. But, in order to practise 
 it with success, to avoid the gross mistakes that it may cause us to 
 commit, to derive from it every possible advantage, it is necessary 
 to practise it for a long time, inasmuch as practice alone can make 
 us skilful in such an operation. 
 
 317. Position of the woman. When the woman is affected with 
 ascites, hydrothorax, asthma, organic disease of the heart or great 
 vessels, when her breathing is difficult, she should stand up during 
 the operation of the touch, so as to avoid the fatigue and even dan- 
 ger that might be incurred by placing her in a horizontal posture. 
 If on the other hand she is weak, threatened with syncope, hemor- 
 rhage, or convulsions ; if the womb is strongly inclined forwards, or 
 if from any other cause the neck is thrown very far backwards, it is 
 better for her to lie down. Finally, if any difficulty be experienced, 
 she should be examined in both positions, alternately. 
 
 318. The muscles must first be placed in a state of relaxation; 
 If the woman is lying down, she should be told to bend her legs 
 and thighs, as well as her head and breast, which are to be gently 
 raised with pillows or bolsters. In the contrary case, she is to be 
 placed against a wall, a piece of furniture, or any solid body for her 
 support ; she then separates and slightly bends her lower limbs, 
 while she at the same time inclines her head and breast a little for- 
 wards. To prevent the awkwardness of such a posture, she may be 
 permitted to rest her elbows or hands upon the arms of some other 
 person, or simply upon the edge of a fable, or on a couple of chairs 
 placed expressly for that purpose on each side of her. 
 
 319. Before we begin the operation, the finger should be covered 
 with mucilage of fiaxseed, or marshmallow root, olive or almond oil, 
 butter, hog's lard, cerate, white of eggs, or any kind of grease. 
 Mucilage is the best ; but when it is not at hand, it little matters 
 what substance we have recourse to, provided it be unctuous, and 
 not irritating. 
 
 Q
 
 122 OF TRUE PREGNANCY. 
 
 320. There are two reasons for making use of grease in this way; 
 it would not be so easy without this precaution to penetrate into the 
 vagina ; the labia, and the hairs that cover them, might be pulled, and 
 thus be to some women very painful ; if the accoucheur should hap- 
 pen to have any excoriation upon his finger he would by this means 
 be less exposed to contract syphilis, the itch, or other contagious 
 disease with which the woman might be affected. 
 
 We should learn to touch as readily with the left hand as with 
 the right. 
 
 321. Supposing that two fingers can appreciate the physical cha- 
 racters of a body better than one, Stein recommends the introduc- 
 tion of the fore and middle finger together : some of .that writer's 
 countrymen have followed his advice ; but with the exception of a 
 few very rare cases, it is never conformed to in France. The sen- 
 sation felt, instead of being clearer with two fingers, is on the con- 
 trary more confused, and the index when employed singly very cer- 
 tainly penetrates much farther than ifthemedius is introduced along 
 with it. 
 
 322. In the first place, in order to introduce it, it should be held 
 straight and strongly abducted from the other finger ; or these lat- 
 ter are flexed so that the thumb is placed in the palm of the hand. 
 In common, either of these two methods may be employed indiffer- 
 ently, but the former does not suit for women whose external or- 
 gans of generation are swelled, sensitive, inflamed or painful; the 
 latter is applicable to all cases, and, consequently, I think it prefer- 
 able, but that does not prevent me from using the other mode some- 
 times. 
 
 323. It is never indispensably necessary to uncover the woman ; 
 if she be lying down, the accoucheur should place himself beside her 
 bed, and the hand being put under the bed clothes, is carried up to 
 the vulva, passing beneath the ham corresponding to the hand that 
 is employed ; if she is standing up, one knee should be put to the 
 floor ; according to some it should be the one that corresponds lo 
 the hand that is made use of; according to others it should be the 
 opposite one. The former allege the advantage of having a place 
 to rest the elbow on, and of thus obtaining more firmness and surety 
 in the requisite motions. For my part, I think we can touch very 
 well in cither way ; however, I have for a long time past adopted 
 the latter mode, both in my own practice, and in my instructions ; 
 I find that the arm is freer, that it may be more easily inclined for- 
 wards or backwards, raised or depressed ; that it accommodates it- 
 sdf belli r to the necessarily varying stature of women, to the dif- 
 ferent decrees of pregnancy, and height of the womb. After all, 
 it is rather a matter of choice than of necessity.
 
 OF TRUE PREGNANCY. 123 
 
 324. The index finger arranged as before said, with its radial 
 edge turned towards the arch of the pubis, is first directed on to the 
 perineum, or posterior part of the vulva ; the point of the finger is 
 then drawn along forwards so as to pass in between the labia, and 
 penetrate into the vagina in the axis of the perineal strait, that is to 
 say, from below upwards, and from before backwards, as if it were 
 intended to reach the sacro-vertebral angle. Previously to search- 
 ing for the neck, it is proper to explore the state of the rectum, of 
 the bas -fond of the bladder, of the longitudinal columns of the vagina, 
 and the conformation of the straits and excavation of the pelvis : 
 after this first stage, the os tineas is to be examined ; the thickness 
 and length of its lips whether relative or absolute should be ascertain- 
 ed, as well as their bumps or tubercles, their depressions or slits, their 
 regularity or unevenness, and the form and direction of the orifice ; 
 we should next endeavour to determine the length of the neck as well 
 as the size of the womb, which must be raised up so as to learn its 
 weight, while its dimensions also may be ascertained, if, while the 
 finger touches it in the vagina, we can also succeed in feeling and 
 pressing upon its fundus through the abdominal parietes with the 
 other hand. 
 
 325. With these precautions, it is often possible, after the end of 
 the third month, in a lean woman whose abdomen is pretty flaccid, 
 to take hold of the womb by its neck and fundus at the same time ; 
 to make it incline backwards, or to either side ; to judge of its mo- 
 bility, form and size ; to measure very exactly its length and weight ; 
 to become certain whether or not it is in a natural state, and whether 
 or not the substance it contains is fluid. 
 
 326. The depression of the cervix, its gentle inclination forwards 
 or backwards, its density, its length and volume, whether a little 
 more or less considerable, exhibit varieties too multiplied, and may 
 depend upon causes too diverse for us to place much reliance upon 
 them. Besides, to judge of them, we should have touched the same 
 woman once or oftener, before she was suspected of being pregnant, 
 and every one knows that this is a condition rarely met with. 
 Alphonse Le Roy, in asserting with the decided tone that character- 
 ised him, that augmented heat of the cervix was sufficient ground for 
 him to affirm that pregnancy had taken place, has only given an addi- 
 tional proof of his arrogance and temerity. If conception does in- 
 crease the calorification of that part, indeed, do not all the irritative 
 affections produce the same result ? Is not the heat of the cervix 
 various in different women, and even in the same woman at every 
 moment of the day, of the week, or month, or year ? Must it not 
 present innumerable shades, according to the heat peculiar to each
 
 124 OF TRUE PREGNANCY. 
 
 practitioner's finger, and also according to the necessarily varying 
 temperature of the same practitioner's hand ? 
 
 327. Hippocrates and the ancient physiologists taught that the va- 
 ginal orifice of the womb closes immediately after fecundation, so as 
 to prevent the escape of the semen; Mauriceau and other accoucheurs 
 have remarked, further, that the cervix becomes sharper than it was 
 in the course of the two months preceding fecundation ; that it 
 assumes the form of a cone with its base turned upwards. These 
 changes, it is true, take place in some women, but they so often fail 
 in those who have never borne children, and are so fugacious, so 
 so difficult in common to recognize, so slightly marked after a first 
 pregnancy, that it is almost impossible to derive any advantage from 
 them. 
 
 328. Stein affirms that in the first two months, the posterior lip, 
 naturally the shortest, becomes the longest, and at length reaches the 
 same level with the anterior one ; that the slit in the os tineas is trans- 
 formed into an opening more or less regularly rounded and circular; 
 that the pubic face of the lower segment of the womb gives birth to 
 a soft and more or less projecting tumour ; and that these changes 
 most commonly suffice to prove that the woman is with child. But 
 it is so common to meet with a circular form of the lower orifice of 
 the womb in women who are not pregnant and who have borne 
 several children, and even in young virgins to see the posterior lip 
 as long or even longer than the other, either absolutely or only in 
 appearance, that the assertions of Stein do not really deserve a se- 
 rious refutation. 
 
 329. I cannot, however, refrain from mentioning a peculiarity 
 which perhaps imposed itself upon him as that anterior projection 
 which is vaguely treated of in the French translation of his work. 
 It has happened to me several times, and I have pointed it out to a 
 number of my pupils, to find, in women who had been already touched 
 by a good many persons, that the anterior lip was sensibly longer 
 and softer than at the commencement of our practical sittings ; ex- 
 amining this lip with care, it was then easy to feel a real crepitation, 
 and to find that it was swelled, and fungus-like ; but this was a state 
 wholly foreign to gestation, and which was produced solely by the 
 frequently repeated touchings to which we had subjected the woman. 
 At other times, we feel above the vagina, immediately in front of the 
 anterior lip, a softer, larger, more regular and less elastic tumour 
 which does not crepitate ; but this projection, which I have met with 
 at every stage of pregnancy, evidently depends upon the bladder, 
 the bas-fond of which presses the corresponding wall of the vagina
 
 OF TRUE PREGNANCY. 125 
 
 more or less downwards ; I should not dare to affirm, moreover, 
 that it does not pretty frequently exist independently of the state of 
 gestation. 
 
 330. Thus., until the second or third month, the sensible signs, 
 the touch itself cannot, any more than the rational signs, give us a 
 mathematical certainty of the existence or non-existence of gestation. 
 They sometimes permit us to establish a diagnosis that is more or 
 less probable, but never certain ; so that during this period, the touch 
 is in fact but a feeble resource, and women should not, without strong 
 motives, be subjected to it. 
 
 At a later period, although the practitioner cannot affirm posi- 
 tively that there is a foetus in the womb, he can at least be sure that 
 the organ is considerably increased in size. Thenceforth all that is 
 necessary is to distinguish real gestation from the diseases that are 
 sometimes confounded with it. Soon afterwards we are able to 
 perform the ballottement, and to perceive the spontaneous move- 
 ments of the child, which are the only phenomena that prove beyond 
 question the existence of pregnancy. 
 
 331. Ballottement. In effecting what is called ballottement, after 
 having first placed the index finger under the cervix, the summit of 
 the other hand is to be applied over the fundus of the womb, by 
 pressing it against the belly, which is to be carefully depressed so as 
 to push away the bowels and fat. In this way the womb is held in 
 the most exact manner possible, by the two extremes of its longitu- 
 dinal diameter, and now the womb is to be suddenly pushed upwards 
 with the finger that is in the vagina, while the hand on the hypogas- 
 trium attends to and judges of the motion experienced by the ovum. 
 The fcetus, which is movable, free, and the only solid substance 
 within the amniotic fluid, strikes directly opposite to the point 
 that received the impulse. If the hand that is outside receives no 
 shock, the motion is to be sent back to the other one in the vagina. 
 Should the first attempt fail, it is repeated several times, communi- 
 cating the impulse with each hand alternately, and taking all proper 
 precautions not to give the woman any pain. The same thing hap- 
 pens here that is seen in physics when experiments are made on the 
 transmission of motion. Indeed, let a vessel full of water be struck 
 on any part of its circumference, and the little figures that have been 
 suspended in it by means of glass bubbles or small bits of cork will 
 immediately move to the opposite side. But it is easy to understand, 
 that in order to obtain this result, the fostus must have attained to a 
 certain size, that there must be a sufficient quantity of liquor amnii, 
 that the uterus and parietes of the abdomen must not be too thick,
 
 !2G OF TRUE PREGNANCY. 
 
 and that the operation must be done with a dexterity and skill that 
 can only be acquired by practice on the natural subject. 
 
 332. Whenever a solid and movable body has struck one or both 
 hands during the operation for ballottement, there can be no further 
 doubt as to the woman's being pregnant ; but care should be taken not 
 to be imposed upon by the jar of a fluid, or any other kind of motion. 
 It is only from the fourth to the sixth month that the ballottement 
 presents a resource of any importance ; for it is rarely that the jar 
 of the foetus can be perceived before the end of the third ; and in 
 the next three months of gestation it is in general too easy to deter- 
 mine the state of the woman to make such a recourse needful. 
 
 333. Motions of the child. Ballottement impresses on the ovum 
 only a passive motion, which is the same whether the foetus is dead 
 or alive, and which would be the same were it possible for a poly- 
 pus or any other solid and large body to be free and movable in a 
 uterus filled with any kind of fluid. Ballottement makes us know 
 that pregnancy exists ; but active or spontaneous motions alone give 
 us the certainty that the foetus is living. 
 
 334. The child does not move in an active manner until after its 
 muscular system has acquired a certain degree of development ; and 
 still its motions must be so weak, that the woman can hardly per- 
 ceive them until in the course of the fourth month. At the begin- 
 ning she has a feeling of formication; after which they acquire a force 
 that varies according to the vigour of the child, the stage of preg- 
 nancy and the good or bad health of the mother. Their strength 
 most commonly increases until the birth ; sometimes they increase 
 for one or two months, become less marked in the sixth and seventh, 
 and resume their activity towards the end of pregnancy. M. De- 
 sormeaux has seen them cease entirely from the end of the fifth 
 month, and the child nevertheless be born strong and healthy at full 
 term ; in other instances they are never perceived at all : some able 
 practitioners, such as Mauriceau, De la Motte, Baudelocque, &c. 
 mention women in whom attempts had in vain been made to excite 
 them, and who were nevertheless delivered of robust and well grown 
 children. It may be supposed that plethora, some constraint, some 
 difficulty in the circulation of the fluids of the ovum, or even those of 
 the woman herself may render them duller, slower, more obscure and 
 vague ; and that the free exercise of all the functions, cheerfulness 
 and contentment of the mother, and a proper degree of strength on 
 the part of the child give them more energy arid vivacity. Deli- 
 cate, nervous, and irritalilo women feel them sooner and plainer 
 than those whose sensibility is less exquisite, who are not in the
 
 OF TRUE PREGNANCY. 127 
 
 habit of carefully analyzing their sensations, and who, in consequence 
 of their temperament or disposition being naturally more quiet, pos- 
 sess a calmer imagination and less impressible organs : the former 
 sometimes assert that they have felt the child move at the end of the 
 third month, (which seems almost impossible, since the muscles are 
 still mostly gelatinous,) while the latter do not commonly speak of 
 it until towards the end of the fourth. 
 
 If the motions of the child are very decided, quick, and frequent, 
 it is not necessary for them to move the abdominal parietes in an 
 evident manner, as is sometimes seen, to guard the woman against 
 confounding them in any way with motions of another kind ; but 
 when they are weak and return but rarely, nothing is more common 
 than for other sensations wholly independent of them to be mistaken 
 for them ; so that the prudent accoucheur should never pronounce 
 upon them without having made himself perfectly sure. 
 
 335. For this purpose it often suffices to apply the hand, which 
 must be cold and naked, to the abdomen : it may be previously rub- 
 bed with brandy, Cologne water, &c. or dipped in cold water, with 
 vinegar and ammoniac in it. This application produces a sudden 
 transition in the temperature of the hypogastrium, which re-acts upon 
 the child and causes it to move in a convulsive manner. If this 
 simple means does not succeed, the palm of the hand is to be placed 
 on one side of the abdomen, which should then be properly struck 
 with the other, as in examining into the existence of ascites. The 
 foetus thus disturbed scarcely ever fails to move with some force : 
 and this is a sort of ballottement, which possesses the advantage over 
 the common method of not requiring the finger to be introduced into 
 the sexual organs, but which has also the disadvantage that it cannot 
 be usefully employed until after the fifth month. 
 
 Auscultation. After having properly performed the touch, having 
 attempted to effect the ballottement, and to feel the motions, whether 
 active or passive, of the foetus in vain, we have no method of solving 
 the problem left except auscultation. 
 
 336. After Laennec had shown that it is possible to see with the 
 ear what is passing inside of the chest, it was natural to suppose 
 that auscultation would soon be applied to the investigation of the 
 diseases or functional changes of other parts of the body. MM. 
 Major and Fodere had already given some hints on the subject 
 when Mr Kergaradec, in an interesting memoir, maintained, that 
 gestation may be ascertained with great certainty by means of the 
 stethoscope. According to that physician, two kinds of sounds may 
 be heard in the womb of a pregnant woman : one, which although 
 quicker and shorter, is analogous to that of a feeble respiration, is the
 
 128 OF TRUE PREGNANCY. 
 
 bruit de souffle which he has denominated the placental sound ; the 
 other, similar to the ticking of a watch wrapped up in cloths, de- 
 pends on the beating of the heart, and may be called the sound 
 of the heart. The former is isochronous with the pulsations of the 
 mother, which hinders it from being confounded with the respira- 
 tory sounds ; but it is in almost every respect similar to that caused 
 by muscular contractions, that heard in the large arterial trunks 
 when spasmodically contracted or compressed by some external 
 tumour, and in the heart itself in certain pathological states at pre- 
 sent not well understood ; so that some well performed experiments 
 are still necessary in order to demonstrate that it appertains to preg- 
 nancy rather than to some other condition of the female. M. Ker- 
 garadec thought that it corresponded to the place where the placenta 
 is attached, and was produced by the passage of blood from the womb 
 to the vessels of the ovum, or in other words by the uterine or pla- 
 cental circulation ; but although some facts seem to support this 
 explanation, there are many others opposed to it, and my own ob- 
 servations lead me to regard them as but very improbable conjec- 
 tures. In the majority of cases, it requires a very practised ear to 
 perceive them at all, and this is doubtless the reason which has in- 
 duced many physicians to reject them altogether. 
 
 337. I have myself in vain sought for it in a great many subjects; 
 on the other hand I have distinctly heard it in a great many others. 
 It was sufficiently strong in three women who were confined at the 
 Hospital de Perfectionltement, and in two others who were made use 
 of for the practical demonstrations of my course, for the least skilful 
 medical students and female pupils in midwifery to hear it very plain- 
 ly. I have never met with it except in the second half of pregnancy. 
 If Laenncc and M. De Lens, who say that they have heard it before 
 the end of the third month, were not mistaken, that alone appears 
 to me to be reason enough why it is impossible to attribute it to the 
 placento-uterine circulation. 
 
 338. It should be sought for between the anterior edge of the 
 pelvis and the navel, and lower down in proportion as the pregnancy 
 is less advanced. 
 
 339. The double-beat, or sound of the heart cannot be confounded 
 with any other ; for the pulsations can be counted to the number of a 
 hundred to a hundred and forty or a hundred and fifty per minute, 
 while the mother's pulse beats only from sixty to seventy-five in the 
 same space of time : growing stronger as the foetus grows older, 
 this sound can scarcely be appreciable before the fourth month ; of 
 ;i necessarily variable intensity, on account of a great many circum- 
 stances that are difficult to characterize, it is never heard better
 
 OF TRUE PREGNANCY. 129 
 
 than when the child's back corresponds to some part of the anterior 
 surface of the uterus ; I have scarcely ever failed to detect it when 
 able to seek for it with all suitable care ; the anterior curve of the 
 foetus, and the relations of the heart to the spine, are the reasons 
 why the back is the only part that is evidently capable of transmit- 
 ting the double beat to the ear of the observer. From this remark 
 it may be conceived that they may change their place if the foetus 
 changes its position, and that before affirming that they do not exist 
 at all, we should have by turns explored the hypogastrium and the 
 loins, the flanks, and all the various parts of the circumference of 
 the pelvis. 
 
 340. In order to perform the auscultation, the woman must be 
 lying down, although in fact she might be allowed to stand up ; if 
 the pregnancy be somewhat advanced the ear will suffice, and some- 
 times succeeds better than the stethoscope with persons not in the 
 habit of using that instrument. However, it can only be conveniently 
 applied on the anterior half of the abdomen; Moreover, the friction 
 of the gown or any other part of the woman's dress, whom it is un- 
 necessary to uncover during the operation, may frequently deceive us 
 as to the nature of the sounds we hear. The stethoscope in gene- 
 ral yields a clearer or more intense sound ; besides, it can be applied 
 at all stages of pregnancy, and to all the points to which the foetus 
 seems able to turn its back : the end piece is to be taken off; then 
 after having felt for the womb, it is placed first on the left, then on 
 the right, and next on the middle of the hypogastrium ; it is even 
 applied to the loins, the posterior face of the sacrum, the cristoe of 
 the ilia, the front of the pubis, &c. 
 
 34 1 . Were it always possible, the child's back, the corresponding 
 parietes of the womb and abdomen, the stethoscope and the ear of 
 the accoucheur should not be separated by any void space and by no 
 other part, and they should constitute as it were a continuous body, 
 without any interruption whatever. 
 
 342. The sound of the heart is a certain sign both of pregnancy 
 and ofthe child's being alive ; its strength, in general, indicates the 
 vigour and good health of the child ; during labour, when accidents 
 occur, or when a serious operation appears to be indispensable, its 
 simultaneous existence at two opposite sides of the abdomen will 
 render it certain that the womb contains two children ; if met with 
 in a woman whose uterus is but little developed, no doubt remains 
 of there being an extra uterine pregnancy ; but its absence, like that 
 ofthe active or passive motions ofthe foetus, does not afford a con- 
 clusive proof that there is no gestation, or that the child is not living. 
 
 343. As to the bruit de souffle, its nature is still too little under- 
 R
 
 130 OF TRUE PREGNANCY. 
 
 stood to enable a circumspect practitioner, at present, to pronounce 
 from its single testimony that such or such a woman is or is not 
 pregnant. 
 
 343. To determine the stage of pregnancy. After having by 
 means of the simple touch, of ballottement, of muscular movements, 
 or of auscultation, ascertained that there is pregnancy, it is still fur- 
 ther useful, sometimes, to determine its stage ; on this subject I shall 
 not repeat what has already been said concerning the changes ef- 
 fected every month in the state of the cervix, the body and fundus of 
 the womb ; I shall content myself with remarking that, in order to 
 obtain a just idea of these changes, especially those of the neck, it is 
 often needful to touch in a different manner from that in which it is 
 commonly done. In the first place we are not to understand by 
 the neck that portion merely of the womb that projects into the 
 vagina, but rather all the cylindrical portion of the summit of the 
 uterine ovoid, a kind of appendix which cannot be completely felt 
 except by pushing back the vaginal cul de sac with the finger, in the 
 centre of which is felt the os tincae; in the second place, in women 
 who have had children, we should make an allowance for the thick- 
 ness of its lips ; lastly, when the uterus is oblique in front, and the 
 pelvis not very large, the orifice may be so high up, that in order to 
 reach it, the radial side of the finger must be turned backwards, or 
 the perineum somewhat depressed, while with the other hand ap- 
 plied upon the epigastrium, the fundus of the womb is thrust back- 
 wards towards the vertebral column. In other cases, particularly 
 where the superior strait is very ample, the neck looks directly to- 
 wards the anterior surface of the sacrum ; to touch here, we are 
 obliged to carry the finger almost horizontally backwards, and then 
 to bend it forwards in the shape of a hook; in other women we meet 
 in the superior half of the excavation, a rounded tumour, in the pos- 
 terior part of which the neck appears to be obliquely hollowed out, 
 like the ureters in the parietes of the bladder: with all these precau- 
 tions, a skilful accoucheur can say, what is, within from fifteen to 
 thirty days, the period of pregnancy ; but it would be dangerous to 
 forget that there arc: numberless causes of error, and that we should 
 never, before a court, give 3 decisive opinion until we have previ- 
 ously acquired a mathematical certainty of the fact concerning 
 which we have to pronounce. 
 
 :!!. Compound pregnancy. It was natural to suppose that the 
 uterus would be larger when containing two or more children, than 
 \vheu it encloses only a single one. Hence also almost all those 
 appearances that depend upon the pressure upon and displacement 
 of the soft parts both of the pelvis and abdomen, have been enumc-
 
 OF TRUE PREGNANCY. 131 
 
 rated among the symptoms of compound pregnancy. But all that 
 has been said on this subject throws but a vague light upon the ques- 
 tion ; varices, infiltration, oedema, swellings, difficulty in moving the 
 lower limbs, engorgement of the labia pudendi, dyspepsia, difficulty 
 in making water, in walking, breathing, digesting ; an elliptical or 
 flattened shape of the bag of waters ; weakness of the uterine con- 
 tractions ; lypothymia and syncope ; the belly being larger, rounder, 
 rather depressed than salient along its median line ; motions o. he 
 foetus felt with more force and frequency, and on both sides of the 
 abdomen at once, &c. all fail, too frequently in twin pregnancies, for 
 us to place much confidence in them: besides, all these signs are rarely 
 met with together, and a majority of them may be met with where 
 there is only a single foetus in the womb ; which, further, may be 
 easily imagined to be the case, inasmuch as the size of the gestative 
 organ may be much larger in some cases of simple pregnancy than 
 in others where the gestation is evidently double or triple. 
 
 345. Baudelocque teaches that the touch is able to conduct us to 
 more satisfactory results. He says, for example, that where the belly 
 is very large, if there be only one foetus, the ballottement will be 
 very easy ; while if there be two of them, there will, on the contrary, 
 be some difficulty in effecting it, and that their motions or their 
 most projecting portions can be distinctly felt, through the parietes 
 of the abdomen, in several places at the same time. It may be added 
 that we ought to be able by means of auscultation to hear the sound 
 of the heart at two places, at some distance from each other, and 
 that if the pulsations denominated placental are of any use in'obste- 
 trics, they will also be heard at two distinct points. 
 
 346. The union of these signs would 'give us, without the least 
 doubt, a certainty of the woman's being pregnant with two or more 
 children ; but the want of them is far from always constituting a 
 negative sign of compound pregnancy. M. Desormeaux cites a 
 case wherein the most manifest ballottement coincided with a very 
 great size of the abdomen, and in which that able accoucheur could 
 only detect a single fcetus, while the ovum in fact contained two. 
 On the other hand, the ear cannot detect the cardiac pulsations of 
 two foetuses, when they are so situated that one is above or in front 
 of the other, so that it is most commonly impossible, previously to 
 delivery, to affirm whether the pregnancy is simple or double.
 
 132 OF TRUE PREGNANCY 
 
 SECTION 2. 
 Of Extra-uterine Pregnancy. 
 
 . I. Of ovarian .pregnancy. 
 
 347. Andry, and the animalculists, who, like him, supposed that 
 the living corpuscles of the seed passed along the Fallopian tubes in 
 order to join the ovule in the female seminal gland, did not attempt 
 to contest the existence of ovarian pregnancy, and among modern 
 practitioners there are few who think of calling it in question ; Boer- 
 haave even thought he could divide it into external and internal, but 
 this question appears to me to have been too lightly judged, and to 
 deserve a new examination. 
 
 348. In whatsoever manner, indeed, fecundation is really effected, 
 whether by means of an aura, an animalcule, or by any other prin- 
 ciple of the semen, it must happen that the germs of the two sexes 
 shall come in contact with each other; this contact cannot take 
 place without a rupture of the covering of the ovary, and of the 
 capsule of the ovule ; so that by the simple admission that an ovule 
 is vivified, it can no longer be said to be enclosed in the ovary, un- 
 less we believe with Chaussier, that the male germ reaches that of the 
 female by means of absorption. A great many cases of ovarian preg- 
 nancy are to be found in the various scientific collections : an infinity 
 of physicians and accoucheurs of merit have stated that they -have met 
 with them in practice ; but it is easy, upon a moment's reflection, to 
 perceive that not one of the cases hitherto published, not even those 
 of Littre and Smith, prove undeniably that ovarian pregnancy has 
 over been seen. It is so easy in the dead body to confound this 
 kind with abdominal pregnancy, those who have treated of them have 
 riven so few details, pathological anatomy was at that period so little 
 cultivated, that no result can in fact be obtained from the observa- 
 tions of the authors ; and while the moderns shall not have demon- 
 -t rated, with the scalpel, that the ovum is sometimes really situated 
 in the ovary and not in the adjacent parts, reason dictates to us that 
 we hoiild not admit the existence of ovarian pregnancy. 
 
 :; I!'. I have learned at my own expense how easy it is to be im- 
 posed upon in this matter. In ].">M and l.">- r > 1 met with the re- 
 mains of extra-uterine conceptions in four dillerent subjects; I re- 
 mo\ed tin; sexual parts with great care, and thought I was in pos- 
 "ii "l linn lae.t.s ill proof of the existence ol' ovarian gestation- 
 I |re-enii-i| them to the >',//, l'lii/i/iii//ii</nt , where .several mem- 
 
 tii the poMibility of the fact. MM. Blain- 
 ville and >d enon-jli to as ist at the dissection, which
 
 OF TRUE PREGNANCY. 133 
 
 [ performed the next day. We satisfied ourselves that three of these 
 tumours were outside of the germiferous gland ; we experienced 
 greater difficulty in regard to the fourth, which did not exceed an 
 inch in size ; but at length, after having completely isolated the Fal- 
 lopian tube, we found that the detritus of the conception was con- 
 tained in a special sac between the peritoneal coat and the proper 
 covering of the ovary, which was wholly distinct from it. Certainly, 
 none of the facts that have been cited as proofs of the existence of 
 ovarian pregnancy have been more carefully examined ; and certes, 
 if it had not been for the objections and the presence of an able de- 
 fender of the opposite opinion, we should have remained convinced 
 that the seat of the tumour was in the very parenchyma of the ovary. 
 
 . II. Abdominal pregnancy (peritoneal, ventose, external, ^-c.). 
 
 350. Admitting that fecundation is effected in the ovary, it is very 
 natural that the vivified ovule should sometimes fall .into the belly 
 instead of being engaged in the Fallopian tube ; in reflecting upon 
 the anatomical arrangement of the parts, one is disposed to believe 
 that such accidents are not uncommon ; if, says Bianchi, it does not 
 occur more frequently, it is doubtless because a very great majority 
 of the germs that escape in this way die before they become attached 
 to the serous membrane that receives them. However, some mo- 
 dern accoucheurs have asserted that it could not occur ; that the pe- 
 ritoneum is not sufficiently vascular to supply to the germ the requi- 
 site means of development ; that in the instances in which dissection 
 had shown the foetus and its secundines to be in the abdomen, there 
 had been previously a tubal or uterine pregnancy. It is true that the 
 tube and the ovary are commonly, and sometimes a part of the uterus 
 itself is, lost as it were in the mass of the tumour, and that it would 
 be imprudent in that case to affirm that the ovum was not originally 
 located in another place ; but it is at the same time an incontro- 
 vertible fact that in many of the published cases, both the ovary and 
 the tube retained their natural condition, and were completely foreign 
 to the sac which contained the foetus. On the other hand, the vete- 
 rinary physicians, more competent even than accoucheurs to solve 
 this problem, have completely embraced the affirmative, relying on 
 numerous and authentic facts that have been noted for thirty years 
 past : besides, the difference between the structure of the peritoneum 
 and that of the womb cannot in fact serve as a basis for any good 
 argument ; the ovum, which may be compared to the bud of a plant 
 endowed with life that is still very obscure, is so constituted as to 
 unite witli the first living part whereon nature places it. The in- 
 terior of the womb or of the tube doubtless suits it better ; but are
 
 134 OF TRUE PREGNANCY. 
 
 we allowed on that account to say that it can never take root in any 
 other situation ? Therefore nothing in the laws of the organism for- 
 bids us to admit the possibility of a peritoneal pregnancy ; and I 
 should not have taken the trouble to combat the opposite opinion, 
 were it not that M. Dubois still maintains it, and throws around it 
 all the weight of his imposing authority. 
 
 351. The fecundated vesicle, soon covered with a velvety pile 
 similar to the spongioles of the roots of plants, must rapidly contract 
 adhesions with the surfaces on which it rests ; there is an afflux of 
 fluids to that point, appearances similar to those of a local and very 
 circumscribed inflammation soon occur, and an accidental sac is 
 soon organized around the little ovum, which is, so to speak, thence- 
 forth protected against the action of the surrounding organs. 
 
 III. Of tubal pregnancy. 
 
 352. Tubal pregnancy, more common than any of ,the others, 
 and the only one that has not been contested by the partizans of 
 ovarian fecundation, could only be rejected by authors who believe 
 that vivification takes place in the womb ; but the cases on record 
 are now so numerous that it is no longer permissible to entertain 
 the slightest doubt in relation to it. Without mentioning those that 
 are detailed in the works of Bartholin, of Riolan, of Bianchi and 
 others; in the dissertations of MM. Bry, de Bouillon, Bonis; of those 
 related in the Revue Medicale ( 1 826), the Nuovo Giorn. del Lett. Ital. 
 (1825), of another reported by M. Vallerand, Nouv. BibL Med. 
 (1826), and of an infinitude of others that have been published in the 
 French and Foreign Scientific Collections, I will state that in 1816 
 I saw in the body of a woman who died at the hospital of Tours, a 
 very perfect ovum in the second month of its growth, which was 
 very completely enclosed in the outer half of the Fallopian tube, 
 of which the root, the fimbriated extremity, the canal, and all the 
 other parts were still easy to be recognized. Any one may see, in 
 the Museum of the Ecole de Medccine, a wax model which mathe- 
 matically demonstrates the samp thing. We may conceive, further, 
 that in this species of pregnancy, the product of fecundation may 
 attach itself to any portion of the length of the tube, but that it will 
 ino.4 frequently stop in the trumpet part of it, and that after a cer- 
 tain hpse of time it must be diflicult to decide, at a glance, whether 
 tin; pregnancy is tubal, rather than abdominal or ovarian. It may 
 lionlcs IK- conceived, that the uterine duct, soon distended, and 
 thinned, might burst, and transform a tubal into a peritoneal preg- 
 iiinicy ; so that the hitter may, in fact, be cither primitive or essen- 
 tial, or el.-e secondary or accidental; but it is superfluous, with
 
 OF TRUE PREGNANCY. 135 
 
 Boehmer, to describe both an internal and an external tubal preg- 
 nancy. 
 
 . IV. Of interstitial pregnancy. 
 
 353. The ancients made no mention of what M. Mayer has pro- 
 posed to denominate interstitial pregnancy. Noticed by Schmidt, 
 Albers, Hederich, Carus, MM. Cliet, Bellemain and Lartet, Dance 
 and Moulin, it had been studied with some care by MM. Mayer and 
 Meckel in Germany ; but scarcely any thing had been said on the 
 subject when M. Breschet, to whom MM. Bellemain and Lartet 
 had abandoned the specimen which had served as the basis of their 
 observation, undertook to collect all the known facts in relation to 
 the topic. 
 
 The ovum in this case does not lodge betwixt the peritoneum or 
 the mucous coat and the proper tissue of the womb ; but in the very 
 substance of the fleshy structure. In five out of seven cases, it has 
 been found on the left side, above, behind, before, or below the 
 tube, which did not in any case, as we are assured, communicate 
 with the cavity which contained the production. It is at least cer- 
 tain, that in the one I had an opportunity of examining along with 
 M. Breschet, there was no communication between the natural 
 cavity of the genital organs and the preternatural sac which con- 
 tained the fcctus. M. Meniere has published in the Archives Gene- 
 rales de Medecine some very judicious reflections on interstitial preg- 
 nancy; but the case he had in connexion with M. Dujardin does 
 not appear to me to belong to that class. Dionis, Canestrini, 
 Einsenman and Ramsbotham, have each related a case which seems 
 to be more like it. 
 
 Attempts have hitherto been vainly made to explain the mechanism 
 of this kind of pregnancy; M. Breschet has supposed that when the 
 ovule is about to enter the uterus, it might, upon meeting with some 
 obstacle, engage in the open orifice of some one of the venous 
 sinuses that open at the origin of the Fallopian tubes, and thus 
 gradually insinuate itself into the very substance of the parietes of 
 the womb. But as these orifices have no existence in fact, the ex- 
 planation falls to the ground of itself. On the other hand, admitting 
 that the angles of the uterus, at birth, being very long, bear a partial 
 resemblance to the horns of the womb or the ad uterum of quad- 
 rupeds, M. Brechet presumes that the narrow passage which then 
 leads to the seminiferous tube, might, by becoming obliterated, com- 
 pel the germ to deviate from its ordinary route. But if be true that 
 such a conformation is sometimes met with, I can at least affirm 
 that it is rarely so, and is not according to the natural order of
 
 13G 
 
 OF TRUE PREGNANCY. 
 
 things. This, therefore, is also but a gratuitous hypothesis. The 
 same must be true of the passage discovered by M. Baudelocque, 
 Jun. in the side of the womb, as well as of the preternatural cavities 
 mentioned by Morgagni, Valsalva, &fc. It is true we may have 
 recourse to anatomical varieties, to diseases, anomalies, to deviations 
 of all sorts, and indulge in a thousand suppositions ; but the wisest 
 course is to confess, frankly, that the mechanism of interstitial preg- 
 nancy is wholly unknown. 
 
 . V. Causes of extra-uterine pregnancy. 
 
 354. The density, the preternatural thickness of the covering of 
 the ovule, or envelopes of the ovary, too strong an adhesion of the 
 germ, its being situated too deep or too near the ligament of the 
 ovary, the obliteration, paralysis, spasm, bad direction, excessive or 
 insufficient length, engorgement, or antiperistaltic motion of the 
 Fallopian tube, inflammation and ulceration of its mucous membrane, 
 induration of its trumpet end, or of one or more of its fringes, the 
 contraction of its external orifice, all the changes and anomalies that 
 this canal may exhibit, whether in regard to its conformation or its 
 situation, a laceration of the womb, spoken of by Boehmer, Bianchi, 
 and Weinckneicht, may well have produced some instances of extra- 
 uterine pregnancy ; but it is certain, that in this respect science is 
 possessed of scarcely any thing beyond probabilities. Astruc believed 
 that unmarried women were more liable to be affected with this sort of 
 accident than others. Kruger, who unites in this opinion, supposes 
 that the ovule remains in the ovary, stops in the tube, or slips into the 
 peritoneum, because fear, alarm, indignation, by attacking women 
 suddenly in the midst of the most lively enjoyment, or shortly after- 
 wards, must occasion a disturbance in the whole organism, whose 
 effects reach even to the sexual organs. A case by M. Lallemand, 
 and another by Baudelocque, seem to lend some support to the 
 opinion of Astruc ; in fact, the extra-uterine conception in the two 
 women who were the subjects of it, seemed to have been effected, 
 at the very instant of a violent fright, occasioned in one by the re- 
 membrance of some piece of forgetfulness, and in the other by a 
 sudden noise, which made her afraid of being caught in Jlagrantc 
 dclicto; but as nothing similar has been noticed in other cases, this 
 explanation can only be regarded as a tolerably plausible hypothesis. 
 Those; who insist that fecundation is effected in the womb, 
 necessarily reject all these modes of viewing it, and can give no 
 ml of extra-uterine pregnancy, but by supposing a retrograde 
 movement, by IDCMUM of \\liinli the ovule returns from the uterus into 
 tin.; tube, &c. The assertions of Planchon, who affirms that the tubes
 
 OF TRUE PREGNANCY. 137 
 
 are slightly dilated in the first weeks of conception, a remarkably 
 curious case reported by Patune, in which it is said that the umbili- 
 cal cord of a foetus enclosed in the fimbriated extremity was insert- 
 ed into a globose placenta, situated in the very cavity of the womb, 
 are very rare facts, and ought to be met with anew before they can 
 give much weight to such conjectures. 
 
 . VI. Signs and terminations of preternatural pregnancy. 
 
 356. The continuance of the menses, severe pains in the hypo- 
 gastrium, nausea, and frequent vomiting, as well as several other 
 distressing symptoms, considered as signs of extra-uterine pregnancy, 
 sometimes indeed do accompany it ; but as they also are oftener 
 wanting, and not at all uncommon in. natural pregnancy, their pre- 
 sence is, on that account alone, of very little weight. Though the 
 breasts undergo no change, secrete no milky fluid ; though the belly 
 is uneven, its srowth more rapid, and its development chiefly on one 
 side ; though the motions of the foetus are earlier felt, and through 
 surfaces apparently very thin ; though the womb remains quite small, 
 in some cases of extra-uterine pregnancy, the contrary happens in a 
 still greater number of cases, and one or more of these irregularities 
 is frequently met with even in simple pregnancy. 
 
 However, though it is true that the womb sometimes increases in 
 size in such cases, it is equally true that the changes which it then 
 experiences are rarely sufficiently marked to make us believe in the 
 existence of a natural pregnancy of four or five months standing. 
 If, therefore, the abdominal tumour has risen early above the mar- 
 ginal strait, and is found in one of the iliac fossae ; if it appears to be 
 full of bumps, varicose, and if pulsations can be felt in it ; if it be 
 easy to feel the protuberances and motions of the foetus, while the 
 parietes of the abdomen preserve nearly their natural thickness, and, 
 on the other hand, we can ascertain by the touch that the weight 
 and size of the womb are not at all, or but slightly increased ; that 
 the cervix has not to any sensible degree diminished in length, al- 
 though it has altered in respect to its position, direction, density, and 
 even form, then it is evident that the pregnancy is preternatural. 
 
 357. However, it may be conceived, that if the ovum has fixed itself 
 to some part in the pelvis, or to some point on the periphery of the 
 womb ; that if it has been arrested very near the root of one of the 
 tubes, or even in the substance of the parietes of the uterus, all these 
 signs may in fact not exist, and the preternatural pregnancy be con- 
 founded with an ordinary gestation. In these cases the uterus swells, 
 softens, undergoes a major part of the changes that characterize real 
 
 S
 
 OF TRUE PREGNANCY. 
 
 pregnancy, its cavity becomes filled with a concrescible matter which 
 is amorphous, a kind of membrana caduca or anhistous Zcryer, ob- 
 served by Bertrandi, Chaussier and others ; the form of the belly and 
 the motionsW the foetus exhibit nothing peculiar, and ballottement 
 itself is not always impossible. 
 
 358. In general, the sexual organs depart but very little from 
 their natural state, when the fetal cyst is not within the tube, and 
 contracts no adhesions with the womb. On this subject, the case 
 noticed by M. de Bouillon should be regarded only as an uncommon 
 exception. In these cases the cervix rarely becomes much short- 
 ened, nor does its orifice dilate in any considerable degree ; it is 
 found to be much lower or higher, more forward or backward, or to 
 one side, than the presumed period of the pregnancy would seem to 
 indicate. 
 
 359. After all, neither the rational nor sensible signs suffice, until 
 the end of the third month, to prove that pregnancy is extra-uterine. 
 After this period, it will in most cases be possible, by means of some 
 or all of them, to establish an almost certain diagnosis ; the evidence 
 derived from them will at least give rise to suspicions sufficiently 
 strong to fix the attention of the practitioner. 
 
 360. As to the distinctive signs of the different species of extra- 
 uterine pregnancy, I do not think it would be useful to treat of 
 them in this place ; the knowledge of them could not be beneficially 
 applied ; besides, all those that have been mentioned are too uncer- 
 tain to deserve the least confidence : since, even on the dead body, 
 we can scarcely decide, even by means of the scalpel, whether the 
 ovum is situated in the tube, the ovary, or the peritoneum, it would 
 be in some measure ridiculous to desire to obtain any certainty in 
 relation thereto, on the living subject. 
 
 361. Extra-uterine pregnancy commonly terminates before the fifth 
 month ; Baudelocque, MM. Arnault, Novara, Delisle and some 
 others have nevertheless seen it much more prolonged, and even to 
 the term of ordinary gestation. These authors, especially the for- 
 mer, mention a very remarkable circumstance ; it is that in these 
 cases, at the close of a kind of labour, attended with intermittent 
 pains, that are sometimes pretty strong, a commencement of dilata- 
 tion of the neck, a discharge of mucus, of a bloody fluid, and what 
 secrns still more surprising, very regular contractions of the womb 
 or of the failal cyst are observed to take place. In fact we may 
 conceive of a part of these phenomena in tubal pregnancy ; the tube 
 beiti;. -I of the same elements as the womb, it is quite na- 
 tural lor it to -:ijoy tin- same properties; but, in abdominal preg- 
 nancy, we can only account for the contraction of the cyst by sup-
 
 OF TRUE PREGNANCY. 139 
 
 posing that there has been a development of fleshy fibres in its 
 parietes, at the cost of the elastic cellular layer which is enclosed in 
 the peritoneum of the pelvis. 
 
 362. Termination. Interstitial pregnancy alone admits of a pos- 
 sibility of extracting the fetus by the natural passages ; the caliber 
 of the tube, its slight dilatability, do not allow us even to think of it 
 in the other species ; in this view, therefore, extra-uterine pregnancy 
 is always dangerous, both for the mother and child : its natural ter- 
 minations are the death of the fetus, and rupture of the cyst. 
 
 363. Death of the foetus. It is rare for the fetus to continue 
 alive beyond the second or third month ; after its death, which hap- 
 pens for want of nutrition, or in consequence of inflammation of its 
 envelopes, it sometimes happen? that the liquor amnii as well as all 
 the other fluid portions of the ovum are absorbed, the child hardens, 
 petrifies, or is transformed into gras de cadavre, the cyst contracts, 
 thickens, and becomes fibrous, fibro-cartilaginous, or even osseous, 
 and the whole resolves itself into a solid tumour, which may remain 
 in the abdomen for an indefinite period, without compromitting the 
 life of the woman. In other cases the sac is transformed into a real 
 suppurating cavity, the fetus is decomposed, dissolved, or putrefies, 
 and then the cyst soon contracts'adhesions with the surrounding parts, 
 so as speedily to open into the bladder, the caecum, the colon, the 
 small intestines, the rectum, or directly outwards through the pari- 
 etes of the belly or perineum, if not immediately into the peritoneum. 
 Sometimes the ovum becomes merely filled with a fluid which is 
 more or less thick and transparent, of a yellow, brown, grey, or red- 
 dish colour, but not purulent ; or it is converted intom cyst, in which 
 as much as one hundred and fifty pounds of fluid have been found, 
 and containing the debris of a fetus: an instance of which is report- 
 ed by Vassal. 
 
 The first case is the most fortunate of all ; with it should be class- 
 ed most of those pretended pregnancies that have been said to last 
 two, four, ten, fifteen, twenty, thirty, and even forty years : the 
 second is always accompanied or followed by serious symptoms ; 
 inflammation is propagated to the circumjacent parts, gives rise to 
 violent fever, and sooner or later brings on a fatal termination ; the 
 patient most commonly becomes hectic, for she is exhausted by an 
 abundant suppuration ; sometimes, also, all the parts of the fetus 
 escape one after another ; the sac is gradually Emptied, becomes 
 clean, and contracts ; the suppuration ceases by degrees, and the 
 wound at last closes, or at least is reduced to the state of a fistulous 
 ulcer, which is rather more troublesome than dangerous. 
 
 364. Every species of extra-uterine pregnancy may terminate by
 
 140 OF TRUE PREGNANCY. 
 
 the laceration of the ovum, and of the sac which serves in place of a 
 womb ; examples of this kind, if we may credit M. Mesniere, have 
 been noticed both in interstitial and abdominal pregnancy ; but tubal 
 pregnancy most frequently terminates in this way : although very 
 extensible, the parietes of the tube are, nevertheless, too thin to ad- 
 mit of the enlargement of the cyst beyond the third or fourth month. 
 In some instances the rupture occurs suddenly, and seems to be 
 occasioned by some exertion, or fall, &,c.; sometimes, on the other 
 hand, it is effected and prepared for by slow degrees, by the mecha- 
 nical thinning, the softening, or some other change of a portion of 
 the fcetal sac. Tn all cases where no conservative adhesions have 
 been formed, the water of the amnios, the foetus, and the blood that 
 flows from the lacerated surfaces, pass into the cavity of the perito- 
 neum ; lipothymia, syncope, convulsions incessantly repeated, and 
 intolerable pains, often carry off the sufferer in a few hours ; in other 
 instances vital resistance does not so readily yield ; a violent perito- 
 nitis comes on, and death succeeds on the second, third, or fourth 
 day. Finally, in some rare cases, nature, with proper assistance, 
 resists the first dangers of this redoubtable tempest, and a protracted 
 inflammation permits the effused matters to accumulate in a more 
 circumscribed space, and give birth to a real abscess, which may 
 still leave some chance of saving the patient. 
 
 365. Treatment. The impossibility of certainly recognising the 
 nature of extra-uterine pregnancy in the first months of its existence, 
 is the reason why attempts to remedy it are scarcely ever made un- 
 til the occurrence of symptoms, announcing the death of the fetus 
 or rupture of its. coverings : besides, the powers of art are so limit- 
 ed in these circumstances, that the only assistance which it is pos- 
 sible to afford would be almost as dangerous, in itself consider- 
 ed, as the natural terminations of the affection. Gastrotomy, the 
 only remedy that has been proposed, can boast of no successes as 
 yet; in one case, published by M. De Bouillon, the woman sur- 
 vived eighteen days ; nature, on the contrary, when left to her own 
 resource, has several times succeeded in triumphing over all obsta- 
 cles. Nevertheless, the fears of Levret and Sabatticr, in regard to 
 hemorrhage, suppuration, and wounds of the peritoneum, arc evi- 
 dently exaggerated ; it would seem, a priori, that gastrotomy ought 
 to br much less frequently fatal than is commonly supposed. 
 
 366. On the; other hand, although \ve li;ive no right to invoke past 
 experience in its favour, we should not forget that, having been 
 hitherto pcrli>nncel in despair of all other assistance, we have no 
 reason to be surprised at its not having prevented death from taking 
 place. I think, therefore, witli I\l. J><>oimeaux, that if recourae
 
 OF TRUE PREGNANCY. 141 
 
 were had to it early, before the formidable array of inflammatory 
 symptoms have developed themselves, before peritonitis becomes of 
 itself mortal, a considerable number of women might be saved. It 
 has been maintained that in all cases it should not be had recourse 
 to until the seventh month of pregnancy, unless it be certain that the 
 foetus is dead, and the cyst opened into the peritoneum ; that other- ' 
 wise, we should, without advantage to the mother, sacrifice the life of 
 a child which we might possibly have conducted to its full term, and 
 rescued alive. This reasoning is good for nothing ; the chances of 
 success in the operation are so much the more numerous in propor- 
 tion as the pregnancy is less advanced ; in this case there is too lit- 
 tle probability of the future life of fhe foetus, for it to be balanced 
 against that of the mother. After seven months, when the child is 
 viable*, reason and humanity both dictate its performance without 
 hesitation. Even although the accoucheur should not arrive until 
 after the rupture of the cyst, he should still instantly open the parie- 
 tes of the abdomen : with the operation death is but too probable, 
 but without it, it is nearly certain. 
 
 367. In cases where gastrotomy is not applicable, we must be 
 content to prescribe for symptoms, to moderate the violence of in- 
 flammation, to prevent as far as possible the formation of pus, to fa- 
 vour the production of adhesions, so as to circumscribe the effusion, 
 to sustain, or also to diminish the strength by means of regimen or 
 blood-letting, according as the appearances of reaction or exhaustion 
 may seem to require ; we must assist in the escape of those portions 
 of the ovum which present themselves in the vagina, the bladder, 
 the rectum ; if abscesses form, they must be opened ; and we must 
 prevent the stagnation of pus or of any matters in a state of decom- 
 position ; in one word, we should put under contribution, one after 
 another, accordingly as they may be indicated, baths, injections, 
 enemata, a severe diet, an analeptic regimen, general or local bleed- 
 ing, and rest or exercise. 
 
 * I have left this word untranslated : it expresses that state of development in 
 which a child may live, when independent of its connexion with the mother. I 
 trust the reader will pardon me for introducing it here, especially as it is getting 
 fast into us among the profession in this city. TR.
 
 142 OF FALSE PREGNANCY. 
 
 ARTICLE II. 
 
 Of False Pregnancy. 
 
 368. Numberless cases prove that various diseases may give rise 
 to a belief in the existence of pregnancy in women who are not 
 gravid, and vice versa. A woman of the Fauxbourg Saint Marceau 
 was with child, says M. Desormeaux ; certain impudent quacks 
 plunged a trocar into her abdomen, 'and she died in a few hours af- 
 terwards ! I was called, in consultation, to a lady, in order to de- 
 cide whether it was necessary to perform the caesarian operation ; 
 the patient was affected with peritonitis of which she recovered, and 
 a scirrhous ovariuni of which she died ! It is useless to invoke the 
 rules of art against errors so gross ; but there are cases so obscure 
 that the most skilful practitioner may really mistake their true na- 
 ture. M. Lefebvre, in his thesis, has shown that even animals 
 pretty frequently exhibit similar anomalies. 
 
 369. Retention of the menses, ascites, or encysted dropsy, tym- 
 panitis, polypi, scirrhus, cancers of the womb, tumours in the ovaria, 
 the tubes or the pelvis, and other lesions besides, often produce a 
 major part of the rational signs, and even some of the sensible signs 
 of pregnancy. However, one must be very inattentive or inexpe- 
 rienced, not to avoid mistakes in almost all these cases. 
 
 370. Who can confound the symptoms of scirrhus of the cervix 
 and ulcers of the uterus with the phenomena of gestation, after hav- 
 ing touched the woman ? Is not the presence of a polypus most 
 commonly accompanied with hemorrhage ? Does it ever admit of 
 ballottemcnt, or make us believe we feel the spontaneous motions of 
 a fu;tus? Do the progress of the affections, the state of the cer- 
 vix, &LC. in any case resemble those of natural pregnancy ? 
 
 371. The accumulation of blood, serum, or gas in the womb 
 might indeed impose upon us in this matter. On this subject we 
 may refer to the memoir lately published by Madame Boivin. But 
 if the womb is filled with blood, or if the person lias always had dif- 
 ficult menstruation, the touch shows that the hymen is im perforate, 
 that the vau'ma or some other part of the genital organs are not 
 properly funned ; if it be a married woman, or one whose menses 
 had been previously rorular, there will, in general, be found at the 
 same time more or less numerous indicalionn oi'discasc, which clear 
 up the diagnosis ; besides, the motions of the fcetus are never met 
 with in those cases.
 
 OF FALSE PREGNANCY. 143 
 
 372. In the case of Jiydrometra we are in possession of the same 
 resources, and the local affection is accompanied with so serious a 
 change in the general health, that with a little reflection error be- 
 comes from that very circumstance almost impossible. 
 
 373. In uterine tympanitis the womb may acquire a considerable 
 size, but it always remains very light, there is no balloltement, and 
 percussion of the belly occasions such a resonance as at once dis- 
 sipates all uncertainty. 
 
 374. Encysted dropsy, fibrous or scirrhous tumours, any unna- 
 tural growth in the ovary or parts connected with the womb, might, 
 at most, be confounded with extra-uterine pregnancy, inasmuch as 
 the neck in those cases undergoes only very slight changes ; the 
 want also of the positive signs of the presence of a child, the general 
 state and progress of the affections will always suffice to prevent us 
 from asserting that there is one, and frequently to lead us to main- 
 tain that there is no gestation in the case. 
 
 375. As to ascites, peritoneal tympanitis, effusions of pus or blood 
 in the abdomen, encephaloid, fibrous, scrofulous, steatomatous, or 
 any other kind of tumours, and the various lesions of organs contain- 
 ed in the belly, they are so many diseases or symptoms of diseases, 
 which only resemble pregnancy in the distention of the abdomen 
 they occasion, and a few other still more inconclusive signs. If the 
 peritoneum is distended with gas, percussion will show it at once to 
 be so : in ascites the fluid, falling to the lowest places, according 
 to the laws of gravity, will give to the belly a form too readily dis- 
 tinguishable from that of pregnancy for those two states to be con- 
 founded, and the difference is still greater in all the other affections 
 that I have just now mentioned. 
 
 376. The group of symptoms, known as nervous or hysterical 
 pregnancy, have most frequently been the cause of error on this 
 head. It is most frequently met with about the period of cessation 
 of the catamenia, or in unmarried women of an irritable or nervous 
 habit, in such as having lost their firsf children, are much tormented 
 with a desire of having more, those who have remained several years 
 in a state of widowhood, and think they have been fecundated by a 
 second husband. The menses are suppressed, nausea, qualms, 
 changes in the breasts, in the digestion, and sometimes all the ra- 
 tional signs of pregnancy supervene, and now and then the woman 
 goes so far as to affirm that she feels the motions of the child quite 
 strong : and what is more, there have been skilful accoucheurs who 
 have partaken of the error. According to M. Orfila, professor Du- 
 bois was not afraid to confess that he had himself been deceived. 
 
 377. A lady, thirty-eight years of age, who had had no children
 
 144 OF FALSE PREGNANCY. 
 
 for twelve years, and who would have given the world to become a 
 mother by the man with whom she was associated, sent for me in 
 1823 to prevent an abortion with which she thought herself threat- 
 ened. According to her account, she was four months gone with 
 child ; the size of her abdomen, and numerous sympathetic pheno- 
 mena seemed to confirm her assertions ; she had felt the motion, 
 and the slight discharge of blood that alarmed her had been provoked 
 by violent exercise. After two or three days her fears were quieted; 
 but they recurred again two months later. New hopes again suc- 
 ceeded. The period so ardently desired arrived at last; labour 
 pains came on ; a skilful midwife repaired to the woman, who was 
 overwhelmed with joy : three days passed away in pretty severe suf- 
 fering without appearing to advance the period of delivery ; I was 
 called upon: I examined her, and found the cervix as well as the body 
 of the womb in a natural state. I pronounced her to be not preg- 
 nant; she became enraged ; I was dimissed, and learned four days 
 afterwards that her belly had fallen, that nothing had passed out 
 from the sexual organs, and that the woman's health was restored. 
 
 378. Here, as in all analogous cases, the examination of the organ 
 of gestation would have sufficed after the fifth month to destroy the 
 illusion ; but the patient cherished her error so dearly, that she would 
 not permit herself to be examined, and more particularly as she en- 
 tertained not the shadow of a doubt as to her condition. 
 
 I do not here treat of molar pregnancy, nor hydatid pregnancy, 
 because moles and hydatids of the womb being nothing but products 
 of unnatural conception, give rise to the same phenomena as natu- 
 ral pregnancy, and always end in abortion. 
 
 ARTICLE III. 
 Of Pregnancy j as it regards the Sex of the Foetus. 
 
 I. Is it possible to ascertain the sex of the foetus during preg- 
 nancy ? 
 
 379. When we reflect on the powerful and various reasons that 
 should lead man to seek in the future for what may subserve or dis- 
 turb his interests and his passions, the desire of knowing the sex of a 
 child still inclosed in the womb of its mother surely seems to be quite 
 mat'-. The, woman who becomes pregnant rarely fails to attach 
 an idea of greater happiness to one sex than to the oilier. In the most 
 common conditions of social life the husband himself is often tor-
 
 SEX OF THE FffiTUS. 145 
 
 mented with the same inquietudes. If to this sentiment which is so 
 general be added the fears of a whole family threatened with extinc- 
 tion for want of heirs male ; the alarm of a whole people ; the various 
 clashing designs of all nations united by the bonds of civilization 
 when the reigning dynasty of a great empire has no hope save in 
 the being who is as yet unborn, we shall comprehend the efforts 
 that have in all past time been made to satisfy public curiosity on 
 this head. 
 
 380. The gods, diviners, and sorcerers, have in turn been con- 
 sulted : at Rome, Livia had patience enough, assisted by her women, 
 to complete the incubation of an egg with the warmth of her hands ; 
 being persuaded that if a male was hatched from this egg, the child 
 with which she was pregnant would be a boy, and that the reign of 
 Augustus might thus be continued. The Egyptians and Indians 
 depended on the state of the heavens, or on the nature of the con- 
 stellations, at the moment of fecundation ; the Greeks and all the 
 people of the ancient world used to rely upon the phases of the 
 moon, &c. But unfortunately not one of these auspices but has 
 deceived the credulity of poor man. 
 
 381. Founding on the debatable principle that the male embryo 
 is sooner developed than the female, Aristotle pretends, as well as 
 Hippocrates and many other ancient authors, that the woman 
 quickens earlier with a boy and later with a girl. Setting out with 
 the same idea, the relative strength of the foetus has been transferred 
 to the mother ; it has been said that she feels more vigour, activity, 
 gaiety, contentment ; that her eyes are more lively, her face more 
 blooming, her pulse larger, more frequent, her digestion easier ; 
 that all her functions, in a word, are executed more freely, when 
 she is to bear a male child, than when she is pregnant with a female ; 
 that a brown or black ray along the median line of the belly, greater 
 strength, livelier colour, nipples more prominent, a harder and 
 tenser breast, stronger pulsation of the carotids, veins larger on the 
 right than on the left side, announce the presence of a boy ; that in 
 getting up or walking the woman advances the right knee or foot 
 first ; that the womb is inclined to the right, that the urine is con- 
 stantly loaded, that it deposits a lateritious sediment, if there be a 
 male child ; and that opposite phenomena are observed when it is 
 of the female sex. 
 
 382. 1 do not think it needful to combat in a serious way the 
 reasons by which physiologists and physicians have supported these 
 assertions ; I should not have deemed it worth while even to mention 
 them, if they had not given rise to a crowd of prejudices that are 
 spread among the vulgar, prejudices which the quacks make the 
 
 T
 
 146 SEX OF THE FffiTUS. 
 
 most of, and which the ablest accoucheur is sometimes compelled 
 to manage as well as he can, when unable wholly to destroy them. 
 I shall content myself with observing that the several phenomena 
 I have just now enumerated have been, and continue to be met with 
 every day, as much, and not more for one sex than for the other ; that 
 what passes as indicating a boy, Osiander, relying upon calculations, 
 asserts that he has most frequently observed in women who brought 
 forth only girls, and that none of the numerous signs, established 
 d priori, upon false notions, have ever been confirmed by the care- 
 ful observation of facts. All that can be said in this regard is, that 
 certain women, when they arc pregnant with a boy, feel certain 
 symptoms, so distinct from those they experience when carrying a 
 female, that they can scarcely be deceived ; but then the signs attri- 
 buted to pregnancy with the male sex sometimes announce the pre- 
 sence of a female foetus, and vice versa ; most frequently there is a 
 blending of the phenomena proper to the two opposite sexes, which 
 always return with the same character for the same sex ; so that these 
 peculiarities, entirely individual, only applicable to a few subjects, and 
 moreover pretty rare, can be of no use except to those women alone 
 who arc affected with them. 
 
 383. The old women say that if the first conception takes place 
 during the waxing of the moon it will produce a boy, but if in the 
 wane the woman will on the contrary be delivered of a girl ; others 
 equally skilful admit that the child will be of the same sex with the 
 last one the mother bore, provided the moon did not change within 
 three days after that confinement ; finally, some accoucheurs, freely 
 trusting to chance, ascertain first what the family or the lady most 
 desire, and very good naturedly promise what is wanted. It is best 
 in my opinion to pursue just the contrary course : if a girl is wanted, 
 promise a boy, and vice versa. The reason of this is, that if you 
 are deceived, the woman, happy to have the sex she longed for, 
 readily forgives your mistake, and is satisfied to laugh at your pre- 
 tended skill. If it turns out as you promised, on the other hand, 
 the parents are compelled in spite of their disappointment to pro- 
 claim your cleverness. 
 
 384. Here is, besides, another unfailing method : as our ances- 
 tors performed so many miracles with the moon, we may also make 
 a small trial of the power of this wonderful planet. If obliged to de- 
 clare the sex of the foetus before its birth, we may content ourselves 
 with asserting that it will be like the last child, provided the moon 
 does not change within the first nine days of the lying in, and that 
 the contrary will happen in the other event : now if the event should 
 confirm the sentence, nothing more is wanting ; but if on the con-
 
 SEX OF THE FCETUS. 147 
 
 trary it should be of the sex that was not expected, all we have to 
 do is to go back and see that the reckoning had been badly made ; 
 that if the moon has not changed her nature, she has at least changed 
 her phase, which amounts to the same thing ; any body may see that 
 in this way error cannot occur, for the Innar phases recur every 
 seven days. There is perhaps a little tricking, in this course of pro- 
 ceeding ; but provided no more weight is given to it than it really 
 deserves, we may, in acting thus, satisfy every body and do no harm 
 to any one. 
 
 . II. Is it possible to procreate either sex at pleasure ? 
 
 385. The desire of knowing before hand the sex of the foetus has 
 given rise to one of the most piquant questions in physiology. It 
 has been asked whether man can by means of known influences 
 determine the production of one sex rather than the other; and 
 this point in the science, which was discussed in the time of Hippo- 
 crates, still engages the attention of several naturalists. 
 
 386. Relying, we scarcely know on what, unless it be upon 
 the grand idea that the strongest side belongs to the strongest be- 
 ing, the father of medicine teaches that both in animals and in the 
 human species, the right testicle and the right ovary produce male 
 germs, while female germs come from the left ; this opinion of the 
 ancients, without having ever been generally adopted, without having 
 ever been fortified by a single direct experiment, has nevertheless 
 passed down for ages, and claims even in our day some partisans, 
 even among learned physicians. However, admitting the fact, one 
 great difficulty would still remain to be got over in applying it. 
 How shall the seminal matter of the right gland, rather than that of 
 the left, get into the womb, and vice versa ? In quadrupeds indeed 
 it would be possible to take away from one the right and from an- 
 other the left prolific gland ; but what man would submit to such a 
 mutilation for the sake of being able to procreate a boy rather than 
 a girl ? Another expedient was evidently necessary ; and Millot has 
 gravely advised the couple to lie, during a fruitful copulation, on the 
 side where the germ of the sex they desire to have is found. We 
 might to a certain extent excuse the ancients, who believed that the 
 human uterus was two-horned like that of brutes, for entertaining 
 such an opinion, for believing that the semen of the right ovary 
 would perhaps stop in the right horn, provided the two individuals 
 took the precaution of lying on the corresponding side during the 
 coition ; but in the nineteenth century such conjectures are merely 
 subjects for ridicule, and scarcely deserve the trouble of refutation. 
 
 387. Moreover, it is actually demonstrated that the basis of this
 
 14 8 SEX OF THE F(ETUS. 
 
 hypothesis is entirely false. Legallois caused rabbits from which 
 he had removed one ovary to be covered, and found that it did not 
 prevent them from engendering young of different sexes ; as to the 
 human species, without mentioning the cases of men who having 
 lost one of the genital glands have notwithstanding procreated both 
 boys and girls, I will relate two facts that are decisive on this subject. 
 A woman died some years ago at the Maternite at Paris ; she was 
 the mother of ten or twelve children of both sexes, and neverthe- 
 less her sexual organs were so disposed, that there was only one 
 ovary and one tube attached to the corner of a womb which was 
 itself reduced to one of its halves. In the case by MM. Jouvet and 
 Gamier, communicated to the Academy by M. Ollivier (d' Angers), 
 it appears that the woman had been confined five times ; that she 
 had had four boys and one girl, that the four first pregnancies seemed 
 to have been effected in the left uterine sinus, and the fifth and last 
 only in that on the right side. Lastly, all naturalists know that, in 
 animals, where the uterus is completely bi-lobated, the same horn 
 is often filled at the same time with both male and female foetuses. 
 
 388. While doing justice to these suppositions physiologists have, 
 notwithstanding, retained a hope of one day ascertaining the con- 
 ditions which cause one sex to be born rather than the other. 
 M. Bory-de-Saint- Vincent has already emitted the bold opinion, 
 that certain organic particles are susceptible of passing with nearly 
 the same facility into the vegetable or animal state. Mr Edwards 
 thinks he has observed that the molecules of several conferva, and 
 other beings of doubtful nature, may be at will transformed into in- 
 dividuals of either organic kingdom. Finally, there were commu- 
 nicated, in 1825, to the Societe Philomatique, certain researches 
 which would tend to induce the belief that by modifying in a certain 
 way the influences under which the fecundation and entire repro- 
 duction of insects is effected, it is possible to occasion the produc- 
 tion either of males or females at pleasure. 
 
 389. The ancient agriculturists were convinced, and country peo- 
 ple still think, that if the north wind prevails, that if the season be 
 dry and cool rather than warm and moist, when goats, sheep and 
 COWB are admitted to the males, there will be fewer females pro- 
 duced, than under the influence of a contrary state of the atmos- 
 phere. They are persuaded, moreover, that in order to obtain a 
 larger proportion of males, there is no better plan than to cause the 
 females to be covered by the most vigorous animal of the kind. 
 They therefore take care to choose the most active, the strongest, 
 the youngest and most robust buck, or ram, or bull, or stallion they 
 can find.
 
 SEX OF THE FCETUS. 149 
 
 390. Besides, these traditions have been lately subjected to the 
 teat of experiment, and fully confirmed by the interesting researches 
 of M. Girou De Bussaringue. Numerous observations have been 
 made by this philanthropic cultivator on horses, cows, sheep, birds. 
 &c. for several successive years, and according to all appearance, 
 with the greatest care. Now, they go to show that the stronger 
 the male at the period of fecundation, the greater is the chance of 
 obtaining males. For instance, in a flock of sheep, those that are 
 first covered produce fewer males than those that come immediately 
 after them, and these many more than the last moiety ; for the ram 
 does not appear to enjoy his whole prolific energy until after a cer- 
 tain number of copulations, and afterwards he becomes exhausted, 
 gradually losing his strength. 
 
 391. Other reasons still may be cited in support of those above 
 mentioned ; pigeons, doves, partridges, and many other birds that 
 unite in couples, during each season of their loves, produce nearly 
 the same number of males as of females. The gallinaceae, the com- 
 mon fowl, on the contrary, and geese, ducks, turkeys, &c. where the 
 same male suffices for several females, furnish many more females 
 than males of their respective species ; while bitches, cats and she 
 wolves, which ordinarily permit the approaches of several dogs, &c. 
 engender more males than females. In fine, it is supposed that where 
 polygamy is allowed in the human species, as in Persia and Turkey, 
 there are more girls than boys born, and that in Europe where this 
 custom is not tolerated, the contrary is generally found to be the 
 case, or at least that the proportions of the two sexes are about 
 equal. 
 
 Consequently, it becomes probable that the nature of the sex is 
 determined by that one of the couple whose prolific power, whether 
 absolute or relative, is greatest at the moment of conception. It is 
 true that numerous researches are yet necessary, to transform this 
 proposition into a mathematical truth ; but if it should ever be con- 
 firmed by authentic and careful observation, it is evident that the 
 act of procreating the sexes at will, will no longer be a chimera, 
 and that we ought not to give up the hope of being able to predict 
 to pregnant women, that they shall be delivered of a boy rather than 
 of a girl. But it is doubtful whether by adopting the course and 
 language of M. Mayer, we shall ever attain to any thing satisfactory 
 on this interesting point of physiology. 
 
 . III. Of the influence of the seasons and of public prosperity on 
 the production of the sexes and on the proportion of conceptions. 
 392. An important inquiry, and which flows naturally from the
 
 150 SEX OF THE F(ETUS. 
 
 preceding, would be to know, whether, in poor countries or in years 
 of scarcity, and in provinces where the inhabitants are naturally weak- 
 ly, idle and wretched, the female sex exceeds the male in number : 
 in order to resolve it, it would be necessary to consult the records of 
 the civil state of people in the most opposite conditions ; this work, 
 which several moderns are on the point of undertaking, has by 
 M. Bailly been already performed for the city of Celles, from which 
 it appears that the proportion of girls is decidedly larger than 
 that of boys, in that barren and poor canton. However, M. Vil- 
 lerme, who devotes himself with such praiseworthy ardour to this 
 branch of statistics, and who has made his observations on a much 
 larger scale, has not come to the same conclusions ; he has found 
 that, in Sologne and other very poor departments, there are born 
 as large a proportion of males as in the most opulent and agreeably 
 situated cities ; that the miserable peasants of Scotland, reduced to 
 the necessity of living on potatoes and beans, procreate as many 
 male children as the rich inhabitants of the environs of London. 
 
 After all, though it be right to state that prosperity or misery 
 exert no marked influence on the proportion of the sexes, there is no 
 reason why we should be surprised at it ; for men and women are 
 placed in the same circumstances. That merely proves that abso- 
 lute force is not in this case one of the essential conditions, but it 
 does not in any respect diminish the important bearing of the rela- 
 tive force of the couple. 
 
 393. There is no one who has failed to remark that births are 
 more numerous at certain times and in certain countries, and more 
 rare in others ; but no attempt had been made to explain these appa- 
 rent anomalies, nor prove that they were in some degree fixed in 
 their recurrences. M. Villerme has taken upon himself this double 
 care : in a memoir read to the Academy of Sciences, he says that 
 out of a total of 7,651,437 births, reduced (ramenees) to 12,000; 
 1093 took place in January, 113G in February, 1117 in March, 
 1057 in April, 1000 in November, 981 in December, 981 in Sep- 
 tember, 964 in October, 965 in May, 927 in August, 896 in June, 
 and 884 in July, and that, consequently, the relative frequency of 
 conceptions is far from being the same at all seasons of the year. 
 
 394. M. Villerm6, always relying on calculations, in the same way 
 pnsses successively in review the influence of holidays and public re- 
 joicings, the first periods of marriage, fasts and privations, tempera- 
 ture, latitude, vegetable or animal regimen, prosperity, civilization, 
 liberty, the poverty and the calamities of the population, on the num- 
 ber of fecundations, and demonstrates that many more children are 
 born under a fine climate, in countries where the arts, industry:
 
 SEX OF THE FCETUS. 151 
 
 commerce and the sciences flourish, where the air is salubrious and 
 the earth fertile, than in the contrary conditions ; that famine and 
 years of scarcity, especially occasion extraordinary changes in the 
 rate of population, &c. 
 
 In regard to the faculty of procreating at will children that shall 
 be beautiful, endowed with great genius, and without bad passions, 
 I can only refer the reader to the Callipedie of Cl. Quillet, to the 
 Megalanthropogenie of M. Robert, or lastly to the Traitt de la 
 Philopedie.
 
 Jfe* 
 
 152 
 
 CHAPTER IV. 
 
 Of the Human Ovum. 
 
 395. The human ovum, like that of other mammiferae, is com- 
 posed of the foetus and its appendages. 
 
 ARTICLE I. 
 
 Of the Appendages of the Foetus. 
 
 396. The appendages of the foetus consist of the membranes, the 
 placenta and cord, of the umbilical vesicle and aliantois, and of the 
 liquor amnii. 
 
 SECTION 1. 
 Of the Membranes. 
 
 The covering of the ovum is formed of three concentric layers, 
 the caduca, the chorion, and the amnios. 
 
 . I. Of the caduca or connecting membrane. 
 
 397. The caducous membrane, membrana decidua, cellulosa^ sin- 
 o*a, spongiosa, common or pre-existing membrane, connecting or 
 conjunctive membrane, cpichorion^ &c. , is so evident at all periods 
 of gestation, that it must have been noticed by every physiologist 
 who has paid much attention to the examination of the human se- 
 cundines. Thus, Aretaeus speaks of it pretty clearly under the 
 name of porous layer ; Fabricius under that of membranous substance 
 of the placenta ; G. Fallopius, under the title offashy substance, fyc.; 
 Spigelius, under that of the thick andjlcshy portion of the chorion; 
 Iluysch under that of the velvety chorion ; Rouhault, Littre, Hobo- 
 ken, under that of chorion ; Haller, under that of external or fun-
 
 CADUCA. 153 
 
 gous chorion; lastly, Needlmm, Diemerbroeck, Noorthwyck, with 
 Hoboken, Rouhault and Littre, have described it by the name of 
 chorion, while to the true chorion they give the name of allantois ; 
 but these obscure descriptions were only fit to hinder the researches 
 of observers, and can in no respect be compared with that given of 
 it by W. Hunter. 
 
 398. Formation. Impregnation determines in the uterus, a spe- 
 cific irritation, which is promptly followed by an exudation of co- 
 agulable matter, which concretes and soon transforms itself into a 
 kind of sac filled with a transparent and slightly rosy fluid. In 
 contact with the whole extent of the parietes of the uterine cavity, 
 this kind of bladder or membrane continues in some instances 
 within the origin of the Fallopian tubes, and always into the upper 
 part of the cervix, in the shape of solid concrete cords ; it never in 
 a natural state has any opening. 
 
 399. The ovule, after having passed through the tube, necessarily 
 depresses the caducous membrane, so that it may glide on betwixt 
 it and the uterus, to the internal surface of which it at last attaches 
 itself; from this moment the pre-existing membrane is composed 
 of two portions : one, very large, lining the whole interior of the 
 womb, except the part which is in contact with the germ, bears the 
 name of uterine or external caduca ; the other, very small, depressed 
 by the lower half of the fecundated vesicle, which it envelopes, con- 
 stitutes the reflected caduca, internal caduca or epichorion. The 
 extent of the former augments in the same ratio with that of the 
 womb, and the aggrandizement of the latter necessarily follows the 
 growth of the germ. Therefore the cavity which separates them, 
 and which is nothing more than the altered cavity of the primitive 
 sac, is the greater, the nearer we are to the first periods of ges- 
 tation. 
 
 400. The uterine caduca preserves a pretty considerable thick- 
 ness, especially in the vicinity of the placenta, until the close of 
 pregnancy ; the epichorion, on the contrary, grows insensibly thin- 
 ner, so that at the period of labour it is sometimes of an extreme 
 tenuity. 
 
 One, by sinking down into the other, at length comes to be in 
 contact with it, a little sooner or later, about the fourth month, 
 for example ; after this, the two layers remain in a state of more or 
 less perfect contiguity until the expulsion of the afterbirth, with- 
 out however being even confounded together, notwithstanding the 
 assertions of Hunter and all others who have treated of this subject 
 since his day. It it evident, then, that this membrane is managed 
 U
 
 154 APPENDAGES OF THE FffiTUS. 
 
 in regard to the ovule, as the pleura is in relation to the lung, or as 
 the serous membrane of the pericardium is in respect to the heart. 
 
 401. The external surface of the caduca is uneven and porous, 
 in contact with the interior of the womb, and invests the chorion as 
 far as to the circumference of the placenta, but is not prolonged 
 over the spongy surface of that body : to the former its adhe- 
 rence is very slight, is effected only by means of mucous filaments 
 very easy to break, and which certainly are neither vessels nor nerves; 
 to the latter the union is much more intimate, and so much the 
 more so as the development of the ovum is more advanced. During 
 the first two months indeed it is pretty easy to extract the ovule from 
 that portion of the sac which constitutes its epichorion ; while at a 
 later period, the numerous filaments that habitually invest the germ 
 contract such solid adhesions with the reflected caduca, that it be- 
 comes more and more difficult to effect this separation without rup- 
 ture. 
 
 402. The internal surface being moistened by a fluid, although 
 tuberculated, is nevertheless smooth, and lined with an extremely 
 delicate pellicle. After the fluid has disappeared and the reflected 
 portion has come to be in contact with the uterine layer, this sur- 
 face soon assumes the characters of the former. The liquid which 
 fills the cavity of the caduca, and keeps its two surfaces apart, is 
 sometimes quite limpid, but most commonly reddish, viscid, similar 
 to melted glass, or rather to white of eggs, and appears to be com- 
 posed of a large proportion of water, and of albumen, and gelatin. 
 
 403. Circumference. At the place where the caduca turns back 
 so as to invest the ovum, it forms a circle, which at first exhibits the 
 form of a fold more or less regularly rounded, but which afterwards 
 is gradually transformed into a thin and sharp edge, and ends at 
 last by being more or less evidently continuous with the circum- 
 ference of the placenta. 
 
 This is a point in the history of the, connecting membrane on 
 which I most insisted in 1824, and is, notwithstanding, one on which 
 the greatest doubt has remained in the minds of observers. 
 
 404. Hunter, Baillie, Wrisberg, Krummacher, Blumenbach, 
 Stein, MM. Lobstein and Meckel, Beclard, &c. have indeed ad- 
 mitted the two laminon of the caducous membrane, but still persist 
 in the belief that the placenta does not fix itself to the womb until 
 after having passed through them. 
 
 1<>.,. ( lhauasier and M. Duges, on the contrary, suppose that the 
 uterus is at first merely filled with lymph or coagulable albumen ; 
 that the little egg, on arriving from the ovjiry, dips into the midst of 
 (Ins substance, and becomes covered with it ; that the villi of the
 
 CADUCA. 155 
 
 chorion must be confounded or blended with it in order to form the 
 placenta, and that, in consequence of the growth of the womb, the 
 caduca, at first single, is separated into two layers. But I now pos- 
 sess so many facts in favour of the doctrine laid down above, that I 
 cannot unite in any respect with the sentiment of these authors. 
 
 406. Ruysch, Haller, the two Hunters, M. Lobstein, and all 
 those who have treated at some length of the membrana caduca, say 
 they have met with vessels in it, even in great numbers, and, conse- 
 quently, that it is organized. I, on the contrary, do not believe that 
 it is organized at any period of gestation. It is so easy to convince 
 one's self of its organic condition by examining it in a fresh after- 
 birth, that I can hardly understand how this remark has escaped the 
 attentive observers whom I have above mentioned, as well as all 
 those who have succeeded them. 
 
 By examining it previously to the end of the second month, it will 
 be found to be soft, supple, spongy ; that it is very elastic, tears with 
 extreme facility, and contains not a vestige of organic elements ; 
 that it is only contiguous to the womb, and adheres to the chorion 
 merely by means of the villi that always cover the ovule. 
 
 At the close of pregnancy, it preserves the same softness, the 
 same elasticity : it is always of a reddish grey colour, easily reduci- 
 ble into shreds ; its adhesions to the uterus have not undergone any 
 change, only its epichorion layer has become considerably thinner, 
 in consequence of the mechanical distension it has been subjected 
 to ; its composition is in all respects the same as at first ; in one 
 word, from the instant of its formation, until its exclusion from the 
 sexual organs, it has never appeared to me that the caduca could be 
 regarded in any other light than as a simple inorganic layer ; how- 
 ever, I can affirm that I have carefully examined it in more than 
 four hundred specimens discharged at full term or by abortion. 
 
 407. It is true that it is sometimes sprinkled with reddish, stellated 
 points, or bloody stria?, which might, under certain circumstances, 
 induce a belief of the existence of vessels in its substance ; we may 
 also see, especially on its inner surface, an extremely delicate pel- 
 licle, which might frequently be mistaken for a cellular coat ; lastly, 
 it also seems to be pretty frequently formed of fibres placed side by 
 side, or even interlaced in various directions; but these spots, and 
 strias of blood, no more indicate the presence of vessels here, than 
 when they are met with on those membraniform concretions that 
 are thrown off by children in croup, &c. 
 
 408. If this membrane were really organic, if it were the seat of 
 a real circulation, can we conceive that it would never contract any 
 adhesions, that it would not be intimately blended with the internal 
 surfaces of the womb, and the external one of the chorion, which it
 
 156 APPENDAGES OF THE FCETUS. 
 
 lines for nine months ? Finally, to decide the question, it should 
 suffice us to remember that the characters of this singular membrane 
 are in every respect similar, at the moment of parturition, to what 
 they were at the commencement of pregnancy, a period wherein 
 nobody has pretended to have seen a trace of organization. 
 
 409. If then the caducous membrane is not an organic membrane, 
 if it is merely an adventitious coat, as M. Blainville calls it, or the 
 result of a concretion taking place in the uterus, the name of an- 
 histous* membrane which I propose to bestow upon it, and which 
 is synonymous with inorganic membrane, appears to me to be the 
 only one that can be advantageously applied to it. 
 
 410. Uses. I shall not stop to combat the opinion of those who 
 think that the anhistous membrane serves to nourish the foetus dur- 
 ing the first weeks of its existence ; to remark that the umbilical 
 cord is always inserted on that portion of the ovule which is not 
 covered with this concretion, ought to be sufficient to demonstrate 
 that it is unconnected with the nutrition of the first lineaments of the 
 foetus. Its use is to sustain the vesicle on some one point of the 
 uterine cavity. I know it may be objected that it fixes and main- 
 tains itself as firmly in animals as in women, and just as well in 
 extra-uterine as in natural pregnancy ; but in brutes, the surface of 
 the ovule, and the form of the parts through which it has to pass, are 
 far from being in all respects similar to those that are noticed in 
 the human species. The uterine horns in brutes differ from the 
 human uterus in this respect, that they never dilate enough to permit 
 the germ that passes through or stops in them to be in contact 
 with all the points of the circle to which it corresponds, in one of 
 those organic tubes. Further, when the product of fecundation 
 accidentally developes itself in the peritoneum, or the tube, or even 
 in the substance of the uterus, it remains uniformly contiguous to the 
 walls of the cavity which it has appropriated ; so that the caduca, 
 sucli as I understand it, is not at all necessary in these two circum- 
 stances, arid its absence, therefore, does not at all prove that in re- 
 lation to ordinary gestation it has not the uses I have just assigned 
 to it. 
 
 Another use of the anhiskms membrane seems to me to be to 
 circumscribe the placenta, and determine the place of its insertion; 
 but I defer tin- examination of this point to another article. 
 
 111. Analogy. Those who have embraced the opinion of Hun- 
 ter have averted that the caduca does not exist except in WO- 
 mei), and they were, so liir right, that it lias no when) been found 
 possessed of the same cliaracd i .- it exhibits in the human spot 
 
 * From ta-Toc tcla, and '/ pnvativc.
 
 CHORION. 157 
 
 but if, laying aside the idea of a complete analogy, we are content 
 to seek for its elements, more or less modified in other vertebral 
 animals, we soon perceive that it is in almost all of them replaced 
 by a coat which is equally inorganic. Thus, in the ophidian rep- 
 tiles its analogue is a simple mucous induitus ; in the batracians it 
 is represented by a similar but much thicker layer ; in birds, not- 
 withstanding what M. Dutrochet has said, the calcareous shell is its 
 substitute, and as M. Cuvier has already maintained; lastly, in 
 almost every species of the mammifera3 there is to be found a lamella 
 on the external surface of the chorion, which is sometimes nearly- 
 fluid, at others pretty consistent, and of a considerable thickness, 
 of a greenish or yellowish colour, and which serves as a caduca. 
 
 . II. Proper membranes of the ovum. 
 
 A. Of the Chorion. 
 
 412. To prevent, for the future, the chorion from being con- 
 founded with any other membrane, it will suffice to remember what 
 I have just said concerning the caducous membrane, and that it 
 constitutes the first organized or solid tunic of the ovum as we pass 
 from the womb to the fo3tus, and the second in proceeding from the 
 foetus to the womb. 
 
 413. Primitive condition. In a product of ten or twelve days 
 standing, the chorion presents the appearance of a velvet-like hyda- 
 tid, or a small transparent vesicle ; its external surface, free from all 
 adhesions, is somewhat fungous or fretted throughout its whole ex- 
 tent ; its interior is filled with a clear serous fluid. 
 
 414. In products of three or four weeks, the chorion is not smooth 
 on both its surfaces, as has been erroneously stated by a multitude 
 of commendable writers. I have never, whatever care I may have 
 taken, seen it smooth exteriorly, nor velvety internally. At a fort- 
 night, at three weeks, at one month as well as at two, I have 
 always found its external surface covered with the same down, its 
 internal surface even and polished, and its transparency neither 
 more nor less decided than at any other period of gestation. 
 
 415. Granulations, and villosities. It is generally thought that the 
 down that covers the chorion is of a vascular nature ; but as early as 
 1823 I ventured to oppose this hypothesis. What proves that the fila- 
 ments of the chorion are not vessels is this, that they are to be seen 
 before the blood vessels of the cord are recognizable. Besides, until 
 the sixth week, every flock is at least as large as one of the umbilical 
 vessels : so that as there are only three of these, it is difficult for 
 them to give birth to the others, which amount to several hundred.
 
 !58 APPENDAGES OF THE FffiTUS. 
 
 Further, these villosities, all independent of each other, are regu- 
 larly spread over the whole periphery of the ovule, while the cord 
 and placenta are only connected with one point of this vesicle ; and 
 notwithstanding the efforts of an infinitude of very able anatomists, 
 nobody has proved that they are hollow rather than concrete, vas- 
 cular rather than solid cellular filaments; lastly, when examined 
 with a lens, they are found to form certain areolar spongioles, and 
 not permeable conduits. 
 
 416. The abnormal continuance, or preternatural growth of the 
 swellings abovementioned have led me to suppose that such hyda- 
 tids as are found in bunches in the womb are not vesicular worms, 
 as is commonly supposed, but rather the product of an abortive 
 ovum, whose small gangliform bodies have taken on an unnatural 
 growth. I am in possession of a considerable number of specimens 
 which sustain this view of them : some of them T have shown to 
 M. Desormeaux, and again, very recently, M. Delange, physician 
 at Falaise, has sent me one, the examination of which leaves no 
 doubt on this point. My opinion on this subject is further fortified 
 by the cases of Albinus, Wrisberg, Reuss, Sandifort, and even by 
 those recently made public by Madame Boivin. 
 
 417. Until the third, fourth or fifth week of pregnancy, the inner 
 surface of the chorion is in contact with a very delicate lamella, 
 constituting part of a peculiar body which I shall, provisionally, de- 
 nominate the reticulated sac. From this period until the sixth week 
 or second month, it is no longer separated from the amnios except 
 by a perfectly transparent, vitriform substance. In the natural state, 
 this substance never contracts any intimate adhesions to any organ 
 capable of altering its natural appearances. 
 
 418. According to Needham, J. Fabricius, Noorthwyck, Harvey, 
 Lacourvt'c, Hoboken, Littrc, Rouhalt, &c. the thickness of the cho- 
 rion is considerable ; but the error of these anatomists evidently 
 depends upon their having confounded the chorion and caducous 
 membrane tinder the same title. 
 
 I have' studied the chorion, whether at term or other periods of 
 pregnancy, in a great number of specimens, and have always found 
 in my dissections, that it is every whore transparent and thin, as 
 well upon the placenta as elsewhere. This, indeed, is a fact, which 
 any one may readily ascertain, by taking care to macerate a na- 
 tural afterbirth in water, so as more easily to separate the reflected 
 caducn from it. Then the appearances of the chorion are found to 
 .. -icily the .same throughout ; so that the thesis of Phil. Beclard, 
 I's Manual of Anatomy contain several manifest errors 
 on this subject.
 
 CHORION. 159 
 
 Hewson, and many who preceded him, have asserted that the 
 chorion is formed of several coats, which, being early applied to 
 each other, come at last to constitute only a single one ; that the 
 placenta results from the unfolding and thickening of these laminse, 
 from which each of the umbilical vessels receives a sheath, &c. 
 But I have already shown, in 1824, that the reason of this 
 supposition probably depends upon the presence of a concrete 
 lamellar layer, which indeed does invest the vascular roots of the 
 placenta, and separates it from the external surface of the chorion. 
 At present I may add, that if Ruysch, Haller, and so many others, 
 supposed the chorion to be constituted of a variable number of 
 layers, it was because they had never separated it from the mem- 
 brana caduca ; but I do not understand how MM. Chevreul, May- 
 grier and Dutrochet could have ever reproduced this old notion. 
 
 At a fortnight, and at three weeks, as well as at two months, the 
 chorion in the human subject is simple, and although, at a later 
 period, other laminae become connected with it, they belong to bo- 
 dies not as yet described, and which cannot, under any pretext, be 
 considered as its appendages. 
 
 419. Hippocrates has pretended that the membranes of the fetus 
 arise from the umbilicus. Harvey has said that the chorion, the 
 amnios and chord, are merely prolongations of the child's belly ; and 
 Burton, defending the same opinion, expresses himself still more 
 positively on this subject. I myself related some cases, in 1824, in 
 support of such an hypothesis. At the same time an Italian anato- 
 mist, M. Mondini, contributed to strengthen it by mearts of some 
 particular researches and reasonings. M. Moux states that the 
 chorion, after investing the cord, is continuous with the derm of the 
 fetus. It should be remarked that M. Chevreul is of the same opi- 
 nion. Finally, M. Blainville seems to have held a similar opinion. 
 
 But the chorion constitutes a part of the ovule at the moment of 
 fecundation ; the abdominal parietes are not developed until after 
 the spine ; the chorion presents the same characters and form be- 
 fore the appearance of the skin that it exhibits afterwards ; the cho- 
 rion and the skin are therefore two parts quite independent of each 
 other. 
 
 420. The chorion can be referred neither to the derm, the mus- 
 cles, the aponeuroses, nor peritoneum ; however, it is difficult to call 
 in question its cellular nature, or to deny its analogy with the 
 serous membranes, of which, besides, it presents all the characters, 
 whether physical or physiological. Does it contain nerves and 
 lymphatic, sanguineous, exhalant and inhalant vessels ? 
 
 These two last mentioned kinds of vessels having only been ad- 
 mitted in animal bodies upon the say so of the physiologists, espe-
 
 160 APPENDAGES OF THE FffiTUS. 
 
 cially Bichat, who never saw them, it is good philosophy to reject 
 their existence without discussion, until they shall have been demon- 
 strated by more conclusive proofs. The same may be said of the 
 lymphatics, which the imagination alone of Schrceger and some 
 others seems to me have detected in the chorion. As to nerves, I 
 think I may say without offence to Chaussier, MM. Ribes, Home, 
 and Bauer, that they are no more to be found there, than the ex- 
 halants and lymphatics. 
 
 421. The question in relation to blood-vessels deserves much 
 more attention. Admitted by a great many savans of the highest 
 merit, and that too upon a certain number of proofs ; rejected by 
 other authors not less able, and upon considerations not less powerful, 
 it becomes, upon that account merely, very difficult to settle one's 
 opinion in relation to them. 
 
 In attempting to separate the reflected anhistous coat from the 
 exterior surface of the chorion, we soon perceive an indefinite num- 
 ber of filaments passing from each one of these laminae to the other, 
 and which are more numerous as we approach the circumference of 
 the placenta, or are nearer to the commencement of the pregnancy. 
 But these filaments, which Sandifort and others mistook for vessels, 
 are nothing but the remains of the villous tomentum of the ovule, 
 and not canals carrying on any circulation whatever. The chorion 
 exists before the embryo ; with the exception of the portion that is 
 to support the placenta, it is completely separated from the womb 
 by an inert stratum ; the umbilical and placental vessels do not make 
 their appearance in the new being until the ovule attaches itself to 
 the internal surface of the uterus ; it is only, therefore, in the area 
 circumscribed by the reflection of the anhistous membrane, that the 
 villi of the chorion can allow any vessels to be developed. 
 
 422. The chorion is met with in all the vertebral animals ; but 
 with such modifications that most physiologists have been unable as 
 yet to agree concerning its nature : in the batracian reptiles, as in 
 women, it forms the covering of the ovule ; in the saurians, it ex- 
 hibits a much greater thickness and solidity, although it has the same 
 relations with the organs of the female. In the ophidians it com- 
 poses that membrane which is so dense and difficult to break, and 
 which constitutes the shell or outer covering. In birds tho chorion 
 
 ><,]) farther removed from the vitcllus, and in fact is not formed 
 until afl.nr several other lamin.-e. This is the membrane that lines 
 the inner surface of the H, and which is known as the 
 
 naiic of tin- slid!. riualiy, in the iiiainmilcra-, as well as in 
 the liiimai, . placenta m- ihu cotyledons, and 
 
 throughout the rcmaind- i.aiatcd from the womb
 
 CHORION. 161 
 
 or its horns, only by an inorganic layer of variable consistence and 
 thickness. 
 
 B. Of 'the Amnios. 
 
 In the opinion of all observers, the amnios, also designated by the 
 terms amiculum, aguelette, aurelia, charta virginea, &c. is the inner 
 membrane of the human ovum ; smooth, transparent, separated from 
 the foetus by the fluid which bears the same name, it slightly ad- 
 heres to the chorion by means of the mucous filaments or lamellae 
 which cover its outer surface. 
 
 423. In an abortion of from ten to twelve days, for which I am in- 
 debted to the kindness of Madame Lachapelle, and which was only 
 four lines in diameter, I found inside of the chorion a small trans- 
 parent sac, on the upper part of which the microscope detected an 
 opaque corpuscle of a whitish colour. Did this little sac represent 
 the amnios ? Was the white point the embryo ? 
 
 In an ovule of twelve or fifteen days, presented to me by M. Ber- 
 mond of Bourdeaux, I found fixed on a part of the cavity of the cho- 
 rion a small transparent sac, about three lines long. 
 
 In another of about three weeks, and for which also I am indebted 
 to the extreme complaisance of M. Bermond, the amnios represented 
 a vesicle three or four lines in diameter, and was stuck, as it were, 
 on the inner surface of the chorion. 
 
 In a fourth very perfect specimen of about twenty days, which 
 Madame Charonnet was good enough to give me in April 1825, 
 the ovule, separate from the reflected coat of the anhistous mem- 
 brane, measured only eight or ten lines ; the amnios, excessively 
 delicate and 1 white, was separated from the embryo only by a space 
 of a line and a half, and after being reflected along the origin 
 of the cord, seemed to be continuous without any line of demarca- 
 tion with the integuments of the little foetus, which, further, was 
 well formed. 
 
 In an ovule of about an inch in diameter aged three weeks or a 
 month, given me by Madame Le Brun, the amnios formed a little sac, 
 separated from the foetus by a moderately thick stratum of fluid, 
 and which left the greater portion of the cord exposed in the cavity 
 of the chorion. 
 
 In an ovum received from M. Fournier, Surgeon of the Royal 
 Stables, one which, from the accounts of the woman, and the size 
 of the chorion, must have been from two months and a half to three 
 months old, but which, from the size of the embryo, seemed not to 
 be more than four or Jive weeks, the amnios was a sac three or four 
 times smaller than the chorion, and was reflected along the cord 
 V
 
 162 APPENDAGES OF THE FCETUS. 
 
 at the distance of a line and a half from its root, so as to give it a 
 sheath quite up to the belly. This amnios, besides, presented all the 
 characters of the normal state. 
 
 In an ovum of six or seven weeks, presented to me by Madame 
 Lachapelle, the amnios, nearly as large as the chorion, had begun 
 to reflect itself in the form of a funnel upon the cord, at the distance 
 of six lines from the navel, which it reached after enveloping the 
 vessels, the pedicle of the vitelline sac, the intestinal bulb, &c. 
 
 In another older ovum, which was brought to me by M. Morisse, 
 an accoucheur at Paris, the amnios was still separated by a consi- 
 derable space from the chorion, and was applied to the cord so as 
 to sheathe it, beginning at the place where the prolongation of the 
 umbilical cord was implanted, and extending as far as the belly, 
 where, according to all appearances, it was continuous with the 
 epidermis. 
 
 In a specimen of eight or nine weeks, which M. Boulon d' Abbe- 
 ville gave me, the external surface of the amnios touched, so to 
 speak, the chorion, and invested the whole of the cord, which, already 
 very long and spiral, still contained the intestinal mass in one of 
 its enlargements. 
 
 In one of at least three months, very perfect, which M. Morisse 
 procured for me twenty-four hours after it had been passed by the 
 woman, the epidermis was so entirely separated from the other parts 
 of the foetus by a thick stratum of slightly muddy serum, that it might 
 have been removed with the greatest ease ; the same was observed 
 along the cord from one end to the other ; only the pellicle was here 
 close to the vessels at four different points, which gave rise to four 
 contractions and four vesicles placed at equal distances ; but the 
 adhesions of the amnios at the contracted spaces of the umbilical 
 cord, and those that the epidermis had preserved with some portions 
 of the limbs, did not prevent me from remarking the most perfect 
 continuity between all these lamellas. 
 
 424. From these notions it follows, that during the first fortnight 
 of gestation, the amnios has no immediate connexion with the fetal 
 end of the umbilical cord, on which, at a somewhat later period, it 
 doubles, so as to furnish it with a sheath, and place itself in contact 
 with the inner surface of the chorion ; that this disposition is main- 
 tained, saving in a few exceptions, until the abdominal parictes arc 
 completely formed ; that until then there is no continuity between 
 the amniotic membrane and the epidermis, but that this continuity 
 is afterwards difficult to deny. 
 
 425. It also follows, that the amnios is far from touching the in- 
 ternal surface of the chorion at all periods of pregnancy, as is gene-
 
 AMNIOS. 163 
 
 rally supposed, but that these two membranes are, on the contrary, 
 separated from each other by a considerable space, during a period 
 which differs in different individuals. 
 
 This space, which is at first very large in proportion to the cavity 
 of the chorion, much larger than the amnios itself during the whole 
 of the first month, afterwards diminishes by degrees, in proportion 
 to the increase of the amnios, so that at two months it about equals 
 that which separates the embryo from its envelope ; at length the 
 disproportional growth of this last named membrane causes it to 
 disappear almost entirely, so that towards the fourth or fifth month 
 we are obliged to suspect, in order to be able to recognize its ex- 
 istence. 
 
 426. It is useless to repeat what I have said as to the non-exist- 
 ence of vessels in the proper tissue of the chorion, for the purpose 
 of showing that they are far more certainly wanting in the amnios : 
 indeed, nothing leads us to admit of their existence in the latter ; it 
 is never covered withvilli like the former ; it never has any intimate 
 connexion with any vascular organ, and all that has been said upon the 
 subject by various authors, in fact, consists of mere assertions, or 
 rather of pure suppositions. 
 
 As the remarks in this article prove evidently that the amnios 
 forms only one single coat at the various periods of gestation, I shall 
 not stop to combat those who have thought it to be composed of 
 several layers in the commencement of its development. 
 
 . III. Of the water of the amnios. 
 
 427. Besides the foetus and the cord, the amnios contains a fluid 
 called the water of the amnios, or amniotic liquor. 
 
 428. At the beginning these waters form but a thin stratum ; their 
 proportional quantity afterwards increases rapidly, until towards the 
 end of the second month, when the inner membrane of the ovum 
 comes in contact with the chorion : at three months the weight of 
 the amniotic fluid considerably exceeds that of the fcetus ; but at 
 term the weight of the fetus, in turn, considerably exceeds that of 
 the fluid in which it floats. At birth, in fact, there are commonly 
 not more than from ten to thirty ounces of fluid. However, it would 
 not be correct to say, with Madame Boivin and several others, that 
 the quantity of fluid diminishes in an absolute manner from the mid- 
 dle of pregnancy until the moment of parturition. It is, on the 
 contrary, certain that it augments until the close, but in less pro- 
 portion than at the commencement of gestation. 
 
 But in this respect very great differences are observed : instead of 
 one pound, there may be two, four, and even ten pounds, or only a
 
 164 APPENDAGES OF THE FffiTtJS. 
 
 few ounces ; its abundance is generally in an inverse ratio to the 
 vigour, size, and strength of the foetus, and robust constitution of 
 the woman ; so that a foetus weighing five pounds for example, will 
 float in two, three, or four pounds of the water, while only three or 
 four spoonfuls will be found about a child of eight or nine pounds 
 weight. 
 
 429. According to some authors, its nauseous insipid smell some- 
 what resembles that of semen ; on the whole, it is nearly similar to 
 that exhaled from the belly of a slaughtered animal : unctuous, pos- 
 sessing rather more consistence than pure water, the liquor amnii is 
 clear, like simple serum, or of a slightly citron or greenish colour; 
 ordinarily transparent, it is not unfrequently lactescent, thick, mixed 
 with albuminous flocks, of a grey, yellow or blackish colour ; its 
 taste is both sweetish and slightly saltish ; in some cases it is so acrid 
 and astringent as to pucker the skin of the accoucheur's fingers, 
 when he keeps them beyond a few seconds in the vagina or womb. 
 
 430. It does not appear to contain more animal matter in the first 
 than in the last half of pregnancy, and in this respect the remarks of 
 Harvey, Lacourvee, Ruysch, and Osiander seem to me to be 
 wholly faulty ; its chemical composition is very complicated, and 
 besides, has only been studied in animals. MM. Vauquelin and 
 Buniva found it to contain : water, 98.8 ; albumen, salts of soda 
 and lime, 1.2. M. Berzelius says that it contains fluoric acid; 
 Scheele says he found free oxygen in it ; M. Geoffroi Saint-Hilairc 
 admits that it contains atmospheric air in a state of mixture ; but 
 MM. Lassaigne and Chevreul, at a later period, discovered that 
 what one of them had mistook for air, was nothing but a gas com- 
 posed of carbonic acid and azote. 
 
 431. The chemical nature of the water of the amnios differs, as 
 has been truly said by Van-den-Bosh from all the other fluids of the 
 body. The acids, alcohol, ebullition coagulate it only with great 
 difficulty, or even not at all : some suspect it to contain a free acid ; 
 others an alkali ; but one of these opinions must be incorrect, for 
 acids, as is well known, do not remain in contact with alkalies with- 
 out soon forming salts. From all the foregoing, we may conclude 
 that the composition of the amniotic liquid requires new analyses. 
 
 432. Trusting to certain experiments of Monroe, who by inject- 
 ing warm water into the uterine vessels, found it to transude upon 
 the inner surface of the amnios ; to Haller's assertion that the waters 
 become impregnated with the odour, colour, and even nature of me- 
 dicinal substances taken by the woman ; to the existence of supposed 
 vessels between the womb and envelope of the ovum, most physio- 
 logists have admitted that the liquor amnii is directly furnished by
 
 LIQUOR AMNII. 165 
 
 the mother. Others, however, have maintained the contrary, and 
 believe with Scheele, Winslow, Van-den-Bosh, and M. Lobstein, 
 that it comes chiefly from the ftetus, particularly from the placental 
 vessels ; Chaussier, Beclard and Meckel seem to hold a mixed opi- 
 nion, and endeavour to reconcile both the above hypotheses. 
 
 433. Those who refer the liquor amnii to the foetus, have placed 
 its source in the sweat, the insensible transpiration, or the urinary 
 secretion, or in the glands or particular bodies of the placenta, or in 
 the vessels which Needham, Fabricius, Ruysch and Haller say they 
 observed betwixt the lamellae of the amnios ; some of the ancients 
 made of it a cottiquamentum, coming from the semen, &c. Such as 
 attribute it to the mother merely say that it is poured out by exha- 
 lation in the interior of the ovum. 
 
 434. I do not think it would be useful to refute these opinions 
 one by one ; I shall content myself with remarking that there is no 
 vascular connexion betwixt the womb and the membranes ; that the 
 spongy coat is separated from that organ by an inorganic layer, the 
 membrana caduca, and that for more than a month the amnios does 
 not even touch the inner face of the chorion, to show that the fluid 
 in question is not derived immediately from the uterus ; the propor- 
 tional quantity of the liquid being much greater in the first period 
 of pregnancy, ought also to suffice to show that it cannot be sup- 
 posed to come directly from the foetus, 
 
 Every thing proves that the water of the amnios is the product of 
 a transudation, or of a simple exhalation, like the serosity of the 
 pleura, the pericardium, the peritoneum or arachnoid, and like the 
 synovial fluid of the tendinous sheaths, or of the articulations ; and 
 that this perspiration does not require for its production the exist- 
 ence of special canals ; that it is an instance of mere vital imbibition : 
 the viscid matters, the muddy appearance, the yellow or greenish 
 flocks frequently met with in it, do not in any respect belong to it ; 
 for they are nothing more than portions of meconium, or of the 
 induitus separated from the foetus, or even of the vitriform substance, 
 and also of the vesicles which exist primarily between the membranes. 
 
 435. Its uses are, 1. To favour the active or passive motions of 
 the foetus, which, if it were without the liquor, would be every where 
 pressed by the uterus, and could not develope itself; 2. To permit 
 the isolation of the limbs and of their different parts ; to prevent the 
 fingers from remaining in contact and adhering together ; to oppose 
 the adhesion of the fore-arm, or of the legs and thighs to the breast and 
 abdomen, as happened in a case related by M. Morlanne, where the 
 foetus was born with such adhesions six weeks after the discharge of 
 the waters ; 3. To protect the child against the shocks and jars that
 
 166 APPENDAGES OF THE FOETUS. 
 
 might be experienced by the mother, and particularly by the womb $ 
 to protect the tender being from all kinds of compression, and to 
 furnish it with a kind of tepid bath which might favour the circula- 
 tion of its fluids, and afford to it a facility for moving according to the 
 laws of gravitation, and to have the head always directed towards the 
 neck of the uterus; 4. To keep the membranes always apart, main- 
 tain the dilatation of the womb, and keep up a gentle pressure upon 
 the cord and surface of the child ; 5. In labour, to permit the for- 
 mation of the bag of waters, a real segment of a sphere, which by 
 gradually engaging in the cervix, singularly promotes its dilatation ; 
 6. After the rupture of the membranes, to lubricate the genital or- 
 gans, to soften them, and thereby render the passage of the head 
 easier and less painful ; 7. Lastly, to render operations much more 
 simple and free from danger when compelled to introduce the hand 
 into the womb. 
 
 SECTION 2. 
 Of the Vesicles of the Embryo. 
 
 . I. Of the umbilical vesicle. 
 
 436. The umbilical vesicle is an organ that was unknown to the 
 ancients, of which much has been said by the moderns, either with 
 a view to place its existence beyond doubt, or on the contrary to 
 reject it as among anomalies or pathological changes^ but which has 
 not been described so exactly as to enable physiologists to get a 
 clear idea of it. 
 
 Albinus was the first author who really observed it, and had a draw- 
 ing made of it ; if several persons have supposed they could discover 
 some notions concerning it in the works of a remoter period, that 
 is because the same anatomists, having seen it only a few times, they 
 were often mistaken in regard to its characteristics. 
 
 437. It is wrong, for example, for MM. Lobstein, Beclard and 
 Meckel, to carry the knowledge of it back to the times of Needham 
 and Diemerbroeck, or even of Ruysch ; MM. Oken, Dutrochet, 
 Beclard, Meckel, Bojanus, &c., taking as a type the one described 
 by M. Lobstein, have asserted that the umbilical vesicle is at first 
 supported by the front of the embryo spine ; that when at its greatest 
 dimensions, it may be from four to six lines in diameter ; and that at 
 first its dimensions exceed those of the embryo. Now if it be true that 
 many assertions emitted on this subject are correct, it is not less so, 
 that what M. Lobstein has observed docs not prove it to be so ; for the 
 vum of which he has given a drawing being certainly in an uuna-
 
 UMBILICAL VESICLE. 167 
 
 tural state, all the data resulting from the examination of such a spe- 
 cimen, can be of no weight in science. 
 
 Another figure of the umbilical vesicle, in the human species, is 
 annexed to M. Meckel's memoir ; but it must be that the drawing 
 is a bad representation of the original, or that the original has un- 
 dergone some change, for the vitelline sac, the embryo itself, and its 
 envelopes are not commonly disposed in that way at the end of the 
 fourth week. 
 
 Among all the drawings that have been mentioned by authors, 
 without excepting that of M. Dutrochet, I am acquainted with 
 only two that incontestably represent the umbilical vesicle in its na- 
 tural state in the first six or eight weeks of pregnancy ; they are 
 those of Albinus and Scemmering, and yet. much is wanting, espe- 
 cially to the former, in a great many respects. 
 
 438. However, the numerous cases I have collected enable me 
 to affirm that the human ovum always contains, until the eighth week 
 of its growth, a vesicle similar or nearly similar to those noticed by 
 Albinus, Scemmering, MM. Meckel, Dutrochet, &c. ; that if nu- 
 merous naturalists failed to meet with it, it was because they sought for 
 it in specimens from which it had disappeared, either by the natural 
 progress of pregnancy, or by the rupture of the membranes in the 
 abortion, or in consequence of some morbid state, or the decom- 
 position of the parts that enter into the texture of the ovum, or 
 lastly, because they were not sufficiently practised in these sorts of 
 researches always to detect it, though it really existed. 
 
 In a total of about one hundred and thirty specimens, examined 
 before the end of the third month, I only met with the umbilical ve- 
 sicle in a state that could be called natural, thirty times. I have had 
 drawings made of six of these vesicles, and I still possess some that 
 are pretty well preserved in alcohol. 
 
 439. The umbilical vesicle is a small pyriform sac of a rounded 
 or spheroidal shape, which about the fifteenth or twentieth day after 
 fecundation is as large as a common pea, that is to say, from two 
 to four lines in diameter. It probably acquires its greatest dimen- 
 sions in the course of the third or fourth week ; at least, I have al- 
 ways found it smaller beyond the first month. I confess I never 
 had an opportunity of examining but one before the first fortnight, 
 and that was also smaller. When reduced to the size of a corian- 
 der seed, which commonly takes place about the fifth, sixth or 
 seventh week, it generally ceases to diminish, but becomes flattened 
 and then insensibly disappears ; sometimes it can no longer be found 
 at the third month, while in other cases it may be met with in abor- 
 tions of four, five or six months.
 
 168 APPENDAGES OF THE FCETUS. 
 
 440. It is incontestably situated betwixt the chorion and amnios. 
 If I maintained a contrary opinion in 1824, it was because I then 
 confounded it with a vesicular body which to a certain extent re- 
 sembles it, but which in fact differs very widely from it, as I shall 
 have occasion to show in the sequel. 
 
 441. Until the fortieth or fiftieth day it is enclosed in the reticu- 
 lated body or vitriform layer ; after that it unites with, and applies 
 itself either to the internal surface of the chorion or to the outer sur- 
 face of the amnios. It would seem then that one of these membranes 
 encloses it betwixt its layers ; indeed it is most frequently met with 
 thus, though I have found it perfectly free in ova of two and even 
 three months. 
 
 442. The characters of the pedicle by which it is attached to the 
 embroyo vary according to the stage of the pregnancy : until the 
 end of the first month, and in the natural state, I have not found it 
 less than two, nor more than six lines long ; at this period of its de- 
 velopment it is often a quarter of a line thick, and in becoming 
 confounded with the vesicle undergoes a sort of infundibuliform ex- 
 pansion. Towards the abdomen it does not enlarge, neither does 
 it contract in any sensible degree. Its continuity with the intestinal 
 tube can now no longer be called in question in the human subject. 
 Before the parietes of the abdomen are completely formed, it is 
 divided, as it were, into two portions by the amnios, which it appears 
 to have traversed or perforated. One of these portions is found 
 betwixt the spine and the spot to be subsequently occupied by the 
 umbilicus ; the other remains without, between the amnios and the 
 vesicle. 
 
 443. After the first month the canal elongates, becomes more 
 and more delicate ; its umbilical portion is lost in the cord, and can 
 no more be traced as far as the belly ; its length may extend to half 
 an inch, an inch or even one inch and a half. Whenever I have 
 found the vesicle further than this from the root of the cord, it mani- 
 festly depended upon its pedicle having been broken by the trac- 
 tions naturally exercised upon it by the membranes when these 
 parts acquire an early and pretty strong adherence to each other. 
 Accordingly as this rupture is effected earlier or later, as the adhe- 
 sions are stronger or weaker, as the pregnancy is more or less 
 advanced, the vitelline sac is found to be more or less remote from 
 the umbilical cord, or if you please, more or less approximated to 
 the circumference of the placenta. 
 
 444. This stem is unquestionably hollow until the twentieth or 
 thirtieth day, for I was able in two specimens to squeeze the liquid 
 from the vcaicle into the intestine without rupturing any thing ;
 
 UMBILICAL VESICLE. 169 
 
 whence it follows that the objections of MM. Emmert, Hoech- 
 stetter, Cuvier, &c. are of no value, at least in so far as they are 
 applicable to man. It becomes obliterated at a period which has 
 not appeared to me to be always the same ; in general, however, it 
 may be said to be no longer permeable at five weeks, and its oc- 
 clusion takes place from the navel towards the vesicle in proportion 
 as the cord becomes more complete. 
 
 445. The parietes of the vitelline sac are strong, resisting, pretty 
 thick, and difficult to lacerate ; they have never appeared to me to 
 be more frail than the other membranes of the ovum, unless they 
 had been previously rendered thinner by some morbid change or by 
 some mechanical cause. Smooth and even when the vesicle is 
 full, they wrinkle or fold, on the contrary, when that little body is 
 emptied ; they are generally of a yellowish colour, but perhaps 
 this tint depends upon the fluids they contain ; their transparency 
 too is imperfect, which may depend upon the same cause. 
 
 446. Those who have examined the umbilical vesicle in brutes, 
 and who have admitted its continuity with the intestines, pretend 
 that it is composed of three lamina. According to M. Dutrochet 
 the same is observable in the human species ; but, so far as T know, 
 this is only a mere assertion advanced without proof. However, as 
 to the vesicle, I have never in any instance found it to consist of 
 several membranes ; its pedicle in particular is homogeneous and 
 not lamellated. So that I think we may very well admit in this 
 apparatus the existence of a mucous surface and a serous surface, 
 but not of a serous membrane and a mucous membrane ; still less 
 of a muscular coat : besides, it is not until a much later period of 
 life that these distinctions of the tissues are effected, even in those 
 organs where they are subsequently most decided (166). 
 
 447. However this may be, arterial and venous vessels are visibly 
 distributed upon it ; I have observed them not only in the substance 
 of the parietes of the vitello-intestinal canal, but also in those of 
 the vesicle itself; in the latter twice, and more than twenty times in 
 the former. Jn the former case I saw them compose a very beautiful 
 net work with arborescent ramifications extremely easy to follow, 
 without any particular preparation, and even with the naked eye. 
 In the latter, they consisted of two trunks becoming larger and 
 larger as they approached towards the abdomen. 
 
 448. These vessels, denominated the ompkalo-mesenteric vessels, 
 would be better named vitello-mcsenteric, or simply vitelline. Ac- 
 cording to my own observation, they do not empty themselves into 
 the superior mesenteric vein and artery ; I have always remarked 
 that they join one of the branches of the second or third order of these 
 
 W
 
 170 APPENDAGES OF THE FOETUS. 
 
 great vessels, particularly those that proceed to be distributed to 
 the caecum. I have often traced them in the abdomen, through 
 the umbilical ring, and as far as one, two, and even three inches 
 along the cord, in products of six weeks, and two or three months 
 old. But they disappear at these different periods, and at last are 
 lost in the spongy tissue of the umbilical cord, before arriving at the 
 vesicle. I have several times succeeded in injecting them, and then 
 they appeared of the size of a large hair ; in general, however, they 
 are so fine, that they are easily broken if sought for without the 
 greatest care. 
 
 449. Inasmuch as I have seen them in an ovule at the same time 
 with the pedicle of the vitelline sac, from which they were perfectly 
 distinct, it appears to me they should henceforth be considered as 
 destined to carry to and take up from the parietes of the vesicle 
 and its canal, the materials that serve for the nutrition of this curi- 
 ous apparatus ; and not for the transfer of the vitelline substance 
 into the general circulation. 
 
 Many reasons, drawn from analogy, have led to a comparison be- 
 tween the vitelline matter and the yelks or vitelline substance of 
 the eggs of birds. In the largest umbilical vessel I ever saw, and 
 perhaps the only one where there was no possibility of this sub- 
 stance having undergone any change whatever, it was of a very de- 
 cided pale yellow, consequently opake, of the consistency of a pret- 
 ty thick emulsion, and different in all respects from serum or any 
 other known fluid of the economy. In others I have found it more 
 fluid and clearer, and in others yellower and thicker ; in several spe- 
 cimens it consisted of one or two small concrete clots, resembling in 
 a remarkable manner the yelk of egg cooked and floating in a 
 slightly coloured fluid ; to conclude, its colour is analogous to that 
 exhibited by the parietes of the vesicle itself, after the sixth week 
 of its growth. We ought, consequently, to admit, that it is a 
 nutritious substance, a sort of oil in a great degree similar to that 
 which constitutes the vitelline fluid of the hen's egg. 
 
 450. The uses of this apparatus then are evidently connected 
 with the nutrition of 'the primary lineaments of the foetus ; it fur- 
 nishes to the embryo its means of growth, until the cord and um- 
 bilical vessels are formed, or rather until the ovule becomes exactly 
 applied to the inner surface of the womb ; numerous materials then 
 pass from the parts of the woman to those of the ovum, and the 
 umbilical vesicle soon becomes useless. Under (his view, the appa- 
 ratus I am speaking of can be but temporary, and created to the 
 end of giving time to nature to establish with her accustomed gen- 
 tleness and regularity, the permanent means of nutrition in the ova
 
 UMBILICAL VESICLE. 171 
 
 of mammiferous animals. Frdm the moment of fecundation until 
 the ovule is found in immediate contact with the inner surface of 
 the womb, the product of human conception is in almost all respects 
 similar to the egg of a bird : like it, free, and independent of every 
 part of the mother, it must contain whatever is necessary within 
 itself; it must contain a substance, by the expenditure of which the 
 growth of the embryo can be effected, just as the chick must enclose 
 within its shell a material subservient to its evolution. But in one 
 this arrangement is only transient, while in the other it remains until 
 the embryo is hatched : but this difference depends upon this, that 
 in the former, incubation is performed in the interior of a living 
 organ, an organ capable of distributing nutritive matter in abun- 
 dance to the young product within it ; while in the second, it all 
 passes in the open air, outside of the parts of the adult animal. 
 
 . II. Oftheallantois. 
 
 451. The allantois has by turns been admitted and rejected in 
 the human ovum, from the earliest history of anatomy until our own 
 times, and even now most authors agree in rejecting its existence. 
 All indeed who have described it speak of it merely from analogy, 
 or have mistaken it for an organ with which it is important that it 
 should not be confounded. 
 
 M. Lobstein has described the umbilical vesicle itself for the 
 allantois; M. Dutrochet is still farther from the truth in taking for 
 this organ the inorganic pellicle that lines the interior of the mem- 
 brana caduca. Lacourvee, Hoboken, Diemerbroeck, Hales, Nouf- 
 ville, Littre, Rouhault, &c., affirm that they have observed it at all 
 periods of pregnancy ; some have even given drawings of it ; but all 
 their observations are referable to a primary error ; it is the chorion, 
 confounded anteriorly to their day with the anhistous membrane, 
 that they have described in place of the allantois. 
 
 452. In an ovum of about twenty days old, for which I am in- 
 debted to the kindness of Dr Terreux, the space between the amnios 
 and chorion, which was quite considerable, as it should be in. the 
 first month of pregnancy, was almost entirely filled by a fungous 
 substance of a brownish yellow colour, which was less thick the 
 nearer it was observed to the umbilical cord, while it was several 
 lines thick at the point diametrically opposite. Notwithstanding 
 this great thickness, it was impossible for me to divide it into seve- 
 ral lamina; ; it appeared to be formed of an infinite number of fila- 
 ments and lamellae, disposed without regular order, but so as to form 
 a sort of reticulated magma. By pressing upon it with the dissect- 
 ing needle, I squeezed from it some particles of a whitish pulpy
 
 172 APPENDAGES' OF THE FCETUS. 
 
 matter ; upon detaching it from the'chorion, I found it adhered to it 
 by some very delicate and fragile filaments ; that its adherence to 
 the amnios and vitelline sac was less regularly established ; lastly, 
 that it also enveloped the cord on which the amnios was not as yet 
 folded, and that it could be traced to the belly of the embryo, as far 
 as the pedicle of the umbilical vesicle. 
 
 453. It is rare, exceedingly rare, to have an opportunity of ex- 
 amining so perfect a product of conception ; M. Henoque, however, 
 procured one for me that was still more so. This ovum, three or 
 four weeks old, and very recent, had undergone no change of shape, 
 nor laceration ; immediately under the chorion there was a tissue of 
 a dull white colour, extremely delicate, and almost as easy to tear as 
 the retina. Notwithstanding all the care taken, it was ruptured 
 merely by the pressure I made upon another point of the ovum in 
 dividing the chorion. It was full of an emulsive or cream-like sub- 
 stance of a slightly yellowish white, and which tended to escape in 
 homogeneous grumes. Its inner surface gave birth to fibres and 
 lamellae, and to numberless prolongations which decussated in every 
 direction, like what is observable in the spleen, the seminal gland, 
 the corpora cavernosa, and as is said to be the case also, in the 
 hyaloid membrane of the eye. These filaments, after traversing the 
 semi-fluid white matter, proceeded to a second lamella, which, with- 
 out any intermedium, was in contact with the periphery of the am- 
 nios, of the umbilical vesicle, and of its pedicle. Certain isolated 
 shreds, being washed and floated, exhibited an almost perfect trans- 
 parency, and much less thickness than the amnios. 
 
 454. To sum up, this new organ constituted a sac with a double 
 coat, moulded upon the cavity of the chorion, enclosing the umbili- 
 cal vesicle and the amnios, after the manner of the serous mem- 
 branes, forming interiorly a true net work with large unequal meshes, 
 in which the emulsive fluid was lodged. Its two coats, separated at 
 one place by a distance of more than three lines, became more and 
 more proximate towards the root of the umbilical cord ; near the 
 belly they appeared to be confounded with each other, but their ex- 
 treme tenuity prevented me from ascertaining what organ of (he 
 abdomen they were continuous with. 
 
 Have I now any right to conclude that this body was really the 
 allantois ? It is true I did riot succeed in demonstrating its com- 
 munication with the bladder, but this communication has been no 
 better demonstrated in reptiles, and even in many of the mammifera) ; 
 in-. i cover, the bladder itself was so small, or so little developed in 
 this specimen, that I am not sure of having seen it ; besides, as on 
 the one hand the summit of the urinary bladder naturally reaches
 
 ALLANTOIS. 173 
 
 as far as the umbilicus, and as on the other I traced the reticulated 
 sac from the root of the cord as far as the navel, it was impossible 
 to make a nearer approach, without reaching it, or without actually 
 demonstrating it, to render this communication more probable. 
 
 In embryos more advanced, I have many times traced the urachus 
 into the umbilical cord, where it unravels and is transformed into a 
 porous tissue, and terminates either in one of the swellings when 
 they still exist, or in the gelatinous tissue of the placental stem after 
 passing on for six or eight lines, or one inch, or fifteen lines. I have 
 seen more : in an ovum of five or six weeks old, the prolongation 
 from the bladder proceeded to, and was lost in the vitriform layer, 
 which at this period takes the place of the porous body of the ovule ; 
 I must however confess, that having blown air into the bladder, I 
 could not make it penetrate into the urachus, which always retained 
 the characters of a solid filament. 
 
 455. From the fifth week after conception until the close of preg- 
 nancy, there is betwixt the chorion and ^pnios a transparent stra- 
 tum, either colourless or of a somewhat greenish red ; this stratum, 
 instead of being merely serous, is lamellated after the manner of the 
 vitreous body ; it diminishes in thickness in proportion to the devel- 
 opment of the other membranes ; the quantity of fluid contained in 
 its meshes is, on the contrary, in the inverse ratio of the progress of 
 gestation ; by diminishing in thickness, it at length comes to form 
 only a homogeneous pulpy stratum, to transform itself into a simple 
 gelatinous or mucous coating, which, in many women, wholly dis- 
 appears before the period of delivery ; several of its lamellae are 
 confounded together at the external surface of the,amnios, princi- 
 pally in the environs of the root of the umbilical cord ; the same 
 thing takes place, but more rarely, as to the chorion, which explains 
 why the umbilical vesicle, observed after the sixth week of gestation, 
 is very often united, as if framed in, with the membranes of the cho- 
 rion and amnios : this matter occupies the place of the reticulated 
 body, and like the latter is continuous with the gelatinous portion 
 of the cord. But is it independent of the porous sac which precedes 
 it; or rather is it only a modification thereof? This last conjecture 
 seems to me to be, if not certainly true, at least extremely probable. 
 
 456. In order to acquire more enlarged notions concerning the 
 bodies in question, naturalists may advantageously have recourse 
 to comparative anatomy ; for I have found betwixt the allantois of 
 oviparous reptiles, and the reticulated body of the human ovum, the 
 most exact resemblance. 
 
 In mammiferas I have observed, even at the close of gestation, 
 that the urachus, after traversing the umbilical cord, expands into a
 
 174 APPENDAGES OF THE FOETUS. 
 
 smooth tissue, that is porous, and as it were, drilled full of holes, 
 which at last unites intimately with the corresponding; surfaces of 
 the membranes between which it is naturally placed. In this crib- 
 .riform membrane we meet at other periods with certain pelotons of 
 concrete fatty matter, similar to the hippomanes of horses ; and as 
 the bladder opens into it, it unquestionably constitutes part of the 
 allantois. 
 
 There are, therefore, between the sac known as the allantois in 
 the mammiferse, birds, and reptiles, and the reticulated body which 
 I discovered in the human ovum, the most striking agreement in 
 respect to resemblance and nature. 
 
 457. In maintaining that the allantois is designed to contain the 
 urine of the fetus, naturalists have in all ages relied chiefly upon its 
 communication wkh the bladder in brutes, upon the saline taste of 
 the fluid met with in it, and, according to Daubenton, on the uri- 
 nary smell observed in it. I do not think that, even in the vivipa- 
 rous animals, these data are sufficient to establish such an opinion ; 
 the urinary odour is a character which is surely too fugacious for 
 us to attach any great importance to it, and on this point is it quite 
 sure that Daubenton was not mistaken ? In the second place, what 
 does the salt taste prove ? Do we not meet with it in the water of 
 the amnios ? Was it not communicated by the last named fluid to 
 the former ? What connexion can there be between the urine and 
 the viscid, fatty, whitish matter contained in the allantois of the bi- 
 sulcac ; between the urine and that white, feculent and reticular mass 
 contained in the allantois of the chick about the tenth day of incu- 
 bation ; between the urine and the milky, flaky fluid I have observed 
 in the ovum of an adder ? Certainly none : to contain the urine is 
 not the only, is not even the chief use of the allantois. 
 
 As to the human species, whether the reticulated body is analo- 
 gous to the allantois, or constitutes a different organ, whether it 
 communicates with the bladder by means of some channel, or is 
 independent of it, it appears to me impossible to establish the least 
 nllinity between the substance found in it and the urinary fluid. 
 
 Its functions, like those of the reticulated body, arc in my opinion 
 mnnectcd witli the early nutrition of the germ. Perhaps it serves 
 for the development of some particular organ, or some special appa- 
 ratus ; on this subject we may indulge in a thousand conjectures ; 
 but fearing to stray in the field of suppositions, I prefer to wait for 
 new facts. I shall content myself with showing that the inner sur- 
 <<;ds I have turned back on it, were covered with an 
 adherent layer of a cream-like matter contained in its interior; that, 
 in the microscope, it presented a villous appearance, and that from
 
 ALLANTOIS. 175 
 
 this double peculiarity it is probable that the substance in the reti- 
 culated body is secreted by its own parietes. This, moreover, would 
 be an argument in favour of the opinion of Harvey, of Joerg, and of 
 Oken, in relation to the fluid of the allantois in animals. 1 will ob- 
 serve further, that this matter preserves its cream-like, flaky aspect, 
 its appearances of an emulsive fluid, its characters of a nutritive 
 substance, until the ovule is well fixed in the womb, and then dis- 
 appears very rapidly, giving place to the albuminous stratum, which 
 remains until the termination of pregnancy. I make no mention 
 here of a third vesicle described in the Isis by M. Pockels, under 
 the title of the crythroid vesicle, because I have never noticed it, and 
 because I believe the author is mistaken in relation to it. 
 
 SECTION 3. 
 Of the Cord and Placenta. 
 
 . I. Of the umbilical cord (funiculus umbilicalis). 
 
 458. The umbilical cord is a stem by which the abdomen of the 
 foetus is conpected with the membranes of the ovum, from the com- 
 mencement flntil the end of pregnancy. 
 
 459. Its length, although variable, is notwithstanding generally 
 the same as, or a little greater or less than that of the fetus at birth, 
 that is to say, from fifteen to twenty inches. Denman, L'Heritier, and 
 MM. Morlanne and Maygrier, have spoken of cords measuring four, 
 five, and even six feet in length ; others have been seen only a few 
 inches long, which even retained the placenta in contact with the 
 foetus ; but these extremes of dimension are rare, and some of the 
 notices of them require to be repeated. 
 
 460. Some times thicker, at others more slender, it generally is 
 about the size of the little finger. In this respect its anomalies, 
 which are much more apparent than real, depend upon whether the 
 spongy tissue of which it is partly composed is engorged with fluids 
 which constitutes fat cords, or on the other hand almost entirely 
 desiccated, and then the cord is lean. However, they may also de- 
 pend upon varieties in the absolute thickness of their vessels or 
 sheaths. 
 
 46 1 . Although smooth and polished like the serous membranes, the 
 human cord, nevertheless, exhibits many nodosities of different kinds, 
 on which I must dwell for a moment : on some occasions they are 
 real knots, either simple or complex ; more frequently, however, 
 they are doublings, vascular nooses, whether of the arteries or of
 
 176 APPENDAGES OF THE FCETUS. 
 
 the vein ; the former are met with particularly where the cord is very 
 long, are owing to the movements of the fretus, are effected in the 
 same way as the twisting of the cord about the neck, limbs, or other 
 parts of the child, frequently met with in parturition, and it may be 
 said are but the definitive result of this last mentioned disposition. 
 
 The second, known in all ages, are, according to Harvey, more 
 frequently formed by the vein than by the arteries ; but, according 
 to my own researches and those of Hoboken, more frequently by the 
 arteries than by the vein : being produced by the folding of one or 
 both these vessels, after the manner of the varicose knots in other 
 parts of the body, there may be only one or several of them on the 
 same cord. Rhodion and Avicenna among the ancients, and the old 
 women of all periods, pretend that by means of the number of these 
 knots, their remoteness from or nearness to each other, and their 
 colour, it is possible to ascertain the number and sex of the children 
 the woman is to have in future, the interval between each of the 
 confinements, &c. These ridiculous pretensions, begotten by the 
 superstition of our ancestors, doubtless do not deserve to be seri- 
 ously opposed ; but they are so often met with among the public, that 
 I thought they ought not to be passed over in silence. Although 
 they have never been accused of interfering with the omphalo-pla- 
 cental circulation, it may nevertheless be concluded* that if very 
 numerous and close, and presenting very acute angles, these turn- 
 ings might be the means of obstructing to a greater or less degree 
 the flow of the blood in its proper vessels. 
 
 462. The point of the belly which gives insertion to the umbilical 
 cord, is at a greater distance from the breast, or nearer the pubis, 
 in proportion as the pregnancy is less advanced. At birth, it gene- 
 rally corresponds, according to Chaussier and M. Bigeschi, to the 
 middle of the space between the vertex and soles of the feet. It or- 
 dinarily terminates in the centre of the placenta; but it is also some- 
 times found attached very near the circumference of that body : in 
 the former case, the branches of which it is composed diverge by 
 expanding in the covering of the ovum ; in the latter, it is not a rare 
 occurrence to find it creeping betwixt the membranes a longer or 
 shorter time before it is lost in the placcntul parenchyma. Of an 
 equal size throughout its whole extent in some subjects, it is in others 
 much more slender near its root than near the abdomen, and reci- 
 procally. 
 
 Development. Trusting to false analogies, hypothetical 
 data, or careless observations, authors have asserted that it does not 
 begin to be distinct until after the first month of gestation. The 
 youngest embryos 1 have ever dissected had the umbilical cord. I
 
 UMBILICAL CORD. I7?v 
 
 am now in possession of several of from one fortnight to three weeks 
 old, which are only three or four lines long, and in which the cord 
 is equal to, or even exceeds the length of the foetus. Relying upon 
 very numerous facts, I think I can establish it as a general rule, that 
 the length of the cord is about equal to, or somewhat exceeding that 
 of the foetus, at all periods of pregnancy. 
 
 It is slender and cylindrical until the end of the third week : a 
 little later, from the fourth to the seventh, the eighth, or even the 
 ninth week, it acquires a considerable relative size, exhibits tuber- 
 cles, vesicles or swellings, which I have no where seen described, 
 which are to the number of two, three or four, and separated by the 
 same number of contractions. In the course of the third it becomes 
 smaller, in consequence of the shrinking away of its swellings; 
 finally, from this period until the termination of pregnancy it ceases 
 to grow in proportion to the other parts of the foetus. 
 
 464. Its composition is far from being the same at all stages of its 
 evolution. At the commencement, it really consists only of a small 
 solid cylinder, to which the amnios does not furnish any coat. From 
 the fifth week it contains the duct of the umbilical vesicle, and a por- 
 tion of the urachus or allantois, and some of the intestines. But 
 about the second month, the alimentary canal has re-entered the 
 abdomen, the urachus, the vitelline duct and its vessels have become 
 obliterated, so that at three months, as at nine, the umbilical stem is 
 formed only of two arteries, the vein of the same name, of the gela- 
 tin of Warthon, or spongy tissue of Rouhault, and of the amniotic 
 sheath. 
 
 465. Diemerbroeck, Wrisberg, Schroeger, and Michoelis have ad- 
 mitted the existence of lymphatic vessels in the cord ; MM. Chaus- 
 sier, Darr, Reuss, &c. think they have discovered nerves in it going 
 to the solar plexus ; but it is probable these authors permitted them- 
 selves to be imposed on by some remains of the urachus, the vitel- 
 line vessels or duct, &c. At least I have never been able, with all 
 the pains I could take, to verify their assertions ; a circumstance in 
 which my researches agree with those of MM. Lobstein and Meckel. 
 
 466. Although there is in man only one umbilical vein, as an 
 ordinary rule, cases are cited where there were two, as occurs in a 
 great many of the mammiferEe. In other cases, instead of two arte- 
 ries, only one is found ; I have seen an instance of this sort, and M. 
 Blandin has deposited a second in the museum of the Faculty. 
 
 These vessels are not visible until the first fortnight, or the second 
 
 month after conception, and do not assume the spiral form until after 
 
 the disappearance of the swellings of the cord, that is, from the 
 
 seventh to the eighth week. The reason of this twisted appearance 
 
 X
 
 178 APPENDAGES OF THE FCETUS. 
 
 seems to me to be very plain : it depends on the rotatory movements 
 of the child in the womb, and ten times out of twelve it turns from 
 left to right, according to my own and Meckel's observations. In 
 some subjects, the cord is turned in one direction near the placenta, 
 and in the opposite one near the child's belly ; most frequently it 
 looks like a real rope, and hence, doubtless, is derived its name, 
 cord. Sometimes all three of the vessels turn on one ideal axis ; at 
 others the vein is twisted round the arteries, but in general the 
 arteries are twisted round the vein. 
 
 467. It is altogether incorrect to say with Hoboken, Reuss and 
 some other anatomists, that there are valves in the umbilical vein ; 
 I have been convinced of the contrary a hundred times by careful 
 dissection. Rouhault has remarked that the dimensions of this vein 
 are double those of both the arteries. 
 
 The common sheath that envelopes them continues transparent for 
 about two months, and during this period permits us very distinctly 
 to see them in its centre ; after which it grows more and more 
 opaque as the pregnancy advances. I have already said that it does 
 not exist at the commencement ; it is seen to form by degrees be- 
 tween the first and the end of the second month, progressing from 
 the embryo towards the root of the cord in the following manner : 
 the amnios, at first much smaller than the chorion, and as if pierced 
 with a circular hole, to allow the pedicle of the vitclline sac and 
 umbilical vessels to penetrate into the abdomen, is afterwards re- 
 flected along the umbilical cord as the ovum enlarges, but so as not 
 to afford a complete sheath to its vessels until the tunics of the foDtus 
 come into contact with each other. 
 
 468. Notwithstanding that these vessels do not in general sepa- 
 rate or divide until they reach the placenta, it would be a mistake to 
 suppose they never do so. Their division may take place at the 
 distance of one, two or four inches from the inner surface of the 
 chorion, and even very near the abdomen of the child. In this case 
 their, first divisions, diverging like the rays of a parasol, fall upon 
 points pretty near the circumference of the placenta. Examples of 
 this kind have been figured by various authors. I have seen one 
 belonging to M. Deneux, and have two of my own. Those obser- 
 vers," who, like Van-der-Wiel, Schurig, &c. have supposed that a 
 single foetus might have more than one umbilical cord, have pro- 
 bably been misled by this anomaly, for it i.s pretty nearly certain that 
 two cords never existed in the snme subject. 
 
 4G9. In the scientific collections may be found facts tending to 
 prove that the belly is not tin: only point to which the cord may be 
 attached ; that it ha.s been seen inserted upon the breast, the neck, 
 the limbs, &c. But none of these observations are of a nature t< 
 f
 
 UMBILICAL CORD. 179 
 
 enforce conviction ; they should be received with great reserve, for 
 they rather give evidence of the credulity of their authors, than of what 
 they wish to prove. However, there is at Brussels, in the anatomical 
 museum of a gentleman of that city, a foetus, with the cord inserted 
 upon the cranium, and which M. J. Cloquet has had an opportunity 
 of examining. If I might speak of a thing I have never seen, I 
 should say the abnormal cord originally belonged to a second foetus, 
 and became accidentally attached to the cranium, that the natural 
 cord also existed, and that the cranial cord did not penetrate be- 
 yond the integuments : I have seen one case that might give rise to 
 ideas similar to those I am now combating. A monstrous foetus, 
 born at the seventh month, and for which I am indebted to the 
 goodness of Madame Jagu, had the umbilical cord so disposed, that 
 at first view there seemed to be four of them ; two of them depart- 
 ing from the belly and the other two from the breast. But it was 
 only a natural cord, doubled several times, and the angles of the 
 folds of which had adhered to the membranes and also to the skin 
 of the foetus. 
 
 . II. Of the placenta (hepar uterinum). 
 
 470. The placenta, thus named by Fallopius from its resem- 
 blance in shape to a flattened cake, is that part of the ovum which 
 is found in immediate contact with the organs of the mother, and 
 is continuous at its circumference with the reflected caduca. It is 
 only found in the mammiferous animals, where it exhibits very va- 
 rious shapes. In the dog it is a complete zone surrounding the en- 
 tire chorion ; the placenta of the ruminating animals is multiple, 
 and presents itself to the view of the observer under the appearance 
 of unequal and pcdicillate masses. In the rodentia it is composed 
 of a circular plate formed of two layers, which are to a certain extent 
 dissimilar. In the horse it consists of a simple reddish and granular 
 layer, which covers the whole extent of the chorion. In the hu- 
 man species where I have particularly to examine it, it is a softish 
 and spongy, flattened, circular, oval or reniform body ; its width, or- 
 dinarily from six to eight inches, is sometimes smaller and at others 
 greater. Its thickness is also very variable, and, moreover, very un- 
 equal in different parts of the same one ; generally from one. inch to 
 an inch and a half at the centre, it goes on lessening towards the cir- 
 cumference, which is frequently only a few lines in thickness, but 
 which is occasionally, in some points, thicker than the centre itself. 
 
 As its diameters are from six to eight inches, it is uselcsa to say 
 that its circumference is from eighteen inches to two feet. 
 
 471. One of its surfaces, the fatal, inner, smooth, vascular,
 
 APPENDAGES OF THE FCETUS. 
 
 membranous, &c. surface, is lined by the chorion, which adheres to 
 it, and by the amnios, which can always be separated from it by 
 merely peeling it off. In spreading upon it, the principal divisions 
 of the vessels of the cord form a very beautiful diverging net work. 
 472. Its other, external or uterine surface, viewed in the womb 
 or upon an entire ovum, appears porous and fungus-like, but even ; 
 neither cracks nor orifices of sinuses are seen ; it only exhibits a 
 few salient points ; the anhistous membrane does not cover it ; a 
 simple pellicle lines it and covers its lobes. 
 
