'f-fCfAfT; 'GEY-jIff; 
 
 ECLECTIC OBSTETRICS 
 
 - 
 
 Rewritten, Revised and Enlarged 
 
 ROBERT C. WINTERMUTE, M. D. 
 
 I'UOFKSSOK OF OMSTKTKIC'S AM) DISEASES OF WOMEN AND CHILDREN* IN THE ECLECTIC 
 MEDICAL INSTITUTE OK CINCINNATI. 
 
 NINTH EDITION. 
 
 CINCINNATI : 
 
 THE OHIO VALLEY COMPANY. 
 1892.
 
 Entered according to Act of Congress, in the year 1855, by 
 
 MOORE, WILSTACH, KEYS & CO., 
 In the Clerk's office of the District Court for the Southern District of Ohio. 
 
 Entered according to Act of Congress, in the year 1S6G, by 
 
 MOORE, WILSTACH & BALDWIN, 
 In the Clerk's office of the District Court for the Southern District of Ohio. 
 
 Entered according to Act of Congress, in the year 1875, by 
 
 WILSTACH, BALDWIN & CO., 
 In the office of the Librarian of Congress at Washington. 
 
 Copyright, 1892, by 
 THE OHIO VALLEY COMPANY.
 
 ROBERT C. WINTEBMUTE, M. D., 
 
 1 33 W. Seventh Street, Cincinnati, 0. : 
 
 DEAR SIR When my feeble health, two years ago, compelled me 
 to resign my position as Professor of Obstetrics, I realized that I would 
 never have the strength to revise my book on Obstetrics. I had 
 felt the necessity for such a revision for several years, and the ques- 
 tion arose who would do it? Fortunately, you consented to under- 
 take the work, although already burdened by the duties of your 
 Professorship of Obstetrics and Diseases of Women and Children, 
 in my place, at the Eclectic Medical Institute of Cincinnati. Your 
 task for more than a year has been a difficult one, but your faithful 
 work has at last been completed, and I offer you my congratulations 
 on your success. I now feel that my confidence in you was well 
 placed, and that the new Obstetrics will be all that is required by 
 practitioners and students, especially in regard to the use of specific 
 remedies and therapeutics. . Yours, very truly, 
 
 XOUTH BEND, O., May 27, 1892.
 
 3 7 
 
 PREFACE TO NINTH EDITION, 
 
 Ox being called to the chair of Obstetrics in the Eclectic Medical 
 Institute two years ago, my attention was at once called to the fact 
 that a new and revised edition of the text-book of the department was 
 badly needed. The broken health and advanced age of the author 
 rendered it impossible for him to undertake the work; it thus 
 devolved upon me to make the revision. Arrangements being com- 
 pleted with Dr. King, I at once set about the task of overhauling the 
 old and building up the new. The great advance that has been made 
 in the art and science of obstetrics during the past fourteen years (the 
 time since the last revision by Prof. King) has rendered necessary a 
 thorough and systematic rewriting of the entire work, in order to 
 bring it up to the present state of knowledge on the subject. I 
 assumed the responsibility of the work with a very keen sense of the 
 many difficulties and great labor involved in the undertaking. 
 Numerous and extensive additions have been made to every chapter 
 of the work. Especial attention is called to the treatment of the dis- 
 eases of pregnancy ; specific medication being substituted for the old 
 style of prescribing. Where reference is made to remedial agents, the 
 specific tinctures peculiar to the eclectic school of medicine are 
 understood. 
 
 For valuable suggestions from Prof. J. M. Scudder, and the late 
 Prof. HoAve, also cuts Xos. 50, 55, 76, and 81, kindly loaned me by the 
 latter, I must acknowledge my obligations. 
 
 This work is here submitted to the profession in the hope that, as 
 now issued, it may meet the requirements both of a text-book for the 
 student and a work of reference for the busy practitioner, as I have 
 endeavored to present a clear and practical description of the subject 
 in question. 
 
 R. C. WINTERMUTE, M.D. 
 
 CINCINNATI, July 1, 
 
 -73'
 
 PREFACE TO THIRD EDITION, 
 
 IN presenting this new edition of the "American Eclectic Obstetrics " 
 to the profession, it may be proper to state that the work has been 
 subjected to a thorough revision. For the purpose of presenting a 
 more regular and systematic study of the subjects treated upon, some 
 modifications have been made in the arrangement of the First and 
 Second Parts of the previous edition, which it is believed will meet 
 with the approval of the reader. 
 
 Owing to the publication of the American Dispensatory, and various 
 other Eclectic works on Materia Medica and Practice, in which the 
 therapeutical agents pertaining to the department of Obstetrics are 
 fully and accurately described, it has been deemed advisable to omit 
 Part Six of preceding editions; this exclusion has permitted consid- 
 erable additions to the work without an unnecessary increase in the 
 number of its pages. Some idea of the additions made may be formed, 
 when it is observed that at least seventy pages of -the last edition have 
 been entirely excluded, the greater portion of which is, in the present 
 work (and independent of revisions and other additions), occupied with 
 new and valuable matter (about sixty-three pages). The recent prog- 
 ress in the Obstetrical Department of Medical Science has rendered 
 these additions very necessary. 
 
 It has been the Author's endeavor to render the work satisfactory, 
 thorough, and essentially practical for both practitioners and students, 
 and he confidently believes that it will be found at least approximat- 
 ing these qualities, and in no way secondary to its predecessors. 
 
 For the many favors and kindnesses received from Eclectics, and 
 from the medical profession generally, the author avails himself of 
 this opportunity to express his assurances of great regard and pro- 
 found gratitude. 
 
 JOHN KING.
 
 CONTENTS. 
 
 PAGE 
 
 CHAPTER I. Woman 11 
 
 CHAPTER II. The Pelvis: "True" and "False" Difference between Male 
 
 and Female Pelvis : Pelvic Articulations, etc 16 
 
 CHAPTER III. Syniphyses and Ligaments of the Pelvis 23 
 
 CHAPTER IV. Straits and Cavities of the Pelvis The Pelvis as a whole 29 
 
 CHAPTER V. Deformities of the Pelvis 35 
 
 CHAPTER VI. Indications of Malconformation of the Pelvis 47 
 
 CHAPTER VII. The Fetus, its Divisions and Dimensions 54 
 
 CHAPTER VIII. The Female Organs of Generation 61 
 
 CHAPTER IX. The Internal Organs of Generation - 68 
 
 CHAPTER X. Of the Uterine Appendages -The Ligaments, the Fallopian 
 
 Tubes, and the Ovaries 81 
 
 CHAPTER XL Of the Corpus Luteum 88 
 
 CHAPTER XII. Theories of Impregnation 94 
 
 CHAPTER XIII. Menstruation Ovulation Conception 100 
 
 ( 'HAPTER XIV. Development of the Human Ovum 109 
 
 CHAPTER XV. Of the Fetus and its Development 128 
 
 CHAPTER XVI. Position, Nutrition, Respiration, Circulation, Dimensions, 
 
 and Death of the Fetus Superfetation 142 
 
 CHAPTEU XVII. Changes in the Condition of the Uterus during Pregnancy. 156 
 
 CHAPTER XVIII. Of Pregnancy 171 
 
 CHAPTER XIX. Compound and Mixed Pregnancy. 178 
 
 CHAPTER XX. Signs of Pregnancy 190 
 
 ('HAPTER XXI. Diseases of the Pregnant Female 209 
 
 ( 'HAPTER XXII. Diseases of the Pregnant Female Continued 234 
 
 CHAPTER XXIII. Hemorrhage and Abortion 249 
 
 CHAPTER XXIV. Labor 271 
 
 CHAPTER XXV. Management of Natural Labor 285 
 
 CHAPTER XXVI. Attentions Required Subsequent to Delivery, during the 
 
 Puerperal Period 318 
 
 CHAPTER XXVII. Presentations and Positions 332 
 
 CHAPTER XXVIII. Mechanism of Labor 340 
 
 CHAPTER XXIX. On Difficult Labor First Stage 358 
 
 CHAPTER XXX. Difficult Labor Second Stage :'>77 
 
 CHAPTER XXXI. On Difficult Labor, from Tumors, Pelvic Deformities, etc.. 390 
 CHAPTER XXXII. On Difficult Labor from Faulty Conditions of the Child, 
 
 Mai-position of the Head, etc 407 
 
 CHAPTER XXXIII. On Preternatural Labor Pelvic Presentations 429 
 
 CHAPTER XXXIV. Of Preternatural Labor Shoulder Presentations 446 
 
 CHAPTER XXXV. On Preternatural Labor Transverse Presentations Pro- 
 lapsus of the Umbilical Cord Plurality of Children Monsters -168 
 
 9
 
 10 CONTENTS. 
 
 PAGE 
 
 CHAPTER XXXVI. Complicated Labor Uterine Hemorrhage from Placenta 
 
 Prtcvia Puerperal Hemorrhage Placental Presentation 484 
 
 CHAPTER XX XVII. Complicated Labor Treatment of Placenta Prsevia 
 
 Syncope from Hemorrhage 491 
 
 CHAPTER XXXVIII. Complicated Labor Accidental Hemorrhage Con- 
 cealed Hemorrhage Hemorrhage After Placental Delivery Effects of 
 Loss of Blood . 502 
 
 CHAPTER XXXIX. Complicated Labor Retention of the Placenta Hour- 
 glass Contraction Morbid Adhesion of the Placenta Putrefactive 
 Absorption 522 
 
 CHAPTER XL. Complicated Labor Inversion of the Uterus Rupture of the. 
 Uterus Rupture of the Vagina Rupture of the Bladder Syncope 
 Thrombus 537 
 
 CHAPTER XLI. Complicated Labor Puerperal Convulsions Eclampsia 
 
 Hysterical Convulsions Apoplexy Epilepsy 552 
 
 CHAPTER XLII. Turning, or Version Cephalic Version Podalic Version 
 The Fillet The Vectis, Lever, or Tractor Blunt Hook Placental 
 Forceps 573 
 
 CHAPTER XLIII. The Forceps Davis' Forceps Hodge's Forceps Cases in 
 which to be used Cases in which not to be used Period for using 
 them 586 
 
 CHAPTER XLIV. Rules for Applying the Foi'ceps Mode of Applying the 
 
 Forceps in the Various Positions of the Head 602 
 
 CHAPTER XLV. Mode of Applying the Forceps at the Brim In Face Pres- 
 entations, and in Pelvic Presentations 615 
 
 CHAPTER XLVI. Craniotomy Perforator Crotchet Cesarean Operation 
 
 Symphyseotomy (i22 
 
 CHAPTER XLVII. Induction of Premature Labor (540 
 
 CHAPTER XLVIII. Puerperal Fever Peritonitis Puerperal Septicemia 
 Inflammation of the Uterine Appendages Metritis Uterine Phlebitis 
 Inflammation of the Uterine Absorbents Treatment of Puerperal 
 Fever 654 
 
 CHAPTER XLIX. Phlegmasia Dolens Crural Phlebitis Treatment of Phleg- 
 
 masia Dolens. 680 
 
 CHAPTER L. Phrenitis Puerperal Mania Treatment of Puerperal Mania 
 
 Intestinal Irritation Acute Tympanitis Diarrhea 691 
 
 CHAPTER LI. Inflammation of the Breasts Mammary Abscess Ephemeral 
 
 Fever Weed Miliary Fever Sore Mouth of Nursing Women 700 
 
 CHAPTER LII. Cyanosis Retention of Urine Red Gum Jaundice Infan- 
 tile Ophthalmia Flatulent Colic Constipation Umbilical Hernia 
 Excoriation of the Navel Hemorrhage from the Cord Hemorrhage 
 from the Navel Nsevus Materni Tongue-tied Hydrocele Swelling 
 of the Breasts Hare-lip 713 
 
 CHAPTER LIII. Aphthse, Thrush Trismus Nascentium Porrigo Larvalis, 
 
 Milk Scab . 722
 
 KING'S 
 
 ECLECTIC OBSTETRICS. 
 
 THE ART OF MIDWIFERY, AND SCIENCE OF OBSTETRICS. 
 
 CHAPTER I. 
 
 WOMAN. 
 
 THE professional delivery of women has been an art ever since the 
 human race had a history ever since the race began and improve- 
 ment in methods took place as observation extended and experience 
 developed knowledge. During periods of savagery and barbarism 
 there may have been little progress in the rudest of arts, when knowl- 
 edge was traditional, and nothing was recorded for the instruction 
 of coming generations. The wives of the builders of the pyramids 
 and the bondwomen whom Moses led out of Egypt were delivered 
 with some degree of skill with the advantages to be derived from 
 experience ; yet enlightened obstetricy was evolved only as progress 
 developed in other branches of learning. Substantial progress is of 
 slow growth. Great discoveries do not spring from the brain of any- 
 body as fabled Minerva came from the head of Jove. The art of 
 delivering a parturient woman is merely a professional matter a de- 
 gree of tact acquired by the ordinary midwife, and not much improved 
 upon ; but the science of obstetrics pertains to the evolution of the 
 human race, and bears upon the origin and descent of mankind. 
 11
 
 12 KIX(i's KCLKCTIC OHSTKTUICS. 
 
 The science <>f obstetriey takes j)l]ilosoj)hical cognizance of differ- 
 entiation in sex ; woman is to be studied in all her peculiar physical, 
 mental, moral, and sentimental peculiarities, and as a creature quite 
 at variance with man her companion and admirer. Woman is' not 
 originally xi<! </ntcrix, but spiritually peculiar. She is moved by sen- 
 timents her partner in life never feels; she is swayed by impulses a 
 man never experiences. 
 
 A French writer, Colombat de L'Isere, says of woman : " Feeble 
 and sensitive at birth, and destined by nature to give us existence; 
 and by means of her tender and watchful care to preserve us after- 
 ward, woman, the most faithful companion of man, may be regarded 
 as the very complement of the benefits bestowed upon us by the 
 Divine Being as an object fitted to excite our highest interest, and 
 as presenting to the philosopher, as well as to the physician, a vast 
 field for contemplation. 
 
 " What subject, indeed, is more worthy of our attentive meditation 
 than the series of changes physical, moral, and physiological that 
 accompany every stage of woman's existence. Through a long suc- 
 cession of modifications and revolutions, she discloses all the phases 
 of her constitution. In infancy she differs slightly from the male in 
 whose pleasures and amusements she participates, as well as in his 
 dispositions and tastes, his inconstancy and vivacity. At that early 
 period ignorant of her own sex, ignorant, so to speak, of her own 
 nature the blush of modesty does not mantle on her cheek : and her 
 eyes, which reveal no passions, seem to seek only what has reference 
 to her real wants. 
 
 "Although at this early epoch her body is but a sketch of the 
 forms it^is destined to assume at a later period, she always retains, 
 even after her entire development, some touch of the softness and 
 delicacy peculiar to her childhood, and does not depart so widely as 
 her playmate from the idea of her original constitution. 
 
 " The reproductive faculty divides the life of the female into three 
 very distinct periods or stages. In the first, this property has no ex- 
 istence: in the second, it is in full activity; and in the third, it has 
 become null again. The duration of the first, commonly decides that 
 of the two last periods; so as to establish the general rule that the old 
 age of woman comes earlier in proportion as her puberty has been 
 more precocious. 
 
 ' The vital forces that regulate the organic system, and the organs 
 that constitute that system, gradually increase during the first period
 
 WOMAN. 13 
 
 of life: they attain their perfect development; and diminish and be- 
 come extinct at the close of the third, whose term, like that of the 
 others, may be accelerated or retarded by different accidental causes and 
 circumstances, dependent on certain physical and moral conditions. 
 
 "Upon setting out in the career of life, the two sexes exhibit 
 .nearly the same physiognomical characters and the same delicacy of 
 organization. Their type and their character, as yet indeterminate, dif- 
 fer only by almost imperceptible modifications, and which it is not pos- 
 sible to trace out in full detail. Subject to the same functions and 
 wants, their isolated and individual existence fails, as yet, to reveal 
 the sympathetic relations that are in the end destined to establish Be- 
 tween them a state of reciprocal dependence. Subjects of the same 
 kind of diseases, they are principally liable to the convulsive affec- 
 tions, and especially to inflammation of the brain, because the head, 
 which in infancy has a proportional size greater than in any other age, 
 is in them a vital center, towards which almost all the efforts of the 
 organisms are directed. 
 
 " The shades of difference in the sexes soon assume a more decided 
 tone, and their peculiar characteristics become so much the more 
 marked as the development of each individual is more perfect and 
 approaches more nearly to the period when by a sudden change nature 
 reveals the completion of those preparations she has been silently 
 making. 
 
 "The interval between the tenth year and the age of puberty is a 
 period of transition, a sort of passage from childhood to adolescence, 
 which appears to be the happiest era in the life of a female. Her ex- 
 treme nervous mobility prevents her being too deeply impressed by 
 the grave sentiments that might be fitted to interfere with her happi- 
 ness. As this stage is for young women the period of gentle pleasures 
 and of the most unrestrained gaiety, it follows that imagination ex- 
 hibits every object under the most attractive colors, and that the exist- 
 ence of young females is agreeably varied by a piquant freedom of 
 action and a great mobility of tastes and affection. Exempt, at this 
 age, from cares and troubles, they sing, they weep and laugh at the 
 same moment; and, as their joys, so their pleasures and their griefs, 
 as well as all their impressions, are ephemeral; they proceed along a 
 flowery path up to the age when nature calls on them for the tribute 
 which they owe to the species. 
 
 "The young girl who, until now, was an equivocal non-sexual 
 creature, becomes a woman in her countenance and in all the parts of
 
 14 KING'S KcLKtTir OBSTETRICS. 
 
 her body: in the elegance of her stature and beauty of her form ; tin 
 delicacy of her features; in her constitution, in the sonorous and me- 
 lodious tones of her voice, in her sensibility and affections, in her char- 
 acter, her inclinations, her tastes, and even in her maladies. Very 
 soon all the tracts of resemblance between the two sexes are found to 
 be effaced. The bud newly expanded blossoms among the flowers, 
 and tli is brilliant metamorphosis is signalized by the rosy tints of the 
 cheeks and lips, and the perfect development which discloses the* 
 arrival of the age of puberty. 
 
 "This important period, this first moment of triumph, in which 
 nature seems to renew herself, is announced by a sentiment of neces- 
 sity to multiply, within the principle of life and by various striking 
 and admirable phenomena which put an end to the social inertia, in 
 which the young girl has lived from the period of her birth. The 
 sexual system soon becomes a centre of fluxion; nature makes great 
 efforts to establish the periodical discharge, and the whole machine, 
 in its inmost recesses, experiences a succession, a violent commotion, 
 a general movement. The new energy of the womb imparts a pow- 
 erful impulse to the entire system of organs: their functions become 
 more active ; the body grows rapidly ; the various portions of the figure 
 become more expressed and bring out those graceful contours, that be- 
 long to the tender sex alone. At the same time other important changes 
 take place: the pelvis and the sexual organs, which were in a. merely 
 rudimental condition, now acquire their full proportions; the throat 
 rises and becomes more sensitive ; the breasts become rounded and full, 
 while they establish their correspondence of sympathy with the womb. 
 The mons veneris comes into complete relief, and clothes itself with a 
 thick down, which, like a veil covering the organs of modesty, seems 
 to announce that they are destined soon to become fitted to act the 
 important part assigned to them by the law of nature. The meshes 
 of the cellular tissue, becoming rapidly filled under the influence of 
 the uterine irradiation, soon impart to the surface of the body a volup- 
 tuous embonpoint, which lends the highest splendor to the attractive 
 freshness and beauty of youth. 
 
 " The physiognomy of the young woman has now acquired a new 
 expression: her gestures bear the stamp of her feelings; her language 
 has become more touching and pathetic; her eyes, full of life but 
 languishing, announce a mixture of desires and fears, of modesty 
 and love in fine, every thing conspires to excite, to caress, and to 
 incite.
 
 WOMAN. 15 
 
 "Her tastes, her enjoyments, and her inclinations are likewise 
 modified; her most pressing want is to experience frivolous emotions; 
 she is passionately given to the dance, to show and to company; the 
 curiosity so natural to her sex acquires new force and activity; she 
 devours books of romance, or, niore than ever fervent in devotion, is 
 excited by the expansive passions, and particularly by religious piety, 
 which is to her a sort of love. 
 
 " At this brilliant period of life, her moral, which depends upon 
 her physical condition, undergoes great mutations. The young girl 
 becomes more tender-hearted, niore sensitive, more compassionate, and 
 appears to attach herself to every thing about her. The new sensa- 
 tions arising within her soul make her timid in approaching the com- 
 panions of her childhood; a strange trouble, a sort of restlessness and 
 agitation before unknown, are the heralds of a power whose existence 
 she does not even suspect. 
 
 "The action of the new forms of vitality established within the 
 sexual organs augments more and more, and reacts with energy upon 
 the whole system. Under the sympathetic irradiations of the uterus 
 the general sensibility becomes changed and even excited in a peculiar 
 manner. A new sentiment soon gives rise to desires which, as yet, 
 have no definite object, and to vague emotions, of an instinct that 
 seeks some object it knows not what. This rising want produces 
 the impression of a touching melancholy, a charming bashfulness, 
 whose principle is founded in ingenious love presaging new disposi- 
 tions, and announcing that the inclinations and habits of childhood 
 are exchanged for other sentiments. The young virgin becomes timid, 
 reserved, abstract, and dreaming. She sighs less for pleasure than for 
 happiness; the necessity of loving makes her seek solitude; and this 
 new want, that troubles her heart and engages it wholly, becomes, if 
 it remains unsatisfied, a source of multiplied disorders and derange- 
 ments." 
 
 Thus I have ventured to introduce the career of woman the ob- 
 jective feature of the art and science of midwifery. The next step 
 will be to depict the anatomical and physilogical peculiarities of such 
 parts of the female organism as are essential to reproduction. It is 
 said, that the boy is the father of the man : and with more propriety it 
 might be declared that the girl is the mother of the woman. The doll 
 is the ideal representative of the race.
 
 16 
 
 KING'S ECLECTIC OBSTETRICS. 
 
 OH A I'TKR II. 
 
 THE PELVIS: "TRUE" AND " FALSE" DIFFERENCE BETWEEN MALE 
 AND FEMALE PELVIS: PELVIC ARTICULATIONS, ETC. 
 
 THE PELVIS, so named from its fancied resemblance to an an- 
 cient basin, is a bony ring-like structure, of conical shape, with the 
 base directed upward; situated between the last lumbar vertebra and 
 the lower extremities, receiving the weight of the body above, trans- 
 mits it to the lower limbs. It is formed by the union of four bones 
 viz: the two Ossa Innominate, the Sacrum, and the Coccyx. It is 
 divisible into two parts or cavities, an upper and a lower, the dividing 
 line being the liiica ilio pcctinea. The upper portion is the larger, or 
 False Pelvis, formed solely by the alae ilia. The lower is the smaller, 
 or True Pelvis, formed by the sacrum, ilium, pubis, and ischium. 
 
 FIG. 2. 
 
 ADULT MALE PELVIS. 
 
 The SACRUM is situated on the superior-posterior part of the 
 pelvis, immediately below the last lumbar vertebra, with which its 
 superior surface articulates, above the os coccyx, and between the two 
 ossa innominata, to each of which it is united by means of ligaments. 
 It is a large bone, pyramidal or triangular in shape, the base being
 
 THE PELVIS. 
 
 17 
 
 upward ; its anterior face is smooth and concave, and its posterior 
 irregular and convex. The concavity of its interior face is from above 
 downward, and its depth, in a well-formed pelvis, is such, that a per- 
 pendicular let fall from a line, drawn from the apex to the base of the 
 bone, upon the deepest point of the concavity, will measure from nine 
 to twelve lines, or from three-quarters of an inch to an inch; this con- 
 cavity is termed the hollow of the sacrum; it may, however, vary very 
 much, and when too strait or too much curved, it presents an obstacle 
 to the easy passage of the child's head through the excavation. 
 
 FIG. 3. 
 
 A. The Sacrum. 
 
 B. The Os Coccyx. 
 
 C C. The Two Iliac Bones. 
 D D. The Two Pubic Bones. 
 E E. The Two Ischiatic Bones. 
 1 1. The Crest of the Ilium. 
 
 ADULT FEMALE PELVIS. 
 
 2 2. 
 
 The Anterior-superior Spinous processes 
 of the Ilia. 
 
 3 3. The Acetabula or Cotyloid Cavities. 
 
 4 4. The Tuberosities of the Ischia. 
 
 5 5. The Obturator Foramina. 
 
 6. The Promontory of the Sacrum. 
 
 During childhood, the os sacrum is composed of five distinct pieces, 
 termed false vertebrae, which become firmly consolidated at adult age, 
 and leave five surfaces nearly quadrilateral, and which are separated 
 from each other by four projecting transverse seams or ridges, at the 
 original points of separation. At the sides or lateral portions of these 
 seams, are a series of openings, termed foramina, usually four on each 
 side, which terminate outwardly in large grooves converging to each 
 other, and which are named the anterior sacral foramina and grooves^ 
 2
 
 18 KING'S ECLECTIC OBSTETRICS. 
 
 and which serves to lodge and transmit the sacral nerves coming from 
 the spinal canal. The nervous cords lying in these shallow grooves 
 are comparatively secure from injurious pressure during labor, yet it 
 is sometimes the case, that during the passage of the child's head, these 
 sacral nerves are exposed to much pressure, which, as in other instances 
 of compression upon a nerve, occasions a numbness, pain or severe 
 <-ramps in the parts to which they are distributed, as in the thigh, leg, 
 or foot. This usually ceases as soon as the pressure is relieved by the 
 expulsive progress of the head, but when the nerves have been severely 
 bruised or compressed, the unpleasant effects may remain for some time 
 after delivery. 
 
 External to these sacral foramina, and on the projecting cristae, 
 which separate the grooves, arise the asperities, which serve as points 
 of attachment to the fibers of the pyriform muscles. 
 
 The posterior surface of the sacrum is convex from above down- 
 ward, rough and unequal, presenting on the median line, four emi- 
 nences or spinous processes, which decrease in size as they descend; 
 on either side of these eminences, there are four openings or forimina, 
 smaller than those on the anterior surface, which are named the pos- 
 terior sacral foramina, and which transmit the posterior branches of 
 the sacral nerves. External to these foramina are a number of pro- 
 cesses, which serve as points of attachment to several muscles and 
 ligaments. 
 
 The lateral surfaces of the sacrum are rough, thick above, but 
 diminishing as they descend, and in the recent subject are covered 
 with cartilage, which unites them to the iliac bones. The superior 
 portion of each lateral surface, which articulates with the ilium, is 
 broad and irregular; and the inferior edges, are thin and nearly sharp, 
 and give attachments to the greater and lesser sacro-sciatic ligaments. 
 
 The base of the sacrum is about two and a half inches thick, and 
 about four inches in breadth and articulates with the last lumbar ver- 
 tebra in such a manner, as to form a projection at the superior strait, 
 called the promontory of the sacrum or the sacro^vertebral angle. At 
 the posterior surface of the base, is a triangular aperture, which is the 
 commencement of a canal, traversing the whole extent of the sacrum, 
 which gradually diminishes in size as it descends, and in which the 
 spinal cord is continued. The apox of the sacrum is small, having an 
 oval surface which articulates with the base of the coccyx. 
 
 The texture of the sacrum is spongy and cellular, and covered ex- 
 ternally by a thin lamina of compact tissue ; its length is about four
 
 THE PELVIS. 19 
 
 and a half inches. The union of the sacrum with the ilia is so 
 arranged as to give great firmness and security to its position, so that 
 it may sustain without injury, any Weight from within outward, and 
 from above downward ; the sacrum entering the ilia like a wedge, 
 having its superior portion broader than its inferior, and its anterior 
 point of union broader than its posterior. 
 
 The OS COCCYX or cuckoo bone, so named from its resemblance 
 to the beak of the cuckoo, is the caudal extremity of the spinal column. 
 It is a small, single, triangular bone, the base of which points upward, 
 and unites with the apex of the sacrum by means of an oval articular 
 surface, which, it is said, admits of a backward motion of the coccyx, 
 when pressed by the fetal head, to the extent of half an inch. Yet 
 the firmness by which the coccyx is fastened to the ischia, through 
 means of the saero-sciatic ligaments, is unfavorable to any such mo- 
 bility, except by severe and continued pressure. The coccyx is flat- 
 tened, curved from behind forward, and bears some resemblance to the 
 sacrum, though it differs from it in being much smaller, about one and 
 a half inches in length, and in having no spinal canal. Its anterior 
 surface is slightly concave and rough, and supports the lower extremity 
 of the rectum ; its posterior surface is convex and unequal, is separated 
 from the skin only by the posterior sacro-coccygeal ligament, and has 
 inserted into it some of the fibers of the gluteeus magnus muscle. Its 
 lateral edges are rough, giving attachment to the small sciatic liga- 
 ments and the ischio-coccygeus muscle. Its apex, generally project- 
 ing in front, gives attachment to the fibers of the external sphincter 
 ani muscle. In childhood the coccyx is formed of three or more bony 
 pieces, but which become consolidated in adult age. The internal 
 structure of this bone is cellular, and covered externally by a very 
 delicate lamina of compact texture. It is called by the various names 
 of buckle, knuckle, or whistle bone, crupper bone, etc. 
 
 The OSSA INXOMINATA, or nameless bones, and sometimes 
 termed the haunch bones, are two in number; they are the largest and 
 most irregular of the pelvic bones, are of a quadrilateral form, con- 
 tracted in their central portions, and form the lateral, anterior, and in- 
 ferior portions of the pelvis. Each one of these bones consists, in 
 early childhood, of three distinct pieces, but which become firmly con- 
 solidated in the adult. These are called the os ilium, the os ischium, 
 and the os pubis, whose union takes place in the acetabulum or cotyloid
 
 20 KING'S ECLECTIC OBSTETRICS. 
 
 cavity; the dividing lines of these three bones meet nearly in the 
 center of the aectabulum, giving the upper and outer two-fifths to the 
 ilium, anteriorly one-fifth to the pubis, and the remaining two-fifths 
 to the ischium ; these several bones entering into the; formation of the 
 acetabulum. For purposes of description, and as a matter of more 
 easy reference, the above division is preserved by anatomists. 
 
 The OS ILIUM, hip or coxal bone (one on each side of the sacrum, 
 and which form the upper and lateral portions of the pelvis), is the 
 largest bone of the os innominatum, is flat, broad, and nearly triangular 
 in shape. The base or body of the bone is situated at the thick and 
 narrow part which forms the upper portion of the acetabulum, and the 
 large expansion or wing which passes from it, upward and outward, is 
 termed the ala, and which aids in forming the cavity of the false pelvis. 
 The external or femoral surface of the ilium is convex, and is called 
 the dorsum il'd or gluteal region, having the three glutei muscles lying 
 upon it ; and presents below, in its inferior and outer part, a cavity 
 for the head of the femur, called the acetabulum or cotyloid cavity. 
 
 The internal or abdominal portion, called the ventor or costa presents 
 at the upper part a broad, smooth, concave surface, termed the internal 
 iliac fossa, on which the internal iliac muscle is situated, and which 
 likewise supports the large intestine; in one of these fossae, the child's 
 head is placed during the operation of turning. Below, is a prominent 
 ridge or curved line, running from behind forward, that is, from the 
 superior part of the sacro-iliac junction to the top of the pubis, forming 
 part of the lined ilio-pectinea, or ttio-pubic line which defines the 
 superior strait. The excavation above this ridge, which is also named 
 the brim of the pelvis, is termed the false, upper, or superior basin or 
 pelvis, while the cavity below is termed the true, lesser, or lower basin 
 or pelvis, or the pelvic cavity. 
 
 The superior or upper convex edge of each wing, is called the crest, 
 or crista of the ilium, and to which the principal muscles of the ab- 
 domen that are called into action during labor are attached, as the in- 
 ternal and external oblique, and the transversalis ; this crest is rough 
 and thick, for the insertion of muscles, is shaped like the letter/, being 
 thicker in front and behind than in the middle, and terminates in 
 front, in an anterior-superior spinous process, from which some of the 
 muscles of the abdomen and thigh arise, and into which others are also 
 inserted and behind, in a posterior-superior spinous process, under- 
 neath each of which processes is a semi-circular notch, terminating
 
 THE PELVIS. 21 
 
 inferiorly in an anterior and & posterior-inferior spinous process ; all of 
 which processes serve as points of origin and insertion of muscles and 
 ligaments. The surface which articulates with the sacrum is rough 
 and irregular. Immediately below the posterior-inferior spinous pro- 
 cess is an arched sinuosity, forming at the union of the ilium and sacrum 
 the great sciatic notch, which is two inches in depth, and terminates 
 inferiorly, by an acute and sharp spinous process called the spine of 
 the ischium; which points backward and slightly inward. 
 
 The OS ISCHIUM, os sedentarium, or seat bone, occupies the 
 lower part of the pelvis ; its base or body forms the inferior portion 
 of the cotyloid cavity, and is very thick and strong. The internal 
 surface of this bone is smooth and slightly concave, and is called the 
 plane of the ischium; it is nearly an equilateral triangle, and is three 
 and a half inches in length. The planes of the two opposite ischia 
 incline toward each other, forward and downward, and which conver- 
 gence exerts an influence on the fetal head during labor, repelling or 
 deflecting the vertex toward the pubic arch, as the head approaches 
 the outlet of the pelvis. 
 
 The spine of the ischium, proceeding from the posterior portion of 
 the os ischium, furnishes a place of attachment for the lesser sacro- 
 ischiatic or sacro-sciatic ligament; beneath this process is a concavity 
 or no-tch, named the lesser ischiatic, or sciatic notch in which the tendon 
 of the obturator interims plays. Below this, is the inferior or lower 
 portion of the ischium, or that part upon which the body rests when 
 in a sitting posture ; it is rough, thick, and strong, and is termed the 
 tuberosity of the ischium; the great sacro-sciatic ligament arises on the 
 inside of this tuberosity, and its outside, inside, and central surfaces 
 give origin to various muscles. 
 
 Passing obliquely from without inward, and from below upward, 
 from the tuberosity of the ischium, is a flat process of bone called the 
 ramus of the ischium, which unites with the descending branch or 
 ramus of the pubis, and assists in forming the pubic arch. In the 
 female pelvis, the anterior edge of this ramus is beveled or turned 
 outward, thus affording more space for the passage of the fetal head 
 under the pubic arch. The opening in the anterior part of the pelvis, 
 formed by the ischium and os pubis, is called the thyroid, sub-pubic, 
 or obturator foramen, through which pass the obturator vessels and 
 nerves, and to its inner side is attached the adductors and the obturator 
 externus. This foramen is rounded in man and triangular in woman.
 
 22 KINt.'s ECLECTIC OBSTETRICS. 
 
 The OS PUBIS, otherwise variously called the .shear bone, the 
 cross bone, the bar bone, or pecten, is situated at the inner and an- 
 terior part of the os innominatum, and is joined to its fellow of the 
 opposite side, by a union or articulation termed the symphysis pubi*. 
 It may be divided into, the body, a horizontal, and a descending 
 ram us or branch. The body, or base, of each os pubis is placed trans- 
 versely before the anterior part of the ilium ; and from the side of the 
 body proceeds the horizontal ramus, going outward to meet the ilium. 
 The superior face of the os pubis is flat, and upon its outer and an- 
 terior portion is its spiuous process, which gives attachment to Pou- 
 part's ligament, and from this process two eminences proceed, one pass- 
 ing outward to be lost in the acetabulum ; the other, running along the 
 inner margin of the horizontal ramus, is called the crest of the pubis, 
 or crista pubis. This ridge is sharp and elevated, and forms the an- 
 terior third of the linea ilio-pectineal eminence. The descending 
 ramus of the pubis passes downward to unite \yith the ascending ramus 
 of the ischium. As with the rami of the ischia, the anterior edges of 
 the pubic rami are beveled or turned outward, affording a sufficiently 
 large and free opening for the fetal head to pass. The descending 
 ramus is connected with its fellow of the opposite side, toward their 
 origin, by a ligamentous substance, called the triangular ligament, 
 which is a part of the interpubic ligament, binding the two tubes to- 
 gether, and rendering the arch of the pubis broader or lower, and also 
 stronger. The arch of the pubis is formed on the anterior and inferior 
 part of the pelvis, by the union of the two pubic rami ; it is much 
 wider in the female than in the male. . 
 
 The anterior face of the body of the os pubis is concave and rough, 
 for the origin of the adductor muscles of the thigh ; its posterior sur- 
 face is nearly flat and smooth, but contributing a little to favor the 
 general concavity of the pelvis. The largest or thickest portion of the 
 pubic bone is that employed in the formation of the acetabulum; the 
 next thickest portion is at the symphysis pubis, from which it becomes 
 gradually thinner as it extends toward the obturator foramen. 
 
 It will be seen that the ilium forms no portion of the inferior strait,, 
 but enters largely into the superior also that the ischium forms no 
 portion of the superior strait, but only of the inferior while the 
 pubic bones form a large portion of both straits. Hence a deformity 
 of the ilium would affect only the brim, or the false pelvis ; a deformity 
 of the ischium would implicate only the outlet; but a distorted pubes 
 would necessarily involve each of the straits.
 
 SYMYHYSES AND LIGAMENTS OF THE PELVIS. 23 
 
 CHAPTER III. 
 
 SYMPHYSES AND LIGAMENTS OF THE PELVIS. ' 
 
 THE BONES of the PELVIS are united together in such a man- 
 ner as to give to it great strength, the articulations being effected by 
 means of ligaments and the interposition of cartilage giving support 
 to the trunk and favoring the movements of the lower extremities. 
 The joints to be considered which have received the name of Sym- 
 physes: each symphysis being designated according to the bones which 
 form it are, the symphysis pubis, the two sacro-iliac symphyses, the 
 sacro-coccygeal symphysis, and the lumbo-sacral or sacro-vertebral 
 symphysis. They all belong to the class of joints termed amphiar- 
 throdial. 
 
 The SYMPHYSIS PUBIS, or pubic articulation, is formed by the 
 junction of the oval articular surfaces between the bodies of the 
 ossa-pubis. A thick layer of tough fibro-cartilage is firmly united to 
 the articulating surface of each pubic bone; this passes across from 
 one bone to the other, and is so strong as to admit rather of the dis- 
 ruption of the bone than of its own tissue. At the center of the sym- 
 physis, and toward the posterior third of the fibro-cartilage, are two 
 smooth, polished, oblong articular surfaces, covered by a cartilage, 
 and lined by a synovial membrane, which arrangement is difficult to 
 detect in man, or even in woman, except when she has died shortly 
 previous to, or soon after, parturition. 
 
 Some authorities doubt the existence of a synovial membrane in 
 the pubic joint. The ligaments which strengthen the pubic articula- 
 tion are four in number: 1, the anterior pubic ligament, lying on the 
 anterior face of the symphysis pubis ; 2, the posterior pubic ligament, 
 which is an expansion of the periosteum; 3, the superior pubic liga- 
 ment, or supra-pubic ligament, which supports the superior edge of the 
 pubis, and effaces all its inequalities; and 4, the inferior, or sub-pubic 
 ligament, which is remarkably strong and thick, and of a triangular 
 form; by some, it is considered as a continuation of the inter-pubic 
 ligament. It adds greatly to the strength of the articulation, and its 
 inferior edge constitutes the crown of the pubic nrcJi.
 
 24 KING'S ECLECTIC OBSTETRICS. 
 
 The SACRO-ILIAC SYMPHYSIS, or junction, is the articulation 
 formed by the corresponding rough surfaces of the sacrum and ilium, 
 and of which there are two one on the right, and the other on the left 
 superior lateral portion of the sacrum. Each of these articulating sur- 
 faces has a covering of cartilage, which is thicker on the sacrum than 
 on the ijia, and between which exists a thick, yellowish fluid, which 
 serves to lubricate the parts; and in children and pregnant women 
 there is said to be a synovial membrane in each joint. 
 
 The ligaments which aid in strengthening this articulation, are 
 four in number: 1. The posterior sacro-iliac ligament fills nearly the 
 whole of the deep excavation comprised between the sacrum and the 
 two posterior spinous iliac processes; their union constitutes a pyra- 
 midal ligament, capable of immense resistance. This ligament arises 
 from the posterior and inferior spinous processes of the ilium, and 
 from the margin of the sacrum and coccyx, and passes outward and 
 downward to be inserted into the tuberosity of the ischium; it is broad 
 at its origin, but narrow and thick at its insertion. 2. The anterior 
 sacro-iliac ligament, which extends transversely from the sacrum to the 
 ilium, is an expansion of the periosteum of the pelvis, which passes 
 in front of the articulation, and adheres to it but feebly. 3. The 
 superior sacro-iliac ligament, which passes transversely from the base 
 of the sacrum to the ilium, is very thick and strong. 4. The infe- 
 rior sacro-iliac ligament arises from the posterior-superior spinous 
 process of the ilium ; its superior fibers being inserted below the third 
 sacral foramen, while the lower portion is inserted anteriorly into the 
 tubercle of the extremity of the edge of the sacrum, and posteriorly to 
 the great sacro-sciatic ligament. 
 
 The foregoing articulations are still further strengthened by the 
 following ligaments, which pass between the sacrum and ischium, and 
 which assist in completing the parieties of the pelvic cavity viz. : 1. 
 The posterior, or greater sacro-sciatic ligament, which arises from the 
 internal lip of the tuberosity of the ischium, and from its ascending 
 ramns; it is situated obliquely in the posterior-inferior part of the 
 pelvis, is contracted in its center and expanded at its extremities, and 
 passes upward and backward to be inserted into the margin of the 
 coccyx and sacrum, and into the posterior-inferior spinous process of 
 the ilium. 2. The anterior, or lesser sacro-sciatic ligament, is placed in 
 front of the greater sacro-sciatic ligament, which it crosses; it arises 
 from the free margin of the sacrum and from all the bones of the 
 coccyx, and is inserted into the summit of the spine of the ischium.
 
 SYMPHYSES AND LIGAMENTS OF THE PELVIS. 25 
 
 These two ligaments convert the great sciatic notch into two openings 
 or foramina; the upper foramen is the larger, irregularly oval, and 
 transmits the pyriformis muscle, the great sciatic nerve, gluteal, ischi- 
 atic and internal pudic vessels and nerves, while the lower foramen is 
 of a long triangular shape, and gives passage to the internal obturator 
 muscle and internal pudic vessels and nerves. 
 
 The obturator, or sub-pubic ligament, may likewise be mentioned ; 
 it is inserted by its internal semi-circumference to the posterior face 
 of the ascending ischiatic ram us, and by its external semi-circumfer- 
 ence to the outline of the obturator foramen. This ligament (doses 
 the obturator foramen, with the exception of an opening at its upper 
 part, through which pass the obturator vessels and nerves. The obtu- 
 rator muscles are attached to the two surfaces of this membrane. ' 
 
 The SACRO-COCCYGEAL SYMPHYSIS is the articulation be- 
 tween the apex of the sacrum and the base of the coccyx; it is similar 
 to the joints between the bodies of the vertebrae. The union is effected 
 by two ligaments, and strengthened by an inter articular jibro-cartilage. 
 1. The anterior sacro-coccygeal ligament, which arises from the inferior 
 extremity of the sacrum, extends over the whole anterior face of the 
 coccyx, becoming blended with the periosteum. 2. The posterior sacro- 
 coccygeal ligament, which arises from the last sacral bone, is inserted 
 into the posterior surface of the second bone of the coccyx. This 
 ligament closes in and completes the lower and back part of the sacral 
 canal. 
 
 The Jnterarticular Fibro-cartilage, interposed between the articu- 
 lating surfaces of the sacrum and coccyx, differs from the ordinary 
 intervertebral cartilage in that it is thinner and firmer; it assists in 
 maintaining the connection between the bones, rendering mobility, it 
 is claimed by some authors, impossible. This joint is undoubtedly 
 subject to slight motion under certain circumstances, which will be 
 noticed further along in the work. 
 
 There are, in early life, coccygeal articulations which unite the 
 several pieces of the coccyx with each other; their consolidation takes 
 place more rapidly in males than in females. 
 
 LUMBO-SACRAL SYMPHYSIS is formed by the articulation of 
 the fifth lumbar vertebra with the upper surface of base of the sacrum. 
 The oblique position of the bones forming this articulation results 
 in a projection anteriorly, at the superior strait, called the promon-
 
 26 KING'S ECLECTIC OBSTETRICS. 
 
 tory of 1li<- Min-tnii, or the ^aero-vertebral angle. The ligaments of this 
 articulation, in addition to those commonly existing between the ver- 
 tebne, are two in number: 1. The lumbo-aacral ligament passes from 
 the lower j)ortion of the transverse process of the last lumbar vertebra 
 to the lateral portion of the base of the sacrum. 2. The lumbo-iliac 
 ligament passes horizontally from the tip of the transverse process of 
 the last lumbar vertebra to the crest of the ilium, covering the sacro- 
 iliac articulation. The intervertebral disk also contributes to the for- 
 mation and straightening of this joint, which is one of the strongest 
 of the pelvis. 
 
 The ilio-femoral articulation, or the junction of the femoral bones 
 with the ilia, in the cotyloid cavity, is a pelvic articulation ; it bears 
 no relation to parturition, however, and only needs a passing reference. 
 
 MOVEMENTS AT THE PELVIC AKTICULATIONS. 
 
 It has long been a question whether the articulations of the pelvis 
 are possessed of any motion. An examination of the method by which 
 the bones are united with each other, and the solidity of their union, 
 would lead us to consider them as perfectly immovable, at least in the 
 ordinary conditions of life. Yet, when we reflect that they are sup- 
 plied with synovial membranes, which are only found in movable ar- 
 ticulations, we may admit them to possess, under certain circumstances, 
 a slight degree of motion, as for instance, the shock of a fall from a 
 height, upon the feet, is much diminished in its influence upon the 
 body and brain, by a slight mobility. Dr. Laborie, from examinations 
 of the pelves of women shortly after delivery, is led to believe that 
 there is a mobility of these articulations tending to enlarge the trans- 
 verse diameter at the outlet; the other diameters being increased by 
 relaxation of the sacro-sciatic ligaments and the mobility of the sacro- 
 coccygeal symphysis; the sacro-iliac and pubic symphyses presenting 
 characters partaking partly of enarthrosis, and partly of ginglymus. 
 
 There is no doubt, but that during pregnancy or parturition, there 
 may be a relaxation, or separation of the symphyses; the symphysis 
 pubis especially being more frequently involved than the sacro-iliac 
 joints : any considerable separation however, favoring marked mobility, 
 is an uncommon event, and one which is seldom met with, being a 
 pathological condition dependent upon some disease of the parts them- 
 selves. 
 
 For, were it a circumstance common to parturient women, it would 
 be impossible for them to walk or exercise immediately previous, as
 
 SYMPHYSES AND LIGAMENTS OF THE PELVIS. 27 
 
 well as subsequent, to confinement (acts which are accomplished daily), 
 from the fact that an appreciable degree of mobility would not only 
 render it impossible to walk, but likewise very painful to stand. The 
 tissues about the joints may, probably, become softer, and perhaps 
 more movable during pregnancy and parturition, yet any appreciable 
 relaxation or separation must necessarily be unfavorable, and owe 
 their origin to some disease not connected with these conditions. 
 
 \Vhen relaxation does take place, the symphyses become .swollen, 
 and sometimes dilate so much as to separate the bones which aid in 
 their formation, permitting them to glide over each other, and occa- 
 sioning uneasiness and fatigue in the movements of the female, with 
 difficulty of standing. Should labor come on, the auxiliary muscles 
 of the uterus, not having any longer a fixed point of insertion in the 
 vacillating bones of the pelvis, draw the symphyses apart, producing 
 great agony; and the female, dreading the pain occasioned by their 
 contraction, remains passive, and allows the uterus slow r ly and diffi- 
 cultly to expel its contents, unaided by her efforts. Instances of this 
 kind have taken place, and have always proved a source of much dis- 
 tress and suffering, causing more or less intense pain on motion, with 
 much difficulty in moving the lower extremities, and an inability to 
 stand. 
 
 Occasionally there is not only a relaxation, but likewise an actual 
 separation of the pelvic joints, giving rise to most intense suffering, 
 inflammation, peritonitis, and all the symptoms of simple relaxation 
 in a more aggravated form, greatly endangering life. This separation 
 may be accidental, resulting from the powerful efforts made by the 
 patient to expedite her delivery; or it may ensue from the employ- 
 ment of the lever or forceps in extracting the fetal head. Sometimes 
 it is congenital, and usually accompanies exstrophy or extroversion of 
 the bladder, of which it may probably be the result. 
 
 There is but little protection given by ligaments to the anterior 
 part of the sacro-iliac symphyses, the only ligament of any size being 
 the anterior sacro-iliac; the, principal ligaments are placed on the outer 
 edge of the joint, and any tendency to open at its inner margin is pre- 
 vented by the ligaments of the symphysis pubis. Hence, a separation 
 of the pubic bones will occasion a relaxation or separation of the sacro- 
 iliac symphyses; and when a separation takes place in consequence of 
 the pubic junction being cut or ruptured, the sacro-iliac symphyses 
 immediately open considerably, the effect of which is pain, inflamma- 
 tion, and, if not remedied, caries of the bone, suppuration of the parts y 
 and hectic fever.
 
 JS KING'S ECLECTIC OIJKTKTRICS. 
 
 Decided separation of the pelvic symphyses may be diagnosed by 
 carefully examining the parts. When the pubic symphysis is involved, 
 it may be recognized by grasping the symphysis between the thumb 
 externally and one or two fingers within the vagina, with the patient 
 standing; an effort at walking will at once impart the degree of mo- 
 bility existing between the bones. Rupture of the sacro-iliac joints 
 may be determined by placing the open hands over the symphyses and 
 wings of the ilium, and directing the patient at the same time, to move 
 the lower limbs as in walking; the degree of mobility and separation 
 will at once become apparent. Relaxation or rupture of the pelvic 
 joints may develop during the last months of pregnancy, or not until 
 after labor, and is always attended with pain on the least exertion. 
 Inflammation is occasionally present, and may result in suppuration 
 and the evacuation of pus. Locomotion is usually impaired, and be- 
 comes impossible if there exists a decided degree of separation of the 
 symphyses. 
 
 TREATMENT. Rest is the most essential factor in the treatment 
 of either relaxation or separation of the symphyses of the pelvis. It 
 will be absolutely necessary for the patient to remain quiet, and in a 
 recumbent position for a long-continued period of time. The patient 
 must not be permitted to stand on the feet, or attempt to walk; walk- 
 ing, particularly, is likely to prove injurious, and excite inflammatory 
 action. Internal medication is uncalled for in the treatment of this 
 affection. Local agents, to control inflammatory development, and 
 anodynes to relieve pain, may be useful in some cases. The treatment 
 in the main, however, will consist in the application of dressings and 
 bandages, together with such mechanical apparatus as will favor the 
 support of the parts. The pressure of the bandage should be at first 
 gentle, but gradually increased. The bowels should be kept regular, 
 and the surface of the body frequently bathed. 
 
 The patient should be advised not to attempt walking too soon after 
 delivery, and when it is considered prudent to test her strength, it 
 must be done with great care. A well-padded leathern girdle should 
 be fixed around the hips, as tightly as the patient can bear, and kept 
 in its place by straps passed under the thighs; the upper part of the 
 body should also be supported on crutches, in order to lessen the weight 
 and pressure of the trunk on the articulations, which must, at first, be 
 unable to maintain its whole weight.
 
 STRAITS AND CAVITIES OF THK PELVIS. 
 
 29 
 
 CHAPTER IV. 
 
 STRAITS AND CAVITIES OF THE PELVIS THE PELVIS AS A WHOLE. 
 
 THE union of the several bones already considered by means of 
 their symphyses or articulations, forms the Pelvis, which is of a con- 
 ical shape, with its base looking upward and forward, and its apex 
 pointing downward and inward. The internal surface of the pelvis is 
 divided into the upper basin, false or greater pelvis, located above the 
 superior strait, and the lower basin, true or lesser pelvis, more com- 
 monly termed the pelvic cavity or excavation, and which occupies the 
 space comprised between, the superior and inferior straits so called 
 because they are rather more contracted than the space between them. 
 The greater pelvis is bounded posteriorly b^y the lumbar vertebra?, lat- 
 erally by the ahe ilii, and anteriorly by the abdominal parietes; the 
 lesser pelvis is marked posteriorly by the sacrum and coccyx, laterally 
 by the ischia, and anteriorly by the pubes. 
 
 Between these two cavities is an aperture of an elliptical or curvili- 
 near triangular form, somewhat resembling the shape of a playing- 
 card heart, with its base resting on the sacrum, and at which location 
 a prominent ridge is observable, which has received the names of ilio- 
 pubic line, linea ilio-pectineal protuberance and brim of the pelvis; it 
 is formed by the crest of the pubis, and the ridge which is continuous 
 along the lower part of the alre ilii, and which, together with the pro- 
 montory of the sacrum, consti- 
 tutes the SUPERIOR STRAIT. Ill 
 a well formed pelvis its circum- 
 ference measures from fourteen 
 to sixteen inches. The diame- 
 ters of the superior strait are as 
 follows: 1. The antero-posterior 
 or sacro-publc, or conjugate di- 
 ameter (A A, Fig. 4), extending 
 from the superior- posterior edge 
 'of the symphysis pubis to the 
 promontory of the sacrum, DIAMETERS OF THE SUPERIOR STRAIT. 
 
 measures from four to four and A A ' Antero-posterior C C, Oblique Diameters. 
 
 Diameter. A C, Sacro-cotyloid Space. 
 
 a half inches. 2. The transverse B B, Transverse Diameter. 
 
 or bis-iliac diameter (B B, Fig. 4), passing from one ilium to the other, 
 
 FIG. 4.
 
 30 
 
 KING'S ECLECTIC OBSTETRICS. 
 
 FIG. 5. 
 
 and crossing- the antero-posterior diameter, at a right angle, measures 
 five inches. In the recent subject, this diameter is lessened by the 
 psose and iliac muscles, which overhang the sides of the brim. 3. The 
 oblique di(tmcters* (c c, Fig. 4), passing from the ilio pectineal emi- 
 nence, just above the acetabulum, to the sacro-iliae symphysis of the 
 opposite side, measure, each, from four and a half to five inches. The 
 one passing from the right ilio pectineal eminence, to the left sacro- 
 ili:ic symphysis, is called the right oblique diameter; and that which 
 passes from the left ilio pectineal eminence, to the right sacro-iliac 
 symphysis, is called the left oblique diameter. 4. The sacro-cotyloid 
 space, or diameter (A C, Fig. 4), extending from the center of the 
 promontory of the sacrum, to the ridge just above the cotyloid cavity, 
 measures from three and three-quarters of an inch to four inches. 
 The articulation of the spinal column witfi the pelvis, is such, that 
 
 the axis of the superior strait is not 
 parallel with that of the body, the su- 
 perior-posterior part of the pubic sym- 
 physis being about four inches below 
 the level of the sacral promontory. If 
 a piece of pasteboard be accurately 
 cut and fitted to the pectineal line, or 
 superior strait, it will represent the 
 plane of that strait (c H, Fig. 5), and 
 will be neither horizontal nor vertical, 
 but will form, with a horizontal line, 
 an angle of about 54 to 56, varying 
 more or less according to the position 
 of the body. The axis of the superior 
 strait will, therefore, be an imaginary 
 line passing through the center of the plane at right angles (A B, Fig. 5), 
 and will be found to extend from the neighborhood of the umbilicus, 
 downward and backward, to the central portion of the coccyx. 
 
 The INFERIOR or PERINEAL STRAIT, also termed the outlet 
 
 * I am aware that many writers term the oblique diameters, right or left, accord- 
 ing to the sacro-iliac symphysis from which they commence their measurements. 
 I have always considered this an incorrect mode of measuring, one less readily 
 comprehended by the student, and consequently instead of taking the posterior 
 extremities of these diameters as the origin, I commence at their anterior extrem- 
 ities, and call the diameter right or left oblique, according as its extremity is sit- 
 uated anteriorly and laterally to the right or left side. 
 
 A B, Axis of the Superior Strait. 
 C H, Plane of the Superior Strait. 
 C D, Horizontal Line. 
 C D, Plane of the Inferior Strait. 
 E G, Axis of the Inferior Strait.
 
 STRAITS AND CAVITIES OF THE PELVIS. 
 
 31 
 
 Fia. 6. 
 
 of the pelvis, is bounded posteriorly by the apex of the coccyx, laterally 
 by the inner edges of the ischiatic tuberosities and the sacro-sciatic 
 ligaments, and anteriorly by the rami of the ischla, and the inner edges 
 of the pubic arch. Its circumference measures between thirteen and 
 fourteen inches. The conformation of this strait is apparently very 
 irregular, but if a sheet of paper be applied to it, and its outline 
 traced by a pencil, it will be found of an oval form, with its large 
 extremity pointed backward, and broken by the projection of the 
 coccyx. The diameters of the inferior strait are as follows : 
 
 1. The antero-posterior diameter (A A, Fig. 6), extending from the 
 lower edge of the symphysis pubis 
 to the apex of the coccyx, measures 
 four inches, but in some women it 
 may be increased to five, in con- 
 sequence of the regression of the 
 coccyx. 2. The transverse, or bis- 
 ischiatic diameter (B B, Fig. 6), ex- 
 tending from one tuberosity of the 
 ischium to the other, measures four 
 inches. 3. The oblique diameters 
 (c C, Fig. 6), extending from the 
 center of the great sacro-sciatic lig- 
 ament of one side, to the point of 
 union between the ascending ramus 
 of the ischium and descending ramus 
 of the pubis, measure, each, from 
 four to four and a-half inches. At 
 the period of delivery, this diameter may be slightly increased, owing 
 to the mobility of the sacro-sciatic ligaments. 
 
 That which passes from the right lateral anterior region to the left 
 lateral posterior, is called the right oblique diameter; and that which 
 passes from the left lateral anterior region to the right lateral posterior, 
 is called the left oblique diameter. 
 
 An imaginary line extending from the lower edge of the symphysis 
 pubis to the coccygeal apex, will represent the direction of the plane 
 of the inferior strait (c E, Fig. 5), and a line passing through the cen- 
 ter of this plane, at right angles or perpendicular to it, will give the 
 direction of the axis of the inferior straits (FG, Fig. 5), which extends 
 from the center of the strait to the first sacral bone, and crosses the 
 axis of the superior strait near the center of the pelvic cavity, forming 
 
 DIAMETERS OP THE INFERIOR STRAITS. 
 A A, Antero-posterior diameter. 
 B B, Transverse diameter. 
 C C, Oblique diameters. 
 
 1. Base of the Sacrum. 
 
 2. Pubic Symphyses and Pubic Crest. 
 
 3. Anterior-superior Spinous Process of the 
 
 Ilium. 
 4 4. Obturator Foramina.
 
 32 
 
 KING'S ECLECTIC OBSTETRICS. 
 
 FIG. 7. 
 
 at their point of contact a very obtuse angle ; it is parallel with the axis 
 of the body. The direction of tin- axes of the two straits, should be 
 well understood, as they determine the direction which the fetal head 
 takes in passing through the pelvis, and which course should be fol- 
 lowed whenever delivery has to be effected by instruments; the curved 
 direction of the two axes through the center of the pelvis, may be 
 considered as the true axis of the pelvis (G K, F'ty. 7). 
 
 In consequence of the arrangement of the pelvic bones, which 
 causes this variation in the direction of the axes of the two straits, the 
 pelvic contents are prevented from falling downward, which might 
 otherwise, be the result, either from their own gravity, or from the 
 pressure of the abdominal viscera above them. 
 
 The PELVIC CAVITY or EXCAVATION, includes all that 
 space occupied between the superior and inferior straits ; it is bounded 
 posteriorly by the sacrum, the coccyx, the sacro-iliac symphyses, and 
 a portion of the sacro-sciatic ligaments; anteriorly, by the symphysis- 
 pubis, pubic bones and the internal obturator fossa?; and laterally, by 
 the two inclined acetabular planes, the sciatic openings, and the sacro- 
 
 sciaitc ligaments. The canal of this 
 cavity possesses a curvature cor- 
 responding to the curve of the sac- 
 rum, and which gives to it a greater 
 extent than that of the straits. The 
 axis of this canal represents the 
 route taken by the fetus in its expul- 
 sion through the cavity, and should 
 be well understood by the practi- 
 tioner, if he expects to meet with 
 success in the operations which may 
 be necessary to effect artificial de- 
 livery. The axis of the pelvis is 
 not formed by two straight lines, 
 nor does it, as supposed by Cams 
 and others, represent the arc of a 
 circle ; but it has been well deter- 
 mined by M. Cazeaux, who ob- 
 serves (Fig. 7) : 
 
 " To form an exact idea of the 
 general disposition of the pelvic 
 cavity, it seems best to cut that canal by a series of planes, passing 
 
 A B, Plane of the Superior Strait. 
 I O, -Plane of the Inferior Strait. 
 Q', The point where these two planes would 
 
 meet, if prolonged. 
 M N, The Horizontal Line. 
 E F, The Axis of the Superior Strait. 
 G K, The Axis of the Pelvic Cavity. 
 P Q R S T, Various points taken on the Sacrum 
 
 to show the plane of the excavation at each 
 
 point.
 
 STRAITS AND CAVITIES OF THE PELVIS. 33 
 
 from the point Q' (the point of intersection of the planes of the superior 
 and inferior straits), to the points r Q K s T, of the anterior face of the 
 sacrum. Each one of these planes will determine the opening of the 
 pelvic cavity at that point. Now, to determine with precision the di- 
 rection of the general axis of the excavation, it will be necessary to 
 erect a perpendicular to the geometrical center of each one of these 
 sections, and to draw a line ( K) along the extremities of the perpen- 
 diculars. This line (G K) is curved, and is called the general axis of 
 the pelvic cavity. It is easy to see that this line is nearly parallel 
 with the anterior face of the sacrum, and its extremities are lost in the 
 axes of the superior and inferior straits. This curve represents exactly 
 the axis of the whole excavation ; that is to say, the line which the 
 fetus traverses in passing through the pelvis." 
 
 The depth of the pelvic excavation, posteriorly, along the sacrum 
 and coccyx, is from five to six inches; laterally, three and a-half 
 inches ; anteriorly, along the os pubis, one and a-half to two inches. 
 Its diameters are: 
 
 1. The antero-posterior diameter, passing from the symphysis pubis 
 to the center of the sacrum, measures four and a-half inches, or 
 more. 
 
 2. The transverse diameter, extending from the plane of one ischium, 
 to that of the other, measures about four and a-half inches. 
 
 There is considerable difference in form and texture, between the 
 pelvis of a female and that of a male. (Figs. 2 and 3.) The female 
 pelvis is not so strong nor so thick as that of the male, and contains 
 less osseous matter; in the male, the long diameter of the superior, 
 strait, is from before, backward, while in the female it is from side to 
 side; in the male, the brim is more triangular; in the female, more 
 oval. In the female the ilia are more distant; the tuberosities of the 
 ischia arc also further apart from each other, and from the coccyx, and 
 the space between the pubes and coccyx is greater than in the male. 
 The sacrum of the female is broader and more curved than in the 
 male, and the superior articulations are more distant from each other, 
 occasioning a peculiarity in her walking, apparently rendering it 
 more difficult for her to preserve the center of gravity. The sym- 
 physis pubis is not so long in the female as in the male, and the ranii 
 of the pubes and ischia are smoother on their inner face, and have 
 their anterior edges turned more outwardly ; the obturator foramen is 
 3
 
 34 KING'S KCLKCTIC OBSTETRICS. 
 
 more triangular in the female; and the cotyloid cavities are more 
 widely apart. 
 
 The following dimensions of the male and female pelvis are by 
 Meckel : 
 
 IN THE MALE. IN THK FEMALE. 
 
 Inches. Lines. Indies. Lines. 
 "The transverse diameter of the great pelvis between 
 
 the anterior-superior spinous processes of the ilia. . 78 8 (i 
 
 Distance between the cristse of the ilia 8 3 9 4 
 
 Transverse diameter of the superior strait 46 50 
 
 Oblique diameter of the superior strait 45 45 
 
 Antero-posterior diameter of the superior strait 4 4 4 
 
 Transverse diameter of the cavity 4 4 8 
 
 Oblique diameter of the cavity 5 5 4 
 
 Antero-posterior diameter of the cavity 5 4 
 
 Transverse diameter of the lower strait or outlet 3 4 5 
 
 Antero-posterior diameter of the lower strait or outlet. 33 44 
 
 " The latter may be increased to 5 inches, from the mobility of the coccyx." 
 
 The above dimensions of the straits and cavity of the female pel- 
 vis are assumed as the standard, and any considerable deviation from 
 these measurements, may present an obstacle to the progress of deliv- 
 ery, and the pelvis is then said to be vitiated or malformed. 
 
 It may be proper to make a brief reference to some of the vessels 
 and soft parts which cover the pelvis, especially those which occupy 
 its cavity. In the greater or false pelvis, we find anteriorly, the mus- 
 cles and the anterior parieties of the abdomen, which assist in com- 
 pleting this basin; laterally, the iliac fossa3 are filled with the internal 
 iliac muscles; and posteriorly, are the psoas major and minor muscles, 
 which pass downward along and on the sides of the lumbar column, 
 and along the pelvic brim, to be inserted into the trochanter minor. 
 These muscles, in connection with the iliac veins and arteries, are so 
 arranged as to contract the size of the transverse diameter of the su- 
 perior strait, to even an inch less than its true length, thus apparently 
 presenting its oblique diameter as the largest ; but these muscles are 
 capable of great compression, especially when they are completely 
 relaxed by flexing the thighs upon the pelvis, and hence in the ma- 
 jority of cases, they present but little obstacle to the passage of the 
 fetus. 
 
 The pelvic excavation is lined by fascia, which assist in diminishing 
 its diameters; it is also lessened posteriorly, by the sacral plexuses of 
 nerves, the pyriform muscles, the hypogastric blood-vessels, and the
 
 DEFORMITIES OF THE PELVIS. 35 
 
 rectum ; anteriorly, by the bladder, the obturator nerves and vessels, 
 and the internal obturator muscles ; and in its vertical diameter, by 
 the floor of the pelvis or perineum, which is a muscular membranous 
 plane closing the pelvis inferiorly, acting in antagonism to the dia- 
 phragm and abdominal muscles, and on whose median line are the 
 urinary, generative, and fecal or anal orifices. Inclosed within these 
 soft parts are the vagina and uterus. The muscles of the perineum 
 are: the sphincter ani, surrounding the lower part of the rectum, and 
 which arises from the coccyx, and is attached to the center of the peri- 
 neum ; the sphincter or constrictor vagince, which arises from the body 
 of the clitoris, and is attached to the center of the perineum ; it is about 
 fifteen lines wide, and surrounds the anterior opening of the vagina, 
 acting as a sphincter to it; the erector clitoridis arises from the ascending 
 ramus of the ischium, covers the inferior face of the crus clitoridis, 
 and is inserted into the upper part of the crus and body of the clitoris; 
 it draws the clitoris downward and backward; and the transversalis 
 perincei arises from the fatty cellular membrane which covers the tuber- 
 osity of the os ischium, and is inserted into the perineal center; it keeps 
 the perineum in its proper place. 
 
 CHAPTER V. 
 
 DEFORMITIES OF THE PELVIS. 
 
 ANY remarkable deviation from the standard measurements of the 
 pelvis produces a malformation or deformity of it; yet it does not fol- 
 low that every slight variation should be viewed as a deformity, but only 
 those instances, in which it may so far depart from its normal form as 
 to render it extremely difficult, or even impossible to deliver the full- 
 grown fetus by the natural passage. A pelvis, the small diameter of 
 which measures three and a-half or four inches, may, in case there be 
 no unusual enlargement of the fetal head, admit of its safe passage at 
 full term with but very little difficulty; below this measurement, say 
 from three inches to three and a-half, the forceps will undoubtedly 
 be demanded ; if it be still smaller than this, the induction of prema- 
 ture delivery would be prudent and justifiable, and if the fetal head 
 should be unable to pass, the perforator would be required. In cases,
 
 36 KING'S ECLECTIC OBSTETRICS. 
 
 however; where the measurement of the small diameter does not ex- 
 ceed one inch and ii-half, the perforator can not be used with safety, ;md 
 in these instances, the Caesarean section is recommended as the only 
 chance for the mother's life. 
 
 The more general causes of vitiated or malformed pelvis, are rick- 
 ets and mollities ossium. Rickets is probably the most frequent cause ; 
 this is a disease common to children, especially those of a strumous 
 diathesis, and is very seldom met with in adults. In this affection the 
 bones become very much softened, in consequence of the deficiency of 
 the calcareous matters natural to them, owing to their absorption or 
 non-deposition: and in connection with the disease there is most usu- 
 ally an arrest of development of the bones, in which the pelvis, instead 
 of becoming properly developed with the growth of the female, retains 
 its infantile condition, and thus presents a permanent obstacle to de- 
 livery. From these circumstances the bones curve unnaturally in vari- 
 ous directions, especially those upon which there is much pressure, or 
 upon which is exerted a long-continued action of the muscles; and the 
 pelvis in particular, which sustains the weight of the trunk, becomes 
 more or less deformed, according to the duration and severity of the 
 disease, and the deformity continues even after the disease has been 
 cured. Most generally, this disease commences in the bones of the 
 inferior extremities, and gradually extends itself to the pelvis, the 
 spinal column, etc. 
 
 TREATMENT. Children, affected with rachitis, will require both 
 hygienic and therapeutic measures to overcome it. Rachitic softening 
 of the pelvic bones in tlie female infant, demands the most careful 
 and pains-taking treatment the deformity following, results in after 
 life in the most serious consequences. The invigoration of fresh air 
 is one of the first essentials in the treatment of this disease. The 
 child should be taken into the open air every day, as the weather will 
 permit. While indoors, the child should be kept in a state of rest, in a 
 reclining position ; the apartment should be well lighted and ventila- 
 ted, also dry, and on damp days a fire in an open fire-place would be 
 advantageous. We should next advise the mother as to diet, and this 
 is of the greatest importance. During the first year, the child should be 
 nourished at the breast, providing the mother is in good condition. 
 If breast milk can not be furnished, cow's milk may be used, properly 
 diluted. After the age of weaning, the diet, recommended, in the Xew
 
 DEFORMITIES OF THE PELVIS. 37 
 
 York hospitals, is meat soups, beef tea, peptonized beef the diet 
 being principally animal. The usual internal treatment consists in 
 supplying lime-salts to the system. Prof. J. Lewis Smith, in his 
 Treatise on the Diseases of Infancy and Childhood, recommends the 
 following formula, which he claims will be found useful in most cases : 
 
 R Olei morrhuae fgiv 
 
 Aq. calcis. 
 Syr. calcis lactophosphatis, aa fgij Misce. 
 
 Of this, one teaspoonful should be given four or five times daily to an 
 infant of one year. 
 
 Lime-water, codliver oil, the compound syrup of the phosphates 
 are recommended by most authors as valuable internal agents in the 
 treatment of this disease. The formula I have quoted contains these 
 ingredients in about the proper proportion. In moving the patient, 
 great care should be taken to prevent deformities : the softened and 
 yielding bones may be easily twisted or distorted. Children, and 
 especially female children, who are disposed to rickets, should never 
 be allowed to creep or walk at too early an age, lest pelvic deformity 
 occur as a consequence. Before exertion of lower extremities is 
 allowed, as standing or walking, the parts should be supported by stif- 
 fened dressings. 
 
 Mollifies Osslum, or Malacosteon, is the usual cause of those deform- 
 ities which take place during adult age, It also consists in an undue 
 softening of the bones, owing to the absence of their salts, especially 
 the phosphate of lime, and is usually connected with a gouty or rheu- 
 matic diathesis; sometimes it is the result of mercurial treatment. 
 This disease is gradual in its progress, and the deformity resulting 
 from it, may occur in women who have previously given birth to sev- 
 eral children, and who may subsequently become so deformed in the 
 pelvis, as to render delivery by the natural passage absolutely impos- 
 sible. 
 
 The cause of the deformity, in either rickets or mollities ossium, 
 is essentially the same ; thus, the sacrum being softened by either 
 disease, will, from the superincumbent pressure, be forced from its 
 natural position, occasioning an increase or decrease of the pelvic 
 diameters, at the superior strait, inferior strait, or in the pelvic cavity. 
 Or the oblique diameter of the pelvis, or its antero-posterior diameter 
 may be diminished, in consequence of the acetabula being driven in-
 
 38 KING'S ECLECTIC OBSTETRICS. 
 
 ward; these alterations may exist singly, or may be variously eom- 
 bined. 
 
 In cases of Mollities Ossiutu, the TREATMENT will be similar to 
 that named for rickets, together with such other measures as may be 
 indicated; however, the disease is seldom cured. 
 
 Deformities of the pelvis may arise from other causes than those to 
 which I have just referred; thus, the very erroneous practice of forc- 
 ing children to walk, by means of go-carts, baby -jumpers, and the like, 
 may at an early age give rise to malformations which will continue 
 irremediable through life. When children are allowed to walk vol- 
 untarily, gradually perfecting this exercise as their locomotive organs 
 acquire energy, strength, and development, deformities rarely occur. 
 A child carried constantly on one arm, may cause a malformation, and 
 I am acquainted with a lady, who has a deformed pelvis, originating 
 from carrying her mother's children during her girlhood, constantly 
 resting them on the one hip. Carrying heavy burdens in early life, or 
 remaining too long in one position, before the bones have acquired 
 the necessary firmness, are very apt to cause this kind of malfor- 
 mation. 
 
 An old unreduced luxation of the femoral bones, caries of the 
 bones, exostoses, the result of syphilitic or rheumatic affections, im- 
 perfectly consolidated fractures, and pelvic tumors, may contribute 
 to deformity of the pelvis, or occasion a diminution in its capac- 
 ity. Sometimes, it is impossible to determine the origin of the de- 
 formity. 
 
 Pelvic deformity is more common to the females of Europe than 
 to those of this country which is probably owing to the fact, that our 
 countrywomen are better nourished, take more healthful exercise, and 
 are not exposed to the many causes, common to Europe, which con- 
 tribute to destroy health among the working and indigent classes. 
 Many of the cases, which are met with in this country, are among 
 females, whose early life was passed in some portion of Europe. But, 
 there is no doubt, that as our population increases, together with an 
 increase of poverty, factory-working, etc., these results will cease to 
 be uncommon among us. 
 
 The various forms, given to the pelvis by the above causes, are very 
 numerous, and must ever vary, according to the multitudinous local 
 accidents, severity and duration of the causes, etc.; and to enter into a 
 minute description of them, or to arrange them into distinctive classes, 
 is almost impossible ; nor, indeed, is such an attempt absolutely neces-
 
 DEFORMITIES OF THE PELVIS. 39 
 
 feary. Some of the more common deformities have, however, been 
 classified by authors as follows: 1st. The abnormally large pelvis, or 
 where there is an excess of dimension ; 2d. The dwarfish pelvis, or 
 where there is a diminution of dimension ; 3d. The unequally con- 
 tracted pelvis ; and 4th. The obliquely distorted pelvis. 
 
 1st. The abnormally large pelvis (pelvis equaliter justo major], or 
 excess of the dimensions of the pelvis. This can not properly be 
 termed a deformity, yet its presence may give rise to many accidents, 
 which it is the duty of the accoucheur to prevent or relieve. Females, 
 in the unimpregnated state, in whom this condition exists, are very 
 liable to various uterine displacements, which often prove extremely 
 difficult to remedy. And during pregnancy, from the absence of due 
 support to the uterus above the superior strait, this organ readily de- 
 scends into the pelvic cavity, producing a sense of weight, with various 
 painful and unpleasant symptoms; as painful or difficult micturition, 
 constipation, obstinate tenesmus, hemorrhoids, pains, cramps, etc., the 
 necessary result of compression of the bladder, rectum, and the blood- 
 vessels and nerves which line the pelvis, by the enlarged and prolapsed 
 uterus. 
 
 Again, during parturition, and especially if the female should 
 exert herself by bearing down before the os uteri be sufficiently di- 
 lated, the uterus may be forced through the inferior strait; or, dilata- 
 tion being perfected, together with frequent and energetic uterine con- 
 tractions, the fetus, from the want of proper resistance, may pass 
 easily through the pelvic straits and cavity, and suddenly present 
 itself at the perineum, which has not yet been sufficiently distended, 
 and lacerate it. Or, should the- perineum yield without laceration, 
 precipitate birth frequently follows, rendering the female exceedingly 
 liable to hemorrhage, inversion, or other accidents. These inconven- 
 iences, however, may be readily obviated by a careful practitioner; 
 the recumbent position during the first months of pregnancy and dur- 
 ing labor, will generally overcome them. 
 
 2d. The dwarfish pelvis (pelvis equaliter justo minor), or diminution 
 of the dimensions of the pelvis. This deformity, although not very 
 common to this country, is occasionally met with. The pelvis retains 
 the proper form and dimensions externally, yet its internal cavities 
 are very much diminished in extent, varying from a quarter of an 
 inch to an inch, in each of the diameters. This kind of deformity is 
 not connected with rickets nor malacosteon ; nor can it be attributed 
 to arrest of development, as the pelvis is usually well formed, and
 
 40 KING'S ECLECTIC OBSTETRICS. 
 
 bears no resemblance to the undeveloped pelvis of the child ; its causes 
 are not well understood. 
 
 The difficulty in giving birth to 'a child, depends entirely upon the 
 degree of deviation of the pelvic dimensions from the standard size, 
 and the proportions existing between the diameters of the fetal head 
 and the pelvis; yet a pelvis smaller than the average size, may occa- 
 sion no other difficulty than a tedious, disagreeable, painful, and per- 
 haps exhausting labor. 
 
 The diagnosis of this deformity is always difficult to correctly 
 determine, unless we have bad its existence indicated by a previous 
 labor, and in cases where we suspect its presence from the size of the 
 patient, a certainty may be acquired by an examination. All the di- 
 ameters of the pelvis are equally contracted in the dwarfish pelvis, 
 hence it has been termed " the equally contracted pelvis," and as no 
 favorable changes can be effected in consequence of the impossibility 
 of bringing the long diameter of the head to correspond with the long 
 and uncontracted diameter of the pelvis, as in the unequally contracted 
 pelvis, very great obstacles to delivery are presented, and most labors 
 result fatally to both mother and child. 
 
 3d. The unequally contracted pelvis, or partially deformed pelvis, in 
 which there is a great alteration c-r disproportion between the various 
 parts, so that during labor the female is subject to much suffering, and 
 even death, and the practitioner frequently becomes embarrassed. The 
 deformity may exist in the greater pelvis, the lesser pelvis, the supe- 
 rior strait, the inferior strait, or in two or more of these united. 
 
 FIG. 8. The most usual mal- 
 
 formations in the greater 
 pelvis are an exaggera- 
 tion of the curvature of 
 the lumbar column, pre- 
 senting a deviation or 
 projection of its anterior 
 surface ; or the wings of 
 the ilia, or the iliac fossa? 
 may be turned too much 
 ELONGATION OF THE ANTERO-POSTERIOR DIAMETER outwardly. These defor- 
 OF THE SUPERIOR STRAIT. mities do not materially 
 
 affect either pregnancy or parturition, although when excessive, they 
 undoubtedly influence the presentations of the fetus, and sometimes
 
 DEFORMITIES OF THE PELVIS. 41 
 
 occasion a permanent obliquity of the uterus, which may prevent the 
 natural expulsion of the child. (Figs. 8 and 9.) 
 
 The lesser pelvis, or pelvic cavity, may be deformed by a deficiency 
 or excess of one or more of its diameters, and which must, conse- 
 quently, influence, in a greater or less degree, the diameters of the 
 superior and inferior straits more frequently those of the superior 
 strait. 
 
 The antero-posterior diameter of the superior strait may be affected 
 FIG. 9. by the advancement of the promon- 
 
 tory of the sacrum toward the cen- 
 ter of the strait, in which case we 
 usually find an excessive curvature 
 of the sacrum, which is sometimes 
 so great, that its apex looks up to- 
 ward the pubic arch, interfering 
 
 T, " with the antero-posterior diameter 
 
 DIMINUTION OP THE ANTERO-POSTERIOR r 
 
 DIAMETER OF THE SUPERIOR STRAIT, of tnc inferior strait; or, while the 
 AND ELONGATION OP THE TRANSVERSE base of the sacrum diminishes the 
 DIAMETER. antero-posterior diameter of the su- 
 
 perior strait, in consequence of its abnormal projection, its apex may 
 be thrown backward, and thus increase the diameter of the inferior 
 strait. Sometimes the sacrum may be unchanged, but the pubes will 
 be found retreating toward the sacrum, diminishing the antero-poste- 
 rior diameter of the brim ; at other times, both the change in the sac- 
 rum and pubes may exist simultaneously. 
 
 The transverse diameter of the superior strait may be diminished 
 in consequence of one side of the pelvis being much narrowed, or the 
 horizontal rami of the pubes may approximate toward each other, be- 
 coming nearly parallel, and with this there may likewise exist an ap- 
 proach of the iliac bones. The forward projection of the pubes caused 
 by this deformity, increases the antero-posterior diameter of the brim. 
 A diminution of the transverse diameter of the brim, is seldom accom- 
 panied by an increase in that of the inferior strait ; although it may be 
 present where the contraction is the result of an upward and backward 
 dislocation of the femur, drawing the ischiatic tuberosities and pubic 
 rami more distantly apart. The transverse diameters of both straits 
 may be lessened by improper pressure upon the pelvis at a time when, 
 in consequence of disease, the bones are softened. 
 
 The oblique diameter of the superior strait may be decreased by
 
 42 KING'S ECLECTIC OBSTETRICS. 
 
 one side of the pubes projecting inwardly, while the other projects 
 outwardly, or the iliac bones may turn inwardly. If, in the first 
 deformity, the long diameter of the fetal head presents in the direction 
 of the great oblique diameter of the brim, and the transverse occupies 
 the diminished diameter, labor may terminate safely without artificial 
 assistance. 
 
 The superior strait may not be at all changed, while the inferior 
 strait is much diminished; thus, the antero-posterior diameter of the 
 inferior strait may be lessened by the apex of the sacrum turning 
 within and upward toward the pubic arch; or the coccyx may project 
 forward too much. 
 
 The transverse diameter of the inferior strait may be contracted in 
 consequence of the approach of the ischiatic tuberosities toward each 
 other, as well as of the sides of the pubic arch, which will render it 
 absolutely impossible for the head of the child to pass, or even the 
 hand of the accoucheur. This deformity is the most to be dreaded; 
 the head readily passes through the brim and pelvic cavity, and be- 
 comes arrested only at the outlet, and the practitioner, after delaying 
 for a length, of time, in hope of its expulsion, is finally obliged to 
 employ the forceps or perforator. 
 
 The oblique diameters of the inferior strait may be changed by the 
 maldirection of the ischio-pubic branches. 
 
 These malcoriformations of the two straits may exist singly, and 
 sometimes in combination, but in opposite directions; thus, if one 
 strait be contracted, the other will be enlarged. The consequences 
 which must arise 'from these various changes, will be evident to the 
 student who compares the diameters of the child's head with those of 
 the bony passages through which it must pass. 
 
 The pelvic cavity may be deformed, 1st, by a turning backward of 
 the pubes; 2d, by the abnormal length of the symphysis pubis, which 
 retards delivery by preventing the head from engaging in the arch of 
 the pubes; 3d, by the too great or small curvature of the sacrum; 4th, 
 by exostosis, and fibro-cartilaginous morbid productions. Various 
 other forms, than those referred to, may be assumed by the pelvis, 
 which, however, can not be satisfactorily classified, as they must ever 
 vary, according to circumstances. 
 
 4th. The obliquely distorted pelvis. (F/g. 10.) This deformity is 
 usually dependent upon an arrest of development of one or the 
 other side of the sacrum; more generally the right side, and which 
 occasionally extends to, and includes the ilium. Nseg6le was the first 
 writer who seems to have noticed this deformity, and of whose re-
 
 DEFORMITIES OF THE PELVIS. 
 
 43 
 
 marks M. Cazeaux has given 
 us the following -in his work 
 on Midwifery, translated edi- 
 tion, p. 434: 
 
 " The peculiar characteristics 
 of these deformed pelves are 
 as follows: 
 
 " 1st. Complete anchylosis of 
 one of the sacro-iliac symphyses, 
 or partial fusion of the sacrum 
 and one of the iliac bones. 
 
 " 2d. Arrest of development, 
 or defective development of 
 
 the lateral halt of the Sacrum, 
 
 and defect in the amplitude of ^ 
 
 th 
 
 the anterior 
 
 FIG 
 
 OBLIQUELY DISTORTED PELVIS, 
 
 In which the autero-posterior diameter traverses from 
 
 tor y * ^ sacrum to th left acetabuim; 
 
 the left oblique diameter is also lessened, while tho 
 
 sacral foramina of right is normal. 
 
 the anchylosed portion. ' 
 
 "3d. On the same side, diminished length of the ilium, with diminu- 
 tion in the extent of the sciatic notches of this bone; that is to say, the 
 distance from the anterior-superior spinal process of the jlium, to its 
 posterior-superior spinous process, as also the length of a line drawn 
 from a point at the pelvic inlet, corresponding with the sacro-iliac junc- 
 tion, if it existed, along the linea innominata, and the linea ilio- 
 pectinea to the symphysis pubis, are shorter than (the same distances) 
 on the other side. But farther upon the anchylosed bone, the part 
 corresponding with the articular surface, which is continuous without 
 interruption, with the sacrum, is not so high, and descends to a shortei 
 distance than it does on the opposite side, and than it would do in a 
 bone normally formed; or to express myself more clearly, if on the 
 anchylosed side we suppose the ilium and sacrum separated, or reunited 
 only by the interposition of a nbro-cartilaginous disk, such as exists in 
 the normal joint, the articular surface or the reunion of the two bones 
 would be found less long, and would descend less low than it would 
 on the non-anchylosed side, or upon the pelvis normally constituted. 
 
 " 4th. Tho sacrum seems to be pushed toward the anchylosed side 
 and it is toward that side that its anterior face is more or less turned, 
 while the symphysis pubis is pressed toward the opposite side, a dispo- 
 sition which prevents the symphysis pubis from being directly opposite 
 the promontory of the sacrum, and gives it an oblique direction. 
 
 "5th. On the anchylosed side, as much of the internal surface of the 
 ilium as concurs to the formation of the pelvic excavation is flattened,
 
 44 KING'S ECLECTIC OBSTETRICS; 
 
 and where considerable vitiation exists, it is almost entirely plane, so 
 that a line drawn from the middle or even from the posterior end of 
 the linea innominata, along the body and the transverse branches of 
 the pubis to its symphysis, will be nearly straight. We have never 
 seen at the lateral half of the anterior wall of the pelvis, of which we 
 now speak, any inclination inward, nor have we ever especially noticed 
 that sort of fracture of the horizontal branch of the pubis, which is 
 observed in pelves deformed from the effects of malacosteon in adults. 
 
 "6th. The other lateral half of the pelvis, that is to say, the one in 
 which there exists a sacro-iliac synchondrosis, also differs from the 
 normal condition. At first sight, in examining the pelvis under con- 
 sideration, and especially where the obliquity is considerable, it is easy 
 to induce oneself to believe in the normal conformation of the non- 
 anchylosed half; but this opinion is not correct ; thus, let us suppose 
 two pelves equally contracted, with this difference only, that in one 
 the left sacro-iliac symphysis is anchylosed, in the other, the anchylosis 
 is on the right side ; let a section of each be made so as to pass through 
 the middle of the sacrum and the symphysis pubis if now we under- 
 take to fit the right half of the first pelvis to the left half of the second, 
 so that the. cut surfaces shall cover each other, we will discover that 
 the pubic bones are separated by a distance of from eight to twelve 
 lines. Thus, the lateral half of the pelvis, which is free from anchy- 
 losis, participates not only in the abnormal situation and direction of 
 the bones, but also in their irregular form, in such a way that in meas- 
 uring this half, a line drawn from the center of .the promontory of the 
 sacrum, along the linea innorainata, and pectinea, to the symphysis 
 pubis, would be at its posterior half more curved, and at its anterior 
 half less curved than in a pelvis well formed. 
 
 "7th. It folloAvs from this, that the pelvis is obliquely contracted, 
 that is to say, in a direction which would intersect a line passing from 
 the anchylosed joint to the cotyloid cavity of the opposite side, while 
 the extent of the last-mentioned line is not diminished but may be 
 increased where the obliquity is very marked. In consequence of this, 
 the shape of the superior strait (that is to say, an imaginary surface ' 
 passing along the linea innominata and the linea pectinea over the 
 sacrum), and the shape of the middle of the excavation (situated mid- 
 way between the superior and inferior straits, called the apertura pelvis 
 media), would both resemble, properly speaking, an oblique oval when 
 examined in front the transverse or small diameter of which would 
 be represented by the contracted oblique diameter of the pelvis, while 
 its great or longitudinal diameter would correspond to the other oblique
 
 DEFORMITIES OF THE PELVIS. 45 
 
 diameter. On this account we may, as far as the form is concerned, 
 term this variety of pelvic deformity the obliquely oval pelvis. 
 
 "That the distance from the sacral promontory to the point corres- 
 ponding to the one or the other cotyloid cavity (the distance sacro- 
 cotyloid), as well as the distance from the obtuse point of the sacrum 
 to the spine of the ischium on either side, is less on the side where 
 the anchylosis exists. 
 
 "The distance from the tuberosity of the ischium on the side of the 
 anchylosis to the posterior-superior spinous process of the ilium of the 
 opposite side, as well as the distance between the spinous process of 
 the last lumbar vertebra, and the anterior-superior spinous process 
 of the ilium on the side of the anchylosis, are smaller than the same 
 measurements on the opposite side. 
 
 "The distance from the inferior edge of the symphysis pubis to 
 the posterior and superior spinous process of the ilium, when the 
 anchylosis exists is greater than that extending from the same point 
 of the symphysis pubis to the posterior-superior spinous process, of 
 the opposite side. 
 
 " The walls of the pelvic excavation converge, in a certain oblique 
 manner, from above downward, and the pubic arch is more or less 
 contracted, so as to give it a resemblance to the male pelvis. These 
 two conditions, as well as the contraction of the sciatic notch, the 
 diminution of the distance existing between the spines of the ischia, 
 and the one-sided and defective development of the sacrum, bear a 
 direct proportion with the degree of obliquity. 
 
 "Finally, on the flattened side, the cotyloid cavity is placed more 
 directly in front than is observable in the normally-formed pelvis, 
 while on the opposite side, it looks almost directly outward, in such 
 a way that when examining the pelvis in front the eye rests directly 
 upon the cotyloid cavity of the flattened side, while the edge of the 
 one on the other side can only be seen, or at least very little of its 
 cavity. 
 
 " In order to give to those who never have seen a pelvis of this 
 kind as accurate an idea as possible, we will remark that when first 
 seen they give us the impression that the deformity has been occasioned 
 by a pressure acting from above downward, and from without to with- 
 in, in an oblique direction upon one of the lateral halves of the an- 
 terior pelvic walls, and upon one of the cotyloid cavities, while, at 
 the same time, the other half seems to have been qpmpressed on its 
 posterior portion from without inward. 
 
 " Another peculiarity f this variety of deformed pelvis is, that they
 
 46 KING'S ECLECTIC OBSTETRICS. 
 
 differ from each other only in the degree of their obliquity, and at the 
 point where the sacrum is soldered to the ilium, while in every other 
 respect (that is to say, in reference to the principal peculiarities of the 
 deformity), they resemble each other as much as two eggs. It is on 
 this point that a skillful person, not knowing this peculiarity,, would 
 be disposed to take two different specimens presented to his inspection 
 for the same, and it would be difficult to convince him of his error. 
 
 " The condition of the bones of the pelvis (exclusive of the varia- 
 tions already mentioned), as it regards their strength, their volume, 
 their texture, their color, etc., is exactly similar to that of healthy 
 bones, such as are observed in young persons exempt from all deform- 
 ity. It is for this reason that we find on these bones none of the 
 signs, either as it regards form, etc., which are met with, as the con- 
 sequence of rickets or malacosteon of adults. If we divest our mind 
 of the existing deformities, the pelvis which we have seen, would seem 
 to resemble, in general, the healthy pelvis. The majority of them 
 belong to the medium-sized pelvis, while the others are either under 
 or over the average size. In no case that we have specially noticed, 
 have we discovered the least sign of the existence of rickets; in none 
 have there appeared any of the phenomena, or accidents, or morbid 
 modifications, w r hich usually precede or follow the English disease, or 
 the mollities ossium after puberty. Nowhere have we been able to 
 establish the injurious effects of external causes, such as falls, blows, 
 etc., and never has there existed any antecedent pain. It has riot been 
 proved, in any of the cases which we have specially examined, that 
 there existed any lameness. In one case only, we thought in seeing 
 the person walk we observed a slight limp, but other connoisseurs 
 present at the examination, did not observe it, and the parents, and 
 all the family of the person in question, assured us positively, that 
 they never remarked any lameness. 
 
 "In the pelvis of this kind, with the lumbar vertebrae attached, the 
 vertebral column was strait in the lumbar region ; in other cases, it 
 inclined to the side exempt from anchylosis. In ail the pelves of our 
 collection, provided with lumbar vjertebrse, the anterior face of the 
 bodies of the vertebrae was more or less turned toward the anchylosed 
 side." 
 
 The anchylosis of the sacro-iliac symphysis, above-named, as a 
 peculiarity of this deformity, is usually so perfect, that the articulation 
 can not be discovered ; and the two bones appear as one, without any 
 perceptible line of demarkation between them.
 
 MALCONFORMATION OF THE PELVIS. 47 
 
 CHAPTER VI. 
 
 INDICATIONS OF MALCONFORMATION OF THE PELVIS. 
 
 UNDOUBTEDLY, the greatest earthly happiness consists in a domestic 
 life, where harmony and co-operation can be maintained; and there is 
 nothing so truly calculated to embitter it, and render it a source of 
 constant wretchedness to husband, wife, and relatives, as a knowledge 
 of the existence of pelvic malconformation in the wife, rendering her 
 incapable of giving birth to a full-grown fetus ; and to determine such 
 conformation and capability, in the otherwise marriageable female, 
 physicians are often consulted. It is, therefore, highly desirable that 
 every practitioner should be thoroughly acquainted with all the symp- 
 toms and indications necessary to determine the presence as well as the 
 extent of a pelvic deformity, for should he decide incorrectly, from 
 lack of proper information, and thus cause the parties to engage in a 
 contract for life, the responsibility of the death of the female, accruing 
 therefrom, would rest solely upon him. Or, as is sometimes the case, 
 the pregnant woman may require his knowledge to correctly ascertain 
 the extent of malformation, that a course may be pursued to preserve 
 both the parent and child, if possible at all events the mother also, 
 whether there would be safety in allowing gestation to continue its 
 full term, or in the induction of premature delivery. 
 
 Various causes may give rise to a suspicion of pelvic deformity, 
 as the pre-existence of rickets, fractures, unusual shortness of the 
 inferior extremities, or an inequality in their length, as well as an 
 inequality in the height of the hips, etc.; a short female with long 
 arms, when compared with the rest of the body, projecting chin, and 
 short, crooked legs, has also been named among those disposed to 
 pelvic malformation. 
 
 In the investigation of this matter, the physician should make 
 himself as thoroughly acquainted as possible with the previous history 
 of the patient, even from her infancy ; the presence of scrofulous 
 symptoms, or rickets, or any lameness or difficulty in walking at 
 any antecedent period, any fall upon the sacrum, or carrying heavy 
 weights, must be carefully inquired into ; and if there should be found 
 any spinal curvature, or shortening, or incurvation of the inferior 
 extremities, the age at which these changes occurred should be noticed; 
 though it must be remembered, that pelvic deformity is by no means
 
 48 
 
 KING'S ECLECTIC OBSTETRICS. 
 
 a constant accompaniment of either of these last named conditions. 
 In sixty-nine cases of spinal deformity, reported l>y M. Bouvier, there 
 were but twelve cases where pelvic deformity was present. Should 
 there be present an inequality in the length of the inferior extremities. 
 it must be ascertained whether this arises from dislocations, or im- 
 properly united fractures independent of rickets, or whether it be 
 owing to rickets, or mollities ossium. 
 
 The above indications, however, though they may occasion a suspi- 
 cion of some existing deformity, are, of themselves, insufficient to 
 give a precise idea of its extent or character; yet when they are pre- 
 sent, they afford competent grounds for further and more accurate 
 examination. For this purpose there are various methods recognized; 
 as the measurement of the pelvis by instruments designed therefor, 
 termed callipers, or pelvimeters; or by the employment of the hand. 
 The first is termed instrumental pelvimetry, the latter, manual pclvim- 
 etry; and by the term pelvimetry is understood, a process having for 
 its aim the measurement of the various diameters and extent of the 
 pelvis. 
 
 The principal object for which pelvimeters have been used, is to 
 ascertain the capacity of the superior strait, which is the fetal entrance 
 to the pelvis, and more particularly, the extent of its antero-posterior 
 -diameter, though the dimensions of other parts may likewise be deter- 
 F I0 . 11. mined by some of them. The pelvim- 
 
 eters most usually employed, are Cou- 
 touly's, Stark's, Baudelocque's, Mad. 
 Boivin's, Simeon's and Stein's; some 
 of which are for external pelvic measure- 
 ment, and the others for internal. 
 
 Baudelocque's pelvi meter is for ex- 
 ternal examination, and is most com- 
 monly preferred to any others yet in- 
 vented for that purpose. It (F'njiire 
 11) consists of two movable metallic 
 branches or arms, curved externally 
 in a semicircular form, and of sufficient 
 concavity to embrace the hips, or antero- 
 posterior diameter of the pelvis. One 
 extremity of these arms is straigl.' 
 for the distance of about five inches, and, at its superior portion, is 
 attached to its fellow by a hinge, while the other, or free extremity 
 terminates in a knob, or button. At the inferior portion of the 
 
 PEL.VIMETER.
 
 MALOOXFORMATION OF THE PELVIS. 49 
 
 straightened arms of the compass, commences its curvature, and at 
 this point a graduated scale is attached, which moves in a groove, and 
 indicates the degree of separation of the free extremities. The instru- 
 ment should always be applied to the naked body. In an examina- 
 tion, one of the knobs must be placed on the first spinous process 
 of the sacrum, which will be found a short distance below the hollow 
 of the loins, and the other must be placed on the symphysis pubis, 
 or in the separation of the labia majora at the most elevated point 
 of the anterior commissure of the vulva; and in effecting this, the 
 skin must be carefully drawn upward, so as to reach, as nearly as 
 possible, the upper part of the symphysis pubis, or else an error of 
 several lines may be made. This position of the instrument indicates 
 the distance from the posterior edge of the spinous process of the 
 sacrum to the anterior surface of the symphysis pubis, which, in a 
 well-formed pelvis, will be seven inches. But, in order to determine 
 the precise extent of the antero-posterior diameter of the superior 
 strait, the thickness of the sacrum, two and a half inches, as well as 
 that of the symphysis pubis, half an inch, must be subtracted from 
 the external measurement, seven inches, and which will give four 
 inches as the length of the diameter sought. 
 
 From the fact, however, that the knob of the posterior extremity 
 can not always be correctly placed upon the first spinous process of 
 the sacrum, and that there is more or less variation in the thickness of 
 the soft parts over which the instrument is to be applied, as well as of 
 the bones, and especially in the latter cases, where there has been an 
 arrest of development, the measurement of the antero-posterior diam- 
 eter of the superior strait, obtained by Baudelocque's pelvimeter, can not 
 be depended upon as being definitely certain; neither can the instru- 
 ment be rendered useful in the detection of other varieties of mal- 
 formation, whether dependent on exostosis, projection of the sacral 
 promontory, or other causes. And although its use is recommended in 
 cases where minute accuracy is not required, and in those unmarried 
 females in relation to whose pelvic dimensions the physician is con- 
 sulted, in each of which instances its employment may aid us in our 
 diagnosis; yet a reliance solely upon its indications is, under all cir- 
 cumstances, exceedingly imprudent and hazardous. 
 
 These objections to Baudelocque's pelvimeter, occasioned the inven- 
 tion of Coutoufy's pelvimeter, which, unlike the former, is designed for 
 the internal measurement of the pelvis. It is composed of two straight 
 steel arms, parallel with each other, and which slide with equal facility, 
 the one upon the other; these terminate in two raised extremities, and 
 4
 
 50 
 
 KING'S ECLECTIC OBSTETRICS. 
 
 FIG. 12. 
 
 when introduced into the vagina, one of the extremities is applied 
 against the symphysis pubis, and the other against the promontory of 
 the sacrum; the application of which, however, is exceedingly difficult 
 to effect with accuracy. To the horizontal branch is attached a scale, 
 which indicates the exact amount of separation of the two extremities. 
 The introduction of this instrument is difficult, always attended with 
 more or less pain, and rather disgusting to female delicacy ; all of which 
 render its employment very objectionable. 
 
 The pelvimeter of Coutouly has undergone several modifications, 
 though the same objections still remain. The improvement of this 
 instrument, by Prof. M. Van Huevel, at Brussels, is considered 
 superior to any other. The following description of it is given 
 by Tucker: 
 
 " This instrument is composed of two 
 metallic rods, A A and B B (Fig. 12), united 
 by means of a joint, so arranged as to allow 
 the extension of the rods at pleasure, at the 
 same time that this joint may be tightened 
 by means of a nut-screw. The rod A A, in- 
 tended to be introduced into the vagina, is 
 curved anteriorly, and flattened at its ex- 
 tremity in the form of a spatula; the other 
 rod, B B, is not so long, and is traversed at 
 one extremity by a rod, c, movable backward 
 or forward, by means of a screw. In apply- 
 ing this instrument, the female is placed upon 
 her back, with the legs and thighs well 
 
 , flexed, and separated as widely as possible. 
 
 VAN HUEVEL'S PELVIMETER. -, 
 
 The point on the skin corresponding to the 
 
 upper edge of the symphysis pubis, should be marked with a dot 
 of ink; at the same time, a similar mark may be made to desig- 
 nate the position of the ilio-pectineal eminence, for the purpose of 
 measuring the oblique, as well as the antero-posterior diameter of 
 the superior strait. This being done, one or two fingers should be 
 introduced into the vagina, and placed against the sacral promon- 
 tory ; when this has been found, the internal rod, A A, is to be 
 inserted into the vagina, and carried along the fingers to the pro- 
 montory of the sacrum, against which the broad extremity of the 
 rod is to be placed. In this position it may be firmly held by hook- 
 ing the thumb of the hand introduced into the vagina, over the 
 hook attached -to the rod A A. When this rod has been accurately
 
 M A LCOX FORMATION OF THE PELVIS. 
 
 51 
 
 placed, the button extremity of the rod C, FIG. 13. 
 
 .should be fixed upon the dot of ink, indi- 
 cating the superior edge of the symphysis 
 pubis. When the point of union between 
 the two rods has been made firm, by tightly 
 screwing the nut, the instrument may be 
 withdrawn, and the distance from the ex- 
 tremity of the rod c to that of A A, may be 
 ascertained. But, in order to obtain the 
 length of the sacro-pubic diameter, we must 
 subtract the thickness of the pubis, and to 
 do this, it must be measured by reintroduc- 
 ing the instrument, as is seen in Fig. 13. 
 The distance first ascertained, minus the 
 thickness of the pubis, will give us the exact 
 length of the antero-posterior diameter of 
 the pelvic brim. VAN HUEVEL'S PELVIMETER. 
 
 "The length of the oblique diameter may be ascertained in a similar 
 manner. In this case, the extremity of the rod A A, must be placed 
 against the sacro-iliac junction, while that of the rod C will rest on a 
 point a little external to the iliac artery. If the sacro-iliac junction 
 can not be reached, we may measure, instead of the obliqu'e diameter, 
 the distance sacro-cotyloid, which will give us every measurement of 
 importance, since, where the oblique diameter is contracted, it is due 
 (except in some cases of exostosis), not to compression inward of the sac- 
 ro-iliac joint, but to that of the sacral promontory or the cotyloid cavity. 
 
 " This instrument may be employed also in measuring the pelvis 
 externally, but its application in this case is too simple to require 
 farther explanation." 
 
 The other pelvimeters, by Stein, Simeon, and Mad. Boivin, are 
 somewhat similar in construction to those just named, and are liable to 
 the same objections. The pelvimeter of Stark, is rather simple in its 
 formation, but is decidedly objectionable, on account of its application 
 requiring the introduction of the whole hand within the vagina, which 
 w\)uld be exceedingly improper in an unmarried female; beside which, 
 in a small or deformed pelvis, much pain and difficulty must necessarily 
 attend its use. Prof. Lazarewitch, of Charkoff, Russia, has devised a 
 pelvimeter which may be used for internal or external measurements, 
 or for these two combined ; it is in many respects superior to any that 
 have yet been presented to the profession, but has not been generally 
 received.
 
 52 KING'S KCLKCTIC OKSTKTUICS. 
 
 All artificial pelviineters are liable to more or less inaccuracy, and 
 in some instances are of no use at all; still we should not omit their 
 employment in those cases which come before us for examination, as 
 they will usually afford some aid toward forming a correct diagnosis. 
 The hand, and, under certain circumstances, the index finger of the 
 accoucheur, when skillfully introduced into the vagina, is undoubtedly 
 the most certain and accurate pelvimeter we have, and can be employed 
 with all females, whether married or not. I am aware that writers 
 generally oppose the use of the finger in the examination of the un- 
 married, and would impress it upon all practitioners as a correct rule 
 by which to be governed, more especially in this country, where pelvic 
 deformities are rarely. to be met with; but when the female has arrived 
 at the marriageable period, and is about to enter into wedlock, yet 
 doubts are entertained as to the perfect formation of the pelvis, and 
 the other indications lead us strongly to suspect some defection, we 
 should not hesitate a moment in performing a manual exploration, con- 
 sidering the future health, happiness, and life of the individual of too 
 much importance to herself, her friends, and society, to be trifled away 
 by an unwise regard to customs or opinions, which are only strictly 
 applicable to the healthy, and those of perfect conformation. 
 
 In the manual examination, it is preferable to have the female 
 standing erect, with her shoulders against the wall; the index finger, 
 having been previously oiled, should then be carefully introduced into 
 the vagina, with the end of the finger pointing upward and backward 
 in the direction of the promontory of the sacrum. If, when the radial 
 portion of the finger has reached the lower edge of the symphysis 
 pubis, the sacral promontory can not be felt, we may safely determine 
 that this diameter of the superior strait, the antero-posterior, is not 
 deformed; but if the sacral promontory can be felt, a mark should be 
 made upon the finger, at its point of contact with the symphysis pubis, 
 (or the index finger of the other hand may be placed upon this part 
 and held there), and then withdrawing it, the distance between the 
 mark and extremity of the finger will give us the exact measurement 
 of this diameter, if we deduct from it six lines, for the thickness of 
 the symphysis pubis, and two or three lines for the obliquity of tlie 
 measurement. 
 
 But this is only useful where the pelvis is much distorted, or where 
 the antero-posterior diameter of the brim is less than three inches. 
 Other methods have been advised where greater accuracy is required, 
 such as the introduction of the whole left hand within the vagina, to 
 such a distance that the external edge of the little finger may be placed
 
 MALCONFORMATION OF THE PELVIS. 
 
 against the inner surface of the symphysis pubis, and the first finger 
 against the promontory of the sacrum. As the FIG. 14. 
 
 hand must be opened, after having entered with- 
 in the vagina, the practitioner can ascertain both 
 the antero-posterior and transverse diameters, 
 by knowing whether the whole width of the 
 digital extremities of the hand can be introduced 
 into the space under investigation whether he 
 must spread his fingers to touch the extreme 
 limits of the diameters or, whether he can 
 only introduce two or three fingers. In the 
 first instance, the diameters will be equal to 
 the width of the digital extremities of the 
 hand; in the second, they will be more than 
 three inches, and perhaps four; and in the 
 latter, the measurement will be from one and MANUAL PELVIMETRY. 
 a half to three inches, according to the measure of the fingers intro- 
 duced. (Fig. 14.) 
 
 The distances between the ischiatic tuberosities can be ascertained by 
 moving the finger from side to side, or by means of a pair of compasses 
 applied externally. The finger can likewise measure the antero-pos- 
 terior diameter of the inferior strait, by applying its radial portion to 
 the symphysis pubis, with the extremity pointing toward the apex of 
 the coccyx. The transverse and oblique diameters of the superior 
 strait may also be ascertained, sufficiently accurate for all practical 
 purposes, by carefully examining the circumference of the brim with 
 the finger, in cases where this is practicable. 
 The length of the symphysis pubis, the curve 
 of the sacrum, the projection of the spine of 
 the ischium, the shape of the straits, the con- 
 dition of the lateral parietes of the cavity, and 
 the presence of any tumor within the pelvis, 
 can always be decided by the finger much 
 better than by any instrument. And in cases 
 where the fetal head does not advance during 
 labor, the finger can readily determine the space 
 existing between the circumference of the head 
 and that of the pelvis, and thus instruct us 
 whether the pelvis be sufficiently proportioned 
 or not. 
 
 In cases where the child's head is somewhat MANUAL PELVIMETRY. 
 
 FIG. 15.
 
 54 KING'S ECLECTIC OBSTETRICS. 
 
 protruded into the pelvis, even when the brim is contracted, and the 
 hand can not in consequence be carried up to make an accurate ex- 
 amination, Ramsbotham recommends two fingers of the left hand 
 to be introduced within the vagina, the extremity of the first finger 
 being placed exactly behind and against the symphysis pubis, and the 
 tip of the second against the sacral promontory. If the examiner will 
 then carefully withdraw the fingers, keeping them steady, the distance 
 between their extremities may be measured on a scale of inches, or 
 otherwise, and thus give the exact dimensions of the antero-posterior 
 diameter. (Fig. 15.) 
 
 CHAPTER VII. 
 
 THE FETUS, ITS DIVISIONS AND DIMENSIONS. 
 
 IN order to understand the mechanism of labor, beside having a 
 knowledge of the pelvis and its divisions, it is likewise necessary to 
 become well acquainted with the dimensions of the various parts of the 
 fetus, especially those which, from increase of size, may render it diffi- 
 cult or even impossible for labor to progress. Accoucheurs generally 
 divide the fetus into three distinct parts, namely : the head, the trunk, 
 the extremities; some, however, in consequence of the peculiar manner 
 in which it is curved upon itself when within the uterine cavity, object 
 to this division, and prefer another, comprising, 1, the cephalic ex- 
 tremity, or head; 2, the pelvic extremity, including the pelvis and the 
 inferior extremities; and 3, the torso, or trunk, having reference to 
 the parts between the head and upper pelvis. But the first arrange- 
 ment is sufficient for all practical purposes. 
 
 The head is of an oval shape, and is the largest and least reducible 
 part of the fetus, and a familiarity with its obstetric divisions and 
 dimensions is highly necessary for the successful accoucheur. The 
 bones of the fetal cranium are the same in number as in the adult 
 head, but they are soft, and are not united by firm sutures as in the 
 adult; their imperfect ossification gives rise to membranous spaces be- 
 tween them of greater or lesser extent, called commissures or sutures, 
 from the Latin word suo, to sew, and which are often of much benefit 
 to the safety of the child during its passage through the pelvic canal, 
 inasmuch as in every delivery they admit a certain degree of com-
 
 THE FETUS ITS DIVISIONS, ETC. 55 
 
 pression or reduction of the head, and even a riding of the bones over 
 each other. They also serve as indications by means of which the 
 position of the head in the pelvis may be correctly ascertained. There 
 are several of these sutures, but those which are the most important 
 are three in number the others are of no practical utility in an ob- 
 stetrical point of view. 
 
 1st. The sagittal or median suture or commissure, is situated between 
 the two frontal and the two parietal bones, and extends from the root 
 of the nose to the superior angle of the occipital bone, dividing the 
 anterior and superior portion of the cranium into two equal parts ; 
 anteriorly, it is crossed at right angles by the coronal suture, and ter- 
 minates posteriorly at the lambdoidal suture. Occasionally, but very 
 rarely, instances are found where this suture extends throughout the 
 occipital bone, dividing it into two parts. 
 
 2d. The coronal suture, sometimes called the transverse, anterior, or 
 fronto-parietal, crosses the sagittal suture at right angles, separating 
 the frontal from the parietal bones, and extends from the extremity 
 of the greater wing of the sphenoid bone of one side, to that of the 
 opposite side. 
 
 3d. The lambdoidal, or occipito-parietal suture, separates the upper 
 edge of the occipital bone from the posterior edges of the parietal 
 bones ; in shape it resembles the Greek capital, lambda. 
 
 At the points of intersection and junction of these commissures are 
 membranous spaces or openings, occasioned by the incompleteness of 
 the ossification of the angles of the bones. There are six of these 
 spaces in the fetal head, of which a knowledge of but two is all that 
 is required for practical purposes; they are technically termed fon- 
 tanelles from/ons, a fountain; they have also been called bregmas, from 
 a Greek word signifying "to sprinkle," each name originating from 
 an ancient idea that a moisture passed from the brain through these 
 membranous spaces. 
 
 The anterior fontanelle, also called the bregmatic, or frontal, is the 
 opening situated at the intersection of the coronal and sagittal com- 
 missures; it is of a quadrangular or diamond-shape, and may be dis- 
 tinguished by the four bony angles, the edges of which are soft and 
 smooth, being almost always tipped with cartilage. The opening is 
 of considerable size, which, however, varies in different heads, and 
 the finger can readily detect it by its soft, smooth, and yielding 
 character. 
 
 The posterior or occipital fontanelle, is situated at the center or angle 
 of the lambdoidal commissures at its point of junction with the pos-
 
 56 KING'S KCLKCTIC OKSTKTKICS. 
 
 terior extremity of the sagittal commissure. In the immature fetus it 
 may he felt distinctly, but in the full-developed infant it consists of 
 merely a kind of triangle formed by the meeting of the two commis- 
 sures, and is frequently wanting. This fontanelle may be distinguished 
 by its triangular shape ; its narrowness, being much smaller than the 
 anterior fontanelle; having but three bony angles; and in consequence 
 of the more complete ossification of the edges of the bones, they im- 
 part to the finger, on pressure, a hard serrated sensation, which is 
 never possessed by the edges of the anterior fontanelle, and which, 
 therefore, will enable the practitioner to distinguish the one fontanelle 
 from the other. In many instances the posterior fontanelle is so small 
 that it can only be distinguished by the three commissure lines that 
 radiate from a common center. 
 
 It has been previously remarked, that occasionally the sagittal com- 
 missure continues throughout the occipital bone, dividing it into two 
 parts, and in instances where this occurs, four bony angles will be per- 
 ceived by the finger. The practitioner, however, can not err in this, 
 if he will recollect that the posterior fontanelle is always smaller, 
 and its edges rougher and harder than the anterior, and that 
 on the slightest compression of the head, the occipital bone al- 
 ways glides under the ossa parietalia. The anterior fontanelle is 
 invariably larger than the posterior, no matter how well marked this 
 last may be. 
 
 A thorough knowledge of the sutures and fontanelles is absolutely 
 required in the practice of midwifery for it is from them that the 
 position of the head within the pelvis is ascertained with certainty; 
 and in cases where interference is demanded, from a too early de- 
 parture of the head from its proper or flexed position, or from some 
 other cause, the educated accoucheur can at once render the necessary 
 assistance to bring the labor to a safe and prosperous termination. But 
 if he have neglected to inform himself on these points, his patient may 
 be subjected to much unnecessary suffering, and, perhaps, from lack 
 of timely aid, the death of both mother and child may ultimately 
 ensue. Hence, a peTfect acquaintance with these peculiar marks can 
 not be too strongly impressed on the mind of the student. It is from 
 these alone, that the situation of the head when in the pelvis can be cor- 
 rectly ascertained, and never by an ear, nose, or other part of the head. 
 
 There are four principal DIAMETERS belonging to the fetal 
 head, viz.: 
 
 1. The large, oblique, or occipito-mental diameter (A B, Fig. 16),
 
 THE FETUS ITS DIVISIONS, ETC. 57 
 
 extending from the vertex or posterior F IG . 15. 
 
 fontanelle to the symphysis of the chin ; 
 
 its measurement is from five to five and 
 
 a half inches. It is important to recollect 
 
 this diameter, for if it enters the cavity with 
 
 either .extremity descending, it can not be 
 
 reversed, from want of space, but must 
 
 either be allowed to escape as it presents, 
 
 or be returned above the superior strait to 
 
 effect a change. This diameter may be 
 
 * i i .IT / .0, DIAMETERS OF THE FETAL 
 
 saielv elongated by compression ot the TJ 
 
 ~ * HEAD. 
 
 cranium with the forceps or otherwise, to A B occipito-mcntai. 
 the extent of six or, ten lines, so that its D E - Occipito-fnmtai. 
 
 , C H. Cervico-bregmatic. 
 
 whole measurement may be six or seven T G . Tracheio-bregmatic, or vertical 
 
 inches A ^' F ron t- m ental, or facial. 
 
 2. The longitudinal, horizontal, antero-posterior or occipito-frontal 
 diameter (D E, Fig. 16), extends from the center of the forehead to 
 the occipital protuberance; its measurement is from four to four and 
 three-quarter inches. 
 
 3. The perpendicular, vertical, occipito-bregmatio or trachelo-breg- 
 matic diameter (Gi,Fig. 16), extends perpendicularly from the most 
 elevated point of the vertex, or top of the head to the anterior portion 
 of the great occipital foramen ; its measurement is from three and a 
 half to three and three-quarter inches. 
 
 4. The small, transverse or bi-parietal diameter (A B, Fig. 17), ex- 
 tends from the center of one parietal protuberance to that of the other; 
 its measurement is from three and a half to nearly four inches. This 
 diameter may, by compression of the cranium with the forceps or 
 otherwise, be diminished one-third or even three-fourths of an inch, 
 without any injury to the child. 
 
 In addition to these measurements of the fetal head, with which 
 the student must become familiar, authors have given several others, 
 a knowledge of which, however, is not necessarily important in prac- 
 tice ; they are : 
 
 1. The cervico-bregmatic diameter (c H, Fig. 16), whioh extends 
 from the back part of the neck to the center of the anterior fonta- 
 nelle; it measures from three and a half to three and three-quarter 
 inches. 
 
 2. The fronto-mental or facial diameter (A D, Fig. 16), extends from 
 the symphysis of the chin, to the center of the forehead ; it measures 
 from three to four inches.
 
 58 
 
 KING'S KCLECTIC OBSTETRICS. 
 
 3. The post trachelo-frontal diameter, which extends from a point 
 midway between the occipital protuberance and the occipital foramen, 
 to the center of the frontal bone ; it measures from four to four and 
 three-quarter inches. 
 
 4. The prce-trachelo occipital diameter, extends from the hyoid bone 
 to the posterior fontanelle ; it measures from three and a half to four 
 inches. 
 
 5. The bi-temporal diameter (c D, Fig. 17), extends from the root 
 of the zygomatic process on one side to the same point opposite; it 
 measures from two and three-quarters to three inches. 
 
 6. The sub-occipito bregmatie diameter, extends from a point midway 
 between the foramen magnum and the occipital protuberance to the 
 anterior fontanelle ; it measures three and three-quarter inches. 
 
 In order that the diameters of the fetal head may, at one glance, 
 be compared with those of the pelvis, I present the following tables 
 after the manner of Cazeaux : 
 
 Diameters of the pelvis, 
 (in inches). 
 
 Antero-posterior. 
 
 Transverse. 
 
 Oblique. 
 
 Sacro-cotyloid. 
 
 Superior Strait 
 
 ...4 to 4i 
 
 ...5 to 5 
 
 .4i to 5 
 
 33 to 41 .. .. 
 
 
 .4 to 5 
 
 4 to 4J 
 
 4 to 4J 
 
 
 Kxcavation 
 
 ...4 to 5 
 
 4J to 4f 
 
 . 41 
 
 
 
 
 
 
 
 DIAMETERS OF THE FETAL HEAD. 
 
 I Occipito-mental 5 to 5 inches. 
 
 Longitudinal Diameters.... J Occipito-frontal 4 to 4f *' 
 
 ( Siib-occipito-bregmatic 3| 
 
 Transverse Diameters , 
 
 Vertical Diameters. 
 
 ( Bi-parietal 3 to 3| 
 
 ( Bi-temporal. 3 
 
 ( Trachelo-bregmatic 3J to 3f 
 
 Fron to-mental 3 to 4 
 
 A comparison of the diameters of the fetus with those of the pelvis, 
 will be found of much utility, enabling the practitioner more readily 
 to effect a correspondence between the large diameters of the head and 
 the long diameters or axes of the pelvis, in all cases where such a 
 change may be required. From an investigation of these measure- 
 ments, it will be seen that at full term, the fetus, to be safely and 
 readily expelled must present one end of its long diameter (A or B, Fig. 
 16) ; and also, that if its occipito-raental diameter is parallel with the
 
 THE FETUS ITS DIVISIONS, ETC. 59 
 
 plane of the inferior strait, delivery will be impossible; either the chin 
 or the occiput must descend first. It will likewise be observed, that 
 the most favorable position for the expulsion of the fetal head, is to 
 have it strongly flexed upon the body, so that its largest diameter, the 
 occipito-mental, shall correspond to the long diameters or axes re- 
 spectively of the straits and cavity, while its sub- j? IG> jy 
 occipito-bregmatic diameter, shall be parallel to the 
 plane of the straits, and the occiput shall, during its 
 passage, correspond to one extremity of an oblique 
 diameter, until the rotation ensues which places the 
 presenting extremity under the arch of the pubis. 
 
 Each of the diameters of the fetal head have a 
 circumference assigned to them, the largest of which 
 is the occipito-mental circumference, and which with 
 the occipito frontal or horizontal circumference, are 
 more important than the others, because during A B . Bi-Parietai. 
 labor they successively come into relation with the c D - Bi-Temporai. 
 pelvic parietes. The fronto-mental circumference passes over the 
 chin, cheeks, and forehead, and is consequently termed by several 
 writers, the facial circumference. The remaining circumferences are 
 unimportant. 
 
 The other diameters of the fetus are : 
 
 1. The bis-aoromial diameter, extending from one acromial process 
 to the other; it measures four and a half inches. 
 
 2. The dorso-sternal diameter, extending from the vertebral column 
 through to the sternum; it measures three and a half inches. 
 
 3. The bis-iliac diameter, extending from the crest of one ilium to 
 that of the other ; it measures three and three-quarter inches. 
 
 4. The bi-trochanterie diameter, extending from one trochanter to 
 the other; it measures three and a half inches. 
 
 The movements which the fetal head is enabled to execute with 
 safety; in consequence of the laxity of the articular ligaments between 
 the head and vertebral column, must not be forgotten. In head pre- 
 sentations the shoulders are usually expelled so soon after the head 
 has passed, that accidents are rarely met with ; but in breech or feet 
 presentations, or in cases of turning, in which the head may be re- 
 tained for some time within the cavity from mal-position or otherwise, 
 the careless or unskilled accoucheur may, by the employment of an 
 ill-directed force, occasion the death of the child. 
 
 The head may be moved in four different directions, termed flexion,
 
 60 KING'S I'X'LKCTIC OBSTETRICS. 
 
 cxt 'ii*loii, lateral inclination, and rotation; and the extent to which 
 these movements may be carried, must never be lost sight of. 
 
 The movement of flexion, is that in which the head is thrown for- 
 ward and downward, so that the chin is depressed upon the neck or 
 upper part of the sternum, and to which extent this motion is limited. 
 By it, the occipito-mental diameter of the head is made part of the 
 long diameter of the fetal ovoid or ellipse. This movement of the 
 head should never be forgotten, as when it is incomplete, or there ia 
 too early a departure of the chin from the breast, during the passage 
 of the head through the pelvic canal, an attention to it, with the 
 proper manipulation to restore the flexion, as hereafter described, will 
 very much facilitate the expulsive progress of the head ; but a want 
 of care or knowledge in this matter may, in these instances, render 
 the labor tedious, painful, and even hazardous. 
 
 The movement of extension, is the reverse of the former; the head is 
 thrown backward; and the motion is limited by the occiput coming 
 in contact with the back of the neck. This motion takes place in 
 occipito-anterior positions of the head, in which the vertex becomes 
 placed under the pubic arch, while the forehead, face, and chin, leav- 
 ing their previous state of flexion, pass successively along the arch of 
 the sacrum, coccyx, and perineum. 
 
 The movement of lateral inclination is that in which the head is 
 thrown to one side or the other, and is limited by the side of the head, 
 meeting with the corresponding shoulder. 
 
 The movement of rotation is that in which the face of the child is 
 turned from one side to the other. All the.other motions are limited 
 in their extent by an opposing obstacle, but in this last there is none 
 presented, and if it be carried too far the life of the child will be 
 endangered. I have met with several cases of still-born infants, occa- 
 sioned by the midwife rotating the body of the child beyond its proper 
 limits ; and instances are recorded where the body has been made to 
 turn once and even twice, almost, if not actually twisting off the neck. 
 It must be borne in mind that the head can not be rotated upon the 
 neck, with safety, beyond one-quarter of a circle, or in other words, 
 the face of the child can not be turned to the right or left beyond the 
 corresponding shoulder; and this applies to the head when out of the 
 pelvis, and the body within, and likewise to the body out of the pelvis 
 and the head detained. 
 
 One thing may be adverted to here, which will be again noticed in 
 another place, and which is, that pulling the body of the child for the 
 purpose of extracting the head, or pulling with the forceps applied to
 
 THE FEMALE ORGANS OF GENERATION. 
 
 61 
 
 the head, the body not being expelled, are not only improper but ex- 
 ceedingly culpable. I have known a practitioner, in his endeavor to 
 extract the head with the forceps, pull so forcibly and continuously, as 
 to almost tear the head from the body, at the same time lacerating the 
 soft parts of the mother in a most shocking manner. 
 
 CHAPTER VIII. 
 
 THE FEMALE ORGANS OF GENERATION. 
 
 HAVING referred to the 
 osseous portions of the fe- 
 male and of the fetus, in 
 their obstetrical relations, it 
 becomes necessary to briefly 
 notice the soft parts which 
 cover them, constituting in 
 the adult female, the organs 
 of generation, and which are 
 divided into external and in- 
 ternal. The external organs, 
 to which the term Pudendum 
 is applied, are situated on 
 the exterior of the pelvis, 
 where they may be noticed 
 by the eye, and comprise, 
 1st. The mons veneris ; 2d. 
 The vulva and its parts; 3d. 
 The perineum. The inter- 
 nal organs are more deeply 
 seated, and can not be seen 
 or studied except by dissec- 
 tion ; they are, 1st. The 
 vagina; 2d. The uterus; 
 3d. The Fallopian tubes and 
 ligaments; and 4th. The 
 ovaries. 
 
 The MONS VENEEIS, 
 or supra-pubal eminence, is 
 
 FIG. 18. 
 
 THE EXTERNAL FEMALE ORGANS OF GEHERA- 
 TION. 
 
 A. The Mons Veneris. 
 
 B. The Labia Externa, or Labia Pudendi. 
 
 C. The Fourchette, or Posterior Commissure of the Vulva. 
 D D. The Perineum, extending from the Posterior Com- 
 missure of the Vulva to the Anus. 
 
 E. The Anus. 
 
 F. The Clitoris. 
 
 G. The Preputium Olitoridis. 
 
 H. The Nymphte, or Labia luterna. 
 
 I. The Vestibulutn. 
 
 K. The Meat us Urinarius. 
 
 L. The Hymen.
 
 62 KIN(;'s KCLKCTIC OIJSTKTinrs. 
 
 a triangular space situated at the lower part of the hypogastrium, 
 immediately on the lore part of the pubis, in front of, and just above, 
 the symphysis pubis. It presents a prominent rotundity, which varies 
 according to the quantity of adipose matter deposited, and of which 
 it is principally composed ; it is more prominent in young and vig- 
 orous virgins than in mothers and aged females, and is said to be much 
 more so in young females the natives of tropical climates. The cutis 
 or skin which covers this part is smooth in early life, but becomes 
 covere 1 with short curled hair or capilli at maturity, and is supplied 
 with numerous sebaceous follicles; a straight long hair is said to be 
 indicative of sterility, and also of a lack of energy of the reproductive 
 organs. Through the adipose and cellular tissue, are ramifications of 
 some branches of the external pudic vessels and nerves, and in it are 
 distributed some fibers of the round ligaments of the uterus. 
 
 The uses of the mons veneris during copulation are not satisfactorily 
 ascertained, though it is said to be more elevated when the female is 
 laboring under sexual excitement, and immediately previous to men- 
 struation. Moreau states, that in parturition, owing to the extensi- 
 bility of the skin, and laxity of the cellular tissue contained within it, 
 it assists in augmenting the size of the vulva. This part is sometimes 
 attacked with inflammations and abscesses which prove exceedingly 
 painful, and may suffer from the various forms of disease common to 
 the tissues entering into its formation. 
 
 The VULVA is the slit, or longitudinal fissure (fissura vulvce, or 
 genital fissure) , which extends from the mons veneris superiorly, along 
 the median line to the perineum inferiorly. The orifice of the vulva 
 serves as an entrance to some of the internal organs; it varies in ex- 
 tent in different persons; is very small in infancy, small and narrow 
 in girls, of greater width and extent in women, and during parturition 
 distends to a size which admits of the free passage of the child through 
 it. After copulation its size is usually double that of the vagina! 
 orifice; and in women who have borne many children, or who have 
 had laceration of the perineum, it most commonly remains quite 
 large. 
 
 Along the lateral portions of the vulva are two rounded folds, or 
 oblong eminences, or lips, which extend in a longitudinal direction 
 from the mons veneris to the posterior part of the vulva; these are 
 called the LABIA MAJORA, labia externa, or labia pudendi. As 
 they proceed from before backward, they diminish in thickness, which 
 renders them more prominent above than below; their superior ex-
 
 THE FEMALE ORGANS OF GENERATION. 63 
 
 tremity is adherent, the inferior being free and rounded. Externally, 
 the labia majora are covered with the common skin, on which a few 
 hairs may be found, and which is supplied with numerous sebaceous 
 follicles; internally, it is covered with a beautifully fine, smooth, and 
 sensitive mucous membrane, of a florid color in young persons, but 
 which is lost on the approach of age. The inner, or mucous surface, 
 is supplied with glands that secrete a fluid preventing an adhesion of 
 these parts, as well as protecting them from the effects of friction. 
 By their approximation, the labia majora cover and protect the in- 
 ternal parts from the air and external agencies; and during parturition, 
 when the child is about to be expelled, by their elongation and almost 
 entire disappearance, they increase the capaciousness of the vulva. 
 They may be attacked with inflammation, abscess, hernia, serous in- 
 filtration, or other diseases, which sometimes interfere with their 
 functional activity, or occasion various accidents. 
 
 The point of union of the labia majora, at their upper or anterior 
 extremity, at the symphysis pubis, forms the anterior commissure of 
 the vulva; and at their lower or posterior extremity they form a kind 
 of bridle at the anterior edge of the perineum, called the FOUK- 
 CHETTE, frcenum, or posterior commissure of the vulva, which is 
 sometimes slightly lacerated during first labors, but which occurrence 
 causes no trouble. The posterior commissure is the most dense and 
 resisting point of the vulva, not yielding without difficulty. 
 
 On separating the labia majora, we observe several other parts; the 
 NYMPH.ZE, labia internet, or labia minora, which are two mem- 
 branous folds, located between, and running parallel with, the labia 
 majora, and which extend from the anterior commissure to about the 
 genital fissure; they are formed of cellular, as well as spongy tissues, 
 covered with mucous membrane, and contain many vessels and nerves 
 which render them highly sensitive. Their superior edge is coherent, 
 the inferior loose; and a little below the anterior commissure of the 
 vulva they unite, the anterior extremity passing around the clitoris so 
 as to form a hood, or prepuce to it, while the posterior is lost in the 
 corresponding labium pudendi. In young persons,their color is lively 
 red, they are firm, and their surface is not corrugated, but smooth; in 
 women who have had children they become darker and wrinkled. 
 Females of a phlegmatic temperament, and especially those laboring 
 under leucorrhea, have them pale and flaccid ; and in brunettes they 
 are dark, granulated, and sometimes quite long. They are furnished 
 with a sebaceous substance, which, if allowed to accumulate in quantity, 
 occasions a disagreeable fetor.
 
 64 KI.NC's KCLKCTIC OHSTKTHICS. 
 
 In early life the nymphse are so long as to project beyond the ex- 
 ternal lips, or labia majora, which, however, usually disappears at 
 puberty. Occasionally, the labia minora have projected so far as to 
 produce much inconvenience, requiring an operation for their removal ; 
 and among the South Africans, especially the Bochisman women, this 
 elongation is found in an excessive degree, extending to eight or ten 
 inches below the margin of the labia, forming what has been named 
 the apron of the Hottentots. 
 
 The uses of the nymphse are unknown, although they are supposed 
 to add to the voluptuousness of copulation, and to amplify the vulva 
 during parturition, by becoming distended or effaced ; this last view, 
 however, does not agree with my own observations, as I have repeat- 
 edly ascertained their presence during the passage of the fetal head 
 into the world. 
 
 The CLITORIS is situated at the superior and median part of the 
 vulva, at the junction or origin of the labia minora, and just below 
 the anterior commissure of the vulva. It is a small red projection, 
 bearing some resemblance to the male penis, having two corpora cav- 
 ernosa, which are attached by crura to the rami of the pubes and ischia, 
 a spongy, cellular tissue, somewhat similar to the corpus spongiosum 
 in the male, two erector muscles inserted into the above named crura 
 rendering the organ erectile, and is surrounded with a fold of the in- 
 ternal mucous membrane of the labia, which forms the prepuce, or 
 preputium clitoridis. It is, however, imperforate, being without a 
 canal, or urethra. At its external termination is a round, red protu- 
 berance, which, from its shape, has received the name of glans clitoridis. 
 
 The clitoris is supplied with arteries and veins from several sources, 
 and its nerves, which chiefly arise from the sacral plexus [branches 
 of the pudic], endow it with intense erotic sensibility. Its length is 
 variable, and when uncommonly long or hypertrophied, has sometimes 
 occasioned doubts as to the sex of the individual. It is of no service 
 in parturition, but is considered as the principal seat of venereal 
 pleasure in the female ; the excision of this organ in the adult female 
 very much lessens the voluptuousness of sexual congress; and its 
 titillation alone will give completion to the venereal orgasm, as in in- 
 stances of masturbation. In infants, this organ presents an apparent 
 excess of size, projecting beyond the vulva, and which is owing to the 
 want of development of the proximate organs, especially of the labia 
 majora. 
 
 The VESTIBULE is a triangular space or depression, about an 
 inch in length, having the clitoris above, the meatus urinarius or ori-
 
 THE FEMALE ORGANS OP GENERATION. 65 
 
 fice of the urethra below, and the nymphse laterally. The lower, or 
 inferior portion of this depression, is divided by a line or raphe, which 
 can be readily felt 'with the point of the finger, and which leads di- 
 rectly to the orifice of the urethra. It is supplied with numerous 
 mucous glands. Immediately beneath the vestibulum may be recog- 
 nized, situated on a line with the top of the pubic arch, a small bulb- 
 ous projection or cushion, which incloses the orifice of the urethra. 
 A knowledge of this arrangement will render the catheterism of the 
 female an easy operation. 
 
 The FEMALE URETHRA is a slightly curved canal, from one to 
 two inches in length. It is larger and more dilatable than that of the 
 male, and passes directly beneath and behind the symphysis pubis in 
 an oblique direction, upward and backward, having its concavity up- 
 ward, on the pubic side, and its convexity downward, on the vaginal 
 side. During labor or parturition, the urethra becomes elongated, and 
 its direction, as well as that of its orifice, changes, so as to create diffi- 
 culty in the introduction of 'the catheter. For instance, distension of 
 the bladder with urine, distension of the vagina by the presenting 
 parts, or the elevation of the uterus, may carry the urethral canal 
 high upward, and sometimes thrust it against the pubes, so that its 
 orifice will be brought behind the symphysis pubis ; in such cases, the 
 sound or catheter must be introduced behind and parallel to the sym- 
 physis. The urethra is lined internally with mucous membrane, the 
 folds of which usually run longitudinally and not transversely. 
 
 The external orifice of the urethra, called the meatus urinarius, is 
 situated below the vestibule, and immediately above the vaginal open- 
 ing; it is irregularly round, and is more constricted than the upper 
 portion of the urethral canal. A membranous swelling, or cushion, 
 abundantly supplied with numerous follicles, surrounds it; and in 
 ordinary cases, where the introduction or the catheter is necessary, 
 after having found this raised cushion, which, as already stated, is at 
 the lower part of the vestibule, directly under the symphysis pubis, 
 the orifice will be discovered in the center of it. The point of the 
 catheter should be directed perpendicularly to the surface of the ves- 
 tibule, introduced within the orifice, then by depressing the handle, the 
 point will turn upward behind the pubis and toward the bladder. 
 This tubercle or caruncle of the urethra varies in its development, 
 the orifice being sometimes very thin, merely membranous, and at 
 others very patulous and funnel shaped. 
 
 In instances where from long-continued pressure of the child's head, 
 or from other causes, the practitioner is unable to detect the meatus 
 5
 
 B6 KING'S ECLECTIC OBSTETRICS. 
 
 urinarius, and it is absolutely necessary that the bladder should be 
 evacuated to avoid its rupturing, or the probable formation of a 
 fistulous passage between it and the vagina, it may be necessary 
 for the practitioner to expose the parts to sight, in order to in- 
 troduce the catheter; indeed, it is his duty to do so; but under 
 ordinary circumstances the patient should never be exposed for the 
 operation. 
 
 The urethra may be so severely pressed by the fetal head as to 
 occasion sloughing, resulting in urethro-vaginal fistula, which is a 
 very difficult malady to remove; and in operations with the forceps 
 or crotchet, the practitioner sho'uld be extremely cautious not to bruise 
 or lacerate this canal, as it is almost certain to result in permanent 
 stillicidium of urine. The urethra! mucous membrane is subject to 
 prolapsus, tumefaction, and occasionally polypus growths. 
 
 The HYMEN, also termed the virginal valve, vaginal valve, fios 
 virginitatis, claustrum virginale, etc., is a membranous fold formed by 
 the mucous membrane of the genital surface. It is situated about 
 half an inch within the vulva, at the orifice of the vagina (ostium 
 vagince), which it closes more or less perfectly, and is usually in the 
 shape of a crescent, with its convexity downward and adhering, and 
 its concavity upward and detached. Sometimes it is oval from right 
 to left, or circular, with one or more openings which allow the various 
 secretions and discharges from the vagina and uterus to pass out; 
 occasionally, it is imperforate, preventing the egress of these dis- 
 charges". Ordinarily, the hymen is quite thin and delicate, being 
 ruptured by the slightest causes ; sometimes it is soft and lax, yielding 
 without rupturing; and instances have occurred in which it was so 
 firm as to present an obstacle to copulation, or to embarass the 
 process of parturition; to remedy which, it has been found necessary 
 to make a circular or crucial incision in it. 
 
 The uses of this membrane are not well defined, nor can they be 
 of much consequence, since it is lost daily without injury. The pres- 
 ence of the hymen has long been regarded as a sign of virginity, but 
 when we reflect that it is sometimes readily ruptured in females of 
 undoubted chastity, even in the acts of laughing, coughing, sneezing, 
 lifting, etc., and again that it has been found entire at the time of 
 parturition, most convincing proof is afforded, that, as an emblem 
 of virginity, this membrane can not be depended upon under any 
 circumstances whatever; for its absence affords no evidence that 
 sexual intercourse has taken place, nor does its presence prove the 
 condition of chastity. It is often destroyed, during infancy, by care-
 
 THE FEMALE ORGANS OF GENERATION. 67 
 
 less nurses who rub these parts roughly with a coarse towel. I have 
 met with seven instances only, of firm and imperforate hymen in 
 which it was impossible for the nuptial rites to be consummated, 
 and one in which it was present at the parturient period, and in each 
 of which the difficulty was removed by the bistoury. 
 
 Along the circumference of the orifice of the vagina, are several 
 small, flat, or rounded reddish tubercles, commonly numbering from 
 two to four, occasionally five or six. Sometimes they are pale, or 
 livid, and vary in firmness. They exist in pairs, the two posterior 
 being generally larger and longer than the anterior. These are termed 
 the CARUNCUL^E MYRTIFORMES, and are considered by some 
 anatomists as the remains of the ruptured hymen, while others view 
 them as existing independent of this membrane. I have in three 
 instances, witnessed the unrupturcd hymen simultaneously with the 
 presence of the carunculse. As they disappear during the expulsion 
 of the fetus, they may probably be designed for enlarging the capacity 
 of the vulva, thereby diminishing the risk of severe contusion or 
 laceration. When they become so large as to cause unpleasant symp- 
 toms they may be removed by the scissors. 
 
 Between the posterior commissure of the vulva, or fburchette, and 
 the hymen and the external orifice of the vagina, is a space or depres- 
 sion bearing some resemblance to the cavity of a small boat, which is 
 called the FOSSA NAVICULARIS, or concha. Its greatest extent 
 is six lines, or half an inch. It is found in girls and in women who 
 have not given birth to children, but is usually ruptured in a first con- 
 finement by the efforts made to expel the fetal head, and which is fol- 
 lowed by no serious consequences unless more or less of the perineum 
 be likewise involved. It is the most inferior part of the vulva, and 
 hence becomes a receptacle for vaginal and uterine discharges ; inflam- 
 mation and syphilitic ulcerations are frequently located there among 
 public women, which occasion obstinate and intractable difficulties, 
 not easy to cure. 
 
 The PERINEUM proper, includes the whole of the space between 
 the coccyx and the pubes, including the terminal orifices of the urinary, 
 generative, and digestive apparatus; but in Obstetrics, by the term 
 perineum, is meant the space lying between the posterior commissure 
 of the vulva and the anus. It is from an inch to an inch and a half in 
 length, and presents on its external surface, on the mesial line, a .prom- 
 inent, hard ridge, which is termed the raphe of the perineum. Exter- 
 nal ty,the ]>erineum is covered with the skin; internally, it consists of
 
 68 KING'S ECLECTIC OJ:STJ:TKICS. 
 
 adipose cellular tissue, of fascia, aud of several muscles. In some 
 females it is thick, hard, and resisting; in others it is thin, soft, and 
 easily dilated ; conditions which render labor tedious or otherwise, by 
 retarding the passage of the fetal head when rigid and unyielding, or 
 allowing ib to pass by a ready dilatation. 
 
 In the last stage of labor, the perineum usually offers more or less 
 resistance, but eventually becomes thinner, elongates, and extends, 
 even to four or five inches, thus affording a passage for the child ; and it 
 is at this period, when the head is passing, that it becomes occasionally 
 lacerated, or more rarely, perforated through its center. This acci- 
 dent, however, may generally be avoided, by supporting the perineum 
 with the hand, making such firm but moderate pressure as will pre- 
 vent the head from advancing too rapidly, and which, at the same 
 time, will allow the tissues an opportunity to acquire the proper degree 
 of extensibility. Excessive and injudicious support will undoubtedly 
 effect more mischief than benefit. The condition of the perineum 
 should never be overlooked by the practitioner, as it frequently pre- 
 sents an obstacle to delivery far greater than the os uteri, the straits, 
 and the vagina together, owing to its unyielding resistance ; and 
 a labor which, under ordinary circumstances, would be finished in 
 from fifteen to thirty minutes after the head has reached this point, 
 may be continued for several hours. This rigid 'condition of the 
 perineum is often brought on by excessive meddling, frequent exam- 
 inations, etc. I have overcome several instances of obstinate resist- 
 ance, in a very short time, by relaxing the parts by means of a process 
 of dilatation, which may be produced by sweeping the finger through 
 the posterior commissure of the vulva. Rigidity of the perineum is a 
 condition which frequently retards the completion of labor ; support to 
 the parts as usually applied is a feeble agent in overcoming it; the 
 sweeping movement, however, if applied at frequent intervals, for a 
 brief period, will, as a rule, result in complete muscular relaxation. 
 
 CHAPTER IX. 
 
 THE INTERNAL ORGANS OF GENERATION. 
 
 THE internal organs of generation, belonging to the female, are, as 
 previously remarked, the vagina, the uterus and its appendages, the 
 Fallopian tubes, ligaments, and ovaries (Fig. 19). 
 
 the VAGINA is a cylindrical membranous canal, which con- 
 nects the internal with the external organs of generation; it is
 
 INTERNAL ORGANS OF GENERATION. 
 
 69 
 
 located in the pelvic cavity, FlG - 
 
 being posterior to the bladder 
 and urethra, and anterior to the 
 rectum. Its direction is nearly 
 coincident with the axis of the 
 pelvis, which gives a curved form 
 to it, the concavity of which, is 
 on its anterior or pubic surface, 
 and the convexity on its posterior or 
 rectal surface. The walls of the 
 vagina are soft and yielding, and 
 slightly flattened from before back- 
 ward the anterior wall being 
 shorter than the posterior. In well 
 formed women its length is five or 
 six inches, and its width one; but 
 this usually varies according to age, 
 and the different circumstances of 
 life. In girls, it is longer and 
 narrower than in married women, 
 and especially those who have 
 borne children ; and in African 
 women it is -longer and wider 
 than in European. The middle 
 portion of the vaginal tube is larger than at the extremities, and the 
 lower or inferior orifice is more contracted than at its upper or superior 
 extremity. The walls of the vagina are generally in contact, when 
 undisturbed. As females advance in years, the vagina gradually con- 
 tracts its dimensions to nearly those found in young girls. It is com- 
 posed of a fibrous and mucous membrane; the first is placed exter- 
 nally, and consists of condensed cellular tissue, highly elastic, and of 
 .a reddish color. 
 
 The external surface of the vagina is united, in front to the bas-fond 
 of the bladder and to the urethra, by cellular tissue, which becomes 
 denser as it 'approaches the vulva; behind, to the rectum, by similar 
 cellular tissue, but which is less dense than in front; laterally, to the 
 broad ligaments and ureters above, and below to the umbilical arteries, 
 the sacral plexuses, the hypogastric vessels, the levator muscles of the 
 anus, and the pelvic cellular tissue; and superiorly, above and behind, 
 by a double fold of peritoneum. 
 
 The internal surface of the vagina is divided into an anterior and a 
 
 THE INTERNAL FEMALE GENITAL 
 ORGANS. 
 
 A. The Uterus, seen on its Anterior Face. 
 
 B. The Intra-vaginal portion of the Neck of the 
 
 Uterus. 
 
 C C. The Fallopian Tubes. 
 D. The flmbriated Extremities of the Fallipoan 
 
 Tubes. 
 
 E E. The Ovaries. 
 F. The Ligament of the Ovary. 
 G G. The round Ligaments. 
 H. The Vagina laid opun. 
 
 On the right the fimbriated extremity of the 
 Fallopian Tube is seen applied to the Ovary.
 
 70 KIND'S r. LECTIC OBSTETRICS. 
 
 posterior wall. In the center of each of these parietes is a longitudinal 
 line or ridge, the one on the anterior being more distinct and prominent 
 than that on the posterior wall; these ridges are called columnar vaginae, 
 or columns of the vagina one, the anterior column of the vagina, 
 the other, the posterior column of the vagina. One or two tubercles 
 are generally found at their inferior terminations. These columns are 
 intersected at right angles by transverse parallel ruga?, folds or 
 wrinkles, which become more prominent and approximate more closely 
 as they advance toward the vulva; these ruga?, however, do not con- 
 stantly exist ; they are more distinctly marked in girls and in aged 
 women ; and during pregnancy, as well as for a short period after par- 
 turition, they are nearly eifaced. Some writers consider them as aids 
 to the enlargement of the vagina during labor ; others, that they assist 
 in the elongation which it undergoes during pregnancy, caused by the 
 ascent of the uterus ; and others again, that by multiplying the points of 
 contact between the vaginal walls and the male organs, the voluptuous- 
 ness of coition is increased. 
 
 The superior, internal, or upper extremity of the vagina, is attached 
 around the upper part of the neck of the uterus, being a little higher 
 behind than in front. The peculiar manner by which it embraces the 
 neck, gives rise to a circular fissure or groove, to which the name cul- 
 de-sac has been applied ; the one in front, being termed the anterior 
 cul-de-sac; that behind, and which is more distinctly marked, the pos- 
 terior cul-de-sac. These culs-de-sac are of greater or less depth, accord- 
 ing to the projection of the neck of the uterus. This portion of the 
 vagina is in immediate contact with the peritoneum, which separates 
 it from the abdominal cavity ; and it is here where injuries are most 
 commonly inflicted by the use of instruments, often resulting in in- 
 flammation and death ; hence, when operations are demanded, great 
 care should be observed by the operator. 
 
 The inferior, external, or lower extremity of the vagina, sometimes 
 termed the external or vuVvar orifice, which terminates below r the 
 urethra, is narrowed at its entrance, and, in the virgin } is usually par- 
 tially closed by the hymen. 
 
 The internal parietes of the vagina are composed of a mucous mem- 
 brane, which is the continuation of that of the vulva, and the internal 
 membrane of the uterus; inferiorly, this membrane is of a red or ver- 
 million tinge, and superiorly it has a whitish or grayish appearance. 
 Occasionally, it presents posteriorly, bluish or livid spots, which are 
 more or less irregular. It is furnished with numerous mucous follicles, 
 the secretions from which constantly keep the parts during health, and
 
 INTERNAL ORGANS OF GENERATION. 71 
 
 especially during parturition, in a state of lubricity. If this organ 
 becomes dry and inflamed, while labor is progressing, a rigid and un- 
 yielding condition of it ensues, which must necessarily occasion much 
 distress to the patient; hence the importance of examining during 
 labor, as seldom as possible, because the frequent introduction of the 
 finger into the vagina not only removes the moisture of the parts, but 
 likewise irritates them ; beside frequent touchings are useless, deleteri- 
 ous, and immodest. 
 
 The part surrounding the orifice of the vagina, is termed the bulb 
 of the vagina or the plexus retiformis; it is a dense, compact, erectile 
 spongy tissue, somewhat resembling that of the corpus spongiosum 
 urethne, of a grayish or bluish color, about an inch in breadth, and 
 two or three lines in thickness. During the venereal orgasm, it con- 
 tracts the vaginal cavity, and thus increases its resistance. The 
 sphincter vagince or constrictor vagince muscle is formed by some mus- 
 cular fibers on the outside of this spongy tissue ; it contracts the 
 vaginal orifice, and depresses the clitoris. 
 
 The arteries of the vagina come from the internal iliac ; its veins, 
 which are numerous, form a kind of net-work called plexiform, and 
 flow into the hypogastrics ; its nerves arise from the sacral plexus, 
 and its lymphatics are lost in the hypogastric lymphatic plexus. The 
 contractility of the vagina is of the peculiar elastic character common 
 to all cellular structure. As soon as the fetus has been expelled, this 
 organ resumes its natural condition in a very short time, except in 
 cases where the head has been confined in the cavity for a longer 
 period than usual, when its contraction will not take place for one or 
 two hours ; and the hand may be very readily introduced within it for 
 some hours after delivery. 
 
 The vagina serves as a medium through which external bodies may 
 pass toward the uterus, as during copulation, and also through which 
 the* uterine contents and vaginal secretions may pass oif, as the fetus, 
 menses, etc. It is subject to inflammation, uleeration, eversion, inver- 
 sion, etc., the history and treatment of which, more properly belong 
 to a treatise on " Diseases of Women." 
 
 The UTERUS, or womb, is a hollow organ, whose principal func- 
 tions are to receive the impregnated ovum, as it escapes from the 
 Fallopian tube, to assist in its nourishment, growth, and preservation, 
 until the parturient period arrives, and then to act as the principal 
 agent in forwarding its expulsion. It is a yestative not a generative 
 organ.
 
 72 KING'S ECLECTIC OBSTETRICS. 
 
 In shape, the uterus is conical or pyriform, usually described as 
 resembling a pear flattened from before backward, with its base turned 
 upward, and its apex downward. It is situated obliquely in the pelvic 
 cavity, below the small intestines, between the bladder and rectum, 
 and above the vagina; and is retained in its position by the round and 
 broad ligaments, and the vagina. Its axis or long diameter very 
 nearly corresponds with the axis of the superior strait. In very young 
 females its base is below the superior strait ; in adults it is nearly on a 
 level with it. 
 
 In childhood it is quite small, but rapidly increases in growth to- 
 ward puberty and adult age, and after the period of child-bearing, it 
 diminishes to nearly its infantile size. Its average length, in the adult 
 woman, is two and a quarter to three inches ; its breadth at the fundus, 
 one and a third to two inches, and toward the neck, including the os 
 tincse, one inch to one and a half inches; and its thickness from eight 
 to twelve lines, or from four to six lines for each of its walls. 
 
 Immediately previous to menstruation and during that term, it 
 usually becomes greatly augmented in volume, which may be mis- 
 taken for the commencement of a pregnancy. Its weight, in the 
 virgin female, is seven or eight drachms, and in those who have had 
 children, from twelve drachms to an ounce and a half, while in the 
 aged female it dwindles to one or two drachms. 
 
 The uterus is divided into three parts: 1, the base or fundus uteri, 
 which is only a few lines high, being confined to all that portion which 
 rises above the insertion of the Fallopian tubes; 2, the body or corpus 
 uteri, which is the largest division of the uterus, and includes all that 
 part of the organ situated between the fundus and the neck, or con- 
 tracted portion ; 3, the neck or cervix uteri, which is the contracted 
 and elongated portion found below the body, about an inch in 
 length, and which is embraced by the vagina, forming in its cavity a 
 projection of four to six lines, at the extremity of which is an open- 
 ing, termed os tincoe, from its fancied resemblance to the mouth of the 
 tench fish, also called os uteri externum. The orifice, at the junction 
 of the uterine cavity with the superior extremity of the canal of the 
 cervix, is termed os uteri internum. The uterine sound is frequently 
 checked in its progress to the uterine cavity at this point, from con- 
 traction, and generally with more or less pain ; but if the instrument 
 be held steadily, pressing lightly upon the parts, the contraction will 
 yield, and the sound pass onward. But this should not be persisted 
 in when severe pain persists. 
 
 Generally, the uterus is slightly inclined to the right, sometimes to
 
 INTERNAL ORGANS OF GENERATION. 73 
 
 the left, or backward. Its position, however, is not constajit, being 
 determined by its own condition, as well as that of the neighboring 
 parts. Thus females, in whom the vagina is short, will have the axis 
 of the uterus approximating that of the inferior strait; sometimes the 
 fundus is thrown so far forward that the anterior wall is the most in- 
 ferior part, constituting an anteversion; at other times it may be the 
 reverse of this, the fundus being thrown in the hollow of the sacrum, 
 and the neck behind the symphysis pubis, producing a retroversion ; 
 or, the fundus may be thrown to one side of the pelvic cavity, with 
 the neck to the opposite side, which is termed lateral version; and 
 again, the body of the uterus may be bent on the neck, either behind 
 or in front, constituting an anteftexion or retrqflexion. 
 
 We distinguish, in the uterus, an external and an internal surface. 
 The EXTERNAL SURFACE is divided into an anterior and a 
 posterior face, a superior and two lateral borders, two superior angles, 
 and an apex. 
 
 The anterior face is smooth, polished, slightly convex, covered on 
 its superior two-thirds by a prolongation of the peritoneum, and is in 
 contact with the posterior face of the bladder, from which it is some- 
 times separated by some folds of the small intestine ; inferiorly, it is 
 united to the bas-fond of the bladder by loose cellular tissue, and 
 which adhesion may account for the involvement of the bladder in 
 many uterine displacements. 
 
 The posterior face is more convex than the anterior, and is covered 
 throughout its whole extent by a prolongation of the peritoneum ; it is 
 likewise in contact with the anterior surface of the rectum looking 
 toward the concavity of the sacrum. The superior border, base or 
 fundus, is convex, looking upward and forward, and is covered in its 
 whole extent by a prolongation of the peritoneum, and by the convo- 
 lutions of the small intestines. In the unimpregnated state it never 
 reaches the level of the superior strait, and can not, therefore, be felt 
 through the inferior abdominal wall, except by making considerable 
 pressure. The two lateral borders are irregular, being convex in their 
 superior half, and concave in their inferior; they are situated between 
 the two duplicatures of the peritoneum; which constitute the broad 
 and round ligaments, and which ligaments being attached to the an- 
 terior edge of the lateral borders, are consequently on the same plane 
 as the anterior face of the uterus. The two superior [grooved] angles, 
 or cornua uteri, are formed at the junction of the superior with the 
 two lateral borders, and from which point arise' the Fallopian tubes
 
 7 4 KING'S ECLECTIC OBSTETRICS. 
 
 and ovarian ligaments; the apex is the inferior extremity of the uterine 
 neck, and is situated in the upper part of the vagina. 
 
 The CERVIX UTERI, or NECK OF THE UTERUS, should be 
 thoroughly studied by the practitioner, with regard to its form, size, 
 and consistence, in order to facilitate his diagnosticating the state of 
 pregnancy, full term, etc., as well as the many abnormal conditions to 
 which it is liable. 
 
 The neck of the uterus in the adult female, who has never borne 
 children, will be found to vary considerably from that of one who 
 has; it is from twelve to fifteen lines in length, cylindrical, flattened 
 from before backward, and fusiform; being about nine lines in its 
 transverse diameter at the center, and from four to six lines at its ex- 
 tremities. It is embraced by the vagina toward its upper portion, 
 leaving about two-thirds within the vagina, and one-third above the 
 vaginal adhesion. The inferior or vaginal extremity of the neck, is 
 of less volume than any other part of it, and is perforated in its center 
 by a transverse fissure or orifice, of one or two lines in length, to 
 which several names have been applied, as, os tinea:., os uteri, os inter- 
 num, mouth of the womb, uterine orifice, etc. In the virgin, this orifice 
 is completely closed up, and is sometimes difficult to find; the sensa- 
 tion conveyed to the finger in contact with it, is similar to that expe- 
 rienced by feeling the depression between the alse nasi, at the end of 
 the nose, with the pulp of the finger, and which sensation will assist 
 us in recognizing the opening. The os tinea? divides the apex into 
 two lips, an anterior and a posterior lip. These lips are smooth, 
 regular, small, firm, thin, and closely approximated; the one anterior 
 being slightly thicker and more prominent than the posterior. As 
 the long diameter o/ the uterus is nearly parallel with the diameter 
 of the superior strait, the face of the apex will be found looking to- 
 ward the lower portion of the sacrum, in an inclined position; from 
 which arrangement the anterior lip will be found a little lower down 
 than the posterior. 
 
 In the woman who has borne children, the uterine neck varies in its 
 extent, being reduced in length, according to the number of births, so 
 much so, that instances are recorded in which the mothers of nineteen 
 or twenty children had the portion within the vagina completely de- 
 stroyed; the orifice is usually deformed, gaping, larger, and less 
 regular, and sufficiently patulous to admit the introduction of the end 
 of the finger; the lips are thicker and softer than in the virgin, and 
 are filled with fissures or inequalities, which are more frequent on the 
 left side of the neck, and are the results of lacerations of the fibers-
 
 INTERNAL ORGANS OF GENERATION. 
 
 75 
 
 which occur during the passage of the child's head through the os 
 uteri, and which have been prevented from uniting by the lochial dis- 
 charges. These fissures are of variable depth, and sometimes are so 
 numerous as to divide the lips into eight or ten small tubercles. These 
 differences are of much importance in legal medicine ; yet they may 
 occasionally be produced by other causes than parturition, or may even 
 be wanting in the mother. 
 
 The INTERNAL SURFACE of the uterus presents a narrow, 
 oblong, irregular cavity, with contiguous walls, which is divided into 
 two parts, the cavity of the body and the cavity of the neck. (Fig. 20.) 
 
 The cavity of the body is triangular in shape, flattened, and when 
 empty is not very extensive, being hardly large enough to contain a 
 split almond. At each of its three angles there is an orifice, the knver 
 or inferior one leading to, and establishing a communication with, the 
 cavity of the neck, and the two upper or superior ones forming the 
 entrance into the Fallopian tubes; the openings in these latter are 
 very narrow, and will scarcely admit a hog's bristle. Occasionally, 
 this opening is divided by a perfect septum, which may render super- 
 fetation possible, and very rarely there exists a congenital deficiency 
 of it. In the absence of the catamenial discharge this cavity is con- 
 stantly moistened by a sero-mucous fluid. 
 
 FIG. 20. 
 
 CAVITY OF THE UTERUS, AND THE FALLOPIAN TUBES. 
 
 A. Fundus of the Womb. 
 
 B. Cavity of the Womb. 
 
 C. Cavity of the Neck of the Womb. 
 
 D D. The Canal of the Fallopian Tubes 
 
 laid open. 
 E E. The fimbriated Extremities. 
 
 F F. The Ovaries. . 
 G G. The round Ligaments. 
 H H. The Ligaments of the Ovaries. 
 I. The Cavity of the Vagina. 
 6, H'. The Uterine Orifices of the Fallopian 
 Tubes. 
 
 The canal, or cavity of the neck, affords a communication between the 
 cavity of the body and the vagina; it is oval and cylindrical, about 
 twelve or fifteen lines in length, and five or six in its greatest breadth; 
 it is fusiform, flattened from before backward, presenting on its
 
 76 KINfi's KCLKCTIC OIJSTKTKICS. 
 
 anterior and posterior wall several longitudinal and transverse rugae or 
 wrinkles, to which the terms arbor rifn mternus, palmce pUcatce, &nd 
 /icnnifonit r u gee, have been applied; they are formed by the lining 
 membrane of the neck, and which are so arranged as to represent a 
 fern leaf in relief; they extend during the dilatation of the mucous 
 membrane of the cervix in the uterine development from gestation, 
 an<! during parturition, and frequently disappear after delivery. On 
 the mucous membrane of the neck are a number of muciparous fol- 
 licles, more abundant about the os uteri, which were mistaken by 
 Naboth for eggs, and hence have been called ovula Nabothi, glandula 
 Nabothi, or the glands of Naboth. In the healthy uterus of the virgin, 
 these follicles can hardly be seen; but during pregnancy, or when dis- 
 ease attacks the parts, they enlarge so as to be readily recognized by 
 the eye, and when touched with the finger they feel like shot. During 
 pregnancy, they secrete a thick, tough, pellucid, gelatinous mucus, in 
 quantity sufficient to close up the cavity, and, thus prevent any com- 
 munication between the cavity of the body and the vagina. The in- 
 ternal surface of the neck is less vascular than in the body. ' Ciliated 
 cylinder epithelium is observed upon the mucous membrane of the 
 canal of the cervix, but, at its lower part, instead of cylinder there is 
 squamous epithelium resembling that of the vagina, and beneath which 
 are found verrucose or filiform papillae, containing one or two vascular 
 loops; those seated more directly in the neighborhood of the os uteri 
 apparently possess a peculiar sexual sensitiveness. 
 
 The character of the uterine tissue is very difficult to understand 
 in its unimpregnated condition, but becomes more manifest during 
 gestation. Its constituent parts are: an external peritoneal membrane, 
 an internal or mucous membrane, a peculiar tissue, and numerous 
 blood-vessels and nerves. 
 
 The external peritoneal membrane is furnished by the peritoneum, 
 which, after having covered the posterior surface of the bladder, is 
 reflected from behind forward, upon the anterior face of the uterus, 
 covering its superior three-fourths, and extending over the fundus 
 uteri and posterior surface of the uterus; it is then prolonged on the 
 vagina for a short distance, and from thence reflected upon the rectum. 
 In front of, and behind the uterus, this membrane forms four small 
 falciform folds; those which are in the space between the bladder and 
 uterus are named the vesico-uterine, or anterior ligaments; and those 
 situated between the rectum and uterus, being termed the recto-uteri in , 
 or posterior ligaments. On the borders of the uterus the attachments
 
 INTERNAL OUOJANS OF GENERATION. 77 
 
 of the peritoneum are quite loose, but become more intimate toward 
 the median line. 
 
 The existence of the internal, or mucous membrane, has been very 
 much doubted by many anatomists, as may be seen from the following 
 observations by Moreau : ' 
 
 "On examination, we find the inner surface of the body of the 
 uterus to be soft, pulpy, having neither the brilliancy of the peri- 
 toneum, nor the whiteness of the mucous membrane of the vagina; 
 of a reddish or blackish brown color; it generally contains, whatever 
 may have been the circumstances preceding the death of the woman, 
 a brown or dirty gray fluid. When the uterus is macerated, or boiled, 
 or dissected soon after death, it is impossible to trace the mucous 
 membrane beyond the cavity of the neck. If, on the other hand, we 
 observe that all the hollow organs provided with mucous membranes, 
 such as the stomach, intestines, bladder, and the vagina itself, and which 
 are required, by their, functions, to change in size, present, when 
 empty, a rugose surface and folds more or less projecting, formed by 
 the lining membrane; that this membrane is furnished, moreover, 
 with numerous follicles, which pour out mucus intended to protect the 
 organ from the irritation of the substances or bodies they may contain, 
 or which may pass through them, we will see that no similar arrange- 
 ment obtains in the cavity of the body of the uterus; the follicles are 
 found only in the cavity of the neck; they are there disposed symmet- 
 rically, on four opposite lines, two on the anterior and two on the 
 posterior paries. If the uterus were provided with a mucous mem- 
 brane, could it bear the enormous enlargement resulting from preg- 
 nancy, without lacerations of its internal surface, such as frequently 
 occur in the vagina at the time of delivery, and of which traces 
 may be seen almost always in women who have borne children? 
 Moreover, in advanced age, we often find obliteration of the cayity of 
 the body of the uterus, as well as of the tubes. We have long 
 observed this fact, which is confirmed by the researches of Mayer, 
 reported by Breschet, and what is very remarkable, this obliteration, 
 the natural consequence of age, does not extend beyond the internal 
 orifice, at the point at which we have said the mucous membrane 
 terminates. In organs lined by a true mucous membrane, the cavity 
 always remains. In old cases of artificial anus, that part of the intes- 
 tinal canal below the accidental opening, no longer giving issue to 
 fecal matter, contracts, but never consolidates. 
 
 " We shall terminate these considerations by a single remark. The 
 serous and mucous tissues, evidently communicate by means of the
 
 78 KIND'S ECLECTIC OI5STETUICS. 
 
 aperture of the Fallopian tubes. Is there a point at which these 
 ti>.-ui's change, and are transformed into each other? Undoubtedly 
 there is; l>ut \\here is it? Is the serous tissue suddenly arrested at 
 the dictations of the tubes? Does it line the cavity of the fimbiiated 
 extremity? Does' it extend along the tube as far as the uterus? Or 
 does the mucous tissue occupy the whole cavity ? Is the latter pro- 
 longed, as it is said, into the cavity of the tube? Does it terminate 
 ;tt the fimbriated extremity, or extend beyond? This can not be 
 demonstrated. If it be impossible to assign the precise point at 
 which one of these tissues commences, and the other ends, is it not 
 reasonable to regard the cavity of the body of the uterus, and of the 
 Fallopian tubes, as respiratory surfaces, intermediate by their position, 
 organization, and uses, to the serous and mucous tissues; upon them 
 the transformation is exerted, but in a gradual, successive manner, 
 without being able to determine accurately the point of mutation. 
 
 " This opinion acquires more value if we observe that the exhala- 
 tions of the internal surface of the uterus are not identical over its 
 whole extent. Haller had already found in the cavity of the body, 
 a serous, whitish, muddy, and thin liquid, which, in the uterus of 
 a newly born child, resembled milk, while that in the cavity of the 
 neck was a thick, dense, and reddish mucus. The exhalations of the 
 cavity of the body of the uterus, present under various circumstances, 
 but normal for them, the characters of exhalation of the mucous 
 and serous tissues, alternately morbid and physiological. Thus, in 
 ordinary health, the matter exhaled by the uterine cavity, has a great 
 analogy with mucus. When this surface is excited in a special manner 
 by the act of generation, the fluid produced resembles more the serous 
 exhalations; it is a concrescible, plastic lymph, which becomes con- 
 densed, and quickly changed into a species of false membrane, the 
 caducci* When simply the seat of some fluxive function, as at the 
 menstrual periods, a phenomenon is manifested which belongs equally 
 to overexcited or highly inflamed mucous and serous tissues, a san- 
 guine discharge is. established, the affluxus is dispelled, and nature 
 resumes her usual course. 
 
 " We may hence conclude, that the cavity of the body of the uterus 
 possesses no mucous membrane ; or if it exists, it has undergone such 
 modifications as to leave no longer any resemblance to the same tissue 
 in other parts." 
 
 Cazeaux, likewise, observes in relation to this membrane : " To the 
 reasons already offered by Morgagni, Chaussier, etc., in favor of its 
 existence, we shall add those presented by Cruveilhier, which appear
 
 INTERNAL ORGANS OF GENERATION'. 79 
 
 to us perfectly conclusive, viz.: 1st. Every organic cavity communi- 
 cating with the exterior is lined by a mucous membrane. 2d. Anatomy 
 demonstrates that the vaginal mucous membrane is continued into the 
 cavity of the neck, and then into that of the uterus, only it is deprived 
 of its epithelium in penetrating the latter. 3d. When examined by a 
 lens, the internal surface of the uterus exhibits a papillary disposition, 
 but the papillae are imperfectly developed. 4th. This internal surface 
 has follicles or crypts spread over it, from which mucous can b< j 
 squeezed out, and which, if their orifices be obstructed or obliterated, 
 become distended by the liquid, and form little vesicles. 5th. It is 
 continually lubricated by mucus. 6th, and lastly; the internal surface 
 of the uterus, like all other mucous membranes, is subject to sponta- 
 neous hemorrhages, to catarrhal secretions, and to the mucous, fibrous, 
 and vesicular vegetations, called polypi; and it is generally admitted 
 that, wherever there is an identity of action, there is also an identity 
 of nature." 
 
 That the inner membrane of the uterine walls is composed of a mu- 
 cous body or tissue, has, according to the recent microscopic observa- 
 tions of M. Coste, and others, been decided in the affirmative, and 
 which is probably continuous with the lining mucous membrane of the 
 vagina, and of the Fallopian tubes, but which has no submucous tis- 
 sue, being closely attached to the muscular coat. It consists of tubular 
 utricular follicles or glands, arranged perpendicularly with the surface, 
 simple or bifurcated, spirally contorted at the end, from one thirty- 
 third to one fiftieth of a line in diameter, their length being that of 
 the thickness of the mucous membrane, and consisting of very deli- 
 cate membrane and ciliated cylindrical epithelium ; the cilia vibrating 
 from below upwards, and thus very likely aiding in conveying the 
 spermatic filaments to the Fallopian orifices. The secretion from these 
 glands probably forms the decidua. 
 
 The peculiar tissue of the uterus, which is under the mucous mem- 
 brane, and is named the middle, fleshy, or muscular coat of the uterus ; 
 is very dense in structure, resisting, of a dirty grayish color, being 
 sometimes slightly pearly near the neck, crackles like cartilage under 
 an incision with the scalpel, and constitutes the greater part, if not the 
 fundamental structure of the organ. In the unimpregnated state of 
 the uterus, it is very difficult to determine the true character of the 
 uterine tissue, as it varies in color and density, its fibrous organizations 
 being concealed by the state of condensation of the organ. There has 
 been considerable difference of opinion upon this point, some viewing 
 it as belonging to the fibrous tissue, and others to the muscular ; the
 
 80 KIXCi'K ECLECTIC 015STETRICS. 
 
 condition of pregnancy, however, removes all doubt and uncertainty, 
 and presents to us a true muscular tissue. 
 
 The arteries of the uterus come from the hypogastrics, or internal 
 iliacs, under the name of uterine arteries, and from the aorta, or renal 
 arteries, under the name of ovarian or spermatic arteries. The uterine 
 arteries penetrate the uterus by its lateral borders, and describe a num- 
 ber of flexuosities in the proper tissue of the organ ; the branches of 
 the same side frequently anastomose with each other, and unite on the 
 median line with those of the opposite side. They likewise commu- 
 nicate above and laterally with the branches of the ovarian arteries, 
 and terminate in the interior tissue, continuing into the veins, and, 
 probably, presenting orifices within the uterine cavity. 
 
 The veins follow the course of their respective arteries ; they are 
 very numerous, have no valves, and empty into the corresponding 
 trunks : the right spermatic into the inferior cava, the left into the 
 renal vein, and the uterine veins into the internal iliacs. The arrange- 
 ment of the veins, in the uterine tissue, is analogous to that observed 
 in the corpora cavernosa, and the erectile tissues ; and their orifices on 
 the internal surface of the uterus, are very large during pregnancy, 
 and become visible just after delivery. 
 
 The nerves are derived, one portion, from the sacral plexus of the 
 cerebro-spinal system, which more especially supplies the cervix with 
 nervous filaments, and, consequently, renders it more sensitive to the 
 touch than any other part of the organ ; the other portion, being des- 
 tined to the organic life alone, is from the great sympathetic nerve, 
 which supplies the body of the organ with filaments, and which will 
 explain to us how most of the vital organs of the body, especially the 
 brain and stomach, sympathize so readily with the uterus, both in dis- 
 ease and during pregnancy. The performance of the several functions 
 of menstruation, conception, and parturition, is, without doubt, chiefly 
 owing to the influence of the uterine nerves. 
 
 The lymphatic vessels are very numerous, and arise from different 
 parts of the organ, forming reticulations, branches, and trunks, which, 
 united in bundles, leave the uterus in three different directions. The 
 least numerous leave the abdomen by the inguinal canal, and are 
 distributed to the inguinal ganglia; others, united to the lymphatics 
 of the vagina, accompany the uterine and vaginal arteries, and ter- 
 minate in the hypogastric lymphatic plexus. But the most numerous 
 arise from the anterior and posterior surfaces of the neck and of the 
 body, run toward the lateral borders, follow their direction, are then 
 united with those of the ovaria, the tubes, and fundus uteri, ascend
 
 THE UTERINE APPENDAGES. 81 
 
 the ovarian arteries and veins, in front of the psoas muscle, to 
 join the ganglia situated in front of the aorta, the vena cava, and in 
 the vicinity -of the kidneys. 
 
 All the above vessels, etc., are very small during the condensed or 
 unimpregnated condition of the uterus, but increase in size during 
 pregnancy, and at full term acquire an enormous size, supplying the 
 organ with torrents of blood. The lymphatic vessels, also, play a very 
 important par,t in the diseases of the uterus. 
 
 Sometimes the uterus is absent entirely, at others but slightly devel- 
 oped, or it mayjbe malformed, or in an abnormal position. It is liable 
 to hernia, prolapsus, retroversioii, anteversion, inversion, ulcerations, 
 inflammations, etc., the history and treatment of which may be found 
 in any treatise on the diseases of women. 
 
 CHAPTER X. 
 
 OF THE UTERINE APPENDAGES THE LIGAMENTS, THE FALLOPIAN 
 
 TUBES, AND THE OVARIES. 
 
 THE uterus is supported, in the pelvic cavity, by six duplicatures of 
 peritoneum two anterior, or vesico-uterine, and two posterior, or recto- 
 uterine ligaments, to which reference has been heretofore made ; also 
 two lateral, or broad ligaments, which are much larger and more im- 
 portant than the others, as within them we find contained the round 
 ligaments, the Fallopian tubes, and the ovaries (Fig. 19). 
 
 The BROAD LIGAMENTS are formed by two duplicatures of 
 the peritoneum, which, covering the anterior and posterior faces of the 
 uterus, are prolonged transversely, extending to the ilia; these two 
 folds rest against each other, and divide the pelvis into two cavities 
 the anterior cavity containing the bladder, and the posterior the rec- 
 tum. These ligaments are of a quadrilateral shape, and from their 
 supposed resemblance to the wings of a bat extended, have been 
 named the alee vespertilionis. Outwardly, and below, these ligaments 
 are continuous with the peritoneum that lines the excavation; their 
 upper, or superior border is loose, and extends from the angles of the 
 uterus to the iliac fossse, presenting three small folds, called a/ce,,<or 
 wings. The anterior wing is not distinctly developed, and is denied 
 by some anatomists ; it is occupied by the round ligament. The. mid-*
 
 82 KING'S ECLECTIC OBSTETRICS. 
 
 die wing incloses the Fallopian tube, and the posterior contains the 
 ovary and its ligament. 
 
 The space between the two serous folds, constituting the broad liga- 
 ment, is filled by a loose and very extensible lamellated cellular tissue, 
 continuous with the fascia propria of the pelvis, and which is traversed 
 by the uterine vessels and nerves. As gestation advances, and the 
 uterus enlarges, the two laminaB of the peritoneum separate to receive 
 the uterus, assisting to cover its anterior and posterior surfaces, and in 
 consequence, during the latter month of pregnancy, the broad liga- 
 ments entirely disappear. 
 
 The ROUND LIGAMENTS, or supra-pubic cords, are two in 
 number, one on each side ; they are of cylindrical form, six or seven 
 inches in length, of a fibrous appearance, and of a grayish white color. 
 They arise from the lateral borders of the uterus, below and a little in 
 advance of the Fallopian tube, and are directed upward and outward, 
 following the direction of the pelvis ; they are enveloped in a cellular 
 tissue, and are covered by a prolongation of the peritoneum, to which 
 the name " Canal of Nuck," has been given. They enter the inguinal 
 canal on each side, traverse it, emerge by the corresponding inguinal 
 ring, and divide in front of and above the pubes into a number of 
 fibrous fasciculi, which are lost in the cellular tissue of the groins, 
 mons veneris, and labia pudendi. They contain a great number of 
 veins, which are liable to become varicose. 
 
 There has been considerable controversy as to the structure of these 
 ligaments, but the investigations of modern anatomists have ascer- 
 tained them to be expansions or prolongations of the muscular fibers 
 of the uterus, containing blood-vessels, nerves, lymphatics, and cellular 
 tissue. 
 
 The real uses of the round ligaments are not satisfactorily known ; 
 they are supposed to be, to retain the uterus in its proper position, and 
 to prevent its displacements. During pregnancy, chronic affections, 
 or uterine displacements, these ligaments are subject to inflammation 
 and engorgement, and which conditions may, probably, be the cause 
 of the pains in the groins, frequently experienced by women thus 
 circumstanced. 
 
 The FALLOPIAN, or UTERINE TUBES, (oviducts, vector ca- 
 nals), are two cylindrical canals, from four to five inches in length, 
 of a conical shape, flexuous and waving, and extend from the upper 
 or superior angles of the uterus to the ovaries; they are placed in the
 
 THE UTERINE APPENDAGES. 83 
 
 thickness of the middle wing of the broad ligaments. The internal 
 cavity of these tubes is very narrow at their uterine extremities, but, 
 as they extend outwardly, i| gradually increases in size, but again con- 
 tracts just before opening at the fimbriated extremity. The internal 
 extremities of the tubes are inserted into the superior angles of the 
 uterus, where they open into the cavity of its body, their orifices 
 being named the internal or uterine. The external or free extremities 
 of the tubes, called the fimbriated extremities or pavilion, communicate 
 with the peritoneal cavity by an oblong, inverted opening, with digi- 
 tated or fringed edges, of which one is longer than the other, curved, 
 and inserted into the external extremity of the ovary ; the other hangs 
 loosely over the ovarium. The openings at these ends .of the tubes 
 are named the free orifices of the tubes; the orifice at either uterine 
 angle is called the ostium uterinum, that at either fimbriated extremity, 
 the ostium abdominale. 
 
 The tubes are enveloped by the peritoneum, which forms the outer 
 or external tunic or membrane ; the internal membrane is a prolonga- 
 tion of the uterine mucous membrane (which, however, is denied by 
 some authors), and is also continuous with the serous peritoneum; the 
 tubes are composed of two laminae of unstriped muscular fibers, the 
 exterior of which have a longitudinal direction, while the internal are 
 circular. Their vessels are derived from the ovarian arteries, and their 
 nerves from the great sympathetic. The middle layer or proper tissue 
 of the tubes, is a continuation of, and identical in texture with, that 
 of the uterus. The internal lining mucous membrane of the Fallopian 
 tubes is thin, in longitudinal folds permitting dilatation, and is covered 
 by ciliated cylindrical epithelium, the movements of which are directed 
 from the ostium abdominale to the ostium uterinum. 
 
 The Fallopian tubes serve to conduct the fecundating principle of 
 the male to the ovaries, and to seize the impregnated germ or ovule 
 of the female and transmit it to the uterus. At the moment of fecunda- 
 tion, the fimbriated extremity grasps the escaping ovum (morsus dia- 
 boli), and probably also at each menstrual period; a failure of this 
 action, or of the peculiar offices of the tubes, may, probably, be a 
 cause of extra-uterine pregnancy. 
 
 The OVARIES furnish the ovula which contain the rudiments of the 
 future animals ; they are situated in the thickness of the posterior wing 
 of the broad ligaments, behind and below the Fallopian tubes ; they 
 are two in number, oblong, oval, whitish, twelve or fifteen lines long, 
 and flattened from before backward, being about the size and shape of
 
 84 KING'S ECLECTIC OBSTETRICS. 
 
 an almond. Previous to puberty, and sometimes in virgins and women 
 who have not borne children, their surface is polished and embossed; 
 but after puberty, owing to the escape of ^he ova, they become rough 
 and fissured. Their superior border is convex and loose ; their in- 
 ferior, straight, or slightly concave, and adhering to the broad liga- 
 ments, by which they are maintained in position, as also by a special 
 one, named the ligament of the ovary (ligamentum ovarii), a dense, 
 imperforate cellule-fibrous cord, which fixes the internal ovarian ex- 
 tremities to the uterus. The external extremities are joined to, or ap- 
 proximate, the fimbriated Fallopian extremities. The nerves of the 
 ovaries come from the renal plexus, and the blood-vessels which are 
 called the ovarian, have a similar origin with the spermatic vessels in 
 the male. The situation of the ovaries varies according to circum- 
 stances; in the fetus they are in the lumbar region; during gestation 
 they rise into the abdomen along with the body of the uterus, upon 
 the sides of which they are attached; and immediately after delivery, 
 they occupy the iliac fossae, where they sometimes continue through 
 life. It is not uncommon to find them p IG 2 i. 
 
 turned backward, and adhering to the 
 posterior uterine surface. They like- 
 wise vary in size, being larger in pro- 
 portion in the fetus than at maturity, 
 decreasing after birth, enlarging at pu- 
 berty and during pregnancy, and dwind- 
 ling away as old age approaches; they 
 
 frequently become the seat of organic 
 
 * EXTERNAL FACE OF THE OVARY 
 
 alterations. (Fig. 21.) 
 
 The external covering of the ovaries is obtained from the peri- 
 toneum, and is named -the indusium. Beneath this covering, the body 
 of each ovary is invested with a whitish, dense, fibrous membrane, 
 called the tunica albuginea, which is the proper tunic of these organs, 
 and- which may be considered as an expansion, or extension of the 
 ovarian ligaments. From the internal surface of this membrane 
 proceed prolongations which divide the ovaries into many small cells 
 filled by their proper tissue. The parenchyma of the ovaries, or tissue 
 proper, is of a reddish brown color, spongy, dense, and vascular, 
 bearing some resemblance to the erectile tissue, it is called the stroma; 
 in this tissue are found imbedded a number of small transparent folli- 
 cles or vesicles, varying in size from the smallest pin's head to that 
 of a large shot, the smaller being within the larger and better de- 
 veloped more toward the surface. These last sometimes produce small
 
 THE UTERINE APPENDAGES. 
 
 85 
 
 FIG. 22. 
 
 elevations on the stroma, which give a rough or tuberculous appear- 
 ance to the whole ovary; they are called the ovisacs, or Graafian vesicles, 
 after De Graaf, who gave a,, description of them. 
 
 The Graafian vesicles number from fifteen to twenty in the adult 
 female, in, or near a state of maturity, but with the aid of a microscope 
 many more can be seen which gradually become developed as the others 
 perfect their function. They are hardly visible in children and old wo- 
 men, but are very distinct during the menstrual life. (Fig. 22.) Each 
 ovary at birth contains not less than thirty- five thousand ova. (Foulis.) 
 
 The vesiculaB Graafianse, consist 
 of two separate tunics ; 1. The ex- 
 ternal tunic or tegument, which is firm, 
 fibrous, and vascular in its character, 
 like the stroma or proper ovarian 
 tissue ; 2. The internal tunic, formed 
 of dense cellular tissue, but thin, 
 smooth, delicate, diaphanous, and 
 easily torn ; some consider it desti- 
 tute of vascularity, which is, again, 
 denied by others. From the close 
 approximation of these two tunics, it 
 is sometimes difficult to separate them. 
 
 The internal face or cavity of the A . The Ovule abou7i-i7a line in diameter. 
 
 inner tunic Contains the nucleus, COm- G '- The Granular Cumulus, or ProligerousDisk. 
 
 K. The Cavity of the Graafian Vesicle. 
 
 prising: 1. Ihe granular membrane, M. The MUCOUS surface, 
 which is a delicate membrane formed v - The vascular Layer. 
 
 F. The Fibrous Layer. 
 
 oi granules or cellules. I his mem- p. The Peritoneal Coat, 
 brane is exceedingly thin and very G " The Granular Membrane, 
 easily torn ; its thickest portion corresponds with the free side of the 
 vesicle, or that portion which is nearest the surface of the albuginea, 
 and here the granulations are more numerous, constituting the cumulus 
 proligerus, or discus proligerus. 2. A fluid either limpid, reddish, or 
 slightly lemon-colored, concrescible, and composed principally of albu- 
 men, as it is coagulated by heat, alcohol, and the strong acids. In 
 this liquid float, vitellary corpuscle, oil globules, and a great number of 
 small grains, which settle themselves, touching each other, upon the 
 inner wall of the vesicle, and form the above named granular mem- 
 brane. 3. The ovule or human egg, which is found in the center of the 
 proligerous disk. (A, Fig. 22.) 
 
 The OVULE, or HUMAN EGG was first discovered as a distinct 
 organ in the Graafian vesicle by Charles Ernest Baer, though DeGraaf 
 had suggested the idea previously. It is imbedded, as stated above, 
 
 THE 
 
 OVULE IN THE 
 VESICLE. 
 
 GRAAFIAN
 
 86 
 
 KINGS ECLECTIC OBSTETi: ! -. 
 
 A NON-FECUN'DATED OVULE OB 
 HUMAN EGG. 
 
 Pur kin je, about 1-60 of a line in 
 diameter. 
 
 D. The Germinal Spot, from the 1-400 to 
 the 1-600 of a line in diameter. 
 
 FIG. 23. in the midst of the proligerous disk, and 
 
 is perfectly formed in the ovary during 
 the earlier years of life. It is extremely 
 minute and hardly to be seen by the 
 naked eye, but when examined with the 
 microscope, presents an opaque, rounded 
 appearance. Bischoff says : " The largest 
 human ovules I have seen and manipu- 
 lated, did not exceed the tenth of a line, 
 being barely perceptible to the naked 
 eye." As seen by the microscope, the 
 ovule is possessed of an exterior covering 
 called the vitelline membrane, transparent 
 zone, cortical membrane, or chorion; of a 
 
 A. The Vitelline Membrane, or Trans- 
 
 parent zone. substance denominated the yelk or vitellus, 
 
 B. The Vitellus, or Yelk. 3 t i '.i/u' A i n 
 
 & The Germinal Vesicle, or Vesicle of and f a Vesicle Within the yelk, termed 
 
 the germinal vesicle. 
 
 The Zona Pellucida, or vitelline mem- 
 brane, is an elastic, thick, hyaline, and 
 transparent membrane, without a determinate texture, whose external 
 and internal outlines assume the appearance of two circular lines 
 inclosing a transparent ring. (A, Fig. 23.) 
 
 The yelk or vitellus of the human ovum occupies the cavity of the 
 vitelline membrane; it is formed according to Bischoff, of a coherent 
 indistinctly granular, yellowish, transparent, and viscous mass, which 
 does not run out when the egg is cut or crushed; each portion of the 
 zone reserving its particular segment of yelk, or the latter escaping 
 altogether. It usually fills the interior of the viteliine sphere com- 
 pletely, though it is sometimes smaller, and its granulations are 
 placed in juxtaposition with its sole envelope, the transparent zone. 
 (B, Fig. 23.} 
 
 Within the yelk, or on one of the points of its circumference, is 
 discovered a slightly oval, colorless, and perfectly transparent vesicle, 
 consisting of a very delicate membrane, which incloses a clear and 
 transparent liquid, but which occasionally contains a few granulations. 
 This colorless vesicle scarcely measures the sixtieth of a line in diame- 
 ter, is surrounded by a mass of deep yellow, and is identical in 
 character with that found in the unfecundated eggs of birds. Fecun- 
 dation destroys it. This is called the germinal vesicle or the vesicle of 
 Purkinje (c, Fig. 23). The honor of its discovery is variously attrib-
 
 THE UTERINE APPENDAGES. 87 
 
 uted to Purkinje, Baer, and Coste, though the latter is more justly 
 entitled to it. 
 
 If, according to Wagner, the germinal vesicle be attentively exam- 
 ined with the lens, at four or five hundred diameters, there will be 
 seen on some part of its periphery, a small, dark, round spot, which 
 consists of a collection or stratum of fine, small lenticular granules or 
 globules, and which stratum appears to be the true living .animal 
 germ, existing previously to impregnation. This is called the germinal 
 spot, and was cotemporarieously discovered and described by Professor 
 Rudolph Wagner, of Germany, and T. Wharton Jones, of England. 
 Two, or more germinal spots have been met with in the mammiferse. 
 (D, Fig. 23). 
 
 The ovule, therefore, previous to impregnation, is composed: 1, of 
 an exterior tunic, the zona pellucida or vitelline membrane, within which 
 is contained, 2, a yelk, which again incloses, 3, a vesicle, the germinal 
 vesicle, within which we find, 4, a dark spot, the germinal spot or germ 
 from which it is presumed the future man originates, after it has been 
 fertilized by the male semen. 
 
 The Graafian or ovarian vesicles experience considerable changes 
 during menstruation, conception, and after impregnation. The inves- 
 tigations of Gendrin, Negrier, Pouchet, Raciborski, Jones, Lee, Pat- 
 terson, Bischoff, and several others, have led to the belief, which 
 has been general among medical men, that the phenomena of men- 
 struation is owing to the development or maturity of these vesicles. 
 Until the period of puberty these ovisacs are hardly discernible, but 
 on the completion of this period, they develop themselves, maturing 
 periodically, in women once in every twenty-eight days. At each 
 period of ovulation or menstruation, a vesicle becomes much enlarged, 
 its upper segment rapidly rises above the surface of the ovary, forming 
 a prominence there about the size of a small nut (A, Fig. 24), and the 
 walls of the vesicle become less transparent in consequence of the 
 thickness of the internal membrane, and the hemorrhage that finally 
 takes place in the interior of the vesicle. The quantity of blood 
 effused within the vesicle adding to the amount of fluid it naturally 
 holds, distends it so much as eventually to lacerate or rupture its 
 walls, at a point about a line in extent, the situation of which can be 
 distinguished by its reddish appearance and its more elevated pro- 
 jection. The ovum and contents of the vesicle escape into the peri- 
 toneal cavity, or are carried down to the womb by the Fallopian tube : 
 the vesicular walls shrink up, their cavity holding a clot of blood
 
 88 
 
 KING'S ECLECTIC OBSTETRICS. 
 
 FIG. 24 
 
 about as large as a cherry, which has oozed from the torn margins, 
 
 and which, as the vesicular cav- 
 ity diminishes, is gradually ab- 
 sorbed. The margins of the 
 fissure approximate, giving rise 
 to more or less cicatricula of 
 various forms, being sometimes 
 linear, again radiated, and at 
 others triangular; when recent, 
 they are red, but gradually be- 
 come brown, forming deep fur- 
 rows by their retraction. 
 DIAGRAM SHOWING THE OVARY, AND A __ . , . , 
 
 GBAAFIAK VESICLE AT ITS HIGHEST BE- This rupture of the vesiclea 
 GREE OF DEVELOPMENT, AND JUST BE- not only takes place at the period 
 FORE ITS RUPTURE. o f impregnation, but also at each 
 
 A. The hypertrophied Vesicle iod f ovu l at i on . an d the 
 
 B C C. Radiated cicatrices left by previously rup- f 
 
 tured vesicles. scars which are left, instead of 
 
 being an evidence of so many previous conceptions, as was formerly 
 supposed, are merely the remains of ruptured ovisacs. (See Nidation.) 
 
 CHAPTER XI. 
 
 OF THE CORPUS LUTEUM. 
 
 THE term CORPUS LUTEUM, or yellow body, is applied to the 
 remains of the Graafian vesicle, after the ovum has been expelled from 
 it, whether from copulation or from menstruation. And as there has 
 been considerable discussion upon this body, regarding its presence as 
 a sign of conception, it becomes a matter of some moment, in a medico- 
 legal point of view, to determine its true character. 
 
 The corpus luteum is a peculiar glandular mass, varying in size 
 from that of a pea to half an inch in length ; it is of a dull yellow 
 color, friable in consistence, having a lobulated appearance, with 
 slight convolutions, somewhat resembling a section of the human 
 kidney, and very vascular ; according to Montgomery, an injection 
 through the spermatic artery will easily pass into its substance. The 
 true corpus luteum is found in the ovary of a recently pregnant woman, 
 and varies in size and appearance accord-ing to the period of gestation,
 
 THE CORPUS LUTEUM. 89 
 
 gradually diminishing in size, and losing its deep yellow color, until 
 about the fifth month after full term, when it disappears, leaving a 
 small pit over the place it had previously occupied. So that the idea 
 that it is a permanent formation is erroneous. Dr. Montgomery, who 
 has bestowed considerable attention to this subject, thus speaks of its 
 appearance : 
 
 " Its center exhibits either a cavity, or a radiated or branching white 
 line, according to the period at which the examination is made; if 
 within the first three or four months after conception, we shall, I 
 believe, always find the cavity still existing, and of such a size as to 
 be capable of containing a grain of wheat at least, and very often of 
 a greater dimension; this cavity is surrounded by a strong white cyst; 
 and, as gestation proceeds, the opposite parts, of this cyst approximate, 
 and at length close together, by which the cavity is completely oblit- 
 erated, and in its place there remains an irregular white line, whose 
 form is best expressed by calling it radiated or stelliform. This is 
 visible as long as any distinct trace of the corpus luteum remains. I 
 am unable to state exactly at what period the central cavity disappears 
 or closes np, to form the stellated line. I think I have invariably 
 found it existing up to the end of the fourth month. I have one 
 specimen, in which it was closed in the fifth month, and another in 
 which it was open in the sixth later than this I have never found it. 
 
 " After the period of gestation has been completed, or the contents 
 of the uterus pi'ematurely expelled, so that gestation ceases, the corpus 
 luteum soon begins to exhibit a very decided alteration in all its char- 
 acters, until, at length, it is no longer to be found in the ovary. The 
 exact period of its total disappearance I am unable to state ; but I 
 have found it distinctly visible, so late as at the end of five months 
 after delivery at the full time ; but not beyond this period ; and the 
 corpus luteum of a preceding conception is never to be found along 
 with that of a more recent, when gestation has arrived at its full term; 
 but in cases of miscarriage, repeated at short intervals, it may. 
 
 " At the time of delivery the corpus luteum is neither so large nor 
 so vascular as at the earlier periods of pregnancy, except the woman 
 should happen, at the time of her death, to be laboring under inflam- 
 mation of the uterine system ; in which case the corpus luteum partakes 
 of the turgescence of the other parts, and, very remarkably, of their 
 increased vascularity, a striking instance of which is represented in a 
 preparation in the writer's museum, taken from the body of a woman 
 who died of inflammation of the womb, two days after delivery; the 
 central radiated white line is very distinct, and the vessels having been
 
 90 KING'S ECLECTIC OBSTETRICS. 
 
 injected, the substance of the corpus luteum is quite crimsoned, and, 
 externally, the ovary continues to exhibit the superficial cicatrix, and 
 the alteration of form produced by the projection of the part contain- 
 ing the corpus luteum." 
 
 With reference to the corpus luteum, as a test of conception, there is 
 some diversity of opinion; some viewing the existence of a true corpus 
 luteum, so called^ as an infallible test; while others maintain that no 
 real distinction can be made between true and false corpora lutea, or 
 that which forms independent of impregnation. This question still 
 remains unsettled, though the observations of Dr. Montgomery, which 
 are corroborated by other investigators, as Haller, Pouchet, Haighton, 
 Jones, Lee, Raciborski, etc., seem to confirm the former view; he re- 
 marks : " I have seen many of these virgin corpora lutea, as they are 
 unhappily called, and have preserved several specimens of them ; but 
 not in any one instance did they present what I should regard as even 
 an approach to the assemblage of characters belonging to the true 
 corpus luteum, the result of impregnation, from which they differ in 
 all the following particulars: 
 
 " 1. There is no prominence or enlargement of the ovary over them. 
 
 " 2. The external cicatrix is almost always wanting. 
 
 " 3. There are often several of them found in both ovaries, especially 
 in subjects who have died of tubercular disease, such as phthisis, in 
 which case they appear to be merely depositions of tubercle, and are 
 frequently without any discoverable connection with the Graafian 
 vesicles. 
 
 " 4. They present no trace whatever of vessels in their substance, 
 of which they are in fact entirely destitute, and of course can not be 
 injected. 
 
 " 5. Their texture is sometimes so infirm that it seems to be merely 
 the remains of a coagulum, and at others appears fibro-cellular, like 
 that of the internal structure of the ovary; but never presents the soft, 
 rich, lobulated, and regularly glandular appearance which Hunter 
 meant to express, when he described them as ' tender and friable, like 
 glandular flesh.' 
 
 " 6. In form they are often triangular or square, or of some figure 
 bounded by straight lines. 
 
 " 7. They never present either the central cavity or the radiated or 
 stelliform white line which results from its closure. 
 
 "This latter peculiarity, in common with several others observable 
 in these spurious productions (whether .occurring in virgins or in other 
 women, but not the result of conception), even when they are connected
 
 THE CORPUS LUTEUM. 91 
 
 with a Graafian vesicle, depends on their different mode of formation; 
 a circumstance which deserves especial attention, as pointing out the 
 essential difference between a very large class of these pseudo-structures 
 and the true ones. 
 
 " The history of their formation appears to me to be this : accidental 
 or morbid determination takes place toward a vesicle, in consequence 
 of which it is distended with fluid, and either bursts arid discharges its 
 contents (in which case there may be found an external cicatrix), or 
 the fluid is again absorbed ; but, in either case, there is often deposited 
 on the internal surface of the vesicle, a substance somewhat resembling 
 the corpus luteum in color, but in general not more than about one- 
 sixteenth of an inch in thickness, and entirely destitute oi> blood- 
 vessels : sometimes it is very much thinner even than this, amounting 
 to little more than a mere layer of coloring matter lining the vesicle. 
 In this condition I have often found them, the vesicle being enlarged 
 to three or four times its natural size, full of fluid, and its internal sur- 
 face of a bright yellow color; but when the vesicle collapses, either in 
 consequence of rupture of its coats, or the absorption of the contained 
 fluid, the inner surface of this new deposit closes upon itself, and forms 
 an irregular line of junction, which is generally darker than the rest 
 of the structure, and not unfrequently, they present the yellow color 
 only on the circumference, while their center is so dark as to be almost 
 black; but, from their situation, they are entirely without lining mem- 
 brane, to form either a central cavity or white stellated line, which, in 
 the true corpus luteum, is formed by the closure of the inner coat of 
 the vesicle; for the same reason also, these accidental formations are in 
 general much smaller than the others; and they are moreover totally 
 without vessels in their structure, so-, that, however minutely the rest 
 of the ovary may be pervaded by fine injection, not a particle of it will 
 pass into the bodies thus formed." 
 
 Among those who have not considered it as a test of conception, but 
 only as an evidence of perfect ovulation, may be named Hume, Blu- 
 menbach, Bischoff, Cuvier, Cazeaux, Prof. Meigs, of Philadelphia, etc. 
 This latter gentleman, in his "Treatise on Obstetrics," maintains that 
 the yellow matter found in a corpus luteum, "is of the same apparent 
 structure, form, color, odor, coagulability, and refractive power," as 
 the yelk of eggs. His views are based upon the following observa- 
 tions : 
 
 " 1. Equal masses of yelk and corpus luteum are equally yellow. 
 
 " 2. They alike fill the tube, before the focus is got, with a brilliant 
 yellow light.
 
 92 KING'S ECLECTIC OBSTETRICS. 
 
 " 3. They alike consist of pellucid fluid, in which float granules, 
 corpuscles containing yellow fluid, oil-globules, and puuctiform 
 bodies. 
 
 '" 4. These bodies, placed on the same platine, and diligently com- 
 ]>;iiv<l together, exhibit the same forms, size, tint, and refractive 
 power. 
 
 " 5. Yelk, boiled hard, is granular and friable ; it is coagulated by 
 heat. 
 
 " 6. Corpus luteum, boiled, becomes hard, granular, and friable ; it 
 is coagulated by heat. 
 
 " 7. Both substances, raw or boiled, stain paper alike of a yellow 
 color. 
 
 " 8. There is this difference : the crushed mass of corpus luteum 
 contains patches of laminar cellular tela, detritus, and blood-disks 
 forced out by the compressorium ; which can not occur in the yelk, as 
 that is contained within a vitellary membrane, in which its corpuscles 
 are free ; whereas, in the corpus luteum, they are confined by the deli- 
 cate cellular substance lying betwixt the concentric laminae of the 
 Graafian follicle. 
 
 " 9. They refract alike. 
 
 " 10. Projected on a live coal, they alike give out the odor of roasted 
 
 These opinions require further investigation, in order to establish 
 their correctness. 
 
 The formation of the true corpus luteum, is thus explained by 
 Ramsbotham : " It has been demonstrated that the Graafian vesicle 
 possesses two membranes : one. adhering to the substance of the 
 ovary, the other inclosing the fluid in which the ovule of Baer 
 floats. When a fruitful connection takes place, a great determination 
 of blood is made to that ovary which supplies the germ. The 
 gland becomes larger, rounder, and more vascular than the other ; 
 to the touch it feels fuller and softer. But the vascularity is con- 
 fined to one spot the neighborhood of the corpus luteum ; and the 
 increased size and softness result, not so much from an alteration in 
 the structure of the whole organ, as from the quantity of lymph and 
 fluid blood deposited between the membranes of the vesicle, which is 
 converted into the characteristic yellow gland-like mass. This effusion 
 causes the vessel to be thrown prominently out toward the peritoneal 
 surface; the attenuated coats burst, or rather an opening is formed by
 
 THE CORPUS LUTEUM. 93 
 
 absorption, and the fluid, with the ovule previously contained within 
 them, passes into the tube." 
 
 The changes that occur in the ovisac take place with less intensity 
 when impregnation is not present, and hence the difference in the 
 appearance between the true and false corpora lutea. AVhen impreg- 
 nation has taken place, there' is increased vascular excitement in the 
 ovaries and uterus; and from the augmented accumulation of blood in 
 the generative parts, the changes in the ovisac occur with more slug- 
 gishness, because they are " conducted upon a larger scale and with a 
 greater abundance of materials." 
 
 Leishman, in his System of Midwifery, closes a very able article on 
 this subject as follows : 
 
 " What is called the Corpus Luteum is due to a deposit of yellow 
 fatty matter in, and hypertrophy of, the internal layer of the Graafian 
 vesicle (ovisac). 
 
 " The formation of a corpus luteum always succeeds the rupture of 
 a Graafian vesicle. 
 
 " Up to a certain point the changes in the Graafian vesicle are uni- 
 form, and have no relation to pregnancy. The corpus luteum of preg- 
 nancy may, however, be distinguished in its subsequent course by its 
 higher development and longer duration, its hardness, its vascularity, 
 and, at a later stage, by the formation of the white lining membrane, 
 and large central stellate cicatrix. 
 
 " The presence in the ovary of a corpus luteum is no evidence of 
 pregnancy, unless the characteristics last indicated are distinct and 
 unequivocal under which circumstance it is a certain sign. 
 
 " With reference to the above conclusions, it may be remarked that 
 much confusion has arisen from the employment loosely of the terms 
 'true' and 'false,' as applied to the corpus kiteum, in so far as they 
 are assumed to imply a distinction, which proves or disproves the oc- 
 currence of pregnancy. 
 
 " ' There is as little reason,' says Farre, with justifiable emphasis, ' for 
 the use of the last term as there would be for denominating a child a 
 false man. . . . These terms actually represent the same body, 
 only in different stages of growth or 'decay/ 
 
 "During the whole of the child-bearing period of a woman's life, 
 the ripening and dehiscence of the Graafian vesicles are of periodic 
 occurrence. In those animals in which plural births are the rule, sev- 
 eral vesicles ripen and discharge their contents at, or near, the same 
 time; but in man this is exceptional, and we thus find that one vesicle
 
 94 KING'S ECLECTIC OBSTETRICS. 
 
 only, as a rule, ripens at a time, bursts, discharges its contents, and 
 rapidly shrinks as it retires toward the centre of the ovary, to give 
 place, in a normal condition of the parts, to a constant succession of 
 vesicles, which, one by one, run a similar course after discharging their 
 ova. There is every reason to believe, further, that, during pregnancy 
 and stickling, while the uterine functions are in abeyance, those also 
 of the ovary are temporarily arrested, in so far as the development of 
 new Graafian vesicles is concerned the whole generative force being, 
 as it were, turned into other channels. 
 
 "The numerous lacerations which, in consequence of repeated rup- 
 tures, take place on the surface of the ovary, leave, in the process of 
 healing, corresponding cicatrices. On this account, the smoothness 
 of surface is soon lost, and it becomes more and more fissured and 
 wrinkled, until, toward the end of the child-bearing epoch in a wo- 
 man's life, the ovary is so irregular on the surface, as to warrant the 
 comparison which Raciborski has instituted between it and the kernel 
 of a peach. After this, the organ becomes atrophied, and, like the 
 uterus and other parts, is restored, in some measure, to the form which 
 it presented in early life." 
 
 The medical expert, if called upon to determine the existence or non- 
 existence of pregnancy, by the appearance of the corpus luteum in a 
 post-mortem examination, would undoubtedly find an extremely diffi- 
 cult question to decide. Every author cites numerous differential 
 characteristics, which I believe to be misleading ; also impossible to 
 diagnose pregnancy, beyond the peradventure of doubt, simply by the 
 appearance of the corpus luteum. 
 
 CHAPTER XII. 
 
 THEORIES OF IMPREGNATION. 
 
 GENERATION comprises those' several phenomena which are neces- 
 sary to the development or reproduction of organized bodies, and which 
 include, in the human family, the various functions of menstruation, 
 copulation, conception, gestation, and labor or parturition. The partic- 
 ular method by which generation is effected in the organic world, 
 varies according to the character of the organization, being more sim-
 
 THEORIES OF IMPREGNATION. 95 
 
 pie as this approaches elementarity. Moreau has described the several 
 modes somewhat as follows: 
 
 1. Generation may be spontaneous, doubtful or unknown, as in case 
 of intestinal worms. 
 
 2. It may result from an individual, by division or separation of its 
 parts; a, by simple division of the individual, each fragment pro- 
 ducing a new individual, as in the instances ofjissiparce or vegetables, 
 cuttings of trees, and animal infusoria; 6, by separation of a vegetable 
 product, either on the exterior or interior of the individual, as with 
 the gemmiparce, or vegetables, buds of trees, and some polypi. 
 
 3. It may be effected by impregnation, requiring the connection of 
 the sexes, and varies according to the character of the sexes. 1st. 
 As in hermaphrodism, or where the sexes are united in the same indi- 
 vidual, and which may be divided into, , where the sexes are united 
 in a common envelope, in which instance one individual is sufficient, 
 as with many vegetables and some molusca; 6, where the sexes are 
 separated on the same individual, as in monoecious plants; c, with the 
 sexes separated in the same individual, but requiring the connection 
 of two similar individuals, and even reciprocal impregnation, as with 
 gasteropodous mollusca, and worms. 2d. When the sexes are sepa- 
 rated on different individuals, and which may be divided into, a, with- 
 out approximation, the parents and offspring remaining unknown to 
 each other, as with dioecious plants, and fishes ; 6, with approximation, 
 but without copulation, the parents knowing each other, but the off- 
 spring being ignorant of them, as with the batrachia, or reptiles, frogs, 
 toads, etc.; c, with approximation and copulation, as with the majority 
 of insects; the reptilia, chelonia, sauria, ophidia, birds, and mammalia. 
 
 4. This last method of generation by copulation and approximation, 
 offers great varieties, differing according to the mode of development 
 of the fecundated product, thus: a, by incubation, as with insects, and 
 the greater part of reptiles and fishes ; 6, by external incubation, as 
 with birds; c, by internal incubation in the parts of the mother, with- 
 out adhering to them, as with some of the ophidian, and ovovivipa- 
 rous animals; d, by an organ of gestation, to which the impregnated 
 product adheres, from which it derives the greater part of its nourish- 
 ment, and from which it separates after a certain time, as with all the 
 mammiferous animals. To this last and most complicated process 
 belongs the generation of man. 
 
 The mode in which fecundation is accomplished in the human being 
 belongs more especially to the physiologist's department to determine;
 
 96 KING'S ECLECTIC OBSTETRICS. 
 
 but as the matter has long been a subject of inquiry, and presents a 
 field of interest to many, I will briefly refer to the various opinions 
 that have from time to time been advanced and maintained in the 
 medical world. 
 
 In the male, the semen, or spermatic fluid secreted by the testicles, 
 is undoubtedly the agent especially called into action in the function 
 of reproduction ; this is manifest from the fact that, removal of the 
 testes not only destroys all sexual propensity, but likewise renders the 
 individual forever after incapable of begetting offspring: The same 
 may be said in relation to the removal of the ovaries of the female ; 
 she loses all sexual inclination, the procreative functions are annihi- 
 lated, and all those graces, emotions, and feelings which distinguish 
 the sex, gradually disappear. Observations have likewise been made 
 in relation to this matter, of a highly interesting character, to some 
 of which a very concise reference will here be made. 
 
 Spallanzani, during his investigations, noticed, that as soon as the 
 female frog laid an egg, the male immediately cast a fluid upon it, 
 which soon impregnated it. He then confined the gentials of the 
 male frog in a silk bag, and ascertained that in this condition impreg- 
 nation could not occur. He, likewise, applied to some of the freshly 
 laid ova, a small quantity of the male semen or fluid which he had 
 previously collected, and impregnation was the result. He also insti- 
 tuted similar experiments on a bitch in heat, and which had been kept 
 confined for twenty-three days before heat commenced, in order to 
 prevent the approach of any dog ; the result was, that by injecting 
 nineteen grains of semen into the vagina, at 100 Fah., fecundation 
 followed, and, at the proper period, the animal gave birth to three 
 pups which bore a strong resemblance to herself and the dog from 
 which the semen was gathered. Prevost and Dumas arrived at simi- 
 lar results ; they expressed the semen from the testicle of a frog, and 
 after diluting it with water, they placed some ova upon it, which be- 
 came prolific. According to these gentlemen, it is important to dilute 
 the male fluid in order to have the experiment prove successful. 
 
 Sir Everard Home, in his " Lectures on Comparative Anatomy," 
 vol. iii, p. 315, records a similar experiment on man, performed by 
 Hunter ; the husband was affected with hypospadias, which prevented 
 him from impregnating his wife; Hunter advised him to inject his 
 semen into his wife's vagina through a warm syringe ; the result was, 
 she became pregnant. 
 
 These experiments, with others of similar character, prove conclu-
 
 THEORIES OF IMPREGNATION. 97 
 
 sively, that the agents engaged in the generating process, are the semen 
 furnished by the male testes, and the ova of the female. Spallanzani, 
 as well as Prevost and Dumas, determined from further and satisfac- 
 tory trial, that the fructification of the ova only took place when 
 brought into actual contact with the male semen ; thus refuting the 
 doctrine held by some physiologists, that impregnation did not require 
 this mutual junction, but was effected merely by the presence or influ- 
 ence of a seminal halitus or vapor. 
 
 Another point of inquiry among physiologists, was, the method by 
 which the spermatic fluid is carried to the ovaries; some contending 
 that impregnation was effected in the uterus, while others maintained 
 that the semen was conducted to the ovaries, and that fecundation was 
 possible even beyond the angles of the uterus; indeed, this fluid has 
 been found on the surface of the ovaries, by Adelon, Bischoff, and 
 other investigators. But by what means it reaches the ovaries, has 
 never yet been satisfactorily explained; for the male penis, certainly 
 has not sufficient power to throw it beyond the uterus. 
 
 Various views have likewise been supported at different periods, 
 relative to the manner in which the union of the male and female 
 principles necessary to the formation of a new being, is effected, and 
 how this new being, of whatever species, comes to bear the impress of 
 the mental and physical features of one or both parents. But the 
 solution of these particulars is still involved in mystery. The oldest 
 theory on this subject, is that of epigenesis, which holds that the new 
 being is created entirely anew, and at the moment of conception, 
 receives at once the materials necessary for its formation, one portion 
 being derived from the testes of the male parent, the other from the 
 uterus or ovaries of the female. Aristotle, Galen, and others, sup- 
 posed that the material furnished by the female was the menstrual 
 fluid; and Hippocrates considered that the female supplied all the 
 substance required for the development of the future being, while the 
 male fluid merely contained that vivifying principle necessary to im- 
 part vitality to the female materials. This theory of epigenesis, with 
 various modifications, was the prevailing one for many years, and was 
 for a time renewed by Buffon in the beginning of the seventeenth 
 century, whose views were entirely speculative and untenable. His 
 notion was, that the growth and nourishment of individuals during 
 youth, was effected by certain organic molecules common to both 
 sexes ; but which being required in less quantities for these purposes 
 at maturity, the predominance was emitted by the male testes with the 
 7
 
 98 KING'S ECLECTIC OBSTETRICS. 
 
 spermatic fluid, and also by the ovaries, or female testes, as he termed 
 them, for the purposes of reproduction of the species. He imagined 
 that the body of each parent supplied each of these molecules with 
 atoms derived from its various parts, and that whichever parent af- 
 forded to the newly organized being the major portion of these mole- 
 cules, the resemblance to that parent would be the most marked. 
 
 During the sixteenth century another theory was originated, being 
 based upon investigations and discoveries of the physiologists of that 
 period, among whom may be named, Leuwenhoeck, Harvey, De Graaf, 
 and others. It is termed the theory of evolution; and was strenuously 
 supported under some form or other, during the whole of this century. 
 The adherents of this theory maintained that the germ of the new 
 being existed in only one of the parents, while the other furnished the 
 principle which communicated life to it. They were divided into 
 ovarists, and animalculists or spermatists. The ovarists, among whom 
 I may mention Harvey as the principal, having discovered numerous 
 small vesicles in the ovaries, which apparently decrease according to 
 the number of conceptions, held that these vesicles were the fetal 
 germ, which only needed the animating power of the male semen to 
 usher the new being into existence. But this view was objected to by 
 many, on account of its exclusiyeness, whereby the male fluid had but 
 a minor part to perform; beside which, if the semen merely exerted a 
 vivifying influence upon these vesicles, it did not explain why the 
 offspring so often resembled its male parent. 
 
 In consequence of these objections, a different opinion was supported 
 by those who were called animalculists, and which originated princi- 
 pally from the microscopic discoveries of Leuwenhoeck and other in- 
 vestigators, who found myriads of animalcules in the male semen. 
 These held, that after having been thrown into the uterus during copu- 
 lation, the animalcules perished, with the exception of one or two, 
 which entering the Fallopian tubes/ were conveyed through to the 
 ovaries, and there deposited and nourished in a nidus formed by the 
 ovum. As this spermatozoid progressed in growth, it ruptured the 
 nidus which inclosed it, and was again conveyed to the uterus to be 
 nourished and preserved until the period of parturition. To this 
 view, wherein the female merely supplies the nourishment for the 
 embryo furnished by the male, an objection similar to the one above 
 is suggested, as to the cause of resemblance, in many instances, to the 
 female parent. 
 
 Those who desire to have these several views more in detail, are
 
 THEORIES OF IMPREGNATION. 99 
 
 referred to the several physiological treatises in which they are fully 
 related and discussed ; and as they have become at the present day 
 obsolete, a mere glance at them was deemed all-sufficient in the pres- 
 ent work. But, before terminating this subject, a reference to the 
 views of physiologists of the present day must be made, without which, 
 this portion of our work would be imperfect. 
 
 In Chapter X, will be found a description of the ovaries, Graafian 
 vesicle, ovule, germinal spot, etc.; these are the discoveries of recent 
 physiological investigators, and have been the means of eifecting a 
 revolution in relation to the views of impregnation, giving rise to a 
 theory, the ovular theory, which is, undoubdtedly, more in proximity to 
 the truth, than any of the previous doctrines which have been held on 
 this subject. The theory is, that the egg, ovum or germ, is supplied by 
 the female, in whom it exists in indeterminate quantities ; that at the age 
 of puberty, these germs commence maturing; at their period of ripen- 
 ing, they rupture the vesicular tissue in which they are contained and 
 pass from it, being accompanied by a sanguineous discharge, probably 
 from the uterus, called menstruation, the appearance of which is signifi- 
 cant of the fact, that the female has reached the age at which she is capa- 
 ble of giving birth to children ; these ovules escape either into the peri- 
 toneal cavity, or into the womb through the Fallopian tubes, and pass 
 off with the menstrual flow, or are retained in consequence of 
 fecundation. 
 
 On the other hand, the male supplies a fluid in which is contained 
 minute, round and granulated bodies, the spermatic granules, as well as 
 bodies possessed of motion, like the epithelial cells, which are not, how- 
 ever, animalcules, but, more properly, spermzoons or spermatozoids ; 
 these bodies, by means of ciliary movement, the result of wavy motion of 
 the ciliated epithelium lining the walls of the uterus and of the Fallo- 
 pian tube, assisted perhaps by a kind of peristaltic action of the latter, 
 are conveyed to the uterus, tubes, or ovaries, when coming into contact 
 with the nude, uncovered ovum wherever this may be, in the ovary, 
 the tube, or the uterus through some inscrutable agency, probably 
 an intermingling or mutual permeation of the male semen and female 
 germ, animalization takes place ; and a creature is brought into exist- 
 ence, which, possessing certain elements derived from each parent, will, 
 necessarily, present mental and physical resemblances to-either or both 
 of them. Ovarian and ventral pregnancy prove that the spermzoons 
 are conveyed even to the ovary ; but impregnation undoubtedly occurs 
 in the tube or in the uterus after the ovum has left its ovarian vesicle.
 
 100 KING'S ECLECTIC OBSTETRK s. 
 
 How long a period is occupied between the emission of the ovum from 
 the ovary and its entrance into the uterine cavity is unknown, proba- 
 bly five or six days. 
 
 Repeated experiments on animals have proved, that any obstacle to 
 this contact of the germ and semen, will prevent conception. Martin, 
 Barry, Bischoff, and others have observed the spermzoons freely mov- 
 ing about in the transparent zone of recently impregnated ova of ani- 
 mals, and it is by no means improbable that a similar result occurs in 
 impregnation of human ova. 
 
 CHAPTER XIII. 
 
 MENSTEUATION OVULATION CONCEPTION. 
 
 AT a certain age, the female reaches the period of puberty, which is 
 made manifest by a sanguineous discharge from the uterus, occurring 
 periodically once a month, and which is called menstruation. It has 
 likewise many other names applied to it as menses, catamenia, courses, 
 terms, periods, monthly sickness, menstrua, flowers, monthlies, times, etc. 
 It is not a secretion, but an effusion or hemorrhage; very much resem- 
 bling venous blood, and is undoubtedly blood rendered impure by the 
 addition of mucus and epithelial scales with which it meets during 
 its flow. 
 
 Strieker, of Vienna, " has demonstrated the passage of red and 
 white blood corpuscles, through the walls of the capillaries of the uter- 
 ine mucous membrane. Some of these capillaries become ruptured in 
 the process. The blood oozes through the mucous membrane of the 
 uterine cavity, impregnates its epithelium, causing it to swell and be- 
 come detached, and passes on, mixed with epithelial debris, into the 
 vagina, and thence out of the body." 
 
 As a general rule, the discharge, in females of this climate, is estab- 
 lished at the fourteenth or fifteenth year, though it varies with some, 
 oftentimes appearing as early as the twelfth or thirteenth year, and 
 again not until the seventeenth or eighteenth. In the 'former instance, 
 it is termed precocious menstruation, and is significant of an unnatural 
 increase or development of certain organs, at the expense of others; it 
 is commonly followed by premature death, especially if an early mar- 
 riage, resulting in pregnancy, should take place, in consequence of
 
 MENSTRUATION OVTILATION CONCEPTION. 1 01 
 
 these unseasonable and abnormal indications of puberty. In the latter 
 instance, the term tardy menstruation is applied, and which is usually 
 the result of some debility or disease, that may eventually destroy the 
 female. 
 
 Climate, constitution, education, modes of life, etc., affect the ap- 
 pearance of this discharge; it being earlier in warm climates than in 
 cold, and i-n city females, than in those of the country. It likewise ap- 
 pears earlier and more abundantly in females of a nervous tempera- 
 ment, than in those who are phlegmatic. 
 
