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. - 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, . 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 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 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//iid 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 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'.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, 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 .'itp< 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;!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 % 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 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. University of California SOUTHERN REGIONAL LIBRARY FACILITY 405 Hilgard Avenue, Los Angeles, CA 90024-1388 Return this material to the library from which it was borrowed. A ' nnn o 'iii