 When the placenta is out of the womb, this surface is, on the 
 contrary, extremely uneven ; lobes of various sizes are seen upon 
 it, and they are separated by fissures of greater or less depth ; and 
 this happens because, in detaching and expelling the placenta, the 
 uterus by doubling it up lacerates the thin inorganic pellicle which 
 concealed the intervals between its numerous cotyledons. 
 
 I have had six opportunities of observing it in situ, and in none 
 of them could I discover either sinus or opening having the least 
 resemblance to what authors have described as such. It is proba- 
 ble that the observers have been deceived by some accidental open- 
 ings and excavations, such as are often met with, but which are 
 owing to the pellicle, before mentioned, being lacerated here and 
 there, and rendering it an easy matter to penetrate into the placental 
 fissures, as into so many excavations. 
 
 At tho full term of pregnancy, the circumference of the placenta 
 is continuous, without any decided line of demarcation, with the 
 double layer of the caducous membrane ; and this is doubtless what 
 has led to the belief that the first mentioned part of the ovum is 
 only a thickened portion of the latter. 
 
 473. Arantius, Hoboken, Warthon, Ruysch, Malpighi, and many 
 other old writers ; Wrisbcrg, Rcuss, MM. Lobstein, Meckel, &c. 
 among modern ones, have made many attempts to unveil tho 
 nature or structure of the placenta. It might be supposed that in 
 this respect science has nothing more to desire ; but in turning over 
 the most esteemed works on the subject, one's opinion is soon alter- 
 ed, on perceiving that twenty different sentiments yet have their an- 
 tagonists and defenders. 
 
 Warthon, opposed by Arantius, was one of the first to say that 
 the placenta consists of two halves, one uterine or maternal, and the 
 other membranous or fcctal. If Warthon, and those who have 
 adopted this division of the placenta have not taken the ovum of 
 tho rodcntia as ihcir model, I am unable to discover in the human 
 after-birth any appearances that could account for their mistake ; 
 which besides has been imitated by many of tho moderns.
 
 PLACENTA. 181 
 
 It is sufficient to cast a glance on the porous surface of any pla- 
 centa, to be convinced that one of its halves has not remained ad- 
 herent to the uterus ; to remark that this surface is smooth, and 
 covered with a thin lamella, noticed even by those who admit the 
 double layer, in order to see that the fact is not so, and indeed can 
 not be so, &>c. 
 
 474. This membranule, which covers the fungous surface of the 
 placenta, admitted by Arantius, Littre, Hunter, MM. Lobstein, 
 Chaussier, Meckel, and most of the modern anatomists ; rejected 
 by Ruysch, Mery, Rouhault, &-c. seems to me to have been gene- 
 rally ill understood : some, contrary to the opinion of Wrisberg, 
 have thought it to be only a thin portion of the caduca ; according 
 to most observers, it contains many vessels ; many authors state 
 that it passes directly from one lobe of the placenta to another 
 without dipping down into the interval between them ; a still great- 
 er number, on the contrary, pretend that it dips down, also, between 
 the cotyledons, betwieen each bundle, and every vascular filament, 
 to which it furnishes a kind of sheath. Lastly, there are some who 
 believe in its existence during the whole period of pregnancy ; while 
 others say they have only met with it in the three or four last 
 months. 
 
 As long as the placenta does not form a compact mass, that is, 
 until about the twelfth week, there is not a trace of the pellicle in 
 question ; as soon as the tomentose groups of the chorion become 
 entirely agglomerated, it appears, as if to cover their summits, and 
 soon afterwards is found to be continuous and confounded with the 
 reflected edge of the anhistous membrane. 
 
 It certainly contains no vessels, and the idea of a circular venous 
 sinus, which according to the reports of certain anatomists exists 
 along the circumference of the placenta, can only be the result of 
 a careless observation. 
 
 The utero-placental pellicle is here disposed in the same manner 
 as the arachnoid is on the brain : on the top of the projections and 
 protuberances it adheres intimately ; whilst opposite to the spaces 
 betwixt the lobes it may be easily separated, in the shape of a deli- 
 cate, transparent lamella ; like the arachnoid, it also remains on 
 the surface, and in general does not penetrate into the parenchyma. 
 Its nature is similar to that of the pellicles, which soon after their 
 formation cover almost all sorts of fibrinous concretions. It is 
 not a tissue ; it is destroyed by placing it in water, and after a few- 
 hours dissolves as readily as all the other membraniform concre- 
 tions. 
 
 475 . A coat of deposit, much thicker, more fragile, and not so 

 
 182 APPENDAGES OF THE FCETUS. 
 
 smooth as the preceding one, surrounds all the vascular trunks ; 
 this is what has given occasion to the belief that the vessels of the 
 placenta ramify in the very substance of the caduca ; that the chorion 
 is composed of several coats ; that the anhistous membrane lends 
 one lamina to the external and another to the internal surface of 
 the placenta, and that the delicate pellicle of the latter is doubled 
 down between all the fibrillas of its lobes and lobules. The lamellae 
 of which it is composed appear to me to be a concreted product 
 of a peculiar exudation from the womb, the chorion, and its to- 
 mentose portion. In this respect there is some analogy between 
 them and the caduca ; but they differ from it in this, that they are 
 not to be seen until a long time after the ovum has reached the 
 uterus, while the anhistous sac forms immediately after fecundation ; 
 and also in this, that one is very soft and somewhat elastic, while 
 the others are dry, hard, and break almost as easily as glass. 
 
 476. The glandular bodies, to which Blancardi, Malpighi, and 
 Littre attributed important functions in the placenta, are no longer 
 admitted by any body to exist ; those anatomists probably allowed 
 themselves to be deceived by the primitive and natural granulations 
 of the chorion. Notwithstanding the assertions of Warthon, Cruik- 
 shank, Mascagni, Wrisberg, Michsclis, and Schrccger, it is now 
 pretty generally agreed to deny the existence of lymphatic vessels 
 in the after-birth. The same is the case as to the nerves which 
 Verheycn, MM. Ribes, Home, and Bauer tell us they have seen. 
 
 477. However, Dr Lauth has recently published a work tending 
 to prove that a great number of lymphatic filaments of a peculiar 
 kind pass from the placenta to the uterus. It is true that when we 
 carefully separate the ovum from the womb we perceive an infinite 
 number of small whitish threads, extremely easy to break ; but it is 
 also certain that similar threads are to be seen when separating the 
 caduca from the surfaces which it lines, the amnios from the chorion, 
 &c., that these are merely gelatinous or mucous tracts, but not 
 vessels, nerves, nor even cellular filaments. 
 
 47". The blood vessels therefore compose the fundamental ele- 
 ment of the placenta ; these vessels arc but expansions or ramifi- 
 cations of those of the cord, and like those of the navel string 
 are not developed until after the third week, and then by intus- 
 susception and gradually. 
 
 Previously to this period, the villous matter of the chorion docs 
 not contain any of them, and this villous portion may until then be 
 compared to the Iiairy part of the roots of plants. It contains, in- 
 deed, spongiolc.s, radicles, and articulated filaments analogous to 
 those described by MM. DC Candollc, Correa and Dutrochct ; if it
 
 PLACENTA. 183 
 
 doe's take up any fluids from the surrounding parts, it must imbibe 
 or absorb them after the manner of vegetables. At a later period, 
 vascular channels are formed, as happens in new tissues. Being at 
 first much smaller than the radicles with which they are surrounded, 
 they do not seem to extend throughout the whole length of the 
 chorion, even at a pretty advanced period of their growth. I have 
 injected them with coloured alcohol, size, spirits of turpentine, &c. 
 at the third and fourth months, and afterwards examined them with 
 the microscope, and although the injection had passed into vessels 
 finer than those of the choroid, it always stopped at a considerable 
 distance from the extremities of the villous branches. This por- 
 tion, which cannot be injected, has always appeared to me to be, 
 like the primitive tomentum, unprovided with any central channel, to 
 be of a spongy nature, and to absorb only by means of imbibition. 
 
 The bands and solid white filaments that are found in the pla- 
 centa even after delivery, and which are attached to the. chorion, 
 are not, as some contemporary authors too confidently assert, oblite- 
 rated vessels : they never were hollow, and remain solid, as they 
 were at the commencement. They are similar to those which con- 
 nect the reflected portion of the anhistous membrane to the villous 
 coat, and belong to some primitive branches of the villous coat of 
 the ovule, in which no vessels were developed*. 
 
 Do the venous capillaries appear before the arterial capillary ves- 
 sels ? Is the contrary the case ? The assertions of Beclard, of 
 Meckel, of Lobstein, &c., concerning this point in anatomy, are any 
 thing but conclusive : having always met with arterial at the same 
 time with venous branches, I am disposed to believe that both these 
 kinds of canals appear together ; and how could it be otherwise ? 
 If the blood enters in one, must it not return by the other kind of 
 vessels? 
 
 Each vascular branch, in separating from the outer surface of the 
 chorion, is composed of a single artery and a single vein, which are 
 already twisted in a spiral manner ; the trunk soon divides into two 
 branches of each sort, and these again into two others, so that these 
 dycotomic ramifications go on almost ad infinitum : being pressed 
 
 * I maintained this opinion in the year 1823 (Archiv. Gen. de Med. 1S24), 
 and have ever since continued to inculcate it in ray public lectures on midwifery. 
 I am, therefore, not without reason surprised to see MM. Breschet and Raspail, 
 who have confirmed it by some recent microscopical experiments, endeavouring 
 to attribute it to themselves, or refer it to Carus, who never spoke of it before the 
 year 1827; M. Breschet should have recollected, however, that while examining 
 the granulations of the chorion with a lens in his study in February 1S24, we 
 discussed this subject, and that ho was not then of wy way of thinking.
 
 134 APPENDAGES OF THE FOETUS. 
 
 together and united to each other by means of the fibrous layer, 
 these divisions and subdivisions constitute a lobe, or cotyledon of the 
 placenta. In ruminating animals, particularly in the cow, these 
 lobes being very remotely separated from each other, form so many 
 distinct placentae. 
 
 All the vessels of one lobe communicate with each other ; but the 
 experiments of Wrisberg, which I have repeated, prove that they do 
 not in general communicate with those of a neighbouring lobe. 
 
 479. When any of these lobes separate from the others, and are 
 at some distance from the placental disc, they form a small distinct 
 placenta, and this has assuredly been the reason which has on more 
 than one occasion led to the belief that there were two placentae to 
 one single fcetus. Each one unites to those about it, as the different 
 lobules of the same cotyledon are united among themselves, and 
 their adhesion, which takes place in the third month, may easily be 
 broken up at full term : being thus disposed, they constitute the 
 parenchyma of the placenta, so that this parenchyma is entirely com- 
 posed of vessels, of solid filaments, of granulations, and a fibrinous 
 matter which serves as a common bond of union for them, but not 
 of any cellular basis analogous to that of other organs. 
 
 480. MM. Dubois and Biancini state that they have injected the 
 arteries, and probably the veins also, which pass from the uterus to 
 the placenta, and vice versa; Reuss has given a drawing of them, 
 and Albinus had already noticed them ; I have vainly sought for 
 these utero-placental vessels in a great number of subjects, and the 
 condition of the parts has convinced me that if they do sometimes 
 exist, they are far more frequently wanting. I can assure the reader 
 that whenever I have examined the ovum in the uterus after the 
 third month, its surface, as well as that of the womb, was smooth 
 throughout its whole extent, and that not a single vessel served to 
 maintain the connexion between these two parts. Might not the 
 learned authors whom I have mentioned have been deceived by some 
 anomaly, some pathological state, or some false appearances ? Could 
 1 have been mistaken myself? Time and additional facts alone can 
 resolve this question, which I leave for the curious. 
 
 Development. Anatomists have all treated of the formation of 
 the placenta ; but only a few of them have studied it methodically, 
 even since Hunter made us better acquainted with the nature of the 
 lua. It has been said, that when the ovule reaches the womb 
 there appear on its external surface certain brandling villi which 
 penetrate tliroujjli the unhistous membrane so as to conic in con- 
 tract with the womb, and that the placenta is formed in this ni;m 
 ncr ; that these villi, at first regularly disseminated over the entire
 
 PLACENTA. 185 
 
 surface of the ovule, soon begin to collect in groups and to assemble 
 together at one point, but becomes every where else smooth and 
 transparent ; that the placenta cannot be distinguished until after 
 the end of the second month ; that it then covers two-thirds or at 
 least one half of the ovum, and that its proportional breadth becomes 
 less and less as the pregnancy advances, &c. 
 
 481. The following is an account of what we do observe : after 
 gliding betwixt the inner surface of the womb and the caduca, and 
 becoming attached to the organ destined to contain it until the end 
 of pregnancy, one half of the villous vesicle is necessarily in contact 
 with it, while the other half pushes away the anhistous membrane. 
 From this moment one disc of the ovule is left in direct contact 
 with the living surface, without the interposition of the deciduous 
 membrane, and here the placenta is developed : this is the only spot 
 in the womb at which the germ can take up the principles of its 
 nutrition, resembling in this respect a vegetable inclosed in a vessel, 
 and having no communication with the earth save by a small open- 
 ing at the bottom. 
 
 It is then evident that the placenta in some sort begins to grow 
 as soon as the ovule reaches the uterus, and not merely after the 
 two first months of gestation ; that the relative dimensions of it and 
 the whole ovum are about the same from first to last ; and that 
 it is consequently incorrect to say that it covers more than one 
 half of the chorion at the second month, but at a later period only 
 a third, a fourth, &c. I have reason to believe that it constantly 
 augments in the same proportion as the surface of the womb with 
 which it is in immediate contact ; so that its width at birth depends 
 upon the size of the uterus or the dimensions of the point left ex- 
 posed by the decidua at the commencement of gestation. 
 
 482. It is well known that the placenta may be attached either 
 to the fundus, the front, the back or sides, and sometimes to the 
 neck of the uterus ; but hitherto the cause of these anomalies has 
 not often been inquired into. Those who say that it attaches itself 
 to the most vascular part of the uterus, make an assertion that is 
 void of sense ; for, admitting that the ovule is at first entirely con- 
 cealed in the centre of the decidua, as several authors have stated, 
 and still continue to assert, who is to tell the villi that the womb is 
 more favourably disposed for their reception in one place than in 
 another ? Since observation proves that the villi at first cover the 
 whole vesicle, instead of growing on one portion of it, why should 
 not the placenta occupy more or less regularly the whole superficies 
 of the ovum instead of covering only one-fifth of it ? 
 
 Y
 
 186 APPENDAGES OF THE FffiTUS. 
 
 Had Osiander, Stein, and some other writers, reflected more 
 carefully upon the subject, they doubtless would not have advanced the 
 opinion that the point of insertion of the placenta depends upon ihe 
 specific weight of the fecundated ovum, and consequently, on the atti- 
 tude assumed by the woman immediately after impregnation. Indeed, 
 two remarks suffice to overthrow this system: 1. As the vivified 
 ovule does not leave the tube for eight days, it is manifest that until 
 then, the attitude of the woman is a matter of indifference as to the 
 point in question ; 2. Be the time what it may that is considered 
 necessary for the germ to pass from the ovary to the womb, it is 
 clear that it will find the woman on foot more frequently than in any 
 other posture, and if the idea of Osiander were correct, that the 
 implantation of the placenta over the cervix, instead of being very 
 rare, ought on the contrary to be the commonest of all. 
 
 483. I think I have discovered a much more natural explanation 
 of this phenomenon, and shall venture to submit it to the examina- 
 tion of naturalists : upon entering the womb, the ovule necessarily 
 meets with the anhistous sac, and can proceed no farther without 
 detaching it ; now, if the adhesion of this sac is the same throughout, 
 the vesicle follows its original direction, glides along the fundus of 
 the womb, which, with the assistance of the decidua, seems to pro- 
 long the channel of the tube to that of the opposite one, or else it 
 stops as soon as it issues from the tube, and then the placenta at- 
 taches itself to one of the angles of the uterus. If the adhesion is 
 stronger above than it is below, we may conceive that the ovum will 
 descend more or less towards the cervix ; if the adhesion be strongest 
 in front, it will be directed backwards, and so of the other points. 
 This hypothesis is further confirmed by direct observation ; of tliirty- 
 four women who died while pregnant, or soon after delivery, at the 
 Hospital de Perfectionnernent, I found upon examining the parts, that 
 the centre of the placenta corresponded to the orifice of the tube in 
 twenty cases, it was in front of it in three cases, behind it in two, 
 below it in three, and in six cases only, towards the front of the 
 uterus. 
 
 The mode of union betwixt the placenta and the womb is another 
 point that has occupied much of the attention of physiologists : 
 Noorthwyck, Astruc, Haller, Mery, and Baudelocque, thought that 
 the large venous trunks of the womb were uninterruptedly conti- 
 nuous with those of the placenta. 
 
 Warthon, Reuss and a great many of the moderns suppose that 
 the part of the womb which is in contact with the ovum at the com- 
 mencement of gestation becomes fungous ; that these fungosities,
 
 PLACENTA. 187 
 
 which constitute the uterine placenta, intermingle and unite with 
 those of the chorion, from which arises an intimate adherence, which 
 the womb must tear off before it can expel the after-birth. 
 
 It even appears that Professor Dubois argues from this rupture 
 that the milk fever is really a traumatic fever. 
 
 According to Stein the lobes of the placenta are impressed into 
 the womb like a seal into soft sealing-wax, and the ramifications of 
 its vessels are implanted into the largest vessels of the womb, pretty 
 much as the roots of a shrub are implanted into the earth. Asdru- 
 bali thinks that the placenta adheres to the womb in the same man- 
 ner as the pulp of a peach clings to the stone. Leroux maintained 
 that it is in the same way as a leech attaches itself to the skin ; 
 others have said that it is like the graft of a tree, that it is effected 
 by means of an accidental cellular tissue, of peculiar vessels, fee. &c. 
 
 484. It appears to me that what I have said above concerning the 
 structure of the external surface of the placenta, proves that none of 
 these hypotheses are rigorously correct. I may repeat with Ma- 
 dame Boivin, that in several women who died whilst pregnant, the 
 membrane which covers and unites the lobes of the placenta ap- 
 peared to me to be the only bond between it and the womb. I have 
 remarked, further, that the adherence of the ovum was the same 
 every where, that it may be destroyed with the handle of a scalpel 
 without the least difficulty, and without rupturing any thing save 
 some mucous tracts like those found between the amnios and cho- 
 rion, between the croup membrane and the membrane that secreted 
 it. The error of the authors upon this subject manifestly depends 
 upon their having but few opportunities of examining the ovum in 
 the womb, and especially upon this : viz. that in women who die a 
 few days after delivery, the internal surface of the last named organ 
 remains swelled and fungus-like at the part that corresponded to 
 the placenta. 
 
 485. Double ova. After what I have said heretofore of the dif- 
 ferent parts of the ovum, I may dispense with entering into any con- 
 siderable details relative to double pregnancy. If two ovules reach 
 the womb, each by a different tube, or if they attach themselves to 
 it at a certain distance from each other, they will each have a dis- 
 tinct placenta, chorion and amnios, and sometimes even an epicho- 
 rion, until a certain stage of the gestation. If, on the contrary, they 
 had already contracted some adhesion together previously to leaving 
 the Fallopian tube, or if they happen to remain very near each other 
 in the uterus, it may be that they shall be enclosed in one single leaf 
 of the decidua, and that their villi, as well as their chorion, shall be 
 early confounded together. In this case it may be that the septum
 
 188 APPENDAGES OF THE FffiTUS. 
 
 formed by their conjunction, shall give way, and cause the two 
 foetuses to be found enclosed at birth in one single bag of membranes, 
 numerous instances of which are related in the scientific collections, 
 and of which one of the most authentic has been recently laid before 
 the public by Madame Boivin. Nevertheless, such a circumstance 
 is of very rare occurrence, for in double after-births, I have always 
 succeeded in tracing the chorion and amnios to the intermediate 
 septum, where the two membranes were more or less promptly con- 
 founded, and in a more or less intimate degree. In general, the 
 vessels of the two placentas do not communicate with each other, 
 any more than the vessels of the different lobes of the same placenta ; 
 but it is easily conceived that the contrary may take place some- 
 times, as seems to be demonstrated by facts carefully examined. 
 
 ARTICLE II. 
 Of the Foetus. 
 
 486. The ancients retained the name ^o, seed for the product 
 of conception for the first six days. During the next nine days they 
 called it JH/D^U*, then embryo for twelve days, after which they made 
 use of the term ref/ev, to designate the foetus until the forty-fifth day, 
 and these four supposed periods were characterized by them in the 
 two following verses : 
 
 Sex in lacte dies, ter sunt in sanguine terni, 
 Bis scni carnem, ter seni membra figurant. 
 
 At present it is generally agreed to give to the germ, when with- 
 out its membranes, the name of embryo, until the third month of 
 pregnancy ; or according to some, until its several parts can be dis- 
 tinguished from each other ; it is afterwards called foetus as long as 
 it remains in the womb, and the term child is not applied to it until 
 after its birth. Although this division is entirely arbitrary and diffi- 
 cult to justify, I feel bound partially to conform to it in this work. 
 
 SECTION 1. 
 Development of the Embryo, and of the Foetus. 
 
 487. The period at which the embryo first appears in the uterus 
 is still enveloped in darkness, and vain attempts have for twenty cen-
 
 EMBRYO. 189 
 
 turies been made to penetrate the mystery with which it is surrounded. 
 At the sixth day, says Hippocrates, the semen is changed into a 
 transparent bubble, in which a very small point appears, which is 
 probably the navel. According to Hauler and most of his pupils, the 
 embryo is not perceptible until the fifteenth or twentieth day. Of 
 those authors who, with the ancients, suppose that fecundation takes 
 place in the womb, a part maintain that the embryo is formed first, 
 and the membranes afterwards ; others, with Hippocrates, Mauper- 
 tuis, de Buffon, &c., teach that the membranes, on the contrary, 
 appear first ; yet no one has succeeded in showing on what day the 
 embryo begins to be visible. Again, the ovarists and animalculists, 
 are in the first place far from agreeing with each other ; and we cannot 
 perceive that the proofs they adduce in support of their assertions are 
 much more satisfactory than those of the partisans of the ancient 
 hypothesis. Finally, the opinion of Haller, which had been generally 
 adopted as the most probable, has been lately very much shaken by 
 the publication of a fact which has been supposed to be of a nature to 
 dissipate every uncertainty ; I allude to the case recently made public 
 by Messieurs Home and Bauer at London. 
 
 However, the sensation produced in the scientific world by this 
 case, seems to me as extraordinary as it is difficult of comprehension, 
 and can only be explained by the urgent desire that is felt to escape 
 from the uncertainty that still prevails in science upon this interest- 
 ing point in natural history. 
 
 What ! shall we dare to conclude, because a servant girl returns 
 sick to her master's house, and eight days afterwards dies with con- 
 vulsions and delirium, that she became pregnant the day she went 
 out ? Because the sexual organs of a woman whose menses are sup- 
 pressed are not in a natural state, it is thought possible to assert 
 that she was pregnant ! Further, even admitting this last point, which 
 certainly proves nothing, what right have vre to maintain that the 
 corpuscule which was found in the midst of a mass of coagulable 
 lymph, was a germ rather than any thing else ? Let those who feel 
 interested in this subject, take the trouble to examine Mr Home's 
 note and the accompanying plate, (PlKlos. Trans. 1817, page 252.) 
 let them weigh all the circumstances, and then say whether such 
 men as Beclard and M. F. Meckel ought to modify their opinions 
 upon suoh a case. 
 
 488. The experiments of R. de Graaf and Nuck, repeated by 
 Duverney, Haighton and Cruikshank, if they are accurate, have long 
 since demonstrated that the product of fecundation in animals is a 
 vesicle, and that this vesicle takes up some days at least to pass 
 from the ovary to the womb. It is true we are ignorant whether
 
 190 THE FCETUS. 
 
 the time that elapses between the vivification of the germ and its 
 arrival in the womb is always the same in the same animal, or 
 whether there is any fixed and certain time for the different species ; 
 but it appears that this term is three days in rabbits, and according 
 to MM. Prevost and Dumas, who have lately made numerous re- 
 searches on the subject, that it is from six to seven days in the 
 bitch. 
 
 489. Strato, as Macrobius informs us, supposed that the fetus 
 does not begin to assume the human form until about the thirty- 
 fifth day, when it is as large as a bee. Aristotle teaches that at 
 forty days the embryo is of the size of a large ant ; and that we 
 can distinguish its limbs and all its parts, even the penis, if it be a 
 male. It has been stated by others, but less correctly, that from the 
 fifteenth to the twentieth day the embryo is vermiform, oblong, or 
 tumid in the middle. M. Orfila, in speaking of the primitive 
 state of the foetus, is very wide of. the truth. The same may 
 be said of M. Meckel when he asserts " that the part that first ap- 
 pears corresponds almost exclusively to the trunk ; that we only re- 
 mark at its upper part a small projection, separated from the rest by 
 a notch, and whose thickness is not near equal to that of the mid- 
 dle portion of the body ; that the embryo is almost entirely strait, 
 &c." Ph. Beclard by reproducing the ideas of the celebrated 
 German anatomist, has fallen into the same mistake ; nor has M. 
 Adelon been more fortunate in admitting that the embryo exhibits 
 no traces of a head at three weeks, and that the belly appears un- 
 der the form of a conical projection resting on the inner membrane 
 of the ovum. Nor do I understand why Madame Boivin affirms 
 that " at the tenth day, the embryo is merely a greyish semi-trans- 
 parent flake, easily liquefied, and of a form difficult to determine." 
 It is also certain, that when comparing it to a lettuce seed, or 
 grain of barley, as Burton did, or even to the malleus of the ear, 
 like Baudelocque, they could have had before them only preterna- 
 tural specimens. 
 
 . I. Of the embryo in gltieral. 
 
 Previously to the end of the first week, there is a striking resem- 
 blance between the human embryo and that of some of the serpents, 
 putting aside the proportional length. It is a curved body, form- 
 ing nearly a complete circle, which in this state may be two or 
 iliicc. lines in diameter, but which if straight would be at least four 
 or five. It may bo compared to some of the animalcules figured 
 by MM. Prevoat and Dumas, particularly to the animalcule of the 
 dog ; that is to say, one of its extremities is bulbous and rounded, 

 
 EMBRYO. 191 
 
 and the other terminates in a point : which gave rise to a belief in 
 the existence of a primitive tail in the human species. Being hol- 
 low and semi-transparent, this stock seems to be filled with a limpid 
 fluid, in the centre of which may be seen, even with the naked eye, 
 an opaque filament, of a white or yellowish tint, which represents the 
 cerebro-spinal system. 
 
 490. Numerous observations made on very young embryos seem 
 to me to prove : that the rachis is the fundamental part of the body ; 
 that it appears previously to any of the other organs ; that for a 
 considerable time it exists alone ; that its form does not essentially 
 differ from that which it possesses during the remainder of its intra- 
 uterine life ; that for twenty days, or a little longer, the embryo is 
 neither straight nor enlarged in the middle ; that the head and neck 
 constitute at least one half of its total length ; that the younger it 
 is the more does its curve approach to the form of a circle ; that 
 the appearances of its external circumference differ very little at 
 first from what they are at a subsequent period, while its interior con- 
 tour or concavity merits the most serious attention, on account of 
 the changes it must undergo. 
 
 491. In fact, the organs appear in succession upon this concave 
 surface ; at first the different parts of the face, then the Jimbs, and 
 between these latter the thoracic and abdominal viscera. Nothing is 
 so admirable as this development ; it might be called a real vegeta- 
 tion ; the lower jaw, the members, the mass that is to occupy the 
 abdomen and the breast, increase and come forwards, like buds 
 springing from the branch of a tree, or axile of a plant. 
 
 The spinal circle thus fills up by degrees ; the forehead becomes 
 farther removed from the coccyx ; the thoracic and abdominal por- 
 tions of the original stock are forced to become straighter ; the 
 head remains constantly inclined upon the breast, but in such a way, 
 however, that the chin at last takes the situation previously oc- 
 cupied by the forehead. The coccyx does not retire backwards 
 until a very late period ; it is moved in that direction by an ex- 
 tremely simple mechanism ; to wit, the development of the pelvis 
 and lower extremities. 
 
 492. From seeing that the lateral' and anterior portions of the 
 body do not become manifest for a considerable length of time af- 
 ter the vertebral frame, I have more than once been tempted to be- 
 lieve, with MM. Tiedemann and Meckel, Serres and Geoffroy St 
 Hilaire, that the organic evolution really takes place from the sides 
 towards the median line, and with M. Richerand, to say that the 
 embryo is at first only a groove, the edges of which vegetating 
 from behind forwards, can only unite by a species of suture upon
 
 192 
 
 THE FOETUS. 
 
 the anterior median line. But attentive and frequently repeated ob- 
 servation compelled me to abandon this hypothesis ; in the median 
 line of the face and neck I never could discover any void ; I have 
 found it to be as completely closed at the twentieth as at the six- 
 tieth day ; nor have I even seen the thoracic organs entirely expos- 
 ed, although the mass from which they grow seems to be covered, 
 as far as the belly is concerned, only with a very delicate tissue ; the 
 parietes of the chest nevertheless exhibit their natural appearances 
 as soon as they can be discovered. 
 
 . II. Of the head, and organs of the senses. 
 
 At the beginning the head resembles a very long club ; its subse- 
 quent growth is proportioned to that of the rachis ; but the appear- 
 ance of the abdomen and thorax soon occasion it to lose a portion 
 of its apparently enormous size. As neither the face nor chest 
 exist at first, there is in fact no neck at the commencement of 
 embryo life. At five weeks the face is very distinct from the cra- 
 nium, and the head, quite isolated, no longer resembles a mere pyri- 
 form enlargement ; and its cranial portion also permits us, most 
 commonly, to discern in the vesicle which it constitutes, the general 
 arrangement of the encephalon. Its facial portion is already quite 
 opaque. 
 
 493. The mouth. The mouth is the first organ of the senses that 
 can be perceived : I have found it in the youngest embryos that have 
 fallen under my notice ; consequently, it exists at the twentieth day, 
 and then forms a very large, elliptical or triangular opening ; as the 
 upper jaw is very projecting, while the lower one, on the contrary, 
 is very short, it follows that the mouth of a human embryo bears a 
 striking resemblance to that of a young snake. Anatomists have 
 never altered the ideas they had formed as to the manner in which 
 the lower lip is constituted ; they have all supposed that it was pri- 
 mitively composed of two lateral portions, which at length united at 
 a middle line, like the two bony pieces which support it ; but it is 
 not so with the upper lip. As long as it was thought that the upper 
 jaw consisted only of two pieces, it was supposed that the corres- 
 ponding lip must be also formed of only two pieces. But since an 
 intermaxillary bone has been discovered in the human skeleton, it is 
 generally agreed that the lip is formed of three portions, one middle 
 tubercle and two lateral parts, which by tlicir union give birth to 
 the two columns, or naso-labial ridges. This is the theory upon 
 which modern writers account for the formation of simple or double 
 hare-lip, which, according to them, should never be met with exactly 
 in the middle of the lip ; finally, still improving upon these divisions, 
 which are already too numerous, it has recently been asserted that
 
 THE FCETUS. 193 
 
 the upper lip is developed from four separate points. I think I may 
 venture to affirm, that such ideas could only have arisen from obser- 
 vations not attentively made, or too rarely repeated. In the course 
 of the period I am now examining, the lower lip begins to be per- 
 ceptible ; the chin causes the middle of it to project forwards ; but 
 its loose edge, which is pretty thin, is not interrupted by any slit, 
 and represents a very regular semicircle ; it is longer, and has a 
 deeper curve than the other ; but in embryos of six weeks, and in 
 some a little above twenty days.nld, i have found the edges of both 
 lips perfectly formed, and without any division whatever. 
 
 494. The nose. It is incorrect to say that the organ of smell 
 cannot be recognized until towards the sixth or eighth week. At 
 thirty days it is often in our power to distinguish its anterior open- 
 ings, which are round, situated immediately above the mouth, 
 look directly forwards, and resemble two blackish spots. However, 
 neither the nasal protuberance properly so called, nor the naso- 
 palatine vault exist as yet. It is true, nevertheless, that, in several 
 embryos of from five to seven weeks, the orifices of the nose were 
 not very evident to me, while a very decided eminence already 
 occupied its place. 
 
 495. The eyes. The organs of vision appear at the same time 
 with the mouth, if not earlier. I have distinguished them in em- 
 bryos not exceeding four lines in length, and they are never sought 
 for in vain in the course of the fourth week. At this period its 
 structure is surprisingly simple, if compared to what it must become 
 at a later period. Without lids, canthi, or lacrymal apparatus, re- 
 sembling a circular disc half a line in diameter, and slightly convex, 
 the visual bulb is separated from the surface only by a slight, super- 
 ficial, and very flarrow groove, which can only be found by searching 
 for it with a needle. Two spots seem to constitute it entirely : one 
 of a yellowish white composes the centre ; the other, of a black 
 colour, exhibits the appearance of a circle, on the one hand en- 
 closing the former, and on the other continuous with the integuments. 
 The central spot is at first much larger than the black circle that 
 surrounds it, but in general the latter seems to me to exceed the 
 former in size towards the end of the sixth week. The whole in- 
 dubitably represents the sclerotica, and the transparent cornea, 
 which is still completely opaque, and seems not to differ from the 
 nails, except in regard to colour. It might in fact be called a por- 
 tion of skin or epidermis that becomes modified according to the 
 wants of the system. Far from being directed in front during this 
 period, the eyes are, on the contrary, turned very much to the sides 
 of the head, as is the case in a majority of quadrupeds. I have no 
 
 Z
 
 194 1'HE F(ETUS. 
 
 need to say that they are neither separated nor surrounded by any 
 projecting portion of the face, for the orbitar arches and root of the 
 nose are not as yet apparent. 
 
 496. The ears. The ear also appears very early ; it is distin- 
 guishable on the thirtieth day at the latest, and undergoes no re- 
 markable changes until the sixth or seventh week ; at first it looks 
 like the simple orifice of a cutaneous follicle, or a shallow and nar- 
 row pyramidal depression ; some days later it might be mistaken at 
 a first glance for a leech bite, excenting that it has four angles in- 
 stead of only three. There is no trace nor rudiment of the auricula ; 
 its opening is on a level with the skin, and like the eye, the or- 
 gan of hearing appears to be only a modification of a point on 
 the tegumentary surface ; from the fifth to the sixth week the inner 
 angles of this crucial or rhomboidal depression begin to rise above 
 the level of the skin ; the tragus appears first, then the anti-tragus, 
 and after that the rest of the concha. All these parts grow by a 
 sort of excentric vegetation ; and it is some time before they incline 
 towards the head, and dispose themselves in regular order. 
 
 . HI. Of the members, and lower parts of the trunk. 
 
 I have in vain endeavoured to learn which of the members ap- 
 pears first. Whenever I have been able to distinguish the thoracic 
 appendages, the pelvic extremities were equally visible. Neither 
 have I found in their dimensions such great disproportions as are 
 mentioned by authors : at first there is only a small interval be- 
 twixt them ; the former emerge from the anterior part of the lateral 
 bands of the spinal trunk, at about an equal distance from the 
 top of the head and the point of the coccyx, supposing the embryo 
 to be straightened out ; the latter are seen about one line above the 
 coccyx, which is curved from behind forwards, and concealed as it 
 were in the space between them. 
 
 As long as none of the abdominal or thoracic organs are yet de- 
 veloped, they are not so near to the convex as to the concave sur- 
 face of the spinal circle ; but the roots of them seem to be farther 
 backwards, as we pass farther and farther beyond the fourth week. 
 
 The hand is seen first in the shape of a sort of pallet with a loose 
 and thin but undivided edge ; the foot does not sensibly diller from 
 it ; these two parts have a .slightly concave surface, which is turned 
 towards the median line ; their edges, which are somewhat inclined 
 towards each other, look chiefly in a forward direction. 
 
 '197. From the thirtieth to the fortieth day the fore-arm and the leg 
 arc visible, and the points of thelii m to emerge. At forty- 
 
 five or fifty days the elbow and arm be-iiii iu detach themselves from
 
 THE FffiTUS. 195 
 
 the breast to which they had been before attached by means of a mem- 
 brane. The heel and knee also become evident ; nevertheless, the 
 thigh appears very short, as well as the arm, which doubtless depends 
 upon its not being as yet completely detached from the sides of the ab- 
 domen. All the fingers are very distinct, and the gelatinous substance 
 which unites their base no longer extends as far as their ends ; the 
 foot ceases to resemble the hand ; the toes are arranged differently 
 from the fingers ; in one word, these two organs exhibit nearly the 
 same characteristic appearances they are to have at birth. It is 
 manifest that one is designed for the purpose of standing, and the 
 other to be used for the prehension of objects. This peculiarity alone 
 might serve completely to expose the absurdity of those sophists 
 who have insisted that the primitive mode of walking, in man, was 
 similar to that of brutes. 
 
 498. Coccyx and. genitals. From the foregoing it will have 
 been seen, that during the three first weeks the trunk terminates by 
 a vermiform extremity, and this sort of sacro-coccygeal tail, which 
 is bent very much forward, becomes straighter as its cavity becomes 
 more filled up. I ought here to remark, that its edges soon become 
 continuous with the abdominal mass, or are concealed by the roots 
 of the pelvic extremities. The space between it, the insertion of 
 the umbilical cord and the feet, the extent of which, until the fifth 
 or sixth week, scarcely exceeds a line or a line and a half, retains 
 for a considerable time the appearance of an excavation ; it is sub- 
 sequently filled by the gradual growth of the genito-urinary organs ; 
 and the development or concentric increase of the abdominal pa- 
 rietes and sides of the coccyx and sacrum at last complete it. 
 
 499. Towards the fortieth or forty-fifth day a black point is dis- 
 tinguishable in front of the coccyx, and indicates the situation of the 
 anus ; a little more towards the umbilicus may be seen a conical 
 tubercle, with a groove on its inferior part, constituting the rudi- 
 ment of the clitoris, or penis, according to the sex of the foetus. A 
 slit which is of sometimes greater and sometimes less breadth and 
 depth extends from one of these points to the other. In several in- 
 stances, however, I have thought that the intervening space in well 
 formed embryos was smooth ; so that, up to this period, there is 
 nothing to point out the difference between the sexes : we are 
 tempted to suppose that every foetus belongs to the male sex, for 
 there are in fact neither labia nor scrotum, and the sub-pubic pro- 
 longation is alike in all specimens. 
 
 500. The umbilicus. Properly speaking, there is no navel until 
 the thirtieth or fortieth day, and the cord merely proceeds to be 
 lost beneath the visceral mass of the abdomen. However, the
 
 196 THE FffiTUS. 
 
 parietes of the abdomen, gradually increasing towards the omphalo- 
 placental stem, soon afterwards give birth to it. 
 
 501. After the sixth week, or the fiftieth day, the organization of 
 the embryo becomes rapidly perfected. The eyes become more 
 convex ; a very distinct palpebral circle soon afterwards surrounds 
 them ; the two extremes of the vertical diameter of this circle, by 
 gradually approaching each other, soon give it the form of an 
 ellipse, and thenceforth the two angles of the eye are observed to 
 exist. In nine or ten weeks at latest, the edges of the eyelids are 
 in contact, and so closely in some specimens, that several authors 
 have supposed that adhesion had taken place between them. Pre- 
 viously to coming in contact they were thin and sharp ; but their thick- 
 ness now exceeds that of the eyelids themselves ; they completely 
 cover the front of the eye, but are so transparent that its colour 
 may be easily distinguished through them. The central spot before 
 mentioned grows yellow and enlarges ; one is easily convinced that 
 it constitutes the cornea, and that its posterior surface is in contact 
 with a substance of the same colour. The blackish circle is also 
 enlarged, and being extended farther backwards, is found to belong 
 to the sclerotica, and that its tint depends upon the substance that 
 lines it internally. 
 
 502. The nose, particularly, undergoes remarkable alterations : 
 the protuberance which it forms above the lip, increasing by degrees, 
 forces its anterior opening to incline gradually downwards. Its in- 
 ternal surface, which until the fifth week composes a part of the 
 buccal cavity, begins in the course of the sixth to be separated from it. 
 
 503. The mouth does not undergo any essential change ; its 
 depth increases ; the tongue grows larger and thinner ; the lower 
 jaw projects more, which renders the anterior cervical notch more 
 manifest ; the lips are more distinct, more isolated, but their form 
 is the same. 
 
 504. The external ear, reduced to the appearance of a leech 
 bite, in an embryo of four or five weeks, soon acquires its proper 
 characters, Every part of its concha is unfolded. After the tragus 
 and anti-tragus, we observe the slit of the helix to appear, and con- 
 sequently the concha. The lobule soon manifests itself as well as 
 the rest of the helix, witli which it is continuous ; and lastly, the 
 anti-helix itself is visible as early as the seventieth day. Although 
 all these purls are formed behind the mcatus auditorius, the ear 
 nevertheless seems to extend forwards during this whole period, 
 and to approach much nearer to the angles of the mouth and 
 
 505. The members very early reach the form of their perfect
 
 THE FOETUS. 197 
 
 state ; in eight or nine weeks the fingers are all separate, or only 
 adhere to each other by a transparent gelatinous substance ; their 
 three phalanges are distinguishable, and tend already to bend to- 
 wards the palmar surface of the hand ; the last phalanx exhibits upon 
 its dorsal surface a spot which must be considered as the rudiment 
 of the nail ; certain opaque lines indicate the situations to be occu- 
 pied by the bones of the metacarpus. The proportional length of 
 the arm and thigh, as respects the fore-arm and leg, is no longer ex- 
 traordinary. The germ of the shoulder and hip can not be over- 
 looked. 
 
 506. The coccygeal point is more completely concealed by the 
 pelvic members, and projects less than it does a fortnight later. 
 The anus ceases to exhibit the appearance of a blackish depressed 
 spot ; at sixty days it forms a small conical projection, not perforat- 
 ed, and of a more or less intense yellow colour. The genital tu- 
 bercle continues to increase in length, and its base is surrounded by 
 a very thick cushion ; at some distance from its extremity is seen a 
 circular groove, which corresponds to the corona of the glans. 
 The channel along its inferior surface is in a great many embryos 
 entirely shut, but in some it is still prolonged in the form of a slit 
 to within one line of the anal tubercle. The development of the 
 perineum, of the pelvis, and hypogastrium, occasions the cord, 
 which in the first period appeared to be inserted betwixt the roots 
 of the inferior extremities very near the coccyx, to remove to a 
 considerable distance from those parts, as it approaches nearer to 
 the centre of the abdominal protuberance. The circle of the um- 
 bilicus at last unites so intimately with the cord which passes 
 through it, that there is no longer any line of demarcation between 
 the teguments of the one and the membranous sheath of the other. 
 Then, if as until birth, the size of the belly appears to be enormous, 
 it must be attributed in part to the circumstance that the organs con- 
 tained in the pelvis on the one hand, and in the thorax on the other, 
 do not attain their perfect development until a very late period. 
 
 507. Dimensions of the foetus at different stages of pregnancy. 
 As the embryo is curved forwards while it remains loose in the 
 centre of the ovum, it seems to me that it ought always to be placed in 
 this situation when we go about to measure its length. How can we 
 otherwise obtain determinate results ? If, during the first six weeks, 
 we should attempt to straighten it out for the purpose of measuring 
 the distance from the vertex to the os coccygis, the front of the neck 
 and the abdomen would rarely fail to be lacerated ; at two months 
 the firmness of the parts mostly enables us to avoid such an accident,
 
 198 THE FOETUS. 
 
 but as the foetus may be either more or less straight, there will arise 
 numerous discrepancies in the results. The habitually flexed state 
 of the lower extremities renders it too difficult to extend them so as 
 to comprise their length in a rigorous admeasurement of the embryo. 
 Authors not having informed us which of these methods they 
 adopted, it is useless to look further for the reasons of the discre- 
 pancy observable in their accounts of this subject. It is true that 
 the most minute precautions will not permit us to specify, within one 
 line, the length of a foetus more than a month old ; but happily, such 
 a degree of precision can be a matter of small moment in the eyes 
 of the observer. In the present instance, the measurements that I 
 shall point out must in general be understood as applying to the 
 foetus in its naturally curved position, that is, the space extending 
 from the occiput to the coccyx ; and I believe this diameter never 
 exceeds eighteen or twenty lines before the end of the second month. 
 
 508. The skin of the human embryo has no real existence until 
 at a pretty advanced period of its growth, while the sort of circle 
 which it at first constitutes, is nothing more than a homogeneous 
 gelatinous substance of slight consistency ; the epidermis cannot be 
 distinguished from the skin until after the second month. 
 
 509. At three months the teguments are distinct, but still gelati- 
 nous and of a rose colour. The eye-lids and mouth remain shut ; 
 the nose is very projecting, the head very large ; the costal arches 
 and bones of the fore-arm are visible through the transparent sub- 
 stances in which they are inclosed. The fingers and toes are per- 
 fectly distinct, and covered on the dorsal surface of their extremities 
 with a reddish plate which possesses the shape of the nail ; from the 
 vertex to the coccyx the fcetus is three inches in length. 
 
 510. At four months the skin is much firmer, and at certain 
 points is furnished with adipose granulations. The head begins to 
 be covered with down ; the scrotum, or the greater and lesser labia 
 are formed ; the anus is open ; and if in the measurement we comprise 
 the lower extremities, which, notwithstanding the common opinion 
 to the contrary, arc as long as the thoracic members, the foetus 
 will be from five to six inches in length. 
 
 Ml. At fire, month.'} a little down and some particles of seba- 
 
 rnnttcr are observable upon various portions of the skin; the 
 
 M to grow, but arc still white, or without any determinate 
 
 colour. The teguments are less transparent, although still of a rose 
 
 ir, anrl hut slightly extensible ; the nails arc evident; the umbili- 
 
 ral CDI-.I in n -moved from the penis or clitoris. No pupil can l>^ 
 
 uitl tlifj tu;tus is from six to seven inches long.
 
 THE FOETUS. 199 
 
 512. At six months, the period of viability the down and the 
 sebaceous deposit are visible, at least in the axilla3 and groins. The 
 hairs of the head may be easily distinguished from those that grow 
 upon other parts of the body ; the eyelids are no longer transparent : 
 it has been said that there is at this period no pupil ; but it has ap- 
 peared to me, on the contrary, to be extremely large ; the xiphoid 
 cartilage occupies the middle of the great axis of the fostus, whose 
 whole length is from eight to nine inches. 
 
 513. At seven months the hair is longer, and not so pale, the 
 down and cutaneous induitus more generally diffused ; the skin is 
 less coloured ; the nails are large ; the membrana pupillaris bursts, 
 according to the authors ; but it is by no means certain that this 
 membrane really exists in the manner usually understood : I have 
 reason to think that the iris originates at first as a simple ring, which 
 grows concentrically, so as at last to leave the opening commonly 
 called pupil or apple of the eye. The riavel is still below the middle 
 of the foetus ; the external genital organs are all apparent, except 
 the testicles in the male, and the foetus is about ten inches long. 
 
 514. At eight months the foetus is only distinguished by its greater 
 maturity ; its length is about eleven inches. Its hair is more or less 
 coloured ; its skin, covered with sebaceous matter and down, is thick, 
 and not so smooth as before ; the lower ^aw, which at first was very 
 short, is now almost as long as the upper one, and the nails exhibit 
 a certain degree of consistency. 
 
 515. At term. The development and weight of a well formed 
 foetus, at term, are far from being alike in all cases. The knowledge 
 of them, however, even if approximative, is so important in Jlhe 
 practice of midwifery, that their extremes and average ought to be 
 sought for with great care. At this period, the length of the occipito- 
 coccygeal diameter is twelve inches, but the average length of a 
 foetus straightened out, and taken from the heel to the vertex, is 
 eighteen inches, according to the very multiplied experiments of 
 professor Chaussier ; seventeen, sixteen, nineteen, twenty, and even 
 twenty-two inches, are also pretty common measurements, but it is 
 rare to meet with only twelve inches, or to find twenty-three. The 
 instances of children twenty-six, twenty- eight, thirty, and even thirty- 
 six inches in length, or of only ten, eight, or even six inches, which 
 we find in old scientific collections, instances which the common 
 people always receive with cordiality, may be boldly classed among 
 other popular stories. 
 
 516. The weight of a fetus is generally six pounds, frequently 
 six and a half or seven, sometimes eight, and rarely nine or ten
 
 200 THE FffiTUS. 
 
 pounds. Among four thousand children, born at the Maternite at 
 Paris in a given time, Madame Lachapelle never met with one 
 weighing as much as twelve pounds. Baudelocque, who had a case 
 where the child weighed twelve pounds and three quarters, main- 
 tains that it is incredible that a larger one was ever seen ; the weight 
 of the child also, according to Chaussier, is frequently only five, 
 four, and sometimes three, or two and a half pounds; but in the 
 latter instances, it seems to me evident that pregnancy had not 
 reached its full term. 
 
 517. Out of the profession, we daily hear of children weighing 
 fifteen, eighteen, twenty, twenty-five, and even thirty pounds at birth : 
 those stories too, which may be found in many authors of the six- 
 teenth, seventeenth, and even of the eighteenth century, are owing 
 to the fact, that persons who will not take the trouble to weigh such 
 children, very easily attribute a weight of twelve or fifteen pounds to 
 children that actually weigh only seven or eight. In fact, a new 
 born child of eight or nine pounds is enormous ; the persons sur- 
 rounding the lying-in woman, when they see such an one, rarely fail 
 to cry out that it is a child of twelve or fifteen pounds ; and it is 
 very likely that, in order to render the fact still more curious, four or 
 five pounds will be added to its weight after the fifth or sixth repe- 
 tition of the story. In order to reduce such fables, which are founded 
 upon gross errors of observation, to their real value, it is only neces- 
 sary to reflect that thirty pounds is the weight of children of from 
 two to three years of age. 
 
 518. If the absolute length of the fetus is subject to such great 
 varieties, it is easy to conceive that the relative length of different 
 parts of it cannot be more precise and determinate. Nevertheless, 
 we are sometimes obliged in medical jurisprudence to have recourse 
 to it in order to determine the age of a given foetus. According to 
 Chaussier, taking eighteen inches as a mean term, there are ten 
 inches and four lines from the vertex to the navel, and seven inches 
 eight lines from the navel to the sole of the foot ; eleven inches nine 
 lines from the pubis to the vertex ; six inches three lines from the 
 pubis to the sole of the foot ; two inches three lines from the clavicle 
 to the lower end of the sternum, and six inches from the extremity 
 of the sternum to the pubis. From the top of one acromion to the 
 other we find four inches and a half, which may be easily reduced 
 to three inches and a half by squeezing the shoulders together. 
 Tlic greatest antero-posterior thickness of the thorax is four inches 
 and a half, while there arc only three inches from one crista of the 
 ilium to the other.
 
 THE FCETUS. 201 
 
 . IV. Of the foetal head, at term. 
 
 519. The head, being of all parts of the foetus the largest and 
 most incompressible, ought to be studied with the most particular 
 care. The bones of which it is composed, its articulations, its 
 diameters, its motions, and the degree of reduction it is susceptible 
 of, ought to be perfectly known to the practitioner who desires not 
 to be more dangerous than useful in applying the assistance of the 
 art to cases of dystocia. It is composed, as in the adult, of the 
 cranium, which is its most interesting part, and of the face, which is 
 as yet but little developed, and whose pieces consist of the ossanasi, 
 the ossa malarura, the ossa maxillaria superiora, the ossa unguis, 
 the ossa palati, the ossa spongiosa inferiora, the vomer, and the os 
 maxillare inferior. 
 
 520. Form. The head of the foetus, chiefly remarkable from the 
 flexibility of its vault, exhibits in its ensemble the form of an oval, the 
 attitude of which has occasioned a sort of literary quarrel between 
 MM. Capuron and Van Solingen : the former of these authors 
 insists that the large extremity of the head is turned backwards, 
 while the latter, who is also followed by M. Duges, places it, on 
 the contrary, in front. If the external occipital protuberance occu- 
 pies the centre of the strait in labour, it is difficult not to agree with 
 the Dutch accoucheur, that the large extremity of the oval is repre- 
 sented by the face; but when we take hold of the head by the chin, 
 its large extremity is undoubtedly to be found posteriorly, in this 
 case, as in many others, the dispute is rather about words than things ; 
 both sides are right, and both are wrong in some respects. How- 
 ever, by reflecting that all the diameters of the posterior part of the 
 head are three inches and a half in length, while the longest of 
 those of the face is only three inches at most, it will be evident that 
 we ought to adopt the opinion of our countryman, and say that the 
 large extremity of the fcctal head is formed by the occiput. 
 
 521. Diameters. The axes or diameters of the head are imagi- 
 nary lines, which pass through it in determinate directions. They 
 may be multiplied ad infinitum ; but those only that are liable to be 
 placed in certain relations to the axes or diameters of the pelvis, de- 
 serve our attention. I think that it is sufficient to describe seven : 
 1. The octipito-mental, five inches in length, extending from the 
 most projecting part of the occiput to the point of the chin, also 
 called the great or oblique diameter, and which M. Flamant de- 
 nominates the sur-occipito-mcntal ; 2. The occipito-J rental, about 
 four inches long, which extends from the occipital protuberance 
 to the forehead, and which is also called the straight or antero- 
 posterior diameter , 3. The bi-parietal. or transverse diameter, 
 
 2 A
 
 202 THE 
 
 reaching from one parietal protuberance to the other, and which 
 is three inches and a half; 4. The bi-temporal, or smallest diameter, 
 measured from the root of one zygomatic apophysis to the opposite 
 one, and whose length is two inches and a half; 5. The vertical or 
 trachelo-bregmatic, which passes through the head perpendicularly, 
 descending from the vertex to the anterior part of the occipital fo- 
 ramen, and is about three inches and a half; 6. Thefronto-mental, 
 or facial, whose name sufficiently indicates its situation, and whose 
 extent is three inches ; 7. Finally, the occipito-bregmatic, the most 
 important of all, whose posterior extremity is situated between the 
 occipital protuberance and foramen magnum, and proceeds to ter- 
 minate at the anterior fontanelle ; its length is nearly three inches 
 and three quarters. 
 
 522. Circumferences. These various diameters are accompanied 
 with an equal number of circumferences, which should receive the 
 same names, and whose lengths are equally various : 1 . The occipito- 
 mental or great circumference, which divides the head into two late- 
 ral halves exactly similar to each other, passes at the same time over 
 both extremities of the occipito-mental diameter, and which, when 
 multiplied by three, equals the length of the circumference, and also 
 over those of the fronto-mental, occipito-frontal, vertical, and occipito- 
 bregmatic ; 2. The facial circumference, which passes over the 
 forehead, the chin, and the cheeks ; 3. The circumference of the 
 vertical diameter, which passes a little in front of the parietal pro- 
 tuberances, and thus divides the head transversely ; 4. That of the 
 occipito-frontal diameter, which at the same time embraces the ex- 
 tremes of the transverse diameter, and separates, horizontally, the 
 vault from the base of the cranium ; 5. That of the occipito-breg- 
 matic axis, which is also the special circumference of the bi-parietal 
 diameter, and the most important of all, for in all natural labours it 
 is found in relation with the circle of the pelvic straits ; 6. Finally, 
 the circumference of the bi-tcmporal or smallest diameter should 
 pass also over both ends of the vertical or occipito-bregmatic ; its 
 existence ought not to be admitted except in the greatest possible 
 degree of reduction of the head ; a knowledge of it then becomes of 
 the highest practical interest, for by comparing its line of tension, 
 that is to say, its bi-temporal axis with the vitiated diameters of the 
 l>< Ivis through which the child has to pass, we can ascertain whe- 
 Iclivcry be practicable or not. 
 
 \'nri<tifx. It is not necessary for me to observe that these 
 
 'I<1 be taken merely as mean torms, and that there 
 
 H no more uniformity in the si/.e of the fuital head than in the other 
 
 parts of the body ; but J ought not to fail to remark, that they arc
 
 THE FffiTUS. 203 
 
 susceptible of various degrees of reduction or elongation, whether 
 by means merely of the uterine contractions, or by the mechanical 
 action of the instruments that are sometimes employed in midwifery. 
 Thus the occipito-frontal diameter, when compressed at its extre- 
 mities, may be shortened several lines, by the over-riding of the 
 corresponding edges of the frontal, parietal, and occipital bones. 
 The same is true of the transverse and occipito-bregmatic axes, 
 whenever the pressure bears chiefly on the two opposite points of 
 their circumference ; but in order to form a clear idea of the changes 
 that the head may undergo in this regard, it is indispensably neces- 
 sary to obtain correct notions as to the arrangement of the bones of 
 the head at birth. 
 
 524 Bones of the skull. In the foetus at term, the eight bones 
 of the skull, the frontal, occipital, the two parietal, the two tem- 
 poral, the sphenoid, and ethmoid bones are far from possessing the 
 same firmness as those of the adult ; those of the vault are still quite 
 flexible, and separated from each other by membranous spaces of 
 greater or less size ; the frontal is formed of two symmetrical pieces ; 
 the thin or flattened portion of the occipital and the squamous portion 
 of the temporal are pretty frequently separate from the petrous and 
 condyloid portions respectively ; the basilar apophysis, the body of 
 the sphenoid, the petrous portion of the temporal, and the several 
 pieces which constitute the base of the cranium, are on the contrary 
 almost completely ossified, or at least form with the cartilages which 
 unite them an incompressible mass. 
 
 525. From the above arrangement it follows, 1 . That the diame- 
 ters of the vault of the cranium alone are reducible in labour ; 
 2. That whenever the diameters of the pelvis are smaller than those 
 of the base of the fetal skull, delivery is physically impossible without 
 the aid of art ; 3. That in this way the medulla oblongata, the 
 pons varolii, the tubercula quadrigemina, and the peduncles of the 
 cerebrum and cerebellum, are completely protected, while the cere- 
 bral and cerebellar lobes, which are almost unconnected with the 
 maintenance of the vegetative life of the fcetus, are alone liable to 
 be slightly compressed. 
 
 The numberless varieties of which the dimensions of the head are 
 susceptible has long since convinced accoucheurs of the necessity 
 of discovering some means by which to ascertain what they are in 
 the fetus while still contained within the maternal organs ; but it must 
 be confessed, notwithstanding M. Flamant's opinion, that all attempts 
 of the sort have been hitherto fruitless. But while I release the 
 reader from a tedious description or even enumeration of all the 
 different methods that have been proposed at various periods, it
 
 204 THE FCETUS. 
 
 seems indispensably necessary for me to. say a few words on the 
 researches of one of my former fellow students upon this subject. 
 
 526. Mensuration. By measuring a certain number of dried 
 heads, M. Fouilhoux ascertained, 1. That a line drawn from the 
 fronto-nasal suture to the edge of the upper alveoles, represents, 
 very nearly, one half of another line, drawn from the superior angle 
 to the great foramen of the occipital bone ; 2. That the space be- 
 tween the fronto-nasal and fro n to- parietal sutures is equal to that 
 which extends from the posterior edge of the coronal, and the point 
 of the occipital ; 3. That by adding five or six lines to the occipital 
 arch we obtain the length of the sagittal suture ; 4. That the bi- 
 parietal diameter is six lines longer than the sagittal suture; 
 5. That the facial line multiplied by three also gives the length of 
 the transverse diameter; 6. That the occipito-frontal diameter 
 exceeds the bi-parictal by nine lines. So that if we can succeed 
 during labour in measuring, with any degree of precision, either the 
 fronto-maxillary line, or the naso-parietal arch, or the occipital arch, 
 or lastly, the sagittal suture, it is afterwards easy to determine the 
 antero-posterior and transverse diameters of the cranium. 
 
 527. The assertions of M. Fouilhoux, subjected to pretty nume- 
 rous experimental tests, have appeared to me to be, in general, 
 correct; but I have also found that the proportional differences 
 which he endeavours to establish are too variable to admit of their 
 being very usefully employed in practice. Even were they to prove 
 constantly and rigorously correct, how shall we ever be able to dis- 
 tinguish through the soft parts, and within the maternal organs, the 
 precise length of the occipital arch, or the frontal arch, or even the 
 facial line? The thing appears to me to be impossible. 
 
 528. The sutures of the fcctal cranium are more numerous, more 
 movable, and wider than those of the adult. As they, together 
 with the fontanrls, serve to mark the positions of the head, it is 
 very important for the accoucheur to have them always present to 
 his memory. 
 
 The sagittal, straight, or antero-posterior suture extends from 
 the root of the nose to the superior angle of the occipital bone, and 
 may be divided into two portions, the naso-parietal, which unites 
 (In- I wo pieces of the frontal bone, and the parietal portion, which 
 -led by the conjunction of the two parietal bones at their supe- 
 rior edges. The fronto-parictal, coronal, transverse or anterior 
 uiun: crosses llic one above mentioned at right angles, at the place 
 ; :lves unite. The occipito-parktal, lambdoidal, pos- 
 "il uiun: Poems to be only a bifurcation of the 
 il: as the .s<|uainous, or temporo-parietal sutures arc con.
 
 THE FOETUS. 205 
 
 cealccl under a thick layer of soft parts, they hardly deserve to be 
 mentioned in a work on midwifery. 
 
 529. The lambdoidal suture, so called from its resemblance to 
 the Greek A is perhaps the most frequent cause of error, as it may 
 be mistook for the fronto-parietal. It differs from it, however, be- 
 cause its two branches, which are oblique to each other and to the 
 sagittal suture, really form two distinct and independent sutures, 
 while the two moieties of the anterior suture are only continuations 
 of each other, and constitute but one and the same line. 
 
 530. There are usually found at the points where these sutures 
 cross or terminate, certain membranous spaces called fontanels or 
 fountains of the brain. 
 
 The anterior or frontal fontanel, which is sometimes called the 
 bregmatic fontanel, because it in fact answers to the bregma, forms 
 the common point of union of four bony angles, viz. the superior angles 
 of the two portions of the frontal bones, and the two antero-su- 
 perior angles of the parietal bones ; it is larger or smaller accord- 
 ingly as these angles are sharper or rounder ; it is of a lozenge 
 shape, and generally extends much farther between the two portions 
 of the coronal than of the parietal bones. 
 
 The posterior, or occipital fontanel, which forms a part of the 
 summit of the head, is situated at the spot where the sagittal loses 
 itself in the lambdoidal suture ; it is always very narrow, and in 
 some subjects scarcely distinguishable ; its triangular shape pre- 
 vents it from being mistaken for the one before mentioned ; but as 
 a middle suture sometimes divides the occipital bone into two 
 pieces, and as the superior angle of this bone is sometimes wanting, 
 it must be remembered that only three branches issue from this fon- 
 tanel, or if there should be four, the two lateral branches proceed 
 obliquely towards the mastoid processes, and do not cross the other 
 at right angles, as is the case at the anterior fontanel. This is the 
 most important fontanel, since it indicates the presence of the sum- 
 mit of the head. 
 
 The inferior or lateral fontanels, four in number, two on each 
 side, are found at the points of termination of the anterior and pos- 
 terior sutures, and are of no use in the practice of midwifery. 
 
 531. The head is further divided into five regions or ovals: one 
 superior, in which is to be observed, the summit behind, the bregma 
 and sinciput in front, the vertex in the middle, and which is bound- 
 ed below by the occipito-frontal circumference ; another, inferior, 
 which is represented by the base of the cranium and posterior part 
 of the face ; a third, anterior or facial, which is enclosed in the 
 fronto-mental circumference ; the two last, lateral or temporal,
 
 206 THE FOETUS. 
 
 which comprise whatever is left out by the other, and whose dimen- 
 sions have reference, in labour, to those of the occipito-mental 
 diameter, which renders presentations of them highly disadvanta- 
 geous. 
 
 532. The articulation of the head with the vertebral column 
 merits the most serious attention ; for want of a careful study of it 
 a vast number of accoucheurs and midwives bring children still born 
 into the world, who, a few minutes before, were strong and full of 
 vigour. 
 
 The union of the atlas with the occipital bone is a very close ar- 
 ticulation, which scarcely admits of any motion except flexion and 
 extension ; that of the atlas with the axis is a rotatory ginglymus, 
 so arranged, that if the pivot motion of the head is carried beyond 
 a quarter of a circle, the articular surfaces immediately separate, 
 and the spinal marrow is at the same moment compressed, torn, or 
 even entirely broken off; so that, if the chin of the foetus turns so 
 far as to pass behind the point of the shoulder, death ensues im- 
 mediately. On the other hand, it is in the occipito-vertebral articu- 
 lation that we find the cause of the so frequent presentations of the 
 vertex rather than the face. In fact, when seen in an antero-pos- 
 terior direction, the head resting on the top of the spine represents 
 a lever of the third kind ; during the efforts of parturition, the power 
 being evidently represented by the vertebral column, the points of 
 rest and of resistance must necessarily be met with at the extremi- 
 ties of the occipito-mental diameter. Now, if the occiput almost 
 always descends first, while the chin descends but very rarely, it 
 depends upon the more advantageous action of the power upon the 
 occipital than upon the opposite extremity of this lever, the condyles 
 being nearer the former than the latter of these points. 
 
 . V. Of the attitude, and position of the foetus during preg- 
 nancy. 
 
 533. During the whole course of pregnancy the foetus is bent 
 forwards, so as to form a kind of circle, more or less complete ; at 
 full term it is found with the head bent forwards on the breast, the 
 feet turned up to the front part of the legs, the legs against the hind 
 part of the thighs, the thighs on the anterior surface of the abdo- 
 men, the heels crossed and very near the ischia, the arms applied 
 to tin- sides of the thorax, the fore-arms bent, and crossed in front 
 of tin; sternum, as if to support the chin betwixt the two hands. 
 It therefore forms an oval mass whose large end is represented by 
 the pelvic extremity of the trunk, and its apex by the cephalic ex- 
 inmity. In this state its great or occipito-coccygcal diameter is
 
 THE FCETUS. 207 
 
 only ten or twelve inches in length, and may even be shortened one 
 or two inches by pressure exerted upon its two extremities. 
 
 534. It may be affirmed, in general, that the laws of gravity de- 
 termine the position of the fcetus, until the last stage of gestation ; 
 suspended in the centre of the ovum by means of the umbilical 
 cord, loose and very movable in the amniotic liquor, it necessarily 
 falls to the lowest point of the cavity in which it is contained : the 
 cord being inserted much nearer to the coccyx than to the occiput, 
 renders it necessary for the cephalic extremity of the foetus to fall 
 to the lowest part of the womb : therefore, since, even when the 
 woman is lying down, the neck is lower than the fundus of the 
 womb, it is clear that the head must naturally be turned towards 
 the superior strait in a great majority of cases, as is proved by daily 
 experience. 
 
 535. However, the ancients entertained a different opinion ; ac- 
 cording to them, the foetus has its head upwards, the pelvic extremity 
 turned towards the margin of the pelvis, and the hinder' part of 
 the breech resting against the sacro-vertebral angle, until about the 
 seventh month ; then, by means of certain quick and somewhat 
 convulsive motions, it turns over, performing a somerset : so that 
 the forehead comes to take the place of the breech, and vice versa. 
 This hypothesis, generally adopted until the time of Baudelocque, 
 and since that period still defended by several authors, principally 
 in Germany, is now abandoned to the vulgar, who also are begin- 
 ning to give it up. 
 
 536. If a pregnant woman dies before the seventh month of ges- 
 tation, the head of the foetus is found turned towards the neck of the 
 uterus, just as it is at the full term. I have opened the bodies of 
 three women who died between the third and sixth months of their 
 pregnancy, and in these three cases the occiput was below. Who 
 has not seen the foetus come head foremost in abortion as at the 
 full period? From October 1823 to the month of April 1826, 
 eight miscarriages of from four to seven months took place under 
 my care at the Hospital de Perfectionnement ; I have observed nearly 
 the same number in my private practice, and at my public lying-in 
 ward : but in all these cases I found the breech presenting in only 
 two instances. Further, it is not uncommon to find the neck suffi- 
 ciently softened before the seventh month to permit the finger to 
 pass in so as to touch the naked ovum in the womb, and we almost 
 always find that the head is downwards. Another reason advanced 
 by the moderns as decisive, but which if taken singly would not ap- 
 pear to me to be very conclusive, is derived from the length of the 
 foetus, compared with the dimensions of the uterine cavity. It has
 
 208 
 
 THE F<ETUS. 
 
 been said, since the foetus after the sixth month is from ten to 
 twelve inches long, it is physically impossible for it to turn after that 
 period in the cavity of the womb, whose transverse and antero- 
 posterior diameters do not exceed six or eight inches : no doubt ; 
 but they forget that the foetus is doubled up in the amnios, and in- 
 stead of twelve, its long diameter is only six or eight inches long ; 
 they also forget, that even at full term the child sometimes changes 
 its position during labour, and that even at the period of its greatest 
 development, the diameter passing from its occiput to the coccyx 
 does not always exceed the length of the horizontal diameter of the 
 womb. 
 
 It is not therefore correct to maintain that the proportional 
 dimensions of the uterus and foetus raise an insurmountable barrier 
 to the somerset motion ; if this transposition has no existence, it is 
 because the relative weight of the head renders it unnecessary. 
 
 . VI. Of superfoetation. 
 
 537. The name of superfcctation is given to the vivification of a 
 germ, in a woman who already contains a fecundated ovule in some 
 part of her generative system. 
 
 The existence and the possibility of this fact, admitted and denied 
 by turns by the physicians of all ages, constitutes a question upon 
 which modern naturalists have not as yet decided. The ancients 
 have handled it so slightly, that it is really useless to oppose them. 
 According to Aristotle, " cases of superfoetation have been seen in 
 women, and twelve foetuses have been seen to come away in a single 
 miscarriage, in this manner. When the two foetuses have been pro- 
 duced soon after each other, they are born as if they had been twins, 
 as the poets tell us of Iphicles and Hercules." The philosopher 
 also cites, as an instance of supcrfoctation, a woman who brought 
 into the world two children, one resembling her husband and the 
 other her lover! 
 
 538. Almost all the casea we have of superfoetation seem to me 
 to be referable, 1 . To twin pregnancies, in which one of the chil- 
 dren, having died long before the full term, has been preserved 
 within the membranes, not to be expelled until the other which con- 
 tinued to live ; 'i. To pregnancies of twins unequally developed, or 
 born at (lillerent periods; 3. To Cases of cxtra-uieriiio pregnancy, 
 which did not interfere with natural gestation ; 4. Lastly, to cases 
 
 of double liter 
 
 mimon <h:ui 1.0 see, in compound prcg- 
 
 y, our of llie I'c lu-e.^ lose its life, and when born exhibit the 
 of from two to bix months, although in fact
 
 SUPERFOETATION. 209 
 
 it is nine months old, and every body knows that most monsters are 
 met with in company with a well formed foetus. 
 
 A lady of la Varenne, near Tours, was brought to bed of a stout 
 boy in 1819 ; with the afterbirth, Mr Mignot, her surgeon, received 
 another foetus enclosed within the same ovum, but without a head, 
 neck or arms. 
 
 A lady of the fauxbourg Saint-Germain was delivered in 1824 of 
 a vigorous and very stout child; Madame Forbet, the midwife, brought 
 me the afterbirth, and at some distance from the umbilical cord I 
 found, supported by a pedicle two inches in length, a fleshy mass, 
 in which were the evident remains of a foetus. In March 1827, 
 M. Baroilhet had the kindness to give me a monstrous, product, 
 which possessed neither head nor members, and which was expelled 
 together with a healthy foetus, &c. 
 
 In 1824, at the Hospital de Perfectionnement, I received at the 
 same time with a full grown foetus, a. dead one, which as to devel- 
 opment had not passed beyond the third month. M. Defermont 
 has shown me a similar instance. In the month of October 1826, 
 Madame Badinier, a midwife, brought me two foetuses, one of which, 
 quite deformed, appeared to be of about two months, and the other of 
 five or six ; they had both escaped from the same ovum, and before 
 the full term. Bauhin speaks of a woman who gave birth on the 
 same day to a foetus at term, and to an embryo as long as the finger, 
 both enclosed in a single envelope. Ruysch saw the wife of a surgeon 
 of Amsterdam delivered, with an interval of two hours, of one child, 
 full of life, and of an embryo which could not have been of more 
 than three months growth, with its cord full of hydatids. Percy 
 speaks of a woman who, after giving birth to a small but lively boy, 
 brought forth, surrounded by a black fungous mass, a female fetus 
 of the fourth month, in a pretty good state of preservation. Lau- 
 rette, says Zacchias, was delivered, eight months after the death of 
 her husband, of a badly formed male child, which never gave any 
 signs of life. One month and one or two days after this she was 
 delivered of a second child, which was in good health, and which 
 lived. 
 
 And the authors conclude that these were cases of superfetation ! 
 
 540, 2d. When two fetuses are contained within the uterus, one 
 may grow more rapidly than the other ; one may be expelled before 
 its full time, and the other not be born till some time afterwards, &.c. 
 
 To this class belongs, if indeed there be not a good many belong- 
 ing to the same category, the case of a lady named Dupuis, at Saint- 
 Germain-en- Laye, who had a miscarriage at four months and a half, 
 and four months after that brought a healthy boy into the world ; 
 2B
 
 210 THE FffiTUS. 
 
 the case which MM. Desgrange and Fodere look upon as decisive, 
 and in which B. Franquet was delivered of a healthy foetus five 
 months and sixteen days after she had miscarried of a seven months' 
 pregnancy ; the case of Madame Bigaud, who on the 30th of April 
 1748 brought forth a living male child, and notwithstanding that,, 
 was delivered on the i?th of the following September of a second 
 fcctus quite as strong and lively ; another communicated by M. 
 Rexain, in which one of the children was born three months after 
 the other ; those of M. Delmas of Rouen, of M. Pignot of Issoudun, 
 of M. Wendt of Breslaw, of Dr Fahrenhost, &c. 
 
 541. The two cases by B. Franquet and Madame Bigaud, the 
 one mentioned in the Recueil de la Societe de Medecine, in which 
 it is stated that a woman at Aries was delivered of a full grown 
 child in 1796, and of another, also at full term, five months after- 
 wards, in 1797; another by Dr Stearns, in which a negro woman 
 was delivered of a black child'in about the eighth month, and a few 
 hours afterwards of a white foetus of about four months, which ex- 
 hibited signs of life, are beyond dispute the most difficult to under- 
 stand. But as it is not impossible that they might at Lyons have 
 supposed a fetus to' be seven months, when in fact it was not more 
 than five months old, while the one last born might have exceeded 
 the ninth month of gestation ; and as they might have made the same 
 mistake at Strasburgh ; and as the signatures of notaries do not con- 
 stitute evidence in such cases, we may be permitted to suspect that 
 some error has crept into these stories. 
 
 542. 3d. When an extra-uterine conception takes place, the womb 
 sometimes swells and becomes filled with concrescible matter, as in 
 an ordinary conception ; in such a case superfoetation appears to be 
 impossible : but if the womb remains in the same state as before 
 fecundation, it is clear that a new conception may take place during 
 the existence of the first gestation.- In support of these assertions, 
 I may refer to an instance of extra-uterine pregnancy which lasted 
 for three years, during which time the woman conceived and brought 
 forth a well formed child ; and another case for which we are in- 
 debted to M. Clict, in which it is said, that in a woman who died 
 suddenly, one fetus was found behind the womb in the excavation 
 of the pelvis, and another in the cavity of the womb itself. 
 
 543. 4th. When the womb is divided into two cavities by a perpen- 
 dicular septum, and these cavities open separately into the vagina, 
 it is evident that two germs may be fecundated at intervals more or 
 lesa remote ; in a word, that superfetation may take place. This 
 IB the way in which the following fact ought to be understood, which 
 has been cited by M. Cassau, and collected by Madame Boivin : a
 
 SUPERFCETATION. 211 
 
 woman forty years of age, was delivered of a little girl on the 1 5th 
 of March 1810; the cavity of the uterus, which was already con- 
 tracted, was examined without any thing being found in it ; and yet, 
 this woman, whose abdomen had remained pretty large, gave birth 
 to another child on the 12th of May of the same year. 
 
 544. We ought also to admit the existence, or at least the possi- 
 bility of another kind of superfcetation. A woman at Charleston 
 gave birth on the same day to twin children, one of which was black 
 and the other white, and accounted for it by stating that after leav- 
 ing the arms of her husband in the morning, one of his negroes, 
 armed with a pistol, came and compelled her to have connexion with 
 him. A negro woman at Guadaloupe brought forth two full sized 
 boys, one a black and the other a mulatto, and confessed she had 
 had connexion on the same evening with a negro and a white man. 
 Another negro woman had three children at a birth ; one black, one 
 white, and the third a cabre. A white servant girl in Montgomery 
 county brought into the world at the same lying-in a white girl 
 and a boy that was -perfectly black. A negro and a white servant 
 both disappeared, upon learning that the girl was pregnant. Accord- 
 ing to M. Gardien, M. Valentin has related a case similar to the 
 one above. A mare foaled a colt and a' young mule at an interval 
 of a quarter of an hour ; she had been covered by a horse, and five 
 days' after that by an ass. 
 
 545. Granting all possible authenticity to these observations, and 
 supposing their correctness to be demonstrated, the ideas of physio- 
 logists that prevail at the present day admit of their easy explana- 
 tion. Two ovules may become impregnated, one after the other, in 
 a woman who grants her favours to two or more men on the same 
 day or in the space of two or three days, that is to say, up to the 
 moment when the excitement of the first fruitful coition occasions 
 the effusion of that coagulable lymph in the cavity of the womb 
 which afterwards becomes the membrana caduca. 
 
 546. Of two germs vivified by the same copulation, one may not 
 descend into the uterine cavity until a considerable time after the 
 other ; the maturity of the two ovules may not have arrived at the 
 same degree of perfection at the instant of their union with the 
 principle furnished by the male ; one of the germs may happen to 
 be disengaged with difficulty from the ovary, remain adhering to it 
 without growing with the same rapidity as its congener, and not 
 escape from the vesicle, nor pass into the tube until after a greater 
 or less lapse of time. 
 
 547. I am astonished that modern physiologists, and even some 
 medico-jurists, among whom should be mentioned M. Orfila, have
 
 212 THE FffiTUS. 
 
 admitted the existence of superfcetation up to the moment when the 
 ovule reaches the womb, while they deny the possibility of its occur- 
 ring after that period. It ought to bo equally rejected in both cases. 
 The concrescible lymph or anhistous membrane is fully as capable 
 as the ovum itself of intercepting all contact between the seminal 
 principle of the male and that of the female. To conclude, super- 
 fcetation may take place ; 1 . In the case of extra-uterine pregnancy 5 
 2. In that of a double uterus ; 3. Where a woman has -had com- 
 merce with two different men on the same day, or even at short in- 
 tervals with the same man ; 4. and lastly, While the uterine cavity is 
 not filled with any substance, and the orifices of the tubes remain 
 perforate. 
 
 SECTION 2. 
 Functions of the Fcetus. 
 
 . I. Of the nourishment of the foetus. 
 
 548. Few questions in physiology have occupied so much of tho 
 attention of the learned, as that of the nourishment of the foetus. 
 Different authors have by turns placed its source in the liquor amnii 
 and in the placenta, in the umbilical vesicle and in the allantois, in 
 the gelatine of the cord, and in the caducous membrane. 
 
 549. What I have elsewhere (410) said of the anhistous membrane 
 and its fluid, seems to me to prove at least that that tunic cannot 
 concur in the development of the ovum longer than during the first 
 fortnight of its existence : if Chaussier and some others have enter- 
 tained a different opinion, it is because they had acquired false no- 
 tions concerning the caduca, and its nature. 
 
 550. The gelatine of the cord, which, by Warthon, Rouliault, 
 Lobstein and Beclard, has been supposed to play a part in the 
 matter, has no more to do with it than the caduca, and it is not true 
 that it becomes loss abundant in quantity as the foetus grows larger. 
 
 The idea of making the fretus live upon the fluid with which it is 
 surrounded, is the most ancient of all, and apparently the most na- 
 tural ; it gives rise to two very distinct theories ; by one the water 
 of the amnios is supposed to be swallowed and digested ; according 
 to the other it is absorbed in various ways. 
 
 551. In order to prove that the water of the amnios serves for the 
 nourishment of the foetus, the old writers-, particularly Harvey and 
 Diemerbroeck, have treated at great length on its nutritious qualities, 
 and mi the lactescent matter which in their opinion it always con- 
 tains ; later authors have relied upon the assertion that small animab
 
 NOURISHMENT OF THE FffiTUS. 213 
 
 plunged in it live longer than they do when plunged in common 
 water ; on its being more abundant and fuller of nutritive principles, 
 in proportion as pregnancy is less advanced ; on the diminished 
 power of absorption in the cutaneous surface of the foetus, as it ap- 
 proaches nearer to the full term ; and on certain cases of foetuses 
 being born alive without any umbilical cord. 
 
 552. Without stopping to refute these various propositions one 
 by one, it may be remarked that previously to drawing practical 
 consequences from them, their correctness should have b<;sn ascer- 
 tained : but it has never been proved that the liquor amnii is more 
 nutritious at the beginning than at the close of pregnancy ; or that 
 the foetus absorbs more at one time than another. As to the ob- 
 servations of Van-der-Wiell, of Dennis and Littre, on the absence 
 of the umbilical cord, and on the rupture and cicatrization of its 
 divided extremities, they are too improbable, and accompanied with 
 details far too vague for them to deserve the least credit. 
 
 Nothing, positively nothing, warrants our believing with Alcmaeon, 
 Boerhaave, Buflbn, and Van-den-Bosch, that the waters are taken 
 up by the cutaneous surface. The last author, it is true, tells us he 
 saw the lymphatic vessels full of a fluid resembling the water of the 
 amnios, and that they became fuller in the limb of a cow's foetus, 
 strongly bound round with a ligature and plunged in the liquor of 
 the membranes ; but even admitting the experiment to be correct, 
 what conclusion can we draw from it ? Are not the lymphatic ves- 
 sels habitually filled with serosity ? Do they ever fail to become 
 distended when a mechanical obstruction prevents the free passage 
 of the blood through a part, or the whole of a limb ? 
 
 553. Founding on the opinion of Hippocrates, of Harvey, Rud- 
 beck, &c. and on some facts of his own, Diemerbroeck maintains 
 that the foetus is nourished by the mouth. His reasons are, frhat the 
 child's stomach is always filled with a lacteous matter ; that there 
 are excrements in its bowels ; that immediately after birth, or pre- 
 viously to sucking, it frequently vomits a whitish fluid ; that it sucks 
 a finger if put into its mouth, even while still within the sexual or- 
 gans ; and that its stomach would not be able to perform its diges- 
 tive function immediately after parturition, if it were not previously 
 accustomed to it. If asked whence the fcetus derives this nourish- 
 ment, he answers that it is at first from the seminal fluid, and sub- 
 sequently from the lacteous juice contained in the amnios. 
 
 Haller, Darwin, &c. add to the reasons of Diemerbroeck and 
 La Courvee, that the amniotic liquid has been found in the stomachs 
 of many foetuses ; that in a pregnant cow that had been frozen, Heistor 
 found the mouth, oesophagus and stomach of the foelus filled with an
 
 THE F(ETUS. 
 
 214 
 
 icicle which was continuous with the waters ; that many observers have 
 met with silky hairs in the meconium, and they conclude that all these 
 matters could not have got into the digestive passages by any other 
 means than deglutition. 
 
 More recently, this opinion has been strengthened by the case of 
 a foetus in which the bowel was completely divided near the caecum, 
 and contained meconium in the portion connected with the stomach, 
 while the Jarger intestine was almost completely obliterated ; by 
 another case mentioned by M. Dubois, in which the alimentary 
 canal being contracted near the pylorus, contained meconium only 
 in the part above the contraction ; and lastly, by the fact that Be- 
 clard having coloured the liquor amnii with ink, in a bitch that he 
 experimented on, found some of it in the cesophagus and stomach 
 of the young. 
 
 554. None of these proofs are conclusive ; most of them do not 
 even deserve to be seriously combated. The presence of hairs in 
 the intestines might, in fact, be explained in another way ; but the 
 cases of that kind that have been reported are far from authentic. 
 To the facts noticed by MM. Desgranges and Dubois, may be op- 
 posed one published by M. Piet, and in which the intestine, though 
 separated from the stomach, is said to have been, nevertheless, filled 
 with meconium. I have myself dissected a foetus, at full term, whose 
 oesophagus upon reaching the diaphragm ended in a completely im- 
 pervious blind sac, notwithstanding which its colon was full of me- 
 conium. While enclosed in the membranes, the mouth of the fcetus 
 is closely shut, at least until a pretty advanced stage of pregnancy ; 
 to swallow, cither by suction or deglutition, it should be able to per- 
 form the motions of inspiration and expiration, of elevation and de- 
 pression of the larynx. Acephalous and astomatous fcetuses, and those 
 which -come into the world with all the openings of the mucous 
 membranes occluded, are not on that account less completely de- 
 veloped, and their alimentary canal, according to the reports of 
 certain observers, docs not contain less of meconium or of hairs. 
 It does not necessarily follow from the circumstance that liquor 
 amnii has been found in the stomach, that the fcetus swallows and 
 is nourished by it ; would it be right to infer that a swimmer natu- 
 rally drinks water, because we find some of it in the stomachs of 
 drowned persons? Finally, ought it not to be enough to decide for 
 ever the question as to the nutritive properties of the liquor amnii, 
 t<> observe, that Bartholin and M. Morlanne have seen the fcetus 
 continue to live in llic. womb more than a month after the complete 
 ,:ition of the waters. 
 
 It is therefore superfluous to inquire whether the water of
 
 NOURISHMENT OF THE FffiTUS. 215 
 
 the amnios, after passing into the intestines, is simply absorbed from 
 them, as was thought by La Courvee to be the case, or whether, as 
 Diemerbroe.ck, Boerhaave and others pretend, it must undergo a 
 previous digestion in those organs ; neither is it necessary to refute 
 M. Lobstein, who is not far from making it pass in, partly, by the 
 genital organs of the foetus ; nor Osiander and Muller, who make 
 out, that it is absorbed, then modified by the breasts, to be subse- 
 quently carried to the thymus gland and thoracic duct ; nor, finally, 
 Schurigius, David, Rcederer, Scheele, Winslow, Heroldt, Bcclard 
 and M. Geoffroy-Saint-Hilaire, who believe that it penetrates into 
 the trachea and bronchia, in order to be there elaborated, or serve 
 in some way for the purposes of the foetal nutrition. 
 
 Notwithstanding the importance attributed by some writers to the 
 water of the amnios, all the authors, except La Courvee and a few 
 others, have confessed that the placenta performs the principal part 
 in the nutrition of the foetus, at least during the latter half of the 
 period of gestation. 
 
 There are some who, with the ancients, suppose that the placenta, 
 by means of some peculiar lymphatics, takes up a milky juice, a 
 real chyle, for the purpose of modifying or transmitting it to the 
 organs of the foetus. 
 
 556. Others have asserted that the placenta takes nothing from 
 the womb except the oxygen, that it performs the functions of a respi- 
 ratory organ, that it is the physiological lungs of the foetus, and that in 
 this view the uterine arteries represent, in some measure, the bronchia 
 and trachea. In a figurative,sense these assertions are not wholly with- 
 out foundation, as I shall remark further on ; but when taken in a 
 literal sense, as they have been by an infinite number of physiologists, 
 they become valueless. 
 
 557. A majority of writers maintain that the foetus is nourished 
 and developed by blood furnished to it by the mother ; this is another 
 disputed point : is it real blood, or only some of its principles ? 
 Does it pass directly from the vessels of the mother into the circu- 
 latory system of the foetus ? Is it merely poured into the sinuses of 
 the placenta ? Must it, or must it not be subjected to some prepa- 
 ratory elaboration before it reaches the placenta ? 
 
 558. Galen, Aristotle, Vesalius, Columbus, Maurocordatus, Hil- 
 danus, Haller, and a majority of accoucheurs have been of opi- 
 nion that the blood passes directly from the mother to the foetus ; 
 the partisans of this hypothesis, which has been combated in detail 
 by Diemerbroeck, rely upon the existence of vessels passing from 
 the womb to the placenta ; on this latter body having been seen, as 
 by M. Ribes, to grow and live after the expulsion of the foetus ; on
 
 216 THE FOETUS. 
 
 the circumstance, that the detachment of the placenta, whether 1 
 during pregnancy or after delivery, always gives rise to hemorrhagy 5 
 that uterine hemorrhages cause the foetus to die exsanguious ; on 
 blood having been observed to flow from the placental end of the 
 cord so as to constitute a dangerous hemorrhage ; on M. Magen- 
 die's having found the odour of camphor, and the colouring matter 
 of madder in the young of animals fed on those substances ; on the 
 presence of large orifices observed by various authors on the internal 
 surface of the womb ; on the fact, that the best mode of arresting 
 flooding is to compel the womb to contract ; and above all, on the 
 passage of various substances, when injected in the uterine vessels, 
 into the organs of the foetus. 
 
 559. None of these reasons are demonstrative ; we have seen, 
 above, that it was necessary to imagine the existence of vascular 
 anastomoses between the ovum and uterus : supposing the placenta 
 does sometimes remain adherent to the uterus, and continues to live, 
 that does not at all prove that there is a direct sanguine circulation 
 from one to the other ; it is false to say that the detachment of the 
 placenta always occasions hemorrhage ; and even if it were true, it 
 would no more militate in favour of than against the idea of im- 
 mediate anastomoses, for the blood in that case may just as well be 
 poured out by exhalation, as from ruptured vessels. If it be true 
 that the heart and vessels of the foetus are emptied of their blood 
 when the mother dies with hemorrhage, Wrisberg proves that the 
 contrary has been very often observed ; besides, it docs not follow, 
 because a child is born anemic after a ulorine hemorrhage of several 
 weeks duration, that the blood passes unchanged to the cord, for if 
 the woman be for a long period anemic herself, it is very natural 
 that the fruit of her womb should also be feeble : further, it seems 
 to be forgotten that many of those hemorrhagies, as those that depend 
 upon insertion of the placenta over the cervix, may come from the 
 vessels of the placenta, and consequently, from the foetus, as well as 
 from the mother. When blood flows from the uterine end of the 
 cord that has just been cut, it is not at all because the circulation 
 continues to go on from the womb to the placenta, but.it is simply 
 owing to the contraction of the wornb and of the vessels of the 
 placenta itself, and of the cord ; it is the after-birth disgorging the 
 fluids it contained, and not new blood coining from the woman. The 
 presence in the foetal organs of medicinal or alimentary substances 
 taken by the mother, is explained by the laws of imbibition or by ab- 
 sorption, quite as satisfactorily, as by an uninterrupted continuity of 
 the vascular system, .,!' the ovum and uterus. 
 
 5GO. Still there are the anatomical injections : they have been in
 
 NOURISHMENT OF THE FffiTUS. 217 
 
 vain attempted by Ruysch, Haller, &c.,but as a thousand negative 
 facts do not destroy a single positive one, these injections are con- 
 stantly appealed to in support of the hypothesis in question. 
 
 561. M. Dubois formerly exhibited to the Academy of Surgery 
 a specimen he had prepared, and in which the injection passed into 
 the placenta through what he denominated the placento -uterine 
 vessels ; Chaussier succeeded in impelling mercury into it ; Beclard 
 and M. Duges have succeeded with coloured oil. In the body of 
 a pregnant woman prepared for examination, M. Deneux saw the 
 uterine sinuses completely filled with injection, and continuing 
 without any line of demarcation into the placental sinuses, which 
 were also filled with the same material. Mr D. Williams has re- 
 cently performed some experiments, -from which it appears that 
 linseed oil, injected into the aorta or hypogastric arteries, penetrates 
 into the organs of the foetus ; and M. Biancini, who has performed 
 experiments on one woman who died whilst in labour, on another 
 who died in a week after delivery, and on a third who died with 
 flooding, as also on cats, rabbits and cabiais, assures us he obtained 
 the same results with size and with mercury, which, he thinks, 
 answer better than oil : in addition to the utero-placental arteries, 
 the Italian physiologist describes a set of veins of a corresponding 
 character. 
 
 562. But it seems to me there is a strange misconception of the 
 value of such experiments. How happens it that they have not 
 been regarded as but little applicable to the explanation of what 
 takes place in the living female. How long has the passage of 
 foreign matters from one vessel to another proved incontestably 
 that the same thing takes place with the natural fluids during the 
 life of the individual ? 
 
 563. When a pretty fine injection is thrown into the arteries of 
 the belly, the matter readily escapes from the internal substance of 
 the intestines ; when thrown into the vena port, it returns not only 
 by the veins and the hepatic artery, but also through the excretory 
 bile ducts ; when thrown into the emulgent artery, it soon passes 
 into the emulgent vein, as also into the pelvis of the kidney, and the 
 ureter. Notwithstanding the above, we do not conclude that the 
 blood during life is continually transuding into the alimentary canal, 
 nor that it passes from the vessels of the liver into the hepatic ducts, 
 or from the kidneys into the tubuli uriniferi and ureters ; the oil, 
 glue and mercury employed by Chaussier, and Messrs Williams and 
 Biancini, are of too penetrating a nature not to go wherever it 
 may be desired to send them ; but whether the passage in question 
 
 2C
 
 218 
 
 THE FffiTUS. 
 
 does or does not take place, it will certainly never serve to resolve 
 the problem at issue. 
 
 564. Hanter and several modern physiologists expect to get rid 
 of the difficulty by admitting that the uterine sinuses pour their 
 blood into the sinuses, or interlobular anfractuosities of the placenta, 
 whence it is subsequently taken up by the numerous capillary orifi- 
 ces of the umbilical vein. This hypothesis, although more specious 
 and rational than the preceding one, is not therefore less difficult 
 to adopt ; without referring on this point to what I have already said 
 (478) concerning these pretended sinuses and their adaptation, I 
 remark : I . That such an arrangement cannot be admitted to take 
 place in extra-uterine pregnancies ; 2. That until the second or 
 third month, the placenta being composed of merely agglomerated 
 filaments, there can be no sinuses betwixt its lobules ; 3. That a 
 placenta, although attached upon a fibrous polypus, or upon some 
 indurated portion of the uterus, has nevertheless been found to sup- 
 ply all the materials required for the foetal nutrition ; 4. That I 
 have seen the uterine surface of the afterbirth hard, coriaceous, 
 and without any orifice throughout almost its whole extent, in women 
 who were delivered of children that, although weak indeed, were 
 nevertheless living ; 5. That the large vessels of the womb, said to 
 be continuous with the vessels of the placenta, are, by the very parti- 
 sans of the doctrine, admitted to be veins ; 6. That the uterine veins 
 being, like the veins of all other parts of the body, the vessels of a 
 convergent and not of a divergent circulation, as they should Jae, con- 
 sistently with the views of that party, it follows that they are pleased 
 to get venous and not arterial blood from the mother into the pla- 
 centa. 
 
 565. Should it be insisted upon that the fcctus receives completely 
 elaborated blood From the mother, it could only be possible, at the 
 utmost, to say, as indeed it lias been said, that that fluid enters the 
 placenta through simple pores, by a sort of imbibition which might 
 be explained by a mere contiguity of surfaces. To this 1 can only 
 object that the blood, as such, does not appear to pass in any way 
 into the ovum. It certainly does not pass there at least in the early 
 periods ; for the villous portions of the chorion do not contain ves- 
 sels until pretty late, and besides, its filaments are never hollow quite 
 to their extremitics(475). On the other hand, both Autcnreith's 
 and my own experiments demonstrate that tlio blood of the foetus 
 docs not present the same aspect as tluit of the mother: it is at 
 first of a rose colour; it then becomes redder, then blacker, and 
 does not exhibit any difference of colour in the veins and arteries. 
 Ticdemann and others have found that it contains a much larger
 
 4 
 * NOURISHMENT OF THE FOETUS. 219 
 
 proportion of scrum than the blood of an adult, and is less coagu- 
 lable ; in fine, every thing proves that its chemical composition is 
 very different from that of the mother. Even although chemistry 
 had not been able to ascertain for us these differences, would it be 
 right to believe that this fluid need not have, like our aliment, a due 
 relation to the period of our life, whether extra or intra-uterine, and 
 that the blood of an adult woman would not be, in some sort, a poison 
 to so frail and delicate a being as the embryo, or foetus ? Were it 
 wo~rth while to insist upon this point, I might add that according to 
 the microscopical observations of MM. Prevost and Dumas, the 
 blood-globules are so small in the foetus, that it would be impos- 
 sible for those of the mother to pass through the same canals or 
 same orifices without destroying th'e equilibrium of all the functions, 
 and producing sudden death. 
 
 If, therefore, the blood is poured into the caverns of the placenta, 
 or taken up by the pores of that organ, it must at least undergo 
 some elaboration, some important modification before it reaches the 
 umbilical vein ; but what is the nature of that modification ? I 
 know not. 
 
 566. In conclusion, the nourishment of the ovum is dependent 
 on various sources ; at first it is a mere vegetable, which imbibes 
 the surrounding moisture. The villi of its superficies, real cellular 
 spongioles, acquire, in the tube or in the womb, the nutritive princi- 
 ples required for the development of the embryo vesicles ; after 
 which the embryo is nourished after the manner of the chick in ovo, 
 or rather like the young plant, w.hich is at first evolved at the ex- 
 pense of principles contained in its cotyledons. It gradually ex- 
 hausts the vitelline matter contained in the umbilical vesicle ; the 
 emulsive substance of the reticulated body or allantois is also gradu- 
 ally absorbed. It reaches the end of the second month ; the ves- 
 sels of the cord are formed ; the placenta soon begins to show itself, 
 and suffices to keep up the evolution of the fcetus ; by its contact, 
 the spongy cake takes up from the womb the elements of repara- 
 tion, and operate; on them, forming a fluid more or less analogous to 
 blood, which is then absorbed by the radicles of the umbilical vein. 
 The placenta absorbs in the uterus, so as to form the fluids of the 
 foetus, as the liver, the kidney, the seminal gland, &c. take up from 
 their own vessels the materials from which to form the bile, the 
 urine, the prolific liquor, &c. ; as trees and plants absorb from the 
 ground the principles of the numerous compounds they contain : 
 and I see nothing in all these actions very difficult of comprehen-
 
 220 TH E FOETUS. 
 
 . II. Circulation of the fetus. 
 
 Whatever may be the manner in which blood or other fluids reach 
 the placenta, it is, notwithstanding, necessary for them afterwards to 
 traverse the various organs of the fcetus for their nourishment : 
 however, their circulation does not in all respects resemble that 
 which takes place after the birth of the child. 
 
 667. In the adult, the septum that divides the two auricles of the 
 heart is complete, and separates them from each other perfectly ; in 
 the foetus, on the contrary, this septum has an opening through it, 
 called the foramen ovale, which is largest in the early stages of 
 pregnancy. Previously to birth, instead of two large trunks, the 
 pulmonary artery furnishes only two small branches to the lungs ; 
 but it is prolonged, under the name of the arterial canal (ductus 
 arteriosus} as far as to the aorta, into which it opens below the left 
 subclavian artery. The hypogastric branches of the primitive iliacs 
 send only small branches to the pelvic organs, which are as yet 
 scarcely developed ; but they rise along the sides of the bladder and 
 urachus, under the name of umbilical arteries, and proceed to the 
 umbilical ring and to the cord. Unlike the adult, the foetus also 
 has an umbilical vein, which, upon entering into the abdomen, pro- 
 ceeds backwards and upwards, and somewhat from left to right, so 
 as to pass into the longitudinal fissure of the liver, through which it 
 passes, giving off here and there a branch to the right and left lobes 
 of the liver. Having reached the under surface of the liver in the 
 transverse fissure, the umbilical vein divides into two trunks : one, 
 which is called the venous canal (ductus venosus), and which, like 
 the ductus arteriosus. grows smaller and smaller as the term of gesta- 
 tion approaches, appears to be a continuation of the primitive vein, 
 and proceeds to open into the trunk of the vena cava, below the dia- 
 phragm ; the other, which constitutes the right branch of the vena 
 portai, penetrates into the liver, where it at length anastomoses with 
 the radicles of the hepatic veins, which, as in the adult, proceed to 
 open into the vena cava a little above the ductus venosus. 
 
 568. Course of the blood. From the above arrangement of the 
 circulatory organs, it is evident that the course of the fluids must be 
 much more complicated than in the adult. From the smaller brandies 
 of the umbilical vein, the blood passes into the larger ones, and soon 
 afterwards into the groat trunk of that vessel, it then passes along the 
 cord through the umbilicus, and divides beneath the liver into two prin- 
 cipal currents, one of which follows the venous canal so as to go and be 
 mixed with the blood of the inferior cava, while the other proceeds 
 along the umbilical branch of the vena porta:, to be ramified in the 
 right lobe of the liver, and taken up by the hepatic veins, which pour
 
 CIRCULATION OF THE FCETUS. 221 
 
 it into the trunk of the cava as it passes through the diaphragm. 
 There it forms three columns ; that of the venous canal, that of the 
 hepatic veins, and that which is brought by the cava from the lower 
 half of the body, which unite, and together enter the right auricle, 
 thence passing through the foramen ovale into the left auricle ; from 
 the latter, the blood falls into the corresponding ventricle, which 
 forces it along the aorta towards all parts of the body, but chiefly to 
 the head and upper extremities, by means of the brachio-cephalic 
 trunk, the left carotid, and the subclavian. 
 
 569. After losing among the tissues the nutritive principles with 
 which it was charged, the blood is brought back by the jugular and the 
 axillary veins to the subclavians, and thence to the superior cava, 
 which also receives that of the azygos ; the superior cava carries it to 
 the right auricle, the auricle to the right ventricle, and the latter to the 
 pulmonary artery, which directs only two small columns of it to the 
 lungs, and causes the rest of it to pass through the arterial duct to 
 the descending aorta, where it meets with a part of what the left 
 ventricle had already expelled. That portion which reaches the 
 primitive iliacs is in part distributed to the lower extremities by the 
 external iliacs ; but by far the largest portion of it returns along the 
 umbilical arteries, through the cord, and at last to the placenta, 
 from whence it set out. 
 
 570. In the heart. Haller, Wolf, Sabattier, MM. Portal, Riche- 
 rand, &c. supposed that the blood of the two venae cavas does not 
 mix at all in the right auricle, that that of the ascending or inferior 
 cava passes entirely to the left, and that of the superior cava entirely 
 into the right ventricle. 
 
 571. Bichat was opposed to this view of the subject, and M. 
 Magendie does not adopt it ; it is difficult, say they, to understand 
 how two columns of fluid can pass into the same cavity without being 
 mixed together ; the two auricles contract simultaneously, and not 
 one after the other ; it is not probable that the vivified blood fur- 
 nished by the umbilical vein passes wholly to the superior half of 
 the body, and that the venous blood alone is expended in the re- 
 maining moiety. But seeing that the vena cava inferior, surmounted 
 by the Eustachian valve, seems to be continuous with the foramen 
 ovale, rather than to open merely into the right auricle, .and that the 
 cava superior opens opposite to the orifice of the right ventricle, and 
 on a plane which is rather in front of the inferior cava, it appears to 
 me we may conceive that the blood of the two vessels may really 
 pass into the left auricle and left ventricle, without necessarily mixing. 
 The simultaneous contraction of the auricles does not seem to oppose 
 this transfer ; the blood of the inferior cava does not pass through
 
 222 THE FffiTUS. 
 
 the foramen ovale during the contraction of the organ, nor does that 
 of the superior cava get into the ventricle during that action ; if they 
 are both full of fluid at the moment the systole commences, what is 
 to prevent their passing" it, without mixing, into the corresponding 
 cardiac ventricle ? 
 
 I believe, therefore, that Sabattier's theory is the best founded, 
 and that only a very small quantity of the blood poured into the right 
 auricle by the two cavoe respectively is mixed there. 
 
 572. However, it must not be supposed that the head and limbs 
 receive none but the blood brought to the heart by the umbilical 
 vein and its branches, nor that the abdomen and inferior extremities 
 are nourished only by the blood of the superior cava : on the one 
 hand, it would be absurd to suppose that that which is driven by the 
 left ventricle into the arch of the aorta, passes on into the carotid 
 and subclavian arteries, without some of it descending along the 
 thoracic aorta ; and on the other, even were that the case, this blood 
 is no longer as pure as it was on leaving the placenta, for it is neces- 
 sarily mixed with the venous blood of the lower extremities and 
 abdomen. Further, the blood that passes along the aorta descen- 
 dens is not merely the blood of the ductus arteriosus, but with it 
 also is mixed that of the inferior cava. 
 
 573. In the placenta. Some persons have supposed that the blood 
 brought back by the umbilical arteries is taken up by the uterine 
 veins, and proceeds to be revivified in the lungs of the mother, before 
 returning to the ovum ; others have thought that 'only a portion of it 
 is absorbed, while the rest passes immediately into the capillaries of 
 the vein ; that there is in some sense two circulations, one great cir- 
 culation, completely under the influence of the heart and lungs of 
 the mother, and one lesser circulation, the only one really belonging 
 to the foetus. What has been said above will, I think, suffice to 
 cause such opinions to be appreciated at their just value ; I shall 
 content myself with remarking here, that in order to admit of what 
 is called a great circulation, the pulsations of the foetal must be iso- 
 chronous with those of the maternal heart. But the mode of aus- 
 cultation introduced by M. Kergaradec proves, as it had indeed 
 been before remarked by Diemerbrocck, that there is no such iso- 
 ohroiiism, aad that the foetal heart beats one half ol tenor than that 
 of a majority of women. 
 
 If it were true that the blood of the umbilical arteries is 
 poured, ;1S pretended, into the placcutal sinuses, it evidently would 
 mix uitli 1h;it of tin: uterine urtericH, which, according to the same 
 theory, in also drpo.-iii <] therein; if so, we inuH be eonipeHed to 
 believe tlrnt the ub-orb'mg mouths of the umbilical veins have tin;
 
 CIRCULATION OF THE FffiTUS. . 223 
 
 faculty of choosing the arterial blood out of this mixture, while the 
 uterine veins take up only venous blood : such an idea is not to be 
 defended. Besides, as the matter of injection, even the coarsest, 
 passes with an astonishing facility from the arteries to the veins of 
 the placenta without being effused on its uterine surface, it appears 
 to me that we may with certainty conclude that the blood of the fetus 
 is not taken u^S by the womb. 
 
 575. This does not, however, imply that the blood from the arte- 
 ries re-enters the umbilical vein without undergoing any changes ; 
 but rather, only that these changes, purely molecular, are effected 
 in the placenta itself. This elaboration is not the less undeniable 
 because its essence is not understood. It may be compared to that 
 which is effected after birth in the general capillary system ; and to 
 that which occurs in the secretory organs, and in the lungs themselves. 
 The fluids of the ovum are brought into contact with those of the 
 mother, and at that instant a change of principles is effected between 
 them, as takes place in the bronchia between the atmospheric air 
 and the venous blood of the lungs ; but here all our information is 
 limited. 
 
 576. In the liver. The truly enormous size of the liver during 
 the intra-uterine life, long ago gave rise to the supposition that it 
 was an organ of hematosis, or that it modified the blood in some 
 manner. M. Lobstein appears to be still of this opinion. Fourcroy 
 says that if this modification does take place, it must consist in a 
 kind of decarbonization and dishydrogenization. More recently 
 still, MM. Prevost and Dumas thought they had observed that the 
 first blood globules of the fetus appeared in the liver. If, says M. 
 Geoffroy de Saint Hilaire, the liver receives so great a quantity, and 
 exhibits such a considerable size, it is, that it may secrete a great 
 quantity of bile, which, being poured into the small intestine, occa- 
 sions th? formation therein of an abundant quantity of mucus that 
 the fcctus digests, and on which it grows. Finally, Dr Lee of Lon- 
 don has just performed some new experiments, whence it results, 
 that the use of the liver is to secrete an abundant albuminous and nu- 
 tritive matter; that this substance fills the hepatic ducts, the duodenum 
 and snjall intestines ; while in the stomach we find only an acid fluid, 
 and meconium in the large intestines. 
 
 577. Of these different uses, not one is matter of demonstration ; 
 those indicated by Fourcroy, M. Lobstein and M. Geoffroy, are even 
 based upon mere suppositions, that are easy to overthrow ; and 
 although the theory of Dr Lee and Dr Prout is supported by some 
 facts, it seems to be the dictate of prudence that we should wait
 
 224 THE FOETUS: 
 
 before we decide, and admit that at present we do not know what 
 influence is exerted by the liver on the foetal blood. 
 
 . III. Of the respiration of the foetus. 
 
 578. Air being indispensable to respiration, it seems quite natural 
 that that function should have no existence in the foetus ; but on the 
 other hand, as absorption of air or oxygen seems to b*e indispensable 
 to the maintenance of life in all organic beings, attempts have been 
 frequently made to prove that all animals respire during their fetal 
 life. 
 
 579. As to the human species, it has been said that the placenta 
 receives oxygen from the blood of the mother at the same time that 
 its own parts with certain heterogeneous principles, as, for example, 
 a portion of its serum : this opinion, which is of an ancient date, has 
 been latterly defended by MM. Lobstein, Meckel, and Muller. 
 
 It is true, that in order to explain the changes undergone by the 
 blood in passing through the placenta, we may compare that work 
 to respiration ; but to accept such a comparison in the very letter, 
 would be most strangely to wrest the analogies. The blood which 
 re-enters the umbilical vein is doubtless modified, but it is not red- 
 der than it is in the arteries ; the change it has just experienced 
 does not therefore in the least resemble that which occurs in its 
 passage from the pulmonary arteries into the pulmonary veins of the 
 adult. 
 
 580. Some other persons, and particularly M. Geoffrey de Saint 
 Hilaire, have admitted that the foetus absorbs air or a vivifying gas 
 from the whole surface of its body, by a kind of tracheae like those 
 of insects, or even by the pulmonary passages, which might in such 
 case be compared to branchiae, and that it respires after the 
 manner of fishes ; but I have already stated that the gas obtained 
 by M. Lassaigne in his first experiments was only a compound of 
 carbonic acid and azote. 
 
 581. Some, however, have persisted in maintaining that the lung 
 exerts a certain action on the water of the ainnios ; that it separates 
 air or some other principle from it ; in a word, that it exercises a 
 sort of respiration : on this subject reliance lias been placed on 
 some researches made in Denmark by Scheele, Wiborg, Winslow, 
 llcruldt, &c. ; experiments that tend to prove that the liquor amnii 
 fills the traehtia and bronchia of the foetus ; on those of Beclard, 
 who saw the same tiling ; and further, that the young of a bitch, still 
 enclosed in the membranes, executed the motions of dilating and 
 contracting the alac nasi, and of the chest ; lastly, on the fact that
 
 RESPIRATION OF THE FCETUS. 225 
 
 the foetus has on more than one occasion been heard to cry while in 
 the mother's womb. 
 
 582. But It has been seen, farther back, what ought to be thought 
 of the presence of liquor amnii in the gastric or pulmonary passages 
 of the dead foetuses. De Buffon and Autenreith, who got the foetuses 
 of animals to live in that fluid ; Wrisberg and Osiander, who have 
 both seen the human foetus live ten and fifteen minutes out of the 
 womb with the membranes unruptured, did not see the respiratory 
 movement mentioned by Beclard ; I too had an opportunity, in 1825, 
 of witnessing a fact that was very curious, and well adapted to 
 illustrate this point : a woman at the hospital de Perfectionnement, 
 and who said she was six complete months pregnant, was suddenly 
 delivered at five o'clock in the morning of the 23d of August ; the 
 ovum, which came away whole, was received by M. Lafond, a resident 
 student at the hospital. The specimen was immediately brought to 
 me, and I placed it in a large bowl of tepid water. The foetus did 
 not appear to be of more than five months and a half ; I left the 
 membranes whole ; I carefully examined the nose, the mouth, the 
 abdomen and thorax of the foetus, which continued tp live in this way 
 for thirty-six minutes, but I discovered no motion in the thorax, 
 except the slight throbbing occasioned by the action of the heart. 
 We were also able to convince ourselves that the water of the amnios 
 had penetrated neither into the trachea nor the stomach. 
 
 583. Uterine vagitus. As to the cries generally known under 
 the title of vagitus uterinus, examples of it may be found in Albert 
 Legrand, Libavius, Solinus, Camerarius, Sennertus, Bartholin, Deu- 
 singius, Velthusius, Boyle, and Needham himself; but these ac- 
 counts being given only upon the hearsay of old women, do not de- 
 serve the trouble of being repeated. The subject has come up 
 again in our own day : Osiander affirms that he heard these cries 
 in two different women ; M. Zitterland cites an instance of it which 
 he himself witnessed, after having taken all proper precautions to 
 avoid being deceived ; MM. Henri and Jobert have observed the 
 same thing at Paris, in an incontestable manner, in 1825, according 
 to the report of M. Marc ; M. Hesse has related a fifth case ; and 
 M. Lesauvage assures us that he very distinctly heard the cries of 
 young puppies while still in their mother's belly. 
 
 584. When the membranes are ruptured and the waters discharg- 
 ed, when the orifice is dilated, and the child's face engaged more or 
 less deeply in the excavation, we may conceive, indeed, that the foetus 
 might breathe and utter some cries before its complete expulsion ; 
 but still the state of compression and constraint of the thorax ren- 
 ders the possibility of such an occurrence very doubtful ; but when 
 
 2 D
 
 226 THE F<ETUS. 
 
 the ovum is entire, as in the case given by M. Lesauvage, the fact is 
 so improbable, that we are not authorised to draw any conclusions 
 from it. * 
 
 It is sometimes so difficult to avoid all the causes of error, 
 all subterfuges, not to be deceived by strange and unexpected 
 noises, such for example as are often produced by air in the 
 intestines, that before we admit as positive a phenomenon which 
 it is impossible to reconcile with the laws of physiology, the 
 same person should have ascertained its existence repeatedly ; in 
 the mean time, I may say with Fontenelle, that, since learned and 
 credible men have heard it, I will believe it, but I should not believe 
 it if I had heard it myself. 
 
 585. Further, if the foetus really breathed ; if air passes through 
 its lungs, they would be permeable and spongy, while at birth they 
 arc, as is well known, quite compact, and as heavy as a slice of mus- 
 cular tissue. 
 
 . IV. Of the viability of the foetus. 
 
 586. The word viability, derived from via, is employed in medi- 
 cal jurisprudence to express the possibility of passing through the 
 various phases of human life. To render a child viable, it should 
 possess at birth an aptitude to live independently of its mother ; 
 from this definition it will be perceived that a fcetus at term, as has 
 been remarked by M. Billard, may be born not viable, provided it be 
 affected with some faults of conformation, or with certain diseases, 
 as also that a fo3tus may be born viable although dead when passing 
 from its mother's womb. 
 
 At what stage of pregnancy is viability possible ? Although 
 debated by accoucheurs and physicians in all ages and countries, this 
 question has continued until this moment undecided. The fcctus, 
 which according to some persons is viable at four months and a half, 
 does not, according to others, really enjoy viability until the seventh 
 month. 
 
 587. The law having determined that a child born before the one 
 hundred and eightieth day alter marriage may, if it is pronounced to 
 bo viable, be disowned by the husband, implicitly declares that viabi- 
 lity commences with the seventh month. As a legislative measure, 
 this decision is extremely wise, and could not be more just ; but it 
 docs not by any means prove that a foetus is never viable before the 
 end of the sixth month, nor that it is always so at the commence- 
 ment of the seventh. Tin; determination as to the viability of the 
 child ou^lit to depend on the degree of perfection attained by the 
 
 organs, and not on the stage of pregnancy. But, us the evo-
 
 VIABILITY OF THE FCETUS. 227 
 
 lution of the foetus is not always in the same ratio, it follows that an 
 eight months fcetus may be less viable than one of seven months. 
 
 588. Should we refer on this head to the cases related by various 
 authors, we might have examples of children that were infinitely 
 small, of some born at four months or four months and a half, and 
 nevertheless become robust and vigorous men. Who is unacquaint- 
 ed with the history of the celebrated Fortunio Liceti, related by Van 
 Swieten ? His mother, frightened by the roughness of the sea while 
 passing from Reco to Rapallo, brought him into the world before 
 the sixth month of her pregnancy ; he was not bigger than a hand ; 
 his father had recourse to the heat of an oven to bring him up, and 
 notwithstanding all that, Fortunio lived to be seventy-nine years old. 
 An abortion, says Brosset, was born in 1748, at the fifth month of 
 pregnancy, and lived to tire ninth month, without sucking, without 
 producing any excretion, or performing any other motion, save to 
 swallow a few drops of milk ; but, four months after its birth, it sud- 
 denly cried, and sucked, and moved its limbs, so that at sixteen 
 months old it was stronger than children of that age commonly are. 
 To be sure, one ought really to have been, like Brousset, a wit- 
 ness to such a miracle to be able to believe it. Thebesius also pre- 
 tends to have seen a fetus, born before the seventh month, which 
 could not cry until the ninth, but which was still very weak after the 
 lapse of a year. Pleissmann cites another such case, quite similar 
 to that of Brousset, except that the foetus was born at a more ad- 
 vanced stage of the pregnancy. The daughter of P. Soranus, ac- 
 cording to Cardan, came into the world at the sixth month : to 
 nourish her they were obliged to pour milk into her mouth by means 
 of a funnel, which did not prevent her from running a long career*. 
 Millot, who, in the matter of proof, does not seem to be very diffi- 
 cult, speaks of a certain Julius Modie, born in the year V, at five 
 months and a half, and who was so small and weak that at first he 
 could not suck at all. This child, however, grew very well. Have 
 we not also had, as proof of anticipated viability, the history of the 
 famous Bebe de Nanci, who only weighed one pound at birth, 
 whose first cradle was a sabot, says the Count de Tressan, and of 
 which there is a wax model in the cabinets of the school of Medicine 
 at Paris. But I ask, what conclusion can we draw from observa- 
 tions so imperfectly substantiated, from facts encompassed with so 
 many marvels, and citations so improbable. 
 
 * Spigelius speaks of a man who was born at the commencement of the sixth 
 month, and who was obliged to be kept wrapped up in cottoa for more than six 
 weeks. Montus says that the cup-bearer of Henry III was born at five months; 
 Avicenna, Diemerbroeck, Vallesius, and Mena speak of facts nearly similar, and 
 quite as authentic.
 
 228 THE FOETUS. 
 
 589. While admitting with Chaussier, M. Orfila, and some others, 
 that none of the facts related by the authors demonstrate beyond 
 reply that the foetus is viable before the seventh month, I cannot, 
 however, agree with them that the thing is impossible. A woman 
 came in 1825 to be delivered at my amphitheatre, after she had had 
 a fall ; her last child was six months and three days old ; she sup- 
 posed herself to be only five months gone with child, and if she had 
 had commerce with her husband fifteen or even twelve days after 
 her lying-in, it was at any rate impossible for her to have entered 
 on her seventh month. Now this woman brought into the world a 
 little girl that weighed two pounds, which besides presented all the 
 appearances of a foetus of about five months, whose cries were so 
 weak they could scarcely be heard, who notwithstanding breathed, 
 and lived in this state for four days. 
 
 590. In the course of the same year, a young woman miscarried 
 at the hospital de Perfectionnement ; having been delivered of a child 
 at term five months and twelve days before, in the same hospital, it 
 was impossible for her to be more than five months pregnant. The 
 foetus she brought forth weighed only one pound and a quarter, its 
 skin was of a bright rose colour, and had on it no down nor seba- 
 ceous matter ; its length from the vertex to the sole of the foot was 
 only nine inches. Notwithstanding this, my attention and that of the 
 pupils was attracted to it by some stretchings and slight movements 
 of its limbs ; we wrapped the delicate creature in cotton, and placed 
 it near its mother, who was told to pour a few drops of milk into its 
 mouth from time to time ; but as she thought such an abortion could 
 not live, she did not judge it proper to do any tiling to prevent it 
 from dying. It expired in fact the next morning, twenty-eight hours 
 after it was born. 
 
 591. My object is not by any means to maintain that these foetuses 
 were viable; I merely wish to show that it is not strictly correct to 
 say in a positive manner, that a child born previously to the last 
 three months of pregnancy must be reputed not viable. 
 
 592. A foetus is niabk when sufficiently developed to move its 
 limbs, and when it really does move them ; when it cries and breathes 
 freely ; when its head is covered or begins to be covered with hair ; 
 when its skin is no longer transparent, is covered with down and 
 coated with sebaceous matter ; when the bones of the cranium touch 
 along the greater part of their edges, and the sutures and fontancls 
 arc consequently very much closed ; when it passes off its meconium 
 am! unim ; wtirn iho proportions and dimensions of the different 
 
 of its body arc not too far removed from what is observed in 
 foetuses at term : and not because it is exactly seven months old or
 
 VIABILITY OF THE FCETUS. 229 
 
 more. For the same reason it ought not to be declared not viable 
 because it is born before the three last months of gestation, but rather 
 because the absence of its cry, a respiration scarcely discernible, 
 very feeble motions, inability to take hold of the nipple or finger, to 
 void its meconium and urine, softness and separation of the bones of 
 the head, the absence or fewness of hairs, the transparency and red 
 colour of its skin, the want of a sebaceous deposit, the thinness of 
 its nails, &c., prove that its organs are still far from the degree of 
 perfection necessary for the maintenance of its exterior life. 
 
 593. Hippocrates and many other physicians of antiquity taught 
 that the foetus is more viable at seven months than at eight. At first 
 view, such a proposition appears somewhat absurd ; all other things 
 being equal, a foetus likely to live at the seventh month, will, a for- 
 tiori, be viable if not born until the eighth month. The very strong 
 movements of the fetus about the seventh month, and which gave 
 rise to a belief in the somerset, rendering premature delivery much 
 more common at that period than at any other, the ancients drew 
 from it the conclusion that the seventh month is a natural term of 
 pregnancy, and that if the foetus over-passes that, it could not be 
 born without danger until the end of the ninth month. It is difficult 
 to understand how they should have made a double mistake on this 
 subject, unless, with M. Dubois, we admit as a fact, that if labour 
 takes place in consequence of the lively agitation of the foetus, as 
 pretty often happens at the seventh month, the cervix dilating with 
 its accustomed gentleness and regularity, the child will be exposed 
 to less risk than if born at eight months, when delivery is provoked 
 by a fall or some other external accident. In the former case, in 
 fact, early parturition is in some sort natural, while in the latter, it 
 is only a kind of abortion. 
 
 ARTICLE III. 
 Of Abnormal Expulsions of the Human Ovum. 
 
 SECTION 1. 
 ^* Of Abortion. 
 
 504. When the expulsion of the ovum takes place within the first 
 six months of pregnancy, it is called an abortion, miscarriage, or 
 Uessure,
 
 230 THE FCETUS. 
 
 According to Aristotle, " if the foetus comes away before the 
 seventh day after the conception, the accident is called a show ; at 
 a later period, but before the fortieth day, the woman is said to be 
 wounded." In the former case it is an efflux; according to Bonac- 
 ciolus, effluxiones, qua intra diem septimum ; in the latter it is an 
 aborsus ; dborsus qua primis mensis ; or an abortus ; abortus quce 
 intra quadragesimum. But these arbitrary and insignificant dis- 
 tinctions have been neglected for a century past, both by physicians 
 and accoucheurs. 
 
 595. Frequency. In twenty-one thousand nine hundred and sixty 
 cases of pregnancy, Madame Lachapelle informs us that she observed 
 one hundred and sixteen abortions. According to that author, mis- 
 carriages are more frequent at six months, then at five, then at three, 
 than at any other period of gestation. M. Desormeaux, in accord- 
 ance with almost all the ancient authors, with reason, and with my 
 own observations, thinks, on the contrary, that it is the more com- 
 mon as pregnancy is less advanced. If Madame Lachapelle men- 
 tions a different result, it is evidently because abortion in the early 
 periods does not occasion so much inconvenience to women as to 
 cause them to go to the hospital ; which is not the case after the 
 first half of pregnancy has been passed through ; or perhaps because 
 in the first six weeks, the ovum and the embryo, frequently confound- 
 ed with clots of blood, occasion the woman to suppose that she has 
 only had a return of the menses, while at a later period she cannot 
 make such a mistake. 
 
 596. Morgagni was of opinion that he had noticed more abortions 
 of female than of male foetuses; M. Desormeaux is of the same way 
 of thinking, and says that if the vulgar think differently, it is owing 
 to the circumstance, that in the early stages it is very easy at a first 
 glance to mistake a girl for a boy. This remark, which had been 
 previously made by Morgagni, is very just, provided it be applied 
 only to the first two or three months. Madame Lachapelle has seen 
 more female than male embryos, and more male than female foetuses. 
 Upon the whole, abortions of females seem to exceed those of males 
 in proportion to the nearness to the period of conception ; and if it 
 were true, as it is in Germany said to be, that the two sexes are at 
 first confounded, or that the creation of the female sex depends 
 merely upon an arrest of the growth of the genital organs, the female 
 abortion ought to be the only one at the early stage. 
 
 f>'.n. ('au.scs. Tt appears that the causes of abortion have been 
 till lately l>ut ill understood, and tlie labours of M. Desormeaux, of 
 Madame Lachapelle, of M. DIIIM'-S and Madame Boivin could not 
 have come more opportunely to throw some light upon this matter.
 
 ABORTION. 231 
 
 They may be divided into remote and proximate causes ; or into 
 efficient and determining causes. The proximate or efficient causes 
 are constituted by the contractions of the womb, assisted by the mus- 
 cular efforts of the woman ; the determining causes may be divided 
 into predisposing and occasional. 
 
 The predisposing causes may be connected with the state of the 
 woman or of the ovum ; relatively to the woman, some of them de- 
 pend on certain general dispositions of the economy, and others on 
 a special state of the sexual organs only. 
 
 598. General state. Women who are plethoric, who menstruate 
 abundantly and regularly, who are irritable, excessively sensitive, 
 nervous, hysterical, lymphatic, of a fair complexion, weakly, sickly, 
 who have large eyes and a bluish sclerotica ; persons affected with 
 syphilis, scurvy, rickets ; those who have a badly formed pelvis, some 
 organic lesion, or any chronic disease ; those who are asthmatic, 
 dropsical, affected with cancer ; those who are badly nourished, and 
 those who compress their bellies by lacing, or wear their clothes too 
 tight, miscarry more frequently than others : and the reason of it may 
 be easily conceived. Marshy and unhealthy countries ; certain atmos- 
 spheric constitutions, formerly mentioned by Hippocrates, and fre- 
 quently observed since his day, and which render abortions really 
 epidemic at some seasons ; watchings, and fatiguing occupations 
 are also classed among the predisposing causes of miscarriages. 
 
 599. Affections of the sexual organs. On the part of the sexual 
 organs these are, all the chronic diseases to which they are subject, 
 adhesions, deformity, displacements ; alterations, whether scirrhous, 
 encephaloid, or hydatiform ; sub-inflammation of the ovaries and all 
 the disorders that it occasions ; organic alterations of the Fallopian 
 tubes ; fibrous, polypous or other productions in the tissue of the 
 womb itself, or the neighbouring parts ; preternatural adhesions of 
 the broad or round ligaments, or of the tubes or ovaries to the sur- 
 rounding parts, or to each other ; chronic metritis and all its con- 
 sequences ; anteversion and retroversion ; scirrhus and cancer ; 
 transformations and affections of whatsoever nature ; in fine, what- 
 ever may interfere with the easy and regular enlargement of the 
 womb during pregnancy. 
 
 600. This genus of causes, formerly noticed by several authors, 
 amongst others by M. Delpech, has lately been well discussed by 
 Madame Boivin in a memoir ad hoc, which in fact deserves the at- 
 tention of every accoucheur ; its mechanism and frequency may be 
 easily conceived of by reflecting on the affections that take place 
 in a multitude of women at the period of puberty, before or after 
 the occurrence of that revolution, and indeed at all periods of their
 
 232 
 
 THE F(ETUS. 
 
 lives ; affections that are most generally occasioned by a material 
 lesion of some portion of the generative system ; and do not com- 
 monly disappear without leaving behind them the indelible traces of 
 their existence. Sometimes it is a tumour in the excavation that 
 prevents the enlargement of the uterus ; at others it is an ovary that 
 has degenerated or been transformed into a cyst, and become lodged 
 in the recto-vaginal fossa, a case of which came under my own no- 
 tice ; sometimes the right tube is glued to the ligament of the left 
 ovary, and vice versa, and even, besides, so as to adhere behind the 
 cervix, of which I saw an instance in a woman who died when about 
 three months gone with child ; more frequently, there are encepha- 
 loid and scirrhous masses, either occasioned by the pregnancy, or 
 whose germs existed previously to the conception, which, by affecting 
 the ovaries, the tubes, the pelvic peritoneum, or the substance itself of 
 the womb, oppose an invincible obstacle to the changes of structure 
 and dimensions indispensable in these organs for the completion of 
 gestation, of which I have collected pretty numerous examples, &c. 
 
 601. Leucorrhoea, hydrometry, irritability ; too great a degree of 
 contractility ; rigidity of the fibres and even of the vessels, and if we 
 may believe Hauenschild and Loder, of the peritoneum of the uterus ; 
 and a laxity or atony of its neck, on which M. Desormeaux rationally 
 insists, are also admitted among the number of the predisposing 
 causes of abortion ; but for the most part their action is far from 
 being so evident as the preceding. The same may be said of a want 
 of extensibility of the uterus, occasioned by a too great firmness of 
 its fibres, a firmness on which many authors lay so much stress. 
 According to their statements, abortion is to be feared because the 
 womb does not yield with facility to the effort which tends to dis- 
 tend it. In this respect, their language, always similar to that of 
 the ancients, who supposed that the ovum acted mechanically upon 
 the womb, would lead us to suppose that there is a sort of contest 
 between the containing and the contained ; however, nothing of the 
 sort takes place : the womb enlarges in consequence of the unfolding 
 of its fibres, and the affluxion of fluids into its vessels ; the ovum 
 ceases to grow as soon as the organ that contains it ceases to de- 
 velope itself, and abortion may follow as a consequence thereof, but 
 without our being able to accuse a distending power which it by 
 no means possesses. By rigidity of the uterus we ought to under- 
 stand a want of disposition in it to imbibe, to soften and distend, in 
 consequence of the accumulation of fluids in the interstices of its 
 tissue, and not any resistance it may oppose to tlic swelling of the 
 ovum. 
 
 602. Diseases of the ovum. The foundation of an abortion in a
 
 ABORTION. 233 
 
 majority of cases is laid in some peculiar disposition of the ovum 
 itself, and I am astonished that authors have paid so little attention 
 to this predisposing cause : like fruits that perish before they have 
 attained their full growth, and separate and fall at the slightest shake 
 of the branch on which they grow, so the embryo or the fetus in ani- 
 mals must become detached and soon afterwards expelled from the 
 womb when it has ceased to live. 
 
 603. The alterations capable of bringing about the death of the 
 foetus are extremely numerous, and so much the more so, in pro- 
 portion as the pregnancy is advanced. Since I began to pay regu- 
 lar attention to (he subject of embryology, I have carefully observed 
 one hundred and fifty products that had not gone beyond the term 
 of three months ; now I can assert that of this number at least one 
 half were diseased. 
 
 604. Sometimes the disease commences in the membranes ; the 
 chorion thickens, becomes opaque, and is covered with rugosities 
 on its internal surface; the granulations on its external surface 
 swell, and give birth to hydatids-in-bunches in the womb, and to 
 the hydatiform mole, which Madame Boivin erroneously regards as 
 a dependency on the amnios, &c.; the latter undergoes alterations 
 that are nearly similar, is disorganized, or contracts adhesions with 
 the surrounding parts ; the placenta is not formed, or is irregularly 
 developed, is transformed into hydatic granulations, and becomes the 
 seat of all sorts of degenerations. 
 
 Sometimes, and perhaps most frequently, the disease attacks the 
 umbilical vesicle or its duct ; in others it affects the cord or the em- 
 bryo itself, and in this respect the forms and degrees of the altera- 
 tions are exceedingly various. 
 
 605. Almost all the diseases to which the child is liable after 
 birth, may manifest themselves during its intra-uterine life. In an 
 embryo of two months I have seen adhesion of the whole length of 
 the members to the trunk ; I have seen ulcerous destruction of the 
 head, belly, hand, &c. in subjects quite as young as the above- 
 mentioned ; also, manifest alterations in the lungs, the liver, the peri- 
 toneum, and other parts of the body as early as the third month ; I 
 have found the umbilical cord in a state of atrophy, and its vessels 
 either quite or almost obliterated, at every stage of its development. 
 In several specimens the umbilical vesicle was hard, and as it were, 
 stony ; in others it was full of a clear limpid fluid, and in two cases 
 it was not of a natural size, nor had it the other appearances that 
 naturally belong to it. In some embryos the head alone was atro- 
 phied and deformed ; in others the same state was observed in one 
 or more of the limbs, the breast or the belly ; most commonly, the 
 
 2 E
 
 234 
 
 THE FCETUS. 
 
 atrophy, or the disorganization is general, and in some cases the 
 embryo at last wholly disappears. In such instances the amnios is 
 most commonly destroyed also ; I have many times found the ovum a 
 mere sac, filled with an albuminous, limpid and viscid fluid ; I could 
 almost believe with Walter, Burns, Beclard, and M. Duges that 
 such ova, composed merely of the caduca and chorion, had never 
 contained an embryo ; that they might be compared to those eggs 
 without germs, that are laid by pullets, that have never been fecun- 
 dated by the cock ; but as in several of them there were still to be 
 found the traces of an amnios, an umbilical cord, or of the fetus 
 itself, it was necessary to renounce such an idea at once. 
 
 606. I have, besides, certain proof that most of the cases of mon- 
 strosity, even those vvhioh in our times are so complacently ac- 
 counted for on the theory of an arrest in the process of evolution, 
 are nothing more than the results of disease in some part of the 
 ovum ; but I reserve the development of these assertions for another 
 work ; let it suffice to remark in this place, that the human embryo, 
 a mere vegetable during the first months of pregnancy, is surrounded 
 with too many causes of destruction to be able always to resist them 
 successfully ; that nothing ought to be more easy to ascertain than 
 the disease and even the death of a being whose existence is so frail 
 and precarious ; and finally, whenever the ovum is diseased to such 
 an extent as to cause the death of the embryo, abortion is in some 
 measure one of its necessary consequences. 
 
 607. I will not, with Madame Lachapelle, say that, after the death 
 of the foetus, the womb becomes the seat of a congestion, because 
 the blood, which previously passed into the placenta, surcharges it 
 by stagnating in its vessels ; nor that this embarrassment, definitively, 
 is the cause of abortion. Such a supposition does not appear to me 
 to be tenable, and I should not have alluded to it, had not M. De- 
 sormeaux seemed to lend it a new force by the strength of his au- 
 thority. As soon as the ovum ceases to live, it becomes only a 
 foreign body in the uterus ; thenceforth the organism tends to 
 throw it off, as it does whatever interferes with its operations, as a 
 thorn, for example, but not because the blood primarily destined 
 for the fetus is compelled to re-enter the torrent of the maternal 
 circulation. 
 
 608. Weakness of the fetus, its convulsive motions, the super- 
 abundance, or too small quantity of the liquor amnii, circumvolu- 
 tions of the cord around its neck, &.C., knots in it, its shortness, its 
 excessive length, cyats, or any accumulations of fluids between the 
 membranes, effusions of various kinds, whether diffuse or circiiin 
 scribed, in the substance of the placenta or caduca, are also causes
 
 ABORTION. 235 
 
 capable of bringing on abortion, but not inevitably, like the affec- 
 tions I spoke of just now. 
 
 609. Occasional causes. The predisposing causes alone would 
 very rarely fail to bring on the expulsion of the ovum ; they in fact 
 frequently do produce it, and in these cases the abortion is said to 
 be spontaneous; however, it is almost always attributed to some 
 accident, some particular circumstance, which, in the eyes of the 
 public, and even of many physicians, passes as the only and principal 
 cause of it. The generality of people being unable to conceive, and 
 professional people having scarcely imagined that the principle of 
 abortion might reside in the ovum itself, it has followed that a thou- 
 sand insignificant causes have by turns been brought to its explana- 
 tion ; that the slightest actions, those capable of effecting the smallest 
 change in the economy, have been classed amongst its occasional 
 causes. 
 
 610. Such for example among others are yawning, pandiculation, 
 the act of going to stool, of voiding urine, of coughing, great exer- 
 tions, disappointments, joy or grief, the odour of the snuff of a can- 
 dle, the impression of any strong odour whatever, an hysterical fit, 
 epilepsy, coitus, dancing, sleeplessness, diarrhoea, tenesmus, and all 
 the causes that might occasion uterine hemorrhage during preg- 
 nancy. 
 
 611. I do not wish to be understood, however, that none of these 
 causes may give rise to abortion ; but only, that, without the ante- 
 cedent existence of one of the predisposing causes above enume- 
 rated, they would scarcely ever determine it, and that they most 
 commonly are merely coincidences. The same may be said of the 
 acute diseases of the woman, of asphyxia, of all sorts of inflamma- 
 tions, of crying, of singing, of the jolting of a carriage, of vomiting, 
 of the use of certain medicines, of falls, blows, violent motion of 
 what part of the body soever, of any thing that might shake or shock 
 the uterus. 
 
 612. It has been generally thought that these causes act by de- 
 taching the placenta; but when it is remembered that the ovum fills 
 the womb exactly, and is itself perfectly filled with the liquor amnii 
 and foetus, it is evident that motions impressed on the womb by ex- 
 ternal shocks are as incapable of separating the placenta from the 
 womb, or the chorion from the amnios, as they would be to separate 
 two bladders, one contained within the other, and the inner one full 
 of fluid : the most active and imprudent women, those who give 
 themselves up to the most violent exercises, do not on that account 
 fail, most generally, to go their full time ; while many others are 
 found to abort in spite of the most minute precautions, and the most
 
 236 THE FffiTUS. 
 
 persevering attentions. A woman, says Maurieeau, who was seven 
 months gone with child, in order to escape from her chamber, which 
 was on fire, got out of a third story window ; fear soon made 
 her let go her hold, and she fell on the stones, and fractured her 
 fore-arm, but her pregnancy was not disturbed. A young midwife, 
 mentioned by Madame Lachapelle, who was pregnant, and affected 
 with deformed pelvis, threw herself from . the top of a stair into a 
 deep cellar, with a view to bring on abortion, and thereby avoid the 
 Cesarean operation : she died a few days afterwards of her wounds, 
 but there was no abortion. 
 
 613. Medication. Bloodletting, baths, emetics, purgatives and 
 emmenagogues also enjoy a great reputation among the women, as 
 abortives, which happily is but little deserved. Diseases are daily 
 met with in practice which require repeated bleedings, whether ge- 
 neral or local, and for which the tartar emetic is administered, as well 
 as drastic purgatives and other equally active substances, without the 
 pregnancy seeming to suffer from them. Maurieeau speaks of a 
 woman who was bled from the arm eighty-six times in one preg- 
 nancy, and who notwithstanding was at the end of it delivered of a 
 fine large child : he mentions another who was bled from the foot 
 ten times without experiencing any inconvenience. Delamotte has 
 seen the most powerful evacuants produce gastritis, enteritis, perito- 
 nitis and even death itself, without being followed by the expulsion 
 of the ovum. I had the care of a young person who, with a design 
 of concealing the proofs of her dishonour, had produced a violent 
 abdominal inflammation by taking medicines to promote abortion ; 
 she died on the eighth day without any symptom of abortion havin^ 
 appeared. I was consulted for another person, who had, with the 
 same view, taken fifteen grains of tartari/ed antimony : it produced 
 most violent efforts at vomiting, but the progress of the pregnancy 
 was not interrupted. 
 
 C 1 4. It ought not however to be concluded from the above facts that 
 bloodletting, particularly from the foot, or the application of leeches 
 to the vulva, or that baths too frequently repeated, &.c. can never 
 be injurious to pregnant women ; I merely wish to say, that except 
 in case of some peculiar predisposition, these measures most com- 
 monly produce no effect, and that they may be had recourse to if 
 circumstances require them, just as if the woman were not pregnant. 
 M. Dcsormeaux had already pointed out the fact that abor- 
 tion is frequently preceded by a state of irritative congestion of the 
 ;ltcri ''-il ii:brilo pxcitemcnt, the train of .symptoms which 
 
 constitute tho mttlhncn hcmorrhagicum. Very recently Madame l,n- 
 chapelle and M. DUL'.-.-S have strongly insisted on this condition, UK
 
 ABORTION. 237 
 
 wards which, in fact, almost all the predisposing and occasional 
 causes of abortion tend, previously to bringing into play the con- 
 tractile powers of the womb ; but it was an error to regard it as the 
 primitive cause of almost all miscarriages ; it is commonly only a 
 secondary phenomenon, an effect of some other external or internal 
 cause, and not a necessary result of any of them ; however, there are 
 some women who exhibit it in an evident manner at each menstrual 
 period throughout the whole course of gestation ; whence it follows, 
 that it may suffice to detach the ovum, especially within the first 
 three or four months, and that Klein, as approved by M. Desor- 
 meaux, Madame Lachapelle and M. Duges, had a right to say, that 
 abortion is never more common than during the menstrual periods ; 
 besides, it plays in this case the same part it does in the causation 
 of floodings. 
 
 616. Periodical abortion, or that which in the same woman re- 
 curs at nearly the same period from conception, is one which ap- 
 pears to be most evidently connected with a menstrual or spontaneous 
 molimen. It may, however, also depend on a special state of the 
 
 r omb, either congenital or acquired ; for example, upon the womb 
 sing incapable of distension beyond a certain degree. On this 
 >int the influence of habit or hereditary constitution is commonly 
 referred to ; the cases of many women are cited whose mothers 
 were subject to abortion, and never able to carry a foetus to full 
 term. Observation has proved that miscarriage is so much the 
 more to be apprehended in proportion as the individual has been 
 previously subject to it ; the case is mentioned of a young girl who, 
 having by criminal methods several times procured abortion of her 
 foetuses, could never carry one to the full term after she became a 
 married woman. 
 
 617. The mechanical causes, or certain manoeuvres, recommended 
 by some authors, in cases of deformity of the pelvis, and which in 
 the midst of our refined society are also employed by degraded 
 wretches not less criminal than the unnatural women who are not 
 ashamed to submit to their disgusting ministrations, must be arranged 
 amongst the same class with emmenagogues and drastic purgatives. 
 Those who make use of them most frequently fail of attaining their 
 object, and succeed only in seriously injuring the womb. I once 
 prescribed for a female, in whom such attempts had brought on a 
 flooding which conducted her to the verge of the grave ; she suffered 
 horribly from pain in the interior of the pelvis for two months, not- 
 withstanding which abortion did not take place, and she is now 
 a prey to a large ulcer of the neck of the womb. I opened the 
 body of an unhappy creature who suffered from the like attempts,
 
 238 THE FCETUS, 
 
 which did not succeed any better than the one above mentioned. 
 M. Girard of Lyons mentions a similar instance. Very recently, 
 also, (October 1828) a young woman, who became pregnant against 
 her wishes, succeeded by such manoeuvres only in producing an 
 organic lesion of the uterus, which, after frightful sufferings, led hei 
 to the commission of suicide. 
 