 The advent of the menstrual discharge, is the chief external sign of 
 the approach of puberty; and is one of the most interesting periods in 
 the life of the female. At this time, a Graafiau vesicle for the first 
 time projects from the surface of the ovary, gradually developing to a 
 state of complete maturity, the maturation of which marks an impor- 
 tant epoch in the life of the female a transformation in which the girl 
 passes into womanhood and becomes capable of reproduction, a process 
 attended by growth and development of 'the peculiar organism of the 
 female by which a new life and individuality assert themselves. 
 Thus ovulation is established, which, at puberty, is usually concurrent 
 with menstruation, and is probably the immediate or exciting cause of 
 menstruation ; however, as will be seen presently, the two may exist 
 independently of one another. This interesting period, in the life of 
 the female, is ushered in by many symptoms and changes in her mental 
 and physical developments that manifest themselves gradually. A re- 
 markable advancement toward the perfection of the reproductive organs 
 is presented ; the ovaries rapidly enlarge, and change from their pre- 
 vious long, flat, and smooth condition, to one in which they are large, 
 oval, rounded, and embossed; the Fallopian tubes become elongated, 
 their fimbriated extremities widened, and the fimbriae enlarged; the 
 uterus becomes more fully supplied with blood, and its tissue more 
 florid; the body and fundus likewise obtain more rotundity and devel- 
 opment than the cervix, which appears proportionally shorter and nar- 
 rower; the vagina is widened and dilated, and its vascular structure is 
 supplied with increased quantities of blood, and its mucous folds aug- 
 ment in number. The pelvis becomes larger and wider, with a dimi- 
 nution of its inclination forward; the pubic region more prominent, 
 round and covered with hair; the labia pudendi more amplified, red, 
 and sensitive; the hips more projecting, and inclined outwardly; the 
 pelvic cavity enlarged ; and the breasts rounder, full, and prominent, 
 with the nipples projecting, more sensitive, and the areola of a darker
 
 102 KING'S ECLECTIC OBSTETRICS. 
 
 hue. The whole person improves in grace and elegance, and the voice 
 becomes more sonorous and melodious. 
 
 Corresponding with these modifications of the physical system, are, 
 changes in the mental character; the gay, light-hearted girl loses her 
 playfulness, and assumes the dignity of womanhood ; she becomes more 
 reserved, more 'sensitive, and full of sympathy; she manifests strong 
 attractive feelings toward the opposite sex, and seeks to love, as well as 
 to be loved; the social and moral sentiments become of a purer and 
 more exalted character; a great fondness for children is displayed ; and 
 in her, we find the most perfect combination of modesty, devotion, pa- 
 tience, affection, gratitude, loveliness, and Christian virtue. 
 
 The menstrual discharge, being a sign of maturity and fertility of 
 the reproductive organs, does not appear during childhood, nor in old 
 age. It usually ceases at the ages of from forty to fifty, though occa- 
 sionally, it extends to a very advanced age. The period of its cessation 
 is termed the turn of life, the menopause, or the critical time of life ; from 
 which time, women cease to bear children. And on account of the vari- 
 ous unpleasant, and often serious symptoms presenting at this period, 
 its approach is much dreaded by nearly all of them. 
 
 The amount of fluid discharged, varies in females, averaging from 
 six to eight ounces; some -will lose only four ounces at each menstrua- 
 tion, and others twelve, and yet each will remain in health, because 
 the system of each is controlled and affected according to its individ- 
 ual wants, habits, strength, and activity. The discharge usually con- 
 tinues from three to six days, occasionally from eight to ten, and must, 
 as a general rule, have revealed itself before impregnation can take 
 place. 
 
 All cleanly women \vcar a napkin during menstruation, which is 
 placed, by means of a girdle, in a manner similar to a T bandage, for 
 the purpose of concealing their situation, which it does by absorbing 
 the fluid discharged; from four to twenty of these napkins will be 
 worn during one menstrual term. 
 
 In the consideration of menstruation and ovulation, many strange 
 theories have been advanced, that appear quite absurd in the light of 
 modern research; some authors use the terms synonymously. Physi- 
 ological investigation, however, gave rise to such inquiries as : What 
 is the cause of menstruation? From whence comes the hemorrhage? 
 To what extent does menstruation depend on ovulation ? Is the ani- 
 mal rut, or oestrus, and menstruation, analogous? And many other 
 questions that we need not notice here.
 
 .MENSTRUATION OVULATIOX CONCEPTION. 103 
 
 Menstruation is believed by many to be merely the phenomenon of 
 that function which matures and discharges an ovum from the ovary 
 periodically. The prevailing belief seems to be, that menstruation is 
 co-existent with, or rather the result of, functional ovarian activity ; that 
 menstruation is an indication of ovulation. That ovulation occurred 
 only at the menstrual period, \vas generally accepted as a fact, until 
 within a few years. It is a special function, and consequently may oc- 
 cur independently of menstruation ; causes, of which we know nothing, 
 may hasten the development of a vesicle, or excite the bringing forth 
 of an immature ovum, and thus establish inter-menstrual ovulation. 
 
 The Jewish female furnishes, it seems, evidence indicating the occur- 
 rence of inter-menstrual ovulation. According to Rabbinical ruling, 
 intercourse is prohibited until twelve days after the appearance of 
 menstruation ; at the expiration of this time, the bath of purification 
 is taken, the Jewess scrupulously cleansing herself every part of the 
 body being immersed in the bath. Mosaic law has named this the 
 Micva. Not until now, does the wife receive the husband. These 
 women are surely as prolific as other females, and their impregnation 
 demonstrates the fact, that the maturation of the ova occurs at any 
 time. 
 
 A Graafian vesicle may rupture during sexual excitement, as during 
 coitus, or from the sequence of such excitement; and this is an ex- 
 planation why women may conceive at any time. That ova are dis- 
 charged at irregular periods from the ovaries, and not merely monthly, 
 about the menstruating period; that there can be no menstruation 
 except in connection with ovulation, though there may be oyulation 
 without menstruation, is now becoming the opinion of obstetricians in 
 general. 
 
 Mr. Lawson Tait says : " The growth and ripening of Graafian folli- 
 cles before puberty constitutes one of the many arguments in favor of 
 the view, that menstruation and ovulation are wholly distinct processes, 
 and abundant examples can be given of them being carried on each 
 independently of the other. The statement constantly made in text- 
 books that, if the ovaries are extirpated, or become atrophied, men- 
 struation does not re-appear, is not accurate ; and equally incorrect is 
 the assertion that the first ovular dehiscence corresponds with the first 
 appearance of the menses. It is perfectly certain, that ovulation is by 
 no means a periodic process, in the sense of being monthly; and the 
 fact that a periodic flow from the uterus is almost confined to the hu- 
 man race, is sufficient to show, that it is not in the ovaries that we
 
 104 KING'S ECLECTIC OBSTETKK s. 
 
 have to look for the cause of this curious and objectionable phenome- 
 non, for which Johnson alone has so far suggested a useful purpose. 
 Where the cause does exist, we do not know ; but it is quite certain, that, 
 as it continues for months, in some cases, after the removal of both ova- 
 ries, it can not be in those glands. Nor is it in the uterus; for in three 
 cases in which I have removed the uterus, as completely as it can be 
 done, menstruation has persisted ever since in one of them for nearly 
 seven years. Removal of the ovaries alone, is followed by immediate 
 and complete arrest of menstruation in about fifty per cent, of the 
 cases. Removal of both tubes, with or without the ovaries, is followed 
 by the same arrest in about ninety per cent, of the cases; and I suppose 
 that in hysterectomy the arrest occurs in at least ninety-seven per cent. 
 But it is the exceptions, in such a case as this, which prove the rule; 
 and I suppose that we shall some day find a special nerve mechanism 
 which is the real cause and governor of the phenomena of menstrua- 
 tion ; and this is certain to be ganglionic ; for a ganglionic system gov- 
 erns all other rythmic phenomena." 
 
 As to the source of the menstrual discharge, strange and varied the- 
 ories have been advanced. The most recent is that of Dr. A. W. John- 
 stone, to which Mr. Tait calls attention in his work on Diseases of 
 Women and Abdominal Surgery viz: that it depends on the action of 
 a special nerve, which lies in the broad ligament, in the angle between 
 the tube and round ligament, close to the uterus. Some claim it has 
 its origin in the cervix and os uteri; others in the vagina, tubes and 
 ovaries. 
 
 Coste believed it to be a transudation through the walls of the cap- 
 illary vessels of the uterus, being chiefly venous. Dr. Farre advances 
 the theory, that there may be permanent vascular orifices through which 
 the blood escapes during the menstrual period; that these orifices are 
 closed during the inter-menstrual period, by the contractility of the 
 tissue surrounding them. 
 
 Pouchet claimed, that the greatest part of the mucous membrane is 
 shed at each menstrual period ; its separation from the uterine walls 
 involved a rupture of vessels, and thus the menstrual flow. The most 
 reasonable theory, however, is, that the tubes are the starting point of 
 the catamenial discharge; that the epithelial lining and a portion of 
 the uterine mucous add to the detritus, the blood being largely from 
 the uterine walls, the result of a process of diapedesis. A case of 
 chronic inversion of the uterus was recently reported before the Cin- 
 cinnati Eclectic Medical Society, in which this condition was clearly
 
 MENSTRUATION OVULATION CONCEPTION. 105 
 
 illustrated. Menstruation has occurred regularly for many years; at 
 each period the mucous surfiace of the inverted uterus is bathed in 
 blood, prior to which many drops of blood, giving it a beaded appear- 
 ance, are noticeable; also the loosening and casting off of small shreds 
 of the epidermis the cause of the hemorrhage. 
 
 The fact of menstruation occurring after the removal of the uterus 
 and its appendages, may be due "to segments of the organs left at the 
 pedicle, either in hysterectomy or oophorectomy, or, perhaps, to the 
 existence of a supernumerary ovary. 
 
 Since the female among the lower animals will not cohabit with the 
 male at any period other than the rutting season, it would indicate that 
 the oestrus and ovulation are concurrent. I am aware, that doubts are 
 entertained by some, as to whether the oestrus and human menstrua- 
 tion are analogous; however, admitting that they are, this would not 
 be positive proof but that ovulation may exist irregularly and inde- 
 dendently of the rut. 
 
 By ovulation, is understood the functional action of the ovaries: at 
 which time occurs the escape of the ovum from the ovisac, from whence 
 it is either received by the Fallopian tube and transmitted to the uterus, 
 or is lost in the peritoneal cavity. The fluid contents of the ovisac 
 gradually increase with its development, until, at the time of complete 
 maturation, the distention is so marked that rupture is the result, fol- 
 lowed by the dehiscence of the ovum. The functional relation ex- 
 isting between the oviduct and the ovary, and the exact manner by 
 which the ovum, as it escapes from the ovisac, finds lodgment in the 
 oviduct through its fimbriated extremity morsus diaboli and is then 
 conveyed to the uterus, does not appear to be clearly defined. Numer- 
 ous opinions have been advanced as the subject has been studied and 
 investigated. Lusk, in his Science and Art of Midwifery, speaks as 
 follows, on the MIGRATION OF THE OVUM : 
 
 " The number of ova in each ovary has been estimated by Henle at 
 thirty-six thousand. Only a small proportion of them, however, meet 
 with the conditions requisite for fruition. It is probable, that many 
 ova perish while still surrounded by the stroma of the ovary. The 
 history of extra-uterine pregnancies teaches us that, in some instances 
 at least, the ovum, after its discharge from the Graafiau follicle, escapes 
 into the abdominal cavity. It, therefore, becomes an interesting subject 
 of inquiry as to the conditions which ordinarily determine the passage 
 of the ovum from the ovary into the Fallopian tube of the correspond- 
 ing side. It will not do to assume, as is usual, a peculiar erectility of
 
 106 KING'S ECLECTIC OBSTETRICS. 
 
 the Fallopian tube, which enables it to apply its funnel-shaped extrem- 
 ity to the ovary just at the moment of the rupture of the Graafian 
 follicle. Setting aside the inherent improbability of the existence of 
 such a degree of intelligence in the fimbrire as would lead to the exact 
 adaptation of the tube to the precise point at which the ovum is to be 
 discharged, it has been proved that the Fallopian tube possesses none 
 of the characteristics of erectile tissue. Injections of its vessels after 
 death do not communicate to it the slightest change of form or place. 
 
 " Muscular action has also been often invoked to explain the assumed 
 manner in which the fimbrise seize the ovary; but galvanization of the 
 tubes, practiced upon criminals recently executed, produces only ver- 
 micular contractions, which do not affect the position of the fimbrise. 
 Indeed, w T hen we remember the position of the Fallopian tubes in the 
 pelvis, and bear in mind that they are at all times necessarily subjected 
 to the pressure of the intestines, it becomes difficult to understand how 
 they can execute any very extended movements. 
 
 " In the absence of direct experimental proof, the suggestion of 
 Henle, that the passage of the ovum into the Fallopian tube is due to 
 currents produced in the serum by the ciliated epithelium, which cov- 
 ers both the external and internal surfaces of the fimbrise, is, on the 
 score of probability, entitled to the most consideration. One of the 
 fimbrise (fimbria ovarica) is permanently attached to the lower angle 
 of the ovary. . 
 
 "It is likely that the ovum, discharged from a Graafian follicle, is 
 floated down by the peritoneal serum toward the lower and outer border 
 of the ovary, where a sufficient current is present to insure its being 
 caught up and conveyed into the infundibulum tubse. Failures on the 
 part of the ovum to reach its destination are, in all probability, not 
 uncommon. Support is given to the theory of the importance of the 
 cilia? in influencing the migration of the ovum by the observation of 
 Thiry, that in batrachians, which have the oviducts fixed to the ab- 
 dominal walls, and situated at a distance from the ovary ; during the 
 rutting period little pathways of ciliated epithelium form in the peri- 
 tonaeum, which collectively converge toward the openings of the tubes. 
 
 "While the ovum remains in tlie ampulla, or dilated portion of the 
 tube, its further progress is at first dependent upon the movements of 
 the cilia? ; but, after the isthmus is reached, an additional propelling 
 force is furnished by the circular muscular fibers, which possess a peri- 
 staltic action." 
 
 The attention of physiologists has recently been called to an adenoid
 
 MENSTRUATION OVULATION CONCEPTION. 107 
 
 /unction of the endometrium and subjacent tissue. The cited evidence 
 of secretory power, in the lining of the uterus, is based on the develop- 
 ment of the decidual structure, which is always evolved as soon as 
 pregnancy occurs, and which not infrequently developed during nor- 
 mal menstruation. Such a membrane, or vascular meshwork, may be 
 exuded during ovulation the low grade of structure not depending 
 upon either menstruation or pregnancy. The decidual exudate de- 
 pends upon exalted vascular activity in the endometrium, and not 
 upon any secretory function. In fact, a membrane or vascular texture 
 can not be secreted any more than a tongue or an ear can be the result 
 of adenoid action. 
 
 It has been assumed and asserted by speculative physiologists, that 
 during inter-menstrual periods there is evolved from the endometrium 
 a membranous meshwork, which is to entrap or ensnare the fertilized 
 ovum when it emerges from the Fallopian conduit. If the ovum be 
 not fructified, it is not prevented from traversing the uterine cavity, 
 and falling into the vagina. In other words, the speculative net-work 
 developed from the endometrium is to be discriminative is to let the 
 unfecundated ovum pass the barrier, but to entrap and ensnare the 
 fertilized body. However, to get rid of discriminating power ascribed 
 to ,the deciduous membrane, the meshw r ork is to entangle the unim- 
 pregnated egg and take it out of the womb, but is to arrest the out- 
 ward course of the fertilized ovum. An objectionable feature of the 
 scheme is, that the inter-menstrual meshwork is to be denominated 
 nidus, a nest, and the entrapping is called nidation, or nesting, after 
 the manner of birds; when in fact the uterine exudate is more a net 
 than a nest. The endometrium does secrete mucus by means of crypts 
 and follicles in its free surface, and contributes to the exudative forma- 
 tion of the decidual structure, but it does not develop anything in 
 health except uterine mucus, which, in some respects in odor, for 
 instance is peculiar. In a normal condition between menstrual ac- 
 tivities the endometrium secretes or throws off endothelium, as the 
 mucous lining of the mouth does, or any other localized portion of a 
 mucous structure. 
 
 The mucous secretions differ to an appreciable extent. The secre- 
 tions of the urethra differ from those of the bladder and ureters. The 
 free surface of the endometrium is pale and smooth, except when men- 
 strual epochs are approached; the structure then attains a pinkish 
 flush of vascularity, and at length becomes so congested that corpus- 
 cles of blood burst through the alternated walls of the vascular capil-
 
 108 KING'S ECLECTIC OBSTETRICS. 
 
 larics. The corpuscles mix with mucus and exuded lymph, making a 
 fluid which is decidedly sanguineous, but is never pure blood unless a 
 hemorrhage occurs. 
 
 Toward the end of a catamenial nisus, there is little blood and much 
 plastic lymph exuded, as in ordinary trumatism, and then the decidual 
 exudate or meshwork is elaborated. "Lining the fundus of the womb 
 as it does, it can not help ensnaring the ovum as it leaves the salpin- 
 giau canals, whether the egg be impregnated or not. If the ovum be 
 not fertilized, it passes off with the detached decidua; and if it be 
 fructified, the pregnant state excites uterine vascularity, and secures 
 the services of the, decidual membrane in fixing and nourishing the 
 developing ovum. The neoplastic membrane makes no discrimination 
 between the unimpregnated and the fertilized egg, but the condition 
 of pregnancy enforces the kind of action which is to result in a loss 
 of the structure, or in the utilization of its possible offices in the nutri- 
 tion of the ovum. It has been suggested, that the decidual exudate of 
 menstruation occludes the canal of the uterine cervix, producing me- 
 chanical obstruction membranous dysmenorrhoaa ; but as catamenial 
 pains are mostly over before the menstrual exudate is shed or cast off, 
 the theory has few substantial facts to sustain it. The womb in a state 
 of physiological hypertrophy pregnancy is augmented in weight 
 from ounces to pounds. Yet, in the enlarged state it is increased 
 mostly in muscular evolution; after parturition, the organs enter upon 
 rapid involution, so that in a few weeks it returns to normal weight 
 and size. In the manifestation of these great changes, there is no dis- 
 play of increased glandular action or adenoid activity. 
 
 The endometrium undergoes important transformations, yet does 
 not become appreciably glandular or adenoid. In ectopic gestation a 
 decidual exudate is always found upon the free surface of the endo- 
 metrium, as if ready to ensnare the fertilized ovum, but the function 
 of the membrane is not forced into use.
 
 DEVELOPMENT OF THE HUMAN OVUM. 109 
 
 CHAPTER XIV. 
 
 DEVELOPMENT OF THE HUMAN OVUM. 
 
 IT will now be proper to notice those changes which occur, during 
 pregnancy, in the ovum, as it progresses in its development. Shortly 
 after conception, a layer of coagulable lymph lines the whole internal 
 surface of the uterus, which is at first of a soft, gelatinous nature, but 
 which soon becomes imperfectly organized, vascular, and of a reddish 
 color ; it is called the membrana caduea (caducous membrane), or 
 membrana decidua (deciduous membrane). Several other names have 
 been applied to it, as epichorion by Chaussier, epione by Dutrochet, 
 perione by Breschet, anhistous membrane by Velpeau, adventitious 
 lamina by de Blainville, nidal decidua by Aveling, etc. This mem- 
 brane is about one line in thickness, and is in contact with the whole 
 of the inner uterine surface ; its inner, or fetal surface is smooth and 
 polished, with striae and depressions which lead into canals, bearing 
 some resemblance to that of serous membranes, and its external or 
 uterine surface is rough and unequal, and closely adheres to the 
 internal surface of the uterus. It is not persistent in its character, 
 as it is formed only during conception, or as stated under nidation, 
 in the preceding chapter; and it is expelled with the ovum and its 
 membranes whenever this occurs. Within this membrane is a space 
 or cavity called the cavity of the decidua, which is filled with a limpid, 
 serous fluid, to which M. Breschet has given the name hydroperion. 
 This fluid is present simultaneously with the caducous membrane, 
 or perhaps with the impregnation of the ovum, increases in quantity 
 as the uterus enlarges, and continues to be secreted, according to 
 Breschet, until the caduea vera and caduea reflexa come in contact 
 with each other, or toward the fourth month ; it is supposed that this 
 liquid aifords nourishment to the embryo during the early months, 
 before a direct placental communication is established between it and 
 its mother. 
 
 The manner by which the ovum becomes enveloped in this mem- 
 brane is supposed to be as follows: having passed through the Fal- 
 lopian tube, until it arrives at its uterine orifice, it pushes before 
 it a portion of the membrana caduea, until the whole ovum is sur- 
 rounded and inclosed by this membrane (F. Fig. 25). The por-
 
 110 
 
 KING'S ECLECTIC OBSTETRICS 
 
 A. The cavity of the uterine 
 Neck - 
 
 Fallopian Tubes. 
 
 C. External, or Uterine Ca- 
 
 duca. 
 
 D. Cavity of the Decidua. 
 
 E E. Angles at which the De- 
 
 tion of membrane thus covering the ovum, is 
 called the decidua ovuli, or reflexa (ovuline, or 
 reflected decidua), while that in contact with'the 
 uterine walls, is termed the decidua uteri, or vera 
 (uterine, or true decidua). As the ovum grows, 
 the decidua reflexa approaches nearer and nearer 
 to the decidua vera, the cavity of the decidua 
 diminishes, until, finally, at the third month the 
 cavity is obliterated, and the two decidua, coming 
 in contact, become agglutinated into one mem- 
 brane. The ovum, it will be seen, is not com- 
 pletely surrounded by the decidua reflexa, and at 
 THE CADUCA, AFTER that part of the uterus from which this membrane 
 was detached by the advancing ovum, the surface 
 is lined by no membrane whatever. At this un- 
 covered point a new structure is developed be- 
 tween it and the ovum, bearing some resemblance 
 to the membrana decidua, and which is called 
 decidua serotina, and here the subsequent forma- 
 
 igies at wnicn me ie- , n ,-> i , i i rr*i_ 
 
 cidua vera is reflected tion of the placenta takes place. The uses of 
 by the advance of the the membrana caduca, are, according to Moreau, 
 
 F. chorion. " to prevent the ovum from floating loosely in the 
 
 G. Amnios. cavity of the uterus ; to maintain it in contact 
 with a fixed point of the parietes of this organ, until it has contracted 
 sufficiently numerous and firm attachments to enable the embryo, after 
 being developed during the first stages of pregnancy at the expense 
 of the surrounding fluids, to extract from the blood of the mother, 
 the materials suitable for its nutrition and subsequent growth ; to. de- 
 termine the place of insertion, form, and extent of the placenta ; to 
 prevent superfetation ; and, according to Lobstein, to transmit to the 
 chorion and amnion the vessels which furnish these membranes with 
 the elements of nutrition and exhalation." 
 
 The above is the description generally given by authors relative to 
 the caducous membrane; still, it is not a settled question, and much 
 diversity of opinion prevails in regard to it. Some consider it to be 
 a secretion, or exhalation from the internal mucous coat of the uterus, 
 effected by the peculiar excitement resulting from conception ; while 
 others view it as an exfoliation of this mucous coat, itself, which, from 
 a similar cause, has undergone considerable changes in its consistence 
 and vascularity. The former is the most commonly received opinion, 
 and, probably, the most correct one ; it maintains, that the excitement 

 
 DEVELOPMENT OF THE HUMAN OVUM. Ill 
 
 caused by a fruitful coition occasions the secretion of a plastic lymph, 
 \vhich coagulates and forms a kind of false membrane or caduca, anal- 
 ogous to those produced on inflamed surfaces by the exhalation and 
 coagulation of an albuminous fluid, and which is entirely distinct from 
 the mucous membrane, although it adheres, more or less firmly; to the 
 latter by numerous vascular villi, or prolongations, which frequently 
 * extend into the canal of the cervix, or Fallopian tubes. When the 
 adhesion of this false membrane is but slight, the ovum, upon entering 
 the uterine cavity, instead of pushing forward a decidua reflexa at the 
 orifice of the tube, may slip between the caduca and uterus, and form 
 an attachment at some other point, thus giving rise to the various pla- 
 cental insertions which are met with in practice. 
 
 The opposite opinion maintains that the utricular glands of the 
 uterus become elongated, augmented in size, and contorted, their se- 
 cretion increases, the vessels of the mucous membrane become more 
 fully developed in size and number, and a substance composed of 
 nucleated cells fills up the interfollicular spaces in which the blood- 
 vessels are contained. These changes produce a thickening and soft- 
 ening of the mucous membrane itself, with increased vascularity, thus 
 forming the deciduous membrane. But, as Prof. Meigs observes, " I 
 can not readily comprehend how, after all this structure is once thrown 
 off as a decidua, it can ever be reproduced for the service of subse- 
 quent pregnancies." Dr. Carpenter inquires, if the views relative to 
 the mucous membrane of. the uterus being the decidua, are well- 
 founded, how are we to explain the formation of the decidua continu- 
 ously over the upper orifice of the cervix uteri, and over the orifices 
 of the Fallopian tubes, as is frequently, though not always, the case ? 
 
 Again, it has been asserted by Dr. Lee, that this membrane is not 
 formed unless the ovum reaches the uterus, but in this he is evi- 
 dently in error, as there are, at least to my mind, a sufficient num- 
 ber of facts recorded to prove its presence independent of the 
 arrival of the ovum at the uterus. And, if I am not mistaken, Prof. 
 Meigs, as well as other investigators, have observed the decidua in 
 cases of extra-uterine pregnancy. Moreau states, that " it is even found 
 in cases of tubular and ovarian pregnancy, provided the pregnancy be 
 not too far advanced, and have not exceeded five or six months, for 
 we are inclined to believe that it disappears at a later period." Vel- 
 peau denies that the membrane is organized, hence, he has called it 
 anhistous; but there are sufficient proofs of its organization, as, for 
 Jnstance, its vascularity; it has also been injected by Ruysch, Burns,
 
 112 KING'S ECLECTIC OBSTETRICS. 
 
 Lobsteiri, and others beside, it is liable to disease, and toward the 
 last becomes very thin, like serous or cellular tissue. 
 
 Hunter asserted that the deciduous membrane had three openings, 
 one at the inner orifice of the cervix, and one at each orifice of the 
 Fallopian tubes ; were this the case, no decidua reflexa would be formed, 
 but the ovum in entering the uterus, would at once pass through the 
 opening into the cavity of the decidua, from whence it could escape 
 out of the uterus through the opening at the inner orifice of the cer- 
 vix, and no conception would result. Such openings in the membrane 
 may occasionally be present, but according to the investigations of 
 many excellent observers they do not occur as a general rule. It has* 
 also been denied that the decidua reflexa is a mere reflected portion of 
 the decidua vera, as the texture of the two are said to be non-identical ; 
 and that the reflexa is probably formed by the agency of nucleated 
 cells from the plastic materials thrown out from the decidua vera, in 
 the same manner as the chorion is supposed to be formed in the Fal- 
 lopian tube, from similar materials secreted from its lining membrane. 
 More recently it has been advanced that the decidua is formed inde- 
 pendently of impregnation (see Nictation) ; that it consists of two dis- 
 tinct layers, one, lining the wall of the uterine cavity, and termed, the 
 decidua vera, d. uteri, or parietal decidua, the external surface of which 
 presents numerous filaments, while its internal surface is smooth, 
 shining, but presenting numerous elevations. The other, forms the 
 inner layer, is named the decidua reflexa, d. ovuli, d. chorii, and pre- 
 sents similar elements as the preceding, its internal surface being 
 studded with numerous pits, probably for the reception of the villi of 
 the chorion.* 
 
 *From recent investigations by Dr. Kundrat, of Vienna (Rokistansky's senior As- 
 sistant), and which are published in the Medizinische Jahrbiicher, 1873, No. 2, and 
 described in the Medical Times and Gazette, Aug., 1873, it appears that the generally 
 accepted description of the human Impregnated uterus and embryo, is only partially 
 correct. The purport of his observations are: The mucous membrane (mucosa) 
 of the recently gravid uterus is known as the decidua, and which has been commonly 
 divided into a decidua vera, d. reflexa, and d. serotina; at first, its structure bears some 
 resemblance to the uterine mucosa, in or before menstruation ; it is thickened, the 
 ghmds are dilated, elongated, and tortuous, and there is a great increase of intertubular 
 cells. In every respect the structure of the three portions of the decidua is very 
 similar. Inferiorly the d. vera abruptly terminates in an overhanging border at a 
 short distance from the cervix, this last taking no part in the formation of the fetai 
 cavity. During the entire period of pregnancy, the Fallopian tubes, as well as theii 
 inferior openings, are patent. Kundrat farther observes that when the impregnated 
 ovum reaches the inferior tubal opening, its progress is not obstructed by an adhesive 
 growth of the opposite mucous surfaces to each other, as some investigators believe
 
 DEVELOPMENT OF THE HUMAN OVUM. 113 
 
 From this brief review of the subject, it will be seen that it is still 
 involved in obscurity, and those who desire further information re- 
 garding it, are referred to the various essays by Hunter, Lee, Chaus- 
 
 for no such adhesion exists. For the same reason the ovum does not push before it 
 and invaginate a portion of the nmcosa, which becomes the decidua reflexa. The 
 latter is clearly an outgrown and infolded portion of the decidua vera, possessing 
 glands on its deep or ovular surface, as well as on its free. The ovum is retained at 
 the fundus of the uterus by the swollen decidua. If the swelling is not very great, 
 the ovum may travel down toward the cervix; and it is for this reason that placenta 
 przevia is more common among multiparae. He does not believe that the ovum enters 
 the mouth of a gland, but that it develops on the irregular surface of the d. serotina. 
 As pregnancy advances the uterus enlarges, and the connection between it and the 
 ovum becomes more intimate and complex. At first the enlargement of the uterus is 
 out of proportion to the growth of the embryo, and a free cavity exists between the d. 
 vera and the d. reflexa, which is filled with a somewhat opaque mucoid fluid. The 
 embryo does not fill the uterine cavity until the fourth month, and the walls, which 
 were previously disproportionately thick, become disproportionately thin, while the 
 envelopes become transparent. In the fifth month the process has advanced still an- 
 other step, by the adhesion partial at least of the opposite walls of the uterine 
 cavity ; that is, of the d. vera and the d. reflexa. 
 
 As regards the connection between the chorion and the decidua, it has frequently 
 been stated that the processes or villi of the former pass into the glands of the latter. 
 Kundrat remarks that this arrangement was "but seldom" to be discovered. On the 
 contrary, the chorion-villi were found to be fixed in the grooves of the d. serotina and 
 on the sides of its elevations by a connective mass composed of mucus and degener- 
 ated epithelium. Other villi had buried themselves in the tissue of the d. serotina, 
 and formed a connection so intimate that any attempt at separation ended in rupture. 
 It is here that, the placenta is afterward developed. As gestation proceeds the changes 
 of the decidua are very considerable, and in the last months peculiarly interesting. 
 The d. reflexa becomes attenuated by pressure until reduced to a simple layer of the 
 transparent envelopes of the embryo, of which it forms the most external portion. On 
 the other .hand, the d. vera and the d. serotina remain as comparatively thick layers 
 of tissue, compact and cellular on the surface, but spongy in their deep portion from 
 the presence of the numerous ends of the dilated glands, which represent sinuses 
 lined by epithelium. As the termination of pregnancy approaches there occurs a re- 
 markable change on the lining membranes of the uterus. These, as well as the d. 
 reflexa, become whitish, dull, and of a pale yellowish or even yellowish-gray tint, 
 opacity replaces transparency, and the process, which is discovered by the microscope 
 to be one of fatty degeneration, passes into the deeper layers. This description, of 
 course, reminds us of t'he simultaneous fatty degeneration of the placenta. When par- 
 turition occurs, a portion of the membranes is expelled with the fetus, and it is inter- 
 esting to inquire what part, if any, of the envelopes is retained. Careful examination 
 certainly reveals that the superficial portion of the decidua vera is, as a rule, in- 
 cluded in the fetal membranes, while the deeper portion is retained, although this is 
 not always the case. During the first week post-partum the discolored lining mem- 
 brane of the uterus may be found, under the microscope, to present the characters of 
 the decidua vera, but the sinuses are full of blood, the superficial cellular layer gone, 
 the fatty degeneration extends to the deepest layers, and the tissue generally is infil- 
 trated with round cells and blood. The lochial discharge consists of such cells and 
 
 8
 
 114 KING'S ECLECTIC OBSTETRICS. 
 
 sier, Breschet, Velpeau, Cams, Granville, M. Coste, Weber, Sharpey, 
 Farre, Priestley, Barry, etc. 
 
 At the period of full development of the ovule, it escapes from the 
 vesicle inclosing it, and passes into the Fallopian tube through the 
 agency of the fimbriated extremity of 'this organ, gradually traversing 
 its canal until it arrives at the uterine cavity. The modifications un- 
 dergone by the human ovule in its passage through the Fallopian 
 tube, are unknown, but are supposed to be similar to those which 
 occur in the eggs of mammiferous animals, particularly those of the 
 rabbit and dog. In these animals, the first change which has been 
 observed in the ovule after its escape from the ovary, is the entire dis- 
 appearance of both the germinal vesicle and germinal spot, while at 
 the same time there will be found a collection of granules in the cen- 
 tral portion of the ovum. During its travel through the first half of 
 the oviduct, the vitelline membrane becomes somewhat thickened, 
 while a layer of the granulations which formed the proligerous disk 
 of the ovule previous to its departure from the ovary, surrounds the 
 ovum, but which disappears as it traverses the second half of the 
 oviduct, having a layer of a transparent, gelatinous substance to occupy 
 its place around the vitelline membrane, and which albuminous layer, 
 as well as the thickening of the vitelline membrane, continues to in- 
 crease. While these changes are being effected, the yelk gradually 
 increases in density, forming a compact, homogeneous mass a trans- 
 parent fluid occupying the space existing between it and the interior 
 surface of the vitelline membrane ; finally, the yelk separates into two 
 regular spherical divisions ; these again separate, forming four spheres, 
 and this separation continues, until from the numerous small spherical 
 divisions which are thereby formed, the yelk presents a mulberry or 
 raspberry appearance. These spheres or granulations decompose as 
 the ovum advances toward the cavity of the uterus, and finally disap- 
 pear, being replaced by a clear and transparent fluid. They are sup- 
 posed to condense on the inner wall of the vesicle, forming there a 
 second vesicle which has been called the blastodermic or umbilical 
 vesicle or membrane, or germinal membrane or area. As this blastoderm 
 
 of products of disintegration. In the second week post-partum the process has still 
 farther advanced, and the epithelium of the exposed sinuses is found to be prolifer- 
 ating. Restitution now begins and advances, and soon there is found on the surface of 
 the muscular coat a fine layer of connective tissue, covered by epithelium and fur- 
 nished with young glands, to represent the mucosa of the uterus, which is again at 
 rest.
 
 DEVELOPMENT OF THE HUMAN OVUM. 115 
 
 becomes developed after the arrival of the ovum in the uterus, the 
 albuminous layer surrounding the vitelline membrane disappears, 
 while this membrane diminishes in thickness. About the sixteenth or 
 seventeenth day will be observed a rounded, whitish spot, at some 
 point of the blastodermic vesicle, standing oat apparently detached, 
 and w r hich is named the embryonic spot, tache embryonnaire, or area 
 germinativa ; it is composed the same as the blastoderm, of cellular 
 granulations, and from it commences the gradual development of the 
 embryo. The blastoderm is composecj of two laminae, the external 
 animal, or serous layer, and the internal, mucous, or vegetative layer, the 
 former of which is supposed to give origin to the brain and spinal 
 cord, organs of sense, cartilage, bones, skin, and muscles, or organs of 
 animal life; and the latter to the lungs, liver, spleen, and digestive 
 tube, or organs of nutrition. A third layer has also been recognized 
 by some investigators, which is situated between the two just named; 
 it is called the middle or vascular layer, ancj is supposed to assist in 
 the development of the heart, circulatory apparatus, etc. The time 
 required for the passage of the human ovum from the ovary to 
 the uterus is supposed to be from eight to ten or twelve days, 
 and it is about this latter period, the twelfth day of pregnancy, 
 that we can distinctly observe the embryo, which then appears to 
 be a mere amorphous vesicle, measuring about three lines, while 
 the entire ovum measures six or seven lines. The envelopes of 
 the ovum are three, the CHORION, TUNICA MEDIA, or MIDDLE 
 MEMBRANE, and the AMNION; and its accessories are four, the UM- 
 BILICAL VESICLE, the ALLANTOIS, the PLACENTA, and the UMBIL- 
 ICAL CORD. 
 
 The CHORION is a thin, glistening, transparent membrane, very 
 analogous to serous tissues, quite resisting for its tenuity, and forms 
 the external covering of the ovum, passing also over the fetal surface 
 of the placenta and the external face of the umbilical cord, and may 
 be considered as corresponding to the internal lining membrane of an 
 eggshell. It is formed by the union of the vitelline membrane with 
 the albuminous envelope which this acquires while in the oviduct; 
 however, this is still a question among physiologists, some of whom 
 suppose it to be formed by the external layer of the blastodermic 
 vesicle and the allantois. It has two surfaces, an inner or fetal sur- 
 face, and an external or uterine surface. Both of these surfaces are 
 smooth at first, but at an early period, about the second week of preg- 
 nancy, the external surface presents minute granulations, which rapidly
 
 110 KING'S ECLECTIC OBSTETRICS. 
 
 augment in length, forming numerous villi or velvety prolongations 
 with which the chorion soon becomes covered, and which penetrate 
 into the decidua, preventing the ovum from injuriously moving about. 
 These spongy, cylindrical villi disappear from the general surface 
 about the second or third month, but at the spot where the chorion 
 comes in contact with the uterus, and where the secondary caduca or 
 decidua serotina is formed, they enlarge and become vascular, giving 
 origin to the placenta. The vascularity of the chorion does not man- 
 ifest itself until after the development of the allantois, about the 
 second month, when it consists of two layers or laminae, the external 
 or primitive one of which is non-vascular, and is called the exochorion ; 
 while the other, the internal or allantoid layer, is highly vascular, and 
 is named endochorion. 
 
 In the early period of pregnancy the chorion is separated from the 
 amnion by an albuminous layer, which condenses into a thin web-like 
 membrane termed tunica media; and this albuminous fluid is more 
 abundant in the first weeks of gestation. In the midst of this fluid is 
 situated the umbilical vesicle, or yelk-bag. As the ovum matures, the 
 external face of the chorion unites with the decidua reflexa, while its 
 inner face comes in contact with the amnion after the second month ; 
 there have been instances, however, where at full term, a considerable 
 quantity of fluid existed between the amnion and chorion, termed false 
 waters; its escape has given rise to the belief that the liquor amnii 
 had passed off. When this fluid is discharged several times during 
 one pregnancy, it constitutes hydrorrhea (see page 180). The chorion 
 serves to envelope and protect the ovum during its passage from the 
 oviduct to the uterus, furnishes a sheath for the umbilical cord, assists 
 in the production of the placenta, and, probably through the attach- 
 ment of its villi to the decidua, nourishment is absorbed from the 
 maternal blood by which the vitality of the embryo is sustained ; at 
 the parturient period it assists, in connection with the amnion, to form 
 a bag containing the amniotic liquor, which materially promotes the 
 softening and dilatation of the os uteri. 
 
 The AMNION is the most internal covering of the embryo, around 
 which it forms a sac; it is very thin, smooth, and transparent, and 
 is more dense and resisting than the chorion, which it very much re- 
 sembles in structure and appearance. It is supposed to be formed by 
 the internal lamina of the fold of the external serous layer of the 
 blastoderm around the embryo (which forms the cephalic and caudal 
 hoods), and is continuous with the margins of the ventral opening of
 
 DEVELOPMENT OF THE HUMAN OVUM. 117 
 
 the embryo; however, there are several other views concerning its 
 origin. Its internal surface exhales a liquid in which the embryo 
 floats freely ; its external surface is more or less separated from the 
 chorion, the space between them being filled with an albuminous 
 liquid. It apparently consists of condensed cellular tissue, in which 
 neither blood-vessels nor nerves have yet been recognized. As the 
 development of the ovum progresses, the space between the amnion 
 and chorion diminishes, the albuminous fluid found between them 
 gradually disappears, until finally the two envelopes come in contact 
 and adhere to each other. The amnion forms the outer coat of the 
 fetal face of the placenta, and of the cord ; and a division of the cord 
 shows us the chorion placed between the cord proper and the amnion. 
 Its uses are to furnish the liquor amnii, to aid in forming the mem- 
 branes, and bag of waters, and to serve as a covering to the umbilical 
 cord, the liquor amnii, and the fetus. 
 
 The LIQUOR AMNII, also known as the amniotic fluid, waters of 
 the amnios, etc., is a fluid contained within the amnion, and in which 
 the embryo floats ; by some it is supposed to be an exhalation or 
 secretion from the amnion, by others to be a product of the fetus, and 
 ' by others again to be a secretion from both the fetus and its parent. 
 The probability is, that the liquor amnii proper is exhaled by the 
 internal surface of the membranes of the ovum, the elements of which 
 are furnished by the uterine vessels, and that it may be mixed or 
 adulterated with the fetal excretions, especially at an advanced period 
 of pregnancy. This fluid varies in quantity as well as in its proper^ 
 ties ; during the early stage of gestation, when compared with the 
 fetus, it is proportionally greater, there being from half a fluidrachm 
 to a fluidrachm present when the embryo can hardly be seen by the 
 naked eye, and although it continues to increase until full term, yet 
 its relative proportion to the size of the fetus gradually diminishes, so 
 that at parturition, while the fetus may weigh from six to eight 
 pounds, the quantity of fluid will seldom be found to exceed a pint. 
 lu some few cases it may amount to quarts. Its appearance varies 
 from that of a transparent and limpid fluid, more commonly observed 
 in the early period of pregnancy, to that of a thick, slightly yellow, 
 green, or brown color, and which is more usual to the advanced stage. 
 It is soft and viscous to the touch, has a specific gravity of 1.004, and 
 emits an odor somewhat resembling that of semen, though occasion- 
 ally, especially when the fetus is dead, this odor is putrid and very 
 offensive ; its taste is saltish. Sometimes it becomes milky or clouded,
 
 118 KING'S ECLECTIC OUST ETHICS. 
 
 and frequently contains white clots, which are detached pieces of the 
 fetal sebaceous covering ; greenish or dark-colored flakes, being por- 
 tions of undiluted meconium, are likewise often observed in it. Its 
 most common appearance at parturition is that of a dingy liquid, hav- 
 ing a tinge of yellow or green. Heat renders it cloudy; alcohol or 
 caustic Potassa causes a fleecy precipitate, with which nutgalls form a 
 brownish deposit, similar to a dilute solution of gelatin ; Nitrate of 
 Silver occasions an abundant white precipitate, which is insoluble in 
 Nitric Acid ; and the tincture of Violets becomes changed to green by 
 it. Analysis has found in it a large proportion of water, with albu- 
 men, albuminate of soda, chloride of sodium, carbonate of soda, phos- 
 phate and carbonate of lime, urea, and, probably, a peculiar free acid, 
 called amnic or amniotic acid. Its use appears to be to protect the 
 embryo from any severe compression of the uterine walls ; to protect 
 it from the effects of falls or blows ; to prevent any adhesion of the 
 fetus while in utero, and allow it free motion ; to protect the fetus, 
 during parturition, from the injurious effects of uterine contraction 
 upon its body, until all its parts are in a suitable condition to permit 
 its expulsion ; to aid in the dilatation of the os uteri, at term, by means 
 of the bag of waters, as well as to lubricate the parts through which 
 the fetus has to pass, thereby facilitating its delivery. Some physi- 
 ologists believe that it likewise aids in nourishing the fetus, pre- 
 vious to the formation of the placenta and establishment of the fetal 
 circulation. 
 
 . The UMBILICAL VESICLE, vesicula umbilicus, or vesicula alba, 
 yelk-bag ; is formed by the internal, or mucous layer of the blasto- 
 derm ; it is of a rounded, or pyriform shape, is situated in the space 
 between the amnion and chorion, and communicates by a long pedicle, 
 or duct, with the intestinal tube, upon which it lies. It forms 
 FIG. 26 . a sac, seldom larger than a small pea, and 
 
 contains a viscid, transparent, yellowish-white 
 fluid, in which may be seen a few globules 
 and numerous granules. It appears to be com- 
 posed of an external or vascular layer, and an 
 internal or mucous layer. The following account 
 of its formation, is given by Prof. Meigs : 
 "When the blastoderm has partly undergone 
 the morphological -changes that convert it into 
 SEGMENT OF THE SPHERE the earliest rudimental embryon, part of the yelk 
 OF THE VITELLUS. corpuscles still remained unappropriated ; and as
 
 DEVELOPMENT OF THE HUMAN OVUM. 
 
 119 
 
 they are still contained in their original vitel- 
 line membrane, they constitute a small but 
 visible ball, called the umbilical vesicle. 
 Originally, the vitellus was a sphere, of 
 which Fig. 26 represents a segment. The 
 blastoderm is developed upon a segment of (\ I 
 this sphere as at A, in Fig. 27. When the 
 blastoderm doubles or folds its edges in- 
 ward, it pinches (or contracts) a portion of 
 
 the vitellary ball, as in Fig. 28. In a still 
 
 * BLASTODERM DEVELOPED UP- 
 
 further progress, as shown by Fig. 29, the ON THE SEGMENT OF THE 
 portion of the vitellary ball that remains out- SPHERE OF THE VITELLTJS. 
 side of the embryon is connected to the embryo by a delicate tube, or 
 vitellary duct." Velpeau states, that this duct opens into the fetal 
 ilium; Rigby, Ludlow, and Oker, consider FIG. 28. 
 
 the appendicula vermiformis as the re- 
 mains of it. As pregnancy advances, the 
 yelk having been transformed, the umbilical 
 vesicle becomes atrophied, and the develop- 
 ment of the amnion removes it further and 
 further from the embryo, at the same time 
 elongating its duct or pedicle, the canal of 
 which remains open till the sixth or. eighth 
 week of gestation, after which it is obliter- INWARD FOLDING OF THE 
 ated, and the umbilical vesicle becomes flat- EDGES OF THE BLASTODERM. 
 tened, diminished, of a lenticular shape and gradually fused into the cord, 
 and entirely disappears after the third or fourth month ; in a few rare 
 cases, it has been found at full F 
 
 term. Its use is supposed to 
 be to afford nourishment to 
 the embryo, until its pla- 
 cental connection with the 
 mother is established. 
 
 The external or vascular 
 layer of the umbilical vesicle 
 has ramifying over its pari- 
 eties two blood-vessels, an 
 artery, and a vein, which are 
 called the omphalo-mesenteric, or vitello mesenteric vessels, and which ac- 
 company the pedicle, forming a part of it. The omphalo-mesenteric 
 artery arises from the aorta, and as it reaches the summit of the intestinal 
 
 FURTHER PROGRESS OF THE BLASTODERM.
 
 120 
 
 KING'S ECLECTIC OBSTETRICS. 
 
 convolutions, it gives off branches to the mesentery and to the intestine ; 
 then it extends to the pedicle, through which it passes until it reaches 
 the umbilical vesicle, upon which it is distributed. In the adult, that 
 part which supplies the mesentery is converted into a mesenteric artery, 
 all the rest being obliterated, as the umbilical vesicle disappears. The 
 omphalo-mesenteric vein, enters the abdomen, passes around the duode- 
 num, and opens into the umbilical vein just as this is emerging from 
 the liver. In its passage around the duodenum it gives off branches 
 to the stomach and intestines, and when it empties into the umbilical 
 vein, it sends a large trunk to the liver; the whole disappears with 
 the vesicle and its pedicle, except that portion which furnishes the 
 
 above branches, which remains 
 in the adult as the ventral, or 
 hepatic-portal vein. Profes- 
 sor Meigs admirably illustrates 
 the arrangement of the om- 
 phalo-mesenteric vessels, and 
 cord, by the following dia- 
 gram, Fig. 30 : " Let A A, be 
 a portion of the abdomen of 
 the embryo, and c c, the na- 
 vel, or umbilical ring; B B, 
 the navel string, or cord, laid 
 open ; D, the umbilical vein, 
 bringing back the blood from 
 the placenta, and passing into 
 the belly at the ring, to go to 
 the liver; E, F, the two um- 
 bilical arteries of the fetus ; 
 H, the umbilical vesicle, or 
 vitelline sac, whose pipe, con- 
 duit, or efferent-duct runs 
 along the umbilical cord to the navel, and passing into the belly 
 empties itself into the ilium, G G, which bends up to receive the dis- 
 charge ; K, L, represents the omphalo-mesenteric vessels." 
 
 The ALLANTOIS, or attantoid vesicle, is a small sac, or bladder, 
 which may be observed about the tenth day, and which arises from the 
 inferior part of the intestinal canal, or caudal extremity of the embryo ; 
 it is found near the umbilical vesicle, between the chorion and amnion ; 
 its growth is rapid, and soon becomes attached, by its base, to the 
 
 DIAGRAM OF THE OMPHALO-MESENTRIC 
 
 VESSELS.
 
 DEVELOPMENT OF THE HUMAN OVUM. 121 
 
 inner surface of the chorion. On the parietes of the allantois are dis- 
 tributed the terminal branches of the two umbilical arteries and vein. 
 The uraehus, or pedicle of the allantois, is a cord, which is pervious in 
 early embryonic life, and which passes out of the fetal body at the 
 navel, being accompanied by the umbilical blood-vessels to the chorion, 
 which they pierce, sending branches into its villi, which increase in 
 size as these villi form the placental connection with the uterus. 
 
 The allantois rapidly disappears, so that in a few days after its ap- 
 pearance there can be observed only a cord of greater or less length, 
 passing from the embryo to the chorion, and containing the umbilical 
 vessels within it ; this cord, likewise, gradually becomes lost in the sub- 
 stance of the umbilical cord, only a portion of it remaining within the 
 abdomen of the embryo, to form the uraehus, at the rectal termination 
 of which is subsequently formed the urinary bladder. In consequence 
 of this early disappearance of the allantois, many physiologists have 
 denied its existence. The use of this vesicle, or membrane, is to con- 
 duct blood from the embryo to the chorion, or, as remarked by Prof. 
 Meigs, " the allantois may be said to be a bladder, or vesicle, upon 
 which the umbilical arteries climb toward the wall of the womb, to 
 attach themselves there." It is, likewise, stated to receive the urine 
 of the fetus, secreted in early uterine life. Dr. Carpenter makes the 
 following remarks in relation to this vesicle : 
 
 " With the evolution of a circulatory apparatus, adapted to absorb 
 nourishment from the store prepared for the use of the embryo, and to 
 convey it to its different tissues, it becomes necessary that a respira- 
 tory apparatus should also be provided, for unloading the blood of the 
 carbonic acid, with which it becomes charged during the course of its 
 circulation. The temporary respiratory apparatus, now to be described, 
 bears a strong resemblance in its own character, and -especially in its 
 vascular connections, with the gills of the mollusca; which are pro- 
 longations of the external surface (usually near the termination of the 
 intestinal canal), and which almost invariably receive their vessels from 
 that part of the system. This apparatus is termed the allantois. It 
 consists at first of a kind of diverticulum, or prolongation, of the lower 
 part of the digestive cavity, the formation of which has been already 
 described. This is at first seen as a single vesicle, of no great size; 
 and in the fetus of mammalia, which is soon provided with* other 
 means of aerating its blood, it seldom attains any considerable dimen- 
 sions. In birds, however, it becomes so large as to extend itself 
 around the whole yelk-sac, intervening between it and the membrane 
 of the shell; and through the latter it conies into relation with the
 
 122 
 
 KING'S ECLECTIC OBSTETRICS. 
 
 external air. The diagram (Fig. 31), will serve to explain its origin 
 and position in the human ovum. The chief office of the allantois, in 
 
 FIG. 31. 
 
 E, GI F 
 
 DIAGRAM o? THE HUMAN OVUM AT THE TIME OF THE 
 FORMATION OF THE PLACENTA. 
 
 A. Muco-gelatinous substance blockiug up the Oi Uteri. 
 
 B B. Fallopian Tubes. 
 
 C C. Pecidua Vera, at 2 C, prolonged into the Fallopian Tube. 
 
 D. Cavity of the Uterus, almost completely occupied by the Ovum. 
 
 E E. Angles at which the Decidua Vera is reflected. 
 
 F. Decidua Serotina. 
 
 G. Allantois. 
 
 H. Umbilical Vesicle. 
 
 I. Arnnios. 
 
 K. Chorion, with the outer fold of Serous Tunic. 
 
 mammalia, is to convey the vessels of the embryo to the chorion ; and 
 its extent bears a pretty close correspondence with the extent of sur- 
 face, through which the chorion comes into vascular connection with 
 the decidua. Thus, in the carnivora, whose placenta extends like a 
 band around the whole ovum, the allantois also lines the whole inner 
 surface of the chorion, except where the umbilical vesicle comes in 
 contact with it. On the other hand, in man and the quadrumana,
 
 DEVELOPMENT OF THE HUMAN OVUM. 123 
 
 whose placenta is restricted to one spot, the allantois is small, and con- 
 veys the fetal vessels to one portion only of the chorion. When these 
 vessels have reached the chorion, they ramify in its substance, and 
 send filaments into its villi ; and in proportion as these villi form that 
 connection with the uterine structure, which has been already de- 
 scribed, do the vessels increase in size. They then pass directly from 
 the fetus to the chorion, and the allantois being no longer of any use, 
 shrivels up, and remains as a minute vesicle, only to be detected by 
 careful examination. The same thing happens in regard to the um- 
 bilical vesicle, from which the entire contents have been by this time 
 exhausted ; and from henceforth the fetus is entirely dependent for 
 the materials of its growth, upon the supply it receives through the 
 placenta, which is conducted to it by the vessels of the umbilical cord. 
 This state of things is represented in the diagram (Fig. 31). The al- 
 lantois has a correspondence in situation with the urinary bladder ; but 
 it is only the lower part of it pinched off, as it were, from the rest, 
 that remains as such. The duct by which it is connected with the ab- 
 domen gradually shrivels ; and a vestige of this is permanent, forming 
 the urachus, or suspensory ligament of the bladder, by which it is con- 
 nected with the umbilicus. Before this takes place, however, the al- 
 lantois is the receptacle for the secretion of the corpora wolffiana, and 
 of the true kidneys, when they are formed." 
 
 The PLACENTA, or afterbirth, is a soft, spongy, vascular mass, 
 occupying about one-third of the external covering of the ovum, and 
 forming the principal connection between the embryo and the uterus. 
 It is a flattened, irregularly circular body, of a more or less intense 
 reddish-gray color, varying in diameter from six to nine inches, some- 
 times having one diameter longer than the others, about an inch in 
 thickness at its point of junction with the umbilical cord, from which 
 it gradually tapers off toward the circumference, which seldom exceeds 
 two or three lines, and weighing one or two pounds, depending, 
 however, upon its size and the amount of blood it contains. It most 
 usually has the umbilical cord inserted at its center ; occasionally this 
 passes into it, at or near the circumference, and with this disposition 
 the vessels of the cord will frequently be found to separate into 
 numerous branches before they reach the substance of the placenta ; 
 this is termed the battledore placenta. The placenta, umbilical cord, 
 and membranes, are collectively called the secundines. 
 
 The placenta presents two surfaces, an external or uterine, and an 
 internal or fetal. The fetal surface has a smooth, polished appearance,
 
 124 KING'S ECLECTIC OBSTETRICS. 
 
 and is marked by the numerous radiations of the vessels of the umbili- 
 cal cord, forming a kind of network, which may enable us to dis- 
 tinguish the placenta in artificial deliveries ; this surface is covered by 
 the chorion and amnion, the former of which intimately adheres to 
 it, and sends processes between the lobules, while the latter is loose 
 and nearest the fetus. Each one of the umbilical arteries upon reach- 
 ing the placental surface divides into two branches, and this dichoto- 
 mous division is repeated until these vessels have diminished in size 
 to a diameter of about three-sixteenths of an inch, when they pass 
 through the chorion into the placental tissue, numerously subdividing 
 to form the ultimate villous tufts or ramifications ; the blood is then 
 conveyed back to the cord, by about sixteen veins, which run on the 
 placental surface along side of the chief branches just referred to, and 
 terminate in the one vein of the umbilical cord. The uterine surface, 
 when removed from the uterine wall, presents a uniform, but not 
 smooth appearance, and is slightly convex; it has a fleshy resemblance, 
 and is divided by deep sulci or furrows into numerous irregularly 
 shaped lobes, from half an incli to about an inch and a half in 
 diameter, which are connected with each other, at the bottom of these 
 sulci, by a loose cellular, or, according to Velpeau, lamellated, albumin- 
 ous tissue, which is easily lacerated. ' Upon an investigation, it will 
 be found that each of these lobes or cotyledons, is formed by the . 
 ramifications of one branch of the umbilical arteries and veins, on 
 their first separation, and that the vessels of one lobe do not anasto- 
 mose with those of another, and but slightly with each other. This 
 surface is not in direct contact with the uterine wall, but is separated 
 from it by the interposition of the decidua serotina or placental decidua, 
 an albuminous layer analogous in appearance to the true caducous 
 membrane, which is more firmly attached to the placenta than to the 
 uterus, and which enters into the fissures separating the lobes, when 
 not too deep, in which latter case it passes from one lobe to another, 
 forming a kind of membranous bridge, while a thick partition of 
 cellulo-mucous substance penetrates deeply between the lobes. The 
 circumference of the placenta is thin and irregular, and measures from 
 twenty-one to twenty-seven inches ; its margin is continuous with the 
 chorion, and is contiguous to the fold formed by the caduca when 
 passing over the ovum to constitute the decidua reflexa ; between this 
 fold and the placental circumference is a thickening or density of 
 substance, so disposed for the reception of the placental border as to 
 form a triangular sinus. 
 
 The earliest rudiments of the placenta are observed toward the
 
 DEVELOPMENT OF THE HUMAN OVUM. 125 
 
 termination of the first month of pregnancy, which become gradually 
 developed until the third month, when the organ acquires its proper 
 character, and continues to increase in size with the growth of the 
 fetus. As soon as the ovule has reached the uterus, the chorion is 
 observed to be covered with numerous villi which give to it a downy 
 appearance, but those villi in contact with the decidua reflexa, proba- 
 bly from an absence of proper material for their development, become 
 atrophied and filamentous, serving merely as points of union between 
 the chorion and decidua; while those which are exposed to the uterine 
 wall, receiving nourishment from the exudation of lymph which takes 
 place on the surfaces of both the uterus and ovum, continue to 
 develop themselves, elongate, become converted into vessels, and 
 ultimately form the placental part of the placenta. (Fig. 31.) The 
 uterine portion of the placenta is the lymph above referred to, which 
 forms a thin, soft, delicate tissue known as the decidua serotina, and 
 which is furnished more copiously by the uterus, on account of the 
 superior size and vitality of this organ compared with those of the 
 ovum. At that portion of the uterus where the placenta is situated, 
 will be found large cells or sinuses which communicate freely with 
 each other, but which do not extend beyond the decidua serotina, this 
 membrane answering the purpose of a valve to prevent the blood in 
 them from passing into the cavity of the gravid uterus; these cells are 
 the uterine sinuses, and into them the blood is poured by the curling 
 uterine arteries terminating in a capillary extremity. The capillary 
 vessels of the fetus, covered by the thin decidua, insinuate themselves 
 into these sinuses, and, without any interference of the circulation 
 of either the fetal or maternal fluid, the change is here effected which 
 probably removes the effete matter of the fetal blood, while at the 
 same time this fluid absorbs oxygen from the maternal blood; and 
 these changes are brought about without the existence of any vascular 
 intercommunication between the mother and fetus, the action some- 
 what resembling that which takes place in the lungs of an adult, 
 between the venous blood and the atmospheric air Weber, Kolliker, 
 Turner, "Wincklen, and Delore, have demonstrated that the maternal 
 blood does circulate in the placenta, bathing the villosities of this 
 formation. And Dr. T. Snow Beck affirms that u the cavernous 
 structure of the placenta is in direct communication with the canals 
 of the sinuses or veins, and that these vessels carry the blood away 
 from the placenta, which is brought there by the utero-placental 
 arteries," and that there " is no such thing as a feeble wall or delicate
 
 ll>|| KIN(.'s K( LKCTIC OI5STETKK S. 
 
 membrane, either at or forming the line of separation, nor, indeed, 
 structures of any kind that prevent the flow of blood direct from the 
 placenta into the uterine sinuses or veins." 
 
 The placenta may attach itself to any part of the internal surface 
 of the uterus, more commonly at or near the orifice of one of the 
 tubes, occasionally in the vicinity toward the fundus, rarely toward 
 the neck, and still more seldom over the inner os uteri; this latter 
 position is termed placenta prcevia, and is dangerous to both mother 
 and child on account of the hemorrhage which is apt to ensue as it 
 becomes detached from the uterine wall, during labor, by the dilata- 
 tion of the os uteri. These placental situations are supposed to be 
 determined by the character of the adhesion existing between the 
 caduca and uterine wall, as to firmness as well as to the degree of 
 resistance afforded by the caduca to the advancing ovule ; thus, if the 
 adhesion be weak between the decidua and uterine wall at the utero- 
 tubal orifice, the ovule may slip or pass down between them until 
 it meets with sufficient resistance to impede its further progress, and 
 at this point, where it is stayed, commences the formation of the 
 decidua reflexa, as well as of the placenta. And if the attachment 
 be so slight as to permit the fecundated ovule to pass out of the 
 uterus and through the canal of the cervix, conception does not take 
 place. It must be borne in mind, that the attachment of the placenta 
 is by apposition only, the decidua serotina being interposed between 
 it and the uterine wall; and when actual adhesion occurs, it is in- 
 variably the result of disease. 
 
 In cases where more than one fetus is present, we generally find a 
 separate cord, placenta, and set of membranes for each one, and though 
 the placentae may be joined together, forming apparently a single or- 
 gan, yet there will be no anastomosing of the blood-vessels, the circu- 
 lation of each child being perfectly independent, so that should one 
 die or become diseased in utero, the other may continue to live or be 
 healthy. In some few instances, there have been found exceptions to 
 this two children have been inclosed in one bag of membranes, or 
 when in separate ones, there has been a communication of their vas- 
 cular systems. The use of the placenta is to form the principal con- 
 nection between the embryo and the uterus in order to contribute to 
 the nourishment of the former. (Fig. 31.) 
 
 The UMBILICAL CORD, funis umbilicalis, or navel string, is a 
 long, flexible, and vascular cord which serves as a connecting medium
 
 DEVELOPMENT OF THE HUMAN OVUM. 127 
 
 between the fetus and placenta. It has two insertions, a placental and 
 a fetal. The placental insertion is usually in the center of the placenta, 
 though it may occur at any point between the center and circumfer- 
 ence of this organ ; the fetal insertion is at the umbilicus. At birth, 
 its average length is from sixteen to twenty-four inches, though it fre- 
 quently varies from this measurement, having been found several feet 
 long, and again only six or seven inches. Its thickness is likewise 
 variable ; ordinarily it is about equal to that of the little finger ; when 
 it exceeds this it is termed a fat cord, and when it is smaller it is called 
 a lean cord. This variation in its thickness depends upon the larger 
 or smaller amount of a viscid, semi-transparent fluid which is infil- 
 trated in the cellular tissue of the cord, and which is named the gela- 
 tine of Wharton; this fluid is coagulable by heat and acids, and when 
 unequally distributed occasions swellings or nodes on the cord. 
 
 During the early weeks of pregnancy the umbilical cord does not 
 exist ; its first appearance is about the end of the first month, when 
 the embryo is fully separated from the blastodermic vesicle, at which 
 period it is composed of the duct of the umbilical vesicle, urachus. 
 omphalo-mesenteric vessels, and a covering of amnion and chorion. 
 It is now cylindrical, thick and short, but elongates in proportion as 
 the umbilical vessel removes and disappears. At about the commence- 
 ment of the third month, the umbilical vesicle, urachus, and omphalo- 
 mesenteric vessels being obliterated and amalgamated with the cord ; 
 this now consists of two arteries, one vein, fine areolar tissue, gelatine 
 of Wharton, and an external covering of amnion and chorion, which 
 elements remain until the termination of pregnancy. At first the cord 
 is straight, but after the second month, a torsion of the vessels com- 
 mences, the two arteries run uniformly and spirally ardund the vein, 
 usually in a direction from left to right ; the vein thus occupying the 
 axis of the cord. 
 
 The vein of the umbilical cord is of a thickness nearly, if not quite 
 equal, to that of the two arteries combined ; it has no valves, its walls 
 are thin but firm, and it performs the functions of an artery, carrying 
 the pure and vitalized blood from the placenta to the fetus. It arises 
 from the placenta ; the venous ramifications of each placental lobe 
 uniting on the surface of the placenta to form the cord, which passes 
 onward into the umbilical ring of the fetus, where it separates from 
 the two arteries and proceeds toward the liver. 
 
 The two arteries of the umbilical cord arise from the fetal internal 
 iliacs, of which they are branches, and proceed toward the umbilicus,
 
 128 KING'S ECLECTIC OBSTETRICS. 
 
 where they separate and traverse the vein in a tortuous manner until 
 they reach the placenta, into which they give off numerous ramifica- 
 tions. The walls of the arteries are thick, resisting, and contractile, 
 and they pulsate strongly. The arteries perform the office of veins, 
 as they convey the adulterated blood from the fetus to the placenta. 
 It is very rarely that any different arrangement of the cord from the 
 above, has been observed ; a few instances have been related where but 
 one artery was present, and Velpeau has stated that two veins have 
 been met with. The colors of the blood in the vein and arteries re- 
 semble each other so nearly as to be scarcely distinguishable. 
 
 The cord is subject to abnormities and accidents, as, a division of 
 the vessels before having reached the placenta, a varicose or hydatidic 
 condition, a rupture of the coats, a closure of the vessels, an insertion 
 into some other part of the fetus than the umbilicus, or into a wrong 
 part of the decidua, and twists or knots r ^especially when the cord is 
 very long, which interfere more or less with the circulation and con- 
 sequent nutrition of the fetus. Any of these conditions may occasion 
 the death of the fetus, and abortion, though, some of them, when 
 slight, exert no important influence. The cord is most commonly 
 above the head of the child, yet there are often exceptions ; it has been 
 found coiled once or twice around the child's neck, or body, or a limb, 
 in some instances causing death by strangulation, or the loss of a limb ; 
 occasionally, it is found presenting before the fetal head. In cases of 
 twins, each fetus has its own cord, though instances have been met 
 with where there existed a communication between the cords of the 
 several fetuses. 
 
 CHAPTER XV. 
 
 OP THE FETUS AND ITS DEVELOPMENT. 
 
 THE ovule, or ovum, is the human egg previous to its impregnation, 
 though these terms are frequently applied to the embryo and the fetus; 
 as long as this is amorphous or of an undetermined form, it has re- 
 ceived the name of germ; from the period when a definite form can be 
 observed until the third month, it is called the embryo, from which 
 time until its expulsion from the uterus, the term fetus is applied to it.
 
 THE FETUS AND ITS DEVELOPMENT. 129 
 
 After birth it becomes the child or infant, though either of these latter 
 terms are often used synonymously with fetus. 
 
 The study and investigation of the de- FIG. 32. 
 
 velopment of the. human embryo (Fig. 32), 
 is one which the student finds attended 
 with considerable difficulty ; for, notwith- 
 standing the many discoveries of physiol- 
 ogists on this point, there still remain much 
 obscurity and uncertainty attached to it, as 
 is evident from the various views which 
 have from time to time been presented to 
 the profession. Dr. Rigby, in his work on 
 
 Midwifery, has probably, given the clearest, SECTION OF A MORE DE- 
 and at the same time the most concise ^ELOPED OVUM, IN WHICH 
 
 . n ,. n. ,1 i 3 i THE TWO PORTIONS THE 
 
 illustration ot the researches and conclu- 
 
 EMBRYONIC AND UMBILICAL 
 
 sions of those who have investigated the VESICLE BEGIN TO APPEAR. 
 subject, as will be found in the following o. umbilical vesicle. 
 
 , i i -n T I- Internal laydr of the Blasto- 
 
 (^uotation, which will, I trust, prove ac- derma ' 
 
 ceptable to all who are interested : E - External layer. 
 
 -, -r-r , mi i i V. Vitelline Membrane. 
 
 "Embryo. ihere is, perhaps, no de- 
 partment of physiology which has been so remarkably enriched by 
 recent discoveries, as that which relates to the primitive development 
 of the ovum and its embryo. The researches ot Baer, Rathke, Pur- 
 kinje, Valentin, etc., in Germany; of Dutrochet, Prevost, Dumas, 
 and Coste, etc., in France; and of Owen, Sharpey, Allen, Thompson, 
 Jones, and Martin Barry, in England, but more especially those of 
 the celebrated Baer, have greatly advanced our knowledge of the'se 
 subjects, and led us deeply into those mysterious processes of nature 
 which relate to our first origin and formation. 
 
 " These researches have all tended to establish one great law, con- 
 nected with the early development of the human embryo, and that 
 of other mammiferous animals, viz.: that it at first possesses a struct- 
 ure and arrangement analogous to that of animals in a much lower 
 scale of formation ; this observation also applies, of course, to the 
 ovum 'itself, since a variety of changes take place in it after impreg- 
 nation, before a trace of the embryo can be detected. 
 
 " At the earliest periods, the human ovum bears a perfect analogy 
 to the eggs of fishes, amphibia, and birds ; and it is only by carefully 
 examining the changes produced by impregnation in the ova of these 
 lower classes of animals, that we have been enabled to discover them 
 in the mammalia and human subject. 
 9
 
 130 
 
 KING'S ECLECTIC OBSTETRICS. 
 
 FIG. 33. 
 
 SECTION OF A HEN'S EGO WITHIN 
 
 Periphery of the Yelk. 
 
 B. Vesicle of Purkinje, imbedded in the 
 
 Cumulus. 
 
 C. Vitellary Membrane. 
 
 D. Inner and Outer Layers of the Cap- 
 
 sule of the Ovum. 
 
 E. Indusium of the Ovary. 
 
 " As the bird's egg, from its size, best 
 affords us the means of investigating 
 these changes, and as in all essential 
 respects they are the same in the hu- 
 man ovum, it will be necessary for us 
 to lay before our readers a short account 
 of its structure and contents, and also 
 of the changes which they undergo, 
 after impregnation. In doing this, we 
 shall merely confine ourselves to the de- 
 scription of what is applicable to the 
 THEOVAR*. human ovum. (.%. 33.) 
 
 A.. The Granular Membrane forming the " The 6gg IS knOWU to Consist of twO 
 
 distinct parts, the vitellus or yelk sur- 
 rounded by its albumen or white; to 
 the former of these we now more par- 
 ticularly refer. The yelk is a granular 
 albuminous fluid, contained in a granu- 
 lar membranous sac (the blastodermic membrane), which is covered by 
 an investing membrane called the vitelline membrane or yelk-bag. The 
 impregnated vitellus is retained in its capsule in the ovary, precisely 
 as the ovum of the mammifera is in the Graafian vesicle. The whole 
 ovary in this case has a clustered appearance, like a bunch of grapes, 
 each capsule being suspended by a short pedicle of indusium. 
 
 " In those ova which are considerably developed before impregna- 
 tion, the granular blastodermic membrane is observed to be thicker, 
 and. the granules more aggregated at that part which corresponds to 
 the pedicle,, forming a slight elevation with a depression in its center, 
 like the cumulus in the proligerous disk of a Graafian vesicle. This 
 little disk is the blastoderma, germinal membrane, or cicatricula; in 
 the central depression just mentioned is an exceedingly minute vesicle, 
 first noticed by Professor Purkinje, of Breslau, and named after him ; 
 FIQ. 34. ' n more correct language, it is the germinal ves- 
 
 ick. (Fig. 34.) 
 
 " According to Wagner, the germinal vesicle 
 is not surrounded by a disk before impregnation ; 
 and it is only after this process that the above- 
 mentioned disk of granules is formed. By the 
 time the ovum is about to quit the ovary, the 
 vesicle itself has disappeared, so that an ovum 
 has never been found in the oviduct containing a germinal vesicle, 
 
 A. Vitelline Membrane. 
 
 B. Blastoderma. 
 
 From T. W. Jane*.
 
 THE FETUS AND ITS DEVELOPMENT. 131 
 
 nothing remaining of it beyond the little depression in the cumulus 
 of the cieatricula. 
 
 "The rupture of the Purkinjean or germinal vesicle has been sup- 
 posed by Mr. T. "W. Jones to take place before impregnation ; but the 
 observations of Professor Valentin seem to lead to the inference that 
 it is a result of that process, and must be therefore looked upon as 
 one of the earliest changes which take place in the ovum or yelk-bag 
 upon quitting the ovary.* 
 
 " During its passage through the oviduct (what in mammalia is called 
 .the Fallopian tube), the ovum receives a thick covering of albumen, 
 and as it descends still farther along the canal the membrane of the 
 shell is formed. 
 
 "On examining the appearance of the ovum in mammiferous ani- 
 mals, and especially the human ovum, it will be found that it presents 
 a form and structure very analogous to the ova just described, more 
 especially those of birds. It is a minute, sphericle sac, filled with an 
 albuminous fluid, lined with blastodermic or germinal membrane, in 
 which is seated the germinal vesicle or vesicle of Purkinje. When 
 the ovum has quitted the ovary the germinal vesicle disappears, and 
 on its entering the Fallopian tube it becomes covered with a gelatin- 
 ous, or rather albuminous covering. This was inferred by Valentin, 
 who considered that ( the enormous swelling of the ova, and their 
 passage through the Fallopian tubes/ tended to prove the circum- 
 stance. (Edin. Med. and Surg. Journal, April, 1836.) It has since 
 been demonstrated by Mr. T. W. Jones, in a rabbit seven days after 
 impregnation. The vitellary membrane seems, at this time, to give 
 way, leaving the vitellus of the ovum merely covered by its spherical 
 blastoderma, and incased by the layer of albuminous matter which 
 surrounds it. 
 
 " From what we have now stated, a close analogy will appear be- 
 tween the ova of the mammalia and those of the lower classes, more 
 especially birds, which from their size afford us the best opportunities 
 of investigating this difficult subject. 
 
 "In birds, the covering of the vitellus is called yelk-bag; whereas, 
 in mammalia and man it receives the name of vesieula umbilicalis. 
 Its albuminous covering, which corresponds to the white and mem- 
 brane of the shell in birds, is called chorion: by the time that the 
 
 * We said, " one of the earliest changes." Mr. Jones considers that " the breaking 
 up of the surface of the yelk into crystalline forms," is the first change which he has 
 observed.
 
 132 
 
 KING'S ECLECTIC OBSTETRICS. 
 
 ovum IKIS reached the uterus, this outer membrane has undergone a 
 considerable change; it becomes covered with a complete down of little 
 absorbing fibril l;i\ which rapidly increase in size as development ad- 
 vances, until it presents that tufted, vascular appearance, which we 
 have already mentioned when describing this membrane. 
 
 " The first or primitive trace of the embryo is in the cicatricula or 
 germinal membrane, which contained the germinal vesicle before its 
 disappearance. In the center of this, upon its upper surface, may be 
 discovered a small dark line:* 'this line or primitive trace is swollen 
 at one extremity, and is placed in the direction of the transverse axis 
 of the egg.' (Fig. 35.) 
 
 FJO. 35. "As development ad- 
 
 vances, the cicatricula ex- 
 pands. ( We are indebted 
 to Pander/f says Dr. Allen 
 Thompson, in his admirable 
 essay, above quoted, ' for 
 the important discovery, 
 that toward the twelfth or 
 fourteenth hour, in the hen's 
 egg the germinal membrane 
 becomes divided into two 
 layers of granules, the serous and mucous layers of the cicatricula ; 
 and that the rudimentary trace of the embryo, which has at this time 
 become evident, is placed in the substance of the uppermost or serous 
 layer.' . ' According to this observer, and according to Baer, the part 
 of this layer which surrounds the primitive trace soon becomes thicker; 
 and on examining this part with care, toward the eighteenth hour, we 
 observe that a furrow has been formed in it, in the bottom of which 
 the primitive trace is situated; about the twentieth hour this furrow is 
 converted into a canal open at both ends, by the junction of its mar- 
 gins (the plicce primitives of Pander, the laminae, dor sales of Baer) : the 
 canal soon becomes closed at the cephalic or swollen extremity of the 
 primitive trace, at which part it is of a pyriform shape, being wider 
 here than at any other part. According to Baer and Serres, some 
 time after the canal begins to close, a semi-fluid matter is deposited in 
 it, which on its acquiring greater consistence, becomes the rudiment of 
 
 Allen Thompson on the Development of the Vascular System in the Fetus of Ver- 
 tebrated Animals. (Edin. New Philosoph. Journal, Oct. 1830.) 
 
 t Pander, Beitragezur Entwickelungs-geschichte des Hunchens im Eie. Wurzburg, 
 1817. 
 
 A. XiauspareiH Area. 
 
 15. Primitive Trace.
 
 THE FETUS AND ITS DEVELOPMENT. 
 
 133' 
 
 the spinal cord; the pyriform extremity or head is soon after this seen 
 to be partially subdivided into three vesicles, which being also filled 
 with a semi-fluid matter, gives rise to the rudimentary state of the 
 eucephalon. 3 ' As the formation of the spinal canal proceeds, the parts 
 of the serous layer which surround it, especially toward the head, be- 
 come thicker and more solid, and before the twenty-fourth hour we 
 observe on each side of this canal four or five round opaque bodies ; 
 these bodies indicate the first formation of the dorsal vertebrae. (Fig. 36.) 
 
 FIG. 36. 
 
 A. Transparent Area. 
 
 B. Lamina Dorsales. 
 
 C. Cephalic End. 
 
 D. Rudiments of Dorsal Vertebrae. 
 
 E. Serous Layer. 
 
 F. Lateral Portion of the Primitive Trace. 
 
 G. Mucous Layer. 
 H. Vascular Layer. 
 
 K. Laminae Dorsales united to form the Spi- 
 nal Canal. 
 
 " ' About the same time, or from the twentieth to the twenty- 
 fourth hour, the inner layer of the germinal membrane undergoes 
 a farther division, and by a peculiar change is converted into the 
 vascular mucous layers.' (A. Thompson, op. cit. ) It will thus 
 be seen, that the germinal membrane is that part of the ovum 
 in which the first changes produced by impregnation are observed. 
 The rudiments of the osseous and nervous systems are formed by the 
 outer or serous layers ; the outer covering of the fetus or integuments, 
 including the amnios, are also furnished by it. 'The layer next in 
 order, has been called vascular, because in it the development of the 
 principal parts of the vascular system appears to take place. The 
 third, called the mucous layer, situated next the substance of the yelk, 
 is generally in intimate connection with the vascular layer, and it is to
 
 134 
 
 KINGS ECLECTIC OUSTKTRICS. 
 
 FIG. 37. 
 
 A. Serous Layer. 
 B C. Vascular Layer. 
 
 D. Mucous Layer. 
 
 E. Heart. 
 
 the changes which these combined layers undergo, that the intestinal, 
 the respiratory, and probably also the glandular systems, owe their 
 origin.' (A. Thompson, op. dt., p. 298. (Fig. 37.) 
 
 "The embryo is therefore 
 formed in the layers of the ger- 
 minal membrane, and becomes 
 as it were, spread out upon the 
 surface of the ovum: the 
 changes which the ovum of 
 mammalia undergoes appear, 
 from actual observation, to be 
 precisely analogous to those 
 in the inferior animals. 
 {Boer, Prevost, and Dumas.) From the primitive trace, which 
 was at first merely a line crossing the cicatricula, and which now 
 begins, rapidly to exhibit the characters of the spinal column, the 
 parietes of the head and trunk gradually approach farther and farther 
 toward the anterior surface of the abdomen and head until they unite ; 
 in this way the sides of the jaws close in the median line of the face, 
 occasionally leaving the union incomplete, and thus appearing 10 pro- 
 duce in some cases the congenital defects of hair lip and cleft palate. 
 In some way the ribs meet at the sternum ; and it may be supposed 
 that sometimes this bone is left deficient, and thus may become one of 
 the causes of those rare cases of malformation, where the child has 
 been born with the heart external to the parieties of the thorax. In 
 like manner the parietes of the abdomen and pelvis close in the linea 
 alb'a and symphysis pubis, occasionally leaving the integuments of the 
 navel deficient, or, in other words, producing congenital umbilical 
 hernia, or at the pubes a non-union of its symphysis with a species of 
 inversion of the bladder, the anterior wall of that viscus being nearly 
 or entirely wanting. 
 
 " The cavity of the abdomen is therefore at first open to the vesicula 
 umbilicalis or yelk, but this changes as the abdominal parietes begin 
 to close in ; in man and the mammalia merely a part of it, as above 
 mentioned, forms the intestinal canal, whereas, in oviparous animals, 
 the whole of the yelk-bag enters the abdominal cavity, and serves for 
 an early nutriment to the young animal. Another change connected 
 with the serous or outer layer of the germinal membrane is the forma- 
 tion of the amnion. The fetal rudiment, which from its shape has 
 been called earina, now begins to be enveloped by a membrane of ex- 
 ceeding tenuity, forming a double covering upon it; the one which
 
 THE FETUS AND ITS DEVELOPMENT. 135 
 
 immediately invests the fetus is considered to form the future epider- 
 mis; the other, or outer fold, forms a loose sac arpund it, containing 
 the liquor amnii. While these changes are taking place in the serous 
 layer of the germinal membrane, and while the intestinal canal, etc., 
 are forming on the anterior surface of the embryo, which is turned to- 
 ward the ovum, by means of the inner or mucous layer, equally im- 
 portant changes are* now observed in the middle or vascular layer. 
 1 In forming this fold,' says Dr. A. Thompson, ( the mucous layer is 
 reflected farthest inward ; the serous layer advances least, and the space 
 between them, occupied by the vascular layer, is filled up by a dilated 
 part of this layer, the rudiment of the heart.' (Op. Git., p. 301.) 
 
 " While this rudimentary trace of the vascular system is making its 
 appearance, minute vessels are seen ramifying over the vesicula um- 
 bilicalis, forming, according to Bae'r's observations, a reticular anasto,- 
 mosis, which unites into two vessels, the vasa omphalo-meseraica. 
 (British and Foreign Med. Rev. No. 1.) These may be demonstrated 
 with great ease in the chick ; the cicatricula increases in extent ; it 
 becomes vascular, and at length forms a heart-shaped network of 
 delicate vessels, which unite into two trunks, terminating one on each 
 side of the abdomen. (Fig. 38.) 
 
 " The umbilical vesicle now begins to separate 
 itself more and more from the abdomen of the 
 fetus, merely a duct of communication passing to 
 that portion of it which forms the intestinal canal. 
 The first rudiment of the cord will be found at 
 this separation ; its fetal extremity remains for a 
 long time funnel-shaped, containing, beside a por- 
 tion of intestine, the duct of the vesicula umbili- 
 calis, the vasa omphalo-meseraica (the future vena ^^ 7?^LZ 
 portse), the umbilical vein from the collected ven- wi' n which at A, is the 
 
 T i /> ,1 i n Fundus of the diminutive 
 
 ous radicles of the chonon, and the early trace of Human Aiiantois. 
 
 the umbilical arteries. These last named vessels c ; The Duct of the Vesi - 
 
 .n IT i n cula Umbilicalis, dividing 
 
 ramity on a delicate membranous sac of an elon- into two i ntes tinai P or- 
 gated form, which rises from the inferior or cau- tions ' and besldes this duct 
 
 X . _ , . are two vessels which are 
 
 dal extremity of the embryo, viz.: the atlantois; distributed upon the vesi- 
 whether this is formed bv a portion of the mucous cula Urabilicalis and fwiu 
 
 . a reticular AnactouioBM 
 
 layer of the germinal vesicle, in common with the with each other. From 
 other abdominal viscera, appears to be still uncer- Baer ' 
 tain ; in birds this may be very easily demonstrated as a vascular 
 vesicle arising from the extremity of the intestinal canal ; and in 
 mammalia, connected with the bladder by means of a canal called
 
 136 KING'S ECLECTIC OBSTETRICS. 
 
 urachux; from its sausage-like shape, it has received the name of 
 allantois. 
 
 " The existence of an allantois in the human embryo has been long 
 inferred from the presence of a ligamentous cord, extending from the 
 fundus of the bladder to the umbilicus, like the urachus in animals. 
 But from the extreme delicacy of the allantois, and from its functions 
 revising at a very early period, it had defied all*research, until lately, 
 when it has been satisfactorily demonstrated in the human embryo by 
 Baer and Rathke. It occupies the space between the chorion and am- 
 nion, and gives rise occasionally to a collection of fluid between these 
 membranes, familiarly known by the name of the liquor amnii spurius, 
 which, strictly speaking, is the liquor allantoidis. 
 
 " The function of the allantois is still in a great measure unknown. 
 In animals it evidently acts as a species of receptaculum urinse during 
 the latter periods of ge'station; but it is very doubtful if this be its 
 use during the earlier periods. It does not seem directly connected 
 with the process of nutrition, which at this time is proceeding so 
 rapidly, first by means of the albuminous contents of the vitellus, or 
 vesicula umbilicalis, and afterward, by the absorbing radicles of the 
 chorion; but, from analogy with the structure of the lower classes of 
 animals, it would appear that it is intended to produce certain changes 
 in the rudimentary circulation of the embryo, similar to those which, 
 at a later period of pregnancy, are effected by means of the placenta, 
 and after birth, by the lungs, constituting the great functions of res- 
 piration. 
 
 " In many of the lower classes of animals respiration (or at least 
 the functions analogous to it) is performed by organs situated at the 
 inferior or caudal extremity of the animal; thus, for instance, certain 
 insect tribes, as in hymenoptera, or insects with a sting, as wasps, 
 bees, etc.; in diptera, or insects with two wings, as the common fly; 
 and also the spider tribe, have their respiratory organs situated in the 
 lower part of the abdomen. In some of the Crustacea, as, for instance, 
 the shrimp, the organs of respiration lie under the tail, between the 
 fins, and floating loosely in the water. Again, some of the mollusca, 
 viz.: the cuttlefish, have the respiratory organs in the abdomen. We 
 also know that many animals, during the first periods of their lives, 
 respire by a different set of organs to what they do in the adult state ; 
 the most familiar illustration of this is the frog, which, during its tad- 
 pole state, lives entirely in the water. 
 
 " As the growth of the embryo advances, other organs, whose func- 
 tion is as temporary as that of the allantois, make their appearance :
 
 THE FETUS AND ITS DEVELOPMENT. 
 
 137 
 
 these also correspond to the respiratory organs of a lower class of an- 
 imals, although higher -than those to which we have just alluded we 
 mean branchial processes, or gills. (Fig. 39.) It is to Professor 
 Eathke (Acta Naturce Curios., vol. xiv), that we are indebted for 
 pointing out the interesting fact, that several transverse, slit-like aper- 
 tures may be detected on each side of the neck of the embryo, at a 
 very early stage of development. In the chick, in which he first ob- 
 served it, it takes place about the fourth day of incubation : at this 
 period the neck is remarkably thick, and contains a cavity which com- 
 municates inferiorly with the esophagus and stomach, and opens ex- 
 ternally on each side by means of the above-mentioned apertures, 
 precisely as is observed in fishes, more especially the shark tribe; 
 these apertures are separated from each other by lobular septa, of 
 exceedingly soft and delicate structure. Rathke observed the same 
 structure in the embryo of the pig, and other mammalia : and Baer 
 has since shown it distinctly in the human embryo. It is curious to 
 see how the vascular system corresponds to the grade of development 
 then present: the heart is single, consisting of one auricle and one 
 ventricle; the aorta gives off four delicate, but perfectly simple 
 branches, two of which go to the right, and two to the left side : each 
 of these little arteries passes to FlG 39 
 
 one of the lobules, or septa, at 
 the side of the neck, which cor- 
 respond to gills, and having again 
 united with three others, close to 
 what is the first rudiment of the 
 vertebral column, they form a 
 single trunk, which afterward be- 
 comes the abdominal aorta. In 
 a short time these slit-like open- 
 ings begin to close ; the branchial 
 processes or septa become ob- 
 literated, and indistinguishable 
 from the adjacent parts; the heart 
 looses the form of a single heart ; a crescentic fold begins to mark the 
 future division into two ventricles, and gradually extends until the 
 septum between them is completed. It is also continued along the 
 bulb of the aorta, dividing it into two trunks, the aorta proper, and 
 pulmonary artery : at the upper part the division is left incomplete, so 
 that there is an opening from one vessel to the other, which forms the 
 
 A. Branchial Processes. D. Allantois. 
 
 U. Vesicula Umbilicalis. E. Amnion. 
 
 C. Vitellus. From Baer.
 
 138 KING'S ECLECTIC OBSTETRICS. 
 
 duct us arteriosus.* A similar process takes place iu the auricles, the 
 foramen ovalc being apparently formed in the same manner as the 
 ductus arteriosus; these changes commence in the human embryo 
 about the fourth week, and are completed about the seventh. 
 
 "At first the body of the embryo has a more elongated form than 
 afterward, and the part which is first developed is the trunk, at the 
 upper extremity of which a small prominence, less thick than the 
 middle part, and separated from the rest of the body by an indenta- 
 tion, distinguishes the head. There are as yet no traces whatever 
 of extremities, or of any other prominent, parts; it is straight, or 
 nearly so, the posterior surface slightly convex, the anterior slightly 
 concave, and rests with its inferior extremity directly upon the mem- 
 branes, or by means of an extremely short umbilical cord. 
 
 " The head now increases considerably in proportion to the rest 
 of the body ; so much so, that at the beginning of the second month, 
 p G 40 it equals nearly half the size of the whole body : 
 
 previous to, and after this period, it is usually 
 smaller. The body of the embryo becomes con- 
 siderably curved, both at its upper as well as its 
 lower extremity, although the trunk itself still 
 continues straight. The head joins the body at a 
 right angle, so that the part of it which corres- 
 ponds to the chin is fixed directly upon the upper 
 DIAGRAM OF THE FE- P ar ^ ^ ^ ne breast; nor can any traces of neck 
 TUS AND MEM- be discerned, until nearly the end of the second 
 BRANES, ABOUT THE month. (Fig. 40.) 
 
 "The inferior extremity of the vertebral column, 
 
 A. Vesicula Umbilicalis, i_ i_ L .c 11 ^i T / j-i 
 
 already passing into wnicn at nrst resembles the rudiment of a tail, 
 the ventricular ami becomes shorter toward the middle of the third 
 
 rectum intestine at G. ,1 j , i /> i 
 
 B. Vena and arteria Om- montn , and takes a curvature forward under the 
 
 phaio-meseraica. rectum. In the fifth week the extremities become 
 
 C.Allantois springing from -Mil 
 
 the pelvis with the visible, the upper usually somewhat sooner than 
 
 D. Embryo* 8 ' Ane S ' the lower > in the form of sma11 blunt prominences 
 
 E, Amnion. the upper close under the head, the lower near the 
 
 -F rom ca. caudal extremity of the vertebral column. Both 
 are turned somewhat outward, on account of the size of the abdomen; 
 the upper are usually directed somewhat downward, the lower ones 
 somewhat upward. 
 
 In making these observations upon the formation of the ductus arteriosus, we must 
 request our readers to consider this as still an unsettled question.
 
 THE FETUS AND ITS DEVELOPMENT. 139 
 
 " The vesicula umbilicalis may still be distinguished in the second 
 month as a small vesicle, not larger than a pea, near the insertion 
 of the cord, at the navel, and external to the amnion. From the 
 trunk, which is almost entirely occupied by the abdominal cavity, 
 arises a short, thick umbilical cord, in which some of the -convolutions 
 of the intestines may still be traced. Beside these, it usually contains, 
 as already observed, the two umbilical arteries and the umbilical vein, 
 the urachus, the vasa omphalo-meseraica, or vein and artery of the 
 vesicula umbilicalis, and perhaps, even at this period, the duct of 
 communication between the intestinal canal and vesicula umbilicalis, 
 the fetal extremity of which, according to Professor Oken's views, 
 forms the processus vermiformis. 
 
 " The hands seem to be fixed to the shoulders without arms, and thb 
 
 FIG, 41. 
 
 DIAGRAM OF THE FETUS AND MEMBRANES, ABOUT THE SIXTH WEEK. 
 
 A. Chorion. G. Communicating Canal between the Vesicula 
 
 B. The larger Absorbent Extremities, the Site of Umbilicalis and Intestine. 
 
 the Placenta. H. Vena Umbilicalis. 
 
 C Allantois. II. Arterise Umbilicalis. 
 
 D Amnion. K. Arteries Omphalo-meseraica. 
 
 E. Urachus. L. Ven Omphalo-meseraica. 
 
 E. Bladder. N. Heart. 
 
 F. Vesicula Umbilicalis. O. Rudiment of Superior Extremity. 
 
 P. Rudiment of Lower Extremity. From Cants. 
 
 feet to adhere to the ossa ilii; the liver seems to fill the whole abdo- 
 men ; the ossa innominata, the ribs, and scapulae, are cartilaginous. 
 
 " In a short time, the little stump-like prominences of the ex- 
 tremities become longer, and are now divided into two parts, the
 
 140 KI.Mi's KCLKCTIC OBSTETRICS. 
 
 superior into the hand and the fore-arm, the inferior into the foot 
 and leg; in one or two \\vrks later, the arms and thighs are visible. 
 (/'///. 11.) These parts of the extremities, which are formed later 
 than the others, are at first smaller, but as they are gradually developed 
 they become- larger. When the limbs begin to separate into an upper 
 and lower part, their extremities become rounder and broader, and 
 divided into the fingers and toes, which at first are disproportionately 
 thick, and until the end of the third month are connected by a mem- 
 1 > numus substance analogous to the webbed feet of water-birds; this 
 membrane gradually disappears, beginning at the extremities of the 
 fingers and toes, and continuing the division up to their insertion. 
 The external parts of generation, the nose, ears, and mouth, appear 
 after the development of the extremities. The insertion of the umbili- 
 cal cord changes its situation to a certain degree; instead of being 
 nearly at the inferior extremity of the fetus, 'as at first, it is now 
 situated higher up, on the anterior surface of the abdomen. The 
 comparative distance between the umbilicus and pubis continues to 
 increase, not only to the full period of gestation, when it occupies the 
 middle point of the length of the child's body, as pointed out by 
 Chaussier, but even to the age of puberty, from the relative size 
 of the liver becoming smaller. 
 
 " Though the head appears large at first, and for a long time con- 
 tinues so, yet its contents are tardy in their development, and until 
 the sixth month the parietes of the skull are in a great measure mem- 
 branous or cartilaginous. Ossification commences in the base of the 
 cranium, and the bones under the scalp are those in which this process 
 is last completed. 
 
 " The contents of the skull are at first gelatinous, and no distinct 
 traces of the natural structure of the brain can be identified until the 
 close of the second month ; even then it requires to -have been some 
 time previously immersed in alcohol to harden its texture. There are 
 many parts of it not properly developed until the seventh month. In 
 the medulla spinalis no fibers can be distinguished until the fourth 
 month. The thalami nervorum opticorum, the corpora striata, and 
 tubercula quadrigemina, are seen in the second month ; in the third, 
 the lateral and longitudinal sinuses can be traced, and contain blood. 
 In the fifth we can distinguish the corpus callosum ; but the cerebral 
 mass has yet acquired very little solidity, for until the sixth month it 
 is almost serai-fluid. (Campbell's System of Midwifery.) 
 
 " About the end of the third, during the fourth, and the beginning 
 of the fifth months, the mother begins to be sensible of the move-
 
 THE FETUS AM) ITS' DEVELOPMENT. 141 
 
 Dients of the fetus. These motions are felt sooner or later, according 
 to the bulk of the child, the size and shape of the pelvis, and the 
 quantity of fluid contained in the amnion ; the waters being in larger 
 proportionate quantity the younger the fetus. 
 
 " The secretion of bile, like that of the fat, seems to begin toward 
 the middle of pregnancy, and tinges the meconium, a mucous secretion 
 of the intestinal tube, which had hitherto been colorless, of a yellow 
 color. Shortly after this the hair begins to grow, and the nails are 
 formed about the sixth or seventh month. A very delicate membrane 
 (membrana pupillaris), by which the pupil has been hitherto closed, 
 now ruptures, and the pupil becomes visible. The kidneys, which at 
 first were composed of numerous glandular lobules (seventeen or 
 eighteen in number), now unite, and form a separate viscus on each 
 side of the spine ; sometimes they unite into one large mass, an inter- 
 mediate portion extending across the spine, forming the horseshoe 
 kidney. 
 
 " Lastly, the testes, which at the first were placed on each side of 
 the lumbar vertebrae, near the origin of the spermatic vessels, now de- 
 scend along the iliac vessels toward the inguinal rings, directed by a 
 cellular cord, which Hunter has called Gubernaculum testis : they then 
 pass through the openings, carrying before them that portion of the 
 peritoneum which is to form their tunica vaginalis. 
 
 " The length of a full-grown fetus is generally about eighteen or 
 nineteen inches ; its weight between six and seven pounds. The dif- 
 ferent parts are well developed and rounded ; the body is generally 
 covered with the vernix caseosa ;* the nails are horny, and project be- 
 yond the tips of the fingers, which is not the case with the toes ; the 
 head has attained its proper size and hardness ; the ears have the firm- 
 ness of cartilage ; the scrotum is rugous, not peculiarly red, and 
 usually containing the testes. In female children, the nymphse are 
 generally covered entirely by the labia, the breasts project, and in both 
 sexes frequently contain a milky fluid. As soon as a child is born, 
 which has been carried the full time, it usually cries loudly, opens its 
 
 *The vernix caseosa is a viscid, fatty matter, of a yellowish-white color, adhering 
 to different parts of the child's body, and in some cases in such quantity as to cover 
 the whole surface ; it seems to be a substance intermediate between fibrine and fat, 
 having a considerable resemblance to spermaceti. From the known activity of the 
 sebaceous glands in the fetal state, and from the smegma being found in the greatest 
 quantity about the head, armpits, and groins, where these glands are most abundant, 
 there is every reason to consider it as the secretion of the sebaceous glands of the ffkin 
 during the latter months of pregnancy.
 
 14:2 KING'S KCLFCTIC OI-.STKTRICS. 
 
 eyes, and moves its arms and legs briskly; it soon passes urine and 
 fteoes, and greedily takes the nipple. (Xsegel&'s Hebammenbuch.') 
 
 "Tlm< then, in the space of forty weeks, or ten lunar months, from 
 an inappreciable point, the fetus attains a medium length of about 
 eighteen or nineteen inches, and a medium weight of between six and 
 
 .-rvril pounds." 
 
 CHAPTER XVI. 
 
 POSITION, NUTRITION, RESPIRATION, CIRCULATION, DIMENSIONS, 
 AND DEATH OF THE FETUS SUPERFETATION. 
 
 IT was formerly believed that the fetus in utero maintained a sitting- 
 position during the early months of pregnancy, and that as it pro- 
 gressed in its development, the superior weight of the head, effected a 
 revolution, so that at the latter period of pregnancy its position was 
 reversed, the head being downward ; but this is incorrect, the position 
 of the intra-uterine fetus remains unaltered from the commencement 
 to the termination of gestation, no matter what may have been its 
 primary or original position. Its usual position is with the head 
 downward, the most dependent part being the vertex; the head is 
 flexed forward so that the chin rests on the anterior superior portion 
 of the breast; the thighs are drawn up toward the abdomen, with the 
 knees apart from each other, and thrown upward so as to strongly flex 
 the legs on the posterior surface of the thighs; the heels approximate 
 at the posterior part of the thighs, the feet being usually crossed ; the 
 arms rest upon the sides of the thorax, Avhile the fore-arms are flexed 
 and crossed in front of the sternum ; the neck and back are bent for- 
 ward into a curve. In this position it constitutes an oval figure, whose 
 long diameter is about eleven inches, and forms a line nearly parallel 
 with the long diameter of the uterus; and we can not conceive of a 
 more easy and compact position for such an irregular and bulky body. 
 
 The cause of the dependent position of the head, which is by far 
 more common than any other, has given rise to much speculation; it 
 has been supposed to be the result of gravitation that the fetus being 
 suspended by the umbilical cord, its heaviest extremity, the cephalic, 
 would naturally fall downward. Again, it has been stated to depend 
 upon the instinctive will of the fetus itself, which assumes the position 
 as the most convenient for its intra-uterine existence, and as the most 
 advantageous for an easy expulsion. Various other reasons have been
 
 POSITION, NUTRITION, RESPIRATION, ETC., OF THE FETUS. 143 
 
 given, but none of them are satisfactory, and the subject remains in as 
 much obscurity as ever. 
 
 The principal functions of the fetus while in its intra-uterine con- 
 dition, are nutrition, respiration, and circulation, upon each of which 
 a brief notice will be bestowed. In relation to the first, nutrition, 
 many hypotheses have been advanced; it is at present supposed that 
 during the early embryonic life, nourishment is accomplished by super- 
 ficial imbibition, or probably by absorption through the villi of the 
 chorion, and that its sources are, at first, the vitellus, or the liquid in 
 the umbilical vesicle, and perhaps the albuminous matter existing be- 
 tween the amnion and chorion; the amniotic liquid, after its formation, 
 is also considered to contribute much toward this end, as it contains 
 several nutrient principles. It is probably absorbed by the cutaneous 
 surface, for acephalous fetuses, and those with the natural mucous 
 orifices closed, as well as those which have been born without a pla- 
 centa or umbilical cord, have been, with these exceptions, as well de- 
 veloped as the perfectly-formed fetus. It has also been stated that 
 this fluid is probably swallowed, or conveyed into the digestive tube, 
 from the fact that hair and portions of epithelium have been found 
 mixed with it in 'the stomach; and the meconium is supposed to be 
 the result of digestion. It has also been suggested by Dr. Montgom- 
 ery, that the milky liquid in the decidual cotyledons, may assist in the 
 nourishment of the fetus. The placenta has likewise been thought to 
 assist during the latter months of pregnancy, but this is rather de- 
 signed for hematosis than nutrition, and acts as a substitute for the 
 undeveloped lungs of the fetus, somewhat in the manner of the gills 
 of fishes, whose blood is aerated by the water passing through them. 
 It must be remembered that fetal nutrition has continued in instances 
 where the liquor amnii had been evacuated for weeks, which would 
 seem to indicate some other source of nutrition; beside, although 
 meconium, hair, etc., have been found in the digestive tube, still it 
 appears to me that the function of deglutition must be very difficult 
 to perform in cases where inspiration and expiration are absent, as 
 with the fetus. It will thus be seen that the subject of fetal nutrition 
 is involved in great obscurity. 
 
 By FETAL KESPIKATION, is meant, not the inhalation and 
 exhalation of atmospheric air, such as takes place after birth, but the 
 phenomenon by which the blood in the placenta is modified to suit it 
 for the purposes of fetal life. As with the function of nutrition, this
 
 141 KING'S ECLECTIC OBSTETRICS. 
 
 is also ;ui unsettled and incomprehensible subject. It is supposed, that 
 although the placenta may be the medium by which a vivifying prin- 
 ciple is taken from the maternal blood and conveyed to the fetal, yet 
 the materials which form in the latter and become unsuited to nutri- 
 tion, are not removed by the placenta alone, but principally by the 
 liver, which employs the superabundance of carbon and hydrogen to 
 fu nn bile, as well as to aid in perfecting its own development. Respi- 
 ration and nutrition appear to exist together, acting in harmony, with- 
 out disturbing each other, and both being probably performed through 
 a similar means, that of absorption. 
 
 In the FETAL CIRCULATION, there are several anatomical 
 peculiarities, not existing in the adult, which it may be proper to 
 notice: 1. There is a vein termed the ductus venosus, which is situated 
 at the thick edge of the liver, and communicates between the umbil- 
 ical vein and the vena cava ascendens or inferior vena cava; after 
 birth this vein contracts, closes on the seventh day, and becomes oblit- 
 erated. 2. In the center of the septum, between the auricles, is an 
 oval aperture, called the foramen ovule or foramen of Botal ; this is 
 furnished with a valve, which it is stated allows the blood from the 
 vena cava ascendeus to pass into the left auricle, without mingling 
 with the blood of the, vena cava descendens ; after birth, this closes, 
 rarely persisting beyond seven or eight days occasionally it remains 
 unclosed during life, giving rise to a morbid condition known as 
 morbus caruleus. 3. Soon after the origin of the pulmonary artery, a 
 branch is given off, which communicates between this artery and the 
 aorta, entering this latter just below its transverse arch ; it is called 
 the ductus arteriosus, and after birth gradually closes and becomes 
 obliterated. 4. The umbilical arteries and umbilical vein have been 
 already referred to. 
 
 The fetal circulation is entirely independent of that of the mother, 
 its blood resembles venous blood, being of a uniform dark color, and 
 becoming of a bright florid tint as soon as exposed to the atmosphere ; 
 it contains less fibrin than adult blood, but coagulates on standing ; no 
 difference can be perceived between the color of the fluid passing in 
 the umbilical arteries and that in the umbilical vein. Under the 
 microscope it presents corpuscles, resembling those seen in the blood of 
 an adult. 
 
 The course of the circulation is as follows : The blood is conveyed 
 from the ramifications of the umbilical vein in the placenta to this 
 vein; through which it passes, traversing its whole length, to the
 
 POSITION, NUTRITION, RESPIRATION, ETC., OF THE FETUS. 145 
 
 umbilicus; as soon as it has entered into the abdomen through the 
 umbilical ring, it proceeds to the longitudinal sinus, or fissure of the 
 liver, where a portion of it flows into the ductus venosus which con- 
 veys it immediately to the vena cava ascendens ; while the remainder 
 passes through the vena portse into the liver, circulates through it, and 
 flows into the hepatic veins where it is collected and also emptied into 
 the vena cava ascendens just as it is traversing the diaphragm. It is 
 from thence conducted, together with the blood conveyed through the 
 ductus venosus, to the right auricle of the fetal heart, where it is pre- 
 vented from mixing with the venous blood from the vena cava 
 descendens by the curtain-like eustachian valve, which conducts it 
 through the foramen ovale into the left auricle, and then into the left 
 ventricle, which throws it into the ascending aorta, through which it is 
 distributed to all parts of the body, but especially to the head and 
 superior extremities. The venous blood carried by the vena cava 
 descendens into the right auricle is at the same time directed by the 
 eustachian valve into the right ventricle. 
 
 The arterial blood having supplied the superior parts of the fetus, 
 it returns from these parts through the jugular and axillary veins, 
 passes into the subclavians, and then into the vena cava descendens, 
 through which it flows into the right auricle, then into the right ven- 
 tricle, and, together with that portion which passed into the right 
 ventricle without having entered into the foramen ovale, is thrown 
 into the pulmonary artery, from which a portion is conveyed to the 
 lungs, while the major part passes through the ductus arteriosus into 
 the descending aorta, where it mixes with the blood from the left 
 ventricle, not required for the head and superior extremities, and 
 flows along with it to the descending aorta. That portion which 
 entered the lung through the pulmonary artery returns by the pul- 
 monary veins to the left auricle, and thence to the left ventricle, and 
 into the descending aorta, where it mixes as just stated above. A 
 part of the blood in the descending aorta is distributed to the viscera 
 and inferior extremities, while the larger portion returns to the 
 placenta, through the umbilical arteries, there to be revivified, and be 
 again taken up by the umbilical vein to traverse the same route as 
 before. (Fig. 42.) 
 
 From this arrangement of the circulation it will be seen that the 
 blood with which the head and superior extremities are furnished, is 
 nearly fresh and pure from the placenta, while that flowing through 
 the inferior parts of the fetus, having previously circulated through 
 the system, must be less pure ; and this may, probably, be a reason why 
 10
 
 146 
 
 !:< I.KCTIC OBSTETRICS. 
 
 FIG. 42. 
 
 DAIQKAM OP THE FETAL CIRCULATION. 
 
 1. Umbilical Cord, consisting of the Umbili- 
 
 cal Vein, and two Umbilical Arteries. 
 
 2. Placenta. 
 
 3. Umbilical Vein dividing into three 
 
 branches. 
 4 4. Two branches of the vein to be distributed 
 
 to the Liver. 
 
 6. Ductus Venosus, or third branch of the 
 Umbilical Vein. 
 
 6. Inferior Vena Oava into which the Ductus 
 
 Venosus enters. 
 
 7. Portal Vein, which returns the blood from 
 
 thb Intestines, and unites with the 
 right Hepatic branch. 
 
 8. Right Auricle, through which the blood 
 
 passes to the left Auricle. 
 
 9. Left Auricle. 
 
 10 Left Ventricle, through which the blood 
 
 pastes to the arch of the Aorta. 
 11. Arch of the Aorta, from which the blood 
 is distributed, through its branches, to 
 the head and upper extremities. 
 13 18. The Arrows represent the return of the 
 blood from the head and superior ex- 
 tremities through the Jugular and Sub- 
 clavian Veins to 
 
 14. The Superior Veno Cava, to the right Au- 
 
 ricle, and in the course of the Arrow, 
 through 
 
 15. The Eight Ventricle to 
 
 16. The Pulmonary Artery. 
 
 17. The Ductus Arteriosus, a proper contin- 
 
 uation of the Pulmonary artery; the 
 commencement of the fight and left 
 Pulmonary Artery, are seen on each 
 side. 
 
 18 18. The descending Aorta, joined above by 
 the Ductus Arteriosus ; further down 
 it divides into the common Iliacs, 
 which become the Umbilical Arteries. 
 
 19. The Umbilical Arteries which return the blood along the cord to the Placenta, while the External 
 
 Iliacs are continued to the lower extremities. 
 
 20. The External Iliacs ; the Arrows making the return of the venous blood by the Veins to the In- 
 
 ferior Cava. (Neitt and Smith.) 
 
 the head and superior extremities are more rapidly developed than the 
 inferior portions of the fetus. 
 
 Previous to birth, the proper functions of the lungs are not 
 required, and they are small, dense, firm, and unaerated, being 
 nourished by small branches passing from the pulmonary artery; 
 but after birth, considerable change ensues, the lungs become more 
 or less inflated with atmospheric air, and pulmonary circulation is 
 established. The foramen ovale is closed by the valve perfected for 
 this purpose, which closure propels all the blood, entering the right 
 auricle, from the ascending and descending cava, immediately into the 
 right ventricle ; from thence it is propelled into the pulmonary ar-
 
 POSITION, NUTRITION, RESPIRATION, ETC., OF THE FETUS. 147 
 
 teries (which increase in diameter), and passes into the lungs, where, 
 from the action of the atmospheric oxygen, it is converted into arterial 
 blood. The ductus arteriosus being now useless, gradually contracts 
 and disappears. The blood from the inferior extremities, not being 
 able to pass through the umbilical arteries, flows through the vena 
 cava ascendens into the right auricle and ventricle of the heart, thence, 
 as above, into the lungs, and the circulation becomes changed from 
 that of the intra-uterine to that of the extra-uterine or adult. In ad- 
 dition, other changes also occur, the liver becomes more active, the 
 excretory functions of the kidneys and intestinal canal become estab- 
 lished, and proper digestion of the food received into the stomach 
 takes place. 
 
 The dimensions, appearances, and weight of the fetus at different pe- 
 riods of its mtra-uterine development, have been somewhat accurately 
 ascertained by various investigators; and as it is not only a matter of 
 mere curiosity, but frequently, one of great practical importance, in a 
 medico-legal sense, to determine the age of the expelled fetus, it is 
 necessary that the student should be informed on these points. The 
 following summary of statements of various observers are therefore 
 presented : 
 
 The first distinct microscopic view which can be had of the embryo 
 is about the third or fourth week; it is oblong, swollen in the middle, 
 bluntly pointed at one extremity, obtuse at the other, and is slightly 
 curved forward ; it is semi-opaque, of a gelatinous consistence, grayish- 
 white color, varying from two to five lines in length, and weighing 
 one or two grains. It is surrounded by the amnion, and has a vermi- 
 form or serpent-like appearance. Its head appears as a small tubercle, 
 separated from the body by a notch ; its mouth is indicated by a cleft ; 
 its rudimentary eyes by two black points ; its caudal extremity is 
 slender, and a white line may be observed in it, which indicates the 
 continuation of the medulla spinalis. The members present nipple- 
 like protuberances ; the liver occupies the whole abdomen, the cavity 
 of which is opened in front to a considerable extent ; the umbilical 
 vesicle is very large ; the chorion is villous, the villosities being dif- 
 fused over its whole surface. 
 
 At the sixth week (Fig. 41), its length is from nine to twelve lines ; 
 its weight from forty to seventy-five grains; and all its parts are 
 distinct. The head has greatly increased, and is separated from the 
 thorax by the depression of the neck ; the eyes still appear as two dark 
 epots; the mouth presents a small, triangular orifice; the face is
 
 148 KINii's KOI,ECTIC OKSTKTRICS. 
 
 distinct from the cranium ; the hands, fore-arms and fingers can be 
 recognized; the chiviclc and maxillary bone present a point of ossifi- 
 cation; the legs and feet are situated near the anus, which remains 
 closed ; the umbilicus, for the attachment of the cord, may be observed, 
 the cord consisting of the omphalo-mesenteric vessels, a portion of 
 the urachus, a part of the intestinal tube, and of filaments, which 
 represent the umbilical vessels; the formation of the placenta com- 
 mences ; the chorion and amnion are separated from each other ; and 
 the umbilical vesicle is very large. The divisions of the vertebra? can 
 be seen, also the imperfect interventricular septum of the heart, and 
 the lungs, which appear as five or six lobules, in which the bronchii 
 may be distinguished terminating in somewhat swollen culs-de-sac. 
 Extending from the lung to the bottom of the pelvis, along each side 
 of the vertebral column, may be seen two glandular structures ; these 
 are the Wolffian bodies, or false kidneys, and are constituted of an 
 excretory canal running through their whole length. Alongside of 
 this canal may be observed another, which becomes, according to the 
 gender of the new being, either the oviduct or the vas deferens. Both 
 of these canals empty below into the transitory pouch or cloaca. 
 
 In early embryonic life may be seen on each side of the neck four 
 transverse fissures; these open into the pharynx, are separated from 
 each other by fleshy bands, and are analogous to the bronchial arcs 
 of fishes. The aorta sends three or four branches to these fissures, 
 but which, together with the fissures soon become obliterated, but two 
 on the left side remaining, one of which becomes the arch of the 
 aorta, while the other forms the common trunk of the pulmonary 
 arteries ; the first branchial fissure of each side also remains, and is 
 converted into the external ear. The upper jaw is composed of a 
 pimple or piece on each side, which gradually approximate and form 
 a single body; the nostrils are each split down to the mouth, and are 
 separated by the incisive pimples, but approach each other, and assume 
 their proper form, as the pimples diminish in size ; and if the progress 
 of this development is arrested, hare-lip is the result. 
 
 At two months, the embryo is from one and a half to two inches in 
 length, and weighs from three drachms to nearly an ounce ; the head 
 forms about one-third of it, the eyes are prominent but not yet covered 
 by the lids, which are still rudimentary; the nose forms an obtuse 
 eminence, with rounded and separated nostrils; the mouth is gaping; 
 the elbows and fore-arms are detached from the trunk, and the fingers 
 are isolated, or adhere by a transparent gelatinous substance; the 
 rudimentary shoulder and hips are just observable; the penis or
 
 POSITION, NUTRITION, RESPIRATION, ETC., OF THE FETUS. 149 
 
 clitoris is apparent, but can not readily be distinguished from each 
 other, on account of the length of the latter. The anus forms a small 
 conical projection, but is imperforate, and its location is marked by a 
 dark spot; the rudiments of the lungs, spleen, and supra -renal* cap- 
 sules are observed ; the ccecum is placed behind the umbilicus ; the 
 digestive tube is withdrawn into the abdomen; the urachus is visible; 
 osseous points are apparent in the frontal bone and in the ribs; the 
 ehorion commences to come in contact with the amnion at the point 
 opposite the insertion of the placenta, which now begins to assume 
 its regular form ; the cord is inserted low down in the abdomen, is 
 infundibuliform in shape, and four or five lines in length, and the 
 umbilical vessels commences their spiral twisting; its base contains a 
 portion of intestine. The umbilical vesicle begins to disappear. The 
 epidermis is distinguishable. 
 
 At ten weeks, the embryo is from one and a half to two and a half 
 inches in length, and weighs an ounce, or an ounce and a half; the 
 eye-lids are apparent and cover the eyes, and the lachrymal puncta 
 are visible ; the hips commence to develop themselves, and the buccal 
 fissure begins its obliteration. The parietes of the thorax are seen, 
 and the motions of the heart are no longer visible; the fingers are 
 distinct, and the toes appear as tubercles united by some soft sub- 
 stance; the cord assumes the spiral appearance, is longer than the 
 embryo, is less infundibuliform, is not inserted so low down, and still 
 contains a portion of intestine. 
 
 At three months, the embryo is from two and a half to five or six 
 inches in length, and weighs from an ounce and a half to three or four 
 ounces ; the head is voluminous, but bears a better proportion to the 
 rest of the body ; the eyelids are very distinct, and are in contact by 
 their free margins; the pupillary membrane is visible; the nose pro- 
 jects ; the mouth is closed but perfectly delineated ; the thorax is 
 well formed; the fingers are completely separated, and the nails pre- 
 sent the appearance of thin membranous plates ; the inferior extremi- 
 ties are of greater length than the rudimentary tail ; the clitoris and 
 penis are very long, but the sex may frequently be discriminated by 
 a longitudinal fissure, the edges of which form the labia pudenda; 
 the thymus gland, as well as the supra-renal capsules are present; 
 the ccecum is placed below the umbilicus ; the cerebrum is five lines 
 in diameter, the cerebellum four, the medulla oblongata one and a 
 half, and the medulla spinalis three-fourths of a line; the two ven- 
 tricles of the heart are distinct; the decidua reflexa and vera come 
 in contact ; the cord contains a little of the gelatin of Wharton, and
 
 150 KIMi's K< LK'TIC OBSTETRICS. 
 
 umbilical vessels which twist and form long spiral turns; the placenta 
 becomes completely isolated, and the allantois, umbilical vesicle, and 
 omphalo-mesenteric vessels have disappeared. 
 
 \t four montlis, the embryo takes the name of Fetus. Its length is 
 from five to eight inches, and its weight from three to seven or eight 
 ounces. The skin is rosy, tolerably dense, and begins to be covered 
 with down ; and a sensible motion may be perceived in the muscles. 
 The fontanelles and sutures are very large, and sometimes whitish 
 hairs may be seen on the head; the face is elongated but imperfectly 
 developed ; the eyes, nostrils, and mouth are closed, and the tongue 
 and projection of the chin are observable ; the membrana pupillaris is 
 very evident ; the nails become more developed ; the sex may be re- 
 cognized ; the coecum is placed near the right kidney ; the gall-bladder 
 commences to appear ; meconium is found in the duodenum ; the 
 ccecal valve is visible; the umbilicus is placed near the pubis; the 
 ossicula auditoria are ossified ; the superior part of the sacrum presents 
 points of ossification ; the decidua serotina is formed ; and the chorion 
 and amnion are in close contact with each other. A fetus born at this 
 period might live for several hours. 
 
 At jive months, the length of the fetus is from seven to ten inches, 
 and its weight from seven to twelve ounces. The head is still large, 
 with appearances of hair ; white substance in the cerebellum ; the 
 nails are very distinct ; the skin is more consistent, frequently pre- 
 senting patches of sebaceous matter; the heart and kidneys are very 
 voluminous ; the ccecum is situated at the inferior part of the right 
 kidney; the gall-bladder is distinct; points of ossification are manifest 
 in the pubis and heel ; germs of permanent teeth appear ; the me- 
 coniurn has a yellowish-green tint, and occupies the commencement of 
 the large intestine ; the umbilical cord is longer. 
 
 At six months, the length of the fetus is from ten to twelve and a 
 half inches, and its weight from twelve ounces to a pound. The liver 
 is large and red, some fluid in gall-bladder. The hair is -longer and 
 thicker, white or silvery; the face of a purplish-red; the eyelids some- 
 what thicker but still in contact, the pupillary membrane also remains, 
 and the eyebrows are filled with delicate hairs. The skin is better 
 organized, presenting some appearance of fibrous structure, and 
 sebaceous covering; the nails are solid; sacculi begin to appear in the 
 colon ; the cord is inserted a little above the pubis; the scrotum is very 
 small, quite red, and empty, the testes being near the kidneys ; points 
 of ossification are developed in the divisions of the sternum. 
 
 At seven months, the fetus is from twelve and a half to fourteen
 
 POSITION, NUTRITION, RESPIRATION, ETC., OF THE FETUS. 151 
 
 inches in length, and weighs three or four pounds. All its parts are 
 more perfectly developed and better proportioned; the brain possesses 
 more consistency ; the skin is rosy, thick and fibrous, with sebaceous 
 covering; the eyelids are partly open; the pupillary membrane disap- 
 pears ; the iris commences as a simple ring, which increases in a con- 
 centric manner, ultimately leaving an opening called the pupil; the 
 nails have not yet reached the extremities of the fingers ; a point of 
 ossification is observed in the astragalus; the left lobe of the liver is 
 nearly as large as the right ; the gall-bladder contains bile ; nearly the 
 whole of the large intestine is filled with meconium ; valvulse con- 
 niventes begin to appear; the coecum is placed in the right iliac fossa; 
 the testicles leave the kidneys and approach the inguinal ring. 
 
 At eight months, the fetus is from fourteen to sixteen or eighteen 
 inches in length, and weighs four or five pounds. The skin is very 
 red, covered with long down, and a quantity of sebaceous matter, 
 called the vernix caseosa, or smegma, which is a secretion of the fetal 
 skin, and is found more abundantly on some fetuses than on others ; it 
 is a fat, slippery, viscous substance, of a yellowish-white color, is in- 
 soluble in water, alcohol or oil, and only partially soluble in potash, 
 and is apparently of service, during labor, by aiding to facilitate the 
 expulsion of the fetus. The pupillary membrane disappears; convo- 
 lutions appear in the brain; the inferior maxillary bone, which was at 
 first very short, is now as long as the superior ; the nails are much 
 firmer, and reach the extremities of the fingers ; a point of ossification 
 is observed in the last vertebra of the sacrum ; no center of ossifica- 
 tion is presented by the cartilage of the inferior extremity of the 
 femur ; the testicles descend into the internal ring, and one is usually 
 contained in the scrotum; generally that on the left side; the hair of 
 the head is much darker and longer. 
 
 At full term, the fetus is from sixteen to twenty-three inches in 
 length, and weighs from five to seven, ten, and sometimes even twelve 
 pounds, the average weight being about six and a half pounds. The 
 head is covered with a greater or less quantity of hair, varying in 
 length from six to twelve lines; the white and gray substances of the 
 brain become distinct; convolutions well marked; tlie pupillary mem- 
 brane no longer exists ; four portions of the occipital bone remain 
 distinct; the external meatus auditorius still remains cartilaginous; 
 the os hyoides is not yet ossified ; the skin is deep red, and covered 
 with sebaceous matter, especially at the flexures of the joints ; the 
 liver descends to the umbilicus ; the testes have passed the inguinal 
 ring, and are frequently found in the scrotum ; meconium is found at
 
 152 KING'S ECLECTIC OBSTETRICS. 
 
 the termination of the large intestine; the center of the cartilage at 
 the lower extremity of the femur, exhibits a point of ossification. 
 
 A full developed fetus is characterized by a ready movement of the 
 limbs, an ability to cry, and a capability of sucking; its mouth, eye- 
 lids, nostrils, and ears are open ; the hair, eyebrows and nails are fully 
 ilrvrloped; the cranial bones are firm, and the edges of the fontanelles 
 are not far apart, the body is of a clear red color; and the meconium 
 is discharged within a few hours after birth. The meconium is a semi- 
 fluid, of a dark green color at term, which is found in the fetal intes- 
 tines, and is a mixture of bile with the secretions of the mucous 
 membrane ; some suppose it to be digested amniotic fluid. 
 
 An immature fetus may be known by its feeble motions, its small 
 size, and incapability of sucking ; its head is covered with down or 
 sparingly with short hair ; the bones are soft ; the fontanelles widely 
 separated ; the skin is red with blue streaks ; the nails are not per- 
 fected; the eyelids and mouth are closed; and the urination and defe- 
 cation are imperfect. 
 
 As will be stated under Abortion, the fetus is liable to numerous 
 diseases, some of which may be independent of the condition of the 
 mother, while others occur secondarily through her. Cases of inter- 
 mittent fever have occurred to the fetus where the mother was laboring 
 under the disease; small-pox has attacked the fetus both where the 
 mother was suffering with it, and in other instances where she was en- 
 tirely exempt from it, and the same may be said of measles. Various 
 cutaneous diseases have also attacked the fetus in utero, as well as hy- 
 drocephalus, pleurisy, abscesses of the lungs, oedema, scirrhous indu- 
 ration, tubercles, lobular pneumonia, calcareous deposition in the 
 lungs, peritonitis, and enteritis. It is also especially liable to hyper- 
 trophy or atrophy, worms, calculus, dropsy, rickets, caries, and necro- 
 sis. Various forms of syphilitic disease are very apt to injure or 
 destroy it, when the system of one or both parents is contaminated 
 with the syphilitic virus. The heart, liver, kidneys, stomach, and 
 other organs may become organically affected, and it is by no means 
 uncommon to observe fractures and dislocations of various bones, 
 which took place previous to birth. Previous to the expulsion of the 
 fetus, it is impossible to detect any of these maladies, and even had 
 we the means of doing so, it is very doubtful whether any curative or 
 even palliative measures could be beneficially pursued; the greater 
 part of them may be ascertained after its death and expulsion, and all 
 the advantage to be derived from such information, at this time, is to
 
 POSITION, NUTRITION, RESPIRATION, ETC., OF THE FETUS. 153 
 
 lead to the adoption of such measures as may prevent similar attacks 
 in subsequent pregnancies. 
 
 The signs by which we may determine the death of the fetus, are fre- 
 quently of great importance, especially in reference to the best time 
 for obstetric operations, when these have to be performed. There are 
 no signs upon which, separately, the accoucheur can positively deter- 
 mine a dead fetus ; indeed its diagnosis is extremely difficult, and must 
 be decided by the aggregate of symptoms present. These are named 
 by Dr. Churchill, in his work on Obstetrics, as follows : 
 
 1. The cessation of the fetal movements; but these may be suspended 
 for several days, and yet the fetus be alive. 2. The subsidence or 
 flaccidity of the abdomen; this varies much during pregnancy, less 
 tension being present in women who have had several children. 3. 
 The recession of the umbilicus ; but a dead fetus may remain in utero 
 for months without this sign. 4. The loose feel of the uterine tumor. 
 5. A rolling of the tumor in the abdomen, and a sensation of dead weight 
 and coldness; these may exist and yet the fetus be alive, the rolling 
 may proceed from a loss of tone of the abdominal muscles women 
 who give birth to a living child, frequently complain of the uterine 
 tumor feeling as a weight or foreign body ; again, there is no appre- 
 ciable difference between the temperature of a living fetus and that of 
 a dead one the coldness is a mere sensation that may be experienced 
 independent of fetal death. 6. The breasts* suddenly become flaccid, 
 and their secretions suppressed ; this rarely occurs from any cause save 
 the death of the fetus. 7. The health of the female becomes deteriorated; 
 but a dead fetus has frequently been retained for weeks or months 
 without any change. in the maternal health, beside the health may be 
 impaired from other causes. 8. Bad appetite, sunken countenance, 
 a dark areola around the eyes; feted breath, repeated rigors; these are 
 all minor signs, and may exist independent of pregnancy, or when oc- 
 curring during its presence may be owing to causes not connected with 
 the condition of the fetus ; yet taken in connection with other signs 
 they may become useful in aiding the diagnosis. 
 
 When the motions of the fetus have been very active up to the 
 fifth, sixth or seventh month, or longer, and suddenly subside, and at 
 the same time the breasts which had been firm and tense, become 
 flaccid and decrease in size, while the abdomen loses its previous tense 
 and rounded form, the uterine tumor becoming weighty and rolling 
 loosely in the lower belly, we have almost a positive proof of the death 
 of the fetus, which is rendered still more certain by the absence of the 
 beating of the fetal heart. But, although much assistance may be
 
 154 KING'S KCLKCTIC OBSTETRICS. 
 
 derived from the use of the stethoscope, yet it frequently proves un- 
 certain, either from want of tact and experience on the part of the 
 aiiM-ultator, or because the position of the fetus may be unfavorable to 
 the transmission of sound to his ear, or the pulsations may be tem- 
 porarily suspended. If, however, the pulsations have been distinctly 
 heard on a previous occasion, and subsequently become suddenly or 
 gradually inaudible, the evidence in favor of the death of the fetus, in 
 connection with the other symptoms, is rendered unequivocal. 
 
 After the rupture of the membranes, there are other diagnostic 
 symptoms of a more determinate character. 1. The liquor amnii be- 
 comes dark, thicker than usual, fetid, and bloody, especially where the 
 fetus has been dead for some time; but it must be remembered that 
 these conditions have been present with the living fetus. 2. When 
 the death is not recent, having occurred some time previous to the 
 examination, the scalp will feel emphysematous when the finger is 
 pressed upon it, crepitating under the touch, and a portion of the 
 cuticle will peel off; where the death is recent, the bones of the skull 
 will overlap each other loosely, and the edges of the bones will convey 
 a sensation of peculiar sharpness. These, together with the absence 
 of pulsation at the anterior fontanelle, and its decrease from the col- 
 lapse of the bones, are considered conclusive signs. 
 
 In face presentations, the flabby lips, flaccid and motionless tongue, 
 and a slight swelling of the presenting part, are evidence of the child's 
 death. In breech presentations, the finger can be readily introduced 
 within the sphincter ani in case of death, which contracts and resists 
 the finger, if the fetus be alive ; the discharge of meconium is a symp- 
 tom of no value. In an arm presentation, the pulse at the wrist may 
 be imperceptible, the arm may become cold and livid, and yet the 
 fetus be alive; but if the epidermis peel off, the child is dead. In 
 prolapse of the umbilical cord, the absence of pulsation in it is usually 
 regarded as conclusive evidence of the child's death; but this has 
 occurred and the child been born alive. 
 
 Before closing this chapter, I will make a few remarks on super- 
 fetation, which subject has not been noticed in the preceding pages. 
 By superfetation is meant, a second impregnation and conception, 
 where the female is already pregnant. The early writers were 
 impressed with the belief, that such an occurrence was possible, 
 while among recent authors we find a difference of opinion. The 
 reasons which have been advanced in its favor, are: 1. Females, at 
 full term of pregnancy, sometimes give birth to a well-developed
 
 POSITION, NUTRITION, RESPIRATION, ETC., OF THE FETUS. 155 
 
 fetus, and a blighted ovum at the same time; or, where the children 
 are living, one of them will be more matured than the other. The 
 disparity between them has aiforded ground for belief that they were 
 the products of different impregnations; but these cases do not prove 
 superf'etation, as it not unfrequently occurs that the development of 
 one of the twins is retarded, or it may die and be expelled while the 
 other is retained; and it is by no means uncommon for one twin to be 
 larger and more matured than its fellow. 
 
 2. Cases have been recorded where the female has brought forth, at 
 one parturition, two children, one of which was white, and the other 
 black, or mulatto. But these cases have, so far as I know, been the 
 result of two coitions, shortly succeeding each other, one with a white 
 and the other with a black person. There is abundant evidence to 
 prove that superfetation of this kind is possible at a very early period 
 of pregnancy; impregnation having taken place before the canal of 
 the cervix became closed by decidual membrane, or by the tough, 
 gelatinous secretion of the glandule Nabothi. But after the forma- 
 tion of these substances, which effectually prevents any egress into the 
 uterus, I do not believe that conception can occur, unless, indeed, 
 there be some other route through which the semen can reach the im- 
 pregnated ovum, independent of the uterine cavity, and Fallopian 
 tubes. 
 
 3. Instances have been related where from three to four months 
 after the delivery of a well-developed child, another child, fully ma- 
 tured, has been born. In some of these cases, the difficulty has been 
 removed by the discovery of a double uterus. But where these cir- 
 cumstances have happened with but a single uterus present, if such in 
 reality has ever occurred, the subject is involved in much obscurity. 
 It may be that the development of one fetus progressed much more 
 slowly than that of the other ; and that when this latter was born, the 
 uterine contractions not having destroyed the integrity of the mem- 
 branes of the former, nor destroyed its utero-placental attachment, it 
 continued to remain in utero, until its maturity again determined 
 uterine action. It has also been supposed in cases of single uterus, 
 that this organ may have been divided by a longitudinal septum, and 
 thus impregnation could be effected in each at different periods ; but 
 this is as difficult to my mind as in the previous instance, unless it -be 
 admitted in each, thai immaturity of the fetus favors protracted ges- 
 tation, and that the contractions of the uterus to expel a full grown 
 fetus, do not, necessarily, involve the immediate expulsion of another 
 in utero, but imperfectly developed.
 
 156 KING'S ECLECTIC OBSTETRICS. 
 
 CHAPTER XVII. 
 
 CHANGES IN THE CONDITION OF THE UTERUS DURING PREGNANCY. 
 
 FROM the moment of conception, the uterus gradually undergoes a 
 series of changes, in volume, form, situation, and direction, a knowl- 
 edge of all of which is highly important to the accoucheur. These 
 changes occur both in the neck, and in the body, each of which I will 
 review individually. 
 
 CHANGES IN THE NECK OF THE UTERUS. As gestation 
 proceeds, the congestion and ramollissement of the substance of the cer- 
 vix gradually advances, until finally the whole neck becomes softened. 
 
 Toward the end of the first month, the lower or inferior portion of 
 the cervix commences to undergo this change, which is principally con- 
 fined to the mucous covering of the part, imparting to the finger a 
 fungous softness, but through which deeper pressure will detect the 
 firm consistency of the proper tissue. The softening always com- 
 mences below and advances upward, gradually progressing, so that 
 at the end of the third month, or commencement of the fourth, this 
 modification extends into the substance of the lips, softening them 
 through their whole thickness to the extent of a line and a half, and 
 increasing as gestation progresses, until at the sixth month it embraces 
 one-half of the vaginal projection of the neck. It continues to ad- 
 vance gradually upward during the last three months, until finally 
 the whole cervix, together with the ring of the internal orifice becomes 
 so softened, that at "term" it has occasioned, in the practice of the 
 inexperienced physician, much difficulty in discriminating it from the 
 vaginal walls. It may be proper for me to remark that, in five or six 
 cases, I have encountered a cushiony, spongy sensation of the inferior 
 portion of the uterine cervix, the patients not being pregnant, but 
 laboring under abnormal conditions of the uterus. 
 
 This ramollissement of the neck is an important indication of preg- 
 nancy, being present at an early period, and is found in all females 
 in whom the neck is in a normal condition ; it likewise renders 
 material assistance in determining the stage of pregnancy. But in 
 the investigation of this last point, it must always be recollected that 
 in females who have given birth to a number of children, the vaginal 
 .projection of the neck loses a considerable portion of its length, and
 
 CHANGES IN THE UTERUS DURING PREGNANCY. 157 
 
 consequently, if one half of this projection has been lost, the softening 
 will not commence in the lower extremity of the remaining portion, 
 until the period at which it would have ensued, were the neck of its 
 original extent, or at a period proportioned to the amount of length 
 which has been lost. Thus, in a woman who has 'given birth to eight 
 or ten children, the neck will vary very much in the extent of its 
 softening at the sixth month, when compared with that of a female 
 at the same stage of gestation, who has borne only two or three 
 children. In primiparse, or women with their first child, this soft- 
 ening progresses more slowly than in multiparse, or women who have 
 previously had children. 
 
 Beside the softening of the neck, it undergoes other modifications. 
 During the early months of pregnancy it becomes thicker, with an 
 increase of its volume, more especially at its superior portion; it is 
 also found at a lower point within the vagina, inclined a little to the 
 left, with the os tincse looking more toward the pubis, and, as a larger 
 extent of it can now be felt and examined by the finger, it has given 
 rise to an erroneous impression that its length was likewise increased. 
 At the fifth month the cervix looks more toward the sacrum, and still 
 a little to the left, becomes more elevated and is difficult to reach; 
 this elevation of the neck gradually increases as pregnancy advances, 
 rendering it more and more difficult to reach, and which has, probably, 
 led to the mistaken views of several authors, that the cervix became 
 gradually shortened from the fifth month until "term," at which 
 period it was completely effaced. The fact is, however, that there is 
 no shortening of the neck until the ramollissement has occupied its 
 whole extent, rendering it yielding and incapable of resistance, which 
 generally commences in the last fortnight of pregnancy, and during 
 the last few days, both in primiparse and multipart, and then in 
 consequence of uterine action at the time of labor (pressure of the 
 bag of waters and of the fetal head) it dilates, shortens, and disappears, 
 forming, for the time being, a part of the uterine sphere. As the 
 neck ascends, looking backward and to the left, the fundus is nearly 
 always carried forward and to the right. 
 
 Perhaps, it would be proper to remark, that in primiparse, toward 
 the seventh month, there exists a slight diminution of the length 
 of the cervix, but which does not materially affect the correctness 
 of the above statement ; this shortening is occasioned by the spindle 
 shape assumed by the cervix at this period, or a bulging of its 
 central part, which necessarily causes a slight approximation of the
 
 158 
 
 KINO'S ECLECTIC OBSTETRICS. 
 
 external and internal orifices of the neck. This does not happen in 
 multipart. 
 
 The form of the cervix is different in primiparse and multipart, 
 during gestation. Among the former it will be found more pointed 
 and contracted at its inferior extremity, and enlarged at its superior, 
 and the os tincse changes from a hardly perceptible transverse fissure, 
 to one of a circular form, though it is seldom, if ever, opened, until 
 dilatation occurs during labor. About the seventh month, the walls 
 of the neck having become softened, they readily yield to the pressure 
 of the secretions from their internal surface, and as the os tincse 
 remains closed, the central portion of the canal of the cervix is pressed 
 outward, which gives to the whole neck a fusiform appearance. The 
 external surface remains smooth and polished, and the os tineas 
 regular and rounded, without any roughness or inequalities ; the 
 circumference is sometimes soft, and occasionally, during the latter 
 FIG. 43. FIG. 44. FIG. 45. 
 
 These Figures show the softening and opening of the cervix uteri, as pregnancy advances ; also, how 
 the finger ultimately gets into direct contact with the naked membranes. 
 
 months, presents a sharp and thin border. Among multipart, the 
 form of the cervix is quite different, somewhat resembling a thimble, 
 with its small extremity upward, its orifice instead of being closed is 
 opened sufficiently to admit the extremity of the finger, and its 
 periphery is very irregular on account of numerous cicatrizations and 
 fissures, the results of previous lacerations. As the softening advances 
 upward, the opening of the os tinea? and inferior portion of the cavity 
 of the neck simultaneously continues to increase, so that each month 
 the finger may penetrate deeper into this thimble-shaped, and some- 
 times funnel-shaped cavity. Toward the ninth month, the second 
 phalanx of the finger can be introduced within this opening, its free 
 extremity being arrested by the closed and puckered ring at the internal 
 orifice, which finally softens and dilates, allowing the finger to pass 
 through the cavity of the neck, and to come in direct contact with the 
 membranes. At this period the canal through which the finger passes,
 
 CHANGES IN THE UTEEDS DURING PEEGNANCY. 159 
 
 instead of being shortened, will be found to vary from one inch, to an 
 inch and a half in length. (Figs. 43, 44, 45.) 
 
 The softening and spreading out of the neck is said to be greatly 
 accelerated by frequent touchings or examinations .during pregnancy, 
 and occasionally the internal orifice opens at too early a period, even 
 in the seventh month, especially among those women who are subject 
 to floodings. 
 
 It is sometimes the case, that the presenting part of the fetus, in 
 engaging in the excavation, presses the anterior inferior portion of the 
 uterus before it, which, in a large pelvis, may even descend to the in- 
 ferior floor, occasioning much embarrassment to the inexperienced 
 practitioner, who not being able to ascertain the situation of the os 
 tincoe, might erroneously suppose it to be imperforate. It will be 
 readily seen that, as the portion of the uterus mentioned is pushed 
 downward, the neck will be carried behind it, with the os tincse look- 
 ing toward the anterior face of the sacrum, and much difficulty may 
 be experienced in gaining access to it; but when once reached, the 
 finger must be bent like a hook and introduced into its cavity from 
 behind directly forward, pulling the neck by its anterior lip down to- 
 ward its normal location at the center of the cavity, while at the same 
 time, efforts may be made with the other hand on the abdomen, or by 
 means of an assistant, to elevate or push the body of the uterus up- 
 ward and backward. While the womb remains in this mal-position, 
 it will be impossible for delivery to be accomplished until the above 
 change in its direction is effected; and when effected, if the female 
 has been long in labor, with evident symptoms of dangerous exhaust- 
 ion, the os uteri soft and dilated or dilatable, and the head at the 
 superior strait, my own experience is in favor of at once terminating 
 the labor by turning and delivering by the feet, at the same time 
 administering sufficient stimuli to sustain the sinking powers of the 
 system. This is the course I have adopted in three instances of simi- 
 lar character, and in each of which success crowned my efforts, with 
 the exception of one child being still-born. 
 
 PHYSICAL CHANGES IN THE BODY OF THE UTERUS, 
 etc. In the non-gravid state, the uterus may be said to be in an in- 
 active or dormant condition, from which it is suddenly aroused by 
 conception, and becomes more susceptible, with increased temperature 
 and swelling, from the greater sanguineous determination toward it. 
 The volume of the uterine walls increases in every direction, and the 
 uterine cavity enlarges, which enlargement is maintained by the new
 
 160 KING'S ECLECTIC OBSTETRICS. 
 
 formation called the caducous membrane, and which is present long- 
 before the impregnated ovum reaches the uterine cavity. As soon as 
 the ovule has reached the uterus, the increase of volume or develop- 
 ment of the embryo, continues and progresses until the moment of 
 parturition, being more rapid in the latter than in the early months. 
 
 The shape of the uterus is not materially changed during the first 
 month of pregnancy, but subsequently, as its volume augments, from 
 being flattened from before backward, it gradually grows rounder, 
 assumes the shape of a pear, or gourd, then spheroidal, until toward 
 the termination of gestation, it becomes of an ovoid form, slightly 
 flattened in its antero-.posterior diameter, with its anterior face more 
 convex, and its posterior somewhat concave, to adapt itself to the pro- 
 jection of the lumbar vertebrse. 
 
 - The situation of the uterus must necessarily vary in proportion to 
 its increasing size and shape; thus, we find that during the first three 
 months of pregnancy it is lower in the vagina, or pelvic cavity, with 
 the os tincse a little inclined to the left, and thrown forward to the 
 pubis; but after this period it gradually rises from the excavation into 
 the abdominal cavity, pushing the opposing contents of this cavity 
 before it. From a knowledge of the various points at which the 
 fundus is located, we may, by palpation, be enabled to determine the 
 period of gestation; thus, at the fourth month, it will be found two or 
 three fingers' breadth above the pubis ; at the fifth month, it will be 
 found within one finger's breadth of the umbilicus; the hypogastrium 
 projects and is rounded, the vagina is elongated and narrowed, and 
 the motions of the- fetus are felt; the cervix is more elevated, is turned 
 upwardly, and is more difficult to reach; from the fifth to the sixth 
 month, the fundus passes the umbilicus, and, at the sixth month, is 
 found half an inch above this depression, which now begins to project 
 beyond the integuments ; the vagina still farther elongated and nar- 
 rowed, with only a few projecting wrinkles at its lower portion ; the 
 cervix will be found nearly on a level with the superior strait, softer 
 and larger than previously ; ballottement is now readily effected ; at 
 the seventh month the fundus will be found three fingers' breadth above 
 the umbilicus, with increased abdominal and umbilical projection, and 
 often pain in the groins, from distension of the muscles of the ab- 
 domen ; the neck is still farther softened, more voluminous, and more 
 difficult to distinguish ; at the eighth month the fundus extends into 
 the epigastric region, the abdomen is farther distended, and the skin 
 frequently cracks and presents livid marks or lines ; the ramollisse- 
 ment, or softening of the cervix is still farther advanced; during the
 
 CHANGES IN THE UTERUS DURING PREGNANCY. 161 
 
 ninth month, the fundus still continues to ascend, but in the last fort- 
 night of gestation, there is an evident depression of the abdominal 
 projection, the fundus is on a lower level than before; the respiration 
 becomes more free, the woman more lively, and expresses herself as 
 feeling lighter; the cervix is entirely softened. This sensation of 
 sinking of the womb, is, probably owing to descent of the fetus, the 
 head of which can usually, at this period, be readily felt, presenting a 
 voluminous tumor within the pelvic excavation. 
 
 Although the above is the average of a number of observations, yet 
 they are not invariable ; as, in many females, the shape and capacity 
 of the pelvis and abdomen, and the resistance of the abdominal pari- 
 etes, will affect, more or less, the rapidity and extension of these 
 changes. 
 
 The direction of the uterus is altered by the changes which take 
 place in the organ during pregnancy ; while it remains within the ex- 
 cavation where it is supported by the pelvic bones, it holds its vertical 
 direction, but as it passes upward into the cavity of the abdomen, 
 where the soft parts alone sustain it, it inclines forward, following the 
 direction of the axis of the superior strait, and which may be owing 
 to the unyielding resistance of the lumbar prominence, and the yield- 
 ing of the anterior abdominal wall ; from the same cause it is made to 
 lean toward one side of the abdomen, most commonly the right, form- 
 ing the right lateral obliquity of the uterus. The reason of the greater 
 frequency of this right obliquity, is, according to Mad. Boivin, that 
 the round ligament of the right side is shorter, stronger, and more 
 abundantly supplied with muscular fibers than the left ; and as they 
 draw the uterus toward the right, they necessarily cause this organ to 
 rotate on its axis, carrying its anterior surface somewhat to the right 
 side, and its posterior to the left ; both of which changes are import- 
 ant to be understood. 
 
 The thickness 'of the uterine parietes has given rise to much contra- 
 dictory speculation ; some writers concluding, that in consequence of 
 the great distension of the uterus, its walls become very much attenu- 
 ated, while others consider that they become very much thicker during 
 pregnancy ; but the fact is, that at the period of parturition, if an ex- 
 amination of the uterine parietes be made, they will be found to vary 
 according to the portion examined, the neck being very thin, and the 
 body and fundus of the same thickness as when in the non-gravid 
 condition, with the exception of the part corresponding to the inser- 
 tion of the placenta, which is thicker than at any other place. As 
 there is, then, no diminution of the uterine walls during gestation,
 
 162 KING'S ECLECTIC OBSTETRICS. 
 
 there must necessarily be a great augmentation of their bulk, which ia 
 ascri taiiH-d to -be the case, as at term, the uterus has been found to 
 weigh two pounds ; and in one instance, cited by M. Moreau, it reached 
 nearly four pounds. In a few rare instances, the parietes of this or- 
 gan have been found to be only a few lines in thickness. 
 
 The density of the uterine parietes likewise changes during gestation. 
 In the non-gravid condition they are hard, resisting, and of a consist- 
 ency approximating fibrous tissue, but in pregnancy they become 
 softer and relaxed, which condition is present even at the first month, 
 the walls, having a softness which gives a sensation on pressure, simi- 
 lar to that of an oedematous limb, or of caoutchouc softened by boiling 
 in water, and which is of some value in determining pregnancy. As 
 the parturient period approaches, this ramollissement and yielding 
 character of the walls continue to increase, so that the inequalities-of 
 the fetus may be felt through them, and its motions may not only be 
 distinctly perceived, but will often produce a momentary projection of 
 some part of the organ, and even of the abdominal parietes. In con- 
 sequence of this suppleness of the uterine fibers, the fetus can change 
 its position within the cavity of the organ during gestation, and thus 
 cause its diameters to vary according to the position assumed, shorten- 
 ing its normal long diameter, and lengthening its short ones. The 
 fetus is also protected from the evil results of blows upon the abdo- 
 men, or severe shocks received by the mother, which would ensue 
 were the walls more dense and unyielding. 
 
 VITAL CHANGES IN THE UTERINE TISSUES. The most 
 remarkable changes of the uterus, during pregnancy, are those effected 
 in its texture, especially that of its proper tissue, or middle coat. This 
 tissue, which, as I have heretofore remarked, is of a grayish color, 
 dense, and composed in the non-gravid womb of minute spindle-shaped 
 fiber-cells, with elongated oval nuclei, and which on account of the 
 great quantity of nucleated embryonic connective tissue, can be isolated 
 only with great difficulty ; during pregnancy these muscular fiber cells 
 become enlarged, their length being increased from seven to eleven 
 times, and their width from two to five times, while at the same time 
 new ones are formed. The uterus, in pregnancy, changes, therefore, 
 from a state of density to one of 'softness and elasticity, extending its 
 substance, enlarging, gradually assuming a reddish hue, having its 
 fibers gradually unfolded, elongated, and presenting unequivocal evi- 
 dence of its muscular nature. 
 
 Although the muscular character of the middle uterine coat has
 
 CHANGES IN THE UTERUS DURING PREGNANCY. 163 
 
 been determined, yet the arrangement of its fibers is still involved in 
 uncertainty. Mad. Boivin, who has minutely examined the uterine 
 structure, has probably given us the most correct account of the dis- 
 position of some of these fibers ; still, there is much left to ascertain 
 on this point. She states, that there is an exterior plane of fibers, 
 running or radiating from the middle line, outward and downward, to 
 the lower third of the womb; upon this part they terminate, and aid 
 in forming the round ligaments located there, while the most superior 
 ones are distributed to the Fallopian tubes and the ovarian ligaments. 
 There is also an internal plane of fibers, the arrangement of which 
 varies considerably from the external, in being circular, and located at 
 the uterine superior angle; having the internal orifice of the tubes as 
 their center, they surround each of them, describing concentric cir- 
 cles, being very small and close toward the focus, but gradually sepa- 
 ting as they advance from this point, so that the last and largest are 
 found upon the median line, and extend in the direction of its length. 
 Other muscular fibers are found between these two planes, but they 
 can not be traced. At the inferior part of the organ is a semicircular 
 order of fibers, which commence at the median line of this region, 
 and reunite on the sides near the round ligaments. 
 
 "This structure of the uterus resembles that of all hollow organs, 
 having longitudinal fibers externally, and circular and horizontal ones 
 internally. The greatest development of muscular structure is found 
 in the fundus, which is part of the organ more especially concerned 
 in the expulsion of its contents, and this structure is so disposed that, 
 during contraction, the uterine surface approaches toward the center. 
 The least resistance, during labor, should be made at the inferior part 
 of the uterus, in which we find merely the horizontal fibers, form- 
 ing an arrangement which will bear some comparison to a sphincter 
 muscle." 
 
 Other anatomists have attempted to trace the uterine muscular fibers, 
 and have separated them into layers, planes, and fasciculi; yet, not- 
 withstanding all these attempts, there is so much irregularity and con- 
 fusion in the course and arrangement of these fibers, so many cross- 
 ings and intercrossings, and such an interweaving of them, that it is 
 impossible to demonstrate them satisfactorily ; we have presented to 
 us only an inextricable muscular network, rendering the uterus fully 
 capable of performing all its various movements of extension, con- 
 traction, dilatation, and shortening. M. Moreau observe^that "a skill- 
 ful dissector may give the fibers any direction he chooses, without the 
 possibility of proving the contrary." Farre observes, " Nothing like
 
 1(54 KING'S ECLECTIC OBSTETRICS. 
 
 a continuous arrangement of muscular fibers in the form of circular or 
 longitudinal bands, surrounding or investing the organ can anywhere 
 be demonstrated by the aid of the microscope." 
 
 That the longitudinal and horizontal fibers are separate and inde- 
 pendent parts of the uterine structure, and probably all the other 
 fibrous arrangements, may be inferred from the fact, that we often 
 have one set of them powerfully acting, while, at the same time, the 
 other is contracting with but slight force, or even not at all. Thus, 
 in the hour-glass contraction, we have an example of forcible con- 
 traction, and a want of it at the two antipodal extremities. Again, 
 not unfrequently there appears to be a want of action o,f those fibers 
 which contract the organ in its longitudinal diameter, elongating the 
 uterus to such an extent, that, as ascertained by an examination through 
 the relaxed abdominal walls, after delivery, its length will be ten or 
 eleven inches, with the fundus elevated toward the epigastrium, w r hile 
 its transverse diameter will be only three or four inches, resembling 
 an intestine, rather than the womb. 
 
 A female during labor, as is often the case, may suffer intense pains, 
 and make the most vigorous efforts, without any advance, whatever, 
 of the child, although the pelvic formation is normal, and the uterus 
 sufficiently dilated ; may this not be owing to a want of simultaneous 
 action of the two separate sets of fibers, the horizontal being active, 
 while the longitudinal are slightly so, or altogether inert? This want 
 of synchronism in the movements of the fibers, may be owing to irri- 
 tation occasioned by protracted or severe labor, by rheumatism, by the 
 administration of ergot, or by officious intermeddlings, and which may 
 also result from extreme susceptibility of the nervous system. Gel- 
 semium will be the remedy if the irritation has developed spasmodic 
 action ; or Lobelia, by relaxation, may overcome the irregular action 
 in the two sets of muscular fibers. If the condition depends upon 
 rheumatism, think of Macrotys. In either case, to relieve this painful 
 condition, the internal use of Opium, Morphia, or Diaphoretic pow- 
 der, may be given as often as the urgency of the symptoms indicate; 
 the room must be freely ventilated, the drinks should be cool, and no 
 examinations per vaginam must be instituted until the contractions 
 become normal, and not then, without they are actually necessary. 
 Occasionally, under these circumstances, and where there have been 
 no previous violent contractions, in addition to the above treatment, 
 I have found firm, but moderate, pressure over the fundus to restore 
 the energy of the inactive fibers. 
 
 The serous, or external peritoneal coat of the uterus, during preg- 
 nancy, extends in. every direction, with a more active nutrition that
 
 CHANGES IX THE UTERUS DURING PREGNANCY. 165 
 
 prevents any diminution of its depth, there being but little difference 
 in the thickness of this external covering, either in the gravid or non- 
 gravid womb. The serous covering is movable on the tissue which 
 unites it to the middle or muscular coat, this tissue being apparently 
 diminished in density. 
 
 The internal, or mucous coat of the uterus, about which there have 
 been so many discordant opinions, becomes very evident during preg- 
 nancy ; it is softer, more lax, and redder, is more distinctly denned 
 from the muscular coat, its vessels become more distended ; and be- 
 coming hypertrophied, it presents an increased and villous appear- 
 ance, and from its great development its nutrition undoubtedly be- 
 comes more active. Its follicles become more marked, with an increase 
 of their secretion. There are also glands found imbedded in the 
 thickness of this coat, which appear to enter into the internal mus- 
 cular layers; these enlarge after conception, and are viewed by some 
 authors as the principal elements of the caducous or nidal membrane. 
 These glands resemble small canals, and run tortuously within and 
 behind the mucous uterine coat, forming a kind of knot, throwing out 
 ramifications, and opening on the internal face of the inner mucous 
 layer : they have been called the utricular glands. 
 
 The blood-vessels of the uterus likewise undergo changes which may 
 be briefly noticed. In the unimpregnated condition the arteries are 
 small, flexuous, and very much contracted, but during gestation, as 
 they become less compressed by the uterine fibers, they expand, soften, 
 and describe more regular curves ; their caliber increases, the blood 
 circulates more largely and rapidly, and a more active and energetic 
 nutrition ensues. The arteries of the uterus, as heretofore stated, are 
 furnished by the spermatics and hypogastrics, the superior portion of 
 the uterus receiving chiefly the branches from the spermatics, and the 
 body and cervix those only from the hypogastrics. The arteries are 
 always tortuous, and when they arrive at the uterus, they do not run 
 any distance under the peritoneum, but immediately enter into the 
 muscular coat, pass toward the inner surface, and especially to the part 
 where the placenta is attached, ramifying and anastomosing freely as 
 they proceed; those branches which reach the lining membrane ter- 
 minate in the tortuous canals in the placental decidua, while those 
 which do not arrive at the inner surface ramify upon the coats of the 
 veins. The veins of the uterus are greatly dilated, much more so 
 than the arteries, and their points of communication with each other 
 are multiplied to that degree, that at the parturient term, an inextrica- 
 ble mass of venous vessels is presented, giving to the uterine tissue a 
 resemblance to that of the erectile. That part of the uterus to which
 
 KINC'S i;ru:<Tir OIISTKTUICS. 
 
 the placenta is attached IB more abundantly supplied with veins; and 
 on removing the placenta, the veins which open into the uterine cavity 
 will be seen, presenting large, smooth-edged and oblique apertures. 
 There are no proper valves to the veins, so that if any fluid be injected 
 into the trunks of the spermatic and hypogastric veins, it will flow in 
 a full stream into the cavity of the uterus, which may afford some ex- 
 planation of the cause of the large quantity of blood discharged in so 
 short a time from the uterus during parturition, together with that 
 from the exposed arteries. The venous circulation in the uterus and 
 placenta may be readily interrupted by the various derangements of 
 function in the thoracic and abdominal viscera, and the removal of 
 these obstructions during pregnancy is an important point. 
 
 The lymphatic vessels, or absorbents, likewise, become greatly en- 
 larged during pregnancy: according to Cruikshank, the first who 
 observed them, they are as large as a goosequill, and are so numerous, 
 that when injected with mercury, they give to the uterus the appear- 
 ance of a mass of lymphatic vessels. Those of the neck run into the 
 pelvic ganglia, and those of the body into the lumbar ganglia. Cruik- 
 shank supposed their function to be that of carrying on a " copious 
 absorption in the uterus toward the mother," during pregnancy; but 
 Dr. Eobert Lee has suggested another very probable function ; he ob- 
 serves, "The sudden removal of the uterine structures after delivery 
 by absorption, is probably the most important 'office they perform, and 
 the cause of their enlargement to such a vast size during the latter 
 months of pregnancy." 
 
 The nerves of the uterus likewise become considerably developed 
 during gestation, for the undoubted purpose of furnishing the uterus, 
 during the parturient act, with all the nervous energy that may be 
 necessary. After delivery, the nerves, together with all the augmented 
 tissues and vessels of the uterus, return to their original size and 
 condition. 
 
 CHANGES IN THE PROPERTIES OF THE UTERUS. In 
 
 the unimpregnated condition, the vital properties of the uterus are 
 very obscure, so that it may be touched, compressed, pricked, or even 
 cauterized without causing pain or much uneasiness, unless it be mor- 
 bidly affected; at this time its properties are chiefly limited to its tonic 
 forces, or organic sensibility and insensible contractility, the separa- 
 tion of the principles of growth and nutrition from the circulating 
 fluids, and the elimination of de-vitalized or decomposed elements 
 which are no longer necessary to the maintenance of life.
 
 CHANGES IN THE UTERUS DURING PREGNANCY. 167 
 
 It is true, that when the finger is brought into contact with the 
 neck, the female is conscious of the touch ; however, the sensation goes 
 no farther ; but during pregnancy the animal sensibility becomes much 
 more marked, and the female more readily recognizes the contact of 
 bodies with the neck, as well as the fetal movements, and which sensi- 
 bility becomes more developed as gestation advances, so that in its 
 latter stages even the touch becomes excessively painful with many 
 women, and during parturition the uterine contractions produce intense 
 agony. The introduction of the hand within the uterus, for the pur- 
 pose of turning, effects similar pain, and when the adhering placenta 
 is removed artifically, the woman experiences sensations as if she were 
 being eviscerated. This exaltation of animal sensibility is principally 
 confined to the neck, the body of the organ being nearly insensible ; there 
 exists, however, a relation between these two parts, from which irrita- 
 tion of the neck will influence the fibers of the body. And this 
 relation will account for the premature births effected by repeated 
 touchings, frequent coition, the irritations of the cervix from artificial 
 dilatation, or the use of agents which stimulate the cerebro-spinal sys- 
 tem. It occasionally happens, that the female will be unconscious of 
 any movements of the fetus until the latter months of gestation, or 
 even not until labor actually commences, owing to the slight develop- 
 ment of sensibility, but in the majority of cases it is the very reverse 
 of this. 
 
 The most remarkable property, however, which the uterus manifests 
 during pregnancy is its organic contractility, which either did not pre- 
 viously exist, or if it did, it remained latent. This property, precisely 
 resembles the contraction of a muscle, and is never manifested except 
 under some irritating or stimulating influence ; it varies in intensity 
 in different females, and is so marked and energetic in many instances 
 as to benumb the hand of the strongest man, when introduced to per- 
 form artificial delivery. It is this contractile power which effects the 
 expulsion of the fetus and its secundines, as well as other productions 
 which may be accidentally developed within the uterine cavity, and 
 which, likewise, causes the womb, as well as its various vessels, to 
 gradually return to the diminished condition in which they were pre 
 vious to conception. Should the organic contractility of the uterus, 
 from any cause, fail to manifest itself after parturition, a hemorrhage 
 would ensue that would prove rapidly fatal to the parturient woman ; 
 and, when such cases occur in practice, the most important indication 
 is to arouse this power of contraction, which is the natural remedy, 
 and which produces its beneficial results by closing and obliterating
 
 168 KING'S ECLECTIC OHSTETRICS. 
 
 the large open mouths of the blood-vessels on the internal placental 
 surface of the organ. 
 
 In the human family the presence of these contractions is always 
 accompanied with more or less pain, which is never found among ani- 
 mals in a state of nature, and which exists among savages and domes- 
 ticated animals in only a minor degree. Accident or disease may, 
 however, be the cause of pain with these last when in labor; and we 
 have good reasons for believing that the excessive pains undergone by 
 parturient females of our own race, are the results of the enervating 
 influence of civilization and its various customs, habits, and refine- 
 ments upon the constitution. In 1842, I was called upon to attend 
 Mrs. D , about twenty years of age, a short, thick-set female, bru- 
 nette, and in apparent good health, with her first child; there had 
 been observed a discharge of the waters, " the show," together with 
 some singular and indescribable feelings, but no pain. From these 
 symptoms, together with the calculations made upon the matter, it was 
 presumed that labor could not be far distant ; and it was, likewise, 
 deemed expedient by the mother that the advice of a physician should 
 be resorted to. Having ascertained that no pains of any kind had 
 been experienced, I thought myself unwarranted in making any ex- 
 amination, but did so at the urgent request of the mother, when to my 
 great astonishment I found the head within the pelvic cavity, and upon 
 placing my hand upon the abdomen, I felt very distinctly the con- 
 tractions of the uterus as they occurred, but the patient complained of 
 no pain whatever. I now seated myself by the bedside to watch the 
 progress of labor, as well as to be ready for any emergency in so sin- 
 gular a case, and the whole process of parturition was effected without 
 any untoward accident, and without the least pain, if the asseverations 
 of the female are to be believed; during the latter stage she evidently 
 contracted the abdominal muscles and made bearing down efforts, not, 
 she stated, from any painful influences, but from a strong sensation or 
 desire to make them. Shortly previous to my visiting the West, I 
 again attended this lady in her second labor, when she suffered as se- 
 vere pains as I remember to have ever witnessed in the parturient 
 chamber. The cause of this anomaly I do not pretend to understand. 
 The female, as a rule, suffers more severely with the pains in her first 
 labor, than in subsequent ones; however, there is no law governing 
 this matter so far as individuals are concerned : each accouchment of 
 the same woman is peculiar unto itself. In prognosing the probable 
 outcome of a labor, the practitioner should not be influenced by for-
 
 CHANGES IN THE UTERUS DURING PREGNANCY. 169 
 
 mer experiences with the same person. As in the case cited, the con- 
 dition of the woman may be so favorable, that delivery will be accom- 
 plished and she -scarcely experience any uneasiness whatever, and but 
 very slightly the pains peculiar to labor, while her next lying-in may 
 be characterized by the most severe pains, and suffering so intense as 
 to demand relief by the administration of remedies, in some cases ne- 
 cessitating the effect of an anaesthetic. 
 
 The exercise of these organic contractions ensues involuntarily and 
 without any dependence on the will, yet we sometimes find them in- 
 fluenced by mental impressions, so much so, that a violent emotion 
 may arouse them at a premature period, and it is not an uncommon 
 circumstance for the appearance of the accoucheur in the room of the 
 lying-in woman to cause a suspension of them for several hours, or 
 even days. They may likewise be suspended for some hours by the 
 administration of opiates, as well as excited by stimulants, or irritation 
 applied to the neck, or, ergot, strychnia, electricity, borax, and many 
 other agents internally administered. If the uterus is excessively 
 distended if the labor has been too rapid, or prolonged the con- 
 tractions are very apt to diminish become more slow and feeble, or 
 entirely cease. I have met with instances, in which the contractions 
 have been suspended for several hours, in consequence of an intoxi- 
 cating draught of hot gin or brandy sling having been given by the 
 nurse, to "ease the pains and give the woman strength." 
 
 These changes in the condition of the uterus, necessarily effect some 
 modifications of the neighboring parts. In the early period of preg- 
 nancy, as the uterus enlarges in the cavity, the vagina becomes short-i 
 ened, but as soon as the former rises above the superior strait, the 
 latter becomes narrower and longer; in its elevation the uterus carries 
 its surrounding peritoneum along with it, the folds of which, or the 
 broad ligaments, disappear, and the tubes and ovaries approach nearer 
 to the uterus, where they rest, nearly in a perpendicular position; the 
 round ligaments present short linear fibers, among which are prolonga- 
 tions of the muscular fibers of the uterus, and which contract with 
 that organ. 
 
 From the increased vitality of the re-productive organs, as well as 
 from the obstruction of circulation by the enlarged uterus, the veins 
 of the vaginal walls become more developed, with various appearances, 
 which are often recognized, toward the termination of gestation, by the 
 finger. The vaginal pulse, of Osiander, which he estimated highly as 
 a diagnostic sign of pregnancy, may be felt, at some portion of the
 
 170 KING'S ECLECTIC OBSTETRICS. 
 
 vagina, and is owing to the excessive enlargement of the vaginal and 
 uterine arteries. About the seventh or eighth month, the vaginal 
 mucous membrane is frequently covered with granulations the size of 
 a pin's head, which not only line the whole extent of this canal, but 
 also the exterior surface of the neck, and even the interior. When 
 these are present, there is an increased vaginal secretion. 
 
 One of the important changes to be understood by the practitioner, 
 is that undergone by the bladder. This organ is gradually pressed 
 above the superior strait, the urethra] canal is elongated, and its orifice 
 will be found behind the edge of the pubic symphysis, so that in intro- 
 ducing a catheter it must be directed nearly if not quite parallel with 
 the pubic bone, with its concavity in front, and, in some instances, the 
 curve of the canal becomes so great, from the bladder being pressed 
 forward and above the pubis, that a male catheter will be introduced 
 with more facility. This compression on the upper part of the canal, 
 impedes the circulation in the lower parts, from which results tume- 
 faction of its whole length. Tenesmus of the bladder is often the 
 consequence of compression on the body and neck of this organ, occa- 
 sioning frequent, urgent, and ineffectual efforts to urinate. In not a 
 few instances the catheter will have to be used to relieve the irritated 
 and distended bladder.
 
 OF PREGNANCY. 171 
 
 CHAPTER XVIII. 
 
 OF PREGNANCY. 
 
 WHEN the fecundated ovum becomes attached to some portun of 
 the uterus, conception is said to have taken place, and the peculiar 
 condition of the woman, from the moment of conception to the period 
 of parturition, is called pregnancy or utero-gestation ; this usually com- 
 prises nine calendar months, or two hundred and eighty days from the 
 last menstrual show, or one hundred and forty days after quickening 
 the time at which most females perceive the first motions of the fetus, 
 and which generally occurs about the twentieth week after conception. 
 Although this is the period which seems to have been generally 
 recognized from the earliest ages, yet it is not invariable, as it occa- 
 sionally terminates sooner, and again, may extend to even ten months, 
 of which there are well attested cases on record. The determination 
 of this subject is one of great difficulty, as we can seldom ascertain the 
 precise moment of fecundation, and yet it is one of immense import- 
 ance, from the fact that the legitimacy of the oifspring may depend 
 upon a correct decision. 
 
 The only method by which we can ascertain the commencement of 
 utero-gestation, is by reference to the period of the last menstrual 
 flow, as well as to the time of quickening; but even these means are 
 very uncertain, as conception may occur sometime during the inter- 
 menstrual period; beside which, the period of quickening varies in 
 different women. On account of these difficulties, laws have been 
 established in several nations, fixing the term within which legitimacy 
 is acknowledged by them; thus, in France, the "Code Napoleon," 
 admits the legitimacy of a child born within three hundred days after 
 wedlock, divorce, or death of the husband; and if born after that 
 time, its legitimacy may be contested, though it is not to be viewed 
 as a bastard. In Prussia, three weeks beyond the usual time are 
 allowed, or three hundred and one days. In Scotland, ten calendar
 
 172 KIND'S KCLECTIC OBSTETRICS. 
 
 months are considered the extent of legitimacy. In England and in 
 this country, the limit of gestation is not determined by law. 
 
 That the term of utero-gestation varies in many females is, I 
 believe, generally admitted by observing accoucheurs of the present 
 day, and the existence of the laws on this subject, in the countries 
 above referred to, are strong confirmations of the possibility of pro- 
 tracted gestation. Indeed, I have met with several instances in which 
 I had every reason for believing that the pregnancy had been pro- 
 longed to two and three weeks beyond the usual period ; and two, in 
 particular, in which I positively know that gestation was continued 
 for ten months. Drs. Blundell, Desormeaux, Hunter, Montgomery, 
 Rigby, Hamilton, Burns, Dewees, Velpeau, Merriman, Moreau, Simp- 
 son, Meigs, Atlee, and many others, have met with similar instance:?, 
 in which the term of gestation had extended from one to four weeks 
 beyond nine calendar months. Their reported cases, taken in con- 
 nection with investigations made on animals, as rabbits, sheep, cows, 
 mares, etc., that likewise are found to vary considerably in their 
 periods of gestation, certainly aiford the strongest evidence in favor 
 of prolonged pregnancy. Eelative to this subject, Dr. Montgomery 
 justly observes : " We can not imagine why gestation should be the 
 only process connected with reproduction, for which a total exemption 
 from any variation in its period should be claimed. The periods of 
 menstruation are, in general, very regular ; but who is there who does 
 not know, that as there are, on the one hand, women in whom the 
 return of that discharge is anticipated by several days, so there are 
 also many in whom the return is postponed an equal length of time, 
 without the slightest appreciable derangement of the health. Again, 
 menstruation and the power of reproduction in the female, very gen- 
 erally, indeed almost universally, ceases about the forty-fifth year, in 
 these countries ; yet occasionally instances are met with, in which both 
 are prolonged ten or fifteen years beyond that time of life ; and a 
 similar variety is observable, in the period of the first establishment of 
 that function in the system. If we turn our attention to brutes, the con- 
 ditions of whose gestation so closely coincide with those of the human 
 female, and are less disposed to have it disturbed, we can not Tor a 
 moment doubt the fact, that there is a great irregularity in the term 
 of gestation in different individuals of the same species." 
 
 Dr. Charles Clay, of England, has advanced the view that the term of 
 utero-gestation is regulated by the ages of the individuals concerned in 
 the act; that the younger these individuals the shorter the term, and, as
 
 OF PREGNANCY. 
 
 173 
 
 age advances, the period of gestation is proportionately lengthened. 
 From what he has been enabled to glean, the term of gestation has 
 occurred as follows : 
 
 
 .... 264 days 
 
 
 274 davi 
 
 15 " " 
 
 .... 267 " 
 
 " 30 " " 
 
 276 " 
 
 " 15 to 15J " " 
 
 ..... 267 " 
 
 " 35 " 
 
 278 " 
 
 " 15 to 17 " " 
 
 .... 270 " 
 
 " 44 " " 
 
 84 " 
 
 '( 19 
 
 .... 272 " 
 
 52 " " 
 
 290 " 
 
 
 
 
 
 But, he observes, the age must be calculated not by that of the 
 mother alone, but by the combined ages of both parents. Thus, if 
 the female be twenty, and the male thirty, a result must be expected 
 equal to an age of twenty-five, or, taking into consideration the earlier 
 maturity of the female, of twenty-four. If, however, the female be 
 thirty, and the male twenty, then the result would equal an age of 
 twenty-six. For the extension of inquiry on this subject, he remarks: 
 " It will be desirable in all cases to be recorded, whether in favor 
 or against the propositions here laid down, to secure the following 
 data : 1st. Date of conception arising from a single contact. 2d. Date 
 of parturition commencing. 3d. Age of the mother. 4th. Age of 
 the father. 5th. In statements of age, where the female is the 
 younger, it must be fixed at the year below the mean ages of the 
 two combined. 6th. Where the female is the older, the age must 
 be fixed a year above the mean of the two combined; by this rule 
 the average age on the [above] table will give the days of gestation 
 more correctly than by any other known rule." (The Complete Hand- 
 book of Obstetrics, Surgery, etc., by Charles Clay, M. D.) This hy- 
 pothesis of Dr. Clay's does really appear to be supported by the data 
 he advances, and is certainly deserving more thorough investigation. 
 
 I will give here a table which will be found useful for determining 
 the period at which menstruation, quickening, parturition, etc., may 
 probably occur. This table is so arranged that the dates on the 
 same line in the several columns are consecutively twenty-eight days 
 or one lunar month distant from each other. Thus, if a female 
 menstruates on the 7th January, her next period will occur twenty- 
 eight days subsequently, on the 4th February, the next on the 4th 
 March, then 1st April, and so on. 
 
 Pregnancy is usually dated from the last menstruation, on account 
 of the difficulty of determining the precise period of a fruitful coitus j
 
 174 
 
 KING'S ECLECTIC OBSTETRICS. 
 
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 OF PBEGNANCY. 175 
 
 two hundred and eighty days after the last menstruation is the usual 
 period allowed for full term of pregnancy ; or two hundred and 
 seventy-five days from a fruitful coitus when this is known. Hence, 
 five days may be allowed in the calculation with the accompanying 
 table; thus, if a pregnant female had her last menstruation on 29th 
 July of any year, her period of confinement will occur at about two 
 hundred and eighty days, or ten lunar months subsequently, which, 
 upon counting, we find will be on the 8th April of the ensuing year; 
 or by allowing five days, we may expect her labor to come on between 
 the 8th and 13th of April. 
 
 Quickening is generally supposed to be first experienced at about 
 the one hundred and fortieth day of pregnancy ; hence, if a female 
 perceives quickening for the first time on llth August, by count- 
 ing along in the table for the balance of the period of pregnancy, that 
 is, one hundred and forty days, or five lunar months, we find that 
 labor will probably occur upon or about the ensuing 29th December. 
 I say, probably, because there is less certainty in this, as quickening 
 may be perceived at a much earlier period, or, at a more advanced 
 stage of the pregnancy. 
 
 .After December, the present year in question terminates, so that, 
 upon finding on what day in January, in the last or fourteenth column, 
 the counting along on the same line terminates, and it is necessary to 
 count on still farther, we must return to the same date of January in 
 the first column, as we left in the last or fourteenth column, and then 
 count along on the corresponding line as far as may be required. 
 Thus, if we desire to count nine lunar months from 1 8th October, we 
 find that three lunar months brings us to 10th January of the next 
 year in the last or fourteenth column we now find the 10th January 
 in the first column, and by counting along for the balance of the time, 
 six lunar months, it brings us to the 27th June of the subsequent year. 
 
 In leap year one day may be deducted from the ascertained period, 
 after having passed the month of February of the leap year ; thus, two 
 hundred and eighty days from 19th November would be 26th August 
 of the ensuing year but, if this be a leap year, it will be 25th August ; 
 again, two hundred and eighty days from 13th August would be 
 20th May of the next year, or, if le.ap year, 19th May. 
 
 By reference to the figures at the bottom of each column, counting 
 from the first column, we can always determine how many lunar 
 months or columns must be included within any number of days, and 
 vice versa. Thus, six lunar months or columns are equal to one 
 hundred and sixty-eight days then one hundred and sixty-eight days
 
 176 KING'S ECLECTIC- OBSTETRICS. 
 
 from the 18th July would be six columns or lunar months, carrying 
 us to 2nd January of the next year. The reader may find various 
 other uses for this table. 
 
 Another point to determine, is the earliest period at which a child 
 may be born, consistent with its existence subsequently. This is like- 
 wise a subject of much moment, involving the reputation of a mother, 
 the legitimacy of oifspring, and the peace and happiness of families, 
 especially in those instances where the fetal developments exceed those 
 which are generally found at the various periods of pregnancy. I 
 remember an incident which occurred some years since, and which 
 I will relate here, to show the importance of prudence. I was called 
 to attend a lady who had aborted three months after her marriage: 
 the fetus presented all the appearances of one between the fourth and 
 fifth months, and on seeing it, I innocently remarked, " it is a good- 
 sized one." This imprudent remark occasioned much unhappiness in 
 the minds of the husband, the mother of the lady, and herself; and 
 they each inquired of me, in private, if I supposed there "was any- 
 thing wrong?" having reference to the wife's chastity. I had long 
 known each of the parties, before their marriage, and had no reasons 
 whatever for the most distant idea of want of purity and virtue, and 
 it was from this consciousness of undoubted integrity of character 
 that the observation was inadvertently made and I so replied to their 
 inquiries. About eighteen or nineteen months afterward, I delivered 
 this lady of a male child, at full term, which having been weighed on 
 the day of its birth, was found to exceed twelve pounds. Here was 
 an extraordinary development of size at full term, and a similar excess 
 of growth was undoubtedly the case with the previously aborted fetus. 
 
 The seventh month is generally viewed as the shortest period in 
 which a viable child may be born, yet there are many instances in 
 which it has occurred still earlier. These cases, do not however 
 militate against the general view regarding viability, and should be 
 considered exceptional, exerting no influence as to the justifiability of 
 inducing premature labor at the seventh month, in the hope of pre- 
 serving the life of the child. Dr. Dewees states, that he has known 
 instances of this kind : one " in which labor habitually occurred at the 
 seventh month, and two, in which it regularly took place at the eighth 
 month of pregnancy." In Scotland, a child born six months after 
 marriage, or after the death of the father, is considered legitimate. 
 Carpenter, in his Physiology, mentions an instance in which a child, 
 born twenty-five weeks after wedlock, lived between six and seven
 
 OF PEEGNANCY. 177 
 
 months, and was declared to be legitimate by the Presbytery of Scot- 
 land. Dr. Dodd and Dr. Christian relate similar cases, as well as 
 many other physicians. Dr. "W. Hunter observes, that " a child may 
 be born alive, at any time after three months ; but we see none with 
 powers of living to manhood, or of being reared, before seven calen- 
 der months, or near that time. At six months it can not be." Beside 
 the many recorded cases where children, born previous to the seventh 
 month, lived for an hour to several days or weeks thereafter, it may be 
 interesting to refer to the following : M. Capuron mentions the case 
 of Fortunio Liceti, who, born after a gestation of four months and a 
 half, lived subsequently for eighty years. M. Devergie relates the case 
 of Cardinal Richelieu, who was born at the fifth month. Dr. Hamilton 
 cites a case where a child born only nineteen weeks after conception 
 lived eighteen months. Dr. Lavirotte, in Lyon Me'dical, April, 1873, 
 observes that viability does not solely depend upon the intra-uterine 
 age of a fetus, but likewise upon its volume, its weight, its muscular 
 force, the more or less advanced organization of its skin and nails, and 
 especially upon respiration, digestion, nutrition, and normal condition 
 of the heart and large blood-vessels. The fact that a child, born at 
 the seventh month of gestation, may subsequently continue to live, is 
 of importance in another point, viz.: the induction of premature labor. 
 Upon these various deviations from the most common course of 
 pregnancy, it is not my intention to offer any speculative views, as the 
 present work is intended to be, not one of theorizing, but of utility in 
 a practical point, to those who consult its pages ; I will, therefore, 
 leave this subject, by observing, that an opinion in these cases should 
 always be given very guardedly and reservedly, lest by a hasty and 
 improper decision we tarnish the reputation, and consequent happiness 
 of the innocent. 
 
 It sometimes happens that the ovum, after impregnation does not 
 reach the cavity of the uterus, but becomes attached to the interior 
 walls of the Fallopian tubes, abdomen, etc., in consequence of which, 
 from want of a proper and natural connection with the mother, the 
 development of the ovum is much retarded, is seldom perfected and 
 disease often attacks it; under these circumstances, a well-formed 
 living fetus could not be produced. I am aware, that some writers ob- 
 ject to these facts as being without foundation ; but the objections are 
 commonly presented by those who support the theory that the male 
 semen never extends beyond the uterine cavity, within which, alone*, 
 
 fecundation occurs. As before stated, the spermatic fluid has been 
 12
 
 178 KINc's FCLKCTIC Ol'.STKTRICS. 
 
 found in the tubes, and on the ovaries of various animals by rigid in- 
 vestigators; beside, the fact that fetal formations, without the uterus, 
 do occasionally exist, is, in connection with the above, an evidence 
 tending, to say the least of it, to support a belief of the possibility, as 
 well as the probability, of fecundation occurring beyond the uterine 
 cavity. 
 
 When the impregnated ovum reaches the uterus, and is developed 
 within its cavity, it is termed a normal or uterine pregnancy, which is 
 divided into simple uterine pregnancy, when there is but one fetus ; com- 
 pound or multiple pregnancy, when there are more than one ; and mixed, 
 complex, or complicated pregnancy, when, with the existence of the 
 fetus, there is also, a mole, hydatids, or some morbid condition of the 
 uterus, or its appendages. When, instead of passing into the uterus, 
 the vivified ovulum becomes fixed upon the tubes, abdomen, etc., it is 
 called extra-uterine pregnancy, of which there are several varieties, ac- 
 cording to the place of adhesion of the ovum, and which I wilt refer 
 to in the ensuing chapter. To those pathological conditions which 
 simulate pregnancy, often misleading both the patient and her physi- 
 cians, and which occur independently of true conception, the term 
 false pregnancy has been improperly applied. 
 
 CHAPTEK XIX. 
 
 COMPOUND AND MIXED PREGNANCY. 
 
 COMPOUND or multiple pregnancy, are the terms applied to those 
 pregnancies in which more than one fetus exists within the uterus at 
 the same time. The cause of this peculiar disposition which some 
 women have to compound pregnancies, is a matter of mere conjecture, 
 and but little is known relative to it which is either satisfactory or 
 worthy of confidence. It has been attributed to the impregnation of 
 two or more Graafian vesicles during a fruitful embrace, and which may 
 happen either in one or both ovaries; again, and with some degree of 
 probability, it is stated that one vesicle may contain two or more ovules, 
 each of which becomes fecundated upon the rupture of the vesicle 
 during copulation. By some physiologists it has been supposed that 
 this anomaly is not the result of one act of impregnation but of two 
 or more, and this is undoubtedly true in many instances, as examples
 
 COMPOUND AND MIXED PREGNANCY. 179 
 
 are 011 record of females having given birth to twins, one being white 
 and the other colored, the result of intercourse successively with a 
 white man and a negro. And previous to the secretion of the mucus 
 which fills the canal of the cervix during gestation, or to the appear- 
 ance of the membrana decidua, superfetation may be possible. 
 
 Cases of a marvelous and probably fabulous character, are recorded 
 where women have given birth to five, six, or even nine children at 
 one birth, but it is rarely the case that more than two are present 
 during pregnancy. In the course of a practice of thirty-one years, I 
 have met with but three cases of triplets, and one in which a woman 
 had four children at one birth, all closely resembling each other; 
 while of twins or couplets I have met with quite a number, averaging 
 about one in every eighty labors. From the want of sufficient vital 
 force bestowed upon them, triplets seldom attain adult age, and twins 
 rarely attain the meridian period of manhood. 
 
 As a general thing, in compound pregnancies, each fetus or embryo 
 is surrounded by its own proper membranes, the chorion and amnion, 
 so that the children do not come in contact with each other ; but have 
 between them four layers or laminse, the two amnios, and the two 
 chorions which touch each other. Sometimes} one chorion incloses 
 both ovules, each, however, being enveloped with its proper amnion, 
 and in which case there are but two layers or laminse separating them, 
 the two amnios which rest against each other. Occasionally, the 
 fetuses are all inclosed in one amniotic cavity; and very rarely, one 
 fetus is contained within the body of another. 
 
 In the first-mentioned variety, should the placentas be united, there 
 will be no vascular communication between them; and should one 
 child die while within the uterus, it will not necessarily involve the 
 life of the other; this will frequently be found to occur in twin and 
 triple pregnancies. The same labor may expel both children, or, if 
 permitted, one child may be born two or three days earlier than its 
 brother. 
 
 In the second variety, the chorion being common to each, there will 
 be two cords and but one placenta, and as in the first, one fetus may 
 continue to live independent of the death of the other. In this variety 
 the birth of the two children must take place during one labor, the 
 one being immediately expelled after the other. 
 
 In the third variety, one placenta will be common to each, with two 
 cords, which sometimes extend to the placenta, and at others bifurcate 
 from one common trunk at various distances from the placenta. In 
 these cases, we often meet with monstrosities or imperfectly-formed
 
 180 KING'S i-:< ].}-.( TIC OHSTKTRICS. 
 
 children. The birth of the children must take place in this as in the 
 second variety, during one labor; and possibly, the death of one may 
 endanger the life of the other. 
 
 In the last form, monstrosity is frequently the result. One fetus 
 may be inclosed in the abdominal cavity of the other, which is termed 
 profound or abdominal inclusion; or, it may be merely surrounded by 
 the integuments of the other, forming an external tumor having no 
 communication with its internal cavities, which is termed the cutaneous 
 or exterior inclusion. 
 
 There are no positive signs by which we can indicate the existence 
 of twin pregnancy, although some have been noticed by writers. 
 Thus, an unusual development of the uterus but this may be owing 
 to an increase of the liquor amnii ; a flattening or longitudinal depres- 
 sion of the abdomen on the median line, in connection with the above, 
 might justly give rise to a suspicion of twins, but this could only 
 happen when the fetuses lie one upon each side of the uterus; two dis- 
 tinct shocks or motions, are sometimes felt at the same time in different 
 parts of the uterus, but no reliance can be placed upon this as a sign ; 
 again, ballottement is exceedingly difficult in compound pregnancies, 
 as one child must necessarily interfere with the ascent of the other. 
 Auscultation has been named as a mode of detecting twin pregnancies, 
 but we may err even in this, as the sound of the fetal heart can often 
 be distinctly heard in distant parts ; Cazeaux says, " Whenever the pul- 
 sations are heard at two distant points, the line between these should 
 be carefully sounded with the instrument ; for if they are produced 
 'by the presence of two fetuses, the pulsations will become feeble, or 
 almost disappear toward the center of this line; but if, on the con- 
 trary, they are due to a single child, they will be just as strong at its 
 middle part as at either extremity." The diagnosis is rendered more 
 certain if with these varied pulsations we ascertain them to be non- 
 synchronous in action, and with a different rhythm. However, it is 
 of little importance to determine the presence of more than one fetus 
 within the uterus during gestation, as a knowledge of it could be of 
 no utility whatever, until parturition had taken place, at which time 
 it can readily be detected. 
 
 Compound pregnancy, in consequence of the excessive development 
 of the uterus, frequently induces labor previous to full term, and it is 
 not uncommon in these instances to find the uterus contracting and 
 expelling its contents during the seventh and eighth months of utero- 
 gestation.
 
 COMPOUND AND MIXED PREGNANCY. 181 
 
 In addition to the above there are, 1st, false pregnancies, improperly 
 o called, in which the uterus contains a false germ, mole, or hydatidi- 
 form o-rowths; and 2d, mixed pregnancies, where the uterus contains 
 both a fetus and mole. 
 
 Moles and hydatoid iormations, are undoubtedly the results of 
 some diseased condition of the ovum, by which it becomes destroyed, 
 or metamorphosed, into a growth possessing sufficient vitality to exist 
 and augment in size, until removed by the uterine contractions. It is 
 a true conception at first, but which becomes blighted by disease, and 
 degenerates into morbid development. The vesicular mole is more 
 generally met with, though it is rare to find it perfect, and in the ex- 
 amination of abortive ova, vesicular degeneration of the chorionic 
 tufts will very often be found, and in the membranes of fetuses born 
 at the full time a few stalked vesicles may be seen. (Fricker.} Other 
 moles may form from a hypertrophied condition of the membranes, 
 from hemorrhage between the decidual layers, or into the placental cells, 
 etc., and consist of a mass of solid substance. The disease occasioning 
 the vesicular form may commence with the ovum in the ovary; if the 
 solid mole be the result of an abnormal condition of the nidal decidua, 
 it may possibly occur without impregnation, or even copulation, but 
 such cases are extremely rare. 
 
 These false pregnancies are extremely difficult to detect. When the 
 uterus increases in size with greater rapidity than is natural under 
 ordinary causes, with nausea, or vomiting, and tendency to fainting, 
 more severe than with normal pregnancy, great constitutional irrita- 
 bility, occasional attacks of uterine hemorrhage, emaciation, quick 
 pulse, absence of the fetal-heart sounds, fetal movements, and ballotte- 
 ment ; a want of correspondence between the duration of the preg- 
 nancy and the rapid uterine development, occasional discharges of 
 portions of the mole, a presentation at the os uteri of a substance 
 somewhat like that of the placenta, but between which and the inner 
 margin of the uterine cavity the finger glides along without difficulty, 
 etc., we may be led to suspect the presence of hydatidoids ; and upon 
 a vaginal examination, if we find a soft mass in the cervix, which 
 upon being roughly pressed, bleeds, and discharges upon the finger 
 portions of aqueous vesicles, our suspicion becomes certainty. Under 
 these circumstances we must endeavor to promote an early expulsion 
 of them. The index finger may be passed within the os uteri suffi- 
 ciently far to reach the mass and break it in pieces; as soon as the 
 contractions of the uterus have removed the detached pieces, we must 
 examine again to ascertain whether any portion remains, and if any
 
 182 KING'S KCLECTIC OIISTKTUICS. 
 
 are found, they must be again broken, and thus proceed till the whole 
 mass is discharged. If the finger can not be readily introduced for the 
 above purpose, a sponge-tent may be placed in the canal of the cervix 
 for the purpose of inducing uterine contractions, or ergot may be 
 administered. Dr. Lawson Tait's compressed carbolized sponge-tent 
 may also be used, or Molesworth'a uterine dilator. 
 
 The prognosis is not very favorable in molar pregnancy, as the 
 woman is exposed to death from hemorrhage, from the effects of the 
 operative assistance more generally required, and from remote acci- 
 dents; and, even should recovery ensue, she may suffer for a long 
 time from extreme debility, anemia, etc. 
 
 Hemorrhage to an alarming extent often accompanies a labor for 
 the expulsion of hydatidiform growths, for which, in the early months, 
 the tampon may be employed, or the os uteri and vagina may be 
 plugged by means of muslin torn into strips, or a sponge saturated in 
 a mild solution of per-sulphate of iron; together with other means for 
 arresting uterine hemorrhage referred to under the head of Abortion, 
 while at the same time the strength and general condition of the pa- 
 tient must be closely attended to. In cases where the practitioner is 
 thoroughly satisfied that the uterus does not contain a living fetus, 
 the previous symptoms of pregnancy having disappeared, and there 
 is a continued hemorrhage gradually reducing the patient, the safest 
 plan is to dilate the cervix, examine the uterine cavity, and at once 
 remove any form of molar pregnancy contained therein, or any dead 
 fetus; or, if it be a tumor that has occasioned the uterine develop- 
 ment, treat it according to the indications. 
 
 Mixed pregnancies are likewise very difficult to distinguish, and are 
 almost always a cause of abortion, at which time the practitioner must 
 be watchful of the hemorrhage which may ensue, endeavoring to check 
 it, if possible, that the fetus may be saved ; but, in any case, when the 
 hemorrhage is profuse, and does not readily yield to treatment, the safest 
 method will be to cause a speedy discharge of the uterine contents. 
 
 When the ovule becomes impregnated within the ovary, it is seized 
 upon by the fimbriated extremity of the Fallopian tube, through the 
 canal of which it passes until it enters the cavity of the uterus, in 
 which it becomes gradually and fully developed. Many writers be- 
 lieve that fecundation takes place only within the uterus, but the exist- 
 ence of extra-uterine pregnancies proves that it may ensue in the ovary 
 itself; and the idea advanced by some that the ovule after impregna- 
 tion may make a retrograde movement from the uterine cavity through-
 
 COMPOUND AND MIXED PREGNANCY. 183 
 
 the tubes to the ovary or abdomen, is both absurd and opposed to 
 reason. Undoubtedly impregnation may take place in the ovary, 
 tubes, or within the uterus,- whenever the male semen comes in contact 
 with the matured ovum at any of its various points of discharge. 
 However, let it occur where it may, it is occasionally found that the 
 ovum does not reach the uterine cavity, but is arrested or diverted 
 from its route, and attaches itself upon some unnatural point, from 
 which it proceeds toward a partial development; these instances are 
 termed abnormal, or extra-uterine pregnancies. 
 
 The causes of extra-uterine pregnancy are involved in much obscu- 
 rity ; in some instances there have been found partial or complete ob- 
 literation of the canal of the tubes, either at some particular point, or 
 throughout their whole extent, but the occasion of these closures or 
 their period of occurrence, is not satisfactorily explained. Blows upon 
 the hypogastrium soon after conception, have been named among the 
 causes, though there is no certainty in relation to the subject, which is 
 still one of inquiry. Cases are recorded in which fecundation took 
 place, although the tubal canals were imperforate throughout, and 
 many others where it has occurred, without a rupture of the hymen, 
 eo that notwithstanding what has been advanced in relation to the mat- 
 ter of impregnation, much yet remains for investigation. 
 
 In the early period of extra-uterine pregnancy, its determination is 
 very difficult, if not impossible. At a later period, we may be led to 
 suspect the presence of extra-uterine pregnancy, when we discover a 
 premature enlargement of the abdomen above the symphysis pubis 
 when this enlargement is less uniformly developed, and more irregular 
 in its shape, than in normal pregnancies when the tumor or enlarge- 
 ment is foilnd. in one of the iliac fossae, or not central in the median 
 line, being easily felt through the parietes of the abdomen and when 
 upon a vaginal examination, the uterus is found not to have increased 
 in size, nor undergone any change from a firm, unyielding tissue, to 
 one softened and elastic ; and very often this organ will be found 
 pressed by the abnormal tumor against some part of the pelvic walls. 
 The cervix is apt to be patulous. Pain is generally present, especially 
 when the motions of the fetus can be felt, and which gradually be- 
 comes more severe as its development proceeds. The pain is some- 
 what similar to uterine pains, and at times it is constant, fixed, and cir- 
 cumscribed in the pelvis, groin, or umbilical region. We may be 
 positive of extra-uterine pregnancy when, having ascertained fetal 
 movements, fetal-heart pulsations, etc., the sound detects an empty 
 state of the uterine cavity. While it exists, some of the symptoms of
 
 184 KINC'S K( !.!:< 'TIC <>l!STKTi;irS. 
 
 pregnancy, as cessation of menstruation, nausea, vomiting, mammary 
 enlargement, etc., may be present ; but in many instances these have 
 been absent. There is a discordance of opinions among writers rela- 
 tive to the membrana decidua, some of whom assert that the internal 
 surface of the uterine cavity becomes covered with it during extra- 
 uterine pregnancy, while others deny it; among the latter may be 
 named Dr. Robert Lee, of London. But the statements of M. Caz- 
 eaux, Prof. Meigs, Ramsbotham, and other investigators, tend to prove 
 conclusively, that the membrana decidua is formed within the uterine 
 cavity in abnormal pregnancies. Ramsbotham remarks, " It is a cu- 
 rious circumstance in the history of these cases, that if the child should 
 live until the term of gestation is completed, as soon as that time has 
 expired, the uterus takes on itself expulsive action, which is attended 
 with pain similar to the throes of labor, and during these pains the 
 deciduous membrane is expelled from the cavity, with a slight san- 
 guineous discharge ; the same also occurs on the death of the ovum, 
 provided that be premature." See Nidation* In these pregnancies 
 we will frequently discover an increase of the uterine volume, with 
 ramollissement, especially during the early stages, and will sometimes 
 find a thick, ropy, gelatinous substance or mucus in the uterine neck. 
 Great care is necessary not to confound extra-uterine pregnancy with 
 displacement of the normally pregnant uterus during the early months, 
 pregnancy complicated with fibro-myoma or cystic disease of the 
 uterus, and, after the death of the fetus especially, with pelvic hema- 
 tocele, ovarian tumor, dermoid cysts, cancer, fibro-cystic uterine dis- 
 ease, uterine hydatiform growths, and phantom pregnancy. 
 
 The duration of extra -uterine pregnancy is very variable; most 
 commonly it terminates in a few weeks or months ; seldom exceeding 
 five months; and occasionally it has continued through a series of 
 years, even as long as forty-six years. It is stated, that in those cases, 
 where it has continued during the full period of labor, there have been 
 at the termination of the ninth month, symptoms simulating labor, as 
 intermittent uterine pains more or less severe in character, a com- 
 mencement of dilatation of the os uteri, a discharge of muco-sanguine- 
 ous fluid, and true uterine contractions ; and where this condition has 
 continued for several years, these" phenomena have recurred at fixed or 
 irregular periods but they are by no means constant. 
 
 The most common termination of extra-uterine pregnancy, is by a 
 rupture of the cyst which incloses the fetus, and which may be effected 
 by a blow, violent exertion, or some similar cause, or it may ensue 
 slowly and gradually. This rupture is accompanied with several
 
 COMPOUND AND MIXED PREGNANCY. 185 
 
 symptoms of a grave nature; at first, there will be severe pain for 
 several hours, and finally an agonizing pain will be followed by tran- 
 quillity and a perfect quiet from suffering, with a subsidence or flatten- 
 ing of the abdominal enlargement, or, perhaps, its entire disappear- 
 ance ; the abdominal cavity experiences an increased heat, and the 
 patient, if the development was of some months' date, will feel as if a 
 voluminous body had been displaced ; the skin grows pale, faintings 
 come on, the pulse becomes small and contracted, a cold sweat covers 
 the whole body, and frequently death follows, owing to the hemor- 
 rhage produced by the rupture of the cyst. Or, if hemorrhage to a 
 copious extent should not ensue, or it should be arrested, violent 
 peritoneal inflammation will be the result. The fetus in all these 
 cases is usually dead, which may have been the result of defective 
 nutrition or some other cause unknown ; and if a new cyst is formed, 
 which is sometimes the case, although very dangerous to the mother, it 
 is more favorable, because it may probably form an abscess from which 
 the fetus may be discharged, and thus save the patient's life, or it may 
 permanently hold the fetus while this undergoes several alterations, as 
 hardening, or passing into the state of adipocire, all the fluid parts 
 being absorbed, and the cyst becoming gradually a solid, non-malig- 
 nant tumor. Again, it may terminate in a sac containing pus, in 
 which the fetus putrefies, and is eventually discharged into the 
 peritoneal cavity, the intestine, or bladder, and which may give rise to 
 violent peritonitis ; or, it may become coated with a bony, earthy, or 
 semi-coriaceous crust, and remain comparatively harmless, producing 
 no distress, except that occasioned by its weight and bulk. Indeed 
 death is pretty certain in these cases, from peritonitis, purulent infec- 
 tion, or exhaustion from long continued suppuration. 
 
 Extra-uterine pregnancies have been divided into several varieties, 
 each variety being determined by the point of fixation of the ovule, 
 thus: 
 
 1. Ovarian Pregnancy, is that rare form in which the ovum remains 
 adherent to the surface of the ovary, and is of two kinds where the 
 ovule is found within the vesicle which held it previous to conception, 
 and where it is partly developed in the abdomen, and partly in the 
 substance of the ovary itself. It may continue for five or six months, 
 when, from the augmented size of the fetus, the cyst ruptures during; a 
 paroxysm of pain, and, as found after death, the fetus, with a large 
 amount of blood is expelled into the abdominal cavity. During the 
 presence of this abnormal pregnancy, most, excruciating pain about 
 the pelvis, is experienced by the patient from time to time, with con-
 
 186 KIN<;'s K< LECTIC OI'.si I.IK'IOS. 
 
 stipation and dysuria ; and an examination of the uterus per vaginam, 
 detects it unaltered in size, form, and consistence. The pain is not 
 constant, but regularly or irregularly intermittent, with intervals of 
 ease. But after the rupture of the cyst, the pain becomes more severe, 
 with syncope and finally death from peritoneal inflammation. The 
 existence of this form of extra-uterine pregnancy, is denied by some 
 authors. 
 
 2. Tubar, or Tubal Pregnancy, is probably the most frequent variety 
 of extra-uterine pregnancy. An arrest of the ovule takes place in 
 some portion of the Fallopian tube, between its fimbriated extremity 
 and its uterine orifice, and at which point the imperfect placenta be- 
 comes attached to the inner face of the tubal canal, the walls of the 
 tubes forming the fetal sac. The growth and development of the 
 fetus proceeds for two, three, or four months, rarely seven or nine, when 
 the sac ruptures. In this form of misplaced pregnancy, there is an 
 early enlargement over the symphysis pubis, and a vaginal examination 
 will find the uterus unchanged in size, etc., and movable, but uncon- 
 nected with the mobility of the tumor. As the fetus continues to 
 grow, the female suffers severe pain in the pelvis, which is increased 
 after the rupture of the sac, and is followed by excessive prostration 
 and death. The fetus is most commonly discharged into the abdom- 
 inal cavity. 
 
 3. In Ventral, or Abdominal Pregnancy, the impregnated ovule fails 
 to reach the tube and falls into the abdomen, upon some portion of the 
 walls of which the placenta attaches itself. The pain, experienced by 
 the female in this variety of pregnancy, is situated in the abdomen; 
 the enlargement is found in the iliac fossa, at an early period; upon 
 an examination per vaginam, the uterus, as in the previous species, is 
 found unaltered, and more movable than in any other of the abnormal 
 pregnancies; and the fetal movements may sometimes be observed till 
 the ninth month. The sac, which incloses the fetus, gradually forms 
 adhesions with the surrounding parts, and inflammation most generally 
 occurs, at some period, followed by abscess, which discharges the fetus, 
 in fragments, through the w r alls of the abdomen, the vagina, the rec- 
 tum, or the bladder. Cases are reported in which the fetus has re- 
 mained within the abdomen for forty and fifty years, in a mummefied 
 or cretified condition, and others in which normal pregnancy occurred 
 during the presence of the first fetus in the cavity of the abdomen. 
 
 There are several other varieties named by authors, to which a brief 
 reference may be made, as, Sub-peritoneo-pelvic pregnancy, in which 
 the ovum is situated between the two laminae of the broad ligament^
 
 COMPOUND AND MIXED PREGNANCY. 187 
 
 where it becomes developed, and which is, probably, the least danger- 
 ous of any, as its situation favors the spontaneous expulsion of the 
 fetal debris, and renders them more accessible, should their extraction 
 become necessary ; Tubo-ovarian pregnancy, in which the cyst sur- 
 rounding the fetus is party formed by the ovary, and partly by the 
 opening of the dilated tube, whose extremities have contracted some 
 adhesions with the ovarian tunic ; Tubo-abdominal pregnancy, in which 
 the cyst is partly made up by the walls of the tube, the placenta being 
 attached to their interior face, while the other portion of the surface of 
 the ovule is in the cavity of the abdomen, and in which cavity the fetus 
 is usually developed ; Interstitial, or parietal pregnancy, in which the 
 ovule penetrates into the midst of the uterine fibers, the cyst being 
 formed by these muscular fibers alone how this is accomplished, is at 
 present an enigma; Utero-tubal pregnancy, where the ovum is retained 
 partly within the tubes, and partly within the uterine cavity; and 
 Utero-tubo-abdominal pregnancy, in which the fetus is in the abdominal 
 cavity, the umbilical cord passing through the canal of the tube and into 
 the uterus, to the inner face of which organ the placenta is attached. 
 
 In all these abnormal pregnancies; ihe ovule retains its proper 
 membranes, as the chorion and amnion, by means of the first of which 
 circulation is effected *bet\veen the mother and embryo, and in those 
 cases where inflammation has been produced by the presence of the 
 ovum in the peritoneal cavity, a membraneous cyst is formed somewhat 
 similar to the caducous membrane of the uterus, but undoubtedly not 
 a true decidua. 
 
 TREATMENT. Diagnosis of extra-uterine pregnancy is always 
 difficult. Menstruation is apt to recur in a few months ; the peculiar 
 sensations of pregnancy usually experienced by the patient are not 
 always present, and a physician is seldom called until an advanced 
 period, and often only at the time when rupture of the cyst is about 
 to ensue. It is best determined by palpation of the abdomen, and 
 careful vaginal exploration ; and may be decided by exclusion, after 
 bimanual and pelvic examination, that the abdominal enlargement is 
 neither salpingian nor ovarian ; that it is not the result of hypertrophy 
 of the abdominal or pelvic viscera, but must depend, after excluding 
 every kind of swelling except that of abdominal pregnancy, on ectopic 
 gestation. The best treatment at this critical period is to execute lap- 
 arotomy and remove the fetus with its surroundings, as soon as dis- 
 covered, whether the ovum be dead or alive. Morphine, injected
 
 188 KING'S ECLECTIC OBSTETRICS. 
 
 hypodermically into the fetal cyst, has been recommended to produce 
 the death of the fetus. It has also been advocated that electricity be 
 employed for the same purpose ; the object being to prevent the growth 
 of the ovum and ultimate bursting of the sac. If the dead i^tuo re- 
 main incarcerated in the abdominal sac, the woman will sooner or later 
 develop septicaemia the result of putrefactive gases arising from the 
 decomposing fetus. Infection always follows the death of the fetus, 
 though the poisoning in some cases is so slow that it has taken years 
 to wear out the victim. A process of ulceration may establish a fistu- 
 lous outlet, through which will pass the fetal bones denuded of flesh; 
 as the decomposing mass is cast off, inflammatory action develops, ad- 
 hesions exist between the pelvic viscera, intestines and sac, rendering 
 separation impossible, and the death of the mother soon follows as the 
 inevitable result. 
 
 In the execution of laparotomy, to remove the product of extra- 
 uterine conception, the same general rules should be observed as in 
 ordinary ovariotomy. The following instructions are given by one of 
 the best known writers on surgical subjects : The patient is to be in 
 a clean and comfortable room, on a table, and with clothing fresh ; the 
 abdomen is to be sponged, and it is well to have a rubber cloth cover 
 the skin, an aperture having been cut in the cover in the median line 
 to operate through ; pans of hot water or antiseptic fluids are to be at 
 hand, and scrupulously clean sponges; all instruments are to be un- 
 questionably aseptic, as well as the operator's hands and arms; the 
 patient is to be kept steadily under the anesthetic, and it is well to 
 have the limbs tied to the operating table, to prevent troublesome 
 movements of the body. The abdominal incision is to be along the 
 linea alba, just below the umbilicus, and extended enough to admit 
 the hand ; after division of the peritoneal lining of the abdomen, a 
 quantity of serum may escape, and the fetal envelope come into view, 
 appearing redder and more vascular than the sac of an ovarian cyst. 
 This is to be manipulated to determine the position of the fetus,, and 
 to find its connections with the Fallopian tube or with the peritoneal 
 surface of the uterus. Generally, the pedicle of the ovum is as small 
 as that of ovarian tumors in general, but it may be larger or more 
 extensive in its attachments. But, be the pedicle large or small, it 
 must be ligated and then severed with scissors on the distal side of the 
 knot. After the ligature is tied, the sac may be opened and the fetus 
 removed ; then the pedicle may be divided a half inch or more out- 
 side the line of strangulation. Adhesions are to be overcome before
 
 COMPOUND AND MIXED PREGNANCY. 189 
 
 or after division of the pedicle, as the operator may choose, or as may 
 be convenient. 
 
 Scrupulous care should be exercised to arrest all bleeding from trau- 
 matic surfaces, and the long rubber drainage tube should be employed. 
 In other words, the management of the case is to be like that of hys- 
 terectomy or ovariotomy. If the peritoneal cavity could be made dry 
 and free from coagula, there would be no necessity for drainage tubes, 
 but there is no surety for such an aseptic state. There will be oozing 
 after reaction, and a consequent fermentation. The long drainage tube 
 does not irritate or even create perceptible worry, and is very efficient 
 to carry off septic fluids. 
 
 The wound in the abdominal walls is to be carefully closed with deep 
 sutures, the outer end of the drainage tube projecting from the lower 
 angle of the wound. Vomiting on the part of the patient is to be 
 allayed by taking sups of hot water. A hypodermic injection of mor- 
 phia is to allay great pain, yet is not to be employed unless there is 
 need of an anodyne. Nutritious enernata may be employed on the day 
 following the laparotomy. The drainage tube is to be removed in the 
 course of a week, or as soon as offensive flows cease. The abdominal 
 sutures, which may have been silver or silk, are to be cut and disen- 
 gaged as soon as the tenth, day, and adhesive strips put across the 
 wound to aid the sutures, may be renewed as a protection against ven- 
 tral hernia in the line of the incision. 
 
 The danger in the operation is from peritonitis, and that is caused 
 by septic fluids, which an efficient drainage tube carries away, espe- 
 cially if irrigation be coupled with drainage. Warm antiseptic fluids 
 are to be forced into the perforated tube in quantities to wash and rinse 
 the peritoneal cavity of the abdomen. Especially are the washing and 
 rinsing to be done when there is much febrile disturbance. 
 
 There is a condition that may be met with in females at almost any 
 period of life, and whether they have previously given birth to off- 
 spring or not, that has been termed false, apparent, or spurious preg- 
 nancy, and which has sometimes so strongly resembled pregnancy as 
 to deceive very experienced practitioners. There will be found in 
 these cases, cessation of menstruation, morning sickness, sympathetic 
 changes in the mammary glands, enlargement of the abdomen, with 
 other symptoms, even to a resemblance of the true pains of labor. 
 The patient is thoroughly satisfied that she is pregnant, and frequently 
 becomes indignant when this is doubted or denied; and cases are re- 
 corded in which the females even suffered from pains supposed to be
 
 190 KING'S ECLKCTIC OBSTETRIC. 
 
 those of labor. And yet, when the symptoms present are closely inves- 
 tigated, there will be found some irregularity in their true character 
 and proper development, together with an absence of softening of the 
 cervix, of uterine enlargement, of development of the sebaceous areolar 
 glands around the nipple, of fetal pulsations, of ballottement, etc. A 
 tympanitic distension of the abdomen, when present, will give more 
 or less resonance on percussion. If the patient be placed under the 
 influence of chloroform by inhalation, the semblance of pregnancy will 
 promptly disappear. 
 
 But little that is satisfactory is known as to the cause or pathology 
 of this condition ; hysterical women, and those who >uil'er from ovarian 
 or menstrual functional derangements, are more subject to it, and a 
 tympanic distention, in the generality of cases, appears to be the cause 
 of the abdominal enlargement; but the origin of this flatus is yc-t un- 
 determined. Sometimes the symptoms will continue for a longer time 
 than that of normal gestation, and again they may disappear in a few 
 weeks or months. In all doubtful cases of pregnancy, a very thorough 
 and minute investigation should be pursued by the practitioner, espe- 
 cially of the ovaries, uterus, and abdomen, and any existing malady of 
 these organs be treated according to the indications, while at the same 
 time the general health should be attended to by proper hygienic and 
 other required measures. 
 
 CHAPTER XX. 
 
 SIGNS OF PREGNANCY. 
 
 PHYSICIANS are frequently consulted to decide the existence or non- 
 existence of pregnancy, in cases where it may be of immense impor- 
 tance in determining the reputation of a female, the legitimacy of a 
 child, or even the life of a new being, and in instances when a preg- 
 nant woman is condemned to capital punishment. Hence, a knowl- 
 edge of the signs common to pregnancy can not be too thoroughly 
 understood by the accoucheur. Women with illicit offspring, when 
 suspected and interrogated, will almost always endeavor to mislead us 
 by an obstinate denial, and even by an appearance of much indigna- 
 tion ; and this will usually apply to all females, whether married or 
 not, who desire to abort, or destroy their conception. We can not, 
 therefore, be too cautious in giving full credence to the statements of 
 any female upon this subject, unless we have a sufficient acquaintance
 
 SIGNS OF PREGNANCY. 191 
 
 with her to justify implicit confidence in her assertions; and we should 
 always depend upon our own knowledge of the symptoms, rather than 
 upon any light we may elicit from the female. 
 
 Again, in cases where there is no desire or interest to deceive, as 
 when pregnancy is suspected from the presence of abdominal enlarge- 
 ment, suppressed menstruation, morning sickness, etc., it will often 
 require all the skill of the physician to diagnosticate correctly, and, if 
 an incorrect opinion is pronounced, it will frequently place him in an 
 extremely mortifying situation. It is not many years since, that a cele- 
 brated Professor plunged the trocar into the gravid uterus and shoul- 
 der of the fetus of a woman, whose condition he mistook for dropsy. 
 I know an instance where a female, supposed to have erred, was exam- 
 ined by two or three physicians, who decided that she was some three 
 or four months advanced in pregnancy; she denied the charge, but if 
 was of no avail ; her friends forsook her, and even her parents became 
 harsh, severe, and cold toward her; she pined away in secret, hiding 
 her grief from the world, and in a few months died. An investiga- 
 tion being held, a morbid growth within the uterus disclosed the true 
 cause of her symptoms. Many instances of similar character might 
 here be related, showing the value and importance of a full acquaint- 
 ance with all the signs which are to guide us in our investigation and 
 decision. We should exercise great discretion, and rely entirely on 
 the indisputable evidence of our senses; not forming our opinion on 
 one sympton, but on a combination of unquestionable symptoms, and 
 if the least doubt be entertained, we should unhesitatingly express it; 
 for it is much safer to remain in uncertainty, than to pronounce an 
 incorrect diagnosis. Females usually suppose themselves pregnant 
 when after iutercouse they find a cessation of menstruation followed 
 by an enlargement of the abdomen and fetal movements at a proper 
 time, and generally they are correct, yet all these signs may be appa- 
 rently without conception present. 
 
 To determine a recent conception is not only difficult, but as far as 
 the physician is concerned, absolutely impossible; yet many females 
 resolve this point very correctly, from certain 1 voluptuous sensations, 
 peculiar to each, individually, experienced during a fruitful copulation ; 
 and where they have previously given birth to children, having felt 
 similar sensations at the period of fecundation, we have on subsequent 
 occasions, when these occur, some grounds for believing them to be 
 again pregnant. Yet it is commonly the case that "cold women," as 
 they are called, are more easily impregnated than those warm, ardent,
 
 192 KIND'S ECLECTIC OBSTETRICS. 
 
 amorous beings who, during copulation, enjoy exquisite voluptuous 
 .-(fixations, with spasms, and nervous agitation. 
 
 The dryness of the penis when withdrawn after an embrace, and the 
 retention of semen by the female, are looked upon by some persons as 
 undoubted evidence of 'fecundation. An anxiety or depressed condi- 
 tion of the woman a few days afterward, paleness of countenance, a dull, 
 sunken, languishing appearance of the eyes, with a bluish circle sur- 
 rounding them, spots on the face of various sizes, and swelling of the 
 neck, have all been enumerated as signs of early conception, but they 
 are extremely uncertain and doubtful. 
 
 It is only when pregnancy has somewhat progressed that we are ena- 
 bled to diagnosticate with any degree of confidence, and the more ad- 
 vanced this is, the more correctly can we decide. The signs of preg- 
 nancy are divided into the RATIONAL and the SENSIBLE; the 
 rational are again subdivided into general, local, and sympathetic, 
 
 The general signs are those which result from increased activity of 
 the nutritive functions, and from the modifications which take place in 
 the nervous system. The pulse is more frequent and strong, full, and 
 hard; occasionally, in the latter months, intermittent and contracted; 
 the blood is said to be buify and more plastic; respiration is more ac- 
 tive with an augmentation of the heat of the body; and all the secre- 
 tions are more abundant, with increased odor. The changes in the 
 nervous system are usually the greatest and most remarkable. The 
 sensibilities become more refined, the female becomes more susceptible 
 as well as more liable to moral and physical influences; sometimes her 
 nature appears completely changed, so that those who were kind, lov- 
 ing, and amiable, become peevish, irritable, jealous, and malicious, 
 and vice versa; the silent become loquacious, and the talkative become 
 taciturn; in some, the intellect becomes more active, and they are ren- 
 dered more subject to nervous derangements. If diseases are already 
 existing in the female their further progress is either retarded or more 
 rapidly hastened toward a serious termination. Pregnancy renders 
 the female system more liable to disease, constituting a condition called 
 puerperal, which is induced by conception is more fully developed as 
 pregnancy advances and reaches its maximum point at childbirth ; it 
 then gradually diminishes until after lactation, when it ceases ; mani- 
 festing itself again, in a greater or less degree, during every subsequent 
 pregnancy. It is owing to this puerperal condition that pregnant and 
 lying-in women are more liable to epidemic and other diseases, and 
 which are usually more rapid and severe at this time than during the 
 ordinary state and habits of the animal economy. Although these signs
 
 SIGNS OF PREGNANCY. 193 
 
 are indicative of pregnancy, yet in the early months they are very 
 obscure, and when taken by themselves at any period, very uncertain, 
 affording very little aid in diagnosis unless associated with the others 
 hereafter mentioned. 
 
 Among the local signs, that upon which females place the greatest 
 reliance, is the suppression of menstruation ; this is, to be sure, a valua- 
 ble and most important indication, and one that is very common with 
 pregnant females, yet too much confidence must not be placed in it as 
 an unerring sign. It often happens that women fail to menstruate for 
 one, or several periods in succession, without conception being present, 
 and this may or may not be accompanied with an augmented protuber- 
 ance of the hypogastric region. This suppression may be owing to 
 cold, functional or organic disease of the reproductive system, or other 
 cause, which should always be carefully investigated with a view to a 
 correct solution. Again, there are many instances where menstruation 
 or a periodical sanguineous discharge is present during pregnancy 
 others, where females have conceived without any previous monthly 
 flow, and, occasionally, some menstruate regularly, or rather have a 
 periodical discharge of blood, only when pregnant. Usually, when 
 the catamenia have failed in non-pregnant females, there is a greater 
 or less derangement in the general health, but when the health con- 
 tinues in its ordinary condition, with a gradual enlargement of the ab- 
 domen, morning sickness, and the development of the glandular fol- 
 licles of the areola, we have strong reasons for suspecting pregnancy, 
 especially in the married woman. In the unmarried, where illicit 
 commerce is strenuously denied, the diagnosis will be involved in much 
 uncertainty and difficulty; yet the physician should not bestow a too 
 ready credence on the statements of his patient, but rather postpone a 
 positive declaration, until the other signs have advanced so far as to 
 give an undoubted indication of the true state of the case. When the 
 least doubt exists in the mind of the practitioner, he should be very 
 particular not to prescribe or administer any remedies tending to the 
 restoration of the monthly evacuation. 
 
 A change in the color of the vulva, from its natural pinkish hue to a 
 bluish tint, has been named as a sign of pregnancy ; but as this is prob- 
 ably owing to an obstructed circulation, pelvic tumors or other abnor- 
 mal conditions may produce it. It is usually more marked when the 
 female is in the erect or sitting posture, and disappears more or less 
 in the recumbent. 
 13
 
 194 KIN(i's KCL&TIC OBSTETRK'S. 
 
 A change in the color of the skin, called cpliclix, and sometimes morph, 
 or mask, accompanies many women during every pregnancy. It is a 
 brownish, yellowish, or earthy colored stain or freckle, of greater or 
 less extent, usually occupying the forehead, cheeks, and even the neck 
 and breast, but is not a constant sign of pregnancy. It is a minor sign 2 
 and one, probably, more important among those females ^Yho have been 
 disfigured by it in previous conceptions. It often becomes permanent, 
 remaining after parturition, and occasioning considerable uneasiness to 
 the female. Efforts have been made to remove it ; success has been 
 reported in several instances, by employing, as a lotion, the saturated 
 aqueous solution of Sulphuret of Potassa, to be applied on the stain 
 three or four times a day, in connection with mild laxative agents to 
 regulate the bowels and restore the cutaneo-hepatic sympathetic rela- 
 tions; but a subsequent conception has always brought with it a return 
 of the dark spot. 
 
 Dr. Schlesinger, in an address before the Vienna Medical Society, 
 proposed to determine pregnancy in is earlier months by thermometry. 
 From several investigations, he has ascertained that between the axilla 
 and the vagina there is a difference in temperature of 0.21 C., and be- 
 tween the vagina and non-pregnant uterus of 0.16 C.; the cavity of the 
 uterus being of a higher temperature than that of the cervix. The 
 temperature of the fetus in utero is higher than that of the mother, 
 and which is imparted in a certain degree to the uterus. Hence, the 
 gravid uterus is of a still higher temperature than that of the non- 
 gravid. Pulse test: the pulse rate varies in health, from eight to ten 
 beats per minute, depending on the upright or horizontal position; 
 while in pregnancy it remains unchanged is not influenced by posi- 
 tion. This, it is claimed, is the result of an hypertrophied condition 
 of the heart, always existing during pregnancy. Recent observers 
 claim this to be one of the most reliable among the many signs of preg- 
 nancy. Further investigation should be made and reported. 
 