 618. Signs. After protracted disease, and within the first two or 
 three months, the expulsion of the ovum is often effected without 
 being accompanied by any particular symptoms, and does not sen- 
 sibly differ from what takes place at a somewhat painful menstrual 
 period. But at a more advanced stage it can only give rise to the 
 ordinary phenomena of a natural labour ; yet it is most commonly 
 preceded by lowness of spirits, a general depression, by lipothymia, 
 syncope, a feeling of coldness in the epigastrium, palpitations, pale- 
 ness, fetid breath, flaccidity of the breasts, and a major part of the 
 rational signs indicative of the death of the fetus. Ordinarily, as 
 has been before remarked by Roderic a Castro, MM. Foder6 and 
 Desormeaux, Madame Lachapelle and M. Duges, the woman at 
 first, for one or more days, has rigors, horripilation, a hot skin, 
 thirst, want of appetite, increased movements of the heart and arte- 
 ries, a feeling of weight in the pelvis, about the fundament or loins, 
 and a general lassitude of the limbs, as if threatened with some 
 severe disease ; next appears hemorrhagy, accompanied with pain 
 of greater or less severity, and all the symptoms of real labour; but, 
 amongst all these signs, scarcely any, saving hemorrhage and pain, 
 afford any certainty previously to the dilatation of the cervix, and 
 the presence of a portion of the ovum in the upper part of the 
 vagina. 
 
 G19. Hemorrhage itself is not invariably followed by abortion, as 
 is proved by the observations of Mauriceau. Raymond, de Boer, 
 &c.; nevertheless, there is good reason to fear it when that symptom 
 once takes place. But before we accord to it any value, we should 
 know how to distinguish it from the menstrual discharge, which 
 sometimes continues throughout the whole of pregnancy. I have 
 already at another place (312) hinted that this discrimination is 
 at the beginning very difficult, and must here repeat that this kind 
 of abnormal menstruation, to which Madame Lachapelle appears 
 not to give much faith, is notwithstanding not of very rare occur- 
 rcnr.e ; I could add two instances to those related by Portal, De- 
 Amand, Baudclocquo, &,c., and I can affirm that in these 
 two women the catamcniao had never occurred with greater regu- 
 larity. 
 
 0. As to the pains, it is important that they should not be con-
 
 ABORTION. 239 
 
 founded with the colic, or with those uterine pains that are also 
 occasionally met with during menstruation ; for this end, reference 
 should be made to the signs indicated in regard to the pains of 
 labour. 
 
 621. The discharge of a certain quantity of brownish matter, or 
 of serosity, the softening of the cervix, the rupture of the mem- 
 branes, the formation of the bag of waters with pains extending 
 from the navel towards the excavation, constitute the most conclusive 
 signs of miscarriage ; nevertheless, M. Desormeaux has known all 
 these signs to be present after a fall, and yet abortion did not ensue. 
 M. Morlanne relates the case of a woman who was not delivered 
 until six weeks after the discharge of the waters; there has also 
 been recently mentioned the case of a woman six months gone, in 
 which the bag of waters was formed, and then ruptured, so that the 
 arm of the child engaged in the vagina ; after which the labour was 
 arrested, the fetus returned to its proper position, and the preg- 
 nancy proceeded in its natural course ! The author of it saw and 
 felt : we must believe him. 
 
 622. The fluid that escapes from the cervix may besides come 
 from an hydatic cyst, or from between the membranes ; in such a 
 case, it is very evident that the pregnancy might not be necessarily 
 disturbed ; it may also proceed, in double pregnancy, from the rup- 
 ture of one ovum, while the other may not suffer the least alteration ; 
 but with the exception of these anomalies, it appears evident that 
 the rupture of the membranes, followed by the discharge of the 
 waters, positively indicates miscarriage, or at least the death of the 
 foetus, if it is not soon expelled. 
 
 623. The child having ceased to live, is generally soon thrown 
 out by the uterus ; but in some cases, its expulsion does not take 
 place for a pretty considerable period. I have seen it not take place 
 until the twenty-eighth day in a woman who was seven months with 
 child. In another woman, the pregnancy, which was ascertained by 
 ballottemcnt. and active motion of the foetus, suddenly stopped at six 
 months ; all the signs of the death of the child supervened ; the belly 
 gradually lost one half of its size ; from this period eight months 
 elapsed ; the cervix remains closed, and nothing indicates that mis- 
 carriage is about to take place soon. M. Prout gave me an oppor- 
 tunity of seeing a foetus of from three to four months, which was not 
 discharged for five months after the first symptoms of abortion, and 
 numerous authors have mentioned similar instances. 
 
 If the membranes are not broken, and the air does not get access 
 to their interior, the foetus may be preserved without change for
 
 240 THE P(ETUS. 
 
 several months, or even several years, which lias given rise, I pre- 
 sume, to the supposed pregnancies of fifteen, twenty, or thirty months 
 duration, &c. that are spoken of in the scientific collections. This 
 occurrence is met with, particularly in compound pregnancy : one 
 of the foetuses dies at two or three months ; the other continues to 
 grow ; and at the lying-in, the practitioner is astonished to receive 
 both a full grown child and an abortion. I am in possession of a 
 great number of facts of this sort ; MM. Bouvier, Colombe and 
 Defermont, have each communicated one to me, and many of the 
 instances of superfetation that have been most insisted on, are noth- 
 ing more than such as these. 
 
 At other times it is decomposed, putrefies, passes into the state 
 of adipocire, and then the pregnancy goes OB as indicated when 
 we were upon the subject of extra-uterine pregnancy (363). In 
 the first months it may become atrophied, and when the ovum is 
 thrown off, only exhibit the dimensions of an embryo of four or five 
 weeks, although the woman was three or four months gone. It 
 may also dissolve in the waters, and then the ovum is found to be 
 transformed into a real mole. If the membranes give way, the 
 foetus generally escapes first, and the membranes follow soon after- 
 wards. M. Trelat, however, has seen a case in which the ovum 
 was not discharged until twelve days after the expulsion of its in- 
 volucra. 
 
 624. Although the foetus may no longer be in the womb, its 
 coverings may still stick there by means of some adhesion, and con- 
 tinue to live and grow. The caducous membrane soon acquires 
 a considerable degree of thickness ; the amnios disappears ; the 
 cavity of the chorion by degrees contracts, and the mass comes at 
 last to be a reddish fleshy tumour, in the centre of which is most 
 commonly, but not always, found a small serous cavity. In this way 
 are formed most of the fleshy moles, or molts of generation. The 
 placenta may continue to grow alone, or it becomes infiltrated, and 
 when at last it is expelled, it exhibits no resemblance to its original 
 form or nature. 
 
 625. Sometimes the ovum comes away whole; indeed, this is 
 most frequently the case until the end of the second month ; but 
 after this its size does not admit of its being so expelled, in a 
 majority of instances, and so much the less, as the gestation 
 is at a more advanced stage ; however, I saw an ovum of full six 
 months expelled at the Hospital de Perfectionnement, which was 
 not in the least broken. M. Larrey sent me another of five months 
 and a half, which was also quite whole. In the first months of
 
 ABORTION. 241 
 
 pregnancy, instead of coming away with all its appendages, the 
 foetus is sometimes expelled with the amnios alone, or with its am- 
 nios and chorion only. 
 
 626. Prognosis. A miscarriage is generally more dangerous 
 than a labour at term, and those authors have erred who find fault 
 with Hippocrates for having uttered this opinion ; the former is a 
 disease, while the latter is only the termination of a natural function. 
 But to speak correctly, abortion is sometimes not such a serious 
 matter in itself considered, but because the causes which induce it, 
 and the accidents which accompany it generally constitute important 
 diseases ; because the pregnancy, which is terminated by it, has re- 
 called to the genital organs the germ of affections whose existence 
 was not suspected, or which perhaps would have never reappeared 
 but for it. The prognosis ought therefore to vary according to cir- 
 cumstances. If it'appears to draw in its train a variety of nervous 
 affections, pains in the hypogastrium, chronic inflammation of the 
 womb, ulcers, degenerations, and all sorts of organic lesions, it 
 frequently is so because these alterations existed previously to the 
 miscarriage itself; excepting always those cases of abortion produced 
 by the direct agency of mechanical causes. 
 
 627. The least dangerous abortion is that which is determined by 
 a disease of the ovum, and the most serious is that which a violent 
 occasional cause, unaided by any predisposing one, has given birth 
 to ; moreover, all other things being equal, a spontaneous abortion 
 is less to be dreaded than a forced one, and in general, so much the 
 less, in proportion as it is effected with gentleness ; the danger, which 
 for the woman is greater in proportion to the degree of advance- 
 ment of the pregnancy, is, for the foetus, the same at all stages of the 
 gestation. 
 
 Where the cervix is naturally soft and relaxed, while the rest of 
 the womb retains its ordinary density, the miscarriage is both easier 
 and less serious to the woman than in the contrary circumstances ; 
 when produced by a very decided molimen, if there are no compli- 
 cations, it may terminate as favourably as the most simple case of 
 parturition ; but as this hemorrhagic effort is, most frequently, merely 
 the first degree or the symptom of a more or less extensive inflam- 
 mation, there is reason to fear, especially if fever" attends it, either a 
 metritis, an acute peritonitis, or some other phlegmasia equally 
 dangerous. Some authors have contended that abortion may have 
 its advantages, as for example, to render menstruation regular, 
 or restore fecundity ; but it is evident from her miscarrying, that 
 the woman was not sterile ; and besides, if the menses sometimes 
 2F
 
 242 THE FOETUS. 
 
 resume their original type after an abortion, they would have done 
 so with more certainty after a complete pregnancy. 
 
 628. I can conceive of only one case in which abortion could be 
 of advantage by being frequently repeated, and that is where the 
 womb is not sufficiently permeable, or too dense to dilate in pro- 
 portion to the wants of the ovum ; then one miscarriage must ne- 
 cessarily diminish this abnormal rigidity a little ; a second one dimi- 
 nishes it still more ; and finally, a third or a fourth may completely 
 overcome it so as at last to render it possible for the woman to con- 
 duct the foetus to delivery at full term. 
 
 Treatment. The practitioner should turn his attention to the pre- 
 vention of miscarriage, for when it has once commenced, all he has 
 to do is to hasten its termination. 
 
 629. The preservative treatment must necessarily vary according 
 to the nature of the determining causes we have to remove or com- 
 bat : if the woman is irritable and very sensible, we must do all in 
 our power to protect her from moral commotions ; she should be 
 kept out of large cities ; travelling should be recommended to her 
 for change of scene, &c. Those who are weakly and lymphatic, 
 should follow an analeptic regimen, and keep quiet, or at least en- 
 gage only in agreeable exercise : in some cases a tonic medicine may 
 be administered. Should there be a disease of the uterus or of 
 some other organ, its nature should be carefully inquired into, so 
 as to apply the suitable remedy. When signs of plethora or of con- 
 gestion are present, blood is to be taken from the arm, which may 
 be repeated once or oftener if circumstances require it, particularly 
 in women in whom each menstrual period is marked by an evident 
 molimen. 
 
 Bleeding is certainly one of the best means of preventing abor- 
 tion ; but it would be dangerous to conclude with the vulgar, that 
 it is useful in all pregnancies indiscriminately ; where no particular 
 circumstance calls for it, it may be injurious to pregnant women as 
 well as to other persons, and too much fault cannot be found with 
 the habit that some fall into of being bled once or twice during their 
 pregnancy without knowing whether there is any real need for it 
 or not. 
 
 630. As soon as the signs of abortion become manifest we ought 
 to act in the manner I shall point out in the article on uterine hem- 
 orrhagies ; in general, the most absolute rest, horizontal posture, 
 cold acidulous .drinks, external revulsives, applications of ice itself, 
 and anti-spasmodics and composing medicines, if there is any agita- 
 tion and tendency to convulsions, will be successively tried ; blood- 
 letting is stiH the most powerful resource to be made use of, but
 
 ABORTION. 243 
 
 nevertheless it is not to be employed without reserve and caution, for as 
 it does not always prevent miscarriage, it is liable to be charged with 
 the production of an accident which it was impossible for it to pre- 
 vent ; bathing the feet, the hands, and the whole bath should be 
 avoided while there is any hope remaining of being able to avoid 
 the expulsion of the ovum ; otherwise they may be used with ad- 
 vantage. 
 
 631. Where the hemorrhage is of an alarming character, we 
 have a precious resource in the tampon, which has been too much 
 neglected by the moderns ; it not only often arrests flooding, but be- 
 sides this, it does not always hinder pregnancy from going to its full 
 term, as noticed by Gallandat, M. Desormeaux and Madame Lacha- 
 pelle. Denman, Kok, and Kluyskens have spoken highly of its em- 
 ployment in such circumstances ; and like M. Hervez de Chegoin 
 who makes frequent use of it, I for my part have nothing to say, ex- 
 cept what is wholly in favour of its employment. Perhaps also the 
 ergot might be efficacious in such cases ; but as it favours the ex- 
 pulsion of the ovum, it would not be prudent to make use of it until 
 after having tried all other means. Finally, when abortion is once 
 decided, it requires the same cares as hemorrhage, properly so 
 called, or as convulsions. 
 
 632. To promote the expulsion of the product of conception, 
 when the impossibility of retaining it in the womb is once ascertain- 
 ed, we continue the use of the same means ; if the woman is strong 
 we recur to bloodletting ; but rest and the horizontal posture are 
 less indispensable ; baths and ergot may be administered without fear. 
 Opium administered internally if the pains are very strong ; seda- 
 tive ointments, or ointment of belladonna applied to the cervix, if that 
 part is painful, and in a state of spasmodic constriction ; and emol- 
 lient injections into the vagina may be of use in some cases. If the 
 ovum is too long in passing through the cervix, it may be of advan- 
 tage to insert the finger into that part and thus assist in the expul- 
 sion ; but we should not determine to remove it with the pinces a 
 
 faux germe of Levret, the placenta hook of Dewees, nor any other 
 instrument, unless there should be a pressing necessity to deliver 
 the woman at once, for we run the risk of not getting the whole 
 away, and of being unable subsequently to reach the remaining por- 
 tions which could not be seized at first. 
 
 633. After the escape of the foetus, every thing returns to its na- 
 tural state, just as it does after a lying-in. The deliverance of the 
 placenta, the milk fever, and the sequelae of the labour require the 
 same cares, particularly if the pregnancy have exceeded the fourth 
 month, and even in the first months, when the ovum comes away
 
 244 THE FCETUS. 
 
 whole ; but if the membranes are left behind after the expulsion of 
 the foetus or embryo, as they compose the chief portion of the pro- 
 duct, the consequences do not always terminate at once ; in such 
 cases we can never feel secure until after their complete expulsion, 
 and it would be wrong not to extract them as soon as it is possible 
 to seize them in the vagina*. 
 
 SECTION 2. 
 Of the Term of Gestation, and of Retarded Births. 
 
 634. The natural duration of gestation in the human species is 
 generally nine months, or rather two hundred and seventy days. 
 "Man only," says Aristotle, "is born at seven, eight, nine or ten 
 months ; the last named period is the most common ; sometimes, 
 however, pregnancy lasts until the commencement of the eleventh 
 month." According to Pliny, gestation may continue a whole year. 
 Riolan thought he had seen pregnancies of twelve, thirteen, four- 
 teen, fifteen, and even of eighteen months. Kiperus, according 
 to Millot, and Chanvalon pretend that the duration of pregnancy 
 varies according to climate. Heister thinks we may establish 
 that the term of nine months is the most ordinary one, and that 
 the time fixed by nature is that which elapses from the seventh to 
 the eleventh month. Sennertus thinks that every birth should be 
 deemed regular that happens within one year. Blancard, Hoff- 
 mann, Mauriceau, Schenk, and De la Motte have related cases 
 confirmatory of the opinion of Heister. Levret contents himself 
 with advancing that the woman most commonly carries the child 
 nine months, that many exceed that term, but that few go beyond 
 the tenth month. 
 
 635. In a cause that was pleaded by the celebrated lawyer Gerbier, 
 the duration of pregnancy suddenly gave rise to some very animated 
 discussions, about the middle of the last century. 
 
 Ilallcr, Berlin, Lieutaud, A. Petit especially, and Lebas, Vicq- 
 d'Azyr, and Roussel, who were partisans of protracted pregnancy, 
 were vigorously opposed by Bouvart, Mahon, Ilebenstreit, and 
 Louis. The latter author had no difficulty in demonstrating that 
 the numerous histories of protracted pregnancies mentioned by his 
 antagonists prove nothing in the present case, and that women scarcely 
 ever know the precise period at which they were fecundated ; but he 
 was wrong to appeal to the immutability of the laws of nature, and 
 
 * Soa the article on Delivery of the Placenta.
 
 DURATION OF PREGNANCY. 245 
 
 the necessity of not interfering with social order. "If," cried he 
 in his enthusiasm, " you add to the means women already possess 
 of deceiving those about them, the faculty of giving posthumous chil- 
 dren to their husbands whenever they choose, what will become of the 
 order of succession, and even of the entire social order ?" As if, in 
 the natural sciences, we ought not to seek after truth rather than 
 concern ourselves about social conventions ! On the other hand, 
 Petit and Lebas too complaisantly admitted as proved what was not 
 even in every instance probable ; so that in spite of the numerous 
 analogies with which they fortified their opinions, the question re- 
 mained undecided both by naturalists and physicians. 
 
 636. At present the state of the case is changed ; the antagonists 
 of Petit relied chiefly on the circumstance that, according to Aris- 
 totle, " the period of gestation in animals is limited to a fixed space, 
 and the term at which they bring forth is not subject to any varia- 
 tion." But as Buflbn had before pointed out, this assertion is wholly 
 false ; Millot speaks of a cow which brought forth its calf five 
 days after the term, and of a cat that kittened nine days before the' 
 regular period. Besides, M. Tessier, member of the Academy of 
 Sciences, a man whose honour and good faith cannot be called in 
 question, has removed all doubt upon this subject. 
 
 He found that, of one hundred and sixty cows, which commonly 
 carry their young nine months, as women do, only three brought 
 forth on the two hundred and seventieth day ; that fifty of them 
 went from the two hundred and seventieth to the two hundred and 
 eightieth ; sixty-eight from the two hundred and eightieth to the 
 two hundred and ninetieth ; twenty to the three hundredth, and 
 that five of them did not calve until the three hundred and eighth 
 day, which is thirty-eight days beyond the term. On the other 
 hand, fourteen of them calved from the two hundred and forty-first 
 to the two hundred and sixty-sixth ; so that we find sixty-seven 
 days betwixt the two extremes. 
 
 Of one hundred and two mares, whose term is eleven months, 
 three of them foaled on the three hundred and eleventh day ; five 
 from the three hundred and tenth to the three hundred and thirtieth ; 
 forty-seven from the three hundred and fortieth to the three hundred 
 and fiftieth ; twenty-five from the three hundred and fiftieth to the * 
 three hundred and sixtieth ; twenty-one from the three hundred and 
 sixtieth to the three hundred and seventieth ; and one on the three 
 hundred and ninety -fourth day, which gives a latitude of eighty-three 
 days. 
 
 637. Thus, far from being fixed, the duration of pregnancy in 
 brutes is, on the contrary, extremely variable, and as the habits and
 
 246 TH E FffiTUS. 
 
 constitutions of women render them incomparably more liable to 
 impressions than any of the inferior species of animals, it is evident 
 they must be liable to the same irregularities. Besides, the follow- 
 ing proof taken in the human species, and admitting of no reply, is 
 related by M. Desormeaux. A lady, the mother of three children, 
 was seized with insanity in consequence of a severe fever, and all 
 the resources of hygieine and therapeutics had been exhausted upon 
 her case in vain ; a physician thought that a new pregnancy might 
 perhaps restore her intellectual faculties. The husband consented 
 to note down in a register the day of each sexual union, which took 
 place only once every three months, so as not to interfere with any 
 still imperfect conception. Now, this lady who was watched by her 
 servants, and who was moreover endowed with very severe princi- 
 ples both of morality and religion, was not confined until the lapse 
 of nine months and a half. 
 
 Being agitated anew in a celebrated cause before the house of 
 Lords, at London, in 1825 and 1826, this question was decided in 
 the affirmative ; but the physicians did not agree upon a fixed term 
 which must be always admitted. Out of twenty-five who were ex- 
 amined, seventeen said that pregnancy terminates about the thirty- 
 ninth or fortieth week, or betwixt the two hundred and seventieth 
 and the two hundred and eightieth day ; but some of them did not 
 consider the case of Elizabeth Adderley, the wife of lord Hyde 
 Gardner, who was brought to bed on the three hundred and eleventh 
 day, as impossible. Dr Blundell mentioned one pregnancy of two 
 hundred and eighty-seven days. Dr Merriman said he had seen 
 several of two hundred and eighty-five and two hundred and eighty- 
 seven days ; two or three of two hundred and ninety-six, one of 
 three hundred and three, and one of three hundred and nine days. 
 Dr Dewees relates one where tie woman was not delivered until 
 the two hundred and ninety-third day, &c. To these testimonials 
 I may add a case which fell under my own notice. A woman in 
 her fourth pregnancy computed that she was four months gone 
 when she came to my amphitheatre. I distinctly felt both the active 
 and passive motions of the foetus. Appearances of labour took 
 place at the end of the ninth month, were soon suspended, did not 
 return for thirty days, languished a whole week, so that in fact the 
 delivery did not take place until the three hundred and tenth day. 
 
 638. We may therefore conclude that tardy births are incontesta- 
 ble ; but that in the present state of our knowledge it is not possi- 
 ble to affix to them any precise limits. Moreover, since the French 
 code, in order to do away any thing arbitrary in the decision on such 
 cases, has determined that the legitimacy of a birth may be con-
 
 DURATION OF PREGNANCY. 247 
 
 tested when it occurs after the three hundredth day, or the tenth 
 month, this point of physiology has lost much of its importance ; 
 for at present what is essential for the physician.to know is, whether 
 a child can or cannot remain longer than nine months in the womb. 
 
 SECTION 3. 
 Of Precocious or Early Births. 
 
 639. If fruits ripen sooner in certain climates and years than 
 others, if the appearance of flowers, if vegetation generally may be 
 more advanced ; if the hatching of the chick varies from the nine- 
 teenth to the twenty-first day, or even from the eighteenth to the 
 twenty-second ; if some cats who carry their young only nine weeks, 
 may bring them forth nine days before their term ; if out of one 
 hundred and sixty-two cows, fourteen of them calve from the two 
 hundred and forty-first to the two hundred and sixty-sixth day ; if 
 out of one hundred and two mares, six of them foal from the three 
 hundred and eleventh to the three hundred and twenty-sixth day, 
 while their natural term is three hundred and thirty days ; if sows, 
 rabbits, &c. exhibit the same variety, wherefore may not the dura- 
 tion of human pregnancy be also advanced or abridged in the like 
 manner ? I do not see that any thing reasonable can be objected 
 against the possibility of precocious or early births. 
 
 640. Every body knows that one foetus is sometimes better grown 
 and stronger at six months than another at seven or more ; that a 
 child at term is sometimes not so stout nor tall as another which is 
 only of seven or eight months gestation, that on this point the de- 
 velopment of the ovum exhibits varieties that are almost infinite ; 
 that the changes that take place in the organization of the womb, 
 from the period of fecundation onwards, tend to develope in it a 
 force similar to that which directs the action of the muscles ; that, 
 except in case of accidents, parturition is not effected until this force 
 attains such a degree as that the uterus may contract with the 
 utmost force of which it is susceptible ; which necessarily takes 
 place sooner or later, according to an infinitude of circumstances; 
 all these things are known, I say, and shall any one dare to maintain 
 that precocious births are impossible !
 
 248 
 
 CHAPTER V. 
 
 Of Labour. 
 
 When gestation has passed through all its stages, when the 
 ovum has attained its last degree of maturity, and the organism of 
 the foetus is sufficiently perfect to enable it to live independently of 
 the mother, the birth of man takes place, and this is the phenomenon, 
 the fifth of the great function of reproduction, which is called labour. 
 
 It has been recommended at different times to replace the word 
 accouchement derived from ad and cubare, placed near to, by that 
 of parturition, derived from partus^ partio, parturire, or by that of 
 child-birth, puerperium; but as custom cannot give place to a false 
 or erroneous acceptation, these different substitutes have not been 
 adopted*. 
 
 Definitions. Levret has defined labour as a natural operation, truly 
 mechanical, and susceptible of geometrical demonstration ; which is 
 neither figuratively nor really true. Astruc, imbued with the same 
 notions, thought he could reduce the art of delivery to the solution 
 of the following problem : " An extensible cavity of a certain capa- 
 city being given, to extract therefrom a flexible body of a given 
 length and size, through an opening which is dilatable to a certain 
 extent." As if it were a matter of indifference whether the foetus 
 should be extracted artificially, or whether its expulsion should be 
 left to the powers of nature ! Baudelocque also has said that labour 
 is a purely mechanical operation, subjected to the laws of gravity 
 and motion ; as if it were possible to make precise calculations of 
 organic actions, by reasoning upon the laws that govern the physical 
 world ! In asserting " that labour is nothing more than the passing 
 of the child and its appendages from the womb," M. Maygricr also 
 employs a faulty definition, inasmuch as it does not express the ac- 
 tion which occasions this passage. Neither is it correct to say, with 
 Madame Boivin, that labour is the emission, expulsion, or excretion 
 of a living child at full term, together with its appendages, occasion- 
 ed by the contraction of the uterus, and the disposition of the genital 
 
 * In France.
 
 OF LABOUR. 249 
 
 organs of the mother. This definition, in the first place, is incon- 
 venient, in being too long ; and then it comprises only natural labours, 
 and does not embrace either precocious or retarded births, nor cases 
 in which the child is dead in utero. According to M. Desormeaux, 
 who has properly felt the insufficiency of the principles of Levret, 
 Astruc and Baudelocque, " labour is a function which consists in 
 the expulsion of a fo3tus from the womb, in which it grew during 
 the whole time of gestation." By substituting for the words opera- 
 tion and escape those of function and expulsion, this able practi- 
 tioner has rendered his definition incomparably better than any that 
 existed before. However, were it of any great consequence in prac- 
 tice to adopt one definition rather than another, I should prefer 
 simply to say, that labour is a function that consists in the expulsion 
 of the ovum from the toother's organs. 
 
 641. By making use of the word operation, physicians have gra- 
 dually become accustomed to see in labour a phenomenon almost 
 wholly foreign to the economy ; and thence their eagerness to ter- 
 minate an action which did not require their assistance ; by admit- 
 ting, on the contrary, that labour is a function, we feel ourselves 
 naturally prompted to let nature act, whom we assist, but whose 
 place we carefully abstain from taking, except in cases where we 
 have before-hand ascertained with mathematical precision that the 
 resources of nature are incompetent. 
 
 642. Classification. Many plans have been proposed for the 
 classification of labours ; Mauriceau, adopting the sentiment of Hip- 
 pocrates, calls those natural labours in which the child's head pre- 
 sents, and which terminate without assistance ; all others he calls 
 preternatural. Peu makes use of the word laborious instead of 
 preternatural. De la Motte describes them as natural, non-natural, 
 preternatural and untoward. Soon afterwards were admitted, under 
 the title of natural labours, all those in which the head or the breech 
 presented ; under that of laborious, those which, notwithstanding the 
 favourable position of the foetus, are so long protracted that we are 
 obliged to assist them ; all those were called preternatural in which 
 neither the head nor the breech presented to the strait. Smellie 
 modified this classification, and said, " I call that a natural labour in 
 which the head presents, and the woman is delivered by her pains 
 and the assistance commonly given : but should the case be so tedious 
 and lingering that we are obliged to use extraordinary force in 
 stretching the parts, extracting with the forceps, or (to save the 
 mother's life) in opening the head and delivering with the crotchet, 
 I distinguish it by the appellation of laborious : and in the preter- 
 natural, comprehend all those cases in which the child is brought 
 
 2G
 
 250 OF LABOUR. 
 
 by the feet, or the body delivered before the head." Smellie's divi- 
 sion, taught at the same time by Astruc, adopted by Solayres, and 
 propagated by Baudelocque, is still followed by a majority of French 
 accoucheurs. 
 
 643. There are few authors, however, who have not attempted to 
 show its incorrectness, and readily succeeded in doing so ; but as 
 those which have been proposed as substitutes are not less incon- 
 venient, it has preserved at least the advantage of being more gene- 
 rally known than any other. 
 
 It would be quite as well to follow it, for example, as with Millot, 
 to admit of a division into natural labours, properly so called (the 
 child presenting the head) ; irregular natural labours (the child 
 coming breech foremost) ; artificial labours (those which require 
 the employment of thte hand, either alone, or armed with some in- 
 strument, but without any necessity for dividing the mother's parts) ; 
 preternatural labours (where it is necessary to make an artificial 
 passage for the child) ; or, with M. Gardien, to admit of mixed 
 labours (where the position of the fcetus only requires to be changed); 
 or with MM. Maygrierand Gardien, and Madame Boivin, to make 
 a division of artificial labours (preternatural and laborious labours); 
 with M. Capuron, mechanical labours (where recourse is had to 
 instruments), or manual labours (the preternatural of Baudelocque); 
 or to make along with Denman a fourth class, under the title of 
 anomalous labours ; or with Burns, to establish seven classes to 
 confuse every thing: 1. Natural labour; 2. Premature labour; 
 3. Preternatural labour ; 4. Tedious labour ; 5. Instrumental la- 
 bour ; 6. Impracticable labour ; 7. Complicated labour. In fact 
 these accoucheurs have only changed the acceptation of the terms 
 they employ, or the new ones they propose are still mpre faulty than 
 the old ones, and I cannot perceive that the modifications adopted 
 by MM. Herman of Berne, and Dewees of Philadelphia, obviate this 
 inconvenience. Besides, there is no such thing as a labour purely 
 artificial, and the student cannot at a first glance understand the dif- 
 ference between a manual and a mechanical labour, any better than 
 that between preternatural and laborious labours. 
 
 The division that I prefer approaches very nearly to the one in- 
 dicated by Mauriceau. All labours that terminate under the sole 
 influence of the powers of the organism, alter the manner of M. 
 Lebreton, I call spontaneous, fortunate or simple ; those, on the con- 
 trary, that present difficulties of what nature soever, and which in 
 any way endanger the life or the heallhof the mother or of the child, 
 I call difficult, troublesome or complicated ; and each of these great 
 classes may in turn be divided into orders, genera, species arid va- 
 rieties, if the wants of the science call for it.
 
 OF LABOUR. 
 
 251 
 
 TABLE I. 
 
 DIVISION OF LABOURS. 
 
 r 
 
 f 1. Positions of the vertex. 
 
 
 1, Natural labours. Re-J 2. Positions of the feet. 
 
 
 quiring no assistance, j 3. Positions of the knees. 
 
 BAtTDELOCQTJE. 
 
 ^4. Positions of the breech. 
 2. Preternatural labours. ) , ^ , 
 
 5 Classes. 
 
 T> Ai_ t\ * -T fluiiv positions. 
 jxGouinncr tnc use ol Va* 1 1 j IK 
 
 
 3. Laborious 
 
 labours. ) 1. Faults of the female organs. 
 
 
 Requiring the use ofJ-2. Monstrosity of the fetus. 
 
 
 instruments. 
 
 ) 3. Want of power of the organs. 
 
 VfM. DUBOIS and"l 
 
 
 DESORMEAUX. \ Like those of BAUDELOCQUE. Presentations of the face 
 
 Vlesd. BOIVIN and j are classed among the natural labours. 
 
 LACHAPELLE. J 
 
 
 
 '1. Eutocia. 
 
 1 2' Tr| C f 6r 6X A " labours that termi- 
 3. The p'elv'is. 5 nate spontaneously. 
 
 The AUTHOR. 
 
 
 *1. Hemorrhagic. 
 2. Convulsive. 
 
 
 * 
 
 
 3. Aneurismal. 
 
 
 2 Classes. 
 
 
 4. Hernial. 
 
 
 
 
 5. With procidentia. 
 
 AH labours re- 
 
 
 2. Dystocia. - 
 
 6. From disease of the 
 
 quiring as- 
 
 
 woman. 
 
 sistance. 
 
 
 7. From narrowness of 
 
 
 
 the pelvis. 
 
 
 
 8. From wrong positions. 
 
 
 
 ^9. From exhaustion, &c. ^ 
 
 
 ARTICLE I. 
 
 Of Labour in General. 
 
 644. Labour is said to be at term or timely if it takes place at the 
 ninth month of pregnancy ; tardy or retarded, if the pregnancy ex- 
 tends beyond this period ; advanced, hastened, precocious or prema- 
 ture, if it takes place between the seventh and the ninth months ; 
 and it is called miscarriage or abortion if it occur previously to the 
 seventh month. As it is in some sort produced by the same causes, 
 and accompanied with the same phenomena in all cases, I shall first 
 examine it in a general manner before entering into details upoq 
 each class in particular.
 
 252 OF LABOUR. 
 
 SECTION 1. 
 Of the Causes of Labour. 
 
 645. It is common to divide the causes of labour into proxi- 
 mate and remote, or also into occasional or determining, and effi- 
 cient or immediate. 
 
 . I. Efficient causes. 
 
 646. The efficient causes are those which effect, or properly speak- 
 ing, constitute (font) labour ; they have greatly occupied the attention 
 of physiologists and accoucheurs in all ages ; they have by turns been 
 attributed to the foetus, the womb, the abdominal muscles, the dia- 
 phragm, and sometimes to all these parts together. Hippocrates 
 and most of the ancients thought that at the end of gestation the 
 foetus tears the membranes, extends itself like a spring, and pushes 
 with its feet and breech against the fundus of the uterus, while with 
 its head it presses upon the cervix so as to dilate it, pass through it, 
 and then escape from the genital organs. This opinion, which still 
 prevails amongst the vulgar, was founded upon what takes place in 
 birds, where the little chick, for example, breaks the surrounding 
 shell with its beak, when it reaches the period of hatching; upon 
 the circumstance that children that die while in the womb are born 
 with more difficulty than those who are strong and vigorous; and 
 lastly, on the fact that children have been frequently known to 
 escape spontaneously from the womb after the death of the mother. 
 
 647. Nevertheless, it has never been generally admitted that the 
 foetus is the sole agent, the sole efficient cause of delivery ; indeed, 
 the wisest authors believed that it played an important part in this 
 grand function ; but that it could not come forth without calling 
 other powers to its aid. In this respect the opinion of the moderns 
 is entirely opposed to that of the ancients. During the process of 
 its birth the foetus does not exert in any way an active power ; the 
 analogy which it was attempted to trace between child-birth and the 
 hatching of a chick cannot withstand the very weakest objection : in 
 most c;isi;s the death of the child does not affect its expulsion at all ; 
 hp-idon, the slowness of the labour in such a case is explained by 
 tho fact that tin; ftr.tus when dead is Jlaccid, and cannot present to 
 the womb the same firm resistance as if it were alive ; that if putre- 
 faction have commenced, the irritability and contractility of the 
 womb often receive a mischievous influence therefrom, and to a 
 grcatrr or less extent lose their natural vivacity ; finally, that the
 
 CAUSES OF LABOUR. 253 
 
 vitality of the fcelus being generally proportioned to that of the organ 
 in which it is contained, it is quite natural that the labour should be 
 more prompt and easy where the child is robust and healthy than 
 where it is feeble or diseased. 
 
 648. Those labours that sometimes take place after the death of 
 the woman, and form the principal argument of the partisans of the 
 ancient hypothesis, furnish on the contrary a decisive proof in sup- 
 port of the opposite doctrine. In these cases the children have 
 always been found lifeless between the mother's legs; it might even 
 be affirmed that they died first. They escape from the womb by 
 means of a power wholly extrinsic to them ; after death, the organs of 
 the life of relation, especially the muscles, become relaxed, while 
 those of vegetative life continue for some time in possession of their 
 contractility ; sometimes the abdomen becomes filled with gas with 
 surprising rapidity ; so that if the labour is far advanced when the 
 woman dies, it is not a surprising matter that the uterus, being me- 
 chanically compressed from without, meeting with no further resis- 
 tance from the perineum, and still retaining the power of contraction, 
 is enabled completely to expel the ovum without any necessary par- 
 ticipation on the part of the foetus. This was evidently the nature 
 of the case with the woman named Homer, who gave birth to a dead 
 child, thirty-four hours after she had herself ceased to exist. 
 
 649. In the second place, observation has demonstrated that de- 
 livery takes place pretty nearly in the same manner whatever be the 
 period at which it happens : now, where abortion takes place in the 
 first half of the period of utero-gestation, it is evidently impossible 
 for the foetus to make the least effort to escape from the organs. 
 How can so delicate a creature be supposed capable of dilating an 
 opening, through which the most vigorous man might vainly essay to 
 pass his hand? Who does not know that until the fourth or fifth 
 month it is scarcely capable of making a few motions ; that it is 
 rarely strong enough to be born alive, or at least to live over a few 
 minutes after birth ? Were it to act of itself in labour, it would com- 
 mence by rupturing the membranes : however, the bag of waters is 
 not broken until the last stage of labour ; in some cases it does not 
 break at all, and the ovum comes away whole ; besides, the very 
 moment when the bag of membranes presses upon the cervix in 
 order to engage in it, is the time when the fetus retires from it, 
 instead of pressing upon it. If it be true that the birth of a dead or 
 very feeble child is generally effected more slowly than that of a 
 fo3tus that is strong and full of vigour, it is also true, that the differ- 
 ence between the birth of a living and dead one is not sensible. 
 In all cases, the after-birth comes away at last, and we are compelled
 
 254 CAUSES OF LABOUR. 
 
 to agree that the action of the foetus has nothing to do with that. 
 Let the head, the trunk, or any separate part be left in the womb, 
 and it will be expelled, just as if the foetus were whole, and living. 
 The placenta, the membranes, the clots, the whole after-birth, a 
 mole, a fibrinous concretion, a polypus, and all kinds of bodies, 
 in short, that are met with in the womb are incapable of any spon- 
 taneous action, and yet their expulsion is effected by the same laws, 
 and announced by the same phenomena as those of the most robust 
 and the healthiest foetus. It is therefore undeniable that the foetus is 
 not the efficient cause of labour ; that instead of performing a part 
 essentially active in this process, it is on the contrary completely 
 passive from the beginning to the end of it. 
 
 650. This cause should be sought for in the organs of the mother, 
 which was not done until in the last century. Galen, J. Fabricius, 
 Gelee, Harvey, Levret, &c. had, it is true, already maintained that 
 delivery is effected under the influence of the contractions of the 
 uterus, the abdominal muscles, and diaphragm ; but this opinion, be- 
 ing vaguely expressed, did not have any effect on the theory of par- 
 turition. Besides, Haller thought that the womb is but a secondary 
 agent, and that the abdominal muscles and diaphragm are the chief 
 agents. To A. Petit was reserved the glory of demonstrating be- 
 yond dispute, that the efficient cause of labour is essentially consti- 
 tuted by the contractions of the uterus, and partly by those of 
 muscles of the abdomen and thorax. 
 
 651 . Essential efficient cause. We acquire by direct observation 
 the proof that the contractions of the uterus constitute the efficient 
 principle of labour. By applying the hand upon the epigastrium 
 during a pain, the womb is felt to grow hard, to shrink, to lessen 
 in size, in one word, to contract ; the finger, when introduced into 
 the vagina, perceives the orifice to become stretched, to grow thin, 
 and dilate or contract according to the stage of the labour. As 
 soon as the pain ceases, nothing of this sort can be perceived; all 
 the parts become relaxed ; as soon as it returns, all the phenomena of 
 contraction reappear ; but it is particularly when we are compelled, 
 in performing some operation, to introduce the hand into the interior 
 of the womb, that we abandon all doubt as to the important part 
 which it performs in the expulsion of the ovum. It pretty often 
 happens here that the operator is obliged not only to suspend his 
 progress during each contraction, but he also sometimes loses for a 
 short spam all sensibility, all power to act, and the hand, which is 
 lioiuiiiihi (], and as it wore paralyzed, becomes incapable of distin- 
 guishing the objects it touches. What practitioner has not had 
 occasion to sec that it is not possible, during a pain, to pass through
 
 CAUSES OF LABOUR. 255 
 
 the os uteri ? Who does not know, that when passed up to search 
 for coagula, the placenta, or the fetus itself, the hand is soon 
 forcibly expelled, together with the foreign body it was designed to 
 remove ? 
 
 652. Strictly speaking, the contractions of the uterus might suf- 
 fice for the expulsion of the child ; in several cases of complete 
 procidentia of the womb, such as those reported by Peu, Jalouzet and 
 Madame Lachapelle, the pregnancy has been found to go to the 
 full term, and the labour to terminate spontaneously ; many women 
 have been unconsciously delivered during an attack of lethargy, of 
 asphyxia, or in a deep sleep, into which they had fallen in conse- 
 quence of criminal attempts. Women weakened by protracted dis- 
 ease, a hemorrhage, or exhausted by suffering unconnected with 
 childbirth ; those who are affected with ascites, inflammation in the 
 chest, delirium, or madness ; those whose abdominal muscles, thin 
 and pale, have lost almost all their contractility ; such as are pusilla- 
 nimous, timid, excessively irritable, or of a very marked lymphatic 
 constitution ; and lastly, all such as from debility, disease, want of 
 courage, excess of sensibility, or want of power, do not bear down 
 at all, and who, on the contrary, employ all the resources of their 
 volition to arrest the least effort of their muscular system, are deli- 
 vered notwithstanding. The womb alone in such cases bears the 
 whole burthen of parturition. 
 
 653. Accessory efficient cause. Nevertheless, the womb in most 
 cases requires to be sustained by the action of the diaphragm and 
 abdominal muscles. The concurrence of this action is so evident 
 in most women that no observer has thought of denying its exist- 
 ence, and that it is sufficient to announce it as a simple proposition ; 
 but its importance has not been understood in the same way by 
 all authors. According to Haller, the womb contracts only for 
 the purpose of preventing the child from being pressed together 
 into a confused mass, to force it to present one extremity of its 
 occipito-coccygeal diameter to the straits ; by their contractions, 
 the abdominal muscles support the womb in front and on its sides, 
 so as to prevent it from deviating, or from abandoning the direction 
 of the axis of the pelvis, or bending in any direction, and make it 
 in some respects resemble a straight canal, continuous with the 
 pelvis. The descent of the diaphragm then bears wholly upon the 
 fundus of the uterus^; the cervix, being unsupported, yields to the 
 effort ; and the foetus, being forced from above downwards, passes 
 through the genital organs as an inert and solid trunk, passing out 
 of a long canal with inflexible parietes.
 
 256 CAUSES OF LABOUR. 
 
 654. By carefully noticing the proceedings of nature, it will be 
 perceived that the idea of Haller expresses very well the mode in 
 which the diaphragm and abdominal muscles operate ; but it is in- 
 correct, inasmuch as it attributes to the uterus only a secondary 
 part, whereas it is a matter of demonstration that its contractions 
 constitute the chief cause of delivery. Upon this hypothesis, the 
 expulsion of the ovum is almost wholly submitted to the volition of the 
 woman, but no one is ignorant of the fact that parturition is almost 
 entirely involuntary. Further, it was not so much Haller himself, 
 as his commentators, who desired to limit in this way the importance 
 of the uterine contractions ; for that great man says positively, that 
 the efforts of the woman are not always indispensable to the termi- 
 nation of the labour. 
 
 655. On the contrary, far from acting with so much power on 
 the womb, the diaphragm, as has been remarked by M. Bourdon, 
 only serves' as a firm point d'appui for the abdominal muscles. 
 Whenever an effort is made, the chest dilates, the lungs fill with air, 
 after which the glottis closes ; the diaphragm gives to the base of the 
 thorax, which is moreover supported within by the distended lungs, 
 a degree of immovableness and solidity, which affords to the muscular 
 powers a fixed point that they could not otherwise have obtained ; 
 whence it follows, that it is not by pressing the viscera from above 
 downwards, as is generally supposed, that the diaphragm assists the 
 uterus, but rather by giving to the chest the power of resisting the 
 contractions of the abdominal muscles, which contractions are thus 
 rendered effective upon the body to be expelled. 
 
 656. .In most women the uterus is the first and only part to con- 
 tract until the foetus has reached the excavation of the pelvis. From 
 this moment a sense of weight, of straining, or of tenesmus, irre- 
 sistibly invites the concurrence of the contractions of the abdominal 
 muscles. Whilst the sole object of the womb is to dilate its neck, it 
 needs no aid ; but when the orifice is sufficiently large, the foetus 
 must next be forced through a firm and very narrow canal.; greater 
 powers become indispensable, and the uterus, redoubling its efforts, 
 rarely fails to solicit the action of all the muscles of the body. The 
 head and litnbs being first fixed, the chest dilated, the diaphragm 
 depressed, the lungs filled with air, and the glottis closed, permits 
 the abdominal parietes, firmly attached to the pelvis and base of the 
 thorax, to contract from before backwards, as well as laterally ; the 
 viscera, being unable to raist; the phrenic septum which separates 
 them from tin: lmi<r.s, transmit directly to the fundus of the womb the 
 lively impression they have received ; the latter organ, also sustained
 
 CAUSES OF LABOUR. 25t 
 
 on all sides, now efficaciously employs all its powers to expel the 
 foetus through the cervix, the only point which now offers no resist- 
 ance, and upon which all its efforts come to operate. 
 
 657. This is the way in which the process takes place in a na^ 
 tural state, but the organism is sometimes obliged to take another 
 course; the woman is not always capable of effecting this combina- 
 tion of actions. In certain cases the uterus, compelled to suffice for 
 itself, sometimes succeeds in producing the desirable result without 
 any difficulty ; but in other cases, being too feeble, either in conse- 
 quence of over distention,, which destroys its tone by reducing the 
 thickness of its walls, or of contractions too long continued or too 
 frequently repeated, or because its function is interfered with by 
 some modification of the natural state of its structure, it yields in im- 
 portance to the muscles, which, if directed with a vigorous and cou- 
 rageous will, are sometimes able to expel the foetus with but a feeble 
 co-operation on the part of the womb. 
 
 658. In this sense only may labour be regarded as in some cases 
 a partly voluntary function, like the excretion of stool, and the 
 emission of urine. Doubtless, a woman who bears down, as it is 
 called, who enforces her pains, no matter how feeble soever they 
 may be, will get rid of the product of conception sooner ; and that 
 another may, to a certain extent, protract its expulsion by prevent- 
 ing as much as possible the contraction of her muscles. 
 
 659. A woman presented herself at Baudelocque's amphitheatre^ 
 to be delivered there ; the labour at first went on very regularly ; 
 the pupils were assembled ; the dilatation of the orifice was suspend- 
 ed, and a whole night passed away without its making any progress ; 
 the spectators, who were fatigued, now dispersed ; the pains soon 
 returned, and the dilatation went on ; the young people being noti- 
 fied, reassembled ; again the phenomena of the labour ceased. 
 Baudelocque, suspecting the cause of these irregularities, gave a 
 hint to the pupils, who all left the apartment with an injunction not 
 to go far, and to return upon the first signal ; the woman imme- 
 diately began to bear down, and the child's head soon reached the 
 vulva ; the pupils were then called, and the labour, which it was 
 no longer in her power to suspend, soon terminated. I witnessed 
 a nearly similar case in 1825. One of the first women that came 
 to lie in at my amphitheatre, had pretty smart pains, and the neck 
 of the uterus dilated regularly and promptly as long as there were 
 only a few pupils present. When they had all assembled, she con- 
 tinued to complain in the same manner, but the labour did not ad- 
 vance at all ; the whole day and night passed in this manner ; in the 
 tnorning all the witnesses went away to get some sleep ; the dilata- 
 
 2H
 
 CAUSES OF LABOUR. 
 
 tion began again ; about noon it was quite advanced th 
 returned, and the phenomena were immediate], ^ spend'ed '"' 
 o clock , n the evening she was left alone and as H : ' C 
 S31 d it would be well to assemble again be l ^J Ut ' * 
 
 o'clock at night. A few minutes % ward sT '" "* ***" 
 paniedwith ; sensible Hil.f * J f , ' P&lns wer eaccom- 
 
 rid of the students, and to dise^bar's h ' gC ' 
 
 ? II. Determining or occasional causes. 
 
 by 
 and accidenta, 
 
 particular predisposition, &c. ; they are riotl , P " S mC
 
 DETERMINING CAUSES. 359 
 
 turity led it to detach itself, as a ripe fruit falls from the limb of a 
 tree ; and that the circulation could not be longer performed without 
 the action of the lungs. At a first glance, it might seem superfluous 
 to repeat all these various opinions, since it is actually demonstrated 
 that the child is not the active agent of its own escape ; but as it has 
 been on the other hand pretended that it only puts the uterine con- 
 tractions into play, under the influence of the same causes of uneasi- 
 ness, embarrassment or necessity, I thought it best not to pass them 
 over in silence. 
 
 662. In the first place, all this scaffolding is supported on mere 
 suppositions. As has been said by A. Petit, no fluid in the animal 
 economy is less acrid than the liquor of the amnios ; if it ever does 
 acquire any irritating properties, it happens as often at six, seven, 
 or eight months as at nine, and it has never been shown that the 
 pregnancy in such cases was advanced one single day. 
 
 663. The child is so little disturbed by the necessity of voiding 
 its meconium or urine ; that it sometimes remains several days after 
 birth without discharging them ; who told it that outside of its 
 place of habitation there was air for it to breathe, and to cool the 
 heat of its blood ? The temperature of the uterine cavity is the same 
 as that of the rest of the woman's body, and a thermometer placed 
 there during labour, would not rise any higher than one held in her 
 mouth ; moreover, the experiments of M. Edwards prove that, far 
 from being burning hot, the temperature of the fo3tus is two degrees 
 lower than that of the mother, as long as it remains in the womb ; 
 it is not true that the anatomical disposition of the utero-fcetal vas- 
 cular system is at child-birth sensibly different from what it was a 
 few weeks previously ; nor is it more true that the ovum is permea- 
 ble by fluids, or less adherent at the end than about the middle, or 
 even the commencement of gestation ; it is an ingenious metaphor 
 to say that it separates like a ripe fruit, but nothing like explanation 
 has been thereby gained. 
 
 664. But if it be true that the sudden, violent and convulsive-like 
 movements of the child sometimes force the labour to come on be- 
 fore the natural term, it is not less true that that is an accident 
 which ought to be classed among the causes of abortion, and that 
 labour most frequently comes on without any thing of that kind being 
 noticed. Neither can the contraction of the ductus arteriosus, the 
 ductus venosus, and foramen ovale, as they do not take place to the 
 same extent in every fetus, be the cause of a phenomenon whose 
 period very rarely varies, and with which variations it has besides 
 no correspondence. 
 
 665. An anonymous author, who was fora long time opposed by
 
 DETERMINING CAUSES. 
 
 Millot, speaks of a vacuum that takes place in the sac of genera* 
 tion, in consequence of the transudation of its waters, and pretends 
 that the uterus, obeying its natural elasticity, closes up so as to re- 
 move this void ; hut it is easy to perceive that this author mistakes, 
 the effect for the cause, and has misunderstood the question. 
 
 666. Steinzel and others have referred the occasional cause of 
 parturition to the periodical nisus of each menstrual period. But 
 in the first place many pregnant women are met with, in whom the 
 habit of menstruation has never been exhibited. Now the influence 
 of habit is felt so much the more powerfully the nearer we are to the 
 instant when it was left off. Yet, in the hypothesis of Stein, pre- 
 cisely the contrary is remarked. Besides, in order to see at once 
 the futility of such a theory, it is merely necessary to advert to the 
 fact, that the ninth catamenial revolution takes place in some 
 females at the commencement of the eighth month, in others at 
 the seventh, often at the end of the tenth, and that a good many wo- 
 men do not menstruate more than two or three times a year, while the- 
 differences observed in the duration of pregnancies are so few, that 
 many persons still doubt as to their existence. 
 
 667. MM. Lobstein and Chaussier seem to admit that this cause, 
 which has been so much sought for, is found in the completion of 
 the organization of the womb, which waits until the muscular 
 character of its fibres is fully developed before it contracts. But 
 miscarriages and premature labours fully demonstrate the insuffici- 
 ency of such an explanation. 
 
 668. According to Loder the extensibility of the womb is con- 
 fined within certain limits ; the fibres of the womb, fatigued by a 
 long continued state of distention, being unable to yield any further, 
 react, at the end of the ninth month, upon the body that had kept 
 them so long extended, and thus decide the act of parturition ; but 
 ypon reflecting that the development of the womb is not a passive 
 phenomenon, that twin pregnancies, or those where the ovum from 
 -ome cause attains to very great dimensions, do not terminate any 
 sooner than those where the womb acquires but a very small size, 
 we ,-iro compelled to reject this hypothesis also. 
 
 I'f'O. The opinion of Lev ret and Baudclocque, entertained also 
 by M. Desorraeaux, has at the present day the greatest number of 
 partisans. Founded on the arrangement of the uterine fibres, and 
 upon observation of the phenomena of pregnancy, it has appeared 
 to be more saiisfaetory than ;my other. It is said if the cavity of 
 the body of Ihe womb, only, enlarges during the four or live first 
 month-. :MM! thai of (lie eervix afterwards dilates by degrees, from 
 '! confounds itself with the former, it dep' ,
 
 DETERMINING CAUSES. 261 
 
 upon the circumstance that the fibres of the body and fundus, placed 
 lengthwise, and being the softest and most extensible, distend and 
 yield more easily than those of the neck, which are circular, denser, 
 more compact, and situated transversely. Between them is estab- 
 lished a kind of balancing or contest, which results in the induction 
 of labour : those of the body must be looked upon as so many loops 
 which embrace the ovum in their concavity, while their extremi- 
 ties are attached to different points of the circles of the neck ; the 
 former at first yield without difficulty, and even without reacting 
 upon the latter ; but about the middle of pregnancy, by elongating, 
 they stretch the fibres of the neck, whose circles disappear or are 
 thus drawn in succession into the body of the organ ; so that at last 
 the canal of the neck no longer exists, but merely an orifice with a 
 circumference of greater or less thickness. There is then an equi- 
 librium between the neck and body of the womb ; but as the looped 
 fibres have now no other resistance to overcome but the circular 
 fibres, they triumph over the os uteri with great facility, the equili- 
 brium is soon broken, and labour commences. 
 
 670. According to this view of the circumstances, I should define 
 the determining cause of labour to be, the tendency of the fibres of 
 the body of the uterus to contract ; a tendency or effort which pro- 
 duces no real and sensible effect, until from the moment when the 
 cervix ceases to furnish any further materials to the enlargement of 
 the womb. 
 
 671. A. Petit expressed himself upon this subject somewhat dif- 
 ferently : " It cannot be doubted," says that author, " that the deter- 
 mining cause of the uterine contractions is the irritation experienced 
 by the uterus when pregnancy has reached its full term. I consider 
 the cervix as a magazine in which nature has placed in reserve the 
 quantity of muscular fibres which she needs, to furnish by their de- 
 velopment materials for the expansion of the womb during the 
 course of gestation. In the natural state this expansion, when once 
 begun, proceeds pan passu with the growth of the foetus ; every 
 thing is proportioned, fixed, so that when the latter is sufficiently 
 developed to bear the action of external agents, and employ them 
 for its own benefit, all the fibres of the cervix have yielded, and the 
 magazine is exhausted ; labour will therefore take place when all 
 the fibres that had been placed in reserve in different parts of the 
 womb, and chiefly in the substance of the cervix, shall have been 
 employed. As long as any of them remain, the womb may go on 
 increasing, and no irritation will be occasioned ; a simple develop- 
 ment is not capable of producing it." 
 
 672. This explanation is more rational than the version given of
 
 262 DETERMINING CAUSES. 
 
 it by Baudelocque. The idea of a struggle between the fibres of 
 the different points of the uterus is doubtless ingenious, but the fact 
 which it expresses has no existence in nature. To me it seems evi- 
 dent, that by imbibing fluids during the pregnancy, the organ of 
 gestation is enabled to unfold its fibres in an active manner ; that 
 this unfolding takes place first in the body and fundus, because 
 there the ovum is lodged in the commencement ; that it afterwards 
 takes place in the neck by the same mechanism, that is, by the ac- 
 cumulation of liquid molecules, which gradually separate the con- 
 stituent molecules of the fibres ; that this unfolding being brought 
 to a conclusion, and the womb besides having acquired the comple- 
 ment of its muscular organization, enters upon its contractile state 
 for the purpose of expelling the body that fills its cavity, and that 
 now begins to produce in it a more lively state of irritation. 
 
 673. Miscarriages, and premature labours, as well as protracted 
 gestation, &c. might be rigorously accommodated to this mode of 
 interpretation ; but another one is required for extra-uterine preg- 
 nancy. Where the ovum is developed in the tube, or in the abdo- 
 men, or substance of the womb, what in fact becomes of this 
 balance betwixt the action of the fibres of the neck and body, this 
 magazine held in reserve, this unfolding of the fibres, which at a 
 first view gives so satisfactory a solution of all the other cases ? 
 Let us then frankly confess that the deeper we search into the ques- 
 tion of the determining causes of labour, the greater will be the 
 number of objections against the explanations that have been given ; 
 but do we any better know the determining causes of the contrac- 
 tion of the heart, and of an infinity of other actions which like it must 
 be admitted as facts 1 
 
 SECTION 2. 
 Of Labour. 
 
 674. The name labour or travail is given to the collection of 
 phenomena which constitute child-birth ; or, if we choose, child-birth 
 
 s rise to a series of phenomena, local or general, which are 
 embraced under the one title of labour. 
 
 675. As the phenomena of labour are numerous, and appear in 
 succession, it has been frequently attempted to group them, to form 
 diHrrcnt bundles of them, so as to class them better in the memory ; 
 but ;is tlic.-c divisions have never been established otherwise than 
 upon arbitrary or purely conventional data, it has happened that 
 they do not re.sunblf: each other in any two books. A. Petit, for
 
 OF LABOUR. 263 
 
 example, admits three, without saying any thing of the Kmits to be 
 allowed to each of them. Stein describes four, and that too, not 
 less vaguely than the former. Millot also thinks that labour ought 
 to be divided into four stages : the first, which he calls the secret 
 stage, because the women are scarcely conscious of it, comprises 
 the different symptoms that manifest themselves in the four, five or 
 six days immediately antecedent to the term of gestation ; the second 
 extends from the first appearance of the pains to the discharge of 
 the waters ; the third begins after the rupture of the membranes ; 
 and the fourth when the child is on the point of being delivered. 
 
 676. Millot's secret stage is classed among the precursory signs 
 by Madame Boivin, who, like Chaussier and Adelon, admits five 
 stages ; four for the labour itself, and the fifth for the delivery of the 
 after-birth, but without indicating any very well marked line of dis- 
 tinction between them. M. Maygrier also reckons four stages, as 
 Stein does, and does not circumscribe them either. Denman seems 
 to have been the first to lay the foundation of a good division of 
 labour : according to him the first stage commences with the first 
 pains, and ends with the complete dilatation of the neck, or with 
 the rupture of the membranes ; the second extends to the complete 
 expulsion of the foetus ; and the third comprises the delivery of the 
 after-birth. In this way, each stage forming a period rigorously 
 determined, it becomes no longer possible to extend or limit as we 
 please, the acceptation of the terms made use of. We might also, 
 after the example of Burns, describe only two stages, properly so 
 called, and make the delivery of the secundines a separate labour, 
 which appears to me to be rational. M. Desormeaux, who was 
 fully sensible of the advantages of Denman's method, has done better 
 by carrying the first stage to the complete dilatation of the os uteri, 
 without regard to the rupture of the membranes. I shall adopt this 
 course myself, and divide labour only into two principal stages : one 
 which terminates when the dilatation is finished, and another which 
 begins at that moment, and ends with the delivery of the child. 
 
 Nevertheless, I shall add, as an independent period, what Millot 
 calls the secret stage, or what Madame Boivin describes under the 
 title of precursory signs. 
 
 . I. Precursory signs, or preliminary symptoms of labour. 
 
 677. Labour sometimes comes on suddenly, and without any 
 preliminary symptom ; however, the organism, which rarely pro- 
 ceeds to the exercise of its smallest functions without some pre- 
 lude, is most commonly true to its accustomed march, whenever the 
 question is upon terminating the great act of reproduction.
 
 264 PRECURSORY SIGNS. 
 
 From two to fifteen, and even twenty days before the period, na- 
 ture in some subjects seems to try her forces ; the belly diminishes 
 in size sensibly ; the fundus, and even the whole mass of the womb 
 subsides ; the motions of the child are felt more than in common 
 the infiltration and the varicose condition of the lower extremities 
 increase or now become manifest, if not previously present ; the 
 labia pudendi in particular become swelled, softened, and occasion- 
 ally painful ; the digestion is better performed ; the nausea, vomit- 
 ings, and curious appetite are done away with, if they had not long 
 before ceased to exist ; the respiration is not so short, nor so im- 
 peded ; the women regain their habitual gaiety and lively humour, 
 are not so sleepy, more disposed to exertion, more active, and often 
 induced to believe, at least in first pregnancies, that their term is 
 further off than they had before supposed. They have a sense of 
 weight in the pelvis, or, as they say, at the fundament, with more 
 frequent disposition to stool, and to void their urine. It is then, par- 
 ticularly, that all the articulations, all the ligaments of the pelvic 
 cavity become softened and relaxed ; which renders walking, and 
 even standing itself more difficult, more fatiguing, and sometimes 
 even absolutely painful, although the woman is more disposed for 
 them. The secretion of rnucus in the genital passages becomes' 
 more active, and glairy matter in more or less abundance escapes in 
 flocks from the vagina and vulva ; it is not very rare to find the 
 womb in an altogether peculiar state of fibrillar contraction, which 
 may be regarded as a passage from its state of rest to that of its 
 real contraction : that is to say, by touching the os uteri, we feel 
 that it is from time to time in a slate of slight tension or constric- 
 tion, and by feeling of the body of the organ above the pubis, a 
 movement is found to take place in it ; so true is it, that the point 
 of departure of labour cannot always be precisely determined. 
 
 678. These different phenomena, which necessarily vary in num- 
 ber, progress and degree in different women, are in general of good 
 augury, provided they are not converted into symptoms of disease. 
 They announce that nature is collecting her forces, uniting her re- 
 sources, and making all suitable dispositions to accomplish the func- 
 tion she has been so long preparing for. As to their explanation, it 
 is perfectly natural ; they all refer directly or indirectly to the change 
 of position of the womb. By plunging down into the excavation, 
 this organ necessarily presses with more or less force upon the reo- 
 tum, the bladder, the nervous plexuses and the blood vessels ; thenco 
 come the tenesruus, the bearing down, the lymphatic or sanguine 
 engorgement of the lower limbs and vulva, the relaxation of the
 
 PRECURSORY SIGNS. 265 
 
 sympliyses, the formation of mucus, &c. By sinking lower down, 
 and removing to a distance from the epigastrium, the womb leaves 
 the stomach and liver more unconstrained ; the diaphragm, being 
 less elevated, permits the lungs to dilate more, whence more freedom 
 in respiration, circulation, the digestive functions, and consequently 
 in the exercise of the intellectual and locomotive faculties. 
 
 . II. First stage, or period of dilatation. 
 
 679. After these preliminaries, labour at length begins; its origin 
 is marked by pains, and short and slight colicky sensations, recur- 
 ring at considerable intervals. The external parts of generation 
 become moist, and the secretion of glairy mucus, provided it had 
 not appeared before, is added to the number of precursory symp- 
 toms. When the colic pains are present, the womb hardens, be- 
 comes rounder, and its summit sinks into the excavation, it dimin- 
 ishes in all its diameters, in one word, it contracts ; the lips of the 
 os tineas are effaced, and in an evident manner grow thinner ; the 
 orifice stretches, and from the same cause loses its thickness, assumes 
 more decidedly the form of a circle, and manifestly contracts ; by 
 introducing the finger into it, the membranes of the ovum will be 
 found endeavouring to engage in it, they are compressed by it and 
 forced lower down, they grow harder, become tense, very elastic, 
 and difficult to indent. The woman is now frequently torment- 
 ed with sinister forebodings ; she becomes low spirited, and despairs 
 of safety, says she is going to die, loses all her courage, and is over- 
 whelmed with gloomy thoughts, and a sadness which nothing seems 
 able to dispel ; she weeps, is agitated, or remains motionless, and in 
 some instances feels horripilations all over the body. Animals 
 themselves, a very remarkable circumstance, also fall into this state 
 of lowness at the commencement of labour ; they refuse to eat or 
 drink, seem to be tormented with fear, and to be occupied only with 
 the dangers that threaten them. 
 
 680. The pains, which gradually increase in strength and severity, 
 at the same time become longer and more frequent ; reddish or 
 bloody stria? are soon found to be mixed with the mucous discharges, 
 which are also found to be increased in quantity ; the mouth of the 
 womb begins to open, and dilates by degrees ; the lower segment of 
 the ovum passes through it, and under the title of bag of waters, 
 projects into the upper part of the vagina ; as the pains grow more 
 severe, the general irritation becomes more considerable ; the inter- 
 val between the contractions is not calm ; the woman is touchy, cross, 
 impatient, difficult to control ; she cannot keep in one place, is dis- 
 contented with every body, and has an extreme susceptibility ; every 
 
 21
 
 266 STAGES OF LABOUR. 
 
 pain in some degree resembles a paroxysm of fever ; it is preceded 
 with a rigor and sometimes even with a tremor and rattling of the 
 teeth together ; the quickness, frequency and hardness of the pulse 
 and temperature of the body augment ; the skin is higher coloured 
 and becomes moist ; the mouth and tongue dry ; the teeth and lips 
 are encrusted, become fuliginous, as in an adynamic fever ; a great 
 thirst comes on ; she has nausea, vomiting and cough ; she wanders, 
 and the intellectual derangement is often carried to such an extent 
 as to resemble delirium. In irritable women, the anguish and rest- 
 lessness are sometimes carried to the highest degree ; and the hardest 
 heart could scarcely resist a feeling of compassion and pity at the 
 sight of these unhappy beings, who with dishevelled hair, blackened 
 mouths, flushed countenances, burning skin and haggard eyes, can 
 only become mothers at the cost of so many sufferings and dangers. 
 When a contraction is over, every thing returns to its natural state ; 
 the restlessness ceases ; the pulse recovers its ordinary type ; the 
 mouth becomes moist ; the skin regains its natural colour and habi- 
 tual temperature ; if an examination be now made, the membranes, 
 having returned within the cavity of the womb, feel flaccid and 
 wrinkled, and the bag of waters cannot be felt ; the edges of the os 
 uteri, which during the pain were hard, thin and sharp, are supple, 
 thick, and rounded immediately after it. The nausea is suspended, 
 but the belly, particularly the epigastrium, most generally remains 
 very tender. Each pain reproduces the same series of phenomena, 
 and is succeeded by a more and more complete remission, which also 
 grows shorter and shorter. The os uteri, which represests the re- 
 sistance to be overcome, gradually yields ; its dilatation at length 
 becomes so complete, as that there is no contraction betwixt the 
 uterus and vagina. Thus is terminated the first stage of labour, the 
 longest and most fatiguing period of parturition, but not the most 
 dangerous or difficult. 
 
 . III. Second stage, or period of expulsion. 
 
 681. In the first stage the womb performs almost the whole duty 
 of the labour ; it dilates the cervix, and forces the apex of the ovum 
 to engage itself therein ; it either does not solicit at all, or but very 
 feebly, the contractions of the muscles, whose concurrence has not 
 as yet become indispensable. In the second stage, the contractions 
 in the first place become stronger, last for a longer period of time, 
 are not so far apart, and yet are followed by a more decided calm ; 
 the courage returns, the sadness is dissipated ; some women, op- 
 pressed with the want of rest, sleep quite soundly during the short 
 interval between the pains ; I once attended a lady in labour, who
 
 STAGES OF LABOUR. 267 
 
 having been three days and nights in the anguish of a most painful 
 travail, slept several times on the morning of the fourth, notwith- 
 standing that the contractions were carried to the highest degree of 
 intensity, and there was scarcely more than one or two minutes be- 
 tween them. A feeling of weight and bearing down, by some re- 
 ferred to the pressure experienced by the cervix, but which depends 
 rather upon that of the rectum and bladder, soon compels the woman 
 to second her pains ; and almost in spite of herself, to contract the 
 abdominal muscles and make the most violent efforts. 
 
 682. The bag of waters, the only portion of the ovum which is 
 not compressed externally, having no support whatever in the supe- 
 rior part of the vagina, bursts in the midst of one of the most vio- 
 lent pains ; the foetus, forced downwards by the same contraction, 
 immediately takes the place occupied by the segment of the mem- 
 branes, and by engaging in the passage like a stopper or plug, pre- 
 vents the escape of the rest of the waters; and the head, if it be the 
 presenting part, is then said to be at the crownirfg (cotironnemenfy; the 
 void thus produced in the womb is the reason why the labour seems 
 to slacken for a little while ; but when this void disappears, and the 
 uterus is recovered from its astonishment, (I hope the expression will 
 be pardoned,) the pains recover all their energy, and succeed each 
 other with greater rapidity. Each one is ushered in with a general 
 shiver ; the severest ones are often preceded by another which is 
 milder, and serves as a prelude to it ; on other occasions we observe 
 one stronger and one weaker, alternately, regularly, and without 
 our being able to regard one as a sequel to the other. When they 
 come on, the woman lays hold of any thing solid in her reach, plants 
 her heels upon the mattrass, seizes with her hands the sides of the 
 bed or bolster, or the persons around her, to secure a point d'appui ; 
 she then throws her head back, draws a long breath, and all the levers 
 of her skeleton being thus fixed, contracts, with all her power, the 
 muscles of the belly, while the diaphragm, and all the muscles of her 
 body act with the same energy ; the neck and face swell, are engorged 
 with blood, and become purple or livid ; the jugular veins acquire 
 an enormous size ; the carotids beat violently ; the thyroid gland 
 becomes engorged, the eyes sparkle, grow red, and seem to start 
 from their orbits ; all the symptoms of cerebral congestion become 
 manifest ; the general circulation is strongly excited ; sweat some- 
 times pours from the skin, but only about the head, breast and ab- 
 domen, for the lower extremities, receiving less blood than common, 
 not unfrequently remain below their ordinary temperature; at length, 
 when the contraction is just about to cease, this agitation gives 
 place to rapid sobs, which soon restore calmness to the functions.
 
 268 STAGES OF LABOUR. 
 
 683. After a certain length of time, generally very short, another 
 pain cornea on, accompanied with the same anguish, and followed by 
 the same phenomena. As it begins, a small quantity of liquor 
 amnii is seen to flow off, because the child does not exactly fill up 
 the cervix during the interval between the pains : but by forcing the 
 presenting part to engage in the utero-vaginal orifice, the uterine 
 contraction soon puts a stop to this discharge, which reappears 
 towards the close of each pain, because the foetus, ceasing to be 
 pressed downwards, returns into the cavity of the womb. If the 
 pains be somewhat strong, the head soon passes through the cervix 
 into the upper part of the vagina, which gradually dilates to receive it, 
 and it descends into the excavation, exerting an increasing pressure 
 on the rectum and bas-fond of the bladder ; the bearings down are now 
 redoubled, strangury comes on, and cramps are felt in the thighs and 
 legs ; if any faecal matters are contained in the rectum below the su- 
 perior strait, they are mechanically forced out ; the amplitude of 
 the vagina increases* in every direction by the unfolding of the 
 wrinkles, always, except during labour, observable on its interior. 
 The head approaches the inferior strait, the coccyx retires back- 
 wards, the anus projects ; the whole perineum is elongated, and be- 
 comes thinner as the inferior angle of the vulva is carried forwards, 
 and the plane of this opening at last comes to be almost parallel with 
 the axis of the body, instead of representing, as before, the plane of 
 the lesser strait of the dried pelvis ; the labiae being put on the 
 stretch are undoubled, and even drag a portion of the skin of the 
 thighs towards themselves : the mons veneris is lessened in size ; 
 but it is false, entirely false, to say that the nymphas are also unfold- 
 ed : at length a pain, which is stronger than any preceding one, 
 which forces the woman to utter cries of despair, and which is com- 
 posed of two pains of unequal violence, for which nature seems to 
 have rallied all her remaining muscular power, triumphs over all re- 
 sistance ; the most powerful contraction that has yet occurred brings 
 the parietal protuberances on a level with the tuberosities of the 
 ischia ; one more last degree of power is about to force them 
 through, but that power is just about to diminish ; nature, who has 
 almost overcome all obstacles, seems to be ready to fail in her last 
 effort ; just as she is about to attain the object of so many exertions, 
 she is seen ready to yield once more to the reactions of the peri- 
 neum ; but one more attempt of the organism gives rise to a new 
 pain, which comes to the assistance of the preceding one before it 
 has quite ceased, as if to sustain it, and the head finally escapes 
 through the vulva. In consequence of the vacuity which has just 
 occurred in the womb, provided the body of the child does not im-
 
 STAGES OF LABOUR. 269 
 
 mediately follow the head, it is not commonly expelled until after a 
 calm of a few seconds or a few minutes, when a short and moder- 
 ately strong contraction occasions its escape, together with that of 
 the remainder of the liquor ainnii. 
 
 684. The labour is finished. One of the most melting scenes, a 
 scene most adapted vividly to affect the human heart, is presented to 
 the eyes of the philosophical accoucheur. To those piercing cries 
 and violent agitation, to those transports of despair, those excessive 
 efforts, those inexpressible agonies, those dilacerating pains, which 
 seem to be intolerable, instantly succeeds a delicious calm, full of 
 charms, says M. Desormeaux, and interrupted only by the happy 
 idea of being a mother. The new born child cries, and all the suf- 
 ferings of the mother so courageously borne are forgotten ; pas- 
 sionate expressions of satisfaction are substituted for those of pain, 
 sobs of happiness succeed to the sobs of despair ; and this sudden 
 transition from the extremest dread, from a frightful state of anxiety, 
 to the height of joy and of the tenderest affections, is, in sensible and 
 amiable women, one among those appearances which most imperi- 
 ously demand our admiration for a sex whose other claims to it are 
 so numerous ! 
 
 685. Duration of labour. There is no occasion for me to remark 
 that this general picture is far from being applicable to all women, 
 or even to all the labours of the same woman ; most of these nu- 
 merous phenomena are to be met with, chiefly among those who 
 are robust, vigorous, young, and in labour for the first time : in 
 others, they exhibit very varied appearances. Their development 
 requires a lapse of time which also presents very great variety in 
 different countries and in different women. 
 
 The duration of labour is, according to the reports of travellers, 
 much shorter among savages than among civilized people ; among 
 the Negroes and Indians of America than among Asiatics and 
 Europeans ; in hot climates than in cold countries ; in Italy, Spain, 
 and Portugal, for example, than in France, Russia, and Germany ; 
 in women who have passed their lives in luxury and idleness, than in 
 those who live in the country, and are obliged to labour hard for a 
 support. In general, labour lasts from four to eight or ten hours 
 in Holland, England and France : it is about the same in Switzer- 
 land and Germany ; so that Haller was evidently deceived when he 
 stated that the duration of a labour is from an hour and a half to 
 two hours. The mean term of this function, therefore, as is re- 
 marked by M. Desormeaux, is about four hours. 
 
 The four most constant and essential phenomena of labour are, 
 as may have been above seen, the contraction of the uterus, or
 
 270 STAGES OF LABOUR. 
 
 pain, the dilatation of the cervix, the formation of the bag of waters, 
 and the discharge of glairy mucus. 
 
 . IV. Of Labour-pains. 
 
 686. In midwifery, the word pain is synonymous with uterine 
 contraction ; nevertheless, it should not be forgot that this is only 
 conventional language, employed by physicians to make themselves 
 understood by the vulgar, and that these two things are essentially 
 distinct. It is true that pain is connected with contraction of the 
 womb ; that they begin, progress, decrease, and cease together ; 
 that the energy of the one is most commonly in a direct ratio to the 
 acuteness of the other ; but it is very certain, also, that the contrary 
 may be met with, so that no labour can be concluded without the 
 contraction, while many may be cited as having taken place without 
 pain. Every body has observed, like M. Flamant, that in most wo- 
 men the contractions come on a good while before the pains. 
 Nevertheless, it is by the pain that we estimate the contraction and 
 its strength ; the former is the sign of the latter. However, there 
 may be numerous shades of difference in the intensity of the pains, 
 without the strength of the contraction being on that account 
 necessarily different. In a nervous and extremely irritable woman 
 a very slight contraction sometimes produces the very severest pain ; 
 on the contrary, a woman of a lymphatic temperament, indifferent 
 as to small matters, and who has but little sensibility, scarcely suf- 
 fers at all, although the womb contracts powerfully ; some women, 
 from an excess of timidity, fear, or pusillanimity, cry out aloud upon 
 the slightest contraction of the womb, while courage and resigna- 
 tion lead others to bear the stongest contractions without complain- 
 ing. Finally, there are a few who, for the purpose of securing more 
 attention or inspiring more compassion and pity, scream and worry 
 themselves in a most extraordinary manner, although they, in re- 
 ality, suffer but very little. There are also those who arm themselves 
 with artificial courage, who resolve beforehand not to complain nor 
 cry out, no matter how strong the pains may be, and at the ex- 
 pense of life make the most incredible efforts to impose silence 
 upon the most violent sufferings, and refrain from the most legitimate 
 outcries ; so true it is that charlatanism and ostentation find occa- 
 sions for exercise even in human infirmities ! It may also happen 
 that the presence of strangers, or of persons displeasing to the wo- 
 man in labour, of whom she is afraid, or with whom she naturally 
 has no familiarity, restrain her and prevent her from giving free ex- 
 pression to the sensations she experiences. 
 
 687. At the commencement, the pains are so weak and super-
 
 LABOUR-PAINS. 371 
 
 ficial, that they have received the title of flies (mouches), doubtless 
 in allusion to the slight sensation produced by the bite of that insect, 
 or that occasioned by its creeping on the skin. They are then 
 called, also, preliminary pains, little pains : characterised by a sort 
 of shuddering of the body of the womb, they arise in the umbilical 
 region, and are lost therein, or spread, so to speak, over the whole 
 hypogastrium and flanks. At a more advanced stage, when the 
 labour is fairly set in, the pains, which are longer, stronger, nearer 
 together, and more decided, are called preparative; never was 
 epithet better applied ; their business is, in fact, to prepare for the 
 expulsion of the ovum, or preside over the dilatation of the cervix ; 
 from the neighbourhood of the umbilicus they generally extend to- 
 wards the sacro-vertebral angle, or to the centre of the strait ; this 
 is the period during which the woman is most impatient, cross, sad, 
 worried, difficult to govern, and utters the sharpest cry, which per- 
 haps depends upon the womb acting alone, and leaving to the wo- 
 man the free exercise of her general sensibility. 
 
 At the end of the first stage, and more particularly in the second, 
 the pains visibly change their character, assume the denomination 
 of bearing or expulsive pains, and in fact announce that nature is 
 employing all her resources for the expulsion of the foetus. These 
 pains, which are also designated as the great pains, are much 
 stronger, longer, and more complete than those of the first stage, 
 and are, besides, characterised by being separated by intervals more 
 perfect, better marked, and more calm, by giving rise to strangury and 
 tenesmus, or a sense of weight which brings the abdominal muscles 
 into play, force the woman to bear down, and make exertions to assist 
 the uterus. Notwithstanding their severity, they do not excite her 
 irritability so much, and are borne with more resignation and patience. 
 The women who seem carefully to avoid every preparative pain, are, 
 on the contrary, anxious for the return of the expulsive ones ; they in- 
 vite and solicit them ; they converse, are tranquil, and during the in- 
 tervals between them, are even lively, and forget the dangers, a sense 
 of which had previously caused them to be so downcast. Their cries 
 are different from those they uttered in the first or second stages. 
 The cries which accompany the first are sharp, and resemble those 
 occasioned by any other species of suffering. Those of the second 
 stage, on the contrary, seem to be suppressed like those of a person 
 carrying a heavy burthen. The former are free and open, and take 
 place during the act of expiration ; the latter are restrained by the 
 closure of the glottis, and can scarcely be heard except during inspi- 
 ration ; the former are expressive of suffering, the latter of exertion. 
 
 688. When the labour approaches its termination, the pains,
 
 272 LABOUR-PAINS. 
 
 which are sometimes of an extreme degree of violence, are pretty 
 frequently accompanied with a kind of convulsive trembling, during 
 which it seems as if the bones of the pelvis are about to separate or 
 break, and all the genital organs threatened with immediate lacera- 
 tion, have been denominated dolores conquassantes, a barbarous and 
 ill-sounding term, but strongly expressive of the state of the case ; 
 their only special character, however, is their high degree of inten- 
 sity, for they do not otherwise differ from the expulsive pains, pro- 
 perly so called. 
 
 689. As has been already seen, the direction of the pains is not 
 the same in every stage of the labour ; they most frequently follow 
 the great axis of the womb, or the occipito-coccygeal diameter of 
 the foetus, and consequently terminate at a point which is so much 
 the nearer to the centre of the vulva, in proportion as the foetus is 
 nearer its passage through the inferior strait ; whence it follows that 
 an anterior obliquity of the womb is one of the most evident causes 
 of those disagreeable pains that are called pains in the back, and to 
 the consideration of which I shall return in another page. 
 
 Causes. The pains of labour are occasioned by the contractions 
 of the uterus : but what is the nature of their mechanism ? At the 
 time of labour the womb is a muscle ; but, in the natural order of 
 things, muscular contractions are not at all painful. The heart, the 
 diaphragm, the stomach, the intestines, the rectum, and the bladder 
 give rise to no pain by their contractions. The most violent con- 
 tractions, even, of the muscles of the abdomen, in labour, are not 
 painful ; we cannot therefore look to the fleshy structure of the 
 womb for the cause of the pain. Stein says that women would 
 doubtless bring forth their children without any pain, were it not 
 for the powerful resistance offered to the passage of the foetus by 
 the inferior segment of the womb and the neighbouring parts, which 
 by their antagonism give rise to pain. According to Levret, Asdru- 
 bali, &c. there is not the least doubt that the seat of labour pain is 
 in the very orifice, non vi cade questions alcuna die in csso orificio 
 6 il luogo positivo ove si articolano i dolori del parto, &c. and not 
 in the body and fundus of the uterus, as supposed by most accouch- 
 eurs. Denman, in speaking of labour-pain, does not attempt to de- 
 fine their seat ; he is satisfied with stating that, in labour, the de- 
 gree of power can only be estimated by the resistance, the resist- 
 ance by the pain, and the pain by the expression. So that his 
 opinion, which is adopted by most of the English practitioners, and 
 which Hopkins characterises as the most rational one, is very nearly 
 the same as that of Stein and Levret. 
 
 Hay and M. Bilon have endeavoured to prove that the seat of
 
 LABOUR-PAINS. 373 
 
 labour-pain is in the cervix much more than in the body of the 
 womb ; their principal argument is, that the former receives its 
 nerves from the sacral plexus, which is one of the divisions of the 
 cerebral nervous system, while the latter receives its supply from the 
 hypogastric plexus, which belongs to the ganglionic system, and 
 which has no communication with the brain. Madame Boivin, who 
 speaks from what she has experienced in her own person, advocates 
 the same idea, and thinks that the contractions of the body and 
 fundus of the womb are not more painful than those of the abdo- 
 minal muscles and bladder. 
 
 690. If it be true that the cervix is endowed with a more acute sen- 
 sibility, receives a more abundant supply of nerves than the rest of 
 the organ, and is powerfully stretched by the contractions, and that 
 all the efforts of the uterus are directed upon that point, it is not 
 less so, that, during the strongest as well as the weakest contractions, 
 the pains are equally felt throughout the whole extent of the womb. 
 If the pressure of the foetus and the tractions exerted upon the 
 cervix were the only causes of pain, women ought not to suffer at 
 all after the dilatation is completed ; yet, notwithstanding, their most 
 violent sufferings are experienced from that very period ; and dur- 
 ing the delivery of the placenta, is it in the neck that we are to 
 place the seat of the pains ? 
 
 691. Others have asserted that the pains of labour are owing to 
 the compression of organs contained within the pelvis, of the ner- 
 vous plexuses, for example. But when the lumbar or sacral nerves 
 are compressed, pain is felt in the limbs and not in the excavation. 
 The pains extend from above downwards, both at the beginning and 
 end of the process, and occupy the whole hypogastrium,and not mere- 
 ly the lesser basin ; as long as the head remains above the superior 
 strait, where the foetus presents transversely, or when it comes by the 
 feet, we cannot refer the pains to this kind of compression. To 
 maintain, with some writers, that they depend on compression of the 
 nervous branches distributed upon the inner surface of the womb, is 
 only to advance one of those numerous assertions, hazarded with- 
 out proof, which are but too often met with in medical works. 
 
 Thus the essential cause of labour-pain is wholly unknown ; it is 
 a question in physiology which deserves and requires new re- 
 searches. What is demonstrated by observation is, that all parts of 
 the womb, either unitedly or singly, may be the seat of pain during 
 labour ; that in certain cases, the stretching of the neck concurs, 
 perhaps, more than all other causes in its production, and that pres- 
 sure upon the neighbouring parts is not always unconcerned in it. 
 
 692. There is another long debated question relative 'to the in- 
 2K
 
 274 LABOUR-PAINS. 
 
 termittence of the pains of labour. A. Petit says, that were noi 
 the pain to cease after it had set in, or if there were only one single 
 pain, the woman would sink under it, and could not bear it ; 
 whereas, being reduced as it is into fragments, the sum of her suf- 
 ferings is really lessened ; in other words, the pains of parturition 
 are intermittent because they are not continuous, for that is all the 
 explanation given by A. Petit. A physician whom Millot opposes 
 with much warmth has entered more deeply into the question, as- 
 serting that the cause of the intermittence of the pains is found in 
 the resistance offered by the ovum to the contractions of the womb. 
 Others have since endeavoured to explain the facts as follows : when 
 the womb contracts with much force, say they, the nerves between 
 its different strata, or even on its inner surface, being compressed by 
 the external surface of the ovum, soon produce a degree of numb- 
 ness in them, that necessarily puts a stop to the contraction. 
 
 But the pains, in these cases, ought to be very long and very near 
 to each other at the commencement of the labour, instead of being 
 so fugacious and far apart, as the contractions are then extremely 
 feeble ; on the other hand, they ought at the close to be shorter and 
 less frequent, inasmuch as the compression is then sudden and 
 most violent ; nor are the pains that accompany the delivery of the 
 secundines, or the after-pains that follow delivery, and which still pre- 
 serve the intermittent type, explained in a manner at all more satis- 
 factory, under this hypothesis. 
 
 693. Buffon thought that the cessation of each pain was due to 
 the detachment of the placenta ; that is to say, according to this 
 celebrated man, the object of each contraction of the uterus is 
 to detach a small portion of the after-birth, and as soon as this de- 
 tachijnent takes place, the pain, like the contraction, must cease for 
 a moment. Two remarks suffice to show the little value of such a 
 supposition. The placenta sometimes comes away before the 
 foetus, and the pains are not on that account less intermittent until 
 the labour is concluded. In other cases the placenta retains its ad- 
 herence even after the delivery of the child, which does not change 
 the intermittent character of the pains. 
 
 694. In stating that the cause exists in the cessation of the con- 
 traction of the muscular fibre, as insisted on by Millot, who thinks 
 he has made a great discovery, we fall back again to the petitio 
 principii for which A. Petit has already been censured, above : this 
 is to displace and not to solve the problem. 
 
 695. During the contraction the blood is forced back into the 
 torrent of the general circulation, says Dr Dewees ; the womb 
 grows pale, and the contraction ceases ; a new affluxion takes place,
 
 LABOUR-PAINS. 275 
 
 and the contraction immediately returns, &c. ; but this explanation, 
 which in fact is perfectly similar to the one which I have been just 
 now opposing, is liable to the same objections, and not at all more 
 admissible. 
 
 696. In conclusion, we do not know the cause of the intermit- 
 tence of the uterine contractions, any more than we do that of the con- 
 tractions of the heart, the intestines, and the muscles in general, 
 or that of all imaginable intermittence, whether functional or 
 organic. Inasmuch as we cannot grasp a body strongly in the 
 hand without being soon obliged to relax it, wherefore should it be 
 supposed that the contraction of the womb does not require to be 
 alternated with relaxation ? The nature of the phenomena is simi- 
 lar in each of the cases ; its cause must be identical, and I cannot 
 perceive why we should with so much ardour seek for it in the one, 
 when we have, in some measure, agreed to abandon it in the other. 
 It is a question which will doubtless long remain unsolvable, but 
 which belongs much more to general physiology than to tokology 
 in particular. 
 
 . V. Of the dilatation of the os uteri. 
 
 697. Pain is the first symptom of labour ; but it is neither the 
 most essential nor constant one ; for, as has been pointed out by 
 Levret, Denman and Hopkins, it may be conceived, that there may 
 be cases in which it is possible for women to be delivered without 
 any pain, whereas it is materially impossible for her to be so with- 
 out the dilatation of the os uteri. This process of dilatation, which 
 is wholly subordinate to the power of the uterine contractions, re- 
 quires to be well understood. It is slow and not very perceptible 
 at the commencement, but is effected with great rapidity towards the 
 close of labour. It generally requires more time to enlarge it to 
 the size of a crown piece, than to complete its dilatation, when its 
 diameter is about three inches. The orifice, which is for the most 
 part very thin and somewhat sharp, when touched at the beginning, 
 especially in a first labour, communicates an impression like that 
 which would be felt upon touching a ring of fine cord slightly 
 stretched. In the latter half of the first stage it becomes, on the 
 contrary, thicker, and sometimes forms a kind of roundish cushion, 
 which seems to yield before the child's head, but gradually disap- 
 pears when the head passes or engages in the strait. The very con- 
 trary of this is remarked in women who have had many children ; 
 the lips of the os uteri, which at first are soft and supple, still some- 
 times retain a thickness of several lines, even although the labour 
 may be somewhat advanced ; it is, however, only at a later period,
 
 276 LABOUR-PAINS. 
 
 when the bag of waters begins to form, that they begin gradually 
 to grow thinner. 
 
 698. In both the above cases, the diminution in thickness is far from 
 taking place with the same regularity on every point of the circum- 
 ference of the circle. I have often seen its posterior half as thin as 
 the edge of a sheet of paper, while its anterior semi-circumference 
 formed betwixt the head and pubis a cushion from three to four 
 lines in thickness. This inequality, which is in some sort natural, 
 and almost always to be met with in various degrees, ought not to 
 be overlooked, whenever we attempt to determine the duration of 
 the labour : by touching the anterior half of the cervix without car- 
 rying the finger far back, one might be led to prognosticate a pretty 
 tedious time, while another person, after having explored the opposite 
 side, would announce that the labour is just about to come to a 
 conclusion. 
 
 699. The shape of the os uteri during the process of dilatation is 
 no less variable than the thickness of its lips. It is pretty nearly 
 circular where it corresponds to the centre of the pelvis ; but more 
 commonly it is oval, with the broadest part turned backwards, or to 
 one side, right or left, according as the fundus is inclined in this or 
 that direction ; sometimes elliptical, especially when the child pre- 
 sents in a transverse direction, it exhibits, in other cases, certain 
 inequalities which depend upon its different points not having the 
 same consistence nor the same extensibility. 
 
 700. All those authors who have maintained that the fetus is the 
 efficient cause of delivery, have necessarily also admitted that it is 
 the cause of the dilatation of the os uteri. The common people, 
 mostly, still reason in this way, and Vigorous seems to be of the 
 same way of thinking ; but since it has been ascertained that, in the 
 expulsion of the whole or part of a dead fetus, the os uteri dilates 
 just as it does for a living child, this opinion, now become superan- 
 nuated, has been completely rejected. We have, says A. Petit, one 
 decisive proof that the fetus does not dilate the orifice, in the fact, 
 that if we place a finger on the point of the ovum where it tends 
 strongly to engage in the opening, we find that the head of the 
 foetus, instead of pressing into it, actually retires from below up- 
 wards, being repelled by the fluids which pass betwixt it and the 
 womb in order to fill up the bag of waters. 
 
 This however does not imply that the child has nothing to do with 
 the production of this phenomenon, but merely that it is not the 
 active cause in it, and oan only concur in it by being under the in- 
 fluence of some other power. 
 
 701. Tlu; real cause of it is to be found in the contractions of
 
 LABOUR-PAINS. 277 
 
 the womb. It is of the essence of fleshy fibres to shorten themselves, 
 and tend to approach a straight line, when they contract ; the womb is 
 composed of curved fibres, the most numerous and strongest of which 
 occupy its fundus and body, and are principally placed lengthwise ; 
 the cervix is the weakest part of the whole organ ; the ovum is an in- 
 compressible body. Now, it is manifest that with such a disposition, 
 the dilatation of the cervix must commence with the contractions of 
 the womb. The vertical and oblique fibres, by their two extremities, 
 which are their movable points, draw the horizontal fibres to which 
 they are attached, or with which they are interlaced, upwards to- 
 wards their middle, where is to be found the real fixed point. The 
 transverse fibres, in contracting upon the ovum, a smooth oval body, 
 necessarily tend to slide towards its apex or towards its base ; but 
 as they are at least as numerous above as below the middle trans- 
 verse zone, it follows, that the circular fibres of the inferior portion 
 of the uterus will, in any general contraction, be found to resist, 
 alone, the efforts of all the longitudinal and circular fibres of its su- 
 perior half. 
 
 On the other hand, as the ovum can only be pushed by the con- 
 cavity of the uterine fibres towards the least resisting point of the 
 organ, it engages in the partly open orifice, and becomes a powerful 
 though secondary cause of the dilatation of the os uteri, and in this 
 case acts like a wedge ; it is an inert force which acts in aid of a 
 vital or organic force. Thus it may be admitted that the ovum is 
 depressed while the os uteri is raised upwards ; in other words, that 
 these two parts, under the influence of the same power, the uterine 
 contraction, slide one upon the other, and that the latter must 
 dilate in the direct ratio of the force which causes the former to 
 descend. 
 
 At the commencement of labour, when the os uteri just begins to 
 open, it is known to contract instead of dilating during the pain, but 
 in such a way, notwithstanding, that it remains larger after the pain 
 than it was before it. At a more advanced stage, when the bag of 
 waters begins to form, we observe, on the contrary, that the os uteri 
 dilates considerably during the contraction, and contracts somewhat 
 as soon as it is over. The cause of this peculiarity is easy to be 
 understood : at the commencement, the fibres of the neck still resist 
 with great energy the action of the fibres of the body and fundus ; 
 as the womb contracts at all points at the same time, and not in one 
 or another of its planes, as A. Leroy supposed, or in different por- 
 tions of its substance alternately, as taught by some others, the orifice, 
 instead of dilating so as to allow the membranes to engage, on the 
 contrary contracts, as if to prevent their passing out ; whereas, at a
 
 , 
 278 LABOUR-PAINS. 
 
 more advanced stage, when it is sufficiently open to permit the point 
 of the ovum to lodge in it, the bag of waters unites in assisting the 
 uterine contraction to force them to distend. 
 
 702. Immediately after the discharge of the liquor amnii, the head 
 of the foetus occupies the situation of the bag of membranes, fulfils 
 its uses, and acts upon the neck in the same manner ; nearly all 
 practitioners think this part less favourable for the dilatation than 
 the segment of the membranes, inasmuch as it is not so even, as it 
 does not form a tumour so equally stretched ; but we shall see, in 
 examining the subject of the premature rupture of the ovum, that 
 upon this subject observation requires to be consulted anew. It is 
 principally from this very moment that the uterine circle is con- 
 verted, in first labours, into a circular cushion of various thickness, 
 and that the dilatation seems sometimes to diminish to such a degree 
 as to impress us with a belief that the labour is retrograding instead 
 of advancing. 
 
 . VI. Of the discharge of glairy mucus. 
 
 703. The term glairy or mucous discharge is given to certain 
 flakes of matter of a very clear yellow or greenish white colour which 
 escape from the sexual organs during labour : this glairy matter occa- 
 sionally resembles white of egg slightly cooked, and differs from the 
 mucus of the nostrils by being less adhesive and by forming masses 
 or lumps which are less coherent and more albuminous. It escapes 
 in masses or flakes which tremble like jelly, come away especially 
 during the contractions, appear in some instances several days be- 
 fore the onset of labour, of which they constitute one of the most 
 certain preliminary signs*, become more and more abundant as the 
 dilatation progresses, and at last, in a majority of women, become 
 tinged with blood. 
 
 704. Nothing is more variable than the quantity of this discharge ; 
 sometimes a few lumps only are observed, and at others very large 
 quantities of it escape with each pain ; when in small quantity 
 or wholly wanting, the labour is said to be a dry one; when abun- 
 dant, it leads us to believe the labour will be soon terminated. 
 Where red striae are mixed with it, the woman is said to have a 
 *Aou>, and the bystanders think it a good sign ; or a proof that the 
 labour will be quickly over. This notion, although not without some 
 foundation, for it is generally observed about the close of the first 
 stage, is far from being always correct ; because there are cases 
 
 * In a great many animal*, both domestic and wild, parturition is also preceded 
 by a discharge of raucous matters, which is sometimes very abundant.
 
 DISCHARGE OF GLAIRY MUCUS. 279 
 
 where the red coloured mucus does not appear at all, while there 
 are others in which it occurs with the first pains. 
 
 705. Some authors have supposed that this semi-fluid matter 
 escapes by transudation from the membranes, and upon leaving the 
 ovum becomes thickened in consequence of the increased tempera- 
 ture of the parts of generation ; as if there was the least resemblance, 
 either as to nature or appearance, between the water of the amnios 
 and the mucous discharges! Others have believed that the fluids 
 brought to the external surface of the ovum, meeting only with vessels 
 of extreme tenuity whereby to penetrate within the amnios, decom- 
 pose, become in some measure filtered, and that their finest and most 
 subtle particles pass through the membranes to form the waters; while 
 their grosser principles remain without, accumulate in the vessels 
 nearest the internal surface of the womb, whence they are expelled 
 during the contractions to give rise to the glairy discharges ; but such 
 an hypothesis need only be mentioned in order to show its futility. 
 The glairy matter is furnished by the mucous membrane, and I cannot 
 conceive why its source should have been looked for any where else. 
 The vagina is lubricated with it every moment during the lifetime 
 of the individual ; many women discharge pretty large flakes of it 
 at the approach of the catamenias ; it is not uncommon to find the 
 womb filled with it in women who die in the unimpregnated state ; in 
 leucorrhoea and other diseased states, it sometimes exhibits the same 
 characters, and runs off in as large quantity as during labour ; finally, 
 if it be of the very essence of organs lined with mucous membranes 
 to secrete mucus, is it surprising that some of it should be formed 
 in the sexual organs during labour ? 
 
 706. The blood mixed with it comes neither from a rupture of 
 the utero-placental vessels, for these vessels have no existence, nor 
 from slight lacerations of the cervix, at least, most generally ; for it 
 is very common to find the bloody mucus appear before the cervix 
 has been at all stretched : the mucus is coloured with blood in the 
 same manner as the sputa in cases of pulmonic irritation, or as the 
 mucous excretions of the nose in cases of irritation seated in the 
 schneiderian membrane, &c. Whether this blood be derived from 
 the interior of the womb, or even from some cracks in the cervix 
 uteri, it may be conceived that though it ordinarily goes only so far 
 as to redden the mucus, it may nevertheless go to a much greater 
 extent, so as to constitute a real hemorrhage. 
 
 707. The use of the glairy matter is to moisten and lubricate the 
 parts over which the child has to pass, to increase their suppleness 
 and extensibility, and make it more easy for the ovum to slide over 
 the surfaces. Where the discharges fail to take place, the dilatation
 
 280 DISCHARGE OF GLAIRY MUCUS. 
 
 of the os uteri is always more painful, slower, and the organs more 
 disposed to become inflamed ; their superabundance, in general, in- 
 dicates great softness of the tissues, weakness and a disposition to 
 inertia ; so that this phenomenon really deserves great attention in 
 practice, and the accoucheur ought carefully to study its progress 
 and its particular modifications. 
 
 . VII. Of the bag of waters. 
 
 708. The name of bag of waters is given to the protuberance 
 formed by the membranes in the upper part of the vagina during 
 labour. A true segment of a sphere, or of an ovoid figure, which 
 was compared by A. Petit to a tymbal, this sac varies, however, in 
 respect to its shape, for it is generally moulded upon the opening 
 through which it tends to escape. Round, globular, and even, where 
 the os uteri corresponds to the centre of the pelvis, and dilates in a 
 regular manner, commonly elliptical, where the child presents trans- 
 versely, wider behind and to the right or left in cases where the 
 womb is strongly inclined in the opposite direction, it sometimes 
 presents the appearance of a cone, somewhat elongated, or of a 
 portion of intestine, or, as it is called, the shape of a saussage or 
 blood pudding, particularly when the foetus presents by the feet, or 
 also where the os uteri is very hard at the same time that the mem- 
 branes exhibit a great degree of extensibility ; it has, finally, been 
 seen to enlarge beneath the orifice and become pyriform. 
 
 709. During the presence of a pain the bag of waters is hard, 
 tense, and elastic ; after the contraction is over it becomes wrinkled 
 and contracts or disappears. Constituted like the rest of the ovum 
 of the anhistous membrane, the chorion and arnnios, its formation, 
 according to some persons, depends upon the elongation of the 
 membranes ; but A. Petit has fully refuted this opinion, by demon- 
 strating that the foetal tunics are scarcely extensible ; according to 
 some other writers, and particularly the last named author, every 
 contraction causes a small quantity of water to exude from them out- 
 wards ; a vacuum is gradually effected in the amnios ; and the ovum, 
 being powerfully pressed in all directions, gradually engages, through 
 the orifice, in the upper part of the vagina ; but if this transudation 
 really took place, the surface of the bag would become covered witli 
 small drops of water or a kind of dew, in a word, it would become 
 moist, during the pains, whereas it is never drier than it is during the 
 very strongest contractions; besides, it has already been seen that 
 
 I here is no analogy between the liquor aninii and the glairy dis- 
 charges, into the composition of which A. Petit gratuitously sup- 
 posed them to enter so readily.
 
 BAG OF WATERS. 2SI 
 
 710. The bag of waters, like the dilatation of the cervix, is pro- 
 duced by the contractions of the womb, and by a mechanism equally 
 easy to be understood: by acting upon the periphery of the ovum as 
 upon the throat of a pulley, the uterine fibres compel it to descend, 
 while, on the other hand, the cervix, by dilating, is obliged to ap- 
 proach nearer to the fundus, and to leave a more or less considerable 
 segment of the membranes outside of the orifice ; the point of the 
 foetal ovoid, lubricated with mucus, forces the orifice to open a little, 
 as the finger, when previously covered with a peach skin turned in- 
 side out, will force the fingers of the other hand to open when we 
 try to push it betwixt them. It would, notwithstanding, be wrong 
 absolutely to deny the extensibility of the tunics of the foetus. On 
 the contrary, every thing proves that they may sometimes extend to 
 a considerable degree, and that it is in consequence of this elonga- 
 tion that the bag in certain cases affects the form of a cone or of a 
 pear ; I merely wish to say that this property is in general very slight. 
 Even if it be true that the amniotic tymbal is almost always curved 
 upon a cord that is shorter than the rest of the ovum, it is also true 
 that this peculiarity, which seems to demonstrate that the membranes 
 have yielded at that point, is owing to another cause ; any one who 
 has had occasion carefully to open a pregnant womb, has had an 
 opportunity of being convinced that the mere weight of the ovum is 
 sufficient to flatten it very considerably, as soon as it ceases to be 
 exactly supported by the surrounding organs : therefore, it is quite 
 evident that a portion of the membranes may in this state of relaxa- 
 tion engage very well in the os uteri, and in a very small volume, 
 without undergoing any real elongation. 
 
 711. After having wholly, or in part, dilated the os uteri, the bag 
 of waters, now become very large, and besides, ill-supported in the 
 upper part of the vagina, yields to the impulsion of the liquid, and 
 breaks ; the contained fluid escapes, and the head of the child being 
 at the same moment pushed forwards by the same effort, stops up 
 the passage to the rest of the liquor amnii. But this rupture is far 
 from always taking place at the same point, or under the same de- 
 gree of dilatation, or at the same stage of labour in all women. The 
 membranes may be too dense, too thick and too resisting, or too 
 thin and fragile ; the os uteri itself, which is sometimes very hard, 
 rigid, and difficult to distend, is, on the contrary, in other cases ex- 
 tremely soft. In the most natural and regular state of things, the 
 sac gives way about the end of the first, or commencement of the 
 second stage ; but it may open at the beginning, or not till the end 
 of the labour. It happens also, sometimes, that the membranes burst 
 either one or several days before the appearance of the first pains, 
 
 2L
 
 282 BAG OF WATERS. 
 
 or that they do not rupture at all, the ovum being forced to pass 
 whole through the straits of the pelvis. 
 
 The perforation commonly takes place in the centre, and in that 
 case the sac becomes instantly empty ; if it happen near the edge 
 of the orifice or high up, it collapses only imperfectly, or appears 
 again with each return of the pains, and the fluid escapes in small 
 quantities only. When the tumour does not open until it nearly 
 reaches the vulva, and the rupture does not take place in the centre, 
 the head carries a segmentbf the membrane along before it, and the 
 fo3tus escapes covered with a sort of hood, and is born with a caul. 
 
 712. It was formerly predicted that a child born in this way 
 would be lucky or unlucky according to the colour of the caul ; 
 that if it swallowed its caul previously reduced to powder, or 
 always carried it about its person carefully enclosed in a box, it 
 would be fortunate and always happy ; that if it lost it, it would be 
 unhappy in every thing, perhaps epileptic, constantly tormented by 
 phantoms or infernal spirits ; whence it follows, says Diemerbroeck, 
 that the midwives seize upon this portion of membrane as a matter 
 of right, in order to frighten the parents, and get more money from 
 them by selling it to them at a dear rate. How many good women 
 in the country are still imbued with this absurd prejudice ! Should 
 the caul extend over the mouth and nose, it might, strictly speaking, 
 hinder respiration from taking place, and perhaps cause the death of 
 the child, as some authors have supposed ; but to justify such fears 
 as these, the lying-in woman herself must be supposed to be insen- 
 sible, and to have no body with her : this, therefore, is one of those 
 possible misfortunes of which we are as yet in possession of no ex- 
 amples. 
 
 ARTICLE II. 
 
 Of Eutocia, or Simple, Fortunate, or Spontaneous Labour 
 (natural labour of the. French writers]. 
 
 In order that labour may terminate without foreign aid, a consi- 
 derable number of conditions are required. 
 
 713. On the part of the woman, there must be no fault nor de- 
 formity in the pelvis ; no serious affection of the womb, no scirrhus 
 nor old cicatrices ; the organ must enjoy a certain degree of energy ; 
 the general powers of the system must not have been exhausted, 
 either by a profuse hemorrhage, or any long continued disease ;
 
 EUTOCIA. 283 
 
 there must be no affection, making it dangerous for the woman to 
 give herself fully up to the efforts she is compelled to make, and no 
 accident must supervene during the labour. 
 
 714. On the part of the child, it is important that the occipito- 
 coccygeal axis should present one of its extremities to the straits, 
 that the foetus should descend with the head, the feet, the knees or 
 the breech foremost ; that it should not be hydrocephalous, gibbous 
 or ascitic ; not of a size disproportioned to the capacity of the pel- 
 vis ; that there be not two heads attached to a single trunk, or two 
 trunks to a single head, nor two children united together in any 
 manner whatever. 
 
 715. Notwithstanding the number of these conditions, it is a rare 
 thing for them not to be met with ; for spontaneous child-birth forms 
 a large proportion of the sum total of labours. We find in Merri- 
 man's Synoptical Table, that out of 1800 cases 1746 might have 
 terminated spontaneously, since the child presented by the vertex in 
 1654 instances, four times by the lower extremities, twenty-three 
 by the face, forty-two by the hip, and that in twenty-three cases the 
 labour was only regarded as dystocial because they were multiparous 
 pregnancies. 20,357 labours took place at the Maternite at Paris 
 from 1797 to the end of 1811 ; of these 20,183 were natural. Out 
 of 1897 that took place under the superintendence of Dr Bland, 
 1860 were brought to a conclusion by the hand of nature. It is 
 seen, therefore, that at the Maison d'Accouchement at Paris, diffi- 
 cult labours have occurred in the proportion of one to sixty-two ; 
 and at the Westminster Dispensary and Middlesex Hospital, accord- 
 ing to Merriman and Bland, out of forty-three labours, forty-two 
 terminate spontaneously. 
 
 Madame Lachapelle, in her new tables, divides the labours that 
 have fallen under her notice into two periods ; the first, extending 
 from the 1st Germinal, year IX, to the 31st December 1811, com- 
 prises 15,662 cases, of which 15,380 were spontaneous, and two 
 hundred and seventy-two difficult ; the second, which extends from the 
 1st of January 1812 to the 31st December 1820, comprises 22,243 
 labours, of which 21,974 terminated without any artificial assis- 
 tance, and two hundred and sixty-nine by the assistance of art. 
 According to Boer, there were 958 cases from September 1 787 to the 
 same period in 1790, in the Obstetrical School of Vienna ; and of 
 this number seventeen required turning, the forceps, or the perforation 
 of the head ; from September 1790 to September 1791, there were 
 eighteen cases of dystocia out of 950 labours ; from September 1791 
 to September 1792, out of 1015 labours, there were eight requiring 
 turning, and seven the forceps ; from the 1st January 1801 to 31st
 
 284 EUTOCIA. 
 
 December 1802, among 2234 labours, thirteen were concluded by 
 turning, eight by forceps, and two by the perforation of the head ; 
 from January 1st, 1803 to December 31st, 1805, out of 2,399 
 labours there were five cases of turning, eleven of application of the 
 forceps, and three of perforation ; in 1806, out of 2030 cases, seven 
 required turning, two the forceps, and one the perforation of the head. 
 At Heidelberg, out of 1296 labours mentioned by M. Nasgele, 1230 
 were natural, and sixty-four not natural ; which gives the proportion 
 of one to twenty, while the view by Boer exhibits, upon a total of 9590 
 only 102 requiring turning, the employment of the forceps, or the per- 
 foration of the head ; which makes about one case of dystocia in 
 ninety-five. But these proportions must be understood only as show- 
 ing the practice of the authors who have published them, and not 
 practice out of the public establishments. The discrepancies now 
 existing in reports on this head are already sufficiently great ; as may 
 be evident upon reference to the London and Paris reports, and 
 those of M. Boer, and those of the clinic at Pavia, for, accord- 
 ing to M. Lovati, out of sixty-seven labours, twenty-two re- 
 quired to be assisted. However, the proportions found in private 
 practice are still more variable, for, in great cities as well as in the 
 country, the resources of art are called in, at least in one case in 
 six, by some individuals, whilst others employ them only once in 
 ten, twenty, or thirty, or even sixty, eighty or one hundred cases. 
 
 716. Admitting the result of the last period mentioned by the 
 Vienna professor, as the farthest possible limit, as the last term, and 
 beyond which nature cannot pass, we ask, can we rely upon enjoy- 
 ing equal advantages ? On this subject I think it important that 
 we should not confound the possible with the useful. Although 
 Boer's work proved that only one case out of one hundred and 
 thirty-two labours was terminated by the assistance of art, it does 
 not by any means prove that it would not have been better to have 
 had recourse to it in some other of the hundred and thirty-one cases. 
 Is it not certain that in many cases where parturition may, rigorously 
 speaking, take place spontaneously, nature would, by a proper kind 
 of assistance, conclude the function more happily both for the mo- 
 ther and the child ? As to Merriman and Bland, who mention one 
 case of dy.st.ocia out of forty-five, it is not proved that they were not 
 in a hurry to act in many cases where the organism, if left to itself, 
 would have fully sufficed for its own welfare ; besides, every body 
 knows that patience is not the prevailing quality of English practi- 
 tioners. Ho this as it may, if the results obtained in the hospitals 
 of Vienna and London lie taken as the two extremes, it seems to 
 me that we may admit those of the Matcrnite at Paris to be the
 
 EUTOCIA. 285 
 
 mean term, and then it will appear that the active co-operation of 
 the accoucheur will be useful in one out of fifty or sixty cases. 
 
 717. Now what is the reason that a different result is found to 
 occur in private practice ? Ought dystocia to be met with more 
 frequently in women in easy circumstances, who live well in their 
 own families, than in the poor, who are tormented with fear or re- 
 morse, and who go to the hospitals to be confined ? No, doubtless ; 
 for every thing concurs to increase the number of difficult labours 
 in the hospitals, and diminish it in private practice. Deformed pel- 
 vis and all sorts of diseases of the genital organs are most frequently 
 to be met with among the poorer class of women ; many women, 
 who would otherwise have remained at their own houses to be de- 
 livered, go to lie-in at the hospital, because they are of a bad con- 
 formation, or because they are fearful of having a dangerous labour; 
 many others go there while in labour, because they are found, by the 
 person originally called in, to need the assistance of art, and because 
 they will have an opportunity of receiving that assistance better than 
 they would at home. 
 
 718. But in the hospitals none, in general, except skilful persons, 
 are appointed, who do not act for the mere pleasure of doing so, 
 who repose in nature all the confidence that she deserves, and do 
 not vainly interfere to assist her to do better ; who know how to 
 apply in proper season, and only where they are indispensable, or 
 at least evidently useful, the resources of an art whose fundamental 
 principle is, always to preserve, and never to destroy, except in 
 cases of absolute necessity. But out of those public institutions, how 
 many imprudent, ill-timed, unskilful, or rash maneuvres! Here it 
 is an ignorant midwife, whose audacity and effrontery supply the 
 place of knowledge, who cannot remain unemployed about the un- 
 fortunate women who are so thoughtless as to confide in her ; there, 
 it is a practitioner not less inept and more dangerous than the old 
 woman, inasmuch as he inspires confidence ; such men, who are, 
 unfortunately, too numerous, who call themselves accoucheurs, be- 
 cause they are incapable of becoming any thing else, take a pride 
 in the number of difficult labours that they have terminated ; they 
 resolve to deliver by force, without giving nature, who is wiser 
 than themselves, time to finish her work ; and so that they may but 
 seem to be necessary, fear not to obstruct, interfere with and tor- 
 ment the organs, so as to convert the most natural labour into a 
 dangerous one ! 
 
 There again, it is an impatient practitioner, who, being in too 
 great a hurry to wait, needlessly applies the assistance of art, so 
 as to be sooner at liberty to pursue his occupation somewhere else.
 
 286 EUTOCIA. 
 
 Sometimes it is a timid young physician, who, led away by the cries 
 of the patient, her relations, and assistants, rather than lose the 
 confidence he wishes to inspire, decides on resorting to measures 
 he knows to be useless. Finally, on other occasions, there are 
 wretches, equally criminal and despicable, who, in order to obtain 
 reputation among the people, make haste to operate wherever they 
 suppose they can profit thereby, without thinking upon the dangers 
 to which they expose both mother and child. Such scandalous 
 conduct as this, to the shame of the authorities, the laws, and of 
 the establishments for instruction be it spoken, is daily observed far 
 more in the large cities than in country places. 
 
 719. "I feel compelled," says Diderot, " by the interest that every 
 honest man ought to feel in the birth of the citizens, to declare, that 
 being urged by curiosity, I caused myself to be conducted one day 
 to one of those midwives who take in pupils, and that I there wit- 
 nessed samples of inhumanity which would be almost incredible 
 among barbarians ; these midwives, in hopes of attracting a greater 
 number of spe-ctators, and consequently of peasants, would cause 
 their emissaries to announce that they had a woman in child-birth, and 
 that the labour would certainly prove preternatural ; the spectators 
 collected, and in order not to deceive the general expectation, they 
 returned the child into the womb, and brought it down by the feet ! 
 I should not dare to state this fact if I had not several times been a 
 witness to it, and if the midwife had not the impudence to confess 
 it to me. I therefore charge those who are appointed to watch 
 over the disorders of society, to keep their eyes upon this one." 
 
 Would to Heaven the fact related by Diderot had never been re- 
 peated since, and that it had never been witnessed except among 
 midwives ! But let us draw a veil over a kind of conduct which 
 lends hut too much support to the idea of Denman, " that the abuse 
 of art produces evils more numerous and serious than the imperfec- 
 tions of nature." 
 
 Such, doubtless, are the chief causes that render dystocia more 
 common in private than in hospital practice. 
 
 720. However, it must be confessed that the proportions between 
 the different kinds of labour must of necessity vary from circum- 
 stances wholly accidental. Thus, of two practitioners who are 
 equally skilful and equally circumspect, one may attend several 
 hundred labours without being obliged to yive any assistance to na- 
 ture ; while the other may be several times obliged to have re- 
 course to the artificial means. Since I began carefully to notice the 
 facts that have fallen under my own notice in tokology, I have 
 found a very great difference between what has occurred at my
 
 EUTOCIA. 287 
 
 amphitheatre and in my private practice. Out of five hundred and 
 fifty labours that took place in the Hospital de Perfectionnement 
 while I had charge of it, and in my own amphitheatre, only eight 
 required any assistance ; in my private practice, on the contrary, 
 out of less than three hundred cases, I had thirty cases of dystocia ; 
 which gives for the former only one difficult labour in upwards of 
 sixty, and for the latter, so to speak, one for every eight labours. 
 Such a disproportion is, however, not difficult to account for ; at 
 my public hall, and at the hospital, we received without distinction 
 all the women who presented themselves, without any of them, ex- 
 cept two, having previously undergone any examination ; while the 
 cases of dystocia that fell under my notice elsewhere, were almost 
 all procured for me by my brethren, or by mid wives, who, from ex- 
 cessive timidity, or for want of practice in the use of instruments, pre- 
 ferred calling on me rather than to attempt to deliver the women 
 themselves. 
 
 SECTION 1. 
 
 Of Natural Eutocia (simple or spontaneous labour, the head of the 
 child presenting'). 
 
 721. What I have said concerning the attitude and position of 
 the foetus in the womb, makes it sufficiently evident, that the child 
 ought properly to present its cephalic extremity to the straits of the 
 pelvis, and that the cases where it descends in any other way should 
 be regarded only as anomalies. It was correct, therefore, in Hip- 
 pocrates and most of the ancient authors, not to give the title of 
 natural labours except to those in which the head of the child came 
 first, 'and to call all labours where the feet, the breech, or knees 
 presented, non-natural. The moderns having rejected this doctrine 
 depends upon their having misconceived the acceptation of the 
 terms: the word natural is admitted by them to be synonymous 
 with spontaneous, and consequently, that labour where the pelvic 
 extremity presents ought to belong to the class of natural labours. 
 
 722. There is no doubt that the principles taught by the father 
 of medicine have been the cause of important errors in practice, by 
 leading practitioners to deliver by the head when it did not origi- 
 nally present, and in denying the possibility of a labour terminating 
 alone, where the feet present ; but, although they abandoned these 
 ideas, have not the authors of the last century replaced them by 
 others equally incorrect ? Is it right, with Dionis and A. Petit, to 
 say that the fetus may be extracted with as much or more ease by 
 drawing it away by the feet, than if it descends with the head fore-
 
 238 NATURAL EUTOCIA. 
 
 most ; and that it is almost a matter of indifference as to the result, 
 whether the cephalic or pelvic extremity presents ? I do not think 
 so, and I dare to say that such a way of thinking would be scarcely 
 less dangerous in practice than the ancient doctrine. There is no 
 position of the child in which the labour has not sometimes termi- 
 nated alone ; and yet it has entered into no one's head to call a 
 shoulder presentation, for example, a natural one. If a dystocia 
 takes place, it is not because the child is in this or that position, but 
 because 'the interference of art becomes indispensably necessary ; a 
 labour may be fortunate, and simple, or spontaneous, although the 
 fo3tus presents with its pelvic extremity ; but strictly speaking, the 
 positions of the head are alone natural or normal. 
 
 723. Delivery by the encephalic extremity contains two very dis- 
 tinct genera : in the first the summit of the head presents ; while in 
 the second, the face or some other part of the head offers at the 
 straits. 
 
 . I. Presentation of the vertex. 
 
 1664 times in 1800 cases (Merriman); 1792 times in 1897 cases 
 (Bland); 19,730 in 20,357 cases (Madame Boivin); 14,677 times 
 in 15,652 cases (Madame Lachapelle); 20,698 times in 22,243 (Id.); 
 1210 in 1296 cases (Nacgele); 61 in 67 (Lovati); 392 in 400 
 (Hospital of the Faculty). 
 
 724. The presentation of the vertex is incomparably more fre- 
 quent, as may be seen above, than all the others. Is any thing fur- 
 ther wanting to prove that it is the only natural one, that which the 
 organism always tends to produce, when nothing arises to interfere 
 with the regular accomplishment of the grand act of reproduction? 
 In this presentation the posterior fontanel tends to place itself in the 
 centre of the pelvis. The principal diameters of the straits are 
 adapted to the occipito-bregmatic and bi-parietal diameters. The 
 occipito-mental diameter, and the occipito-bregmatic circumference 
 should be parallel to the planes of the openings of the excavation, 
 and to the axes of the straits. These general relations are always 
 to be observed in regular positions of the vertex ; but the occiput is 
 far fron looking to the same point of the pelvic circle in all cases, 
 whence have arisen the various positions at present admitted in 
 tokology. 
 
 Antecedently to the time of A. Petit, Solayrcs, ;ind Baudelocque, 
 accoucheurs were content to say that the occiput had < <>m<: in front 
 or backwards, that the face was turned towards the sacrum or 
 towards the piibis ; and this old method of coiisidci in<: it, \vliicli 
 M. Delpcch defends, is still generally adopted in England, in (ier-
 
 TABLE IT. 
 
 Positions of the Foetus according to different Authors. 
 
 1. Occiput behind the left acetabnlurn. 
 
 2. Occiput behind the right acetabulum. 
 
 3. Occiput behind the symphysis pubis. 
 
 4. Occiput before the right sacro-iliac symphysis. 
 
 5. Occiput before the left sacro-iliac symphysis. 
 6 Occiput before the sacrum. 
 
 f 1. Forehead upon the symphysis pubis. 
 
 1 2. Forehead upon the sacro-vertebral angle. 
 
 \ S. Forehead upon the left ileo-pectineal eminence. 
 
 C 4. Forehead upon the right ileo-pectineal eminence. 
 
 f 1. Heels behind the left acetabulum. 
 
 \ 2. Heels behind the right acetabulum. 
 
 i 3. Heels behind the symphysis pubis. 
 
 * 4. Heels in front of the sacrum. 
 
 f 1. Front of the legs behind the left acetabulum. 
 
 1 2. Front of the legs behind the right acetabulum. 
 
 1 3. p'ront of the legs behind the symphysis pubis. 
 
 ' 4. Front of the legs before the sacrum. 
 
 r 1. Sacrum behind the left acetabulum. 
 
 \ 2. Sacrum behind the right acetabulum. 
 
 i 3. Sacrum behind the symphysis pubis. 
 
 ' 4. Sacrum in front of the promontory. 
 
 {1. Occiput. 
 2. Neck. 
 3. Breast. 
 4, Loins. 
 5. Sacrum. 
 {1. Face. 
 2. Neck. 
 3. Sternum. 
 4. Abdomen. 
 5. Genitals. 
 {1. Neck. 
 2. Shoulder. 
 3. Thorax. 
 4. Flank. 
 5. Hip. 
 
 Vertex. 
 
 Face. 
 
 Feet. 
 
 Knees. 
 
 Breech. 
 
 Trunk. 
 
 1. Head in front. 
 
 2. Head behind. 
 
 3. Head left. 
 
 4. Head right. 
 
 r Vertex. 
 
 Face. 
 
 Feet. . 
 
 Knees. 
 
 Breech. 
 
 Trunk. 
 
 Same as BAUDF.T.OCCICE. 
 
 1. Forehead left. 
 
 2. Forehead right. 
 
 3. Forehead front. 
 . 4. Forehead back. 
 
 1. Heels, legs, or sacrum left. 
 
 2. Heels, legs, or sacrum right. 
 
 3. Heels, legs, or sacrum front. 
 
 4. Heels, legs, or sacrum back. 
 Lateral surface. 
 
 Posterior surface. 
 Anterior surface. 
 
 No subdivisions. 
 
 1. Head left. 
 
 2. Head right. 
 
 3. Head front. 
 
 4. Head back.
 
 Vertex. 
 Face. . 
 Feet. . 
 
 Knees. 
 Breech. 
 
 Trunk. 
 
 TABLE II. Continued. 
 
 1. Left oedipito-cotyloid. 
 
 2. Right occipito-cotyloid. 
 
 3. Right occipito sacro-iliac. 
 . 4. Lett occipito sacro-iliac. 
 
 Same as Gardien. 
 
 1. Left calcaneo-cotyloid. 
 
 2. Right calcaneo-cotyloid. 
 
 3. Right calcaneo sacro-iliac. 
 
 4. Lett calcaneo sacro-iliac. 
 
 Same relations. 
 
 f Anterior surface. 
 
 Back. No subdivisions. 
 
 \. Hip. 
 
 Lateral surface. 
 
 r\. 
 
 42. 
 (.3. 
 
 Same as GAUD. 
 
 Shoulder. 
 Ear. 
 
 f Vertex. 
 
 Feet. . 
 
 Knees. 
 
 Breech. 
 
 Face. 
 
 I Ti-unk. 
 
 x- 1. Left oceipito-anterior. 
 
 V 2. Right oceipito-anterior. 
 
 } 3. Right oceipito-posterior. 
 
 ( 4. Left oceipito-posterior. 
 
 e 1. Left calcaneo, tibio, or sacro-anterior. 
 
 \ 2. Right calcaneo, tibio, or sacro-anterior. 
 
 j 3. Right calcaneo, tibio, or sacro-posterior 
 
 * 4. Lett calcaneo, tibio, or sacro-posterior. 
 f 1. Chin behind and right. 
 
 \ 2. Chin behind and lett. 
 \ 3. Chin in front and left. 
 
 * 4. Chin in front and right. 
 
 f Cl. Occiput. 
 
 {Posterior surface. 1 2 Back l 
 ,. S 1. Face. 
 Anterior surface. ^ 2 Breast 
 r /-Side of the 
 Right lat. surface. S head . 
 Left lat. surface. (.Shoulder. 
 
 II. Head front and left. 
 2. Head front and right 
 
 3. Head back and right 
 
 4. Head back and left. 
 
 Vertex. 
 Face. . 
 
 Feel. . 
 
 Knees. 
 
 Breech. 
 
 TrunL. 
 
 Like GAHDIEN. 
 
 1. Mento-sacral 
 
 2. Mento-pubic. 
 
 3. Right mento-iliac. 
 
 4. Lett mento-iliac. 
 
 Sternal surface. Like BAUDELOCQ.UE ; but no subdivision 
 
 1. Cervico-sacral. 
 
 % 
 
 Poster. 
 
 Like BAUD. 
 
 .Lateral surface. 
 
 4. Lett cervico-iliac. 
 r 1. Costal region. f 1. 
 X 2. Region of the > 2. 
 \ shoulder. 1 3. 
 
 ' 3. Region of the ear. ' 4.
 
 r Vertex. 
 
 Face. . . 
 Feet. . . 
 Knees. 
 Breech. . 
 Shoulder. 
 
 TABLE II. Continued. 
 
 . 1st of BAUDELOCQUE. 
 
 2. Idem. 
 
 3. 4th of BAUDEIOCO.UE. ' 
 
 4. 5th of BAUDELOCQ_UE. 
 
 5. Occiput to the left. 
 
 6. Occiput to the right. 
 
 )f Moreover there are intermediate 
 imperfect, and inclined posl 
 Like BAUDELOCQUE. -| tions. 
 I No other position of the trunk. 
 
 Vertex. 
 
 Breech. 
 
 Trunk. . 
 4 surfaces. 
 
 1. Occipital fontanel above the left acetabulura. 
 
 2. Occipital fontanel above the right acetabulum. 
 
 3. Occipital fontanel above syraphysis pubis. 
 
 4. Occipital fontanel above right sacro-iliac symphysis. 
 
 5. Occipital fontanel above left sacro-iliac symphysis. 
 
 6. Occipital fontanel above sacro-vertebral angle. 
 
 7. Occipital fontanel above left iliac fossa. 
 
 8. Occipital fontanel above right iliac fossa. 
 Eight species, like those for the vertex. 
 
 c \. Face. 
 
 2. Throat. 
 
 3. Sternum. 
 
 4. Abdomen. 
 
 1. Nucha. 
 
 2. Back. 
 
 3. Loins. 
 
 4. Sacrum. 
 
 1. Cheek. 
 
 2. Neck. 
 
 3. Shoulder. 
 
 4. Hip. 
 
 'Anter. surface. 
 
 Poster, surface. 
 
 Lat. surfaces. 
 
 1. Head to the left. 
 
 2. Head to the right. 
 
 3. Head in front. 
 
 4. Head behind. 
 
 Vertex ...... 4 positions, like MM. MAYGRIER and CAPUROIC. 
 
 (~l. Loins to the left. 
 
 Loins towards the back. 
 
 Right shoulder. 
 Left shoulder. . 
 
 ... C 1. Vertex to the left. 
 
 2 positions. J 2> Vertex to the right. 
 
 a ... Cl. Back in front. 
 
 2 positions. } 2 . Back to the rear. 
 
 2 positions. 
 
 "1. Back in front. 
 ' 2. Back to the rear. 
 
 Making 
 
 in all 14 
 
 species. 
 
 Vertex. 
 
 Face. 
 
 Feet. 
 
 Knees. 
 
 Breech. 
 
 Trunk. 
 
 f Like BAUDELOCQUE. 
 Like BAirDEtoccitJE, except the subdivisions.
 
 
 TABLE II. Continued. 
 
 
 r rl. Left occip.-acet. 
 j 1. Occip.-ant. 3var.-<2. Right occip.-acet. 
 f Vertex. } v.3. Occip.-pubic. 
 
 
 Jlenrl 
 
 j 2 species. | rl. Left fronto-acet. 
 j 2. Oceip.-post. 3var.-< 2. Right fronto-acet. 
 (.3. Fronto-pubic. 
 
 
 J1CUU. 
 
 2 species. 
 
 <.Ffl.Onin fl. Right mento-iliac. 
 one spe- Mento-pubic. 4va- - T 5 mon 
 
 
 cies atV rietiesatthesupe-^; ; 
 the inf. nor strait. ^- Mento-sacral. 
 ^_ strait. J 
 
 o 
 ea 
 F 
 P 
 
 Lower end of] 
 the trunk, rl. Feet. } 
 only one > 3 shades. 4 2. Knees. v-2 spec, 
 kind : the (.3. Breech. 3 
 Pelvis. } 
 
 1. Sacro-rl. Left, 
 ant. -52. Right. 
 3 var. (.3. Pubic. 
 2. Sacro- rl. Right, 
 post. 4 2. Left. 
 3 var. (.3. Sacral. 
 
 CH 
 
 ( I. Lateral surface. One species. { 1. Head left. 
 
 
 
 IThe shoulder. 2 Varieties. 
 
 I 2. Head right. 
 
 
 Trunk. 
 
 2. Posterior surface. One species. ( 1. Head left. 
 
 
 3 genera. 
 
 The back. 2 varieties. 
 
 2. Head right. 
 
 
 
 3. Anterior surface. One species. ( 1. Head left. 
 
 
 
 [ The breast. 2 varieties. 
 
 j 2. Head right. 
 
 
 Besides these, there are inclined positions of the head, 1. The temple; 
 2. The forehead ; 3. The occiput ; and of the breech there are, 1. The 
 
 ^hip; 2. Sacrum; 3. The parts of generation. 

 
 PRESENTATION OF THE VERTEX. 289 
 
 many, and in most foreign countries. It is therefore in France 
 particularly, and almost only in France, that attempts have been 
 made to subject labours to the methods followed in natural history. 
 But upon this, as upon all other subjects that are merely matters of 
 convention, it has happened that the same fact has not been looked 
 at in the same light by all observers. In the opinion of some we 
 ought to admit six positions of the vertex ; according to others, the 
 number may be extended to twelve and even to twenty-four ; many 
 think that there should be only four, and some not more than two. 
 Again, those who agree in respect to the proper number differ in 
 regard to the proper method of counting them or locating them. 
 For example, Madame Lachapelle, who like Baudelocque admits 
 of six positions, does not adopt the two antero-posterior positions of 
 that author, but in place of them establishes two transverse positions, 
 &,c. ; so that it is a pretty difficult matter for students to make a 
 choice in such a conflict of authorities. 
 
 In a theoretical point of view it cannot be denied that the vertex 
 may present itself to every point of the circumference of the superior 
 strait, and consequently, that an infinite number of positions may be 
 established if we choose ; but the question is, how many of them 
 would it be useful to adopt in practice, which are those we ought 
 to study with particular care, and not how many we might admit. 
 In the first place, it is evidently superfluous to suppose there are 
 more of them than there are points corresponding to the ends of the 
 four principal diameters of the pelvis ; therefore it seems that the 
 number established by M. Flamant, and which unites the classifica- 
 tion of Baudelocque with that of Madame Lachapelle, might be 
 considerably reduced. In fact, the occiput scarcely ever presents in 
 more than two ways to the inferior strait ; in one it looks forwards 
 and lodges under the arch of the pubis ; in the other, it is turned 
 backwards, and presses the anterior edge of the perineum forcibly 
 backwards. 
 
 Agreeably to this observation I have thought that all the presenta- 
 tions of the vertex might without inconvenience be referred to two 
 fundamental positions : one, in which the occipital protuberance 
 answers to some one point of the anterior semi-circumference of the 
 superior strait ; the other, where the same part is turned to the 
 opposite portions of the strait. This modification, although slight, 
 and in itself considered of very little importance, answers, notwith- 
 standing all the wants of both theory and practice ; it enjoys the 
 great advantage of not excluding the other classifications, and of 
 accommodating itself to all the various doctrines. 
 
 The occipito-anterior position comprises the three first position* 
 2M
 
 290 NATURAL EUTOCIA. 
 
 of Baudelocque, or the two first of MM. Maygrier, Capuron 
 and Duges, and of Mesd. Boivin and Lachapelle. The occipito- 
 posterior position naturally includes the fourth, fifth and sixth of 
 Baudelocque, or the third and fourth of the authors just now men- 
 tioned. As to the lateral positions established by Madame Lachapelle 
 and M. Flamant, they are at least very rarely, if ever to be met with. 
 It is evident that the first, second and third have one common 
 termination, and that their mechanism is in almost all respects 
 similar. It is also undeniable that the fourth, fifth and sixth do not 
 differ more than the others. I do not perceive, therefore, the utility 
 in any way, of admitting these varieties, otherwise than as so many 
 shades of the two fundamental positions, to which all others must 
 of necessity be at last reduced. As to these, I think that no one 
 ever attempted to confound them ; their mechanism is so different, 
 that the English accoucheurs, such as Burns, Merriman and Bland, 
 bestow the title of natural labour Only upon the occipito-anterior 
 position, while, according to them, the occipito-posterior position 
 belongs to the class of preternatural labour. 
 
 1. Occipito- Anterior Position. 
 
 1634 in 1800, Merriman ; 19,370 in 20,517, Madame Boivin ; 14,253 in 
 15,652, 20,268 in 22,243, Madame Lachapelle ; 60 in 67, M. Lovati. 
 
 Many foreign practitioners think that the occipito-anterior position 
 is the only one we ought tc abandon to the resources of nature. 
 The causes of its great frequency are wholly physical and easy to 
 be understood. The head is the heaviest part of the foetus ; the 
 plane of the neck of the womb is always lower than that of the 
 fundus ; the head therefore ought to incline constantly towards the 
 cervix uteri. The posterior half of the head is much more weighty 
 than the anterior half. The weight of the hinder part of the trunk, 
 during the intra uterine life, is much greater than that of the an- 
 terior portion. When the woman is standing up, sitting down, or 
 kneeling, and even when lying on her side, the anterior wall of the 
 womb is much more inclined towards the cervix than its posterior 
 wall ; the back of the foetus will therefore more frequently be found 
 turned towards the front of the mother than towards her back. In 
 quadrupeds, the young are often found to have their bellies down- 
 wards, and almost always come head foremost, although the womb 
 is lower than the vulva ; but it is to be observed that the abdomen 
 in tlicx .-|). <;ics weighs most, and the head least. Another no less 
 powerful cause of the frequency of this position is found in the pro- 
 portional dimensions and inclinations of the head and pelvis ; the
 
 PRESENTATION OF THE VERTEX. 291 
 
 abdominal strait being much larger in front than behind, and strongly 
 inclined towards the pubis, it is quite natural that the occiput should 
 commonly assume this direction, &c. The cause which so often 
 directs the occiput towards the anterior semi-circle of the strait, is 
 therefore not more difficult to understand, than that which occasions 
 the head to descend first ; hence physicians were wrong to abandon 
 their researches in relation to it. 
 
 A. First Variety. 
 
 Left occipito-acetabular position. 
 
 1st position of Baudelocque, Maygrier, Mesdames Boivin and Lachapelle ; 
 15,809 in 22,343, Madame Lachapelle; 15,693 in 20,517, Madame Boivin ; 36 
 in 67, Lovati. 
 
 In this position the back of the foetus looks towards the front and 
 left ; its abdomen towards the back and right. The occiput is placed 
 behind the corresponding ileo-pectineal eminence much more fre- 
 quently than behind the acetabulum, and the top of the forehead or 
 the anterior fontanel, rather than the forehead properly so called, 
 looks towards the right sacro-iliac symphysis ; the right side is to 
 the right and in front, and the opposite one is behind and towards 
 the left. Its great frequency seems to depend upon the rectum be- 
 ing in pregnancy commonly filled with fasces, which forces the fore- 
 head to incline towards the right side ; such at least is the opinion 
 of accoucheurs in the present day ; an opinion which, besides, 
 seems to be sustained by direct observation, since M. Duges has 
 seen the fetus in Baudelocque's second position in two women 
 who had the rectum on the right side : but this point is worthy of 
 new researches. 
 
 725. In this position the head of the child does not pass through 
 the pelvis without undergoing four particular motions. 1st, flexion ; 
 2d, rotation ; 3d, extension ; 4th, restitution. 
 
 Flexion. Immediately after the rupture of the membranes, the 
 uterine contractions must necessarily press the several parts of the 
 fetus upon each other ; being pressed from above downwards, the 
 spine causes the head to bend forwards so that the occiput sinks 
 towards the centre of the pelvis, and the chin is squeezed more or 
 less firmly against the breast. This flexion movement does not 
 seem to have been well understood, even by the most esteemed 
 authors. They teach us that antecedently to the very first contrac- 
 tions of the womb, the head should be disposed in such a manner, 
 that its occipito-frontal and bi-parietal diameters should be parallel 
 to the oblique diameters of the strait ; whose axis would then be re-
 
 NATURAL EUTOCIA. 
 
 presented by the vertical diameter of the foetus. According to 
 them, the object of the flexion motion would be to alter all these 
 relations; that is to say, to compel the occipito-mental and occipito- 
 bregmatic diameters to assume the places of the vertical and occi- 
 pito-frontal diameters, which would be much more favourable. In 
 order that the above might be correct, it would be necessary for the 
 chin, during pregnancy, to be kept habitually remote from the breast, 
 which it would not approach until the period of labour, otherwise 
 the occipito-frontal diameter cannot be parallel to one of the diame- 
 ters of the pelvis ; but, it is well known that the foetus, in the na- 
 tural state, is always doubled up, and that its chin is pressed upon 
 tiie sternum. The flexion motion therefore really takes place long 
 before the commencement of labour, and instead of being wholly 
 effected, is only a little increased during labour. 
 
 726. In this way the occiput by being depressed soon corres^ 
 ponds to the centre of the superior strait ; the occipito-bregmatic 
 diameter is then parallel to the oblique diameter, which extends 
 from left to right and from front to rear ; the bi-parietal diameter 
 represents the other oblique diameter ; the occipito-mental diame- 
 ter is parallel to the axis of the pelvic circle, and the occipito-breg- 
 matic circumference corresponds to the plane of the strait. 
 
 727. Rotation. In this state the head is disposed in the best pos- 
 sible manner to pass without difficulty through the upper strait ; by 
 successive pains it is forced to descend a little ; it reaches the ex- 
 cavation, and being soon stopped by the floor of that cavity, it 
 executes the rotation or pivot motion ; that is to say, it turns upon 
 its great axis, the occiput sliding upon the left anterior inclined 
 plane, from behind forwards and from left to right, so as to place 
 itself behind the symphysis or under the arch of the pubis, while the 
 forehead slides from right to left and from before backwards on the 
 right posterior inclined plane, so as to get into the hollow of the 
 sacrum. This is the moment when the sacral plexuses are most 
 forcibly compressed, and when most women are affected with 
 cramps in the legs and thighs, 
 
 728. Extension. Hitherto the flexion of the head has gone on 
 increasing ; henceforth it diminishes ; the extension movement is 
 about to begin ; as it approaches the inferior strait the occiput 
 rises, and by degrees causes the chin to abandon the front of the 
 thorax ; instead of continuing to bend forwards, the head tends to 
 turn over backwards, in order that the occipito-mental diameter 
 may be brought into parallelism with the axis of the, inferior strait, 
 without hindering the rest of the trunk from still following the course 
 of the central line of the superior strait ; the rectum and neck of
 
 PRESENTATION OF THE VERTEX. 293 
 
 the bladder being now more forcibly compressed than before, give 
 rise to a straining, and tenesmus ; the womb and abdominal muscles 
 contract more violently than ever ; the perineum distends, elongates, 
 grows thin, and in this way prolongs the posterior wall of the pelvis 
 to an extent of from three to four inches. The head being once 
 engaged in the inferior strait, is no longer in the same relation to 
 the diameters as before. Yet, it is well to observe that its great 
 diameter and occipito-bregmatic circumference have not undergone 
 any change of this sort, and that below as well as above they still 
 represent the plane and axis of the strait. But instead of being 
 situated obliquely, the bi-parietal and occipito-bregmatic axes are 
 so situated, that the former corresponds to the direction of the 
 bi-sciatic diameter, and the latter to that of the coccy-pubal diame- 
 ter ; which is the reason why at the end as well as at the beginning 
 of labour the great diameters of the occipito-bregmatic circumfer- 
 ence are always found to correspond to the largest diameters of the 
 pelvis, and why the chief end of the rotation motion is to establish 
 these favourable relations. 
 