 Dr. A. Rasch has stated as among the important early symptoms 
 of pregnancy, the increased desire to void urine, especially at night, and 
 fluctuation, which has been detected as early as the seventh week of 
 gestation, but generally after the second mouth. Two fingers are to 
 be introduced into the vagina, the womb being steadied through the 
 abdominal walls with the other hand, and then alternately manipulate 
 the uterus with the two fingers. Sometimes the fluctuation will be 
 detected in one corner of the fundus, sometimes lower down ; after 
 three months, outward manipulation alone would feel it. When the 
 fingers have diagnosed an enlargement, the practitioner must, of
 
 SIGNS OF PREGNANCY. 190 
 
 course, determine whether it be from hypertrophy, tumor, or preg- 
 nancy. When anteversion is present, as is more generally the case 
 in early pregnancy, the above manipulation is more readily performed 
 than in retroversion. Fluctuation, combined with increased tempera- 
 ture, softening of the cervix, and the areolar changes of the mamma, 
 is almost a certain symptom. 
 
 The sympathetic signs are usually confined to the digestive system, 
 and are only useful as means of diagnosis when taken in connection 
 with the more positive sensible signs; they sometimes become so 
 severe and troublesome as to require treatment, for which the reader 
 is referred to the chapter on "Disorders of Pregnancy, and Treat- 
 ment." Among the sympathetic signs are nausea, or morning sick- 
 ness, vomiting, anorexia, pica, malacia, acidity of stomach, heartburn, 
 and toothache, which are more common in the earlier months of preg- 
 nancy, gradually disappearing in the latter months, being followed by 
 constipation, hemorrhoids, and more or less headache. 
 
 All the rational signs, of whatever subdivision, are only important 
 when accompanied with the sensible signs, and when they occur 
 together, the diagnosis is rendered more easy and certain. 
 
 The SENSIBLE SIGNS are subdivided into the visible, the audi- 
 ble, arid the tangible. 
 
 The visible signs are those which may be recognized by the eye, as 
 enlargement of the mammae. The breasts, during the earlier stages of 
 pregnancy, acquire new life from sympathy with the uterus; the 
 lactiferous glands are aroused into action, the breasts increase in 
 magnitude, becoming round, tense, hard and tender, with frequently 
 a pricking sensation in them, which sometimes continues during gesta- 
 tion, and at other times the enlargement diminishes about the fourth 
 or fifth month, and may not appear again until near the period of 
 parturition, or even subsequently. Occasionally the axillary glands 
 enlarge. 
 
 Simultaneously with the augmentation of the breast, or about the 
 commencement of the third month, the nipples increase in size and 
 sensitiveness, and are sometimes quite painful, they become of a 
 deeper red, and it is often the case that a yellowish or milky fluid 
 can be obtained from them. The surrounding skin likewise becomes 
 tense, thin and more transparent, and the veins more conspicuous. 
 The enlargement of the breasts, and increased size of the nipples are 
 most commonly present during pregnancy, yet taken alone, they can
 
 196 KINCi's K< LECTIC OBSTETRICS. 
 
 not be depended on as signs, for pregnancy often exists without them, 
 and again, they may originate from other causes, as ovarian or uterine 
 tumors, amenorrhea, etc. 
 
 The areola, shortly after conception, becomes changed from its 
 natural pink color to a deep brown, and which is a more valuable 
 sign in first pregnancies than succeeding ones, as in the latter it 
 would be difficult to decide whether the change was owing to the 
 former pregnancy, or the one under examination, especially, if only 
 a short time has elapsed between them. By some medical men, 
 especially Smellie, 'and Hunter, it was viewed as a positive sign of 
 pregnancy. Cazeaux says, "and I should diagnosticate the existence 
 of pregnancy, with a degree of confidence, in a young woman who 
 had never borne children, and whose breasts presented both a brown- 
 ish-colored areola, the tubercles (sebaceous glands), and the freckled 
 characters before described." But, notwithstanding, this sign has its 
 objections; it is sometimes absent during pregnancy it may be modi- 
 fied by the color of the skin, being more distinct in women with dark 
 hair and eyes, and less so in blondes and brunettes ; and it has been 
 present when conception did not exist, being induced by disease, as 
 amenorrhea, or organic disease of the ovaries, or uterus; all of which 
 should be considered during the investigation. 
 
 With this alteration of color, the papilla?, or sebaceous glands which 
 are seated under the skin of the areola, and especially near its margin, 
 become enlarged, appearing like small tubercles, and which is consid- 
 ered a more positive sign of pregnancy than the areolar discoloration, 
 and more especially so when these enlarged follicles contain sebaceous 
 matter. 
 
 The secretion of milk, is a sign of some value ; yet the accoucheur 
 must remember, that it has occurred in females who were not preg- 
 nant, likewise in children ; and that cases are on record, where milk 
 has been obtained from the breast of the male. In females, this 
 secretion may be present in consequence of the sympathy existing 
 between the breasts and the reproductive organs in a state of disease ; 
 instances of which are frequently met with ; consequently, this sign is 
 only of importance when attended with others of a positive character. 
 Beside, it must not be forgotten that disease may give rise to the dis- 
 charge of a fluid apparently resembling milk, but differing from it in 
 many respects. 
 
 Enlargement of the abdomen, affords to the public a strong presump- 
 tion of pregnancy, because it is an invariable concomitant of this con- 
 dition. Yet a mere dependence on this sign will often deceive us, as
 
 SIGNS OF PREGNANCY. 197 
 
 it may be present from many other causes than pregnancy. Thus, the 
 accumulation of adipose matter in the omentum and walls of the ab- 
 domen, ascites, uterine and ovarian tumors, amenorrhea, tympanitis, 
 etc., will cause its enlargement. An appreciable increase of size, in 
 the abdomen, is commonly observed about the third month, and if 
 with it we have enlargement of the breasts, areolar changes of the 
 mamrnse, cessation of menstruation, increased uterine temperature, 
 fluctuation, with usual health, and previous morning sickness, the 
 inference is strong that conception exists; yet even these may mislead 
 us; hence, the necessity for great caution in forming a diagnosis on 
 this subject, can not be too strongly enforced. 
 
 Previous to the third month, or soon after conception, the ab- 
 domen generally becomes flat, its anterior wall retracts, and ap- 
 proaches toward the vertebral column ; but about the third month, it 
 commences to project, first on the median line, gradually increasing 
 and extending from the pelvic to the umbilical and epigastric regions, 
 reaching this last at full term, and leaving a sunken, or depressed ap- 
 pearance over the iliac fossa3. In women who have had several chil- 
 dren, the abdomen inclines more forward and downward, from laxity 
 of the parietes, while with those in their first pregnancies it is usually 
 less projecting, but larger and more uniform. The volume of the 
 abdomen, at different stages of gestation, likewise varies from several 
 circumstances, as twins, amniotic dropsy, etc. If, with the above 
 appearances, we ascertain that the umbilicus is sunken at first, and 
 then becomes gradually more prominent as the projection of the abdo- 
 men proceeds, our suspicions of pregnancy are still further corrobo- 
 rated. During the latter months of pregnancy the umbilicus may be 
 thrust forward from one-fourth of an inch to even an inch beyond the 
 anterior surface of the abdomen ; and this projection may also origi- 
 nate from the presence of pathological tumors within its cavity. 
 
 Quickening, a term applied to a fluctuation, or fluttering sensation, 
 experienced about the end of the fourth month, may be mentioned in 
 connection with the augmentation of the abdomen. By some authors 
 this is considered as the result of life being imparted to the fetus at 
 the time it is felt ; by others, it is viewed as being caused by the im- 
 pregnated uterus when rising from the pelvic excavation, etc. It is 
 undoubtedly owing solely to the fetal movements, which take place as 
 soon as the embryo attains size and strength sufficient to make its 
 motions felt by the mother, and which generally commences about the 
 eighteenth or twentieth week of utero-gestation. However, preg- 
 nancy may exist, and no quickening have been experienced by the
 
 198 KIN<;'S KCLKCTIC ( U5STKTR K X. 
 
 mother; again, females often mistake other sensations for this symptom r 
 as a flatulent motion, etc.; yet, if the' sensation continues to increase 
 in strength, until the fetal movements can be distinctly felt, all doubts 
 will of course be removed. If, during the latter months of gestation, 
 firm and continued pressure be made by the fingers against opposite 
 sides of the uterus, it will produce such disturbance to the fetus, as to 
 make it move vigorously; or, if one hand be placed on one side of 
 the abdomen, and the same point on the opposite side be struck with 
 the other hand, the fetus is very apt to move actively. The motion.- 
 of the child, if it be alive, may likewise be determined, by dipping 
 the hand in a bowl of cold water, and applying it suddenly over the 
 abdomen. It must be borne in mind, that although the motions of 
 the fetus are a strong evidence of pregnancy, yet its absence does not 
 prove the reverse condition, as the child may be dead, or very feeble. 
 In the strict sense of the word, quickening really occurs at the period 
 of conception. 
 
 Among the visible signs, may be named a peculiarity observed in the 
 urine of some pregnant women, first described by M. Nauche, iii 1831, 
 and after him by several other gentlemen. The urine on being 
 allowed to stand in a glass for some twenty or twenty-four hours, 
 presents on its surface a number of brilliant, crystalline granules, 
 resembling small specks, or oblong filaments, irregularly isolated, 
 which often unite, forming a transparent layer or pellicle about a line 
 in thickness, which can only be seen in certain positions. After a few 
 days a portion of this pellicle gradually falls to the bottom of the glass, 
 forming a white, milky crust there. At one time this pellicle was 
 considered a positive proof of pregnancy, but the investigations of Dr. 
 E. K. Kane, of Philadelphia, have determined, that Mesteine, the 
 name given to this material, is not peculiar to pregnancy, but may 
 occur during the presence of milk in the breasts, especially if it be 
 not freely discharged from the mammae, and that its presence is rather 
 an indication of the existence of this mammary secretion, than of 
 pregnancy. 
 
 
 
 The audible signs, are those detected by the ear, with or without 
 the aid of the stethoscope, among which is, the placenta! sound, or 
 bruit de souffle, which is variously represented as resembling the blow- 
 ing of air, the cooing of a dove, the drone of a bagpipe, having a 
 peculiar rasping sound, similar to that which is heard in the carotid 
 arteries of chlorotic females, in varicose aneurisms, and in some car- 
 diac affections ; this sound is owing to the arterial and venous circula-
 
 SIGNS OF PREGNANCY. 199 
 
 tion of the walls of the impregnated uterus, as well as to pressure 
 upon the arteries, and not to the utero-plaeental circulation; it is 
 always synchronous with the mother's pulse, and is occasionally heard 
 in the course of the linea alba, but more frequently on the sides of the 
 abdomen, over the course of the iliac arteries; sometimes it can be 
 heard over a large extent of surface. When the female is placed in 
 such a manner as to remove the pressure of the gravid uterus upon 
 the arteries, as upon her knees and elbows, this sound can n^ot be 
 heard; and there are cases in which it can .not be detected, although 
 the motions of the fetus may be distinctly felt. It is first heard about 
 the fourth or fifth month of pregnancy, though some writers profess to 
 have observed it even before the end of the third month, and becomes 
 more audible as gestation advances. This is neither a constant, nor a 
 positive sign of pregnancy, for it may be owing to various other 
 causes, as aneurism, abdominal tumors, or whatever may compress the 
 arteries, and has been heard even after delivery; hence, but little con- 
 fidence is bestowed upon it at the present day. 
 
 Dr. Verardini in an address before the Academy of Bologna, stated 
 that intra-vaginal auscultation is of the greatest importance for detect- 
 ing early pregnancy, and will enable us to avoid many possible errors. 
 The instrument, vagina-uteroscope, may be made of gutta percha, very 
 light, and of various shapes. By pressing the vaginal extremity of 
 the instrument against the cervix uteri, if pregnancy exist, a soft, pro- 
 longed sound is heard, similar to that heard in aneurismal tumors 
 when the stethoscope is pressed upon the arteries, this is the character- 
 istic utero-placental bruit. The examination may be made w r ith the 
 patient lying upon her back or side ; but if no sound be heard in this 
 position, the female should be placed in the knee-elbow position, when 
 the auscultator will succeed without difficulty. The bruit which is 
 distinctly heard during the first months, ceases at the commencement 
 of the sixth or seventh month. If the bruit be absent while other 
 symptoms common to early pregnancy are present, the diagnosis is 
 uncertain, as there may be uterine disease. In making the examina- 
 tion, it is important to be certain that there is no pulsating tumor or 
 artery in the vicinity of the cervix. If the bruit continues to be 
 heard after the seventh month, it is indicative of placenta prsevia. 
 
 The sound of the fetal heart, differs entirely from the placenta! 
 souffle; it closely resembles the ticking of a watch, and differs ma- 
 terially from the mother's pulse in frequency and rapidity, beating 
 from one hundred and twenty to one hundred and forty in a minute, 
 the pulsations being sometimes so rapid as to render it impossible to
 
 200 KING'S ECLECTIC OBSTETRICS. 
 
 count them, but returning to their natural character, without any 
 cognizable cause. 
 
 The pulsations of the fetal heart are first perceptible between the 
 fourth and fifth months, and are more commonly heard on the anterior 
 inferior portion of the abdominal wall, just above the iliac fossa, oc- 
 casionally on the median line, and over an extent of two or three 
 inches; as the fetus advances in growth the pulsations become more 
 marked. 
 
 These pulsations, whenever they can be heard, afford positive evi- 
 dence of pregnancy, yet their absence is no indication of non-preg- 
 nancy, as the fetus may be dead, very feeble, or it may be in a position 
 unfavorable to the transmission of sound to the ear; or an excessive 
 quantity of the liquor amnii may destroy the sound. The presence 
 of twins, and even the position of the child in the uterus has been 
 attempted to be determined by the presence of these pulsations, but 
 from the discordant and contradictory statements made by authors in 
 relation to these points, no confidence can be placed in t them ; though 
 if the sound of the fetal heart should be heard emanating from two 
 different points, and especially when non-synchronous in action, or of 
 different rhythm, it would be of some value in the diagnosis of twins. 
 In auscultating a female suspected of pregnancy, especially during the 
 fourth, fifth or sixth months, it is advisable to have her lie upon her 
 back, with the thighs flexed upon the abdomen ; the bed should be of 
 a height sufficient to allow the practitioner to auscultate without stoop- 
 ing too much, which would render it impossible for him to hear any 
 internal sound. The stethoscope, and not the ear, should be applied 
 to the abdomen, which is less disagreeable to females, and it should be 
 placed, first, over the part where the pulsations are most commonly 
 heard, and then changed as may be required. 
 
 The tangible signs, or those which are ascertained by the touch, are 
 exceedingly important in assisting us in our diagnosis of pregnancy, 
 for by them we are not only enabled to determine this condition, but 
 also its degree of advancement; hence, every practitioner should fully 
 qualify himself to perform this operation of touching or manual ex- 
 amination. 
 
 The examination per vaginam or vaginal touch, is usually made by 
 means of the index finger, which is always preferable to the middle 
 finger, as recommended by some writers; occasionally, however, it 
 may become necessary to introduce both index and middle fingers at 
 the same time; this, however, is usually done for the purpose of reacb-
 
 SIGNS OF PREGNANCY. 201 
 
 ing more deeply into the vagina, and the touching should be accom- 
 plished with the index finger alone, for if both are employed, there 
 may be a double perception, and an uncertain, confused idea of the 
 condition of the parts under examination. The practitioner should be 
 able to manipulate with either hand, as occasion should require, and 
 should be very careful that his finger nails are not too long or pointed, 
 in order to avoid giving pain or injury, as well as to render the touch 
 more easy, delicate, and certain ; long finger nails, in an accoucheur, 
 manifest negligence and carelessness, and are always inexcusable. The 
 finger, in order to admit of its easy introduction, should be anointed 
 with oil, lard, pomatum, butter, etc., and not with mucilaginous liquids, 
 as advised by many, because these last do not adhere so firmly to the 
 skin, and are less apt to protect the finger, especially if there be excor- 
 iation of it, from the absorption of any infectious virus which may be 
 present. As to the length of the finger necessary to become an ex- 
 pert accoucheur, that is of little consequence, as the shortest fingers 
 and smallest hands become, as perfect in this art, as the longer and 
 larger. 
 
 The female may be placed in the erect, recumbent, or sitting posture, 
 according to the circumstances ; thus, for ballotement, or for the detec- 
 tion of uterine displacements, the erect position should be assumed ; to 
 ascertain the advance of pregnancy, the size of the uterus, tumors, etc., 
 the recumbent position is the best, with the female lying upon her back 
 or side; the latter is preferable in these cases, with the head and chest 
 elevated .and inclined forward and the inferior extremities separated and. 
 flexed as much as possible on the abdomen, so as to relax the abdom- 
 inal muscles, and consequently render the examination more easy. In 
 some instances where the erect position can not be maintained, or 
 where the recumbent would give rise to suffocation, as in debility, 
 dropsy, dyspnoea, etc., the sitting posture will be found the best, in 
 which the patient is so placed upon a chair that the weight of the body 
 rests upon the sacrum, the body being inclined backward and the vulva 
 being beyond the edge of the chair, so as to allow the operation to be 
 performed. If the patient be standing, the physician should -place 
 himself in front, resting on that knee opposite to the operating hand, 
 with the other knee, demiflexed, and placed between the limbs of the 
 female, to act as a support for the elbow to lean upon, thus preventing 
 the hand from trembling, and allowing the examination to be made more 
 easily. If she is in the recumbent position, he will place himself on 
 that side of his patient corresponding with the hand he intends to 
 employ, and should be seated on a chair of a suitable height. The
 
 KIN(i's KCLKCTK' OUSTKTKK'S. 
 
 woman, in whatever position she may be placed, must not be exposed, 
 but have a proper covering over her. 
 
 The extended hand of the operator is now to be passed lightly and 
 quickly along the internal surface of the thigh nearest to him if she 
 lies on her back or of the lower one if she lies on her side toward 
 the nates, and as soon as it is arrested by the soft parts, and the fissure 
 between the nates recognized by the index finger, this must then be 
 carried forward toward the vulva. Some writers advise the finger to 
 be carried to the symphysis pubis and then moved downward and back- 
 ward; but in doing this, friction against the clitoris and meatus urin- 
 arius must necessarily ensue, but which should always be carefully 
 avoided. The practitioner must be careful not to commit an error by 
 introducing the finger within the rectum, instead of within the vagina, 
 indeed, this could only happen from inattention, or an inexcusable 
 carelessness. On finding the vaginal opening, the condition of the 
 external labia, its size and firmness must be ascertained by passing 
 them between the thumb and index finger, and the fourchette may also 
 be detected if there has been no previous labor, but if there has been, 
 it will be absent, and its place supplied with inequalities. The finger 
 is then to be pressed nearly backward with its palmar surface directed 
 toward the symphysis pubis, examining, as it passes along the urethral 
 canal, which is generally more swollen in pregnant women than others, 
 the condition of the mucous membrane of the vagina, whether smooth 
 or wrinkled, whether any abnormal conditions of its walls are present, 
 and the width and length of the vaginal canal. 
 
 When about one-third of the finger has passed into the vagina, the 
 wrist is to be strongly depressed, and the finger directed nearly verti- 
 cal, when the bos fond of the bladder, the vaginal cul-de-sac, and 
 cervix uteri may be examined. At this time of the operation the 
 thumb is to be extended and applied against the anterior face of the 
 symphysis pubis; the other three fingers will vary in position accord- 
 ing to circumstances, being generally extended on the perineum, press- 
 ing it upward, and sometimes flexed with the thumb, into the palm of 
 the hand, for the purpose of ballottemeut, or for examining the parts 
 on the anterior plane. 
 
 However, if the female lies upon her side, with her back toward the 
 practitioner, the positions of the fingers will be nearly reversed, the 
 palmar surface of the index will be looking toward the sacrum, and the 
 other fingers and thumb more or less flexed in the palm. 
 
 The same method of introducing the finger may be pursued for the 
 detection of malformations of the pelvis, the dilatation of the os uteri,.
 
 SIGNS OF PREGNANCY. 203 
 
 the presentation of the fetus, etc. The various changes which the 
 neek of the uterus undergoes during pregnancy, have already been 
 described, and to which the reader is referred. 
 
 Abdominal palpation or exploration, may assist us in forming a cor- 
 rect diagnosis of pregnancy, and can be practised in all cases, with a 
 few rare exceptions, which may be owing to an excessive thickness of 
 the abdominal walls. In making this examination the female must be 
 placed in a recumbent position, on her back, with the hips elevated, 
 the head flexed on the chest, and the thighs on the abdomen, which 
 position completely relaxes the abdominal muscles. At first, both 
 hands are to be applied over the abdomen, to determine its size, form, 
 and hardness, more especially in the hypogastric region. 
 
 To ascertain the growth of the uterus, the practitioner will place the 
 ends of the eight fingers immediately above the symphysis pubis, and 
 make deep but gradual pressure until they feel the resistance of the 
 uterine globe ; and in this manner he will continue to ascend gradually 
 along the abdomen until the fundus is gained, which may be known 
 by the absence of any further resistance, and by the fingers sinking 
 deeper and gliding over the convexity of the fundus. If pain should 
 accompany the examination, or if the abdominal muscles be in a state 
 of great tension, further procedure must be postponed until a more 
 favorable occasion. The uterine globe invariably retains its oval form, 
 is circumscribed, presenting a resistance somewhat of an elastic charac- 
 ter, and which is firmer in the early months of gestation than during 
 the latter; and the practitioner will often be enabled to recognize 
 movable, irregular masses, and even the various parts of the fetus, 
 depending upon the period of pregnancy in which the exploration is 
 made. The elastic character of the uterine partetes is not so appreci- 
 able when the enlargement of the organ is dependent upon chronic 
 disease, and should it be owing to the presence of a mole within its 
 cavity, it will be impossible to decide, unless at an advanced period, 
 when the absence of the fetal movements, of the pulsations of the 
 heart, and of the fetal inequalities, may furnish grounds for such a 
 supposition. 
 
 The vaginal touch is usually practiced at the same time with the 
 abdominal exploration, especially in the earlier months of pregnancy. 
 The finger introduced within the vagina, is applied on the neck, or 
 against that portion of the uterus between the neck and the symphysis, 
 or between the neck and the sacrum, while the other hand is placed 
 above the pubis, pressing firmly to recognize the uterine tumor. The
 
 204 KING'S K<M.K<TI<' OI-.STKTUICS. 
 
 womb being tnus located between the finger within and the hand with- 
 out, the degree of its enlargement may be ascertained, by instituting 
 a comparison between it and the non-gravid organ. Again, the finger 
 may elevate the uterus, which will be recognized by the hand, or the 
 hand may depress the organ, which will be felt by the finger, and thus 
 its condition and situation as well as any fluctuation, be determined. 
 However, during the first three or four months there are no unequivo- 
 cal .signs of pregnancy, and the practitioner will often be mistaken 
 should he depend on any of them at this time, yet he may, in nearly 
 all instances, satisfy himself of the unimpregnated condition of the 
 uterus. 
 
 Another mode of determining the presence of pregnancy, is from 
 the passive movements of the fetus in utero, and which is called bal- 
 lottement; these motions depend upon physical laws, and are entirely 
 independent of the vitality and muscular strength of the fetus, as they 
 are present whether it be dead or alive. As a certain size and weight 
 of the fetus is required for ballottement, it can not be produced in the 
 early months of gestation, or if it can, it is imperceptible. The sen- 
 sation of ballottement is, according to most writers, analogous to that 
 produced by striking a marble ball, which has been placed in a blad- 
 der full of \vater, or in a glass tube likewise filled with water sus- 
 pended in a vertical position, with the lower end closed by a dia- 
 phragm of bladder or parchment. The blow is to be given with the 
 palmar face of the finger applied just under the spot where the ball 
 rests, striking from below upward, when the ball ascends in proportion 
 to the force of the blow, and when this force is exhausted, it descends 
 and falls back upon the finger which displaced it, communicating a 
 shock to it, and which motion and sensation constitute ballottement. 
 
 To perform the ballottement, the female should be standing, with 
 her shoulders placed against some solid body, as a wall, to cause a 
 projection of the abdomen. The finger, properly oiled, is then to be 
 introduced into the vagina as far as the neck, and should be applied 
 anteriorly, on that portion of the uterus between the symphysis pubis 
 and the projecting portion of the neck, at which point a smart blow is 
 to be given, sufficiently strong to cause the fetus to ascend ; the blow 
 should be made from below upward, and from behind forward, which 
 last may be effected by suddenly flexing the first phalanx as the shock 
 is imparted. As the uterus is generally inclined forward with its long 
 diameter corresponding somewhat with the axis of the superior strait, 
 this last direction of the blow will be required to cause the fetus to
 
 SIGNS OF PREGNANCY. 205 
 
 ascend in the direction of the uterine long diameter, otherwise, it will 
 merely be pushed against the posterior wall of the uterus, being dis- 
 placed without ascension. At the time the blow is imparted, the op- 
 erator should place his other hand upon the abdomen, over the fundus, 
 to firmly fix the uterus in its position, and a short time .after the shock 
 has been communicated to the fetus, he will press upon the fundus from 
 above downward, to hasten the descent, and thus increase the intensity 
 of the sensation to be experienced by the finger within the vagina, 
 which finger is to be held firmly and steadily against that portion of 
 the uterus which has been struck, until it has received the shock of 
 the descending fetus, or until a sufficient length of time has passed for 
 that result. Ballottement is best obtained when the woman is in the 
 erect position ; yet, there may be cases in which, from inability to 
 stand, the recumbent posture may be employed, when the operator will 
 have to place the finger at various points both anterior and posterior 
 to the vaginal projection of the cervix. 
 
 Ballottement may be effected at the fourth month of utero-gestation, 
 though it is frequently absent during this as well as the fifth month ; 
 at the sixth or seventh month it is very distinct, and conveys a sen- 
 sation similar to that of a solid ball inclosed in a fluid and falling 
 upon the finger, as above described. As the fetus continues to grow, 
 ballottement becomes less distinct, is hardly perceptible at the end of 
 the eighth month, and is impossible in the latter weeks of pregnancy. 
 During the early period of ballottement it may be advisable, in cases 
 where accuracy is absolutely required, and in which it can not be 
 recognized, to make several trials ; as from the fact that the small size 
 of the child allows it to easily change its position, this sign may be 
 present one day, and be quite impossible to detect at another. 
 
 By many authors ballottement is considered as a pathognomonic 
 symptom of pregnancy, being equally applicable to the dead or living 
 fetus, and, indeed, we know of no other cause to produce it, than the 
 actual presence of a child within the uterus. However, the practi- 
 tioner should always ascertain that there is no displacement of the 
 uterus which might create a mistake, as in anteversion, and also that 
 the shock communicated to his finger is not from stone in the bladder; 
 each of these conditions, has, heretofore, occasioned some difficulty in 
 determining true ballottement. 
 
 From what has been stated, it will be observed, that in order to 
 determine the condition of pregnancy with certainty, the practitioner 
 will be obliged to procure a delay until the motions of the fetus and
 
 20G Ki.\(i's KCI.KCTIC <I;STI-:TI;I< s. 
 
 other signs :irc manifested with force and distinctness, and which 
 usually will beat the fourth or fifth month; though, from feebleness of 
 the fetus he may have to wait for a still longer period. In all difficult 
 cases, the physician, when called upon, should never positively aHiriu 
 the existence oil pregnancy, until he has distinctly perceived the pul- 
 sations of the fetal heart, ballottement, and the proper changes in the 
 condition of the uterus; in ordinary cases, an experienced practitioner 
 can form a correct diagnosis from these last uterine changes; the ra- 
 tional signs afford but little evidence of any value or certainty. 
 
 Occasionally, the physician is called upon to determine the stage of 
 pregnancy ; this is often very difficult. However, reference should be 
 had to the length of time which has elapsed since the last menstrua- 
 tion, the position of the fundus uteri, the condition of the cervix, 
 ballottement, auscultation, and the time of quickening, if it have 
 taken place, and from all which, an approximation to the period of 
 gestation may be obtained. As to the sex of the fetus in utero, 
 I know of no method of determining it ; Drs. T. J. Hutton and 
 Braxton Hicks have stated, however, that this may be determined 
 in most cases by auscultation practised toward the end of pregnancy. 
 If the fetal pulsations number from 138 to 144, the child is probably 
 a female; from 124 to 130 it is probably a male. Steinbach was 
 correct in 45 out of 57 cases examined by this method, and Franken- 
 hauser was correct in all the 50 cases which he examined. And Dr. 
 Hutton further remarks that if the uterus be divided into two equal 
 parts by an imaginary horizontal line, fetal pulsations heard below 
 this line indicate a presentation of the vertex ; above it, of the nates ; 
 and below it and to the right, of the second vertex position. Neither 
 is there any reliable mode of ascertaining the presence of twins, 
 further than already stated. 
 
 SYNOPSIS OF THE SIGNS OF PREGNANCY AT DIFFERENT STAGES. 
 During the First -and Second Months. 
 
 RATIONAL SIGNS. SENSIBLE SIGNS. 
 
 1. Suppression of the catamenial dis- 1. Increase in the size and weight of the 
 charge. uterus, with slight prolapsus. The cer- 
 
 2. Nausea, vomiting, ptyalisra, anor- vix uteri is directed to the left and toward 
 exia, etc. the symphysis pubis, fluctuation, increased 
 
 3. Unnatural flatness over the hypogas- temperature, 
 triurt.
 
 CHANGES IN THE UTERUS DURING I'UKCXANCY. 
 
 207 
 
 RATIONAL SIGNS. 
 
 4. Tumefaction 
 mammae. 
 
 and tenderness of the 
 
 SENSIBLE SIGNS. 
 
 2. Diminished mobility of the uterus, 
 its walls soft like caoutchouc. 
 
 3. The os uteri round and regular in 
 primiparse, but in mnltiparse, irregular in 
 its circumference and more or less open. 
 
 4. Eamollissement and apparent oedema 
 of the mucous membrane, covering the 
 lips of the cervix uteri. The fibers of the 
 neck not vet softened. 
 
 During the Third and Fourth Months. 
 
 1. Suppression of the catamenia (an oc- 
 casional exception). ' 
 
 2. Continuance of nausea, vomiting, an- 
 orexia, ptyalism. 
 
 3. Slight prominence over the hypogas- 
 trium. 
 
 4. Depression of the umbilicus. 
 
 5. Tumefaction of the breasts increased, 
 with prominence of the nipple, and a 
 Blight discoloration of the areolse. 
 
 6. Kiesteine in the urine. ? 
 
 1. The fundus uteri elevated rather 
 above the superior strait, at the end of the 
 third month. At the termination of the 
 fourth month, it rises two or two and a 
 half inches above the pubis. 
 
 2. Fullness, and dullness on percussion 
 over the hypogastrium. 
 
 3. Existence of a small tumor in the 
 hypogastric region, detected by abdominal 
 palpation, about the size of a child's head 
 a year old. 
 
 4. The direction of the long diameter of 
 the uterus is now changed, so as to cor- 
 respond with the axis of the superior 
 strait. At the fourth month the os uteri 
 is considerably elevated in the excavation, 
 looking backward and to the left; in- 
 creased temperature. 
 
 5. Ramollissernent of the inferior por- 
 tion of the cervix is more marked ; os 
 uteri more open in the multiparae, but still 
 closed and rounded in those who have not 
 borne children. 
 
 During the Fifth and Sixth Months. 
 
 1. Suppression of the catamenia. (Some 
 rare exceptions.) 
 
 2. Cessation of nausea, vomiting, etc., 
 now usually takes place, though they may 
 continue throughout pregnancy. 
 
 3. Increased prominence of the sub-um- 
 bilical region. 
 
 4. The size of the abdominal tumor is 
 increased, it is round, elastic, and if the 
 abdominal walls be thin, the inequalities 
 of the fetus may be felt. 
 
 1. At the end of the fifth month, the 
 fundus uteri is within an inch of the um- 
 bilicus, and the same distance above it at 
 the sixth. 
 
 2. Movement of the fetus is now active. 
 
 3. The bruit de souffle and the fetal pul- 
 sations may now be distinguished. 
 
 4. Ballottement. 
 
 5. Between the cervix and the pubis z 
 tumor may now be felt, either soft and 
 fluctuating, or round, hard, and resisting.
 
 208 
 
 KING'S ECLECTIC OBSTETRICS. 
 
 RATIONAL SIGNS. 
 
 5. The umbilical depression nearly ef- 
 faced. 
 
 6. Discoloration of the areolae more 
 marked, with an enlargement of the sub- 
 cutaneous glands. 
 
 7. Kiesteine in the urine. ? 
 
 SENSIBLE SIGNS. 
 
 6. Ratnollissement of the inferior half 
 of the cervix uteri ; increased tempera- 
 ture. 
 
 7. In the primiparse, the os uteri is still 
 closed, but in the multipart, it is suffi- 
 ciently open to admit the half of the first 
 phalangeal bone, although in each it is 
 softened to the same extent. 
 
 During the Seventh and Eighth Months. 
 
 1. Suppression of the catamenia. 
 
 2. Nausea, vomiting, etc., ordinarily ab- 
 sent 
 
 3. Abdominal tumor much increased in 
 size. 
 
 4. Dilatation of the umbilical ring, and 
 pouting of the navel. 
 
 5. Increased discoloration of the areolse, 
 with enlargement of the sebaceous folli- 
 cles, and increased prominence of the nip- 
 ple. The milk may be pressed from the 
 swollen mammae. 
 
 6. Discolorations on the skin of the ab- 
 domen. 
 
 7. Vaginal-granulations. 
 
 8. Kiesteine still exists in the urine.? 
 
 1. Increased size of the abdomen. 
 
 2. The fundus uteri, at the end of the 
 seventh month, has risen two and a half 
 inches above the umbilicus; at the eighth, 
 it is placed within the epigastric region ; 
 uterus commonly inclined to the right. 
 
 3. Movements of the fetus become more 
 violent. 
 
 4. The fetal pulsations and the bruit de 
 souffle still continue. 
 
 5. Ballottement perfectly felt during the 
 seventh month, but becomes obscure in 
 the subsequent months of pregnancy, on 
 account of the increase in the size of the 
 fetus. 
 
 6. The ramollissement of the cervix is 
 more extensive, and at the end of the 
 eighth month is nearly complete; in- 
 creased temperature. 
 
 7. In the primiparae, the cervix is ovoid 
 and apparently shortened ; the os uteri is 
 still closed. 
 
 8. In the multipart, the os uteri is co- 
 noidal and wide enough open to admit the 
 whole of the first phalangeal bone ; the 
 superior fourth of the neck still hard and 
 firmly closed. 
 
 During the First Half of the Ninth Month. 
 
 1. Reappearance of vomiting, not from 
 nausea but from pressure of the gravid 
 uterus against the stomach. 
 
 2. The abdominal tumor is increased 
 in size ; skin much stretched and tense. 
 
 3. Respiration difficult. 
 
 4. All the other symptoms remain and 
 are augmented in intensity. 
 
 1. The fundus uteri occupies the epigas- 
 tric region. 
 
 2. The movements of the fetus; the 
 pulsation of the fetal heart and bruit de 
 souffle are still present. At this time bal- 
 lottement has disappeared. 
 
 3. The whole cervix uteri is softened, 
 except the internal orifice, which remains
 
 CHANGES IN THE UTERUS DURING PREGNANCY. 209 
 
 RATIONAL SIGNS. SENSIBLE SIGNS. 
 
 firm and closed. The os uteri in primi- 
 parse is slightly opened, though not suffi- 
 ciently to admit the finger, as in the case 
 in multiparse, although the softening is 
 equally extensive in each ; increased 
 temperature. 
 
 During the Last Half of the Ninth Month. 
 
 1. The vomiting ceases, as the abdom- 
 nal tumor sinks from the epigastrium. 
 
 2. Respiration less oppressed. 
 
 3. Considerable difficulty exists in walk- 
 ing, owing to the sinking of the presenting 
 part into the pelvic excavation. 
 
 4. Constant and ineffectual desire to 
 evacuate the bladder and rectum. 
 
 5. The hemorrhoids, the oedema of the 
 limbs and the varicose condition of the 
 veins of the inferior extremities are all 
 increased. 
 
 6. Pains in the loins, and colics. 
 
 1. The fundus uteri has sunk low down 
 in the abdomen. 
 
 2. The sensible signs still persist, except 
 ballottement, which is usually, though not 
 always, absent after the fetus has acquired 
 considerable size. 
 
 3. In multiparse, the internal orifice of 
 the cervix is softened and dilated, so that 
 the membranes may be felt. In the primi- 
 parae, the internal orifice is soft and di- 
 lated, but the external remains partially 
 closed. During the last ten or twelve 
 days, owing to the dilatation of the in- 
 ternal orifice of the cervix uteri, the 
 whole cavity of the neck becomes en- 
 larged, so as to increase the size of the 
 uterine cavity; so that in touching, the 
 finger reaches the membranes, in the 
 primiparse, after having passed the thin 
 and even margin of the os uteri. While 
 in the multiparse, this margin is thick and 
 unequal. 
 
 CHAPTER XXI. 
 
 DISEASES OF THE PREGNANT FEMALE. 
 
 BETWEEN the uterus, and every part of the body, a strong nervous 
 sympathy exists, owing to the intimate relation maintained between 
 the sympathetic and cerebro-spinal system of nerves ; and this sym- 
 pathy is more especially marked during the condition of pregnancy, 
 when the ganglia and plexuses of nerves, together with the blood- 
 vessels and absorbents of the uterus enlarge, and become roused 
 from a state of apparent inertia to one of energetic activity. This 
 change in the female system gives rise to many symptoms, which may 
 14
 
 210 KING'S ECLECTIC OBSTETRICS. 
 
 be considered as indications of the healthy act of conception, a;;<l 
 which, as a general rule, should not be meddled with; but, when they 
 Ixrome unusually severe or protracted, they are then termed the "dis- 
 eases of i>n u'liancy," and require proper treatment for their palliation 
 or removal. As pregnant females are liable to the same diseases as 
 the unimpregnated, it would require a volume to treat separately upon 
 them ; I shall, therefore, confine this part of the subject to those con- 
 diti >ns more common during pregnancy. 
 
 When the female is supposed, from the presence of the ordinary 
 symptoms, to have become pregnant, certain measures are necessary 
 for her to pursue, as well for her own benefit as for that of her off- 
 spring. All compression upon the abdomen or around the waist, such 
 as stays, corsets, belts, etc., should be removed, modified or worn 
 loosely, and should not be resorted to until after parturition; an at- 
 tention to this point may prevent abortion, varices, oedema, uterine, 
 and other disease, on the part of the mother, which difficulties are 
 very apt to be the result of pressure and consequent obstruction of the 
 portal circulation, as well as of the great arterial trunks and veins of 
 the abdomen ; and on the part of the fetus, hydrocephalus, deformity, 
 or positions which may render the labor tedious and even fatal. She 
 should likewise be especially observant of her diet, selecting that 
 which is the most nutritious as well as most easily digested, bearing 
 in mind, that the gastro-uterine sympathy, as well as the gradually 
 increased volume of the uterus, tend greatly to diminish the energy 
 of the digestive powers. Stimulants especially, as alcoholic, vinous, 
 or malt liquors, fats, much acidulous food, and in instances where 
 they prove decidedly hurtful, tea and coffee, are to be avoided. The 
 use of farinaceous vegetables, ripe fruits, boiled or roasted meats, 
 water, and milk, may be named as among the best kinds of food and 
 drink ; and, though many females may have indulged their appetites 
 without any resulting unpleasant symptoms, yet such a course is more 
 apt to produce various difficulties than is generally supposed, especially 
 upon the future of the fetus. Moderate exercise in the open air, espe- 
 cially during the early months of pregnancy, should be very strongly 
 advised, with only occasional and not too prolonged bathing. Coition, 
 though commonly indulged in during pregnancy, is extremely unwise 
 and improper; and though often practiced with impunity, yet it is very 
 apt to be followed by metrorrhagia, abortion, or some defect in the 
 mental or physical organization of the offspring. Females subject to 
 leucorrhea, immoderate menstrual evacuations, abortions, as well as
 
 DISEASES OF THE PREGNANT FEMALE. 211 
 
 those of a nervous or impressible temperament should be particularly 
 warned against cohabitation during pregnancy. If parents desire 
 physically and mentally healthy offspring, the sexual passion must be 
 permitted to remain dormant or undisturbed during the period of ges- 
 tation. The symptoms or diseases of pregnancy, which frequently 
 require medical treatment, are first, those which are the result of de- 
 ranged circulation and nervous sympathy; second, those originating 
 from the compression of the enlarged uterus upon the neighboring 
 organs; third, diseased conditions of the uterus or its contents; aod 
 fourth, accidental diseases. 
 
 Among those symptoms depending probably upon deranged circu- 
 lation and nervous sympathy, one of the most common, as well as the 
 earliest, is vomiting, or morning sickness, as it is usually termed. Vari- 
 ous explanations have been given from time to time as to the cause of 
 this phenomenon, but none of them are wholly satisfactory. With the 
 major part of females it is the first sign of pregnancy, commencing 
 usually about the fourth or sixth week, and sometimes immediately 
 after conception, and continuing for a few months, or even up to the 
 parturient period. It partakes of the character of sea-sickness, or of 
 that experienced by persons commencing to smoke tobacco. The 
 female experiences more or less nausea from the time of rising in the 
 morning, which may at first be removed by eating the morning meal, 
 but which soon becomes followed by vomiting of a greater or less 
 degree of severity and duration; occasionally, the vomiting becomes 
 exceedingly violent, everything being rejected from the stomach, and 
 if not checked, the female may die from exhaustion or starvation ; or 
 premature labor may ensue, followed by hemorrhage of an alarming 
 character. Where the vomiting occurs during the first three or four 
 months of pregnancy it is dependent upon gastro-uterine sympathy 
 is principally confined to the morning, lasts from ten minutes to an 
 hour or two, each day, and usually ceases in from two to four months; 
 the matter evacuated is thick, slimy, colorless, greenish or blackish, 
 frequently acid, and if the effort at vomiting be severe, a little bile or 
 even blood may be mixed with it. This sympathetic vomiting seldom 
 falls under the practitioner's care, unless it becomes very severe ; and 
 indeed, no especial means are required for its removal when not too 
 violent or prolonged, as it is merely a normal effect of conception. 
 
 When the vomiting occurs only in the morning, and is compara- 
 tively slight, it may be palliated by some aromatic infusion, and if the 
 discharges are very acid, magnesia, alkalies, with aromatics, or char-
 
 212 KINO'S KCLKCTIC OBSTETRICS. 
 
 coal, will bo found efficient; sometimes these agents will exert but 
 little effect upon the acidity, in which cases, they will have to be laid 
 aside and acids employed, as Lemon-juice and water, a solution of 
 Tartaric or Citric acid, or acid wines. Should the discharges contain 
 much bile, mild cholagogue laxatives will be found beneficial, as a 
 combination of two parts of Rhubarb and one of Bicarbonate of Po- 
 tassa, administered three times a day, in doses of eight or ten grains 
 of the mixture, or sufficient to produce one or two mild alvine evacu- 
 ations, daily; may also use Citrate of Magnesia, or Seidlit/ powders. 
 When the vomiting is accompanied with much pain in the stomach, 
 Sp. Tr. Nux Vomica or Ignatia, with counter-irritation to the epigas- 
 tric region, may be employed with advantage ; and in severe and ob- 
 stinate cases of pain I have succeeded in giving relief, when other 
 means have proved inutile, by applying a hot fomentation of water 
 over the epigastrium, together with hot sponging, Chloroform, Aqua 
 Ammonise, or a Sinapism. 
 
 When the vomiting is violent and obstinate, various means have 
 been advised, all of which have at times proved beneficial; it must be 
 remembered, that while a certain course may produce a good influence 
 on one patient, it may have no effect whatever upon another, hence 
 the necessity of an acquaintance with these several means. As severe 
 vomiting is frequently accompanied with gastric or hepatic derange- 
 ment, Chionanthus or the small Podophyllin pill often controls it. 
 Macrotys will control a larger number of these cases than any other 
 single agent, and though it may fail in the beginning, I often pre- 
 scribe it again, after having exhausted the list of remedies, and in 
 this way frequently succeed; Pulsatilla is also a good agent, especially 
 when nervous excitation is present. They may be used singly, in 
 alternation, or together. Jn cases where the circumstances of the pa- 
 tient will allow, Champagne w r ine, according to Prof. Meigs, taken 
 during the meal (should vomiting occur after the meal) will almost 
 always prevent it. I have occasionally met with severe cases of vom- 
 iting, in which, after the employment of the usual remedies without 
 effect, Lobelia has produced the desired influence ; in such cases, I have 
 rubbed together one drop of Oil of Lobelia and thirty grains of Sugar, 
 and given one-sixth of the mixture for a dose, repeating it every ten 
 or fifteen minutes until relief ensued, which generally followed the 
 first or second dose, rarely requiring a third or fourth. Notwithstand- 
 ing all these remedies, it will happen, sometimes, that no relief will 
 be experienced, and the patient continues to suffer up to the fourth
 
 DISEASES OF THE PREGNANT FEMALE. 213 
 
 month without any amelioration of her condition; yet, even in such 
 cases, the physician should not add to her suffering by giving up the 
 case as beyond remedial action, but should cheer her up, and endeavor 
 to fortify her spirits by the anticipation of better effects from the next 
 means to be used. In some instances food is only retained while cold; 
 and in others nothing will lie on the stomach but what is hot. Ice 
 will sometimes check it, and bismuth has a good effect. Effervescing 
 draughts have been extolled in attempts to allay the sickness, and will 
 often give satisfactory results, as Seidlitz powders, Soda or Mineral 
 water. 
 
 The use of peptics is to be commended. 
 
 Acidulated camphor water makes a pleasant drink, and will, in 
 some cases, control a rebellious stomach, where other agents fail; 
 Fowler's solution of arsenic, administered in drop doses on an empty 
 stomach, or with a restricted diet, .has been highly commended. I 
 have succeeded in overcoming obstinate cases, in several instances, 
 by the use of Macroty's and Fowler's solution in alternation. Prof. 
 Howe speaks of the alternate use of these agents, and says he has long 
 considered arsenic as the specific for the vomiting of pregnancy. 
 Many other agents have been used and recommended for this dis- 
 tressing symptom, as Bromide of Potassium, Creosote, Turpentine, 
 Salicin, Lime water, Oxalate of Cerium, and infusions of Peach and 
 AVild Cherry-tree bark, etc., etc. In fact, there is scarcely anything 
 considered remedial that has not been tried in the vomiting of preg- 
 nancy. 
 
 In persistent nausea, with inability to retain any kind of food on the 
 stomach, and having exhausted the list of internal remedies, I have 
 succeeded in subduing the trouble, temporarily, or until food could be 
 taken, by the hypodermic injections of Morphia. Dr. Girabetti states 
 that he has successfully treated obstinate cases of this character by 
 rectal injections of solution of Bromide of Potassium, commencing 
 with 90 grains of the salt the first day; 120 the second; and 150 the 
 third day and then lessening the dose in proportion to the effect. 
 Dr. Simmons has met with a similar success by rectal injections, morn- 
 ing and evening, of a solution in mucilage of 30 or 40 grains of Hy- 
 dro-chloral. We do not commend such heroic measures, however, 
 believing milder means to be more effectual. Carbolic acid, in the 
 dose of from one-fourth to one-half a grain, in a teaspoonful of glyc- 
 erine or mucilage, and repeated three times a day, has likewise proved 
 effectual in certain cases, especially when gastric acidity, flatus, or fer-
 
 214 KING'S ECLECTIC OBSTETRICS. 
 
 mentive dyspepsia was present. In all these cases, the diet should be 
 of the lightest character, and if the stomach be found to possess less 
 irritability at any certain period of the day, this period must be selec- 
 ted for taking the principal meal. The practitioner must likewise 
 ascertain whether fluid or solid food agrees best with the stomach, and 
 advise the patient accordingly. The patient should not move about 
 too much, and, sometimes, rest in the horizontal position will be ab- 
 solutely required. Gastritis, indigestible food, constipation, certain 
 odors, etc., may likewise give rise to, or increase the severity of vom- 
 iting during uterogestation, all of which should be borne in mind 
 during treatment, that, if present as existing causes, they may be 
 removed. . 
 
 Where vomiting occurs only during the early part of the day, Prof. 
 Meigs recommends a cup of coffee with toast, to be taken by the 
 patient while in bed, after which she should, if possible, sleep again 
 for a short time ; upon subsequently arising no nausea or vomiting 
 will take place. I have tested this method, and found it to succeed 
 admirably in the majority of cases. Hot milk, or hot water, will 
 prove serviceable when preferred to coffee. 
 
 In some cases recently seen in consultation with other physicians, 
 where the usual remedies had been tested, I relieved vomiting by 
 local applications to the neck of the pregnant w r omb. A solution of 
 cocaine two grains to the fluid drachm of water I believe to be the 
 best local agent. The patient can wet a piece of lint with the solu- 
 tion, and carry it to the os uteri every six to eight hours. The fluid 
 extract of Veratrum viride,- incorporated with vaseline and applied to 
 .the os uteri, will, it is claimed, produce about the same effect as 
 cocaine. The local use of Tinct. Iodine, and the application to the 
 cervix uteri of colorless Iodine, have given very satisfactory results. 
 The practice of dilating the neck of the uterus has many able advo- 
 cates. The cervix is to be dilated to he depth of near a half inch. 
 
 Good results have followed in several cases, in which the cervix was 
 dilated by means of a small silk sponge saturated with the cocaine 
 solution. 
 
 The vomiting that occurs after the fourth month of pregnancy is 
 supposed to be owing to the pressure of the gravid uterus upon the 
 stomach, and is often very difficult to relieve ; indeed, palliation, as 
 the rule, is all that can be expected. Tonics, and antispasmodics may 
 be employed in these cases. I have frequently met with cases which 
 resisted all treatment, ceasing only at parturition ; and again, I have
 
 DISEASES OF THE PREGNANT FEMALE. 215 
 
 considerably mitigated the severity of this distressing symptom, by 
 keeping the bowels in a regular condition preventing constipation, and 
 administering the small doss of macrotys ; relieving the irritable stom- 
 ach to such an extent, within a short time, as to retain light food. 
 The application of coacine becomes valuable, and more often called 
 for in sickness occurring after the fourth month, than before that time ; 
 and should be remembered as an agent soothing and kindly in its 
 action; often relieving when internal remedies are not tolerated. 
 Counter-irritation over the last dorsal vertebrse is often a valuable 
 adjunct to the treatment. In this form of vomiting, all food, or what- 
 ever is received into the stomach is generally rejected, and the patient 
 suffers from inanition; indeed, the principal subject of fear is, that 
 she may die from actual starvation. It should be our aim to discover 
 what variety of food best agrees with the stomach, and the period cf 
 the day in Avhich this organ is the least irritable, that advantage may 
 be taken of that period for taking a light meal. In some instances 
 where vomiting followed the reception of everything taken into the 
 stomach even in moderate quantity, I have succeeded in sustaining 
 the powers of the patient up to the period of parturition, by giving 
 half-teaspoonful, or teaspoonful doses of milk, cream, gruel, etc., every 
 hour or two throughout the day, occasionally with a few drops of 
 Brandy, or other stimulant added. In one case, ice cream was all in 
 the way of food that could be taken for a number of days, and proved 
 very serviceable in tiding the patient along until more substantial 
 nourishment could be taken. In extreme cases, where all forms of food 
 are ejected by the stomach, rectal alimentation may become necessary. 
 The whites of two eggs, in eight ounces of water, may be injected 
 every six or eight hours. In these cases, the less medicine the patient 
 swallows, the better will it be for her, except when imperiously de- 
 manded. 
 
 Frequently the vomiting becomes so excessive as to threaten the 
 life of the patient, as before observed, from starvation; for it is sel- 
 dom the case that abortion is produced by puerperal nausea, though 
 it frequently ensues from emetics. In such instances, after a fair and 
 patient, but fruitless trial of all remedies to overcome the difficulty, 
 and sustain the patient's strength, we may be compelled to resort to 
 premature delivery. This, however, is not to be thought of, unless, 
 the patient's life is actually endangered, and should never be under- 
 taken without having first consulted with one or more medical men. 
 Dubois, who in the course of thirteen years met with twenty fatal
 
 216 KING'S ECLECTIC OBSTETRICS. 
 
 cases, advises never to perform the operation, even though the vomit- 
 ing be violent, when the patient, however feeble and emaciated she 
 may be, is not obliged to retain her bed, when a small portion of 
 aliment can be retained, and when intense and continuous febrile 
 action has not been induced; he also prohibits the operation when 
 signs of extreme exhaustion are present, as loss of vision, cephalalgia 
 coma, somnolence, and mental disorder. A timely interference is 
 advised, at a period characterized by an incessant vomiting, whereby 
 all food, and sometimes even a drop of water is rejected ; where 
 emaciation and debility are present, requiring absolute rest ; where 
 the least movement or mental emotion causes syncope; where .the 
 features become decidedly changed ; where there is severe and con- 
 tinuous febrile action, with excessive and penetrating acidity of the 
 breath, and a failure of all other means. Dr. Churchill considers the 
 pulse to be the best guide; and when this rises there should be no 
 hesitation in at once producing an abortion, lest the patient may 
 become so far prostrated, from a delay, as to render death certain. 
 
 When vomiting has been very distressing during labor, I have 
 frequently given prompt relief by the administration of the tincture 
 of Gelsemium, and would suggest its employment in these obstinate 
 vomitings during pregnancy. 
 
 Ptyalism or salivation, frequently occurs during the early months 
 of gestation, and seldom requires any treatment. Rarely, however, 
 it becomes very severe, resembling mercurial ptyalism, but differing 
 from this in the absence of tenderness of the gums and disagreeablei 
 fetor of the breath ; the fluid secreted is colorless and transparent, or 
 tenacious and frothy, with an unpleasant taste, commonly accompanied 
 with acidity, and often inducing vomiting. As a general rule, this 
 symptom needs no treatment. Phytolacca or Hamamelis, However, 
 should be thought of when treatment becomes necessary ; a good 
 plan is, to regulate the action of the bowels by mild aperients, and 
 wash or gargle the mouth and throat with Borax water. I have 
 never had this symptom to contend with, excepting in one case. I 
 succeeded in relieving it, after several agents had failed, by the admin- 
 istration of Sulphate of Atropia, hypodermically, the one-hundredth 
 of a grain once a day, until relieved. In cases of acidity, Lime-water 
 may be used with some advantage. The secretion, when profuse, may 
 be moderated, by constantly holding in the mouth some candied Sugar, 
 or a lump of Gum Arabic.
 
 DISEASES OF THE PREGNANT FEMALE. 217 
 
 Anorexia, or a want of appetite, and a dislike for ordinary aliments,, 
 are symptoms frequently met with at various stages of utero-gestation. 
 These may be owing to the sympathetic actions existing between the 
 uterus and digestive organs, to a torpid state of the organs subser- 
 vient to digestion, or to an unloaded condition of the alimentary canal. 
 Usually, puerperal anorexia requires but little attention ; but where 
 treatment is required, it must be based upon the supposed cause of 
 it thus, if it be suspected as a result of nervous sympathy, Pulsatiila 
 or Macrotys will generally remove it; if it originates from torpor of 
 the digestive apparatus, Nux Vomica, or the compound tonic mixture 
 will be found useful ; and if it be induced by plethora, or an accumu- 
 lation of morbid matter in the alimentary canal, Ignatia may be used 
 or the first decimal trituration of Podophyllin, in two or three grain 
 doses; or if persistent, mild purgatives will be essential. Indeed, 
 I would remark here, that throughout the whole period of utero- 
 gestation, if the bowels be kept in a soluble condition by mild 
 aperients, or by the use of proper food, many of the distressing 
 symptoms common to this period will be avoided. Flatulence may 
 be removed by the use of Sp. Tr. Viburnum, or by compound spirits 
 of Lavender given in some sweetened water. To overcome these 
 difficulties, some authors recommend emetics, but I am decidedly op- 
 posed to their use : firstly, because milder measures will accomplish 
 all that can be desired ; and secondly, because emetics have a tendency 
 to produce abortion, and which may be avoided by other efficient and 
 less hazardous means. There are some practitioners who proceed, 
 apparently, as if they supposed every patient's stomach to be a strong 
 metallic vessel, capable of being acted upon by emetics, powerful stim- 
 ulants, drastic purgatives, etc., etc., without the least injury whatever, 
 but always with benefit ; such physicians, of all men, are the least 
 adapted to obstetric practice, and I might add truly, or any other. 
 
 Either with or without anorexia, the patient may have " longings," 
 or a desire for certain articles, which are sometimes unnatural and even 
 disgusting. When these longings are not directed to unwholesome or 
 dangerous articles, there is no reason why they should not be indulged ; 
 neither is there any necessity for interfering with any particular dis- 
 likes which may have been produced in the patient's mind. In rela- 
 tion to these longings, and their influence upon the fetus in utero, 
 when ungratified, as well as to the effects of the maternal mind, gen- 
 erally, upon it, there is much discordance of opinion among medical 
 men, some believing that the embryo is acted upon by strong mental
 
 218 KING'S ECLECTIC OBSTETRICS. 
 
 emotions of the mother, .while others deride the idea. I must confess, 
 that too much evidence, of a direct and satisfactory character, has been 
 at various times presented to me, to permit me for a moment to doubt 
 this point; and I am thoroughly convinced, that the fetus in utero is 
 subject to influences and changes, resulting entirely from the mind of 
 its mother, when under strong or continuous action. How, or why 
 this is produced, is as difficult for me to explain, as it would be to 
 account for the cessation of a severe labor-pain on the entrance of 
 the accoucheur into the puerperal room, or the sudden dissipation of 
 toothache upon obtaining a sight of the forceps, or to explain why one 
 man should be actively purged upon seeing another swallow a nauseous 
 dose of medicine. I know, " sympathy," and " imagination " are held 
 up as replies but if these are applicable to the latter cases, why not 
 to the former? A greater attention to the efforts of nature, as wit- 
 nessed in the human system, and less attention to speculative hypoth- 
 esis and dogmatic authority, w r ould tend much to advance the true 
 science of medicine. He who really desires a knowledge of the truth, 
 will not hesitate to receive it from any source. 
 
 There is no direct vascular communication between the mother and 
 the fetus, nor have physiologists been able to detect any nervous con- 
 nection between them, and, for this reason, some have denied the 
 mental influence of the mother upon the fetus in utero, and consider 
 the supposed effects of this influence as mere coincidences, and not 
 proofs. And yet, it appears to me, these coincidences, as they are 
 termed, have been too numerous, and often too prominently marked, 
 to admit of any doubt. It certainly appears to have been believed, 
 acted upon, and with successful results, in ancient times (Genesis, 
 chapter xxx, verses 30 to 41). It has heretofore been referred to, 
 that, notwithstanding the absence of direct vascular communication, 
 the fetus has been acted upon by medicine taken by the mother. 
 Nerves or their congeners appear to be necessary to animal life and 
 development, and yet how many most perfectly and astonishingly 
 made living creatures are there in whom not a trace of nerve-tissue 
 has been discovered ! 
 
 Diarrhea may occur, and usually yields to the ordinary treatment 
 for this disease when independent of pregnancy. It may be owing to 
 intestinal irritation, which may be the result of constipation preceding 
 pregnancy, or it may be induced by the sympathy existing between 
 the intestines and the excited uterus; under either of these circum-
 
 DISEASES OF THE PREGNANT FEMALE. 219 
 
 stances, the early administration of Aconite and Ipecac, in the usual 
 small dose, will, a.s a rule, give prompt relief. Epilobium is Prof. 
 Scudder's remedy. In some instances, the small dose of the first dec- 
 imal trituration of Podophyllin will be the remedy ; the base of the 
 tongue showing a dirty coat is the indication. And again, I have 
 found Sulphate of Quinia with essence of Cinnamon to be decidedly 
 beneficial. "When the diarrhea depends upon chronic inflammation of 
 the mucous membrane of the intestines, it becomes of a serious char- 
 acter, and unless treated promptly and properly, may terminate fatally. 
 In this case, Euphorbia, given in doses of from one to ten drops, will 
 relieve the irritation and promote functional activity hot fomenta- 
 tions should be applied over the abdomen, and mustard to the dorsal 
 and lumbar portions of the vertebral column. The soluble Citrate of 
 Bismuth (Liquor Bismuth) is a very good agent in overcoming diar- 
 rhea; one grain to a dram of water is the dose. In addition to these, 
 the ordinary treatment for inflammation of a similar character must be 
 pursued, meeting the symptoms as they present themselves. Much 
 benefit will be derived in these cases by the alternate use of tincture 
 of Aconite, and tincture of Ipecacuanha, in small doses, and in most 
 cases no other treatment will be called for. The diet should be light, 
 and small in quantity, consisting principally of boiled Milk, boiled 
 Rice, Arrowroot, etc. Diarrhea more often occasions abortion than 
 does constipation, in consequence of tenesmus, and which usually 
 occurs about the third month. As with all other affections during 
 pregnancy, care must be taken to avoid active or powerful catharsis, 
 whatever may be the agents employed in their treatment. 
 
 Heartburn, or cardialgia, is a distressing symptom, and may be pres- 
 ent during the early period of conception, not until the third or fourth 
 month, or may be entirely absent. It may be occasioned by sym- 
 pathetic action, by the use of certain articles of diet, and .by the pres- 
 ence of bile in the stomach, but most generally it arises from acidity 
 of the stomach ; it is also said to be caused by emotions of the mind, 
 and an affection of the eighth pair of nerves. There is heat or a burn- 
 ing sensation in the epigastric region, which extends upward along 
 the esophagus, with pyrosis or eructations of a clear, bilious, sour and 
 bitter fluid, and is frequently accompanied with a peculiar sensation of 
 dragging from the stomach toward the spine ; eating aggravates the 
 difficulty. There is generally no febrile or other constitutional dis- 
 turbance present ; the appetite is commonly impaired. This symptom
 
 220 KINO'S ECLECTIC OBSTETRICS. 
 
 may usually be mitigated by an attention to the bowels, removing 
 acidity 1 y alkalies in aromatic infusion, by a rigid attention to diet, 
 which should be light, nourishing, and easy of digestion, and by the 
 use of moderate exercise in the open air. In very painful and obsti- 
 nate cases, counter-irritation, as sinapisms, etc., applied to the epi- 
 o-astrium will be productive of benefit. A long-continued use of 
 alkalies will injure the tone of the stomach. Sometimes alkalies will 
 fail to produce the slightest relief; in such cases a resort to acids will 
 often effect the desired result; solution of Citric acid, Tartaric acid, 
 or Lemon-juice may be used, or elixir of A r itriol. As soon as some 
 relief has been afforded, an attempt may be made to invigorate the 
 powers of the stomach, for which purpose I have met with much 
 benefit from very small doses of Pulv. Hydrastis Can. and Capsicum, 
 administered three times a day, near meal times. Nux Vomica and 
 Ipecac are good agents to tone the stomach. Generally females obtain 
 a temporary relief from this symptom, when not obstinately severe, by 
 taking Lime-water, or chewing Magnesia,. Chalk, or Peach-kernels. 
 
 Gastrodynia, spasm or cramp of the stomach, is frequently the 
 result of some error in diet, but may also be occasioned by cold or 
 violent mental emotions. Its attacks are often sudden, more transient 
 than heartburn, but far more severe. Violent pains of a neuralgic 
 character dart from the sternum through to the back or shoulders, being 
 accompanied with great distension, flatulence, restlessness and anxiety ; 
 it may be so severe as to occasion premature labor, or the death of the 
 fetus. The treatment should be prompt and energetic; warm fomen- 
 tations, or sinapisms, should be applied to the epigastrium. Colocynth 
 is a good agent where the pain is severe, or Viburnum where cramps 
 are present. In some instances of a severe and obstinate character, I 
 have succeeded in giving relief with the compound tincture of Lobelia 
 and Capsicum, also with the tincture of Gelsernium. When the attacks 
 are frequent, they may be overcome by keeping the bowels regular, 
 neutralizing acidity of the stomach, and administering small doses of 
 Nux Vomica several times a day. The diet should be light and 
 nutritious, avoiding fats, acids, and stimulants. Alkalies, aromatics, 
 and anti-spasmodics, are the only internal remedial agents generally 
 required. 
 
 Constipation is a common attendant of pregnancy, and is frequently 
 very obstinate and troublesome. It is caused by the compression of
 
 DISEASES OF THE PREGNANT FEMALE. 221 
 
 the gradually-developed uterus upon the rectum, which diminishes its 
 diameter, as well as impairs its activity; constipation may also be 
 owing to digestive derangements, improper food, sedentary living, and 
 other causes calculated to lessen the energy of the intestines. Various 
 symptoms depend upon this condition of the bowels, as headache, or 
 a sense of fullness and weight in the head, sleeplessness, irritability, 
 pains in the abdomen, bloody mucous discharges, nausea, and, in the 
 latter period of pregnancy, false pains. Sometimes, notwithstanding 
 accumulation of fecal matter in the intestines, there will be small dis- 
 charges of a liquid character. Constipation is a symptom always to 
 be dreaded in the pregnant female, because of its liability to produce 
 abortion from the large amount of feces collected in the rectum, 
 requiring great expulsive effort to remove, as well as its tendency, at 
 the time of parturition, to cause protracted labor, peritonitis, or con- 
 vulsions. Piles are usually a consequence of constipation in the preg- 
 nant female. In the treatment of costiveness during pregnancy, 
 especially when dependent upon impaction of the lower bowel, or 
 pressure of the growing uterus, I prefer the use of warm laxative 
 enemas to active purgatives administered by the mouth, and for this 
 purpose an emulsion of Castor Oil, may be used daily, and after the 
 rectal accumulation has been removed, a daily enema of warm water 
 may be substituted for the previous one. If it be possible, it is 
 always decidedly better to overcome constipation by hygienic than by 
 therapeutical measures, which always occasion more or less debility, 
 or else some digestive derangement. If medicine is required, and the 
 tongue is broad and pallid, with a white coating, indicating an alkali, 
 I prefer small doses of Bicarbonate of Potassa or Soda, to any other 
 agent with which I am acquainted. Tincture of Nux Voniica, given 
 alternately with Tincture of Belladonna, or Pulsatilla, in very small 
 doses, has proved serviceable in cases where the constipation was due 
 to lack of nervous energy. Podophyllin is often called for in these 
 cases, and may be given, either in the form of the small pill or the 
 trituration, one part of Podophyllin to one hundred parts of sugar of 
 milk. Active cathartics are seldom required, and should al\vays be 
 used with great care during pregnancy, on account of their tendency 
 to produce premature labor; the secret of success consists entirely in 
 maintaining one daily alvine evacuation. I have recently tested 
 Glycerine Suppositories, with very satisfactory results, in constipation; 
 the action is prompt, and the effect pleasant. In diarrhea, the prac- 
 titioner should always ascertain if it was preceded by constipation,
 
 K I Mi's ECLECTIC OBSTETRK -. 
 
 and should, this be the case, laxative measures must be the first 
 adopted. No female should he allowed by a, physician to enter the 
 parturient state -with constipated bowels; and in those instances where 
 the practitioner attends the patient previous to full term, he is highly 
 reprehensible if he neglects the proper attention to this condition. 
 The diet in these cases may be such as to assist very much in bringing 
 about the desired regularity, without the aid of physic, as brown 
 bread, mush and maple syrup, hasty pudding, oatmea'l, figs, stewed 
 prunes, dates, ripe fruits, and dried laxative fruits stewed, as apples, 
 peaches, plums, etc. Any irritability of the bowels which may follow 
 a removal of constipation can be allayed by some gentle sedative, as 
 Aconite and Ipecac or Sp. Tr. of Amygdalus Per. 
 
 Headache, or oephalcUgia, is of very common occurrence during 
 pregnancy, and attacks all temperaments, and as it is frequently a 
 premonitory symptom of convulsions or mania, the practitioner should 
 not fail to devote especial attention to its removal. The pain may be 
 constant or periodical, acute or dull, and may be located in one par- 
 ticular part of the head, or over the whole of it. Sometimes, espe- 
 cially when acute, it is also of a throbbing character, and not unfre- 
 quently there is an intolerance of light and sound. Usually it is 
 owing to some deranged condition of the digestive organs, and may be 
 readily removed by proper attention to diet, and prescribing such 
 agents as are specifically indicated. If characterized by periodicity, 
 Quinia, or Arsenicum, i* the remedy. If pain is localized, think of 
 Rhiis Tox. or Bryonia, and if the pain is throbbing, Belladonna. It 
 may, likewise, originate from mental emotions, fatigue, stimulants, 
 and coitus, requiring special sedatives, and quiet, with proper hygi- 
 enic measures; if anemia exist, some preparation of iron is neces>ary. 
 I prefer the Acid Solution of Iron, and suggest its use in this condi- 
 tion ; if albuminaria be present, treat as herea'fter directed. The 
 headache which occurs during the early months of utero-gestation is 
 of a nervous character, and is not regarded as a dangerous symptom; 
 while that which occurs during the latter months is owing to plethora, 
 is usually attended by evident signs of cerebral congestion, and must 
 be treated promptly and energetically, that serious results may not 
 ensue. This latter form, unlike the former, instead of being relieved 
 by the recumbent position is more or less aggravated by it, and is 
 frequently accompanied with a quick, full, strong pulse, flushed 
 countenance, suffused or heavy eyes, heaviness of the lids, and pho-
 
 DISEASES OF THE PREGNANT FEMALE. 223 
 
 tobia; the carotids pulsate with unusual force and a sensation of 
 giddiness is present, which is increased on stooping. Belladonna is 
 the remedy for this condition. If this form of headache is permitted 
 to continue without relief it will almost assuredly terminate in con- 
 vulsions, more especially if albuminous urine be present. 
 
 The nervous form of headache may be removed, as before observed, 
 by regulating the bowels, and attending to the diet. I have derived 
 considerable advantage from Rhus Tox., Gelsemium, Ammonia Carb., 
 and Bryonia, either separately or in such combinations as indications 
 direct, and, in some severe instances, counter-irritation to the sub- 
 occipital region, or behind the ear. This annoying symptom may 
 occasionally prove quite persistent, and after several days Pulsatilla 
 may become the indicated remedy, the patient showing symptoms of 
 fear. The administration of this agent at such times, will promptly 
 overcome the trouble. 
 
 The plethoric variety requires somewhat different treatment; the 
 bowels must be kept entirely free from any disposition to constipation, 
 counter-irritation must be intermittingly applied to the whole length 
 of the spinal column, and active diuretics may be safely and freely 
 given. Tincture of Nux Vomica, or tincture of Belladonna, in small 
 doses, will frequently remove the headache. If the urine contains 
 albumen, the means hereafter named must -be promptly resorted to. 
 In very severe cases cupping may be applied to the temples, or nape 
 of the neck. Moderate diaphoresis will likewise be found serviceable, 
 and should be effected by the use of the simple diaphoretics, without 
 the administration of any preparation of opium. Although local de- 
 pletion may act as a beneficial palliatory measure, yet general bleeding, 
 which is so frequently resorted to and recommended by certain 
 physicians and authors, must be specially guarded against, as it debil- 
 itates the female, rendering her liable to premature delivery, tedious 
 labor, perhaps requiring instrumental aid or hemorrhage after parturi- 
 tion, and frequently tends to the destruction of the fetus. 
 
 Convulsions often attend the condition of pregnancy; their most 
 usual periods of attack are in the latter months, during parturition, 
 or shortly after delivery. Those convulsions attended with or pre- 
 ceded by signs of general plethora, and cerebro-spinal congestion, and 
 commonly termed " puerperal convulsions," will be treated of in an- 
 other part of the work. At the present time, I would call attention 
 to a form of convulsions, which I have met with as early as at the
 
 224 KIND'S KC I.KIT 1C OBSTETRICS. 
 
 second month of gestation, and which occurs much more frequently 
 than the true puerperal convulsions. They most generally occur in 
 aiuemic or hysterical patients, or in those whose nervous systems 
 have been exhausted by any depressing cause, and though when the 
 attacks are light no bad results follow, yet they frequently occasion 
 premature labor, or, by appearing at the parturient period, perplex, 
 embarrass, and, perhaps, alarm the -practitioner. They are, undoubt- 
 edly, of an hysterical character, and differ from the true puerperal 
 convulsions, in being often preceded or attended by the globus hyster- 
 icus and borborygmus, with a small, hard -pulse peculiar to ordinary 
 hysterical attacks; the motions of the limbs are likewise more violent, 
 the eyes roll or store with a wild expression, and though they may be 
 unnaturally brilliant, yet there will be no suffusion, and the pupil is 
 not insensible. Occasionally the ordinary concomitants of sobbing, 
 crying, or screaming will take place. Urine, of a pale color, is fre- 
 quently voided in large quantities. In the treatment of this form of 
 convulsion the greatest reliance was formerly placed on the officinal 
 compound tincture of Lobelia and Capsicum (Antispasmodic tincture), 
 in doses of from a fluid drachm to half a fluid ounce, and repeated 
 every ten or twenty minutes, nntil the attack was overcome. This 
 compound is probably one of our most powerful antispasmodics ; but 
 owing to its disagreeable taste, together with the large dose required, 
 it is not so generally used as heretofore. Gelsemium is now used quite 
 extensively in these cases, and in small doses frequently repeated will 
 prove quite efficient. Bromide of Ammonium is also a good agent, 
 and may be used either singly or in combination with Gelsemium. In 
 obstinate cases, Chloroform should be inhaled by the patient until 
 spasmodic action is overcome and complete relaxation produced. In 
 the meantime, dring the absence of these convulsions, the patient must 
 be placed upon a generous diet of an easily digestible character ; the 
 bowels must be kept regular, wine or ale may be allow r ed, with some 
 chalybeate preparation, the use of which should be continued during 
 the whole course of utero-gestation, unless otherwise contra-indicated; 
 all exciting influences should be removed as much as possible, quiet 
 should be enjoined, excessive depletion by diaphoresis, diuresis, or 
 catharsis are to be avoided, and coitus must be absolutely prohibited. 
 In these instances, I commonly leave some such agents as above 
 named with the patient, to be administered by her friends whenever 
 an attack occurs, and which effects its influence without the necessity 
 of my presence on every occasion. With this class of patients, the
 
 DISEASES OF THE PREGNANT FEMALE. 225 
 
 practitioner should always be prepared to meet this symptom as a 
 complication at the period of parturition, for it not uncommonly hap- 
 pens that one or several attacks come on during the labor, as well as 
 subsequently. Occurring at this time, Chloroform should be promptly 
 administered, which will usually immediately overcome all convulsive 
 action. 
 
 When there is a tendency to epileptic convulsions, more or less 
 giddiness is apt to be present, and the urine will always be found to 
 contain a little albumen. Again, when albumen is continuously pres- 
 ent in the urine of a pregnant woman, there is always danger to fear 
 from puerperal convulsions, and more especially if this be associated 
 with a plethoric condition. It is, therefore, the positive duty of every 
 obstetrician to examine the urine of his patients from time to time 
 during pregnancy, and especially when oedema of the extremities is 
 present, and also in the latter months, to discover whether it contains 
 albumen, as well as a diminished quantity of urea, and thus enable 
 him to promptly resort to measures for the prevention of a convulsive 
 attack; though it must not be forgotten that puerperal convulsions 
 frequently come on without any previous albuminous condition of the 
 urine. Headache, dimness of vision, giddiness, are apt to be present, 
 and, sometimes even amaurosis, when albumen exists; and this con- 
 dition is often accompanied with oedema of the extremities and cellu- 
 lar tissue of the body, and appears to be more common with primipars& 
 than with multiparse. It has been attributed to pressure of the gravid 
 uterus upon the kidneys, and likewise, with much greater probability, 
 to sympathetic irritation of these organs. There is no doubt that not 
 only albuminaria, but often even true kidney disease, follow the renal 
 congestion kept up by the pregnant condition. In cases of albuminous 
 urine it will be found useful to produce derivative action by hot or 
 stimulating local applications, dry cupping or even cupping with scari- 
 fication over the loins and renal region; and even active catharsis. 
 We should, however, be extremely careful that the bowels are not acted 
 on to such an extent as to produce exhaustion, or that an irritation of 
 the intestinal mucous membrane is not excited that will prevent proper 
 digestion. The Spirit-vapor Bath is very useful in all cases. The in- 
 ternal remedies will depend entirely upon the general conditions and 
 surrounding circumstances of the patient; we would think of Macro- 
 tys, Rhus Tox, Bryonia, Gelsemium, Eryngium, or Belladonna, as in- 
 dicated. In some cases we find the urine alkaline, and we supply the 
 acids, Nitric acid being specially indicated. Again there are cases in 
 15
 
 226 KING'S ECLECTIC OBSTETRICS. 
 
 which it is decidedly acid, and Bicarbonate of Soda becomes the indi- 
 cated remedy. Digitalis, Tannin, Bcn/.nic acid, Citric acid, Gallic 
 acid, etc., IKIVC each, been found advantageous when administered un- 
 der the proper circumstances. When there is a deficient oxygcui/ation 
 of the blood, Nitric acid, Nitrate of Ammonia, Peroxide of Iron, etc., 
 are indicated. And after the albumen has diminished, with an in- 
 crease of urea and urine, blood restoratives as, the Acid Solution of 
 Iron, Citrate, Pyrophosphate, or Carbonate of Iron, with or without 
 Quin ia or other tonics, must be administered, together with a nutri- 
 tious, digestible diet. 
 
 According to Andral and Gavarret, the fibrin of the blood is dimin- 
 ished during the first six months of pregnancy, but subsequently be- 
 comes augmented, even to a considerable amount above the usual 
 physiological portion, assuming the characteristics of inflammatory 
 blood, and manifesting the buffy coat after venesection. In addition 
 to which, the quantity of the blood is also considerably increased be- 
 yond the usual normal proportion. These changes in the blood are, 
 very probably, due to an increased nutrition, by which chyle is formed 
 in greater abundance from the food, and conveyed to the blood-vessels. 
 This plethoric condition is a natural and salutary consequence of preg- 
 nancy, and under ordinary circumstances requires but little attention, 
 further than active exercise and moderate diet. But occasionally these 
 additions to the quantity and quality of the blood become so great as to 
 develop symptoms demanding prompt therapeutic treatment, which is 
 more especially the case with indolent females, those who live luxuri- 
 ously, and those of sanguine habit ; it may also be induced by constipa- 
 tion. These symptoms are headache, somnolence, flushed face, vertigo, 
 dyspnoea, full and frequent pulse, heat of the skin, depressed spirits, and 
 high-colored urine. Sometimes the general plethora gives rise to local 
 plethora, which may be followed by congestion of a serious character 
 in the brain, lungs, or uterus. This latter organ, during pregnancy, 
 is the most liable to hyperasmia, which may be known by a sensation 
 of fullness and weight in the pelvis, groins, and thighs, tension or 
 swelling of the abdomen, pain in the kidneys or loins and even symp- 
 toms of premature labor; and, not unfrequently, this condition of the 
 mother exerts an influence on the fetus, in consequence of which, its 
 movements become less frequent and weaker, or perhaps" cease alto- 
 gether, but which, if not allowed to proceed too far before giving re- 
 lief, will again appear with the removal of the local plethora.
 
 DISEASES OF THE PREGNANT FEMALE. 227 
 
 Whenever the symptoms of general or local plethora become so 
 severe as to require remedial measures, and no symptoms of approach- 
 ing miscarriage have been manifested, it will frequently, but not always, 
 be advisable to commence the treatment with a cathartic, followed by 
 diuretics, which will be found to exert a safer and more salutary de- 
 pletory influence, than even general bleedings, which are so highly 
 recommended by many medical writers. Infusion of Digitalis, Sp. Tr. 
 Apis Mel. Asclepias, and Gelscmiuin will be found quite useful agents 
 in diminishing the plethoric condition. The hot water bath, and dry- 
 ing with a rough towel, will favor general depiction by stimulating 
 the action of the skin. Counter-irritation by dry cupping, sinapisms, 
 or other means should be applied to the upper portion of the spine; 
 the legs and arms may be rubbed or bathed with some stimulating 
 liquid, and, very frequently the wet sheet, or rather bandage applied 
 around the abdomen and pelvic region will effect much benefit; if the 
 case be very severe, tending to a miscarriage, cupping may be pursued, 
 applying the cups to the loins and over the sacrum. On no account 
 must large or small general bleedings be had [except when the urine 
 is found to be excessively albuminous, endangering an attack of con- 
 vulsions, in which case cupping upon the loins may tend to preserve 
 from such attack], for though they may occasionally be followed by 
 present relief, yet their after consequences are much to be dreaded; 
 beside it is a well-established fact at this day, that bleeding rather in- 
 creases than diminishes. the tendency to an inflammatory condition of 
 the blood. After the symptoms have been removed by the above 
 treatment, the subsequent measures should be light diet, moderate ex- 
 ercise,, regularity of the bowels, and use of Macrotys, or the Parturi- 
 ent Balm, which will be found a most excellent agent at this time, 
 with an occasional use of diuretics, and the use of a bandage or proper 
 support to the uterus, if necessary. Hemorrhage, or symptoms of 
 miscarriage, are to be treated as laid down elsewhere for these diffi- 
 culties. 
 
 I should observe here, that local congestion of the uterus, or of any 
 other organ is not necessarily connected with general plethora, but 
 may exist with a state of general anaemia; under which circumstances, 
 the nervous and vascular systems will be found in an extremely ex- 
 citable condition. In such cases, after the removal of the local hyper- 
 sernia, proper attention should be bestowed upon the existing anaemia. 
 
 Odontalgia, or toothache [facial neuralgia], is frequently a trouble- 
 some symptom with pregnant women; it may occur with or without
 
 228 KINO'S KCi.ECTtr OP.STKTRICS. 
 
 caries, and may appear at any period of utero-gestation, often contirv- 
 uing until parturition; the pain is most usually intermittent, but is 
 occasionally continuous. Generally, it is owing to increased irritabil- 
 ity of- the nervous system, and at times to a sanguineous congestion 
 of the jaw. As the extraction of a tooth during pregnancy is fre- 
 quently followed by premature labor, it is not prudent to resort to this 
 expedient, even should caries be present; and it seldom happens that 
 any alleviation of the suffering follows the operation. However, should 
 the pain be owing to a carious tooth, the patient suffering severely 
 without any relief being afforded, and other means have failed, then 
 the tooth may be extracted by a skillful dentist, and probably the ad- 
 ministration of Chloroform would entirely prevent any bad influence 
 upon the generative system from the shock of the operation. The 
 proper treatment in these cases is the administration of Aconite, Ver- 
 atrum, Rhus, Macrotys, or Viburnum, as they may be severally indi- 
 cated. Where the pains occur periodically, Sulphate of Quinia should 
 be given; the bowels should be kept in a regular condition by gentle 
 laxatives; and as a local application, washing the mouth frequently 
 with cold or tepid water and salt will be found useful. In very 
 severe and obstinate cases, counter-irritation behind the ears will be 
 followed by excellent results, as a sinapism, or stimulating liniments. 
 Tinture of Aconite root, employed in friction beneath the ear, is said 
 to be a very effectual remedy, and is certainly deserving a trial in this 
 distressing complaint. Chloroform applied locally, either alone, or in 
 combination with equal parts of tinctures of Camphor, Aconite root, 
 and Opium, has likewise proved efficacious. If caries be present, the 
 cavity should be cleansed, and the following mixture applied on cot- 
 ton or lint, and frequently repeated until relief is obtained, viz.: Take 
 of Oils of Cajeput, Cloves, and Amber, each one fluid drachm, Camphor 
 one drachm, rub the Camphor with the oils until it is dissolved. Or, 
 Chloroform may be applied similarly. In the toothache of pregnancy, 
 the breath is very apt to be acid, and will redden litmus ; frequently, 
 when constipation is a concomitant, its removal will be followed by a 
 cessation of the pain. 
 
 It is frequently the case that the nervous excitement produced in 
 the uterus by the condition of pregnancy extends to the kidneys and 
 ureters, giving rise to spasmodic action of the ureters, attended with 
 severe pain along their course, and occasionally strangury, and which, 
 if not promptly relieved, may induce premature labor. In these in-
 
 DISEASES OF THE PREGNANT FEMALE. 229 
 
 stances counter-irritation should be applied over the lumbar region, 
 and sedatives administered internally. The tincture of Gclsemium 
 alone, or combined with the tincture of Macrotys, will prove a very 
 useful remedy. Where strangury is present, Gelsemium and Lobelia 
 will prove valuable agents as relaxants. The inhalation of Chloro- 
 form may be necessary in some cases. The hot hip-bath will be found 
 a soothing means of relief in this complication. Constipation is usu- 
 ally present, and may be overcome by copious warm enemata. 
 
 The bladder may likewise become the seat of sympathetic nervous 
 excitement, especially the urethra and neck, giving rise to a constant 
 sensation or desire of urinating, and the urine passes in small quanti- 
 ties, frequently with pain and difficulty, and is likewise, with some 
 patients, attended with excessive irritability of the external genera- 
 tive organs, and more or less severe and distressing itching, which is 
 increased at night. The internal use of Aconite, Gelsemium, Rhus, 
 Apis and Eryngium are the remedies usually indicated ; hot applica- 
 tions over the region of the bladder may also be used as an additional 
 means of relief; sometimes, liquor Potassa may be advantageously ad- 
 ministered with other means. The bowels should be kept regular, 
 and the diet should be of a mild, not stimulating, character. In all 
 troublesome or obstinate cases the urine should be examined, and if 
 an excess of" uric acid, urea, or phosphates, etc., be discovered, the 
 proper treatment therefor must be pursued. For the itching of the 
 genitals, cold applications should be employed, and the parts kept well 
 cleansed. (See Pruritus of the Vulva.} 
 
 Occasionally, from pressure, or perhaps from an increased deter- 
 mination of blood to the uterus, which withdraws this fluid from the 
 immediate neighboring parts, there w r ill be found a torpor of the blad- 
 der, giving rise to a retention of urine and its difficult passage. This 
 is a more serious difficulty than the previous one, on account of its 
 tendency to produce retroversion of the uterus. Eupatorium Pur will 
 favor an increased flow of urine ; Apis in some cases Mall prove effect- 
 ual. Santonin, in two or three grain doses, exerts a specific action, by 
 stimulating contractions of the bladder. Acetate of Potassa should 
 also be thought of; the patient should be advised to empty the blad- 
 der often, if possible, by her own efforts, and should these means fail, 
 the urine must be removed by the careful introduction of a catheter; 
 w r hich operation must not be delayed for too long a period.
 
 230 KINc's K< I.K< TIC OBSTETRICS. 
 
 Syncope, or Jit* o/'/i'mf//^ frequently attend the pregnant condition, 
 and may occur at any period from conception to parturition, though 
 more commonly during the earlier months; vertigo, or dimness of 
 sight, is also apt to be present, with sometimes tinnitus, and weakness 
 of the knees. These affections may be owing to debility from what- 
 ever cause, to extreme nervous susceptibility, or to plethora. Syncope 
 generally occurs while the patient is standing, is seldom of long dura- 
 tion, and very seldom causes any serious results. However, when 
 frequently repeated it may induce premature labor, which should be 
 carefully guarded against. The treatment should be that usually pur- 
 sued in syncope at other times; put the patient in a recumbent posi- 
 tion, in a place where there is a circulation of cool air dash cold 
 water on the face apply Ammonia, Ether, or Vinegar, etc., to the 
 nose, and after her recovery, should there be much debility, with cool- 
 ness of the surface, diffusible stimuli may be administered internally, 
 with frictions to the limbs, and, in severe cases, along the spinal col- 
 umn. When the attacks are severe, and occur frequently, Pulsatilla, 
 Gelsemium, Digitalis, and in some cases, Bromide of Ammonium may 
 be given with benefit. The food should be wholesome, and restricted 
 somewhat as to quantity, and if the patient be weak, tonics may also 
 be employed. When these attacks are frequent, Sulphate of Quinia, 
 or Strychnia will be efficacious ; if anemia be present, the Acid Solu- 
 tion of Iron. 
 
 Palpitation of the heart is not an unusual occurrence, during preg- 
 nancy ; it is a distressing symptom, and though by no means danger- 
 ous, it occasions i much alarm to the patient. It may happen at any 
 period of utero-gestation, and may be owing to mental excitement, 
 derangement of the digestive organs, pressure, flatulency, or sympa- 
 thetic nervous irritation. During its presence, it may be relieved by 
 the administration of an alkali, if acidity and flatulency are present; 
 by a mild laxative if the bowels are confined ; and under other cir- 
 cumstances, Digitalis, Lobelia, Cactus, Strophanthus, and in some cases 
 stimulants may be employed, according to indications. Four to eight 
 drops of the Sp. Tr. of Digitalis, given daily for some time after a 
 paroxysm subsides, may prevent a return of the same. During the 
 interval, some of the bitter tonics may be administered, and will often 
 be found beneficial in preventing a return of the palpitation, and 
 should the patient be of an anaemic habit, the proper chalybeate^ 
 must be used in conjunction. The diet must be mild and stimulating,.
 
 DISEASES OF THE PREGNANT FEMALE. 231 
 
 the patient should exercise moderately, her dress should be loose, 
 coitus should be abstained from entirely, and the mind should be kept 
 perfectly tranquil. 
 
 Dyspnoea, or difficulty of breathing, may occur, in the early months, 
 from sympathy, and at a later period from plethora, or from pressure 
 of the enlarged uterus; it may likewise be owing to derangement of 
 the digestive organs, thoracic disease, cardiac disease, tumors, etc. The 
 treatment will consist in the administration of antispasmodics, as Gel- 
 semium, Lobelia, Ether Carbonate of Ammonia, etc., attention to the 
 regularity of the bowels, and a course similar to that just named for 
 palpitation. When owing to organic diseases, or congestion of the 
 lungs, these must be attended to according to their indications. When 
 the difficulty is owing to the enlargement of the uterus, but little relief 
 can be expected until the delivery of the fetus, hence, there will be no 
 necessity for injuring the patient's system by the employment of 
 medicines. 
 
 Cough sometimes occurs, independent of cold or existing disease, 
 and which, in the earlier months, is owing to sympathetic action ; in 
 the latter to pressure. The cough is usually short, dry, hacking, and 
 constant ; occasionally very severe, with but little or no expectoration, 
 no febrile symptoms, and no change in the pulse, and is apt to cause 
 premature delivery. It may be treated by narcotics, antispasmodics, 
 rest, and regularity of the bowels, with a proper attention to diet. 
 
 In the latter months of pregnancy, when the cough is severe and 
 persistent, Belladonna, Pulsatilla, Sanguinaria, and occasionally an 
 anodyne may be employed.. Drosera, Bromide of Potassium, Trifolium, 
 Bromide of Ammonia, etc., are advised by Prof. J. M. Scudder. If 
 the cough be due to irritation of the diaphragm and lungs from upward 
 pressure of the enlarged uterus, but little can be done, except to keep 
 the bowel? regular, the urinary organs healthy, and during sleep to 
 have the head kept in a somewhat elevated position. The cough will 
 pass away after parturition. 
 
 Mastodynia, or a painful and distended condition of the breasts, is 
 very apt to attend pregnancy, especially with prirniparaB, and may be 
 owing to the rapid development of these organs and flow of blood to 
 them. When severe, relief is frequently afforded naturally by a thin, 
 colorless, serous discharge from the nipple. To relieve congestion,
 
 232 KIND'S KCLKCTIC 
 
 aiul prevent inflammation, which are the principal indications, topid 
 fomentations may be applied, together with an anodyne liniment, as a 
 mixture of Oil and Laudanum; the bowels must be kept free, and all 
 pressure upon the breasts removed. The Sp. Tr. of Phytolacca Dec. 
 will be found exceedingly useful in these cases, in doses of one to two 
 minims, administered in some water, and repeated every three or four 
 hours, at the same time applying it locally. Tincture of Iri.s Versi- 
 color will also prove beneficial in many instances. 
 
 pain about the pelvis and hips, as well as the abdomen, 
 frequently accompany pregnancy; the cause of these pains is supposed 
 to be owing to pressure on the anterior branches of the sacral nerves ; 
 but this could only happen when there has been a descent of the uterus, 
 at the termination of utero-gestation, for prior to this period the uterus 
 is too much elevated for its inferior portion to compress these nerve-. 
 As these pains are more common after fatigue, they are probably de- 
 pendent on an irritable condition of the nerves of the painful muscles, 
 and should be treated principally by rest. In severe cases Macrotys 
 may be given internally, and stimulating liniments may be rubbed 
 over the affected parts, and the back; and the pain of the abdominal 
 muscles may be frequently relieved by the use of a bandage. 
 
 Mania, or insanity, usually attacks pregnant females of a hysterical 
 disposition, or those who are hereditarily predisposed to it. It may 
 occur at any period of utero-gestation, from conception to parturition, 
 and as a general rule, is not so severe as that which occurs in the 
 puerperal state, and ceases with delivery. The treatment must be 
 principally moral, meeting any symptoms which present themselves, 
 according to their indications; employing tonic means, where debility 
 is present; Pulsatilla, Macrotys, Stramonium, and the Bromides, as 
 they may be specifically indicated, where there is much nervous irri- 
 tability; and the means recommended for plethora, or albuminous 
 urine, should these exist. The application of cold to the head, stimu- 
 lants to the spine, and cups to the temples or back of the neck, should 
 always be employed, as may be indicated, to overcome any local con- 
 gestion. When the mania is acute, treat it in the manner recom- 
 mended for Puerperal Mania, which see. 
 
 Beside the several affections which have just been named, as owing 
 to nervous sympathy and deranged circulation, there will be found
 
 DISEASES OF THE PTIPXiXANT FEMALE. 233 
 
 certain changes in the mental condition of the patient; thus .she may 
 become very despondent, or very irritable. The former, when severe 
 and obstinate, and accompanied with gradual loss of health, may 
 terminate eventually in puerperal mania ; the latter has nothing serious 
 in its tendency, and disappears after delivery. The first must be treated 
 by moral as well as therapeutical means; the patient should be kept 
 from all depressing circumstances, should be led into cheerful society, 
 where she will not hear of any wonderful or fatal accidents having 
 occurred to parturient women, and should be exhorted to overcome 
 the tendency to despondency as much as possible ; the therapeutical 
 measures should be Pulsatilla, Viburnum, the Compound Tonic Mix- 
 ture, cold to the head, diuretics, etc., if plethora exist; and chalybeate 
 tonics when an anaemic condition is present. 
 
 The second should be treated by the use of Macrotys, keeping the 
 bowels regular, and should wakefulness be present, the following may 
 be administered, Sp. Tr. of Aconite, Sp. Tr. of Hyoscyamus, Sp. Tr. 
 of Gelscmium, etc., as indications direct. The patient should take 
 moderate, but regular exercise daily in the open air, and the diet 
 should be of a non-stimulant and non-heating character. 
 
 Pruritus of the Vulca, Prurigo, or itching of the Genitals, occurs 
 during the early months of pregnancy, and is sometimes very distress- 
 ing; occasionally it continues during the whole period of utero-gesta- 
 tion, and disappears immediately after delivery. It may be caused by 
 uncleanliness, acrid discharges, and frequently, according to Dewees, 
 from aphthous efflorescence of the vulva ; at times, it occurs without 
 any known cause. In the treatment of this distressing symptom, 
 means must be employed according to its severity, and the pathologi- 
 cal condition of the parts affected. In the greater number of cases 
 a solution of Borax will be found efficient; if much inflammation of 
 the parts is present, a w r eak solution of the Sesquicarbonate of Potassa, 
 or of Nitrate of Silver may be applied locally, and as it subsides an 
 astringent infusion may be substituted, as of Geranium and Golden 
 Seal ; a compress of lint or soft linen should be moistened with these 
 applications, and placed between the labia immediately in contact 
 with the affected parts. A very excellent preparation is composed of 
 Carbolic acid five grains, Acetate of Morphia four grains, Dilute Hy- 
 drocyanic acid one fluid drachm, Glycerin two fluid drachms, distilled 
 Water a sufficient quantity to make two fluid ounces of the mixture; 
 moisten some lint with this, and apply it upon the part affected. In
 
 234 KING'S ECLECTIC ORSTETRICS. 
 
 all cases the bowels should be kept regular, and the parts well cleansed. 
 Occasional tepid baths may be employed with benefit, and sometimes 
 the induction of diaphoresis will produce a favorable result. Inter- 
 nally, but little means are required; Rims Tox, Apis, or Eryngium 
 may be administered, if such agents are desired. If the pruritus pre- 
 sents characters pf periodicity, Sulphate of Quinine, Macrotys, or 
 Arsenicum, etc., may be administered, according to the indications 
 present. The Juniper Pomade applied on lint, I have found highly 
 successful in a number of cases; and in others, the disease has disap- 
 peared as if by magic, upon the local application of a lotion composed 
 of a saturated aqueous solution of Sulphurous Acid Gas one fluid 
 ounce, and rain-water three fluid ounces. The saturated solution may 
 be made by passing a stream of the gas through water, until this is 
 saturated. Wet a piece of lint or linen with it and apply to the part. 
 One part of Carbolic acid to fifty or sixty parts of water may fre- 
 quently be locally applied with advantage. If the itching be due to 
 pediculi, Cologne, or the above carbolic preparations, will remove 
 them without any necessity for the use of that filthy and undesirable 
 mercurial ointment. 
 
 CHAPTER XXII. 
 
 DISEASES OF THE PREGNANT FEMALE Continued. 
 
 THE symptoms or affections originating from compression of the 
 enlarged uterus upon neighboring organs are several. (Edema, or 
 serous infiltration into the cellular tissue of various parts of the body, 
 will be first noticed. It may occur in the early months of pregnancy, 
 but is most common in the latter months, and is generally attributable 
 to pressure of the enlarged uterus upon the blood-vessels of the pelvis, 
 thereby interrupting the circulation, and finally resulting in effusion. 
 It is not, however, always produced from this cause, as frequently the 
 size of the uterus bears no proportion to the extent of the oedema, but 
 is usually small; and, again, w r e frequently find the uterus enormously 
 distended, either by excess of liquor aranii or plurality of children, with- 
 out any accompanying oedema. In those instances where the swelling 
 is caused by uterine pressure, it is mostly confined to the lower extrem- 
 ities, but where it spreads over the whole body it is due to plethora,
 
 DISEASES OF TJTE PREGNANT FEMALE. 235 
 
 or renal congestion, which may be known by the presence of albu- 
 minaria, and either of which is unfavorable. Convulsions are very 
 apt to succeed oedema from these latter causes. Ordinarily, no pain 
 accompanies this affection, yet, occasionally, it is very painful. Where 
 the swelling is confined to the feet and ankles, quickly disappearing 
 on assuming the recumbent position, but little treatment is required; 
 but where it becomes so great as to render the recumbent position 
 almost impossible, from dyspnoea, or where it is complicated with 
 effusion into any of the important cavities of the body, it becomes of 
 a serious nature, and requires energetic treatment. In the milder 
 cases, when confined to the lower extremities, and where treatment is 
 required, relief may be afforded by the administration of laxatives, 
 with cold applications to the cedematous part, at the same time sup- 
 porting the limbs with a bandage well applied. The rubber, or 
 elastic, bandage is more efficient in these cases than if made from 
 other material, as the degree of pressure can be regulated, thus pro- 
 ducing more uniform support. In severe cases, purgatives and di- 
 uretics will be beneficial, and it will often become necessary to induce 
 premature labor as the only means of saving the patient's life, who 
 can not possibly live up to the full period with an increasing infiltra- 
 tion. When oedema is not dependent upon some important organic 
 lesion, it usually disappears after parturition. When renal conges- 
 tion is a cause of the effusion, in addition to the above treatment cups 
 may be applied over the region of the kidneys, and, if obstinate, a 
 discharge may be maintained from this region by means of an irritat- 
 ing plaster. Puncturing and scarification of the cedematous limbs are 
 advised by some authors, but they should not be attempted, as they 
 are most usually followed by gangrene. 
 
 When, by pressure of the enlarged uterus upon the pelvic blood- 
 vessels, the circulation within the lower extremities is obstructed, it 
 gives rise to a varicose condition of their veins. This difficulty is a fre- 
 quent accompaniment of the latter months of utero-gestation, and is 
 more apt to occur in women of an advanced age, than in young females. 
 As they are owing to the impeded circulation in the extremities, their 
 cure can not be effected until the cause is removed, when they usually 
 disappear spontaneously. Sometimes they continue after delivery, 
 gradually increasing, and on each subsequent pregnancy augmenting 
 considerably in size, forming tumors which are more or less painful, 
 embarrassing the movements of the female, and often terminating in
 
 *23<) KIN<;'s KCLKCTIC OBSTETRICS. 
 
 obstinate nlcerations. Rupture of these veins is the principal acci- 
 dent to fear, as it may prove fatal, and the practitioner's treatment 
 .should be especially directed to a prevention of its occurrence. The 
 patient should not be long at a time on her feet, but should keep in a 
 horizontal position, with the dress loose, and the employment of 
 properly graduated pressure over the veins by means of bandages, or 
 elastic stockings. The bowels should be kept free, the diet spare, and 
 the bandages may be kept moistened with cooling applications, 
 especially in severe cases. If the varices are situated in the genital 
 parts, as the vulva or vagina, compresses moistened with cooling 
 lotions may be applied, and continued for some time, or until the 
 enlargements disappear, in order to prevent rupture, which sometimes 
 happens, especially at the time of parturition, during the passage of 
 the fetal head through the pelvic canal. Within a year or so, new 
 modes of treating varicose veins have been suggested; one by Dr. 
 Linon, in which he thoroughly moistens a flannel compress with a 
 solution of six drachms of perchloride of iron in eight ounces of 
 water, applies this upon the varicose part, and holds it there for 
 twenty-four hours by means of a roller bandage of flannel applied 
 moderately tight. This application is to be repeated daily for ten or 
 twelve days in succession, or until the varices have disappeared, after 
 which the bandage may be continued for some days without wetting 
 the compress. This is stated to have cured enormous varices, accom- 
 panied with pain and dark spots; an improvement in the venous di- 
 latations will be observed from the first appplication. Dr. Rugge, of 
 Berlin, has met with success by subcutaneous injections of one or two 
 grains of Ergotin, repeated every few days, the varices gradually dis- 
 appearing from the first injections. Pain and infiltration followed 
 each injection, but were succeeded by no abscess, nor any influence in 
 provoking uterine contractions. The best vehicle is Glycerine, five 
 grains of the Ergotin to one fluid drachm of this fluid. Prof. Scudder 
 prefers the Hamamelis. 
 
 From a cause similar to the above, hemorrhoids, or piles, may be 
 produced, and more particularly if constipation be present. Occasion- 
 ally they are an attendant of diarrhea. They are similar in nature and 
 appearance to those occurring at other times, and require the same 
 local treatment. When slight, they may be removed by producing 
 regularity of the bowels by means of laxative medicines, with cold 
 and astringent applications to the parts. Although Magnesia, as the
 
 DISEASES OF THE PREGNANT FEMALE. 237 
 
 rule, is contra-indicated in pregnancy, on account of its tendency to 
 accumulate in the intestines, the following preparation is stated to be 
 very beneficial in procuring daily soft alvine evacuations without 
 pain : take of Sulphate of Magnesia, Carbonate of Magnesia, Bitar- 
 trate of Potassa, Sublimed Sulphur, each, equal parts. The dose is 
 from one to three teaspoonfuls before breakfast, according to its action. 
 Internal agents may be administered, in the hope of overcoming the 
 trouble by stimulating the venous circulation ; Hamamelis and Col- 
 linsonia may be employed, either singly or in combination, for this 
 purpose, and will oftentimes effect a cure. Owing, however, to the 
 fact of this condition being the direct result of mechanical pressure, 
 therapeutic means do not always relieve ; the annoyance and suffer- 
 ing continuing until the cause is removed by parturition. If pain or 
 irritation exist, narcotic ointments, as Poke, Stramonium, etc., may 
 be applied with benefit, and where the tumor protrudes externally the 
 pain and iritation may be relieved by the application of Laudanum, 
 incorporated in Juniper pomade, or Glycerole of Tannin on absorb- 
 ent cotton. The removal of piles by an operation, during pregnancy, 
 is totally inadmissible and unjustifiable. Nor can a perfect cure be 
 expected until after parturition, when the pressure has been removed 
 by a return of the uterus to its nongravid condition. I have derived 
 considerable benefit, in this difficulty, from an ointment composed of 
 Stramonium ointment, one ounce, Alum, two drachms, Sulphate of 
 Morphia, ten grains; mix, and apply a small quantity on lint or 
 cotton. Another valuable local application is the Persulphate of Iron. 
 A solution of Borax, also, is a cooling application, and will relieve 
 the itching and burning ; the parts may be washed with it morning and 
 evening. An ointment composed of Tannin, ten grains, Acetate or Mu- 
 riate of Morphia, two grains, pure Lard, or Spermaceti ointment, one 
 ounce, has also been advantageously employed as a local application. 
 All these ointments should be applied two or three times a day, and 
 be carried well up into the rectum. Occasionally the pain and irrita- 
 tion become so excessive that the direct application of anodynes will 
 be called for. Cocaine may be employed ; a four per cent, solution 
 will usually mitigate the suffering. Many other remedies have been 
 employed in piles with benefit, and others may suggest themselves to 
 the mind of the practitioner, but whatever local means may be used, 
 it is of the greatest importance to keep the bowels regular, the diet 
 spare but nutritious and easily digested, and avoid too much exercise, 
 or even long standing.
 
 238 KINGS KCLKCTIC OI'.STKTKK 'S. 
 
 Should hemorrhage l>e present, it must be checked, especially when 
 considerable, or it may occasion miscarriage; for this purpose astrin- 
 gents, cold applications, and compression may be employed. A prep- 
 aration composed of Stramonium ointment, one ounce, Styptic powder 
 (calcined Sulphate of Iron), two drachms, and powdered Alum, one 
 drachm, employed as a local application, and introduced as far as 
 possible into the rectum by means of the finger or otherwise, will be 
 found very valuable in all cases of hemorrhoids accompanied with 
 hemorrhage. Persulphate of Iron, diluted about one-half, and ap- 
 plied on cotton or lint, will also act promptly in controlling the bleed- 
 ing. Injections of warm water may be used for this purpose, when 
 other means are not at hand. Fluid extract of Witch-hazel bark, 
 taken internally, has also proved very useful. 
 
 Prolapsus ani is occasionally met with as a concomitant of piles, or 
 it may occur independently; it is often attended with excessive pain 
 during an alvine evacuation, together with distressing tenesmus, and 
 is usually produced by the same causes which occasion piles, viz.: 
 pressure. This symptom is exceedingly annoying and distressing, 
 and but little can be done toward a cure of it, until after delivery is 
 accomplished, when, as a general thing, the cause being removed, a 
 spontaneous cure is effected. 
 
 With this complication, the parts are usually relaxed to the degree, 
 that extrusion of a portion of the mucous membrane of the rectum is 
 produced by the slightest causes. It is cpaite likely to follow constipa- 
 tion ; in some cases every evacuation of the bowels is followed by a 
 return of the difficulty; straining at stool, and coughing are also ex- 
 citing causes. Temporary relief is all that can be expected in the 
 way of treatment ; whenever the prolapsus occurs it should be returned 
 as soon as possible. Place the patient in the knee-elbow position, 
 anoint the fingers before manipulating the parts, and endeavor care- 
 fully to return the part first, which escaped last. This is a simple 
 operation, and one the patient can execute after a short time, without 
 professional assistance. If painful, the protrusion can be painted with 
 a solution of Cocaine before an attempt is made to return it, after 
 which the parts may be supported by passing within the anus a pledget 
 of cotton, which may be saturated with Glycerole of Tannin, or other . 
 mild non-irritating astringents. The female should be instructed as 
 to the after treatment, in order to properly apply it in subsequent 
 attacks. Prolapsus ani is a very troublesome affliction during par-
 
 DISEASES OF THE PREGNANT FEMALE. 239 
 
 turition, as every pain is apt to cause a protrusion of the bowel, ren- 
 dering it irritable and most acutely sensitive. 
 
 Cramps of the inferior extremities, sometimes extending as high as 
 the upper pelvic region, are occasioned by pressure of the gravid uterus 
 upon neighboring nerves; they may likewise be occasioned by stand- 
 ing upright for a long time, too much exercise, fatigue, constipation, 
 or extension of ligaments. They are sudden in their attacks, are occa- 
 sionally very frequent and painful, and mostly occur during the latter 
 months of pregnancy. Friction over the affected part, and change of 
 position will ordinarily remove them; and when they are frequent in 
 their attacks, relief can often be afforded, and this disposition to fre- 
 quency obviated, by an attention to the bowels, together with the use 
 of Macrotys, or Xanthoxylum. Viburnum will often overcome this 
 trouble, especially if the patient take the recumbent position during 
 its administration, and so remain, quietly, until the paroxysm sub- 
 sides. The application of a liniment composed of equal parts of Aq. 
 Ammonium, Turpentine and Olive oil, will be found quite serviceable 
 in relieving the spasm of the part. The soreness caused by the cramps 
 may remain for sometime after their cessation, and may be removed 
 by rubbing the parts with some Camphorated oil, or the officinal com- 
 pound tincture of Camphor. . Gelsemium may also be administered 
 with benefit. 
 
 The pregnant female frequently suffers from a deep seated pain in 
 the right side, which most commonly manifests itself after the fifth 
 month; it is unaccompanied by cough, or any febrile or inflammatory 
 symptoms, and is attributed to the fundus of the uterus pressing 
 against the concave surface of the liver. It is not present until after 
 the ascent of the uterus above the superior strait never occurs in left 
 lateral, or anterior obliquity of the uterus, but only in right lateral 
 obliquity, and is much relieved, after the eighth month, by the falling 
 or descent of the uterus into the pelvis. Permanent relief can not be 
 had until after delivery, yet when severe, the female may derive con- 
 siderable benefit from change of position, standing, lying on the left 
 side, stretching upward, and leaning to one side ; in addition to which 
 the bowels should be kept free. At least one evacuation should be 
 solicited daily. Regularity in going to stool will often correct any 
 irregularity in this regard. Proper attention to diet, and judicious 
 exercise should be advised. One drop of Nux in a glass of water
 
 J4 KING'S ECLECTIC OBSTETRICS. 
 
 may be taken each morning, or mild laxatives, if they become neces- 
 sary. When the pain is excessively severe, cupping will sometimes 
 mitigate it. The diet should be light and non-stimulant. 
 
 Jaundice, occasionally occurs during pregnancy, and is owing to 
 pressure upon the gall-ducts by the neighboring viscera, which are 
 compressed by the gravid uterus, in consequence of which there is not 
 a free escape of bile; it is more severe when it happens during the 
 latter months, and is usually attended with dyspeptic symptoms. But 
 little can be done for this evil; though it .is proper to regulate the 
 bowels, and attend to the diet. Should it remain after delivery, it 
 must be met with the appropriate treatment. 
 
 Females who have given birth to many children are sometimes 
 annoyed with a lax condition of the abdomen, in which the abdominal 
 parietes, from their excessive looseness, do not afford support to the 
 enlarged uterus, thereby allowing it to fall in any direction. The best 
 treatment, in such cases, is a local application composed of astringent 
 and slightly-stimulant agents, together with mechanical support by 
 means of an appropriate belt or bandage, and the patient should as- 
 sume the recumbent position daily, for three or four hours at a time. 
 
 In opposition to this, we frequently meet with a very rigid condition 
 of the abdomen, in which its parietes do not give way in proportion to 
 the gradual augmentation of the volume of the uterus. This is most 
 common among primiparse, occasioning much distress, in consequence 
 of the tender and irritable condition of the parts, the skin over which 
 often cracks. This may sometimes be relieved by rubbing Sweet oil, 
 Almond oil, simple ointment, etc., over the part, and if very painful 
 or tender, it may be relieved by hot, or soothing applications, Cloths 
 wrung out of hot water, or a fomentation of Hops. If abrasions exist 
 the parts may be painted with a solution of Cocaine. Internal treat- 
 ment is useless. 
 
 There are other symptoms occasionally met with during pregnancy, 
 which are due to pressure, or nervous and vascular sympathetic de- 
 rangement, and \vhich deserve a passing notice. Thus, in the latter 
 months of pregnancy, females are unable to retain their urine, which 
 escapes upon the least exertion, and may or may not be accompanied 
 with tenesmus or a frequent desire to evacuate the bladder; this incon-
 
 DISEASES OP THE PKEGXANT FEMALE. 241 
 
 tinence of the urine seldom admits of relief until the removal of the 
 cause the pressure of the bladder by the enlarged uterus by deliv- 
 ery; perhaps, some benefit may accrue by giving support to the abdo- 
 men. It is a very annoying symptoin, but is by no means dangerous. 
 
 Occasionally, pustules around the genital organs may appear, or 
 vaginal mucous discharges of a whitish color, tinged sometimes with 
 green, or blood. These symptoms disappear after delivery, and require 
 no other treatment than cleanliness, frequently bathing and injecting 
 the parts with Fluid Hydrastis, or solution of Borax, or other similar 
 combination. The practitioner must be careful not to injure his pa- 
 tient's reputation as well as his own, by pronouncing either of these 
 as syphilitic, on too slight grounds, for they are often the legitimate 
 results of pregnancy. 
 
 Pressure of the uterus is apt to occasion congestion of various 
 organs, especially of the lungs, or stomach, in consequence of which 
 hemoptysis or hematemesis may result from exudation of blood from the 
 mucous membrane. These hemorrhages may be treated by laxatives, 
 sedatives, astringents, and the means usually employed for them when 
 existing at other times. Should they, at the time of parturition, be- 
 come excessive, resisting the treatment employed, the delivery should 
 be hastened by artificial means. 
 
 There are likewise symptoms which occur during utero-gestation, 
 depending upon an abnormal condition of the uterus, its supports, or 
 its contents. Among the displacements of the organ, prolapsus or 
 descent, are the most common, and it usually takes place during the 
 first months, before the ascent of the uterus above the superior strait; 
 though it must not be forgotten that, during the early weeks of preg- 
 nancy, there exists, probably from an augmentation of the weight of 
 this organ, what may be termed a normal prolapsus; but when it 
 exceeds this normality it then becomes abnormal and demands treat- 
 merit. The patient will complain of a bearing-down sensation, with 
 pain and uneasiness in the sacral region, and frequently in the lower 
 part of the abdomen. The prolapsus will be more or less perfect ac- 
 cording to the capaciousness of the pelvis, and the laxity of the liga- 
 ments. Where there is an excess of pelvic dimension, a sudden 
 prolapsus may take place in an advanced stage of pregnancy, from 
 straining, over-exercise, or some unusual exertion. This displacement 
 not only occasions abortion, but is frequently caused by it, from the 
 16
 
 242 KING'S ECLECTIC OBSTETRICS. 
 
 uterus being left in an inflamed or hypersemic condition ; it may also 
 be produced by straining, debility, and whatever circumstances would 
 give rise to it in the uuimpregnated state. This difficulty may give 
 rise to very serious evils, and should be promptly treated. Ordinarily, 
 the employment of astringent vaginal enema, rest in the recumbent 
 position, the wearing of external supports or bandages, and regularity 
 in the evacuations from the bladder and bowels, will answer the pur- 
 pose. In very severe and obstinate cases other measures may be 
 required; the rectum and bladder should first be evacuated; the pro- 
 lapsed organ should then be carefully placed in its proper position, 
 and retained there by a piece of fine sponge introduced into the vagina, 
 and the patient should maintain as much as possible the recumbent 
 position, until the increased volume of the uterus would prevent any 
 further prolapse. The sponge may be moistened with some astringent 
 lotion, if desired, and should be cleansed every two or three days. 
 Any accompanying symptoms, as debility, constipation, etc., must be 
 met by appropriate treatment. If the mechanical treatment, by sponge 
 or other pessary, occasions irritation, increased suffering, or pain, it 
 will have to be omitted, and the preceding measures be pursued. 
 AVhen we find an impaction of the uterus within the pelvis, render- 
 ing its reduction impossible, abortion will have to be induced. 
 
 Retroversion of the gravid uterus, is sometimes met with, as well as 
 in the unimpregnated organ ; in this displacement, the fundus is found 
 backward, at or below the promontory of the sacrum, while the os 
 tincse is carried forward and upward, either upon, or above the pubic 
 symphysis, and the vagina being dragged along with the os, its ante- 
 rior wall will be likewise carried forward and upward, while its pos- 
 terior wall will be considerably depressed. Retroversion of the uterus 
 may come on slowly or suddenly, it seldom exists in the latter months 
 of pregnancy, and usually takes place between the second and fourth 
 months. It may be owing to various causes; a very common one is 
 a retention of urine until the bladder becomes enormously distended, 
 which extending backward and downward, thrusts the uterine fundus 
 along with it in the same direction ; or a large pelvis may predispose 
 to this accident, but it is not an essential condition ; relaxed condition 
 of the uterine supports, augmented weight of the fundus with relaxa- 
 tion of the parts, great concavity of the sacrum, ovarian enlargement, 
 tumors, violent efforts, straining at stool, blows, falls, vomiting, poly- 
 pus, hydatids, etc., are each capable of effecting this displacement
 
 DISEASES OF THE PREGNANT FEMALE. 243 
 
 under favorable circumstances. The symptoms accompanying retro- 
 version are, a partial or complete retention of urine, which often takes 
 place suddenly ; when it is partial there is a desire to urinate frequently, 
 the water passes off in small quantities at a time, but never in suffi- 
 cient amount to empty the bladder, and finally, it involuntarily drib- 
 bles away, and the enormous distension of the bladder creates a chronic 
 inflammation, or what is yet worse, it may become ruptured. Defe- 
 cation is also very difficult, the feces being flattened and passing in 
 small quantities; and both the dysuria and difficult defecation are in- 
 creased by any efforts at evacuation. When retention of urine is pres- 
 ent in the early months of pregnancy, the practitioner should suspect 
 retroversion, and adopt the proper means to satisfy himself in relation 
 to it. In connection with these two prominent symptoms, there w r ill 
 be an aching pain in the sacrum, thighs, and pubes, with weight in 
 the pelvis and disagreeable bearing-down sensations. When retrover- 
 sion is suspected in the pregnant female, an examination should be 
 immediately demanded, for if it be not promptly attended to, it may 
 occasion the death of both the mother and child, as may be readily 
 imagined, when an enlarging uterus becomes impacted in the cavity 
 of the pelvis, preventing micturition by its pressure upon the urethra, 
 causing irremediable constipation by compression of the rectum, and 
 intense suffering by pressure upon the anterior sacral foramina and 
 nerves. Upon an examination per vaginam, which must in all cases 
 be made, the uterine fundus will be found depressed below the prom- 
 ontory of the sacrum, with the cervix toward the bladder, and higher 
 than the crown of the pubic arch; in some instances, the os uteri may 
 be found in its normal position, with the fuiidus depressed, the cervix 
 being bent or flexed at an angle, in which the uterus is shaped some- 
 what like a retort; this is termed retroflexion, and is not common in 
 the pregnant condition. If this displacement be not relieved, the pains 
 continue to increase, vomiting takes place, with peritonitis, and the 
 patient dies from inflammation or sloughing ; and it must be remem- 
 bered, that the later the gestating period in which the retroversion 
 occurs, the greater is the danger. 
 
 In treating a case of this character, before any attempt at reduction 
 is made, the bladder must be emptied by means of a male elastic 
 catheter, bearing in mind that the displaced uterus, having elevated 
 the neck of the bladder, causes an elongation of the urethra. Some- 
 times considerable difficulty will be experienced in introducing the 
 catheter, which may be overcome by pressing the uterus backward,
 
 244 KING'S ECLECTIC OBSTETRICS. 
 
 and thus liberating the urethra, until the instrument has entered. 
 Soon after the evacuation of the bladder it will often be found that 
 the uterus assumes its normal position without further interference; 
 should this not take place, the rectum must be unloaded by copious 
 injections, as an accumulation of fecal matter within it will very much 
 interfere with the attempt to replace the uterus properly. Though it 
 should be stated that injections have sometimes failed to produce the 
 desired effect, and instead of relieving has aggravated the difficulty. 
 The patient is now to be placed upon her face, or the operation may 
 be performed while she lies on her left side, with the nates near the 
 edge of the bed, and two fingers be passed into the posterior part of 
 the vagina along the curve of the sacrum, until they come in contact 
 with the presenting part of the depressed fundus, which must be pressed 
 cautiously and firmly upward and forward, in the direction of the axis 
 of the superior strait; for if the pressure be made in any other course, 
 no reduction can be accomplished. When the reduction is effected, 
 the womb assumes its position with a sudden jerk, and sometimes a 
 clicking noise. Sometimes this attempt will fail ; it will then be 
 proper to introduce one or two fingers into the rectum for the purpose 
 of pushing the fundus upward and forward, while a finger or two of 
 the other hand enters the vagina, for the purpose of bringing down 
 or depressing the cervix, and all these trials should be made steadily, 
 cautiously, and firmly. In very obstinate cases, the patient may be 
 placed on her knees, "having the pelvis elevated as high as possible, 
 while the shoulders rest upon the bed, table, or whatever she is placed 
 upon, and in this position, having the aid of gravitation, we may 
 undertake the last named manipulation; this posture is a favorable 
 one, inasmuch as it tends to overcome tenesmus and bearing-down 
 efforts. Various other means have been advised to reduce the retro- 
 verted organ as the use of Bond's instrument for retroversion ; Gariel's 
 India-rubber pessary, etc., and to produce a thorough muscular relaxa- 
 tion, the use of Chloroform, or Hydrate of Chloral. 
 
 Having accomplished reduction, the patient should be kept in a 
 recumbent state, until the ascent of the uterus above the promontory, 
 when its volume has so far augmented as to render any further dis- 
 placement of the kind impossible; and the bladder should likewise be 
 emptied every four or five hours . If necessary, anodynes or tonics 
 may be given according to the indications. Instances are sometimes 
 met with, in which, afcer the organ has been reduced, it will not re- 
 main so, but falls over again upon the slightest exertion, and the
 
 DISEASES OF THE PREGNANT FEMALE. 245 
 
 operation will have to be performed again and again before the reduc- 
 tion will remain permanent. In these cases advantage has ensued 
 from the introduction of a thin gum-elastic air bag, of a fusiform 
 shape, into the rectum; the large end of this to be introduced, after 
 which it is to be distended with air, and constantly worn by the 
 patient, until no longer required ; it admits of easy removal at auy 
 time by permitting the inclosed air to escape, and then withdrawing it. 
 
 The reduction of the uterus may only be partial, so that although 
 remaining in the pelvis, a part ascends, giving the organ a deformed 
 shape, still an attention to the bladder and rectum may enable the 
 patient to reach the full term ; in these cases the labor may be com- 
 pleted without artificial aid, though it may be tedious and difficult. 
 
 Where retroversion has occurred previous to pregnancy, and the 
 organ is rendered almost immovable by adhesions, or where from 
 other causes, after a persevering attention to the bladder and rectum, 
 no permanent reduction can be obtained, it has been proposed to 
 induce premature labor as the only means of saving life ; but \ve must 
 be cautious in a resort to this expedient, and should never undertake 
 it without the opinion of a second or even third practitioner. 
 
 In anteversion of the uterus, the displacement is exactly contrary to 
 the last ; the fundus pressing forward toward the symphysis pubis, 
 near the level of the superior strait, while the cervix is thrown back- 
 ward and upward, the os uteri looking toward the hollow of the 
 sacrum. This may originate from severe exertion while the bladder 
 is empty, and is more apt to ensue when the ligaments are in a relaxed 
 condition from blows, falls, tumors, diarrhea, relaxed abdomen, fecal 
 accumulations, lifting heavy weights, violent exercise, etc. The symp- 
 toms are, a constant desire to pass urine, which is accomplished with 
 some difficulty and heat; constipation is frequently present, with 
 pelvic heaviness, hypogastric pain, and a distressing, dragging sensa- 
 tion, which is augmented by standing or walking. It is rarely present 
 during pregnancy, and w r hen it does occur is not so serious as retro- 
 version. The treatment is : after placing the patient on her back, to 
 elevate the fundus and pull down the cervix with a finger, or hook, 
 and afterward, if required, a bandage may be worn, with a compress 
 over the pubes ; the bow r els should be kept open, but the urine should 
 not be passed too frequently. The woman should remaiiwlying upon 
 her back for several days or weeks, as may be required ; though from 
 the debility following a prolonged confinement of this kind, I gen-
 
 246 KING'S ECLECTIC OBSTETRICS. 
 
 erally advise more or less exercise, according to circumstances, the 
 uterus being held in place by a bandage, and proper support for the 
 time being. 
 
 An aqueous discharge, of a limpid, or yellow color, sometimes takes 
 place during pregnancy, being variable in quantity, at times passing 
 by drops, and again occurring suddenly and in large amount. It is 
 called hydrorrhea, or false waters. Usually this is not a serious affec- 
 tion, but occasionally uterine contractions of a severe character accom- 
 pany it, which, if not overcome, will result in the premature expulsion 
 of the uterine contents. As regards the source from which this fluid 
 originates, we have no satisfactory evidence ; authors vary in opinion 
 concerning it, some considering it to be the result of an uterine dropsy, 
 others to a transudation of the amniotic fluid through the membranes, 
 some again to a rupture of the allantois, or rupture of the chorion, and 
 caduca, etc. Most generally, the woman goes on to the full term of 
 utero-gestation. Where there is danger of miscarriage, the bowels 
 should be kept in a soluble condition by mild laxatives or injections, 
 the patient should be enjoined to keep in a state of rest in the recum- 
 bent position and agents administered to allay any uterine excitement, 
 among which I prefer the compound powder of Ipecacuanha and 
 Opium. As soon as any danger of premature labor has passed away, 
 the patient should take the Parturient Balm, or Macrotys, for the pur- 
 pose of imparting tonicity to the reproductive organs, in connection 
 with chalybeates if anaemia be present. When a symptom of this 
 character attacks a pregnant female, the practitioner should be careful 
 to ascertain the condition of the bladder, as not unfrequently a dis- 
 charge of urine may be mistaken for it. 
 
 Not unfrequentfy the uterus is attacked with spasmodic action the 
 organ may be felt rapidly moving from side to side, with frequent 
 convulsive movements, and will speedily induce premature labor if not 
 relieved. I find it the best treatment in these cases, to evacuate the 
 rectum by enema, and the application of heat to the part, as cloths 
 wrung out of hot water, while internally such agents as Macrotys, 
 Lobelia or Gelsemium may be given. Anodyne liniments may also 
 be rubbed on the abdomen. 
 
 The impregnated uterus is sometimes attacked with rheumatism, 
 commonly produced by the same causes which give rise to rheuma- 
 tism of other parts. It is most common to those of a rheumatic dia-
 
 DISEASES OF THE PREGNANT FEMALE. 247 
 
 thesis, and is frequently a metastasis of the pain from some other part. 
 The symptoms are pain, augmented sensibility of the uterus, which 
 may be limited to only a part of the organ, or extend over the whole 
 of it, no contractions, pressure often increases the pain, which may 
 extend into the loins, groins, and thighs, or which may suddenly be 
 translated to some other part of the system. There is tenesmus or a 
 constant desire to evacuate the bladder and rectum. 
 
 To remove this last condition, Eryngium, Gelsemium, or Rhus, may 
 be employed, together with the hot hip bath. Rheumatism as a rule 
 will be attended with more or less fever; the treatment, then, should 
 begin, by selecting the proper sedative in combination with anti-rheu- 
 matics; thus Aconite and Macrotys may be called for, or the pulse 
 being full and strong, Veratrum should be used in place of the Aco- 
 nite, or one of the other anti-rheumatics being indicated, it replaces 
 the Macrotys. The anti-rheumatics in common use are the Macrotys, 
 Bryonia, Apocynum, Phytolacca, Sticta, Colchicum, Rhus, and Eupa- 
 torium; Acetate of Potassa and Asclepias are also useful in some 
 cases. Within a few years several new agents, derivities of coal tar, 
 have been introduced to overcome pain; they are known as Antipy- 
 rine, Antifebrine, Antikamnia, as well as several others; they should 
 be given with care, and their action studied ; they are positively 
 contra-indicated in weakened heart action. Quinia is often a useful 
 agent, administered after secretion is established. The alkalies and 
 acids often prove valuable anti-rheumatics, especially the alkaline 
 diuretics. Baths, in these cases, are usually more harmful than 
 beneficial. 
 
 The movements of the fetus in utero, are sometimes very violent, or 
 turbulent, not only occasioning alarm to the mother, but much uneasi- 
 ness, a sense of sickness, with general nervous agitation, sleeplessness, 
 febrile symptoms, and often local pain. 
 
 This may be owing to an irritability of the nervous system, or to 
 some preternatural susceptibility of the uterus. It may be removed 
 by an attention to the bowels, and the administration of Viburnum, 
 Pulsatilla, Macrotys, or Gelsemium, either singly or in such combina- 
 tion as indications may direct; the Parturient Balm will frequently 
 prove beneficial ; and when obstinate, a few doses of the compound 
 powder of Ipecacuanha and Opium may be given. However, the 
 practitioner should bear in mind, that narcotics should be employed 
 as seldom as possible, during pregnancy, on account of their deleteri-
 
 248 KIND'S i-:< LKCTIC OBSTETRICS. 
 
 ous influence upon the nervous system of the fetus. The agents, as 
 named above, will, as a rule, act promptly in overcoming the trouble, 
 and should be used in preference. 
 
 Dropsy of the ovum usually takes place during the early months, and 
 may be suspected by an unnaturally great increase in the size of the 
 abdomen, which comes on suddenly, thereby differing from the gradual 
 enlargement in ascites, and which is rendered still more certain when 
 the pregnancy is positively determined. It is frequently, however, 
 very difficult to form a correct diagnosis, and some of our oldest and 
 most experienced practitioners have been mistaken in relation to it. 
 Abortion is the common result, the fetus generally perishing before 
 this accident occurs, especially if the collection of the fluid is great; 
 and should it be born alive, it seldom survives a few days, or weeks at 
 farthest. The only treatment, in this affection, is strict attention to 
 the health of the female, and an absolute avoidance of the operation 
 of paracentesis ; for no practitioner is justified in performing this 
 operation on a female who affords the smallest possible suspicion of 
 pregnancy ; at least until a sufficient time has elapsed for its determi- 
 nation by the positive signs, as revealed by auscultation, ballotteraerit, 
 etc. When the quantity of fluid is enormous, giving rise to serious 
 consequences, the propriety of inducing premature labor by evacuating 
 the amniotic liquid, may then be considered. Hemorrhage and Abor- 
 tion will be treated of in the following chapters. 
 
 The accidental concomitants of pregnancy, are hernia, tumors, syphi- 
 litic affections, calculus, deformed pelvis, and extra-uterine pregnancy ; the 
 latter two have already been treated upon, the others require no espe- 
 cial consideration at this place; they will be again referred to under 
 the head of Labor. The treatment for syphilitic affections will be the 
 same as pursued under other circumstances, independent of pregnancy.
 
 HEMORRHAGE AND ABORTION. 249 
 
 CHAPTER XXIII. 
 
 HEMORRHAGE AND ABORTION. 
 
 WHEN the fetus is capable of continuing its existence, independent 
 of any uterine connection, it is said to be viable; and the period of its 
 viability, theugh not precisely fixed, is generally admitted as early as 
 at the commencement of the seventh month. There are, however, a 
 few instances on record where children, born as early as the commence- 
 ment of the sixth month have been reared, but these may be considered 
 as the exceptions to the general rule. A fetus may move at birth, but 
 this does not constitute viability. In cases where it is non-viable, or 
 incapable of sustaining an extra-uterine existence, that is, previous to 
 the seventh month, and is expelled from the uterus, owing to any 
 cause whatever, an abortion is said to have taken place. Its expulsion 
 at any time between the seventh month and full term, is a premature 
 delivery ; and the term miscarriage is popularly applied to either of 
 these, indiscriminately, and generally conveys an idea of loss of off- 
 spring previous to the ninth month. 
 
 As hemorrhage and abortion are intimately related, being generally 
 dependent on, or connected with each other, I will consider them under 
 one head. Hemorrhage may take place at any period of pregnancy, 
 and is owing to a greater or less detachment of the ovum from the 
 uterus, and the more extensive the detachment, the greater is the 
 probability of, or disposition to abortion. In the earlier months, life is 
 seldom endangered by hemorrhage, in consequence of the smallness of 
 the uterine blood-vessels, which tlo not admit of a large and rapid dis- 
 charge of blood ; but in the latter months, where these vessels have 
 become much augmented in size, there is always danger from the 
 hemorrhage which may then occur. It should be stated here, that 
 women, laboring under hemorrhage in the earlier months, are occa- 
 sionally lost, the flooding obstinately resisting all treatment ; this is 
 more usual with debilitated or anaemic individuals, especially those who 
 have had previous discharges, with large loss of blood. 
 
 Abortion may be spontaneous, accidental, or designed, and may 
 occur at anytime prior to the seventh month, but more frequently about 
 the third or fourth month, and generally at a period coincident with 
 what would otherwise have been a menstrual period ; this is undoubt-
 
 ECLECTIC OI5STETKICS. 
 
 edly owing to the delicate connection existing between the ovum and 
 uterus at this time, Avhereby a separation of the former may ensue 
 more readily from even slight causes than in the latter months, when 
 this connection is more persistent. Abortion is not usually a serious 
 accident, as many females abort several times, successively, and few 
 women who bear offspring pass through their menstrual life without 
 aborting one or more times. The principal dangers are from excessive 
 hemorrhage, or the constitutional injury inflicted by a series of suc- 
 cessive abortions. The causes of this accident are numerqus, and have 
 been divided into constitutional, or depending upon the condition of 
 the maternal health ; ovuline, or attributable to some disease of the 
 ovum ; uterine, or originating from an abnormal state of the uterus 
 and its appendages; and accidental, or owing to circumstances not 
 immediately connected with the condition of the uterus, ovum, or 
 mother. 
 
 No particular class of females are especially liable to abortion ; it 
 occurs among those who enjoy the idle, sedentary, luxurious habits of 
 fashionable life, and among those who are obliged to earn their daily 
 subsistence by hard labor ; the most robust may abort as well as those 
 of a delicate and nervous disposition ; though it may, probably, be 
 more frequently observed among those who neglect an attention to the 
 rules of hygiene. Authors state that plethoric females, those who are 
 nervous or irritable, or extremely susceptible to external impressions, 
 and those of indolent habits, abort more frequently than others ; it has 
 likewise been stated that abortion may occur as an epidemic. The con- 
 stitutional causes are tuberculous diseases, as scrofula, anemia, phthisis, 
 and recent cutaneous affections, epilepsy, hysteria, abdominal tumors, 
 leucorrhea, diarrhea, dysentery, constipation, strangury, or, measles, 
 scarlatina, pelvic peritonitis, typhoid fever, small-pox, and other acute 
 diseases. Syphilis is likewise a common cause. Among these causes, 
 when they occur, probably, syphilis, epilepsy, small-pox, and scarlet 
 fever, are the most certain. Ascarides, piles, or other diseases of the 
 rectum, as well as of the bladder, ovaries, and kidneys, by the irrita- 
 tion they communicate to the uterus, may likewise become causes. 
 
 Females, during pregnancy, or even after a recent confinement, 
 should never be vaccinated, because in either case it exposes them to 
 great hazard ; this- is a point to which especial attention should be paid, 
 not only on account of the abortion which would very probably follow, 
 in the first condition, but, in either, violent fever or inflammation of 
 the veins, might be produced, resulting in death.
 
 HEMORRHAGE AND ARORTIOX. 251 
 
 The ovuliue causes are numerous; thus, the fetus may be affected 
 with the parental diseases, as measles, small-pox, scarlatina, lead pois- 
 oning, mercurial salivation, typhus, etc., which may either occasion 
 its death, or cause its attachment to the uterus to become so delicate 
 as to render abortion unavoidable. Syphilitic disease may be commu- 
 nicated to the ovum by the male parent, as well as the female ; and a 
 seminal fluid vitiated by debauchery, or having its vitality enfeebled 
 by age, may also give rise to an unhealthy embryo, the result of which 
 will be an abortion. Atrophy, also hypertrophy of the placenta, may 
 so debilitate its connection with the uterus as to become a cause of 
 this accident. An effusion of blood between the placenta and uterus, 
 termed by M. Cruveilhier placental apoplexy, may separate the pla- 
 cental connection, and give rise to abortion ; placentitis, hydatids, 
 syphilitic or fatty degeneration of the placenta or chorion, rupture of 
 the umbilical vein, etc., will also produce it. Whenever the fetus is 
 dead, from whatever cause, it becomes a foreign body, excites uterine 
 contraction, and must inevitably be expelled, though frequently some 
 time may pass between its death and expulsion. Other diseases of 
 the embryo or its appendages as, hydrocephalus, pulmonary disease, 
 disease of the chorion or amnion, etc., may likewise occasion abortion. 
 Indeed, it is supposed, that the most common causes of this accident, 
 are those referable to the condition of the ovum. 
 
 Among the uterine causes are, prolapsus, retroversion, anteversion, 
 adhesions, uterine irritability, uterine congestion, fibroid tumors, poly- 
 pus, cancer of the cervix, diseases of .the tubes or ovaries, ulceration 
 of the cervix, corroding ulcer, etc. Madam Boivin found that, among 
 a great proportion of those females who habitually aborted at a regu- 
 lar period of utero-gestation, dissections revealed uterine adhesions to 
 the bladder, rectum, or other neighboring organs ; of course, if these 
 adhesions are considerable, there can be but little expectations of cure. 
 
 The accidental causes are falls, blows, coitus, severe exercise, lifting 
 heavy weights, working on sewing machines, rough motion on horse- 
 back, in carriages, or, in railroad coaches, or violent concussion of the 
 body from jumping; and the membranes'of the ovum may be so frail 
 as to rupture upon a very slight compression of the uterus, occasioned 
 by coughing, sneezing, extracting a tooth, or straining at the stool. 
 Abortion is also occasioned by emesis, drastic purgation, tight-lacing, 
 terror, grief or excess of joy, together with the criminal means fre- 
 quently employed for this purpose. It is unnecessary to enter into 
 a detailed relation of these causes, as they can seldom be obviated 
 by the practitioner, whose principal efforts will be directed toward
 
 252 KING'S ECLECTIC OBSTETRICS. 
 
 preventing their results from becoming dangerous. Some women abort 
 from the slightest causes, while with others again, the most serious 
 accidents produce no influence of this kind. It is stated that abortion 
 has been caused by the mere smelling of a pungent odor, but I pre- 
 sume such instances must be very rare. Among newly-married 
 jxT.-oiis, abortions frequently occur from the abuse of coition, and this 
 will likewise prove a very fertile cause of the accident among child- 
 bearing females at any period, especially when they have some 
 displacement or disease of the uterus; and I am fully of the opinion 
 that what are termed, "abortions from habit," are chiefly due to this 
 act. A recent author claims that fully one-half the spontaneous abor- 
 tions 'are directly the result of excessive sexual indulgence during 
 pregnancy. As a general rule, it may be observed, that when the 
 ovum is healthy, and its placental connection is firm, the production 
 of abortion in a pregnant female will be found very difficult to effect, 
 except it be attempted by some mechanical means, when it will be 
 apt to assume its more serious character; but if the ovum be diseased, 
 the tendency to abort will be in proportion to the influence of the 
 disease upon it, and its placental connection with the uterus. 
 
 Abortion is undoubtedly produced by the mammary irritation result- 
 ing from continued lactation during pregnancy; and with many 
 females, conception, as well as menstruation, is retarded while the 
 child continues to suck. But whenever the menses appear during suck- 
 ling, the child should be immediately weaned, both for its own advant- 
 age as well as that of its mother ; and the same course should be 
 adopted when pregnancy happens. Frequently, a threatened abortion 
 may be checked, and the female be enabled to reach full term, by 
 immediately weaning the child upon the first appearance of pain or 
 bloody discharges. 
 
 The symptoms of abortion are very much modified by the causes 
 which produced it, and the period of pregnancy at which it occurs. 
 If it happens during the first days of pregnancy, it is accompanied by 
 little or no pain, and is often mistaken by the female for a difficult 
 menstruation ; and the ovum which usually passes away entire, and 
 accompanied by a greater or less amount of blood, is looked upon 
 merely as a coagulum or clot. When the pregnancy is more advanced, 
 and especially when the abortion proceeds slowly and gradually, vari- 
 ous premonitory symptoms may present themselves, as a feverish or 
 irritable condition of the system, loss of appetite, nausea, cold extremi- 
 ties, swelling of the eyelids, with lividity, mental depression, intermit- 
 tent pains in the loins, a sensation of weight about the vulva, frequent
 
 HEMORRHAGE AND ABORTION. 253 
 
 desire to urinate or defecate, and flaccidity of the breasts; the pains 
 continue to increase in frequency and force; they extend over the 
 abdomen, running toward the coccyx, and finally assume the characters 
 of true uterine contractions. A sanious and bloody vaginal discharge 
 takes place, and, as the pains continue, the dilatation of the os uteri 
 progresses, the membranes protrude, become ruptured, the liquor 
 amnii escapes, and, sooner or later, the ovum, either entire or in part, 
 i.s expelled. As all these symptoms, with the exception of rupture of 
 the membranes, may occur in pregnancy without any subsequent abor 
 tion, the practitioner must be guarded in his diagnosis, unless he 
 knows positively that the fetus is dead. 
 
 Most frequently, however, there are no precursory or constitutional 
 symptoms; the first sign being the hemorrhage, which is more or less 
 abundant, and is followed by a cessation of the fetal movements, 
 diminished size of the abdomen, flaccid breasts, a sense of coldness in 
 the hypogastrium, uterine contractions or pains, and expulsion of the 
 fetus. If the fetus is dead, or the liquor amnii has been discharged, 
 abortion will almost certainly take place, sooner or later, though no 
 time can be positively determined after the death of the fetus, for its 
 expulsion. 
 
 Between dysmenorrhea and abortion there is considerable resem- 
 blance in the character as well as the seat of the pains; both are 
 intermittent, and both cease after expulsion of the uterine contents; 
 hence, it becomes the accoucheur to proceed cautiously in forming his 
 diagnosis. He must first endeavor to ascertain whether pregnancy 
 has. taken place ; failing in this, he must inquire into the character of 
 the previous menstruations, whether they were painful, accompanied 
 with much hemorrhage, etc. And he should never fail to examine all 
 the discharges, especially the clots, if they have not been thrown away, 
 breaking them down between the fingers, and among which he may 
 discover the entire ovum, or only a portion of it; indeed he should 
 require the nurse to save all the discharges during the progress of the 
 abortion, that he may, by this examination, not have a clot of blood 
 mistaken for the ovum, and every practitioner should perfect himself 
 in a knowledge of this kind, not only by an examination whenever 
 the opportunity occurs, but also by procuring, if possible, ten or 
 twelve specimens of ova at various periods of pregnancy, and preserv- 
 ing them, so as to accustom the eye to a familiarity with them; though 
 it must not be forgotten, that the ovum may pass away without having 
 been observed, or even be discharged in minute portions with the 
 sanguineous discharge, more or less hemorrhage continuing for some
 
 jr>4 KING'S ECLECTIC OBSTETRICS. 
 
 time subsequently. If he ascertains that the former menstruations 
 were healthy, and that between the present difficulty and the last 
 menstruation, one or two months have been passed without any dis- 
 charge, these are strong grounds for suspecting abortion; if pregnancy 
 e\i.-ts, abortion is undoubtedly in progress. The blood in dysmen- 
 orrhea is menstruous, while that in abortion is sanguineous, and 
 escapes in larger quantities than is usual to the catamenia. The finger 
 should likewise be introduced into the vagina for the purpose of ascer- 
 taining the condition of the cervix, and if it be found shorter than 
 normal, its orifice patulous and sufficiently dilated to admit the end 
 of the finger, and especially if during a pain, the membranes are 
 found tense and protruding, the diagnosis becomes more certain. 
 
 The diagnosis of abortion is more positive as the period of utero- 
 gestation advances, because the development of the uterus can then be 
 readily ascertained, the pains will be more violent, the hemorrhage 
 more abundant, and the dilatation of the os uteri more easily detected. 
 After the fifth month the death of the fetus may also be more posi- 
 tively ascertained by auscultation, which will fail to detect the sounds 
 of the fetal heart, and if it has been dead for a few days, there will be 
 found an emaciation and flaccidity of the breasts, a diminution in 
 volume of the abdomen, with weight in the hypogastrium, dragging 
 sensations about the loins, and cessation of the fetal motions which 
 were previously observed by the female. In the early months of 
 pregnancy, if nausea, vomiting, or other sympathetic irritations con- 
 nected with this condition, and which are present with a patient, 
 beqome suddenly suspended, it affords grounds for suspicion of ap- 
 proaching abortion. 
 
 The prognosis of abortion varies according to its cause, as well as 
 the period in which it occurs; females who abort are always exposed 
 to more danger than when delivery takes place naturally at full term. 
 In a few cases, death takes place during the accident, but more com- 
 monly no immediate fatal effects happen, though they are very apt to 
 ensue as secondary results, being the consequence of some chronic 
 disease of the uterus, ovaries, etc., produced by the abortion. Females 
 at full term are more subject to acute maladies, which often prove 
 immediately fatal, while the serious results of abortion more commonly 
 manifest themselves at a remote period ; yet grave consequences may 
 occur speedily under either of these conditions. Abortion is very 
 generally unfavorable to the fetus, because its expulsion happens 
 during its stage of non-viability, and its death must inevitably take
 
 HEMORRHAGE AND ABORTION. 255 
 
 place; or, the abortion may have been determined by its death. In 
 this latter ease, the fetus, acting as a foreign body, excites the uterus 
 to contractions : but this eifect may not take place for weeks and even 
 months after its death. 
 
 Abortion occurs with more difficulty, and is attended with more 
 danger, after the second month of pregnancy than before, on account 
 of the increased size of the ovum, and the unfavorable condition of 
 the cervix to dilatation; and the more advanced the pregnancy, the 
 greater is the danger from hemorrhage. Probably, abortions occuring 
 during the third and fourth months of pregnancy, are, as a general 
 rule, more dangerous than at any other period. If the hemorrhage is 
 profuse, abortion will be very apt to follow, though the practitioner 
 must bear in mind, that large and frequent hemorrhages may occur, 
 and yet pregnancy continue to the full term. If the pains occur at 
 regular intervals, with dilatation of the os uteri, and protrusion of 
 the membranes, the abortion almost always follows ; and if the mem- 
 branes be ruptured, it will certainly occur; though I know of one in- 
 stance in which, in order to effect an abortion, the membranes had 
 been perforated, and a large amount of fluid (liquor amnii) escaped, 
 and yet the woman went to full term with a living fetus. The death 
 of the fetus will likewise positively determine it, though a few in- 
 stances are related of an opposite character. 
 
 If the abortion be produced by constitutional, accidental or mechan- 
 ical causes, it is usually more violent or alarming in its results, than 
 when owing to the uterine or ovuline. When it occurs during acute 
 attacks, as measles, erysipelas, scarlatina, small-pox, typhus, etc., being 
 the result of the severity of the attack, it is very apt to prove fatal, 
 especially when it takes place before a mitigation or cure of the acute 
 disease has been effected. When produced mechanically, the principal 
 danger is from hemorrhage, peritonitis, or metritis. Usually, the more 
 slowly the abortion comes on, the less danger is there to fear from 
 hemorrhage, though the constitutional effects are more to be dreaded, 
 than when it is accomplished with rapidity. Previous abortions 
 always exert an unfavorable influence upon subsequent pregnancies, 
 predispo'sing to a similar accident, and which, of course, requires the 
 especial attention of the practitioner. 
 
 The ovum, in an abortion previous to the third month, is usually 
 expelled entire, but after this period it commonly proceeds as at full 
 term, the liquor arnnii being first discharged, followed by the embryo, 
 and sooner or later by the placenta. At the third and fourth months.
 
 256 KING'S ECLECTIC OBSTETRICS. 
 
 the placenta has considerably augmented in size, and has likewise 
 formed close adhesions with the uterus ; and this latter organ, though 
 it may have acquired a degree of contractile power sufficient to expel 
 the ovum, does not possess the contractility of tissue as developed at 
 full term, and is frequently incapable of overcoming the attachment 
 existing between it and the placenta. In an abortion at this period, a 
 partial evacuation of the uterine contents, is very apt to be followed 
 by a closure of the os uteri, and a cessation of the symptoms, leading 
 the practitioner to believe that the abortion has happily terminated ; 
 but after several days the hemorrhage, generally preceded and accom- 
 panied with pains, again appears with increased severity, and if the 
 cause be not removed, the patient dies. The cause, in this instance, 
 is a retained placenta and membranes; the utero-placental adhesions 
 having been overcome, hemorrhage, and sometimes copious hemor- 
 rhage, follows the separation of the placenta from the uterus, which 
 remains detached in the uterine cavity, irritating the uterus and pre- 
 venting its complete contraction, thereby promoting an increased 
 hemorrhage, and causing a fatal termination, if the patient be not 
 relieved by art. And whenever hemorrhage occurs, several days 
 subsequent to an abortion, the practitioner should always suspect the 
 presence of the placenta and membranes within the uterus, without 
 regard to the statements that may be made to him, affirming that these 
 have been expelled. He should at once make a vaginal examination, 
 when he will probably find a partially dilated os uteri, with a portion 
 of the placenta protruding. Should the placenta be only partially 
 detached, the os may be slightly dilated, but without protrusion of the 
 placenta, depending however upon its situation and extent of separa- 
 tion. Occasionally, the placenta decomposes, the uterine discharges 
 become fetid, absorption of the putrid matter takes place, and an 
 irritative fever ensues, requiring all the skill of the practitioner to 
 overcome, or to avert its fatal eifects. Putrefaction of the dead fetus 
 takes place only when the membranes are ruptured, which admits the 
 air into the cavity of the uterus ; decomposition without putrefaction 
 ensues when the membranes are entire. Absorption of the placenta 
 has been observed, both after an abortion, as well as after a 'natural 
 accouchement. Sometimes an effusion of blood into the placenta may 
 occur, and by imparting to it a kind of organization, produce wha< 
 are known as " fleshy moles." 
 
 The TREATMENT varies according to the symptoms which are 
 presented the principal indications being, to prevent the abortion if
 
 HEMORRHAGE AND ABORTION. 257 
 
 possible, and when this can not be effected, to assist the expulsion of 
 the uterine contents, and likewise to remedy any subsequent accidents. 
 When the pains are somewhat continuous, and are experienced pre- 
 vious to the hemorrhage which considerably mitigates their severity, 
 the case is very probably one of uterine congestion; but when the 
 hemorrhage is observed first, followed by pains increasing in severity 
 and with well marked remissions, abortion is about to ensue. In all 
 cases of abortion, the practitioner should carefully examine the con- 
 dition of the cervix, except in instances where the death of the fetus 
 has been positively ascertained; if it be of normal length nud thick- 
 ness, but slightly dilated, unfavorable to the speedy expulsion of the 
 ovum, and if the hemorrhage be not too threatening, an attempt may 
 be made to check its farther progress; but if it be dilated, short, the 
 os patulous, and attended with considerable hemorrhage, means must 
 be adopted w r hich will favor the speedy expulsion of the uterine con- 
 tents. And in making this examination, no roughness or violence 
 must be used, lest the symptoms of the abortion be aggravated. 
 
 In a great number of cases, whether abortion ensues or not, all the 
 treatment required will be, rest in the recumbent position, a cool, 
 hard bed, perfect quiet, avoidance of stimulants, and all excitement, 
 quieting of nervous fears or anxieties, cooling drinks and light diet, 
 with an occasional dose of the compound powder of Ipecacuanha and 
 Opium, say four or five grains repeated every two, three, or four 
 hours, for the purpose of subduing the pains. It is claimed by the 
 most recent writers, that to arrest uterine action, nothing can be com- 
 pared with Opium ; it is recommended in half-grain doses, repeated 
 in thirty minutes, if necessary, to allay uterine excitation and control 
 the pains. Laudanum may be used; a drachm in starch-water 
 enema. But where this course does not speedily effect a mitiga- 
 tion of the symptoms, there having been no escape of the liquor 
 amnii, Viburnum Prunifolium should be given; one or two 
 drachms to four ounces of water, in teaspoo^ful doses, will usually 
 prove efficient. A blister applied to the sacrum was formerly 
 much in use; it will likely prove beneficial in some cases, and should 
 be tested where other means fail. Should any displacement of the 
 uterus, or other affection exist, it must be treated as heretofore advised. 
 Nauseating with a preparation composed of three or four parts of the 
 tincture of Lobelia, and one of the tincture of Opium, has been rec- 
 ommended and successfully employed in some cases, but I deem it 
 inferior to the means above named; although it may be used, should 
 17
 
 _'.">> KING'S ECLECTIC OBSTETRICS. 
 
 that fail. Care is required not to cause emesis, which might render 
 the abortion inevitable. The administration of Stramonium seed has 
 been highly spoken of, but I have never seen its action in such 
 cases, and can, therefore, say but little about.it. Tincture of Cannabis 
 Indica, in doses of five or six drops every one, two, four or six hours, 
 has also been advised as an anodyne as well as to arrest the sanguin- 
 eous discharge. If the hemorrhage be slight, it may not require any 
 special attention, but when it is considerable, effort should be made to 
 check it. For this purpose, cloths wet in cold vinegar and water, or 
 ice applied to the hyp9gastrium and pudendum has been recommended; 
 but the application of ice within the vagina, or cold vaginal injec- 
 tions, recommended by some authors, should be used with great 
 caution, lest they produce the accident we are attempting to avert. 
 Injections of water as hot as can be endured, will give better results, 
 and affect the patient more pleasantly. In cpnnection with these, in- 
 ternal means may be used, a few drops of the oil of Erigerou, or oil of 
 Erechthites may be given, in mucilage or on sugar, evey ten, thirty, 
 or sixty minutes, according to the severity of the hemorrhage ; or a 
 powder composed of burnt Alum and Sulphate of Iron, three grains, 
 Capsicum, one grain, may be administered as often as the urgency of 
 the symptoms demand; the burnt Alum and Sulphate of Iron form a 
 valuable hemostatic, and may be made by mixing together two parts 
 of Sulphate of Iron and one of Alum, and exposing them to heat in a 
 stone or clay dish, until the mixture assumes a reddish color. Other 
 astringents may be employed in the absence of those named, as Tan- 
 nin, Hamamelis, Gallic Acid, etc. An agent in common use as a 
 hemostatic is powdered Alum and Nutmegs; the late Prof. Meigs 
 recommended it in the proportion of five grains of the former to one 
 of the latter as a dose, to be repeated every half-hour or hour. It 
 will frequently be found that internal remedies derange the digestive 
 organs and occasion constipation, without everting any influence what- 
 ever upon the hemorrhage ; in such instances a soft sponge, or plug 
 of cotton wadding moistened with solution of Alum, Tannin, or Per- 
 chloride of Iron, and introduced within the vagina so as to slightly 
 press against the os, will promote coagulation and tend to arrest the 
 flow; and this application may be worn for several hours at a time, 
 changing it only as required. I regard the solution of Perchloride 
 of Iron, as just mentioned, as one of the most reliable agents at our 
 command, in controlling uterine hemorrhage, and have frequently 
 gotten prompt results from it, after other means have failed. It may
 
 HEMORRHAGE AND ABORTION. 259 
 
 be used on absorbent cotton, after which all coagula resulting 
 therefrom should be removed by hot water vaginal injections. 
 A rectal enema, composed of Lloyd's Ergot, two fluid drachms, 
 thin Starch solution, one fluid ounce, retained in the rectum for an 
 hour, repeating it two or three times a day, if necessary, has proved 
 successful in some instances in arresting the pains and checking the 
 hemorrhage. It is not required that the patient should be confined 
 to the recumbent posture for more than the first two or three days, 
 and, subsequently, even though some flow be present, only occasion- 
 ally, according to the symptoms; a constant lying in bed will affect 
 the general health, occasion anorexia and nervous excitement, and 
 rather tend to facilitate instead of prevent the abortion. On the 
 other hand, should there exist any congestion or irritability of the 
 uterus, an erect position, or any bodily movements, increase the 
 liability to abort, hence, these conditions must be removed before 
 allowing the female to move about. 
 
 Should these means fail to arrest the hemorrhage, and there is no 
 doubt in the mind of the practitioner but that the expulsion of the 
 ovum must take place is inevitable the tampon or plug should be 
 employed. This consists of pieces of linen cloth, muslin, silk, or 
 balls of absorbent cotton. The tampon can, as a rule, be best applied 
 by using Sims' speculum. It is always well to wash the vagina out 
 with hot water; then, if the cotton is used, the balls may be carried 
 to the parts by means of dressing-forceps, firmly packing them around 
 the cervix. The first few balls should be sprinkled with lodoform. 
 If muslin is used, the pieces should be about, three or four inches 
 square, which are separately introduced into the vagina, until it is 
 completely filled and distended; these are to be kept in place by a 
 napkin or bandage, and may be allowed to remain for six or twelve 
 hours, but never to exceed twenty-four. Sometimes sponge is used, 
 but I think it inferior to the pieces just referred to. The first piece 
 introduced may be medicated with Tannin, Alum, or other astringent, 
 and the remaining pieces forming the tampon should be moistened 
 with Carbolized Oil, to admit of their ready removal, and to act as an 
 antiseptic. It must be especially borne in mind by the practitioner, 
 that the tampon is never, under any circumstances, to be used after 
 the fifth month of pregnancy ; because, the uterine capacity having 
 become much augmented, its cavity may become distended with 
 blood or coagula, and cause a fatal result. Previous to the fifth 
 month, however, it is incapable of containing an amount of blood
 
 260 KING'S ECLECTIC OHSTHTKICS. 
 
 sufficient to prove fatal from a concealed hemorrhage. Upon the re- 
 moval of the tampon, a roagulum may be observed attached to its 
 upper part, in the center of which the ovum, or its remains, will gen- 
 erally be found. Cotton-wool was regarded by J. Marion Sims as 
 the best material from which to prepare a tampon. He advises that 
 it be soaked in some .antiseptic solution and then molded into small 
 disks; they are now carried high up, with the dressing-forceps, and 
 packed tightly around the intra-vaginal portion of the cervix, and so 
 on until the vagina is filled. This makes, probably, the most solid 
 tampon that can be used. When the tampon is removed, after 
 about twelve hours, the parts should be carefully examined, and, in 
 case the cervix is not sufficiently dilated to allow the ovum to pass, 
 then at once re-apply the tampon as in the beginning, and so continue 
 until dilatation follows. The tampon not only acts as a mechanical 
 agent in controlling the hemorrhage, but hastens the expulsion of the 
 ovum by exciting contractions of the uterus. Ergot is usually indi- 
 cated in cases requiring the tampon; and when associated they act 
 very well. The ovum, as a rule, is expelled entire in cases where this 
 treatment is used. Should the presence of the tampon induce dysury, 
 the bladder must be evacuated by means of a catheter ; and during 
 the whole treatment the female should be kept in the recumbent posi- 
 tion, and not allowed to arise until all danger from hemorrhage is 
 over. The tampon ought never to be used when there is any pos- 
 sibility of checking the abortion, as it is very apt to increase the ten- 
 dency to abort, in consequence of the irritation of the cervix produced 
 by its presence having extended to the fundus ; beside, the external 
 discharge of blood being suppressed, it continues to be effused inter- 
 nally, gradually separating the ovum from the uterus, until it finally 
 passes off, surrounded with a compressed coagulum. Neither should 
 it be employed after the expulsion of the ovum, nor when the os uteri 
 has dilated to an extent that will admit a finger to pass and remove 
 the embryo. 
 
 Females who habitually abort in the early months of pregnancy, 
 should, after the symptoms of abortion have been removed, be advised 
 to remain most of the time in the horizontal position, avoiding all 
 fatigue and violent exertion, until the uterus has risen above .the 
 superior strait of the pelvis. The employment of the lancet, in cases 
 of abortion, is recommended by some authors, but I can not perceive 
 its utility ; the detachment of the placenta from the uterine wall, which 
 is the cause of the hemorrhage, can not certainly be remedied by a
 
 HEMORRHAGE AND ABORTION. 261 
 
 loss of blood from some other part of the system, for in all the cases 
 which I have witnessed treated by blood-letting, the separation con- 
 tinued to progress, with augmented hemorrhage, and the only result 
 gained was a degree of debility and disposition to disease, on the part 
 of the female, probably greater than would have resulted had the use 
 of the lancet been omitted. It is true, that in consequence of the 
 prostration of nervous and muscular force effected by its use, it may 
 overcome rigidity of the cervix, and favor the dilatation of the os uteri, 
 when the fulfillment of these indications is desired; but then we have 
 remedies which produce the same results without disposing a part or 
 all of the constitution to any of the after disastrous consequences so 
 common to blood-letting; as Lobelia, and still better, the tincture of 
 Gelsemium, from the relaxing influences of either of which the patient 
 will speedily recover. I am aware that bleeding, in many cases, may 
 arrest or modify the expulsive contractility of the uterus, but it is ef- 
 fected at a great expense to the constitution of the patient, and is by 
 no means a safe or desirable method of treatment; Opium, either alone 
 or combined with Lobelia or Gelsemium, will not only produce the 
 same results, but will succeed in cases where bleeding fails. As to 
 bleeding for the relief of plethora, or of a congested condition of the 
 uterus, the hemorrhage undoubtedly affords all the benefit that can be 
 had from venesection, especially in the latter condition; and the ordi- 
 nary means advised for overcoming or relieving either of these states 
 will be found fully efficient without a resort to the lancet though the 
 lancet saves time and labor, to the physician. For the purpose of 
 equalizing the circulation, it has been advised by some accoucheurs to 
 bathe the lower extremities of the female in warm water; with some 
 patients this course may be attended with benefit, but it should always 
 be employed with caution, as among many women it will be found to 
 facilitate the abortion ; it is only in hemorrhage after the expulsion 
 of the ovum where much advantage will be derived from this local 
 bathing. 
 
 If by the means employed the abortion is not prevented, or if it be 
 so far advanced that no hope for checking it can be reasonably enter- 
 tained ; the pains increasing together with the hemorrhage, the os uteri 
 gradually dilating, and the ovum being within reach of the finger, all 
 that the practitioner can do is to patiently await the efforts of nature, 
 and carefully watch and treat the hemorrhage ; as a general rule, any 
 artificial interference is highly improper, and might give rise to serious 
 consequences. The practitioner must be very careful not to rupture
 
 262 KING'S ECLECTIC OBSTETRICS. 
 
 the membranes in the early months, for the purpose of facilitating 
 expulsion, as it is always desirable that the ovum be expelled entire, 
 for when the membranes are retained after the discharge of the fetus, 
 there is danger from hemorrhage; and when, in cases of such reten- 
 tion, it is found that the contractions of the uterus are insufficient to 
 separate and expel the membranes, the os being sufficiently dilated, 
 agents may be administered which will promote these contractions, as 
 Ergot, Macrotys, Pulsatilla, or Quinine. Creed's method will often 
 stimulate the uterus to increased -action. Agents of this class are not 
 to be depended on when the hemorrhage is alarming, but give way to 
 more radical treatment, as will be presently noticed. The fresh inner 
 bark of Cotton root, in strong infusion, will generally excite the uterus 
 to energetic action ; but this agent can rarely be had. So will pow- 
 dered or grated Nutmeg in teaspoonful doses; also a combination of 
 Borax and Cinnamon. If this does not produce the desired effect, and 
 the hemorrhage continues unabated, it will be proper for the practitioner 
 to introduce a finger within the canal of the cervix, as far as possible, 
 then bend it so as to resemble a blunt hook, and in this way remove the 
 membranes, and in doing this it may become necessary to introduce the 
 whole hand into the vagina ; or a wire blunt-hook, which will admirably 
 answer the purpose, may be made, by bending a piece of fine wire so as 
 to form two parallel strips nearly in contact with each other, the curved 
 end of which is to be again bent so as to .form a hook; this may be 
 introduced into the uterus, whenever hemorrhage is owing to retained 
 membranes, for the purpose of removing them. Other instruments 
 have likewise been recommended for this purpose, as Bond's placental 
 forceps, and Dewees' placental hook. But in the introduction of the 
 finger, or any of these instruments into the canal of the cervix, no 
 force must be employed, too much care and gentleness can not be 
 observed; no attempts whatever should be made, to effect dilatation, 
 nor should these means be employed at all until the cervical canal has 
 become cylindrical and sufficiently open for their free intromission. 
 And as the development of the uterus previous to the fifth month is 
 not such as to warrant any fears of a serious internal hemorrhage, the 
 tampon may be used, in conjunction with the other means, to check 
 flooding, if circumstances prevent the removal of the membranes. 
 The introduction of the tampon is sometimes attended with such dis- 
 agreeable and painful sensations that the patient can not endure its 
 presence for even ten minutes ; in such cases, as well as in cases w r here 
 it does not check the hemorrhage, the evacuation of the uterine con- 
 tents must be promoted as soon as possible. It may be proper to
 
 HEMORRHAGE AND ABORTION. 263 
 
 remark here, that when the hemorrhage is such as to threaten the life 
 of the mother, every means must be employed to arrest it, even should 
 the means effect the death and expulsion of the fetus, as the safety of 
 the mother always demands s-uch sacrifice. When the death of the 
 fetus has occasioned the abortion the hemorrhage is not generally 
 excessive. 
 
 A very good rule to govern one's actions in cases of hemorrhage 
 from abortion is, after deciding it to be inevitable,to use the tampon 
 as has been suggested, in cases where there is no dilatation of the cer- 
 vix, and so continue together with the administration of Ergot, until 
 dilatation is produced. .Should the hemorrhage be alarming, and the 
 cervix already fully dilated and relaxed, then forcibly remove the ovum 
 by introducing the fingers or hand. 
 
 In the more advanced stage of pregnancy, when in consequence of 
 excessive hemorrhage or other cause it becomes necessary to facilitate 
 the expulsion of the fetus, the membranes may frequently be ruptured 
 with advantage, because at this period, the uterus has increased in size 
 sufficiently to receive two or three fingers, or even the whole hand, 
 should it become necessary to remove a retained placenta. And the 
 extraction of the placenta should always be effected, when the abortion 
 occurs at .a period of utero-gestation, in which the uterus will permit 
 the introduction of the hand within its cavity. Other means may 
 likewise be employed to favor the expulsion, as Ergot, Macrotys, in- 
 jections of hot water together with Creed's method. Cold applications 
 may be made to the pubes and hypogastrium, to aid in arresting 1 the 
 hemorrhage. At this period I usually prefer as an internal hemostatic, 
 the tincture of Cinnamon, of which from half a fluid drachm to a 
 fluid drachm may be given every ten, thirty or sixty minutes, as the 
 urgency of the case requires, in a wine-glass of sweetened water; ten 
 or fifteen drops of Laudanum or Viburnum may be added to each dose, 
 in case the pains are very severe. The Cinnamon and Ergot may be 
 administered together in doses of from fifteen to thirty drops of each; 
 the combination of the two agents exhibit more striking haemostatic 
 properties than either administered singly. After the embryo and its 
 membranes have passed away from the uterus, should hemorrhage still 
 continue, it must be treated in the same manner as recommended for 
 flooding after delivery at full term. Intra-uterine washings of a solu- 
 tion of Iodine after the evacuation of the contents, have been advised 
 both for its antiseptic and haemostatic effect. 
 
 A weak solution of Sulphuric Acid has been frequently employed in 
 hemorrhages occurring during pregnancy, as well as after delivery,
 
 264 KING'S ECLECTIC OBSTETRICS. 
 
 with decided benefit. It is exhibited as a vaginal enema, ten or fifteen 
 drops of the acid being added to three or four ounces of warm water. 
 Care should be taken, however, not to employ it when it is desired to 
 check the abortion. Many persons use this injection with the criminal 
 intention of procuring an abortion. 
 
 In cases of excessive hemorrhage occurring several days after the 
 abortion has apparently terminated, and which, as previously stated, 
 are owing to a retention of the placenta and membrane, the wire 
 blunt-hook may be slowly and carefully passed within the canal of 
 the cervix, and the membranes extracted by means of a gentle manip- 
 ulation ; if this can not be accomplished, the practitioner will most 
 likely have to contend with the effects of putrefactive absorption. 
 The patient with whom there is a retention of the placenta is exposed 
 to hemorrhage, to septicaemia, to hydatoid degeneration of the placenta, 
 or to polypoid growths of which the placenta forms the nucleus ; 
 hence the necessity for not allowing it to remain too long within the 
 uterus, and especially when the flow is continuous or excessive. Putre- 
 factive decomposition may be known- by a fetid lochial discharge, and 
 absorption of the putrid matter gives rise to an irritative fever which 
 may prove dangerous. The fever must be treated upon general prin- 
 ciples, using Aconite or Veratrum as' indicated, and being careful to 
 support the strength of the patient; and the vagina must be frequently 
 syringed with water, as hot as the patient can endure, in which shall 
 be used Borax, Asepsin, Carbolic Acid, Distillate of Hamamelis, or 
 Fluid Hydrastis, as the practitioner may prefer, for the purpose of 
 removing the putrified material as soon as it forms; and for the pur- 
 pose of obviating putridity of the remaining portions of the placenta 
 or membranes, soft cotton wool has been recommended moistened with 
 diluted Carbolic Acid, or other antiseptic, and carefully introduced 
 within the canal of the cervix, (dilating this, if necessary, by means 
 of tents), removing it every two or three hours, and replacing it with 
 a new pledget. As a rule, I believe pledgets of lint should not be 
 introduced into the cervix at this time, as it might be an obstruction 
 to the free drainage of the uterus, and as a result of pent up purulency 
 thwart the very object we are trying to accomplish. Internally, to 
 lessen the dangers from septicaemia, such agents as Chlorate of Potash, 
 Baptisia, Phytolacca, dilute Nitro-Muriatic Acid, Asepsin and such 
 other remedies as would tend to eliminate the poison that might have 
 been absorbed by the system may be administered, as well as tonics, 
 good diet, etc., as indicated from time to time. I have in several in- 
 stances succeeded in preventing any serious consequences by adminis-
 
 HEMORRHAGE AND ABORTION. 265 
 
 tering, in connection with the general treatment, Macrotys, Pulsatilla, 
 Phytolacca, together with direct sedatives, if there happens to be an 
 increased temperature, as Aconite, Veratrum or small doses of Digi- 
 talis. The Parturient Balm (Am. Dispensatory) as a uterine tonic is 
 a good remedy, especially during convalescence. The infusion of Digi- 
 talis is useful in some cases. Peruvian bark in Port wine has also 
 been used in a few cases with apparent benefit, where a tonic in called 
 for. 
 
 After an abortion, especially in advanced pregnancy, it may become 
 proper to apply a bandage around the abdomen, the same as after or- 
 dinary labor, and the patient should be kept for a few days in a state 
 of rest ; if there be much exhaustion from loss of blood, the diet must 
 be similar to that recommended in uterine hemorrhage, or flooding 
 after labor at full term. A lochial discharge, as well as secretion of 
 milk, is most commonly present, after abortion in the advanced stage 
 of gestation. 
 
 The sequelce, or after consequences of abortion, are irritative fever, 
 metritis, peritonitis, phlebitis, ulceration of the cervix, anemia, leucor- 
 rhea, menorrhagia, dysmenorrhea, organic disease of the uterus, 
 sterility, or phthisis, either of which, when present, will require the 
 treatment appropriate to such abnormal condition. 
 
 When an abortion has once taken place, it is very liable to recur 
 during the following pregnancy, and to prevent the occurrence of 
 which, the practitioner should endeavor to ascertain its cause, and 
 remove it, if possible, by the appropriate treatment pursued during 
 the intervals between the pregnancies, as well, as during pregnancy 
 previous to the manifestation of the aborting symptoms. It will be 
 still more efficacious, however, if the patient, while endeavoring to 
 become cured of her difficulty, will give the reproductive organs rest 
 by an absolute avoidance of sexual excitement, cohabitation, and 
 pregnancy, for a considerable length of time. Should it be owing to 
 tumors, diseased ovum, or other intra-uterine diseases, internal treat- 
 ment will be of little avail ; though in these cases the internal use of 
 alteratives, uterine tonics, proper diet, exercise, etc., may be adopted, 
 with a faint hope that good may follow. If a fissured os and cervix 
 uteri be the cause, as determined by a careful examination, and which 
 is often present in those cases of abortion that occur successively in 
 the same woman at the same period of gestation, the fissures must be 
 healed by local applications of Nitric Acid, Nitrate of Silver, Caustic 
 Iodine, or Chromic Acid, etc., being careful to apply these agents in
 
 266 KING'S ECLECTIC OBSTETRICS. 
 
 a manner that will not destroy the tissues of the parts; at the same 
 time administering such agents internally as may be indicated to 
 relieve pain, remove anemia, or lessen uterine congestion, etc., \vhen 
 either of these are present. The trouble being a slight fissured con- 
 dition, it may often be cured, or at least benefited, by the direct 
 application of caustics; if, however, the cervix should be deeply 
 lacerated,- then nothing short of a careful operation, known as traehe- 
 lorraphy, will restore the parts and overcome the trouble. It is 
 necessary to remove all cicatricial tissue, after which the parts may be 
 sutured together. Uterine congestion, as a cause of abortion, requires 
 an avoidance of coition, diuretics, regularity of bowels, moderate diet 
 and exercise, and sometimes warm hip baths. If the uterus be dis- 
 placed, it must be restored to its normal position; should ulceration 
 of the cervix uteri be a cause, it must be treated by applying locally 
 concentrated Nitric Acid by means of a pine stick porte-caustic, Xi- 
 trate of Silver, solution of Sesquicarbonate of Potassa, solution of 
 Sulphate of Zinc, etc., the application to be made by means of a spec- 
 ulum. The patient must likewise be kept in a state of rest, and if 
 treated during pregnancy, no vaginal injections must be used. Dys-r 
 menorrhea is frequently a cause of abortion, and when present, the 
 functions of the uterine system must be attended to, administering 
 uterine tonics, Chlorate of Potassa, and pursuing the means generally 
 recommended in Eclectic teachings to remove the difficulty ; and so 
 in all other uterine derangements. In those cases of abortion due to 
 an enfeebled condition of the uterus, to a premature disintegration 
 and exfoliation of the decidua, or to morbid nervous excitability of 
 the reproductive system, I have found the Helonias Dioica, Pulsatilla, 
 Senecio and Macrotys to be excellent remedies, in combination with 
 Chlorate of Potassa; and, indeed, have even found it efficacious in 
 geveral instances where the cause of the abortion was quite obscure; 
 it is especially required in all these instances that the uterus have a 
 long period of rest. If the abortion is owing to a syphilitic taint of 
 the system, this must be remedied by the usual treatment for this dis- 
 ease, administered, in most instances, to both parents. The bowels 
 must be kept regular, the diet must be nutritious, avoiding fats and 
 acids, the surface of the body must be frequently bathed with a weak 
 alkaline solution, and too much exercise must be prohibited ; if the 
 male parent is contaminated with the disease, but little benefit can be 
 expected unless he is also placed under proper treatment. The ad- 
 ministration of Mercury, so highly recommended by some authors, is
 
 HEMORRHAGE AXD ABORTION. 267 
 
 of no utility, as this agent will not only effect no cure of the disease, 
 but has a strong tendency to destroy the vitality of the fetus, and thus 
 add to the already existing cause of abortion. Any other disease with 
 which the patient may be affected, whether general or local, must, if 
 possible, be eradicated by the appropriate remedies, which may be 
 employed not only during the interval between pregnancy, but like- 
 wise when this condition is present. Fatty degeneration of the chorion 
 and placenta, detected by careful microscopic investigation, will re- 
 quire the same treatment pursued in similar degeneration of other 
 organs. Chlorate of Potash has been recently used, with marked 
 success, in a number of cases where women habitually aborted owing 
 to degeneration of the placenta, and, as a consequence, faulty nutrition 
 of the fetus. This^remedy, when further tested, will, I believe, prove 
 to be a specific in this diseased condition of the placenta. 
 
 Ansemic or chlorotic patients should be treated with vegetable 
 and chalybeate tonics, among which I prefer Acid Solution of Iron; 
 those who are plethoric require light and moderate diet, exercise, reg- 
 ularity of bowels, and depletion by diuretics; and coition should be 
 very moderate until pregnancy occurs, during which it must be pos- 
 itively prohibited. If the patient resides in a miasmatic district, 
 usually so called, a removal will in many instances be followed with 
 benefit ; though occasionally the internal use of Sulphate of Quinine, 
 Fowler's solution of Arsenic, or dilute Kitric Acid, will be found to 
 answer an excellent purpose. If she be giving suck when pregnancy 
 occurs, the child must be weaned; if there be any vesical or rectal 
 irritation, hemorrhoids, or a constipated condition of the bowels, these 
 may be overcome by an attention to diet, aided by laxatives, anodyne 
 and mucilaginous enemata, quiet, and an avoidance of all active med- 
 icines. As habitual abortions usually occur at a regular period of 
 pregnancy, the patient should at this period more frequently assume 
 the recumbent position, upon a hard mattress, in a cool room, and be 
 otherwise treated according to the peculiarities or indications of her 
 individual case ; and which treatment should be perseveringly pursued 
 until the aborting period has passed by. 
 
 When habitual abortion obstinately resists our endeavors to remove 
 it, it will ultimately destroy the constitution of the patient; and it 
 therefore becomes necessary on her part to pursue a rigid and self- 
 denying course. The indications are: firstly, to avoid pregnancy, 
 until the functions of the reproductive organs have been restored to a 
 normal condition; and, secondly, to effect this restoration. The only
 
 2(5s KING'S ECLECTIC OBSTETRICS. 
 
 method by which the first indication can be fulfilled is absolute and 
 positive discontinuance of sexual intercourse for a year or longer or 
 for such a length of time as may be required to effect a healthy con- 
 dition of the generative functions. I am aware that various other 
 means may be suggested, or pursued, to prevent pregnancy, but, in 
 tin- cases under consideration, it must be especially borne in mind, 
 that not only is an avoidance of this condition required, but it is im- 
 peratively demanded that the sexual organs be maintained in a state 
 of quiet, entirely free from all excitement, and which can only be 
 effected by rigid abstinence. 
 
 The second indication is to be accomplished by bestowing a care- 
 ful attention toward both the uterine and general systems, employing 
 tonics, alteratives, and such other measures as may from time to time be 
 required. The tonics which I have found more commonly beneficial are, 
 Macrotys, Pulsatilla, Achillea, Aletris farinosa, Helonias Dioica, as in- 
 dicated; they are given either singly, or any two that are indicated 
 may be combined or given in alternation. Sulphate of Quinine will 
 sometimes be called for. The Parturient Balm (Am. Dispensatory), 
 as prepared by Lloyd Bros., I regard as an excellent uterine tonic also ; 
 indeed, the vegetable uterine tonics, generally, may be employed with 
 advantage. The agents which I term uterine tonics, and which are 
 described in the Am. Dispensatory, appear to exert an especial health- 
 ful influence upon the uterus, but of their peculiar modus opcrantli, I 
 am free to confess my ignorance. In addition to the special tonics 
 mentioned, it was formerly the custom of the earlier Eclectics to ad- 
 minister, in these cases, alteratives, so called, as compound syrups of 
 Sarsaparilla and Stillingia; together with Iodide and Bromide of Po- 
 tassium; at present these are seldom thought of. The general tonics, 
 however, may be used in connection with the special treatment, as the 
 practitioner may deem proper. 
 
 In conjunction with this treatment, the .bowels must be kept in a 
 soluble condition by the use of mild laxatives, so given as to produce 
 one, but not over two, alvine evacuations daily, approximating as 
 nearly as possible to the natural healthy discharges; and for this pur- 
 pose I prefer the trituration of Podophyllin, or the small Podophyl- 
 lin and Hydrastin pill; this may be omitted occasionally, and cold or 
 tepid enemata employed, as may be found to suit each particular case. 
 In many cases, a few doses of Cascara Segrada, or Cascara Cordial, 
 will prove useful, repeated once or twice a day for several consecutive 
 days at a time, according to its effect. Active purgation is invariably
 
 HEMORRHAGE A.ND ABORTION. 269 
 
 to be prohibited, except in plethoric patients, when it may be resorted 
 to every week or two, if not contra-indicated. Bathing the surface 
 daily with cold or tepid water, and once a week with a weak alkaline 
 solution, and drying with considerable friction, will materially assist 
 in the restoration to health, by bringing about a normal condition of" 
 the skin, the functions of which will be found more or less impaired 
 in these cases ; the shower-bath has also been advised, either of rain- 
 water or salt water, and where it is applicable it will usually prove 
 beneficial ; its temperature should range between 75 and 85, and the 
 best time for using it is upon rising in the morning. Moderate exercise 
 will be found indispensable, and an avoidance of all indolent habits im- 
 perative, as lying in bed late in the morning, lying down after a meal- 
 to sleep, sleeping, on feather beds, etc. The diet should be light but 
 nutritions, using tender fowls, meats, etc., but always avoiding fats 
 and acids ; and very weak patients may use Port \vine, porter, or other 
 suitable stimulants, in moderate quantity, during the dinner meal. 
 Occasionally, a change of air will prove serviceable. All bathing 
 must be omitted during menstruation. By a perseverance in this 
 course for one or even two years, the most obstinate cases of habitual 
 abortion, when not owing to uterine adhesions, may be cured; and it 
 may be proper to remark, that should pregnancy occur shortly after 
 dismissing the patient as cured, it is very necessary that close atten- 
 tion be bestowed upon that condition, until five or six weeks have 
 passed beyond the previous aborting period, in order to promote the 
 certainty and permanency of the cure. 
 
 It may be briefly stated that when habitual abortion is due to a 
 morbid nervous excitability of the reproductive system, to premature 
 disintegration and exfoliation of the decidua, Helonias, Dioica and 
 Chlorate of Potassa are the remedies; when due to uterine displace- 
 ments, overcome the trouble by using supports, if necessary, and ad- 
 minister Aletris, Nux, Parturient Balm, and Belladonna; when to a 
 low grade of uterine inflammation, Aconite, Pulsatilla, and Macrotys; 
 to a hard, contracted condition of the cervix, with more or less irrita- 
 bility, Gelsemium, Aconite, Macrotys and Lobelia; to a neuralgic or 
 rheumatic aifection of the uterus, Aconite, Macrotys and Gelsemium ; if 
 there be a sluggishness of the circulation, lack of nervous energy, Nux, 
 Xanthoxylon, Gelsemium, and Rhus; to irritability of nerve centers, 
 Bromide of Potassium, Belladonna, Gelsemium, Conium, etc. < Any 
 constitutional disease under which either of the patients may be labor- 
 ing, will require the proper treatnient for such affection.
 
 270 Kl.Ml's K< LIX'TIC OI5STKTIJH-S. 
 
 Before leaving this subject, I wish to refer to two things which may 
 occa.-ion .-nme trouble to the practitioner in the treatment for prevent- 
 ing abortion ; the first is, the difficulty in prevailing on some females 
 to keep quiet and confine themselves to the recumbent position for a 
 sufficient length of time. Xot feeling any sickness, nor suffering from 
 any pain, the patient will be apt to treat the advice of her physician, 
 in this matter, very lightly, unless it is especially urged upon her, 
 explaining to her the consequences of a different course of action, and 
 the advantages attending its observance, among which may be named 
 the diminution of the tendency to abort, by checking or overcoming 
 irritability or other morbid results due to the cause of such tendency, 
 and the strong probability of its permanent cure, when the habit has 
 been overcome in any one pregnancy. The practitioner can not be 
 too particular in regard to this matter. Though he must not forget 
 that too long a continuance in the recumbent position is apt to give 
 rise to morbid symptoms that may promote instead of prevent the 
 abortion. The second point is relative to the decided objections which 
 are frequently made to vaginal examinations. When a female, during 
 an abortion, objects to an examination of this kind, and the symptoms 
 are not very urgent, the physician will treat the case as well as circum- 
 stances will permit; but when the hemorrhage is great, and the serious 
 consequences that may happen from a persistence in the objection have 
 been explained, without effecting any change in the will of the patient, 
 it would be improper for the practitioner, so- far as his own reputation 
 alone is concerned, to assume the whole responsibility of the case. 
 He will, therefore, not manifest any irritation, nor abruptly leave the 
 patient, but will state to the friends, or the patient, that the case has 
 assumed a character which leads him to desire council, and then, should 
 any fatal result ensue from a continuance of such obstinaucy, this 
 course will free him from any subsequent imputations, of neglect, 
 malpractice, etc. 
 
 In a premature labor, the management will be the same as recom- 
 mended for labor at full term ; for as a general rule, during the last 
 three months of pregnancy, the hand may be introduced within the 
 uterus for the purpose of performing any manipulations which may 
 be required. But I would make one observation, that if the hand of 
 the practitioner be very large, and a manual operation is demanded 
 during the seventh or eighth month, it will be safer for the patient, 
 and very humane on the part of the medical attendant, to send for 
 some medical friend, with a small' hand. This is a point too little 
 heeded, and which, of itself, is frequently a cause of grave results.
 
 LABOR. 271 
 
 CHAPTER XXIV. 
 
 LABOR. 
 
 LABOR, or PARTURITION, is that function by which the matured 
 fetus, together with its secundines, are expelled from the uterus; it 
 occurs at the end of nine calendar months and one week, or about two 
 hundred and eighty days from the last menstrual appearance, and about 
 one hundred and forty days after quickening. A few days, either 
 previous or subsequent to this time, constitute practically no material 
 difference. At this period, the hitherto inactive nervous and muscular 
 systems of the uterus become stimulated into action, causing contrac- 
 tions of this organ, which are always accompanied with pain, in a 
 greater or less degree, and which cease only when the uterus has 
 expelled its contents; as the contractions are invariably attended with 
 pains, the terms, labor pains, and uterine contractions are employed 
 synonymously. As a general rule, labor, though painful and exposed 
 to danger, may be expected to terminate favorably, and without arti- 
 ficial aid. The average duration of labor is six hours, or according to 
 some authors, four, but which depends upon the amount of power in 
 action, and the degree of resistance which is presented. Cases have 
 been known, in which labor has been completed in ten or fifteen min- 
 utes, while with others, again, from four to seven, and even ten days 
 have passed, before the fetus has been expelled into the world. The 
 investigations of M. Quetelet, Dr. Buck, and others, indicate that 
 more births occur at night than during the day, there being five chil- 
 dren born at night, for every four born during the day ; and also, that 
 the least number of births occur at midnight, and at noon. Yet 
 these day-births may, in many instances, require the attention of the 
 accoucheur during the night. 
 
 The immediate or exciting cause of labor, is not satisfactorily under- 
 stood, though physiologists of all ages have advanced various theories. 
 Thus, some have attributed it to a supposed struggling of the fetus, in 
 an endeavor to procure a more adequate amount of nourishment than 
 is received while within the uterus ; others again, have supposed it to 
 depend upon the motions of the fetus, in seeking to relieve itself from 
 its constrained position, to remove itself to a less elevated tempera- 
 ture ; or, to obtain access to the atmosphere for the purpose of breath-
 
 272 KING'S ECLECTIC OBSTETRICS. 
 
 ing. But these, or any other theories which suppose the fetus to be 
 the principal agent in its own expulsion, are now known to be incor- 
 rect ; the fetus is merely a passive agent in parturition, and a dead one 
 is expelled as easily as one living. Some, viewing the uterus alone as 
 possessing the power necessary to effect labor, have supposed, that 
 when no further development of uterine fiber can take place, the con- 
 tractions ensue; others assert, that they commence as soon as the 
 antagonizing condition, which exists between the fibers of the cervix 
 and those of the fundus, are overcome, the latter having the prepond- 
 erance of action. Dr. Tyler Smith believes the expulsion of the ovum 
 to be effected by certain changes occurring in the uterus, and which 
 are due to ovarian excitement, the ovaries, in all cases of pregnancy, 
 assuming a regular periodical action at or near the tenth period from 
 the last menstruation. This hypothesis, however, is inconsistent with 
 the recent views concerning nidation. Cases have been recently 
 reported, also, in which the ovaries have been removed during 
 pregnancy without affecting labor in the least, which came on and 
 was perfectly natural at the proper time. Sir James Simpson has 
 advanced the opinion that parturition is the result of a separa- 
 tion between the deciduous membranes and the uterine walls, and 
 which is due to degeneration of the decidual structure occurring 
 toward the full 'term of pregnancy. But it is unnecessary to enter 
 into an explanation of all the views which have been promulga- 
 ted on the subject ; suffice it to say, that they are all unsatisfactory, and 
 we are compelled to admit that it is the result of an unknown natural 
 law, or, as expressed by Avicenna, an Arabian physician of the eleventh 
 century, " that at the proper time, labor comes on, by the grace of 
 God ;" or, as a medical man once remarked, " it is involved in as 
 much obscurity as the cause why peaches ripen in August, and straw- 
 berries in June." But though the researches of physiologists have 
 failed to discover the exciting cause of labor, they have established the 
 fact, that .as with all other uterine functions, periodicity exists in this 
 also ; as labor manifests itself at a period corresponding to that of 
 menstruation, and which, but for the conception, would have been a 
 menstrual term. 
 
 The principal agents, in the accomplishment of parturition, are the 
 contractions of the muscular fibers of the uterus, aided in ordinary 
 cases, during the second stage, by -the diapbragm and the abdominal 
 muscles ; the expulsory efforts of all these agents finally determine the 
 evacuation of the uterine cavity, which, when completed, the organ 
 returns to its non-gravid state, measuring from two and a half to three
 
 LABOR. 273 
 
 inches in length, about an inch and a half in width, and a half or 
 three-fourths of an inch in thickness. The pain, which attends each 
 uterine contraction, is supposed to be owing to the pressure these con- 
 tractions exert upon the nerves of the uterus, and also to the constant 
 traction upon the circular fibers of the cervix, by the longitudinal 
 fibers. 
 
 The PREMONITORY SIGNS OF LABOR are several; a sub- 
 sidence, or sinking down of the uterus in the abdomen, is the first, and 
 probably most striking ; the uterus, which had previously extended to 
 the epigastric region, sinks lower, and appears to spread out laterally. 
 This symptom may occur as early as two weeks previous to the first 
 pains of parturition, but usually, it is observed only a few days before. 
 The mechanical impediment to respiration being thus removed, the 
 female experiences much relief, she respires with greater ease, feels 
 lighter, cheerful, and more comfortable, less apprehensive, and is better 
 able and more disposed to action and motion than she had been for 
 some time previously. The lowering of the uterus occasionally pro- 
 duces a puffiness and swelling of the lower extremities, rendering 
 locomotion difficult or impossible. In those cases where nausea or 
 vomiting was present, from mechanical pressure upon the stomach, 
 this subsidence at once relieves the patient from any further disposi- 
 tion to these unpleasant symptoms. 
 
 This falling of the uterus generally takes place gradually, so that 
 several days pass before the patient is aware of it sometimes it occurs 
 suddenly, or in a short time, as in ten or twelve hours. As the head, 
 covered by the cervix, must enter the brim, to a greater or less extent, 
 during the above sinking, this is looked upon as a symptom indicative 
 of a large* or well-formed pelvis ; being seldom observed in cases of 
 contracted pelvis. The sinking of the uterus is usually considered to 
 be the result of the complete softening of the cervix uteri, with a 
 relaxation of the uterine tissue, which permits it to expand laterally. 
 The late Dr. Meigs considered the womb wholly passive in the matter, 
 it being pushed downward by the action of the diaphragm and 
 abdominal muscles. In some females, this sinking of the uterus* is 
 followed by an unpleasant sensation of weight in the inferior part of 
 the pelvis, with an irritable condition of the rectum and bladder, 
 occasioning frequent and ineffectual desire to evacuate these organs, 
 with other unpleasant symptoms, and which are owing to pressure of 
 the presenting part upon the bladder, rectum, blood-vessels, etc. These 
 symptoms can not be relieved by treatment, though when dysury ia 
 present the patient may urinate freely, by placing herself upon her 
 18
 
 274 . KING'S ECLECTIC OBSTETRICS. 
 
 hands and knees, with the hips somewhat elevated; tenesmus, when 
 severe, may frequently be relieved by an injection of starch, or elm 
 infusion, to which a few drops of Laudanum have been added, or the 
 support oi a bandage carefully applied might prove advantageous. 
 
 One, two, or three weeks previous to labor, contractions of the 
 uterus are frequently observed, to which the names of painless uterine 
 contractions, or fibrillar contractions, have been applied. The patient 
 experiences a squeezing sensation in the abdomen, which is unaccom- 
 panied with pain, and which occurs at intervals ; during its presence, 
 if the hand be placed upon the abdomen, the uterus will, be found hard 
 and well-defined. They occur much sooner in primiparse than in mul- 
 tiparae, and are supposed to be sometimes occasioned by the child's 
 motions ; it is believed that these painless contractions produce gradual 
 changes in the cervix and os uteri, before actual labor commences, and 
 may, possibly, assist in bringing about the subsidence of the uterus. 
 
 In connection with the above symptoms, the parts become somewhat 
 relaxed and soft ; though it is very doubtful whether any relaxation 
 of the pelvic symphysis occurs, as stated by some authors. With these 
 are frequently other symptoms, of a minor character, as cramps in the 
 lower limbs, swelling of the labia, increase of appetite, etc.; all of 
 which, collectively, indicate the approach of labor. But the symptom 
 upon which we may rely as an evidence that labor is close at hand, is 
 a muco-serolent discharge, called by nurses and midwives, " the show" 
 It is, usually, observed from twelve to twenty-four hours previous to 
 the commencement of actual labor, and consists of a greater or less 
 quantity of mucus, of a thin, or thick and viscid character, colorless, 
 until labor has commenced, when it becomes mixed with more or less 
 blood. The mucus is an exalted secretion of the follicles of the 
 vagina, and is not to be regarded as an indication of labor, unless 
 there be found mixed with it the gelatinous substance which had pre- 
 viously occupied the canal of the cervix ; and the blood arises from 
 the separation of the membranes, and the rupture of the blood-vessels 
 which pass from the cervix uteri to the fetal membranes. According 
 to Wigand, when the mucus is thick and viscid, it is mpre favorable. 
 It evidently prepares the passages for the exit of the fetus by lubrica-. 
 ting them. It may be proper to state here, that the show 4s frequently 
 absent, and also, it is sometimes observed for some days previous to 
 actual labor ; but these cases may be looked upon as the exceptions to 
 the general rule; for it is usually only when the dilatation of the os 
 uteri has commenced, with descent of the membranes, that the san- 
 guineous show is seen it is, therefore, a good sign of commencing 
 labor.
 
 LABOR. 275 
 
 Some females suffer for a week or longer previous to labor, with a 
 restless anxiety, a wakefulness at night, pains of an irregular character 
 about the uterus, and a peculiar nervous irritability. Others again, 
 especially those of nervous temperament, are attacked with rigors or 
 tremors, of greater or less severity, but which are unattended with 
 any feeling of cold. These rigors are usually indicative of rapid dila- 
 tation of the os uteri, and require no attention, unless accompanied 
 with a sensation of cold. They frequently occur immediately after 
 labor, and are sometimes so severe as to create some alarm in the minds 
 of the friends of the patient, as well as of herself, and heating drinks 
 are often injudiciously administered. Some warm diluent drink, as tea, 
 and an extra covering over the patient will be all that are required. 
 " If these shiverings be followed by symptoms of fever, this must be 
 guarded against; if by severe pains in the head and abdomen, 
 evidently not proceeding from the labor, then you may suspect that 
 there is inflammation. If there be much flushing of the face, throb- 
 bings of the carotids,* and the pulse high, there is reason to apprehend 
 that convulsions may supervene. These accidents are rare, however ; 
 and when the rigors occur without the above accompanying symptoms, 
 it is indicative that the labor will be active and its termination 
 speedy." Blundell. 
 
 Dilatation -of the os uteri is frequently attended with nausea or 
 vomiting; these are not the causes, but the effects of the dilatation, 
 and have no weight in sustaining an erroneous impression once enter- 
 tained, that nauseants or emetics favor dilatation. The only agents 
 proper to overcome a rigid os uteri, and forward the dilating process, 
 are relaxants. The practitioner who, in the first stage of labor, meets 
 with a rigid os uteri, which seems disposed to obstinately maintain its 
 rigidity, notwithstanding the strength and frequency of the pains, 
 will observe that an attack of spontaneous vomiting is followed by a 
 softening, relaxation, and dilatation of the os, and is therefore a 
 favorable symptom. As a common rule, it seldom lasts any length 
 of time, occasions but little distress to the patient, and needs no treat- 
 ment. Occasionally it becomes very painful and obstinate, requiring 
 the aid of the physician; a few drops of Laudanum, or of tincture of 
 Gelsemium in a draught of Soda water, will usually prove sufficient 
 to check it; and should ^constipation be present, a laxative enema 
 must be administered. It is rarely that a sinapism is required over 
 the epigastrium ; vomiting during a protracted labor must not be 
 confounded with that just referred to; it is a very unfavorable sign, 
 and the matter ejected will be in large quantity, dark colored, and 
 often fetid ; it will be noticed under Rupture of the Uterus.
 
 27(1 KI.\<;'s ECLECTIC OBSTETRICS. 
 
 Usually labor commences with pain, but considerable progress may 
 be made without any pain ; and occasionally the patient experiences 
 no pain until the os has become fully dilated, and the suffering attends 
 the expulsive effort only. True labor pains are intermittent in their 
 character, having an interval of ease between them; at first they are 
 short and weak, with long intervals, but gradually become stronger, 
 more frequent, with but little or no interval between them. They may 
 be suspended by many causes, as passions of the mind, anger, fear, sur- 
 prise, grief, etc.; sudden and unexpected news, or even the entrance 
 of the physician into the parturient room, has frequently suspended 
 the labor for hours. The administration of stimulating liquors, which 
 is rather common with some old nurses, is very reprehensible ; I have 
 known labor to be suspended for twelve hours, by a draught of gin- 
 sling, advised for the purpose of easing the pains. Anodynes, as Mor- 
 phine or Opium, act in a similar manner; a full dose of either will 
 overcome uterine contraction, and may result in the suspension of 
 labor for hours. 
 
 There are two kinds of pain recognized at the commencement of 
 labor, which arc termed true and false pains, and it is of importance 
 to the patient, as well as to the reputation of the physician, to be 
 enabled to discriminate between them. True pains are regularly inter- 
 mittent, and are confined to the uterine region, and during their con- 
 tinuance, if the hand be placed on the abdomen, over the uterus, it 
 will be found to contract and grow harder with the pain, and to 
 become softer as the pain passes off; upon making a vaginal examina- 
 tion, the os uteri will be found to contract during the presence of a 
 true pain, with a protrusion of the membranes, and to dilate during 
 its absence. 
 
 False pains, are more frequent in first pregnancies than in subse- 
 quent ones; they are irregular or constant, and exert no influence 
 whatever upon the uterus or os uteri, though contraction of the abdom- 
 inal muscles may attend them, and which it is important not to mistake 
 for uterine contractions. They are very apt to harass the patient 
 during the night, and disappear through the day; and may be dependent 
 upon rheumatism or congestion of the uterus, intestinal irritability, 
 constipation, overfatigue, etc., and are sometimes attended with febrile 
 symptoms. 
 
 True pains, commence generally in the back, pass around to the 
 front of the abdomen, as far down as the groin, recur at regular 
 intervals, gradually increase in frequency and power, and occasion 
 contractions of the uterus and os uteri, and protrusion of the bag of
 
 LABOR. 277 
 
 waters. False pains, usually commence in the neighborhood of the 
 fundus, have a limited extent, are irregular, spasmodic, often quite 
 sharp, and exert no influence on the uterus or os. There appears to 
 be a disagreement among obstetricians as to the order of uterine action, 
 some believing it to commence in the os uteri and from thence to pass 
 to the fundus, while others assert that it begins in the fundus, passes 
 in an undulate manner to the cervix, and then returns to the fundus, 
 the uterus being firmly contracted all this time. As to the manner 
 in which peristaltic uterine action occurs, Leishman cites Wigand, 
 who has taught,, in so far as the contractions of labor are concerned, 
 as^follows: The earliest contractions always take place at the neck, 
 which grows tense. From this point the vermicular action extends 
 gradually upward in the direction of the fundus, from whence it 
 again returns toward the os, obvious mechanical advantages being 
 attendant upon this method of action ; my own observations lead me 
 to coincide with the latter opinion. 
 
 To remove false pains, we must endeavor to learn their cause; if 
 they be owing to intestinal irritabilitv, or constipation, a mild pur- 
 gative, or a purgative enema will answer; if from overfatigue, rest 
 must be enjoined, and an opiate may be administered, or, what is 
 better, Sp. Tr. Pulsatilla or Valerian ; if from rheumatism, the com- 
 pound powder of Ipecacuanha and Opium, with an occasional lax- 
 ative, will remove them, or specific tinctures of Gelsemium, Macrotys 
 and Aconite. -Ordinarily a few doses of compound powder of Ipecac- 
 uanha and Opium (Dover's Powder) will give relief. If the patient 
 is annoyed by a return or a continuance of the pains, I would recom- 
 mend half teaspoonful doses of the Parturient Balm three times daily. 
 This preparation has a direct and kindly action on the uterus, and 
 satisfactory results will follow its administration. 
 
 I have met with many cases, in practice, where the pains were sharp, 
 regular, occurring at short intervals, with dilatation of the os to nearly 
 the size of a silver half dollar, and everything indicating a speedy 
 labor ; when, after waiting a few hours, the pains ceased, and did not 
 recur again for several days ; the longest time I have observed to pass 
 in such cases, before the re-appearance of labor, was two weeks ; I do 
 not pretend to account for these anomalies. 
 
 Labor has been variously classified by different authors, for the 
 purpose of facilitating an acquaintance with it. The arrangement 
 which I have adopted, is one followed by several recent writers, and
 
 278 KINO'S ECLECTIC OBSTETRICS. 
 
 will be found fully sufficient for all practical purposes; it divides labor 
 into four classes, viz.: 
 
 1. Natural labor, in which the fetal head presents, and where 
 delivery is effected within twenty-four hours, without the aid of any 
 artificial power. 
 
 2. Difficult labor, also called lingering, tedious, and protracted, in 
 which the fetal head presents, but where labor continues beyond 
 twenty-four hours, and may require some medicinal, manual, or instru- 
 mental assistance. 
 
 3. Preternatural labor, in which some other part than the head 
 presents, where there is a prolapse of the umbilical cord, or a plurality 
 of children. 
 
 4. Complicated labor, in which some serious accident occurs, not 
 connected with the presentation of the fetus. 
 
 From its commencement to its termination, natural labor is one con- 
 tinued process, marked, however, by certain peculiarities which have 
 led to a division of it, among obstetricians, into several parts or stages. 
 The most usual, and, probably, the most natural division, is that of 
 Denman, who describes labor as consisting of three stages. The first 
 stage, extending from the commencement of labor to the full dilata- 
 tion of the os uteri ; the second stage, occupying the period between 
 the dilatation of the os, until, and including, the birth of the child ; 
 and the third stage, including the delivery of the placenta. The time 
 which each of these stages occupies varies with different patients 
 according to circumstances. 
 
 In the FIRST STAGE OF LABOR, the stage of dilatation, the os 
 uteri will, at an early period, be found looking toward the sacrum, and 
 will gradually approach toward the center of the brim as labor advances. 
 The pains which are present during this stage, are of a peculiar character, 
 and are variously described by patients, as " grinding, cutting, or saw- 
 ing." They are entirely confined to the uterus, producing no sensible 
 change in the position of the fetus, but influence the condition of the os 
 uteri, dilating it that the head of the fetus may pass through. These 
 are termed the preparatory pains, and the rapidity with which dilata- 
 tion ensues, very much depends on their force and frequency. 
 Generally, it proceeds more rapidly during the latter half of the first 
 stage, and is effected more slowly in primiparse than in multiparse. 
 
 These pains commonly commence in the back, extend to the loins, 
 from thence to the front of the abdomen and pubes, a'nd terminate in
 
 LABOR. 279 
 
 the neighborhood of the groins, or upper part of the thighs. Some- 
 times females are able, especially in the first part of this stage of labor, 
 to conceal these pains, but usual]}' they cause much suffering, obliging 
 the patient to suspend for the time whatever occupation she may be 
 engaged in, and forcing from her moans, or a short and fretful cry. 
 The pains are not attended with any bearing-down or expulsive efforts, 
 and the practitioner should be careful to caution the patient against 
 any of those voluntary bearing-down efforts during the preparatory 
 stage of labor, w^ich are so often unwisely advised by ignorant nurses 
 and midwives. As the pains proceed, they increase in severity, and 
 last for a longer time, having shorter intervals between them, and 
 when absent, the female manifests a certain degree of restlessness and 
 uneasiness ; the pain in the back may sometimes be relieved by 
 pressure, but not always, and when this is the case, the matter should 
 be left to the care of the friends, and not to the practitioner, who must 
 be careful not to fatigue himself at an early period, lest he be unable 
 to afford more important aid at an advanced stage, should it be 
 required. Sometimes each pain is preceded by a slight nervous tremor 
 or shivering, and it is not uncommon for nausea and vomiting to 
 attend the whole of the first stage. The vomiting in beneficial, in con- 
 sequence of its removing crude and indigestible substances from the 
 stomach, when they are present, and also from the relaxation of the os 
 uteri, which is certain to accompany it. When it is very severe and an- 
 noying, I have frequently checked it by administering a hot drink ; the 
 common tea or hot water may be used. Frequently the female becomes 
 irritable, restless, impatient or despondent, and may suy or do things 
 which are extremely unpleasant to the physician, but which good sense 
 will teach him to pass by in a pleasant, friendly manner, at the same 
 time endeavoring to console and encourage his patient. By an atten- 
 tion to the moans or peculiar cries of the female, her expressions, and 
 respirations, the practitioner can frequently determine the first from 
 the second stage of labor. Respiration will be free, or if the breath 
 be suspended, it will be for a few seconds only, without any straining 
 or bearing-down efforts, and which is the reverse of the second stage. 
 Generally, there is no increase of the temperature of the surface, 
 and no perspiration, especially during the first half of this preparatory 
 stage; and the pulse is seldom quickened until the second stage. 
 Hohl has remarked, however, that during the first part of a pain, the 
 pulse will be found more frequent, then remain stationary for a 
 moment, and afterward subside into its natural action. Upon auscul- 
 tation, just as a pain is coming on, there will l)e heard, a short, rushing
 
 280 KIXc's KCLKCTIC OUSTKTKK S. 
 
 sound, apparently proceeding from the liquor amnii, and which ma} 7 , 
 probably, be caused in a degree by the fetal movements, or the mus- 
 cular contractions of the uterus, at the same time all the tones of the 
 uterine pulsations become stronger and more distinct; sounds also, are 
 heard which were not noticed before, especially those of a piping, 
 resonant character, and which seem to vibrate through the stethoscope. 
 As the pain reaches its maximum, these sounds become gradually 
 dull or altogether inaudible, and return with the decline of the 
 pain, resuming the original character during the intervals between 
 the pains. 
 
 If we examine through the abdominal walls, during the pains, the 
 body of the uterus will be found hard and rigid, and thrown forward, 
 so as to place its long diameter in correspondence with the axis of the 
 superior strait, and without which the labor would progress w r ith much 
 difficulty ; as the pain ceases, the organ relaxes. An examination per 
 vaginam will detect the os uteri high up, looking toward the promon- 
 tory of the sacrum, and more or less dilated; most commonly, it will 
 admit the end of the index finger, at the commencement of labor. 
 If it be much dilated, each pain will cause a protrusion of the mem- 
 branes into the vagina, which is called the "bag of waters" and the 
 presenting part, if it be low down, will be found to ascend during each 
 contraction, but will resume its original position as the pain subsides. 
 
 This ascent of the head is due to the liquor amnii, which, being 
 compressed downward by the uterine contraction, must exert an action 
 that will cause any body floating in it to ascend, in accordance with 
 the laws of hydrostatics. 
 
 The bag of waters is the name given to that portion of the mem- 
 branes which protrudes through the os into the vagina during a pain. 
 Its shape is generally round or elliptical, and sometimes elongated, 
 like a sausage, and which is supposed to be owing to the nature of 
 the presentation. During a pain it is hard, and must be carefully 
 touched, as it frequently becomes ruptured from the slightest cause; 
 as the pain disappears, it becomes lax and wrinkled, and recedes into 
 the uterine cavity. It undoubtedly assists in the dilatation of the 
 os uteri. It usually ruptures at its dependent extremity, and when 
 the rupture occurs, that portion of the liquor amnii, situated between 
 the fetal head and the membranes, escapes, the head descends and 
 prevents the too rapid flow of the remainder, and delivery is soon 
 effected. Sometimes the rupture occurs high up, the waters escape 
 gradually, and the head being in immediate contact with the mem- 
 branes, the child may be born with a caul, especially when the
 
 LABOR. 281 
 
 membranes in contact with its head remain unbroken. Rupture 
 of the membranes may occur at any period of the first stage of labor, 
 depending on their power of resistance ; if it should happen at an 
 early period, it will delay the delivery, and may cause a difficult labor. 
 Sometimes it is not ruptured at all, but the fetus is born enveloped in 
 the membranes, yet such cases are rare. It is important for the practi- 
 tioner, as a general rule, to retain the membranes entire, if possible, 
 until complete dilatation of the os uteri has been effected. 
 
 The os uteri may present several variations in its character during 
 the first stage of labor. Thus, it may be found thick, soft, spongy, 
 moist, dilated, or if not dilated, relaxed, and dilatable, which is a 
 favorable condition; or it may be thick, hard, rigid perhaps likewise, 
 hot, dry, and tender, feeling somewhat like cartilage, and which is an 
 unfavorable condition, generally indicating a difficult labor. Toward 
 the latter part of the first stage of labor it may be found soft, moist, 
 cool, sensitive to the touch, but not painful, and so thin that the 
 presenting part of the fetus can be distinctly felt through its substance ; 
 this is likewise a favorable condition. Or, it may be thin, hard, rigid, 
 perhaps tender when touched, with its edge tightly embracing the 
 presenting part of the fetus, like a piece of cord; this is an unfavor- 
 able condition, indicating, as with the former instance of rigidity, a 
 difficult labor. Rigidity of the os uteri will be treated of hereafter. 
 
 To return to the progress of the preparatory stage of labor; the 
 os uteri becomes thinner and softer as the labor advances, its dilatation 
 continues to increase, and usually, the head of the fetus passes the 
 superior strait, occupying a considerable portion of the pelvic cavity, 
 until complete dilatation having been effected, the os uteri is wholly 
 effaced, and the head passes through into the vagina. Sometimes, 
 however, the anterior lip may be felt, thick and somewhat cedematous, 
 between the fetal head and the pubis, requiring no interference, unless 
 the progress of labor be impeded by inefficient pains, but which is 
 more commonly encountered during the second stage. Generally, 
 if the membranes have not previously given way, they rupture at this 
 moment, and the liquor amnii escapes with a gush. Sometimes they 
 do not rupture but pass through the vagina and its orifice, upon the 
 external* parts, which they aid in dilating. With the full dilatation 
 of the os uteri, which may be accomplished in from four to eight 
 hours, the first stage of labor terminates. The duration of this stage, 
 however, varies with different women, and frequently with the same 
 women in different labors, and almost always occupies more time with 
 primiparse.
 
 282 KING'S ECLECTIC OBSTETRICS. 
 
 Tlie os uteri liaving become fully dilated, the SECOND STAGE 
 OF LABOR the propulsive and expulsive stage now commences, 
 between which and the first stage, especially if the membranes have 
 ruptured, there is usually a short interval of freedom from pain; and 
 with some women, several hours of rest will follow without any pain. 
 
 A new order of things is now presented, the pains become much 
 stronger and more perfect, and change from the grinding character 
 to that of the expulsive, and it is only in this stage that the accessory 
 powers of the diaphragm and abdominal muscles are called into 
 action the rectus abdominis, the external and internal oblique, and 
 the transversalis. The action of these muscles is rarely witnessed 
 until the os uteri has retracted over the head, and then it commences 
 powerful and continued. The patient fills her chest with air, and 
 fixes it as a fulcrum for muscular exertion by closing the glottis, 
 which prevents the escape of the air; she then grasps any object near 
 her for support, fixing the feet firmly upon some immovable point, 
 and forcibly bears down. Any noise or outcry is usually suspended 
 until the termination of the pain, the breath being held until it is 
 over; though, sometimes when the pain continues for a long time, 
 a kind of half-breath with a short cry will be uttered once or twice 
 during the pain, apparently- for the purpose of more firmly renewing 
 the condition necessary for powerful bearing-down efforts. The tone 
 is not of the fretful, moaning character of the first stage, but is of a 
 straining character, sometimes terminating in a short cry and gasping 
 for breath, and affords a good test for the practitioner to determine 
 the second stage from the first. Between each pain there is a perfect 
 condition of repose, and should this stage be much prolonged, the 
 patient will frequently doze during the intervals. The dozing is 
 owing to fatigue, and partly to the congestion about the face and head, 
 the result of the suppressed breathing, and requires no interference, 
 unless it be excessive and attended with severe pain in the head, 
 which are the premontory signs of convulsions. 
 
 During the presence of a pain, and while the patient is so power- 
 fully exerting herself, the heat of the skin becomes increased, also the 
 frequency of the pulse, the eyes are bright, profuse perspiration takes 
 place, and during the suspension of respiration, the vessels of the head 
 and neck become congested from an arrest of the circulation, the face 
 being florid and sometimes purple. The patient manifests much agita- 
 tion, though she bears her sufferings with more patience and cheerful- 
 ness than in the first stage, and appears to have changed her fretful or 
 despondent condition to one of courageous determination. Vomiting.
 
 LABOR. 283 
 
 occasionally occurs in this stage also, and is usually a favorable symp- 
 tom, unless it be dark, greenish, and fetid, with fever, suspension of 
 pains, and tenderness of abdomen, when it is a very unfavorable indica- 
 tion. 
 
 Upon making a vaginal examination, the head of the child will be 
 found in the pelvic cavity, each pain forcing it toward or upon the 
 perineum; the pressure exerted upon the head causes a wrinkling of 
 the integuments, and overlapping of the parietal bones; and if the 
 external parts are unyielding, the labor being protracted, a tumor, 
 caput succedaneum, will form under the scalp, owing to an effusion of 
 blood into the loose cellular membrane between the bones and integu- 
 ments. The head most usually lies in an oblique or diagonal position 
 in the pelvis, having the occiput looking toward the left acetabulum, 
 and the forehead to the right sacro iliac symphysis, the most dependent 
 part being the vertex. As the head is forced onward by the pains r 
 the soft parts of the canal through which it is passing become gradu- 
 ally dilated, rotation of the head ensues, the perineum becomes thin 
 and distended, and the occiput appears between the labia. On the 
 subsidence of the pain the head recedes, and the external parts resume 
 their natural appearance ; but on the return of another pain, the head 
 is thrust still further down, the distension of the perineum is increased, 
 the anus projects, and probably there may be, at this time, a discharge 
 of the contents of the rectum, as well as of the bladder. The patient 
 suffers most intensely, as manifested by her loud, piercing cries, or by 
 deep, suppressed groans. As the pains continue, the distension of the 
 perineum increases, it becomes thinner, tense, elongated, and widened, 
 the vulva begins to unfold, and the head advances to the external 
 labia ; with the subsidence of the pains the elasticity of the perineum 
 forces the head to recede upward, to be again thrust forward upon 
 their renewal. Finally, all resistance is overcome, a succession of 
 strong, expelling pains, called double pains, because they follow each 
 other so rapidly, that a new one commences before the previous 'one 
 has terminated, causes the head to emerge from the vulva, while, at the 
 same time, the female utters a sharp, agonizing shriek, which is fol- 
 lowed by panting and sobbing, and, after a short period of repose, the 
 remainder of the child is delivered. As soon as the head is born the 
 child commences respiring and crying, or if this does not immediately 
 occur, it will as soon as the mucus in the mouth is removed by means 
 of a finger. 
 
 Dilatation of the perineum, like that of the os uteri, is accomplished 
 in different cases, at various' periods of time, sometimes requiring sev- 
 eral hours before it is completed, especially in first labors, and as often
 
 2X4 KIND'S ECLECTIC OBSTETRICS. 
 
 requiring only a few pains. Its distension is so great during the 
 passage of the head and shoulders as to endanger its laceration, which 
 must be carefully guarded against by the practitioner. 
 
 After delivery of the child, the female is relieved from all her suf- 
 fering and anxiety, and enjoys a greater or less period of repose, until 
 the THIRD STAGE OF LABOR or, supplemental stage, commences; 
 though, usually, she will be much excited or exhausted, with a rapid 
 pulse, flushed countenance, and profuse perspiration. The pains are 
 again renewed, but with less severity than before, and after one or two 
 have been experienced, the placenta and membranes are expelled. 
 Sometimes the placenta is delivered with the same pain that expelled 
 the child, but usually from a few minutes to half an hour or longer, 
 elapses before this takes place ; as the placenta is not, commonly, com- 
 pletely detached before the birth of the child. 
 
 The delivery of the placenta is usually followed by a variable 
 amount of blood, not to exceed a pint in normal cases ; and frequently 
 a shivering, with chattering of the teeth ensues, which, however, is 
 not the result of cold. When the placenta is not delivered within 
 an hour after the birth of a child, it must be managed as a retained 
 placenta. If the distance between the perforation in the membrane, 
 through which the fetal head passed, and the placenta, be ascertained 
 after their expulsion, it will give us the exact distance between the 
 placenta and os uteri, and thus enable us to estimate the situation of 
 the placenta in utero. 
 
 After the secundines have been expelled, the uterus contracts, and 
 gradually returns to its normal, unimpregnated condition, and it may 
 be felt through the abdominal walls, directly above the pubic sym- 
 physis, soon after the delivery, imparting the sensation of a hard, 
 round tumor, somewhat like a large ball. For a few days subsequently, 
 the exposed vessels of the uterus, at the placental site, discharge a 
 sanguineous fluid called the lochia, which changes to a greenish, or a 
 creamy hue, having a peculiar odor, and which gradually disappears as 
 the uterus resumes its. non-gravid state. 
 
 Professor Haughton, who has bestowed considerable attention upon 
 the subject, concludes, from his investigations, that the involuntary or 
 uterine effort during labor amounts to 3.4 pounds to the square inch, 
 while the voluntary or abdominal force equals 38.6 pounds to the 
 square inch, giving a total of 42 pounds. Now, if it be admitted that 
 the diameter of the fetal head is 4 inches, we have a propelling 
 power, exerted upon its surface, during uterine action, equivalent to 
 593 pounds. And as the voluntary force exceeds the involuntary more
 
 MANAGEMENT OF NATURAL LABOR. 285 
 
 than ten times, it may readily be seen how the progress of labor must 
 be impeded by destroying the will power under the influence of anaes- 
 thetics. It will, however, become necessary in some cases of nervous 
 patients, to allay the suffering, to a degree, by allowing a few inspira- 
 tions of chloroform during the pain, withdrawing it during tho inter- 
 val between the pains, and so continue during the last throes of the 
 second stage. It is very probable, however, that the real force ex- 
 erted is less than .that named above, though we are aware it is very 
 great from the difficulty experienced, if not impossibility, of intro- 
 ducing the hand into the uterine cavity during a pain, from the in- 
 fluence of these pains upon the accoucheur's hand when within this 
 cavity, as well as from the force required in delivering the head with 
 forceps, in the absence of pains, and when the head is in the upper 
 part of the vagina. 
 
 CHAPTER XXV. 
 
 MANAGEMENT OF NATURAL LABOR. 
 
 IT must be remembered by the practitioner, that labor is not a 
 case of sickness, but a function natural to females, for which as com- 
 plete provision is made as for any other function of the system; 
 and all that he can do is, to carefully witness and superintend its 
 progress, without any improper, or uncalled for interference. Indeed, 
 the ma"xim of every obstetrician should be, "allow nature to pursue 
 her own course, without any officious intermeddling." But, sometimes, 
 as is the case with other functions, this of labor may fail from certain 
 causes, and it is only in these failures, when the natural powers are 
 insufficient to safely finish the labor, that the aid of the practitioner is 
 demanded ; and it is his duty to thoroughly inform himself relative to 
 all the circumstances which may require his assistance, as well as the 
 means of removing, or overcoming them, in the safest, gentlest, and 
 most successful manner. In a natural labor, nothing further is 
 required, after having satisfied one's self that the presentation and 
 condition of the parts are normal, than to patiently await the ex- 
 pulsion of the head, receive it and the rest of the child, tie and 
 separate the cord, and remove the placenta. But as the young 
 physician, especially, may be at a loss how to proceed in the manage- 
 ment of a case of this kind, I shall lay down a line of conduct, an 
 attention to which, I trust, will be found advantageous; for without
 
 KIN<;'s KCLKCTIC MISTKTI: K 'S. 
 
 a knowledge of the proper course to be pursued, a very slight inter- 
 ference of an improper character, may convert a simple .case of labor 
 into a protracted or even dangerous one. 
 