 729. As the rotation takes place only at the expense of a twist 
 of the child's neck, and not of its whole body, the shoulders retain 
 their primitive direction at the superior strait, so that their great 
 diameter is parallel to that oblique diameter which proceeds from 
 left to right, and from behind forwards. 
 
 730. The efforts of the woman are now redoubled, the head 
 gradually engages in the vulva, its back part being forwards, and 
 slides down the plane presented by the anterior surface of the coccyx 
 and extended perineum, which plane is strongly inclined forwards ; 
 the great labia are slowly effaced, and grow thin from their perineal 
 commissure towards their pubal extremity ; the nymphre are forci- 
 bly pressed in an upward and lateral direction, but they do not un- 
 fold ; they could sooner be torn and separated from the inner sur- 
 face of the vulva ; sometimes even the skin of the upper part of 
 the thighs yields, so as to assist the pudendum and perineum in 
 forming the sort of casque, with which the head remains partially 
 covered until it escapes entirely from the pelvis ; the parietal protu- 
 berances at length pass through the bi-sciatic diameter, and the head, 
 now arrested by the resistance of the soft parts only, is soon com- 
 pletely expelled. Whilst it is passing through the vulva, the pos- 
 terior end of the occipito-bregmatic diameter, continues to rest 
 under the symphysis pubis, as upon a transverse axis, and rolls from 
 behind forwards, as the occiput, the sagittal suture, the parietal pro- 
 tuberances, the anterior fontanel, the frontal bone, the orbits, the 
 nose, the mouth and chin are seen to emerge in succession.
 
 294 NATURAL EUTOCIA. 
 
 When the occipito-bregmatic circumference is expelled, the anterior 
 edge of the perineum, being drawn backwards by its natural elasti- 
 city, slides over the face, which affords it a plane inclined obliquely 
 from the forehead to the chin, and approaching near the coccyx 
 goes afterwards to place itself on the fore part of the neck, forcing 
 meanwhile the head to turn over upon the mons veneris. 
 
 731. Restitution. The head, now freed from all constraint, and 
 incapable of retaining the twist which had brought it under the arch 
 of the pubis, soon recovers its natural relation to the shoulders and 
 rest of the body, which had been temporarily changed ; that is to 
 say, its antero-posterior diameter again crosses the transverse diame- 
 ter of the shoulders at right angles, as it did when at the superior 
 strait. In one word, the occiput turns towards the left groin, while 
 the chin is directed towards the opposite sub-iliac space, and the 
 title of act of restitution has been given to this rotation. 
 
 732. After a calm of a few seconds or minutes duration, the 
 shoulders descend into the excavation, and perform a pivot mo- 
 tion upon the anterior right and posterior left inclined planes ; the 
 right shoulder being directed behind the symphysis or under the 
 pubic arch, and the left on the front of the sacrum, forces the 
 head to undergo a similar motion, which places it entirely cross- 
 wise, the occiput being to the left and the face to the right. In 
 this direction they engage in the inferior strait. The right appears 
 first under the pubis ; the child's body bends on its right side so as 
 to accommodate itself to the pelvis ; the left shoulder comes down 
 upon the perineum ; the vertical axis of the thorax is parallel with 
 the axis of the perineal strait ; the vertical axis of the a"bdomen 
 represents that of the superior strait ; they pass the vulva together, 
 and the rest of the body, rendered very slippery by the liquor amnii 
 and sebaceous matter, and now representing only the point of a cone 
 whose base has already escaped, is expelled by the power of the 
 same effort, and the labour is terminated. 
 
 B. Second Variety. 
 Right occipito-acetabular position. 
 
 2d position of Solayrcs and Baudelocque ; right antero-lateral of Madame Boivin ; 
 right occipito-anterior, Dugs; 3682 in 20,517 cases, Madame Boivin ; 4659 in 
 
 22.2S2 rpa Mailnmp I .nnhnnnlltv 
 
 22,282 cases, Madame Lachapelle. 
 
 733. Admitting that the situation might determine the occurrence 
 of the first variety, the same cannot be said of the second. M. Duges, 
 it is true, mentions two cases, where, in this last named position, the 
 bowel was transposed, being found on the right instead of the left
 
 PRESENTATION OF THE VERTEX. 395 
 
 side ; but anatomical observations in daily repeated dissections show 
 that such an anomaly does not occur once in every three or four 
 subjects, as ought to be the case were it the only or even the prin- 
 cipal cause of the position : and besides, when it has been met with, 
 was it not rather an effect than a cause ; and is it not more rational 
 to attribute the second position to the contractions of the womb 
 itself? If it be true, for example, as several facts carefully examined 
 might lead me to believe, that previously to the commencement of 
 labour, the occiput has no determinate position, and does not pro- 
 perly belong to one anterior variety more than to the other, may 
 we not suppose that the uterus, being inclined to the right and in 
 front, is more disposed to push the head towards the left than the 
 right side of the pelvis ? The impulse received by the foetus in this- 
 inclination of the womb is necessarily directed from right to left ; in 
 which case the forehead, being arrested by the musculo-vascular 
 edge found in the apex of the triangle represented by the abdominal 
 strait in the living subject, must compel the occiput to yield alone 
 to the moyement, and go to place itself opposite the left ilio-pectineal 
 eminence. Without attaching any great importance to this idea, I 
 should find it an easy task to advance a considerable number of 
 reasons in support of it, and I think it deserving of the attention of 
 those practitioners who love to give an account of what they observe. 
 
 734. However it may be, as to the causes of the right acetabular 
 position, it is true that its mechanism differs but little from that of 
 the preceding one : the child is impelled by the same power ; the 
 head executes the same movements, presents the same circumfe- 
 rence in the different planes of the pelvis, and offers the same dia- 
 meters to the principal diameters and axes of the straits, &c. But 
 the occipital fontanel is turned to the right instead of the left ; the 
 occipito-bregmatic diameter, instead of proceeding from left to right, 
 goes from right to left, and takes the place of the bi-parietal diame- 
 ter ; during the act of rotation its extremities slide upon the right 
 anterior, and left posterior inclined planes, to conduct the occiput 
 under the arch of the pubis, and the forehead in front of the sacrum. 
 
 735. At the inferior strait and vulva there is not the least differ- 
 ence remaining betwixt the two positions ; but after the escape of 
 the head, the occiput in its act of restitution turns to the right in- 
 stead of inclining itself towards the left ; the left shoulder, and not 
 the right, comes under the symphysis pubis, the right side, and not 
 the left, slides along the sacro-perineal curve ; the face and whole 
 anterior surface of the fcetus look towards the inside of the woman's 
 left thigh, instead of turning towards the right ; but nothing of all
 
 296 NATURAL EUTOCIA. 
 
 this process changes the proportional relations of the foetal head; 
 to the maternal pelvis. 
 
 736. This variety is considered as less favourable than the other ; 
 some have said that it renders the labour slower and more fatiguing ; 
 when the forehead is turned towards the right sacro-iliac symphysis 
 it is separated from the parietes of the pelvis only by fat and a layer 
 of peritoneum, on which it slides without any difficulty, while in the 
 second position, the rectum shortens the opposite oblique diameter 
 a little. When in the first position, the occiput and forehead rest on 
 two regular planes, equally solid and smooth ; while in the second, 
 the anterior part of the head depresses the rectum from above down- 
 wards, pushes it along before it, and folds it so as soon to form a 
 kind of cushion, whose thickness is also increased by the foecal mat- 
 ters contained within it ; it at least follows, that the left posterior 
 surface of the basin is too soft to allow the head to glide rapidly 
 down into the lower part of the excavation. The foetus might here, 
 to a certain extent, be compared to a solid straight stick, one end 
 of which is applied upon a smooth hard plane, as for example a 
 plate of glass, or on the other hand upon an uneven or spongy sur- 
 face, such as a woollen cloth or a mattress. In the former case, 
 the stick would slide along without the least obstacle and under the 
 slightest impulse, while in the latter it would not slide at all, or with 
 difficulty. Further, it may be conceived that this state of the plane, 
 on which the forehead is obliged to descend, may in the same way 
 interfere with the act of rotation or the pivot motion, &c. All this 
 may doubtless be true, but upon looking at the subject a little closer* 
 we soon perceive that much is to be retracted of these pretended 
 difficulties ; for, 1 . The thickness of the rectum when compressed 
 by the head is reduced to a very small degree ; 2. The matters with 
 which it is filled are or may be evacuated at the very beginning of 
 labour ; and 3. The forehead in every case presses on the rectum, 
 through the parietes of the womb, which does riot rise in folds. 
 
 On this subject I think I ought to point out a contradiction found 
 in the authors on midwifery. On the one hand, they say that the 
 right-acetabular position is determined by the presence of the rec- 
 tum on the right side of the sacrum, and on the other, that this same 
 position is rendered less favourable by the friction of the head on the 
 bowel on the left. 
 
 Remarks. The act of rotation in these two positions has not been 
 interpreted in the same way by all authors. Maduine Boivin and 
 some others account for it by referring it to the contraction of the 
 muscles that line the excavation. But it is evident that such an ex-
 
 PRESENTATION OF THE VERTEX. 397 
 
 planation is inadmissible ; for, 1. This rotation sometimes takes place 
 when the head is still above, and most generally does not occur 
 until it is below the muscular bundles, to whose contractions it is 
 attributed ; 2. If the pyramidal and internal obturator muscles, by 
 their contractions, could make the head revolve on its own axis, they 
 would carry it across the pelvis, and not from front to rear. By 
 referring it to the action of the sterno-mastoid muscles of the foetus 
 itself, an opinion has been advanced still less worthy of being com- 
 bated than the preceding one. 
 
 Besides, what need is there for us to look for the cause of this 
 movement, either to the muscles of the pelvis, or of the child's neck ? 
 The occiput turns towards the pubis, because it finds a vacant space 
 there, while it is strongly resisted on the sides ; it deviates from its 
 original direction for the same reason that the forehead turns, at the 
 superior strait, towards the sacro-vertebral angle. The form of the 
 pelvis and the laws of mechanics give a perfectly clear account of 
 this peculiarity : the anterior wall -of the excavation, which is much 
 shorter than the posterior, being deeply notched and somewhat 
 hollowed out, any salient part of the head, when strongly urged by 
 the contractions of the womb, could scarcely fail to engage in it, not 
 only without the assistance of the contractions of the inclined planes, 
 but even in spite of those contractions, were they really to take 
 place. 
 
 C. Third Variety. 
 
 Occipito-pubic position. 
 
 The 3d of Solayres, Baudelocque, &c. : 6 in 20,517, Madame Boivin. 
 
 737. The ancients regarded the occipito-pubic as the most fre- 
 quent position, because they did not distinguish the two antero- 
 lateral ones, and only judged from what is observed at the inferior 
 strait. Baudelocque admitted it rather for the purpose of filling 
 up his plan than from the testimony of his senses. Since his time 
 MM. Gardien, Dubois, Flamant, Dewees, and Desormeaux, as well 
 as Madame Boivin, have continued to describe it, at the same time 
 admitting it to be very rare. In fact, out of twenty thousand five 
 hundred and seventeen children, six only were found to present in this 
 manner. MM. Maygrier, Capuron and Duges have argued against 
 the possibility of its occurrence-, and Madame Lachapelle affirms 
 that she never observed one single instance of it in more than 
 thirty-six thousand labours. 
 
 The question therefore is, whether it is proper to retain it in a 
 2N
 
 298 NATURAL EUTOCIA. 
 
 regular classification. The labours and researches of the moderns 
 are almost the only ones that can be usefully consulted for the pur- 
 pose of deciding upon this point ; for as Baudelocque found no ob- 
 jections that he thought it worth while to combat, he neglected to cite 
 any particular facts for the purpose of demonstrating the possibility 
 of its occurrence. It is objected by MM. Maygrier and Capuron, 
 that the forehead, being a solid and round part, cannot maintain itself 
 in front of the sacro-vertebral angle during the expulsive contrac- 
 tions of the womb ; that two round and equally salient bodies cannot 
 slide upon each other without turning off to the right or left ; in one 
 word, that previously to the close of pregnancy, or at least at the 
 very commencement of labour, the forehead of the foetus is neces- 
 sarily repelled by the promontory towards one of the sacro-iliac 
 symphyses. 
 
 738. Without denying the force of these objections, I may, not- 
 standing, be permitted to observe, that in the recent pelvis the 
 sacrc-iliac hollow is to a great degree effaced by the psoas muscles 
 and iliac vessels ; that the vertebral projection is thus considerably 
 diminished ; that the entrance to the excavation is then not so large 
 behind as it is in front (72) ; that the womb being directed in con- 
 formity with the axis of the superior strait, rather than with the axis 
 of the spine, and the head of the child habitually bent upon its breast, 
 the forehead, at the commencement of labour, ought to correspond 
 to the anterior surface of the first piece of the sacrum, and not to 
 the sacro-lumbar projection, properly so called ; and therefore that 
 it docs not seem impossible for the head to descend in a direct posi- 
 tion. I add, with M. Desormeaux, that authors have reasoned upon 
 this case as if the pelvis were always the same, always regular. 
 Where the vertebral angle is but slightly expressed, or thrown back, 
 the sacro-pubic diameter is sometimes longer than common, without 
 the cavity of the pelvis being really vitiated ; in such a case the third 
 position, far from being impossible, should, on the contrary, be the 
 most natural and the easiest, inasmuch as the head, in engaging, 
 always strives to place the great diameter of the circumference that 
 presents parallel to the greatest diameter of the pelvis. Although 
 Madame Boivin states on the one hand that she has met with it six 
 times in twenty-five thousand five hundred and seventeen cases, on 
 the other, Madame Lachapelle affirms that it is never met with. 
 Tlir.-i; coiitnulictory assertions at Jeast prove that the situation of 
 tli' lirad ;it the commencement of labour has not always been recog- 
 iii/rd with certainty at the Paris Matcrnite. And how could it be 
 otherwise? Ry the confession of all practitioners, it is very often 
 impossible, previously to the rupture of the membranes, to tell 
 
 '
 
 PRESENTATION OF THE VERTEX. 399 
 
 whether the occipital fontanel is in front or behind, and d fortiori, 
 whether it is to the right or left, rather than in the middle of the 
 strait. Now, is it probable that Mesdarnes Boivin and Lachapelle 
 could, themselves, have touched each of these thirty-six thousand 
 women before the head had engaged in the excavation ? To con- 
 clude, although it be true that the occipito-pubic position, three very 
 authentic cases of which are mentioned by Dr Dewees, is of very 
 rare occurrence, it is not less true that we are not, in the present 
 state of the science, authorised to deny its possibility ; and as its 
 mechanism is not altogether the same as that of the occipito-aceta- 
 bular positions, I think it right to say a few words in regard to it. 
 
 739. When at the superior strait, the occipito-mental diameter 
 and the occipito-bregmatic circumference are placed as in the two 
 first positions, and always correspond to the axis and plane of that 
 opening : but the bi-parietal diameter is situated transversely, and 
 the occipito-bregmatic from front to rear, instead of being parallel to 
 the oblique diameters ; the pivot movement is not necessary and does 
 not take place ; the direction of the various axes of the head is the 
 same at the end as at the commencement of the labour ; as the shoul- 
 ders look towards the iliac fossoe at the commencement, it is uncertain 
 which way the act of restitution will take place ; in fact, there will be 
 none, because there was no previous act of rotation ; however, as it 
 is a rare occurrence for the shoulders not to place themselves one in 
 front and the other behind, before they pass through the inferior 
 strait, the occiput, after a few moments of indecision, turns to the 
 right or left, but without our being able to know beforehand which ; 
 after that, there is nothing peculiar in the rest of the labour. 
 
 740. Remarks. Tt cannot be denied that these three positions are 
 in fact but shades of each other. In all three cases the head begins 
 by flexing itself strongly down upon the breast, and ends by extend- 
 ing itself as it passes out under the arch of the pubis ; the occiput, a 
 projecting part that always comes out first, never has more than two 
 inches, or at most, two inches and a half to pass over before it 
 reaches the arch of the pubis, and in escaping from the pelvis, it 
 slides on a surface that is plane and even convex, but not at all 
 concave. Although in the first variety every thing is disposed in 
 the most advantageous manner, the presence on the one hand of 
 the rectum, and on the other of the bladder and sacro-vertebral 
 angle, cannot, after all, render the second and third any more difficult 
 or dangerous. 
 
 2. Occipito- Posterior Position. 
 320 in 35,895 cases, Madame Lachapelle ; 203 in 20,517, Madame Boivin
 
 300 NATURAL EUTOCIA. 
 
 74 1 . Of far less frequent occurrence than the occipito-anterior 
 position, the occipito-sacral position is also much less easy, and less 
 natural. In order to emerge first, the occiput is compelled to tra- 
 verse the whole extent of the anterior face of the sacrum, the coccyx, 
 and perineum, that is to say, a surface of from seven to eight inches 
 in length ; while in the other position it escapes after passing over not 
 more than two inches. The posterior wall of the pelvis is deeply 
 excavated, while its anterior half circle is rather convex than con- 
 cave ; the summit of the head falls nearly at right angles upon each 
 point of that wall, and the occiput meets a new resistance at every 
 effort ; which is not the case when it is turned in front. The vertex 
 cannot present itself at the vulva until a considerable part of the 
 breast has descended into the excavation ; so that it is no longer 
 merely the occipito-bregmatic diameter, but it is a line drawn from 
 the anterior fontanel to the posterior part of the thorax that is re- 
 ferred to the antero-posterior diameter of the lower part of the ex- 
 cavation. Here the vertebral column is so strongly curved that it 
 cannot but lose a considerable part of the force impressed upon it 
 by the womb, before that power can reach the head. The head 
 and trunk both together, and not the head alone, traverse the exca- 
 vation and inferior strait ; and finally, the forehead is commonly too 
 broad to fill up the top of the pubic arch accurately, and the coccy- 
 pubic diameter may on this account lose as much as half an inch of 
 its length. 
 
 742. The causes that occasion the posterior position to occur are 
 little understood ; it is better frankly to avow our ignorance than 
 vaguely to refer them to this or that shape of the pelvis, to the direc- 
 tion, or disproportioned dimensions of the womb, to certain habits 
 of the woman, to uncommon movements of the foetus, &c. The 
 only thing that can be affirmed about them is, that it is pretty com- 
 mon to meet with them several times in succession in the same 
 woman. Besides, this is a question that requires some careful re- 
 searches before it can be decided. Although the three principal 
 varieties of this position differ only by slight shades from each other, 
 I nevertheless think, but merely for the purpose of not deviating too 
 far from generally adopted opinions, that I am bound to give a suc- 
 cinct explanation of its peculiar mechanism. 
 
 A. First Variety. 
 
 Left fronto-acctabular position. 
 4lh position of Baudelocque, Gardien, Dubois, Dcsormcaux, Lcbrcton, Fla- 
 mant, Madame Boivin: 3d of Maygrier, Capuron, Dugtis, and Madame Lacha- 
 pelle; 109 in 20,517 cases, Madame Boivin; 164 in 22,243 cases, Madame La- 
 rhapclle.
 
 PRESENTATION OF THE VERTEX. 301 
 
 743. The left fronto-acetabular position is the most common of 
 the three posterior varieties. It unites all the most favourable con- 
 ditions of its species, and in this respect it excels all the others. 
 The back of the fetus being turned backwards and to the right, the 
 abdomen towards the front and left, its left side to the front and 
 right, and its right side behind and towards the left side of the womb, 
 engages in the superior strait in such a way that the occipito-mental, 
 bi-parietal, and occipito-bregmatic diameters, and occipito-bregmatic 
 circumference are parallel with the oblique diameters, the plane, and 
 axis of that strait, respectively, as in the first anterior position. 
 There is this difference however, that the frontal extremity of the 
 occipito-bregmatic axis occupies the place of the sub-occipital ex- 
 tremity, that the left extremity of the bi-parietal diameter has 
 assumed that of its right extremity, that the anterior fontanel glides 
 behind the ilio-pectineal eminence, instead of descending before the 
 sacro-iliac symphysis, and that the posterior fontanel, instead of 
 being slightly inclined in front and towards the left, is, on the con- 
 trary, turned more or less backwards and towards the right, which, 
 as is evident, does not at all interfere with the proportional relations 
 of the head and pelvis, and prove, that so far the posterior are not 
 more unfavourable than the anterior positions. 
 
 744. After the dilatation of the neck and the rupture of the mem- 
 branes, when the occipito-bregmatic circumference has passed the 
 superior strait, the head, meeting with a deep excavation behind, is 
 rapidly urged to the very bottom of the excavation, and at first the 
 labour seems to progress more rapidly than in the very opposite 
 position ; but, from this moment, the difficulties mentioned above 
 become more and more manifest. Instead of being gradually re- 
 placed by the act of extension, as in the anterior positions, the 
 flexion still continues to increase with every pain ; whilst the fore- 
 head is arrested behind the pubis and the occiput is abutted against 
 the front of the sacrum, the coccyx and perineum, which resist so 
 as to force it to move forwards, the breast engages in the excavation, 
 slides in some measure behind the face, opposes the turning of the 
 chin towards the centre of the pelvis, and makes it very difficult for 
 the occipito-mental axis to become parallel with the central line of 
 the inferior strait, and especially with the axis of the vulva. The 
 vertebral column being too much curved loses a part of the power 
 impressed upon it by the womb ; as it presses upon the head at an 
 angle which becomes more and more acute, it cannot urge it on- 
 wards with the same degree of energy, even although the same de- 
 gree of force might be employed. 
 
 The pivot movement takes place, nevertheless, and the forehead.
 
 302 NATURAL EUTOCIA. 
 
 or the bregma, sliding along the left anterior inclined plane, comes 
 from left to right, and from behind forwards, to place itself under 
 the arch of the pubis, whilst the vertex, or occiput, moving upon the 
 right posterior inclined plane, proceeds from before backwards and 
 from right to left, into the hollow of the sacrum ; but this rotation 
 is effected with some difficulty, because the forehead is too wide to 
 adapt itself accurately to the sub-pubal notch ; because, beneath the 
 superior strait, the lateral regions of the hinder half of the pelvis are 
 made up of soft parts, which do not repel the head with sufficient 
 force towards the median line ; lastly, because the extremities of the 
 occipito-frontal diameter and its circumference, and not those of the 
 occipito-bregmatic, roll in inverse directions upon the planes of the 
 excavation, as is the case in the occipito-anterior position. 
 
 745. Notwithstanding so many unfavourable circumstances, the 
 occiput descends, by bearing strongly upon the sacrum, the coccyx, 
 and perineum, and the foetus finally passes the strait. In this situa- 
 tion it is upon the posterior commissure of the vulva, and not upon 
 the inferior edge of the symphysis pubis, that the occipito-bregmatic 
 diameter now presses, slides, and reverses itself from above down- 
 wards and from before backwards ; so that the posterior fontanel, 
 the sagittal suture, the anterior fontanel, the parietal protuberances, 
 the frontal protuberances, and the several parts of the face, are seen 
 to appear in succession in front of the perineum. As soon as the 
 chin is disengaged from the summit of the pubic arch, the act of 
 restitution takes place ; the face inclines towards the left groin, and 
 the occiput towards the right sub-ischiatic notch ; the left shoulder 
 proceeds in front, under the symphysis ; the right shoulder reaches 
 the concave surface of the sacrum ; the head, governed by the 
 movement of the trunk, places itself crosswise ; and the rest of the 
 labour is concluded as it is in the right occipito-acetabular position. 
 
 B. Second Variety. 
 Right fronto-acetabular position. 
 
 5th position of Baudelocque, Gardien, Dubois, Desormcaux, Madame Boivin, 
 &c. ; 4th of Maygrier, Oapuron, Duges, Madame Lacliapelle, &c. : 92 in 20,517 
 cases, Madame Boivin ; 66 in 22,243 cases, Madame Lachapclle- 
 
 74 G. The right fronto-acetabular position, Although rather more 
 
 rare than the preceding one, is, notwithstanding, more common, re- 
 
 liitivt-ly to the opposite fronto-acetnbular position, than the right 
 
 .'it<i-:n:i:ilnil;ir is when compared to the left occipito-acetabular 
 
 'ion. This peculiarity comes in .support of the opinion I ad- 
 
 iicit detailing the causes of the first position of the vertex :
 
 PRESENTATION OF THE VERTEX. 303 
 
 it may in fact be conceived, that if once placed behind, at the supe- 
 rior strait, the occiput may descend almost indifferently to the right 
 or left of the median line, while, if turned forwards, it must be most 
 frequently repelled towards the left side. 
 
 In this position the back of the foetus is directed to the left and 
 backwards, the right shoulder to the left and forwards; the bi- 
 parietal diameter represents the left antero-oblique diameter ; the 
 occipito-bregmatic is parallel with the right antero-oblique ; and the 
 lesser circumference and occipito-mental diameter are parallel with 
 the plane and axis of the strait. The head, when engaged in the 
 excavation, revolves a half quarter of a circle upon its vertical axis. 
 The occiput, sliding upon the left posterior inclined plane, proceeds 
 to lodge in the hollow of the sacrum ; while the bregma, rolling 
 upon the right anterior inclined plane, is directed to the symphysis 
 pubis. 
 
 Upon emerging from the vulva, when the act of restitution takes 
 place, the occiput gradually turns towards the inside of the left thigh, 
 and not the right, as in the fourth position. As to the rest of the 
 labour, it is terminated like the former, except that the front of the 
 fetus at last looks towards the right, and its right side directly in 
 front, whereas in the other variety, directly the reverse is observed. 
 Moreover, it is said to be rather more difficult, in consequence of 
 the presence of the rectum, which must retard the progress of the 
 occiput. 
 
 747. M. Na3gele maintains that the fourth position of the vertex 
 is much more common than the second, and that the French ac- 
 coucheurs did not perceive it, because, being led away by the autho- 
 rity of Baudelocque, they did not perceive that the former of these 
 two positions commonly converts itself into the right occipito- 
 acetabular position, as soon as the head gets through the superior 
 strait. These assertions of the German professor ought to be taken 
 into consideration, not that they are perfectly correct, for even 
 provided the very numerous observations collected at the Paris Ma- 
 ternite could not be cited as proofs of the contrary, the form of the 
 pelvis and the specific gravity of the fcetus would alone prevent the 
 admission of such an opinion, until its correctness had been irrever- 
 sibly demonstrated by multiplied facts ; but they should be taken into 
 consideration, because it appears certain, that when the occiput 
 reaches the bottom of the excavation, it does, in fact, in some in- 
 stances turn towards the acetabulum instead of proceeding towards 
 the posterior median line. I have already observed and pointed out 
 to many students the reality of this phenomenon, so as to leave no 
 doubt upon the subject. Upon passing the pelvic circle, the head
 
 304 NATURAL EUTOCIA. 
 
 by degrees inclines to one side, and places itself exactly cross-wise, 
 soon after it descends into the excavation. This pivot motion con- 
 tinues, under the influence of the uterine contractions ; if it be the 
 fourth position, the posterior fontanel gradually reaches the arch of the 
 pubis, by gliding from behind forwards, and from right to left, along 
 the right anterior inclined plane, and on the other hand from left to 
 right for the fifth, &c. 
 
 748. I am ignorant of the causes to which such anomalies ought 
 to be attributed ; I have never found any thing peculiar in the con- 
 formation of those women who have exhibited them ; the labours 
 have progressed regularly, and there was nothing unusual in the 
 weight of the children ; I think I have only noticed that from the 
 very beginning of the labour, the antero-posterior diameter of the 
 head was much nearer to the bis-iliac than to the sacro-pubic line 
 of the strait, and that the pubis, being slightly depressed above, 
 seemed to favour the anterior rotation, by the hollowness of the 
 arch, and by the distance to which the acetabula were separated. 
 
 749. The knowledge of these conversions ought not to be over- 
 looked in practice : in the first place, because, as they are favoura- 
 ble, we may in some instances be enabled to promote, and even to 
 enforce them whenever such a thing is possible ; in the next place, 
 because they afford a very natural explanation of the mistakes, 
 which we have been heretofore compelled to attribute to the ignor- 
 ance of those who committed them. For example, it pretty often 
 happens that two accoucheurs, called to the same woman, one at 
 the commencement of the labour and the other at its close, an- 
 nounce, each, a different position ; that one announces an occipito- 
 anterior, and the other the contrary position, and that upon seeing 
 the head emerge, one of them remains convinced that he had been 
 really deceived. Notwithstanding, both of them may have been 
 right, for the fourth or fifth position might really have existed, al- 
 though the labour terminated in the second or first. It would be 
 wrong, however, to generalise this remark too far, and apply it to 
 all cases where the escape of the footus contradicts the diagnosis 
 established by the practitioner from whom the woman first receives 
 attention : it would be too convenient a resource for the conceal- 
 ment of real mistakes, and one of which the inept and ill taught 
 would not fail to avail themselves at the expense of truth. 
 
 C. Third FanV/i/. 
 IVonto-pubic position. 
 M\ posiiiim of H.iutlrlorquc, MM. (iardien, Dubois, Dcsonncaux, Mailimie 
 rial of MM. Fl.,i,i.,ni, I.fbrcton ; is rejected by MM. Maygrici, 
 r.,|,im.n. M .d Lnrl.apelle, and M. Dug.
 
 PRESENTATION OF THE VERTEX. 305 
 
 750. All the arguments advanced by authors against the possibility 
 of Baudelocque's third position apply equally well to the sixth. If 
 the forehead cannot maintain itself upon the sacro-vertebral angle, 
 it is, a fortiori, impossible for the occiput, which is much narrower, 
 to maintain itself in that situation and not to deviate either to the 
 right or left. But as the impossibility of the occurrence of the 
 occipito-pubic position is far from being a matter of demonstration, 
 so also is the same thing to be admitted as regards the opposite 
 position. 
 
 Sometimes the sacro-vertebral angle, in the living subject, pro- 
 jects but very slightly, a fact to which sufficient attention has not 
 been paid, and it is evidently wrong to reason as if the head were 
 not already flexed upon the breast from the very beginning of la- 
 bour, and as if it were the occipito-frontal, and not the occipito- 
 bregmatic diameter, that is at the very commencement parallel to 
 the antero-posterior diameter of the strait. 
 
 751. If it be true, as we learn by the touch at our amphitheatres, 
 that, in many women, we can readily feel the most prominent part 
 of the foetal head over the centre of the pelvis, quite above its abdo- 
 minal opening, long before the commencement of labour, I cannot 
 perceive how the sacro-vertebral angle can constitute an insurmoun- 
 table obstacle to the sixth position. It must therefore be admitted, 
 at least, as a possible shade, if not as a real variety. 
 
 752. Its mechanism, moreover, scarcely differs from that of the 
 two oblique varieties ; the posterior surface and occiput of the 
 foetus being, from the beginning, turned directly backwards, there 
 is no occasion for the head to perform its pivot movement in the 
 excavation, so as to engage in the inferior strait ; the shoulders pass 
 through the superior strait parallel to the bis-iliac diameter, and 
 there is no act of restitution without, any more than there is an act of 
 rotation within the pelvis, and if the face comes at last to turn 
 towards one of the thighs and the occiput towards the other, it hap- 
 pens so because the trunk, in revolving on its vertical axis to place 
 the shoulders in an antero-posterior attitude, necessarily carries the 
 bi-parietal diameter in the same direction. 
 
 It is less favourable than the corresponding oblique positions, only 
 because it renders the forehead and face more liable to be turned 
 downwards, and to permit the great diameters of the head to become 
 parallel to the smallest ones of the pelvis. When they attributed 
 the difficulties accompanying it to the friction of the face behind 
 the pubis, accoucheurs of past ages, doubtless, had not reflected 
 on the state of flexion in which the head is found to be placed ; for 
 2O
 
 306 NATURAL EUTOCIA. 
 
 it would have been easy for them to see that it is the anterior ex- 
 tremity of the occipito-bregmatic diameter, and not that of the occi- 
 pito-frontal diameter, that must rest upon the hinder part of the 
 pubic articulation. 
 
 753. Remarks. Besides these six varieties, there would be a great 
 many intermediate ones, provided the occiput were obliged, in 
 each of them, to correspond to some indicated point of the pelvic 
 circle : in effect, if there be some of them that we can bring in re- 
 lation with the extremities of the four principal diameters of the 
 strait, [ cannot perceive why eight others might not be established 
 betwixt those just now mentioned ; and this number once agreed 
 upon, there is no reason why we might not add sixteen others, and 
 so on ad infinitum. But it is quite enough to make a particular 
 position of all the cases where the occiput looks towards any por- 
 tion of the left anterior quarter-circle of the pelvis, another for the 
 right, and a third and fourth for the posterior half of the pelvis ; 
 since these varieties, which differ more in degree than reality, ought, 
 after all, to be considered as mere shades, constantly changing, be- 
 fore the close of labour, into occipito-anterior, and occipito-posterior 
 positions : so that, in fact, the four diagonal positions of the su- 
 perior strait, when reduced to the two antero-posterior ones of the 
 inferior strait, constitute the whole of those, the study of which is 
 really important. We are not, however, on this account to deny 
 the existence of the direclly anterior and transverse positions estab- 
 lished by Baudelocque, M. Flarnant, and Madame Lachapelle. 
 
 754. I have treated in greater detail of the occipito-pubic and 
 sacral positions than of the occipito-iliac positions, because their 
 mechanism presents some peculiarities which it is well not to be 
 ignorant of, for, the doctrine of Baudelocque being extensively 
 known, it might be attended with some inconvenience, were I to 
 overlook positions admitted by that author to exist, which, though 
 they are of rare occurrence, yet really do occur, and substitute 
 for them others equally rare, and which, moreover, soon become 
 confounded with the oblique ones. 
 
 755. When Madame Lachapelle says that the occipito-iliac are 
 more frequently to be met with than the fronto-acetabular positions, 
 she must surely be misled by some preconceived idea. Previously 
 to the descent of the head into the excavation, it is often difficult 
 to say whether the occiput looks exactly towards one of the ex- 
 tremities of the transverse diameter, rather than a few lines for- 
 wards or backwards of it, or to know whether it constitutes a trans- 
 versal position, rather than an oblique one very much inclined :
 
 PRESENTATION OF THE VERTEX. 3Q7 
 
 further, as the author herself admits tliat the head remains but a 
 short time thus directed towards the iliac fossa?, either the occiput 
 or forehead soon deviating in front to gain the pubic arch, and the 
 left occipito-iliac position being the most common of the two, it is 
 manifest that the transverse positions are completely converted into 
 the corresponding oblique ones, and that they do not deserve a par- 
 ticular description. 
 
 756. Anomalies. In some positions of the vertex the movements 
 of the head seem to deviate wholly from the ordinary march of a 
 labour ; for example, it may happen, and indeed it does happen 
 pretty often, that after having passed obliquely through the superior 
 strait, it places itself transversely in the excavation, where it re- 
 mains for a longer or shorter time previously to performing its pivot 
 motion ; in other cases this motion is not performed at all, or but 
 imperfectly ; the head, therefore, passes the inferior as it did the 
 superior strait diagonally, or even emerges from it in a transverse 
 position, so as to bring the occipito-bregmatic, into parellelism with 
 the bi-sciatic diameter. In some other instances, the occiput upon 
 escaping from the vulva turns in a direction directly contrary to that 
 it ought to pursue, provided the restitution were regular ; it was in 
 this way that Solayres and Baudelocque saw, and that I myself have 
 seen, the face, in a left occipito-acetabular position, turn towards the 
 woman's left thigh, as it ought to do in the second position, and 
 vice versa ; so that from the commencement to the close of labour, 
 the fcetus performs about half a spiral turn,.from behind forwards, 
 and from left to right, or from right to left, according to the posi- 
 tion. Baudelocque was mistaken when he attributed this irregu- 
 larity, on the one hand, to the smallness of the (cetal head, or on the 
 other to the excessive amplitude of the pelvis ; I have had occasion 
 to notice it in women whose labours were very slow, and whose 
 pelves were not larger than necessary for the transmission of the 
 child. Might it not depend upon some peculiarity in th^ form of 
 the inferior strait or excavation, some anomaly in the uterine con- 
 tractions, or rather of the impulsion originally communicated to the 
 foetus ; and which, after having first produced the common act of 
 rotation, might be strong enough to compel the head and shoulders 
 to turn so as to perform a complete semi-circular turn ? In the 
 present state of tokological science it is impossible to answer this 
 question. 
 
 . II. Presentation of the face. 
 
 4 in 1800 cases, Merriraan ; 5 in 1897, Bland ; 74 in 20,517, Boivin ; 103 in 
 22,243, Madame Lachapelle ; 58 in 6,555, Boer.
 
 308 NATURAL EUTOCIA. 
 
 757. It never until lately entered any one's imagination to trust 
 the delivery to the hands ofnature, where the face of the child pre- 
 sented at the superior strait of the pelvis ; it is true we find in Mau- 
 riceau, De La Motte, and Smellie, cases of spontaneous termination 
 of the labour where the face presented ; P. Portal and Deleurye also 
 maintained that these positions are not in general very dangerous ; 
 Rcederer and Petit even agree that some of them may terminate 
 without any assistance ; but Baudelocqueand Stein having professed 
 that they cannot possibly terminate spontaneously except where the 
 foetus is very small or the pelvis very large, it has happened that 
 MM. Maygrier, Gardien, Capuron, &c. continue to class them 
 among the preternatural labours. 
 
 758. Such was .the state of the subject when Madame Lachapelle 
 laid it down as a principle, that this sort of labour is nearly as easy 
 and as natural as that by the vertex, and affirmed, that out of seventy- 
 two cases of this kind, forty-two were concluded without danger 
 either to the mother or child. M. Desormeaux ranged himself on 
 the side of the midwife in chief of the Maternite ; and the same ideas 
 are found in the work of Boer, who, after saying that delivery by the 
 face is very simple and very natural, describes its mechanism in the 
 following manner : Caput foetus, ex quo supra in margine pubis 
 haret, per illam ita transmovetur, ut frons sensim in incurvaturam 
 ossis sacri vergat. Utque Jades apertures infra appropinquat, 
 mentum propemodo admittitur sub pube, simul atque frons cum ver- 
 tice supra perinceum protruditur. En facialis omnis partus exor- 
 dium, progressus acjlnis ! 
 
 M. Chevreul expresses himself in nearly the same manner : " / 
 can enumerate eighteen labours, says he, that occurred since 1 792, 
 either in my private pvactice, or at the Maternite at Angers, where 
 the children presented the face, and which terminated naturally. All 
 these chj^dren were of the common size ; fifteen of them were born 
 alive ; three were dead, but appeared to have been so previously to 
 the commencement of labour." 
 
 However, a distinguished professor, M. Capuron, has recently 
 come out with great vigour in opposition to this doctrine, endeavour- 
 ing to demonstrate upon geometrical principles, that delivery by the 
 face, according to the mechanism pointed out by Boer, is generally 
 impossible, provided the woman does not receive any artificial aid. 
 But no geometry can hold good in this case ; as numerous facts 
 exist, they are evidently possible. I have myself seen seven cases 
 of face presentation ; the children were born alive and well ; I trusted 
 {))< cases to nature, and no particular difficulties were observable. 
 
 This kind of labour, therefore, is not only possible, but also for
 
 PRESENTATION OF THE FACE. 309 
 
 the most part quite easy. M. Capuron and many others have thought 
 otherwise, because they did not perfectly understand its mechanism, 
 and were misled by the idea that the breast in such cases must ne- 
 cessarily pass the strait at the same time with the head, which is 
 wholly incorrect. It is clear, when the head presents at the superior 
 strait, with the chin towards the pubis and the forehead towards the 
 sacrum, that the fronto-mental diameter, which is only three inches, 
 or if prolonged to the anterior fontaneJ, three inches and a half, is 
 parallel with the sacro- pubic diameter, equal to four inches and a 
 half, and that it occupies the situation that belongs, in vertex pre- 
 sentations, to one of the diameters of the occipito-bregmatic circum- 
 ference. So far there is no disadvantage in a face presentation. 
 But at a later period, when the head descends, the chin gets below 
 the pubis before the occiput reaches the excavation, and the breast 
 is still at the superior strait while the face is actually engaging in 
 the inferior pelvic circle ; then, the front of the neck, being stopped 
 by the lower edge of the symphysis pubis, compels the vertebral 
 column <to react upon the posterior part of the head, which it urges 
 from behind forwards, so as to force it through the vulva, by pre- 
 senting to that opening a series of circles, whose principal chords are 
 measured by the vertical diameter of the head. The laws of me- 
 chanics, therefore, in accordance with facts, permit us to class face 
 cases among the spontaneous labours. 
 
 759. According to Deventer, the causes of this presentation are 
 to be sought for in the obliquities of the uterus, which, from the very 
 beginning of its action, cause the extremity of the occiput to lodge 
 upon the margin of the strait, and thus oblige the face to descend 
 first. According to M. Gardien, the cause lies much more in the 
 inclination or obliquity of the fcetus itself, than in that of the organ 
 which contains it. Madame Lachapelle, who rejects both of these 
 hypotheses because she saw the face presenting at the upper strait 
 in two women who died previously to labour, attributes it to the cir- 
 cumstance that the anterior obliquity of the womb being very com- 
 mon, the weight of the occiput must in such cases prevent the chin 
 from remaining applied against the sternum, and. must bring the 
 rnento-bregmatic diameter into parallelism with the sacro-pubic 
 diameter from the very commencement of labour. It seems to me 
 that all these opinions have some foundation, but that none of them 
 suffice to explain all the facts, and that it is for the most part impos- 
 sible to say why the face and not the occiput presents. 
 
 760. The face positions being in fact only reverted vertex posi- 
 tions, it is plain that we must for both admit the same number of 
 species and varieties. Authors, however, have generally described
 
 310 NATURAL EUTOCIA. 
 
 only four ; and they have rarely agreed as to the manner of arrang- 
 ing them. Some make them correspond to the four oblique posi- 
 tions of the vertex ; others, as Smellie, Stein, Baudelocque, and 
 MM. Gardien and Desormeaux, dispose them transversely, and from 
 front to rear, and admit a right mento-iliac and a left mento-iliac 
 position, as well as a mento -pubic, and a mento- sacral position. 
 
 Perhaps, in studying the subject, there is some advantage in this 
 latter mode of classifying them ; but it is important in practice to 
 know, 1. That the antero-posterior positions are rare, so much so, 
 that Madame Lachapelle has never seen a single case of that kind, 
 although Rcederer, Deleurye, Stein, &,c. admitted them as very 
 common, and as the easiest ; 2. That if they do sometimes occur at 
 the commencement, as in one case that I saw, they soon become 
 converted into lateral positions ; 3. That the mento-sacral position, 
 which Stein gives as the best, and of which one case is related by 
 Smellie, is altogether impossible without this conversion ; and, 
 4. That in the iliac positions, the fronto-mental diameter is more 
 frequently directed obliquely than transversely. 
 
 761. It ought also to be known that the face does not always 
 present in full ; that the forehead often sinks lower than the chin ; 
 that the contrary obtains in other cases ; that in some instances, 
 also, it descends with one of the cheeks foremost, &c., and that 
 these anomalies constitute the varieties pointed out by Madame La- 
 chapelle ; and which may be either primitive, that is, they may exist 
 from the very commencement of labour, or secondary, that is, not 
 become manifest until after the first efforts, and even at a very ad- 
 vanced stage of parturition ; and that the last case ought to be con- 
 sidered as possible, for example, in vertex presentations with the 
 occiput backwards, or where the pelvis is very large, and also where 
 the sacrum is too concave. 
 
 A. Right Mento- Iliac Position. 
 
 3d of Baudelocque, M. Gardien, Madame Boivin ; 53 cases in 22,243, Madame 
 Lachapelle. 
 
 762. In the right mento-iliac position, which evidently is a devia- 
 tion of the first or fifth of the vertex, and ought therefore to be, and in 
 fact is the most common (41 to 31 ; 58 to 45), the face comes down 
 transversely into the excavation ; but as the length of the neck would 
 not allow ilio chin to get down to the level of the tuberosity of the 
 ischiutn without dragging the upper part of tho thorax through the 
 superior strait, without throwing the occiput forcibly backwards on 
 to the chest, without, putting tho whole length* of the vertical diame- 
 ter of the head, protracted as far as the sternum, into the situation
 
 PRESENTATION OF THE FACE. 311 
 
 that ought to be occupied by the fronto-mental diameter, a rotative 
 movement soon takes place, and changes the relations of all these 
 parts : the chin and front of the neck slide from behind forwards upon 
 the right anterior inclined plane, and lodge in the top of the arch of 
 the pubis, while the bregma slides in an opposite direction, upon the 
 left posterior inclined plane, and proceeds to occupy the anterior 
 surface of the sacrum. Then the forehead, followed by the sagittal 
 suture and occiput, passes gradually down the plane presented to it 
 by the anterior surface of the coccyx and perineum, in front of which 
 all these parts are in succession disengaged. As it emerges from 
 the vulva, the chin rises, by degrees, towards the mons veneris, the 
 hyoidian region, or lower extremity of the vertical diameter, really 
 forms the centre of the semicircle described by the head as it clears 
 the strait, and the rest of the labour terminates as in the correspond- 
 ing positions of the vertex. 
 
 B. Left Mento-Iliac Position. 
 
 4th of Baudelocque ; M. Gardien, Mesdames Boivio, Lachapelle, etc. ; 31 to 
 41 ; 45 to 53. 
 
 763. Where the chin looks towards the left iliac fossa, the position 
 of the face answers to the second or fourth of the vertex. It is rather 
 more frequently met with than the preceding one, but does not 
 differ from it except that the chin slides on the left anterior in- 
 clined plane, and the bregma on the right posterior one, so as to 
 place the head in an antero-posterior direction, in order to pass the 
 perineal strait ; and that the act of rotation must be somewhat easier, 
 if, as is asserted, it be true that the presence of the rectum may im- 
 pede that of the right occipito and fronto-acetabular positions of the 
 vertex. 
 
 It is said that the head has been, but very rarely, seen to emerge 
 from the vulva in a diagonal or even transverse position ; but it does 
 not appear to me certain, that, in these cases, the observers were 
 not deceived by an incipient act of restitution. 
 
 C. Mento- Sacral Position. 
 1st of Baudelocque. 
 
 764. The third position is extremely rare, 1 . Because the occipito- 
 pubic position, which must give rise to it, is itself not very common ; 
 2. Because if it be true that it does sometimes or even pretty often 
 exist at the very beginning of labour, the contractions of the womb 
 soon transform it into a diagonal or transverse position ; 3. Be- 
 cause, if it should maintain itself for any length of time, the chin, 
 which is too prominent not to lodge against the sacro-vertebral
 
 314 UNNATURAL EUTOCIA. 
 
 the action of the heart, cannot but be very much impeded , if not ab- 
 solutely suspended. In delivery by the head, the spine represents a long 
 handle of a lever, to which the womb applies itself forcibly, until 
 the termination of the labour ; in presentations of the pelvic ex- 
 tremity, before the head has completely passed through the superior 
 strait, it is in a great measure beyond the influence of the uterine con- 
 tractions ; at the very moment where the greatest amount of uterine 
 power is wanted, all the benefits of it are lost. Finally, the pressure 
 sustained by the parts, in succession, from below upwards, necessarily 
 drives the blood up towards the head, and determines that state of 
 congestion so often met with in children that are delivered footling, 
 and which Osiander and M. Flamant erroneously attributed to the 
 action of cold air upon the child's body previously to the delivery of 
 its head. 
 
 These disadvantages cannot be denied, or unknown by any well 
 informed practitioner : it would be wrong, however, to conclude from 
 the above, that the assistance of art will be always required merely 
 because the pelvic extremity of the child presents ; on the con- 
 trary, I think that we should always, in such cases, abandon the 
 labour to the resources of the organism, except an opposite con- 
 duct should be imperiously demanded by some peculiar circum- 
 stances. If the rupture of the membranes does not occur until after 
 the complete dilatation of the os uteri, if the position is regular 
 and the pains good, the foetus will, indeed, pass out without running 
 much more risk than in a delivery by the head ; but if the mem- 
 branes give way very early, if the least traction be employed under 
 the pretext of hastening the delivery, it is certain that difficulties 
 will be infinitely multiplied, and the life of the child seriously com- 
 promitted. This is a point which young students, as well as prac- 
 titioners, ought never to lose sight of. This, also, is one of the mp- 
 tives that have induced me, both in my lectures and in this work, to 
 deviate from the ideas generally received among us in relation to 
 pelvic presentations of the foetus. 
 
 769. Previously to the time when De la Motte, Petit and Bau- 
 delocque had demonstrated that the somerset motion described by 
 their predecessors was a mere chimera ; as long as it was supposed 
 that the foetus naturally remained squatting on the sacro-vertebral 
 angle until the end of the seventh month of pregnancy, there was 
 no difficulty in accounting for the presentations of the breech, knees 
 or feet ; to explain their occurrence, it was sufficient to say that 
 something had prevented the somerset from taking place ; that the 
 child, either through forgetful nesg, weakness, or something else, had 
 allowed the opportune moment for performing this pretty feat to
 
 PRESENTATION OF THE PELVIS. 315 
 
 elapse ; but at present, when we cannot resort to this subterfuge, 
 we are brought to confess that the causes of presentations of the 
 pelvis are but little known. 
 
 770. It is probable that, about the period when the length of the 
 occipito-coccygeal diameter of the foetus begins to exceed that of 
 the transverse or horizontal diameter of the womb, it may happen 
 that the head of the child, being carried upwards by some sudden 
 movement, by the decubitus of the woman, or some other cause, cannot 
 resume its original position. It has been observed at the Maison 
 d'Accouchemens at Paris, and I have had occasion myself to notice 
 it, that presentations of the pelvic extremity are much more com- 
 mon in abortions and in twin pregnancies than in simple labours oc- 
 curring at full term ; and this remark might perhaps be used to 
 sustain the above explanation ; but how can we refer the cause of 
 this anomaly to the foetus, or to mere peculiarities of attitude in the 
 mother, in those tolerably numerous cases, where all the deliveries 
 of one individual terminate in this way, and when it is well under- 
 stood that a woman having once been delivered of a breech pre- 
 sentation, warrants us in fearing that it will happen so to her again ? 
 Would it not, rather, be reasonable to seek for this cause in the 
 conformation of the womb or pelvis in such a case ? 
 
 771. The positions of the pelvic extremity may, like those of 
 the head, be divided into regular and irregular or deviated ones. In 
 the former, the thighs are applied against the abdomen, the legs are 
 bent upon the thighs, and the breech and feet present together at the 
 superior strait, and the great occipito-co.ccygeal axis is parallel to 
 the axis of the pelvic circle. In the latter, the foetus is more or 
 less inclined to the right or left, forwards or backwards ; the pos- 
 terior surface of the coccyx, or one of the tuberosities of the 
 ischia, or the forepart of the legs and the sexual organs, corres- 
 pond to the centre of the pelvis ; most generally, the latter are re- 
 duced to the former as soon as the waters are gone off ; in other 
 instances they maintain themselves for a much longer time, retard 
 the labour, and, in certain cases entirely prevent it from terminat- 
 ing spontaneously. 
 
 772. The regular positions may also become irregular, especially 
 after the rupture of the membranes, either because the feet con- 
 tinue to descend pressed against the breech ; or because one of 
 the legs rises up on the anterior surface of the trunk, while the 
 other is extended, and descends first ; or because one of them be- 
 comes situated transversely, so that the knee and heel press on two 
 opposite points of the strait ; or because one knee descends together 
 with a foot or a buttock, or one of the legs is turned up in front, and
 
 316 UNNATURAL EUTOCIA. 
 
 the other back ; or lastly, because this last mentioned condition is 
 met with concurrently with one knee, one foot, or a foot and buttock 
 together, &c. ; but in general, they remain frank until the conclusion 
 of the labour. The two legs and thighs then extend, and the feet 
 escape first. At other times, again, the legs rise upwards and the 
 child comes away doubled, or by the breech properly so called. 
 In other instances, the knees alone descend together, the feet con- 
 tinuing to be applied to the ischia, which constitutes presentation 
 of the knees : whence it results, that there are really no primitive 
 presentations of the feet nor of the knees, and that until the rup- 
 ture of the membranes, there are no other positions except those 
 of the breech. 
 
 Thus these various kinds of positions ought to be considered only 
 as shades of a single and even fundamental species, the presentation 
 of the pelvic extremity of the foetus . 
 
 773. Instead of six, Baudelocque proposes only four positions 
 for the breech, feet and knees ; in the first the back looks 
 forward and to the left, forwards and to the right in the second, 
 directly forward in the third, and directly backwards in the 
 fourth. MM. Capuron and Maygrier have rejected the two latter, 
 and substituted for them two diagonal positions, which renders their 
 classification of the pelvic positions in all respects similar to the one 
 they thought proper to establish for the head. Madame Lachapelle 
 has acted differently ; she retains Baudelocque's third and fourth ; 
 but in place of the first and second, she admits two others, in 
 which the back looks directly towards the right, or towards the left 
 side of the pelvis. 
 
 One thing seems to me to be proved by this discrepancy : it is, 
 that we might, strictly speaking, establish, as M. Flamant has done, 
 eight positions of the breech. But, on the subject of the pelvic 
 extremity, I shall repeat what I said in relation to the cephalic ex- 
 tremity : disagreement has arisen on the subject, because, instead 
 of seeking every possible number and kind, we ought, to endeavour 
 to ascertain only such as it might be useful to know. 
 
 774. Admitting that it were not perfectly correct to say, with 
 Mauriceau, Dionis, Dela Motte, and Levret, that the loins are, in 
 breech cases, most generally turned backwards, MM. Capuron, 
 Maygrier, Duges, &c. would not be less in the wrong to assert that 
 they as well as the sacro-anterior positions are purely hypothetical : 
 Asdrubali, who has noticed them, partakes the opinion of Mauri- 
 ceau, and of Smellie ; and the tables published by Madame Lacha- 
 pelle show that out of 1390 cases wherein the pelvic extremity pre- 
 sented, there were thirteen anterior, and twenty-six posterior ones.
 
 PRESENTATIONS OF THE PELVIS. 317 
 
 775. Thus the direct positions, either anterior or posterior, are 
 possible, as well as the diagonal ones, and the breech may present 
 in as many ways as the head. Like those of the head, too, these 
 positions may be reduced to two principal ones : the one, sacro-an- 
 terior, and the other sacro-posterior. This is the way the ancients 
 understood them, and if Baudelocque could be satisfied with one 
 position for the posterior semi-circle of the pelvis, I see not why 
 the three positions of its anterior semi-circle should deserve a more 
 special description. In the first, second, and third positions of that 
 author, whether the hips engage just transversely or somewhat ob- 
 liquely, it always happens that one of them looks to the left and the 
 other to the right, exactly as in the three posterior varieties. In 
 the first case the occiput always ends by placing itself behind the 
 pubis ; in the second it proceeds to lodge on the fore part of the 
 sacrum, as is observed to happen in the corresponding positions of 
 the vertex. The anterior position differs essentially from the pos- 
 terior one ; but the two last being admitted as possible, it is quite 
 useless, as to practice, to establish others, except as shades of them. 
 Notwithstanding, out of respect for received opinions, I shall not 
 fail to point out the particular mechanism of each one of these 
 shades, and instead of uniting all the positions of the pelvic ex- 
 tremity in one single genus, I shall for the same reason continue to 
 examine separately those of the feet, the knees and breech. 
 
 . I. Presentation of the feet. 
 
 538 out of 37,895, Madame Lachapelle ; 23 in 1800, Merriman; 18 in 1897, 
 Bland ; 68 in 6555, Boer. 
 
 776. What I have stated in relation to the dangers of delivery by 
 the pelvic extremity, applies strictly to presentations of the feet. In 
 that case the child resembles a cone or a very sharp wedge, descend- 
 ing from its point towards its base ; the bag of waters being generally 
 less regular in shape, more elongated than in other positions, and 
 almost always rupturing before the dilatation of the neck has had time 
 to be completed, it follows that the pressure upon the foetus constantly 
 increases from the root of the lower limbs up to the superior part of 
 the chest, and that the viscera are violently repelled from below up- 
 wards ; in one word, the parts of the woman are dilated, and a passage 
 for the head opened by the hips, the belly, and the thorax. If the ab- 
 dominal and thoracic cavities were formed of bones as solid, and if 
 their horizontal diameters were of length equal to those of the head, 
 they would bear the pressure of the os uteri with quite as little in- 
 convenience, and the child would not run much more risk in one 
 way than in the other ; but this is not the case, and I cannot too 
 strongly insist upon the disadvantages of such presentations.
 
 318 UNNATURAL EUTOCIA. 
 
 1. Calcaneo- Anterior Position. 
 347 in 37,895 cases, Madame Lachapelle. 
 
 A. First Variety. 
 Loins in front and towards the left. 
 
 1st position of Baudelocque, Gardien, Maygrier, Capuron, Madame Boivin and 
 M. Dcsonneaux. 
 
 777. In the first position of the feet, the anterior surface of the 
 foetus looks backwards and to the right of the womb ; the right hip 
 is turned towards the left sacro-iliac symphysis, and the left hip to- 
 wards the right acetabulum ; whence it follows, that if the presence 
 of the rectum were the principal cause of the great proportional 
 frequency of the first vertex position, the first position of the feet 
 ought to be more rarely met with than the second ; however, the 
 contrary is observed to happen ; for, by the statement of Madame 
 Boivin, in a total of 234 labours by the feet, the left calcaneo-aceta- 
 bular position alone occurred 135 times. 
 
 778. The heels, which previously to the rupture of the mem- 
 branes are more or less near to the tuberosities of the ischia, do not 
 actually engage within the os uteri, until the moment when the 
 waters run off", and sometimes even much later than that. If the 
 amnios does not give way until after the orifice is properly dilated, 
 the legs and thighs follow the feet immediately, and the hips, which 
 traverse the superior strait in a diagonal position, soon reach the 
 vulva. In the contrary case, all these parts descend slowly, and by 
 degrees, with each returning pain. The foetal pelvis, before it en- 
 gages into the inferior strait, generally performs a rotation upon the 
 right anterior and left posterior inclined planes of the excavation ; 
 the left hip occupies the arch of the pubis, while the right hip goes 
 to fill up the hollow of the sacrum. The whole child bends upon its 
 anterior or left side ; the belly next passes through the os uteri ; the 
 elbows, pressed against the ribs, or somewhat in front upon the 
 breast, yield to the contractions of the womb, and descend along 
 with the thorax into the excavation. The shoulders follow the 
 chest through the abdominal opening of the pelvis, where they re- 
 main in the same direction they affected at the commencement of 
 the labour, that is to say, diagonally, the right before the left sacro- 
 iliac symphysis, and the left behind the right acetabulum. When 
 below the strait, they are subjected to the same pivot motion as the 
 hipa, and like them, are soon placed in the antero-posterior direc- 
 tion. The head, strongly flexed, follows the upper part of the breast ; 
 the ovoid which it represents engages with its apex foremost ; its
 
 PRESENTATIONS OF THE PELVIS. * 319 
 
 occipito-mental diameter is parallel with the axis of the strait, the 
 "plane of which soon becomes parallel to the occipito-bregmatic cir- 
 cumference ; the bi-parietal and occipito-bregmatic diameters mea- 
 sure the oblique diameters ; in fine, the relations of the head to the 
 upper pelvic circle are absolutely the same as in the first position of 
 the vertex : there is only this difference, that the small, instead of 
 the large extremity of the cone represented by the head, videl. the 
 chin, the face and base of the skull instead of the superior oval and 
 occiput advance foremost. 
 
 779.- The root of the umbilical cord, the abdomen, and the lower 
 part of the thorax are now emerged ; the left elbow appears at the 
 top of the pubic arch ; the right elbow, arm and shoulder slide gra- 
 dually along the sacrum and perineum, and successively appear in 
 front of the posterior commissure of the vulva, which strongly raises 
 the trunk of the foetus up towards the mons veneris ; so that the 
 shoulder that is in front does not commonly disengage itself until 
 after the other, although the corresponding elbow had appeared at 
 the vulva first. Immediately after this, if not supported, the child 
 falls backwards again by its own weight, and rests on the anterior 
 edge of the perineum ; a kind of movement of restitution which 
 again carries the left shoulder to the right, and the right one to the 
 left side, soon takes place, and the bis-acromial again crosses the 
 occipito-bregmatic diameter at right angles. 
 
 780. When fairly in the excavation, the head revolves on its 
 occipito-mental diameter, so as to carry the face directly backwards, 
 and the nape of the neck and occiput directly in front ; the two ex- 
 tremes of the occipito-bregmatic diameter slide from right to left, 
 and from before backwards, on the right posterior inclined plane, 
 and from left to right and from behind forwards, on the left anterior 
 inclined plane, as in the first vertex position, so as to become parallel 
 to the coccy-pubal diameter. The womb can now no longer act 
 immediately upon the head, which is entirely or partly in the vagina ; 
 but the disposition to straining, produced by the pressure now ex- 
 perienced by the rectum and bladder, soon compels the woman to 
 gather up all her powers and redouble her courage, and the contrac- 
 tions of the abdominal muscles soon come to the assistance of the 
 powerless womb, for whose forces they are now the substitutes. 
 From this moment the occiput receives the whole weight of the ex- 
 pulsive power : in order that it may become parallel to the axis of 
 the perineal strait, the occipito-mental diameter gradually executes 
 a see-saw motion, which brings the anterior fontanel near to the 
 anterior surface of the hollow of the sacrum, and causes the chin to 
 thrust the breast towards the symphysis of the pubis. Finally, the
 
 320 UNNATURAL EUTOCIA. 
 
 nape of the neck, bearing upon the summit of the arch, as upon a 
 fixed axis, permits the head to describe an arc of a circle, the radii 
 of which seem to have the lower edge of the articulation for their 
 centre, and to be composed of the occipito-mental, occipito-frontal, 
 occipito-bregmatic, and vertical diameters ; so that we see the chin, 
 the forehead, and the anterior fontanel appear in regular succession 
 at the vulva, after which the occiput escapes from above downwards, 
 and emerges thus from the pelvis to put an end to the labour. 
 
 B. Second Variety. 
 Loins forward and to the right. 
 
 2d position of Baudelocque, Gardien, Capuron, Maygrier, Desormeaux and 
 Duges ; 86 times in 234 feet presentations, Madame Boivin ; 175 in 37,895 la- 
 bours, Madame Lachapelle. 
 
 781. In the right calcaneo-acetabular position, the soles of the 
 feet, the fore parts of the legs, and the whole anterior surface of the 
 fetus look towards the left and back part of the mother ; the right 
 side is towards the front and left of the mother. 
 
 The feet and legs, as in the preceding position, are not mechani- 
 cally stretched out, are not really pushed into the orifice, until after 
 the perforation of the membranes. The hips, arms, and shoulders 
 pass through the straits and present themselves at the vulva in the 
 same way ; that is to say, diagonally at the superior strait, and 
 antero-posteriorly at the inferior strait ; but the act of rotation takes 
 place from left to right instead of from right to left, as before : both 
 the right hip and right shoulder, and not the corresponding parts of 
 the left side, proceed to lodge in the arch of the pubis ; the abdomi- 
 nal surface turns towards the left, and thus takes the situation of the 
 posterior surface, which now looks towards the right iliac fossa ; 
 the occipito-mental and bi-parietal diameters, and the occipito-breg- 
 matic diameter and circumference, preserve the same relations with 
 the axis, the oblique diameters and plane of the superior strait, and 
 with the coccy-pubal and bi-sciatic diameters of the inferior strait ; 
 but the face and forehead are obliged to descend along the front of 
 the sacro-iliac symphysis, and the pivot motion occurs along the 
 right anterior and left posterior inclined planes ; in one word, the 
 second position differs no more from the first than the left hand does 
 from the right ; and the mechanism of the one is so similar to that 
 of the other, that it would be really fastidious to enter into any longer 
 details concerning it.
 
 PRESENTATIONS OF THE PELVIS. 331 
 
 C. Third Variety. 
 Loins directly in front. 
 
 3d position, Baudelocqua, MM. Gardien, Maygrier, Capuron, Desormeaux, 
 fitc. ; 7 in 254, Madame Boivin ; 6 in 235, Madame Lachapclle. 
 
 782. It is true we find undoubted instances of the third position 
 in Mauriceau, Smellie and Levret, &c.; but as these authors, as well 
 as de La Motte, Deleurye, and Asdrubali, did not distinguish them 
 from the two preceding ones, we cannot ascertain in what propor- 
 tion they met with them. Be this as it may, we do not perceive 
 that the form of the strait can in any way prevent such a presenta- 
 tion from taking place ; the pelvis is wide enough in front to admit 
 of the two hips engaging in it transversely ; the sacro-vertebral angle 
 might very well lodge betwixt the thighs or legs of the child, whether 
 flexed or extended ; the belly and breast are too easily depressed to 
 occasion the least difficulty in this respect ; and the shoulders them- 
 selves would pass transversely through the strait as easily as the hips. 
 As to the head, although in penetrating to the excavation it would 
 not experience more, or might have even less difficulty, than if the 
 vertex were presented in the third position, it notwithstanding rarely 
 fails to deviate to the right or left side of the promontory. It is easy 
 to see that in this respect there has been more dispute about words 
 than things. In fact, if those accoucheurs who reject the third po- 
 sition of the feet, admit under that title only those cases where the 
 middle line of the child's back glides along behind the symphysis pubis 
 to the very close of labour, they are no doubt partly right, and such 
 a labour must be extremely rare ; but if, on the contrary, in order 
 to constitute such a case, it suffices for the child to descend in this 
 way until the arrival of the head only, we are not permitted to be 
 ignorant, not merely of its possibility, but also of its very great 
 frequency. 
 
 During the progress of the labour, then, this third position almost 
 always converts itself, a little sooner or later, into the first or second ; 
 sometimes it lasts only until the arrival of the hips at the superior 
 strait ; sometimes it maintains itself until the shoulders engage j 
 sometimes it is not converted into a diagonal position until the breast 
 has descended quite into the excavation ; finally, it may happen that 
 it does not become converted at all, and then one of two things is 
 observed to take place : either the hips, the shoulders, and the head 
 do not turn upon their axes at the abdominal strait, in the excava- 
 tion, nor at the inferior strait, and the child's back continues to look 
 to the front of the mother both out of the pelvis and inside of it, and 
 2Q
 
 322 UNNATURAL EUTOCIA. 
 
 there is no pivot movement within the pelvis, nor restitution nor 
 rotation outside of it ; or, on the other hand, the hips and shoulders, 
 which were engaged transversely at the upper strait, place them- 
 selves in an antero-posterior direction to pass through the vulva in 
 which case the head is the only part that does not turn on its axis. 
 
 2. Calcaneo- Posterior Position. 
 
 4th position of Baudelocque, MM. Gardien, Desormeaux, &c.; 10 in 538, Ma- 
 dame Lachapelle; 6 in 234, Madame Boivin. 
 
 783. Under the title of fourth position, Baudelocque comprised 
 all the cases where the dorsal surface of the foetus looks towards 
 any point of the posterior half of the superior strait, and not merely 
 those in which it is turned directly backwards, as we might be 
 tempted to believe from reading a great number of modern works. 
 In this respect he has only imitated Mauriceau, Dionis, De La 
 Motte, Portal, Smellie, Asdrubali, &c. 
 
 In the usual folded state of the fetus, the soles of the feet, the 
 fore parts of the legs, and the forehead and abdominal surface of 
 the child are directed forwards. The lower limbs being more or 
 less rapidly extended and elongated by the uterine contractions, 
 they pass through the vagina, and reach the vulva ; the hips soon 
 follow, and sometimes pass the superior strait in the direction of the 
 bis-iliac diameter, more frequently in that of one of the oblique ones, 
 or at least, after being slightly inclined, one forwards and the other 
 backwards, provided they were previously quite transverse. When 
 in the excavation, they are observed to engage in the perineal strait, 
 sometimes parallel with the bi-sciatic line, at others by following 
 the oblique diameter, and most frequently, after one of them has 
 been placed behind the symphysis pubis, and the other in front of 
 the sacrum. 
 
 784. The arms and shoulders present themselves in their turn, 
 and act like the hips, with the exception only, that they more rarely 
 fail to execute the pivot motion before they pass through the vulva, 
 even though they had previously affected a transverse position ; 
 being repelled by the anterior edge of the perineum, these different 
 parts, as they emerge, are raised upwards towards the mons veneris ; 
 to accommodate itself to the curve of the pelvis and genital parts, 
 the ffEtus bends in the shape of a very long arc of a circle, convex 
 behind and concave before, as it does in an anterior position. The 
 elbow that is below the pubis shows itself first at the upper part of 
 the vulva ; but the opposite arm and shoulder, more particularly 
 urged by the efforts of the womb, proceed from behind forwards
 
 PRESENTATIONS OF THE PELVIS. 333 
 
 along the posterior median line, and actually are the first to escape 
 from the pelvis ; the edge of the perineum immediately afterwards 
 retires upon the neck, as if to permit the trunk to fall back towards 
 the anus, and the other shoulder to disengage from beneath the 
 pubic symphysis ; the back then turns back again, as by a sort of 
 movement of restitution, which replaces the shoulders, the one to 
 the left and the other to the right, or diagonally. The head cannot 
 become engaged without being strongly flexed ; on the one hand 
 the occiput almost invariably deviates towards one of the sacro-iliac 
 symphyses ; on the other, the occipito-frontal diameter, or even the 
 entire head, represents a lever of the first kind, whose anterior ex- 
 tremity more particularly supports the action of the expulsive pow- 
 ers ; the chin, although more or less prevented by the breast, ends 
 however by being depressed, and the occipito-mental diameter by 
 finding itself almost parallel with the axis of the strait ; the forehead 
 and anterior fontanel come, one after the other, to hide behind the 
 symphysis of the pubis, and thenceforth the cccipito-bregmatic cir- 
 cumference is in correspondence with the plane of the pelvic mar- 
 gin, as in all the anterior positions. 
 
 785. When in the excavation, the head rolls on the inclined planes, 
 replaces itself in an antero-posterior direction by means of the pivot 
 motion, and afterwards glides with much more difficulty than when 
 the occiput is forwards ; the breast, which is situated in front, opposes 
 the lowering of the chin ; the occipito-bregmatic diameter, which is 
 three and a half inches long, not being able to place itself in cor- 
 respondence with the antero-posterior diameters of the excavation 
 and apex of the pelvis, has its place occupied by the occipito-frontal 
 diameter, which has an extent equal to at least four inches. The 
 face, and particularly the forehead, are too broad and ill-disposed 
 to fit the form of the pubic arch so exactly as the nape of the neck 
 and occiput do ; finally, the shoulders hardly emerge before the chin 
 presents itself at the vulva. 
 
 Nevertheless, immediately after the expulsion of the thorax and 
 upper extremities, the upper and hinder part of the neck rolls from 
 before backwards upon the anterior edge of the perineum, as upon 
 an axis, and the nose, the forehead, the anterior fontanel and remain- 
 der of the head successively disengage, by forcing the breast back- 
 wards. 
 
 786. Remarks. The mechanism of this position, as now seen, 
 is very unfavourable, and much more difficult than that of the 
 calcaneo-anterior positions ; if the chin or forehead lodge upon the 
 upper edge of the pubis, the act of flexion of the head is prevented 
 or destroyed, and the occipito-mental diameter, or the occipito-
 
 324 UNNATURAL EUTOCIA. 
 
 frontal diameter and circumference, occupy the situation of the 
 occipito-bregmatic diameter and circumference; then the labour 
 cannot be terminated without assistance. 
 
 It would, notwithstanding, be wrong to conclude that art must of 
 necessity aid the economy in all the posterior positions of the feet : 
 attempts to change them would favour the reversion of the head, 
 and most frequently produce just the state of things which it is de- 
 sired most carefully to avoid. Besides, nature, when left to herself, 
 generally succeeds better than any foreign power in flexing the head 
 and placing it diagonally at the superior strait. In a very great 
 majority of cases this position spontaneously converts itself into an 
 anterior position, either suddenly, after the head has got into the 
 excavation, or, on the other hand, gradually, in proportion as the 
 hips, the shoulders, and the head itself present. 
 
 787. In a case of this kind I have seen the hips emerge trans- 
 versely from the vulva, turn in the direction of the oblique diameter 
 that extends from behind and right to the left, then place itself in the 
 antero-posterior direction, as the shoulders became engaged, then 
 continue their rotation movement after the escape of the latter, and 
 at last turn quite across, with the back in front, yet the head escape 
 as in a direct anterior position. Now, this is what almost always 
 happens if the accoucheur is skilful enough to do nothing, to content 
 himself with sustaining the fetus, as it passes the vulva, without 
 employing the least traction. 
 
 788. If the loins are sometimes turned directly to the left or right, 
 which cannot be doubted, inasmuch as Madame Lachapelle informs 
 us that she has seen it so, we may be at least allowed to suppose 
 that in this direction persons have been often deceived by the ob- 
 lique position that approaches most nearly to it. But for this, the 
 celebrated midwife would not have said that out of 1038 labours by 
 the feet, there were found to be 347 left iliac positions, and 175 
 right iliac positions ; moreover, by the admission of Madame La- 
 chapelle herself, the really lateral positions almost always convert 
 themselves into anterior or posterior, diagonal or direct positions. 
 
 789. In all the feet positions, the hips and shoulders ordinarily 
 execute n rotation movement, previously to engaging in the inferior 
 strait ; according to Baudelocque, this movement may, however, 
 possibly not take place, and the parts may therefore continue parallel 
 to the bi-sciatic diameter ; according to most of the modern accou- 
 cheurs, on the contrary, the hips and shoulders almost never pass 
 the vulva otherwise than parallel with the coccy-pubal diameter. 
 To reconcile these two extremes, there remained one intermediate 
 opinion, and Madame Lachapelle embraced it, maintaining that the
 
 PRESENTATIONS OF THE PELVIS. 325 
 
 pelvis and upper part of the thorax pass through the inferior strait, 
 in an oblique or diagonal direction, and not in a directly transverse 
 nor antero-posterior direction, strictly so called. For my own part, 
 if I can believe my own eyes, both parties are right, an error is 
 found only in the exclusion by which each party endeavours to 
 put down the other. 
 
 790. All the accoucheurs, both ancient and modern, have main- 
 tained, that in delivery by the feet, the arms rise along the sides of 
 the neck and head. Wiedemann was one of the first to oppose this 
 doctrine, and he pretends that they always remain applied against 
 the breast, if no tractions of any kind are exercised upon the foetus. 
 M. Desormeaux and Madame Lachapelle adopted this opinion also. 
 In the deliveries by the feet that have fallen under my notice, the 
 forearms and elbows did not abandon the breast, and always escaped 
 before the shoulders, when the woman was left to her own powers, 
 and nothing more was done than to support, without pulling at the 
 trunk until the expulsion of the head. 
 
 79 1 . Though so many authors have professed the opposite opinion, 
 which still prevails very generally, it depends solely on the circum- 
 stance, that the persons who assist lying-in women, rarely consent 
 to remain inactive in a footling delivery ; they lay hold on the mem- 
 bers that spontaneously present, and the very natural, and in itself 
 considered, laudable, desire to put an end to the sufferings of the 
 mother, causes them to pull with more or less force upon the child, 
 and a phenomenon which is produced merely by art, is then very 
 readily mistook for a naUnal one. Where the womb, assisted by 
 the muscular contractions of the abdomen, is alone charged with 
 the duty of expelling the ovum, all the parts of the child are pushed 
 down simultaneously, and so folded and pressed together, that it is 
 very difficult for one of them to rise upwards while the others are 
 descending ; as the uterus does not contract from its fundus towards 
 its cervix only, but also circularly, from above downwards, by a sort 
 of vermicular or peristaltic movement, the elbows or arms run no 
 risk of lodging against the upper edge of the pelvis. 
 
 792. If, on the contrary, the foetus is extracted and not simply 
 expelled, as the tractions come to act ultimately upon the breast 
 and head, it follows, that these parts only are dragged downwards, 
 while the arms, retained in their position by the womb, remain 
 where they were, and can only descend in a direction extending 
 from the shoulders towards their free extremities. 
 
 Nevertheless, I do not believe it right to deny, as Madame La- 
 chapelle does, the possibility of the phenomenon admitted by the older 
 accoucheurs to take place in every spontaneous delivery. We may
 
 326 UNNATURAL EUTOCIA. 
 
 conceive that the arms, when once they have reached the excavation 
 along with the shoulders, being no longer directly urged by the 
 uterine efforts, may rise upwards by sliding along the sides and 
 fore part of the breast, or rather, that the head, supporting from this 
 moment, the whole action of the expulsive powers, may cause the 
 face and breast to descend into the inferior strait, Avithout necessa- 
 rily carrying the elbows along with them. It must be so, further, 
 since M. Gardien affirms that in many labours terminated by the 
 feet without any assistance, he has seen the arms rise along the sides 
 of the neck and head, and since M. Deneux told me he had observed 
 the same thing. 
 
 Presentation of the knees. 
 4 in 20,517, Madame Boivin ; 9 in 22,243, Madame Lachapelle. 
 
 793. The position of the knees being in all respects like that of 
 the feet, it is useless to give the mechanism of it apart ; in fact, 
 whether the legs have descended, or remain bent upon the thighs, 
 the lower extremities traverse the os uteri and straits of the pelvis 
 with equal facility. Perhaps they descend with rather less facility 
 in the second than in the first case mentioned, provided the mem- 
 branes give way wiien the neck is still incompletely dilated ; but the 
 knees scarcely reach the vulva before the legs become extended, and 
 thenceforth every thing proceeds as if it had been a footling qase. 
 
 The knees present first, because they have been reversed, either 
 mechanically or by muscular action, in the cul de sac formed by the 
 apex of the ovum, at the moment when the membranes are ruptured, 
 or because the rush of fluid forces them along with it, rather than 
 the feet, which may be farther from the orifice ; or because the 
 breech, which, presented first, mounts upwards again along with the 
 feet, under the influence of the contractions of the womb, so that 
 the knees only can be depressed into the opening of the neck ; or 
 yet again, because, after the discharge of the waters, the legs are 
 situated crosswise above the uterine orifice, or have been arrested 
 against two opposite points of the strait. Moreover, we may con- 
 ceive that they may both descend at once, or only one of them along 
 with one foot, without that circumstance changing the progress of 
 the labour ; and it was entirely wrong to attribute more danger to 
 delivery by the knees, than to those that take place by the feet. 
 
 Presentation of the breech. 
 
 887 in 37,895, Madame Lachapelle ; 375 in 20,517, Madame Boivin ; 42 in 
 1800, Menimtn ; 86 in 1897, Bland; 126 in 6555, Boer. 

 
 PRESENTATIONS OF THE PELVIS. 327 
 
 794. Presentation of the breech has always beqn regarded as 
 more dangerous, difficult, and unnatural than that by the feet or 
 knees. It was thought that the size of the buttocks would not admit 
 of the expulsion of the child without the neck of the womb as well 
 as the perineum being violently contused or extensively lacerated ; 
 but even had experience not pronounced upon the value of these 
 exaggerated fears, a moment's reflection would have shown how 
 unfounded they were. It is merely necessary to recollect the di- 
 mensions of the foetal pelvis, to be instantly convinced that, even to- 
 gether with the thighs, the size of the breech could never form an 
 insurmountable obstacle to delivery, unless there were some faulty 
 conformation of the straits. When the child comes doubled, the 
 pelvic extremity is too supple, too flexible, and accommodates itself 
 too easily to the form of the openings it has to traverse, for it to ex- 
 pose the neck of the uterus and the perineum, any more than the 
 head does, to the lacerations of which we have spoken. 
 
 795. In presentations of the feet or knees, the bag of waters is in 
 general more elongated, tears more readily, and the os uteri has less 
 need of being so largely dilated. With the breech, on the contrary, 
 the amniotic sac is as large as in a head presentation, and does not 
 open until it has produced a considerable dilatation ; the buttocks 
 and hips, which have to open a passage, react without inconvenience 
 against the resistance of the neck ; the belly and breast pass the 
 straits and vulva without the risk of a very violent pressure ; for, ex- 
 cepting the head, the hips exceed, as to dimensions and firmness, any 
 other part of the child. 
 
 796. In breech cases it is true that the labour, in general, goes on 
 very slowly until they have passed through the cervix, and sometimes, 
 even until they have traversed the vulva ; while in feet or knee pre- 
 sentations, it seems, at first, that the process of child-birth is going 
 to be extremely prompt. But these differences are all in favour of 
 breech positions ; for in the second case, the phenomena then suc- 
 ceed each other, producing so much the less effect as the body is 
 nearer being completely expelled ; while in the first case, where the 
 hips have once descended into the vagina, the rest of the body 
 emerges with much less difficulty. I dwell upon this idea because 
 it is well calculated to show how imprudent it may be, in a presen- 
 tation of the pelvic extremity, to bring down the feet artificially, with 
 the sole view of hindering the breech from engaging first, before the 
 dilatation is completely effected. 
 
 797. Baudelocque admits four positions for the breech, as he does 
 for the feet, and divides them in the same manner ; M. Flamant
 
 328 UNNATURAL EUTOCIA. 
 
 reckons eight of them, and MM. Maygrier and Capurdn, four, as 
 for the head, &c. 
 
 798. Without speaking of the cases where the foetus engages 
 squatting, having the heels glued, as it were, against the ischia, cases 
 in which art is almost always required for the assistance of nature, 
 I must say that in women endowed with but little moral and mus- 
 cular energy, the softness and flexibility of the breech will absorb 
 the greater part of the motion communicated to the spine of the 
 child by the womb, which often ends by falling into a state of 
 inertia, and that the labour cannot then be always abandoned to 
 itself without danger; besides, in the three anterior positions, the 
 external organs of generation of the male sex are exposed to fric- 
 tions more or less violent against the promontory ; and it is also by 
 no means rare to find black and contused echymoses in new born 
 children that come by the breech. 
 
 Whether the buttocks have passed the upper strait in a transverse 
 or oblique direction ; whether the back is in front or rear, it is not 
 less a rare thing for them to fail to place themselves in an antero- 
 ppsterior direction in the excavation ; being strongly pressed against 
 each other they swell ; in boys, the scrotum becomes puffed and 
 infiltrated ; as they curve towards the pubis to gain the vulva, they 
 distend the perineum almost as much as the head does, the form of 
 which they partly simulate ; they are next seen to disengage of them- 
 selves, and then every thing goes on as in a footling labour. 
 
 SECTION 3. 
 Of the Conduct of the Accoucheur during Labour. 
 
 799. When called to a woman who supposes herself to be in 
 labour, there are two ways in which the accoucheur may behave, 
 accordingly as he may have for a long time enjoyed her confidence, 
 or as he may never have been much acquainted with her before. 
 
 In the former case he should examine at once, in order to ascer- 
 tain whether the labour has really commenced ; in the latter, it is 
 often necessary to be not quite so much in a hurry, unless indeed 
 the labour seems to be very far advanced. 
 
 He may begin to talk about one of the thousand subjects of futile 
 conversation that every body understands, and which admits of 
 only a gradual approach to the principal object ; in this way time is 
 allowed for quieting the agitation commonly occasioned in most 
 women by the presence of a stranger, and particularly an accou- 

 
 DIAGNOSIS. 329 
 
 cheur ; during this parley, he should endeavour to possess himself 
 of the shades of character, the caprices, tastes, and habits of the 
 person he is called upon to direct, in order to adopt such a plan of 
 conduct as is most likely to inspire her with great confidence in her 
 attendant ; the subject of her pregnancy is soon brought up, the 
 symptoms that have accompanied it, the peculiarities that have 
 marked it, and its term ; he may ask whether she has had several 
 pregnancies, or whether this is the first ; he can ask about the gene- 
 ral state of her health, the inconveniences and diseases that she has 
 heretofore suffered ; after which he may be allowed to think of the 
 labour properly so called. 
 
 . I. Of the diagnosis. 
 
 800. Nothing is easier, in the opinion of by-standers, than to say 
 whether a woman is in labour or not ; but this is not the case with 
 the well-instructed physician. As women in their first child-birth 
 lack a term of comparison, they very frequently deceive themselves 
 in regard to the sensations they experience ; even in the second, 
 third or fourth pregnancy women deceive themselves sometimes. 
 How often have the neighbours, relations, the widwife or accou- 
 cheur been seen to fix and arrange every necessary preparation for 
 the birth of the child, and the supposed labour cease for a whole 
 month or six weeks, just when the bed had been made up for the 
 reception of the woman, and when the clouts, the ligature for the 
 cord, the scissors, the caps and other clothes of the child were only 
 waiting for the arrival of the stranger to be applied to it ! How often 
 have even still greater mistakes been committed ! Who does not 
 know how poor women have been kept for days together on the 
 child-bed, even by physicians, and at last found that their pregnancy 
 was several months off from its close, or even that they were not 
 pregnant at all ! A young woman in her ninth pregnancy was 
 seized with pain, and thought herself at term ; several accoucheurs 
 were called in succession. One said that the bag of waters was 
 formed ; another, that the head was about to engage ; a third, that 
 he could not find the os uteri ; a fourth, that the forceps must be 
 applied. This poor creature, in despair, sent for me on the fifteenth 
 day ; I found the cervix as it is at the seventh month ; there was an 
 anterior obliquity of the womb ; I stated that labour had not begun, 
 and would not take place for more than a month and applied a 
 broad bandage round the abdomen. In a month, a student who 
 staid by her, came to tell me that the os uteri was dilated, and de- 
 livery about to take place. I repaired to her, found no symptom of 
 labour, and in fact, the child was not born till a month afterwards. 
 2 R
 
 330 DIAGNOSIS. 
 
 When persons who are strangers to the science of medicine are 
 deceived in this way, the public only laugh at them ; but what con- 
 fidence can an accoucheur inspire who is guilty of such stupidity ? 
 It imports us therefore to be on our guard against such causes of 
 error, and it is easy for those who have any positive knowledge in 
 tokology to do so. 
 
 801. The pains of labour, the true pains, are intermittent, sepa- 
 rated by intervals more or less short, progressive, return at regular 
 periods, are not accompanied with tenderness of the abdomen nor 
 heat of the skin nor fever ; they begin in the neighbourhood of the 
 umbilicus, and end in the pelvis or flanks. 
 
 Pains foreign to labour, false pains, are, on the contrary, vague, 
 irregular, sometimes more, sometimes less acute, do not entirely 
 cease, increase under pressure, and are, most commonly, accom- 
 panied with fever or some kind of functional disturbance ; they an- 
 nounce a lesion of the stomach, the bowels, the liver, the kidneys, 
 the bladder, or some other organ contained in the abdomen, and 
 have been called false because they are entirely unconnected with 
 parturition, appear in pregnant women as they do in those who are 
 not pregnant, or as they do even in persons of the other sex. 
 Nothing, therefore, but the greatest want of reflection, can cause 
 them to be confounded with the true pains those which depend 
 upon the contractions of the womb. 
 
 802. I, however, ought not to omit speaking of a state that might 
 render this discrimination very difficult, and a mistake at the same 
 time highly dangerous : if an inflamed point be established in the 
 neighbourhood of the womb, in that organ itself, in the bladder, rec- 
 tum, &c. just as labour comes on, the pains of child-birth will pro- 
 gress just as those of the disease do, and if it were absolutely neces- 
 sary to decide from the testimony of the pains alone, the most skil- 
 ful person might be led into a mistake. But the science possesses 
 other means of ascertaining the existence of labour. If, when the 
 suffering is at the height, the hand, placed upon the hypogastrium, 
 feels the womb grow hard, contract, and become rounder, it is de- 
 cided that child-birth is about to take place, and, in this case, the true 
 pains may exist alone, as they may also be met with in conjunction 
 with false pains. If the hand discovers the womb to be unmoved, 
 without action, and without connection with the cries uttered by 
 the patient, it may, to a certain extent, be affirmed that the labour 
 has not begun. 
 
 803. In fine, we are by the touch enabled to solve the question 
 without any fear of being deceived. While ever the cervix is still 
 un-eflaced, while it retains some few lines of length as a canal, we
 
 DIAGNOSIS. 331 
 
 may, in general, assert that the woman is not at full term ; only we 
 must avoid mistaking the lips of the os tineas for the cervix itself, 
 and remember that in persons who have had several lyings-in before, 
 it is now and then found to be extremely soft and very wide, several 
 days or even several weeks previously to the end of pregnancy ; and 
 that in such women the orifice frequently forms a cushion or an 
 edge several lines in thickness at the commencement of labour. - If 
 it be a first labour, the cervix does not begin to gape antecedently 
 to the appearance of the true pains, and if it feels like a tubercle, 
 pierced through its centre, we may be satisfied that there have been 
 as yet no uterine contractions ; where, on the contrary, it is thin, like 
 a sharp circle, the gestation is necessarily at its]term,and if the par- 
 turition have not commenced, it is almost a matter of certainty that 
 the labour will not fail to show itself within a few days. 
 
 To obtain a decisive proof on this point, we have, at most, only to 
 touch during a pain ; if the finger feels, in such a way as to ad- 
 mit of no doubt, that the membranes become tense, that they try to 
 engage in the os uteri, which manifestly becomes thinner, contracts, 
 or opens a little, to return immediately afterwards to its primitive 
 condition, nothing further is wanting, the labour has began ; if 
 nothing of all this is observed, we may be content, the moment for 
 lying-in has not arrived. 
 
 804. However, I cannot quit this article without calling the at- 
 tention of young practitioners to a peculiarity in the diagnosis, that 
 is not sufficiently known, and which might lead them to deceive 
 themselves, after what has been above said. Modern accoucheurs 
 have with one accord rejected, as among apocryphal or ill-under- 
 stood facts, the very numerous cases tending to prove that labour 
 may begin, the contractions of the womb be brought into evident 
 play, and that, after having continued for several hours, the labour 
 may be suspended so that delivery shall not take place for a whole 
 month afterwards : such anomalies as these have been cited chiefly 
 on occasions of protracted gestation, and as proofs of superfoeta- 
 tion ; it has been pretended that such powerless efforts as the above 
 had masked the natural term of gestation, and that the time that 
 elapsed betwixt their cessation, and the real labour, was an excess 
 over nine months. But 1 have acquired the conviction that this in- 
 complete labour, or, as Levret calls it, false labour, is not a mere 
 chimera. In March 1824, I was called to a woman in the rue 
 d'Orleans, in her second pregnancy, and who had been in pain for 
 about twenty-four hours ; the pains were regular, weak, and sepa- 
 rated by pretty long intervals ; the os uteri, which was very soft, 
 and wide enough to admit of the introduction of three fingers, was
 
 332 DIAGNOSIS. 
 
 not completely effaced ; the point of the ovum had already begun 
 to engage within it, and when the pains came on, the membranes 
 were on a level with the top of the vagina, and became smooth and 
 tense, while, on the other hand, I felt the orifice and body of the 
 womb harden and contract with a certain degree of energy. It 
 was ten o'clock at night ; I announced that the labour would not 
 terminate for several hours. I returned home after giving orders to 
 send for me as soon as the waters should break ; not being sent for 
 the next day, nor the day after, I supposed they had had recourse to 
 the advice of some other practitioner, and thought no more of it. 
 Six weeks afterwards, being called upon again, I confess I was sur- 
 prised, for I supposed the woman had been delivered long before. 
 This time the symptoms persisted, and delivery took place. M. 
 Nivert has published in the Clinique des Hopitaux a case of the 
 same kind which he met with at my amphitheatre. MM. Gerdy 
 and Tanchou assure me that they have witnessed cases nearly simi- 
 lar, and I have, myself, since met with two others. 
 
 . II. To determine the position. 
 
 When the existence of labour is no longer doubtful, we must en- 
 deavour to learn in what position the fffitus presents. 
 
 805. The vertex is in general easily known by its round and re- 
 gular shape, by the posterior fontanel, and occipital point, by 
 the anterior fontanel, the sagittal, transverse, and lambdoidal 
 sutures, and by the parietal protuberances ; however, when the 
 head has been for a long time engaged, the teguments occa- 
 sionally form so large a tumour upon its summit, it is itself 
 sometimes so elongated, that one has need of some practice 
 in order not to mistake it. It is in many cases so movable, and 
 particularly so high up, as to render it difficult to distinguish it with 
 certainty from any other part. As long as the membranes remain 
 unbroken, we ought, besides, not to try to reach it except in the 
 absence of the pains ; otherwise we should be liable to rupture 
 them prematurely. We can, therefore, best judge of the presenta- 
 tion of the foetus, at the moment when the waters come off: the 
 upper oval of the head may then be touched throughout its whole 
 extent ; the integuments are not yet swelled, and the bones have 
 not had time to ride over each other. In the three varieties of the 
 occipito-anterior position, the posterior fontanel approaches more or 
 less near to the pubal semi-circumference of the pelvis, and is be- 
 hind one of the acetabula or the symphysis pubis, while the frontal 
 fontanel is more or less elevated behind, and looks towards the op- 
 posite point of the pelvic cavity ; in the varieties of the posterior 
 position the fontanela are disposed of in the inverse directions. Al-
 
 DIAGNOSIS. 333 
 
 though it approaches very near the centre of the straits, the pos- 
 terior fontanel, notwithstanding, almost never corresponds to it ex- 
 actly ; both in the anterior and posterior positions, this fontanel is 
 always placed upon a much lower plane than that occupied by the 
 anterior fontanel. In order more correctly to distinguish the dif- 
 ferent varieties of the vertex, we should endeavour to recognize the 
 sutures ; by adding their direction to the notions we derive from the 
 particular situation of the fontanels, it is commonly easy to avoid 
 confounding the anterior with the posterior varieties, and to attach 
 to each shade of one and the same position, those characters by 
 which it is separated from all the others. 
 
 806. Thence is so different from every other part, that, at a first 
 glance, it seems impossible to mistake such a presentation : this is an 
 error ; the proof of the contrary is contained in all the collections of 
 cases, "and is daily met with in practice ; the chin may be mistook for 
 the elbow, the shoulder for the heel, or the knee ; the mouth for the 
 anus, the nose for the sexual organs, and the cheeks for the tube- 
 rosities of the ischia. Least the testimony of an infinite number of 
 learned observers should not suffice to demonstrate the possibility of 
 such mistakes, I will relate a well known anecdote of a former pro- 
 fessor of midwifery at the Ecole de Paris : being a man of a rather 
 decided character, he had just touched a woman in labour, and sup- 
 posing he had found a face presentation, he asserted with great ges- 
 ticulation that such a position could in no case be confounded with 
 one of the breech, not perceiving that his finger, which was covered 
 with meconium, was giving him the lie, in the faces of the students, 
 who could not help bursting into loud laughter. 
 
 It is chiefly in cases where the soft parts of the face have had time 
 to swell and puff up, that we may be readily deceived, especially 
 when the mind, pre-occupied with such or such a position, receives, 
 with a sort of avidity, the most equivocal signs as certain proof of 
 what we had predicted. With proper attention, however, we shall 
 be enabled, without difficulty, except in a few very rare cases, to 
 recognize the face whenever it presents, and the rupture of the 
 membranes allows us to examine it naked ; the eyes and eye lids, 
 the nose and lips, the alveolar arches and tongue, the chin and ears, 
 which are found near at hand, possess characters too decided for 
 the positions of the face not to be always clearly ascertained. 
 
 807. The feet cannot deceive the accoucheur when they pre- 
 sent : the heel, to be sure, has some resemblance to the elbow, and 
 the toes some similarity to the fingers ; but when we remember the 
 difference of length between the latter named parts that the one 
 are arranged upon the same line and short, that the others are of
 
 334 
 
 DIAGNOSIS. 
 
 unequal lengths and much flexed ; when we reflect on the form of 
 the ancles and legs, one must be very careless to compare it with the 
 fist and fore-arm, and not to distinguish the feel from the hands, ex- 
 cepting when these parts are still above the superior strait. 
 
 808. The knees might indeed be mistaken for the elbows or 
 shoulders, although rounder than the former and smaller than the 
 latter. But as two elbows cannot, any more than two shoulders, 
 present at once at the strait, we may be sure that they are the knees, 
 from the mere fact that there are two such tumours together in the 
 strait at the same time } and as a single knee is generally accom- 
 panied with one foot, or at least with the breech, it will always be 
 easy to satisfy ourselves that we are touching some part of a lower 
 extremity, and not one of the arms. There is, notwithstanding, one 
 circumstance that seems as if it might impose upon us ; I mean the 
 simultaneous presence of a knee and an elbow. But besides the 
 rarity of these coincidences, we learn, by penetrating a little further 
 with the finger, that these parts, instead of approaching towards each 
 other at their origins, separate farther and farther from each other. 
 
 809. Presentations of the breech have, more frequently than 
 others, led into error on this subject ; where the buttocks have had 
 some difficulty in getting through the os uteri or the strait, they 
 swell like the vertex ; the crease that separates them may be mis- 
 took for the sagittal suture ; the coccyx and space in front or on 
 the side of it, for the occipital angle, the posterior fontanel, and 
 lambdoidal suture ; and lastly, the ischia may be mistook for the 
 parietal protuberances ; but this same crease, being a slit and not a 
 fold, the movableness of the coccyx, the presence of the anus and 
 of the genital parts, the roots of the members, &c. soon bring the 
 accoucheur back to the knowledge of the truth, when he has de- 
 parted from it for an instant. The anus and genital parts might be 
 mistook for a face presentation, were we not to remark that the 
 mouth, bordered with thick lips, contains a conoidal, movable, and 
 fleshy body, the tongue, and that the finger, when withdrawn from 
 the rectum, is found to be covered with meconium. Still, another 
 circumstance might deceive us. I shall give the particulars, because 
 the authors have omitted to mention them. Having been called 
 upon by Madame Lebrun, the midwife, to terminate a preternatural 
 labour, I thought I could feel the feet, the buttocks, the coccyx, and 
 anus ; but my finger penetrated into an opening, bordered by thick 
 lips, at the bottom of which I felt a tubercle similar to the tongue. 
 Disconcerted by this combination of signs, I for a moment thought 
 I had to deal with a monstrous child ; I again introduced my hand 
 further ; I brought down the feet, and the emergence of the hips
 
 DIAGNOSIS. 335 
 
 soon put an end to my uncertainty. It was the vagina that I had 
 mistaken for the mouth, and the cervix uteri, which is very salient 
 at that age, had made me suppose I felt the tongue. In order to 
 obviate all hesitation in such a case, it is merely requisite to remem- 
 ber that the mouth is open behind, so as to be continuous with the 
 pharynx ; whereas the vagina ends in a cul de sac, at the bottom of 
 which the os tincae is to be found, in the shape of a tubercle, more 
 rounded, shorter, and particularly, less movable than the tongue. 
 
 . III. Of the prognosis. 
 
 810. After having established the diagnosis, a new question natu- 
 rally presents itself to the mind of the accoucheur, while it is very 
 soon propounded to him also by the patient herself or her attendants. 
 Will the delivery be prompt and easy, or slow and difficult ? When 
 will it take place ? The answer here is an extremely delicate mat- 
 ter, and ought only to be given after maturely weighing it, and then, 
 with the greatest reserve. The duration of labour is so variable, 
 depends upon circumstances so diverse, and sometimes so unex- 
 pected, that it is often impossible for the most skilful practitioner to 
 fix it beforehand, even approximatively. On the one hand, it would 
 be necessary from the very beginning to know the proportions of 
 the foetus and pelvis, with how much energy the womb shall con- 
 tract, and how often the pains shall succeed each other ; on the 
 other, he ought to be able to affirm that the progress of the 
 labour shall or shall not be interfered with by a hemorrhage, an 
 attack of convulsions, a prolapsion of the cord, or some other acci- 
 dent ; that the fairest and best position shall not be converted to an 
 abnormal one ; that the membranes shall give way at such a particular 
 period, and not at any other ; that there shall or shall not occur a 
 spasmodic resistance of the cervix, &c. Now, none but ignorant 
 women or impudent quacks can pronounce upon all these points, 
 and, in spite of so many uncertainties, say at what hour the labour 
 is to terminate. 
 
 811. All that we are permitted to promise in a general way is 
 the following : the child is well situated ; the pelvis is neither small 
 nor deformed ; the genital organs are healthy and well disposed ; 
 the os uteri soft and very dilatable ; the pains occur regularly and 
 with constantly increasing force ; the woman is courageous and well 
 constituted ; therefore the termination of the labour will be prompt 
 and fortunate : a little less prompt if it be a first labour ; a little 
 more so if she have had several children before, and still more so, 
 even too rapid, if the pelvis be possessed of excessive amplitude. 
 On the other hand, the position of the fetus, without being posi-
 
 336 PROGNOSIS. 
 
 lively bad, is not, however, one of the best, or perhaps it may be a 
 very large one ; the pelvis is slightly contracted ; its axes are too 
 much or not sufficiently inclined ; the os uteri is hard, or covered 
 with cicatrices ; the woman is of a delicate, nervous, or lymphatic 
 constitution ; in all these, we ought to fear that the labour may be- 
 come a long one, and that the resources of art may become neces- 
 sary. We can also, to a certain extent, judge of the duration of the 
 present labour by her former ones, and particularly by the effect 
 produced by each pain upon the dilatation of the os uteri, and upon 
 the progress of the foetus through the pelvis. In fine, when all the 
 phenomena occur in their most common order, we may, by calcu- 
 lating the time that has elapsed since the first pains, tell, within a 
 few hours, how long the woman has still to suffer. If, for example, 
 only two or three hours were required to bring the dilatation of the 
 os uteri to the size of a five franc piece, it is extremely probable that 
 not more than that will be necessary to complete the expulsion of 
 the child ; but this is the highest degree of precision to which we 
 can pretend, and those who pique themselves upon the possession 
 of more exact knowledge in this matter, either impose on the public 
 or deceive themselves. 
 
 812. The accoucheur who, for the purpose of making a parade 
 of vain knowledge, thinks himself able to announce the precise term 
 of delivery, not only exhibits his own ignorance or bad faith, but he 
 also compromits the dignity of his profession and the safety of the 
 woman. If indeed it be true that chance is often on the side of 
 impudence and quackery, it often happens that the predictions of 
 ignorance or rash vanity are not realized ; but, if promises, gene- 
 rally made with much emphasis and assurance, are not fulfilled at 
 the appointed time, that alone is enough to give rise to the liveliest 
 solicitude, in the minds of relations or assistants, and especially in 
 the patient herself, who never fails, afterwards, to think either that 
 her destruction is certain, or that she is to have a bad labour. 
 
 . IV. Of the attentions necessary for a woman in labour. 
 
 813. Inasmuch as spontaneous parturition is a natural function 
 and not a disease, are we thence to conclude that the art of the 
 accoucheur is unnecessary, and that women in labour have no need 
 of assistance ? Some physicians, misled by mistaken philanthropy, 
 have thought so. In animals, say they, pregnancy brings no incon- 
 veniences, and delivery is almost unattended with pain. The wives 
 of the Oatiacks, who are still strangers to the refinements of Euro- 
 pean civilization, are delivered of their children upon the spot where 
 they happen to be, and immediately resume their accustomed occu-
 
 PROGNOSIS. 337 
 
 pations, or continue their march, if they happen to be on a journey. 
 Those of the inland of Arnboyna, who live under a directly opposite 
 temperature, behave in the same way. The aborigines of certain 
 countries in America bathe themselves in cold water and return to 
 their work as soon as the child is born, while the husband goes to 
 bed and plays the patient for a week or two ! Parturition is a mere 
 nothing to country women, who cannot spare time to drag them- 
 selves, methodically, from the bed to the sofa, and vice versa. Who has 
 not seen soldiers' wives bring the most robust and finest children into 
 the world, without in any respect deviating from their active modes of 
 living, or without ceasing by forced marches to follow their regi- 
 ments ? Even in the large cities it is not uncommon for poor wo- 
 men to go on foot to a midwife while the pains are upon them, and 
 return home the next day in spite of Hygieine, their poverty not allow- 
 ing them to attend to themselves for more than three or four days. 
 I, like Roussel, have seen a young girl who found means to conceal 
 from her parents both the humiliating proofs of her weakness and 
 the operation that delivered her from it. What practitioner is there 
 who has not had an opportunity of making the same observation ! 
 The pregnancies of these poor creatures being illegitimate, it would 
 seem as if they had no right to be sick. But these remarks in no 
 wise prove that women ought to be left to themselves during partu- 
 rition. In the first place it is false to say that parturition in animals 
 never requires any assistance, and is never accompanied with serious 
 accidents : sows, mares, cows, &c. are even, in general, quite ill in 
 bringing forth their young, and country people are by no means 
 ignorant of the fact. Does it follow, because some women, 
 when compelled by imperious motives to deliver themselves in pri- 
 vate, or without taking the least precaution, escape from the serious 
 dangers with which they supposed themselves to be threatened, that 
 all others may imitate them without exposure to more imminent 
 perils ? If there are some whose health is not disturbed by such 
 painful experiments, how many others are there who become the 
 victims of their temerity ? Because one man falls from the top of 
 a roof without breaking his bones, does it follow that we should 
 advise others to go to the house top to have the pleasure of tumbling 
 down to the ground ? Will people never be tired of referring us 
 back to a period of primitive nature, that every body talks about, 
 and that nobody understands ? By attempting to substitute the 
 exception for the rule, we inevitably fall into absurdity, and that is 
 what happened to the elegant Roussel. If, in order to avoid the 
 dangers of abuse, it were always necessary to forego the use, what 
 would become of the human race ? The business of the accoucheur, 
 2 S
 
 338 PROGNOSIS. 
 
 doubtless, is not to put himself in nature's place where a labour is 
 natural ; but somebody ought to be with the woman .who is able to 
 give her proper directions, to foresee accidents, to recognize them, 
 and to remedy them when they do take place ; to apply the resources 
 of art when necessary, and at the opportune moment; who, by the 
 confidence he inspires, calms all her fears, and gives courage and 
 resignation, by tranquilizing her in regard to the future ; but who 
 differs more and more from the mere spectator, in proportion to 
 the extent of his knowledge and skill. 
 
 814. Hygienic treatment. The chamber and every thing con- 
 nected with it should be first attended to. In great cities a back 
 room should be preferred, or the quietest and best aired apartment 
 of the establishment. It is important that this chamber should be 
 sufficiently spacious, well lighted, and so constructed that its tem- 
 perature may be easily altered. Too great a degree of heat would 
 promote sweats, cerebral congestions, convulsions, nausea and vomit- 
 ings, to which women are already but too much predisposed during 
 the efforts of labour ; cold would not be less injurious, both by the 
 disagreeable sensations it would be sure to excite, and especially by 
 hindering the expansive movements of the fluids. 
 
 815. Odours, even the sweetest, are also not without inconve- 
 niences. During labour the nervous irritability of the woman is 
 generally of the highest grade, and the senses become excessively 
 excitable. The most valuable perfumes are sometimes borne no 
 better than the most disagreeable odours. It would not, for exam- 
 ple, be always safe to place a woman in labour in an apartment 
 filled with the emanations of muse, amber, lilies, orange flowers, or 
 roses. I have seen a lady fall down insensible and with convulsions 
 upon entering a room containing a pot of reseda. I am acquainted 
 with another who, without being pregnant, is seized with syncope 
 or lipothynia whenever a fresh rose is brought near her. 
 
 816. The regimen of the patient requires the most careful super- 
 intendence of the accoucheur ; indiscretions in respect to it may 
 give rise to the worst consequences. In regard to this point, atten- 
 tion must be paid to the probable duration of her sufferings, to her 
 constitution, and habits : if the delivery may be expected to take 
 place \vithin from four to six hours at farthest, all kinds of aliment 
 are hurtful, by loading the stomach, whose digestive power is tem- 
 porarily suspended. If, on the contrary, the labour progresses 
 slowly, she may have broths or some light kind of potage ; but she 
 ought to refuse coffee and chocolate, usually preferred by women 
 in large cities, as well as bread, fruits, vegetables and meats of every 
 description, which are best liked by country people ; coffee has too
 
 HYGIENIC TREATMENT. 339 
 
 much influence upon the innervation, and circulation, and chocolate, 
 bread, and meats are too difficult of digestion to be given without 
 some fear in these circumstances. All this, however, ought to be 
 understood only in a general way : a woman who is healthy, but 
 rather feeble than strong, whose digestive organs are in good con- 
 dition, may without inconvenience, and sometimes even with ad- 
 vantage, take a breakfast of coffee or chocolate, at the commence- 
 ment of her labour, especially if she has been long in the habit of 
 using them, just as we see stout, vigorous country women, as well 
 as robust women of the labouring classes, eat one or several cutlets 
 without being at all incommoded by them. It ought to be known 
 that these exceptions are numerous, for by proscribing food in all 
 cases indiscriminately, we just favour the evil we wish to avoid ; no 
 matter how absolute the threats of the accoucheur, it is not uncom- 
 mon for them to be disregarded, and if no bad consequences follow, 
 the woman, emboldened by impunity, no longer submits to advice, 
 relates her story to her acquaintances, and as all beings are not 
 less alike in their liability to illness than in shape, the punish- 
 ment of her indocility fails not to fall upon some of those who have 
 had the imprudence to listen to her. I was called to a woman in 
 her first confinement, in the month of March 1824: this lady's 
 mother had had thirteen children ; she had never omitted to drink a 
 bottle of wine and eat one or two cutlets during or immediately after 
 her travail ; in spite of my remonstrances the daughter must follow 
 her example, but the unfortunate lady expiated her mother's impru- 
 dences with her own life ! We must therefore allow to some what 
 we would rigorously refuse to allow to the far greater number, and 
 content us with laying before the most obstinate the dangerous risks 
 they run, and then leave them at liberty to do as they like. 
 
 817. Drinks. Where the duration of a labour does not extend 
 beyond the most ordinary limits, the woman herself is pretty often 
 the first to perceive that she ought not to eat, that food would do 
 her harm. This is not the case as to drinks ; the excess of heat 
 observed during the strong pains has the effect of drying the 
 organism, and loudly demands the introduction of fluids into the in- 
 terior. Those that may be allowed are innumerable ; the infusions of 
 mallows flowers, of marshmallow roots, of linden, of violet, of buglass, 
 and borrage ; decoctions of barley, of dandelion, liquorice, &c. 
 either pure or edulcorated with sirup of sugar, gum, honey, capil- 
 laire, cherries, or marshmallows, may be given almost without distinc- 
 tion, as well as all imaginable ptisans, provided they do not exert 
 any evident action upon the organism, and are not acid ; for it is the 
 water and not the medicaments that is here demanded by the organs.
 
 340 HYGIENIC TREATMENT. 
 
 Lemonade and acidulated drinks would suit as well or even better 
 than any other ; but the stomach does not bear them well because 
 they increase its tendency to acidity. Wine and water produces 
 the same effect ; the other ptisans often diminish the thirst very little, 
 particularly if the woman does not like the decoctions of barley, dan- 
 delion and liquorice, which are more refreshing, though they happen 
 not to suit or be agreeable to her taste ; if pure cool water is taken 
 with more pleasure and satisfaction, I see no reason why it should 
 be refused to her, taking care always to correct its crudity with a 
 few drops of orange flower water, or sirup of cherries in very small 
 quantity. In the country,- and among the lower classes, where the 
 disembodied relics of old medical doctrines ordinarily take refuge, 
 hot wine and rotiesau vin sucre are still given, with the view of sus- 
 taining her strength, and eau de carmes, and a hundred other more or 
 less heating compositions to accelerate the labour whenever it ap- 
 pears somewhat tedious ; but these incendiary measures, which in- 
 flame the already irritated organs, disturb all the functions, and some- 
 times excite fever that no means is capable of allaying, and pro- 
 duce a dreadful hemorrhage much more commonly than they do 
 any good in hastening the delivery, begin to go out of fashion, and, 
 let us at least hope, will before long cease to enjoy any favour. 
 Madame Malville, a skilful and prudent midwife, was, on the night 
 between the 20th and 21st of January 1828, called to a poor wo- 
 man, and though all the phenomena succeeded each other with the 
 greatest regularity, all she could do was insufficient to prevent the 
 administration of hot wine ; a hemorrhage came on ; new doses of 
 wine were taken ; the blood flowed still faster, and wine was again 
 given to obviate the faintness ; the child nevertheless was expelled, 
 but a frightful discharge took place immediately afterwards ; and 
 but for the coolness and firmness of the midwife, the poor creature, 
 pale and exhausted, and unable to turn her head upon the pillow 
 without falling into syncope, must have inevitably lost her life. 
 
 It is only in cases of weakness or languor, depending upon old 
 diseases, or the peculiar constitution of the woman, that it is oc- 
 casionally found useful to give a few spoonfuls of good red or white 
 wine ; but there must be no counter-indication, arising from the 
 state of the digestive organs, nor a state of excessive nervous exci- 
 tability. 
 
 818. The state of the alvinc and urinary excretions will also re- 
 quire the attention of the practitioner. The constipation, which is 
 so common during pregnancy, causes the rectum to remain inac- 
 tive at the approaches of labour ; its contents may prevent the 
 head from gliding downwards, irritate the sphincter and mucou s
 
 HYGIENIC TREATMENT. 341 
 
 membrane in the neighbourhood of the anus, occasion too violent 
 a straining, and promote the formation of hemorrhoids, which are 
 naturally of too common occurrence in parturition. Consequently, 
 provided the woman does not feel the necessity of going to the close 
 stool, an injection of a decoction of marsh mallow root or flax 
 seed, or simple tepid water should be given. 
 
 819. Provided no discharge of urine takes place before the head 
 becomes engaged in the superior strait, the emission becomes more 
 and more difficult, in consequence of the compression which the 
 bas-fond of the bladder soon suffers ; it may therefore be supposed, 
 that if the delivery is protracted, the retention of the urine may be 
 followed by a painful distension of the bladder, and that the woman, 
 who is restrained by the fear of increasing her pain, will cease to bear 
 down, except very moderately. The action of the abdominal mus- 
 cles, as it can then be transmitted to the womb only through a 
 stratum of fluid, ceases to be so efficacious, or if the woman gives 
 herself up without reserve to the whole force of the exertions she 
 is capable of making, there may be reason to fear a rupture of the 
 bladder, a terrible accident, which is almost necessarily mortal. 
 
 The woman should therefore be advised to evacuate the bladder 
 while she is still able to do so, and if the natural efforts are insuffi- 
 cient to effect the object, the catheter should be employed for that 
 purpose. We are in such cases sometimes obliged, in consequence 
 of the shortness and slight curve of the female catheter, to make 
 use of a male one ; but if we take care to push the fimdus of the 
 womb backwards with one hand, whilst we try to introduce the in- 
 strument with the other, I do not think that the flat catheter which 
 is recommended by some of the English physicians, can ever be in- 
 dispensably necessary. 
 
 820. The period of labour is, without contradiction, one in which 
 the moral state of women demands the greatest attention ; conse- 
 quently, we ought with all possible care to abstract what ever may 
 be disagreeable to them, or likely to vex them, and to respect even 
 their caprices and the oddities of their characters. 
 
 None should be permitted to remain in the room except those 
 persons who are indispensably necessary ; that is, one, or at most, 
 two friends, the nurse, and accoucheur. More than these would 
 render the air impure ; some could not bear the spectacle of suf- 
 fering without reflecting the impress of it from their countenances ; 
 others could not keep their tongues still, would always have a sup- 
 ply of stories of dreadful cases, and a thousand imprudent things 
 to say ; at one while, that Mrs such-a-one, was delivered of a 
 monster, or neighbour such-a-one, died with convulsions ; at
 
 342 HYGIENIC TREATMENT. 
 
 another, they delivered Mrs so-and-so with instruments, &c. ; 
 from tenderness or real interest or affectation, they grow quite sad, 
 and lament over the possible consequences of the lying-in ; and 
 whisper or talk in a low tone, or at least they sit gloomy and silent, 
 and merely throw a furtive glance of pity towards the woman in 
 labour, who, as she is almost always disposed to make an evil inter- 
 pretation of all that is said and done about her, every moment 
 looks for her sentence of death in remarks only half heard, in ges- 
 tures, or in the expression of sadness and compassion she observes 
 in her attendants. 
 
 82 1 . Parturition is a function that seeks the shade, that may be 
 obstructed by indiscreet looks, and which as far as possible is made 
 a mystery of by modest women. The accoucheur ought to under- 
 stand that the mother, the aunt, grandmother or sister are not always 
 considered as the most agreeable attendants in this painful moment. 
 As a discreet as well as a circumspect and prudent interpreter, he 
 ought to dismiss without distinction every one whose presence is not 
 desired by the woman. How careful should he be himself! impas- 
 sible and firm, of an imperturbable coolness, he must, notwithstand- 
 ing, know how to compassionate the distress of which he is a wit- 
 ness, encourage, console, amuse ; inspire her with boundless confi- 
 dence and great familiarity, by the affability of his conduct, by rea- 
 sonings that every body can understand, by his patience, the amenity 
 of his temper and the gravity of his manners ; he should be able to 
 procure obedience without constraint, and by all the means which 
 are suggested by moral philosophy, his own understanding and 
 education, incessantly combat the discouragement and dread of all 
 sorts, and the sadness and alarms to which the most resolute as well 
 as the most timid women sometimes give way. 
 
 822. The dress of a woman in labour was formerly a matter of 
 great consequence ; there were gowns, jackets and head dresses 
 devoted to this purpose alone ; every country, each province, and 
 even each family, had its peculiar fashion ; a woman of good family 
 would think she could not lie-in decently without her gown and 
 other lying-in clothes ; at present these old customs are no longer 
 to be found, except in a few countries or families, where, out 
 of a mistaken feeling of respect, people obstinately resolve not to 
 live differently from the mode adopted by their ancestors. To this 
 the accoucheur has nothing to say, provided the form of the dress 
 and its arrangement arc not of a nature to interfere with the free 
 exercise of any of the functions, provided there be no constriction 
 of the abdomen, the breast or the neck, that the motions of the 
 limbs arc led free, that the materials are light, neither too hot nor
 
 HYGIENIC TREATMENT. 343 
 
 cold, and that the circulation does not suffer from their employ- 
 ment. 
 
 823. The bed for child-birth, which is also called lying-in bed, 
 bed of labour, bed of pain, bed of misery, little bed, &c. is also a 
 matter of fashion or custom, which has singularly varied as to its 
 form, according to times, places and whims. There are some wo- 
 men who will not make use of them, and who are delivered stand- 
 ing up, the elbows resting on a mantel piece, the back of a chair, 
 a table, a bureau, or some other piece of furniture, or even leaning 
 on the shoulder of some friend. Some women place themselves on 
 their knees upon the floor ; others place themselves on their hus- 
 band's knees, with their legs much bent and elevated. The ancients 
 made use of a peculiar kind of seat or elbow chair, a lying-in-chair, 
 having supports for the arms, a movable back-piece, with notches 
 in a piece to keep it at different degrees of elevation, a support for 
 the feet, and a pierced seat ; so as to be converted at will, either 
 into a real bed, or an arm chair. These chairs, still made use of in 
 Germany and Switzerland, and very good drawings of which may 
 be seen in the works of Stein and M. Hermann, are no longer 
 employed in France, notwithstanding M. Rouget has lately attempt- 
 ed to revive them by presenting to the Academy, and to the admin- 
 istration of the hospitals of Paris, a new lying-in bed of his own 
 invention. They are not wholly destitute of advantages, but as they 
 can without inconveniene be replaced any where by other means 
 more common, and always at hand, no person feels the necessity of 
 resorting to them ; and it would be too ridiculous to see a surgeon, 
 as in former times, always followed by his lying-in bed, when pro- 
 ceeding to visit a woman in labour. 
 
 824. The best bed is one with a sacking-bottom, tight, of a middling 
 size, and so placed that the upper end may rest against one of the walls 
 of the chamber, and leave room to pass conveniently all round the 
 rest of the bed ; one mattress is laid on this sacking-bottom, and a 
 second one, bent double in the middle, is arranged upon it in such a 
 way that the edge of one of its extremities may support the buttocks, 
 while its folded portion supports the back and head; a piece of cloth, 
 some oil cloth or some cushions, pillows and bolsters, to supply 
 an inclined plane for the head and breast, complete the preparations. 
 
 We may also be content with a cushion, to be slid under the 
 middle of the first mattrass, so as to raise the pelvis up and leave 
 the perineum naked ; the head of the bed is then formed with one or 
 two common chairs, turned downwards, with the legs against the 
 wall, and the upper edge of their backs towards the woman's breech ;
 
 344 HYGIENIC TREATMENT. 
 
 the rest of the arrangement is completed as before, and the second 
 mattress is not wanted. 
 
 A single mattress, without any cushion, will also answer ; it is to 
 be doubled ; the head of it is to be raised with chairs ; all that 
 portion of the sacking-bottom that is to be in front of the pelvis is 
 left uncovered, and by means of some cloths to receive the discharges 
 upon, we may avoid soiling any part of the bed clothes. Some per- 
 sons add a stick, fixed cross-wise to rest the feet against during the 
 expulsive pains ; but this fixture is more troublesome than useful, the 
 hands of an experienced nurse answer much better, for they can 
 follow the different degrees of flexion and extension of the limbs. 
 In the country, a bed is often made by placing six or eight chairs 
 face to face and laying a mattress upon them. 
 
 Indeed, a strong and well formed woman may be delivered in any 
 posture, on a chair, on the floor, a bundle of straw, on foot, and on 
 all the kinds of beds that have been proposed ; so that it is only in the 
 cases where nothing interferes with the accoucheur's prescribing 
 just what he thinks best, that he ought to attach some value to the 
 composition of the lying-in bed ; further, the only essential matter 
 is, that the woman should be as comfortable as possible, that she be 
 not incommoded, neither during the pains nor the intervals between 
 them, and that the perineum may have room to dilate. 
 
 825. There is not, neither can there be any fixed period at which 
 all women should place themselves on the lying-in bed : some women 
 feel the necessity of going on to the bed as soon as their pains get 
 to be pretty strong ; others not until a much later period, and most 
 women may be guided in this matter by what agrees best with their 
 own particular feelings ; as long as they keep on the bed, or on foot 
 either, because they are more comfortable in either case respec- 
 tively, and not for the sake of gratifying some preconceived notion, 
 they ought to be indulged ; it would be absurd to compel them to 
 remain on the bed from the beginning to the end of a labour, while 
 the only means of alleviating their distress consists in moving about 
 from place to place ; on the other hand, by compelling them to keep 
 up till the close of the labour, their courage and strength are ex- 
 hausted to no purpose, they are exposed to the danger of bringing 
 on flooding, to the prolapsion, and overturning of the womb, lace- 
 ration of the perineum, and to the too prompt and precipitate escape 
 of tin- foetus. 
 
 Therefore, in regular labours, where there is no special indication 
 to be fulfilled, it is useless for the woman to lie down previously to 
 the rupture of the membranes, unless it be for the purpose of resting
 
 MANAGEMENT OF LABOUR. 345 
 
 when she feels fatigued. When, on the contrary, the dilatation of 
 the os uteri is complete, and especially when the head has descended 
 into the excavation, it is better, but not always indispensably neces- 
 sary, for her to lie down on the bed in readiness for it. Where the 
 pains are weak and far apart, and where the membranes give way 
 early, or the head remains very high above the superior strait, and 
 the os uteri, although soft and very dilatable, opens with diffi- 
 culty, she ought to keep up and move about as long as her strength 
 will permit. Again, she should be persuaded to lie down early if 
 her pelvis be a very large one, and the membranes do not give way, 
 though the os uteri be dilated, when the labour progresses too 
 rapidly, and when there is a threatening prospect of hemorrhage, 
 or when there is an obliquity of the womb. Women affected with 
 curvature of the spine, asthma, hydrothorax, ascites, or some other 
 abnormal disposition, are sometimes constrained not to lie down at 
 all, and are obliged to be delivered while standing up, or seated, or 
 on their knees, &c., while there are others who could not leave their 
 beds before the termination of the labour without difficulty. But 
 these are cases of exceptions which do not belong to the class of 
 eutocia. 
 
 826. When the woman is on the bed, she should, during the 
 pains, be on her back with the legs and thighs half flexed, and the 
 feet resting on the mattress or sacking. This posture, which is so 
 natural that women assume it of their own accord, and if they have 
 changed it for a moment, always return to it as soon as the pain re- 
 turns, is particularly necessary where the womb is strongly inclined 
 forwards. But in the intervals of the contractions it would be as 
 ridiculous as it would be cruel to exact any determinate attitude ; 
 the woman ought then to be left free to choose a position that is 
 most agreeable to herself, on either side ; a being, when suffering 
 unavoidable pain, at least hopes, by changing its situation and trying 
 various positions, for some alleviation of its distress ; to deprive it 
 of such a resource, would be a real act of barbarity. Moreover, 
 the attitude on the back is very rarely necessary except in cases of 
 very decided obliquity. Most of the English and American women 
 lie on the left side, with the breech near the right edge of their 
 common bed, which is properly prepared, the legs and thighs flexed, 
 the knees separated by pillows or cushions, and notwithstanding, we 
 do not find that childbirth is much more dangerous in England than 
 in France. However, it is evident that such an attitude must be 
 very uncomfortable and unfavourable to the muscular contractions 
 that occur during the pains. The British accoucheurs who recom- 
 mend it, think it admits of their supporting the perineum more ef- 
 2T
 
 346 EUTOCIA. 
 
 fectually, of employing the touch more freely, and, which I cannot 
 understand r of operating more readily with the forceps, the hand, 
 or any instrument whatever ; but when we remember to what extent 
 the modesty of the English ladies is carried, and reflect on their ex- 
 treme delicacy, and the reserved character of their manners and 
 customs, we are rather led to think that the lateral position, which 
 prevents them from looking the accoucheur in the face, has been 
 chosen to gratify and save them from unpleasant feelings. 
 
 827. The accoucheur places himself to the right of the bed ; he 
 is there most commodiously situated to touch, to follow the progress 
 of the labour, and support the perineum ; all of which may be done 
 under the bed clothes, for it is with the finger or hand, and not with 
 the eye, that he must here act and ascertain the state of the parts. 
 As the will and the courage of the patient exert a great influence on 
 the progress of parturition, it imports him to know how to direct 
 their powers. We daily meet, in practice, with women who bear 
 down, and endeavour to make the most of their pains, as soon as 
 they become somewhat strong ; the old women, the midwife, and 
 sometimes the accoucheur himself, encourage them to act in this 
 way, by persuading them that they will be the sooner delivered. 
 Such conduct is extremely blameable, and can only be the fruit of 
 ignorance or want of reflection. Where the os uteri is not dilated, 
 the membranes unbroken, or at least, where the head is not as yet 
 engaged in the superior strait, efforts to hasten the delivery only 
 serve to exhaust the woman to no purpose whatever ; until the end 
 of the first stage, the action of the muscles is not solicited, the womb 
 does not demand their aid, and they can be of no use. 
 
 But as soon as the foetus penetrates into the excavation, the os 
 uteri being dilated, and the membranes ruptured, and the sense of 
 weight about the fundament, tenesmus, and strainings are felt, they 
 occasion a desire to bear down, and compel the muscular contrac- 
 tions to come on stronger and stronger in aid of the womb, in pro- 
 portion as the child is nearer the moment of expulsion. The womb 
 now compels the efforts to take place, independently of the woman's 
 will ; the thing is, to know how to make the best use of them, and 
 there are many women who do not know how to do it who do not 
 know how to deliver themselves ; who, with the expense of a con- 
 siderable degree of power, cause the labour to advance but very 
 little ; the accoucheur should teach them their apprenticeship, if I may 
 use such nn expression, should teach them that when the pains arc 
 regular, they should not employ their voluntary efforts until the con- 
 traction is fairly begun, or until the muscular action is positively 
 solicited ; then, by pressing the pelvis, feet, and hands upon the bed
 
 MANAGEMENT OF LABOUR. 347 
 
 or upon the persons stationed to support them, they should bear down 
 with all their might, as if at the stool ; as soon as the womb itself 
 ceases to act, all effort ought to be suspended, and the woman 
 should be strictly directed to rest, and be as still as possible, never 
 losing sight of the fact, that the muscles are not intended to force 
 the fetus downwards, but only to aid an.d support the contractions 
 of the uterus. 
 
 828. The pains are sometimes so acute, so intolerable, when the 
 head reaches the inferior strait, that instead of bearing strongly on 
 the pelvis, and pushing downwards, the woman, in spite of her- 
 self, draws it upwards as if to avoid the pain. In this she is 
 doubly disappointed ; in the first place, because nothing can save 
 her from the distress she endures, and because she in this way 
 voluntarily protracts the period of her deliverance; and then, far 
 from being an evil, violent contractions are what she should above 
 all things desire, for upon them depends the prompt termination of 
 the labour. The same thing often takes place in women who are 
 too pusillanimous, too nervous or timid ; they are restrained by the 
 fear of making the pains too sharp ; they are restless, and toss about 
 from place to place, and rather than assist and make the most of 
 their pains, do all they can to hinder or suspend them. 
 
 829. Some of them fall into the opposite kind of excesses, give 
 themselves up to such immoderate efforts, that unless care were 
 taken, very serious consequences might ensue, such as a great con- 
 gestion of the brain, and even an apoplexy, the sudden swelling of 
 the thyroid body, and the rupture of the large veins of the throat, 
 the formation of hernias of all sorts, temporary paralysis of the lower 
 limbs, &c. The dangers to which they expose themselves by 
 inconsiderately bearing down in this manner, ought to be painted 
 in strong colours and exhibited to their view, and all the means of 
 persuasion and controul should be skilfully employed in order to 
 oblige them not to give way so completely to their feelings. If 
 reason, entreaty and gentleness do not succeed, a firm and even 
 menacing tone, properly adapted, sometimes becomes necessary. 
 There are a thousand means to be made use of to quiet them, to 
 inspire them with dread, and restrain them. Thus, Baudelocque, 
 after having in vain exhausted all his resources, thought of bringing 
 two lawyers dressed in their robes into the chamber of a woman in 
 labour, by which she was so intimidated that she thenceforth became 
 reasonable, and submitted to the counsels of her accoucheur. 
 
 830. The touch is performed at different periods of labour, for 
 the purpose of ascertaining the position of the foetus, the degree of 
 dilatation of the neck, and to learn how far the head has descended.
 
 m
 
 - - -
 
 348 EUTOCIA. 
 
 Rigorously speaking, it would be sufficient to touch three times dur- 
 ing a labour : once at the commencement, to learn certainly whether 
 the womb is contracting ; a second time, just as the waters break, 
 to make ourselves positively sure of the position ; and a third, when 
 the pains and efforts have acquired a certain degree of strength, in 
 order to see whether the . parts engage properly in the excavation ; 
 but, generally speaking, unless the vulva and vagina are very sensible 
 and irritable, we may repeat this operation much more frequently, 
 and that without any ill effect. Provided the touch were never 
 practised but for the purpose of learning the progress of labour, it 
 would rarely be followed by any other inconvenience than that of 
 annoying the woman and wounding her scruples, how often soever it 
 might be repeated, always excepting the cases where it is made an 
 object of study, as in our public halls, where a very great number of 
 students touch the same woman in succession. But there are ac- 
 coucheurs who resort to it with very different motives, who, furnished 
 with an apron, the coat off and shirt sleeves tucked up, seat them- 
 selves betwixt the woman's knees, and perform what they call her 
 lesser labour, and forcibly dilate the vulva and os uteri, under the 
 pretext of accelerating the progress of the case. The poor crea- 
 tures who submit to such procedures, and are even the first to ask 
 for them, do not know to what dangers they are thereby exposed. 
 We might pity those who put them in practice through ignorance or 
 temerity, but what ought we to think of those who make use of them 
 as a system, in order to appear more skilful and important in the 
 eyes of the vulgar? 
 
 831. If it be sometimes useful or even permissible to introduce 
 one or more fingers into the vagina, so as to aid in the dilatation of 
 the parts, it is only in cases where rigidity or an irritated condition 
 of some point in the vulvo-uterine canal indicates that it would be 
 well to introduce some mucilage or soothing ointment, such as 
 Galen's cerate, or the cucumber ointment, and not oil, as recom- 
 mended by Consell. When the head, in engaging in the strait, and 
 even in passing through the excavation, pushes the cervix before it 
 like a cap, there may be some use in supporting the circle with the 
 end of one or more fingers during the pain ; but if it is not always 
 dangerous, it is at least always useless to try to overcome its resis- 
 tance by artificial means. 
 
 832. To support the perineum. When we reflect on the form of 
 the pelvis and the direction of its axes, it is easy to perceive that 
 the perineum, which is a continuation of the sacro-coccygeal wall of 
 the pelvis, but much less solid, must be violently distended, and run 
 the greatest risk of being torn, as the head emerges from the lower
 
 MANAGEMENT OF LABOUR. 349 
 
 strait. Hence all accoucheurs have recommended some mode of 
 preventing this accident from taking place. Some have supposed, 
 with Mesnard, that it is only necessary to push the coccyx back- 
 wards, or to place two fingers between the head and perineum when 
 the occiput reaches the vulva ; others, that the object may be better 
 attained with the assistance of Roonhuysen's lever, or a wide piece 
 of whalebone ; lastly, some practitioners are content with the appli- 
 cation of the hand to the exterior. But inasmuch as, in spite of all 
 these precautions, the perineum sometimes tears, certain modern 
 surgeons have concluded that it is wholly useless to support it in any 
 way. If I can give credence to several young German and English 
 physicians, the accoucheur of the public establishment at Gottingen, 
 and the one who in 1824 directed the lying-in hospital of Dublin, 
 are of this opinion, and I am assured they even go so far as to think that 
 the precautions recommended on this head are all dangerous. As 
 success here depends less upon the means employed than upon the 
 hand that employs them, it is likely that a long time must elapse 
 before every body can be of one accord as to the value of those that 
 have been proposed. . 
 
 833. However this may be, the conduct recommended by reason 
 and experience is the following : the hand, either naked, or what is 
 better, wrapped in a linen cloth, is applied transversely, so that its 
 cubital edge may correspond to the point of the coccyx, and that its 
 radial edge may be below the anterior commissure of the perineum, 
 the ends of the fingers may lodge betwixt the labia and the thigh, or 
 extend on to the thigh, while the finger and thumb being separated, 
 are placed between the other labium and opposite thigh. Tn this 
 way we convert the inclined plane that the head has to pass over in 
 emerging from the soft parts, into a firm wall ; the hand is placed 
 there as if to continue the concave surface of the sacrum and coccyx, 
 and as to compel the head to adapt itself to the axis of the vulva ; the 
 power that we employ must therefore act from behind forwards, from 
 the coccyx towards the pudendum, and not in the opposite direction 
 nor laterally. We must force the occiput to turn upwards towards 
 the pubis, and not hinder it from descending ; besides, it is only at 
 the moment when the head begins to distend the vulva with a cer- 
 tain degree of force, that it imports us to act ; previously to this 
 period the operation would be without object, and the accoucheur 
 would prove merely that he is ignorant of its mechanism. By trying 
 to bend the fingers a little, as has been recommended, for the pur- 
 pose of bringing the soft parts towards the median line, the hand is 
 rendered too concave, and does not support the head sufficiently, 
 and we thus promote exactly what we wish to avoid ; by placing the
 
 350 EUTOCIA. 
 
 hand, as others recommend, in a state of supination, vertically, with 
 the fingers towards the coccyx, and the wrist towards the vulva, we 
 again miss the object, for our efforts are then directed with more 
 facility in front than behind, while the contrary is what we wish to 
 do. Finally, to prevent, as certainly as possible, any laceration 
 from happening, we may, after the manner of M. Flamant, take 
 hold of the skin on the buttocks or posterior part of the pelvis 
 with both hands, and draw it forwards as much as possible ; it is 
 proper, it is even important, as soon as the parietal protuberances 
 have passed the level of the tuberosities of the ischia, to engage 
 the woman to moderate her efforts, instead of exciting her to bear 
 down more, and more as is too commonly done. This is the moment 
 that the parts, being surprised or astonished, are lacerated, if the 
 head, pressed too rapidly forwards, does not give them time to yield 
 and mould themselves by it. Therefore, the slower the progress 
 of the head, the greater will be the chance of preserving the peri- 
 neum uninjured. . *. 
 
 I am far from saying that laceration of the perineum is in all cases 
 a serious accident ; on the contrary, I believe it to be very rarely 
 dangerous ; but the accoucheur ought nevertheless to do all he can 
 to prevent it from occurring ; and I cannot too strongly condemn the 
 negligence, in respect to it, of which most of them are culpable. 
 If it be not in our power to prevent the woman from suffering, it is 
 at least a duty to preserve the natural form of her organs as far as 
 possible. The wound will heal up, no doubt ; but the dimensions 
 of the external orifice of the vagina remain too large, and we cannot 
 divine what distress may be indirectly' produced by this accident, 
 though in appearance a slight one. 
 
 834. To support the head of thefatus. As soon as the head has 
 passed out of the vulva, it should be supported by both hands ; the 
 fingers being separated, are applied under the occiput, the ear, and 
 lower jaw on each side, being careful not to prevent the act of res- 
 titution from taking place. Rigorously speaking, we might dis- 
 pense with any tractive effort ; for the remainder of the foetus is 
 often expelled with the same pain that delivers the head ; or else 
 another pain soon comes on to complete the delivery ; however, as 
 there is no advantage to be derived from retarding the termination 
 of the labour, and the woman has nothing so much at heart as to 
 be promptly delivered, it is best to follow up the impulsion given by 
 the womb, and whilst it is still contracting, to draw very prudently 
 and moderately upon the head or armpits, in the axis of the inferior 
 strait. 
 
 conduct I have just above indicated is particularly applicable
 
 MANAGEMENT OF LABOUR. 351 
 
 in the three true varieties of the occipito-anterior position. It may, 
 and indeed ought to be slightly modified in most of the other pre- 
 sentations. 
 
 835. Occipito-posterior position. When the occiput looks to- 
 wards the back part of the pelvis, delivery being in general more 
 difficult, it is natural that we should profit by its tendency to turn for- 
 wards, in order that we may by degrees convert it into an anterior 
 position, in which we may sometimes succeed by imitating the na- 
 tural processes. When the head sinks into the excavation almost 
 immediately after the evacuation of the waters, we endeavour to 
 make it deviate to the right or left, in the intervals between the con- 
 tractions, by passing two or three fingers up in front of the sacrum. 
 During the pain, we prevent it from returning to its original posi- 
 tion, by leaving the fingers, with which we displaced it, betwixt it 
 and the median line ; these attempts are repeated as often as they 
 may be deemed necessary, and if we cannot always succeed in con- 
 verting the fourth or fifth positions of Baudelocque into the first or 
 second, we are at least sure that we occasion the mother and child 
 both, no additional hazard where the maneuvre is properly execut- 
 ed. The perineum is in more danger of being lacerated in this 
 than any other position ; in order to support it efficiently, we should 
 take care not to incline the hand too much forwards, for the point 
 of the head would fall almost perpendicularly upon it, and would 
 rather turn backwards towards the anus than glide in the direction 
 of the vulva. This is the situation in which M. Flamant's precept 
 is especially applicable. 
 
 836. Face positions. Although the face positions do not render 
 delivery much more difficult than those of the vertex, yet, as they 
 are less exactly according to nature, it is always prudent, where it 
 appears easy to do so, to change them into positions of the vertex. 
 It can no longer be thought of after the head has once reached the 
 excavation ; it should be attempted while it is still movable at the 
 superior strait, and that in two different ways : we may either try, 
 with two fingers, to push the chin towards the breast by acting on 
 the forehead, or we may endeavour to hook the occiput, to draw it 
 down and produce the same effect. In both cases we leave the 
 fingers in place until a contraction comes on, so as to transfer to 
 the occipital branch of the lever represented by the head, the power 
 that previously acted upon the facial or anterior branch of it. 
 It would be particularly important to effect this conversion in the 
 mento-sacral position, if it should ever be met with. Further, 
 where the face emerges first, it is not so easy to support the peri- 
 neum as it is in the vertex positions ; but the rupture of the peri-
 
 352 EUTOCIA. 
 
 neum is the less to be feared, because the front of the neck, and 
 not the bregma, presses against the lower edge of the symphysis, 
 while the upper oval of the head passes along the perineum to reach 
 the vulva. The hand ought therefore to press but moderately, and 
 not at all until the forehead is without ; otherwise we might in- 
 crease the danger to which the foatus is exposed, or at least inter- 
 fere with the termination of the labour. 
 
 837. Inclined positions of the head. When the whole forehead, 
 or one side of it, the anterior fontanel, one of the parietal protuber- 
 ances, the upper part of the nucha, the chin, or one of the cheeks 
 is substituted for the frank vertex or face positions, they do not 
 always prevent the delivery from being spontaneous, because the 
 woman's efforts generally succeed in causing the occiput or face to 
 descend. Nevertheless, as these intermediate or bastard positions 
 may to a certain extent embarrass the progress of the pains, or of the 
 labour in general, we ought, as soon as they are discovered, to attempt 
 to change them to the regular positions to which they correspond. 
 As long as the head continues at the superior strait, and the womb is 
 not too strongly contracted upon the body of the child, we might 
 hope, by introducing a couple of fingers behind, in front, or on the 
 sides of the occiput, to bring it back to the centre of the strait, or 
 at least, if we could do no better, force it to enter fairly with the 
 face in the opening. 
 
 838. Positions of the feet. In maintaining that footling labours 
 commonly terminate without assistance, I did not mean to have it 
 inferred that we must never touch the foetus in any way until, it is 
 completely expelled ; but merely, that it is unnecessary, and even 
 dangerous, to exert any tractive force upon it. 
 
 As soon as the legs appear, they should be supported, after wrap- 
 ping them in a napkin ; the same is to be done with the hips, the 
 arms, the breast and shoulders ; when only the head remains in the 
 excavation, we place a couple of fingers on the chin, in the mouth, 
 or what is still better, on the sides of the nose ; two or three fingers 
 of the other hand are slid under the symphysis pubis, so as to sup- 
 port the occiput, and as soon as the least contraction cqmes on, we 
 draw the whole downwards in the direction of the axes of the in- 
 ferior strait and vulva, as if we were trying to turn the child's back 
 up over the mons veneris, and upon the hypogastrium of the 
 mother. 
 
 839. The head now having nothing to pass through except the 
 perinea] strait, is beyond the influence of the uterus, and may be 
 Mr.icted without difficulty ; but while ever it has not traversed the 
 uterine orilice, or the abdominal opening of the pelvis, the least at-
 
 MANAGEMENT OF LABOUR. 353 
 
 tempt to accelerate its escape could tend only to produce a case of 
 real dystocia. As to the perineum, it is easily managed, since it de- 
 pends upon the accoucheur to pull the head with more or less force, 
 or to incline it more or less forwards, as it passes through the vulva. 
 