 Having been engaged to attend a female in her confinement, the 
 physician should endeavor so to arrange his business, that, at the 
 expected time, he can readily be found by those who are dispatched 
 to summon his presence to the parturient chamber. He should obey 
 the summons as promptly as possible, not only that he may secure 
 the confidence of the patient and her friends, by displaying a readi- 
 ness, cheerfulness, and willingness to accord his services, but more 
 especially that he may be in time to rectify any accidents which may 
 occur, and to which all females are liable during parturition as, 
 presentation of the superior extremities, uterine hemorrhage, and (in 
 cases where delivery takes place rapidly, with but a few pains), an 
 encircling of the neck of the child by the umbilical cord. If he 
 reside in a city, it is hardly necessary to take along with him any 
 medicines or instruments, lest he be tempted to needlessly administer 
 the one, or rashly employ the other; beside, when either are required, 
 they can readily be obtained, and in sufficient season. Perhaps a 
 flexible male catheter, and some compound powder of Ipecacuanha 
 and Opium, may be the only exceptions to this rule. But with a 
 practitioner in the country, who frequently has to attend patients many 
 miles distant from his office, and where the delay occasioned by 
 sending for the requisite articles may prove fatal to his patient, the 
 case is entirely different. He should take with him, his instruments, 
 and several vials, containing compound powder of Ipecacuanha and 
 Opium, Ergot, Macrotys, some preparation for uterine hemorrhage, 
 as tincture of Cinnamon, and tincture of Gelsemium, or compound 
 tincture of Lobelia and Capsicum. He should likewise include an 
 .anaesthetic, as Chloroform, Ether, or a mixture of the two. The use 
 of any of these may not generally be needed ; but if one patient 
 among fifty is saved, or benefited, the physician will be fully repaid 
 for his attention to these patients. 
 
 On reaching the patient's house, he should have his arrival made 
 known to her before he enters the room, as it is frequently the ease, 
 especially in first labors, that the sudden introduction of the physician 
 has caused a suspension of the pains for some time ; beside, the female 
 may wish to have her room arranged before the entrance of the phy- 
 sician, or she may be very averse to his presence, requiring some time 
 for her friends to remove her scruples. But this can not always be 
 done, for with the poorer classes, who occupy but one room, he is
 
 MANAGEMENT OF NATURAL LABOR. '^87 
 
 obliged to be ushered into the patient's presence at once, and his good 
 sense will teach him how to conduct himself in such cases. Unless 
 from the general symptoms and appearance of the patient, he suspects 
 the second stage of labor to be at hand, or where symptoms are present 
 which demand his immediate attention, it will be proper to remove 
 any embarrassment under which she may be laboring, and allow her 
 to collect herself, by entering into conversation with her upon any sub- 
 ject foreign to her situation. Should the pains come on, while thus 
 engaged, if they are of trifling importance, the practitioner may leave 
 the room, or occupy himself in conversation with some of the friends 
 present, and especially with the nurse, from whom he may gain infor- 
 mation as to the condition of the bowels, bladder, and previous charac- 
 ter of the pains. But if the pains are frequent and active, or occasion 
 much complaining, he may then inquire of the patient, herself, in a 
 low tone of voice, relative to these points ; and he may also form some 
 idea of the probable advance of the labor from the character of the 
 pains. He should likewise interrogate as to the general health of the 
 patient, and with multipart, the character of previous labors ; ascer- 
 tain the present condition of the pulse, skin, and tongue, and make 
 such other inquiries as may be necessary. 
 
 If the bowels are in a constipated condition, in the early part of the 
 first stage of labor, a mild cathartic may be administered, as castor oil, 
 or, whatever unobjectionable purgative the patient may prefer ; but if 
 the labor has advanced to nearly the commencement of the second 
 stage, or if this stage is already present, a laxative injection should be 
 used in preference, as being more apt to cause a speedy evacuation of 
 the rectum. And at all times, during the labor, whenever the female 
 desires to evacuate the bladder or rectum, the practitioner should leave 
 the room; indeed, it is proper that- he should request the patient, 
 through the nurse, or some friend, not to retain these discharges, but 
 to have him notified, whenever they are called for, while he is in the 
 room, that he may retire. 
 
 As soon as it is deemed necessary to make a vaginal examination, 
 and which should not be delayed for too long a time, the request must 
 be made of the patient, through some friend or the nurse ; the object 
 of such an examination is usually understood, but where it is not, an 
 explanation should be given, stating that it is " for the purpose of 
 learning the condition of the parts, the manner in which the child is 
 coming, and to know that everything is right to insure a safe deliv- 
 ery." Sometimes, an objection is made, especially by those in their 
 first labors, but by a firm and gentle course, representing to the patient,
 
 L ; S,S KIX<;'s ECLECTIC OBSTETRICS. 
 
 that her own safety, as. well as that of her child, may depend upon an 
 early examination, the objections will generally be overcome. Should 
 the female be pettish, or fidgety, and notwithstanding these represen- 
 tations, persist in her objections, declaring that she will never submit 
 to an examination, and perhaps using harsh words to the physician, all 
 that he can do, will be to wait patiently until the pains have subdued 
 her caprices and antipathies, when the examination will be cheerfully 
 granted. Generally speaking, however, there will be found no diffi- 
 culty in obtaining the consent of the patient, if the request be delicately 
 made through a third (female) person. 
 
 One other reason for requiring an early examination, is, that the 
 accoucheur may not be detained for hours, waiting upon false pains. 
 I have known several young practitioners, who, having been misled 
 by these pains, and a delicacy as to insisting upon a vaginal examina- 
 tion, have been deprived of their rest for many hours, and were only 
 made aware of their error, when the loss .of confidence in their abilities 
 determined the patient to send for another medical man, who at once 
 explained the cause of the delay. Truly, a mortifying situation for 
 any one to be placed in! Again, it may be the case, that no pregnancy 
 exists. 
 
 It is not only highly proper, but it is a positive and imperative duty 
 of the practitioner, to conduct himself, throughout the whole course 
 of rjarturition, with firmness and kindness, but especially with de- 
 corum, using no language, arid manifesting no actions which might 
 offend the delicacy or modesty of the most fastidious. It will, there- 
 fore, be proper for him to observe the persons who are in the room, 
 previous to making an examination, prudently dismissing all but two 
 or three, whose presence as assistants may subsequently be needed ; 
 and unmarried females should by no means be allowed to remain, as 
 they can render but little assistance, or afford but a small share of con- 
 solation to the patient. The presence of relatives should always be 
 preferred, and if the husband remains it is an attention which many 
 men neglect to pay to their wives at this period, and should be rather 
 encouraged than condemned; his presence will tend to check the 
 obscene language of the filthy-minded, should any such be present. 
 No pure-minded nor well-meaning practitioner would hesitate for a 
 moment to perform all the necessary duties of his profession in the 
 presence of a husband, which he would do in his absence, or in the 
 presence of females. servant in attendance, to do the errands that 
 may be requisite, will be found a valuable acquisition, when one can 
 be had.
 
 MANAGEMENT OF NATURAL LABOR. 289 
 
 Previous to the examination, the physician must see that the nail of 
 the finger to be introduced into the vagina is short, otherwise, it might, 
 by coming into contact with the tense membranes, at this early period, 
 rupture them, and occasion serious results. Indeed, a physician with 
 long nails, and kept in a state of uncleanliness, is not a very proper 
 nor desirable object for the parturient chamber. Filthiness of person, 
 in any respect, implies filthiness or carelessness in practice. 
 
 There are various positions recommended for placing the female 
 during an examination. Sims' position, in the early part of labor, 
 is the preference with many ; directing the patient to lie on the bed, 
 upon her left side, her back being toward 'the physician, with the 
 hips near to the edge of the bed, and the knees drawn up toward the 
 abdomen, and separated a little by a pillow or cushion placed be- 
 tween them. Other positions may be advised, as to lie upon the 
 right side, or upon the back, in which case the right or left hand 
 may have to be used ; but an accoucheur should accustom himself to 
 examine readily with either hand. I usually allow the patient to 
 take the position, in the beginning, that seems; most comfortable to 
 her. I find it more convenient, however, if she remain on the back, 
 to pass the hand, in making the examination, beneath the flexed 
 limb, etc. The position having been taken, the index or middle 
 finger is to be annointed with lard, sweet oil, pomatum, or other 
 unctuous substance, both for the purpose of an easy introduction and 
 that the parts may not be readily irritated by its presence, as well as 
 to guard against the contraction of disease, should any be present. 
 A cloth, or napkin, .should be at hand, as likewise a basin of water, 
 soap, and towel, for the subsequent washing of the hands. In all 
 cases, when possible, never make a vaginal examination unless in the 
 presence of a third person. 
 
 Having loosely thrown a sheet over the patient, for any exposure of 
 her person is unnecessary and reprehensible, the practitioner will seat 
 himself by the bedside in such a manner as will admit a ready intro- 
 duction of the 5nger into the vagina, that is, with his face looking 
 toward the head of the patient, and his side to the side of the bed next 
 the patient. As simple as this direction may be, an error or a hesita- 
 tion as to the proper mode of placing the chair, may destroy the 
 confidence of the patient or her friends. During the presence of a 
 pain is the period generally advised for the introduction of the finger, 
 hence, it is frequently termed "taking a pain." The sheet is now to 
 be raised, but without any exposure of the female, and the examining 
 hand of the accoucheur passed quickly upward toward the vagina; the 
 finger is to be carefully and slowly introduced along the posterior 
 19
 
 KING'S K( I.KCTK' OBSTETRICS. 
 
 commissure, and into the vagina, carrying it along the posterior wall 
 of this canal, until its upper extremity is reached ; then, by bringing 
 the point of the finger toward the symphysis pubis, the os uteri will be 
 felt. The practitioner will be very careful, in this examination, not to 
 introduce his finger into the rectum instead of the vagina, a very 
 mortifying accident, and one which I have known to occur in the early 
 obstetric practice of some young medical gentlemen ; it will not be 
 likely to happen, if presence of mind is retained, with a freedom from 
 restraint and bashful diffidence. The advice to envelop the arms in a 
 towel, or cover them with oil-silk sleeves at this early examination, is 
 altogether unnecessary. 
 
 In this first vaginal examination, there are several conditions to be 
 ascertained, in effecting which, the physician must proceed carefully 
 and cautiously, and without undue -haste; nor must he remove his 
 finger, until he has positively satisfied himself in relation to the more 
 important symptoms. A great fault with young practitioners, is a 
 species of delicacy or bashfulness, which, although highly commend- 
 able, is very apt to prompt them to make a hurried and unsatisfactory 
 examination. The knowledge to be acquired is : 1, whether pregnancy 
 exists ; 2, whether the woman be in labor, and the progress it has 
 made ; 3, which is the presenting part of the child ; 4, whether the 
 membranes are entire, or have ruptured; 5, the condition of the os 
 uteri, vagina, perineum, and pelvic diameters; and the finger should 
 not be withdrawn until the pain has passed away, and a sufficient part 
 of the succeeding interval has been occupied in making the examina- 
 tion thorough and satisfactory. 
 
 The recommendation to ascertain the existence of pregnancy in a 
 female who declares herself pregnant, that she has felt the motions of 
 the child very sensibly, and that she is suffering from labor-pains, 
 may, at first sight, appear rather absurd, but when we reflect that 
 instances have not unfrequently occurred, in which the physician, 
 misled by the professions of the woman, who was herself deceived "in 
 regard to her condition, has remained in attendance for days and even 
 weeks, until the discovery was made that she was not even pregnant, 
 rendered him the mark for the jest and ridicule of all who heard of 
 his exploits; this caution will be deemed very proper and essential. 
 Many circumstances may occasion an enlargement of the abdomen, as 
 flatulency, an effusion of fluid in the peritoneal cavity, tumors, etc.; 
 and a near resemblance to labor-pains may be occasioned by spasmodic 
 action of different muscles, leading the female to believe, not only that 
 she is pregnant, but that labor has actually commenced. It will, 
 therefore, be readily understood, that the accoucheur can place no
 
 MANAGEMENT OF NATURAL LABOR. 291 
 
 reliance upon any other source than a correct, personal examination. 
 The means by which pregnancy may be determined have already been 
 given in preceding pages; but it may not be amiss to call attention 
 to a few matters relating thereto. In many instances, the hand placed 
 on the abdomen for the purpose of detecting the contractions of the 
 uterus during the pains, the condition of the abdomen as to its softness 
 or hardness, and elasticity, the extent of the swelling, and its shape, 
 will frequently decide the question; but if there still remains am 
 doubt, the vaginal examination will be more likely to solve it. There 
 will be found, if pregnancy be absent, the protruding, unexpanded 
 cervix, with a close, undeveloped os uteri, and the uterus when poised 
 on the end of the finger, will, if not diseased, be found small, light, 
 and very movable; but, if pregnancy be present, and labor com- 
 mencing, the cervix will be found expanded, and the os uteri fully 
 developed, and perhaps sufficiently open to allow the finger to enter, 
 and detect the presence of the fetus. When doubt still remains, bal- 
 lottcment, auscultation, and the means previously recommended 
 should be resorted to. 
 
 The female may be pregnant, but not in labor, and this is to be 
 determined by the rules given in the previous chapter. This is a point 
 that must, as well as the preceding, be fully solved, or else the prac- 
 titioner may subject himself to much ridicule by waiting upon "false 
 pains" instead of true ones, a circumstance which has, unfortunately, 
 happened more than once in practice. Labor may be detected by the 
 true pains hardening the uterine globe; by the os uteri contracting 
 during the presence of a pain, and dilating during its absence; by the 
 bag of waters being tender, tense, and protrusive during the uteiine 
 contractions, and becoming soft and relaxed in their absence, receding 
 within the uterine cavity. 
 
 During the presence of a pain, a careful examination should be made 
 to ascertain the effect produced by it upon the os uteri ; whether this 
 is high up in the pelvis, or low down : whether it is thick or thin, 
 soft, and yielding, or thick, rigid, and unyielding ; and in doing this, 
 no pressure should be made upon the membranes, which are generally 
 tense and thin during the presence of pain, lest they rupture, and a 
 natural labor be thereby converted into a protracted one. Upon the 
 cessation of the pain, as soon as the os uteri has relaxed, and the mem- 
 branes have collapsed, and not before, cautiously introduce the finger 
 within the orifice of the os uteri, to ascertain whether the head pre- 
 sents, and should a pain come on, while the finger is within, graduallv 
 remove it as the membranes protrude, without exerting any pressure 
 upon them, and re-introduce it on the subsidence of the pain and col-
 
 29'2 KING'S KCLKCTIC OUSTKTHICS. 
 
 lapse of the membranes. The head may readily be known by its 
 rounded form, its peculiar hardness, and its sutures. Tf the hard 
 edges of the parietal bones can be felt along the sagittal suture, there 
 can be no difficulty in determining the presentation. The endeavor 
 to ascertain the position of the head at the commencement of labor, 
 or previous to the rupture of the membranes and completion of the 
 first stage, is unnecessary, and exceedingly improper, and endangers 
 the rupture of the membranes; it is sufficient to know positively that the 
 head presents, and this information should always be obtained, before 
 withdrawing the finger, for it quiets any fear or anxiety on the part of 
 the practitioner, who knows, that nature is most generally capable of 
 overcoming or rectifying any improper positions of the head without 
 artificial interference. " Any attempt to determine in which of the 
 numerous positions described by some authors, the head is placed at 
 the brim of the pelvis, would only endanger the rupture of the mem- 
 branes, and disturb the regular order observed by nature in the process. 
 Indeed, I can not discover what benefit could result from knowing 
 during the first stage of labor, provided you can touch the vertex with 
 the point of the finger, in which of the six or eight positions of Bau- 
 delocque and other foreign authors, the head is placed, The import- 
 ance attached by some authors to a knowledge of these positions, some 
 of which are wholly imaginary, has probably arisen from the dangerous 
 practice of employing the long forceps before the os uteri is fully dilated, 
 and before the head has passed into the cavity of the pelvis. At this 
 early stage of the labor, no instrument of this description can be safely used, 
 and if the operation of turning were required, the position of the head 
 would have no influence upon the method we would adopt in turning. 
 Be sure that the head presents before you state this to the nurse or 
 patient, as they will not soon forget your mistake, if it should turn 
 out to be a case of nates presentation." Lee. 
 
 Should any other part present than the head, the practitioner, has 
 by the examination, gained information which will enable him to give 
 the necessary assistance at the proper time ; but by neglecting to 
 obtain this knowledge, he is highly culpable, as he not only runs the 
 risk of exposing his patient to much unnecessary suffering, but may 
 actually endanger her life, that of the fetus, or the lives of both. The 
 method of determining face, nates, and other presentations, together 
 with their treatment, will be described hereafter. I may state here, 
 that if the index finger fails to reach the os uteri, or feel the present- 
 ing part, two fingers, the index and middle, should then be introduced, 
 for it is imperative that the practitioner should decide the presentation 
 at as early a period as possible. It is frequently the case, especially in
 
 MANAGEMENT OP NATURAL LABOR. 293 
 
 females of irritable habits, that the most cautious introduction of the 
 finger within the os uteri will occasion the uterus to contract ; and in 
 nearly all patients, the excitement produced by the finger being need- 
 lessly moved round to discover the position of the presenting part, will 
 induce contractions, which may, more or less suddenly, force the mem- 
 branes against the finger and rupture them, occasioning a premature 
 dischage of the liquor amnii, an accident always to be dreaded in the 
 early part of the first stage of labor. When the membranes are. entire, 
 the protruding bag of waters will be felt during the pain, and there 
 will be no dribbling away of the liquor amnii ; if they be ruptured, 
 the presenting part can be more readily detected, the hairy scalp puck- 
 ering up during the pain, and becoming smooth and even, when it 
 subsides ; while, on the contrary, the membranes are smooth and tense 
 while the pain is on, and lax during its absence. 
 
 The finger being withdrawn from the os uteri, the dimensions of the 
 pelvis and its conditions, should then be explored, for the purpose of 
 determining the probable character of the labor. The point of the 
 finger should be carried toward the promontory of the sacrum, as ex- 
 plained when describing the pelvic diameters, and if this be not 
 touched, the space is ample enough for the passage of the fetus, and if 
 deemed necessary, the other diameters may be ascertained by the rules 
 heretofore given. The condition of the soft parts, as to whether they 
 are hot or normally cool, dry or moist, soft and yielding, or hard and 
 unyielding, should also be observed the finger should then be with- 
 drawn, wiping it with a napkin, while still under the sheet; after 
 which, the hands may be washed. 
 
 As soon as the examination is finished, the patient and her friends, 
 being naturally anxious to know whether everything is right, will 
 interrogate the physician relative thereto. This is a very delicate 
 position for him to be placed in, for if the reply, or opinion expressed, 
 prove incorrect, the confidence which the parties repose in him, will be at 
 once lessened or altogether .destroyed, and another physician may be 
 sent for ; beside which, it may give rise to some apprehensions on their 
 part, that difficulty or danger in the case exists, not recognized by the 
 medical attendant. Consequently, a reply to such interrogations 
 should be very guarded ; the physician should never permit himself to 
 be betrayed into the expression of a positive opinion on this subject. 
 When the head presents, and everything appears to be in a favorable 
 condition, he may state this, and add, that if no unforeseen circum- 
 stances occur, and the labor progresses uninterruptedly, she will, prob- 
 ably, be delivered by such a time, naming the longest possible time 
 suggested by the examination ; and if delivery is eifected previous to
 
 294 KI.\<;'s KCLKCTIC OBSTKTUK'S. 
 
 this time, it will prove anything but a disappointment to the patient,, 
 and will occasion no doubt of the accoucheur's skill or acquaintance 
 with his profession. The reasons for such a course are sufficiently 
 obvious ; for it frequently happens that a labor which commences 
 rapidly and with a prospect of speedy termination, becomes protracted 
 during its latter part ; and one that has a slow and tedious beginning, 
 may advance with rapidity during the second stage ; Reside, many cir- 
 cumstances may transpire during the progress of labor, which may 
 convert it into one of a protracted and even dangerous character. By 
 remembering the following points, which have been laid down by 
 accoucheurs, a pretty accurate estimate as to the duration of labor may 
 be formed, when not interfered with by unexpected accidents : 
 
 1. First labors are commonly more tedious than subsequent ones. 
 
 2. Labor advances more rapidly where the pelvis is of large 
 dimensions than where it is small. 
 
 3. In proportion to the softness and yielding of the soft parts, will 
 be the rapidity of the labor. 
 
 4. The duration of labor is always modified by the character of the 
 pains. 
 
 5. Labor will be accomplished at an earlier period when the os uteri 
 is dilated, or thick, soft, and dilatable, than when it is thin and firm, 
 even though somewhat dilated. 
 
 6. A soft and slightly dilated os uteri, moist and relaxed condition 
 of the soft parts, and regularity in the pains, are signs of a speedy 
 delivery. When these symptoms are present, and the os uteri is 
 dilated to a size corresponding in diameter to that of half a dollar, 
 most accoucheurs consider it improper to leave the patient, especially 
 if it be in the night and which will be found a good general rule to 
 adopt in practice. 
 
 7. Labor will be rapid where the vagina is large and yielding 
 throughout its whole extent; but will be slow where it is small and 
 unyielding. " If the entrance of the vagina is small, the neighboring 
 parts cool, dry, inelastic, and as if tightly drawn over the bones ; if 
 the finger, in spite of being well oiled and carefully introduced, pro- 
 duces pain upon the gentlest attempt to examine, we may expect a 
 tedious and difficult labor." 
 
 8. When the upper portion of the vagina is well dilated, and its 
 lower portion is rigid and contracted, the labor will be rapid during 
 its first half and protracted afterward; and vice versa. 
 
 9. Labor is almost always tedious in primiparse of advanced years. 
 10. Notwithstanding all the above points, unexpected changes may 
 
 occur which will materially alter the character of the labor, and hence
 
 MANAGEMENT OF NATURAL LABOR. 295 
 
 the necessity of expressing an opinion, as to the duration of labor, 
 with a cautious reserve; for "no one can know beforehand, when a 
 labor shall be terminated," and no good practitioner ever makes prog- 
 nostics. Should the examination, at any time during the first stage of 
 labor, discover rigidity of the parts, it must be treated as described 
 under difficult or protracted labor. If the breech, an arm, or any other 
 unusual part presents, it should be made known to the nurse, or some 
 friend, but not to the patient, and the proper means should be pursued, 
 as hereafter laid down. 
 
 The examination being over, the condition _of the patient's bowels 
 and bladder must be attended to, if this has not been done previously, 
 using the catheter to evacuate this latter organ if required ; and it 
 must be recollected, that these are essential and necessary measures to 
 insure a safe and speedy delivery. Now is also the time to make the 
 proper arrangements for the delivery, as preparing the bed, and getting 
 in readiness the ligatures, scissors, bandage, etc.; an attention to these 
 little but very necessary matters, serves to secure the confidence of the 
 patient and her friends, a very important desideratum in obstetric 
 practice. The adjustment of the bed is usually attended to by the 
 nurse, still it is requisite for the practitioner to understand the method 
 of doing it, as he will frequently be called upon to give directions in 
 relation thereto. A cot, hair mattress, or straw mattress may be used, 
 but by no means a feather bed; and, if the patient have but the one 
 feather bed, it must be removed or rolled to one side, that the under 
 mattress may be used for her to lie upon. OveV this a folded sheet, 
 blanket, or any soft material, to protect the mattress or cot from the 
 discharges, must be placed, covering that part of it which will be 
 occupied by the .patient's hips. During the second stage of labor, 
 some recommend a piece of oil-cloth, or leather, or india-rubber 
 cloth these are all proper, but are not always at hand. Upon the 
 folded blanket, or material that is employed, ,the sheet upon which the 
 patient is to Lie, maybe placed. Care must be taken that in preparing 
 or guarding the bed, as it is sometimes called, no depressions or con- 
 cavities are formed, into which the pelvis might sink down; at this 
 point it should rather be elevated a little. Thus arranged, the bed is 
 ready for the delivery when it comes on. 
 
 A piece of narrow tape, or bobbin, or linen thread doubled, two or 
 three times, and a few inches in length, must be secured for a ligature. 
 I generally use two ligatures, and which, together with a pair of 
 sharp scissors, should be placed in a convenient position for the prac- 
 titioner to reach, when it becomes necessary to ligature the umbilical 
 cord and divide it; or these may be handed to him by one of the
 
 296 KIN(;'S I-X 'LECTIO OBSTETRICS. 
 
 female assistants. Long and strong pins should also be held in readi- 
 ness, with which to pin the binder or bandage, after the delivery ; 
 but it will often be found that the female has a binder already made 
 which requires to be fastened and retained with a cord, like a corset 
 but these are generally troublesome and in the way, and I do not like 
 them as well as a good stout towel, or piece of unbleached muslin, 
 about a foot wide, and three or four feet long. 
 
 The room must be kept comfortably cool, and free from unpleasant 
 odors, the clothing of the patient should be light and loose, and the 
 diet, if any is required, composed of crackers, gruel, toast-water, tea, 
 and cold water; no stimulating articles of food or drink, nor meats 
 should be allowed, nor should any solicitations be used to induce an 
 appetite. 
 
 Everything having been thus attended to and prepared, nothing 
 else can be done than to wait patiently for the second stage of labor ; 
 the practitioner can do nothing to facilitate the progress of the first 
 stage, and any interference to dilate the os uteri, or passages through 
 which the child has to be expelled, or in any other way to hasten the 
 labor, is a mark of ignorance, and is fraught with serious consequences. 
 Even the too frequent repetition of the vaginal examination is im- 
 proper ; probably, another examination may not be required for an 
 hour or two, but this will depend very much upon the increased 
 strength and frequency of the pains, as well as the capaciousness of 
 the pelvis, and the yielding character of the soft parts. It is proper 
 to examine the hypogastrium occasionally to be certain that the bladder 
 does not become distended with urine, and this may be done at the 
 time of the vaginal examinations ; during a protracted labor, an atten- 
 tion to this circumstance is very important, that the catheter may be 
 used without delay, as soon as a necessity for it arises. 
 
 In reference to the condition of the bladder, the accoucheur should 
 always personally satisfy himself, for it often happens that he will 
 be told the urine passes freely, when, in fact, there is only a mere 
 dribbling of fluid upon the recurrence of each uterine contraction, and 
 which may be the liquor amnii, or a portion of urine forced out of the 
 bladder in consequence of its contraction by the abdominal muscles ; 
 this latter circumstance is an indication that the bladder contains a 
 large amount of fluid, which requires an artificial evacuation. In 
 introducing the catheter, the index finger of the left hand is to be 
 passed between the labia majora, and carried toward the vestibulum, 
 at the lower part of which, just within the lower angle of the pubic 
 symphysis, the meatus urinarius may be detected by a slight pressure 
 of the finger upon this part ; the point of the catheter should then be
 
 MANAGEMENT OF NATURAL LABOR. 297 
 
 passed along the inner surface of the finger, until it reaches the 
 urethra] orifice, when a slight movement will cause it to enter. It 
 should be passed upward without force, until about three-fourths 
 of it has entered, being careful not to allow it to slip entirely into the 
 bladder ; some small vessel must be in readiness to receive the urine 
 as it passes. When the pelvis is occupied by the head, a flat catheter 
 will be preferable to a round one, as it does not take up so much space 
 in the antero-posterior diameter. Sometimes the introduction of the 
 instrument into the bladder will be facilitated by gently raising the 
 head of the child, during the absence of uterine contraction. 
 
 Some time may elapse before the commencement of the second 
 stage of labor, and a few suggestions relative to the mode of employ- 
 ing the time, may be of service, especially to the young accoucheur. 
 If the labor has just commenced, and everything is found right on 
 examination, there will be no necessity for tarrying at the house; the 
 practitioner may return home, or visit other patients, being careful not 
 to allow his absence to exceed one hour, as it may then become 
 necessary to institute another vaginal exploration. Much, however, 
 will depend upon circumstances; if it be a first labor, it will not, 
 probably, progress very rapidly ; if previous labors have been rapid, 
 too long an absence, from the patient is not advisable, and more 
 especially when the os uteri is dilated to nearly the size of half a 
 dollar, or is very soft and dilatable ; for it must be remembered, that 
 although it may have required several hours to obtain the above 
 degree of dilatation, the remainder of the process may be effected in a 
 very short time, and labor be completed by only a few more pains. 
 Should the physician conclude to remain with the patient during the 
 first stage of labor, and which is the course usually pursued when the 
 visit is late at night, it is not proper that he should continue all the 
 time in the parturient chamber, as it may prevent his patient from 
 attending to the fecal and urinary discharges, the calls to one or both 
 of which are apt to be rather frequent. He should retire to some 
 other room, generally, if possible, so situated that he can hear the 
 cries of the female, and thus be able to determine the progress of the 
 labor, as well as the necessity for another examination. Or, if this can 
 not be done, the room not being favorably situated for the purpose, 
 he will request the nurse to, inform him, from time to time, of the 
 advance of the pains, their frequency and strength. While thus 
 absented in another room, he may employ himself in reading, in con- 
 versation, etc., but should never permit himself to become so far 
 interested in whatever employment he adopts, as, for a moment, to 
 .forget his patient. Or, if there is a probability that the labor may
 
 '2V$ KINti's ECLECTIC OBSTETRICS. 
 
 not require his immediate attention for a few hours, he may lie down 
 on a sola or bed, and enjoy ;i short sleep, until the nurse awakens 
 him, at such time as he may have requested. If there is but one room 
 occupied by the family, as is frequently the case with the poorer 
 classes, it will be proper for him to leave it occasionally to take a peep 
 at the stars, or a glance at the weather, or to inhale a little fresh air, 
 for the purpose of relieving a little dullness of feeling, etc., remarking 
 as he goes out, that he will return in ten or twelve minutes ; thus 
 giving the female an opportunity to attend to her evacuations. These 
 little attentions, and especially if performed wiih a degree of delicacy, 
 will always produce a favorable impression, which may subsequently 
 prove advantageous to the physician. 
 
 "While in the room with the patient, it is always proper to speak 
 encouragingly to her, and endeavor to cheer her up, occasionally 
 assuring her when such is really the case, that everything is going 
 right. But, above all things, avoid that very reprehensible and 
 demoralizing practice, which is too common among some persons, 
 of indulging in filthy and obscene convei'sation ; some individuals, 
 and among them I regret to say are found females, seem to select this 
 as the best time for the delivery of all the obscenity with which their 
 minds are filled, and vie with each other as to who shall bear off the 
 palm in such disgusting loquaciousness. This kind of chat has a 
 depressing and injurious influence upon the patient, beside polluting 
 the minds of all present ; and I have no doubt, but that the first 
 approach toward a departure from virtue, has, with many females, 
 commenced in the parturient room, where these coarse and indelicate 
 conversations were permitted. No gentleman, and certainly no lady, 
 would be guilty of such low and undignified behavior. It is the duty 
 of the physician, at all times, and under all circumstances, not only 
 to preserve and protect the health of his patient, but likewise to 
 preserve and protect the purity of her mind, and any one who pursues 
 a different course, should not be recognized as a professional brother 
 nor as a man worthy the confidence of community. 
 
 It is not necessary, during the first stage of labor, that the female 
 should retain the recumbent position, she may sit up, walk about, lie 
 down, and change her position, according to her inclination ; nor 
 should any bearing-down efforts be permitted during this stage, as 
 they exhaust the patient's strength, without effecting the least benefit 
 whatever, and may also cause a premature rupture of the membranes, 
 and thus convert the labor into a difficult one. It is onlv when the
 
 MANAGEMENT OF NATURAL, LABOR. 299 
 
 os uteri is fully dilated, and the membranes have ruptured, that she 
 must assume the recumbent position, or make use of any voluntary 
 efforts at bearing down. 
 
 After the full dilatation of the os uteri, until the birth of the child, 
 the female should be required to remain in the recumbent position, 
 lest, while moving about, the child should suddenly be expelled upon 
 the floor, and the uterus, following the cord and placenta, become 
 inverted. But, in a prolonged labor, where there is no immediate 
 danger of rapid expulsion, she may be permitted to sit up at short 
 intervals, as well as to change her position on the bed. If, at the 
 complete dilatation of the os uteri, the membranes have not ruptured, 
 the head presenting, and the soft parts being yielding, the accoucheur 
 should rupture them ; but not under other circumstances, except those 
 referred to hereafter. Sometimes, the head emerges from the vulva 
 .simultaneously with the rupture of the membranes, but this most 
 commonly occurs in cases where the membranes are unusually tough, 
 and have been allowed to remain entire until the head has cleared the 
 os uteri and advanced considerably into the pelvic cavity. 
 
 During the second stage of labor, many practitioners pass a towel 
 around each fore-arm, without removing the coat, as a protection 
 against the discharges. The towel is doubled so as to form a triangle, 
 the base, or folded edge of which, is passed rather tightly around the 
 wrist, but not so as to interfere with its free motion, the rest being 
 folded with one end over the other, around the arm, and then pinned, 
 and which is usually done by some female present. Others, again, 
 have oil-silk sleeves for the purpose which they draw on over the coat 
 sleeves. Some, merely remove the coat, and roll up the shirt sleeves^ 
 thus having a free, unimpeded use of the hand and arms, especially in 
 cases where manual assistance is required. This latter plan is the 
 one which I prefer; but the accoucheur may please himself in these 
 respects. 
 
 After the rupture of the membranes, the practitioner should make 
 no delay in ascertaining the position of tho presentation ; and an early 
 examination, at this time, is often of much importance, as any mal- 
 position may be more readily rectified than at a later period. The 
 situation of the head at the time of tho rupture varies; most com- 
 monly it will be found just within the brim, sometimes midway in the 
 pelvic cavity, or at the perineum, etc. The position of the head may 
 be determined by the rules heretofore named. During this stage 
 of labor, the patient should not be left by her medical attendant, 
 who will find it necessary to repeat his examinations every four, six.
 
 300 KIND'S KCI.KCTIC nnsTKTKlrs. 
 
 or. eight pains, according to their frequency and strength, and the 
 rapidity with which the head advances; and after these examinations, 
 it is not necessary to wash the hands each time, but merely to dry 
 them on a napkin, secured for the purpose. It is also an excellent 
 plan for the accoucheur, by means of a flexible stethoscope, to examine 
 the condition of the fetal heart from time to time, both during natural 
 and unnatural labors, as the information thus acquired may prove 
 of great value in the management of the case, and save his patient 
 much suffering and danger. Should the patient suffer from cramps 
 of the lower extremities, they may be removed by frictions with the 
 hand over the part affected, or ligatures around it, or warm applica- 
 tions; pain in the sacrum, occasioned by pressure of the presenting 
 part upon the anterior sacral nerves, may be relieved by firm, counter- 
 pressure against the posterior face of the sacrum, during a pain, and 
 which should be made by the nurse, or some female present; the 
 practitioner should avoid any fatiguing exercise, or manipulation, 
 unless when imperatively required. If, however, the pain should be 
 very severe, and no relief be afforded by the counter-pressure, and 
 the efficiency of the pains be, at the same time, diminished, it may 
 become necessary to relieve the agony of the patient, by hastening the 
 delivery with the forceps. I have heard of a Professor of Obstetrics, 
 who informed his class, that he had relieved several instances of this 
 kind, by placing a folded handkerchief between the head and the 
 nerves. But it must* be remembered, that this would still further 
 diminish the diameter of the pelvic cavity, and be very apt to produce 
 irritation, dryness, and probable inflammation of the parts; perhaps 
 the Professor may have dreamed of these several cases, and forgotten 
 that they were but dreams. 
 
 The position which I prefer for the delivery, is on the back, having 
 the knees flexed toward the abdomen, and the feet resting against some 
 support, as the footboard of the bed ; and a sheet or towel fastened to 
 the bedpost, may he held by the patient, upon which she may pull 
 during the presence of the pain, or the hand of an attendant may be 
 used. In this stage, the auxiliary aid of the diaphragm and abdomi- 
 nal muscles are useful, and the patient may be advised to make bearing- 
 down efforts, when the pain is on. Her dress should be so far drawn 
 up underneath her, as to prevent it from being soiled by the discharges. 
 And until the period when the head presses upon the perineum, it is 
 not necessary for her to remain in one position all the time, though 
 she must not be allowed to get out of the bed. It is during this stage, 
 that many practitioners have applied an obstetrical supporter. As a
 
 MANAGEMENT OF NATURAL LABOR. 301 
 
 general thing, supporters have notfbeen found so useful in practice a& 
 was at first supposed, and are seldom, if ever, made use of by the 
 obstetrician. 
 
 Various other positions for delivery, are recommended by writers, 
 and assumed by females ; as sitting, kneeling, leaning over a chair, and 
 lying on the left side. Females, generally, will assume the position 
 recommended by the physician, but where they obstinately prefer a cer- 
 tain position, and it is immaterial, so far so the delivery is concerned, 
 it is better to allow them their own way. Lying upon the left side, 
 with the knees flexed, and a pillow placed between them, is the posi- 
 tion most generally recommended in this country and England; but I 
 do not think that the delivery proceeds with so much ease and rapidity, 
 nor it so convenient for the practitioner in every respect, as when the 
 female is placed upon the back. Some writers maintain, that the 
 action of the uterus is frequently interfered with, and the progress of 
 labor impeded, when the female lies on her left side, in consequence 
 of an obliquity of the uterus, caused by this position ; also, that the 
 too close condition of the limbs, produced thereby, retards the labor, 
 and to overcome which the advocates of this position, advise a pillow 
 to be placed between them, which causes much unnecessary heat. 
 When lying upon the back, the limbs can be kept apart with ease, the 
 axis of the uterus is brought into a favorable direction 'for an easy 
 delivery, and the patient, being in a position requiring no muscular 
 exertion to maintain, can freely and more powerfully employ the 
 abdominal muscles. 
 
 "When the head has reached the perineum, the practitioner will take 
 his seat, by the bedside, in the position heretofore named, and as the 
 part begins to distend, he should keep his finger gently upon the head, 
 during each pain, so as to ascertain the proper period for supporting 
 the perineum, in order to protect it from becoming lacerated, and the 
 advance of the head must be determined, not by its condition at the 
 pubic arch, but at the perineum. As soon as the perineum is fully dis- 
 tended and protruding, and the head about emerging, and not before, a 
 folded cloth, or napkin, light and not too thick or bulky, may be 
 placed over it, extending from its anterior edge to the coccyx, and 
 which must be sustained by either hand, as the case may require, more 
 commonly the right. The pressure, made in giving support to the peri- 
 neum, must be moderate, it must not interfere with the advance of the 
 head, the part requiring firmer support toward the coccyx than at its 
 anterior edge ; and instead of making efforts to retract the skin over 
 the head, as it passes through the orifice, the perineum and the head
 
 : JOl' KIN<,'s KCLECTIC OBSTHTHK S. 
 
 ghould be carried upward and forward in the direction of the axis of 
 tlie inferior strait; this action would press the fetal head toward the 
 pubic arch, and tend to elongate the perineum forward ly, thereby 
 diminishing the risk of laceration, by facilitating the movement of 
 extension of the fetal head. This pressure should not be long contin- 
 ued, nor should it be made at all, except when the pain is present, an. 1 
 it would be much better to leave the part entirely untouched, than t< 
 make improper pressure, which has frequently, of itself, occasioned tht 
 very difficulty it was intended to obviate. There is scarcely any 
 necessity for this support when the perineum is gradually yielding to 
 the normal advance of the fetal head ; .but when the head is rapidly 
 advancing, the perineal tissues not being sufficiently softened, support 
 of this kind may prevent laceration ; and it may also be useful in 
 oases of delivery by the forceps. Some authors advise to support by 
 pressing the bare thumb upon the anterior edge of the perineum, while 
 the index and second finger rest upon the vertex to check its too rapid 
 advance ; this, to my mind, is equal to no support at all, the object of 
 support being, in my opinion, to elongate, as it were, and aid in the 
 relaxation of the perineum, and at the same time to press the occiput 
 against the pubic arch and facilitate the movement of extension. ' 
 
 My experience in this matter, leads me to believe, that laceration of 
 the perineum would be a rare accident, were the rule to support it 
 during the latter part of the second stage of a normal labor, entirely 
 dispensed with in obstetrical practice. Some writers recommend the 
 support of the perineum, not only during the passage of the head, but 
 likewise of that of the shoulders, from a belief that the perineum is 
 frequently lacerated as the bis-acromial diameter is emerging ; in some 
 instances, an attention to this point may prove serviceable, but I do not 
 regard it necessary as a general rule. 
 
 While the head is at the perineum, pressing upon the lower part of 
 the rectum, a great disposition to evacuate the bowels will be produced, 
 and the female will desire to rise and attend to the call ; but it must 
 by no means be granted, as a violent pain might come on, and the 
 child be delivered, and perhaps, destroyed, before the physician could 
 bestow the necessary attention. Beside, these desires generally dis- 
 appear with the delivery of the head, the pressure of which upon the 
 parts has occasioned the tenesmus. I have twice witnessed the delivery 
 of the child, and its reception into the chamber-utensil, where the physi- 
 cians had permitted the females to attempt an evacuation of the rectum, 
 at this stage of the labor. Again : should the bowels not have been 
 opened, early in the labor, and the probability is, that a fecal discharge
 
 MANAGEMENT OF NATURAL, LABOR. 303 
 
 may happen, the patient must not be permitted to rise from the bed, 
 but must perform the evacuation on some old, useless cloths, to be 
 placed under her for such purpose, and which are then to be immedi- 
 ately removed. 
 
 It is sometimes the case, that the pains cease, or diminish in strength, 
 toward the close of the second stage, but they may be renewed by 
 making firm pressure with the left hand, upon the uterus, each time 
 of its contracting, or, by pressing firmly on the end of the sacrum. 
 
 As the head passes through the vaginal orifice, the leg on the side 
 toward the practitioner should be raised and flexed at the knee, to 
 facilitate its passage, and to enable the attendant to act with greater 
 accuracy and promptness ; the fetal head should be received into the 
 right hand, holding it loosely, so as to admit of the motion of restitu- 
 tion, and, at the same time, a finger should be passed around the neck 
 of the child to ascertain whether the umbilical cord is coiled around it, 
 and which commonly occurs when the cord is of more than ordinary 
 length. 
 
 If the neck be embraced by one or more turns of the cord, it must 
 be liberated by loosening it, and passing it over the head ; or else the 
 following results may ensue, especially if the cord be short : the com- 
 pression may arrest the circulation in the blood-vessels of the neck, 
 and prevent the access of air into the lungs by closure of the trachea, 
 thus destroying the child ; or, the expulsion of the child by a strong 
 pain, might cause inversion of the womb, or serious hemorrhage by 
 tearing the placenta from its uterine attachment. If the cord can not 
 be easily passed over the head, it must be loosened as much as possible, 
 so as to prevent strangulation of the vessels of the neck; for it must 
 be remembered, that ordinarily, even with two or three coils around 
 the neck, the cord will be sufficiently long for delivery to take place, 
 without any evil consequences to the mother. Sometimes, the cord is 
 so placed around the neck, that it has to be divided before the body 
 can be born, a ligature being applied as soon as possible; but this is 
 done only in those extremely rare cases, where the free portion of the 
 cord is rendered so short as to endanger inversion, should the child be 
 delivered. It is frequently the case, that an evacuation of the rectum 
 occurs with the expulsion of the head, but the compress at the peri- 
 neum serves to protect the hand of the accoucheur from being soiled 
 by it. The use of a napkin or compress in supporting the perineum 
 has been termed most absurd, the objection being that it absorbs the 
 great secretion of mucus designed to lubricate the parts and thereby 
 render the passage of the head more easy. I have never found any
 
 ;J04 KING'S ECLECTIC OBSTETRICS. 
 
 difficulty from this cause, which may be readily obviated by applying- 
 oil or lard upon the perineum, and, if necessary, also upon the com- 
 press. The principal object of the compress has just been referred 
 to the support can be given as well without as with it. 
 
 As soon as the head is born, the child commonly commences crying 
 lustily ; frequently, however, the presence of mucus interferes with its 
 breathing, and the practitioner should pass a finger into its mouth for 
 the purpose of removing any mucus or other obstruction that may 
 exist there. More commonly, simply wiping its mouth with a small 
 napkin, will answer the purpose, by removing any mucus that may 
 have accumulated around the lips. 
 
 No attempt, whatever, should be made at removing the body, unless? 
 much delay occurs in the natural process, or, the life of the child is in 
 danger. After the birth of the head a short interval generally fol- 
 lows, but if this is prolonged, serious consequences may result; under 
 such circumstances, a finger may be inserted into the axilla nearest the 
 perineum, and traction made in the direction of the axis of the inferior 
 strait, while, at the same time, pressure is to be made by the other 
 hand, or by an assistant, on the abdomen over the uterus. One 
 shoulder disengaged, the other follows, and the child is born without 
 any further trouble. I prefer, however, as the rule, to arouse the 
 uterus to act and expel the child, by making firm pressure, through 
 the abdominal walls, upon the uterine fundus, and which will also be 
 found to facilitate the delivery of the placenta. But, when the body 
 follows the head without requiring any assistance to expel it, the 
 right hand must be passed along with the head, supporting it as it 
 moves, and the body must be supported by the left hand ; and as soon 
 as the child is expelled, it should be laid upon its right -side with its 
 back to the mother's genitals, to prevent it from receiving any of the 
 copious discharge which follows, into its mouth ; or it may be placed 
 with its abdomen toward the mother, so that the mouth is protected 
 from the discharges. And in moving the child, care must be taken 
 not to make sudden or powerful traction on the cord, as the uterus may 
 become thereby inverted, or a portion of the placenta by being roughly 
 detached, may occasion alarming hemorrhage. 
 
 The expulsion of the child terminates the second stage of labor; 
 and it must be ever borne in mind by the physician, that in a case of 
 natural delivery, there is nothing for him to do in these two stages, 
 except to witness the progress of the labor, to console and encourage 
 his patient, and to receive the child after its expulsion. Any inter- 
 ference, in either the first or second stages, when everything i&
 
 MANAGEMENT OF NATURAL LABOR. 305 
 
 proceeding favorably, further than I have just described, is exceed- 
 ingly improper and criminal. 
 
 I am aware that some writers advise, and many practitioners adopt 
 the plan of administering Ergot to all parturient women, in the second 
 stage of labor, for ^ the purpose as they say, of promoting the easy 
 expulsion of the placenta, and a subsequent uterine contraction, thereby 
 lessening the risk of hemorrhage; but, more for the purpose, as I 
 strongly fear, that they may the sooner visit another patient and 
 procure another fee, or, perhaps, from want of sympathy and patience. 
 I consider this a very unscientific and censurable practice, and have 
 witnessed many accidents resulting from it; indeed, when the influence 
 of the Ergot has subsided, the reaction that must ensue, would be very 
 apt to produce a condition of the. uterine tissue favorable to hemorrhage 
 from that organ. From a practice and observation of thirty years, I 
 am thoroughly convinced, that the administration of Ergot to cause 
 contractions of the uterus, whether indicated or not, occasions and 
 develops a greater proportion of diseases of the organ, than is generally 
 suspected by the profession. I have found Sulphate of Quinia, to 
 answer a much better purpose, when it is desired to keep up permanent 
 uterine contraction after delivery, though, as with Ergot, it sometimes 
 fails. It may be given alone, or in combination with powdered 
 Cinnamon. 
 
 A natural labor may be accomrlished in two hours, or it may con- 
 tinue for twenty-four or even longer, without any danger. The danger 
 is never to be estimated by the time which the process occupies, nor by 
 the severity of the pains, but by the symptoms which are present. So 
 long as the parts are in a proper condition, position and presentation 
 right, and the pulse unaffected, there is no necessity for haste, alarm, 
 or officious intermeddling, no matter how long the labor continues ; 
 the practitioner should appear cheerful, resolute, and confident, at once 
 check any complain cs or whisperings among the female attendants, 
 and use all means to sustain the patient's spirits, and preserve her from 
 a despondency, which may cause a suspension of uterine contraction, 
 and convert the labor into a difficult one. But, if the parts become 
 hot and dry, with more or less tenderness on being touched, and the 
 pulse accelerated, it is then necessary to interfere, calmly, deliberately, 
 without violence or rudeness, and employ the proper means to over- 
 come the difficulty. 
 
 Sometimes, after the delivery of the child, the female will be 
 attacked with violent pains, and forcible straining, or bearing-down 
 efforts ; as these may be owing to a disposition to inversion of the 
 20
 
 :',();; KINO'S KCLKCTIC OHSTETUICS. 
 
 uterus, the practitioner should endeavor to ascertain their cause, and 
 remove it if possible, at the same time urging upon the female the 
 importance of resisting these efforts as much as possible, lest inversion 
 should be produced by them. 
 
 The third stage of labor commences after the birth of the child [the 
 placenta not having been expelled simultaneously with the child], and 
 may be considered the most important period of the process, for by far 
 the greater part of the accidents of labor occur at this time, either from 
 improper intermeddling, or from an ignorance of the correct mode of 
 proceeding. After having observed that the child is living, as made 
 known by its crying, it must be separated from its uterine attachment; 
 and this must be effected without any exposure of the mother a point 
 which I desire the reader especially to impress upon his mind as 
 many practitioners, at this stage, are very apt to needlessly expose 
 their patients. 
 
 As soon as the pulsation of the cord of the living child ceases 
 toward its placental extremity, say at a distance of five or six inches 
 beyond its abdomen, or, as far as can be reached by the hand without 
 introducing it into vagina, the accoucheur will proceed to cut the cord. 
 The child must be withdrawn from beneath the bedclothes, if the 
 length of the cord will permit; or if too short, the operation must be 
 performed under the bedclothes, raising them to effect it, taking 
 especial care, however, to previously place over the parts of the patient 
 a well-aired cloth or towel, that they be perfectly covered and con- 
 cealed. 
 
 The ligatures, which had been prepared in the early part of the 
 labor, are now to be used ; they should not be so thin as to risk cutting 
 through the membranes and vessels of the cord, nor so thick as to be 
 incapable of making firm compression, sufficient to prevent bleeding 
 after the separation. The cord is to be tied tightly with one of these, 
 at a distance of an inch or two from the umbilicus, care being had 
 not to include any portion of protruding intestine, which is occasionally 
 met with; as in these cases, the incautious ligaturing of the intestinal 
 protrusion would give rise to the most disastrous consequences. This 
 first' ligature is of importance, for if it be not tied securely, so as to 
 compress the vessels, the child may lose its life from hemorrhage ; 
 hence, when the cord is large or fat it may require considerable force 
 to ligate it properly ; and shortly after dividing it, it will be well to 
 examine and ascertain whether any hemorrhage is occurring from its 
 free extremity. The second ligature is to be applied two or three 
 inches beyond the first, and the division must be made between the
 
 MANAGEMENT OF NATURAL LABOR. 307 
 
 two with the scissors, being careful not to excise, at the same time, a 
 finger, or a portion of the child's penis, if it be a male. In this 
 operation the practitioner should see whafrhe is doing. 
 
 I am well aware that many authors advise the application of but one 
 ligature, and consider the employment of the second superfluous, but 
 I prefer two in all cases, not from an erroneous impression held by 
 some, that the female may lose blood through the unprotected, open 
 vessels of the cord, but for the following reasons : In the first place, I 
 am well convinced, that, in many instances, by thus retaining the 
 blood within the cord and placenta, it acts as a provocative to uterine 
 contraction and insures a speedy detachment and expulsion of the 
 placenta; secondly, it is much more cleanly, and dispenses with the 
 pressure of the thumb and finger to prevent the blood from spurting 
 over the bedclothes, or even on the clothing of the practitioner; thirdly, 
 it is safe in case of twins, with anastomosed circulation in the placenta, 
 should the practitioner, as is frequently the case, have neglected to 
 place his hand on the abdomen to ascertain the size of the uterine 
 tumor, and the probability of the presence of a second child ; and 
 fourthly, should it be judged advisable not to have the second ligature, 
 it can very readily be removed, or another division of the extremity 
 of the placental portion of the cord be made. 
 
 It is sometimes the case that the child is born in a state of defective 
 vitality, asphyxia, or apoplexy. If the pulsation in the cord continues, 
 and the child does not breathe, some cold brandy sprinkled on the 
 region of the diaphragm, or suddenly dashing cold water upon its 
 back and chest, and perhaps a few light frictions made rapidly over 
 the body and extremities with a piece of warm flannel, will be all the 
 means required for its resuscitation ; previous to which, however, the 
 finger must be passed carefully into the mouth, as far down as possible, 
 .in order to remove any mucus which may be present, obstructing the 
 respiration. 
 
 Where these means do not suffice, it may become necessary to 
 produce artificial respiration, which will not, however, be found of so 
 great value in cases of congenital asphyxia (in which air has never 
 entered the fetal lungs) as in other forms; a flexible catheter, or laryn- 
 geal tube must be cautiously and correctly introduced into the larynx, 
 after which the angles of the mouth must be closed to prevent the 
 escape of air ; the practitioner will then apply his mouth to the free 
 end of the tube and slowly and gently inflate the lungs, simulating 
 breathing by making gradual pressure on the chest to expel the air, 
 which he continues to introduce for some time ; with these attempts
 
 Kix(;s KCLKCTI 
 
 he may also sprinkle water or brandy over the face and chest, apply 
 warm flannel to the surface and administer an injection. Some 
 children are not resuscitated until after a persevering trial of an hour 
 or two. Respiration may also be excited by the Sylvester method, 
 which consists in lifting the child by its two arms and then lowering 
 it to a sitting posture, gradually carrying the arms to the correspond- 
 ing sides of the body ; these elevating and depressing movements are 
 to be continued alternately for some time; they tend to produce 
 movements strongly resembling those of natural respiration. Dr. 
 Harvey L. Bird, of Baltimore, advises an easy and speedy method in 
 asphyxia, which consists essentially in placing the palms of the hands, 
 (the ulnar edges being in approximation) under the back of the child 
 in the dorsal decubitus, the thumbs being extended toward the head 
 and extremities. Keeping the ulnar edges of the hands together, the 
 radial sides are simultaneously and alternately elevated and depressed 
 so as to raise and lower the child's body about forty-five degrees above 
 and below the horizontal line, the downward movement allowing air to 
 enter the lungs, while the upward facilitates its escape. These alternate 
 movements performed with gentleness and regularity, the child's head 
 being kept in the median line of the body, rarely fail in effecting 
 respiration in a short time, where life is not extinct. The first 
 symptom of returning life is a short sob, which increases in frequency 
 until respiration is established, after which, the child should be -kept 
 at a sufficiently elevated temperature, and in a state of rest and quiet. 
 Upon the first return of vitality, the warm bath used for a very short 
 time, frequently facilitates the restoration. 
 
 This condition of the child may arise from a premature detachment 
 of the placenta, from uterine hemorrhage, or from defective nourish- 
 ment, and is generally accompanied with little or no pulsation in the 
 cord, and but slight action of the heart, and as nothing is to be gained 
 by maintaining the connection of the fetus with the uterus, it will .be 
 proper to ligate and cut the cord ; but in all instances where the pulsa- 
 tion of the cord is distinct, though feeble, I deem it inadvisable to 
 make the division, until respiration has been fully established ; and in 
 those cases where the" placenta has been expelled, it should be Wrapped 
 in warm, damp cloths, and no separation be made until all pulsation in 
 the cord ceases. 
 
 Apoplexy may be known by the lividity of the face, blueness of the 
 surface, labored, or obscure action of the heart, and feeble, or imper- 
 ceptible pulsation in the cord; while, in the instances above referred 
 to, the color of the surface is natural, or pale. Apoplexy may result
 
 MANAGEMENT OF NATURAL LABOR. 309 
 
 from prolonged labor, compression of the head by a narrow pelvis, or 
 from a delay in the expulsion of the body after the delivery of the 
 head, etc., and it must be treated by removing the cerebral and pul- 
 monary engorgement. In these cases it is recommended to cut the 
 cord without ligaturing it, and allow the escape of from half an ounce 
 to an ounce of blood, at the same time sprinkling tepid water over the 
 head, face, and chest. As in the previous instances, the mouth and fauces 
 should be freed from mucus, and artificial respiration may be attempted. 
 If recovery ensues, the surface becomes paler, or slightly rosy, the pulse 
 more frequent and stronger, and efforts at inspiration are made ; and 
 when these symptoms appear, the cord may be tied. In all these 
 instances, the practitioner should not become discouraged at too early 
 a period, and therefrom slacken his efforts, as almost hopeless cases 
 have been resuscitated after long, but patient and continued treatment. 
 When the pulsations in the heart and cord have ceased for several min- 
 utes, attempts at restoration will be useless. 
 
 The cord having been cut, the child is to be passed to the nurse, who 
 is generally ready to receive it in a small blanket, prepared for the 
 purpose ; but as its body is very slippery with the waters, blood, or 
 vernix caseosa, there may be danger of dropping it, if it be not taken 
 .hold of properly. To avoid any such mortifying accident, the prac- 
 titioner will seize it by the ankles, with his left hand, placing a finger 
 between the two ; and will have the back of its neck to rest in the 
 arch formed by the thumb and index finger of his right hand, resting 
 the upper portion of its back upon the palm of his hand, and placing 
 the points of the three remaining fingers under its right axilla ; thus 
 held, it can not fall. Some advise the left hand to be placed at the 
 breech, with one finger between the legs, the left thigh grasped by 
 the thumb, and the right thigh and nates resting on the remaining 
 fingers and palms at the same time making gentle pressure of the hands 
 toward each other, for the purpose of more firmly securing the child. 
 Either of these methods may be safely adopted. 
 
 The next thing is to ascertain, if it has not been previously done, 
 whether there is another child in the uterus ; this may be known by 
 placing the hand on the abdomen, when the fundus uteri will be felt 
 still in the epigastric region; and an examination per vaginam w r ill 
 detect the bag of membranes, and the presenting part. If, however, 
 the uterus be found small and hard like a solid ball, when grasped 
 through the abdomen; or small, but soft and doughy ; or small, but 
 becoming hard and soft alternately, no second child is present, and the 
 placenta has probably passed, either partly or wholly into the vagina.
 
 310 KINC'S KCLKCTIC or,sTi"r uics. 
 
 If it be hard and nearly the size of the adult head, there is no child, 
 but a contraction of the uterus, upon the mass inclosed within its cav- 
 ity; and if it be thus large, but soft and doughy, contraction of the 
 organ has not yet taken place for the purpose of expelling the pla- 
 centa. The treatment of twin cases will be considered hereafter. 
 Having ascertained that no twin-child is present, the practitioner will 
 attend to the delivery of the placenta ; occasionally, the same pain which 
 expelled the child likewise ejects the placenta. But, usually, from five 
 to thirty minutes elapse from the birth of the infant, before the uterine 
 contractions are renewed for the purpose of removing the secundines. 
 The left hand should be placed on the hypogastrium, and if the uterus 
 be found hard and well defined, and the patient complains of some 
 pain, but not so severe as before, the organ is contracting and expelling 
 its contents, and the right hand should be ready to receive them as 
 they emerge. If, however, the uterus be found large, soft, and yield- 
 ing, or, if it be not felt at all, it may be caused to contract by gentle 
 friction and pressure on it, through the abdominal parietes, and as soon 
 as it contracts, the woman should bear down, and slight traction be 
 made upon the cord with the right hand in the direction of the axis 
 of the superior strait, which will carry the cord backward to the os 
 coccyx, and as soon as the placenta moves the motion will be recog- 
 nized by the hand, frequently, a crackling sensation, or as if tearing 
 a piece of thin silk. In the meantime, the left hand should continue 
 upon the hypogastrium, both for the purpose of exciting the contrac- 
 tions, as well as to admonish a cessation of the traction, whenever the 
 uterus grows soft, or manifests a tendency at some portions of the 
 fundus, to become depressed and follow the direction of the traction, 
 and thus, probably, be partially or completely inverted. "Whether the 
 placenta be in the uterus or vagina, if the soft condition of the uterua 
 continues, notwithstanding the means used, the labor may be compli- 
 cated with hemorrhage, to treat which, according to the rules hereafter 
 given, the physician must be thoroughly prepared. Crede's method 
 of aiding or forcing the delivery of the placenta is stated to be supe- 
 rior to any other, as it does not endanger the tearing away of the cord, 
 produces a tonic contraction of the uterus that diminishes the tendency 
 to subsequent hemorrhage or to severe after-pains, and aids in the pre- 
 vention of puerperal disease. It simply consists in grasping the 
 uterine fundus, through the abdominal parietes, with the hands, in 
 such a manner that the organ can be forcibly compressed from above 
 downward and backward ; and which, as the rule, causes the detach- 
 ment and ejection of the placenta. The operation is the more readily
 
 MANAGEMENT OF NATURAL LABOR.. 311 
 
 effected the sooner it is employed after the delivery of the child. Of 
 course this method is inapplicable when hemorrhage is present. 
 
 When the placenta has emerged from the vulva, it should be twisted 
 or turned around several times, for the purpose of forming a cord or 
 string of the membranes, that, thereby, no portion of them be left 
 attached to the uterine surface, thus effecting a clean and perfect 
 delivery, and the accoucheur should always examine its uterine surface 
 to ascertain whether any portion of it has remained within the uterine 
 cavity. If a portion of the membranes be left within the uterine 
 cavity, it may give rise to unpleasant symptoms, as hemorrhage, putre- 
 faction, offensive discharges, etc.; or should portions of them pass- 
 away in a few hours afterward, they may occasion alarm to the patient, 
 or lead her to think that her medical attendant is not perfect in this 
 department of his profession. 
 
 It is always proper for the practitioner to ascertain as early as possi- 
 ble after the birth of the child, whether the placenta is detached, that 
 he may remove it, and this may usually be known by the absence of 
 pulsation in the cord, which becomes cold and flabby, and, generally,, 
 renewed but less severe pains with a slight discharge of blood; but, 
 unless there be flooding, or some other circumstance demanding the 
 immediate delivery of it, it is inadvisable for him to make any more 
 active efforts than above named, to bring about its expulsion when not 
 effected naturally, for at least one hour subsequent to the child's 
 egress ; then he will treat it as a retained placenta. And in all cases 
 of natural labor, it must be thoroughly impressed upon the mind, that 
 no force or haste is required in the removal of the placenta and mem- 
 branes, but they should be drawn forth slowly and carefully, to 
 prevent any tearing of the membranes, or cord, or other unpleasant 
 accidents arising from too hasty a removal of them from the uterine 
 or vaginal cavity. 
 
 The secundines being completely removed, the practitioner will 
 request the nurse to bring a basin or some other vessel, in which to 
 place them, covering them with a cloth, "for the sake of decency. " 
 Then he will ascertain, by placing a hand on the abdomen, whether 
 the uterus is small and contracted, or large and soft, which latter 
 condition indicates a tendency to internal hemorrhage, and the pulse 
 and countenance of the patient should be at once examined, as described 
 hereafter. The delivery of the placenta closes the third stage of 
 labor; a stage of the process which requires much judgment and 
 presence of mind, for the slightest mistake or misconduct might lead 
 to the most serious consequences ; and with ail diiTiculties which may
 
 312 KI.\(;'S KCI,I-:< TIC OHSTETIJICS. 
 
 occur at this stage, as well as their treatment, the physician should be 
 thoroughly and familiarly conversant. 
 
 As soon as possible after the birth of the placenta, and especially in 
 cases where it has been found necessary to extract it artificially, the 
 practitioner should ascertain that there is no inversion of the uterus, 
 and, if it has not been previously accomplished, should likewise 
 examine the placenta and membranes to see that the whole of them 
 have passed away, and that no portion of them has been left within 
 the uterine cavity, subjecting the patient to severe pains, nausea,, 
 vomiting, and hemorrhage. In this examination both surfaces of the 
 placenta should be inspected. 
 
 Unless there are certain circumstances, or symptoms present, which 
 will be referred to hereafter, it is not material that the bandage or 
 binder should be applied until after the expulsion of the placenta. It 
 should be passed under the patient's back, carefully, being made to 
 embrace the hips and the whole abdomen, and without requiring any 
 efforts on her part to assist in its application; it should be pinned or 
 fastened from below upward, having that portion around the hips and 
 lower part of the abdomen, more tightly applied than the rest, or 
 sufficiently tight to occasion a very slight degree of uneasiness when 
 first placed on. If, however, there should be considerable of the 
 discharges present, so as to endanger wetting the binder, these must 
 first be removed, or covered over with dry cloths. When hemorrhage 
 is present, the bandage is in the way, and should not be applied until 
 this is overcome. Many writers consider the bandage of no practical 
 importance, but I am well convinced of its utility during the first 
 forty-eight hours after labor when it is carefully and properly applied. 
 When firmly applied, and pressing equally upon the anterior surface 
 of the abdomen, it promotes the regular contraction of the uterus, and 
 gives support to the viscera and to the suddenly relaxed abdominal 
 walls, thereby diminishing the risk of concealed hemorrhage, and 
 syncope, and also tends to prevent air from passing into the uterine 
 cavity; it likewise assists a return to the natural condition of the 
 abdominal parietes, preventing that lax state of the integuments 
 which causes a "pendulous belly," but if used simply for this purpose, 
 it can well be dispensed with. When, in dropsy of the abdomen, the 
 sudden removal of the pressure is effected by tapping, unless a bandage 
 is applied and tightened as the water passes off, syncope and nausea 
 are very apt to ensue; and fatal syncope has occured shortly after 
 parturition, from no other attributable cause than the omission of the
 
 MANAGEMENT OF NATURAL LABOR. 313 
 
 bandage; the removal of the uterine contents in labor, whereby a 
 removal of pressure is speedily accomplished, is a somewhat analogous 
 case, requiring similar measures for relief. The binder may, if neces- 
 sary, be worn for a % few days succeeding delivery, not certainly to 
 exceed three or four ; and its longer employment, as advised by some 
 physicians, for two or three weeks, strikes me as being a useless 
 measure. A bandage applied too tightly, and especially when worn 
 longer than the first few days, would, in my estimation, very much 
 endanger some displacement of the uterus, paralyze or greatly weaken 
 the abdominal muscles, force the uterus into the pelvic cavity by 
 pressing the intestines upon it, check to a greater or lesser extent a 
 free circulation in the organ by compression of the vena cava and 
 pelvic veins, and greatly interfere with the accomplishment of involu- 
 tion. It should be applied so that the uterus will be pressed down- 
 ward rather than backward ; and, in some cases, it may be advisable 
 to place a sufficiently thick compress under it, in order to secure the 
 proper compression to aid in preventing uterine relaxation with flood- 
 ing. It will be observed from the above, that since the publication 
 of the last edition of this work, further and more attentive experience 
 has considerably modified the views therein expressed relative to the 
 binder. Generally, the binder is applied by the nurse or some female 
 friend, but the physician should understand how to apply it himself, 
 and should always ascertain that it is properly placed and tightened 
 before leaving the patient. He will, frequently^ be requested to place 
 the bandage on his patient, but, as a general rule, I consider it a 
 task entirely out of his province, and one which should be invariably 
 performed by a female. To be of the greatest service, the bandage 
 should be applied next the skin, and I can not conceive of any office 
 more offensive to female purity and modesty, and more repugnant to 
 the sensitiveness of a man of honor and refinement, than that of 
 bandaging a naked and exposed parturient woman. True, physicians 
 and females have often to be placed* in even more delicate and exposed 
 situations than this, but then it is only in those cases in which health 
 and life render it imperatively necessary, and in which, from the 
 dangers to the patient, modesty becomes a vice. She must be, truly, 
 an ignorant nurse, who is incapable of correctly bandaging a parturient 
 female. Although I consider the application of the bandage, the duty 
 of the nurse, yet it is the physician's duty to ascertain, after it has been 
 done and the female covered, whether it is applied properly. And in 
 those instances where he is desired to place the bandage, himself, and 
 no excuses will be received, he may adjust it over the body-garment
 
 KINC'S K( LKCTIC 
 
 of the patient, and thus obviate the necessity for exposure. After the 
 application of the binder, some 1 warm, dry. cloths .should be loosely 
 applied to the vulva, for the purpose of absorbing the discharges, and 
 preventing them from soiling the dry clothes of the patient. These 
 cloths should be examined from time to time, while in the house, for 
 the purpose of aiding in the determination of the degree of hemor- 
 rhage; and for the same purpose, the hand may be placed upon the 
 abdomen occasionally, to learn if the uterus continues contracted ; the 
 pulse likewise ought to be felt several times, and inquiries be made 
 as to whether the patient experiences any sensations of faintness. 
 
 The " putting to bed," as it is termed, in which the patient is moved 
 into her regular bed, should take place as soon as circumstances will 
 permit ; in ordinary labors it may be accomplished in an hour after 
 the delivery, or, following the washing and dressing of the child ; but 
 if the labor has been tedious, or very painful, it must be delayed 
 according to the strength and circumstances of the patient. In the 
 process of "putting to bed" the practitioner must be very careful that 
 the patient uses no exertions on her part for the purpose of giving 
 assistance/ and that she be not removed from the horizontal position, 
 lest hemorrhage be thereby induced. The husband and two females 
 may carefully raise and remove her, or she may be carried in a strong 
 sheet, held by four persons,-- it matters not how the removal, or 
 "putting to bed," is executed, so it is with care, and an attention to 
 the above points. But, under any circumstances, the patient should 
 not be allowed to lie for any length of time with the discharges and 
 damp cloths around her, these must be removed as promptly as the 
 condition of the patient will admit, and in a manner not calculated to 
 unnecessarily expose her to any dangers. 
 
 As soon as the mother can be safely left for a short time, and the 
 nurse's attention to her can be dispensed with, the child, which had 
 been warmly wrapped up and placed in some safe location, must be 
 attended to. It must be washed and dressed. This is almost always 
 the task of the nurse, or some female present ; yet the practitioner 
 should understand how it is to be done, in case inquiry be made of 
 him, or he should be left in a condition where he would be required 
 to act the part of nurse ; a part, however, to which I most decidedly 
 object, except in imperative cases. 
 
 The body and limbs should be lubricated with Sweet Oil, fresh 
 Lard, or fresh Butter, which will assist in the more ready removal 
 of the sebaceous matter with which the skin of the child is covered 
 at birth; after which, warm Soap-suds will be the only application
 
 MANAGEMENT OF NATURAL LABOR. 315 
 
 required. If the above substance is not thoroughly cleansed from the 
 skin, it may occasion painful and troublesome cutaneous excoriations. 
 Be careful that, in washing and drying, the tenderness and integrity of 
 the infant's skin be regarded, as too much pressure, or too much fric- 
 tion may bruise or abrade it; soft cotton, or linen should be used, both 
 in the washing and drying. Some apply cold water to the infant, 
 but this is wrong, and frequently injurious, requiring a very robust 
 child to pass through the ordeal with safety. The child has just 
 emerged from a situation of an elevated temperature, and a reduction 
 of this temperature too suddenly, or too soon after birth, would, 
 especially in those who are weak and delicate, be very apt to occasion 
 serious and even fatal consequences. In washing the child's head, 
 many nurses are accustomed to apply a small portion of warm spirits 
 of some kind, for the purpose, as they say, of preventing its taking cold ; 
 whether this accomplishes the intention or not, there can be no objec- 
 tion to the practice, if too great a quantity of liquor be not employed. 
 After the washing, the accoucheur will be called upon to dress the 
 cord; but previous to this, it will be proper for him to examine the 
 child, and ascertain that it is not malformed or blemished with nsevi, 
 and that its limbs, hands, feet, mouth, genital organs, etc., are perfect. 
 Some examine for this purpose, even before its washing. This having 
 been done, a piece of soft linen must be doubled, so as to form a square 
 whose sides measure six or seven inches ; this is again doubled and 
 folded in a triangular form, somewhat in the manner of preparing a 
 paper filter, so that its point, which will be the center of the square 
 when opened, may be applied to the flame of a lamp or candle, to form 
 an opening of sufficient size, through which to pass the- cord. I prefer 
 making the orifice by burning instead of cutting, as its edges are 
 thereby much softer and less liable to increase any existing irritation 
 of the parts in contact with it. This is then opened, and through the 
 orifice thus formed in the piece of linen, doubled, the cord is to be 
 passed. The linen may now be allowed to lie upon the abdomen, and 
 another piece placed over it and the cord, or the cord may be wrapped 
 up in the first piece. But whichever plan is adopted, the cord must 
 be placed upward along the abdomen, rather to the left, in order to 
 avoid any compression of the liver, and then be secured in this position 
 by a bellyband or bandage, passed, but not too tightly, around the 
 child's body. If any blood be found to ooze from the end of the cord 
 previous to dressing it, another ligature must be applied nearer the 
 umbilicus. The remaining piece of the funis umbilicalis dr,ies up, 
 and usually falls off in five or six days, though this may vary from
 
 316 KING'S ECLECTIC OHSTKTIMCS. 
 
 two to sixteen days. It is not, commonly, necessary for the practi- 
 tioner to examine the cord at subsequent visits, for every time the 
 nurse bathes the child, she makes it a matter of duty to inspect its 
 condition herself, and from her any information relative to it, under 
 ordinary circumstances, can be obtained. As the cord shrivels and 
 diminishes in thickness, it soon has the appearance of a fine spider- 
 web, and which may lead the accoucheur to hasten its separation 
 by cutting it with a knife or scissors, but he must be careful not to 
 attempt this; I' have known such an operation to be followed by 
 severe ulceration, and also by hemorrhage. After the application 
 of the bandage, the child should be lightly and loosely dressed, 
 according to the season, and all cumbersome and tight clothes placed 
 aside, as injurious to its health and welfare. 
 
 The child should be placed to the breast as soon as possible, for, in 
 many instances, it will at once obtain a supply of the mother's milk ; 
 or if there be no milk present, the attempt at sucking is very apt to 
 be followed by its early secretion ; but should it fail to suck, or should 
 no milk have been secreted, there will be no necessity for feeding it 
 until several hours have elapsed. Some recommend it to be kept from 
 the breast for ten or twelve hours ; this may answer in cases where 
 there is much exhaustion, or where the labor has been protracted ; but 
 in ordinary instances I prefer placing it to the breast as early as possi- 
 ble; and this, not so much for the purpose of food, as to excite uterine 
 contraction and thereby prevent hemorrhage. I have met with many 
 instances in which, for several hours after the birth of the child, any 
 attempt made by it to suck, was instantly followed by more or less 
 severe after pains. Should it become advisable to feed the child, a 
 little warm milk and water, without sweetening, or some thin gruel, 
 will be the only food required [if, however, these articles must be 
 sweetened, it will be better to use sugar of milk, and not cane sugar] ; 
 but after it obtains the mother's milk, no other food, whatever, should 
 be allowed, unless, for some urgent reason. 
 
 The substance collected in the intestines of the fetus during utero- 
 gestation, is called " meconium," and if it be not removed soon after 
 birth, it will occasion gripings, colic, etc. The first breast-milk of the 
 mother, secreted after delivery, is the best agent for the removal of 
 the meconium ; it is called colostrum, and contains, in addition to the 
 common milk globules, numerous large cells, or granular corpuscles, 
 whose investing membrane is filled with oil, or common milk globules, 
 similar to those which are floating free in the surrounding fluid. This 
 colostrum appears to exert a laxative influence on the child, and is
 
 MANAGEMENT OF NATURAL LABOR. 317 
 
 superior to any other agent for the above purpose ; if it can not be 
 had within a few hours succeeding delivery, some Sweet Oil, or Castor 
 Oil may be given, to effect the evacuation. I do not believe in dosing 
 an infant with medicine as soon as it is born, for, owing to the cus- 
 toms and habits of society it will become a charge to the physician 
 soon enough, without attempting medication from the moment of birth ; 
 therefore, care and prudence should be manifested in making use of 
 laxatives to purge off the meconium. And, above all things, for the 
 sake of decency and of science, forbid that nauseous, abominable, and 
 worse than heathenish practice, which some old. nurses have, of forcing 
 down the child's throat, a disgusting mixture of urine and molasses. 
 
 During these attentions to the child, the mother must by no means 
 be neglected; her pulse should be examined from time to time, and 
 other investigations pursued to ascertain the condition of the uterus, 
 and whether any disposition to hemorrhage exists. The practitioner 
 should NEVER leave the house for at least one hour after the delivery 
 of the placenta, and he who leaves earlier than this, is criminally 
 guilty of the loss of his patient, should she, shortly after his leaving, 
 die, from uterine hemorrhage. There is no excuse for him. If it is 
 absolutely necessary for him to leave the house, previous to the ter- 
 mination of the hour, let him have another physician called in, to 
 temporarily supply his place. If the labor has been a tedious one, 
 or the patient is much exhausted, or if the womb does not contract 
 properly, the house should not be left for even a longer period than 
 an hour, depending, however, upon the circumstances of the case. 
 
 When about to return home, the accoucheur should place his hand 
 upon the patient's abdomen, to learn whether the uterus is small, hard, 
 and contracted; he should examine the condition of the pulse, and 
 likewise request the nurse to show him the cloth which had been 
 placed at the vulva, that he may form some idea of the quantity of 
 blood discharged. He should direct a light, non-stimulating, but 
 nutritious diet, as, of toast and tea, gruel, barley-water, and similar 
 articles, favoring the patient's desires in this respect when they are not 
 decidedly objectionable, and positively prohibit the admission of friends 
 into the parturient room, for a period of at least twenty-four hours ; 
 the room must be kept comfortably warm, and properly ventilated 
 without exposure of the patient, and perfectly free from any noise or 
 excitement. Nervous irritation, fretfulness, feverishness, mania, and 
 even death, have followed the use of a diet not sufficient to afford the 
 nourishment and strength required during the puerperal period. He 
 should leave the most positive orders that the female shall not assist
 
 318 KING'S K( I.I (Tic OBSTETRICS. 
 
 herself in anything, and especially that she continue in the horizontal 
 position, for the first twenty-four hours after labor, for even the 
 momentary semi-erect posture has frequently occasioned alarming 
 hemorrhage; and he should also ascertain that the bandage is properly 
 secured. 
 
 CHAPTER XXVI. 
 
 'ATTENTIONS REQUIRED SUBSEQUENT TO DELIVERY, DURING THE 
 PUERPERAL PERIOD. 
 
 IN about twelve hours the patient should be again visited by her 
 medical attendant, and even sooner than this, where the labor has 
 been tedious, or where there is a disposition to hemorrhage. As with 
 the process of natural labor, so with the puerperal state, when unin- 
 terrupted by accidents, no interference is required on the part of the 
 practitioner; the patient will gradually attain her normal condition, 
 unaided; yet as many females, who pass through their labors with 
 safety, perish in the subsequent puerperal condition from inflammatory 
 attacks, it is the duty of the attendant to superintend this condition, 
 that he may at once adopt the proper measures to remove any abnor- 
 mal symptoms that may arise. 
 
 The shock to the nervous system from labor, effects a derangement 
 varying from mere restlessness to absolute hysteria; in easy labors, 
 the patient soon recovers from it, requiring only a state of rest and 
 sleep. When severe, it is characterized by symptoms of exhaustion, 
 with an alteration in the appearance of the eye, an anxious counte- 
 nance, derangement of the brain, the sensibility of which is either 
 diminished or increased, and a disturbance of the circulating and 
 respiratory systems, as manifested by the pulse, which is slow and 
 labored, or rapid and fluttering, or alternating from slow to rapid, and 
 which must not be mistaken for the pulse of peritonitis, and also by 
 the hurried, panting breathing. 
 
 The pulse will be found to increase during the second stage of labor, 
 to diminish after this is completed, and to rise again on the secretion 
 of the milk. A pulse ranging from 100 to 110 in the puerperal state, 
 should be watched, though it is not always indicative of danger. A 
 quick pulse may be present when a large clot is in the uterus, it may 
 occur with diarrhea, gastric disturbance, or severe after-pains ; and 
 when found immediately after delivery, it frequently indicates hemor-
 
 ATTENTIONS SUBSEQUENT TO DELIVERY. 319 
 
 rhage. A quick, feeble, fluttering pulse occurs in the collapse from 
 the nervous shock. There is a sensation of fatigue experienced in the 
 shoulders and in the muscles of the abdomen, which sometimes persists 
 for three or four days. It is occasioned by the muscular efforts made 
 during the second stage of labor, and which may be discriminated from 
 peritonitis, by the pulse not being increased, by no aggravation of the 
 pain on pressure, and by the absence of febrile symptoms. When 
 these symptoms are not very severe, they will subside upon keeping 
 the patient quiet, and free from excitement, together with a few hours 
 sleep. If severe, small doses of the compound powder of Ipecacuanha 
 and Opium may be administered with advantage. In some instances, 
 the indication for Sp. Tr. Xanthoxylum, Pulsatilla or the Parturient 
 Balm will be present. The support derived from the bandage will, 
 usually, quickly overcome any weakness that may exist in the abdom- 
 inal walls. Not unfrequently small doses of Sulphate of Quinia, Sp. 
 Tr. of Macrotys, of Aconite, of Golsernium, or even of Nux Vomica, 
 according to the indications, will prove efficacious. The diet should 
 be nutritious, the patient kept quiet, the visits of friends prohibited, 
 and for a few days nursing may be avoided. When symptoms of col- 
 lapse or great exhaustion are present, stimulants may be allowed, as 
 a moderate quantity of brandy and water, wine, or Aqua Ammonia, and 
 these may be given in conjunction with the compound powder of Ipe- 
 cacuanha and Opium. Special attention has recently been called to 
 Erythroxylon Coca, either in tincture, fluid extract, or infusion, which 
 will, in many instances, no doubt, be found decidedly beneficial. In 
 anemic conditions, small doses of the Acid Solution of Iron may be 
 associated with the other remedial measures. The stimulants may be 
 omitted as reaction comes on, for if continued beyond this, they will 
 be likely to produce mischief. 
 
 The vagina, notwithstanding its great distension, soon recovers its 
 normal size, and the heat and soreness speedily disappear, unless the 
 labor has been protracted during the second stage; or the lochial dis- 
 charge becomes acrid. The integuments of the abdomen do not so readily 
 recover their natural condition; they remain loose and flaccid for a 
 long time ; but if the bandage be properly applied, the only evidence 
 of pregnancy which they afford, will be the white streaks on the exter- 
 nal surface of the abdomen, linece albicantes. The contractions of the 
 uterus after delivery, not only reduce its size, but prevent uterine 
 hemorrhage, remove all substances from within its cavity, and diinm-
 
 320 KING'S ECLECTIC OBSTETIUCS. 
 
 ish the caliber of its vessels and sinuses. The contraction, however 
 is not permanent, but is followed, after a short time, by an interval of 
 relaxation; and these alternate contractions and relaxations continue 
 for eight or ten days, during which time the organ can be felt and 
 examined through the relaxed Avails of the abdomen, after which it 
 becomes so reduced in size as to descend in the pelvis, when it can no 
 longer be distinguished through the abdomen. A day or two after 
 delivery, the lining membrane of the internal cavity of the uterus, 
 appears loose, somewhat softened, wrinkled, and covered, more or less, 
 with patches of decidua. At the placeutal site the part is raised, and 
 the surface is unequal, like a granulating ulcer, and its size is very 
 much reduced. The whole internal surface of the organ is of a dark 
 ash color, with a greenish or brownish discharge upon it, which has 
 been mistaken for a gangrenous condition. The uterine structure is 
 not so dense as in its natural state ; its fibers are more distinct, and 
 the sinuses are still evident, being, filled with clots of blood at the pla- 
 cental site. The os and cervix uteri appear bruised and ecchymosed, 
 and small lacerations or abrasions may sometimes be observed, which 
 occasionally degenerate into ulcers. The orifice remains open for 
 several days, closing gradually. 
 
 The contractions of the uterus, which ensue after delivery, are usually 
 accompanied with more or less pain, termed AFTER-PAINS, and 
 which are more common to multiparous women than primiparous; 
 being more generally absent in the latter. Females who are the sub- 
 jects of dysmenorrhea are said to be the most liable to these pains, 
 which vary greatly in their severity and duration. They commence 
 soon after delivery, say from half an hour to an hour, and continue 
 from twenty-four to sixty hours. No bearing-down efforts accompany 
 them, nor is the frequency of the pulse increased. These pains are 
 useful not only in reducing the uterus to its non-gravid condition, but, 
 by expelling coagula, pieces of membrane, .and the fibrinous clots 
 which plug up the sinuses, they also prevent irritative fever. They 
 are frequently brought on, or increased, upon applying the child to the 
 breast, which is an argument in favor of this being done at an early 
 period after delivery, in order to assist in promoting these contractions 
 and thereby lessening the risk of hemorrhage. 
 
 After-pains may be usually distinguished from peritonitis, by their 
 periodical returns, by being unaccompanied with fever or an excited 
 pulse, by the persistence of the secretion of milk, and the discharge of
 
 ATTENTIONS SUBSEQUENT TO DELIVERY. 321 
 
 the lochia, and by not increasing in severity upon pressure, though it 
 must be recollected that the muscles of the abdomen may feel sore 
 when pressed upon. They require no treatment unless severe, wheii 
 they may be overcome by the administration of Sp. Tr. Macrotys, or 
 compound powder of Ipecacuanha and Opium, either singly or in 
 alteration; the mixture known as Diaphoretic Powder has been admin- 
 istered with benefit. Should the pains resist the use of these agents, 
 and which resistance will usually be found to depend upon retention 
 of coagula, the rectum should be unloaded by a purgative enema, and 
 hot fomentations should be applied to the abdomen, which will cause 
 a prompt discharge of the clots, followed by immediate relief to the 
 patient. The application of Hops, heated in a small sack or equal parts 
 of Hops and Tansy, made into a fomentation with Whisky or some 
 kind of Spirits, and applied over the abdomen warm, renewing it from 
 time to time, together with the internal administration of compound 
 powder of Ipecacuanha and Opium five grains, repeating the dose 
 every three hours, has, in my practice, afforded prompt relief in severe 
 after-pains that had obstinately resisted all previous treatment. Sul- 
 phate of Quinine, in doses of two to five grains, one, two, or three 
 times a day, alternating with Sulphate of Morphia, in doses of one- 
 eighth to one-fourth of a grain, will frequently check after-pains which 
 have resisted other means. The process of involution is greatly facil- 
 itated in a majority of instances by the use of Macrotys and Pulsatilla; 
 Phytolacca also seems to exert a specific influence in this regard, as 
 well as the Parturient Balm. Other remedies have been recommended 
 in this difficulty, but I have found the above all-sufficient in the nu- 
 merous cases which have come under my notice. There is a species 
 of pain, of a very excruciating character, which sometimes follows 
 delivery ; it does not intermit like the ordinary after-pains, but is con- 
 tinuous, and is located in the coccyx and extremity of the sacrum. It 
 may be relieved by introducing an opiate suppository into the rectum, 
 or by thejnternal administration of the compound powder of Ipecac- 
 uanha and Opium, or other mild anodyne. 
 
 Rheumatism of the uterus may render the retraction of this organ 
 after delivery, very imperfect, causing it to continue enlarged above 
 the superior strait. In this case the after-pains are prolonged and 
 very severe,' and the want of sufficient contraction upon the bleeding 
 vessels may give rise to profuse hemorrhage. This may be overcome 
 by pursuing a treatment similar to that named in another chapter. 
 
 21
 
 322 KINO'S ECLECTIC OBSTETRICS. 
 
 In addition to the above-named conditions, there are several others, 
 which it is important to inquire into upon the first visit after delivery; 
 among these may be named the state of the excretions. During the 
 second stage of labor, perspiration becomes quite copious, diminishing 
 after the delivery, but not immediately returning to the ordinary 
 standard; sometimes it has a greasy feel, and a sickly odor, and the 
 skin is soft and flabby, gradually returning to its natural state. 
 
 Particular inquiry should be made as to the urinary discharge, and 
 on this point the practitioner should fully satisfy himself. It is 
 frequently the case, that the patient is unable to void the urine, or 
 it passes with difficulty, and in small quantity. This may distend the 
 bladder, giving rise to pains, fever, violent spasms, and, perhaps, 
 rupture of the bladder. Pressure of the head upon the bladder and 
 urethra, during its passage through the pelvis, usually occasions this 
 difficulty. Whenever there exists any want of free urination, the 
 bladder should be at once emptied by means of a catheter, which may 
 have to be used several times before the parts recover their tone 
 sufficiently to do without it. In attending to the evacuations during 
 the first twenty-four, or thirty-six hours after labor, the patient should 
 never be allowed to rise in the bed ; it has often been the case that a 
 sudden rising up in bed, within a day or so after delivery, especially 
 when this has been accompanied with hemorrhage, has been followed 
 by immediate death. The late Professor Meigs considered this to 
 arise from the "heart clot" emboly. The excessive loss of blood 
 disposes the remaining portion of this fluid circulating in the system 
 to a ready coagulation; consequently, if on rising, the debilitated 
 patient should faint, the activity of the circulation is impeded, and a 
 mass of coagulated blood forms in the heart, filling it so that the 
 circulation can not be re-established, and death must ensue ; or if this 
 does not supervene, restoration takes place very slowly, with symp- 
 toms of restlessness, difficult respiration, and a peculiar action of the 
 heart. Dr. Meigs says, that he has not seen a patient, struggling and 
 breathing violently, from the above cause, who has ever recovered. 
 
 The condition of the bowels should likewise be inquired into ; if the 
 patient is doing well, and had a thorough alvine evacuation previous 
 to delivery, there will be no necessity for any medication in two or 
 three days, if at all. But, if the bowels were costive, or if there are 
 febrile symptoms, restlessness, with slight pain upon pressure of the 
 abdomen, some mild laxative medicine should be administered. If 
 an enema can be given without worrying or exciting the patient it
 
 ATTENTIONS SUBSEQUENT TO DELIVERY. 
 
 may be employed in preference to the internal laxative ; but on no 
 account should the patient be actively purged, as it increases her 
 already existing debility, favors absorption of any septic poison that 
 may be present, and may give rise to some uterine displacement. 
 Castor Oil is the agent most generally employed for this purpose, but 
 many females have an aversion to it, consequently other laxatives will 
 have to be used, as the compound powder of Rhubarb, calcined Mag- 
 nesia, or one of the mild aperient waters may bo substituted, as 
 Hunyadi. Small doses of Cascara Cordial is a favorite with many. 
 In fact, any one of the mild, non-irritating laxatives may be em- 
 ployed, when an agent of the kind is indicated. I have frequently been 
 called to patients, several days after their delivery, who were suffering 
 from pains in the abdomen, headache, restlessness, and febrile symp- 
 toms, caused by the medical attendant having neglected to evacuate 
 the bowels, and in whom all these symptoms disappeared, after the 
 action of a dose of mild purgative medicine. This inattention to the 
 condition of the bowels of the puerperal female, appears to constitute 
 a part of the practice of a certain class of physicians. It is, however, 
 a very reprehensible omission. 
 
 The LOCHIA is a discharge consisting of blood, broken-down 
 coagula, and decidual debris, which takes place from the partially 
 closed vessels of that part of the uterine surface to which the placental 
 attachment was formed, as well as from the naked surface of the 
 uterus deprived of its decidual membrane ; it generally lasts five or 
 six days, or longer, until the womb is restored to its normal size; 
 though with some females, the discharge continues until the re-appear- 
 ance of the menses. It is, at first, bloody, but in twelve or thirteen 
 hours becomes thinner and paler, changing to a discharge of bloody 
 serum. According to its color, the lochia is distinguished by the 
 names of sanguineous, sero-sanguineous, and purulent or puriform; 
 it exhales a peculiar, disagreeable odor, varying in intensity with 
 different women, which is called gravis odor puerperii. During the 
 milk-fever, the discharge generally ceases, but returns on its subsid- 
 ence, being then of a yellowish-white color; it varies in quantity, 
 being with some women very small, while others will soil from six to 
 fifteen napkins in the twenty-four hours; but this quantity gradually 
 diminishes, and the discharge assumes a greenish or paler color before 
 it ceases. The lochial discharge serves to relieve congestion, and to 
 lessen the chances of an inflammatory attack; during fever, it becomes
 
 324 KING'S ECLECTIC OBSTETRICS. 
 
 checked, hence, its presence is indicative of the absence of fever. This 
 flow is considered to bear a relation to the expulsion of the uterine 
 contents, somewhat similar to that which exists between menstruation 
 and the discharge of the monthly formed decidua. 
 
 Generally, the lochia requires no interference ; it is only when its 
 condition affects the health of the patient, that medical attention will 
 be needed. Thus, it may be very small in quantity, but continue the 
 usual time without any unpleasant results, and which is apt to occur 
 after flooding; or it may be abundant, and cease at the usual time, 
 without any detriment to health ; or it may stop shortly after delivery, 
 without any evil consequences, as is frequently witnessed in the case 
 of still-born or putrid children. When this flow continues beyond 
 fourteen or sixteen days, it is indicative of existing ulcerations of the 
 cervix, of a check to the act of involution, or of both. Should these 
 conditions be found, upon examination, to exist, astringent solutions 
 may be locally applied to the vaginal walls and to the ulcerations, as, 
 of Tannin, Borax, Chlorate of Potash, Asepsin, Persulphate of Iron, 
 etc.; while, to forward uterine involution, agents should be admin- 
 istered internally that occasion contraction of uterine fiber, as, Ergot, 
 Sulphate of Quinia, Macrotys, Cinnamon, Strychnia, etc. 
 
 Sometimes, however, the discharge is very excessive, producing 
 much debility; in these cases, remedies must be employed which will 
 diminish the quantity of the flow, as well as strengthen the patient's 
 system. To check the discharge, astringents may be employed; Ma- 
 crotys, Aletris, Pulsatilla, or the Parturient Balm may be 'given, as 
 suited to each particular case. Perchloride or Persulphate of Iron 
 will often prove serviceable, in dilute solution. I have also gotten 
 good results from teaspoonful doses of a mixture of soluble Citrate of 
 Iron ; a drachm to the ounce of Port wine. As tonics, Quinine, 
 preparations of Iron, or some of the ordinary vegetable bitter agents, 
 may be used; the diet of the patient should be more nourishing, but 
 not stimulating, and. she should be kept in a state of rest and quietude. 
 If, with the excessive discharge, there is vascular excitement, as quick 
 pulse, heat of surface, furred tongue, pain in the back, etc., the patient 
 should be placed on a low, mild diet, with cooling drinks, the bowels 
 must be gently moved by Seidlitz Powders, or other cooling laxative, 
 and the febrile symptoms may be overcome by the administration of 
 Aconite, Gelsemium, or such other specific agents that may be espe- 
 cially indicated, prepared as usual, in the half-glass of water, and 
 given in teaspoonful doses, every one or two hours. Macrotys will
 
 ATTENTIONS SUBSEQUENT TO DELIVERY. 325 
 
 be often called for, at which time the most satisfactory results will 
 follow its use ; it may be either given singly or with the sedative. 
 Beside the sedative and antiphlogistic influence exerted on the sys- 
 tem by these agents, we also obtain the peculiar tonic action of the 
 Macrotys upon the uterus, thus rendering the compound a highly de- 
 sirable one. The generative parts should be bathed with cool water, 
 three or four times a day. Should the increase of the flow be owing 
 to the presence of a portion of the placenta within the uterine cavity, 
 and which may be presumed if the discharge is offensive, with vomit- 
 ing, the vagina may be syringed two or three times daily with hot 
 water, in which may be used Chlorate of Potash, Borax,- Asepsin, or 
 diluted Carbolic Acid, one to fifty or sixty parts of distilled Water, 
 or, solution of Permanganate of Potash, one to one hundred or one 
 hundred and twenty parts, etc., and if the offending portion can be 
 easily removed it should be done, when the symptoms are very urgent. 
 Should it become necessary to apply any of these to the inner uterine 
 walls, it must be effected by a soft uterine probang, and not by injec- 
 tion ; the greatest circumspection and care must be observed in mak- 
 ing these applications. Generally, however, the uterus will evacuate 
 its contents with more safety when not interfered with by injections 
 or manual operations. ..-. 
 
 At times, the lochial flow, after having diminished in quantity, sud- 
 denly becomes increased and of a red color; this arises from the 
 patient sitting up too soon, or, at a later period, from too much exer- 
 cise, as of walking. Rest in the recumbent position will, usually, be 
 the only treatment needed; but should it prove obstinate, the red dis- 
 charge still continuing, secondary hemorrhage may ensue, for which 
 the practitioner must be prepared; Ergot, Cinnamon, Macrotys, Pul- 
 satilla, etc., are among the articles that may be used in these instances, 
 together with a confinement to the horizontal position. Some of the 
 astringent preparations of Iron may frequently be employed with 
 benefit in these cases. 
 
 The lochia may be checked, or deficient in quantity, from other 
 causes than uterine contraction, in which cases febrile symptoms will 
 be present; and if the discharge be not promptly restored, it may 
 form the basis of some fatal disease. The treatment which I have 
 found to be most commonly beneficial, is, to evacuate the bowels by a 
 mild purgative, after which the sedatives and other agents usually 
 indicated where we have febrile excitation should be given ; at the 
 same time bathing the groins, thighs, and inferior extremities with
 
 326 KING'S ECLECTIC OBSTETRICS. 
 
 the officinal compound tincture of Camphor has been recommended. 
 Hot fomentations to the abdomen have also proved serviceable. 
 
 When the above treatment fails to remove the abnormal symptoms, 
 they may be owing to inflammation of the uterus, or other local in- 
 flammation, which will require to be treated upon general principles. 
 I would remark here, however, that the combination of the Sp. Tr. 
 of Aconite and Macrotys, above mentioned, with attention to the con- 
 dition of the bowels, and warm fomentations to the abdomen, have 
 been employed in my own practice very successfully. I have also 
 administered the tincture of Gelsemium, in these cases, with the most 
 remarkable results. A similar course may be pursued where the dim- 
 inution of the lochial discharge is owing to uterine rheumati-m ; 
 which is apt to be the case when the uterus is attacked by this 
 disease. 
 
 Sometimes the lochia has a very fetid odor, is acrid, and of a dark 
 color; this may be owing to putrefaction of retained coagula, or de- 
 composition of pieces of the placenta or membranes which have been 
 left within the uterus. An injection of hot water, with the addition 
 of an astringent, or of a very weak solution of chloride of lime, 
 passed into the vagina two or three times daily, will be found 
 sufficient to remove the fetor. Or, weak solutions -of Chlorinated 
 Soda, of Permanganate of Potassa, or of Carbolic acid may be 
 injected into the vagina, as well as sprinkled upon that part of the 
 bed in the vicinity of the reproductive organs. When the discharge 
 continues of a purulent character, long after deliver}', with lumbar 
 pains and sense of weight accompanying, it may be owing to ulcers, 
 or abrasions of the cervix or vagina, which will have to be determined 
 by the speculum, and treated accordingly. When the lochia is acrid, 
 an infusion of Elm bark and Black Cohosh root, may be injected into 
 the vagina, several times a day, with advantage. 
 
 With some women the secretion of milk is attended with considerable 
 vascular excitement; rigors, headache, pains in the back and limbs, 
 quick pulse, furred tongue, etc., are present in a greater or less degree. 
 This condition is termed milk-fever, and is by no means common to 
 every parturient woman ; it usually manifests itself in two or three 
 days after delivery; occasionally sooner, and sometimes later. It may 
 generally be avoided by placing the child to the breast as soon after 
 labor as is compatible with the strength and condition of the mother, 
 and by the early administration of a mild purgative. It commonly
 
 ATTENTIONS SUBSEQUENT TO DELIVERY. 327 
 
 lasts for twelve or twenty-four hours, rarely forty-eight, and may be 
 overcome by the use of cooling purgatives, fomentations to the breasts, 
 if they are full, hard, and painful, and the frequent application of the 
 child. "When very severe, diaphoretics or sedatives may also be given. 
 When the rigors are very intense, or when the fever assumes peri- 
 odicity, febrifuges and antiperiodics must be administered, and the 
 practitioner should be on his guard lest it be attended with puerperal 
 peritonitis. 
 
 Milk-fever is often occasioned, or aggravated by too long a delay 
 in giving suck to the child, and which may arise from deficient, mal- 
 formed, or sore nipples. Where the nipples are deficient or mal- 
 formed, the milk will have to be extracted by artificial means, as the 
 breast-pump. The secretion of milk is liable to become diminished 
 when the uterus is suffering under a rheumatic attack; and this, 
 together with the severe pain, diminution of lochia, pain on pressure, 
 etc., may be readily taken for peritonitis. From recent investi- 
 gations it seems more probable that the symptoms, to which the 
 name of "milk-fever" has been applied, are in no w T ay associ- 
 ated with the secretion of milk, but are rather the result of a 
 mild form of puerperal septicemia arising from absorption of any 
 putrid lochia that may be present within the uterus or vagina, and 
 may be remedied by keeping up proper uterine contraction, with 
 cleanliness, antiseptics, and tonics or febrifuges as required. 
 
 Excoriation and ulceration of the nipplqs is a very common aifection 
 among nursing women, indeed, some suffer severely from it after every 
 confinement. It is, sometimes, so severe and painful that it is impos- 
 sible to bear the application of the child's mouth to the nipple, and, 
 in some instances, a persistence in suckling, gives rise to large, foul,, 
 painful, superficial ulcers, or deep cracks, which bleed upon every 
 application, of the child ; occasionally, the woman loses her nipple. 
 This difficulty may be obviated, by the use of artificial shields, or 
 prepared teats, which can be had in every drug-store; but frequently 
 the child refuses to suck with them, and the aid of the physician is 
 demanded. Whenever inflammation is present, it must first be subdued, 
 previous to the application of any healing salve or ointment. This 
 may be effected by a poultice of Elm bark, or Flaxseed, which should 
 cover the whole nipple and areola", after which any of the preparations 
 named below may be applied. Sometimes, the inflammation will be 
 so intense, as to require the application of a few leeches on the breast 
 outside of the areola, before any benefit will result from the emollient 
 poultices. The severe pain may frequently be relieved by a careful
 
 328 KING'S ECLECTIC OBSTETRICS. 
 
 application of a solution of Nitrate of Silver to the excoriated parts 
 only ; the solution may be of the strength of from two to six Drains 
 of salt to the fluiclounce of water. 
 
 After the reduction of the inflammation, and in those cases where 
 it is but slight, the following applications have been recommended : 
 1. Take of Spermaceti Ointment, six drachms; Balsam of Peru, ono 
 drachm; mix together, and apply a small portion to the nipples, several 
 times a day. 2. Take of Mutton Suet, one ounce; Balsam of Peru, 
 two drachms ; Honey, Glycerin, of each, one drachm ; melt the Suet, 
 and add the remainder of the articles, stirring well together. I Rw 
 same as above. 3. Take of Balsam of Tolu, Balsam of Peru, Honey, 
 of each, fourteen drachms; Camphor, Opium, of each, two drachms; 
 Alcohol, two pints ; mix together and allow them to stand for seven 
 days, frequently agitating them. A piece of linen is to be moistened 
 with this, and kept constantly applied to the nipple when the child is 
 not suckling; if too severe, it may be slightly diluted with water. It 
 must be washed off every time previous to the application of the child. 
 I have used this successfully, in many cases. 4. Take of Beef-mar- 
 row, Olive Oil, white Wax, of each two ounces; Cherry Wine, made 
 of common cherries (Cerasus avium, C. vufgarus, etc.), two fluidounees ; 
 place the articles together in a vessel, apply it over a gentle heat, and 
 allow it to remain until all the wine has evaporated. This ointment 
 may be applied just previous to the child's suckling, and immediately 
 after. Should the child's mouth be sore, this will have a tendency to 
 heal it. It forms an elegant preparation, one which I have su< 
 fully employed in the most distressing and obstinate cases. And as 
 my object is to render this work one of practical utility, even in minor 
 difficulties, I do not hesitate to give publicity to these small details. 
 5. Take of Glycerin, Tannin, each, two drachms; mix, dissolve the 
 Tannin, and apply frequently. 6. Take of Gum Tragacanth, 8 to 15 
 parts; Lime water, 120 parts; Glycerin, 30 parts; Rose water, 100 
 parts ; mix, and employ in ointment or embrocation. The agents I more 
 commonly employ are, however, No. 3, of the preceding, and diluted 
 Carbolic acid, or Carbolate of Soda. I have frequently been called 
 upon to prescribe in cases of sore nipples, which had baffled the treat- 
 ment of four or five preceding medical attendants, but which yielded 
 at once to the course above named.* 
 
 * The above named form nlse are old; most of them are taken from the Am. Dis- 
 pensatory. They, however, will be found quite efficient, and may be used where 
 other means fail. A cure, in most cases, will follow the application of Glycerole of 
 Tannin.
 
 ATTENTIONS SUBSEQUENT TO DELIVERY. 
 
 After having bestowed the proper attentions to the mother, and 
 Ascertained the condition of the bowels, bladder, uterus, lochia, pulse, 
 breasts, etc., the practitioner may then inquire concerning the child. 
 Whether it has had evacuations from the bowels and bladder, and 
 whether it sucks. In cases -where the urine is scanty, or where there 
 has been no urinary discharge, and the parts are natural, requiring no 
 surgical operation, a warm bath, cold water sprinkled upon the hypo- 
 gastrium, or the administration of one of the diuretic infusions, 
 will be very serviceable; if, however, these do not cause a copious 
 urinary discharge, and the hypogastric region be swollen from 
 accumulation of fluid in the urinary bladder, it may become neces- 
 sary to introduce a small flexible catheter, in order to remove the 
 urine, and which will be found a difficult operation, requiring great 
 care. If the bowels have not been evacuated, and there is no imper- 
 forate anus requiring the surgeon's aid, a mild laxative as before 
 remarked, may be given ; Castor Oil is usually preferred, though I 
 prefer Sweet Oil in almost every instance. The light should not be 
 too intense for the delicate eyes of the child, but should be kept sub- 
 dued for several days after birth, gradually accustoming these organs 
 to ordinary daylight. The clothing of the child should be warm, and 
 loosely applied, that it may be free in its motions; caps are to be 
 avoided as injurious; the dress should be high up on the neck, with 
 long sleeves ; and the diapers must be soft, and never allowed to 
 become dry and stiffen with the excretions, and thus give rise to 
 troublesome excoriations. 
 
 The only proper food for an infant, is its mother's milk, and when 
 this can be obtained, little else should be given it, for at least six or 
 seven months. All paps, panadas, gruels, and cordials are to be 
 avoided, and their use among infants, as food, can not be too severely 
 censured. Colics, diarrheas, green and watery stools, and severe 
 aphthous affections are the penalties of such unnatural practices. 
 When the mother's milk can not be had, from \vhatever cause, and 
 a wet nurse is not at hand, and it becomes necessary to feed the child, 
 a mixture of one part of water to two or three parts of cow's milk, 
 and warmed, forms an excellent substitute for the parent fluid. The 
 milk used should be procured from one healthy cow regularly, and bo 
 given as soon as possible after it has been milked out. The addition 
 of cane sugar to the preparation, as advised by some writers, I con- 
 sider uncalled for and pernicious, frequently producing diseases of 
 the stomach and bowels, which are attributed to other causes. If 
 sugar is at all desired as an addition, it should be sugar of milk alone.
 
 330 KINGS ECLECTIC OB8TETBICS.' 
 
 The following table, by Simon, showing the mean of fourteen analyses, 
 made at different periods, with the milk of the same woman, and 
 which very nearly corresponds with the analyses of other investigators, 
 will conclusively show the folly of adding sugar to a preparation 
 intended to supply the place of breast-milk : 
 
 Water 883.6 
 
 Solid constituents 116.4 
 
 Butter 25.3 
 
 Casein 34.3 
 
 Sugar of milk, and extractive matters 48.2 
 
 Fixed salts 2.3 
 
 And as to the sugar of milk, it very nearly corresponds in quantity 
 to that of cow's milk, as may be seen by the following analysis of this 
 animal's milk, by Chevallier and Henri : 
 
 Casein 4.48 
 
 Putter 3.13 
 
 Sugar of milk 4.77 
 
 Saline matter 0.60 
 
 Water 87.02 
 
 It will be observed that cow's milk contains more casein and butter 
 than human milk, which may, probably, lead to the production of a 
 still better substitute for this last, than the one proposed above. 
 
 In feeding the child its artificial food, it should be done in a manner 
 to simulate, as closely as possible, the natural functions; that is, it 
 should not be fed with a spoon, but should be taught to suck from 
 a vessel, through some porous substance, by which means the saliva is 
 invited into the mouth to be swallowed with the food, which latter is 
 thereby rendered more easily digestible. 
 
 The parturient woman should be kept in a state of rest and quiet 
 for nine or ten days, in order that the process of involution may 
 progress uninterruptedly, or in other words that the uterus may return 
 to its non-gravid size, without hemorrhage, inflammation, or displace- 
 ment, and that the system may fully recover from the shock given 
 to it by the labor. The first two or three days, she must not be 
 allowed to remove from the horizontal position (though she may 
 move around in bed), especially if the labor has been protracted, or 
 if there has been hemorrhage ; after this time, if not contra-indicated, 
 she may be permitted to sit up in bed a few minutes at a time, or in a
 
 ATTENTIONS SUBSEQUENT TO DELIVERY. 331 
 
 chair, while the bed is being fixed, and should from this time lengthen 
 the duration of sitting each day, until there is no further occasion for 
 remaining in the bed. But in this matter, the judgment of the 
 accoucheur based upon the conditions present must, after all, decide 
 the proper degree of motion to allow the patient; some strong, healthy 
 women may sit up and even walk about in a day or two subsequent to 
 labor, while delicate and weak females, or those who have been much 
 enfeebled by a prolonged labor, hemorrhage, etc., will require rest and 
 quiet in the recumbent position for three or four days, or even longer. 
 Too much rest in bed relaxes muscular fiber and weakens nerve 
 power, while proper movements tend to equalize the circulation, to 
 remove passive uterine congestion, and to excite the contractile power 
 of the uterus sufficiently to enable it to expel any putrid lochial clots 
 that may form within its cavity, and thereby tend to the avoidance 
 of septicaemia. Where there is a sense of fatigue, weariness, mild 
 stimulation will prove beneficial. 
 
 The room should be well ventilated 1 , but without exposing the 
 patient, and be kept clean, quite free from all unpleasant odors, and 
 moderately warm. The female should be kept clean, especially about 
 the genitals, which must be frequently bathed with lukewarm water, 
 or warm water and spirits; and her diet must be light, nutritious, and 
 of easy digestion, especially during the first days. Gruel, mush and 
 milk, toast, panada, arrowroot, rice, etc., are all that is usually per- 
 mitted until the fifth or sixth day, when, if she be doing well, the 
 use of soft-boiled eggs, oysters, and weak soups, may be allowed. 
 After the tenth day, and during the puerperal month, animal food, 
 fowls, and other diet of a nourishing but non-stimulating character, 
 may be given; if she be- weak, a little porter will be admissible. 
 However, it will more frequently be found that a compliance with the 
 desires of the patient, as to diet, will answer a much better purpose, 
 than any arbitrary rules that can be laid down, when such desires are 
 not morbid or otherwise contraindicated. 
 
 If the patient, previous to pregnancy, was afflicted with prolapsus 
 uteri, an intermittingly continued recumbent position [but not neces- 
 sarily in bed] for eight or ten weeks after delivery, together with 
 Sulphate of Quinia, Macrotys, Pulsatilla, Aletris, Strychnia, etc., in- 
 ternally, according to the indications [to improve the tone and con- 
 dition of the uterus], will contribute much toward a radical cure; 
 the medical man observing that the uterus is kept in position during 
 the intervals of sitting or standing. 
 
 The visits of the practitioner should be daily, for the first two or
 
 332 KING'S ECLECTIC OBSTETRICS. 
 
 three days, or oftener, if required ; after which, a visit every second or 
 third day, made on two different occasions, will be sufficient in ordinary 
 cases. However, this is governed by custom ; in some places, after the 
 first visit succeeding delivery, no other is made, unless the physician is 
 sent for; in others, the visits are continued more or less often, as may be 
 required, until the ninth or tenth day. I consider the last-named plan 
 of visiting, the preferable one, both as regards the safety of the woman, 
 and the reputation of the accoucheur. If, after the fourth or fifth 
 week from parturition, the patient suffers from pains in the back and 
 loins, debility, profuse leucorrhea, irritable bladder, with more or less 
 straining and tenesmus, and perhaps some hemorrhage, we may be led 
 to suspect defective involution, and if examination confirms our 
 suspicion, we should at once pursue the treatment necessary to remove 
 the subinvolution, which consists, in some cases, of gently stimulat- 
 ing vaginal injections, together with uterine tonics, as Macrotys, 
 Pulsatilla, Aletris, Parturient Balm, etc. 
 
 CHAPTER XXVII. 
 
 PRESENTATIONS AND POSITIONS. 
 
 FOR the purpose of more clearly understanding the mechanism of 
 labor, it is necessary that a knowledge of the various presentations and 
 positions of the fetus, be had. By the term presentation, in obstetrics, 
 is meant the part of the fetus which occupies the pelvic superior strait 
 at the commencement of labor; while position designates the relations 
 which the presenting part assumes with the circumference of this strait, 
 or with some fixed point. Thus, if it is said the vertex present*, we 
 understand it to mean a presentation of the head, in which the head 
 of the child will be the part first delivered ; if it is still further said, 
 that it is in the left occipito-anterior position, we learn that the occiput 
 of the child looks toward the left acetabulum of its mother, while its 
 forehead is toward her right sacro-iliac symphysis, and the sagittal 
 suture will consequently be found running in an oblique direction in 
 the pelvis between these two points or, in other words, we have the 
 position in which the head presents. 
 
 There are two PRESENTATIONS recognized in obstetrics one
 
 PRESENTATIONS AND POSITIONS. 
 
 333 
 
 Cephalic, the other Pelvic. The cephalic, is divided into vertex, face, 
 and shoulder presentations; the pelvic, into breech, knees, and feet. 
 Occasionally, some portion of the trunk may present, or perhaps the 
 ear and side of the head, but these are so extremely rare, as to form 
 exceptions rather than exemplifications ; and their management would 
 be similar to that recommended for arm or shoulder presentations. 
 
 The most common, as well as the most favorable presentation for 
 both mother and child, is that of the vertex or head, and which alone 
 constitutes a natural labor ; the others are only deviations. That this 
 is the fact may be gathered from the following statistics : Bland 
 records 1792 head presentations in 1897 cases of labor; Dubois 10,262 
 in 10,742; Kluge 257 in 298; Lovati 61 in 67; Mazzini 439 in 452; 
 Nfflgele 1210 in 1296; Pacord 49 in 53; Ramoux 266 in 275; Riecke 
 214,134 in 219,258; Siebold 132 in 137; Smellie 920 in 1000; and 
 Velpeau 392 in 400. 
 
 The relative frequency of the various presentions, are given in the 
 following table, taken from Churchill's Obstetrics, 
 
 Author. 
 
 Total No. of 
 cases. 
 
 Head presen- 
 tations. 
 
 Breech pre- 
 sentations. 
 
 Inferior ex- 
 tremities. 
 
 Superior ex- 
 tremities. 
 
 
 20 517 
 
 19 810 
 
 372 
 
 238 
 
 80 
 
 Mad La Chapelle 
 
 15652 
 
 14677 
 
 349 
 
 255 
 
 68 
 
 Dr Jos Clarke 
 
 10 387 
 
 9 748 
 
 61 
 
 184 
 
 48 
 
 DP Merriman 
 
 2947 
 
 2735 
 
 78 
 
 40 
 
 19 
 
 Dr Granville 
 
 640 
 
 619 
 
 2 
 
 3 
 
 1 
 
 Edin Hospital 
 
 2452 
 
 2 225 
 
 17 
 
 8 
 
 4 
 
 Dr. Maunsell 
 
 839 
 
 786 
 
 
 21 
 
 4 
 
 
 691 
 
 645 
 
 14 
 
 7 
 
 4 
 
 Dr. Collins 
 
 16414 
 
 15912 
 
 242 
 
 187 
 
 40 
 
 Dr Beatty... 
 
 1 182 
 
 1 105 
 
 28 
 
 15 
 
 4 
 
 
 4666 
 
 4 266 
 
 59 
 
 29 
 
 12 
 
 Dr Churchill 
 
 1 640 
 
 1 119 
 
 35 
 
 22 
 
 9 
 
 
 
 
 
 
 
 The POSITIONS of the two presentations and their divisions or 
 deviations, vary considerably, so much .so that some authors have 
 given one hundred and two distinct positions. (Baudelocque.} But 
 these have recently been so reduced and simplified by Nsegele, Dubois, 
 Stoltz, and other accoucheurs, that the whole of them may be com- 
 prised in sixteen positions, and which will be found fully sufficient for 
 all practical purposes. The many slight alterations and deviations 
 in position, which may occur with the several presentations, and which 
 have given rise to the numerous positions above referred to, may, 
 singly, either be reduced to some one of the distinct positions, here- 
 inafter named, before the termination of labor, or may hold such
 
 334 KINCi'.S KCLKCTIC OI5STETRICS. 
 
 a close relation to it, as to require no material difference in its man- 
 agement. 
 
 In a VERTEX or CRANIAL PRESENTATION, although it 
 mav become necessary to determine the situation of the anterior and 
 |H.-ierior fontanelles, and the direction assumed by the sagittal suture, 
 in order to ascertain its position, yet it is the posterior fontanelle alone, 
 which distinguishes the situation of the occiput; and this fontanelle, in 
 all natural labors, is the most readily reached by the finger. A vertex 
 position is characterized by the relation existing between the occiput 
 of the fetus, and the acetabulum, symphysis pubis, or sacro-iliac sym- 
 physes of the maternal pelvis. Thus, then, the positions of a vertex 
 presentation, may be arranged as follows : 
 
 POSITIONS OF THE VEKTEX OR CRANIAL PRESENTATION. 
 
 1st. LEFT OCCIPITO-ANTERIOR, in which the occiput of 
 the child looks toward the left acetabulum of the mother, or anteriorly 
 and to the left of the pelvis. In this position the forehead of the 
 child, and consequently the anterior fontanelle, will be found toward 
 the right sacro-iliac symphysis, the sagittal suture running obliquely 
 across the pelvis anteriorly from the left, to the right posteriorly. 
 This position has also been called the' left occipito-cotyloid, or first 
 (oblique) cranial position.* 
 
 2d. RIGHT OCCIPITO-ANTERIOR, in which the occiput of 
 the child looks toward the right acetabulm of the mother, or ante- 
 riorly and to the right of the pelvis. In this position, the anterior 
 fontanelle will be found toward the left sacro-iliac symphysis, the 
 sagittal suture running obliquely across the pelvis anteriorly from the 
 right, to the left posteriorly. This position has also been called the 
 right occipito-cotyloid, or second (oblique) cranial position. 
 
 3d. OCCIPITO-PUBAL, in which the occiput faces the sym- 
 physis pubis of the mother, or is placed anteriorly without any lateral 
 obliquity. In this position, the anterior fontanelle will be toward the 
 
 * I see no necessity for .the changes in name which some authors have given for the 
 varions positions in which the head, or other parts of the fetus, may present. The 
 names which I still adhere to, and which originated with eminent obstetricians, appear 
 to me to convey a clearer and much better understanding of the positions than any 
 others that have yet been proposed as substitutes. Indeed, the new terms attempted 
 to be introduced by recent writers are not only more apt to confuse the student and 
 practitioner, but are, certainly to my mind, very unsatisfactory. The term left occipito- 
 anterior, will much better convey to the mind of the accoucheur the fact that the occi- 
 put is to the left anteriorly, than the term first cranial position. K.
 
 PRESENTATIONS AND POSITIONS. 335 
 
 sacrum, the sagittal suture running in the direction of the antero- 
 posterior diameter of the pelvis. This position has also been called 
 the first (direct) cranial position. 
 
 4th. LEFT OCCIPITO-POSTERIOR, in which the occiput 
 looks toward the left sacro-iliac symphysis of the mother, or poste- 
 riorly and to the left of the pelvis. In this position, the forehead of 
 the child, or its anterior fontanelle, will be found toward the right 
 acetabulum, the sagittal suture running obliquely across the pelvis 
 anteriorly from the right, to the left posteriorly as in the second posi- 
 tion. This position has also been called the right fronto-cotyloid, or 
 third (oblique) cranial position. 
 
 5th. RIGHT OCCIPITO-POSTERIOR, in which the occiput 
 looks toward the right sacro-iliac symphysis of the mother, or poste- 
 riorly and to the right of the pelvis. In this position, the forehead 
 of the child, or its anterior fontanelle, will be toward the left 
 acetabulum, the sagittal suture running obliquely across the pelvis 
 anteriorly from the left, to the right posteriorly, as in the first posi- 
 tion. It has also been called the left fronto-cotyloid, or fourth (oblique) 
 cranial position. 
 
 6th. OCCIPITO-SACRAL, in which the occiput faces the sacrum 
 of the mother, or is placed posteriorly without any lateral obliquity. 
 In this position the anterior fontanelle will be found toward the 
 symphysis pubis, the sagittal suture being in the same direction as in 
 the third position. This has also been called the second (direct) cranial 
 position. 
 
 The student can readily master a knowledge of these positions, if, 
 taking the vertex or occiput as the guide, he will bear in mind, that it 
 may be placed either anteriorly or posteriorly in the maternal pelvis, 
 and that, commencing with its anterior position as the first, he has 
 merely to give to it the directions, left, right, and/row^. Thus, vertex 
 to the left anterior, vertex to the right anterior, vertex anterior, vertex 
 to the left posterior, vertex to the right posterior, and vertex posterior. 
 Professor Meigs simplifies the positions, the better to impress them 
 upon the student's mind, thus : " vertex left, vertex right, vertex 
 front; forehead left, forehead right, forehead front," and which 
 enumeration is, undoubtedly, as he remarks, " the easiest one to 
 remember." The importance of a knowledge of these positions, is, 
 that in cases where an interference is demanded, the accoucheur may 
 have a certain guide by which to govern his operations, with an eye to 
 the safety of the mother, as well as of the child ; and, without this 
 knowledge, any assistance which may be attempted, is more likely to
 
 336 KING'S ECLECTIC OBSTETRICS. 
 
 effect mischief than benefit. And I hold a man, who is ignorant of 
 these matters, criminally responsible for any fatal consequences that 
 may follow his rash attempts to accomplish he knows not what. Nor 
 is the excuse, "that he has no malice or evil feeling toward his patient, 
 but was endeavoring to do the best he could for her," a valid one he 
 has no right, whatever, even with the authority of a diploma,. to under- 
 take a practice which concerns health and life, with an entire ignorance 
 of his duties; the very attempt alone, is, in my estimation, criminal. 
 
 More recently writers have given but four positions, the first or left 
 occipito-anterior;. the second or right occipito-anterior; the third or 
 left occipito-posterior; and the fourth, or right occipito-posterior. 
 The other positions, four in number, occipito-pubal or sacral, and left 
 or right transverse vertex positions, from their rare occurrence, and 
 from the fact that they must assume an oblique position before the 
 head can be born, unless it be very small as compared with the maternal 
 pelvis, are merely referred to. Yet as the first mentioned do sometimes 
 occur, I think it proper to recognize them. The transverse positions, 
 as far as my own experience is concerned, are nothing more than 
 positions which are incidentally encountered during the movement of 
 the head toward an oblique position. 
 
 When the head presents well flexed, it is a vertex presentation, but 
 when extension has occurred, it then becomes a FACE PRESENTA- 
 TION, in which but two positions are recognized. In the diagnosis 
 of face positions, the mentum or chin of the child, must be taken as 
 the guide. 
 
 Although the labor in face presentations is tedious, and more painful 
 to the mother, and somewhat more dangerous for the child than in 
 vertex presentations, yet we find that in the majority of cases they 
 terminate naturally, and without any artificial aid. From statistics 
 collected from French, German, and English authorities, it appears 
 that in 136,123 cases, the face presented in 640 or about 1 in 21 2| 
 cases, so that these deviations of the natural vertex presentation are 
 very rare. As to the labor, we have a record of 344 cases, in which 
 248 were delivered naturally, 42 required version, 20 the forceps, and 
 15 craniotomy. The mortality to the mother averages about 1 in 50 ; 
 to the child 1 in 7; and it has been found the greatest to both mother 
 and child in those cases where assistance was given ; so that the 
 necessity for interference is not so great as was formerly supposed.
 
 PRESENTATIONS AND POSITIONS. 337 
 
 POSITIONS OF FACE PRESENTATIONS. 
 
 1st. LEFT MENTO-ILIAC, in which the child's chin is to the 
 left side of the maternal pelvis, and its forehead to the right side. 
 This is also termed the second or left face position. 
 
 2d. EIGHT MENTO-ILIAC, in which the chin of the child is to 
 the right side of the mother's pelvis, and its forehead to her left side. 
 This is also termed the^rs^ or right face position. 
 
 Some authors give two other positions, one the mento-sacral or fourth 
 face 'position, in which the chin is toward the sacrum or nearly so, and 
 the forehead toward the pubic symphysis, and the other, the mento-pubic 
 or third face position, exactly the reverse of the preceding one. The 
 former is said to be extremely rare, and I very much doubt whether it 
 can occur, except in children with very small heads, or in premature 
 labors. The latter is likewise seldom met with, although it is the 
 position which the two principal positions assume at the termination 
 of labor. For practical purposes the two positions above named are 
 sufficient. The right mento-iliac position is much more frequently 
 encountered than the left, and is commonly given by authors as the 
 first face position ; but, as I have commenced with the vertex presenta- 
 tion by giving the first position to the left, and the second to the right, 
 I have considered it better to adhere to this arrangement with all 
 presentations without regard to the frequency of any one position 
 among them, and which certainly presents more uniformity and less 
 complexity. 
 
 A SHOULDER PRESENTATION may be considered a deviation 
 of the cephalic presentation, and includes those of the arm, elbow, and 
 hand; according to statistics it has occurred 358 times in 93,398 cases, 
 or about I in 260f, and its mortality to the mother is about 1 in 9, 
 while of the* children rather more than one-half have been lost. There 
 are four shoulder positions; two for each shoulder, and the points by 
 which the practitioner is to be guided in his diagnosis, are, the head of 
 the fetus, and the ilium of the mother ; some authors name the back 
 of the fetus instead of its head, while others again have two dorso- 
 anterior, and two abdomino-anterior positions. The right arm or 
 shoulder presents oftener than the left, and in the majority of instances, 
 the back of the fetus will be looking toward the maternal abdomen. 
 First, is the distinctive term applied to the two positions of the right 
 shoulder presentation : and second, to those of the left. 
 22
 
 338 KING'S ECLECTIC OBSTETRICS. 
 
 POSITIONS OF SHOULDER PRESENTATIONS. 
 
 FIRST LEFT CEPHALO-ILIAC, in which the right shoulder 
 presents, the head of the fetus being in the maternal left iliae fossa, 
 its face looking posteriorly, and its back anteriorly. This is likr\vi.M> 
 called the first dorso-anterior position. 
 
 SECOND LEFT CEPHALO-ILIAC, in which the left shoulder 
 presents, the head of the fetus being in the maternal left iliac fossa, 
 its face looking anteriorly, and its back posteriorly. This is likewise 
 called the^r.s^ dor so-posterior position. 
 
 FIRST RIGHT CEPHALO-ILIAC, in which the right shoulder 
 presents, the head of the fetus being in the maternal right iliac fossa, 
 its face looking anteriorly, and its back posteriorly. This is likewise 
 called the second dorso-posterior position. 
 
 SECOND RIGHT CEPHALO-ILIAC, in which the left shoulder 
 presents, the head of the fetus being in the maternal right iliac fossa, 
 its face looking posteriorly, and its back anteriorly. This is likewise 
 called the second dorso-anterior position. 
 
 The PELVIC, or BREECH PRESENTATION, is divided into 
 four positions, the sacrum of the fetus being the diagnostic guide. In 
 this presentation, the delivery is generally accomplished by the natural 
 powers, without the intervention of art, though it is slow, tedious, and 
 painful to the mother, and more dangerous to the fetus than vertex, 
 or face presentations; the mortality to the child is owing to pressure 
 of the os uteri on its body, which, by forcing the blood toward its 
 head, produces congestion of that organ; it may also be owing to the 
 tardiness of the labor, and the compression of the cord during the 
 delivery of the head. Why the breech should present, has not been 
 satisfactorily explained. Breech presentations have occurred, accord- 
 ing to statistics, 2,438 times in 129,117 cases, or about 1 in*52, and the 
 mortality to the child is recorded at 195 deaths in 678 cases, or about 
 1 in 3j. Those breech presentations in which the back of the child is 
 directed anteriorly, and which are more commonly encountered, are 
 termed first positions; those in which the fetal back is directed 
 posteriorly, are termed second positions. The other positions which 
 have been given by former writers, as, sacro-pubic, sacro-sacral, etc., 
 I have wholly omitted, as I doubt very much whether they really 
 occur ; but should they ever be presented to the accoucheur, he will 
 be guided in their management, by the rules hereafter laid down 
 Knee and feet presentations are mere deviations from the breech, and
 
 PRESENTATIONS AND POSITIONS. 339 
 
 are even more tedious and dangerous to the child than this, on account 
 of the delay in the delivery of the head, the maternal parts not being 
 so well dilated, as when the breech presents, with the extremities 
 flexed upward. Knee presentations are rare, occurring about once in 
 3,445 cases; statistics give 1,268 foot and knee presentations in '117,640 
 cases, or about 1 in 92f, and the mortality to the child is recorded at 
 210 deaths in 562 cases, or about 1 in 2J. 
 
 POSITIONS OF BREECH PRESENTATIONS. 
 
 1st. FIRST LEFT SACRO-ILIAC, in which the back or sacrum 
 of the fetus looks anteriorly and to the left; its abdomen posteriorly 
 and to the right; its transverse or bitrochanteric diameter occupying 
 the right oblique pelvic diameter. 
 
 2d. FIRST RIGHT SACRO-ILIAC, in which the sacrum of the 
 fetus looks anteriorly and to the right; its abdomen posteriorly and 
 to the left ; its transverse diameter occupying the left oblique pelvic 
 diameter. 
 
 3d. SECOND LEFT SACRO-ILIAC, in which the sacrum of the 
 Ait us looks posteriorly and to the left; its abdomen anteriorly and to the 
 right; its transverse diameter occupying the left oblique pelvic diameter.- 
 
 4th. SECOND RIGHT SACRO-ILIAC, in which the sacrum of 
 the fetus looks posteriorly and to the right; its abdomen anteriorly 
 and to the left; its transverse diameter occupying the right oblique 
 pelvic diameter. 
 
 In KNEE PRESENTATIONS, the feet are always to be brought 
 down, and the positions of the feet (corresponding with those of the 
 breech), are determined by the heel; thus, first left calcaneo-iliac , or 
 heels to the left and front; first right calcaneo-iliac, or heels to the 
 right and front; second left calcaneo-iliac, or heels to the left and 
 posteriorly; second right calcaneo-iliac, or heels to the right and 
 posteriorly. The position of the heels enables us more readily to 
 determine the position of the breech. 
 
 To briefly recapitulate, the presentations and positions are as follows : 
 
 Presentations. Positions. ' Presentations. Positions. 
 
 VERTEX. 
 
 1. Left Occipito-anterior. 
 
 2. Right Occipito-anterior. g HOULDER . . 
 
 3. 
 
 4. Left Occipito-posterior. 
 
 1. First Left Cephalo-iliae. 
 
 2. Second Left Cephalo-iliac. 
 
 3. First Right Cephalo-iliac. 
 
 4. Second Right Cephalo-iliac. 
 
 5. Right Occipito-posterior. f j_ p irst L eft Sacro-iliac. 
 
 6. Occipito-sacral. , J 2. First Right Sacro-iliac. 
 
 It Sacro-iliar. 
 'lit Sacro-iliac. 
 
 . ccpito-sacra. j 2 . First Right Sacro-iliac. 
 
 -r,. _ f 1. Left Mento-iliac. 1 3. Second Left Sacro-iliar. 
 
 I 2. Right Mento-iliac. t 4. Second Right Sacro-ilia
 
 340 KI.Nc's ECLECTIC OBSTETRICS. 
 
 .CHAPTER XXVIII. 
 
 MECHANISM OF LABOR. 
 
 IT has been heretofore remarked, that presentation of the vertex is 
 the most common of all the mechanism of which includes descent, 
 liexion, rotation, restitution aiid expulsion of the trunk; and among 
 the positions, the left occipito-anterior, or that in which the occiput is 
 directed toward the left acetabulum, is more frequently met with, oc- 
 durring, according to statistics, about 69 times in every 100 cases. In 
 .1,913 cases, reported by M. Dubois, 1,339 were left occipito-anterior, 
 494 right occipito-posterior, 55 right occipito-anterior, and 12 left oc- 
 cipito-posterior. Why the occiput is found so much more frequently 
 in front is difficult to determine; but its position at the left anterior 
 of the pelvis may be accounted for by the rectum on the left side, 
 which, being usually distended w y ith fecal matters, diminishes the 
 right oblique diameter, so that the head being forced to traverse the 
 most ample diameter, the occiput is thrown to the left acetabulum, 
 and the forehead to the right sacro-iliac symphysis. 
 
 As already remarked, vertex presentations are always more favor- 
 able for both mother and child, than any other. The occipito-posterior 
 positions are, however, less so than the occipito-anterior, in conse- 
 quence of the difficult descent of the head, the more frequent demands 
 for artificial aid, the greater liability of laceration, or perforation of 
 the perineum, and from the delay in the advance of the head often 
 creating sloughs, and urinary, or stercoral fistulse. 
 
 The presence of a vertex presentation may frequently be recognized 
 during the last few weeks of pregnancy, even before the finger can be 
 introduced within the os uteri; a regular, solid, rounded tumor may 
 be felt through the inferior portion of the uterine parietes, which can 
 be raised by the finger with more or less difficulty as the pregnancy is 
 more or less advanced. And when, at the commencement of labor, 
 the presenting part can not be easily reached, or the round, resisting 
 surface of the head is not encountered, .there may be some other than 
 a vertex presentation, and the labor should be closely watched during 
 the first stage, in order to determine, as soon as possible, the nature 
 of the presenting part, and be thereby enabled to rectify, at the proper 
 period, any accidents which may present themselves. Nseg^le states, 
 that various circumstances, independent of malposition, may occur, 
 which will prevent the presenting part from being felt at the end
 
 MECHANISM OF LABOR. 341 
 
 of gestation; as in cases of multipart, where the uterine fundus is 
 -strongly inclined forward; in twin cases; in breech presentations; 
 where a large quantity of amniotic fluid is present ; where the uterus 
 is not oval at its inferior part; when there is a hydrocephalous head ; and 
 where the pelvis is narrow. As soon as the dilatation of the os uteri 
 has so far proceeded as to admit the introduction of the finger, during 
 the absence of a pain, the large, rounded, smooth and solid surface 
 of the head can be felt through the membranes, and if the dilatation 
 be sufficient, membranous spaces, answering to the sutures and fonta- 
 nelles, may be recognized; and if the head be pressed upon, a resist- 
 ance of a somewhat elastic character may be noticed. But great care 
 is necessary to prevent these examinations from prematurely rupturing 
 the membranes. After the membranes have ruptured, at the close 
 of the first stage, these diagnostic signs are more manifest. 
 
 After having correctly ascertained 'the presentation, the next thing 
 will be to determine the position, and this should always be done at 
 as early a period as possible, in order, the more readily to remedy 
 any difficulties which may occur. The diagnosis can, in many 
 instances, be effected previous to the rupture of the membranes; 
 but, most frequently, it will be impossible to arrive at it, until after 
 this has occurred, and then, it should always be accomplished without 
 <lelay. 
 
 Auscultation has been spoken of, as affording aid in determining 
 the position; thus, if the fetal heart is heard pulsating in the left 
 iliac fossa, the occiput is to the left, and if in the right, it is to the 
 right, etc. ; but there is too much uncertainty in this mode of 
 diagnosticating, to admit of its employment in actual practice ; the 
 examination per vaginam is the only one on which dependence 
 must be placed. The same may be said in relation to the active 
 motions of the fetus, whose anterior region is supposed to corre- 
 spond with the point of the uterus at which these have been 
 recognized for a long time. The practitioner may attend to these 
 symptoms, for the purpose of verifying their accuracy, or of leading 
 to a more positive determination of their real value ; but he should 
 not allow a labor to proceed solely upon the indications they afford. 
 
 In order to arrive at the position of a vertex presentation, the 
 accoucheur should render himself enabled to recognize at once, the 
 character of the fontanelles and sutures, a description of which has 
 already been given, and the exploring finger should be pressed with 
 sufficient firmness upon the head to enable it to detect them. He 
 must also bear in mind that, frequently, while the head is descending,
 
 342 
 
 KINGS ECLECTIC ORSTETKK S. 
 
 the compression it undergoes, is such, that the bones are forced to 
 overlap each other, and the sutures, instead of a membranous sensa- 
 tion, convey to the finger, one of longitudinal ridges or prominences ; 
 and the distinctive character of the posterior fontanelle especially, is 
 lost, being recognized merely by the junction of the sagittal and 
 lambdoidal sutures, or rather the longitudinal prominences which 
 they present from the pressure. 
 
 IST. LEFT OCCIPITO-ANTEKIOR POSITION. 
 
 DIAGNOSIS. In this position, the finger, upon being introduced 
 into the vagina, or within .the os uteri, will first come in contact with 
 the boss or protuberance of the right parietal bone of the fetal head, 
 which is the most depending part, and not the posterior fontanelle,. 
 which latter will be found in the region of, and corresponding nearly 
 to the maternal left acetabulum ; the sagittal suture may then be 
 FIG. 46 traced running from 
 
 this triangular fon- 
 tanelle, obliquely 
 across the pelvis, 
 from below upward, 
 and from before 
 backward, and from 
 left to right, until 
 it meets with the 
 large, soft, mem- 
 branous, and quad- 
 rangular anterior 
 fontanelle, w h i c h 
 will be toward the 
 right sacro-iliac 
 symphysis. The 
 back of the child 
 will be toward the 
 front and left of the 
 mother's abdomen, 
 while its abdomen 
 will be toward her 
 back and right; its 
 
 right shoulder will be in front and to the right, and its left, back and 
 to the left. (Fig. 46.)
 
 MECHANISM OF LABOR. -,4.> 
 
 MECHANISM. The waters having been discharged by the rup- 
 ture of the membranes, the expulsive contractions of the uterus force 
 the head, which presents obliquely at the superior strait, down into 
 the brim of the pelvis, its flexion upon the chest is increased, so that 
 .the neck is bent more into a curve, and the body of the fetus is more 
 or less compressed and rolled, as it were, into a ball, occupying much 
 less space than before. At first, the two fontanelles are nearly on a 
 level, but as labor progresses, and the head advances, one of them, 
 more commonly the posterior, will be found gradually descending, as- 
 the uterine contractions cause the vertex to sink. The flexion causes 
 a change in the relations of the head. Previous to the rupture of the 
 membranes, and the flexion of the head, the occipito-frontal diameter 
 of the fetal head was parallel to the left oblique diameter of the 
 superior strait, and the biparietal of the former coincided with the 
 right oblique of the latter ; but now, while the position of the latter 
 diameters remains unaltered, the former changes, the occipito-breg- 
 matic of the fetal head corresponding to the left oblique diameter 
 of the strait, in place of the occipito-frontal. The axis of the 
 pelvis, which, previous to the rupture, coincided with the trachelo- 
 bregmatic diameter of the head, now corresponds very nearly with it& 
 occipito-mental. If the student will compare the diameters of the 
 fetal head with those of the maternal pelvis, he will ascertain that this 
 movement of flexion, brings the smallest diameters of the head in cor- 
 respondence with the smallest of the pelvis, thus placing it in a position 
 highly favorable to its ready expulsion. 
 
 The descent of the head is due to the continuation of the uterine 
 contractions, which force it through the strait, into the pelvic cavity,, 
 and onward to the lower strait of the pelvis. In its passage through 
 the pelvic excavation, it undergoes great compression, the bones over- 
 lap each other, as above stated, forming longitudinal ridges along the 
 sutures, and sometimes, when the pressure is very considerable, a 
 tumor is formed upon the scalp, called the CAPUT SUCCEDANEUM. 
 The obliquity of the head at the superior strait is preserved throughout 
 its descent, with the exception that one fontanelle (the posterior) is,, 
 more commonly, lower than the other. The contractions urge the 
 head downward, the occiput descends on the left antero-lateral inclined 
 plane, while the forehead moves in the direction of the right sacro-iliae 
 ftymphysis, and the descent is wholly perfected, when the occipito- 
 bregmatic circumference coincides with the plane of the inferior 
 strait, or when the two protuberances of the parietal bones have 
 arrived at this level, and to attain which, the left protuberance, which
 
 344 
 
 KINOES ECLECTIC OBSTETRICS. 
 
 is behind, must traverse the whole anterior face of the sacrum, 
 describing the arc of a large circle, while the right, which is anterior, 
 traverses a shorter distance, describing the arc of a much smaller 
 circle. 
 
 When the head arrives at the floor of the pelvis, its further progress. 
 
 is arrested by the perineum, sacro-sciatic ligaments, etc., etc., which 
 
 FIG. 47. form this part; but 
 
 the continuation of 
 the uterine contrac- 
 tions effects a move- 
 ment of rotation 
 from left to right, 
 in which the occiput 
 is passed behind the 
 symphysis pubis, a 
 little to its left, 
 while the forehead 
 rotates into the hol- 
 low of the sacrum, 
 remaining, however, 
 a little to the right. 
 (Fig. 47.) In this 
 situation the occip- 
 ito-mental diameter 
 of the head is al- 
 most parallel with 
 the axis of the in- 
 ferior strait, and 
 the sagittal suture 
 
 nearly coincides with the antero-posterior diameter of this strait. As 
 the resistance at the floor of the pelvis is gradually overcome, the 
 occiput continues to descend, passing under the arch of the pubis 
 until the neck comes in contact with it, when its further advance is 
 arrested. At the period when the occiput is engaged at the pu- 
 bic arch, the shoulders and upper part of the body engage in the 
 superior strait with their long diameters in the same direction as 
 was taken by the biparietal diameter of the head, viz.: its right 
 oblique diameter. 
 
 The neck being immovably fixed against the pubis, the contractile 
 efforts being always in a line with the axis of the superior strait, are 
 directed upon the chin, or that portion of the head which lies in the
 
 MECHANISM OF LABOR. 
 
 rvr 
 
 Concavity of the sacrum ; the chin gradually departs from the chest, 
 while the occiput ascends, forming the FIG. 48. 
 
 motion of extension. (Fiy. 48.) During 
 this extension, with the neck fixed against 
 the symphysis pubis as a pivot for the head 
 to turn upon, the forehead and face pass 
 over the curves of the sacrum, coccyx, and 
 perineum, and as the head emerges, the 
 vulva becomes distended, the labia majora 
 are effaced, the nymphse are pressed up, 
 the perineum becomes thin, yielding, and 
 distended, and the sagittal suture, ante- 
 rior fontanelle, forehead, nose, mouth, 
 and chin, appear in succession at the 
 vulva, and the head is born. It must be 
 remarked here, that although the fetal head is impelled toward the 
 outlet during each pain, yet each remission is followed by a recession 
 of the head; and this may frequently be observed when the occiput, 
 which has appeared at the vulva during a pain, recedes within the 
 cavity during its cessation, having the labia closed over it. This 
 recession is of immense benefit to the woman, as the distension of the 
 parts is thereby relieved. Were the head to be forced onward without 
 any such relief, the circulation in the parts would be obstructed, the 
 vessels would be more or less strangulated, and inflammation, fol- 
 lowed by gangrene, would be very apt to ensue. From a similar 
 cause, it is likewise advantageous to the fetus, an undue and con- 
 stant pressure upon the head of which, would be likely to cause 
 its death. 
 
 The passage of the fetal head through the pelvic cavity is often 
 accompanied with cramps in the inferior extremities, which do not, 
 however, interfere with the action of the uterus or the progress of the 
 labor, but are sometimes so agonizingly painful as to demand a hasten- 
 ing of the delivery with the forceps : the cramps are owing to the 
 compression of the internal sacral nerves by the head. 
 
 A few seconds after the delivery of the head, it undergoes another 
 motion, called restitution, in which it becomes directed as it was pre- 
 vious to rotation, that is, with the face looking toward the internal 
 posterior surface of the right thigh of the mother, and the occiput 
 toward her left groin. (Fig. 49.) From a supposition that the rota- 
 tion was effected without any participation of the body therein, merely 
 occasioning a twisting of the neck, and that after the birth of the
 
 346 
 
 KING'S ECLECTIC OBSTETRICS. 
 
 head, the neck untwisted, restoring the head to its natural relation* 
 
 FIG. 49. 
 
 with the body, the 
 term restitution was 
 applied to this last 
 motion. But, accord- 
 ing to Gerdy, this view 
 ig erroneous, for the 
 trunk does rotate with 
 the head in such a 
 manner as to bring the 
 long diameter of the 
 shoulders, which was 
 at first in the direction 
 of the right oblique 
 diameter, to nearly 
 correspond with the 
 transverse diameter of 
 the pelvic cavity. They 
 descend and reach the 
 
 floor of the pelvis in this transverse position, which presents their 
 bis-acromial diameter to the small, or bis-ischiatic diameter of the 
 inferior strait, rendering it almost, if not quite impossible for them to 
 be delivered. Consequently, the resistance offered to their further 
 advancement, at this point, by the uterine contractions, as was the case 
 with the head, establishes a rotation, which causes the right shoulder 
 to pass from the right side toward the pubic arch, while the left passes 
 into the concavity of the sacrum, and the bis-acromial becomes nearly 
 coincident with the antero-posterior diameter of the inferior strait, and 
 it is this rotation of the shoulders which causes the motion of the head 
 called restitution; it necessarily following the impulse impressed on 
 the shoulders. 
 
 Sometimes, however, the head executes a motion, a short time pre- 
 vious to its restitution, and which occurs immediately after its expulsion. 
 This appears to be owing to a slightly oblique position of the shoulders, 
 while the occiput is about passing under the pubes in an antero- 
 posterior direction, which imparts a slight twist to the child's neck, 
 and from which it is relieved, as soon as the head is delivered, and 
 free from the soft parts. 
 
 Shortly after the expulsion of the head, the shoulders having 
 executed the motions above named, the right shoulder appears at the 
 vulva and is fixed against the pubes, while the posterior or left shoulder
 
 MECHANISM OF LABOR. 
 
 347 
 
 traverses the perineal cavity in the same manner as the face in the 
 delivery of the head, and after its disengagement at the anterior 
 commissure of the perineum, the right or sub-pubic shoulder follows. 
 During the birth of the shoulders, the trunk of the child becomes 
 curved laterally, so as to correspond with the curvature of the pelvic 
 excavation ; the concavity being on its right side, and the convexity 
 on its left. 
 
 Frequently, the right shoulder will be the first delivered; or both 
 shoulders may emerge from the vulva at the same time. After the 
 delivery of the shoulders, the remainder of the body is easily expelled, 
 describing in its passage, a more or less marked spiral movement. 
 
 Thus, then, in a natural labor, with an- occipito-anterior position, 
 we have the head to offer its smallest diameters and circumference to 
 those of the pelvis, and to perform the motions of flexion, descent, 
 rotation, extension and restitution. (Fig. 50.) 
 
 FIG. 50.
 
 KINGS ECLECTIC oliSTETUlcs. 
 
 _'n. RIGHT OCCIPITO-ANTERIOR POSITION. 
 
 DIAGNOSIS. In this position, the finger will first come in con- 
 tact with the left parietal protuberance, which is the most depending 
 part, and the posterior fontanellc will be found corresponding nearly 
 .to the right aeetabulum; from this fontanelle may be traced the sagit- 
 o. 51. tal suture, running ob- 
 
 liquely across the pelvis 
 from below upward, and 
 from before backward, 
 and from right to left, 
 until it meets the ante- 
 rior fontanelle, which 
 will be toward the left 
 sacra - iliac symphy.Ms. 
 The back of the child 
 will be toward the front 
 and right of the moth- 
 er's abdomen, while its 
 abdomen will be toward 
 her back and left; its 
 left shoulder will be in 
 front and to the left, 
 and its right, back and 
 to the right. (Fly. 51.) 
 Madam Boivin re- 
 cords 3,682 instances of 
 this position in 20, -317 
 cases, or about 1 in 5-f cases. Nsege'le states that though more ca.-e.-- 
 are terminated in this position, yet that its frequency as an original 
 one is .07 per cent. Between this and the previous position there 
 will be found but little difference in practice. Dewees states that on 
 account of the right lateral obliquity of the uterus prevailing so often, 
 and the rectum being occasionally impacted with hardened feces, this 
 position is less favorable than the first; but, he adds, we may control 
 the obliquity by placing the woman upon her left side, and can empty 
 the rectum by an injection. 
 
 MECHANISM. In the right occipito-anterior position the occip- 
 ito-frontal diameter of the fetal head is parallel to the right oblique 
 diameter of the superior strait, and the biparietal of the former coin-
 
 MKCHAXISM OF LABOR. 349 
 
 cides with the left oblique of the latter; but, as in the first position, 
 when the membranes rupture and the head descends, the occipito- 
 bregmatie diameter of the head takes the place of the occipito-frontal, 
 the biparietal remaining unaltered. The flexion, descent, rotation, 
 extension and restitution are the same as in the previous position, 
 \vith the exception that rotation takes place from right to left, and 
 restitution directs the face toward the internal posterior surface of 
 the left maternal thigh, and the occiput toward the right groin. The 
 delivery of the shoulders is likewise the counterpart of the first 
 position. 
 
 3c. OCCIP1TO-PUBAL POSITION. 
 
 DIAGNOSIS. In this position the occiput, or posterior fontanelle, 
 will be detected behind the symphysis pubis, and the sagittal suture 
 may be traced [running parallel, or nearly so, to the antero-posterior 
 diameter of the pelvis], from before backward and upward, until it 
 meets the anterior fontanelle, which will be toward the sacrum. The 
 back of the child will face the mother's abdomen, while its abdomen 
 will be toward her back ; its right shoulder will be toward her right 
 side, and its left toward her left. 
 
 This position occurs but very rarely, though Nsegele considers it to 
 be the original one in all occipi to-anterior positions, these being 
 merely secondary transformations of it, and recognized only because 
 the examination is made at too advanced a period. Baudelocque met 
 with it twice in 10,329 cases; Madam Boivin 6 times in 20,517; and 
 Madam La Chapelle not once in 30,000. 
 
 MECHANISM. In the occipito-pubal position, the occipito- 
 bregmatic diameter of the fetal head corresponds with the antero- 
 posterior pelvic diameter, and its biparietal with the pelvic trans- 
 verse. The mechanism, when the head is small, as compared with 
 the pelvis, differs from the two preceding positions, in the head 
 executing only the motions of flexion, descent and extension; as rota- 
 tion is unnecessary, and the direction of restitution will depend 
 entirely upon which shoulder engages at the pubic arch, as rotation 
 of the shoulders must ensue before they can be delivered. The labor, 
 if not interfered with by any uterine obliquity which will remove the 
 head from the center of the pelvis, will be as favorable as in either of 
 the preceding cases. 
 
 Labor may be facilitated, when the head is in this position, making 
 but little advance, by changing it to one of the occipito-anterior
 
 350 
 
 KINti's ECLECTIC OBSTETRICS. 
 
 positions, especially when the vertex is high up, and manifests no dis- 
 position to assume one of these positions after the occurrence of three 
 or four pains. To effect this change, the head may be grasped be- 
 tween the thumb and fingers, and the face inclined laterally; but the 
 operation must not be attempted until the os uteri is well dilated, the 
 soft parts yielding, and the head at the superior strait, not impacted, 
 but free and movable, and during the absence of pain. If the change 
 can not be effected, we must then wait until symptoms present them- 
 selves indicating the necessity of interference by forceps or otherwise. 
 Indeed, when the head is large, unless it be changed, either naturally 
 or artificially, to an occipito-anterior position, there will be but little 
 progress in the labor. 
 
 4Tii. LEFT OCCIPITO-POSTERIOR POSITION. 
 
 DIAGNOSIS. In this position the occiput is placed at the left 
 
 sacro-iliac symphysis, and the forehead at the right acetabulum. The 
 
 anterior fontanelle will 
 be found behind the 
 right acetabulum, from 
 which the sagittal suture 
 may be traced running 
 obliquely across the pel- 
 vis, from before back- 
 ward, and from above 
 downward, and from 
 right to left, until it 
 meets with the posterior 
 fontanelle, which will be 
 toward the left sacro- 
 iliac symphysis. The 
 right parietal protuber- 
 ance is the lowest in the 
 pelvis, and the finger 
 will come in contact 
 with it the first. The 
 back of the child will 
 be toward the back of 
 the mother and to the 
 
 left, while its abdomen will be toward her abdomen, and to the right; 
 
 its right shoulder will be toward her abdomen and to the left, and its 
 
 left to her back and right. (Fly. 52.)
 
 MECHANISM OF LABOR. 351 
 
 This position is very rare, occurring, according to Noegele, in the 
 ratio of .03 per cent.; to La Chapelle of .04 per cent.; and to Boivin 
 of. 05 percent. It is more unfavorable than the right occipito-pos- 
 terior position, the labor being more painful and protracted; this 
 arises from causes similar to those named under the second position, 
 and may be remedied, to a certain extent, by the same means as 
 therein mentioned. 
 
 MECHANISM. If the examination per vaginam be made at an 
 early period, before the head has undergone much flexion, the oc- 
 cipito-frontal diameter will be found to coincide with the right 
 oblique pelvic diameter, and the biparietal with the left oblique. 
 With the descent of the head, the same as in the previous positions, 
 flexion takes place, which changes the situation of the head so as to 
 bring the occipito-bregmatic diameter in correspondence with the 
 right oblique diameter of the pelvis; and the occipito-mental diam- 
 eter of the head runs nearly parallel with the axis of the superior 
 strait. At first the anterior fontanelle will be found in the center of 
 the pelvis, but as the head becomes flexed and descends it rises, while 
 the posterior fontanelle, previously beyond the touch, descends, and 
 engages in the pelvic cavity. The descent occurs in the same manner 
 as already described in the preceding instances. When the head has 
 reached the floor of the pelvis, rotation, which is much more extended 
 than in the occipito-anterior positions, takes place, the occiput de- 
 scribes an arc from left to right, and is carried round to the symphy- 
 sis pubis, through the left side of the pelvis, when the head is deliv- 
 ered in the same manner as if it had been an original anterior position : 
 the first. This extensive rotation could not be effected with safety 
 to the child unless the body participated in the motion, and which 
 must, of course, require a long time to accomplish ; but w T hen com- 
 pleted the labor proceeds favorably, the right shoulder is soon, brought 
 under the pubic arch, and the left passed into the sacral concavity, 
 and the delivery is terminated as usual. The movement of restitu- 
 tion places the face of the child toward the internal part of the right 
 maternal thigh, and its occiput toward the internal part of the, left 
 thigh. It is often the case in this position, and especially in primip- 
 arous women, that, nature becoming exhausted, artificial assistance is 
 demanded. 
 
 The above method is the one in which delivery is most commonly 
 effected in the posterior occipital positions, but occasionally it occurs 
 in another ^way. W T hen the head arrives at the floor of the pelvis,
 
 352 
 
 KINGS ECLECTIC OBSTETRICS. 
 
 the rotation places the forehead under the symphysis pubis, and the 
 occiput in the hollow of the sacrum. (Fig. 53.) In this position the 
 face of the child will be to the front of its mother, and its back to 
 her sacrum; the occipito-frontal diameter of its head will coincide 
 with the pelvic antero-posterior, and the biparietal will be transverse, 
 as well as the bis-acromial. 
 
 In this position, the uterine contractions still further increase the 
 flexion of the head, the occiput is forced to gradually traverse the 
 FIG. 53. sacral, coccygeal, and peri- 
 
 neal curve, the perineum 
 becomes greatly distended 
 and elongated, the occiput 
 passes over the posterior 
 commissure, and the head 
 passes out by its occipito- 
 frontal diameter. As the 
 occiput is passing outward, 
 the forehead rises behind 
 the symphysis pubis, thus 
 giving more space for the 
 head to pass through. Some- 
 times, after the delivery of 
 the occiput, the neck be- 
 comes fixed against the per- 
 ineum, and the forehead, 
 face, and chin of the child, 
 successively, emerge from under the pubic arch. Should the fore- 
 head descend so low that the eyebrows may be felt, it will, by pre- 
 senting an impediment to its elevation behind the pubic symphysis 
 at the time of the passage of the occiput over the perineal curve, very 
 much increase the difficulty of the labor. 
 
 Dr. Dewees states, "\Ve almost always have it in our power to 
 reduce this and the fifth " (when they occur with the occiput in the 
 hollow of the sacrum, as just described), "one to the second, and the 
 other to the first, and we should always do so when nature does not 
 do it for us. Nor is this change of position of the head an operation 
 of the slightest difficulty to the accoucheur; neither does it cause the 
 smallest pain to the patient, provided advantage be taken of the 
 proper conditions of the uterus, and head of the child, and state of the 
 labor. For the uterus must be well dilated, the membranes ruptured,
 
 MECHANISM OF LABOR. 353 
 
 the head occupying the lower strait, and the' labor active. When 
 these prerequisites obtain, the point of the forefinger must be placed 
 against the edge of the sagittal suture either before or behind the an- 
 terior fontanelle, and, in the absence of pain, this part must be pressed 
 toward the left sacro-iliac symphysis,* and maintained there during 
 the subsequent contraction of the uterus. Should this attempt fail in 
 changing the position of the head, by bringing the posterior font- 
 anelle to the right acetabulum, the attempt must be repeated again 
 and again until it succeeds, which it will almost constantly do." 
 
 The expulsion of the head in the occipital posterior positions may, 
 in consequence of a premature extension, fix the occiput in the hollow 
 of the sacrum, and thus the face be forced downward by the contrac- 
 tions, delivery occurring as in face presentations; but, in order to 
 effect such a change in the pelvic cavity, the natural size of the head 
 must be considerably reduced, or the diameters of the excavation 
 must be very large. 
 
 In all the occipito-posterior positions there may be a failure of 
 complete rotation, a want of energy of uterine contraction, or exhaust- 
 ion, etc., either of which will require the interference of art. 
 
 
 STH. RIGHT OCCIPITO-POSTERIOR POSITION. 
 
 DIAGNOSIS. In this position the occiput is placed at the right 
 sacro-iliac symphysis, and the forehead at the left acetabulum, the 
 anterior fontanelle will be found behind the left acetabulum, from 
 which the sagittal suture may be traced running obliquely across the 
 pelvis, from in front backward, and from above downward, and from 
 left to right, until it meets with the posterior fontanelle, which will 
 be toward the right sacro iliac symphysis. The left parietal protu- 
 berance is the most depending part, and with which the finger will 
 first come in contact. The back of the child will be toward the back 
 of the mother and to the right, while its abdomen will be toward her 
 abdomen, and to the left; its right shoulder will be toward her back 
 and to the left, and its left to her abdomen and right. (Fig. 54.) 
 
 This is considered the most common of the occipito-posterior posi- 
 tions, and is stated by Nsegele to be the next in frequency, among the 
 
 *In the fourth position of the vertex, while attempting the above reduction, the fore- 
 head must be pushed toward the right sacro-iliac symphysis, which will reduce it to the 
 first position; in the fifth position, the pressure must be made in the direction toward 
 the left sacro-iliac symphysis, which will place the head in the second position. Author. 
 
 23
 
 354 
 
 KING'S ECLECTIC OBSTETRICS. 
 
 FIG. 54. 
 
 vertex presentations, to the left occipito-anterior, occurring in the 
 ratio of 29 per cent. In 355 cases, related by Simpson, 256 were 
 in the first position, 1 in the second, 2 in the fourth, and 76 in 
 the fifth. Its frequency is supposed to be owing to the same cause 
 
 which gives rise to the 
 left occipito-anterior 
 position, viz.: the press- 
 ure of the rectum on 
 the left side of the pel- 
 vis, which happens 
 especially when, as is 
 common to women ad- 
 vanced in pregnancy, 
 there is an accumulation 
 of hardened feces. It 
 is a more unfavorable 
 position than the first 
 three, and the labor, 
 though generally ac- 
 complished by the nat- 
 ural powers, is more 
 tedious and painful than 
 with the occipito-ante- 
 rior positions. 
 
 MECHANISM.- 
 This is the counterpart 
 of the fourth position, and difficulties or changes may be encountered, 
 similar to those met with in that position. At the commencement of 
 labor, the occipito-frontal diameter will be found to coincide with the 
 left oblique pelvic diameter, and the biparietal with the right oblique; 
 the two foutanelles, as in the preceding case, being at nearly the same 
 level. As the labor advances, flexion ensues, and the occipito-breg- 
 matic diameter takes the place of the occipito-frontal, the axis of the 
 superior strait corresponding nearly with the occipito-mental diam- 
 eter. Flexion, descent, extensive rotation and restitution, occur as in 
 the preceding case, with the exception that the rotation takes place 
 from right to left, the occiput sweeping around the right side of the 
 pelvis, the left shoulder is brought to the pubic arch, and restitu- 
 tion brings the face of the child toward the internal part of the left 
 maternal thigh, and its occiput toward the internal part of the right
 
 MECHANISM OF LABOR. 
 FIG. 55. 
 
 355 
 
 thigh or, as in the preceding position, rotation may place the fore- 
 head under the pubic arch, and the occiput in the hollow of the sac- 
 rum, as shown in Fig. 55. 
 
 BTH. OCCIPITO-SACKAL POSITION. 
 
 DIAGNOSIS. In this position the forehead or anterior fontanelle 
 will be detected behind the symphysis pubis, and the sagittal suture 
 may be traced [running parallel or nearly so, to the antero-posterior 
 diameter of the pelvis], from before, backward, and downward, until 
 it meets the posterior fontanelle or occiput, which will be toward the 
 sacrum. The back of the child will face the mother's back, while its 
 abdomen will be toward her abdomen ; its right shoulder will be 
 toward her left side, and its left toward her right. 
 
 This position is of very rare occurrence, so much so that its exist- 
 -ence is doubted by some accoucheurs, and, together with the third, it 
 is not classified as a position by several authors. In 20,517 deliveries 
 it was met with but twice. Boivin. 
 
 MECHANISM. In the occipito-sacral position, the occipito-breg- 
 matic diameter of the fetal head corresponds with the antero-posterior 
 .pelvic diameter, and its biparietal with the pelvic transverse. The 
 mechanism differs from the two preceding positions, in the head exe- 
 cuting only the motions of flexion, descent, increased flexion and
 
 356 KINfi's ECLECTIC OBSTETRICS. 
 
 extension. The motion of rotation' is unnecessary, and the direction- 
 of restitution will depend upon which shoulder engages at the pubic 
 arch. If nature does not reduce this to an occipito-posterior position. 
 and the labor is slow and painful, it may be facilitated by effecting the 
 reduction artificially, in the same manner, and guided by the same 
 rules, as named, when treating of the mechanism of occipito-pubal 
 positions. The head may present in positions not exactly agreeing 
 with those just given, relative to which, Dr. Dewees very correctly 
 remarks : " Mathematical precision is not required in such cases, 
 especially as the mechanism of the labor is not altered ; for when the 
 posterior fontanelle is at all in advance of the sacro-iliac junction, 
 either right or left, it will almost always eventually place itself under 
 the arch of the pubes, and this is all that is necessary." 
 
 In may be proper to remark here that sometimes the movements of 
 the head do not occur exactly in the manner just described. Flexion, 
 for instance, will be found to occur previous to the descent of the 
 head, or simultaneously with it, or not until the head has reached the 
 pelvic floor ; and, occasionally, extension will take place so far as to 
 gradually place the anterior fontanelle in the center of the pelvic 
 cavity, flexion occurring, however, as soon as the descent is completed ; 
 this last irregularity is more usual with the occipito-posterior positions. 
 Again, Dubois has met with a few cases, in which excessive flexion 
 brought the posterior fontanelle to the center of the excavation (or 
 perhaps, an inclination of the trunk backward, may have effected it), 
 but which was restored to its proper situation upon meeting with the 
 resistance from the pelvic floor. 
 
 Rotation may also vary ; it may commence while the head is at the 
 upper part of the pelvic cavity, so that flexion, descent, and rotation 
 occur simultaneously; or it may not take place until the head has 
 almost passed the posterior commissure of the vulva. Rotation may 
 also be incomplete, or it may be so extensive as to carry the occiput, 
 not only to the pubic symphysis, but even beyond it, to the acetabulurn 
 of the opposite side ; in these latter instances, after a short period of 
 rest, it again places itself behind the symphysis, by a retrograde 
 motion. These irregularities are not easily accounted for, and though 
 they may render the delivery tedious, yet it will generally be effected 
 without any artificial interference. 
 
 Rotation of the shoulders likewise, offers some irregularities; it may 
 be wanting, or it may be incomplete, or it may be excessive, the sama 
 as with the rotation of the head.
 
 MECHANISM OF LABOR. 357 
 
 The pressure upon the circumference of the head, produces a sero- 
 sanguineous engorgement over the part not subjected to the compres- 
 sion, and which is always the lowest or presenting part. This tumor, 
 caput succedaneum, may become so developed as to obscure the 
 diagnosis, or lead to the supposition of a breech presentation ; but, if 
 the finger be carried beyond its circumference, the bony resistance of 
 the head will determine the presentation. The diagnosis of the posi- 
 tion, may, however, not be so readily ascertained, as this engorged 
 condition of the scalp may prevent the detection of the fontanelles ; in 
 such cases, the delivery will require to be performed without inter- 
 ference, bearing in mind, that in vertex presentations, the major part 
 are delivered by the unaided efforts of nature. 
 
 This tumor of the scalp is an unerring indicator of the position 
 of the fetal head ; thus, in the left occipito-anterior position, it will 
 be found on the right parietal protuberance, and in the right 
 occipito-anterior on the left; in the occipito-posterior positions, it 
 is located about the center of the vertex, sometimes on the anterior 
 fontanelle, but, generally, to correspond with the part originally at 
 the os uteri, and subsequently with the part which presents under the 
 pubic arch. 
 
 It may be distinguished from a sanguineous tumor of the head, 
 which Nsege'le has termed cephalcematoma, by the following charac- 
 teristics : it is irregularly circumscribed, being larger in proportion 
 to the tediousness of the labor ; is always single ; is oedematous, 
 retaining the pit of the finger ; has no fluctuation ; and the scalp is 
 of a well-marked violet color. The cephalsematoma vary in size, from 
 a small nut to a hen's egg ; it is distinctly circumscribed ; possesses 
 a well-marked fluctuation, sometimes pulsations ; its center is some- 
 times so greatly depressed as to be mistaken for a perforation of the 
 bone ; its base is limited by a prominent osseous border, which, how- 
 ever, is often not developed for several days after the commencement 
 of the disease ; and the skin covering it is colorless. Again, the caput 
 succedaneum appears directly after birth, and disappears in from 
 twelve to forty-eight hours, while the cephalsematoma seldom appears 
 until some hours after the delivery, and lasts for several weeks. 
 Cazeaux.
 
 358 ' KING'S ECLECTIC OBSTETEICS. 
 
 CHAPTER XXIX. 
 
 ON DIFFICULT LABOR FIRST STAGE. 
 
 DIFFICULT, lingering, tedious, and protracted labor, belongs to the 
 second class, and includes all labors where the fetal head presents, but 
 where they continue beyond twenty-four hours, and may require some 
 medicinal, manual, or instrumental aid. It is true, that cases will be 
 met with, in which artificial delivery may be required within the twenty- 
 four hours, and others, again, which may continue for a period con- 
 siderably beyond twenty-four hours, but these instances form exceptions 
 to the above definition. As a general rule, however, the one given 
 will be found exceedingly salutary and beneficial in practice, and an 
 attention to which, will be calculated to prevent the occurrence of any 
 mischief from a rash or premature interference of the practitioner. 
 This class of labor has also been termed unnatural, but as I can see no 
 especial reason for changing the terms usually applied to it, and which 
 in my opinion much better express the character of the labor, I still 
 adhere to the designation " difficult," which comprises every descrip- 
 tion of labor in which the process fails to be accomplished in a prompt 
 and regular manner. 
 
 The danger in a difficult labor depends entirely upon the stage in 
 which the delay happens ; thus, the first stage of labor may continue 
 for even sixty or seventy hours, with but little, if any danger, espe- 
 cially if the membranes remain entire, and there is a proper amount 
 of liquor amnii present, and no mechanical impediment exists. But 
 delay in the second stage, is always attended with danger, if it con- 
 tinues beyond a comparatively short time ; hence, in estimating the 
 necessity for interference, we are not to be governed so much by the 
 length of time occupied by the first stage, as by the interval which has 
 elapsed since the rupture of the membranes and the discharge of the 
 amniotic fluid ; and the experience of accoucheurs has demonstrated 
 that the danger is, commonly, in proportion to the duration of the 
 labor. From statistics of the Dublin Lying-in-Hospital, it appears 
 that when labor exceeds thirty hours, one woman in thirty-four dies ; 
 when it exceeds forty hours, one in thirteen dies ; beyond fifty hours, 
 one in eleven ; and beyond sixty hours, one in eight. 
 
 Difficult labors are more common among primiparae, and are, like- 
 wise, not unfrequent among multipart who have given birth to a large 
 number of children. According to the statistics of English obstetri-
 
 DIFFICULT LABOK FIRST STAGE. 350 
 
 cians, 653 cases of difficult labor occurred in 23,758, or about 1 in 36 ; 
 and it will frequently happen, that a practitioner in his individual 
 private practice, may meet with even a much larger average than this. 
 
 The continuance of a labor beyond a period of twenty-four hours is 
 necessarily calculated to arouse the fears of the patient and her friends, 
 as to the cause of the delay ; and if the practitioner does not proceed 
 properly in such instances, the anxieties and doubts of the friends may 
 lead them to require the aid of a second accoucheur, or perhaps the 
 dismissal of the first. It is therefore always proper, when the labor 
 has continued thus long, to institute a careful investigation of the con- 
 dition of the patient, arid of all the presenting symptoms, for the 
 purpose of learning the cause of the delay, and at once applying the 
 remedy. " In estimating lingering labors, we calculate from the first 
 commencement of true uterine action ; but in estimating the length of 
 labor, in reference to the patient's strength and its effects on her sys- 
 tem, we principally take into consideration the time that has elapsed 
 since the membranes broke ; for it is reasonable to infer that no great 
 exertion has been sustained, consequently that little or no exhaustion 
 has appeared; and particularly, that scarce any injurious pressure can 
 have taken place on the soft parts within the pelvis, while the mem- 
 branous cyst remained entire, provided there be an ordinary quantity 
 of liquor amnii. Thus, when called to a case of lingering labor, in 
 considering the chance of injury from its duration, our mind should 
 be directed, not so much to the interval which has elapsed since the 
 first accession of uterine pains, as to the time at which the membranes 
 ruptured ; and that should be looked upon as the period when it was 
 possible for dangerous pressure to have commenced." Ramsbotham. 
 
 The management of a patient in difficult labor must be similar to 
 that required in natural labor. She should not be kept in one posi- 
 tion, but should be allowed to sit, walk, or lie down, as she may prefer,, 
 and more especially in the early part of labor ; in the latter stage,, 
 circumstances may require her to preserve the recumbent posture. She 
 must not bear down or make any efforts to assist the uterus during it* 
 contractions, as such efforts may cause the membranes to give way 
 prematurely, exhaust the patient's strength uselessly, or otherwise 
 interfere with the progress of the delivery ; and this is a point which 
 can not be too strongly insisted upon. It is only during the second 
 stage of labor, when the presentation and position are both favorable, 
 that the action of the muscles of the abdomen may be exerted with 
 advantage. The room should be kept cool and quiet, to prevent fever 
 and induce sleep. Bland, nourishing fluids, weak tea, or acidulated
 
 360 KING'S ECLECTIC OBSTETRICS. 
 
 
 
 draughts, may be allowed, but stimulants and solid food must be pro- 
 hibited. Too frequent vaginal examinations are injurious, but the 
 condition of the bladder should be ascertained every two or three 
 hours, and much urine should not be allowed to collect in it. This is 
 of especial importance in difficult labors : the urine must be passed 
 often, either naturally or by catheter ; and in the use of the latter, no 
 force should be employed, and care must be taken not to permit it to 
 slip into the bladder. If the metallic instrument can not be intro- 
 duced, an elastic catheter must be substituted ; and although under 
 ordinary circumstances no exposure of the female is allowable, yet 
 there may be instances where, from the failure in introducing the 
 above instrument, and the condition of the parts, an exposure will be 
 necessary to accomplish the desired evacuation of the bladder. This, 
 however, must never be practiced, except under the most imperative 
 requirements. This class of labor may be owing to one or more of 
 several causes, referable to : 1, the uterus; 2, the parts or passages 
 through which the child passes ; or, 3, to the child itself, and which I 
 shall now proceed to designate and treat upon : 
 
 1. Among the abnormal conditions of the uterus, that may occur 
 during the first stage of labor may be named as a very common cause 
 of protracted labor, INEFFICIENT ACTION OF THE UTERUS, 
 in which the contractions are partial, feeble, or irregular ; they may 
 continue only for a few seconds, they may hardly be appreciable, or 
 they may occur at irregular and lengthy intervals ; and in each 
 instance, the os uteri may be soft and dilatable. This cause will, 
 in some cases, be owing to a torpid, inactive, and sluggish condition 
 of both mind and body, or a want of tone or proper nervous irrita- 
 bility in the constitution ; to some depressing action, as debility result- 
 ing from excessive discharges, previous disease, etc.; to sudden and 
 violent emotions of the mind, and other circumstances which exert an 
 influence on the brain and nervous system. Debility of the system, 
 or even the presence of serious disease, does not invariably occasion 
 inertia of the uterus, for we frequently meet with females laboring 
 under tubercular phthisis, hectic fever, etc., who pass through their 
 labors with great facility. With some females the tendency to difficult 
 or easy deliveries appears to be a peculiarity transmitted from parent 
 to child, and occurs independent of any abnormal conformation, or 
 habit of the system. A deranged condition of the digestive organs 
 will frequently influence the character of the uterine contractions, as 
 will likewise irritation of the os or cervix uteri. Cancer of the uterus,
 
 DIFFICULT LABOR FIRST STAGE. 361 
 
 fibrous tumors, uterine inflammation, rheumatism of the uterus, etc., 
 may also interfere with the uterine contractions, rendering them 
 deficient in dilating or expelling power, and irregular in their intervals, 
 but these causes are more apt to prove dangerous during the second 
 stage, and will, therefore, be more particularly noticed hereafter. 
 
 Females are often annoyed, at the -close of gestation, with false, 
 spasmodic, or irritable pains, which have no connection whatever with 
 the contractions in the fibers of the uterus, and which have, in some 
 instances, given rise to the absurd statements that labor has continued 
 uninterruptedly for one, two, or more weeks. Care should be taken 
 to distinguish these from the proper contractions of the uterus. 
 
 Inefficient action of the uterus may occur during the first or second 
 stage ; and, as before remarked, the danger is greater in the latter 
 than in the former instance. In the First Stage we may find the pains 
 feeble or irregular, and exerting but little influence upon the bag of 
 membranes ; yet if there is only a slight increase of the pulse, " with 
 the surface of the body cool, tongue moist, absence of thirst, no tender- 
 ness of the abdomen on pressure, no heat or tenderness of the vagina 
 and os uteri, and dilatation is advancing, however slowly, we ought 
 not to interfere, for many hours may elapse before this stage will be 
 completed, and yet the pressure of the fetal head upon the soft parts 
 will produce no evil effects if the apartment be kept cool, the posture 
 be occasionally changed, voluntary efforts at bearing down be avoided, 
 and nothing but mild nourishment and diluents be allowed." 
 
 TREATMENT. When there is considerable delay in the advance- 
 ment of the first stage of labor, the patient should be kept in as 
 cheerful condition as possible, and she may occupy the time by 
 walking about but not to cause fatigue by reading or sewing, by 
 frequently changing her position, etc.; and should be encouraged to 
 exercise patience, which virtue the practitioner will find equally 
 demanded on his part. If the bowels have not been freely evacuated, 
 a stimulating enema or a dose of purgative medicine may be given, 
 and which will frequently arouse the uterus to increased action. If 
 the pulse is weak and slow, and no heat, but rather coolness of the 
 surface, nor hemorrhage, some arrowroot, or gruel, or wine and water, 
 may be beneficial, but their use should be permitted with caution. 
 If, from the want of sleep, continued suffering, and anxiety of mind, the 
 patient should become fatigued or exhausted, a soporific dose of some 
 desirable agent should be administered, and natural sleep encouraged, 
 indulging her in rest and sleep for one or two hours; upon awaken- 
 ing, she will not only feel refreshed, but will very likely have a
 
 362 KING'S ECLECTIC OBSTETRICS. 
 
 recurrence of the pains with increased energy. If an opiate is admin- 
 istered, it should always be preceded by a purgative when constipation 
 exists. In a number of instances I have succeeded in restoring nor- 
 mal power and proper intermittent action to the uterus solely by the 
 administration of Sulphate of Quinia in a five or ten grain dose. 
 
 If there is a plethoric condition of the uterus, or an irritated state 
 of the os and cervix uteri, this may be frequently overcome by the 
 use of the sedative, which will usually be Aconite, in addition with 
 the specially indicated agents, as Macrotys, Lobelia, Gelsemium, or 
 Pulsatilla, as they may be severally indicated, together, in some cases, 
 with the compound powder of Ipecacuanha and Opium. Plethora 
 of the uterine tissue may be known by the energy with which the 
 pains are at first manifested, but which soon diminish in frequency 
 and intensity. The cervix is soft and yielding, but the presenting 
 part does not engage during the pain; the pulse is hard and full, the 
 respiration laborious, and the pains are equally diffused over the whole 
 abdomen. 
 
 Sometimes the employment of warm diluent drinks, with frictions 
 over the abdomen, will frequently succeed in restoring or increasing 
 the contractions, without other aid being required. 
 
 When the pains which occur at very irregular periods are confined to 
 the uterus, and do not render the bag of waters tense, nor impart any 
 hardness to the uterus when felt through the abdominal parietes, the 
 pulse being quick and full, and the uterus unusually developed, the 
 inertia is owing to an Excess of Liquor Amnii, overdistending the 
 organ, or perhaps to the presence of Twins. In this case, although 
 the soft parts are relaxed and dilated or dilatable, the labor does not 
 progress any, the uterus being, from this cause, rendered incapable of 
 contracting sufficiently powerful to rupture the membranes, and the 
 patient becomes fretful and restless. The only remedy in this case, is 
 a discharge of the liquor amnii by an artificial rupture of the mem- 
 branes, which should be done during the absence of pain [the os uteri 
 being well dilated], and made as high up as possible, in order to avoid 
 a falling or washing down of the cord; though I would especially 
 desire to impress it upon the mind of the student that this procedure 
 is entirely unjustifiable in ordinary labors, and must not be attempted 
 unless it is well ascertained that there is no mechanical impediment, 
 that the head presents, and the os uteri is dilatable. A premature 
 rupture of the membranes, by discharging the bag of waters and- 
 bringing the hard and unyielding head of the child upon the sensi- 
 tive os uteri, may delay the labor by lessening the pains, or producing
 
 DIFFICULT LABOR FIRST STAGE. 363 
 
 rigidity of the os. Still-born children are more frequently the results 
 of too early rupture of the membranes, and, probably, the use of in- 
 struments are likewise oftener required in such cases. 
 
 If the relaxation or cessation of uterine contractions depends upon 
 moral influences, the attendant, by ascertaining the trouble, may per- 
 haps, by a prudent and sagacious course, remove them ; but if this 
 is impossible, he will be governed by the effects produced, using 
 stimulants in case of depression, and sedatives where much nervous 
 excitement exists ; Pulsatilla is likewise an excellent remedy, espe- 
 cially where there are unpleasant sensations with the nervous excite- 
 ment, the patient complaining that "there is something n-rony ivith the 
 child." The induction of sleep, also, will frequently be followed by 
 uterine efforts. 
 
 I am decidedly opposed to the use of Ergot during the first stage 
 of labor, where the only difficulty is the inefficiency of the uterine 
 contractions, for, as a general rule, an attention to the various symp- 
 toms which may present themselves, during this stage, with their 
 appropriate treatment, will be all that is demanded. But, should 
 circumstances require the use of agents which exert a parturient in- 
 fluence upon the uterus, Macrotys, Aconite and Macrotys, or Pul- 
 satilla if the patient is nervous, will prove, as a general rule, more 
 salutary than the Ergot. Occasionally females will be met with, upon 
 whose uterine systems these agents produce but little if any influence, 
 and in whom, under imperious circumstances, it may become neces- 
 sary to administer Ergot, but I shall have occasion to refer to these 
 cases hereafter, as well as to others in which Ergot may be employed. 
 Usually, however, the remedies above noticed, both during the first 
 and second stages of labor, will prove fully as efficacious as Ergot, 
 without any of its injurious tendencies. As heretofore observed, I 
 have found that Sulphate of Quinia will frequently correct the ineffi- 
 cient action of the uterus. Want of pain, or tardy pains, are met by 
 Lobelia in some cases, which may be given with the Macrotys if there 
 is a fullness and oppression of the pulse. 
 
 2. RHEUMATISM OF THE UTERUS may be present during 
 the non-gravid condition of the organ, at an early period of gestation, 
 and at the time of labor during either of its stages. It is produced 
 by the same causes that favor the development of rheumatism in other 
 parts, as exposures to cold and moisture, insufficient clothing, sudden 
 changes of temperature, especially from a high to a low one, and
 
 364 KING'S ECLECTIO OBSTETRICS. 
 
 occasionally, from a rheumatic metastasis; females constitutionally 
 disposed to rheumatism are more liable to it, though it frequently 
 r\i<ts without any other part of the system being affected by it. 
 
 "The most prominent symptom of this disease is pain, or a dis- 
 tresssing sensation, without any appreciable cause, and which may 
 involve the whole or only a portion of the uterus. The intensity of 
 the pain is variable, and the whole organ may suffer from it, or only a 
 part, as the fundus, corpus, or cervix. The location of the pain 
 depends upon the portion of the organ which is affected; thus if it be 
 seated in the fundus, the sub-umbilical region will suffer the most; 
 if in the inferior portion of the uterus, acute dragging sensations will 
 be experienced extending from the loins to the groins, thighs, and 
 external genital organs. Pressure upon the organ augments the pain, 
 and if the inferior part of the womb be affected, much suffering will 
 be caused by pressure upon the cervix during a vaginal examination. 
 Frequently the contractions of the abdominal muscles, or even the 
 weight of the bedclothes, will increase the pain. The pains, as with 
 all rheumatic affections, frequently metastasize, and pass from one 
 point of the organ to another, or to some other organ, and not un fre- 
 quently disappear suddenly. Remissions occur sometimes, during 
 which a sensation of weight in the part is experienced. Recto-vesical 
 tenesmus almost always accompanies the pain, and the evacuation of 
 urine is attended with considerable smarting and acute pain, and at 
 other times the evacuation of both the bladder and rectum is impos- 
 sible. The pain is usually attended with febrile symptoms, but some- 
 times these are absent. A repetition of the attacks of pain is very 
 apt to occasion uterine contractions, which may determine an abortion. 
 
 " When rheumatism of the uterus occurs during labor, it generally 
 impedes the progress of the labor, and sometimes, even prevents the 
 spontaneous expulsion of the child. Normal contractions of the 
 uterus only begin to be painful, when it has accomplished the greater 
 part of its task, and is in the act of distending and dilating the os 
 uteri; or in other words, true labor-pains begin only at the instant 
 when the energy of the corpus uteri overcomes the resistance of the 
 cervix. While in rheumatism of the uterus, the contraction is painful 
 from the first, and before any influence is exerted on the cervix ; so 
 that the cause of the pain is not in the violent distension of the os 
 uteri, but in the contraction itself, in the other morbid conditions and 
 in the altered relations of the nerves and contractile fibers of the 
 uterus. 
 
 " Again, in a natural labor, the contractions commence at the
 
 DIFFICULT LABOR FIRST STAGE. 365 
 
 fundus, and are directed toward, and terminate at the cervix. In 
 rheumatism, instead of commencing at the fundus, they begin at the 
 painful part, and run toward the cervix in an irregular manner. The 
 rheumatic pains also exist before the uterine contractions, and under 
 the influence of the latter, they rapidly acquire a high degree of 
 intensity ; and sometimes their violence arrests the contractions before 
 they have traversed their ordinary cycle, in which case they are rapid, 
 short, and grow less and less frequent. 
 
 " Toward the close of the labor, when the action of the uterus 
 requires to be aided by the voluntary contraction of the abdominal 
 muscles, the female, for fear of augmenting her sufferings refrains 
 from contracting these muscles, thereby causing the labor to be ex- 
 cessively slow. She is in a state of extreme anxiety, with an increase 
 of the frequent pulse, the hot skin, the thirst, and urinary tenesmus. 
 When these sufferings are much prolonged, she falls into a state of 
 swooning, which frequently proves serviceable, as the pains are 
 suspended while it lasts; under these circumstances a profuse perspira- 
 tion has been observed, which has had a most salutary influence on the 
 rest of the labor. But, in other instances, the uterus becomes more 
 and more painful; it is rather in a state of permanent contraction 
 or fibrillar vibration, than of normal contraction ; the pulse being 
 accelerated, and the woman threatened with a metritis, which renders 
 the labor extremely painful." Cazeaux. 
 
 Uterine rheumatism is frequently mistaken for acute inflammation 
 of the womb, and as the symptoms resemble each other very much, it 
 is very difficult to discriminate between them. Rheumatism attacks 
 mostly very nervous and susceptible women, and may be more readily 
 suspected when the patient has had previous attacks of rheumatism or 
 neuralgia, in other parts. Cazeaux determined the disease by touch- 
 ing; thus, rheumatism and inflammation of the uterus are both painful ; 
 but in rheumatism, although the first touch of the womb is painful and 
 quick, yet upon gently and slowly raising it upward with the index 
 and middle finger, the pain either ceases altogether, or is much miti- 
 gated, by removing the tenesmus uteri ; while in inflammation the 
 touch becomes mo're painful the more it is prolonged. 
 
 TREATMENT. The means which may be adopted with benefit in 
 these cases are various. In the first place the bowels, if they have 
 not been previously evacuated, must be emptied by an injection ; if 
 the pain be not very severe, but troublesome and annoying, the com- 
 pound powder of Ipecacuanha and Opium may be given, in doses of 
 three to five grains, and repeated every half-hour or hour; other
 
 366 KING'S ECLECTIC OBSTETRICS. 
 
 agents, however, will usually be called for, and among the first Ma- 
 crotys should be thought of, and in many cases will be all that is 
 needed. If the pain is attended by an excited circulation, Aconite 
 should be added, always observing the usual small dose. If the pain 
 is inclined to extend down the thighs, and to the region of the back, 
 Pulsatilla may be given with the Macrotys. If there are marked 
 remissions, Quinine may be given in doses of three to six grains, and 
 repeated as often as seems necessary. Fomentations of Stramonium 
 leaves, or other narcotics, may also be advantageously applied over 
 the abdomen, and, when the pain is very severe, much benefit will 
 be derived from the application of dry cups over the lateral inferior 
 portions of the sacrum. Should the disease manifest itself soon after 
 the sudden disappearance of a rheumatic pain in some other part, 
 revulsives or counter-irritants should be placed over the part pri- 
 marily affected, for the purpose of recalling the pain, if possible, to 
 that part. 
 
 Other means may likewise be used in some cases, in addition to 
 those just named; Lobelia may be indicated by the unpleasant sense 
 of weight and dragging in the abdomen and pelvis, or if the pains 
 are associated with a sense of muscular debility Nux Vomica will be 
 the remedy. 
 
 The disposition to uterine rheumatism at the period of labor 
 may, in most instances, be entirely overcome by the use of the 
 Parturient Balm during gestation. General venesection, although 
 it may afford relief, is never necessary, as its results are ultimately 
 more disastrous to the patient than beneficial, and a more per- 
 manent advantage is gained over the disease by the above course, 
 than could possibly be effected by the employment of the lancet ; and 
 by pursuing it, there will exist but little necessity for forceps, unless 
 other symptoms, not immediately connected with the rheumatic attack, 
 are present. 
 
 3. RIGIDITY OF THE OS UTERI, during the first stage of 
 labor, is a frequent cause of its protractedness. This may occur in 
 any case, but is more frequently met with in primiparse, in females of 
 an advanced age, and in instances where the membranes are prema- 
 turely ruptured. It may be occasioned by repeated and unnecessary 
 examinations, the use of stimulants, mental excitement, constipation, 
 or retained urine. It may also be owing to dysmenorrhea, or a dis- 
 eased condition of the os itself, either natural, or effected by the 
 improper use of pessaries or other mechanical aids to support the
 
 DIFFICULT LABOR FIRST STAGE. 367 
 
 uterus, as well as the imprudent application of escharotics to the os, 
 for the removal of some real or imaginary affection. 
 
 Rigidity of the os uteri may be suspected in cases where the head 
 .presents and the pains are regular and,normal, but dilatation proceeds 
 very slowly, if at all ; the pains gradually lose their force, and the 
 patient becomes exhausted ; in addition to which, Madam La Chapelle 
 refers to another symptom, viz.: pains in the loins. On examination, 
 the os uteri will be found thin, resisting, hot, dry, and painful to the 
 touch, or, soft, cedematous, semi-pulpy, and undilatable, and which 
 must be carefully distinguished from the soft and flabby condition into 
 which the thin and rigid cervix must pass before it will dilate. Some- 
 times the rigidity is excessive, the os being unusually dense, feeling like 
 cartilage, with a stubbornly unyielding edge ; or if this be thin, the 
 same resistance will be met with, and a sensation is conveyed to the 
 touch, similar to that produced by a hole made in thin, extended 
 parchment. 
 
 Very frequently the rigidity will not be confined to the os uteri, 
 but will extend into the vagina and soft parts ; they will be found hot, 
 dry, swollen, and extremely sensitive to the touch, and if this condition 
 be not overcome, the patient becomes restless and feverish, the pulse 
 rises to 100 or 110, and finally, exhaustion of the vital forces mani- 
 fests itself. Occasionally the os uteri will be found to contract during 
 a pain, remaining rigid in the interval ; and in such instances a rup- 
 ture of the uterus may occur. Instances are recorded in which the 
 rigidity was so obstinate that the os uteri has been torn off and expelled 
 in the form of a ring. 
 
 TREATMENT. Formerly venesection, ad deliquum animi, was 
 considered the most successful and potent remedy in this difficulty, 
 and was the one on which the utmost reliance was placed by the 
 major part of the profession. I admit that bleeding will, in most 
 cases, have the effect of overcoming rigidity of the os uteri, but I by 
 no means admit it to be a proper or safe remedy. A female in labor 
 requires all the strength natural to her system, not only to sustain 
 her during its progress, but also to enable her to withstand and 
 quickly recover from the nervous shock. By the loss of an amount 
 ot blood sufficient to cause syncope, a debility of the nervous and 
 circulatory systems must ensue, producing a condition unfavorable 
 to either of these requirements; and a tedious second stage, with 
 subsequent hemorrhage or other evils, frequently followed a bleed- 
 ing practiced in the first stage, and which, no doubt, were aug- 
 mented, if not actually produced, by the venesection. Debility of the
 
 368 KING'S ECLECTIC OBSTETRICS. 
 
 system, and more especially when sudden, persistent, and at the period 
 of parturition, is incompatible with a safe or energetic labor. Beside 
 the weakening influence of venesection upon the constitution, we have 
 an increased prostration of nervous and muscular force, produced by 
 the shock imparted to the brain and nervous system, as well as by the 
 lo.-s of blood which necessarily follows the birth of every child. In- 
 deed, it is impossible for any practitioner to determine what amount 
 of blood may be lost from the labor itself, independent of any artificial 
 discharge; and who can tell hew many precious lives have been lost 
 from uterine hemorrhage, or other fatal symptoms, in the practice of 
 believers in this treatment, which might have been preserved had the 
 lancet been cast aside? Indeed, so well were the adherents of this 
 practice satisfied of its danger to the parturient woman, that they 
 especially advised not to resort to it until the -parts become swollen 
 and tender, the pulse increased, with febrile symptoms, or a tendency 
 to cerebral congestion ; and even then to use it with great care. The 
 injurious tendencies of bleeding do not cease with the completion of 
 delivery, for, whether it be artificially effected by the lancet, or nat- 
 urally by uterine hemorrhage, not only is the puerperal month one 
 of slow, tedious convalescence, if this term can justly be applied to 
 it, but very frequently a life-time of irremediable suffering and dis- 
 ease is the inevitable consequence. Tartar Emetic was also a favor- 
 ite remedy of the champions of venesection, and was administered in 
 nearly every case of rigidity of the os. 
 
 In the treatment of this difficulty, u-e "have no occasion to wait for 
 the appearance of the above symptoms before attempting relief, be- 
 cause we have means to subdue it without the infliction of any imme- 
 diate or permanent injury to the system, and as soon as the evil man- 
 ifests itself, we at once apply the remedy, saving the patient a great 
 amount of suffering, and the friends and ourselves much anxiety and 
 alarm. And hence, we believe our practice has a vast advantage over 
 that which dare not attempt certain relief until after a lengthened 
 period of pain and distress, and when exhaustion of the vital forces is 
 about to commence. Promptness in combating this condition, as well 
 as many others, is the only method by which to insure certainty of 
 success. 
 
 In cases of rigidity, during the early part of labor, it will be neces- 
 sary to pay particular attention to the evacuation of the contents of 
 the rectum as well as of the bladder; if, after having waited for ten 
 or fifteen minutes subsequently, the rigidity still remained, the old 
 time treatment of eclectics was to administer at once the compound
 
 DIFFICULT LABOR FIRST STAGE. 369 
 
 tincture of Lobelia and Capsicum, in doses of one, two, or four fluid 
 drachms, according to the urgency of the case, to be repeated in ten 
 or fifteen minutes should it be required; and, in the generality of 
 cases, this would effect a speedy and safe relaxation. In some cases, 
 in conjunction with the above, an injection of the same tincture was 
 employed, in the quantity of half a fluid drachm, or a fluid drachm 
 diluted with a similar amount of water, requesting the patient to re- 
 tain it as long as possible. In many instances this enema, it is claimed, 
 was sufficient to overcome the rigidity, without the administra- 
 tion of any medicine by mouth. This compound is not at present 
 used, to any great extent; it was, no doubt, a good antispasmodic, 
 and was an efficient means in overcoming the condition for Avhich it 
 was prescribed, and was only discarded on account of its disagreeable 
 taste and the large dose required. Lobelia, or Gelsemium, are the 
 specific agents now recommended for this difficulty. The emetic in- 
 fluence of Lobelia is not necessary, to produce the required result, 
 nor, indeed, is it always desirable that emesis should follow; much 
 more salutary and immediate results will ensue from nauseating and 
 relaxing closes and when vomiting has once occurred from its use, 
 without relaxation, it will frequently be found that smaller doses will 
 nob be retained sufficiently long upon the stomach to exert any relax- 
 ing influence. Lobelia is the remedy commonly indicated; its effect 
 is direct and certain, especially where the parts are full and doughy; 
 it not only overcomes the rigidity, producing dilatation, but at the 
 same time favors uterine contractions. It is, indeed, one of the most 
 valuable remedies in obstetrics. Gelsemium is likewise an efficient 
 remedy, and may be used in many cases with benefit. It possesses an 
 advantage over Lobelia, in not causing nausea or vomiting; but, as a 
 general rule, its influence is not so readily experienced as with that 
 agent. Gelsemium should be selected when the tissues are thin and 
 tense, want of secretion, the contractions are painful, the patient nerv- 
 ous, the vagina hot and dry. 
 
 In those cases where inflammation of the os uteri is caused by un- 
 equal pressure of the child's head upon it, the Gelsemium will be y 
 found a valuable remedy. 
 
 The induction of copious perspiration, by the spirit vapor-bath or 
 otherwise, has been advised, and will, probably, be found effectual in 
 some cases; but, on account of the trouble attending its application 
 during parturition, and the danger of chill subsequently, it is better 
 to employ it -only when imperatively required. 
 24
 
 370 KING'S ECLECTIC OBSTETRICS. 
 
 The direct application of extract of Belladonna to the os uteri, 
 artificial dilatation, etc., have been recommended by various writers, 
 but I have never used them ; the above means having proved suc- 
 cessful in my own practice, as well as in that of others presented to 
 my notice.*' 
 
 * In relation to manual dilatation of the os uteri, which has been recommended by 
 some writers, under certain circumstances, it may be well for the student to acquaint 
 himself with the following rules, given by Prof. Dewees, which may prove serviceable 
 in the cases to which he alludes : 
 
 " 1st. When this part does not coincide with the direction of the uterine forces, and 
 the axis of the vagina. In this case, labor may become very tedious, for the want of 
 a correspondence of the axes; I therefore attempt to establish them, as directed in cases 
 of obliquity of the uterus. 
 
 " But I never attempt even the slight change here spoken of, until the os uteri is 
 yielding, and at the same time dilated, to the size of a dollar, and the pains in pretty 
 full force. By this method, not the slightest violence is committed, nor is even pain 
 excited. 
 
 " 2d. When the pains are powerfully protrusive, and the os uteri, though pretty 
 amply dilated, yet not sufficiently so to permit the parietal protuberances to pass freely 
 through it. In this case, much time and suffering are very often saved, by running 
 the extremity of the finger round the margin of the os uteri, and gently stretching it. 
 For, in many instances, if we gain an increase of half an inch in the diameter of this 
 part, it is all that is required, to enable the head to pass it. 
 
 "3d. When the head is detained by the anterior portion of the uterus being in 
 advance of it, and holding it as it were, in a sling. In this case, that portion of the 
 neck of the uterus, which is placed before the head, is obliged to sustain the whole 
 force of the uterine efforts ; in consequence of which, it becomes not only severely 
 stretched, but it very effectually opposes the advancement of the presenting part, and 
 gives rise to much unnecessary delay, as well as very much augmenting the sufferings 
 of the patient. 
 
 "This case is one of very frequent occurrence; and women who have ample pelves, 
 and especially those who have had several children, and are liable to the anterior obli- 
 quity of the uterus, are more particularly obnoxious to it. I do not know that any 
 writer has noticed this cause of tedious labor; and though this can not. strictly speak- 
 ing, be considered as an instance of rigidity, it nevertheless has all the effects of that 
 condition, as it creates delay, by a portion of one of the soft parts opposing the passage 
 of the head ; and may, therefore, with much propriety, be considered under the present 
 head of onr subject. 
 
 "We are every way satisfied, from long observation, that this situation of the uterus, 
 and of the head of the child, is one of the most common causes of delay when every- 
 thing else is favorably disposed, that occurs in practice at least in this country. 
 Whether this be so in Europe, where the remote causes, namely, large pelvis, are not so 
 reneral, we are unprepared to say; but we are certain, that the frequency of this 
 relation of the head of the child, and the anterior portion of the uterus, in this country, 
 render such labors more tedious, by hours, than they would be, if no such interposition 
 of the neck of the uterus took place. 
 
 "It is true, that the remora which the neck of the uterus offers to tjie passage of the 
 head when down before it, never of itself creates a serious difficulty ; the evil chiefly 
 consists in a painful and unnecessary delay ; but as the case is always manageable,
 
 DIFFICULT LABOR FIRST STAGE. 371 
 
 Rigidity depending on disease of the os uteri may be removed by 
 the above plan, but it can not always be expected to answer. In- 
 cising the cervix lias been advised as a successful measure in those 
 cases which prove very obstinate and protracted ; but I have never 
 had occasion to attempt the operation. The inhalation of Chloro- 
 
 when it is proper to offer aid, it is certainly right to correct this deviation from a 
 strictly healthy labor, as early as circumstances will permit. 
 
 "The proper time to act is, when the head occupies the inferior strait and vagina, 
 completely; when the pains are active; and when the os uteri is sufficiently dilated 
 to permit the head to pass, if the axis of the head, and that of the os uteri were co- 
 incident. 
 
 "To relieve the head from this state of embarrassment, we must draw the prolapsed 
 edge of the os uteri by the point of the finger, in the absence of pain, toward the sym- 
 physis pubis, and maintain it there, until a pain comes on. At this moment, the point 
 of the finger is to be placed against the edge of the uterus, which is to be pushed 
 upward between the head of the child and the pubes. Should we be able to carry 
 the prolapsed portion of the uterus above the advancing portion of the head, the 
 former will suddenly withdraw itself from the finger; the vertex will apply itself to 
 the arch of the pubes, and the labor terminate almost immediately. 
 
 "It sometimes, however, requires several trials of this kind before they may succeed; 
 but the attempt must not be abandoned because it fails a few times, for the principle 
 is a correct one, and should, be acted upon perseveringly, should perseverance be 
 necessary. We have everything to gain, if we succeed, and nothing to lose if it fail ; a 
 disappointment, by-the-by, which can not well happen, if the process for the restoration 
 of the prolapsed part be properly conducted. 
 
 "We are convinced that we have seen very many labors, shortened by hours, by 
 acting as just proposed for such cases. It would be extremely difficult to determine, a 
 priori, the duration of a labor of this kind, if left to itself; as the resistance which the 
 margin of the uterus offers to the head, will for a long time be more than equal to the 
 power of the uterine forces ; consequently, the labor becomes stationary, and will con- 
 tinue to be so, until the margin of the uterus is obliged to yield, by its losing a part of 
 its power from attenuation, or perhaps by tearing. 
 
 " Nobody estimates the general rule, 'to let a labor alone that is advancing well, 
 and is natural in its general relations,' more highly than we do; we look upon it as a 
 most wholesome restraint when acted upon ; and is every way calculated to diminish 
 ignorant and mischievous officiousness. But this rule, like every oth_er general rule, 
 has its exceptions; and we may be even accused of violating it unnecessarily, when 
 we make the cases under consideration exceptions; but we should feel but little con- 
 cern upon this head, if the charge be even preferred against us, as we are certain that 
 we are justified in making them from ample experience. 
 
 "Many, nay, perhaps everybody (for we have said that we did not know that this 
 case had been noticed), will condemn what we have said upon this subject, and con- 
 sider our directions as unnecessary, if not mischievous, because they have never had 
 recourse to them, but have permitted the uterus to perform this duty unaided; there- 
 fore they say nature is competent to the work, and when she is competent, she is not to 
 be interfered with. Were this rule rigidly acted up to, there would be an end to 
 improvement, not only in the obstetric art, but in the whole range of practical medi- 
 cine. Our experience, however, teaches us not to heed this sweeping, indiscriminate 
 rule; for it is not sound practice to permit nature to struggle through difficulties,
 
 372 KING'S ECLECTIC OUSTETKICS. 
 
 form is a very efficacious remedy in overcoming rigidity of the parts,. 
 and is used by many in preference to other means. 
 
 When the various means recommended to subdue the rigidity fail to 
 accomplish this result, and artificial delivery becomes necessary, it is 
 recommended to complete the labor with the forceps, provided the os 
 is fully dilated, and the fetal head has descended so low into the pelvic 
 cavity that an ear can be felt. But if the os is not fully dilated, and 
 the greater part of the fetal head remains above the superior strait, 
 and circumstances present, demanding prompt delivery in order to 
 save the mother's life, the perforator and crotchet must be employed, 
 for in such instances, the attempt to deliver by forceps would be rash 
 and unjustifiable; however, it will seldom happen, unless in cases of 
 diseased os, that the treatment above named will fail in overcoming 
 the rigidity. 
 
 The tendency to this cause of difficult labor, as well as of inefficient 
 uterine contractions, may generally be obviated by a proper course of 
 management through the gestating period, or at least during its latter 
 months, in all cases where the physician is aware of his selection as the 
 accoucheur. For a few months previous to the expected labor, he 
 should explain and impress upon his patient's mind, the necessity and 
 advantages to be derived from a proper preparatory course, especially, 
 if any circumstances exist, which might lead him to anticipate a diffi- 
 cult parturition. The course to be pursued at this time, and which has 
 proved generally successful, is, to keep the bowels in a normal condi- 
 tion by diet, if possible, otherwise, by mild laxatives; avoid fatigue, 
 overstimulus, and improper food, and administer once or twice daily, 
 a dose of the Parturient Balm, which exerts a healthy tonic influence 
 over the uterus, disposing it to act with proper energy at the time of 
 labor. 
 
 merely because it is supposed she can struggle through them; and to leave it for 
 some time a moot point, whether or not the case will eventuate in safety, when aid, as 
 certain, as safe, is always at command. Nor does this application of the finger ever 
 produce pain or other inconvenience, if properly and gently managed. 
 
 "Beside much delay is sometimes experienced from this dropping down of the 
 anterior portion of the uterus, by interrupting the pivot-like motion of the head, from 
 completing itself; especially when the head occupies pretty strictly the inferior strait. 
 In this case, the posterior fontanelle will remain for a long time stationary behind one 
 of the foramina ovalia; for its advancement toward the arch of the pubes, is prevented 
 by the prolapsed portion of the uterus interfering with the motion just mentioned, by 
 embracing too strictly the advancing part of the head. 
 
 " But the pivot-like motion of the head is almost always restored, the instant we 
 succeed in passing the depending portion of the uterus above the head of the child by 
 the point of the finger, as directed above."
 
 DIFFICULT LABOR FIRST STAGE. 373 
 
 4. The proper position of the uterus is when it occupies the middle 
 of the abdomen, with its longitudinal diameter in the direction of the 
 axis of the superior strait ; but in persons of a lax and flaccid habit 
 of body, and especially with those in whom the walls of the abdomen 
 have become relaxed, it frequently inclines anteriorly or laterally, 
 which inclination is termed OBLIQUITY OF THE UTERUS, and 
 which may, by producing rigidity, or other symptoms, retard labor ; 
 the positions of the presentations are frequently affected by these 
 obliquities, and the deviations of which, continue, in many instances, 
 even after the uterus has been restored to its normal situation. There 
 are three varieties of obliquity : an anterior obliquity, in which, from 
 excessive relaxation of the abdominal parietes, the fundus uteri falls 
 forward, throwing the os uteri upward and backward in an unusual 
 degree ; a right lateral obliquity, in which the fundus falls toward the 
 right side ; and a left lateral obliquity, in which it falls to the left 
 side. Among these the left lateral obliquity is more frequently met 
 with. In an anterior obliquity, the female will be very apt to imagine 
 herself larger than usual, or perhaps, that she will give birth to 
 twins. These obliquities may be ascertained by observing that the 
 fundus of the uterus falls to the right, or left, or anteriorly, and that 
 the os uteri, instead of its normal situation in the center of the pelvic 
 cavity, is directed laterally to the right, or left ; and in the anterior 
 obliquity it will be found upward and backward, elevated to an extent 
 corresponding, relatively, with the anterior inclination of the fundus. 
 These obliquities, when excessive, especially the anterior, have fre- 
 quently given rise to the. idea that the os uteri was imperforate ; and 
 if not readily recognized and overcome, they may occasion more or 
 less serious accidents to both mother and child. 
 
 TREATMENT. This difficulty can be removed, by placing the 
 patient upon the side opposed to the obliquity, or upon her back in 
 the anterior variety ; and when the replacement of the uterus is ac- 
 complished, by applying a bandage firmly around the body, the organ 
 may be kept in its normal position. In the early stage of labor, it 
 will be found advantageous, in these cases, to keep the patient upon her 
 back, having the shoulders somewhat depressed, and the hips slightly 
 elevated. Any attempt to remove these obliquities by pulling upon 
 the os uteri is highly improper. 
 
 Sometimes there is an Obliquity of the Os Uteri only, and this is 
 more apt to procrastinate the labor, than when the whole organ is 
 inclined. Upon an examination, the os uteri will be found facing the 
 sacrum, and oftentimes being difficult to reach. Should this condition 
 remain for any length of time, without change, the expulsive efforts
 
 374 KlXCi's KCLF.CTIC OHSTKTKK 'S. 
 
 of the uterus being necessarily directed against the anterior part of 
 the cervix, which occupies the open space in the pelvis, may, by 
 forcing the head downward, occasion a rupture at this point. 
 
 In a case of this kind the female should be kept in bed as much a> 
 possible, and as soon as it can be reached, the anterior lip of the os 
 should be hooked by a finger, brought carefully to the center of the 
 navity and sustained there until one or more subsequent contractions, 
 by pressing the head downward and into the opening, will thus pre- 
 vent the lip from resuming its previous abnormal position. 
 
 Labor is occasionally protracted in consequence of the Anterior Lip 
 of the Os Uteri being retained between the head and pubic symphysis. 
 either being caught thus during the dilatation, or occasioned by an 
 unequal dilatation of the anterior and posterior portions of the cervix. 
 This may delay the first stage of labor for several hours. It may be 
 overcome by the following operation, provided the head does not fill 
 the pelvis too tightly, and the lip of the os uteri is not cedematous 
 from the pressure, or inflamed, in which case, it is better to trust to 
 the natural efforts. The operation is, to gently push the anterior lip 
 over the crown of the head, during the absence of a pain, and retain 
 it there by firm and constant pressure, during one or two subsequent 
 pains, until it retracts and slips over the head. Not unfrequently, 
 this operation will prove unsuccessful, and the continued pressure of 
 the finger upon the lip and soft parts, will cause increased swelling and 
 inflammation; in the majority of cases of this kind, if the constriction 
 of the lip be relieved by pressing the fetal head more toward the pelvic 
 cavity, or toward the sacrum, and holding it thus during a few pains, 
 the lip will retract without any further aid. If the projecting anterior 
 lip be hypertrophied, these manipulations will prove of no utility. 
 
 Occasionally, at the commencement of labor, and especially in cases 
 where the fetal head is very small, or the pelvis uncommonly large, 
 the os uteri may descend with the head, as far as, or even through, the 
 pelvic outlet; this must be remedied by placing the patient upon her 
 back, with the shoulders depressed, and the hips elevated then by 
 gentle and steady pressure with the expanded fingers, return the pro- 
 lapsed organ to its proper location. 
 
 During the first stage of labor, the principal abnormal condition of 
 the parts through which the child has to pass, aside from actual disease 
 of these parts, is RIGIDITY OF THE VAGINA and soft parts in which it 
 may become necessary to employ vaginal injections, or to apply fomen- 
 tations to the perineum. A warm infusion of equal parts of Elm bark
 
 DIFFICULT LABOR FIRST STAGE. 375 
 
 and Lobelia may be used in injection; and the same articles may be 
 used as a cataplasm or fomentation of the parts. These, however, will 
 not always be required, as the means recommended for rigidity of the 
 os uteri \vill generally likewise overcome the rigidity to the soft 
 parts. When the vagina is dry, harsh, and hot, Gelsemium is the 
 indicated remedy; or warm Lard Oil, or Lard itself, warmed into 
 a state of fluidity, may be injected into it with much advantage; but 
 the parts should never be anointed by friction. 
 
 Among the causes referable to the child or its envelopes, certain 
 conditions of the membranes may be named. As a common rule, 
 when the os uteri becomes fully dilated, the membranes are ruptured 
 by the internal pressure upon them; but there will frequently be 
 found exceptions to this rule. These exceptions are owing to: 1. A 
 RIGIDITY OR TOUGHNESS OF THE MEMBEANES, and 
 which render the labor protracted, by retaining the liquor amnii, and 
 thus hindering the uterus from acting with energy, after the os has 
 become fully dilated. 
 
 TREATMENT. In cases of this kind, the membranes should be 
 ruptured artificially, after which the contractions will become stronger 
 and more regular. But a proper degree of caution is required before 
 attempting this operation, because, if prematurely effected, it may 
 terminate in more serious results than had no interference taken place. 
 In the first place, there should be good ground for attributing the 
 delay to this cause ; secondly, before attempting it, the os uteri should 
 be fully dilated and the soft parts in a yielding condition ; and thirdly, 
 with primiparse, it should always, if possible, be postponed until the 
 first stage of labor is wholly completed. Feeble and inefficient con- 
 tractions for several hours, with softness and dilatability of the parts, 
 and the labor having nearly or fully terminated its first stage, are 
 among the symptoms indicating an artificial rupture. It is sometimes 
 difficult to effect a rupture of the membranes, especially when the 
 pains are feeble, and the use of a probe or sharpened quill has been 
 recommended; but we must be careful in using any cutting or punctur- 
 ing instrument not to injure the soft parts of the mother, nor the 
 presenting parts of the child. I have always succeeded with the 
 finger nail, pressing it upon the membranes during the pain, and 
 making a sawing motion with it from before backward, or from side 
 to side, and continuing it until the liquor amnii escapes. 
 
 2. The wedge-like pressure of the bag of waters is an important 
 mechanical agent in the relaxation and dilatation of the cervix and 
 os; but when the MEMBRANES HAVE RUPTURED PREMA-
 
 376 KING'S ECLECTIC OBSTETRICS. 
 
 TURELY, either spontaneously or artificially, this bag is absent, the 
 fetal head then presses upon the os uteri, but is illy adapted to aid its 
 dilatation, and the result is a tedious and painful labor. The pre- 
 mature rupture may be owing to a weakness of the membranes, to 
 violence, or to a careless examination, and which last is perhaps a 
 more frequent occurrence than is generally imagined. An early rupt- 
 ure of the membranes is also an indication of a preternatural presenta- 
 tion, and whenever it occurs the character of the presentation should 
 be determined as soon as possible, that timely measures may be adopt- 
 ed, if required. When the membranes are prematurely ruptured, the 
 liquor amnii may be discharged in a very short time, or if the rent be 
 small, or the fetal head lies over its orifice, this fluid may slowly 
 dribble away, and add much to the discomfort of the patient. 
 
 TREATMENT. If the as uteri is dilatable, and the pains are 
 .active, nothing is required but a little patience, as the labor will 
 usually proceed with safety to both mother and child. If, however, 
 the os uteri be rigid and unyielding, this condition must be overcome 
 by the means already mentioned. If the liquor amnii passes off slowly, 
 the os being dilatable, and the pains feeble, the orifice in the mem- 
 branes should be enlarged, and the fetal head elevated, between the 
 pains, toward the sacrum, in order to admit of a free discharge of the 
 liquor, and which will be followed by active contractions. The dila- 
 tability of the os may be increased by Lobelia or Gelsemium admin- 
 istered internally, or by a rectal enema of the compound tincture of 
 Lobelia and Capsicum. 
 
 In closing this chapter on the causes which may protract the first 
 stage of labor, I desire to impress upon the mind of the student that 
 the mere fact of the tediousness of this stage does not justify any 
 attempts to hasten the labor. Delay in this stage seldom causes any 
 serious accident to either the mother or child, unless, from a want of 
 patience and prudence, it be unnecessarily or improperly interfered 
 with. True, the female may become worn out or exhausted, but this 
 is soon removed by an energetic uterine action in the second stage, 
 and in which stage only is the shock given to the nervous .system 
 which may produce unpleasant or serious results. He should, there- 
 fore, be very cautious and particular in ascertaining that artificial 
 assistance is positively required, before attempting to render it; 
 always bearing in mind the wholesome and oft-repeated saying of 
 Blundell, that " a meddlesome midwifery is bad" No interference of 
 any kind must be undertaken, unless it be desired to produce certain 
 results or conditions favorable to a safe labor, and which results or. 
 conditions we know are absolutely indicated, or required.
 
 DIFFICULT LABOR SECOND STAGE. 377 
 
 CHAPTER XXX. 
 
 DIFFICULT LABOR SECOND STAGE.. 
 
 THE SECOND STAGE OF LABOR may be protracted, even 
 when the first has progressed favorably, and may be owing to causes 
 not necessarily nor immediately connected with the first stage, or which, 
 although present in that stage, can not be determined until the com- 
 plete dilatation of the os uteri, and which causes, I shall consequently 
 consider under this head. 
 
 As before remarked, although labor may be delayed for a long time 
 during its first stage, without any hazard to the mother or child, yet 
 such is not the case in the second stage, for any procrastination beyond 
 a certain period is fraught with serious consequences to both, hence, 
 the accoucheur should allow no more delay in the labor than is abso- 
 lutely necessary, but should promptly and skilfully employ all measures 
 for facilitating this stage of the labor, that are compatible with the 
 health and safety of the woman ; to allow her to suffer unnecessarily 
 from a tedious, lingering labor, is to say the least of it, a very cen- 
 surable course. The development of bad symptoms may not take 
 place for some hours after the commencement of the second stage, or 
 they may occur within six or eight hours ; and, as a general rule, if 
 this stage of labor has continued for twelve or fifteen hours, symptoms of 
 constitutional suffering will manifest themselves. The pains, after hav- 
 ing continued regular and forcible for a time, gradually become more 
 and more feeble, occurring at less regular intervals, and causing little 
 or no advance of the head. They may return only at long intervals. 
 or the intervals may be alternately short and long, or they may be 
 regular, the pains gradually diminishing in force, until they are scarcely 
 felt. Or, the pains may commence each time of their occurrence, with 
 energy, but subside, almost suddenly, before they have reached their 
 maximum development ; or they may cease entirely. 
 
 This impaired condition of uterine action, is very frequently accom- 
 panied with several unpleasant symptoms, varying in degree : as severe 
 shiverings, frequently resembling light convulsive attacks; distressing 
 and frequent vomitings, of green, or bilious matter ; restlessness and 
 uneasiness of the patient ; the skin may be dry or moist, but in either 
 case it is hot; increase of pulse, ranging from 100 to 140; the tongue 
 dry and furred, with sordes about the teeth ; the mind despondent, 
 disturbed, and fearful ; the vagina hot, and with the os uteri, tender
 
 378 KING'S KCLKCTK OHSTKTRIO. 
 
 to the touch ; the mucous discharge from the vagina becomes brown or 
 yellowish, and occasionally fetid or acrid; and urination is rendered 
 difficult, or altogether prevented by the pressure of the fetal head. 
 These symptoms usually occur in the order just given, and in all cases 
 of prolonged second stage, some of them will be present. If relief 
 be not afforded, they increase in severity ; the vomiting occurs more 
 frequently, with ejection of dark-colored matters ; restlessness increases, 
 with obstinate hiccough ; the abdomen becomes tender ; the skin cov- 
 ered with a cold, clammy sweat; the pulse rapid and feeble; the 
 tongue dry and brown ; stupor and low-muttering delirium ensues, and 
 death terminates the scene. Not only is the life of the mother endan- 
 gered in such cases, but also that of the child, by the delay of proper 
 interference. 
 
 The causes of difficult labor in its second stage may be referred to : 1, 
 the uterus ; 2, to the parts or passages through which the child passes ; 
 3, to abnormal conditions of neighboring organs; 4, to the child. 
 
 1. Among those attributable to the conditions of the uterus, 
 one of the most common causes of delay in the second stage, is a 
 CESSATION, OR INEFFICIENCY OF THE UTERINE CON- 
 TRACTIONS. As may have been observed in the previous chapter, 
 this is also a cause of prolonged first stage, but its effects are by no 
 means so grave in that stage. It may be owing to disease, sudden and 
 violent emotions of the mind, tumors, constitutional debility, etc. 
 Females of an irritable, nervous temperament, may have labor pro- 
 tracted, during its second stage, from this cause ; and those of debili- 
 tated constitution, frequently have a failure of uterine action in this 
 stage, and especially, when from prolongation of the first stage, great 
 exhaustion occurs. 
 
 TREATMENT. When attending a case in which the action of 
 the uterus becomes lessened, the pains short and inefficient, or at long 
 intervals, with no advance of the fetal head ; increased and irregular 
 pulse, restlessness, anxiety, and wakefuLness being also present, it will 
 become necessary for the practitioner to institute a very minute and 
 careful examination not only of the genital organs, but likewise of the 
 condition of the tongue, pulse, skin, head, and abdomen. By the 
 examination of the genital organs he will ascertain, if possible, the 
 cause of the delay, and determine by it the best method of affording 
 assistance ; and by the condition of these parts, in connection with 
 the general condition of the system, he will be guided as to the proper 
 time for interference.
 
 DIFFICULT LABOR SECOND STAGE. 379 
 
 The cause of the delay can, of course, be learned only from the 
 examination. The best method of affording assistance, is, invariably, 
 that which readily and most easily terminates the labor, and with the 
 least danger to the mother and child, and which must vary according to 
 the causes and conditions present. Among these means may be named, 
 Ergot, Sulphate of Quinia, Macrotys, etc., the Vectis, the Forceps, and 
 the Crotchet ; each of which will be considered hereafter. The proper 
 time for interference, will depend entirely upon the symptoms; an in- 
 crease of the pulse, febrile symptoms, soreness and tension of the 
 abdomen ; exhaustion ; watchfulness, and anxiety ; a dry, hot, puffy, 
 or swollen condition of the soft parts, caused by the long-continued 
 pressure and interrupted circulation, and accompanied with a degree 
 of tenderness which renders a vaginal examination painful ; a retention 
 of urine, from pressure of the fetal head on the urethra and neck of 
 the bladder, requiring the use of the catheter, which can be introduced 
 only with difficulty ; and a change in the character of the vaginal 
 discharges, they becoming offensive are all symptoms requiring im- 
 mediate delivery. Indeed, as a general rule, it is good practice to 
 interfere, even before the local symptoms have appeared. 
 
 If, in cases of protracted labor from rigidity, the* constitutional dis- 
 turbance is excessive, with exhaustion of the vital forces, and determi- 
 nation of blood to particular organs, especially the brain, the prognosis 
 is very unfavorable. Fever, in either stage of labor, manifested by 
 chills, increased pulse, furred tongue, and flushed countenance, indi- 
 cates the want of artificial aid; and the case assumes a still more 
 serious aspect, if the pains gradually lessen in frequency and power, 
 the fetal head ceasing to advance, and the female becoming exhausted. 
 Sometimes, these symptoms come on very suddenly, requiring an 
 immediate interference ; the pains cease, the mind becomes confused 
 and wandering, a clammy perspiration covers the face and body, rest- 
 lessness with constant hiccough occurs, and the patient becomes so 
 completely changed in features and in tone of voice, as to be hardly 
 recognized by her friends. These symptoms may occur during the 
 first stage, but they will be more frequently met with in the second 
 stage, where the head has passed through the os uteri into the pelvic 
 cavity, and has been pressing for a considerable time upon the parts at 
 the inferior strait. 
 