 840. Positions of the knees. The knees present very few pecu- 
 liar indications ; if they present in a regular position, they should be 
 allowed to come down of themselves, and when they reach the vulva, 
 all we have to do is to assist in disengaging the legs. If one of them 
 assumes a bad direction, lodges against some part of the pelvis, or 
 is arrested by the cervix or some fold in the vagina, it is commonly 
 disengaged without difficulty, and brought alongside of the other 
 one. For the remainder we are to act as in feet presentations, 
 taking care not to pull unnecessarily. 
 
 841. Positions of the breech. When the buttocks descend first, 
 and the feet tend to engage at the same time, it is sometimes well 
 to push the latter back, and keep them somewhat raised during 
 several pains ; if not, there is nothing to be done until they get to 
 the bottom of the excavation. It is in this state improper to pull at 
 the breech except during the contractions of the womb ; if, how- 
 ever, its size is very great, and there should be some difficulty in its 
 passing through the vulva, the finger hooked into the groin that is 
 towards the sacrum may be of some service by enabling us to give 
 timely assistance to the woman's efforts. The hips are scarcely 
 delivered before the constriction they had experienced is transferred 
 to the child's belly. It is important then to pull on the thighs and 
 legs, which should be extended in order to diminish this dangerous 
 compression ; the management of the rest of the labour is in all 
 respects similar to that required where the feet or knees present. 
 As the buttocks are escaping from the inferior strait, they sometimes 
 distend the perineum as much as the head does when it comes first ; 
 but as they are much softer, and the flexibility of the trunk admits 
 of their accommodating themselves much more easily to the direc- 
 tion of the axes as well as to the forms of the spaces they are ob- 
 liged to traverse, they much more rarely occasion a laceration ; so 
 that in such cases it is not always indispensably necessary to support 
 the perineum. 
 
 842. In oblique positions of the breech we must act as in the in- 
 clined positions of the head ; we must endeavour to restore them to 
 a correct state : if the posterior surface of the coccyx and point 
 of the sacrum are in the centre, the woman should be directed to 
 lie down early ; she should be made to lie as much as possible on 
 the back, while the hand applied to the hypogastrium pushes the 
 womb backwards and upwards ; if this precaution should not suffice, 
 
 2U
 
 354 EUTOCIA. 
 
 we might, with a couple of fingers of the other hand, hook the ischia 
 and draw them down into the strait. If one of the buttocks engages 
 alone, with or without the corresponding hip, it should be raised up 
 during the absence of the pains, or we should try to reach it directly, 
 by passing some of the fingers up along its external surface. 
 
 Where, instead of one buttock or the coccyx, we meet with the 
 genital organs or fore part of the legs in the centre of the dilated 
 os uteri, it is generally easy to bring the legs down in place of the 
 breech ; and this ought to be done whenever both the breech and 
 feet present at the same time, for it would evidently be too difficult 
 to compel the former to engage alone. 
 
 843. Obliquities. Anterior inclination of the womb may be said 
 to be the only one that demands attention during labour. When it 
 does exist the foetus always engages with difficulty ; the abdominal 
 muscles being too much curved, contract with but little energy ; if, 
 nevertheless, the child's head engages in the excavation, the back 
 part of the cervix rises, while its fore part, which becomes thin and 
 distended, covers the head like a cap, and descends beneath the strait. 
 
 This state of things, moreover, cannot fail to embarrass young 
 beginners. It may lead them to suppose that the dilatation is com- 
 plete in some cases where it has scarcely begun ; finding no os uteri, 
 they most generally begin to dream about anomalies, or else know 
 not what to think about it. Here is what one of my young brethren, 
 who had been practising in the capital with distinction for three 
 years, wrote to me on the 3d of January 1827. " I have been all 
 night with Madame de S. A., the labour appears to go on regu- 
 larly, but I cannot find the os uteri ; I have passed the finger up 
 towards the promontory, then towards the iliac fosg, and also up 
 behind the pubis ; at all these places I have reached the cul de sac 
 formed by the upper extremity of the vagina, but I have found no 
 cervix ; what must I do, what does it mean ?" The truth was that 
 the orifice had gone so far upwards and backwards behind the 
 tumour that projected into the excavation, it was necessary, in order 
 to reach it, to crook the finger quite forwards. 
 
 Whenever I have met with this peculiarity, which, I repeat it, is 
 very common, the labour has gone on very slowly until the end of 
 the first stage, but I have always found it afterwards to progress 
 with much energy, and to require no particular management. 
 
 844. Tedious labour In former times, every physician and every 
 midwife had an oxcytocic* remedy, some sure means of bringing 
 labour to a prompt termination ; upon this head all the arcana and 
 
 * From ovc quick, and i-cxot child-birth.
 
 MANAGEMENT OF LABOUR. 355 
 
 amulets have had their share of puffs. Some put a bit of precious 
 stone, as jasper, topaz, emerald, &c. in a small bag, which was 
 suspended from the woman's neck ; others advised her to hold a 
 piece of loadstone in the right hand ; sometimes an eagle's plume 
 was fastened to the thigh, or the first feather of the right wing o 
 that bird was secured to the sole of her corresponding foot ; some 
 times again she was to have the belly rubbed with viper's fat and 
 snake's gall, or the navel was covered with a very hot snake or rabbit 
 skin ; finally, some saffron placed on the hip, some cabalistic sentence 
 on the forehead the breast or pit of the stomach, and a thousand 
 other absurdities of the same kind, were also frequently made use of. 
 
 As M. Desormeaux remarks, it would be almost puerile to make 
 the least mention of such nonsense, provided we were not obliged, 
 from a human respect, to reply to certain folks who hold them to 
 be great secrets, and in certain cases to show, like Van Swieten, 
 some condescension for the weaknesses of females. These reme- 
 dies at least will do no mischief, and may perhaps prevent the ad- 
 ministration of some less inoffensive remedy. 
 
 The aromatic waters, as balm and mint waters, the tinctures of 
 canella, of cloves, all sorts of compounds, and all sorts of alcoholic 
 elixirs have each had their day, and many women who used them have 
 fallen victims to their imprudence. Purgatives and emetics have 
 had great vogue even among medical men, and are not yet wholly 
 forgotten by the vulgar. Preparations of manna, or of senna, to 
 which, by way of corrective, was added lemon or orange juice, were 
 very much used in the time of Mauriceau ; but, without denying 
 that such preparations may possess the faculty of restoring the pains 
 in some particular cases, and without fearing their action on the 
 alimentary canal so much as some physicians of our day do, it is, 
 notwithstanding, manifest, that, if they ever may become dangerous, 
 it is chiefly to women in labour that they are likely to be so. 
 
 845. Purgative articles, given in the form of clysters, are not 
 attended with the same disadvantages, and, in fact, they appear to 
 have been employed in this way with some advantage; amongst 
 others, the decoction of senna, whose operation is generally accom- 
 panied with smart colic, is perhaps not to be wholly neglected. It 
 is at least certain that I have, at the Maternite of Tours, seen it im- 
 press upon the contractions an energy that could scarcely be attri- 
 buted to mere chance. Bleeding, baths, antispasmodics, opiates, 
 borax, and many other articles, are in the opinion of some persons 
 possessed of very decided oxytocic properties ; but in order not to 
 be misled in this manner, we should be careful not to confound 
 what depends on time, circumstances, or chance, with the real
 
 356 EUTOCIA. 
 
 effects of the means employed, and never lose sight of the possi- 
 bility of those singular coincidences which often put to flight the 
 most skilful combinations. 
 
 846. Labour sometimes progresses with extreme slowness, and 
 may last from two to five or even eight days, without there being 
 any thing particular to be done, and that in two opposite cases : 
 1. In young nervous women at their first lying-in, and who are of 
 a rigid and excitable fibre ; 2. In those of a delicate, feeble and 
 lymphatic constitution, or where the os tineas is very soft for some 
 time before the full term. In the former, the labour can with diffi- 
 culty set in fairly, because the orifice is too resisting, or of too great 
 a degree of sensibility ; here a small bleeding, if warranted by the 
 state of the pulse, and the strength and habitual coloration of the 
 patient, a tepid bath, unctions with belladonna ointment, and slightly 
 narcotic and soothing drinks may sometimes be employed with advan- 
 tage; in the latter, it seems as if the womb were in a state of uncer- 
 tainty, as if it were assaying its strength, as if under the necessity of 
 preparing in silence before entering openly into action ; I have seen 
 some remain two three or four days in this state ; but when the con- 
 tractions once acquire a certain degree of energy, the labour termi- 
 nates in general with an extreme rapidity, which singularly contrasts 
 with its former slowness ; indeed, it is to this circumstance that a crowd 
 of remedies are indebted for the vogue they enjoy. Nature, here, 
 has no need of assistance, this slowness is necessary for her, and it 
 ought not to be disturbed in any way ; we are merely permitted to 
 support the strength by giving some analeptic aliments, or a few 
 spoonfuls of wine, repeated from time to time, and always with the 
 greatest reserve. 
 
 847. On other occasions, the pains, after having been regular 
 and pretty smart, begin to return only at long intervals ; sometimes 
 this is owing to the general weakness of the woman or the fatigue 
 of the womb ; sometimes, on the contrary, it must be referred to ill 
 directed efforts of the womb, or to its not possessing a great share 
 of excitability. In the former case, rest, and some broth, if there be 
 any appetite, a little wine if there be not too much thirst and heat, 
 and resignation, are all that we can recommend. In the latter, we 
 also recommend rest if the woman is much fatigued, but otherwise 
 she should be advised to walk about ; for it cannot be denied that 
 walking about and a vertical posture positively accelerate the pro- 
 gress of labour. 
 
 Time and patience are here the great remedies ; but this is a sad 
 resource for one who is in a state of suffering, and the accoucheur 
 must expect the most multiplied solicitations, and all sorts of proposals 
 and entreaties from all the by-standera. As long as they are satis-
 
 MANAGEMENT OF LABOUR. 357 
 
 fied with amulets and inert topical applications, and do not insist on 
 giving active substances internally, they should be allowed to say 
 and do as they like ; it is one way to amuse the women ; while they 
 see us busy in regard to their sufferings, they bear them more cou- 
 rageously. Should the practitioner be compelled, for the sake of 
 quiet, to prescribe some remedy, he should follow the advice of Mau- 
 riceau, and, in the first place, make a bargain with the patient, obtain 
 from her as much time as possible, and promise her that, if at such 
 an hour the pains do not return, he will then cause them to begin 
 again ; then, when the hour agreed upon arrives, if the pains continue 
 to be still weak, take care that the article to be made use of cannot 
 be procured except from some considerable distance ; that the per- 
 son sent to bring it be a dull messenger, who will be apt to lose his 
 way ; let it be some sort of wood, or bark, or root, or at least some 
 hard substance. When the remedy at length arrives, it must be 
 pulverised or rasped for a long time ; after which it should be boiled 
 for several hours. In the next place the liquid must have time to 
 cool ; it is next passed through a piece of linen, something more is 
 to be added, and then it should be boiled over again ; at last it is 
 given to the patient, and as three or four hours are necessary for it 
 to produce its effect, it is easy to see that we may in this way gain 
 more than half a day, and that within that interval the pains will 
 rarely fail to resume their natural course. 
 
 848. In certain cases the labour becomes slow, because the con- 
 tractions are difficult, extremely painful, unequal or partial. The 
 first mentioned case ordinarily depends upon plethora, either local 
 or general, which is the cause why the uterine fibres, engorged with 
 blood, and as it were stupified, cannot contract with suitable energy ; 
 women who are strong, robust, sanguine, and very muscular, are 
 most liable to this state of things, which is known by a feeling of 
 general uneasiness, weight and distress felt in the hypogastrium and 
 pelvis, a highly coloured skin, and especially by the pulse, which is 
 either strong and large, or contracted, small and hard ; in this case, 
 bleeding from the arm, by means of the depletion it occasions, fre- 
 quently succeeds in restoring to the pains all necessary activity. 
 
 The second case may be met with alone, or concurrently with 
 the former: and as its cause is an exalted sensibility, whether 
 natural or accidental, of the whole economy, or of the sexual organs 
 in particular, it is proper after bleeding, if that has been deemed 
 useful, to have recourse to baths, to the mildest anodynes, and even 
 to the thebaic preparations. 
 
 The third case is of much more frequent occurrence than the 
 generality of practitioners suppose, and I can hardly comprehend
 
 358 EUTOCIA. 
 
 why the authors make scarce any mention of it in the treatises put 
 into the hands of students. The work of Wigan, which is highly 
 esteemed in the north, proves that these contractions have fixed the 
 attention of the German accoucheurs in a very special manner : 
 among us hardly any body but Madame Boivin speaks of it ; but 
 Burns and Dewees treat it somewhat more at length. Sometimes 
 it is the fundus of the womb that contracts thus spasmodically, 
 while the rest of the organ hardly contracts at all ; sometimes, 
 again, it is one of its angles, a portion of its anterior wall, of its 
 posterior wall, or one of its sides ; the pains are not less acute 
 than they would be if the whole organ contracted, they may even 
 be more severe, but they are in pure waste, or at least, far from 
 having as much influence on the progress of the labour as the re- 
 gular contractions. If the parietes of the belly are not too thick, 
 we can, by applying the hand upon the hypogastrium, feel that the 
 uterine ovoid is not even, that there are lumps or inequalities, and 
 that, too, independently of the form of the foetus. Wigan, who gives 
 to this disposition the appellation of tetanus, appears to me to have 
 made too many divisions ; practice can derive no benefit from it, 
 and theory gains by it nothing but confusion. 
 
 Whenever the general state of the patient does not contra-indi- 
 cate it, we must here also have recourse to bleeding, then to baths, 
 and next to simple anodynes, diffusible anti-spasmodics, opiates, 
 &c. J, for example, use with success a potion composed in the 
 following manner: B lettuce and wild poppy water 5 iv, orange 
 flower or mint water 3j, syrup of pink or white poppies 3j, or syrup 
 of marsh-mallows, 3j, with extract of opium gr. i, or laudanum, from 
 grs. v to grs. x. Simple frictions on the belly, long continued, also 
 succeed pretty often. They are sometimes performed with the hand 
 alone, or with a flannel, either dry and hot, or wet with oil of chamo- 
 mile, camphorated alcohol, or cologne water, &c. Although nature 
 herself frequently succeeds in restoring the natural order of things, 
 this state is, notwithstanding, not to be overlooked, in the first place, 
 because it indefinitely prolongs the labour, and in the next because 
 it may be looked upon as a morbid state, or at least as evidence of 
 great predisposition to diseases, or to inflammation of the womb. 
 
 849. Spasmodic contractions of the os uteri have also been ob- 
 served, and I have several times seen its dilatation completely ar- 
 rested, or considerably retarded for hours together by this irregu- 
 larity, which in general requires the same treatment as the preced- 
 ing. In some instances, the os uteri is at the same time very sensi- 
 ble, dry, hot, highly irritated and painful, although regular in shape; 
 a valuable remedy in such a state of things, and far more efficacious
 
 MANAGEMENT OF LABOUR. 359 
 
 than hip baths, and emollient, mucilaginous, or narcotic injections, 
 or various sorts of ointments usually recommended, is found in the 
 belladonna ointment, proposed by Chaussier and Dr Conquest, and 
 frequently made use of by Madame Lachapelle at the Maison d' Ac- 
 couchement at Paris. Its employment too is followed with no incon- 
 venience : when I have occasion for it, I direct one drachm of the 
 juice or extract of belladonna to be triturated with one ounce of 
 cerate or hog's lard ; with the fingers I easily introduce a portion 
 of this ointment, as large as a filbert, up to the os uteri, the whole 
 circumference of which is soon anointed with it. The belladonna 
 acts here as it does upon the iris, when applied betwixt the eye lids 
 a few hours previously to performing the operation for cataract, and 
 often with a promptitude that is really surprising. 
 
 In the spring of 1 825, a young woman of good constitution was seiz- 
 ed with labour pains at five o'clock in the evening ; the labour went 
 on regularly all night. The next morning, at six o'clock, the os uteri 
 was as large as a three livres piece at least ; from that time the dilata- 
 tion progressed slowly, although the force of the pains did not di- 
 minish at all ; a vein was opened in the arm ; the agitation of the 
 patient went on increasing, and the orifice continued in nearly the 
 same state. M. Ribail, who had the care of the woman, sent her 
 to the hospital, where I saw her at half past six in the evening : the 
 os uteri was a little larger than a five franc piece, and formed a thin 
 circle, almost sharp, hot, and extremely sensible ; the pains still 
 continued ; the ointment was applied at seven o'clock, and before 
 the clock struck eight the delivery was completed. 
 
 Conclusive as was this result, it nevertheless appeared to me dif- 
 ficult to attribute it exclusively to the action of the ointment, but 
 since then I have used it in five different cases, and in all of them 
 the effect has been, if not altogether as prompt, at least quite as un- 
 deniable. 
 
 850. I have elsewhere said in what manner the premature rup- 
 ture of the membranes or their too long continuance in an unbroken 
 state, might retard a labour or render it a bad one. In the former 
 case we ought to do every thing in our power to favour the dilata- 
 tion of the orifice without increasing the power of the uterine con- 
 tractions, for it is important to relieve the foetus as soon as possible 
 from the dangerous compression it has to suffer ; to fulfil this indica- 
 tion, it appears to me to be proper to direct the woman to walk 
 about, to moisten the parts in some way, and especially to have re- 
 course to the ointment of which I have just been speaking. 
 
 In the latter, that is, where the point of the ovum is too slow in 
 giving way, it must be ruptured. To be done without inconveni-
 
 360 EUTOCIA. 
 
 ence, this little operation requires the combination of the following 
 conditions : 1 . That the dilatation shall be, at least, very much ad- 
 vanced ; 2. That the pains shall be maintained, without any threat- 
 enings of inertia ; 3. That the child shall be in a good position ; 
 and 4. That there shall be no other obstacle to the delivery. 
 
 851. Should the os uteri not be largely dilated, we should be ex- 
 posed to the inconveniences connected with a premature rupture of 
 the membranes ; if the womb should cease to contract, or contract 
 only a little, we might give rise to complete inertia and all its con- 
 sequences ; were the fetus badly situated, we shoold increase the 
 dangers of the presentation, and should the resources of art become 
 necessary, their application would be far less easy. But it should 
 be well understood that these general rules are not without excep- 
 tions : for instance, where the puid enclosed in the amnios is in too 
 large quantity, it may be allowed to escape even although the open- 
 ing of the cervix is not considerable ; the same holds, too, where 
 the position of the child is not fixed, where the hips, shoulders, head, 
 or any other part is found to present by turns at the centre of the 
 strait. In this case we seize the moment when the head is well 
 situated to rupture the membranes, because, were this rupture 
 left to nature, it might as well take place while it is unfavour- 
 able as while the position is favourable. Where the bag of 
 waters does not retain the shape of a segment of a sphere, is very 
 much elongated, or pyriform, its presence being no longer of any use 
 as to the progress of the dilatation, it should be broken without too 
 much regard to the degree of the dilatation. The same principles 
 guide us in respect to the strength of the pains ; their absence 
 ought not always to deter us, for the rupture of the membranes is 
 often the best, and sometimes the only means of restoring them. 
 
 852. To effect this rupture there are a thousand different modes 
 of proceeding : the point of a bistoury, of a pair of small scissors, 
 of a common sewing needle or a knitting needle, of a pin, directed 
 by the pulp of the fore finger, has often been found sufficient, and 
 perhaps been employed with advantage ; for one must be very un- 
 skilful or careless seriously to wound the mother or fo3tus with 
 either of those instruments ; however, at the present day we proceed 
 generally in a different manner : the membranes are scratched 
 through with the finger nail, while they are tightly stretched ; or we 
 endeavour to burst them with the end of the finger by suddenly 
 pushing upon the tumour from its point towards its base ; and if 
 the first attempt does not succeed, we make a second, a third, &c. 
 always during the height of the pain ; or again, and the method is a 
 better one, we firmly pinch a fold of the membranes, while in a
 
 MANAGEMENT OF LABOUR. 361 
 
 state of relaxation, and in such a way that the next contraction of 
 the uterus in essaying to form the bag again, does not fail to rupture 
 them. 
 
 Where the membranes have given way spontaneously very high 
 up above the cervix, and the tumour that had engaged in the vagina 
 does not disappear, and seems to interfere with the progress of the 
 natural phenomena of the labour, we ought most generally to per- 
 forate them as if nature hid not yet effected it. Lastly, when the 
 membranous sac does not permit the liquor amnii to escape until 
 long after the dilatation of the orifice, as it is generally found that 
 the rest of the labour proceeds with great celerity, the woman 
 should always from the time the rupture takes place preserve a 
 horizontal posture. 
 
 853. Another cause of protracted labour is the weakness, whether 
 absolute or relative, of the uterine contractions ; this is almost always 
 the cause that is kept in view by the authors of oxytocic remedies ; 
 nevertheless it is fa/ from being the most common one, and as the 
 means proper to overcome it are most generally hurtful in the other 
 cases, it is easy to explain the discordance met with in the works on 
 the effects of substances employed to accelerate the process of par- 
 turition. 
 
 When the inaction of the womb is evident, and depends neither 
 upon general nor local fatigue, when it prevents the labour from 
 proceeding, and the attention and regimen which were spoken of 
 at the comme'ncement of this article have been tried in vain, and 
 especially when, instead of diminishing, it goes on increasing hour 
 after hour, those substances that seem to exert a special action on 
 the gestative organ should be tried. This is the case in which 
 small injections of senna are indicated ; in which stimulants in 
 general are indicated ; in which the borate of soda, extolled by the 
 ancients, by Hornberg among others, and in our own day by M. 
 Lobstein, might be successfully administered ; but a substance is 
 now known that seems to deserve a preference over all others, and 
 of which I am about to speak in more detail. 
 
 854. The ergoted rye, clavus secallnus, secale luxurians, calcar, 
 secale mater, (ble farouche, ble noir, ble cornu, ble ivre, ergot, seigle 
 eperone, clou de seigle, seigle de matrice) seems to have been used 
 from time immemorial by the old women, and by some country mid- 
 wives for the purpose of hastening delivery; it was mentioned in the 
 Acta Natur. Curios, for 1688, and the title of womb -rye which was 
 adopted by the Germans shows that this idea was not a new one. 
 These traditions of the vulgar at length attracted the attention of 
 the profession, and M. Desgranges published his first researches upon 
 
 2V
 
 362 EUTOCIA. 
 
 the oxytocic properties of the ergoted rye in the Gazette de Sante 
 for 1777. Since that period numerous observations have been col- 
 lected and made public in the American, English, and French jour- 
 nals, &c. &c. Stearns, Prescot, Chapman, Bordot, Goupil, Chev- 
 reul, Legras, Bigeschi, Gendrin, and especially M. Villeneuve, have 
 collected an infinite number of facts that prove decisively that the 
 ergot of rye is capable of restoring the contractions of the womb 
 during labour. However, MM. Desormeaux and Capuron do not 
 appear to have much confidence in it, and Madame Lachapelle has 
 published a long series of experiments, which tend to show that it 
 enjoys no property of the kind, whether given in fine or coarse pow- 
 der, in infusion or in decoction, in extract or in syrup. In the last 
 four years I have used it more than twenty times; M. Delanglar and 
 M. Terreux have also used it at my solicitation, and in every case 
 its action has appeared to be evident, undeniable. It forces the 
 uterus to contract in a few minutes, in a quarter of an hour, or, at 
 most, in twenty minutes after it is exhibited. I have very recently had 
 another most convincing proof of its efficacy: to a young woman 
 who had been twenty-four hours in labour, I gave three doses in the 
 space of forty minutes; within five minutes after the first one, the 
 pains, which had for several hours been very feeble and slow, sud- 
 denly became strong and very frequent, but soon relaxed again; the 
 second dose brought them back in the same way: they diminished a 
 second time, and it was not until after the third dose that they were 
 maintained until the complete expulsion of the foetus, which soon 
 took place. 
 
 I prescribe it in the quantity of fifteen or twenty grains in a 
 spoonful or half a wine glassful of sweetened water, and repeat the 
 dose two or three times, at intervals of fifteen or twenty minutes. 
 Perhaps a larger quantity may be safely given: Parmentier took half 
 a drachm of it; MM.'Lapre and Campernon a drachm, and a 
 drachm and a half, for several days together, without experiencing 
 any sensible effects from it; its use might therefore be continued for 
 a long time and in large doses, before any well grounded fear of 
 inducing ergotism could be entertained. 
 
 855. It is to be hoped that the chemists will ere long separate the 
 essentially active principle of this substance; MM. Desgranges and 
 Lapre have already observed that four or five grains of the bark 
 produce a greater effect than twelve or fifteen of the entire grain. 
 I have no doubt that a preparation will be discovered ere long, 
 whose energy shall ho uniform; but, meanwhile, a fine powder made 
 of the entire grain appears to me to be preferable to the decoctions, 
 extracts, &c.
 
 MANAGEMENT OF LABOUR. 363 
 
 856. In order that the ergot of rye may be given with some chance 
 of success, and without any danger, it is necessary, 1st, that there 
 should be no manifest tendency to hemorrhage from excess of irrita- 
 tion; 2d, that it be possible for the delivery to take place through the 
 natural passages; 3d, that tlie child be in a good position; 4th, that 
 the cervix be soft arid dilatable; 5th, that the general irritability be 
 not too great; 6th, that thn digestive organs be in a good state, and 
 7th, that the weakness of the uterine action shall depend upon the 
 want of irritability of that organ. M. Legras advises that it be 
 given, also, for the purpose of steadying the head at the superior 
 strait, previously to applying the forceps. 
 
 ARTICLE III. 
 
 Of Dystocia, or Difficult Labour (preternatural labour, la- 
 borious L, mechanical L, manual L, artificial I., tyc.). 
 
 857. Labour ceases to deserve the title of spontaneous, whenever, 
 by leaving it wholly to the powers of nature, it threatens to become 
 dangerous either to the mother or child. These kinds of labour 
 were for a long time designated by the simple epithets of preterna- 
 tural or laborious: but the distinct acceptation that was attempted 
 to be given to each of these qualifications being quite arbitrary, too 
 much confusion has ensued among the authors who adopted them, 
 not to make it desirable to replace them by others. As the name 
 of dystocia*, employed by Hippocrates, Sauvages, and M. Desor- 
 meaux, expresses aH the cases that require the assistance of art, it 
 appears to me the most proper one, and will doubtless be preferred 
 at a future day as a generic term. 
 
 858. As to the subdivisions to be established, it is contrary to the 
 rules of reasoning to found them upon the nature of the means that 
 are employed where nature is insufficient for us any longer to con- 
 form to the principles laid down by Solayres, Baudelocque, &c. The 
 faults of such a method are too evident for it to be necessary to 
 enumerate them; it should suffice us to remember that by following 
 them, the same cause of dystocia, the same accident, for example 
 a hemorrhage, may by turns cause the same fact to be classed by 
 turns among the preternatural, laborious, mechanical, mixed, manual, 
 
 * From fut, an inseparable particle which imports difficulty, trouble, misfor- 
 tune, and roxoct child-birth.
 
 364 DYSTOCIA. 
 
 &c. labours, according to the ability or good pleasure of the 
 accoucheur. 
 
 It is, therefore, infinitely better to base them upon the causes that 
 may give rise to difficult labour. This plan, which has been adopted 
 by Merriman and M. Desormeaux, exhibits real and indisputable 
 advantages ; it readily applies to all possible cases, enables us to 
 reduce or multiply genera and species without, in any way, interfering 
 with the general classification, and, besides, can combine with all 
 the other methods proposed by the various authors. After all, diffi- 
 cult labour is characterised by the accident which complicates it, and 
 not by the kind of assistance required in it. 
 
 859. The causes that render labour difficult depend either upon 
 the mother or the child. Some of them are unforeseen, do not occur 
 until the moment of parturition ; the title of accidental may be 
 appropriated to them. Others exist beforehand, and render the 
 labour necessarily difficult : they merit the denomination of pre-ex- 
 isting causes. 
 
 The accidental or unforeseen causes are : any serious disease, such 
 as inflammation of the brain or its coverings, of the lungs or pleura, 
 of the peritoneum or uterus, &c. which takes place during labour ; 
 any hemorrhage sufficiently abundant to endanger the life of the 
 mother or her offspring ; convulsions, syncope, laceration of the 
 womb, the premature escape of the cord, hernia, aneurism, asthma, 
 great debility, &c., and some positions which do not become bad 
 until after the first pains. 
 
 The pre-existing causes are : deformities of the pelvis, malfor- 
 mation or disease of the organs of generation, calculus in the blad- 
 der, fibrous or other tumours in the excavation, deformities in respect 
 to height, transverse positions, monstrous conformation, and diseases 
 of the foetus. 
 
 As these different causes are in reality only complications of 
 labour, it follows that dystocia comprises all cases of complicated 
 labour, as eutocia comprehends all simple labours. 
 
 SECTION 1. 
 Accidental Dystocia. 
 
 1. Of hemorrhagic dystocia. 
 
 Whether the hemorrhage be an epistaxis, nn hemoptysis, an he- 
 matemesis, a hcmaturia, or a metrorrhagia, any one may conceive 
 that the efforts of child-birth must to a considerable degree augment 
 the danger which accompanies it. In the five first named cases we
 
 HEMORRHAGIC DYSTOCIA. 365 
 
 are to act ,is we should ^do in relation to all hemorrhages in general; 
 and if the blood still continues to flow, we should begin to think of 
 terminating the labour as promptly as possible ; the sixth-named 
 case, uterine hemorrhage, is met with so frequently, constitutes an 
 accident of so serious a nature, that it becomes necessary, in this 
 place, to examine it, not only as a complication of labour, but also 
 as one of the essential and distinct diseases of pregnant women. 
 
 860. This hemorrhagy is called internal, latent, or conceaeld he- 
 morrhage, when the blood that flows from the vessels is retained in 
 the womb and does not escape from the genital organs;- it is, on the 
 contrary, denominated external, apparent, when the sanguineous 
 fluid escapes from (he genital organs as fast as it is poured out by 
 the mouths of the vessels. It is owing to two kinds of causes : effi- 
 cient causes, and occasional or determining causes. 
 
 861. From the time of Puzos, accoucheurs have generally placed 
 the efficient cause of flooding in the detachment of the placenta ; 
 they state that the placenta separates itself from the internal surface 
 of the womb, and thenceforth the blood flows abundantly from the 
 large and numerous vessels which open on it; this opinion appears 
 to me to be ill-founded. Puzos and his partizans have mistaken the 
 effect for the cause. It is not the detachment of the placenta that 
 produces the hemorrhage, but the hemorrhage on the contrary that 
 detaches the placenta : blows, falls and great shocks may certainly 
 affect the womb and its contents ; but as the ovum constitutes a full 
 bladder in immediate contact with the whole extent of the cavity of 
 the organ that contains it, the most violent commotions would not 
 be able to detach it. While ever the membranes remain unrup- 
 tured, it cannot be conceived how the adherences of the placenta 
 can be destroyed otherwise than by the efforts of a fluid endeavour- 
 ing to effuse itself into the cavity of the womb. It is astonishing 
 that such a doctrine should have been maintained so long by so 
 many celebrated men ; for even admitting a previous detachment of 
 the placenta, we should still have given no explanation of floodings. 
 In fact this detachment takes place every day, either wholly or par- 
 tially, from the middle stage of the most natural labour, and not- 
 withstanding there is no hemorrhage. Besides, an anatomical dis- 
 position that has no real existence is relied on here, the ovum is 
 merely stuck (plaque) on the inner face of the womb, and not in- 
 timately united to it ; the placenta and organ of gestation commu- 
 nicate with each other only by means of pores, and not by means 
 of large vascular mouths. 
 
 862. The efficient cause of flooding seems to me to be analogous 
 to those of all other hemorrhagies, to that of epistaxis, for instance.
 
 366 DYSTOCIA. 
 
 The sanguine exhalation takes place in the womb as it does in the 
 nose, under the influence of a local congestion, an affluxion, a pe- 
 culiar state of irritation, of the molimen hemorrhagicum so much 
 talked of by Stahl. When this affluxion, or molimen, exists to a 
 certain degree, the blood transudes with greater or less force, and 
 from a more or less extensive surface, as happens during the pre- 
 sence of the menses ; only, it requires a stronger impulsion, because, 
 during pregnancy, the ovum that it is compelled to detach in order 
 to effect a passage, necessarily presents a certain degree of resistance 
 to it ; moreover, it seems to me, that in respect to its intimate me- 
 chanism, an uterine hemorrhage that does not depend upon any 
 traumatic lesion, is always the same, at whatever period and in what- 
 ever condition it may occur, as well during gestation as during and 
 after parturition. 
 
 The idea which I now set forth, and which is nearly similar to 
 that which has already been taught by Costa, M. Desormeaux, 
 Madame Lachapelle and M. Duges, merits the most serious atten- 
 tion, and ought to have great influence on the therapeutics of flood- 
 ing, and upon some other points of tokological science. 
 
 The determining causes are as numerous as they are diversified ; 
 they may be referred to a general state of the woman, to a peculiar 
 state of the sexual organs, and to external accidents. 
 
 863. General state. Stoll, Finke and other observers have re- 
 marked that during the prevalence of certain epidemics, all the 
 bilious affections were accompanied with metrorrhagy : it has been 
 stated that verminose diseases, various lesions of the alimentary 
 canal, and all those indispositions that are accompanied with sympa- 
 thetic reaction upon the womb, are capable of giving rise to it. 
 Fatigue, frequent attendance at balls, plays, whole nights passed 
 without sleep, an exciting regimen, heating liquors, purgatives, the 
 warm bath, substances used to produce abortion, moral commotions, 
 in fine, whatever tends to render the menstrual flux more abundant 
 and more precocious, is also capable of giving rise to the flooding ; 
 to these causes may be added an ulcer, a polypus at the neck of the 
 womb, fibrous and other tumours in the substance of the parietes, 
 or in the neighbourhood of the external surface of the uterus, cri- 
 minal maneuvres, and every thing calculated to produce a determi- 
 nation of fluids towards the pelvis, violent exertions, the jolting of a 
 rough-^oing carriage, riding on horseback, efforts to carry or lift a 
 heavy burthen, coughing, vomiting, shocks communicated to the 
 trunk of the body by falls upon the feet the knees or seat, blows 
 on the abdomen or pelvis, diseases of the rectum and bladder ; in 
 one word, all conditions, whether of temperament or of disease, all
 
 HEMORRHAGIC DYSTOCIA. 367 
 
 circumstances, whether. natural or eventual, that are susceptible of 
 producing a sanguine congestion, a raptus towards the vessels of 
 the womb, and all the causes of abortion ; so that pregnancy and 
 labour in themselves constitute one of its most powerful causes. 
 
 864. In some particular cases, an entirely special cause of hem- 
 orrhage is superadded to the preceding ones, and may of itself pro- 
 duce the flooding ; I mean the implantation of the placenta over 
 the cervix uteri. 
 
 Whether the placenta corresponds to the orifice by its very cen- 
 tre or by some point more or less near its circumference, there re- 
 sults nevertheless a hemorrhage whose distinctive character is, that 
 it occurs only in the last months of gestation, or from the period 
 when the cervix uteri begins to dilate from above downwards. The 
 authors who attribute it to the rupture of the utero-placental vessels 
 have certainly been deceived by theoretical prejudices, or false ana- 
 tomical appearances. I offer the following as the results of several 
 observations collected with great care. 
 
 When the placenta is inserted upon the neck of the womb, these two 
 parts proceed together in their development until about the fifth, the 
 sixth, the seventh, and sometimes even until eight months and a half; 
 but from that time forwards, the environs of.the orifice are so rapidly 
 withdrawn from the centre, that a constantly increasing portion of 
 the ovum necessarily remains without any adherence to the womb, 
 and this portion, which is soft, vascular, and constantly on the 
 stretch, may crack or even tear, and thus give rise to a hemorrhage 
 which puts the child's life much more at hazard than the mother's. 
 On the other hand, this displacement does not in general take place 
 without the inferior portion of the womb being more or less irritated 
 by it, and soon becoming the seat of an affluxion, a more or less 
 decided congestion, and thenceforth, the general efficient cause of 
 floodings is superadded to the peculiar cause constituted by the 
 presence of the placenta on the cervix. Is it necessary for me to 
 remark that these two causes, the rupture of some vessels of the 
 placental parenchyma, and a state of congestion of the uterus, may 
 exist separately ; that although the former almost always super-in- 
 duces the latter, it is not, however, impossible for it to exist alone, 
 and that the latter may pre-exist, or even exist to such an extent as 
 to give rise to the most imminent danger, without necessarily com- 
 bining with the other? Besides, it is well known, that blows, 
 shocks, vivid emotions, and all the other causes of ordinary uterine 
 hemorrhage are equally fitted to produce it where the placenta is 
 inserted over the orifice ; it therefore follows that both these kinds* 
 of flooding depend on the same proximate cause, the hemorrhagic
 
 368 DYSTOCIA. 
 
 molimen, and upon the same occasional causes ; bat that the presence 
 of the placenta upon the cervix constitutes a peculiar determining 
 cause, which rarely fails of being in itself sufficiently powerful to 
 produce it. 
 
 865. Vessels of the cord. It is at present pretty generally be- 
 lieved that the vessels of the umbilical cord may break during labour, 
 and give rise to one of the most serious kinds of hemorrhage. 
 Doubtless, it would not be wise to deny the possibility of such an 
 accident ; but it must be confessed that the observations relied upon 
 to prove it are any thing but conclusive. The one mentioned by 
 Lamotte was evidently only a case of ordinary hemorrhage : the 
 blood had begun to flow previously to the rupture of the mem- 
 branes ; the woman rapidly grew weak, and the author believed that 
 the hemorrhage took place from the cord, because he found one of 
 its vessels to appear as if eroded to such a degree as to admit of the 
 transudation of blood. Levret's case, when carefully analysed, 
 proves nothing more in favour of the opinion of the surgeon of 
 Valogne ; and the case by Baudelocque, who at first refused to coin- 
 cide with the opinion of Levret, certainly ought not to have induced 
 him to change his views. Had the rupture of the cord been the 
 cause of the hemorrhage, the foetus would not have been born alive 
 in the cases reported by De la Motte and Baudelocque. In the 
 example cited by Levret, the fcetus, it is true, was dead born, but 
 the forceps had been employed, and the meconium continued to 
 come away while blood was still flowing. In fine, in all'three cases, 
 the mothers became so weak as to excite the serious alarm of the 
 accoucheur ; which seems to me clearly to demonstrate that the 
 blood came from the uterus and not from the child. Did the nature 
 of this work admit of it, it would be an easy matter for me to show 
 that none of the reasons invoked by these authors are capable of 
 demonstrating the correctness of the opinion they desire to support : 
 let it suffice me to say that in the actual state of our knowledge, the 
 hemorrhage from the cord, as understood by De la Motte, Levret, 
 and Baudelocque, can only be admitted as possible, and not as 
 proved. In this respect, moreover, I am completely of accord with 
 Mesdames Boivin and Lachapelle. 
 
 866. Nevertheless, the umbilical vessels, and their branches rami- 
 fying upon the futal surface of the placenta, are sometimes subjected 
 to rupture ; I am in possession of several examples of the kind ; but 
 it is because they were previously in a diseased state, and that too 
 generally in the early periods of pregnancy. Then, the fetus dies 
 promptly, abortion takes place, and the hemorrhage is not discovered 
 until the ovum comes to be .examined. I have very often found
 
 FLOODING. 369 
 
 embryos of six weeks, two months, &c. still enveloped in the mem- 
 branes, separated wholly or partially from their cord, close to which 
 were discovered one or more small clots of blood ; at other times 
 small varicose or aneurismal sacs, sometimes upon the cord, some- 
 times upon the secondary divisions of its vessels, the walls of which 
 are exceedingly thin, and liable to be ruptured by the slightest effort. 
 In an after-birth at full term, I have seen some of these dilatations 
 that had been ruptured, and which communicated with a large clot 
 covering a part of the placenta, and which had not lacerated the 
 amnios ; but it is easy to perceive that this kind of accident is but 
 indirectly similar to those spoken of by authors. 
 
 867. Diagnosis. Uterine hemorrhages have certain common 
 symptoms and certain peculiar signs ; among the general signs, 
 there are some which announce the approach of hemorrhage, and 
 others which accompany or succeed it. 
 
 868. Precursory signs. Although in some women the flooding 
 appears on a sudden, and without any precursory symptoms, it is 
 not the less true that this accident is almost always preceded by 
 a more or less decided disorder of some function. Thus, one 
 or more hours, or one or even several days before the appear- 
 ance of the blood, the individual has a sense of uneasiness, rest- 
 lessness in the limbs, weight, fullness in the pelvis, alternate flushes 
 and chills throughout the body, and rather more thirst and less ap- 
 petite than common ; flushes of heat ascend to her head ; she has 
 fits of giddiness, and becomes much redder or paler than in her 
 habitual state ; the pulse acquires strength, frequency, and quick- 
 ness ; there is, pretty commonly, a degree of febrile action. 
 
 869. Signs offloading. When a quantity of blood sufficient to 
 excite alarm has flowed, the pulse loses somewhat of its strength and 
 hardness, soon becomes irregular and tremulous ; the face grows pale 
 and the skin cooler ; dimness of sight, ringing in the ears, and weak- 
 ness of the stomach, which induce the woman to ask for some kind 
 of aliment ; yawning, pandiculation, nausea, lipothymia, syncope and 
 even convulsive movements appear in succession, and sometimes 
 with frightful rapidity. 
 
 In external floodings, the precursory symptoms are succeeded by 
 a discharge of blood from the external organs, and this character- 
 istic is too evident for it to be needful to indicate any others ; 
 nevertheless, it has appeared to be difficult to some persons, not to 
 confound, at times, a real flooding with a simple menorrhagia. 
 Baudelocque did all in his power to clear up this point of diagnosis : 
 according to him, menstruation occurring during pregnancy differs 
 from metrorrhagia, properly so called, in respect that it takes place 
 2 W
 
 370 DYSTOCIA. 
 
 without any pain, without effort, without any notable disorder of the 
 health, without any antecedent molimen ; in respect that the fluid 
 which escapes is serous, very slightly coloured, and does not coagu- 
 late ; in that it is very small in quantity, terminates in two, three, or 
 four days, appears at the ordinary epochs of the menstrual flux, and 
 that far from debilitating, it is, on the contrary, followed by an im- 
 preved state of health, and greater freedom in the exercise of the 
 functions ; while the very opposite circumstances are observed in a 
 real hemorrhagy. But, in looking a little closer at the subject, it is 
 soon found that these characteristics are for the most part quite 
 illusory. In the first place, it is a fact that, in many women the 
 menses are frequently preceded by the same symptoms as the most 
 dangerous floodings, and that the blood of the menses, far from 
 being fluid and colourless in all cases, is on the contrary sometimes 
 charged with cruor and very coagulable ; besides, flooding is not 
 always accompanied or announced by the general signs heretofore 
 indicated ; it may be very moderate in the beginning, and formed 
 of serous blood, or blood charged with fibrine, and coincide with 
 one of the catamenial epochs ; indeed, as the mechanism of men- 
 struation is the same with that of metrorrhagia, I do not see that it 
 is possible to distinguish the one from the other by any special 
 signs. Moreover, this differential diagnosis leads to nothing ; while 
 the flow is slight, the precautions prescribed by art are incapable 
 of interfering injuriously with the menstrual function ; and as soon 
 as the blood escapes in sufficient quantity to require more active 
 interference, it would be almost ridiculous any further to seek to 
 discriminate between menorrhagia and metrorrhagia. 
 
 870. In internal flooding, admitted by Mauriceau, Do la Motte, 
 Levret, Baudelocque and Merriman, who have related cases of it, the 
 blood tends to accumulate between the placenta, or membranes, and 
 the corresponding part of the womb ; a lenticular coagulum might in 
 such case form with variable rapidity, depressing the ovum in an ec- 
 centric manner on the one hand, and on the other compelling the ute- 
 rus to distend mechanically, so as to receive the fluid that is effused : J 
 am aware, that in presence of facts, argument ought to be silent ; but 
 then, those facts ought to be incontestable, well noted, and properly 
 interpreted : now can these conditions be recognised in a majority 
 of those that have been mentioned in favour of internal floodings? 
 Is it quite certain that the blood in some instances found betwixt 
 the placenta and the womb had accumulated there during life, rather 
 than immediately after death ; that that which escaped in torrents as 
 the membranes pave way was riot efl'used before hand in the interior 
 of the animus '.' How, indeed, can we conceive that the blood which
 
 FLOODING. 37! 
 
 escapes from the uterine vessels in somewhat considerable quantities 
 is capable of dilating beyond measure, and almost instantaneously, the 
 cavity of the womb, instead of running between the gestative organ 
 and its contents,' so as to escape outwards, or of rupturing the mem- 
 branes and becoming effused within their cavity ? How can we 
 admit that the adherences of the placenta, which are habitually so 4 
 weak, could resist the effort of the blood, tending to form a new 
 cavity for its own reception, more powerfully than the uterus, which 
 yields with so much difficulty ? 
 
 Until these various questions shall be solved rigorously, I shall 
 continue, with Mesdames Boivin and Lachapelle, to think that the 
 existence of internal flooding, such as it is generally understood, 
 ought not to be admitted, except under pretty numerous restrictions, 
 and also, that what has been hitherto said in relation to it needs con- 
 firmation. 
 
 It should in all cases be accompanied with the same symptoms as 
 external hemorrhagy, from which it should be distinguishable only by 
 the absence of blood flowing externally, or by the unnatural size of 
 the womb or abdomen. 
 
 871. Flooding with implantation of the placenta over the cervix. 
 According to Rigby, floodings produced by the attachment of the 
 placenta in the vicinity of the orifice, ought to be of extremely fre- 
 quent occurrence ; for, in one hundred and six cases, he met with 
 it forty-three times, and Madame Lachapelle goes so far as to say 
 that uterine hemorrhage occurring in the three last months of preg- 
 nancy, depends almost upon no other cause. Be this as it may, this 
 kind of flooding is distinct from other species, in that, it never takes 
 place before the fifth month ; that the blood, at first, flows in small 
 quantity, and stops of its own accord, to re-appear in greater 
 abundance after a week or two ; in that, it pretty often comes on 
 without any assignable cause, or precursory symptoms ; that it 
 returns after shorter intervals, and is in greater abundance as the 
 stage of pregnancy is more advanced ; in that, during labour, the 
 blood flows especially during the contractions, and not in the inter- 
 vals, as in the other species. When it commences early, as the 
 blood flows in small quantity, the woman becomes exhausted but 
 slowly, the muscles become osdematous, the face is bloated, the lips 
 grow pale, and the skin soon assumes a dull yellow tint, the colour of 
 wax, through its whole extent. These, however, are only rational 
 signs, which may even not be met with near the commencement of 
 the flooding ; whenever, therefore, it becomes desirable to remove 
 all doubt upon the subject, recourse should be had to the touch. The 
 orifice is, in general, very soft, and somewhat dilated ; instead of the
 
 372 . DYSTOCIA. 
 
 membranes, a spongy body is felt, engaged, as the point of a cone 
 with a large base might be, in the upper part of the cervix ; but care 
 should be taken not to mistake a coagulum of blood for the placenta, 
 and in order that the operation should not be performed unnecessa- 
 rily, to recollect that this exploration may possibly reproduce the 
 hemorrhage, by disturbing the concretions by means of which the 
 economy had succeeded in suspending it. 
 
 872. Instead of following the course that I have just indicated as 
 the most general one, the hemorrhage sometimes pursues a very 
 different one. M. Duparcque has seen a case which came on as early 
 as the sixth month, which ceased spontaneously, and did not return 
 until the appearance of the labour. M. Desormeaux has met with it 
 once in the fifth month; and it became so profuse in the sixth, that it 
 was found necessary to deliver the woman. I have seen a case where 
 it did not appear until the end of the ninth month, in a woman to 
 whom I was called by M. Baroilhet, and where it did not become 
 serious until the approach of her confinement, although the centre 
 of the placenta was situated over the orifice. In other cases, espe- 
 cially in first pregnancies, and where the uterus is very much 
 inclined in front, the os uteri is sometimes so little opened, and so 
 high up, that the blood may accumulate below it, to a certain 
 amount, and in some sort produce an internal hemorrhagy. Did the 
 flooding depend upon the rupture of some of the vessels of the pla- 
 centa or cord, it would be characterised by causing the sudden 
 death of the foitus, and by debilitating the mother secondarily. 
 Moreover, it would doubtless produce, as in cases where the blood 
 is effused into the interior of the membranes, a feeling of weight in 
 the pelvis and hypogastrium, with dragging in the loins, the groins, 
 and about the pit of the stomach. 
 
 873. Prognosis. The dangers that follow in the train of uterine he- 
 morrhage necessarily vary according to a multitude of circumstances, 
 according to the species and amount of the flow, the stage of tlio 
 pregnancy, and the ability of the prescribing attendant. In the 
 early stages of pregnancy it is rare for the woman not to be saved, 
 for abortion is ncaily an invariable consequence of it. In the last 
 three months, on the contrary, the life of the child is pretty frequently 
 preserved, while that of the mother is exposed to much greater risks. 
 Upon this subject it may be established as a general rule, that, for 
 the woman, (he danger is the <rreatcr as the preirnaricy is the more 
 advanced, and that the converse is true in respect to the child. 
 Internal hemorrhage is always less redoubtable than internal ; be- 
 
 1 , in the latter, the; evil, when discovered, is often beyond (he 
 resources of ,-irt, wliilo it is easy to reco^ni/i; the former fron
 
 FLOODING. 373 
 
 very commencement. Where the flow takes place from the cord or 
 placenta, the life of the foetus is more seriously menaced than that 
 of the mother, and vice versa as to uterine hemorrhage, properly so 
 called. 
 
 The danger is not to be estimated by the quantity of blood that 
 is lost, but rather by the effect produced by it upon the system in 
 general. There are women, who, other things being equal, are 
 led to the verge of the grave by the loss of a pound of blood, while 
 others lose double or triple the quantity without being seriously 
 incommoded by it ; and it is not requisite for me to say that those 
 who are strong, sanguine, and robust, suffer from it less than such as 
 are lymphatic, weakly and anemic. 
 
 874. Even although we should be so fortunate as to allay the 
 storm, and prevent the death of the patient in a case of profuse 
 flooding, there would still be reason to dread relapses that would 
 become more and more dangerous, general or local infiltrations, 
 chronic inflammations of the womb, peritoneum pleura and peri- 
 cardium, and nervous affections of all sorts ; as to the dangers of 
 the moment, they are estimated by the severity of the symptoms 
 under notice at the time. While ever the debility is not great, the 
 pulse retains some strength and hardness, and the colour of the skin 
 and features of the countenance remain without any too evident 
 alteration, the flooding need not excite our alarm ; on the contrary, 
 there is not a moment to lose where the face grows pale, the extre- 
 mities become cold, the sight grows dim, the pulse weaker, tremu- 
 lous, and irregular ; finally, but little hope remains where lipothymia, 
 syncope and convulsions supervene. 
 
 876. Notwithstanding that the death of the foetus is one of the 
 ordinary consequences of hemorrhage occurring in the four or five 
 first months of pregnancy, and that at later stages it becomes most 
 generally necessary to empty the uterus, it would however be wrong 
 to conclude that a happier termination of it can never be obtained. 
 
 Indeed, all observers have remarked that slight floodings, es- 
 pecially those occurring in the first stage of pregnancy, when 
 arrested by a well understood mode of treatment, sometimes permit 
 the ovum to continue its evolutions, and the foetus to live and grow 
 until its natural term ; the blood has been seen to flow even to the 
 extent of exciting fears for the woman's life, and yet abortion not 
 to take place (4GO); I attended a young lady who was seized with 
 a profuse hemorrhage in the third month of her second pregnancy, 
 who lost more than two pounds of blood in the space of thirty-six 
 hours, and notwithstanding did not miscarry ; M. Desormeaux men- 
 tions another case, where the blood flowed with such force that it
 
 374 DYSTOCIA. 
 
 was necessary to have recourse to the tampon, and where the preg- 
 nancy, nevertheless, went to its full term. 
 
 876. Uterine hemorrhage is cured in three ways. 
 
 1. The blood that escapes externally sometimes becomes itself 
 the remedy of the evil it constitutes, disengorges the uterus, destroys 
 the molimen, removes the congestion, and permits the equilibrium 
 to establish itself naturally ; here, the flow may have been effected 
 at the expense of the cervix, the vagina, or the inferior portion 
 of the womb, and may not have destroyed the principal adherences 
 of the ovum, which remains uninjured, and thus is but slightly dis- 
 turbed in regard to its development ; or the placenta, although par- 
 tially detached by the blood that exudes from its external surface, 
 continues to resist, the hemorrhage stops, and, as in the other 
 case, the child's life is preserved. 
 
 2. In other cases, the flooding, after it has continued for a longer 
 or shorter time, ceases ; the ovum, although detached and more or 
 less altered, is not expelled, and remains in the uterus for a period 
 that is variable. 
 
 3. It most frequently happens that the contractions of the uterus 
 are brought into play, and, in these cases, we can rely only upon abor- 
 tion, delivery, turning, or the forceps, to save the patient from the 
 dangers with which she is threatened. 
 
 Puzos has maintained that, when the flow is once arrested, the 
 parts may contract new adhesions : a case by Noorthwyck, that of 
 his own wife, has been supposed to confirm this opinion ; but upon 
 careful reflection, numerous doubts soon occur to any impartial and 
 unprejudiced mind as to the value of this fact. 
 
 According to Pasta, whenever the union of the ovum \vith the 
 womb is destroyed by the flow of blood, it is impossible for it to be 
 re-established, and when abortion, or labour, or at least the death of 
 the foetus do not follow flooding, it is because the hemorrhagic 
 excitement takes place in some part beyond the limits of the pla- 
 centa. 
 
 877. The following is what observation has demonstrated : while 
 the blood is endeavouring to glide towards the os uteri, a more or 
 less extensive portion of the placenta or anhistous membrane be- 
 comes fully saturated with it ; first one clot forms, then a second, then 
 
 third; and these several layers, of various thickness, soon become 
 tiniciently numerous, provided the energy of the hcmorrhagic 
 aflluxion becomes diminished, to exert such a degree of pressure as to 
 retain the blood within its own vessels; it is not by stopping up 
 <>p< iiiii^H, by filling large vascular trunks, but by being plas- 
 tered again.st the pores of the womb, that coagula are enabled to sus-
 
 FLOODING. 375 
 
 pencl a hemorrhage ; the same mechanism by which they succeed in 
 putting a stop to epistaxis, when they accumulate within the cavities 
 of the nose. 
 
 878. Provided these coagula are not very extensive, the ovum 
 continues to live, like a tree from which one or more of the roots 
 have been removed : the fluid part disappears by means of imbibi- 
 tion, and the fibrinous layers becoming drier and drier, and less and 
 less evident, remain, sometimes, until labour takes place, although 
 the points which they separate are not re-united. At the Maternite 
 at Tours, I saw a young woman who was thrice seized with slight 
 flooding, at intervals of a fortnight, in the two last months of her 
 first pregnancy. There was nothing peculiar in her labour ; but 
 there were found on the surface of the placenta, three distinct layers, 
 about the size of a three livres piece; one of these layers, which was 
 very near the edge of the placenta, was composed of a clot that was 
 still red, of a lenticular shape, and with difficulty separable from the 
 after-birth ; the second was composed of a fibrinous concretion, much 
 firmer and scarcely coloured at all ; the third looked more like a 
 sort of cicatrix. Is it not evident that these three points corresponded 
 to the seat of the three hemorrhages that had taken place ante- 
 cedently to the occurrence of the labour ? 
 
 879. Treatment. It may with truth be said that the uterine 
 hemorrhages of pregnant women are diseases which require, on the 
 part of the practitioner, the greatest coolness, knowledge and skill ; 
 indeed, in presence of such accidents, a few seconds, more or less, 
 often decide as to the life or death of two beings, equally dear ; such 
 are the cases where it imports us to know how to choose the remedy 
 and apply it properly, and where a distrustful timidity might become 
 equally fatal with imprudence and rashness. 
 
 The means to which we can have recourse are extremely nume- 
 rous ; some of them are, to a certain extent, applicable to all cases 
 indiscriminately, and others are to be employed only under peculiar 
 circumstances. 
 
 880. Rest, low diet, a horizontal posture upon a hair mattress, 
 rather than upon a feather bed, in a chamber which ought to 
 be darkened rather than too much lighted, quiet and not noisy, cool, 
 and well ventilated, rather than hot and close, with diluting or cold aci- 
 dulous drinks very frequently suffice when early recourse is had to 
 them, in moderate cases of hemorrhage : if the woman is strong or 
 sanguine, and especially if there have been precursory symptoms, if 
 there are ri<rors, and the state of the pulse warrants it, six or eight 
 ounces of blood may be drawn from the arm. When these slight 
 succours do not succeed at once, and where there has been no pre-
 
 
 376 DYSTOCIA. 
 
 cursory molimen, and the woman is naturally weak, we have re- 
 course to revulsives, and to external refrigerants. We prescribe 
 manuluvia, either simple or containing mustard, dry friction of the 
 arms, the breast and along the spine, and apply large cups to the 
 breasts ; aspersions are made upon the abdomen and inner part of 
 the thighs, with cold water, either alone or with the addition of vine- 
 gar, ether, or ammoniac, &c. ; compresses wetted vviththe same 
 liquids, or with ice water, may also be applied to the same parts. 
 Burns praises the effects of alum ; Duncan and Rigby seem to have 
 derived great advantages from the use of opium and sugar of. lead 
 (acetate of lead), which had previously been recommended by Et- 
 muller, &c. and is frequently employed by Dewees ; the digitalis is 
 also recommended by many of the English physicians ; but these va- 
 rious articles are rarely made use of in France. Rhodion, Hamilton, 
 and some others have recommended the application of tight ligatures 
 to the limbs. A practice that seems to me to deserve the attention of 
 practitioners is the application of a sinapism between the shoulders ; 
 I have made use of it often enough, and in cases sufficiently various, 
 to enable me to affirm that it is one of the most powerful and most 
 useful revulsives that can be recommended. MM. Trastour, La- 
 roche, Nivert, and several young physicians who have seen me em- 
 ploy it, or put it in practice themselves, have already made mention 
 of it in their theses. I have elsewhere stated the anatomical and 
 physiological considerations by which I was led to its employ- 
 ment. I resort to it both in the first months of pregnancy and 
 during labour, as also in the interval betwixt these periods ; and the 
 effect has always been extremely prompt. A young woman, nine- 
 teen years of age, was brought to the Clinique Externe of the School 
 of Medicine towards the close of 1825 ; she was about three months 
 gone with child, and had been flooding for twelve hours ; we tried 
 the remedies indicated higher up, but the flow continued neverthe- 
 less to increase until evening'; being then alarmed by her extreme 
 weakness and the appearances of approaching syncope, I applied a 
 mustard cataplasm to her back ; in a quarter of an hour the dimi- 
 nution of the hemorrhagy was evident ; it soon became a mere 
 draining, which continued until the next day, when the ovum was 
 expelled. 
 
 There ought to be nothing surprising in such a result, when we 
 reflect with what case peoplr in the; country sometimes put a stop 
 to cpistaxis, by placing a ki;y, or sonic pirceb of linen, or the like, 
 wetted with cold water betwixt the shoulders, and will) what rapidity 
 sympathetic irradiations are brought into play by the action of mus- 
 tard. Nevertheless, it would be unreasonable to think that the action
 
 FLOODING. 377 
 
 of this medicament is infallible, and that it ought to be employed in 
 all cases. Reason indicates that it would be injurious rather than 
 useful where the flooding is attended with a general reaction of the 
 system, and the symptoms of the hemorrhagic effort continue in 
 full force ; both in pregnancy and during labour, as the placenta 
 is to a great extent detached, and its expulsion inevitable, it might 
 serve to diminish the impetuosity of the affluxion, but there would 
 be little wisdom in relying upon it to completely suppress a he- 
 morrhagy that had already become serious and alarming. 
 
 881. The tampon. Doubtless one of the first ideas to occur to the 
 mind upon observing a flow of blood from the wornb, was to stop up the 
 orifice of that organ ; however, notwithstanding what Costa says upon 
 the subject, the use of the tampon was hardly mentioned in the science 
 until since the times of Madame Bourgeois, o P. Portal, F. Hoff- 
 mann, and Sraellie. If we may confide in Leroux, the tampon is an 
 heroic remedy, which is almost always followed by success ; accord- 
 ing to the modern classics, on the contrary, it is rarely an useful, 
 and most frequently a dangerous remedy, that ought to be proscribed 
 from sound practice. Amongst others, M. Demangeon, who has 
 been well combated by M. Gardien, has expressed himself strongly 
 against the tampon, which, in his opinion, can only serve to augment 
 the dangers of the disease. Rigby and Merriman scarcely make 
 mention of it. Specious arguments, theoretical prejudices, excep- 
 tional cases generalized, and false reasonings, comprise, notwith- 
 standing, all that has been brought to. bear against the innumerable 
 facts that have been reported by an infinite number of authors : in 
 fact, it is not possible, after reading the work of Leroux, to partici- 
 pate in the fears that are attempted to be awakened by the antago- 
 nists of the tampon, or in common with Burns, Mesdames Boivin 
 and Lachapelle, and Dr Dewees, not to consider it as one of the 
 most powerful means of rescuing women from the dangers of a 
 serious attack of flooding. 
 
 882. It ought not upon this account to be said that it never can 
 be injurious. The tampon, like all important therapeutic resources, 
 is a weapon of protection in the hands of a skilful practitioner, but it 
 may become a murderous one in those of an ignorant person. For 
 example, it would be imprudent to make use of it at the commence- 
 ment of a flooding, before the symptoms of plethora have been dis- 
 sipated, or where the blood is being effused within the interior of 
 the membranes with the uterus in a state of inertia ; for in such a 
 condition it could not fail to augment the excitement, or by retain- 
 ing the blood in the womb, favour the indefinite distention of the 
 parietes of that organ. Nevertheless, it has not as yet been very 
 
 2X
 
 378 DYSTOCIA. 
 
 positively demonstrated, that even here it would not be more fre- 
 quently useful than hurtful ; reasoning, which accords with a pretty 
 considerable number of facts, leads me to believe, along with M. 
 Chevreul, that it affords, perhaps, one of the surest means of forcing 
 the uterus to contract, or arouse it from its lethargy ; this is the 
 property, even, which renders it redoubtable where we are fearful 
 of facilitating the expulsion of the ovum, and which makes it impro- 
 per to resort to it until after we have ascertained the inefficacy of 
 other modes of treatment. 
 
 883. It is composed in very various ways : many persons content 
 themselves with filling the vagina with tow, lint, old linen, sponge, 
 &c. Dewees says it is never necessary to carry the tampon as far 
 as the os uteri ; there are some who prefer a small bag, or sort of 
 purse, filled with astringent substances ; but the simplest method, 
 which also is that adopted by M. Desormeaux, consists in making 
 a kind of sac with fine linen well greased with cerate, and which is 
 introduced empty as far as the os tineas, to be afterwards filled 
 with little rolls of lint or tow, or some such substance, and 
 then secured with a T bandage. The oil in which Burns advises 
 us to soak the tampon appears to me to be of no other use but 
 to favour its introduction. Vinegar, and oxycrate, recommended by 
 others, are of less doubtful value, although their styptic action is 
 soon annihilated by the coagula, and by the flow of the blood ; 
 moreover, it is a mechanical barrier and not a pharmaceutic sub- 
 stance by which we attempt to oppose the hemorrhagy. It is a 
 real stopper, which, by closing up the passage to the blood, compels 
 it to coagulate by little and little, and as it becomes concrete, to com- 
 press and shut up the exhalent orifices that furnish the fluid ; on the 
 other hand, by its quality as a foreign body, it excites the cervix, 
 and changes the vitality of the womb, whose contractility it arouses, 
 whose reaction it recalls, to such a degree as soon to occasion the 
 expulsion of the ovum. 
 
 If it is to succeed, the blood ceases to flow from the vulva, the 
 general symptoms are gradually allayed, the hypogastrium becomes 
 more firm without increasing in size, and provided the womb is 
 not to be emptied, the woman only experiences a feeling of tenes- 
 mus, straining and weight in the pelvis, and sometimes slight colic 
 pains ; while, in the opposite case, pretty smart pains, and real 
 contractions of the womb supervene ; in consequence of which the 
 clots, the tampon, and the product of the conception are all expelled 
 one after another from the genital organ?. 
 
 In some women it is followed by such a degree of uneasiness, 
 rvrn although there may bo no uterine contractions, that they insist
 
 FLOODING. 379 
 
 upon its being removed ; in general, their entreaties should be re- 
 sisted, provided no evidences of internal hemorrhage are discovered, 
 unless, indeed, the pain is so acute as to give rise to certain nervous 
 affections, or convulsions ; complaints in these cases are rather to 
 be desired than feared. After some time the functions are seen to 
 return to their natural state ; and, in order to avoid the risk of a 
 return of the flooding, the tampon is left in situ as long as possible, 
 at least for several hours, or even a whole day ; then, when it is 
 no longer considered to be indispensably necessary, the T bandage 
 only is removed, for the tampon, being no longer kept in the organs 
 by an external force, it escapes spontaneously and gently. 
 
 884. Dilatation of the os uteri, and rupture of the membranes. 
 Before proceeding to forced delivery, Puzos recommends the trial 
 of a practice which is, in his opinion, much more simple, and par- 
 ticularly much more consonant to the nature of the organism ; in- 
 troduce, says he, first one, then two, then three fingers into the 
 orifice, which you should titillate and irritate, but very gently ; and 
 you will often find that this alone will suffice to stop the hemorrhagy, 
 and to induce the womb to contract. If this does not suffice, begin 
 to dilate it, enlarge it with all the care and gentleness that the seve- 
 rity of the symptoms will admit of your using, and if you still do not 
 succeed, perforate the membranes, and the vacuum that will take 
 place in the membranes will rarely fail to be followed by the expul- 
 sive contractions of the womb. You will have, it is true, a prema- 
 ture delivery, but which will be less dangerous both to the mother 
 and the child than if the practitioner had undertaken to deliver 
 the fetus. 
 
 885. This conduct is particularly adapted to cases where hem- 
 orrhage takes place during labour, or where the pregnancy is very 
 much advanced, and the placenta is not attached near to the neck. 
 Notwithstanding, it is evident that with the exception of the rupture 
 of the membranes, the tampon fulfils pretty nearly the same indica- 
 tions, and that where the flooding is violent it would be wrong to act 
 with so much reserve, and not to terminate the delivery as soon as 
 possible. 
 
 Forced delivery. When a labour proceeds with a certain degree 
 of regularity, notwithstanding the hemorrhage may continue, and the 
 powers of the woman may diminish too rapidly, it generally suffices 
 to accelerate the contractions as hath been mentioned, and to en- 
 gage the woman to keep up her courage and use her best efforts to 
 enable the womb to get rid of its contents as well as to put a stop to 
 the flooding. ' Provided, on the other hand, the infrequency of the 
 pains does not permit him to rely upon the powers of the economy,
 
 380 DYSTOCIA. 
 
 the accoucheur should hasten to deliver the child. If the head be 
 already engaged in the superior strait, and the os uteri sufficiently 
 open, and a fortiori if it have already reached the excavation, it 
 should be seized with the forceps : otherwise the child should be 
 turned ; but in order to admit of the hand being carried into the 
 womb, the orifice must have reached a certain degree of dilatation, 
 or at least be in a very dilatable state. Therefore, it is only in the 
 last stages of pregnancy, and where nature or the means hereto- 
 fore pointed out have forced the labour to begin, that we may 
 resort to this method, which is particularly applicable to cases of 
 hemorrhagy from implantatidn of the placenta over the cervix uteri. 
 Happily, when there is a flooding, the orifice is commonly very soft, 
 and admits of a ready passage. Moreover, it is manifest that where 
 the danger is pressing, it would be better to make use of some 
 violence in overcoming the resistance, than to abandon the woman 
 to the so frequently fatal chances of an overwhelming flooding. 
 
 886. The termination of the labour should never, under any pre- 
 text, be left to the powers of nature, when the hemorrhagy is in- 
 contestably occasioned by the insertion of the placenta upon the os 
 uteri. 
 
 In this particular case, many practitioners have recommended, 
 that as soon as the fingers have got within the os uteri, we should 
 try to find that part of the edge of the placenta that is nearest, so 
 as to pass up the hand in that direction ; others have thought that 
 in difficult cases, or where there is no time to temporise, it would be 
 better to neglect this minute research, and to perforate or rupture 
 that point of the ovum that corresponds to the orifice, so as instantly 
 to lay hold on the child's feet. The former of these two modes of 
 practice would occupy too much time ; and the latter would not 
 fail to augment very greatly the violence of the hemorrhagy, and 
 seriously endanger the life of the fcetus, should its extraction hap- 
 pen to bo tedious or difficult. Besides, the child would have to be 
 withdrawn through the opening in the placenta, which, being pulled 
 downwards by the shoulders or head, would necessarily raise great 
 obstacles to the operation. 
 
 The method followed by P. Portal, M. Dubois, &c. is in all re- 
 spects to be preferred. Without any regard to the edge of the 
 placenta, the hand, after reaching the os uteri, is to be first carried 
 in front, and then to the right of the woman if it bo the left hand, 
 and to her left if it be the right hand that is made use of, and in 
 less than a second, the membranous part of the ovum is reached, 
 and must be perforated ; the feet arc now promptly seized, and the 
 fcctU8 may be delivered before the after-birth.
 
 FLOODING. 381 
 
 887. In the other species of hcmorrhagy, when the turning has 
 been effected, and the hips are at the vulva, it seems to be wise, 
 provided there be no inertia of the womb, to leave the closing of 
 the labour to nature, whereas, in cases of implantation over the 
 cervix, when the operation is once begun it cannot be terminated 
 too soon. The reason of this difference strikes us at once : in the 
 first mentioned case, as the omphalo-placental circulation continues 
 to go on, the life of the child is not compromitted, and that of the 
 mother is no longer in danger as soon as the blood ceases to flow ; 
 in the second, the functions of the placenta ceasing, a few moments 
 of delay might occasion the death of the foetus. , 
 
 Is it necessary for me, in closing, to state that the reader must 
 look to the articles on abortion and delivery of the placenta for the 
 details which I cannot introduce here ? 
 
 II. Of convulsive dystocia. 
 
 The agitation, the agonies of a woman in the midst of the most 
 violent labour pains are sometimes carried to such an extent, that to 
 have been witnesses of them is sufficient to make us feel that such a 
 state borders closely upon the convulsive affections, and convince us 
 that convulsions must be frequently met with in women in labour. 
 
 The convulsions of pregnant women, like those of other women, 
 may be general or local ; affect only one or all the limbs ; the face or 
 any other part separately ; or they may bring into play all the mus- 
 cles of the life of relation : most commonly none but the muscles 
 that are habitually subject to the will are affected ; but in certain 
 cases, those viscera which contain a muscular membrane are also 
 seized. Thus the pharynx, the oesophagus, the stomach, the intes- 
 tines, the bladder, the uterus itself, the heart, and especially the dia- 
 phragm, are at times violently tormented by them. 
 
 Hysteria, epilepsy, catalepsy, and the convulsions produced by 
 some material lesion, such as a phlegmasia, or any disease of the 
 encephalon or its meninges, or of the general nervous system, ap- 
 pear pretty frequently, and sometimes become aggravated during 
 the course of pregnancy ; but it is to be observed that the three first 
 rarely manifest themselves during labour. Moreover, in these cases 
 the disease is complicated by the state of gestation, and that is not 
 what is generally understood by the convulsions of pregnant women. 
 
 888. Puerperal convulsions, also called apoplectic convulsions, 
 hysterical apoplexy, milk apoplexy, sympathetic apoplexy, eclamp~ 
 sia of labour, differ from other diseases, in that they are evidently 
 connected with the state of pregnancy, which they complicate. 
 
 889. Their proximate cause is always located in the brain, and,
 
 382 DYSTOCIA. 
 
 consequently, I do not perceive the use of dividing them into sym- 
 pathetic and idiopathic convulsions. This proximate cause, doubt- 
 less, is an irritation, or stimulus, which reacts upon the whole 
 nervous system, but whose nature appears to be extremely variable : 
 sometimes it is a precedently irritated point in the brain which invites 
 the fluids into that organ, which thus becomes a centre of fluxion ; 
 sometimes, on the contrary, the fluids themselves, by being deter- 
 mined towards the brain in too large quantity, produce a state of 
 congestion therein, and in consequence thereof, a convulsive re-ac- 
 tion. In this, as in the other case, the remote causes are very nume- 
 rous. There are predisposing and determining causes. Although 
 eclampsia is observed at all seasons, at every age, in all classes of 
 society, and under all temperatures, it is, notwithstanding, true to 
 say, that strong persons, those who are plethoric, of a dry fibre, very 
 animated countenance, short neck, abundantly and frequently re- 
 gulated, nervous, delicate, irritable, subject to nervousness, and 
 young women in the first pregnancy, are more liable to them than 
 others. 
 
 Air that is impure, charged with odours, and too rarely renewed ; 
 the summer heats, too high an artificial temperature, anger, grief, 
 vexation, some unexpected news, joy, and all the vivid emotions ; 
 loss of sleep, frequenting of balls and theatres ; labouring at night ; 
 the abuse of baths, of hot drinks, of coffee, tea, spirituous liquors, and 
 spiced or high-tasted dishes ; a succulent regimen, and whatever in- 
 creases the afflux of blood towards the head ; the presence of a 
 great quantity of water in the membranes, or of several children in 
 the womb ; rigidity or extreme sensibility of the fibres of that organ ; 
 hardness or spasmodic contraction of the neck of the womb ; the 
 pressure which it exerts upon the surrounding vessels and nerves ; the 
 thrusting of the stomach upwards ; coition ; the suppression of an 
 issue or any habitual discharge ; the use of corsets, and too tight 
 dresses ; and want of exercise, &.c. have been ranked among the 
 causes of eclampsia. To these have been also added, infiltration of 
 the limbs or leucophlegmasia, living in hot countries, indulging in too 
 much sleep, leisure, the use of alcoholic elixirs and tinctures ; the 
 habit of lying long in bed, atmospheric vicissitudes, and almost all 
 the common causes which the authors never fail to recall upon the 
 occasion of each disease they describe, those causes which seem 
 to produce all the evils because they do not necessarily create any 
 one of them. 
 
 890. No one can deny that such circumstances have sometimes 
 produced eclampsia ; but it is also undeniable that it often comes on 
 without its being possible to assign any satisfactory reason for it.
 
 CONVULSIONS. 383 
 
 Convulsions appear most commonly towards the end of pregnancy, 
 and their most common occasional cause is labour ; they may then 
 depend upon some obstacle which by obstructing the escape of the 
 foetus, soon produces a general disturbance of the system ; or upon 
 a simple irritation that reacts upon the whole economy ; or, also, a 
 repulsion of the fluids towards the interior of the body, occasioned 
 by the efforts which the woman is compelled to make. They may 
 also be the consequence of an attack of hemorrhage, or of exhaus- 
 tion, or the symptom of some rupture, &c. Many practitioners, 
 among whom are M. Desormeaux and Madame Lachapelle, have 
 observed that eclampsia sometimes prevails almost epidemically. 
 " When one of our women had been seized with convulsions, 
 we rarely failed," says Madame Lachapelle, " soon afterwards to have 
 several others in the same state." A tendency to imitation would 
 be here insufficient to account for the fact, and, besides, could not 
 be applicable to cases occurring out of the public establishments, in 
 private practice, or in those singular epidemics that have been so 
 often observed. 
 
 891. Signs. The attack of eclampsia is, in some women, an- 
 nounced by various precursory symptoms, such as flushes of heat 
 about the head, giddiness, confusion of ideas, hallucinations, indis- 
 position to move, uneasiness in the limbs, a dull or frightened look, 
 redness of the conjunctiva, or of the whole countenance, headach, 
 vertigo, stammering, vivid brightness of the eyes, irregularity of 
 the pulse, slight convulsive motions of the muscles of the face, 
 subsultus of the muscles of the extremities ; but it is often, also, 
 found to appear in a sudden and unexpected manner, and to 
 attack at once, with the most alarming symptoms. The woman 
 suddenly becomes insensible, and seems to revive for a moment only 
 to fall again into the most violent agitation ; the limbs writhe, con- 
 tract, become flexed and extended with astonishing strength and 
 celerity ; the body is bent backwards, as if the head and heels were 
 about to approach each other ; the hands are powerfully directed 
 towards the breast or the epigastrium, which they strike, and some- 
 times appear to tear with rage ; the features of the face become dis- 
 torted and convulsed; the lips, which are drawn in various directions, 
 move in the most singular manner; the eyes roll, are agitated and 
 turned up under the orbits ; the pulsation of the carotids and tem- 
 poral arteries is seen through the skin ; the jugulars swell ; the throat 
 and face become tumid, and almost purple ; the eyes seem as if they 
 would start out of the head; the mouth fills with water, which is spirted 
 sometimes to a great distance upon the assistants ; the tongue, irre- 
 gularly agitated, is often pinched, and even violently bitten, by the
 
 384 DYSTOCIA. 
 
 grinding of the teeth and the spasmodic motions of the jaws. In these 
 terrible moments the woman is truly a frightful object, and highly 
 deserving of pity ; the diaphragm by its rapid contractions gives rise 
 to sobs, and an appearance of suffocation, and forces from the mouth 
 and nostrils the substances accumulated in them. The stomach and 
 bowels, the bladder and uterus itself, when they become the seats of 
 such motions, produce vomitings, involuntary expulsion of the faeces 
 and urine, and sometimes of the ovum, with an extreme prompti- 
 tude ; in fine, it might be said that all the viscera participate in the 
 disordered movements of the limbs. At other times, the face and 
 rest of the body pass, so to speak, with the rapidity of lightning, 
 from this state of agitation and vivid colour into the most perfect 
 calm, and fall into a mortal paleness ; at last, and more or less 
 promptly, the congestion of the brain brings on coma, which gene- 
 rally succeeds the attacks of syncope and insensibility. 
 
 892. The duration of an attack is not less variable than its in- 
 tensity ; it lasts in some cases only from ten minutes to a quarter of 
 an hour or half hour ; whilst in others it continues half a day or 
 even twenty-four hours ; if coma supervenes, it may prolong the 
 insensibility for several days and terminate in a complete and prompt 
 restoration to health ; but it is also found to assume all the charac- 
 ters of apoplexy, and occasion the death of the patient. It also some- 
 times happens that certain of the functions remain in a perverted state 
 after the cessation of the convulsions ; sometimes the sight, or hear- 
 ing, or smell, or some one of the intellectual faculties appears to have 
 suffered the severest pressure of the disease ; at others, there arc 
 found internal lacerations or particular effusions, that occasion a 
 deviation from the natural state of the organism, &c. 
 
 When the woman comes to herself, fatigued and worn out, her 
 limbs bruised, as after long and violent exercise, astonished at the 
 situation in which she finds herself, she is, sometimes, ignorant of 
 every thing that has taken place, can scarcely believe what is told 
 her, and has no knowledge of the extraordinary movements execut- 
 ed by all parts of her frame, or the violent cries she has uttered ; 
 some are mentioned, even, who have been delivered without know- 
 ing it, and after the attack was over could not understand that they 
 were really delivered ! 
 
 On the parts that have been struck with considerable force we 
 afterwards find blackish spots, which arc real contusions, attended 
 with more or less pain. 
 
 Where the woman recovers her senses in the intervals of the 
 paroxysms, the convulsions have been denominated cjnlept iform ; 
 in the contrary case, and especially where they are accompanied
 
 CONVULSIONS. 385 
 
 with stertor and coma, they are called apoplecliform or eclampsie. 
 This division can be of use no further than this viz. that the 
 former, which are more easily confounded with epilepsy or hysteria. 
 are rarely so dangerous as the latter; but in fact they are only dif- 
 ferent shades of the same affection. 
 
 893. The examination of the body after death is far from always 
 giving a satisfactory explanation of the severity of the symptoms. 
 A small quantity of serum in the ventricles of the brain ; the veins 
 and sinuses of the brain more or less engorged ; the meninges and 
 cerebral substance somewhat red, or of a natural appearance ; in 
 some cases evident traces of congestion, or a slight extravasation 
 of blood ; but, most generally, no appreciable lesion, is what the 
 unprejudiced observer finds within the cranium. Neither have the 
 other splanchnic cavities exhibited any alterations, that constantly 
 occur in these cases ; the heart is flaccid and almost empty ; the 
 lungs choked up or pale ; a few ounces of citron- coloured or red- 
 dish serum in the serous cavities, are the principal traces left by the 
 disease in the abdomen and thorax. 
 
 Without being rare, eclampsia is, notwithstanding, not a disease fre- 
 quently to be met with, since Madame Lachapelle met with it only sixty- 
 five times in nearly forty thousand pregnant women ; the prognosis is 
 in general unfavourable, for by the admission of that lady, in spite of the 
 most rational and careful treatment, one third of the cases proved fatal. 
 It is more frequent in the last three months and during labour than 
 at other periods, and is less dangerous when it occurs after delivery, 
 or previously to the sixth or seventh month of gestation. Not so 
 serious, ca3teris paribus, when occurring during labour, as before 
 it, it is less so in proportion as the labour is more" advanced at the 
 moment of the first attack. As the emptying of the uterus is often 
 the only means of putting an end to the convulsions, it is evident 
 that the danger arising from them will be in a direct ratio to the 
 difficulty of effecting that object ; if the neck of the womb and the 
 head of the foetus are disposed in such a way as to make it an easy 
 matter to extract the child, the disease may be considered as less 
 alarming than if the orifice is still hard and undilated. Those cases 
 that attack women who are hysterical, epileptic, or endowed with 
 great nervous susceptibility, or whose form exposes them more par- 
 ticularly to these two affections ; those in whom the paroxysms are 
 short, or separated by well marked intervals of calm, and of restora- 
 tion of all the functions, are always less to be dreaded than such as 
 possess no analogy with an anterior nervous state of the woman, 
 which supervene in women who are sanguine, plethoric, or whose 
 organs are all surcharged with serosity ; which are accompanied 
 2 Y
 
 386 DYSTOCIA. 
 
 with apoplectic phenomena, as coma, stertor, or complete insensibi- 
 lity during the intervals of the paroxysms ; and also of such as are 
 only the symptoms of organic disease of longer or shorter stand- 
 ing, seated in the brain, the lungs, the heart, or any other important 
 organ, and which had been greatly aggravated by pregnancy. 
 
 894. The child runs scarcely less risk than the mothe ; in the 
 first place, it often dies in the midst of the extraordinary motions 
 that mark each paroxysm ; and then, wherever abortion takes place, 
 its life cannot be preserved ; the same thing often takes place when 
 premature delivery cannot be avoided ; and even in forced delivery 
 also, at full term, the foetus is often lost ; nevertheless it is incorrect, 
 with some authors, to state that the loss of the child almost always 
 occurs where the attack of puerperal convulsions is somewhat 
 severe. Mauriceau, De la Motte, Levret, Smellie, Baudelocque, 
 the cases gathered or collected by MM. Bouteilloux, J. C. Baude- 
 locque, Madame Lachapelle, &c. afford proof enough of the con- 
 trary. 
 
 895. Treatment. A disease exhibiting itself under forms so 
 diverse, and in such various degrees, cannot be cured by a treat- 
 ment that is alike in all cases ; it is therefore not astonishing that 
 we have so many boasted remedies for it. There are few sub- 
 stances among the anti-spasmodics, the sedatives, the narcotics, the 
 revulsives and the anti-phlogistics, which have not had their vogue ; 
 but as there is always too much disposition to generalise, in thera- 
 peutics as well as in the other branches of medicine, facts have not 
 been wanting to prove that such or such an article, puffed beyond 
 measure by different physicians, is more injurious than useful in 
 eclampsia. 
 
 Ether, balm water, orange-flower water, and mint water, mixed 
 in various proportions with infusions of linden flowers, wild poppies, 
 orange leaves, lettuce water, &c. and with some sedative syrup, arc 
 not be neglected in a number of cases where the convulsions have 
 more analogy with hysteria or epilepsy than with apoplexy, especi- 
 ally if the patient is nervous, very excitable, or lymphatic, rather 
 than plethoric and sanguine. 
 
 In these cases, also, the syrup of clove pinks, of white poppies, 
 of diacodium, pills of cynoglossus, the extract and tinctures of 
 opium, may be usefully given, either alone, or added to the above 
 mentioned vehicles, or under some other form, and combined in 
 some other manner. 
 
 ; . Rigidity, scirrhous induration and spasmodic contraction of 
 the os uteri being sometimes the only, or at least the principal cause 
 of convulsions, we ought not to omit to examine it carefully. Pro-
 
 CONVULSIONS. 387 
 
 vided that it should seem to be the point of departure for the dis- 
 ease, we should apply to it some of the opiate cerate, from which 
 M. Schweighaeuser asserts that he obtained very successful results, 
 or what is better still, the belladonna ointment. Were it really too 
 hard to be overcome by the efforts of the womb, I do not see that it 
 would be possible to dispense with incising the neck. Upon this sub- 
 ject the fears of Madame Lachapelle are, to say the least, exaggerated; 
 for I have not learned that the passage of the head, after this opera- 
 tion, has in any case enlarged the wound, so as to perforate the 
 peritoneum. However, notwithstanding what has been said by M. 
 Bodin, it is a resource not without danger, to which we should not 
 under any pretext resort, except in case of indispensable necessity. 
 
 897. Bleeding has always enjoyed much favour among obstetric 
 physicians : Mauriceau, De la Motte, Puzos, &c. have repeated it 
 six, eight, ten, seventeen and even as much as eighty-six times in one 
 pregnancy in the same woman ! The loss of blood is always useful 
 where there are signs of congestion about the head, a strong pulse, 
 or any signs of plethora. The blood is sometimes drawn from a 
 superficial vein, sometimes by means of leeches or cups, and at 
 others by all these means together. Except wliere there is some 
 particular counter irritation, we commonly begin with a general 
 bleeding of six, eight, ten, twelve, or even fifteen ounces, 
 according to the severity of the disease, and the constitution 
 of the woman. After this first venesection, if it appears to produce 
 some amelioration, it is repeated a second time, a third, or even a 
 fourth, at intervals more or less considerable, always remembering 
 that in this way the strength of the woman is rapidly exhausted. 
 When the general bleeding can no longer be repeated with the hope 
 of obtaining any decided advantage from it, leeches may be applied 
 to the number of fifteen, twenty, thirty, forty, or fifty, behind the 
 ears, or on the neck, or even in the neighbourhood of the vulva, 
 provided there should be any appearances of irritation or evident 
 congestion in the pelvis. Should the coma be very profound, and 
 blood not to be got except in very small quantity, scarified cups on 
 the nape of the neck, or on the mastoid apophyses, ought also to be 
 tried. As to bleeding from the temporal artery, or even from the 
 radial artery, proposed by some persons, I do not think that it de- 
 serves any preference over venesection : but which vein ought to be 
 opened ? 
 
 In the prevailing theory of blood-letting bleeding in the foot passes 
 for being essentially revulsive, while bleeding from the neck is rather 
 derivative, and that from the arm merely depletive ; but these dis- 
 tinctions are scarcely justified by practice : Baudelocque has seen 
 bleeding from the saphena aggravate the affections that were inva- 

 
 388 DYSTOCIA. 
 
 riably diminished by opening a vein in the arm, and other practi- 
 tioners have observed the inverse. In eclampsia the object is to 
 disengorge the vascular system, and when bleeding is deemed neces- 
 sary, I think it matters little whether it is taken from one vein rather 
 than another. If the cerebral congestion is fixed and too great, 
 should the opening of the jugulars appear to be indicated, leeches or 
 cupping might be regarded as preferable, considering that bleeding 
 in the neck is not always an easy nor even practicable matter, espe- 
 cially in a person labouring under convulsions. 
 
 Another reason of the same kind will long continue to render 
 bleeding in the arm much more general than bleeding in the foot ; 
 it is always, or almost always possible, no matter how agitated the 
 patient may be, for us to open a vein in the bend of the arm, 
 whereas as much cannot be said as to the veins of the legs : by 
 bleeding in the arm, we act at the instant, when we please, and 
 how we please, and we take much or little, and that without any 
 difficulty. By bleeding in the foot, on the contrary, various prepa- 
 rations are required ; we must take advantage of a moment of calm, 
 the vein is often found to be too small or too deep-seated, and it 
 frequently happens that enough blood is not obtained. 
 
 898. Tepid baths allay irritation, whether sympathetically by 
 their soothing action on the skin, whether by diminishing the ex- 
 citing qualities of the fluids by the water which they occasion to 
 pass into the circulatory system, or by diminishing the force of 
 radiation of heat. They are administered with success where the 
 symptoms of apoplexy do not predominate ; but they ought not to 
 be prescribed until a bleeding has been premised, provided the state 
 of the patient is such as to admit of her losing blood without danger ; 
 otherwise it might favour the affluxion and congestion in the brain ; 
 they should be rejected in cases depending on flooding, a serous 
 plethora, and where there are any threats of inertia ; the woman 
 may remain immersed in a ba'h for half an hour, an hour, or even 
 longer, according to the relief she derives from it. 
 
 899. The application of cold water to the belly, according to the 
 recommendation of Sigaud, has not a sufficient number of facts in 
 its favour to enable us to recommend it in this form as a general 
 proposition. Ablutions, and ice-water to the head, either used 
 alone, or whilst the rest of the body is plunged into a hot bath, 
 which Denman and most of the English authors, as well as M. A. 
 <' Maudelocque, Madame Lachapelle, &c. have boasted so much 
 of, appear as if they might indeed be usefully combined with the 
 other rational moans where there is reason to fear a lively reaction 
 in the brain ; nevertheless their employment seems to me to require 
 a great deal of prudence and circumspection.
 
 CONVULSIONS. 389 
 
 900. Oily or irritating injections of all sorts are frequently used 
 in England, and not without success. In France, they prefer ex- 
 ternal revulsives, sinapisms or sinapised cataplasms, to the feet, legs, 
 or thighs, a large blister on the back of the neck, and dry frictions 
 along the spine, and on the limbs. Madame Lachapelle, who does 
 not place much confidence in them, and is even afraid of them where 
 there is a threatening of inflammation in any one of the organs, also 
 rejects the employment of digitalis and camphor, to which Hamilton 
 attributes very great virtue, and blames the conduct of our trans- 
 marine neighbours, which consists in a recourse to purgatives and 
 even to emetics, after bleeding. Without charging myself with the 
 defence of the accoucheurs of Great Britain, I cannot, however, 
 omit to observe, that out of twenty-two women treated by bleed- 
 ing, calomel in purging doses, neutral salts given by the mouth or 
 by injection, and lotions made with liquid acetate of ammonia or 
 spirit of rosemary, to the head, Merriman lost only six, while in 
 spite of the energy of the practice employed at the Maternite, they 
 have almost as many deaths as cures in that institution. 
 
 The digitalis purpurea, which is recommended by Hamilton, may 
 be tried in convulsions preceded by oedema of the limbs. The seton 
 in the back of the neck, as advised by M. C. Baudelocque, ought 
 not to be employed until all other remedies have been found insuffi- 
 cient ; moxas and scarified cups are not likely to be at all more suc- 
 cessful than leeches and the common revulsives. 
 
 901. To conclude, bleeding from the arm, the foot, or the jugular 
 vein, is useful, and oftentimes even indispensable, in the convulsions 
 of pregnant and puerperal women, whether of a slight or severe 
 character, where the patient is young, strong, and of a good consti- 
 tution, and not exhausted by preceding hemorrhages. Local blood- 
 letting is the only kind we can resort to where the convulsions super- 
 vene upon a flooding, or in persons who have been debilitated in any 
 way, or those of a lymphatic constitution, &c. In that case, if they 
 occur after delivery, and the lochiae have ceased to flow, leeches may 
 be applied to the labia or to the groin, as recommended by M. C. 
 Baudelocque, otherwise they should be applied to the mastoid apo- 
 physes, according to the counsel of Chaussier. 
 
 When the vascular system has been depleted, if the state of the 
 patient admits of it, a tepid bath should be prescribed ; if irritation 
 or spasmodic contraction of the os uteri appears to be the cause of 
 the phenomena, some opiate cerate, or belladonna ointment should 
 be applied to it. After a flooding, or a painful or fatiguing labour 
 or delivery of the placenta, some analeptic broths and a few spoon- 
 fuls of sound wine will occasionally be found the best remedies that
 
 390 DYSTOCIA. 
 
 can be made use of. Where the woman is delicate and nervons. 
 we have recourse to sedative infusions and waters, narcotic prepa- 
 rations, &c. Sinapisms, blisters, scarifications and other revulsives 
 are, in severe cases, particularly useful as accessory in effect to 
 blood-letting, or as supplementary to those evacuations, where they 
 are themselves inadmissible. Finally, should there be manifest 
 symptoms of disordered stomach or bowels, without any of the signs 
 of inflammatory irritation, I do not perceive that there would be any 
 temerity in promoting either the vomiting or the alvine evacuations 
 by means of gentle emetics and purgatives : but, during the labour, 
 the best remedy beyond dispute is the delivery of the child. 
 
 902. Where the disease comes on before the end of the sixth 
 month, we ought to do every thing in our power to succeed without 
 soliciting the expulsion of the fretus ; its viability being at a later 
 period possible, there is no longer any need for so many precautions 
 on this head. 
 
 To admit of the child being delivered, either with the hand or 
 with the forceps, it is necessary that the dilatation of the cervix 
 should be very advanced, or at least that the os uteri should be 
 soft enough to admit of the womb being entered without the em- 
 ployment of any great degree of force. However, if a trial have 
 been ineffectually made of ointments, injections, and baths"; if the 
 woman or the child were in imminent danger, and a forced delivery 
 the only means of safety ; and in a case where the os uteri should be 
 thin, but hard and undilatablc, and obstinately resist the contrac- 
 tions of the womb, there ought to be no hesitation in following the 
 counsel of M. Bodin, to make one or more incisions into its con- 
 cave edge, or in resorting to what has been called since the time of 
 Simson and Lauvergeat the vaginal-cesarian operation. 
 
 . III. Dystocia caused by the premature descent of the umbili- 
 cal cord. 
 
 903. Although not a rare occurrence, procidence of the cord is 
 not very frequently met with, for it was observed to happen forty-one 
 times in 15,652 labours, at the Maternite at Paris ; its being more 
 frequently met with in private practice seems to depend upon the 
 hasty maneuvres of the persons who assist the lying-in woman, 
 rather than any other caueo : Black has even asserted, but it is evi- 
 dent erroneously, that the descent of the cord is always the effect of 
 attempts to hasten the delivery. A woman was brought to my 
 amphitheatre while I was delivering a lecture ; she was compelled 
 to wait half an hour at the porter's lodge ; no one examined her, 
 and when she was brought up to the ward, the cord formed a loop
 
 PROLAPSED CORD. 391 
 
 of several inches hanging out of the vagina, although the os uteri 
 was but very little dilated. Moreover, there are but few accouch- 
 eurs in large practice who have not had several opportunities of 
 observing the same thing. 
 
 904. The causes of this accident may be referred, 1. To the ex- 
 cessive quantity of the liquor amnii ; 2. To too great a length of 
 the cord ; 3. To the too sudden escape of the waters upon the 
 rupture of the membranes. 
 
 905. The procidence of the cord has always been noted by 
 authors as a dangerous accident. Not because it renders the 
 labour more difficult, or causes the woman to run any greater risk,, 
 but because the fo3tus is thereby exposed to the hazard of dying 
 before it can be delivered. Its death in this case is indisputably 
 produced by the cessation of the circulation of the blood through 
 the cord, and all the reasons collected in the memoir by Thouret 
 are insufficient to weaken this proposition ; but the obstacle to the 
 circulation has not been understood in the same way by all ac- 
 coucheurs. 
 
 Until the time of De la Motte, who did justice to this notion, it 
 had been generally supposed that the blood, from becoming chilled 
 by the external temperature, coagulated, or became concrete in the 
 loop of the cord hanging out of the vulva. 
 
 At present, the accidents attending it are attributed to compres- 
 sion alone. In fact, as soon as the waters are all gone off, if the 
 cord descends before the head, the breech, &c. its vessels are 
 almost necessarily flattened during the expulsive efforts. Neverthe- 
 less, if the pelvis be very large and the fetus small, and the cord is 
 placed near one of the sacro-iliac notches while the forehead or the 
 occiput is towards the opposite one, the compression of its vessels 
 may be so slight as not to prevent the blood from pursuing its route. 
 
 906. Death takes place from an excess of blood, or apoplexy, if 
 M. Chambon is to be believed ; from anemia or syncope, according 
 to Baudelocque, MM. Capuron, Deneux, &c.; from asphyxia, or 
 want of oxygenation of the blood, according to Muller. But neither 
 of these three hypotheses is correct. It is impossible to maintain 
 with Freteaux, that the vein is less compressed than the arteries, or 
 with others, that just the contrary happens. All three of the ves- 
 sels are compressed alike, and the death of the fffitus is to be ex- 
 plained not upon the quantity, but the quality of the blood it re- 
 ceives. 
 
 907. Prognosis. If the cord is cold, without pulsation, shrunk, 
 and greenish, the death of the child is indubitable ; if the labour is 
 still far from its termination, the head strongly engaged, and it is
 
 392 DYSTOCIA. 
 
 difficult to alter its position, the prognosis will be very unfavourable. 
 On the contrary, if the pulsations are kept up with some degree of 
 force, and the labour goes on rapidly, even although the cord be 
 lank and shrunken, its premature escape may be followed by no un- 
 pleasant effect. 
 
 908. Treatment. There are different ways of remedying this pro- 
 cidence. If the child presents transversely, by the shoulder, or by 
 the hip, and the os uteri be not sufficiently dilated to admit of an at- 
 tempt to turn, we must try to return the loop into (he womb ; where 
 the labour is pretty well advanced, we have to seek for the feet, and 
 it would even be dangerous, whenever the pulsations of the cord are 
 found to grow sensibly weaker, to wait for a complete dilatation 
 before we act. 
 
 Where the pelvic extremity of the foetus presents, as soon as the 
 contractions become sufficiently strong, we have to favour their 
 effect by pulling downwards in a proper way upon the lower 
 extremities. But it is, particularly, where it escapes before the head 
 that the cord requires prompt assistance. 
 
 In such cases the ancients confined themselves merely to pushing 
 it up again, and keeping it wrapped up in a linen rag in the vagina ; 
 modern surgeons make use merely of their fingers, or of a piece of 
 whalebone surmounted with a sponge or with a ring. Ducamp has 
 recommended a species of pincers, enclosed in a canula, in most 
 respects similar to the porte-nceud of Dessault ; M. Dudan thinks 
 we should be satisfied with a gum elastic catheter, No. 9, furnished 
 with its wire, which serves to fix the end of a ribbon passed through 
 one of the eyes of the instrument. With this ribbon M. Dudan sus- 
 tains the cord at the end of the catheter without compressing it, and 
 returns it into the cavity of the womb, where he afterwards leaves it, 
 first withdrawing the wire, and then the catheter itself. The canula 
 a. charnitrc, proposed by Wel'ernborg, would in fact be more dange- 
 rous than useful, and I doubt whether any accoucheur will be ever 
 tempted to make use of it. It has also been advised to introduce 
 and fix graduated compresses or bits of sponge betwixt the head of 
 the foetus and the parts of the mother. Finally, Mr Croft finds it 
 more expeditious and more safe to carry the whole hand into the 
 womb, so as to hook the loop of the cord over one of the limbs of 
 the child. 
 
 Doubtless, most of these means might succeed ; but there is not 
 one of them that ought to be adopted exclusively; for the conduct to 
 be pursued will necessarily vary according to the state of the cir- 
 cumstances. 
 
 909. When the child is dead, the presence of the cord requires no
 
 PROLAPSED CORD. 393 
 
 particular maneuvre. If it be living, the head may be, 1. Upon the 
 point of clearing the inferior strait ; and in that case we need only 
 urge the woman to bear down upon the pains as hard as she can ; 
 
 2. In the excavation, and the labour may go on but slowly ; the re- 
 duction is here impossible, and if, after trying it, we find the pulsa- 
 tions of the 1 cord diminishing, we must hasten to apply the forceps ; 
 
 3. Lastly, scarcely engaged ; here we take hold of the cord, and roll 
 it up into a kind of ball which we endeavour to return by pushing 
 it up by the side of, or even above the head, if possible, and if there 
 is any tendency for it to fall down again, it should be kept there until 
 the contractions have firmly fixed the cranium in the strait. Pro- 
 vided the introduction of the fingers were found too difficult, or in- 
 sufficient, some mechanical means might be tried ; such as the 
 instrument of Ducamp, or Dudan's, or what is still better, the porte- 
 cordon in the shape of a fork, invented by M. Guillon. Rather than 
 proceed to turning, recourse ought to be had even to the method 
 recommended by Dr Croft. 
 
 On this subject Madame Lachapelle, as well as many other mo- 
 derns, says that the precept of the English surgeon ought not to be 
 followed, inasmuch as, where the hand is introduced, it would be 
 quite as speedy to draw down the feet. For my part, I am not of 
 that way of thinking; the life of the child is too much endangered 
 in forced delivery by the feet, for us not to prefer delivery by the 
 head whenever it is possible. 
 
 When compelled to extract the foetus by the hand or by the for- 
 ceps, it is important to conform to the precept of Boer, which is, 
 that previously to acting either upon the feet or the head, we ought 
 not the less to endeavour to return the cord, which, without such 
 precaution, could scarcely fail to be very much compressed, either 
 by the hand of the accoucheur, or by the hips, the shoulders, or 
 some other solid part of the child. 
 
 . IV. Dystocia from excessive length or shortness of the umbili- 
 cal cord. 
 
 910. Shortness. Until the time of Baudelocque it was supposed 
 that the delivery of the fcetus might be prevented, or at least consi- 
 derably retarded by a very short cord. When the placenta is 
 attached to the fundus of the womb, if the cord is less than six or 
 eight inches in length, says De la Motte, the head, which is forced 
 towards the inferior strait during the contractions, is found to rise 
 upwards again during the intervals between the pains ; the occiput 
 is seen to engage in the vulva, to be on the point of clearing the 
 strait at every effort made by the woman, and then, as soon as the 
 2Z
 
 394 DYSTQCIA. 
 
 pain is off, it re-enters the passage ; and this continues for several 
 hours. 
 
 The circumstance really takes place, but is altogether independent 
 of the umbilical cord ; it is chiefly to be met with in young women 
 who are strong and robust, and at their first confinement. It de- 
 pends upon the elasticity of the perineum : this flooring of the pelvis 
 gives way while the womb, assisted by the abdominal muscles, urges 
 the head onwards and makes it project from the parts ; but as soon 
 as the contraction ceases, its natural resistance returns the vertex 
 into the interior of the pelvis. 
 
 However, it would be incorrect to assert, as Baudelocque does, 
 that a cord's being too short cannot in any case interfere injuriously 
 with delivery ; in such a case the placenta is liable to be prematurely 
 detached, which might facilitate the occurrence of inversion of the 
 womb, give rise to hemorrhagy, and bring the child's life into dan- 
 ger, should the labour be prolonged ; the strain arising from it might 
 weaken, or even arrest, or at least disturb the contractions of the 
 womb, and suspend the labour ; but in no case can the mere short- 
 ness of the cord mechanically binder the expulsion of the child. 
 
 911. Excessive length. When the cord is, on the contrary, too 
 long, it generally has a strong tendency to procidence, and particu- 
 larly to the formation of one or more loops around the limbs or 
 body of the foetus. These turns are frequently met with in prac- 
 tice, and oftener round the neck than any where else ; where there 
 are many of them, that portion of the cord that remains free may be 
 really too short, whence the same accidents as under the former 
 head might be feared. It has also been thought that they might 
 obstruct the passage of the blood in the jugular veins, and act like 
 ligatures, so as to produce a state of asphyxia. I have seen many 
 children born with turns of the cord about the neck, and it has never 
 seemed to me to be productive of danger in any case. Besides, in 
 strangulation, death is produced by the stoppage of respiration, and 
 death cannot take place in that way in the foetus : again, 1 do not 
 see how the cord can be drawn so tightly as to obliterate the inter- 
 nal jugulars or the carotids ; therefore, at most, only the umbilical 
 vessels are liable to be interrupted. It would appear, however, that 
 these turns of the cord may exist for several months before the pe- 
 riod of delivery, and thus give rise to some very curious anomalies. 
 A fact lately observed by M. Monod, a resident pupil at the Mater- 
 nite, proves that they may, like a branch of ivy round a tree, leave 
 very deep grooves, and produce strangulations, &c. from which 
 even the bones do not wholly escape. Moreover, it is fortunate 
 that these causes of dystocia either do not exist at all, or but very
 
 THE CORD, ANEURISM, ASTHMA. 395 
 
 rarely, for it is impossible to discover them until the head has 
 passed the inferior strait ; except in certain cases of breech presen- 
 tation, in which the cord may be felt tightly stretched, either betwixt 
 the thighs, around one of the limbs, or merely up along the abdo- 
 men, we can suspect the existence of these turns only upon conjec- 
 tures that are too uncertain and vague to deserve the least confidence. 
 If, however, it should be ascertained that the cord is too short, it 
 ought to be immediately cut, provided there should be any danger 
 to the child, and the labour still far from its termination ; care should 
 be then taken to deliver the woman as early as possible, either by 
 the hand or with the forceps. When it is not discovered until the 
 escape of the head, it is in general easily to be remedied : if the 
 turn be a very loose one, and the cord very long, the birth of the child 
 is most generally not at all obstructed by it, and nothing need be done ; 
 in the contrary case, we must either disengage or cut the loop, so 
 that the respiration may not be long in becoming established*. 
 
 . V. Aneurismal dystocia. 
 
 912. An aneurism within the splanchnic cavities, or even in one 
 of the great external arteries, is always a serious disease ; but it is yet 
 rendered still more dangerous by the efforts of labour. The con- 
 tractions of the muscles and the repulsion of the blood consequent 
 thereto might readily occasion the rupture of a sanguine tumour, if 
 haste were not made in emptying the womb. In such cases, there- 
 fore, the patient should be advised to assist her pains as little as pos- 
 sible, and as soon as the orifice is sufficiently dilated or dilatable, 
 the child should be extracted either with the hand or the forceps. 
 
 . VI. Dystocia from asthma, hydrothorax, gibbosity, dropsy, &c. 
 
 913. All diseases that render the respiration difficult, may make 
 it necessary for us not to trust the. labour to the mere resources 
 of the organism. It is well known that asthmatic persons are soon 
 threatened with suffocation when under any state of violent exer- 
 tion ; and that the same holds good of those who are labouring under 
 some effusion in the chest, or in whom the free expansion of the 
 chest is restrained by a deviation of the spine, &c. All wise prac- 
 titioners therefore have recommended that in these circumstances 
 the efforts of the woman should be controlled, and that she should 
 be artificially delivered as soon as the state of the parts admits of 
 the child's feet being brought down safely. 
 
 * Dr Smith, who relates a case of inversion of the womb, produced by the 
 shortness of the cord, recommends, with reason, that we should draw down a 
 portion of that which is connected with the placenta, and then slip the noose 
 over the shoulders, and not over the head of the child.
 
 396 DYSTOCIA. 
 
 914. The same precept has been given where the labour is com- 
 plicated by the presence of some large tumour in the abdomen, or 
 with a dropsy in that cavity ; and that, because here, as in the pre- 
 ceding cases, the efforts of the womb might give rise to a fear of 
 asphyxia, or at least might be followed by a dangerous collapse. 
 
 915. However, I ought to remark that many dropsical women go 
 through their labours almost as easily as those who are in the enjoy- 
 ment of perfect health. I saw at the hospital de Perfectionnement, 
 in 1824, a woman labouring under ascites who had been tapped 
 thirty-six times, and who was, notwithstanding, delivered very natu- 
 rally after a labour of a few hours duration. Another one came 
 to the same establishment in 1826, who had been dropsical for four 
 years, and whose labour lasted only two hours, although her abdo- 
 men was enormously large, and although from ten to fifteen litres 
 of fluid had been several times drawn off from the belly by tapping. 
 
 Nevertheless, as the abdominal muscles are generally very much 
 weakened, and separated, in ascites, by a thick stratum of flqid, their 
 mediate action can be possessed of but little energy in the expulsive 
 part of labour. 
 
 . VII. Hernial dystocia. 
 
 916. When the hernia, of whatever species it may be, is reducible, 
 it should be returned to its proper situation before the pains become 
 very strong, and then during each contraction its escape is to be 
 prevented by holding the thumb, a compress, or the hand, upon the 
 opening through which it passes outwards. This maneuvre is to 
 be attended to by the accoucheur, or at least by an assistant fit 
 to be trusted, and not by the woman herself. When it is an old 
 and irreducible one, we must be content to support it exactly, 
 so as to prevent it from becoming strangulated, or receiving an ad- 
 dition of new portions of viscera to those already contained wjthin 
 the tumour. Beyond this, the labour requires no particular assis- 
 tance, and we should confine ourselves merely to moderate the dis- 
 position of the woman to improve her pains by bearing down ; neve- 
 theless, should the violence of the efforts be such that nothing could 
 prevent the descent, or if there should be strangulation and the 
 labour far advanced, the child should be extracted with all suitable 
 precautions as soon as the dilatation of the os uteri admits of it. 
 
 . VIII. Dystocia from syncope. 
 
 917. Some women are so delicate, or so irritable and nervous, 
 that they fall into syncope from the least pains ; in other cases the 
 syncope and fainting are due to the extreme distention of the uterus, 
 to the force of the contractions, to inanition, to an attack of hemor-
 
 SYNCOPE. 397 
 
 rhage, &c. In a lady who was pregnant with twins, M. Desor- 
 meaux found them to last throughout the whole interval of the con- 
 tractions, and the woman only came out of them while the womb 
 was reacting with violence upon its contents. Antispasmodics and 
 opiates, either applied to the os uteri or taken internally by the 
 mouth or anus, cordial tinctures and other such articles, a few 
 spoonfuls of sound wine, or of broth, light food, &.c. may be tried 
 in succession or by turns ; but, says M. Desormeaux, provided the 
 life of the woman be threatened, we cannot wait for the effects of 
 remedies, no matter how well chosen they may be : under such cir- 
 cumstances, to temporize would be a serious fault; we should ter- 
 minate the labour as soon as possible, in order to prevent a fatal 
 exhaustion. 
 
 918. It is uncommon for weakness, properly so called, to render 
 a labour difficult ; every day, valetudinary and phthisical women are 
 met with who can scarcely stand, and yet bear their children without 
 difficulty. Others are not prevented from being delivered naturally by 
 a state of lethargy, of asphyxia, &.C., and on more than one occasion 
 the womb has been found to retain enough contractility in dying wo- 
 men, or in those who had just expired, to effect the expulsion of the 
 ovum. There are two principal reasons why our succours are most 
 commonly unnecessary in these cases : 1 . Although the muscles and 
 the uterus have to a great degree lost their contractile faculty, the soft 
 parts of the pelvis and the perineum also offer much less resistance ; 
 2. The feeblest women, even those who seem to be upon the point 
 of expiring, ordinarily recover an amount of courage and energy 
 that forms a striking contrast to their extreme exhaustion. 
 
 919. Notwithstanding, it is not a rare thing to see these mo- 
 mentary efforts followed by an oppression and sinking, from which 
 the women recover only after having run the greatest risks - f many 
 of them even are scarcely delivered till they fall into a morbid col- 
 lapse, or sink gradually into death after a few hours, as if, in acting 
 with some degree of violence, nature's only object had been to ter- 
 minate the great act of reproduction happily, at the risk of exhaust- 
 ing in an instant the small remaining strength still belonging to the 
 organs! A young woman six months gone with child, who had 
 been labouring for thirteen days with an attack of phlebitis, and who 
 was in a decidedly adynamic state, was seized with the pains of 
 abortion at four o'clock in the morning ; at ten o'clock the os uteri 
 was soft, and of the size of a three livres piece ; at each contraction 
 her cries, anguish, and agitation restored an appearance of strength, 
 the existence of which was not suspected a few hours before : the 
 poor woman was urged to redouble her courage, and make the
 
 398 DYSTOCIA. 
 
 utmost of her efforts ; in fact the child was delivered at about eleven 
 o'clock, but in an hour afterwards she was no more. 
 
 Consequently, as soon as the os uteri is sufficiently dilated, where- 
 ever there is reason to fear too great a degree of exhaustion, pru- 
 dence requires us to have recourse to a forced delivery. The for- 
 ceps should be preferred in such cases, provided turning be not 
 absolutely indicated, inasmuch as it is less fatiguing for the woman. 
 
 SECTION 2. 
 Essential Dystocia. 
 
 Labour is essentially difficult where the passage of the foetus re- 
 quires the interference of art, from its being rendered impossible, 
 or greatly obstructed from some mechanical obstacle. Of these 
 obstacles, some depend upon the woman ; others, oh the contrary, 
 depend upon the foetus itself. 
 
 . I. Dystccia occasioned by the state of the female organs. 
 
 The difficulties that arise in the organs of the female are sometimes 
 referred to the soft parts, and at others to the hard parts of her struc- 
 ture. The former alone will occupy our attention here, for as much 
 as the latter were treated of in the section on deformed pelvis. 
 
 920. Various tumours have been observed in the pelvic excava- 
 tion, and on more than one occasion, great difficulty has arisen from 
 them in regard to the birth of the child. 
 
 They are pretty frequently found to occur in the perineum, or in 
 the recto^vaginal septum ; being variable as to size, consistence, 
 nature, &c. they are far from always requiring the same kind of 
 treatment ; when not very large or capable of being flattened by 
 pressure, if other circumstances are favourable, they do not always 
 prevent the spontaneous delivery of the child ; scirrhous or fibrous 
 masses connected with the ovary, the intestines or epiploon, when 
 sufficiently movable to sink down and lodge betwixt the uterus and 
 sides of the pelvis, present a peculiar indication ; they require to be 
 displaced and carried above the superior strait ; for this purpose, 
 the woman must be placed upon her back or side, in such.away that 
 the pelvis may be higher than the breast, and all the muscles in a 
 state of relaxation ; then, by means of the hand or fingers, we at- 
 tempt to push the tumour out of the passage ; finally, when all at- 
 tempts at reduction have proved to be fruitless, it may become indis- 
 pensably necessary to extract the tumour by making incisions 
 throu:li tlic vagina or rectum, or even to have recourse to the 
 operation.
 
 TUMOURS, URINARY CALCULI. 399 
 
 921. Sarcomatous, scrofulous, fibrous or other tumours that are 
 situated in the cellular tissue of the pelvis, and that cannot be dis- 
 placed, are much more dangerous than the foregoing ones ; by 
 resisting the head of the child, they expose the womb and other 
 organs contained within the excavation to contusions, perforations 
 and lacerations that it is not always an easy matter to prevent; 
 they also induce inertia and exhaustion, and pretty frequently excite 
 hemorrhagies, convulsions, or various kinds of inflammations. 
 
 922. Those of the recto-vaginal-septum are, most generally, sim- 
 ple encysted tumours ; this at least seems to result from the obser- 
 vations of Plenck, of M. Pelletan, and a case recently noticed by 
 M. Roux at La Charite at Paris. The woman has sometimes suc- 
 ceeded in expelling them, either through the anus or through a 
 laceration in the perineum. In some cases they have been ruptured 
 by the muscular efforts, and that without any ill consequences, when 
 the fluid they contained was permitted to escape into the rectum, 
 the vagina, or even to be effused in the surrounding cellular tissue. 
 But they may also end in abscess, gangrene, or a mortal peritonitis, 
 if the laceration extends into the peritoneum. It is, therefore, most 
 prudent to empty them or extract them as soon as they are ascer- 
 tained to be capable of hindering the escape of the foetus, or ren- 
 dering it dangerous. In such cases, it is not always an easy matter 
 to distinguish an hydatid or encysted tumour from such as are solid ; 
 but, as has been pointed out by M. Desormeaux, a puncture with a 
 small trocar will suffice to remove all doubts upon the subject. 
 
 923. Calculi in the bladder. It is evident that a large stone 
 might, during labour, become situated directly behind the pubis, so 
 as to shorten the antero-posterior diameter of the pelvis. But a 
 stone being violently pressed from above downwards, by the child's 
 head, would almost necessarily give rise to contiipn or laceration 
 of the bladder or of the recto-vaginal septum, a's well as the pain 
 that would ensue thereupon. It would be easy, at the commence- 
 ment of labour, to push the stone upwards, and retain it above the 
 symphysis pubis, until the head could get beloyv it. Should the 
 practitioner arrive late, and find the stone coming down before the 
 head, he should, notwithstanding, endeavour to raise it above the 
 strait. Where it is impossible to get it up, there is one resource 
 left, which is to cut down on to the stone through the anterior side 
 of the vagina, or to perform vaginal lithotomy. 
 
 924. The labia or nymphce may have become agglutinated pos- 
 teriorly to the fecundation, and either wholly or partially close up 
 the vagina. The hymen may be hard, fibrous or cartilaginous, so 
 as to leave but a small orifice, and thus interfere with the escape of
 
 400 DYSTOCIA. 
 
 the child (143). Delivery is not in such cases impossible: such 
 feeble barriers are incapable of counterbalancing the energetic 
 contractions of the uterus ; but it is better to divide with an in- 
 strument those parts that have to be separated, than to expose the 
 woman to the risk of ruptures and irregular lacerations whose 
 limits can not be prescribed, and which might go to a dangerous ex- 
 tent. 
 
 925. Where the vulvar extremity of the vagina is completely 
 obliterated, no conception could possibly have taken place by the 
 natural passages ; but it is not uncommon to meet with bridles or 
 partial contractions in some part of the canal. Where these frena 
 are not very old, or very hard, they ordinarily become softened and 
 yield to the mere progress of the labour ; where they resist, so far 
 as to awaken a fear of laceration of the womb, inertia, convulsions, 
 exhaustion, or their own rupture, they should be divided by making 
 a few small incisions on their anterior edges. A woman who was 
 in labour of her third child, and who two years previously was 
 delivered by means of instruments, was brought to the hospital de 
 Perfectionnement, by M. Dubourguet, after having been three days 
 in travail : I was about to apply the forceps, but was soon arrested 
 by a large crescent-shaped bridle, which was hard, and, as it were, 
 fibro-cartilaginous, which was two inches above the vulva, and on 
 the free edge of which I found it necessary to make three incisions. 
 
 926. When the vagina opens into the bladder, fecundation being 
 on that account evidently impossible, it is therefore useless to class 
 this deviation among the causes of dystocia. 
 
 Several authors, and among others Barbaut, and still more re- 
 cently M. Marc, have made mention of women in whom the vagina 
 opened into the rectum, who notwithstanding became pregnant, and 
 yet were delivered without any artificial aid. 
 
 Stegmann relates the case of a girl whose vagina opened above 
 the pubis, and Morgagni speaks, after Gianella, of a case in which fe- 
 cundation nevertheless took place : in such a case it would be neces- 
 sary first to try, like the Italian accoucheur, to dilate the preternatu- 
 ral opening, and should that prove insufficient, to make seyeral eccen- 
 tric incisions upon the orifice, not losing sight of the proximity of 
 the peritoneum and bladder. 
 
 Scirrhous or fibrous tumours capable of affording an obstacle to 
 delivery, and requiring serious operations, rarely occur in the vulva ; 
 but chronic or acute phlegmons are met with that might be singu- 
 larly aggravated by the passage of the foetus, and it is important, 
 therefore, that they should be very energetically treated in women 
 who are approaching their term.
 
 TUMOURS. 401 
 
 The labia are, at times, the seat of bloody tumours, of a particu- 
 lar kind, that I have long mentioned in my lectures, which Dr 
 Dewees also has described in the American journals, and to the con- 
 sideration of which I shall return when I come to treat of the ac- 
 cidents of parturition ; for the present, I shall content myself with 
 stating, that where they are sufficiently large to interfere manifestly 
 with the birth of the child, or expose the mother to very acute 
 suffering, I should not hesitate about plunging a bistoury into them, 
 so as to empty them completely. 
 
 927. Some women, though in other respects robust, are affected, 
 towards the close of pregnancy, with a considerable infiltration in 
 the lower limbs, and even in the whole body. The cutaneous and 
 mucous folds of the vulva may in such cases attain to an enormous 
 size, and completely close the vagina ; the termination of a labour 
 is thus rendered, of necessity, much more difficult, and above all 
 much more painful ; it cannot be dissembled, that by leaving nature 
 to herself here, there will be reason to fear the occurrence of gan- 
 grene, or of more or less extensive lacerations ; unhappily, although 
 threatened with such dangers, there is little that the accoucheur can 
 do ; some punctures, the application of emollient and sedative 
 lotions, and care in relation to the disposition of the parts and to 
 the muscular efforts of the woman, afford all the materials for his 
 counsel. 
 
 928. Inversion of the vagina may take place during pregnancy 
 and even during labour. I was called last spring, by Madame Beva- 
 let, to see a woman who had been suffering for thirty hours without 
 being delivered. The head of the foetus was quite down in the ex- 
 cavation ; but the vagina, which was entirely inverted, exhibited out- 
 side of the vulva, the appearance of a fungous and livid cushion 
 larger than two fists. It was necessary to apply the forceps for the 
 delivery of the patient. 
 
 929. Much has been said about the obliteration of the os uteri 
 of women in labour ; but if it is not wholly certain, it is at least 
 highly probable that the authors who have mentioned it were mis- 
 led by some deviation affecting the os tineas. I have already seen 
 so many practitioners, even experienced ones, affirm that there was 
 no os uteri at all, in cases where it was merely raised up towards 
 the sacro-vertebral angle, that it seems to me very easy to refer a 
 great majority of the cases of supposed obliteration of the os uteri 
 to this mistake alone. It is evident that nothing less than some 
 severe disease, some acute inflammation, could thus close up the 
 mouth of the womb, betwixt the fecundation and the term of gesta- 
 tion ; but in that case the parts would necessarily be affected with 
 
 3 A
 
 402 DYSTOCIA. 
 
 concomitant alterations of structure, sufficient to remove all doubts ; 
 the anamnestic signs would have attracted attention precedently, 
 and abortion could rarely fail to take place. 
 
 However, if authentic examples be wanting of complete obliter- 
 ation at the period of labour, we at least possess several instances 
 of coarctation, partial or total induration, and still more numerous 
 ones of stricture in some other portion of the os uteri. 
 
 Were the canal closed by a spongy or polypous mass, like those 
 met with by Denman and M. Evrat, we should wait for its descent 
 into the vagina, to attempt its extraction, after which we should 
 proceed as in any other case of parturition. 
 
 930. A scirrhous induration, of partial extent, might require no 
 particular assistance. In a case mentioned by M. Desormeaux, the 
 whole dilatation took place at the expense of only two-thirds of the 
 circumference of the orifice, and the escape of the ovum was 
 scarcely retarded ; but if the whole of the cervix uteri were involved, 
 either at its vaginal extremity, or at a point near the cavity of the 
 uterus, the vaginal-cesarian operation would be indicated, it being 
 well understood that a forced dilatation with the fingers or the 
 speculum, either could not be attempted, or had been vainly tried. 
 
 931. A fibrous tumour, a scirrhus, a polypus, cicatrices, an ulcer, 
 an abscess in the substance of the womb, or even upon its internal 
 substance, would also require particular precautions, provided it 
 were possible to ascertain their existence. In the first place, the 
 diseased point does not in general partake in the extension of the 
 organ during pregnancy, or does not contract again after delivery ; 
 in the next place, it deranges or interrupts the contractions during 
 labour, and in that way favours the occurrence of convulsions, lace- 
 ration of the womb, hemorrhage, inertia, and general exhaustion. 
 In order, therefore, to protect the woman as far as possible from 
 such dangers, it would be necessary to extract the child, without 
 waiting too long, either by the hand or with instruments. 
 
 932. Labour is also sometimes rendered very difficult, and even 
 wholly impossible, by means of displacements and deviations of the 
 womb. 
 
 There are instances of complete prolapsus which did not prevent 
 the woman from being fecundated ; witness the peasant woman 
 mentioned by Morgagni. In other cases, the falling of the womb 
 occurs during pregnancy. In both cases, provided the gestation 
 goes to its full term, it is possible for the womb, which here can not 
 be seconded by the abdominal muscles, to deliver itself alone; but 
 it is also possible that the pains should prove to be insufficient, and 
 thenceforth prudence requires us to make use in succession- of de-
 
 DISPLACEMENTS OF THE WOMB. 4Q3 
 
 coctions, mucilages and ointments of an emollient nature, and 
 resort to the dilatation or incision of the edges of the orifice, and 
 afterwards bring down the child's feet. 
 
 Sennertus and Ruysch have related cases of hernia of the womb, 
 where the women have, notwithstanding, become pregnant; but every 
 consideration leads to the belief that mistake here has more than on 
 one occasion arisen from a very decided anterior obliquity of the 
 womb. 
 
 This kind of displacement forms, in the opinion of several authors, 
 an insurmountable obstacle to the spontaneous termination of la- 
 bour ; so that, under such circumstances, they have thought of no 
 better counsel than that of resorting to the cesarian operation ; how- 
 ever, this last recourse will hardly be taken by a man who is fully 
 acquainted with the resources of the animal economy. Provided the 
 reduction be possible, the accoucheur will attempt it ; in the con- 
 trary case, he should be content with recommending the horizontal 
 posture, and advising the woman not to bear down. During the 
 contractions, and even during the intervals between them, it is pro- 
 per to press the uterus backwards, with the two hands applied to the 
 epigastrium, as if to make it re-enter the abdomen ; by means of 
 these precautions, which are not even always indispensable, the os 
 uteri dilates, opens, and the labour most frequently terminates with- 
 out further assistance, and without danger, even in cases apparently 
 the most difficult. An accoucheur at Copenhagen was called to a 
 woman who had for a long time had a crural hysterocele, and who 
 exhibited some symptoms of pregnancy ; the period of delivery ar- 
 rived, the surgeon had given the most unfavourable prognosis, and 
 thought he should be under the necessity of performing the opera- 
 tion of hysterotomy. But nothing of the kind happened, and the 
 labour terminated spontaneously. Ruysch and Simon relate two 
 cases of uterine hernia equally remarkable : in one of them the ce- 
 sarian operation was performed and the woman died ; in the other, 
 nothing was done, and both the mother and child were saved ! 
 
 Simple deviations of the womb may also interfere with the pro- 
 gress of parturition and require some particular care. Upon this 
 subject I ought to remark, that it is far more important than writers 
 seem to suppose, not to confuse deviations of the cervix with those 
 of the womb strictly so called. In fact, although the deviation of 
 the orifice pretty frequently coincides with that of the fondus of the 
 organ, it is nevertheless undeniable, that one is often met with with- 
 out the other. 
 
 933. When the womb is inclined laterally or backwards, no great 
 difficulty can arise as to the delivery of the child, provided there
 
 404 DYSTOCIA. 
 
 should be no other cause of dystocia. In the anterior obliquity, on 
 the contrary, especially when it is to a great extent, the assistance 
 of art may become indispensably necessary. The woman should 
 be directed to lie down at the very beginning of the labour, and told 
 to remain in a horizontal posture, taking care to keep the hips con- 
 siderably elevated ; the hypogastrium is to be pressed backwards, 
 while by means of one or two fingers introduced into the vagina we 
 attempt to draw the os uteri to the centre of the pelvis. These last- 
 mentioned tractions, which are useful where the orifice is found 
 raised upwards towards the sacro-vertebral angle, need not be tried 
 in cases where the womb, instead of being inclined by a see-saw 
 motion, is bent forwards on its anterior surface, like a chemist's 
 retort ? But in that case we should direct the woman to mode- 
 rate, or even to suspend, her efforts ; for, during the pains, the ac- 
 tion of the diaphragm and abdominal muscles tends constantly to 
 augment the obliquity, and thus to annul the efforts of the practi- 
 tioner in a contrary direction. In the spring of 1825 I was called 
 by M. Majeste to a woman whose labour had been at a stand for 
 several hours, notwithstanding the pains were very severe. The 
 womb, bent into the form of a retort, was so disposed that at each 
 contraction its posterior surface became quite horizontal. I showed 
 the patient that her efforts were not only of no use, but also that 
 they were sufficient to prevent her labour from coming to a conclu- 
 sion. She was obedient to the counsel I gave her, and resisted, as 
 far as she possibly could, the sensations that excited her to bear down. 
 It was not long before the womb rose up of its own accord during 
 the contraction, the head soon engaged, and in two hours after- 
 wards the child was born. There are, therefore, certain cases of 
 inclination where the labour ought to be abandoned almost entirely 
 to the mere contractions of the womb. 
 
 934. Doubtless, Moschion and Deventer were wrong in main- 
 taining that obliquity of the womb most frequently produces a trans- 
 verse position of the fcctus ; but it would be quite as unreasonable 
 to maintain that this effect never does take place. If the inclina- 
 tions of the w.omb do rarely suffice to produce real transverse or 
 shoulder presentations of the foetus, they, at least, seem to me to be 
 very frequently the causes of presentations of the face, the forehead, 
 the nucha, the parietal protuberances, the hips, &c. and in this res- 
 pect to deserve the attention of the accoucheur. 
 
 935. I ought in this place to mention a kind of deviation that I 
 have never met with but once, of which I have been unable to find 
 any cases described by the various^uthors, and which ought not to 
 be confounded with anterior obliquity. In a woman who came to
 
 DISPLACEMENTS OF THE WOMB. 405 
 
 * w 
 
 be confined at my amphitheatre in the month of May 1828, the 
 fundus of the uterus was rather inclined backwards than forwards ; 
 the head of the foetus formed above the strait a considerable projec- 
 tion, which descended nearly to the vulva, and was at last situated in 
 front of the symphysis pubis ; the os uteri, which was on a level with 
 the superior strait, seemed to be scooped out of the substance of the 
 posterior wall of the womb, which made it much longer behind than 
 before ; in order to reach the orifice and penetrate towards the head 
 of the child, I was obliged to bend my finger so as to make it pass 
 almost horizontally above the pubis. Such a state of things sur- 
 prised me, and I mentioned it to the students, who easily satisfied 
 themselves as to its existence. The progress of the labour was so 
 much retarded by it, that after seven hours of pain and pretty strong 
 contractions, the os uteri, although very soft and very dilatable, was 
 scarcely opened at all. M. Desormeaux, whom I invited to see this 
 remarkable case, said that he had never noticed one like it, and 
 agreed with me that by means of position and the assistance of the 
 hand properly combined, I ought to try to carry the head to the 
 centre of the superior strait, by making it slide from below upwards 
 and from before backwards over the pubis. I began to execute 
 this maneuvre at half past eight o'clock, and continued it, alternat- 
 ing with several of the students until nine o'clock. From this time 
 there was no longer a tumour in front of the symphysis, and the 
 labour progressed so rapidly that in less than an hour the child was 
 born and the placenta itself expelled. 
 
 Such a state of things seems to depend : 1st, on a posterior 
 inclination of the womb ; 2d, on excessive inclination of the supe- 
 rior strait ; 3d, on some deviated position of the foetal head, and, 
 perhaps, upon the thickness, or the unequal density of the walls of 
 the womb; to this displacement should be referred the positions 
 described under the name of sur-pubal by Madame Lachapelle and 
 M. Duges. 
 
 936. I have many times found the orifice turned so much back- 
 wards or to the outside, that its plane was almost parallel to the axis 
 of the woman's body, although the rest of the womb was scarcely 
 deviated at all. Excessive amplitude of the pelvis, great inclination 
 of its superior strait, ancfcpresentations of the vertex, are probably 
 the causes that most favour its obliquity. In touching, we feel, 
 sometimes almost at the bottom of the excavation, and at others 
 rather higher up, a tumour, generally very even, and which consists 
 of the child's head covered with the anterior wall of the distended 
 cervix of the uterus. This state of things has to me seemed to im- 
 press upon labour a peculiar character of tediousness, and often
 
 406 DYSTOCIA. 
 
 coincides with what is called pains in the reins. The ablest wri- 
 ters, and Baudelocque himself, recommend, as a remedy, that we 
 should hook the os uteri with one or two fingers, draw it towards 
 the centre of the pelvis during the intervals between the pains, and 
 keep it there during the contractions ; or also, have recourse to 
 vaginal hysterotomy, the only means of avoiding gangrene or rupture 
 of the womb, &c. Were I to depend upon my own experience in 
 this matter, I should be led to think that the interference of art, in 
 this state of things, is rarely necessary, and that in more than one 
 case there has been too great haste in acting, to the great detriment 
 both of the mother and child. I for a long time conformed to the 
 precepts laid down in the books, I pulled at the os uteri, and did 
 all I could to bring it back to the centre of the excavation ; it is true 
 I succeeded, but pretty often not until I had remained several hours 
 with the woman. I was one day obliged to leave a student as my 
 substitute, who neglected the directions I gave him ; after an ab- 
 sence of three hours I returned, found the os uteri completely 
 dilated, the membranes ruptured, and the head strongly engaged. 
 From that time I have never interfered in such cases, and the 
 organism has always succeeded in restoring things to their natural 
 state. My design is not to conclude from this, that we must never 
 do any thing but wait, but merely to observe, that, excepting in a 
 small number of cases, nature herself may suffice, and that a resort 
 to bloody operations ought not to be lightly resolved on. 
 
 937. Gibbosities and acute diseases do not become a cause of 
 dystocia, excepting as they often do not allow the woman, without 
 danger, to give herself up to the efforts needed for the delivery of a 
 child ; but there is another very remarkable cause of difficult labour 
 which no author has mentioned. A strong, robust woman, pregnant 
 with her first child, in the forty-fifth year of her age, had been in 
 labour for forty hours, when M. Morisse sent for me to see her. 
 The presentation was good, the head had been in the excavation for 
 twelve hours without advancing, in spite of the energy of the uterine 
 contractions. The skin on the fore part of the thighs and abdomen 
 was all covered with old cicatrices, which were hard and fibrous, 
 and confined the lower part of the hypogastrium, so that the womb 
 was as if strangulated immediately above the pubis, and the child 
 could not descend. I applied the forceps, and the child was brought 
 away living. 
 
 . II. Dystocia depending on the foetus. Monstrosity. 
 930. Excessive volume. There is no doubt, says M. Duges, that 
 where UK; child is very tall it may render a labour more tedious,
 
 MONSTROUS FCETUS. 4O7 
 
 painful and distressing, especially if the passages are not soft and 
 small, as in a first labour ; but it is not yet proved that great size in 
 a well formed child at full term has ever alone constituted an in- 
 surmountable obstacle to spontaneous parturition. 
 
 If it be true that Baudelocque, Chaussier, M. Capuron, &c. have 
 seen children born, weighing near thirteen, twelve, or even ten 
 pounds, it is nevertheless certain that we no longer see them reach- 
 ing to the weight of fifteen, twenty, and twenty-five pounds, nor any 
 whose length exceeds from twenty-two to twenty-three inches. But, 
 as it is an easy matter to ^ascertain that the head of a foetus of 
 twenty-two inches will not be quite four inches in its occipito- 
 bregmatic and bi-parietal diameters, it is at once evident that, 
 even in case of extreme size, spontaneous delivery is not impos- 
 sible. It should be remarked, however, that in that case the least 
 narrowness of the pelvic cavity, especially in the perineal strait, must 
 promptly become the cause of dystocia. 
 
 On the other hand, the practitioner ought to know that under such 
 circumstances, version by the feet is never proper. Indeed, where 
 the head presents, although its shortest diameter and smallest cir- 
 cumference are almost always in relation with the largest diameters 
 of the pelvis, it is rarely that in extracting the child by the feet the 
 occiput is not forced to turn over more or less upon the back, while 
 the occipito-frontal, which would be nearly five inches long, would 
 take place of the occipito-bregmatic diameter ; perhaps it might even 
 be the occipito-mental that would be thus situated, and that would 
 be at least five and a half inches in length. 
 
 The best course is to confide in the resources of the organism, 
 and where it is indispensably necessary to act, to attempt the appli- 
 cation of the forceps rather than venture upon turning ; and should 
 it be a presentation of the pelvic extremity of the foetus, either ori- 
 ginally or by turning, every precaution should be employed to pre- 
 vent an arm from becoming locked behind the neck. 
 
 939. Infiltration of the integuments of the head, and sanguine 
 tumours, sometimes evidently increase the size of the head, but 
 rarely to such an extent as to furnish any real obstacle to delivery. 
 Harnier, to be sure, has remarked that where thrombuses and in- 
 filtrations are of such magnitude as to deserve any particular atten- 
 tion, by engaging in the space under the arch of the pubis, such 
 tumours prevent the rotation movement which the head ought to 
 execute in order to clear the inferior strait. 
 
 940. Hydrocephalus constitutes a much more real, and particu- 
 larly much more serious cause of dystocia ; it is recognized by 
 various signs: the finger feels a broad and tense tumour; the bones
 
 408 DYSTOCIA. 
 
 of the head are evidently separated and very movable ; the dimen- 
 sions of the fontanels are very considerable ; sometimes we meet 
 with Wormian bones of various sizes in the midst of spaces that are 
 completely membranous; as to the infiltration of the limbs and 
 hypogastrium of the mother during gestation, ascites, hydramnios, 
 anasarca, the lymphatic constitution, and the rational signs, that 
 have been supposed derivable from the size of the head, tongue, 
 and forehead of the woman, they can give rise only to conjec- 
 tures that are wholly useless in the establishment of a positive diag- 
 nosis. Moreover, it is necessary to take care not to be imposed 
 upon by an accidental deficiency of ossification, by a fontanel, by 
 abnormal sutures, or a great degree of flexibility of the bones, and 
 to recollect that hydrocephalus during intra-uterine life is so rare, 
 that according to Madame Lachapelle and M. Duges it was only 
 met with fifteen times in 43,555 labours. 
 
 941. In order to comprehend the dangers of this species of dys- 
 tocia, it should be well understood that serous fluids may accumu- 
 late in various quantity in the cranium, and that if the head is soft 
 and its size not very greatly augmented, the mere energies of the 
 woman in general suffice for its expulsion. When its size is not 
 excessive and the womb threatens to fall into inertia, recourse is 
 had to the forceps, taking care to make use of a moderate degrqe 
 of pressure, so as not to burst the head, nor allow of the instrument's 
 slipping. Where the child is dead and the head is too large to get 
 through the straits, cephalotomy becomes a last resource, which 
 we are obliged to employ. 
 
 Notwithstanding, I ought not to conceal that this subject has 
 been and still is the subject of a very important question among 
 practitioners. Where we have a certainty that the child is -dead, 
 every body is agreed ; but in the contrary case, it has been asserted 
 that we have no right to kill it, and that it would be better to per- 
 form the cesarean operation or symphyseotomy. Others have ob- 
 jected that a child ought not to be the assassin of its mother ; that 
 as hydrocephalous children die very soon after their birth, it would 
 be contrary to humanity as well as to morality to sacrifice a sound 
 and healthy woman for a being whose existence is so precarious. 
 These reasons are, in tny opinion, of the highest authority ; for 
 although, as M. Duges asserts, it be true that a slight degree of 
 hydrocephalus ought not necessarily to occasion the death of the 
 child, does not always prevent its viability, and may sometimes be 
 cured, it is equally certain, that in case the head is not so large as 
 absolutely to require the operation, and t lint where even the diseac 
 is BO advanced as to render the delivery impossible, we have no
 
 MONSTROUS FCETUS. 409 
 
 gfound to rely upon the viability of the child. But how is the 
 liquor amnii to be evacuated ? Should it be done with Smellie's 
 scissors, Stein's pcrcc-crdne, a common bistoury, or is it better, like 
 MM. Maygrier and Duges, to be content with a simple trocar ? 
 Since, according to Holbrock, Vose, &c. the puncture has been 
 successfully performed after birth, and as large lacerations are not 
 required to give issue to the serum of hydrocephalus, I perceive no 
 inconvenience likely to arise in pursuing this last named course, 
 inasmuch as it at once satisfies the indications of prudence and the 
 wants of practice. But if the head should not be thereby emptied 
 sufficiently to render its escape easy, I should not hesitate about 
 plunging one of the other instruments into the head. 
 
 After the operation of cephalotomy has been performed, the con- 
 tractions of the womb generally suffice for the expulsion of the head ; 
 but if this should not be the case, recourse is had to the forceps, to 
 turning, or to the crotchet. 
 
 942. I do not know that hydro-rachis has ever proved to be a real 
 obstacle to the termination of a labour. It is a dangerous disease 
 to the fffitus, and that is all ; besides, nothing could be easier than 
 to empty the tumour by pushing a trocar into it, should it appear to 
 interrupt the progress of the labour. 
 
 943. It is rare also for ascitcs, and particularly for hydrothorax, to 
 be of such extent as to furnish considerable obstacles to the delivery 
 of the child, asappears from the remarks of Baudelocque, M. Lamour- 
 eux, and M. Duges. In all cases those lacerations and eviscerations 
 that were practised by Deventer should be avoided, as well as the 
 mode recommended by Mauriceau, of perforating the navel or the 
 neighbouring parts with the finger ; simple punctures, made with a 
 trocar or a bistoury, always suffice to produce the effect which it is 
 desirable to obtain. 
 
 944. Solid tumours developed upon certain parts ef the trunk, 
 or any decided deformity, like the case related by Baudelocque, and 
 another one published by M. Nivert, might require some peculiar 
 attention, or even render delivery wholly impossible. Cases of this 
 sort are particularly untoward, inasmuch as it is, generally, quite 
 impossible to ascertain the circumstances until after delivery. Thus, 
 in the case that fell under M. Nivert's notice, the foetus had a very 
 solid and projecting gibbosity which lodged above the pubis ; the for- 
 ceps was applied, but without oflcct, for it. became necessary to empty 
 the head ; still, it was only by means of the crotchet and by employ- 
 ing the utmost strength, that he succeeded in extracting the trunk 
 of the foetus. Who could have suspected the existence of such an 
 obstacle ? and even had it been understood, what could have been 
 
 3B
 
 410 DYSTOCIA. 
 
 done ? Ought turning to have been attempted ? Would any ad- 
 vantage have been derived from pressure suitably applied to the 
 lower part of the hypogastrium ? It belongs to future experience 
 to solve these questions. 
 
 945. The simultaneous presence of several foetuses in the womb 
 is far from always being a cause of dystocia, especially when they 
 are independent of each other, and are each enclosed within a 
 separate amnios. But this is not the case where they are contained 
 within the same set of membranes, or have contracted any adhesions 
 that compel them to present simultaneously at the straits of the 
 pelvis. 
 