 It is frequently the case that the contractile power of the uterus is 
 BO readily exhausted, that after having effected the first stage of labor, 
 the pains cease, or become very feeble in the second. In these 
 instances the pelvic diameters will be sufficiently ample, the soft parts
 
 380 KING'S ECLECTIC OBSTETRICS. 
 
 in a yielding condition, and the head, in whatever portion of the 
 cavity it may be, will be found in a normal position. In such cases, 
 and under such circumstances, the labor may be readily terminated 
 by applying the forceps, but if it seems that the case needs no instru- 
 mental interference, but will probably result within a short time in 
 natural delivery, Macrotys should be administered, in the usual 
 small dose, every fifteen or thirty minutes; and if this fails, and 
 symptoms of exhaustion manifest themselves, it will then be proper to 
 administer Ergot, or apply the forceps and deliver at once; or if 
 having administered Ergot and it fails, within a reasonable time, to 
 stimulate the uterus to action, resort to the forceps without further 
 delay. And, indeed, this course may be pursued in all cases of ineffi- 
 cient uterine contraction, owing to mere debility or exhaustion of the 
 organ. Notwithstanding that Ergot has been so frequently employed 
 to facilitate labor, with no apparent immediate pernicious results, yet 
 the practitioner should ever bear in mind that it is a dangerous rem- 
 edy at best, requiring much judgment and discrimination in its em- 
 ployment. The dangers attending its use to the mother are, rupture 
 of the uterus, rupture of the perineum, inversion of the uterus, etc., 
 to the child death, -and more certainly if the cord is around its neck. 
 And, although it has been employed with impunity in many cases, 
 where the only indication for its use was the impatience of the practi- 
 tioner a regard to his ow r n comfort and feelings, in preference to the 
 safety of his patient still, it is an agent whose action is always to be 
 dreaded; and the success attending its administration in the instances 
 just referred to have been the results of good luck, and not of any 
 superior skill or wisdom of its prescribers. 
 
 Ergot has, undoubtedly, a specific action upon the uterus, which 
 usually commences within twenty or thirty minutes after its exhibi- 
 tion ; and the character of the contractions produced by it are mate- 
 rially different from those of natural labor. They are stronger and 
 of longer duration, resembling a number of violent or spasmodic 
 uterine contractions continued into one another without intervals. 
 During a contraction, the circulation of the maternal blood in the 
 uterus and placenta must be interrupted; and when this interruption 
 occurs for a long continued time, as when effected by ergotic influence, 
 preventing the necessary changes in the fetal blood, we should anti^ 
 cipate unfavorable results to the child, and not be unexpectedly 
 astonished upon finding it born in an asphyxiated condition. 
 
 As it is not uncommon to meet with individuals whose constitutions 
 are insusceptible to the specific influences of one or more drills, go
 
 DIFFICULT L \IJOR SKCOND STAGE. 381 
 
 must we expect to meet with females upon whom Ergot exerts but 
 little or none of its peculiar action; and this want of susceptibility 
 may account for many of the failures which have been recorded by 
 authors. Another cause of failure has been, undoubtedly, the want 
 of a recent article; for an inferior preparation of Ergot, often 
 found on the market, does not possess the property of exciting 
 uterine action, and, no matter how carefully it may be admin- 
 istered, it being a worthless article, failure will follow. One of the 
 best and most reliable preparations is Lloyd's Ergot, the usual dose 
 of which is from thirty to sixty drops. This preparation has the ad- 
 vantage over others, in that it may be used hypodermically, being 
 free from Alcohol. In extreme cases it should be used in this way, 
 by means of the ordinary hypodermic syringe, the dose being from 
 five to twenty drops, repeated if necessary, governed by the effect 
 produced. As constipation, or a disordered condition of the digestive 
 organs, is frequently a cause of deficient uterine action, the practi- 
 tioner should never administer Ergot without having first unloaded 
 the bowels by enema, or by the administration of a mild laxative. 
 
 In the administration of Ergot to females during parturition, 'there 
 are certain rules to be guided by, which are based upon the recorded 
 experience and observation of many medical men, and which should 
 .be thoroughly impressed upon the mind of every individual who at- 
 tempts the conduct of a labor; they are, briefly, as follows: 
 
 Ergot should never be given for the relief or comfort of the practi- 
 tioner; where any deformity of the pelvis is suspected; where the 
 head is suspected to be disproportionately large; where the presenta- 
 tion is beyond reach, or can not be determined; wlrere there exists 
 an obstruction in the soft parts, as rigidity, etc.; where there is a 
 malpresentation ; where there exists increased excitement of the 
 nervous or vascular system ; . where there is a tendency to cerebral 
 symptoms ; afld w r here the os uteri is not fully dilated. It should never 
 be given while the woman's strength is greatly exhausted, lest the ex- 
 haustion produced by it be more excessive than her system can bear. 
 
 Ergot should be avoided, as much as possible, in first labors, lest 
 rupture of the perineum ensue. 
 
 Ergot may be given, ix CAREFUL HANDS, in multiparse, where the 
 sole cause of delay is deficient uterine contraction; where the head 
 presents and is low in the pelvis, the os uteri soft and fully dilated, 
 the soft parts yielding and dilatable, and the membranes have rup- 
 tured ; and the pelvis must be ample, with normal proportions be- 
 tween it and the fetal head. The patient must also be somewhat
 
 382 KING'S ECLECTIC OBSTETRICS. 
 
 exhausted, but without any symptoms of fever or inflammation; I 
 must confess, however, that I prefer not to wait for any considerable 
 degree of exhaustion before administering this article. 
 
 Some authors recommend the administration of twenty or thirty 
 grains of Ergot in powder, or infusion, for a single dose; but in my 
 own practice, in all cases where I have considered its use indicated 
 and advisable, I have succeeded in arousing the contractions of the 
 uterus, in fifteen or thirty minutes, by the use of one of the fluid prep- 
 arations, either a reliable fluid extract or the specific tincture; my 
 preference, however, is the article previously mentioned, and known 
 as Lloyd's Ergot, in half to one drachm doses. 
 
 I would remark here, however, that among those practitioners who 
 are acquainted with the parturient virtues of Macrotys, the employ- 
 ment of Ergot for the purpose of inducing (spasmodic) contractions 
 of the uterus, is not so often required. . It might be well, in the cases 
 under consideration, to give this agent a fair trial before resorting to 
 the ergotic preparations; more especially as it may be exhibited with 
 greater safety, and at an earlier period of labor ; beside, the contrac- 
 tions induced bear a greater resemblance to those caused solely by the 
 natural powers. 
 
 It will sometimes be found that, although the contractions of the 
 uterus may be aroused by the administration of Ergot, they are not 
 of an expulsive character; in such cases the uterus contracts firmly 
 upon the part of the child within it, preventing its advance, and caus- 
 ing its death by the pressure maintained around it, unless timely 
 assistance be afforded by the employment of the forceps. Hence, it is 
 recommended by our best accoucheurs to have a forceps at hand when 
 this drug is exhibited. It must be recollected, however, that so long 
 as the pains continue, with an advance of the head, however slowly, the 
 pulse continuing good, no trouble in urinating, and no pain of the 
 abdomen on pressure, ARTIFICIAL INTERFERENCE is NOT REQUIRED; 
 but in debilitated patients, in whom symptoms of exhaustion and 
 fever appear, interference will be demanded, even though the head be 
 very slowly advancing. And by delaying the necessary aid, the 
 patient may die after delivery, from the shock of the labor, or from 
 hemorrhage and retained placenta, or, should life be spared, sloughing 
 of the uterus, vagina, bladder, and rectum may take place, rendering 
 her subsequent existence painful and burdensome in the extreme. 
 
 I have known Sulphate of Quiuia, in a dose of three to five grains, 
 to increase the expulsive action of the uterus in several instances, in
 
 DIFFICULT LABOR SECOND STAGE. 383 
 
 which this action was inefficient ; and yet a large numoer of practi- 
 tioners have denied that it possesses such influence. In the cases 
 under consideration, where the diminution of uterine action has no 
 other cause than general or local debility, Crede's operation has been 
 successfully employed. The woman being placed on her back, the 
 accoucheur applies the palmar surface of his open hands upon the ab- 
 dominal walls, immediately over the fundus and sides of the uterus, 
 and, as soon as a pain commences, he makes firm pressure downward 
 and in the direction of the axis of the superior strait, ceasing his 
 efforts with the cessation of the pain and repeating them as soon as it 
 recommences, and so on, until the head is born. This operation should 
 not be practiced with violence or rudeness, and can only prove ser- 
 viceable in cases of normal vertex presentation, and where the mater- 
 nal pelvic diameters are sufficiently large. It increases the strength 
 as well as the duration of the pains. 
 
 2. PRECIPITATE LABOR may be due to violent or excessive 
 action of the uterus, to great relaxation of the maternal tissues, to an 
 abnormally large pelvis, to premature rupture of the membranes, or to 
 the child being quite small. AVomen who are subject to dysmenorrhea, 
 or who are well developed muscularly but at the same time excessively 
 nervous, are liable to powerful uterine action ; sometimes it appears 
 to be hereditary. Occasionally ovarian excitement, mental excitement 
 of any kind, and even hysteria, will give rise to an increase of the 
 labor paiu in the second stage. The dangers of such increased and 
 hurried action of the uterus are, injury to the child, rupture of the 
 cord, sudden detachment of the placenta followed by dangerous hem- 
 orrhage, inversion of the uterus, rupture of the uterus, vagina, and 
 perineum, and syncope, etc.; and from the continuous and forcible 
 straining of the w T oman, not unfrequently, subcutaneous emphysema 
 of the neck and head, as well as more or less cerebral disturbance. If 
 the practitioner is present at the time of this violent action, he must 
 promptly employ means to palliate according to the cause. The woman 
 must be kept constantly in the recumbent position, 'and, to lessen ex- 
 cessive uterine action, opiates, Gelsemium, compound tincture of 
 Lobelia and Capsicum, Chloral-hydrate, Bromide of Potassium, or 
 Chloroform, etc., may be used in full doses. All stimulus must be 
 avoided ; unnecessary examinations must be dispensed with ; the 
 bowels should be opened by laxative enema, followed subsequently by 
 sedative; and the woman should not be allowed to bear down, but
 
 384 KING'S ECLECTIC OBSTETRICS. 
 
 rather encouraged to cry out loudly. When the pelvis is large, or the 
 head of the child small, the methods named under Abnormally Large 
 Pelvis may be pursued. 
 
 3. Very rarely, the labor is interfered with by an IMPERFO- 
 RATE OS UTERI, which may be suspected when .the pains are reg- 
 ular, increasing gradually in force, pushing the lower segment of the 
 uterus into the cavity of the pelvis, rendering it very thin, without any 
 opening of the os uteri being discoverable. 
 
 There may be an Agglutination of the Os Uteri, the result of some 
 previous inflammation of the part, and which may be detected by 
 finding an indentation, or depressed fold at the center of the os uteri, 
 without any opening; the pains will be regular, increasing gradually 
 in force, pushing the lower segment of the uterus into the cavity of 
 the pelvis, rendering it extremely thin ; or the Os Uteri may be oblit- 
 erated. These conditions are, however, rarely met with. 
 
 TREATMENT. It may be that the os uteri is merely rigid and 
 not dilatable, and the means recommended for this difficulty may be 
 pursued, whenever the os can be discovered. Sometimes the os uteri 
 is closed by agglutination, resisting the most powerful uterine con- 
 tractions; in such instances, Dr. Rigby remarks, "A moderate degree 
 of pressure against it while in a state of strong distension, either by 
 the tip of the finger or a female catheter, is quite sufficient to over- 
 come it; little or no pain is produced, and the appearance of a slight 
 discharge of blood will show that the stricture has given away." 
 
 If no opening, however, can be found, it will become necessary to 
 divide the presenting wall of the uterus, and form an artificial os 
 uteri, through which the child may pass. A crucial incision is to be 
 made upon the anterior-inferior part of the wall, as near the situation 
 of the os uteri as possible, by means of a sharp-pointed bistoury; this 
 knife is carefully passed along the left forefinger as a guide, and must 
 not be pushed too deeply into the uterine wall, lest the presenting 
 part of the fetus be injured. In performing the antero-posterior in- 
 cision, care must be taken not to extend it so far, either forward or 
 backward, as to injure the bladder or rectum. After the operation, 
 the delivery may be left to the natural efforts. 
 
 It must be recollected, however, that it is frequently the case that 
 from uterine anterior obliquity the os uteri will be higher up, perhaps 
 entirely beyond the reach of the finger, and looking toward the prom- 
 ontory of the sacrum, and in which position it may remain for several
 
 DIFFICULT LABOR SECOND STAGE. 385 
 
 hours, retarding the progress of the labor, and a careful search should 
 always be instituted previous to attempting any operation. If it be 
 found thus elevated and inclined, the labor may be expedited by 
 drawing it downward and forward with one or two fingers, in the 
 direction of the axis of the superior strait, and holding it there until 
 the engagement of the head will prevent a return to its former in- 
 clination. 
 
 Sometimes the orifice of the os uteri will be found so minute or 
 contracted, from disease or other causes, that the head can not pass 
 through it, even when dilated ; for which the same course must be 
 pursued as named for cancer of the os uteri, being careful in all opera- 
 tions not to carry the incisions into the rectum or bladder. 
 
 I would remark here, that some of these latter conditions, existing 
 as causes of difficult labor, may be found present in the first stage of 
 labor, when they should be as promptly attended to as the circum- 
 stances of the case will permit ; preparing the parts, if possible, so 
 that no delay may take place during the second stage. 
 
 3. FIBROUS TUMORS of the CERVIX UTERI, are occa- 
 sionally met with, instances of which are recorded, where the labors 
 were finished without more than ordinary assistance, the mothers 
 recovering, but the children being still-born. In such cases it is bet- 
 ter to delay all operations, if there is the least possibility of the deliv- 
 ery being effected by the natural powers; but when this is impossible, 
 from the excessive size of the tumor, from the want of proper uterine 
 contractions, or from exhaustion of the mother, the child will have to 
 be extracted by means of embryotomy, or, if this be impracticable, by 
 the Cesarean operation. 
 
 4. A POLYPUS may arise from the body or neck of the uterus, 
 or it may be adherent to the walls of the vagina, and in either case 
 present an obstacle to the delivery. It may be known by its firm, 
 fleshy feel, its movability, its pear-shape, and its long, narrow neck ; 
 during labor it has sometimes been mistaken for the child's he;>d. 
 
 TREATMENT. If the tumor be detected at an early period of 
 labor, it m'ight be prevented from descending, by pressing it back 
 during the absence of a pain, and holding it thus until the head has 
 passed beyond it; but this is not practicable in all instances, and 
 especially when the tumor is very large. In every case of this kind 
 it will be proper to trust, for a time, to the resources of nature ; but 
 25
 
 386 KING'S ECLECTIC OBSTETRICS. 
 
 when the parts become hot, dry, and swollen, and the uterine efforts 
 inefficient, interference is required, for a too protracted delay is 
 hazardous to both mother and child. The only operation necessary 
 is the removal of the tumor by excision, and not. perforation of the 
 child's skull ; for the danger from hemorrhage after the operation is 
 not so great as to justify the destruction of the child. "The polypus 
 should be drawn down as much as "possible by a forceps proper for the 
 purpose, a temporary ligature applied, and the stem cut through." 
 " It is not likely that the ovum could be brought to maturity, if a 
 large polypus occupied the cavity of the uterus; it is therefore fair to 
 assume, that when a polypus is found to impede parturition, it must 
 be attached to the mouth of the uterus, and therefore it can be the 
 more easily traced to its origin, so that you have every facility to 
 assist your diagnosis." (Murphy.) If the presence of a polypus in 
 the pelvic canal be discovered during the latter period of utero-gesta- 
 tiou, and its size be such as to possibly render labor protracted and 
 difficult, it should at once be ligated and excised, or it may be 
 removed by the ecraseur, when this can be done. 
 
 5. Other tumors may be present as impediments to the progress 
 of labor, as FUNGOUS, or CAULIFLOWER TUMORS, which, 
 from their spongy character and tendency to hemorrhage, may be mis- 
 taken for a placenta prsevia ; these may spring from, either lip of the 
 cervix, and when small may allow the birth of the child without any 
 artificial aid, but when large they may have to be incised, or entirely 
 removed by excision; iu either'case, there will be but a slight chance 
 for the mother's recovery. Embryotomy and gastrotomy have both 
 been performed in these cases, but generally with fatal results. 
 
 Among the causes due to the condition of the passages through 
 which the child passes, are: 1. RIGIDITY OF THE SOFT 
 PARTS, especially of the perineum. In such cases a resort to Ergot, 
 or the forceps, while the rigidity remains, is highly censurable. Oc- 
 casionally, during the advance of the fetal head, the os uteri, instead 
 of yielding, grasps the head during each pain, and prevents its further 
 progress; this is apt to alarm the practitioner, who, having ascer- 
 tained that the position of the head is correct, finds it to remain sta- 
 tionary, notwithstanding pain after pain continues with much force and 
 severity. A careful examination, as to the presentation and position 
 of the head, and its relative proportions with the pelvic diameters,
 
 DIFFICULT LABOR SECOND STAGE. 387 
 
 in >y determine the cause of the delay. -The same cause frequently 
 prevents the head from rotating. 
 
 TREATMENT. Patience is required in these cases, in conjunction 
 with the means named for overcoming rigidity in the previous chap- 
 ter. In the instance of rigid os delaying the advance of the fetal 
 head, it will always be proper to correct any abnormal position of the 
 uterus which may be present, so that its longitudinal axis may corres- 
 pond with the axis of the superior strait. 
 
 The following abstract is taken from Braithwaite' s Retrospect : 
 "Dr. Washington has recently discovered that dry-cupping, applied 
 to the lowest part of the sacrum, produces dilatation of the os uteri ; 
 and, applied higher up, contraction of the uterus. In a case, where 
 the pains had endured fourteen hours without producing any per- 
 ceptible effect, in consequence of rigidity of the os uteri, Dr. Wash- 
 ington applied a dry cup as low down on the sacrum as possible, so 
 as to cover the origin of the nerves to the os uteri. Complete relaxa- 
 tion ensued; at the next pain, the head descended to the outlet; and 
 .at the second pain the patient was safely delivered ; and that in less 
 than ten minutes from the application of the cups. In tedious labor, 
 the cup should be applied first to the lowest point of the sacrum, and 
 if, in the course of ten or fifteen minutes, the patient is not delivered, 
 another should be applied higher up, so as to cause the uterus to con- 
 tract. The lower one should always be on when the upper one is applied, 
 so as to insure relaxation of the os uteri when the pains come on. 
 
 ' "In retained placenta, the cups are to be applied higher up, so as to 
 cause the uterus to contract at once, the relaxation of the os uteri 
 being always sufficient after the fetus has passed. When Ergot is 
 administered, the woman is delivered by main force, without any 
 relaxation except that produced by the most fearful pains. By dry- 
 cupping, two or three pains are sufficient, and the amount of suffering 
 is not more than ordinary." 
 
 2. A CICATEIX IN THE VAGINA, will sometimes be met 
 with, which will present 'an impediment to the delivery; it is usually 
 the result of sloughing effected in a previous tedious labor, in which, 
 the healing of the ulcer which remains after the separation of the, 
 slough, occasions a diminution of the diameters of the vaginal canal. 
 An examination will detect, at some portion of the vaginal wall, a 
 .firm, unyielding band, which may occupy from three to six lines
 
 388 KING'S ECLECTIC OBSTETRICS. 
 
 longitudinally, or which may present merely a very thin edge, the 
 thickness of a water. The difficulty will, of course, be proportioned 
 to the firmness and extent of the cicatrix, and is always a serious ob- 
 stacle to labor. 
 
 TREATMENT. In thesv cases we should not interfere prema- 
 turely, but always wait and learn Avhat the natural efforts can do; 
 strong and energetic contractions, with the pressure of the fetal head, 
 may overcome the difficulty. But where assistance is required, relax- 
 ation, effected by Lobelia or Gelsemium, administered by mouth, and 
 by rectal enema of compound tincture of. Lobelia and Capsicum will 
 usually produce the desired dilatability, and the head will advance 
 without any further delay. Where the cicatrix is of great extent, and 
 very firm and unyielding, the inhalation of Chloroform will in some 
 cases, relax the parts after the ordinary internal medication has failed; 
 anasthesia should be carried to the extent of producing complete relax- 
 ation. Occasionally it happens that the cicatricial bands are so firm, 
 that to induce dilatation more radical measures must be resorted to. 
 It is advised in such cases, by excellent authority, to slightly incise 
 the edges of the constricted part in three or four places, being careful 
 to avoid the neck of the bladder, the rectum, and the two uterine ar- 
 teries, which pass up from below on each side of the vagina; and for 
 this purpose the incisions should be made one behind each groin, and 
 one toward each sacro-iliac symphysis. The least snip is sufficient, as 
 the advance of the head will probably widen it. After the delivery, 
 a sponge or bougie, well oiled, should be introduced into the canal 
 and changed two or three times a day, so that as the part heals, the 
 diameters of the vagina do not again become lessened. The artificial 
 increase of the vaginal passage by incisions, should be attempted with 
 great care, and under the advice of counsel, for, however slight the 
 operation may be, the advance of the head may cause the cut to widen 
 and produce a much more extensive laceration than if the case had 
 been left to the natural powers. Indeed, I am somewhat inclined to 
 believe that the operation will very rarely be found necessary, where 
 the previously-named treatment has been faithfully pursued. Some- 
 times considerable hemorrhage follows, and cases have occasionally 
 terminated fatally. If the contractions of the uterus become inefficient, 
 or unfavorable symptoms present themselves, the labor may demand 
 a prompt termination by instruments, the use of which, in such cases, 
 even with the greatest care, is apt to produce more or less extensive 
 lacerations, and which are not without danger; and a knowledge of 
 this fact may lead to the practice of patience and caution.
 
 DIFFICULT LABOR FROM PELVIC DEFORMITY. 389 
 
 Where the practitioner is aware of this difficulty at an early period 
 during gestation, or has reasons to suspect it, it is proper for him to 
 explain the matter to his patient, and request an examination, when 
 if the constriction be found very great, he may induce premature labor, 
 and thereby save the mother the hazards that she would run at full 
 period ; and the same course may be pursued with females known to 
 be laboring under Cancer of the Os Uteri. In. this latter condition of 
 the cervix, at ,full term, when the labor is delayed thereby, it may 
 become necessary to divide the diseased part sufficiently to admit the 
 passage of the child. But, as this operation is only to be 'attempted 
 for the child's safety, we must be certain that it is alive before per- 
 forming it ; the death of the mother is to be expected in such cases, 
 no matter what course is pursued. Cauliflower Excrescence may be 
 similarly managed. 
 
 3. IMPERFORATE or UNRUPTURED HYMEN, may pre- 
 vent the passage of the head. Impregnation may be effected without 
 lacerating the hymen, which will be found perfect at the period of 
 labor. It usually yields to the pressure of the head, but should it 
 resist for too long a time, a slight incision may be made into it by the 
 scalpel, taking care to prevent the laceration from extending into the 
 perineum, as the head passes through the external orifice, by giving 
 careful support to the perineum. 
 
 4._Where, from a continued DELAY OF THE CHILD'S HEAD 
 
 in the Pelvic Cavity, the circulation of the parts becomes interrupted, 
 the soft parts are apt to swell, thereby offering still greater opposition 
 to the advance of the head, and which may terminate in some structural 
 lesion of the parts, if prompt -and energetic measures be not adopted. 
 Dr. Campbell observes, " Unless a practitioner has had the manage- 
 ment of the patient from the commencement of labor, he is apt to view 
 this variety of diminished capacity, as arising from original defect in 
 the development of the bones themselves." 
 
 TREATMENT. This condition may be overcome, to a great 
 extent, by emollient vaginal injections, or injections of warm Lard or 
 Oil, and if necessary, relaxation may be produced by the adminis- 
 tration of Gelsemium or Lobelia. Should the pains be feeble, labor 
 may be facilitated by an injection into the rectum of compound 
 tincture of Lobelia and Capsicum, slightly diluted with water; or 
 Macrotys, Ergot, etc., may be exhibited according to the directions
 
 390 KING'S ECLECTIC OBSTETRICS. 
 
 heretofore given, when treating of inefficient action of the uterus. 
 The forceps have been advised*, but I should, in these instances, fear 
 some injury to the parts from their employment. I have frequently 
 given the Gelsemium to cause relaxation, and when produced, have 
 followed it with Ergot, with the happiest results, in cases requiring an 
 expeditious delivery, where the pains were feeble, with a degree of 
 rigidity or tumefaction of the soft parts. 
 
 5. (EDEMA OF THE LABIA MAJORA, is sometimes so great 
 at the time of labor, as nearly to obliterate the vaginal entrance, 
 rendering the delivery difficult and very painful ; and the pressure of 
 the fetal head in its passage over the tumefied parts, may cause an 
 extensive rupture, or produce gangrene. The same treatment may be 
 pursued as in the preceding instance, but, if the tumefaction be very 
 excessive, or the labor considerably advanced, it is recommended to 
 puncture the engorged parts with the lancet, in different places, the 
 number of punctures depending on the extent and degree of oedema. 
 But it must be remembered that the parts after having been punctured 
 are liable to inflammation and sloughing. 
 
 CHAPTER XXXI. 
 
 ON DIFFICULT LABOR, FROM TUMORS, PELVIC DEFORMITIES, ETC. 
 
 i 
 
 6. THE capacity of the pelvis is occasionally diminished during 
 labor, by the presence of Tumors in its Cavity. These tumors may 
 vary in their size, consistency, and pathological characters ; 'they may- 
 be osseous, fibrous, adipose, steatomatous, sarcomatous or scirrhus, and 
 the difficulty occasioned by them, will depend upon their size and 
 degree of solidity. The history and surgical management of these 
 tumors, together with other details, are not within the province of this 
 work, in which I will merely refer to the diagnostic signs, and the 
 indications for treatment when they interfere with the progress of labor. 
 
 A hard, bony tumor of extremely rare occurrence, termed EX- 
 OSTOSIS, has been met with. It takes its origin from some portion 
 of the osseous parietes, more commonly from the sacro-iliac symphy- 
 sis, and sometimes from the first bone of the sacrum, from the last
 
 DIFFICULT LABOR FROM PELVIC DEFORMITY. 391 
 
 lumbar vertebra, from the internal surface of one of the ischia, or 
 from some portion of the posterior face of the pubic bones: and may 
 be detected by its hard, knotty, and irregular feel, its insensibility to 
 pressure, its immobility, and its projection into the interior of the 
 vaginal canal, but always covered by the wall of this canal. 
 
 TREATMENT. If the presence of the exostosis be known at an 
 early period of gestation, it would be proper, according to circum- 
 stances, to effect an abortion, or induce premature delivery. At full 
 term, it may be possible, that when the tumor is very small, the labor 
 will progress without assistance, but when it is large, so as to mate- 
 rially interfere with the capacity of the pelvic diameters, the case 
 assumes a more serious aspect. As we can not remove this obstruction 
 by an operation, we must be governed by the nature of the case. If 
 there is a probability that the head may pass, it will be prudent to 
 wait until symptoms, demanding artificial delivery, present themselves, 
 when the labor may be terminated by the forceps, or perhaps the per- 
 forator. When the diminution of the pelvic cavity, from this cause, 
 is so great that the fetus can not pass through the vagina, the only 
 chance for the mother will be in the performance of the Cesarean 
 section, or the Porro operation, a description of which will be found 
 in another part of this work. Fortunately, these instances are rare; 
 I have never met with one. 
 
 7. Other osseous tumors may occasionally render a labor difficult, 
 as OSTEO-SARCOMA of the pelvis; this is very difficult to distin- 
 guish from exostosis ; it presents greater inequalities, has a semi- 
 cartilaginous softness, a degree of depressibility, and at some parts of 
 its surface crepitation may be observed. From the depressibility of 
 this tumor, the pressure of the head may flatten it, and effect a suffi- 
 cient amplification of the parts to admit of the passage of the fetus ; 
 and should the natural efforts fail, or symptoms appear requiring 
 interference, the labor may be terminated, according to circumstances, 
 as in the preceding difficulty. 
 
 Sometimes the pelvic cavity may be diminished by bony protuber- 
 ances, depending upon irregular consolidation of fractures in the part, 
 or perforation of a carious acetabulum by the head of the femur, etc. 
 In these cases, whatever may be the situation of the protuberance, the 
 indications for treatment will be the same as in pelvic deformities. 
 
 8. ENCYSTED TUMORS, may adhere to the cervix uteri, or to 
 the vaginal walls ; they are usually round, well-defined, movable, 
 elastic, and sometimes fluctuating, and require the same treatment as
 
 392 KING'S ECLECTIC OBSTETRICS. 
 
 heretofore named for other tumors, as do also those of a Scirrhwt or 
 Phlegmonous character, Polypi, and various Excrescences, and Syphilitic 
 Vegetations which may be found on the external parts of the genera- 
 tive organs. 
 
 From the great fatality which attends the presence of pelvic tumors, 
 as obstacles to delivery, it must be regarded as a fortunate matter that 
 their occurrence is not very frequent. Perhaps, less fatality would 
 attend these cases, when known at an early period, and both mother 
 and child be saved, were the induction of premature labor accom- 
 plished ; although, it is by no means improbable, that even at the 
 seventh month, instances may be met with which will offer an obstacle 
 to the operation, and with these, the production of an early abortion 
 affords the only chance of safety for the mother. 
 
 As a general rule of action, in all cases of tumors at full term, the 
 first attempt of the practitioner should be to push the tumor up above 
 the superior strait, beyond the head, so as to remove its interference 
 with the advance of the latter. And the operator will be more likely 
 to succeed by placing the patient on her knees, with the pelvis eleva- 
 ted, and the breast on the bed, in a line with the knees ; this position 
 deprives the patient of any tenesmic, or bearing-down power, beside 
 causing the uterus to gravitate further from the pelvis, in a direction 
 toward the epigastrium, and thus affording greater space into which 
 the tumor may be placed. The manipulation may be conducted 
 according to circumstances, with the hand in the vagina, or one or two 
 fingers in the rectum, or both combined. 
 
 Where the tumor can not thus be placed out of the way, it is recom- 
 mended to puncture it with a trocar, and in case this fails, to perforate 
 the child's head, either of which operations do not always lessen the 
 danger to the mother. In relation to puncturing or incising the pos- 
 terior vaginal wall, in these tumor cases, Prof. Meigs remarks in his 
 valuable work on Obstetrics, " I do not feel at liberty to recommend 
 such an operation in this volume an operation which could only be 
 legitimately performed, upon due and mature consideration with the 
 most acute and able practitioners of the vicinity. They alone should 
 feel themselves vested with the authority to act under such terrible 
 circumstances. I merely remark, en passant, that an incision into the 
 posterior wall of the vagina, should it even have the good effect suffi- 
 ciently to reduce the size of the tumor, fearfully exposes the patient 
 to the risk of vaginal laceration from the subsequent distension by the 
 descending head, and the escape of the child into the peritoneal sac.
 
 DIFFICULT LABOR FROM PELVIC DEFORMITY. 393 
 
 A small aperture in the thin posterior paries of the tube, is more 
 likely to yield and become a frightful laceration, than to resist the dis- 
 tending force of the advancing head." These remarks, from one of 
 the most eminent accoucheurs of America, are entitled to the serious 
 consideration of every medical man. Up to this period, I have met 
 with only one instance of tumor offering an impediment to delivery ; 
 it was a cauliflower excrescence of the cervix, in a female with her 
 fifth child, and terminated fatally. 
 
 DEFORMITIES OF THE PELVIS, are another cause of pro- 
 tracted and difficult labors, not unfrequently rendering the descent of 
 the child impracticable, and are much more common to the women of 
 Europe than to those of America. In another part of this work I 
 have referred to the character of these malformations, and the method 
 of determining them ; it now remains to speak of the management of 
 labor when they are present. 
 
 9._The ABNORMALLY LARGE PELVIS, can scarcely be con- 
 sidered a deformity ; but as the head of the child may meet with but 
 little resistance in its passage through the canals, the various motions 
 of flexion, rotation, etc., may not take place at all, or else be very 
 imperfectly effected, and thus modify the labor. The consequences 
 which may result in these kind of labors from deficient resistance, 
 have already been named. Where the labor proceeds rapidly, the 
 child may unexpectedly be expelled and fall upon the floor, even 
 before the practitioner has deemed it advisable to make the usual pre- 
 liminary preparations. In these cases, the best method of manage- 
 ment, when called in time, is, to prevent the head from being too 
 hastily expelled, by pressure upon it during a pain, giving firm sup- 
 port to the perineum until it is sufficiently yielding to allow the head 
 to pass without causing a laceration, and to guard against hemorrhage 
 by pressure over the uterine globe. After delivery, the patient should 
 be kept in the horizontal posture, for a longer time than usual. 
 
 10. The DWARFISH PELVIS, will offer an impediment to 
 labor, according to the degree of contraction present; the labor may 
 be accomplished by the natural powers, but it will be tedious, difficult, 
 and attended with much suffering, and perhaps, from the long-con- 
 tinued compression of the head, result in the death of the child ; or, 
 it may be impossible for the child to be born without assistance. And, 
 indeed, the same observations will apply to the Unequally Contracted 
 Pelvis, and the Obliquely Distorted Pelvis.
 
 394 KING'S ECLECTIC OBSTETRICS. 
 
 The character of the labor, in these instances, will depend entirely 
 upon the amount of deformity which may be arranged as follows: 
 1st. Where the diminution of the pelvic diameters is not so great but 
 that the child may be born, after a long time, by the natural powers, 
 aided, in most cases, by the forceps, for the application of which there 
 will be found sufficient space. 2d. Where the diminution of the 
 pelvic diameters renders it impossible for the head to advance, and the 
 forceps can not be applied for want of space, and, consequently, the 
 only resource is the perforator. 3d. Where the pelvic canal is so 
 reduced in size, that even a mutilated child could not be extracted. 
 
 The difficulty of the labor will not depend so much upon the positive 
 size of the pelvic diameters themselves, as upon their adaptation, 
 relatively, to the diameters of the fetal head; for, though the pelvis 
 may be considerably contracted, yet, if the child's head be smafl, the 
 labor may progress with comparatively little difficulty. A pelvis, 
 whose small diameter is less than three inches, may generally be con- 
 sidered as one through which a living child can not pass ; on this 
 point, however, it may be proper to state, that accoucheurs vary in 
 their estimate, some placing the limit at two inches, some at two and 
 a half, and others at three, and even three and a quarter inches. In 
 instances where the small diameter is less than three, but exceeds two 
 inches, the labor will belong to the second arrangement or class, 
 as given above; in such cases the forceps could not be employed 
 advantageously, or if an attempt were made to use them, it would, 
 undoubtedly prove useless, and perhaps injurious the perforator and 
 crochet would be demanded here. Authors likewise vary in the limit 
 of measurement in these labors requiring the mutilating instruments, 
 some placing \t at one and a half inches, and others at one and three 
 quarters, and two inches. When the small diameter is below two 
 inches, the labor belongs to the third arrangement, and will, very 
 probably, require the Cesarean operation before the child can be 
 removed. 
 
 When there is a deformity of the pelvis, we are informed by Dr. 
 Rigby, that the uterine contractions are frequently irregular during 
 the first stage, of labor, exerting but little influence in dilating the <>s 
 uteri ; the head remains high up, does not descend against the os uteri, 
 and shows no disposition to enter the pelvic cavity beinir pushed 
 forward by the promontory of the sacrum, it rests upon the pubic 
 .syinphysis, pressing forcibly ag-.iinst it. The mode of determining 
 deformity a: the superior strait, has been already explained in another 
 part of the work. When the deformity is in the cavity or at the in-
 
 DIFFICULT LABOR FROM PELVIC DEFORMITY. 395 
 
 ferior strait, it is detected with much less difficulty, as the parts are 
 more readily reached ; we will discover that the head makes no advance- 
 ment during a pain, and if the finger be passed around during the 
 absence of pain, the head will be found larger than the canal through 
 which it has to pass. When the labor is allowed to proceed without 
 interference in these extremely deformed pelves, various symptoms 
 may present, which are generally met with during the second stage, 
 as: inefficient contractions, exhaustion, and febrile symptoms, inflam- 
 mation and sloughing of the soft parts, the result of long and forcible 
 pressure of the head, and which may occur at either of the straits, or 
 in the cavity, and may, likewise, penetrate into the bladder, or rectum; 
 rupture of the uterus not unfrequently occurs in these cases. The child 
 may have one or more bones of the cranium fractured, or the pressure 
 may cause inflammation or sloughing of the scalp, or its death may be 
 occasioned by strong and continued compression of the head. 
 
 TREATMENT. This will depend much upon the class to which 
 the deformity belongs; no positive or fixed rule can be laid down; if 
 it be of the first class, a fair trial should be given to the natural powers, 
 and if they be found insufficient to effect the child's expulsion, or if 
 symptoms of exhaustion appear, assistance should be given with the 
 forceps, provided there be space enough for their application. If the 
 case belongs to the second or third class, I deem it advisable to operate 
 at as early a period as possible, before the system of the patient has 
 become exhausted from the long-continued exertion and sufferings of 
 the labor, thereby materially increasing the chances of a favorable 
 result. In instances w r here the perforator is indicated, the child is 
 generally dead from the pressure, before the symptoms have arrived at 
 a point demanding the operation. In alt cases where deformity of the 
 pelvis is suspected during labor, the practitioner should at once pro- 
 ceed by a careful examination to determine the character and location 
 of the distortion, and the method of .management should be decided 
 upon only after a consultation with experienced accoucheurs. 
 
 The following extract from Dr. R. Lee's Lectures on Midwifery, 
 relative to the treatment of pelvic deformities, will, no doubt, prove 
 acceptable to the reader ; he observes : " In cases of slighter distor- 
 tion of the pelvic, it is impossible to predict at the commencement 
 of labor whether the head will pass or not, and while it continues to 
 advance and no unfavorable symptoms are present, you ought not to 
 interfere wait patiently and see what nature can do. If the head 
 descends so low into the cavity of the pelvis that an ear can be felt,
 
 396 KING'S ECLECTIC OBSTETRICS. 
 
 and the os uteri is fully dilated, and there- is room to pass up the blades 
 of the forceps without the employment of much force, it is always 
 proper, when delivery becomes necessary, to attempt to extract the 
 head with the forceps. It is necessary, however, to remember that 
 sloughing is apt to follow the use of the forceps where the soft parts have 
 been long pressed upon by the head, and that perforation of the head 
 is a much safer operation for the mother, when the distortion is con- 
 siderable. 
 
 "The employment of the long forceps, in cases of distorted pelvis, 
 has been recommended by Baudelocque, Boivin, La Chapelle, Capuroi>, 
 Maygrier, Velpeau, and Flammant, whose works contain ample in- 
 structions for its use, before the head of the child has entered the brim 
 of the pelvis; and the la"st of these writers has expressed his belief that 
 the instrument is more frequently required while the head of the child 
 remains above the superior aperture of the pelvis, than after it has 
 descended into the cavity. 
 
 "In thi country there are no practitioners of judgment and ex- 
 perience, who have frequent resource to the forceps, or who employ it 
 before the orifice of the uterus is fully dilated, and the head of the 
 child has descended so low into the pelvis that an ear can be felt, and 
 the relative position of the head to the pelvis accurately ascertained. 
 The instrument is very seldom used in England where the pelvis i.s 
 much distorted, or where the soft parts are in a rigid and swollen state ; 
 but it is had resource to, where delivery becomes necessary in conse- 
 quence of exhaustion, hemorrhage, convulsions, and other accidents 
 which endanger the life of the mother. It is used solely with the 
 view of supplying that power which the uterus does not possess." 
 
 Again, " Where there exists a great degree of distortion of the brim 
 of the pelvis, you may be unable to determine, positively, the distance 
 between the base of the sacrum and symphysis pubis; and it is not 
 necessary, for practical purposes, to do so with mathematical accuracy ; 
 but when it is under two inches and a half, you will readily discover, 
 if you have had considerable experience, on making the ordinary 
 examination, from the unusual manner in which the sacrum projects, 
 that it is impossible for a child at the full period to pass through it. 
 If labor has commenced at the full period of pregnancy, and you 
 discover, before it has continued many hours, that the pelvis is greatly 
 distorted, and that the child can not possibly pass alive, no advantage 
 can result from allowing the labor to endure till the patient is ex- 
 hausted, and you are satisfied that the difficulty can not be overcome
 
 DIFFICULT LABOR FROM PELVIC DEFORMITY. 397 
 
 by the powers of the constitution. In such a case delay is dangerous, 
 and there is nothing which can save the woman's life but opening the 
 child's head with the perforator, and extracting it with the crochet. 
 But this should never be had recourse to without a regular consulta- 
 tion of experienced practitioners, and before it has been placed beyond 
 all doubt, by the most candid investigation, that the delivery can be 
 accomplished in no other manner, so as to preserve the mother's life. 
 " In the greater number of cases of difficult labor from a high 
 degree of distortion of the pelvis, which have come under my observa- 
 tion, where it has been the first child, the process has been allowed to 
 go on till the efforts of the patient had been nearly discontinued, or 
 had ceased entirely, and the favorable period for operating was lost. 
 In some cases, even when the duration of the labor, and the local and 
 constitutional symptoms, have made it manifest that such interference 
 was justifiable and necessary, I have unfortunately delayed too long to 
 deliver, in consequence of employing the stethoscope, and ascertaining 
 that the child was alive. In cases of extreme distortion of the brim 
 of the pelvis the proper practice is, to perforate the head as soon as 
 the os uteri is sufficiently dilated to admit of the operation being done 
 with safety, and afterward leaving the patient in labor till the head 
 has partially entered the brim, and the os uteri is considerably dilated. 
 There can be no doubt that, in some cases, it is right to interfere 
 before we certainly know that the child has been destroyed by the 
 pressure; but we have nothing here to do with the question respecting 
 the life or death of the child ; our conduct will be biased if we en- 
 deavor to solve this question. We have only to determine positively, 
 that delivery is absolutely necessary to save the mother's life, and that 
 it is impossible for the head of the child to pass, till its volume is 
 reduced. Pare*, Guillemeau, Mauriceau, Portal, Puzos, Levret, Smellie, 
 and all the best accoucheurs who have since appeared in Britain, have 
 performed the operation of craniotomy in many cases of distortion 
 from rickets and malacosteon, without reference to the condition of 
 the fetus. ( True religion and the common sense of mankind,' observes 
 Dr. Denham, ' appear to have nothing contradictory. The doctrine 
 they teach, of its being our duty to do all the good in our power, and 
 to avoid the mischief we can, is applicable to the exigencies of every 
 state, and we may be easily reconciled to it on the present occasion. 
 In, some cases of difficult parturition, it is not possible that the lives, 
 both of the mother and child, should be preserved. Of the life or 
 death of the mother, we can, under all circumstances, be assured: of
 
 398 KING'S ECLECTIC OBSTETRICS. 
 
 the life or death of the child, there is often reason to doubt, when we 
 are called upon to decide and to act. The destruction of the mother 
 would not, in the generality of cases which may bring the operation 
 of which we are speaking under contemplation, contribute to the 
 preservation of the child ; but the treatment of the child as if it were 
 already dead, with as much certainty of success as is found in other 
 operations, secures the life of the parent. It then becomes our duty, 
 and is agreeable to our reason, to pursue that conduct which will give 
 us the most probable chance of doing good ; that is, of saving one life, 
 when two lives can not possibly be preserved.' 
 
 " 'The only means of effecting delivery/ observes Dr. Collins, 
 'where the disproportion between the head of the child and the pelvis 
 is so great as to prevent us reaching the ear with the finger, is by 
 reducing the size of the head and using the crochet. This is, how- 
 ever, an operation that no inducement should tempt any individual to 
 perform, except the imperative duty of saving the life of the mother 
 when placed in imminent danger. I have no difficulty in stating, that 
 after the most anxious and minute attention to this point, that where 
 the patient has been properly treated from the commencement of her 
 labor; where strict attention has been paid to keep her cool, her mind 
 asy; where stimulants of all kinds have been prohibited, and the 
 necessary attention paid to the state of the bowels and bladder ; that, 
 under such management, the death of the child takes place in labori- 
 ous and difficult labor before the symptoms bcome so alarming as to 
 cause any experienced physician to lessen the head. This is a fact 
 which I have ascertained beyond all doubt by the stethoscope, the use 
 of which has exhibited to me the great errors I committed before I 
 was acquainted with its application to midwifery, viz : in delaying the 
 delivery, often, I have no doubt, so as to render the result precarious 
 in the extreme, and in some cases even fatal.' 
 
 " The operation of craniotomy is now performed by all British 
 practitioners of reputation, whether the child be alive or dead, if the 
 condition of the mother is such as to render delivery absolutely neces- 
 sary, and the head of the child is beyond the reach of the forceps, or 
 where, from distortion of the pelvis, or rigidity of the os uteri and 
 vagina, it can not be extracted if its volume is not reduced. This 
 operation is performed from a conscientious belief and deep conviction 
 that if neglected to be done at a sufficiently early period, the mother's 
 life will be sacrificed, and the life of the mother is considered to be 
 much more important than that of the child. Some continental writers
 
 DIFFICULT LABOR - FROM FELVIC DEFORMITY. 399 
 
 affirm, but I believe unjustly, that in England we have frequently 
 recourse to craniotomy without due consideration, and without proper 
 regard to the life of the child; and, whatever the state of the parent 
 may be, they refuse to open the head till they can obtain certain evi- 
 dence, which, in some cases, it is impossible to obtain, that it is dead. 
 ' Xothing could excuse the conduct of the practitioner/ says Baude- 
 locque, ' who would perforate the head of a child without previously 
 knowing with certainty that it was not alive, a circumstance which 
 can only authorize us to employ the perforator and crotchet.' By fol- 
 lowing this erroneous principle, the lives of both mother and child 
 would, I believe, in the majority of cases, be sacrificed." 
 
 As will be noted, since reading the preceding pages, craniotomy, or 
 the perforation of the skull and evacuation of the brain contents, is 
 the operation commonly resorted to, to overcome the disproportion 
 existing between the child's head and the parturient canal. Mechan- 
 ical obstacles to natural delivery are more frequent than one would at 
 first suspect; statistics indicate that fully seven thousand children an- 
 nually, suffer embriotomy in the United States alone. 
 
 This subject is at present, owing to the terrible mortality reported, 
 receiving the attention of the foremost obstetricians; whether crani- 
 otomy is ever justifiable if the child is alive is doubted; as to whether 
 some protection should not be offered in the interest of the child, etc. 
 
 The saving of the mother's life should, under all circumstances, be 
 the first consideration, and to that end every effort should be directed. 
 But in guarding her interests, is there not often reckless sacrifice of 
 the child's life ? Should there not be an awakening to a keener sense 
 of responsibility in such cases ? In addition to premature labor, which 
 I believe, as a rule, should be induced, when the diagnosis can be made 
 at the proper time, there is but one other alternative suggested as a 
 substitute to craniotomy, in cases where the diameters of the parturient 
 outlet fall so far below normal as to render both natural and instru- 
 mental delivery impossible, and that is abdominal section. Abdom- 
 inal section includes both the Cesarean and Porro's operations, which 
 will be clearly defined in a subsequent chapter. In view of the ad- 
 vancement made in abdominal surgery, during the past few years, 
 statistics clearly indicate a marked falling off in the death rate, and 
 one of the operations looking to the saving of the child does not ma- 
 terially increase the maternal mortality. In view of this fact, crani- 
 otomy, it seems, should not be executed until the circumstances of each 
 individual case are carefully considered, and the concurrence and
 
 400 KING'S ECLECTIC OBSTETRICS. 
 
 endorsement of eminent consultation is obtained. The reader is 
 referred to the chapter on Abdominal Section for further details. 
 
 The operation of turning has been recommended, in cases of pelvic 
 deformity, by some authors. The advantages of this method, revived 
 by the late Dr. Simpson, of Edinburgh, Scotland, are, in the first 
 place, that it can be performed at an early period of the labor, in 
 which respect it has greatly the advantage over craniotomy, which 
 must be performed at a later period, and after the woman has become 
 more or less exhausted by her long continued sufferings, at the same 
 time that she escapes the risk of injuries to the vagina and soft parts 
 by instruments. It also affords a greater chance for the safety of the 
 fetus. The idea upon which this operation is based is, that the 
 bimastoid diameter of the fetal' head being from half an inch to three 
 quarters of an inch smaller than the biparietal, the head, thus turned, 
 is somewhat wedge-shaped, the small part being at its base, the broad 
 part at the vertex. By delivering the fetus in the manner named, the 
 small part of this wedge is first brought down, and the broad part- 
 especially as it is kno\vn that the biparietal diameter may be com- 
 pressed to a considerable extent may, very probably, likewise be 
 drawn through the contracted parts. That there are instances in 
 which this operation has proved successful, can not be doubted, if the 
 statements published in our medical journals from many accoucheurs 
 are to be believed. It appears to have been more successful in the 
 dwarfish and the obliquely distorted pelvis, and when the antero- 
 posterior diameter of the superior strait is not less than two and a 
 half inches; notwithstanding, I consider the operation a very haz- 
 ardous one, which should never be undertaken without due consid- 
 eration and careful examination; for if it fails, the perils of the 
 woman are increased. It must be recollected that and especially in 
 cases of pelvic deformity it is not always possible to tell how the 
 diameters of the head may compare with those of the pelvis; and, in 
 turning, the head may be so placed as not only to expose the female 
 to the pains and difficulties incident to the operation, but to the 
 subsequent difficulties attending the employment of the forceps, 
 or perhaps the perforator, one of which will most certainly be required 
 in case of turning from error of diagnosis; beside affording not the 
 least chance for the safety of the child. 
 
 After the delivery, every means should be employed to guard 
 against sloughing; warm water should be injected into the vagina two 
 or three times a day ; or we may administer internally Hamamelis or 
 Collinsonia. Febrile or inflammatory symptoms may be combated
 
 DIFFICULT LABOR FUOM PELVIC DEFORMITY. 401 
 
 with the Sp. Tr. of Aconite, Veratrum, Gelsemium, Macrotys, etc. 
 Water, as hot as can be endured, in which a small amount of Borax 
 or Chlorate of Potash has been dissolved, used as an injection, will 
 often prove advantageous in connection with the internal agents; and, 
 to relieve excessive weakness or prostration, it may become necessary 
 in some cases to use stimulants, either Wines or diluted Brandy, until 
 the patient reacts. Uterine tonics, as Macrotys, Pulsatilla, Phyto- 
 lacca, or Nux Vomica, may be indicated ; and later, the bitter or 
 chalybeate tonics called for. 
 
 In all instances where a deformity of the pelvis is known to exist, 
 and especially when from careful measurement, or the results of a 
 previous labor, it is ascertained that a living child can not be born at 
 full term, the induction of premature labor should be unhesitatingly 
 performed; likewise, in cases where the life of the mother would be 
 endangered from the difficulty or impossibility of delivery at this 
 period. And in those cases where, at the seventh month, premature 
 labor would be hazardous to the mother, on account of excessive 
 diminution of the pelvic diameters, or distortions, I should not hesitate 
 a mome'nt in adopting measures to produce abortion. 
 
 The rule generally adopted in pelvic deformities is, that when the 
 antero-posterior diameter of the superior strait measures from 
 
 3^ to 4 inches, the forceps may answer ; 
 
 2ij to 3^ " turning may answer ; 
 
 If to 2^r " craniotomy required ; 
 
 Less than 1% inches, Cesarian section required. 
 
 If the existence of the deformity be known in time, the safety of 
 the mother, and probably that of the child, may be secured in the^rsZ 
 two instances, by the induction of premature delivery at the seventh 
 month ; in the third instance, turning may prove, successful at the 
 seventh month ; in the fourth instance, the production of abortion at 
 an early period is a justifiable procedure. 
 
 11. Occasionally the CONDITION OF THE COCCYX may be such as to 
 render labor difficult, as from anchylosis at the sacro-coccygeal articu- 
 lation, from malposition due to previous fracture, from scrofulous 
 disease, etc. It is only, however, when the coccyx, having become 
 fixed, diminishes the diameter of the inferior strait, that it materially 
 interferes with labor. An examination will reveal whether it be im- 
 movable or anchylosed, and the degree to which it interferes with the 
 
 diameter of the strait, from a curvature slightly varying from the 
 26
 
 402 KINO'S ECLECTIC OBSTETRICS. 
 
 normal to one at a right angle with the apex of the sacrum. These 
 abnormities of the coccyx are, fortunately, extremely rare causes of 
 difficult labor. The treatment consists according to circumstances, in 
 inducing premature delivery, use of forceps or perforator, or, breaking 
 down the anchylosis, and which will be found an exceedingly difficult 
 and painful operation, when undertaken during the progress of labor. 
 
 12. Labor may be rendered difficult by VAGINAL VESICO- 
 CELE, or VAGINAL CYSTOCELE, in which the urinary bladder 
 falls from its proper position in front of the uterus, and descends 
 below the fetal head, overlapping the pelvic brim. The head, in its 
 descent, pushes the fundus of the bladder before it into the excavation, 
 forming a tumor of greater or less size at the anterior-superior part 
 of the vagina, and which, if not timely relieved, may terminate very 
 seriously. Sometimes the depressed bladder has been found directed 
 to one side of the pelvis. The patient experiences a sensation of 
 weight or fullness in the pelvis, a dragging sensation about the 
 umbilicus, .with a constant, but ineffectual desire to urinate; though, a 
 small quantity of urine may pass during each uterine contraction. On 
 an examination per vaginam, the finger detects a more or less oval 
 tumor, usually in front of the pelvis, which is smooth, soft, and 
 fluctuating during the intervals between the pains, but hard and tense 
 while they are on, and painful on being steadily pressed. The head 
 of the child is only partially covered by it, and may be felt by passing 
 the finger above and behind it; but any attempt to slip the finger 
 between the tumor and the symphysis pubis, will prove unsuccessful. 
 Some care will be required lest it be mistaken for the -bag of waters, 
 or a hydrocephalic head, and improperly punctured. 
 
 TREATMENT. This difficulty, whenever met with, must be 
 promptly remedied. A male elastic catheter should be introduced 
 into the bladder, having its point directed backward and downward, 
 and to facilitate its introduction, the head may be slightly elevated 
 with one or two fingers; the whole operation must be done during the 
 absence of a contraction, and it may be effected more readily by 
 entering the point of the catheter, with the hand below the vagina, 
 and as it passes on toward the bladder, gradually raising the hand. 
 After the urine has been withdrawn, the bladder must be pushed 
 upward, by one or two fingers, above the top of the pubes, and held 
 there till a pain thrusts the presenting part of the child below it. 
 Should it be impossible to introduce the catheter, attempts must be
 
 DIFFICULT LABOR FROM PELVIC DEFORMITY. 403 
 
 made, during the intervals, to press up the head, and at the same 
 time also press up the tumor, when, frequently, the urine will be 
 discharged without the aid of a catheter. If. these attempts fail, and 
 the progress of the labor is checked by the tumor, or a rupture of the 
 bladder is feared, from its overdistension and from the pressure, the 
 only resource is to puncture the presenting inferior surface of the 
 bladder with a very fine trocar, having a consultation previously, if 
 possible, with some skillful physician. In these cases, the patient 
 should be carefully watched after delivery, evacuating the bladder at 
 once, and not allowing it, for some days, to become distended, to any 
 extent, with urine. 
 
 As these instances are more apt to occur in the first stage of labor, 
 and when the bladder is more or less filled with urine, the necessity 
 for keeping the bladder evacuated at such a time, will be readily seen. 
 It may be proper to observe here, that no tumor in the pelvis, 
 especially those presenting fluctuation, should ever be punctured, 
 without having first employed the catheter, to ascertain that it is not 
 vesical. 
 
 13._Very rarely, a CALCULUS IN THE BLADDER may 
 
 prove an obstacle to the labor, by projecting backward, and then 
 pressed downward by the head, thus seriously bruising the bladder. 
 It is not always easy to diagnosticate this difficulty ; it will present as 
 a hard tumor of greater or lesser size, circumscribed, painful on 
 pressure, whether of the finger or child's head; and the diagnosis may 
 be still further verified by the introduction of a sound or catheter into 
 the bladder. Relief may be attempted, if the head has not descended 
 too far, by pushing it up above the strait, and then pressing the 
 calculus upward and anteriorly. If, from any cause, this can not be 
 effected, vaginal lithotomy, with the consent of counsel, is advised, or, 
 perhaps, craniotomy may be preferred. 
 
 14. COLLECTION OF FAECES IN THE RECTUM, may inter- 
 pose as an obstacle to the passage of the head. These form a rather 
 hard, irregular, inelastic tumor, which will be felt in the situation of 
 the rectum, and which when pressed upon, downward, will slowly 
 yield and cause the escape of feces. An examination per anum will 
 at once detect the hardened scybalse. This condition seldom happens 
 except among careless and inattentive females, and a proper attention 
 to the condition of the bowels at the early stage of labor, by the prac- 
 titioner, will prevent its occurrence.
 
 404 KING'S ECLECTIC OBSTETRICS. 
 
 TREATMENT. The feces should be removed by injections of 
 warm water; or, should they be so hard and compact as to resist tins- 
 method, it will then become necessary to remove as much as possible, 
 by a scoop, spatula, or the handle of a spoon, after which administer 
 an injection of warm water. 
 
 15. A portion of intestine may become engaged in the cul tie sac 
 between the rectum and the posterior wall of the vagina, and form a 
 tumor of variable size. This VAGINAL HERNIA, especially when 
 it contains fecal matter, opposes the descent of the head, and, from the 
 pressure of the head upon it, may terminate in serious inflammation, 
 and even gangrene. 
 
 TREATMENT. The hernia must be reduced as promptly as pos- 
 sible; the woman must be placed on her knees and elbows, with the 
 hips elevated, and the intestine returned by pressure with two or three 
 fingers. In some cases it may be necessary to relax the system by 
 means of Gelsemium or Chloroform, when the patient will lie upon 
 her back, with the thighs flexed upon the abdomen, and supported 
 there by assistants, while the reduction is attempted. If the reduc- 
 tion can not be accomplished, the labor may readily be terminated by 
 the forceps if required. 
 
 The principal abnormal conditions of neighboring parts that may 
 interfere with th normal progress of labor are : 
 
 1. RELAXATION OF ABDOMINAL MUSCLES, or DIMIN- 
 ISHED POWER OF ACTION, and which may be due to some 
 existing disease -interfering with -the voluntary and reflex action of the 
 associated muscles concerned in labor (respiratory and abdominal), as, 
 diseases of the lungs, of the heart, of the abdomen (especially ascites), 
 paraplegia, etc.; or, which may be the consequence of long-continued 
 pain, or exhaustion, or the persistent and improper use of abdominal 
 bandages or corsets. It is impossible to lay down any specific rules 
 for treatment in these cases, as each one must be managed according 
 to its character and indications; the great object during parturition is 
 not to remove these causes, but to overcome their immediate influence 
 at this time by the use of measures to expedite delivery. In some 
 cases, a tight bandage around the abdomen, with compress beneath 
 pressing upon the uterine fundus, and changed and retightened from 
 time to time, as may be required from the advance of the labor, will 
 be found to answer ; Strychnia is frequently highly efficacious in some 
 other cases; Crede's method, heretofore referred to may prove useful
 
 DIFFICULT LABOR FROM PELVIC DEFORMITY. 405 
 
 in a third class of cases; Sulphate of Quinia, or electricity, with a 
 fourth; in others again, the forceps may be required, or the perforator. 
 If the accoucheur is attending a patient during gestation, who is 
 laboring under serious disease of the respiratory, circulatory, digestive, 
 or other organs, that may affect her seriously or dangerously at the 
 period of parturition, it may become his duty to induce premature 
 delivery. 
 
 2. The ovary is liable to several diseases, which augment its volume 
 to an enormous extent. Among these, dropsy and scirrhus are the 
 most common; and if, at the time of parturition, an OVARIAN 
 TUMOR is present, it may become a cause of difficult labor by 
 impeding the birth of the child. Generally, as the ovary enlarges, 
 it gradually rises from the pelvic into the abdominal cavity, where 
 from its bulk, it may interfere with the development of the uterus and 
 occasion a premature labor; or else, by pressing this organ to the side 
 opposite, it may give rise to a difficult labor, by producing a uterine 
 obliquity. Or it may interfere with the perfect action of the abdom- 
 inal muscles during the expulsive stage of labor. Frequently, how- 
 ever, adhesive inflammation causes the ovary to remain within the 
 pelvic excavation ; or it may have been prevented from ascending into 
 the abdominal cavity by the gravid uterus having already occupied 
 that space ; in either of which instances, if the female arrives at the 
 full term of utero-gestation, the labor must be exceedingly difficult, 
 depending, however, on the size and character of the tumor. 
 
 The diagnosis of an ovarian tumor, at the period of labor, is not 
 always an easy matter. It will be found external to the vaginal coats, 
 commonly toward the posterior part of the pelvis, within the recto- 
 vaginal septum, will be more or less movable, elastic, and fluctuating, 
 or hard and apparently solid, with some degree of sensibility. The 
 dropsical tumor presents a round, smooth, and polished surface, while 
 the scirrhus one presents nodules and irregularities. It is proper to 
 examine in these cases both by vagina and rectum simultaneously,, for 
 the purpose of more clearly determining them from vaginal or uterine 
 tumors. 
 
 TREATMENT. In the management of these cases, much will 
 depend upon the size and character of the tumor, bearing in mind 
 that these tumors are " more likely to be moved out of the way of 
 the child at the time of labor, than any other, and also more apt to 
 give way and burst under the pressure of the head." (Churchill.} 
 If the tumor be detected previous to the engagement of the head at
 
 40G KING'S ECLECTIC OBSTETRICS. 
 
 the superior strait, and it is movable, attempts should be made to push 
 it up above this strait by steady pressure, so as to place it beyond the 
 head. If this can not be accomplished, we must rely upon the natural 
 powers, until the symptoms demand our interference. If the tumor 
 be soft, it may be flattened, or ruptured, and thus allow the head to 
 advance; if it be solid, we certainly should not interfere until we are 
 compelled to. When the removal of the obstacle can not be accom- 
 plished, and interference is called for, it is recommended to puncture 
 the tumor by means of a trocar, and evacutate the fluid ; and if the 
 contents of the tumor be viscid, or gelatinous, not passing readily 
 through the canula, or if the tumor be formed of numerous cysts, not 
 communicating with each other, the opening must be enlarged by 
 making an incision into the tumor of half an inch or an inch in 
 extent. When the tumor is located between the sacrum and rectum, 
 it is recommended to make the puncture through the rectum ; but in 
 other instances through the vagina, as there is less danger from hem- 
 orrhage from the vaginal blood-vessels. Should a fibrous or polypus 
 tumor be punctured, from an error in diagnosis, no great harm will be 
 done. Great care, however, must be exercised in the examination of 
 fluctuating tumors, especially when they are toward the pubic side of 
 the pelvis, as the bladder may prolapse and present a fluctuating tumor,, 
 and which must not be punctured under ordinary circumstances. 
 
 If the tumor be solid, and can not be pushed up above the brim, or 
 if the means previously employed fail to lessen its size, the delivery 
 should be effected by the forceps, in all cases where it is possible; but 
 where this can not be done, the only resource left is embryotomy, 
 extracting the brain, and, if required, the contents of the chest and 
 abdomen ; unless, indeed, the physician is willing to subject the mother 
 to 'the hazard of the Cesarean operation, or the extirpation of the dis- 
 eased mass. 
 
 Dr. Merriman has recorded the history of eighteen cases of ovarian 
 tumors impeding labor, in which nine mothers died, three recovered 
 very imperfectly, and six escaped ; of the children, fifteen were still- 
 born, and three were born alive. He states : " Twice, the labor was 
 effected by the pains, unassisted by the art of the accoucheur ; but one 
 of these women lost her life, and one of the children was still-born. 
 Five times the perforator was used, after a longer or shorter duration 
 of labor: three of these women died, another recovered very imper- 
 fectly, and one got well. Five times the labor was terminated by turn- 
 ing the child ; all the children were lost, and only one mother recovered.. 
 Three times, the tumors having been opened, the labor was afterward
 
 DIFFICULT LABOIJ 7ItOM MAL- POSITION* OF THE* HEAD, ETC. 4>7 
 
 trusted to nature ; two of these women recovered, but the other re- 
 mained for a long time in an ill stale of health ; two only of the 
 children were preserved. In three cases, the tumors having been 
 opened, it was still found necessary to have recourse to the perforator; 
 one of these women died, one remained in an Ul state of health for 
 eighteen months, and then sank under her sufferings; the third re- 
 covered. " " Upon the whole," Dr. Merriman observes, " the evidence 
 we at present possess, is more in favor of opening the tumors when 
 they contain a fluid, than of any other mode of procedure ; for of the 
 nine women who recovered more or less perfectly, five appear to owe 
 their safety to this operation, and of the children born alive, two were 
 preserved by the same means." 
 
 In all these case.s, the time of the operation must be determined by 
 the constitutional symptoms, never delaying assistance after symptoms 
 of powerless labor have commenced. The danger, in these tumors, 
 arises, not so much from the obstruction to the labor, as from the 
 influence exerted upon the disease itself; the pressure upon the tumor, 
 and its consequent irritation, together with the debility, or exhaustion 
 of the patient, occasioned by the prolonged and painful parturition, 
 render her unable to sustain the effects of the irritation and nervous 
 shock after the conclusion of the labor. 
 
 CHAPTER XXXII. 
 
 ON DIFFICULT LABOR FROM FAULTY CONDITIONS OF THE CHILD, 
 MAL-POSITION OF THE HEAD, ETC. 
 
 OF the faulty conditions of the child or its appendages, that may 
 occasion a protracted labor in the second stage, are : 
 
 1. SHORTNESS OF THE UMBILICAL CORD. It may be 
 
 very short, naturally, not exceeding six or seven inches in length, so 
 that it becomes torn as the trunk and inferior extremities are expelled, 
 or its ligation and division may be required before these can be 
 extracted. Most commonly, however, the shortness of the cord is 
 accidental, occasioned by its being twisted several times round the 
 neck or body of the fetus. The delay in the progress of the labor 
 may be suspected to depend upon this difficulty, when in either stage of 
 labor, the head not only retracts upon the subsidence of the pain, but 
 does not advance with the usual force when the pain is present ; some-
 
 408 KING'S ECLECTIC ORSTETRICS. 
 
 times the cord may be so shortened, and the head held up so high, as 
 to prevent the practitioner from ascertaining the presenting part until 
 the commencement of the second stage. Should the placenta he 
 attached to some portion of the uterine cavity, near the neck, instead 
 of toward the fundus, the above symptoms will be absent, and the 
 diagnosis will be very obscure. But to whatever part it may he 
 attached, a sensation of dragging, or tearing, with pain, will be 
 experienced by the patient during the expulsive contractions, when- 
 ever the cord is shortened. 
 
 Should the case be suspected a shoulder presentation, from the fact 
 that at the full dilatation of the os uteri, the presenting part can not 
 be felt, the practitioner may be induced to attempt turning, but the 
 introduction of the hand within the uterine cavity, at once ascertains 
 the presentation of the head retained by a short cord. When, in the 
 second stage, the head presents in a proper position, and is of normal 
 size, the soft parts being free from any rigidity, the head in any part 
 of the pelvic cavity, and the pains regular, shortness of the cord may 
 be suspected when the head is found to recede very much with the 
 cessation of the pains, and making no further advance when they are 
 on, for several hours in succession. If two fingers, or even the whole 
 hand, be passed up as high as possible, between the head and symphysis 
 pubis, the diagnosis will be positive, upon feeling the cord passing 
 around the neck. 
 
 TREATMENT. If the pulsations in the cord be strong and vigor- 
 ous, the best practice is to have patience, and leave the case to nature. 
 If the pulsations are feeble, or gradually becoming so, we are recom- 
 mended by Dr. Lee to deliver immediately with the forceps, and to 
 carefully abstain from the use of Ergot. To attempt turning, in such 
 a case, would be downright stupidity. 
 
 Prof. Meigs recommends loosening the cord by pulling upon its 
 yielding end, and endeavoring to cast it off over the head. "This," 
 he says, " can not always be done ; if so, in any case, let the child pass 
 through it by slipping if down along its body over the shoulders. If 
 it seems impossible to slip the cord over the head or shoulders either, 
 it should be let alone; and in a great majority of cases it will not 
 prevent the birth from taking place, after which, the cord can be cast 
 off. Should the child seem to be detained by the tightness of the cord, 
 as does rarely happen, or in danger from the compression of its jugular 
 vessels, the fun is may be cut with the scissors, and tied after the 
 delivery. Under such a necessity as this, a due respect for one's own 
 reputation should induce him to explain to the bystanders the reasons
 
 DIFFICULT LABOR FROM MAL-PORITIOX OF THE HEAD, ETC. 409 
 
 which rendered so considerable a departure from the ordinary practice 
 indispensable." In the event of considerable hemorrhage, it would 
 probably be judicious to place a ligature on the umbilical side of the 
 severed cord. It is not always, however, that the cord can be 
 reached, at least so as to pull it down, or otherwise operate upon it, 
 and in such instances we m.ist expect the means recommended by 
 Prof. M. to be impracticable. Should tha child be dead, as ascer- 
 tained by absence of the beating of the fetal heart, and the cessation 
 of pulsation in the cord, the labor should not be interfered with. 
 
 2. HYDROCEPHALUS is occasionally a cause of difficult la- 
 bor ; in which case, notwithstanding the active expulsory pains and 
 the dilatable condition of the os uteri, the head remains above the 
 superior strait, and if the cause be not early ascertained, exhaustion, 
 or rupture of the uterus ensues. The danger is in proportion to the 
 size of the child's head ; where the effusion is inconsiderable, the soft 
 and flexible condition of the head may admit of its delivery, by 
 gradually adapting it to the canal through which it has to pass, and 
 lengthening its long diameter very considerably. But when the 
 effusion is abundant, and the diameters of the head exceed those of 
 'the pelvis so much as to render delivery impossible, interference 
 will be demanded. If a dropsical head be allowed to remain for 
 any time impacted in the pelvic cavity, the continued pressure it 
 exerts upon the soft parts would be very apt to produce sloughing; 
 and in nearly all those cases, where the cause of the delay has not 
 been early ascertained, a fatal result has followed to both the mother 
 and child. 
 
 A hydrocephalic head may be detected by the extraordinary size of 
 the head, and the great separation of its bones, by which the sutures 
 are enlarged to the size of a finger, or more in breadth, and the fon- 
 tanelles being also augmented, at times, to an extent equal to the 
 hollow of the hand. The cranial bones are thin and softer than usual, 
 and, likewise, during the pains, a sense of fluctuation will be per- 
 ceived in some places, though this sensation may not frequently be 
 observed, owing to the great compression the head undergoes. In 
 nates or feet presentations the diagnosis is extremely difficult ; the 
 child's limbs are usually shrunken and wasted, and descend into the 
 pelvic cavity until *the head is -about to engage at the brim, when, 
 notwithstanding strong and continuous pains, any farther advance 
 toward delivery is suddenly and persistently arrested. In cases where 
 hydrocephalus is suspected, we should be very careful to obtain ail 
 accurate diagnosis lest we perforate the head of a healthy child.
 
 410 KING'S ECLECTIC OBSTETRICS. 
 
 TREATMENT. But one course is to be pursued in a difficulty of 
 this kind, when we are certain that the head can not be delivered 
 naturally, or without endangering sloughing of the maternal soft 
 parts, and when we are also positive that hydrocephalus is pre.-ent. 
 The necessity for being enabled to detect presenting parts, as well as 
 their condition, is fully shown in a case of hydrocephalus; for should 
 a careless or ignorant practitioner neglect to ascertain the positive con- 
 ditions present in a difficult labor owing to this cause, and administer 
 Ergot, or other agents, to excite energetic contractions of the uterus, he 
 would be very apt to occasion a rupture of this organ ; or should the 
 head be expelled, it would be at the hazard of the mother's life, from 
 sloughing. 
 
 In hydrocephalus, where the head can not be delivered by the 
 natural powers, the best chance for the mother's safety is, to evacuate 
 the effused fluid by puncturing with the perforator at an early period, 
 while she has sufficient strength and vigor to withstand the shock ; if 
 the operation be delayed too long, she may die from rupture of the 
 uterus, or from exhaustion. Cases are on record in which the accu- 
 mulation was external to the cranial cavity, and it may likewise be 
 lodged immediately within the cranium; consequently the puncture 
 should be guarded, in the hope of evacuating the fluid without dis- 
 turbing the cerebral structure, and saving the life of the child. After 
 the evacuation of the fluid, the collapse of the bones will permit the 
 labor to be terminated by the uterine contractions alone ; and if these 
 fail, means may be employed to excite them into greater activity, or 
 the forceps may be demanded. Hydrocephalus is not always readily 
 detected during labor, and when it is the discovery is usually too 
 late for the mother to derive any advantage from it, as it alniQst 
 always terminates fatally. It is very rarely the case that the paiu.< 
 occasion a rupture of the head, with escape of the fluid, and delivery 
 but we must never wait for this result after having made our 
 diagnosis. 
 
 Should the case be one of pelvic presentation, and the head delayed 
 from disproportion, the perforation must be made behind the ears; or, 
 as has been suggested by Dr. J. Simpson, the fluid may be permitted 
 to escape" by opening any part of the vertebral canal; or the cranial 
 cavity may be reached by perforating the base of the skull through 
 the roof of the mouth. 
 
 Sometimes Ascites, or Dropsy of the Abdomen, may prevent the 
 body of the child from being expelled ; or this may occur from
 
 DIFFICULT LABOR FROM MAL-POSITION OF THE HEAD, ETC. 411 
 
 Tympanitis, or a Distension of the Abdomen with air ; in these cases, 
 the perforator must be thrust into the child's body, and the air or fluid 
 evacuated. 
 
 3. Difficult Labor may arise from TOO EARLY A DEPAR- 
 TURE OF THE CHIN FROM THE BREAST cm Abnormal, 
 or Premature Extension of the Head giving rise to the Brow Presen- 
 tations of some authors. The nearer to the center of the pelvic cavity 
 we find the posterior fontanelle, the greater will be the flexion of the 
 head, and the more readily will it advance; and the nearer to the walls 
 of the pelvic cavity we find this fontanelle, the greater will be the 
 abnormal extension, or the departure of the chin from the breast, and 
 the more slowly will labor progress ; it is an excess of this departure 
 which gives rise to face presentations. 
 
 In all normal vertex presentations the posterior fontanelle should 
 be down toward the axis of the pelvic cavity, nearly in approximation 
 with it ; but in proportion as it recedes from this point, and approxi- 
 mates toward the side of the pelvis, will the anterior fontanelle be 
 brought toward the center of the excavation. And at an early stage 
 of the labor, this abnormal position may loe known by finding this 
 latter fontanelle near the center of the pelvis; but, if the head should 
 have advanced as far as the inferior strait, one of the parietal pro- 
 tuberances will be at or near the pubic arch, while the anterior fonta- 
 nelle will be found looking toward the inner perineal surface. 
 
 TREATMENT. In a difficulty of this kind, the labor will speedily 
 be finished, after having restored the flexion. To accomplish this, 
 two modes are advised; the first is to be performed when the head 
 has not entirely passed the superior strait, the os uteri being well 
 dilated, the membranes ruptured, and the pains sufficiently energetic. 
 And, when possible, it is always better to effect the adjustment at this 
 period, than when the head has completely passed through the superior 
 strait. Should any obliquity of the uterus exist, it must first be 
 removed, according to the preceding directions; then introduce 
 two or three fingers into the vagina, and, during the absence of 
 pain, slightly elevate the forehead and hold it thus, supported by the 
 fingers during one or more pains, until the vertex is found to descend, 
 and the forehead to apparently ascend, when the fingers may be with- 
 drawn, and the case left to the natural powers. The object of the 
 operation is not to push the anterior fontanelle above the superior 
 strait, which will be found a difficult task, but to make counter- 
 pressure during a pain, to prevent it from descending any further,
 
 412 KING'S ECLECTIC OBSTKTIIICS. 
 
 thus allowing the vertex, or occiput to descend with the expulsive 
 efforts of the uterus, and which descent will restore the normal flexion 
 of the head. It may sometimes require the introduction of the whole 
 hand, to effect this change. In performing this operation, the practi- 
 tioner should be careful not to make any pressure upon the anterior 
 fontanelle itself, but only in its neighborhood. 
 
 The second mode of operating is to be pursued when the head is 
 completely in the excavation. The fingers, or half of the hand, if 
 necessary, must be introduced into the vagina, and perhaps, also, 
 within the cervix, so as to grasp the posterior-superior portion of the 
 head, and during the absence of a pain, the head should be directed, 
 or pressed in such a manner as to bring its anterior portion against 
 that part of the pelvic wall facing it, while at the same time the 
 fingers should obtain a purchase on the edge of the parietal bones, 
 formed by the gliding of' the occipital bone under them, and carefully 
 pull the vertex down toward the center of the pelvis; this accom- 
 plished, the vertex should be retained thus, until a subsequent pain 
 renders the change permanent. Thus, if the vertex be toward the 
 left acetabulum, the head will be pressed toward the right sacro-iliao 
 symphysis, while, at the same time, the vertex is pulled downward. 
 The hand to be introduced in this operation must be that, the palm 
 of which is directed toward, or may be applied upon, the vertex. In 
 cases of this kind but little could be accomplished by making pressure 
 upward, with the fingers upon the forehead, besides which, the upper 
 edge of the os frontis being imperfectly ossified, the force required to 
 elevate it might indent the yielding bone, and produce some injury to 
 the brain ; hence it is better to apply the power to the more perfectly 
 ossified posterior edges of the parietal bones. Sometimes, but very 
 rarely, a vectis will be required to effect the proper adjustment of the 
 head when in the pelvic cavity. 
 
 4. It was remarked in the Chapter on the Mechanism of Labor; 
 that in occipito-posterior positions of the head, the movement of 
 rotation usually changed them so that toward the latter period of 
 labor, the occiput became placed under the pubic arch, the same as 
 if the positions had been originally oceipito-anterior. Sometimes, 
 however, this change is not effected, and the head presents at the 
 inferior strait, with the occiput to the sacrum, and the FOREHEAD 
 TOWARD THE PUBIC ARCH. If the diameters of the pelvis 
 and fetal head be normal, and the contractions of the uterus efficient, 
 the delivery may be accomplished without any interference; the head
 
 DIFFICULT LABOR FROM MAL POSITION OF THE HEAD, ETC. 413 
 
 may be expelled presenting its oecipito-frontal diameter to the antero- 
 posterior diameter of the inferior strait, or the forehead may remain 
 at the pubic arch until the posterior part of the head has passed over 
 the perineum. This position of the head, notwithstanding it may not 
 interfere with a safe delivery, may be considered a mal-position. In 
 29,684 cases recorded by various authors, the forehead was under the 
 pubic arch in 87, or about 1 in 342J ; and of 22 children born in this 
 position, where the results were noted, 9 were lost. 
 
 As remarked above, the delivery may be safely accomplished by 
 the natural powers; and where the head is large, or the pelvis narrow, 
 or where both these conditions occur at the same time, the labor will 
 be necessarily protracted, yet the child may be born without any 
 serious consequences to its mother or self. But where the pelvis is 
 considerably narrower than usual, the aid of the accoucheur will 
 undoubtedly be required. 
 
 Cases of this kind maybe ascertained by making a careful examina- 
 tion after the rupture of the membranes ; the forehead not being as 
 round as the occiput, will present a flatter surface which does not fill 
 up the pubic arch, the anterior fontanelle will be found toward the 
 pijbic symphysis, the sagittal suture will be felt passing backward, in 
 the direction (nearly) of the antero-posterior diameter, to the posterior 
 fontanelle, which latter will be toward the sacrum. The parietal 
 bones do not overlap one another as usual, the swelling of the scalp 
 forms less rapidly, and sometimes the finger can be passed up behind 
 the symphysis pubis and detect the eyes and root of the nose. If the 
 head has suifered for a long time from pressure while in the pelvis, 
 there may be some difficulty in detecting the sagittal suture and 
 posterior fontanelle. 
 
 TREATMENT. "We should not interfere in these cases as long as 
 the uterine contractions are regular, and the head advances, however 
 slowly. But when the contractions cease, or are not sufficient to cause 
 any advance of the head, a careful examination of the parts and of 
 the fetal head must be made to ascertain their relative proportions, 
 and such aid must be aiforded as the circumstances of the case may 
 require. On a preceding page I have given the mode of manage- 
 ment recommended by Dr. Dewees for the purpose of overcoming 
 the difficulty under consideration, which contemplates the anterior 
 rotation of the occiput; the uterus being fully dilated, the mem- 
 branes ruptured, the head occupying the lower strait, and the labor 
 active, the index finger is to be placed against the edge of the sagit- 
 tal suture, either before or behind the anterior fontauelle, and, in the
 
 414 KING'S ECLECTIC OUST ETHICS. 
 
 absence of a pain, the part is to be pressed toward the right or left 
 .-acro-iliae symphysis, as the primary position would indicate, and 
 held steadily during the subsequent contraction of the uterus, reduc- 
 ing a fourth to a first, and a fifth to a second position. But although 
 this frequently succeeds, it as often fails, and the practitioner will 
 then have to resort to the forceps, especially where there is a failure of 
 uterine power, or perhaps the perforator may be demanded ; of course, 
 the period for operating will be selected according to the degree of 
 the difficulty, and the symptoms of the patient. 
 
 Not unfrequently, in occipito-posterior positions, there may be a 
 delay in the descent of the head, before it has reached the inferior 
 strait. The membranes having ruptured, the expulsive contractions 
 are found to cause no advance of the head; an examination will detect 
 the posterior fontanelle toward one of the sacro-iliac symphyses, and 
 the sagittal suture may be traced upward and forward to the anterior 
 fontanelle, which will be located behind the opposite acetabulum. In 
 cases of this kind, an early interference is improper, the practitioner 
 should wait until from the number of strong pains, he is satisfied that 
 they are unable to advance the head, when, for the purpose of ulti- 
 mately bringing the occiput under the pubic arch, he may grasp the 
 oranium between the thumb and fingers, during the absence of a pain, 
 and move the face toward the right or left ilium, according as it 
 originally presented to the right or left acetabulum; being careful not 
 to carry it into the hollow of the sacrum, notwithstanding the readiness 
 with which so great a change might be effected, because, should the 
 child's body fail to follow the rotation given to the head, a serious 
 injury to the neck would, very probably, be the result; therefore, after 
 having inclined the face to one of the ilia, the rest of the process must 
 be left to nature. Should the manipulation fail, the face returning to 
 its original position with the pain, it may be repeated several times 
 tmtil it succeeds. Should the head become impacted in the pelvic 
 cavity before the operation is attempted, it is very probable that the 
 forceps or the perforator, will be required to terminate the delivery. 
 (See Occipito-Pubal Position, and Occipito-Sacral Position.] 
 
 5. As a general rule, FACE PRESENTATIONS, may be included 
 among natural labors, from the fact that they commonly terminate 
 without any artificial aid; the labors, however, are very tedious and 
 painful to the mother, and occasion considerable distortion of the 
 Child's features. They are now correctly considered to be deviations 
 from a head or vertex presentation, and though delivery, in the greater
 
 DIFFICULT LABOR FEOM MAL-POSITIOX OF THE HEAD, ETC. 415 
 
 number of instances, is effected by the natural powers, still they should 
 always be regarded as mal-positions. 
 
 When the head is in a proper state of flexion, the chin touching or 
 approximating toward the breast, the presentation is always a normal 
 one of the head, but if there is a premature extension or departure of 
 the chin from the breast, the tendency w r ill be toward a face presenta- 
 tion, in which the head gradually becomes bent backward so far as to 
 ultimately place the face nearly flat across the oblique diameter of the 
 superior strait, looking down into the pelvis; and this position almost 
 always occasions a tedious labor, not unfrequently requiring the aid of 
 the accoucheur. 
 
 In relation to the cause of the difficulty in this presentation, Prof. 
 Meigs remarks: "The fetal head being an oval, five inches long, from 
 the vertex to the chin, and more than three and a half inches wide at 
 the widest part, it ought to make no difference, as far as the mere head 
 is concerned, whether the chin or the vertex advances first in labor, 
 because, in either case, the same circumferences of the head are pre- 
 sented to the planes through which they are to be transmitted. The 
 foramen magnum of the occipital bone being equidistant from the 
 vertex and chin, and situated on one side of the oval, the peculiar 
 difficulties and hazards of these labors are attributable, rather to the 
 nature of the articulation by which the neck and head are conjoined, 
 than to the form of the head itself, when advancing with the face 
 downward. The nature of this articulation is such, that extension of 
 the head can not take place so well as flexion ; hence the requisite 
 dip of the occipito-frontal diameter is not effected in face cases without 
 difficulty, and the consumption of much time. 
 
 " Let the reader figure to himself the state of the spinal column cf 
 a child, urged on in labor by powerful uterine contractions, directed 
 to its expulsion with the face in advance. The inferior-posterior part 
 of the head is pressed against the back of its neck, or between its 
 scapulas, which could not be the case without bending the cervical 
 spine backward, like a bow, while the dorsal and lumbar vertebras are 
 curved in the opposite direction, causing thus a double antero- posterior 
 curve, on which, in consequence of the elasticity of the two arches, 
 much of the expulsive force is vainly expended ; so that, though the 
 power may be as great as in a common labor, it produces much less 
 effect than in a common labor a great part of every pain being 
 expended in reproducing the greatest amount of curvature : for the 
 elasticity of the two curves is such that they are straightened as soon 
 as the pains subside, at least in some measure, while the rest of the
 
 KI.MJ'.S ECLECTIC OBSTETRICS. 
 
 pain is used in pushing the face onward." These remarks of Prof. 
 Meigs are undoubtedly correct, and should be constantly kept in view 
 during a labor of the kind under consideration. 
 
 Face presentations are usually forehead presentations at first, in 
 which there .is a departure of the chin from the breast at an early 
 period of labor, and an examination at tbis time, when the forehead 
 presents, may mislead the practitioner, who, feeling the firm, globular 
 presenting brow, rests satisfied that it is a head case, and only discovers 
 his error when the labor has too far advanced for successful inter- 
 ference. In these cases, it must be remembered that the forehead 
 presents first ; and as the uterine contractions continue, extension of 
 the head gradually progresses, so that one eye, then the other, the nose, 
 the mouth, and the chin, are successively placed within reach of the 
 finger. Instances have been met with, however, where the face 
 originally presented at the brim. 
 
 The cause of presentation of the face is not satisfactorily understood; 
 the most common belief is, that it is owing to uterine obliquity. For 
 instance, if the obliquity carries the fundus far down on the right side, 
 the vertex, instead of presenting in the direction of the axis of the 
 brim, will present at a greater or less degree of inclination to it, and 
 the expulsive contractions of the uterus, acting in the direction of its 
 longitudinal axis, will force the fetus from above downward, and from 
 right to left, so that the vertex will be made to glance upward into 
 the left iliac fossa, and a shoulder be presented at the brim, or, the 
 vertex being arrested at the left border of the superior strait, the 
 forehead will present, extension will gradually be produced by the 
 continuance of the pains, .and the head be forced backward upon the 
 child's back. This is, probably, the cause of the major number of 
 these presentations, yet they are sometimes, met with where there is no 
 obliquity present, and it is very difficult to assign any correct reasons 
 for their occurrence. Labor coming on before the position of the fetus 
 is normally established, as in case of premature rupture of the mem- 
 branes, etc., and excessive coughing, have been named among the 
 causes, and may occasionally effect a change in the position of the fetal 
 head ; but where a face position is a primitive presentation, we have no 
 satisfactory idea of its origination. 
 
 DIAGNOSIS. If the examination be made at an early period of 
 labor, before the membranes are ruptured, it will be very difficult to 
 ascertain the character of the presentation, from the fact that the fore- 
 head, which only presents at that time, may readily be mistaken for a 
 vertex position. But after the extension of the head is completed, and
 
 DIFFICULT LABOR FEOM MAL-POSITIOX OF THE HEAD, ETC. 417 
 
 the membranes have ruptured, the diagnosis becomes more easy : on 
 one side of the pelvis we find the forehead imparting the sensation of 
 a rounded, solid surface, through which the anterior portion of the 
 sagittal suture may be felt traversing; carrying the finger slowly along 
 to the opposite side, in the median line, it meets with a triangular 
 elevation, increasing in size as it leaves the forehead, and crossing the 
 pelvis somewhat obliquely, and which is the nose; at its base will be 
 found two small openings, the nares, which always look toward that 
 portion of the pelvis where the chin is situated, and which consequently 
 afford great aid in determining the position. On either side of this 
 triangular protuberance, at its apex, the eyes will be felt as two soft 
 tumors, surrounded by a circle of bone ; and the examination should 
 be gently and carefully conducted, lest the eyes become seriously 
 injured or even destroyed. A short distance from the base of the nose 
 will be found the mouth, conveying the sensation of a transverse 
 fissure bounded by the superior and inferior maxillary arches. At the 
 commencement of labor, in a face presentation, the mouth is, as it 
 were, substituted for the anterior fontanelle, the nasal bridge for the 
 sagittal suture, and the orbital ridges, according to the position, for 
 the coronal or lambdoidal suture. As the face does not look directly 
 downward, but presents with one cheek more dependent than the- 
 other, the malar bone and eye of the dependent part will be the first 
 points with which the examining finger will come in contact. 
 
 If a long time has elapsed after the rupture of the membranes, 
 before the delay in the labor induces the accoucheur to make a more 
 careful examination, the diagnosis will be more difficult; hence the 
 necessity for making a thorough examination immediately or very 
 soon after their rapture, in all cases of labor. The tedious progress 
 of the head, and the compression which it undergoes, cause the face 
 to become very much tumefied ; the cheeks being greatly swollen and 
 at the same time pressed toward each other, a fissure is formed between 
 them, in which the diagnostic characters of the face are concealed, and 
 which might lead the practitioner to confound them with the nates and 
 their intervening fissure. The lips also swell, become wrinkled, and 
 turn in, presenting a rounded orifice instead of the usual transverse 
 fissure, and which has been mistaken for the anus, but which may be 
 at once known by introducing the finger into it, and feeling the tongue 
 and alveolar processes. 
 
 "Whenever a case of face presentation is met with, it should be an- 
 nounced to the friends of the patient, together with the probability of 
 27
 
 418 KING'S ECLECTIC OBSTETRICS. 
 
 considerable distortion of the features of the child when born, else its 
 frightful appearance may be attributed to some improper violence, or 
 perhaps want of skill, on the part of the medical attendant. If the 
 labor is a tedious one, the appearance of the new-born child will be 
 very repulsive, its face swollen, the eyelids in a tumefied state, and 
 one or both eyes closed, the nose also swollen to an enormous extent, 
 and the whole features presenting a dark or livid appearance, scarcely 
 being recognized as the countenance of a human being. These ap- 
 pearances generally pass off in a few days. Sometimes, when the labor 
 is very tedious, the congestion or stasis of the blood extends even to 
 the brain, creating an apoplectic condition, and occasionally the death 
 of the child. 
 
 Although the face may present in various positions, yet for practical 
 purposes, the two heretofore named are all-sufficient, viz.: the left 
 mento-iliac, and the right mento-iliac. And these names will apply to 
 the positions when the chin is to the left or right side of the pelvis, 
 whether they be directly transverse, as more frequently happens, or 
 have the chin turned more 0r less anteriorly near the body of the 
 pubic bone, or posteriorly toward the sacro-iliac symphysis. So that, 
 for instance, should the face be placed in the pelvis exactly in a trans- 
 verse position, with the chin to the right ilium, or obliquely with the 
 chin toward the right sacro-iliac symphysis, or toward the right pubic 
 bone, the obliquity of the position does not, in either case, interfere 
 with its claim as a right mento-iliac position ; and so of the left, when 
 the chin is placed at the left side of rhe pelvis. The transverse posi- 
 tions of face cases being the most frequent, are regarded as the primitive 
 positions, from which the oblique positions are derived during the 
 progress of labor. 
 
 A. MECHANISM OF LEFT MENTO-ILIAC POSITION. 
 
 This position is not so frequent as the right mento-iliac, and is 
 usually termed the second position ; but for the purpose of preserving 
 regularity, and aiding the student in recollecting all positions, as being 
 successively to the left, right, and front, I have given it as the first 
 position. As a general rule, previous to the rupture of the membranes, 
 the forehead will be found near the center of the superior strait, the 
 chin being placed at the left, and the anterior fontanelle at the right 
 side of the pelvis. The mento-bregmatic diameter of the fetal head 
 corresponds to the transverse diameter of the upper pelvis, the bi-
 
 FIG. 56. 
 
 DIFFICULT LABOR FROM MAL-POSITION OF THE HEAD, ETC. 419 
 
 temporal of the former to the antero-posterior of the latter, and the 
 occipito-frontal diameter of the head is in a direction with the axis of 
 the superior strait. The back of the child is toward the right side of 
 the mother, and its abdomen toward her left side ; its left side is in 
 front, and its right behind ; the feet are above and to the left. (Fig. 
 56.) (Figures 56, 57, and 58, represent the right mento-iliac positions, 
 but as far as the mechanism of labor is concerned, they ivill answer to 
 illustrate the left mento-iliac positions.] 
 
 As soon as the membranes rupture, 
 :and the expulsive contractions com- 
 mence, the head being in a state of 
 moderate extension, and meeting with 
 resistance, forced extension takes place, 
 which gradually causes the face to 
 present at the superior strait instead 
 of the forehead, as heretofore ex- 
 plained. The fronto-mental diameter 
 of the head now corresponds, instead 
 of the mento-bregmatic, to the trans- 
 verse diameter of the brim ; the bi- 
 temporal to the antero-posterior, and 
 the fronto-mental circumference offers 
 
 to that of the superior strait; the body of the child remains unchanged, 
 and a line drawn from the upper lip of the child to the posterior 
 fontanelle, will give the direction of the axis of the upper strait. 
 
 (Fig. 57.) As soon as the extension 
 of the head is completed, it engages in 
 the pelvic cavity and descends as low 
 as possible, or as far as the length of 
 its neck will permit. The depth of 
 the lateral part of the pelvis is three 
 inches, and as the length of the neck 
 does not reach this measurement, the 
 descent of the head is limited, and 
 must cease at some point short of the 
 pelvic floor; for if it advanced further, 
 the head and part of the child's breast 
 would be contained in the pelvic cavity 
 at the same time, a thing not ordin- 
 arily possible. The resistance of the 
 -soft parts, the anterior surface of the spine of the left ischium [which 
 
 FIG. 57.
 
 420 
 
 KING'S ECLECTIC OBSTETRICS. 
 
 acts upon the right side of the chin], and the inclined pelvic planes- 
 cause the head to rotate, carrying the chin from left to right, in front 
 and behind the symphysis pubis, while the forehead passes from right 
 to left, backward into the hollow of the sacrum. Should the chin fail 
 to rotate toward the symphysis pubis, the labor will be immensely 
 difficult, if not altogether impossible, because the oceipito-mental 
 diameter of the head must, toward the termination of the process, offer 
 to the antero-posterior of the inferior strait, or nearly so, before the 
 head can be born. The descent and rotation of the head being now 
 completed, the process of flexion commences, the pains push the body 
 of the inferior maxillary bone, and finally the fore-part of the neck 
 against the posterior surface of the pubes, which arrests its progress,, 
 and, in consequence of the impossibility of any further descent of the 
 neck, the expulsive force is exerted at this time, principally upon the 
 occiput, and the head is gradually delivered by successively presenting 
 at the vulva, first the chin, then the mouth, nose, eye. c , forehead, 
 anterior fontanelle, posterior fontanelle, and occiput, which latter has 
 to traverse the whole anterior sacral surface, a distance of about five 
 inches and a quarter; and during the delivery the perineum becomes 
 greatly distended. As the chin emerges under the pubic arch, there is 
 not a correspondence of the whole measurement of the oceipito- 
 mental diameter of the fetal head with the antero-posterior diameter 
 of the inferior strait, as shown in the linear representation of the 
 various degrees of the head's disengagement, in Fig. 58, in which, 
 while the head is in the same position, the occiput is represented as 
 departing more and more from the shoul- FIG 58. 
 
 ders. The head being disengaged, the 
 motion of restitution follows, placing the 
 occiput to the. right side qf the mother, 
 and which, as in vertex presentations, is 
 owing to the rotation of the shoulders at 
 the lower strait. The head being deliv- 
 ered, the expulsion of the body is effected 
 as in ordinary vertex positions. It must 
 be recollected, that in this position the left 
 side of the child's face is anterior and 
 rather more depressed than the other side 
 upon entering the superior strait, and on 
 making an examination, the finger comes in contact with the left eye 
 or malar bone, upon which part is formed the primary tumor. Nsege'le 
 observes that the swelling forms "first upon the upper part of the"
 
 DIFFICULT LABOR FROM MAL-POSITION OF THE HEAD, ETC. 421 
 
 left "half of the face, which in this species of a face presentation (left 
 mento-iliac) is always situated lowest." " If the progress of the head 
 through the external passages be unusually rapid, this is the only 
 tumefaction observed; but if it advances slowly, and the head remains 
 a long time in the cavity of the pelvis before it actually enters the 
 vagina, the inferior half of the left side of the face, viz.: part of the 
 left cheek, will be remarked after birth as being the principal seat of 
 the swelling/' a secondary tumor being formed there. * 
 
 It is sometimes the case, especially when the chin is situated rather 
 posteriorly, that previous to the movement of rotation a certain degree 
 of flexion takes place, which causes the forehead to descend to the 
 pelvic floor, after which the chin rotates to the pubic symphysis, and 
 the delivery is accomplished as in other instances. 
 
 B. MECHANISM OF EIGHT MENTO-ILIAC POSITION. 
 
 This is the most frequent of the face presentations, and is usually 
 named the first position. The positions of the diameters of the fetal 
 head, and their relations with the pelvic diameters, will be the same 
 as in the left mento-iliac cases; the exceptions are, that in the present 
 position the forehead corresponds to the left iliac fossa, and the chin 
 to the right iliac fossa; the child's back is toward the left side of the 
 mother, and its abdomen toward her right side ; its right side is in 
 front, its left behind, and the feet are above and to the left. (Fig. 56.) 
 The right side of the face is anterior and more depressed than the 
 other side, and the finger comes in contact with the right eye or malar 
 bone, anu upon which part is formed the primary tumor. The 
 mechanism in this case is precisely similar to the one just described, 
 with the exception that rotation takes place from right to left, the 
 spine of the right ischium being the directing agent and acting upon 
 the left side of the chin. 
 
 TREATMENT. Although face presentations are accidents, or 
 deviations from vertex positions, yet, as a general rule, the natural 
 powers will be found adequate to safely terminate the labor, and the 
 practitioner must not interfere as long as the pains are regular and 
 energetic, the parts cool, the patient free from febrile symptoms, and 
 the head advancing, however slowly. If, however, the pains become 
 feeble and insufficient, or accidents should occur, then interference will 
 be required. Turning was formerly recommended by authors, but 
 from the difficulty, and the danger to both the mother and child, 
 attending this operation, it is at the present day very rarely attempted 
 and is not advised by recent authorities.
 
 422 KING'S ECLECTIC OBSTETRICS. 
 
 In relation to face presentations, Dr. Dewees has recommended the 
 following manipulation : 
 
 "In the first and second positions, we must have the concurrence 
 of the following circumstances, before we attempt the reduction of 
 the head; first, the uterus must be sufficiently open to permit the 
 hand to pass, with little or no difficulty; second, the head must not 
 have entirely passed the superior strait ; third, the waters must have 
 been recently, expended. If these advantages combine, after having 
 the woman properly placed, a hand must be passed into the uterus; 
 and the choice of the hand is a matter of the first consequence to tin- 
 success of the operation: the governing rule is simple, and easily 
 remembered; namely, the hand which is to the. side on which the 
 vertex and forehead are placed ; that is, in the first, the right hand 
 must be used; because, when before the patient, the right hand otters 
 to the left side of her, or the pelvis ; if the second be the position, the 
 left hand must be employed, for a like reason. [These positions are 
 reversed, in my arrangement. K.] 
 
 "In the first position of the face, we pass the right hand into the 
 uterus in such a manner as shall put the back of the fingers to the 
 posterior part of the pelvis, or before the left sacro-iliac symphysi.-, 
 and place them on the side of the head, while the thumb is pressed 
 against the opposite side ; the hea.d is then to be firmly grasped, and 
 raised to the entrance of the superior strait. When the head is thus 
 poised, the extremities of the fingers are to be carried over the vertex, 
 while the thumb is moved to the center of the upper part of the fore- 
 head ; the fingers are then made to draw the vertex downward, while 
 the thumb tends by its pressure, to carry the face upward, thus 
 executing a compound action upon the head. All this, it should be 
 remembered, must be executed in the absence of pain; if we find, 
 when pain comes on, that the vertex moves sufficiently downward, 
 and the face upward, to give assurance it will now descend, we may 
 withdraw the hand, and trust the rest to the action of the uterus. 
 But if, on the contrary, upon the accession of the pain, we find the face 
 still has a tendency downward, we may be certain that the reduction is 
 incomplete; and we must again and again attempt it, in the absence 
 of pain, if it be necessary : for, under the circumstances I have stated, 
 we are pretty sure of success under a well-directed management. 
 
 " In the second position, we employ the left hand, under the condi- 
 tions I have stated for the first, and act in every respect as directed 
 for that presentation."
 
 DIFFICULT LABOR FliOM MA [.-POSITION OF. THE HEAD, ETC. 423 
 
 It is extremely doubtful whether this manipulation can really be 
 effected; in the first place, if the waters have been discharged, it will 
 be very difficult, if not impossible to introduce the hand as stated, from 
 the brim being occupied by the head, and the fetus being directly 
 pressed upon by the uterine walls, besides the attempt will be exceed- 
 ingly painful. In the second place, a failure will expose the mother 
 to the still more dangerous necessity of pelvic version, the forceps, or 
 even the perforator, and more especially should the presentation be 
 complicated with descent of an arm or foot, or prolapse of the cord. 
 
 Most generally, the existence of a face presentation is not ascer- 
 tained until the part has so far descended into the pelvic cavity, as to 
 render it impossible, either to push it into the upper pelvis, or effect 
 the above operation of bringing down the vertex. In such instances,, 
 it will become necessary to be guided by the general principle of 
 obstetrics, to wait until symptoms present which indicate the need of 
 artificial aid, and then make use of those means best calculated to 
 overcome the difficulty. The vectis will probably be found the most 
 appropriate instrument in a majority of cases; if the head be low 
 down, and particularly if rotation does not occur, the forceps may,, 
 perhaps, be employed advantageously though the selection of the 
 instrument must depend upon the peculiar character of the case, and 
 the judgment of the practitioner. If these means fail, the only resource 
 is craniotomy. The perforator, however, will not be needed except 
 in extreme cases; and should not be resorted to until all hope of de- 
 livery by the forceps is abandoned, and only then after the concur- 
 rence of another physician. The reckless sacrifice of the child's life 
 is too often the case under such circumstances. The delivery can 
 usually be accomplished with the forceps, where operative interfer- 
 ence becomes necessary. In these cases, much patience, gentleness 
 and sympathy are required on the part of the practitioner, who must 
 encourage his patient from time to time, and endeavor to keep her 
 from becoming depressed and discouraged. 
 
 I have not, heretofore, named the only and positive rule to be 
 observed in all face cases, whatever may be their position, viz.: to bring 
 the chin to the pubic arch, so that the original flexion of the head may 
 be restored as soon as possible after the delivery of the chin ; and 
 in by far the greater number of instances in which this rotation 
 is effected, the labor will terminate without any formidable re- 
 sults. If this rotation can not be effected, and the forehead 
 should present at the pubic symphysis, the practitioner must make 
 use of means the most applicable to the emergency. Professor
 
 424 KING'S ECLECTIC OBSTETRICS. 
 
 Meigs remarks, that in all face presentations, " the great doctrine 
 is, to bring the chin to the pubic arch, because the chin, being the 
 mental extremity of the five-inch mento-occipital diameter, may escape 
 by gliding an inch downward, behind the symphysis pubis; whereas, 
 if it be directed backward to the sacrum, it must slide five inches 
 down the sacrum and coccyx, and from three to three and a half 
 inches over the extended perineum before it can be born ; but five 
 inches and three inches make eight inches. The child's neck is not 
 eight inches long. Therefore, before the chin can slide down the 
 sacrum, and off the anterior edge of the extended perineum, a good 
 part of the child's thorax must be pressed or jammed into the excava- 
 tion along with the head, the vertical diameter of which alone is 
 more than three and a half inches." This is a correct representation 
 of the matter, and the practice alluded to, of bringing the chin to the 
 pubic arch, is the one at present universally pursued by all scientific 
 accoucheurs. 
 
 6. EAR PRESENTATIONS, or Presentations of the Side of the 
 Head } occur very rarely ; they are considered as deviations from the 
 vertex presentations, and occasioned by an undue obliquity of the 
 uterus, or, perhaps, in some instances, an abnormal amount of liquor 
 amnii. In 20,517 instances, they have been met with only six times, 
 five of which were of the left side of the head, and the remaining one 
 of the right. They are known by the presence of an, ear at the supe- 
 rior strait. Each side of the head may present in three different posi- 
 tions, which are determined by the relations of the ear to the maternal 
 pelvis ; they have been classified as follows : 
 
 PRESENTATION OF THE EIGHT SIDE. 
 
 1st. Position Lobulo pubal. 
 
 2d. Position Right lo! ulo-iliac. 
 
 3d. Position Left lobulo-iliac. 
 
 PRESENTATION OF THE LEFT SIDE. 
 
 1st. Position Lobulo-pubal. 
 
 "Id. Position Right lobulo-iliac. 
 
 3d. Position Left lobulo-iliac, 
 
 DIAGNOSIS. As there is no part of the fetal body likely to be 
 confounded with the ear, its detection may be accomplished with but 
 little difficulty. The ear may be felt, with the surrounding bony
 
 DIFFICULT LABOR FROM MAL-POSITION OF THE HEAD, ETC. 426 
 
 head ; we know the face to be situated anterior to the tragus, and the 
 occiput to be behind the helix, or circumference of the ear, so that 
 from these marks we may readily determine the position of the head. 
 
 A. In the LOBULO-PUBAL POSITION, of the Right Side of 
 the Head, the lobe of the ear, as well as the base of the cranium, look 
 toward the pubes, the long diameter of the external ear presents in 
 the direction of the antero-posterior diameter of the superior strait, 
 the vertex is at the promontory of the sacrum, the convexity of the 
 helix and the occiput are directed toward the left side of the pelvis, 
 and the face and tragtis toward the right side. The child's back is 
 toward the left side of the mother, its front toward her right side, its 
 left side looks posteriorly, its right side anteriorly, and its feet are 
 above and to the right. 
 
 Tiiis is a deviation of a left occipito position, produced by an ante- 
 rior obliquity of the uterus, and should be remedied by placing the 
 patient upon her back, with the pelvis somewhat elevated, raising the 
 fund us upward and backward, and then applying a bandage firmly 
 around the abdomen. The obliquity removed, the vertex passes in 
 front of the sacral promontory, the head rises, and gradually recovers its 
 original left occipito position, and the delivery is terminated naturally. 
 
 B. In the RIGHT LOBULO-ILIAC POSITION, of the Right 
 Side of the Head, the lobe of the ear looks toward the right side of 
 the pelvis, the long diameter of the external ear presents in the direc- 
 tion of the transverse diameter of the pelvis (or nearly so), the vertex 
 is at the left iliac fossa, the convexity of the helix and the occiput are 
 directed toward the pubes, and the face and tragus toward the sacrum. 
 The child's back is anteriorly, its front posteriorly, its left side is 
 toward the left of the mother, its right side toward her right, and the 
 feet above, and toward her left, and back. 
 
 This is, likewise, a deviation from a left occipito position, occasioned 
 by an extreme right lateral uterine obliquify, and should be managed 
 by placing the female on her left side, elevating the fundus upward 
 and to the left, and applying the bandage as before. The obliquity 
 removed, the head engages in the brim, and the delivery terminates 
 naturally. 
 
 C. In the LEFT LOBULO-ILIAC POSITION, of the Right 
 Side of the Head, the lobe of the ear is toward the left side of the 
 pelvis, the long diameter of the concha is parallel, or nearly so, to the 
 pelvic transverse diameter, the vertex is at the right iliac fossa, the
 
 420 KING'S ECLECTIC OBSTETRICS. 
 
 convexity of the helix and the occiput look toward the sacrum, and 
 the face and tragus toward the pubes. The child's back is toward 
 the maternal back, its front anteriorly, its left side toward the right 
 of the mother, its right toward her left, and the feet above, and toward 
 her right, and front. 
 
 This is a rare presentation, and is a deviation from a left occipito- 
 posterior position ; it is produced by an extreme left lateral obliquity. 
 The treatment is similar to the previous instances ; the female must 
 be placed upon her left side and bandaged ; the vertex engages in the 
 brim, and the labor terminates as in a left occipito-posterior position. 
 
 In these lateral obliquities, the object of the bandage is to prevent 
 the uterus, after a change in its position has been effected, from return- 
 ing to its original inclination. 
 
 D._ When the LEFT SIDE OF THE HEAD presents, the 
 relations with the pelvis are the same as in the preceding instances 
 but the partial relations are inverted. Thus, in the LOBULO-PU- 
 BAL POSITION of the Left Side of the Head, the lobe of the ear 
 is toward the pubes, the long diameter of the concha corresponds with 
 the pelvic antero-posterior diameter, and the vertex is at the sacral 
 promontory ; but the convexity of the helix and the occiput are 
 directed toward the right side of the pelvis, and the face and tragus 
 toward the left. The child's back is toward the right side of the 
 mother, its front toward her left side, its left side looks anteriorly, its 
 right posteriorly, and its feet are above and to the left. 
 
 E. In the RIGHT LOBULO-ILIAC position of the left side, 
 the lobe of the ear will be directed toward the right side of the pelvis, 
 the vertex toward the left, the occiput and convexity of the helix 
 toward the sacrum, and the face and tragus toward the pubes. The 
 fetal back will be directed backward, its anterior plane in front, its left 
 side to the right of the mother, its right to her left, and its feet above, 
 toward her left and front. 
 
 F. In the LEFT LOBULO-ILIAC position of the left side, the 
 lobe of the ear is to the left side of the pelvis, the vertex to the right, 
 the convexity of the helix toward the pubes, and the tragus toward 
 the sacrum. The fetal back is directed to the front of the mother, its 
 front to her back, its left side to her left, its right side to her right, 
 and its feet above, toward her right, and back. All these mal-positions 
 are to be rectified upon the general principles described above; if these 
 fail, efforts may be made to bring down the vertex, when the head is 
 at the brim, by a manipulation (somewhat similar to that recommended
 
 DIFFICULT LABOR FROM M A L- POSITION OF THE HEAD, ETC. 427 
 
 by Dr. Dewees for restoring face presentation to vortex, and which is 
 extracted from his Obstetrics and noticed in the present chapter), in 
 which the head will have to be slightly elevated, and then have lateral 
 or anterior pressure or pushing made upon the vertex in a direction 
 toward the chin, followed by a drawing down of the vertex. It may 
 be best performed, after reduction of the uterine obliquity and the 
 application of the bandage, by placing the patient on her hands and 
 knees, with the hips elevated and the shoulders depressed, which 
 position will, in a measure, remove the weight of the child's head 
 from the brim, and thus facilitate the operation. This operation, how- 
 ever, will seldom be needed, and may frequently fail. In cases 
 requiring further aid, it will be prudent to wait, in order to ascertain 
 the adequacy of the natural efforts ; and should these fail, or the usual 
 symptoms demanding interference present themselves, the delivery 
 must be terminated by the vectis, the forceps, or the perforator, as the 
 exigencies of the case may require. Turning has been recommended, 
 previous to the rupture of the membranes, when the os uteri is con- 
 siderably dilated, soft, and dilatable, and may possibly be advantageous 
 in some cases; but after the membranes have given way, it must not 
 be attempted. 
 
 7. Labor may be rendered difficult, by a COMPOUND PRE- 
 SENTATION, in which one of the Extremities Presents with the Head, 
 as a hand, arm, or foot. While the fetus is within the uterus, its 
 position is generally with the arms across the chest, and sometimes 
 with one or both hands against each ear on the sides of the head; in 
 these latter instances, when the membranes rupture and the liquor 
 amnii is discharged, one or both hands, or even the whole arm, may 
 descend with the head, and this is more apt to* occur when the mem- 
 branes have ruptured prematurely. These compound presentations 
 are frequently occasioned by a large pelvis, and when such is the case, 
 the delivery may be safely accomplished without assistance. But when 
 the pelvis is small, the presence of the limb or hand increases the 
 diameter of the head, and prevents its descent into the cavity; and if 
 the uterine contractions are energetic, an arrest or impaction of the 
 head may take place at the superior or inferior strait, and, perhaps, 
 terminate fatally. When the foot, hand, or arm presents with the 
 head, it must be pushed back with two or three fingers, during the 
 absence of a pain, and held there until one or more subsequent pains 
 causes the head to descend so low as to prevent any further falling of
 
 428 KING'S ECLECTIC OBSTETRICS. 
 
 the extremity, after which the labor must be left to the natural powers. 
 In performing this operation, the accoucheur must be exceedingly 
 careful not to draw the arm or hand down, nor to displace the head, as 
 he might thereby convert the case into a shoulder presentation. In 
 order to effect a successful manipulation of this kind, the whole hand 
 will require to be introduced into the vagina, and partly through the 
 os uteri. The operation should not be attempted until the ps uteri is 
 sufficiently dilated, and the expulsive pains have commenced ; for if 
 it be attempted in the first stage of labor, there will be more danger 
 of displacing the head, and of producing an unnecessary degree of 
 irritation of the cervix uteri, and the practitioner should be governed 
 by this rule, even should the membranes have become prematurely 
 ruptured. The upper extremities will generally be more easily 
 returned, on account of their less volume, than the lower. 
 
 If the limb can not be returned, the practitioner must wait, as in 
 other instances, until satisfied that the natural ettprts are inadequate to 
 terminate the labor, and unfavorable symptoms begin to manifest 
 themselves, when it will become necessary to turn, or employ the 
 forceps, or perform craniotomy, according to the peculiar circumstances 
 of the case. It is impossible to lay down any special management of 
 these cases: each one will have its own peculiarities, which, together 
 with the tact and judgment of the attending accoucheur and his 
 medical advisers, must determine the course to be pursued. 
 
 Sometimes both the hands and feet will present together, when it 
 may become necessary to bring down the feet (and more especially 
 when the feet present with the breech), and thus convert it into a 
 . footling case. In doing this, the practitioner can not be too careful in 
 his examination, lest he occasion a descent of the arm or hand, or 
 bring down a hand instead of a foot. Should there be a prolapse of 
 the cord, in connection with these limb presentations, the case becomes 
 still more serious, as far as the child is concerned ; and the manage- 
 ment should be in accordance with the rules hereafter given for this 
 complication hastening the delivery as soon as the pulsations are 
 found to diminish.
 
 PRETERNATURAL LABOR PELVIC PRESENTATIONS. 
 
 CHAPTER XXXIII. 
 
 ON PRETERNATURAL LABOR PELVIC PRESENTATIONS. 
 
 PRETERNATURAL LABOR, is where the head does not present, 
 as, in shoulder or breech presentations; prolapsus of the umbilical 
 ^cord, plurality of children, and monsters, are likewise included in this 
 class. Females frequently have preternatural presentations in several 
 successive labors, and it is impossible to assign any satisfactory cause 
 for them. They can not be the results of violent shocks experienced 
 during gestation, for they more frequently occur in cases where the 
 period of pregnancy has passed free from any accidents. Dr. Denman, 
 in 1795, remarked: "It seems doubtful, therefore, whether we ought 
 not to exclude accidents as the common causes of these presentations, 
 and search for the real cause from some more intricate circumstance ; 
 such as, the manner after which the ovum may pass out of the ovarium 
 into the uterus; some peculiarity in the form of the cavity of the 
 uterus or abdomen ; in the quantity of the waters of the ovum at 
 some certain time of pregnancy ; or, perhaps, in the insertion of the 
 funis into the abdomen of the child, which is not in all cases confined 
 to one precise part, but admits of considerable variety." At the 
 present day we are no further enlightened on this point than were the 
 profession in his time. Some instances may, probably, be owing to 
 uterine obliquity, or to peculiarity of the formation of the pelvis; 
 thus, in three successive labors, I have delivered the same female by 
 turning, each instance being a shoulder presentation in the second left 
 cephalo-iliac position. This person, when young, had been employed 
 to take care of children, and was in the habit of carrying them the 
 greater part of the time on one hip ; the crest of the left ilium was 
 from an inch to an inch and a half higher than that of the right, when 
 she stood erect. Whether this irregularity was owing to the manner 
 in which she held the children during her youth, or whether it was 
 the occasion of the shoulder presentations, I am not prepared to state: 
 it is very difficult, in such obscure matters, to obtain, from one or two 
 incidents connected with them, more than suggestions.
 
 430 KING'S ECLECTIC OBSTETRICS. 
 
 During gestation it is a very difficult, if not an impossible matter, 
 for females to determine with certainty a preternatural position: they 
 may suspect that such is the case, and may almost be positive of it, 
 from certain circumstances not usual with them during this period ; 
 yet although their fears are occasionally confirmed when the labor 
 comes on, they more frequently find themselves mistaken. Nor is it a 
 more easy task for the accoucheur to ascertain, during pregnancy, a 
 preternatural presentation, although some have professed an ability to 
 decide by the sensation imparted to the hand, upon an abdominal 
 exploration over the uterus at an advanced period; also, by the situa- 
 tion at which the pulsations of the fetal heart are heard. But I place 
 no confidence in these methods, either singly or combined. It is not> 
 until the labor has actually commenced, that we can learn with posi- 
 tiveness the presentation of some other part than the head. When 
 the membranes do not present the globular form usual in head presen- 
 tations, but may be felt protruding into the vagina, having a peculiar, 
 elongated, or conical-pointed shape, we may suspect a preternatural 
 presentation, though this has been occasionally met with in vertex 
 positions. " Sometimes, before the os uteri is much dilated, the mem- 
 branes, filled with liquor amnii, pass into the upper part of the vagina, 
 and form a considerable sac with a narrow neck." (Lee.} A spontane- 
 ous and premature rupture of the membranes, is generally a diagnostic 
 sign of preternatural presentation, in which case an internal exam- 
 ination should be made as soon as possible, in order to determine its 
 character. If, previous to the rupture of the membranes, when the os 
 uteri is somewhat dilated, we can not feel the presenting part, or, if 
 felt, it is more movable, less smooth, globular, and resisting, than the 
 head, a preternatural presentation may be suspected: such instances 
 must be closely watched, and great care be had not to rupture the 
 membranes, as an early discharge of the liquor amnii will render the 
 operation of turning very difficult, or entirely impossible. Sometimes 
 a foot, or a hand, or the umbilical cord, may be felt and clearly recog- 
 nized through the membranes, but usually the presenting part can not 
 be ascertained until these have ruptured. 
 
 In all labors, it is of great importance that the practitioner should 
 ascertain, as early as possible, the nature of the presentation, in order 
 that, where assistance is required, it may not be delayed until the 
 golden opportunity for saving mother and child is lost. And, when- 
 ever he is positively satisfied that some other part than the head 
 presents, he should inform the nurse, or friends of the patient, of 
 the fact.
 
 PRETERNATURAL LABOR PELVIC PRESENTATIONS. 431 
 
 Presentations of the head are by far more common than those of 
 :any other part of the child, and have, therefore been arranged under 
 the head of Natural Labors; other presentations being less frequently 
 met with, will be considered under the present head of Preternatural 
 Labors. A preternatural labor may terminate by the natural powers, 
 but the labors are, as a general rule, slow and tedious, more painful 
 to the mother, and more hazardous to the child than iu head presenta- 
 tions; accidents are, likewise, more apt to take place, requiring artifi- 
 cial assistance. 
 
 PRESENTATIONS OF THE PELVIC EXTREMITIES, as 
 of the breech, knees, or feet, belong to preternatural labors. In the 
 majority of these cases the delivery may be safely effected by the natural 
 powers, in consequence of which some eminent authors have included 
 them among natural labors ; but I consider the present arrangement 
 as being more in accordance with the nature of the cases, and better 
 adapted to facilitate an acquaintance with them. From the statistics 
 heretofore cited, which are the recorded statements of British, French 
 and German accoucheurs, it will be observed that the danger to the 
 child is much greater in pelvic presentations than in those of the 
 head, and that the cases in which the inferior extremities present are 
 more hazardous than in true breech deliveries. 
 
 The principal danger in these breech labors is to the child ; the 
 soft passages are not so thoroughly dilated by the body as by the head, 
 because the breech, even with the legs turned up, does not present so 
 great a bulk in circumference or diameters as the head, and conse- 
 quently, when the head is in the pelvic cavity, it can not descend until the 
 parts become still further distended and better adapted for its advance. 
 This renders the delivery of the head slow and tedious, during which 
 the cord may be exposed to a pressure resulting in fetal asphyxia; 
 or the same result may ensue from detachment of the placenta, before 
 the head has passed the outlet; or by pressure upon the placenta when 
 situated between the fetal head and the uterine walls ; in either of 
 which instances the utero-placental circulation is suspended. The 
 first (compression of the cord) is a more common cause of the child's 
 death in footling presentations; the latter, in those of the breech. 
 When the thighs are not flexed upon the abdomen, the child being 
 delivered by the feet or knees, the head will advance more slowly, in 
 consequence of the greater resistance offered to it, than where the 
 limbs are turned up, and the greater delay and longer-continued pres- 
 sure upon the cord renders this species of pelvic deliveries more fatal 
 to the child.
 
 432 KING'S ECI-KITR- OBSTETRICS. 
 
 The danger to the mother in these cases is owing entirely to a delay 
 in the second stage of labor beyond a certain period, to injuries of the 
 soft parts from compression, or improper efforts to facilitate the childV 
 expulsion, and to narrowness or deformity of the pelvis. 
 
 DIAGNOSIS. Previous to labor a pelvic presentation may some- 
 times be ascertained, especially among women whose abdominal walls 
 are thin, soft, and flaccid, by feeling the fetal head in the upper part 
 of the uterus, inclined either toward the right or left side; if auscul- 
 tation be resorted to, the pulsation of the fetal heart may be heard in 
 the upper portion of the abdomen, either above or on a level with the 
 umbilicus; if a vaginal exploration be made it will be found difficult 
 to reach or distinguish the presenting part, though sometimes, instead 
 of the hard, globular tumor felt in head presentations, a small tumor, 
 the foot, may be felt, and ballotted. . 
 
 But the most certain method of diagnosis is during labor, in the 
 absence of pain, when the presenting part can be felt. The breech may 
 be known from the head by its soft and fleshy feel, and by the absence 
 of sutures and fontanelles; it is not so round or so hard as the head. 
 Upon some part of the anterior surface will be felt the hard, resisting 
 trochanter ; passing the finger carefully around, the tuberosities of the 
 ischia may be detected, also the fissure between the nates; at the bottom 
 of this fissure are found the most important signs, as the sacrum, coccyx, 
 anus, and external genital organs; and the anus may be detected 
 from the mouth, by the difficulty, if not impossibility, of introducing 
 the finger into it. The presence of the somewhat sharp-pointed, 
 movable coccyx not only assists us in determining the character of the 
 presentation, but also that of the position, because its point or apex i.s 
 always directed toward the side of the maternal pelvis corresponding 
 with the child's abdomen. The presence of the meconium, which has 
 been noticed by some writers as a diagnostic sign, is really of little 
 value, as it is frequently met with in head presentations, and also 
 occurs as a sign of the child's death. 
 
 Having become positively certain that the breech presents, it should 
 be named to the husband, nurse, or some relative, but great care must 
 be taken to conceal it from the patient, lest it impart a shock to her 
 mind which may suspend or retard the labor for several hours. The 
 communication should be made to the husband in a separate room, 
 and all the dangers to which the child is exposed, fully made known, 
 so that in case it be still-born, the skill or ability of the medical 
 attendant may not be called into question. Should the sex of the
 
 PRETERNATURAL LABOR PELVIC PRESENTATIONS. 
 
 433 
 
 child have been ascertained during the examination, it must not be 
 made known to any one, lest it reach the patient's ears, and effect 
 an unfavorable influence over the progress of the labor, by the dis- 
 appointment it might occasion should it be different from the one 
 desired. 
 
 By reference 1o a preceding page it will be s'een that four positions 
 are given, in any one of which the breech may present; and which 
 positions are ascertained by the coccyx, ischiatic tuberosities, genitals, 
 etc., and named according to the situation of the back or sacrum of 
 the child. 
 
 1. MECHANISM OF FIRST LEFT SACEO-ILIAC POSITION. 
 
 In this position the sacrum of the fetus faces the maternal left ilium 
 anteriorly, while the hips or bi-trochanteric diameter are parallel with 
 the right oblique diameter of the superior strait [or, for a time with 
 its antero-posterior or transverse diameter] ; the abdomen, and pos- 
 terior part of the fetal thighs flexed upward, are toward the right ilium 
 posteriorly, its left side is in front, and its right side to the back of 
 the mother; the head is slightly flexed on the chest, and inclined to 
 the right and posteriorly. But in all the positions named, as soon as 
 the bag of waters rupture and all the liquor amnii escapes, the uterus 
 comes directly in contact with the fetus, perfecting the flexion of the 
 head, and at the same time maintaining its limbs in close contact with 
 its body. 
 
 As soon as the membranes rupture, 
 a large amount of the liquor amnii 
 escapes, and the presenting part, which 
 was previously high up, engages in the 
 brim, and its position can now readily 
 be ascertained. The hips usually en- 
 gage in the direction of the right 
 oblique pelvic diameter, occasionally 
 of the transverse. (Fig. 59.) As the 
 uterine contractions continue, the nates 
 generally descend, with the hips in the 
 right oblique diameter, into the pelvic 
 cavity until they arrive at the inferior 
 strait, the left or anterior nates being 
 the lowest. [This oblique diameter is 
 soon taken by the hips, should they be at first situated transversely.] 
 At this point a slight or partial rotation sometimes, but not always, 
 28 
 
 FIG. 59.
 
 434 
 
 KING'S ECLECTIC OBSTETRICS. 
 
 takes place, and the child's left hip is carried slightly to the left, and 
 FIG. GO. somewhat toward the pubis, while its 
 
 right similarly rotates to the right 
 toward the hollow of the sacrum. 
 (Fig. 60.) The left hip appears first 
 at the vulva, under the pubic arch, the 
 bi-trochanteric diameter being nearly 
 if not quite in the direction of the 
 right oblique diameter; this hip main- 
 tains its position there, while the right 
 hip is made to gradually traverse the 
 hollow of the sacrum, and inner per- 
 ineal surface, describing an arc of a 
 circle around the left hip as a center. 
 In some cases the left hip, during this 
 motion of the right, ascends behind 
 the pubic symphysis. 
 
 "While the right hip is passing over the posterior wall of the pelvis, 
 the body of the child becomes curved laterally on its anterior side, so 
 FlG 61 as to accommodate itself to the curvature of 
 
 the pelvic cavity. (Fig. 61.) This lateral 
 curvature continues until the body is ex- 
 pelled; though as the parts are disengaged 
 they recover their original position. 
 
 As the right hip advances toward the pos- 
 terior commissure, the bis-iliac diameter of 
 the fetus corresponds with the pelvic antero- 
 posterior diameter, and the process of resti- 
 tution takes place after the delivery of the 
 pelvis, placing it in its original diagonal 
 position; though, in most cases, this oblique 
 
 position is retained throughout the delivery. The hips having 
 been delivered, the fetal breast engages in the excavation, and as 
 the body descends, the inferior extremities fall out. The shoulders 
 are commonly in the same oblique pelvic diameter as the hips, when 
 they arrive at the inferior strait, and are born in a similar manner, 
 the right or posterior shoulder being generally delivered first. It 
 has been advanced, heretofore, by many writers, that when the hips 
 or shoulders reached the floor of the pelvis, that rotation, somewhat 
 like that of the head, occurred, placing one hip or shoulder under 
 the pubic arch and the other in the hollow of the sacrum. But that
 
 PRETERNATURAL LABOR PELVIC PRESENTATIONS. 435 
 
 careful observer, M. Xseg^le denies this in something like the follow- 
 ing language: "In its (the breech) farther advance into the pelvis, it 
 is always found in an oblique direction, the hip directed forwards 
 standing lowest. In this oblique position, with reference to its trans- 
 verse and perpendicular diameters, it is forced through the inlet, the 
 cavity, and the outlet of the pelvis; and in general none of these 
 rotations occur, erroneously described in many manuals and com- 
 pendia as appertaining to this species of labors." 
 
 The arms are usually applied closely to the thorax, and are thus 
 delivered; but it sometimes happens, that one or both of them get up 
 along the sides of the head, rendering the delivery of the head very 
 difficult, and requiring artificial interference. This may be occasioned 
 by the smallness of the pelvis, or the unusual size of the child; but 
 it more commonly arises from an imprudent traction made by the 
 accoucheur on the pelvic extremity, in order to facilitate the delivery, 
 and which improper interference may still further increase the diffi- 
 culty of the labor, by effecting an extension of the head. In ordinary 
 instances, where one arm has been thrown up by the side of the head, 
 it will most commonly be the one behind the pubic symphysis. 
 
 While the shoulders are being disengaged, the head, usually well 
 flexed upon the thorax, has entered the superior strait in the direction 
 of its left oblique diameter, the forehead being toward the right sacro- 
 iliac symphysis, and the occiput toward the left acetabulum, which 
 flexion and diagonal position it retains until it has reached the inferior 
 strait. At this strait, the relation of the pelvic diameters with those 
 of the fetal head will vary according to the degree of flexion. If the 
 flexion be moderate, the occipito-frontal diameter will be parallel to 
 the left oblique of the strait, and the bi-parietal to the right oblique, 
 while the trachelo-bregmatic diameter will very nearly correspond 
 with the axis of the inferior strait. But if there be a greater degree 
 of flexion, the sub-occipito-bregmatic will correspond with the pelvic 
 left oblique diameter, and the axis of the lower strait will very nearly 
 pass in the direction of the occipito-mental diameter. 
 
 Upon arriving at the inferior strait, the head undergoes the move- 
 ment of rotation, by which the face is carried into the hollow of the 
 sacrum, the occiput behind the symphysis pubis, and the nck under 
 it; the sub-occipito-bregmatic diameter is placed nearly in correspond- 
 ence with the pelvic antero-posterior. At this period, the head is 
 nearly, or altogether in the vagina, and consequently the contractions 
 of the uterus exert but little or no expulsive influence upon it; the 
 further progress of the head is, therefore, to be effected by the con-
 
 436 KING'S ECLECTIC OBSTETRICS. 
 
 tractions of the abdominal muscles. As the neck is situated firmly 
 against the pubic arch, preventing the descent of the occiput, the 
 contractions will occasion the head to become more and more flexed 
 upon the chest, and while this motion is taking place, the chin, face, 
 forehead, and posterior fontanelle, traverse the internal face of the 
 sacrum and perineum, and successively appear in front of the posterior 
 commissure of the vulva, while the occiput is the last delivered. 
 
 2. MECHANISM OF FIRST RIGHT SACRO-ILIAC POSITION. 
 
 In this position the sacrum of the fetus faces the maternal right 
 ilium anteriorly, while the bi-trochanteric diameter is parallel with the 
 left oblique diameter of the superior strait [or, for a time, with it* 
 antero-posterior or transverse diameter] ; the abdomen, and posterior 
 part of the fetal thighs flexed upward, are toward the left ilium 
 posteriorly, its right side is in front, and its left side to the mother's 
 back ; the head is flexed and inclined to the left and posteriorly. 
 
 The mechanism in this position is precisely similar to the one just 
 described, with the exception of an inversion of the relations of the 
 parts. The right hip is the one placed at or near the pubic arch, while 
 the left traverses the posterior wall of the pelvis. The right shoulder 
 assumes the same oblique diameter as the hips had previously, and the 
 head engages in the cavity with the occiput toward the right acetabu- 
 lum, and the forehead toward the left sacro-iliac symphysis. 
 
 3. MECHANISM OF SECOND LEFT SACRO-ILIAC POSITION. 
 
 In this position the sacrum of the fetus faces the maternal left ilium 
 posteriorly, while the bi-trochanteric diameter is in the direction of 
 the left oblique diameter of the superior strait; the abdomen and 
 posterior part of the thighs flexed upwardly, are toward the right 
 ilium anteriorly, its left side is in front, and its right side to the mother's 
 back; the head is flexed and inclined to the right and anteriorly. 
 The left hip presents, and is the lowest during the whole of the 
 expulsion, and the whole of the body is expelled, as in the previous 
 instances, with the exception of the abdomen looking forward to the 
 right. The left hip is the one placed at or near the pubic arch, while 
 the right traverses the posterior wall of the pelvis. The left shoulder 
 assumes the same oblique diameter as the hips had previously, and the 
 head engages in the cavity with the occiput toward the left sacro-iliac 
 symphysis, and the forehead toward the right acetabulum. As with 
 an occipito-posterior position, when the head is in the pelvic cavity 
 near the floor of the pelvis, extensive rotation occurs from left to right,
 
 PEETEENATURAL LABOR PELVIC PRESENTATIONS. 437 
 
 which places the occiput under the pubic arch, and the face in the 
 hollow of the sacrum. The whole body of the child may be observed 
 to partake in this rotation, which brings the back of the child to the 
 front, and its abdomen to the back. The head is then born as in the 
 first sacro-iliac positions. It may be observed here, that in these 
 second sacro-iliac positions, it is better, in order to avoid difficulty 
 when the head reaches the floor of the pelvis, to aid in effecting the 
 extensive rotation, as hereafter explained in the treatment of breech 
 cases, provided it does not take place naturally. 
 
 4. MECHANISM OF SECOND EIGHT SACRO-ILIAC POSITION. 
 
 In this position the sacrum of the fetus faces the maternal right ilium 
 posteriorly, while the bi-trochanteric diameter is in the direction of the 
 right oblique diameter of the pelvic brim; the abdomen, and posterior 
 part of the thighs flexed upwardly, are toward the left ilium anteriorly, 
 its right side is in front, and its left side to the mother's back ; the 
 head is flexed and inclined to the left and anteriorly. The right hip 
 presents, and is the most dependent part. The mechanism of- this 
 position is the converse of the preceding, the occiput engaging toward 
 the . right sacro-iliac symphysis, and the forehead toward the left 
 acetabulum. 
 
 TREATMENT OF BREECH PRESENTATIONS. 
 
 In all presentations of the pelvic extremity, the cases should be left 
 to the natural powers, unless accidents occur imperatively calling for 
 assistance, and this point can not be too strongly urged upon the 
 student. Great care must be taken to preserve the first stage of the 
 labor as thorough as possible, that the os uteri may become well 
 dilated, and not only should the accoucheur be extremely careful not 
 to rupture the bag of waters, but he should also prevent any efforts 
 on the part of the woman that may tend to this end ; she should be 
 kept quiet and urged to move about as little as possible. The mere 
 fact of a child being born " doubled up," as in a breech presentation, 
 does not necessarily presuppose interference, especially when we call 
 to mind the diameters of the parts. The largest diameters of the fetal 
 breech, as the bi-trochanteric and bis-iliac, are smaller than the 
 bi-parietal diameter of the head, or the bis-acromial diameter. When 
 a presentation of this kind is met with, no attempts should be made to 
 bring down the feet and inferior extremities, unless there be proper 
 cause for so doing; to do otherwise is bad, meddlesome practice. 
 When the breech descends with the limbs flexed upon the abdomen,
 
 438 KING'S ECLECTIC OBSTETRICS. 
 
 the labor proceeds slowly, sometimes lasting for hours, in consequence 
 of the yielding character of the presenting parts, which, not being firm 
 and resisting, like the head, give way, to a certain extent, during each 
 pain, and thus require a longer time to render the soft parts of the 
 mother sufficiently yielding. But this protractedness in the delivery 
 of the fetal pelvis, is rather to the child's advantage; for the maternal 
 parts become so thoroughly dilated and yielding thereby, that the head 
 passes without any difficulty, a few efforts of the patient being suffi- 
 cient, in ordinary instances, to expel it shortly after the delivery of 
 the shoulders. But, if the feet be imprudently brought down by an 
 unskillful accoucheur, the smaller bulk offered to the soft tissues of 
 the maternal generative parts, w r ill not so completely dilate and adapt 
 them to the easy passage of the head, which in consequence may. 
 be so long delayed in its expulsion as to occasion the death of the 
 child. 
 
 Neither is it proper to employ any extracting force, for the purpose 
 of facilitating delivery, as the child may be destroyed by a severe and 
 injurious extension of the neck; it being borne in mind that the neck 
 of the child before birth is capable of sustaining no more extractive 
 force than afterward, and any great amount of traction must injure 
 the spinal cord; beside, the arms not being maintained in their 
 position by the contractions of the uterus, become arrested, and do 
 not simultaneously participate in the descent accomplished artifi- 
 cially by traction; hence, as the head advances by the traction, they 
 become placed on its sides, and greatly interfere with its expul- 
 sion during the last period of the labor. When the contractions of 
 the uterus expel the child, the arms are born in the position originally 
 assumed by them ; but if traction be made, its influence is exerted 
 only on the body, and there is invariably a tendency of the arms to 
 rise along the sides of the head, because the pressure of the uterine 
 fundus is then no longer exerted upon them to keep them in place. 
 Consequently, it is bad practice in ordinary cases, to bring down 
 the feet, as well as to attempt to hasten labor by making artificial 
 traction. . 
 
 In these preternatural cases, the physician should be more attentive 
 to the progress of labor than in natural cases, being careful, however, 
 not to alarm his patient by an unnecessary display of over-anxiety, or 
 officiousness, nor to make any injudicious attempts to advance its 
 progress during the early stage. During the escape of the breech 
 from the vulva, the perineum becomes greatly distended, and it 
 should be steadily supported in order to prevent the too rapid advance
 
 PRETERNATURAL LABOR PELVIC PRESENTATIONS. 439 
 
 of the pelvic extremity, as well as to impart a motion to it in the 
 direction of the inferior part of the pelvic axis, and without which 
 movement much delay would be occasioned. Dr. Collins remarks: 
 " The most critical part of the delivery, should much delay take place, 
 is during the passage of the head, which pressing continuously on the 
 funis speedily deprives the child of life. To guard against this, 
 therefore, the breech should be permitted to pass slowly and unas- 
 sisted, so as gradually and perfectly to dilate the soft parts, thereby 
 greatly facilitating the completion of the labor." When the contrac- 
 tions of the uterus are sufficient to expel the fetus, however slowly, no 
 interference whatever is required; it is only when the breech has so 
 far advanced externally as to permit the cord to be reached, that any 
 aid will be needed. The cord must be drawn down a little, in order 
 to prevent it from being broken off, as well as to prevent its vessels 
 from being stretched. The umbilical arteries of the cord run in a 
 tortuous manner around the vein, and consequently any stretching 
 of the cord would, by diminishing their caliber, as effectually check 
 the circulation, as from direct pressure of the head while in the 
 pelvis; hence, by keeping a loop of the funis slack, we prevent any 
 danger to the child from tension of the cord during the advance of 
 the body. After the cord has been placed within reach, the necessity 
 for interference can always be determined by the character of its 
 pulsations; if these be strong, haste is not required; if they become 
 feeble, irregular, or intermittent, assistance must not be delayed, and 
 the body of the child may be brought down during a pain ; if they 
 have ceased, an indication of the child's death, the case should be left 
 to nature. A soft napkin should always be wrapped around the 
 child's body, as soon as the feet have been delivered, which will 
 protect its surface from being injured, as well as enable the physician 
 to hold it more firmly when performing any manipulation which may 
 be required. 
 
 The passage of the shoulders through the external parts must be 
 carefully attended to, and if they do not present favorably at the 
 outlet, rotation should be made, to bring the proper one under, or 
 nearly under, the pubic arch, and the other into the cavity of the 
 sacrum. If the arms remain by the side of the child, there will be no 
 delay in the expulsion of the shoulder, but if they have become ele- 
 vated, the advance of the shoulders and head will be very much, if not 
 entirely, retarded. To obviate this, one or two fingers are to be 
 passed along the arm, as near as possible to the elbow, when the elbow 
 must be drawn downward and forward, across the face and chest, until
 
 440 KING'S ECLECTIC OBSTETRICS. 
 
 it arrives at the outlet; one arm having been liberated, the other may 
 be drawn down with but little difficulty. The easiest way of effecting 
 the descent of the arms, is to begin with the one nearest to the 
 perineum, and to draw downward, and anteriorly over the face and 
 chest of the child ; if the force be directly downward, or toward 
 the back of the child, or be made with suddenness or violence, the 
 arm may be broken or dislocated, and the soft parts of the mother be 
 considerably injured. The blunt hook has been advised in these 
 cases, but I see no necessity for it, as the arms may always be reached 
 by the fingers. 
 
 The shoulders and arms having escaped, the situation of the head 
 must be ascertained by an examination. For this is the critical period, 
 in which the child is subject to great peril from the following causes, 
 and in w r hich its life or death is determined in a few seconds: 1, 
 compression of the cord ; 2, the uterus being, as it were, in an empty 
 state, diminishes in size, which interferes with and prevents a full flow 
 of blood to and from the placenta, thereby lessening the aeration of 
 the fetal blood to a greater or lesser extent; 3, the reduction in size of 
 the uterus is followed by a detachment of the placenta from the uterine 
 wall ; 4, the head now being nearly or entirely out of the uterus, is no 
 longer under the influence of its expulsive action its vis & tergo 
 and unless this lost force is compensated, the child will certainly be 
 lost. If no improper interference has been attempted, all these dan- 
 gers may generally be avoided by the straining or bearing-down efforts 
 of the diaphragm, abdominal muscles, etc. 
 
 During the progress of the labor the accoucheur must so manage, 
 if required, as may occasionally be the case in the second sacro-iliac 
 positions, that when the head is in the pelvis, the face will be directed 
 toward the hollow of the sacrum. When this is effected, either natu- 
 rally or artificially, he will elevate the child's body toward the maternal 
 abdomen, so as to bring the long diameter (mento-occipital) of its head 
 in correspondence with the axis of the inferior strait ; and should the 
 chin have departed from the breast, he will introduce two fingers and 
 place them upon the child's upper jaw, and by gentle pressure depress 
 the chin upon the breast, thus facilitating the expulsion of the head by 
 presenting a shorter diameter of the head to the inferior strait ; and, 
 if necessary, the flexion may be still farther facilitated by parsing a 
 finger or two behind the symphysis pubis, for the purpose of pushing 
 the occiput somewhat upwardly at the same time that the chin is being 
 depressed. At this time, the head, being freed from the uterus, is not 
 influenced by its contractions, and the auxiliary aid of the abdominal
 
 PRETERNATURAL LABOR PELVIC PRESENTATIONS. 441 
 
 muscles, etc., will be required to terminate the delivery ; consequently, 
 instead of waiting for a pain, the patient should be urged to bear 
 down, to use her utmost effort in bearing down, that the head may be 
 expelled, for any delay will endanger the life of the child, from the 
 continued pressure of the head upon the cord, etc. Assistance may 
 likewise be given, by applying gentle extractive force to the shoulders 
 in the direction of the axis of the inferior strait, bearing in mind, 
 however, that an excessive amount of such force, will seriously injure 
 the child's neck. But no force whatever must be employed that 
 would so far stretch the neck as, in the least, to affect the upper part 
 of the spinal cord. Should a delay in the passage of the head occur, 
 the child may be frequently saved, by introducing a finger into its 
 mouth to remove any mucus which may be there, and then "pass two 
 fingers upward until, they reach the two maxillary bones, and cover 
 the nose ; by doing this, the backs of the fingers, pressing the perin- 
 eum backward, serve to keep an open communication with the air, and 
 the child can breathe very well until the expulsive efforts come on." 
 (Meigs.) [A flat, flexible tube introduced into the mouth of the child, 
 has also been advised, for the same purpose.] This author also recom- 
 mends the forceps to be within reach in all pelvic presentations, feeling 
 well assured that he has saved several lives which would have been 
 lost but for this precaution ; I am satisfied that this course is not only 
 wise and prudent, but that a resort to the forceps in all cases of delay 
 in the delivery of the head, in which the pulsations of the cord are 
 becoming feeble, will result in benefit to both the child and mother. 
 
 O ' 
 
 In these cases, the practitioner must act promptly, for a few moments' 
 delay may prove fatal to the child. It should, however, be stated 
 here, that the forceps will not be so frequently required in those cases 
 in which the head is at the superior strait, and in which the bearing- 
 down efforts of the woman are insufficient, as has been generally rep- 
 resented. If the accoucheur or an assistant, will make the bearing- 
 down efforts, by placing his hands upon the inferior portion of the 
 abdomen so as to make strong pressure upon the fetal head, he can 
 supply the required degree of a vis a tergo, and thus obviate the 
 necessity for the application of forceps. The forceps, I consider 
 useful in breech presentations, only after the head has passed through 
 the brim into the pelvic cavity, the expulsive efforts being insufficient 
 for its delivery. If, however, the child be dead, as known by the 
 cessation of pulsation in the cord, and the head be very large, or some 
 obstacle presents rendering it very difficult to extract with the forceps, 
 the perforator may be introduced behind one or both ears, for the pur-
 
 442 KING'S ECLECTIC OBSTETRICS. 
 
 pose of lessening the size of the head, and thus terminating the labor. 
 The head being born, the rest of the labor will be managed as in 
 natural labors. 
 
 When the uterine contractions become inefficient, previous to the 
 expulsion of the breech, or when, from any cause, a quick delivery is 
 demanded, one or two fingers may be passed up and hooked into the 
 groin, and steady and gentle traction be made, in the proper direction, 
 during the presence of a pain ; the pains may, likewise, be rendered more 
 efficient by compressing or manipulating the uterine fundus through the 
 abdominal walls; by the internal administration of Sulphate of Quinia; 
 or the administration of Macrotys may stimulate the uterus to more 
 powerful contraction; the small dose may be repeated every half- 
 hour until the desired result is produced. Sometimes a few doses 
 of the Parturient Balm may be administered, but on no account 
 is Ergot to be given in a case of pelvic presentation. For the purpose 
 of extracting the breech, the fillet and blunt hook have been recom- 
 mended these may sometimes be useful, but great care is required in 
 using them, lest the thighs of the child be fractured. And it must 
 never be lost sight of, that whenever extracting force is employed, it 
 should always be made in the direction of the axis of the pelvic cavity, 
 according to the part at which resistance is offered, whether the force 
 be made with the hand or fingers, or with an instrument. 
 
 The most difficult cases of breech deliveries are those in which the 
 sacrum of the child is directed posteriorly, or toward the maternal 
 sacrum, and during the descent, rotation has not been effected, as may 
 happen in the second sacro-iliac positions; in consequence, when the 
 head reaches the inferior strait, the face of the child will be to the 
 pubis, and its occiput to the sacrum. This will occasion considerable 
 difficulty in the delivery of the head, beside being a very dangerous 
 situation for the child. A complete rotation of the child's body, so as 
 to reverse the positions, and bring the face eventually to the hollow 
 of the sacrum, must be produced, either spontaneously, or by the 
 management of the accoucheur. In these second sacro-iliac positions,, 
 when the breech is low in the pelvis, and not yet delivered, and the 
 desired rotation has not taken place, two or three fingers may be 
 introduced for the purpose of forcing, by steady and continuous pres- 
 sure, that hip which is situated the most anteriorly, toward the pubic 
 symphisis: and the delivery of the hips being achieved in this position, 
 they may be enveloped in a soft napkin, and as the pains expel the 
 body, the accoucheur will gradually continue the rotation in such
 
 PRETERNATURAL LABOR PELVIC PRESENTATION. 443 
 
 manner that the face will be in the desired position at the time it 
 reaches the lower part of the pelvic cavity. And in effecting this 
 change, should the pains urge the body too rapidly onward, he must, 
 by counter-pressure, prevent its too hasty exit, until the rotation is 
 satisfactorily accomplished. 
 
 Sometimes the body of the child will be held by the womb so forcibly, 
 during a pain, that the rotation can not be performed; the practitioner 
 should then operate during the absence of pain, first pushing the 
 child's body upward as far as possible, and then giving to it a compound 
 movement, by drawing it downward and at the same time rotating it. 
 By this manipulation, the arms are prevented from passing up by the 
 sides of the head. 
 
 Should the head, however, have reached the inferior strait with the 
 face to the pubis, the practitioner will cause the female to lie on her 
 back, her hips being brought over the edge of the bed, and the feet 
 supported on chairs by two assistants. As soon as the shoulders are 
 delivered, an assistant will carry the body of the child backward, while 
 the accoucheur will press the perineum back, with one hand, to prevent 
 its forcing the throat against the pubis, and with the other he will 
 bring down the chin, either by introducing two fingers into the mouth, 
 or better, by placing them upon the upper jaw. The chin having 
 been thus depressed, the woman must be urged to bear down forcibly, 
 in order to facilitate the expulsion of the head. Should this method 
 fail, the forceps will probably be required, or perhaps the perforator. 
 
 Notwithstanding the rules just laid down for bringing the occiput 
 under the pubic arch, it must always be borne in mind, that, whether 
 the position be a first or second sacro-iliac, if there has been -no im- 
 proper interference with the labor, the rotation of the head, in the 
 pelvic cavity, will almost always effect the desired results, naturally, 
 bringing the occiput under the pubic arch without any artificial assist- 
 ance. " It appears to be a law in nates presentations, that whatever may 
 be the direction of the child (first or second sacro-iliac) at the begin- 
 ning of labor, it will always, if not interfered with, be found with its 
 anterior surface turned toward one or other of the sacro-iliac sym- 
 physes when the thorax or the shoulders are beginning to pass through 
 the outlet of the pelvis." (Rigby.} Relative to the sacrum of the 
 child being directed toward the maternal abdomen, another writer 
 observes : " It is very desirable the child should be delivered in this 
 position, as it renders the getting away of the head much less diffi- 
 cult ; yet where there has been no interference by the attendant in the 
 previous part of the labor, he will rarely find it necessary to subse-
 
 444 KING'S ECLECTIC OBSTETRICS. 
 
 quently alter the child's position, the breech naturally making the 
 turn, above alluded to, in its passage." (Collins.} 
 
 I have stated heretofore, that it is bad practice, in breech presenta- 
 tions, to bring down the feet ; still, there may be instances where this 
 will be demanded, and where it will become necessary, also to employ 
 some forcible traction, in order to expedite delivery. Thus, in cases 
 where the breech is large and the pelvis narrow, it may be almost 
 impossible for delivery to be effected, without some interference of this 
 kind ; accidents may also occur, at the commencement of labor, which, 
 by jeopardizing the life of the mother, require a hastening of the 
 labor, as in convulsions, hemorrhage, etc. But should these occur 
 while the os u'teri is undilated, temporizing and palliative measures 
 only can be employed, and no attempts whatever should be made to 
 introduce the hand within the uterus for the purpose of bringing down 
 the feet. 
 
 Should these accidents occur when the breech is low in the pelvis but 
 still within the uterus, we must be guided by the circumstances. If the 
 os uteri be rigid, no attempts to introduce the hand must be made 
 until the rigidity is overcome : if it be dilatable and in proper condi- 
 tion the hand may be introduced, whether the membranes be ruptured 
 or not, and the feet brought down. 
 
 If interference is demanded after the breech has been expelled from 
 the uterus, the feet must not be brought down, unless the pelvis be 
 large, or the breech be small, and unless the pains have ceased to be 
 efficient. In this case, if the breech be very low in the pelvis, a finger 
 may be passed above one or both groins, and during the presence of 
 pain, traction may be made in the direction of the pelvic axis. If the 
 breech can not be delivered by this means, the fillet may be employed, 
 and if this can not be applied, the blunt hook must be resorted to. 
 
 As remarked in a previous chapter, knee and feet presentations 
 are mere deviations from the breech, the labors being more painful 
 and difficult, with greater risk to the child, but requiring a similar 
 management. When the KNEE presents, it may be mistaken for an 
 elbow, but may be distinguished from it by the rounded patella with 
 its flat surface, and which is more or less movable on the con dy lea 
 of the thigh bone; the olecranon of the elbow is pointed and sharp- 
 not flat, like the patella, and is not movable. NsegSle observes that 
 the u knee is thicker, has two prominences, and a depression between 
 them, while the elbow is thinner, and presents to the feel, between the 
 two prominences, a projection (olecranon), in which it seems to end."
 
 PRETERNATURAL LABOR PELVIC PRESENTATIONS. 
 
 The shoulder has but one prominence or tuberosity, " from which the 
 bony ridges of the clavicle and scapular spine may be traced." 
 
 In knee presentations it is always advisable to convert them into 
 footling cases, which may be effected by pushing the fetus upward 
 during the absence of pain, so that sufficient space may be gained to 
 bring down the feet. 
 
 A FOOT may be determined from a hand, by its rounded instep, its 
 prominent heel, the toes being all in one line, and no one of the digits 
 being an opponent to the others : the hand has no rounded instep, no 
 prominent heel, the digits are not all in one line, there is a flattened 
 palm, the fingers longer than the toes, not all of the same length, and 
 the thumb opposed to the fingers. The foot is also longer than the 
 hand, and its sole flatter, and the presence of the heel, with the ankle- 
 bone on each side, will distinguish it from the hand and wrist. 
 
 When one foot only descends, we should determine whether it be 
 the right or left but it is not always so easy to detect the position of 
 the child by the foot, at least, not until the hips have engaged in the 
 superior strait. But when both feet come down, crossing each other, 
 the toes will lie in the direction of the child's abdomen or anterior 
 surface. In knee or footling cases, as with those of the nates, 
 nothing can be done by the attendant, except to patiently observe 
 nature's operations, and to quickly detect any departure from their 
 normal course. The labor will be slower and more painful to the 
 mother than if the nates had presented, but its management will be 
 exactly the same, unless, as ascertained from the diminution of the 
 pulsations in the cord, or otherwise, the child's life becomes endangered, 
 when the delivery must be expedited by the means already referred to. 
 
 In cases of breech presentation, various means should be in readi- 
 ness, as a warm bath, etc., to resuscitate the child, should animation 
 be suspended ; its limbs and genitals should also be carefully examined 
 before leaving it ; and if they present appearances of injury, a proper 
 dressing should be applied, in accordance with the nature of the case. 
 If the child be born in a state of defective vitality, some of the 
 measures looking to resuscitation may- be pursued, according to 
 circumstances. 
 
 Rigidity of the os uteri, pelvic tumors or deformities, and other 
 circumstances which may also be present in vertex presentations, 
 occasioning difficult labor, must be treated as directed under the 
 head of Difficult Labor.
 
 446 KING'S ECLECTIC OBSTETRICS. 
 
 CHAPTER XXXIV. 
 
 OF PRETERNATURAL LABOR SHOULDER PRESENTATIONS. 
 
 IT is as difficult to assign a sufficient explanation of the cause of 
 presentations of the superior extremities as of those of the pelvic. 
 They have been attributed to irregular distension of the uterus, to 
 uterine obliquity, to irregular contractions at an early period of labor, 
 etc., and they may have existed primarily. Dr. Rigby remarks: "We 
 may, therefore, state that the causes of arm or shoulder presentation 
 are of two kinds, viz.: when the uterus has been distended by an 
 unusual quantity of liquor amnii, or when, from a faulty condition of 
 the early pains of labor, its form has been altered, and with it the 
 position of the child." Dr. William Leishman, in considering the 
 causes of transverse presentations, calls attention to the fact that 
 "Any fault or deformity in the structure of the- pelvic brim, which 
 may act by preventing the descent of the head into the cavity, may 
 turn aside, toward the iliac fossa, that extremity of the fetal ovoid, 
 when the shoulder may slip down and take its place. The unfort- 
 unate tendency to a recurrence of this presentation in women who 
 have already had a child or children, presenting by the superior 
 extremity, would almost seem to indicate that some anatomical peculi- 
 arity of the parts may be the cause; and it was this which led 
 Wigand to suppose that the form of the uterine cavity was the deter- 
 mining cause, and that, in those cases in which cross-birth occurred, 
 the transverse diameter of the uterus was in the first instance aug- 
 mented, the long diameter of the cavity being thus relatively dimin- 
 ished." Still, these "cross-births," as they are often called, are 
 involved in much obscurity ; there appears to be a natural tendency 
 to them with some women (as above stated), who have them at every 
 labor. 
 
 Previous to the commencement of labor, there are no positive signs 
 by which we can determine the presentation of a shoulder, or of any 
 part of the body; and no dependence can be placed in an unusual, 
 figure of the uterus, as ascertained by applying the hand over the 
 abdomen. A transverse presentation of the fetus may be suspected 
 when the os uteri dilates slowly, when the membranes protrude into 
 the vagina in an elongated form, when the presenting part is beyond
 
 PRETERNATURAL LABOR SHOULDER PRESENTATIONS. 447 
 
 the reach of the finger, and when, after the rupture of the membranes, 
 the pains cease for several hours. A vaginal examination wUl deter- 
 mine the correctness of our suspicions, as well as inform us of the 
 position; and both of these points should be satisfactorily ascertained 
 before any interference is attempted by the practitioner. 
 
 I have already remarked, in a preceding chapter, that there are two 
 positions for each shoulder, viz.: FIRST LEFT CEPHALO- 
 ILIAC, and FIRST RIGHT CEPHALO-ILIAC of the RIGHT 
 SHOULDER, and SECOND LEFT CEPHALO-ILIAC, and 
 SECOND RIGHT CEPHALO-ILIAC of the LEFT SHOUL- 
 DER; and to which the reader is referred for an explanation of the 
 situation of the child in these several positions. 
 
 DIAGNOSIS. Previous to the rupture of the membranes, the 
 presenting part is commonly elevated beyond the reach of the practi- 
 tioner's finger, which alone should lead us to suspect a preternatural 
 presentation; but it may always be felt after they have given way; 
 and then a careful examination should be made, that no doubts, may 
 exist with regard to the nature of the case. This should be satisfac- 
 torily accomplished, in all instances, immediately after the membranes 
 have ruptured, and if necessary, a part of the hand, or even the whole 
 of it, should be introduced into the vagina, for the purpose of making 
 a correct diagnosis. Should the presenting part be an elbow or hand, 
 it may be felt offering at the mouth of the uterus before the rupture of 
 the membranes; and sometimes, after a hand has been clearly detected 
 at the os uteri, it has subsequently become withdrawn, and the vertex 
 found presenting. The shoulder may be known from the head by its 
 being less bulky, less firm and resisting, and by the absence of sutures 
 and fontanelles; from the breech, by the absence of the anus and 
 parts of generation, and by being not so large and less fleshy. The 
 finger, on coming in contact with it, first detects the projecting acro- 
 mion, in front of which will be felt the clavicle, below which the ribs 
 and intercostal spaces will be readily made out; then carrying the 
 finger behind the acromial process, the hard, spinous process of the 
 scapula will be detected, the surface inferior to it will be found plane 
 and smooth, terminating below in the acute inferior angle of the scap- 
 ula, which i^ movable and will permit the finger to pass under it. 
 The arm may also be felt and distinguished from the thigh by its size, 
 and sometimes the depression in the neck can be recognized. Great 
 care must be taken in the examination, especially when a hand or 
 arm is felt, to determine whether it is due to a transverse presenta-
 
 448 KING'S ECLECTIC OBSTETRICS. 
 
 tion, or is the troublesome complication of a vertex presentation ; and 
 to positively ascertain these matters it will become necessary to intro- 
 duce the fingers or the hand through the os uteri. It is likewise 
 proper to learn whether the shoulder has engaged in the brim. . In 
 these cases the accoucheur should not leave his patient until he has 
 clearly satisfied himself both of the presentation and the position. 
 
 Having ascertained the case to be a shoulder presentation, the next 
 and most important point is to determine which shoulder presents, 
 and its position. If this can not be ascertained at an early stage of 
 the labor, it always can in time to be remedied, and that is, when the 
 dilatation will admit; this may be effected by ascertaining where the 
 fetal head lies, and the situation of its back. The side to which the 
 head is directed may be known by the axilla, which must always look 
 in an opposite direction to that of the head; thus, if the axillary space 
 looks toward the left ilium of the mother, the fetal head will be to her 
 right ilium, and vice versa. The direction of the back may be known 
 by the scapula and vertebrae behind, and the clavicle, ribs, and inter- 
 costal spaces before. Should there be the least doubt relative to these 
 points, the practitioner should not hesitate to bring down an arm in 
 order to assist him in his diagnosis, as it will occasion no difficulty in 
 the operation of turning; but in effecting it great care should be 
 taken not to make the slightest traction upon the fetus. 
 
 When the elbow presents, it may be recognized by three bony prom- 
 inences, viz.: the olecranon and the two condyles, and by the bend of 
 the elbow occasioned by the flexion of the fore-arm upon the arm. 
 The position of the fetal head may also be known readily, being 
 always toward the side opposite to that in which the elbow is directed ; 
 and the fore-arm usually rests upon the anterior of the child's body, 
 as just remarked above. I repeat, should there be the least doubt as 
 to the position, or the presentation, and provided the membranes have 
 ruptured, the arm may be carefully brought down, making no trac- 
 tion whatever upon the fetus. To distinguish a knee from an elbow 
 has already been explained in the preceding chapter. 
 
 Sometimes a hand will hang down in the vagina, or even out at the 
 vulva, and be mistaken for a foot. If the young accoucheur will 
 accustom himself to feel and handle the various parts of a newly-born 
 child, as the feet, knees, hands, elbow, shoulders, etc., he will acquire 
 a ready tact in diagnosticating, which will prove greatly advantageous. 
 We may learn which shoulder presents by the hand. If the palmar 
 surface be found directed toward the pubic symphysis, the thumb
 
 PRETERNATURAL LABOR SHOULDER PRESENTATIONS. 449 
 
 turning to the right side of the maternal pelvis, it is the right hand, 
 md consequently a presentation of the right shoulder; if the thumb 
 turn to the left side, it is the left hand, and left shoulder presentation. 
 If the dorsal surface or back of the hand be directed in front, the 
 thumb being toward the right side of the pelvis, it indicates the pres- 
 ence of the left hand and shoulder; if the thumb be toward the left 
 side, it is the right hand and shoulder presenting. The head is always 
 in the direction of the thumb; thus, if the thumb be toward the left 
 side, the head will be in the left iliac fossa, and vice versa; if the 
 palmar surface of the hand be in front, the child's face will be looking 
 towards its mother's abdomen ; if the dorsal surface be in front, the 
 back of the child will be toward the maternal abdomen. 
 
 Having ascertained that the presentation is of the shoulder, the 
 practitioner should immediately inform the husband or friends that 
 it is a "cross-birth," and explain to them, without any reserve, the 
 necessity for interference, and the hazards to the child as well as to 
 the mother. The earlier assistance can be given after the membranes 
 have ruptured, or after the os uteri has fully dilated, the better will it 
 be for all the parties concerned. Delay, after these conditions, com- 
 promises the patient's life, as each pain not only augments in severity, 
 but forces the shoulder more and more tightly into the pelvis, so that 
 the woman becomes exposed to the consequences of exhaustion, or 
 rupture of the uterus, while the child is lost from the constant press- 
 ure. Whenever it is possible, council should be had, that the friends 
 may be thoroughly satisfied, and also that no subsequent censure may 
 be attached to the attendant, should serious consequences result. The 
 patient should, likewise, be informed that labor can not proceed with- 
 out artificial aid, and the reason made known to her ; and this should 
 be done in a kind and gentle manner, carefully avoiding any dis- 
 couraging word, look, or action. But this communication should not 
 be made to her until we are about to commence attempting the version. 
 
 TREATMENT OF SHOULDER PRESENTATIONS. 
 
 When a shoulder presentation is suspected. or ascertained previous 
 to the rupture of the membranes, and before the os uteri is sufficiently 
 dilated, every means should be used to preserve the membranes 
 entire; examinations should be made with care, and the female should 
 be kept in a horizontal position. No attempts whatever should be 
 made to force the hand into the uterus until it is dilated or dilatable, 
 and even then not until the position is satisfactorily determined. In 
 29
 
 450 KING'S ECLECTIC OBSTETRICS. 
 
 the meantime, the rectum should be evacuated by the administration 
 of a mild, emollient enema, if necessary, and the bladder by a cath-., 
 eter; for the operation of turning, which is the one usually recom- 
 mended and pursued in these cases, should never be undertaken until 
 these evacuations have been effected either naturally or artificially. 
 
 As soon as the os uteri has become dilated to the size of half a dol- 
 lar, sufficient to permit the introduction of the hand, it being also, 
 together with the vagina and soft parts, perfectly soft and yielding, 
 the membranes remaining entire, the practitioner, having been enabled 
 to clearly diagnose the position, may carefully proceed to effect the 
 operation of turning the child. This is, in fact, the most favorable 
 period for the operation, as the presence of the amniotic fluid within 
 the cavity of the uterus not only admits a ready introduction of the 
 hand, but, by floating the child, permits it to be turned in any direc- 
 tion. The practitioner can not be too careful as to the time when he 
 enters a hand into the uterine cavity: if he makes the attempt at too 
 early a period, the most lamentable results w r ill follow; if it be too 
 long delayed, the hazards and difficulties are increased, and the patient 
 suffers uselessly. 
 
 The position and presentation having been clearly ascertained, the 
 os uteri dilated, soft and yielding, with no rigidity of the soft parts, 
 and the practitioner having waited for a period consistent with the 
 integrity of the membranes and the preservation of the liquor amnii, 
 it would be unwise to wait until the complete dilatation of the os 
 uteri. The rectum and bladder of the patient having been previously 
 evacuated, she must be placed in position for operating ; lying on her 
 back, across the bed, with her hips brought a little over its edge, her 
 feet properly supported by assistants, so as to flex the limbs well, and 
 thus favor a relaxation of the abdominal muscles, is probably the 
 position more often chosen. Some operators prefer that she should be 
 on her knees and elbows, while others favor Sims' position, the patient 
 resting on her left side, the limbs flexed, and the nates brought con- 
 veniently near the edge of the bed. She should by no means be ex- 
 posed, but should be co.vered by some bed-clothing, suitable to the 
 temperature of the season, and, for the purpose of receiving discharges, 
 a thick layer of cloths should be placed on the floor, immediately be- 
 neath her. 
 
 The practitioner will now remove his coat, bare his arm to the 
 elbow, and anoint it well with sweet oil or lard ; if the vagina be sim- 
 ilarly anointed, it will favor the easy introduction of the hand. To
 
 PRETERNATURAL LABOR SHOULDER PRESENTATIONS. 451 
 
 protect himself from the discharges, a sheet or apron may be worn 
 over his dress. While the practitioner is thus engaged, an assistant 
 should administer an anesthetic. The patient should he brought well 
 under its influence; it not only produces insensibility to pain, but 
 overcomes spasmodic action, and promotes relaxation and dilatation, 
 and thus facilitates the passage of the hand, and serves to expedite the 
 version. Everything thus prepared, he will take his seat, at a con- 
 venient distance for operating, between the patient's limbs, or near 
 the side of the bed, according to the position assumed by the patient; 
 and throughout the whole operation he should be cool and deliberate, 
 manifesting no haste, excitement, trepidation, nor hesitation. 
 
 There is some choice of the hand to be introduced ihat one 
 should always be used which- can the most conveniently effect the 
 version; and the common rule is, to use the hand whose palmar sur- 
 face would, when opened within the uterine cavity, be directed to the 
 anterior surface of the child's body. Should the child's hand present, 
 this may readily be ascertained by grasping it as in shaking hands, 
 and that hand should be used the palm of which comes in contact 
 with the fetal palm. 
 
 It is not unfrequently the case that the contractions of the uterus so 
 completely benumb the hand which has been first introduced, that the 
 accoucheur, being unable to use it, is compelled to withdraw it, and 
 employ the other, and this will, of course, render the version much 
 more difficult, should the liquor amnii have been discharged. Dr. 
 Lee advises us, in all cases, no matter what the situation of the trunk 
 and extremities, to pass the hand up between the anterior and shallow 
 part of the pelvis, and the presenting part of the child. 
 
 The proper period for passing the hand within the vagina, is during 
 a pain; the fingers may be held together, in a conical form, and thus 
 slowly introduced, or, two fingers, then three, four, and lastly the 
 thumb, strongly flexed into the palm, may be" passed within the 
 vulva; while passing the vaginal sphincter considerable pain will be 
 produced, but this will be materially, if not entirely, lessened after 
 the hand has entered the vagina. The hand may now rest stationary 
 for a short time, to produce toleration of its presence as well as to 
 dilate the parts. Its introduction ivithin the uterine cavity, must be 
 during the absence of pain; an attempt to pass it within the womb 
 during a pain would probably rupture the membranes, and allow the 
 amniotic fluid to escape before the vagina was sufficiently plugged up 
 by the arm to prevent it. The fingers are to be passed within the os
 
 452 
 
 KING'S ECLECTIC OBSTETRICS. 
 
 FIG. 62. 
 
 uteri in a conical form, gently and slowly dilating this, from time to 
 time, by separating them, and then again, with the hand in the cone 
 shape, carefully and gently pushing it upward until it is fully within 
 the uterine cavity. If the presence of the hand has -not excited uter- 
 ine contractions, followed by rupture of the membranes, the bag of 
 waters should rest on the hand, and be passed up as far as possible 
 
 before rupturing them; the presenting 
 part should also be pushed upward and 
 to the left or right, according as the 
 head may be on the left or right side of 
 the uterus. (Fig. 62.) While the hand 
 is entering the os uteri, the uterus should 
 be kept steady by the other hand of the 
 operator, or, what is much better, the 
 assistant should place his hand on the 
 abdomen, over the fundus of the womb, 
 to steady the organ, and at the same 
 time to maintain a gentle pressure down- 
 ward, to keep the os uteri within the 
 strait. Usually, the membranes give way as the hand is passing 
 within the uterine cavity, even before the feet are reached, in which 
 case the hand and arm must be pressed firmly forward to plug up the 
 orifice, lest the amniotic fluid escapes, thereby causing the version to 
 be more difficult. 
 
 Should a pain come on during the entrance of the hand into the 
 uterus, it must be kept perfectly still, and when within the cavity of 
 the womb it should be opened and made to cover the body of the 
 child whenever uterine contractions come on ; for any attempts at 
 moving, or resisting the action of the organ at this time might oc- 
 casion its rupture. The membranes having been ruptured, the hand 
 enters into the cavity of the ovum, along the anterior surface of the 
 child, and should be passed up to the umbilicus, where the funis will 
 be felt, and in the neighborhood of which a foot will generally be 
 found. Having reached a foot, secure it between two fingers, and 
 search for the other; and if the contractions come on, the hand must 
 be opened and clasped over the child's body. If, after a reasonable 
 time, the other foot can not be found, the version may be accom- 
 plished by the one foot, being certain, however, that it is a foot before 
 attempting the change. Frequently, the contractions of the uterus 
 are so severe that the hand of the operator becomes cramped, numbed,.
 
 PRETERNATURAL LABOR SHOULDER PRESENTATIONS. 453 
 
 or extremely painful, and its nicer tact of feeling becomes so impaired 
 that, without the greatest care, he may confound a hand with a foot. 
 On this point be exceedingly cautious. We are advised by Dr. Rud- 
 ford, of Manchester, England, who has had much experience in diffi- 
 cult cases of obstetrics, " never to bring down more than one foot in 
 the manual operation of turning; because the other thigh, being flexed 
 upon the abdomen, offers a larger circumference than if it were ex- 
 tracted, and thus prepares the passages for the more easy transit of the 
 shoulders and head. The advantage of this practice consists in its 
 affording greater safety to the child; the disadvantage, in its creating 
 more difficulty in accomplishing the evolution." (Ramsbotham.} The 
 late Professor Meigs observes, in his Obstetrics : " At length, after 
 more or less research, one or both feet, or a knee, is found ; and 
 whether it be one or the other, it should be taken hold of; for it is 
 nearly a matter of indifference whether it be one foot or both, or one 
 knee, that is used as the point on which to act in turning the child. 
 Dr. Collins remarks, on this point, that ' it is quite sufficient to bring 
 down one foot/ and I find that Dr. Simpson, of Edinburgh, is of the 
 same opinion deeming it far more injurious to make perverse 
 attempts at exploration, than to deliver by one foot only. I say, 
 nearly a matter of indifference, because, the object being to turn the 
 child as soon as practicable, with proper caution it may be effected in 
 either of these ways; it is always desirable to get the hand out of the 
 uterus as soon as may be, and it is far 1 better to turn by one foot or by 
 a knee, than to incur the risk of laceration or contusion of the organ 
 by a tedious search alter the foot, which, if it be not originally near 
 its fellow, is very hard to be found by any search for it. The inex- 
 perienced student can have little notion of the extreme difficulty there 
 is to move the hand about while it is compressed betwixt the womb 
 and the child; a short experiment of this difficulty would suffice to 
 convince him of the propriety of the foregoing directions. If he 
 should use the knee as a point of traction, it would be very easy, 
 when the version is nearly complete, to draw the foot down. If he 
 use only one foot to turn by, he will have nearly all the proposed 
 advantage of the breech presentation, combined with the greater 
 facility enjoyed in manipulating in the footling case that is to say, 
 he will have the abundant dilatation, and the power of traction of the 
 limb. It sometimes happens that a foot is met with close to the 
 orifice; so that, even without carrying the hand within the uterus, 
 the foot can be hooked down by means of one or two fingers, as has
 
 454 KING'S ECLECTIC OBSTETRICS. 
 
 been done by Dr. Robert Lee, of London." It will be observed, by 
 the following from Dr. William Leishman, Professor of Midwifery 
 in the University of Glasgow, whose views, while more modern, are not 
 especially different from those of the older writers, "much argument 
 has been wasted as to the propriety of bringing down one leg or two. 
 The sound rule in practice is, that when we succeed in securing one 
 foot, we should never pause to search for the other;, as one is all that 
 is necessary; unless, perhaps, in cases of pelvic deformity. Nay, 
 more than this, the descent of one leg has a positive advantage as 
 compared with two, as thus, by increasing the diameter of the pelvis 
 of the child, the parts are more thoroughly dilated, so as to admit of 
 the ultimate passage, rapidly, and with comparative safety, of the 
 head of the child. And, as this is the stage at which the life of the 
 child is most frequently compromised, it is assumed that by abridging 
 its duration, fetal life in the aggregate must, by this process, be saved. 
 Still, when a very rapid delivery is desired, the operator know's that 
 he has a better and more efficient hold upon two limbs than he can 
 have upon one; and he will, therefore, very naturally, bring down 
 both when they are within easy reach ; but, when the discovery and 
 seizure of the other limb involves extra effort or delay, not even in 
 such a case as this should he be otherwise than content with what he 
 has already achieved. The foot or knee which is lowest in the womb 
 or easiest of access should at once be seized; but, in a transverse 
 presentation, there is no doubt that turning will be more easily 
 effected when we seize the leg of the side opposite to the presenting 
 shoulder." It will thus be perceived that the most eminent accouch- 
 eurs of this country and Great Britain are opposed to any lengthy 
 search after both feet, in cases of turning, and my own experience is 
 in favor of performing version by one foot when there is any consid- 
 erable delay or difficulty in securing both. 
 
 If it be possible to select a foot, we should take that which is 
 opposite to the presenting hand or elbow, and which will be situated 
 more toward the anterior part of the pelvis. The period for effecting 
 the version is during the absence of pain, and any attempts to turn 
 during a pain will not only be found nugatory, but may be productive 
 of serious consequences. While the pains are off, the uterus will be 
 found soft and yielding, and the operation may be effected with less 
 danger ; the version should be made over the anterior and not the poste- 
 rior surface of the child, holding the limb or limbs firmly, and slowly 
 and gently drawing them down into the vagina, and, if possible, to
 
 PRETERNATURAL LABOR SHOULDER PRESENTATIONS. 455 
 
 the external orifice. (Fig. 63.) Should the uterus contract, the 
 operator must cease his efforts, and if the pain be severe, it may be 
 necessary for him to straighten out the p IG 
 
 hand and let the foot go, recovering it 
 after the pain has subsided. He should 
 place his unoccupied hand externally on 
 the patient's abdomen, and aid in ac- 
 complishing the version by pushing the 
 child's breach downward, while he is 
 making traction with the other hand. 
 As the arm is gradually withdrawn, the 
 amniotic fluid will gush out and soil the 
 dress of the operator, if he has not pre- 
 viously protected it by a covering. 
 
 The version having been completed, 
 the patient may be carefully placed in bed, leaving the rest of the 
 labor to the natural efforts, and managing it as directed in the chapter 
 devoted to breech and feet presentations, being particular to have the 
 child's face in the hollow of the sacrum when the head arrives at the 
 lower strait. Some obstetricians recommend to terminate the delivery 
 by a continuation of artificial efforts, gently and cautiously extracting 
 the body whenever the pains are on ; but I consider this as meddle- 
 some and unnecessary; no such attempt should be made, unless 
 circumstances are present demanding them. After the delivery of 
 the placenta, the female should be properly bandaged, put to bed, and 
 a soothing preparation administered, if her condition demands it, as. 
 three to five grains of the compound powder of Ipecacuanha and 
 Opium. The indications for Macrotys and Pulsatilla may be man- 
 ifest, and for several days their administration may be necessary. 
 The weakened condition produced by so serious an operation may 
 demand stimulation. Meet the indications promptly, as they may 
 develop, being governed by the circumstances surrounding each indi- 
 vidual case. She should also be kept quiet and free from noise and 
 company, and, if possible, take a short sleep. Some gruel may be 
 allowed, if requested. 
 
 The operation of turning, no matter how skillfully performed, is. 
 always a dangerous one for the mother, and should be performed with 
 the greatest care and gentleness; any hasty or careless pushing, any 
 thrusting of the knuckles in opposition to the contracted womb, any 
 attempts at version during a pain, may occasion laceration of the
 
 456 KING'S ECLECTIC OBSTETRICS. 
 
 vagina, rupture of the uterus, or, perhaps, both of these may occur. 
 "If, under your attempts to turn, you feel any fibers giving way, 
 whether in the womb or vagina, withdraw the hand immediately. "- 
 (Blunddl.) 
 
 Should the membranes have ruptured before the attempt at version 
 has been made, and which is more frequently the case, the rules just 
 given are those by which the practitioner must be guided; and the 
 sooner he undertakes the operation after their rupture, the os uteri 
 being sufficiently dilated, and dilatable, the greater will be the chances 
 of safety for the mother and child, and the easier will it be for the 
 successful accomplishment of the version. 
 
 Unfortunately, however, preternatural presentations do not always 
 present the same features. It is frequently the ease that the mem- 
 branes will have prematurely ruptured, and the os uteri will not be 
 sufficiently dilated; or, when fully dilated, there may be violent 
 pains, with rigidity and irritation of the parts. In these instances no 
 attempts whatever must be made to force the hand within the uterus, 
 as they will only tend to increase the difficulty. Dilatation must be 
 aided by the internal use of Gelsemium, in the frequently repeated 
 small dose. The compound tincture of Lobelia and Capsicum will 
 accomplish the same purpose, and was formerly much in use; at 
 present the Sp. Tr. Lobelia is more often used singly, and is a most 
 excellent agent as a relaxant, in rigidity of the os uteri. Vaginal 
 emollient injections with or without Laudanum, according to the 
 nature of the case, may likewise be exhibited in some instances. 
 Fomentations to the vulva, of Hops and Lobelia combined, have 
 been recommended to aid in the relaxation of the parts; the means 
 already suggested, however, will usually be all that is necessary. 
 Chloroform or Ether, inhaled to produce anesthesia, should always 
 be used, unless positively contra-indicated, and will undoubtedly be 
 found of advantage, by removing the voluntary efforts of the mother, 
 especially the actions of the diaphragm and abdominal muscles and 
 thus enabling the operator to more readily effect turning, even in 
 cases where, without anesthesia, it would have been impossible to 
 accomplish it though it must be recollected that the most profound 
 anaesthesia does not completely check the contractions of the uterus. 
 Bleeding, ad deliquum animi, is the practice most commonly advised 
 in these cases, and there is no doubt but that it will generally produce 
 the desired relaxation, but I am decidedly opposed to it, because its 
 aftereffects upon the patient are frequently irremediable; it induces a
 
 PRETERNATURAL, LABOR SHOULDER PRESENTATIONS. 457 
 
 debility of the nervous and vascular systems, which, if ever positively 
 recovered from, will require months and even years of proper treat- 
 ment to accomplish; it occasionally fails to effect the desired relax- 
 ation; and should hemorrhage or other symptoms come on after vene- 
 section, there may not remain sufficient energy or vitality in the 
 system to successively oppose a fatal result. On the other hand, the 
 desired relaxation can always be effected by the use of Gelsemium, 
 Lobelia, or the combination of Lobelia and Capsicum, by which all 
 rigidity will be overcome, the pulse will be lessened, abnormal heat 
 and tenderness of the parts alleviated, and no strength of the patient 
 actually lost, and should symptoms occur requiring an opposing force 
 of the system, the patient may readily and permanently be restored to 
 her usual vigor by the employment of stimulants. 
 
 No haste is required in these cases viz.: when the os is not 
 dilated, with premature rupture of the membranes, or, when it is fully 
 dilated, the waters having been discharged, and the pains violent 
 the safety of the mother is the grand object, and patience is required 
 on the part of the practitioner, together with cool, calm and deliberate 
 action. As soon as the parts are in proper condition, the hand may 
 be introduced, and version effected as before explained. In these 
 cases, where the waters have been discharged, it is better to turn by a 
 knee, than allow the hand to remain too long within the uterus 
 searching for a foot. When the pains are very violent, and the uterus 
 contracts firm-ly about the body of the child, the tincture of Gelsem- 
 ium should be given, combined with a sufficient quantity of Lauda- 
 num, which will commonly arrest the powerful action of the organ, 
 and at the same time produce considerable relaxation of it, as well as 
 of the soft parts, so that the hand can be introduced. I have likewise 
 found Gelsemium, combined- with Aconite, gtts xx to gss of the former 
 and gtts v to x of the latter to a half-glass of water and administered 
 in half-teaspoonful doses every half-hour or hour, as the case may 
 require, will overcome the powerful contractions of the uterus, lessen 
 the pains materially, and render* the organ more yielding; and it is 
 more especially in these instances where a resort to ansesthctics is 
 advised. Of course, in these cases, the hazard to the child is always 
 much greater.- 
 
 Sometimes, although, the foot descends into the vaginal cavity, yet 
 the shoulder, being wedged in the pelvic brim, does not recede, and 
 the more forcible the traction is upon the foot, the more firmly does 
 the shoulder become fixed in the brim, while the breech will not pass
 
 458 KING'S ECLECTIC OBSTETRICS. 
 
 clown. In these cases, a noose of strong tape or ribbon must be fixed 
 round the ankle of the foot in the vagina, upon which traction may 
 be made with one hand, in the direction of the pelvic axis, while the 
 other, with the ends of the fingers placed against the ribs or axilla," 
 must make at the same time a steady, upward pressure, by means of 
 which the shoulder will be dislodged, affording, by its recession, a 
 space for the descent of the breech. The rest of the delivery is then 
 terminated as in the before named instances. 
 
 In cases of shoulder presentation where the arm lias descended, it 
 should never be returned within the uterine cavity, unless in attempt- 
 ing cephalic version, as referred to hereafter. The presence of the arm 
 assists the practitioner in forming his diagnosis as to the position, etc., 
 and never interferes with the introduction of the hand for the opera- 
 tion of turning. A piece of ribbon may, however, be attached to the 
 wrist, for the purpose of preventing the arm from rising along side of 
 the head after the version is accomplished, and thus avoiding any 
 difficulty in its delivery. Any pulling or twisting of the arm is 
 highly censurable; pulling at the arm will not assist the least in the 
 delivery of the child, and twisting or amputating it has been per- 
 formed on several occasions, in which the children were subsequently 
 born alive, and some of whom lived to advanced age in this mutilated 
 condition. Should any cause be present demanding the removal of 
 the prolapsed arm, it should always be made known to the relatives, 
 together with the reasons, previous to any attempt at the mutila- 
 tion. 
 
 It will sometimes be the case that, notwithstanding our treatment, 
 the contractions of the uterus will continue powerful and almost 
 unremitting, obstinately resisting the slightest attempts to introduce 
 the hand; in such instances, the only method is to wait, in the hope 
 that spontaneous evolution may expel the fetus; but if it be dead, as 
 known by auscultation, or if symptoms of sinking or exhaustion appear 
 in the mother, we should proceed at once to remove the child by ex- 
 visceration. In thes-e instanccSj the child will generally be dead 
 before interference will be required, and the grand object of the prac- 
 titioner must always be to save the mother's life, if possible. In many 
 instances Macrotys, or the mixture of Gelsemium and Aconite pre- 
 viously referred to, will be found very successful in overcoming this 
 excitable condition of the uterus. And when the stomach is also 
 irritable, rejecting almost everything exhibited, minute doses of mor- 
 phia will frequently prove useful.
 
 PRETERNATURAL LABOR SHOULDER PRESENTATIONS. 459 
 
 X 
 
 Dr. Matteucci. an Italian physician, asserts that chloral will arrest, 
 or at all events, sensibly diminish uterine contractions, and may there- 
 fore be advantageously administered in cases where version can not 
 be accomplished on account of excessive uterine action; from five to 
 seven grains may be given, and this dose be repeated only once sub- 
 sequently, at an interval of twelve minutes from the first; if the 
 woman can not retain the remedy from vomiting, one drachm of 
 chloral added to three fluidounces of water may be injected into the 
 rectum, repeating the injection, if necessary, in half an hour. Subcu- 
 taneous injection of one-sixth of a grain of morphia in the region of 
 the linea alba, and midway between the umbilicus and pubis, has been 
 successfully employed by Prof. Braun, of Vienna, to overcome the 
 violent spasmodic, tetaniform contractions of the uterus. The child 
 being extracted by version, without pains. 
 
 SPONTANEOUS EVOLUTION, is an idea, which was advanced 
 by Denman, in 1772, who noticed that the labor, in shoulder presen- 
 ta^ions, where the liquor amnii had long been discharged, occasionally 
 terminated by the natural efforts, the breech being expelled first, and 
 who, consequently supposed, that the efforts of the uterus gradually 
 turned the child so as to cause the shoulders to rise as the breech 
 descended. In 1811, Dr. Douglas, of Dublin, showed that this view 
 was not correct, but that the fetus instead of being turned was actually 
 expelled doubled up. His description of the occurrence, which he 
 has more correctly named " spontaneous expulsion," is, according to 
 Ramsbotham, as follows : "By the continuance of the powerful uterine 
 contractions, the whole of the arm is protruded externally, the shoul 
 der and chest being propelled low into the pelvic cavity. The 
 acromion then appears under the symphysis pubis ; and as the loins 
 and breech descend into the pelvis on one side, the apex of the- 
 shoulder is directed upward toward the mons veneris. Further room 
 is thus gained for the complete reception of the breech into the cavity 
 of the sacrum, and that part of the child's body is eventually expelled, 
 sweeping the sacrum, and distending the perineum to a vast extent. 
 As, during the whole of this process, the head remains above the 
 pelvic brim, it is evident that the apex of the shoulder being external, 
 the clavicle must be strongly pressed against the under surface of the 
 symphysis pubis; on which point, indeed, the fetal body partially 
 revolves, as on an axis; the other shoulder and arm, and the head, 
 being expelled last." 
 
 Spontaneous evolution, or spontaneous expulsion, seldom happens, 
 oeing more common in premature labors, and is always fatal to the
 
 460 KIN(i's KCLKCTK' <>!>'! KTUHS. 
 
 child, and exceedingly dangerous to the mother; the intense and pro- 
 tracted sufferings which the mother undergoes are beyond description, 
 and no practitioner should ever trust to a delivery by this method, 
 unless under the circumstances heretofore named, viz.: where every 
 other resource fails. Beside, it is exceedingly doubtful whether this 
 spontaneous action will ensue at all, except when the fetus is very 
 small, or the pelvis much larger than ordinary. Dr. Douglas says; 
 " If the arm of the fetus should be almost entirely protruded, with 
 the shoulder pressing on the perineum ; if a considerable portion of 
 its thorax be in the hollow of the sacrum, with the axilla low in the 
 pelvis; if, with this disposition, the uterine efforts be still powerful, 
 and if the thorax be forced sensibly lower during the pressure of each 
 successive pain, the evolution may with great confidence be expected." 
 A labor in which spontaneous evolution is effected, requires unpar- 
 alleled voluntary efforts on the part of the female, and is always 
 accompanied with extreme bodily and mental suffering, frequently 
 occasioning death, either before, or soon after delivery; and should the 
 patient survive, she is commonly left with some incurable difficulty, 
 which renders life anything but desirable. Velpeau states that, in 
 one hundred and thirty-seven labors of this description, only twelve 
 children were born alive. When the fetus has fairly engaged in the 
 pelvic brim, spontaneous expulsion only can occur ; when it remains 
 free above the brim, spontaneous evolution, to a certain extent, may 
 take place. 
 
 EXVISCERATION, should be resorted to only as a last resource, 
 and should be employed in those cases where the membranes have 
 been ruptured for several hours, with no advance of the labor, and 
 also in instances where the child's body is firmly wedged at some part 
 of the pelvis, rendering the introduction of the hand impossible or 
 extremely dangerous. In performing this operation there is no neces- 
 sity for amputating the arm, but an assistant will make traction upon 
 it, for the purpose of bringing as much of the child's thorax into the 
 pelvis as possible ; the operator will then pass two fingers of the left 
 hand upward within the vagina, until he feels one of the intercostal 
 spaces, selecting a point as near the axilla as he can ; the perforator is 
 then to be passed along these two fingers, and a free opening made 
 with it in the selected intercostal space. As it will be necessary to 
 introduce the hand within this opening, and into the cavity of the 
 fetal thorax, for the purpose of removing its contents, the operator 
 may divide one or more ribs, so that the opening will be sufficiently
 
 PRETERNATURAL LA15OU SHOULDER PRESENTATIONS. 461 
 
 large. After the removal of the thoracic contents, the diaphragm 
 may be perforated, and the liver and intestines extracted. The 
 removal of these organs will occasion a collapse of the body, which 
 will be expelled doubled up, if the uterine contractions are sufficiently 
 energetic, without any further interference : but if the pains are weak 
 and inefficient, or have entirely ceased, the delivery must be artificially 
 accomplished by the crotchet, removing rib after rib, hips, buttocks, 
 etc.; or the instrument may be "carried through the opening and fixed 
 within the fetal ilium ; the breech will soon be observed to descend, 
 and the case will be terminated as though nature had expelled the 
 child unaided." 
 
 Ramsbotham refers to an operation for decapitating the child, in 
 transverse presentations, when turning is impracticable, and when the 
 neck is directly over the brim : fortunately, I have never had occasion 
 to resort to it. He recommends the finger to be passed around the 
 neck, a large-sized blunt hook to be introduced upon it, and the 
 presenting part to be then brought as low into the pelvis as is con- 
 sistent with the woman's safety. The hook must then be steadied by 
 an assistant, while the operator introduces the decapitator (a hook with 
 an internal cutting edge) by the side of the blunt hook : this latter is 
 then removed, and the finger of the left hand being kept constantly in 
 contact with the blunt point of the cutting hook, a sawing motion is 
 communicated to it by means of the right hand, and the separation is 
 thus effected ; after which the child's body may be drawn out by the 
 protruding arm, and the head removed by a crotchet or blunt hook, 
 introduced into the mouth or the foramen magnum. These operations, 
 of course, are only to be performed when the child is dead, and which 
 will almost always be the case before a resort to them will be sanctioned 
 by a skillful accoucheur. 
 
 In cases of shoulder presentation, CEPHALIC VERSION has 
 occasionally been attempted, in which the presenting part has been 
 pushed away and the head brought to the brim ; but the operation has 
 not received the sanction of many obstetricians, on account of the 
 difficulties attending it. Professor Meigs, in his work on Obstetrics, 
 remarks: "It may be that those old practitioners of the days of Queen 
 Elizabeth may have sometimes succeeded, by pushing up the present- 
 ing shoulder, in getting the head at last: to come to the strait again, 
 Out such an event appears to me in any case most improbable." 
 Professor Miller observes: " Cephalic version has but few advocates 
 at the present day, and is confessedly applicable to such a limited
 
 462 KING'S ECLECTIC OBSTETRICS. 
 
 number of cases, that it is scarcely worthy of our formal considera- 
 tion." 
 
 It.will thus be seen that authors generally agree in considering 
 cephalic version, at best, a doubtful expedient, and one to be attempted 
 only as a dernier resort in some particular instances; yet, notwith- 
 standing the observations of the above gentlemen concerning this oper- 
 ation, and the disrepute in which it is held, Dr. M. B. Wright, a former 
 talented and skillful physician of Cincinnati, and Professor of Obstet- 
 rics in the Ohio Medical College, has made known a method of cephalic 
 version, which, I think, will become the more general practice in the 
 management of shoulder presentations as it becomes better known: 
 since having perused his essay, I have tried his method in several cases, 
 and was highly pleased at the successful results. Dr. Wright's essay 
 was on "Difficult Labors and their Treatment," and was read before 
 the Ohio State Medical Society at one of their meetings, who awarded 
 a gold medal to him. In order that my readers may understand his 
 views, I will give his own language and quote freely from his essay 
 After describing several cases treated successfully, he remarks: 
 
 "Now after all this, are we not justified in declaring: 
 
 "1. That at an early period in labor, and especially if called before 
 the uterus has been deprived of its liquid contents, a shoulder may be 
 converted into a vertex presentation more easily than turning by the 
 feet is ordinarily performed. 
 
 " 2. That although the membranes may have been long ruptured, 
 turning by the head can be accomplished with great facility. 
 
 " 3. That delivery by cephalic version may be speedily effected, after 
 repeated and ineffectual efforts have been made to turn by the feet. 
 
 " 4. That cephalic version should receive a prominent, nay, leading 
 place, as a means of expediting delivery in shoulder presentations. 
 
 " The second of the questions already proposed is, what mode of 
 proceeding will prove most favorable for the mother ? 
 
 "In his chapter on Podalic Version, Churchill - observes : 'On the 
 other hand, its disadvantages are not to be overlooked. From the 
 distance the head has to traverse, and the difficulty of seizing the feet, 
 and of turning the child in utero, there must ever be a fearful risk of 
 injury to the mother.' 
 
 " Upon an examination of the tabular views given by Lee, we find 
 that out of seventy-one cases of shoulder presentations, in which 
 turning by the feet was resorted to, f seven women died from rupture, 
 and three from inflammation of the uterus !' Laceration and inflam- 
 mation of the uterus are, therefore, the consequences chiefly to be
 
 PRETERNATURAL LABOR SHOULDER PRESENTATIONS. 463 
 
 dreaded. Four of these cases of rupture occurred in the practice of 
 other accoucheurs, and three in patients under my own care, and 
 where no great difficulty was experienced or force employed in 
 turning.' 
 
 " In cephalic, version the hand does not enter the cavity of the uterus, 
 and, consequently, neither its walls, nor any portion of them, are 
 forcibly pushed out. The fetus is moved comparatively little within 
 the uterus, the head being already near the superior strait ; while in 
 podalic version the part to be first delivered is most remote from the 
 canal through which it must pass. In the former, the injury to the 
 mother can not result without great awkwardness on the part of the 
 obstetrician, while in the other we have reason to feel surprised at the 
 escape from injury. In turning by the feet, the hand must necessarily 
 be moved considerably within the uterus, and often while it is con- 
 tracting violently. In turning by the head there is but little, if any, 
 direct contact of the hand within the uterus. In the one case, con- 
 tusion of the uterus by the hand is to be expected ; in the other case 
 there is no injury, because there is no contact. Turning by the feet 
 may occasion a severe nervous shock : not so in changing the shoulder 
 for the head. 
 
 " How may the life of a child be best preserved? is the third inquiry 
 to be briefly answered. 
 
 " In describing the disadvantages of turning by the feet in all cases, 
 Churchill says : ' The mortality among the infants thus brought into the 
 world is very great. As far as our statistics extend they yield 174 out 
 of 518 delivered, or one in three.' 
 
 " The mortality in shoulder presentations is, doubtless, greater than 
 this. In the first place the position of the fetus weakens its hold upon 
 life. In the second place the hand is more difficult of introduction 
 into the uterus in shoulder than in head presentations, and whatever 
 force is required is sensibly felt by the fetus, and upon that part of 
 the body where pressure is made with the least impunity. 
 
 " A timely resort to cephalic version gives to the fetus almost as 
 much certainty of life as if the presentation had been originally of 
 the head. "Why not? The manoeuver amounts to but little more than 
 in rectification of deviated head positions. 
 
 " We are informed by Churchill, that ' Bush gave an account, in 
 1826, of fifteen cases, in which fourteen were born living. In 1827, 
 Kitgen collected forty-five successful cases. Eiecke has had sixteen 
 cases.' In all the cases treated by myself from the beginning, the 
 children were born alive. The liability to compression of the cord
 
 464 KING'S ECLECTIC- OBSTETRICS. 
 
 and consequent death of the fetus, is in proportion to the length 
 of the labor, or rather to the descent of the fetus in the cavity of the 
 pelvis. Hence, to be wholly successful, cephalic version should be 
 performed a short time before, or soon after the commencement of the 
 second stage of labor. 
 
 " Can any one mode of treating shoulder presentations be relied on 
 exclusively ? The answer must be in the negative. We are disposed 
 to adopt the language of Cazeaux, " that at the present day it would 
 be improper to embrace either opinion exclusively, for some cases are 
 better suited to the cephalic version, while there are others on the 
 contrary, where the pelvic one is alone practicable ; consequently, both 
 operations should be retained in practice, leaving the judgment of the 
 accoucheur to determine the cases, where the one or the other ought to 
 be preferred.' And we will conclude this part of the subject by 
 stating a few of the circumstances under which the different modes of 
 turning may be adopted. 
 
 " Turning by the feet is to be preferred in cases of inefficient uterine 
 action, or in exhaustion from long continuance of labor; in hemor- 
 rhage, convulsions, or in any case in which there may be a demand 
 for speedy delivery. 
 
 " Turning by the head should be selected in all cases where difficulty 
 arises from mal-position merely ; or in convulsions, hemorrhage, or 
 prolapsus of the funis, if the uterus should be engaged in vigorous 
 expulsive efforts. In rupture of the uterus our great reliance is in 
 artificial delivery ; and the question naturally suggested would be, 
 which will guarantee the greatest safety, podalic version, or cephalic 
 version aided by the forceps ? And we would be guided in our action 
 by the answer we gave to the question. 
 
 "THE HAND TO BE USED. The relations of the fetus to the 
 pelvis having been ascertained, and the patient placed in a proper 
 position for the version, the next question is, which hand shall be 
 introduced into the vagina? We answer, the hand, the palm of which 
 is directed naturally toward the breech of the fetus. It will be seen 
 at once, that if the fetus is to be moved in the direction of the breech, 
 and in correspondence with the right side of the mother, and the left 
 side of the operator, the right hand could be used with most success. 
 In cases in which the head occupies the right iliac fossa, a choice could 
 be given to the left hand. 
 
 " THE PROLAPSED ARM. It is generally conceded, that in 
 turning by the feet, it is not necessary, nor would it be advantageous,
 
 PRETERNATURAL LABOR SHOULDER PRESENTATIONS. 465 
 
 to return above the brim of the pelvis, the-arm which may have fallen, 
 or been brought into the vagina. In turning by the head, on the con- 
 trary, its reposition admits of no doubt ; it is imperatively demanded. 
 It is not demanded in consequence of any difficulty in moving the 
 shoulder by its presence, but in the adjustment of the head at the 
 superior strait, and its subsequent descent through the pelvis. By 
 bending the fore-arm of the fetus until the hand is directed to the 
 upper portion of the vagina, and then pushing up the arm, the entire 
 member will soon ascend above the brim of the pelvis, and be no 
 longer an obstacle to complete version. 
 
 " The uterus undergoing gradual distension by the growth of the 
 fetus, and by increase in the quantity of liquor amnii, is not from 
 this cause alone excited to an expulsion of its contents. Let a strong 
 and sudden mechanical force be applied to the fibers of the uterus, 
 even to a limited extent, and contraction will speedily follow. If any 
 portion of the fetus should be pushed forcibly against the fundus of 
 the uterus, by atteknpts to rectify a Dial-presentation, a more than 
 corresponding resistance would soon apprise us of a want of adroitness, 
 and the probabilities of failure. The hand of the manipulator in the 
 vagina imparts a sense of fullness, and induces expulsive efforts on the 
 part of the mother. Pressure on the internal face of the perineum, 
 or along the recto-vaginal septum, urges the uterus to renewed or more 
 energetic action. Simple contact of the uterine and fetal surfaces in 
 turning does not produce undue contraction of the uterine walls. The 
 presence of the hand, added to that of the fetus, within the uterus, is a 
 common cause of irritation and expulsive force. But the fact, which 
 we most desire to enforce here, is, that when the fetus, in the operation 
 of turning, is moved in straight lines, and sensibly displaces the uterine 
 fibers with which it comes in contact, it is speedily forced back to its 
 original mal-position ; nor can its displacement be easily rectified, 
 except it be moved in conformity to the curvatures of the cavity in 
 which it is contained. 
 
 "THE MANNER OF PEE FORMING CEPHALIC VER- 
 SION. Suppose the patient to have been placed upon her back, across 
 the bed, with her hips near its edge the presentation to be the right 
 shoulder, with the head in the left iliac fossa the right hand to have 
 been introduced into the vagina, and the arm, if prolapsed, having 
 been placed, as near as may be, in its original position across the breast. 
 We now apply our fingers upon the top of the shoulder, and our thumb 
 in the opposite axilla, or on such part as will give us command of the 
 chest, and enable us to apply a degree of lateral force. Our left hand 
 30
 
 46> KING'S KCLI-XTIC OBSTETRICS. 
 
 is also applied to the abdonlen of the patient, over the breech of the 
 fetus. Lateral pressure is made upon the shoulders in such a way as 
 to give to the body of the fetus a curvilinear movement. At the same 
 time the left hand, applied as above, makes pressure so as to dislodge 
 the breech, as it were, and move it toward the center of the uterine 
 cavity. The body is thus made to assume its original bent position, 
 the points of contact with the uterus are loosened, and perhaps dimin- 
 ished, and the force of adhesion is in a good degree overcome. Without 
 any direct action upon the head it gradually approaches the superior 
 strait, falls into the opening, and will, in all probability, adjust itself 
 as a favorable vertex presentation. If not, the head may be acted 
 upon as in deviated positions of the vertex, or it may be grasped, 
 brought into the strait, and placed in correspondence with one of the 
 oblique diameters. 
 
 " It will be observed that we do not act upon the shoulders by raising 
 them. Perhaps a slight elevation would facilitate the movement 
 already described or it might be better to depress them and again, 
 by lateral pressure, without either elevation or depression, our object 
 might be accomplished. Pushing up the shoulders, therefore, does not 
 constitute a prominent part of turning, if by pushing up is meant the 
 mere raising of the shoulders above the brim of the pelvis. 
 
 "As the body of the fetus makes its curved movement under the 
 hand of the operator, it advances upward, as well as laterally, by a 
 combined, rather than a single action, which would give it only one 
 direction. 
 
 " The back of the hand, with which we have been acting upon the 
 shoulder, is toward the head of the fetus consequently, its hold upon 
 the head would be apparently slight yet, after the shoulders have 
 reached the iliac fossa, the vertex may fall upon the palm of the hand 
 in occupying the strait, and its adjustment become easy. If, however, 
 there should seem to be a necessity for grasping the occiput, there 
 could be no reasonable objection to a speedy change of haripls. 
 
 " The entire process of cephalic version is to be adopted in the 
 absence of uterine contraction ; or, rather, during the intervals of 
 expulsive force. And, as it is now a vertex presentation, we must be 
 governed, as to the time and manner of delivery, by those general 
 rules applicable to such cases. 
 
 "In all our cases, except the one which terminated as a face pre- 
 sentation, the occiput assumed a position corresponding with the first 
 or second position of the vertex. In this case the occiput was before
 
 PRETERNATURAL LABOR SHOULDER PRESENTATIONS. 467 
 
 one of the saero-iliac symphyses, and to this fact we have attributed 
 the tendency of the occiput to slide above the brim of the pelvis, and 
 the difficulty in keeping it in place. If there had been the usual 
 degree of uterine contraction, however, the head would, in all proba- 
 bility, have become fixed, and the presentation would have continued 
 as one of the vertex, instead of changing for the face. 
 
 "It will be seen that we lay no claim to the introduction of cephalic 
 version as a mode of treating wrong presentations, and expediting 
 delivery. A very brief examination of the subject, however, may 
 induce some to award to us originality in respect to the means by 
 which a successful change of presentation may be accomplished. 
 
 " That cephalic version, by external manipulation by acting upon 
 the fetus through the parieties of the abdomen and uterus should 
 have few advocates, is not surprising. To be successful, it confessedly 
 requires a combination of favorable circumstances not often presented. 
 The tissues both of the abdomen and uterus must be thin and 
 yielding the liquor amnii must have been retained, and in consider- 
 able quantity and the fetus must be proportionally small. 
 
 " In all the obstetrical works we have examined, in which cephalic 
 version is recommended by internal manceuver, it is directed to raise 
 the shoulder as the first necessary impression upon the fetus. Viewed 
 anatomically or mechanically, men have not been persuaded into the 
 belief, that raising the shoulder can facilitate the permanent descent 
 of the head into the superior strait. They claim, what is apparent to 
 the eye in viewing a proper engraving, and as it can be demonstrated 
 with the manikin, that the elevation of the shoulder at the brim of 
 the pelvis, tends to increase the long diameter of the fetus, and the 
 transverse diameter of the uterus, and without any favorable adjust- 
 ment of the head after pressure upon the shoulder has been withdrawn. 
 
 "Suppose we follow out the directions given by some, and after 
 the elevation of the shoulder, attempt to force .the body of the fetus 
 iji a lateral direction, will not the breech impinge against the walls 
 of the uterus transversely? To enable the head to engage in the 
 superior strait, the body must be entirely removed from it, and this 
 can only be done by raising the breech toward the fundus of the 
 uterus. Kaising the shoulder, therefore, is very naturally considered 
 a means to prevent cephalic version. And we are not surprised that 
 podalic version is almost universally adopted in the treatment of 
 shoulder presentations. 
 
 " If our mode of performing cephalic version is sufficiently clear, in 
 the description already given, it will readily be distinguished from
 
 468 KING'S ECLECTIC OBSTETRICS. 
 
 others. We claim for it great importance, on the ground that it is- 
 easily executed that the mother and fetus receive* no injury that 
 there is little or no danger of subsequent displacement after the vertex 
 has been fully adjusted that, although it is most successful in recent 
 cases, delivery may be accomplished after the membranes have been 
 long ruptured that it may be executed, after ineffectual efforts to 
 bring down the feet." 
 
 I commend these views of Dr. Wright, together with his mode 
 of performing cephalic version, to the special attention of the profes- 
 sion, and more especially, as in shoulder presentations, his operation 
 is much more easily and promptly performed than the "combined 
 external and internal version " of Dr. Braxton Hicks. 
 
 CHAPTER XXXV. 
 
 ON PRETERNATURAL LABOR TRANSVERSE PRESENTATIONS PRO- 
 LAPSUS OF THE UMBILICAL CORD PLURALITY 
 
 OF CHILDREN MONSTERS. 
 
 THE transverse presentations which follow, are rarely met with, 
 and some obstetricians have expressed doubts as to the possibility of 
 their occurrence. However, as they are treated of by several writers, 
 I have deemed it proper to make a brief reference to them. ' 
 
 Should the Side of the child present, it may be distinguished from 
 the head by its want of firmness and roundness, as well as by the 
 absence of sutures and fontanelles ; from the breech, by the want of 
 the furrow between the two rotund nates, with no coccyx, anus, or 
 genital organs. The principal discriminating signs of a side presenta- 
 tion are the presence of two or three ribs, with the intercostal spaces; 
 and should any doubt exist, the hand should be passed into the 
 vagina sufficiently to allow two fingers to be carried fully up to the 
 superior strait. A single intercostal space may be mistaken for the 
 sagittal suture. 
 
 If the child's Back presents, three or four of the spines of the 
 vertebra can be detected, and also the origins of 'the ribs; and these 
 may be felt even previous to the full dilatation of the os uteri. 
 
 A Sternum presentation may be known by the introduction of two 
 fingers, which will distinguish the sternal bones, the continuance of 
 the bony plane, the cartilages of the ribs at their origin from the 
 eternum, and the intercostal spaces.
 
 PRETERNATURAL LABOR TRANSVERSE PRESENTATIONS, ETC. 469 
 
 When the Abdomen presents, there will be felt no osseous promi- 
 nence, but only the large, soft abdomen, and, perhaps, the ensiform 
 cartilage maybe distinguished, as well as the insertion of the umbilical 
 cord ; though the practitioner must recollect that the cord itself may 
 present when the abdomen does not, as in prolapsus of the cord. 
 
 It is recommended in all these transverse positions to effect the 
 delivery by turning, the practitioner being governed in the operation 
 by the rules given under the management of Shoulder Presentations. 
 
 A PROLAPSUS OF THE CORD, is where the umbilical cord 
 presents along with the head, nates, or extremities of the child, and 
 may be considered under the head of Preternatural Labor. It is not 
 frequently met with, having occurred, according to statistics, 437 times 
 in 105,146 cases, or about 1 in 240. Of itself, the falling of the cord 
 has no influence upon the advance of labor, its smallness of size and 
 compressibility offering but little or no hinderance to the passage 
 of any part of the child through the pelvic canal. The danger is 
 to the child, which, from pressure upon the umbilical vessels, may die 
 by asphyxia. Until the fetus is expelled into the world, its life 
 depends upon, and is sustained by, a free circulation through the 
 arteries and vein of the cord, and any suspension of this circulation, 
 by compression or otherwise, will necessarily occasion death, by inter- 
 rupting the communication between the child and its mother. We 
 may form some idea of the peril to which the child is exposed from 
 the statistics of various authors, in which 245 children were lost out 
 of 392 cases of prolapse, being considerably more than one-half. 
 
 Various circumstances have been referred to as favoring, or causing 
 a descent of the cord ; as mal-positions of the child ; an uncommon 
 length of the cord; uterine obliquity ; and malformation of the pelvis, 
 especially the contracted pelvis. A small child, with an excessive 
 amount of liquor aninii, may contribute to the descent of a loop of the 
 cord, by allowing the fetal head to move away from the pelvic brim. 
 When there is a copiousness of the amniotic fluid, the sudden rupture 
 of the membranes being followed by a forcible gush of this fluid, may 
 carry with it a loop of the cord ; and this would be more likely to 
 occur should the patient be standing, or in some other unfavorable 
 attitude when the rupture happens. Prolapse of the cord may also 
 arise from a want of energetic contractions of the uterus, in which the 
 fetal head is not maintained with sufficient power at the superior strait, 
 .nor closely enough adapted to the inferior segment of the uterus. 
 The attachment of the placenta near the os uteri, by which the cord
 
 470 KIKCK8 K( LKCTK' OH.STE Tl;K>. 
 
 is held just at the orifice of the uterus, likewise favors a prolapsus. 
 Cases have occurred which were not due to any of the above-named 
 causes, and which could not be satisfactorily accounted for. Consid- 
 ering the length of the cord, and facility with which it moves about in 
 the liquor amnii, it is somewhat surprising that prolapsions of it are 
 not more frequently met with. Vertex presentations are less fre- 
 quently complicated by prolapse of the funis, than footling, in which 
 it is often encountered. It is more dangerous in vertex, less so in 
 shoulder, and least of all in feet presentations. 
 
 DIAGNOSIS. Prior to the rupture of the membranes, it is very 
 difficult, if not entirely impossible, to detect the cord ; it is only after 
 the rupture that we can determine its prolapse with any degree of 
 certainty. The cord then hangs down in the vagina, is of more or 
 less length, sometimes passing down beyond the vulva ; its roundness, 
 smoothness, and softness may enable the practitioner to distinguish it 
 when in the vagina, and especially its pulsations, if the circulation has 
 not been suspended, and which are not synchronous with the pulse of 
 the mother ; when it appears externally, it can be readily recognized. 
 Care should be taken not to mistake a prolapsed intestine for a loop 
 of funis ; this has been done, the coil of intestine passing through a 
 rent at the superior part of the vagina, or through a ruptured uterus, 
 and which, in several instances was cut in two, under the erroneous 
 supposition that it was the cord. 
 
 TREATMENT. In the management of cases of this character, 
 various modes of treatment have been advised, but none of them have 
 been generally successful. If the cord be cold and flaccid, with no 
 pulsations, the child will undoubtedly be dead, and as assistance is 
 required only for the safety of the child, the labor should be allowed 
 to progress without any interference, unless called for by other cir- 
 cumstances. We must, however, be cautious in pronouncing the 
 child's death, for the pulsations may cease during the contractions of 
 the uterus, and return again as soon as these have subsided ; beside, 
 instances have occurred where the pulsations have not been recog- 
 nized for ten or fifteen minutes, and yet the child has lived. If the 
 membranes have not ruptured, when the prolapse is detected, care 
 should be had to preserve them entire until full dilatation of the os- 
 uteri, and thus prevent any dangerous pressure upon the cord, until 
 the chances are greater for affording relief. 
 
 The several means recommended by authors, in cases where the 
 child is known to be alive, are as follows : 
 
 1. Returning the prolapsed cord above the superior strait and the 
 presenting part of the child, and retaining it there until this has so-
 
 PRETERNATURAL LABOR TRANSVERSE PRESENTATIONS, ETC. 471 
 
 far descended that any further prolapse will be prevented. If this 
 could always be accomplished, it would be a very certain and desirable 
 method ; but, usually, the difficulty is not detected until after the 
 membranes have ruptured, and the head together with the cord have 
 been forced down into the brim; and then any such attempts would 
 not only prove unsuccessful, but, if persisted in, might still further 
 increase the difficulty by displacing the head. Not unfrequently the 
 os uteri may be incompletely dilated, and then any attempts' to return 
 the cord would be impracticable. When it is fully dilated, the attempt 
 to ejevate the presenting part, or to carry the fingers with the cord 
 between the os uteri and the presenting part might occasion a return 
 of the pains, and thus prevent the reposition from being accom- 
 plished. Various instruments have been presented to the profession 
 for the purpose of returning the cord; but I have less confidence in 
 their utility, at least so far as I have become acquainted with them, 
 than with the manual method, by which a few cases have been saved. 
 When the waters have been freely discharged, an 1 the uterus acts 
 with energy, any attempts to return the cord will almost always be 
 unsuccessful. 
 
 If the cord can, however, be carried above the presenting part, by 
 the introduction of the hand in the vagina, and two fingers into the 
 uterine cavity, I would advise placing it in the axilla, if possible, or 
 above the knees ; and if these can not be effected, to carry it carefully 
 from one side to the other. However, it too frequently happens, that 
 after the cord has been raised above the presenting part, it immediately 
 prolapses again on the removal of the fingers. This has sometimes 
 been prevented by introducing a piece of soft sponge, carrying it 
 upward with the cord. 
 
 2. If the head has not entered the pelvic cavity, but is still at the 
 brim, a resort to turning has been advised, provided the os uteri be 
 fully dilated and not rigid; but as this operation is ahvays attended 
 with danger to the mother, we should not too hastily nor too rashly 
 decide upon it. If the soft parts be well dilated, the pelvis capacious, 
 and the female has given birth to one or more children previously, the 
 child may possibly be saved by the operation; but the accoucheur 
 should always remember that no interference, of whatever nature, is 
 justifiable, which has for its object the safety of the child at the risk 
 of injury or death to the mother. Where turning has been performed, 
 about seven out of ten children have lived: the consequences to the 
 mother are not given. Merriman advises turning only, in instances 
 where the child is living, as known by the pulsations o r the cord, the
 
 472 KIN(;'s KCLKCTIC OIJSTETRICS. 
 
 head not having entered the pelvis, the parts relaxed and os uteri well 
 dilated, and the pains weak and inefficient; and even then it should 
 not be attempted, unless the practitioner has had some experience in 
 the operation. Dr. Collins says : " As to turning, the risk to the 
 mother is, in the majority of cases, so great as to forbid its employ- 
 ment, nor do I think the practitioner justified by the circumstances in 
 so greatly hazarding his patient's life." 
 
 3. If the head has escaped into the vagina, and the pulsations of 
 the cord are felt, and especially when they are diminishing or becom- 
 ing feeble, the delivery may be hastened and the child's life saved by 
 a resort to the forceps, and this may be accomplished with but very 
 little risk to the mother. The forceps must be carefully applied, so 
 as not to fix the cord between either of its blades and the head, and 
 the extraction must be as rapid as possible, but always consistent with 
 the safety of the mother. Unfortunately, however, we more frequently 
 find the child destroyed by the compression of the cord, before the 
 instrument can be applied. 
 
 4. It has been recommended to place the cord in the angle formed 
 by the junction of the sacrum and ilium, where it will be less exposed 
 to compression, and that sacro-iliac symphysis is to be selected, which 
 will not be occupied by the forehead or occiput. This has sometimes 
 proved successful, and will probably answer in cases where the pelvis 
 is large and the head small. In ordinary-sized pelves but little re- 
 liance can be placed in this method. 
 
 5. The "postural treatment," by Professor T. Gaillard Thomas, 
 M. D., of New York city, appears to have been more generally suc- 
 cessful than any other method. This method consists in inverting the 
 uterine axis or long diameter, by placing the woman upon her hands 
 and knees, the face or shoulders resting upon a pillow, while the hips 
 are elevated as much as .possible, so that if the membranes are not 
 ruptured, the cord will sink below the brim and toward the uterine 
 fundus by gravitation alone. But if the membranes be ruptured, the 
 patient keeping the position named, the accoucheur, introducing his 
 whole hand into the vagina, will seize a loop of the cord between his 
 fore and middle fingers and carry it up to the pelvic brim, holding it 
 there until the whole of it has glided downward along the anterior 
 surface of the child toward the fundus. The woman will retain her 
 position until the pains have engaged the presenting part in the brim 
 to such an extent that there is no longer any danger of a renewal of 
 the prolapsus, when, she may be carefully turned upon her back, and 
 the labor be allowed to proceed as usual. As this position tends, from
 
 PRETERNATURAL LABOR TRANSVERSE PRESENTATIONS, ETC. 473 
 
 gravitation, to delay the entrance of the presenting part into the 
 pelvic cavity, however strong and regular the pains may be, the ac- 
 coucheur, passing a hand each side of the patient, should lock the 
 fingers of the hands, and make sufficiently strong pressure, during 
 each pain, in a direction toward the superior strait, so as to sustain the 
 weight of the uterus and its contents, as well as to keep the presenting 
 part in close proximity with the brim. And during the intervals the 
 uterus may be sustained, so as to prevent recession of the presenting 
 part, by means of a folded blanket or firm cushion placed between it 
 and the bed. 
 
 If the prolapsus be ascertained at an early period of the stage of 
 labor, it will be unnecessary to place the woman in the above position, 
 [which is very irksome, and which may also, when long continued, 
 occasion a sense of suffocation from pressure upon the diaphragm], 
 until this stasje is Dearly terminated, or until there is indication that 
 
 O / ' 
 
 the presenting part will shortly engage in the brim the* membranes, 
 of course, being unruptured. 
 
 If the membranes are ruptured, and the funis when carried to the 
 brim does not glide toward the uterine fundus, it will be necessary to 
 carry the hand and cord within the uterine cavity, even as far as the 
 child's breast. 
 
 The position is not an elegant one, and many women will object to 
 or decidedly oppose it; but when it is fully explained to them, the 
 reasons therefor, and the dangers to the child, few mothers will persist 
 in their opposition. An inclined plane can be arranged with the bed 
 clothing or otherwise, with a soft covering upon which the woman 
 can rest, and which will be much easier and less objectionable to 
 her, besides obviating the necessity for the support, named above, to 
 the uterine tumor. 
 
 Of these various modes, the selection must be left to the judgment 
 of the accoucheur, who will determine according to the stage of the 
 labor, the condition of the soft parts and os uteri, the conformation of 
 the pelvis, the presenting part of the child, and various other circum- 
 stances which may be present. In a premature labor, I should advise 
 no- other interference than that named in method No. 4. No. 5, 
 the "postural treatment," will, however, be found the best, suitable 
 for nearly, if not quite, all cases, rendering a recourse to turning or 
 instruments wholly unnecessary. 
 
 The patient's friends should always be informed of the fact, when 
 there is a prolapsus of the funis, together with the great probability 
 of the child's being still-born ; and should she exhibit any surprise or
 
 474 KING'S ECLECTIC OHSTETRICS. 
 
 uneasiness at our uncommon attentions, there is no harm in acquaint- 
 ing her that "the cord has fallen down, adding, however, that it will 
 not interfere with the labor in the least, but may occasion the child's 
 death;" nor would there be any impropriety in explaining to her the 
 uses of the cord, and the reasons why the child may be lost, as well 
 as the necessity for the measures about to be pursued. 
 
 It is also proper to have the ordinary means for resuscitating the 
 child in readiness, and which should be used in all instances when 
 delivery has been effected shortly after the cessation of the pulsations 
 of the cord, the slightest action of the heart being a sufficient cause 
 for attempting resuscitation. 
 