 In the latter case, the union of the children may be in very vari- 
 ous degrees. Sometimes they are connected together by a very 
 circumscribed point upon the inferior, middle or superior part of the 
 back, sometimes by almost the whole back, side, or front ; at others 
 they are conjoined at the head, or placed end to end at the breech. 
 The fusion is in some cases much more complete : or, there may 
 be only one single trunk to two heads and two or four arms ; or, on 
 the contrary, there may be only one head to two trunks, with limbs 
 more or less completely isolated. 
 
 94G. The signs of these monstrosities are so vague, that they 
 really do not deserve to be repeated in this place ; there can be no 
 certainty, nor even probability, of their existence, except in so far 
 as certain portions of the foetus are already emerged ; and even 
 then, it is for the most part very difficult to characterise the nature 
 of the monster we are about to receive. 
 
 We have enough of cases of monsters from excess of parts, born 
 living and under the mere resources of nature, to warrant us in not 
 acting too hastily in such circumstances. If a double foetus with 
 a single head presents by the vertex, or even by the feet, provided 
 the conformation of the pelvis be good, the delivery will not require 
 any particular interference; the same would be the case with two 
 foetuses attached to each other by their extremities, either the head 
 or breech, as is proved by the cases mentioned by Meckcl, Palfyn, 
 Duverncy, Home, &c. Further, M. Dugos saw one born without 
 assistance, though it was completely double, at full term, and of 
 large size. But again, the observations of Plenck, Smellie, &c. 
 demonstrate that monsters of a much smaller size have, on more 
 than one occasion, rendered delivery very distressing, both to the 
 mother and the accoucheur, particularly where there was a great 
 to have them born alive. 
 
 VVIn-ii there arc two heads to a single trunk, provided the 
 uuc that iu iti front succeeds in engaging first, the second may fol- 
 low without any extreme difficulty, and being forced downwards,
 
 MONSTERS. 411 
 
 they will clear the vulva, almost as easily as if there had been but 
 one. When such a monster presents by the feet, the posterior head 
 ought to descend first into the excavation, whilst the other remains 
 above the pubis ; the woman may exhaust herself in vain efforts, 
 and the intervention of the accoucheur may become indispensable. 
 But, previously to operating, several questions present themselves 
 to the practitioner ; is the monster dead, or is it living ? In the lat- 
 ter case, are we to act upon the woman, or upon the foetus ? I 
 know that a double child, or one that is simply bi-cephalous, may 
 live and grow after birth ; that several have lived for seventeen, or 
 twenty years, and even to a very advanced age ; that a foetus seen 
 by Everard Home, that was born in the East Indies, and which died 
 at three years of age of the bite of a serpent, grew as regularly as 
 the best formed child, though it had two heads united together at the 
 vertex. Who is unacquainted with the history of the monster 
 noticed in China, and of which an account was laid before the 
 Academic des Sciences last year ? I do not wish therefore to 
 maintain that such beings are of necessity unlikely to live ; but is it 
 true that they have the same rights as any other foetuses to our care 
 and solicitude ? Is their life so valuable, that with the view, and 
 under the few chances of preserving and raising them, we are bound 
 to perform on the mother a most dangerous and too commonly 
 fatal operation ? I am aware that by the cesarian operation we 
 may save the child, and not cause the mother to perish ; but is it 
 not well known that one half of the women who submit to it lose 
 their lives, and that almost all the foetuses soon undergo the same 
 fate ? ^ I do not hesitate to say, and I believe in conformity to the 
 sacred laws of humanity, that if I were obliged to choose between 
 hysterotomy and the murder (meurtre) of a monster, I should not 
 vacillate a moment, I would sacrifice the foetus. Happily, the skil- 
 ful accoucheur can scarcely ever be subjected to this distressing 
 alternative ; maneuvres well arranged, and performed either with 
 the hand, the forceps, or the lever, almost always succeed in disem- 
 barrassing the woman through the natural passages, without injuring 
 the child. 
 
 948. The turning and delivery by the feet resorted to by Pen, 
 Walter, Walgen, M. Evrat, M. Brez, Regnoli, &c. and recom- 
 mended by Asdrubali, MM. Desormcaux, Duges and others, whe- 
 ther the child be exactly double or merely bi-cephalous, living or 
 dead, and at any stage of gestation, will suffice in nine cases out of 
 ten, at least, where there are no other causes of dystocia present. 
 It ought therefore to be tried in all cases. However, if one of the 
 heads should be already so far engaged, that it could not possibly be 
 
 

 
 412 DYSTOCIA. 
 
 returned, we might, after the manner of Plenck, try the application 
 of the forceps. Should the forceps prove insufficient, there would 
 be a last recourse, the removal of the parts that had descended into 
 the excavation, that is to say, of the head alone, or the head and 
 arms ; after which the feet could be brought down so as to deliver 
 by turning, as was done by M. Retel, in 1818, in such a case. 
 There would be less to fear in such a case, as the foetus generally 
 dies long before we are reduced to this extremity. The difficulty of 
 separating two children, united to a certain extent, outside of the 
 womb, and the danger to which by such operations they are exposed, 
 clearly show how imprudent it would be to follow the advice of Smel- 
 He, and attempt to do so, in the interior even of the uterus. 
 
 949. When, in twin pregnancy, two foetuses present simulta- 
 neously at the straits, the intervention of art almost always becomes 
 necessary, and sometimes indispensable. If it be found that both 
 the heads tend to engage at the same time, which is excessively rare, 
 it is proper to push up the most movable one with the fingers, so as 
 to let the other advance first ; the same procedure may be adopted 
 for the feet, the knees or breech ; if the children present across, or 
 in any other way except by the head or the pelvis, recourse must be 
 had to turning ; but it may happen that one of them comes by the 
 head, whilst the other descends by the feet, and that upon reaching 
 the superior strait the chin of the latter hooks in with the chin of 
 the former, so that the two heads at length become immovably fixed, 
 each opposing an insurmountable resistance to the other, and con- 
 stituting one of the most embarrassing cases in the practice of mid- 
 wifery ; neither turning nor the application of the forceps can be 
 thought of; even the cesarean operation itself, which has been re- 
 commended by some authors, would not always enable us to disengage 
 the foetus ; so that the detruncation of the one that is without, consti- 
 tutes almost the only resource left to us for the safety of the mother 
 and one of the children. 
 
 SECTION 3. 
 Dystoda from Wrong Presentations of the Foetus. 
 
 It has been seen in another article that the presence of one of the 
 extremities of the occipito-coccygeal diameter of the foetus at the 
 suprrior strait, is one of the first conditions of cutocia. All the cases 
 in which any other point than the head or pelvis presents ought
 
 WRONG PRESENTATIONS. 413 
 
 therefore to be classed among the cases of clystocia. I will add that 
 to them should be conjoined all the deviated positions of the head 
 or breech. 
 
 . I. Deviated positions of the head. 
 
 Under this title I comprise the positions of the sides of the head, 
 of the ears or of the temples, admitted by Mauriceau, Deventer, De 
 la Motte, and Baudelocque ; and those of the occiput, in so far as they 
 really exist, as was understood by the last named author : as to the 
 forehead and face positions, since they do not, in general, prevent a 
 labour from terminating without assistance, I shall say nothing about 
 them in this place. 
 
 950. Positions of the occiput or upper part of the nucha are rare, and 
 scarcely occur except in very decided anterior inclination of the womb. 
 Then the vertex may be turned towards some point on the circum- 
 ference of the pelvis instead of corresponding to the centre of the 
 strait ; should pushing the womb backwards, keeping the woman on 
 her back, or the mere efforts of the organism prove to be insufficient 
 to re-establish the natural position, it would be necessary, with the 
 fingers, the lever, or one of the blades of the^ forceps, to hook the 
 upper part of the cranium, and draw it down towards the centre of 
 the excavation, upon which the labour would return to the natural 
 order. 
 
 951. The lateral positions of the head, being nothing more than 
 slightly modified positions of the vertex, are the same in point of 
 number with them ; they arc marked by the presence of the ear, of 
 the angle of the jaw, or the parietal protuberance : they are distin- 
 guished from each other by considering to which point of the strait 
 the posterior edge and lobule of the ear are turned ; they are, more- 
 over, rare, and generally end in conforming themselves, spontane- 
 ously, to the corresponding positions of the vertex or shoulder. 
 
 We ought, consequently, to trust to the efforts of the womb, as 
 long as the os uteri continues to be sufficiently dilated ; if they then 
 persist, we must, as in positions of the occiput, endeavour to bring 
 back the vertex to the centre, by means of the fingers, the lever, or 
 one branch of the forceps ; or, where it is a shoulder that is too far 
 advanced, the child should be turned and delivered. 
 
 . II. Deviated breech positions. 
 
 952. The pelvis may, like the vertex, incline in any direction, and 
 give rise to what have, by the authors, been denominated positions of 
 the hips, sacrum, front of the thighs, and genital organs. Produced 
 sometimes by the inclination of the child no longer agreeing with the
 
 414 
 
 DYSTOCIA. 
 
 vertical axis of the womb, and sometimes, which is more common, 
 by obliquities of the uterus, the deviated positions of the breech do 
 not always prove insurmountable obstacles to spontaneous delivery. 
 Nature often succeeds, alone, in transforming them into direct posi- 
 tions, so that if the labour progresses in other respects regularly, 
 the assistance of art rarely becomes necessary. 
 
 However, we must not, for fear of acting unnecessarily, remain 
 inactive under accidents or sufferings which it would be easy to 
 prevent or alleviate by a skilful maneuvre. Whilst the membranes 
 continue unruptured, all we ought to do is to restore the womb as 
 far as possible to its natural attitude, either by pushing it with the 
 hand into the axis of the strait, or by causing the woman to assume 
 such or such an attitude, according to circumstances. But if, the 
 membranes being ruptured, the os uteri, although soft, should dilate 
 with exceeding slowness ; if the pains should be directed with great 
 force towards the reins, or the strength appear likely to be exhaust- 
 ed ; or lastly, should any accident supervene, the accoucheur 
 ought to wait no longer : he should try to reach the deviated part 
 with his fingers, or even with the lever, if it be the hip or sacrum, 
 and restore it to the centre of the pelvis ; or he may proceed at once 
 to seek for the feet or the knees. 
 
 . III. Positions of the trunk of the body. 
 
 It is incontestable that the trunk sometimes presents at the supe- 
 rior strait otherwise than by the head or pelvis ; this has been ad- 
 mitted by practitioners in all ages, and has been a thousand times 
 proved by observation. But is it true thai these presentations ex- 
 hibit shades so various and multiplied as has been asserted by the 
 authors? In the first place, is it possible for positions that are 
 frankly transverse, to take place either before or after the discharge 
 of the liquor amnii, when the foetus is at full term and well grown ? 
 For that end it would be required that the transverse diameters of 
 the womb should exceed the perpendicular ; but even should such 
 a disposition exist before the commencement of labour, can we 
 conceive that it could maintain itself under the contractions of the 
 gestative organ ? Would not those contractions necessarily compel 
 the head or the breech to descend towards the os uteri ? Mauriceau, 
 Deventer, Smellic, Roederer, &c. have given drawings representing 
 such positions, it is true ; but none of them is said to have been 
 take n from nature, and a mere glance suffices to satisfy us that they 
 arc all fancy-pieces. Ifthe ideasof these authors have in our own day 
 i ]M -oiliirfid, with additions, is it not rather in order to be conform- 
 able to the notionaof the ancients than from direct observation? Could
 
 POSITIONS OF THE TRUNK. 415 
 
 Solayres and Baudelocque be fit judges of a question never precedent- 
 ly agitated, particularly as they had such motives to retain it as it had 
 been laid down, in order to magnify the importance of a classification 
 which in a great measure constituted their reputation and their glory? 
 I desire that, here, as well as in the succeeding articles, no one 
 will misconceive of my intentions, and that I may not be charged 
 with want of reverence for so many celebrated names ; I merely 
 express my doubts, and do not pronounce judgment ; but, were it 
 necessary to combat the opinion and the arguments of those ac- 
 coucheurs, whether ancient or modern, who have admitted the ex- 
 istence of transverse positions, by means of authorities not less 
 respectable than they are, I would suggest, without any allusion to my 
 own experience, that out of more than forty thousand cases noticed by 
 Madame Lachapelle, and twenty thousand mentioned by Merri- 
 man, not one of these presentations was observed ; finally, that M. 
 Dubois and M. Duges reject them as chimerical or superfluous. 
 
 953. Is it, then, demonstrated that the child may present either of 
 its three principal surfaces at the entrance of the pelvis, and (hat 
 inclined positions of the side have not been mistaken for positions 
 of the dorsal or abdominal surface ? A multitude of cases are found 
 in books, which, if taken according to the letter, would lead to an 
 affirmative answer to these questions ; but, upon analysing them 
 with some degree of care, they are soon found to be accompanied 
 with details not sufficiently circumstantial to serve as incontrovertible 
 proof of what their authors have averred to be the facts. Accord- 
 ing to Madame Lachapelle, positions of the anterior and posterior 
 regions never do take place, and those of the side are the only ones 
 that we can conceive of, except it be in some abortions ; she main- 
 tains that positions of the dorsal surface would not fail, under the 
 influence of the uterine contractions, to be soon transformed into 
 positions of the shoulder, should they not result in being reduced to 
 some positions of the head or pelvis ; that those of the abdominal 
 surface would require a reversement of the occiput, of the lower 
 extremities and spine, incompatible with the life of the foetus. For 
 my own part, I think that the back and the anterior surface of the 
 foetus may present at the superior strait ; that these positions have 
 been observed ; that proofs of them are contained in the works of 
 Deventer, De la Motte, &c., but that they are rare, and differ so 
 little from the positions of the side, as to require only very slight mo- 
 difications in the maneuvres appropriate to these latter. 
 
 954. Baudelocque admits, further, that in the posterior surface 
 we should distinguish the occiput, the nucha, the back, the loins,
 
 416 DYSTOCIA. 
 
 and the posterior surface of the pelvis ; and that the anterior and 
 lateral surfaces require the same subdiv ; nons. But while we ad- 
 mit that the foetus may, indeed, present by these different points, it 
 would be, nevertheless, useless to adopt such numerous positions, 
 for they are of no practical application, overload the memory with- 
 out any object, and only serve to discourage the student. 
 
 955. The simple good sense and observations of Denman and 
 Madame Lachapelle, prove that the nucha cannot maintain itself at 
 the superior strait, that it would soon give place to the head or 
 shoulder, and that positions of the hip or loins could not fail to be 
 soon transformed into a direct or inclined position of the breech. 
 
 It is, then, evident that a position of the abdomen has often been 
 supposed present, when, in reality, it was only an inclined position 
 of the breech, feet, or knees, complicated with one of the arm, or 
 with a premature escape of the umbilical cord. Madame Lacha- 
 pelle thinks that the throat would not, under the contractions of the 
 womb, be long permitted to remain at the orifice, for the pains 
 would bring the face there far more easily. I am in possession of 
 no facts to militate against the opinion of this author, and know 
 that on this point many practitioners might have been deceived by 
 the touch ; however, I can conceive that, where the occiput is 
 very much reversed backwards, the chin may lodge upon some 
 part of the pelvic circle, and compel the anterior part of the 
 breast and neck to fix itself at the orifice, while the breech, although 
 retaining its natural relations to the abdominal members, remains at 
 the fundus of the uterus. In order, therefore, to avoid the reproach 
 of abandoning one extreme for the purpose of falling into another, 
 I shall admit the positions of the back, and of the anterior face of 
 the thorax, as at least possible occurrences. 
 
 956. As to presentations of tJie side, they are too frequently met 
 with, for their existence over to have been tiie subject of a doubt ; 
 but the classification of Baudelocque, although recently brought 
 forward again in America by Dr Dewees, one of the most dis- 
 tinguished accoucheurs in the new world, liere requires the same 
 reform as in the anterior and posterior surfaces. The sides of the 
 neck form too deep a notch betwixt the shoulders and head, not to 
 yield a passive to one of these parts; the side of the chest being 
 
 round, and particularly not so smooth as the point of tho 
 shoulder, could not hinder ihe- latter from rii'>;!<rmo- in the os uteri ; 
 
 . the tlanLs would soon bring about a hip or breech position. 
 
 i a. Inclinations of the womb or of the straits of the 
 
 pelvis, sudden and irregular movements of the loutus, certain atti-
 
 SPONTANEOUS EVOLUTION. 417 
 
 tildes of the woman long persisted in, are the principal causes to 
 which, in the present st->te of our knowledge, we may attribute the 
 bad positions of the foetus. 
 
 958. Hippocrates was the first one to say that the foetus in utero 
 was in some degree situated similarly to an olive or a cork in a long 
 necked bottle ; that in order to escape from the genital organs, it 
 must present one of the ends of its long diameter ; and that any 
 other presentation was dangerous, rendered delivery impossible, and 
 imperiously demanded the assistance of art. 
 
 This doctrine, which has been republished by all the authors since 
 the father of medicine, and against which no one has made any ob- 
 jections even in our own days, is, notwithstanding, not free from all 
 doubt. 
 
 The comparison instituted by Hippocrates is not correct, except 
 in so far as the foetus remains in a normal position ; in the other 
 cases, the child represents neither an oval nor a cone placed trans- 
 versely or obliquely : whilst the head turns on one of its sides, be- 
 hind, or in front, whilst the shoulder, the breast, or the back tend 
 to engage, the remainder of the trunk continues, notwithstanding, 
 in due relation with the vertical axis of the uterus, whenever the con- 
 tractions are somewhat energetic ; and thenceforth the foetus is in 
 no respect like a cork that presents crosswise in the throat of a vial. 
 
 959. No doubt the hand of the accoucheur is often necessary, and 
 even indispensable, when it is neither the head nor pelvis that pre- 
 sent ; but it is also certain that the organism alone would, in many 
 cases, triumph over this obstacle were the labour left to itself. Peo- 
 ple have in practice reasoned as if the positions of the trunk, when 
 once determined, could never change. But daily observation proves 
 that the different points of the foetus, though very remote from each 
 other, may, during a labour, present alternately at the orifice ; that 
 positions of the back or shoulder may be converted into positions of 
 the head or breast ; that positions in appearance the most unfavour- 
 able might sometimes be replaced by normal positions, were all ac- 
 coucheurs sufficiently well informed to know how to wait. 
 
 960. Those passive movements undergone by the fostus in utero, 
 which Denman has mentioned under the title of spontaneous evolu- 
 tion, and which M. Murat calls spontaneous version, have been 
 carefully observed by Madame Lachapelle, and noticed by Garth- 
 shore, Martineau, &c. Neither were the ancients wholly unaware 
 of them, since they advise that, for the purpose of bringing the head 
 back to the strait, the woman should be shook or assume certain 
 positions. Most modern authors have also remarked them, since 
 they have laid it down as an established rule, that the position of the 
 
 3C
 
 418 DYSTOCIA. 
 
 child, while still enclosed in the membranes, is so variable, that, in 
 order to fix it, it becomes necessary to rupture the ovum, choosing 
 a moment when the head corresponds to the centre of the pelvis ; 
 but upon this, as upon all those phenomena that have not been the 
 objects of special study and attention, little thought has been given 
 to the practical consequences that might follow it. 
 
 961. Although the spontaneous evolution takes place most fre- 
 quently where there is a superabundant quantity of liquor amnii, 
 where the foetus is not large, where the womb is very much inclined, 
 or where the pelvis is badly formed, it may, nevertheless, be some- 
 times observed in the directly contrary conditions. Although it 
 more commonly and easily takes place before the rupture of the 
 membranes, it is, notwithstanding, found to occur after the evacua- 
 tion of the waters : a young woman, in her second pregnancy, was 
 admitted into the hospital of the Ecole de Medecine, at ten A.M. 
 in the month of August 1825. The os uteri was then but little 
 dilated ; nevertheless, 1 discovered that the shoulder presented in 
 the second position. The waters were not discharged until three 
 o'clock in the afternoon ; four students, who were already well ad- 
 vanced, touched and recognised the presence of the shoulder, as I 
 had done. I did not wish to bring down the feet ; the pains were 
 neither very strong nor very frequent, and I had some confidence in 
 the assertions of Denman. At eight o'clock the shoulder was found 
 to be evidently moved towards the left iliac fossa, and I could easily 
 feel the ear to the right. At eleven o'clock the temple was nearly in 
 the centre of the orifice : the energy of the contractions was greater, 
 and the os uteri completely effaced. At midnight the occiput came 
 down, and in the space of an hour the child was expelled in the 
 right occipito-acetabular position. 
 
 962. It appears to me that the explanation of spontaneous evolu- 
 tion is an easy matter : the head of the fetus, which is its most solid, 
 voluminous, and regularly rounded part, and on that account its 
 most slippery portion, naturally tends towards one of the two ex- 
 tremities of the great diameter of the uterus, and towards the cavity 
 of the pelvis ; if, under the influence of any cause, it has assumed 
 any other position, it is very natural that when pressed by the organ 
 in which it is enclosed, it should gradually, and without much diffi- 
 culty, reassume the situation it occupies when in its natural circum- 
 stances. When the womb contracts, if the foetal ovoid is well situ- 
 ated, it becomes compressed equally in every direction, but if, on 
 the contrary, it is in a deviated position, its extremities support, 
 almost alone, the whole effort of the contraction, and but for the 
 shoulder, which is from its salient form apt to be arrested at the
 
 SPONTANEOUS EVOLUTION. 419 
 
 strait, either the head or the breech would be almost always brought 
 to the strait. 
 
 For this consequence to fail taking place, which is almost impos- 
 sible, the middle of the child's body ought to correspond exactly to 
 the centre of the pelvis, so that, of its two extremities, one should 
 not be more disposed than the other to slide up towards the fundus, 
 or down to the orifice of the womb ; besides, the difference of the 
 shape of the head and breech would render this equilibrium extremely 
 difficult. There is nothing very extraordinary, therefore, in the evo- 
 lution or spontaneous version of the child ; it is quite a natural phe- 
 nomenon, easily explained by the action of the womb and its rela- 
 tions to the form of the ovum and fetus. The mechanism of this 
 evolution explains why the anterior and posterior positions of the 
 trunk are so rare, and shoulder cases so common. If, when some 
 point on the dorsal or abdominal surface of the child offers at the 
 strait, the head or the pelvis are too far removed from it to be 
 brought back again, the pains never fail to act with a certain degree 
 of force upon the two extremities of the bis-acrimonial diameter, 
 which then becomes inclined, and one of the shoulders is soon com- 
 pelled to engage in the open part of the strait. 
 
 963. To conclude, from the above details I think it follows : 
 
 1st. That all those positions of the trunk that can not be referred 
 to those of the shoulder, the back, or the anterior part of the thorax, 
 ought to be classed among the inclined positions of the head. 2d. That 
 shoulder presentations are, so to speak, the only ones that require 
 particular attention, inasmuch as all others are naturally reduced to 
 them. 3d. That the child is never situated completely crosswise in 
 the womb, and that the most untoward positions may sometimes be 
 expected to be reduced to those that are most favourable. 4th. 
 That there are a good many cases, in which the interference of art 
 is any thing but indispensable, although the foetus may present by 
 neither end of its great diameter. 
 
 964. The indications to be fulfilled in cases of faulty position of 
 the child necessarily vary according to a great variety of circum- 
 stances. Until the waters are discharged, nothing is to be done. 
 We should wait for the dilatation of the os uteri ; if the uterus is 
 obliquely situated we must endeavour to restore it to .its natural at- 
 titude ; should the head project over the hypogastric notch of the 
 pelvis, it should be pushed backwards over the edge of the strait ; 
 when the foetus is so movable that the head, the shoulder, or some 
 other part come to present successively at the orifice, it is proper, as 
 has been said, to rupture the membranes without waiting too long,
 
 
 420 DYSTOCIA. 
 
 and choosing the exact moment when the head happens to be over 
 the strait. 
 
 But if the os uteri is already sufficiently dilated, if the membranes 
 are already ruptured or on the point of giving way, it is important 
 to decide at once, whether or not the hand is to be carried into the 
 womb. Denman tells us that we may dispense with doing so in a 
 majority of cases, seeing that the womb, most generally, will bring 
 about the spontaneous evolution, and that if the child should really 
 come down doubled, its escape would not, on that account, be 
 wholly impossible. The French accoucheurs think, on the contrary, 
 that we ought to act immediately in all cases; for, say they, the 
 longer we wait the more will the womb contract, and the more dif- 
 ficult will it become to enter it and effect the turning. 
 
 The conduct of Denman in this case does not appear to me to be 
 of the very wisest : by imitating him, it is true, some fetuses that 
 we deliver by the feet might come away spontaneously, but many 
 more of them would fall victims to such an expectant mode of prac- 
 tice, and which might be saved by operating in good time. As to 
 delivering the foetus double, it is manifest that it must be very diffi- 
 cult, that it will most generally not take place at all, and that the 
 woman will be exhausted with useless efforts, and may lose her life ; 
 that even under the most favourable conditions of this kind, the 
 child generally dies long before it is born, at least if we may judge 
 from Denman's own cases, since out of thirty of them only one was 
 born living. 
 
 Thus, although spontaneous evolution may take place, and rigo- 
 rously speaking, some women may be delivered without it, it is 
 nevertheless more conformable to the dictates of prudence and hu- 
 manity to turn the child, or apply the forceps. To this rule an ex- 
 ception should be made of those cases where the shoulder is not 
 fully engaged, those where the vertex or the pelvis is near enough 
 to the orifice to allow us to rely upon a fortunate transmutation, 
 and lastly, those where the introduction of the hand is so difficult 
 that it would not be more dangerous to wait than to proceed at 
 once to the operation. 

 
 
 
 

 
 TABLE III. 
 Anormal Presentations of the Foetus. Tokologic.al Pperqtions. 
 
 
 t-i E 
 
 U 3 
 
 
 
 
 
 
 
 tr. 
 
 1" 
 
 AUTHORS. 
 
 .0 
 
 s -s 
 
 3 5 
 
 fc ri 
 
 8 
 B 
 
 - 
 
 V 
 V 
 
 PH 
 
 
 
 B 
 
 E 
 
 V 
 
 a 
 
 1 
 
 o 
 
 Turnin 
 
 J3 
 
 "a 
 
 _= 
 
 e. 
 
 
 
 
 
 
 
 
 
 
 V 
 
 
 
 
 
 
 
 
 
 
 U 
 
 Boer 
 
 6 555 
 
 126 
 
 68 
 
 58 
 
 * 
 
 
 
 
 
 Bland f 
 
 1 897 
 
 36 
 
 10 
 
 e 
 
 
 
 
 
 10 
 
 Merriman 
 
 1 800 
 
 42 
 
 23 
 
 4 
 
 
 
 
 
 10 
 
 Madame Boivin 
 
 20,517 
 
 363 
 
 234 
 
 74 
 
 4 
 
 96 
 
 96 
 
 218 
 
 7 
 16 
 
 Madame Lachapelle. . . . 
 
 22,243 
 
 492 
 
 203 
 
 103 
 
 9 
 
 118 
 
 76 
 
 174 
 
 12 
 
 M. Nsegele. *. . . . 
 
 415 
 
 15 
 
 
 
 4 
 
 
 
 2 
 
 15 
 
 3 
 
 1 
 
 
 
 1,296 
 
 61 
 
 
 
 
 
 
 
 18 
 
 41 
 
 19 
 
 4 
 
 
 Total. 
 
 54,723 
 
 1135 
 
 546 
 
 248 
 
 13 
 
 234 
 
 287 
 
 491 
 
 60
 
 421 
 
 CHAPTER VI. 
 
 Of Obstetric Operations. 
 
 ARTICLE I. 
 Of Turning. 
 
 965. The word turning is, in tokology, applied to the act of 
 turning the child with the hand, and bringing one of the extremities 
 of its great diameter to-4he superior strait. There are two kinds 
 of turning ; in one the head, and the other the feet are brought 
 down first. 
 
 Hippocrates has a few words upon the subject of turning, but 
 only of version by the head. Celsus advises that the feet should be 
 drawn down where it is too difficult to get hold of the head, but he 
 dares not perform this maneuvre except when the child is dead. 
 Aetius and Paul of Egina are the only ones among the ancients 
 who have applied the idea of Celsus to the living foetus ; although 
 it is mentioned in Wolf's Collection, and though Franco and Pare 
 have treated of it as a common practice, we must come down as 
 late as the time of Guillemeau before we can obtain any circum- 
 stantial details concerning it. Previously to the time of this last 
 mentioned author, all those practitioners who were either ignorant 
 of, or refused to adopt the operation of turning by the feet, Were 
 reduced to the necessity of bringing away the child piece-meal 
 from the womb, after having allowed it to perish, or else to extract 
 it with the crotchet or some other instrument in all cases where 
 they thought it not possible to bring the head to the strait. Besides, 
 until then there never had been any question about bringing down 
 the feet, except as a remedy for faulty positions, as positions of the 
 body, for example. It is only since Guillemeau's day that it has 
 been recommended to bring down the feet and make a complete 
 version and delivery of the child, in cases attended with some acci- 
 dent, the head being already at the strait.
 
 422 TURNING. < 
 
 SECTION 1. 
 Of Turning in general. 
 
 The necessity of acting with the hand to change the position of 
 the fetus or assist in its expulsion having been clearly ascertained, 
 it should be communicated to the relatives or friends of the woman, 
 and they should be informed of the dangers to which the child is 
 exposed. Provided the case be at all doubtful, or if the family have 
 not implicit confidence in him ; if his age, or above all his reputation 
 do not place him beyond the reach of the envenomed shafts of envy, 
 it is well for the safety of all parties, that the accoucheur should 
 request a consultation with one or more of his brethren, best known 
 by their experience and knowledge. 
 
 966. As to the woman herself, she ought to be informed of the 
 advantages of the operation, and of the evils of retarding it or of not 
 performing it ; but it is important that she should be kept in igno- 
 rance of the risks the fetus is about to run, and the sufferings to 
 which she is exposed herself. These precautions being taken, we 
 should next think of what period of the labour we should choose for 
 the operation, of the position most favourable for the woman and 
 for the accoucheur, then of the position of the child, and lastly, 
 determine which hand should be introduced. 
 
 967. The time for acting. As long as the membranes remain 
 whole, and the orifice undilated, we may wait : if the labour is dif- 
 ficult only in consequence of the faulty position of the child, and 
 the woman is in danger, it suffices that the orifice be soft and dilata- 
 ble ; we may operate. In all cases where the membranes are rup- 
 tured, there is not an instant to lose ; however, where the womb has 
 been for a long time contracted ; where there are great irritation, 
 heat, fever, or any symptoms of inflammation, these epiphenomena 
 ought to be first combated by bleeding, baths, sedatives, ointment 
 of belladonna, &c. according to circumstances. 
 
 Upon the whole, the most favourable moment for turning is just 
 when the membranes are whole and the os uteri completely dilated. 
 This period ought, therefore, always to be chosen if possible, and if 
 there be no counter indication present. 
 
 968. Position of the woman. Should it be necessary only to 
 bring back the head or buttocks, in case of deviated position of those 
 parts, to the superior strait, we might indeed leave the woman upon 
 IH r common bed ; or in the situation she had occupied on her little
 
 TURNING. 423 
 
 bed during the pains ; but whenever it becomes necessary to seek 
 after the head or feet at some distance from the vulva, we ought to 
 act differently ; however, the essential point on this subject is that 
 the vulva and perineum shall be completely at liberty, and that 
 nothing about the pelvis shall be left to interfere with the move- 
 ments of the accoucheur, and that the muscles shall not require to 
 be put in tension for the support of some other parts of the body. 
 Thus, she may be placed on her side, conformably to the precepts 
 of the English and American practitioners : on the edge or foot of 
 the bed ; on the knees of some stong person ; on a chair, a settee, 
 a table, or any piece of furniture suitably prepared for her. Upon 
 the whole, her attitude ought to be like that of a patient during the 
 operation of lithotomy. 
 
 969. At the Maternite at Paris, and the Strasburg Hospital, one 
 side of the lying-in-bed is placed against a wall ; as soon as an ope- 
 ration becomes necessary, the woman places herself crosswise upon 
 it, with pillows under her head and shoulders, towards the wall ; 
 the sacrum rests upon the free edge of the bed ; an assistant is 
 placed on the outside of each leg, and charged with the duty of 
 keeping them separate, and the legs and thighs flexed, while a third 
 is prepared to hand any thing that may be wanted during the opera- 
 tion. If they can be disposed of, other assistants secure the pelvis, 
 and prevent those disorderly movements which the sufferings of the 
 woman sometimes deprive them of the power of controlling. 
 
 970. The same conduct may be followed in private practice, but 
 it appears to me better to slip the mattress down so that the folded 
 edge may correspond to the foot of the sacking- bottom. The wo- 
 man is then in exactly the same condition as before, and the assis- 
 tants can more easily move round about her. It should be observ- 
 ed, that many women are so courageous that it is not necessary to 
 support either the legs or the head, and indeed, two chairs or two 
 stools, fixed so as to support the feet, might serve instead of assis- 
 tants to hold her legs, if assistants are wanting. 
 
 There is no fixed rule as to the height of the bed ; but it is well 
 to pay some regard to the stature of the accoucheur, the degree of 
 inclination of the axes of the straits, and perhaps also to the stage 
 of the labour. 
 
 971. Position of the accoucheur. If the bed be a low one, the 
 accoucheur may sit down or kneel upon the floor. Nevertheless, a 
 standing posture is unquestionably the best, and whenever there is 
 a necessity for using much power it should be preferred. The pre- 
 cept of Levret on this subject has long been forgot, which was thus : 
 " the accoucheur should stand up, with his legs separated at an
 
 424 TURNING. 
 
 angle of forty-five degrees, one foot being placed forward and the 
 other backwards ; that he should have the spine bowed, and lean 
 with the hand that he does not operate with upon some solid sub- 
 stance." 
 
 All this, says Roussel, may be called mechanics and geometry by 
 an operator who wishes to shed lustre on his art ; but certain it is, 
 that a simple midwife, by relying upon her native dexterity, absolving 
 herself from the constraints of a prescribed position, and executing 
 all the motions that may be required by circumstances rather than 
 those demanded by the rule, will operate better than an accoucheur, 
 no matter how gravely he may straddle his forty-five degrees. 
 
 972. Taking off the coat, rolling up the sleeves, and putting on 
 an apron has seemed too grotesque to many moderns, who think 
 that the women might be frightened by so many preparations, and 
 they ought therefore to be dispensed with : people may declaim after 
 this sort as much as they please in the study, but by the lying-in 
 bed it is otherwise. 
 
 In fact it is not merely for fear of spoiling it that the accoucheur 
 ought to take off his coat, but because, unless he does so, the move- 
 ments of his arms would not be free enough to permit him to ma- 
 neuvre conveniently, and penetrate to the fundus of the womb. As 
 to the apron, it may doubtless be dispensed with : but what harm 
 can it do, and why is it more frightful here than in a surgeon making 
 his visits, or preparing for an operation ? 
 
 Some cloths to put under the feet, some napkins to wipe his 
 hands and arms when they become soiled, warm water, Cologne- 
 water, some vinegar, and a little good wine, in case the woman 
 should be likely to be ill, are also necessary previously to com- 
 mencing the operation. Moreover, the condition of the fetus must 
 be attended to, its position ascertained, and the hand to be intro- 
 duced to be decided upon. 
 
 973. The christening or provisional baptism is only applicable to 
 a living child, and that, provided it be not a monster. Where there is 
 ground to fear that it is dead, we should say, " Child, 1 baptise thee, 
 &c. if thou art living ;" and where there is reason to suspect it of 
 being a monster, we substitute for if thou art living, the worJl if 
 thou art worthy of being baptised. In order to baptise, some part 
 of the naked surface of the child should be touched, if not with the 
 fingers, at least with the water of christening, which it is sometimes 
 necessary to inject to a considerable distance. 
 
 This precaution, which, as is manifest, belongs to the dogmas of 
 religion, ought never to be neglected with persons who make of it 
 an article of faith. Whatever be his personal belief, the physician
 
 PROLAPSED CORD, ANEURISM, ASTHMA. 435 
 
 ought to respect the opinions of the families he attends, whether 
 they agree with his own or not ; and to me nothing seems more 
 blameworthy than those pragmatical practitioners who, under pre- 
 tence of reforming consciences, openly revolt against every custom 
 that does not square with their own way of thinking. 
 
 974. To ascertain the position of the f&tus. The positions of 
 the head, the feet, the knees, raid the breast, having been charac- 
 terized in the article on eutocia, I have now to attend only to those 
 of the trunk. 
 
 Presentations of the shoulder, whether frank or inclined, will, if 
 the arm have not come down, be ascertained by the rounded form 
 of the tumour in the orifice, by the presence of the clavicle, the 
 ribs, the scapula, and one side of the neck. turifc 
 
 When the arm escapes first, it not only indicates that the shoul- 
 der is at the superior strait, but it also teaches us to which side of 
 the pelvis the vertex and also the face are turned. The thumb cor- 
 responds to the summit of the head, while the palm of the hand an- 
 swers to the abdominal surface. However, it is important to know, 
 that, instead of being in a state of supination, or even of slight pro- 
 nation, the hand and the whole limb may be twisted in a contrary 
 direction, and especially into forced pronation ; so that previously 
 to giving a definitive judgment, it is best to slip some of the fingers 
 into the vagina, along the cubital edge of the arm, as far as the arm- 
 pit, so as to make sure of its relative situation. 
 
 If the back should stop at the centre of the strait, the range of 
 the vertebral spines and the ribs would suffice to point it out. The 
 absence of ribs in the lumbar region, or on the one hand the hips, 
 and on the other the scapula; and back part of the neck, might 
 serve to show which way the head is directed. 
 
 The sternum, the ribs and clavicles, above which we can also 
 sometimes feel the front of the neck, indicate presentations of the 
 anterior face of the thorax. 
 
 Where the os uteri is largely dilated and the membranes ruptured, 
 and the presenting part is not too high up in the pelvis, and has not 
 had time to swell and alter its shape under the influence of the ute- 
 rine contractions, it is in general pretty easy to distinguish the differ- 
 ent positions of the trunk from each other; it is at least always 
 possible to avoid confounding them with those of the head or pelvis; 
 but in the contrary circumstances the most consummate experience 
 is sometimes deceived, and it is often impossible to establish a 'cer- 
 tain diagnosis until aftur iiavii-- uul into the womb. 
 
 Choice of tin hand. \V in i.. nn, ha;: of Wiiiers is still un- 
 broken, or the foetus retains a considerable degree of mobility, it is 
 3D
 
 426 IMHVl DYSTOCIA. 
 
 useless to delay about the choice of a hand to operate with : the one 
 that is most easily used is to be introduced, or the one which -habi- 
 tually brings down the child in the least unfavourable position ; 
 where the position has not been ascertained, or is merely a matter 
 of doubt, the practitioner ought to act in the same manner, or may 
 make use of the hand commonly employed in operating for those 
 positions most frequently met with ; if, however, there should occur 
 any difficulty after reaching the womb, it is best to withdraw it and 
 introduce the other hand. ^vfVMMj^^^H 
 
 In cases where the presentation is well determined, we may 
 know at once which hand is most favourable to the success of the 
 operation ; this is moreover liable to vary according to the kind of 
 maneuvre about to be executed, or which it is indispensably neces- 
 sary to u(l(Mupk^p^|{|iAiAjQ|MMMi* 
 
 976. For those inclined positions of the head and breech which 
 do not require immediate version by the feet, the left hand ought to 
 be preferred. Whenever the deviated parts correspond to some 
 portion of the right half of the pelvis ; the right hand, on the con- 
 trary, in the opposite deviations, and either of them, indifferently, if 
 the deviation takes place directly front or back. The cephalic ver- 
 sion ought to be subjected to the same rule of practice. 
 
 977. For the feet, knees, or breech, those positions in which the 
 posterior surface of the foetus looks towards the left side of the pel- 
 vis, are best operated on with the left hand, and the inverse posi- 
 tions with the right hand, although it may be most frequently in our 
 power to do just the contrary if we please. 
 
 978. When the vertex presents first and we have to bring down the 
 feet, the left hand is most suitable, in left-occipito-pelvic positions, 
 that is, the first and fifth of Baudelocque. (First and fourth of MM. 
 Maygrier, Capuron,Duges, &c ; first, fourth, and fifth of Madame 
 Lachapellc ; left-occipito-acetabular, and right fronto-acetabular of 
 M. Gardien.) The right hand, rigorously speaking, is only for the dia- 
 metrically opposito positions ; but as it terminates a labour in the 
 first position of the feet, as it is more handy from customary use, 
 and as it maneuvres as well as the other in median positions, it 
 ought to bo selected lor all the right and antero-postcrior positions. 
 
 979. In shoulder presentations we may lay it down as a general 
 rule, that the left side requires the use of the left hand, and that 
 the right hand should operate in the positions of the right shoulder. 
 
 980. Lastly,- we ought to make use of the right hand in presen- 
 tations of the sternum, or back, whenever the head is not turned to 
 the left, and of the left hand in the opposite casq. 
 
 9C1. These general rules appear to -me to be simple, applicable
 
 TURNING, CHOICE OF THE HEAD. 43? 
 
 to all cases, and easy to be understood. Baudelocque, Madame 
 Lachapclle, M. Duges, M. Desormeaux, and very recently, M. 
 Major of Lausann^also, have advised us to introduce that hand 
 which, when in a state of semi-pronation, will have the palm turned 
 towards the front of the child, and the fingers towards its lower ex- 
 tremities ; bu-t this rule is too vague, and liable to too many excep- 
 tions for it to be used in practice. It is not perfectly exact, either 
 in positions of the pelvis, or those of the' back or shoulder, and in 
 positions of the head and sternum His only suitable in the first stage 
 of the operation. 
 
 Those who have recommended the introduction of the hand that 
 is naturally turned towards the side of the pelvis where the feet are 
 situated, did not observe that it most commonly happens, even in 
 shoulder positions, that the feet remain up towards the fundas of the 
 womb, without being sensibly inclined to one side more than to the 
 other ; neither did they remark that precisely the contrary rule is 
 followed where the pelvis presents first. 
 
 When M. Gardien says that the right hand is required in all 
 those cases where the feet are to be brought down in the first, and 
 the left where they are to be brought down in the second position, 
 he has approached nearer to the truth, although his assertion is not 
 correct either, except for-positions of the head and trunk ; but he lias 
 rather expressed a fact than endeavoured to .lay down a rule, which, 
 however, naturally follows from the principles that I have indicated 
 above. 1flHlpl|ftH|JNA|MWV' 
 
 Dr Breen advises us always to use the left hand, inasmuch, says 
 he, as the right is infinitely more commodious in assisting the action 
 of the other, in pressing upon the hypogastrium. M. Major thinks 
 that we can maneuvre with the same hand in all kinds of positions, 
 but always in conformity to the rule indicated above. Fcr this end 
 we have only to vary the posture of the woman, to place her on one 
 side or the other, or on the back or abdomen, accordingly as the 
 abdominal surface of the foetus, for example, looks to the right, to the 
 left, in front, or to the rear ; but I do not see what advantage such a 
 course can have over the one generally pursued in France ? 
 
 .982. Now the hand being chosen, in order to let it slip easily 
 through the passages, render its introduction easy, and guard against 
 the infection of contagious diseases, we should cover it with some fatty 
 or mucilaginous substance. It may be immersed in oil or mucilage, 
 greased with butter, lard, or the whiteof eggs, &c. may be used: which 
 ever of these substances is selected, it seems to me right always to 
 follow the counsel of Roederer, that is to say, only to annoint the 
 back of the fingers and hand, which alone exert any friction upon
 
 428 DYSTOCIA. 
 
 the parts of the mother, while the other surface of the hand has to 
 do only with bodies that are already but too slippery. The fore-arm 
 ought also to be greased as far as its upper errtl: if the part of the 
 child we are to pull by were at the vulva, or not high up in the 
 vagina, this precaution might be rather injurious than useful, and 
 the hand should be applied quite dry. 
 
 SECTION 2. 
 Version by the Head. 
 
 983. Long imbued with the idea that the positions of the head 
 were the only ones which admitted of a fortunate delivery, physi- 
 cians only thought* in the first place, of restoring that part to the 
 straits, when the child presented otherwise than by the head : the 
 precept of Hippocrates was followed, and they endeavoured to bring 
 down the head, not only in positions of the shoulder and other 
 regions of the trunk, but also in those of the breech, knees, and 
 even of the feet themselves, which were .then looked upon as very 
 dangerous. Celsus showed that the fetus might escape with its 
 lower extremities foremost ; but version by the head was not the less 
 regarded as the safest and most practicable process, until the time 
 of Franco and A. Pare. Since the time of Guillemeau, on the 
 contrary, it has been almost wholly abandoned, and at present the 
 standard authors scarcely mention it, except for the purpose of con- 
 demning it. Notwithstanding what a few modern authors have said 
 about it, no person in France has felt it a duty to put it in practice. 
 The objections urged against it arc the difficulty of its execution, 
 the smallness of the hold- afforded by the head to the hand that at- 
 tempts to seize it, and the impossibility of bringing it back to the 
 strait, where the womb is ever so slightly contracted upon the 
 child ; that even in the most favourable cases, where turning is once 
 effected, the hand cannot assist in the delivery, which must be left 
 to the powers of nature, unless recourse be had to the forceps ; 
 whereas, by acting upon the feet, it is an easy matter to extract the 
 foetus without employing any instrument but the hand that brought 
 them down. Lastly, that as delivery by the pelvic extremity is 
 almost as natural as by the head, it is evidently preferable to turn 
 and deliver by the feet ; and that it is the only method that ought to 
 bo attempted where it becomes proper to change the position of 'tin; 
 child. 
 
 984. To the above, I answer : 1. That it is not always very difficult 
 to take hold of the head while it is in the womb, nor o exnrt a con-
 
 TURNING. 429 
 
 siderable degree of power on it where that may be required; 2. That 
 unless the waters have been long discharged, we may often succeed, 
 without much difficulty, in laying hold of the occiput, and bringing 
 it down to the strait, no matter how far it may have been removed 
 therefrom ; 3. That in this operation we have not so much to catch 
 hold on the head and compel it to descend, as to push up the part 
 that has engaged in its place ; 4. That far from being a simple and 
 desirable case, a delivery by the pelvis, on the contrary, exposes the 
 child to the greatest danger, while that by the vertex, even when as- 
 sisted by the forceps, is rarely dangerous. M. Flamant seems to 
 have been the first to introduce it in our day ; notwithstanding what 
 Osiander says about it, who has attempted to divide the credit of it. 
 In fact, the German professor did not describe it until 1799, 
 whereas it was taught at Strasburgh in 1798 ; since that time much 
 attention has been paid to it in the north of Europe, and MM. 
 Labbe, Eckard, Wigand, Sclmaubert, Siebold, d'Outrepont, M. 
 Wenzel, Busch, Carus, Ritgen, Schweighaeuser, Toussaint, Vallee, 
 Deroche, and Ubersant, have expressed themselves more or less at 
 length upon turning by the head, and endeavoured to diffuse the 
 principles laid down by Professor Flamant. 
 
 Cephalic version may, therefore, be attempted, 1. In a well 
 formed pelvis, where no other accident has happened except the 
 vicious position of the foetus, and the head is found in an inclined 
 position in the vicinity of the strait ; 2. In presentations of the 
 shoulder, back, or anterior part of the thorax, provided the arm is 
 not prolapsed, and the uterus not too much contracted. Lastly, it 
 seems prudent to try it whenever the feet are farther removed from 
 the strait than the head is, and where it is probable that the labour 
 would terminate spontaneously if the head were at the strait. 
 Moreover, after having attempted to perform it in vain, we are not 
 prevented from still proceeding in search of the feet, which can be 
 as readily found after as before the attempt has been made : if the 
 head seems disposed to come down, we may endeavour to bring it 
 down ; if not, we have only to direct the hand towards the feet. I 
 do not think, however, that this kind of turning ought to be prefer- 
 red in the inclined positions of the pelvis, nor, a fortiori, where the 
 breech presents fairly. MM. Flamant and Schweighaeuser wish 
 it to be preferred in all cases, even where there are accidents on the 
 part of the mother, because, when the head is once brought to the 
 strait, it can be laid hold of with the forceps. Perhaps they might 
 be imitated with advantage in some cases where the fetus is very 
 movable in the uterus ; but I doubt if it be possible where the waters 
 are gone off, and the womb strongly contracted on the child.
 
 
 430 DYSTOCIA. 
 
 ^.985. Thus, the woman being placed as has been directed, the 
 left hand is introduced if the head is to the right, and the right hand, 
 on the contrary, if to the left ; and either one or the other almost 
 indifferently, if the vertex is turned in front or directly behind. 
 
 In the first place, the part that is engaged is to be pushed up- 
 wards ; we should try to remove it from the strait, and direct it to- 
 wards the iliac fossa that is opposite to the one occupied by the 
 vertex ; in this way the womb is enabled to exert its power on the 
 head and return it to the centre of the pelvis. After having thus 
 raised up the shoulder, if the head does not descend, it must be 
 sought for with the hand, and taken hold of with all the fingers, which 
 draw it down as with a crotchet, and at the same time endeavour 
 to make it assume, in preference, one of the occipito-anterior po- 
 sitions. When the head has been brought to the centre of the pelvic 
 circle, it is left there, and the delivery requires no further assistance, 
 provided there be no other accident in the case ; if the contrary 
 should happen, the forceps should be immediately substituted for 
 the hand. :-4rte <AWiiliMMift%IHfe4yi 
 
 Wigand, in speaking of cephalic version, says that we may often 
 succeed in operating without introducing the hand into the genital 
 organs ; he thinks that by acting upon the womb through the abdo- 
 minal parietcs, and assisting it by the posture of the woman, we may 
 most commonly bring back the head to the superior strait. Before 
 I was .acquainted with the doctrine o the German professor, I had 
 already followed this precept, and have in conforming to it found 
 that it is, in fact, sometimes possible to restore to the vertex its na- 
 tural position ; but I do not think that this mancuvre can ever be 
 of much use where, the waters have been long discharged, and the 
 womb. strongly contracted on the child. 
 
 SECTION '3. 
 Of Turning Inj the Feet or Pelvis. 
 
 The maneuvre in turning by the feet consists of three principal 
 stages. It is necessary, 1. To introduce the hand; 2. To change 
 the position of the child ; 3. To assist in the expulsion of the ovum. 
 
 These llirco stages are never found together in turning by the 
 head, where, as has been already seen, the action of the hand is of 
 no further use after the head has been properly placed at the supe- 
 nnr sirnit; in some of the feet positions the mancuvre is almost 
 wholly ruiiiim.,1 to the stage of extraction. 
 
 Introduction of the hand. Many authors advise us to penc-
 
 TURNING. 431 
 
 trate into the vagina at tbe very moment of a strong uterine con- 
 traction ; in this way, say they, the pain produced by the operation 
 becomes confounded with the pain of the contraction, and the wo- 
 man does not distinguish them apart ; then also the vagina is both 
 enlarged and shortened by the temporary descent of the womb, 
 which in some sense comes down to meet the hand. In theory 
 these assertions may be very correct ; but in practice they certainly 
 do not authorize the precept which it has been attempted to draw 
 from it, and, like M. Desormeaux, I think, from my own expe- 
 rience, that the hand should generally be passed through the vulva 
 in the intervals between the pains. 
 
 Whatever mode be adopted on this point, the fingers being placed 
 side by side, must first be introduced in the direction of the length 
 of the vulva-; after which they are brought together in such a way, 
 that their palmar surface forms a kind of gutter, in which the thumb 
 is lodged, so that the whole may form a very long cone, the base of 
 which is found at the place of the metacarpo-phalangial articulations. 
 The hand thus gets into the vaginal cavity, following the direction 
 of the axis of the inferior strait. 
 
 987. In order to penetrate through the os uteri, it is absolutely 
 necessary to choose a time when the pain is off, so much so, that 
 nobody has ever dared to prescribe the contrary. Otherwise, in- 
 deed, it would often be impossible to get into the uterus ; there 
 would be a risk of lacerating thp orifice ; in fine, it would be volun- 
 tarily to create a thousand difficulties, and to expose the woman to 
 numerous dangers. 
 
 If the dilatation is very much advanced, the fingers, which are at 
 first held together, should be almost immediately more or less sepa- 
 rated, so as to accommodate them to the form of the part that pre- 
 sents, and allow them to slip easily between it and the parietes of 
 the womb. In the contrary case, they are to be introduced one 
 after the other, and the cone formed by their junction is soon repro- 
 duced. They are then gently passed onwards, taking care to stop 
 upon the recurrence of each pain, and always move in the axis of 
 the superior strait. Here it is above all important not to be in a 
 hurry ; for the movements and the efforts require the greatest gen- 
 tleness ; instead of pressing forwards to dilate the os uteri, it is some- 
 times better to separate the base of the fingers moderately and by 
 degrees, or at least the portion of the cone already introduced into the 
 orifice. During this maneuvre the other hand should be applied to 
 the patient's hypogastrium, for the purpose of supporting the uterus, 
 and inclining it backwards or to one side if necessary. As soon as 
 the roots of the fingers have passed through the os uteri, the whole
 
 432 DYSTOCIA. 
 
 hand enters without difficulty into the uterine cavity, and thenceforth 
 the intromission is effected. ^ 
 
 988. Period of exploration. Before proceeding any farther the 
 state of the case must be ascertained ; we must be sure not to be 
 deceived as to the position of the foetus, not to confound the arms 
 with the legs, to see if any partis twisted out of its proper position, 
 and endeavour to learn where are the feet or breech after having 
 first recognized the head. Then, to get hold of the child for the 
 purpose of extracting it or changing its position, it is essential to 
 remark* that several points of its body could not bear the degree 
 of pressure which it is sometimes found to be necessary to exert. 
 For example, we ought to avoid pressing the ends of the fingers 
 upon the sutures, the fontanels, the abdomen, and sides of the tho- 
 rax ; for the purpose of pushing up, turning, or extracting the fetus, 
 we ought to apply the hand only to the forehead, the occiput, the 
 temples, the parietal tones, the shoulders, the spine, the sternum, 
 the hips and the limbs. ^^^^^Sjt^ 
 
 989. Mutation. After having ascertained the part that presents, 
 it is pushed up to free the superior strait, taking care to apply the 
 fingers to a surface as extensive as possible ; then the feet should be 
 sought for, seized, and brought to the orifice. The foetus must 
 never be brought down otherwise than in conformity to its natural 
 flexures ; that is to say, it must be rolled up, on its anterior surface. 
 By turning it over backwards, it would necessarily be brought in 
 the direction of its extension; it -would soon become an inflexible 
 trunk, or arc of a circle, which most generally would render the 
 remainder of the operation impossible ; the uterine cavity would not 
 'be sufficiently spacious to admit of the evolution, and the least force 
 
 would hazard the luxation or fracture of the limbs, the rupture of the 
 spinal marrow, and would give rise to extremely severe pains on the 
 part of the woman, and perhaps even to lacerations of the uterus- 
 Whilst engaged in exploring, and turning the child, it is not less 
 essential to support the womb outwardly than it is during the time 
 of intromission. The hand that is held applied to the hypogastrium 
 may aid also by suitable pressure in causing the head, the shoulder, or 
 the limbs to descend, which renders the turning in all respects easier 
 and surer ; but for this precaution, the accoucheur would be liable, 
 when compelled to exert a certain degree of force, and particularly 
 where the liquor amnii has been long discharged, to .produce dan- 
 U3 stretchings, to separate llio vagina from (lie cervix, to rup- 
 'ln- womb itself at some weak part, qr at those poini - \ 
 the womb in most strongly contracted on the projecting and solid 
 parts of the foitus.
 
 TURNING. 433 
 
 These maneuvres ought always to be executed in the intervals 
 between the pains ; they would be excessively dangerous if perform- 
 ed during the contractions, and would generally occasion fatal lacer- 
 ations to take place ; besides, it is often impossible at those times 
 to move the fetus ; the hand soon becomes so compressed that it is 
 quickly benumbed, and completely loses all its powers of sensation 
 and motion ; as soon, therefore, as a pain appears, all exertion is 
 to be suspended ; it should not be begun again until the contrac- 
 tion has ceased, unless, however, some serious circumstance neces- 
 sitates a very prompt termination of the labour. 
 
 I ought, also, to warn the young practitioner, that in order to reach 
 the fundus of the womb, the arm must be introduced much farther 
 than he would at first suppose, and that to get into the axis of the 
 superior strait, the hand should be much more inclined forwards 
 than would be imagined upon the inspection of a dried pelvis. 
 
 Most accoucheurs have recommended and still advise that the 
 feet should be seized, and not any other part of the limbs ; in fine, 
 the feet are the only parts by which we are advised to pull, in the kind 
 of turning under consideration. Nevertheless, it is possible, it is in 
 many cases even advantageous, to follow the counsel given first by 
 Burton, reproduced by Delpech, and very recently again by Dr 
 Breen that is, to take hold of the knees or hams, rather than the 
 feet. 
 
 990. Extraction. When the mutation has been completed, and 
 the child reduced to one of the positions of the extremities of its 
 great diameter, we may stop, provided the pelvis be well formed 
 and the womb retains sufficient energy to terminate the rest of the 
 labour. This is the way we are compelled to act in all cases of 
 version by the head, unless we choose to apply the forceps ; but when 
 the feet are brought down, ought they also to be abandoned after 
 they are placed in a situation which no longer prevents the sponta- 
 neous delivery of the child ? To authorise this advice it has been 
 supposed : 1. That pulling on the child ought always to be 
 avoided when not absolutely necessary ; 2. That tractions force 
 the arms to rise along side of the head, which prevents its ad- 
 vance, and that they almost always place the occipito-frontal or 
 occipito-mental diameters in the situation that ought to be occupied 
 by the occipito-bregmatic ; 3. That in rapidly passing through the 
 os uteri, the belly and breast of the foetus are subjected to too sud- 
 den a compression ; 4. Lastly, that the womb, being too suddenly 
 emptied, may become inverted, fall into inertia, and give rise to 
 hemorrhage, &c. All these inconveniences are real, and nothing 
 would be so easy as to enlarge the list ; but on the other hand, it 
 3E '
 
 434 DYSTOCIA. 
 
 should not be overlooked that the woman submitted to the opera- 
 tion only for the hope of being soon delivered ; that her family and 
 attendants cannot be satisfied until the child is completely expelled ; 
 that, in case of abundant hemorrhage, of syncope, of lipothymia, 
 convulsions, premature descent of the cord and exhaustion, we 
 have no right to wait ; that inertia ought rarely to occur in such 
 circumstances, seeing that the maneuvre is better calculated to 
 remedy than produce it ; that the compression of the abdomen, 
 when the hand has been previously introduced into the womb, ought 
 not to inspire any great alarm ; that, at least, it is scarcely more to 
 be feared where we draw the foetus down by the hand, than where 
 it is simply pushed down by the efforts of the mother ; lastly, that 
 it is possible to avoid ohe extreme without falling into another, and 
 that, it is as dangerous, in the practice of midwifery, not to act 
 apropos, as to do so without any necessity. 
 
 A well informed and prudent man will therefore preserve a just 
 medium, and proportion his maneuvre to the circumstances of each 
 particular case. If .not pressed by any important circumstance, he 
 will wait, and excite the uterine actions so as to draw the child down- 
 wards concurrently with them, for the two actions ought to be so 
 combined as to constitute, as it were, but one ; at each pain the 
 womb ought to commence before the hand, and finish after it. By 
 pursuing this course we imitate a spontaneous delivery ; the arms 
 sometimes descend before the head, which continues bent down upon 
 the breast, and the occipito-bregmatic diameter does not lose its 
 natural relation to the straits of the pelvis ; it is in no case indis- 
 pensably necessary to pull hard enough to rupture the spinal mar- 
 row or detruncate the foetus. If, on the contrary, there should be 
 no other chance of safety either for the mother or the child, than in 
 a prompt delivery, and should the contractions of the womb be too 
 slow and feeble to admit of his relying upon them, the tractions per- 
 formed by the accoucheur ought not only to assist, but they should 
 more or less become the substitutes of the powers of the woman : 
 there can be no hesitation in such a case ; of two unavoidable evils 
 we must choose the least. I need not repeat that in the former as 
 well as in the latter case the tractions ought to be performed with 
 great caution, never by jerks, and always in the axis of the straits. 
 
 To conclude, extraction may be considered under two principal 
 points of view : 1. As a mere accessory power added to that of the 
 womb, and which hastens the termination of a painful function ; 
 2. As a principal, or even sole resource, in cases where the organism 
 is powerless, or where it is of importance to empty the uterus within 
 a few minutes. This distinction being once established, I do not see
 
 TURNING. 435 
 
 how any discussion can afterwards arise as to whether the child 
 may or may not be pulled downwards after it has been turned. As 
 long as the tractions are confined to the part first assigned to them, 
 it is evident they can be only of service, and no well informed man 
 will ever make use of them in the other way without a clearly un- 
 derstood necessity for so doing. 
 
 . I. Of bringing down the feet when the head is at the orifice. 
 
 Relatively to turning by the feet, the positions of the head ought to 
 be reduced to two : the left occipito-iliac, to which we bring the 
 first and fifth of Baudelocque ; and the right occipito-iliac, which 
 comprises the second and fourth of the same author, to which also 
 we ought to bring the occipito and fronto-pubic positions, should 
 they be met with. 
 
 991. The first of these requires the left hand, and the right band 
 is preferable for the second. 
 
 A. Left Occipito-iliac Positions. 
 
 992. The left hand enters the vagina in a state of pronation, 
 passes along the anterior face of the sacrum, penetrates into the 
 orifice, and if the occiput is turned directly to the left, remains in a 
 state of semi-pronation, approaches a state of supination if the ver- 
 tex is in the first position, but must be held quite prone if the ver- 
 tex is turned backwards and to the left, &c. The head is to be 
 taken hold of and held in the hand, and not merely with the points 
 of the fingers. The thumb is placed on the right temple, or parietal 
 protuberance, and the other fingers, being more or less separated, 
 are applied to the face and opposite temple. 
 
 At first this part is thrust upwards and along the axis of the supe- 
 rior strait, that is to say, upwards and forwards ; it is afterwards- 
 rejected towards the left iliac fossa, taking care to favour this move- 
 ment with the right hand, which, being placed upon the hypogas- 
 trium, sustains the fund us of the womb, and inclines it more or less 
 backwards and to the right. 
 
 993. Now is the time to go in search of the feet : for this end 
 the hand may pass along the anterior surface of the child, and arrive 
 directly at the knees, or at the roots of the thighs ; this is the shortest 
 route ; but by following it we are liable to several errors, in short, 
 to mistake the elbow for the knee, the foot for the hand, the arms 
 for the legs, and the safest way is to act in the following manner : 
 we begin by extending all the fingers, and the thumb also, towards 
 the left side of the head ; they ought to be placed side by side, and 
 extended in order to occupy the least possible space ; they are then
 
 436 DYSTOCIA. 
 
 passed over the whole of the left lateral surface of the child, by 
 sliding along behind the neck, the shoulder, the breast, the flank 
 and the hip ; during all this time the anterior part of the wrist sup- 
 ports the forehead and prevents it from descending again into the 
 strait ; the other hand pushes the womb backwards as much as 
 necessary or possible, and endeavours to bring the parts we are try- 
 ing to get hold of as near as possible to the fingers. 
 
 994. If the legs are in their natural state of flexion, we endeavour 
 to carry the whole hand, flattened, above and behind the breast, 
 turning it more and more into a state of pronation as we proceed ; 
 if they are on the contrary turned out of the way or displaced from 
 their natural positions, if it appears too difficult to envelope their 
 posterior surface in the palm of the hand, we should take hold of 
 both of them if possible, or at least that one which is nearest the 
 posterior surface of the womb, embracing their root with the thumb 
 which is fixed in the groin, and with the fingers which are kept 
 upon the posterior surface of the thighs. Should they be twisted 
 or crossed ; should one of them be found flexed, and the other ex- 
 tended ; finally, if we have attempted in vain to get hold of them both 
 together, and should be obliged to bring them down one after the 
 other, we should at all events carefully try to bring down the pos- 
 terior limb first, even although it should be the most distant one 
 from the orifice. 
 
 995. In the first case, to continue the operation, the hand has 
 only to slip along behind the thighs and legs, which it pushes before 
 it, extending them as they come down ; in this way the feet can 
 neither escape nor deviate, and may be conducted without difficulty 
 to the superior strait. 
 
 In the second case, more difficulty is generally met with ; we are 
 sometimes obliged to act successively on the thigh and leg as if they 
 were levers of the first kind ; while we are searching for one foot 
 the other escapes, and it is always a difficult matter to draw them 
 both down together, unless we have been so fortunate as to get hold 
 of the hams with the fingers and thumb at tne commencement of 
 the search. 
 
 In the third case, that is to say when the limbs are far removed 
 from their natural attitude, and always when we arc obliged to bring 
 them down one after the other, we act as we best can ; only we 
 should, while pulling at the leg first got hold of, endeavour to make 
 it approach the opposite limb ; by abducting it, which is naturally a 
 very limited motion, and which would expose the child to the risk 
 of luxations or fractures, we should also have the disadvantage of 
 fatiguing the uterus far more than by following an adductivc move-
 
 TURNING. 437 
 
 merit ; for its free exercise, also, the last named movement requires 
 much less space than the other. 
 
 996. However it may be, when one of the feet has reached the 
 vagina or the vulva, it should be secured by means of a fillet pre- 
 viously to going in search of the other ; not with a view of hindering 
 it from mounting upwards again, as some of the ancient authors 
 imagined, but only that it may be found again, when wanted. This 
 precaution being taken, the left hand is again carried into the womb; 
 and that it may more readily reach the other foot, it should follow 
 along the inner and posterior surface of the one held in the fillet ; 
 by conforming to this rule we necessarily meet with the crease of 
 the breech and sexual organs; the thigh we are in search of cannot 
 now be mistaken, and we thus avoid a good deal of tiresome feeling 
 after an object. It ought to be well understood that this foot is 
 to be brought down in adduction, by following the anterior surface 
 of the foetus, and the side of the other leg. 
 
 After having succeeded, in any way, in extending the legs, and 
 bringing them down into the excavation, we place the index between 
 them above the inner ankles, while the thumb and the other fingers 
 are applied to their outer surfaces, and in such a way that the heels 
 lodge in the palm of the hand. If the head, forced down by the 
 womb, or ill supported by the wrist, should have approached too 
 near the orifice, we should, before we pull the feet down, and with- 
 out letting them go, push it up again towards the left iliac fossa 
 with the thenar. 
 
 997. The first object of the tractions now to be performed, is to 
 turn the child, to compel the head to rise up towards the fundus of 
 the womb, whilst the pelvis is drawn into the superior strait, and to 
 convert one of the left positions of the vertex into one of the right 
 positions of the feet; that this mutation may yield all the advan- 
 tages we are authorised to expect from it, the back of the child 
 must always turn to the right, then a little in front, but never back- 
 wards. Consequently, the operator will carefully avoid inclining 
 the hand in supination, after he has begun to pull on the legs ; he 
 should keep it in semi-pronation, to reduce to the second position of 
 Baudelocque ; and even if that should not suffice, he ouglit to try to 
 get the right foot, which is in front, with the right hand, and draw 
 down solely, or almost solely, by it, until the tendency of the back 
 to direct itself backwards shall have been overcome. 
 
 998. As soon as both of the feet have passed through the vulva, 
 they should be wrapped in a dry cloth so that they may be held 
 more firmly. The hips soon pass through the orifice, and present 
 at the inferior strait. As the limbs come forth, the hands, which
 
 438 DYSTOCIA. 
 
 are applied, the right one in front and the left one behind, ought 
 to extend along them towards the vulva, so as to hold them by as 
 large a surface as possible ; the thumbs are therefore placed 
 behind, the two last fingers on the anterior surface, and the index 
 and medius extended on the outside of each leg or each thigh, until 
 the hips shall have been born. 
 
 999. Before proceeding any further, it is proper to attend to 
 the umbilical cord, to see that it be not stretched, by carrying the 
 index and the thumb, or two other fingers of the right hand, towards 
 its insertion on the belly of the child. If it should be found tense, 
 a loop of it of sufficient length should be brought down by pulling 
 the placental portion, but never by pulling its abdominal portion ; if 
 it is found not to be stretched any about the navel it may be let 
 alone ; if it should proceed from the navel down betwixt the thighs 
 and then mount up along the child's back, so that the circulation 
 should appear to suffer, it ought to be disengaged, and even divided, 
 should the danger appear to be pressing, and no other means of 
 disengaging the limbs be discoverable ; but after that the labour 
 ought to be terminated within a very few minutes. 
 
 1000. We continue the tractions obliquely downwards and back- 
 wards, that is to say, in the axis of the superior strait. As the 
 hips are disengaged they are in turn taken hold of, the left or pos- 
 terior one with the left hand, and vice versa, but in such a way 
 that the fingers are not applied higher up than the crista3 of the 
 ilia, so as to avoid pressing upon the abdominal viscera. The belly 
 and the breast soon follow ; this is the time that the arms rise up- 
 wards, that the shoulders engage, and that it is essentially important 
 to combine the efforts of the accoucheur with those of the woman, 
 in order to avoid a departure of the chin from the breast. What- 
 ever resistance may be met with in engaging the shoulders in the 
 excavation, we ought never to imitate those routine practitioners, 
 who, while they are pulling the child downwards, can never think of 
 any thing better than to make it revolve on its axis, or make its 
 whole body perform a more or less extensive movement of circum- 
 duction ; neither should we move it alternately from the internal 
 surface of one thigh to that of the other, nor raise and depress it by 
 turns from sacrum to pubis and vice versa ; such maneuvres could 
 not do any good, and would stretch the dorsal or cervical portions 
 of the spine too dangerously ; when it is found insufficient to draw 
 downwards in the direction of the straits, it may be barely proper 
 to try the effect of diagonal tractions, that is to say, we may pull 
 downwards towards that oblique diameter, which at the superior 
 
 t corresponds to the greatest diameter of the shoulders. In the
 
 TURNING. 439 
 
 first place, while continuing to pull gently, we raise up the child's 
 pelvis, as if we intended to carry it towards the mother's left groin ; it 
 is then depressed towards the right sacro-sciatic notch ; afterwards 
 we continue to raise and depress it, until the shoulders, which in this 
 way engage one after the other, and receive the greatest part of the 
 force employed, are near enough to the inferior strait tp be easily 
 got hold off; when the child has advanced thus far, we must attend 
 to the extraction of the arms. 
 
 1001. When the child is small or the pelvis very large, the pre- 
 sence of the arms offers but a small obstacle to the escape of the 
 head, and we ought, properly, to abstain from disengaging them ; 
 but, in all other cases, they could not fail to embarrass the rest of 
 the operation, and prudence, if not an indispensable necessity, re- 
 quires that they should be brought down. Some authors have saifl, 
 that when applied alongside of the neck, they facilitate the passage 
 of the head, the dilatation of the vulva, that they obviate the con- 
 traction of the uterine circle, and the strangulation of the foetus, 
 and that they are never so large as to prevent the delivery from 
 taking place; but as this opinion is not founded on any plausible 
 reason, it does not deserve the trouble of being opposed, and at 
 present no one follows the practice. 
 
 The member nearest the sacrum must always b^e extracted first ; 
 should we begin with the other, we should meet with great difficul- 
 ty, and when we had succeeded, the other arm would not be found 
 to be at all more free. 
 
 1002. The trunk, which should always be wrapped up in a cloth, 
 is supported by the right hand, as it is performing the oblique trac- 
 tions. The left thumb, in a state of pronation, is placed in the hol- 
 low of the corresponding axilla, while the index and medius are 
 applied to the outer and anterior surfaces of the arm, as far as the 
 bend of the elbow, as if to form a tackle for the humerus. We 
 then act upon the whole arm as upon a lever of the third kind ; the 
 thumb represents the fulcrum, the fingers the power, and the resist- 
 ance is found in the forearm of the child. While we are thus act- 
 ing on the arm to bring it down, it must be carried in the direction 
 of adduction, so that as it sinks down it may slide over the fore part 
 of the breast. If we should be content with hooking it with one or 
 two fingers, we would run a risk of fracturing the bone, or at least 
 of exerting the force only upon the shoulder-joint. When the 
 whole shoulder is much elevated, it is sometimes found advanta- 
 geous to follow the advice of Baudelocque, which has been re- 
 peated by almost all the accoucheurs of our -own day, namely, to 
 divide this little operation into two stages, to put the hand, at first
 
 440 DYSTOCIA. 
 
 in pronation, 90 that the thumb may for an instant take the place 
 of the other fingers, and operate in succession upon the whole limb, 
 beginning at the root of it ; but this precaution is most frequently 
 unnecessary, ami I have had no occasion to repent of having gene- 
 rally neglected it. 
 
 The arm having been brought down, it is to be extended along 
 the side of the thorax ; the right hand deposits the trunk of the 
 child in the left hand, and then proceeds to disengage the anterior 
 or sub-pubal member, according to the method indicated above. 
 
 1003. Instead of following their natural tendency to rise up along- 
 side of the head, the arms are sometimes turned backwards, and 
 that in two different ways : 1 . One of them, or both, but generally 
 only one, and especially the one that ought to be found in front, is 
 fixed behind the neck, so as to arrest the progress of the occiput ; 
 2. Previously to rising upwards, or even "while in the act of rising, 
 they get behind, and cross each other upon the back, below the 
 shoulders, which may occasion their being luxated, or even fractur- 
 ed, and greatly increase the difficulties of the maneuvre, provided 
 it be not remedied in good time. 
 
 In the first case, we commence by disengaging the arm that is not 
 deviated ; we then push the trunk up a little, so as to compel the 
 head to rise, ands far as possible to diminish the pressure upon 
 the other arm ; lifter which the fingers and the thumb ought to be 
 applied as has been already directed, and act upon the same prin- 
 ciples, but with rather more gentleness. If the arm resists, we 
 attempt to make it rise up above the occiput, and the blunt-hook 
 proposed by M. Dubois ought not to be employed until all other 
 attempts shall have proved to be insufficient. 
 
 In the second, even although the forearm should have passed 
 quite across to the opposite side, as seems to have happened in a case 
 under the care of M. Duges, and even though it should have risen 
 as high as the nucha, it ought always to be hooked with the middle 
 and fore finger to draw it down along the child's back, and bring it 
 out of the vulva ; it is generally pretty easy to succeed in this ma- 
 neuvre, but the breast has sometimes to be pushed strongly up, or 
 the trunk more or less considerably rotated, before it can be ef- 
 fected. 
 
 1004. Should the exertions of the accoucheur have been well 
 seconded by the contractions of the womb, the head ought now to 
 have descended into the excavation, or at least be considerably on- 
 gaged within the superior strait, so that the occipito-bregmatic and 
 btrparieUri diameters would be found to be in proper relation to the 
 oblique diameters of the pelvic circle.
 
 TURNING. 441 
 
 In that case, the right hand, passing along the front of the breast 
 and throat, penetrates in a flattened and half-supine position quite 
 into the vagina ; the thumb and two last fingers are placed on the 
 sides of the throat ; the index and raedius should be directed on to 
 the chin, or in the mouth, or what is still better, on each side of the 
 nose, for the purpose of keeping the head in its natural state of 
 flexion, and approximate the facial extremity of the occipito-mental 
 diameter as much as possible to the sternum ; after having placed 
 the right hand properly, the foetus is to be laid on its belly upon the 
 anterior surface of the corresponding arm, whick is then much 
 depressed towards the perineum, without, however, pulling, for the 
 object at that moment is merely to disengage the vertex from the 
 pubic arch. In the next place, two or three of the first fingers of 
 the left hand are to be carried under the occiput, to sustain it, and 
 prevent it from engaging before the chin ; the thumb, the other 
 fingers, and the rest of this hand are applied naturally behind the 
 neck, and we attempt to push the head upwards in the axis of the 
 superior strait, so as to cause it more easily to perform its pivot- 
 motion. 
 
 When we have succeeded in getting the face into the hollow of 
 the sacrum and the occiput behind the symphysis, we should wait 
 for a pain ; the woman should be told to bear down, and the two 
 hands being fixed as has been stated, we immediately begin to exert 
 some tractive force on the head, which is gradually drawn down in 
 the axis of the straits, while at the same time the trunk of the child 
 is gradually raised upwards, as if we were going to turn it over on 
 to the hypogastrium of the mother. 
 
 100&. When the efforts of the accoucheur have not been suffi- 
 ciently seconded by the contractions of the womb, or when, after 
 the delivery of the shoulders, the head has not performed its flexion 
 movement, and is found to be arrested at the superior strait, it is 
 sometimes very difficult to reach it, and still more so to get it down ; 
 however, until we can reach it, all tractive force on the trunk is to 
 be suspended, for it would only tend to reverse it still more. The 
 hands, placed as before, should be carried further up. At this junc- 
 ture it is particularly useful to apply the fore and middle fingers to 
 each side of the nose ; for by applying them to the inside of the 
 mouth, there would be a risk of depressing the lower jaw only, or 
 of luxating it or straining it to an injurious_degree ; but in this case 
 also it is most difficult to reach this part of the face ; and further, it 
 must be confessed that when we have reached it, if a good deal of 
 force is required, the fingers slip and get off from it with surprising 
 facility ; so that we are mostly under the necessity of fixing them on 
 3F
 
 442 DYSTOCIA. 
 
 the most movable part of the face, a part the least calculated to bear 
 the force necessary to make the head turn forwards. 
 
 1006. It is therefore indispensably necessary to stimulate the 
 action of the womb or that of the abdominal muscles ; as the efforts 
 of the woman oblige the anterior or mental branch of the sort of 
 lever represented by the head to descend first, the least pulling at 
 the jaw in a direction from above downwards is then very effica- 
 cious ; those tractions, on the contrary, which the accoucheur exerts 
 on the trunk of the body, being more particularly transferred to the 
 occiput, tend naturally to produce the inverse effect of the one we 
 wish to obtain. It is therefore essential not to pull, except upon the 
 face, whether there be any pains or not, until we have brought the 
 occipito-bregmatic diameter of the bead to correspond with one of 
 the diameters of the pelvis. 
 
 1007. To the inconvenience of a reversion of the head there is 
 sometimes added another that never fails to be embarrassing ; in- 
 stead of looking backwards and to the left, or directly left, the face 
 is sometimes found to turn more or less in front, or directly back- 
 wards, so that the neck is twisted round on its own axis. In this 
 state of things all tractions on the trunk of the body would be dan- 
 gerous. Previously to doing any thing of that sort, we ought, in 
 the absence of a pain, to push up the breast, and take hold of the 
 chin with two fingers of the right hand, disengage it and direct it 
 towards the sacro-iliac symphysis, while with the left hand on the 
 hypogastrium we favour, first the rotation, and then the flexion of 
 the entire head ; afterwards we proceed as in the former case. 
 
 B. Right occipiio-iliac position. 
 
 1008. In the third and sixth positions of Baudelocque, we might, 
 strictly speaking, use the left hand with the same facility as the 
 right ; but the latter is preferred because it terminates the delivery 
 in the first position of the feet, which appears to be rather more 
 advantageous than the second, and because we can generally 
 maneuvre with it better than with the other hand. 
 
 1009. Whether, therefore, the occiput be towards the pubis, the 
 sacrum, the right acelabulum, or the right sacro-iliac symphysis, the 
 right hand ought always to be made use of, in a supine position in 
 the first case, prone in the second, half supine in the third, and in a 
 state of semi-pronation in the fourth. By placing the thumb on the 
 left temple, and the fingers on the opposite temple and side of the 
 face, we can embrace the head in the hand, raise it up in the axis 
 of the superior strait, push it towards the right iliac fossa, and then 
 reach the ear of the same side, so that the hand may be supine, and
 
 TURNING. 443 
 
 the thumb brought close to the radial side of the index finger ; the 
 hand, being then flattened out, may slip all along the child's right 
 side, and as it becomes prone, get hold of the feet, and act in all 
 respects as the left hand does in a left occipito-iliac position. 
 
 1010. When the face presents first, the maneuvre does not sen- 
 sibly differ from that which is used for the positions of the vertex. 
 The right hand is always to be introduced where the chin is to the 
 left, in front, or to the rear ; or to speak more generally, and per- 
 haps also more correctly, the right hand is to be employed in all 
 cases where it seems easier to push the forehead towards the right 
 iliac fossa than towards the opposite one and the left hand in all 
 other cases. 
 
 1011. The other inclined positions, that is to say, those of the 
 temples and posterior part of the occiput, when they cannot be early 
 reduced to the corresponding ones of the vertex, are classed among 
 the positions of the trunk of the body, whence it manifestly follows, 
 that in turning by the feet there can be only two positions of the 
 head ; therefore, as these two positions themselves, as to their prac- 
 tical indications, differ only in one requiring the right hand more 
 particularly, and the other the left hand, and as it is only necessary to 
 transpose to the right hand the rules already laid down for the 
 government of the left it is clear, in point of fact, that all the 
 maneuvres of the head are naturally reduced to a single one, and 
 that by multiplying them, we naturally fall into fastidious repetitions, 
 evidently of no use, and fit for nothing but to overload the memory 
 of the student. 
 
 . II. Of turning by the feet in presentations of the trunk. 
 
 1012. Although it may not be certain that no case has been 
 seen, in a well formed pelvis, where the trunk of the foetus was so 
 situated that the head was turned directly*backwards ; although it is 
 difficult to conceive of such a phenomenon, an error was commit- 
 ted by those who maintain that the same holds good of the anterior 
 part of the pelvic circle. The ossa pubis being lower than the 
 sacro-vertebral angle, and the soft parietes of the abdomen being very 
 distensible, the posterior concavity of the symphysis does not, like 
 the projection of the spine, repel the head towards the sides of the 
 median line, and admit of its fixing itself directly in front. 
 
 1013. Besides, this last mentioned position has been many times 
 met with. To the proofs already in possession of the profession on 
 this subject, I might add several more ; but I shall content myself 
 with citing only one. A woman, in her fourth pregnancy, and 
 whose former labours had exhibited nothing peculiar, continued
 
 444 DYSTOCIA. 
 
 several days in labour at my amphitheatre ; she was carefully atten- 
 ded to by the students, and all of them had an opportunity of satis- 
 fying themselves that the right shoulder was at the orifice, while 
 through the remarkably thin parietes of the abdomen the head could 
 be felt almost naked, above and in front of the symphysis pubis. 
 However, as these positions are rare, and do not at all alter the fun- 
 damental rules of the maneuvre, I shall refer all the presentations of 
 the trunk, as I have done those of the head, to two principal ones : 
 namely, a left-lateral one, comprising the first and fourth of MM. 
 Maygrier, Capuron, Duges, and Madame Lachapelle ; and a right 
 lateral one, to which the second and third of the same authors must 
 be reduced. 
 
 In fact, what does it import to the hand with which we operate, 
 whether, in presentations of the side for example, the head is a lit- 
 tle nearer or a little further off from the anterior or posterior me- 
 dian line of the pelvis ? If we wish to take hold of the posterior sur- 
 face of the child's legs, we shall still be obliged to deliver in the first 
 position of the feet if we use the right, and in the second if we use 
 the left hand ; as we always have to bring the child as near as pos- 
 sible to a transverse position, in turning there will be rather more 
 difficulty in those cases where it is farthest removed from that posi- 
 tion, and rather less where it is nearest to it ; but there is no other 
 difference, and surely that is not enough to justify the importance 
 attributed by modern writers to the question, whether the cephalo- 
 anterior positions of the trunk ought or ought not to be admitted. 
 
 1014. I have already pointed out the reasons that induce me to 
 admit the possibility of presentations both of the anterior and pos- 
 terior surfaces of the foetus ; although they in reality require the 
 same maneuvre as those of the lateral regions, I shall say a few 
 words about them notwithstanding, and successively pass in review 
 the positions of the side, the posterior and anterior surfaces, taking 
 care meanwhile to dwell only upon those to which a major part of 
 the others ought to be reduced in operating. 
 
 A. Positions of the Shoulder and Side. 
 
 1015. By following a numerical order in indicating positions, so 
 much confusion has been introduced, that it is almost impossible for 
 students to understand each other if they happen not to have studied 
 the same books. Thus, to speak only of positions of the trunk, in 
 Baudelocque's first the head is in front, in front and to the left ac- 
 cording to Maygrier, and directly to the left according to M. 
 Gardien : now, as this mode of proceeding is entirely arbitrary, and 
 as nothing can prevent one accoucheur, if he chooses, from calling that
 
 SHOULDER POSITIONS. 445 
 
 a first position which another chooses to denominate the third, I 
 have thought I might arrange all the shoulder presentations under 
 the titles of dorso-pubic, dorso-sacral, and right or left dorso-iliac. 
 This is the way to avoid all ambiguity, and reduce to their just value 
 the numerous classifications which have successively appeared in 
 France since the time of Solayres. 
 
 1. Positions of the Left Shoulder. 
 
 1016. Dorso-sacral position (3d of Baudelocque). In this po- 
 \ sition, the head, which is on the left side, maybe stopped above the 
 
 foramen ovale, the sacro-iliac symphysis, or even the iliac fossa ; 
 being referable to the corresponding varieties of the vertex positions, 
 its different shades require to be operated on like the left occipito- 
 iliac position. Only, instead of the head, it is the shoulder that is 
 to be pushed up, and instead of placing the thumb and fingers on 
 the temples, they are to be applied to the back, and to the fore part 
 of the thorax ; in fact, turning, in this case, differs from that in ver- 
 tex positions, .only, in respect that the head is already raised or re- 
 versed, and that the first stage of the operation is effected by natural 
 means. 
 
 1017. The left hand is to be introduced; the thumb is to be 
 pressed on the anterior face of the shoulder or the sternum; the 
 other fingers slip behind the scapula or chest, and the little finger 
 remains turned tow'ards the child's occiput. 
 
 To conform to this rule, the hand ought to be introduced half 
 supine, or in a more or less complete state of supination or prona- 
 tion, accordingly as the vertex happens to be near the symphysis 
 pubis, the sacro-vertebral angle, or the iliac fossa; after having 
 raised up the shoulder, taking care at the same time to push it 
 backwards so that the anterior surface of the fetus may look some- 
 what downwards, we should endeavour to push the head towards 
 the middle of the iliac fossa, provided it were at too great a dis- 
 tance from it before, which often requires a skilful combination of 
 the efforts of the hand that presses upon the hypogastrium with 
 those of the one which is operating in the womb. The thumb then 
 abandons the sternum, is placed alongside of the index, and for the 
 remainder of the procedure we act as was directed in speaking of 
 the left occipito-iliac position. 
 
 1018. When the head is found completely in front (left dorso- 
 iliac position), or even somewhat near the right acetabulum, we may 
 proceed as above ; only that in order to get hold of the right shoul- 
 der, the hand is in a forced state of supinalion, and that after having 
 lifted it up, the head is to be carried from right to left, as far as pos-
 
 446 DYSTOCIA. 
 
 sible, towards the iliac fossa, by acting chiefly with the thumb ex- 
 actly applied to the sternum. 
 
 In cases where it is situated very near the posterior median line 
 (right dorso-iliac position), it is very difficult to bring it back to the 
 left extremity of the great diameter of the pelvis, because the thorax 
 only moves, whereas the head retains its primitive position. To 
 overcome this difficulty, we are to support the upper part of the 
 chest with the thumb and fore finger, while the others are extended 
 as far as the occiput, and thus serve to push from behind forwards, 
 and from right to left, as if we wished to tilt it over from the occiput 
 towards the chin. 
 
 1019. Dorso-pubal position (4th of Baudelocque). The maneu- 
 vre is generally much more difficult in this than in the preceding po- 
 sition, for it can scarcely be terminated without first being converted 
 into a left cephalo-iliac position, or into a position of the right side. 
 But, in either of these cases, the change we are obliged to make in 
 the situation of the foetus is so great, that if it be somewhat com- 
 pressed by the uterus, its life is often found to be exposed to the 
 greatest dangers. This is certainly a case where it would be pro- 
 per to bring the head to the orifice, and afterwards apply the for- 
 ceps, instead of turning and delivering by the feet. 
 
 1020. However this may be, provided the waters have not been 
 long discharged, if the membranes are not ruptured, and lastly, if 
 the child is to a certain extent movable in the womb, the best prac- 
 tice is to reduce it to a dorso-sacral or left dorso-iliac position : this 
 may be effected in two different ways. 
 
 Unless the head happens to be nearer to the sacro-iliac symphysis 
 than to the right acetabulum, we might, by turning the hand into a 
 very forced state of supination, get hold of the shoulder, as in the 
 cases heretofore treated of, that is, so that the thumb may tend to 
 reach the sternum whilst the fingers remain behind the thorax, the 
 little finger being towards the head ; then we act by raising it up- 
 warda a little, tiie vertex in front; the hand afterwards assumes 
 during the operation an attitude of pronation, which is more and 
 more complete in proportion as the occiput moves more towards 
 the left iliac fossa. 
 
 1021. Should it be too difficult thus to move the cephalic extre- 
 mity of the child, from right to left, over the major part of the an- 
 terior semicircle of the pelvis, we might, after raising the shoulder 
 and head above the pubis, go immediately in search of the feet or 
 knees, proceeding along the left side. Having got hold of the legs, 
 the act of turning would compel the head, which, besides, is already 
 repelled by the forearm within the uterus, to rise upwards and take
 
 SHOULDER POSITIONS. 447 
 
 a situation in the fundus of the womb. But in this case special care 
 should be taken not to permit the child's back to turn to the poste- 
 rior surface of the womb. 
 
 Should the shoulder be so disposed of that the head were to be 
 found above the right sacro-iliac symphysis, that is to say, in the 
 third position of Maygrier, or still nearer to the sacro-vertebral an- 
 gle, the left hand, introduced in a forced state of pronation, might 
 attempt to raise the shoulder, and move the head from the right 
 sacro-iliac symphysis to a situation above the left sacro-iliac sym- 
 physis ; but although this maneuvre may sometimes be found rather 
 easier than the former one, it should be stated that it is perhaps a 
 more dangerous one ; for provided the two or three last fingers 
 should not act with force upon the occiput while the thumb and 
 index are pushing against the upper part of the chest, there is a risk 
 of doing nothing more than effecting a retroversion of the head on 
 to the back while endeavouring to displace it. 
 
 Should the membranes have been long ruptured, the womb 
 stongly contracted, and the child not to be moved but with very 
 great difficulty, there is a third maneuvre that ought then to be 
 preferred, and which perhaps it would be well to employ in other 
 cases ; it consists in pushing the shoulder up with the right hand, 
 from behind forwards, as if to make the spine turn upon its own 
 axis ; then trying to reach the right side by passing along the front 
 of the chest, while the womb is forcibly pushed backwards with the 
 left hand ; lastly, in taking hold of the feet, the right one first, so as 
 to bring them down in the first position. 
 
 1022. In conclusion, all the positions of the left side may be ma- 
 neuvred with the left hand. By not losing sight qf the rule that the 
 thumb should always correspond to the sternal surface, the fingers 
 to the dorsal surface, and the cubital edge of the hand to the child's 
 head ; by remembering that previously to going in search of the 
 feet, the head ought to be moved as near as possible to the left iliac 
 fossa, the practitioner will be aware of every thing that it is essential 
 to know concerning the maneuvre for the left lateral surface. Should 
 he make use of his right hand, as his first object would be to raise 
 up the left shoulder, so as more readily to reach the right shoulder and 
 side, the case would evidently be converted into a right shoulder 
 position, properly so called, which I am now about to treat of. 
 
 2. Positions of the Right Shoulder. 
 
 1023. What I have now said of the left shoulder positions being 
 strictly applicable to those of the right shoulder, it would be super- 
 fluous to enter upon new details concerning the latter. I shall merely
 
 448 DYSTOCIA. 
 
 remark, that in the present case, the right hand performs the part 
 which was entrusted to the left in the former case ; that the head is 
 to be moved towards the right iliac fossa previously to searching 
 further for the feet ; lastly, that the foetus should be delivered in the 
 first and not in the second position of the feet. After all, to save 
 the necessity of particular description, in shoulder positions it is 
 enough to remember that the right hand always goes to the right 
 side, and the left hand to the left side, and that in all cases, the 
 fingers ought to be situated in regard to the fetus as has been 
 already mentioned. 
 
 I will, however, observe, that these rules cannot be absolute; that 
 a knowledge of them merely renders the operation rather easier ; 
 that they may be modified in a great variety of ways ; that they are 
 principally established for young physicians who are as yet insuffi- 
 ciently enlightened by experience, and who require a certain number 
 of clues to lead them through the labyrinth of practice ; lastly, 1 will 
 state that in cases where the hand is carried into the womb pre- 
 viously to the rupture of the membranes, whether the child pre- 
 sents with its right side or its left side, and in any position of the 
 shoulder whatever, we may arrive at the feet directly, and almost 
 with equal facility with either hand. 
 
 B. Presentation of the Sternum. 
 
 1024. The cephalo-pubic position (1st of Baudelocque) of the 
 sternum might, rigorously, be as well reduced to the left cephalo- 
 iliac, as to the right cephalo-iliac position ; but it is generally re- 
 duced to the latter, because it terminates it in the first position of 
 the feet. 
 
 1025. In the right cephalo-iliac position (4th of Baudelocque) the 
 right hand must be made use of; it is to be introduced supine if the 
 head is in front, prone if in the contrary situation, and betwixt these 
 two attitudes, provided the head be fairly to the right. The part that 
 is engaged must always be pushed back until the trunk of the fetus, 
 instead of being convex on its anterior face, shall become concave ; 
 then the operator should endeavour to reach the right shoulder, be- 
 hind which the fingers are to be applied, while the thumb rests 
 on the anterior surface of the thorax ; afterwards, nothing more re- 
 mains to be done except to swing the bis-acromial diameter, so that its 
 posterior extremity may turn downwards, by acting upon it as upon 
 a lever of the first kind, whose fulcrum is represented by the thumb, 
 and the power by the fingers ; this being done, the position differs 
 in no respect from the corresponding one on the right side, and is 
 to be managed in the same way.
 
 SHOULDER PRESENTATIONS. 449 
 
 1026. In the left cephalo-iliac position (3d of Baudelocque) the 
 left hand does what the right should do in the opposite position ; it 
 pushes up the breast, gets hold of the left shoulder, draws it down 
 a little, and if the head were too far from the iliac fossa, it brings it 
 nearer to it, obtains a dorso-sacral position of the left shoulder, 
 and the rest of the rnaneuvre presents nothing of a special character. 
 
 C. Presentations of the Back. 
 
 1027. Right cephalo-iliac position. If the head is to the right, 
 in front, or to the rear, in positions of the back, the right hand is to 
 be made use of as in positions of the sternum, and according to the 
 same rules. Consequently, it is introduced half prone, supine, or 
 more or less completely prone, accordingly as the head looks to the 
 right, in front, or to the rear ; but in such a manner that the thumb 
 may always pass in front of the right shoulder and breast, while 
 the fingers rest upon the dorsal surface. In the first place, this 
 shoulder is to be brought down so as to make the other rise ; it is 
 then to be repelled, by acting on it as upon the end of a powerful 
 lever, which the thumb tends to move and to oblige the foetus to 
 turn on its great axis, until the position of the back is converted 
 into a corresponding or dorso-sacral position of the right shoulder. 
 
 This movement requires great care, for if the head does not go 
 with the trunk, the cervical portion of the spinal marrow runs 
 the greatest risk of being lacerated, or violently twisted in the 
 second stage of the operation ; this danger is to be avoided as far 
 as possible, by pushing the chest very far backwards and upwards, 
 so as to give great depth to the curve of the anterior surface of the 
 foetus ; or if it should be absolutely necessary, by getting hold of the 
 head itself to force the face to turn forwards and downwards. 
 
 1028. Left cephalo-iliac, position. The left extremity of the bis- 
 acromial diameter is taken hold of, the fingers on the back, and the 
 thumb in front of the left shoulder or sternum, and the cubital edge 
 turned towards the occiput ; while the trunk is turning on its occipito- 
 coccygeal axis, we should endeavour to comprise the head in the 
 movement, and, if necessary, bring it near to the iliac fossa. In one 
 word, the left hand here acts as the right hand does in the opposite 
 positions ; it converts positions of the back into positions of the left 
 side, which it afterwards terminates by delivery in the second posi- 
 tion of the feet. 
 
 3G
 
 450 DYSTOCIA. 
 
 SECTION 3. 
 Of the Maneuvre in Presentation of the Pelvis. 
 
 The maneuvre in positions of the pelvis reduces itself in some sort 
 to that of the last stage, or stage of extraction, in the head or trunk 
 positions ; I need therefore only add a few words to what has been 
 said farther back, in order to conclude all that concerns it. 
 
 1029. Although, strictly speaking, the right hand might be easily 
 made use of in all the positions which it is proper to terminate by the 
 first of the feet positions, and the left only in the opposite cases, it 
 is, notwithstanding, better to do the very reverse. We can, with the 
 right hand, in all the right dorso-pelvic positions, push up one but- 
 tock, or even both of them towards the right iliac fossa, reduce inclin- 
 ed to central positions, and take hold of the limbs by their anterior sur- 
 faces, withoutbeing obliged to assume an awkward attitude ; whereas 
 with the left hand the breast could not be raised without difficulty, 
 and it would be still less easy to reach the feet, if they were not at 
 some distance from the orifice. Lastly, by using the hand that cor- 
 responds to that side of the mother's pelvis towards which the child's 
 heels are to be turned, while coming down, a half prone position brings 
 the palmar face of the fingers in front and on one side ; the operator 
 is consequently in the most favourable condition to prevent the back 
 of the fetus from moving towards the sacro-iliac symphysis, and on 
 the contrary, to compel it to turn towards the acetabula ; the ope- 
 rator can also pull with all the force that circumstances may require, 
 an advantage not to be obtained by adopting an inverse order in the 
 application of the hand. 
 
 Whenever, therefore, it is intended to deliver in the first position 
 of the feet, that is, whenever the child's back shall look more or less 
 towards the left of the pelvis, or even directly towards the pubis or 
 sacrum, the left hand should be introduced ; and the right hand in all 
 the other cases. 
 
 A. Positions of the Feet. 
 
 1030. Inasmuch as the positions of the feet, previously to the 
 rupture of the membranes, are scarcely distinguished from those of 
 the breech, there can hardly be any question concerning them until 
 after this rupture. The accoucheur then may be called under two 
 different circumstances, which it is important that he should not con- 
 found with each other : either the feet have not cleared the vulva, 
 or the trunk has more or less completely emerged.
 
 PELVIS PRESENTATIONS. 451 
 
 In the former case, if the two feet present together at the orifice or 
 in the vagina, all he has to do is to take hold of them and draw them 
 down so as immediately to extend the legs, and that the hips may soon 
 arrive at the inferior strait ; provided only one of them can at first 
 be found, some attempts should be made to discover the other, which 
 it is rarely difficult to do ; should the attempt not succeed, the first 
 one should be brought down, then secured by a fillet, and made use of 
 as a guide to the second, which may perhaps be found reversed to- 
 wards the breech, moved off far in a state of abduction, or with the 
 leg and thigh doubled up on the belly, &,c. 
 
 In the latter case, the presence of the feet offers no particular 
 indication ; nothing is to be done, as was mentioned in speaking of 
 turning in head positions, but to pull the different parts that are 
 still unexpelled downwards. 
 
 A very necessary precaution, when extracting a child by the feet, 
 is, to act in such a way that at the moment when the child is passing 
 the straits, the occiput may look towards some part of the anterior 
 semicircumference of the pelvis. The thing is easy ; and no skilful 
 practitioner will ever fail in bringing it about, when he goes in 
 search of the feet in a head or trunk presentation. But it is no 
 longer the case where the pelvis presents spontaneously at the supe- 
 rior strait ; mistimed or unskilful tractions may have been instituted 
 in his absence, or when he reaches the bed-side of the patient the 
 hips may have been already expelled and the face turned in front. 
 
 1031. The position of the feet where the child's dorsal surface 
 looks backwards may give rise to three particular cases : 1. The 
 feet are still at the superior strait, or in the vagina ; 2. The delivery, 
 if left to the natural powers, may be complicated with no accident? 
 or give no evidence of requiring the assistance of the hand, until the 
 lower extremities, or even the hips are born ; 3. Turning has been 
 attempted on account of some position of the head or trunk, the 
 feet have been brought down, but the operator has failed to make 
 the occiput turn in front. 
 
 1032. Let us here suppose the first hypothesis : after having got 
 hold of the limbs in the manner heretofore mentioned, the back 
 ought to be directed first towards the sacro-iliac symphysis or iliac 
 fossa, then towards the acetabulum ; with each pull, as the hips 
 approach the perineal strait, they are taken in both hands, and in the 
 interval betwixt two pains the whole trunk is pushed upwards again, 
 as if we wished to make it mount up above the superior strait ; as 
 soon as the womb, which is thus momentarily distended, appears to 
 be about to contract, the pelvis should be suddenly pulled down, 
 while at the same time we endeavour to make the body of the child
 
 452 DYSTOCIA. 
 
 revolve on its axis ; in this way, says Baudelocque, the cavity of the 
 womb is first enlarged, and as we endeavour in the next place to 
 empty it suddenly, the organ is in some measure surprised, and can 
 not contract so fast as to prevent the head from following the turn 
 we give to the body. These attempts are to be renewed from one 
 to ten and even fifteen times, according to th,e necessity of the case, 
 that is, until the anterior position has taken place of the, posterior 
 one, or until the impossibility of effecting the change is ascertain- 
 ed ; when the attempt proves successful, no particular difficulties 
 remain, and the rest of the maneuvre is the same as in feet presen- 
 tations in general. 
 
 When all hope of succeeding is abandoned, we must even be 
 resigned to let the face come along uppermost; we must redouble 
 our precautions against letting the chin depart from the breast ; the 
 arms should be disengaged, the hindermost one first, by pulling them 
 from behind forwards, and in a direction from the head towards the 
 thorax ; immediately after this, two or three fingers of each hand 
 should be applied to the two extremes of the occipito-mental diame- 
 ter ; we should endeavour to push the head upwards, or raise it so 
 as to give it more freedom, and finally, make it execute a pivot 
 movement, by whicli the face is gradually carried backwards. 
 
 Supposing it should be found impossible to turn the occiput in 
 front, the shoulders and chest should be pulled downwards, and 
 rather backwards than forwards, so as to deliver the chin, the fore- 
 head, and anterior fontanel before the occiput ; if these tractions 
 should prove incompetent, the forceps should be had recourse to. 
 
 1033. In the second case, provided the head has not as yet arrived 
 at the straits, we should act as in the first case, that is, the foetus 
 should be pushed upwards every time we wish to give the body a 
 turn ; but we must expect to succeed still more rarely. 
 
 1034. In the third, these attempts are of no use; we may 
 neglect them altogether, and immediately disengage the arms if it 
 be not already done ; we then conform, as to the head, to the prin- 
 ciples established higher up : some of the fingers must be applied 
 to the chin, which we endeavour to turn from right to left, while 
 with the other hand we act on one of the shoulders or the occiput, 
 so as to favour the complete rotation of the head and trunk, and 
 then proceed to deliver. 
 
 B. Position of the Breech. 
 
 1035. As the knees occasion no difficulty, by their presentation 
 mrrcly, in delivering a lying-in woman ; as their presence does not 
 at all altrr the principles, nor even the practical details of the ma-
 
 PELVIS PRESENTATIONS. 453 
 
 neuvre ; as one or more fingers are all that is required to disengage 
 them, or give them a regular position when in the vagina ; and 
 lastly, in as much as, where this presentation does not return into 
 the class of breech presentations, it is always an easy matter to 
 reduce it among the presentations of the feet, I shall not devote a 
 special article to the consideration of it, but shall pass at once to 
 the consideration of breech presentations. 
 
 1036. The left hand should be preferred in breech presentations, 
 as in those of the feet, whenever the back is turned more or less to 
 the left, and vice versa for the right hand. The child being doubled 
 up, with the thighs and legs raised up along the abdomen, if the 
 hips have cleared the orifice of the womb and descended into the 
 excavation, or even to the inferior strait, the groin that is most 
 backwards should be hooked with a finger or two, while the thumb 
 of the same hand is applied to the outer surface of the anterior hip. 
 If any resistance is experienced, there will be some advantage in 
 substituting one or two fingers of the other hand for the thumb, 
 and if that will not answer, the blunt hook should be made use of. 
 As soon as the hips have cleared the vulva, it is generally very easy 
 to extend the limbs, and the rest of the process is merely a footling 
 delivery. 
 
 1037. Previously to the rupture of the membranes, and where 
 the breech is not yet so far engaged as to render it impossible to 
 push it up again above the superior strait, whether the foetus be 
 doubled up or merely in a squatting attitude, we should always en- 
 deavour to bring down the feet. 
 
 1038. In order to push the breast up, the hand is placed under it 
 and along the posterior surface of the thighs ; the thumb is placed 
 on the anterior arid the fingers on the posterior hip ; or, where the 
 foetus is still very movable and very high up, it is enough to apply 
 the thumb under one of the ischia, and the fingers under the other ; 
 the pelvis is then pushed towards the iliac fossa that corresponds to 
 the hand that is made use of; then by passing along on the outer 
 surface of the limb that is nearest the sacrum, the feet may be got 
 hold of and brought down, so as to allow us to embrace the fore- 
 part of the legs with the hand, and deliver, as in a corresponding 
 position of the feet ; that is, in the first if the left hand is used, and 
 in the second position if it is the right hand. 
 
 1039. In conclusion, the maneuvre of the pelvis presents us but 
 two particular indications : 1 . To draw it down with the fingers or 
 blunt hooks, when it is too low down to be pushed back again ; 2. 
 To displace it whenever the thing is possible, so as to let the feet 
 pass down first. In both cases, when we employ only one hand, the
 
 454 DYSTOCIA. 
 
 palm of which is directed so as to slide up along the child's abdo- 
 men and breast, we surely require for our guidance only the follow- 
 ing rule ; that the fingers shall always be applied to the ischium or 
 hip that is opposite, and the thumb to the ischium or hip that cor- 
 responds to the hand that is operating. Were the limbs found to 
 be reversed upon the dorsal surface, instead of being turned 
 towards the abdomen, the thighs should be acted on as we do on 
 the arms, when disengaging them at the inferior strait ; the 
 thumb fixed in the groin might serve as a point d'appui ; the 
 fingers being moved along towards the ham, would represent the 
 power, and the knee would be obliged to descend, drawing the 
 leg along with it. The two limbs ought thus to be brought, either 
 together or in succession, to their natural position. In whatsoever 
 way they may present, it is always better to make them descend 
 together, than one by one ; however, where too much difficulty is 
 experienced, it would be imprudent to persist in endeavouring to 
 make them descend simultaneously. If one of them should have 
 already escaped, the anterior one for instance, and it should be im- 
 possible to get the other one down, the delivery, in most cases, 
 would not be rendered on that account much more difficult : it 
 should be made use of to draw down by, while the index and medius 
 fingers, or a blunt hook, should be applied to the posterior groin, as 
 has already been mentioned. If, on the other hand, the anterior 
 member only should be retained at the superior strait, it is still more 
 important than in the former case to draw it near the other limb, be- 
 cause we cannot so readily reach the groin in this situation, and espe- 
 cially because the action of the blunt hook is not so advantageous. 
 
 1040. Remarks. In concluding this article, I shall take the 
 liberty of again suggesting to students and young accoucheurs, that 
 if, in turning by the feet, they wish to avoid the risk of often killing 
 the footus, they ought never to lose sight of the fact that the head 
 cannot rotate on the spine more than a quarter of a circle, without 
 luxating it^ or straining the spinal marrow in a very dangerous way ; 
 that, in general, it does not follow the motion of the trunk of the 
 body, by means of which attempts are made to rotate it ; that it is 
 impossible, in any case, to affirm that it has rotated, merely on the 
 ground that the back, for example, has been turned from behind 
 forwards ; consequently, that in any species of maneuvre whatever, 
 we should commit a very great error if we caused the child's body 
 to turn more than a quarter of a circle, without being assured that 
 the head accompanies it in its movement. 
 
 loll. Neither can I leave this subject without returning for a 
 moment to the consideration of the maneuvre recommended by
 
 PELVIS PRESENTATIONS. 455 
 
 Baudelocque for bringing the child's back in front, and which was 
 spoken of some pages back. It would, in my opinion, be wrong to 
 rely upon such attempts. If the womb is but slightly contracted, 
 it is useless to act in that way ; when, on the contrary, the foetus is 
 forcibly compressed, the force which we exert upon it from below 
 upwards, seldom extends as far as the head, and even then it cer- 
 tainly does not change the general disposition of the womb, so as to 
 render the child at all more movable. This is not all : if it be not 
 certain that we shall be enabled, in this way, to render the rotation 
 of the occiput easier, it seems to me manifest that the abdomen, the 
 thorax, and even the cervical portion of the spine would not always 
 safely bear the various kinds of pressure and the twists to which 
 they will necessarily be subjected ; lastly, to express my unreserved 
 opinion, I will say that this precept of Baudelocque seems to me to 
 be more the fruit of imagination than of observation, and that mo- 
 dern writers ought, previously to copying it, at least to have<called it 
 in question and submitted it to a new examination. 
 
 SECTION 4. 
 Presentation of the Arm. 
 
 1042. The premature escape of the arm does not, of itself, con- 
 stitute a position, and forms only a complication of other positions, 
 particularly that of the shoulder. Both arms have been seen, but 
 rarely, to present together at the vulva ; unless brought there by 
 inconsiderate maneuvres, they could not both thus descend except 
 in back or sternum positions. It is said that they have been both 
 felt at the orifice at the same time with the feet, and it is at least 
 certain that they may precede the head at the inferior strait ; so 
 that, although the presence of the hand commonly indicates a posi- 
 tion of the shoulder, it may also happen that it is only a complica- 
 tion of a head or pelvis position. 
 
 1043. Until in the last century, nothing was deemed more dread- 
 ful than the appearance of the arm in the course of a labour ; and 
 in our day, the common people still look upon such an occurrence 
 as extremely dangerous. But these fears are explained by the 
 fact, that until the time of Levret it was not thought possible to 
 penetrate into the womb without having previously returned the 
 prolapsed member into its cavity. In reflecting upon the dangers 
 occasioned by the ridiculous or barbarous measures adopted in cases 
 of this kind, could it be believed that physicians would have seriously 
 recommended that a piece of ice should be put into the child's hartd,
 
 456 DYSTOCIA. 
 
 that it should be pinched, or fillipped, to make it pull its arm back .' 
 Others have invented a sort of forks, or crutches, &c. to push it up 
 with, by acting upon the chest ; the more timid pushed it up to the 
 top of the vagina, and sometimes succeeded in returning it into the 
 cavity of the womb ; but their attempts were generally in vain, and 
 the arm if somewhat swelled seemed to them to constitute an insur- 
 mountable obstacle to the introduction of the hand into the os uteri. 
 Under such circumstances, the old women, and even the physician 
 himself, could imagine no alternative save pulling at the arm until 
 the child yielded and came away doubled, or until the arm was torn 
 off. Pare advises that the soft parts below the shoulder should be 
 first cut round, and that we should then resort to sharp pincers to 
 cut the bone with ; De La Motte recommends us to twist the limb 
 round like the limb of a tree that we might wish to tear off from 
 the trunk ; lastly, the most timid were satisfied with making deep 
 scarifications in the tumefied part, so as to lessen its size. 
 
 Happily, at the age in which we live, such a dreadful doctrine is 
 held by nobody. Baudelocque and his successors did it justice long 
 ago ; and at present it is not without a sentiment of indignation, that 
 we still hear from time to time of practitioners who dare to conform to 
 it in practice. I should not even insist upon this point, had not certain 
 persons had the inconceivable audacity to renew this revolting prac- 
 tice of late years, in Bretagne, Normandy, Champagne, and even 
 in the environs of Montpellier, almost at the same time ; particu- 
 larly, had not these practitioners found some defenders in the capital ; 
 had not certain persons had the hardihood to publish, in 1826, 
 1827 and 1828, various pamphlets to justify a conduct so far re- 
 moved from tokological doctrines, and had they not anew appealed 
 to the authority of A. Pare, Mauriceau, Deventer, De La Motte, 
 Puzos, Mesnard, Levret, &c. as if the modern accoucheurs had not 
 overturned without exception all the reasons advanced by their pre- 
 decessors in favour of the amputation, or tearing off of the arms! 
 
 1044. I do not intend to deny that it never has been necessary 
 to separate from the trunk a member prematurely escaped, in 
 order to penetrate more readily into the womb ; I merely assert that 
 I cannot conceive of such a necessity ; that it is impossible to admit 
 of it, except where the child is dead ; that no matter how much the 
 arm may be infiltrated or swollen, a skilful accoucheur will always 
 be able to carry his hand into the womb without mutilating any 
 tiling ; lastly, that without being able to say how far the Norman 
 surgeon may have departed from sound rules, we must at least 
 admit, that the reasons and proofs cited by M. Roux for his excuse 
 would be dangerous if taken in the very letter.
 
 ARM PRESENTATIONS. 457 
 
 1045. In order that delivery may be effected, the child's head 
 must pass through the os uteri : but the hand of the physician and 
 the arm of the child can never be equal in size to the volume of the 
 child's head. Therefore, the presence of an arm is incapable of 
 preventing the hand from passing into the uterus, even although 
 there should be infiltration and tumefaction of the labia ; arid after 
 that, it becomes completely useless to return the arm previously to 
 going in search of the feet. 
 
 Therefore, when a hand appears at the vulva, and it is impos- 
 sible to ascertain certainly that the corresponding shoulder is at the 
 superior strait, far from becoming alarmed, and pushing it back, it 
 is, on the contrary, best to secure it with a fillet ; the fillet being 
 fixed, the shoulder is next pushed up, and we proceed to get hold of 
 the feet, just as if there were no complication whatever. As we 
 draw the lower extremities downwards, the arm mounts upwards, 
 and the fillet serves to pull it along at the same time with the feet, 
 after the version is complete. 
 
 1046. Although the descent of the arm along with the head is not 
 a serious cause of dystocia, there are, notwithstanding, cases where 
 the course of the labour is really embarrassed by such an occur- 
 rence. Consequently, We may get rid of the complication if pos- 
 sible: If called before the superior strait has been passed, there is 
 no difficulty in returning the child's hand into the uterus, and re- 
 taining it there by means of a few fingers until the head is well 
 engaged. If called at a later period, great difficulties are sometimes 
 experienced ; in some instances the thing is impossible ; we must, 
 under such circumstances, endeavour to make the hand slip along 
 the forehead towards the sacro-iliac symphysis or obturator foramen 
 of the side where there is the least pressure ; but should some new 
 difficulty arise, rendering the immediate termination of the labour 
 necessary, the forceps would be applied, without regard to the pre- 
 sence of the arm. 
 
 In case the hands should present at the same time with the feet, 
 they doubtless would not long maintain their position ; the contrac- 
 tions of the womb would soon force them to rise, by urging the 
 breech down. Besides, in order to obviate all cause of alarm, it 
 would be merely necessary not to confound them with the lower 
 extremities, and to pull upon the latter until the hips had come 
 down. 
 
 Pean and Deleurye have advised, where an arm and shoulder 
 
 fill up the orifice too exactly to allow the hand to reach the child's 
 
 foot, that we should begin by bringing down the other arm, so as to 
 
 enable us to penetrate more easily into the womb. This precept 
 
 3H
 
 458 DYSTOCIA. 
 
 has been the object of much criticism : it has been said that two 
 arms must necessarily occupy more space than a single one ; that by 
 bringing a second one alongside of the first, instead of overcoming 
 the obstacles, we should only increase them ; and that, if the hand 
 may be carried up as far as to the arm that has not yet escaped, there 
 is no reason why it could not reach to the feet themselves. 
 
 I have had no occasion to repeat the practice of Deleurye in this 
 respect ; nevertheless, it seems to me to have been proscribed pre- 
 viously to being sufficiently examined. Baudelocque is, assuredly, 
 deceived, when he maintains that it is always as easy to reach the 
 feet as the arm that is still retained above the orifice of the womb ; 
 the arm may be near enough to be seized with two or three fingers, 
 whilst the feet always require the whole hand to be introduced, and 
 most commonly to a great depth. By pulling upon the second arm 
 we tend to make the engaged shoulder mount upwards, and to c6n- 
 vert a position of the lateral surface into one of the sternal surface, 
 or dorsal surface, and I can conceive that in some cases there would 
 result an increased facility of passing the hand and of performing the 
 remainder of the maneuvre. 
 
 But what shall I say of Dr Davis, who recommends us in certain 
 cases of arm presentation to terminate the delivery by means of 
 embryotomy ! of Douglas, and of Sims, who profess the same senti- 
 ment ; and above all, of Dr Lee, who, to spare the mother, separates 
 the arm from the body, perforates the thorax, fixes a crotchet upon 
 the pelvis or inferior part of the foetal spine, and by means of suffi- 
 cient force thus extracts the child ! as if this operation were not an 
 hundred times more dangerous, even for the woman, than the most 
 painful and complicated version ! Who shall say how far the teme- 
 rity of certain persons shall carry them ? Has not a surgeon in one 
 of the colonies lately had the hardihood to perform the hypogastric 
 cesarian operation simply because turning appeared to him to be 
 too difficult in an arm presentation,-and what is still more surprising, 
 to boast of his conduct, as a model to be followed ? It is only by 
 remembering, that, in the sciences, where men are always to be 
 found who invariably substitute for the bounds of the possible the 
 limits of their own knowledge and capacity, that we are enabled to 
 conceive of such scandalous practices. 
 
 As long as the accoucheur is not in possession of certain proof 
 of the child's death, he has no right, under any pretext, to mutilate 
 it ; and if ever the presence of the arm could really prevent the in- 
 1 1 'mission of the physician's hand, it would be far better to follow the 
 advice of Bodin, and perform the vaginal cesarian operation, than 
 to have recourse to embryotomy. Even although the child be dead,
 
 TURNING. 459 
 
 we should proceed in the same manner, and, in the first place, put 
 in requisition blood-letting, the bath, injections, ointments, indeed 
 all sorts of relaxing and sedative measures. 
 
 General Recapitulation on the Maneuvre. 
 
 1047. In the maneuvre, all the positions of the head may be re- 
 duced to two; all the positions of the side belong to the second stage 
 of the maneuvre for the head positions ; all the positions of the back 
 and of the sternum should be reduced to shoulder positions ; and all 
 positions of the shoulder are at first converted into positions of the 
 feet. In turning, therefore, there are, in fact, but two positions 
 which it is essential to study profoundly, and consequently but two 
 maneuvres which it is indispensable to know well : further, as these 
 two maneuvres differ only in requiring the employment of a differ- 
 ent hand, as in reality the right hand does not maneuvre differently 
 from the left, it follows that the whole maneuvre in labours is re- 
 duced to the rules which were laid down in speaking of version by 
 the feet in positions of the vertex. I am aware that, as thus pro- 
 posed, the question will not be always exactly understood ; but I also 
 doubt whether those to whom these general rules will not suffice, 
 will be able to make much out of the most elaborate explana- 
 tions. In the detailed applications there are an infinity of shades 
 which words cannot describe, but which are easily guessed at by an 
 intelligent man, or which practice alone may teach him to discrimi- 
 nate. 
 
 ARTICLE II. 
 
 , r.'.c-W* ,=??-' -;?.. , 
 
 Of the Forceps. 
 
 SECTION 1. 
 The Forceps in itself considered. 
 
 1048. The forceps is an instrument with which the child, while 
 still within the organs of the mother, is seized and drawn forth. It 
 is not very precisely known who was the first inventor of this sort 
 of pincers, nor at what period it was first made mention of. It is 
 true that in the time of Avicenna certain blades with teeth in them 
 were made use of for the extraction of the dead foetus ; Rueff also 
 speaks of a pincers he made use of to extract the separate bones of
 
 460 THE FORCEPS. 
 
 the cranium ; but what comparison is there between these clumsy 
 instruments, which no one would have ventured to apply to a living 
 child, and the forceps employed at the present day ? 
 
 J049. The Chamberlains were for a long time in possession of a 
 secret for terminating difficult labours. One of the members of 
 that family came to Paris for the purpose of convincing the French 
 of the value of his instrument ; but as he was not successful in his 
 first attempts, and was ill satisfied with his reception in France, he 
 returned with his secret to London. Chapman and Giffard, who pre- 
 tend to have been acquainted with the means employed by Cham- 
 berlain, published a description of it at the commencement of the 
 eighteenth century, and asserted that it consisted of a forceps for 
 taking hold of the head with ; a surgeon of Brentford, whose name 
 was Drinkwater, is also spoken of as the author of a similar for- 
 ceps ; but it is really impossible to determine whether the Cham- 
 berlains made use of a forceps or a lever, or some other instru- 
 ment, nor whether the hands, which Palfyn says he first thought of, 
 and the invention of which was claimed by Ledoux, were any thing 
 else than the instrument used in England. 
 
 J050. However this may be, it was about this time that the use 
 of the forceps was introduced into the practice of midwifery. At 
 first, formed of two blades, either full or fenestrated, which were in- 
 troduced separately into the pelvis, and which were but slightly 
 curved, they soon received the addition of a double notch, to admit 
 of their being crossed. Smellie made them an extremely simple 
 instrument, the application of which is as easy as possible ; this 
 accoucheur even thought it would be well to have two forceps, one 
 very short, to be applied to the head when already down in the ex- 
 cavation, and the other rather longer, having a concave edge, for 
 the purpose of penetrating as far as the superior strait. 
 
 Levret, on his part, introduced such important modifications of 
 the forceps, that he in some sort made a new instrument of it, 
 which is still known in the science as Levrefs forceps. Like all 
 the others this forceps is composed of two branches : one called the 
 male branch, which I prefer to call the left branch, and the other the 
 female branch, which 1 shall call the right branch ; the blade of each 
 is largely fenestrated, has a bead or blunt crest on the circumfer- 
 ence of its concave surface, and on one of its edges exhibits a 
 curve which corresponds with the curve of the axes of the pelvis. 
 The handles, which are entirely metallic, and not quite so long as 
 the blades, terminate by a flattened hook. At the place where they 
 cross there \s a flat surface, a pivot and a mortise, which admit of
 
 THE FORCEPS. 461 
 
 their being firmly united, and prevent them from sliding on each 
 other when they are once applied. 
 
 1051. Since the time of Levret and Smellie the forceps has un- 
 dergone numerous changes, without speaking of those of Roederer, 
 Crantz, Walbaum, Johnson, Fried, Stein, Leake, Plenck, and an 
 infinity of others, the figures of which may be seen in the treatise of 
 Muller. We have the jointed forceps of Saxtorph, which in other 
 respects very closely resembles Smellie's instrument ; that of Cou- 
 touly, also jointed, but at the same time much more complex than 
 the former, and which admits of various shaped blades being fixed 
 to the same handle, according to circumstances ; another one, by the 
 same accoucheur, for the handle of which there is substituted a trans- 
 verse metallic hilt, and which, in consequence of the manner in which 
 the branches are united, must act like a lever of the third kind ; that 
 of Baudelocque, or Pean, which differs from Levret's only in being 
 rather longer ; the forceps of Thenance, the branches of which need 
 not be crossed, and which unite near to the curved end of the han- 
 dle, and is thus converted into a lever of the third kind, like one of 
 those of Coutouly. The two forceps of M. Dubois ; that of Brula- 
 tour, jointed by a peculiar mechanism ; that of Bruninghausen, the 
 pivot, of which is replaced by a sort of round-headed nail, and with 
 very small fenestres in the blades ; then the forceps of Meryen, which 
 is also jointed; then that of doctor Guillon, also jointed, and which 
 has no need of a movable pivot in order to be united, and contains 
 in its handle a pelvi-cephalometer, blunt hooks, sharp crotchets, a 
 perforator, and an extractor. Lastly, MM. Capuron, Maygrier, 
 Flamant, Colombat, and Prout have also thought proper to propose 
 some modifications in the construction of the forceps, so that the 
 profession is now in the possession of near an hundred species. 
 
 1052. There is not, strictly speaking, one of these forceps with 
 which the principal object proposed, viz. the extraction of the 
 fetus, cannot be attained ; but at the same time, not one of them 
 presents more real advantages united than Levret's. Its inventor, 
 who applied it so often, Baudelocque, whose practice was so exten- 
 sive, Mesdames Lachapelle and Boivin, who must have assisted the 
 delivery of so many women, MM. Desormeaux, Gardien, Evrat, 
 &c. never felt the necessity for modifying Levret's forceps, and M. 
 Dubois himself has long since rejected in his own practice several 
 alterations in them introduced by himself. 
 
 It is well to remark, besides, that most of these pretended im- 
 provements have been proposed only by young men, who had had 
 no opportunity of convincing themselves that in this, as in all other 
 surgical operations, much less reliance is to be placed upon the
 
 462 THE FORCEPS. 
 
 form of the instrument than upon the address or skill of the ope- 
 rator. 
 
 1053. The Levret forceps, made somewhat larger, according to 
 the views of Pean, deprived of the bead upon its concave surface, 
 and file-polished, in the way directed by Professor Flamant, termi- 
 nating in blunt hooks, containing a pique, as recommended by 
 M. Dubois, without any shoulder near the joint, and without a 
 sliding plate to secure the pivot, is the one I prefer. A correction 
 that I would willingly adopt, provided it could be effected without 
 weakening the instrument, would consist in having hinged joints, so 
 as to permit them to be doubled up, and thus rendered more port- 
 able ; but up to the present time this has been attempted in vain, 
 and an examination of the forceps lately made by M. Colombat, 
 leads me to think that that ingenious surgeon will not be more for- 
 tunate in this respect than his predecessors. 
 
 SECTION 2. 
 Of the Use of the Forceps. 
 
 1 . The cases that require the employment of the forceps are nu- 
 merous, and may be divided into two classes : in the one, no other 
 means except the forceps can be had recourse to ; in the other, it 
 would, strictly speaking, be possible to have recourse to turning, or 
 to rely upon some other means of succour, should it be desirable to 
 avoid applying the forceps. Antecedently to the invention of this 
 instrument, all those labours that could not be terminated by the hand 
 alone, were treated by embryotomy, or by some serious operation 
 upon the mother ; at present we are rarely reduced to the necessity 
 of thus sacrificing the child, and of equally compromitting the safety 
 of the mother, because the forceps generally suffices to obviate this 
 destructive practice. 
 
 1054. It has been laid down as a general rule that the forceps 
 must be applied, 1. Whenever the head is too large, cither relatively, 
 or absolutely, to pass through the passages without exposing the 
 woman to the hazard of exhaustion, or other dangers ; 2. When the 
 womb is in a state of inertia, and efforts to restore its contractility 
 prove to be in vain, and the head is found to bo so far engaged that 
 it is impossible to restore it to the superior strait ; 3. When any 
 accident renders the extraction of the foetus indispensable, and the 
 head has already descended into the excavation. 
 
 1055. Too large a head. If, as is already proved by the expe- 
 riments of Baudelocque and gome other authors, the head of a new
 
 USE OF THE FORCEPS. 463 
 
 born child, when squeezed so as to bend a forceps of the best con- 
 struction, is reduced in diameter not more than three or four lines 
 at the utmost, it is evident that when taken hold of within the pelvis, 
 where it is already more or less compressed in various directions, it 
 would not be prudent to depend upon any greater degree of re- 
 duction ; and besides, to obtain a reduction to that amount, it would 
 be necessary for the instrument to be applied exactly to the two ex- 
 tremes of the bi-parietal diameter. But when we come to reflect 
 upon the difficulty of fixing the blades exactly upon the points de- 
 sired, and that each of them arc a line and a half in thickness, it is 
 difficult to believe that a head too large to pass through the pelvis 
 under the influence of the powerful contractions of the womb and 
 the well directed efforts of the woman, could derive any great assis- 
 tance from the application of the forceps. 
 
 1056. Weakness of the organism. Inertia, or want of contrac- 
 tions of the womb, is one of the cases for which the forceps is most 
 frequently applied. When the head passes with difficulty through 
 the straits, and the woman is exhausted with vain efforts, the efficacy 
 of this instrument is not contested by any one ; but this is not the 
 case where there is inertia only, without any narrowness of the pas- 
 sages. Here every thing should be tried with a view of restoring 
 the action of the womb, and the forceps ought not to be made use 
 of until after the ergot has been tried in suitable doses. 
 
 1057. Accidents. When the child presents by the vertex or by 
 the face, and one of the complications pointed out in another article 
 renders it necessary to deliver the woman without delay, one of the 
 two following conditions will necessarily exist : 1 . The membranes 
 have been ruptured and the waters discharged for a long time ; the 
 womb is strongly applied to the foetus, and the head has reached 
 the excavation, or it is at least pretty firmly engaged in the superior 
 strait ; in which case nothing can supply the place of the forceps ; 
 2. The os uteri is dilated, the head is engaging, the membranes are 
 ruptured : strictly, the forceps might be applied ; but the child is 
 still sufficiently movable to admit of our going in search of its feet. 
 In this case practitioners are not agreed as to the best mode of pro- 
 ceeding ; some think, with Levret, Smellie, Plenck, and especially 
 with M. Flamant, that the forceps promises greater advantages than 
 turning ; others, along with Madame Lachapelle, M. Desormeaux, 
 and almost all the modern practitioners, are of a contrary opinion. 
 I think there is error and reason on both sides. M. Flamant speaks 
 the truth when he maintains that the forceps is much less dangerous 
 for the foetus than turning by the feet, and that it is to be preferred 
 in all cases where too much difficulty does not arise in its applica-
 
 464 USE OF THE FORCEPS. 
 
 tion ; but he relies too much upon his personal address, and certainly 
 inculcates a dangerous principle when he affirms that turning and 
 delivering the child by the feet is almost never necessary ; and that, 
 however movable and high up above the abdominal strait the head 
 may be, the forceps is always to be preferred. 
 
 1058. Every accoucheur knows that if the head is still movable, 
 it will displace itself during the introduction of each branch of the 
 forceps, and most generally is difficult to get hold of; that as the 
 blades of the instrument cannot in reaching it be accompanied by 
 the fingers, unless, as is M. Flamant's practice, the whole hand is in- 
 troduced into the pelvis, they are in some measure introduced at 
 hap-hazard into the uterine cavity ; that it is most generally impossi- 
 ble to say, exactly, whether they embrace the occipito-frontal diame- 
 ter, rather than any other ; finally, that the woman is exposed to a 
 thousand dangers, whereas the feet may be brought down with far 
 less difficulty, and at a much smaller risk of accidents ; but it is 
 also undeniable, and it appears to be too much overlooked at the 
 present day, that although the woman runs incomparably less risk in 
 turning, the same is not true as to the child, which too frequently 
 becomes the victim of this maneuvre, while it scarcely suffers at all 
 under the methodical application of the forceps. 
 
 1059. It is therefore wisest to pursue a just medium betwixt these 
 two extremes, to prefer the forceps, when we are much accustomed 
 to handle them, when they can be applied without too much diffi- 
 culty, and without any fear of injuring the woman ; on the con- 
 trary, to have recourse to the hand to draw down the feet, under 
 the opposite circumstances, that is to say, when the head is too high 
 up, or too movable to be easily got hold of, and where there is noth- 
 ing to prevent the artificial evolution of the foetus. 
 
 2. The forceps should only be applied to the head of the foetus ; 
 Smellie and others were wrong to advise their being applied upon 
 the foetal pelvis ; for should even a small amount of force be em- 
 ployed, they would crush the bones of the hips ; the upper ends of 
 the blades would contuse or lacerate the abdominal viscera, and in- 
 evitably kill the child ; besides, the blunt hook or fingers would 
 always advantageously supply their place here ; the head is the only 
 part upon which it can act or be placed without inconvenience, and 
 for which it was constructed. 
 
 1060. From Levrct and Smellie down to the most modern ac- 
 coucheurs, the French and English authors have all recommended 
 that the forceps should be applied so that its two claws should cover 
 the two extremes of the bi-parietal diameter; that its long axis should 
 be parallel to the occipito-uiental diameter, and its concave edges
 
 USE OF THE FORCEPS. 455 
 
 turned towards the occiput, excepting always those cases where the 
 head is delivered in an occipito- posterior position ; it is true, that De- 
 leurye and Baudelocque had admitted that where the head is locked 
 transversely at the superior strait, it might at first be grasped by the 
 occiput and forehead, so as to make it descend into the excavation, 
 to be afterwards laid hold of in a more advantageous manner ; but as 
 far as I know, no body has followed this advice, especially as the 
 case supposed by Baudelocque has, perhaps, never occurred. 
 
 1061. The practitioners of Germany, Prussia, and Russia, fol- 
 low quite a different rule ; they pay no regard to the position ot 
 the head ; the pelvis alone guides them ; according to them, if the 
 convex edges of the blades look towards the iliac fossae, they are 
 well placed ; the reason they assign is that we can very rarely be- 
 forehand determine what is the exact situation of the occiput ; 
 that even supposing we could ascertain it, it would not on that ac- 
 count be necessary to change the mode of application of the instru- 
 ment, inasmuch as, in the diagonal positions, the mere power exert- 
 ed in fixing and uniting the blades brings the forehead in front ot 
 the sacrum or behind the pubis ; that completely transverse posi- 
 tions are exceedingly rare, and would render the application of the 
 forceps too difficult, if the design of embracing the parietal pro- 
 tuberances were obstinately persisted in ; lastly, that by conforming 
 to their doctrine the operation is always extremely simple, and that 
 the head almost always ends by placing itself, if it were not so 
 already, in an antero-posterior position ; so that, after all, the same 
 result is obtained, only, by conforming to the principles generally 
 adopted among us. 
 
 1062. Without denying that there may be somewhat of truth in 
 this view of the subject, which, it seems to me, has not been suffi- 
 ciently attended to by the French, it may, nevertheless, be objected, 
 that as a general proposition, it will always be better to pass the 
 blades of the forceps immediately upon the temporo-parietal regions 
 of the head, than always to introduce them along the sides of the 
 pelvic cavity ; that if it is rare to find the head situated directly across 
 the pelvis, it is at least common to find it turned towards one of the 
 acetabula, or sacro-iliac symphyses ; that it is not only good, under 
 such circumstances, to have the forceps turned somewhat to the 
 right or left ; but also, that it most commonly assumes that direction' 
 spontaneously ; and, so to speak, in spite of the operator, provided 
 the head be pretty firmly fixed in the passage. Let us observe, fur- 
 ther, that by grasping the two ends of the occipijlp-ff ontal diameter, 
 the head is prevented from flexing ; it is forced to descend trans- 
 versely, to present one of its longest diameters to the different pas- 
 
 31
 
 466 USE OF THE FORCEPS. 
 
 sages, and that if taken hold of in this situation, it cannot pass through 
 the inferior strait. 
 
 1063. To conclude, inasmuch as the occipito-bregmatic and 
 occipito-frontal diameters always turn more or less directly from 
 front to rear when they reach the excavation ; as in cases where the 
 head has not yet cleared the superior strait, the occiput or forehead 
 almost always looks towards one of the cotyloid cavities ; as the 
 clains of the forceps, after their introduction, naturally incline to- 
 wards the sides of the head, or, when it opposes but little resistance 
 to the force exerted upon it, cause it to turn on its vertical axis, it 
 may be said that, the difference between our practice and that of the 
 Germans is greater in appearance than in reality, and that, in fact, 
 it does not appear that it can ever be indispensably necessary to 
 place one of the branches of the instrument in front and the other 
 behind. 
 
 1064. Thus the forceps may be applied to the head when the 
 vertex or the forehead comes first, and even when the trunk escapes 
 before the head. 
 
 To render this application indispensable, it is necessary : 1 . That 
 the head shall not require to be reduced more than two or three 
 lines, or that it shall be possible to displace it, and direct it more 
 advantageously through the straits ; 2. That there shall be a press- 
 ing need for terminating the labour without delay, or that no further 
 reliance can be placed on the powers of the woman in the expulsion 
 of the child ; 3. That the head shall be engaged so far that it would 
 be impossible without difficulty to return it and proceed in search 
 of the feet ; 4. That the membranes shall have been ruptured and 
 the os uteri completely dilated for a greater or less period of time. 
 
 1065. Previously to commencing the operation the same precau- 
 tions should be taken as for turning : the woman should be situated 
 in the same manner ; however, there may be circumstances hi which 
 the accoucheur need not alter her position ; fof example, in case of 
 convulsions, hemorrhage, or extreme debility, indeed any circum- 
 stances which would render any shock or movement dangerous ; 
 but then the head must have cleared the abdominal strait, in which 
 case a short forceps may be made use of, such as Smellie's, for 
 example. 
 
 The posture on the side adopted by the English for spontaneous 
 delivery is also preferred by them as most favourable for the appli- 
 cations of the forceps, which I can hardly conceive of. 
 
 As it is wrong to introduce the forceps into a woman's organs, 
 without advertising her of it, I think the best mode of quieting anl 
 ^reassuring her is la show her the median ism of the instrument.
 
 OCCIPITO-ANTERIOR POSITION. 467 
 
 There should be in readiness some warm water to attemper the 
 instrument ; and some butter, oil, or mucilage, to make it slip more 
 easily over the surfaces; when every thing is properly disposed of, and 
 the position of the head has been ascertained, nothing remains but to 
 introduce the blades ; but as there is some difference in the maneu- 
 vre, according as the occiput is directed in this or that manner, as 
 the head descends before or after the trunk, I shall now proceed to 
 examine these different cases. 
 
 . 1. Occipito-anterior position. 
 
 1066. This position, the most advantageous, and most frequent 
 of all, requires that the left branch should be introduced first. Two 
 or three fingers of the right hand, in a flattened position, are to be 
 passed up betwixt the left side of the vagina and the parietal pro- 
 tuberance, so that their extremities may touch the os uteri ; the 
 instrument is then taken by the left hand, as a writing pen is held, 
 and the handle is first raised high up in front of the woman's right 
 groin, so as to bring the other extremity in the line of the axis of 
 the vulva or inferior strait : as for the introduction of the hand, the 
 interval between two pains must be chosen ; it is introduced gently, 
 without force ; in proportion as it enters, the handle is by degrees 
 brought from above downwards and from right to left, towards the 
 median line ; after this it is frequently necessary to place the thumb 
 above and to the right of the pivot, instead of leaving it beneath it; it 
 is thus moved onwards, making it follow the left posterior inclined 
 plane or front of the sacro-iliac symphisis, rather than the left side 
 of the pelvis properly so called, until its entablement shall have ar- 
 rived between the labia ; after which the handle is brought near the 
 internal surface of the left thigh, depressing it more or less accord- 
 ing to the depth to which the blade has been carried. 
 
 During this introduction the point of the clam, held very strictly 
 betwixt the head of the foetus and the parts of the woman, ought 
 never to deviate from the curve of the excavation. By deviating 
 from the axes of that cavity, it would be arrested by the vagina, 
 which it turns up in folds, or might lacerate ; if inclined too much in 
 front or to the rear, it would involve the bladder or rectum in the 
 danger of being wounded. On the other hand, by turning too 
 much inwards, which almost always happens in using a forceps with 
 a very concave blade, it abuts against the child's head, and is soon 
 stopped by the folding up of the scalp ; so that in any way it would 
 be dangerous to introduce it by force. 
 
 Whenever, therefore, any resistance is experienced that does not 
 appear to be natural, instead of pushing it on with too much vio-
 
 468 USE OF THE FORCEPS. 
 
 lence the instrument should be withdrawn a little ways so as to dis- 
 engage it, and afterwards slip it up in a more favourable direction. 
 
 Where the head has passed through the os uteri, as long as the 
 forceps does not abandon the fingers that are in the vagina, one 
 must be very awkward to go amiss ; but this is not the case 
 where the head is almost inaccessible, and where the circle of the 
 orifice still envelops it in the shape of a crown fitting more or less 
 tightly. The greatest attention is necessary here : if the end of the 
 clam deviates from the cranium, it slides over the outer surface of 
 the os uteri, and gets into the cul de sac, or circular groove formed 
 by the vagina, where it is attached to the neck of the uterus. If 
 the accoucheur should not perceive this deviation, it is easy, without 
 pointing them out, to comprehend the havoc and danger that might 
 ensue. However, in order to avoid them, it suffices never to make 
 the instrument penetrate beyond the parietal protuberances without 
 being previously assured of the position and state of the os uteri. 
 
 1067. When we are sure that the left branch is well placed, an 
 assistant takes hold of it and keeps it in contact with the thigh 
 while the physician introduces the other. 
 
 This one is to be taken in the right hand, and guided by the 
 fingers of the left, to the right side of the pelvis, or corresponding 
 sacro-iliac symphisis ; to make it enter, we are to act exactly as 
 was just now directed, in speaking of the left branch. If the occi- 
 put is inclined to the left, we endeavour to move the blade forwards 
 behind the right thyroid foramen. If it be a right occipito-acetabu- 
 lar position, on the contrary, we leave it in front of the sacro-iliac 
 symphysis, while we endeavour to get the left branch behind the left 
 acetabulum. 
 
 1068. In order to be able to unite the two branches of the for- 
 ceps, they must both be at the same depth in the pelvis ; the mortise 
 in one must correspond exactly to the pivot in the other ; their place 
 of crossing must not be more to the right than to the left, and their 
 handles must be sufficiently depressed. When the occiput is behind 
 the symphysis pubis, it is sometimes difficult to fix them exactly 
 upon the sides of the pelvis; they incline towards each other at their 
 convex edges, while their concave edges tend to separate, which 
 doubtless depends upon the head being not so thick towards the 
 forehead as towards the occiput. This difficulty may be overcome 
 by taking a firm hold of the blunt hooks of the forceps, so as to use 
 them as a bent lever of the third kind, but we should be very sure 
 that the obstacle depends upon no other cause. By following this 
 precept, the concavity of the blades comes to be applied over the 
 parietal protuberances when the occipito-frontal diameter is in line
 
 OCCIPITO-ANTERIOR POSITION. 469 
 
 with the sacro-pubic, and, in the oblique positions, the vertex is dis- 
 placed, and promptly directs itself to the top of the arch of the pubis. 
 Further, it is evident that when the head is too firmly fixed, one 
 of the branches of the forceps will, under efforts of this kind, resist 
 less than the other, and place itself under the corresponding anterior 
 inclined plane of the pelvis ; so that the three occipito-anterior po- 
 sitions, so far, do not sensibly differ from each other as regards the 
 application of the instrument. The hand generally suffices to turn 
 the pivot, otherwise the kind of lever called the key of the forceps 
 is had recourse to. 
 
 1069. In the next place, we ascertain that the head is the only 
 part embraced by the blades, and that the os uteri, the womb, or some 
 other part of the woman is not taken hold of; the mode of acquiring 
 a degree of certainty upon this point, consists in moving the instru- 
 ment gently from handle to handle, in the direction of the axes of 
 the pelvis. If it moves readily, and without making the woman 
 suppose that she is getting torn or pinched, there is nothing to fear ; 
 in the contrary case, it is almost certain that some fold of the genital 
 organs has got pinched in the clams of the instrument, and until the 
 head shall have been more properly embraced, all pulling and every 
 species of pressure should be carefully avoided. 
 
 1070. In operating with a view to lessen the size of the head, a 
 loop of ribbon, of thread, or of a fillet, is fixed on one of the blunt hooks 
 of the forceps ; a turn is then made over the other branch, and the 
 handles are brought as near together as is deemed necessary ; the 
 fillet is then carried over the first handle, then brought back over 
 the second, and so in the form of a figure 8 until it is all used ; it 
 being well understood that the pressure exerted must be greater or 
 less, according to the degree of reduction which it is desirable to 
 obtain. 
 
 1071. Where the passage is capacious and the forceps is only 
 had recourse to for the purpose of speedily delivering the woman, 
 this compressing method may indeed be dispensed with ; neverthe- 
 less, as it is always well to have both hands disposable, so as to be 
 able to rest them from time to time, it seems to me better to apply 
 the fillet as recommended, in all cases, with this difference, that 
 under the circumstances now supposed, it is employed solely for the 
 purpose of keeping the branches of the forceps in a fixed and pro- 
 perly approximated situation. 
 
 After having wrapped the handles in a napkin, the right hand is 
 placed near the blunt hooks, above as long as it is necessary to pull 
 in the axis of the superior strait, and below, on the contrary, when 
 the head is at the inferior strait ; the left hand is applied at the roots
 
 470 USE OF THE FORCEPS. 
 
 of the blades, beyond the pivot, below when the right hand is above, 
 and above when it is underneath. 
 
 1072. The forceps being properly held, and the head firmly 
 grasped, before we begin to pull downwards the occiput must be 
 directed diagonally, provided it be still at the superior strait ; if it 
 be in the excavation, it is brought behind the symphysis pubis. To 
 compel it to descend to the centre of the pelvis, and to prevent the 
 forehead from descending prematurely, it has been recommended to 
 sustain the latter with a couple of fingers of the left hand ; but T 
 think it would be wrong to place much dependence upon this pre- 
 caution, which, besides, deprives the accoucheur of a great portion 
 of his power. I prefer trusting to the depression of the handles, to 
 such an extent as to keep the blades in the axis of the superior strait, 
 and to tractions performed in the same line of direction. 
 
 1073. If the head is locked, or too firmly fixed at the superior 
 strait, we first attempt to start it as we start a cork in a bottle or a 
 nail that we want to draw; it is then to be pushed up so as to oblige 
 the occiput to descend in a more favourable manner. We are to 
 pull obliquely downwards and backwards until the strait is com- 
 pletely cleared ; as soon as the rotation movement is effected, and 
 the head is in a direct antero-posterior position, we ought, in pulling, 
 to move the handles of the forceps alternately right and left, until 
 the parietal protuberances have passed the ischiatic strait. These 
 tractions ought to be at once powerful, slow, and moderate ; should 
 there be no reason for haste, we need not pull except during the 
 uterine contractions, which, besides, rarely fail to become very ener- 
 getic and frequent as soon as we commence the operation ; but 
 when the very moments are counted, or the womb in a state of in- 
 ertia, it would be useless or dangerous to wait ; we ought to act 
 immediately. 
 
 1074. When the head reaches the vulva and is retained only by 
 the soft parts, we leave off pulling from handle to handle. We 
 ought even not to pull at all, provided the womb appears to have 
 preserved a sufficient degree of energy to enable it to terminate the 
 labour ; for at this juncture it is highly important not to proceed too 
 rapidly, and to be assured that the best way of managing the peri- 
 neum is to retain the head as long as may be at the vulva. In- 
 stead, then, of engaging the woman to bear down, and pulling at 
 the same time with great force, as we had previously done, she is 
 urged to be careful of making strong efforts ; it is often best, even 
 to withdraw the instrument, which, if the head be born, requires no 
 particular precaution, while, in the contrary case, the blades are re- 
 moved one after the other, holding them in the same way as when
 
 OCCIPITO-POSTERIOR POSITION. 471 
 
 they were introduced, and beginning with the right branch, which is 
 uppermost. Should it be afterwards necessary to exert any tractive 
 force, it might be effected by placing the fingers upon the temples 
 or under the arm-pits of the foetus, as is done in some cases of 
 spontaneous delivery. 
 
 1075. Authors have expressly advised that the noise made by the 
 striking or rubbing of the two branches of the instrument together 
 should be avoided, because, say they, this noise might frighten the 
 woman. It would doubtless be imprudent to take no precaution on 
 this head, and to clash the blades together as we would the foils at a 
 fencing match ; but I can perceive no reason for the minute precau- 
 tions that are indicated in relation to the matter in the latest publi- 
 cations on midwifery. 
 
 . II. Occipito-posterior position. 
 
 1076. The forceps ought to be introduced and fixed in the same 
 manner as in the former position ; only, it is unnecessary to depress 
 the handles so much while drawing down : as the occiput, which 
 however ought to emerge first, constantly tends to lodge against 
 the anterior face of the sacrum and coccyx, which is very long and 
 very concave, more numerous difficulties must be expected, as well 
 as greater dangers to the perineum. But the operation would be 
 still more dangerous and difficult, if, as has by some been advised, 
 the concave edge of the instrument should be turned backwards in- 
 stead of looking towards the pubis. In the first place, to conform 
 to this precept, it would be necessary to change the posture of the 
 woman ; and then it would be impossible to grasp the head at the 
 superior strait, otherwise than in a line from the anterior fontanel to 
 the nucha ; in the third place, as the forceps would no longer be 
 parallel with the curve of the pelvis, its concave edge would, during 
 the tractions, of necessity press the vagina and bladder with violence 
 against the pubis, while the ends of the blades would operate in 
 the same manner, and still more certainly upon the soft parts be- 
 hind. If, on the other hand, the head should be grasped only with 
 the view of turning the occiput round to the front of the pelvis, as 
 it would be nearly impossible to act at the same time upon the trunk 
 of the foetus, we should succeed only in wringing the child's neck. 
 In this, as in the occipito-anterior position, the forceps ought there- 
 fore to be so placed that its concave edge may look forwards, even 
 though it may be turned towards the child's forehead, and not to- 
 wards the occiput, as the general rule would require. 
 
 . III. Left occipito-iliac position. 
 
 1077. It does not appear to me that such a position, in the exca-
 
 472 USE OF THE FORCEPS. 
 
 vation, is admissible ; but should it ever be met with at the superior 
 strait, and require the application of the forceps, I do not see how 
 we could dispense with following the precept of the German accou- 
 cheurs, unless indeed we should imitate M. Flamant, and proceed 
 beforehand to take hold of the head with the hand and place it in a 
 more convenient position ; a proceeding much easier to recommend 
 than to execute, in a majority of cases. The sacro-vertebral angle, 
 the coccyx and the perineum would not admit of the instrument being 
 placed transversely ; at least, it would be absolutely impossible to 
 extract in the direction of the axis of the superior strait. 
 
 1078. Admitting, however, that the case may occur, this is the 
 advice given by the authors : the right branch of the forceps is to be 
 introduced first, and conducted with the ordinary precautions, in 
 front of the right sacro-iliac symphysis, as high up as the forehead ; 
 then the ends of the first fingers of the left hand are placed under 
 its convex edge, and in concert with the right hand move it from 
 behind forwards and from right to left, until its concave edge is 
 turned towards the left iliac fossa, and the blade has arrived upon 
 the right parietal protuberance. The handle, strongly depressed, 
 is then given to an assistant, who holds it against the woman's 
 left thigh. 
 
 1079. The left branch is held in tile left hand, and passed up 
 along the posterior part of the pelvis until its point is above the 
 superior strait, and the pivot even with the mortise that is in the other 
 branch. After having joined them and dislodged the head, if it be 
 still in the superior strait, and forced the occiput to descend into 
 the excavation, provided it were not already there, the concave 
 edges of the instrument are gradually brought to the front, and the 
 remainder of the operation is conducted as in the occipito-pubic 
 positions. 
 
 . IV. Right occipito-iliac position. 
 
 What I have just now said of the left occipito-iliac position is 
 entirely applicable to the right occipito-iliac position ; they only 
 differ from each other in regard to the application of the forceps, 
 in doing which the led branch is to be introduced first. 
 
 . V. Positions of the pelvis. 
 
 It may happen that after the child has been drawn down by its 
 pelvic extremity, great difficulty shall be experienced in attempting 
 to disengage the head. The same thing may be met with at the 
 close of a pelvis labour which up to that moment had exhibited no- 
 thing peculiar ; if the fingers and hands do not suffice for the deli-
 
 PELVIS POSITIONS. 473 
 
 very of the woman, it will probably be found that it is occasioned 
 by a contraction of the pelvis, more or less considerable, in which 
 case the forceps may be of little avail. However, it must be tried, 
 rather than resort to symphyseotomy or the cesarian operation, 
 particularly provided the head is below the superior strait. 
 
 If the occiput is in front or a little to one side, an assistant should 
 raise the trunk upwards, and first the left branch, then the right is 
 introduced, following the same rules as if the head had descend- 
 ed first. 
 
 If it is behind, and it be found impossible to turn it round to the 
 front of the pelvis by means of the hands, the foetus is to be turned 
 back over the perineum, and the branches of the forceps are still to 
 be introduced as before. But in extracting the head we should 
 endeavour to act with sufficient force upon the forehead and chin 
 to make those parts descend early under the symphyses of the pubis. 
 
 Lastly, should it be found on one side, the trunk ought first to be 
 moved to the right or to the left, and then we should proceed as 
 has been directed for the corresponding positions of the vertex. 
 
 Thus, in all cases, the trunk is to be turned towards the direction 
 in which the occiput looks, and the forceps introduced along the 
 sides of the head, in such a way that the concavity of its edges may 
 be towards the front, or shall be brought there in the progress of 
 the operation. 
 
 1080. It is easy to perceive that the presence of the trunk must 
 add to the difficulties that are experienced in head presentations. 
 Still, many practitioners have thought, that under such circumstances 
 the fingers might be beneficially substituted for the forceps, and that 
 it is entirely useless to attempt its application where the head has 
 not yet reached the excavation. 
 
 This seems to me to be dangerous doctrine. I know very well 
 that a skilful accoucheur will generally triumph over the difficulties 
 presented by this position without having recourse to the forceps ; 
 I am also aware that the forceps, here, cannot easily be applied to 
 the head at the superior strait ; but it is also undeniable that the 
 head may be arrested at the superior strait by such a degree of con- 
 traction (hat the best combined efforts of the hand shall be insufficient 
 for its extraction ; but, why should not the forceps offer the same 
 advantages in this case as in the positions of the vertex ? Moreover, 
 excepting symphyseotomy, what other means is there of extracting 
 the fcctus alive ? I will add, that, the trunk being without, and the 
 head in some measure beyond the reach of the uterine contractions, 
 any force exerted upon the body with the hand, and sufficient to 
 enforce its passage through the organs, will generally act on the 
 3K
 
 474 USE OF THE FORCEPS. 
 
 spine of the child to the extent of seriously compromitting its exist- 
 ence, whereas the forceps does not export it to the same dangers. 
 
 1081. Consequently we may have recourse to the forceps, in 
 pelvis presentations, 1. When the head is stopped by the inferior 
 strait only, and we are convinced that the powers of the hand 
 alone would be insufficient, or too dangerous ; 2. When the same 
 part has not cleared the superior strait. But then, it must be en- 
 gaged in it, or at least the face must be chiefly in the excavation, 
 and it must be possible to reach the os uteri with some of the 
 fingers. It is well understood, moreover, that in both cases, the 
 chin must have been previously forced to descend, the head must 
 have executed its rotation movement, and the shoulders must have 
 been disengaged. 
 
 . VI. The child is completely or partially double. v 
 
 1082. In cases where two children are united to each other at 
 their anterior or posterior surface, and where two large heads are 
 supported by a single trunk, it is possible that the efforts both of the 
 woman and accoucheur, although properly combined, may be insuf- 
 ficient to effect the delivery without the aid of the forceps. 
 
 If the trunk or the two trunks have escaped, it will be necessary, 
 in order to admit of the application of the instrument, that one of 
 the head's shall be in the excavation ; nor, provided the monstrous 
 fetus should present by the vertex, ought this instrument to be re- 
 jected, although neither of the two heads should have cleared the 
 superior strait. In the former case, that is to say, where the trunk 
 is delivered, the head nearest the posterior plane of the pelvis ought 
 to come down first, and in the latter, on the contrary, that one which 
 is naturally turned towards the pubes. 
 
 Finally, the operation, if conducted agreeably to the general rules 
 indicated higher up, would require no other precaution than that of 
 raising the handle of the forceps forcibly upwards at an early 
 period, and to pull, amiost from the commencement, in the line of 
 the axis of the vulva. This would be the only way to avoid forcing 
 the second head, still contained in the womb, to reverse itself, or to 
 remain hitched, as it were, above the pubis or the sacro vertebral 
 angle. 
 
 . VII. The head, separated from the body, remains alone in the 
 pelvis. 
 
 1083. Formerly so little (are was taken in regard to the extrac- 
 
 tivr I, ,1 upon tlic Urdu-, when it was deemed necessary to 
 
 deliver it l.otlin<r, that it was not very uncommon to see the neck part
 
 DETRUNCATED HEAD IN PELVIS. 475 
 
 from the head, and the trunk thus torn off during the violence of 
 the exertions. At the present day this accident could happen only 
 to the most ignorant or thoughtless practitioner ; for it is never 
 allowable to employ a force with the hand alone, sufficient to pro- 
 duce the occurrence. It is only where one of the passages, of size 
 sufficient to admit of the transit of the trunk, is so contracted as 
 completely to.arrestthe head, that it might perhaps become useful to 
 separate the portion of the child that is without from that which 
 remains enclosed within the genital organs. 
 
 But admitting that this necessity does exist in some cases, it still 
 must be very rare, since the delivery of the body does not absolute- 
 ly prevent the application of the forceps to the head ; nevertheless, 
 as we unfortunately meet with a good many persons who undertake 
 the practice of midwifery without possessing the least knowledge 
 of the subject, it would be imprudent for the educated practioner 
 not to reflect upon what lie would do if called to a woman whose 
 foetus had been thus detruncated, either voluntarily or involuntarily, 
 by immoderate pulling or by means of an instrument. 
 
 1084. In the first place, the head must be placed in a proper 
 situation, that is to say, its occipito-mental diameter must be adapt- 
 ed to the axes of the pelvis, and the face turned backwards. 
 
 When in the excavation, it is almost as easy to get hold of it as 
 if it were not separated from the body. At the supe/ior strait, the 
 operation is often found to be one of the utmost difficulty, and appears 
 to be even impracticable, when the womb is scarcely contracted, 
 and the face and occiput are not yet engaged. When the head is 
 firmly fixed by the contraction of the uterus, or when it can be kept 
 still with the hand, so as not to slip out of the grasp of the instru- 
 ment, we are to proceed just as if the body were still attached ; only, 
 in order to make surer of its not turning so as to put the occipito- 
 frontal in place of the occipito-mental diameter during the process 
 of extraction, we should endeavour to steady it by applying a couple 
 of fingers of the hand that holds the root of the forceps near the 
 vulva, to the face or chin. 
 
 . VIII. Recapitulation, on the employment of the forceps. 
 In bringing this article to a close, I think it a duty to repeat the 
 following corollaries : 
 
 1. The forceps ought never to be applied without an evident 
 necessity, because, although it might not be mischievous to the 
 child, the mother may receive the greatest injury from it. 
 
 2. In the practice of good accoucheurs, the forceps is scarcely 
 employed once in two hundred labours; and as every thing tends to
 
 476 USE OF THE FORCEPS. 
 
 show that the ergot will be advantageously substituted for it in a mul- 
 titude of cases, its employment will doubtless continue to be more 
 and more rare. Most of those who make a more frequent use of 
 it are not wrong merely because they perform an operation that is 
 useless, but also, and especially, because they needlessly derange the 
 progress of a natural function ; and because they voluntarily expose 
 themselves to the risk of complicating the sequel of delivery, even 
 admitting they are sure of not wounding any organ. 
 
 3. The forceps cannot be beneficially applied, except to the head, 
 either when it descends foremost, or when it follows the trunk of 
 the body. 
 
 4. It is much more to be relied on for the purpose of grasping, 
 and extracting the head, than for diminishing its size. 
 
 5. It is not allowable to introduce it into the womb until the ori- 
 fice is sufficiently dilated, and the head ceases to be movable and 
 loose above the superior strait. 
 
 6. As far as possible, the blades of the forceps ought accurately 
 to embrace the two sides of the head in the direction of the occipito- 
 mental diameter ; nevertheless, where some difficulty or doubt is 
 experienced, it is more convenient and more prudent to pass them 
 up along the sides of the pelvis. 
 
 7. Except in the right occipito-iliac position, if it ever does occur, 
 and we should wish not to grasp the head by the occiput and fore- 
 head, the left branch must always be introduced first, because it is 
 the undermost. 
 
 8. In whatever manner the branches tire introduced, their concave 
 edges must be ultimately brought in front ; but if the head had been 
 seized by the ends of its occipito-frontal diameter, and had not, while 
 descending, rotated between the clams of the instrument, it must be 
 abandoned at the inferior strait, to be taken hold of more advantage- 
 ously, should the forceps still continue to be necessary. 
 
 9. The extraction should always be performed in the line of the 
 axes ; always with gentleness,- never precipitately, nor by jerks; the 
 tractions from handle to handle are of no use after the head occupies 
 the vulva, and if performed while it is at the superior strait, would 
 sometimes be dangerous. 
 
 10. It is not only because it has become useless that the instru- 
 ment should be taken ofi' when the head, at the lower strait, is only 
 resisted by the soft parts, but also, and chiefly, in the view of avoiding 
 laceration of the perineum, and allowing the vulva to dilate more 
 slowly and regularly.
 
 THE LEVER. 477 
 
 
 
 ARTICLE III. 
 Of the Lever. 
 
 SECTION 1. 
 Of the Lever in itself considered. 
 
 1085. Herbiniaux, and Denman, the British Baudelocque, have 
 decidedly maintained that the lever is incomparably superior to the 
 forceps ; and notwithstanding that it has not been so highly thought 
 of in France, it has occupied much of the attention of the physicians 
 of our country since the middle of the last century. 
 
 1086. Its inventor is no better known than that of the forceps. 
 Was the idea of it derived from the uncus of Celsus or the curette 
 of the lithotomists ? Is it the instrument made use of by the Cham- 
 berlains, as Mulder pretends, or the spoon of Palfyn, or one of 
 the branches of Smellie's forceps, variously modified ? Still it is 
 true that Roonhuysen, who made a secret of it, acquired celebrity 
 as an accoucheur, by means of a peculiar instrument, since used 
 under the title of Roonhuysen' s lever. This instrument, which, 
 from Roonhuysen passed into the hands of Bruyn, was purchased 
 and made public by de Vischer and Van de Poll in 1753; but, as 
 was the case with regard to the forceps, a great number of very 
 discrepant accounts of it appeared in the course of a short time ; 
 there was soon a lever by Boom, another of De Bruyn, a third by 
 Titsing, one by Palfyn or Heister, one by Cole, one by Griffith, a 
 lever by Wathen, one by Aitken, &c. There was no less discre- 
 pancy upon its mode of acting : according to some it was to be ap- 
 plied to the occiput, potentia agit in os occipitis, was the family 
 secret; according toothers it was to be applied to the temples; 
 Titsing directed it to be applied to the mastoid process ; and lastly, 
 others thought it should be fixed upon the side of the chin, As to 
 its advantages, if De Bruyn was to be believed, they were immense, 
 no difficulty could withstand it ; whether the head were reversed, 
 arrested or locked, the lever triumphed over them all, and by means 
 of this marvellous instrument, the Dutch accoucheur pretends to 
 have unlocked eight hundred heads in the course of forty-two years. 
 The French authors have, on the contrary, maintained that it is
 
 478 THE LEVER. 
 
 only^ useful in correcting the positions of the head, in compelling the 
 reverted occiput to replace itself at the centre of the pelvis. 
 
 1087. However this may be, instead of a bar of steel about ten 
 inches long by an inch and a half in breadth, curved at each end like 
 a spatula, enveloped in adhesive plaster, according to De Bruyn, or 
 chamoy leather, as Boom says ; instead of a simple spatula or kind 
 of flat spoon, the handle of which was terminated by a broad ring, 
 which constituted the lever of Titsing, the modern lever, such as it 
 appeared when modified by i?ean and Baudelocque, is nothing more 
 than one of the branches of Smellie's forceps, very much elongated, 
 without its notch, and very little curved. This stock, the blade 
 of which is very widely fenestrated, and the root supported by an 
 ebony handle, has also been itself modified in a great variety of 
 ways by the moderns, either in regard to its length, or the degree 
 and shape of its curve, or because some have added a joint in the 
 stock, so as to bend and make it more portable. 
 
 SECTION 2. 
 Use of the Lever. 
 
 1088. Subsequently to the idea originated by the axiom of Roon- 
 huysen, and which has particularly been adopted among us, it was 
 generally agreed that the lever is not destined to supply the place 
 of the forceps, that at most it can but serve to restore the flexion- 
 movement of the head, by hooking down the occiput ; thenceforth 
 its employment necessarily became much restricted, for under those 
 circumstances the fingers almost always suffice, and if, after all, any 
 instrument were necessary, one of the branches 'of the forceps 
 would answer as good a purpose as the lever itself. 
 
 But this is not the view the English accoucheurs take of the sub- 
 ject, nor that taken by its inventors, nor indeed is it a correct one. 
 
 1089. The lever is an instrument that is applicable to two differ- 
 ent objects : on the one hand, it may be employed for the purpose 
 of restoring or reducing the head to its natural position ; and on the 
 other, it is possible to make use of it, as we do of the forceps, to 
 extract the head when it has descended into the excavation. In the 
 former case, the fingers, or one branch of the forceps, might, strictly 
 speaking, in most circumstances, be substituted for it : but, in the 
 latter, I am convinced that it is susceptible of advantageously 
 taking place of the forceps, and that pretty frequently. In the first 
 case it acts upon the occiput, or on a parietal protuberance like a
 
 USE OF THE LEVER. 479 
 
 simple crotchet ; in the second, it really performs the office of a 
 lever of the first kind. 
 
 As a crotchet, -the lever offered for sale by the different cutlers in 
 the vicinity of the Ecole de Medicine, and which is very nearly the 
 instrument modified by Pean and Baudelocque, leaves nothing to be 
 desired ; as a lever, I prefer one that is rather shorter, and that may 
 shut up by means of a hinge joint, which does not at all diminish its 
 strength ; further, it ought to be strait from the extremity of the 
 handle to within about three inches of the end of the blade ; the 
 latter should be broad, oval, and ending in a long flat root, which 
 narrows, gradually, to continue into the handle ; its curve should be 
 considerable, at least greater than that of the forceps ; with the ex- 
 ception of the middle part, its concavity, that which ought specially 
 to bear upon the head, it ought to be very well polished; and lastly, 
 in the construction of such instruments the best steel ought to be 
 selected. 
 
 . I. Use of the lever as a crotchet. 
 
 1090. If then it be intended to make use of the lever in con- 
 formity to the principles of the French authors, it must be taken 
 hold of with the right hand for the right occipito-iliac position, and 
 with the left hand in a case of the left occipito-iliac position, and 
 with either hand in the antero-posterior positions. Introduced with 
 the same precautions as if it were one of the branches of the for- 
 ceps, it is passed up between the surface of the genital organs and 
 the child's head, until it gets beyond the occipital projection or pari- 
 etal protuberance, and in such a way that its concavity may be 
 easily applied to one of the parts above mentioned ; as, in the ocei- 
 pito and fronto-pubic positions, it is impossible to pass it up directly 
 behind the occiput, it must be at first carried a little to one side, 
 and afterwards conducted on the part which it is intended to de- 
 press ; vhen it is well placed, the hand that directed the blade takes 
 hold of the root of the instrument ; in order to make sure that it 
 shall not slip, and that the back of it shall not rub against the soft 
 parts of the woman, the operator should employ the extracting force 
 with the hand that holds the handle, in a direction backwards, for- 
 wards, or sideways ; in short, in a direction opposite to that pointed 
 to by the protuberance which he wishes to depress. In general, the 
 intervals between the pains is to be selected for acting, and as soon 
 as the vertex has reached the centre of the pelvis, the operation is 
 complete ; the instrument is to be withdrawn, and the labour aban- 
 doned to itself; or, if necessary, other means of assisting it are re- 
 sorted to.
 
 480 THE LEVER. 
 
 . II. Of the Lever used as a Lever. 
 
 1091. The use of the lever after the manner of the Dutch and 
 English accoucheurs, that is, as a substitute for the forceps, is very 
 simple as to its mechanism : in the first place, it is best that the head 
 should be in the excavation ; then that it should have already, or at 
 least chiefly executed its pivot-movement ; in the third place, that 
 there should be but a slight degree of contraction of the inferior 
 strait, or that the retardation of the labour should depend solely 
 upon a want of action of the womb, or of the woman herself. 
 Whatever may be the position of the head, the right hand must be 
 made use of for extracting with, at least in all cases where the ac- 
 coucheur is not left-handed ; for the purpose of introducing it, we 
 have recourse to the right hand, if the lever is to be passed upon 
 the right side of the pelvis, and to the left hand in the contrary 
 case. 
 
 1092. Where the occiput is in front or somewhat to the left, the 
 left hand introduces the lever, as if it were the right branch of the for- 
 ceps, in front of the right sacro-iliac symphysis ; when it has passed 
 up sufficiently far, the action of the two hands is combined so as to 
 guide the concavity of its blade on to the right temporo-parietal re- 
 gion, that is to say, in the direction of the occipito-mental diameter, 
 and on to the same parts that would be embraced by the corres- 
 ponding blade of the forceps. The left side of the vertex is sup- 
 ported by the fingers of the left hand ; the thumb, placed near to 
 the vulva, embraces the back of the lever, to which, conjointly with 
 the right side of the pubic arch, it serves as a point d'appui ; we 
 are now to wait for a pain, and then draw down slowly but strong- 
 ly, as if we were making a lever of the first kind swing from below 
 upwards, and from left to right ; the head generally yields readily ; 
 it is gradually drawn down in the axis of the inferior strait, which it 
 clears as it executes its extension-movement. 
 
 In this way the force exerted upon the head acts in a direction 
 from the chin towards the occiput, or in that of a line drawn from 
 the anglo of the right jaw to the left side of the vertex ; so that, 
 as it is supported elsewhere by the left side of the pelvis, there is 
 nothing surprising in the circumstance that it allows itself to be so 
 easily extracted. 
 
 1093. Should the occiput be on the right side, in the second posi- 
 tion for example, the li lit to be introduced with the left 
 hand ; but then it must be changed, as above, and the right hand 
 seizing the handle <!' tho instrument, should also extract in the same 
 ID. IIIIM T, with this difference only, that thesee-.'iaw movement should 
 tal mil right to left, and not from left to right.
 
 THE LEVER. 481 
 
 Should the vertex be turned backwards instead of towards the 
 front of the pelvis, the lever ought to be applied to the temporo- 
 parietal region, in the direction of the occipito-bregntatic diameter, 
 and the see-saw should be performed in such a way that the occiput 
 which ought here to support the principal effort, may escape first, in 
 front of the perineum, and be strongly raised towards the centre 
 of the vulva ; this position is less favourable than the other, without 
 doubt, but still, it is not very difficult. 
 
 1094. I know that what the lever effects under these circum- 
 stances could be equally well done by the forceps, and perhaps 
 with more certainty ; and indeed, it is not my design to substitute 
 the former of these instruments for the latter ; I have merely wished 
 to show, that among us, the mechanism of the lever has been 
 generally misunderstood ; that its employment, without being indis- 
 pensable, is perhaps not to be despised ; and that its application is 
 too simple, too harmless, as compared with that of the forceps, for it 
 not to be had recourse to where the head presents at the perineal 
 strait, and appears to be arrested only by want of action of the wo- 
 man's organs ; I will even add that its introduction will often be at- 
 tended with the great advantage of exciting the uterine contrac- 
 tions, as well as those of the abdominal muscles, and thereby of 
 accelerating, at least indirectly, the termination of the labour, with- 
 out exposing either the woman or her child to any danger ; I am 
 happy, moreover, in finding myself supported in almost the whole of 
 this doctrine by M. Desormeaux. 
 
 ARTICLE IV. 
 
 Of the. Fillet. 
 
 1095. The noose consists of cloth, thread or silk, wool, leather, 
 or cotton, sometimes strengthened by the addition of bulrushes, 
 whalebone, brass-wire, or plates of iron or steel, variously inter- 
 laced and worked, and which was formerly applied to different parts 
 of the fcstus, so as to effect its extraction. The employment of 
 these means is of a very ancient date, and doubtless extends back 
 as far as the age of Hippocrates. Previously to the discovery of 
 the forceps and lever, the noose and fillet were the only instruments 
 made use of for the extraction of the child, where there was some 
 hope of preserving its life. Avicenna recommends that they should 
 be applied to the trunk ; but it was particularly with a view of fixing 
 3L
 
 482 THE FILLET. 
 
 it upon the head that Mauriceau, Pugh, Smellie, Burton and others 
 thought of a sort of purses, sheaths, or caps, slings, and little bands, 
 which are now^wholly forgotten. If the forceps is a substitute for all 
 the various nets that were formerly applied to the head, turning by the 
 feet, which is better understood, and especially better executed than 
 it was previously to the last century, also renders superfluous all the 
 fillets which certain accoucheurs used to apply to the trunk for the 
 purpose of extracting it artificially ; so that at present the noose is 
 merely a strip of linen, silk, or worsted, about an ell in length and 
 an inch wide, by means of which a limb that has escaped from the 
 organs is secured, while we proceed to search for the other one, or 
 the rest of the foetus. Some persons, however, still make use of it 
 for the purpose of employing extractive force upon the ham, the 
 groin or the axilla ; but as the blunt hook or fingers always offer 
 us greater advantages, they are really useful only when applied to 
 the wrist or ankle in arm presentations or in turning and delivery 
 by the feet. 
 
 1096. In order to apply it, the strip is in the first place to be 
 doubled ; then a slip-knot is made upon it and held apart with the 
 end of the thumb and two or three of the fingers of the hand which 
 is to take hold of the foot or hand of the foetus ; after this, it is 
 slipped up and secured with the other hand, the noose being fixed 
 above the articulation of the tarsus or carpus ; it is then given in 
 charge to an assistant, who is to hold it, but without pulling it, 
 while the operator proceeds to search for the other parts that he 
 wishes to bring down to the inferior strait. When both of the 
 lower limbs have been brought down there is no further use for the 
 noose, provided it had been secured upon the leg ; if it is upon the 
 wrist it may still be of service in keeping the arm extended along 
 the body, and consequently in favouring the delivery of the corres- 
 ponding shoulder. To conclude, the noose is a means whose appli- 
 cation at the present day is confined within extremely narrow limits, 
 and whose mechanism is too easily understood for it to be needful 
 that I should say any thing further about it here. 
 
 ARTICLE V. 
 Of the Locked- Head. 
 
 1097. According to Pcu, who was the first writer to speak of it, 
 the head is locked in the passage whenever it is firmly held betwixt the
 
 LOCKED-HEAD. 483 
 
 pubis and sacrum, without being able to advance or recede, and so 
 that it is almost impossible to apply the instrument to it. Accord- 
 ing to De la Motte, the head, when locked, is griped by the bones 
 of the pelvis, like the key stone in an arch. Roederer presents 
 another view of it : he thinks that in order to constitute locked 
 head, the head must be so embraced in the strait, or in the excava- 
 tion, by every point of its circumference, that a lamina of metal or 
 the smallest probe cannot be passed between it and the organs of 
 the woman. Baudelocque says that the head is locked, whenever 
 it is fixed at the superior strait by the two extremities of one of its 
 diameters, so that it can neither advance under the influence of the 
 natural powers, nor be forced back by the hand of the accoucheur. 
 Baudelocque's definition, which has been adopted by all modern ac- 
 coucheurs, and slightly modified by M. Desormeaux, is without con- 
 tradiction the most correct, and may be construed as follows : the 
 head is locked in the pelvis whenever two diametrically opposite 
 points of its superficies are so compressed that it cannot possibly 
 descend under the influence of the expulsive power alone, and when 
 it cannot be pushed up without the very greatest difficulty. The 
 locked-head, according to the view of it presented by Roederer, or 
 paragomphosis, cannot possibly occur. Madame Lachapelle will 
 not even admit the existence of any species of it, and thinks that all 
 that has been written under that title ought to be referred to vicious 
 conformations of the pelvis, to bad positions of the head, or, lastly, 
 to powerful and permanent contractions of the uterus. 
 
 1098. However this may be, locked-head has become very rare 
 at the present day, and De Bruyn, who pretends to have met with 
 eight hundred cases of it in the course of forty years, Berkman and 
 Titsing, who cite two hundred and sixty-two cases in nineteen 
 years of practice, must have had a different idea of it from ours. 
 It is to me evident, from the accounts given by Camper on this sub- 
 ject, that the Dutch accoucheurs gave the denomination of locked- 
 head to all cases in which the head, from being arrested in any way 
 in the pelvis, makes the employment of Roonhuysen's lever necessary; 
 so that what they have said concerning locked-head has almost no 
 connexion with what has since been written by Baudelocque under 
 that title. Dr Dewees, who treats of locked-head upon the principles 
 of Baudelocque, is astonished that he scarcely ever meets with it, and 
 thinks that the circumstance depends upon the American women 
 having better formed pelves than the European women ; but he 
 would probably hold a different language if he knew that Madame 
 Lachapelle never met with it all, and that but a few instances of the 
 kind are met with in the course of a year.
 
 484 LOCKED-HEAD. 
 
 1099. In the first place, the case \vhere the head is simply fixed 
 at the superior strait, because the liquor amnii has been long dis- 
 charged and the womb is closely contracted upon the body of the 
 child, must not be confounded with locked-head, nor that case where 
 it stops in the excavation, betwixt two very contracted straits, 
 and after having with great difficulty cleared the superior pelvic 
 circle, nor those in which its escape is prevented by the resistance 
 of the perineum or narrowness of the inferior strait. 
 
 1100. The head can scarcely become locked except between the 
 pelvis and the sacrum, at the superior strait ; further, in order that 
 it may happen at all, the conjunction of a great number of condi- 
 tions is required: 1. That it shall present in a direct manner; 
 2. In a well formed pelvis, it must be of enormous size ; 3. The 
 narrowness of the pelvic cavity shall not exceed a certain degree ; 
 and there shall be a space of two inches and a half between the 
 sacrum and pubis for an antero-posterior position, or three inches 
 for a transverse position, for, locked-head cannot take place except 
 where the head can get as low down as the level of its greatest 
 thickness ; 4. The uterine contractions shall have been energetic. 
 
 Among these conditions there is one upon which I must dwell 
 for an instant. I find a difficulty in conceiving how the occipito- 
 frontal diameter can really get fixed in this way in the sacro-pubic 
 diameter. The ends of the lever, which it may be considered to 
 represent, are too unequal for its occipital portion to fail to come 
 down first, especially when the efforts of the woman react violently 
 upon it through the intermedium of the vertebral column ; it seems 
 to me, then, much more probable that it is the occipito-bregmatic 
 diameter that becomes locked, and that the head may be retained 
 betwixt the sacrum and pubis, as well by any one of the other dia- 
 meters of the occipito-bregmatic circumference as by the bi-parietal 
 diameter alone. 
 
 We may further admit, along with M. Desormeaux, that locked- 
 head may sometimes take place in the excavation, when the sacrum, 
 flat, or nearly flat, makes the head pass along a canal that gradually 
 diminishes in size, as it descends, until at last it cannot turn upon 
 its axis, nor advance nor recede, beyond a few lines, towards the 
 superior strait. 
 
 1101. Tumefaction of the lips of the os uteri and external organs 
 of generation, and extreme degree of swelling of the hairy scalp and 
 over-lapping of the cranial bones, have been given out as signs of 
 locked-head ; but most of the phenomena may take place without 
 the locked-head, and are therefore no sufficient basis for a sure 
 diagnosis.
 
 LOCKED-HEAD. 435 
 
 The pathognomonic sign, in these cases, is derived from the fixed- 
 ness of the head, which, in spite of the energy of the pains, makes 
 no advances for several hours together. While the pain is present, 
 it seems to advance a little ; but immediately afterwards it rises 
 again tip to the same point it occupied before ; if the accou- 
 cheur endeavours to push it up again with his hand, he finds that 
 it is immovable, and cannot succeed in dislodging it but with the 
 greatest difficulty. It should also be understood that, by elongating, 
 the head may appear to descend, and approach near to the vulva, 
 although its position does not really undergo any alteration. This 
 circumstance must be what has so often deceived the accoucheur, 
 making him suppose that the superior strait was cleared, while in 
 fact the occipito-bregmatic circumference was not as yet engaged 
 in it. An examination is made ; the vertex is found a few lines from 
 ,the vulva, whence the conclusion is drawn, that it has descended 
 into the excavation : to avoid this mistake, and understand it, the 
 practitioner should remember, 1. That the symphysis pubis is only 
 from eighteen to twenty-four lines in depth, and, consequently, 
 that the swelling of the cranial integuments may easily bring the 
 vertex down even with the vulva, although the parietal protuberances 
 are still at the superior strait ; 2. That the finger must be carried 
 backwards, especially, and not merely in front, when we wish to 
 ascertain what part of the pelvis is occupied by the head ; and, 
 3. That the locked-head may take place below the superior strait. 
 
 1 102. There are several degrees of this cause of dystocia: some- 
 times the disproportion between the head and pelvis is so small that 
 it only results in a somewhat slower labour and more fatigue for the 
 woman ; at other times it is so great as to render the delivery ex- 
 cessively difficult, but absolutely impossible without assistance, pro- 
 vided the contractions are well sustained ; again, lastly, it is so great, 
 that nature is absolutely unable to triumph over it, and the resources 
 of art become indispensably necessary. 
 
 In the case first mentioned, the locked-head is not very danger- 
 ous, and ordinarily is accompanied only by a slight degree of irrita- 
 tion and disposition to inflammation. 
 
 In the second and third, it constitutes a serious accident, both as 
 regards the mother and the child. The pains, which follow each 
 other to no purpose, though strong and frequent, at length end in a 
 state of general exhaustion and inertia, should the woman even be 
 so fortunate as to escape an attack of inflammation of the womb or 
 peritoneum, a flooding, or convulsions. The bladder, the rectum, 
 the vagina, the urethra, and other soft parts in the pelvis, from
 
 486 LOCKED-HEAD. 
 
 being long and severely compressed, may become contused, ulce- 
 rated, or gangrenous, and give rise to fistulas that are too com- 
 monly incurable, or to some other alteration equally terrible. The 
 compression of the nerves, and of the vessels in particular, may 
 give rise to paralysis, tumefaction, and the infiltration of the lower 
 limbs and vulva ; the symphyses themselves, from being violently 
 distended, occasionally run some risk, where the expulsive efforts 
 are vigorously sustained. 
 
 The long continuance of the labour after the discharge of the 
 waters, and the direct action of the contractions upon the body of 
 the child, expose it, in the first place, to the same accidents as all 
 long and difficult labours, that is to say, to asphyxia and death. 
 Again, the head, particularly where the pelvis is badly formed, as 
 the sacro-vertebral angle is very salient, cannot adapt itself to the 
 straits or excavation, as in a mould, without the brain itself under- 
 going a dangerous, and sometimes fatal compression. It may also 
 be followed by fractures, and external or internal extravasations, 
 lacerations, &c. 
 
 1 103. It is clear that, in order to avoid so many dangers, the prac- 
 titioner ought promptly to interpose for the assistance of the power- 
 less organism ; but by acting speedily there is risk of acting unne- 
 cessarily ; by waiting he may lose the opportune moment ; how then 
 are these tv/o extremes to be avoided ? The well informed physi- 
 cian will readily succeed in this difficulty by taking care not to lay 
 it down as a principle, as has recently been done in some medical 
 journals, doubtless from oversight, that he must make haste to ex- 
 tract the child with the forceps, whether the head is locked or not, 
 whenever it has remained an hour or two in the excavation ; the 
 woman ought never to be assisted in this way until there is a cer- 
 tainty that the head will not pass the passages spontaneously, or that 
 the delivery will not take place without exposing the patient to the 
 accidents heretofore indicated. 
 
 1104. Turning by the feet, as recommended by the ancients, 
 must not be performed merely because the head is really locked ; 
 the slings, bandages, and fillets would in such cases be wholly in- 
 sufficient, and are at present no longer recommended by any body. 
 The lever, the spatula, and the separate branches of the forceps, 
 so much lauded by the accoucheurs of the last century, were suc- 
 cessful only because they were employed in cases very different from 
 those which are understood to be lockcd-head at the present day. 
 Roonhuyscn's instrument is manifestly incapable of compelling the 
 
 to descend, where there is a disproportion between it and the
 
 LOCKED-HEAD. 43? 
 
 straits ; it might, at the most, serve to dislodge it and give it a more 
 favourable position, and in that case it would not be absolutely 
 locked. 
 
 1105. It is otherwise with the forceps, which admits of the ef- 
 forts of the accoucheur to be conjoined with those of the womb and 
 abdominal muscles. However, as the clams can be applied only 
 upon the sides of the pelvis, some practitioners have objected that 
 by compressing the head in a line from right to left, this instrument 
 might augment the pressure already experienced from front to rear, 
 instead of diminishing it ; that it is better calculated to give rise to 
 locked-head than to relieve it ; and consequently, more dangerous 
 than useful ; but these fears, inspired by a theoretical view of the sub- 
 ject, must yield to facts ; besides, it is not correct to say that the 
 diameters of the head gain by compression in one way what they 
 lose in another ; I repeat that I am certain the forceps succeeds in 
 extracting the locked-head far more by compelling it to traverse a 
 circle, which acts upon it like a ring, than by reducing it by means 
 of a direct pressure. 
 
 Should it not succeed, and the child were ascertained to be dead, 
 recourse should be had to cephalotomy, and then to the crotchet ; 
 but if the foetus were still living, the operation of symphyseotomy 
 would be indicated, and ought to be preferred to the cesarian ope- 
 ration, which, in such a case, can never be necessary. 
 
 ARTICLE VI. 
 
 Of the measures rendered necessary by narrowness of the 
 
 Pelvis. 
 
 When the pelvis is so deformed as to render delivery impossible, 
 even with the assistance of the means I have now passed in review, 
 there remain only three kinds of resources for the delivery of the 
 woman : 1. To act upon the foetus so as to lessen its size ; 2. To 
 increase the size of the pelvis ; 3. To extract the child by an arti- 
 ficial passage. As these three modes of delivery are excessively 
 dangerous, whether to the mother or her offspring, it is necessary, 
 previously to putting them in practice, to determine in what cases 
 they are really indispensable. 
 
 1106. To attain this object, the accoucheur ought to know the 
 exact dimensions of the head and pelvis, in those diameters which 
 correspond to the diameters that correspond to each other in the
 
 488 TOO SMALL A PELVIS. 
 
 different stages of labour ; also, to know how far the head is capa- 
 ble of being reduced, and what amount of courage and energy are 
 likely to be exhibited by the woman ; but these notions can only be 
 acquired approximatively. Notwithstanding the numerous cephalo- 
 nieters proposed by various authors, and in spite of the means re- 
 cently indicated by M. Fouilhoux, We must still depend upon the 
 finger for the most certain result under such circumstances : and, 
 with the exception of M. Flamant, what practitioner is so bold as 
 to dare to pronounce that the dimensions of a head he has just 
 examined are. within from two to three lines, of precisely such or 
 such an amount ? The degree of solidity of the pelvis, the form of 
 the contracted strait, and the direction of its axes, also deserve the 
 most serious attentions : for example, the symphysis may be soften- 
 ed to such a degree as to admit of the bones sliding one over the 
 other, so that one os pubis may extend in front, while the opposite 
 coxal bone falls backwards, which would render the corresponding 
 oblique diameter so much longer. According to Deventer and 
 Madame Lachapelle, the two hip bones may also be both carried 
 forwards by the forcing of the sacrum into the space between them, 
 and thus give rise to an unexpected augmentation of the sacro-pubic 
 diameter. If the superior strait is of the shape of* a figure 8, or if 
 the contraction occupies only one side, the head being situated 
 transversely, with the occiput towards the widest part of the pelvis, 
 may sometimes traverse the canal notwithstanding a considerable 
 degree of contraction. 
 
 Where the axis of the strait approaches that of the spine, the 
 two extremities of the bi-parietal, or the occipito-bregmatic diame- 
 ter will be compelled to engage at the same time, and will require 
 a space of about three inches. Should it, on the contrary, be very 
 much inclined to the front, one of the parietal protuberances might 
 engage before the other, so as to give a gain of three or four lines 
 in the act of passing through the pelvic circle. 
 
 On the other hand, a head that is very flexible, and energetically 
 urged onwards by the uterine and muscular contractions of a vigor- 
 ous woman, may be elongated and moulded in the passages, be con- 
 siderably reduced (Denman says, to one-third of its original vio- 
 lence), and, according to Baudelocque, attain to the length of eight 
 inches, while its thickness is proportionally diminished ; it may be- 
 come so much flattened as to pass through a strait of two inches 
 and a half, and recover its ordinary volume within the excavation, 
 if \vc may give credit to the assertions of DC Boer; and, in all cases, 
 admit of the child's being born alive. Lastly, how many women arc 
 there who have been fortunate enough to bring their children into
 
 TOO SMALL A PELVIS. 489 
 
 the world without any aid, when in their previous confinements they 
 could be delivered only by symphyseotomy, the cesarean operation, 
 or embryotomy ! Here, then, the operator stands in need of all the 
 integrity of a sound judgment, of prudent and sage counsels, of 
 attention to a thousand diversified circumstances, and of proceeding 
 only witii extreme caution, if he desires not to compromit the dig- 
 nity of his art, or the safety of those beings who look to him for the 
 conservation of their existence. 
 
 1107. Instead of accommodating itself to the form of the open- 
 ings, the head may be fractured, or the brain mortally compressed. 
 Long continued pressure upon the foetus, and particularly upon the 
 umbilical cord, which most commonly gets down into the excava- 
 tion, rarely permits it to escape with its life ; the woman herself 
 soon becomes exhausted ; the bladder and other soft parts, against 
 which the head presses with great violence, may inflame, be lacerat- 
 ed or perforated ; the womb, violently irritated, by its repeated con- 
 tractions, may be ruptured, ajid death ensue. The softening and 
 separation of the symphyses often leave behind them a movable state 
 of the articulations, and a degree of lameness which are at least 
 very troublesome, and where the distention is carried to a great ex- 
 tent, are often followed by caries and abscesses, which sooner or 
 later terminate in the death of the patient. There are, therefore, 
 two evils, which it imports to avoid with equal care; there is a just 
 medium we should endeavour to secure. 
 
 1 108. Let us suppose that the application of the forceps and 
 turning have been attempted in vain, or that the pelvis is so deform- 
 ed, that no greater confidence is to be placed in those means than 
 in the efforts of the woman, one question presents itself; on whom 
 shall we operate the child, or the mother ? Where there is a cer- 
 tainty that the pelvis is so contracted as to render the delivery of a 
 mature and full grown child either dangerous or impossible, have 
 we a right to bring on abortion, either at an early stage of preg- 
 nancy, or only between the seventh and eighth months. Would it 
 not be possible, by means of regimen, or a debilitating treatment, to 
 oppose, to a certain extent, the development of the foetus, so that 
 at full term it shall be of a very small size ? 
 
 SECTION 1. 
 
 Of Regimen, as a means of enabling women with contracted pelvis 
 to be delivered without the assistance of any surgical operation. 
 
 1 109. Were it true that the strength of the foetus while enclosed 
 3M
 
 490 NARROW PELVIS. 
 
 in its irivolucra is always in proportion to that of the mother, nothing 
 would be more natural, nor better indicated, than to weaken a de- 
 formed woman during the progress of her pregnancy. But as the 
 most robust women do not always bear vigorous children ; as those 
 who are naturally feeble and sickly often give birth to very stout 
 and large ones ; it is to be feared that the severest diet and most 
 abundant sangine evacuations, would only serve in such a case to 
 incapacitate the woman from supporting the operations that would 
 notwithstanding be requisite when she should fall into labour. 1 
 know one person who, having been delivered twice by means 
 of art, was bled ten times, and confined to a vegetable diet dur- 
 ing her third pregnancy, with a view of retarding the growth of 
 the child ; this lady was, it is true, exceedingly weakened by it, but 
 the fetus did not appear to have been affected, and in parturition she 
 required the same succours as before. Another woman who had 
 two very fatiguing pregnancies, and could not be delivered until 
 after three days of painful labour, and then by means of the for- 
 ceps, also became pregnant for the third time, found herself less in- 
 commoded than usual, and was, nevertheless, delivered without as- 
 sistance and without difficulty, of a child sensibly smaller than the 
 preceding ones. I am well aware that practitioners worthy of credit 
 assert that they have obtained directly contrary results, and T can 
 well conceive, as a general rule, that by exhausting the woman, 
 the growth of her offspring will be retarded. But there are so 
 many exceptions to this rule, and what we gain on the one hand is so 
 disadvantageously comp'ensated by the loss of resources of which we 
 deprive ourselves on the other, that I would scarcely venture to re- 
 commend such a course, except to persons affected with a very 
 slight degree of contraction, and in whom delivery might, in fact, 
 take place spontaneously, should the head of the fetus not be too 
 large. 
 
 SECTION 2. 
 
 Of Abortion, brought on for the purpose of rendering symphysto- 
 tomy or tlie ccsarcan operation unnecessary. 
 
 1110. It was about the middle of the last century that the most 
 distinguished physicians of London derided that, in women affect- 
 ed with deformity of the pelvis, it is proper to solicit delivery as soon 
 as the viability of the child is well established ; according to the 
 statement of Kelly, Macaulay was the first person who had recourse 
 to this operation, which resulted favourably in lii.s hntids : since
 
 NARROW PELVIS. 491 
 
 then, Dr Barlow has published a memoir in which he essays to prove 
 that artificial abortion ought to be substituted for the sigaultian and 
 cesarean operations in all cases. Ramsbotham says he brought on 
 abortion three times with success in a woman in whom the perfora- 
 tion of the fetal head had been deemed necessary in a proceeding 
 pregnancy ; Drs Davis, dough, Wigand, and, very recently, Bang, 
 and Dr Blundell, have supported the doctrine advanced by Barlow. 
 M. Costa has even inquired whether it is proper to resort to it in 
 the cases of women affected with aneurism of the heart. 
 
 1111. In France, this question has been considered under a point 
 of view which has not admitted of its value being discussed. It has 
 been said that no one has a right to destroy a living foetus, even in 
 the first months of its existence. But delivery, when provoked pre- 
 viously to the seventh month, kills it inevitably, and rarely fails to 
 cause its death in the seventh and eighth. Besides, if it must be 
 destroyed, why not wait for the term of labour ; by so doing we 
 shall at least not destroy the few chances we have of seeing the 
 labour come to a favourable conclusion. 
 
 For my own part, I confess I cannot possibly balance the life of a 
 fetus of three, four, five, or six months, a being which so far scarcely 
 differs from a plant, and is bound by no tie to the external world, 
 against that of an adult woman whom a thousand social ties engage 
 us to save ; so that in a case of extreme contraction, if it were ma- 
 thematically demonstrated that delivery at full term would be im- 
 possible, I would not hesitate to recommend abortion in the first 
 months of gestation. 
 
 But the case is different whenever there is a space of two inches 
 and a half, at least, between the sacrum and the pubis : as in that 
 case the ovum has been seen to come away without assistance, and 
 the fetus born alive, the honour of the art and humanity combine 
 to forbid the employment of any destructive instrument, or any 
 attempt that must end in the death of the child. 
 
 1112. The induction of labour at the seventh month would be par- 
 ticularly applicable where the pelvis is two inches and a half at least, 
 and two inches and three-quarters at the utmost, because it is clear, 
 from measurements taken by Madame Lachapelle, that at seven 
 months the bi-parietal diameter is at most not over three inches, 
 and may be much less in extent ; which gives the same chances as 
 if the delivery were to take place at term, and through a strait of 
 three inches and some lines. But how are we to learn accurately 
 whether the fetus is viable ? If, for greater security, we should 
 defer the operation till two weeks later, what assurance could we
 
 492 NARROW PELVIS. 
 
 have that the head is not already too large to pass through the 
 straits ? And if it can clear them at eight months, is it not probable 
 that it will succeed equally well at the end of the ninth ? 
 
 I am far from thinking that the difficulty consists in penetrating 
 as far as the membranes so as to rupture them ; nevertheless, wounds 
 of the uterus are so dangerous, that we should always dread to in- 
 introduce an instrument into its interior: and then it would be a 
 strange misconception to suppose that abortion brought on in this 
 way is not more dangerous, c&teris paribus, than a delivery at full 
 term : without mentioning the hemorrhagies, convulsions, or inflam- 
 mations of the peritoneum, that are but too frequently the results of 
 the operation, we ought also to expect the foetus to perish either 
 before or soon after birth, in a large majority of cases. Being 
 scarcely viable, it is too feeble to bear the contractions of the uterus. 
 Although, after the membranes are perforated, the womb, some- 
 times, enters powerfully into action, it also happens that it remains 
 two, three, and even as much as fifteen days, before it begins to 
 react upon the product of conception ; besides, its contractions are 
 generally slow, feeble, and too far apart to expel it when its size is 
 considerable. 
 
 Unless a very slight value is attributed to the life of the foatus, 
 this recourse is, then, of small advantage ; at least, previously to 
 making a general precept of it, it deserves to be maturely considered 
 by unprejudiced men, and in a more philosophical way than seems 
 to have been done hitherto in England and in Germany. 
 
 1113. Signs of the death of the fcetus. There is no doubt that 
 the foetus is still living if it moves, or if auscultation enables us 
 to hear the movement of the heart ; there is, also, no doubt of 
 its being dead when portions evidently belonging to its structure, and 
 in a state of putrefaction, escape from the organs ; but with the ex- 
 ception of these cases, which leave not the slightest uncertainty upon 
 the subject, the question of life or death is, here, one of the most 
 delicate subjects in physiology, and one of the most difficult of solu- 
 tion of any in tokology. The same thing takes place in regard to 
 the death of the fujtus as occurs in relation to the question of preg- 
 nancy ; it is announced by numerous signs, but they arc extremely 
 variable and never certain. How could it be otherwise, inasmuch 
 as it is sometimes impossible to pronounce upon the state of the 
 foetus that has juet been born, and that is before our eyes ? 
 
 However it may be, the signs of death may be divided into rational 
 and sensible, like those of gestation. The rational signs arc observnd 
 before or during labour.
 
 ARTIFICIAL ABORTION. 493 
 
 1114. Previously to reaching the full term the woman has had a fall, 
 or has made some violent movement or strong effort ; she has struck 
 her abdomen against some solid body ; she has used too much ardour 
 in coition; she has abandoned herself without reserve to vivid impres- 
 sions of a moral kind ; she has had a severe attack of disease, has 
 taken very active medicines ; in fine, she has exposed herself to some 
 one of the causes that are capable of producing abortion ; in which 
 case there is some reason to presume that the child is dead ; pro- 
 vided she should, shortly after the accident, have had rigors, nausea, 
 a sense of weight above the middle of the pelvis, disgust, horripila- 
 tions, or a sense of coldness in the belly; if the breasts are enlarged, 
 full of milk, or shrunk ; if the womb tends towards the lowest part 
 of the body, and moves to the right, left, or in front, like an inert 
 mass ; if the foetus have ceased to exert any active power; if the abdo- 
 men cease to enlarge ; if the mouth exhale a putrescent odour ; if 
 there be a general uneasiness, or a constant febrile state, it becomes 
 extremely probable that the foetus is dead. 
 
 1115. During labour the death of the foetus is announced by the 
 escape of the meconeum; by the entire absence of motion; by a 
 putrid odour that escapes from the vagina, or rather from the uterus, 
 along with the waters; by the diminution of the labour pains, and 
 by most of the phenomena which I mentioned just now. There is 
 reason to fear it, especially, where the amniotic fluid has escaped 
 prematurely, or at least where it has been long evacuated, and where 
 the position is bad, or where the contractions of the womb have in any 
 way borne directly upon the foetus itself. The sensible signs are not 
 appreciable until some portion of the ovum itself can be touched 
 with the finger. Among them is classed the premature descent of 
 the cord, and the absence of its pulsation; inability to excite motion 
 in the foetus, although it be raised up in the womb; the escape of 
 shreds of the cuticle; the want of a soft elastic tumour on the 
 head; mobility of the cranial bones; the slight resistance offered to 
 pressure by the thorax or any other part; the absence of pulsation 
 in the heart, &.c. 
 
 But it must be confessed that, perhaps, not one of these signs, 
 taken singly, would be, to a prudent man, a sufficient warrant to 
 pronounce unhesitatingly on the death of the foetus; indeed very few 
 of them deserve much consideration. It is only when united, when 
 constituting a whole, that we are sometimes warranted in drawing 
 pretty rigorous conclusions: the swelling of the breasts and their 
 subsequent shrinking away may occur, although the child continues 
 to live; but this sign will, notwithstanding, be very important, if it 
 coincide with a majority of the other rational signs, because, says M.
 
 494 NARROW PELVIS. 
 
 Dubois, when the child dies, its delivery, regarded as the completion of 
 the great act of reproduction, is, in some sort, effected for the sake of 
 the economy, and the secretion of milk tends to take place just as if 
 the ovum were expelled. The same may be said as to the disagreeable 
 load felt by the woman in all her movements, and the sense of weight 
 which she experiences in the bottom of the pelvis. 
 
 The waters may have been evacuated for three, four, ten, fifteen, 
 thirty, and even fifty-seven days, according to Bauhin, Boer, and M. 
 Morlanne, without being necessarily followed by the death of the 
 foetus; but the contrary will, however, much more commonly be met 
 with. If the meconium escapes, and the pelvis is not the presenting 
 part, there is great reason to fear that it is dead, although more than 
 one case has been seen where, under such circumstances, the foetus 
 has been born after several hours, strong and healthy : when the 
 breech comes down first, there is nothing unnatural in the discharge 
 of the meconium which is occasioned by the pressure experienced 
 by the belly as it passes through the os uteri, or the straits ; it is 
 altogether a mechanical effect. But when the head is the present- 
 ing part, the same cause no longer exists, and, in general, the 
 bowels are not evacuated, unless the sphincters, by being weakened, 
 like the other muscles, relax so as to oppose no resistance to the 
 action of the womb, which will scarcely take place unless the child 
 is near expiring. Lastly, the practitioner ought not on this subject 
 to let himself be imposed on by the muddy appearance or greenish 
 colour of the waters ; for this is an appearance often assumed by 
 them without the meconium having any thing to do with it. 
 
 1116. A living foetus sometimes suddenly ceases to move alto- 
 gether, and may remain several days or weeks, or indeed until its 
 birth, without moving, and yet may not have incurred any danger ; 
 on the other hand, the woman often supposes she feels it move after 
 it has really been dead for a long time, and I could relate many 
 cases of the kind, one of which I very lately saw with Dr Leseble, 
 in a young woman who gave birth to a child that had been dead at 
 least four or five days, although she told us an hour before fhe de- 
 livery that she felt it move. But this does not prevent the sign from 
 being a very important one to the practitioner who knows how to 
 estimate it, and when, in the course of a long and difficult labour, the 
 motions of the child arc found suddenly to cease after having been 
 agitated with more or less violence, and, as it were, convulsively, 
 there is good reason to fear for its safety. 
 
 Portions of the epidermis, and some of the hair, might, indeed, 
 become detached from so/ne inflamed, gangrenous or ulcerated point, 
 without the child being dead: if this sign depended upon putrefaction,
 
 DEAD FffiTUS. 495 
 
 it could in no case occur until after life had long ceased; in fine, I 
 can scarcely believe that any one could be deceived who should pay 
 a careful attention to all the circumstances. 
 
 1117. The odour that escapes from the vagina has always seemed 
 to me to have but little significancy, as long as the membranes are 
 unruptured; but after that, I regard it as one of the most certain 
 signs; it incontestably depends on the circumstance, that the air, by 
 gaining access to the uterine cavity while at a high temperature, 
 under the influence of the uterine contractions, actively promotes 
 the putrefaction of the liquids still remaining within the membranes ; 
 this odour at times is rapidly manifested, and may, in the course of 
 a few hours, become almost insupportable. It would be difficult to 
 confound it with any other odour, such, for example, as that ex- 
 haled from an ulcer, or a suppurating surface of any kind, and up to 
 the present time I have never met with it where the child did not 
 afterwards come dead into the world. 
 
 1118. As to the swelling of the hairy scalp, since it is produced 
 by the accumulation of fluids beyond the point of the head, which is 
 strictured more or less violently and for a longer or shorter period 
 by the os uteri, or the strait of the pelvis, it is evident that it will not 
 form, provided the child should be dead previously to the rupture of the 
 membranes ; but, if the child should not die until after its formation, 
 it might then continue, just as if death had not taken place; I do not 
 speak of the over-lapping and movableness of the cranial bones, 
 because they may too easily lead us into error, and also because 
 these two phenomena may depend upon causes far too diverse. 
 
 Where it is possible to reach the umbilical cord, we can easily de- 
 termine whether it continues to pulsate or not; and I cannot well 
 conceive how this sign could deceive a well informed practitioner, 
 as to the real state of the child ; I know that the vessels of the cord 
 may suspend their pulsations, during each effort made by the womb 
 or by the mother, without the foetus really running any great risks ; 
 but we should not decide upon the child's death simply because we 
 have examined the cord during the presence of a pain, or because 
 we have for a moment felt it to be without pulsation. It is only 
 after having satisfied himself that the pulsation is entirely abolished 
 for several minutes, and equally during the presence and the absence 
 of the pains, below, as well as above the head, either free or com- 
 pressed, that the accoucheur is at liberty to pronounce without fear 
 upon the state of the foetus. To be still more certain, if the head 
 had not cleared the superior strait, I cannot see why the hand 
 might not be passed up more or less into the womb, so as to ascer- 
 tain whether the heart continues to beat, and to touch the umbilical
 
 496 NARROW PELVIS. 
 
 cord nearer its root, or at some point where it should be free from 
 all compression. 
 
 1119. If then the combination of all these signs, or the chief of 
 them, were always to be met with where the child is dead, there 
 will rarely be any embarrassment in giving a decision; but they fail 
 so often when it is indispensable to proceed to action, when there is 
 no time for temporising, that it is easy to imagine how practitioners 
 have been led to the performance of serious and even mortal opera- 
 tions on the mother, although the child was actually dead ; and that 
 at other times, the child has been cut to pieces while still full of life. 
 Hitherto, medical men have made only vain efforts to escape from 
 so distressing a position, and may God grant that the method lately 
 proposed by MM. Bermond, Baudelocque, Jr. /and Toirac, may 
 not deceive the expectations of its inventors. These three physi- 
 cians seem to have thought, at the same time, and without each 
 others knowledge, that by bringing the two extremes of an electric 
 circle, in the womb, in contact with some given part of the child, or 
 merely upon the belly, that its muscular contractions would necessa- 
 rily be brought into play, provided it were not dead. It is a fact, 
 that both reason and analogy are in favour of this idea; but upon so 
 difficult and serious a subject we ought to wait for a longer experi- 
 ence and not pronounce lightly. 
 
 1 120. The foetus is alive, and to keep it so, we have either to en- 
 large the openings through which it has to pass, or make new ones : 
 at the commencement of the last century, even when accoucheurs 
 met with a case of a pelvis so deformed as to render delivery im- 
 possible, they preferred to sacrifice the child rather than perform 
 any operation upon the mother. Some of the boldest of them, like 
 Mauriceau, had immediate recourse to embryotomy, or at least to 
 cephalotomy; while others, as Delamotte, being more timid, and 
 more humane, in appearance, but in reality more barbarous, pa- 
 tiently waited until the child was dead before they would pro- 
 ceed to cut it to pieces. At the present day, inasmuch as sympby- 
 seotomy and the cesarcan operation have been successfully performed 
 a great many times, the operation of embryotomy is not admissible 
 until every thing announces that the fuetus is dead, or that it cannot 
 live.
 
 SYMPHYSEOTOMY. 497 
 
 SECTION 3. 
 Of Symphyseotomy. 
 
 1121. Historical. Being persuaded that the articulations and 
 even the bones of the pelvis were capable of being softened during 
 pregnancy, Fernel, S. Pineau, arid many other old writers, conceived 
 that it would be useful to favour their softening, in cases of contract- 
 ed pelvis, and that this might be effected by means of embrocations, 
 cataplasms, and topical or general bathing ; founding their opinion 
 upon these vulgar traditions, which are spoken of by Riolan and Pare, 
 and which induce the common people to believe that in many coun 
 tries there is a practice of breaking the os pubis in young girls as 
 soon as they are born, for the purpose of rendering child-birth more 
 easy for them; upon what Galen, in speaking of the pelvis, says, viz. 
 non tantum dilatari, sed et secari, Into possunt, ut intends succurra- 
 tur, some modern physicians have supposed that the operation of 
 symphyseotomy must have been conceived of in the remotest anti- 
 quity ; it is true that Cl. Delacourvee* mentions a deformed woman 
 who died previously to delivery, and in whom, after death, he divid- 
 ed the symphysis pubis for the purpose of enlarging the pelvis ; 
 Plenck acted in the same manner in 1766 upon another subject; 
 but it is proper also to state that no one had formally thought of pro- 
 posing the performance of this operation in the living subject with the 
 view of facilitating delivery, when Sigault, who was still a medical 
 student, made it the subject of a memoir, which he presented to the 
 Academy of Surgery in 1768. 
 
 1122. The idea of symphyseotomy is, therefore, really due to this 
 surgeon ; the Academy was hardly willing to hear the first proposal 
 of it, and Louis, who communicated it to Camper, treated it as a 
 ridiculous project, engendered in a young brain that was as yet inca- 
 pable of any reflection ; but not so the celebrated Hollander, who, after 
 performing several experiments upon the dead subject, replied to the 
 secretary of the academy, that at some future day it might be advan- 
 tageously resorted to. On his part, Sigault was not disconcerted, 
 and reiterated the same idea in his thesis at the school of Angers 
 in 1773. Four years afterwards he performed his operation in pre- 
 sence of A. Leroy, upon a woman named Supiot, and was so for- 
 tunate as to save both the mother and the child. This success gave 
 rise to an extraordinary degree of enthusiasm ; the hundred tongues 
 
 * JDe Nutritions Fatus in utero paradoxa. Dantisci, 1655 
 3N
 
 498 SYMPHYSEOTOMY. 
 
 of fame, seemed insufficient to celebrate the glory of the author of 
 so brilliant a discovery. The faculty of medicine of Paris thought 
 they could not reward him too highly by passing a solemn decree, 
 and causing a medal to be struck in honour of him ; so that this 
 same Sigault, whom the academy of surgery would not deign to 
 hear, a few years before, was soon proclaimed the greatest bene- 
 factor to humanity, and almost equal to the gods. Such exaggera- 
 tion as this soon gave rise to a lively opposition amongst the sur- 
 geons, and was the signal of a combat, in which a great number of 
 the medical men of different countries felt themselves called on to 
 take a part. The Academy of Medicine warmly supported the 
 opinions of Sigault ; the Academy of Surgery, as much perhaps 
 out of spite for not having retained them in its own bosom as from 
 conviction, continued to reject them with no less ardour. Both par- 
 ties were unjust : the dispute became scandalous ; libels were pub- 
 lished, personalities were not spared, and being divided into Sym- 
 physians and Cesareans, as they were then called, the accoucheurs, 
 actuated by inveterate hostility to each other, were not ashamed to 
 keep up this controversy, equally curious and extraordinary, until the 
 commencement of the present century without coming to an under- 
 standing. Plenck, Siebold, A. Leroy, Baudelocque, Saccombe, 
 Giraud, and Ansiaux, descended into the arena, but without per- 
 ceiving that the question was illy stated. Sigault in fact was wrong 
 to propose symphyseotomy as a substitute for the cesarean opera- 
 tion ; every body would have been on his side, had he only propos- 
 ed it as a new resource, fit to enrich the art, an operation attended 
 with its own peculiar applications, advantages, and dangers, and 
 which at least renders cephalotomy and the cesarean operation more 
 rarely indispensable. Weidemann and Desgranges were the first 
 to view it in this light, and by imitating them, Thouret and M. Gar- 
 dien have at last put an end to this disgusting polemics, which served 
 as an excuse and skreen for the jealousy and envious rivalry of all 
 the little spirits of the period, to blacken the fame of a great many 
 most respectable men. 
 
 But at the present day, when all the passions awakened on the oc- 
 casion of this quarrel have become extinct, it is an easy matter to 
 estimate the operation of symphyseotomy at its just value. 
 
 1123. Mechanism. When the inter-pubal fibro-cartilage is divi- 
 ded cither after death or on the living subject, the bones generally 
 separate about one inch, of their own accord, and this separation 
 might, rigorously speaking, be carried artificially to the extent of 
 three inches, without disorganizing the posterior articulations : when 
 the cartilage is divided, the coxal bone somewhat resembles a lever
 
 SYMPHYSEOTOMY. 499 
 
 of the first kind ; the centre of motion is found at the posterior part 
 of the articular facette of the sacrum ; the posterior branch of this 
 lever, very short, and formed by the tuberosity of the ilium, is drawn 
 backwards and towards the median line by the posterior sacro-iliac 
 ligaments ; its anterior branch, which is very much bent, (coudee) 
 separates (from the corresponding pubis) in proportion to its excess 
 of length over the branch, which represents the power; the fore part of 
 each posterior symphysis becomes somewhat open ; the fibrous tissue 
 which covers them yields, is elongated, stretched, and detached ; 
 the elastic cushion which is behind them becomes relaxed, and the 
 sacrum compressed, from behind forwards, tends to escape towards 
 the interior of the pelvis. When the surgeon adds still more to the 
 separation of the pubes by pressing upon the cristae of the ileurn, 
 the power is transferred to the anterior branch of the lever, and it 
 is evident, that thenceforth no very violent effort would be required to 
 tear away all the bonds of the posterior articulations. This is the 
 situation, particularly, where the displacement of the sacrum in front 
 must cause the increase of the length of the antero-posterior diameter 
 to disappear as fast as it tends to take place. In the empty pelvis and 
 upon pieces of paper this is really the case ; but in the living subject, 
 while the pubes are separating, the child's head pushes the sacrum 
 backwards, beyond its natural limits, rather than admits of its 
 advancing into the excavation. Nevertheless, it would, in most 
 women, be dangerous to separate the ossa pubis from each other 
 more than one or two inches : we could not go beyond that without 
 lacerating the loose and abundant cellular tissue of the excavation, 
 the anterior sacro-iliac ligaments, and part of the posterior ones, 
 without giving rise to the most violent pain, and causing the most 
 redoubtable inflammations, unless the symphyses should happen to 
 be already very much softened beforehand, under which circum- 
 stance it is not likely that symphyseotomy would ever be required. 
 Since you agree, say the antagonists of the operation, on the one 
 hand, that it is not prudent to attempt a greater degree of separation 
 than two inches or two inches and a half; and on the other, that 
 the antero-poslerior diameter is never enlarged more than two lines 
 for one inch, four lines for two inches, and six or eight lines for 
 three inches* of separation, it is manifest that you can depend upon 
 only three or four lines of ampliation of the pelvis : now, is it right 
 that we should perform so serious an operation for the purpose of 
 gaining only three lines, and perhaps not more than two ? This 
 argument at first seemed almost unanswerable : then it was said in 
 
 Boer even asserts that, when carried to the extreme, this separation can never 
 give more than three lines additional to the antero-posterior diameter.
 
 500 SYMPHYSEOTOMY. 
 
 reply : doubtless we obtain an elongation of only th/ee lines for the 
 antero-posterior diameter, but by engaging in the void space between 
 the separate pubes, the parietal protuberance or projecting part of 
 the occiput will abstract at least three or four lines from the diame- 
 ters of the head, so that we gain at. least half an inch. In speaking 
 after this fashion, authors have forgotten that the occiput or the 
 parietal protuberance is commonly found behind the body of the 
 pubis or acetabulum, and not behind the posterior face of the sym- 
 physis. But, further, this last disposition, in its turn, gives great 
 advantages in the operation, and I am astonished that the authors 
 have scarcely mentioned it. I mean that, if the antero-posterior 
 diameter is augmented only two or three lines, the oblique ones will 
 be increased by at least six lines; and as the occipito-frpntal, breg- 
 matic and bi-parietal diameters are not directed from front to rear, 
 but obliquely, it follows, in fact, that the section of the symphysis 
 appears to be less limited in its applicability than has been generally 
 imagined. The researches of M. Desgranges prove that it permits 
 the oblique and transverse diameters of the pelvis to enlarge to the 
 extent of near an inch ; that at the inferior strait particularly, it would 
 procure a considerable ampliation, and that upon this subject there 
 is, such is my opinion, a want of some additional experiments. 
 
 1124. Advantages and disadvantages. The operation of sym- 
 physeotomy, therefore, seems to be applicable in all cases where an 
 increase of space to the amount of four, five, or six lines would per- 
 mit the head to pass ; for example, in all cases where the forceps is 
 insufficient, and where, nevertheless, the smallest diameter of the 
 strait exceeds two inches and a half. But as it is seldom possible, 
 in the living subject, to ascertain how far the head is susceptible of 
 reduction under pressure, and whether the strait is two inches and 
 eight lines rather than two inches and a half, it has happened that 
 the accoucheur, finding a difficulty in marking the point where the 
 section of the pubis becomes indispensable, and that where it can 
 no longer suffice, has generally decided in favour of the cesarean 
 operation, whenever the absolute necessity of doing something to 
 save the child's life has been ascertained. As to the dangers of tho 
 operation, it appears to me difficult to prevent them, where the volume 
 of the head requires a considerable separation of the pnbcs, and 
 wherever the pelvic articulations are naturally very little relaxed. 
 Even could we dispense with acting on the hips or thighs, the child, 
 nevertheless, must pass through, and, whether we extract it with 
 the forceps or by turning, or whether tho contractions suffice for its 
 expulsion, nothing seems able to hinder the head, as it passes through 
 the contracted strait, from violently distending the posterior articu-
 
 SYMPHYSEOTOMY. 501 
 
 lations, and even lacerating them if its dimensions exceed those of 
 the circle through which it must traverse. 
 
 I am, however, far from thinking, along with Denman, Lauverjat, 
 Hunter, Osborn, and Dr Dewees, that it ought to be rejected in all 
 cases ; I merely wish to show that its partisans, in their representa- 
 tions, have singularly lessened its dangers, and exaggerated its ad- 
 vantages. 
 
 It is the only means of safety that can be resorted to : 1. Where 
 the head is locked in the excavation, after having passed through a 
 very contracted superior strait ; 2. Where the head has cleared the 
 os uteri, and is arrested by narrowness of the inferior strait ; 3. 
 Where the trunk is delivered, the life of the child unquestionable, 
 and it is impossible for the head to get through the natural passages. 
 In these three cases, it is preferable to the cesarean operation, even 
 after the death of the woman ; and that, because it would be almost 
 impossible to avoid killing the child by attempting to extract it by 
 the abdominal opening. 
 
 1125. Further, it offers unquestionable advantages wherever 
 the contraction affects the transverse and oblique diameters ; 
 where it exists at the inferior strait ; when it depends on barrure, 
 an exostosis, any solid tumour situated laterally, or on a pro- 
 tuberance of the acetabulum ; the same holds good of locked- 
 head, whether of the species called by Roederer paragom- 
 phosis, or whether the head is pinched at the two extremities of its 
 bi-parietal or occipito-frontal diameter, or in any other way that 
 prevents it from descending, and from being easily pushed upwards ; 
 and lastly, whether this locked-head be understood after the manner 
 of Baudelocque, of Madame Lachapelle, or of M. Desormeaux, pro- 
 vided always, that the inferior strait be not extremely contracted ; it 
 is manifest, further, that if the elongation of the sacro-pubic diame- 
 ter, produced by the section of the pubis, must be so much the 
 greater in proportion as the contraction of the pelvis is so much the 
 more considerable, as maintained by Giraud and Ansiaux, the very 
 contrary may also happen, as has been well observed by Boer and 
 by Madame Lachapelle. 
 
 1126. To perform this operation, it is necessary : 1. That the 
 foetus shall be living, for notwithstanding what M. Gardien says, where 
 symphyseotomy is indicated, should the child be dead, we ought 
 to prefer the operation of cephalotomy, which would always suffice 
 in that case ; 2. That the presentation shall be natural, and that, 
 as far as possible, we shall not be compelled to extract the foetus by 
 the feet, because turning too frequently occasions its death ; 3. 
 That the os uteri shall be largely dilated : for otherwise there could 
 be no certainty that the operation is indispensable, and moreover, we
 
 502 SYMPHYSEOTOMY. 
 
 might, after performing it, find it impossible to terminate the deli- 
 very with the necessary rapidity ; 4. That the woman shall be 
 young enough to obviate all fears in relation to anchylosis of the 
 pelvis. 
 
 1127. Manner of operating. The patient, being placed upon an 
 operation table, or on the bed, in the same manner as for the ap- 
 plication of the forceps, having her thighs and legs slightly flexed, 
 and properly separated, an assistant must hold her shoulders, and 
 two others take charge of her knees, while a fourth stretches the 
 skin of the belly, and a fifth is prepared to hand the operator what- 
 ever may be required. 
 
 1128. Situated to the right or betwixt the legs of the patient, 
 the surgeon, with a convex and very sharp bistoury makes an inci- 
 sion, which should commence a little above the symphysis and ex- 
 tend close to the clitoris ; this incision divides the skin, previously 
 shaved, and all the soft parts that compose the mons veneris ; being 
 parallel to the median line, it ought to fall as nearly as possible upon 
 the centre of the articulation ; at its lower part, however, it is well 
 to give it a slight inclination to one side, between the top of the 
 greater and lesser labium, and, even to separate one of the roots of 
 the clitoris from the ramus of the pubis, for the purpose of avoiding 
 dangerous lacerations at a later stage of the process. There can 
 be none but very small arteries to tie, unless the internal pudic 
 should be divided by incautiously carrying the incision too far down- 
 wards. For the purpose of dividing the cartilage, some have re- 
 commended that we should act from below upwards, others from 
 above downwards, and several from behind forwards, or from within 
 outwards, and most writers from before backwards. There are 
 some who have made use of a bistoury, a sort of scalpel en ron- 
 dache, of the pliable knife of Aitken, of a probe-pointed bistoury, 
 or a common bistoury, the point of which M. Gardien recommends 
 to be covered by the point of the nail of the left fore finger, so as 
 to prevent any injury to the internal organs. In such a case every 
 man ought to be allowed to choose the instrument that pleases him 
 best ; for my own part, I think that in this, as in other cases, regard 
 is rather to be paid to the hand that acts than to the shape of the 
 bistoury, and that the only essential quality of the operating knife 
 is strength and sharpness. The safest way is to cut the sym- 
 pliysis from above downwards, and from the cutaneous surface to 
 the pelvic surface of the symphysis. The incision ought to be ex- 
 tended upwards half an inch, or even a whole inch, along the linea 
 alba. To avoid the risk of wounding the bladder, or urethra, as 
 has happened with some surgeons who went at one stroke quite to 
 the head of the child, through the bladder and womb, I think it will
 
 SYMPHYSEOTOMY. 503 
 
 always suffice to hold the blade of the bistoury at some distance 
 from its point with the left finger and thumb, while we make its cut- 
 ting edge act with the right hand : with the view of still more cer- 
 tainly avoiding the bladder and urethra, the catheter should be 
 introduced early, or at least previously to commencing the second 
 stage of the operation. By this means the bladder is emptied, and 
 the catheter serves to push the urethra a little to the right, while the 
 incision is inclined slightly to the leftside of the sub-pubal ligament. 
 When the ligarnentbus matter is almost divided, the precautions are 
 to be redoubled ; the cutting should now be done almost wholly by 
 touches with the point of the knife, and it is to be laid aside as soon 
 as we find no more resisting and elastic material to divide. 
 
 1129. Frightened with the imaginary disorders which might be 
 produced by the access of the air into the articulation, Alphonse 
 Leroy advised that the operation should be divided into two stages: 
 for that end M. Lescure, his pupil, thinks that an incision of nine 
 or ten lines should first be made through the skin; then, after having 
 divided one-third of the cartilage with extreme gentleness, that we 
 should return and prolong the section of the ligaments as far as 
 the clitoris, and afterwards proceed to divide the remainder of the 
 cartilage, " without minding the blood that escapes from the small 
 external pudic vessels, this section is performed, says he, very slowly, 
 and by carefully feeling the cartilage." 
 
 Others have supposed they could more certainly attain the same 
 end, by dividing the skin only above and below the symphysis, or, 
 even only to the extent of a few lines opposite its middle portion, 
 which would surely render the section of the ligament very difficult; 
 but at the present day these ill founded fears are dismissed : it is uni- 
 versally known that the accidents that too often follow the operation 
 of symphyseotomy are unconnected with the action of the air upon 
 the cartilage; and further, that such modifications in the mode of 
 conducting the operation would in no wise prevent it. 
 
 1130. Previously to commencing, it is important to make sure of 
 the spot occupied by the articulation; for when the pelvis is deformed, 
 it is not uncommon to find it deviated so far to one side as that the 
 operator has on more than one occasion fallen on the body of the 
 bone, instead of uncovering the cartilage itself. 
 
 Should it so happen that the symphysis is found ossified, as in the 
 pelvis mentioned by Wiedemann and Lauverjat, and as Boer and 
 Madame Lachapelle inform us is often the case, there would be so 
 small a chance of obtaining even a tolerably large opening, that in- 
 stead of sawing the articulation, as was done by Siebold, I should 
 prefer to have recourse to the cesarean operation. By applying the
 
 504 
 
 SYMPHYSEOTOMY. 
 
 saw beyond the symphysis, upon the very body of the bone, accord- 
 ing to the counsel of M. Desgranges, the operation would not be ren- 
 dered either more or less dangerous; for the difficulty exists behind, 
 in the sacro-iliac articulations, and not in front. 
 
 1131. Immediately subsequent to the division of the cartilage, 
 the posterior branch of the bent lever, formed by the coxal bone 
 being acted on by the elasticity of the posterior sacro iliac ligaments, 
 occasions a separation of from six to twelve lines between the pubes. 
 This separation must necessarily vary, according to the degree of 
 contraction of the pelvis, and the rigidity or softness of the 
 symphyses : if it is sometimes effected in equal proportions by both 
 of the bones, there must also be cases where one is much more con- 
 cerned in it than the other. Be this as it may, I find it difficult to 
 understand how it can go, spontaneously, to such an extent as to 
 prove dangerous, or that it is worth while to restrain it by securing 
 the hips previously to the conclusion of the operation. On the 
 contrary, to carry it to a sufficient extent, it is almost always requi- 
 site slowly and moderately to press the hips from within outwards, 
 and from before backwards, or carefully to separate the woman's 
 thighs. 
 
 1132. Unhappily, when the operation is terminated, the delivery 
 is still far off. If the contractions are energetic and well sustained, 
 the delivery is entrusted to the natural powers, to which also it would 
 doubtless be better to refer the care of separating the divided 
 symphysis to the required extent; but if the womb does not react, if 
 the labour grows languid, or any circumstance arises demanding 
 the prompt extraction of the foetus, we are obliged to apply the for- 
 ceps, or turn the child, and that conformably to the principles that 
 have already been laid down; remembering, further, that turning 
 causes the child to incur the greatest risks, and that it was for the 
 preservation of its life that the mother was subjected to the section 
 of the pubis. 
 
 I should so greatly fear to bring down the feet in such a case, 
 that, unless they had originally presented, I would without hesitation 
 give the ergot to excite the uterine contractions, and would attempt 
 the employment of the forceps, even should the head, still engaged 
 in the superior strait, be found to be situated transversely. During 
 this part of the operation it would probably be necessary to support 
 the hips or whole pelvis, either with the hands or a suitable bandage, 
 so as to prevent the articulations from being too much lacerated by 
 tluj cxccntric pressure of the foetal head or the efforts of the ac- 
 coucheur. 
 
 1133. Dressing. When the delivery is complete the woman is
 
 SYMPHYSEOTOMY. 505 
 
 to be cleansed; the pubes are brought into contact with each other; 
 some lint, spread with cerate, and some compresses are to be placed 
 over the womb; a body bandage passed round the pelvis keeps every 
 thing in place, and should be sufficiently tight to prevent, at least to a 
 certain extent, anew separation of the bones from taking place; the 
 patient being now put to bed, ought to lie on her back, and be kept 
 in a state of the most perfect rest; her thighs especially ought not 
 to move for six weeks or two months, a period of time which is in- 
 dispensably necessary for the consolidation of the symphyses; she is 
 also to be kept upon the regimen proper in serious operations, and if 
 any accidents make their appearance, they must be vigorously com- 
 bated. 
 
 The discharge of the locliKE must be carefully attended to, and if 
 they threaten to disappear too soon, emollient or detergent injec- 
 tions should be thrown into the vagina, and the woman should be 
 advised, if she can, to suckle the child, and care must be taken to 
 preserve the lips of the wound in constant contact. When the term 
 of cure approaches, motion, and particularly walking, should not be 
 allowed, except with great reserve. Should there still remain any 
 mobility and pain in the pelvis, recourse must again be had to rest 
 for a longer or shorter period, and it often happens that walking 
 and standing cannot be permitted without danger for three or four 
 months. Doubtless nothing can be more desirable than the conso- 
 lidation of the divided symphysis ; but there have been women in 
 whom it could not be obtained, and who were notwithstanding able 
 to walk, stand, and leap, without sensible inconvenience, which is 
 to be explained upon the supposition that the posterior symphyses 
 had acquired a great degree of firmness. MM. Mansuy and Du- 
 bois have each related a case of this sort. A. Leroy and M. Les- 
 cure even go so far as to say that it ought to be promoted by omit- 
 ting any bandage round the pelvis ; they say, and perhaps they are 
 not wholly wrong, that the space between the symphysis fills with a 
 cellulo-fibrous tissue, which does not prevent the articulation from 
 being firm, and also allows the woman to bear children subsequently 
 with much greater facility. 
 
 1134. Results. Upon the whole, when we consider that out of 
 forty-three women who have undergone the operation of symphy- 
 seotomy fourteen died ; that several remained crippled for life, par- 
 ticularly the two spoken of by Madame Lachapelle, and vrho were 
 operated on at the Maternite ; that in some of them the operation 
 was not indispensably necessary, since, as we find in Baudelocque's 
 work, that they were afterwards delivered without assistance or 
 difficulty ; that most frequently the child has not been saved, and 
 3O
 
 506 SYMPHYSEOTOMY. 
 
 that, in fact, it must in a majority of cases perish under the opera- 
 tion of turning or the forceps, which we are almost always obliged 
 to try; lastly, as observed by Lauverjat, that in eighteen opera- 
 tions, twenty-one individuals, mothers or children, perished ; that in 
 two cases it was found necessary to have recourse to the cesarean 
 operation ; that five were followed by incontinence of urine, and one 
 by claudication ; that in the thirty-four cases mentioned by Baude- 
 locque, only eleven children were saved ; when we consider, I say, 
 all these dangers, and compare them with the advantages derived 
 from it in the most successful cases, it is difficult not to concur with 
 M. Desormeaux in regarding the section of the symphyses as, being 
 in fact scarcely less serious than the cesaraen operation, and that 
 its employment ought to be restricted within pretty narrow limits. 
 
 1135. Catolica's operation. If I understand correctly what was 
 told me by Professor Vulpes, it would appear that Dr Catolica of 
 Naples has substituted another operation for that of symphyseotomy, 
 which, properly speaking, is but a modification of the one already 
 proposed by M. Desgranges of Lyons. Instead of dividing the car- 
 tilage, he proposes that the body and ramus of the pubis on each 
 side should be divided between the two oval foramina, as was recom- 
 mended by Aitken. In this way, the sacro-iliac symphyses remain 
 uninjured ; no risk of wounding the bladder or urethra is incurred ; 
 the cellular tissue of the pelvis is scarcely stretched, and the conso- 
 lidation is easily obtained ; there is no fear of abscess, caries, fistulae, 
 claudication nor peritonitis, and a considerable ampliation of the 
 sacro-pubic diameter is obtained. I am not sufficiently acquainted 
 with the reasons of the author to enable me to combat or approve 
 the operation, and until I shall have become more fully informed, 
 shall content me with the little I have now said concerning it. 
 
 SECTION 4. 
 
 Of the Cesarean Operation, (Hystcrotomy, Hysterotomotocia, Cesa- 
 rean Delivery, Gastro-Hysterotomy). 
 
 The denomination of cesarean section is given to an opening 
 made into the belly and womb for the purpose of extracting the 
 fo3tus when it cannot be delivered through the natural passages; 
 since the time of Simon its application has been further extended 
 to the incision or incisiens which it is sometimes necessary to make 
 in the cervix of the uterus, with the view of facilitating the passage 
 of the head through it. 
 
 1 136. Historical. Being lost, as it were, in the night of time,
 
 CESAREAN OPERATION. 507 
 
 t 
 
 the origin of this operation has not as yet been precisely ascertained 
 by any one. In the fabulous ages, it was said that a foetus, the 
 son of Jupiter, was extracted from the belly of Semele by Mer- 
 cury. The Romans made the same statement concerning Escula- 
 pius, who was extracted from the- belly of his mother by Apollo, 
 afte.r she had been already placed on the funeral pile destined to 
 consume her. Virgil also says that Lycus came into the world in 
 the same manner. These vague traditions, a passage in Pliny, and 
 certain Roman laws, induce a belief that the cesarean operation 
 must have been employed in the most remote ages. M. Mansfield, 
 in a work, an extiact of which is contained in the Bulletin des 
 Sciences Alcdicales, attempts to prove that it was practised even by 
 the Jews. It is said in the Talmud and the Mischajoth that a child 
 born by a section of the belly has not the rights of primogeniture. 
 Jaschi has described it in his commentary on the Nidda, and says 
 that women who have undergone it are not compelled to perform the 
 forty-days purification. There is, however, no certain proof that it 
 was performed upon a living woman anteriorly to the year 1520, 
 unless we admit as authentic the case of the lady at Craon, who, 
 according to the statement of Goulin, was subjected to the section 
 of the belly in 1424, and, as well as her child, survived the operation. 
 The ancient Greek and Latin physicians make no mention of it 
 whatever. Guy de Chauliac, who seems to have first described it, 
 founding his opinion upon the following passage of Pliny, (Auspica- 
 tius, enecta parente, gignuntur, strut Scipio Africanus prior natus, 
 primusque Ccesus, Cceso matris utero, dictus; qua de causd, Ccesones 
 appellati. Simili modo natus est Manlius qui Carthaginem cum 
 exercitu intravit'), believes that it took its name from Julius Caesar; 
 others, on the contrary, think that the general and his family took 
 their name from the operation. Bayle remarks that Aurelia, the 
 mother of Caesar, was still living when he went to Britain, and con- 
 sequently that the story related by Pliny ought to be rejected as 
 fabulous ; the researches of Weidemann and those of Sprengel 
 having given no satisfactory solution of this problem, we are obliged 
 to confess that the etymology of the cesarean operation is no better 
 known than its origin. 
 
 1137. Rousset was the first author who dared to maintain that it 
 may and ought to be had recourse to in the living subject ; after 
 having cited various experiments and numerous analogies, he men- 
 tions seven women who had been subjected to the cesarean operation 
 with complete success ; but can we rely upon the authenticity of the 
 case of the woman named Godon, who was operated upon seven 
 times ; upon that spoken of by the surgeons Lenoir and Lebrun, who
 
 508 CESAREAN OPERATION. 
 
 operated upon the same subject three times ; the recital of Alibax, 
 of Sens, of Colot, or the story of the woman who had a long scar 
 upon the right side of the belly, and who said she had a child ex- 
 tracted through the part seven years before ? Ought we to receive, 
 according to the very letter, what G. Bauhin says of the person 
 called Alipaschie of Siergershensen in Germany, who was operated 
 upon by J. Nufer, a spayer of cattle, after she was given over by 
 several midwives, and who recovered so happily, that several years 
 afterwards she was delivered, without danger, of two other children? 
 What are we to think of the other fact mentioned by Pare and 
 Schenk relative to Nicola Berenger ? How happened it that this 
 woman was delivered two years afterwards of a girl, and subsequent- 
 ly of a boy, if there was any necessity for her to undergo the cesa- 
 rean operation ? The same may be said of the case of Elizabeth 
 Turgois, who subsequently gave birth to four children, by the na- 
 tural passages, according to the report of the same Bauhin. Lastly, 
 it is certain that of the sixty-odd cases related by Rousset, Bauhin, 
 and Simon, only a very small number are quite conclusive, and that 
 Pare, Guillemeau, Marchant, Mauriceau, and all persons who were 
 unwilling to be convinced except by well established facts, were pos- 
 sessed of excellent reasons for combating the assertions of Rousset. 
 
 1138. Be this as it may, according to Baudelocque himself, the 
 cesarean operation has been successfully performed twenty-four times 
 from 1750 up to the commencement of the present century, and 
 without counting the two cases of Lauverjat, which are unquestion- 
 able, it has been since performed at Nantes twice upon the same 
 woman, by Bacqua, once by M. Lemaistre of Aix, once by M. 
 Dariste at Martinique, once by Vonderfuhr, in 1823, at Dahlen, once 
 by the physicians of the hospital of Florence, on the 18th of May 
 1827, twice by Schenck, once by Bulk, once by Groefe, once by 
 Leuch, once by Buren, another time, recently, in one of the colo- 
 nies ; so that we cannot refuse to believe that at least some women 
 may possibly be saved by means of the cesarean operation. 
 
 1139. The danger attending it cannot, however, be denied. 
 Boerhaave and Boer were doubtless wrong in stating, that scarcely 
 one successful case could be found in fourteen operations ; but it 
 is at least certain that it has been performed four times within 
 the last twenty years at the Paris Matcrnitr, and that the wo- 
 men all perished ; that out of seventy-three cases cited by Baude- 
 locque, forty-two were followed by death ; that of one hundred and 
 fiix cases reported by Sprengel, forty-five were unsuccessful, and 
 that of the two hundred and thirty-one operations mentioned by 
 Kelly and Hull, one hundred and twenty-three were incompetent to
 
 CESAREAN OPERATION. 509 
 
 save the lives of the women ; let us add that all the successful cases' 
 have certainly been published, and that there is a great number of 
 them whose authenticity may justly be called in question ; whereas, 
 according to all appearances, the same thing has not happened as to 
 the unsuccessful cases, of which perhaps the greater proportion 
 may have been passed over in silence. It may be stated, there- 
 fore, that, up to the present day, the cesarean operation has proved 
 fatal in at least one out of two cases, and that Tenin was mistaken 
 in asserting that, since the time of Bauhin, it has been performed at 
 the Hotel Dieu on seventy women, who recovered. By the report 
 of J. Burns and S. Cooper it appears that not a single well at- 
 tested case of its successful performance has occurred in Great 
 Britain, although the number of operations amounts to fifteen or 
 twenty. 
 
 I think these details will suffice to exhibit this operation to young 
 practitioners in all its importance, and to prevent them from resort- 
 ing to it in any case save where the necessity is absolute. 
 
 Nevertheless, it is difficult to conceive a priori that it is of so 
 redoubtable a character. The wound which it is necessary to make 
 in the abdomen is indeed very large, but the parts divided are not 
 very delicate ; there are no arteries, no large nerves, and nothing 
 of any great importance to guard against ; the peritoneum is 
 wounded, but the digestive organs may be easily avoided ; besides, 
 how often have, the largest and most complicated eventrations, and 
 penetrating wounds of all kinds been seen which yet gave rise to 
 no very serious consequences, and admitted of the recovery of the 
 patients ; is not the serous membrane of the belly laid open every 
 day, without our being alarmed about it, in subjects affected with 
 strangulated hernia ? Would the wound of the uterus alone prove 
 dangerous ? but every thing in this organ indicates that it possesses 
 but a slight degree of irritability, a slight tendency to take on inflam- 
 matory action, and has the most favourable conditions for a sure and 
 prompt cicatrization. Are there not several cases of women who 
 underwent the cesarean operation successfully, subsequent to rupture 
 of the womb, and particularly the one' recently made public by 
 doctor Frank ? The wound, which is at first very large, is soon 
 reduced to one-fifth or one-sixth of its original size, and when the 
 organ is free to contract, the hemorrhage ceases too quickly for any 
 alarm to be felt in relation to it. Lastly, is it not possible by pro- 
 per precautions to prevent the liquor of the amnios, the blood, and 
 other fluids from being poured out into the peritoneum during and 
 immediately after the operation ? 
 
 1140. It would seem then that it is not so much upon itself, as
 
 - 
 
 510 CESAREAN OPERATION. 
 
 upon the peculiar state of the woman at the time, that the serious 
 nature of the cesarean operation depends. Consequently, I can 
 scarcely refuse to admit the idea, that if we were to act as soon as 
 the indication becomes positive, without waiting until the person 
 becomes exhausted with vain efforts, the uterus in a state of inertia 
 or on the point of becoming inflamed, if not already so ; until peri- 
 tonitis or enteritis has became imminent, or existent; or lastly, until 
 the patient's life is in danger the cesarean operation would not be 
 near so often fatal, as, unfortunately, it has hitherto been found to be. 
 In support of this view of the subject, I hope I may be permitted 
 to allege a sentiment of Dr Hull, who attributes the unfortunate 
 results obtained by his countrymen to the circumstance that they 
 never operate, in England, except in desperate cases, whereas upon 
 the continent they are willing to have recourse to it at an early 
 period. 
 
 1141. When the smallest diameter of the pelvis is less than fif- 
 teen lines, be the foetus dead or alive, the operation of hysterotomy 
 is the only chance of safety that we can propose to the woman. 
 When this diameter amounts to from eighteen lines to two inches and 
 a quarter, it is equally indispensable, where we do not wish to act 
 upon the child ; but in this case, the child must be alive, and further, 
 it remains for us to decide whether it is better to follow the English 
 doctrine and destroy the foetus, than to expose the mother to the 
 danger of losing her life. Lastly, it may happen that we shall be 
 compelled to resort to it, even although there should be two inches 
 and a half or two inches and three-quarters at the smallest passage, 
 provided the forceps, turning, or the section of the pubis shall have 
 been deemed useless, or have been tried in vain. 
 
 1142. Not only ought the cerarean operation to be performed 
 upon the living subject, but it is also a rule of practice to subject those 
 to it who perish after the seventh month of pregnancy without being 
 delivered. 
 
 The child does not always cease to live at the same moment with 
 its mother, although most frequently it dies first. We might even 
 believe, admitting as true what has been written upon the subject, 
 that life may be maintained in the ovum more than twelve, twenty- 
 four, or even forty-eight hours. The princess of Schwartzenberg, 
 who died at Paris in consequence of a burn, could not be opened 
 until the next day, and the foetus was, notwithstanding, found to be 
 living. Another woman, mentioned by M. Gardien, was not ope- 
 rated on until after forty-eight hours had elapsed, and the child 
 was found to be still alive. Flajani, Veslingius and several other 
 authors relate cases of a similar character ; but may we give credit
 
 CESAREAN OPERATION. 511 
 
 to the assertions of Cangiamila, when we find him affirming in his 
 Sacred Embryology that in the space of twenty-four years, twenty- 
 one children were saved in this manner at Montereali, thirteen at 
 Girgenti, and that the cesarean operation was performed under these 
 circumstances twenty times at Syracuse in the course of eighteen 
 months. 
 
 1143. Be this as it may, the Roman law, lexregia*, which is 
 referred to Numa Pompilius, ordered the physicians of that period 
 to open the bodies of all women who died pregnant, with the view 
 of preserving citizens for the state. To fortify this ancient usage, 
 without compromitting the lives of women who might be only in a 
 state of apparent death, the senate of Venice issued a decree in 
 1608 and 1721, which ordered severe penalties upon those members 
 of the profession who should operate upon a person supposed to be 
 dead without the same degree of care as if she were actually living. 
 In 1749, the king of Sicily made another law, by which he inflicted 
 the penalty of death upon physicians who should omit to perform 
 the cesarean operation upon women who should have died in the 
 last months of pregnancy. 
 
 It is very useless, no doubt, to think of preserving the life of a 
 foetus previously to the end of the eighth month ; but in Catholic 
 countries there is a desire at least to baptise them, and that the 
 operation should be performed, in fact, if the woman has passed 
 through one half of the period of pregnancy. 
 
 1144. As to the necessity of acting, immediately subsequent to 
 the death of the mother, with the same precautions as if the woman 
 were known to be living, no one will entertain a doubt in view of 
 the difficulty of ascertaining with certainty that life is irrevocably 
 extinct, and of the promptitude with which we ought to act under 
 such circumstances. Precipitation might really produce a decease 
 which might possibly be otherwise avoided, and the time required 
 to establish the certainty of the woman's death would more than 
 suffice to ensure the loss of the child, which, in fact, is never ex- 
 tracted alive, excepting in a few cases, appertaining somewhat to 
 the miraculous, unless the extraction be effected during the first 
 moments that succeed the death of the mother. 
 
 Van Swieten and Baudelocque mention three cases of women, 
 * supposed to be dead, on whom the cesarean operation was about to 
 be performed, when they recovered from their lethargic state. Peu 
 relates an instance far more calculated to excite alarm : he com- 
 menced his incision, when- the woman gave a shudder, accompanied 
 
 * Digest, lib. IX, tit. viii, L. 2, et lib. I. tit. v. &c.
 
 512 CE SAKE AN OPERATION, 
 
 with grinding of the teeth and a movement of the lips. Rigaudeaux 
 has related another one not less remarkable : he was sent for, two 
 leagues from Douai, to see a woman whose labour had excited great 
 uneasiness ; when he arrived she was believed to have been dead for 
 two hours. Instead of opening the abdomen without any examina- 
 tion, he explored the genital organs, found the pelvis well formed, 
 and proceeded to turn and deliver the chiM by the feet, which was 
 born in a state of apparent death, but which with great exertion was 
 brought to life in about two hours. The limbs of the mother pre- 
 serving their suppleness, he forbid them to bury her until the abdo- 
 men should have turned green ; after a few hours this woman reco- 
 vered so completely from her insensibility, that sire came herself, four 
 years afterwards, to inform Rigaudeaux that she was not dead ! 
 
 Thus, when called to a woman who has lately expired, the first 
 thing to be done is to ascertain the state of the pelvic passages, and 
 whenever they are sufficiently capacious, an attempt should be made to 
 extract the child through the natural passages. In the second place, 
 if hysterotomy is found to be indispensable, it is to be performed 
 according to the same rules, and with as great care as if the woman 
 were living. By acting in this manner, whatever may chance to 
 occur, we have nothing to reproach ourselves with, and nobody is 
 liable to be blamed. 
 
 1145. When the cesarean operation used to be performed only 
 upon the dead subject, the incision was made upon the left side of 
 the abdomen ; " let the woman be opened with a razor along the left 
 side," says Guy de Chauliac, u inasmuch as that part is freer on 
 account of the liver." But since it has been attempted upon the 
 living female, it has been subjected to rules formed on a better foun- 
 dation. Among the various methods proposed by different accou- 
 cheurs, there are five which have attracted special attention : in one 
 the incision is made upon the median line, and parallel to the axis 
 of the body ; in the second, the cut is made outside of the rectus 
 muscle ; in the third, the abdominal parietes are divided transversely, 
 upon one of the sides ; in the fourth, the wound is made immediately 
 above the Fallopian ligament and parallel to that fibrous band ; and 
 lastly, the fifth is made at the level of the crista of the ilium. 
 
 114C. 'Mauriccuu\t method, Solayrcs, Henkel, Deleurye, &c. 
 are wrong in attributing the idea of cutting down upon the median 
 line to Plainer, to Guerin, or to Varoquier. Mauriceau had ex- 
 pressed himself in the following terms : " Most persons direct the 
 incision to be made on the left side of the belly, but the opening 
 will be better in the middle, between the recti muscles, for in that 
 part there is nothing but the integuments and muscles to be cut."
 
 CESAREAN OPERATION. 513 
 
 This proceeding, which is preferred by Baudelocque, and now gene- 
 rally followed in France, England and Germany, permits us to avoid 
 the muscles, and to act only upon the linea alba; only a slight de- 
 gree of pain is produced ; no artery can be wounded, and moreover, 
 the uterus is incised parallel to its principal fibres. But it has also 
 been said that this method exposes us to the hazard of inflicting a 
 wound upon the bladder, and that the discharge of the fluids, whether 
 during or after the operation, cannot be effected without difficulty ; 
 the wound occupying none but fibrous tissues, is slow in healing, and 
 the uterus being laid open throughout almost the whole extent of its 
 anterior wall, instead of tending to approximate the lips of the divi- 
 sion, rather separates them by its contraction. 
 
 1147. Method of .the ancients. In operating upon the side of 
 the abdomen, the ancient accoucheurs generally chose the left 
 side, and made sometimes a straight, sometimes a slightly oblique 
 incision, or one of a crescent shape, but always immediately out- 
 side of the rectus muscle. According to the statements of the phy- 
 sicians who employed it, this method has over the preceeding one 
 the advantage of avoiding all danger of wounding the bladder, of 
 permitting the cicatrization to be easily effected, and of rendering the 
 issue of matters that must escape from the wound far more easy. 
 As the womb almost always undergoes a twist upon its axis, inclin- 
 ing to the right or left, it has been supposed that by making the in- 
 cision along the median line, it would fall nearer to its left edge than 
 to the middle of its anterior region ; this also is one of the consi- 
 derations from which it has been recommended that the operation 
 should be performed upon the side towards which the uterus has 
 naturally deviated. Even admitting all these advantages to be real, 
 they would, nevertheless, be compensated, it seems to me, by the 
 risk of wounding the epigastric artery or some of its branches ; of 
 having a wound, the lips of which it would be almost impossible to 
 keep in contact, on account of the retraction of the oblique and 
 transversalis muscles, and by the impossibility of obviating the 
 absence of parallelism in the two wounds of the abdomen and womb. 
 
 1148. Method of Lauverjat. To avoid the disadvantages con- 
 nected with these two methods, Lauverjat, who had at first admitted 
 the great superiority of hysterotomy at the median line, attempted 
 to methodize a procedure which had already been resorted to by 
 some practitioners, and recommended a transverse incision about 
 five inches in length, between the rectus muscle and the spinal co- 
 lumn, somewhat below the level of the third false rib, and more or 
 less so according as th^fundus of the womb is more or less remote 
 from it. By proceeding in this manner the fibres of the transverse 
 
 3P
 
 514 CESAREAN OPERATION. 
 
 muscle are rather parted than divided ; the epigastric and lumbar 
 arteries are avoided ; we fall upon the fundus of the womb, whose 
 .cavity forms a sort of funnel, which renders the discharge of the 
 lochia very easy, both by the vagina and hypogastrium ; the parallel- 
 ism is easily maintained ; the suture is not required ; mere position 
 suffices to keep the wound in exact apposition ; lastly, the external 
 angle of the cut occupying a low situation, extravasations into the 
 abdomen are incomparably less to be dreaded than in the other 
 methods. But it may be objected that the fibres of the external and 
 internal oblique muscles are necessarily divided ; that the least ef- 
 fort must force the viscera out ; that the womb being divided at its 
 fundus, where its vessels are largest, soon removes to a considerable 
 distance from the external opening, and .that its fibres, by contract- 
 ing, must rather hinder.than promote the approximation of the edges 
 of the inner incision ; so that, notwithstanding the two successful 
 cases of Lauverjat, and the preference apparently given to him by 
 Sabatier and M. Gardien, this method is evidently scarcely less 
 dangerous than the two former ones. 
 
 1149. Method of M. Ritgen. Dreading above all things the 
 wounding of the peritoneum and of the body of the uterus, Ritgen 
 has of late recommended that the attachment of the broad muscles 
 of the abdomen should be divided above the crista of the ilium ; that 
 the peritoneum should be detached as far as the superior strait; and 
 that the neck of the womb should be divided to a sufficient extent 
 to admit of the extraction of the child. In the first place, I cannot 
 perceive how it would be possible to incise the apex of the womb 
 without cutting the serous membrane with which it is enveloped ; 
 then, the difficulties inherent in this proceeding, added to the de- 
 tachment, which would be produced in the iliac fossa, do not appear 
 to me to be of a nature to render the operation at all less serious 
 than those which have been mentioned ; besides, as far as I know, 
 at least, the operation is as yet only a project, and no one has put 
 it in practice in the living woman. ~<:**MMrt*i*' 
 
 1160. Method of M. Bauddocque, Jun. Attributing the princi- 
 pal dangers of the cesarean operation to the double wound of the 
 peritoneum; and further, regarding wounds of the uterus as almost 
 essentially mortal in their character, M. Baudelocque has proposed 
 a now method, which in both these respects appears to him to be 
 infinitely preferable to all others, and which in fact differs from them 
 very considerably. 
 
 The incision is commenced near the spino of the pubis, and ex- 
 tends, parallel to the Poupart'a ligament, bqpond the antero-superior 
 spine of the ilium. He selects the left side, on account of the in-
 
 CESAREAN OPERATION. 515 
 
 clination of the cervix, when the womb is oblique to the right, and 
 the right side where there is a left lateral obliquity. After having 
 divided the abdominal parietes without touching the epigastric 
 artery, he pushes away the peritoneum from the iliac fossa, quite 
 down into the excavation, and detaches it from the upper part of 
 the vagina, which he opens ; through this opening, which ought to 
 be sufficiently free, the finger is conducted into the os uteri, which 
 is now to be drawn up towards the wound in the abdomen, while 
 the fundus is at the same time pressed in an opposite direction, so 
 as to make it turn over more readily. When the operator has suc- 
 ceeded in bringing the orifice of the womb apposite to the opening 
 made in the abdominal parietes, the delivery is entrusted to the 
 uterine contractions, or provided it should be absolutely necessary, 
 the orifice might be dilated with the fingers, and the foetus extracted 
 either with the hand or the forceps. 
 
 1151. The idea of this method, which, the author denominates 
 elytrotomy, is certainly ingenious ; he has performed on the dead 
 subject, both pregnant and not pregnant, a number of experiments, 
 which have confirmed him in the favourable opinion he had previ- 
 ously formed concerning if, and which have sufficed to induce some 
 practitioners to suspend their judgment in relation to its value. 
 Nevertheless, I can scarcely believe that it will be found practicable 
 in a majority of cases, or that the laceration of the vagina, in addi- 
 tion to the disturbance necessarily occasioned in the iliac fossa or in 
 the excavation, would be less redoubtable than the simple and metho- 
 dical incision of the peritoneum and womb, such as may be per- 
 formed in ordinary hysterotomy. I may further add, that M. Bau- 
 delocque himself has very recently been obliged to have recourse to 
 the cesarean operation, properly so called, after having tried the 
 operation of elytrotomy in the case of a woman who had long been 
 under his supervision, and in which he was assisted by M. Hervez 
 de Chegoin. I am aware that one single fact does not warrant us 
 in drawing rigid conclusions ; but this, which is the only one we 
 have in regard to the living subject, seems to me to lend great force 
 to the distrust of the author's notions, derived, a priori, from reason- 
 ing. 
 
 1152. Method of Dr Physick. Another mode of operating, 
 which is somewhat like that of Professor Ritgen, and also is not 
 very different from that of M. Baudelocque, appears to have been 
 proposed, almost at the same time, by Dr Physick. After having 
 remarked that, in pregnant women, the peritoneum is easy to sepa- 
 rate from the bladder and parts about the os uteri, this surgeon con- 
 ceived that by making a horizontal incision immediately above the
 
 516 CESAREAN OPERATION. 
 
 pubis, the os uteri might be reached and opened without interesting 
 the peritoneum : but notwithstanding what Dr Horner may say 
 concerning it, this operation is but little worthy of its inventor, and 
 does not deserve the trouble of being discussed. 
 
 1153. Previously to commencing the operation, it is proper to 
 soothe the mind of the patient by inspiring her with the greatest 
 possible confidence ; a good condition of the general strength, and 
 of the womb in particular; an obtuse, rather than a lively sensibility; 
 a great degree of resignation, such as are pretty often observed in 
 country-people, is most of all to be desired : if the child is incur- 
 ring any risks, we should make haste ; otherwise, bleeding, baths, 
 purgatives or any other proper means may be sometimes made use 
 of; and lastly, the conduct here in relation to the preparations, is 
 the same as in all the great operations. 
 
 If the bagoficaters is not ruptured, ought it to be torn, as Plan- 
 chon advises, previously to making the incision into the womb, or 
 must it be let alone, as most other authors advise? By empty- 
 ing the membranes the escape of the liquor amnii into the perito- 
 neum is prevented, and there is less reason for fear as regards hem- 
 orrhage and inertia of the womb. But these are not the most to 
 be dreaded of all the occurrences that may take place during the 
 operation ; we are much more frequently embarrassed by the con- 
 traction of the womb than by its inertia. When the ovum is whole, 
 the child can be much more easily extracted ; the wound in the 
 uterus, at first more extensive, is however reduced at last to much 
 smaller dimensions ; lastly, there is less irritation excited in the 
 womb, and upon a careful consideration of all the circumstances, I 
 believe, in common with M. Desormeaux, that it is better to preserve 
 the membranes whole. 
 
 We should never omit to empty the rectum and bladder, especially 
 if it be intended to follow the method of Mauriceau. The appa- 
 ratus consists of a convex bistoury, a straight probe-pointed bistoury, 
 pincers, scissors, suture needles, thread, quill-barrels, adhesive strips, 
 lint in rolls and in pledgets, of pieces of linen spread wit'h cerate, of 
 compresses both oblong and square, a bandage for the body, small 
 and large sponges, a syringe, canulas of gum-elastic, to be used in 
 case it should be necessary to make any injections, water, both cold 
 and warm, and vinegar; wine and cologne-water are also necessary. 
 
 If possible, the patient should be laid on the bed that she is to oc- 
 cupy during the first few days after the operation ; her position 
 ought to be an easy one. She should be placed on her back, with 
 the lops and thighs very slightly bent, and assistants are charged to 
 li atrninst anv midden movements which Iho pain might compel
 
 CESAREAN OPERATION. 517 
 
 her to execute ; two intelligent assistants must apply their hands 
 upon the sides and fundus of the womb, so as to circumscribe it 
 very exactly, in order that no organ may happen to slip betwixt its 
 surface and the abdominal parietes, and so that it may compose 
 with the latter parts but one single mass. For this purpose the 
 naked hands seem to me less suitable than they would be if applied 
 upon pieces of broad flat sponge, as advised by Dr Hedenus. 
 
 1154. With the convex bistoury the surgeon makes an incision 
 through the integuments, from near the umbilicus towards the pubis, 
 in length from five to six inches, without its being necessary, or al- 
 ways even possible, to pinch up a large fold of them, as advised by 
 Levret. The sub-cutaneous layer, the aponeurosis and the muscu- 
 lar fibres, as well as the cellular tissue, provided we do not operate 
 upon the median line, are successively divided in the same manner 
 and to the same extent. This incision ought not to be carried too 
 near to the pubis, on account of the bladder, and because the ab- 
 dominal parietes are generally very thick in that situation. It 
 would be better to extend it above the umbilicus, taking care to pass 
 to the left of it, so as to avoid the umbilical vein, and more parti- 
 cularly, the anastomosis which may exist between it and the epigas- 
 tric vein, an anastomosis which has latterly been noticed by M. 
 Mesniere, Clement, and Martin. 
 
 After having opened the peritoneum so as to admit of the intro- 
 duction of the left fore finger, to serve as a conductor for the in- 
 strument, the woutid in that membrane is to be enlarged by means 
 of the probe-pointed bistoury, to the same extent as the wound in 
 the skin. 
 
 The womb is now exposed ; it is to be incised layer by layer, and 
 slowly, until we reach the surface of the ovum ; then, in order to 
 retain for the cervix as much of its length as possible, the assistants 
 are told gently to press the fiindus of the uterus downwards and 
 make it turn somewhat in front ; we might, indeed, like Dr Kluge, 
 hook the lower angle of the wound of that organ with the finger, so 
 as to favour such a movement, which by affording a facility for ex- 
 tending the section very far upwards, permits us to guard the cer- 
 vix. In order to avoid the risk of wounding the vessels of the 
 placenta, it is better to use the probe-pointed bistoury to finish the 
 incision, than to have recourse to the grooved director to guide the 
 bistoury with. Further, I can conceive no objection to letting the 
 point of the finger detach the placenta and membranes to a certain 
 extent. 
 
 This is the moment, and not before the commencement of the 
 operation, that it would be perhaps well to follow the advice of Plan- 
 chon, and rupture the membranes by passing the finger up the
 
 518 CE SAKE AN OPERATION. 
 
 vagina, either with the fingers alone, or with the instrument of Sie- 
 bold, as is generally done in Germany ; supposing, which appears 
 to me preferable, that the membranes should be pierced from the 
 incision, it will be necessary for the assistants to redouble their care 
 to prevent the parietes of the abdomen from abandoning the womb; 
 in this way the effusion of the waters into the cavity of the perito- 
 neum will be obviated, and the tendency of the viscer.a to escape 
 outwards will remain ineffectual. 
 
 1155. The extraction of the child ought to take place without 
 delay ; when it presents by the head or by the breech it is drawn 
 away in that position, and to favour its escape, the assistants are 
 told to press gently upon the sides of the womb through the parietes 
 of the abdomen ; if it be situated otherwise, the feet must be got 
 hold of, and the extraction performed with the same precautions as 
 in delivery by the natural passages, special care being taken not to 
 bruise or stretch the lips of the wound in the uterus. 
 
 1156. As soon as the foetus is withdrawn, the practice recom- 
 mended by Planchon might be adopted, viz. by means of a sound, 
 the cord might be repassed through the wound, for the purpose of 
 removing the after-birth through the vagina, but no beneficial effects 
 would be ultimately obtained by it, and the celerity of the operation 
 would be sensibly lessened; after all, the retraction of the womb, 
 which would most generally render this operation impossible, soon 
 forces the placenta to engage in the wound, and thus points out the 
 route we should select in extracting it. In order that it may pre- 
 sent less volume and less resistance, one of its edges even may be 
 taken hold of, if possible, rather than pull it away by the cord only. 
 As to the membranes, they must be carefully twisted into a rope as 
 in a natural delivery, to prevent any of them from remaining in the 
 uterus. Should any blood have been lost and formed into clots, 
 they ought to be removed with the hand. It would be well, more- 
 over, to cleanse all the parts by means of an injection of warm wa- 
 ter ; but I do not think that for the purpose of keeping the os 
 uteri open, it is of any advantage to place in it the tent recom- 
 mended by Baudclocque, nor the cierge pertuise of Ruleau, nor the 
 tent of Rousset, nor the sound of M. Tarbes, nor any species of 
 canula whatever ; these means would not prevent the os uteri from 
 closing, and would augment the irritation to no purpose. The finger 
 introduced from time to time suffices to keep it free enough, should it 
 cease to give issue to the matters, which, after all, nothing can pre- 
 vent from passing wholly or partly out at the wound. 
 
 1157. The operation being terminated, we must next think of 
 putting a atop to the flow of blood. In the lateral operation, and 
 (specially in that of Lauvcrjat, several arteries may have been
 
 CESAREAN OPERATION. 519 
 
 divided ; they should now be tied r provided they should not have been 
 secured during the progress of the operation. During the operation, 
 the principal orifices of the uterine arteries have been closed by the 
 fingers of the assistants ; there never can arise any question about 
 obliterating them with the ligature ; but it has been recommended 
 to cauterise them with vitriol, and generally, to trust them to the 
 contractions of the womb, which is to be solicited, provided it be 
 slow in taking place, by irritating the cavity of the organ or the lips 
 of the wound with the fingers, or linen moistened with vinegar and 
 water; after a few minutes the length of the incision in the womb is 
 reduced to from one to two inches, and thenceforth hemorrhage of 
 any kind becomes impossible. >% i jrtBjfr)'< 
 
 1158. In England, in Germany, and also in France, the wound 
 in the abdomen is generally closed by the interrupted or twisted 
 suture, because, it is said, that is the only means of keeping the lips 
 in contact, and of preventing hernia of the viscera. Sabatier, how- 
 ever, thinks it ought to be dispensed with, and says that unless the 
 whole thickness of the abdominal parietes be included in each stitch, 
 which would be dangerous, the adhesive strips will do as much as 
 the sutures, without compromitting, in the same manner, the safety 
 of the patient. But notwithstanding the reasons urged by that 
 learned author, it seems to me to be preferable to have recourse to 
 the suture, even where Lauverjat's operation has been adopted. 
 In all cases, the lower corner of the wound should be left free, to 
 allow the matter to escape. Besides, the sutures do not prevent the 
 application of adhesive strips over their intervals, nor the favourable 
 action of the uniting bandage, and a proper position. 
 
 The wound is then covered with a piece of linen, perforated, or 
 with strips spread with cerate ; two long and broad compresses are 
 placed on the sides ; some pledgets of soft lint, common compresses, 
 and a body-bandage well applied, will complete the dressing. 
 
 Previously to leaving the woman, the linens soiled during the 
 operation should be removed ; she is to be placed in the middle of 
 her bed, taking care to move her as little as possible, and we should 
 endeavour to place her so that her muscles may be all in a state of 
 relaxation. 
 
 1159. Some antispasmodic potions, slightly opiated, to calm the 
 nervous agitation ; some precautions to ensure the discharge of the 
 lochia by the vagina instead of their escaping into the peritoneum ; 
 diluting drinks, bleeding and leeching as soon as any symptoms of 
 inflammatory action become manifest, and the greatest repose, both 
 of mind and body, are all that the surgeon can recommend to the 
 patient to obviate the dangers which threaten her.
 
 520 VAGINAL CESAREAN OPERATION. 
 
 SECTION 5. 
 Vaginal- Cesarean Operation. 
 
 11 CO. According to the reports of authors, a great number of 
 causes may necessitate the performance of the vaginal-cesarean 
 operation: an obliteration with fibro-cartilaginous induration of the 
 os uteri, as in the case related by Simson, and also in that other 
 case spoken of by Van-Swieten ; violent convulsions which endanger 
 the life of the woman while the orifice is too tense, and still insuffi- 
 ciently dilated to admit of the introduction of the hand, as is observed 
 in the cases by Dubosq and Lambron ; an extreme obliquity of the 
 orifice backwards, while the head of the child at the same time 
 forces down in the excavation, and even as low as the vulva, the 
 anterior portion of the womb, which it distends, renders thin, and 
 would at last rupture, provided an incision were not soon made, as 
 was done by Lauverjat such are the occurrences which have most 
 frequently rendered it necessary ; it may also become useful where 
 the uterus, having escaped from the pelvis during pregnancy, has 
 never been reduced, and where its orifice cannot be dilated by 
 means of the fingers, although there may be danger in delaying the 
 delivery, as in the examples cited by M. Thenance, Jacornet, and a 
 surgeon at Vaux mentioned by M. Bodin ; but it has been proposed 
 more particularly in cases of scirrhus, and where the orifice presents 
 such a resistance to the contractions of the womb that the woman 
 is exhausted in vain efibrts without effecting its dilatation ; lastly, it 
 would be equally well indicated, as M. Bodin has attempted to de- 
 monstrate, in cases of arm presentation, should it ever in any case be 
 found really impossible to proceed in search of the feet, and if no 
 other means of avoiding the amputation of the arm could be availed of. 
 
 1101. Although generally attended with but little danger, the 
 accoucheur would be blamcable who should perform it without a well 
 ascertained necessity ; 1 cannot therefore but condemn in decided 
 terms the temerity of those practitioners who do not hesitate to 
 employ it, simply because the os utciT happens to be somewhat 
 dense, and does not dilate according to their impatient desires ; and 
 according to what I said when speaking of deviations of the os uteri, 
 I have no doubt that it has often been performed when it might 
 have been easily dispensed with. 
 
 in all cases, if there is an orifice, nothing is easier than to per- 
 form this operation ; the speculum, employed by some persons is oi 
 no use ; a probe-pointed bistoury, wrapped round with a narrow
 
 VAGINAL-CESAREAN OPERATION. 521 
 
 strip of linen to within eight or twelve lines of its point, is passed 
 up upon the index finger ; in this way we carry it without difficulty 
 within the os uteri, provided it be not too far distant from the centre 
 of the pelvis ; in the contrary case, Pott's curved bistoury should be 
 substituted for the straight one. Strictly speaking, one incision 
 might be deemed sufficient ; but/us it is important that it should not 
 be too deep, it would be preferable to make several of them, at a 
 small distance from each other. At a first view, it would seem that 
 the passage of the head could not take place without enlarging such 
 wounds so as to extend them to the body of the womb, and lacerate 
 the peritoneum ; but in fact this does not happen, and they com- 
 monly remain limited to the substance of the os uteri. In operating 
 for a scirrhous or fibrous induration, but a very few ounces of blood 
 are found to flow from the wound. M. Duges is, in my opinion, right 
 in recommending that all the diseased parts should be removed at 
 once, instead of merely incising them. 
 
 1162. When the anterior wall of the uterus is divided without 
 extending the cut down to the os uteri, we are obliged to make use 
 of a straight, or convex, and not a probe-pointed bistoury, to begin the 
 operation with, which is always a more delicate one than the pre- 
 ceding. Too much care cannot be taken to avoid wounding the pre- 
 senting part of the fcetus while making the incision. But, when 
 the womb has been once penetrated, the forefinger becomes a sure 
 director, and the instrument may enlarge the womb as much as 
 necessary, without any danger ; let us however observe that there 
 is less hazard in extending the incision backwards than forwards, 
 on account of the bladder, and also, that it is useless to make it very 
 large. After the delivery, the wound contracts very rapidly, and it 
 often happens that not a half day elapses before the os uteri recovers 
 its natural situation. If the blood should flow in too large a quan- 
 tity, it would be easily arrested by injections of oxicrate, and by the 
 tampon ; and the cautery, which is easy to apply, will rarely be 
 necessary in such cases. As to the lochia, they escape either from 
 the wound or from the orifice of the uterus, and in these respects 
 the woman requires only such cares as are common after an ordinary 
 parturition. 
 
 SECTION 6. 
 Of Cephalotomy and Embryotomy. 
 
 1163. In England the perforation of the cranium or reduction of 
 the foetus, by removing successive portions of it, even where it is still 
 
 3Q
 
 522 CEPHALOTOMY AND EMBRYOTOMY. 
 
 known to be living, is generally preferred to the cesarean operation. 
 Wigan, combatted by Busch, maintains the same sentiment in Ger- 
 many. In France the operation of cephalotomy is not performed 
 except where the death of the child has been certainly ascertained, 
 or at least become very probable, and where the delivery by the 
 natural passages is altogether impossible. When the pelvis has a 
 diameter less than fifteen lines, of the whole hand cannot penetrate 
 into the womb, the cesarean operation is preferred, even though the 
 child be dead. Upon this subject I will remark that our neighbours 
 too rarely have recourse to hysterotorny, and that they are too ready 
 to sacrifice the child, for fear of compromising the life of the mother ; 
 that here we fall into an excess of quite an opposite kind, and 
 which is, perhaps, scarcely less blameable. In a case where every 
 circumstance announces that the foetus is still in full vigour, and that 
 it is robust, there is no doubt that, instead of sacrificing it, as is done 
 in Great Britain and at the north, it ought to be extracted without 
 endangering its life, by means of operations which indeed are severe, 
 but not always fatal to the woman ; there is also no doubt, in my 
 opinion, that cephalotomy ought to be preferred when there are good 
 reasons for fearing the child's death, or for believing that it cannot 
 continue to live. It would be too cruel, after performing the cesa- 
 rean operation, to be able to present only a corpse, or a feeble, mise- 
 rable being, which must perish in a few minutes or hours, to the 
 unhappy mother as the price of all her sufferings and dangers! 
 But it would be a great mistake also to suppose that embryotomy is 
 wholly unattended with danger to the mother ; it is, on the contrary, 
 one of the most redoubtable and revolting operations in tokology, 
 whenever it extends beyond the mere operation of craniotomy. 
 
 1164. To sum up, the operation of cephalotomy is indicated, 
 
 1. When the foetus is dead and the passages are too much con- 
 tracted to permit its extraction with the forceps or by turning ; 
 
 2. When it is very probable that the child is dead, or at the point 
 of death, and when it cannot be got away whole without the per- 
 formance of the operation of hysterotomy ; 3. When the head alone 
 remains in the pelvis and cannot be extracted by the hand, the for- 
 ceps, or crotchet. It would be useless, dangerous, and ought to be 
 proscribed even in case the foetus were dead, provided the small dia- 
 meter of the inferior strait were less than eighteen or twenty lines 
 in extent. 
 
 1165. Embryotomy, that is to say, that operation which consists 
 in introducing a cutting instrument within the cavity of the womb, 
 for the purpose of lessening tho. size of the child, dividing, and re- 
 ducing it to small pieces, so as to be afterwards able to extract it
 
 CEPHALOTOMY AND EMBRYOTOMY. 523 
 
 piece-meal, was frequently employed by the ancients, who had no 
 other resource, and did not confide enough in the powers of the sys- 
 tem 5 but at the present day the forceps, the lever, turning, symphy- 
 seotomy, and the cesarean operation, properly appreciated as to their 
 respective value, render it almost wholly useless ; it is therefore no 
 longer performed at the present day, except by certain country me- 
 dicasters, who are as ignorant of the art of midwifery, which they 
 disgrace, as they are of the plainest principles of the other branches 
 of medicine. 
 
 1166. Even the operation of craniotomy must very rarely be 
 necessary or indispensable, since out of a total of more than twenty 
 thousand labours Madame Lachapelle has indicated only three in- 
 stances of it. In performing it, Avicenna and Mauriceau made 
 use of sharp extractors in the shape of a crotchet ; Levret, Denys, 
 Fried, and Ould, made use of sheathed perforators ; Simson boasted 
 of a ring-scalpel; spear-pointed perforators have been recommended 
 and modified in an infinite variety of ways ; but at present a simple 
 bistoury is employed, or the scissors of De la Motte, improved by 
 Smellie and by Walbaum, are made use of when it is necessary to 
 penetrate to a great depth within the organs, and to exert a cer- 
 tain degree of force to perforate the bones. 
 
 1 167. The woman should be placed as for the application of the 
 forceps ; the bistoury, wrapped with a small linen roller to within 
 a few lines of its point, which Baudelocque guarded with a small 
 ball of wax, is directed along the palmar surface of one or two 
 fingers of either hand, previously introduced into the vagina, and so 
 on to the head which is to be opened. To insert the scalpel, a fon- 
 tanel, or at least a suture, is to be selected, when the vertex is the 
 presenting part : where the trunk of the body is delivered we may 
 be obliged to perforate the bones themselves, in which case we ad- 
 dress the instrument to- the forehead, or even to the base of the oc- 
 cipital bone. When the head is left in the pelvis, we ought also to 
 endeavour to find one of the membranous spaces ; but it is not al- 
 ways easy to reach them, and the accoucheur must then choose the 
 bone which offers the least resistance, and which his finger can 
 touch. During this operation, if the head be somewhat movable, 
 an assistant ought to embrace the womb with both hands, as advised 
 by Celsus, and push it down towards the strait, so as to steady, as 
 much as possible, the parts about to be divided. On the other hand, 
 the point of the instrument ought never to move, while within the 
 maternal organs, without being guarded by covering it with the 
 point of one of the fingers. When it is once plunged into the 
 cranium, the incision is prolonged as far as possible, at least to the
 
 524 CEPHALOTOMY AND EMBRYOTOMY. 
 
 extent of an inch ; most commonly, we should not be satisfied with 
 making only one incision ; we ought to make a cracial opening, 
 through which the finger may be passed so as to break up the brain, 
 which may also be lacerated with the cephalotome itself. 
 
 If Smellie's perforator is selected for the operation, it is to be intro- 
 duced and shut with the same precautions pointed out when speak- 
 ing of the use of the bistoury ; when closed it resembles a common 
 cephalotome ; but as the two branches of which it is composed are 
 sharp on their outer edges, when they are opened, it necessarily en- 
 larges the incision at first made by its introduction, in direct pro- 
 portion to the degree of the opening ; it is then shut, to be opened 
 again in another direction ; after which it may be made use of to 
 reduce the brain to the consistence of gruel. 
 
 If the disproportion betwixt the child's head and the pelvis is not 
 considerable, and the womb still retains its energy, the remainder 
 of the labour is confided to the efforts of the woman, and termi- 
 nates with much rapidity ; in the contrary case, we are obliged to 
 resort to the employment of the forceps, or crotchet. The forceps 
 would be always preferable where it could be applied, and when the 
 head is still somewhat firm ; and provided it where not so liable to 
 slip and lose its hold, upon the application of some degree of ex- 
 tractive force. 
 
 SECTION 7. 
 Of Crotchets, and their Use. 
 
 Crotchets were formerly employed in almost all the cases that are 
 now happily terminated by means of the forceps, and in an infinity 
 of others, which, by means of turning, or the skilful use of the hand, 
 are capable of being brought to a favourable conclusion ; but their 
 employment becomes more and more rare, as the knowledge of 
 obstetrics extends, as well as that of all the other destructive in- 
 struments which were so much abused by the ancients. 
 
 1168. Crotchets are of two kinds: one, terminated by a blunt 
 and rounded extremity, or else of an olive shape, and more or less 
 bulbous, which are proposed as substitutes for the fingers or (lie 
 fillet, do not divide the parts of the child, and are applied either 
 while it is living, or after its death, upon different parts of its body. 
 They are constructed of various forms. It has been recommended 
 that they should all be replaced by the one which terminates the 
 handle of the modern forceps ; but the best ones consist of a long 
 piece of steel, supported by a wooden handle, and curved into an
 
 THE CROTCHET. 525 
 
 arc of a circle, the sinus of which is sufficiently open to embrace 
 without difficulty the groin, the ham, or the axilla ; when only bent 
 at a right angle, as advised by Madame Lachapelle, they slip too 
 readjlv ; if bent into the shape of the letter S, or contracted in too 
 acute an angle, they will not fit accurately to the part on which they 
 may have to be applied ; Baudelocque, Steidele, and most of the 
 accoucheurs of the present day, have imagined that the two blunt 
 crotchets of the forceps might be united, so as to form a pincers 
 with a curved end, and to be applied to botli groins at once ; but 
 it does not appear that such a modification can ever be wanted. A 
 single branch commonly suffices, and, with the exception of a few 
 cases, the fingers are a very good substitute. The utility of the 
 blunt crotchet, however, can scarcely be doubted when from 
 any cause whatever the head has been separated from the trunk, 
 which cannot be extracted except by acting upon the axilla ; m such 
 a case, as in breech and knee positions, the only rule that it is im- 
 portant to follow is, always to act upon the bend of the limb that 
 looks to the back part of the woman's pelvis, and in drawing down, 
 not to lose sight of the axes of the pelvis. 
 
 1169. The point of the sharp crotchet is sometimes round, as in 
 the olive of the forceps, sometimes flat and triangular, as in Mauri- 
 ceau's and most of the ancient instruments, so that the entire instru- 
 ment is nothing more than a cephalotome with a bent blade. 
 This point, which is single in some and in others double, may be 
 continuous with a straight or with a curved stem, or it may resem- 
 ble a hook of a chain, of greater or less length, like what is seen in 
 Scultetus's Armamentarium; the point, which in most of the speci- 
 mens is fixed, may however bend, and also open as in the instruments 
 of Aitken and Saxtorph. Forceps or pincers with sharp crotchets 
 have also been constructed; Mesnard, Levret, Smellie, Baudelocque, 
 and many others have boasted of the value of the crotchet-forceps, a 
 model of which is to be seen in the Museum de la Faculte", and which 
 are nothing more than Smellie's small forceps without fenestres in the 
 blades, which are terminated by a triangular, sharp and bent point. 
 The forceps with wolf-teeth of Avicenna, and the dentated pincers 
 of Rueft' ought also to be classed among the sharp crotchets. 
 
 ^1170. After the performance of craniotomy, if the powers of na- 
 ture are insufficient, Burns thinks that we ought to wait twenty-four 
 hours before we resort to the triple forceps of Levret, and more es- 
 pecially to the sharp crotchet ; he founds this doctrine on the circum- 
 stance, that the foetus, passing rapidly into a state of putrefaction, 
 softens, and becomes much easier to extract the longer we wait, 
 even admitting that it shall not be spontaneously expelled. 
 
 This practice, although recommended by Kelly, M'Kenzie, Den-
 
 526 THE CROTCHET. 
 
 man, Osborn, Boer, Simson and Asdrubali, does not appear to me 
 to be one that ought to be followed ; I agree with M. Duges that 
 it is useless to protract, in this way, the patient's anguish ; and be- 
 sides, a labour that is already tedious cannot be with impunity pro- 
 tracted for twenty-four or forty-eight hours longer ; and were there 
 no other reason than the necessity for renewing the preparations for 
 a forced delivery, which are always frightful, it ought to be rejected. 
 
 1171. The sharp crotchet is to be applied to one of the most 
 solid parts of the cranium, for example, to the occiput or the 
 mastoid process, when the head comes foremost ; upon the lower 
 jaw, in the orbit, or upon the forehead, when it descends after the 
 trunk ; in short, in such a way as to prevent, as far as possible, the 
 occipito-mental diameter from abandoning the line of the axes of 
 the pelvis, and to retain it in its natural state of flexion. It may 
 also be applied inside of the cranium, by fixing it on the petrous 
 portion or the basilar apophysis ; but in that case it is of essential 
 importance that it shall not slip, that it shall not act upon one of the 
 bones of the vault of the cranium, for by pulling them downwards 
 it might pass through them and injure the organs of the woman. 
 Like the perforator, the sharp crotchet ought never to be plunged 
 into the foetus without being guided, in some sort protected, or even 
 covered by the accoucheur's finger ; when fixed either on the in- 
 terior or exterior of the cranium, the stem must be supported by 
 the thumb, while the fingers remain firmly applied to the opposite 
 side of the head, and the other hand applied to the handle exerts 
 the requisite extractive power. In this way it cannot let go its hold 
 without the accoucheur's perceiving it at once ; both the hands also 
 act in concert, their efforts may be exactly combined, and the oper- 
 ation ceases to be dangerous. There is no longer any danger of 
 those dreadful slips, which chance alone could prevent, when the 
 operator is so rash as to pull, blindfold as it were, with a single in- 
 strument. 
 
 1172. When one of the bones breaks or gives way, the crotchet 
 must be again applied, upon a firmer part. Some advise that the 
 point should be directed in front towards the pubes. Others have 
 directed it to be applied behind, for the purpose of more easily 
 drawing the head down through the superior strait ; but it is not 
 easy to lay down general rules on this subject ; we must act in either 
 way, according to circumstances. Should the head rise up again, 
 strongly, whenever we cease to pull with the crotchet fixed at 
 the back part, it would be well to follow M. Duges's plan and fix 
 a second crotchet in front, while the head continues to be held down 
 with the first ; this may be got higher up, or a third instrument may
 
 THE CROTCHET. 527 
 
 be attached, while the head is kept as low down as possible with 
 the others. 
 
 To force the base of the cranium to clear the superior strait, we 
 sometimes meet with obstacles that are excessively difficult to over- 
 come. The bones of which it is composed do not bend like those 
 of the vault of the cranium, and the crotchet is quite as incapable 
 of lessening its size as the forceps ; it is only by engaging it in an 
 oblique direction that we most generally succeed in extracting it 
 in cases where the antero-posterior diameter does not exceed two 
 inches or two inches and a quarter. 
 
 Perhaps the terebellum of M. Duges might be beneficially em- 
 ployed in such cases as these : this is a sort of cooper's-turrel, which 
 is capable of perforating the bones and cartilages, of breaking up 
 the base of the cranium so as to render it flexible, and of acting as 
 a substitute for most of the cephalatomes. 
 
 1173. M. Baudelocque, Jun. has lately constructed a forceps, 
 the object of which is to overcome all these difficulties, and to ren- 
 der all the perforators and most of the sharp crotchets superfluous. 
 The clams of this forceps are not fenestrated, and are but slightly 
 curved ; so that by being closed they may pass through a strait that 
 does not exceed fifteen lines in its small diameter; through the 
 handles of the instrument passes a screw, which enables them to 
 be closed with such force that the head of the foetus will be easily 
 reduced to any desirable dimensions without exposing the woman 
 to the least risk. This instrument appears to me to be an ingenious 
 one ; but previously to forming a decided opinion concerning it, I 
 should like to have an opportunity of seeing it employed in a case 
 of labour. 
 
 1174. However, when the base of the cranium has reached the 
 excavation, the head may be taken hold of with the hands, and the 
 crotchet is of no further use, unless it should be applied to the trunk, 
 supposing, moreover, that the blunt crotchet when applied to the 
 axilla? should prove incompetent to the extraction. 
 
 In this, as in all cases where the head is completely separated 
 from the body, there are only three points upon the trunk which 
 can bear the action of the sharp crotchet: these are the spine, 
 the sternum, and the ribs, and even the latter is a very insecure 
 hold, so that the whole of the ribs of one side are sometimes found 
 to give way one after the other, as soon as a certain degree of 
 extractive force has to be employed. It is therefore particularly 
 upon the vertebral column that we should endeavour to fix the point, 
 and then act as we should have to do provided it were attached 
 upon the head.
 
 b 
 
 528 THE CROTCHET. 
 
 1175. There is one single circumstance which seems tome to 
 require the use of the sharp crotchet upon the trunk in a pelvis pre- 
 sentation ; it is where the lower limbs have been separated from the 
 body, or where they are wanting in consequence of monstrous con- 
 formation, or where they do not admit of a hold being taken, suffi- 
 ciently firm to pull the body down by them. In such cases the 
 crotchet should be applied to the pubis, the crista of the ilium, or 
 what is still better, to the sacrum. 
 
 SECTION 8. 
 
 Of the Extraction of the Head when it has been left alone in the 
 Genital Passages. 
 