 Professor Meigs suggests the following measures in prolapse of the 
 funis, which, however, had not been tried by himself; " Take a 
 piece of ribbon or tape, a quarter of an inch wide and four or five 
 inches long. Half an inch from the end, fold the tape back, and sew 
 the edges so as to make a small pocket. Then fold the other end in the 
 opposite direction, and sew that also to make a pocket of it. Now, if 
 the cord be taken in the tape, and held as in a sling, a catheter may be 
 pushed into one of the pockets, and that one thrust into the other, so 
 that we shall have the cord held as in a sling, which is itself supported 
 on the end of the catheter or uterine-sound. Let the catheter be now 
 pushed up into the womb, beyond the fetal head : it will carry the 
 secured portion of cord with it, and the catheter being withdrawn, the 
 tape is left in the uterine cavity, where no harm can be occasioned by 
 its presence. If required, several such tapes could be secured round 
 the cord, and all of them fixed on the end of the same catheter, and 
 pushed at the same moment far up within the cavity of the womb." 
 This plan may answer in some cases, but I doubt its general applica- 
 tion. Dr. Arneth has succeeded in saving ten out of eleven cases, by 
 carrying up the cord, with the introduction of the whole hand into the 
 uterine cavity. 
 
 In a previous part of this work I have made some observations 
 relative to COMPOUND or MULTIPLE PREGNANCY, the 
 signs by which it may be suspected or recognized, and the several 
 circumstances under which it may be present. At this place I 
 shall refer more particularly to the management required for such 
 cases According to statistics laid down by Churchill in his work 
 on Obstetrics, 167,676 cases occurring in British practice, 2,572 
 were twins, or about 1 in 651; and 37 were triplets, or 1 in 4,531 J. 
 In 36,570 cases in French practice, there were 332 twins, or about 1
 
 PRETERNATURAL LABOR TRANSVERSE PRESENTATIONS, ETC. 475 
 
 in 110; and 6 triplets, or 1 in 6,095. In German practice, 251,386 
 cases gave 2,967 twins, or about 1 in 84 ; and 35 of triplets, or about 
 1 in 7,185. The average occurrence of the whole, 455,632 cases, would 
 be 5,871 of twins, or 1 in 77| ; and 78 of triplets, or 1 in 5,840. 
 
 In the plurality of children, or where women give birth to two or 
 more, the danger is always greater than in single pregnancies, being 
 about 1 in 20 ; yet many females are promptly delivered with but little 
 more pain than in cases where one child is born. The danger in these 
 is owing principally to an over-distension of the uterus ; to a preter- 
 natural presentation of one or both children ; to hemorrhage after the 
 expulsion of the placenta, the uterus contracting feebly or not at all ; 
 and not unfrequently, inflammation of the veins and deep-seated 
 structures of the uterus occurs, terminating fatally. 
 
 The mortality to the children in twin births is, according to statis- 
 tics, about 1 in 3 J ; in triplets, 1 in 3. Though it must be recollected 
 that in this calculation the death of the child can not, in every 
 instance, be attributed to the labor. In 184 twin cases recorded, 4& 
 were still-born ; and in 240, premature labor occurred 54 times, with 
 12 cases of a putrid fetus. The fatality appears to be greater among 
 male children, and especially when they are twin cases of opposite 
 sexes. These statistics are based upon the records of various accouch- 
 eurs, and may be found in detail in Churchill's Midwifery. 
 
 DIAGNOSIS. The difficulty in diagnosing twins during pregnancy 
 has already been spoken of; but at the time of labor, after the 
 expulsion of the first child, the presence of a second can be positively 
 determined, and it is the duty of the practitioner to institute a proper 
 examination, that he may have no doubts upon the subject. A plurality 
 of children may be suspected, from the uncommon size and shape of 
 the abdomen, though it is frequently the case that in this respect the 
 female is not larger than those who carry but one child; from the 
 feeble and irregular action of the uterus, even after the labor has con- 
 tinued for several hours; and from the slowness with which the bag 
 of waters is formed. After the delivery of the first child, its small 
 size may likewise occasion us to suspect that there is another. Yet 
 these various circumstances may.be present, and the case be one of 
 single pregnancy. 
 
 It is, therefore, required of the accoucheur, in every case of labor 
 which he may attend, immediately after the birth of the first child, to 
 place his hand on the abdomen of the mother, for the purpose of 
 ascertaining whether there be a second child ; if there be another, he 
 will find the uterus still hard, large, and unequal; the fund us remain-
 
 476 KING'S ECLECTIC OBSTETRICS. 
 
 ing at the epigastrium, or considerably above the umbilicus, and 
 occupying' nearly as much space as previous to the birth of the first. 
 He should not, however, stop at this external exploration; it is 
 absolutely necessary that he positively ascertain not only the presence 
 
 'of another child, but likewise its presentation and position; and to 
 effect this will require an internal examination. Holding the cord of 
 ihe first child tense with one hand, but without making any traction 
 upon the placenta, he will pass one or two fingers of the other hand 
 along the cord, and if another child be present, the fingers will come 
 in contact with the second bag of membranes, when he should correctly 
 ascertain the nature of the presentation, after which it will always !>< 
 
 . proper for him to inform the husband or nurse of the fact ; but it 
 should not be immediately made known to his patient, lest such a 
 depressing influence on her mind be caused, as to materially retard the 
 delivery of the second child. No particular secresy is necessary, 
 but the time of giving the information to the patient should depend 
 much upon her mental and physical condition, and the circumstances 
 connected with her case. It may be proper to observe here, that 
 practitioners have been deceived in both their external and internal 
 examinations, having mistaken a large placenta, a large quantity of 
 coagula, an accumulation of blood behind the membranes of the 
 retained placenta, etc., for the sac of another child: on rupturing these, 
 the escape of blood or coagula, instead of the amniotic fluid, will at 
 once solve the case. 
 
 TREATMENT. Usually, there are no suspicions of a twin labor 
 until after the birth of the first child, and the delivery may proceed as 
 favorably as in single cases. But it frequently happens that the force 
 and frequency of the pains become greatly diminished, in consequence 
 of the uncommon distension of the uterus; or the contractions being 
 energetic, the delivery progresses slowly, because the contracted uterus 
 can not act directly upon the whole of the body of the child which 
 first reaches the superior strait. And in cases of premature labor 
 occasioned by twin pregnancy, the delivery may be delayed, from the 
 immatured condition of the cervix uteri, which has not undergone 
 those changes which facilitate its dilatation at full term. 
 
 When the practitioner suspects twin labor in a case where the delivery 
 of the first is proceeding very slowly, and more especially when his 
 suspicions are strengthened by hearing sounds of the fetal heart at two 
 distinct locations, he must be very cautious how he ventures to admin- 
 ister Ergot, or other agents to increase the action of the uterus, prior 
 to the birth of the first child: no interference of this kind is required,
 
 PRETERNATURAL LABOR TRANSVERSE PRESENTATIONS, ETC. 477 
 
 or at all necessary. The labor should be allowed to proceed, no mat- 
 ter how slowly, until the first child is born. But should any accidents 
 or circumstances offer requiring aid, they should be treated in the 
 same manner as recommended when they occur in single labors; 
 being careful, however, should a resort to turning be deemed advisa- 
 ble, as in a shoulder presentation, to obtain a hold of the feet of the 
 right child before making the evolution. If the children arc con- 
 tained in one sac, or if there are two sacs and both have become rupt- 
 ured, a difficulty in relation to this matter will be very apt to occur. 
 By passing the hand along the external part of the limbs, until it 
 reaches the breech or genital organs, we may avoid the mistake of 
 bringing down a limb of each child. As a rule, each child has its own 
 bag of membranes, and its own placenta, and the placenta of the child 
 born first should not be removed, until after the birth of the second 
 child, as it will almost certainly give rise to more or less serious hem- 
 orrhage. 
 
 As I have already, when treating on the Management of Labor, 
 recommended two ligatures to the umbilical cord, previous to separat- 
 ing it, it is unnecessary to enter into any special remarks upon the 
 subject at this place. After the birth of the first child, if the presen- 
 tation of the second is proper, and the contractions of the uterus con- 
 tinue, no interference is necessary; indeed, it not unfrequently hap- 
 pens that the pains are so energetic, and the expulsion so rapid, that 
 the second child is born before the first can be separated from its 
 cord. But in cases where there are no pains after the birth of the 
 first child, or, when they are present, but feeble and inefficient, means 
 should be used to forward them, after having waited some fifteen or 
 twenty minutes. A bandage should be firmly applied around the 
 abdomen, frictions and compression should be made over it upon the 
 uterus, and as the passages are already dilated there is no objection to 
 the administration of Ergot; in fact, if there is delay in normal ex- 
 pulsive action, its judicious administration is commended, or stim- 
 ulants, if necessary, should likewise be exhibited internally. Should 
 the second child present naturally, that is, either the head or breech 
 presenting at the brim, and half an hour or an hour has passed since 
 the birth of the first, the application of the bandage, together with the 
 artificial rupture of the membranes, will generally occasion a renewal 
 *of the contractions, and delivery will be terminated without any 
 further interference.
 
 478 KING'S ECLECTIC OBSTETRICB. 
 
 In ordinary eases, where the pains do not return, notwithstanding 
 the means employed, I would not advise the accoucheur to wait beyond 
 an hour; because the parts being yet soft, dilatable, and amplified 
 from the expulsion of the first child, the second may be expelled with 
 more facility, and with less suffering to the mother, than would be the 
 case if a longer delay was permitted. The hour having therefore 
 expired, and no return of uterine action, the presentation of the second 
 child being known, the parts being soft and yielding, and the os uteri 
 dilatable, the membranes should be ruptured, and, if necessary, the 
 hand passed upward to reach the feet, and the evolution proceeded with 
 according to the rules already given, being very careful not to empty 
 the uterus of its fetus before contractions come on. Too sudden an 
 evacuation of the uterus may give rise to hemorrhage, inversion, or 
 other accidents. 
 
 Turning, however, must never be attempted when the resources of 
 nature are adequate to the expulsion of the child. 
 
 After the delivery of the first child, the parts of the female being 
 soft and yielding, and also sufficiently amplified by its expulsion, a foot 
 or breech delivery of the second child, either natural or effected arti- 
 ficially, is by no means so difficult or so painful to the mother, as in 
 similar labors with but one child ; nor, as a general thing, is the safety 
 of the child so greatly compromised. In a shoulder presentation of 
 the last child, cephalic version, according to Dr. Wright's method, in 
 the last chapter, might probably be performed with success. 
 
 Sometimes, the female becoming very much fatigued and worn out 
 by the tediousness of a twin labor, may require artificial aid, as for 
 instance, with the forceps, for the delivery of the first child ; and in 
 such cases, it will generally be found advantageous as well as necessary 
 to expedite the delivery of the second by bestowing similar assistance. 
 Interference will always be demanded during the expulsion of the 
 second child, when it presents transversely, or when it is complicated 
 with convulsions, hemorrhages, or other accidents. And these com- 
 plications must be combated according to the rules advised for them, 
 when occurring in single labors. 
 
 Hemorrhage is always to be dreaded in twin births, and must be 
 most carefully watched ; it may almost always be ascertained at an 
 early period, even before the practitioner would be led to suspect it 
 from the character of the discharge externally, by closely observing 
 the expression and color of the patient's face. When hemorrhage 
 occurs before the birth of the second child, it will demand prompt 
 action, the labor must be hastened by turning, if the presenting part 
 is above the superior strait by the forceps, when the head is in the
 
 PRETERNATURAL LABOR TRANSVERSE PRESENTATIONS, ETC. 479 
 
 pelvic cavity. Hemorrhage after the birth of the second child, must 
 be treated as hereafter recommended for hemorrhage occurring previ- 
 ous to, or after, the birth of the placenta, as may be. 
 
 Occasionally, there will be a simultaneous presentation of parts of 
 the two children, as, the two heads, the feet or arms of each, or the 
 head of one with the extremities of the other, etc. In these cases, it 
 will be necessary to push up one of the presenting parts, in order that 
 the remaining one may advance ; and should these double presenta- 
 tions prevent the labor from progressing safely, a resort to instrumental 
 aid may be demanded, as decapitation of one child, or such other 
 measures as the exigency of the case may require. 
 
 The practitioner must recollect that in twin labors, one placenta may 
 be common to both children, or, there may be a placenta to each child, 
 but connected with each other marginally ; and, an improper manage- 
 ment of either of these conditions may occasion dangerous hemorrhage. 
 No attempts at removing the placenta of the first child should be made 
 previous to the delivery of the second, as uncontrollable hemorrhage 
 might thereby be excited. And, after he expulsion of the second 
 child, a much longer interval than in ordinary cases must be allowed 
 for the delivery of the placenta (unless the presence of hemorrhage 
 renders its prompt removal necessary), as the uterus being somewhat 
 enfeebled or exhausted, does not so readily renew its contractions as 
 in single labors. The removal of the placentae must never be effected 
 by forcible traction upon the cord, but by arousing and securing 
 permanent uterine contractions, using frictions and compressions 
 externally, and making slight tractions upon the cord, as heretofore 
 recommended in single labors. 
 
 In hemorrhages, after the birth of the last oirild, the hand will 
 require to be introduced within the uterine cavity, in order to detach 
 and remove the placentae; and it should not be withdrawn, until a 
 perfect separation of both has been accomplished and even then, not 
 until uterine action has been aroused sufficiently to induce due and 
 permanent contractions of the organ. After the placentas have been 
 removed, their uterine surfaces should invariably be examined, to as- 
 certain whether any part has been left behind within the uterus. 
 
 In cases where a premature labor has been induced by the presence 
 of twins within the uterine cavity, and the first child has been expelled, 
 the recommendations to rupture the membranes, or in any way hasten 
 the delivery of the second, is exceedingly unwise and improper ; this 
 recommendation is only applicable at full term. After the escape of
 
 480 KING'S ECLECTIC OBSTETRICS. 
 
 the first child, should the uterus cease any further action, the second 
 remaining one may be matured by a further continuance of the preg- 
 nancy, and this result should always be favored by non-interference, 
 unless accidents occur threatening the mother's life, and rendering it 
 imperative to empty the uterus of its contents. 
 
 After the expulsion of the placentae, the bandage should be firmly 
 applied around the abdomen, with a compress over the uterine tumor, 
 to secure its permanent contraction, and prevent any tendency to 
 hemorrhage; and as the shock to the nervous system is usually much 
 more severe than in natural labors, the patient must be kept quiet, the 
 presence of company rigidly prohibited, and stimulants, antispas- 
 modics, or anodynes, administered according to the indications. 
 Uterine hemorrhage should always be closely watched for, and every 
 means be employed to guard against it. And the accoucheur should 
 not leave bis patient until, by feeling through the abdominal wall, 
 he has found the uterus about the size of a fetal head and firmly 
 contracted. 
 
 Where three or more children are present, they will require to be 
 managed in accordance with the above rules, recollecting that the 
 labor will generally proceed slowly, but that the dilatation of the soft 
 parts will not be so extensive, nor the sufferings to the mother so great 
 as in labors of one or two children, from the fact that triplets and 
 quadruplets are usually very small. Hemorrhage, however, is always 
 to be suspected. 
 
 In plural births, every variety of presentation may occur; thus, 
 the head of the first child, and the breech of the second, which are 
 favorable positions ; the head of each may present ; the breech or 
 shoulder of one, and the head of the other ; each child may present 
 by a shoulder; together with other varieties, rendering it highly 
 necessary for the accoucheur to be conversant with the modes of diag- 
 nosticating each and all of them. Cazeaux observes: "Pleissman 
 states that, on one occasion, he found the orifice plugged up by the 
 parts that had become engaged, and which at first sight appeared to 
 him to be a quantity of hands and feet. A more careful examination 
 enabled him to distinguish four inferior extremities, which were 
 delivered as far as the hand, and one arm. 
 
 "'At first,' he says, 'I was in great perplexity, because I could find 
 no way of introducing my hand into the womb, for the purpose of 
 distinguishing and seizing the two feet belonging to each child, and 
 because all my efforts to make even one of these extremities go back
 
 PRETERNATURAL, LABOR TRANSVERSE PRESENTATIONS, ETC. 481 
 
 again, proved abortive ; beside which, in drawing on any two of 
 them, I might confound and bring down the feet of two different 
 fetuses at the same time ; and lastly, even if I succeeded in seizing 
 the two feet belonging to the same infant, I might, by drawing on 
 them, engage the other parts, and thus augment the difficulties. Being 
 greatly embarrassed as to the proper course, and yet obliged to act, 
 the employment of a measure recommended by Hippocrates, under 
 different circumstances, happily suggested itself; that was, to suspend 
 the patient by her feet, hoping that the heads and the trunks of the 
 children would, by their weight, draw one or more of the extremities 
 toward the fundus of the womb, which was still distended by the 
 waters. The husband and brother-in-law of the woman passed their 
 arms under her hams, and thus held her suspended, so that only the 
 head and shoulders rested on the bolster. I intended, as soon as I 
 mounted on the bed, to press back one or more of the free extremities 
 into the womb, but two had already returned from the mere position 
 of the mother, and the other three soon followed by the aid of my 
 fingers. Immediately afterward, I was enabled to introduce my hand 
 into the uterus, and to withdraw successively therefrom three children 
 by the feet.' In bringing forward this case, I only desire to illustrate 
 what has been said concerning the difficulty of diagnosis. I ought 
 also to allude to the impossibility of the reduction, and the singular 
 procedure resorted to, with a success that seems to warrant its employ- 
 ment again under similar circumstances." 
 
 Ramsbotham detected, by the direction of the toes, that two feet 
 presenting at the vulva, a right and left, belonged to different bodies ; 
 he terminated the labor by making careful traction at one leg, and 
 gently pushing up the other, extricating each breech from the pelvic 
 brim, and the children were born living. Such cases, as before 
 observed, occur when the children are in one sac, or when the sac of 
 each ruptures before the child is expelled. 
 
 The most difficult complication of presentation is where, as the first 
 child descends, with the pelvic extremity first, its chin becomes locked 
 under the chin of the other, "which was presenting the head, and which 
 had passed into the pelvic cavity. In this case only one child can be 
 saved ; the child which has descended must be eviscerated and detrun- 
 cated, leaving its head in the uterine cavity ; this must be pushed up 
 above the superior strait, the second child brought down and delivered, 
 
 and finally the head of the first must be removed, 
 31
 
 482 KING'S ECLECTIC OBSTETRICS, 
 
 The fetus is subject to various diseases, and to excessive develop- 
 ment, or perversion of parts, while within the uterus, which may form 
 MONSTERS or MONSTROSITIES, and which frequently exert an 
 mi favorable influence upon the parturition. The difficulty in these 
 cases depends altogether upon the relative proportion between the 
 fetus and the pelvis; if the child be small, there will be no delay or 
 trouble in its passage through the pelvis ; if it be large, from excessive 
 development, or from a union of two fetuses in one, the labor will be 
 difficult and preternatural according to the disproportion existing and 
 other circumstances which may offer. 
 
 Hydrocephalus, ascites, and distension of the abdomen with wind, 
 or water, are the most common diseases incident to the fetus which 
 render labor difficult; these have already been treated upon. 
 
 Monsters are occasionally met with in practice, and mainly belong 
 to one of the following classes, viz.: 1. Monstrosity from deficiency 
 of certain parts of the body, as, in anopses, where the eye and orbit 
 are wanting; cyclopes, where there is but one eye, situated in the 
 center of the forehead ; acephalous, where the head is absent ; anen- 
 cephalous, where the head is present, but is devoid of brain, etc. 2. 
 Double monstrosity, where two or more children become united 
 together, as in cephalodymia, where the heads grow together ; hepato- 
 dymia, where the livers are united; pelvidymia, where the pelvic 
 extremities become fused, etc. 3. Monstrosity, or ectopy, in which 
 one or several parts are abnormally situated. 4. Where clefts or 
 fissures occur in parts which are united when in a normal condition. 
 5. Where there is am excess or disproportionate enlargement of certain 
 parts. 6. Atresia, or where parts which are normally opened become 
 closed. 7. Hermaphroditism, or vicious conformation of the genital 
 organs. Various causes have been assigned for these monstrosities, 
 among which the most probable are : 1. A primitive defect in the 
 germs ; 2. Accidental changes undergone by the fetus at some period 
 of its intra-uterine life, effected by the imagination of the mother, 
 injuries, an unhealthy condition of the mother, etc. 
 
 In an obstetrical point, the only instances which are of interest, 
 from their sometimes creating a very painful and difficult delivery, are 
 those belonging to the above 2d, 3d, and 5th, classification', the 2d, 
 more especially : and when they do occur, it is almost impossible for 
 an accoucheur to form a correct diagnosis. But even should he be 
 able to detect a monstrosity, it does not follow that he should inter- 
 fere, for the natural efforts are frequently adequate to the task of
 
 PRETERNATURAL LABOR TRANSVERSE PRESENTATIONS, ETC. 483 
 
 terminating labor, and even without loss of the child's life, as for 
 instance, in the cases of the Siamese twins, and Rita Christina. 
 
 Double monstrosity, or the adherence of two fetuses may be sus- 
 pected only by evidence of a negative character. " If two bags of 
 water are detected by the finger, if it is necessary to rupture the mem- 
 branes twice, if the amniotic waters are discharged at two separate and 
 distinct periods, the presence of independent twins in the womb may 
 be regarded as certain ; for there are never two envelopes for a double 
 monster, and two perfect twins are very seldom shut up in the same 
 amniotic pouch. Again, if two feet or even a single one descend with 
 the head, more particularly if the feet yield to the tractions made on 
 them, and appear at the vulva without the heads having a tendency to 
 reascend, we may affirm there are two infants, because a. monster is 
 never composed of two individuals held together in such a way that 
 the head of one is alongside the feet of the other; but if several limbs 
 present simultaneously, we can only ascertain whether the children to 
 which they respectively belong are joined together or are independent, 
 by carrying the hand up into the womb." (Cazeaux.} 
 
 TREATMENT. The management of monstrosities is similar to 
 that heretofore named, in cases of difficult labor. A fair trial should 
 always be accorded to the eiforts of nature ; if after having waited a 
 sufficient length of time, say for twenty-four hours, during which time 
 the pains have been strong and active, if delivery is not effected, 
 means should then be adopted to expedite it. Or, should symptoms 
 -of exhaustion manifest themselves previous to this time, or hemor- 
 rhage, or other accidents, the accoucheur should at once interfere. No 
 specific rule can, however, be given ; the general principles of obstetrics 
 must be the guide ; the success attending the case will depend alto- 
 gether upon the skill and judgment of the attendant, who will resort 
 to the forceps, perforator, crotchet, etc., according to the peculiar cir- 
 cumstances of the case ; and who should not hesitate to destroy or 
 mutilate the child, if it become necessary, in order to insure the safety 
 of the mother. In case of great pelvic deformity, the Cesarean 
 operation may become necessary, but, with a normal pelvis, the de- 
 formity of the child must be very excessive, which should lead the 
 practitioner to adopt this expedient for its removal. 
 
 When monsters live, and are capable of action as individuals, they 
 have the same rights as other persons ; and the destruction of a monster, 
 after birth, however great the deformity, is a criminal act, punishable 
 as infanticide. This should not be forgotten, as I have heard of mid- 
 wives who did not hesitate to destroy monsters as soon as born.
 
 484 KING'S ECLECTIC OBSTETRICS. 
 
 CHAPTER XXXVI. 
 
 COMPLICATED LABOR UTERINE HEMORRHAGE FROM PLACENTA 
 
 PRvEVIA PUERPERAL HEMORRHAGE PLACENTAL PRESENTATION. 
 
 ONE of the most common complications of labor, and at the same 
 time the most alarming, is HEMORRHAGE or FLOODING. It 
 attacks suddenly, progresses rapidly, and requires prompt and ener- 
 getic treatment; equanimity, self-possession, caution, and a thorough 
 familiarity with the appropriate remedial measures, are necessary re- 
 quirements for success without these the individual who attempts the 
 practice of obstetrics is extremely culpable. No one can tell with 
 certainty, in an early stage, whether hemorrhage will occur during 
 airy given labor; and it is not unfrequently the case, that it attacks 
 suddenly and fatally in instances where least expected ; no one can 
 know at what moment he may be called to treat a formidable puerperal 
 flooding hence, the importance of holding the above requirements. 
 A proper attention, may insure safety to two human beings, while an 
 ignorant or ill-directed course, is almost certain to terminate fatally. 
 
 I have already referred to abortion and the hemorrhage which 
 may be present in the early months of gestation , this may be, and 
 is at times, very profuse, often resulting in the death of the patient. 
 But the more fearful and perilous attacks of flooding are those which 
 take place at the parturient period. These may be divided into four 
 forms: 1st. That which occurs at an early period of labor from pla- 
 cental presentation. 2d. That which occurs during labor, previous to . 
 the birth of the child, but not dependent upon placenta pra;via. 
 3d. That which occurs after the birth of the child, but previous to the 
 expulsion of the placenta. 4th. That which takes place after the 
 delivery of the placenta. 
 
 In 75,596 cases of labor, hemorrhage occurred 517 times, or about 
 1 in 146; out of 630 cases of hemorrhage, 111 mothers were lost, or 
 about 1 in 5; out of 443 cases, 109 children were lost, or about 1 in 4. 
 In accidental hemorrhage, 28 cases proved fatal out of 114, or nearly 
 1 in 4 ; in unavoidable hemorrhage, 51 cases proved fatal out of 182, 
 or about 1 in 3 ; and in hemorrhage after delivery, 22 proved fatal 
 out of 293 cases, or about 1 in 12. (Churchill.}
 
 COMPLICATED LABOE PUERPERAL HEMORRHAGE, ETC. 485 
 
 The placenta may vary in its point of attachment to the internal face 
 of the uterus; thus, in one class of cases it may adhere to some portion 
 of the fundus, in another, to a part of the body, and in others, to the 
 inferior segment of the uterine body, partially or wholly over the inner 
 os uteri, and hemorrhage to any great extent will not take place in 
 either of these conditions, during gestation or parturition, unless the 
 placenta be considerably separated from the uterine surface. A slight 
 detachment may occasion a discharge of blood from some small blood- 
 vessels which have become thereby exposed, but insufficient to create 
 alarm, or amount to a flooding. It is only when the separation has, 
 from any cause, become so extensive as to expose the patulous orifices 
 of the large veins and arteries of the uterus, through which the utero- 
 placental circulation has been carried on, that a quantity of blood 
 escapes giving rise to puerperal uterine hemorrhage. And so long as 
 these orifices remain open, whether from inertia of the uterus, or from 
 the presence of a body within its cavity which prevents its perfect 
 contraction and condensation, .so long will the hemorrhage continue. 
 It is only by the contraction of the muscular fibers of the uterus, that 
 these orifices, as well as the caliber of the whole tract of the bleeding 
 uterine vessels, become diminished to such an extent as to permanently 
 arrest the flooding. And to adopt means for the purpose of effecting 
 such uterine contraction is the duty of every accoucheur who treats 
 puerperal hemorrhage. 
 
 HEMORRHAGE FROM PLACENTAL PRESENTATION, 
 or PLACENTA PR^EVIA, in which the placenta is located "prse 
 via" before the passnge or way, is termed unavoidable hemorrhage ; 
 it is the most dangerous form, and the most difficult to manage. The 
 placenta being attached, partially or completely, over the inner os 
 uteri, to the lower segment of the uterine body, as the fibers of the 
 cervical portion of the uterine body become more and more developed 
 during the latter months of pregnancy, in order to enlarge the lower 
 portion of the uterine cavity, the connection between the placenta and 
 uterus becomes gradually separated, and the utero-placental vessels 
 being thereby ruptured or lacerated, a discharge of blood follows, 
 perhaps some from the placental surface, but chiefly from the uterine, 
 proportionate to the extent of separation and size of the blood-vessels 
 ruptured. And when this occurs during labor, the hemorrhage grows 
 more excessive with the advance of the labor, as each uterine contrac- 
 tion effects an increase of separation. The placenta may be inserted
 
 486 KING S ECLECTIC OBSTETRICS. 
 
 immediately over the inner os uteri, so that the centers of the two 
 are in correspondence, when it is called complete placenta pnevia, or 
 Placenta CentraUs; or it may vary in any degree between this central 
 location and the insertion of its edge near the os intern urn uteri, 
 when it is called partial placenta prsevia, or Placenta Latcralis; the 
 danger in these cases increases as the center of the placenta approach o 
 that of the inner os uteri. The fact that the placenta may lie over the 
 os uteri, was noticed by several of the older French writers, among 
 whom may be named Guillemeau, Mauriceau, Amand, Astruc, and 
 Dionis, as well as by others who have written since the middle of the 
 eighteenth century. About the year 1728, Daventer called the attention 
 of the profession in Holland to this matter, and some twenty-five 
 years later, Bracken and Pugh brought the subject to the notice of the 
 physicians of England. 
 
 Although these writers accurately described the condition of things 
 at the period of labor, they all seem to have entertained the opinion 
 that this malposition of the after-birth was owing to some accident 
 which had dislocated it from its former connection with the fuudus of 
 the uterus, and that it had gravitated downward by its own weight, 
 - until it had become placed in its new position, covering more or less 
 completely the orifice of the organ. 
 
 Such an opinion, however, does not obtain with the well-informed 
 of the profession at the present day, all agreeing that, inasmuch as the 
 chorion, the decidua, and the membranes, as well as the blood-vessels, 
 both of the uterus and placenta, maintain the same relations to each 
 other when the placenta is found in this position, as when in its normal 
 location, that, from some unknown cause it must have been attached, 
 from the first, in the lower part of the womb, and not have fallen from 
 a former attachment. 
 
 As early as in 1730, Giffard published the opinion, that he had 
 "good reasons to believe that the placenta sometimes adheres to, or 
 near, the os internum, and that the opening of it occasions a separa- 
 tion of the blood-vessels, and consequently a flooding." A similar 
 opinion was expressed by Heister, in 1739, who said "some moderns 
 consider as a cause of hemorrhage, the adhesion of the placenta to 
 the mouth of the womb; so that the more the os uteri is dilated, the 
 greater is the separation of the placenta, and the more profuse the 
 flooding." In 1761, Leveret, and in 1779, Smellie, expressed similar 
 views, maintaining that the placenta was from the first over the os 
 . uteri, and that its being there was not the result of a detachment from
 
 COMPLICATED LABOR PUERPERAL F1EMO.RRHAGE, ETC. 487 
 
 the fundus, and a dislocation of the organ. This opinion has uni- 
 versally prevailed among scientific men since that time, and now 
 requires no additional proof to that furnished in abundance by prac- 
 tical men, both by reason and by observation. Dr. Rigby, of Nor- 
 wich, England, however, was the first to call attention to parturient 
 hemorrhage, and the importance of distinguishing its varieties, that 
 the proper treatment might be pursued. Since which placenta prsevia 
 has received the closest attention of several eminent accoucheurs in 
 Europe and the United States. 
 
 Instances of placental presentation have been met with, in which 
 delivery has been safely accomplished by the natural powers without 
 any hemorrhage whatever, but they are very rare, and are never to be 
 anticipated. Most commonly, the first symptom of this presentation 
 is a gush of blood occurring sometimes during the latter months of 
 gestation, from the seventh month to full term. It is from this period 
 that the cervical portion of the uterine body begins to rapidly develop 
 itself; a detachment of the placenta ensues as the uterine fibers expand, 
 and a discharge of blood follows, which is the first symptom observed. 
 Dr. Barnes, of England, does not believe that the hemorrhage in these 
 cases is owing to the separation of the placenta from the gradual 
 development and expansion of the cervix, but to the growth of the 
 placenta itself. He says: "The first detachment of placenta arises 
 from an excess in rate of growth of the placenta over that of the 
 cervix, a structure which was not designed for placental attachment, 
 and which is not fitted to keep pace with the placenta. Hence loss of 
 relation; hence the placenta shoots beyond its site, and hemorrhage re- 
 sults." I must confess, however, that I rather incline to the view which 
 considers the flow at this period due to the more rapid development of 
 the lower portion of the uterine body. The hemorrhage may be so sud- 
 den and copious, even at this first onset, as to prove nearly, if not quite 
 fatal ; more generally, however, its first manifestation is but slight, ceas- 
 ing if the woman lies down and remains quiet. This early sanguineous 
 flow, when slight and so easily checked, is looked upon by the patient 
 as an accident depending, probably, upon some strain, exertion, etc., 
 and after its cessation is no more thought of. In five or six days, a 
 further detachment of the placenta is occasioned by the continued 
 development of the cervical part of the uterine body, and a fresh dis- 
 charge takes place, which is apt to be greater than before ; and from, 
 time to time these attacks of bleeding occur, increasing in severity 
 each time, until, if the woman reach her full term, she may be so com-
 
 488 KING'S ECLECTIC OBSTETRICS. 
 
 pletely exhausted and prostrated from loss of blood, as to be incapable 
 of sustaining the loss of even a few ounces more. A woman who has 
 not suffered from bleedings previous to term, and of strong constitu- 
 tion, is more likely to recover, uninjured, from a placenta prsevia labor, 
 than one the reverse. As regards the hemorrhage at full term, Dr. 
 Barnes observes: "The mouth of the womb must open to give passage 
 to the child. This opening, which implies retraction or shortening of 
 the Cervical zone, is incompatible with the preservation of the adhe- 
 sion of the placenta within its scope. In every other part of the 
 womb there is an easy relation between the. contractile limits of the 
 muscular structure and that of the cohering placenta. Within the 
 cervical region this is lost. The diminution in surface of the uterine 
 tissue is in excess." 
 
 The circumstances under which a vaginal examination must be made 
 are, 1st, when the hemorrhage is copious and continued; 2d, when the 
 patient has reached full term, or is within several days of it; and 3d, 
 when uterine contractions manifest themselves, however slight they 
 may be, or however distant the intervals between them. 
 
 DIAGNOSIS. A placental presentation may be suspected when the 
 first hemorrhage occurs suddenly [about the sixth or seventh month, 
 and up to full term], and without any apparent cause, being renewed 
 every week or two. If the placenta be situated upon the anterior 
 part of the inferior segment of the uterus, it will prevent ballottement. 
 At the period of labor placenta prsevia may be suspected by the gush, 
 or increased flooding during a pain, but which diminishes in the inter- 
 vals. When it becomes necessary to make an examination per vagi- 
 nam, we may then positively ascertain the nature of the case. I have 
 just stated lhat an examination of this kind must be made when 
 hemorrhage is copious and continued, and this observation applies to 
 all hemorrhages taking place from the uterus during the latter months 
 of pregnancy. In these cases we are not to wait for pains, nor be 
 governed by them ; for the probabilities are that the uterus has become 
 so enfeebled or paralyzed from the large quantity of blood discharged 
 that no pains will be felt the organ is too weak to contract. Indeed, 
 the absence or trifling character of pains during these hemorrhages is 
 a most positive indication of the necessity for interference to learn the 
 cause of the flooding, and to check it if possible. 
 
 In making the vaginal examination it is immaterial as to the 
 position assumed by the patient, provided the fingers can be intro- 
 duced. The first two fingers may be passed within the vagina, or, if
 
 COMPLICATED LABOR PUERPERAL HEMORRHAGE, ETC. 489 
 
 the os uteri be high up in the pelvis, it may become necessary to 
 introduce the whole hand. The examination should be conducted 
 with great care, for a quantity of coagula, will generally be found in 
 the vagina, the separation or detachment of which will cause a return 
 of the hemorrhage, or increase it in quantity. Neither should the 
 finger be forced within the os uteri; if this be not sufficiently dilated 
 to permit the entrance of the finger without difficulty, it would be 
 better to wait until the flooding has caused sufficient dilatation or 
 dilatability. 
 
 The placenta will be recognized by the soft, fleshy, fibrous, lobular 
 sensation which it imparts to the finger, differing from a coagulum by 
 being attached to the inner surface of the lower segment of the uterine 
 body, and by not being readily perforated or broken down a coag- 
 ulum is loose, can be removed, and may be pierced by the finger and 
 destroyed without any difficulty. As the examination will produce a 
 discharge of blood, the practitioner must make it a positive one ; he 
 must not allow himself to mistake a clot, nor the cervix, for the pla- 
 centa. The latter will have a thick, spongy feeling; the former is 
 movable and readily broken down, which is not the case with the 
 placenta. Sometimes the detached uterine surface of the placenta will 
 be covered by a thick smooth layer of coagulated blood, which will 
 prevent the finger from coming into direct contact with the placenta ; 
 but any error in diagnosis from this circumstance may always be 
 avoided by carefully breaking down or detaching the coagulum. 
 Whoever will carefully pass the point of his finger over the uterine 
 surface of a recently expelled placenta, whenever the opportunity 
 offers, will never confound a coagulum of blood, however firm, with 
 a placenta inserted upon the lower segment of the uterine body. 
 Repeated examinations in unavoidable hemorrhage are unnecessary 
 and reprehensible; one, or two at most, are fully sufficient to ascertain 
 the true state and condition of the parts, etc. 
 
 Having ascertained the presence of the placenta, the next inquiry 
 will be, whether the presentation be complete or partial? If it be 
 complete, no membranes can be felt; if partial, the edge of the 
 placenta maybe readily detected, together with the membranes passing 
 off from it; a portion of it may be felt closing a part of the inner 
 os uteri, and through the membranes may, probably, be recognized 
 the presenting part of the child. The finger may also be carefully 
 carried around to ascertain where the placenta is free or detached, in 
 a complete presentation, but no efforts should be made to separate it,
 
 490 KIXC'S KCLKCTIC <>I:STI-:TUICS. 
 
 or to pass the finger between it and the inner surface of the uterus. 
 Cazeaux gives the following rules for determining placenta prrevia in 
 certain cases: "When the hemorrhage takes place either in a woman 
 with her first child, or at an early stage of the gestation, when, in a 
 word, the cervix uteri is not sufficiently dilated to permit the intro- 
 duction of a finger, we might still be enabled to determine the cause 
 of the flooding by the following signs, namely : 
 
 "1. A hemorrhage caused by the placenta's insertion over the 
 internal orifice never occurs before the end of the sixth month ; and, 
 very frequently, not until the last four or six weeks of gestation. 
 Beside, it is highly probable that the period at which the flooding 
 comes on, is usually subordinate to the greater or less extent of the 
 placenta corresponding to the neck; that, in cases of insertion, center 
 for center, it is manifested much sooner than where only one of its 
 margins is in opposition with the orifice. Nevertheless, there are 
 numerous exceptions to this (as M. Nsee'gle considers it) nearly gen- 
 eral rule; for, in a large number of the cases of central insertion, the 
 hemorrhage is not developed prior to the commencement of labor. 
 
 "2. It commences spontaneously, without an appreciable cause, and 
 without any precursory phenomena; the woman being often suddenly 
 aroused in the middle of the night by the blood escaping from the 
 genital parts. 
 
 " 3. When manifested for the first time, it is generally inconsiderable 
 in amount and soon over ; but, after having disappeared altogether, it 
 returns, sometimes in the course of a few hours, at others, not for 
 several days; and, at each reappearance, the discharge is a little more 
 abundant, and, lasts somewhat longer. 
 
 " 4. The cervix uteri (considering the period of gestation) is usually 
 thicker, softer, and more spongy, because the placenta, by becoming 
 fixed over this point, determines there a more considerable afflux of 
 blood. 
 
 " 5. If the labor has commenced, and the membranes are still 
 intact, the flooding constantly augments during the uterine contrac- 
 tions, and diminishes in the intervals. But the contrary is observed 
 when the discharge is occasioned by a separation of the placenta 
 attached to any other point; for then the womb, by contracting, 
 obliterates the vessels, either by a retraction of its own proper tissue, 
 or by the' compression they are subjected to from the parts inclosed 
 within its cavity ; but, in the case under consideration, the contractions 
 that affect the dilatation of the cervix, destroy the vascular adhesions
 
 COMPLICATED LABOR PUERPERAL HEMORRHAGE, ETC. 491 
 
 which unite it to the placenta, more and more, and thus multiply the 
 sources of hemorrhage. This sign is one of great value before the 
 membranes are ruptured; but, after the waters are discharged, the 
 child's head presses on the orifice during the contraction, and prevents 
 the blood from escaping. 
 
 " 6. The bag of waters does not form as in an ordinary labor; for 
 the insertion of the placenta over the neck closes its orifice, and 
 prevents the lower segment of the ovum from engaging therein, and 
 from being accessible to the finger. 
 
 " 7. Lastly ; according to Dewees, the blood has a brighter color at 
 the onset of the hemorrhage than when it comes from the fundus, and 
 coagula never come away, excepting when the . discharge has lasted 
 for some time, or is on the point of disappearing." 
 
 The great mortality of placenta prsevia to the mother, may be due 
 to one or more of several causes, as, to the exhaustion from hemor- 
 rhage ; to inflammation of the veins or metritis resulting from the 
 effects of the lochia upon the greatly developed blood-vessels of the 
 prse-cervical part of the uterus, or, from version, should this have 
 been accomplished; to post partum hemorrhage; to rupture of the 
 cervical tissue following version ; or, to the shock occasioned by this 
 operation. The child may die from even a small quantity of blood 
 lost, but more generally from asphyxia arising from deficient aeration 
 of its blood. 
 
 CHAPTER XXXVII. 
 
 COMPLICATED LABOR TREATMENT OF PLACENTA PRSEVIA 
 
 SYNCOPE FROM HEMORRHAGE. 
 
 TREATMENT. The treatment of cases of placental presentation 
 will depend much upon the period at which the practitioner is called, 
 as well as upon the attending circumstances, and will also require upon 
 his part promptness of action, rapid observation, calmness, and 
 firmness. If called some weeks previous to full term, on the occur- 
 reuce of the commencing floodings, and these are not very copious, 
 the only measures required will be to keep the patient in a horizontal
 
 492 KING'S ECLECTIC OBSTETRICS. 
 
 situation, on a hard bed and in a cool room, enjoining rest and perfect 
 quiet; and, as in all cases of uterine hemorrhage, the bed should be 
 placed so that the attendants can easily pass around it: internally, 
 cold and acid drinks may be exhibited, and some cold astringent 
 solution may be injected into the vagina, but great care is necessary, 
 as these local applications are very apt to arouse uterine contractions. 
 The covering should be light, and the bowels must be kept regular. 
 In fulfilling this latter indication, care must be had not to effect active 
 catharsis by internal agents, nor by stimulating enema, as these will 
 have a tendency to increase or cause a return of the hemorrhage a 
 consequence of straining or tenesmus, which may produce a removal 
 of the coagula which are covering the lacerated blood-vessels. An 
 injection of cold water is probably the best agent which can be em- 
 ployed to free the rectum, and it should be repeated, according to 
 circumstances, once or twice daily, or every other day. Xot un fre- 
 quently there will be more or less nervous irritability, generally arising 
 from an excited and alarmed condition of the mind. The practitioner 
 should always endeavor to tranquilize any mental agitation which may 
 be present ; and, to allay the excited condition of the nervous system, 
 Opium, or a pill of Opium, or the administration of Sp. Tr. Pulsa- 
 tilla, may be found beneficial. The diet of the patient must consist ' 
 of light, nutritious fluids, avoiding all stimulating agents of whatever 
 character, and this should be persisted in as long as may be deemed 
 proper or necessary. 
 
 The hemorrhage having ceased, it must be borne in mind that it 
 is liable to return at any moment, and may prove to be very excessive 
 and serious. Before leaving the house, therefore, full instructions 
 should be given to the friends for its management during the accouch- 
 eur's absence, as for instance, the above measures. He should likewise 
 strictly enjoin upon them to send for him instantly on its recurrence ; 
 and lest he may not be readily found, the services of another profes- 
 sional brother should be secured, in order that the female may not 
 perish for want of proper attention. Beside, these measures show 
 that the practitioner feels a deep interest for the welfare of his patient, 
 secure her confidence as well as that of her friends, and add to his 
 reputation. As soon as the causes of the hemorrhage are suspected, 
 the friends of the patient should be informed, and the dangers to 
 which she is exposed fully made known ; but on no account should the 
 patient be notified, lest it might hasten an unfavorable issue, by creating 
 an intense nervous excitability with powerful mental agitation.
 
 COMPLICATED LABOR PUERPERAL HEMORRHAGE, ETC. 493 
 
 Should the hemorrhage be excessive, and resist the energetic measures 
 employed to check it, or should uterine contractions, however feeble, 
 be experienced, with even moderate loss of blood, the practitioner 
 should apply ligatures to the inferior extremities, and then proceed to a 
 vagina] examination, as heretofore explained. If the os uteri be found 
 rigid, resisting the introduction of a finger, no force whatever must be 
 employed ; the os uteri must be soft and yielding, in all cases, before 
 any introduction of a finger or of the hand is to be attempted to do 
 otherwise is unpardonable. There may be cases, where the hemorrhage 
 is very copious, with a rigid and unyielding condition of the parts 
 forbidding the introduction of a finger for diagnosing, or of a hand 
 for version, in which this rule may be violated, for the purpose of 
 endeavoring to afford the patient the only chance for safety ; but it is 
 always hazardous, and most frequently terminates fatally. Generally, 
 however, the rigidity of the os uteri will be speedily overcome by the 
 great loss of blood; if not, Gelsemium, Lobelia, or the compound 
 tincture of Lobelia and Capsicum may be given. 
 
 In placenta prsevia, the danger is from hemorrhage, which increases 
 when uterine contractions come on, or when dilatation of the os uteri 
 is progressing; and the great and important question is, when to 
 deliver ? The established, and probably the safest method of delivery 
 is, by turning and promptly bringing away the child. The operation 
 has its dangers, but it is the best which can be pursued, and its success 
 will depend greatly upon the skill and judgment of the accoucheur. 
 If he waits for the complete dilatation of the os uteri before under- 
 taking the operation, the exhaustion effected may be so great as to 
 afford no hope for the patient's survival, or she may perish before such 
 dilatation is effected. I would repeat, therefore, two great principles* 
 by which all medical men must be guided in their management of 
 placenta prsevia : 1, never attempt to pass the hand within the os uteri 
 when it is in a rigid condition ; 2, never delay interference by version 
 or otherwise, until full dilatation of the cervical orifice has been 
 accomplished. 
 
 The time for operation has arrived, when the os uteri, being soft and 
 yielding, has dilated to the size of a half dollar, or sufficient to easily 
 admit the introduction of the points of the fingers and thumb; to 
 wait for a greater enlargement of the orifice, would be to increase the 
 hazards to the patient, because the hemorrhage becomes more and more 
 copious and alarming as the development of the os continues to ad- 
 vance ; to interfere sooner, would be at the risk of effecting considerable
 
 494 KING'S ECLECTIC OBSTETRICS. 
 
 injury to the os uteri. It is in cases of an insufficient degree of dila- 
 tability of the os, that Barnes' colpeurynter, or Molesworth's climax 
 dilator, is used, to effect the requisite amount of dilatation, as well as 
 to arrest the hemorrhage, previous to introducing the hand for turning. 
 
 The requisite amount of dilatation having been accomplished, the 
 female should be placed upon her back ; or if the hemorrhage be 
 excessive, or she be very much exhausted, she must not be moved, 
 but the version must be effected while she is lying on her left side. 
 It is always advisable to relieve the ruptured vessels from blood pre. 
 .sure, by ligating both limbs high up around the thighs, which by 
 retaining the blood in the extremities, serves as a reserve that may be 
 again admitted into the general circulation as soon as the immediate 
 danger has passed. The pelvic extremity of the patient should, if 
 possible, be considerably elevated above the head, so that the body 
 shall lie in an inclined position, the head being the lowest part, and 
 this may readily be effected by lifting up the bedstead and securing 
 the legs of one end on blocks of sufficient height: this measure may 
 preserve her from a fatal syncope. The operator must remove his 
 oat, bare his arm, and having anointed the arm and fingers, proceed 
 to the introduction of the hand into the vagina. 
 
 Before introducing the hand, however, it is of some importance to 
 ascertain the position of the child; for should the wrong hand be 
 employed at first, its removal will produce an increase of the flooding, 
 and which may involve fatal consequences before the other hand can 
 be entered. If the placenta be only partially attached over the inner 
 os uteri, or if one side of it be wholly detached, the finger may be 
 passed between the free end of the placenta and the uterus until it 
 reaches the membranes, when the position may be ascertained through 
 these; or if this can not be done, and the patient be not too corpulent, 
 an external examination over the abdomen, in the absence of pains, 
 may detect the globular head at the lower portion of the belly, and the 
 curve of the child's spine being found on the right or left side, will 
 determine its position. This can not, however, be easily ascertained 
 in all cases, and the practitioner will then employ his left hand, on the 
 presumption that the head is in the most usual position, or that in 
 which the occiput looks toward the left acetabulum. 
 
 " In every case, before attempting to turn, make a most careful 
 examination of the os uteri, and endeavor, from the degree of dilata- 
 tion, and the thinness and softness of the orifice, to form a correct 
 judgment upon its dilatability before interfering; for if your attempt
 
 PRETERNATURAL LABOR PUERPERAL HEMORRHAGE, ETC. 495 
 
 be unsuccessful, the hemorrhage will be renewed, and the patient 
 will be placed in a worse condition than she was before." (Lee.) 
 
 The fingers and hand are to be slowly and carefully passed within 
 the vagina, in a conical form, as heretofore explained, and carried 
 up to the os uteri. As the fingers are insinuated within the os 
 uteri, they should also gently dilate it, advancing upward between the 
 free or detached side of the placenta (which must be detected by a 
 careful exploration, as already referred to) and the inner surface of 
 the uterus. If the placenta be not sufficiently separated to admit of 
 the entrance of the hand, an artificial separation must be cautiously 
 effected, selecting, when possible, that side of the placenta for the 
 detachment which is ascertained to be the thinnest, which will be the 
 nearest to its edge, and where, consequently, the uterine blood-vessels 
 will be the smallest. As soon as the fingers have entered the os uteri, 
 a greater or less discharge of blood will almost always follow, but at 
 which the practitioner must not be alarmed ; firmness, self-possession, 
 and gentleness are required; and should the practitioner, alarmed at 
 the fresh discharge, attempt the withdrawal of his hand at this time, 
 a fatal increase of it would very probably be the result. As soon as 
 the hand has thoroughly entered the uterine cavity, the wrist or arm 
 prevents any further material loss of blood, by compressing the orifices 
 of the bleeding vessels. 
 
 The hand should be passed as high up between lAie uterus and 
 membranes as possible these should then be ruptured the hand 
 carried within, and the feet of the child be obtained. If both feet 
 can not be readily found, the version may be effected by one only, 
 instead of delaying the delivery by a prolonged search for the other. 
 The version should be carefully effected, but with as much expedition 
 as is consistent with the safety of the child and patient, and the limbs 
 should be brought down into the vagina until the hips or body of 
 the infant is in contact with the uterine cervix ; and 'this is to be 
 performed, not only to facilitate delivery > but tljat the compression 
 of the bleeding vessels by the fetal pelvic region may check any 
 excessive hemorrhage. After the hand has been introduced within the 
 uterus, and the placenta has been detached, if the practitioner with- 
 draws it without effecting version, fatal hemorrhage may immediately 
 ensue. Therefore, in all instances, where it is desired to detach the 
 placenta wholly or partially, without turning the child, the whole 
 hand, or even the greater part of it, should never be passed within 
 the uterine cavity.
 
 496 KING'S ECLECTIC OBSTETRICS. 
 
 A sudden removal of the contents of the uterus might give rise to- 
 inertia of the organ and fatal flooding; therefore, unless the copious- 
 ness of the discharge requires the immediate delivery of the child, 
 this must not be eifected. The uterus must not be emptied too 
 rapidly. And in every case of hemorrhage from placental presenta- 
 tion, as soon as the version is completed, a full dose of Ergot, should 
 be administered, not so much for the purpose of aiding in the expulsion 
 of the child, as to secure permanent contractions of the uterus sub- 
 sequently. For it must be remembered, that the life of the patient 
 depends entirely upon perfect and persistent uterine contractions. 
 Beside the Ergot, frictions, and other means which have been hereto- 
 fore spoken of, to arouse or preserve the action of the uterus, may be 
 employed. The bandage should never be omitted. 
 
 Some writers recommend the perforation of the placenta itself, 
 but this is a very difficult operation, and when accomplished, may 
 effect the death of the child and mother from augmented hemorrhage 
 occasioned by the certain rupture of large blood-vessels, or from a 
 delay or difficulty in the passage of the child through the insufficient 
 opening made by the hand. It should never be attempted. 
 
 The practitioner may, however, be called to a case of this complica- 
 tion, where the hemorrhage is copious and frightful, before the os 
 uteri is sufficiently dilated, and in which delay would be death. If 
 the os uteri be found rigid and unyielding, no attempts at forcibly 
 entering it with the hand are justifiable such attempts are always 
 dangerous. The only course to be pursued is to procure, if possible, 
 a diminution of the discharge, until the os uteri is in a more favorable 
 state. For this purpose, ligatures should be applied to the extremities, 
 the patient should be kept quiet in a recumbent position with the hips 
 slightly elevated. Cold, acidulated, or astringent draughts should be 
 administered internally, as well as heart -sedatives, and the vagina 
 may likewise be plugged with a tampon wet with a solution of Alum, 
 or dilute Perchloride of Iron, and which will occasionally be found 
 useful. In the early part of this work I stated that the tampon was 
 not to be used in hemorrhages from the uterus, occurring after the 
 fifth or sixth month. The present instance may, however, be con- 
 sidered an exception, as there can not be a concealed hemorrhage to 
 any great extent so long as the membranes remain entire, and the 
 cavity of the uterus is not in a condition to receive a large amount of 
 blood, except such as may pass between the inferior part of the mem- 
 branes and the cervix, unless, indeed, the organ be in a very lax
 
 COMPLICATED LABOR PUERPERAL HEMORRHAGE, ETC. 497 
 
 condition with great prostration of the vital forces. Beside, the use 
 of the tampon does not dispense with the careful watching of the 
 patient, observing the features, the pulse, etc. When no unfavorable 
 symptoms follow the employment of the tampon, its removal will be 
 indicated by the strength and frequency of the pains. I do not 
 recommend the use of the tampon in partial placental presentation, 
 but only in those instances where the membranes can not be reached 
 on account of the internal orifice being wholly occupied by the after- 
 birth. In many instances, notwithstanding the use of all the above 
 measures, the flooding will continue unrestrained; it then become^ 
 necessary to hasten the delivery by all possible means. Should the 
 rigidity be subdued by the great relaxation produced by the excessive 
 loss of blood, or by the means employed for this purpose, then the 
 following course may be attempted : 
 
 But if, instead of a rigid condition of the os uteri, a soft, dilatable 
 one be found, however small the opening, the hemorrhage being, as 
 above remarked, frightful, the fingers may be carefully entered within 
 the orifice one by one, gradually dilating it as they proceed, until the 
 hand can be so far introduced as to effect the version. This is not a 
 desirable method, neither is it of easy performance, and being always, 
 more or less hazardous, should never be undertaken except under 
 imperative circumstances; it then becomes the best and only course 
 left us, and should be employed with all the precautions which a 
 knowledge of its disadvantages and dangers would suggest. In these 
 frightful cases a delay may be fraught with fatal results. "As a 
 principle, delivery had better be had recourse to an hour too soon 
 than an hour too late." " It is the loss of the last half pint of blood 
 that kills the patient." " Sometimes, when in these cases, it is impos- 
 sible to pass the whole hand through the os uteri, the delivery may be 
 safely accomplished by merely passing one hand into the vagina, and 
 afterward the fore and middle fingers between the uterus and detached 
 portion of the placenta, grasping with them the feet, which are 
 generally situated near the os uteri, and drawing down the inferior 
 extremities into the vagina and delivering." (Lee.) \ 
 
 In these cases, the physician should always have his forceps at hand, 
 in order to extract the head, should any delay or difficulty occur in its 
 delivery. 
 
 I will observe here that I have known of three' cases of placenta 
 prsevia, in which the delivery was successfully and safely effected, by 
 the accoucheur carefully inserting a finger within the os uteri and 
 32
 
 498 KING'S ECLECTIC OBSTETRICS. 
 
 detaching enough of the placenta to enable him to elevate the child 
 and pass the detached portion upwards along the side of the head. 
 The head descended into the brim, hemorrhage ceased, and the placenta 
 was safely delivered after the child. In dangerous cases, with exhaus- 
 tion that would imperil the patient's life from the shock of turning, 
 also where the child is dead, it has been advised to detach the placenta 
 completely and then leave the case to nature. It is stated that the 
 hemorrhage ceases after the detachment, and the chances for both 
 mother and child are much more favorable than by any other method. 
 
 When the placental presentation is PARTIAL or INCOMPLETE, 
 that is, when its edge extends only to the margin of the inner os uteri, 
 or perhaps, covering one-third, one-half, or any other proportion of 
 this orifice, the remaining part presenting the membranes, symptoms 
 of a character similar to those in complete placenta prsevia will be met 
 with, requiring a somewhat analogous treatment. This form of pla- 
 cental presentation is of. more frequent occurrence than the complete. 
 When labor is on, and the hemorrhage is profuse, the best course is, 
 to rupture the membranes, without regard to the extent of dilatation 
 of the os uteri, which, by allowing the liquor amnii to escape, will 
 permit the head or breech, as the presenting part may be, to descend 
 and compress the bleeding orifices, thereby checking or diminishing 
 the flooding. The head having descended, the forceps may be 
 applied, if necessary, and the delivery hastily terminated. At the 
 same time, the tincture of Gelsemium may be exhibited to forward 
 the dilatation of the os uteri, while the bandage may be applied, and 
 othei means used to cause vigorous uterine contractions;- and at the 
 proper period Ergot may be given to facilitate the expulsive process, 
 but this drug must not be administered when the natural efforts are 
 alUsufficiont, except it be for the purpose of securing permanent 
 contractions after the delivery. 
 
 Should this course fail, the hemorrhage continuing, or, should 
 there be exhaustion of the system, from the amount of blood lo-t, 
 the better plan will be to rupture the membranes and turn; beinir 
 governed by the rules already laid down for version in complrti- 
 placental presentation. 
 
 In case the liquor amnii has been discharged, and version is desira- 
 ble, the hand will find but little difficulty in entering within the 
 uterine cavity, because the excessiye flooding will, very likely, effect 
 a lax, yielding condition of the parietes of the organ ; this is unlike
 
 COMPLICATED LABOR PUERPERAL HEMORRHAGE, ETC. 499 
 
 preternatural presentations, in which a loss of the amniotic fluid is 
 followed by energetic contractions, rendering it almost impossible to 
 introduce the hand for the operation of turning. Beside, in placenta 
 prsevia, should the contractions be sufficiently vigorous to advance the 
 head, the pressure made by it on the orifices of the vessels will dimin- 
 ish the flow, and there will then be no necessity for the introduction 
 of the hand, as the delivery will be effected by the natural powers, 
 except indeed, the pelvis be malformed, or the soft parts be rigid and 
 unyielding. 
 
 In preternatural presentations of the fetus, with placenta prsevia, or 
 in a small or deformed pelvis, it will be proper to turn, provided the 
 hand can be introduced for the purpose and, in the latter instance, 
 when the head can not descend, or pass through the cavity and inferior 
 strait, it will require the use of the perforator to terminate delivery. 
 
 A brief synopsis of the treatment that has been advised in placenta 
 prsevia may prove useful : When copious hemorrhage is present at full 
 term, the woman's strength good ; the os uteri dilatable ; the pelvis 
 normal; the child alive; if the patient be multiparous, version, or the 
 Jorceps, without delay; if primiparous, complete separation of placenta, 
 >or version. If the child be dead ; os uteri rigid; patient exhausted; 
 pelvis abnormal ; previous to full term ; partially or wholly detach 
 placenta, and, if necessary, apply Perchloride of Iron or other styptic. 
 If the patient be exhausted give stimulants. It is in cases of rigidity, 
 .and where the os is not sufficiently dilated, that the colpeurynter, or 
 Molesworth's climax dilator, may be used to overcome the rigidity, or 
 to soften and dilate the os, and check the hemorrhage. In the absence 
 of these,* introduce the speculum and plug up the vagina with absorb- 
 ent cotton, soft sponge, lint, tow, strips of old muslin, or such non- 
 irritating material as heretofore recommended in using a tampon. 
 The first portion should be thoroughly moistened with a solution of 
 Alum, Tannic Acid, or Perchloride of Iron. The tampon should 
 So kept in place or renewed until the condition of the parts are suffi- 
 ciently dilated to permit the accoucheur to deliver. It ii advised, 
 \vlien it becomes necessary to turn before the position has been ascer- 
 tained, that the practitioner proceed on the supposition that the 
 child's head is in the left occipito-anterior position, and that, conse- 
 quently, he employs the left hand, passing it up, in partial placental 
 prsevia, through that portion of the membranes that can be felt; in 
 complete, pass it between the placenta and uterine surface, detaching 
 the cake as ilr.) h:ind is carried along-.
 
 500 KING'S ECLECTIC OISSTKTIMCS. 
 
 The treatment after delivery will be in accordance with the. rules 
 hereafter given, endeavoring to produce persistent uterine contractions 
 which will prevent a return of hemorrhage also to sustain strength, 
 and allay the irritable condition of the system. 
 
 In hemorrhage from placental presentation, as well as in all puer- 
 peral hemorrhages, there is one very important symptom to which the 
 attention must be especially directed I mean SYNCOPE, or a state 
 approaching to it. When the female has lost a large amount of blood 
 the practitioner will probably find her pale, cold, and gasping, the 
 uterus torpid and exceedingly flabby, the pulse nearly gone, with a 
 fluttering of the heart, and a greater or less degree of insensibility. 
 Upon an examination the flow of blood will be found suspended; but 
 in making the examination, when the above symptoms are present, the 
 greatest care must be had not to disturb the patient, nor to pass the 
 finger into the vagina it must be ascertained from the appearance of 
 fresh cloths applied to the external parts. In such cases, the patient 
 must not be moved a change of position frequently results fatally ; 
 neither must any manual operations be performed for the purpose of 
 emptying the uterus or otherwise endeavoring to promote its contrac- 
 tions. Should the patient be not altogether insensible, she will mani- 
 fest an intolerable restlessness of disposition, a desire to change her 
 posture, which, if acceded to, will occasion sudden death. If the hand 
 be introduced within the uterus, for any purpose whatever, a disturb- 
 ance of the coagula will immediately renew the flooding, and sudden 
 death will almost certainly take place. It has been observed that when 
 the female lies on her left side, the tendency to syncope is very much 
 lessened. 
 
 Instead, therefore, of rendering useless attempts at any manual 
 operations, the practitioner should keep his patient with her hips 
 elevated somewhat higher than her head, and then employ meas- 
 ures to rouse the sinking system, and sustain her strength, until 
 she has so far recovered that attempts may be made to empty the 
 uterine cavity, if necessary. And, to accomplish this indication, 
 stimulants must be given. Brandy, Rum, Ether, Ammonia, or 
 other stimulants may be administered. And if these be conjoined 
 with Sulphate of Quinia, the results will generally follow more 
 promptly and continue more persistently. If the spirituous prep- 
 arations be used, it is better to give them undiluted, if the patient 
 can bear it, because it will require a less amount of fluid to be
 
 COMPLICATED LABOR SYNCOPE FROM HEMORRHAGE, ETC. 501 
 
 thrown into the stomach, and this organ will be less likely to reject 
 it. These stimulants must be persevered in, until they have exerted 
 a decided, but not too highly stimulating, influence upon the system, 
 as manifested by an increase of the pulse, an augmentation of the 
 temperature of the extremities, a reddening of the lips, and a return 
 to consciousness; and when these symptoms present, the further 
 exhibition of stimuli may be dispensed with. In cases of this char- 
 acter the stomach will be nearly as insensible as the rest of the system, 
 and will not be so readily acted on by these cordials as when in a 
 more healthy and vigorous condition ; one or two fluid ounces of un- 
 diluted Brandy may be given at a dose, and repeated every five, ten, 
 or twenty minutes, according to the degree of depression of the vital 
 powers. In extreme prostration it may be necessary to administer 
 stimulants hypodermically. If too long continued, the stimulation of 
 the vital powers by spirituous liquids may be followed by a greater 
 and more dangerous prostration of both mind and body; on which 
 account it is decidedly better, after their influence has become man- 
 ifested, to omit them, and give other stimulants, as Carbonate of 
 Ammonia; a mixture of Sulphate of Quinia and Capsicum; Cinna- 
 mon, etc.; by this means they can, if required, be -again resorted to 
 with much better effect. I succeeded in rallying one case, seemingly 
 from the throes of death, by the use of the hundredth of a grain of 
 Digitalin, administered hypodermically, and repeated in twenty min- 
 utes; after the second do'se the patient had sufficiently reacted to 
 partake of alcoholic stimulants. 
 
 But, not unfrequently, witli the fainting or syncope, there may be 
 a continued flow of blood; this is a very serious condition, especially 
 if the female be sinking rapidly. Under these circumstances, the 
 object will be to suppress, if possible, the hemorrhage, and for which 
 it is difficult to give any specific rule. The rupture of the membranes, 
 followed by a discharge of the liquor amnii, or the removal of the 
 fetus, or the delivery of the placenta, may either of them be followed 
 by contractions of the uterus, and a consequent suppression of the 
 flooding, and thereby prove the safest course to adopt; while, on the 
 ether hand, and particularly if the female be much exhausted by the 
 drain from the system, and the syncope be long continued or extreme, 
 the wiser course will probably be to refrain from all operations, trust- 
 ing to the natural resources, aided by the general external and in- 
 ternal measures usually employed in severe hemorrhages, without any 
 disturbance of the patient's position.
 
 502 KING'S ECLECTIC OBSTETRICS. 
 
 CHAPTER XXXVIII. 
 
 COMPLICATED LABOR ACCIDENTAL HEMORH 1 1 ACE CONCEALED 
 
 HEMORRHAGE HEMORRHAGE AFTER PLACENTAL DELIVERY 
 
 EFFECTS OF LOSS OF BLOOD. 
 
 THE SECOND FORM of puerperal hemorrhage is that which 
 occurs in the latter weeks of pregnancy, as well as during labor, in 
 which the placenta is not attached over the inner os uteri, but to some 
 other portion of the uterine parietes. It includes hemorrhages at any 
 stage of labor previous to the birth of the child ; as, before the rupture 
 of the membranes, after the evacuation of the amniotic fluid, after the 
 expulsion of the head, and during the presence of the shoulders in the 
 pelvic cavity. It has been termed accidental or concealed hemorrhage. 
 
 The immediate cause of this kind of hemorrhage is the separation 
 of a part or the whole of the placenta from the uterus, and which may 
 be the result of severe or sudden shocks, as blows, falls, undue pressure 
 over the hypogastrium, mental agitation, excessive laughter, straining 
 at stool, railroad traveling, etc. ; more commonly, it is owing to some 
 internal cause, as shortness of the umbilical cord from surrounding 
 the child's neck or body, abnormal condition of the placenta, etc. 
 Occasionally it takes place without any discoverable cause. A dis- 
 charge of blood may also take place from rupture of one or more 
 vessels of the umbilical cord, but this is of rare occurrence. 
 
 More commonly, accidental hemorrhage is not observed until after 
 the commencement of labor ; but it frequently happens that there may 
 be one or more discharges of blood for some weeks previously. These 
 early discharges may determine the character of the difficulty, and its 
 disconnection with placenta prsevia, by observing that, in almost all 
 instances, they have been preceded by some sudden or unusual shock,, 
 while in placental presentation, the flooding occurs suddenly without 
 any previous excitement or injury, and frequently happens during 
 sleep. 
 
 The hemorrhage may immediately manifest itself upon the presence 
 of the exciting cause, or it may not appear for a greater or less time 
 subsequently, being preceded by uneasy sensations, and an aching and 
 dull pain in the back and abdomen. Its quantity may vary from a few 
 ounces to an amount sufficient to speedily destroy life, being generally 
 proportioned to the extent of surface exposed ; but, very frequently, 
 fatal flooding occurs where the exposed space scarcely exceeds an inch.
 
 COMPLICATED LABOR CONCEALED HEMORRHAGE, ETC. 503 
 
 square. And it may, or may not, be accompanied by labor-pains, 
 depending, however, upon the period of gestation when it happens; 
 but should this be at full term, and the pains present, the hemorrhage 
 will be checked while they are on, but will return again during the 
 intervals between them. 
 
 It must be recollected that, there may be a very serious hemorrhage 
 going on internally, without the appearance of a single drop of blood 
 externally, and if the practitioner is not aware of this fact he may lose 
 his patient, even before he suspects the true state of her case. There- 
 fore, we are never to judge of the condition of the patient by the 
 amount of blood which has been discharged externally and this rule 
 will hold good in all puerperal hemorrhages but, by the general 
 symptoms of exhaustion, as rigors, weight or sudden distension of the 
 uterus, faintness, nausea, vomiting, coldness of the extremities, feeble 
 but rapid pulse, hurried breathing, paleness of countenance, sighing 
 and yawning, and, if the discharge be not arrested, intolerable rest- 
 lessness, dimness of sight, ringing in the ears, hiccough, and death 
 preceded by syncope or convulsions ; and these symptoms may be 
 present when the vaginal discharge is so slight as hardly to attract 
 any notice. Usually, when syncope occurs, it is followed by a suspen- 
 sion of the hemorrhage, which re-appears as often as the patient becomes 
 conscious, and thus syncope and hemorrhage may continue to alternate 
 with each other, until the fatal moment arrives. 
 
 DIAGNOSIS. In all cases of puerperal hemorrhage occurring 
 previous to the birth of the child, it is an imperative duty on the part 
 of the medical attendant to institute a careful examination per vaginam,. 
 in order to ascertain whether or not the placenta be completely or 
 partially over the inner os uteri. Of course, if the hemorrhage should 
 be present previous to the commencement of labor, the os uteri will 
 be found undilated, and no information can be had by the examina- 
 tion. If, however, it happens at term, and especially if pains are, or 
 have been recognized, the cervix will be found relaxed and yielding, a 
 result caused by the hemorrhage, and we can usually introduce the 
 finger within the os uteri so as to detect either the membranes or the 
 placenta ; this must always be done, even if the whole hand has to be 
 passed into the vagina, in order to make a thorough and satisfactory 
 diagnosis, in all cases where the least doubt exists In the flooding 
 under consideration, the finger will not find the placenta at any part 
 of the os internum uteri ; this latter will be free, its marginal circum- 
 ference will be of the same thickness all round, and the membranes
 
 504 KIN<i's KCLKCTIC olJSTKTIJirs. 
 
 only will be felt in contact with the point of the finger when this is 
 advanced upward. 
 
 Beside this investigation, which should, as before remarked, always 
 be made, there are several signs which will materially assist in the 
 diagnosis. Thus, in accidental hemorrhage, some previous excitement 
 or shock will generally have occurred ; if the pains are on, the hemor- 
 rhage is arrested by them, but recurs during the intervals in unavoid- 
 able hemorrhage the flow has presented itself at different periods during 
 the last weeks of gestation, and when labor is on the discharge stops 
 or slightly continues during the intervals, and is augmented by the 
 pains. 
 
 TREATMENT. The treatment of accidental hemorrhage will 
 vary according to the quantity of blood lost, the period at which it 
 occurs, and the condition of the os uteri. When it occurs previous to 
 full term, labor-pains being absent, and no tendency to dilatation on 
 the part of the os uteri, the hemorrhage not being so profuse as to 
 impair the constitutional powers, we should endeavor by all means to 
 stop it, and prevent if possible, its return. 
 
 The patient should be kept in a horizontal position, on a cool, hard 
 bed; her covering should be light, and the surrounding temperature 
 of the room should be considerably reduced. Cold water only should 
 be allowed, or ice; or the water may be acidulated with mineral acids, 
 which exert no injurious influence and are usually acceptable. Injec- 
 tions of cold water, and cold applications over the external organs 
 will frequently prove advantageous, but these should not be used 
 when the system has become excessively depressed. The plug or 
 tampon, is advised by some writers, but I consider its use contra- 
 indicated after the seventh month, from the fact that an external 
 flooding may be changed into an internal one. The patient must not 
 be allowed to get up for any purpose whatever, and in the alvine 
 evacuations, especially to lessen straining efforts, it will be better to 
 aid by rectal enemata. 
 
 Should the flooding be very excessive, some of the means hereafter 
 named, under the treatment of Hemorrhage after the delivery of the 
 placenta, may be employed, as, ligating the limbs, tincture of Cinna- 
 mon, or its combinations, oil of Erigeron, Gallic acid, etc. 
 
 When, notwithstanding all our efforts to check the discharge, it still 
 continues, we can not expect that pregnancy will persist to the full 
 period, and the only course that can be pursued to permanently arrest 
 the hemorrhage and lessen the dangers to the female, will be to effect
 
 COMPLICATED LABOR-^CONCEALED HEMORRHAGE, ETC. 505 
 
 an evacuation of the uterine contents. The palliative measures will 
 now be of no avail. 
 
 The proper course, then, will be to rupture the membranes, and 
 favor the escape of the amniotic liquor, by holding up the child's 
 head ; the contractions of the uterus may be excited by the application 
 of the bandage, by gentle pressure made around the os uteri with one 
 or two fingers, and Ergot and stimulants may be advantageously 
 exhibited. In these cases, the os uteri will most commonly be found 
 soft and dilatable, but should it be rigid and undilated, the rupturing 
 of the membranes should not be attempted until this condition is 
 overcome, and which may be readily accomplished by the tincture of 
 Gelseminum, tincture of Lobelia, or other means heretofore explained. 
 
 The discharge of the waters, and the employment of the measures 
 named, will, in the majority of cases, cause the uterus to contract and 
 speedily evacuate its contents, and which action is almost invariably 
 accompanied with a cessation of the hemorrhage. True, the life of 
 the child may be endangered, but this is never to be taken into 
 account when the mother's life is at stake. 
 
 I am aware that several writers have objected to rupturing the 
 membranes in these instances of flooding, but their objections appear 
 to me very insufficient, and the testimony of many eminent accouch- 
 eurs, together with my own experience, justifies me in strongly 
 recommending this method, instead of immediate delivery by turning; 
 the hand should in no case be passed into the uterine cavity, unless 
 the safety of the female imperatively demands it; and it must be borne 
 in mind, that in cases of uterine hemorrhage, where the membranes 
 are felt at the mouth of the uterus, turning is very seldom required 
 though it is always necessary in complete placenta! presentation. 
 Sometimes, after the membranes have been ruptured and the above 
 means used to arouse uterine action, nothing will be accomplished, 
 the^hemorrhage will continue, and the treatment will fail to bring 
 about the desired contractions; this, however, is not apt to occur, 
 unless the attendant has too long delayed the operation, or, where the 
 whole or nearly the whole of the placenta has become detached, and 
 an excessive internal hemorrhage has consequently ensued. In these 
 cases of failure it will become necessary to effect the delivery by 
 turning, the employment of the forceps, or the perforator, as the 
 exigencies of the case may demand. When a preternatural presenta- 
 tion is ascertained in these cases of hemorrhage, it then always becomes 
 necessary to effect a version as speedily as possible, but not before the 
 os uteri is in a proper state, leaving the subsequent delivery to the
 
 506 KING'S KCLKCTK OBSTETRICS. 
 
 natural powers when these are efficient. When the hemorrhage has 
 occasioned great exhaustion of the system with syncope, the discharge 
 being suspended, as heretofore observed, the practitioner must be 
 extremely cautious how he attempts, or proceeds in, his manual 
 operations. 
 
 Should there be any delay in the delivery of the placenta, it is 
 generally better, in cases where the hemorrhage has been profuse, to 
 extract it, in order to secure permanent contraction of the uterus and 
 thereby lessen any tendency to a continuation of the flow, and every 
 means and care must be employed to guard, not only against a return 
 of the flooding, but also against an attack of inflammation. After the 
 delivery, the female should be managed as hereafter advised. 
 
 The THIRD DIVISION of puerperal uterine hemorrhage, is that 
 which occurs after the delivery of the child, but before the expulsion 
 of the placenta ; it is frequently met with in practice, and usually 
 comes on suddenly and in excessive quantity, greatly alarming the 
 patient and her friends. The cause of this flooding is, as in the pre- 
 vious ones, a more or less complete detachment of the placenta from the 
 uterine walls, with inertia or inefficient action of the uterus. It may 
 occur in instances where previous pains were feeble and with long 
 intervals, as well as in cases where the labor had thus far been prompt 
 and energetic ; and it is frequently manifested even when the preceding 
 stages of labor had been most prudently and skillfully managed. The 
 recommendation, heretofore given, that after the birth of the child the 
 accoucheur should ascertain whether the uterus is contracted or not, by 
 placing his hand upon the abdomen of his patient and feeling through 
 its parietes for that organ, is one which should never be omitted, a 
 rigid observance of this rule will keep him thoroughly informed :i> 
 to the condition of the gestating organ, so that he can always be ready 
 for prompt measures whenever required. 
 
 In these instances of hemorrhage, shortly after the birth of the 
 child, or, perhaps, immediately succeeding it, a profuse quantity of 
 blood is suddenly and rapidly discharged, and the first indications 
 which the practitioner receives of the danger, are the pallid coun- 
 tenance, and the rapid and feeble pulse of his patient, with syncope, 
 or a state approaching to it. On placing his hand upon the abdomen, 
 the womb will be felt soft and flabby, and perhaps, somewhat enlarged ; 
 in a state of contraction it always offers a firm, hard resistance when 
 pressed upon. The female soon becomes utterly unconscious, even 
 before complete syncope has ensued, bsing unable either to see or hoar
 
 COMPLICATED LABOR CONCEALED HEMORRHAGE, ETC. 507 
 
 anything around her, and if relief be not promptly given, the hemor- 
 rhage will speedily prove fatal. 
 
 TREATMENT. In all cases of hemorrhage previous to the deliv- 
 ery of the placenta, there is but one course to pursue, and that is, 
 to artificially separate and remove the placenta, and " no man is 
 thoroughly prepared to undertake the charge of a common midwifery 
 case, who would hesitate to pass his hand into the uterus and remove the 
 placenta, whether adherent or detached/' in a dangerous flooding of this 
 character; and, in my opinion, the sooner this operation is attempted 
 the greater is the security afforded to the \voman; do not wait for the 
 hemorrhage to become profuse and-exhausting before interference. 
 
 The suddenness and profuseness of the discharge may at first startle 
 the young accoucheur but he should not hesitate, and tamper with the 
 case by endeavoring to extract the placenta with pulling up on the 
 cord, because he may invert the uterus or else break the cord off in the 
 neighborhood of the after-birth, in either ca^-e increasing the danger. 
 It will be well, however, to make slight traction on the cord before re- 
 sorting to more radical means, as it may be wholly or almost completely 
 detached, and thus easily withdrawn. Neither should he attempt to 
 overcome the hemorrhage by internal or external means alone leav- 
 ing the introduction of the hand as a dernier resort because, in these 
 cases, a few minutes are of immense value to the patient, and such de- 
 lays are trifling with her life. If the practitioner becomes excessively 
 alarmed, or loses his presence of mind, and feels a hesitancy as to the 
 course he should pursue, he should not attempt interference, lest he 
 might increase the hazards, but should at once send for counsel. 
 
 On the manifestation of the hemorrhage, he will immediately place 
 a bandage around his patient's abdomen with a compress beneath it to 
 make pressure upon the uterine fundus, and will have the whole firmly 
 secured. Then removing his coat, and rolling up his sleeves, lie will 
 gently stretch the cord with his left hand, and following it as a guide, 
 conduct his right hand to the placenta ; if on entering the os uteri, 
 this be found contracted, it may be sufficiently dilated as the fingers 
 and hand pass through it. Upon reaching the placenta, the fingers 
 chould be extended to its circumference, and its adhering portion 
 slowly and cautiously detached, being careful that the separation is 
 complete bpfore attempting its removal from the uterine cavity. After 
 the placenta has been reached, the other hand should be placed ex- 
 ternally upon the abdomen of the patient to support and steady the 
 uterus, otherwise, it will be very apt to move about, and retard the 
 operation. The operator must bear in mind that by following the 
 cord he will reach the fetal surface of the placenta and should he
 
 508 KINO'S ECLECTIC OBSTETRICS. 
 
 become embarrassed by the membranes in his search for its periphery, 
 the hand should be withdrawn to the cervix, placed against the uter- 
 ine walls, and the fingers carefully passed along the placenta. 
 
 In separating the placenta from the uterus, the fingers must not be 
 passed rudely or carelessly between the adhering surfaces, lest some 
 portion of the uterine surface be injured by the nails, or otherwise; 
 neither should the practitioner seize the free part of the placenta and 
 draw it away, lest some of the unseparated placenta be torn off and 
 left behind to continue the hemorrhage and render it fatal, or, at all 
 events to decompose and ultimately to give rise to the usual symptoms 
 of putrefactive absorption. But, he should press upon the placenta at 
 its attached points, with the ends of his fingers, carefully pushing or 
 pressing it off, as though he were removing the peel from a thin 
 orange, without disturbing the inner tunic of the fruit or causing any 
 of its juice to exude. 
 
 The placenta being detached, the uterus will commonly contract and 
 expel it and the hand together ; or the means heretofore advised for 
 causing contractions may be employed. The hand must not be with- 
 drawn, but must be expelled by the uterine contractions; and after 
 the expulsion, contractions occurring, the hemorrhage will cease. 
 However, should it still continue, it must be treated the same as 
 flooding occurring after placental delivery. 
 
 The removal of the placenta is not, as a general thing, a difficult 
 operation; sometimes, however, it may form a partial or complete 
 morbid adhesion to the uterine parietes, when it must be detached 
 according to the mode explained when treating of morbid placental 
 adhesion. In all cases, after having removed the placenta, it should 
 be carefully examined to ascertain whether any portion of it is left 
 within the uterus, and if any considerable part of it be wanting, say, 
 one-fourth, or one-third, the hand should be immediately re-intro- 
 duced, to remove the disrupted part, provided the uterus has not in 
 the meantime contracted around it. 
 
 It may be necessary to again advert to a rule which should not be 
 disregarded; which is, that if the hemorrhage has been very great, 
 causing excessive debility and syncope, an attempt at removing the 
 placenta must not be made until the patient rallies a little; for if, 
 during the state of syncope the flooding ceases, the introduction of 
 the hand, by removing the clot formed, would cause a return of the 
 discharge followed by almost certain death. 
 
 In this, as in all puerperal floodings, the patient must not be left 
 too soon, the medical attendant should remain with her an hour or
 
 COMPLICATED LABOR HEMORRHAGE AFTER DELIVERY. .509 
 
 two after the arrest of the discharge, for the purpose of knowing that 
 the contraction of the uterus is permanent, and that there will be but 
 little danger of a return of the flow, and which may generally be 
 insured by a dose or two of Ergot, as soon as the placenta has passed 
 away, together with a firm application of the bandage ; and on leaving 
 the house, he should, previously, give full instructions to the nurse, or 
 some friend, how to proceed, in case of a return of the flooding. 
 Measures should also be adopted to guard against an attack of in- 
 flammation. 
 
 The FOURTH VAEIETY of uterine hemorrhage, is that which 
 appears after the extrusion of the secundines ; this may be external 
 and apparent, or it may be internal and concealed. It is an extremely 
 dangerous form of flooding, often manifests itself suddenly and 
 unexpectedly, and is frequently very difficult to subdue. It is com- 
 monly owing to inertia, or want of contractions of the uterus, or 
 perhaps the contractions, may be irregular and unequal ; occasionally, 
 it may be the result of rupture of the cervix, and will be severe and 
 dangerous, in proportion to the extent of* the rupture. A certain 
 quantity of blood always escapes from the mouths of the uterine 
 vessels, after delivery, without causing any alarming or serious con- 
 sequences, especially, when the uterine tumor .is found hard and firmly 
 contracted ; but when the system experiences the effects of the loss of 
 blood, and the uterus is found soft, flabby, and uncontracted, the 
 patient becomes exposed to great hazard. Among the causes which 
 may induce inertia of the uterus, may be named, mental excitement, 
 debility of the muscular fibers of the uterus after a labor aided by 
 Ergot, high temperature of the room, reaction from the use of stim- 
 ulants, a clot filling up the os uteri, constitutional or local incapability 
 of muscular contraction, neglect of the bandage, meddlesome inter- 
 ference, etc. Women whose urine contains considerable albumen are 
 likewise more liable to this variety of hemorrhage. 
 
 The hemorrhage may come on immediately after the expulsion of 
 the secundines, even when the labor has been thus far favorable and 
 without any untoward accidents; or, it may not appear for half an 
 hour, or an hour after the delivery; and, sometimes, several hours or 
 even days may intervene before the effusion is manifested. Usually, 
 after the first gush of blood the patient faints, and the discharge 
 becomes lessened or suspended; she rallies, the effusion returns, is 
 again succeeded by fainting and a suspension of the flow, and in this 
 manner the rallying, flooding, and fainting alternate, until the system
 
 ~)1() KING'S ECLECTIC OBSTETRICS;. 
 
 has become so exhausted that reaction is impossible, uud death ter- 
 minates the scene. Sometimes, the discharge will take place slowly, 
 continuing for some time before the patient becomes completely lost in 
 a fatal syncope. Again, the first gush is, occasionally, so great as to 
 produce excessive prostration of the system, with syncope, from which 
 the patient never rallies. The influence of the discharge upon the 
 system, varies with different women ; some may have but an inconsid- 
 erable degree of depression from an excessive flow, while others will 
 be destroyed by the loss of from twelve to eighteen ounces. And the 
 hemorrhage is not to be dreaded, therefore, so much from its quantity, 
 as from its effects upon the constitution. 
 
 SYMPTOMS. This form of hemorrhage usually comes on sud- 
 denly, presenting the symptoms common to copious effusions of 
 blood. Generally, the first intimation the physician has of the 
 danger, is an expression from the patient of excessive faintness: her 
 countenance becomes pale, the breathing difficult and hurried, the 
 extremities cold, with a cold perspiration on the face and forehead, 
 and the pulse rapidly becomes small, quick, feeble, fluttering, indis- 
 tinct, and perhaps entirely suspended for a few beats, accompanied 
 with a state of unconsciousness, which often comes on in a few seconds. 
 On examining the bed and napkins, a large quantity of blood will be 
 found, perhaps so excessive as to find its way from the bed to the 
 floor; or there may be a very small discharge externally, but a copious 
 one internally. 
 
 If the first gush should not prove fatal, after a greater or less dura- 
 tion of the syncope, the pulse returns, gradually increasing in strength, 
 the countenance becomes a little more florid, the extremities warmer, 
 the breathing more natural, and the patient recovers her consciousness. 
 If the system has been considerably depressed by the discharge, she 1 
 now manifests much restlessness and uneasiness, throwing her arms 
 about, gasping and crying for fresh air, to be fanned, etc., Avitji 
 anxious expressions and apprehensions of dying. 
 
 After the first rally, in a short time she sinks again under a return 
 of the hemorrhage, from which she may again recover, and so 
 alternate for several times in succession, until finally she complains 
 3f a tightness of the chest, a sense of suffocation, which may be 
 followed by a few spasmodic struggles or convulsions, terminating in 
 death. The fluttering, indistinct pulse, the pallid countenance, the 
 hurried respiration, the intolerable restlessness, with rigors and vom- 
 iting, are indications of excessive depression of the physical powers, 
 requiring prompt, energetic, and decisive measures, which must be
 
 COMPLICATED LABOR HEMOREHAGE AFTER DELIVERY. 511 
 
 perseveringly persisted in until the patient either recovers, or sinks 
 beyond mortal aid. 
 
 The hand being placed upon the abdomen, will, in case of internal 
 hemorrhage, find the uterus soft and fluctuating, and of a size nearly 
 equaling that previous to the delivery ; and if pressure be made upon 
 it, a gurgling sound will be heard, accompanied with a gush of blood, 
 fluid or coagulated, from the vulva. When the flooding is external, 
 an examination of the bed and napkins will give some idea of the 
 copiousness of the discharge ; and although the uterus will be found 
 soft and flabby, it will not be so large as in the former case. 
 
 In these hemorrhages after delivery, the accoucheur should always 
 ascertain two things : first, that the whole of the placenta has been 
 abstracted, for a small portion retained within tjie uterus has fre- 
 quently given rise to copious flooding ; and when called in to a case 
 as consulting or assisting physician, he should never forget to ask for 
 the placenta, that he may examine it carefully : this should never be 
 omitted, even though the attending physician should insist that it had 
 been completely removed; for cases have occurred in which such 
 assertions have been found erroneous not intentionally, but from an 
 insufficient or hasty attention to the matter. Secondly, ascertain that 
 the uterus is not inverted, a condition which may be readily effected 
 by traction upon the cord, or drawing down of the placenta, when 
 the organ is in a relaxed and paralyzed condition; and the mode 
 of ascertaining this will be explained under the head of Inverted 
 Uterus. 
 
 TREATMENT. The flooding which occurs at the parturient 
 period is not owing to any increased or inordinate action of the heart 
 and arteries, and is, therefore, a passive hemorrhage, being caused 
 solely by the exposure and patulous condition of the orifices of the 
 uterine blood-vessels, the result of placental separation and non- 
 contraction of the uterus. The indications of treatment are, to arouse 
 the contractions of the uterus, by which alone can we expect to 
 suppress or check the hemorrhage, and, to support the strength of the 
 patient. 
 
 If, upon examination, it be ascertained that a considerable portion 
 of the placenta has been left within the uterine cavity, the hand must 
 be immediately introduced, as heretofore stated, for the purpose of 
 removing it; and, usually, the uterus will contract as soon as the 
 removal is effected, thereby arresting any further flooding. 
 
 But the placenta may have been entirely removed, and still a pro- 
 fuse hemorrhage be present; the woman's safety, then, depends entirely
 
 51 2 KING'S ECLECTIC OBSTETRICS. 
 
 upon the induction of uterine contraction. The practitioner must 
 proceed calmly, steadily, and energetically : a hesitation, a falter, a 
 timidity, and above all, an inexcusable ignorance of his duties, are 
 almost certain death to his patient. Everything around is calculated to 
 unman him, if he has not previously instructed and prepared himself; 
 the appalling discharge of blood the sudden pallor of countenance, 
 depression of pulse, and loss of consciousness the intolerable and 
 significant restlessness, gaspings for air, and heart-rending exclama- 
 tions of anticipated death together with the alarm, the agonizing 
 anxiety, and hurried whisperings and questionings of friends, are but 
 little conducive to assist him in tranquilizing his mind. But notwith- 
 standing all these, he must be composed, positive, prompt, and firm 
 must subdue all his 1 own feelings, for the safety of his patient ; and 
 without he is able to do all these, he is unfit for the responsible duties 
 of an accoucheur. 
 
 The hand of the practitioner must be placed upon the abdomen of 
 his patient, for the purpose of making firm and constant pressure over 
 the fundtis uteri, and the pressure may require to be continued for two 
 or three hours, in which case an assistant may relieve the medical 
 attendant by performing this manipulation, and which will always be 
 found superior to a bandage : not only should the fundus be com- 
 pressed, but it should be grasped, squeezed, kneaded by the hand, 
 which will tend to arouse its contractions, as well as to prevent it from 
 becoming filled and distended with blood and clots; and this should 
 be continued, notwithstanding the patient may desire us to desist on 
 account of the pain produced. The pressure or kueadings should 
 never be so powerful as to indent, or cause a partial or complete inver- 
 sion of the uterus. Stimulants should be freely given from the com- 
 mencement of the hemorrhage, or sufficient to keep up the pulse, for 
 this purpose brandy will be found very efficient, or a mixture of brandy 
 and Lloyd's Ergot, which at an early period may arouse uterine con- 
 tractions, but which will be of no service when, from excessive loss 
 of blood, there is also a corresponding loss of the absorbing powers. 
 Sulphate of Quinia, given internally, or by subcutaneous injection, 
 will frequently prove efficient when Ergot fails. The hypodermic 
 injection often or fifteen drops of Lloyd's Ergot will, as a rule, stim- 
 ulate the uterus to immediate and powerful contraction, and in ex- 
 treme cases should be administered in this way. When the flooding 
 has been arrested, a bandage and compress over the fundus may then 
 be substituted.
 
 COMPLICATED LABOR HEMORRHAGE AFTER DELIVERY. 513 
 
 If the hemorrhage still continues, in conjunction with the pressure, 
 cold applications should be applied to the pelvis; thus, cold \vater, or 
 a mixture of cold water and vinegar, should be poured upon the naked 
 abdomen from a considerable height; and napkins may be dipped in 
 the same, and then applied suddenly to the vulva, the thighs, and nates. 
 And this treatment should be persevered in until the shock or succes- 
 sion of shocks arouses uterine action. LIGATURES should be applied 
 around the thighs, in all cases, as early as possible. When the system 
 becomes considerably depressed, some care will be required in the 
 resort to the above cold applications, as their constant use, at this time, 
 will be apt to cause injurious rather than beneficial results. 
 
 Injections of Cold Water into the vagina, uterus, and rectum, and 
 even he application of Ice within the uterus, have been advised, but 
 I have never employed them : should I deem such means requisite at 
 any time I should not hesitate to employ them. 
 
 Internally, Ergot is indicated, but it will frequently fail in effecting 
 any beneficial result. I place great confidence in the exhibition of 
 tincture of Cinnamon, which undoubtedly exerts an influence upon the 
 uterus : it may be given in teaspoonful doses, in some sweetened water, 
 and repeated every ten, thirty, or sixty minutes, according to the 
 urgency of the case; or it may be beneficially combined with other 
 agents, thus: Take of tincture of Cinnamon, tincture of Rhatany, oil 
 of Turpentine, each, equal parts : mix together, and give from half a 
 fluidrachm to a fluidrachm for a dose, in some convenient vehicle, and 
 repeat as may be required. Or it may be combined with Tannic acid, 
 tincture of Ergot, and Port Wine. But it must be recollected that, 
 however valuable they may be in other cases, astringents are of but 
 little value in these floodings, unless the contraction of the uterus is- 
 effected, and then they are not required. It is only in instances of 
 moderate flooding where these agents are apparently beneficial. 
 
 The calcined Deer's Horn (See American Dispensatory] has been 
 highly recommended in uterine hemorrhage by some of the older 
 Eclectics; Several report having always succeeded in arresting the 
 discharge when other means have failed. I have not employed it in 
 practice, having succeeded in these cases by the means above de- 
 scribed. Yet its positive influence in checking hemorrhage has been 
 frequently named to me by physicians who have used it, and whose 
 statements are entitled to confidence; beside, I know of instances 
 where it has been exhibited with success. It is generally admin- 
 istered in drachm doses, repeated every ten, twenty or thirty min- 
 utes; each dose may be added to about a gill of hot water. This 
 33
 
 514 KING'S ECLECTIC OBSTETRICS. 
 
 preparation is considered a powerful styptic, from the facility with 
 which hemorrhages are checked by its internal use; yet, from its 
 beneficial results in menorrhagia and uterine hemorrhage, it must 
 undoubtedly exert a decided influence upon the uterus itself, inde- 
 pendent of any styptic power it may possess. 
 
 Other agents have been advised, but I am not acquainted with any 
 especial value they possess, for instance a mixture of three parts of 
 Alum, two of Capsicum, and one of Geranium, in doses of twenty 
 grains every ten, twenty, or thirty minutes. Likewise, doses of Tannic 
 acid, five grains mixed with half a grain or a grain of Opium, and 
 repeated according to indications. It makes, however, but little 
 matter what remedies be used, so that the most important indication 
 be fulfilled energetic and permanent uterine contractions. 
 
 Professor Meigs recommends the following course, in obstinate cases: 
 " If the student should find the hemorrhage not to be stayed by his 
 treatment, let him press his fingers, gathered into a cone, firmly down 
 upon the aorta, near the umbilicus. If the patient should not be 
 troubled with extraordinary obesity, he will be able to feel the throb 
 of the aorta with the points of the fingers. Let him compress the 
 tube according to his judgment, in such a way as to check the down- 
 ward rush of the torrent. This will operate usefully in two ways 
 first, by lessening the force with which the blood reaches the bleeding 
 orifices, which will then have an opportunity to close themselves, more 
 or less completely; and second, by causing a greater determination of 
 blood to the encephalon, whereby the tendency to deliquium will be 
 lessened. Many lives have apparently been saved by thus compressing 
 the aorta." I have never tested this method, having generally succeeded 
 in checking the hemorrhage by the means above named, yet I have no 
 doubt of its efficacy in some cases, and can bring to mind instances in 
 which it might have been the means of saving several valuable lives ; 
 however, I should not hesitate to adopt it when other means proved 
 ineffectual, and would favorably recommend it to the attention of the 
 student. Baudelocque, I think, advised a somewhat similar course. 
 
 The introduction of the hand within the uterine cavity, in hemor- 
 rnage after the delivery of the placenta, for the purpose of stimulating 
 the uterus to act, was at one time thought to be a most injudicious 
 procedure, but later experience shows it to be a valuable and efficient 
 means in overcoming the trouble in many cases. The hand im- 
 mersed in water as hot as can be borne, and then carried into the 
 uterus, will often, from its reflex effect, produce marked uterine 
 action. In Leishman's System of Midwifery, M. Evrat is cited, who
 
 COMPLICATED LAIiOIl HEMORRHAGE AFTER DELIVERY. 515 
 
 recommended the use of a peeled lemon, which he introduced into the 
 cavity of the uterus and then squeezed, so as to project the acid juice 
 upon the bleeding surface. A sponge wrung out of vinegar, and 
 other astringents have, in the same way and for the same purpose, 
 been introduced, and the effect of such applications has not unfre- 
 quently been to rouse the uterus from its dormant condition. It 
 may, also, frequently be necessary to introduce the hand into the 
 uterus for the removal of the coagula, which sometimes adhere so 
 strongly to the inner uterine membrane as to oppose all natural 
 efforts at expulsion, and by their presence keep up a greater or less 
 amount of flooding, even though contractions may have been induced. 
 The coagulum formed within the uterine cavity, may usually be 
 considered as a means adopted by nature to check the flooding, as well 
 as to eventually stimulate the organ to contraction. In many instances, 
 the introduction of the hand, with frictions internally and externally, 
 and aided by Ergot, fail to arouse the activity of the uterus; it continues 
 soft and flabby, and if the coagula are removed with the womb in this 
 inert condition, it may be followed by a fatal increase of the hemorrhage. 
 The safety of the woman, in such case, depends entirely upon the 
 presence of the coagula, and its continuance until contractions are 
 excited, when they will, as a general rule, be expelled without artificial 
 aid. Again : should the uterus be suddenly aroused, as has been the 
 case, and contract upon the hand within its cavity, the position of the 
 accoucheur, as well as of his patient, will be, at least for a time, any- 
 thing but agreeable the hand being fastened within a firmly-contracted, 
 womb. An artificial removal of the clots, however, is advisable 
 where there has been a failure of the other means employed, with 
 considerable distension of the uterus, and symptoms indicative of a 
 flow internally; here, the removal of the coagula, followed by active 
 means to secure uterine contraction, will prove serviceable, but it 
 should be undertaken with cautiousness and prudence, because, if we 
 fail to induce the desired contractions, the consequences to the patient 
 become more serious. A removal of the coagula may likewise be 
 attempted in cases where the uterus is small, with contractions or a 
 disposition to become firm, but where, notwithstanding, the flow of 
 blood continues in great quantity; in these cases the clots are usually 
 so firmly agglutinated to the inner walls of the uterus that the efforts 
 of the organ can not expel them. Any great accumulation of coagula, 
 however, will not be apt to take place, if strong pressure or kneading 
 be applied over the fundus uteri by the hand, or by a properly adjusted 
 compress and bandage : it is. the neglect of this measure which fre-
 
 516 KING'S ECLECTIC OI:STKTIMCS. 
 
 quently occasions the difficulty. When the external hemorrhage has 
 not been threat, but the constitutional symptoms indicate the loss of 
 much blood, and there is but little distension of the uterus, an exami- 
 nation may find the vagina filled with a coagulum, and this should be 
 at once removed. 
 
 Dr. Rigby speaks favorably of applying the child to the mother's 
 breast, in this variety of flooding; suckling frequently induces after- 
 pains, and from, the sympathy existing between the uterus and mammae, 
 it maybe found an efficacious method of causing the uterus to contract: 
 if the plan be tried, the mother should not be moved or disturbed in 
 her position. Galvanism has been recommended by Dr. Radford, 
 and there is no doubt but it will prove successful in many instances, 
 provided the battery can be prepared and in readiness for immediate- 
 action. 
 
 Among other measures, recently advised in this dangerous complica- 
 tion of labor, may be named that of M. Dupierris, of Havana, and 
 which he has successfully used in more than one hundred cases of 
 uterine hemorrhage: he first removes the clots and other foreign 
 bodies from the uterine cavity, and then slowly and carefully injects 
 into this cavity a mixture composed of tincture of Iodine half a fluid- 
 ounce, Iodide of Potassium ten grains, Distilled Water one fluidounce. 
 He states that it promptly arrests the hemorrhage by arousing the 
 uterus to contractions, seldom having to give a second injection ; 
 beside which, he has found this injection to be of great value in 
 puerperal peritonitis. 
 
 A great deal of discussion, and, unfortunately, some of it of a per- 
 sonal character, has been carried on among the medical men of Great 
 Britain, relative to the use of perchloride of iron in post-partum 
 hemorrhage, many contending that it is a dangerous agent, while others 
 equally as eminent in the profession deny this, and speak highly of its 
 efficacy in their hands. It appears that perchloride of iron was first 
 successfully used by the late Professor d'Outrepont, of Wurzburg, some 
 thirty years ago; recently the attention of the profession has been more 
 directly called to it, from its strong recommendation by Dr. Barnes, 
 of England. The objections to its use are, that it gives rise to violent 
 after-pains, embolism, phlegmasia dolens, pyaemia, metritis, septicaemia, 
 or peritonitis, and generally followed by death. Unless the fluid be 
 forced into the abdominal cavity, or the clots formed by its constringing 
 action be not removed from time to time, thus allowing them to remain 
 and decompose in the uterine cavity, I can not comprehend how such 
 serious effects can follow its employment except as mere coincidences 
 the contractions of the uterus which immediately follow its applica-
 
 COMPLICATED LABOR HEMORRHAGE AFTER DELIVERY. 517 
 
 tion, and the closure of the mouths of the bleeding vessels, are certainly 
 opposed to any supposition that such results are due to its use. The 
 successful results following its employment that are recorded by some 
 of the most skillful and eminent medical men in Europe and this 
 country, certainly entitle it to a just and fair consideration. 
 
 This agent should only be used as a dernier ressort, when all the other 
 means pursued have failed, and especially in those cases where the 
 uterus contracts and relaxes alternately, and, if possible, it should not 
 be delayed too long, but should be resorted to before the exhaustion 
 becomes so great that the uterus is rendered incapable of responding 
 to the stimulus. Immediately previous to injecting it, all clots or 
 remaining portions of placenta structure should be carefully removed 
 from the uterine cavity, to allow the agent to come in direct contact 
 with the bleeding surface; and the extremity of the nozzle of the 
 injecting tube should be passed up to the uterine fundus, the fluid 
 being carefully and slowly injected, especially avoiding the injection 
 of air at the same time. It has likewise been used by swabbing out 
 the uterine cavity with a small brush moistened with it, or by saturating 
 soft, fine sponge with it, with which the uterine surface is swabbed, 
 allowing the sponge to be expelled by the contractions thus excited; a 
 string may be attached to the lower extremity of the sponge, by which 
 it may be withdrawn if desired. 
 
 A day or so after the cessation of the hemorrhage, and when any 
 further danger from it has passed, the hard, black clots formed by the 
 corrugating eifects of the perchloride, should be removed from time to 
 time in order to prevent any evil effects from their decomposition; and 
 to assist in this prevention, solution of Permanganate of Potassa may 
 be injected (or swabbed) three or four times a day into the uterine 
 cavity, until all danger from septic absorption has passed. At the 
 same time a proper sustaining treatment must be pursued. Secondary 
 hemorrhage has in a few instances occurred some ten or twelve days 
 after delivery, due to retained clots, etc., but which has been overcome 
 by further injections of a strong solution of the perchloride. The 
 strength of the solution injected has varied with practitioners, as, 1 
 part of solution of Perchloride of Iron to 32 parts of water ; and 1 
 part to 6, 4, and 2 parts of water 1 part of iron to 4 of water being 
 the strength more commonly used. Although I have never used this 
 agent, having met with success in post partum hemorrhage from the 
 measures heretofore recommended, yet should these ever fail me, I 
 should not hesitate to employ the one under consideration, deeming it 
 safe and justifiable, and should employ 1 part to 15 or 20 of water.
 
 518 KING'S ECLECTIC OBSTETRICS. 
 
 An important point, to which I have heretofore adverted, is not to> 
 interfere when syncope is present. Any depression of vascular action 
 is favorable to coagulation of the blood, and we most commonly find a 
 cessation of the discharge while the patient lies in this condition; and 
 an attempt, at this time, to introduce the hand within the uterus, or to 
 inject fluids into its cavity, may, by removing the clots formed, occasion 
 a fatal renewal of the hemorrhage. Neither should stimulants bo 
 given unless absolutely required, because the sudden increase in arterial 
 action occasioned by their exhibition may not only prevent a coagulum 
 from forming, but may also remove that which has already been 
 deposited over the orifices of the bleeding vessels of course, increasing 
 the dangers of the hemorrhage. 
 
 Indeed, stimulants are only to be administered when the system has 
 become considerably depressed, and when there is reason to fear that 
 the syncope would prove mortal: then the vascular action must be 
 sustained and the vital energies aroused, as indispensable measmv.-. 
 Brandy, rum, ether, ammonia, cordials, etc., may be given, as heretofore 
 recommended in hemorrhage from placenta prsevia. At this time, it 
 will be extremely improper to continue the local applications of cold, 
 as their influence will be to augment the depression of the system. 
 
 Some writers have advised the employment of the tampon, but it is 
 bad practice. The danger of giving rise to a concealed hemorrhage 
 should always deter us from using the tampon in uterine hemorrhage 
 occurring, especially at the parturient period, unless, indeed, we except 
 the instances of placenta praevia already referred to. 
 
 In cases of excessive prostration, transfusion has been advised. I 
 have no knowledge of its effects from my own experience, but the 
 recorded instances, of some years past, with which I have become 
 acquainted did not tend to give me any exalted opinion of it. Still, 
 lives have been saved by it, and the late improvements in the instru- 
 ments, etc., employed .for this purpose, render it very probable that 
 very many more will be. It should be resorted to in all cases, when 
 possible, where loss of blood alone is rapidly destroying life. 
 
 THE AFTER-TREATMENT OF HEMORRHAGE requires 
 some attention : for although the discharge may be arrested, and the 
 uterus contracted, yet there may be a return of relaxation of the uterine 
 muscular fibers, with an accompanying flow ; hence many hours may 
 pass before the patient will be entirely free from this danger. As soon 
 as the flooding has been arrested by the means employed for that pur- 
 pose, a bandage should be firmly applied around the body, so as to 
 secure a steady compression over the fundus uteri : a thick compress
 
 COMPLICATED LABOR AFTER-TREATMENT OF HEMORRHAGE. 519 
 
 placed between the abdomen and the bandage, will materially aid in 
 accomplishing the desired object, viz:: to prevent the occurrence of any 
 relaxation of the uterine fibers. The bandage should be examined 
 every hour or two, to ascertain that it has not moved, but remains in 
 its proper situation : it frequently happens, that when the bandage 
 becomes loosened, or disturbed from its proper position, there will be 
 a return of the hemorrhage, and of the relaxed condition of the uterus. 
 The ligatures which were applied around the thighs may be loosened, 
 but they should not be removed, at least, until a sufficient time has 
 elapsed to guarantee the safety of the woman from further hemorrhage. 
 Upon no account whatever must she be allowed to move for some 
 hours, proportioned to the severity of the attack. In a moderate flow, 
 she may be " put to bed " carefully, and her linen changed, in the 
 course of five or six hours after its cessation; but in profuse and 
 exhausting attacks, twelve or eighteen hours may elapse before it will 
 be proper to attempt her removal. Sudden death has frequently 
 occurred by raising -the patient in a sitting posture, for any purpose; 
 and even a mere change of position from one side of the bed to the 
 other, has resulted fatally. The practitioner will, therefore, see the 
 absolute necessity for strictly enjoining a state of quiescence for a suffi- 
 cient length of time. It is always better to keep the head somewhat 
 lower than the body. As it would be imprudent to allow the patient 
 to lie in the damp and moisture around her for any length of time, 
 means must be adopted to render her comfortable and dry, without 
 moving her in the least, or allowing her position to be changed. A 
 blanket, or something of the sort, may be slowly and carefully insin- 
 uated beneath her, in such a manner as to effect the desired result. 
 
 To favor a state of rest, as well as to moderate any irritability 
 of the system, the compound powder of Ipecacuanha and Opium 
 may be administered in a dose of five grains, or a powder com- 
 posed of Capsicum five grains, Ipecacuanha one grain, Opium half 
 a grain, may be administered every hour or two, as indicated; the 
 addition of Capsicum has an undoubted tendency, it is claimed, 
 to prevent a return of the hemorrhage, in a majority of cases. 
 The apartment in which the female lies should be well venti- 
 lated, darkened, and the temperature must not be too elevated. 
 If much exhaustion is present, cold, nourishing, and easily 
 digested fluids may be given at short and regular periods, as 
 gruel, beef tea, etc. ; and when the prostration is excessive, some 
 stimulant may be added. Visitors must positively be forbidden: 
 % no one is required to be in the room, save the physician, nurse, and
 
 520 KING'S ECLECTIC OBSTETRICS. 
 
 husband. Talking, or mental excitement, whether pleasurable or not, 
 is very apt to induce a return of the flow, and should be prohibited. 
 
 In cases where the hemorrhage has not been profuse, the practitioner 
 should not leave the patient for two or three hours; but in the more 
 copious and exhausting discharges, the female is not thoroughly safe 
 until five or six hours have elapsed since their arrest; and she should 
 not be left, in these instances, until this period has passed by. A care- 
 ful and conscientious accoucheur will never leave his patient at too 
 early a period, but will remain and watch her closely. If the pulse 
 be quick, compressible, and jerking, indicative of hemorrhage, he will 
 be 011 his guard, and prepared to meet it on its first appearance. 
 
 When females are liable to attacks of hemorrhage after the 
 expulsion of the child, or placenta, it may frequently be prevented 
 by the use of some uterine tonic during the last three or four 
 months of utero- gestation ; as, for instance, the Parturient Balm, 
 Sp. Tr. Macrotys, Aletris, etc. And at the time of labor, the os 
 uteri being dilatable, the membranes may be ruptured at an early 
 period, when the presentation is natural; and as soon as the child 
 is born, the bandage and compress over the fundus uteri should be 
 firmly applied. 
 
 In cases of excessive hemorrhage, and after the patient, has fully 
 recovered from the syncope, a powerful reaction usually ensues, accom- 
 panied with a greater or less degree of nervous irritability. The 
 velocity of the circulation becomes increased in proportion to the 
 decrease which the blood has experienced, its momentum probably 
 atoning for the deficiency in quantity. Fever is commonly present 
 when this reaction occurs. 
 
 There will be throbbing of the temples, a distressing pain in the 
 head, vertigo, ringing in the ears, and an intolerance of noise, and 
 occasionally of light. In nearly every case pain in the head will be 
 complained of, accompanied with a sensation or noise, which may be 
 variously compared to the beating of a small hammer within the skull, 
 the ticking of a clock, the singing of a tea-kettle, or the roaring of the 
 sea, and which is probably owing to the forcible contraction of the 
 arteries upon the diminished amount of blood contained in them, pro- 
 pelling it onward by jerks. The pulse will be quick, small, jerking, 
 and wiry or compressible ; the least motion causes great disquietude ; 
 there will be a sense of faintness and of impending dissolution, 
 especially on being raised from the pillow. The skin becomes hot 
 and dry, the mouth dry and parched, and the features are shriveled,
 
 COMPLICATED LABOR AFTER-TREATMENT OF HEMORRHAGE. O'21 
 
 vvith a contracted state of the lips and nose. Palpitations or flutter- 
 ings of the heart are often present, as well as panting, sighing, 
 moaning, dyspnoea, and sometimes a hacking, irritating cough. Fresh 
 air or the smelling-bottle will frequently be called for. On awaking 
 from sleep, or on being suddenly disturbed, the patient will exhibit a 
 degree of hurry and alarm. Sometimes there will be retching, or 
 vomiting, hiccough, and a dislike for solid food. All the secretions 
 become lessened, the bowels are flatulent, and constipation or diarrhea 
 may be present. Wakefulness is not uncommon. Various organs, as 
 the peritoneum, pleura, or brain, may present symptoms of inflamma- 
 tion ; and upon arising or assuming the erect position, death may 
 suddenly occur. 
 
 These symptoms will, of course, vary, both in kind and degree, in 
 different females, depending on the extent of prostration and other 
 concomitant circumstances ; but the peculiar pain and noise in the 
 head will very rarely be absent. 
 
 TREATMENT. The above disagreeable conditions are dependent 
 on a diminution of the quantity of blood in the system, and the indi- 
 cations will be, to increase the amount of blood, to impart tone and 
 vigor to the constitution, and to remove the various unpleasant symp- 
 toms with which the patient is annoyed. 
 
 To fulfill the first and second indications, it will be necessary to 
 allow the patient nutritious and easily-digested articles of diet, as 
 boiled milk, arrowroot, calf's-foot jelly, beef, mutton, and chicken 
 broths, oyster soup, custard, soft-boiled eggs, Indian-meal gruel, etc. 
 If required, wine or brandy may be added to the diet, and even ale 
 or porter is admissible in some cases ; but all stimuli should be allowed 
 with much .caution. The nourishment should be given at regular 
 periods, and in small quantities, so as not to oppress or offend the 
 stomach. 
 
 For the removal of annoying symptoms several means may be re- 
 quired. Thus, the heat and dryness of the surface may be relieved 
 by sponging the head, body, and limbs with cold or tepid water, or 
 vinegar, as circumstances will indicate: the Sp. Tr. Pulsatilla wii; 
 likewise assist in the accomplishment of this result, as well as to 
 allay nerv 7 ous irritability and relieve the distress in the head; and 
 the' patient should be kept in a cool and well ventilated room, and 
 in a state of perfect quiet and rest. Where Opium, or its salts of 
 Morphia, are called for, and disagree, other agents may be advan- 
 tageously exhibited, a.s Sp. Trs. Hyoscyamus, Gelsemium, or a few
 
 522 KING'S KCLKCTIC OBSTETRICS. 
 
 doses ol' Bromide of Potassium, etc. The Sp. Trs. of Hyoseyamus, 
 Pulsatilla, KhusTox. or Aconite will frequently afford much relief in 
 allaying pain and nervous irritation; they should be given either 
 singly or in such combinations as indications direct. As little medi- 
 cine as possible should be employed in these oases; the greatest 
 reliance must be placed upon fresb air, quiet, and nourishment. 
 
 Constipation maybe treated by Seidlitz powders; by the mixt- 
 ure of Rhubarb two parts, and Bicarbonate of Potassa one part, 
 heretofore referred to; or by rectal injections. But in all instances 
 active medication of any kind must be positively avoided. The dis- 
 tress in the head, quick pulse, fever, constipation, etc., may lead the 
 young accoucheur to suppose that relief will be obtained by an active 
 purge, which, if administered, may prove injurious to his patient. 
 The difficulty, as before remarked, is due to the loss of blood, and not 
 to any determination of this fluid to* the brain or other organ ; and so 
 soon as the blood-vessels become filled with the necessary amount of 
 their proper fluid, all the symptoms will disappear. However, should 
 the face, instead of the usual pale appearance, become tumid and 
 slightly florid, from an excess of blood in the veins, warm applications 
 may be applied to the feet and limbs, with cold to the face and head, 
 for the purpose of equalizing the circulation. 
 
 The patient must not be allowed to get up, for any purpose what- 
 ever, until all the above-described symptoms have disappeared; and 
 when this is attempted, care must be taken that it be effected slowly, 
 and that at first the sittings be for a very short period only. And 
 should the sitting posture occasion a sensation of faintness, it must be 
 dispensed with, and not tried again for a few days. Too much atten- 
 tion can not be paid to this point. 
 
 CHAPTER XXXIX. 
 
 COMPLICATED LABOR RETENTION OF THE PLACENTA HOUR- 
 GLASS CONTRACTION MORBID ADHESION OF THE 
 PLACENTA PYTREFACTIVE ABSORPTION. 
 
 IN primiparse, the placenta, in the greater number of instances, 
 immediately follows the expulsion of the child, and with others it 
 usually comes away in from five to twenty minutes thereafter; bin 
 cases frequently occur in which it remains without hemorrhage for
 
 COMPLICATE!) LABOR RETENTION OF THE PLACENTA, ETC. 523 
 
 houiv, or even days, if permitted, before it will pass off; and whenever 
 it is not expelled within an hour after the birth of the child, it is 
 called a retained placenta. 
 
 Young accoucheurs frequently mistake a delayed appearance of the 
 placenta for a retention ; thus, the mass may be detached and lie 
 loosely within the cavity of the uterus, or within the upper part of 
 the vagina, or partly within each, and not advancing any further, may 
 be erroneously considered a retention; whereas, some simple expedient, 
 as firmly grasping the fundus uteri, the patient blowing in her hand or 
 in a bottle, sneezing, coughing, bearing down, or artificially producing 
 retelling, will at once liberate it. Ordinarily, the last uterine pains 
 which effect the delivery of the child, either completely or partially 
 detach the placenta, and the mass will remain within the cavity of 
 the organ until expelled by a return of its contractions. When the 
 detachment is partial, or even when complete, dangerous hemorrhage 
 may ensue, especially when the uterus is in a state of inertia. If, 
 however, no detachment has taken place, and the placenta is entirely 
 adherent to the uterus, there will be no immediate danger from 
 flooding. 
 
 The placenta may be retained without accompanying hemorrhage, 
 and instances are recorded where it has remained within the uterus 
 for several days without causing any bad effects: cases have likewise 
 been met with where it never left the uterus, having been, probably, 
 absorbed by the uterine vessels. Several authors have counseled us 
 not to extract the placenta at all, unless hemorrhage be present, but 
 leave it entirely to the natural powers; it has, however, been found 
 by experience that, more commonly, an attention to this advice is 
 fraught with danger to the female, who becomes thereby exposed to 
 hemorrhage, uterine inflammation, or constitutional irritation (sep- 
 ticaemia) from absorption of putrid animal matter, as marked by 
 vomiting, purging, and typhoid symptoms. Severe after-pains fre- 
 quently accompany a retained placenta, but while these exist, they 
 are useful, being evidences of the contractions of the uterus; still, the 
 female often suifers unnecessarily from them, by not having the after- 
 birth expelled. 
 
 An accoucheur should never leave his patient with the placenta 
 undelivered, because she is not safe while it remains within the uterine 
 cavity ; beside, any uncommon delay will give rise to mental excite- 
 ment and anxiety, from an apprehension on her part that he is not 
 thoroughly versed in his profession, or else that there is some great 
 danger present. Her friends will likewise be very apt to increase her
 
 524 KIN(i's KC'LECTIC OBiSTKTRK S. 
 
 agitation and fears by whispered suggestions of a similar character. 
 And in case of a retention, he should remain for an hour or two with 
 her after the cake has been extracted, to guard against subsequent 
 hemorrhage. 
 
 In 259,250 cases, retention of the placenta occurred 293 times, or 
 about 1 in 661 J; in 186 cases, 36 died, or about 1 in 5; the immediate 
 cause of the fatality being hemorrhage. (Churchill.} Three causes 
 have been assigned for this difficulty: 1, inertia of the uterus, or 
 want of uterine contraction; 2, spasmodic or irregular contraction of 
 the uterus; and 3, morbid adhesion of the placenta to the uterus. 
 These causes and their treatment will be considered separately. 
 Although arranged under different heads, it may be stated here, that 
 rigidity of the os uteri, hour-glass contraction, inversion of the uterus, 
 and violent after-pains are convertible symptoms due to the same 
 cause, irregular uterine action, requiring similar treatment with 
 proper modifications. 
 
 1. RETENTION OF THE PLACENTA, FROM INERTIA 
 OF THE UTERUS, more frequently occurs after a difficult, pro- 
 tracted labor, though it may be due to a large pelvis, in which the 
 uterus is allowed to suddenly evacuate its contents but, in the latter 
 instance, hemorrhage is apt to ensue, before the organ can sufficiently 
 recover, from its abrupt disgorgement, to contract. 
 
 Upon placing the hand on the abdomen, the uterus, instead of being 
 firm, hard, and well defined, indications of its normal contraction, 
 will be found large, soft, and flabby, scarcely distinguishable through the 
 abdominal parietes, from the other viscera in the hypogastrium ; there 
 will be no pains, or, if they do occur, they will be very feeble and 
 indistinct. 
 
 TREATMENT. Retention of the placenta, with accompanying 
 hemorrhage, has already been considered ; those cases will now be 
 referred to, in which flooding is absent. 
 
 The principal indication is, to adopt measures to induce uterine con- 
 traction. For this purpose, frictions and firm pressure with the palm 
 of the hand over the fundus uteri, and at the same time gentle trac- 
 tions upon the umbilical cord in the direction of the axis of the 
 superior strait, should be made. In compressing the uterine globe, in 
 all cases where it is in a soft and flabby condition, much care should 
 be taken not to indent the organ, lest an inversion of it be effected 
 for in a relaxed state, it will be an easy matter fo-r a careless or ignorant, 
 person to cause such a depression by exerting an unnecessary amount
 
 COMPLICATED LABOR RETENTION OF THE PLACENTA, ETC. 525 
 
 of pressure. Again, in making tractions upon the cord, too much 
 force must be avoided, else it may be torn from the placenta: or the 
 placenta may be forced from its uterine attachment, giving rise to pro- 
 fuse and dangerous flooding; or the uterus may be either prolapsed or 
 inverted. Slight tractions upon the cord, to solicit or arouse the 
 uterus to action, are allowable; but no attempts to draw out the pla- 
 centa by it should ever be made while the uterus is in a relaxed condi- 
 tion ; any effort of this kind should only be attempted when the organ 
 is contracted, and then, the amount of force employed should be 
 moderate. Frequently, the sudden application to the abdomen of a 
 napkin wet with cold water, or a sprinkling of cold water upon the 
 abdomen and thighs, will excite the uterus to action. 
 
 So also will coughing, blowing, sneezing, etc., or retching may be 
 produced by titillating the throat and fauces with a feather. If these 
 do not answer, Ergot may be administered ; I prefer Lloyd's Ergot, 
 and it may be administered in one-half to three-quarters of a tea- 
 spoonful as a dose, repeating it every twenty or thirty minutes, until 
 contractions are induced. Cinnamon or Macrotys will frequently 
 prove more advantageous than the Ergot; Sulphate of Quinia, as well 
 as Strychnia, have frequently proved effective in these cases. After a 
 certain time, should the above means prove unsuccessful, it will then 
 become necessary to pass up the hand and extract the placenta. The 
 time necessary to elapse before attempting this manual operation is 
 generally stated at an hour, or an hour and a half; yet there can be 
 no positive rule, to guide us; for instance, when the labor has been 
 very tedious and severe, the uterus being sluggish and inactive, with- 
 out hemorrhage, the operation may be safely delayed for even a longer 
 period ; and in many instances of this kind it will be found that the 
 placenta has been remaining nearly all the time in the upper part of 
 the vagina ; consequently, under such circumstances, it will be well to 
 make an exploration of the parts within a half hour. It must be re- 
 membered, however, that the sooner after delivery the more easily can 
 the hand be introduced into the uterine cavity, as the parts will be in a 
 more relaxed condition ; and the manipulation should never be delayed 
 until the parts have so far recovered their original firmness as to render 
 the entrance of the hand painful and difficult. One hour and a half, un- 
 der ordinary circumstances, or three hours in cases of extremely tedious 
 labor, nmy, perhaps, be considered the limits; although I have, in twoin- 
 'stances, readily introduced the hand within the vaginal and uterine cav- 
 ities, and safely removed the placenta, seven hours after the birth of the 
 child; in each case the labor having been very protracted. The mode
 
 526 KING'S ECLECTIC OBSTETRICS. 
 
 of removing the placenta has already been described under the treat- 
 ment of Hemorrhage during its retention. 
 
 Be extremely careful never to withdraw the hand from the cavity 
 of the uterus, holding the placenta, without first having induced con- 
 tractions of the organ ; and should these not occur, after the placenta 
 has been detached, the hand must be kept in the uterus, until they 
 have been excited by some of the various methods already recom- 
 mended. And after the mass has been abstracted, it should be care- 
 fully examined to ascertain that no portion of it has been left 
 behind. The prudent introduction of the hand into the womb for 
 the abstraction of the placenta, is always safer than the attempt by 
 forcible traction upon the cord. As soon as the placental mass has 
 teen delivered, do not fail to secure the permanency of the uterine 
 contractions, by the application of the bandage, and if necessary, a 
 compress. Crude's method is frequently useful. 
 
 Dr. Murphy, in his Lectures on. Parturition, observes : "Retention 
 of the placenta may arise from different causes. Sometimes the sphinc- 
 ter of the vagina closes upon it, and the placenta is thus retained until 
 removed by the hand, or by firm pressure on the fundus of the uterus. 
 In other instances, the placenta remains in the uterus after the delivery 
 of the child, until it is expelled by its subsequent contractions, ren- 
 dered efficient by similar contractions of the diaphragm and abdominal 
 muscles. This additional aid is required, inasmuch as the action of 
 the uterus alone is not sufficient for the purpose. Hence, when the 
 abdominal muscles are feeble, so that the uterus can derive no support 
 from them, the placenta is retained in this cavity. This cause of reten- 
 tion has been generally mistaken for inertia of the uterus ; and, under 
 this impression, the placenta has been, very necessarily, withdrawn 
 from the uterine cavity. * * .* When the child leaves the uterus, 
 a very powerful stimulus to its action is removed; and this stimulus 
 the placenta is quite inadequate to supply. The uterus, therefore, first 
 ceases to act for a certain time, and when the action is renewed, it is 
 weak, and continues only for a short time. If the uterus fails in dis- 
 charging the placenta by a few of these efforts, it becomes accustomed, 
 as it were, to its presence, and it no longer acts as a stimulus, but 
 remains with the uterus imperfectly contracted around it. A very 
 efficient means of supplying this want of irritation to the uterus, is 
 the pressure of the abdominal viscera whick surround it. When the 
 abdominal muscles are strong, they contract upon the retiring uterus, 
 compressing the intestines, and consequently the uterus, on all sides. 
 These weak pains, therefore, are greatly assisted and rendered effectual
 
 COMPLICATED LABOR HOUR-GLASS CONTRACTION. 527 
 
 by the straining efforts of the patient acting as a stimulus to the uterus 
 from without. But the abdominal muscles are not always strong; on 
 the contrary, in most instances, they are extremely weak, in conse- 
 quence of our civilized habits. They are too often reduced almost to 
 a state of atony from the constant pressure of the corset; hence it 
 follows that the uterus derives little or no support from them, and the 
 placenta is retained, not from any want of power in the uterus to expel 
 it, but from a want of efficient stimulus to cause the uterus to contract. 
 There is no inertia of the uterus, but only a suspension of its action. 
 It is for this reason, and to supply this deficiency, that the pressure 
 of the hand on the fundus of the uterus, during the expulsion of the 
 child, is found so useful ; and, on the same principle, the application 
 of a bandage round the abdomen is always necessary, in order to give 
 it proper support." 
 
 2. IRREGULAR CONTEACTION OF THE UTERUS, termed 
 Hour-glass Contraction, sometimes accompanies retained placenta. It 
 may affect any part of the uterus, but is more commonly met with at 
 the os uteri. True hour-glass contraction is a strictured condition of 
 the central portion of the organ, dividing it into two chambers, an 
 upper one, which usually contains the placenta, and a lower one; it is 
 rarely met with in practice. 
 
 Sometimes the uterus contracts longitudinally upon the placenta, 
 having the shape of a cylinder or sugar-loaf; sometimes, there will be 
 a contraction of only one corner; at others, it contracts upon the pla- 
 centa in a globular form ; again, the constriction at the center, forming 
 the true hour-glass contraction, may be met with. The placenta may 
 be completely inclosed above the strictured part, or only partially, part 
 of it being in the cavity above the contracted portion of the uterus, 
 and the remainder passing through the narrowed section into the 
 cavity below. The placenta, in these cases, may be wholly or partially 
 adherent, or it may be detached. Prof. Meigs believes the placenta 
 to be always adherent in hour-glass contraction ; Dr. Douglass, of 
 Dublin, thinks it almost invariably occurs with morbid placental adhe- 
 sion ; so likewise does Dr. F. H. RamsbotKam, and in the cases which 
 I have met with, I have found placental adhesions to a greater or less 
 extent in each of them. 
 
 This irregular contraction of the uterus may exist in the longitudinal 
 fibers, or in the transverse, and more generally occurs after a rapid 
 delivery by violent and forcible pains. It may, however, follow a 
 protracted or preternatural labor, or a delivery of the child effected
 
 528 KING'S KCLECTIC OHSTKTUICS. 
 
 by Ergot, and sometimes happens as the result of an over-distended 
 uterus. Not unfrequently an improper interference with the cord, 
 making traction in the wrong direction, and by jerks, instead of a 
 can- ful, continuous pull, will irritate the os uteri and cause the 
 womb to contract irregularly ; pressure and friction immediately 
 over the pubes instead of over the fundus uteri, has also occasioned 
 the difficulty. 
 
 Hemorrhage may, or may not be present; and when it does exist it 
 is generally less profuse and alarming than when there is a complete 
 state of inertia, so that less haste will be required for the extraction 
 of tlie placenta; this, however, will be found a more difficult and 
 dangerous operation, than in retained after-birth without irregular or 
 spasmodic contraction. 
 
 DIAGNOSIS. Most instances of irregular uterine contraction are 
 impossible to detect by external examination. Generally, the delivery 
 of the child is followed by several severe and strong pains, without 
 any descent of the placenta, and which symptom, in connection with 
 a hard and enlarged condition of the uterus, when felt through the 
 abdominal parietes, and a full and turgid state of the umbilical cord, 
 may lead to a suspicion of the difficulty. 
 
 Should the uterus contract in the cylindrical form, it may be 
 detected through the abdomen, the fundus being felt at the epigas- 
 trium, and the body conveying to the fingers the sensation of a roll 
 or cylinder. 
 
 If it be a true hour-glass contraction, it may likewise be detected 
 by abdominal palpation. The uterus will be found to form two 
 tumors just above the pubis, the larger one of which contains the 
 placenta, while the smaller is joined to the other by a kind of neck, 
 which is the constricted central portion of the uterus. 
 
 But the more positive method of ascertaining the difficulty is by an 
 examination per vaginam. Passing the hand along the cord, the 
 cervix may be found hard and firmly contracted, resisting the intro- 
 duction of a finger, while the other hand placed upon the abdomen, 
 will find the uterine globe relaxed, or at all events, less firmly con- 
 densed than the cervix. If the constriction is not at this point, the 
 hand must be carefully carried into the uterus, following the cord, 
 when it will, at some point, detect an aperture which leads into the 
 upper chamber, and, perhaps, a portion of the placenta may be felt 
 protruding through it. In this case, the lower part of the uterus will 
 be usually soft and flabby while the portion above the stricture will 
 be harder and firmer. The accoucheur must not mistake this aperture
 
 COMPLICATED LABOR HOUR-GLASS CONTRACTION. 529 
 
 for a rupture of the uterus; for, it must be borne in mind, that while 
 the child escapes through a rupture, the placenta seldom does. 
 
 TREATMENT. This will depend somewhat upon the presence or 
 absence of hemorrhage. If it be present and profuse, the accoucheur 
 will at once attempt the extraction of the placenta, in the manner 
 described hereafter; if it be not very profuse or alarming, he will 
 proceed in his management more slowly and cautiously, being gov- 
 erned, in this respect, by the effects of the loss of blood upon the 
 patient. 
 
 Where hemorrhage does not exist, and the placenta does not pass 
 away, within the ordinary period, there is no necessity for haste, 
 unless, indeed, a true hour-glass contraction be ascertained, when 
 interference should be promptly attempted, there being, in such case, 
 but a small chance for the spontaneous expulsion of the placenta. 
 
 In all other cases, where there are no additional circumstances 
 present requiring interference, attempts should not be made to remove 
 the placenta artificially, for at least an hour after the birth of the child 
 The treatment employed in the mean time, should be the same as 
 already recommended in retention from inertia, as constant pressure 
 over the fund us, slight but continued traction upon the cord in the 
 direction of the axis of the superior strait, etc., and which will 
 frequently subdue the spasmodic action, and effect a sudden ejection 
 of the placenta. And if there be much mental excitement on the 
 part of the patient, this should be allayed by some anodyne. An hour 
 having passed without indications of an expulsion of the placenta, 
 the manual operation will have to be attempted. Introduce the hand 
 into the vagina in the usual way, and then into. the uterus. If the 
 constriction be at the os cervix, gently and carefully introduce first 
 one finger and then another, until, if necessary, the whole hand has 
 entered; but frequently, the^ os maybe dilated with two fingers, so 
 that the placenta may be seized and slowly worked out and, some- 
 times, this dilatation alone will remove the spasm and induce normal 
 contractions, followed by a delivery of' the secundines. 
 
 If the contracted portion be higher up, the hand being guided by 
 the cord, will have to be passed upward until the constriction is 
 reached, and then, as before, first one finger, then another must be 
 introduced, gradually and steadily dilating the strictured part as they 
 enter, until the whole hand has been insinuated; then, if the placenta 
 be adherent, it must be carefully and entirely detached, and the hand 
 and secundines suffered to pass out by the uterine contractions only. 
 If the mass be removed before the uterus acts, hemorrhage may come
 
 530 KING'S ECLECTIC OBSTETRICS. 
 
 on, hence it is important to induce the action of the organ before 
 withdrawing the hand. 
 
 The practitioner must not forget, while attempting the intromission 
 of the hand through the contracted aperture of the uterus, to place 
 his other hand upon the abdomen externally, and press upon the 
 fundus downward, in the direction of the operating hand. If this be 
 neglected, the womb may be so far elevated by the hand within as to 
 render it somewhat difficult, if not impossible, to enter it. Sometimes 
 the hand may be readily passed beyond the contracted part ; at others, 
 time, perseverance, and gentleness, will be required before the object 
 can be accomplished. 
 
 Occasionally the contraction will be extraordinarily firm, and if 
 dilatation be effected, it will be followed by yet firmer contraction, 
 requiring so much force to enable the fingers or hand to enter, as 
 would be liable to cause laceration if the attempt be imprudently 
 persisted in. Such force must never be employed. If the placenta 
 can not be removed without violence, let it alone, and pursue the 
 course named under the treatment of Morbid Adhesion. In these 
 cases the uterus is usually in a very irritable condition. 
 
 Bleeding has been recommended in these instances, to effect relaxation, 
 but it is a very objectionable course, as it must not only unnecessarily 
 debilitate the patient, but place her life in a very precarious situation, 
 should a profuse flooding from the uterus follow the relaxation caused 
 by it. 
 
 Chloroform has been exhibited in these instances, for the purpose 
 of causing .relaxation, with success. In some cases Gelsemium or 
 Lobelia give very satisfactory results, as does also the compound 
 tincture of Lobelia and Capsicum. Ergot has been advised, but, I 
 think, upon unsafe grounds. As soon as the moment of relaxation 
 occurs, the hand should be introduced, and the placenta extracted. 
 
 The compound tincture of Lobelia and Capsicum may be exhibited 
 either by mouth, or by injection into the rectum. I prefer the latter 
 mode, which is the one I have used the oftenest and with decided suc- 
 cess. The contents of the rectum having been first removed by an 
 enema, the above tincture, in the quantity of three or four flui- 
 drachms, may be at once injected. It usually acts with promptness in 
 overcoming the spasms, when the hand should at once be introduced, 
 if demanded. If, as may sometimes be required, it becomes necessary 
 to give this antispasmodic by mouth, one or two fluidrachms may be 
 taken for a dose. In either case it must not be diluted. It rarely 
 produces a degree of relaxation sufficient to give apprehensions of
 
 COMPLICATED LABOR MORBID PLACENTA L RETENTION. 531 
 
 hemorrhage: generally, as soon as the spasm has been overcome and 
 the secundines removed, the uterus contracts regularly and perma- 
 nently. If much relaxation of the system should follow its use, 
 Carbonate of Ammonia, Ether, or other stimulant, will speedily effect 
 a beneficial change. 
 
 In the exhibition of this tincture per rectum, it will sometimes be 
 found, as I have experienced in my own practice, as well as ascer- 
 tained in that of others, that an introduction of the hand will not be 
 needed ; for as the spasm is subdued the uterus will act normally, and 
 the placenta will be expelled without any further assistance. 
 
 The Sp. Tr. of Gelsemium, when the parts are tense, hot and rigid, 
 is especially indicated, and under such circumstances will, it is 
 claimed, produce complete relaxation. That it will effect the desired 
 dilatation will hardly be doubted by any one who has ever used it; 
 but whether the persistency of its relaxing influence can be promptly 
 obviated, and a tendency to flooding thereby lessened or prevented, I 
 am not, from my own knowledge of. its use in these cases, prepared to 
 say, although, in the absence of Chloroform, I think I should not 
 hesitate to administer it, using at the same time, however, a degree of 
 watchfulness and prudence. 
 
 When the placenta is partly within the uterus and partly within the 
 vagina, the os uteri having contracted upon it, no attempts to remove 
 it by forcible pulling should be made, as this would be very apt to 
 tear it; the only method for its removal should be a gentle dilatation 
 of the os by means of the fingers. 
 
 When the placenta has been extracted, examine it carefully, as has 
 been heretofore recommended; and do not forget the necessity for 
 securing a regular, equal, and permanent uterine contractility. 
 
 For irregular pains, Macrotys should probably be first considered ; 
 Lobelia or Gelsemium should be chosen if the irregularity is due to 
 want of complete dilatation; Sulphate of Quinine will likewise over- 
 come the trouble in some cases. The Parturient Balm, taken during 
 the last two or three months of gestation, will prevent irregular action 
 of the uterus at the time of labor. 
 
 3. PLACEFTAL RETENTION from a MOKBID ADHESION 
 to the UTERUS, is sometimes met with, and is of a more critical 
 nature than the previous varieties. It may exist ill conjunction with
 
 532 KINO'S KCLI-X-TK onsi KTUICS. 
 
 irregular contraction, or with inertia of the uterus, which last renders- 
 it more formidable, from the dangerous hemorrhage apt to be present: 
 frequently a few minutes decide the question of life or death. 
 
 The adhesion may be complete, in which case there will be no flood- 
 ing until detachment ensues; or it may be partial, and commonly with 
 hemorrhage. The copiousness of the discharge will be in proportion 
 to the extent of detached surface, and the number of vessels exposed. 
 
 The cohesive energy existing between the uterus and placenta in 
 these cases, varies considerably; , sometimes, the contractions of the 
 uterus are sufficient to detach and expel the mass ; at others, the uterus 
 may not be able to cause its separation, which, however, may be readily 
 effected by the hand; again, the cohesion may be so great, as to resist 
 any justifiable attempts to remove it with the hand. And, instances 
 have occurred where, after death, the separation could not be accom- 
 plished by maceration, and also where it was impossible to distinguish 
 the line of demarcation between the uterus and placenta when a longi- 
 tudinal section of these organs had been made. 
 
 The causes of morbid placental adhesion are not satisfactorily 
 known. By some authors the difficulty is attributed to a deposition 
 of calcareous or tuberculous matter, from the fact, that these have been 
 found in some portion of the placenta, usually on its maternal surface. 
 Again, it is believed by others, that whenever, from any cause during 
 gestation, an excitement or inflammation of the placenta or uterus is 
 produced, it may result in an effusion of lymph, perhaps, forming a 
 new membrane, which more firmly consolidates the utero-placental 
 attachment. But, whatever, may be imagined on this point, it is 
 evident that morbid adhesion occurs altogether independent of the 
 character or management of labor, and is due entirely to abnormal 
 conditions, either of the placenta, or of the uterus, during pregnancy. 
 It is very apt to recur in the same woman, so that when called to 
 attend such cases (when known) the physician should be more prompt 
 in his movements than in ordinary instances. 
 
 DIAGNOSIS. We can know nothing whatever of a morbid adhe- 
 sion, until the hand is introduced for the purpose of extraction. It 
 may be suspected, however, when several strong pains occur, without 
 any loosening of the placenta; likewise, when the cord, being moder- 
 ately drawn upon and then suddenly let loose, springs upward with a 
 jerk. Sometimes the patient, during gestation, complains of a severe, 
 persistent pain at one particular point (that in which the placenta is 
 found attached), and may express her suspicions that "the after-birth 
 is growing fast to her side."
 
 COMPLICATED LABOR MORBID PLACENTAL RETENTION. 533 
 
 TREATMENT. When hemorrhage is present, the case must be 
 managed as described under Hemorrhage with Retention of the 
 Placenta. Hemorrhage requires the detachment and removal of the 
 placenta, or the patient will almost certainly die. If no hemor- 
 rhage exist, the adhesion will be, probably, entire. 
 
 The early treatment of this difficulty, will be similar to that advised 
 in the preceding varieties not knowing its true character. This 
 failing, and an hour having elapsed, the hand must be introduced, in the 
 manner heretofore explained, to effect the detachment, at which time 
 the nature of the adhesion will be ascertained. The placenta should 
 be removed, if possible, even at the expense of considerable trouble ; 
 but sometimes, its detachment will be impossible. 
 
 In these latter cases, there is a diversity of opinion as to the proper 
 course to be pursued, many eminent accoucheurs advise us to remove 
 as much of the placenta as we can, even if it have to be separated in 
 pieces to accomplish this result ; while others, recommend us to leave 
 the mass in the uterus, until decomposition has ensued, and then 
 attempt its removal, or if this can not be done, trust to the natural 
 powers, aided by means to overcome the evil results of putrefactive 
 absorption. 
 
 When the placenta can be removed without any great violence, it 
 should always be effected ; but, if the reverse of this obtains, I think 
 I am warranted by my own experience, in connection with that of 
 many others, in recommending it to be left until decomposition ensues, 
 when a safer opportunity for its extraction may be offered. The tend- 
 ency to hemorrhage will be less when the whole mass is thus left 
 behind, than when a portion .of it has been torn off and removed, the 
 rest remaining adherent. These entire and extremely tenacious adhe- 
 sions are fortunately quite rare. 
 
 In these several instances of retained placenta, no attempts should 
 ever be made to remove it by forcibly pulling upon the cord ; neither 
 should the placenta itself, provided a part of it can be seized, be 
 drawn upon, until it has been satisfactorily ascertained that it is per- 
 fectly loose, and that no portion of it is retained in a firmly contracted 
 os uteri. Otherwise, an inversion of the uterus may be produced, or, 
 the placenta may be torn, and the remaining adherent portion of it 
 within the uterus, occasion a subsequent hemorrhage. 
 
 Should the UMBILICAL CORD BE RUPTURED, then, after a 
 failure of the means heretofore recommended for procuring uterine 
 contractions, the hand must be very carefully and gently introduced 
 within the uterus, the placenta sought for, detached, and removed in
 
 534 KING'S ECLECTIC <>I;STKTJJICS. 
 
 the usual manner, being particular to remove it entire, in order to> 
 avoid an attack of flooding. 
 
 When the placenta is so FIRMLY RETAINED by THE IRREG- 
 ULAR CONTRACTION OF THE UTERUS, or by MORBID 
 ADHESION, as to resist all legitimate endeavors to remove it, or 
 when portions of it have been permitted to remain in the uterine 
 cavity, the mode of treatment will depend somewhat upon the symp- 
 toms which follow. 
 
 Generally, severe after-pains are experienced, which interfering with 
 the patient's sleep and quiet, render her very irritable and these pains 
 are augmented on pressure over the uterine tumour, or when the child 
 is applied to the breast. The discharge from the uterus is at first of a 
 normal amount, and clots are occasionally passed off with it; but in two 
 or three days its .character changes, becoming of a dark brownish color, 
 excessively fetid, and accompanied with pieces of the decomposed 
 placenta. This happens, more especially, when only a portion of the 
 mass is left behind. 
 
 Soon after putrescency has commenced, from (septicaemia) an absorp- 
 tion of the putrid animal matter, a severe irritative fever attacks the 
 patient, manifesting itself at first by rigors. The pulse becomes small 
 and rapid, the skin, and especially that on the abdomen, becomes hot 
 and dry, pain in the head, of a diversified character comes on it may 
 be continuous, and accompanied with beating or throbbing, or, it may 
 be intermittent, sharp, and darting. The tongue is at first white, and 
 slimy, or red, shining, and dry; the thirst is inordinate; vomiting is 
 frequently present, or a choking sensation, particularly when the patient 
 endeavors to drink ; there is constant restlessness and wakefulness, with 
 mental anxiety, which is plainly depicted upon the countenance. The 
 secretion of milk diminishes ; the bowels, at first very torpid, become 
 so excessively loose as to resist the attempts made to check their action. 
 Most usually, erratic pains, of greater or less severity, are present, 
 shooting from one hip to the other, perhaps locating in the neighbor- 
 hood of the diaphragm and interfering with respiration, or, shifting 
 from one part of the body to another. These symptoms continue t& 
 increase, the tongue becomes coated brown or black, the abdomen 
 becomes tumid and tense, the strength rapidly fails, the extremities 
 become cold, vomiting of a dark-brownish granular-like substance 
 occurs, with low delirium, involuntary evacuations of the feces and 
 urine, subsultus tendinum, and iu ten or twelve days following: 
 delivery, the case terminates fatally.
 
 COMPLICATED LABOR RETENTION OF THE PLACENTA, ETC. 535 
 
 Ramsbotham states, that " upon dissection, the veins of the uterus 
 are generally found inflamed, and containing pus; the uterus itself, to 
 a greater or less extent, partakes in the inflammatory disposition, and 
 is perhaps gangrenous; or purulent deposits are observed in its sub- 
 stance; and perhaps also in or around some of the larger joints, or 
 among the tendons, or within the fleshy muscles of the limbs." 
 
 Sometimes, the placenta is expelled in twelve or twenty-four hours 
 without putrefaction, or any unpleasant consequences ; at others, it has 
 been expelled in a putrescent condition, but without causing any irri- 
 tative fever; and again, in some rare cases, it has never been discharged 
 nor produced any injury to the general health, but has, as supposed by 
 some writers, either been absorbed, or continuing adherent, become 
 organized. 
 
 A very favorable indication when putrid absorption takes place, is, 
 to observe that the symptoms are less violent, and the discharge of a 
 puriform character, containing portions of the placenta, having but 
 little or no fetor, and accompanied by no great amount of prostration 
 of the vital powers. 
 
 TREATMENT. "When it is ascertained that the placenta can not 
 be removed, a bandage should be applied around the body, in the 
 manner heretofore indicated, with a compress over the fundus, and in 
 two or three days the attempts to abstract the mass should be cautiously 
 and gently renewed. However, should the pains at any time become 
 very severe and continuous, or the presence of the bandage appear to 
 increase them, it must be removed. 
 
 When the placental mass can not be artificially abstracted, or when 
 portions of it have been left adhering to the inner uterine wall, and, 
 in either case, putrescency occurs, the indications of treatment will be, 
 to subdue inflammation, correct the fetor of the discharge, and support 
 the vital powers: and for the fulfillment of these, various remedies 
 may be used. 
 
 When there is hemorrhage, it must be combated by the means 
 already indicated. When the fever is very high, with great irritability 
 of the system, to subdue it and neutralize to a greater or less extent 
 the influence of the absorbed matter, the proper sedative should fir>t 
 be selected; this will be either Aconite or Veratrum. In addition, 
 agents should be selected to prevent the absorption of putrid matter 
 and the development of septicaemia, as Chlorate of Potassium, Phyto- 
 lacca, Baptisia, Asepsin, Quinine, etc. Vaginal injections should 
 likewise be used in conjunction with internal treatment, as will be 
 noticed in the following page. When the influence of these agents is
 
 536 KIND'S KCLECTIC OBSTETRICS. 
 
 once obtained, by continuing it, together with the other means to 
 combat putrescency, the tendency to vomiting will be considerably 
 lessened. Should there be a great amount of pain, it may become 
 necessary to administer a small dose of Morphia, in conjunction with 
 the means heretofore recommended. The bowels should be kept free 
 by Seidlitz powders and mucilaginous, laxative injections ; and when 
 they become immoderately loose, the tincture of Chloride of Iron may 
 be given in doses of ten or twenty drops in sufficient water, and 
 repeated according to the urgency of the case; or teaspoon ful doses 
 of Liquor Bismuth, repeated every three hours, will act very kindly. 
 
 The surface should be frequently bathed with warm water, or an 
 acidulous solution. In some instances a warm saline solution will be 
 found more efficacious. 
 
 To overcome the fetor, and aid in removing the loosened putrid 
 portions, water, as hot as the patient can endure, in which is dissolved 
 either Borax, Chlorate of Potassium, Asepsin, Carbolic Acid, Per- 
 manganate of Potassium, or some efficient antiseptic should be injected 
 into the vagina and uterus; this should be repeated at least twice a 
 day. The ports should likewise be washed out with the plain hot 
 water injections sufficiently often to overcome the odor of decomposi- 
 tion. Too much force must not be applied in introducing the fluids 
 into the uterus, lest they be passed into the canal of the Fallopian 
 tubes. 
 
 As soon as symptoms of prostration manifest themselves, the above 
 internal treatment must be changed. To overcome the depressing 
 influences of the absorbed putrescency, brewer's yeast may be given 
 internally, ale or porter may also be allowed, and good cider will be 
 found a most salutary and refreshing draught; it may be exhibited 
 frequently. And in the absence of these, an endeavor should be made 
 to sustain the system by Wine, Ether, Ammonia, aromatics, etc. 
 
 In conjunction with these, some preparation of Peruvian bark or 
 Quinia must be given. The Sulphites of Soda, Lime, or Magnesia, 
 have also been advised. Various other agents may also be used, 
 combined to suit the indications, as well as views, of the practitioner. 
 The female should be kept cleanly, and the apartment which she 
 occupies be well ventilated, and maintained at a moderate temperature.
 
 COMPLICATED LABOR INVERSION OF THE UTERUS. 537 
 
 CHAPTER XL. 
 
 COMPLICATED LABOR INVERSION OF THE UTERUS RUPTURE OF 
 
 THE UTERUS RUPTURE OF THE VAGINA RUPTURE OF 
 THE BLADDER SYNCOPE THROMBUS. 
 
 WHEN attempts are made to abstract the placenta by forcibly pull- 
 ing upon the cord, and especially if these be made when the uterus is 
 in a flaccid condition, the cord may be broken, or the uterus may be 
 inverted. INVERSION OF THE UTERUS may likewise be occa- 
 sioned by a rude attempt to effect a removal by pulling upon the 
 placenta itself. It may also be owing to a rapid delivery in a large 
 pelvis; to a short umbilical cord; to delivery taking place when the 
 female is in the erect posture ; to violent straining during the last pains 
 of the second stage ; and it is stated to have occurred spontaneously, 
 or without any satisfactory causes; but, by far the majority of inverted 
 uteri are caused by irregular and violent uterine action. Improper 
 management of the accoucheur may bring it on, but," generally, only 
 in those cases in which the uterus is disposed to active and irregular 
 contractions. It has occurred spontaneously after the mother's death, 
 and has likewise been observed in the unimpregnated and virgin 
 uterus. 
 
 This accident may occur immediately after delivery, when it is 
 termed acute or reducible inversion ; it may not take place for a few 
 days after, in which cases, however, it is stated that a depression of the 
 fundus existed from the first; or, it may happen gradually, in which 
 case, as well as when the acute form has not been removed, it is called 
 chronic or irreducible inversion. Sometimes it takes place in the unim- 
 pregnated uterus, being occasioned by the presence of a tumor, the 
 growth of which enlarges the organ, until its weight carries it through 
 the os with the fundue attached to it. 
 
 An inversion of the uterus is one of the most serious accidents that 
 can befall the parturient female. About one-third of the cases prove 
 fatal, either in a very short time, or within a month after its occurrence. 
 Of one hundred and nine fatal cases recorded, seventy-two died in a 
 few hours ; eight in from one to seven days ; six in from one to four 
 weeks : or eighty-six in one month. 
 
 SYMPTOMS. The inversion may be partial or complete. When 
 it is partial, a portion of the uterine wall, but more commonly the
 
 538 KING'S ECLECTIC OBSTETRICS. 
 
 fuiulus, is depressed within the uterine cavity, presenting, internally, 
 a convex surface. This form may prove fatal. It can be detected 
 only by introducing one or more fingers within the uterus, which will 
 discover the convexity of the depressed part; also by external palpa- 
 tion, which will, if the depressed portion be situated anteriorly, 
 discover the concavity formed by it, instead of the usual globular 
 form of the womb. It is apt to induce violent straining and bearing- 
 down efforts, a tenesmus, which may eventually occasion a complete 
 inversion ; and which efforts, to any great extent, should always be 
 prohibited, after the birth of the child, especially when the uterus is 
 in a non-contracted condition. There may be no pains with it, but 
 a sensation of sinking. Hemorrhage usually accompanies it, and in 
 cases where this is obstinate and long-continued, it may be owing to a 
 depression of the above character, and should be ascertained by passing 
 one or two fingers within the uterine cavity. 
 
 Again, in a partial inversion, the advance or depression of the 
 fundus may be so extensive as to be grasped by the inferior part of the 
 uterus, or even pass through the os uteri, but without changing the 
 situation of the cervix. In this case the palpation will discover a 
 greater amount of concavity, or perhaps a vacuity above the pubes, 
 and the finger will detect the fundus filling the lower part of the 
 uterus, feeling like an elastic tumor, more or less painful, or it may be 
 felt protruding through the os into the vagina, being soft and convex, 
 and the hand, by being passed up, can recognize the encircling cervix. 
 The pulse will become small, rapid, and fluttering, with sudden pros- 
 tration or sinking of the vital energies, which happens independent of 
 any hemorrhage ; also paleness of the countenance, nausea, vomiting, 
 and violent bearing-down efforts. The presence of flooding increase*? 
 the danger. 
 
 In complete inversion, the cervix, as well as the whole body, is 
 inverted; the uterus is completely turned inside out; it maybe re- 
 tained within the labia, but more generally a greater or less proportion 
 of it will be found externally, from an accompanying prolapse and 
 inversion of the vagina. Sudden hemorrhage and sinking occurs, 
 with a sensation of fullness in the vagina, and frequently death super- 
 venes, before the practitioner is aware of the accident, from the shock 
 to the nervous system, resulting from strangulation of the fundus. 
 If this does not take place immediately, all the symptoms above 
 enumerated exist in a greater degree. Should the uterus contract, 
 hemorrhage will, probably, be absent.
 
 COMPLICATED LABOR INVERSION OF THE UTERUS. 539 
 
 " It will sometimes happen that, for hours after the accident, not a 
 single pressing symptom shall occur. In general, however, when a 
 womb is left in the inverted position, the patient is still liable for 
 hours, and days afterward, to large and even fatal eruptions of blood, 
 of which I have myself been a witness ; add to which, that independ- 
 ently of the flooding, mere displacement of the parts may, perhaps, 
 give rise to more or less collapse ; obstruction of the bladder, too, is 
 not unfrequent, and the introduction of the catheter may become 
 necessary." (Blundell.} 
 
 DIAGNOSIS. Great care must be taken not to confound an 
 inverted uterus with some other difficulty. It has been mistaken for 
 a head, or a breech presentation of another child, for a placenta, a 
 polypus, a mole, a clot, an excrescence, etc.; and instances are not 
 wanting, where the uterus, mistaken for something else, has been torn 
 from the female by an ignorant practitioner, occasioning the most 
 agonizing torture, followed by a rapidly fatal termination. 
 
 In connection with the symptoms and examinations named above, 
 the uterus will be recognized, \vhen its inversion is complete, by its 
 rough, flocculent, and bleeding surface, and by its size and shape. If 
 it can be inspected visually, the fibrous tumor will be of a red color, 
 but which gradually changes to a dull brown when the difficulty 
 becomes permanent. Upon abdominal palpation, the uterine fundus 
 is not to be felt, and on attempting to pass the sound into the uterine 
 cavity, the os and canal of the cervix will not be found. The inver- 
 sion usually occurs shortly after the expulsion of the fetus, and may 
 occur with or without attachment of the placenta. 
 
 PROGNOSIS. Those cases which occur spontaneously #re said to- 
 be more hazardous than those occasioned by traction of the cord ; and 
 the rapid attack of the inversion, accompanied with uterine inertia, 
 greatly augments the danger. The more incomplete the extent of the 
 inversion, and the more slowly it occurs, the more favorable will it be 
 for the patient. Again, the sooner the reduction of the inversion is 
 effected the better; delay augments the difficulties attending the 
 operation. 
 
 Usually, the hemorrhage, or the severe shock upon the nervous 
 system occasions the death of the patient. Sometimes the inverted 
 organ becomes inflamed, and, being strangulated by the contraction 
 of the cervix, gangrene and sloughing ensue, followed by death ; 
 cases, however, have been recorded where such a condition has termi- 
 nated favorably. Again, when patients have passed safely through
 
 540 KING'S ECLECTIC OBSTETRICS. 
 
 the early period of inversion, they have been known to live for many 
 years, without its occasioning them much annoyance ; of course, in 
 these instances, the organ very much diminishes in size. Occasionally, 
 the tumor becomes attacked by some malignant form of disease. 
 
 Spontaneous reduction of partial inversions, as well as of chronic 
 inversions, are recorded to have been met with. A ready reduction 
 of acute cases is not always successful, as the patient may have been 
 too much exhausted before it was accomplished ; or, it may be followed 
 after a few days, or even months, by death, the consequence of the 
 violence which the uterus has suffered. Generally, in these latter 
 instances, the danger returns with the catamenia. 
 
 TREATMENT. In partial or incomplete inversion, two or three 
 fingers, or the whole hand, if necessary, may be introduced within 
 the uterine cavity, and the depressed portion be gradually, but con- 
 tinuously pushed upward. When the reduction is finished, provided 
 the w r hole hand has been introduced, it should not be removed until 
 contractions have taken .place, or else, the inversion may be renewed, 
 or, hemorrhage ensue. 
 
 When the inversion is complete, its reduction should be attempted 
 without delay, because, the longer it remains without re-position, the 
 more difficult will be the operation, from the continued contraction 
 of the os uteri, which, by impeding the circulation, causes the uterine 
 tumor to enlarge. A delay of an hour or two may render, any suc- 
 cessful endeavors impossible ; and its continuance for one or two 
 days, generally renders it irreducible. However, a few rare cases are 
 recorded in which re-position was effected after eleven weeks had 
 transpired, .and one of sixty-six weeks ; but such cases are exceptions, 
 and should never be anticipated. Spontaneous reduction of chronic 
 inversion has been noticed by several writers. 
 
 In effecting the reduction, it will be found that it can be accom- 
 plished with greater facility, the sooner it is undertaken after the 
 occurrence of the accident. There are several modes advised for the 
 operation. One is, after anointing the hands thoroughly with lard, 
 vaseline or sweet oil, to grasp the uterus with both hands, lessening 
 its bulk by compression, and steadily pressing upward, so that the 
 mouth, then the cervix, the body, and the fundus, successively pass 
 into their natural positions; this, however, is rather a difficult 
 method, as the pressure exerted upon the organ by the hands will be 
 very apt to occasion contractions, during which all attempts will be 
 futile.
 
 COMPLICATED LABOR INVERSION OF THE UTERUS. 541 
 
 Another method is, to firmly press the back of the fingers against 
 the fundus, the hand being held in a half-closed condition, and effect 
 the replacement in this manner, which usually takes place with a jerk. 
 
 But, probably, the best mode is, to place the fingers in a conical 
 form, press them, thus closed, upon the fundus, indent it ; and carry it 
 upward through the os uteri, the body and neck necessarily follow- 
 ing. Of course, the practitioner will decide which course to pursue 
 according to the conditions present. 
 
 Several points, however, are necessary to be attended to. The 
 female, if not too much exhausted, must be placed on her back, with 
 the hips considerably elevated above the chest (though when the 
 reduction is attempted immediately after the inversion, this is not so 
 essential), and the legs and thighs flexed and separated. The hand to 
 be employed should be well oiled, and the operation should not be 
 undertaken, nor persisted in, while the organ contracts, but only 
 during its state of softness and relaxation. Before attempting the 
 indentation of the fundus, the inverted organ must first, if possible, 
 be pushed up beyond the vaginal orifice, and no effect will be pro- 
 duced until the upward pressure shall have caused some extension of 
 the vagina. The pressure should not be made against the pubic arch, 
 but in the direction of the axis of the pelvic cavity, and to corres- 
 pond as nearly as possible with its center ; the practitioner must not 
 forget the direction of the axes of the straits and pelvis during the 
 operation, as this will only be successful by carrying the fundus up- 
 ward in their line. Should the perineum interfere with the operation, 
 press it backward while passing the organ by it. The pressure should 
 be firm and continuous, making no effort when the uterus contracts, 
 except that of securing what has been gained, by resisting any ten- 
 dency toward a return to its first misplaced condition. Most commonly 
 the fundus returns to its normal situation, by a sudden jerk, or start, 
 somewhat like a gum-elastic bottle when turned inside out. Too 
 much force should never be employed in the operation, lest the uterus 
 or vagina be lacerated ; a moderate force, steadily persisted in, will 
 prove the safest and most successful. Whatever may be the extent of 
 the inversion, after its reduction, the hand being w r ithin the uterine 
 cavity, should be retained there until the contractions of the organ 
 expel it, using means to forward these if required ; and be certain that 
 the restoration is complete before allowing the hand to be expelled. 
 A depression of the fundus remaining, may occasion violent bearing- 
 down efforts, followed by a return, and perhaps an irreducible state,
 
 >1- KING'S ECLECTIC ORSTETRICS. 
 
 of the inversion. A case is recorded in which the inversion was 
 repeated three times, immediately following each replacement ; and 
 finally by holding up the fimdns with the hand externally, filling the 
 uterine cavity with lumps of ice, and giving ergot, the accoucheur suc- 
 ceeded in securing firm contraction, and the patient recovered. In a 
 case of this kind to overcome the violent and irregular action of the 
 uterus, I should either administer the compound tincture of Lobelia 
 and Capsicum, or, alternate Gelsemium with Aconite, or with Sul- 
 phate of Quinine. 
 
 The inversion may happen with complete detachment of the pla- 
 centa, or it may be more or less adherent. When adherent, there is a 
 diversity of opinion as to the management, some recommending it to 
 be removed, before proceeding with the re-position, and others 
 advising us not to remove it, until the restoration has been completely 
 established. 
 
 When the uterus is in a relaxed state, and the placenta is completely 
 adherent, or nearly so, to remove it would be very apt to cause a 
 hemorrhage which might prove suddenly fatal; or uterine contractions 
 might follow the detachment, rendering a reduction of the inversion 
 very difficult, or altogether impossible; hence, in such cases, it were 
 better to return the placenta with the uterus, before detaching it, if 
 this can be done, and then to treat the case as a retained placenta. 
 
 When the placenta is detached to a considerable extent, and the 
 remaining adkesiorts can be readily separated, it may be proper to 
 attempt this previous to the reduction ;. unless the hemorrhage from 
 the vessels already exposed be very profuse, when the safest course 
 would be to abstract the cake only after the replacement of the uterus. 
 A slight and easily-separated adhesion, can not seriously augment 
 the flooding, hence, its removal should be accomplished before the 
 operation. 
 
 There may be cases in which it will be impossible to return the 
 uterus while the placenta adheres, and here the difficulty will be very 
 great; a detachment of it may be followed by dangerous hemorrhage, 
 or by contractions which will interfere with the success of the oper- 
 ation. The case is necessarily one of danger, shall we increase the 
 risks by removing the placenta? Perhaps it may be a better course 
 than to run the chances of a chronic inversion. lean not speak from 
 experience ; but whichever course is adopted, be certain that the 
 reduction is impossible, by a persevering effort, and that the obstacle 
 is the presence of the placenta, and not improper or badly-directed
 
 COMPLICATED LABOR INVERSION OF THE UTERUS. 543 
 
 efforts. Several writers state, that in such cases, they have detached 
 the placenta without any subsequent bad results; while others, strongly 
 advise its removal in all cases previous to attempting reduction of the 
 inversion. 
 
 Exhaustion and depression of the vital energies must be combated 
 by stimuli and appropriate treatment, similar to that laid down when 
 speaking of hemorrhage. The female should not be allowed to get 
 up too soon after the reduction, keeping her in a horizontal position, 
 with the head depressed and the hips considerably elevated, the knees 
 and thighs being bent, and all strainings at stool or bearing-down 
 efforts, should be forbidden; the bowels should be kept free by mild 
 laxatives or injections. 
 
 When the uterus has once been inverted during a labor, it has a 
 strong disposition to renewal of the difficulty in consecutive ones; 
 therefore, with such patients it will be improper to make any tractions 
 upon the cord to abstract the placenta ; if pressure upon the fundus 
 with frictions will not expel it, the best course will be to introduce 
 the hand within the cavity of the uterus, and remove the mass in the 
 manner heretofore explained. 
 
 If the inversion has been of several days' standing, it has been 
 advised not to omit attempts at the reduction, from the fact that it has 
 b6en reduced, in many instances, after a lapse of weeks and even 
 months. But in these cases, from the long-continued strangulation, 
 the uterus becomes swollen, and the parts hot and dry therefore, 
 before operating, these conditions must be overcome by anodyne and 
 relaxing fomentations or soft ointments locally applied, together with 
 such internal measures as may be indicated. Probably, the compound 
 tincture of Lobelia and Capsicum might aid in causing sufficient 
 relaxation to permit its reduction; but from the nausea and vomiting 
 which this might, probably, produce, I would prefer the following 
 plan: Having emptied the bladder and rectum, place the patient 
 under the relaxing influence of the tincture of Gelsemium ; at the 
 same time, should the uterus be external to the vulva, envelop it in 
 cloths wet with warm water, without permitting any evaporation to 
 take place, changing them from time to time, if necessary. Relaxation 
 of the muscular fibers of the organ having followed this course, then 
 attempt the reduction. I have never had an opportunity of trying 
 this method, but merely suggest it to the profession ; from a knowledge 
 of the influence of the agents named, upon the system, I believe it 
 will be found successful in very many instances of chronic inversion.
 
 544 KING'S ECLECTIC OBSTETRICS. 
 
 At all events I should try it, before undertaking any of the severe 
 and painful methods recommended for removing the uterus. Long 
 continuous pressure upon the inverted fundus, by means of elastic 
 bags filled with water, and then passed into the vagina, has also 
 been advised. 
 
 After the replacement of a chronic inversion, the female should be 
 treated the same as advised under the acute form; and, in either form, 
 it may be beneficial to protect the uterus, for a number of weeks or 
 months, from the superincumbent weight of the intestines, by the 
 application of an abdominal supporter immediately below the um- 
 bilicus, whose force shall be directed inward and upward. 
 
 When the inversion can not be overcome, palliative measures are 
 all that can be recommended, and if the uterus falls out of the vulva, 
 it should be placed beyond external danger, by returning it within 
 the vagina, and retaining it there by a bandage and compress; at the 
 same time using the abdominal supporter above referred to. 
 
 It has been advised by several eminent writers to remove the uterus, 
 in irreducible cases, by the ligature, e"craseur, or the knife; and 
 instances are not wanting where its extirpation by these means, or by 
 gangrene and sloughing, the result of its strangulation by the os uteri, 
 has resulted favorably. Still, as long as the female experiences no 
 great amount of discomfort, or any alarming symptoms, I can see no 
 necessity for the operation it appears to me cruel and uncalled for, 
 especially when we bear in mind, that females have labored under 
 this accident for many years without any very unpleasant or exhaust- 
 ing symptoms. Beside which, cases of spontaneous reduction have 
 been recorded, in which pregnancy subsequently occurred ; although 
 th'is is by no means desirable. 
 
 However, should the uterus be attacked by some malignant disease, 
 while in this displaced condition, its extirpation may be followed by 
 favorable results. The ligature employed is usually either silk, silver- 
 wire, or whip-cord ; it may be applied around the uterus at its highest 
 part, and gradually tightened as the patient can bear it, until the sep- 
 aration has taken place. Should it cause any violent symptoms, it 
 must be loosened for a time, until these have been subdued. The 
 strength of the patient must be kept up by a non-stimulating, nutri- 
 tious diet. 
 
 When the knife is employed, a ligature should be first applied as 
 above, for the purpose of preventing hemorrhage, and the excision be 
 made immediately below the ligature. In a case where extirpation of
 
 COMPLICATED LABOR RUPTURE OF THE UTERUS. 545 
 
 the inverted uterus would be desirable, instead of the preceding opera- 
 tions, I would first endeavor to remove it by means of Galvanic Heat, 
 which I believe would eifect it without the loss of much blood, or any 
 subsequent dangerous inflammation. This heat may be applied, by 
 attaching a platina point to the end of a copper or iron wire, then, by 
 bringing the two poles of a galvanic battery to act upon this point, a 
 heat will be obtained of sufficient intensity to destroy all animal tissues 
 to which it may be applied, without any great degree of suffering. I 
 have used this successfully in fistula in ano, and in urethral stricture. 
 
 Occasionally, instances of a RUPTURE OF THE UTERUS are 
 met with, which generally prove fatal. This accident may occur during 
 pregnancy, or at an advanced period of life, but it is only of its exist- 
 ence during parturition that I shall treat. It is stated to occur about 
 once in 1318 cases of labor. 
 
 Rupture of the uterus occurs more frequently among multiparse, and 
 especially, it is stated, with male fetuses, who are usually larger than 
 females ; it may be owing to several causes, as, debility or disorganiza- 
 tion of the uterine tissue, effected by inflammation during pregnancy; 
 cases of thinning, softening, scirrhus, and gangrene of the uterine 
 walls, have been recorded. An abnormal size of the fetal head, 
 may be a cause ; as well as obliquity, or retroversion of the uterus 
 transverse presentation of the body, or the head presenting obliquely 
 at the superior strait ; the presence of a polypus ; an excess of liquor 
 amnii ; and plurality of children, have all been named as causes. It 
 may occur from violence, as falls, blows, kicks, etc., forcible attempts 
 at delivery by turning or otherwise, and has been known to follow a 
 fit of anger. A cicatrix in the os and cervix uteri may tend to its 
 occurrence. A rigid os uteri may occasion it, and instances have been 
 observed where the os has been entirely torn off; females who have 
 deformed pelves, or those on whom the Cesarean operation has been 
 performed at a previous labor, are very liable to it. Violent efforts 
 of the uterus itself,. and especially when induced by the exhibition of 
 ergot, or stimulants, will tend to lacerate the organ. 
 
 Among these enumerated causes, probably, those which more fre- 
 quently give rise to the accident, are morbid alterations in the uterine 
 tissue ; violent contractions of the uterus ; a forcible entrance through 
 the undilated os; and undue violence in turning, or otherwise assisting 
 the delivery; though, it may occur during the operation of turning, 
 from some diseased state of the cervix, the operator being blameless. 
 35
 
 546 KING'S ECLECTIC OBSTETRICS. 
 
 The rupture may happen at any part of the uterus, though it is most 
 frequently met with at the cervix, either anteriorly, opposite the pubes, 
 or posteriorly, opposite the sacral promontory, and generally at the 
 point complained of by the patient as being excessively painful. Its 
 direction is not constant with some it may be longitudinal, and with 
 others oblique or transverse ; and it may be accompanied with a lacer- 
 ation of the vagina. 
 
 Its occurrence may be sudden, or it may take place gradually; and 
 the laceration may be complete, extending through the uterine texture 
 and its peritoneal covering; or, partial, being confined only to the 
 peritoneum, or to the muscular texture. 
 
 SYMPTOMS. Rupture of the uterus most frequently follows a 
 powerful effort of contraction, during which ' the female suddenly 
 screams that something has ruptured within her. The pain accom- 
 panying this sensation is very acute and agonizing, and is frequently 
 expressed as " a crampy pain ;" and it is the intensity of this which 
 causes the shrieks of the patient. Frequently the rupture is mani- 
 fested to the bystanders by a tearing or cracking noise. 
 
 The pains soon become feeble, or cease Immediately, according to 
 the complete or incomplete nature of the rent, and a violent, constant, 
 excruciating pain, entirely different from that caused by uterine con- 
 traction, is most generally complained of, as being confined to one 
 spot. 
 
 The pulse soon becomes rapid, small, feeble, and fluttering ; the 
 countenance quickly assumes a pallid, anxious, and alarmed appear- 
 ance; the respiration becomes hurried and difficult; the surface is cold 
 and clammy; violent retching ensues, with vomiting of mucus, a 
 greenish matter, or a dark-colored substance resembling coffee-grounds ; 
 there is faintness, with an inability to lie, requiring the female to be 1 
 raised in the bed; external or internal hemorrhage may occur, but the 
 flooding is frequently absent, there being but a slight discharge of 
 blood; and sometimes convulsions happen. 
 
 Should the peritoneal coat only be rent, the labor may go on, and 
 the child be delivered ; and, occasionally, the last pains which expel 
 the child, may at the same time effect a complete rupture of the uterus. 
 
 DIAGNOSIS. In connection with the symptoms above named, an 
 examination, externally, will discover the uterus contracted in one or 
 the other iliac region, and the child may be plainly detected, through 
 the abdominal parietes, when the rupture is complete. An examination 
 per vaginam will ascertain that the presenting part has receded so as
 
 COMPLICATED LABOR RUPTURE OF THE UTERUS. 547 
 
 "barely to be felt by the finger, unless it be impacted, or, it may have 
 passed entirely out of reach, the child having escaped into the cavity 
 of the abdomen. The death of the fetus generally happens immedi- 
 ately, so that if the fetal pulsations can be heard, it is considered 
 indicative of no rupture. A partial rent is of more difficult diagnosis; 
 \ve must be guided by the pain, and the collapsed condition of the 
 patient. 
 
 PROGNOSIS. The prognosis is always serious, as very few evei 
 recover from the accident. The shock may destroy the patient imme- 
 diately or in a few hours after the rupture; if the collapse does not 
 prove fatal, she may die subsequently of peritonitis, or, secondary 
 affections may finally destroy her, as lumbar abscess, sub-peritoneal 
 abscess, etc. Even slight lacerations of the os uteri have proved fatal. 
 If the peritoneal coat be not ruptured, there will be danger of peri- 
 tonitis. Metritis will be apt to follow a laceration of the muscular 
 tissue. 
 
 Although the fatality attending this casualty is very great, still, 
 cases are recorded in which recovery has followed, and even where 
 children have been given birth to, subsequently; so that in no case is 
 the practitioner to abandon it as irrecoverable his duty is to use every 
 effort to save his patient. 
 
 TREA.TMENT. In a labor where, from the violence of the pains, 
 or the presence of a fixed, crampy pain, or other well-founded reason, 
 rupture of the uterus is apprehended, the delivery should, if possible, 
 be hastened but not by Ergot, or stimulants. It would also be 
 advisable to moderate the pains by the agents heretofore named, as 
 Sp. Trs. of Gelsemium, Aconite, etc. The forceps should l>e en.- 
 ploycd when safe and practicable ; but if the child be dead, and any 
 resistance be offered to its advance by the forceps, the perforator should 
 IK- used. Counsel should always be sent for. 
 
 If the rupture has occurred, the only chance for the patient is in 
 immediate delivery. If the head be within reach, the child may be 
 cautiously extracted with the forceps; or, if this can not be effected, 
 then the perforator must be used, taking especial care, with either 
 instrument, not to push up the head, lest it slip through the rent into, 
 the abdominal cavity. This may be avoided by an attendant making 
 pressure over the fundus, and the operator causing the perforation to 
 be gently made in a direction, as much as possible, toward the sacrum. 
 Should the presentation be of the shoulder, or the face, or the nates, 
 bring down the feet, and thereby hasten the expulsion, as well as pro-
 
 548 KINK'S ECLECTIC OBSTETRICS. 
 
 vent the child from passing into the abdominal cavity. The child 
 being delivered, follow the cord, and carefully remove the placenta. 
 
 If the child has passed into the ventral cavity, the hand and arm 
 should at once be oiled and insinuated steadily along the vagina, into 
 the uterus, and through the rent into the cavity of the abdomen ; the 
 feet of the child should then be seized and brought down, extracting 
 it through the ruptured opening into the uterus and delivering by the 
 natural passages. This accomplished, reintroduce the hand, if neces- 
 sary, to remove the placenta. But in either case, be especially careful 
 not to abstract any portion of the intestines along with the child, or 
 placenta; and if any part of them has entered the fissure, remove 
 them, that they may not be strangulated by the subsequent contraction 
 of the uterus. Make no attempts, however, toward their proper 
 replacement; when remaining within the abdomen any interference to 
 adjust them is improper. 
 
 But the os uteri may not be dilated, or not sufficiently so for the 
 introduction of the hand, or, after the child has escaped through the 
 rent, the uterus may contract in either case rendering delivery by 
 the natural passages, impossible ; what must be done? It is advised 
 by eminent authority, that if the female has not suffered much from 
 the shock, and other circumstances are favorable, to explain to her 
 the nature of the accident, and with her consent, perform the Cesarean 
 section, and remove the child and placenta through the abdominal 
 parietes. If, however, she be rapidly sinking, or half an hour has 
 elapsed and the fetus is dead, leave the case to nature. The practitioner 
 will, however, be guided by circumstances, everything will depend 
 upon his judgment aided by that of his counsel, and no safe means 
 must be left unemployed which may tend to preserve both mother and 
 child. 
 
 While the patient is in a collapsed' condition, various agents 
 may be given to arouse the vital energy, and prevent it from be- 
 coming too far depressed. Alcoholic stimulants, as well, as Ether, 
 Ammonia, etc., should be given freely; also apply stimulants ex- 
 ternally. 
 
 After the delivery, when all indications of collapse have dis- 
 appeared, to diminish nervous excitement, Opium, Morphia, com- 
 pound powder of Ipecacuanha and Opium, Hyoscyamus, or other 
 anodyne may be given. The subsequent inflammation, if excessive, 
 must be met by Sp. Trs. of Aconite, Gelsemium, Macrotys, Pulsa- 
 tilla, Phytolacca, etc., which should be exhibited in sufficient quan- 
 tity to diminish the severity of the inflammation, but not to overcome
 
 COMPLICATED LABOR - RUPTURE OF THE UTERUS. 549 
 
 it entirely, for a certain amount of inflammatory reaction is required 
 for a cure Severe inflammatory reaction may induce (dangerous) peri- 
 tonitis, to which, indeed, the patient is very liable, and which should 
 constantly be borne in mind. The strength of the system must be sup- 
 ported. Poultices or fomentations of Hops and Stramonium leaves, or 
 the old time Spice Poultice (Am. Dispensatory] over the abdomen, will 
 also be found of much benefit when symptoms of peritonitis are present. 
 
 The VAGINA MAY BE LACERATED, in connection with the 
 uterus, or independent of it; it is more unfrequent than uterine rup- 
 ture. The symptoms resemble those of rupture of the uterus, and are 
 nearly as dangerous. If the laceration be trifling, it is better to leave 
 the case to nature, watching it carefully, however, and bestowing some 
 care to the support of the perineum, as the head passes over it. If 
 there be danger of an extension of the laceration, hasten the delivery, 
 by forceps if possible. The after-treatment will be similar to that in 
 the preceding accident. 
 
 RUPTURE OF THE BLADDER, is a more fatal occurrence 
 than that of the uterus, it is extremely rare, and may arise from neglect 
 or inattention of the practitioner,, or the improper use of instruments. 
 Its symptoms are somewhat similar to those of rupture of the uterus, 
 as a violent and severe pain in the 'region of the bladder; a scream 
 from the patient ; a sensation of something having given away inter- 
 nally ; rapid depression of the vital powers ; tumefaction and tender- 
 ness of the abdomen ; but no recession of the presenting part, or 
 distinguishing the child in the abdomen. The contractions of the 
 womb continue, but grow weaker as the system sinks. 
 
 This accident may be prevented by proper care on the part of the 
 practitioner, who will ascertain that the organ is emptied during labor, 
 or if it be full, and the patient can not void the urine, he must intro- 
 duce a flexible catheter and thus eifect the evacuation. When the 
 rupture occurs, the child should be saved, if possible, there being but 
 little hope for the mother. The delivery should be hastened by turn- 
 ing, or the forceps, if the child be alive ; and if this can not be 
 effected, the Cesarean operation has been advised. The death of the 
 child usually ensues in consequence of the prostration of the mother. 
 
 SYNCOPE, occasionally attacks females either -during labor, or 
 subsequently thereto, and may occur independently of hemorrhage, or 
 rupture of the uterus, vagina, or bladder.
 
 550 KING'S ECLECTIC OBS-TETKH >. 
 
 Those of a nervous, hysterical, delicate habit, are more liable to it,, 
 though it is also met with among those who have prostrated the ener- 
 gies of the system by intemperance, or unhealthy diet with impure air. 
 It may also be occasioned by some organic disease, as of the heart 
 and lungs, or from the rupture of an aneurism, or abscess, in which 
 instances it may prove fatal. It also undoubtedly occurs from the 
 sudden removal of the pressure of the contents of the gravid uterus 
 upon the abdominal viscera and large vessels of the body. Females 
 of a despondent or gloomy state of mind, or who are apprehensive 
 concerning the termination of their labor, are also subject to it. 
 
 A prudent exhibition of Wine, Ether, Ammonia, or other stimu- 
 lants, to invigorate the energies of the system, with moderate warmth, 
 fresh air, depression of the head and shoulders, a sprinkling of 
 Ammonia or Camphor upon the face and neck, and frictions to the 
 extremities, will commonly be sufficient to restore the patient. Sul- 
 phate of Quinia, or, Fluid Extract of Erythroxylon Coca, will also be 
 useful. Of course, when the symptom happens from organic diffi- 
 culty, the probability of rallying the female will depend upon the 
 character of the disease. When it occurs after the delivery, in addition 
 to the above means, apply friction to the abdomen, together with a 
 broad bandage firmly and properly applied. 
 
 Sometimes an extravasation of blood into one or both of the labia 
 pudendi, suddenly o.ccurs during labor, or shortly after the birth of 
 the child, which is termed THROMBUS. It is the result of a rupture 
 of varicose veins of the vagina, or of some of the large blood-vessels. 
 
 The affected labia present the appearance of a livid or black tumor, 
 of -greater or less size, frequently as large as the head of a child, being 
 accompanied with intense pain. 
 
 Dr. Dewees states, that if the inner surface of the attacked labiuin 
 does not burst in the first instance, the tumor is certain to yield iu 
 a short time from gangrene. A large surface of coagulated blood 
 becomes exposed when the part sloughs, which rapidly decomposes 
 and becomes fetid. If the parts do not rupture, the patient suffers 
 most excruciating pain : active fever takes place with delirium, and 
 her life becomes seriously endangered. A retention of urine increases 
 her sufferings, and relief can only be obtained by making a free 
 incision on the mucous face of the labium, to allow the extravasated 
 blood to escape, and which should be done before the process of ulcer- 
 ation has commenced, or the chance of bursting. Then press the-
 
 COMPLICATED LABOR THROMBUS. 551 
 
 enlarged labium to one side, and evacuate the bladder by means of 
 the catheter. 
 
 Thrombus is most commonly present in cases of protracted labor 
 caused by pelvic deformity, and generally proves fatal, especially if not 
 attended to at an early period. Sometimes its progress is very rapid, 
 the blood effused being so great in quantity as to cause syncope ; or 
 the mucous membrane may rupture, followed by a cessation of pain, 
 and a hemorrhage, which may be so excessive as to rapidly destroy the 
 patient. 
 
 These tumors must not be confounded with inversion of the uterus r 
 or of the vagina, or with cystocele, vaginal hernia, etc. 
 
 TREATMENT. If this difficulty happens during labor, and the 
 tumor interferes with the passage of the head, it should be, freely 
 incised on the mucous surface (the extent of the incision being in pro- 
 portion to the size of the swelling), and the fluid allowed to escape. 
 Should it be, however, excessive in quantity, too great a discharge 
 must be checked by applications of cold, ice, and compression, which 
 must be continued until the engagement of the head, by pressing upon 
 the ruptured vessels, prevents any further flow. 
 
 If the thrombus occurs during pregnancy, or after delivery, with 
 only a small tumor, but little discoloration of the skin, and no per- 
 ceptible increase of the effusion, and no fluctuation, attempts should 
 be made to resolve it, by the application to the parts, of cataplasms of 
 Elm and Arnica flowers, or Elm and flowers of St. Johnswort, aided 
 by warm fomentations to the hands, feet, and legs. And the same 
 course may be pursued after delivery, when the tumor ceases to enlarge, 
 carefully watching, however, and opening it, upon the first appearance 
 of inflammatory symptoms. 
 
 If the tumor continues to increase, with debility and sinking of the 
 system, incise it, as before named, evacuate at least the greater part 
 of the clots present, by the fingers, and then make firm and permanent 
 compression upon the whole tumor, together with applications of ice 
 or styptics, if the effusion does not readily cease. As profuse hemor- 
 rhage, or severe inflammation may subsequently supervene, the practi- 
 tioner should be fully prepared to encounter them. 
 
 Always sustain the strength of the patient by appropriate stimuli, 
 nourishing diet, etc.; and keep down febrile symptoms by the proper 
 administration of the indicated sedatives, together with such other 
 agents as are specifically indicated or peculiarly adapted to the con- 
 ditions present. Keep the bowels ngular, enjoin quiet, the recum-
 
 KING'S ECLECTIC OBSTETRICS. 
 
 bent position, and cleanliness of the parts, and do not suffer the 
 bladder to become overdistended with urine. The Sp. Trs. of Gel- 
 .-einiuni, with a small proportion of Aconite added, or the appli- 
 cation of Tr. of Veratrum Vir., will prevent any subsequent attack 
 of erysipelas, or peritoneal inflammation, in many instances. 
 
 CHAPTER XLI. 
 
 COMPLICATED LABOR PUERPERAL CONVULSIONS ECLAMPSIA- 
 HYSTERICAL CONVULSIONS APOPLEXY EPILEPSY. 
 
 ONE of the most dangerous and frightful maladies, with the excep- 
 tion of inversion and rupture of the uterus, with which the puerperal 
 female may be attacked, is CONVULSIONS. (Eclampsia puerperalis). 
 It usually occurs during labor, though occasionally met with for some 
 time previously, but seldom before the sixth month of pregnancy ; and 
 it frequently manifests itself after delivery, when it is generally, but 
 not always, of a more favorable character. 
 
 According to statistics, it is fortunately a rare disorder, having 
 occurred in 172 cases of labor, out of 103,537 ; or about 1 in 602. 
 Primipara? are more subject to it ; instances, however, have presented 
 of multipart who were attacked by it in their tenth or twelfth labors. 
 The fatality of the mother, heretofore, has been about one in every 
 four; most commonly the children are still-born. Females with short, 
 thick necks, of low stature, and square form, and of a sanguine tem- 
 perament, are considered to be more subject to it yet none are 
 entirely exempt from it. It frequently attacks those who, in early 
 life, suffered from epilepsy, hysteria, or who have received injuries of 
 the head. 
 
 Beside the true puerperal convulsions, there are three other varieties 
 which may attack the parturient female,, viz.: the hysteric, the apo- 
 plectic, and the epileptic, each of which will require a separate notice. 
 
 HYSTERIC CONVULSIONS, with their treatment, have been referred 
 to under the Diseases of Pregnancy. A few inhalations of Chloro- 
 form will likeVise frequently remove them. It may be proper, 
 however, to name the distinguishing marks between these and the 
 true puerperal convulsions.
 
 COMPLICATED LABOR PUERPERAL CONVULSIONS. 
 
 553 
 
 IN HYSTERIC CONVULSIONS. 
 
 1. Consciousness may, or may not be en- 
 tirely lost; generally the insensibility is 
 incomplete. A dash of cold water upon 
 the face and chest will often restore the 
 patient, and will at least make her start. 
 If labor pains are on, they will cause her 
 to wince, and an attempt to make an ex- 
 amination will be opposed. 
 
 2. The spasmodic action is moderate, the 
 body being but slightly contorted. 
 
 3. No frothing at the mouth, and no 
 biting the tongue. 
 
 4. The breathing is not stertorous nor 
 hissing. 
 
 5. The convulsive attacks are not fre- 
 quent, the patient recovering shortly after 
 each. 
 
 6. There may be sobbing, sighing, weep- 
 ing, and screaming. 
 
 IN PUERPERAL CONVULSIONS. 
 1. Consciousness is completely lost. 
 
 2. The spasmodic action is violent, with 
 powerful and irregular agitation of the 
 muscular system. 
 
 3. Frothing at the mouth, with biting of 
 the tongue. 
 
 4. The breathing is rapid and violent, 
 with a loud, peculiar, hissing sound. 
 
 5. The paroxysms are frequent, with to- 
 tal insensibility, or incomplete conscious- 
 ness during the intervals. 
 
 6. Sobbing, sighing, weeping and scream- 
 ing, are never present. 
 
 APOPLECTIC CONVULSIONS, when present, almost always, with but a 
 few exceptions, occur toward the termination of labor; and are 
 caused by the pressure exerted upon the cerebral vessels during the 
 contractions of the uterus. They are rarely met with, and most 
 usually prove fatal. 
 
 Sometimes no premonitory symptoms will be present; at others, 
 there will be pain, and throbbing, with other disturbance of the head, 
 for several days previously. During labor, there will usually be more 
 or less headache, and in the expulsive stage, the countenance will be 
 flushed, with a fullness of the vessels of the eyes. There will be 
 some agitation of the limbs and body, with but little spasmodic action; 
 seldom any distortion of the face, no frothing at the mouth ; the 
 pulse is full and slow, and the pupils fixed, and either contracted or 
 dilated, and insensible to light. The breathing is stertorous ; the 
 muscles soon become flaccid and powerless : the patient lies in a coma- 
 tose condition, and very rarely has a second paroxysm. 
 
 The following are the marks of discrimination between these and 
 the true puerperal convulsions : 
 
 IN APOPLECTIC CONVULSIONS. IN PUERPERAL CONVULSIONS. 
 
 1. The convulsive movements at the 1. The convulsions are violent and are 
 
 commencement are slight, and are not re- repeated, with intervals of quiet, and 
 
 peated, the unconsciousness being persist- often a more or less complete return to 
 
 ent. Sense and sensibility are completely consciousness, 
 lost.
 
 554 KING'S ECLECTIC OBSTETRICS. 
 
 2. The breathing is stertorous. 2. The breathing is violent, with a lod v . 
 
 hissing sound. 
 
 3. The muscles become flaccid and pow- 3. The muscles preserve their tone, even 
 erless. during the intervals. 
 
 PATHOLOGY. The brain will occasionally be found much con- 
 gested, without effusion ; sometimes, the pressure of a great effusion 
 of serum causes the attack ; more commonly, blood is poured out into 
 the substance of the brain, or at its base. It is almost impossible to- 
 distinguish the congestive form from that caused by effusion ; the prin- 
 cipal difference exists in the intensity of the symptoms. (Churchill.) 
 
 TREATMENT. Prompt and energetic measures can alone be of 
 service in these cases. In cases that prove fatal, external stimulating 
 measures will not be responded to by any reflex action. Cold water, 
 or ice should be applied to the head and neck, a brisk purgative ene- 
 ma, to empty the lower bowels, should be given as soon as it can be 
 prepared, and warmth and friction should be applied to the inferior 
 extremities and lower half of the trunk. In the application of the 
 water, the head should be withdrawn carefully from the bed, and held 
 over some large vessel to receive the fluid after it has been poured on. 
 If no effect is produced by these measures, active counter-irritation to 
 the occiput and neck may prove valuable. If the attack occurs during 
 labor, the delivery should be hastened as speedily as may be done with 
 propriety, but always without force or rudeness. 
 
 The above measures should be persisted in for some time. If a 
 return to consciousness follows, administer a purgative as soon as the 
 patient can swallow, apply warmth and counter-irritation to the ex- 
 tremities, and keep the head cool. Always be certain that the bladder 
 is evacuated, and does not become distended. 
 
 EPILEPTIC CONVULSIONS do not vary in their symptoms and treat- 
 ment from those of ordinary epilepsy ; they very rarely occur with 
 parturient females, unless they have had previous attacks, and are sub- 
 jects of the disease. But epileptic females are not more liable to 
 puerperal convulsions than others. The symptoms of epilepsy so much 
 resemble those of eclampsia, that it would be impossible to distinguish 
 between them in the parturient female, unless we were apprised of the 
 fact that she had previously been subject to epileptic attacks. And 
 even then, our diagnosis might be incorrect, for the reason that an 
 attack of epilepsy, occurring at this time, might be converted into a 
 true eclampsia. As epilepsy may, however, when manifested during
 
 COMPLICATED LABOR PUERPERAL CONVULSIONS. 555 
 
 labor, be mistaken for the true puerperal convulsions, it may be 
 proper to narie some of the marks of discrimination between them 
 
 IN EPILEPTIC CONVULSIONS. IN PUERPERAL CONVULSIONS. 
 
 1. The aura epileptica is observed. 1. The aura epileptica is never observed. 
 
 2. There is usually but one paroxysm ; 2. There are almost always several par- 
 or where there are several, they do not oxysms, rapidly following each other, 
 succeed each other rapidly. 
 
 3. The patient has generally had pre-. 3. The patient has never been attacked 
 vious attacks. with epilepsy before. 
 
 TRUE PUERPERAL CONVULSIONS appear to partake both of 
 the nature of epilepsy and apoplexy, and are considered by many 
 eminent writers as veritable apoplexy with violent spasmodic paroxysms 
 superadded, the latter being occasioned by the great degree of nervous 
 excitability to which all pregnant and parturient females are liable. 
 
 The causes of puerperal convulsions are not well understood; they 
 appear to be multiform. Plethora, compression of the aorta, long- 
 continued mental excitement, highly electrical conditions of the 
 atmosphere, persistent damp, foggy weather, profuse hemorrhage, and 
 previous diseases or injuries of the head, have been variously named 
 as predisposing causes. Females, not married, who do not enjoy the 
 pleasures of society, and particularly who are given to the use of 
 liquors, are especially liable to them. It has also been- supposed, that 
 blood poisoning, from a retention of urea, occurring, either from 
 the presence of Bright's disease, or from pressure upon the emulgent 
 veins by temporary congestion upon the kidney, has occasioned the 
 paroxysms* According to Dr. Lever, albuminous urine and puerperal 
 convulsions are frequently met with together, very few cases of the 
 latter occurring which do not give evidences of the presence of 
 albumen. Athill states that "it is proved beyond all manner of 
 doubt, that in the immense majority of cases, in at least 90 per cent., 
 albuminous urine and puerperal convulsions are synonymous terms." 
 M. Bouchut holds to the opinion that the cause of eclampsia is 
 encephalo-pathic albuminaria occasioned by serous effusion of the 
 meninges of the brain, or, by uremic or ammoniemic poisoning through 
 secretory insufficience of the kidneys. There is no doubt but there 
 are cases in which the convulsions are wholly post partum, the exciting 
 cause being a septicsemic contamination of the blood. 
 
 Twins, excess of the amniotic fluid, death of the child, distension 
 of the bladder, irritation of some part of the alimentary tube, indi- 
 gestible food, severe labor-pains, rigidity of the os uteri, irritation of
 
 556 KING'S ECLECTIC OBSTETRICS. 
 
 the uterine nerves by the introduction of the hand, terror, or violent 
 mental impressions, etc., have all been viewed as exciting causes. 
 Most probably, however, the nervous system of some organ, as the 
 uterus, stomach, bladder, etc., transmits the irritation, which has been 
 occasioned by some derangement of its functions, to the spinal system 
 and the brain. 
 
 According to Churchill, Dr. Tyler Smith, " has proved that convul- 
 sions are not excited by irritation of the cerebrum alone, but by the 
 primary or secondary effects produced upon the spinal marrow, medulla 
 oblongata, or tubercula quadrigemina. And therefore that the causes 
 giving rise to convulsions may be either, 1, Centric, such as pressure on 
 the medulla oblongata from congestion, coagula, or serous effusion 
 within the cranium ; loss of blood, morbid elements in the blood ; 
 emotion. -Or, 2, Eccentric, acting on the extremities of the excitor 
 nerves, as irritation of the incident spinal nerves of the uterus 
 and uterine passages; irritation of the' excitor nerves within the 
 cranium; irritation of the incidental spinal nerves of the rectum; 
 irritation of the ovarian nerves; irritation of the gastric and intestinal 
 branches of the pneumo-gastric nerve; irritation of the incidental 
 spinal nerves of the bladder; and as probable causes, irritation of the 
 cutaneous nerves, of the nerves of the mammae, and of the hepatic 
 and renal branches of the pneumo-gastric. More than one of these 
 causes may, of course, act at the same time." 
 
 Rosenstein, of Groningen, has made some very interesting and 
 useful researches as to the relation between carbonate of ammonia and 
 uremia; he has ascertained that the first only excites epileptiform 
 phenomena, and that narcotics are of no use whatever. In uremic 
 poisoning, various symptoms may be produced, convulsions, delirium, 
 coma. But should the uremia determine epileptiform attacks, and 
 carbonate of ammonia be found in the blood, we must not accuse this 
 last, because it is not always found at first in such cases, and because 
 the quantity found in the blood is not in relation with the intensity 
 of the epileptiform phenomena. Again, the symptoms occurring in 
 affections of the bladder or prostate, termed "ammoniemia," are in no 
 way associated with poisoning by carbonate of ammonia, the epilepti- 
 form symptoms occasioned by the latter being wholly wanting in the 
 former. Arch. f. Path. Anat., V. Ivi : 3. 
 
 Although all females are liable to attacks of this disease, yet those 
 who labor under any of the following conditions, are supposed to be 
 more disposed to it, and should, therefore, receive the earliest attention 
 of the medical man, in order to prevent its attack : corpulent female?,
 
 COMPLICATED LABOR PUERPERAL CONVULSION'S. -OO< 
 
 those having short necks; those having firm, solid, and unyielding 
 tissues, or who possess great muscular strength; those whose feet and 
 hands swell, and who experience a numbness in the hands, or in the 
 limbs, with swelling of the face, on awaking every morning; those 
 who feel excessively weak, or who labor under partial or complete loss 
 of sensation in one side of the face or limbs ; those who are subject to 
 headache, dizziness, muscse volitantes, dimness of sight, double vision, 
 seeing only one-half of an object, or flashes of light within the eyes; 
 those who experience loud noises in the ears, especially when occurring 
 suddenly, or who feel as if the head had received a violent blow. 
 Anaemic females, and those who constantly complain of headache 
 during the last month or two of gestation, should receive especial 
 attention. 
 
 The proper course by which to prevent an attack in such females, 
 no albumen being detected in the urine, is to keep the bowels and 
 kidneys regular by laxatives and mild diuretics; attend to the surface 
 by occasional bathings, with frictions and the use of a proper amount 
 of clothing; regulate the diet, that it be nourishing, but not gross nor 
 too stimulating, and agrees with the stomach, readily undergoing 
 digestion. ' Exercise moderately but regularly in the open air, and 
 have all sources of mental anxiety or agitation removed. In addition 
 to these measures, strengthen the uterine nervous system by the exhi- 
 bition of the Parturient Balm, Macro tys, Pulsatilla, Gelsemium, 
 Lobelia, either singly or in such combinations as may appear the 
 best adapted to each particular patient. The preparation first named 
 will be found applicable to the greater number of cases. Small 
 doses of some chalybeate preparation should be given, in conjunction, 
 to anaemic patients. If there are serious infiltrations, diuretics may 
 be given, as, the officinal infusion of Digitalis, together with saline 
 draughts, as Seidlitz powders, Acetate of Potassa, etc. 
 
 In all cases where the accoucheur is, for several weeks previously, 
 aware that he will be the attendant of a woman during labor, he 
 should from time to time examine her urine, to determine whether 
 albumen be present, and urea be diminished in amount, or be wholly 
 absent; and these examinations are more especially demanded in 
 primiparous women, those with short necks, where there is a con- 
 dition of fullness or plethora, oedema, and where the woman com- 
 plains of headache or giddiness. If, in the last month or two of 
 pregnancy, there is headache, redema, impaired vision or hearing, 
 vomiting, pain in the epigastrium, or nervous symptoms, the albu- 
 minous urine being scanty, turbid, high-colored, containing granular
 
 558 KING'S ECLECTIC OBSTETRICS. 
 
 or hyaline casts, but no blood or epithelium, the albuminaria is due to 
 compression of the emulgeut renal vessels by the enlarged uterus; and 
 the urine will tend to resume its normal character after parturition. 
 But, if the scanty and albuminous urine exists at an early period of 
 pregnancy, before the size of the uterus can exert any pressure, and 
 contains blood and epithelium, there is, undoubtedly, acute desquam- 
 ative nephritis. Johnson. 
 
 When albumen has been discovered in the urine of a pregnant 
 woman, she should at once be placed under treatment. Cathartics, 
 such as do not affect the uterus, should be employed, as, Cream of 
 Tartar, Roohelle Salts, etc., which, without depressing any, should be 
 kept up regularly until full term. The skin should be kept in a stim- 
 ulated condition by hot air baths, or applications of warm water, fol- 
 lowed by .drying with a coarse towel, using enough friction to produce 
 a glow upon the surface; dry cupping and fomentations over the 
 region of the kidneys are also required. These measures tend to 
 relieve the kidneys, as well as to aid the system in its endeavor to re- 
 move the poison in the blood. Should any nervous irritability be 
 present, such agents are indicated as Pulsatilla, Belladonna, Bromide 
 of Potassium, Digitalis, etc. Where there is a swollen condition of 
 the extremities, or a puffiness of the eyelids, Apocynum Can. should 
 be administered. The diet should be chiefly vegetable and farina- 
 ceous, using fruits, berries, etc., when not contraindicated, and as 
 little meats as possible. There will, in some cases, be a clear indica- 
 tion for acids, and by the judicious administration of Tartaric Acid, 
 or Lemon juice, it is claimed, the carbonate of ammonia already 
 formed in such conditions may be neutralized. By these means the 
 woman may be entirely relieved and prevented from having a con- 
 vulsive attack at full term. 
 
 In the very worst forms of uremic poisoning, in which the urine is 
 rendered almost solid by the excessive amount of albumen present, it 
 is atfvised to perform premature delivery at the seventh or eighth 
 month, in order to save both the child and the mother. 
 
 SYMPTOMS. The most violent puerperal convulsions may take 
 place without any premonitory symptoms; but in the majority of cases 
 they will be met with. For several days, or even weeks, previously, 
 or perhaps for only an hour or two, the patient will complain of more 
 or less severe headache; giddiness; dazzling of the eyes; weight and 
 constriction across the forehead; beating of the temporal arteries; 
 disturbance of the sight and hearing, or, perhaps, a sudden loss of
 
 COMPLICATED LABOR PUERPERAL CONVULSIONS. 559 
 
 sight; double vision; ringing in the ears; rigors; flushed counte- 
 nance; stammering, or iucoherency of speech; confused thought or 
 memory, slight delirium, and other indications of cerebral disturb- 
 ance. Occasionally, pains will be felt in the region of the stomach. 
 One or more of these symptoms are premonitory warnings of an 
 attack, and when they exist demand prompt attention from the ac- 
 coucheur, who must at once endeavor to prevent the paroxysms by 
 appropriate measures, as heretofore explained. 
 
 No relief being had, the symptoms become aggravated until the 
 attack occurs. The face now becomes more flushed and swollen, the 
 eyes fixed, and the pupils dilated [cerebral anccmia, as the rule] ; 
 though occasionally cases will be met with in which the pupils con- 
 tract closely [cerebral congestion, as the rule]. The patient rapidly 
 becomes unconscious. The voluntary muscles of the system become 
 violently and irregulary convulsed. The head is rotated by jerks 
 from right to left, or backward, the back of the neck and spinal 
 column also tend backward (opisthotonos) , and the limbs are thrown 
 with spasmodic violence in every direction, requiring powerful efforts 
 to keep the female in bed. The muscles of the face are commonly 
 affected first; the eyes roll rapidly about, being frequently thrown up- 
 ward and inward to the root of the nose, and irregular convulsive 
 twitchings may be observed about the mouth and eyelids. The lower 
 jaw becomes firmly and spasmodically closed against the upper, or it 
 may be drawn to one side. The tongue is involuntarily protruded, 
 and is generally of a livid color, and if some care be not taken, the 
 spasmodic closure of the jaws will severely wound it, so that the frothy 
 saliva which is blown from the mouth, sometimes to a considerable 
 distance, will be tinged with more or less blood; this may be fre- 
 quently prevented by placing a cork between the teeth as soon as they 
 become separated. The breathing is rapid, irregular, and violent, 
 and is accompanied with a loud, peculiar hissing sound, owing to the 
 presence of froth and the compression of the lips and teeth. The 
 pulse varies, but is generally quick, full, and hard, at the commence- 
 ment, but finally becomes sjlow and hardly perceptible. The face is 
 distorted by the spasmodic contractions, and becomes turgid and livid, 
 and in which color the hands and feet, as well as the body, partic- 
 ipate. Frequently the contents of the bladder and rectum are invol- 
 untarily evacuated. 
 
 Occasionally, the muscles of one side of the face and body are only 
 convulsed, but, as the spasms cease, those of the opposite side become 
 affected.
 
 560 KING'S ECLECTIC OBSTETRICS. 
 
 After a certain length of time, varying from a few minutes to half 
 art hour, the violence of the convulsive motions diminish and grad- 
 ually cease altogether; the features begin to appear more natural, the 
 pulse is still quick but more readily discernible, restoration of the 
 circulation takes place, and the breathing becomes more regular. 
 Consciousness slowly returns in a greater or less degree; the female, 
 wakening, apparently, as if from a sleep, may be aware that something 
 uncommon has occurred, or, as is more generally the case, she may 
 have no recollection whatever, her mind being more or less confused. 
 Pain in the head is nearly always complained of. After an interval 
 of quiet, varying from fifteen minutes to two or three hours, the 
 paroxysms return, when the same phenomena take place as before, 
 followed by another interval; and thus the paroxysms and intermis- 
 sions follow each other, until they cease entirely. I met with one 
 female, in nay early practice, who had sixteen paroxysms in as many 
 hours. Very frequently, in these convulsions, the consciousness 
 returns very slowly, and immediately upon its first manifestation a 
 paroxysm. comes on. 
 
 Consciousness does not, however, return in all cases; not unfre- 
 quently the patient, during the intervals, remains motionless and in- 
 sensible, with stertorous, or hissing respiration, somewhat resembling 
 coma or asphyxia, and which may soon prove fatal ; or she may be 
 unconscious and restless, throwing herself about in the bed, until the 
 next convulsive paroxysm, as in the appoplectiform eclampsia. 
 
 Most commonly the duration of the convulsion does not exceed five 
 or ten minutes, while the intervals may extend to even twelve hours 
 in some cases, and but a few minutes in others. 
 
 When convulsions occur in the pregnant female, it is seldom that 
 she will complete the full term, and the child will be still-born, and 
 frequently putrid; probably the paroxysms may at times be caused by 
 the dead child acting as a foreign irritant to the uterus, its death hav- 
 ing taken place previous to the attack. Occasionally the spasms cease 
 spontaneously, without endangering pregnancy ; but more frequently 
 uterine contractions are aroused, which generally expel the child, 
 and this may happen without any consciousness on the part of the 
 mother. 
 
 If the convulsions come on before the occurrence of labor pains, at 
 the full period, they usually cause dilatation of the os uteri ; and the 
 uterine contractions which may follow, will be feeble, irregular, and 
 apparently spasmodic, often alternating with the convulsive paroxysm.
 
 COMPLICATED LABOR PUERPERAL CONVULSIONS. 561 
 
 During labor, there may or may not be a suspension of the. contrac- 
 tions of the uterus; but more commonly it participates in the general 
 spasmodic irritability, and contracts powerfully, effecting delivery 
 without the patient being aware of it. The paroxysm usually ensues 
 just upon the return of uterine action, though not always with each 
 pain. Generally, the ordinary character of the pains are not changed 
 by the convulsions, and the labor proceeds regularly, unless hastened 
 by art. Not unfrequently, however, the action of the uterus becomes 
 inefficient, and the delivery must be artificially completed. 
 
 When puerperal convulsions occur during labor, they most fre- 
 quently cease when delivery is effected, or soon after, unless they 
 prove fatal; and the patient is generally left with a strong tendency 
 to metritis and peritonitis. 
 
 Puerperal convulsions may terminate by recovery; by developing 
 some other disease, as paralysis, cerebral lesions, mania, epilepsy, 
 rupture of the uterus, metritis, peritonitis, etc.; or by death. 
 
 The recovery may take place rapidly, especially when the par- 
 oxysms have been few and of a mild character, or it may be tedious 
 and for a long time uncertain ; the intellectual faculties very gradually 
 returning to their normal condition, the memory being excessively 
 debilitated or destroyed, as well as the hearing and sight. This de- 
 rangement may continue for a day or two, or may extend to several 
 months before complete restoration takes place. 
 
 When other diseases are occasioned by the convulsions, the patient 
 may ultimately recover, but generally with impaired health for the 
 remainder of her life; and frequently these diseases contribute to a 
 more or less speedy fatality. Death most usually occurs when the 
 paroxysms are of great intensity and long duration, with short inter- 
 vals between them, and especially in those cases where the female re- 
 mains motionless and unconscious during the intermissions. It may 
 be caused by effusions on the brain, or by a too prolonged and com- 
 plete suspension of respiration; also by a rupture of the uterus. 
 
 The above description of symptoms, together with the preceding 
 tables for distinguishing the attack from hysteria, apoplexy, and 
 epilepsy, will render it unnecessary to detail any further diagnosis. 
 
 PROGNOSIS. This is undoubtedly an extremely fatal disease, the 
 most favorable statistics showing that one-fourth of those who have 
 been attacked by it were lost. But the practitioner may generally be 
 enabled to form a prognosis, somewhat approximating positiveness, 
 by ascertaining, if possible, the cause that produced the attack, and by 
 36
 
 562 KING'S ECLECTIC OBSTETRICS. 
 
 observing the period at which it occurs, and the progress and charac- 
 ter of the symptoms. 
 
 If the paroxysms are very severe and of long duration, the intervals 
 being short, and no return of consciousness, the patient lying in a 
 state of stupor, with stertorous brealhing, she will be in a very critical 
 situation, and more especially if she be insensible to the application 
 of stimulants. The longer the duration of the intervals, and the more, 
 perfect and rapid the return of consciousness, the more favorable will 
 be the case, notwithstanding the severity of the paroxysms. And the 
 milder the convulsions, with the last named character of intervals, the 
 less will be the danger. 
 
 Females whose nervous systems are extremely susceptible, who are 
 hysterical or subjects of epilepsy, or whose minds are very sensitive, 
 are less apt to have formidable attacks than those who are disposed to 
 apoplexy or coma, or who are laboring under serous infiltrations. 
 
 Convulsions occurring during pregnancy, or during labor, are more 
 dangerous than those which take place only after delivery ; and when 
 they occur early in labor, before the parts are sufficiently dilated to 
 admit of the ready expulsion of the uterine contents, they are less 
 favorable than toward the termination of the delivery, when this may 
 be effected either naturally or artificially. They are likewise more 
 fatal among primi paras. 
 
 When the convulsions come on during the last stage of labor, and 
 continue equally strong after the delivery, whether this has been 
 effected naturally or artificially, the case is extremely dangerous; but 
 if the patient falls into a gentle sleep, with an arrest of the paroxysms, 
 after the expulsion of the uterine contents, they seldom return, and 
 convalescence ensues. After the delivery and the disappearance of 
 the convulsions, the practitioner must carefully watch the patient, in 
 order to guard her against any subsequent abdominal inflammations, 
 more especially if puerperal peritonitis be, at the time, a prevailing 
 complaint. 
 
 The maternal disorder necessarily exerts an unfavorable influence 
 upon the child, and we find that the major part are either still-born, 
 or die in a few days after birth of convulsions, having, probably, while 
 in utero, received the germ of the disease through the mother's blood. 
 
 M. Bourneville, who has investigated this subject, states that in 
 uremia poisoning, there is a progressive and considerable lowering of 
 the temperature, which increases as death approaches, and which 
 attains its maximum when this occurs, even to 41 (105 8' F.); while
 
 COMPLICATED LABOR PUERPERAL CONVULSIONS. 563 
 
 in puerperal eclampsia the temperature continues to rise from its com- 
 mencement to its termination, during coma, and in the intervals 
 between the paroxysms, diminishing only with the disappearance of 
 the attack; descending at the moment of death even to 28 V (82 5' 
 F.). If the coma diminishes in eclampsia, or ceases entirely, and the 
 temperature subsides, the prognosis is favorable, and vice versa. In 
 cerebral hemorrhage, there is at first a lowering of the temperature, 
 followed by an elevation. Epileptic attacks elevate the temperature, 
 which is not effected by hysteria. However, further investigations 
 are required. 
 
 PATHOLOGY. Post-mortem examinations have shed but little 
 light upon the nature of puerperal convulsions, no appreciable anatom- 
 ical lesions having been found no traces of injection nor changes in 
 the character of the tissues. 
 
 Sometimes a serous effusion has been observed in the ventricles, or 
 arachnoid cavity, and perhaps a slight congestion of the encephalic ves- 
 sels; but these are viewed as secondary lesions, being merely the 
 effects of the convulsions, when the cerebral congestion is very great. 
 The heart is commonly empty and relaxed, the lungs pale, and occa- 
 sionally fluid has been met with in the pleura, or pericardium ; traces 
 of peritoneal inflammation have likewise been observed. 
 
 In considering the cause of this disease, and the morbid conditions 
 resulting therefrom, the words of Leishman might be quoted: "That 
 albuminuria and puerperal eclampsia are mutually dependent upon 
 eacli other, or, at least, are of simultaneous occurrence in the vast 
 majority of all cases, is an assertion not likely, in these days, to be 
 seriously controverted. But it is by no means agreed, as to the albu- 
 men and the paroxysm, which is the cause and which the effect. Ac- 
 cording to Braun, and those who support his views, the albumen 
 appears in the urine as the result of that inflammatory affection of the 
 kidney commonly known as Bright's disease. As a result of this, the 
 blood is poisoned with excrementitial elements of the urine, and espe- 
 cially with urea. The experiments and researches of Frerichs have 
 conclusively shown that the presence of urea in the blood, even in 
 considerable quantity, does not give rise to eclampsia; and the con- 
 clusion which he has reached is, that the active poison is the carbonate 
 of ammonia, produced, as he assumes, by the decomposition of the 
 urea; which must, therefore, be acted upon by some particular fer- 
 ment, the nature of which has yet to be discovered by the pathological 
 chemist. Frerichs does not admit the essentially inflammatory nature
 
 564 KING'S ECLECTIC OBSTETRICS. 
 
 of the disease; at least, he appears to do so only to a limited extent, 
 when he assumes, in explanation of the formation of the hyaline tube- 
 casts, that the inflammatory theory can only hold good in so far as the 
 exudation of blood plasma is connected with a paralytic dilatation of 
 the capillaries. Braun, however, broadly maintains that the disease 
 is of inflammatory origin, and that the nature of the morbid process is 
 identical with that of Bright's disease. 
 
 "The other theory is that held by those who, while admitting the 
 existence of albumen in the urine, as an essential phenomenon, assert 
 that this is the effect of eclampsia, and not its cause which is, by 
 them, supposed to be the result of some blood disease, or of some 
 blood poison hitherto unknown to science. And certainly the fact 
 that, in so many instances, the convulsions precede the albuminuria, 
 lends some confirmation to this view." 
 
 Lusk quotes Seyfert on this subject, in addition to his own views, as 
 follows : 
 
 " 1st. That convulsions may occur without albuminuria. 
 
 " 2d. That the albuminuria is in many cases the effect and not the 
 cause of the convulsions. 
 
 " 3d. That in many fatal cases the kidney-lesions were absent or 
 wholly insignificant. 
 
 "4th. That convulsions are rare in chronic Bright's disease, which 
 had existed prior to pregnancy. 
 
 " 5th. That in true uraemia, such as necessarily is produced by the 
 suppression of urine when, in uterine cancer, the ureters are invaded, 
 convulsions do not occur. 
 
 " That, in the main, these propositions are correct, hardly admits 
 of question. But, in drawing conclusions from these, unnecessary 
 stress is laid upon the presence or absence of albumen in the urinary 
 secretion. It is the renal insufficiency, it should be fixed in the mind, 
 and not the albuminuria, which causes urasmia and convulsions. The 
 mere absence of albumen from the urine does not even exclude the 
 existence of Bright's disease. Braun is careful to note that, in certain 
 cases of fatal eclampsia, in spite of the absence of albuminuria, the 
 post-mortem examination revealed amyloid degeneration of the kidneys 
 and of the heart-structures ; and again, in others, of atrophy of both 
 kidneys, where the dropsy, and the albumen, and casts, which had 
 been present earlier in pregnancy, had entirely disappeared at the 
 moment the convulsions occurred. Bailly has shown that not rarely 
 albuminuria in pregnant women may disappear for several hours, and
 
 COMPLICATED LABOR PUERPERAL CONVULSIONS. 565 
 
 then re-appear once more; so that it is possible for an examination to 
 be made during the short period when the urine ceases to be albu- 
 minous." 
 
 TREATMENT. The indications of treatment in puerperal con- 
 vulsions are, 1st, to subdue spasmodic action; 2d, to overcome cereb- 
 ral congestion, and equalize the circulation ; 3d, to hasten the delivery, 
 when labor is on, by the most appropriate means, provided the par- 
 oxysms are not subdued ; and, 4th, to prevent any secondary attacks, 
 and gradually strengthen the patient. 
 
 For the fulfilling of the first indication, bleeding to the amount of 
 from thirty to sixty ounces, and taken in a full stream from the arm 
 or temporal artery, was the treatment formerly recommended ; indeed it 
 was the remedy, and tlie principal remedy, upon which the majority of prac- 
 titioners at one time relied. Prof. King remarks that in former years he 
 was in the habit of bleeding in these cases, and with various results; 
 but, in an experience covering a large number of cases, he became 
 thoroughly convinced that many of the unsuccessful cases could have 
 been saved by different treatment, and that, in the successful ones, the 
 bleeding eifected but very little service. Many practitioners still 
 adhere to this old treatment, and recommend it in the cases under 
 consideration ; but what benefit can any thinking man consider to be 
 the consequence of excessive bleeding, when, at farthest, but only one 
 out of every four patients is saved? Beside, those who are saved by 
 these excessive depletions rarely have a complete restoration to health 
 subsequently, but linger for a longer or shorter time, under some 
 malady resulting from the bleeding, and which ultimately occasions 
 their death. These large bleedings seriously injure the vital force, 
 and, I believe, frequently prevent recovery where it might otherwise 
 have, taken place. The treatment which I shall now r-ecommend to 
 the profession, in puerperal convulsions, will be found fully as suc- 
 cessful as the depletive one just referred to, and vastly superior to it, 
 inasmuch as it does not cause any serious affections from sudden, 
 excessive, and persistent prostration of the vascular and nervous 
 systems. 
 
 The former treatment, used and recommended by the eclectics of 
 the olden time, in puerperal eclampsia, consisted almost exclusively 
 in the internal use of Gelsemium, and the compound tincture of 
 Lobelia and Capsicum per rectum. This antispasmodic compound 
 was also given in large doses internally, in cases where the patient 
 was able to swallow. It was claimed that a paroxysm could be
 
 566 KING'S ECLECTIC OBSTETRICS. 
 
 frequently shortened in its duration by the administration of the com- 
 pound while it was on; and that its use at such times did not contra- 
 indicate, nor interfere with, the employment of Gelsemium during the 
 intervals, should this be deemed necessary. The continued use of the 
 compound tincture of Lobelia and Capsicum, in this manner, was 
 advised, until a positive influence had been exerted upon the muscular 
 system of the patient, rendering it powerless) when its further use; was 
 not required, unless there should be a return of the paroxysm ; how- 
 ever, the patient should always be placed under its relaxing influence 
 as soon as practicable. Frequently, it is cited, this agent will not 
 only overcome the spasmodic. tendency of the voluntary muscles, but 
 will at once relieve cerebral congestion, favor dilatation of the os 
 uteri, and thus aid in hastening delivery when labor is on, and also 
 prevent any disposition to subsequent abdominal inflammations. 
 
 Counter- irritation to the extremities was also a common adjunct to 
 the old treatment, as well as the application of cups to the back of the 
 neck and lumbar region, and ligatures to the thighs to prevent too 
 much blood from being thrown into the trunk and head. This was 
 the line of treatment pursued for years in puerperal convulsions; and 
 while it would, no doubt, prove quite unsatisfactory to the majority 
 of physicians of the present time, it, nevertheless, gave decidedly bet- 
 ter results than bleeding a popular treatment of the time with many 
 physicians. 
 
 The present treatment does not include a large number of remedies; 
 probably a half-dozen would include the entire list. Physicians vary 
 in the selection of agents for the treatment of this, as in other diseases; 
 each having a preference of one or two of the usual remedies that have 
 given satisfactory results, and with which he successfully treats his 
 cases. 
 
 I have always regarded Chloroform as deserving first place in the 
 consideration of remedies that is, during labor, the woman being in 
 spasms. Administer it at once, to the extent of anesthesia sufficiently 
 profound to produce relaxation and overcome spasmodic action. As 
 soon as the convulsive action begins to subside, Morphia should be 
 administered a hypodermic injection of one-third to one-half grain, 
 gradually substituting the Morphia for the Chloroform. If after the 
 first, or even the second, injection of Morphia, there should develop 
 symptoms of a return of the convulsions, again allow the patient to 
 inhale the Chloroform as at first, repeating the Morphia every half to- 
 one hour until all indications of spasmodic action have disappeared.
 
 COMPLICATED LABOR PUEIiPERAL CONVULSIONS. 567 
 
 By many, Morphia is believed to stand first among the remedies in 
 puerperal convulsions, its action being direct upon the spinal center, 
 and thus overcoming the perverted innervation. No doubt many cases 
 are cured by the use of Morphia alone ; however, my observation has 
 been, where the convulsions are severe, with general spasmodic action, 
 that quicker results follow the inhalation of Chloroform than the use 
 of any other remedy ; but it should, I believe, be discontinued as soon 
 as the spasms can be held in subjection with other agents, and, for 
 this second effect, Morphia hypodermically is the remedy that will 
 give the most satisfactory results, and upon which I place the greatest 
 reliance. This treatment, I believe, if given early, and persisted in, 
 will overcome as many of the curable cases, in as short a time, as any 
 other line of treatment that could be prescribed. 
 
 Chloral stands very high in the estimation of many as a curative 
 agent in this trouble. Given in large doses, an anesthetic effect is- 
 claimed for it, and to this end it should be given, rather than in the 
 usual dose as a sedative. M. Charpentier, after observing the results- 
 of bleeding, Chloral, and other anesthetics, as agents in the treatment 
 of eclampsia, contrasts the effects as follows: 
 
 Mortality in cases treated by bleeding, . . 35 per cent. 
 " anesthetics, . .11 " 
 
 Chloral is often given with Bromide of Potassium. Several 
 physicians of my acquaintance report the most gratifying results from 
 the use of a combination of grs. xxx of each of these agents, admin- 
 istered per rectum, to be repeated according to the severity of the 
 case, and the effect produced. Some practitioners, after quieting the 
 convulsions in the beginning with Chloroform, substitute the Bromide 
 and Chloral instead of Morphia. 
 
 In some cases the indication for Gelsemium appears to stand out 
 clearly, and where the patient is able to swallow, it may be given with 
 beneficial results. I have noticed the specific indications for this 
 agent, it seems to me, more often in cases of eclampsia occurring after 
 delivery, than at any other time. Desirable results might be obtained 
 by administering it in combination with other remedies, in cases 
 where it was especially called for. 
 
 Another remedy that was thoroughly tested, both in hospital and 
 private practice, a few years since, was Tr. Veratrum Vir. It was 
 supposed, by some of the more sanguine champions of this agent, that 
 in it almost a specific for the disease had been discovered. As to the
 
 568 KING'S ECLECTIC OBSTETRICS. 
 
 action of Veratrum, Lusk quotes Dr. Kenyon, who .-ays: "The drug 
 is quickly al)sorl)C(l, and enters the circulation rapidly. It enters the 
 vasa vasorum, and through them impairs the sensibility of the vaso- 
 motor nerves, the blood-vessels thus losing their tonicity and power 
 of contraction." It is claimed by most writers that very large 
 doses are necessary, in administering Veratrum, in order to produce 
 the effect desired; by some, fifteen drop doses every fifteen or twenty 
 minutes is suggested; others claim that sixty to one hundred drops 
 every thirty or sixty minutes will answer a better purpose. The toxic 
 effect of the drug is manifested by vomiting and which is usually 
 provoked when pushed to the full dose. The poisonous effect is 
 counteracted, it is claimed, by the morbific principle of the disease ; 
 thus the theory that large doses can be safely administered, and should 
 be continued until vomiting is induced. 
 
 Physostigma may also be classified among the remedies to be 
 thought of in the disease under consideration ; its use, however, in 
 this connection has been quite limited. It is a powerful spinal sed- 
 ative, relaxing the capillaries and diminishing the circulation in the 
 nerve-centers, and overcoming the active hyperaBmia present with 
 eclampsia. It would, no doubt, prove a valuable remedy in many 
 cases. It should be further tested, and its action carefully studied. 
 Prof. Scudder, in writing of Physostigma, says : " I used it in a case 
 of puerperal convulsions, where other remedies had failed, with 
 marked success." As to dose, he says: "The dose of the extract will 
 be from one-sixteenth to the one-fifth of a grain ; of a good tincture 
 from one to ten drops." 
 
 As to bleeding, I shall give it no further consideration as a remedy, 
 feeling that it should be ignored, in view of the several very excellent 
 remedies we now possess, as well as the fact of the material decrease 
 in the death rate since more rational remedial measures have been 
 substituted for it. 
 
 Perhaps cups to the head, nape of the neck, and lumbar region, 
 which have been advised by some, may be advantageously employed, 
 but they can not be readily applied during the paroxysms, and during 
 the intervals I would prefer the means already named. I have never 
 used cups in this disease. 
 
 All these means will not be required in every instance, but when 
 the convulsions are intense, with excessive cerebral congestion, the 
 plan of treatment as suggested, or the selection of some of the other 
 agents mentioned, should be promptly, energetically, and persistently
 
 COMPLICATED LABOR PUERPERAL CONVULSIONS. 569 
 
 brought to bear upon the disease; and it must be truly a desperate 
 case which can not be overcome by timely application. Of course, 
 no cure can be expected where there is considerable effusion on the 
 brain; but as we can not determine with positiveuess whether this 
 has occurred or not, we should be persevering in our efforts, however 
 hopeless the case may appear. 
 
 During the continuance of the attack the bladder should be attended 
 to, and evacuated by the catheter on the occurrence of an interval, if 
 it becomes too much distended; and after the delivery of the child be 
 careful that the placenta is not retained. 
 
 Frequently, during labor, when the child is delivered, the convul- 
 sions cease, and from a knowledge of this fact some writers have 
 recommended the hastening of the delivery as a part of the treatment, 
 even when the os uteri is rigid and tindilated. Others claim that such 
 interference is never justifiable, and the consequence has been, that 
 more females have been destroyed by officious and forcible delivery 
 than have been lost by leaving them to the natural resources of the 
 system. 
 
 It is far better, says Blundell, that the woman should die convulsed 
 in the hands of nature, than that she should perish by the cruel and 
 savage operation of rough and unskillful midwifery. 
 
 Lusk, in closing the chapter on Puerperal Eclampsia in his work 
 on obstetrics, offers the following : 
 
 " As convulsions which occur after the advent of labor have a tend- 
 ency to recur so long as the labor continues, and in the larger propor- 
 tion of cases cease after the birth of the child, every obstetrical 
 resource compatible with the safety of the mother should be employed 
 to hasten delivery. In the early part of the first stage, the pains, if 
 sluggish, should be stimulated by catheterization of the uterus. 
 
 "Braun advocates rupturing the membranes, as he claims that the 
 escape of the amniotic fluid often diminishes the frequency and 
 violence of the convulsions. The water-bags of Dr. Barnes, if neces- 
 sary, should be used to promote the dilatation of the cervix. 
 
 " After the first stage is completed, if no mechanical disproportion 
 exists between the head and the pelvis, a careful attempt to extract 
 the child with forceps should be made. Every precaution should 
 be used to avoid injuring the soft parts. Obstetrical aid is only 
 warrantable where it can be employed without detriment to the 
 mother."
 
 570 KING'S ECLECTIC OBSTETRICS. 
 
 When the accoucheur has faithfully employed the various means 
 recommended for the removal of puerperal convulsions during labor, 
 and no favorable impression has been made upon them after a 
 reasonable time has progressed, he may then ascertain whether the 
 condition of the parts is favorable for an artificial delivery; indeed, it 
 is proper for him to examine from time to time while the fits last, 
 lest the child be expelled unconsciously; also, to learn how the labor 
 is progressing, and what may be the influence exerted upon it by the 
 spasms. But he must be extremely cautious how he interferes with 
 the delivery, lest his attempts prove more fatal than the disease. It 
 is not always that the evacuation of the uterus is followed by a cessa- 
 tion of the convulsions; and not (infrequently these become aggra- 
 vated by the attempts made to hasten the labor. When the female 
 manifests periodically much uneasiness, moaning, and groping and 
 writhing about, it is indicative of uterine contractions taking place ; 
 and when the head is at the perineum, she will frequently be observed 
 to strain. 
 
 In a case where interference is indicated by the severity of the 
 attack and its unyielding character, if the os uteri be found rigid, or 
 soft and dilatable, but not fully dilated, the accoucheur may be able 
 to aid the dilatation by sweeping the finger about the os, or by such 
 other means as heretofore recommended; however, the effect on the 
 patient, of such means, should be carefully watched. Convulsive 
 action may be aggravated or increased by reflex excitation, the result 
 of slight irritation the effect,- sometimes, of the finger coming in con- 
 tact with the uterus. Consequently, if an attempt to promote dilata- 
 tion should cause a return of the spasms, or other alarming symptoms, 
 he must wait; he must be patient, until complete dilatation is nearly 
 accomplished, when he may rupture the membranes a course which 
 frequently expedites the labor but he must not attempt turning, 
 even should it be a breech presentation : turning is a very hazardous 
 measure in convulsions, but few females having recovered where it 
 has been performed. Mai-presentations, according to the observa- 
 tions of accoucheurs, are very rarely met with in puerperal convul- 
 sions. If, however, the head be found in the pelvis, and within reach 
 of the forceps, they may be immediately applied and the delivery ter- 
 minated in this manner. But no attempts at artificial delivery must 
 be made while the paroxysms are on, unless the patient lies in a 
 motionless and comatose condition; else, irreparable injury to the 
 soft parts may accrue, owing to the violent struggles of the patient : 
 and should a fit come on during the application of the blades, they
 
 COMPLICATED LABOR PUERPERAL CONVULSIONS. 571 
 
 must be immediately withdrawn, to avoid being forced through the 
 walls of the vagina or uterus. 
 
 If the head be found steadily advancing, without any delay in its 
 progress, artificial aid will not, as a rule, be required. Sometimes the 
 head may be so firmly fixed in the pelvis as to resist all justifiable 
 efforts to remove it with the forceps; here 'the perforator would be 
 indicated, and should be used as heretofore advised, and if delivery by 
 the forceps be impossible, operate without further delay. However, 
 the judicious practitioner will be guided more by the circumstances 
 of the case, than by any specific rules. 
 
 After the delivery, means to prevent any secondary attacks, and 
 gradually restore the tone of the system, will be called for, when the 
 convulsions have ceased. 
 
 Whatever may be the condition of the patient at this time whether 
 she complains of pain in the head or abdomen, or whether she be 
 maniacal the apartment which she occupies must be darkened, the 
 greatest stillness must be observed, and every source of irritation 
 removed, that she may be kept as quiet as possible. The lightest 
 nourishment only should be permitted at first; afterward, as her 
 strength improves, it should be more substantial, gradually increasing 
 the diet as convalescence progresses. The bowels and bladder should 
 be attended to, regulating the former either by injections or internal 
 laxatives, as circumstances w r ill allow. 
 
 Symptoms of secondary attacks may necessitate the continued 
 administration of some of the remedies used in the beginning. An 
 occasional dose of Morphia, may be called for. Sulphate of Quinia 
 may be given in some case ' Gelsemium should be administered 
 where there is jerking, or inclination to spasmodic action. Extreme 
 nervousness calls for Pulsatilla. The indication for Rhus Tox. will 
 sometimes be present also. 
 
 It will be w r ell to use local antiseptic precautionary measures, as 
 vaginal injections of Hot Water, in which has been dissolved a small 
 portion of Chlorate of Potassium, or Borax. This should be repeated 
 twice a day, until all danger has passed. 
 
 Dr. J. S. McClelland, in a recent paper on Puerperal Eclampsia, 
 made the following report of treatment, mortality, etc., as gathered 
 from a number of eclectic physicians: 
 
 " Of the twenty physicians to whom I sent blanks, thirteen re- 
 sponded. Those thirteen reported 7,190 births, with 28 cases of 
 eclampsia; or 1 to 256.
 
 572 KING'S ECLECTIC OBSTETRICS. 
 
 "Of the 28 case's, 22, or nearly SO per cent., recovered; and 6, or 
 20 per cent., died. 
 
 "Of the cases recovering, we find that six women convulsed during 
 or-iminediately preceding labor; three at from six to eight months; 
 two after labor was completed; and one as late as twelve hours after 
 labor was completed; and in ten cases the time not given, out, from 
 the above, it would be safe to say that four of the ten occurred during 
 labor. 
 
 "Taking the fatal cases, we find that in five the convulsion came on 
 before or during labor. In the remaining case the time that the con- 
 vulsion came on is not given. 
 
 "Those physicians reporting fatal cases have, together, 21 cases of 
 convulsions, of which nearly 30 per cent. died. One physician 
 reported 1 fatal case in 7; one, 2 in 6; another, 1 in 4; and another, 
 2 all he had. 
 
 " Enumerating the remedies used in the treatment of the cases 
 reported, we find that the list includes Morphine, Gelsemium, Yerat- 
 rum Vir., Chloroform, Antispasmodic Tincture, Chloral, Physostigma, 
 Lobelia, Bromide of Potassium, Ergot and Bleeding. 
 
 "Taking each remedy in order, we find that Sul. of Morphia was 
 used in ten cases recovering, and in five of the fatal cases. Four of 
 the cases recovering were given Morphia alone, in one it was com- 
 bined with Chloral, and with bleeding in one. Morphia was not used 
 alone in any of the fatal cases. 
 
 " Gelsemium was used in nine cases recovering, and in three fatal 
 cases. In four of the cases recovering it was combined with Anti- 
 spasmodic Tincture; in two cases it was used with Chloral; in the 
 other three cases it was associated with two or more other remedies. 
 
 "We find Veratrum used in seven cases recovering, and in four 
 cases that died. In one of the cases recovering it was used with 
 Chloroform only, but never alone. In the fatal cases it was not used 
 alone. 
 
 " Chloroform was associated with other remedies in ten cases re- 
 covering, and in five of the fatal cases. 
 
 "Antispasmodic Tincture was used in conjunction with Gelsemium 
 in four cases recovering, and in one fatal case. 
 
 '' Chloral Hydrate was used alone in three cases, and associated with 
 Bromide of Potassium in two that recovered and in five that died. 
 
 "Physostigma was used alone in one case that recovered. 
 
 " Lobelia was used alone in one fatal case.
 
 COMPLICATED LABOR PUERPERAL CONVULSIONS. 573 
 
 " Bromide of Potassium was given with Chloral in two oases recover- 
 ing, and with Ergot in one fatal case. 
 
 "Bleeding was done in three cases, two of which proved fatal. 
 (The first of the fatal cases was bled before the physician reporting 
 saw it; the other was bled through the advice of an allopath who was 
 called in consultation.) The physician reporting the case that recov- 
 ered did not attribute any curative properties to the bleeding, but 
 wholly to the Sul. of Morphia. 
 
 "From the above it will be seen that Sul. of Morphia and Chloral 
 were used alone in more cases recovering than any other remedies. 
 
 " Physostigma was not used often enough to prove its value. 
 
 "Gelsemium, Vcratrum and Chloroform follow closely after Mor- 
 phine and Chloral. Antispasmodic Tincture and Bromide of Potas- 
 sium, in many cases, may be the remedy." 
 
 CHAPTER XLII. 
 
 TURNING, OR VERSION CEPHALIC VERSION PODALIC VERSION 
 
 THE FILLET THE VECTIS, LEVER, OR TRACTOR- 
 BLUNT HOOK PLACENTAL FORCEPS. 
 
 ALL operations during labor, for the purpose of artificial delivery, 
 whether manual or instrumental, are necessarily accompanied with 
 more or less danger, *and hence, they should never be attempted, for 
 any purpose whatever, unless nature is found incompetent to termi- 
 nate the delivery, or, when absolutely required to preserve the 
 mother's life, or that of the child, when the mother's life is in a hope- 
 less situation. 
 
 The great sacrifice of health and life, among females, from indis- 
 criminate and unjustifiable interference, has led some practitioners to 
 set aside all artificial means of relief, and to rely entirely on un- 
 assisted nature, in every case of labor. This, however, is passing 
 into another extreme, and is decidedly wrong; aid is sometimes 
 demanded, and then it must be given to withhold it would be crim- 
 inal; and it is among these cases in which the properly educated 
 accoucheur distinguishes himself from the ignorant pretender, by his 
 calmness and prudence, his proper selection of the time for affording 
 assistance, as well as of the means to be used, and the cautious and 
 skillful employment of these means.
 
 574 KING'S ECLECTIC OBSTETRICS. 
 
 Let the student remember, that in no ease are the efforts of nature 
 to be intermeddled with, either by manual or instrumental operations, 
 niilos it be known that the welfare of the mother, and possibly the 
 life of the child, demands it ; the woman should not be allowed to 
 suffer extreme exhaustion, for the want of instrumental interference, 
 notwithstanding the fact that the natural efforts may be sufficient to 
 complete th.e labor. Prolapsus of the uterus, rupture of the uterus, 
 inversion of the uterus, profuse hemorrhage, peritonitis, permanent 
 dysmenorrhea, laceration of the vagina, and also of the perineum, etc., 
 have frequently resulted from ill-timed, injudicious, and unwarrantable 
 endeavors at forwarding the delivery. These accidents have occurred 
 in the practice of the most eminent obstetricians in instances where 
 the greatest care and prudence were exhibited; how much more readily 
 then will they happen in the practice of the ignorant, officious, and 
 unconscientious practitioner? Were females, or their husbands and 
 friends, generally aware of the great want of skill and knowledge 
 in this department of medicine, which prevails so extensively in the 
 profession, and which is based upon the fact, that in the majority of 
 labors the unassisted and natural resources of the system are adequate 
 to the task of completing labor, they would be more careful and 
 scrupulous in their selection of obstetric attendants, and by this means 
 would compel students to be more attentive to the means of becoming 
 efficient and skillful. I do not refer merely to a want of knowledge 
 and practice in labors actually requiring assistance, but, more particu- 
 larly to those in which no aid is needed, and in which the practitioner 
 destroys either health or life, by vain and ignorant displays of unwar- 
 rantable manipulations. 
 
 Among the operations occasionally required during labor, and to 
 which some reference has been made in the preceding p'ages, that of 
 TURNING or VERSION, may be noticed. According to Churchill, 
 49,323 cases in English practice, required turning in 190 instances, or 
 about 1 in 260 ; 37,479 cases in French practice, required it in 400 
 instances, or about 1 in 93J; 21,516 cases in German practice, required 
 it in 337 instances, or about 1 in 64. Making 927 cases of version 
 out of 108,318, or about 1 in 117. In' 192 cases, in which the mor- 
 tality to the mother has been named, 12 died, or 1 in 16. In 565 
 cases, 187 children were last, or nearly 1 in 3. Some allowance must 
 be made, however, for the various and serious accidents which render 
 the operation necessary. 
 
 There are two modes of turning mentioned by writers; one, the 
 CEPHALIC VERSION, or Version by the Head, in which the head
 
 TURNING, OR VERSION PODALIC VERSION. 575 
 
 is brought to the pelvic brim ; the other, PODALIC VERSION", or 
 Turning by the Feet, in which delivery by the feet is substituted for 
 that by the original presenting part. 
 
 CEPHALIC VERSION, has been recommended at various times 
 by eminent accoucheurs, but, heretofore, it has not proved so efficacious 
 as could be desired, although less dangerous to the child than podalic 
 version, and hence is not much practiced. It has been advised in mal- 
 positions of the vertex, in face and*ear presentations, and sometimes 
 in shoulder presentations ; but where prompt delivery is demanded, 
 turning by the feet is preferred, because cephalic version as ordinarily 
 performed, renders the delivery more tedious. In reply to objections, 
 that it is difficult to seize the head firmly, and bring it to the brim, 
 Velpeau observes : " 1st, it is not always very difficult to seize the 
 head, and to exert considerable force upon it ; 2dly, if the waters have 
 not long been discharged, one may often without difficulty seize the 
 vertex, and bring it to the center of the brim, however far it may have, 
 been distant ; 3dly, that in general it is better to force the head to 
 descend, by pushing up the presenting part, than by bringing down 
 the head ; 4thly, that delivering by the breech is far from being a 
 simple and safe operation; as regards the child, it is less so than 
 cephalic version, even if the forceps should be afterward applied." 
 Notwithstanding this reply, there is much weight in the objections; 
 and attempts to push up the presenting part will frequently induce 
 such violent uterine contractions as to cause the operator to desist. 
 
 In cases where ordinary cephalic version is preferred, the bladder 
 and 'bowels should be emptied, the female placed upon her back, the 
 vagina and soft parts, as well as the hands of the accoucheur, well 
 greased, and, to relax the abdominal walls, the legs should be flexed, 
 with the thighs well up toward the abdomen. Any uterine obliquity 
 should be remedied. The hand is to be introduced into the vagina 
 and uterus in the same manner as named for podalic version. Main- 
 taining the uterine fundus steadily with the external hand, the fetus 
 may be manipulated carefully with the other hand, until the head is 
 brought into proper position; this can often be effected without passing 
 the whole hand into the uterus. If the membranes are not ruptured 
 by the operation, they should be as soon as it is terminated. In many 
 cases external manipulation will greatly aid the operation, as, where 
 the abdominal and uterine walls are thin. If the uterus does not 
 promptly contract after the version is accomplished, the forceps will 
 be required. The operation is readily performed in some instances, 
 but is very difficult, if not quite impossible, in others where it is indi- 
 cated, and would seem easy of execution.
 
 576 KING'S KCLI-'.OTIC OKSTKTIMCS. 
 
 PODALIC VERSION, or turning by the feet, is the operation 
 generally practiced and preferred in those cases where a change of 
 position, or prompt delivery is required. It possesses several advan- 
 tages as well as disadvantages. The advantages are, that the accoucheur 
 has the labor more completely under his control, and can deliver or 
 not. as the case may require, with or without uterine action ; it is 
 nearly equal, in point of safety, to vertex labors, and is considered 
 superior to any other ; it is frequently the only method by which to 
 save the child's life, or to avoid exvisceration ; and often it is the only 
 chance for the safety of the mother. Its disadvantages are, that the 
 risk to the mother's life is always enhanced by an introduction of the 
 hand into the uterus; that it is sometimes very difficult, if not 
 impossible to effect it, and that the fatality to the child is very great 
 where it has been performed, about one in three being lost. 
 
 The cases in which turning may be effected with advantage, are in 
 shoulder presentations; transverse presentations of the body; mal- 
 positions of the head ; difficult breech labors ; placenta pra?via ; 
 hemorrhages ; convulsions ; prolapse of the cord ; rupture of the 
 uterus; syncope; and whenever the mother's life is jeopardized. It 
 must not be forgotten, however, that turning is never to be attempted 
 when the head or presenting part has passed through the brim into 
 the pelvic cavity ; delivery must, in this case, be effected by the 
 forceps or perforator. When the head passes into the vagina, the 
 cervix will contract around the neck of the child, and it will then be 
 impossible to return it into the uterus. But when the head has not 
 completely passed beyond the os uteri and the superior strait into the 
 vagina, it may be pushed upward into the uterus, and version may 
 then be accomplished. 
 
 The most important point for the accoucheur to determine, is the 
 suitable time for the operation; a precipitate interference, or too long 
 a postponement, are equally fraught with danger. There are, however, 
 instances in which delivery by turning should be promptly effected, 
 and others, again, in which it should be delayed. 
 
 Turning, when required, should always be accomplished as soon as 
 possible, in placenta prsevia, in preternatural presentations, in profuse 
 hemorrhage, and whenever symptoms arise which threaten the life of 
 the mother or child, provided, in each instance, the os uteri be soft, 
 dilatable, and sufficiently dilated. 
 
 It should be delayed, when the os uteri is rigid, or soft but not suf- 
 ficiently dilated, until these conditions, especially the first, have been 
 overcome naturally, or by proper treatment; and, when the mem-
 
 URNING- OR VERSION PODALJC VERSION. 577 
 
 branes have been long ruptured, the liquor amnii having entirely 
 escaped, and the uterus contracting powerfully upon the fetus. 
 
 At an early period of labor it is very difficult to detect a mal- 
 presentation, or a mal-position, although it may be suspected by 
 the shape of the protruding bag of waters, as heretofore mentioned; 
 but, when the os uteri has nearly completed its dilatation, and 
 more especially when the membranes have ruptured, any preter- 
 natural presentation may be correctly determined. And this period is 
 always the most favorable for the operation of the version. Should, 
 however, a mal-presentation, requiring turning before labor can be 
 terminated, be detected before the membranes have ruptured (as a 
 shoulder presentation, or placenta prsevia, etc.), the operator may 
 attempt the version, as soon as the state of the os uteri will permit the 
 introduction of the hand, without the employment of force ; in this 
 case, as the hand advances, the membranes become ruptured, the wrist 
 and arm prevent the liquor amnii from escaping, the uterus remains 
 distended, and the turning is readily accomplished. But, although 
 prompt action of this kind is required in placenta prsevia, or hemor- 
 rhage, a delay, until the os uteri is fully dilated and the membranes 
 ruptured, does not necessarily occasion any greater risk in a presenta- 
 tion of the shoulder. 
 
 When the os uteri is rigid, or when, the waters having been long 
 discharged, the uterus contracts powerfully upon the fetus, no attempts 
 at introducing the hand must be made until the rigidity has been 
 overcome, or the irritable condition of the uterus lessened by the means 
 heretofore named. 
 
 Turning has been advised as a substitute for the employment of the 
 perforator, in some cases of narrow or deformed pelvis ; but, from the 
 difficulty in always being able to correctly ascertain the relative pro- 
 portions between the fetal head in utero and the pelvic diameters, it 
 seems to me an infeasible plan. The risks to the mother must be 
 greatly augmented by the operation if unsuccessful, while those to the 
 child will be by no means diminished. And yet cases are recorded in 
 which the operation has proved a success. The reason given for this 
 practice in pelvic deformity is, however, certainly one deserving con- 
 sideration, namely : that the bimastoid diameter or base of the fetal 
 skull being smaller than the bi-parietal diameter by from half an inch 
 to three-quarters of an inch, it may be drawn through the brim of a 
 pelvis, the antero-posterior diameter of which is 2J to 2f inches ; and 
 that when delivery is effected in this manner, the bi-parietal diameter 
 will admit of compression that will elongate the head and diminish 
 37
 
 578 KING'S ECLECTIC OBSTETRICS. 
 
 this latter diameter so that the passage of the head may be effected. 
 While, on the other hand, when the vertex presents at the deformed 
 brim, the contractions of the uterus cause it to bulge out laterally and 
 thus increase the bi-parietal diameter. The operation is not advised 
 where there is diminished transverse diameter of the brim, but only 
 where the antero-posterior diameter is small, or where there is oblique 
 deformity. The advantages of this practice are, that it can be per- 
 formed at an early period of the labor, and does not subject the mother 
 to injuries from the use of instruments; the disadvantages are, as 
 stated above, and likewise, should it prove unsuccessful, the woman 
 would have to undergo a still further shock from the employment of 
 the perforator. It is better never to attempt this operation until one 
 or more experienced consulting accoucheurs have examined the deform- 
 ity and the diameters of the fetal head, and pronounced it practicable. 
 whenever such consultation can be had in time. 
 
 It may be useful here to mention some points made out by Prof. J. 
 Matthews Duncan, M.D., of Edinburgh, concerning the tensile strength 
 of the fully developed fetus, being the result of experiments insti- 
 tuted with the view of determining this matter; according to his 
 statements, the spinal column snaps under a weight of about 105 
 pounds, while the neck, which is the first to give way. requires a force 
 of 120 pounds. So far as mere strength of materials is concerned, 
 traction upon one leg only is sufficient to dissever the neck. As in 
 the neck, so in the legs, the bones give way before the soft parts. Ifi 
 a contracted brim, the body being delivered, the accoucheur should 
 never exert a traction-force over 120 pounds in his efforts to draw 
 the head through the brim, if he does, the neck will give way. Al- 
 though a much greater extractive force can be used when the forceps 
 are applied, in podalic version it should never exceed 1 20 pounds'. 
 
 The mode of performing podalic version has already been de- 
 scribed; the principle of the operation is about the same in all cases. 
 I will, therefore, at this place, merely recapitulate. Empty the 
 bladder and rectum, the first more especially ; place the female on 
 her back, with the hips brought a little over the edge of the bed, her 
 legs flexed back and properly supported. Protect the floor from 
 the discharges. Select that hand for the operation, whose palmar 
 surface corresponds to the anterior surface of the child's body. (If 
 an arm presents, secure it by a ribbon, in order to prevent its rising 
 and interfering with the passage of the head.) The hand and arm 
 must be oiled, and warmed in water [there is no necessity for 
 oiling the palmar surface of the hand] and the former carefully intro-
 
 TURNING, OR VERSION PODALIC VERSION. 579 
 
 duced, in a conical form, within the vagina, during a pain ; it must 
 be passed into the uterine cavity during the absence of pain, while, at 
 the. same time, the external hand must be placed on the abdomen, over 
 the fundus, to support the uterus; seize the child by the knee (hook- 
 ing the finger in its flexure), or by the feet, being careful that a foot 
 and not a hand be grasped, and turn the child during the absence of 
 pain, bringing the inferior extremities downward and over its front. 
 If the limbs be brought over the back of the child, the spine may, 
 probably, be dislocated. The traction must be gentle and con- 
 tinuous, and not by jerks or forcible measures. Be careful to so 
 manage the operation, that at the last stage of the delivery, the face 
 of the child will be in the hollow of the sacrum. When the version 
 is finished, replace the female in the bed, and leave the delivery to 
 nature ; or, should it be necessary to effect this artificially, wait for the 
 uterine contractions and act in concert with them ; for if the tractions 
 be continued, and the delivery completed without uterine action having 
 taken place, the sudden evacuation of the organ would be apt to give 
 rise to inertia, hemorrhage, or other difficulties. While the hand is 
 within the uterine cavity, should a pain come on, do not present the 
 knuckles for the organ to contract upon and run the risk of rupture, 
 but grasp the body of the child with the open hand, removing it from 
 the child's body, only when the pain has ceased. When the uterus acts 
 powerfully and vigorously, it interferes with the introduction of the 
 hand, as well as the detection of the feet, and the version: and the 
 operation becomes not only a difficult o-ne, but painful to both the 
 physician and patient. The operation is, however, comparatively an 
 easy one, when the uterus does not act with much force. The best 
 period for performing the version, is when the os uteri is fully dilated, 
 or nearly so, is soft and the membranes are entire; if they have rup- 
 tured, the os being soft and dilatable, the version should be promptly 
 accomplished. Frequently, however, there will be no choice, and we 
 may be obliged to operate under very disadvantageous circumstances. 
 Sometimes, it will only be necessary to pass two or three fingers within 
 the cavity of the uterus, as one or both feet may be within easy reach. 
 Dr. Barnes, the eminent English gynecologist, has given the following 
 rules: "In all dorso-anterior positions (the back of the child looking 
 to the abdomen of the mother), lay the patient on her left side ; pass 
 your left hand into the uterus it will pass most easily along the curve 
 of the sacrum and the child's abdomen ; your right hand is passed 
 between the mother's thigh, to support the uterus externally. In the 
 ease of abdomino-anterior positions (the abdomen of the child look-
 
 580 KING'S ECLECTIC OBSTETRICS. 
 
 ing to the maternal abdomen), lay the patient on her back, and you- 
 may introduce your right hand, using the left hand to support the 
 uterus externally." 
 
 The hazards to which the mother is exposed in the accomplishment 
 of version, are, 1st, A rupture of the vagina, through which the fingers 
 or hand of the operator may pass, and which may be occasioned by 
 the employment of too much force, omitting to support the fundus 
 externally, or, a neglect in passing the hand in the direction of the 
 pelvic axes. 2d, If the search for the feet be conducted rudely or 
 forcibly, the hand may be driven through the uterine walls. 3d, The 
 hand of the operator, or the limbs of the child may so bruise or injure 
 the uterus as to occasion subsequent inflammation ; but this may arise 
 independent of such injury. 4th, The shock to the nervous system is 
 usually more serious than in natural labors of the vertex or breech. 
 
 The child may be destroyed by compression of the cord; or its hip, 
 or spine may be dislocated by forcible traction, or perhaps a limb may 
 be actually torn from it. It must be recollected, that the cord com- 
 mences being compressed at the period when the nates emerge from 
 the vulva; hence, the greater the delay in the delivery after this time, 
 the more dangerous is it for the child artificial respiration may be 
 attempted, even while the head is in the vagina. 
 
 Some writers recommend us to seize the hips and bring them to the 
 pelvic brim, but this is difficult and seldom attempted ; others advise, 
 instead of searching for the feet to bring down the knees when these 
 are readily obtained; for the purpose of turning, I can see no objection 
 to this plan.* As stated on a preceding page, it is recommended to 
 turn by one foot, or knee, instead of two, more especially on account 
 of the increased dilatation of the soft parts, which must follow, and 
 thus afford greater facility for the expulsion of the head. Generally, 
 
 * Dr. GueVioit believes it to be useless to seize both feet in podalic version, one 
 alone will suffice. But we may fail to get the foot, and we may then introduce a finger 
 into the rectum. The finger is hooked in a manner upon the point of the sacrum, 
 which serves as a point of support fully sufficient for giving the proper movements to 
 the child. It may readily be conceived how much more easy this process is than the 
 search for the foot, as it requires only a finger instead of the whole hand. With the 
 hand, the foot slips, and is held with difficulty; the finger in the rectum has a solid 
 hold, and permits the operation to be rapidly finished. For a dead child, this process 
 should be resorted to at once ; for a living one Dr. G. would hesitate to employ it lesl 
 there should result a temporary relaxation of the sphincter, a paralysis of the anus, and 
 an incontinence of the stools for some time. But if very great difficulties are presented 
 to version by the feet, he would overlook these considerations and act at once according 
 to the process. Jour, de Med. et de Chir. Prat.
 
 PODALIC VERSION THE FILLET. 581 
 
 this will be found to answer. According to actual measurements, the 
 circumference of the presenting porti6n of the head, in labor, is from 
 12 to 13-j inches; that of the breech, w r ith both thighs flexed upon the 
 abdomen, is from 12 to 13J inches; that of the breech, with only one 
 thigh flexed, the other being brought down, is from 11 to 12J inches; 
 and that of the hips, both legs being brought down, is from 10 to llj 
 inches. So that it is much safer for-the child, to accomplish version 
 by one foot or knee only. I was called, some time since, to a case 
 where a foot and arm protruded beyond the vulva, and no justifiable 
 degree of traction could move the child, neither was it possible to 
 return the arm. The waters had been discharged at an early period of 
 the labor, the uterus acted energetically, and the accoucheur had not 
 been able to find the other foot. Finally, after some attempts at 
 changing the position of the fetus in utero had been made, he was 
 enabled to pass his hand upward, when he found the leg across and at 
 right angles with the presenting one ; he carefully brought it down, 
 and the child was delivered in a few minutes. In this case it would 
 have been impossible to have effected the version by the one foot. 
 
 After the delivery, dq not place the child too soon to the breast, 
 but allow the mother a rest for some hours; pursue the means here- 
 tofore named, and be prompt to combat the first manifestations of 
 inflammatory action 
 
 It may be proper to observe here, that when turning is attempted 
 in vertex presentations, the same rules as laid down heretofore, are 
 applicable ; but the head will require to be elevated some or moved, 
 so that it will be placed in one or other iliac fossa. 
 
 The FILLET, is a strong piece of linen or ribbon, about three 
 inches in width, and twenty-five or thirty inches in length, and has 
 been recommended in breech labors, when the pains are not sufficient 
 to complete the delivery. Its mode of application is to oil or grease 
 it, and then, having rolled up some five or six inches of one end, pass 
 it into the vagina, and by means of the fingers push it between the 
 child's thigh and abdomen from one side to the other; then bring 
 down the rolled-up end, as it passes from the side opposite to that at 
 which it was first carried, and tie the two ends together. By this 
 means, the fillet is secured across the thighs, so that traction may be 
 made upon them, and which must always be done during a pain, acting 
 in concert with uterine action, or the bearing- down efforts of the 
 patient. It is very difficult to adjust the fillet, and, probably its use 
 may be dispensed with altogether. A finger, or the blunt hook, passed
 
 582 
 
 KING'S ECLECTIC OBSTETRICS. 
 
 FIG. 65. 
 
 between the hips and abdomen, may, with a prudent force, perform 
 all that can be expected from thv ribbon. It is used, also, to secure 
 the presenting hand in a shoulder presentation, when turning is at- 
 tempted, and thus prevent it from rising and embarrassing the deliv- 
 er)' of the head. It should be applied to the wrist. 
 
 Whalebone and steel fillets have also been invented for passing over 
 the head to aid in its delivery when this is required, as substitutes for 
 FIG. 66. the vectis and forceps in certain 
 cases. The best are stated to be Dr. 
 AVestmacitt's and Dr. Sheraton'.-: I 
 have never had occasion for them, 
 considering them to be unscientific, 
 and vastly inferior to the forceps. 
 FIG. 64. 
 
 The VECTIS, LEVER, or 
 TRACTOR, is an instrument some- 
 what resembling one blade of the 
 obstetric forceps. It consists of a 
 steel blade fitted into a roughened 
 handle of hard wood, the whole in- 
 strument being twelve or thirteen 
 inches in length. The extremity of 
 the blade is expanded like a forceps 
 blade, is furnished with a fenestra, 
 and one side is so curved as to adapt 
 it to the convexity of the head of the 
 child. Sometimes it is made with a 
 hinge, for the purpose of carrying in 
 the pocket, and again it is made 
 without a hinge, but having the 
 handle to screw on the blade ; both 
 
 * 
 
 VECTIS. BLUNT HOOK. 
 
 able. It 
 
 into a minute description of the instrument, from the fact that very 
 few obstetricians of the present day make use of it; in former times, 
 however, it was much in vogue. (Fiy. 64.) 
 
 The vectis has been recommended for the purpose of correcting 
 mal-positions of the head, or of aiding its movements, whether at the 
 brim or in the pelvic cavity; it has also been advised as a tractor to 
 aid in the delivery of the head. The rules for its introduction are 
 
 BLUNT HOOK of these latter forms are objection- 
 
 AND CROTCHET. i i TJ. 
 
 is not necessary to enter
 
 THE VECTI.S LEVER OR TRACTOR. 583 
 
 somewhat similar to those for the forceps. The instrument should not 
 be applied unless the os uteri is dilated and yielding, as also the soft 
 parts, and labor-pains must likewise be present, or its employment 
 would be attended with no success. Instead of being secretly used, as 
 has been frequently the case, the patient and her friends should be ac- 
 quainted with the necessity for interference, the same as in the use of 
 the forceps, and which must never be attempted unless positively de- 
 manded. Then having emptied the bladder, and rectum also if neces- 
 sary, place the female on her left side, or on her back, as the practitioner 
 prefers though in the latter position it will be necessary to bring the 
 hips over the edge of the bed, the same as when the forceps are em- 
 ployed. The operator will now pass three or four lingers of his left hand 
 as high up as possible within the vagina, over the head of the child, to 
 serve as a director for the vectis which, having been properly warmed 
 and oiled, is to be carefully and slowly passed over the convexity of 
 the fetal head, until the point is reached to which the force is to be 
 applied. Then withdraw the hand to about the middle of the instru- 
 ment, forming a fulcrum with it at that point; the lever is then of the 
 first kind the right hand acting on the handle by pressing it in a 
 direction opposite to the one which it is desired the head should take- 
 Sometimes, it is formed into a lever of the third kind the right hand 
 serving as the fulcrum or point of support, while the left, at the middle 
 of the lever, gives to it the necessary movements. 
 
 It is frequently the case that the vectis will have to be placed on 
 several parts of the head in succession, in order to reduce its mal- 
 position and aid in its descent, and this may be accomplished by 
 carrying the instrument gently over the circumference of the head, 
 from point to point, without withdrawing it; and should any difficulty 
 be present interfering with its application, no force must be employed 
 to overcome it if it can not be passed without rude measures withdraw 
 the vectis, and and reintroduce it. It may also be necessary to use it 
 alternately as a lever, and as a tractor. When used as a tractor, both 
 hands are to be employed in making firm, but not violent traction in 
 the direction of the axes of the pelvis, according to the location of the 
 head, and the efforts should be made only during the presence of a 
 pain, ceasing during an interval, and slightly raising or loosening the 
 instrument from the cranium. The least force sufficient for the purpose 
 is the best. When the head is at the brim, the vectis must be applied 
 over the occiput; when at the inferior strait, it must be introduced 
 over the sides. The necessary changes may be effected by only three 
 or four efforts, sometimes thirty or forty will be required.
 
 KINGS Kri,K<:TIC OHSTETHK s. 
 
 At the present day those who advise the vectis, limit its application 
 to cases where the head can not execute its motion of rotation in the 
 pelvic cavity; in face presentations applying it early in labor over 
 the occiput, making traction, while at the same time the chin is to be 
 pushed up by the hand, for the purpose of bringing down the vertex ; 
 in presentations of the side of the head and, likewise, in instances 
 where the head does not advance, the pains being strong, and where 
 there is only room sufficient for one blade to act. However, in nearly 
 ail these cases, the forceps, or a manual operation, will usually be found 
 sufficient, and, should the vectis be required, one of the forcep blades 
 will be found fully adequate to effect all that can be accomplished by 
 it. I should hesitate a long time before attempting to use this instru- 
 ment on the head, above the superior strait. 
 
 In the hands of the unskillful or imprudent operator, the vectis may 
 occasion serious results; thus, if it be introduced while the os uteri 
 is not dilatable, iior sufficiently dilated, it will give rise to contusions, 
 and laceration of the parts, and death to the mother. If it be rudely 
 or carelessly introduced, the vagina or the uterus may be ruptured. If 
 the traction be not made in the direction of the axes of the pelvis, as 
 the situation of the head may require, not only will the female be 
 seriously injured, but the operation will prove of no avail. If a 
 portion of the uterus be engaged in the cavity of the blade, between 
 it and the fetal head, a fatal injury may be the result. If the traction 
 be made regardless of the pains, not only will the operation prove 
 useless, but the female will be exposed to much danger. If the 
 instrument be pressed upon the soft parts of the mother, they must 
 suffer more or less from contusion. If too much force is applied as 
 the head glides over the perineum, or if this be not supported at the 
 time, a very serious rupture may be the consequence. Too much 
 pressure with the point of the instrument upon the child, may occasion 
 a troublesome wound. 
 
 Dr. A. K. Gardner's tractor is undoubtedly a most excellent instru- 
 ment for the purposes for which it was designed, as it does not exert 
 any injurious pressure upon the hard or soft parts of the mother when 
 properly employed. It may be used to flex the head in early departure 
 of the chin from the breast, to aid in rotation in face presentations, 
 and for delivering the head when necessary, after the birth of the body 
 of the child. In some cases it is preferable to the forceps, as but one 
 blade is to be applied (a saving of time), and which has nearly the 
 same power as the forceps. It is applied similar to a forcep's blade.
 
 THE OBSTETRICAL FORCEPS. 585 
 
 The BLUNT HOOK (Fig. 65) consists of a round rod of metal, curved 
 at one extremity, and having the other fastened into a roughened 
 handle of hard wood. Hodge's forceps (Fig. 68) are so arranged that 
 either blade may be employed as a blunt hook ; it may likewise be 
 obtained in one rod without any handle, the extremity opposite to the 
 blunt hook being formed into a crotchet. It is used in presentations 
 of the breech, when delay in the labor renders it necessary to makf. 
 traction, and the finger can not be introduced into the groin, or wheii 
 the finger can not exert a sufficient degree of traction : it may also be 
 used in those cases where it becomes necessary to pull down the feet, 
 but which it is impossible to effect by the fingers. It is also occasion- 
 ally employed in those cases where, the head having been delivered, 
 the thorax, from its size, prevents any further advance of the labor; 
 in these instances, it is passed into the axilla of the shoulder nearest 
 the sacrum, to disengage this first. It has also been recommended aa 
 a substitute for the crochet, when the cranial bones are so loose as to 
 render it almost impossible to obtain a purchase upon them by the 
 crotchet : the blunt hook may in these cases be passed behind an 
 orbit, or into the foramen magnum. 
 
 This instrument is to be applied in a manner similar to that recom- 
 mended for one blade of the forceps: it should be passed with its point 
 directed toward the palmar surface of the hand by which it i guided, 
 and when it has reached the point on which AVC design to have it act, 
 give to it a rotatory motion in the direction of its axis, and thus cause its 
 free extremity to pass into the axilla or fold of the groin, being care- 
 ful, in the latter instance, not to injure the genital organs of the child. 
 After the blunt hook is applied, always examine and ascertain that it 
 has been properly adjusted, and is in a position to effect no injury to 
 either the mother or child. 
 
 When the groin can not be hooked by passing the instrument in 
 front of the anterior hip, this may be effected by introducing it be- 
 tween the thighs. An improper use of the blunt hook may give rise 
 to serious difficulties. It is not very frequently employed at this day.
 
 586 K I Mi's ECLECTIC OBSTETRICS. 
 
 CHATTEB XLIII. 
 
 THE FORCEPS DAVls' FORCEPS HODGF/S FORCEPS (ASKS IN 
 
 WHICH TO BE USED CASES IX WHICH NOT TO BE 
 
 USED PERIOD FOR USING THEM. 
 
 FORMERLY, when there was any delay in the advance of the pre- 
 senting part of the child, from whatever cause, it was the custom to 
 insert a hook into the eye or some other part of the child's head, and 
 then apply extracting force ; consequently, but few children were 
 saved, and those who did live subsequently, were more or less di>li^- 
 ured or mutilated. Such an operation must have been repugnant to 
 every feeling and conscientious man, causing him to postpone its per- 
 formance as long as possible, and which delay would necessarily add 
 to the hazards of the mother. 
 
 But the invention of the forceps has relieved the obstetrician in a 
 great measure of these unpleasant operations, while at the same time 
 it has been, and still continues the means of saving the lives of numer- 
 ous children, as well as mothers. The forceps were invented in the 
 sixteenth century, prior to 1647, by Dr. Peter Chamberlen, who, 
 together Vith his sons, kept it secret until some time in the. early part 
 of the seventeenth century j when it became gradually known to the 
 profession. However, it had been employed by Solinger in Germany, 
 and Palfyn in France, for some time before it became generally known 
 what the instrument was, or who was its inventor. Since its intro- 
 duction the original instrument has undergone various modifications, 
 some of which are less objectionable than others, or, perhaps, are 
 superior only in certain cases. It is unnecessary to enter into a 
 detailed history of the invention and introduction of the instrument, 
 or to describe the many changes through which it has passed ; for such 
 information, there are various works to be readily obtained, which 
 contain all the particulars, and which those who are curious in thiei 
 matter may consult. The limits of this work will not permit more 
 than a close adherence to the practical and useful. 
 
 The obstetrical forceps is composed of two arms or branches, each 
 of which has three distinguishing parts : 1st, the cochlea, blade, jaw, 
 or clamp, which is shaped somewhat like the bowl of a spoon, and the 
 concavity of which is intended to be applied on one side of the child's 
 head ; 2cl, the junctura, joint, lock, or hinge, at which point the two*
 
 * THE OBSTETRICAL FORCEPS. 587 
 
 blades articulate with each other ; and 3d, the manubrium, or handle 
 which should be of sufficient length to enable the accoucheur to operate 
 with facility. The blade of each branch has an opening or fenestrum, 
 which lessens its weight materially, beside having the advantage of 
 allowing the parietal protuberance to pass out beyond them, when 
 applied over the sides of the headland thus lessening the diameter 
 which would be presented, were the blades solid ; each blade is 
 curved in the direction of its longitudinal axis, as well as in that of 
 its transverse, which enables the instrument to be more readily intro- 
 duced and acted upon in the direction of the pelvic axis. The joint 
 in each blade varies, one being furnished with a pivot and the other 
 with a notch or mortise ; when the two are properly united, the blades 
 are firmly locked. Others are made with the double mortise joint; 
 the blades firmly locking without a pivot, making it less difficult to 
 adjust them. To distinguish the blades from each other, the one 
 with the pivot is termed the male blade, and that with the mortise the 
 female blade. The handles of the Hodge forceps are similar in each, 
 having a curvature externally, which not only admits of their being 
 firmly grasped without slipping, but also serves to fulfill all the pur- 
 poses of a blunt hook. In other varieties the handles are shorter, 
 not curved, and usually mounted with wood. 
 
 There are two descriptions of forceps in general use, the short and 
 the long; the former were more in vogue some years ago, but since the 
 excellent improvements made in the long forceps by Prof. Hodge, it 
 is more in favor because, while it possesses all the benefits of the 
 short forceps, it has an advantage in its applicability to operations at 
 the brim, when these are required. The short forceps are only useful 
 when the head is at or near the inferior strait. 
 
 Nearly every obstetrician has some favorite model of this instru- 
 ment; but among the short forceps, I believe those of Prof. Davis, 
 of London, have been more generally preferred by the profession of 
 this country. Prof. Meigs, who adopted them, gives the following 
 description : " It weighs ten ounces and three-quarters, and is in length 
 twelve inches ; its lock is the English lock, composed of a notch in 
 the upper surface of the left and in the lower surface of the right- 
 hand branch. When the handles are closed, the ends of the clamps 
 are seven-tenths of an inch apart, while the fenestrse, at their widest 
 part, are two and three quarter inches asunder. The broadest part 
 of the fenestrum is equal to two inches, while its whole length is five 
 inches. From the extremities of the handles to the lock or point 
 where the branches cross, is four and a quarter inches. After the
 
 588 KIN<;'s KCLKCTIC OBSTKTHJ* s. 
 
 branches are crossed, they do not divaricate, but proceed in parallel 
 lines one inch and a quarter; hence, if a fetal head be ever so con- 
 siderably elongated by the pressure of the parts, the clamps are suffi- 
 ciently capacious to contain it, being seven inches long. In this in- 
 strument, such are the width and length of the fenestrse, that a large 
 part of the parietal protuberances jut out through or beyond them 
 when they are fixed on the head." * "Its interior face 
 
 is perfectly adapted to the rotundity of those parts of the head which 
 it touches; while the fenestrse are so vast as to permit considerable 
 portions of the parietal protuberances to project as segments of curves 
 
 outside and beyond the 
 fenestral openings. It 
 would be true to say that 
 the instrument, when ac- 
 curately adjusted upon the 
 
 sides of the cranium, 
 HALE'S SHORT OBSTETRICAL FORCEPS. i i_ j.i 
 
 scarcely touches the mater- 
 nal tissues within the pelvis. The exterior curves are also arranged 
 so accurately that the tissues of the mother can never touch the edges 
 of them; so that they can not be cut by them, the surfaces of contact 
 being everywhere broad and gently rounded. The admirable form 
 of the old-curve, or head-curve, enables the instrument to touch very 
 large portions of the cranial surfaces, pressing them equally, and not 
 unequally; so much so, indeed, that, when the instrument is ac- 
 curately applied, it would be a very difficult matter to do with it the 
 least injury to the fetus, since it can scarcely slide." 
 
 The short forceps designed by Prof. Hale answers a very good 
 purpose also, and is preferred by many physicians. (Fig. 67.) 
 
 But, however useful the above forceps may be, it is a matter of con- 
 siderable moment to so simplify all our instruments, that one only of 
 them may be adapted to the accomplishment of several purposes; and 
 this is more especially necessary in obstetrics, in which it frequently 
 occurs that delay, even of a short interval, is attended with serious 
 results. On this account Hodge's improved long forceps have been 
 more usually preferred by many than others, not only because of their 
 lightness and correct form and adaptation to the purposes for which 
 they are intended, but likewise because they combine the utility of the 
 short forceps, the long forceps, the vectis, and the blunt hook. This 
 instrument is a modification of the long French forceps, and is de- 
 scribed by Prof. Hodge himself, as follows:
 
 HODGE'S FORCEPS. 589 
 
 " The great object of the forceps is to extract the head of the fetus 
 from the mother's organs, in suitable cases, without injury to the 
 mother or child. It is notorious that injuries to one or both parties 
 frequently result, exciting a too-well founded dread of this instrument 
 in the minds of females, and even of physicians. Many causes con- 
 tribute to this unfortunate result. No doubt much depends on the 
 size, weight, and especially on the form of the instrument employed, 
 a fact confirmed by the almost innumerable varieties which have been 
 suggested. The instrument, as heretofore used, is evidently imperfect; 
 and the one now suggested, is presented under the impression that, 
 while it maintains all the excellencies of the former varieties, the 
 injurious influences are partly, if not wholly, avoided. It is a modifi- 
 cation of the long French forceps, but may be well termed an eclectic 
 forceps, as combining, as much as possible, the peculiar excellencies 
 of the English, German, and French varieties. 
 
 " The advantages of the French or long forceps are, I think, many 
 and decided, as, 1st, by them, any operation pertaining to this instru- 
 ment, can be performed. There is no necessity to vary the form, 
 structure, or size, of the instrument, whatever may be the presentation 
 of the head, its position, or its location. 2d. By them, sufficient 
 power can be applied in cases of necessity, which can not be done by 
 the short forceps. Their leverage is greater. 3d. The narrowness of 
 the blades, which, without detracting from the utility of the instru- 
 ment, will allow of their application to the sides of the head, even in 
 oblique and transverse positions. Many of the modern English forceps 
 are too broad to allow the proper manipulation of the instrument in 
 the cavity of the pelvis. They can not be introduced through the 
 vulva without pain, especially in first labors. The French forceps 
 can very generally be applied without pain. 
 
 "4th. It may be added as another advantage, that as habit in the 
 use of an instrument is all-important, the practitioner will sooner 
 become accustomed to a forceps which he can employ on all occasions, 
 than when he is obliged, to vary it continually; especially when it is 
 remembered that among the strong and well-formed females of 
 America, cases for the forceps are not very numerous in the circle of 
 any practitioner. 
 
 " The disadvantages, which experience has taught me arise from the 
 French forceps are : 
 
 " 1st. Its unnecessary weight. 
 
 " 2d. The pelvic curve, in the variety most in use in this country, 
 is not sufficiently great. Hence, when the head is high in the pelvis,
 
 590 KINO'S ECLECTIC OBSTETRICS. 
 
 the perineum will be too much pressed upon, or else the blndes will be 
 applied in the direction of the occipi to-frontal or longitudinal diameter, 
 instead of the occipito-mental or oblique diameter. 
 
 " 3d. The divergence of the blades commencing at the joint must 
 necessarily distend the vulva (especially its posterior margin) prema- 
 turely, and when the head is high up, gives pain and endangers the 
 laceration of the perineum. 
 
 "4th. The small size and kite-like shape of the fenestra prevents 
 any portion of the cranium, even of the parietal protuberances pro- 
 jecting into their openings: hence, the hold on the head is less firm, 
 and space is occupied by the blades, the thickness of which is added 
 to the transverse diameter of the head. 
 
 "5th. The flatness of the internal or cephalic surfaces of the blades, 
 so that the margin of the fenestra, often measuring three-eighths of 
 an inch, is much thicker than the external edge of the blade, increases 
 the space occupied by the instrument. Hence, in cases of difficulty, 
 where compression is employed, contusion or even wounding of the 
 scalp results. 
 
 "6th. The mode of junction of the French forceps is decidedly 
 inconvenient when compared with the English, and especially with 
 the German mode. 
 
 " These disadvantages I have endeavored to obviate without dimin- 
 ishing or circumscribing the utility of this most valuable instrument, 
 to which the profession and the public are so much indebted. My 
 experience encourages the hope, that the attempt has been in a very 
 great degree successful, so that even in inexperienced hands, the dangers 
 of the forceps have been materially lessened. 
 
 " 1. The weight of the instrument has been diminished from twenty 
 ounces, avoirdupois, to seventeen ounces. 
 
 " 2. The pelvic curve has been slightly increased, so that the peri- 
 neum may not be dangerously pressed upon when the blades are in 
 the axis of the superior strait. To counteract any loss of power which 
 may ensue, from the increased curvature, there is an angular bend in 
 the handles, in an opposite direction, that the direct line of traction 
 may be preserved, a suggestion of our skillful and experienced instru- 
 ment maker, Mr. Rorer. 
 
 " 3. The shanks or commencement of the blades are nearly parallel, 
 diverging no more than is absolutely necessary, until they approximate 
 the head of the child, when a more rapid curvature, than in the Levret 
 forceps, occurs.
 
 HODGE'S FORCEPS. 591 
 
 "4. The proper blades of the instrument, from the shanks to the 
 extremities are nearly of the same breadth throughout, being equal to 
 that of the extremity of the French forceps. 
 
 " 5. The advantages are a more secure hold of the head, and 
 especially allowing larger fenestraB, so that the parietal protuberances 
 may project into the openings, and no space occupied by the blades, 
 when properly applied. 
 
 " 6. The cephalic surface of the blade is concave, so as to be adapted 
 to the convexity of the head, as suggested by Dr. Davis in his improved 
 forceps, hence no edges touch the scalp, and there is no wounding of 
 the tissues, even when great compression is made. 
 
 " 7. The very ingenious and scientific mode of locking the blades, 
 as in the German or Siebold's forceps, by means of a conical pivot, 
 and the corresponding oblique conical opening for its reception, is 
 adopted, by which all the facilities of the English junction are enjoyed, 
 and the security and firmness of the French joint are maintained. 
 
 "The eclectic forceps weighs one pound and one ounce, being nine 
 ounces lighter than the French forceps, as usually manufactured by 
 Rorer, of this city, and eleven ounces lighter than a specimen of 
 Dubois forceps in my possession, made in Paris. 
 
 " The whole length of the instrument (Fig. 68) in a direct line from 
 b to c is 16 inches; from the joint a to the extremity 6, the length of 
 the handles, is 6.8 ; from a to d, length of parallel shanks, is 3.5 ; 
 from d to c, the proper blades in a direct line, is 6 inches; from c c, 
 the extremities, to ef, the greatest breadth, 3.7 inches. 
 
 " The separation between the points c c, when the handles are in 
 contact, is .5 of an inch; from e to /, the greatest breadth when the 
 handles touch, is 2.5; when the separation at ef is 3.5, the points c c 
 are separated to two inches; the breadth of the blade is 1.8, slightly 
 tapering to 1.7 near c c, the extremities. The breadth of the fenestra 
 is 1.1; the thickness of the blade is .2 of an inch. The perpendicular 
 elevation of the points c c, when the instrument is on a horizontal 
 surface, is 3.4 inches, which indicates the degree of curvature of the 
 blades. 
 
 "The elevation of the handles near the point, above the same 
 horizontal line, is 1.3 (including the thickness of the blades), which 
 indicates the extent of the angular bend in the handles." 
 
 It is sometimes the case that the head is delayed in its descent in 
 consequence of its bi-parietal being slightly larger than the antero- 
 posterior diameter of the superior or inferior strait ; in such instances, 
 the instrument of Professor Hodge may be applied along the sides of
 
 592 
 
 KING'S KCLKCTIC OBSTETRICS. 
 
 the head, and sufficient compression oe made upon this diameter to 
 insure its passage through the brim, and into the pelvic cavity, or 
 through the. outlet. Too much compression, however, will dcstn>v 
 the child, and this should always be kept in mind when operating. 
 
 From experiments instituted by Baudelocqtie, upon several still- 
 born children, as to the amount of compression which the fetal head 
 will safely bear, he found that the degree of reduction which the 
 diameters may harmlessly undergo, is very inconsiderable, not exceed- 
 ing four and a half or five lines; that the extent of the reduction 
 
 HODGE'S FOBCEPS. 
 
 depends much upon the more or less perfect ossification of the cranial 
 bones, and the ratio of closure of the sutures and fontanelles, and that 
 it can not be properly estimated from the amount of force employed 
 in approximating the handles, nor from the distance remaining 
 between them when thus approximated in delivering the head. 
 
 Professor Meigs most emphatically pronounces the forceps to be the 
 child's instrument, and not the mother's that it is by no means to be 
 viewed as a compressive instrument, but always as an extractor; a dec- 
 laration which should never be forgotten by the obstetric operator.
 
 USE OF FORCEPS. 
 
 593 
 
 However, it may be proper to state that there are many accoucheurs 
 \vho, though recognizing the correctness of Professor Meigs' remarks 
 FIG. G9. on this point, as a general principle, yet consider 
 
 that there may be some exceptions, as in moderately 
 contracted pelves, in which a gradual compression 
 of the head may effect delivery, without evil re- 
 sults to either the child or its mother. Among 
 them I may name Dr. Rigby, who says: "The slow 
 and gradual pressure of the forceps thus exerted (by 
 tying the handles together and tightening them 
 after every successive effort), upon the head of a 
 living fetus, will have a very different result to 
 that of the experiments of Baudelocque and others, 
 in attempting to compress the head of a dead fetus, 
 by the application of a sudden and powerful force. " 
 So that, from these remarks, it may be well to con- 
 sider the use of the forceps as a compressor, above 
 the brim, either when its diameters FIG. 70. 
 are slightly diminished, or the bi- 
 parietal of the head somewhat aug- 
 mented, as a mere exception to the 
 general rule that the forceps are not 
 intended for compression. And when 
 compression is made, the head being 
 within the pelvic cavity, it should 
 never be in the direction of the oc- 
 cipito-frontal diameter, but always in 
 that of the bi-parietal, as being less 
 likely to injure the child. Judicious 
 management will frequently render a resort to the per- 
 forator unnecessary. 
 
 In addition to the forceps heretofore named, there are 
 many others employed by the profession, each of which, 
 though framed upon the same general principles, appears 
 to have certain advantages in its favor, and which the 
 accoucheur generally selects according to his own views 
 but it is not necessary to give more than this brief 
 reference to them, especially as the rules herein given EA5n 
 for their employment are equally adapted to all or any of them. 
 As with many other things, the forceps have not only undergone real 
 38 
 
 ELLIOT'S FORCEPS.
 
 594 
 
 KING'S ECLECTIC OBSTETRICS. 
 
 or supposed improvements, but have likewise passed through what 
 may be termed periods of fashion, as to short or long, style, design, etc. 
 An objection made by some practitioners to the Hodge forceps is 
 the inability to grasp the metallic handles in the middle, and make 
 traction, without the hands slipping; to overcome this, some operators 
 either hook the index finger over the lock, or wrap a napkin or towel 
 about them. There are numerous other forceps, however, that differ 
 from the Hodge in the shape and finish of the handles, FIG. 72. 
 being mounted with wood, and designed to give a firm 
 FIG. 71. and permanent hand-hold. Among 
 
 these may be noticed Elliot's (Fig. 
 69), Reamy's (Fig. 70), Sawyer's 
 (Fig. 71), as well as one of my own 
 designing (Fig. 72). 
 
 Elliot's forceps differs from the 
 Hodge, not only in the handles, 
 but is of much greater width be- 
 tween the blades, both through the 
 point of greatest excavation as well 
 as the tips; it is more especially re- 
 garded as an instrument of extrac- 
 tion rather than of compression, 
 and was designed for application 
 to the sides of the pelvis rather 
 than the sides of the child's head. 
 Dr. Sawyer's forceps is also of this 
 design. The forceps bearing my 
 name is of much lighter weight 
 SAWYER'S FORCEPS, than the Elliot, and can be easier 
 locked than those with the pivot joint, and I think will be found a 
 very satisfactory instrument. 
 
 In some countries the forceps are employed much more frequently 
 than in others; thus, according to Churchill, in 52,268 cases of labor 
 occurring in British practice, the forceps were applied in 144 cases, 
 or about 1 in 362|. In 44,736 labors in French practice, they were 
 used in 277 cases, or about 1 in 162; and in 261,224 labors in Ger- 
 man practice, they were resorted to in 1,702 cases, or about 1 in 153J. 
 The whole amounting to 358,228 cases of labor, in which the instru- 
 ment was applied 2,123 times, or about 1 in 168J. The results to the 
 mother in British practice, was 1 death in 20J cases; to the child 1 in 
 4J. In French and German practice, 1 mother was lost in 13J, and 
 
 WINTERMUTE'S 
 FORCEPS.
 
 USE OF FORCEPS. 595 
 
 about 1 child in 5. As the result to the mother has not been named 
 in many instances, nor the peculiarities of each case given, these 
 statistics can be considered as only approximative. In our own 
 country, the statistics have been too meager and limited to enable us 
 to form any idea of the comparative frequency of forcep labors, or 
 their results. It has been recently stated that "the more frequently 
 the forceps are employed, the less is the mortality to the mother and 
 child." I am not prepared to either deny or admit this statement. 
 If, however, the remark be true, I can only account for it from the 
 fact that, in cases where the instrument is required, it is used at a 
 much earlier period than formerly, while the strength of the patient 
 enables her the better to sustain the shock of the operation, and 
 while the soft parts are yet free from any tendency to sloughing there- 
 from ; and, perhaps, likewise to a more perfect knowledge of the cir- 
 cumstances under which they may be efficaciously employed, as well 
 as to a more scientifically "correct application of them. 
 
 The cases in which a resort to the forceps has been advised, are the 
 following recollecting, however, that the short forceps are never to 
 be used when the head has not passed the superior strait : 
 
 1. To effect delivery in cases where the uterine contractions are 
 weak and inefficient, and can not be aroused by the ordinary means. 
 Thus, the head may be in the superior strait, not impacted, but mak- 
 ing no advance, in consequence of the inefficiency of the pains; here 
 the long forceps have been advised, to assist in accomplishing the 
 descent Or, the head may present at the brim, in a mal-position, 
 which, not being corrected by the pains, as well as being incapable of 
 reduction by the hand, may be rectified by the long forceps, provided 
 the os uteri be in a proper condition. 
 
 In the use of the long forceps, I would remark here, that when em- 
 ployed at the superior strait, the blades are to be introduced in the 
 transverse diameter of this strait, so that a blade will be within each 
 ilium; while both the long and short forceps are to be introduced 
 over the sides of the child's head when it has entered the pelvic 
 cavity, a blade being over each ear and which rules must be borne 
 in mind when the long forceps are employed as a substitute for the 
 short ones. 
 
 2. To hasten delivery when dangerous symptoms to the mother are 
 present, whether from too prolonged labor, hemorrhage, convulsions, 
 exhaustion, rupture of the uterus when the head is within reach, or 
 from resistance of the muscles of the perineum.
 
 596 KING'S ECLECTIC OBSTKTIJIC.S. 
 
 3. To save the child's life in some face presentations, and in the 
 occipito-posterior positions when the forehead is behind the pubic sym- 
 physis. This, however, is not necessary in all instances of the above 
 character, as delivery frequently terminates by the natural efforts, 
 though more slowly, and with a greater amount of suffering than in 
 ordinary cases. 
 
 4. To preserve the child in prolapsus of the cord, when the pulsa- 
 tions grow weak. 
 
 5. When there is a detention of the head within the pelvic cavity, 
 heretofore referred to when speaking of the compressive action of the 
 instrument. 
 
 6. When an extremity descends with the head, and can not be 
 returned, the augmentation of the diameter within the pelvis, may 
 require a greater degree of expulsive force than can be given by the 
 natural powers. 
 
 7. In breech labors, when there is a delay in the advance of the 
 head ; the body and extremities having been delivered, the child may 
 die, in consequence of compression of the cord, unless it be removed 
 by the forceps. A few minutes, in these instances, generally deter- 
 mine the life or death of the child. 
 
 The forceps are never to be employed when the os uteri is rigid and 
 undilatable, or relaxed but not sufficiently dilated ; when the peri- 
 neum is unyielding ; when the soft parts are inflamed and swollen : 
 when the diameters of the pelvic cavity are diminished by the presence 
 of tumors; in deformities of the pelvis; when the child is dead; and 
 when the fetal head is hydrocephalic, or firmly ossified. Neither is it 
 to be applied to the breech. And unless there exists some urgent 
 reasons for their use, as hemorrhage, large head, small pelvis, convul- 
 sions, etc., they are never to be employed except the pains are inefficient. 
 Indeed, the instrument should always be considered the " child's 
 instrument," and a substitute for absent or inefficient expulsive force 
 of the uterus ; and, under no circumstances whatever, is it justifiable 
 to employ them to save trouble, or in any other way accommodate the 
 convenience of the practitioner. 
 
 When the uterus acts energetically, the pulse not being over one 
 hundred beats in a minute, the countenance natural, the spirits good, 
 the tongue and mouth moist and clean, the abdomen and soft parts 
 free from pain on being pressed or touched, and the head makes the 
 slightest advance, no interference is required, notwithstanding the 
 labor may have continued over twenty-four hours. 
 
 If attempts be made to introduce the forceps before the os uteri and 
 soft parts are in a favorable condition, rupture of the uterus, or lacer-
 
 USE OF FORCEPS. 597 
 
 ation of the perineum and vagina may be the consequence, and which, 
 when occurring, always proves more or less hazardous to the mother. 
 Nor is it proper, when the head is in the pelvic cavity, to carry the 
 forceps within the os uteri, until this has so far risen above the parietal 
 protuberance that it can not readily be felt. 
 
 When the soft parts are swollen and inflamed, a condition which 
 will seldom occur in the hands of a careful accoucheur, it will be 
 inexpedient to use the forceps, because of the disposition to sloughing 
 of the parts under such circumstances, and, therefore, the perforator 
 will be the safer instrument for the mother. The same course will be 
 pursued in diminished pelvic diameters from tumors, deformities, or 
 other causes. In these cases the child must be sacrificed for the safety 
 of the mother this is a fundamental principle of obstetrics. Gen- 
 erally, in instances where the perforator will be required, the pressure 
 will destroy the child, before the symptoms become so threatening as 
 to induce a skillful obstetrician to operate. 
 
 When the child is known to be dead, which may generally be deter- 
 mined by the stethoscope, the perforator is advised in preference to 
 the forceps; and this is likewise recommended in hydrocephalic or 
 ossified heads, to be used, even before the child's death, if the safety 
 of the mother requires it. 
 
 As the instrument is intended for the head only, it could not be 
 applied to the breech with any degree of safety or success, as it would 
 be very apt to tear or mangle the soft parts of the breech and trunk 
 upon which it might be exercised. But it may be frequently used 
 with advantage to extract the head, after the body of the child has 
 been expelled, when any difficulty or delay occurs in its delivery. 
 
 In impacted or locked head, the perforator will generally be re- 
 quired, on account of the impossibility of moving the head with the 
 forceps; this condition of the head is usually connected with a small 
 pelvis, or a large, and perhaps ossified head. But in cases where 
 there is a mere arrest of descent, from a close fitting of the circum- 
 ferences of the head to those of the pelvis, the forceps may be used. 
 
 In all cases where the head is considerably larger than the pelvis, 
 the forceps, as well as a resort to turning are improper; and either 
 the perforator or the Cesarean operation will be required. Yet, as 
 our means of accurately determining the size either of the head or of 
 the pelvis, are not always absolute, it is never improper to attempt the 
 delivery by a careful and gentle employment of the forceps. It will 
 frequently happen that when the antero-posterior diameter of the brim 
 .has not reached three inches, the forceps may be successfully used.
 
 598 KING'S ECLECTIC OBSTETRICS. 
 
 The PERIOD FOR OPERATING, will depend entirely upon 
 the circumstances attending each individual case. Previous to the 
 rupturing of the membranes, the employment of the forceps will be 
 unnecessary; but after their rupture, in ordinary cases, we are to "be 
 guided more by the constitutional symptoms than by a mere lapse of 
 time. There is one exception to the statement just made, and that is 
 when the difficulty "is at the superior strait, and the head can not 
 descend through it, in this case, as too great a delay may give rise to 
 serious symptoms, the second stage may be considered to have com- 
 menced as soon as the os uteri is fully dilatable. The rule governing 
 our action will depend on the condition of the patient; if the case is 
 progressing 'naturally, no signs of exhaustion, the pains increasing, 
 with gradual advancement of the head, interference is uncalled for. 
 Exhaustion, or want of advancement of the head, however, calls 
 for action. It was formerly the rule not to interfere until the 
 second stage of labor had continued for twenty-four hours; it 
 frequently occurs, however, that symptoms present themselves be- 
 fore the twenty-four hours have expired which demand interference; 
 and, again, many females will sustain a prolonged and painful labor, 
 with more fortitude, and less prostration of the system, or other 
 unfavorable symptoms, than others. We must, therefore, be governed 
 principally by the symptoms, and partly by the lapse of time, being 
 careful not to delay too long, or until the parts become dry and 
 inflamed, and the labia and perineum become infiltrated with serum, 
 for then, laceration and sloughing will almost inevitably ensue. If 
 the head remains arrested for four hours, we are justified in operating 
 even though no unfavorable symptoms exist, because by so doing we 
 preserve the integrity of the soft structures. 
 
 In the selection of the proper period for operating with the forceps, 
 in connection with what has already been stated, an attention to certain 
 circumstances, will materially assist us. Thus if the health of the 
 female has been impaired, or if she has previously suffered from a long- 
 continued sickness, the powers of the system will be less likely to 
 sustain her under a lingering labor, or to terminate the delivery, than 
 when she has been in the possession of good health ; though we often 
 meet with females laboring under consumption, dropsy, etc., whose 
 labors are as vigorous and natural as those of the most healthy and 
 robust. If the female has previously given birth to children, there is 
 a greater reason to suppose that the present one may also be born 
 without aid, unless there exist a mal-position or abnormality of the 
 head.
 
 USE OF FORCKPS. 599 
 
 Several hours having elapsed since the commencement of the 
 second stage of labor, with symptoms of exhaustion, together with 
 strong and regular pains without advancement of the head, the 
 forceps will very probably be required ; we should not be too hasty 
 in their application, however, being governed, in a great measure, 
 by the symptoms present. Yet we must remember that if the head 
 remains stationary, pressing upon the soft parts for four hours, 
 their structure becomes much endangered. But, "if the head ad- 
 vances ever so slowly, the patient's pulse continuing good, the 
 abdomen free from pain on pressure, and no obstruction to the 
 removal of urine," the strength and spirits of the patient being 
 also good, interference, as a general rule, is not required, unless the 
 child be dead. The mortality to the mother and child, in cases where 
 this rule has been applied, is less than among those where the forceps 
 have been resorted to, and, it must also be borne in mind, that the 
 death of the child alone does not justify any interference, unless there 
 be sufficient cause aside from this fact. 
 
 The condition of the patient's strength, and her capacity of endurance 
 must also be taken into consideration ; and we must be careful not to 
 be misled as to the exhaustion of the female. The uterus may be 
 acting energetically, and the woman be walking about the room, and 
 yet she will complain of being exhausted ; the practitioner must be 
 guided by other symptoms than merely such expressions. When 
 exhaustion is present, the pulse will be very quick, over one hundred 
 beats in a minute; below this there is seldom any danger. The pains, 
 also, gradually become weak, with lengthened intervals, and finally 
 cease ; and accompanying this condition there will be a greater or less 
 discharge from the vagina, of a faint, unpleasant, but not putrid odor, 
 and of an olive color, and which is, probably, the secretion from the 
 lining uterine membrane, changed in consequence of the long-continued 
 and powerful .exertions of the organ; this may be considered one of 
 the first manifestations of exhaustion. The countenance of the patient 
 assumes an anxious appearance, the cheeks become pale, sallow, or 
 spotted, the eyes sunken and dull, and the tongue will be dry and 
 loaded, either with a brown sordes, or, if fever is present, with a white 
 fur. The respiration is also hurried, and other unfavorable symptoms 
 may appear. Vomiting of a dark fluid, having the appearance of 
 coffee-grounds, is most generally present, when exhaustion has 
 advanced; and when a long period has been allowed to elapse, a 
 shiveringcoklness of the extremities, with cold, clammy perspiration 
 on various parts of the body, and delirium come on, indicative of great
 
 600 KING'S ECLECTIC OBSTETRICS. 
 
 local injury and extreme danger. But we must not wait for these 
 more severe symptoms, before operating but should promptly act 
 upon the first manifestations of exhaustion, and, in cases of immediate 
 clanger, even at a still earlier period. 
 
 The condition of the abdomen, and of the soft parts, will also indi- 
 cate operative interference. Thus, if there is tenderness of the 
 abdomen on pressure, inflammation is to be dreaded ; and immediate 
 delivery will be the safest course to pursue, before inflammatory action 
 becomes developed. If the soft parts, instead of being cool, soft, and 
 moist,- become dry, hot, swollen, and painful, so that the least touch 
 can scarcely be allowed, it has been advised by some writers to deliver 
 by forceps; but from the tendency to sloughing in such cases, I do not 
 deem it the best practice. Still, an attempt to subdue the tenderness 
 and inflammation by the application of fomentations may be under- 
 taken in such cases; always, however, recollecting, that the danger 
 increases in proportion as the pressure is continued. To wait, how- 
 ever, for the appearance of vomiting of dark fluid, of cold shiverings 
 or sweats, hurried breathing, delirium, or swelling and inflammation 
 of the soft parts, would be extremely injudicious. 
 
 In all these protracted cases of labor, great vigilance is required 
 that we do not delay the operation so long as to endanger the life of 
 the mother; and if there is a chance for saving the child's life without 
 any injury to the mother, the delivery may be undertaken even before 
 those symptoms appear which indicate a failure of the powers of the 
 system. There is always a greater possibility of injury from too long 
 a delay, than from interfering a little too soon. 
 
 Occasionally, circumstances will exist which demand the use of the 
 forceps for delivery before the rupture of the membranes ; in such 
 cases, if the os uteri is in a favorable condition (and positively not 
 without), the membranes may be artificially ruptured and the instru- 
 ment applied. Such instances are, fortunately, very rare. 
 
 The principal dangers to which the mother is exposed when the 
 forceps are used, are laceration of the vagina, or of the perineum, or 
 of both; laceration of the cervix; and contusion of the soft parts. 
 The child may have its head too much compressed; its -scalp, or ear, 
 may be bruised or torn ; and the pressure may induce paralysis of the 
 facial nerve. 
 
 The principle of axis traction is at present exciting considerable 
 discussion, and has been adopted by a number of obstetricians in the 
 use of the forceps. The idea was suggested by Dr. Tarnief, and has 
 for its object traction directly in the axis of the pelvis, by means of
 
 USE OF FORCEPS. 
 
 an attachment to the ordinary forceps. I quote the following from 
 Leishman's Midwifery, in reference to this subject: "An attempt has 
 been made, by Professor Tarnier, to modify the forceps so as to pull 
 FIG. 73. more directly in the axis of the brim, and 
 
 at the same time to protect the perineum, and 
 to avoid injurious pressure in the direction 
 of the pubic symphysis. The instrument, 
 
 in the construction 
 of which great me- 
 chanical ingenuity is 
 displayed, is sigmoid 
 in shape, from the ad- 
 dition of a special 
 perineal curve," etc. 
 
 The instrument of 
 Tarnier was too com- 
 plicated for general 
 use; it, however, has 
 been simplified by re- 
 cent modifications, to 
 the extent of render- 
 ing it a very desirable 
 instrument in many 
 cases, and has received 
 the endorse- 
 ment of some 
 of the fore- 
 most w r riters 
 
 PIG. 74. 
 
 REYNOLDS' ATTACHMENT FOR 
 Axis TRACTION. 
 
 SlMPSON-T.ARNIER FORCEPS. 
 
 on obstetrics. The principle is clearly shown in the Simpson-Tarnier 
 forceps (Fig. 73) ; or possibly it will be better understood by referring 
 to the Reynold's attachment (Fig. 74). This may be used with any 
 forceps. After properly adjusting the forceps, the arms, 6, c, should 
 be attached to the fenestrse of the forceps, then connected at e, after 
 which traction may be made by applying the proper amount of force 
 to the handle, d; the handles of the forceps should, at the same time, 
 be supported by the disengaged hand.
 
 602 KING'S ECLECTIC OBSTETRICS. 
 
 CHAPTER XLIV. 
 
 RULES FOR APPLYING THE FORCEPS MODE OF APPLYING THE 
 
 FORCE1'> IX THE VARIOUS POSITIONS OF THE HEAD. 
 
 BEFOEE stating the manner of applying the forceps, I will briefly 
 recapitulate a few of the general principles referred to in the previous 
 chapter, and which should be constantly kept in view by the accoucheur. 
 
 1. When the powers of nature are sufficient to effect the delivery, 
 interference is not required, unless circumstances occur which threaten 
 the life of the mother. 
 
 2. The forceps, acting as a substitute for the natural efforts, are to 
 be employed as an extractor, and not as a compressor. 
 
 3. They are never, under any conditions whatever, to be used, unless 
 the os uteri is sufficiently dilated and dilatable. 
 
 4. They may be used when a delay in the delivery would endanger 
 the child's life, but never at the expense of injury to the mother. 
 
 5. Under ordinary circumstances, they should not be applied until 
 the symptoms of exhaustion commence ; neither delaying too long 
 until the more severe symptoms come on, nor operating too pre- 
 maturely. 
 
 6. They must not be used when the soft parts are inflamed or 
 swollen, on account of the tendency to subsequent sloughing; neither 
 must they be applied to any part of the child except the head. 
 
 7. The lateral motion or oscillating movement from handle to 
 handle must not be allowed to take too extensive a range ; and 
 remember, that the higher up the forceps are passed within the pelvic 
 cavity, the more limited will be the extent of these motions, and 
 greater attention will be required not to injure the maternal soft parts. 
 
 8. Always avoid hurrying the head through the inferior strait, and 
 fail not to give support to the perineum as it becomes extended by the 
 advance of the head. 
 
 Previous to the introduction of the forcep-b lades, the patient, as 
 well as her friends, should be made acquainted with the character of 
 the operation, and the necessity for it; for it is not to be supposed 
 that any physician would attempt an operation of this kind without 
 the consent of the patient or her relatives. It may, likewise, be a 
 judicious measure, in cases where imperative haste is not required, to 
 show the instruments and explain their method of operating
 
 RULES FOR APPLYING THE FORCEPS. 603 
 
 remarking that, as the hands can not be applied to the sides of the 
 head to assist in its delivery, these are employed as substitutes : and 
 that, in the hands of a careful operator, they will not be apt to cause 
 injury to child or mother. Whenever it is possible to procure the 
 presence of an another accoucheur with whom to consult and share 
 the responsibility, it should be done, and will be found a very 
 judicious measure. 
 
 Consent having been obtained, the bladder must, in every instance, 
 be evacuated, either naturally or by catheter ; and if the rectum has 
 not been recently emptied, or if there be an accumulation of the feces, 
 an injection should be administered. But should the injection fail to 
 clear out the rectum, and the symptoms demanding delivery are 
 urgent, the practitioner may proceed to the application of the forceps, 
 having, however, been careful to empty the bladder. 
 
 The practitioner, having turned up his coat sleeve and shirt wrist- 
 band, and also protected his dress from being soiled, by an apron or 
 something to serve a similar purpose, will have the female brought 
 to the edge of the bed, lying upon her back, as in the position for 
 turning, her feet resting on two chairs, or flexed back to the 
 edge of the bed, and separated sufficiently from each other to 
 permit him to sit or stand between them, and her limbs are to 
 be supported by two assistants (not necessarily professional friends), 
 who are to sit with their backs toward each other. The patient's hips 
 should be brought so far beyond the edge of the bed, that no obstacle 
 will be offered to the introduction of the forceps, or to the free use of 
 them after having been applied. 
 
 In order to prevent the floor from being soiled by the discharges,, 
 some cloths should be placed upon it immediately under the hips of 
 the woman, and that part of the bed on which the inferior portion 
 of her body rests, should also have several fglds of blankets or other 
 suitable articles placed there, to protect the bed from the discharges 
 The female should never, under any circumstances, be exposed : a 
 sheet or blanket, according to the condition of the weather, should be 
 thrown over her. And in order to facilitate the introduction of the 
 blades, lard or some other unctuous substance should be freely applied 
 to the soft parts. An anesthetic should now be administered, either 
 by the obstetrician in charge or by the assistant, providing consulta- 
 tion has been called. 
 
 These preliminary measures having been attended to, and the 
 operator knowing the exact position of the head, he may sit or stand, as 
 preferred, and proceed to introduce the blades. These, having been
 
 KING'S ECLECTIC OBSTETRICS. 
 
 previously wanned to a temperature equal to that of the patient, by 
 placing them in warm water, are to be well greased, and each blade is 
 to be held in its appropriate hand, somewhat similar to the manner 
 of holding a pen, although rather more firmly or it may be held in 
 the manner of a bistoury while making an incision. Generally, the 
 male blade, or the one introduced by the left hand, ifi applied first, 
 then the other ; and the introduction should invariably be effected 
 during the absence of labor-pains, ceasing all efforts when these 
 return. 
 
 Some writers advise that blade to be introduced first which is 
 applied along the posterior part of the cavity, and this will probably 
 hold good in a number of cases; but, as a general rule, it will be 
 found better, in practice, to introduce that blade first which is the least 
 easily applied, always being careful to so apply them that they will 
 readily lock. 
 
 Having carefully passed in two or three fingers of the hand not 
 occupied in holding the blade, and insinuated them between the os 
 uteri and the fetal head, both as a guide for the application of the 
 blade, and to prevent the os uteri from being included in the grasp of 
 the forceps, each blade is to be successively and carefully passed over 
 the sides of the head. If the head is high up, it will then be neces- 
 sary to introduce the whole hand within the vagina, for the purpose of 
 properly guiding the blades ; and the direction of the axes of the 
 pelvis, as well as the exact position of the head, and its relations to 
 the surrounding parts, should not fora moment be lost sight of. Ivich 
 blade must be passed inward with a waving motion, but without any 
 force, and must also be kept in constant contact with the head during 
 the introduction. Should either blade meet with any obstacle to its 
 advance, it must not be forcibly thrust forward, but should be passed 
 beyond the difficulty by -careful and adroit management, withdrawing 
 the blade, if necessary, for a reintroduction ; should any force be 
 employed to overcome the resistance, the ear, or a fo,ld of the skin, or 
 the soft parts of the mother, would, probably, be torn, and which 
 would reflect much discredit on the skill and attainments of the 
 operator. 
 
 As a general rule, the forceps are to be applied, with their concave 
 surface grasping the sides of the head in the direction of the occipito- 
 meutal diameter; and they are always to be so applied, that at the ter- 
 mination of the delivery, when the head is emerging from under the 
 pubic arch, their concave edges will be brought under and facing this 
 arch. By considering for ajiioment, whether the occiput or forehead
 
 RULES FOR APPLYING THE FORCLP.S. 605 
 
 is to be brought under the pubic arch, the practitioner can not fail to 
 properly apply the instrument, for the concave edges of the blades 
 must always be directed to that part of the head which passes under 
 this arch, as it emerges from the outlet. 
 
 After the first blade has been applied, it may be held by an assistant 
 until the second one has also been applied, which latter should be 
 introduced above, and as nearly as possible opposite, the handle of 
 the male blade, in order that they may lock readily. If they do not 
 lock easily, and without force, no rude or violent attempts at twisting 
 or wrenching them round should be made, but the female blade should 
 be removed and reintroduced, and it were better to repeat this several 
 times than to attempt an adjustment by force. Occasionally, it may 
 become necessary to withdraw both blades, and reapply them. When 
 properly locked, a finger should be passed around the lock to ascertain 
 that no portion of the soft parts, or of the genital hair, are fastened 
 within it. 
 
 Having effected the locking, and removed any hairs, etc., which may 
 be found entangled within the lock, screw down the pivot, by giving 
 it two or three turns, grasp the handles firmly and make 'slight com- 
 pression and traction, to ascertain that the instrument is firmly applied, 
 and that no part of the vulva, vagina, or os uteri is included ; and 
 which latter circumstances may be known by the violent pain pro- 
 duced when a withdrawal and readjustment of the -instrument will 
 be necessary. 
 
 The forceps being properly applied, the operator may now proceed 
 to deliver. Seizing the handles with the right hand, he will hold them 
 together with a sufficient degree of firmness to prevent their slipping 
 from the head, and without exerting an undue compression upon it. 
 The left hand must be applied over the lock of the forceps, with the 
 index finger extended so as to touch the vertex of the child, and thus 
 enable him to ascertain whether the head advances or not with the 
 motion of the instrument. If it does not advance, the finger will be 
 found to leave the vertex as the operation proceeds. 
 
 If the handles are held in the left hand, the right should be applied, 
 as above, to the lock ; and the middle finger of the hand, at the lock, 
 may be placed in front of it, that is on the part facing the child's 
 head, to aid in the extraction, should more extractive force be required. 
 The index finger must not be removed from the head until it emerges 
 from the vulva ; and should it leave the head, the operator must cease 
 action, lest the blades suddenly slip off, and, perhaps, occasion a serious 
 injury to the parts.
 
 KINGS ECLECTIC OBSTETRICS. 
 
 The traction should always be made in the direction of the axis of 
 that part of the pelvis, at which the head is successively placed, and 
 must be made only during a pain, ceasing in its absence; or, should 
 the pains have become entirely suspended, the operation should be 
 continued only for two or three minutes at a time, allowing intervals 
 between each effort, and thus imitating, as closely as possible, the 
 course pursued by nature. During the intervals relax the handles, 
 and relieve the head from pressure. 
 
 In accomplishing traction, the impulse of the force employed, 
 although guided in the direction of the pelvic axis, successively, is 
 effected by a lateral motion, from handle to handle, keeping the 
 instrument at first, as far back to the perineum as possible, in order 
 to act in the direction of the axis of the pelvic brim (if this be 
 necessary), and elevating the handles as extension ensues and the head 
 emerges from under the pubic arch. About two-thirds lateral force, 
 and one-third extractive force should be given; and the nearer the 
 head is situated toward the brim, the more limited will be the extent 
 of the motipn from side to side, while at the outlet a large sweep may 
 be taken. 
 
 Most usually the rotation of the head occurs with its descent, 
 carrying the forceps along with it as it rotates, without any effort of 
 the practitioner. But should this motion of rotation not be effected 
 naturally, it must be accomplished by the operator, not by violent 
 exertions, nor by twisting the head, but by continuing the tractions 
 from handle to handle, at the same time slowly and gradually giving 
 to them the proper direction in which the head must rotate. 
 
 This lateral extractive motion causes the instrument to act as a 
 double lever, and in effecting the change in the motion from side, to 
 side, the operator must be very careful to retain every fraction of an 
 inch which the head advances, not allowing the advance made by one 
 lateral extractive movement to recede when he carries the handles in 
 an opposite direction. Should the contractions of the uterus corne on 
 powerfully, and -the head commence advancing naturally, after a few 
 motions of the instrument, the rest of the labor may be left to nature; 
 but the forceps must not be removed until the head is delivered, 
 because, if, from an erroneous view of the natural efforts, the removal 
 of the blades has been premature, requiring a subsequent reappli- 
 cation, it places the operator in a very discreditable and mortifying 
 position. 
 
 As the head passes over the perineum, this must be carefully 
 supported by an assistant, and the operator should slowly and care-
 
 RULES FOR APPLYING THE FORCEPS. 607 
 
 fully deliver the head, requiring the patient to lie still, lest any sudden 
 movement on her part, might cause a severe laceration of the peri- 
 neum. Generally, when the head reaches the outlet, it will occasion 
 tenesmus and sufficient contraction to terminate the delivery, without 
 any further efforts at traction, and all required of the operator will be 
 to gradually carry up the handles of the instrument in front of the 
 pubis, and thus favor the movement of extension ; improper traction 
 at this time will almost always cause a rupture of the perineum. 
 But should there be any difficulty in the advance and extension of 
 the head, a moderate degree of traction will then become necessary. 
 Remove the forceps after the birth of the head, and attend to the 
 remainder of the delivery, the same as in a natural labor. 
 
 Having now given the general rules for the employment of the 
 forceps, it will be proper to refer to its special applications, in each 
 position of the head or face; commencing with those instances in 
 which the vertex has reached the inferior strait. 
 
 LEFT OCCIPITO-ANTEKIOR POSITION. 
 
 This position (as well as all others) should be positively, and cor- 
 rectly ascertained by a vaginal examination ; and if the practitioner 
 is not satisfied with the signs detected by the finger alone, he should 
 not hesitate to introduce three or four fingers, or even the whole hand, 
 extending the fingers over the head, and ascertaining its true position 
 by feeling its various points. 
 
 Having the patient properly situated, he will take the male or left- 
 hand blade of the forceps in his left hand, and using two or three 
 fingers of his right hand as a guide, he will carefully introduce it 
 along the left side of the child's head and in front of the maternal 
 left sacro-iliac symphysis, carrying it upward until the extremity of 
 the blade reaches the chin of the child. When the blade is about 
 to be introduced at the vulva, in the direction of the axis of the 
 inferior strait, the handle will lie in an oblique manner over the right 
 groin of the patient, and as the blade passes within the vagina, being 
 guided in the direction of the pelvic axis, the handle will be grad- 
 ually depressed between the woman's thighs, approaching nearer and 
 nearer toward the median line. When properly applied, the handle 
 will be directed toward the left thigh of the mother, the pivot will 
 look upward and to the left, and the concave edge of the blade will 
 be directed toward the left acetabulum. Having an assistant to hold 
 this blade, the operator will take the female or right-hand blade in 
 his right hand, and with the fingers of his left hand as a guide, he
 
 608 KING-8 ECLECTIC OBSTETRICS. 
 
 will introduce it, above the male branch and nearly opposite to it, in 
 front of the right foramen ovale, gradually conducting it along the 
 side of the head in the occipito-mental direction. When this blade is 
 about to be introduced, the handle will lie obliquely in front of the 
 left groin, and as the blade passes within the vagina, the handle will 
 be gradually depressed between the thighs of the patient, approaching 
 by degrees toward the median line. As soon as this blade has entered 
 to a sufficient distance, and been properly adjusted on the right side 
 of the head both blades being as nearly as possible in the direction 
 of the occipito-mental diameter of the child's head they will lock 
 without any difficulty. When locked, both handles will lie toward 
 the left thigh of the patient, that of the male blade being uppermost, 
 and the pivot will be directed upward and to the left. 
 
 The head being at the inferior strait, as soon as a pain comes on, 
 commence the traction in the direction of the axis of this strait; as 
 the head advances it rotates, the concave edges of the foreep-blades 
 are brought under the pubic arch, and as the movement of extension 
 takes place, the handles must be gradually carried upward in front of 
 the pubic ; ymphysis and abdomen. Accomplishing the remainder of 
 the delivery in the usual way. 
 
 EIGHT OCCIPITO-ANTERIOR POSITION. 
 
 In this position the male blade, which, in all cases, is to be held in 
 the left hand, must be introduced, along the fingers of the right hand, 
 within the left side of the vagina, and by means of a spiral movement, 
 it should be gradually drawn forward so as to apply its concave surface 
 to the left side of the child's head. The handle will at first be 
 inclined obliquely over the mother's right groin, but as the blade 
 advances it will gradually be depressed, and when properly adjusted, 
 the concave edge of the blade will look toward the pubic arch, and 
 the pivot will be directed upward and toward the right thigh. De- 
 pressing the handle, so as to admit the introduction of the opposite 
 blade, place it in charge of an assistant, and proceed to apply Ihe 
 other blade. Taking it in the right hand, and with the fingers of the 
 left hand as a guide, introduce it, above the male branch, along the 
 right side of the head. The handle of this blade will lie, at first, 
 obliquely in front of the left groin, but is depressed as the blade is 
 entered upward. When the blades are properly adjusted, in the 
 occipito-mental direction, there will be no difficulty in locking, and 
 the traction will be made as in the preceding instance.
 
 RULES FOR APPLYING THE FORCEPS. 
 
 609 
 
 FIG. 75 
 
 OCC1PITO-PUBIC POSITION. 
 
 This position may include occipito-anterior positions, in which the 
 movement of rotation has been accomplished, and the occiput brought 
 to the pubic arch. 
 
 In this position, the male blade will be taken in the left hand, and, 
 with the fingers of the right hand as a guide, must be introduced 
 within the left side of the vagina, along the left side of the child's 
 head, and along the left sacro-iliac symphysis. {Fig. 75.) When the 
 blade is about to be introduced at the vulva, in the direction of the 
 axis of the inferior strait, 
 the handle will lie in an 
 oblique manner over the 
 right groin of the patient, 
 and as the blade passes 
 within, being directed in 
 a line with the pelvic 
 axis, the handle is grad- 
 ually depressed, approach- 
 ing nearer and nearer 
 toward the median line. 
 When properly adjusted, 
 the handle will rest 
 against the perineum, the 
 pivot will be directed 
 upward, and the concave 
 edge of the blade will be 
 under the pubic arch. 
 Placing this in the care 
 of an assistant, the fe- 
 male blade being held in 
 the right hand, and guided by the fingers of the left, must be 
 cautiously introduced, above the male blade (Fig. 77), as far within 
 the pelvis, over the right side of the child's head, as may be sufficient. 
 The handle, which, at first, was obliquely over the left groin, is grad- 
 ually depressed as the blade advances, and if a proper application has 
 been made, the two branches will lock very readily, the concave edge 
 of each, as well as the pivot being directed upward, and the head being 
 grasped by the blades in the occipito-mental direction. (Figs. 78, 79.) 
 The traction must be made in the direction of the inferior pelvic axis, 
 39
 
 610 
 
 KING'S ECLECTIC OBSTETRICS. 
 
 that is, forward and downward, and as soon as the occiput is placed 
 under the pubic arch, and extension takes place, the handles of the 
 instrument will gradually rise upward and toward the abdomen of the 
 female. 
 
 FIG. 76. 
 
 A reference to Fig. 76 indicates the grasp of the forceps in an. 
 oceipito-anterior position after rotation. It is not always possible to., 
 reach the occipito-mental diameter, and when forced flexion is wanting 
 the forceps will usually adjust themselves as shown in the above cut, 
 
 LEFT OCCIPITO POSTERIOR POSITION. 
 
 In this position the male blade will be introduced within the left 
 lateral part of the vagina, along the right side of the child's head, 
 gradually advancing it to a proper adjustment as it enters. At the 
 commencement, the handle will lie obliquely over the right groin, 
 but as it enters it is depressed until the blade assumes the direction 
 of the occipito-mental diameter. At first, this direction can not be 
 exactly obtained, and the soft parts at the outlet will be pressed upon 
 considerably ; the pivot of the branch will look upward and to the 
 right, and the concave edges of the blades will look toward the child's 
 forehead. An assistant holding this, the operator will introduce the 
 female blade within the right side of the vagina, and along the left 
 side of the child's head, and when properly applied the two branches 
 will lock readily, with the pivot directed to the right and upward, and
 
 RULES FOR APPLYING THE FORCEPS. 
 
 611 
 
 the handles will be depressed as far backward as the parts will allow. 
 In both this and the succeeding position, as the blades can not be 
 placed exactly along the occip- FIG. 77. 
 
 ito-mental diameter at first, 
 they must be gradually brought 
 into this direction as extrac- 
 tion proceeds, being careful 
 not to bruise or injure the soft 
 parts of the mother, or the 
 child's head. In all the oc- 
 cipito-posterior positions, after 
 rotation has been effected, and 
 the forehead brought to the 
 pubic arch, the remaining de- 
 livery of the head will be 
 accomplished in the same man- 
 ner as mentioned in the occip- 
 ito-sacral position. And, when 
 the head is near the inferior 
 strait, no attempts must be 
 made to rotate the occiput 
 under the pubic arch before extracting, lest the child's neck be dis- 
 located ; though careful efforts may be made to bring the vertex into 
 the hollow of the sacrum. 
 
 RIGHT OCCIPITO-POSTERIOR POSITION. 
 FIG. 78. 
 
 In this position the blades 
 
 will be introduced some- 
 what similar to the mode 
 laid down under the right 
 occipito- anterior. When 
 the branches are correctly 
 adjusted and locked, the 
 soft parts will be consid- 
 erably pressed upon, the 
 pivot will look upward and 
 to the left, the handles will 
 be very much depressed, 
 and the blades, as in the 
 preceding position, will not at first be exactly in the occipito-mental
 
 612 
 
 KING'S ECLECTIC OBSTETRICS. 
 
 direction. (Fig. 80.) Traction and rotation having brought the 
 forehead under the pubic arch, the remainder of the operation will be 
 the same as in the occipito-sacral position. 
 
 OCCIPITO-SACRAL POSITION. 
 
 In this position the blades are to be applied 
 somewhat similar to the manner named under 
 the occipito-pubic, but with the concave edges 
 of the blades looking toward the child's /ore- 
 head instead of its occiput. When properly 
 adjusted, the concave edges of the blades will 
 be directed toward the pubic arch, the pivot 
 will look upward, and the handles will be de- 
 pressed so far backward upon the perineum as 
 frequently to produce a degree of pain. The 
 traction, in this instance, as well as in the two 
 preceding positions, after rotation has been 
 effected, is not to be made in the direction of 
 the pelvic inferior axis. The occiput will have 
 to be the first delivered, and to accomplish this 
 it must traverse over the sacrum and perineum. The handles will, 
 therefore, at first, be carried upward so as to produce increased flexion, 
 and bring the occipito-mental diameter FIQ. so. 
 
 parallel with the axis of the inferior 
 strait. This will advance the occiput 
 over the posterior commissure of the 
 vulva, when the handles must be de- 
 pressed in order to permit the extension 
 of the head to take place, which termi- 
 nates the operation. 
 
 As in these occipito-posterior posi- 
 tions the perineum is greatly dilated, 
 the operator must proceed very patiently 
 and carefully, being especially observant 
 that the proper support be given to it 
 as the head is passing over, lest it be 
 lacerated. After the occiput has been 
 delivered, should there be a delay in the extension, as the instrument 
 is depressed, a sufficient degree of traction downward and backward 
 may be made, to enable the forehead, face, and chin, to pass from
 
 RULES FOB APPLYING THE FORCEPS. 613 
 
 under the pubic arch. The rest of the labor is terminated as in 
 ordinary cases. 
 
 FIG. 81. 
 
 Fig. 81 shows the forceps applied in an occipito-posterior position 
 after rotation. 
 
 LEFT OCCIPITO-TRANSVERSE POSITION. 
 
 Occasionally the head will be found lying transversely within the 
 pelvic cavity; the occiput may be directed toward one ischium, and 
 the forehead toward the other. In the present position, the occiput 
 will lie against the left ischium, and the forehead against the right, in 
 a line with the transverse diameter of the pelvis. In each transverse 
 position the rotation must bring the occiput, and consequently the 
 concave edges of the forcep-blades, to the arch of the pubes, and by 
 recollecting this, it may at once be determined how to apply the blades. 
 
 In the left occipito-transverse position, the male blade will be applied 
 to the lower and left side of the child's head, after which the female 
 blade will be applied to its upper and right side. In order to effect 
 the application with as little difficulty as possible, pass the male blade 
 within the left lateral and posterior part of the vagina, along the left 
 sacro-iliac symphysis, and when it has entered sufficiently, carefully 
 move the blade to the hollow of the sacrum, and its concave surface 
 will be over the left side of the child's head. Having an assistant to
 
 614 KING'S ECLECTIC OBSTETRICS. 
 
 hold this, introduce the female blade along the right anterior part of 
 the pelvis, behind the right acetabulum, and by gentle efforts work it 
 gradually to the symphysis pubis, that its concave surface may be 
 applied over the right side of the child's head. When the blades are 
 properly adjusted, they will lock without any difficulty, and the pivot 
 will be directed toward the left thigh of the mother. 
 
 Traction must now be made in the direction of the pelvic axis 
 corresponding to that part of it, however, in which the head is situated, 
 and at the same time rotation from left to right should be slowly and 
 gently attempted. When this has been effected, the remainder of the 
 delivery will be terminated in the usual manner. 
 
 Professor Meigs observes, that in this position, when the male 
 branch is introduced as above, the handle is strongly abducted toward 
 the left thigh and interferes with the depression and consequently the 
 application of the female branch, and to avoid this difficulty, he 
 advises the female blade to be the first introduced. His method of 
 application is thus : "Take the female or upper blade in the right 
 hand, and introduce it into the posterior and right side of the vagina, 
 conducting its point as near as may be to the chin, and over the face 
 to the right side of the head behind the pubis, leaving the handle to 
 project toward the left thigh. Next, take the male blade into the 
 right hand, and, turning the concave edge of the new curve down- 
 ward, insert the point into the right side of the vagina, below the 
 female branch. Let the fetal face of the .clamp apply itself to the 
 convexity of the head, and slide it onward, and, in proportion as it 
 enters, make it sweep round the crown of the head toward the back 
 of the pelvis. In effecting this, the handle comes gradually down as 
 the clamp gets on the left side of the cranium, and at last the lock is 
 found to be where it ought to be, namely, under the upper or female 
 blade, with which it is then locked." This, undoubtedly, appears to 
 be the better method of introducing the blades, but, as with all other 
 cases, the practitioner who is well versed in the general principles of 
 these operations will be governed by the peculiar circumstances 
 attending each individual case. 
 
 EIGHT OCCIPITO-TRANSVERSE POSITION. 
 
 In this position the head lies in the direction of the pelvic trans- 
 verse diameter, the occiput resting against the right ischium, and the 
 forehead against the left. The application of the forceps is similar to 
 the preceding, with the exception that the female blade must be
 
 MODE OF APPLYING THE FORCEPS AT THE BRIM. 615 
 
 applied to the right side of the child's head, along the posterior part 
 of the pelvis, while the male blade must be over the left side of the 
 head and behind the pubic symphysis. The male branch is generally 
 the first introduced, though some authors advise the female. As before 
 stated, it will commonly be found more advantageous to enter that 
 blade first, which is of the most difficult application, being particular, 
 however, that the introduction be so managed as to cause no difficulty 
 in the locking. 
 
 The same manipulation will be required, as in the preceding 
 position, excepting that the rotation must be made from right to 
 left, in order to carry the occiput under the pubic arch ; this accom- 
 plished, the labor must be terminated as usual. 
 
 Trouble in locking the forceps is sometimes encountered in occipito- 
 anterior or posterior positions, due to the ends of the blades coming 
 in contact with the maternal sacrum. A lowering of the handles will 
 render it possible* to introduce them higher in the pelvis, and thus 
 readily overcome the difficulty. 
 
 CHAPTER XLV. 
 
 MODE OF APPLYING THE FORCEPS AT THE BRIM IN FACE PRES- 
 ENTATIONS, AND IN PELVIC PRESENTATIONS. 
 
 WHEN the HEAD IS AT THE SUPERIOR STRAIT, the pel- 
 vis being of normal size, and circumstances occur requiring the 
 delivery to be expedited, turning should always be preferred to the 
 use of the forceps. But when the head has engaged in this strait and 
 descended so low as to render the operation of turning impossible, the 
 os uteri being dilatable, and immediate delivery necessary, the long 
 forceps may be frequently employed with advantage, even though the 
 head has not advanced so far within the cavity, as to enable an ear to 
 be felt. They may likewise be applied with benefit in cases where the 
 antero-posterior diameter of the superior strait is only three and one- 
 fourth or three and a half inches, and the natural efforts are insuf- 
 ficient to advance the head. To these conditions, therefore, should 
 the application of the forceps at the brim be limited.
 
 616 KING'S ECLECTIC OBSTETRICS. 
 
 It must not be supposed that an operation at the brim, with this 
 instrument, is an easy one ; on the contrary it is both difficult and 
 hazardous. The position of the head above the brim can not be 
 easily ascertained, and if it could be, it would make but little dif- 
 ference, as the forceps can be applied only along the sides of the 
 pelvis; consequently, the head may be grasped by the blades in its 
 bi-parietal diameter, or in its occipito-frontal, the latter more 
 frequently. The mobility of the head, when not held by the brim, 
 also renders the adjustment of the blades a troublesome matter, and 
 frequently, their hold on the head being imperfect, as soon as tractions 
 are made, they may suddenly slip and seriously injure the cervix. 
 Hence, when it becomes necessary to use the instrument at this 
 point, the operator should proceed carefully and judiciously. 
 
 The diiference between the application of the forceps at the brim, 
 and at the outlet, is, that in the former, the whole hand must be carried 
 within the vagina, and two or three fingers be passed as high up as 
 possible between the cervix and head of the child, and the instrument 
 is. to be introduced along the sides of the pelvis, so that a blade will 
 be applied within each ilium. When properly adjusted they will lock 
 more or less readily, and the handles will be depressed backward as 
 far as possible, that the blades may take the direction of the superior 
 pelvic axis. Sufficient compression should be exerted on the handles 
 to hold the head securely, and the traction should be made, as in the 
 other instances, not by sudden, short jerks, nor by any forcible meas- 
 ures, but by a full, slow, regular motion from handle to handle, making 
 traction in the direction of the axis of the brim. 
 
 If the instrument does not lock readily, no force or twisting must 
 be used to effect it, but the operator should withdraw the blade last 
 introduced and reapply it; and this had better be repeated several 
 times, than to endanger laceration of the cervix or soft parts by 
 forcible and unnecessary endeavors to lock the branches. 
 
 Should the head lie with one parietal protuberance resting on the 
 pubis, and the other on the sacral promontory, the forceps will be 
 applied with one blade over the occiput, and the other over the fore- 
 head, or, perhaps, over the face. Should the traction and lateral 
 motions communicated to the instrument cause the head to take a 
 diagonal position and descend into the pelvic cavity, the blades may 
 be withdrawn, provided the natural efforts are sufficient to conclude 
 the labor; if not, the blades must be readjusted, but this time on the 
 sides of the head.
 
 MODE OF APPLYING THE FORCEPS IN FACE PRESENTATIONS. 617 
 
 If, after having used a justifiable force iu the operation, we find it 
 impossible to advance the head, or at least without exerting a power 
 which would unnecessarily expose the mother to dangers, it then be- 
 comes our duty to either resort to the perforator or Cesarean section ; 
 if the decision is in favor of the perforator, and a delay would not 
 add to the mother's risk, the operator need not act until the steth- 
 oscope determines the child's death. We are never to save the life of 
 the child at the expense of the mother's; and, in most cases, the death 
 of the child can be determined by the stethoscope in sufficient time 
 for the mother's safety, before using the perforator. 
 
 When the occiput is fastened behind the pubis, and the forehead is 
 in front of the sacral promontory, the blades will then pass over the 
 sides of the head ; and when this is ascertained to be the case, the 
 operator may exert more force than before, and probably the difficulty 
 Avill be more readily overcome. When the head is locked at the brim, 
 De\vees advises us after having applied the forceps to first elevate 
 the head, by gently carrying the handles from side to side, at the same 
 time pushing the instrument upward. This may be beneficial in some 
 cases, bat usually, where the operation will prove successful, as the 
 handles are rotated from side to side with sufficient traction, the head 
 disengages, rotates, if necessary, to the oblique diameter, and descends 
 into the pelvic cavity. 
 
 The forceps may sometimes be required in FACE PRESENTA- 
 TIONS, in which case the blades are to be applied over the ears of 
 the child, similar to the manner named in vertex presentations ; being 
 careful so to adjust them as to bring the chin toward the pubic arch. 
 And in all operations when the face presents, the operator should 
 proceed slowly, so as to permit the body to undergo a rotation, and 
 thus prevent a twisting or dislocation of the neck. 
 
 LEFT MENTO-ILIAC POSITION. (Fig. 82.) 
 
 As the chin is the part to be brought to the pubic arch in this posi- 
 tion, the male or lower blade will be passed in front of the sacrum, and 
 over the right side of the child's head, as much as possible in the 
 occipito-mental direction. An assistant holding this, the female 
 branch will be gradually insinuated anteriorly, over the left side of 
 the child's head, and when the two are properly adjusted they will 
 readily lock. The concave edges of the blades will then be directed 
 to the left of the pelvis, and the pivot will look toward the maternal 
 left thigh ; both of these may also be directed upward, if, instead of a
 
 618 
 
 KING'S ECLECTIC OBSTETRICS. 
 
 FIG. 82. complete transverse position, the chin 
 
 is placed somewhat anteriorly, in a line 
 with the oblique diameter of the pelvis. 
 The handles must then be rotated from 
 below upward, and from left to right, 
 gradually bringing the chin, as well as 
 the concave edges of the blades, under 
 the pubic arch : this having been ef- 
 fected, traction must be made directly 
 forward and slightly downward, to free 
 the chin from under the arch, after 
 which the handles must be slowly ele- 
 vated to gradually flex the chin, and 
 which motion causes the head to pass 
 successively over the hollow of the 
 sacrum, perineum, and posterior com- 
 
 missure of the vulva, while at the same time the several parts of the 
 
 face are disengaged in succession. 
 
 EIGHT MENTO- ILIAC POSITION* 
 
 In this position the operation will be very nearly similar to the 
 preceding one ; the female blade will be the first applied along the 
 
 * MENTO-PUBIC POSITION. 
 
 The chin being placed at the symphysis pubis, and the forehead at the sacrum. In 
 this position, or when the face has assumed it, the head having descended into the 
 pelvic cavity and performed its movement of rotation, the forceps may be more easily 
 applied than in the two preceding positions. The male blade must be applied along 
 the left side of the pelvis, grasping the right side of the child's head, and the female 
 blade must be passed along the right side of the pelvis to grasp the left side of the 
 child's head. Traction forward and slightly downward must then be made, to disen- 
 gage the chin from under the pubic arch, after which, elevate the handles, thereby 
 effecting at the same time flexion and the liberation of the head. Indeed, this is but 
 a repetition of what has already been stated above; but, as a matter of reference, il 
 has been deemed better to retain it. 
 
 MENTO-SACRAL POSITION. 
 
 The chin being placed at the sacrum, and the forehead at the symphysis pubis. 
 This is a position with which I have never met; and were it not that cases have been 
 recorded by individuals of eminence and undoubted authority, I should be very much 
 inclined to doubt the possibility of its occurrence, except, perhaps, in case of a very 
 small child passing through an exceedingly large pelvis. 
 
 However, should such a position be met with, requiring the use of the forceps, it is 
 recommended to introduce the male blade along the left side of the pelvis and on the 
 left side of the child's head, and the female blade along the right side of the pelvis on
 
 MODE OF APPLYING THE FORCEPS IN FACE PRESENTATIONS. 619 
 
 posterior part of the pelvis to the left side of the child's head, while 
 the male blade will be carefully guided over the right side. When 
 correctly adjusted, they will lock, the pivot being directed toward the 
 mother's right thigh. Rotation may be made from below upward and 
 from right to left, until the chin is brought to the pubic symphysis, 
 when the rest of the operation will be the same as in the one previous. 
 In each of these mento-iliac positions, should the face not have 
 arrived at the inferior strait, it will be proper to conduct it there by 
 tractions and lateral motions, the same as in vertex presentations; after 
 which operate as recommended. Some authors reverse the order of 
 introducing the blades, preferring to use the male blade first, in the 
 right mento-iliac position, and the female, first, in the left mento-iliac. 
 The operator will employ his own judgment in this matter, always 
 bearing in mind the rule to enter the blade of more difficult applica- 
 tion first. 
 
 The FACE MAY BE ABOVE THE SUPERIOR STRAIT, 
 
 and movable. If the methods heretofore advised for changing it to 
 a vertex presentation do not succeed, and pelvic version can not be 
 accomplished, it has been recommended to attempt the delivery by the 
 forceps. This, however, will more frequently be found impracticable, 
 the perforator being required in the majority of instances. When the 
 head is thus situated above the brim, the face usually presents in a 
 transverse direction, and the forceps would have to be applied with, 
 one blade over the forehead and top of the head, and the other over 
 the chin, pressing upon the child's neck ; so that, beside the danger of 
 the blades slipping from these parts, any efficient degree of compression 
 or traction would almost certainly occasion the death of the child. 
 
 The same may be said of those cases where the HEAD HAS 
 PARTLY ENTERED THE SUPERIOR STRAIT; but there is a 
 greater possibility of success, if the blades can be applied n.pon the 
 sides of the head ; in which case the mode of application will be the 
 same as in the preceding face positions. In each of the above condi- 
 tions it will be necessary to introduce the whole hand within the 
 vagina, as a guide to the forcep-blades. 
 
 In the last condition, the head being partly within the cavity and 
 
 the right side of the head. When properly adjusted, the handles will be strongly 
 depressed against the perineum. The face having reached the outlet, the handles 
 must at first be elevated so as to pass the chin over the perineum and posterior com- 
 missure; this having been accomplished, depress the handles, which, with a degree of 
 traction, will flex the chin, and disengage the head from its position at the pubes.
 
 620 KING'S ECLECTIC OBSTETRICS. 
 
 partly within the brim, but with the CHIN DIRECTED TO THE 
 SACRUM, and it being impossible to change the position to a vertex 
 presentation, or to accomplish pelvic version, it has been recom- 
 mended to slowly and carefully rotate the chin to the pubis, as the 
 head is made to descend by the forceps. I consider this not only a 
 difficult task, but almost an impossibility, at least as far as safety to 
 the child is concerned; and, as a general rule, when it becomes neces- 
 sary to expedite delivery in these cases, I believe it will be found that 
 the perforator will ultimately be required before the labor can be 
 terminated. 
 
 In PELVIC PRESENTATIONS, or in cases where pelvic version 
 has been performed, it not unfrequently occurs, that after the expul- 
 sion of the body, there is a delay or difficulty attending the delivery 
 of the head, in which cases, should the accoucheur not be able to 
 remove the obstruction by flexing the head with his hand, as hereto- 
 fore described, he will have to employ the forceps. Hence, as a very 
 short delay may prove fatal to the child, the most prudent course to 
 adopt, in all these labors, is to have the instrument at hand at as early 
 a period as possible, after their character has been ascertained. 
 
 In these labors, the head may be found in one of two positions, 
 viz.: with the occiput to the pubic arch, and the face in the hollow of 
 the sacrum, and which is always the most desirable position ; or, with 
 the face to the pubis and the occiput in the hollow of the sacrum a 
 most undesirable position. If the forceps be required to deliver the 
 head, the rules for operating are similar to those given in vertex pre- 
 sentation, thus: 
 
 OCCIPITO-PUBIC POSITION. 
 
 In which the occiput is to the pubis, and the face to the sacrum. 
 Carefully envelop the arms and body of the child in a -napkin, and 
 carry it upward, or toward the mother's abdomen, but not so far as to 
 endanger its neck ; then, let an assistant hold the child in this position, 
 that its body may not be in the way of the operator. The latter 
 having introduced two or three fingers of his right hand along the 
 inferior and left side of the vagina, as a guide to the forcep-blades, 
 will, with his left hand, carefully apply the blade of the male branch 
 upon the right side of the child's head. Then intrust this to the care 
 of an assistant, who will depress it somewhat to permit the applica- 
 tion of the female blade. This will be introduced, being held by the 
 right hand, and guided by the fingers of the left hand, along the
 
 MODE OF APPLYING THE FORCEPS IN PELVIC PRESENTATIONS. 621 
 
 inferior and right side of the vagina, and thence upon the left side 
 of the head. When properly applied, the forcep-blades will grasp 
 the head in its occipito-mental diameter, and will lock readily. 
 Holding the instrument in the manner heretofore recommended, the 
 operator will commence his tractions and oscillatory movements, and 
 as the head emerges the handles must be gradually elevated, the same 
 as in occipito-anterior positions, by which the chin, face, forehead, 
 and vertex, successively, pass over the perineum and posterior com- 
 missure, and the delivery will be thus terminated. 
 
 Should the occiput be directed to the left, or right lateral-anterior 
 portion of the pelvis, the operator will be governed by the above 
 rules, as well as those named for occipito-anterior positions, being 
 careful to so introduce the blades, that, at the termination of the 
 delivery, their concave edges, together with the child's occiput, will 
 be brought under the pubic arch. 
 
 OCCIPITO-SACEAL POSITION. 
 
 In which the face is to the pubis, and the occiput to the sacrum. 
 This is a very unfortunate position, and one which may prove very 
 painful to the female, and troublesome to the practitioner. Although 
 it is more frequently the result of ignorance, or want of skill, on the 
 part of the accoucheur, yet it will sometimes occur in the hands of 
 the most skillful. In this position, the body of the child being en- 
 veloped in a cloth, as before, must be carried backward, so that its 
 back will rest against the perineum of the mother. The blades are 
 introduced as in the previous position, in front of the child's thorax, 
 the male blade along the left side of the pelvis, and on the left side 
 of the child's head, and the female blade along the right side of the 
 pelvis, and on the right side of the child's head. The instrument 
 being properly applied, and the head brought to the outlet, instead of 
 elevating the handles to pass the occiput over the perineum, they must 
 be strongly depressed downward, with sufficient traction, so as to 
 cause the chin, face, forehead, and vertex to pass successively from 
 under the pubic arch, while at the same time the occiput is made to 
 revolve on its axis, in front 'of, and upon the perineum. 
 
 If the occiput be directed to the left, or right lateral-posterior 
 portion of the pelvis, the above rules, together with those given in 
 occipito-posterior positions, will be sufficient to guide the educated 
 practitioner. 
 
 In addition to the preceding instances, the forceps have been found
 
 <622 KING'S ECLECTIC OBSTETRICS. 
 
 occasionally advantageous in irregular presentations of the head, as of 
 the ear, forehead, etc., in which manual endeavors to correct the 
 position have failed; and also in some cases of diminished size of the 
 diameters of the inferior strait. Whatever circumstances may present 
 during labor, requiring a resort to the forceps, the practitioner will 
 apply them according to the peculiar nature of the case, being, how- 
 ever, always governed by the rules already explained. 
 
 CHAPTER XLVI. 
 
 CRANIOTOMY PERFORATOR CROTCHET CESAREAN OPERATION 
 
 SYMPHYSEOTOMY. 
 
 CRANIOTOMY is an operation by which the life of the child is 
 destroyed, for the purpose of preserving that of the mother; it is also 
 employed in some cases when the child is dead. The terms embry- 
 ulcia, embryotomy, and cephalotomy, have been applied to this 
 operation; while the terms evisceration, exvisceration, and exenter- 
 ismus, have reference to the removal of the contents of the trunk. 
 
 As has been heretofore named and repeated, the safety of the mother 
 is the first and essential consideration in the practice of obstetrics, and 
 if, in order to insure this, it becomes necessary to sacrifice the child, 
 however painful or revolting to the feelings of the operators this 
 unpleasant task may be, he must not shrink from his duty, nor hesitate 
 to adopt every measure in consonance with the preservation of his 
 patient. Beside, it must be recollected that the death of the child is 
 certain, in cases where craniotomy is admissible ; it can not be saved 
 by any means, unless we except the Cesarean operation, which proves 
 fatal, on an average, to the child once in every 3J cases to the mother 
 once in every 2. The operation of craniotomy is not to be under- 
 taken heedlessly, nor without due consideration, and a proper consul- 
 tation with one or more experienced accoucheurs; and is only to be 
 attempted when both mother and child would be destroyed, were the 
 labor left to the natural efforts, and when version, or delivery by the 
 forceps can not be accomplished, and the pelvic diameters are sufficiently 
 spacious to permit the extraction of the mutilated infant. 
 
 According to Churchill, craniotomy has been performed in British 
 practice 270 times in 54,485 cases of labor, or about 1 in. 201f ; in
 
 CRANIOTOMY. 623 
 
 French practice 30 times in 36,169 labors, or 1 in l,205f ; in German 
 practice 132 times in 256,655 labors, or 1 in 1,944J; making a total 
 of 347,309 labors, in which the operation was performed in 432, or 
 about 1 in 803f. The results to the mother have been 60 de.aths in 
 303 craniotomy cases, or about 1 in 5. The operation, therefore, as 
 compared with the employment of the forceps, is less favorable ; and 
 much of this mortality may be owing to the fact, that the feeling and 
 humane obstetrician being unwilling to take the life of the child, even 
 in so justifiable a cause, has hesitated to perforate until assured of its 
 death ; and the delay thus occasioned has rendered the operation much 
 more unfavorable to the mother, than if it had been earlier undertaken. 
 
 Perforation of the fetal skull is generally advised in cases of dimin- 
 ished pelvic diameters, but the degree of this diminution is not posi- 
 tively settled. Thus, Dr. Osborn considers the operation necessary 
 when the antero-posterior diameter is not less than 2f inches. The 
 smallest diameter through which a living child can pass, is stated by 
 Dr. Clarke, to be 3 J inches ; by Dr. Burns 3J ; by Dr. Le Eoy 3J ; by 
 Dr. Atkin 3; by Dr. Ritgen 2; these differences of opinion have, 
 probably, resulted from the various sizes of the fetal heads met with 
 by each practitioner, as well as their degree of skillfulness in the 
 application and use of the forceps. Within a few years past, in many 
 instances of pelvic deformity in which perforation of the head would, 
 previously, have been undertaken, turning has been successfully 
 employed, and the degree of measurement of the pelvic antero- 
 posterior diameter in which craniotomy may be performed, is at this 
 day, placed at from 1J to 2f inches. 
 
 As a general rule, where tjtie superior antero-posterior diameter of 
 the pelvis is contracted to about three and a half inches, and when the 
 forceps fail to extract the fetal head, this being of usual size, the per- 
 forator will be required ; though it must be remembered, that with 
 such a pelvic measurement, there is a possibility of extraction by 
 turning, or, with the forceps. But when the extent of this small 
 diameter is reduced, to two and three-quarter inches, the forceps can 
 usually be of no avail, and craniotomy will necessarily be required. 
 When the pelvic contraction is extraordinarily great, it will be impos- 
 sible to extract even a mutilated child, in which case, the Cesarean 
 operation is recommended. Dewees considers the operation of crani- 
 otomy inadmissible where the diameter measures only two inches; 
 Baudelocque limits it to one and two-thirds of an inch ; and Davis, 
 to one inch. The limit named by Baudelocque is probably the most 
 correct.
 
 624 KING'S ECLECTIC OBSTETRICS. 
 
 Craniotomy may be performed in all cases of deformed pelvis 
 whether of the cavity or of the straits, in which delivery can not be 
 effected naturally, by turning, or by the forceps ; in cases of pelvic 
 tumors er other abnormal growths, which present an obstacle to the 
 expulsion of the child by other means either natural or artificial; in 
 cases of tedious and painful labor, when the child is dead, and can not 
 be removed by the forceps ; in cases of hydrocephalus, when the head 
 can not pass through the pelvis ; in cases of ruptured uterus, hemor- 
 rhage, convulsions, etc., where the life of the woman is endangered, 
 requiring immediate delivery, and where it is impossible to use the 
 forceps ; in cases where an extremity descends along with the head, 
 causing an impaction which can not be overcome by the forceps ; in 
 pelvic labors, when, after the expulsion of the body, the head can 
 not be extracted by the forceps ; in cases where the head, remaining 
 within the pelvis, has been separated from the body ; and, in all cases, 
 where from exhaustion, irregular vertex presentations, or other con- 
 ditions, the patient is placed in imminent danger, and in which the 
 forceps can not be applied, or, in which the circumstances of the case 
 centra-indicate their employment, as well as that of version. 
 
 The practitioner who undertakes the operation of craniotomy, must 
 not be too hasty in his conclusions, nor in his attempts at operating 
 he must be positive that it is imperatively necessary, especially if the 
 child be living to destroy a living child, without undoubted evidence 
 that no other method will save the mother's life, is a criminal act it 
 is murder. When the uterine contractions have been powerful and 
 long continued, without any advance of the head, he will be justified 
 in terminating the labor by the forceps, -if possible, or if not, by the 
 perforator and crotchet. The same may be said, in cases where, from 
 exhaustion, uterine inertia, or other causes, endangering the mother, 
 and when there is little or no hope for the preservation of the child, 
 the forceps are contra-indicated. Nor should the operator hesitate to 
 act at once, in those cases where he clearly ascertains at an early period 
 that the child can not be delivered except by craniotomy as, for 
 instance, in an enormous hydrocephalic head, in a small pelvis, in a 
 large head firmly ossified, etc. To delay the operation in these cases 
 until dangerous symptoms manifest themselves, would be to unjustly 
 compromise the mother's life while prompt action, when her system 
 has not yet become depressed, and is capable of more securely with- 
 standing the shock of the operation, will be the wiser and more pru- 
 dent course. 
 
 In cases requiring immediate interference, at an early period of
 
 CRANIOTOMY. 
 
 625 
 
 FIG. 83. 
 
 labor, the operation must not be attempted until the os uteri is suffi- 
 ciently dilated and fully dilatable. In all other cases we must be 
 governed by the circumstances connected with them, 
 making endeavors to deliver by the forceps if there 
 is the slightest chance of these being made available. 
 The instruments used in the operation of crani- 
 otomy are the perforator, or Smellie's perforating 
 scissors, and the crotchet. Professor Meigs recom- 
 mends the use of a perforating trocar or drill (see 
 Fiy. 86), made especially for this purpose; by the 
 use of this instrument we bore through the skull, 
 after which the opening is enlarged by a knife se- 
 creted in the handle, and acted upon by a spring; 
 and, instead of the crotchet, he has invented two 
 
 FIG. 85. 
 FIG. 84. 
 
 SIMPSON'S CKANIOCLAST. 
 
 embryotomy forceps, one of 
 which is straight, and the other 
 curved; each of these are ser- 
 . rated on their inner jaws, to 
 enable them to take a very sure 
 and strong hold upon the cranial 
 bones, and are rounded on their SIMPSON' s PEBFOKATOE. SMELLIE'S PERFORATOR. 
 
 sides, in order to prevent them from taking hold of any of the mater- 
 nal tissues. These he considers superior to, and much safer than, the 
 40
 
 626 
 
 KING'S ECLECTIC OBSTETRICS. 
 
 ordinary perforating scissors and crotchet. Other instruments 
 have been presented to the profession, as the cephalotribe, crani- 
 oclast, cutting hook for decollation, or amputating limbs, etc., but 
 thry are rarely employed, though some of them are very useful. 
 The cephalotribe is for grasping and crushing the fetal head, includ- 
 ing its base, and is undoubtedly of value in cases where it becomes 
 necessary to diminish the size of the head. It does not expose the 
 female to the risks of following the use of the crotchet, does not 
 
 THOMAS' PERFORATOR. 
 
 require the fatiguing efforts of craniotomy, and can be employed in 
 cases where this operation could not be successfully performed. There 
 are several varieties of this instrument before the profession, the best 
 of which are Lusk's (Fig. 87), Simpson's, Hicks', Kidd's and Lazare- 
 witch's. Its use, however, has not come fully into practice, though 
 medical men are beginning to appreciate its usefulness, under the im- 
 proved forms that have more recently been given to it. The crani- 
 otomy or embryotomy forceps are very useful in dislodging the head 
 after the skull has been perforated. 
 
 LUSK'S CEPHALOTRIBE. 
 
 The dangers to which craniotomy exposes a female are, injury to 
 the vagina or uterus, from slipping of the perforator or crotchet; 
 laceration of the perineum, from the employment of improper extract- 
 ing force; subsequent tendency to inflammation of the vagina or uterus ; 
 perforation of the bladder, especially when the operation has been 
 carelessly or too forcibly performed; and the shock to the nervous 
 system is usually much greater than in turning, or in the use of the 
 forceps. Instances have occurred where, from a neglect to completely
 
 CRANIOTOMY. 
 
 027 
 
 FIG. 89. 
 
 break clown the brain and medulla oblongata, the child has been 
 born breathing and even crying. 
 
 MODE OF OPERATING. Previous to operating, the bladder 
 and rectum of the patient must be thoroughly evacuated. Then she 
 must be placed in the position named for a forceps operation, with the 
 hips over the edge of the bed, and some cloths under her to receive 
 FIG. 88. the pieces of brain, etc., which are 
 
 discharged. An assistant should 
 pluee his hands upon the abdomen, 
 and maintain them there, during 
 the whole of the operation, to fix 
 and steady the uterus. Anaesthesia 
 should be produced, if the patient 
 be in a condition not contra-indi- 
 cating it; some writers entertain 
 objection to it, from the fact that 
 extensive injury might be done to 
 the maternal tissues while she lies 
 in an unconscious state, and no 
 timely warnings could be made, to 
 announce to the operator when 
 the danger from this circumstance 
 commenced ; no such accident, how- 
 ever, is likely to attend the manip- 
 ulation of the careful operator, while 
 with its administration the dread 
 of the operation is largely over- 
 come, as well as the mental suffer- 
 ing and unpleasant after-thought. 
 Introduce two fingers of the left 
 hand within the vagina, and carry 
 them upward until they come in con- 
 tact with the part to be perforated. 
 This should be the most depending portion of the head, and a suture 
 or fontanelle should be avoided, because after the perforation is effected 
 in one of these, the opening becomes closed from a collapse of the 
 cranial bones, which will prevent the discharge of cerebral matter. 
 Then carry the perforator, which must be warmed and greased, care- 
 fully along the inside of the fingers, being particular not to injure any 
 of the parts of the mother, until the sharp point comes in contact 
 (perpendicularly) with the part selected for the incision. 
 
 SIMPSON'S 
 
 CRANIOTOMY 
 
 FORCEPS.
 
 628 
 
 KING S ECLECTIC OBSTETRICS. 
 
 FIG. 90. Still guarding the instru- 
 
 ment from slipping or injur- 
 ing the mother, press it firmly 
 but moderately against the 
 fetal skull, at the same time 
 giving to it a rapid boring or 
 semi-rotatory motion ; a few 
 motions -will suffice to pierce 
 the bone, which may be 
 known by the cessation of any 
 further resistance. (Fig. 90.) 
 Then push up the scissors 
 until the shoulders or rests at 
 the base of each blade prevent 
 their further advance. Hold- 
 ing one branch of the instru- 
 ment firmly, with the thumb 
 passed into its eye or ring, 
 the fingers of the other hand 
 still ' protecting the mother 
 from injury, by being placed 
 upon the elbows or rests as 
 they move, to ascertain that they do not leave the skull an assistant 
 will take hold of the other branch, and separate it from its fellow to 
 an extent of three inches, and which will cause the blades to make 
 an incision about an inch long. (Fig. 91.) 
 
 Then, without withdrawing the instrument from the vagina, turn it 
 round, and place its point upon the outer surface of the skull, so as to 
 form another incision at right angles with the first, and crossing it, 
 and which is to be done in a similar and guarded manner, as before. 
 This having been accomplished, pass the blade through the crucial 
 incision, within the skull, and thoroughly break down the brain, by 
 alternately opening and shutting the blades, and turning them rapidly 
 round in various directions; and be sure to cut across the medulla 
 oblongata, so as to completely destroy the life of the child. The 
 scissors will now be withdrawn, together with the fingers covering 
 their cutting edges. 
 
 If there exists no necessity for immediate delivery after the destruc- 
 tion of the brain, the operator may wait a reasonable time to ascertain 
 whether the natural powers will be sufficient to terminate it. But if
 
 CRANIOTOMY. 
 
 029 
 
 the operation has been commenced after symptoms of exhaustion or 
 other serious symptoms have manifested themselves, he will proceed, 
 without delay, to finish the labor. 
 
 Reintrodueing the fingers of the left hand, the crotchet, having been 
 previously warmed, must be passed along them into the cranium, and if 
 the breaking down of the cerebral F IG< m 
 
 mass was not completely effected by 
 the scissors, it may now be by the 
 crotchet. After which, insert the 
 point of the crotchet on the internal 
 surface of the bone, keeping a finger 
 of the left hand upon the head exter- 
 nally, and opposite to the inserted 
 point of the instrument, in order to 
 cover it, and prevent injury to the 
 maternal parts, should it slip, or break 
 through the bone. (Fig- 92.) Pro- 
 tecting the surrounding parts from 
 injury, by folding the scalp over the 
 edges of the bones, the practitioner 
 will, by a gradual, steady, downward 
 force, applied in the direction of the 
 axis of that part of the pelvic cavity 
 at which the head may be placed, 
 commence the extraction of the bones. 
 He must not pull by jerks, or he will 
 fracture the bones, and the traction 
 must be made during the pains, or, if 
 these are absent, they should be im- 
 itated by allowing intervals from time to time during the extraction. 
 Whenever the boue breaks under the crotchet point, this must be 
 applied to some other resisting part of the skull. 
 
 Frequently the bones will break and come away by pieces, and then 
 great care should be observed in removing them, whether by the 
 fingers or the bone forceps made for this purpose. If the head does 
 not pass readily, or if a secure purchase can not be made with the 
 crotchet, the craniotomy forceps should be used ; or, if delay be not 
 contra-indicated, the structures .will become weakened after some 
 hours, which will render them of more easy extraction. But I con- 
 sider prompt delivery, after perforation of the skull, the better and 
 safer method in all cases.
 
 630 
 
 KING'S ECLECTIC OBSTETRICS. 
 
 FlG - 92 - If much delay follows the perfora- 
 
 tion of the skull, the crauiotomy 
 forceps should be called into service 
 at once ; they are to be used by pass- 
 ing one blade upon the inner surface, 
 and the other upon the outer surface 
 of the skull, so as to take a firm and 
 secure hold, and then make traction 
 at intervals, the same as with the 
 crotchet. (Fig. 93.) After the birth 
 of the head, it should be covered 
 with a cloth, and if there be a delay 
 in the advance of the shoulders, trac- 
 tion may be made upon the neck in 
 the direction of the axis of the brim, 
 or a blunt hook may be passed under 
 one or each axilla, to facilitate their 
 expulsion. Sometimes the trunk 
 will not advance, when it will be- 
 cdme necessary to perforate the chest 
 
 and remove its contents, as well as those of the abdominal cavity, 
 extracting the ribs by the crotchet, somewhat similar to the removal 
 of the cranial bones. 
 
 In case of a separation of the head 
 from the body, the latter being delivered, 
 the forceps will require to be applied in 
 order that the head may be held firmly, 
 while the perforator is being used to re- 
 duce its size. 
 
 After the operation, keep the patient 
 quiet, overcoming the nervous shock by 
 the continuation of the anaesthetic, or 
 after a reasonable time a quarter-grain of 
 Morphia may be administered, or a five- 
 grain dose of the compound powder of 
 Ipecacuanha and Opium, or some similar 
 preparation, and the vagina may be oc- 
 casionally cleansed by injections of warm 
 water. Should symptoms of inflamma- 
 tion set in, promptly remove them by the 
 proper measures. 
 
 FIG. 93.
 
 CESAREAN OPERATION. 631 
 
 CESAKEA.N OPERATION. The Cesarean section, or hysterot- 
 oiny, is a less favorable operation to the mother than either of the 
 preceding, and, consequently, is never to be attempted for the purpose 
 of delivering the child, except as a last resource. Though a simple 
 operation, it is exceedingly dangerous, and should never be under- 
 taken except upon justifiable grounds. According to statistics which 
 are hardly reliable, from the fact that the cases reported are generally 
 the successful ones, a number of the unsuccessful being suppressed 
 about one mother in two and one-third is saved, and about one child 
 in three and one-third. 
 
 The operation is resorted to with a view of effecting delivery with 
 safety to the mother and her offspring, in those cases, where it is 
 impossible to deliver through the natural passages, either by the 
 forceps or perforator. In a pelvis whose superior antero-posterior 
 diameter does not exceed one and a half inches, it will be almost, if 
 not quite impossible, to extract even a mutilated child, without 
 powerful efforts, exposing the mother thereby, to at least as serious 
 results, as would be likely to follow this section. And in such cases 
 the operation will be required whether the child be alive or not. 
 Mollities ossium, or the presence of tumors or other abnormal growths 
 within the pelvis, reducing its diameters, and preventing the advance 
 of the child ; may render a resort to this operation necessary, especially 
 when they can not be removed or lessened in size, by other means,, 
 heretofore referred to. 
 
 When the mother has died suddenly during labor, the child being 
 still alive, the Cesarean operation has frequently been the means of 
 saving it; and in order to afford it every opportunity of being saved, 
 the operation should be performed as promptly as possible. Cases 
 are cited in which the living child has been delivered in this manner 
 in from ten to fifteen minutes after the death of the mother. 
 
 The dangers to which the Cesarean section exposes the female are, 
 hemorrhage, both from the uterine and abdominal blood-vessels, 
 though fatality from this cause occurs less frequently than was for- 
 merly supposed; subsequent inflammation of the uterus, or peritonitis; 
 death from the shock to the nervous system; and, strangulation of a 
 portion of the intestines, which may be held between the lips of the 
 external incision, or that made in the uterus. 
 
 The earlier the operation is performed, the more favorable will it 
 be for the mother, because her strength will be less impaired than 
 after a prolonged uterine action; and in cases where it is positively 
 known that the operation must be performed before delivery can be
 
 632 KING'S ECLECTIC OBSTETRICS. 
 
 effected, it should be undertaken at the commencement of labor. The 
 period named by authors as the most favorable for operating, is after 
 full dilatation of the uterus and before the rupture of the membranes, 
 and the longer the operation is delayed after this has taken place, the 
 more unfavorable will it be for the mother. 
 
 Several cautions are given, by those who have performed the opera- 
 tion, which it is necessary to be mindful of; according to Ramsbotham, 
 these are : 1st, to avoid dividing the tendinous expansion of the recti 
 muscles forming the linea alba, because from its low degree of organ- 
 ization it would not be so apt to heal as kindly as the must-le itself; 
 2d, to avoid making the incision so far toward the side as to run the 
 risk of wounding the epigastric artery; 3d, to expose the naked surface 
 of the uterus no longer than is absolutely required, being especially 
 careful to handle the organ as little as possible ; 4th, to avoid making 
 the incision at the side of the uterus, or at that part of the organ to 
 which the placenta is attached, on account of its being the most vascu- 
 lar part, and which may be ascertained by the stethoscope ; 5th, to 
 avoid wounding the child when incising the uterus; 6th, not to allow 
 much time to elapse between the extraction of the child and that of 
 the placenta; 7th, be especially careful that none of the intestines 
 become included with the lips of either incision, as the risks of strangu- 
 lation would be added to those of the operation. 
 
 Recent reports indicate that nearly seven thousand children are 
 sacrificed annually in the United States by embryotomy; this fact, 
 together with the progress and improvement of modern surgical 
 operations, has inclined many of the best known surgical obstetricians 
 to seek ways and means to overcome this terrible destruction of 
 human life. Premature delivery and abdominal section are the only 
 alternatives to be considered. It is now claimed, by several of the 
 most prominent writers on the subject, that in view of the diminished 
 death rate following the improved Sanger-Cesarean operation, crani- 
 otorny upon the living child is never justifiable. That the child's 
 interests are deserving of some consideration along with those of the 
 mother there can be no doubt, in cases" where the disproportion 
 between the head and pelvis will not admit of natural delivery ; but 
 I can not concur in the belief that relief should always be sought in 
 abdominal section, or, in other words, that craniotomy, under such 
 circumstances, is never justifiable. The condition of the mother 
 should always govern our action in such cases; owing to this fact, 
 the means of relief can not be looked upon as' operations of election.
 
 CESAREAN OPERATION. 
 
 633 
 
 In correspondence with Prof. William H. Watheu, of Louisville, an 
 able supporter of abdominal section, I have been able to glean the 
 following from an article recently written by him. The results of both 
 the Sanger-Cesarean and Porro-Cesarean are given, as well as the 
 indications for each. He refers me to a recent contribution to the 
 American Journal of Obstetrics, in which, after considering the subject 
 of Craniotomy, he goes on to say : 
 
 "Let us now briefly consider the results to mother and child where 
 the alternatives [to craniotomy] have been adopted. We will not 
 waste time considering the old statistics of Cesarean section, where 
 the operation was performed crudely, with none of the modern or 
 more successful modifications, and generally only as a Vernier resort, 
 for in such cases it is not possible to get good results. Xor will we 
 consider the results of laparo-elytrotomy ; for this operation is too 
 complicated for general adoption, and in the practice of expert 
 operators has not given as good results as the improved Cesarean 
 section or Porro's operation. Xor is it hardly fair to include the 
 statistics of the improved Cesarean section or Porro's operation in the 
 United States, for nearly all these operations have been done after 
 exhausting all other means, with the women nearly dead, and seldom 
 as operations of election. 
 
 "The following are the most complete statistics available on the 
 improved Cesarean section, Porro's operation, and the induction of 
 premature labor, for which I am largely indebted to the courtesy of 
 Dr. R. P. Harris, of Philadelphia : 
 
 PORRO-CESAREAN OPERATIONS. 
 
 No. 
 
 Countries. 
 
 Operators. 
 
 Localities. 
 
 Cases. 
 
 Women 
 Saved. 
 
 Women 
 Lost. 
 
 1 
 
 Italy 
 
 52 
 
 35 
 
 92 
 
 48 
 
 44 
 
 2 
 
 Austria 
 
 15 
 
 7 
 
 61 
 
 43 
 
 18 
 
 3 
 
 Germany 
 
 27 
 
 18 
 
 43 
 
 99 
 
 -> 1 
 
 4 
 
 France 
 
 9 
 
 
 17 
 
 6 
 
 11 
 
 5 
 
 England 
 
 10 
 
 t) 
 
 12 
 
 5 
 
 7 
 
 6 
 
 Russia 
 
 G 
 
 4 
 
 10 
 
 
 
 7 
 
 United State? 
 
 9 
 
 
 9 
 
 9 
 
 
 8 
 
 Belgium 
 
 4 
 
 ., 
 
 5 
 
 3 
 
 9 
 
 9 
 
 Scotland 
 
 4 
 
 9 
 
 5 
 
 1 
 
 4 
 
 10 
 
 Switzerland 
 
 9 
 
 9 
 
 4 
 
 3 
 
 1 
 
 11 
 
 Holland 
 
 9 
 
 9 
 
 9 
 
 1 
 
 1 
 
 12 
 
 Australia 
 
 9 
 
 9 
 
 9 
 
 9 
 
 
 
 13 
 
 Spain ^ 
 
 1 
 
 1 
 
 1 
 
 
 
 1 
 
 14 
 
 Mexico *. 
 
 1 
 
 1 
 
 1 
 
 o 
 
 1 
 
 15 
 
 Japan 
 
 1 
 
 1 
 
 1 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 265 
 
 144 
 
 121
 
 634 
 
 KING'S ECLECTIC OBSTETRICS. 
 SANGER-CESAREAX OPERATION. 
 
 N,-. 
 
 Countries. 
 
 Operators. 
 
 Localities. 
 
 Cases. 
 
 W071H'I1 
 
 Saved. 
 
 Women 
 Lost. 
 
 1 
 
 Germany 
 
 44 
 
 00 
 
 92 
 
 79 
 
 
 
 
 Austria 
 
 13 
 
 7 
 
 :;_' 
 
 28 
 
 6 
 
 3 
 
 United States 
 
 24 
 
 13 
 
 32 
 
 15 
 
 17 
 
 4 ' 
 
 Russia 
 
 7 
 
 5 
 
 10 
 
 
 3 
 
 5 
 
 Holland 
 
 5 
 
 5 
 
 9 
 
 9 
 
 o 
 
 <; 
 
 Italy . 
 
 3 
 
 3 
 
 7 
 
 5 
 
 > 
 
 
 France 
 
 9 
 
 1 
 
 4 
 
 2 
 
 .> 
 
 8 
 
 England 
 
 3 
 
 9 
 
 3 
 
 1 
 
 9 
 
 9 
 
 India 
 
 1 
 
 1 
 
 >> 
 
 1 
 
 1 
 
 10 
 
 Switzerland 
 
 2. 
 
 1 
 
 n 
 
 1 
 
 1 
 
 11 
 
 Denmark 
 
 1 
 
 1 
 
 1 
 
 . l 
 
 o 
 
 
 
 
 
 
 
 
 
 
 
 
 194' 
 
 147 
 
 47 
 
 "It will thus be seen that Porro's operation has saved, in all 
 countries, 54.33 per cent, of the mothers, and 82.77 per cent, of all 
 children, or 137.10 lives out of 200 involved, while the improved 
 Cesarean section has saved 75.77 per cent, of the mothers, and 93 81 
 per cent, of the children, or out of a total of 200 lives has saved 
 169.58 lives. But if we properly exclude the improved Cesarean 
 operations in the United States, 81.48 per cent, of all the mothers 
 were saved; thus saving, out of 200 lives, 175.29 lives. The above 
 is conclusive that Porro's operation can not be substituted, only in 
 exceptional cases, for Cesarean section, unless future results materially 
 change the statistics." 
 
 In closing the article, Dr. Wathen speaks of the conditions in 
 which the Pdrro operation should be preferred,- I quote his words as 
 follows: "That the Porro operation is preferable to the Cesarean 
 section, in some cases, no one will deny, and Sanger gives the follow- 
 ing indications for its performance: 
 
 " 1. When the discharge of lochial secretions is rendered difficult or 
 impossible per vias naturales i. e., by stenoses and artesise of the cer- 
 vix and vagina, or by tortuosity and compression of the soft obstetric 
 canal due to a tumor not belonging to the uterus. 
 
 " 2. By pregnancy in the closed-up half of a uterus-bicornis, in 
 which delivery is preferably effected by establishing an artificial 
 opening toward the open half (strictly speaking, this is not a true 
 Porro operation, since the remaining half of tke uterus may be again 
 impregnated). 
 
 "3. When the infection of the corpus uteri is evident.
 
 CESAREAN OPERATION. 635 
 
 "4. After repeated classical sectio Csesaria. 
 
 " 5. By serious osteomalacia. 
 
 "When delivery per vias naturales is prevented by uterine or 
 abdominal tumors, the alternative to craniotomy is to remove the 
 tumors, if it is possible to do so, otherwise the Porro operation is the 
 proper alternative. Porro's operation is also indicated in a ruptured 
 uterus, where the rent extends through all the coats, whether the 
 child is in the abdominal cavity, the uterus, or has been delivered. 
 If the blood, the bloody serum, and liquor amnii be thoroughly 
 removed from the peritoneal cavity before decomposition or inflam- 
 mation, the operation offers but few additional dangers and removes 
 many. But the operation should be done immediately, for all the 
 pathological changes are against the late operation. The woman may 
 have recovered from the shock, but adventitious sacs, plastic adhe- 
 sions, etc., will have formed, will prove troublesome, and will prevent 
 success. 
 
 MODE OF OPERATING. Having previously emptied the 
 bladder and rectum, the female is to be placed upon her back, with 
 her shoulders and head elevated by pillows; she may be in bed, or 
 upon a table with a mattress on it, and may lie lengthwise, or with 
 her hips brought to the edge of the bed, the feet hanging down 
 toward the floor. A table is always preferable, and can be easily im- 
 provised by preparing the common table, found in every house, and 
 covering it with blankets and comforters, as need be, to make it com- 
 fortable. Ramsbotham advises the temperature of the room to be 
 brought to at least 80 Fahrenheit, and properly disinfected; sulphur- 
 ous acid gas, generated by burning sulphur, answers every purpose. 
 In order to avoid injury to any of the uterine appendages, the uterus 
 must be brought in the median line, and kept there by the hands of 
 an assistant being placed over it; and to prevent any part of the 
 intestines from insinuating themselves between the uterine and 
 abdominal walls, a second assistant may make pressure with one hand 
 over the uterine fuudus. Anaesthesia is undoubtedly of great value 
 in performing this operation. Ether is preferred by some operators; 
 Chloroform, however, is less likely to produce nausea, vomiting and 
 retching, greatly embarrassing the operator.. A mixture of the two 
 agents is sometimes used. A profound state of anaesthesia, however, 
 should be induced, regardless of the agent used. 
 
 An incision of about six inches in length is now to be made through 
 the abdominal walls, extending from a short distance below the um-
 
 636 KING'S ECLECTIC OBSTETRICS. 
 
 bilious, to within about two inches of the pubes, as a further extension 
 of it would endanger the bladder. The abdomen should be carefully 
 washed with an antiseptic solution; carbolized water answers a very 
 good purpose. The incision should now be made, from the umbilicus 
 downward in the median line. The parts should be carefully divided, 
 layer by layer, as far as the peritoneum, into which a small aperture 
 is to be cautiously made, sufficiently large to admit the introduction 
 of the index finger of the left hand (or a grooved director) as a 
 director for a probe-pointed bistoury, and to prevent it from wound- 
 ing the intestines. Tho peritoneum must be divided until the incision 
 is of the same dimensions with that of the integuments above, when 
 the uterus will be brought into view. An incision of about five or 
 six inches in length is now to be made into the body only of the 
 uterus, carefully dividing layer after layer, until the placenta, or the 
 membranes are brought into view, and which latter may be known by 
 their transparency. Make a slight opening into the membranes, if 
 these have not been ruptured previously, and by means of pieces of soft 
 sponge remove some of the liquor amnii, or it may be more quickly 
 removed by a proper syringe. Then enlarge the orifice in the mem- 
 branes, withdraw the child, seizing it by the lower extremities, tie the 
 cord, and extract the placenta and membranes, having first twisted 
 them into a cord. Should the placenta, however, present first, it 
 must not be divided, but detached at one side, that the membranes 
 may be reached. 
 
 When the membranes are ruptured, the assistants must be careful, 
 in holding the lips of the wound apart, that the abdominal and uter- 
 ine walls are kept in contact with each other, that none of the amni- 
 otic liquid may pass between them into the abdominal cavity. After 
 the removal of the child, the uterus commonly contracts and detaches 
 the placenta; but if this be not effected , it must be accomplished arti- 
 ficially, by making traction on the cord, and peeling off with the 
 fingers. The operator must also ascertain that the canal of the cervix 
 is free, in order that the lochia may escape, and this may be learned 
 by passing a finger through the os uteri from the wound, and one or 
 two of the other hand per vaginam. In the event of permanent 
 obstruction, characterized by marked stenosis, it is suggested the 
 Porro operation be selected. 
 
 Any blood or other foreign body which may have passed within 
 the uterine cavity, must be removed, and the wound in the organ 
 must be well cleansed. The contraction of the uterus generally brings
 
 CESAREAN OPERATION. 637 
 
 the lips of the wound in contact, so that there will be but little 
 hemorrhage. It is well, however, in the beginning, to throw a tem- 
 porary rubber ligature about the lower uterine segment, to be tight- 
 ened in case of emergency. After cleansing the borders of the uterine 
 incision, the wound should be closed with sutures. 
 
 The great mortality in this operation heretofore has, no doubt, been 
 largely due to the inability to properly close the uterine incision. 
 The modification of Sanger has done much to overcome this defect, 
 and in order to clearly define the Sanger- Cesarean operation, I quote 
 the following from Lusk, page 430 of his work on Midwifery: 
 
 " It is obvious that the classical Cesarean section, even with the 
 addition of the suture and the employment of strict antisepsis, is still 
 far from answering the requirements of a conservative procedure. To 
 place it upon the same plane with other forms of abdominal surgery, 
 it is necessary to devise some means to surely prevent the separation 
 of the uterine wound, which has been found to occur in spite of the 
 suture and the most careful coaptation of the cut surfaces. The sec- 
 ondary gaping is due, in a measure, to the tendency of the external 
 borders of the wound to become everted after section, the wound, in 
 consequence, assuming u prismatic shape, but chiefly to the alternating 
 periods of contraction and relaxation in the uterine muscle itself, 
 whereby the tension of the sutures is subjected to a continual change. 
 Recently both Kehrer and Sanger have proposed modifications in the 
 methods of operating, designed to render more certain the speedy 
 union of the tissues along the lifle of the incision. 
 
 " Sanger, after an exhaustive study of the past history of the 
 uterine suture as employed in cases of Cesarean section, concludes 
 that the prevention of the escape of the lochia from the uterus into 
 the abdominal cavity subsequent to the operation is best secured by 
 the employment of special means for bringing the peritoneal surfaces 
 into immediate contact with one another, as it is a fact, made familiar 
 by Sir Spencer Wells, that two peritoneal surfaces in apposition unite 
 within twenty-four hours. In order to attain this end, Sanger sug- 
 gested that, after the removal of the child through the ordinary 
 incision, and a temporary elastic ligature had been placed around the 
 cervix, a narrow strip of muscular tissue should be removed by a sec- 
 tion running at first parallel to the borders of the wound, but diverg- 
 ing outward as the section approached the peritoneal surface. 
 
 " The peritoneum was next to be detached, and allowed to cover 
 the expanded portion of the Y-shaped section. He then advised the 
 introduction of deep uterine sutures, running obliquely through the
 
 638 KING'S ECLECTIC OBSTETRICS. 
 
 uterine tissues to the inner borders of the wound, avoiding, however, 
 the decidua, with a second set of superficial sutures, designed to secure 
 the contact of the peritoneal borders. The principle of subpcritoueal 
 muscular resection, as Sanger termed his method, has been tested in 
 three instances by Lepold, with the saving of the three mother- as 
 well as the three children. In practice, however, the plan was found 
 to require some modification. Thus Lepold, after raising the peri- 
 toneum with tissue forceps from the borders of the wound, separated 
 it by a horizontal incision, made with a bistoury, to the extent of a 
 half centimeter at the upper and lower angles, and about one centi- 
 meter at the middle of the wound. In carrying out this dissection, a 
 layer of muscular tissue, upward of a millimeter in thickness, was 
 removed with the peritoneum. Then, after lifting the detached serous 
 layer, he removed, cutting from within outward, from each side a 
 segment of muscular tissue extending through the entire thickne.-.- of 
 the uterine walls each segment possessing a wedge-shape, with the 
 base above and the apex directed toward the decidua. In this way he 
 obtained two smooth muscular surfaces overlapped by a wide layer of 
 serous membrane. The deep sutures employed were of silver, while 
 the superficial ones were in one case composed' of catgut, in the 
 two others of fine silk." 
 
 Should any blood have escaped into the abdominal cavity, remove 
 it by lightly sponging; and, while an assistant retains the intestines 
 in their place, close the wound in the abdomen by as many silver 
 wire sutures as may be necessary, leaving a space at the lower part for 
 the exit of the fluids which escape from the abdomen.* Between and 
 over the sutures, strips of adhesive plaster should be applied, over 
 which may be placed a number of layers of antiseptic gauze, the whole 
 being kept in position by a bandage drawn moderately tight. During 
 the operation care must be taken not to permit the intestines to 
 extrude, and to keep them warm and moist by means of hot flannels 
 applied from time to time upon the abdomen. 
 
 Blundell suggests the propriety of rendering the Fallopian tubes 
 impervious, by removing a small portion of their substance on each 
 side, during the operation, thereby preventing the possibility of con- 
 ception, without destroying the sexual appetite. 
 
 * It has been "ad vised to include the peritoneum in the sutures, so that the inner 
 part of the wound will have the peritoneal surfaces in contact, and not to leave an 
 opening for the exit of the fluids, thereby favoring a speedy union; the same as when 
 treating a simple incised wound.
 
 CESAREAX OPERATION. 639 
 
 After the operation, the condition of the patient may render the 
 administration of stimulants necessary. When she has been placed in 
 bed, administer an opiate, and treat the case on general principles to 
 lessen irritability, and prevent or allay any febrile or inflammatory 
 symptoms which may come on, treating them promptly and ener- 
 getically. The patient must be kept quiet, visitors must be excluded 
 from the room, which should be kept rather cool, and any inflamma- 
 tion along the ed^es of the incision must be at once- reduced by cold 
 water, or fomentations, as seems best suited to the case. Small doses 
 of tincture of Aconite, with or without tincture of Gelsemium, will 
 aid considerably in averting inflammation. The diet must be exceed- 
 ingly light, and the utmost care and attention should be bestowed 
 upon the female The catheter should be passed until the patient is 
 able to pass her urine without straining; likewise, the bowels should 
 be held in check for several days. The child should be fed until the 
 mother is beyond danger, and in the meantime the milk, should any 
 be present, may be removed by a young puppy, or by a pump made 
 for this purpose. 
 
 It is always proper to have \varm water on hand, in order to place 
 the child in it, should animation be suspended. 
 
 The PORRO OPERATION. The Porro- Cesarean section con- 
 sists in amputating and removing the uterus, after the delivery of the 
 child, through the abdominal section. The indications for the opera- 
 tion, as well as the statistics relating thereto, have been given in the 
 preceding section. The body of the organ should be dragged through 
 the abdominal incision, and the child delivered as in the Cesarean 
 section ; an elastic cord, encircling the cervix, should be tightened, to 
 prevent hemorrhage. The uterus is held in the abdominal incision by 
 a couple of knitting needles, and is then amputated, including the 
 tubes and ovaries. For a full account of this operation, the reader is 
 referred to Prof. Howe's excellent work on Operative Gynaecology, 
 page 187. 
 
 The operation of SYMPHYSEOTOMY, or an artificial separation 
 of the pubic bones at their symphysis, has been advised in cases of 
 excessive deformity of the pelvis ; but as I can not conceive of a case 
 in which it would be justifiable, being attended with many dangers, I 
 shall not enter into any description of it. 
 
 LAPARO-ELYTROTOMY. This is another of the operations 
 advised, where natural delivery is impossible; it has, however, only
 
 640 KING'S ECLECTIC OBSTETRICS. 
 
 been executed a few times. The advantage claimed for it over 
 abdominal section was that the opening of the cavity of the peri- 
 toneum could be avoided, as well as incising the uterus. The opera- 
 tion consists in an incision from the pubic symphysis, along the line 
 of Poupart's ligament to the ilium, through the walls of the abdo- 
 men to the upper part of the vagina, which is opened. The os and 
 cervix, already dilated, are directed into the wound, and the child 
 extracted therefrom. When the peritoneum is reached, it is pushed 
 away from the line of the incision by raising it. 
 
 A necessity for the operations above named may frequently be 
 obviated, where the pelvic measurements are known to be too small, 
 by the induction of premature delivery, or even, in some cases, of 
 abortion. 
 
 CHAPTER XLVII. 
 
 INDUCTION" OF PREMATURE LABOR. 
 
 IN cases where it is known that the fetus, at full term, would be 
 unable to pass through the pelvis, either naturally or by the aid of 
 forceps, owing to a deformed condition of the pelvic bones, the 
 INDUCTION OF PREMATURE LABOR is recommended; an 
 operation which has for its object the safety both of the mother affd 
 her child. This operation originated in England, where it has been 
 practiced since 1756, at which time, we are told by Denman, a consul- 
 tation of most eminent practitioners in London was held to determine 
 the question of its morality, safety, and utility; which having been 
 decided affirmatively, the operation was first successfully performed 
 by Dr. Macaulay. Frbm England it was carried into Germany, in 
 1799, by A. Mai, but was not practiced until in 1804, by Wenzel. In 
 France it was not performed until 1831, by Stoltz, having previously 
 met with much opposition as an immoral and criminal procedure. At 
 this time, however, it is considered by all obstetricians as a perfectly 
 justifiable operation. 
 
 The induction of premature labor consists in exciting the uterus to 
 contract, leaving the subsequent expulsion to the natural efforts ; con- 
 sequently, it differs from a "forced delivery," in which nearly the 
 whole process is conducted bv artificial means. It is not to be
 
 INDUCTION OF PREMATURE LABOR. 641 
 
 attempted until at the period of fetal viability, or during the seventh 
 or eighth months. Its intention is to safely deliver the living child, 
 instead of waiting for the natural term, to destroy it by the perforator, 
 and thus expose the mother to much risk; and, also, to save the 
 mother from the hazardous Cesarean operation. 
 
 It has been objected, that it is impossible to accurately determine 
 the relative proportions existing between the fetal head and the female 
 pelvis. This is a very trifling objection, and one that should bear no 
 weight at all in the consideration of the question of operating; because 
 these points may be determined with sufficient accuracy for all practical 
 purposes, by the various methods heretofore explained ; and should 
 we, even, arrive at a wrong estimate in these measurements, it would 
 be of no great importance ; I consider the following reasons, given by 
 Velpeau, as correct, and of much value he says: "If the pelvis be 
 wider than we thought, premature delivery (at or after the seventh 
 month) is accomplished without risk. If, on the contrary, the nar- 
 rowing be more considerable, the fetus will certainly perish; but then, 
 had no operation been attempted till the full term, the fetus would 
 equally have been lost, and the mother would have run greater risk." 
 
 But whatever may be the objections raised against this operation, it 
 must always be borne in mind that the results are not so serious to 
 either mother or child, as when pregnancy is permitted to proceed to 
 its full period. Thus, where craniotomy is performed, not only are the 
 infants destroyed, but one in five mothers are lost; where the Cesarean 
 operation is achieved, the children die in the proportion of one in 
 three and a half, and the mothers of one in two and one-third. Where 
 premature labor is effected, more than half of the children are saved, 
 while only one mother in sixteen, is lost. In 161 cases of premature 
 delivery, given by Velpeau, eight died, five of which perished from 
 causes not connected with parturition; in 280 cases, given by Figueira, 
 only six were lost. Here, then, are 441 cases of premature delivery, 
 of which only nine died, or about one in fifty. What sane man can, 
 with these results before him, morally or religiously object to an opera- 
 tion so "highly favorable to both mother and child? Prof. William 
 Wathen calls attention to Maygrier, who gives the following statis- 
 tics in induced labor in pelves of 2.73 inches : " Mothers saved, 66.67 
 per cent.; children saved, 35.30 per cent. 101.97 lives saved out of 
 200." These are the best results that have been obtained, and the 
 percentage of lives saved' might be materially lowered by deducting 
 those children that died within a few days or weeks after birth. 
 41 ,,'.
 
 642 
 
 KINGS ECLECTIC OBSTETRICS. 
 
 The induction of premature labor, in cases of malformed pelvis, is to 
 be effected only when the small diameter of the superior strait ranges 
 between two and a half and three inches; under which circumstances it 
 would be impossible for the full developed fetal head to pass naturally, 
 or even with the aid of the forceps. At seven months, according to 
 the researches of several eminent obstetricians, the bi-parietal diameter 
 of the fetal head is from two and a half to two and three-quarter inches, 
 or not quite three inches, and consequently it may pass very readily 
 through a pelvis the smallest diameter of which is contracted to a 
 measurement between two and a half and three inches: a smaller 
 pelvic diameter than this would render the passage of the fetal head 
 impossible even at the seventh month, unless it should be a very small 
 one; but as we have no means of determining this while the fetus is 
 yet within the uterus, the practitioner is necessarily bound to govern 
 himself by the standard measurement as given. The following ap- 
 proximate measurements of the fetal head have been given by M. 
 Figueira, and will undoubtedly be of some utility to the practitioner: 
 
 Age of the Fetus. 
 
 Bi-parietal 
 Diameter. 
 
 Occi pi to-frontal 
 Diameter. 
 
 Occipito-bregmatic 
 Diameter. 
 
 7th month 
 
 Inches. Lines. 
 2 9 
 
 Inches. Lines. 
 3 8 
 
 Inches. Lines. 
 2 10 
 
 7 " 
 
 3 
 
 3 9 
 
 3 
 
 gth " 
 
 3 1 
 
 3 10 
 
 3 1 
 
 8} " 
 
 3 2 
 
 4 
 
 3 2 
 
 9th " 
 
 3 4 
 
 4 
 
 3 4 
 
 
 
 
 
 (See Diameter of Fetal Head, page 57.) 
 
 Bitgen has given a table of some practical value, relative to the 
 time at which premature delivery may be effected ; thus it may be 
 induced at the 
 
 
 Inches. 
 
 Lines. 
 
 29th week when the antero-posterior diameter of the pelvis is... 
 
 ... 2 
 
 7 
 
 30th ' 
 
 " ' 
 
 " " ... 
 
 ... 2 , 
 
 8 
 
 31st ' 
 
 " 
 
 " " 
 
 ... 2 
 
 ' 9 
 
 35th ' 
 
 M (( 
 
 It <l 
 
 ... 2 
 
 10 
 
 36th ' 
 
 
 
 M 
 
 ... 2 
 
 11 
 
 37th " " " " ... 
 
 ... 3 
 
 
 
 M. Stoltz has given the bi-parietal diameters of the fetal head to be 
 from the 
 
 32d to the 33d week of pregnancy 2| inches. 
 
 34th " 35th " " 3 " 
 
 36th " 37th " " 3 "
 
 INDUCTION OF PIIEMATURE LABOR. 643 
 
 The rule given by some authors is, when the antero-posterior diameter 
 of the superior strait measures three inches, to delay the operation 
 until the thirty-eighth week, or eighth month ; when it measures but 
 two and three-quarter inches, operate at seven and a half months; and 
 when only two and a half inches, operate at the seventh month. If 
 the diameter is less than two inches, an attempt must be made to save 
 the mother's life either by abortion or the Cesarean operation ; and I 
 should not hesitate a moment in resorting to the former method, which 
 every accoucheur must acknowledge as being less hazardous in its 
 results than the latter. 
 
 In cases where the antero-posterior diameter of the superior strait 
 is ascertained to be three and a quarter inches, and where in previous 
 pregnancy the fetus could be delivered only by a resort to embryotomy, 
 the practitioner is justified in effecting premature labor; but not in 
 primiparaB, with whom delivery is usually possible, even under such 
 circumstances, and with whom it is not advisable to operate when the 
 diameter measures beyond three inches. And in all instances the 
 practitioner should be well assured of the life of the fetus before 
 attempting the operation, bearing in mind that the longer the child is 
 allowed to remain within the uterus, compatible with its safe delivery, 
 the greater will be the chances in favor of its living subsequently. If 
 the existence of a twin pregnancy be satisfactorily ascertained, the 
 operation may be dispensed with, because the development, as well as 
 organization of twins, is usually less perfect than in single pregnan- 
 cies; but from the difficulty in determining twin pregnancies, this rule 
 
 will seldom prove of any practical importance. 
 
 <* 
 
 There are other conditions beside that of pelvic contraction, in 
 which the induction of premature labor may be justifiable; as for 
 instance, in cases of excessive vomiting, where no food can be re- 
 tained upon the stomach, notwithstanding various remedial agents 
 have been administered, and where consequently the life of the mother 
 is threatened by starvation. It is likewise proper in all cases where 
 the continuance of pregnancy adds to the dangers which threaten the 
 life of the female, as in aggravated diseases of the heart; in aneurism, 
 where, from the obstruction to the general circulation occasioned by 
 the enlarged uterus, a rupture of the aneurismal tumor is feared ; in 
 strangulated hernia; in excessive serous effusions; in convulsions, 
 especially where they resist the remedial means pursued and recur
 
 G44 KING'S ECLECTIC OBSTETRICS. 
 
 frequently, becoming at the same time more and more severe ; in 
 uterine hemorrhage, more particularly when owing to the attachment 
 of the placenta over the inner os uteri (placenta prsevia); in diminu- 
 tion of the bis-ischiatic diameter; in abdominal or uterine tumors, 
 which interfere with the development of the uterus or the delivery of 
 the fetus at full term ; in case there has been a rupture of the uterus 
 in a previous labor; and, indeed, in all cases where the life of the 
 mother is at stake, and can not be saved by any other means. A dead 
 fetus is not of itself a cause for the operation, unless there be other 
 circumstances of a hazardous character attending it. But whatever 
 may be the nature of the case, it must not be forgotten that the prac- 
 titioner who attempts this operation assumes a very heavy responsi- 
 bility, one in which a failure, or a fatal result to the mother, may 
 seriously involve his reputation for a life-time ; consequently, as a 
 general rule, and more particularly among young practitioners, no 
 operation of the kind should be undertaken without a consultation in 
 the matter, and the sanction of the consulting physicians. 
 
 Denmansays: "There is another situation in which I have pro- 
 posed and tried with success the method of bringing on premature 
 labor. Some women who readily conceive, proceed regularly in their 
 pregnancy until they approach their full period, when, without any 
 apparently adequate cause, they have been repeatedly ^seized with 
 rigor, and the child has instantly died, though it may not have been 
 expelled for some weeks after. In two cases of this kind I have pro- 
 posed to bring on premature labor when I was certain the child was 
 living, and have succeeded in preserving the life of the children 
 without hazard to the mother. There is always something of doubt 
 in these cases, whether the child might not have been preserved with- 
 out the operation ; but as such cases often come under consideration, 
 and as I am disclosing all that my experience has taught me, it seemed 
 necessary to mention this circumstance." I would remark here that 
 I have seen similar cases, occurring especially after a bleeding for 
 fullness of the head or other unpleasant symptom; but whether they 
 were occasioned by the bleeding I am not prepared to say, but make 
 the suggestion for future investigation : again, I have witnessed a few 
 instances where no bleeding has been performed. 
 
 Females sometimes, in a succession of labors, give birth to still-born 
 children, and which is owing, not to pelvic malformity, but to a pre- 
 ternatural energy of the contractions of the uterus, very similar to 
 those induced by Ergot, being permanent, and by constant compression 
 . of the cord causing a suspension of the fetal circulation. Premature
 
 INDUCTION OF PREMATURE LABOR. 645 
 
 delivery has been recommended in such cases, with an intention of 
 lessening the energy of the uterine action, or a hope of finding it less 
 powerful at the seventh or eighth month, in consequence of which the 
 child may probably be saved. But the operation is not justifiable. 
 The disposition to excessive uterine contraction may be overcome by 
 the employment of uterine tonics and antispasmodies during preg- 
 nancy ; and anodynes during parturition, with rectal injections of the 
 officinal compound tincture of Lobelia and Capsicum, slightly diluted 
 with warm water, and in very severe and obstinate cases, a portion of 
 this tincture may also be administered internally, or the Sp. Tr. of 
 Gelsemium. 
 
 It can not be denied that there are several difficulties which inter- 
 fere in a greater or less degree, with the success of the operation; 
 thus, the size of the pelvis may be inaccurately estimated, and the 
 operation be performed at too late a period, or too early, to insure the 
 subsequent existence of the child. Frequently it is almost if not 
 quite impossible to precisely determine the age of the pregnancy, as 
 women are very apt to be mistaken in their calculations, and the 
 results may be similar to those just mentioned above ; but notwith- 
 standing these difficulties, they are by no means of such a nature as 
 to lead us to reject the operation, the results of statistics being greatly 
 in its favoj. Again, abnormal presentations, as of the shoulder, 
 breech, etc., are more frequent in premature labors, for w T hich no sat- 
 isfactory reason has been given, and which generally prove fatal to 
 the child, owing to the constant pressure on the umbilical cord during 
 the passage of the fetal head through the brim ; or, where the presen- 
 tation is natural, the fetus may be destroyed by a long-continued 
 compression of the uterus upon it, owing to the escape of the water 
 and the delay in dilatation of the os uteri. But none of these 
 obstacles are of so grave a nature as to prohibit the operation, -because 
 the life of the mother is to be considered as of the first importance, 
 and that of the child as secondary to be saved, if possible, but 
 always without endangering the mother. 
 
 I would refer here to an ancient prejudice which is still very popular, 
 and is even supposed to be true by many physicians ; it is, that a child 
 born at the seventh month is more apt to live, than one born at the 
 eighth month of pregnancy. This, however, is very absurd and 
 incorrect ; for we would suppose that the longer the intra-uterine life 
 is extended, the greater would be the chances for a perfect develop- 
 ment of organization, and consequently o*f a subsequent independent
 
 646 KING'S ECLECTIC OBSTETRICS. 
 
 existence, and such is actually found to be the case in practice. I am 
 aware that " eighth month children," as they are called, frequently 
 die at a very early age, and I am likewise aware that "seventh month " 
 and "ninth month children" frequently meet with a similar early 
 death; but I have found no peculiar tendency of this kind among 
 those born at the eighth month. 
 
 Various methods have been devised and recommended for the pre- 
 mature expulsion of the fetus, some of which may prove safe, as far 
 as the mother is concerned, but are necessarily fatal to the child ; 
 while others have in view the safety of both mother and child. The 
 former are seldom employed unless the intention is to produce abor- 
 tion, previous to the seventh month or viable condition of the child ; 
 and it should never be attempted unless the antero-posterior diameter 
 of the superior strait is less than two and a half inches. In these 
 cases the question is between abortion and the Cesarean section ; by 
 the former the child is delivered dead, while the hazard to the mother 
 is comparatively small; by the latter, the child has one chance in three 
 of living, while the mother has but one in two and a quarter chances 
 of recovering from the operation. Shall we then sacrifice the child 
 to save the mother, or the mother to save, probably, neither ? My 
 own view of the matter corresponds with that of Velpeau, who says : 
 " As regards myself, I avow I can not put in comparison Hie precious 
 life of a fetus of three, four, five, or six months, a being scarcely 
 differing from a plant, one that is bound by no ties to the external 
 world, with that of an adult woman, whom a thousand social relations 
 interest us to save : therefore, in a case of extreme narrowness of the 
 pelvis, and where it was mathematically demonstrated that delivery at 
 the full period was impossible, I would not hesitate to recommend 
 producing abortion in the first months of gestation." 
 
 Abortion may in some cases be effected by warm pediluvia, copious 
 sweating, and drastic purgation, while in others these will produce no 
 influence at all ; indeed, many unchaste females are in the habit of 
 producing abortion in the early months of pregnancy whenever this 
 takes place, by such means as named above, yet it is generally accom- 
 plished at a great sacrifice to both health and long life. The oil of 
 Savin given in doses of ten drops on sugar, and repeated three times 
 daily for a week or two, will cause abortion, especially in the early 
 months of gestation, in consequence of its destructive influence upon 
 the ovum, yet it frequently .fails, and if given in larger quantities is 
 very apt 'to produce serious inflammation; its action appears to be
 
 INDUCTION OF rilEMATUKK LAUOli. 647 
 
 more positive in females of a strumous diathesis. Borax and Cinna- 
 mon in doses of five grains each, or a mixture of Borax and Ergot, 
 each, in powder, ten grains, powdered Cinnamon one scruple, admin- 
 istered three times a day, will likewise often occasion abortion, l>v 
 their influence upon the contractile tissue or action of the uterus, yet 
 these compounds sometimes produce irremediable and distressing 
 symptoms. Many other agents have produced abortion as various 
 essential oils, or infusions of emmenagogue herbs, with or without the 
 addition of Yeast, etc., but none of these can be recommended as 
 invariably certain in their results, beside which, they often produce 
 disastrous consequences. 
 
 A solution of half a grain, or a grain of Sulphate of Iron in two 
 fluidrachms of water, carefully injected into the pregnant uterus, is 
 much employed among abortionists to effect their object. Another 
 plan, which is considerably used, is to pass up a Simpson's sound into 
 the uterus, feel around with it for the placenta and detach a small 
 portion of its periphery, enough to cause a little blood to flow; in 
 twelve or twenty-four hours, the uterus contracts and sooner or later 
 expels its contents. It is Hardly worth while to state to the medical 
 student, the dangers that are apt to follow abortions thus effected, 
 nor the slavery and the legal liabilities to which the operators are 
 subject. 
 
 Probably the safest as well as the most certain method is the one 
 pursued by Macauley in 1756 perforation of the membranes by the 
 introduction of a catheter or a canula armed with a trocar; the in- 
 strument is introduced into the os uteri, and the membranes pierced 
 by it, care being taken not to injure the parts of the mother. This 
 method is neither painful nor injurious to the mother; by it, the 
 amniotic liquid escapes, the uterine walls retract, dilatation of the os 
 uteri more or less slowly ensues, requiring from twenty to forty hours, 
 and in some instances even sixty ; the uterus, irritated by the constant 
 proximity of the fetus, contracts, but is unable to expel its contents 
 until the os uteri has become sufficiently dilated, hence there is fre- 
 quently excessive hemorrhage from an early detachment of the pla- 
 centa. This method has been also advised to induce premature 
 delivery, but it should never be adopted after the seventh month, :is 
 from the early discharge of the waters and consequent prolonged 
 pressure of the uterus upon the fetus, its life is greatly endangered. 
 
 The above methods are among those which have been used at 
 various times for the purpose of producing abortion, but in instances 
 where it is required to save the life of the child, if possible, that is,
 
 648 KING'S ECLECTIC OBSTETRICS. 
 
 after the seventh month, other measures have been recommended, 
 among which may be mentioned the following: 
 
 1. Frictions over the fundus uteri to induce contractions, at the 
 same time titillating or irritating the os uteri by one or more lingers 
 introduced into the vagina, has been proposed by D'Outrepont and 
 Ritgen; this plan, however, is rarely employed, because it seldom 
 effects any uterine contractions, and when these do occur, they are too 
 feeble and evanescent to produce an expulsion of the fetus. 
 
 2. It has been suggested by Dr. Hamilton, to introduce a finger or 
 gum-elastic catheter beyond the inner os uteri, and separate the mem- 
 branes from the internal uterine surface for some two or three inches 
 around, and where labor can be brought on by this mode, it is safe to 
 both mother and child. But it can not be relied upon as an efficient 
 measure, and in cases where it has succeeded, the result was probably 
 brought about by the irritation produced at the cervix. What has 
 been termed catheterization of the uterus has usually been regarded 
 as quite certain in its action. It consists in introducing an ejastic 
 catheter or bougie between the membranes and the walls of the uterus, 
 allowing it to remai.n in situ until contractions follow. This method 
 has been improved upon by Professor Lazarewitch, who passes an 
 elastic tube between the uterus and its membranes, from the cervix to 
 the fundus, or as nearly so as possible, and then injects through this 
 tube from eight to ten ounces of warm water ; in twelve cases, uterine 
 contraction came on at once, nine of the children were born alive, and 
 none of the mothers died. Two of the cases required a second in- 
 jection to urge the uterus to greater action. The labors by this 
 method usually come on in from ten to twenty-four hours, and ter- 
 minate in from sixteen to twenty-four hours. This is not a painful 
 mode, and is supposed by its originator to produce an effect somewhat 
 similar to the natural process, in which he claims, that the initiative 
 step in labor is detachment of the membranes from the uterine wall 
 that this detachment, as well as uterine contraction, commences at the 
 fundus and that the contractions are not manifested until the detach- 
 ment has occurred. Although this method has proved successful in 
 many cases, yet it has in other cases occasioned alarming symptoms, 
 and even death, which should lead to some hesitation in resorting 
 to it. 
 
 3. M. Meissner, of Leipsic, has given a plan by which he assures 
 us that, in fourteen cases upon whom it was tried, both mother and 
 child were saved in every instance ; it is an improvement upon the 
 method of Macaulay, and has for its object the gradual discharge of
 
 INDUCTION OF PREMATURE LABOR. 649 
 
 the amniotic liquid, thereby avoiding long-continued pressure upon 
 the fetus. The plan is to puncture the membranes, not at their 
 lowest part, but high up, as near the fundus uteri as possible ; and 
 the instrument he employs is a canula about thirteen inches in length, 
 and two lines in diameter, and having a curve corresponding with the 
 segment of a circle whose radius is eight inches. Attached to this 
 canula are two stilets, one bearing at its extremity an olive-shaped 
 button, the other a trocar; a ring is also placed upon the lower 
 extremity of the convex side of the canula, which enables the operator 
 to determine the direction of the curvature when the instrument is 
 within the uterus. The female being placed in an erect position, the 
 operator, stooping down on one knee, proceeds carefully to introduce 
 the canula armed with the olive-shaped button through the os uteri, 
 and as far up between the membranes and uterine walls as possible, 
 say six, eight, or ten inches above the os uteri. This having been 
 accomplished, and also having ascertained that the point of the canula 
 is not in contact with any part of the fetus, the button stilet is with- 
 drawn, and that 'with the trocar introduced and the membranes 
 punctured. Sometimes, when the cervix is high up, and looking so 
 far backward as to be reached with difficulty, the female will have to 
 sit on the edge of a chair, or assume the recumbent position, in order 
 to enable the practitioner to introduce the canula. After the perfora- 
 tion of the membranes, the trocar-stilet is removed, a small portion 
 of fluid is permitted to pass through the canula, and then this is also 
 withdrawn. The waters by this mode escape gradually, pains usually 
 come on in twenty-four or forty-eight hours, and labor is finished in 
 from thirty-six to sixty hours. This operation has not been very 
 extensively employed, but is preferable to any of the plans heretofore 
 named, although rather difficult to satisfactorily accomplish. 
 
 4. Kluge has proposed a mode of inducing uterine contractions 
 without puncturing the membranes, by the introduction of a sponge- 
 tent within the os uteri. The sponge must be soft and fine, of a 
 conical- shape, about two inches long, and half an inch in diameter at 
 its base, and a piece of tape must be attached to its base, by means of 
 which it may be removed when required. It may be prepared by 
 soaking a piece of fine sponge in a solution of Gum Arabic, wrapping 
 it round an awl, and tightly binding it on by a string ; when dry, it 
 can be cut into any required shape. The female, for a few day.- 
 previous to the operation, is directed to use the warm-bath, and warm 
 emollient and narcotic vaginal injections ; and before introducing the 
 .sponge, both the rectum and bladder are to be emptied. She is then
 
 650 KING 8 ECLECTIC OBSTETRICS. 
 
 to be placed in a position somewhat similar to that required for the 
 application of the forceps, and the finger of the operator is introduced 
 into the vagina as far as the os uteri to serve as a conductor; with the 
 other hand, a long pair of forceps, holding the piece of sponge, is to- 
 be passed along the conducting finger and gradually entered within the 
 canal of the cervix. After holding it there for a few minutes the 
 forceps are to be withdrawn, and the sponge kept in its place by filling 
 the vagina with a large sponge, or pieces of linen, and the whole 
 retained by a proper bandage; the patient is then directed to remain 
 in bed. The fluids of the parts saturate the sponge, which swells up, 
 and consequently dilates the os uteri, and irritates its fibers, which, 
 reacting upon those of the corpus uteri, effects contractions, which 
 usually occur in five or six hours. If, in the course of twenty-four 
 hours, active contractions of the uterus are not excited, the sponge 
 must be removed by means of the tape, and a new and larger piece 
 inserted in its place ; this second application is most generally 
 successful. If required, the labor-pains may be increased by 
 titillating the cervix, frictions over the abdomen, and the use of 
 Macrotys or Ergot This plan is a good one, and certainly preferable 
 to that of puncturing the membranes, yet, it is stated to fail occasion- 
 ally. Sea tangle-tents have likewise been used for the same purpose, 
 and are said to act better than the sponge, as they give rise to less 
 irritation, dilate the-os more gradually, and, when hollow, permit the 
 escape of the discharges. 
 
 5. Professor Kiwisch, of Wurzburg, recommends the direction of a 
 stream of warm water from a height, by means of a syphon, continu- 
 ously upon the os uteri; Dr. Smith proposes to improve upon this 
 method, by alternating the temperature of the douche from hot to 
 cold. A vessel capable of holding two gallons of water is placed at 
 an elevation of four or five feet above the patient, to which is affixed a 
 flexible tube, about eleven feet in length and half an inch in diameter, 
 the uterine extremity of "which terminates in an ivory or bone nozzle 
 five or six inches in length, or is connected with the straight tube of 
 an injecting apparatus, and near the upper end of which a stop-cock 
 is attached. In employing this, two gallons of warm water, about 
 110 F., are to be placed into the vessel. The uterine extremity of 
 the tube is then passed into the vagina and directed toward the os 
 uteri, the female being in bed, or in an empty hip-bath; holding the 
 tube steadily, the stop-cock is turned, and the stream immediately 
 commences flowing with considerable force against the os uteri, and 
 which is to be continued until the whole two gallons have been dis-
 
 INDUCTION OF PREMATURE LABOR. 651 
 
 charged. If this is to be followed by a cold douche, the same quantity 
 of cold water is to be poured into the vessel as soon as it is emptied, 
 and allowed to flow in the same manner. The time occupied in the 
 operation is from twenty to thirty minutes, and the only disagreeable 
 sensations experienced are when the warm and cold currents first begin 
 to run. This operation may be repeated two or three times daily, 
 requiring its application from two, to four, eight, or twelve times. It 
 is to be preferred to all others yet named, as its' application is simple, 
 and no possible injury can be done to either the mother or child. 
 However, it is not only a troublesome, unpleasant method, but gen- 
 erally quite a tedious one. If expedient, it should be performed at 
 the period in which the catamenia would have appeared in the non- 
 pregnant condition. A syringe capable of maintaining a continuous 
 stream may be substituted for the vessel and tube. 
 
 6. The employment of galvanism or electro-magnetism, as suggested 
 by Herder in 1803, has been found efficacious in bringing on uterine 
 contractions, even after other means had failed. This is accomplished 
 by placing one pole of the battery on either side of the uterus, con- 
 tinuing the application of the current for half an hour or an hour 
 each time, and renewing it once or twice daily; the ordinary electro- 
 magnetic apparatus in use is the best form, as repeated shocks prove 
 more effectual and certain in stimulating the uterus to contractions 
 than a continued current. In applying the poles' it will be proper to 
 attach to the discs a sponge moistened with water, or salt and water; 
 or pieces of thin flannel likewise moistened may be placed between 
 the discs and the abdomen. Some apply one pole to the neck of the 
 uterus, and the other to the spine or abdomen, immediately above the 
 fundus; but this is unnecessary. Dr. Radford states, " that galvanism 
 not only originates the temporary contractions of the uterus, but also 
 produces such a lasting impression on the organ that pains continue 
 to occur until the labor is terminated. It produces severe pains in 
 the loins, and great bearing down, followed by dilatation of the os,. 
 and expulsive pains." I have employed this agent in a few cases, and 
 with invariable success, though the number and intensity of the appli- 
 cations had necessarily to be varied in each. In relation to its influ- 
 ence on the fetus, Dr. Radford, who has made extensive employment 
 of it in midwifery, states that he has never observed that the child in 
 utero has been injured by its use, which gives it a great advantage 
 over the administration of secale cornutum, which, in many cases, is 
 destructive of it; he also remarks, "Galvanism is especially advanta- 
 geous as a general stimulant in all those cases in which the vital
 
 KINGS ECLECTIC OBSTETRICS. 
 
 powers are extremely depressed from loss of blood. Its beneficial 
 effects are to be observed in the change of countenance, restoring an 
 animated expression; in its influence on the heart and arteries; in 
 changing the character of respiration; and its warming influence on 
 the general surface. I have several times observed, in cases in which 
 
 O * 
 
 other powerful stimulants have failed to produce any beneficial results, 
 the most decided advantages accrue after its application." It may 
 likewise be employed to effect abortion, when the indications show the 
 necessity for, or justify, the expulsion of the ovum. This method is 
 also somewhat tedious. 
 
 7. The fresh Inner Bark of the Root of the Cotton plant is stated 
 by Dr. Bouchelle to have a particular affinity for the sexual organs, 
 modifying their functions in a remarkable manner; that it not only 
 possesses oxytocic properties, invigorating feeble contractions of the 
 uterine fibers, but that it originates expulsive contraction at any 
 period of gestation, and will induce immediate abortion when taken in 
 the proper quantity, and without any detriment to the health of the 
 female. He states, also, that it was habitually resorted to by slaves 
 in the South as an ecbolic for the criminal purpose of inducing abor- 
 tion, a fact which I have in past years had named to me a number of 
 times by Southern practitioners. Dr. B. infers, from its influence on 
 females, that the use of it destroys the generative capacity, rendering 
 the person sterile, without impairing the health ; should this eventually 
 prove to be the case, the bark of cotton root will become a most 
 important article of our materia medica, a boon to physicians, and 
 likewise to females with deformed pelves; and it is to be desired that 
 its value in this matter will 'be thoroughly investigated. It is used in 
 strong decoction as an ecbolic or oxytocic, of which four fluidounces 
 may be taken every twenty or thirty minutes until the desired result 
 is obtained. It is quite difficult to obtain the recent root to use in 
 decoction; owing to this fact, the specific tincture will probably be 
 found the most reliable preparation on the market. It may be used 
 in from five to ten drop doses every two or three hours until the 
 effect is perceptible. 
 
 8. Professor Giordano, of Turin, advises the application of solid 
 nitrate of silver to the cervix, as being of easy execution, prompt and 
 complete in its results, and followed by no ill consequences. Having 
 introduced the caustic within the cervix, he imparts to it repeated, but 
 slight, rotatory movements, so that most of the surface may undergo 
 the process of cauterization. This, however, I do not consider a safe 
 method, and it is certainly one for which there is no necessity.
 
 INDUCTION OF PREMATURE LABOR. 
 
 653 
 
 9. Probably the best and most ready method at present known to 
 the profession is the use of India-rubber bags, which act somewhat 
 similarly to the natural bag of waters, and effect safe delivery in from 
 one to six hours, without any danger of injury to the mother or child. 
 These bags are of several sizes, and have, at one extremity, a long 
 elastic tube with stop-cock attached. Commencing with the smallest, 
 this is well oiled, then introduced into the cervix uteri and a little 
 beyond the inner os, and air or warm water is injected into it through 
 the tube. If required, the next size is then employed in the same 
 manner, and so on. Dr. W. Molesworth, of New York city, has 
 made a decided improvement upon these elastic bags in what he terms 
 his "climax dilator," which is more convenient; can be employed 
 with greater facility; does not increase in length, but dilates uniformly 
 from side to side; can be used with either air or warm water, the latter 
 being preferable; and the degree of dilatation of which can at all 
 times be determined by the amount of water employed. It is also 
 exceedingly useful in placenta prsevia and other conditions, in 
 which it becomes necessary to promptly effect dilatation of the os 
 uteri, as, in operations for uterine polypus, fibroid tumor, etc.* (See- 
 Fig. 94). 
 
 FIG. 94. 
 
 MOLESWORTH'S CLIMAX DILATOR. 
 
 After uterine contractions have been fully established by the 
 adoption of either of the above measures, to induce premature de- 
 livery, the labor will proceed in the same manner as at full term, and 
 its management, as well as that of the placenta, will also be the same 
 as recommended at that period.. As a prematurely delivered child is 
 more feeble than one fully developed, some care will be required in 
 its management; it should be kept warm, allowing it, however, a free 
 use of its limbs, and a wet nurse should always be provided for it, 
 who should be directed to adopt a system of regularity in applying it 
 to the breast, at no time allowing it an excess of aliment.
 
 654 KING'S ECLECTIC OBSTETRICS. 
 
 CHAPTER XLVIII. 
 
 PUERPERAL FEVER PERITONITIS PUERPERAL SEPTICEMIA - 
 
 INFLAMMATION OF THE UTERINE APPENDAGES METRITIS 
 
 UTERINE PHLEBITIS INFLAMMATION OF THE 
 
 UTERINE ABSORBENTS TREATMENT 
 OF PUERPERAL FEVER. 
 
 ONE of the most dangerous forms of disease to which the puerperal 
 woman is liable, is that commonly known as PUERPERAL or 
 CHILD-BED FEVER concerning which there have been, from 
 time to time, various and discordant opinions expressed by medical 
 writers, as well as sundry modes of treatment recommended, each 
 being based upon the particular theory supported by its originator. 
 This clashing of views has, perhaps, originated from the fact, that the 
 malady termed puerperal fever, has included several phenomena which 
 have not been uniform, and which have yielded to the most opposite 
 plans of treatment and, each writer being entirely governed in his 
 opinions upon the subject, by the particular symptoms and circum- 
 stances presented to his individual notice, has, probably, been induced 
 to infer that, while others have mistaken the true nature of the disease, 
 he has correctly ascertained it, together with the best treatment for its 
 cure. At the present day it is generally acknowledged that the malady 
 varies in its pathological characteristics. It has been variously called 
 puerperal peritonitis, puerperal metrophlebitis, puerperal pyemia, and 
 puerperal septicemia; the latter being probably the more correct term, to 
 apply to the severe and rapidly fatal form of the disease which occurs 
 shortly after parturition. Professor J. Matthews Duncan, M. D., of 
 Edinburgh, Scotland, in an address to the British Medical Association 
 at Norwich, August, 1874, in the course of his remarks, observed : " Xo 
 theory of this subject (child-bed fever) can be regarded as final or sure. 
 But the time has come when obstetricians should try to leave off the 
 use of the convenient term puerperal fever, because it embodies error. 
 There is nothing essentially puerperal known in it; nor is there any 
 thing of the nature of a fever, as that term is generally understood. 
 A new name, already widely used, is to be found in the already com- 
 paratively old term pyemia. This new name can be of only temporary 
 utility, but that utility wilJ be very great, and continue till advancing 
 science displaces it by a better, as it should now displace puerperal or
 
 PUERPERAL FEVER. 655 
 
 child-bed fever. It will then have served its time by carrying the 
 ideas of generations of practitioners away from the old, flimsy, and 
 extensively erroneous speculations of the past to the more substantial 
 of this day." 
 
 Puerperal fever (pyemia) has, heretofore, proved very fatal in its 
 result, destroying a large majority of those who have been attacked 
 by it, and has undoubtedly occasioned more than two-thirds of the 
 deaths which have occurred among females at the puerperal period. 
 It is stated to be more malignant in hospital than in private practice, 
 which may be owing to the congregation of too many patients in a 
 ward, as well as to a neglect of proper ventilation, and thorough and 
 constant cleanliness of the various lying-in apartments. The poorer 
 classes of society, from their indigent mode of living, and the illy- 
 ventilated, unclean, and damp rooms, which their circumstances compel 
 them t& occupy, are also said to be more subject to the disease than 
 those who can obtain the proper necessaries and conditions for health, 
 and it also proves much more fatal among them. 
 
 The attack commonly occurs within two or three days after delivery, 
 but it has been met with previous to labor, and also at the third or 
 fourth week succeeding it, depending upon the peculiar form or variety 
 of the disease, its cause, etc.; and when it does occur, it usually runs 
 its course speedily. 
 
 CAUSES. Puerperal fever most generally prevails as an endemic, 
 and it is not uncommon, at endemical seasons, to observe that nearly 
 every puerperal woman within the abnormal district suifers from an 
 attack. This may be owing to the great susceptibility which the parts 
 must have to diseased action, arising from the nervous shock, the 
 sudden evacuation of the abdominal cavity, the powerful contractions 
 of the uterus and abdominal muscles, and other circumstances con- 
 nected with labor, and more especially to the wound* in the uterus, 
 
 * "But it is not * * * to be supposed that practitioners are not bound by the 
 most solemn considerations to take most scrupulous care against being disseminators 
 of disease ; and there is no disease with which they deal, where such care is more 
 imperative in them than puerperal pyemia. The puerperal woman presents in her 
 contused, lacerated, and inevitably wounded passages the most i'avorable nidus for the 
 reception of morbific material; and the woman suffering from puerperal pyemia in any 
 of its forms, and the patient suffering from some of the allied diseases, present this 
 morbific material in its subtlest and most potent essence. A well-demonstrated com- 
 municability arises from this source. No other has been demonstrated, but it is possible 
 that in an ill-managed hospital there may be some other. For the existence of another 
 source, several of the best recent authors offer slight evidence ; but, on the other hand, 
 its existence is rendered very doubtful by the alleged absence of pyemia in those sur- 
 gical hospitals or parts of hospitals where the antiseptic treatment of Lister is properly 
 carried out". Prof. J. Matthews Duncan.
 
 656 KING'S ECLECTIC OBSTETRICS. 
 
 resulting from the detachment of the placenta, to contusion of the- 
 lymphatics, or to laceration of any portion of the genital passage, in 
 association with putrefied material from decomposed particles of 
 placental or decidual tissue, or of the lochial discharge, and which is 
 undoubtedly the chief, if not the only, cause of the true puerperal 
 disease ; indeed, when we consider all the phenomena present during 
 the birth of a child, and more especially in difficult, and instrumental 
 labors, it is rather a source of astonishment, that the disease is not 
 still more frequently met with. When occurring as an endemic, it is 
 more malignant and fatal in its character than when it exists auto- 
 genetically, and those females more readily fall victims to it, who are 
 exposed to any of the causes hereafter assigned for its spontaneous 
 advent. 
 
 Independently of an endemic origin, puerperal fever, it has been 
 stated, may be produced by an exposure to cold, or to dampness; by 
 an omission of the bandage; by the female arising from her bed at too 
 early a period; by allowing her improper food, or stimulants,- during 
 the first puerperal week ; by violent emotions of the mind, whether 
 of a depressing or exciting character; by a retention of portions of 
 the placenta; by want of cleanliness and ventilation; it may likewise 
 follow hemorrhage, manual or instrumental operations, and, not- 
 withstanding that venesection is frequently recommended as a means 
 to overcome the disease, yet we find that it frequently follows exces- 
 sive floodings. I have several times' noticed a disease resembling it 
 (intestinal irritation), to follow a constipated condition of the bowels, 
 in cases where the attending accoucheur had permitted the patient 
 to remain without any alvine evacuation for ten or twelve days. 
 Manual and instrumental labors frequently render the puerperal 
 female especially obnoxious to this disease. And again, it is often 
 impossible to assign any satisfactory cause for its origin. 
 
 It has also been supposed to have been produced or modified in its 
 character by the presence of scarlatina, small-pox, etc. That there is 
 a close alliance between it and epidemic erysipelas I have no doubt, and 
 such are the views entertained by most writers and teachers. It is well 
 known that erysipelas has been occasioned by puerperal fever, while on 
 the other hand erysipelas has given rise to puerperal fever. Thus, 
 these two diseases may present themselves as modifications of the same 
 morbid condition of the blood (putrid infection), each one presenting 
 symptoms of a varied character, according to the changes and conditions 
 resulting from age, character of labor, period of attack after delivery, 
 resisting power, temperament, habits of life, predisposition, etc. With
 
 PUERPERAL FEVER. 657 
 
 regard to the effects of this same cause of infection, an eminent French 
 physician, who has bestowed considerable attention to its investigation, 
 observes : 
 
 " But this morbid influence once felt, the anatomical modifications 
 which accompany it, having neither constancy nor fixed place of 
 election, it will follow that these manifestations will be expressed by 
 the lesion of the organs whose vitality is excited, and which their 
 irritation predisposes to become the seat of serious changes. In the 
 lying-in women, it will be the lymphatic vessels and veins of the 
 uterus, the uterus itself and peritoneum hence, puerperal fever with 
 its so frequent complications of lymphangitis or of uterine phlebitis, 
 of metritis and peritonitis. In the wounded, in whom the venous and 
 lymphatic system is injured, it will likewise be lymphangitis, erysipe- 
 las, and purulent absorption. On the subject whose skin, hardly 
 excoriated, presents but few irritated lymphatics, it will be lymphan- 
 gitis and erysipelas. If we view the local lesion in this way, although 
 we recognize the anterior existence of the general aifection, which 
 alone, to speak truly, constitutes the disease, we find the explanation 
 of its most marked symptoms, the erysipelatous eruption, which, in 
 the women submitted to our observation, had always for a starting 
 point a slight solution of the continuity of the skin," M. Pihan- 
 Dufeillay, 
 
 Of late years there have been considerable thorough and careful 
 researches as to " the infective product of all acute suppurative inflam r 
 mations, as well as into the distinctive characters of the noxious or 
 septic, and the innocuous, bacteria." Dr. B. Sanderson, of London, 
 England, in a communication to the Pathological Society of London, 
 on pyemia, observes : " I wish to show (1) that every pyemic abscesa 
 contains a poison, which, when introduced either into the circulation 
 or into a serous cavity, produces the symptoms of pyemia; and (2) 
 that we have this poison so entirely in our possession, and so' far under 
 our control, that beginning with an agent so mild in its action that it 
 produces no marked symptoms, we can convert it into an agent of such 
 intensity, that it kills in two or three hours, with 'the formidable 
 symptoms seen in the case we have now before us. 
 
 " This intensification is effected by a process which may be called 
 cultivation. Dr. Klein made the important discovery, that,' if a 
 pyemic liquid were transferred to the peritoneum of a guinea-pig, and 
 allowed to remain there for a couple of days, although it did not at 
 first produce any intense symptoms in the animal itself, its tox'ic' in- 
 tensity increased in such a degree that, when the transudation-liquid 
 42
 
 658 KIM;'S KCLKCTIC oi',sTirn;ics. 
 
 produced in this was injected into another animal, it had acquired the 
 most deadly activity; and that all such extremely active liquids were 
 crowded with bacteria of a peculiar character, the increased number 
 of which seemed to be in proportion to their toxic properties."* 
 
 Again, he replied to remarks, from some of the members of the 
 society, concerning the presence of bacteria, etc.: "As regards bacteria 
 in general, I am well aware from my own experiments, that the ordinary 
 bacteria of putrefaction possess no toxic action, and that liquids con- 
 taining them can be injected into the circulation of living animals 
 without result. As regards the bacteria of pyemic products, I have 
 carefully guarded against the inference that they were the efficient 
 causes of pyemia. I regard them as only characteristic inhabitants 
 of infective liquids, and therefore very probably carriers of infection. 
 As regards the word septicemia, I consider it to mean a state of the 
 blood which was only present in the most intense forms of pyemia, 
 and I agree with Mr. Hulke in regarding metastatic abscesses as an 
 accident, rather than as an essential of pyemic infection." 
 
 The malady occurs more frequently, and with greater malignancy 
 in cold seasons, and during damp, or moist conditions of the atmos- 
 phere, while in warm and dry seasons it is less common, and more 
 favorable in its results. 
 
 Much has been said about the contagious, or non-contagious char- 
 acter of puerperal fever; some of our most eminent medical men 
 maintaining that it is decidedly contagious, and others, equally as dis- 
 tinguished, supporting an opposite opinion. It is a very difficult 
 matter to satisfactory determine this question, because the extension 
 of the disease, during its endemic existence, may be safely attributed 
 to its endemic nature; while, on the other hand, instances have 
 occurred which so strongly manifested a contagion, or an extension 
 without endemic influences, that, to say the least, it would be exceed- 
 ingly impolitic to make any positive declarations relative thereto. 
 Perhaps, there may be some forms of this disease, as for instance the 
 erysipelatous, which may be communicable, even when it occurs 
 sporadically; while other spontaneous forms are, probably, never 
 contagious ; the subject requires still further investigation. 
 
 I can not, however, divest myself of the opinion, that it is a con- 
 tagious disease, especially the typhoid and erysipelatous varieties ; for, 
 
 * These microscopic animalcnlar or vegetable infusoria, have been observed hv a 
 number of observers in pyemic pus and blood, as micrococci ; bacterium termo ; b. lineola, 
 b. bacillus,' the latter three due to putrefaction.
 
 PUERPERAL FEVER. 659 
 
 notwithstanding the statements and reasonings of those eminent gen- 
 tlemen who favor the side of non-contagion, I have witnessed so many 
 instances in which its existence could be accounted for in no other 
 way than by contagion, that other explanations than those I have met 
 with will be required to change my views on this subject. Peritonitis, 
 metritis, etc., may exist at the puerperal period, independent of any 
 pyemic infection, and though they may be modified to a greater or less 
 degree by the puerperal condition, it does not absolutely render them 
 contagious ; and where these forms of puerperal fever exist, it is 
 possible the disease may be non-contagious. In the present unsettled 
 condition of this question, whatever may be our opinions, I believe 
 with Dr. R. Lee, " that it is our duty to act in all cases as if the con- 
 tagious nature of the disease had been completely demonstrated." 
 The accoucheur who is attending a case of puerperal fever, should, for 
 a season, avoid waiting upon any parturient females ; he should like- 
 wise forbid the presence of pregnant women within the apartment of 
 his patient, as instances have occurred, where the only assignable 
 cause for the attack, was the presence of the female, during pregnancy, 
 in the room of a child-bed fever patient. It is likewise stated by 
 some authors, that a similar exposure of the non-pregnant female, 
 during the catamenial period, has occasioned fever of a somewhat 
 similar character. 
 
 As to the contagious nature of fevers during the puerperal period, 
 Prof. Leishman calls attention to cases cited by Dr. Tyler Smith, 
 viz.: "Two medical men, brothers and partners, attended, in the 
 space of five months, twenty cases of midwifery. Of these, fourteen 
 were affected with puerperal fever, a fatal result ensuing in eight 
 cases. The only other known death from puerperal fever in the 
 same town, within the period named, occurred in the case of a 
 patient attended by a medical man who had assisted at the post- 
 mortem of one of these puerperal patients. After this disastrous 
 period the two brothers relinquished all their midwifery engage- 
 ments for one month, in which time five of their cases were attended 
 by other practitioners, and no instance of fever occurred in the 
 course of that month. They then returned, and several fatal cases 
 again happened. Mr. Robertou, of Manchester, 
 
 relates, perhaps, one of the most cogent instances of contagion and 
 fatality on record. In the space of one calendar month, a certain 
 midwife attended twenty cases belonging to a lying-in charity; of 
 t'icso, sixteen had puerperal fever, and all died. The other mid- 
 wives of the sain:; charity, working in the same district, attended, in
 
 C60 KING'., ECLECTIC OBSTETRICS. 
 
 the same time, 380 cases, none of whom were affected with puerperal 
 fever. In another large town, containing many thousands of inhab- 
 itants and numerous medical men, fifty -three cases of puerperal fever 
 occurred. Of these, no loss than forty happened in the practice of 
 one medical man and his assistant." Many other instances, in sup- 
 port of the contagious character of this fever, might be given ; the 
 above, however, are deemed sufficient. 
 
 The several varieties of puerperal fever, classified according to 
 the pathological conditions which are present, may be described as 
 follows : * 
 
 1. Peritonitis, or inflammation of the uterine peritoneum, and 
 peritoneal sac. 
 
 2. Inflammation of the uterine appendages, as the ovaries, Fallopian 
 tubes, and ligaments. 
 
 3. Metritis, or inflammation of the mucous, and muscular, or proper 
 tissue of the uterus. 
 
 4. Uterine phlebitis, or inflammation and suppuration of the veins 
 of the uterine organs. 
 
 5. Inflammation of the uterine absorbents. 
 
 6. No primary inflammation, but severe symptoms of a malignant 
 typhoid nature, undoubtedly due to absorption of putrid material. 
 
 I. PERITONITIS, of the lying-in female, is usually, but not 
 always, ushered in with rigors, more or less severe in their character, 
 and which are preceded, accompanied, or followed by uterine tender- 
 ness, or pain. The rigors may be very slight, scarcely perceived by 
 the patient, or they may be very violent, resembling an attack of 
 intermittent fever, with coldness of the extremities. The pain, how- 
 ever slight it may have been at first, gradually increases in severity, 
 at the same time extending itself over the abdomen. In the early 
 part of the disease it may be mistaken for after-pains, but may be 
 determined from them, by making pressure, during the intervals, 
 over the iliac and hypogastric regions if no pain or soreness is 
 produced, there is no peritonitis. But if the pain has obstinately 
 persisted for several days, with symptoms of constitutional disturb- 
 ance, there will be strong reasons for suspecting a lurking inflamma- 
 tion. Commonly, when pressure is made over the regions just named, 
 the patient being attacked with peritonitis, will complain of pain. 
 Cases, however, are recorded in which the most severe form of puer- 
 peral peritonitis existed, without any tenderness or pain in the 
 abdominal region.
 
 PUERP-ERAL FEVER. 661 
 
 The rigors pass away after a short period, and are followed by 
 febrile symptoms, as flushed face, great heat of the surface, thirst, 
 sometimes nausea and vomiting, short and hurried respiration, and an 
 intense pain across the forehead. The pulse, during the rigor, is 
 usually full, strong, and accelerated, beating from 110 to 140 in a 
 minute ; but as the disease progresses, it loses its hardness and volume, 
 and becomes more frequent, small, and wiry, beating from 130 to 160 
 and upward in a minute ; and in all cases when the pulse of a puer- 
 peral female remains persistently above 100 beats in a minute, it is 
 good evidence of the existence of some abnormal action. The tongue 
 is usually covered with a thin, moist, white or cream-like film, but 
 red at the edges; and sometimes the whitish film is absent, and the 
 whole surface of the organ is red. As the disease progresses, the 
 coating becomes yellowish or brown, and occasionally there will be a 
 dryness of the tongue, with a brownish coat from the commencement. 
 The lochial discharge may be completely suppressed, or only lessened 
 in quantity, and occasionally it continues to flow as usual. The secre- 
 tion of milk is most generally suspended, and the mammae become 
 flaccid. The urine is scanty, turbid, or high-colored, with more or 
 less difficulty in voiding it. Obstinate constipation is ..generally 
 present in the early part of the disease. The countenance of the 
 patient is peculiar, after the disease has formed itself completely, 
 presenting a ghastly, pallid, anxious, and suffering appearance, with a 
 livid hue under the eyes. Sometimes a crimson patch will be observed 
 on one or both cheeks, which is an unfavorable symptom. 
 
 At the onset of the disease the abdomen is generally soft and 
 flaccid, but becomes swollen and tympanitic as the disease advances. 
 From the commencement of the attack, any motion of the lower 
 limbs will occasion more or less pain: when this is severe, the patient 
 usually lies upon her back, with the knees drawn up to the abdomen; 
 which posture she retains on account of the pain caused by extending 
 them. The pain eventually becomes so intense that she is unable to 
 bear the least pressure upon the abdomen; the bandage will have to 
 be loosened or removed altogether, and frequently the hands will be 
 employed in holding up the bedclothes to remove their weight from 
 the suffering parts. The least motion, as turning on one side, cough- 
 ing, etc., occasions great suffering, in consequence of which she lies 
 remarkably still, manifesting her distress and uneasiness by screams 
 and moans, by throwing her arms about, and occasionally turning her 
 head from side to side. With the tympanitic condition of the abdo- 
 men the pain will become more aggravated, or it may entirely subside.
 
 KING'S KCI.IOCTIC OIJSTKTUICS. 
 
 The patient will frequently be indifferent to the welfare of her infant,, 
 even refusing to give it suck. 
 
 As the inflammation extends throughout the abdominal organs the 
 tympanitic condition of the abdomen increases; the vomiting, which 
 was at first mucous or bilious matter, becomes green, brown, or 
 blackish, like coffee-grounds; the evacuations become dark and fetid, 
 or a diarrhea may be present, which is an unfavorable symptom ; the 
 skin becomes cold and clammy; the pain ceases, an evidence that 
 effusion has taken place; if the diaphragmatic peritoneum has been 
 involved in the inflammation, hiccough takes place. Generally, the 
 female retains her senses until near the end of the disease, when lo\v. 
 muttering delirium ensues, with carphologia, or picking at the bed- 
 clothes; the lips, hands, and feet become purple; the pulse gradually 
 diminishes, ceasing at the wrist, elbows, and axillae, when death 
 speedily closes the scene. 
 
 All the symptoms named will not generally be found in any one 
 case; perhaps the most uniform among them is the frequent pulse. 
 This, together with rigors, pains, vomiting, and tympanitis, are more 
 commonly observed. 
 
 DIAGNOSIS. It is not a very easy matter to determine between 
 the varieties of uterine inflammation, in puerperal fever, as the symp- 
 toms, in a great measure, bear some resemblance ; nor, in a practical 
 point of view, is it of much importance, as the treatment in each of 
 them, whether existing singly or combined, will be nearly the same. 
 Yet it will be proper, notwithstanding, to name some of the distin- 
 guishing marks between peritonitis and other disorders, for which it 
 may sometimes be mistaken. 
 
 It may be determined from hysteralgia, or after-pains, by observing 
 that in these there is but little tenderness on pressure during the 
 absence of the pains; that the uterus perceptibly contracts and hardens 
 when they are present, which is not the case with the peritonitic pain ; 
 and that the pains dimmish from day to day, w r hile that of peritonitis 
 rapidly augments. The pulse is frequent, in puerperal fever, and but 
 seldom so in hysteralgia; and when this is the case, unlike the pulse 
 of peritonitis, it soon falls to a normal condition. In peritonitis, the 
 disturbance to the general system increases every day, while in hys- 
 teralgia it gradually ceases. 
 
 Intestinal irritation, from depraved secretions or fecal accumulations, 
 is frequently mistaken for puerperal fever. The difficulty generally 
 attacks at a later period than peritonitis, and does not occasion so 
 much constitutional disturbance. The pain in the abdomen is equally 
 diffused, and does not spread from a focus ; the uterus is not tender
 
 1'EKiTu-Nms . G63 
 
 r.or enlarged; the abdomen is soft and puffy, not tympanitic, nor does 
 pressure aggravate the pain to any extent, and the patient can more 
 readily move in bed. In each there may be chills, heat of skin, head- 
 ache, rapid pulse, loaded tongue, flatulence, nausea, vomiting, and 
 diarrhea or constipation. Intestinal irritation is said to be frequently 
 confounded with peritonitis, and has been supposed to be the reported 
 "violent cases of peritonitis in which the patient dies between the 
 stage of excitement and of effusion, and no effusion or signs of inflam- 
 mation are found." 
 
 In metritis or hysteritis, but little pain is produced on pressing the 
 abdominal parietes until the enlarged uterus is touched, while in peri- 
 tonitis, the least degree of pressure on the abdomen causes severe 
 pain. The other symptoms of metritis are less general than those of 
 peritonitis. 
 
 POST-MORTEM APPEARANCES. The peritoneum, especially 
 that portion covering the uterus, is red, vascular, thickened, and some- 
 times softened, and is frequently covered with a layer of lymph, 
 resembling a false membrane, which occasions adhesions between the 
 omentum and intestines, and sometimes between the omentum and 
 fundus uteri. The redness will be the more intense, and the thicken- 
 ing of the peritoneum the greater, in proportion to the duration of 
 the pain and the severity, of the disease. The omentum frequently 
 exhibits marks of inflammation, being red and highly vascular; and 
 this may be found without any evidences of inflammation of the peri- 
 toneum. The serous coverings of the several organs, in the cavity 
 of the abdomen, may exhibit evidences of inflammatory action. . A 
 turbid, whey-colored, or red serum, with purulent or albuminous 
 shreds floating in it, or a yellowish lymph, are effused, in greater or 
 smaller quantity, into the peritoneal cavity, and sometimes blood will 
 be found, alone, or mixed with the serous fluid. Pus is frequently 
 found deposited behind and around the uterus, beneath its peritoneal 
 covering, and at those points where the inflammation has appeared to- 
 be the most active. 
 
 II. INFLAMMATION OF THE UTERINE APPENDAGES, 
 
 may exist in conjunction with inflammation of the peritoneal covering' 
 of the uterus, or it may occur entirely independent of it: more fre- 
 quently, however, they are met with together, and when this happens, 
 the symptoms common to peritonitis will be present, with the addition 
 of those which belong to inflammation of the appendages. 
 
 When the serous membrane and proper tissue of the ligaments, 
 Fallopian tubes and ovaries are attacked with inflammation, while the
 
 6G4 KING'S KCLKCTIC OBSTETRICS. 
 
 peritoneal sac is but slightly affected, or not at all, the pain will he 
 located principally in one of the iliac fossae, extending from thence to 
 the groins, anus, and down the thighs. On making pressure, the pain 
 will be experienced in the lateral portions of the hypogastrium, and 
 will be less intense than in general peritonitis. An examination per 
 vaginara will find the upper part of this canal hot and painful. The 
 constitutional symptoms are. similar to those of peritonitis, as rigors, 
 hot skin, thirst, headache, frequent pulse, etc. When the attack is 
 severe, prostration takes place rapidly, and the disease may speedily 
 prove fatal. Or, it may terminate in resolution, without injury to the 
 organs; with obliteration of one or both of the Fallopian tubes; or 
 with adhesions between the tubes and parts in proximity, or of por- 
 tions of serous membrane, and which may subsequently prove 
 injurious. 
 
 Or, it may terminate in suppuration, matter being formed in the 
 ligament or ovaries, and escaping into the peritoneal sac ; through the 
 vaginal or rectal walls; or, through the walls of the abdomen in the' 
 neighborhood of Poupart's ligament. 
 
 POST-MORTEM APPEARANCES. The surface of the Fal- 
 lopian tubes, ovaries, and broad ligaments, are red and vascular, and 
 are imbedded to a greater or less extent in pus or lymph. The 
 fimbriated extremities of the tubes are of- a deep-red color, and fre- 
 quently softened, and diffused or circumscribed deposits of pus may 
 be observed beneath their coverings, and in their cavities. Effusions 
 of pus or serum may likewise be found between the folds of the broad 
 ligaments, and small masses of pus will be met with, dispersed 
 throughout the enlarged ovaries ; or these organs may be converted 
 into a cyst holding pus, which escapes through ulcerated openings. 
 One or both of the ovaries may exhibit evidences of inflammatory 
 action, their peritoneal coat being red, vascular, and imbedded in 
 lymph. They may be greatly enlarged, swollen, red, and pulpy, or 
 there may be no apparent change in their parenchymatous structure. 
 On dividing the ovaries, a great augmentation of vascularity will be 
 seen, with a softening, or complete disorganization of its proper tissue. 
 Occasionally, there will be an effusion of .blood into the Graafian 
 vesicles, destroying their texture. 
 
 III. METRITIS, HYSTERITIS, or INFLAMMATION OF 
 THE UTERUS, commences most commonly on the third or fourth 
 day after delivery, usually, but not invariably, with rigors, followed 
 by a hot and dry skin, thirst, headache, accelerated pulse, dry and
 
 METRITIS UTERINE PHLEBITIS. 665 
 
 furred tongue, with pain and tenderness in the uterine region, though 
 pressure upon the abdomen occasions no pain until the hard and 
 enlarged uterus is reached. The abdomen, at first soft, becomes 
 tympanitic, and if the proper remedies are withheld the inflammation 
 may extend to the peritoneum, when the pain will spread over the 
 abdomen, being attended with the symptoms peculiar to peritonitis. 
 The lochial discharge may be diminished or suspended, and mav 
 remain unchanged, or become of a dark color, and very fetid. Thr 
 secretion of milk is generally defective; the urine is scanty, occasion- 
 ing much pain when voided. A vaginal examination will find the 
 os uteri very hot and tender. 
 
 In the more severe attacks, the above symptoms will exist in an 
 augmented degree, with a pale countenance expressive of pain and 
 great anxiety. The skin frequently becomes cold, assuming a sallow 
 or bluish tinge. The pulse becomes rapid and feeble; the respiration 
 hurried and distressing, with excessive prostration of strength. The 
 pulse is more'feeble, and the patient becomes more speedily prostrated, 
 than in peritonitis. 
 
 If the disease progresses without amelioration, the tongue becomes 
 coated with a dark or brown fur; the teeth and lips covered with 
 'sordes; the extremities become cold, with cold and clammy perspira- 
 tion; vomiting is most usually present and also an obstinate diarrhea, 
 the strength fails rapidly, with coma, or low muttering delirium, 
 subsultus tendinum, and death. Metritis may terminate in resolution, 
 abscess, softening, or gangrene ; the milder varieties in the first- 
 named, and the more severe in one of the latter. 
 