 1 176. When the head is separated from the trunk, and left in the 
 pelvis, it almost always happens in consequence of its being badly 
 situated at the superior strait, or because the accoucheur was not 
 skilful enough to disengage it in time : in this case the detachment no 
 sooner takes place than the head becomes in some sort movable in 
 the womb, which soon brings it to the best possible situation ; a few 
 pains then succeed in expelling it, and the assistance of art is, for the 
 most part, unnecessary. In other cases the detruncation of the foetus 
 takes place because, having been dead for some time, it is already 
 nearly in a putrid state. If we wait for a short time, under these 
 circumstances, the brain shrinks, the bones of the cranium become 
 very movable, may over-ride each other, and although at first the 
 pelvis might have been too narrow, the head nevertheless escapes 
 spontaneously at last ; upon these results, and also upon the evils 
 that have often been found to follow upon unskilful attempts to 
 hasten the delivery, the English practitioners cited above found the 
 precept, that the expulsion of the head should be confided to the 
 powers of nature alone ; but as the labour has already lasted too 
 long, and as in some instances it would be necessary to wait several 
 days ; as the extreme irritation of the uterus would expose it to the 
 hazard of becoming inflamed, and the woman might die of exhaus- 
 tion before the escape of the head, it would be imprudent and unrea- 
 sonable not to give proper assistance. We ought not, says M. Des- 
 ormeaux, to act with inconsiderate haste ; there are cases where it 
 is proper to temporise ; it may be necessary to restore the strength 
 by means of some aliment, a little wine, or other strengthening arti- 
 cles. Baths and antiphlogistic?, &c. may be required previously 
 to any other recourse, in consequence of an incipient inflammation 
 of the womb, or peritoneum, &c.
 
 EXTRACTION OF THE HEAD. 539 
 
 In cases where the hand alone may suffice, that is to say, where 
 the head is small, or requires to be placed in a better situation for 
 descending, an attempt should be made to get hold of the lower 
 jaw ; then, after having brought the occipito- mental diameter into 
 line with the axes, it should be drawn down as far as possible, coin- 
 cidently with the efforts of the womb or those of the patient. 
 
 Next to the hand the forceps is the best and safest resource that 
 we have ; but it is not always possible to apply it, while the head is 
 still at the superior strait, and in some cases its employment does 
 not always obviate the necessity of having recourse to craniotomy, 
 or even to the sharp crotchet. It is true, that for the purpose of 
 avoiding the latter measures, a great variety of extractors (tire- 
 tetes) have been proposed ; but none of them can be regarded as 
 good substitutes. The double cross of Bacquie, the bascule of 
 Levret, the basiocester of Metzler, the sling of Mauriceau, the T 
 of Stein, the nets of Amand, the cap proposed by M. Desormeaux, 
 Sen. the forceps with three branches of Levret, the small piece of 
 stick, to the middle of which is attached a string, or the one made 
 of iron fixed to the end of the metallic rod in such a way that it 
 may be introduced parallel to the rod, and after reaching the in- 
 terior of the cranium, be altered so as to stand crosswise to it, the 
 invention of which is attributed to Danavia, and also to Assalyii, 
 and which has been too much praised by many authors ; all of these 
 means have ceased . to be made use of at the present day. The 
 crotchet planted somewhere near the occipital foramen, in the up- 
 per jaw, or in some other firm part, whilst the opposite part of the 
 head is supported with the fingers, is in this, as in some other cases, 
 the last resource ; but, nevertheless, it forms the only really effi- 
 cient extractor in all cases where the hand, the common forceps, 
 the toothed forceps, the extracting forceps with three branches, or 
 the crotchet forceps, or the forceps of M. Baudelocque, Jun. are 
 cither inapplicable or insufficient for the delivery of the head. 
 
 3R
 
 530 
 
 CHAPTER VII. 
 
 Of the Natural Phenomena which follow the Delivery 
 of the Foetus. 
 
 ARTICLE I. 
 Of the delivery of the *flfter-birth. 
 
 The placenta and the membranes are, after the birth of the child, 
 called the after-birth, and their expulsion, escape, or extraction is 
 (in France) called Delivery. Like child birth, this is a natural 
 function ; and like it, this function may also be simple or complex, 
 or, if the expression be preferred, natural or preternatural, spon- 
 taneous or artificial. 
 
 SECTION 1. 
 Of simple or natural delivery of the After-birth. 
 
 All the phenomena of simple delivery are referrable, 1 . To the 
 detachment of the placenta; 2. Toils expulsion from the genital 
 organs. 
 
 1177. First stage. The ovum becomes detached during the 
 progress of a labour, and especially towards the conclusion, when the 
 waters have gone off. Being in some sort an inert mass, its adhe- 
 sion must necessarily be destroyed during the alternate contractions 
 and dilations of the womb, unless the labour be so prompt as to 
 require almost no effort of the organism, or unless there be some 
 preternatural adhesions. 
 
 The cause of this detachment is found in the entire uterus, and 
 
 not merely in the orbicular muscle which Ruysch supposed he had 
 
 vered. Sometimes the d< :t;i< luncut lakes place in such a way 
 
 that th" in t;il surface of the placenta presents first at the vulva, and 
 
 the blood, either fluid or coagulated, collects behind the spongy sur-
 
 TABLE IV. 
 
 Labours observed by MM. BLAND, MERRIMAN, DEWEES, ARNELL, 
 MOORE, NCEGELE, BOER, Mesdames Boivm and LACHAPELLE, 
 and at the Dublin Lying-in Hospital. 
 
 
 
 Number 
 of Children. 
 
 Twins. 
 
 Triplets. 
 
 Four 
 at a Birth. 
 
 
 | 
 
 
 
 4 
 "2 
 
 5 
 
 o 
 
 <u 
 Q 
 
 Messrs Dewees, Ar- 
 nel and Moore. 
 
 Madame Boivin. 
 Merriman. . . . 
 Dublin Hospital. 
 Madame Lachapelle. 
 Nojgele 
 
 about 
 35,000 
 
 20,517 
 1,813 
 106,766 
 37,895 
 415 
 
 15,608 
 or 
 6,555 ca 
 
 about 
 200 
 
 153 
 22 
 2,110 
 444 
 6 
 
 Uncer. 
 in 
 ses 92 
 
 Only 
 1 
 
 3 
 1 
 26 
 5 
 1 
 
 1 
 
 Uncer. 
 Uncer. 
 929 
 55,804 
 19,474 
 199 
 Uncer. 
 Uncer. 
 
 Uncer 
 Uncer 
 884 
 50,962 
 18,421 
 216 
 [Jncer. 
 Uncer. 
 
 Uncer. 
 Uncer. 
 Uncer. 
 
 9,497 
 2,291 
 31 
 Uncer. 
 463 
 
 Boer 
 
 
 Total. . 
 
 224,569 
 
 3,027 
 
 37 
 
 1 
 
 76,406 
 
 70,483 
 
 12,282 
 
 Thus there were 3027 twins, 37 triplets, and only one case where 4 children 
 were produced at a birth in about 200,000 births. 146,889 yield 76,406 boys 
 and 70,483 girls; and out of a total of 160,269 children, 12,282 were born dead ; 
 M. Schweighauser reports a second case of 4 at a birth ; the public papers hare 
 mentioned a third instance in France of late years; Merriman speaks of a fourth, 
 which occurred in Worcestershire, in 1820 ; and Osiander says, according to a 
 letter, that a woman was delivered of 5 living children near Oporto in 1788.

 
 DELIVERY OF THE AFTER-BIRTH. 531 
 
 face of the cake, which is concave, like the bottom of a bottle ; 
 sometimes it is effected gradually, proceeding from the centre to 
 the circumference, or it may begin on the edge, and if the involucra 
 resist long, the smooth or internal surface may become the outer 
 one, and the blood being confined on the outside of the membranes, 
 does not escape until after the expulsion of the after-birth, the size 
 of which it sometimes surprisingly augments. 
 
 At other times, in detaching itself, the placenta rolls up in the 
 shape of a cylinder or cornet d'oublie. In that case it presents by 
 its uterine surface or by its edge to the several passages ; the blood, 
 not being confined, flows out at the vulva as fast as it is poured into 
 the womb, and commonly ceases to 'flow as soon as the placenta is 
 delivered. 
 
 Second stage. When once detached, the placenta presses upon 
 the os uteri, engages in the orifice, which it irritates, and the womb, 
 which is irritated by its presence, becomes more and more constrict- 
 ed, contracts, and soon forces it to pass into the vagina. When 
 there, it soon gives rise to a sensation of uneasiness, tenesmus, or 
 bearing down, which still solicit the contractions of the womb, and 
 bring into play the efforts of the abdominal muscles. The diaphragm 
 and muscles of the belly react upon the abdominal viscera and 
 womb, as if for the expulsion of the foetus, and the placenta clears 
 the inferior strait. 
 
 Some persons, and among them M. Desormeaux, divide this pe- 
 riod of expulsion into two stages. It is true, that in order to pass 
 from the womb into the vagina, the after-birth sometimes requires 
 so considerable a degree of dilation of the os uteri, that a particular 
 stage might be made of it, and that it may afterwards remain so 
 long in the passage that its entire expulsion really constitutes a dis- 
 tinct period ; but as these two stages are far from being always so 
 distinctly marked, it appears to me that they may without inconve- 
 nience be confounded together. However, this is an affair of choice, 
 not of necessity. 
 
 If the labour have been a long one, if the woman be strong, if the 
 means of art have been applied for the extraction of the child, and if 
 the womb be in a state of considerable energy, the placenta falls into 
 the vagina and presents itself at the vulva almost immediately after 
 the delivery of the child. In opposite cases, the delivery of the 
 placenta does not take place for half an hour, and sometimes even 
 for several hours. It may also happen, that it shall not take place 
 for a whole day, or even for several days. This difference is easily 
 explained : in the first case, the ovum which has been long detach- 
 ed descends whole, along with the fcetus. The wornb, contracting
 
 532 DELIVERY OF THE PLAGENTA. 
 
 strongly in proportion as it empties itself, simultaneously throws 
 out both the child and placenta. In the second, the promptitude of 
 the delivery of the child is so great, that the womb has not had time 
 to break up the adhesions of the ovum, or to contract sufficiently. 
 Until the cavity of the womb becomes so diminished that the after- 
 birth fills it quite up, it may remain above the orifice. When the 
 child has just passed through the os uteri, provided the placenta be 
 <letached at the time, and urged onwards by the uterus, nothing can 
 prevent it from descending; but if the orifice closes before the body 
 of the organ becomes reduced in proportion, the after-birth remains 
 shut up as it were in the uterine cavity, and cannot escape for a 
 considerable length of time, although its adhesions may have been 
 broken up from the beginning. 
 
 1 178. Although the organism generally suffices to finish the ex- 
 pulsion of the after-birth when it has reached the excavation, some 
 cases are, however, observed in which it would remain there for an 
 indefinite period, provided its escape were not promoted by artificial 
 means. It is on account of this tedious slowness, and to relieve 
 the woman of her fatigue and uneasiness of mind, that a natural or 
 simple case of delivery of the placenta is scarcely ever wholly aban- 
 doned to the efforts of nature. De la Motte, Deventer, Peu, and 
 some modern authors, are scarcely willing that we should wait for 
 it for half an hour: according to them, if we do not act at once, the 
 orifice closes, and may retain the after-birth, from whence accidents 
 of greater or less severity may ensue. Levret and Smellie, Baude- 
 locque, and almost all practitioners of the present day, advise us, 
 on the contrary, not to act until the placenta is completely detached, 
 and presents itself spontaneously at the orifice of the womb. 
 
 Both of these doctrines, if taken according to the very letter, ap- 
 pear to me to be equally incorrect. The practice of the ancients, 
 if followed without exception in all cases, would doubtless some- 
 times be dangerous; but I am induced to believe that at the present 
 day we have fallen into an opposite extreme ; by endeavouring to 
 follow nature as closely as possible, the end which the accoucheur 
 ought to hold in view has been lost sight of. 
 
 Besides, if it is proper to act as soon as the placenta is detached, 
 I do not see wherefore the delivery should be so frequently deferred; 
 for except in a few cases, this detachment takes place previously to 
 the expulsion of the child. I can scarcely conceive, indeed, how 
 the womb can be reduced to a fourth or fifth part of its volume, 
 without destroying the delicate filaments which connect it to the 
 ovum. Most of the facts that are cited to show that the adhesions 
 of the placenta continue to exist after the birth of the child, are any
 
 DELIVERY OF THE PLACENTA. 533 
 
 thing rather than conclusive, and do not seem to have been properly 
 interpreted. 
 
 I know that when the cord has been pulled at an improper time, 
 it has been found to occasion the inversion of the womb; but, in the 
 first place, this accident is a very rare one ; and next, it does not 
 prove that the union of the placenta and womb was maintained at 
 the time; for, if such tractions are performed while the womb is soft 
 and uncontracted, whether the adhesions of the placenta be contin- 
 ued or not, they occasion the woman to bear down, and it is very 
 natural that the womb should then be inverted. The cord has often 
 been pulled so as to break it off, so as to give pain to the woman, 
 and make her feel a dragging sensation within, and the placenta, 
 notwithstanding, has not been moved at all. All this is doubtless 
 true ; but without speaking of the pretended uterine crisis which 
 have formerly been so much spoken of, does the womb never con- 
 tract, except in a regular manner, upon the secundines ? Does it not, 
 on the contrary, mould itself, in some sort, upon the anfractuosities 
 of the placenta, so as to make its extraction somewhat difficult ? 
 and then, are we sure that the extracting force has been applied in 
 the best possible direction, and exactly to the proper extent ; have 
 not the faults of the accoucheur been most commonly attributed to 
 the adhesion of the placenta ? In my amphitheatre I have many 
 times seen the students leave off pulling at the cord from a convic- 
 tion that the placenta was not detached, whereas I had only to pull 
 in a rather more methodical manner than they did, in order to termi- 
 nate the delivery at once, and without difficulty, in their presence. 
 In a woman who came to be delivered at the Hospital de TEcole, 
 and who had a flooding, the cord had already been pulled so as to 
 break it off. I introduced my hand into the womb and found no 
 adhesion at all. Being called to visit a woman, in the Rue de la 
 Montagne-Sainte Genevieve, whose child had been born six hours, 
 I learned that all imaginable efforts had been made to bring away 
 the placenta. The physician had asked for assistance only because 
 he was convinced that the hand must be introduced into the womb 
 in order to destroy the adhesions of the placenta. He repeated his 
 attempts in my presence, and I soon found he would not succeed. 
 I now took hold of the cord, and found that there was no particular 
 difficulty in bringing away the after-birth. I have so frequently 
 met with these cases of supposed adhesion; I have so often intro- 
 duced my hand into the uterine cavity with the design of destroying 
 them, when I was informed that they existed, and when in fact they 
 had no existence ; and from reasoning it is so difficult to admit them, 
 that I do not hesitate to look upon their occurrence as very rare.
 
 534 DELIVERY OF THE PLACENTA. 
 
 How can we conceive, in fact, that they could give way so easily 
 under the feeble contractions that take place after the expulsion of 
 the child, after having resisted the violent efforts of the close of the 
 expulsive stage of the labour ? 1 believe, therefore, that if it is not 
 prudent to deliver the after-birth immediately after the escape of the 
 child, we ought to look for another reason for the caution, than the 
 non-detachment of the placenta; that the object of the uterine con- 
 tractions and their effect is far more to push this body gradually 
 through the os uteri and into the vagina, than to break up its union 
 to the womb ; that it is not indispensably necessary for the woman 
 to have colic pains and dragging sensations in the loins before the 
 accoucheur delivers her; and that there are some disadvantages in 
 not acting as soon as a favourable opportunity presents itself. 
 
 Being (in 1823) still imbued with the prevailing ideas upon this 
 subject, I used to wait till pains came on before I proceeded to act, 
 and I stopped as soon as 1 perceived the slightest resistance ; and 
 in the short space of six months I was obliged to wait, on one oc- 
 casion ten hours, on a second twenty-four, on a third thirty-six, and 
 on a fourth forty-eight hours, before the placenta was delivered, and 
 in the last case, was even obliged after all to introduce the hand in 
 search of the placenta. Since that time I have never been obliged 
 to wait more than one hour : for me it suffices when the womb has 
 contracted and become hard, even although the woman have felt no 
 pain, nor dragging sensation, and up to the present time I have had 
 good reason to be satisfied with my mode of proceeding. 
 
 1179. Thus, after having given the first necessary attentions to 
 the child, we return to the mother, and if the hand applied to the 
 hypogastrium feels the womb contracted with a certain degree of 
 force, we assist the delivery of the placenta ; when the uterine 
 globe does not form, we ought to wait, or make use of the measures 
 proper to remove inertia. 
 
 To favour the expulsion of the after-birth, the cord is to be taken 
 hold of with the right hand, twisting it round the root of the mid- 
 dle and ring fingers, and then bringing it betwixt the thumb and 
 index finger ; or it is merely taken hold of with the hand after 
 being wrapped in a piece of linen, and, always, as near as possible 
 to the vulva ; two or three fingers of the left hand are then to be 
 slipped into the vagina, passing them up under the symphysis of the 
 pubis to the orifice of the womb, or as far as the root of the cord ; 
 as these fingers are to form a sort of gutter or pulley, I prefer 
 three rather than only two fingers, because as the rnedius forms the 
 bottom of the groove, the index and annularis easily prevent the 
 <-<ml from slipping ofl' to the right or loft, whereas, if only two are
 
 DELIVERY OF THE PLACENTA. 535 
 
 made use of, the cord almost always separates them, and therefore 
 it would be quite as well to place them crosswise, in the upper part 
 of the vulva, as is the practice with some persons. 
 
 The way to derive the greatest possible advantage from them is 
 to pass them up as far as the foetal surface of the placenta, even 
 should that be above the os uteri, and then make them act like a 
 lever of the first kind. The back of them rests against the top of 
 the pubic arch, and while the other hand is drawing the cord along 
 the axis of the inferior strait, they are pressed against the root of 
 the cord ; then by a sort of see-saw motion, communicated by 
 the gradual raising of the wrist, they force the placenta along from 
 above downwards and from before backwards, towards the point of 
 the sacrum, and in the axis of the superior strait. 
 
 This stage of the operation is the most delicate, the most impor- 
 tant, and most difficult to perform well. The womb is sometimes 
 so bent forwards that if the fingers do not push the cord almost 
 directly backwards, the placenta remains immovable ; at other times 
 they must be directed a little to the left or right, because the os 
 uteri is deviated more or less to one side or the other ; the axis of 
 the womb, besides, presents a thousand shades which it would be 
 necessary to apprehend, and which practice alone can enable one to 
 recognize. This is the reason why a delivery deemed by one ac- 
 coucheur to be impossible, will often be quite a simple case to 
 another person ; and why this operation, in appearance so easy and 
 unimportant, deserves, notwithstanding, the most minute attention 
 from those who desire to perform it well. Should the pulley (com- 
 posed of the ends of the fingers) be not well placed ; should the 
 lever represented by the fingers not be well situated, or not act pro- 
 perly, the after-birth, from being arrested by the upper edge of the 
 pubis or the posterior surface of the symphysis, would not come 
 down ; the whole of the power would be directed upon the root of 
 the cord, which would certainly break, or upon some part of the 
 uterine orifice, whence that dragging and pain which give rise to the 
 idea of preternatural adhesions. 
 
 Be this as it may, when the placenta has come down into the 
 vagina, the fingers of the left hand should be continued in the same 
 situation they occupied before, but merely so as to favour the escape 
 of the membranes which might not have cleared the os uteri, and 
 to form a sort of inclined plane, along the inferior surface of which 
 the whole after-birth might glide while pulled by the right hand 
 along the axis of the inferior strait. In this way the hand that holds 
 the cord may be raised upwards without fear of being embarrassed 
 by the pubic arch, and we avoid being stopped by the inferior sur-
 
 536 DELIVERY OF THE PLACENTA. 
 
 face of the perineum ; which is an inconvenience frequently met 
 with when the placenta is pulled along in what is properly called 
 the axis of the strait, rather than in that of the vulva. 
 
 As soon as the after-birth appears at the vulva, the left hand is 
 placed underneath it, crossways, and supine, in order to sustain it ; 
 the right hand, in pronation, takes it with the ends of all the five 
 ringers, and rolls it four or five times round, drawing it moderately 
 and slowly downwards ; without these rotatory motions the mem- 
 branes might separate from the placenta, and remain within the 
 female organs, while if twisted in this way they are collected to- 
 gether and resemble a rope, and become easy to extract. 
 
 During these various maneuvres, the womb rarely fails to contract 
 with more or less force, and seems to assist the accoucheur ; the 
 woman herself is generally induced to make some efforts as soon as 
 the womb has descended into the vagina, and these efforts, rigo- 
 rously speaking, would suffice to terminate the delivery, provided 
 they always took place ; but, in reality, they are not very necessary, 
 and may often be injurious : they only favour the expulsion of the 
 placenta indirectly, and are capable of directly producing the descent 
 or inversion of the womb ; the woman ought therefore to be urged 
 to moderate rather than enforce them ; it would not only be useless 
 or ridiculous, but also in some cases very dangerous to administer 
 sternutatories, or advise her to blow into a bottle, or in her hands, 
 or on to a grain of salt to hasten the delivery ; for if ever such mea- 
 sures have any effect, it is merely by occasioning certain succussions, 
 or those straining efforts that I just now was condemning. 
 
 The extracting force necessary in this operation ought never to 
 be carried so far as to rupture the cord : if the placenta resists, the 
 cause of it ought to be sought for in the direction of the orifice, its 
 closure, &.C.; we should wait, or else pull in another direction, and 
 be assured that force is never necessary to enable us to triumph 
 over such obstacles. 
 
 1 1 80. It is recommended that the after-birth should be examined 
 as soon as it is delivered, to make sure that no part of it is 
 left within the genital organs : it will be well to follow this advice, 
 no doubt, whenever the delivery has been attended with some diffi- 
 .culty, or any peculiar circumstances ; but in other cases, it would 
 be puerile to trouble ones-self about it, especially, considering that 
 even should some small pieces of the placenta or shreds of mem- 
 branes be left in the womb, we should not be authorized oh that 
 account to introduce the hand in search of them.
 
 COMPLICATED DELIVERY OF PLACENTA. 537 
 
 SECTION 2. 
 Complicated Delivery of the After-birth. 
 
 Inertia, hemorrhage, convulsions, syncope, the rupture of the 
 cord, preternatural adhesions, an encysted state of the placenta, ex- 
 cessive size of it, and a spasmodic contraction of the os uteri, consti- 
 tute a number of accidents which sometimes complicate the delivery, 
 and require that we should hasten or protract the term of its ex- 
 clusion. 
 
 1181. Inertia of the womb, after delivery of the child, is more 
 particularly observed to happen in women who are weak and ex- 
 hausted by flooding or the fatigue of a protracted labour ; it is also 
 met with after too sudden a delivery of the child, and in these 
 different cases it requires a caution which is peculiar in each. Some- 
 times the proper remedy is a little good wine, sometimes a little 
 light and analeptic aliment, at others rest ; but it is always useful to 
 excite the womb through the epigastrium, by rubbing and pressing 
 it with the ends of the fingers, and even by compressing it with a 
 certain degree of force, alternately from above downwards, from 
 side to side, and from before backwards, as if with a view to mass 
 it, and oblige it to contract its dimensions. Pulling at the cord, if 
 attempted previously to the cessation of the inertia, would hazard 
 the production of an inversion of the womb less, perhaps, in conse- 
 quence of any remaining adhesions of the placenta than from the 
 direct pressure of the abdominal viscera upon a soft and contracted 
 bag ; transmitted to the internal surface of the gestative organ, they 
 might, also, invite an aftluxion of blood to it, and give rise to 
 hemorrhage. They must therefore be dispensed with, unless some 
 serious accident obliges us to act otherwise. Thus, inertia of the 
 womb ought to be classed among the complications which retard 
 the delivery of the placenta. 
 
 1 182. The volume of the after-birth is in some instances the only 
 cause that retards its expulsion. But this excess of size is often 
 more apparent than real, and depends on the blood being amassed 
 behind the membranes. Where the placenta is really too large, 
 moderate and skilful tractions almost always suffice ; if not, we must 
 wait, and the natural retraction of the uterus at last renders its ex- 
 traction easy. In the second case, which is the most common, if 
 the contractions of the womb and force carefully exerted upon the 
 cord are inefficacious, the membranes may be torn, or the placenta 
 
 3S
 
 538 COMPLICATED DELIVERY OF PLACENTA. 
 
 itself perforated with the fingers, and a passage made for the fluids 
 behind them. 
 
 We should, moreover, have reason to suspect the existence of this 
 state of things should the womb be found to preserve a larger size 
 than common above the pubis, although not deficient either in firm- 
 ness or energy ; were the after-birth already in the vagina, the diag- 
 nosis, and the application of suitable means would be too easy to be 
 spoken of at greater length in this place. Upon the whole, exces- 
 sive volume of the appendages of the foetus scarcely constitutes one 
 of the accidents of delivery, unless, indeed, it be coincident with 
 some other complication. 
 
 1183. I may say the same of the spasmodic contraction of the os 
 uteri. In fact, it is difficult to conceive that an opening, through 
 which a child has just passed, can contract spasmodically to such a 
 degree as to oppose the escape of the placenta. To admit such an 
 obstacle, we ought, which is not the case, to have some very authentic 
 instances of the kind. Besides, as it is not a part of the nature of 
 spasm to persist, we might, should such a case occur, refer it to the 
 effect of time, and content us with administering some composing or 
 antispasmoclic medicines, according to circumstances. 
 
 1 184. It is evidently the natural, but somewhat precipitate closure 
 of the os uteri, which has been qualified as the spasmodic contrac- 
 tion : considered under this point of view it is a circumstance de- 
 serving of attention. When the delivery of the child is completed, 
 the os uteri in general contracts more speedily than the body of the 
 organ, and if in this case we endeavour to deliver the woman before 
 the fundus is prepared to overcome the resistance of the orifice, the 
 placenta passes through it with difficulty, which may induce a belief 
 that it is spasmodically contracted. 
 
 A bleeding from the arm where the woman is strong, and there 
 are any signs of irritation ; emollient or slightly narcotic injections; 
 the belladonna ointment, or even a bath, if she is very nervous, not 
 strong, or has a vivid sensibility of the sexual organs, and there 
 are any indications of the approach of convulsions or flooding ; 
 patience, and gentle frictions upon the hypogasirium, should no acci- 
 dents appear ; such are the measures that may be required by such 
 a state as we have indicated : it is only when pressing and grave 
 circumstances arise, that we are allowed to introduce a finger into 
 the orifice to dilate it, while with the other hand we pull gently at 
 the cord. 
 
 1 185. The encysted state of the placenta, which Solinger calls 
 hernia of the after-birth, has not been understood in the same man- 
 ner by the different authors who have spoken of it ; Levret never
 
 ENCYSTED PLACENTA. 539 
 
 saw but one case of it, to which he was called by a midwife, who 
 supposed she was treating a case of rupture of the womb. According 
 to that author the encysted state of the placenta is occasioned by 
 that portion of the womb which corresponds to the placenta remain- 
 ing in a state of inertia, whilst the other parts of the organ contract 
 with more or less force after the birth of the child. Simson, on the 
 contrary, attributes it to the simple tendency of the womb to recover 
 its primitive shape, a tendency which causes the internal orifice to 
 produce, instantly, a real strangulation, above which is found the 
 after-birth enclosed within the cavity of the body, as if it were in a 
 small cell, while the cavity of the cervix remains open below. 
 Plessmann has reproduced the idea started by Levret, but he has 
 modified it : according to his view the womb must be much more 
 highly irritated at those points which press directly upon the foetus 
 than those which only touch it through the placenta during the 
 efforts of labour ; whence it follows that the former contract sooner 
 than the latter, and the formation of a separate sac for the after-birth 
 is very easy to understand. Peu seems to think that the encysting 
 depends upon a peculiar conformation of the uterus ; Leroux and 
 Kok, that it most frequently depends upon the rupture of the ner- 
 vous filaments, which occasions an afflux of humours, and, in con- 
 sequence of that, a spasmodic contraction of some portions of the 
 organ. All these explanations may be true in some particular cases; 
 but Baudelocque prefers Simson's theory ; M. Desormeaux, resting 
 on a fact related by Meyeld, seems to be not far from adopting, at 
 least in part, the view taken of the subject by Levret and Plessmann. 
 An encysted state of the placenta is always the result of irregular 
 contractions of the womb, after the escape of the foetus, but I do 
 not think that these contractions can be explained upon the hypo- 
 theses of Simson, Levret, &c. In a woman to whom I was called 
 by Madame Bevalet, the internal orifice of the cervix offered but a 
 feeble resistance, whereas, a little higher up, I found a very decided 
 constriction, and after penetrating into a cavity situated to the left 
 of the womb, in which cavity a greater part of the placenta was 
 contained, I was obliged to pass through another stricture, to get 
 to the fundus and right side of the organ, where the remain- 
 der of the after-birth was retained. In another woman who 
 died at the Hospice de UEcole, I found the uterus so mould- 
 ed upon the placenta, that it was divided, as it were^ into 
 five shallow cells, and which evidently depended upon the pro- 
 tuberances formed by the corresponding cotyledons of the after- 
 birth. If the placenta were solid and even, like the head, the womb 
 in contracting would necessarily retain the form of an ampulla ; but
 
 540 COMPLICATED DELIVERY OF PLACENTA. 
 
 the cotyledons in the process of the detachment may separate from 
 each other, and the placenta would then offer more resistance in 
 some parts than in others ; so that the uterus soon divides into 
 several compartments or divisions more or less distinct from each 
 other, in the same way as it is found to accommodate itself to the form 
 of the head, of the shoulder, the breast, the pelvis, and all the pro- 
 jecting or contracted parts of the foetus, after the liquor amnii has 
 been evacuated. Besides, what accoucheur of any experience 
 has not had an opportunity of observing, through the abdominal 
 parietes, the womb tuberculated, more or less uneven or elongated, 
 and not always globular or round, as it is too generally said to be. 
 
 1 186. However it may be, the cyst may be formed by the fun- 
 dus of the uterus, as supposed by Simson and Baudelocque, and 
 then the organ approaches more or less to the shape of a calabash ; 
 sometimes, on the contrary, it is found to be upon one side, as was 
 observed by Levret ; and, again, in front or to the rear, and at 
 points of different height. Le Roux says that in one instance the 
 placenta was encased in the fundus of the womb like a watch-glass 
 in the lid. But such a case has not been noticed since, and there 
 is every reason to believe that the author might have been deceived 
 by some peculiar circumstances. M. Herbin must have been mis- 
 taken also, when he thought the after-birth was encysted in the 
 Fallopian tube, in a woman whom he was obliged to deliver artifi- 
 cially. 
 
 The placenta, moreover, may be enclosed wholly or only partial- 
 ly within the accidental cell ; it is sometimes strangulated by the 
 circle of the cyst ; so that one portion of it may remain free in the 
 cervix while the rest of it is in some sort imprisoned above, in one 
 or more cells of the body or fundus of the womb. 
 
 1187. To have understood what has now been said in relation to 
 encysted placenta is sufficient to enable one to guess at the signs of it. 
 The treatment demanded by the case differs accordingly as it is or 
 is not accompanied with some complications. If there be any com- 
 plication, the contractions of the womb alone suffice to make them 
 disappear ; these are to be solicited by means of frictions upon the 
 hypogastriura, and judicious pulling at the cord. In fine, there 
 ought to be no haste; we must wait. If there is any threatening ap- 
 pearance of hemorrhage, convulsions, &c. or the safety of the wo- 
 man appears to be in any way compromised, we must, on the con- 
 trary, make haste to act. The fingers are to be introduced one 
 after the other into the mouth of the cyst, which is to be dilated 
 gently and carefully, and afterwards passed by the whole hand in 
 search of the placenta ; should there be a second opening, it is to 
 
 -3
 
 ENCYSTED PLACENTA. 541 
 
 be treated like the first, and in all cases the cord is a sure guide to 
 the after-birth, which is detached and separated by passing the 
 fingers, flattened, between it and the uterus, and which is lastly ex- 
 tracted by pushing it with the palmar surface of the hand down into 
 the top of the vagina. Should the placenta be found only partially 
 encysted, we might, after dilating the mouth of the cyst, dispense 
 with going any further, take hold of it with the fingers, and immedi- 
 ately extract it. But it is in general, both a surer and quicker 
 method to go into the very cavity of the cyst itself; it being well 
 understood that, during this operation, the hand that remains out- 
 side shall be employed in supporting the fundus of the uterus, in- 
 clining it to either side, and depressing it towards the one that is 
 within the organs. 
 
 1 188. The rupture of the cord, in itself considered, does not com- 
 plicate the delivery of the placenta except by rendering the usual 
 tractions impossible : it may be prevented by ceasing to pull as soon 
 as there is any threat of its giving way ; but it can only be remedied 
 by going in search of the placenta with the hand ; and as long as 
 there is nothing to fear for the woman, this recourse is unnecessary, 
 and we ought to trust to the organism itself. It is particularly apt 
 to take place when the cord is inserted near the circumference of 
 the placenta, or when its vessels divide too soon, and separate like 
 the rays of an umbrella upon reaching the placenta. In the first 
 case the efforts concentrate almost wholly upon the root of the 
 cord, which yields before they can be transmitted to the after-birth ; 
 in the second, the vessels are weaker than if they were united to- 
 gether ; further, as the force cannot act equally upon them all, they 
 break very readily one after the other. 
 
 1 189. The morbid or preternatural adhesion of the placenta may 
 be either total or partial, slighter intimate. The ancients, Smellie, 
 and others, refer it to a scirrhous state of the womb or after-birth ; 
 many modern writers have preferred to attribute it to inflammation. 
 But proofs are wanting on each side of the question. I have seen 
 the placenta hard, thick, and yellowish, having lost its spongy ap- 
 pearance, sometimes in a few points, sometimes throughout the 
 whole extent of its uterine surface ; I have seen it full of homogene- 
 ous masses, as large as nuts or partridge eggs, hard, and elastic ; 
 but, in all these cases the adhesion, instead of being stronger,.was 
 much weaker ; although rugose and tuberculated, its surface was 
 smooth, and exhibited no trace of any laceration. I have also met 
 with the yellowish alteration, the placentas gras as they are called, 
 and almost all the alterations pointed out by M. Brachet of Lyons, 
 and M. Gendrin. But, in common with M. Desormeaux, I have
 
 542 COMPLICATED DELIVERY OF PLACENTA. 
 
 never observed any preternatural adhesion to accompany them. 
 Besides, I have not found, by consulting the authors, that scirrhus 
 has been noticed in the womb, exactly at the place where morbid 
 adhesions existed, and every body knows that the placenta generally 
 contracts a less intimate union with the fibrous tumours on which it 
 is sometimes attached and developed, than with the uterus itself. 
 
 1190. As to inflammation, it may be admitted as a probable 
 cause, in a certain number of cases ; for example, when, in conse- 
 quence of a blow on the belly, a dull pain and sense of heat are 
 found to continue for several weeks, in the corresponding part of 
 the womb, and an adhesion of the placenta to exist at the period of 
 delivery; but these phenomena often continue during the whole 
 course of a pregnancy., without any adhesion taking place ; and in- 
 deed adhesions are most frequently met with without any such 
 precedent symptoms having been noticed. Moreover, it is known 
 that the special character of inflammation of the mucous membranes 
 is, to augment their secretions, and to terminate but very rarely in 
 adhesion of their surface to the bodies with which they are in con- 
 tact. Prudence, therefore, requires that we should wait for some 
 new researches, before we pronounce upon this point of pathology. 
 
 1191. When the adhesion is partial, it occupies sometimes one 
 portion, and at others the entire circumference of the placenta ; 
 sometimes, on the contrary, the edges of the cake are free, and it 
 adheres to the womb at one or more points of its surface or at its 
 middle. When the adhesion is general, a circumstance but rarely 
 noticed, but which has notwithstanding been seen by several practi- 
 tioners, and particularly by M. Desormeaux, it exhibits different 
 degrees of the affection like the preceding case. It may in certain 
 cases be overcome by simply pulling at the cord, without our being 
 obliged to enter the womb ; in other instances it is so strong that 
 the tissues seem to* be confounded together, and it is impossible to 
 overcome it without tearing the parts. 
 
 1192. I will not, with M. Desormeaux, say that we can recog- 
 nize, but that we may suspect, or have a right to suspect, the exist- 
 ence of a morbid adhesion of the after-birth, when, notwithstanding 
 the repeated contractions, hardness, and globular shape of the ute- 
 rus, we find by passing the finger up through the os uteri that the pla- 
 centt does not present, and does not yield to tractions suitably exerted 
 upon the cord ; by remembering, besides, what has already been 
 said, viz. that a morbid adhesion is extremely rare, we ought to 
 avoid confounding it with the cases in which the extraction of the 
 gecundines is rendered difficult by some other cause. 
 
 1193. Two very different modes of proceeding have been follow-
 
 ADHESION OF THE PLACENTA. 543 
 
 ed by accoucheurs in cases of pathological adhesion of the placenta : 
 one party think it ought to be left wholly to the natural efforts ; the 
 others, on the contrary, think that we cannot too soon take mea- 
 sures to overcome it. On the one hand it has been thought that, by 
 allowing the after-birth to remain for an indefinite period within the 
 uterus, we expose the woman to the danger of flooding, or convul- 
 sions ; that by becoming decomposed, by putrefying, this substance 
 must act injuriously upon the whole system, and particularly upon 
 the genital organs and peritoneum, giving rise to fever of a bad 
 character. On the other hand, it is asserted that these accidents 
 are far more the effect of ill-timed maneuvres than of the pro- 
 tracted presence of the placenta. Haller, Sandifort, and M. de 
 Saint-Amand, have reported cases of wombs that had been la- 
 cerated, inflamed, or gangrened, in consequence of attempts to 
 break up preternatural adhesions of the placenta ; the after-birth 
 has been known to remain two, four, six, eight, fifteen or thirty 
 days, or for months together, within the genital organs, without 
 causing the smallest accident ; if it become putrid, the lochiaB wash 
 it away piecemeal, and its absorption may be easily prevented by 
 means of injections ; in fine, the dangers which, it would seem, 
 ought to follow its forced detachment, have appeared to be much 
 greater than those that might be involved in its retention for a 
 greater or smaller period of time. 
 
 J 1 94. There is reason on both sides of this question : although it is 
 undeniable that the placenta may in some cases remain for several days 
 in the womb without causing any accidents, it is very frequently the 
 cause of very severe ones. It has a thousand times been seen to carry 
 the woman to the very brink of the grave, and all the bad symptoms 
 disappear as by magic, immediately upon its expulsion : were new 
 proofs of it wanting, 1 could refer the reader to two cases recently 
 published by M. Goupil, and might cite those that have fallen un- 
 der my own notice. As a foreign body, it irritates the womb, invites 
 the blood to it, and is a constant cause of floodings, nervous affec- 
 tions, and pains of all kinds ; the acrimony which it contracts in 
 putrefying, and the odour which it developes, cannot be matters of 
 indifference in a majority of women ; the sanies and putrescence 
 which result from its decomposition, will not remain in contact with 
 the interior of the womb without penetrating, by means of imbibi- 
 tion or absorption, in greater or smaller quantity into the veins of 
 that organ ; and who will venture to affirm that it would not under 
 such circumstances be dangerous ? Although it has chanced that 
 the hand by being introduced within the uterus has sometimes lacer- 
 ated the parts of the woman instead of detaching the placenta, it
 
 * * 
 
 544 COMPLICATED DELIVERY OF PLACENTA. 
 
 must he attributed to a want of skill in the accoucheur, and not to 
 the operation in itself considered ; besides, the question is not 
 whether we shall tear away or destroy, at all hazards, the intimate 
 adhesions of the placenta, whether we shall 'peel it off as the ancients 
 did, but merely whether we shall carefully separate it and extract it 
 whenever we can do so without lacerating the uterus. Upon this 
 point I agree with M. Duchateau, and unless the child have been 
 delivered for a long time, it would be a mistake to suppose that the 
 introduction of the hand must be vpry painful and irritating to the 
 womb. Is it reasonable to fear any bad effects from the gentle fric- 
 tions of the fingers, or moderate tractions exerted with the hand 
 upon an organ that has been for several hours contracting without 
 any inconvenience, and with much violence before ? Let me not 
 however be understood as recommending here the introduction of 
 the hand as soon as the placenta resists a little, and that I approve 
 of those who, by conforming to the advice of Kushler, never fail to 
 resort to it with the mere intention of removing coagula and other 
 substances that may be contained within the uterus. My opinion 
 is, that we ought to wait a few hours, and if there be no pressing 
 haste from any other cause, we may wait even longer, if the 
 woman is of a good constitution and has no troublesome disease of 
 any sort ; but in the other circumstances we should act without 
 waiting too long. 
 
 1 195. If the cord remains whole, we should pull at it in the way 
 indicated when speaking of simple delivery of the placenta ; when 
 the cord is broken, we must attempt to hook a portion of the placenta 
 itself in the fingers. Levret, Baudelocque and all the moderns 
 insist very much on the necessity of drawing the cord down perpen- 
 dicularly to the plane of the placenta. The following comparison 
 has been made use of. If you pull at a piece of wet paper in a 
 direction parallel to the plane on which it is applied, you will not 
 detach, but you will tear it, says Levret; but if you take hold of one 
 of its edges atfd turn it up, you may easily detach it without breaking 
 it. According to the last named author we must first endeavour to 
 ascertain the spot on which the placenta is seated, for if it be in 
 front, we shall make use of the fingers arranged like a pulley, as has 
 been before mentioned, whereas, if it be situated on the posterior 
 part of the womb, this pulley becomes useless, and it must be car- 
 ried to the right or left, provided it be situated laterally. 
 
 This reasoning would doubtless be very correct, provided we 
 
 ncting in a free space, or if the placenta were not attached to 
 
 the walls of the womb very much distended at the time ; but it seems 
 
 to be overlooked, that the fingers only support the cord below the
 
 COMPLICATED DELIVERY OF PLACENTA. 545 
 
 mouth of the womb ; that the after-birth touches the womb, both 
 by its spongy and its membranous surface ; that, in whatever man- 
 ner we may take hold of it, the cord will always be parallel and 
 not perpendicular to the great diameter of the womb, from its very 
 insertion till it passes through the orifice of . the organ ; that by 
 pushing it strongly backwards, in front, or sideways, as is recom- 
 mended, we compel it to rub and slide on the corresponding point 
 of the os uteri as on the groove of a pulley, without in any way 
 changing its relation of direction to the placenta itself. It is as 
 well, therefore, and even better, to place the three fingers in such 
 a way that they may act at the same time like a lever and like a 
 pulley, and draw the cord and rest of the after-birth down in the 
 longitudinal axis of the womb ; but as this axis may vary, may differ 
 more or" less from that of the strait, by inclining in front, to the right 
 or the left ; as it may remain straight, or become curved, or even 
 zigzag, according to the position, form and direction affected by the 
 womb, it will be consequently necessary to pull sometimes more, 
 sometimes less towards the back or side, as I have already 
 shown, in speaking of cases of natural delivery of the placenta. It 
 is not until we have pulled at the cord, with all proper prudence, 
 or where the cord will no longer bear the requisite force to be 
 applied, that we may proceed to enter the womb in search of the 
 after-birth. Provided the cord is still not broken entirely off, we 
 make use of it as a guide ; when it is completely separated, the hand 
 will distinguish the placenta by its greater softness, its unevenness, 
 if the external surface be touched, and provided the fingers come in 
 contact with its foetal surface, by its polished and slippery feel, and 
 the vascular ramifications with which it is overspread ; and in all 
 cases by the less vivid sensation experienced by the woman when 
 the hand is pressed on it, than when pressed on the womb itself. 
 There is generally no difficulty in this exploration for an experienced 
 person ; but by carelessness it would not be impossible to mistake 
 the projections, sometimes presented by the interior of the womb 
 when it is irregularly contracted, for the reliefs of the placenta, a 
 mistake which in the hands of ignorant and unskilful persons would 
 be dangerous. 
 
 .When found, we should endeavour to get hold of some point of 
 its circumference, if there is one which does not continue to be 
 adherent; it is then detached by turning it over towards its mem- 
 branous surface, or the advice given by Baudelocque may be fol- 
 lowed : the ends of the fingers flattened out may be slipped between 
 it and the womb ; then by carefully moving them from side to side 
 it may be detached just as we would separate two sheets of paper 
 3T
 
 546 DELIVERY OF THE PLACENTA. 
 
 slightly adhering together ; where the adhesion is found to be gene- 
 ral, the hand, disposed as before mentioned, is passed along the ex- 
 ternal surface of some portion of the membranes, and then gradually 
 to the circumference of the placenta ; when there, it should act as 
 has been described. Should the circumference alone have con- 
 tracted morbid adhesions, as seems to have been noticed by Leroux, 
 and the middle portion of the cake be depressed by the blood, as 
 Baudelocque states to have happened under his own observation, 
 we might, after the example of that practitioner, penetrate through 
 the placenta, and then proceed as in the other cases. When its 
 separation is effected, the hand brings it away by pushing it down 
 before it ; we ought to take care to leave no portion of it behind, 
 and at the same time remove all the coagula that may be contained 
 in the uterus. 
 
 1196. In acting thus, it very rarely happens that the adhesions 
 cannot be safely destroyed. However, they are sometimes so firm 
 that it is wholly impossible to make them yield. In such a case, the 
 plan pursued by Smellie, Levret, &c. should be adopted, namely, 
 to destroy the adhesions wherever they are not too firm, arid tear 
 and bring away all that we can detach, and leave the remainder to 
 the natural powers. In peeling off the placenta we can go no fur- 
 ther than this, and it would be extremely dangerous to persist in 
 endeavouring to bring away the whole of it, and not leave the 
 smallest portion behind in the female organs. - 
 
 1 197. Sometimes the portion of the placenta which we have been 
 unable to detach separates spontaneously after a few days, and 
 escapes along with the coagula ; sometimes it becomes decomposed 
 and comes away with the lochia ; at others it is not discharged for 
 a long time ; Smellie asserts that one of his patients did not expel it 
 until two months had elapsed, and it was then hard and quite dried 
 up .; Kerkring relates another instance where it was not passed away 
 till full eight months. M. Prost has related two cases not less re- 
 markable : in one, the after-birth was not expelled until the five 
 hundred and third day ; and in the other, until eight months and a 
 half after the birth of the child. Although its presence may be 
 found not to give rise to any accidents, some precautions ought 
 nevertheless to be taken in regard to it : for instance, the fingers 
 should from time to time be introduced into the vagina to ascertain 
 whether it be detached, and extract it as soon as it tries to engage 
 within the os uteri ; in case the fingers cannot get hold of it, recourse 
 might be had to the pincc a faux-germe of Levret, or to Dr Dewees's 
 crotchet ; injections with mallows water, or barley water sweet- 
 ened with honey, or even with decoction of bark, may be daily 
 thrown into the uterine cavity, to cleanse it, prevent absorption, 
 
 V
 
 COMPLICATED DELIVERY OF PLACENTA. 547 
 
 and bring away the detritus of the after-birth as they separate or 
 putrefy. 
 
 It should not be forgotten, moreover, that these adhesions are the 
 result of a disease, and that after their violent destruction, the inner 
 surface remains in a pathological state calculated to excite some un- 
 easiness, and that they leave behind them a sort of suppurating 
 wound that it imports us to cleanse and heal. 
 
 1198. Hemorrhage may take place before the delivery of the 
 placenta, as a complication of any of the accidents heretofore men- 
 tioned : but it is also observed singly ; whether it depend upon iner- 
 tia, spasm, plethora, or irritation of the womb, it is always a dan- 
 gerous phenomenon, which we ought to make haste to combat ; 
 if the presence of the placenta is not the only cause, it at least serves 
 to keep it up and aggravate it ; we should, therefore, be diligent 
 in extracting it, even although there should be inertia. Some au- 
 thors, however, have thought that the delivery of the placenta ought 
 not to be hurried while the womb does not contract, unless there 
 should be a partial detachment of the placenta. M. Lacour has 
 lately endeavoured to show, that artificial delivery of the placenta 
 can only have the effect of increasing inertia, and consequently to 
 that, of producing flooding ; but daily experience is opposed to this 
 view of the subject, and the contrary opinion is generally adopted. 
 I have no intention of repeating here what I have already said 
 concerning the causes, signs, and general treatment of hemorrhage ; 
 but I must speak of it as one of the complication of delivery of the 
 after-birth. 
 
 1199. I am not sure that its mechanism has been well under- 
 stood ; it is improperly attributed to the non-contraction of the 
 womb, in consequence of which the blood must flow in torrents 
 from supposed orifices that remain gaping upon the internal surface 
 of the organ ; but is it not rather occasioned by the sudden cessa- 
 tion of pressure upon the hypogastric vessels, whereby the blood is 
 allowed to rush into them with great force ; or upon the circum- 
 stance that the blood must in some sort accumulate mechanically in 
 the uterine vessels, which being no longer supported, pour it into 
 the empty space which a few moments before was occupied by the 
 ovum or perhaps on the fact, that together with these dispositions, 
 there may be some irritating cause present in the cavity of the ute- 
 rus itself. 
 
 Upon this hypothesis, the best means of preventing a hemorrhage 
 would not be to rub the navel and the hypogastrium with a spoonful 
 of brandy or cologne water, as advised by A. Leroy, but promptly
 
 548 DELIVERY OF THE PLACENTA. 
 
 to apply a pretty tight bandage to the belly, and place the woman 
 with her head very low immediately after delivery. 
 
 1200. After having extracted the placenta, if the flooding contin- 
 ues to such a degree as to excite apprehensions relative to the wel- 
 fare of the patient, provided the womb remains soft and inactive, or 
 a sinapism applied betwixt the shoulders has been tried in vain, 
 we may without hesitation introduce the hand into the organ. De 
 la Motte had well remarked that this is the most certain method of 
 putting a stop to the inertia ; pressure made by the hand, and in 
 various directions upon the hypogastrium, which is lauded as an im- 
 portant discovery in the Journal des Savans of 1722; can never be 
 a complete substitute for this means of relief. 
 
 Injections of oxycrate, of pure vinegar or iced-water, which are 
 recommended by Saxtorph ; alcohol, and sulphuric or nitric acid 
 diluted with water, with which Pasta advises us to cauterise the 
 uterine vessels ; the introduction of a hog's bladder, to be after- 
 wards filled with air, water or astringent fluids, while within the 
 womb, as proposed by MM. Rouget and Vernet, would offer 
 much fewer advantages, and expose the patient to many more acci- 
 dents, and are not so easy of application as the hand ; let us add, 
 along with MM. Pasteur and Evrat, that where we have any fear 
 lest the hand alone should not suffice, we may always introduce, 
 along with it, a peeled lemon, or a sponge dipped in vinegar. 
 
 1201. But provided there should be no inertia, we ought to have 
 recourse to the treatment indicated at the article on hemorrhage in 
 general, that is, to revulsives, refrigerants, and even the tampon. 
 Perhaps it would be well, where the flooding is overwhelming, to 
 compress the aorla above the sacro-vcrtebral angle, while waiting 
 until other measures might be put in practice ; immediately after 
 the birth of the child, thn abdominal parietcs are soft, and in many 
 women it would not be difficult to act upon the aorta witli the thumbs ; 
 so that without attaching so much importance to this measure, 
 which has already been spoken of by Boer, Madame Lachapelle, 
 M. Duges, &c. as is attributed to it by MM. Trahon and Bau- 
 <leloc<iu, Jim., I would willingly have recourse to it, should an 
 occasion present. 
 
 The ergot of rye, employed by MM. Balardini, Biges- 
 ehi, Bordot, Goupil, Villeneuve, &c. is said to put a stop to iner- 
 tia, to compel the wornb to contract, and thus overcome the 
 adhesions of the after-birth, expel the placenta, and thereby suspend 
 iho flooding. According to these practitioners, as the delivery of 
 flie phciMila has been always limud to bo prompt, and never accom-
 
 COMPLICATED DELIVERY OF PLACENTA. 549 
 
 panied or followed by hemorrhage in women who have taken the 
 oxytocic powder during labour, we ought to conclude that it must 
 be of great service in cases of preternatural adhesion of the placenta, 
 and flooding coming on after the birth of the child. 
 
 I would willingly exhibit the article in cases of adhesion, but hav- 
 ing had no opportunities of meeting with them, I am not in posses- 
 sion of any facts of my own in relation to it. As to hemorrhage, 
 some physicians have thought that they have seen it produced by 
 the obstetrical powder ; a young woman was seized with a violent 
 flooding after the birth of the child, although I had administered to 
 her a dose consisting of forty-five grains of ergot, during the labour, 
 and notwithstanding it had produced all the effect I had anticipated. 
 I have also observed a very similar case quite recently, and am led 
 to believe that although the ergot may be useful where the flooding 
 is produced by inertia of the womb, it might very well be injurious 
 in the other cases, which are far more numerous than is generally 
 supposed. 
 
 1203. Another resource, which was first put in practice by Doc- 
 tor Mojon, then by MM. Hoffmann, Taroni, Lemaistre, &c. con- 
 sists in injecting a cold styptic fluid into the placenta, through the 
 umbilical vein. M. Mojon insists that previously to throwing in the 
 injection, we should draw the blood out of the vein and its branches 
 by exhausting with the syringe ; but MM. Hoffmann and Taroni 
 have succeeded without using this precaution ; the first made use of 
 the oxicrate ; the second employed brandy and water ; and the last 
 named practitioner was satisfied with injecting cold water alone. In 
 all three of the cases, the womb, which had previously been soft and 
 inert, contracted immediately ; the placenta was expelled, and the 
 hemorrhage was arrested ; but nothing, not even the fact recently 
 related by M. Sandras, proves that the placenta was still adherent, 
 and that more skilful tractions exerted upon the cord might not 
 have produced the same effect ; a case related a few days ago in a 
 public journal would even prove, were the journal and the author 
 worthy of credence, that these injections may be wholly inefficacious. 
 
 1204. This remedy might be tried in a case of supposed ad- 
 hesion, with inertia and flooding, after having vainly employed the 
 ordinary resources, and previously to introducing the hand into the 
 uterus. Its action must be both mechanical and chemical ; it un- 
 wrinkles and swells the placenta, distends the womb, and oc- 
 casions a sudden reduction of temperature, a contraction of 
 the vascular mouths, and a more or less powerful constriction, 
 admitting, always, that the fluid injected reaches as far as the 
 uterine surface of the placenta. It must in fact combine a part
 
 550 DELIVERY OF THE PLACENTA. 
 
 of the advantages attributed by certain authors to injections thrown 
 directly into the womb, or through bladders, and to the tampon, so 
 much lauded by Leroux, without having any of the inconveniences. 
 
 1205. The operation is, besides, very simple : after having dis- 
 engaged the cord, the pipe of a syringe containing six or eight 
 ounces of very weak brandy and water, vinegar and water, or any 
 suitable medicinal liquid, may be introduced into the vein ; the in- 
 jection may be pushed up with sufficient force to make it penetrate 
 throughout the placenta, and, to hinder it from escaping before it 
 has produced its effect, a ligature must be thrown round the cord. 
 The woman is soon seized with lenesmus and colic ; the uterus and 
 abdominal muscles contract ; the os uteri yields, and the after- 
 birth is promptly expelled. M. Guillon recommends that instead 
 of all these means, we should inject some bouillie, a sort of liquid 
 cataplasm, astringent, or emollient into the interior of the womb 
 itself, and I see not why we might not follow his example where the 
 intervention of the hand is not allowable. 
 
 1206. Convulsions, and repeated fits of syncope which come on 
 after the birth of the child, may, like flooding, be occasioned by va- 
 rious causes ; but the presence of the after-birth, being of itself 
 sometimes sufficient to produce them, we should begin by delivering 
 it in women so affected. For the remainder, we are to act as has 
 been advised in speaking of convulsions in general. The same is 
 true of the simple debility or exhaustion that sometimes supervene 
 upon a protracted labour, or succeed to other accidents. Provided 
 the after-birth seems to have any influence in occasioning this state, 
 we should make haste to extract it ; nothing but the necessity of 
 leaving the woman in a state of quiet, or the fear of bringing back 
 a flooding, should induce us to temporise, in a case where no other 
 accident was at the moment present. 
 
 1207. In twin pregnancy the delivery of the placenta ought not 
 to be solicited until after the complete termination of the child- 
 birth. As the appendages of the two children always adhere to- 
 gether, at least by some of their points, the one could not be ex- 
 tracted without detaching the other, not that this practice must in- 
 evitably occasion an inertia of the womb or bring on flooding, as 
 has been supposed by some persons, who found the opinion upon 
 the false notion that certain large orifices would remain, through 
 which the blood flows into the uterine cavity, but because it is al- 
 ways dangerous to destroy the organic relation of the foetus with its 
 mother, unless it be on the point of expulsion itself. One single 
 circumstance might permit us to depart from this rule : it is when 
 the after-birth of the first child presents spontaneously at the orifice,
 
 COMPLICATED DELIVERY OF PLACENTA. 551 
 
 before the birth of the second, and then care should be taken not to 
 destroy the adhesions of the one that remains. 
 
 In general, the delivery of the placenta after the birth of twins, 
 is longer in taking place than in the common case, provided it be 
 not provoked by the accoucheur ; which depends upon the uterus 
 having rather less tendency to contract, and perhaps also, upon the 
 fact that the size of a double placenta, is necessarily greater. 
 
 In order to assist it, we may take hold of one of the cords, or 
 one of the placentae, and draw down the two after-births, one after 
 the other ; but it is better, more prompt, and safer to twist the two 
 cords round each other, so as to make one string of them, and then 
 act as in a simple case. The placentae, being almost never at the same 
 level in the organs, present at the orifice in succession, and not 
 both at once ; besides, if the contrary should happen to be the case, 
 and their escape rendered difficult, it would be too easy to over- 
 come such an inconvenience for it to be necessary for me to enter 
 into any long explanations concerning it. 
 
 1208. After an abortion, the delivery of the placenta is generally 
 not so easy as it is after a labour at full term ; in the three first 
 months of pregnancy the ovum is almost always expelled whole, and 
 there is therefore no delivery, properly so called ; but after that 
 period, this expulsion in mass becomes more and more rare and dif- 
 ficult. The foetus escapes first ; its involucra remain and are not 
 expelled until sometime afterwards, sooner or later. The cervix 
 recovering its original form and length, soon resists the necessarily 
 feeble efforts of the uterus; the after-birth having scarcely changed 
 its relations to the organs in which it is contained, cannot clear its 
 orifice and fall into the vagina, but with great difficulty. On the 
 other hand, the cord is so weak that it wjll bear only slight pulling, 
 and notwithstanding, retention of the placenta after abortion is 
 scarcely a less serious matter than after labour at full term. ' 
 
 As inertia, and inversion of the womb are not to be dreaded in 
 this case, the wisest course in my opinion is to make haste to effect 
 delivery before the cervix has had time to close, either by pulling 
 moderately at the cord, or by getting hold of the placenta with the 
 fingers if possible. But when we have waited too long, or have 
 been called too late, we are compelled to wait still longer, and confine 
 ourselves to endeavours to promote the contraction of the uterus. 
 Should any accidents supervene, the hand could not be carried up as 
 far as the placenta, on account of the resistance of the cervix, and 
 the smallest extractive force would soon rupture the cord. I pre- 
 sume this would be the proper case to try the injections recom- 
 mended by Dr Mojon. If, however, the placenta should appear at 
 the orifice, or could be felt with the finger, and the tractions or the
 
 552 DELIVERY OF THE PLACENTA. 
 
 hand should prove insufficient to extract it, an attempt might still be 
 made to bring it down with the pince a faux germes. Otherwise, 
 its expulsion is to be left to the natural powers, and we must take 
 care to prevent the occurrence of accidents, or if they do occur, to 
 combat them as soon as they make their appearance. We may re- 
 sort to blood-letting, opiates, and baths, general and local ; emollient 
 or detergent injections are thrown into the vagina, and even into 
 the womb, so as to neutralise the effects of putrefaction; the woman 
 is confined to a strict diet, and as soon as the os uteri becomes some- 
 what open, such portions of the after-birth as may present themselves 
 are to be removed. 
 
 Sometimes all these precautions are of no avail, provided the os 
 uteri has closed soon after the escape of the fetus, and the placenta 
 may remain in the uterus for a longer or shorter period without 
 putrefying ; cases have been seen where the women in some sort 
 forgot it, did not discharge it until after the lapse of one or two years, 
 when they even became impregnated again, proceeded to their full 
 term, and then discharged it together with the new placenta. But 
 the placenta and membranes are most commonly expelled either 
 piecemeal or in one mass, in the course of the first week after the 
 miscarriage, or they are gradually discharged along with the lochia, 
 or by means of injections. It will be understood, further, that these 
 difficulties become more frequent and numerous in proportion as 
 the abortion takes place nearer to the middle period of gestation ; 
 that they are, on the contrary, less severe, and more easy to over- 
 come, the nearer they occur to the natural period of parturition. 
 
 ARTICLE II. 
 
 Management of the Child. 
 
 The management of the child varies according to the state in 
 which it happens to be at birth, and accordingly as it is healthy or 
 in a diseased slate. 
 
 SECTION 1. 
 Of the Fcetus in a Healthy State. 
 
 \\ In :n the child is born alive and in good health, which is known 
 by its cricH and movements, after placing it properly between the
 
 MANAGEMENT OF THE CORD. 553 
 
 mother's limbs, the cord is the only thing that requires the ac- 
 couchers attention at first. 
 
 As soon as the child passes from the vulva, it should be laid 
 crosswise, upon its side, with the face turned towards the foot of the 
 bed, between the woman's thighs. In this situation it can breathe 
 and run no risk of being suffocated by the matters flowing from the 
 vagina. Should the cord be found coiled round the body, it must be 
 disengaged ; it should be freed from any portions of the membranes 
 that it may have brought along with it, and also from the mucous 
 which sometimes obstruct the mouth or throat ; and lastly, we 
 proceed to tie and cut the umbilical cord. 
 
 SECTION II. 
 On Tying and Cutting the Cord. 
 
 1209. In the time of Hippocrates the cord was not cut until the 
 placenta was delivered. If the placenta was slow in coming away, 
 the child was placed upon a pile of wool, or on a leather bottle with 
 a small hole in it, so that by the gradual subsidence of the skin or 
 pile of wool, the weight of the child might react by almost insensi- 
 ble degrees upon the placenta, and extract it without any kind of 
 violence. Deventer thinks the placenta should be extracted pre- 
 viously to dividing the cord ; Dionis followed sometimes one plan, 
 sometimes another. Where the secundines required only gentle 
 pulling to extract them, he did not cut the cord until after they 
 came away, and pursued an opposite practice when he found it 
 necessary to introduce the hand in search of the after-birth. Since 
 the time of Levret it has been established as a general rule, among 
 accoucheurs, to separate the child from the mother as soon as it has 
 passed through the vulva, and that it is never necessary to wait for 
 the expulsion of the foetal appendages. At first view the conduct 
 of the ancients appear to be more rational and more physiological 
 than that of the moderns ; it seems that the placenta ought immedi- 
 ately to follow the foetus, or at least be separated from the uterus 
 before the cord can be prudently cut; that before it is divided, the 
 circulation ought to be permitted gradually to take on its new type, 
 which soon becomes similar to that of the adult; but in reality it is 
 not perceived that the present mode of practice produces the least 
 inconvenience to the foetus, and is certainly better for the mother. 
 It would be in vain to object that this conduct is not natural, for it 
 is followed by most of the animals themselves, who tear off the um- 
 bilical cords of their young as they escape from the vulva. Not 
 3 U
 
 554 MANAGEMENT OF THE CHILD. 
 
 only should we not wait until the placenta is delivered, but it is of 
 no use to wait until the pulsations have ceased, before we cut the 
 cord, as recommended by Denman and A. Leroy. Neither is there 
 a general agreement as to whether the cord should be cut or tied first. 
 
 1210. If we begin by applying the ligature, we have to do it 
 under the bedclothes ; and on the lying-in bed, it is not so easy to 
 examine the umbilicus, and we deprive ourselves of the advantage 
 of disengorging the viscera of the blood with which they are some- 
 times overloaded. In fine, as soon as respiration is established, the 
 placental circulation becomes completely useless. If we cut the 
 cord before we tie it, we are at liberty to carry the foetus to any 
 convenient place, attend to it if it be not well, and examine it with 
 all desirable attention. However, it must be confessed that if the 
 child present nothing peculiar as to its ( condition, one of these 
 modes of proceeding is scarcely preferable to the other, and that each 
 practitioner is at liberty to adopt the one that pleases him best, with- 
 out its having any influence upon the result of his practice. 
 
 1211. The place where the cord is to be divided is altogether a 
 matter of choice. If it be cut at the distance of four or five inches 
 from the navel instead of nearer to or farther from the placenta, it is 
 done in order that what is left of the cord may not be troublesome 
 by its quantity, and may admit of the ligature being applied at a cer- 
 tain distance from the abdomen. Any cutting instrument may be 
 made use of, and the scissors are used only because they are rather 
 more convenient than a bistoury. Although a rusty instrument can 
 not possibly occasion any redoubtable accident, such as tetanus, as 
 A. Leroy supposed, it is nevertheless best to make use of such only 
 in cases where sharper ones cannot be obtained; on the other hand, 
 there could be no advantage obtained by tearing off, bruising, or 
 sawing of the cord, as some authors have recommended, with the 
 view of more closely imitating the quadrupeds, even although we 
 intend to dispense with the use of a ligature. 
 
 1212. The cord being cut, it should be squeezed between the 
 fore finger and thumb, if there should be any disposition in it to 
 bleed ; the other three fingers take hold of the breech; the other hand 
 is placed under the shoulders and nape of the child's neck, which is 
 thus removed from the lying-in bed, and commonly deposited on the 
 nurse's lap; there it can be examined at leisure. Previously to put- 
 ting on the ligature, we ascertain that no loop of intestine has got out 
 through the umbilicus, thai tlinrc is not an omphalocele. Should such 
 a tumour exist, we, ought to try to reduce it, or at least riot to include 
 it within tin- li^itim; we arc: about to place on the cord, as happen- 
 ol to some children under the notice of M. Sabatier and Madame
 
 MANAGEMENT OF THE CORD. , 555 
 
 Boivin. In the time of Aristotle the midwives were in the habit of 
 forcing the blood contained in the cord into the belly of the foetus 
 before they tied it, and pretended by means of this practice, which 
 lias been revived at the commencement of the present century, to 
 restore strength and vigour to feeble children. Some again have 
 maintained, along with Rhazes and the other Arabian physicians, 
 the Abbe Bizance and M. Sarton, that this blood ought to be very 
 carefully squeezed out instead of forcing it in; that it is particularly 
 necessary to evacuate the kind of serosity or lymph, more or less 
 of which is contained in the cord, either by covering it with punc- 
 tures, or squeezing it with the fingers, either naked or covered with 
 a piece of rag, for they attributed to the retention of these matters 
 the property of producing the small pox, crusts on the head, 
 tetanus, and convulsions. Levret, also, thinks that by squeezing out 
 these humours we may prevent the occurrence of infantile jaundice, 
 that at least which he compares to ecchymosis ; but this opinion, 
 which M. Desormeaux seems to partake in some measure, cannot 
 be maintained, and scarcely deserves to be discussed. 
 
 In my opinion it is of very little consequence whether we take this 
 precaution or omit it : if it is sometimes of use, it is so because it 
 admits of the ligature being applied upon the vessels more exactly, 
 without its being so easy to cut them off, and admits of their drying 
 sooner, and without putrefaction. 
 
 1213. As to the ligature itself, De la Motte advises us to apply it 
 at the distance of one inch, Deventer, Levret, and the moderns at 
 the distance of two fingers breadth, others at three, four, five, six, 
 and even twelve inches from the abdomen. Some persons have re- 
 commended the application of two, and in such a way that the one 
 nearest the abdomen should not be so tight as the other. Some- 
 times it has been recommended to draw it very tightly, at others 
 very loosely. One person is content with a single turn and a single 
 knot; another thinks there should be two turns and a double knot; 
 a third, like Plenck and M. Desormeaux, makes first one turn and 
 one knot and then bends the cord into a noose to tie another knot 
 upon it. Some would not dare to use any thing except tape, whereas 
 wiser persons make use of what they can find at hand ; but in fact, 
 is this ligature really necessary ? 
 
 No animal can have recourse to it. At the period of the con- 
 quest of Brazil travellers reported that the aborigines merely chewed 
 or tore on" the cord with their teeth, and that they did not lie it up. 
 If a careful attention be paid to what happens after an ordinary birth, 
 it will be seen that the pulsations grow weaker, and soon disappear 
 in the cord, beginning at the placenta, and that after a few minutes
 
 556 MANAGEMENT OF THE CHILD. 
 
 it may be cut without being followed by the least hemorrhage. 
 This remarkable phenomenon, which is attributed to the change of 
 direction of the iliac arteries, and to the difficulty experienced by the 
 blood in passing into the aorta through the ductus arteriosus, and 
 into the cord through the umbilical arteries, always takes place 
 where every thing occurs in a natural and regular order, but in re- 
 ality depends upon the circumstance that the attractive force exerted 
 by the placenta upon the blood, is replaced by that of the respira- 
 tory organ ; and that the after-birth is no longer any thing more 
 than an inert substance, without vitality, which is abandoned by the 
 blood, as it abandons a gangrenous or asphyxiated limb. 
 
 It is so independent of any mechanical change in the arrangement 
 of the vessels, that if, as was done by Vesalius, the belly of an ani- 
 mal at the full term of gestation be opened, the pulsations of the 
 cord are seen to continue as long as the foetus continues to live 
 without respiring, and, on the contrary, to cease as soon as the air 
 enters freely into the lungs. Beclard has seen the same thing in the 
 dog. I ortte received a human foetus, at the sixth month of preg- 
 nancy, enclosed within its membranes. The umbilical arteries con- 
 tinued to beat strongly as long as the membranes were unruptured ; 
 but they fell into inertia as soon as the lungs and chest, upon coming 
 in contact with the air, attempted to perform some respiratory 
 movements. And do we not every day see the blood flow or stop 
 spontaneously in the same child, accordingly as the respiration is 
 free or embarrassed ? 4Mi^pfc| 
 
 1214. Whatever may be the fate of the explanation, it is not the 
 less true, that if the cord were left to itself without any ligature, it 
 would not expose the fcetus to any hemorrhage, or any accident, 
 even although it should be cut oft' clean, and not contused or torn. 
 However, as the contrary may happen, as a mere compression of 
 the chest, or an embarrassed state of the function of any organ suf- 
 fices to disorder the general circulation and enable the blood again 
 to pass through the umbilical ring ; as cases are reported of children 
 who have died from bleeding in consequence of the cord being not 
 well secured ; and lastly, as there is no danger occasioned by the 
 application of a ligature, as it presents no difficulty, we are not au- 
 thorised to dispense with it ; we should even be culpable to neglect 
 it. Although the observations of Fautoni and Schultz, prove that it 
 is not indispensable, those of Daniel prove that it would not always 
 be safe to omit it even after a rupture of the cord ; and the cautery, 
 made use of in Turkey, will always be less safe and more trouble- 
 some. 
 
 Further, whether tied or not, the cord constantly separates from the
 
 MANAGEMENT OF THE CORD. 557 
 
 abdomen at the same place, that is to say, at the spot where it joins 
 the skin, and consequently, a few lines beyond the surface of the 
 belly ; and I do not think it my duty to combat the old women's no- 
 tion, which was derived from the physiology of the ancients, and 
 which requires that the cord should be cut very near the umbilicus 
 if the child is a girl, and very far from the abdomen if it is a boy, 
 such a mode of cutting it being supposed to exert a great influence 
 upon the development of the organs of copulation ! 
 
 1215. I always make one turn of the ligature, which I tie with a 
 single knot, sufficiently hard to close the vessels ; I then carry the 
 two ends behind, cross them, and bring them back again in 
 front, where they are secured by a double knot which is tied some- 
 what more firmly. I pursue this method because it is very simple, 
 and because I have never seen it followed by any accident. But if 
 the cord were a very large one, I would willingly, for the sake of 
 greater security, imitate the conduct of M. Desormeaux and Plenck, 
 that is to say, that after tying the first knot, I would make a loop of 
 the cord, and secure it in the second turn of the ligature. Besides 
 this ligature, some practitioners apply one to the placental end of the 
 cord, to prevent, as they say, any hemorrhage from taking place 
 from the woman. But what I have said concerning the utero-pla- 
 cental vascular system, proves that this is an unnecessary precau- 
 tion. It can be of no use except in twin cases, and even there, to 
 make it necessary, the vessels of one placenta ought to communi- 
 cate directly with those of the other, as appears to have been the 
 case in two instances met with by M. Mancel, but which must be a 
 very rare occurrence. 
 
 . II. Of cleansing the child. 
 
 1216. Without undertaking to decide whether our first parents 
 took the trouble of removing the unctuous matter which covers and 
 soils the skin of the fetus at birth ; without recurring to the question 
 whether, as is supposed by M. Richerand and most of the modern 
 physiologists, this substance is a mere result of the sebaceous secre- 
 tion, rather than a deposit of some principle contained in the liquor 
 amnii, as is supposed by the chemical physicians in accordance 
 with the sentiments of M. Vauquelin, I will say, notwithstanding 
 the ideas of Gaultier de Claubry, that none but beneficial effects 
 can follow its removal. If it were the intention of nature to retain 
 it upon the surface, why would the goat, the cow, and so many 
 other animals lick their young so carefully and sometimes so rudely 
 as soon as they are born ? I know that no very serious inconve- 
 nience would follow should it be left adhering to the surface, and
 
 558 MANAGEMENT OF THE CHILD. 
 
 that it would come off in a few days by sticking to the clothes, or 
 with the epidermis to which: it adheres, and which always desqua- 
 mates within the first few weeks ; lastly, } do not believe its presence 
 can have any great intluence in producing scabs on the head, of 
 crusta lactea of the head in children at the breast, or crusts on other 
 parts of the body ; nor, consequently, that it is absolutely necessary 
 to remove it with scrupulous minuteness, even to the very smallest 
 portion ; but I think that none of it ought to be left except in cer- 
 tain spots from which it cannot be Yeadily got off. 
 
 Where nothing is made use of but a napkin to wipe it off, some 
 portions always remain adhering to the skin, unless it is rubbed so 
 long and so violently as to be sometimes dangerous ; nor can we 
 succeed much better by immersing the fetus in a warm bath, unless 
 it be composed of a mucilaginous or saponaceous fluid. 
 
 It should be first diluted and thinned with a little fresh butter or oil, 
 mucilage, or any kind of grease^ or what is still better, the yelk of an 
 egg, which renders it miscible with water. A weak solution of soap 
 and water might also be made use of very properly, but the other sub- 
 stances are preferable. This ceruminous substance is met with in 
 greatest abundance at the principal bends of the limbs, and on the 
 head and neck : when it is well detached from the body, it should 
 be gently wiped with a dry napkin ; after which, in order to finish 
 the cleansing of the child, we may first merely rub its skin with a 
 soft sponge dipped in warm water, or weak wine and water, and 
 then again with the sponge squeezed dry, to clean off any blood or 
 other matter adhering to it. *4.. 
 
 Some persons think the whole child should be plunged into a bath, 
 and I do not see why the accoucheur should refuse this little grati- 
 fication to. the parents when they desire to have it done; if I gene- 
 rally neglect it, it is because it takes up too much time, and assu- 
 redly does not deserve to be made of so much consequence as is 
 done by some accoucheurs. 
 
 1217. It is difficult to conceive how certain grave authors can 
 defend the conduct of. the ancient people of Germany, Britain, 
 Scythia, and Greenland, and recommend the Lacedaemonian custom 
 of plunging the fetus into cold water or ice-water, or even to roll 
 it in the snow immediately after its birth, as appears to be still the 
 practice in some remote districts of the .vast empire of Russia. 
 The vigour and tho robust constitution of those people depended 
 upon their diet and the exercises to which they were accustomed. 
 If they had among them no weak and delicate children, that may 
 counted for, not by saying that the cold bath gives strength 
 and iic;,llh to weakly children, but that those that wore weakly
 
 CLEANING AND DRESSING THE CHILD. 559 
 
 at first soon died, and that none remained but such as were endowed 
 with more vigorous constitutions. This practice was quite a natural 
 test among a people who desired to have in their republic none but 
 strong citizens, and looked upon infirm men as more troublesome 
 than useful ; but in our present state of civilization the most robust 
 men are not always those who perform the most important parts in 
 the state ; it is no longer allowable to be careless of the life of any 
 individual, and every child, whether delicate or vigorous, has an 
 equal right to the protection of its parents and of society in general. 
 The foetus has enough to do to bear the intemperature of the 
 atmosphere ; and can any thing be more absurd than to wish to 
 make it pass at once from a temperature of 32 of Reaumur to 
 some degrees below zero ? A transition so sudden as this in a 
 being so frail is it natural ? Even although it should be effected 
 by degrees, as Rousseau wished, it would nevertheless be dangerous 
 and wrong. 
 
 1218. Medicated, alcoholic, or strengthening 1 baths seem to me 
 to deserve the same reprobation, as a general rule : if they are 
 strong they deprive the skin of its suppleness, interfere with the 
 expansive movement of the fluids, and may give rise to the most 
 serious accidents ; if weak, they at least do no good, and I should 
 not make use of them except where the fetus might be excited in 
 a general manner, so as to communicate a greater degree of activity 
 to its languid functions. Thus, except under particular indications, 
 lotions and baths of plain warm water are the only ones that pru- 
 dence permits us to recommend. 
 
 . III. Of dressing the child. 
 
 1219. The foetus being washed, cleaned and wiped dry, still re- 
 quires some attention ; the accoucheur should direct its first dress- 
 ing ; he should at least superintend the application of the belly band 
 and the cutting of the cord. 
 
 The form of this compress, in itself considered, is of little conse- 
 quence ; Baudelocque directs it to be made double, and that a pretty 
 deep cut of a half moon shape should be made in the folded edge 
 with the scissors ; that after splitting one of the halves from the 
 hole quite out to the end, the root of the cord should be lodged in 
 the space between ; that the part not split should remain below, and 
 the two halves of the divided portion should be turned over and 
 crossed in front. There is another method. Let the compress be 
 placed at the upper and left side of the abdomen, rather than at the 
 right, on account of the presence of the liver ; a second compress, 
 soft and of a square shape, covers the first ; a band as wide as three
 
 560 MANAGEMENT OF THE CHILD. 
 
 or four fingers, and long enough to go once and a half round the 
 belly, keeps the whole in place ; this band is fastened at the side 
 rather .than at the middle of the belly, with a pin, which is" far from 
 being so dangerous as some persons have supposed, or it may be 
 secured with a needle and thread. If drawn too tightly it would 
 do harm, if too loose, it would slip off, and do no good. This 
 little apparatus, the object of which is to prevent the cord from 
 being pulled or stretched, and from sticking to the skin, ought to 
 be continued or reapplied until the cord drops off. It may even be 
 continued for some days, some weeks, or months afterwards, pro- 
 vived the navel projects too much, or there is any danger of an om- 
 phalocele taking place. The cord generally separates from the 
 navel about the fifth day ; but in some children it takes place as 
 early as the second, while in others it does not happen until the 
 ninth or tenth day. It begins to dry at its loose end, as has been 
 correctly observed by M. Billard ; the gelatin which it contains con- 
 tracts upon the vessels, which are soon somewhat strangulated by 
 it, as far as the umbilical ring, and not by the epidermis, as M. 
 dardien supposed. Being reduced to a mere pedicle which grows 
 smaller and smaller, the vessels soon separate from the living parts, 
 so that the gangrene of which Haller speaks, the contraction indi- 
 cated by Gardien, the eliminative inflammation observed by Beclard, 
 Chaussier, and M. Orfila, as well as the kind of putrefaction noticed 
 M. Denis, are merely accidental phenomena, and not the cause of 
 the fall of the cord. When a small wound is left after the separa- 
 tion of the cord, it generally heals spontaneously in from eight to 
 twelve days. All the ointments and waters recommended by the 
 good women to force it to close sooner are of no use, and might 
 even produce an opposite effect. It is sufficient to cover it with a 
 piece of fine dry linen, or to sprinkle it over with a little flour or 
 powder of lycopodium. 
 
 1220. Previously to wrapping up the navel string, it was formerly 
 the custom to begin to dress the child and cover the head, arms and 
 breast. Thanks to the elegant pen of Rousseau, it is rarely neces- 
 sary for us at the present day to combat the employment of those 
 absurd swaddling bands, which render a new born infant an im- 
 movable mass, a sort of doll which could be taken hold of by the 
 feet and lifted up stiff. The reform upon this subject is carried so 
 far in England, that instead of the barra-coat they make use of a long 
 frock, a sort of sac of fine wool stuff, which serves for the dress of 
 the child. In France, they also put a shirt, or small woollen jacket, 
 provided with a soft chemisette, which is fastened behind with pins ; 
 it is then wrapped in a linen barra and another made of wool or
 
 DRESSING OF THE CHILD. 561 
 
 cotton. These ban-as come up as high as the axillas, and go 
 once and a half round the body, and cross in front all the way 
 down ; the end is then folded up so as to reach quite to the upper 
 part of the breast, and the corners are carried round behind, to the 
 back, where they are also fastened with pins. 
 
 However, all these matters belong rather to the women, and par- 
 ticularly the nurses, than to the physician. Provided that the child 
 is comfortable, free in its motions, the dress soft and warm, it is 
 of small consequence what shall be its form, nature, or arrange- 
 ment ; every thing over and above these points should be left to the 
 taste or caprice of the family or assistants. 
 
 SECTION 3. 
 Of the Fatus in a State of Disease. 
 
 The fetus may be born weak, or even in a state of apparent 
 death ; the treatment it shall receive under these circumstances 
 should vary according to the danger and the nature of the accident 
 which compromits its life. 
 
 . I. Of asphyxia. 
 
 If the child is only weak without being actually sick, it should be 
 treated in the way that has already been directed ; only we should 
 sooner attend to putting the finger in the mouth so as to cleanse it 
 from any mucus contained in it ; great care is to be taken to avoid 
 cold; a little wine may be added to the water to be used in washing it, 
 and nothing is to be done that might in any way whatever interfere 
 with the freedom of its respiration. 
 
 But the weakness may be carried to the extreme ; sometimes the 
 fetus neither cries nor respires, its skin is pale ; the circulation is 
 languid, the heart scarcely beats; and but for the heat which remains, 
 and the obscure motion of the umbilical arteries and heart, the 
 death of the child would be evident. 
 
 1221. This is the state which is called asphyxia of new born 
 children, which M. Gardien prefers to denominate syncope, and 
 which others have denominated anemia ; but which in fact differs 
 from those three morbid states in a great many respects, and which, 
 rigorously speaking, are much more nearly allied to the latter than 
 to the two former. 
 
 It is met with particularly after very precipitate delivery, where the 
 child has been turned, when it is born before the full term, where 
 there has been a flooding during labour or several days before it, 
 3V
 
 562 MANAGEMENT OF THE CHILD. 
 
 especially that kind of flooding which is caused by implantation of 
 the placenta over the os uteri, or that which comes direct from the 
 vessels of the cord. 
 
 Its cause therefore is, on the one hand, a deficiency of blood, 
 which does not pass through the brain and lungs in sufficient quan- 
 tity to keep those organs in a state of action ; on the other, the want 
 of incitation of the inspiratory muscles, and perhaps also, in some 
 cases, the presence of too great a quantity of mucus, or wa- 
 ter of the amnios in the trachea, as supposed by Heroldt and 
 Scheele; M. Desormeaux seems to agree with Freteau, that the 
 compression of the cord may also occasion it, by closing the passage 
 for the blood in the vein, whilst it leaves the arteries more or less 
 permeable ; but I have elsewhere shown what ought to be thought 
 of this view of the subject. 
 
 Upon the whole, it seems to me that asphyxia of new born chil- 
 dren ought to be attributed to the affection suffered by the blood 
 in the last moments of the labour, its placental modification, and its 
 having ceased to be subjected to that sort of internal respiration 
 which, under ordinary circumstances, is kept up, until the real respi- 
 ration becomes positively established. 
 
 1222. Treatment. The first thing to be done is to remove the 
 viscid mucus from the mouth by means of the finger, or with a brush, 
 -either dry, or dipped in a solution of common salt ; there is no rea- 
 son to believe that it is either safe or useful to turn the foetus with 
 the face downwards to force the matters contained in the trachea to 
 escape therefrom, nor to suck them out into a tube as Heroldt and 
 Scheele state that they have done. Where there is reason to be- 
 lieve that the placenta still maintains a part of its natural relations 
 with the womb, and especially where there is still some tremor, 
 some pulsation in the cord, we may follow the advice of Levret, 
 Smellie, Freteau, M. Piet, Chaussier, &c. not to cut it too soon ; 
 but if the womb be well contracted, if the adhesions of the placenta 
 be evidently destroyed, it would be better to separate the foetus at 
 once from its mother. The fact related by A. Petit, wherein he 
 saw the child in some measure die and revive again accordingly as 
 the cord was compressed or free, to command our entire belief, 
 would require a fuller detail of all the accompanying circumstances. 
 Supposing that the secundines are either wholly expelled, or on the 
 point of being expelled, and that there should be still some pulsa- 
 tions in the cord, I should not object to keeping them for some time 
 in warm wine and water, as again recommended even in our own 
 day by many authors, as MM. Beauchesne and Dorthal among 
 others ; but in other cases I cannot perceive any advantages in act-
 
 OF ASPHYXIA. 503. 
 
 ing thus-. As it is important for the foetus to preserve what little 
 blood it has, the cord should be tied previously to cutting it off; the 
 child is to be immediately taken out of the mother's sight ; it should 
 be taken near a good fire, or it may be plunged up to the axillae in 
 a warm bath, rendered somewhat exciting by the addition of a little 
 wine or brandy ; we should give it slight shocks by slapping it with 
 the flat of the fingers upon the breast, the back, or the breech ; the 
 cord should also be gently pulled in such a way as to move the dia- 
 phragm a little. Van Swieten speaks of midwives who applied the . 
 mouth to the left nipple of the child, and derived great advantages 
 from suction performed on this or other parts of its body. Instead 
 of the mouth, a cup might be made use of. This practice, which 
 was reinstated by Saccombe, M. Desormeaux thinks may be of 
 some use, by exciting the action of the muscles ; but it cannot pro- 
 duce, as is pretended, a real mechanical dilatation of the chest. The 
 temples, the nostrils, the forehead, the root of the neck, and the 
 spine, ought to be rubbed with the fingers dipped in cologne water, 
 alcohol, &c. or with a pretty stiff dry brush ; the inside of the mouth 
 and nose are to be stimulated by the introduction of vinegar, brandy, 
 or some other irritating liquor, or merely with the barbs of a dry 
 feather. I have, in imitation of M. Desormeaux, advantageously 
 employed a mouthful of spirituous liquor, held a few moments in the 
 mouth and then spirted with force, in the form of a douche,or of ab- 
 lution over the breast of the child: the smoke of burnt linen or paper 
 introduced into the rectum has been beneficially employed in some 
 cases; some onion or garlic introduced into the anus, the mouth, or the 
 nose, produce nearly the same effect, and are not so dangerous as am- 
 monia or radical vinegar, which promptly act as caustics if not largely 
 diluted with water. The belly and thorax should be simultaneously 
 and properly pressed so as to try to induce the diaphragm to contract; 
 and during all these processes the foetus should be always kept very 
 warm, for without this precaution the action of all the other means 
 will generally be inefficacious. We should persevere with them for 
 a long time, and not get tired, and redouble our patience as soon as 
 the least sign of life becomes manifest; sometimes the efforts of the 
 accoucheur are not crowned with success until after they have been 
 continued half an hour, an hour, or even two hours, and cases are 
 .not wanting where children, after being several hours abandoned as 
 dead, have come to life, without any other succour than the temper- 
 ature of the place where they were deposited. 
 
 1223. When these different means prove ineffectual, recourse is 
 to be had to inflating the lungs, which may be done either through 
 a quill-barrel, a female-catheter, or any kind of canula introduced
 
 564 MANAGEMENT OF THE CHILD. 
 
 into the mouth and nostrils, or by merely blowing with the mouth 
 directly into the air-passages. The laryngeal-tube invented by 
 Chaussier, having the advantage of pretty exactly filling the glottis 
 when introduced into it, is better than the straight canula of 
 Heroldt ; but a simple gum-elastic catheter, an instrument which 
 may be got any where, is almost as convenient ; it is introduced 
 through the mouth, as far as the bottom of the pharynx ; then, while 
 it is passed onwards, the point of it may be bent with the little finger, 
 so as to compel it to enter into the larynx rather than the oesopha- 
 gus; when fixed right, the nostrils and mouth of the foetus are 
 closed, and the inflation commenced. However, if it should be 
 admitted that the experiments tried by Winslow, Heroldt, Scheele, 
 Viborg, Schmidt and Beclard, incontestibly prove that the liquor 
 amnii penetrates during intra-uterine life as far as the bronchia, it 
 would perhaps be useful to free the trachea from it by suction or 
 otherwise, previously to trying the effects of inflation ; but there 
 is still too much uncertainty upon this point for it to serve as a basis 
 for any practice whatever. 
 
 1224. Curry, Chaussier, and others, had at first thought that by 
 blowing into the mouth none but vitiated or more or less changed 
 air was forced into the lungs of the foetus, and that it would be 
 better to make use of a bellows; but it was soon found that all these 
 precautions were useless, that air, slightly warmed in the lungs of 
 an adult, and charged with a gentle humidity, would be more con- 
 genial to the lungs of the child than a drier and colder air. Be- 
 sides, Heroldt and others have proved, that the gas given out by ex- 
 piration, contains only one hundredth less of oxygen than atmos- 
 pheric air. 
 
 As it is important that the air should enter the lungs and not 
 the alimentary canal, an assistant ought to press his hand against the 
 larynx, so as to keep it against the cervical vertebra, and flatten the 
 oesophagus as much as possible 
 
 1225. We should blow at first very gently. When the lungs are 
 sufficiently filled to lower the diaphragm and raise the sides of the 
 thorax, as is done in a natural inspiration, we must stop, and gently 
 compress tho abdomen and breast in imitation of the act of expira- 
 tion. We then begin again in the same manner, and thus establish 
 a sort of artificial respiration, the advantages of which have cer- 
 tainly been exaggerated by some authors: M. Desormeaux has been 
 but imperfectly satisfied with it, and in my hands it has succeeded 
 in but a small number of cases, and (according to the researches of 
 M. Lcroy d'Ktiolles) it is really dangerous unless managed with 
 very great care.
 
 ASPHYXIA. 565 
 
 In fact, it is not the action of the lungs, but that of the respiratory 
 muscles that ought to be first put in play. But, as the very reverse 
 takes place in inflation, it follows, according to M. Leroy, that 
 the air generally stops in the large branches of the bronchia, and 
 that we can rarely succeed in forcing it into the air-cells, without 
 the risk of producing an emphysema, which of itself is sufficient to 
 occasion the death of the individual. 
 
 The operation of tracheotomy, proposed, in despair of any thing 
 better, by M. Heroldt, as it is very dangerous in itself considered, 
 offers no advantages superior to simple inflation, and ought to be 
 proscribed. 
 
 1226. Electricity and galvanism, which have been recommended 
 under these'circumstances by Greve, Behosends, Boer, M. Gardien, 
 &c. might also be of great service either as a principal or accessory 
 cause in the treatment of the asphyxia of new born children. The 
 current should be directed through the breast, or from the mouth to 
 the anus. I must, notwithstanding, confess that I have twice tried 
 it without success, although I made use of a double battery of 
 twenty-one metallic plates, the action of which was very strong. 
 The electro-puncture which was tried by M. Leroy on animals, 
 might perhaps be more efficacious, by permitting it to act directly 
 upon the diaphragm ; but, so far as I know, it has never been ap- 
 plied to the human fetus. 
 
 If we are to succeed, the pulsations of the heart and cord re-ap- 
 pear by degrees, the muscles gradually recover their natural firm- 
 ness, the skin becomes slightly coloured, the heat returns, and then 
 some respiratory movements, feeble and irregular at first, then more 
 and more decided, soon make their appearance ; cries are soon 
 heard, and the child is saved. It would, however, be imprudent to 
 cry out victory too soon ; I twice succeeded in restoring the mo- 
 tions of the heart, and the respiration, for more than three hours, 
 by means of inflation and galvanism, in two children, which I never- 
 theless was at length compelled to abandon. 
 
 . II. Of the apoplectic state. 
 
 1227. Instead of coming into the world pale, anemic, or exsangui- 
 ous, the child is sometimes born in quite a contrary condition ; its 
 skin is of a bluish red or livid colour, of various degrees of intensity, 
 especially on the face, and appears as if thickened. All the organs 
 seem to be the seat of a general congestion, the limbs are soft and 
 motionless ; the circulation is suspended, either wholly or in part, 
 in addition to which, all the other signs just now indicated are found 
 to be present.
 
 566 MANAGEMENT OF THE CHILD. 
 
 It should also be understood that the disease may exhibit itself 
 under various degrees of intensity, and produce various changes in 
 the interior of the body. Upon opening the dead bodies of such 
 children, fluid blood is often found extravasated between the menin- 
 ges or in the very substance of the brain. Jn other cases, and that 
 most frequently, the blood is not found to have escaped from the 
 vessels, or only forms slight ecchymoses in different parts; but it is 
 in excess in all the organs, which are engorged, and, as it were, 
 soaked in it. 
 
 The apoplectic state is met with, especially in strong children, 
 after long and difficult labours, the application of the forceps, and 
 pelvis labours, either spontaneous or artificial ; where the child has 
 remained for several hours under the direct influence of the uterine 
 contractions after the discharge of the waters ; where it has pre- 
 sented in a bad position ; where it is too large to pass with ease 
 through the various passages ; where a loop of the cord strictures 
 its neck, or is itself in any way compressed, and particularly where 
 any of these accidents occur coincidently with a previous plethoric 
 state. 
 
 Its immediate cause is the compression or engorgement of the 
 brain ; which, however, does not prevent a want of the revivification 
 of the blood from being an occasional cause of it, as well as of as- 
 phyxia; and M. Gardien, while opposing the sentiments of M. 
 Chambon, Courraut, and Capuron, is certainly wrong in maintain- 
 ing that compression of the cord is as incapable of producing the 
 apoplectic state as it is capable of easily producing asphyxia. 
 
 1228. When a child is born in this state we should make haste 
 to disengorge its vascular system ; by acting soon, wjiere there is no 
 effusion, the alarming symptoms may generally be soon dissipated. 
 Under the opposite circumstances, death is commonly inevitable ; 
 but, as has been remarked by M. Dcsormeaux, inasmuch as it is 
 impossible, a priori., to distinguish a simple congestion from an en- 
 cephalic hemorrhage, the accoucheur would be reprehensible who 
 should fail, in any case, to bestow upon the child the same care as if 
 the affection were known to be less serious. 
 
 If the accident have been occasioned by compression by the cord 
 upon the jugular vein, the turns should be quickly cast off, or cut, 
 provided the foetus cannot be otherwise freed from their injurious 
 effects. In other cases it would be equally dangerous to wait for 
 the child to cry before cutting the cord, or to amuse ones-self with 
 immersing the placenta in a warm liquid. The section of the cord 
 is the first and chief remedy to be resorted to. The ligature is not 
 to be applied until after the disappearance of every bad symptom,
 
 APOPLECTIC STATE. 557 
 
 because the advantage of this section is, that it gives free issue to 
 the blood. To promote the escape of this fluid, it is sometimes 
 requisite gently to press upon the breast, the abdomen, and the 
 cord itself. As the blood flows the child seems to revive ; the livid 
 colour of the lips is soon replaced by a purplish or rosy hue ; the 
 parts about the mouth, and nose, the rest of the face, and the whole 
 surface of the body clear up by degrees ; the respiration soon be- 
 comes established, and in a few minutes the danger has wholly dis- 
 appeared ; but the circulation is sometimes so much enfeebled and 
 obscure that no blood flows from the umbilicus. In such cases we 
 are obliged to resort to the remedies recommended for asphyxia, 
 that is to say, to frictions, stimulating baths, inflation, electricity, 
 &c.; and as it is absolutely necessary for the child to lose blood, 
 provided it be impossible to obtain any from the cord, a leech should 
 be applied behind each ear to disengorge the brain. 
 
 1229. When the integuments have recovered their natural colour, 
 the circulation has returned to its natural state, the respiration is 
 no longer doubtful, and the foetus cries and moves freely ; the bleed- 
 ing must be stopped, provided it should not have stopped of itself. 
 After this we proceed as if the child had been born well. On the 
 contrary, should there still remain some obstruction in the pulmo- 
 nary and cerebral functions, as have too frequently been noticed, 
 especially where we have been unable to procure a sufficient quan- 
 tity of blood, leeches ought again to be applied, and are almost 
 the only agents upon which we can place any reliance, in cases 
 where congestion, a sort of secondary apoplexy, does not come on 
 until twelve, twenty-four, or forty-eight hours, or even, as has hap- 
 pened, until three or four days after its birth. 
 
 . HI. Of some other morbid states of the new-born child. 
 
 1230. It is not a part of my subject here to treat of the contu- 
 sions, wounds, luxations, and fractures which take place in certain 
 difficult labours ; neither have I occasion to speak of what is called 
 tongue-tied, adhesion of the tongue, occlusion of the palpebrae or 
 lips, imperforation of the urethra, vagina or anus, of jaundice, in- 
 duration of the cellular tissue, nor any of the faulty conformations 
 or numerous diseases to which the infant is subject ; but I cannot 
 pass over in silence the deformity of the head and some other acci- 
 dents which depend directly upon the compression of the head 
 during its passage through the straits. 
 
 1231. The depression of the parietal or frontal bone with or 
 without fracture, has been several times observed at the Maternite 
 at Paris by Chaussier, M. Duges, and Madame Lachapelle ; there
 
 568 MANAGEMENT OF THE CHILD. 
 
 is reason to fear its occurrence when the head rests against the 
 sacro-vertebral angle, and is for a long time subjected to violent 
 efforts, when the strait is reniform, and when a pretty large head is 
 forced to mould itself to the form of the pelvis through which it 
 passes. 
 
 If the fracture or depression of the bones is not accompanied with 
 extravasation, nature ordinarily succeeds in restoring every thing to 
 its proper condition, and performs the cure herself; otherwise, death 
 is the common consequence, or at least, there ensues stupor and a 
 very great tendency to convulsions. 
 
 1232. By moulding itself according to the contracted straits, the 
 head may be elongated without its bones being depressed or fractured, 
 but in such a way that their edges cross and over-ride one another, 
 more or less; in these cases they pretty often recover their natural po- 
 sition after the delivery; but they may also continue to over-ride, as 
 occurred in one case under my own notice, and thus constitute a 
 perpetual cause of disease, particularly of convulsive affections. 
 
 However, in this, as in the preceding cases, art can do nothing, 
 and we are obliged to trust to the powers of nature. 
 
 1233. A more common, and fortunately less serious accident 
 than these, is a sort of subcutaneous effusion, a swelling of the 
 hairy-scalp, which is almost always met with, but in different de- 
 grees, when the head has traversed the pelvic canal slowly and with 
 difficulty ; this tumour is generally found on that part of the cranium 
 which occupied the open space in the pelvis during the labour ; or 
 one of the points that was longest and most forcibly pressed against 
 the sacro-vertebral angle or pubis ; it is composed in some cases of 
 reddish serum, in some of pure blood, either fluid or coagulated, in 
 others of a mixture of these fluids, and is of various size, from that 
 of a nut up to that of a hen's egg. 
 
 It may be diffused or circumscribed, and it may be fluctuating, 
 though generally elastic and dough-like, and commonly disappears 
 without any assistance; sometimes, however, it suppurates and is con- 
 verted into a real abscess, which may end in denudation and necrosis 
 of the cranial bones. 
 
 Being soft and compressible in the centre, and firmer and more 
 elevated about the edges, it has, on more than one occasion, been 
 mistaken for a fracture or depression of the bones, and excited use- 
 less alarm. But since J. L. Petit, Ledran and Levret have called 
 attention to this sort of mistakes, they have become more and more 
 rare. 
 
 When tho tumour is of small size, it should be left to itself, 
 and disappears in the course of three or four days, leaving behind it
 
 TABLE V. 
 
 Table showing the Mortality of Lying-in Women in different Coun- 
 
 tries and at different Periods ; from the Registers of the Dub- 
 
 lin Lying-in Hospital, MM. DE CHATEAU-NEUF, DUGES, &c. 
 
 
 Years. 
 
 Labours 
 
 Deaths. 
 
 Years. 
 
 Labours 
 
 Deaths. 
 
 
 1757 
 
 55 
 
 1 
 
 1791 
 
 1602 
 
 25 
 
 
 1758 
 
 454 
 
 8 
 
 1792 
 
 1631 
 
 10 
 
 
 1759 
 
 406 
 
 5 
 
 1793 
 
 1747 
 
 19 
 
 
 1760 
 
 556 
 
 4 
 
 1794 
 
 1543 
 
 20 
 
 
 1761 
 
 521 
 
 9 
 
 1795 
 
 1503 
 
 7 
 
 
 1762 
 
 533 
 
 6 
 
 179(5 
 
 1621 
 
 10 
 
 
 1763 
 
 488 
 
 9 
 
 1797 
 
 1712 
 
 13 
 
 
 1764 
 
 588 
 
 12 
 
 1798 
 
 1604 
 
 8 
 
 
 1765 
 
 533 
 
 6 
 
 1799 
 
 1537 
 
 10 
 
 
 1766 
 
 581 
 
 3 
 
 1800 
 
 1837 
 
 18 
 
 
 1767 
 
 664 
 
 11 
 
 1801 
 
 1725 
 
 30 
 
 
 1768 
 
 655 
 
 16 
 
 1802 
 
 1985 
 
 26 
 
 
 1769 
 
 64'2 
 
 8 
 
 1803 
 
 2028 
 
 44 
 
 
 1770 
 
 970 
 
 8 
 
 1804 
 
 1915 
 
 16 
 
 
 1771 
 
 695 
 
 5 
 
 1805 
 
 2220 
 
 12 
 
 
 1772 
 
 704 
 
 4 
 
 1806 
 
 2406 
 
 23 
 
 DCBI.IH LYING-IN 
 
 1773 
 
 694 
 
 13 
 
 1807 
 
 2511 
 
 12 
 
 HOSPITAL. 
 
 1774 
 
 681 
 
 21 
 
 1808 
 
 2665 
 
 13 
 
 
 1775 
 
 728 
 
 5 
 
 1809 
 
 2889 
 
 21 
 
 
 1776 
 
 802 
 
 7 
 
 1810 
 
 2854 
 
 27 
 
 
 1777 
 
 835 
 
 7 
 
 1811 
 
 2561 
 
 24 
 
 
 1778 
 
 927 
 
 10 
 
 1812 
 
 2676 
 
 43 
 
 
 1779 
 
 1011 
 
 S 
 
 1813 
 
 2484 
 
 62 
 
 
 1780 
 
 910 
 
 5 
 
 1814 
 
 2508 
 
 25 
 
 
 1781 
 
 1027 
 
 6 
 
 1815 
 
 3075 
 
 17 
 
 
 1782 
 
 990 
 
 6 
 
 1816 
 
 3314 
 
 18 
 
 
 1783 
 
 1167 
 
 15 
 
 1817 
 
 3473 
 
 32 
 
 
 1784 
 
 1261 
 
 11 
 
 1818 
 
 35S9 
 
 56 
 
 
 1785 
 
 1292 
 
 8 
 
 1819 
 
 3197 
 
 54 
 
 
 1786 
 
 1351 
 
 8 
 
 1820 
 
 2458 
 
 50 
 
 
 1787 
 
 1347 
 
 10 
 
 1821 
 
 2849 
 
 22 
 
 
 1788 
 
 1469 
 
 23 
 
 1822 
 
 2675 
 
 12 
 
 
 1789 
 
 1435 
 
 25 
 
 1823 
 
 2584. 
 
 59 
 
 
 c 1790 
 
 1546 
 
 12 
 
 
 
 
 
 r 1799 
 
 1364 
 
 100 
 
 1809 
 
 1795 
 
 66 
 
 
 1800 
 
 1155 
 
 120 
 
 1810 
 
 1814 
 
 71 
 
 
 1801 
 
 1209 
 
 25 
 
 1811 
 
 2395 
 
 108 
 
 
 1802 
 
 1496 
 
 13 
 
 1814 
 
 2384 
 
 127 
 
 M. Dross, at the Ma- 
 
 1803 
 
 1632 
 
 108 
 
 1815 
 
 2346 
 
 149 
 
 ternite" of Paris. 
 
 1804- 
 
 1662 . 
 
 59 
 
 1816 
 
 2422 
 
 46 
 
 
 1805 
 
 1564 
 
 60 
 
 1817 
 
 2800 
 
 63 
 
 
 1806 
 
 1625 
 
 114 
 
 1818 
 
 2411 
 
 152 
 
 
 1807 
 
 1691 
 
 72 
 
 1819 
 
 1528 
 
 187 
 
 
 . ' 1808 
 
 1690 
 
 57 
 
 
 
 
 M. DB CHATEAU- C 
 NBCF, at Paris. \ 18lg 
 
 9,683 
 10,528 
 
 11,662 
 
 81 || 1819 
 90 1820 
 167. (I 1821 
 
 M,5SII 
 11,634 
 11,481 
 
 100 
 
 228 
 223 
 
 SWasseiala, in Sweden, 1 death in (. J. 
 
 r Hotel-Dieu, Paris, . . 1 in 15. 
 
 Berlin, .... 109 in 10,000. 
 British Hospital, . 1 in 50. 
 
 Manchester, . . 1 in 1128. 
 
 v > Lortdon,in 30 years,820 in 10,000. 
 ") Strasburgh, . . . 1 in 109. 
 * Petersburgh, . . . 7 in 1000
 
 DISEASES OF THE CHILD. 569 
 
 only a simple ecchymosis ; but its resolution may, and indeed should 
 be facilitated, by keeping it covered with compresses dipped in salt 
 water, red wine, or brandy and water, some eau-blanche or other me- 
 dicine of the same kind. Should it be fluctuating and not very painful, 
 it should nevertheless be resolved if possible ; if the means above in- 
 dicated do not suffice, they might be replaced by a solution of half 
 an ounce of hydro-chlorate of ammonia in a pint of red wine ; this 
 liquor, which is recommended by Siebold, and frequently employed 
 by M. Boyer for bloody tumours of the knee, has many times suc- 
 ceeded in dispersing collections which it had seemed indispensably 
 necessary to open. 
 
 However, should it not produce the effect expected from it, and 
 the fluctuation increase, recourse must be had to the bistoury ; and 
 in such a case we ought not to wait too long, which would admit of 
 the skin becoming more extensively detached, and much thinner. 
 The wound should be dressed with lint, cerate, or cataplasms, that 
 is to say, as we would dress an abscess or any sanguine collection of 
 a common kind, and the wound generally heals very speedily. 
 
 ARTICLE III. 
 Management of the Lying-in Woman. 
 
 1235. The accoucheur being now satisfied as to the condition of 
 the child and delivery of the after-birth, has nothing further to do 
 except to attend to the woman herself. After ascertaining that the 
 womb is well contracted, and every thing in a natural state, he 
 cleanses (or orders it done) the vulva, the thighs, and all the parts 
 that have been soiled with blood, waters, or other substances during 
 the labour. Some warm water, either simple or mixed with a little 
 wine, provided the parts are soft and relaxed, is, with the addition of 
 a piece of sponge, all that is necessary in this little operation. 
 
 We next change the woman's clothes ; the chemise ought to be 
 long, soft and wide, and either open in front, or not, and it should have 
 long sleeves, so that the arms may not be exposed. Over this 
 chemise there is worn a cotton shirt, and then a neck-handkerchief 
 round the neck, so that the upper part of the breast, which is gener- 
 ally exposed to the air, may be rather better protected than the rest of 
 the body. In summer, and whenever the weather is not cold, these 
 3 W
 
 570 MANAGEMENT OF LYING-IN WOMEN. 
 
 two pieces, together with the head-dress, compose the whole of the 
 woman's dress ; otherwise she puts on a long wadded silk-gown 
 open in front all the way down ; in this gown there is the double ad- 
 vantage of being warm, and very light. However, like the dress 
 of the child, that of the mother is a matter which we generally leave 
 to the nurse ; and provided the several pieces be sufficiently large, 
 and their number and thickness suited to the temperature of the 
 weather, or the habits of the patient, she should always be allowed 
 to arrange her dress as she pleases. The same may be said as re- 
 gards the head-dress, except that it would not always be safe to 
 permit the patient, which she sometimes requests, to have her hair 
 cut, or sprinkled with salt. 
 
 The breasts do not require to be supported, or provided with 
 wadded cushions, unless they are very large, and where there is fear 
 of taking cold. The bandage which some women use for the pur- 
 pose of compressing them, and preserving their shape, produces 
 quite a contrary effect ; besides, by impeding the action of the re- 
 spiratory muscles, it may oppose the return of blood to the thorax, 
 give rise to apoplectic symptoms, as happened to two imprudent 
 women mentioned by Baudelocque,and become the cause of a num- 
 ber of diseases, each worse than the other ; the astringent or re- 
 pellent cataplasms employed for the same purpose, and to prevent 
 the secretion of milk, deserve the same reprobation. 
 
 1236. I would say as much of the belly-bandage so much blamed 
 by De la Motte, were it used solely for the gratification of a vain 
 coquetry, but I think it useful in another way. In this, as in all 
 other things, we must take care not to confound the abuse with the 
 wise and reasonable use of things. 
 
 Doubtless, by strangulating the abdomen with a towel, to reduce 
 their size and prevent the formation of scars or inevitable wrinkles, 
 women expose themselves to great dangers, without any chance of 
 obtaining their object ; but as has been advanced by Smellie, Bau- 
 delocque, M. Gardien, &c. a bandage that is moderately tight, or 
 simply gives a good support, may be of great service, and counter- 
 act the formation of many serious diseases. The suddenness with 
 which the womb empties itself, causes the abdominal viscera im- 
 mediately after delivery to be all at once relieved from a long con- 
 tinued state of pressure ; the abdominal parietes, as they do not fol- 
 low up the retreating movement of the uterus, no longer support 
 the digestive organs with the same power; a kind of vacuum is ef- 
 fected in the large vascular trunks, and the blood should be determin- 
 ed there with so much the greater force, as it had only penetrated
 
 MANAGEMENT OF LYING-IN WOMEN. 571 
 
 them with difficulty for some months ; hence arises a greater ten- 
 dency to hemorrhage, inertia of the womb, inflammations, and func- 
 tional disturbances of the liver and intestines. Hence, says Van 
 Swieten, the syncopes that are so frequently met with in women re- 
 cently delivered, though M. Desormeaux thinks they often depend 
 upon hysteria; again, Stoll thinks that this is the principal cause of the 
 puerperal peritonites. Now, the bandage, as I understand it, is intend- 
 ed to supply, as far as possible, the action of the abdominal muscles, to 
 promote the concentric movement of the uterus, and prevent the af- 
 flux of blood towards that organ and the engorgement of all the 
 other viscera : besides, it is easy to acquire an idea of its utility, by 
 reflecting upon the dangers that follow the operation of paracentesis, 
 where the surgeon omits the precaution of applying a compressive 
 bandage upon the belly, after the evacuation of the fluid ; for as to 
 degree, the pressure upon the parts contained within the abdomen 
 experiences nearly the same transition in a woman delivered of a 
 child, as it does in a dropsical patient undergoing the operation of 
 tapping. 
 
 It is true, that if not carefully applied, the bandage soon rolls up 
 into the form of a string, and becomes more hurtful than useful ; 
 that, as M. Desormeaux remarks, most of those women who neg- 
 lect to apply it, are not evidently worse off on that account, and that 
 the use of it could not have entered into the original plan of the con- 
 stitution ; but as, when placed so as to produce no uneasiness nor 
 pain, I cannot perceive how it can do any harm, and as in many 
 cases it is incontestably useful, we should by rejecting it expose our- 
 selves, without any motive, to see symptoms arise which at first it 
 would have been very easy to repress or prevent. 
 
 It is composed, first, of a towel folded into a triangular shape, 
 which is placed on the hypogastrium with the point downwards, and 
 then of another napkin which is folded once or twice lengthways, 
 and passed round the body like a bandage, embracing the hips. 
 
 To prevent it from getting into folds, the last napkin should be sup- 
 ported above by a scapulary or the two ends of a bandage arranged 
 like suspenders, and below by pinning the ends of her cloth to it. 
 
 The cloth, formed of a piece of fine linen folded three or four 
 times, and sufficiently long to cover the vulva and go to be pinned 
 to the body bandage both before and behind, is designed to receive 
 the fluids that are discharged from the vagina, and to prevent the 
 bed-clothes from becoming soiled with them ; when care is taken to 
 renew them frequently, and not to pin them too tightly, none of the 
 ill effects will ensue so justly attributed to the old fashioned cloth,
 
 572 MANAGEMENT OF LYING-IN WOMEN. 
 
 of which some women still make use, and which consisted of various 
 tampons kept in the vulva, and which more or less strictly stopt the 
 passage of the vagina. Although it is not an indispensable article 
 of dress, it seems to me that it may safely be permitted as a means 
 of cleanliness to those persons who desire to have it, or who set any 
 particular value upon its use. 
 
 1237. The new bed, to which the patient is about to be transfer- 
 red, ought to be furnished with an oil cloth, if one can be had, and 
 with a sheet folded into four layers, or of any other piece of linen fit to 
 protect the mattrass. The bed clothes, the coverlids, and the arrange- 
 ment of the bolsters, do not require any interference on the part of 
 the accoucheur, and ought, like every thing else, to be suited to the 
 season and the habits of the woman. 
 
 She is to be transferred to the new bed shortly after delivery, 
 and when the vagina is freed from the clots and the fluid blood 
 which commonly follow the expulsion of the placenta. She is then 
 in a state of agitation, and can without inconvenience bear the little 
 shocks which the transfer almost inevitably occasions. If we wait 
 longer, as some authors have recommended from fear of hemorrhage 
 or convulsions, she would be in the situation of the traveller who, 
 having reached his post harassed and fatigued, can still take a few 
 steps while heated, but when he once becomes still and cooled, is 
 quite unable to walk. All this, however*, is to be understood of 
 cases in which every thing has passed naturally ; for if the womb 
 should not contract well, or should there have been any flooding or 
 threatening of convulsions, or any other accidents that commonly 
 ensue from a state of extreme weakness, the removal should be de- 
 ferred for a few minutes, in order to allay the danger or give time 
 for the functions to return to their natural condition, while the wo- 
 man is still upon the bed whereon she had been delivered. 
 
 1238. Those who get up, and go without any support to get into 
 the other bed, run the risk of bringing on inversion, anteversion or 
 retroversion, prolapsion of the uterus, and many other dangerous com- 
 plaints. They ought to be warned of it, and made to understand 
 that they should allow themselves to be carried ; when they are 
 very weak, or any accident has supervened, which might be aggrava- 
 ted or recalled by too much motion, the two beds ought even to be 
 placed side by side, for in this way the woman can be slid on the 
 clean bed without moving her much, by making use of the sheet on 
 which she laid during the labour, and which may be easily removed 
 afterwards. 
 
 When put to bed, it would be useless, and indeed not always free
 
 MANAGEMENT OF LYING-IN WOMEN. 573 
 
 from danger, to compel her to preserve an attitude that she is un- 
 accustomed to, to make her bed represent an inclined plane for ex- 
 ample (descending towards the foot), for the purpose of favouring 
 the escape of the lochia, or on the other hand, to keep her hips 
 raised higher than her head, with a view of moderating the fluxion 
 of fluids towards the genital organs ; she will lie upon the back, 
 with the legs stretched out and close together, should that position 
 appear more convenient and not fatiguing to her ; but she ought not 
 to be prevented from turning on the side, and bending her limbs if 
 she wishes to do so. In all respects she should be allowed to con- 
 sult her own ease,.and her own inclinations should be attended to. 
 The fatigue and weakness brought on by the constraint of a fixed 
 posture, would of themselves be sufficient to bring on some acci- 
 dents, and constitute a morbid state, even in a healthy person sub- 
 jected to them ; and they should, a fortiori, be dispensed with in 
 women whose functions, being temporarily disturbed, require so 
 much care and caution for their restoration to a natural state. 
 
 1239. All that has been said, in speaking of the management of 
 a woman in labour, relatively to the air which surrounds her, the 
 chamber, and her moral condition, is equally applicable to her dur- 
 ing the subsequent confinement. It is important that she should 
 neither speak nor be spoken to, except when necessary. A calm 
 state of the mind and repose of the body are so indispensable, that 
 too much care cannot be taken to remove every cause that might 
 interfere with them. The value of this precept was so well under- 
 stood in ancient Rome, that the magistrates themselves had no right 
 to enter the house of a lying-in woman for the execution of any 
 sentence or decision whatever ; and in order to secure the re- 
 spect of the citizens for her asylum, it was sufficient, says Juvenal, 
 to suspend a crown at her door. 
 
 Foribus suspends coronas, 
 Jam pater es. 
 
 Most of the diseases which affect a woman in child-bed may be 
 attributed to the thousands of visits of friends, neighbours, or ac- 
 quaintances, or the ceremony with which she is too often oppressed: 
 she wishes to keep up the conversation, her mind becomes excited, 
 the fruit of which is headach and agitation; the slightest indiscreet 
 word worries her ; the slightest motives of joy agitate her in the ex- 
 treme ; the least opposition instantly makes her uneasy, and I can 
 affirm that among the numerous 'cases of peritonitis met with at the
 
 574 MANAGEMENT OF LYING-IN WOMEN. 
 
 Hospital de Perfectionnement, there are very few whose origin is 
 unconnected with some moral commotion. 
 
 1240. After the delivery of the placenta, and putting to bed, the 
 woman is commonly seized with a rigor, which sometimes goes so 
 far as to occasion a rattling of the teeth together. Some physi- 
 cians and the public have on this account deemed it best to cover 
 her over with a weight of bed-clothes ; but this rigor, which is suffi- 
 ciently accounted for by the changes that have just occurred in her 
 system, and which must not be confounded with the chill of perito- 
 nitis, lasts but a few minutes, and scarcely deserves any particular 
 attention. 
 
 It would, doubtless, be imprudent to cover the lying-in woman too 
 lightly ; but it would be equally dangerous to fall into the opposite 
 excess. By covering her with thick bed-clothes and surrounding 
 her with well closed bed-curtains, and, in fine, by keeping her too 
 warm, besides the headachs, floodings, and convulsions to which 
 she would be exposed, we rarely fail to produce a more or less abun- 
 dant perspiration, which it is sometimes difficult to suppress ; this 
 diaphoresis probably has a great deal to do in producing the miliary 
 fever, which is so uncommon at the present day, and which was 
 formerly so often met with in lying-in women. 
 
 1241. Sleep being of the first necessity to a being worn out with 
 fatigue, there would be a sort of cruelty in not permitting the wo- 
 man to enjoy it : in advising that she should be kept awake for 
 several hours for the purpose of avoiding hemorrhage, De la 
 Motte certainly did not in this morbid phenomenon distinguish the 
 effect from the cause. Although women sometimes do fall asleep 
 with all the appearances of health, and wake up soon afterwards in 
 the midst of a profuse flooding, there is a far greater number who 
 owe their well being only to the benificent influence of a refreshing 
 sleep. Besides, these floodings were imminent, or had even begun 
 at the time the women fell asleep ; the desire for sleep being one 
 of their most common symptoms ; if they should be unsuspected at 
 first, and the woman yields to the necessity she feels, she in fact 
 falls into a dangerous sleep, and sometimes never awakes from it ; 
 but in this case the sleep is the effect, and not the cause of the dis- 
 ease ; it is consequently not contra-indicated by any thing ; only, 
 prudence requires that the pulse should be watched, and that the 
 hand should from time to time be placed on the hypogastrium, to 
 ascertain that the womb has not fallen into a state of inertia. 
 
 After this first sleep, that is to say, after the lapse of two or three
 
 MANAGEMENT OF LYING-IN WOMEN. 575 
 
 hours, she should set up in bed and take a little broth; this position 
 serves to rest her, and allows the lochia which had accumulated in 
 the vagina to flow readily off. 
 
 In the following days her linen is shifted accordingly as she gets 
 it soiled ; the external parts of generation should be often washed, 
 and cleansed with mallows-water, which may, without inconvenience, 
 be replaced by a decoction of chervil mixed with milk; constipation, 
 so frequently met with in these cases, is combatted by means of 
 mild clysters, without regard to the prejudice which decides that no 
 clyster should be given previously to the occurrence of milk fever : 
 smarting about the meatus urinarius, difficulty of making water, 
 hemorrhoids, and other effects of the frictions which must be ex- 
 perienced by the bladder and rectum while the foetus is passing out, 
 require emollient or slightly aromatic lotions, hip-baths, and some- 
 times the use of the catheter. 
 
 1242. The regimen, both alimentary and medicinal, of lying-in 
 women, is a point deserving the whole attention of the accoucheur 
 not on account of the number or energetic quality of the substances 
 which it is proper to administer, but because there are no where 
 else so many vulgar practices to proscribe, so many ridiculous pre- 
 judices to extirpate, as upon this subject. 
 
 Drink should only be given to satisfy thirst, and not for the mere 
 pleasure of making her swallow ptisan ; the woman requires a drink, 
 and not a medicine. In regard to this, her taste and idiosyncrasy 
 may be consulted. She commonly continues to use one of the 
 ptisans which she had been advised to use during her labour. 
 When tired of one, another is given to her, and provided they do 
 not prescribe some of those bitter, exciting infusions, or some active 
 compound, of which the old women are so prodigal, she may, in 
 general, be allowed to take what pleases her best. Hot wine, aro- 
 matics, alcoholic tinctures, coffee, tea, and chocolate are not more 
 admissible after than before her lying-in. 
 
 The food should be light, and given in small quantity : broth given 
 one, two, or three times a day, or some messes of potage, are all 
 that prudence will allow before the milk comes to flow freely. 
 Eichele has supposed that by abstaining even from the broth, 
 and making use of debilitating measures,, the milk fever would be 
 prevented from coming on ; but I have often had opportunities of 
 proving the absurdity of such an assertion. If the woman is to 
 suckle her child, it is not improper to allow her to have potages 
 of a rather more substantial kind the day after the delivery; 
 in the opposite case I give nothing but broth. Upon this subject,
 
 576 MANAGEMENT OF LYING-IN WOMEN. 
 
 attention must be paid to her state of health, her habits and consti- 
 tution ; we ought not, for example, obstinately to restrict a majority 
 of country women to too severe a diet ; for, although many of them 
 may have fallen victims to the many imprudences they commit, there 
 is a much larger number who, without making any change in their 
 ordinary diet, and continuing to eat cutlets, bread, and all sorts of 
 meats, and at times very gross food, yet get up, walk about, and do 
 their customary work, in two days after child-birth, without any bad 
 effects following such a course. 
 
 1243. When the secretion of milk has taken place and nothing 
 unnatural has happened, she begins to return by degrees to her 
 common mode of living ; she passes gradually from soup and 
 panada, and semoulas and rice-milk, to boiled eggs, white meats, 
 fried fish, chops, and other common dishes ; so that in from eight to 
 ten days the patient has no more need than any body else of being 
 directed in relation to the choice of her food. The same is true of 
 her drinks ; from wine and water she proceeds gradually to the use 
 of beer or pure wine ; in fact the ptisans may be laid aside after the 
 fourth or fifth day. Many women, however, particularly those who 
 cannot or will not suckle, would not think themselves safe were not 
 certain infusions and medicines prescribed for them previous 
 to their resuming their ordinary regimen. The cannede Provence, 
 the arundo phragmytcs, and the lesser periwinkle, especially enjoy 
 a great reputation in this respect with the public. According to 
 the statements of the nurses and old women, the decoction of these 
 phmts is a powerful means of repelling the milk. The woman can- 
 not dispense with its use if she wishes to avoid tetters, swellings, 
 pains and all the consequences of the lait repandu, a common bug- 
 bear even to the best informed women. 
 
 The ptisan of cannc is too insignificant and inoffensive for us not 
 to prescribe it for women who repose any confidence in it ; the 
 arundo phragrnytes is scarcely more active ; but, according to M. 
 Desorrneaux, the periwinkle injures the stomach, excites the pulse, 
 and ought to be proscribed. 
 
 1244. Whether these drinks have been made use of or not, 
 almost all women in child bed desire to be purged before they get 
 up altogether ; they then use sometimes an anti-lactic purge, and 
 at others some one of the ordinary cathartics. Weiss's whey and 
 sal de duobus have long enjoyed great vogue among the former ; 
 while the latter most generally use manna, or castor oil, sedlitz 
 water, or decoction of senna. 
 
 I am aware that it would be dangerous to give such remedies
 
 MANAGEMENT OF LYING-IN WOMEN. 577 
 
 without discrimination to all women, as has heretofore been done ; 
 but is it a much wiser course to reject them all, as a great many 
 physicians of the present day recommend to be done? 
 
 If the accoucheur fails to order them, he exposes himself to a 
 thousand reproaches, which I am sure are unjust, but which, never- 
 theless, cause him to lose the confidence of his patients ; should the 
 woman be seized with headach or rheumatism, even ten years after 
 her lying-in, the milk is the cause of it ; do any pimples, or efflor- 
 escence on the skin, any fever, abscess, or any sort of inflammation 
 make their appearance, it is always owing to the milk ; and upon 
 reaching a certain age it is still worse : if the features lose their 
 freshness, if the colour of the cheeks and lips fades, if the eyes 
 cease to be brilliant and bright, she is very careful not to accuse the 
 inexorable sway of time, but she refers to the lait repandu, and the 
 blame necessarily falls upon the physician who did not drive out 
 that dreadful milk at her last confinement ! 
 
 Such prejudices would doubtless not justify the employment of 
 purgatives, were they as dangerous as some persons choose to say they 
 are, and were they never of any use ; but such are not the facts. 
 I have frequently administered them, and can assert that I have 
 never known them to produce any bad consequences ; and that, in 
 a great number of cases, they have evidently hastened the re-estab- 
 lishment of the digestive functions. I should be afraid of their ac- 
 tion where the tongue is red and lanceolate, or where there are un- 
 doubted signs of phlegmasia in the abdomen ; I believe them to be 
 of no use where the strength and appetite return fairly and rapidly; 
 but where the tongue is broad, whitish, yellow, or greenish, 
 the mouth bitter and clammy, and there is no appetite, even 
 although there might be present some degree of fever, tension and 
 sensibility of the epigastrium, a gentle purgative I have often found 
 to be followed by the very best effects. I have seen these various 
 symptoms disappear on the succeeding day in most cases, and the 
 health be afterwards restored with a degree of promptitude that I 
 had had no reason to hope for. By freeing the intestinal canal of 
 the mucous deposit with /which it is pasted over, the purgatives 
 brings it into a state better fitted for the performance of its func- 
 tions ; the abundant secretions which they occasion to take place 
 from the villous surface of the digestive passages free the system 
 from substances that could prove hurtful only, and impress upon the 
 other functions a sort of shock by which nature profits. 
 
 I prefer the factitious sedlitz water, or from six or eight drachms 
 to two ounces of castor oil; their effect is sufficiently certain, and I 
 3X
 
 578 MANAGEMENT OF LYING-IN WOMEN. 
 
 have oot seen them produce as much irritation as most other evacu- 
 ants. 
 
 1245. The time that a lying-in woman ought to remain in bed is 
 necessarily very variable, and the nine days, the period fixed by the 
 vulgar, can be adopted only as a mean or general term. Five or 
 six days are sometimes sufficient ; but if the smyphyses should seem 
 to bare been somewhat strained, the womb have a disposition to pro- 
 lapse or become inverted, or the health appear frail, we ought to 
 wait, and instead of eight or ten days, we should rather require her 
 to lie still for two weeks. In all cases, it would be wrong to per- 
 mit her to return suddenly to her usual exercise, as some practi- 
 tioners allow their patients to do. The first day she gets up she 
 should remain half an hour upon a sofa, and an hour the next day ; 
 the third she may take a few steps and remain out of bed for two 
 or three hours ; and during the following days she should consult 
 her strength and the degree of fatigue, as the rule for going to bed 
 again. Soon after this she can go down and take a few turns in 
 the garden, or in the yard ; but it would be dangerous to go to 
 church on the first occasion of going out. The churches are ge- 
 nerally large, cold, and very freely ventilated. In what is called 
 their Churching, the women should keep long on the knees ; they 
 are sure to be fatigued before they go out, and often contract there 
 the seeds of serious diseases. Real religion does not demand such 
 imprudences : the woman ought to recover some degree of strength 
 before she goes on foot to present herself at the altar; she ought first to 
 have tried her strength at home, and make sure that it will not be in- 
 jurious to her to go out into the open air. 
 
 1246. Another custom that the physician ought to watch over is 
 the baptismal repast, if it takes place within the first ten days after 
 child birth. In this family feast joy is not forbidden ; they laugh 
 and they talk ; she desires to bold out with every body ; the father, 
 the mother, the godfather and godmother, the brothers, sisters, un- 
 cles, aunts, &c. all talk to her in turn. She only takes a seat at 
 table out of form, to be sure, or to make more sure of her pru- 
 dence she keeps her bed ; all the guests forbid her to eat or drink 
 any thing ; but in the mean time they oblige her to take a mouthful 
 of this wine, a mouthful of that, then taste of this dish, and of that, 
 so that it too often happens that at the close of the day she finds 
 herself seized with symptoms severe enough to conduct her rapidly 
 to the gates of death. It would be better, therefore, for her not to 
 be present, unless it be beyond the tenth or fifteenth day ; and even 
 then, she ought to be extremely cautious.
 
 MANAGEMENT OF LYING-IN WOMEN. 579 
 
 The Lochia, the After-pains, and the Milk-fever, three of the 
 principal natural phenomena of a lying-in, now deserve our particu- 
 lar attention. 
 
 1247. The term Lochia is given to the substances that escape 
 from the vulva, from the moment of the delivery of the secundines 
 until the womb has recovered its normal size and consistence ; the 
 accoucheurs distinguish three kinds of them : the sanguine, the 
 serous and the milky or purulent; or the red, the clear, and the 
 white. The first are observed on the same day with, and on the 
 day after the birth; it is blood nearly pure. The second appear at 
 the end of twenty-four or thirty-six hours,, are formed of serum 
 mixed with a variable quantity of blood, and do not last beyond the 
 period of the milk-fever. The third succeed these, and last until 
 the fifteenth, twentieth, or even thirtieth day, and are produced by 
 the suppurative process going on upon the internal surface of the 
 womb. Nothing, however, is more variable than their abundance 
 and duration: the red lochia may cease from the first day and re- 
 turn on the fourth ; I have even seen them reappear on the ninth. 
 Sometimes the purulent lochia do not appear at all, and in other 
 cases they last so long that it is difficult to distinguish them from a 
 leucorrhoea ; this anomaly is, however, very easily to be understood 
 by reflecting for a moment upon the cause of this evacuation. 
 
 Although freed from the child and the after-birth, the womb does 
 not immediately recover its size and the other qualities natural to it ; 
 they do not return until the end of five, six or eight weeks, a period at 
 which the menses reappear for the first time; the womb indeed always 
 remains a little larger than it was before the woman became preg- 
 nant, and, in general, the more so, as gestation is more frequently 
 repeated. During this period an insensible process goes on, by 
 means of which the uterine parietes are disengorged of the substan- 
 ces they had imbibed. These fluids are directed more especially 
 towards the cavity, because in that direction the tissue is less 
 dense, and they find a freer issue. As long as the great uterine 
 vessels are not emptied, blood only flpws ; at a later period it is 
 serum combined with the detritus of the ovum and the mucous se- 
 cretions of the organ. But a real suppurative irritation is soon 
 established, the product of which, analogous in some sort to the non- 
 contagious discharges from the urethra, by mixing with the serosity 
 and mucus furnished by the womb, constitute the white lochia. 
 
 The lochia require only cleanliness; upon the-access of the milk 
 fever they sometimes cease to flow, or at least sensibly diminish in 
 quantity ; nevertheless it is not uncommon to see these two pheno-
 
 580 MANAGEMENT OF LYING-IN WOMEN. 
 
 mena proceeding together without interfering with each other. 
 When they stop either before or after the milk comes, it appears to 
 me to be generally useful to add to the means employed to recal 
 them, the injection of emollient or slightly detergent fluids into the 
 uterine cavity. 
 
 1248. The uterine colics or after-pains commence soon after 
 the labour is over, and generally cease upon the appearance of the 
 milk-fever, and rarely last longer than the serous lochia : they are 
 more frequent and sharper in proportion as the labour has been 
 more rapid and easy, and are sometimes strong enough to fatigue 
 the woman considerably ; being produced by the efforts of the 
 womb to contract, it is quite natural that they should be stronger 
 and more frequent in women who have had several children, than 
 in those who are in their first child bed. In effect, the womb, too 
 rapidly emptied in the first named case, does not contract soon 
 enough to prevent the formation of clots in its cavity, is obliged to 
 contract for their expulsion as often as they are reproduced, and 
 each one of these contractions gives rise to a pain. In the second, 
 having reacted for a long time upon the ovum, it is too much irri- 
 tated at the close not to resume rapidly its natural size, and not permit 
 the blood to accumulate within its cavity, and then there will be no 
 clots, no contractions, and no after-pains ; thus the presence of 
 clots determines the contractions, and as was the case during the 
 labour, the contractions occasion the after-pains. J ought, how- 
 ever, to remark, that these pains must also vary in respect to their 
 intensity, the constitution of the patient, and the circumstances; 
 being stronger, for example, in nervous and delicate women, when 
 the womb is already sore, and in a state approaching to inflamma- 
 tion, than in those who are in an opposite condition, though in fact 
 the contractions are similar in both cases. It is by attending to 
 these particulars that we are enabled without difficulty to explain 
 their great severity in some women where there is nothing to be ex- 
 pelled from the genital organs, and their mildness in others, where 
 they coincide with the escape of large coagula; and how it happens, 
 that, instead of diminishing after the second day, they, on the con- 
 trary, continue to augment in some cases until the third and fourth 
 day, &c. 
 
 It is important not to confound them with an incipient metritis or 
 peritonitis, which however is a pretty difficult matter where they 
 reach a certain extent of great severity ; having too often avoided 
 making this distinction is the reason why authors differ so much 
 on the subject of puerperal peritonitis, and the treatment adapted to
 
 MILK-FEVER. 581 
 
 it; as long as the after-pains are clearly intermittent, and. during 
 their intervals the belly is not sore, while there is no fever and they 
 have not been ushered in with a chill, there is nothing to fear and 
 nothing to do ; they are frequently followed by a pretty severely 
 painful sensation at the hypogastrium, acceleration of the pulse, 
 thirst, and heat of the skin, and notwithstanding, are not followed 
 by any serious complaints. But we must in such cases pay atten- 
 tion to them, and not forget that they may be the first symptom of a 
 mortal disease. 
 
 When moderate they may be trusted to the resources of the eco- 
 nomy, or we may give one or two cups of a weak infusion of chamo- 
 mile, which rarely fails to make them disappear in the course of a 
 day or two ; otherwise, it is sometimes useful to prescribe a hip 
 bath, and emollient or slightly narcotic injections ; to exhibit seda- 
 tives or antispasmodics internally, or to bleed the patient once or 
 twice, either from a vein or by topical means, while at the same 
 time the hypogastrium is covered with cataplasms, and this accord- 
 ingly as the woman is weak, nervous, or plethoric ; it may be ne- 
 cessary even to introduce one or two of the fingers towards the os 
 uteri for the purpose of assisting in the expulsion of a clot that may 
 adhere too strongly ; but in the great majority, these cases require 
 no assistance. 
 
 1249. The Milk-fever generally appears on the third day, some- 
 times on the first or second, or not until the fourth, fifth or sixth 
 day ; I have seen it not come on until the eighth, in a young wo- 
 man at the Hospital de la Facultf : headach, without chills, heat 
 and dryness of the skin are its common precursors ; the pulse which 
 is at first small and hard is soon developed ; the breasts grow hard, 
 swelled, and so painful in the course of a few hours, as to interfere 
 with the motions of the arms and chest ; first a moisture, and then 
 a sweat succeed this stage ; the pain in the head ceases ; the fever 
 abates in the course of six, eight, ten, twelve or twenty-four hours, 
 and the reaction which produces the milky secretion is completed; 
 but the breasts remain swelled and painful much beyond this period, 
 especially in women who do not give suck. 
 
 While the fever continues, no broths, nor potages, nor heating 
 drinks should be given. Should it be too high, an attempt to mo- 
 derate its violence should be made by means of a small bleeding. 
 But in general it requires only the hygieinic treatment pointed out 
 higher up. The coming of the milk is pretty often preceded v/ith 
 the suspension, or at least a sensible diminution, of the lochial dis- 
 charges, which soon return to their natural course. Sometimes
 
 582 MANAGEMENT OF LYING-IN WOMEN. 
 
 these two phenomena seem to have no influence upon each other, 
 the lochia do not appear again at all after the milk-fever is gone off. 
 For an account of lactation in general, the diet of the fetus, the 
 choice of a nurse, the diseases of the breast and nipple; for the his- 
 tory of fistulas, whether recto-vaginal or vesico-vaginal, or other 
 serious lesions which are the effect or consequence of certain la- 
 borious labours, I can only refer to the general treatises on Physi- 
 ology, Medicine, or Surgery that treat upon them ; particularly 
 those of MM. Richerand, Magendie, Adelon, Leger, Sabattier, 
 Boyer, &c. and to the excellent articles by M. Desormeaux in the 
 Dictionnaire de Medecine. But there are certain accidents of a 
 less redoubtable kind, concerning which I cannot dispense with say- 
 ing a few words in this place. 
 
 1250. Complete or partial Inversion of the womb is recognised 
 by the reddish or livid tumour which projects into the vagina or 
 vulva, by the absence of the uterine globe above the pubis, and by the 
 pains and syncope experienced by the woman, &c.; although none 
 but the grossest ignorance could confound an inversion of the womb 
 with a polypus in that organ, yet men are sometimes seen, even at 
 Paris, to commit this mistake, even though they are clothed with 
 the title of physicians. Haste should be made to reduce the dis- 
 placed organ. For this purpose the woman should be so placed 
 that her hips may be higher than her breast ; then the hand being 
 furnished with a piece of fine linen spread with cerate, the exter- 
 nal tumour should be compressed gradually and without shocks, 
 and in a steady manner, and at all points, pushing it up along the 
 axis of the straits until it has regained its natural situation.* 
 
 1251. The Descent of the womb, which is pretty often met with in 
 the early periods of a confinement, in women who have a very large 
 pelvis, relaxed tissues, a lacerated perineum, or in those who make 
 improper exertions, scarcely requires any thing after the reduction 
 except rest and a horizontal posture ; it is allowable only to add 
 solfe astringent or styptic lotions, the use of small rags moistened 
 with red wine, for example, in cases where there is no irritation. 
 Pessaries cannot be made use of until a much later period. 
 
 1252. The Antcflcxion and Retrofexion, that is to say, the state in 
 which the womb bends like an elbow at right angles, so that its 
 fundus comes to rest upon the sacro-vertebral angle or behind the 
 pubis, a disease very well described by M. Ameline in his disserta- 
 
 For a very good treatise on inversion of the uterus in general, see a thesis 
 maintained, Dec. 1, 1828, at the Faculte" de Paris, by M. Ferrance-Demissols.
 
 MANAGEMENT OF LYING-IN WOMEN. 533 
 
 tion, and an instance of which in the dead body was shown to me 
 by M. Comte, would be recognised by the same symptoms as the 
 anteversion and retroversion, and would require nearly the same 
 kind of treatment. 
 
 1253. Lacerations of the perineum generally get well of them- 
 selves, with the assistance of the hip bath, by avoiding all motion, 
 and by obliging the woman to keep on her side, so that the pus and 
 lochia may not stagnate in the wound. They generally cicatrise 
 more or less completely from the anus towards the commissure of 
 the pudendum. The perineum may be perforated through and 
 through, and the cure not be rendered any more difficult, 
 provided that the anal and vulvar edges remain unhurt. I saw 
 a case of this perforation produced by the passage of a large 
 child, which was entirely cured by the eighteenth day, and did not 
 hinder the woman at all in her subsequent labours. In some cases, 
 however, it is necessary to cut the bridles, apply the caustic, and 
 take up certain points with the needle, &c. but then the disease re- 
 turns under the domain of ordinary surgery, and cannot be regard- 
 ed as one of the simple consequences of child birth. I shall say 
 the same of lacerations of the vagina, of the cervix, body, and fun- 
 dus of the womb; of rupture of the psoas muscles, of the rectus 
 muscles and those of the sternum, observed at the Paris Mater- 
 nite by Mesdames Boivin, Lachapelle, and by M. Corate. Upon 
 this subject the excellent memoirs by Madame Lachapelle maybe 
 consulted, and in this book the article on extra-uterine pregnancy. 
 I have not treated of descents of the ante-version and retro- version 
 as diseases, because they are observed solely in women who are 
 pregnant ; lastly, in treating of hemorrhage, I said nothing relative 
 to transfusion of the Wood, practised anew in these latter times by 
 Messrs Blundell, Doubleday, Waller, Brigham, Boyle, Brown, 
 &c. because it is not yet proved that an operation so dangerous 
 ought really to be adopted by wise and circumspect practitioners. 
 
 1254. Infiltration of the external genitals may go to the extent 
 of closing the passage of the vulva, and consequently, of prevent- 
 ing the discharge of the lochia. If the swelling be purely lympha- 
 tic, and not painful, it will disappear upon making a few pretty deep 
 punctures upon the internal surface of the pudendum. Where there 
 is sensibility and any signs of inflammation, recourse should be had 
 to baths, embrocations, emollient cataplasms, and even to leeches, if 
 the case require it. 
 
 1255. The Thrombus of the labia pudendi, which was noticed by 
 Levret, forgotten by most of the modern writers, pretty well describ-
 
 584 MANAGEMENT OF LYING-IN WOMEN. 
 
 ed by Dr Dewees, and of which I have seen seven or eight oases, 
 may appear at the moment the head is engaging in or clearing the 
 inferior strait, and even in the two first days after the birth of the 
 child, as in the case lately published by M. Wintringer. The tu- 
 mour sometimes involves both of the labia ; more frequently only 
 one is affected. Although in some cases it is from the size of a nut 
 to that of a hen's egg, it is also found to assume in other cases 
 much greater dimensions ; it rarely disappears by resolution, and 
 some women suffer from it horribly. Leeches and poultices are 
 generally insufficient for its cure, but I have always found it to be 
 promptly dissipated, and without any bad consequence, after a large 
 and deep incision. 
 
 THE END.
 


 
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