 POST-MORTEM APPEARANCES. The uterus will be found 
 
 
 enlarged, and its substance soft and flabby, presenting a dark purple, 
 grayish, or yellowish pulp, sometimes of a very offensive odor, and 
 which may exist in patches, or occupy a large tract of the organ. 
 The softening generally proceeds from the inner uterine surface, and 
 extends through, involving the peritoneal covering. Frequently 
 there will be extensive disorganization of the muscular tissue of the 
 uterus, without any change in the character of the peritoneal coat. 
 All parts of the uterus may be attacked by inflammation and soften- 
 ing, and, frequently, that portion to which the placenta was attached 
 is alone found to be disorganized. Coagulable lymph forming false 
 membranes, and mixed with blood, and lochia, are also found on the 
 inner mucous membrane; and in a few instances, instead of a com- 
 plete disorganization of the muscular tissue of the uterus, small 
 -abscesses containing pus have been found in this tissue.
 
 666 KING'S i-;< I,K< TI< <>];STKTRICS. 
 
 The peritoneum, covering the inflamed part of the muscular coat 
 of the uterus, very o,ften presents evidences of inflammatory action ; 
 it may be red, yellow or livid, having a disposition of lymph on its 
 imrface, or without this, but so softened in its texture as to be 
 readily torn. 
 
 IV. UTERINE PHLEBITIS, or inflammation of the veins of the 
 uterus, may be produced by any of the Causes that occasion the other 
 forms of puerperal fever. The symptoms are similar to the preceding 
 attacks, as rigors succeeded by hot skin, thirst, accelerated pulse 
 headache, etc., together with pain in the uterine region, which is much 
 increased on pressure, and a suppression of both the lochial discharge 
 and the secretion of milk. Frequently a confusion of mind, or inco- 
 herency will be observed. 
 
 The disease progresses very rapidly, the symptoms augmenting in 
 intensity; rigors will frequently be present, especially during the 
 early part of the attack, succeeded by an increased heat o-f the surface, 
 the tongue becomes dry and brown, with insatiable thirst, rapid, full 
 pulse, hurried respiration, vomitings of a greenish fluid, tremors of 
 the muscles of the face and extremities, excessive drowsiness, or violent 
 delirium. The body becomes of a deep sallow color, and sometimes* 
 petechise, or vesicular eruptions will be seen on various parts of it. 
 The abdomen is frequently swollen and tympanitic, and the tenderness 
 in the uterine region is increased; occasionally, no pain is present. 
 
 Death may take place during the acute stage, or the patient may 
 recover from the primary attack and have her life shortened by sec- 
 ondary affections of the other parts, as for instance : congestion of the 
 vessels of the brain, and deposition of lymph or serum into the ven- 
 tricles; arachnitis; softening of portions of the brain; or deposit of 
 pus into the cerebral substance. Congestions of the lungs, or disor- 
 ganization of their substance; pleuritis; effusions of serum or blood; 
 gangrene, etc. Hypertrophy of the heart with softening, and occa- 
 sionally depositions of lymph and serum in the pericardium. Inflam- 
 mation and softening of the mucous coat of the stomach; effusions 
 of reddish serum between its mucous and muscular tissues. Softening 
 and perforation of portions of the intestines. Congestion, softening, 
 or abscess of the liver, or of the spleen. Inflammation of the kidneys, 
 with depositions of pus, softening, etc. Inflammation of the conjunc- 
 tiva, with effusion of lymph in the anterior chamber, destroying sight. 
 Inflammation of the joints, with abscess, and infiltration of a sero- 
 sanguineous 'fluid into the muscles or cellular substance of the limbs,.
 
 TRITE PUERPERAL FEVER. 667 
 
 presenting the appearance of erysipelas. Sometimes abscesses form 
 discharging enormous quantities of pus, rapidly prostrating the patient. 
 
 DIAGNOSIS. This is very difficult to distinguish from the pre- 
 ceding varieties, especially during its early stage. The pain and 
 tenderness is- more confined to one spot than in peritonitis, and when 
 the disease has continued for some time, the secondary affections will 
 manifest themselves. 
 
 POST-MORTEM APPEARANCES. The uterine veins are found 
 changed, having their coats thickened, and their canals frequently so 
 closely contracted as to be almost, if not quite impervious; and their 
 lining membrane will be pale and covered with lymph or pus, fre- 
 quently it will be of a bright scarlet color. Similar conditions will 
 be found when distant veins are involved, with a hardening of the 
 surrounding cellular tissue, which contains depositions of pus. Most 
 commonly the inflammation is confined to the veins of one side only, 
 and which is the side corresponding with that of the placental attach- 
 ment. Occasionally the veins will be plugged up with firm coagula, 
 or other abnormal substances. Beside the uterine veins, the spermatic 
 are more frequently affected and the disease may extend rapidly to 
 the hypogastric veins. The renal veins are generally involved, with 
 a soft and vascular condition of the substance of the kidney. 
 
 V. INFLAMMATION OF THE UTERINE ABSORBENTS, 
 or LYMPHATICS, presents all the symptoms common to uterine 
 phlebitis, from which it is almost impossible to distinguish it. It is 
 likewise followed by secondary affections similar to that disease. 
 
 POST-MORTEM APPEARANCES. Pus is found at different 
 points of the lymphatics, generally at nearly regular intervals, pre- 
 senting a beaded appearance. 
 
 VI. NO PRIMARY INFLAMMATION, TRUE PUERPE- 
 RAL SEPTICEMIA, or PYEMIA, in the more severe degrees of 
 which the vital powers rapidly fail, and death occurs before inflam- 
 mation has had an opportunity to manifest itself. It is ushered in, 
 within a few days succeeding delivery, with violent rigors, or with a 
 peculiar, chilly sensation, greatly increased temperature, varying from 
 100 to 108, quick and small pulse, 96 to 150, and extreme depres- 
 sion of the vital powers ; not unfrequently an offensive diarrhea will 
 come on within from twelve to thirty-six hours from the commencement 
 of the attack, and at a later period, say in from twenty-four to forty- 
 eight hours, dyspnoea may appear, being due probably to the blood 
 globules having lost the property of complete hematosis. The face-
 
 068 KING'S KCU-XTI.' OUSTKTIIICS. 
 
 becomes pale with an expression of anxiety, and the features pinched 
 and sunken; headache is frequent, with nervous prostration and mental 
 indifference, the patient seldom complaining or even evincing an inter- 
 est in her condition. The speech and movements of the patient are 
 tremulous; the mind is clear during the day, but at night-, there will 
 often be observed a kind of suhdelirium, however, without agitation. 
 The breath is more or less fetid; the tongue dry and fuliginous: the 
 skin becomes covered with a cold, clammy perspiration : the muscles 
 flabby and enfeebled, with suppression of the lacteal secretion, as well 
 as of the lochial flow. Sometimes, but not always, there are abdom- 
 inal pains; more commonly tympanitis ; and frequently vomiting of 
 a greenish substance. The urine is scant, high colored, containing an 
 excess of urates, and, frequently, albumen. The extremities and 
 trunk become more or less covered with purplish spots. Prostration 
 rapidly ensues, the mind begins to wander, with drowsiness, speedily 
 followed by death on the third or fourth day from the first manifes- 
 tations of illness. 
 
 All these symptoms are not invariably present, but will vary with 
 different individuals, from a mild " milk fever," to one of the most 
 malignant character. Chills are frequently absent in this form of the 
 affection, as in the others; and even, pain, abdominal tenderne-s. or 
 tympanitis, may not exist, even in those instances in which the sep- 
 ticemic form is associated with severe peritonitis. The malady may 
 exist merely as a blood disease, or, it may be associated with, and 
 modified by, the existence of one or more of the preceding named 
 inflammatory lesions. 
 
 M. A. D'Espine, who has devoted considerable attention to this 
 malady, gives the following conclusions: 
 
 " 1. Puerperal septicemia is constituted by a series of symptoms 
 more or less severe, according to the dose of septic material absorbed 
 by wounds on the walls of the utero-vaginal canal. 
 
 " 2. These symptoms present nothing that is special to the puerperal 
 condition, and may be assimilated to those which are caused by 
 septicemia in wounded subjects and in animals. 
 
 " 3. The starting point is always in the uterus or vagina ; all the 
 causes which prevent cicatrization of the uterine wound and which 
 favor the development of septic materials on its surface, are efficient 
 causes of puerperal septicemia. 
 
 "4. The lymphatics are the habitual road of the absorption of the 
 poison; lymphangitis is the usual but not a necessary indication .of 
 its passage.
 
 TKL'E PUERPEKAL FEVEK. 669 
 
 ^5. Peritonitis is an associated lesion due to the transmission of 
 septic material by the uterine lymphatic vessels; it may be compared 
 to the local inflammations which are developed around infected wounds. 
 
 "6. The effect of septic absorption on the organism is to determine 
 congestions and inflammations in all organs, especially the lungs, kid- 
 neys, and intestines ; subserous ecchymoses or interstitial apoplexies, 
 internal or external inflammations localized by preference in serous 
 membranes ; during life this action is manifested by fever, diarrhea, 
 pulmonary congestion, epistaxis, and often by temporary cutaneous 
 eruptions. 
 
 "7. Purulent absorption and septic absorption^ may be confounded 
 by the bedside. 
 
 " 8. There is no such affection as milk fever; the fever of the first ' 
 week is almost always a slight septicemia, due to an absorption of the 
 lochia, by small wounds on the walls of the utero-vaginal canal. 
 When the uterus does not contract,. and the lochia remain fetid, this 
 fever may persist for some weeks. In cases of this kind one may 
 almost always find ulcers in the neck or vagina. 
 
 " 9. These slight infections are often, but not always, accompanied 
 by uterine angioleucitis and signs of mild perimetritis. When the 
 infection is prolonged, it may lead to consumption and death (septic 
 phthisis). 
 
 " 10. Puerperal pyemia is a complication of septicemia, and almost 
 always coincides with suppuration in the veins of the uterus. This 
 complication, which is relatively rare, is due in all probability to septic 
 emboli. Visceral metastatic abscesses are tributary to this, whilst all 
 inflammations of the cellular tissue and of the articulations are due to 
 lymphatic infection, and are not embolic in their nature." Archiv* 
 Gen. de Medicine, October, 1872. 
 
 POST-MORTEM APPEARANCES. No peculiar anatomical 
 lesions belong to this affection. They will vary from a scarcely notice- 
 able softening of the lungs, liver, spleen, or kidneys, or a few weak 
 adhesions, etc., probably resulting from the poisoned and innutritions 
 condition of the blood, to the more severe and extensive pathological 
 appearances heretofore referred to under the various inflammatory 
 conditions with which it may be associated. The character of the 
 post-mortem lesions being due to the degree and extent, of the blood- 
 poisoning, the organs affected by it, and the degree and extent of the 
 inflammatory lesions with which it may be associated. The lesion will 
 often be found in the uterine veins, the mouths of which become
 
 670 KIN(i's KCLKCTIC olJSTKTUlr.S. 
 
 plugged up by little thrombi, the decomposition of which, during life, 
 occasioned the constitutional disturbance. Again, these may be absent, 
 but the uterus itself will be found in a state of gangrenous degenera- 
 tion ; or the pleural and pericardial cavities may contain purulent or 
 aero-purulent deposits. The eyes of the patient have even suffered 
 with pain, suppuration, and corneal rupture ; and, when death hu.- 
 nct taken place so rapidly as usual, secondary abscesses have been 
 found in various parts of the body. 
 
 It must be borne in mind, however, that the lesions observed are 
 not the original cause of the disease, but are the results of the poison 
 occasioning it ; andVvhen this poisoning is intense, death may occur 
 so suddenly that the pathological conditions, which have been supposed 
 to constitute the disease, have not had time to develop themselves. 
 Again, severe peritonitis, phlebitis, etc., may occur at the puerperal 
 period, or previous to it, independent of any poisonous absorption, 
 the symptoms being more or less modified by the condition of the 
 puerperal patient. 
 
 PROGNOSIS. These several varieties of puerperal fever may 
 exist singly or combined, more frequently the latter ; and as their 
 symptoms so closely resemble each other, when combined it will be a 
 difficult matter to positively distinguish between them, yet in a prac- 
 tical view, as before related, this is of minor importance, the treatment 
 being the same. 
 
 The prognosis is always unfavorable, and especially when the disease 
 occurs endemically. The most unfavorable symptoms are suppression 
 of the lochia, tympanitis, delirium, vomiting of greenish, or "coffee- 
 ground" substances; rapid prostration of the vital forces; very high 
 pulse, or thready and fluttering; hiccough; diminished pain on pres- 
 sure, with increased ability to move the legs, and a frequent, feeble 
 pulse, evidencing that the inflammation has terminated in effusion ; 
 cold, clammy skin; diarrhea, or involuntary stools; and dilated pupils. 
 The most fatal period is during the third or fourth clay. 
 
 But if, with an ability of the patient to move herself in bed, we 
 find the pulse to lessen in frequency, the skin to become cooler and 
 softer, the thirst gradually diminishing, the tongue cleaning, the bowels 
 being more easily acted upon, the clearness of the skin returning, and 
 the patient more able to make a deep inspiration, and to obtain refresh- 
 ing sleep, we may augur favorably. The ability to change position 
 without much pain, is frequently one of the first symptoms of improve- 
 ment. Yet, even with all these favorable indications, we must not
 
 TREATMENT OF PUERPERAL FEVER. 671 
 
 cease in our close attentions to the patient, for it has happened, that 
 when there was every indication of a favorable result, and physicians 
 and friends were congratulating each other relative thereto, that the 
 symptoms have returned with increased severity, and the attack has 
 terminated fatally. 
 
 TREATMENT. It is seldom that puerperal fever has exactly the 
 aame features, each endemic presenting symptoms peculiar to itself. 
 If we admit only the five varieties of the disease, as described above, 
 and which may occur separately, or in various combinations with each 
 other, we have, then, twenty-six different modes of manifestation, in 
 which there will be a great diversity of symptoms, in number, char- 
 acter, and severity. But, when, as is frequently the case, it prevails 
 simultaneously with malignant erysipelas, or blood-poisoning, we may 
 then have an additional number of twenty-six, giving to us fifty-two 
 different features which the disease may present; and, probably, this 
 fact may lead us to suspect the reason why writers have given such 
 varied descriptions of it, as having occurred under their respective 
 observations. 
 
 However formidable a disease may at first appear, which is capable 
 of presenting so great a number of differences in its features, yet, for 
 practical purposes, they may be reduced to two conditions, viz.: that 
 in which the inflammatory symptoms predominate, and that in which 
 the typhoid symptoms, or, symptoms of blood-poisoning prevail. And 
 the treatment must be governed by the presence of one ,pr the other 
 of these conditions. The most important object is, to eliminate from 
 the system, or to neutralize the absorbed poison, as much as possible; 
 to sustain the vital forces ; and, in the inflammatory varieties, to over- 
 come the congestion and inflammation of the parts attacked, and bring 
 about resolution for if the disease terminates in effusion,, the woman 
 almost certainly dies. , 
 
 In the INFLAMMATORY FORMS of puerperal fever, agents 
 to control the heart's action and lower the temperature, and thus 
 subdue the local inflammation, should be at once administered. The 
 bowels are usually constipated in the beginning, -and the administra- 
 tion of such means as will properly overcome this condition should bo 
 thought of. Mild but efficient measures should always be selected. Tho 
 compound powder of Jalap will answer in some cases; a teaspoonful 
 of the compound dissolved in two tablespoonfuls of boiling water, 
 sweetened, and taken as a dose, will usually give the desired effect. 
 The Cascara Cordial is preferred by some physicians. All measures 
 that occasion depression of the system should be avoided; under
 
 672 KING'S ECLECTIC OBSTETRICS. 
 
 some circumstances it will be better to use enemas, soliciting one 
 evacuation daily in this way. The bed-pan should always be used, 
 and the patient not allowed to either get up in bed, or out of it; in- 
 deed, it is much better for her to keep in the recumbent posture, and 
 without elevating the head and shoulders by pillows. 
 
 It will not be necessary to wait for the catharsis, but endeavor to 
 get the patient as soon as possible under the influence of such agents 
 as may be specifically indicated. If much pain be present with the 
 fever, Aconite and Macrotys should be thought of, administered in 
 the usual small dose. The Sp. Tr. of Veratrum Viride is likewise 
 very useful, and when the pulse is full and bounding, will be found 
 superior to any other agent for controlling vascular excitement, reduc- 
 ing the pulse from 120 or 140 to 80 or 100; it may be administered 
 in doses varying from one- half to one drop, repeated every hour or 
 two, until it has produced the desired effect; after which it must be 
 continued, if necessary, in such doses, and at such intervals, as may 
 be required to keep the pulse reduced. It may be used either singly 
 or in combination with other agents that may be called for. 
 
 With the high grade of inflammation, the indication for Gelsemium 
 frequently stands out prominently, when it should be administered 
 with the proper sedative, and will be found to answer a good purpose. 
 
 Phytolacca will be often called for in this disease also; it may be 
 given in alternation with the Macrotys and sedative. It favors the 
 return of th^ suppressed lochia, and decidedly beneficial results will 
 usually be found to follow the administration of these agents, and in 
 some cases no other treatment will be called for. 
 
 I frequently administer Chlorate of Potassium in puerperal fever, 
 and with good results. It is indicated by the disagreeable smell of 
 the discharges, and bad smelling breath. It can be used in conjunc- 
 tion with other agents, or may be given in from two to five-grain 
 doses, singly, two or three times a day. 
 
 Equal parts of the tinctures of Digitalis and Stramonium, given in 
 doses of five or ten drops, every hour or two, have frequently been of 
 advantage in this disease, particularly when the attack was mild. 
 
 Fomentations applied over the abdomen, as hot as can be borne, 
 will be found a powerful means for relieving the pain and soreness in 
 that region when due to inflammatory action ; they ma'y be made of 
 Hups and Tansy, or Hops and Poppy-heads, or either of these with 
 Chamomile flowers, and they should be renewed frequently, not 
 permitting them to remain on when cool, and the patient should not
 
 TREATMENT OF PUERPERAL, FEVER. 673 
 
 be made uncomfortable by applying them so wet as to dampen the 
 bed upon which she lies. For a fomentation to the bowels I know 
 of no agent equal to the leaves of Stramonium, which are now being 
 used in various inflammatory affections, by some of my colleagues, 
 upon my recommendation, and with much success ; I have used these 
 when fresh, by bruising and warming them previous to their applica- 
 tion, or, by steeping the dried leaves in boiling water, and frequently 
 changing them upon the abdomen. I have persisted in the appliance 
 of this remedy even after it has caused double vision and other 
 symptoms of its peculiar narcotic influence upon the system, and 
 invariably with benefit. It not only lessens pain, but actually assists 
 in reducing the inflammatory action. When its effects upon the 
 system are no longer desirable, one of the previously named fomenta- 
 tions may be substituted. The fomentations will prove beneficial only 
 during the acute stage, and must be dispensed with when prostration 
 ensues, or when the inflammation has been overcome. The addition 
 of Oil of Turpentine to them, when tympanitis is present, has been 
 found useful. 
 
 For a common drink the patient may take an infusion of Peach- 
 leaves, which will occasion diuresis, and thus aid in lessening the 
 severity of the attack; this may be drank freely, especially in the 
 early part of the attack. A free action of the kidneys is always 
 desirable in this malady, and should be kept up as much as possible, 
 as it not only aids in allaying vascular excitement, but also affords a 
 means of eliminating the absorbed poison from the blood. In the 
 latter part of the disease, other remedies will be called for by the 
 condition of the tongue. A good condition of the stomach is neces- 
 sary, in all eases, for the reception and absorption of medicines, and 
 assimilation of food. 
 
 The dirty tongue is a very common condition in this, disease, as 
 might be expected from the poisoned state of the blood following the 
 absorption of putrid material, together with the high fever, nausea 
 and vomiting, and inability to take food. Sulphite of Soda should 
 here bj given; a teaspoonful every two hours of a solution of % i to 
 Water ^iv, and continued until the tongue cleans and- the -patient no 
 longer complains of a bad taste. 
 
 Another case may present the heavily coated tongue ,a.t.,base, yellow 
 appearance of the skin, fullness of the superficial veins. Here 
 Podophyllin should be thought of; one grain triturated with one 
 hundred grains of Sugar of Milk, and given in- fiVe-grain doses two 
 or three times a day, usually answers a very good purpo.se. v ' *.. 
 43
 
 674 KING'S ECLECTIC OBSTETRICS. 
 
 The broad and flabby tongue, showing the imprint of the teeth on 
 the sides, calls for Lobelia, which .should be administered with the 
 sedative, or such other agents as are being used. 
 
 The elongated, red, and contracted tonr/ue, evidence of irritation, is 
 an indication for Ipecac, and it .should, as a rule, be administered 
 with Aconite. 
 
 There are numerous other remedies that will be found valuable in 
 this affection. We should have the case well in hand, carefully study- 
 ing out the condition and symptoms present, supplying the remedies 
 in each individual case according to the specific indications present. 
 Rhus Tox, Bryonia, Dioscorea, Baptisia, Muriatic Acid, Sulphurous 
 Acid, are all agents to be thought of in connection with puerperal 
 fever, and should be given when indicated. 
 
 Rhus Tox, when the sharp pain in frontal region, burning pain over 
 left orbit, sharp stroke of pulse, are prominent symptoms, will be the 
 Vemedy. Dioscorea is especially useful in subduing the pain of puer- 
 peral peritonitis, and may be given with the sedative. When the 
 tongue becomes coated dark, brown, or yellow, Muriatic Acid should 
 be prescribed, using a few drops in a half-glass of water, enough to make 
 it pleasantly acid, and allow the patient to take a teaspoonful every 
 hour or two. Acidulous draughts are also desirable, as lemonade, 
 tamarind- water, orange-juice, vinegar, and even tart cider, when there 
 is prostration. If the patient during the early days of the fever de- 
 sires ice, or iced water, they should not be withheld. 
 
 When the pain is very severe, and the inflammatory action intense, 
 in addition to the above named measures counter-irritation will often 
 be very useful; mustard, or very stimulating liniment, may be 
 applied along the whole course of the spinal column, and to the legs 
 and inside of the thighs. Some practitioners recommend the applica- 
 tion of cups over the lumbo-sacral region, and even leeches over the 
 abdomen; there may be cases in which some transient benefit will be 
 derived from these, but I have never yet had occasion to employ 
 them still, I should not hesitate to do so, were it necessary. But 
 general venesection, which was at one time so almost universally 
 advised by writers, who placed their greatest reliance upon it, I am 
 decidedly opposed to, and am induced, from the results of observation, 
 to believe that, at least as frequently as the disease itself, it occasions 
 fatal results. 
 
 Excessive nervousness or sleeplessness may be overcome by Sp. Tr. 
 of ' Pulsatilla, Gelsemium, or by Hydrate of Chloral, Bromide of 
 Potassium, etc.
 
 TREATMENT OF PUERPERAL FEVER. 675 
 
 After the more severe symptoms have been subdued, many practi- 
 tioners discontinue the exhibition of the former internal measures, 
 substituting for them the compound powder of Ipecacuanha and 
 Opium, to be given in appropriate doses, and at intervals of two or 
 three hours. The internal administration of Sulphate of Quinia will 
 be useful in some cases, and under certain circumstances, periodicity 
 being its principal indication; it maybe used in two to five-grain 
 doses, alternating with the compound powder just named, every two 
 or three hours, and will be found very beneficial in favoring a rapid 
 convalescence, as it checks the tendency to pus-formation, and in- 
 creases nerve force. Any unpleasant symptoms occasioned by this 
 agent may be removed by adding Bromide of Potassium to it, and 
 which addition will likewise enable us to give the Quinia salt in 
 much larger doses without the subsequent development of any dis- 
 agreeable results. Others prefer the compound powder of Quinia. 
 These preparations may likewise be used with advantage whery 
 typhoid symptoms are present. 
 
 Prof. King suggests that he has found the tincture of Gelsernium, 
 either alone or in combination with the tincture of Aconite, sufficient 
 to resolve the disease, in some cases, without the aid of other rem- 
 edies; "though, when the attack is very severe," he remarks, "I 
 have always found it more advantageous to cause free diaphoresis." 
 Many others have found similar benefits from the continued use, as 
 required, of Veratrum or Aconite with Macrotys. 
 
 It is highly important, in all the varieties of the disease under con- 
 sideration, that all clots and remains of the lochia and other matters 
 that may, from decomposition, form septic virus to be absorbed by 
 exposed surfaces in the uterus or vaginal cavity, be carefully removed 
 by injections or by swabbing out the utero-vaginal canal from time 
 to time with some disinfecting fluid. This is one of the most essential 
 features in the treatment, and for this purpose hot water should be 
 used, to a pint of which about one drachm of Carbolic Acid has been 
 added; I prefer, however, Borax or Chlorate of Potassium, or, in 
 some cases, Asepsin, to Carbolic Acid; or a weak solution of Per- 
 manganate of Potash may be used, or any of the alkaline sulphites or 
 sulpho-carbolites. An infusion of Golden Seal and Wild Indigo bark 
 of root has also been advantageously employed. These injections or 
 swabbings should be repeated several times a day, being careful, when 
 the uterine cavity is injected, not to pass the fluid too forcibly into it, 
 nor in too large a quantity at a time ; say from two to four fluid
 
 676 KING'S ECLECTIC OBSTETRICS. 
 
 drachms at a time, and repeated at intervals of four or five hours. 
 Sometimes benefit will follow injections of warm water into the 
 uterus; from half a pint to a pint may be used at a time, and may be 
 repeated every three, four or five hours. These swabbintis and injec- 
 tions should always be given by the medical attendant never by 
 the nurse, unless she be trained, and understands the importance of 
 cleanliness in such cases; they cleanse the organ from all abnor- 
 mal and putrefied matters, lessen the sufferings of the .patient, and aid 
 materially in restoring the parts to a healthy condition. Cleanliness 
 of the bed and of the utero-vaginal canal, pure or disinfected air, and 
 proper ventilation of the lying-in room, are highly valuable hygienic 
 auxiliaries in the treatment of this terrible malady. 
 
 In addition to the external application of Oil of Turpentine for the 
 tympanitic condition of the abdomen, it will frequently become neces- 
 sary to administer internal means; a mixture of equal parts of Castor 
 Oil and Oil of Turpentine, may be given in fluidounce doses, and 
 repeated every two or three hours, until gentle catharsis is induced. 
 And when this is employed, other cathartics must be omitted. Though 
 it must be recollected that cathartics are not always desirable when 
 tympanitis is present, especially when they tend to depress, or when 
 there is a disposition to diarrhea. Sometimes, Paregoric elixir may be 
 advantageously added to the dose. Or, a combination of equal parts 
 of Oil of Turpentine and Paregoric elixir, may be given in small and 
 repeated doses, while other cathartics are being employed instead of 
 Castor Oil. I have met* with decided benefit from the use of a 
 saturated tincture of Prickly-ash berries, as an injection into the 
 rectum, and also administered internally. As an injection, it may be 
 employed in half fluidounce, or fluidounce doses, very slightly diluted 
 with water, and repeated every half-hour or hour. When there is 
 much pain, half a fluidrachm of Laudanum may be added to each 
 injection. In some instances, I have beneficially combined it with 
 Oil of Turpentine, with the compound tincture of Lobelia and 
 Capsicum, and with these last-named two preparations together. In- 
 ternally, it may be given alone in fluidrachm doses, or, combined with 
 Oil of Turpentine and Paregoric elixir, equal parts of each, of which 
 from half a fluidrachm to a fluidrachm, in some sweetened water, may 
 be repeated every hour or two. The tincture of Prickly-ash bark 
 will not exert the same influence upon tympanitis, as that of the 
 berries, which appears to have almost a specific influence, and may be 
 used per rectum at any period of the disease when tympanitis is 
 present. Its use internally, or by mouth, must not be commenced 
 until the higher inflammatory action has become somewhat lessened.
 
 TREATMENT OF PUERPERAL FEVER. 677 
 
 Vomiting is frequently very obstinate, resisting all measures for a 
 length of time. Aconite and Ipecac in small doses, frequently 
 repeated, will usually give desirable results. Gelsemium, alone or 
 combined with some opiate, does well in some cases; or some aromatics 
 may be used, as Peppermint-water, Anise-water, Spear mint- water, 
 etc. Minute doses of Morphia and Bismuth may be used \vhere 
 other means fail. Frequently a Mustard poultice to the epigastric 
 region will be of service in lessening the vomiting. Sometimes 
 effervescent acidulous draughts will be useful, as Soda or Seidlitz- 
 water, with Lemon-juice and a few drops of Laudanum. And when 
 these do not cause it to yield, it will diminish with the abatement of 
 the inflammation. 
 
 In the TYPHOID or MALIGNANT FORM of puerperal fever, 
 the course of management for the first day or two, during the more 
 active stage of the disease, may be the same as in the preceding form, 
 but afterward it will require considerable change; and the means 
 which I am about to advise for the purpose of combating the typhoid 
 symptoms, may also be employed when symptoms of a similar char- 
 acter are present in the depressing stage following the inflammatory. 
 
 As soon as it becomes evident that th.e disease is assuming the 
 typhoid form, antiseptics should be administered, choosing from that 
 class of remedies such agents as are specifically indicated by the symp- 
 toms present in each case. Among the different remedies to be con- 
 sidered are Sulphite of Soda, Chlorate of Potassium, Muriatic Acid, 
 Baptisia, Sulphurous Acid. The surface should be occasionally 
 bathed with an alkaline bath, rendered somewhat stimulating by the 
 addition of spirits or alcohol. 
 
 The poisonous condition of the blood, in this disease, will be 
 frequently manifested by the pallid, dirty tongue, often pasty and 
 sticky, a disagreeable taste, and frequently loss of appetite ; such are 
 the indications for Sulphite of Soda, a remedy very often indicated 
 when the typhoid symptoms appear, and if given early will often 
 modify the severity of the attack. 
 
 The indication for Chlorate of Potash is manifested by the putre- 
 factive odor present with the suppression of the lochial discharge, the 
 unpleasant odor of decomposition, together with bad smelling breath. 
 Chlofate of Potash 511, Water giv, in teaspoonful doses every two or 
 three hours. 
 
 Muriatic Acid is called for where the tongue shows the brown coat- 
 ing, peculiar to the typhoid state.
 
 678 KING'S ECLECTIC OBSTETRICS. 
 
 Sulphurous Acid is the agent when the dirty coat of the tongue 
 shows sepsis. It is a very mild acid. 
 
 The indication for .Baptisia is given by Prof. Scudder as follows: 
 " It is not so easy to see the exact indications for Baptisia, yet it is one of 
 our very best remedies, if the diagnosis is rightly made. There is a dull 
 red coloration of skin where it has a free circulation, of the lips, and 
 of the tongue and fauces ; or, as we sometimes say, there is an o/f-color 
 of the tongue livid, purplish, dull red. In the advanced stage of 
 the disease (puerperal fever), the tongue is protruded with difficulty, 
 is stiff, fissured, and bleeds, and the tissues of the mouth and fauces 
 look full and lifeless. The pulse is oppressed, and the skin is dry, 
 husky apd lifeless. The excretions are frequently fetid. I prescribe : 
 R. Tinct. Baptisia gtts.; Water giv; a teaspoonful every two hours, 
 usually alternated with the proper sedative." 
 
 The pain and tympanitic condition of the abdomen must be treated 
 as already described. 
 
 As soon as the patient desires acidulous draughts, permit them to 
 be taken, not forgetting that when the tongue is furred dark-brown, 
 or yellow, good tart Cider is not only refreshing, but is powerfully 
 
 sanative in its effects. 
 
 * 
 When the prostration is excessive, Sherry, or sparkling Catawba 
 
 wine, porter, good French brandy, etc., must be freely given to sup- 
 port the system until reaction comes on; together with a light, 
 nutritious, easily digestible diet, as, solution of gelatin, of gum arabic, 
 etc. The vital powers must be sustained by every means possible. 
 
 An equilibrium of the temperature of the surface must be main- 
 Jbained by cooling lotions to the head, and warmth' and stimulants to 
 the extremities. In some cases, where the prostration was -excessive, 
 I have applied cold to the head, with sinapisms around the legs from 
 the hips down to the feet, and around these placed heated rocks, or 
 bottles of heated water, and with marked advantage. It may fre- 
 quently become necessary to cut the hair close, when there is much 
 disturbance of the brain, before applying the cooling lotions. 
 
 When diarrhea is present, I know of no better agent than the 
 Liquor Bismuth, in half to teaspoonful doses. Some physicians always 
 make use of tincture of Chloride of Iron, either with or without some 
 preparation of Opium. It may be given in doses of ten or twenty 
 drops, repeated every hour, in a sufficient quantity of Avater, ami at 
 the same time, in severe cases, an injection, after each diarrheal evacu- 
 ation, should be given, composed of Tannic Acid, ten grains; 
 Glycerine and Water, of each one fluid ounce; mix. This should
 
 TREATMENT OF TYPHOID PUERPERAL FEVER. 679 
 
 be retained by the patient as long as possible. The tincture of 
 Chloride of Iron has a powerful and beneficial influence on the 
 capillary vessels, and it will not only be found valuable in the 
 diarrhea attending this malady, but also in those cases complicated 
 with erysipelatous indications. Tannate of Quinia has also been 
 highly recommended when diarrhea exists. Whenever I have good 
 reasons for knowing that an erysipelatous condition is connected with 
 the puerperal fever, as soon as the more active symptoms have been 
 somewhat diminished, I administer fifteen or twenty drops of the 
 tincture of Chloride of Iron in a proper amount of water, repeating 
 it every hour, until the symptoms have yielded, and in no instance 
 has its exhibition been otherwise than beneficial. In many instances 
 I have, from the commencement of the attack, administered the 
 tincture of Veratrum, and the tincture of Chloride of Iron, alternately, 
 *every half hour or hour, and with the most happy results. But 
 should I meet with a patient in whom it increased the symptoms, of 
 course, I should cease or suspend its use. May not the erysipelatous 
 and typhoid characters of this affection frequently be owing to absorp- 
 tion of putrid matter, as decomposition of coagula within the uterine 
 cavity, or of remaining pieces of placenta or membranes? 
 
 In the early stage of puerperal fever the diet must be light and 
 cooling, but more nourishing in the latter stages, as gruel, panada, 
 toast, bread-water, rice-water, barley-water, apple-sauce, prune-water, 
 tamarind- water, etc. And after the danger has passed, the patient 
 remaining much debilitated, chicken-broth, beef-tea, veal-tea, etc., 
 with or without Sherry or other wine, brandy, etc., as the case may 
 require, may be allowed, increasing the nutritious character of the 
 diet gradually, as she continues to improve. 
 
 It would be impossible to lay down specific rules for the guidance 
 of the practitioner in treating the various forms under which puer- 
 peral fever may individually appear. The above general principles 
 of treatment will be found the most successful, although it may 
 require to be modified, or pursued more or less energetically, accord- 
 ing to the phenomena which are present. Other means have been 
 advised, some of which are undoubtedly valuable, yet I have con- 
 sidered it the better course to name only those principles of treatment, 
 in this malady, which I have found successful in my own experience. 
 And 4n closing upon this subject, I would remind the student that not 
 only must he carefully and attentively watch his patients who labor 
 under childbed fever, but he must also use every means to avoid 
 propagating the disease, the same as if its contagious nature were 
 satisfactorily demonstrated.
 
 680 KING'S ECLECTIC OBSTETRICS. 
 
 Frequently, the disease may be prevented by an early attention to 
 the bowels and kidneys evacuating them by the proper agents; 
 keeping the utero-vaginal canal in a cleanly condition; maintaining 
 a slight determination to the surface by some diaphoretic powder, 
 applying a fomentation to the abdomen when the pains are of a 
 suspicious character, and avoiding exposures to cold, and damp or 
 moist atmosphere. It is sometimes the case that the patient does not 
 promptly recover from the effects of parturition, but keeps her bed 
 for several days more than usual, owing to a sense of general debility ; 
 the milk is not secreted freely; the pulse is corded or wiry, somewhat 
 bounding, and rather more frequent than natural ; and there is slight 
 pain or tenderness when deep pressure is made in the hypogastric 
 region. A slight elevation of temperature is likewise generally 
 present. In such instances there is danger of an attack of this affec- 
 tion; and I have found prompt relief to follow the administration^, 
 every one, two, or three hours, as the severity of these symptoms 
 would indicate, of a powder composed of Prussiate of Iron, two and 
 a half grains ; Sulphate of Quinia, two grains ; Piperin, one grain. 
 
 CHAPTER XLIX. 
 
 PHLEGMASIA DOLENS CRURAL PHLEBITIS TREATMENT OF 
 
 PHLEGMASIA DOLENS. 
 
 PHLEGMASIA DOLENS, is the name applied to a swelling of 
 one or both legs which occurs soon after delivery, and is accompanied 
 with pain and tenderness. The disease has been termed milk-leg, from 
 a mistaken idea that it was owing to a metastasis of milk from the 
 breasts to the legs. It has also received several other names, accord- 
 ing to the views of writers, thus, cedema dolens, oedema lacteum, phleg- 
 masia alba dolens puerper arum, metastasis lactis, depdt du lait, and crural 
 phlebitis. It may attack primiparae but is more frequently met with 
 among multipart. 
 
 Although this disease has been known to the profession for a long 
 time, yet its nature has not been satisfactorily understood, and, even 
 at this time, there are conflicting opinions regarding it. Mr. White, 
 of Manchester, in 1784, considered it to be caused by an obstruction, 
 or some morbid condition of the lymphatic vessels and glands of the
 
 PHLEGMASIA DOLENS* 681 
 
 parts attacked. Mr. Trye, in 1792, supposed it to depend upon a 
 rupture of the lymphatics, as they cross the pelvic brim. Dr. Ferrier 
 attributed it to inflammation of the absorbents. Dr. Hull, in 1800, 
 considered it to be an inflammatory disease, producing a sudden effusion 
 of serum and lymph. In 1817, Dr. Davis made an autopsy, and found 
 evidences of extensive inflammation of the veins. In 1823, M. 
 Bouillaud, supposed it to be owing to obstruction of the crural vein?, 
 having found these veins obliterated in several females who had 
 labored under the disease. In 1829, Dr. Robert Lee succeeded in 
 tracing the inflammation into the uterine branches of the hypogastrio 
 veins, and he gave it the name of Crural Phlebitis. 
 
 A. commonly received opinion, but a few years since, and which was 
 based upon post-mortem appearances, was that the immediate cause of 
 phlegmasia dolens, is inflammation with more or less obstruction of 
 the crural veins, the inflammation, in many instances, extending from 
 the uterine veins, being seated principally in the cellular and middle 
 tunics of the veins. 
 
 Dr. Mackenzie, from the results of a scries of experiments, is of 
 the opinion that phlegmasia dolens is owing to a vitiated condition of 
 the blood, and that the venous inflammation is rather an effect of the 
 original disease. He states that all the phenomena of the affection 
 will not be produced by inflammation of the iliac or femoral veins 
 only ; that, during health, a mere local cause, as inflammation, or an 
 injury, does not produce the extensive venous obstruction which is 
 found in phlegmasia dolens; that, independently of inflammation or 
 local injury, an obstruction of the veins may be produced by an irri- 
 tation of their lining membrane, and will be more or less extensive 
 according to the degree of irritation ; and, that we are rather to look ' 
 upon a morbid condition 'of the blood as the source of this irritation, 
 instead of local injury, inflammation, or disease of the veins. 
 
 These views of Dr. Mackenzie appear to be confirmed by the fact, 
 that, phlegmasia dolens has been kno.wn to exist when the uterus was 
 in a normal state, and also, when the vessels of the thigh manifested 
 no indications of disease, this being confined to the leg only; again, 
 females suffering under carcinomatous, rheumatic, gouty, and other 
 diseases, seem to be more' liable to the puerperal swelled leg than 
 others. Yet, it has occurred among those who were apparently free 
 from any disease up to the time of the attack. Further investigations 
 will be required before a correct and satisfactory theory of the malady 
 can be determined. My own view is, that the disease is primarily an 
 .affection of the lymphatics, anfl that the venous inflammation is merely
 
 682 KINO'S KCI/KCTIC OIJSTKTUICS. 
 
 a secondary result of the original malady. Perhaps, there may exist 
 a previous vitiated condition of the blood, rendering the female more 
 readily susceptible to an attack, or, what is still more probable, the 
 blood may be gradually poisoned by absorption of putrid material, 
 and the septicemic action being (very likely from embolism) limited 
 or confined within a certain sphere, the disease under consideration 
 becomes developed instead of puerperal septicemia; and some cases 
 have occurred under my notice which would favor such an idea, yet, 
 at present, I am not prepared to make any positive statements rela- 
 tive thereto. A physician has observed to me, in a communication : 
 " From careful and oft-repeated observations as to the nature and seat 
 of phlegmasia dolens, I have become confirmed in the opinion, that it 
 is primarily and essentially a disease of the lymphatic glands, and 
 subsequently of the lymphatic vessels of the leg, the inflammation of 
 which extends to the veins, and to the whole limb. 
 
 " This derangement of the lymphatic glands, I believe to be caused 
 by the pressure of the head of the fetus in passing through the superior 
 strait, and the reason why the left leg is more frequently the seat of 
 the disease than the right, is owing to the fact that the occiput of the 
 child is more generally directed to the left side of the pelvis. At the 
 lower part of the superior, and the upper part of the inferior strait, 
 there are many lymphatic glands which are large enough to be much 
 more prominent than the nerves or veins; and they must oftentimes 
 become compressed by the occiput of the child during its passage. 
 This pressure may cause the glands to become inflamed and engorged, 
 and the engorgement will cause an obliteration of the vessels, or, at 
 least, an obstruction to the free flow of lymph through them, which 
 obstruction will lead to congestion and inflammation of the inguinal 
 glands, and gradually to the lymphatics of tlie entire lower extremity. 
 
 "Among the phenomena on w 7 hich I base this opinion, are, briefly, 
 the following: 
 
 "1. The limb does not become seriously implicated for some little 
 time after confinement. 
 
 " 2. The lymphatic glands of the groin, and the lymphatic vessels of 
 the limb are involved for some time before the nerves or veins appear 
 t' be affected; as evidenced by the locality and character of the swell- 
 ing in every case examined; and also by the exudation of lymph 
 whenever scarification has been employed. 
 
 " 3. The general lymphatic engorgement of the whole limb, and the- 
 cold, white appearance of the part, centra-indicate inflammation of the- 
 veins, or of any other tissue except the lymphatics.
 
 PHLEGMASIA DOLENS. 683 
 
 U 4. The invasion of exactly the same form of disease in the arm of 
 one man after amputation, where the lymphatic glands of the axilla 
 had become involved, and the lymphatic vessels of the whole arm had 
 become engorged ; and, also, the appearance of two other cases of 
 phlegmasia in the legs of men where certainly the lymphatics were 
 first involved. "Writers have also observed the same phenomena 
 among males. 
 
 " 5. The veins can not, in my opinion, be the primary seat of the 
 disease, for they do not appear to be affected until after the disease has 
 existed some days, and, in a few instances, even for weeks, after the 
 affection of the lymphatics. 
 
 " 6. The veins, when inflamed, do not present the same phenomena 
 in any other part of the system as are observed in phlegmasia dolens, 
 as, effusion of lymph, a white, shining surface, and a low grade of 
 temperature. 
 
 " 7. The treatment which is found the most successful in cutting 
 short the disease in its earlier stages, is not such as would be demanded 
 if the veins or nerves were primarily affected, but, is such as would be 
 used for inflammation of the lymphatic glands, and vessels elsewhere." 
 Although I do not wholly participate in these views, I give them on 
 account of the description of the phenomena attending the disease. 
 
 Phlegmasia dolens, although more commonly met with among 
 puerperal females, is by no means confined to them; it has been 
 observed among those whose menstrual discharge has been suddenly 
 suspended ; or who have had diseases of the uterine organs, as malig- 
 nant ulceration of the cervix, polypus, etc. Nor do males appear to 
 be exempt from it, for it has been known to occur in them, following 
 dysentery, diarrhea with ulcerated intestines, cancer of the rectum, 
 external injuries, amputation of a limb, etc. A similar affection has 
 likewise been observed to attack the arms in both males and females, 
 after some injury of the upper part of the body, or, during some 
 carcinomatous disease of the breast. In any one of the above mentioned 
 diseases or conditions, will be observed the possibility of decomposi- 
 tion and formation of septic material that may be absorbed into the 
 system. 
 
 Various exciting causes have been named, the most common among 
 which is cold: it is said also to be excited by pressure upon the pelvic 
 veins and nerves, uterine disease, suppurative inflammation of the 
 pubes, injuries, inflammation of the sciatic and obturator nerves, and 
 sometimes to occur as a sequel of fever.
 
 684 KING'S ECLECTIC OBSTETRICS. 
 
 SYMPTOMS. This disease most commonly appears between the 
 tenth and fifteenth day after delivery; though it has been met with 
 as early as on the fourth day, and again at a later period, even after 
 the third week. It is generally preceded by pains or uneasiness in 
 the lower part of the abdomen, with symptoms of uterine or venous 
 inflammation, and a feeble, depressed, or irritable condition of the 
 patient; frequently the patient is suddenly attacked without any pre- 
 monitory symptoms. 
 
 It usually manifests itself with severe rigors, followed by an in- 
 creased temperature of the surface, and by a sudden and deep-seated 
 pain in the groin, or thigh. After a few hours the affected limb 
 commences swelling, and usually upon its inner and anterior surface. 
 In the greater number of cases, this swelling is first observed in the 
 calf, sometimes extending to the inside of the heel, from whence it 
 travels rapidly upward; occasionally, it extends from the thigh down- 
 ward. Not unfrequently, before any pain in the thigh or groin is 
 experienced, the calf of the leg will be found swollen, painful, and 
 hard, as if it were attached to the bone, and can not be shaken, while 
 the calf of the other limb, on being shaken, will be found flabby and 
 movable. It is not unusual for the buttock, and labium pudendi of 
 the diseased side, to share in the abnormal action. 
 
 The swelling is hard and elastic, the skin is tense, shining, white, 
 and exceedingly sensitive to the touch, with an augmented temperature, 
 and all-hough yielding to pressure, does not leave a pit, except upon 
 the parts which are free from pain, or at the decline of the disease. 
 In the direction of the femoral vein, a hard, exceedingly painful cord 
 may be felt, which is the thickened and indurated vein; sometimes, 
 an enlargement of the inguinal glands may be detected. If the limb 
 be punctured, only a few drops of a gelatinous fluid will be discharged. 
 As the swelling progresses, there is, generally, some abatement of 'the 
 pain, but not an entire removal. 
 
 The pain accompanying the swelling is very severe, and is much 
 aggravated by any motion of the limb, or even by the slightest pres- 
 sure. It is usually more intense on the inside and back of the thigh, 
 in the direction of the internal cutaneous, and crural nerve. Sometimes 
 it commences in the back and-hip-joint. It is constant, though there 
 may occasionally be slight remissions ; and the best position in which 
 the limb can be placed is to have it slightly elevated upon an inclined 
 plane, having an angle of from 6 to 10; or, it may be flexed both at 
 the knee and hip-joints. In a depressed or depending position, the 
 pain will be much augmented. From the commencement of the
 
 TREATMENT OF PHLEGMASIA DOLEXS. 685 
 
 attack, the affected limb feels heavy and stiff, and, as the disease pro- 
 gresses, the patient will be unable to move it, not only from the 
 excessive pain produced, but, because the limb has become powerless. 
 
 In connection with the pain and swelling, there will be more or less 
 fever, headache, nausea, or vomiting, quick and feeble pulse, giving 
 frequently 130 to 140 beats in a minute; thirst, restlessness, and 
 sleeplessness. The bowels are usually constipated; the urine turbid, 
 and small in quantity; the lochia are suppressed, or fetid, sometimes 
 the discharge remains unaltered; together with other symptoms, 
 varying in degree, but indicative of the general disturbance to the 
 constitution. These disappear gradually as the pain diminishes, leaving 
 the patient extremely debilitated. Sometimes, there will be a copious 
 perspiration throughout the whole course of the disease, which will 
 debilitate the patient very much. 
 
 It is very seldom that phlegmasia dolens attacks both limbs at once ; 
 though it may happen, that when the pain and swelling of the lirnb 
 first attacked subsides, the disease will manifest itself in the other one. 
 It usually lasts from four to six or seven weeks, though the acute 
 stage may continue for only ten or fifteen days. It may terminate in 
 resolution, the swelling disappearing, and perfect use of the limb being 
 restored; or, the swelling may take place slowly, the female not wholly 
 recovering the use of the affected limbs. Suppuration, with ulceration r 
 occasionally occurs, the consequent exhaustion eventually destroying 
 the woman. And sometimes, death occurs either suddenly, as for 
 instance, when the patient raises herself in the bed, or it may take 
 place gradually from the secondary affections induced. Most generally, 
 the acute symptoms are followed by a chronic form, in which the limb 
 never returns to its original size, and remains almost powerless through 
 life. 
 
 DIAGNOSIS. This affection may be known, by its occurring 
 within a few days or weeks after delivery; by the pain down the 
 affected limb; by the hardness of the swelling; the attending fever; 
 and the hard, cord-like, and painful condition of the femoral vein. If 
 the calf of the leg is firm, hard, immovable, and painful on being 
 compressed, and, if pain is produced in the upper part of the limb on 
 rotating it, these are positive indications of crural phlebitis. The 
 left side is more commonly attacked with the disease than the 
 right. 
 
 PROGNOSIS. The disease seldom proves fatal. The less severe 
 the fever and the swelling, the milder will be the attack. When a 
 favorable change is about to occur, the pain gradually diminishes, 
 leaving a numbness of the leg for some time; the swelling softens and 
 becomes oedematous, pitting upon pressure.
 
 68G KING'S ECLECTIC OBSTETRICS. 
 
 POST-MORTEM APPEARANCES. The cellular'membrane of 
 the limb will be found distended with effused serum. The affected 
 vein will be obliterated by adhering clots of blood, or coagulable 
 lymph; its parietes thickened; its inner tunic of a deep* color; and 
 pus may be contained within its canal. Pus may likewise be found, 
 together with evidences of inflammatory action, in the absorbents ; 
 small abscesses may be observed in the substance of the affected leg; 
 and frequently, traces of secondary affections in the joints, cavities, 
 etc., may be present. 
 
 The veins most commonly attacked, are the femoral, iliac, epigastric, 
 spermatic, uterine, and vaginal, the saphena, and the vena cava. 
 
 TREATMENT. During the acute stage, the indication is to elim- 
 inate or neutralize the absorbed poison, and to allay inflammatory 
 action ; and in the second or chronic stage, to promote absorption of 
 effused fluid and restore the venous circulation. 
 
 To fulfill the first indication, both general and local measures will 
 be required. Among the general measures, the first which demand 
 our attention, provided there is no diarrhea, is the administration of a 
 brisk cathartic, as, for instance, the compound powder of Jalap, with 
 some Nitrate, or Bitartrate of Potassa added ; or, the indication for 
 Podophyllin may be present the heavily coated tongue at base 
 when a few doses of the first or second decimal trituration may be 
 given. The purgative should be administered in a dose sufficient to 
 act thoroughly, without a repetition of it w r ithin four or five hours. 
 It not only empties the intestinal tract, removing any existing mor- 
 bid accumulations, but it likewise has a revulsive and eliminative 
 effect, and renders the system more susceptible to the beneficial 
 influences of subsequent medication. If necessary, the cathartic may 
 be repeated again on the second or third day; and during the whole 
 period of the acute stage the bowels must be kept free, causing one 
 evacuation daily. In some cases Nux Vomica will answer a good 
 purpose, especially where we have the sallow, expressionless face, 
 more or less nausea, broad and flabby tongue; symptoms depending 
 on a bad condition of the stomach. 
 
 After the catharsis, agents must be administered for the purpose of 
 aHaying the inflammation and lessening the pain. The proper sed- 
 ative should be first selected, which will be Veratrum in most cases; 
 to this will be added the indicated remedy. Macrotys will usually 
 control the severe pain to a considerable degree. In some cases the 
 remedy will be Gelsemium, or, when the pain is particularly of a 
 burning nature, Rhus Tox should be thought of, and continued or
 
 TREATMENT OF PHLEGM ASIA DOLENS. 687 
 
 changed according to the degree of inflammatory action, and the 
 influence of the remedy. Sometimes, and more especially when the 
 pain is intense with high inflammation, the Sp. Tr. of Aconite 
 m;iy be added to the above compound, according to the influence it 
 exerts upon the system. The above agent will most generally be found 
 to act promptly in subduing the more active symptoms. 
 
 Other combinations, of equal value^ may be used to fulfill the same 
 indication; thus, the tincture of Gelsemium, administered either alone 
 or in conjunction with the tincture of Aconite, will be found to exert 
 a prompt and beneficial influence. Sp. Tr. of Iris has been used by 
 many practitioners, and with excellent results. I have also derived 
 great benefit, in two cases, from the internal administration of Phyto- 
 lacca, assisted by its local application. 
 
 Occasionally, when there is no mitigation of the pain by -the above 
 means, the Sulphate or Acetate of Morphia may be prescribed in doses 
 of one-fourth or one-half a grain, and repeated as may be required; 
 this may be given more particularly when the patient is restless, 
 irritable and sleepless. Chloral hydrate has likewise been highly 
 recommended; also, subcutaneous injections of Sulphate of Morphia. 
 
 Salicylic Acid lias been found useful in some cases, especially when 
 there is lochial fetor, and severe pain. Bryonia, Belladonna and 
 Apocynum are all valuable remedies, and should be administered 
 according to the special indications calling for them. The same 
 measures must be pursued as named in the treatment of puerperal 
 septicemiay with regard to cleanliness, pure air, ventilation, oxygen- 
 ation of the blood, and antiseptics, as well as to nervousness, sleep- 
 lessness, etc. 
 
 Gastralgia., or a burning pain in the epigastric regiop, is sometimes 
 present, and may be relieved by the administration of a powder com- 
 posed of Nitrate of Bismuth, ten grains; Lupulin, two or four grains; 
 and this may be repeated every four or five hours. An infusion of 
 Peach-leaves will also relieve it, as well as the tinctures of Gelsemium 
 and Aconite, or, when these fail, Nux Vomica. 
 
 Among the local measures, fomentations to the affected limb occupy a 
 prominent position. Vinegar in which Hops have been boiled, or an 
 infusion of Water Pepper (Polygonum punctatuni) may be applied to 
 the whole limb by means of flannel cloths. Sometimes a warm 
 application will be found the most advantageous, at others a cold one ; 
 this point must be determined, by the practitioner, according to the 
 peculiarities of each individual case. Generally, cold applications
 
 688 KING'S ECLECTIC OBSTETRICS. 
 
 will be preferable, but when they occasion a sense of cold or chilliness,, 
 they are contra-indicated, and the warm applications must be sub- 
 stituted. Sometimes a bandage may be loosely applied along the 
 whole limb from the toes to the groins, which should be kept con- 
 stantly moistened with cold or warm water, or with a mixture of water 
 and spirits; and frequently, a solution of Hydrochlorate of Ammonia 
 will be found most valuable; be careful not to bandage tightly in the 
 acute stage. 
 
 The affected limb must be handled most carefully, and be protected 
 from pressure of the bed clothes, etc., -\\ heu these occasion or increase 
 the pain. A very excellent local application, when the skin is 
 unbroken, is a mixture of saturated solution of Hydrochlorate of 
 Ammonia, tincture of Arnica, tincture of Camphor, and Chloroform, 
 equal parts of each ; this should be frequently painted over the pain- 
 ful parts. Sometimes the pain and swelling have been greatly 
 alleviated by hot Turpentine, applied to the whole limb by means of 
 light cloths, repeating the application several times a day, twenty or 
 thirty minutes each time. A solution of extract of Belladonna, fre- 
 quently painted upon the limb along the painful part, has also been 
 found of efficacy. 
 
 In the early part of the attack, much advantage may be derived 
 from the application of cups or leeches on the limb, along the course 
 of the pain, and many of our practitioners have beneficially employed 
 these. I have always, heretofore, succeeded without them, but should 
 not hesitate a moment to use them in any case where I considered it 
 necessary. 
 
 But, of all the applications to the limb during the intensity of the 
 attack, I kno*v of none superior or equal to.recent Stramonium leaves 
 when these can be obtained. They should be bruised, and the whole 
 limb covered with them. It is considerable trouble to collect and 
 prepare the remedy in this manner, but a similar benefit, though in a 
 minor degree, may be obtained by bruising the leaves, and placing 
 them in hot, not boiling, water, and applying this infusion, either 
 warm or cold, by means of flannel cloths! The application may also 
 be extended across the hypogastric region with advantage. Dried 
 Stramonium leaves do not exert the same prompt and decided in- 
 fluence over the inflammation, but their action may be improved by 
 combining them with an equal quantity of Lobelia, and applying as 
 above. The extract of Stramonium, or, of Belladonna, rendered thin, 
 and applied on lint along the course of the pain, will frequently be 
 of service.
 
 TREATMENT OF PHLEGMASIA DOLEXS. 689 
 
 Blisters applied more especially to the groin of the affected limb, or 
 along the course of the pain, have been used with favorable results 
 by many practitioners, though I have never found it necessary to 
 employ them in my own practice. I have, however, frequently and 
 beneficially applied a sinapism across the sacral and lumbo-sacral 
 regions, and I prefer this to a blister on these points, on account of 
 the decubitis being principally and for some time upon the back, or 
 nearly so. 
 
 It should be stated that Sulphate of Iron, locally applied, aided by 
 the internal administration of large doses of tincture of Chloride of 
 Iron, has effected cures where other means had failed. From eighty 
 to one hundred and twenty grains of the Iron Sulphate is dissolved in 
 four fluidounces of water, and this solution must be applied on cotton, 
 lint, or spongio-piline, to the affected limb, as hot as can be comfort- 
 ably borne by the patient, repeating it frequently. These remedies, 
 beside having an antiseptic property, possess likewise the power of 
 controlling vascular dilatation. 
 
 The patient should be kept as quiet as possible during the inflam- 
 matory stage, the apartment should be kept at a moderate temperature, 
 and she must be restricted to a low and cooling diet. After the 
 removal of this stage, a more nourishing diet may be allowed, and 
 should there be much debility, tonics, or wine may be judiciously 
 administered. 
 
 After the inflammatory symptoms have been subdued, measures 
 must be taken to promote absorption and restore venous circulation. 
 Internally, Sp. Tr. Harnamelis and Collinsonia may be given, 3! to ii 
 lo 5iv of Water, and continued in teaspoonful doses for some time. In 
 the advanced chronic stage alteratives must also be used, as, some 
 preparation of Iodine, the compound syrup of Stillingia and Iodide off 
 Potassium, or the compound syrup of Yellow Dock may be substi- 
 tuted. Hydrochlorate of Ammonia may be beneficially ehiployed at 
 this period of the disease ; five or ten grains in solution, or syrup, 
 may be administered every two or three hours; or it may be added 
 to the above syrups instead of the Iodide of Potassium. The Sp. 
 Tr. of Iris, in five-drop doses, answers a very good purpose also. 
 
 The limb should be carefully bandaged from the toes t'o' the thigh, 
 but not so tightly as to render the patient uncomfortable. As the 
 bandage will require to be removed and reapplied twice in the course 
 of every twenty-four hours, these periods may be improved for the 
 purpose of applying friction, as well as some stimulating liniment or 
 44
 
 690 KING'S ECLECTIC OBSTETRICS. 
 
 wash, to the limb ; and the bandage may even be kept moist with the 
 same stimulant, or with a solution of Hydrochlorate of Ammonia, 
 liniment of Iodine, etc. Currents of galvanism or electro-magnetism 
 may likewise be passed through the limb once or twice daily, more 
 especially in the advanced chronic stage. Of course, as in the acute 
 stage, the limb should be kept in an elevated position, for such a 
 length of time as may be deemed proper, in order to render the cure 
 thorough and permanent. An irritating plaster over the sacrum, or, 
 over the lumbo-sacral region, ought never to be omitted in the second 
 s t a ge it tends greatly to facilitate the cure. The sore produced by 
 it should be kept discharging as long as the patient can bear it. And 
 after it has healed, if its further employment be indicated, do nof 
 hesitate to apply it. I know it is exceedingly painful and annoying, 
 but its advantages, in this disease, repay its disadvantages a hundred 
 times over. 
 
 Whenever the lochial discharge is fetid, whether in the first or 
 .second stage of the dis'ease, hot water, in which has been dissolved 
 Borax or Chlorate of Potash, in the proper proportion; diluted 
 Pyroligneous Acid; Carbolic Acid, one part to one hundred of Water; 
 or some other disinfecting liquid, may be injected into the vagina, 
 two or three times a day. Cleanliness, etc., have already been 
 referred to. 
 
 Any abscesses, or ulcers of the leg, caused by the disease, which may 
 present themselves, are to be treated upon the same principles as other 
 ulcers. 
 
 In this stage, the patient should be allowed to sit up more or less 
 during the day, but never with the limb in a depending position; 
 the diet should be nourishing and of easy digestion, and tonics, wine 
 in moderate quantity, or wine and Peruvian bark, and even good 
 brandy, must be allowed when there is much debility. In the more 
 advanced stages of the disease, sea-bathing has been recommended, 
 and may, probably, be occasionally useful. 
 
 The above treatment will, in the majority of instances, effect a per- 
 fect cure, if it be commenced sufficiently early, but the practitioner 
 must not be disappointed in occasionally finding patients who, notwith- 
 standing the active and energetic means employed, recover only to carry 
 for the remainder of their existence, a debilitated and enlarged limb.
 
 PUERPERAL MANIA. 691 
 
 CHAPTER L. 
 
 PHRENITIS PUERPERAL MANIA TREATMENT OF PUERPERAL 
 
 MANIA INTESTINAL IRRITATION ACUTE 
 
 TYMPANITIS DIARRHEA. 
 
 INFLAMMATION of the brain and its membranes is sometimes met 
 with in puerperal females; there will be headache, flushing of the 
 face, throbbing of the arteries, intolerance of light and sound, delir- 
 ium, and all the symptoms of an ordinary phrenitis. The treatment 
 will not vary from that usually pursued when the inflammation 
 occurs at other periods. 
 
 It may be proper to observe here that, for five or six weeks after 
 delivery, females are subject to severe cerebral derangement, from eat- 
 ing indigestible articles of diet, or from partaking too freely at rneals. 
 The most common symptoms in such cases are, headache, delirium, 
 Insensibility, convulsions, and death. They must be actively treated 
 by the usual means for such disturbance, but it will frequently be 
 found that treatment produces no amelioration of the symptoms, the 
 disease steadily advancing toward a fatal termination. 
 
 PUERPERAL MANIA, is more frequently met with than puer- 
 peral phrenitis, and is said to occur more frequently among unmarried 
 females than others. Those of an excitable or very sensitive disposi- 
 tion are the most liable to it, though no constitution or temperament 
 is exempt. It may occur during gestation, during parturition, or 
 subsequently ; the most usual periods of attack are a few hours or 
 days after labor, before the system has fully recovered from the shock ; 
 and, at some period previous to weaning, when the constitution is 
 suffering from the debilitating influence of lactation. It may con- 
 tinue for a few days, or months, and frequently many years may 
 intervene between the commencement of the attack and the mental 
 restoration ; occasionally the mania continues through life. 
 
 There is a species of delirium which is occasionally observed when 
 the head of the child is passing through the os uteri, or when it is 
 distending the perineum, and which is probably caused by the excessive 
 pain experienced at these times. It is not permanent in its character, 
 generally disappearing shortly after the passage of the child through
 
 692 KINO'S ECLECTIC OHSTKTKK >. 
 
 the parts. The female is frequently aware of the wild ness and absurd- 
 ities of her thoughts and expressions during this period, but this is 
 not puerperal mania. 
 
 Puerperal insanity is frequently hereditary, all the females of a 
 family, from generation to generation, being subject to more or less 
 mental derangement at the parturient period ; and when this is known 
 to be the case with a pregnant female, the practitioner should endeavor 
 to ward off an attack by proper treatment during the gestating months, 
 I am not aware whether the use of Chloral Hydrate during the period 
 of labor, or the production of anaesthesia by Chloroform, has, in these 
 cases, prevented the maniacal attack, but, as it appears to me, they 
 certainly deserve a trial. A common predisposing cause is the extreme 
 susceptibility or excitability of the nervous system and brain to which 
 pregnant females, as well as those who give suck, are subject, and 
 which renders them exceedingly liable to morbid impressions. 
 
 Mental emotions, as a great anxiety relative to her condition, or a 
 state of depression, or a severe fright occurring during pregnancy, 
 may likewise predispose the female to an .attack of mania ; and a very 
 common predisposing cause is stated to be derangement of the digestive 
 functions. Profuse hemorrhage has also been considered a predisposing 
 cause. 
 
 The exciting causes are many ; as irritation of the breasts, uterine 
 irritation, suppression of lochia, the vascular disturbance caused by 
 labor, suckling, nervous shock of labor, cold, and frequently it occurs 
 without any assignable cause. 
 
 SYMPTOMS. These do not vary essentially from those which 
 occur during the insanity of non-pregnant females, or of males. The 
 attack may come on suddenly, or it may take place gradually, and is 
 frequently preceded by more or less headache, nervous irritability, and 
 sometimes derangements of the digestive organs. In one form of the 
 malady, the female will be restless and sleepless, incessantly talking, 
 and expressing herself in a wild, disconnected, and most absurd man- 
 ner ; in another form, she will be depressed and melancholy. Females 
 have been known to escape the watchfulness of their attendants when 
 attacked by puerperal mania, and roam for a great distance from home, 
 even through snow and severe cold weather, and without any other 
 result than a restoration to sanity ; which, however, would probably 
 have occurred independent of such exposure and exercise. 
 
 It would occupy more space than is necessary in the present work, 
 to detail the various symptoms which may occur in this disease ; suffice 
 it to say, that though 'there may be some peculiarities attending it, yet
 
 PUERPERAL MANIA. 693 
 
 the general symptoms present the same features as those of the several 
 varieties of insanity met with at other times. 
 
 There are two opposite conditions of the vascular system in this 
 disease ; one is accompanied" with more or less fever, a quick pulse 
 ranging from 120 to 140 beats in a minute, headache, throbbing of the 
 carotids, flushed face, intolerance of light, great mental excitement 
 with incessant raving, it being almost impossible to restrain the 
 patient. The tongue is usually coated with a slimy fur; the urine is 
 turbid and scanty; the secretion of milk diminished, as well as its 
 nutritive qualities ; the bowels constipated; the lochia suppressed, or 
 natural; and often a peculiar and offensive odor emanates from the 
 various excretions. If a disposition to commit violence is present, it 
 is commonjy directed against others, and not against herself. 
 
 In the other condition, the pulse is feeble and but slightly acceler- 
 ated ; the temperature of the surface is natural or diminished ; there 
 is but little or no headache ; the tongue is coated white ; the bowels 
 are constipated ; the countenance is pale and sunken, but sometimes 
 calm and tranquil, with a gradually progressing emaciation. In this 
 condition the patient is usually in a depressed or melancholy state, and 
 is frequently aware of her situation ; there is more or less mental 
 apprehension, perhaps a religious mania, with great physical inactivity, 
 and a strong tendency to commit suicide. 
 
 Puerperal mania may terminate in a few hours, the mind being 
 perfectly restored ; or it may continue for months or years, with 
 ultimate recovery ; or it may, as has been observed in a few cases, be 
 permanent and incurable ; or it may terminate in death, especially 
 in the raving variety, which is attended with quick pulse and febrile 
 symptoms. 
 
 DIAGNOSIS. Puerperal mania may be confounded with phrenitis; 
 but although the pulse be quick in mania, it is not so sharp and hard 
 as in cerebral inflammations, nor is there such a high degree of the 
 heat of the surface and of the febrile symptoms ; in phrenitis there is 
 an intolerance of light and sound, which is seldom the case in mania : 
 phrenitis is attended with fever, headache, and other inflammatory 
 symptoms, for some time before delirium manifests itself, while in 
 mania the incoherency exists from the commencement. 
 
 It may be determined from congestive headache, by observing that 
 this does not commence with delirium : and from delirium tremens, by 
 learning the history of the case, the previous habits of the patient, and 
 by attending to the attack, which, in delirium tremens, is not sudden, 
 and is attended with a cold, clammy skin, profuse sweats, tremors, and 
 tremulousness of the tongue.
 
 694 KIM.'s ECLECTIC OBSTETitlC's. 
 
 When a pregnant female is subject to " frequent hysterical attacks ; 
 unaccountable exuberance or depression of spirits ; morbid aptitude 
 to exaggerate every trivial occurrence and attach to it great import- 
 ance; suspicion; irritability; or febrile excitation; or, what is still 
 more indicative, a soporous state, with very quick pulse, then," saya 
 Burrows, "the supervention of delirium on labor must be dreaded." 
 And to these symptoms Ramsbotham adds, as a prominent forewarn- 
 ing, a great loss of memory. 
 
 PROGNOSIS. The more serious form of puerperal mania, is that 
 which is manifested by a greater or less degree of excitement. When 
 it occurs immediately after delivery, with constant and rapid pulse, the 
 paroxysms being furious and ungovernable, it is much more dangerous 
 to life than when it occurs later, and with milder symptoms. Free 
 evacuations from the bowels are favorable, as are likewise a decrease 
 of the pulse, the patient obtaining some sleep, and not being much 
 prostrated. A rapid pulse, increasing in frequency, is generally indi- 
 cative of a fatal result, the mania being probably connected with an 
 inflammatory action of some of the pelvic or abdominal viscera. The 
 melancholy form of .puerperal mania is more permanent, and more 
 difficult of removal, than the raving. " Mania is more dangerous to 
 life melancholia to reason." (Gooch.) 
 
 TREATMENT. To have the patient placed in a hospital is, very 
 frequently, as the rule, the best and only course to pursue ; yet, from 
 its after effects upon the minds of the patient and her friends, there 
 will always remain a dread of a second attack of insanity ; to avoid 
 which, it is, in every instance, better to attempt her cure at home, 
 advising the hospital only as a dernier ressort. We must attend to the 
 symptoms, as they manifest themselves, endeavoring to overcome the 
 excitable condition of the brain and nervous system, without occa- 
 sioning or allowing any great amount of debility to ensue. The 
 bowels must be opened occasionally by some mild, stimulating purga- 
 tive, and kept free, during the intervals, by gentle laxatives. The 
 compound powder of Jalap will answer as a purgative. As a lax- 
 ative, the powder of Rhubarb and Bicarbonate of Potassa may be 
 used, or the compound syrup of Rhubarb and Potassa. If the patient 
 can not be persuaded to take these, stimulating enema may be used, 
 as Castor Oil, with the compound tincture of Lobelia and Capsicum 
 added. 
 
 Frequently an emetic is indicated at the commencement of the 
 attack, the administration of which has frequently produced results 
 of a decidedly beneficial character; but it must be recollected that
 
 PUERPERAL MAMA. 695 
 
 they are injurious when there is prostration of the system, with a 
 feeble, rapid pulse, pale face, and cold surface. 
 
 Counter-irritation will be found of great value. The whole sur- 
 face should be bathed with a warm alkaline solution to which some 
 alcohol has been added, after which a sinapism may be applied the 
 whole length of the spinal column, together with friction and stim- 
 ulating applications to the inferior extremities from the hips down- 
 ward. In connection with this, the application of tepid or cold water 
 to the head three or four times a day, as a douche, will prove bene- 
 ficial ; or cold applications may be constantly kept on the head. 
 When there is much activity of the circulation, with preternatural 
 heat of the head, the hair should be cut off, and sometimes leeches or 
 cups to the temples and nape of the neck will be advantageous. The 
 sinapisms may be changed alternately from the spinal column to the 
 extremities, and vice versa, removing them when considerable redness 
 of the surface to which they have been applied is produced, or when 
 they appear to augment the disease. An irritating plaster, as, for 
 instance, the Cantharideal Collodion dropped on adhesive plaster, 
 may sometimes be advantageously applied to the nape of the neck or 
 between the shoulders. This will be more serviceable in the melan- 
 cholic form of insanity. 
 
 After the bowels have been evacuated, sedatives should be exhib- 
 ited. The tincture of Gelsemium will be found exceedingly valuable; 
 it may be used alone, or in combination with such other agents as are 
 indicated in each case. In some cases one of the most prominent 
 symptoms will be drowsiness or stupor, or a capillary congestion. 
 Belladonna will be the indicated remedy, under such circumstances, 
 and should be continued, in the usual small dose, as long as necessary. 
 The tincture of Stramonium, or of Hyoscyamus, may be substituted, 
 in some cases, for that of the Belladonna. Other agents may also be 
 employed with benefit, as, a powder composed of Sulphate of Quinia, 
 one grain; Sulphate of Morphia, half a grain; extract of Belladonna 
 (dried), one-eighth of a grain; mix for a dose, which may be repeated 
 every hour. Sleep and quiet are the patient's great restoratives; and 
 every justifiable means should be adopted to procure sleep. Hydrate 
 of Chloral has proved a safe and highly efficacious agent. Chloroform, 
 Indian Hemp, Bromide of Potassium in twenty-grain doses, and 
 medicinal Hydrocyanic Acid, have likewise been serviceable in cer- 
 tain cases. In some cases, subcutaneous injections of Morphia will 
 promptly induce sleep. If ; he be boisterous, struggling against the
 
 696 KING'S ECLECTIC OBSTETRICS. 
 
 attempts made to induce sleep, she should be fastened in such a way 
 as to keep her in bed, and prevent her from exhausting herself by 
 her struggles. As with the preceding puerperal maladies, cleanliness 
 will be of great value; especially the removal of offensive and putrid 
 material from the utero-vaginal canal by injections of some disin- 
 fecting fluid. 
 
 The patient should be kept in a darkened room, free from noise or 
 disturbance, and an experienced nurse should be obtained who is ac- 
 customed to attend such patients, and who understands how to manage 
 their whims and caprices for a scolding, contradictory, or inattentive 
 nurse, will effect more injury than benefit, by increasing the excite- 
 ment and fury of the patient. If the female be very boisterous and 
 unruly, attempting violence, it may become necessary to employ some 
 restraint, as a strait waistcoat, but this must not be used without it is 
 absolutely required; frequently, an observation to the nurse, in the 
 presence of the patient, that this will have to be employed, will at 
 once calm the most raving maniac. She should never be left alone, 
 and the windows of the apartment which she occupies should be well 
 secured, and all knives or other dangerous instruments, with which 
 she might effect suicide, or injure others, must be removed. The diet 
 must be nutritious, using food of ready assimilation, as, milk, solution 
 of gelatin, white of egg, etc.; and should there be much depression 
 of the system, stimulants will be required. It is frequently the case 
 that the patient will refuse to take either food or medicine. A proper 
 amount of food must be taken within the twenty-four hours, and the 
 medicine may frequently be concealed in it; but when she obsti- 
 nately refuses food, a cold douche, if not contra-indicated, a reference 
 to the strait waistcoat, or persuasion, may succeed in causing her to 
 eat. Sometimes, if left within her reach, she will eat the food when 
 under an> idea, probably, that she is unobserved. It is always proper, 
 when it can be accomplished, after the severity of the first attack has 
 subsided, to have the female exercise as much as possible in the open 
 air, but not to such an extent as to cause fatigue. There is frequently 
 an anaemic condition of the system in this disease, which the practi- 
 tioner should carefully observe, and for which some ferruginous prep- 
 aration will be found to act like a charm. 
 
 In the early stages of puerperal insanity, it is not prudent to allow 
 the .female to see her husband, child, or friends, as it generally proves 
 injurious, by giving rise to ideas, or mental efforts, which increase the 
 cerebral disturbance; but, in the passive or chronic stages, short and 
 distant interviews are frequently followed by an abatement of the
 
 INTESTINAL IRRITATION. 697 
 
 mental derangement. Aud, whenever it is deemed desirable that she 
 should see her child, she must not be permitted to handle it, lest in a 
 sudden maniacal fit she should destroy, or seriously injure it. 
 
 In the melancholic form, nutrition, anemia, and debility, are chiefly 
 to be attended to; prescribing a good, nutritious, easily digestible diet, 
 moderate exercise in the clear, open air. chalybeates, quinine, and an 
 attention to the skin and to the alvine and renal discharges. The 
 patient should be placed under cheerful, attractive, and pleasing sur- 
 roundings, in order to lessen the melancholy disposition, while any 
 excitement of the nervous system must be avoided, or be promptly 
 calmed by appropriate means. Tonics will generally prove useful for 
 patients much enfeebled. In both forms of mania, if the mind can 
 be properly directed, it will prove a valuable auxiliary in the treat- 
 ment. In one case, the most desirable results followed the internal 
 use of minute doses of Phosphorus and Nux Vomica, with full doses 
 of Phosphate of Lime. 
 
 When there is reason to anticipate an attack of mania at the partu- 
 rient period, either from a hereditary predisposition, from insanity at 
 a former labor, or from the symptoms heretofore described, a proper 
 course of treatment should at once be instituted. The bowelSj 
 especially, should be kept regular, and no crude, indigestible, or other 
 improper articles of diet should be allowed. All sources of irritation 
 should be removed, the mind must be kept free from exciting or 
 depressing influences; coition during the gestating period must be 
 positively forbidden; moderate exercise must be advised, but not to 
 the extent of fatigue ; the female should not be allowed to remain 
 alone, and the company permitted to visit her must be carefully 
 selected, refusing admittance to those who occasion too great a degree 
 of mirth, as well as to those who are fond of dispensing horrible and 
 melancholy news, whether true or false; pleasant, cheerful, and pru- 
 dent individuals only should be selected. If the patient be sleepless, 
 Bromide of Potassium, Chloral Hydrate, Hyoscyamus, or other 
 hypnotic agent may be used; or subcutaneous injections of the same; 
 and, in certain cases, nervines will be of decided utility, as, fluid 
 extract of Scutellaria, or of Asclepias, Lupulin, Pulsatilla, Gelsemium, 
 etc. Plethora must be overcome by diuretics; anaemia by chaly- 
 beates; and debility by bitter tonics and such other invigorating 
 measures as may be found serviceable. The Parturient Balm will be 
 of advantage in instances where symptoms of the trouble are- man- 
 ifest before delivery. Should there be a constant, dull, or severe 
 pain in the head, cooling lotions to the head, sinapisms to the back
 
 698 KING'S ECLECTIC OBSTETRICS. 
 
 of the neck, with rest and quiet, will, in conjunction with the other 
 means, generally remove it, and prevent the attack at the puerperal 
 season. 
 
 Females are subject to a condition slightly resembling peritonitis, 
 and which has been named INTESTINAL IRRITATION, by Dr. 
 Marshall Hall, and Acute Tympanites, by Dr. Ramsbotlmm. It may 
 be owing to some peculiar excitement or irritation of the lining mem- 
 brane of the intestinal tube, occasioned by a constipated condition 
 of the bowels, improper food, or irregularities of diet, which, by 
 debilitating the muscular fibers of the intestines, causes, soon after 
 delivery, a sudden development of gas. 
 
 The attack occurs generally two or three days after delivery, being 
 ushered in with rigors, which are more or less severe, and are suc- 
 ceeded by increased heat and dryness of the skin ; rapid pulse, fuller 
 and firmer than in peritonitis, or fluttering and tremulous; tongue 
 red, sometimes furred; countenance changed, but not as anxious as in 
 peritonitis; severe headache; intolerance of light and sound; constant 
 wakefulness; and often delirium. At an early period the abdomen 
 swells rapidly and to an enormous extent, being very tense and painful, 
 and the pain is aggravated by pressure ; frequently the transverse colon 
 can be distinctly traced. The secretion of milk becomes suspended, as 
 well as the lochia; the patient lies upon her back in a state of languor, 
 being averse to conversation, or any kind of disturbance; the legs are 
 usually drawn up, and the female appears indifferent to everything about 
 her. As the disease progresses, the pain, and swelling of the abdomen 
 increase, the tongue becomes dry and brown, with vomiting of offensive 
 matter, hiccough, IOW T , muttering delirium, subsultus tendinum, and 
 other symptoms common to the last stage of fever. 
 
 DIAGNOSIS. The principal distinguishing mark between this 
 disease- and peritonitis, is the period of abdominal enlargement. In 
 peritonitis the first symptom is pain, and the swelling does not come 
 on until the disease has existed sometime ; in the disease under con- 
 sideration the swelling manifests itself first, and the pain is subsequent, 
 being, probably, occasioned by the inordinate inflation of the intestines, 
 together with a morbid state of the nerves. In peritonitis the patient 
 is anxious as to the termination of her disease; in the present affection 
 there is a great loss of nervous energy, occasioning a complete state 
 of listlessness. 
 
 PROGNOSIS. A subsidence of the tenseness, swelling, and pain 
 of the abdomen, with the pulse becoming more natural, the tongue 
 clean and more moist, the skin cool and soft, the bowels becoming
 
 INTESTINAL IRRITATION. 699 
 
 free with expulsion of large quantities of wind, vomiting ceasing, 
 intellect unimpaired, a desire for food, and an attention to surrounding 
 circumstances, are indicative of recovery. 
 
 TREATMENT. Should there be any undigested food upon the 
 stomach an emetic may be administered, to be followed by a purgative. 
 The compound powder of Jalap may be given to produce free evacu- 
 arion of the bowels; at the same time an injection of hot water may 
 be given, to aid the evacuation, as well as to relieve the pain. If the 
 patient be very feeble, the purgative may be omitted, using the injec- 
 tion instead, as may be required. 
 
 After the bowels have been freely relieved, Nux Vomica will be 
 called for in many cases; the indication will be the broad, expression- 
 less tongue', nausea, and pain in the bowels. Dioscorea is the remedy 
 where there are cramps, and a pain like colic. Podophyllin should 
 be given in case the tongue shows the heavy coat at base. Much 
 benefit will also be derived, in some cases, from the use of the tinct- 
 ure of Xunthoxylum. These agents allay irritation, aid in expelling 
 the gas, and gradually restore the tone of the intestines. Cloths wet 
 with hot water, or hot fomentations of Hops and Tansy, or other 
 bitter herbs, will prove highly valuable when applied over the 
 abdomen. 
 
 The Oil of Turpentine, exhibited externally and internally, has 
 been highly extolled in this disease. Externally, it is to be applied 
 over the surface of the abdomen ; internally, one or two fluid drachms, 
 mixed with the white of an egg, may be given, and the dose repeated 
 every four hours ; or, if rejected by the stomach, an ounce of it may 
 be injected into the rectum. 
 
 Should any inflammatory symptoms be present, they must be 
 combated by the means already explained. 
 
 The patient should be kept quiet, her room being somewhat dark- 
 ened, and no visitors should be permitted to enter. After the evacu- 
 ation of the bowels, when the swelling begins to subside, a nutritious, 
 easily-digested diet should be allowed, with some stimuli if required. 
 Tonics may also be exhibited. I know of no better agent to rapidly 
 restore the tone of the intestines, after all the dangerous symptoms 
 have been removed, than the continued use of small doses of Nux 
 Vomica. Pulv. Hydrastis and Bismuth answers a very good purpose 
 in some cases also.
 
 700 KING'S ECLECTIC OBSTETRICS. 
 
 CHAPTER LI. 
 
 INFLAMMATION OF THE BREASTS MAMMARY ABSCESS EPHEM- 
 ERAL FEVER WEED MILIARY FEVER SORE 
 
 MOUTH OF NURSING WOMEN. 
 
 INFLAMMATION OF THE BREASTS, mammary afacet*, 01 
 mammitis, is of frequent occurrence among nursing women ; it may 
 happen at any period of lactation, but is most commonly met with 
 during the first month after delivery. At first, the inflammation is 
 usually limited to a circumscribed spot, but continues to extend into 
 the surrounding parts, until the whole breast becomes more or less 
 involved; occasionally, the whole breast may be affected from the 
 beginning, and, sometimes, both breasts become inflamed simultane- 
 ously. There is a strong tendency to suppuration in inflammation of 
 the mamma, which is often very difficult to prevent; and when the 
 constitution suffers therefrom, as by anorexia, nausea, feeble, rapid 
 pulse, great emaciation, excessive nervous irritability, and mental 
 anxiety and despondency, together with chills, exhausting sweats, etc., 
 we are by no means astonished that delirium of a wild character, 
 closely resembling puerperal mania, may sometimes be manifested. 
 
 This affection may be caused by an increased accumulation of milk 
 within the lactiferous tubes, occasioned by the mother not allowing 
 her child to suck, on account of tender and excoriated nipples, or, 
 perhaps, because she absents herself from her child, frequently and at 
 long periods, in order to enjoy parties and places of amusement, thus 
 neglecting to give to the distended breasts the relief they require. A 
 neglect of this kind, repeated several times, will readily induce an 
 abnormal condition of the glands. Epidemic (or endemic) influence 
 appears to be a predisposing cause. The disease may also be produced 
 by cold, and this is undoubtedly a common exciting cause. It may 
 likewise follow mechanical injuries, such as blows, bruises, compression 
 from tight lacing, etc., when the breasts are distended with milk, and 
 may also be induced by strong mental emotions. All females are 
 subject to it, but those of a strumous diathesis, or who are delicate and 
 feeble, are especially so. It is more common to primi parse; but, many 
 females suffer from it after each confinement. 
 
 SYMPTOMS. The inflammation may be limited to the subcuta- 
 neous areolar tissue; to the gland; to the areolar tissue beneath the
 
 INFLAMMATION OF THE BKEASTa. 701 
 
 gland; or, may extend to two or all of these combined. Generally, the 
 first symptoms experienced are more or less severe rigors, followed 
 by fever; a shooting pain in the breast is complained of by the 
 patient, which is aggravated by pressure, and accompanying which 
 there is a gradual swelling of the organ. Upon examining the breast 
 at an early period, a circumscribed hardness may be observed, within 
 which the pain is located, and the skin over which presents a natural 
 appearance. As the disease progresses the swelling becomes more 
 extensive, the pain more severe, the skin hot and shining, and of a 
 dusky-red color, and finally the swelling becomes soft and slightly 
 oedematous, with more or less marked fluctuation, indicative of the 
 formation of pus. The symptoms now increase in severity; the patient 
 becomes fretful in consequence of the severe pain, distressing shiver- 
 ings, want of sleep, and nocturnal perspirations, all of which occasion 
 a gradual loss of appetite, strength, and flesh. Sometimes nausea is 
 present, and not unfrequently an obstinate diarrhea. 
 
 The pain is more severe in proportion to the extent and depth to 
 which the gland is involved. If the inflammation be superficial, the 
 pus is laudable ; if it extend deeply, there is always sloughing of 
 considerable magnitude present, and death from hemorrhage has 
 occurred from the blood-vessels of the part becoming involved in the 
 destructive process. The suppuration ensues more rapidly when 
 the inflammation is superficial, or in the cellular substance under 
 the skin. 
 
 DIAGNOSIS. The subcutaneous variety of mammitis presents the 
 usual manifestations of phlegmonous inflammation; if suppuration 
 ensues, fluctuation will be detected, and the part at which the abscess 
 points will become thin and dark colored, with generally but one 
 abscess when the gland itself is attacked, and which is more commonly 
 the case, the pain will be more severe, and of a lancinating character; 
 there will be more constitutional disturbance, the portion of gland 
 involved becomes indurated, suppuration ensues rnore slowly, and 
 numerous abscesses are formed. In the deeper-seated variety, the pain 
 is located more deeply and is aggravated by pressure upon the gland, 
 though, unless the subcutaneous areblar tissue be involved, there will 
 be no pain upon touching or sljghtly pressing upon the surface of the 
 breast; the inflammation, which is generally circumscribed in the former 
 varieties, tends to become diffuse; and when suppuration occurs, the 
 patient experiences chills and exhausting sweatings, the surface of the 
 breast is smooth and uniform, without any induration, and, when much 
 enlarged, there is an unpleasant sensation of distension and weight.
 
 702 KING'S ECLECTIC OBSTETRICS. 
 
 When these varieties exist together the symptoms common to each 
 will be present, according to the variety and the severity of the 
 inflammation. 
 
 PROGNOSIS. Mammitis, when not properly treated, generally 
 terminates in suppuration; the character of the abscess, and of the 
 constitutional symptoms, depending upon the seat and nature of the 
 inflammation. In the subcutaneous variety, if resolution be m t 
 effected, suppuration will ensue in from five to ten days, the abscc-scs 
 from which may be cured in from seven to twenty-one days. When 
 the gland is attacked, the duration of the disease is much longer, aiul 
 suppuration occurs very slowly, forming abscesses, which are develnpe-1 
 one after another at different intervals of time, and which may continue 
 even under the most appropriate treatment from two to four, and 
 occasionally, even to eight months. 
 
 When the tissue between the gland and the walls of the thorax is 
 attacked, in most cases, we may not be aware of it until the suppura- 
 tion has manifested itself; and even when the diagnosis is readily made 
 out at an early period, it is very difficult, if not impossible, to prevent 
 suppuration; and the abscess continues a much longer time than in 
 the other varieties, generally discharging through a number of fistulous 
 canals. I have seen cases in which from extension of the disease, the 
 whole breast has sloughed away, giving rise to a large, open, as well 
 as fistulous abscess, discharging most profusely, and continuing for a 
 period of two and even three years. Lactation is not always arrested; 
 this depends entirely upon the extent of the sloughing, and the peculiar 
 tissues involved, and is more common with the variety in which the 
 gland itself is implicated. Sometimes, the structural lesion is such as 
 to arrest the function of lactation for a considerable time, but which 
 becomes eventually restored; at other times the loss of this function 
 may remain permanently. 
 
 This disease is more unfavorable to patients of a strumous habit, 
 and, though it rarely proves fatal, yet it requires prompt and energetic 
 treatment. It is frequently of tedious and difficult cure, and has been 
 known to arouse a dormant and inactive predisposition to disease, into 
 a fatal activity. 
 
 TREATMENT. The indication for treatment is to promote reso- 
 lution ; but, if the disease has continued for two or three days, with 
 considerable heat and pain, resolution can seldom be effected, and then, 
 means must be adopted to promote suppuration. ' Suppuration usually 
 occurs in ten or twelve days, seldom sooner.
 
 INFLAMMATION OF THE BREASTS. 703 
 
 In order to prevent the inflammation from terminating in suppura- 
 tion, the treatment must be active and persistent. It is well, in 
 some cases, to administer a mild cathartic in the beginning. The 
 proper sedative should now be selected, which will usually be 
 Aconite ; to this Phytolacca should be added, as a specific, in gland- 
 ular inflammation. About ten drops of each should be prescribed, 
 and given in teaspoonful doses every hour. In the subcutaneous 
 and glandular varieties, the breast should be painted two or three 
 times a day, with some stimulating preparation; I generally employ 
 a liniment made of equal parts of Oil of Cajeput, Oil of Sassafras, 
 Olive Oil and Camphor. After applying this, a warm poultice or 
 fomentation may be applied, and which should be changed two or 
 three times a day, at the periods of bathing with the liniment. 
 
 Although I have just recommeded the application of a fomentation 
 or poultice to the breast, it is only because others have frequently 
 used them with advantage. Prof. King recommends the following 
 ointment, which may be applied immediately after having bathed the 
 breast with the above liniment : Take of Castile Soap six ounces, good 
 Lard four ounces, yellow Beeswax two ounces ; finely cut, or shave the 
 soap, add to it the other articles, and melt the whole together by means 
 of a moderate heat. When thoroughly melted and incorporated, 
 remove the vessel containing them from the fisre, and when nearly 
 cool, add gradually three fluidounces of Jamaica Spirits, in which 
 three drachms of Camphor have been previously dissolved. Continue 
 stirring the mixture until it is cold. 
 
 Prof. King speaks of its use as follows : 
 
 This ointment has been used with success in every case where it 
 was applied at an early stage, or previous to suppuration ; it removes 
 all pain and swelling in from twelve to thirty-six hours, according to 
 the duration of the disease. I have frequently found it efficacious in 
 cases where the patient had suffered severely for twenty-four hours, 
 and when I had every reason to believe that the suppurative stage had 
 actually commenced. I employed it with constant success for nearly 
 fourteen years before having made it known to the profession. 
 
 The manner of using it is as follows : Cut a piece of linen in a cir- 
 cular form, of the size of the whole breast, leaving an aperture in the 
 center sufficiently large for the nipple to pass through. Then soften 
 a sufficient quantity of the ointment by a gentle heat, and spread it on 
 the linen. Apply this over the breast, as warm as can be borne ; at 
 intervals of four or six hours, remove it, soften it as before, and 
 reapply it to the breast immediately after having bathed it with the
 
 /04 KING'S ECLECTIC OI5STETRICS. 
 
 stimulating 1 liniment. A fresh application of the ointment will be 
 needed only once in every twenty-four hours ; the patient should be 
 kept quiet in bed, and the breast should be carefully supported by a 
 bandage, or some similar means. Other local applications have been 
 advised, as: carefully painting the inflamed surface of the breast with 
 tincture or solution of Iodine, solution of Belladonna extract, etc., 
 but I have never used them in this malady. 
 
 During the first stage of the disease more especially, it is of great 
 importance to keep the breasts as empty as possible, and if this can 
 not be effected by the infant, other means must be resorted to, as, some 
 older person accustomed to the business, a young pup, or an exhaust- 
 ing pump. And any febrile symptoms may be mitigated, as well as 
 pain and nervous irritability, by the exhibition of the compound 
 powder of Ipecacuanha and Opium, Sp. Trs. of Aconite or Verat- 
 rum, with Phytolacca. When the pain is excessivelv severe and 
 the febrile symptoms run high, it will be better to avoid feeding the 
 infant at all from the affected breast, and, in some cases, it will be 
 proper not to annoy the mother and increase, her sufferings by 
 requiring her to give it suck, but to feed it for a short time in some 
 other way ; if possible, have a wet nurse employed. In the glandular 
 and subglandular varieties especially, Sulphate of Quinia will be 
 found a most valuable agent, mitigating the constitutional symptoms, 
 and often preventing suppuration ; it should be given so as to effect a 
 prompt influence upon the system, which should be kept up for some 
 length of time. 
 
 If, however, matter should form, then the employment of poultices 
 to hasten its progress will be found of considerable value. And now, 
 the infant should not be permitted to use the milk of the affected 
 breast any longer, because, with the milk, which has lost its nutritive 
 qualities, it may be injured by the reception of pus into its stomach ; 
 the milk must be evacuated by other means. Fresh Poke-root roasted 
 in hot ashes, in the same manner as the potato, until it is soft, then 
 mashed and applied over the breast as a poultice, will materially 
 forward the suppurative stage, though its action will produce more 
 suffering than the poultices ordinarily employed for such purpose. 
 The addition of pulverized Lobelia, moistened with a mixture of warm 
 water and vinegar, to the roasted Poke-root, will materially enhance its 
 value. Flaxseed, Elm, or any of the common non-irritating agents 
 may be used for the poultice. In connection with the local applica- 
 tions, the internal administration of Phytolacca with the sedative 
 should be continued, and will usually be followed by prompt and 
 favorable results. It has been stated that if this treatment bv Poke-
 
 INFLAMMATION OF THE BREASTS. 705 
 
 root, internally and externally, be commenced at an early period of 
 the attack, suppuration will be prevented, and the disease will termi- 
 nate by resolution, even in the deeper- seated varieties. 
 
 When suppuration has occurred, the following rules should be 
 observed : 
 
 " If the abscess is placed superficially, or on the anterior surface of 
 the breast, and progresses with rapidity, not causing an undue degree 
 of suffering, it will be better not to interfere with it, but to allow it to 
 take its natural course. 
 
 " If it be deeply situated, progressing slowly, giving rise to severe 
 local sufferings, and is attended with a high irritative fever, profuse 
 perspiration, and want of rest, much time will be saved, as well as 
 considerable suffering, by opening the abscess at the proper period, 
 with a probe or lancet, and permitting the pus to escape," being care- 
 ful however, not to be in such a hurry as to make an opening before 
 pus has formed. And always, in opening the abscess, carry the 
 incision parallel with the lactiferous vessels, so as to avoid dividing 
 them, as much as possible. In all cases, it will be well to introduce a 
 tent into the openjng to prevent it from closing before the pus has 
 been entirely discharged. 
 
 " If there is a thick covering over the abscess, it is improper to 
 penetrate it with the lancet, because the opening will not succeed in 
 establishing a free discharge of matter, for, as the aperture closes by 
 adhesion, the accumulation of matter proceeds, and ulceration will 
 still continue. On this account, the opening should be made where 
 the matter is most superficial, and where the fluctuation is distinctly 
 perceptible, and its size should be proportioned to its depth." Also, 
 keep it open by the introduction of a tent. 
 
 " When the abscesses are very deep, with several sinuses, the best 
 mode of treatment, is to inject into them a solution of two or three 
 drops of strong Sulphuric acid in a fluidounce of Rosewater; and this 
 may likewise be applied on folds of linen cloth over the bosom, by 
 which the secretion of milk is checked, and adhesion is produced." 
 (Sir A. Cooper.} ., , 
 
 If the ulcer does not readily heal, or assumes an indolent character, 
 apply some sesqui-carbonate of Potassa to it, and dress iit -with the red 
 oxide of Lead plaster, or the compound Lead ointment, treating it 
 similar to ulcers on other parts. 
 
 Should there be a troublesome oozing of blood , r.om the ,wound 
 made by the lancet, in opening the abscess, it must be treated by the 
 application of dry lint, with sufficient compression. 
 45
 
 706 KING'S ECLECTIC OBSTETRICS. 
 
 In the inflammatory stage, the diet must be light and non-stimu- 
 lating; during the suppurative discharge, a nourishing diet should be 
 used, and to support the strength and aid in the formation of healthy 
 pus, Port wine and Cinchona, or the compound wine of Comfrey, 
 will be required. If there is exhaustion with considerable irrita- 
 bility of the system, Morphia and Quinia combined, will be found 
 advantageous. 
 
 Beside MILK FEVER, which has been referred to on another page, 
 there are two other forms of fever which may be occasionally met 
 with in practice. One is termed EPHEMERAL FEVER, or 
 WEED, and is more especially met with in cold, moist weather, 
 among those who reside in low, marshy places, or in the neighbor- 
 hood of stagnant ditches. It may likewise be occasioned by cold, 
 indigestion, constipation, fatigue, mental agitation, want of rest, and 
 improper food. It appears usually in from six to nine days after 
 delivery, and seldom continues over twenty-four or forty-eight hours, 
 whence its name, ephemeral. It commences with severe and long- 
 continued rigors, succeeded by heat and profuse perspiration. During 
 the shivering there will be pain in the back and various parts of the 
 system, shrunken features, eyes hollow, skin dry and harsh, with the 
 integuments at the fingers' ends livid and corrugated, thirst, rapid and 
 perhaps irregular pulse, or feeble and indistinct; and various other 
 distressing symptoms, which increase in severity as the rigors are 
 about passing off. The hot stage is characterized by a throbbing of 
 the temples ; great heat of the surface ; flushed face ; severe headache, 
 generally referred to the forehead and eyeballs; soreness of the breasts 
 and of the abdomen ; rapid, full, hard, and firm pulse ; and a dimi- 
 nution of the various secretions, with occasional delirium. This is 
 followed, after a longer or shorter time, by a profuse perspiration, 
 which appears first on the forehead, neck, and chest, and which is 
 succeeded by an abatement of the fever, and an amelioration o all 
 the previous symptoms. 
 
 This disease may be mistaken for puerperal peritonitis; but the 
 violence and long continuance of the rigors, the absence of marked 
 abdominal tenderness on pressure, and the very profuse perspiration 
 which is followed by relief, will enable us to distinguish it, as well as 
 the absence of a return of the paroxysms. It is seldom a dangerous 
 disease, unless, by improper management, it be allowed to pass into a 
 continued or intermittent fever.
 
 EPHEMERAL, FEVER OR WEED. 707 
 
 TREATMENT. The indications of treatment are to shorten the 
 various stages of the disease as much as possible. During the cold 
 stage, apply warmth to the surface, as bottles of warm water, or warm 
 bricks, etc., to the feet, knees, thighs, and axillae, and warm flannels 
 over the stomach and abdomen; in addition to which, warm drinks 
 and cordials may likewise be given; and, as the case may require, 
 adopting other means similar to those which would be employed in 
 the cold stage of ague. As the bowels are frequently, constipated, an 
 active purgative should be administered either in this or the subse- 
 quent stage; sometimes an emetic will prove advantageous. 
 
 In the hot stage, the surface should be bathed with warm water, 
 and the proper sedative administered; in some cases Sulphate of 
 Quinia may be given, in three-grain doses, for a day or two. If there 
 is much nervous irritability, Pulsatilla or Gelsemium will be found 
 very beneficial agents; and these may be continued for some days 
 after the cessation of the disease, to allay the irritability and lessen 
 the disposition- to any secondary attack. 
 
 In the sweating stage, the Sulphate of Quinia may be continued 
 alone, or in conjunction with Priissiate of Iron; and the patient 
 should use some of the tonics; or small doses of the Aromatic 
 Sulphuric Acid will frequently overcome the trouble. 
 
 The several symptoms which may present during each stage, must 
 be met by measures similar to those employed when they occur in 
 other febrile affections. After the paroxysm has ceased, the diet should 
 be nutritious, with stimulants if there be much depression. Exposure 
 to cold should be guarded against, or any other exciting cause of the 
 disease; and it should be ascertained by a careful examination whether 
 any derangement of the uterine system exists, that it may be promptly 
 subdued. 
 
 The other febrile affection referred to above, is termed MILIARY 
 FEVER: it is still more rarely met with than the preceding, though 
 in former days it was quite common, and was considered a formid- 
 able disease. It may occur as a primary affection, and independent 
 of the parturient state; but more usually it appears as a symptom 
 connected with puerperal, milk, or ephemeral fevers, especially in 
 those cases where perspiration is permitted to become too profuse. 
 Females of debilitated constitutions are more subject to it than 
 others. It generally occurs between the second and twelfth day of 
 delivery, and may be excited by fatigue, relaxation, impure, over- 
 heated air, stimulants, rich or improper food, excessive evacuations, 
 constipation, and personal unclean liness.
 
 708 KING'S ECLECTIC OUSTETUICS. 
 
 It commences with chills, succeeded by fever, and perspiration of 
 an acid, penetrating odor. There is sickness and languor, with a hot 
 skin, frequent pulse, depressed spirits or great anxiety of mind, a great 
 weight about the chest, severe headache, dull and watery or inflamed 
 eyes, with throbbings within the orbits, tongue furred white with 
 raised papillae and red edges, ringing in the ears, and occasionally 
 aphthous ulcerations of the mouth and fauces. The lochial and lac- 
 tiferous secretions are diminished or suppressed, and a pricking or 
 itching of the surface is generally complained of; occasionally there 
 is a sensation of numbness in the extremities. The perspiration is 
 usually followed by no mitigation of the symptoms. After these 
 symptoms have continued for a few days, the skin begins to feel rough 
 like the cutis anserina, and in a short time the eruption appears about 
 the forehead, neck, and breast, from whence it gradually extends to 
 the trunk and extremities : it rarely affects the face. It appears in the 
 form of small, red, generally distinct vesicles, about the size of millet- 
 seed, having a red or inflammatory appearance surrounding their base. 
 In a few hours the vesicles assume a white or yellow appearance, from 
 the change effected in the lymph contained in them, and in ;a few days 
 they dry up, and the crusts fall off in small branny scales. The erup- 
 tion, unless the disease be primary, seldom affords any relief to the 
 symptoms, and may occur frequently and irregularly, should the fever 
 and perspiration continue. Occasionally, the eruption has been met 
 with where but little or no fever was present. The disease is seldom 
 serious, unless the perspiration be suddenly checked, or the eruption 
 recede, under either of which circumstances fatal results may ensue. 
 
 The disease may be determined by the character of the tongue, the 
 oppression at the chest, and the peculiar, strong, and sour smell of the 
 perspiration. 
 
 TREATMENT. Keep the room well ventilated and cool, gradually 
 lessening the amount of bedclothes, but being extremely careful not to 
 allow the patient to "catch cold." Give laxatives to keep the bowels 
 regular, and when there is derangement of the stomach, an emetic may 
 be useful. The drink of the patient should be cold and acidulated; 
 Rhus Tox. should here be given in small doses, together with 
 Aconite. Fowler's Solution and Apis will be useful also in some 
 cases, as well as small doses of Iris. Sulphate of Quinia will be 
 found of much service during convalescence. 
 
 On the abatement of the febrile symptoms, the diet may be im- 
 proved and mild tonics employed. Should there be aphthous ulcer- 
 ations, they may be washed or gargled with a solution of fluid
 
 SORE MOUTH OF NURSING WOMEN. 709 
 
 Hydrastis, or Borax water may answer the purpose. If the disease 
 accompanies other affections, especial' attention must be directed 
 toward the treatment of these, for the secondary difficulty will con- 
 tiryie more or less severe until the primary one is subdued. 
 
 Women who suckle, or who have advanced to the latter months of 
 pregnancy, are sometimes affected with a sore mouth peculiar to them- 
 selves, somewhat resembling follicular stomatitis, or follicular inflam- 
 mation of the mouth; other females and men being exempt from 
 it It is generally known as the SORE MOUTH OF NURSING 
 WOMEN (Stomatitis Maternd). The most robust constitution, or the 
 sickjy and delicate, are indiscriminately attacked by it; those, how- 
 ever, of costive habits, dyspeptic symptoms, and hepatic affections, 
 seem to be more liable to its attacks than others. And when there is 
 a tendency to phthisis, or some constitutional disease, the debility 
 produced by it is of a much more serious nature, than in vigorous and 
 sound systems. I have frequently met with it in females who were 
 liable to attacks of erysipelas, and also those whose constitutions had 
 been injured by the use of mercurials. If this disease is allowed to 
 go on for any length of time without being relieved, the morbid 
 irritation of the tongue and fauces extends to the stomach and bowels, 
 in which case it is apt to prove fatal. I have known the disease to 
 terminate in death during the third, fourth, and fifth puerperal week, 
 even after the child had been kept from the breast. 
 
 The children of females laboring under this affection are generally 
 healthy and robust, being well supplied with milk, the secretion of 
 which is commonly abundant until the last stages, when the patient 
 being reduced by starvation, this secretion fails. The means usually 
 employed for common sore mouth, or follicular inflammation, will not 
 effect any benefit in this disease, unless it be very mild ; and, in many 
 instances, an energetic treatment must be pursued, or the patient will 
 die. Death has taken place within a month from the appearance of 
 the disease, and, again, patients have lingered for three or four months 
 before the fatal termination. It is a singular malady, nearly always 
 disappearing upon weaning the child; yet weaning is not always 
 necessary, nor is it at all desirable, as there is a greater disposition to 
 a return of the disease at every future accouchment, than in those 
 cases where proper treatment has effected a cure, and restored the 
 constitution to its usual normal condition. It must be recollected, 
 that in patients who have been cured of this disease, there will exist a 
 strong tendency to its return from slight causes, at least until the
 
 710 KING'S ECLECTIC OBSTETRICS. 
 
 child is weaned ; as, from exposures to cold, fatigue, indigestible diet y 
 etc., and which in consequence, must be carefully guarded against. 
 
 This disease appears to depend on gastric and hepatic derangement, 
 in connection with a vitiated state of the blood, and is more common 
 to those subject to erysipclatous affections, or of strumous diathesis. 
 
 SYMPTOMS. The accession of the disease is often very rapid 
 from apparent health extremely so : within three hours after seeing 
 the patient in health, perhaps actively engaged in household matters, 
 and not suffering from any unusual irregularity of the stomach and 
 bowels, she will be found with a scalding of the tongue and fauces. 
 and unable to converse or take food. The first sensation is uniformly 
 described by the patient as a severe scalding of the tongue, with pain, 
 at times intense. There is also a peculiarity of the tongue, its color, 
 especially in the severer instances, being pink; and its edges and the 
 roof of the mouth have a. deeper hue of this color, often accompanied 
 with a most profuse watery discharge from the mouth, extremely hot, 
 so much so as to give a scalding sensation to the face when passing 
 over it. The appetite is usually very good, often ravenous, but no 
 food or drink, except the blandest, can be taken into the mouth, 
 without producing more or less intense pain : the food must be of a 
 mucilaginous or farinaceous character. After a continuance of this 
 state of the mouth for a few days or weeks, slight ulcerations on the 
 end or edges of the tongue manifest themselves, as also about the 
 different parts of the fauces. Sometimes the disease gradually com- 
 mences with slight ulcerations on the tongue, and this general scalding 
 of the tongue and fauces follows. The bowels are usually constipated, 
 or soon become so ; no fever, but at times excessive irritation of the 
 whole system, in consequence, probably, of the want of rest ; as the 
 continued pain of the fauces, and the excessive and constant flow of 
 burning saliva prevent any comfortable rest day or night. The tongue 
 is generally free from any coat, or it may have a light, white one. 
 Occasionally, although the surface of the ulcerations is not deep, yet 
 they continue to increase in width, and the inflammation spreads all 
 over the mouth. When it extends from the mouth and fauces to the 
 bowels, diarrhea ensues, and usually, in such cases, the soreness of the 
 mouth becomes better, but the case is attended with more danger. 
 When the disease is severe there will be an anaemic condition of the 
 system, with considerable prostration of the vital energies. 
 
 TREATMENT. In the first two cases of this disease which I 
 attended, having never seen a description of the disease in any medical 
 work, I pursued the usual treatment for aphthous ulcerations, and lost
 
 SORE MOUTH OF NURSING WOMEN. 711 
 
 my patients ; since which, my success in the treatment of it has been 
 such as to justify me in recommending the following plan: 
 
 In the severe or obstinate cases, an emetic frequently answers a 
 good purpose, and, if the patient is not too weak, should be given. 
 The emetic I usually prefer is the compound powder of Lobelia. In 
 the milder cases emetics may generally be dispensed with. 
 
 The constipation may be overcome by the administration of such 
 mild means as will prove efficient and not exhaust the patient. Jalap 
 acts very well in some cases; or, where the tongue shows the heavy 
 yellow coat at base, Podophyllin should be preferred. 
 
 Internally, the tincture of Chloride of Iron may be given, in doses 
 of twenty drops, and should be repeated every two or three hours. 
 Formerly I was in the habit of administering alteratives, as the com- 
 pound syrup of Sarsaparilla, compound syrup of Yellow Dock root, 
 or the compound syrup of Stillingia, with a proper proportion of Iodide 
 of Potassium added to the syrup used; but, though these will be fre- 
 quently found useful, I think the tincture of Iron above advised will 
 be found more generally successful, from its direct influence on the 
 capillary vessels, and the beneficial action of the Iron in anaemia. A 
 saturated solution of Chlorate of Potassa, in doses of a fluiddrachm, 
 repeated every three or four hours, has frequently proved serviceable. 
 And in some instances Bromide of Potassium, or of Ammonium, in 
 conjunction with Sp. Tr. Iris or Nux Vomica, has given prompt 
 relief. 
 
 Sometimes diarrhea is present, in which case no purgative must be 
 administered. The tincture of Chloride of Iron in doses often drops, 
 diluted sufficiently, and repeated every hour or two, will be found to 
 have a most excellent influence over diarrhea, especially when used 
 in conjunction with a stimulating and astringent injection, such as a 
 mixture of Tannic Acid, one drachm, Glycerine, Elm mucilage, of 
 each half a fluid ounce. Mix for an injection, to be repeated imme- 
 diately after each stool. Benefit may also be derived, in diarrhea, by 
 the use of Liquor Bismuth, in teaspoonful doses, two or three times a 
 day. Rice-water, Elm-water, infusion of Epilobium, Blackberry 
 root, or of other vegetable astringents, may be drank freely. 
 
 In nearly all instances of this disease, a deficient action of the 
 cutaneous vessels will be met with, and which it is absolutely neces- 
 sary to remedy. If, as is sometimes the case, the disease comes on 
 previous to parturition, or immediately succeeding delivery, the whole 
 body and limbs should be bathed daily with a weak alkaline wash, to 
 be followed, after drying, with some stimulating application, as whisky
 
 712 KING'S KOLECTIC OBSTETRICS. 
 
 and water, etc. And as soon after delivery as may be prudent, the 
 spirit vapor bath should be administered twice a week, or accord- 
 ing to the strength of the patient. Attention to the surface is an 
 exceedingly important part of the treatment. 
 
 The aphthous condition of the mouth and fauces must also be 
 attended to locally. A solution of Nitrate of Silver, from sixty to 
 eighty grains of the salt to a fluidounce of water, will generally be 
 found useful in allaying the more severe scalding and painful sensa- 
 tions; the whole internal surface of the mouth should be washed with 
 it once every day, or every other day, and it will be best to apply it 
 at bedtime, that the female may obtain some sleep afterward. Solu- 
 tion of Perchloride of Iron, properly diluted, and applied one, two, 
 or three times a day to the aphtha, is likewise serviceable in many 
 cases; the same may be said of a weak solution of Sulphate of 
 Copper. During the day, the mouth and throat must be frequently 
 washed or gargled with a solution of one of the following preparations, 
 a small portion of either of which may be occasionally swallowed 
 with benefit : Fluid Hydrastis, Borax, Chlorate of Potassa, Phyto- 
 lacca or Baptisia. Undoubtedly other astringents, an:l agents which 
 influence mucous tissues, will be of value. Solution of tincture of 
 Chloride of Iron, or of diluted Carbolate of Iodine,* sprayed upon 
 the aifected parts, have each been found of efficacy. 
 
 From a belief that this malady is due to a lack of phosphatic salts 
 in the blood these salts not having been assimilated sufficiently rapid 
 to supply the necessary materials for the growth and nutrition of the 
 pregnant woman and her child Dr. N. S. Davis has advised the in- 
 ternal use of the compound syrup of the Hypophosphites, in doses of 
 one or two fluidrachms, three or four times a day, commencing its 
 use as soon as the disease manifests itself, and continuing it during 
 the entire period of lactation. If anemia exist, the Pyrophosphate 
 of Iron may likewise be used in addition. 
 
 The diet should be light and easy of digestion, avoiding fats, stimula- 
 ting liquors (though wine is indicated when there is a great prostration), 
 gross diet, and everything which will cause acidity of the stomach, or 
 in any way retard or derange the digestive functions. 
 
 *Tlie diluted Carbolate of Iodine to be prepared as follows: Take of Iodide of 
 Potassium, ten to twenty-five grains; Iodine, five grains; crystallized Carbolic acid, 
 five grains; Glycerin, clear, soft Water, each, nine to twenty-seven fluidraclims ; mix 
 and dissolve the solids.
 
 SORE MOUTH OF NURSING WOMEN. 713 
 
 It is always advisable to cure this affection, if possible, without 
 weaning the child, as the female is thereby rendered less liable to its 
 recurrence at another parturient period. But, if the soreness and pain 
 are excessively intense, a-nd appear to be intractable to all treatment, 
 and more especially when diarrhea is present, weaning may become 
 absolutely necessary, in order to save the patient's life. In these cases, 
 and also where a strong disposition exists to a return of the disease at 
 each accouchement, it may be entirely cured, checked, or its severity 
 very much ameliorated, by regulating the bowels during pregnancy 
 with the compound powder of Rhubarb, and preserving, as much as 
 possible, a normal condition of the system, by some alterative, treat- 
 ment persistently used during the whole period of gestation. Prof. 
 Scudder states that he has found tobacco smoking to be of more 
 efficacy in this affection, than any other local application, and he pre- 
 fers it to all mouth washes. 
 
 CHAPTER LI I. 
 
 CYANOSIS RETENTION OF URINE RED GUM JAUNDICE INFAN- 
 TILE OPHTHALMIA FLATULENT COLIC CONSTIPATION - 
 
 UMBILICAL HERNIA EXCORIATION OF THE NAVEL 
 HEMORRHAGE FROM THE CORD - HEMORRHAGE 
 FROM THE NAVEL NvEVUS MATERNI TONGUE- 
 TIED HYDROCELE SWELLING OF THE 
 
 BREASTS HARE-LIP. 
 
 As soon as the child is born, and breathes, a change is effected in 
 its circulation ; the blood which had partly circulated from the right 
 into the left auricle, through the foramen ovale, during intra-uterine 
 existence, as well as that which had flowed through the ductus 
 arteriosus, from the pulmonary artery into the aorta, now changes its 
 direction and flows toward the lungs, through the pulmonary artery. 
 However, cases are occasionally met with, in which no change of this 
 kind is effected, and the blood continues to pass from the right to the 
 left side of the heart. From this circumstance, the blood is imper- 
 fectly oxygenized, as manifested by the livid or blue color of the lips 
 and other parts of the body which are protected by only a thin 
 cuticle. This condition is termed Blue Disease, Morbus Cceruleus, and 
 Cyanosis.
 
 71 -i KING'S ECLECTIC OBSTETRICS. 
 
 The two auricles of the heart form nearly a single cavity, at the 
 fifth month of pregnancy, in consequence of the imperfect develop- 
 ment of the septum auricularum ; but this septum gradually matures 
 until at full term the foramen ovale is generally considered to he nearly 
 or quite occluded. 
 
 Cyanosis may be occasioned by a patulous condition of the foramen 
 ovale, or by some malformation, as, deficient ventricular septum, con- 
 stricted pulmonary artery, or any other abnormal conditions of the 
 heart or its blood-vessels; frequently, the foramen ovale may continue 
 open after birth, or may re-open; and, anything which interferes with 
 the return of the blood to the heart, preventing the formation of 
 arterial blood, ma: give rise to the blue color observed in this 
 disease. 
 
 The symptoms of cyanosis are a violet, blue, or purple color of the 
 surface of the body, especially the face, lips, hands, feet, and genitals, 
 and which color becomes increased by exertion or excitement. In 
 addition to this, indications of cardiac disease are present, in a greater 
 or less degree, as, paroxysms of dyspnoea of long or short duration, 
 palpitation, and sometimes syncope, diminished temperature of the 
 surface, and an extreme susceptibility to the influence of cold, with a 
 strong disposition to serous eifusion. The child is most commonly 
 dull and sleepy, its respiration being slow, and frequently labored, and 
 eventually spasms and convulsions occur previous to the fatal termina- 
 tion. However, it must be borne in mind, that oxygenation of the 
 blood is less important to an infant than to an adult, and infants have, 
 at times, presented symptoms of imperfect oxygenation of the blood, 
 without any detrimental results. 
 
 Post-mortem examinations have, in the majority of deaths by 
 cyanosis, discovered some malformation of the' heart, its blood-vessels, 
 or of both. Meckel states, that "even when the foramen ovale has 
 remained open, there may be no cyanosis, if the pulmonary artery is 
 properly formed." 
 
 TREATMENT. Although cures have been effected in this disease, 
 yet we are not to anticipate such results as a general rule, and especially 
 if the infant be attacked with spasms or convulsions. 
 
 It is always proper to attend to the position of the child, as recom- 
 mended by Professor Meigs, which is, to place it on its right side, with 
 the body inclined at an angle of 30, the head being the highest part. 
 On a moment's reflection it will be seen that the anatomical, as well 
 as the mechanical relations of the parts, indicate this position, which 
 maintains the left auricle perpendiculary above the right, and the
 
 CYANOSIS. 715 
 
 blood must thereby gradually pass into the pulmonary ventricle, from 
 the force of gravity alone. Yet, in cases depending upon malformation, 
 no benefit could result from this or any other position. 
 
 In connection with this position, the child must not be allowed to 
 cry or worry, but should be kept as still as possible, and its body 
 should be occasionally bathed with tepid water Should tli^ natural 
 color of the skin return after several hours, with a freer respiration 
 and a cessation of spasmodic action, all that will be necessary in the 
 way of medicine, is a gentle purgative, or two. 
 
 In many cases the disease terminates fatally in a few days, and, 
 sometimes, not until after several months ; the affected individual 
 seldom reaches the period of maturity. Whenever the disease does 
 not destroy the patient after a few weeks, there may possibly be some 
 benefit derived by treating him for a chronic disease of the heart. 
 
 Sometimes, an infant will pass many hours after its birth with a 
 RETENTION OF URINE. This may be owing to the fact that 
 none has been secreted ; to an obstruction or debility of the parts 
 concerned in ejecting the urine; or, to some malformation, or closure 
 of the urethra. The first cause may be overcome by the use of such mild 
 diuretics as infusion of Pumpkin seed or Watermelon seed, or by the 
 administration of minute doses of Acetate of Potassa, Santonine or 
 Sp. Tr. Apis Mel. ; the second, by placing the child for a short time 
 in a warm bath, and then, after drying it, applying hot fomentations 
 over the. region of the bladder. The third cause will require a sur- 
 gical operation for its removal, according to the character of the 
 difficulty. 
 
 A few days after birth, infants are attacked with a cutaneous 
 affection, called RED GUM (strophulus intertinctus). It is a slight 
 eruption of red, or sometimes whitish pimples, which are surrounded 
 by a reddish halo. This is probably occasioned by the exposure of 
 the surface to the action of the atmosphere, and other external stimu- 
 lating influences, as well as to changes effected in the capillary 
 circulation by the increased oxygenation of the blood. It is of no 
 importance and requires no especial treatment. The skin should be 
 frequently powdered with Arrowroot, and if there be any derangement 
 of the digestive functions, it may be remedied by an occasional 
 dose of Lime-water, or if the child is nursed from a bottle a small 
 portion of it may be added to the milk.' Nurses are frequently
 
 716 KING'S ECLECTIC OBSTETRICS. 
 
 in the habit of giving an infusion of Catnip and Saffron for this affec- 
 tion, and, as no harm can be effected by it, prohibition would not 
 always be prudent. 
 
 Infants are likewise liable to a yellowness of the eyes and skin, 
 shortly after birth, termed JAUNDICE; and with this, the urine 
 may also be so colored with bile as to leave yellow stains upon the 
 diapers. Ordinarily, this is of but little consequence, and is generally 
 treated by an infusion of Saffron and Catnip. But when the stools 
 denote biliary derangement, being whitish, clay-colored, or whitish 
 yellow, it may be overcome by the use of the small dose of Chion- 
 anthus; or possibly a constipated condition of the mother, in such 
 cases, when relieved will overcome the trouble in the nursing child. 
 The surface should be kept clean by daily bathing. Sometimes, how- 
 ever, in consequence of malformation, or disease of the liver or its 
 ducts, a true jaundice may exist, and which is apt to be of a serious 
 nature ; but this is not of very frequent occurrence. 
 
 Shortly after birth, say on the second or third day, and sometimes 
 later, infants are frequently attacked with OPHTHALMIA (ophthal- 
 mia purulenta infantum, or oph. neonatorum) . It commences with a 
 redness and swelling of the lids, and, on awaking, the lids will be 
 observed to slightly stick together. Light occasions pains, and con- 
 sequently the child keeps its eyes closed. At first, a little whitish 
 matter will be observed lying on the inside of the lower lid, and sub- 
 sequently a profuse and constant discharge of thick, yellow matter 
 takes place, and which covers the whole eye. If this be allowed to 
 continue without attention, the child may ultimately lose its eye. The 
 treatment will consist in cleanliness and agents to lessen inflammatory 
 action, and a frequent bathing of the eye with water, as hot as can be 
 borne, in which a few drops of Fluid Hydrastis may be used. If a 
 more stimulating application is required, eight or ten grains of the 
 Sesquicarbonate of Potassa may be added to a fluid ounce of warm 
 Water. The bowels should be kept regular. Other local applications 
 may also be used with benefit, as a mild solution of Borax with Mor- 
 phia, or a weak solution of Sulphate of Zinc. 
 
 INNUTRITION. It is sometimes the case that a rich, creamy 
 milk, supplied in abundance by a healthy mother or nurse, does not 
 afford nutrition to the child, nor appease its appetite, but, on the con-
 
 FLATULENT COLIC. 717 
 
 trary, the child is ravenous, rapidly emaciates, has the look of an old 
 person, and suffers from diarrhea, diuresis, or diaphoresis. "Whenever 
 a case of this kind is presented, the freshly drawn milk from the 
 mother's breast should be carefully examined. It will, in the present 
 instance, be found to vary in color, be neutral or alkaline, rich in 
 saccharine matter, of specific gravity 1024 to 1035, and under the 
 microscope will be found to contain animalcules, vibriones, and monads 
 (vibrio lactis ; monas lactis). These animalcules are attributed to 
 fermentation of the saccharine element of the milk while yet within 
 the mammary glands ; the fermentation being probably due to sexual 
 excitement, together with, perhaps, more or less congested condition 
 of the glands. In these cases the child should be immediately with- 
 drawn from further use of such milk, and be fed by the bottle, using 
 the milk from one cow, which may be properly diluted with Lime- 
 water; or one of the prepared foods may be substituted, among which 
 I prefer the Malted Milk. 
 
 Infants are frequently troubled with FLATULENT COLIC, which 
 may arise from costiveness, exposure to cold, from being allowed to 
 suckle too much, from irregularities in the diet of the nurse, or some 
 bad quality of her milk. It usually comes on suddenly, and may be 
 known by the violent and incessant screaming of the child, the hard- 
 ness of the abdominal muscles, and the constant agitation of the limbs, 
 which are extended to their utmost, and then immediately drawn up 
 toward the abdomen, in rapid succession. 
 
 The TREATMENT consists in giving a laxative and carminative 
 injection, after which a warm infusion of Peppermint (or Spearmint, 
 should a suppression of urine be present), sweetened, and to which a 
 very small quantity of Supercarbonate of Soda has been added, should 
 be given, as an increased acidity of the stomach is apt to be 
 present ; or, the syrup of Rheum Aromatica may be substituted, 
 when further action on the bowels is desired. When the attack is 
 very severe, the bowels and back of the child should be covered with 
 flannels or fomentations, made as hot as can be borne, and the child 
 being held with its abdomen on the nurse's knee, should be trotted for 
 some time, while she gives a succession of light taps with her hand on 
 its back, between the shoulder-blades and down to the small of its 
 back. By this means, I have frequently removed the most severe 
 cases of colic, where the child had been screaming incessantly for 
 hours, and had taken Paregoric, Godfrey's Cordial, hot Gin Sling, etc., 
 without the least benefit.
 
 718 KING'S KCI.KCTIC <>I',STKTUICS. 
 
 CONSTIPATION, is common to some infants, and often 
 obstinate, being rather perpetuated by the administration of purga- 
 tives. The introduction of a suppository of soap is, generally, the best 
 agent that can be used in order to procure a stool ; two evacuations 
 should be obtained daily, at regular hours. And in the interim, the 
 following -should be injected into the rectum, three or four times daily, 
 and retained within as long as possible, by means of a compress, if 
 necessary: Take of a strong infusion of Hydrastis Canadensis, two 
 Huidrachms, tincture of Prickly-ash berries, twenty or thirty minims; 
 mix for an enema. This gives tone and activity to the parts with 
 -vim-hit comes in contact, and also to neighboring parts by sympa- 
 thetic action. Tepid water, with a small amount of Glycerine, will 
 also answer a very good purpose in some cases. Internally, agents, 
 as a rule, prove irritating to the intestines, and should not be given. 
 The massage treatment, over the bowels, will increase peristalsis and 
 frequently be all that is necessary. Tincture of Bryonia, one drop in 
 water, repeated two, three, or four times a day, will frequently be 
 found very efficacious. 
 
 UMBILICAL HERNIA, may occur soon after birth, or at a later 
 period. It may be occasioned by a large umbilicus, or, from straining 
 while crying, coughing, etc. It should always be attended to at once. 
 Place the child on its back, with the shoulders slightly elevated, and 
 the thighs flexed toward \he abdomen. Then carefully push the pro- 
 truding tumor back, apply a compress over it, and maintain it in place 
 by a bandage. In some instances, an umbilicus truss may be required, 
 several kinds of which are in use, but I prefer those manufactured by 
 Max Wocher & Son, or by Mr. W. Autenreith, of this city, surgical 
 instrument makers, who manufacture very available trusses for this 
 and other forms of hernia. The compress, above advised, may be 
 made of linen, folded several times, and moistened with some 
 astringent; or, a piece of cork, may be cut of the proper size and 
 shape, covered with linen or soft leather, and applied. Adhesive 
 inflammation, sufficient to unite the parts, will take place in four or 
 five days, though the treatment should be continued for twelve or 
 fourteen days; and after this period has passed, the abdomen should 
 be properly supported by a bandage, for, several months, in order to 
 prevent a return of the rupture ; and constipation should carefully be 
 guarded against by proper laxatives, etc.
 
 EXCORIATION OF THE NAVEL XJEVUS MATERXI. 719 
 
 EXCORIATION OF THE NAVEL may be successfully treated 
 by washing the part twice a day with some Castile soapsuds, and then 
 dressing it with the Red Oxide of Lead plaster, or the compound 
 Lead ointment ; or frequently a few applications of Tannate of Glycer- 
 ine will be all that is needed. If there is a tendency to gangrene, 
 Sulphate of Zinc, either in powder or solution, may be applied, 
 together with emollient poultices; and the strength of the system 
 should be kept up by tonics. 
 
 Sometimes, from a shrinking of the umbilical cord, or from its 
 being carelessly tied, the ligature will not press sufficiently on its 
 blood-vessels, and a HEMORRHAGE will take place. In such cases, 
 a second ligature must be applied below the original one, and which 
 should make the proper compression upon the vessels without cutting 
 the cord. 
 
 Occasionally, at the time of the separation of the cord from the 
 navel, or a day or two subsequently, HEMORRHAGE FROM 
 THE UMBILICUS, will ensue, being frequently accompanied with 
 fungus growths. This difficulty may be overcome by the application 
 of Sulphate of Zinc, either in powder or in solution followed by the 
 red oxide of Lead plaster, or, compound Lead ointment ; and, if 
 much inflammation be present, emollient poultices should be 
 applied. 
 
 N JE VUS M ATERNI, or mother's marks, -are frequently met with ; 
 they may exist on any part of the body, and present various appear- 
 ances, some being better supplied with blood than others. When they 
 are superficial, manifesting no tendency to spread, no treatment is 
 required, except to remove the disfiguration from the face. When 
 they are of the character of " aneurism by anastomosis," having a 
 tendency to spread or enlarge, to ulcerate, or to bleed profusely, it is 
 advisable to remove them when possible. 
 
 Various modes of TREATMENT have been recommended for the 
 removal of these marks, to which I will merely make a brief reference ; 
 as, destruction of them by the application of platinum wire, heated by 
 galvanism ; the injection of a small quantity of the solution of 
 Perchloride of Iron into various parts of the naevus; the application 
 of the ligature to some varieties; the application of intense cold over 
 the part; and, in the subcutaneous form, it has been removed by 
 vaccinating .in the mark. The application of powdered Sulphate of 
 Zinc over the nsevus, repeated daily, and continued until it is destroyed, 
 then facilitating the removal of the slough by an Elm poultice, and
 
 720 KING'S ECLECTIC OBSTETRICS. 
 
 subsequently treating the ulcer with the compound Lead ointment, has 
 succeeded in several instances in effecting a cure, even in cases, where 
 the nsevus assumed a malignant appearance. If not removed after the 
 slough has passed off, renew the application of the Zinc, and follow by 
 the same treatment as above. 
 
 Infants are occasionally troubled with a condition, known as being 
 TONGUE-TIED. This arises from the frsenum linguae, or bridle 
 under the tongue, being so short, or attached so far forward as to 
 interfere with the motions of the tongue in sucking, as well as in 
 speaking, when further advanced in years; occasionally, it is owing to 
 the presence of a false membrane. If the infant can protrude the 
 tip of the tongue beyond the lips, or can suck well, no interference is 
 demanded, for there is no difficulty of the kind. It is of very rare 
 occurrence. 
 
 The TREATMENT consists in cutting the frsenum, so as to loosen 
 the tongue from its attachment. The best time for operating is when 
 the infant sleeps ; the tongue may then be held up with the index or 
 forefinger of one hand, while with the other, holding a pair of blunt 
 scissors, and having its points directed downward and as near the floor 
 of the mouth as possible, cut loose about one-eighth of an inch of the 
 anterior .portion of the membrane and which will be followed by 
 only a few drops of blood which must be wiped out. Care must be 
 taken not to cut the lingual artery, which is situated on the inferior 
 surface of the tongue ; and, should it be imprudently cut, the 
 hemorrhage must be checked by compression, or the actual cautery. 
 If too extensive a cut be made, the child may swallow its tongue, 
 which, however, may be returned, by passing a spoon dipped in 
 molasses or syrup down to the point or edges of the organ, and 
 bringing it back. 
 
 HYDROCELE, is sometimes met with in infants, and is generally 
 removed by the application of compresses moistened with a solution 
 of Muriate of Ammonia. It is rare that a puncture will be required. 
 
 Infants, soon after birth, are sometimes troubled with a SWELLING 
 AND HARDNESS OF THE BREASTS, which may be owing to 
 cold, blows, bruises, or, an excited condition of the parts. It may be 
 overcome by gentle frictions with Olive Oil and tincture of Camphor 
 applied two or three times a day, employing in the intervals fomenta-
 
 HARE-LIP. 721 
 
 tions of Mullen leaves and blossoms, or a weak solution of 
 Arnica; if there is much inflammation, poultice of Elm and Lobelia 
 may be applied. Occasionally, and especially if neglected, or 
 improperly treated, sloughing will take place ; this may be treated by 
 stimulating \vashes, and the red oxide of Lead plaster, in conjunction 
 with tonics internally, when there is much debility. 
 
 HARE-LIP, is an imperfection often met with after birth. It is a 
 perpendicular or oblique division of the upper lip, either immediately 
 under the septum of the nose, or under one of the nostrils. Double 
 hare-lip is when there are two divisions. Sometimes the fissure 
 extends back through the palate bone, as well as through the soft 
 palate, in which case, an operation has sometimes been performed, 
 which may be found described in surgical works. 
 
 In ordinary cases of hare-lip the deformity is removed by a simple 
 operation ; and, 011 account of the tendency to convulsions in very 
 young children, after the operation, it is better to wait until they are 
 at least two or three weeks old; a year or two is still better, if the 
 child can suck, or be safely fed in the meantime. 
 
 The operation is performed, by removing the edges of the fissure 
 with a pair of long-handled, sharp scissors, made for the purpose. 
 Should the gum and lip be adherent, they must be separated by the 
 knife; and when the frsenulum is in the way of the operation, it 
 must be divided. The incision, by whatever instrument it is effected, 
 should be as smooth and even as possible, that the edges may readily 
 unite by the first intention. 
 
 The fissure, now resembling the inverted letter A, is to be closed, 
 bringing the edges together by means of silver wire. The first suture 
 should be introduced through and across the wound at its inferior 
 lower termination ; it should penetrate sufficiently deep, say about two- 
 thirds through the substance of the lip, to keep the cut surfaces in 
 approximation, but should not pass through the inner surface of the 
 lip. One or two other sutures are then to be passed similarly, at 
 equidistant points from the first, being thrust, as before, sufficiently 
 deep to almost reach the inner mucous lining of the lip. The wire is 
 to be twisted sufficiently to keep the outer surface of the wound in 
 close contact, being careful, however, not to apply them so tightly as 
 to occasion a subsequent sloughing of the parts. Should high inflam- 
 matory action supervene, it may be reduced by the application of 
 cold water; and any tendency to cerebral irritation, or sympathetic 
 fever, should be at once removed by appropriate means. 
 46
 
 722 KING'S ECLECTIC OBSTETRICS. 
 
 The child should be kept in a room, away from any excitement 
 which would occasion crying or laughing, aiid even talking, when old 
 enough, and must be fed with a spoon, the diet being entirely of a 
 fluid character. And should there be any danger of a disarrangement 
 of the parts, the cheeks may be pressed forward, and then a long strip 
 of adhesive plaster, reaching from ear to ear, may be applied between 
 these points and over the lip. 
 
 After four, five, or six days, the sutures may be removed, and strips 
 of adhesive plaster applied, which will be sufficient to hold the parts 
 together. In removing the sutures, loosen them gradually with the 
 forceps, as any sudden jerks, or forcible pulling, would be apt to 
 separate, or otherwise injure the wound. If there be a double hare-lip, 
 it will be better to complete the operation by incising and ligaturing 
 both fissures at the same time. 
 
 CHAPTER LIII. 
 
 PAHTH^C, THRUSH TKISMUS NASCENTIUM PORRIGO LARVA US, 
 
 MILK SCAB. 
 
 INFANTS are subject to an inflammation of the mouth, called 
 APHTHAE, Thrush, or Stomatite Folliculeuse, the symptoms of which 
 vary according to the severity of the attack. Upon an examination, 
 the tongue, lips, and interior surface of the mouth and throat, will be 
 found more or less covered with small, white flakes, or pearl-colored 
 vesicles, which proceed to superficial ulceration, and terminate by an 
 exfoliation of white crusts. These vesicles may be distinct, or con- 
 fluent, and in the more severe forms, are accompanied with so much 
 pain that the child can not suck, its mouth is hot, its lips frequently 
 swollen, with a dribbling of saliva. The breath is usually disagreea- 
 ble and of an acid odor, the pulse quick and feeble, bowels deranged, 
 frequent vomiting, and a diarrhea with green or watery evacuations, 
 and excoriated anus. The disease may extend to the pharynx, and 
 trachea, and, in very severe cases, it is continued through the alimen- 
 tary canal to the anus. The child becomes pale, restless, and fretful, 
 rapidly emaciating, and presenting a countenance indicative of much 
 distress. When mild, but few of these symptoms are manifested ; but 
 when very severe, there may also be cephalic disturbance, severe 
 abdominal pain, diarrhea, and typhoid symptoms, under which the 
 little patient will rapidly sink. Occasionally the ulcers assume a 
 gangrenous condition.
 
 APHTHJE. 723 
 
 Weakly and unhealthy children, as well as those raised by hand, are 
 more subject to this disease than others; it may also be induced by 
 improper food, uncleanliness, unhealthy air, and not nn&equently 
 occurs as a secondary affection to other diseases. 
 
 It is sometimes mistaken for a disease occasionally met with, called 
 White Thrush, or Muguet, but may be distinguished, by remembering 
 that this latter affection presents no ulceratiou, being a deposition of 
 curdy matter or false membrane upon the epithelium, without involv- 
 ing the destruction of the adjacent membrane ; while in true Thrush, 
 the follicular points of the tongue enlarge, without losing their circu- 
 lar form, and from their central orifices a whitish matter escapes, 
 being accompanied by ulceration. The ulcer has rounded edges, is 
 more or less tumefied, and is invariably surrounded by an inflamed 
 red circle. 
 
 In the mild form, the white crusts fall off, and in a few days the 
 ulcers heal. But when the aphthae are confluent, with extensive ul- 
 ceration, vomiting, and diarrhea, or when the crusts, instead of being 
 white, are of a dark color, with an unhealthy appearance of the ulcers, 
 the pulse being quick and feeble, with rapid emaciation, the prognosis 
 is very unfavorable. 
 
 TREATMENT. In the milder forms of this disease little or no 
 treatment is necessary, but in the severe forms it is indispensable. 
 The treatment should be commenced by proper attention to diet; fre- 
 quently, where the child is fed from a bottle, the bottle is allowed to 
 become sour and filthy, and proper attention to cleanliness will over- 
 come the trouble, or the addition of Lime-water to the milk answers 
 well in other cases; it may become necessary, however, to change to 
 a wet nurse. It will be well in most cases to obtain the effect of 
 some mild agent to move the bowels, as the Aromatic Syrup of Rhu- 
 barb. After and during the action of the laxative which should be 
 exhibited daily, at least for a few days two or three drops of the 
 tincture of Chloride of Iron should be given in a sufficient quantity 
 of infusion of Hydrastis Canadensis, or Fluid Hydrastis, and this 
 may be repeated every two, three, or four hours, according to the 
 severity of the disease. I have heretofore made a brief reference to 
 the action of this chalybeate, so that it will be unnecessary here. I 
 have gotten very good results, in this trouble, from the use of Borax, 
 either in powder or solution; some prefer to use it in honey. 
 
 Care must be employed not to irritate the mouth by rough swab- 
 bing, or by forcing off the white flakes or deadened epithelium, as 
 either of these may augment the severity of the disease. There are
 
 724 KING'S ECLECTIC OBSTETRICS. 
 
 other agents which may be used with advantage as local applications, 
 as Hamamelis Virginica, a solution of Alum, or Nitrate of Silver, 
 etc.; but I prefer the above, which I have employed with much suc- 
 cess in a number of cases, always administering some of it internally. 
 Chlorate of Potassa internally, and applied locally, in solution, has 
 been found a very efficacious remedy in most cases. I have used it 
 in a few cases, and with advantage. Sulphite of Sodu one drachm, 
 Distilled Water one fluid ounce, Carbolic Acid two or three grains, 
 mixed together, and applied upon the aphtha? by means of a camel's 
 hair pencil, has often proved highly efficacious. 
 
 When vomiting occurs, Aconite and Ipecac, or Nux Vomica, in 
 minute doses, may be used, or, in some cases, Bismuth may answer a 
 better purpose ; and if the irritation has extended into the stomach 
 or alimentary canal, we will again find the Aconite and Ipecac 
 useful, or an infusion of the bark of the twigs of Peach-tree will 
 often act well. Perhaps Cod-liver Oil, or Cocoanut Oil, might 
 be useful in some cases. When the ulcers assume a dark or brown 
 hue, or exhibit a gangrenous tendency, equal parts of Salad Oil, Yeast, 
 and Spirits of Nitric Ether, may be given in doses suited to the 
 child's age, and which should be repeated at proper intervals. Or 
 some of the agents heretofore named for such condition may be used, 
 as, the Sulpho-carbolites, Baptisia, diluted Nitric acid, Permanganate 
 of Potassa, etc. In addition to this, the system should be supported 
 by Quinia, Iron, and cordials, as wine-whey, milk and wine, chicken- 
 broth and wine, etc. Sometimes the Iodide of Potassium, or, Iodide 
 of Iron, combined with some alterative, will be found valuable, 
 especially with children of scrofulous parents. 
 
 When there is excoriation of the anus, it should be frequently and 
 gently bathed with warm water,, dried carefully, and then sprinkled 
 with Bismuth or finely powdered Elm Bark, or dressed with Tannate 
 of Glycerine. 
 
 The body of the child should be kept clean, frequently bathing it 
 with warm water, or a weak alkaline solution; and if it be much 
 debilitated, brandy or some other stimulant may be added to the 
 solution. Attention should be paid to the condition of the mother's 
 health, who must be placed under treatment if necessary: her diet 
 must invariably be regulated, as well as the condition of the bowels, 
 exercise, etc. It not unfrequently occurs, that a change of the nurse, 
 or weaning the child and feeding it cow's milk, arrowroot, barley- 
 water, etc., will be followed by a disappearance of all the symptoms; 
 shortly after which, if the mother's milk has not been allowed to " dry 
 up," it may be safely restored to its natural fc/od. (See Innutrition.)
 
 MILK SCALL. 725 
 
 Among the several cutaneous diseases to which infants are liable, is 
 Due known as milk scad, or milk scab, and which has been variously 
 termed by writers, thus, Porrigo Larvalis, Crusla Lactea, Pornyo Favosa, 
 Tinea Lactea, etc. The disease is usually first observed upon the fore- 
 head and cheeks, and consists in an eruption of minute superficial 
 pustules, of a yellowish-white color, united in groups on a red surface, 
 and more or less confluent. It sometimes attacks the hands, feet, and 
 other parts of the body, and has likewise been observed in adults. 
 The pustules will at first be found to contain a transparent fluid, 
 Avhich soon becomes yellowish-white and opaque, and being dis- 
 charged, concretes into thin, yellowish, or greenish crusts. As the 
 pustular patches spread, there is a renewal of the discharge, which 
 likewise continues from beneath the crusts, increasing their thickness 
 and extent. The eruption is subject to various modifications some- 
 times the discharge is scarcely perceptible, with a dry and brown scab 
 covering the surface; at other times, the discharge is profuse, with a 
 red and excoriated surface. Occasionally, the whole face, with the 
 exception of the nose and eyelids, is covered like a mask, with a large, 
 thick crust, formed of numerous smaller ones, and, almost invariably, 
 the disease is accompanied with intense itching, and more or less pain. 
 When the disease is about terminating, the discharge gradually ceases, 
 the crusts fall off and are not renewed, the surface under them, at first 
 elevated, red, and tender, gradually lessens in color, slight desquama- 
 tion ensues, and the skin slowly returns to its normal condition without 
 any disfiguration, unless the child has been allowed to tear its cheeks 
 by scratching. 
 
 The duration of the disease is variable, and it is not uncommon for 
 it to remain several months before disappearing. It rarely remains 
 beyond the period of teething, and hence, in obstinate cases, means 
 should be employed to allay the itching, that the face may not be 
 marked by the nails of the child. It does not appear to be conta- 
 gious; and its causes are involved in much obscurity. 
 
 TREATMENT. Microscopic investigations are stated to have 
 discovered that the disease depends upon a vegetable parasitic growth, 
 and may be cured by the local application and internal administra- 
 tion of a solution of Sulphite of Soda in some bitter tonic. I have 
 recently employed this solution internally, together with a solution 
 of Perchloride of Iron locally, to the aphtha, with marked benefit; 
 in some instances, solution of Chlorate of Potassa may be substituted 
 for that of the Ferruginous Perchloride. Carbolate of Iodine, as a 
 local application, will be found highly advantageous in many instances.
 
 72(5 KING'S ECLECTIC OBSTETRICS. 
 
 If there is any derangement of the digestive or hepatic functions,, 
 administer laxative doses, every day or two, of the Aromatic Syrup 
 of Rhubarb. The minute dose of Chionauthus answers well in some 
 cases; in others, Sp. Tr. of Iris may be given; and again, the action 
 of Nux Vomiea or Fowler's Solution is desirable. Good effects may 
 likewise be derived by the administration of Ilhus Tox. The diet 
 of the child should be regulated as to quantity, and the periods of 
 feeding; in several eases the disease has proved unyielding until the 
 child was given to another nurse, when it rapidly disappeared. 
 
 The child should be exercised freely by its attendant, and be 
 exposed as much as possible to the open atmosphere, in pleasant 
 weather. 
 
 CORY Z A, Nasal Catarrh, or Snuffles, is a very common and 
 troublesome disease among infants. It is an affection of the nasal 
 mucous membrane and air passages of the head, and generally com- 
 mences by frequent sneezing; at first there is little discharge from the 
 nostrils, but in a short time, a thin mucous secretion takes place,, 
 which finally becomes profuse, and of a thick, muco-puruient character. 
 Not unfrequently, the discharge is acrid and irritating. The mucous 
 fills the passages, forming a very troublesome obstruction, causing the 
 child to make a snuffling or rattling sound in breathing through the 
 nose, and interfering with its free respiration while sucking. The 
 eyes are more or less suffused, watery, and sensitive to light, and the 
 thirst is increased, with some slight febrile disturbance. Sometimes, 
 especially when the disease appears epidemically, the symptoms are 
 much more severe, with great constitutional debility. After the third 
 or fourth day the symptoms usually diminish, but, and especially when 
 not under treatment, or in the severe forms, it may continue for several 
 weeks. 
 
 Coryza is usually produced by cold ; at times it prevails as an 
 epidemic ; and it is frequently found accompanying other diseases, as 
 the exanthemata. Usually the disease requires but little treatment, 
 but in its severe forms, it must be watched, as the child may die 
 from the obstruction preventing free access of atmospheric air to the 
 lungs. 
 
 TREATMENT. In mild cases, inunction of the nostrils will 
 frequently be all the treatment needed; for this purpose Vaseline 
 answers, or, what some consider still better, an application of goose- 
 grease or tallow may be used. This greasing of the nose and forehead 
 externally is a common practice with nurses, and I have found it
 
 CORYZA. 727 
 
 decidedly beneficial; and, notwithstanding many of our eminent 
 practitioners treat with disdain the simple measures advised by old 
 nurses, it is well to remember that they are more observing of, and 
 have better opportunities to ascertain, the influence of agents upon 
 children than physicians, who seldom remain with a patient to exceed 
 fifteen minutes at a visit; and he who will listen to and watch the 
 opinions and methods adopted by them, especially in the manage- 
 ment of infants, can never fail to derive some useful and valuable 
 suggestions. 
 
 In the severe forms of this disease, the patient is put upon the use 
 of the sedative. Aconite, in the small dose, will be the usual remedy ; 
 this may be aided in its action by the hot bath. When the discharges 
 become acrid, and the membranes show decided irritation, Rhus Tox 
 should be given with the Aconite. The indication for Gelsemium will 
 frequently be present, as well as that for Belladonna. Frequently there 
 will be an enlargement of the lymphatic glands about the neck ; such 
 a condition calls for Phytolacca. Specific medication acts very 
 promptly in children's diseases; consequently, the symptoms should 
 be carefully noted, and the indications followed. 
 
 When the nose is much obstructed, the infant should be taken from 
 the breast for a few days, and be fed at regular intervals, two or three 
 times a day. Children two or three years of age should be kept on a 
 low diet during the first stage of the disease. The surface should be 
 bathed with warm water daily, the body should be kept properly 
 warmed, and a flannel cap should be worn, not only during the disease, 
 but for some days after its cure.
 
 INDEX. 
 
 Abdomen, enlargement of 196 
 
 laxity of 240 
 
 rigidity of 240 
 
 subsidence of 273 
 
 Abdominal muscles, relaxed 404 
 
 Abdominal palpation 203 
 
 Abdominal pregnancy 186 
 
 Abnormally large pelvis 39 
 
 Abortion 249 
 
 causes of 250 
 
 diagnosis of 253 
 
 habitual 264 
 
 hemorrhage during 249, 258 
 
 prognosis of 254 
 
 symptoms of 252 
 
 treatment of 25G 
 
 Abscess, mammary 700 
 
 Accidental hemorrhage 502 
 
 diagnosis of 503 
 
 treatment of 504 
 
 Accoucheur, conduct of, during the 
 
 first stage of labor 286 
 
 conduct of, during the second 
 
 stage of labor 297 
 
 conduct of, during the third 
 
 stage of labor 306 
 
 Acute tympanites 691 
 
 Adherent placenta 506, 524 
 
 Adherent placenta in hour-glass 
 
 contraction 527 
 
 Affections of the bladder during 
 
 pregnancy 229 
 
 After-pains 320 
 
 After-treatment of hemorrhage 518 
 
 Agglutination of the os uteri 384 
 
 Albuminuria during pregnancy. . . . 225 
 
 Alimentation of the child 316 
 
 artificial 316 
 
 Allantois 120, 136 
 
 Alvine evacuations of the child. .316, 329 
 
 PAGE 
 
 Amnion 116 
 
 Amniotic fluid 117 
 
 Amnii, liquor 117 
 
 excess of 362 
 
 Anorexia during pregnancy 217 
 
 Anterior commissure of the vulva. 63 
 Anterior lip of os uteri, retention of 374 
 
 Anteversion of the uterus 245 
 
 Anus, prolapsus of 238 
 
 Aorta, compression of, by Prof. C. D. 
 
 Meigs 514 
 
 Aphthae 72? 
 
 symptoms of , . 722 
 
 treatment of 723 
 
 Apoplexy 553 
 
 fi-tal 308 
 
 Application of the bandage 312 
 
 blunt hook , 585 
 
 forceps . . . , 602 
 
 perforator 629 
 
 Arch of pubes 22 
 
 Areola, in pregnancy 196 
 
 Arm, presentation of 337, 446 
 
 Articulations and ligaments of pelvis 22 
 
 Ascites of the fetus 410 
 
 Asphyxia, fetal 307 
 
 Attention required during the puer- 
 peral state 318 
 
 required subsequent to labor. . .'518 
 Attentions to the child. . . .307, 314, 329 
 
 Attitude of the fetus 142 
 
 Audible signs of pregnancy 198 
 
 Auscultation in pregnancy 198, 206 
 
 Axis of the inferior strait 32 
 
 of the pelvis 32 
 
 Axis of the superior strait 30 
 
 Bag of waters 280 
 
 to distinguish from fetal scalp 
 
 283, 293 
 729
 
 730 
 
 KING S ECLPXTTIC OBSTETRICS. 
 
 Ballottement 204 
 
 Bandage, application of 312 
 
 Baudelocque's pelvimeter 47 
 
 Beating of fetal heart !!)'. 
 
 Bed, putting to 314 
 
 Bladder, affections of 229 
 
 calculus in 248, 403 
 
 descent of 401 
 
 rupture of 549 
 
 Blastoderuiic vesicle 114 
 
 Blunt hook 585 
 
 Body of the uterus, changes iu, dur- 
 ing pregnancy 159 
 
 Bones of the fetal head 54 
 
 of the pelvis 16 
 
 Breast?, enlargement of 195 
 
 inflammation of 700 
 
 Breathing, difficulty during preg- 
 nancy 231 
 
 Breech, how to distinguish 432* 
 
 Breech-labors, management of diffi- 
 cult 437, 442 
 
 Breech-presentation 338, 431 
 
 management of 437 
 
 positions of 338, 433 
 
 Brim of the pelvis 20, 34 
 
 Broad ligaments 81 
 
 Brow presentation 411 
 
 Bruit de souffle 198 
 
 Caducous membrane 109 
 
 Calcaneo-iliac positions 339 
 
 Calculus in the bladder during labor 403 
 
 during pregnancy 248 
 
 Cancer of the os uteri 389 
 
 Caput succedaneum 283, 343, 349 
 
 Cardialpria during pregnancy 219 
 
 Caruncula? myrtiformes 67 
 
 Carus, curve of 32 
 
 Cases in which the Cesarean opera- 
 tion may be performed , 631 
 
 Cases for turning 574, 576 
 
 Cases requiring craniotomy 624 
 
 Cases requiring forceps 595 
 
 Catarrh, nasal 726 
 
 Catheterization 296, 402 
 
 Cauliflower tumor 386, 389 
 
 Cause of labor 271 
 
 Causes of abortion 250 
 
 of phlegmasia dolens 680 
 
 Causes of puerperal fever 655 
 
 of puerperal mania 692 
 
 Causes of relaxation and separation 
 
 of the symphysis 27 
 
 Cautions respecting the use of ergot 381 
 
 Cavity of the decidua 109 
 
 Cavity of the pelvis 16, 29, 32 
 
 Cazeaux on diagnosis of placenta 
 
 prsevia 490 
 
 Cephallut'matoma 357 
 
 Cephalalgia during pregnancy 222 
 
 Cephalic version 461, 575 
 
 Professor Wright's 461 
 
 Cephalo-iliac positions 447 
 
 diagnosis of 447 
 
 Cervix uteri 74 
 
 changes in the 156 
 
 fibrous tumor of the 385 
 
 Cesarean operation t;:;i 
 
 cases in which it may be used.. 631 
 
 dangers of 631 
 
 mode of performing 635 
 
 when to be perform* d 635 
 
 Cesarean section 631 
 
 Changes in the body of the uterus 
 
 during pregnancy 159 
 
 Changes in the cervix uteri during 
 
 pregnancy 156 
 
 Changes in the properties of the 
 
 uterus during pregnancy 166 
 
 Changes in the uterus during preg- 
 nancy 156 
 
 Character of labor, determined .... 294 
 
 Child, apoplexy of 308 
 
 ascites of 41 i) 
 
 asphyxia of 307 
 
 attentions to the 307, 314 
 
 delivery of the 283, .304 
 
 diseases of (see Infai/i.. 
 
 food for the 316 
 
 holding the 309 
 
 washing the 314 
 
 Child-bed fever 654 
 
 Children, plurality of 47"> 
 
 still-born 307 
 
 Child's head, delay of, in the pelvic 
 
 cavity 389 
 
 Chin from the breast, departure of 411 
 
 Chorion 115 
 
 Cicatrix in the vagina 387
 
 INDEX. 
 
 731 
 
 Circulation, fetal 144 
 
 Classification of labor 277 
 
 Clitoris 64 
 
 Coccyx 19 
 
 Coccyx in difficult labor 401 
 
 Colic of infants 717 
 
 Collection of feces in the rectum . . . 403 
 
 Colostrum 316 
 
 Commissures of the vulva 63 
 
 Coin plicated labor 484 
 
 Compound pregnancy 475, 178 
 
 presentations ... 427 
 
 Compression of the aorta 514 
 
 Concealed hemorrhage 502 
 
 diagnosis of 503 
 
 treatment of 504 
 
 Conception 100 
 
 Condition of the female in the first 
 
 stage of labor 
 
 in the second stage of labor. . . . 
 Condition of the uterus in the first 
 
 stage of labor 280, 
 
 in the second stage of labor. . . . 
 Conduct of accoucheur during the 
 
 first stage of labor 286 
 
 during the second stage of labor 297 
 during the third stage of labor 306 
 
 Constipation during pregnancy 220 
 
 of infants 717 
 
 Contraction, hour-glass 527 
 
 irregular 360, 527, 534 
 
 Contractions, fibrillar 274 
 
 painless uterine 274 
 
 uterine 271, 319 
 
 Convulsions, apoplectic 553 
 
 during pregnancy 223 
 
 epileptic 554 
 
 hysterical 224, 552 
 
 Convulsions, puerperal 552 
 
 Cord, around the neck 303 
 
 cutting umbilical 306 
 
 hemorrhage from 719 
 
 umbilical 127 
 
 umbilical around the neck 303 
 
 umbilical, dressing the 315 
 
 prolapsus of the 469 
 
 umbilical, rupture of the 533 
 
 umbilical, shortness of the 407 
 
 umbilical, tying of 306 
 
 Corpus Luteum 88 
 
 Corpus Luteum, by Prof. C. D. 
 
 Meigs 
 
 Coryza 
 
 Cough during pregnancy 
 
 Coutouly's pelvimetcr 
 
 Cramp of the stomach during preg- 
 nancy 
 
 Cramps during pregnancy 
 
 Cramps during labor, treatment of. 
 Craniotomv.. 
 
 cases requiring 
 
 dangers of 
 
 mode of operating 
 
 Crede's operation 
 
 Cross-birth 
 
 Crotchet 
 
 Crural phlebitis 
 
 Crusta lactea 
 
 Curve of Carus 
 
 Cutting the umbilical cord. 
 Cyanosis 
 
 symptoms of 
 
 treatment of 
 
 Cystocele, vaginal 
 
 1)1 
 726 
 231 
 
 49 
 
 220 
 
 2:',9 
 
 300 
 622 
 624 
 626 
 627 
 383 
 44(5 
 625 
 681 
 725 
 32 
 306 
 713 
 714 
 714 
 402 
 
 Dangers of Cesarean operation 631 
 
 of turning .576, 580- 
 
 Davies' forceps 587 
 
 Death of the fetus 153 
 
 Decapitation 254 
 
 Decidua, cavity of the 109 
 
 vera 110 
 
 reflex 110 
 
 serotina 110, 116, 124 
 
 Deciduous membrane 109 
 
 Deficient contractions 360, 378, 506 
 
 lochial discharge 325 
 
 Deformities of the pelvis 35, 393 
 
 management of, in labor. . .394, 403 
 Delay of child's head in pelvic cav- 
 ity 389 
 
 Delivery in natural labor, position 
 
 for 289, 300 
 
 Delivery of the child 283, 304 
 
 of the placenta 284, 310 
 
 Departure of the chin from the breast 411 
 
 Descent of the head 343 
 
 of the os uteri 374 
 
 Despondency during pregnancy. . . . 233 
 Detachment of placenta 495, 507
 
 732 
 
 KINGS KCLECTIC OBSTETRICS. 
 
 Determination of the scalp from the 
 
 membranes 283, 293 
 
 I letermining the character of labor 294 
 
 Development of the fetus 128 
 
 of the human ovtim 109 
 
 I >ia.L r nosis of abortion 250 
 
 of accidental hemorrhage 503 
 
 of breech presentation 432 
 
 of concealed hemorrhage 503 
 
 of ear presentation 424, 426 
 
 of face presentation 414 
 
 of feet presentation 445 
 
 of hour-glass contraction 528 
 
 of inflammation of the uterine 
 
 appendages 662 
 
 of intestinal irritation 698 
 
 of inverted uterus 539 
 
 of knee presentation 444 
 
 of left occipito-anterior position 342 
 of left occipito-posterior position 394 
 
 of occipito-pubal position 348 
 
 of occipito-sacral position 354 
 
 of pelvic presentations 432 
 
 of phlegmasia dolens 685 
 
 of placenta prsevia 488 
 
 of prolapse of the cord 470 
 
 of puerperal mania 693 
 
 of puerperal peritonitis 662 
 
 of right occipito-anterior position 347 
 of right occipito-posterior posi- 
 tion 353 
 
 of rupture of the uterus 545 
 
 of sex of fetus in utero 206 
 
 of shoulder presentations 447 
 
 of transverse presentations 469 
 
 of twins 180, 200 
 
 of uterine phlebitis 666 
 
 of vertex presentations 340 
 
 Diameters of the fetal head 56 
 
 of the inferior strait * . . 30 
 
 of the pelvic cavity 32 
 
 of the superior strait 29 
 
 Diarrhea during pregnancy 218 
 
 Diet after labor 317 
 
 Differences of male and female pelvis 33 
 Difficult brea'thingduringpregnancy 231 
 
 Difficult labor 278, 358, 377 
 
 ergot in 363, 380 
 
 from agglutination of os uteri . . 384 
 from ascites of fetus. . . 410 
 
 Difficult labor from calculus in 
 
 the bladder 403 
 
 from cancer of the os uteri 389 
 
 from cauliflower tumor ::sr. 
 
 from cicatrix in vagina 388 
 
 from condition of coccyx 401 
 
 from delay of the child's head.. 389 
 
 from distension by twins Dill 
 
 from early departure of the chin 410 
 
 from encysted tumors '.'>'. 1 1 
 
 from excess of liquor amnii. . . . 361 
 
 from excrescences 3'.i2 
 
 from exostosis 390 
 
 from feces in the rectum 403 
 
 from fibrous tumors of the cervix : >X5 
 
 from fungous tumor 3X6 
 
 from hydrocephalus 409 
 
 from imperforate hymen 389 
 
 from imperforate os uteri 384 
 
 from inefficient uterine contrac- 
 tions..-. 36o. 37s 
 
 from mal-positions of the head 
 
 411. 41 :5, 424 
 
 from obliquity of os uteri 1174 
 
 from obliquity of uterus ''>!'- 
 
 from osdema of labia inajora. . . 390 
 
 from ovarian tumor 405 
 
 from pelvic deformity 393 
 
 from pelvic osteo-sarcoma 391 
 
 from pelvic tumors 390 
 
 from phlegmonous tumors 392 
 
 from polypus 3x5. : ;< IL> 
 
 from premature rupture of the 
 
 membranes 375 
 
 from relaxed abdominal muscles 404 
 from rheumatism of the uterus 362 
 from rigidity of membranes. . . . 375 
 
 from rigidity of os uteri 365 
 
 from rigidity of soft parts. .374, 386 
 
 from scirrhous tumors 31(2 
 
 from shortness of the cord 407 
 
 from syphilitic vegetations 3! (2 
 
 from toughness of membranes . 375 
 
 from tumors 385, 3S6,\390 
 
 from tympanites of the fetus. ..411 
 
 from vaginal cystocele 4(12 
 
 from vaginal hernia 404 
 
 from vaginal vesicocele 402 
 
 in first stage 358 
 
 in second stage 377
 
 733 
 
 Difficult labor, breech, management 
 
 of 437,442 
 
 Dilatation of the os uteri. 275, 278, 299, 387 
 
 of os uteri by dry cupping 387 
 
 of perineum 283 
 
 Dimensions of the fetus 54, 147 
 
 Dimness of vision during pregnancy 230 
 Discrimination of scalp from bag of 
 
 waters 283, 293 
 
 Diseases of the fetus 152 
 
 of the pregnant female 209 
 
 Distension from twins 362 
 
 Divisions of labor 277 
 
 of the fetus 54 
 
 Dr. Washington on dry-cupping. . . 387 
 
 Dressing the cord 315 
 
 Dropsy of ovum 24S 
 
 Dry-cupping to cause dilatation of 
 
 os uteri 387 
 
 to cause uterine contraction . . . 387 
 Duration of first stage of labor .... 281 
 
 of labor 271 
 
 of pregnancy 171 
 
 of second stage of labor . . .283, 294 
 
 of third stage of labor 284 
 
 Duties of accoucheur, after delivery 312 
 of accoucheur in the first stage 
 
 of labor 286 
 
 of accoucheur in the second stage 
 
 of labor 297 
 
 of accoucheur in the third stage 
 
 of labor 306 
 
 Dwarfish pelvis 3D, 393 
 
 Dyspnoea during pregnancy 231 
 
 Ear presentations 424 
 
 diagnosis of 425 
 
 management of 425, 427 
 
 positions of 424 
 
 Early departure of the chin from 
 
 the breast 410 
 
 Eclampsia 552 
 
 Embryonic spot 87, 115 
 
 Embryotorny 6.2 
 
 Einbryotomy forceps, Meig's 629 
 
 Encysted tumors 391 
 
 Enlargement of the abdomen 19ii 
 
 of the breasts 19". 
 
 Ephelis . ... 194 
 
 Ephemeral fever 706 
 
 Ephemeral fever, symptoms of 706 
 
 treatment of 707 
 
 Epigenesis, theory of 97 
 
 Epilepsy 554 
 
 Ergot, cautions respecting the use of 381 
 
 in difficult labors. . . '. 363, 3S1 
 
 Ergot, in natural labors 3D5 
 
 Evolution, spontaneous 459 
 
 theory of ! is 
 
 Examination, vaginal 288 
 
 Excavation, pelvic 32 
 
 Excess of liquor amnii 362 
 
 Excessive lochial discharge 324 
 
 Excoriated nipples 327 
 
 Excoriation of the navel 719 
 
 Excrescences 392 
 
 Exhaustion, symptoms of 377, 599 
 
 Exostosis 390 
 
 Expulsion of the head 283, 301 
 
 of the placenta 284, 310 
 
 Extension (JO 
 
 External organs (>1 
 
 Extra-uterine pregnancy ls:> 
 
 Exvisceration 461 
 
 Face presentation 336, 414 
 
 diagnosis of 416 
 
 mechanism of 418, 420 
 
 positions of '...... .337, 418 
 
 treatment of 421 
 
 Facial nueralgia during pregnancy. 227 
 
 Fainting 229 
 
 Falling of the womb 241, 331 
 
 Fallopian tubes 82 
 
 False pains 276 
 
 treatment of 277 
 
 False pregnancy 181, 187 
 
 False waters 1 16, 246 
 
 Fecal accumulation 403 
 
 Fecundation 94 
 
 Feet, flow to distinguish 445 
 
 Feet presentation 339, 445 
 
 diagnosis of 445 
 
 treatment of 445 
 
 Female in natural labor 267, 279, 282 
 
 organs of generation 61 
 
 Fetal apoplexy 308 
 
 asphyxia 307 
 
 circulation 1 44 
 
 dimensions and weight 147
 
 7:J4 
 
 KING'S ECLECTIC OBSTETRICS. 
 
 I-Vtal head, diameters of 56 
 
 head, expulsion of 283, 301 
 
 IK -art, beating of 199 
 
 respiration 143 
 
 iralp, to discriminate from bag 
 
 of waters 283, 293 
 
 Fetus and its development 1 28 
 
 ascites of 410 
 
 attitude of 142 
 
 death of 153, 254 
 
 diseases of 152 
 
 full developed 152 
 
 its divisions and dimensions. . . 54 
 
 position of 142 
 
 signs of death of 153. 254 
 
 tympanites of 411 
 
 viability of 176 
 
 violent movements of 247 
 
 Fever, ephemeral 656 
 
 irritative 534 
 
 miliary 707 
 
 milk 326 
 
 puerperal . . 654 
 
 Fibrillar contractions 274 
 
 Fibrous tumors of the cervix 385 
 
 Fifth position of vertex 335, 353 
 
 Fillet 581 
 
 First left cephalo-iliac position. 338, 446 
 
 diagnosis of 446 
 
 First position of vertex 334, 342 
 
 First right cephalo-iliac position. 338, 446 
 
 diagnosis of 446 
 
 First sacro-iliac positions 433, 436 
 
 First stage of labor. 278, 286, 358 
 
 condition of female in 279 
 
 condition of the os uteri in.. 280, 281 
 
 condition of uterus in 280 
 
 conduct of accoucheur in 286 
 
 duration of 281 
 
 inefficient contractions in 359 
 
 management of * 2S6 
 
 mode of examination in 288 
 
 rheumatism of uterus in 363 
 
 rigidity in 366 
 
 Flatulent colic of infants 717 
 
 Fleshy moles 256 
 
 Flexion 59, 343 
 
 Flooding (see Hemorrhage). 
 
 Fluid, amniotic 117 
 
 Fontanelles, and sutures 54 
 
 Food tor the child :;io 
 
 Forceps . >s > 
 
 at the superior strait 597, 615 
 
 cases requiring .'.... 597 
 
 1 'avis' :>,S7 
 
 Hodges' :,ss 
 
 in breech labors 620 
 
 Forceps in face presentations 61 7 
 
 in left mento-iliac positions. ... 617 
 in left occipito-anterior positions ( ii i7 
 in left occipito-posterior posi- 
 tions 610 
 
 in left occipito-transverse posi- 
 tions G13 
 
 in mento-pubic positions (note). 618 
 in mento-saeral positions (note) 618 
 in occipito-posterior positions 
 
 (breech labors) 621 
 
 in occipito-pubic positions 
 
 (breech labors) 620 
 
 in occipito-pubic positions 609 
 
 in occipito-sacral positions .... 'ill 
 
 in pelvic presentations 620 
 
 in right mento-iliac positions . . 618 
 in right occipito-anterior posi- 
 tions 608 
 
 in right occipito-posterior posi- 
 tions Oil 
 
 in right occipito-transverse posi- 
 tions iil4 
 
 in vertex presentation 6 )3 
 
 mode of applying 603 
 
 period for applying 599 
 
 rules for applying (502 
 
 use of the 595 
 
 when not to be used 596 
 
 when the face is at the superior 
 
 strait 619 
 
 when the head is at the superior 
 
 strait 615 
 
 Forehead toward the pubic arch. .355, 4 1 2 
 
 Fossa navicularis 67 
 
 Fourchette ( >3 
 
 Fourth position of vertex 335, 349 
 
 Freenum 63 
 
 Full developed fetus 1 58 
 
 Fungous tumor 386 
 
 Funis, ligature of 306 
 
 prolapsus of 469 
 
 short . . .407
 
 INDEX. 
 
 735 
 
 Funis umbilicalis 127 
 
 Galvanic heat in inverted uterus. . . "45 
 
 Galvanism, in premature labor 051 
 
 Gastrodynia, dimng pregnancy.... 220 
 Gastrotomy (see Cesarcan operation) . 
 
 General signs of pregnancy 192 
 
 Generation 94 
 
 Genitals, itching of 229, 233 
 
 pustules of 241 
 
 Germinal membrane 86, 114 
 
 spot 87 
 
 vesicle 80 
 
 Gestation, duration of 171 
 
 Graafian vesicles So 
 
 Great sacro-sciatic ligament 24 
 
 Habit of aborting 2o5 
 
 Hand-presentation 427 
 
 Hand and foot presentation 428 
 
 Hare-lip 721 
 
 Head and an extremity presenting. . 427 
 
 delay of, in pelvic cavity 389 
 
 descent of 343 
 
 extension of 60, 345 
 
 flexion of 59, 343 
 
 Dial-positions of - 408 
 
 of child, diameters of 50 
 
 positions of (see Vertex). 
 presentations of (see Verte.r). 
 
 presentations of side of 424 
 
 restittition of 303, 345 
 
 rotation of 60, 344 
 
 Headache during pregnancy 222 
 
 Heart, beating of fetal 199 
 
 palpitation of 23 L 
 
 Heat, galvanic, in inverted uterus . . 545 
 
 Hematemesis 241 
 
 Hemoptysis 24 L 
 
 Hemorrhage 484 
 
 accidental 502 
 
 accidental, diagnosis of 503 
 
 accidental, treatment of 504 
 
 after-effects of 520 
 
 after placental delivery 509 
 
 after placental delivery, symp- 
 toms of 510 
 
 after placental delivery, treat- 
 ment of 511 
 
 .after the chilli's delivery 506 
 
 Hemorrhage, after-treatment of 518 
 
 before full term 502 
 
 concealed 502 
 
 concealed, diagnosis of 503 
 
 concealed, treatment of 504, 508 
 
 following abortion 256, 258, 232 
 
 i'rom the cord 719 
 
 Hemorrhage, from the navel 719 
 
 from placenta preevia, tre.;.- 
 
 ment of 4i '2 
 
 in retained placenta 506 
 
 in retained placenta, treatment 
 
 of 507 
 
 prevention of 520 
 
 puerperal 485 
 
 reaction of 520 
 
 syncope from 500, 518 
 
 treatment of after-effects 521 
 
 unavoidable 485 
 
 uterine 484 
 
 with abortion 249, 258, 263 
 
 with adherent placenta 506 
 
 with hour-glass contraction .... 528 
 
 with inverted uterus 542 
 
 with irregular contraction 528 
 
 with placenta prsevia 435 
 
 Hemorrhoids 236 
 
 Hernia 237 
 
 umbilical 718 
 
 vaginal 404 
 
 Hodge's forceps 589 
 
 Holding the child 309 
 
 Hollow of the sacrum 17 
 
 Hour-glass contraction 5i'7 
 
 Hydatids 181 
 
 Hydrocele of infants 720 
 
 Hydrocephalus 409 
 
 Hydrorrhea 116, 238 
 
 Hymen 66 
 
 Hymen, imperforate 66, 389 
 
 Hysterical convulsions 224, 552 
 
 Hysteritis 664 
 
 Ilio-pectineal line 20 
 
 Ilium 20 
 
 Imperforate hymen 389 
 
 os uteri 384 
 
 Impregnation, theories^ of 94 
 
 Incontinence of urine 239 
 
 Indications of mal-formed pelvis. . . 47
 
 736 
 
 KINGS ECLECTIC OBSTETRICS. 
 
 Induction of premature labor (140 
 
 Inertia of the uterus 524 
 
 Ineliicient action of the uterus in 
 
 the first stage of labor 360 
 
 in the second stage of labor 378 
 
 Infantile uH'.-ctions 713 
 
 Infants (sec- < 'hilil}. 
 
 Infants, colic of 717 
 
 constipation of 717 
 
 hydroeele of 720 
 
 jaundice of 715 
 
 ophthalmia of 716 
 
 retention of urine in 715 
 
 swelled breasts of 720 
 
 Inferior strait 16, 31 
 
 axis of 32 
 
 diameters of 31 
 
 plane of 32 
 
 Inflammation of the breasts 700 
 
 symptoms of 700 
 
 treatment of 702 
 
 Inflammation of the uterine absorb- 
 ents 667 
 
 post-mortem appearances of... 667 
 
 symptoms of 667 
 
 Inflammation of the uterine append- 
 ages 66:-} 
 
 diagnosis of 664 
 
 pi ist-mortem appearances of. ... 664 
 
 symptoms of 664 
 
 Inflammation of the uterine veins. . (5(56 
 post-mortem appearances of. . . . 666 
 
 symptoms of 000 
 
 Inflammation of the uterus 664 
 
 Inflammatory puerperal fever, treat- 
 ment of 671 
 
 Innominatum 20 
 
 Innutrition 716 
 
 Insanity after delivery (55)1 
 
 during pregnancy 232 
 
 Interstitial pregnancy 187 
 
 Intestinal irritation 697 
 
 diagnosis of (i'.ls 
 
 prognosis of 098 
 
 symptoms of 0!)8 
 
 treatment of 69S 
 
 Inversion of the uterus 5:',7 
 
 diagnosis of . .* 538 
 
 galvanic heat in 545 
 
 prognosis of 538 
 
 Inversion of the uterus, symptoms 
 
 of ". 5;;: 
 
 treatment of 540 
 
 Irregular contractions. 527, 534 
 
 Irritability, nervous, during preg- 
 nancy 5:!4 
 
 Irritative fever from putrid absorp- 
 tion 265, .">:;:> 
 
 Ischia, plane's of 21 
 
 Ischium 21 
 
 Itching of the genitals 229, 233 
 
 Jaundice, during pregnancy 240 
 
 of infants 715 
 
 Kiesteine 198 
 
 Knee presentation :;:',!) 
 
 diagnosis of 444 
 
 treatment of 445 
 
 Labia majora (>2 
 
 oedema of 3!)f 
 
 Labia minora 63 
 
 Labia pudendi 62 
 
 Labor 271 
 
 attentions required after 318 
 
 cause of 271 
 
 classification of 277 
 
 complicated 484 
 
 condition of female in first 
 
 stage of 27!! 
 
 condition of female in second do. 282 
 condition of os uteri in first 
 
 stage of ' .280, 281 
 
 condition of os uteri in second 
 
 stage of 282 
 
 condition of uterus in first 
 
 stage of 280 
 
 conduct of accoucheur in first 
 
 stage of 286 
 
 conduct of accoucheur in second 
 
 stage of ' 297 
 
 conduct of accoucher in third 
 
 stage of 306 
 
 difficult 27S, 35,s, :;77 
 
 difficult, ergot in 362. 380 
 
 difficult, from mal-positions of 
 
 the head 411, 413, 424 
 
 difficult, in first-stage .'558 
 
 difficult, in second stage 377
 
 INDEX. 
 
 737 
 
 Labor, divisions of 277 
 
 duration of 271 
 
 duration of first stage of 281 
 
 duration of second stage of. 283, 304 
 
 ergot in difficult 363, 380 
 
 ergot in natural 305 
 
 first stage of 278, 288 
 
 induction of premature 640 
 
 lingering (see Difficult Labor). 
 
 management of natural 285 
 
 mechanism of 340 
 
 methods of inducing premature 652 
 
 Labor, mode of examination in first 
 
 stage of 288 
 
 position for delivery in na- 
 
 ural 289, 300 
 
 precipitate 383 
 
 premature 270, 640 
 
 premature, induction of 640 
 
 premonitory signs of 273 
 
 preternatural 429 
 
 protracted (see Difficult Labor). 
 
 rigors during 275 
 
 rules to determine the character 
 
 of : . . . . 294 
 
 second stage of 282, 299 
 
 tedious 278, 358 
 
 third stage of 284, 306 
 
 treatment of cramps during . . . 300 
 treatment of difficult breech .437, 442 
 
 treatment of twin 476 
 
 twin 475 
 
 Labor pains 271, 276, 282 
 
 false 276 
 
 true 276 
 
 with pelvic deformity, treat- 
 ment of (note) 390 
 
 Laceration of perineum 284 
 
 of vagina 549 
 
 Laparo-elytrotomy 639 
 
 Laxity of abdomen during preg- 
 nancy 240 
 
 Left calcaneo-iliac position 339 
 
 Left cephalo-iliac positions 338 
 
 diagnosis of 447 
 
 Left lobulo-iliac positions 424 
 
 diagnosis of 42(5 
 
 Left mento-iliac position 337, 41.8 
 
 diagnosis of 418 
 
 mechanism of 419 
 
 47 
 
 Left oecipito-anterior position . . 334, 
 
 diagnosis of 
 
 forceps in 
 
 mechanism of 
 
 Left occipito-posterior position. .325, 
 
 diagnosis of 
 
 mechanism of 
 
 Left sacro-iliac position 
 
 diagnosis of 
 
 mechanism of 
 
 Lesser sacro-sciatic ligament 
 
 Lever 
 
 Ligament, great sacro-sciatic 
 
 lesser sacro-sciatic 
 
 Ligament, obturator 
 
 Ligaments and articulations of pelvis 
 Ligaments, broad 
 
 of ovary 
 
 of uterus 
 
 round 
 
 sacro-sciatic 
 
 Linea ilio-pectinea 
 
 Linear albicantes 
 
 Lingering labor (see Difficult Labor). 
 Lip of os uteri, retention of anterior 
 Liquor amnii 
 
 excess of 
 
 Lobulo-pubal positions 425, 
 
 Local signs of pregnancy. . . , 
 
 Lochia 284, 
 
 deficient.. . 
 
 excessive . t 
 
 Locked head (note) 
 
 Longings during pregnancy 
 
 342 
 
 333 
 
 607 
 
 343 
 
 610 
 
 350 
 
 351 
 
 339 
 
 432 
 
 433 
 
 25 
 
 582 
 
 25 
 
 25 
 
 25 
 
 23 
 
 81 
 
 84 
 
 81 
 
 82 
 
 25 
 
 20 
 
 319 
 
 374 
 117 
 362 
 426 
 193 
 323 
 325 
 324 
 401 
 217 
 
 Making the bed 295 
 
 Malacosteon 37 
 
 Male and female pelves 33 
 
 Malformation of the pelvis 34 
 
 indications of 47 
 
 Malpositions of the head 414 
 
 Mammary abscess 700 
 
 Management of breech-presentation 437 
 of difficult breech labors. . .437, 442 
 
 ear presentations 425, 427 
 
 face presentation 423 
 
 feet presentation 445 
 
 knee presentation 444 
 
 labor with pelvic deformity. 394, 403 
 mento-iliac positions 423
 
 738 
 
 KING'S ECLECTIC OBSTETRICS. 
 
 Management of monstrosities 483 
 
 natural labor 285 
 
 shoulder presentations 449 
 
 twin labor 477 
 
 Mania during pregnancy 232 
 
 puerperal <>'.>! 
 
 Masto lynia. 231 
 
 .Measurement of the pelvis 48 
 
 Meatus urinarius 65 
 
 Mechanical vomiting in pregnancy. 214 
 
 Mechanism of labor 340 
 
 left mento-iliac position 418 
 
 left occipito-anterior position . . 343 
 left occipito-posterior position . 350 
 left sacro-iliac positions .... 433, 436 
 
 occipito-pubal position 349 
 
 occipito-sacral position 344 
 
 Mechanism of right mento-iliac posi- 
 tion 421 
 
 right occipito-anterior position . 348 
 right occipito-posterior position. 354 
 right sacro-iliac positions. . .436, 437 
 
 Meconium 152, 316 
 
 Meconium, purging the 316 
 
 Meig's etnbryotomy forceps 625 
 
 Membrana caduca 109 
 
 decidua 109 
 
 Membrane, caducous 109 
 
 deciduous 109 
 
 germinal 86, 114 
 
 vitelline 86 
 
 Membranes, premature rupture of. . 375 
 
 rigidity of ! 375 
 
 rupture of 280, 375 
 
 toughness of 375 
 
 Menstruation 100 
 
 suppressed, a sign of pregnancy 193 
 Methods of inducing prema'ture 
 
 labor 646 
 
 Metritis 664 
 
 post-mortem appearances of. ... 665 
 
 symptoms of 665 
 
 Miliary fever. / 707 
 
 symptoms of 707 
 
 treatment of 708 
 
 Milk fever 326 
 
 Milk-leg 680 
 
 Miik, socretion of, in pregnancy. . . . 196 
 
 M iscarriage 249 
 
 Mixed pregnancy 178 
 
 Mobility of the pelvic articulations. 26 
 
 Mode of applying the forceps 602 
 
 Mode of examination in first stage 
 
 of labor 288 
 
 .Mode of performing craniotomy. . . . 627 
 Moles 181 
 
 fleshy :_>:>;; 
 
 Molesworth's climax dilator 6 ~>3 
 
 Mollifies ossium 37 
 
 Mons veneris 61 
 
 Monsters 1 H), 482 
 
 Monstrosities, management of 483 
 
 Morbid adhesion of placenta - 531 
 
 treatment of 533 
 
 Morph 193 
 
 Mother's marks 719 
 
 Mueo-serolent discharge 274 
 
 Mucous discharges from vagina .... 241 
 
 Multiple pregnancy 17s. 475 
 
 Muscular pains during pregnancy. . 233 
 
 Nsevus materni 719 
 
 Nasal catarrh 728 
 
 Natural labor, position for delivery 
 
 28: l, 300 
 
 Nausea during pregnancy 194 
 
 Navel, excoriation of 719 
 
 hemorrhage from 719 
 
 Navel string 127 
 
 Nervous irritability during preg- 
 nancy 234 
 
 Nervous shock 318 
 
 Nidation 1 07 
 
 Nipple, excoriated 327 
 
 sore 327 
 
 sore, treatment of 328 
 
 Nursing sore mouth 709 
 
 Nyniphse S3 
 
 Obliquely distorted pelvis 42. 393 
 
 Obliquity of os uteri 373 
 
 of uterus 372 
 
 Obstetrical instruments 5S6 
 
 Obstetrical operations 586 
 
 Obturator foramen 22 
 
 ligament 25 
 
 Occipital positions 334, 342 
 
 Occipito-pubal position 334, 348, 620 
 
 diagnosis of 348 
 
 mechanism of .. . 349
 
 INDEX. 
 
 739 
 
 Occipitb-sacral position 336, 354, (521 
 
 diagnosis of 354 
 
 mechanism of 354 
 
 Odontalgia during pregnancy -'11 
 
 (Edema during pregnancy 234 
 
 (Edema of 'labia majora 390 
 
 Omphalo-mesenteric vessels 11!) 
 
 Operation, Cesarean 631 
 
 Operation of craniotomy 622 
 
 Operative midwifery 573 
 
 Operation, Sanger-Cesarean 034 
 
 Ophthalmia of infants 716 
 
 Organs of generation 61, 68 
 
 Orifice of the urethra 65 
 
 Os basilare 17 
 
 Os coccyx 19 
 
 Os ilium 20 
 
 Os ischium 21 
 
 Os pubis 22 
 
 Os uteri 74 
 
 ( )s uteri, agglutination of 384 
 
 cancer of 389 
 
 descent of 374 
 
 dilated by dry-cupping 387 
 
 dilatation of 275, 27<S, :5S7 
 
 imperforate 384 
 
 obliquity of - 373 
 
 obliteration of 384 
 
 retention of anterior lip 374 
 
 rigidity of, in first stage of 
 
 labor 281, 366 
 
 rigidity of, in second stage of 
 
 labor 387 
 
 Ossa innominata 20 
 
 Osteo-sarcoma of pelvis 391 
 
 Ovaries 83 
 
 Ovarian pregnancy 185 
 
 Ovarian tumor 405 
 
 Ovular theory 99 
 
 Ovule, or human egg 85, 128 
 
 Ovum, development of 109 
 
 dropsy of 248 
 
 Pain in the right side during preg- 
 nancy 239 
 
 Pain, muscular, during pregnancy.. 232 
 
 Painless uterine contractions 274 
 
 Pains, after 320 
 
 false 276 
 
 irregular 527 
 
 Pains of labor 271, 276, 282 
 
 preparatory 271. 27<i, 2S2 
 
 treatment of false 277 
 
 Palpation, abdominal 203 
 
 Palpitation of the heart 230 
 
 Parietal pregnancy 187 
 
 Parturition 271 
 
 Pathology of puerperal convulsions 5<>3 
 Pelvic articulations, mobility of. ... 26 
 
 Pelvic cavity, diameters of 33 
 
 planes of. ; 32 
 
 tumors in 390 
 
 Pelvic deformities, difficult labor 
 
 from 390 
 
 management of labor with (note) 
 
 391, 392 
 
 Pelvic presentations 338, 437, 439 
 
 diagnosis of 440 
 
 management of 437, 445 
 
 mechanism of 433, 437 
 
 Pelvic symphyses 23 
 
 Pelvimeter, Baudelocque's 48 
 
 Coutoully's 49 
 
 Pelvimetry 48 
 
 Pelvis,. 16 
 
 abnormally large 39, .",93 
 
 articulations of 23 
 
 axis of 28 
 
 bones of 15 
 
 brim of ,.20, 34 
 
 cavity of 16, 29 
 
 deformities of 35 
 
 diameters of 29 
 
 dwarfish 39, 393 
 
 Pelvis, indications of malforma- 
 tion of 47 
 
 obliquely distorted 42, 393 
 
 osteo-sarcoma of 391 
 
 straits of 29 
 
 unequally contracted 40, 393 
 
 Pendulous belly.. 312 
 
 Perforator (530 
 
 Perineum 67 
 
 dilatation of 283 
 
 rigidity of 68, 3S6 
 
 support to the 67, 301, 606 
 
 Period for applying forceps 599 
 
 for turning 576 
 
 Peritonitis 654, 660 
 
 Phlebitis, crural 680
 
 740 
 
 KINGS ECLECTIC OBSTETRICS. 
 
 Phlebitis, uterine 654 
 
 Phlegmasia dolens 680 
 
 causes of 080 
 
 diagnosis of 685 
 
 post-mortem appearances of ... (586 
 
 prognosis of 685 
 
 symptoms of 684 
 
 treatment of 686 
 
 Phlegmonous tumors 392 
 
 Piles during pregnancy 236 
 
 Placenta 123 
 
 adherent 506, 524 
 
 delivery of 284, 310 
 
 detachment of 494, 507 
 
 expulsion of 284, 310 
 
 hemorrhage after delivery of. . . 509 
 
 morbid adhesion of 531 
 
 putrescence of 256, 534 
 
 retained 506, 523 
 
 retained, treatment of 507, 524 
 
 retention of 506, 524 
 
 Placenta, retention of, from, irreg- 
 ular contraction - .... 527 
 
 retention of, from morbid adhe- 
 sion 531 
 
 retention of, from uterine in- 
 ertia 523 
 
 symptoms of hemorrhage after 
 
 delivery of 510 
 
 treatment of hemorrhage after 
 
 delivery of >... 511 
 
 Placenta pnevia 485 
 
 diagnosis of 488 
 
 hemorrhage from 485 
 
 treatment of 491 
 
 Placental presentation 485 
 
 sound 198 
 
 Plane of inferior strait 32 
 
 of the superior strait 30 
 
 Planes of the ischia 21 
 
 of the pelvic cavity 32 
 
 Plethora during pregnancy 226 
 
 Plurality of children 475 
 
 Podalic version 400, 575 
 
 Polypus 385 
 
 Porrigo larvalis 717 
 
 Porro-Cesarean operation 633, 639 
 
 treatment of 717 
 
 Position, first left cephalo-iliac . .338, 447 
 first right cephalo-iliac 338, 447 
 
 Position, first vertex 334, 342: 
 
 fifth vertex 335, 353 
 
 for delivery in natural labor. 289, 300 
 
 fourth vertex 335, 34!) 
 
 left calcaneo-iliac 339 
 
 left mento-iliac .337, 419 
 
 left mento-iliac, diagnosis of . . . 416 
 
 left mento-iliac, mechanism 418 
 
 left occipito-anterior 334, 342 
 
 left occipito-anterior, diagnosis 
 
 of 342 
 
 left occipito-anterior, mechan- 
 ism of 343 
 
 left occipito-posterior 335, 34!) 
 
 left occipito-posterior, diagnosis 
 
 of 349 
 
 left occipito-posterior, mechan- 
 ism of 350 
 
 left sacro-iliac 339, 433, 436 
 
 left sacro-iliac, diagnosis of .4.'!:!, 4:!(i 
 left sacro-iliac, mechanism of 
 
 of 433,436 
 
 occipito-pubal 334, 348 
 
 occipito-pubal, diagnosis of 349 
 
 occipito-pubal, mechanism of.. 349 
 
 occipito-sacral 335, 355 
 
 occipito-sacral, diagnosis of .... 355. 
 occipito-sacral, mechanism of .. 355 
 
 of the fetus 142 
 
 right calcaneo-iliac ... 339 
 
 right mento-iliac 337, 421 
 
 right mento-iliac, diagnosis of. . 421 
 right mento-iliac, mechanism of 421 
 
 right occipito-anterior 334, 347 
 
 right occipito-anterior, diagnosis 
 
 of 347 
 
 right occipito-anterior, mechan- 
 ism of 347 
 
 right occipito-posterior 335, 353 
 
 right occipito-posterior, diag- 
 nosis of 353 
 
 right occipito-posterior, mech- 
 anism of 354 
 
 right sacro-iliac 339, 436 
 
 right sacro-iliac,diagnosis of .436, 437 
 right sacro-iliac, mechanism of 
 
 436, 437 
 
 second left cephalo-iliac 338, 446 
 
 second right cephalo-iliac.. .338, 446 
 second vertex 334, 347
 
 INDEX. 
 
 741 
 
 'Position, sixth vertex. . . . 335, 554 
 
 third vertex 3:54, 34S 
 
 Positions and presentations 332 
 
 left lobulo-iliac 425 
 
 left lobulo-iliac, diagnosis of . 426, 427 
 
 lobulo-pubal 424 
 
 lobulo-pubal, diagnosis cf 425 
 
 mento-iliac, treatment of 421 
 
 of breech presentation 338, 433 
 
 of ear presentation 424 
 
 of face presentation 336, 418 
 
 of feet presentation 339, 445 
 
 of shoulder presentations . .337, 44(5 
 
 of vertex presentation 334, 340 
 
 right lobulo-iliac 424 
 
 right lobulo-iliac, diagnosis of 
 
 425, 42(5 
 
 Post-mortem appearance of inflam- 
 mation of uterine appendages (364 
 appearances of inflammation of 
 
 uterine veins 
 
 appearances of metritis 
 
 appearances of phlegmasia do- 
 lens 686 
 
 Post-mortem appearances of puer- 
 peral peritonitis 663, 669 
 
 Posterior commissure of the vulva. 63 
 
 Precipitate labor 383 
 
 Pregnancy 171 
 
 abdominal 186 
 
 affections of the bladder during 229 
 
 albuminuria during 225 
 
 anorexia during 195, 217 
 
 anteversio uteri during 245 
 
 areola in 196 
 
 audible signs of 198 
 
 calculus during 248 
 
 cardialgia during 219 
 
 cephalalgia during 223 
 
 changes in the uterus during. .. 156 
 
 compound 178, 474 
 
 constipation during 220 
 
 convulsions during 224 
 
 cough during 231 
 
 cramp of stomach during 221 
 
 cramps during 239 
 
 despondency during ^ 233 
 
 diarrhea during 218 
 
 -difficult breathing during 231 
 
 diseases of 202 
 
 Pregnancy, dimness of vision during 230 
 
 dropsy of ovum during 248 
 
 duration of 171 
 
 dyspnea during 231 
 
 extra-uterine 183 
 
 facial neuralgia during 228 
 
 fainting during 2.50 
 
 falling of the womb during. . . . 241 
 
 false 181, 188 
 
 fetal movements during 248 
 
 gastrodynia during 221 
 
 general signs of 192 
 
 headache during 22:5 
 
 heartburn during 195, 220 
 
 hematemesis during 241 
 
 hemoptysis during 241 
 
 hemorrhoids during 2:57 
 
 hernia during 248 
 
 hydrorrhea during 24(5 
 
 incontinence of urine during . . 241 
 
 insanity during 233 
 
 interstitial 187 
 
 jaundice during 240 
 
 laxity of abdomen during 240 
 
 local signs of . . . 193 
 
 longings during 217 
 
 mania during 2:53 
 
 rnastodyn ia during 232 
 
 mechanical vomiting in 214 
 
 mixed 1 78 
 
 multiple 178, 475 
 
 muscular pain during 232 
 
 nausea during 195, 213 
 
 nervous irritability during 233 
 
 odontalgia during 228 
 
 oedema during 235 
 
 ovarian 1 85 
 
 pain in right side during 240 
 
 palpitation during 230 
 
 parietal 187 
 
 piles during 237 
 
 plethora during 226 
 
 prolapsus ani during 238 
 
 prolapsus uteri during 241 
 
 prurieo during 233 
 
 pruritus of vulva during 233 
 
 ptyalism during 217 
 
 pustules of genitals during. .234, 241 
 
 rational signs of 192 
 
 retroversion of uterus during.. 242
 
 742 
 
 RINGS KCLKCTIC OBSTETIMo. 
 
 Pregnancy, rheumatism of the uterus 
 
 during -47 
 
 rigi iiiy of abdomen during 240 
 
 salivation during 217 
 
 secretion of milk during 190 
 
 sensible signs of 192, 1^5 
 
 sL r ns of 190 
 
 sound of fetal, heart during. . . . 199 
 
 spasm of stomach during 221 
 
 spasm of ureters during 229 
 
 spasm of uterus during 240 
 
 sub-peritoneo-pelvic 186 
 
 suppressed menses during 193 
 
 ^ymp.ithftic s'gns ci 195 
 
 syncope during 230 
 
 synopsis of signs of 2()ii 
 
 syphilis during 248 
 
 table of signs of 208 
 
 tangible signs of. 202 
 
 toothache during 197, 22X 
 
 treatment of extra-uterine .... 187 
 
 tubal 186 
 
 tubo-abdoodna] 187 
 
 tubo-ovarian 187 
 
 tumors during 243 
 
 twins 180, 200 
 
 utero-tubal ] 87 
 
 utero-tubo-abdominal 187 
 
 vaginal discharges during 241 
 
 varicose veins during 23(5 
 
 ventral 18(5 
 
 vertigo during 230 
 
 visible signs of 195 
 
 vomiting during 192, 21 3 
 
 with pelvic deformity 248, .",9:5 
 
 Pregnant female, diseases of 2i;9 
 
 Premature labor 249, 640 
 
 modes of inducing 646 
 
 Premature rupture of the mem- 
 branes 375 
 
 Premonitory signs of labor 273 
 
 Preparatory pains 278 
 
 Presentations and positions 332 
 
 compound 427 
 
 diagnosis of breech 432 
 
 diagnosis of ear 425, 427 
 
 diagnosis of face 416 
 
 diagnosis of foot 445 
 
 diagnosis of knee 444 
 
 diagnosis of pelvic 432 
 
 Presentations, Diagnosis of plaeental 488 
 
 diagnosis of shoulder 447 
 
 diagnosis of transverse 469 
 
 diagnosis of v -rtex :i4() 
 
 management of breech 4:',7 
 
 management of ear 42 >. 427 
 
 management of f.ice 421 
 
 management of feet 445 
 
 management of knee 445 
 
 management of plaeental 402 
 
 management of shoulder 449 
 
 management of transverse 46S 
 
 management of vcrt.-x l".M 
 
 of an extremity with the head.. 427 
 
 of the breech 33S, 4:',1 
 
 of the face 336, 414 
 
 of the feet 339, 445 
 
 of the knees 339. 444 
 
 of the pelvic extrrfinitie8..338,429,43] 
 
 of the shoulder 337, 446 
 
 of the side of the he>.i: 424 
 
 plaeental 485 
 
 transverse 409, (113, 614 
 
 turning in shoulder 449 
 
 vertex 334, 340 
 
 Pressure on the aorta 514 
 
 Preternatural labor 429 
 
 Prevention of hemorrlu.g 520 
 
 Prognosis of abortion 254 
 
 Prognosis of intestinal irritui" 09X 
 
 of inverted uterus 539 
 
 of phlegmasia dol"iis 6S5 
 
 of puerperal convulsions 561 
 
 of puerperal fever 670 
 
 of puerperal mania 694 
 
 of ruptured uterus 547 
 
 Prolapsus ani, during pregnancy. . . 23S 
 
 of the cord '. . . . 469 
 
 of the cord, diagnosis of 470 
 
 of the cord, treatment of 471 
 
 uteri, during pregnancy 241 
 
 Promontory of the sacrum 19 
 
 Protracted labor (see Difficult Labor . 
 
 Prurigo during pregnancy 233 
 
 Pruritus of the vulva during preg- 
 nancy 233 
 
 Ptyalism during pregnancy 217 
 
 Pubic arch 23 
 
 Pubic symphysis 22, 24 
 
 Pubis, os 22
 
 INDKX. 
 
 743 
 
 Puerperal convulsions 
 
 causes of 
 
 pathology of 
 
 prognosis of 
 
 symptoms of 
 
 treatment of 
 
 Puerperal fever 
 
 causes of 
 
 prognosis of 
 
 treatment of 
 
 Puerperal hemorrhage 486, 
 
 Puerperal mania 
 
 causes of 
 
 diagnosis of 
 
 prognosis of 
 
 symptoms of 
 
 treatment of 
 
 Puerperal peritonitis 654, 
 
 diagnosis of 
 
 post-mortem appearances of. 663, 
 
 symptoms of (5(50, 
 
 Puerperal phrenitis 
 
 Puerperal septicemia 
 
 diagnosis of 
 
 post-mortem appearances of. . . . 
 
 prognosis of 
 
 symptoms of ..-..' 
 
 Pulse, vaginal 
 
 Pulsation of the fetal heart 
 
 Purging the meconium 
 
 Pustules of genital organs, during 
 
 pregnancy 
 
 Putrefactive absorption. . . .256, 265, 
 Putrescence of placenta. . . .256, 265, 
 
 Putting to bed 
 
 Pyemia, puerperal 
 
 233 
 534 
 534 
 314 
 667 
 
 Quickening 1 97 
 
 Rational signs of pregnancy 192 
 
 Reaction of hemorrhage 520 
 
 Red gum 715 
 
 Relaxation of abdominal muscles.. . 405 
 
 Relaxation of the symphyses 26 
 
 Respiration, fetal 142, 143 
 
 Restitution of the head 303, 346 
 
 Retention of the anterior lip of os 
 
 uteri 374 
 
 Retention of the placenta 524 
 
 from irregular contractions. .527, 534 
 
 Retention of the placenta from mor- 
 bid adhesion 531 
 
 from uterine inertia 524 
 
 treatment of 507, 524, 5: > .:'>, 535 
 
 with hemorrhage 506 
 
 Retention of urine 22!), 322, 35!) 
 
 of urine in infants 715 
 
 Retroversioii of the uterus 292 
 
 Rheumatism of the uterus 246, 363 
 
 Rickets 36 
 
 treatment of 36 
 
 Right ealcaneo-iliac position 3:;',) 
 
 cephalo-iliac positions 33S, 447 
 
 diagnosis of 447 
 
 Right lobulo-iliac positions 425 
 
 diagnosis of 425, 426 
 
 Right meuto-iliac position 337, 419 
 
 diagnosis of 421 
 
 mechanism of 421 
 
 Right occipito-anterior position. 334, 347 
 
 diagnosis of 347 
 
 mechanism of 347 
 
 Right occipito-posterior position. 335, 3~i3 
 
 diagnosis of 353 
 
 mechanism of 354 
 
 Right sacro-iliac positions 33!), 437 
 
 diagnosis of 437 
 
 mechanism of 437 
 
 Rigid abdomen during pregnancy. . 240 
 
 Rigidity of the m-embranc s 375 
 
 of the os uteri 281, 365 
 
 of the perineum 67, 374, 386 
 
 Rigidity of the soft parts. . . .67, 374, 386 
 
 of the vagina 374, 386 
 
 Rigors during labor 275 
 
 Rotation of the head 60, 344 
 
 Round ligaments : 82 
 
 Rules for applying the forceps 602 
 
 Rules for determining the charac- 
 ter of labor 294 
 
 Rupture of the bladder 549 
 
 of the cord 533 
 
 of the membranes 280, 375 
 
 of the membranes, premature.. 375 
 
 of the uterus 545 
 
 of the uterus, diagnosis of 546 
 
 of the uterus, prognosis of 547 
 
 of the uterus, symptoms of 546 
 
 of the uterus, treatment of 547 
 
 of the vagina 549
 
 744 
 
 KING'S ECLECTIC OI'.STKTKICS. 
 
 Sacro-coccygeal >yni|>hysis 25 
 
 iliac symphyses 24 
 
 sciatic ligaments 25 
 
 Sacrum 17 
 
 hollow oi 17 
 
 Sacrum, promontory of 19 
 
 Salivation during pregnancy 210 
 
 Sanger-Cesarean operation 034 
 
 Scirrhous tumors 392 
 
 Second position of vertex 334, 347 
 
 Second stage of labor 2X2, 296 
 
 condition of female in 282 
 
 condition of os uteri in 2S2 
 
 conduct of accoucheur in 297 
 
 difficult 377 
 
 duration of 283, 304 
 
 inefficient contractions in 378 
 
 left cephalo-iliac position 338 
 
 management of 299 
 
 right cephalo-iliac position 338 
 
 rigidity in 366 
 
 Secretion of milk during pregnancy 196 
 
 Section, Cesarean 631 
 
 Sensible signs of pregnancy 192, 19.") 
 
 Separation of the symphyses 26 
 
 treatment of 28 
 
 Septicemia ..256,264, 534, 667 
 
 Shock to the nervous system 318 
 
 Shortness of the cord 407 
 
 Shoulder presentations 337, 44(> 
 
 cephalic version in 460, 576 
 
 diagnosis of '. . 446 
 
 management of 449 
 
 Shoulder presentations, positions 
 
 of 337, 446 
 
 turning in 449 
 
 Show ' 274 
 
 Signs of labor, premonitory 273 
 
 Signs of pregnancy 190 
 
 audible 198 
 
 death of fetus 153, 254 
 
 general 192 
 
 local . 193 
 
 rational 192 
 
 sensible 192, 193 
 
 sympathetic 195 
 
 synopsis of 206 
 
 table of 206 
 
 tangible 200 
 
 visible . . . 195 
 
 Sinking of the xiterus 273 
 
 Sixth position of vertex 335, :;55 
 
 Snuffles 728 
 
 Soft parts, rigidity of 67, :'>Sii 
 
 Sore mouth of nursing women .... 709 
 
 Sore nipples 327 
 
 Sound of fetal heart 199 
 
 Sound, placental 1 9S 
 
 Spasm of stomach, during pregnancy i'L'2 
 of ureters, during pregnancy. . . 230 
 of uterus, during pregnancy. . . 247 
 
 Spine of the ischium 21 
 
 Spontaneous evolution 459 
 
 Spot, embryonic S7, 115 
 
 spot, germinal 87 
 
 Stages of labor 278 
 
 Still-born children 31)7 
 
 Strait, inferior 31 
 
 axis of 32 
 
 diameters of 31 
 
 plane of 32 
 
 Strait, superior f 6, 29 
 
 axis of 30 
 
 diameters of 29 
 
 plane of 30 
 
 Straits of the pelvis 29 
 
 Strophulus intertinctus 715 
 
 Sub-peritoneo-pelvic pregnancy ... 186 
 
 Subsidence of the abdomen 273 
 
 of the uterus 27:! 
 
 Superfetation 1 54 
 
 Superior strait 16, 29 
 
 axis of 30 
 
 diameters of . . . . , 29 
 
 Superior strait, plane .of 30 
 
 Support to the perineum. . . .07, 301, 607 
 Suppressed menses in pregnancy. . 19:; 
 
 Sutures and fontanelles 54 
 
 Swelled breasts of infants 720 
 
 Sympathetic signs of pregnancy ... 195 
 
 Symphyseotomy 639 
 
 Symphyses, pelvic 23 
 
 Symphysis, sacro-coccygeal 25 
 
 eacro-iliac 24 
 
 pubis 24 
 
 Symptoms indicating interference 
 
 377, 599 
 
 of abortion 253 
 
 of aphtha 1 722 
 
 of cyanosis 714
 
 INDEX. 
 
 745 
 
 Symptoms of death of fet-us. . . .153, 255 
 
 of ephemeral fever 70(5 
 
 of exhaustion 377, 599 
 
 of hemorrhage after delivery . . 510 
 of inflammation of the breasts. 700 
 of inflammation of the uterine 
 
 absorbents 667 
 
 of inflammation of the uterine 
 
 veins 663 
 
 of intestinal irritation 698 
 
 of inverted uterus 538 
 
 of metritis 664 
 
 of miliary fever 709 
 
 of nursing sore mouth 711 
 
 of phlegmasia dolens 0X4 
 
 of puerperal convulsions 558 
 
 of puerperal mania 692 
 
 of puerperal fever 6(50, 1567 
 
 of puerperal peritonitis. . . .6(50, 667 
 
 of rupture of the uterus 546 
 
 of uterine phlebitis 665 
 
 Syncope during labor , 549 
 
 during pregnancy 230 
 
 from hemorrhage 500, 518 
 
 Synopsis of signs of pregnancy.... 206 
 
 Syphilis as a cause of abortion .... 250 
 during pregnancy 248 
 
 Syphilitic vegetations 392 
 
 Table for determining the time of 
 
 labor 174 
 
 Table of signs of pregnancy 206 
 
 Tache embryonnaire 115 
 
 Tampon 259, 261, 497 
 
 Tangible signs of pregnancy 200 
 
 Tedious labor (see Difficult Labor). 
 
 Theories of impregnation 94 
 
 Theory of epigenesis 97 
 
 of evolution 98 
 
 ovular 99 
 
 Third position of vertex 334, 348 
 
 Third stage of labor 284, 306 
 
 conduct of accoucheur in 306 
 
 Thrombus 550 
 
 treatment of 551 
 
 Thrush 722 
 
 Tongue-tied infants 720 
 
 Toothache during pregnancy 195, 229 
 
 Toughness of the membranes 375 
 
 Tractor 582 
 
 \ 
 
 Transverse presentations 
 
 Treatment of abortion 
 
 of accidental hemorrrhage 
 
 of after-effects of hemorrhage . . 
 
 of after-pains 
 
 of aphtha: 
 
 of breech presentations 
 
 of concealed hemorrhage. . .504, 
 
 lit" convulsions 
 
 of coryza 
 
 of cramps during labor 
 
 < if cyanosis 
 
 of difficult breech labors.. . .437, 
 
 of ear presentations 425, 
 
 of ephemeral fever 
 
 of extra-uterine pregnancy 
 
 of face presentations 
 
 of false pains . 
 
 of foot presentations 
 
 of habitual abortion 
 
 of hemorrhage after delivery. . . 
 of hemorrhage before term.. 259, 
 of hemorrhage from placenta 
 
 prsevia 
 
 of hemorrhage with retained 
 
 placenta 
 
 of hour-glass contraction 
 
 of inefficient action of uterus..">60, 
 of inflammation of the breasts. . 
 of inflammatory puerperal fever 
 
 of intestinal irritation 
 
 of inverted uterus 
 
 of knee presentations 
 
 of labor with pelvic deformity 
 
 (note) 394, 
 
 of mcnto-iliac positions 421, 
 
 of miliary fever 
 
 of monstrosities 
 
 of natural labor 
 
 of nursing sore mouth 
 
 of obliquity of uterus 
 
 of ovarian tumor 
 
 of phlegmasia dolens 
 
 of placenta praevia 
 
 of porrigo larvalis 
 
 of prolapsed cord 
 
 of puerperal convulsions 
 
 of puerperal fever 
 
 of puerperal hemorrhage491 , 507, 
 of puerperal mania 
 
 46s 
 256 
 504 
 521 
 321 
 72:; 
 437 
 506 
 554 
 729 
 300 
 714 
 442 
 427 
 70(5 
 187 
 421 
 277 
 445 
 265 
 511 
 504 
 
 507 
 529 
 378 
 702 
 671 
 699 
 540 
 444 
 
 403 
 617 
 708 
 483 
 285 
 709 
 373 
 405 
 686 
 491 
 727 
 471 
 565 
 671 
 511 
 694
 
 74(i 
 
 KINO'S KCIJ-XTIC OUSTKTIMo. 
 
 Treatment of puerperal peritonitis.. 691 
 of reaction after lieinorrliage. . . 521 
 
 of relaxation of symphyses 28 
 
 < if retained placenta. .507, 524, 5:'>.">, .">:'>6 
 of rheumatism of t lie uterus. 246, 365 
 
 of rickets 36 
 
 of ri-ridity of os uteri 2*1. :;ii7 
 
 of rupture of tlie uterus 547 
 
 of s -pa ration of the syniphyses. 28 
 
 of septieemia 264. .").",."i 
 
 of shoulder presentations 449 
 
 ( if si re nipples :'>27 
 
 of thrombus .V>1 
 
 of transverse presentations. 469, 613 
 
 of trisnms nascentium 726 
 
 of twin labors 477 
 
 of typhoid puerperal fever 677 
 
 of unavoidable hemorrhage. . . . 491 
 
 Tremors during labor 275 
 
 Trisnms nascentium 725 
 
 treatment of 726 
 
 True labor-pains 276 
 
 Tubal pregnancy 187 
 
 Tubes, Fallopian 82 
 
 Tubo-abdominal pregnancy 187 
 
 Tubo-ovarian pregnancy 187 
 
 Tumor, cauliflower 386 
 
 fibrous 385 
 
 fungous 386 
 
 ovarian 405 
 
 phlegmonous 392 
 
 scirrhous 392 
 
 Tumors during pregnancy 248 
 
 in difficult labor 390 
 
 i)i pelvic cavity 390 
 
 Turning 400, 449, 574 
 
 cases for 574, 57li 
 
 dangers of 576, 579 
 
 Turning, in shoulder presentations. 449 
 
 period for 567 
 
 Twins 180,200,475 
 
 diagnosis of 180, 200, 476 
 
 distension from 362 
 
 Tympanites, acute 698 
 
 Tympanites of the fetus 411 
 
 I'lcerated nipples 327 
 
 Umbilical cord 127, 306, 533 
 
 cutting the 306 
 
 prolapsus of.. 469 
 
 I'mbilical cord, shortness of 407 
 
 treatment of prolapsed 471 
 
 I'mbilical hernia 71s 
 
 vesicle 1 IS 
 
 Unavoidable hemorrhage 4S4 
 
 treatment of 491 
 
 Unequally contracted pelvis 40, 393 
 
 Unruptured hymen 389 
 
 rraclms li'l 
 
 Ureters, spasm of. during pregnancy 22S 
 
 I'rethra. orifice of the 65 
 
 Urine, incontinence of 241 
 
 retention of, in infants 715 
 
 Use of ergot, cautions respecting. . . 3S1 
 
 Use of the forceps 595 
 
 I 'terine absorbents, inflammation of 667 
 Uterine appendages, inflammation 
 
 of 663 
 
 Uterine contractions 271, 320, 378 
 
 by dry-cupping :!S7 
 
 painless 274 
 
 Uterine hemorrhage 4S4 
 
 treatment of 491, 504, 507, 51 1 
 
 Uterine inertia, with hemorrhage.. 5<)6 
 
 with retained placenta 524 
 
 Uterine phlebitis 666 
 
 diagnosis of 667 
 
 post-mortem appearances of.. . . 667 
 
 symptoms of 666 
 
 Uterine prolapsus during pregnancy 24 1 
 
 Uterine veins, inflammation of 666 
 
 Utero-tubal pregnancy 187 
 
 Utero-abdominal pregnancy is? 
 
 Uterus 71 
 
 anteversion of, during preg- 
 nancy ' 245 
 
 broad ligaments of 81 
 
 changes in, during pregnancy. . 156 
 condition in first stage of labor. . 2so 
 
 diagnosis of inverted ":'>'.' 
 
 Uterus, diagnosis of ruptured 546 
 
 galvanic heat in inverted 545 
 
 hour-glass contraction of 5-J7 
 
 inefficient action of 360. :!7s 
 
 inflammation of 664 
 
 inversion of 5: ',7 
 
 ligaments of 81 
 
 obliquity of 373 
 
 prognosis of inverted 5: $9 
 
 prognosis of ruptured 547
 
 747 
 
 Uterus, rheumatism of 246, .'Hi:; 
 
 retroversion of, during preg- . 
 
 nancy 242 
 
 round ligaments of 82 
 
 rupture of 545 
 
 sinking of 273 
 
 spasm of, during pregnancy.. . . 246 
 
 subsidence of 273 
 
 symptoms of inverted 537 
 
 symptoms of ruptured 546 
 
 treat Mi 1 nt of inverted 540 
 
 treatment of ruptured 547 
 
 Vagina 6X 
 
 cicutrix in 3S7 
 
 lacei'ation of 54!) 
 
 rigidity of 374 
 
 rupture of 549 
 
 Vagina! cvstocele 402 
 
 examination in first stage of 
 
 labor 287 
 
 hernia 406 
 
 mucous discharges 241 
 
 pulse 169 
 
 vesicocele 404 
 
 Varicose veins during pregnancy. . . 235 
 
 Vectis 582 
 
 Vegetations, syphilitic 392 
 
 Ventral pregnancy 186 
 
 Vernix caseosa 141, 151, 314 
 
 Version 400, 574 
 
 cephalic 461, 574 
 
 pndalic 400, 575 
 
 Vertex presentation '. . . 334 
 
 diagnosis of 340 
 
 forceps in 602 
 
 mechanism of 343 
 
 positions of 334, 340 
 
 Vertigo during pregnancy 
 
 Vesicle, blastodermic 
 
 germinal 86, 
 
 umbilical 114, 
 
 Vesicle, Graafian 
 
 Vesicula umbilicalis 
 
 Vessels, omphalo-mesenteric 
 
 Vestibulum 
 
 Viability of fetus 
 
 Violent fetal movements 
 
 Visible signs of pregnancy 
 
 Vital changes in the uterine tis- 
 sues during pregnancy 
 
 Vitelline membrane 
 
 Vitellus, or yelk 
 
 Vomiting during pregnancy 195, 211, 
 
 Vomiting in labor 279, 
 
 Vulva 
 
 anterior commissure of 
 
 posterior commissure of 
 
 Vulva, pruritus of 
 
 Washing the child 
 
 Washington, Dr., on dry-cupping. . 
 Waters, bag of 
 
 bag of, to distinguish from fetal 
 scalp 283, 
 
 false 116, 
 
 Weed 
 
 Weight and dimensions of the fetus 
 
 Woman 
 
 Woman in labor 
 
 Womb, falling of 
 
 W T right, Prof. M. B., on cephalic 
 
 230 
 
 114 
 
 114 
 
 118 
 
 85 
 
 ll.s 
 
 119 
 
 64 
 
 176 
 
 247 
 
 L62 
 
 86 
 
 86 
 
 213 
 
 282 
 
 62 
 
 63 
 
 63 
 
 233 
 
 387 
 2SO 
 
 293 
 
 246 
 706 
 147 
 11 
 278 
 241 
 
 Yelk, or vitellus 86 
 
 THE END.
 
 ECLECTIC TEXT BOOKS. 
 
 IK )\VK. A. JACKSON. M. I). Professor of Surycry in tin- Eclectic Medical I n-t it utc. Cincinnati. 
 
 -The Art and Science of Surgery.- 
 
 Revised edition ; svo.. ssd pa.u'es : Sheep ; Price, $7.00. 
 
 Diagnosis and Treatment of Dislocations and Fractures. 
 
 Fourth Edition : 4J6 panes: sheep; Price, $4.00. 
 
 Operative Gynaecology. - 
 
 8vo.. 360 pages ; Sheep : Price, 84.00. 
 
 KIN<;, JOHN, M. 1). Emeritus Professor ot Obstetric-sin the Eclectic Medical Institute. Cincinnati. 
 
 The American Dispensatory, with Supplement by J. U. Lloyd. 
 
 Sixteenth Edition: Svo., KVJ1 pages : Sheep: Price, 310.00. 
 
 Diagnosis and Treatment of Chronic Diseases. 
 
 NVO.. 1700 pages: Sheep: Price, $10.00. 
 
 -The American Eclectic Obstetrics.- 
 
 Eighth Edition: Syo.. ~'.V payvs : sheep; Price. 16.50. 
 
 Woman, Her Diseases and Their Treatment. 
 
 Fourth Edition: 8vo., :W> paires : Sheep; Price. - 
 
 Urological Dictionary. 
 
 Svo., 266 pages : Sheep : Price, $3.00. 
 
 LLOYD, J. I". Professor of Chemistry and Pharmacy in the Eclectic Medical Institute. Cincinnati. 
 
 -The Chemistry of Medicines, 
 
 WITH FIFTY ORIGINAL CUTS. 
 
 One Volume : large l'2mo., 451 pages: Cloth: Price, 92. 75; Leal! 
 
 SCl'DDER, JOHN M., M. D. Professor of Practice of Medicine in the Eclectic Medical Institute. 
 
 -The Eclectic Practice of Medicine. -- 
 
 Thirteenth Edition, revised; 8vo., 816 pa.avs : sheep: ST.IIII. post-paid. 
 
 -Trre Principles of Medicine.- 
 
 Fifth Edition: Svo., 352 pages; Sheep ; Price, post-paid, $1.00. 
 
 The Eclectic Practice in Diseases of Children. 
 
 sixth Edition ; 8vo.. 186 pages : Sheep: Price, post-paid. s.~>.oo. 
 
 A Practical Treatise on the Diseases of Women. 
 
 Fifteenth Edition, revised : Svo., ">:'.i pages : sheep: Price, post-paid. I 
 
 Specific Medication and Specific Medicines. 
 
 Thirteenth Edition, fourth revision ; 12mo., 432 pages ; Cloth: Price, *_'.." n. 
 
 Specific Diagnosis. 
 
 Eighth Edition ; 12ino., 388 pages ; Cloth ; Price, $2..\t. 
 
 American Eclectic Materia Medica and Therapeutics. 
 
 Tenth Edition ; Svo., 748 pages ; Sheep; Price, post-paid, $6,00. 
 
 The Eclectic Practice of Medicine for Families. 
 
 Twenty-first Edition ; Cloth: Price, s:;.no : sheep, S4.00; Half Morocco 
 
 On the Reproductive Organs and the Venereal. 
 
 Second Edition ; Svo., 393 pages ; Sheep ; Price, post-paid, $5.00. 
 \VINTERMUTE, ROBERT C., M. D. Professor of Obstetrics in the Eclectic Medical Institute. 
 
 -King's Eclectic Obstetrics. 
 
 Ninth Edition. Thoroughly revised and re-written. Svo. , 750 pages ; Sheep: Pric. - 
 
 Any book in this list sent fuxt-jmid, on receipt of jn-ir,-. 
 
 THE OHIO VALLEY CO,, Publishers, Cincinnati,
 
 Date Due 
 
 PR.NT.D IN u.*.*. CAT. NO. 24 161
 
 IHHH IIH III" ' ll111 " 
 
 A 000511 620 7 
 
 WQIOO 
 
 K53k 
 1892 
 
 King, John, 1813-1893. 
 
 King f s eclectic obstetrics. 
 
 WQIOO 
 K53k 
 1892 
 King, John, 1813-1893. 
 
 King*s eclectic obstetrics. 
 
 MEDICAL SCIENCES LIBRARY 
 
 UNIVERSITY OF CALIFORNIA, IRVINE 
 
 IRVINE, CALIFORNIA 92664